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Sustainable Development Goal 6.2 aims to end open defecation by 2030 by ensuring universal access to private household toilets. However, private toilets might not be feasible for poor households. As a result, policy makers and academics have suggested well-managed shared sanitation facilities as an alternative solution. Less is known about the associations between shared sanitation use and health. Using data from the fifth round of the National Family Health Survey from 2019 to 2021, we estimated the association between usual defecation location and child anthropometry outcomes among children under 2 years in India. The primary exposure was usual defecation location at the household level. We compared both shared improved toilet use and open defecation to private, improved toilet use. We used linear regression to estimate the associations between the exposures and linear outcomes: height-for-age Z-score, weight-for-height Z-score, and weight-for-age Z-score. We used Poisson regression with a log link to estimate the prevalence ratios of stunting, wasting, and underweight. After controlling for environmental, maternal, socioeconomic, and child confounders, we found no differences in six child anthropometry outcomes when comparing shared toilet use or open defecation to private toilet use. This finding was consistent across both urban and rural households. Our findings confirm the null associations between private toilet use and child growth found in previous studies, and that this association does not vary if the toilet is being shared. Future research should examine these differences between private and shared toilets in the context of other health outcomes.

Infant undernutrition is thought to contribute to growth failure and mortality. We evaluated the patterns in underweight in a population-based sample of children aged 1-11 months in rural northwestern Burkina Faso. Data were collected during the baseline assessment of a community-randomized trial evaluating mass azithromycin distribution in Nouna District, Burkina Faso. A door-to-door census was undertaken for all households in all communities. Infants aged 1-11 months were weighed for weight-based dosing in the trial and their weights were used to calculate weight-for-age Z-scores (WAZ). Underweight was defined as WAZ ≤ 2. We evaluated the age patterns in WAZ and underweight by demographic, seasonal, and geographic characteristics. Of 7,109 infants, 6,077 had accurate weight and global positioning system (GPS) coordinate data (85.5%). Infants were a median of 6 months old (interquartile range [IQR] 3-8) and 48.4% were female. Mean WAZ was -0.68 (SD 1.6) and 19.0% were underweight. The WAZ decreased with increasing age, and the prevalence of underweight increased from 2.5% among 1-month-olds to 27.6% among 11-month-olds. Underweight was more common among boys than girls (22.1% among boys versus 15.6% among girls). Improved latrine use by the household was associated with increased WAZ, and this effect was stronger in male compared with female infants. Given the large burden of underweight among infants, interventions addressing undernutrition should specifically include infants.

Access to improved sanitation and hygiene may improve child nutritional status by reducing exposure to enteric pathogens. We evaluated this relationship as part of the Community Health with Azithromycin Trial, a community-randomized trial of azithromycin versus placebo for the prevention of child mortality in rural Burkina Faso. Before the baseline study visit, a door-to-door household survey was conducted for all households in the study area. During the baseline study census, which occurred approximately 9 months after the household survey, a mid-upper arm circumference (MUAC) measurement was obtained from each child. We evaluated the relationship between household improved latrine use compared with unimproved latrines or open defecation and MUAC in children aged 6-59 months. Among 32,172 children with household survey data and MUAC measurements, 931 (2.9%) had an MUAC less than 12.5 cm and were classified as having moderate acute malnutrition (MAM). The odds of MAM were higher in children living in households with an unimproved latrine than those with an improved latrine (adjusted odds ratio: 1.60; 95% CI: 1.11-2.31). Children in households with unimproved latrines and households that practiced open defection had approximate 0.15 cm reduced MUAC compared with those in households with an improved latrine. There was a small, but statistically significant, association between improved latrine and nutritional status in preschool children as measured by MUAC.

Extended-spectrum beta-lactamase-producing Enterobacteriaceae (ESBL), a family of bacteria that includes Escherichia coli, have emerged as a global health threat. This study examined risks associated with carriage of third-generation cephalosporin-resistant (3GC-R) E. coli, including ESBL-producing, multidrug-resistant, and extensively drug-resistant (XDR) strains in children living in semirural parishes of Quito, Ecuador. We conducted a longitudinal study with two cycles of sampling (N = 374, N = 366) that included an analysis of child fecal samples and survey questions relating to water, sanitation, and hygiene, socioeconomic status, household crowding, and animal ownership. We used multivariate regression models to assess risk factors associated with a child being colonized. Across the two cycles, 18.4% (n = 516) of the 3GC-R isolates were ESBL-producing E. coli, and 40.3% (n = 516) were XDR E. coli. Children living in households that owned between 11 and 20 backyard animals had an increased odds of being colonized with XDR E. coli (odds ratio [OR] = 1.94, 95% confidence interval [CI]: 1.05-3.60) compared with those with no animals. Households that reported smelling odors from commercial poultry had increased odds of having a child positive for XDR E. coli (OR = 1.72, 95% CI: 1.11-2.66). Our results suggest that colonization of children with antimicrobial-resistant E. coli is influenced by exposure to backyard and commercial livestock and poultry. Future studies should consider community-level risk factors because child exposures to drug-resistant bacteria are likely influenced by neighborhood and regional risk factors.

