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

Shared sanitation in informal settlements: A systematic review and meta-analysis of prevalence, preferences, and quality

Shared sanitation facilities are not considered a type of basic sanitation by the WHO/UNICEF Joint Monitoring Programme (JMP), though they may be the only alternative to open defecation in urban informal settlements. Additionally, JMP indicators for sanitation do not cover aspects related to the quality of shared sanitation, such as those outlined in the Human Right to Water and Sanitation (HRTWS) framework. Data on the prevalence of shared sanitation within informal settlement areas is limited, and there is a need to understand user preferences, experiences, and barriers to the use of shared sanitation to inform effective policy and practice. This systematic review aims to summarize the prevalence and number of households sharing sanitation in informal settlements globally, as well as user experiences and barriers to successful implementation of shared sanitation. We included studies available in English and published after January 1, 2000. We retrieved 4741 articles from seven databases and included a total of 167 relevant publications. Among included studies, 54 reported the prevalence of shared sanitation in informal settlements, and 138 studies reported on user perceptions and experiences related to shared sanitation quality. A meta-analysis of studies reporting the prevalence of shared sanitation in informal settlements globally revealed an estimated overall prevalence of 67% [95% CI: 61%-73%]. Commonly reported user preferences included cleanliness to promote continued use of shared facilities, privacy with a lockable door, facilities for menstrual hygiene management, safety and protection against violence, 24/7 access, proper lighting, and shared responsibility for facility management - which align with the HRTWS framework and represent barriers to shared sanitation use. Based on the findings of this review, we recommend including the number of households or people sharing a sanitation facility in monitoring of shared sanitation quality, locating sanitation facilities within compounds, where applicable, and promoting safety, dignity, and privacy of all users in the development of shared sanitation quality indicators.

Spatial analysis of food and water-borne diseases in Ahmedabad, India: Implications for urban public health planning

Spatial analysis of infectious diseases can play an important role in mapping the spread of diseases and can support policy making at local level. Moreover, identification of disease clusters based on local geography and landscape forms the basis for disease control and prevention. Therefore, this study aimed to examine the spatial-temporal variations, hotspot areas, and potential risk factors of infectious diseases (including Viral Hepatitis, Typhoid and Diarrhea) in Ahmedabad city of India. We used Moran's I and Local Indicators of Spatial Association (LISA) mapping to detect spatial clustering of diseases. Spatial and temporal regression analysis was used to identify the association between disease incidence and spatial risk factors. The Moran's I statistics identified presence of positive spatial autocorrelation within the considered diseases, with Moran's I from 0.09 for typhoid to 0.21 for diarrhea (p < 0.001). This indicates a clustering of affected wards for each disease, suggesting that cases were not randomly distributed across the city. LISA mapping demonstrated the clustering of hotspots in central regions of the city, especially towards the east of the river Sabarmati, highlighting key geographical areas with elevated disease risk. The spatial clusters of infectious diseases were consistently associated with slum population density and illiteracy. Furthermore, temporal analysis suggested illiteracy rates could increase risk of viral hepatitis by 13 % (95 % Confidence Interval (CI): 1.01-1.26) and of diarrhea by 18 % (95 % CI: 1.07-1.31). Significant inverse association was also seen between viral hepatitis incidence and the distance of wards from rivers. Conclusively, the study highlight the impact of socio-economic gradients, such as slum population density (indicative of poverty) and illiteracy, on the localized transmission of water and foodborne infections. The evident social stratification between impoverished and affluent households emerges as a notable contributing factor and a potential source of differences in the dynamics of infectious diseases in Ahmedabad.

Associations between Shared Sanitation, Stunting and Diarrhoea in Low-Income, High Density Urban Neighbourhoods of Maputo, Mozambique - a Cross-Sectional Study

INTRODUCTION

Shared sanitation facilities are used by over 500 million people around the world. Most research evidence indicates that shared sanitation conveys higher risk than household sanitation for many adverse health outcomes. However, studies often fail to account for variation between different types of shared facilities. As informal housing development outpaces sanitation infrastructure, it is imperative to understand which components of shared facilities may mitigate the health risks of shared sanitation use.

METHODS

This cross-sectional study determines whether sanitation improvement or compound hygiene were associated with stunting or diarrhoeal prevalence in children under five living in Maputo, Mozambique who rely on shared sanitation facilities. The study uses logistic and linear multivariable regression analysis to search for associations and control for potential confounding factors.

RESULTS

346 children (43.9%) in the study population were stunted. Each unit increase in sanitation score was associated with an approximate decrease of 22% in the odds of stunting (OR: 0.78, CI: 0.66, 0.92), and an increase in height of 0.23 height-for-age z-scores (CI: 0.10, 0.36). There was no evidence that the compound hygiene score was associated with height as measured by stunting (OR: 1.05, CI: 0.87, 1.26) or z-score (-0.06, CI: -0.21, 0.09). Neither sanitation nor compound hygiene score were associated with diarrhoea in the population.

CONCLUSIONS

Use of an improved shared latrine is associated with decreased odds of stunting. There is no evidence of an association between latrine improvement and diarrhoea. Further investigation is necessary to isolate attributes of shared sanitation facilities that may reduce health risks.

Sustainable aquatic food systems: Multisectoral analysis of determinants of child nutrition in coastal Kenya

Marine foods produced by small-scale fishers can make vital contributions to sustainable, healthy food systems with multisectoral considerations of public health nutrition, gender equity, economics, and marine ecology. This pilot study aimed to map the multidimensional determinants of fish food security and young child nutrition in four coastal communities of Kenya with a view toward designing a large intervention trial. We compared anthropometric and dietary diversity indicators of children under 5 years in fishing vs. non-fishing households. Mixed methods included household surveys, 24-h recalls for dietary intake, and anthropometric measures of children. Child dietary diversity score (CDDS) and height-for-age Z (HAZ) were primary outcomes tested in ordinary least square regression modeling. Stunting was widely prevalent (20.2%), as were morbidities for acute diarrhea (29.0%) and fever (46.5%), with no statistically significant differences in fishing compared to non-fishing households. High proportions of children showed nutrient intake inadequacies for vitamins A, C, and E, iron and zinc; &lt;50% met requirements for all nutrients except protein, which was derived primarily from plant-based foods. Regression modeling showed children living in fishing households were associated with lower CDDS. Maternal education, maternal body mass index (BMI), and household livelihood diversity were positively associated with both CDDS and HAZ, while child morbidities and north coast (of Mombasa) residence showed negative associations. Our findings highlight nutritional vulnerabilities within a coastal food system of Kenya and the need to involve multiple sectors—education, environment, health, finance, communications, and governance and policy—in deriving solutions.

Enteric infections and management practices among communities in a rural setting of northwest Ethiopia

Infections with enteric pathogens have a high mortality and morbidity burden, as well as significant social and economic costs. Poor water, sanitation, and hygiene (WASH) conditions are the leading risk factors for enteric infections, and prevention in low-income countries is still primarily focused on initiatives to improve access to improved WASH facilities. Rural communities in developing countries, on the other hand, have limited access to improved WASH services, which may result in a high burden of enteric infections. Limited information also exists about the prevalence of enteric infections and management practices among rural communities. Accordingly, this study was conducted to assess enteric infections and management practices among communities in a rural setting of northwest Ethiopia. A community-based cross-sectional study was conducted among 1190 randomly selected households in a rural setting of northwest Ethiopia. Data were collected using structured and pretested interviewers-administered questionnaire and spot-check observations. We used self-reports and medication history audit to assess the occurrence of enteric infections among one or more of the family members in the rural households. Multivariable binary logistic regression model was used to identify factors associated with enteric infections. Statistically significant association was declared on the basis of adjusted odds ratio with 95% confidence interval and p value < 0.05. Out of a total of 1190 households, 17.4% (95% CI: 15.1, 19.7%) of the households reported that one or more of the family members acquired one or more enteric infections in 12 months period prior to the survey and 470 of 6089 (7.7%) surveyed individuals had one or more enteric infections. The common enteric infections reported at household-level were diarrhea (8.2%), amoebiasis (4.1%), and ascariasis (3.9%). Visiting healthcare facilities (71.7%), taking medications without prescriptions (21.1%), and herbal medicine (4.5%) are the common disease management practices among rural households in the studied region. The occurrence of one or more enteric infections among one or more of the family members in rural households in 12 months period prior to the survey was statistically associated with presence of livestock (AOR: 2.24, 95% CI:1.06, 4.75) and households headed by uneducated mothers (AOR: 1.62, 95% CI: (1.18, 2.23). About one-fifth of the rural households in the studied region reported that one or more of the family members had one or more enteric infections. Households in the study area might acquire enteric infections from different risk factors, mainly poor WASH conditions and insufficient separation of animals including their feces from human domestic environments. It is therefore important to implement community-level interventions such as utilization of improved latrine, protecting water sources from contamination, source-based water treatment, containment of domestic animals including their waste, community-driven sanitation, and community health champion.

The dynamics of household water security and treatment practices: a population-based, cross-sectional study in Osun State, Southwest Nigeria

A minimum of basic water supply service is pertinent to improving living standards and water-dependent quality of life indices. In Nigeria, 14% have access to safely managed drinking water services, though approximately 30% of water pumps and schemes are likely to fail within 12 months of construction. This study aims to determine household water security and its predictors in Osun State, Nigeria. The cross-sectional study recruited 548 households through a five-stage sampling technique and used a semi-structured questionnaire for data collection. Results were presented by descriptive and inferential statistics, while binary logistic regression identified water-security predictors at P_ά 0.05. Hand-dug wells (27.7%) and motorized boreholes (21.2%) were the predominant household drinking water sources. A total of 43.7% of households were water-secured while 35.2% of water sources were within residential settlements. A total of 25.1% of households experienced water scarcity, and 27.2% of households treat drinking water mainly by chlorination (56.7%) and boiling (14.7%). A total of 21.2%, 64.2%, and 9% of households, respectively, have safely managed basic and limited water supply services. Drinking water sources were associated with house ownership (p = 0.001) and residence period (p = 0.025) while water treatment was associated with gender (p = 0.010) and wealth (p = 0.0001). Age (p = 0.002) and wealth (p = 0.0001) are predictors of household water security. Two-fifths of households were water-secured, highlighting the dearth of potable water supply services and the need to incorporate strategic predictors of household water security in the existing national and state-level water resources regulations.

