{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,8,19]],"date-time":"2026-08-19T05:14:22Z","timestamp":1787116462205,"version":"build-2736575974"},"reference-count":56,"publisher":"MDPI AG","issue":"21","license":[{"start":{"date-parts":[[2020,11,2]],"date-time":"2020-11-02T00:00:00Z","timestamp":1604275200000},"content-version":"vor","delay-in-days":0,"URL":"https:\/\/creativecommons.org\/licenses\/by\/4.0\/"}],"funder":[{"name":"NASA\u2019s Group on Earth Observations Work Programme","award":["16-GEO16-0047"],"award-info":[{"award-number":["16-GEO16-0047"]}]},{"DOI":"10.13039\/100000060","name":"National Institute of Allergy and Infectious Diseases","doi-asserted-by":"publisher","award":["1R03AI151564-01"],"award-info":[{"award-number":["1R03AI151564-01"]}],"id":[{"id":"10.13039\/100000060","id-type":"DOI","asserted-by":"publisher"}]}],"content-domain":{"domain":[],"crossmark-restriction":false},"short-container-title":["IJERPH"],"abstract":"<jats:p>Diarrheal disease remains a major cause of childhood mortality and morbidity causing poor health and economic outcomes. In low-resource settings, young children are exposed to numerous risk factors for enteric pathogen transmission within their dwellings, though the relative importance of different transmission pathways varies by pathogen species. The objective of this analysis was to model associations between five household-level risk factors\u2014water, sanitation, flooring, caregiver education, and crowding\u2014and infection status for endemic enteric pathogens in children in five surveillance studies. Data were combined from 22 sites in which a total of 58,000 stool samples were tested for 16 specific enteropathogens using qPCR. Risk ratios for pathogen- and taxon-specific infection status were modeled using generalized linear models along with hazard ratios for all-cause diarrhea in proportional hazard models, with the five household-level variables as primary exposures adjusting for covariates. Improved drinking water sources conferred a 17% reduction in diarrhea risk; however, the direction of its association with particular pathogens was inconsistent. Improved sanitation was associated with a 9% reduction in diarrhea risk with protective effects across pathogen species and taxa of around 10\u201320% risk reduction. A 9% reduction in diarrhea risk was observed in subjects with covered floors, which were also associated with decreases in risk for zoonotic enteropathogens. Caregiver education and household crowding showed more modest, inconclusive results. Combining data from diverse sites, this analysis quantified associations between five household-level exposures on risk of specific enteric infections, effects which differed by pathogen species but were broadly consistent with hypothesized transmission mechanisms. Such estimates may be used within expanded water, sanitation, and hygiene (WASH) programs to target interventions to the particular pathogen profiles of individual communities and prioritize resources.<\/jats:p>","DOI":"10.3390\/ijerph17218078","type":"journal-article","created":{"date-parts":[[2020,11,2]],"date-time":"2020-11-02T19:51:31Z","timestamp":1604346691000},"page":"8078","update-policy":"https:\/\/doi.org\/10.3390\/mdpi_crossmark_policy","source":"Crossref","is-referenced-by-count":33,"title":["Associations between Household-Level Exposures and All-Cause Diarrhea and Pathogen-Specific Enteric Infections in Children Enrolled in Five Sentinel Surveillance Studies"],"prefix":"10.3390","volume":"17","author":[{"ORCID":"https:\/\/orcid.org\/0000-0003-4567-5813","authenticated-orcid":false,"given":"Josh M.","family":"Colston","sequence":"first","affiliation":[{"name":"Division of Infectious Diseases and International Health, University of Virginia School of Medicine, Charlottesville, VA 22903, USA"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Abu S. G.","family":"Faruque","sequence":"additional","affiliation":[{"name":"Centre for Nutrition &amp; Food Security, International Centre for Diarrhoeal Disease Research, Dhaka 1212, Bangladesh"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"M. Jahangir","family":"Hossain","sequence":"additional","affiliation":[{"name":"Medical Research Council Unit\u2014The Gambia at the London School of Hygiene &amp; Tropical Medicine, Banjul P.O. Box 273, Republic of Gambia"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Debasish","family":"Saha","sequence":"additional","affiliation":[{"name":"Epidemiology and Health Economics, GSK Vaccines, 1300 Wavre, Belgium"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Suman","family":"Kanungo","sequence":"additional","affiliation":[{"name":"Suman Kanungo\u2014National Institute of Cholera and Enteric Diseases, Kolkota 700010, India"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"In\u00e1cio","family":"Mandomando","sequence":"additional","affiliation":[{"name":"Centro