The Influence of Household- and Community-Level Sanitation and Fecal Sludge Management on Urban Fecal Contamination in Households and Drains and Enteric Infection in Children

Urban 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.

by reverse transcription PCR. Other ova and parasites, including soil-transmitted helminths, were identified by morphology using a wet prep and modified acid-fast stain. 29 QUANTITATIVE REAL-TIME PCR Total nucleic acids were extracted using the Qiagen Xtractor system (Qiagen Sciences, Germantown, MD), following manufacturer's instructions. EAEC was detected using primers and probes targeting the aatA gene. 31 GI norovirus was detected using genogroup-specific COG1 primers and RING1-TP probe, while GII norovirus was detected using the genogroup-specific COG2 primers and RING2-TP probe. 32 The standard curve for EAEC was generated from a plasmid containing the aatA gene. The standard curve for GI and GII noroviruses was generated from in vitro transcribed RNA. 33
*These questions were asked to the respondent whereas the others were observations. SUPPLEMENTAL *Multivariate models are presented for each sanitation variable, adjusting for neighborhood and hygiene status ("poor" or "good", as discussed previously), and are separated by a blank row in the table. In all models, interaction terms between the sanitation variable and neighborhood were tested and are indicated with a "/ " if significant at α = 0.10, and N = 50 samples.
†Estimates are in log 10 colony-forming units (CFU)/pair of hands. ‡Reference population is households without a toilet or those with "other" FSM practices.
SUPPLEMENTAL *Multivariate models are presented for each sanitation variable, adjusting for neighborhood and hygiene status ("poor" or "good", as discussed previously), and are separated by a blank row in the table. In all models, interaction terms between the sanitation variable and neighborhood were tested and are indicated with a "/" if significant at α = 0.10, and N = 49 samples.
†Estimates are in log 10 colony-forming units (CFU)/100 mL. ‡Reference population is households without a toilet or those with "other" FSM practices.
SUPPLEMENTAL *Multivariate models are presented for each sanitation variable, adjusting for neighborhood and hygiene status ("poor" or "good", as discussed previously), and are separated by a blank row in the table. In all models, interaction terms between the sanitation variable and neighborhood were tested and are indicated with a "/" if significant at α = 0.10, and N = 50 samples.
†Estimates are in log 10 colony-forming units (CFU)/125 cm 2 . ‡Reference population is households without a toilet or those with "other" FSM practices.