Acute respiratory infections cause mortality in young children. We assessed the effects of water, sanitation, hygiene (WASH) and nutritional interventions on childhood ARI. Geographic clusters of pregnant women from rural Bangladesh were randomly assigned to receive 1) chlorinated drinking water and safe storage (W); 2) upgraded sanitation (S); 3) handwashing promotion (H); 4) combined water, sanitation, and handwashing (WSH); 5) nutrition intervention including lipid-based nutrient supplements; 6) combined WSH plus nutrition (WSHN); or 7) no intervention (control). Masking of participants was not possible. Acute respiratory illness was defined as caregiver-reported persistent cough, panting, wheezing, or difficulty breathing in the past 7 days among index children, those born to enrolled women. We assessed outcomes at 12 and 24 months of intervention using intention to treat. Compared with children in the control group (ARI prevalence, P: 8.9%), caregivers of index children reported significantly lower ARI in the water (P: 6.3%, prevalence ratio (PR): 0.71; 95% CI: 0.53, 0.96), sanitation (P: 6.4%, PR: 0.75, 95% CI: 0.58, 0.96), handwashing (P: 6.4%, PR: 0.68, 95% CI: 0.50, 0.93), and the combined WSH+N arms (P: 5.9%, PR: 0.67, 95% CI: 0.50, 0.90). Those in the nutrition (P: 7.4%, PR: 0.84, 95% CI: 0.63, 1.10) or the WSH arm (P: 8.9%, PR: 0.99, 95% CI: 0.76, 1.28) reported similar ARI prevalence compared with control children. Single targeted water, sanitation, and hygiene interventions reduced reported respiratory illness in young children. There was no apparent respiratory health benefit from combining WASH interventions.

We conducted a cross sectional study to assess 1) the association between access to basic sanitation and fecal contamination of sentinel toy balls and 2) if other sanitation factors such as shared use and cleanliness are associated with fecal contamination of sentinel toy balls. We assessed sanitation facilities in 454 households with a child aged 6-24 months in rural Bangladesh. We defined "basic" sanitation as access to improved sanitation facilities (pit latrine with a slab or better) not shared with other households. In each household, an identical toy ball was given to the target child. After 24 hours, the balls were rinsed to enumerate fecal coliforms as an indicator of household fecal contamination. Households with basic sanitation had lower fecal coliform contamination than households with no access to basic sanitation (adjusted difference in means: -0.31 log10 colony forming units [CFU]/toy ball; 95% confidence interval [CI]: -0.61, -0.01). Shared sanitation facilities of otherwise improved type were more likely to have visible feces on the latrine slab compared with private facilities. Among households with access to improved sanitation, households with no visible feces on the latrine slab had less toy ball contamination than households with visible feces on the latrine slab (adjusted difference in means: -0.38 log10 CFU/toy ball; 95% CI: -0.77, 0.02). Access to basic sanitation may prevent fecal contamination of the household environment. An Improved sanitation facility used by an individual household may be better in preventing household fecal contamination compared with improved facilities shared with other households.

Latrines are the most basic form of improved sanitation and are a common public health intervention. Understanding motivations for building and using latrines can help develop effective, sustainable latrine promotion programs. We conducted a mixed-methods study of latrine use in the Amhara region of Ethiopia. We held 15 focus group discussions and surveyed 278 households in five communities. We used the Integrated Behavioral Model for Water, Sanitation, and Hygiene interventions to guide our qualitative analysis. Seventy-one percent of households had a latrine, but coverage varied greatly across communities. Higher household income was not associated with latrine use (odds ratio [OR] = 1.9; 95% confidence interval [CI] = 0.5, 7.7); similarly, cost and availability of materials were not discussed as barriers to latrine use in the focus groups. Male-headed households were more likely to use latrines than households with female heads (OR = 3.5; 95% CI = 1.6, 7.7), and households with children in school were more likely to use latrines than households without children in school (OR = 2.3; 95% CI = 1.6, 3.3). These quantitative findings were confirmed in focus groups, where participants discussed how children relay health messages from school. Participants discussed how women prefer not to use latrines, often finding them strange or even scary. These findings are useful for public health implementation; they imply that community-level drivers are important predictors of household latrine use and that cost is not a significant barrier. These findings confirm that school-aged children may be effective conduits of health messages and suggest that latrines can be better marketed and designed for women.