Environmental and behavioural exposure pathways associated with diarrhoea and enteric pathogen detection in 5-month-old, periurban Kenyan infants: a cross-sectional study

OBJECTIVES

The aim of this study was to test whether household environmental hygiene and behavioural conditions moderated associations between diarrhoea and enteric pathogen detection in infants 5 months of age in Kenya and pathogen sources, including latrine access, domestic animal co-habitation and public food sources.

DESIGN

Cross-sectional study utilising enrolment survey data of households participating in the Safe Start cluster-randomised controlled trial .

SETTING

Kisumu, Kenya.

PARTICIPANTS

A total of 898 caregivers with 5-month (22 week ± 1 week) aged infants were enrolled in the study and completed the enrolment survey.

PRIMARY AND SECONDARY OUTCOME MEASURES

Outcomes were (1) caregiver-reported 7-day diarrhoea prevalence and (2) count of types of enteric viruses, bacteria and parasites in infant stool. Exposures and effect modifiers included water access and treatment, cohabitation with domestic animals, sanitation access, handwashing practices, supplemental feeding, access to refrigeration and flooring.

RESULTS

Reported handwashing after handling animals (adjusted odds ratio (aOR)=0.20; 95% CI=0.06 to 0.50) and before eating (aOR=0.44; 95% CI=0.26 to 0.73) were strongly associated with lower risk of caregiver-reported diarrhoea, while cohabitation with animals (aOR=1.54; 95% CI=1.01 to 2.34) living in a household with vinyl-covered dirt floors (aOR=0.60; 95% CI=0.45 to 0.87) were strongly associated with pathogen codetection in infants. Caregiver handwashing after child (p=0.02) or self-defecation (p=0.03) moderated the relationship between shared sanitation access and infant exposure to pathogens, specifically private latrine access was protective against pathogen exposure of infants in households, where caregivers washed hands after defecation. In the absence of handwashing, access to private sanitation posed no benefits over shared latrines for protecting infants from exposure.

CONCLUSION

Our evidence highlights eliminating animal cohabitation and improving flooring, postdefecation and food-related handwashing, and safety and use of cow milk sources as interventions to prevent enteric pathogen exposure of young infants in Kenya.

TRIAL REGISTRATION NUMBER

NCT03468114.

Development of a diarrhoea severity scoring scale in a passive health facility-based surveillance system

Background

Diarrhoeal disease remains a leading cause of death among children mostly in low and middle-income countries. Factors contributing to disease severity are complex and there is currently no consensus on a scoring tool for use in community-based studies.

Methods

Data were collected during a passive surveillance system in an outpatient health facility in Lusaka, Zambia from March 2019 to July 2019. Diarrhea episodes were assessed for severity using an in-house severity scoring tool (CIDRZ) and previously published scores (Vesikari, Clark, CODA, and DHAKA). The CIDRZ score was constructed using fieldworker-reported clinical signs and exploratory factor analysis. We used precision-recall curves measuring severe diarrhoea (i.e., requiring intravenous rehydration or referred for hospital admission) to determine the best performing scores. Then, we used Cronbach’s alpha to assess the scale’s internal consistency. Finally, we used Cohen’s kappa to assess agreement between the scores.

Results

Of 110 diarrhea episodes, 3 (3%) required intravenous rehydration or were referred for hospital admission. The precision-recall area under the curve of each score as a predictor of severe diarrhoea requiring intravenous rehydration or hospital admission was 0.26 for Vesikari, 0.18 for CODA, 0.24 for Clark, 0.59 for DHAKA, and 0.59 for CIDRZ. The CIDRZ scale had substantial reliability and performed similarly to the DHAKA score.

Conclusions

Diarrhoea severity scores focused on characteristics specific to dehydration status may better predict severe diarrhea among children in Lusaka. Aetiology-specific scoring tools may not be appropriate for use in community healthcare settings. Validation studies for the CIDRZ score in diverse settings and with larger sample sizes are warranted.

A review of rural and peri-urban sanitation infrastructure in South-East Asia and the Western Pacific: Highlighting regional inequalities and limited data

Rural and peri-urban communities in developing countries rely on sanitation systems which are often unsafely managed. One of the major barriers to assess safely managed sanitation is a lack of data about the existing sanitation infrastructure and levels of containment safety. The aim was to review rural and peri-urban on-site sanitation studies in order to understand different infrastructure types, associated management practices and any impacts on human health. The scope was limited to South-East Asia and Western Pacific regions in order to better identify regional inequalities. Among the 155 reviewed articles, 73 studies (47%) linked sanitation infrastructure to poor human health. Nearly all articles reported latrine ownership (n = 149, 96%) while sanitation infrastructure types were covered less frequently (n = 104, 67%). In particular, there was a lack of published literature describing back-end characteristics (dimension and materials) (n = 12, 8%) and/or management practices (n = 4, 3%). This stems from a limited application of research methodologies that characterise sanitation infrastructure and faecal sludge management (containment, emptying and on-site treatment). Inequality between regions was prevalent with three quarters of the studies on latrine back-end infrastructure from Bangladesh and India in South-East Asia. A strategic research approach is needed to address the current knowledge gaps regarding sanitation infrastructure and safe faecal sludge management.

Improved Yet Unsafe: At the Light of NFHS-V

Following UNICEF’s analysis of National Family Health Survey-III Data (NFHS-III), it was opined that households with access to better sanitation and better access to improved water sources have much better infant survival rates than the others. Sahu et al. (2015, The Indian journal of medical research, 141(5), 709), Arun et al. (2017, International Conference on Cognitive Computing and Information Processing (pp. 81–92), Springer) and Tripathy and Mishra (2017, Journal of Tropical Pediatrics, 63(6), 431–439) supported these findings. However, Banerjee (2020a , Journal of Health Management, 22(1), 57–66), analysing NFHS-IV data, has vehemently criticised such findings and showed using regression with robust standard errors that improved access to better water sources leads to higher infant mortality. In another article published in the same year, Banerjee (2020b , Journal of Health Management, 22(3), 466–471) explained this paradox. Now with NFHS-V data coming out, time is apt to test the robustness of Banerjee’s findings (2002a). However, owing to the incomplete NFHS-V data published so far, unlike Banerjee (2002a) that has used data of 29 states, the present analysis is based on only 17 states. The findings support that the findings of Banerjee (2002a) were robust.

Implementing "from here to there": A case study of conceptual and practical challenges in implementation science

There is a significant challenge in global health and development research that pivots on the difficulties of delivering (cost-)effective treatments or interventions that are scalable andtransferable across settings. That is, how does one deliver "true effects", proven treatments, into new settings? This is often addressed in pragmatic trials or implementation research in which one makes adjustments to the delivery of the treatment to ensure that it works here and there. In this critical analytical review, we argue that the approach mis-characterises the cause-effect relationship and fails to recognise the local, highly contextual nature of what it means to say an intervention "works". We use an ongoing randomised controlled trial (RCT)-an informal settlement redevelopment intervention in Indonesia and Fiji to reduce human exposure to pathogenic faecal contamination-as a vehicle for exploring the ideas and implications of identifying interventions that work in global health and development. We describe the highly contextualised features of the research and the challenges these would pose in attempts to generalise the results. In other words, we detail that which is frequently elided from most RCTs. As our critical lens, we us the work of American philosopher, Nancy Cartwright, who argued that research produces dappled regions of causal insights-lacunae against a backdrop of causal ignorance. Rather than learn about a relationship between a treatment and an outcome, we learn that in the right sort of context, a treatment reliably produces a particular outcome. Moving a treatment from here to there becomes, therefore, something of an engineering exercise to ensure the right factors (or "shields") are in place so the cause-effect is manifest. As a consequence, one cannot assume that comparative effectiveness or cost-effectiveness would be maintained.

Risk factors for early childhood growth faltering in rural Cambodia: a cross-sectional study

OBJECTIVE

This study aimed to determine risk factors of growth faltering by assessing childhood nutrition and household water, sanitation, and hygiene (WASH) variables and their association with nutritional status of children under 24 months in rural Cambodia.

DESIGN

We conducted surveys in 491 villages (clusters) randomised across 55 rural communes in Cambodia in September 2016 to measure associations between child, household and community-level risk factors for stunting and length-for-age z-score (LAZ). We measured 4036 children under 24 months of age from 3877 households (491 clusters). We analysed associations between nutrition/WASH practices and child growth (LAZ, stunting) using generalised estimating equations (GEEs) to fit linear regression models with robust SEs in a pooled analysis and in age-stratified analyses; child-level and household-level variables were modelled separately from community-level variables.

