Sanitation and Hygiene-Specific Risk Factors for Moderate-to-Severe Diarrhea in Young Children in the Global Enteric Multicenter Study, 2007-2011: Case-Control Study

Morbidity benefit conferred by childhood immunisation in relation to maternal HIV status: a meta-analysis of demographic and health surveys

The study determined the prevalence of acute respiratory infections and diarrhoea among sub-Saharan African children. It also examined if there was any significant morbidity benefit conferred by three doses of diphtheria-tetanus-pertussis containing vaccines (DTP3) with respect to maternal HIV status. Data were obtained from the Demographic and Health Survey (DHS) program, United Nations Development Programs, World Bank and Joint United Nations Programme on HIV/AIDS. Pooled odds ratio (OR) and 95% confidence intervals (CI) were calculated for the countries. Test of heterogeneity, sensitivity analyses and meta-regression were also conducted. The prevalence of acute respiratory infections and diarrhoea were similar between the children that were vaccinated and those who were not vaccinated with DTP3. The pooled result shows that children who did not receive DTP3 were more likely to have symptoms of acute respiratory infections than children who had DTP3 (OR 1.09, 95% CI 1.02 to 1.17); with low heterogeneity across the countries. The combined result for diarrhoea shows that children who did not receive DTP3 were less likely to have episodes of diarrhoea than children who received DTP3 (OR 0.83, 95% CI 0.74 to 0.92); with substantial heterogeneity across the countries. There was no difference between the estimates of DTP3 vaccinated and unvaccinated children of HIV seropositive mothers with respect to symptoms of acute respiratory infections or episodes of diarrhoea. Tackling various causes and risk factors for respiratory tract infections and diarrhoeal diseases should be a priority for various stakeholders in sub-Saharan Africa.

Where Children Play: Young Child Exposure to Environmental Hazards during Play in Public Areas in a Transitioning Internally Displaced Persons Community in Haiti

Globally, gastrointestinal (GI) infections by enteric pathogens are the second-leading cause of morbidity and mortality in children under five years of age (≤5 years). While GI pathogen exposure in households has been rigorously examined, there is little data about young children's exposure in public domains. Moreover, public areas in low-income settings are often used for other waste disposal practices in addition to human feces, such as trash dumping in areas near households. If young children play in public domains, they might be exposed to interrelated and highly concentrated microbial, chemical, and physical hazards. This study performed structured observations at 36 public areas in an internally displaced persons community that has transitioned into a formal settlement in Haiti. We documented how often young children played in public areas and quantified behaviors that might lead to illness and injury. Children ≤5 years played at all public sites, which included infants who played at 47% of sites. Children touched and mouthed plastic, metal and glass trash, food and other objects from the ground, ate soil (geophagia) and drank surface water. They also touched latrines, animals, animal feces and open drainage canals. Hand-to-mouth contact was one of the most common behaviors observed and the rate of contact significantly differed among developmental stages (infants: 18/h, toddlers: 11/h and young children: 9/h), providing evidence that children could ingest trace amounts of animal/human feces on hands that may contain GI pathogens. These findings demonstrate that water, sanitation and hygiene interventions could be more effective if they consider exposure risks to feces in public domains. Furthermore, this research highlights the need for waste-related interventions to address the broader set of civil conditions that create unsafe, toxic and contaminated public environments where young children play.

The impact of shared sanitation facilities on diarrheal diseases with and without an environmental reservoir: a modeling study

Epidemiological studies have identified an increased risk of diarrheal diseases associated with using shared sanitation facilities. We hypothesized that this might be related to differences in transmission routes of pathogens. We proposed a mathematical model of two fictitious pathogens, one transmitted with an environmental reservoir and one without. We assumed that individuals susceptible to one pathogen are not susceptible to the other, and therefore, decoupled the two models. We initialized the model with 99% individuals being susceptible. We sampled the parameter space using Latin Hypercube Sampling. We simulated 10,000 parameter sets. We varied the effective shared sanitation coverage (the product of latrine coverage and users' compliance). Our results show that, in our hypothetical scenario, across all levels of effective coverage of shared sanitation, the median final cumulative incidence of diarrheal disease was higher than that of zero coverage. Our simulation findings suggest that increasing effective coverage of shared sanitation may have limited benefits against diarrhea-causing pathogens with an environmental reservoir and may lack benefit against diarrhea-causing pathogens without an environmental reservoir given increased human contacts if latrines are poorly maintained.