In preparation for a larger trial, the Water, Sanitation, and Hygiene (WASH) Benefits pilot study enrolled 72 villages and 499 subjects in two closely related randomized trials of WASH interventions in rural western Kenya. Intervention households received hardware and promotion for one of the following: water treatment, sanitation and latrine improvements, handwashing with soap, or the combination of all three. Interventions were clustered by village. A follow-up survey was conducted 4 months after intervention delivery to assess uptake. Intervention households were significantly more likely than controls to have chlorinated stored water (36-60 percentage point increases), covers over latrine drop holes (55-75 percentage point increases), less stool visible on latrine floors (16-47 percentage point reductions), and a place for handwashing (71-85 percentage point increases) with soap available (49-66 percentage point increases). The high uptake in all arms shows that combined interventions can achieve high short-term adoption rates if well-designed.

Poor access to toilets has significant impacts on hygiene, health, safety, and well-being. Women in resource-poor areas may not use public toilets because of concerns about personal safety and the disapproval of others. This study examines social beliefs about women's use of public toilets in India, using data from 5,052 households in rural, semi-urban, and urban slum areas of Bihar and Tamil Nadu in 2018. We asked respondents about their beliefs regarding the prevalence of young women aged 16 to 30 years using public toilets alone and whether this behavior was approved of in their community. We also asked about their personal beliefs on this issue. We used hypothetical vignettes to assess perceptions of a young woman's behavior in different settings regarding public toilet usage by women. Our results show that people who believe many women in their community use public toilets alone and approve of it are more likely to have positive beliefs about this behavior. The experimental vignettes suggest a potential causal link between the prevalence and approval of public toilet usage among young women and their likelihood of using it. These findings are consistent across Bihar and Tamil Nadu and the three administrative regions, indicating that interventions aimed at changing social expectations about women's use of public toilets should focus on highlighting community members' usage and approval. Efforts to encourage woman's access to public toilets and services should target shifting beliefs about public toilet usage among women without disapproval from others.

Sharing of sanitation is common in low-income settlements in Sub-Saharan Africa. However, shared (limited) sanitation facilities have been thought to pose health risks due to poor hygiene levels. Interventions to improve user behavior and cleanliness of shared sanitation are few, both in literature and in practice. This study details the codesign and testing of strategies to improve the cleanliness of shared sanitation facilities in low-income areas of Kisumu City in Kenya. The strategies included a cleaning plan, monitoring system, and discussions among users, and were codesigned through workshops with stakeholders and group discussions with landlords and tenants. These strategies were tested in 38 compound houses through the Trials of Improved Practices approach over a 5-month period. Field staff visited the compounds, observed the cleanliness of the shared toilets, and through discussions, encouraged users to develop a formal cleaning system and a monitoring plan. The discussions built social capital and collective action and facilitated uptake of the cleaning plan with notable improvements in cleanliness of shared toilets. The results support the acceptability of shared sanitation in low-income settlements, the importance of codesigning and coproducing solutions with users, and the need to evaluate the effects of these strategies on cleanliness of shared sanitation.

Water, sanitation, and handwashing interventions that use intensive interpersonal communication improve targeted behaviors, but are expensive at scale. Mass media is an alternative that could reach more people at lower cost but has rarely been rigorously evaluated. We assessed the effectiveness of a mass media campaign in improving handwashing knowledge and practices in rural Bangladesh. We conducted a cross-sectional assessment before the campaign among 8,947 households and again after 4 months of the campaign among 8,400 different households in the same areas. Trained enumerators conducted spot checks of water, sanitation, and hygiene facilities, and recorded reported knowledge and practices. We compared these outcomes after versus before the campaign using generalized linear models with robust standard errors. After the media campaign, caregivers were more likely to recall ≥ 3 messages regarding handwashing (prevalence ratio [PR] = 1.44, 1.34-1.55), sanitation (PR = 1.45, 1.35-1.55), and safe water (PR = 1.17, 1.08-1.26). After the campaign, the prevalence of using soap and water during handwashing demonstrations was higher among caregivers (PR = 1.15, 1.12-1.19) and children (PR = 1.31, 1.22-1.41). Hands were more commonly observed to be visibly clean among caregivers (PR = 1.14, 1.07-1.20) and children (PR = 1.13, 1.05-1.21). Soap and water was more commonly observed in handwashing stations near latrines (PR = 1.12, 1.06-1.19) and in cooking/eating places (PR = 1.09, 1.01-1.18). Our findings indicate improved handwashing knowledge and behaviors following a mass media campaign. This promising approach can be deployed to improve water, sanitation, and hygiene practices at scale and should be evaluated in other contexts.

