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

Abstract

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.

Household sanitation is associated with lower risk of bacterial and protozoal enteric infections, but not viral infections and diarrhoea, in a cohort study in a low‐income urban neighbourhood in Vellore, India

“…While further research is needed to substantiate this observation, it may reflect the poor containment of faeces from these toilets. Owning and using toilets that discharged to open drains may have been of limited benefit during periods of heavy monsoon or flooding because of the high levels of human‐specific faecal contamination discharged into the immediate environment . Previous cross‐sectional evidence from this population has shown that children in households with toilets that discharged to open drains had the highest prevalence of enteric infection, even compared to those in households without toilets, suggesting that contamination of the immediate environment may have reduced the health benefits associated with toilet ownership .…”

“…Annually, Vellore has a dry season (January–May), a southwest monsoon (June–September) and a northeast monsoon (October–December) . Old Town is a small, low‐income urban neighbourhood with high population density (approximately 42 000/km 2 ), poor sanitation and high burden of enteric disease . CMC has a longstanding relationship with the community, including mapping from previous studies .…”

“…Household selection has been previously described in detail . Briefly, 100 households were surveyed (as prespecified in the SaniPath tool), 25 of which were selected based on the results of a hygiene survey completed prior to SaniPath Tool deployment to ensure diversity of household hygiene practices .…”

“…When functioning, both household and public toilets, along with proper faecal sludge management (FSM), contain excreta from human contact throughout the sanitation chain at the household and neighbourhood levels . However, these urban environments may easily become contaminated with faeces and aetiologic agents due to poor maintenance and cleanliness of the sanitation facility and poor FSM, which in turn pose risks to users and local residents .…”

Associations between open drain flooding and pediatric enteric infections in the MAL-ED cohort in a low-income, urban neighborhood in Vellore, India

“…Annually, Vellore has a dry season (January – May), a southwest monsoon (June – September), and a northeast monsoon (October – December) [43]. Old Town is a small, low-income urban neighborhood with high population density (approximately 42,000/km 2 ), poor sanitation, and high burden of enteric disease [28, 43]. CMC has a longstanding relationship with the community, including mapping of neighborhood infrastructure (e.g.…”