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.

Cryptosporidium parvum and Giardia lamblia are zoonotic enteric protozoa of significant health concern where sanitation, hygiene, and water supplies are inadequate. We examined 85 stool samples from diarrhea patients, 111 pooled fecal samples by species across seven domestic animal types, and water from tube wells (N = 207) and ponds (N = 94) across 60 villages in coastal Odisha, India, for Cryptosporidium oocysts and Giardia cysts to measure occurrence, concentration/shedding, and environmental loading rates. Oocysts/cysts were detected in 12% of diarrhea patients. Detection ranged from 0% to 35% for Cryptosporidium and 0% to 67% for Giardia across animal hosts. Animal loading estimates indicate the greatest contributors of environmental oocysts/cysts in the study region are cattle. Ponds were contaminated with both protozoa (oocysts: 37%, cysts: 74%), as were tube wells (oocysts: 10%, cysts: 14%). Future research should address the public health concern highlighted from these findings and investigate the role of domestic animals in diarrheal disease transmission in this and similar settings.

Surface and groundwater contamination with fecal pathogens is a public health concern especially in low-income settings where these sources are used untreated. We modeled observed Cryptosporidium and Giardia contamination in community ponds (n = 94; 79% contaminated), deep tubewells (DTWs) (n = 107; 17%), and shallow tubewells (STWs) (n = 96; 19%) during the 2012 and 2013 monsoon seasons (June–August) in 60 villages in Puri District, India to understand sources and processes of contamination. Detection of Cryptosporidium and/or Giardia in a tubewell was positively associated with damage to the well pad for DTWs, the amount of human loading into pour-flush latrine pits nearby (≤15 m) for STWs, and the village literacy rate (for Giardia in STWs). Pond concentration levels were positively associated with the number of people practicing open defecation within 50 m and the sheep population for Cryptosporidium, and with the village illiteracy rate for Giardia. Recent rainfall increased the risk of Cryptosporidium in STWs (an extreme event) and ponds (any), while increasing seasonal rainfall decreased the risk of Giardia in STWs and ponds. Full latrine coverage in this setting is expected to marginally reduce pond Cryptosporidium contamination (16%) while increasing local groundwater protozoal contamination (87–306%), with the largest increases predicted for Cryptosporidium in STWs.

BackgroundIn many low-income settings, despite improvements in sanitation and hygiene, groundwater sources used for drinking may be contaminated with enteric pathogens such as Cryptosporidium and Giardia, which remain important causes of childhood morbidity. In this study, we examined the contribution of diarrhea caused by Cryptosporidium and Giardia found in groundwater sources used for drinking to the total burden of diarrheal disease among children < 5 in rural India.Methodology/Principal findingsWe studied a population of 3,385 children < 5 years of age in 100 communities of Puri District, Odisha, India. We developed a coupled quantitative microbial risk assessment (QMRA) and susceptible-infected-recovered (SIR) population model based on observed levels of Cryptosporidium and Giardia in improved groundwater sources used for drinking and compared the QMRA-SIR estimates with independently measured all-cause (i.e., all fecal-oral enteric pathogens and exposure pathways) child diarrhea prevalence rates observed in the study population during two monsoon seasons (2012 and 2013). We used site specific and regional studies to inform assumptions about the human pathogenicity of the Cryptosporidium and Giardia species present in local groundwater. In all three human pathogenicity scenarios evaluated, the mean daily risk of Cryptosporidium or Giardia infection (0.06–1.53%), far exceeded the tolerable daily risk of infection from drinking water in the US (< 0.0001%). Depending on which protozoa species were present, median estimates of daily child diarrhea prevalence due to either Cryptosporidium or Giardia infection from drinking water was as high as 6.5% or as low as < 1% and accounted for at least 2.9% and as much as 65.8% of the all-cause diarrhea disease burden measured in children < 5 during the study period. Cryptosporidium tended to account for a greater share of estimated waterborne protozoa infections causing diarrhea than did Giardia. Diarrhea prevalence estimates for waterborne Cryptosporidium infection appeared to be most sensitive to assumptions about the probability of infection from ingesting a single parasite (i.e. the rate parameter in dose-response model), while Giardia infection was most sensitive to assumptions about the viability of parasites detected in groundwater samples.Conclusions/SignificanceProtozoa in groundwater drinking sources in rural India, even at low concentrations, especially for Cryptosporidium, may account for a significant portion of child diarrhea morbidity in settings were tubewells are used for drinking water and should be more systematically monitored. Preventing diarrheal disease burdens in Puri District and similar settings will benefit from ensuring water is microbiologically safe for consumption and consistent and effective household water treatment is practiced.