Information about factors potentially favoring the spread of SARS-CoV-2 in rural settings is limited. Following a case-control study design in a rural Ecuadorian village that was severely struck by the pandemic, SARS-CoV-2 RNA were detected by real-time PCR in swabs obtained from inner and upper walls in 24/48 randomly selected latrines from case-houses and in 12/48 flushing toilets from paired control-houses (P = 0.014; McNemar's test). This association persisted in a conditional logistic regression model adjusted for relevant covariates (OR: 4.82; 95% CI: 1.38-16.8; P = 0.014). In addition, SARS-CoV-2-seropositive subjects were more often identified among those living in houses with a latrine (P = 0.002). Latrines have almost five times the odds of containing SARS-CoV-2 RNA than their paired flushing toilets. Latrines are reservoirs of SARS-CoV-2 RNA, and it cannot be ruled out that latrines could contribute to viral transmission in rural settings. Frequent disinfection of latrines should be recommended to reduce the likelihood of fecal contamination.

Open defecation remains a common practice in developing countries and leads to high incidence and prevalence of acute gastroenteritis, which is most often caused by human noroviruses (human NoV). Encouraging the use of toilets and pit latrines is one method of improving sanitation; however, it is often hindered by not only cultural traditions but also from a reluctance to use latrines and toilets due to their odor and impression of uncleanliness. In an effort to establish new means to encourage toilet and latrine use, laboratory experiments tested the ability of hypochlorous acid (HOCl) to modify the malodorous compounds identified in the air in latrines in developing countries (indole, p-cresol, dimethyl disulfide (DMDS), dimethyl trisulfide (DMTS), and butyric acid) and inactivate MS2 bacteriophage, a surrogate for human NoV. After 5 minutes, > 94% of indole, p-cresol, DMDS, and DMTS was modified as determined by high-pressure liquid chromatography in the presence of 100 ppm HOCl. A log 10 reduction value (LRV) greater than 6 was seen for MS2 bacteriophage after 5 minutes of exposure to 100 ppm HOCl in solution. Sensory studies indicated that there was a significant difference ( P ≤ 0.05) between the untreated and HOCl-treated samples for all five malodorous compounds tested. The findings suggest that introduction of HOCl into the headspace air could encourage latrine and toilet use. Optimization of HOCl dosing in air to accomplish both odor control and reduction of infectious hazards is worthy of further study.

Formative research findings from the fast-growing Babati town were used to assess the prevalence of sanitation and hygiene practices among individuals and institutions and associated factors. A cross-sectional study involving household surveys, spot-checks, focus group discussions, in-depth interviews, and structured observations of behaviors showed that 90% of households have sanitation facilities, but 68% have safely managed sanitation services. The most common types of household sanitation facilities were pit latrines with slab (42%) followed by flush/pour flush toilets (32%). Therefore, the management of wastewater depends entirely on onsite sanitation systems. The majority of households (70%) do not practice proper hygiene behaviors. Thirteen percent of the households had handwashing stations with soap and water, handwashing practice being more common to women (38%) than men (18%). The reported handwashing practices during the four critical moments (handwashing with soap before eating and feeding, after defecation, after cleaning child's bottom, and after touching any dirt/dust) differed from the actual/observed practices. Households connected to the town's piped water supply were more likely to practice handwashing than those not directly connected. Sanitation and hygiene behaviors of the people in the study area were seen to be influenced by sociodemographic, cultural, and economic factors. The conditions of sanitation and hygiene facilities in public places were unsatisfactory. There is an urgent need to ensure that the sanitation and hygiene services and behaviors along the value chain (from waste production/source to disposal/end point) are improved both at the household level and in public places through improved sanitation services and the promotion of effective hygiene behavior change programs integrated into ongoing government programs and planning.