Enteroaggregative Escherichia coli is the predominant diarrheagenic E. coli pathotype among irrigation water and food sources in South Africa

Diarrheagenic E. coli (DEC) has been implicated in foodborne outbreaks worldwide and have been associated with childhood stunting in the absence of diarrhoea. Infection is extraordinarily common, but the routes of transmission have not been determined. Therefore, determining the most prevalent pathotypes in food and environmental sources may help provide better guidance to various stakeholders in ensuring food safety and public health and advancing understanding of the epidemiology of enteric disease. We characterized 205 E. coli strains previously isolated from producer distributor bulk milk (PDBM)(118), irrigation water (48), irrigated lettuce (29) and street vendor coleslaw (10) in South Africa. Enteropathogenic E. coli (EPEC), enterotoxigenic E. coli (ETEC), enteroaggregative E. coli (EAEC) and diffusely adherent E. coli (DAEC) were sought. We used PCR and partial gene sequencing for all 205 strains while 46 out of 205 that showed poor resolution were subsequently characterized using cell adherence (HeLa cells). PCR and partial gene sequencing of aatA and/or aaiC genes confirmed EAEC (2%, 5 out of 205) as the only pathotype. Phylogenetic analysis of sequenced EAEC strains with E. coli strains in GenBank showing ≥80% nucleotide sequence similarity based on possession of aaiC and aatA generated distinct clusters of strains separated predominantly based on their source of isolation (food source or human stool) suggesting a potential role of virulence genes in source tracking. EAEC 24%, 11 out of 46 strains (PDBM = 15%, irrigation water = 7%, irrigated lettuce = 2%) was similarly the predominant pathotype followed by strains showing invasiveness to HeLa cells, 4%, 2 out of 46 (PDBM = 2%, irrigated lettuce = 2%), among stains characterized using cell adherence. Therefore, EAEC may be the leading cause of DEC associated food and water-borne enteric infection in South Africa. Additionally, solely using molecular based methods targeting virulence gene determinants may underestimate prevalence, especially among heterogeneous pathogens such as EAEC.

Within-Compound Versus Public Latrine Access and Child Feces Disposal Practices in Low-Income Neighborhoods of Accra, Ghana

In crowded urban settlements in low-income countries, many households rely on shared sanitation facilities. Shared facilities are not currently considered "improved sanitation" because of concerns about whether hygiene conditions sufficiently protect users from the feces of others. Prevention of fecal exposure at a latrine is only one aspect of sanitary safety. Ensuring consistent use of latrines for feces disposal, especially child feces, is required to reduce fecal contamination in households and communities. Household crowding and shared latrine access are correlated in these settings, rendering latrine use by neighbors sharing communal living areas as critically important for protecting one's own household. This study in Accra, Ghana, found that household access to a within-compound basic latrine was associated with higher latrine use by children of ages 5-12 years and for disposal of feces of children < 5 years, compared with households using public latrines. However, within-compound access was not associated with improved child feces disposal by other caregivers in the compound. Feces was rarely observed in household compounds but was observed more often in compounds with latrines versus compounds relying on public latrines. Escherichia coli and human adenovirus were detected frequently on household surfaces, but concentrations did not differ when compared by latrine access or usage practices. The differences in latrine use for households sharing within-compound versus public latrines in Accra suggest that disaggregated shared sanitation categories may be useful in monitoring global progress in sanitation coverage. However, compound access did not completely ensure that households were protected from feces and microbial contamination.

