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Human fecal and pathogen exposure pathways in rural Indian villages and the effect of increased latrine coverage.

ABSTRACT: Efforts to eradicate open defecation and improve sanitation access are unlikely to achieve health benefits unless interventions reduce microbial exposures. This study assessed human fecal contamination and pathogen exposures in rural India, and the effect of increased sanitation coverage on contamination and exposure rates. In a cross-sectional study of 60 villages of a cluster-randomized controlled sanitation trial in Odisha, India, human and domestic animal fecal contamination was measured in community tubewells and ponds (n = 301) and via exposure pathways in homes (n = 354), using Bacteroidales microbial source tracking fecal markers validated in India. Community water sources were further tested for diarrheal pathogens (rotavirus, adenovirus and Vibrio cholerae by quantitative PCR; pathogenic Escherichia coli by multiplex PCR; Cryptosporidium and Giardia by immunomagnetic separation and direct fluorescent antibody microscopy). Exposure pathways in intervention and control villages were compared and relationships with child diarrhea examined. Human fecal markers were rarely detected in tubewells (2.4%, 95%CI: 0.3-4.5%) and ponds (5.6%, 95%CI: 0.8-10.3%), compared to homes (35.4%, 95%CI: 30.4-40.4%). In tubewells, V. cholerae was the most frequently detected pathogen (19.8%, 95%CI: 14.4-25.2%), followed by Giardia (14.8%, 95%CI: 10.0-19.7%). In ponds, Giardia was most often detected (74.5%, 95%CI: 65.7-83.3%), followed by pathogenic E. coli (48.1%, 95%CI: 34.8-61.5%) and rotavirus (44.4%, 95%CI: 34.2-54.7%). At village-level, prevalence of fecal pathogen detection in community drinking water sources was associated with elevated prevalence of child diarrhea within 6 weeks of testing (RR 2.13, 95%CI: 1.25-3.63) while within homes, higher levels of human and animal fecal marker detection were associated with increased risks of subsequent child diarrhea (P = 0.044 and 0.013, respectively). There was no evidence that the intervention, which increased functional latrine coverage and use by 27 percentage points, reduced human fecal contamination in any tested pathway, nor the prevalence of pathogens in water sources. In conclusion, the study demonstrates that (1) improved sanitation alone may be insufficient and further interventions needed in the domestic domain to reduce widespread human and animal fecal contamination observed in homes, (2) pathogens detected in tubewells indicate these sources are microbiologically unsafe for drinking and were associated with child diarrhea, (3) domestic use of ponds heavily contaminated with multiple pathogens presents an under-recognized health risk, and (4) a 27 percentage point increase in improved sanitation access at village-level did not reduce detectable human fecal and pathogen contamination in this setting.

SUBMITTER: Odagiri M

PROVIDER: S-EPMC4907306 | biostudies-literature | 2016 Sep

REPOSITORIES: biostudies-literature

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Human fecal and pathogen exposure pathways in rural Indian villages and the effect of increased latrine coverage.

Odagiri Mitsunori M Schriewer Alexander A Daniels Miles E ME Wuertz Stefan S Smith Woutrina A WA Clasen Thomas T Schmidt Wolf-Peter WP Jin Yujie Y Torondel Belen B Misra Pravas R PR Panigrahi Pinaki P Jenkins Marion W MW

Water research 20160504

Efforts to eradicate open defecation and improve sanitation access are unlikely to achieve health benefits unless interventions reduce microbial exposures. This study assessed human fecal contamination and pathogen exposures in rural India, and the effect of increased sanitation coverage on contamination and exposure rates. In a cross-sectional study of 60 villages of a cluster-randomized controlled sanitation trial in Odisha, India, human and domestic animal fecal contamination was measured in ...[more]

