Risk Factors for Pediatric Enteric Infection in an Urban Slum: Examining the Contributions of the Household Environment, Neighborhood Geography, and Exposure Behaviors

Abstract

Introduction: Poor water, sanitation, and hygiene conditions contribute to pediatric enteric infection and environmental enteropathy. In urban settings, a child’s exposure to fecal contamination may be affected by the density and geography of an area and their frequency of contact with sources both inside and outside the home. Thus, household-level interventions may not sufficiently mitigate health risk. This study examined the contributions of the child’s household/neighborhood environments and exposure behaviors to enteric infection risk, separated by etiologic agents, in an urban slum in India. Methods: Over the child’s first two years of life, diarrheal and asymptomatic stool were collected and assayed for enteric pathogens. Exposures were assessed using spatial data and interviews with caregivers. Environmental conditions and exposures were evaluated by mixed effects regression models. Results: Though risk factors varied across pathogens, both the household and neighborhood environments contributed significantly to all infections. Within the household, population and the presence of older siblings were associated with elevated risk of viral (odds ratio (OR): 1.09, 95% confidence interval (CI): 1.01-1.17) and parasitic (OR: 1.91, 95% CI: 1.17-3.12) infections, respectively. Spatial clustering of open drain flooding during the heaviest rainy season was associated with increased risk of bacterial infection (OR: 2.26, 95% CI: 1.23-4.19), indicative of the poor neighborhood fecal sludge management. Frequent use of public toilets was associated with viral, especially norovirus, infection risk (OR: 2.05, 95% CI: 1.09-3.86). Conclusions: While positive household-level water and sanitation practices were generally associated with reduced enteric infection risk, conditions and exposures in the neighborhood environment may limit a household’s ability to control health risks, necessitating interventions to reduce fecal contamination in the public domain as well.