RESULTS

After adjustment for potential confounding, we found household-level and community-level water, sanitation and hygiene factors to be associated with child growth among children under 24 months: presence of water and soap at a household's handwashing station was positively associated with child growth (adjusted mean difference in LAZ +0.10, 95% CI 0.03 to 0.16); household-level use of an improved drinking water source and adequate child stool disposal practices were protective against stunting (adjusted prevalence ratio (aPR) 0.80, 95% CI 0.67 to 0.97; aPR 0.82, 95% CI 0.64 to 1.03). In our age-stratified analysis, we found associations between child growth and community-level factors among children 1-6 months of age: shared sanitation was negatively associated with growth (-0.47 LAZ, 95% CI -0.90 to -0.05 compared with children in communities with no shared facilities); improved sanitation facilities were protective against stunting (aPR 0.43, 95% CI 0.21 to 0.88 compared with children in communities with no improved sanitation facilities); and open defecation was associated with more stunting (aPR 2.13, 95% CI 1.10 to 4.11 compared with children in communities with no open defecation). These sanitation risk factors were only measured in the youngest age strata (1-6 months). Presence of water and soap at the household level were associated with taller children in the 1-6 month and 6-12 month age strata (+0.10 LAZ, 95% CI -0.02 to 0.22 among children 1-6 months of age; +0.11 LAZ, 95% CI -0.02 to 0.25 among children 6-12 months of age compared with children in households with no water and soap). Household use of improved drinking water source was positively associated with growth among older children (+0.13 LAZ, 95% CI -0.01 to 0.28 among children 12-24 months of age).

CONCLUSION

In rural Cambodia, water, sanitation and hygiene behaviours were associated with growth faltering among children under 24 months of age. Community-level sanitation factors were positively associated with growth, particularly for infants under 6 months of age. We should continue to make effort to: investigate the relationships between water, sanitation, hygiene and human health and expand WASH access for young children.

Trends of and factors associated with access to residential toilets among the middle-aged and elderly in rural China from 2011 to 2018

BACKGROUND

At the global and country levels, several important sanitation improvement initiatives were launched in the last decade. This study aimed to explore the temporal trend of and factors associated with access to residential toilets among the middle-aged and elderly in rural China from 2011 to 2018.

METHODS

This study used the 2011, 2013, 2015, and 2018 data of China Health and Retirement Longitudinal Study (CHARLS). CHARLS was conducted among adults aged ≥ 45 years in 28 provinces of China. We used descriptive statistics and logistic regressions for data analysis.

RESULTS

We found that residential toilet coverage increased by about 6% among population aged ≥ 45 years in rural China from 2011 to 2018. The coverage of flushable toilets and toilets with seats among this sector of the population increased by more than 10% during this period. We also found that being female, higher levels of education, higher annual per capita household consumption, having running water in the residence, larger household size, and better health status were significantly associated with an increased likelihood of residential toilet ownership among population aged ≥ 45 years in rural China.

CONCLUSIONS

China made progress in sanitation improvement in rural areas from 2011 to 2018. However, considering the current coverage levels of residential toilets and the vulnerable subgroups who are more prone to toilet deprivation in rural areas, we suggest to the government to implement further targeted toilet improvement interventions to ensure universal coverage of sanitation facilities for the whole of the Chinese population.

An assessment of the health risks associated with shared sanitation: a case study of the community ablution blocks in Durban, South Africa

Shared sanitation facilities have been hailed as an innovative approach to solve the challenge with sanitation access. However, these facilities may act as hotspots for disease transmission due to unhygienic conditions. In this study we used quantitative (based on Escherichia coli contamination) techniques to assess the health risks associated with the use of community ablution blocks (CABs). The most contaminated surfaces were the cistern handle (5.7 Log₁₀ cfu/cm²) and internal pull latch (5.8 Log₁₀ cfu/cm²). Based on the E. coli contamination, at least two people out of 100 CAB users might be potentially infected when they touch "hot" surfaces. These risks were modelled assuming transfer of potentially pathogenic E. coli from these surfaces to the mouth. The incorporation of risk-reduction measures, such as wiping of these surfaces or washing of hands, could potentially result in significant reduction of infection risks. The most significant risk-reduction intervention was determined to be wiping of the contact surfaces, especially twice prior to contact. A combination of risk-reduction interventions could further reduce the risks. This study shows that contamination of contact surfaces within shared CABs could lead to increased risks of infections, requiring measures aimed at reducing the associated risks. The risk assessment framework used in this study could therefore be applied in similar settings to estimate associated health risks with the use of such facilities.

Viral infection among children under the age of 5 with diarrhea in Shenyang from 2018 to 2020: A hospital-based study

Diarrhea is one of the leading causes of death among children, especially in the age under 5, but few studies are available on viral diarrhea in Shenyang. To understand the infection status and the relevant epidemiological characteristics of viral diarrhea and to fill gaps of the distribution of viruses across Shenyang in children under the age of 5 with diarrhea, from 2018 to 2020, stool specimens of children with diarrhea aged 0-59 months and surveillance data were collected in Sentinel Hospital of Shenyang. Specimens were then tested to determine the type of viruses, the seasonal and spatial patterns for major viruses were determined. Viruses were identified in 47.9% of the 897 samples from children with diarrhea. The main viruses of stool samples were rotavirus (16.9%, predominant type G9P[8]), calicivirus (14.7%), adenovirus (11.8%), and astrovirus (4.5%). Viral infections were mainly detected in the age of 0-12 months. In the area of Shenyang, Huanggu had the most cases (198, 22.1%), followed by Dadong (137, 15.3%) and Hunnan (135, 15.1%). The positive rate of viruses varied among patients of different ages, seasons, and regions. Public health entities and the government should develop corresponding measures for different age groups, seasons, and regions.

Meteorological and social conditions contribute to infectious diarrhea in China

Infectious diarrhea in China showed a significant pattern. Many researchers have tried to reveal the drivers, yet usually only meteorological factors were taken into consideration. Furthermore, the diarrheal data they analyzed were incomplete and the algorithms they exploited were inefficient of adapting realistic relationships. Here, we investigate the impacts of meteorological and social factors on the number of infectious diarrhea cases in China. A machine learning algorithm called the Random Forest is utilized. Our results demonstrate that nearly half of infectious diarrhea occurred among children under 5 years old. Generally speaking, increasing temperature or relative humidity leads to increased cases of infectious diarrhea in China. Nevertheless, people from different age groups or different regions own different sensitivities to meteorological factors. The weight of feces that are harmfully treated could be a possible reason for infectious diarrhea of the elderly as well as children under 5 years old. These findings indicate that infectious diarrhea prevention for children under 5 years old remains a primary task in China. Personalized prevention countermeasures ought to be provided to different age groups and different regions. It is essential to bring the weight of feces that are harmfully treated to the forefront when considering infectious diarrhea prevention.

Interventions promoting uptake of water, sanitation and hygiene (WASH) technologies in low- and middle-income countries: An evidence and gap map of effectiveness studies

Background

Lack of access to and use of water, sanitation and hygiene (WASH) cause 1.6 million deaths every year, of which 1.2 million are due to gastrointestinal illnesses like diarrhoea and acute respiratory infections like pneumonia. Poor WASH access and use also diminish nutrition and educational attainment, and cause danger and stress for vulnerable populations, especially for women and girls. The hardest hit regions are sub-Saharan Africa and South Asia. Sustainable Development Goal (SDG) 6 calls for the end of open defecation, and universal access to safely managed water and sanitation facilities, and basic hand hygiene, by 2030. WASH access and use also underpin progress in other areas such as SDG1 poverty targets, SDG3 health and SDG4 education targets. Meeting the SDG equity agenda to "leave none behind" will require WASH providers prioritise the hardest to reach including those living remotely and people who are disadvantaged.

Objectives

Decision makers need access to high-quality evidence on what works in WASH promotion in different contexts, and for different groups of people, to reach the most disadvantaged populations and thereby achieve universal targets. The WASH evidence map is envisioned as a tool for commissioners and researchers to identify existing studies to fill synthesis gaps, as well as helping to prioritise new studies where there are gaps in knowledge. It also supports policymakers and practitioners to navigate the evidence base, including presenting critically appraised findings from existing systematic reviews.

Methods

This evidence map presents impact evaluations and systematic reviews from the WASH sector, organised according to the types of intervention mechanisms, WASH technologies promoted, and outcomes measured. It is based on a framework of intervention mechanisms (e.g., behaviour change triggering or microloans) and outcomes along the causal pathway, specifically behavioural outcomes (e.g., handwashing and food hygiene practices), ill-health outcomes (e.g., diarrhoeal morbidity and mortality), nutrition and socioeconomic outcomes (e.g., school absenteeism and household income). The map also provides filters to examine the evidence for a particular WASH technology (e.g., latrines), place of use (e.g., home, school or health facility), location (e.g., global region, country, rural and urban) and group (e.g., people living with disability). Systematic searches for published and unpublished literature and trial registries were conducted of studies in low- and middle-income countries (LMICs). Searches were conducted in March 2018, and searches for completed trials were done in May 2020. Coding of information for the map was done by two authors working independently. Impact evaluations were critically appraised according to methods of conduct and reporting. Systematic reviews were critically appraised using a new approach to assess theory-based, mixed-methods evidence synthesis.