Escherichia coli Contamination across Multiple Environmental Compartments (Soil, Hands, Drinking Water, and Handwashing Water) in Urban Harare: Correlations and Risk Factors

Escherichia coli pathotypes (i.e., enteropathogenic and enterotoxigenic) have been identified among the pathogens most responsible for moderate-to-severe diarrhea in low- and middle-income countries (LMICs). Pathogenic E. coli are transmitted from infected human or animal feces to new susceptible hosts via environmental reservoirs such as hands, water, and soil. Commensal E. coli, which includes nonpathogenic E. coli strains, are widely used as fecal bacteria indicator, with their presence associated with increased likelihood of enteric pathogens and/or diarrheal disease. In this study, we investigated E. coli contamination in environmental reservoirs within households (N = 142) in high-population density communities of Harare, Zimbabwe. We further assessed the interconnectedness of the environmental compartments by investigating associations between, and household-level risk factors for, E. coli contamination. From the data we collected, the source and risk factors for E. coli contamination are not readily apparent. One notable exception is the presence of running tap water on the household plot, which is associated with significantly less E. coli contamination of drinking water, handwashing water, and hands after handwashing. In addition, E. coli levels on hands after washing are significantly associated with handwashing water contamination, hand contamination before washing, and diarrhea incidence. Finally, we observed that animal ownership increases E. coli contamination in soil, and E. coli in soil are correlated with contamination on hands before washing. This study highlights the complexity of E. coli contamination in household environments within LMICs. More, larger, studies are needed to better identify sources and exposure pathways of E. coli-and enteric pathogens generally-to identify effective interventions.

Microbiological risk infection assessment using QMRA in agriculture systems in Côte d'Ivoire, West Africa

Poor wastewater management that results from a lack of appropriate sanitation infrastructure contributes to increasing health risks in urban areas in Côte d'Ivoire. We assessed the health risks associated with the use of wastewater for watering salad destined for human consumption, to help local authorities in developing appropriate risk mitigation measures for Yamoussoukro, the political capital of Côte d'Ivoire. We applied a stochastic approach based on quantitative microbiological risk assessment (QMRA), focusing on wastewater for farming activities and salad consumption at the household level. Farming activities rely on a large degree on contaminated water and are conducted without any protection. The QMRA highlights that the poor quality of watering water increased the microbiological risk of the two assessed groups of urban farmers and individual households. The annual risk of infection due to watering wastewater in the city is estimated at 0.01 per person per year (pppy) for Giardia lamblia and 0.2 pppy for Escherichia coli O157:H7. The annual risk from salad consumption is 0.01 pppy for G. lamblia and 0.9 pppy for E. coli O157:H7. Both the annual risks from farming activities and salad consumption were higher than the tolerable standard of risk of 10^-4 pppy as defined by the World Health Organization. There is a need to conduct a risk analysis and a cost-effectiveness study on intervention to improve public health and the livelihoods of the producers which are women in majority in Yamoussoukro.

Hubungan Ketahanan Pangan dan Penyakit Diare dengan Stunting pada Balita 13-48 Bulan di Kelurahan Manyar Sabrangan, Surabaya

