title: 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.
abstract: BACKGROUND
  Diarrheal disease is the second leading cause of disease in children less than 5 y of age. Poor water, sanitation, and hygiene conditions are the primary routes of exposure and infection. Sanitation and hygiene interventions are estimated to generate a 36% and 48% reduction in diarrheal risk in young children, respectively. Little is known about whether the number of households sharing a sanitation facility affects a child's risk of diarrhea. The objective of this study was to describe sanitation and hygiene access across the Global Enteric Multicenter Study (GEMS) sites in Africa and South Asia and to assess sanitation and hygiene exposures, including shared sanitation access, as risk factors for moderate-to-severe diarrhea (MSD) in children less than 5 y of age.
  
  
  RESULTS
  The GEMS matched case-control study was conducted between December 1, 2007, and March 3, 2011, at seven sites in Basse, The Gambia; Nyanza Province, Kenya; Bamako, Mali; Manhiça, Mozambique; Mirzapur, Bangladesh; Kolkata, India; and Karachi, Pakistan. Data was collected for 8,592 case children aged <5 y old experiencing MSD and for 12,390 asymptomatic age, gender, and neighborhood-matched controls. An MSD case was defined as a child with a diarrheal illness <7 d duration comprising ≥3 loose stools in 24 h and ≥1 of the following: sunken eyes, skin tenting, dysentery, intravenous (IV) rehydration, or hospitalization. Site-specific conditional logistic regression models were used to explore the association between sanitation and hygiene exposures and MSD. Most households at six sites (>93%) had access to a sanitation facility, while 70% of households in rural Kenya had access to a facility. Practicing open defecation was a risk factor for MSD in children <5 y old in Kenya. Sharing sanitation facilities with 1-2 or ≥3 other households was a statistically significant risk factor for MSD in Kenya, Mali, Mozambique, and Pakistan. Among those with a designated handwashing area near the home, soap or ash were more frequently observed at control households and were significantly protective against MSD in Mozambique and India.
  
  
  CONCLUSIONS
  This study suggests that sharing a sanitation facility with just one to two other households can increase the risk of MSD in young children, compared to using a private facility. Interventions aimed at increasing access to private household sanitation facilities may reduce the burden of MSD in children. These findings support the current World Health Organization/ United Nations Children's Emergency Fund (UNICEF) system that categorizes shared sanitation as unimproved.
authors.affiliation: 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.
authors.forename: Kelly K
authors.identifier: http://orcid.org/0000-0002-3774-2628
authors.initials: KK
authors.lastname: Baker
authors.affiliation: Division of Foodborne, Waterborne, and Environmental Diseases, US Centers for Disease Control and Prevention, Atlanta, Georgia, United States of America.
authors.forename: Ciara E
authors.initials: CE
authors.lastname: O'Reilly
authors.affiliation: Center for Vaccine Development, Departments of Medicine, University of Maryland School of Medicine, Baltimore, Maryland, United States of America.
authors.forename: Myron M
authors.initials: MM
authors.lastname: Levine
authors.affiliation: Center for Vaccine Development, Departments of Medicine, University of Maryland School of Medicine, Baltimore, Maryland, United States of America.
authors.forename: Karen L
authors.initials: KL
authors.lastname: Kotloff
authors.affiliation: Center for Vaccine Development, Departments of Medicine, University of Maryland School of Medicine, Baltimore, Maryland, United States of America.|Department of Pediatrics, University of Virginia School of Medicine, Charlottesville, Virginia, United States of America.
authors.forename: James P
authors.identifier: http://orcid.org/0000-0003-4159-0097
authors.initials: JP
authors.lastname: Nataro
authors.affiliation: Division of Foodborne, Waterborne, and Environmental Diseases, US Centers for Disease Control and Prevention, Atlanta, Georgia, United States of America.
authors.forename: Tracy L
authors.identifier: http://orcid.org/0000-0003-4140-3263
authors.initials: TL
authors.lastname: Ayers
authors.affiliation: Center for Vaccine Development, Departments of Medicine, University of Maryland School of Medicine, Baltimore, Maryland, United States of America.|Gates Foundation, Seattle, Washington, United States of America.