Results

There has been an enormous growth in impact evaluations and systematic reviews of WASH interventions since the International Year of Sanitation, 2008. There are now at least 367 completed or ongoing rigorous impact evaluations in LMICs, nearly three-quarters of which have been conducted since 2008, plus 43 systematic reviews. Studies have been done in 83 LMICs, with a high concentration in Bangladesh, India, and Kenya. WASH sector programming has increasingly shifted in focus from what technology to supply (e.g., a handwashing station or child's potty), to the best way in which to do so to promote demand. Research also covers a broader set of intervention mechanisms. For example, there has been increased interest in behaviour change communication using psychosocial "triggering", such as social marketing and community-led total sanitation. These studies report primarily on behavioural outcomes. With the advent of large-scale funding, in particular by the Bill & Melinda Gates Foundation, there has been a substantial increase in the number of studies on sanitation technologies, particularly latrines. Sustaining behaviour is fundamental for sustaining health and other quality of life improvements. However, few studies have been done of intervention mechanisms for, or measuring outcomes on sustained adoption of latrines to stop open defaecation. There has also been some increase in the number of studies looking at outcomes and interventions that disproportionately affect women and girls, who quite literally carry most of the burden of poor water and sanitation access. However, most studies do not report sex disaggregated outcomes, let alone integrate gender analysis into their framework. Other vulnerable populations are even less addressed; no studies eligible for inclusion in the map were done of interventions targeting, or reporting on outcomes for, people living with disabilities. We were only able to find a single controlled evaluation of WASH interventions in a health care facility, in spite of the importance of WASH in health facilities in global policy debates. The quality of impact evaluations has improved, such as the use of controlled designs as standard, attention to addressing reporting biases, and adequate cluster sample size. However, there remain important concerns about quality of reporting. The quality and usefulness of systematic reviews for policy is also improving, which draw clearer distinctions between intervention mechanisms and synthesise the evidence on outcomes along the causal pathway. Adopting mixed-methods approaches also provides information for programmes on barriers and enablers affecting implementation.

Conclusion

Ensuring everyone has access to appropriate water, sanitation, and hygiene facilities is one of the most fundamental of challenges for poverty elimination. Researchers and funders need to consider carefully where there is the need for new primary evidence, and new syntheses of that evidence. This study suggests the following priority areas:Impact evaluations incorporating understudied outcomes, such as sustainability and slippage, of WASH provision in understudied places of use, such as health care facilities, and of interventions targeting, or presenting disaggregated data for, vulnerable populations, particularly over the life-course and for people living with a disability;Improved reporting in impact evaluations, including presentation of participant flow diagrams; andSynthesis studies and updates in areas with sufficient existing and planned impact evaluations, such as for diarrhoea mortality, ARIs, WASH in schools and decentralisation. These studies will preferably be conducted as mixed-methods systematic reviews that are able to answer questions about programme targeting, implementation, effectiveness and cost-effectiveness, and compare alternative intervention mechanisms to achieve and sustain outcomes in particular contexts, preferably using network meta-analysis.

Cost-effectiveness of a weaning food safety and hygiene programme in rural Gambia

OBJECTIVE

The main objective of the economic evaluation was to determine the cost-effectiveness of a weaning food safety and hygiene programme in reducing rates of diarrhoea compared with the control in rural Gambia.

METHODS

The public health intervention, using critical control points and motivational drivers, was evaluated in a cluster randomised controlled trial at 6- and 32-month follow-up. An economic evaluation was undertaken alongside the RCT with data collected prospectively from a societal perspective. Decision-analytic modelling was used to explore cost-effectiveness over a longer time period (4 years).

RESULTS

Direct out-of-pocket healthcare expenditure for households due to diarrhoea was large. The intervention significantly reduced reported childhood diarrhoeal episodes after 6 months (incident risk ratio = 0.40, 95% CI 0.33, 0.49) and 2 years after the intervention (incident risk ratio = 0.68, 95% CI 0.46, 1.02). The within-trial analysis found that the intervention led to total savings of 8064 dalasi 6 months after the intervention and 4224 dalasi 2 years after the intervention. Based on the model results, if the intervention is successful in maintaining the reduction in the risk of diarrhoea, the ICER is US$ 814 per DALY avoided over 4 years. This is cost-effective.

CONCLUSIONS

This study suggests that there are substantial household costs associated with diarrhoeal episodes in children. The within-trial analysis and model results suggest that the community-based approach to improving weaning food hygiene and safety is likely to be cost-effective compared with control.

Narrative Review of Primary Preventive Interventions against Water-Borne Diseases: Scientific Evidence of Health-EDRM in Contexts with Inadequate Safe Drinking Water

Waterborne diseases account for 1.5 million deaths a year globally, particularly affecting children in low-income households in subtropical areas. It is one of the most enduring and economically devastating biological hazards in our society today. The World Health Organization Health Emergency and Disaster Risk Management (health-EDRM) Framework highlights the importance of primary prevention against biological hazards across all levels of society. The framework encourages multi-sectoral coordination and lessons sharing for community risk resilience. A narrative review, conducted in March 2021, identified 88 English-language articles published between January 2000 and March 2021 examining water, sanitation, and hygiene primary prevention interventions against waterborne diseases in resource-poor settings. The literature identified eight main interventions implemented at personal, household and community levels. The strength of evidence, the enabling factors, barriers, co-benefits, and alternative measures were reviewed for each intervention. There is an array of evidence available across each intervention, with strong evidence supporting the effectiveness of water treatment and safe household water storage. Studies show that at personal and household levels, interventions are effective when applied together. Furthermore, water and waste management will have a compounding impact on vector-borne diseases. Mitigation against waterborne diseases require coordinated, multi-sectoral governance, such as building sanitation infrastructure and streamlined waste management. The review showed research gaps relating to evidence-based alternative interventions for resource-poor settings and showed discrepancies in definitions of various interventions amongst research institutions, creating challenges in the direct comparison of results across studies.

Factors associated with diarrheal disease among children aged 1-5 years in a cholera epidemic in rural Haiti

Diarrheal illness is a major cause of morbidity and mortality among children in Haiti, and the impact of diarrheal illness was compounded by a cholera outbreak between 2010 and 2019. Our understanding of risk factors for diarrhea among children during this outbreak is limited. We conducted a secondary analysis of data collected as part of a cholera vaccine effectiveness study to identify factors associated with medically attended diarrhea among children in central Haiti from October of 2012 through November of 2016. We identified 47 children aged one to five years old who presented to medical clinics with acute, watery diarrhea, and 166 matched controls who did not have diarrhea, and we performed conditional logistic regression to identify factors associated with diarrhea. Discontinuing exclusive breastfeeding within one month of birth was associated with increased risk of diarrhea (RR 6.9, 95% CI 1.46–32.64), and diarrhea was inversely associated with reported history of supplementation with vitamin A (RR 0.05, 95% CI 0.004–0.56) and zinc (reported among 0% of cases vs. 17% of controls). Because of the concordance in supplementation patterns, it was not possible to attribute the association to vitamin A or zinc independently. While having a respondent who correctly identified ≥3 means of avoiding cholera was associated with reduced risk of diarrhea (RR 0.43, 95% CI 0.19–1.01), reported household sanitation practices and knowledge of cholera were not consistently associated with risk of diarrhea. These findings support ongoing efforts to reduce barriers to breastfeeding and promote pediatric supplementation with vitamin A and zinc in Haiti. Given the reduced efficacy of current oral cholera vaccines (OCV) among children, the results reinforce the importance of breastfeeding and micronutrient supplementation in preventing all-cause pediatric diarrheal illness generally and during cholera outbreaks.

Diarrheal diseases are leading causes of illness and death among children throughout the world, and children in Haiti were particularly impacted by diarrhea during the cholera outbreak that started in 2010. Between 2012 and 2016, data were collected as part of a case-control study of oral cholera vaccine (OCV) effectiveness in Haiti. We analyzed data from that study to identify factors associated with diarrheal illness, including cholera and non-cholera diarrhea, among children ages one through five years old. We found a direct association between longer duration of exclusive breastfeeding and supplementation with vitamin A and zinc and a reduced risk of diarrhea. These findings shed light on potentially important components of efforts to reduce pediatric diarrheal illness in Haiti generally, and to reduce pediatric diarrhea in the context of cholera outbreaks in Haiti and elsewhere.

Fecal Contamination on the Household Compound and in Water Sources are Associated with Subsequent Diarrhea in Young Children in Urban Bangladesh (CHoBI7 Program)

We investigated the environmental and individual-level risk factors for diarrheal disease among young children in slum areas of Dhaka, Bangladesh. A prospective cohort study was conducted among 884 children under 5 years of age. Caregiver reports were collected on sociodemographic factors and hygiene behaviors. Diarrhea surveillance data was collected monthly based on caregiver-reported diarrhea for children in the past 2 weeks during the 12-month study period. Unannounced spot checks of the household compound were performed at 1, 3, 6, 9, and 12 months after enrollment to check for the presence of feces (animal or human) and the presence of animals in the child's sleeping space, to assess child and caregiver hands for the presence of dirt, and to collect samples of the household's source and stored drinking water. Children with feces found on the household compound during spot checks had a significantly higher odds of diarrhea (odds ratio: 1.71; 95% confidence interval: 1.23-2.38). Children residing in households with > 100 colony forming units/100 mL Escherichia coli in source drinking water had a significantly higher odds of diarrhea (OR: 1.43; 95% CI: 1.06-1.92). The presence of feces on the household compound and source drinking water with > 100 colony forming units/100 mL E. coli were significant risk factors for diarrheal disease for children < 5 years of age in slum areas of Dhaka, Bangladesh. These findings demonstrate the urgent need for comprehensive interventions to reduce fecal contamination on the household compound to protect the health of susceptible pediatric populations.

Diarrhoea among Children Aged under Five Years and Risk Factors in Informal Settlements: A Cross-Sectional Study in Cape Town, South Africa

Background: There is limited data on the association between diarrhoea among children aged under five years (U5D) and water use, sanitation, hygiene, and socio-economics factors in low-income communities. The study investigated U5D and the associated risk factors in the Zeekoe catchment in Cape Town, South Africa. Methods: A cross-sectional study was conducted in 707 households in six informal settlements (IS) two formal settlements (FS) (March–June 2017). Results: Most IS households used public taps (74.4%) and shared toilets (93.0%), while FS households used piped water on premises (89.6%) and private toilets (98.3%). IS respondents had higher average hand-washing scores than those of FS (0.04 vs. −0.14, p = 0.02). The overall U5D prevalence was 15.3% (range: 8.6%–24.2%) and was higher in FS than in IS (21.2% vs. 13.4%, respectively, p = 0.01). Water storage >12 h was associated with increasing U5D (OR = 1.88, 95% CI 1.00–3.55, p = 0.05). Water treatment (OR = 0.57, 95%CI 0.34–0.97, p = 0.04), good hand-washing practices (OR = 0.59, 95%CI 0.42–0.82, p = 0.002) and Hepatitis A vaccination (OR = 0.51, 95%CI 0.28–0.9, p = 0.02) had significant preventing effects on U5D. Conclusions: The study highlights that good hygiene practice is a key intervention against U5D in informal settlements. The promotion of hand-washing, proper water storage, and hygienic breastfeeding is highly recommended.