 Background: Stunting is an acute malnutrition that is one of the leading causes of death in under-five children in the world and can impact on low quality of life in the future. Household food security and infectious diseases especially diarrhea in under-five children are indicated to be factors that cause the stunting state. Toddlers 13-48 months old are likely have a high risk for disease and its effects. Stunting in under-five children is closely related to food insecurity of the family and diarrheal diseases by the children.Objectives: The purpose of this study was to analyze the association of food security of the family and diarrheal diseases to stunting. Methods: This research was an observational analytic with cross sectional design. The sample was 68 children under-five age 13-48 months in Manyar Sabrangan, Mulyorejo Sub-district, Surabaya. Selection of sample was using simple random sampling with lottery technique. The data were collected by interview method with questionnaire. Food security was accessed by US-HFSSM questionnaire. Spearman correlation test was used in the statistical analysis (α=0.05). Results: The data showed that the percentage of stunting, diarrhea, and household insecurity respectively 30.9%, 19.1%, and 61.8%. There was an association between food insecurity with stunting (p<0.05). There was not an association between diarrhea with stunting (p>0.05). Conclusions: It is necessary for family to have a coping strategy to avoid long-term food insecurity. There is another factor such as a history of food intake that may be able to affect stunting in addition to diarrhea.ABSTRAK Latar Belakang: Stunting merupakan keadaan kekurangan gizi akut yang menjadi salah satu penyebab kematian pada balita di dunia dan dapat berdampak pada kualitas kehidupan yang rendah di masa depan. Ketahanan pangan keluarga dan kejadian penyakit infeksi yang dialami balita terutama diare diindikasikan menjadi faktor yang dapat menyebabkan keadaan stunting. Balita usia 13-48 bulan merupakan kelompok yang rentan terhadap penyakit dan dampaknya. Keadaan stunting erat kaitannya dengan kerawanan pangan keluarga dan penyakit infeksi seperti diare yang dialami balita.Tujuan: Untuk menganalisis hubungan ketahanan pangan keluarga dan penyakit diare dengan keadaan stunting balita.Metode: Penelitian ini merupakan penelitian observasional analitik dengan rancang cross sectional. Sampel dalam penelitian ini adalah 68 balita usia 13-48 bulan di Kelurahan Manyar Sabrangan Kecamatan Mulyorejo Kota Surabaya. Pemilihan sampel menggunakan simple random sampling dengan teknik lotre. Pengambilan data dilakukan dengan metode wawancara dengan kuesioner. Ketahanan pangan diukur dengan menggunakan kuesioner United Stated-Household Food Security Survey Module (US-HFSSM). Analisis statistik dilakukan dengan menggunakan uji korelasi spearman (α=0,05).Hasil: Hasil menunjukkan bahwa sebanyak 30,9% balita mengalami stunting, 19,1% mengalami diare, dan 61,8% berada pada keadaan rawan pangan. Ketahanan pangan keluarga dan keadaan stunting menunjukkan adanya hubungan yang signifikan (p<0,05). Penyakit diare balita dan keadaan stunting tidak menunjukkan adanya hubungan yang signifikan (p>0,05).Kesimpulan: Dibutuhkan coping strategi dalam keluarga untuk mengatasi masalah kerawanan pangan yang terus-menerus. Terdapat faktor lain seperti riwayat asupan makanan yang dapat mempengaruhi stunting selain penyakit diare.

Childhood diarrheal morbidity and sanitation predictors in a nomadic community

BACKGROUND

Diarrhea remains a leading killer of young children on the globe despite the availability of simple and effective solutions to prevent and control it. The disease is more prevalent among under - five children (U5C) in the developing world due to lack of sanitation. A child dies every 15 s from diarrheal disease caused largely by poor sanitation. Nearly 90% of diarrheal disease is attributed to inadequate sanitation. Even though, the health burden of diarrheal disease is widely recognized at global level, its prevalence and sanitation predictors among a nomadic population of Ethiopia are not researched. This study was therefore designed to assess the prevalence of childhood diarrheal disease and sanitation predictors among a nomadic people in Hadaleala district, Afar region, Northeast Ethiopia.

METHODS

A community based cross-sectional study design was carried out to investigate diarrheal disease among U5C. A total of 704 households who had U5C were included in this study and the study subjects were recruited by a multistage cluster sampling technique. Data were collected using a structured questionnaire and an observational checklist. All the mothers of U5C found in the selected clusters were interviewed. Furthermore, the living environment was observed. Univariable binary logistic regression analysis was used to choose variables for the multivariable binary logistic regression analysis on the basis of p- value less than 0.2. Finally, multivariable binary logistic regression analysis was used to identify variables associated with childhood diarrhea disease on the basis of adjusted odds ratio (AOR) with 95% confidence interval (CI) and p < 0.05.

