Abstract
Urban sanitation necessitates management of fecal sludge inside and outside the household. This study examined associations between household sanitation, fecal contamination, and enteric infection in two low-income neighborhoods in Vellore, India. Surveys and spatial analysis assessed the presence and clustering of toilets and fecal sludge management (FSM) practices in 200 households. Fecal contamination was measured in environmental samples from 50 households and household drains. Enteric infection was assessed from stool specimens from children under 5 years of age in these households. The two neighborhoods differed significantly in toilet coverage (78% versus 33%) and spatial clustering. Overall, 49% of toilets discharged directly into open drains (“poor FSM”). Children in households with poor FSM had 3.78 times higher prevalence of enteric infection when compared with children in other households, even those without toilets. In the neighborhood with high coverage of household toilets, children in households with poor FSM had 10 times higher prevalence of enteric infection than other children in the neighborhood and drains in poor FSM clusters who had significantly higher concentrations of genogroup II norovirus. Conversely, children in households with a toilet that contained excreta in a tank onsite had 55% lower prevalence of enteric infection compared with the rest of the study area. Notably, households with a toilet in the neighborhood with low toilet coverage had more fecal contamination on floors where children played compared with those without a toilet. Overall, both toilet coverage levels and FSM were associated with environmental fecal contamination and, subsequently, enteric infection prevalence in this urban setting.
Highlights
Poor water, sanitation, and hygiene are associated with multiple adverse health and developmental outcomes.[1,2] Following the Millennium Development Goals, the focus of the sanitation sector has been in rural areas, where 70% of those without access to improved sanitation live.[3]
This study examined the associations between household sanitation—including toilets, fecal sludge management (FSM), and spatial heterogeneity of sanitation coverage—and fecal contamination within the household and the local urban environment and enteric infection in young children
The results suggest that the FSM, neighborhood-level coverage, and spatial clustering of household toilets are significantly associated with householdand neighborhood-level fecal contamination and pediatric enteric infection prevalence
Summary
Sanitation, and hygiene are associated with multiple adverse health and developmental outcomes.[1,2] Following the Millennium Development Goals, the focus of the sanitation sector has been in rural areas, where 70% of those without access to improved sanitation live.[3]. Despite links between poor sanitation and health, evidence of effective sanitation in urban settings remains weak. Recent meta-analyses have identified few interventions in urban neighborhoods and limited evidence, overall, of the positive effects of sanitation on diarrheal disease.[12,13] Among other limitations, the authors highlight bias in outcome measures (self-reported diarrhea) and poor mechanistic evidence of changes in more proximal exposures, such as fecal con-
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