Effects of Hand-Washing Facilities with Water and Soap on Diarrhea Incidence among Children under Five Years in Lao People's Democratic Republic: A Cross-Sectional Study

Diarrhea is a leading cause of death among children under five (U5) in Lao People’s Democratic Republic (PDR). This study assessed the association between the presence of household hand-washing facilities with water and soap and diarrhea episodes among children U5 in Lao PDR. Data from the Lao Social Indicator Survey II were used. The outcome variable was diarrhea episodes in the two weeks preceding the survey. The main predictor variable was the presence of household hand-washing facilities with or without water and/or soap. Mixed-effect logistic regression analysis was used to assess the association, controlling for clustering, and other predictor variables. Of the 8640 households surveyed with 11,404 children, 49.1% possessed hand-washing facilities with both water and soap and 34.7% possessed hand-washing facilities with water alone. Children whose households possessed hand-washing facilities with water alone were significantly more likely to have a diarrhea episode compared to children whose households possessed hand-washing facilities with both water and soap (8.1% vs. 5.9%; odds ratio, 1.49; 95% confidence interval, 1.22–1.81). The association remained significant even after adjusting for other predictors. The absence of soap in hand-washing facilities was associated with higher odds of having a diarrhea episode among children U5 in Lao PDR.

Determinants of stunting among children under 2 years in urban informal settlements in Mumbai, India: evidence from a household census

BACKGROUND

There is limited evidence on the determinants of childhood stunting across urban India or specifically in slum settlements. This study aims to assess the extent of stunting among children under 2 years of age and examine its determinants in informal settlements of Mumbai.

METHODS

Data were collected in 2014-2015 in a post intervention census of a cluster randomized controlled trial to improve the health of women and children. Census covered 40 slum settlements of around 600 households each. A total of 3578 children were included in the study. Mixed effects logistic regression models were used to identify factors associated with stunting.

RESULTS

The prevalence of stunting among children aged 0-23 months was 38%. In the adjusted model, higher maternal education (AOR 0.59; 95% CI 0.42, 0.82), birth interval of at least 2 years (AOR 0.71; 95% CI 0.58, 0.87) and intended conception of the child (AOR 0.80; 95% CI 0.64, 0.99) were associated with lower odds of stunting. Maternal exposure to physical violence (AOR 1.83; 95% CI 1.21, 2.77) was associated with higher odds of being stunted. A child aged 18-23 months had 5.04 times greater odds (95% CI 3.91, 6.5) of being stunted than a child less than 6 months of age. Male child had higher odds of being stunted (AOR 1.33; 95% CI 1.14, 1.54).

CONCLUSIONS

Our findings support a multidimensional aetiology for stunting. The results of the study emphasize the importance of women's status and decision-making power in urban India, along with access to and uptake of family planning and services to provide support for survivors of domestic violence. Ultimately, a multilateral effort is needed to ensure the success of nutrition-specific interventions by focusing on the underlying health and social status of women living in urban slums.

TRIAL REGISTRATION

ISRCTN Register: ISRCTN56183183 , and Clinical Trials Registry of India: CTRI/2012/09/003004.

Where Shared Sanitation is the Only Immediate Option: A Research Agenda for Shared Sanitation in Densely Populated Low-Income Urban Settings

Shared sanitation is not currently accepted within the international normative definitions of "basic" or "safely managed" sanitation. We argue that pro-poor government strategies and investment plans must include high-quality shared sanitation as an intermediate step in some densely populated urban areas. User experience must be considered in establishing the definition of high quality. We call for additional research on effective interventions to reach these quality standards and for the development of rigorous measures applicable to global monitoring.

Moderate to Severe Diarrhea and Associated Factors Among Under-Five Children in Wonago District, South Ethiopia: A Cross-Sectional Study

Background

Diarrheal disease is the second leading cause of death in children under five years old and is responsible for killing around 525 000 children every year. Based on the world health organization estimates, diarrhea contributes to more than one in every ten (13%) child deaths in Ethiopia. Despite the emphasis given to improving child health, many children are still dying due to easily preventable and treatable diarrheal disease in Ethiopia.

Methods

A community cross-sectional study was conducted on randomly selected under-five children who live in Wonago district. Three hundred eighteen households were selected using a systematic sampling technique. Data were collected using a structured closed-ended questionnaire. Data were cleaned, coded, and entered into the statistical package for social sciences window version 20 statistical software analysis.

Results

The magnitude of moderate to severe diarrhea in the Wonago district was 30.9%. The number of family members (AOR: 2.7, 95% CI [1.277-5.716]), presence of animals in households (AOR: 2.591, 95% CI [1.188-5.650]), availability of latrine (AOR: 2.129, 95% CI [1.006-4.505]), and hand washing practice during a critical time (AOR: 2.683, 95% CI [1.139-6.319]) were strongly associated with moderate to severe diarrhea.

Conclusion

Childhood diarrhea remains an important health concern in the study area. This calls for a holistic and multimodal approach for the prevention, early identification, and intervention of diarrhea in children. More emphasis should also be given on personal, household, and environmental hygiene, as well as family planning.

In Vitro Antibacterial Activity of Crude Extracts of Artocarpus heterophyllus Seeds against Selected Diarrhoea-Causing Superbug Bacteria

The current upsurge in resistance to conventional antibiotics, as well as high cost of orthodox medical treatment, called for the use of medicinal plants as an alternative therapy. This research was aimed at determining the antibacterial activity of Artocarpus heterophyllus seed extracts (Jackfruit as it is locally called) in the treatment of diarrhoea. Ethanolic and hexanolic seed crude extracts of the plant were screened for antidiarrhoeal activity against bacteria isolated from clinical samples (methicillin-resistant and susceptible Staphylococcus aureus, multidrug-resistant Pseudomonas aeruginosa, ciprofloxacin-resistant Salmonella typhimurium, and third-generation cephalosporin-resistant Escherichia coli). Plant phytochemical screening was conducted using standard methods. The antibacterial activity was carried out using the agar well diffusion method and compared to the standard antibiotics ceftriaxone and vancomycin. The minimum inhibitory concentration was determined by the microbroth dilution method, whereas the minimum bactericidal concentration was determined by plating out from microtitre plates with no visible growth. The results of phytochemical screening revealed the presence of tannins, flavonoids, reducing sugars, cardiac glycosides, saponins, and steroids from the prepared crude extracts. The ethanolic and hexanolic extracts had activity on multidrug-resistant Pseudomonas aeruginosa, methicillin-resistant Staphylococcus aureus, and methicillin-susceptible Staphylococcus aureus with the mean and standard error zone of inhibition that ranged from 8.5 ± 0.5 to 16.5 ± 0.25 mm; however, the extracts were found not to have activity on resistant E. coli and Salmonella typhimurium. The ethanolic crude extract had the lowest MIC and MBC values of 31.25 and 125 mg/ml, respectively, compared to the hexane extract which had the MIC and MBC values of 62.50 and 250 mg/ml, respectively. This provides the evidence for its usage as an alternative herbal remedy for the treatment of diarrhoea caused by susceptible and methicillin-resistant Staphylococcus aureus and multidrug resistant Pseudomonas aeruginosa.

Demystifying the Aquatic Paradox: The Infant Mortality in India

It is evident that better access to improved water sources will lead to the lessening of infant mortality rate (IMR). However, for India, such inference is ambiguous. There is a strong group of academicians such as Sahu et al. (2015) , Arun et al. (2017) and Tripathy and Mishra (2017) and organizations such as UNICEF that firmly believe that if access to the improved water sources can be improved, then there would be tremendous social welfare and much betterment to the IMR.

On the other hand, Banerjee et al. (2020) have refuted such claims and opined that access to improved water sources increases the IMR. The empirical validation of their claim has been flawless, but they are somewhat silent on why such a direct relationship between IMR and improved water source exists. They have made a comment based on assumptions that it might be complacency that develops with access to improved water sources that refrain the people to consider any type of water treatment before passing it to infants for drinking. Such a comment might be valid, but neither is it built upon a sound literature review nor does it stand on strong empirics. At this juncture, the present article tests the claim of Banerjee et al. (2020) based on pure empirics.