RESULTS

The two weeks period prevalence of diarrheal disease among U5C in Hadaleala district was 26.1% (95% CI: 22.9 - 29.3%). Childhood diarrheal disease was statistically associated with unprotected drinking water sources [AOR = 2.449, 95% CI = (1.264, 4.744)], inadequate drinking water service level [AOR = 1.535, 95% CI = (1.004, 2.346)], drinking water sources not protected from animal contact [AOR = 4.403, 95% CI = (2.424, 7.999)], un-availability of any type of latrine [AOR = 2.278, 95% CI = (1.045, 4.965)], presence of human excreta in the compound [AOR = 11.391, 95% CI = (2.100, 61.787)], not washing hand after visiting toilet [AOR = 16.511, 95% CI = (3.304, 82.509)], and live in one living room [AOR = 5.827, 95% CI = (3.208, 10.581)].

CONCLUSION

Childhood diarrheal disease was the common public health problem in Hadaleala district. Compared with the national and regional prevalence of childhood diarrhea, higher prevalence of diarrhea among U5C was reported. Types of drinking water sources, households whose water sources are shared with livestock, volume of daily water collected, availability of latrine, presence of faeces in the compound, hand washing after visiting the toilet and number of rooms were the sanitation predictors associated with childhood diarrhea. Therefore, enabling the community with safe and continuous supply of water and proper disposal of wastes including excreta is necessary with particular emphasis to the rural nomadic communities.

Sanitation facilities, hygienic conditions, and prevalence of acute diarrhea among under-five children in slums of Addis Ababa, Ethiopia: Baseline survey of a longitudinal study

BACKGROUND

In developing countries, children under the age of five years who live in slums are highly vulnerable to diarrhea. However, there is a paucity of information on the relationship between sanitation facilities and hygienic conditions to acute diarrhea among under-five children in slum areas of Addis Ababa, Ethiopia. Therefore, this study examines the sanitation facilities and hygienic conditions in the slums of Addis Ababa and identifies the main factors significantly associated with acute diarrhea among children aged 0-50 months in those slums.

METHODS

A community-based cross-sectional household survey was carried out between September and November 2014, that then served as the baseline survey of a longitudinal study. For this survey, 697 children aged 0-50 months were recruited from two slum districts in Addis Ababa. A pre-tested structured questionnaire and an observational checklist were used for data collection. Multivariable logistic regression analysis was used to identify sanitation facilities and hygiene-related factors that were significantly associated with acute diarrhea by controlling potential confounding effects of selected socio-demographic factors. Adjusted odds ratio (AOR) with corresponding 95% confidence interval (CI) was used to quantify the strength of association.

MAIN FINDINGS

The prevalence of acute diarrhea among children aged 0-50 months in the study area was 11.9% and 94.6% of the sanitation facilities were unimproved. Sharing of a sanitation facility by six or more households (AOR = 4.7; 95% CI: 2.4-9.4), proximity of sanitation facilities within 15 meters of homes (AOR = 6.6; 95% CI: 2.5-17.0), presence of feces (AOR = 3.9; 95% CI: 1.5-10.3) and flies (AOR = 2.5; 95% CI: 1.3-5.0) on the floor of and/or around sanitation facilities, and presence of uncollected garbage inside house compounds (AOR = 3.2; 95% CI: 1.2-8.4) were significantly associated with acute diarrhea.

CONCLUSION

This study reveals the slum environment to be high risk for diarrhea due to close proximity of sanitation facilities to homes, sharing of sanitation facilities, and poor hygiene of the sanitation facilities and housing compounds. We recommend the development of a comprehensive diarrheal disease prevention program that focuses on improving the cleanliness of the sanitation facilities and housing compounds. Increasing the number of improved sanitation facilities at an appropriate distance from houses is also essential in order to reduce the number of households that share one latrine.