authors.forename: Tamer H
authors.initials: TH
authors.lastname: Farag
authors.affiliation: Center for Vaccine Development, Departments of Medicine, University of Maryland School of Medicine, Baltimore, Maryland, United States of America.
authors.forename: Dilruba
authors.initials: D
authors.lastname: Nasrin
authors.affiliation: Center for Vaccine Development, Departments of Medicine, University of Maryland School of Medicine, Baltimore, Maryland, United States of America.
authors.forename: William C
authors.identifier: http://orcid.org/0000-0001-8174-9643
authors.initials: WC
authors.lastname: Blackwelder
authors.affiliation: Center for Vaccine Development, Departments of Medicine, University of Maryland School of Medicine, Baltimore, Maryland, United States of America.|Emergent BioSolutions, Gaithersburg, Maryland, United States of America.
authors.forename: Yukun
authors.identifier: http://orcid.org/0000-0002-2747-5685
authors.initials: Y
authors.lastname: Wu
authors.affiliation: 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, Switzerland.
authors.forename: Pedro L
authors.initials: PL
authors.lastname: Alonso
authors.affiliation: US Centers for Disease Control and Prevention, Nairobi, Kenya.|Emory Global Health Institute, Emory University, Atlanta, Georgia, United States of America.
authors.forename: Robert F
authors.initials: RF
authors.lastname: Breiman
authors.affiliation: Kenya Medical Research Institute/Centers for Disease Control and Prevention (KEMRI/CDC), Kisumu, Kenya.
authors.forename: Richard
authors.initials: R
authors.lastname: Omore
authors.affiliation: International Centre for Diarrhoeal Disease Research, Mohakhali, Dhaka, Bangladesh.
authors.forename: Abu S G
authors.initials: AS
authors.lastname: Faruque
authors.affiliation: International Centre for Diarrhoeal Disease Research, Mohakhali, Dhaka, Bangladesh.|The University of Queensland, Brisbane, Australia.
authors.forename: Sumon Kumar
authors.initials: SK
authors.lastname: Das
authors.affiliation: International Centre for Diarrhoeal Disease Research, Mohakhali, Dhaka, Bangladesh.
authors.forename: Shahnawaz
authors.initials: S
authors.lastname: Ahmed
authors.affiliation: Medical Research Council (United Kingdom), Fajara, The Gambia.
authors.forename: Debasish
authors.initials: D
authors.lastname: Saha
authors.affiliation: Centre pour le Développement des Vaccins, Bamako, Mali.
authors.forename: Samba O
authors.initials: SO
authors.lastname: Sow
authors.affiliation: National Institute of Cholera and Enteric Diseases, Kolkata, India.|India Public Health Association and PATH India Office, New Delhi, India.
authors.forename: Dipika
authors.initials: D
authors.lastname: Sur
authors.affiliation: Gates Foundation, Seattle, Washington, United States of America.|Department of Paediatrics and Child Health, the Aga Khan University, Karachi, Pakistan; Gates Foundation, Seattle, Washington, United States of America.
authors.forename: Anita K M
authors.initials: AK
authors.lastname: Zaidi
authors.affiliation: Department of Paediatrics and Child Health, the Aga Khan University, Karachi, Pakistan; Gates Foundation, Seattle, Washington, United States of America.
authors.forename: Fahreen
authors.initials: F
authors.lastname: Quadri
authors.affiliation: Division of Foodborne, Waterborne, and Environmental Diseases, US Centers for Disease Control and Prevention, Atlanta, Georgia, United States of America.
authors.forename: Eric D
authors.initials: ED
authors.lastname: Mintz
mesh_terms: D000349:Africa / Q000453:epidemiology; D001208:Asia / Q000453:epidemiology; D016022:Case-Control Studies; D002675:Child, Preschool; D003967:Diarrhea / Q000453:epidemiology* / Q000209:etiology; D005260:Female; D006801:Humans; D006920:Hygiene; D007223:Infant; D007231:Infant, Newborn; D008297:Male; D012307:Risk Factors; D012499:Sanitation / Q000706:statistics & numerical data*