We conducted a comparative cross-sectional study to examine the potential effects of a community-led total sanitation (CLTS) intervention on sanitation and hygiene in Pallisa district in Uganda. Quantitative data were collected from households using a semi-structured questionnaire and an observation checklist, entered and analyzed using univariate, bivariate, and multivariate analyses. Overall, knowledge on sanitation and hygiene was significantly higher (64.5%; 129/200) among households in the CLTS intervention than among those in the nonintervention subcounties (54.0%; 108/200) ( P = 0.033). Latrine quality was rated as fair in a majority (73.3%; 143/195) of the CLTS intervention households compared with 50.8% (93/183) in the non-CLTS households ( P < 0.001). Latrine cleanliness was rated as good in more than a half (51.3%; 100/195) of households in the intervention area, whereas only 13.7% (25/183) for the nonintervention area ( P < 0.001). In this study, 35.0% (70/200) of the households in the intervention subcounty had attained open defecation-free (ODF) status compared with only 6.0% (12/200) in the nonintervention subcounty ( P < 0.001). Level of knowledge on hygiene and sanitation (adjusted odd ratio [AOR]: 2.23; 95% CI: 1.24-4.03) and CLTS status (AOR: 8.89; 95% CI: 4.26-18.56) were significantly associated with achievement of ODF status in the multivariate analysis. The mean cases of diarrhea were significantly lower in CLTS implementing (subcounty (0.42 [SD ± 1.03]) than in the non-CLTS implementing subcounty (0.98 [SD ± 1.39]; t = -4.6; P < 0.001). Sanitation and hygiene outcomes were better in the CLTS intervention subcounty than in the non-CLTS intervention subcounty, suggesting that scaling up CLTS could reduce ODF and the burden of diarrheal diseases.

Soil-transmitted helminth (STH) infections cause devastating effect in human health. School-age children (SAC) account for the highest prevalence of STH infections in sub-Sahara. Open defecation practicing might be the major contributing factor, and creating an open defecation-free (ODF) declared community is also a big challenge. This study aimed to assess the prevalence of STH infections and associated factors among SAC in ODF declared and open defecation-practicing kebeles. A comparative cross-sectional study was conducted among 806 SAC from January 2019 to April 2019. Questionnaire-based data were collected using a structured questionnaire. Stool samples were collected and processed via the Kato-Katz technique. Prevalence and associated factors were computed with descriptive statistics and regression, respectively. Variables with a P -value < 0.05 were considered as significantly associated. This study revealed that the prevalence of STH infections in open defecation-practicing and ODF declared kebeles were 39.0% and 30.0%, respectively. Wearing open shoes, wearing shoes sometimes, and playing with soil were significantly associated ( P < 0.01) with STH infections in ODF declared kebeles. Similarly, wearing shoes sometimes, not using latrine, and playing with soil were also significantly associated ( P < 0.01) with STH infections in open defection-practicing kebeles. In conclusion, lower prevalence of STH infections was recorded in ODF declared than in open defection-practicing kebeles. Wearing shoes sometimes, playing with soil, and not using latrine were associated with STH infections. Therefore, creating an ODF environment and community awareness should be strengthened.

Exposure to fecal pathogens contributes to childhood diarrhea and stunting, causing harmful short- and long-term impacts to health. Understanding pathways of child fecal exposure and nutritional deficiencies is critical to informing interventions to reduce stunting. Our aim was to explore determinants of latrine use, disposal of child feces, and perceptions and provisions of a safe and clean child play environment among families with children under two (CU2) years to inform the design of a behavior change intervention to address water, sanitation, and hygiene (WASH), and nutrition behaviors. In 2016, we conducted a mixed-methods formative research in western Kenya. We conducted 29 key informant interviews with community leaders, health workers, and project staff; 18 focus group discussions with caregivers of CU2 years; and 24 semi-structured household observations of feeding, hygiene, and sanitation behaviors. We used the capability, opportunity, motivation, and behavior model as our theoretical framework to map caregiver behavioral determinants. Latrine use barriers were lack of latrines, affordability of lasting materials, and social acceptability of unobserved open defecation. Barriers to safe disposal of child feces were lack of latrines, time associated with safe disposal practices, beliefs that infant feces were not harmful, and not knowing where children had defecated. Primary barriers of clean play environments were associated with creating and maintaining play spaces, and shared human and animal compounds. The immediate cost to practicing behaviors was perceived as greater than the long-term potential benefits. Intervention design must address these barriers and emphasize facilitators to enable optimal WASH behaviors in this context.