Spatiotemporal and hotspot detection of U5-children diarrhea in resource-limited areas of Ethiopia

Under-five children (U5-children) diarrhea is a significant public health threat, where the World Health Organisation (WHO) reported it as the second leading cause of children's death worldwide. Nearly 1.7 billion cases occur annually with varied temporal and spatial factors. Identification of the spatiotemporal pattern and hotspot areas of U5-children diarrhea can assist targeted intervention and provide an early warning for more effective response measures. This study aimed at examining spatiotemporal variability along with the detection of hotspot areas for U5-children diarrhea in the Bench Maji Zone of southwestern Ethiopia, where resources are limited and cultural heterogeneity is highest. Retrospective longitudinal data of ten years of diarrhea records from January 2008 to December 2017 were used to identify hotspot areas. The incidence rate per 1,000 per year among children was calculated along with seasonal patterns of cases. The spatiotemporal analysis was made using SaTScan version 9.4, while spatial autocorrelations and hotspot identification were generated using ArcGIS 10.5 software. A total of 90,716 U5-children diarrhea cases were reported with an annual incidence rate of 36.1 per 1,000 U5-children, indicating a relative risk (RR) of 1.6 and a log-likelihood ratio (LLR) of 1,347.32 (p < 0.001). The highest incidence of diarrhea illness was recorded during the dry season and showed incidence rate increment from October to February. The risky clusters (RR > 1) were in the districts of Bero, Maji, Surma, Minit Shasha, Guraferda, Mizan Aman Town, and Sheko with annual cases of 127.93, 68.5, 65.12, 55.03, 55.67, 54.14 and 44.97 per 1,000, respectively. The lowest annual cases reported were in the four districts of Shay Bench, South Bench, North Bench, and Minit Goldiya, where RR was less than a unit. Six most likely clusters (Bero, Minit Shasha, Surma, Guraferda, South Bench, and Maji) and one lower RR area (North Bench) were hotspot districts. The U5-children's diarrhea in the study area showed an overall increasing trend during the dry seasons with non-random distribution over space and time. The data recorded during ten years and analyzed with the proper statistical tools helped to identify the hotspot areas with risky seasons where diarrhea could increase.

Improved yet Unsafe: An Aquatic Perspective of Indian Infant Mortality

Infant mortality rate (IMR) is an important development indicator and a vital component of millennium development goals (MDGs) set by United Nations Development Programme (UNDP). According to UNDP, so far India has only fared moderately in reducing IMR (Goal 4 of MDGs). India (32) ranks 144th among 196 countries regarding IMR as per the 2017 data availed from World Development Indicators. Its adjacent countries such as Bhutan (25.6), Bangladesh (26.9) and Nepal (27.8) have fared much better regarding infant survival. Numbers within the parentheses indicate the IMR of the respective country. The United Nations Children’s Fund (UNICEF) has identified that IMR among families with better access to improved drinking water sources and toilet is much lower than those bereft of the same. This inference has been drawn from National Family Health Survey 3 data (NFHS III). The present study investigates into the aforementioned relation analysing NFHS IV data. The result depicts that contrary to UNICEF’s findings, IMR increases with better accessibility to improved water sources. Further to this, the article shows that an additional aqua-related practice together with improved drinking water sources might lead to the betterment of IMR for India.

Human fecal contamination of water, soil, and surfaces in households sharing poor-quality sanitation facilities in Maputo, Mozambique

Identifying the origin of fecal contamination can support more effective interventions to interrupt enteric pathogen transmission. Microbial source tracking (MST) assays may help to identify environmental routes of pathogen transmission although these assays have performed poorly in highly contaminated domestic settings, highlighting the importance of both diagnostic validation and understanding the context-specific ecological, physical, and sociodemographic factors driving the spread of fecal contamination. We assessed fecal contamination of compounds (clusters of 2-10 households that share sanitation facilities) in low-income neighborhoods of urban Maputo, Mozambique, using a set of MST assays that were validated with animal stool and latrine sludge from study compounds. We sampled five environmental compartments involved in fecal microbe transmission and exposure: compound water source, household stored water and food preparation surfaces, and soil from the entrance to the compound latrine and the entrances to each household. Each sample was analyzed by culture for the general fecal indicator Escherichia coli (cEC) and by real-time PCR for the E. coli molecular marker EC23S857, human-associated markers HF183/BacR287 and Mnif, and GFD, an avian-associated marker. We collected 366 samples from 94 households in 58 compounds. At least one microbial target (indicator organism or marker gene) was detected in 96% of samples (353/366), with both E. coli targets present in the majority of samples (78%). Human targets were frequently detected in soils (59%) and occasionally in stored water (17%) but seldom in source water or on food surfaces. The avian target GFD was rarely detected in any sample type but was most common in soils (4%). To identify risk factors of fecal contamination, we estimated associations with sociodemographic, meteorological, and physical sample characteristics for each microbial target and sample type combination using Bayesian censored regression for target concentration responses and Bayesian logistic regression for target detection status. Associations with risk factors were generally weak and often differed in direction between different targets and sample types, though relationships were somewhat more consistent for physical sample characteristics. Wet soils were associated with elevated concentrations of cEC and EC23S857 and odds of detecting HF183. Water storage container characteristics that expose the contents to potential contact with hands and other objects were weakly associated with human target detection. Our results describe a setting impacted by pervasive domestic fecal contamination, including from human sources, that was largely disconnected from the observed variation in socioeconomic and sanitary conditions. This pattern suggests that in such highly contaminated settings, transformational changes to the community environment may be required before meaningful impacts on fecal contamination can be realized.

Hand cleaning with ash for reducing the spread of viral and bacterial infections: a rapid review

BACKGROUND

Handwashing is important to reduce the spread and transmission of infectious disease. Ash, the residue from stoves and fires, is a material used for cleaning hands in settings where soap is not widely available.

OBJECTIVES

To assess the benefits and harms of hand cleaning with ash compared with hand cleaning using soap or other materials for reducing the spread of viral and bacterial infections.

SEARCH METHODS

On 26 March 2020 we searched CENTRAL, MEDLINE, Embase, WHO Global Index Medicus, and the WHO International Clinical Trials Registry Platform.

SELECTION CRITERIA

We included all types of studies, in any population, that examined hand cleaning with ash compared to hand cleaning with any other material.

DATA COLLECTION AND ANALYSIS

Two review authors independently screened titles and full texts, and one review author extracted outcome data and assessed risk of bias, which another review author double-checked. We used the ROBINS-I tool for observational studies, we used RoB 2.0 for three interventional studies, and we used GRADE to assess the certainty of the evidence. We planned to synthesise data with random-effects meta-analyses. Our prespecified outcome measures were overall mortality, number of cases of infections (as defined in the individual studies), severity of infectious disease, harms (as reported in the individual studies), and adherence.

MAIN RESULTS

We included 14 studies described in 19 records using eight different study designs, but only one randomised trial. The studies were primarily conducted in rural settings in low- and lower-middle-income countries. Six studies reported outcome data relevant to our review. A retrospective case-control study and a cohort study assessed diarrhoea in children under the age of five years and self-reported reproductive tract symptoms in women, respectively. It was very uncertain whether the rate of hospital contacts for moderate-to-severe diarrhoea in children differed between households that cleaned hands using ash compared with households cleaning hands using soap (RR 0.97, 95% CI 0.84 to 1.11; very low-certainty evidence). Similarly, it was very uncertain whether the rate of women experiencing symptoms of reproductive tract infection differed between women cleaning hands with ash compared with cleaning hands using soap (RR 0.48, 95% CI 0.12 to 1.86; very low-certainty evidence) or when compared with handwashing with water only or not washing hands (RR 0.50, 95% CI 0.13 to 1.96; very low-certainty evidence). Four studies reported on bacteriological counts after hand wash. We rated all four studies at high risk of bias, and we did not synthesise data due to methodological heterogeneity and unclear outcome reporting.

AUTHORS' CONCLUSIONS

Based on the available evidence, the benefits and harms of hand cleaning with ash compared with soap or other materials for reducing the spread of viral or bacterial infections are uncertain.

Viral Pathogen-Specific Clinical and Demographic Characteristics of Children with Moderate-to-Severe Diarrhea in Rural Bangladesh

Diarrheal disease is a leading cause of childhood morbidity and mortality worldwide, but particularly in low-income countries in sub-Saharan Africa and South Asia. The Global Enteric Multicenter Study (GEMS) examined the infectious etiologies as well as associated demographics, socioeconomic markers, health-care-seeking behaviors, and handwashing practices of the households of children with diarrhea and their age- and gender-matched controls in seven countries over a 3-year period (December 2007-December 2010). Stool studies to determine diarrheal etiologies and anthropometry were performed at baseline and at 60-day follow-up visits, along with surveys to record demographics and living conditions of the children. We performed secondary analyses of the GEMS data derived from the Bangladesh portion of the study in children with diarrhea associated with viral enteropathogens and explored pathogen-specific features of disease burden. Rotavirus and norovirus were the most prevalent pathogens (39.3% and 35%, respectively). Disease due to rotavirus and adenovirus was more common in infants than in older children (P < 0.001 and P = 0.001, respectively). Height for age decreased from baseline to follow-up in children with diarrhea associated with rotavirus, norovirus, and adenovirus (P < 0.001). Based on these analyses, preventive measures targeted at rotavirus, norovirus, and adenovirus will be expected to have meaningful clinical impact. Cost of treatment was highest for rotavirus as well, making it an obvious target for intervention. Association of specific viruses with stunting is particularly notable, as stunting is an attributable risk factor for poor cognitive development and future productivity and economic potential.

Assessment of environmental exposure factors on child diarrhea and systemic inflammation in the Eastern Cape

Poor environmental technologies and gastrointestinal illnesses have been hypothesized to be a primary cause to the lack of impact of child health programs on child stunting rates (low height-for-age) in South Africa. This study assessed correlations between environmental exposures (water source, water treatment, sanitation, refuse), diarrheal occurrences, and systemic inflammation proxies among female and male children under five years of age in the Eastern Cape. A conceptual model was hypothesized using structural equation (SE) modeling and two sex-specific (female and male) datasets were subsequently generated from the data and applied to the hypothesized SE model. Results suggested that environmental exposure variables associated with diarrhea and systemic inflammation proxies were different between females and males. For diarrheal occurrences among females, an increase in local authority management of refuse (compared to household management) (0.161, p-value (p) = 0.007), sharing sanitation facilities (0.060, p = 0.023), and a decrease in the frequency of the treatment of drinking water (-0.043, p = 0.025) were correlated with an increase in diarrhea. For males, an increase in household use of flush toilets (as compared to ventilated pit latrines) was correlated with an increase in diarrhea (0.113, p = 0.027). For systemic inflammation among both sexes, an increase in household use of water pumped into the premises (as compared to a public water tap) and an increase in diarrheal occurrences were correlated with an increase in systemic inflammation. The data support an increased focus on sex and gender specific factors among field practitioners and policy makers working in the environmental health field in South Africa.