Household and Individual Risk Factors for Cholera among Cholera Vaccine Recipients in Rural Haiti

Oral cholera vaccination was used as part of cholera control in Haiti, but the vaccine does not provide complete protection. We conducted secondary data analyses of a vaccine effectiveness study in Haiti to evaluate risk factors for cholera among cholera vaccine recipients. Individuals vaccinated against cholera that presented with acute watery diarrhea and had a stool sample positive for Vibrio cholerae O1 were included as cases. Up to four vaccinated individuals who did not present for treatment of diarrhea were included as controls for each case, and matched by location of residence, enrollment time, and age. We evaluated sociodemographic characteristics and risk factors for cholera. Univariable and multivariable logistic regression were performed to identify risk factors for cholera among vaccinees. Thirty-three vaccine recipients with culture-confirmed cholera were included as cases. One-hundred-and-seventeen of their matched controls reported receiving vaccine and were included as controls. In a multivariable analysis, self-reporting use of branded household water disinfection products as a means of treating water (adjusted relative risk [aRR] = 44.3, 95% confidence interval [CI] = 4.19-468.05, P = 0.002), and reporting having a latrine as the main household toilet (aRR = 4.22, 95% CI = 1.23-14.43, P = 0.02), were independent risk factors for cholera. Self-reporting always treating water (aRR = 0.09, 95% CI = 0.01-0.57, P = 0.01) was associated with protection against cholera. The field effectiveness of water, sanitation, and hygiene interventions used in combination with cholera vaccination in cholera control should be measured and monitored over time to identify and remediate shortcomings, and ensure successful impact on disease control.

Piloting water quality testing coupled with a national socioeconomic survey in Yogyakarta province, Indonesia, towards tracking of Sustainable Development Goal 6

There remains a pressing need for systematic water quality monitoring strategies to assess drinking water safety and to track progress towards the Sustainable Development Goals (SDG). This study incorporated water quality testing into an existing national socioeconomic survey in Yogyakarta province, Indonesia; the first such study in Indonesia in terms of SDG tracking. Multivariate regression analysis assessed the association between faecal and nitrate contamination and drinking water sources household drinking water adjusted for wealth, education level, type of water sources and type of sanitation facilities. The survey observed widespread faecal contamination in both sources for drinking water (89.2%, 95%CI: 86.9-91.5%; n=720) and household drinking water (67.1%, 95%CI: 64.1-70.1%; n=917) as measured by Escherichia coli. This was despite widespread improved drinking water source coverage (85.3%) and commonly self-reported boiling practices (82.2%). E.coli concentration levels in household drinking water were associated with wealth, education levels of a household head, and type of water source (i.e. vender water or local sources). Following the proposed SDG definition for Target 6.1 (water) and 6.2 (sanitation), the estimated proportion of households with access to safely managed drinking water and sanitation was 8.5% and 45.5%, respectively in the study areas, indicating substantial difference from improved drinking water (82.2%) and improved sanitation coverage (70.9%) as per the MDGs targets. The greatest contamination and risk factors were found in the poorest households indicating the urgent need for targeted and effective interventions here. There is suggested evidence that sub-surface leaching from on-site sanitation adversely impacts on drinking water sources, which underscores the need for further technical assistance in promoting latrine construction. Urgent action is still needed to strengthen systematic monitoring efforts towards tracking SDG Goal 6.

Exposure to paternal tobacco smoking increased child hospitalization for lower respiratory infections but not for other diseases in Vietnam