Open defecation is practiced by more than one billion people throughout the world and leads to significant public health issues including infectious disease transmission and stunted growth in children. Zambia implemented community-led total sanitation (CLTS) as an intervention to eliminate open defecation in rural areas. To support CLTS and the attainment of open defecation free communities, chiefs were considered key agents of change and were empowered to drive CLTS and improve sanitation for their chiefdom. Chiefs were provided with data on access to sanitation in the chiefdom during chiefdom orientations prior to the initiation of CLTS within each community and encouraged to make goals of universal sanitation access within the community. Using a survival regression, we found that where chiefs were orientated and mobilized in CLTS, the probability that a village would achieve 100% coverage of adequate sanitation increased by 23% (hazard ratio = 1.263, 95% confidence interval = 1.080-1.478, P = 0.003). Using an interrupted time series, we found a 30% increase in the number of individuals with access to adequate sanitation following chiefdom orientations (95% confidence interval = 28.8-32.0%). The mobilization and support of chiefs greatly improved the uptake of CLTS, and empowering them with increased CLTS knowledge and authority of the program in their chiefdom allowed chiefs to closely monitor village sanitation progress and follow-up with their headmen/headwomen. These key agents of change are important facilitators of public health goals such as the elimination of open defecation in Zambia by 2020.

Diarrhea is a leading contributor to childhood morbidity and mortality in sub-Saharan Africa. Given the challenge of blinding most water, sanitation, and hygiene (WASH) interventions, diarrheal disease outcome measures in WASH intervention trials are subject to potential bias and misclassification. Using the platform of a cluster-randomized controlled trial of a household-based drinking water filter in western province, Rwanda, we assessed the impact of the drinking water filter on enteric seroconversion in young children as a health outcome and examined the association between serologic responses and caregiver-reported diarrhea. Among the 2,179 children enrolled in the trial, 189 children 6-12 months of age were enrolled in a nested serology study. These children had their blood drawn at baseline and 6-12 months after the intervention was distributed. Multiplex serologic assays for Giardia , Cryptosporidium , Entamoeba histolytica , norovirus, Campylobacter , enterotoxigenic Escherichia coli and Vibrio cholerae were performed. Despite imperfect uptake, receipt of the water filter was associated with a significant decrease in seroprevalence of IgG directed against Cryptosporidium parvum Cp17 and Cp23 (relative risk [RR]: 0.62, 95% confidence interval [CI]: 0.44-0.89). Serologic responses were positively associated with reported diarrhea in the previous 7 days for both Giardia intestinalis (RR: 1.94, 95% CI: 1.04-3.63) and C. parvum (RR: 2.21, 95% CI: 1.09-4.50). Serologic responses for all antigens generally increased in the follow-up round, rising sharply after 12 months of age. The water filter is associated with reduced serologic responses against C. parvum , a proxy for exposure and infection; therefore, serologic responses against protozoa may be a suitable health outcome measure for WASH trials among children with diarrhea.

Indiscriminate defecation among young children and the unsafe disposal of their feces increases fecal contamination in the household environment and the risk of diarrheal disease transmission. Improved sanitary technology for children too young to use a latrine may facilitate safe feces disposal and reduce fecal contamination in the household environment. We assessed the acceptability and feasibility of child potties in rural Bangladesh in 2010. Our team introduced child potties into 26 households for 30 days, and conducted semistructured interviews, group discussions, and observations to assess the acceptability and feasibility of their use for parents and children. Residents of this rural Bangladeshi community accepted the child potties and caregivers found them to be a feasible means of managing child feces. The color, shape, design, and size of the potty influenced its acceptability and use. These residents reported that regular use of the potty improved the household's physical environment and caregiver and child personal hygiene. Regular potty use also reduced caregivers' work load by making feces collection and disposal easier. Primary caregivers viewed 4-6 months as the appropriate age to initiate potty training. Sanitation interventions should integrate and emphasize potties for children's feces management to reduce household environmental contamination.

Hymenolepis nana , the dwarf tapeworm, is a common intestinal infection of children worldwide. We evaluated infection and risk factor data that were previously collected from 14,761 children aged 2-15 years during a large-scale program in northern Peru. We found that 1,124 of 14,761 children (7.61%) had H. nana infection, a likely underestimate given that only a single stool sample was examined by microscopy for diagnosis. The strongest association with infection was lack of adequate water (adjusted prevalence ratio [aPR] 2.22, 95% confidence interval [CI] 1.82-2.48) and sanitation infrastructure in the house (aPR 1.94, 95% CI 1.64-2.29). One quarter of those tested did not have a bathroom or latrine at home, which doubled their likelihood of infection. Similarly, one quarter did not have piped public water to the house, which also increased the likelihood of infection. Continued efforts to improve access to basic water and sanitation services will likely reduce the burden of infection in children for this and other intestinal infections.

