Sharing a sanitation facility between households can be linked to increased risk of moderate-to-severe diarrhea (MSD) in children under 5 y at some sites, according to Global Enteric Multicenter Study (GEMS) study findings published this week in PLOS Medicine. The study, conducted by Kelly K. Baker of University of Iowa College of Public Health, Iowa City, United States, and colleagues, suggests that access to private sanitation facilities should remain a global health priority.
Diarrhea kills about three-quarters of a million young children every year. Interventions to improve sanitation and hygiene may benefit the roughly 2.5 billion people who do not use improved sanitation, including the 1 billion who defecate in the open. GEMS is a case-control study of pediatric diarrhea in children under 5 y of age at seven sites in Africa and South Asia. This study compared 8,592 children under 5 y with clinically and laboratory confirmed MSD matched to 12,390 asymptomatic children to uncover associations between household sanitation and incidence of diarrhea.
Compared to having a private household sanitation facility, sharing a facility with one or two households was found to be associated with an increased risk of diarrhea in young children at the study sites in Nyanza Province, Kenya (adjusted matched odds ratio 1.41 [95% confidence interval 1.11-1.79]), Bamako, Mali (1.23 [1.02-1.48]), and Karachi, Pakistan 1.58 [1.19-2.09]). Sharing a facility with three or more households was associated with further increased MSD risk. Sharing a sanitation facility was not found to be associated with increased MSD risk at the sites in Basse, The Gambia (1.69 [0.96-2.97]), Mirzapur, Bangladesh (0.83 [0.70-0.99]), or Kolkata, India (1.04 [0.78-1.39]).
As the study is observational, confounding by related characteristics such as hand washing may limit interpretation of results. In a linked Perspective, Jonny Crocker and Jamie Bartram of University of North Carolina at Chapel Hill, United States, discuss study limitations but argue that "Baker and colleagues present the best dataset yet on diarrheal disease associated with sanitation and hygiene. They provide compelling evidence on sanitation and hygiene risk factors for MSD and variability in that risk."
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Research Article
Funding:
This work was supported by Grant #38874 from the Bill and Melinda Gates Foundation to MML, Principal Investigator. Salary support for CEO was provided by the US Agency for International Development through an Inter-Agency Agreement with the US Centers for Disease Control and Prevention. THF, a current employee of the Bill & Melinda Gates Foundation, contributed as an author to the design and collection of data supporting the preparation of this manuscript while employed by the Center for Vaccine Development, University of Maryland Baltimore.
Competing Interests:
The authors have declared that no competing interests exist.
Citation:
Baker KK, O'Reilly CE, Levine MM, Kotloff KL, Nataro JP, Ayers TL, et al. (2016) 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. PLoS Med 13(5): e1002010. doi:10.1371/journal.pmed.1002010
Author Affiliations:
Center for Vaccine Development, Departments of Medicine, University of Maryland School of Medicine, Baltimore, Maryland, United States of America
Department of Occupational and Environmental Health, The University of Iowa, Iowa City, Iowa, United States of America Division of Foodborne, Waterborne, and Environmental Diseases, US Centers for Disease Control and Prevention, Atlanta, Georgia, United States of AmericaDepartment of Pediatrics, University of Virginia School of Medicine, Charlottesville, Virginia, United States of America Gates Foundation, Seattle, Washington, United States of America Emergent BioSolutions, Gaithersburg, Maryland, United States of America Centre de Recerca en Salut Internacional de Barcelona, Hospital Clinic (CRESIB), Universitat de Barcelona, Barcelona, Spain, and Centro de Investigação em Saúde de Manhiça, Maputo, Mozambique World Health Organization, Geneva, SwitzerlandUS Centers for Disease Control and Prevention, Nairobi, Kenya Emory Global Health Institute, Emory University, Atlanta, Georgia, United States of America Kenya Medical Research Institute/Centers for Disease Control and Prevention (KEMRI/CDC), Kisumu, KenyaInternational Centre for Diarrhoeal Disease Research, Mohakhali, Dhaka, Bangladesh The University of Queensland, Brisbane, Australia Medical Research Council (United Kingdom), Fajara, The Gambia Centre pour le Développement des Vaccins, Bamako, Mali National Institute of Cholera and Enteric Diseases, Kolkata, India India Public Health Association and PATH India Office, New Delhi, India Department of Paediatrics and Child Health, the Aga Khan University, Karachi, Pakistan; Gates Foundation, Seattle, Washington, United States of America
IN YOUR COVERAGE PLEASE USE THIS URL TO PROVIDE ACCESS TO THE FREELY AVAILABLE PAPER: http://journals.plos.org/plosmedicine/article?id=10.1371/journal.pmed.1002010
Contact:
Kelly K Baker
University of Iowa College of Public Health
Occupational and Environmental Health
145 N. Riverside Drive
100 CPHB
Iowa City, IA 52242
UNITED STATES
001-319-384-4008
kelly-k-baker@uiowa.edu
Perspective Article
Funding:
The authors were not funded to prepare this Perspective.
Competing Interests:
The authors have declared that no competing interests exist.
Citation:
Crocker J, Bartram J (2016) Interpreting the Global Enteric Multicenter Study (GEMS) Findings on Sanitation, Hygiene, and Diarrhea. PLoS Med 13(5): e1002011. doi:10.1371/journal.pmed.1002011
Author Affiliations:
The Water Institute, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, United States of America Department of Environmental Sciences and Engineering, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, United States of America
IN YOUR COVERAGE PLEASE USE THIS URL TO PROVIDE ACCESS TO THE FREELY AVAILABLE PAPER: http://www.plosmedicine.org/article/info%3Adoi%2F10.1371%2Fjournal.pmed.1002011
Journal
PLoS Medicine