Exposure to environmental tobacco smoke (ETS) is an important modifiable risk factor for child hospitalization, although its contribution is not well documented in countries where ETS due to maternal tobacco smoking is negligible. We conducted a birth cohort study of 1999 neonates between May 2009 and May 2010 in Nha Trang, Vietnam, to evaluate paternal tobacco smoking as a risk factor for infectious and non-infectious diseases. Hospitalizations during a 24-month observation period were identified using hospital records. The effect of paternal exposure during pregnancy and infancy on infectious disease incidence was evaluated using Poisson regression models. In total, 35.6% of 1624 children who attended follow-up visits required at least one hospitalization by 2 years of age, and the most common reason for hospitalization was lower respiratory tract infection (LRTI). Paternal tobacco smoking independently increased the risk of LRTI 1.76-fold (95% CI: 1.24-2.51) after adjusting for possible confounders but was not associated with any other cause of hospitalization. The population attributable fraction indicated that effective interventions to prevent paternal smoking in the presence of children would reduce LRTI-related hospitalizations by 14.8% in this epidemiological setting.

Does Measles Vaccination Reduce the Risk of Acute Respiratory Infection (ARI) and Diarrhea in Children: A Multi-Country Study?

BACKGROUND

Pneumonia and diarrhea occur either as complications or secondary infections in measles affected children. So, the integrated Global Action Plan for Pneumonia and Diarrhea (GAPPD) by WHO and UNICEF includes measles vaccination as preventive measure in children. The objective of the study is to examine the effect of measles vaccination on Acute Respiratory Infection (ARI) and diarrhea in children in the Democratic Republic of Congo, Ethiopia, India, Nigeria, and Pakistan.

METHODS

We analyzed data from the most recent rounds of Demographic and Health Surveys (DHS) in the selected countries. We included children age 12-59 months in the analysis. We used multivariable binary logistic regression to examine the effect of measles vaccination on ARI and diarrhea in children. We also estimated Vaccination Effectiveness (VE).

FINDINGS

More than 60 percent of the children age 12-59 months were given measles vaccine before the survey in the Democratic Republic of Congo, Ethiopia, India and Pakistan. Children who were given the measles vaccine were less likely to suffer from ARI than unvaccinated children in India and Pakistan. Children who were given the measles vaccine had a lower risk of diarrhea than those who did not receive it in all the selected countries except Ethiopia. Measles vaccination was associated with reduction in ARI cases by 15-30 percent in India and Pakistan, and diarrhea cases by 12-22 percent in the Democratic Republic of Congo, India, Nigeria and Pakistan.

CONCLUSION

The receipt of the measles vaccine was associated with decrease in ARI and diarrhea in children. The immunization program must ensure that each child gets the recommended doses of measles vaccine at the appropriate age. The measles vaccination should be given more attention as a preventive intervention under the Global Action Plan for Pneumonia and Diarrhea (GAPPD) in all low and middle-income countries.

The Knowledge Base for Achieving the Sustainable Development Goal Targets on Water Supply, Sanitation and Hygiene

Safe drinking water, sanitation, and hygiene (WASH) are fundamental to an improved standard of living. Globally, 91% of households used improved drinking water sources in 2015, while for improved sanitation it is 68%. Wealth disparities are stark, with rural populations, slum dwellers and marginalized groups lagging significantly behind. Service coverage is significantly lower when considering the new water and sanitation targets under the sustainable development goals (SDGs) which aspire to a higher standard of ‘safely managed’ water and sanitation. Lack of access to WASH can have an economic impact as much as 7% of Gross Domestic Product, not including the social and environmental consequences. Research points to significant health and socio-economic consequences of poor nutritional status, child growth and school performance caused by inadequate WASH. Groundwater over-extraction and pollution of surface water bodies have serious impacts on water resource availability and biodiversity, while climate change exacerbates the health risks of water insecurity. A significant literature documents the beneficial impacts of WASH interventions, and a growing number of impact evaluation studies assess how interventions are optimally financed, implemented and sustained. Many innovations in behavior change and service delivery offer potential for scaling up services to meet the SDGs.

Interpreting the Global Enteric Multicenter Study (GEMS) Findings on Sanitation, Hygiene, and Diarrhea

In this Perspective on the GEMS study by Kelly Baker and colleagues, Jonny Crocker and Jamie Bartram consider the implications of associations found and not found between diarrheal disease and sanitation and hygiene.