PMID: 27192358

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Project description:Our group conducted a cluster-randomised trial in 100 villages of Orissa, India to measure the impact of a rural sanitation intervention implemented under the government of India's Total Sanitation Campaign, on diarrhoea and soil-transmitted helminth infections. This paper reports on a process evaluation conducted in the context of the trial.Process evaluation data were collected through review of key documentation, quantitative surveys, direct observations, and semi-structured interviews with staff from implementing NGOs and community members. Between March 2011 and March 2012, trained enumerators recorded observations on latrine construction status every 6-8 weeks in the 50 intervention villages and noted activities reported to have taken place based on NGO staff interviews and review of NGO records. A survey among 10% of households in intervention and control villages was conducted to compare levels of awareness of key intervention components. In addition, 10% of village water and sanitation committee (VWSC) members were interviewed to measure their level of involvement in the intervention delivery.The percentage of households with a latrine (completed or under construction) increased from 8% at baseline to 66% one year after the start of the intervention in March 2012. Almost none of the intervention households recall any form of participatory community-level activities at the start of the programme, although intervention households were generally more aware of the Total Sanitation Campaign (91% versus 49%, p?<?0.001), VWSCs (51% versus 9%, p?<?0.001), adolescent girls groups (23% versus 8%, p?<?0.01), wall paintings (44% versus 7%, p?<?0.001) and were more likely to report a household visit on sanitation during the past three months (65% versus 3%, p?<?0.001). We found no strong evidence of an association between levels of awareness of or participation in mobilisation activities and levels of latrine coverage in intervention villages.The levels of coverage achieved and the levels of awareness of the mobilisation process in our intervention villages were lower than planned, but similar to those reported elsewhere in India under the TSC. Our process evaluation highlights important gaps between the TSC guidelines and their implementation on the ground.Number on clinicaltrial.gov: NCT01214785.

Project description:BackgroundAn estimated 2.4 billion people still lack access to improved sanitation and 946 million still practice open defecation. The World Health Organization (WHO) commissioned this review to assess the impact of sanitation on coverage and use, as part of its effort to develop a set of guidelines on sanitation and health.Methods and findingsWe systematically reviewed the literature and used meta-analysis to quantitatively characterize how different sanitation interventions impact latrine coverage and use. We also assessed both qualitative and quantitative studies to understand how different structural and design characteristics of sanitation are associated with individual latrine use. A total of 64 studies met our eligibility criteria. Of 27 intervention studies that reported on household latrine coverage and provided a point estimate with confidence interval, the average increase in coverage was 14% (95% CI: 10%, 19%). The intervention types with the largest absolute increases in coverage included the Indian government's "Total Sanitation Campaign" (27%; 95% CI: 14%, 39%), latrine subsidy/provision interventions (16%; 95% CI: 8%, 24%), latrine subsidy/provision interventions that also incorporated education components (17%; 95% CI: -5%, 38%), sewerage interventions (14%; 95% CI: 1%, 28%), sanitation education interventions (14%; 95% CI: 3%, 26%), and community-led total sanitation interventions (12%; 95% CI: -2%, 27%). Of 10 intervention studies that reported on household latrine use, the average increase was 13% (95% CI: 4%, 21%). The sanitation interventions and contexts in which they were implemented varied, leading to high heterogeneity across studies. We found 24 studies that examined the association between structural and design characteristics of sanitation facilities and facility use. These studies reported that better maintenance, accessibility, privacy, facility type, cleanliness, newer latrines, and better hygiene access were all frequently associated with higher use, whereas poorer sanitation conditions were associated with lower use.ConclusionsOur results indicate that most sanitation interventions only had a modest impact on increasing latrine coverage and use. A further understanding of how different sanitation characteristics and sanitation interventions impact coverage and use is essential in order to more effectively attain sanitation access for all, eliminate open defecation, and ultimately improve health.

Dataset Information

Human fecal and pathogen exposure pathways in rural Indian villages and the effect of increased latrine coverage.

Publications

Human fecal and pathogen exposure pathways in rural Indian villages and the effect of increased latrine coverage.

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