AbstractUrban sanitation necessitates management of fecal sludge inside and outside the household. This study examined associations between household sanitation, fecal contamination, and enteric infection in two low-income neighborhoods in Vellore, India. Surveys and spatial analysis assessed the presence and clustering of toilets and fecal sludge management (FSM) practices in 200 households. Fecal contamination was measured in environmental samples from 50 households and household drains. Enteric infection was assessed from stool specimens from children under 5 years of age in these households. The two neighborhoods differed significantly in toilet coverage (78% versus 33%) and spatial clustering. Overall, 49% of toilets discharged directly into open drains ("poor FSM"). Children in households with poor FSM had 3.78 times higher prevalence of enteric infection when compared with children in other households, even those without toilets. In the neighborhood with high coverage of household toilets, children in households with poor FSM had 10 times higher prevalence of enteric infection than other children in the neighborhood and drains in poor FSM clusters who had significantly higher concentrations of genogroup II norovirus. Conversely, children in households with a toilet that contained excreta in a tank onsite had 55% lower prevalence of enteric infection compared with the rest of the study area. Notably, households with a toilet in the neighborhood with low toilet coverage had more fecal contamination on floors where children played compared with those without a toilet. Overall, both toilet coverage levels and FSM were associated with environmental fecal contamination and, subsequently, enteric infection prevalence in this urban setting.

Trachoma control strategies, including latrine construction and antibiotic distribution, are directed at reducing ocular chlamydia, but may have additional benefits. In a cluster-randomized clinical trial, 24 subkebeles (administrative geographic units) in Ethiopia were offered a single mass azithromycin treatment, and half were randomized to receive an intensive latrine promotion. At a follow-up census 26 months after the baseline treatment, 320 persons had died. The mortality rate of children 1-5 years of age was 3.87 (95% confidence interval [CI] = 2.19-6.82) per 1,000 person-years in the latrine promotion arm, and 2.72 (95% CI = 1.37-5.42) per 1,000 person-years in the control arm. In a multi-level mixed effects logistic regression model controlling for age, there was no difference in mortality in persons randomized into the latrine or control arms (odds ratio = 1.18, 95% CI = 0.89-1.58). Latrine promotion provided no additional effect on mortality in the context of an azithromycin distribution program (clinicaltrials.gov, #NCT00322972).

Sharing latrines is common in sub-Saharan Africa with anecdotal accounts suggesting a link between water-, sanitation-, and hygiene-related disease and poorly maintained communal latrines. This study examines this link by assessing the association between shared latrines compared with private latrines and risk of trachoma. In 2007, as part of a larger case-control study, we conducted a sub-study on latrine sharing in 594 households (92 cases, 502 controls) in seven rural Tanzanian communities. Case households were defined by having a child with clinical signs of trachoma. Latrine use was associated with a decreased risk of trachoma and there was no difference in risk between households using shared compared with private latrines (adjusted odds ratio = 0.95 [95% confidence interval = 0.55-1.67]). This study emphasizes the need to promote latrine use, which can be facilitated through latrine sharing in resource scarce areas, for prevention of trachoma.

In Vietnam, shigellosis, typhoid fever, and cholera are important enteric diseases. To determine their magnitude and geographical distribution, and explore associated risk factors, we examined national surveillance data from 1991 to 2001 and potential ecological determinants. Average annual incidence rates were calculated and mapped for each province. Bivariate and multiple regression analyses were used to explore associations with selected environmental and human risk factors. Overall, shigellosis rates per 100,000 population (median, 41; mean, 70) were higher and more widespread than rates for typhoid fever (median, 7; mean, 23) and cholera (median, 0.3; mean, 2.7). Shigellosis was highest in the Central Highlands and was significantly associated with rainfall and urban poverty; typhoid fever prevailed in the Mekong River Delta and was most associated with vapor pressure and river/stream drinking water; and cholera predominated along the Central Coastal regions and correlated positively with rainfall and public well drinking water. The distinct geographical patterns of each disease appear to be driven by a combination of different ecological factors.

The purpose of the study was to estimate the association of environmental factors (water and sanitation), health behavior (breast feeding practice and vaccination), and mortality among siblings with night blindness. A total of 5,420 children were enrolled in a cross-sectional study from 2,101 households in the northern part of Bangladesh, a high risk area for night blindness. One hundred twenty-four children were reported by parents to have night blindness. Our results indicated that environmental factors, health behavior, and the death of siblings were significantly associated with the occurrence of night blindness in crude analyses, as well as in analyses with adjustment for a number of potential confounding variables. The strongest association was noted for sibling death. The findings support the notion that night blindness should not be viewed as an isolated health problem and that approaches aimed at improving vitamin A status should also include interventions directed to environmental and health-associated behavioral factors.