Does Basic Sanitation Prevent Diarrhea? Contextualizing Recent Intervention Trials through a Historical Lens

Three of four recent major sanitation intervention trials found no effect on diarrhea. These results conflicted with longstanding beliefs from decades of literature. To understand this discordance, we placed recent trials into the historical context that preceded them in two ways. First, we evaluated the history of published literature reviews on sanitation and diarrhea. Second, we conducted meta-analyses on studies from the most recent systematic review to uncover features that predict effectiveness. We found that 13 literature reviews dating to 1983 consistently estimated a significant protective effect of sanitation against diarrhea. However, these were marred by flawed studies and inappropriately averaged effects across widely heterogeneous interventions and contexts. Our meta-analyses highlight that the overall effect of sanitation on diarrhea was largely driven by sewerage and interventions that improved more than sanitation alone. There is no true overall effect of sanitation because variability between intervention types and implementation contexts is too complex to average. Ultimately, the null effects of recent latrine interventions are not surprising. Instead, the one trial that found a strong relative reduction in diarrhea is the historical outlier. The development of transformative sanitation interventions requires a better understanding of the social and environmental contexts that determine intervention effectiveness.

Water, sanitation, and hygiene risk factors of acute diarrhea among children under five years in the Gaza Strip

This cross-sectional community household-based study aims to evaluate the water, sanitation, and hygiene facilities in the Gaza Strip and to investigate their associations with the occurrence of acute diarrhea among children under five years. A survey using a structured questionnaire was conducted on 1,857 households with an child under five years from August 2017 to June 2018. About 69.7% of heads of households reported a diarrheal episode among their children during the two months preceding the survey. Multivariable logistic regression showed that sewage water observed around the households was associated with an increased risk of acute diarrhea (AOR = 2.45; P &lt; 0.001; 95% CI: 1.83–3.27). Nevertheless, the allocation of a special water tank for desalinated drinking water at home (AOR = 0.3; P = 0.02; 95% CI: 0.1–0.8), the connection of households to a closed sewerage system (AOR = 0.56; P &lt; 0.001; 95% CI: 0.43–0.73), and handwashing practices before and after eating (AOR = 0.42; P = 0.003; 95% CI: 0.24–0.74 and AOR = 0.50; P = 0.03; 95% CI: 0.26–0.94, respectively), as well as using desalinated water sources for drinking purposes, were inversely associated with the incidence of acute diarrhea among children under five. Further improvements in the existing sewerage system and the intensification of sanitation and hygiene promotion programs at the household levels may reduce the risk of acute diarrhea among children under five years in the Gaza Strip.

A localized sanitation status index as a proxy for fecal contamination in urban Maputo, Mozambique

Sanitary surveys are used in low- and middle-income countries to assess water, sanitation, and hygiene conditions, but have rarely been compared with direct measures of environmental fecal contamination. We conducted a cross-sectional assessment of sanitary conditions and E. coli counts in soils and on surfaces of compounds (household clusters) in low-income neighborhoods of Maputo, Mozambique. We adapted the World Bank's Urban Sanitation Status Index to implement a sanitary survey tool specifically for compounds: a Localized Sanitation Status Index (LSSI) ranging from zero (poor sanitary conditions) to one (better sanitary conditions) calculated from 20 variables that characterized local sanitary conditions. We measured the variation in the LSSI with E. coli counts in soil (nine locations/compound) and surface swabs (seven locations/compound) in 80 compounds to assess reliability. Multivariable regression indicated that a ten-percentage point increase in LSSI was associated with 0.05 (95% CI: 0.00, 0.11) log10 fewer E. coli/dry gram in courtyard soil. Overall, the LSSI may be associated with fecal contamination in compound soil; however, the differences detected may not be meaningful in terms of public health hazards.

Interventions to improve disposal of child faeces for preventing diarrhoea and soil-transmitted helminth infection

BACKGROUND

Diarrhoea and soil-transmitted helminth (STH) infections represent a large disease burden worldwide, particularly in low-income countries. As the aetiological agents associated with diarrhoea and STHs are transmitted through faeces, the safe containment and management of human excreta has the potential to reduce exposure and disease. Child faeces may be an important source of exposure even among households with improved sanitation.

OBJECTIVES

To assess the effectiveness of interventions to improve the disposal of child faeces for preventing diarrhoea and STH infections.

SEARCH METHODS

We searched the Cochrane Infectious Diseases Group Specialized Register, CENTRAL, MEDLINE, Embase, and 10 other databases. We also searched relevant conference proceedings, contacted researchers, searched websites for organizations, and checked references from identified studies. The date of last search was 27 September 2018.

SELECTION CRITERIA

We included randomized controlled trials (RCTs) and non-randomized controlled studies (NRS) that compared interventions aiming to improve the disposal of faeces of children aged below five years in order to decrease direct or indirect human contact with such faeces with no intervention or a different intervention in children and adults.

DATA COLLECTION AND ANALYSIS

Two review authors selected eligible studies, extracted data, and assessed the risk of bias. We used meta-analyses to estimate pooled measures of effect where appropriate, or described the study results narratively. We assessed the certainty of the evidence using the GRADE approach.

MAIN RESULTS

Sixty-three studies covering more than 222,800 participants met the inclusion criteria. Twenty-two studies were cluster RCTs, four were controlled before-and-after studies (CBA), and 37 were NRS (27 case-control studies (one that included seven study sites), three controlled cohort studies, and seven controlled cross-sectional studies). Most study sites (56/69) were in low- or lower middle-income settings. Among studies using experimental study designs, most interventions included child faeces disposal messages along with other health education messages or other water, sanitation, and hygiene (WASH) hardware and software components. Among observational studies, the main risk factors relevant to this review were safe disposal of faeces in the latrine or defecation of children under five years of age in a latrine.Education and hygiene promotion interventions, including child faeces disposal messages (no hardware provision)Four RCTs found that diarrhoea incidence was lower, reducing the risk by an estimated 30% in children under six years old (rate ratio 0.71, 95% confidence interval (CI) 0.59 to 0.86; 2 trials, low-certainty evidence). Diarrhoea prevalence measured in two other RCTs in children under five years of age was lower, but evidence was low-certainty (risk ratio (RR) 0.93, 95% CI 0.84 to 1.04; low-certainty evidence).Two controlled cohort studies that evaluated such an intervention in Bangladesh did not detect a difference on diarrhoea prevalence (RR 0.91, 95% CI 0.64 to 1.28; very low-certainty evidence). Two controlled cross-sectional studies that evaluated the Health Extension Package in Ethiopia were associated with a lower two-week diarrhoea prevalence in 'model' households than in 'non-model households' (odds ratio (OR) 0.26, 95% CI 0.16 to 0.42; very low-certainty evidence).Programmes to end open defecation by all (termed community-led total sanitation (CLTS) interventions plus adaptations)Four RCTs measured diarrhoea prevalence and did not detect an effect in children under five years of age (RR 0.92, 95% CI 0.79 to 1.07; moderate-certainty evidence). The analysis of two trials did not demonstrate an effect of the interventions on STH infection prevalence in children (pooled RR 1.03, 95% CI 0.64 to 1.65; low-certainty evidence).One controlled cross-sectional study compared the prevalence of STH infection in open defecation-free (ODF) villages that had received a CLTS intervention with control villages and reported a higher level of STH infection in the intervention villages (RR 2.51, 95% CI 1.74 to 3.62; very low-certainty evidence).Sanitation hardware and behaviour change interventions, that included child faeces disposal hardware and messagingTwo RCTs had mixed results, with no overall effect on diarrhoea prevalence demonstrated in the pooled analysis (RR 0.79, 95% CI 0.49 to 1.26; very low-certainty evidence).WASH hardware and education/behaviour change interventionsOne RCT did not demonstrate an effect on diarrhoea prevalence (RR 1.15, 95% CI 0.93 to 1.41; very low-certainty evidence).Two CBAs reported that the intervention reduced diarrhoea incidence by about a quarter in children under five years of age, but evidence was very low-certainty (rate ratio 0.77, 95% CI 0.71 to 0.84). Another CBA reported that the intervention reduced the prevalence of STH in an intervention village compared to a control village, again with GRADE assessed at very low-certainty (OR 0.17, 95% CI 0.02 to 0.73).Case-control studiesPooled results from case-control studies that presented data for child faeces disposal indicated that disposal of faeces in the latrine was associated with lower odds of diarrhoea among all ages (OR 0.73, 95% CI: 0.62 to 0.85; 23 comparisons; very low-certainty evidence). Pooled results from case-control studies that presented data for children defecating in the latrine indicated that children using the latrine was associated with lower odds of diarrhoea in all ages (OR 0.54, 95% CI 0.33 to 0.90; 7 studies; very low-certainty evidence).

AUTHORS' CONCLUSIONS

Evidence suggests that the safe disposal of child faeces may be effective in preventing diarrhoea. However, the evidence is limited and of low certainty. The limited research on STH infections provides only low and very-low certainty evidence around effects, which means there is currently no reliable evidence that interventions to improve safe disposal of child faeces are effective in preventing such STH infections.While child faeces may represent a source of exposure to young children, interventions generally only address it as part of a broader sanitation initiative. There is a need for RCTs and other rigorous studies to assess the effectiveness and sustainability of different hardware and software interventions to improve the safe disposal of faeces of children of different age groups.

Risk factors for acute childhood diarrhea: A cross-sectional study comparing refugee camps and host communities in Gambella Region, Ethiopia

BACKGROUND

Diarrhea is one of the most common causes of child morbidity and mortality in refugee camps, aggravated by inadequate water, sanitation and hygiene services, and malnutrition, particularly in developing countries.

METHODOLOGY

A comparative cross-sectional study was conducted to assess acute diarrhea and associated risk factors among under-five children in refugee and host communities in Gambella Region, Ethiopia. Descriptive statistics were used, and bivariate and multivariate logistic regressions were performed to identify variables associated with diarrhea.

RESULTS

A total of 1667 under-five children was included in this study, and prevalence of diarrhea differed between the refugee (38%) and host (33%) communities [OR = 1.37, 95% CI 1.04, 1.8]. Refugee camp households using uncovered water containers, consuming low quantities of water, and lacking hand washing setups were more likely to report children with diarrhea. Within host communities, households were more likely to report acute childhood diarrhea if they consumed surface water or did not have a latrine.

CONCLUSION

The two-week prevalence of diarrhea was significantly higher among children in the refugee camps than those in the host communities. Therefore, further collaboration between government and non-government organizations is required to identify persisting factors of diarrhea transmission in various communities in the region.

Etiology and severity of diarrheal diseases in infants at the semiarid region of Brazil: A case-control study

Background

Diarrheal diseases are an important cause of morbidity and mortality among children in developing countries. We aimed to study the etiology and severity of diarrhea in children living in the low-income semiarid region of Brazil.

Methodology

This is a cross-sectional, age-matched case-control study of diarrhea in children aged 2–36 months from six cities in Brazil’s semiarid region. Clinical, epidemiological, and anthropometric data were matched with fecal samples collected for the identification of enteropathogens.

Results

We enrolled 1,200 children, 596 cases and 604 controls. By univariate analysis, eight enteropathogens were associated with diarrhea: Norovirus GII (OR 5.08, 95% CI 2.10, 12.30), Adenovirus (OR 3.79, 95% CI 1.41, 10.23), typical enteropathogenic Escherichia coli (tEPEC), (OR 3.28, 95% CI 1.39, 7.73), enterotoxigenic E. coli (ETEC LT and ST producing toxins), (OR 2.58, 95% CI 0.99, 6.69), rotavirus (OR 1.91, 95% CI 1.20, 3.02), shiga toxin-producing E. coli (STEC; OR 1.77, 95% CI 1.16, 2.69), enteroaggregative E. coli (EAEC), (OR 1.45, 95% CI 1.16, 1.83) and Giardia spp. (OR 1.39, 95% CI 1.05, 1.84). By logistic regression of all enteropathogens, the best predictors of diarrhea were norovirus, adenovirus, rotavirus, STEC, Giardia spp. and EAEC. A high diarrhea severity score was associated with EAEC.

Conclusions

Six enteropathogens: Norovirus, Adenovirus, Rotavirus, STEC, Giardia spp., and EAEC were associated with diarrhea in children from Brazil’s semiarid region. EAEC was associated with increased diarrhea severity.

Most childhood diarrheal diseases studies focus on children from health centers or emergency hospitals that contribute to a lack of understanding of the etiology of community diarrhea. We aimed to investigate the etiology and severity of diarrheal diseases in children living in Brazil’s low-income, semiarid region communities. We used a case-control study of diarrhea (1,200 children, 596 cases and 604 controls) and showed that six enteropathogens (norovirus, adenovirus, rotavirus, STEC, Giardia and EAEC) are associated with diarrhea in these communities. Furthermore, enteroaggregative E. coli (EAEC) was associated with a high diarrhea clinical severity score. These findings help further the understanding of diarrheal disease etiology of previously unevaluated children from Brazil’s low-income semiarid region. This study contributes new information that expands our knowledge of diarrheal etiology in non-hospitalized children from developing countries. Moreover, we believe this work will support further research on specific enteropathogens, with special attention to the role of EAEC in severe cases of diarrhea and guide public health policies and physicians in the management of diarrheal diseases in Brazil’s low-income semiarid region.

The Most Important Recommended Times of Hand Washing with Soap and Water in Preventing the Occurrence of Acute Diarrhea Among Children Under Five Years of Age in Slums of Addis Ababa, Ethiopia

Adequate hand washing with soap at five recommended times is particularly important in urban slums in developing countries, but which of the recommended times are the most important in the prevention of diarrhea among children under five years of age living in these areas remains unclear. To address this gap, a community-based cross-sectional study was undertaken in the slums of Addis Ababa, Ethiopia between September and November 2014. Data were collected using a pre-tested structured questionnaire and an observational checklist. Multivariable logistic regression with 95% confidence interval (CI) was used for data analysis. Only 4.4% of the households had hand washing facilities within or near a latrine with soap and water access. The average prevalence of hand washing with soap at the five recommended times was 19.8%. One quarter (24.8%) of caregivers washed their hands with soap before feeding a child, 23.8% before preparing food, and 17.1% after defecation. The most important recommended times in preventing acute diarrhea were before preparing food [adjusted odds ratio (AOR) 0.2; 95% CI 0.1-0.7] and after defecation (AOR 0.3; 95% CI 0.1-0.9). Household size of six or more persons (AOR 2.3; 95% CI 1.4-3.9) and low monthly household income (AOR 2.4; 95% CI 1.4-4.0) were significantly associated with acute diarrhea. Promoting hand washing with soap and advocacy programs at the five recommended times, especially before preparing food and after defecation, and implementation of socioeconomic development programs targeting poor households are essential for increasing the prevalence of hand washing with soap and preventing acute diarrhea in the slums of Addis Ababa.

The Sustainable Development Goal for Urban Sanitation: Africa's Statistical Tragedy Continues?

Sanitation delivery in the urban areas of sub-Saharan African countries has been a chronic issue, particularly difficult to tackle. Under the Millennium Development Goals, the sanitation target in urban sub-Saharan Africa was missed by a wide margin and witnessed almost no improvement. After 2 years of review, the WHO/UNICEF Joint Monitoring Programme published a new measure of access to sanitation as a baseline for the Sustainable Development Goals. There are a number of improvements in the new measure. However, despite the improvements, the new measure continues to be characterized by an important flaw: it continues to disregard how shared toilet facilities contribute towards the SDG sanitation target. As a result, the new measure does not indicate whether progress is being made in low-income urban areas where a large number of households rely on shared sanitation; nor does it provide a goal that can be achieved in cities of the poorest countries over the measurement period. But, its most egregious failing is that it directs resources towards investments which will often fail cost/benefit tests. In sum, it is not a surprise that a Working Group recommended that the measure should be changed to include some shared facilities. Following the Working Group's recommendation would have avoided the adverse consequences of continued reliance on a key component of the methodology used for monitoring sanitation improvements under the Millennium Development Goals. The paper discusses the limitations of this methodology in the context of urban sub-Saharan Africa, where current sanitation conditions are seriously lacking, and the significant future urban population growth will add more pressure for the delivery of vital sanitation services.

Arbi Care application increases preschool children's hand-washing self-efficacy among preschool children

OBJECTIVE

This research aimed to examine the effectiveness of an Android mobile game application called Arbi Care as a means to prevent diarrhea and build self-efficacy in hand washing among preschool children.

METHOD

This research used a pre- and post-test control group and time series design approach. Respondents were chosen randomly from a group of four to six years children. The intervention group (n = 60) received Arbi Care intervention for 25 minutes, twice a week, for five weeks while the control group (n = 60) received standard education. Self-efficacy was measured by using questionnaire and observation. Measurement was carried out three times in the sixth, eight, and tenth week post-intervention. The data was analyzed using the GLMRM test.

RESULTS

There was a significant increase in the average score of self-efficacy in hand washing for the intervention group versus the control group. Moreover, there were significant differences in the results of average scores in which the intervention group showed much better self-efficacy improvement over the control group during the first, second, and final post-test after the intervention was given (p < 0.001).

CONCLUSIONS

An Android-based educational game can be an effective medium to improve hand washing self-efficacy among preschool children, thus helping to prevent diarrhea.

Locals get travellers' diarrhoea too: risk factors for diarrhoeal illness and pathogenic Escherichia coli infection across an urban-rural gradient in Ecuador

OBJECTIVES

Diarrhoea is a common and well-studied cause of illness afflicting international travellers. However, traveller's diarrhoea can also result from travel between high and low disease transmission regions within a country, which is the focus of this study.

METHODS

We recruited participants for a case-control study of diarrhoea at four sites along an urban-rural gradient in Northern Ecuador: Quito, Esmeraldas, Borbón and rural communities outside of Borbón. At each of these sites, approximately 100 subjects with diarrhoea (cases) were recruited from Ministry of Health clinics and were age-matched with subjects visiting the same clinics for other complaints (controls).

RESULTS

Travellers to urban destinations had higher risk of diarrhoea and diarrhoeagenic Escherichia coli (DEC) infections. Travel to Quito was associated with diarrhoea (aOR = 2.01, 95% CI = 1.10-3.68) and travel to Guayaquil (another urban centre in Ecuador) was associated with Diffuse Adherent E. coli infection (OR = 2.09, 95% CI = 1.01-4.33). Compared to those not travelling, urban origins were also associated with greater risk of diarrhoea in Esmeraldas (aOR = 2.28, 95% CI = 1.20-4.41), and with higher risk of diarrhoeagenic E. coli infections in Quito (aOR = 2.61, 95% CI = 1.16-5.86), with >50% of travel from Quito and Esmeraldas specified to another urban destination.

CONCLUSIONS

This study suggests that individuals travelling from lower-transmission regions (rural areas) to higher transmission regions (urban centres) within a single country are at a greater risk of acquiring a diarrhoea-related illness. Investments to improve water, sanitation and hygiene conditions in urban areas could have impacts on outlying rural areas within a given country.

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.