Cryptosporidium is an important cause of diarrheal disease in children worldwide. To elucidate the environmental sources of this parasite, we selected an urban slum in Fortaleza, Brazil, a community with a known high incidence of cryptosporidiosis, and examined both stool smears from household animals (n = 127) and filtrates from local water sources (n = 18) for Cryptosporidium oocysts. Because previous work in this community has demonstrated the seasonal nature of human infection with Cryptosporidium, collections were made separately for the dry and rainy seasons. Of the 64 stools collected during the dry season (September-December 1990), four (6.3%) were positive by acid-fast staining for Cryptosporidium. Of the 63 rainy season samples (March-May 1991), nine (14.3%) were positive. Overall, oocysts were detected in 13 (10.2%) of 127 animal stool samples. Freshwater samples were obtained from a variety of sources including open and closed wells, and running city water and then processed. Four of 18 samples (22.2%), including a sample from city water were positive by at least one of two staining techniques (acid-fast and immunofluorescence). In summary, animals may serve as a reservoir of Cryptosporidium, with potential for the contamination of immediate household water sources. These findings may help to explain the high incidence of cryptosporidiosis among infants in this impoverished community.

A study was conducted to determine the etiology of acute hepatitis among 261 children (age range 1-11 years) living in Cairo, Egypt. A blood sample was obtained from each subject when initially evaluated and a questionnaire was used to collect demographic and risk factor data. Sera were tested by enzyme immunoassay for acute hepatitis A (anti-hepatitis A virus IgM), hepatitis B (anti-hepatitis B core antigen IgM and hepatitis B surface antigen [HBsAg]), hepatitis C (total anti-HCV), delta hepatitis (total anti-delta), and cytomegalovirus infection (anti-CMV IgM). In addition, hepatitis E virus (HEV) infection was diagnosed using a new Western blot technique to test patients with non-A, non-B hepatitis for anti-HEV IgM. Among 261 children, acute hepatitis A was diagnosed in 85 (32.6%) patients, acute hepatitis B in 19 (7.3%), delta hepatitis in 3 (1.1%), mixed hepatitis A and B infection in 2 (0.8%), CMV infection in 1 (0.4%), hepatitis E in 58 (22.2%), and non-A, non-B hepatitis of unknown type in 51 (19.5%). Forty-two (16.1%) subjects had HBsAg without other markers of acute infection. Risk factor analysis indicated that patients living in homes not connected to a municipal source of water were at increased risk of hepatitis E infection. These data provide additional evidence that hepatitis E virus is a common cause of acute sporadic hepatitis in children living in Egypt.

A population-based prevalence survey of ocular disease was conducted in the Lower Shire River Valley of Malawi in 1983. A total of 5,436 children less than 6 years of age and 1,664 persons greater than or equal to 6 years were examined. The prevalence of inflammatory trachoma peaked in the 1-2-year-old age group at 48.7% and declined rapidly with age to less than 5% by age 15. The prevalence of cicatricial trachoma was low in young children and climbed gradually with age to greater than 40% among those greater than or equal to 50 years. Risk factors for inflammatory disease in young children included low socioeconomic status of the family, long walking distance to the household's primary source of water, absence of a latrine in the family compound, and presence of trachoma among siblings. Indices of crowding practices were not associated with inflammatory disease. An apparent inverse association of facewashing and inflammatory trachoma in children did not hold up when adjusted for other risk factors.

Three methods of control of soil-transmitted helminths, namely, sanitation, mass-treatment, and sanitation plus mass-treatment, were tried in 15 villages in Khuzestan, southwest Iran. Stool samples from the inhabitants of each village were examined both quantitatively and qualitatively just before starting each control method and again about 4 years later, except for the inhabitants of one village whose stools were re-examined 7 months after moving to a new settlement. Sanitation measures consisted of one latrine for each family and the provision of a sanitary water supply in each village. The drugs piperazine and bephenium hydroxynapthoate were administered alternately every 3 months. The reduction in rates of infection with Ascaris, hookworm, and Trichostrongylus spp., respectively, for the above mentioned methods were as follows: sanitation alone, 28%, 4% and 30%; mass-treatment alone, 84%, 73%, and 31%; sanitation plus mass-treatment, 79%, 69%, and 30% and in the newly constructed village, 76%, 21%, and 38%. In a control group corresponding reductions were 19%, 11%, and 31%. The percentage of egg reduction in persons still infected with these three parasites was, respectively, as follows: mass-treatment plus sanitation, 88%, 88%, and 53%; mass-treatment alone, 90%, 87%, and 37%; sanitation alone, 60%, 26%, and 0.6%; in the newly constructed village, 87%, 78%, and 39%; and in the control group, 29% increased 12%, and 24.5%. The significance of these findings is discussed.