de Investiga\u00e7\u00e3o em Sa\u00fade de Manhi\u00e7a, Manhica CP 1929, Mozambique"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0002-2378-4720","authenticated-orcid":false,"given":"M. Imran","family":"Nisar","sequence":"additional","affiliation":[{"name":"Department of Pediatrics and Child Health, The Aga Khan University, Karachi 74800, Pakistan"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Anita K. M.","family":"Zaidi","sequence":"additional","affiliation":[{"name":"Department of Pediatrics and Child Health, The Aga Khan University, Karachi 74800, Pakistan"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Richard","family":"Omore","sequence":"additional","affiliation":[{"name":"Kenya Medical Research Institute, Center for Global Health Research, Kisumu, Nyanza 40100, Kenya"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Robert F.","family":"Breiman","sequence":"additional","affiliation":[{"name":"Hubert Department of Global Health, Rollins School of Public Health, Emory University, Atlanta, GA 30322, USA"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Samba O.","family":"Sow","sequence":"additional","affiliation":[{"name":"Centre pour le D\u00e9veloppement des Vaccins, Bamako BP 251, Mali"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0001-7020-0380","authenticated-orcid":false,"given":"Anna","family":"Roose","sequence":"additional","affiliation":[{"name":"Indiana University School of Medicine, Indianapolis, IN 46202, USA"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Myron M.","family":"Levine","sequence":"additional","affiliation":[{"name":"Departments of Medicine and Pediatrics, Center for Vaccine Development and Global Health, University of Maryland School of Medicine, Baltimore, MD 21201, USA"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Karen L.","family":"Kotloff","sequence":"additional","affiliation":[{"name":"Department of Pediatrics, Center for Vaccine Development and Global Health, University of Maryland School of Medicine, Baltimore, MD 21201, USA"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Tahmeed","family":"Ahmed","sequence":"additional","affiliation":[{"name":"Nutrition and Clinical Services Division, International Centre for Diarrhoeal Disease Research, Bangladesh (icddr,b), Dhaka 1212, Bangladesh"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Pascal","family":"Bessong","sequence":"additional","affiliation":[{"name":"HIV\/AIDS &amp; Global Health Research Programme, University of Venda, Thohoyandou, Limpopo 0950, South Africa"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0003-0637-599X","authenticated-orcid":false,"given":"Zulfiqar","family":"Bhutta","sequence":"additional","affiliation":[{"name":"Department of Pediatrics and Child Health, Aga Khan University, Karachi 74800, Pakistan"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Estomih","family":"Mduma","sequence":"additional","affiliation":[{"name":"Haydom Global Health Institute, Haydom P.O. Box 9000, Tanzania"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Pablo","family":"Penatero Yori","sequence":"additional","affiliation":[{"name":"Division of Infectious Diseases and International Health, University of Virginia School of Medicine, Charlottesville, VA 22903, USA"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Prakash","family":"Sunder Shrestha","sequence":"additional","affiliation":[{"name":"Department of Child Health, Institute of Medicine of Tribhuvan University, Kirtipur 44618, Nepal"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Maribel P.","family":"Olortegui","sequence":"additional","affiliation":[{"name":"Asociacion Benefica PRISMA, Iquitos 16006, Peru"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Gagandeep","family":"Kang","sequence":"additional","affiliation":[{"name":"Department of Gastrointestinal Sciences, Christian Medical College, Vellore 632004, India"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Aldo A. M.","family":"Lima","sequence":"additional","affiliation":[{"name":"Department of Physiology and Pharmacology, Faculty of Medicine, Federal University of Cear\u00e1, Fortaleza 60020-181, Brazil"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Jean","family":"Humphrey","sequence":"additional","affiliation":[{"name":"Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, MA 21205, USA"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Andrew","family":"Prendergast","sequence":"additional","affiliation":[{"name":"Centre for Paediatrics, Blizard Institute, Queen Mary University of London, London E1 2AT, UK"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0002-5796-5116","authenticated-orcid":false,"given":"Francesca","family":"Schiaffino","sequence":"additional","affiliation":[{"name":"Faculty of Veterinary Medicine, Universidad Peruana Cayetano Heredia, Lima 15102, Peru"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Benjamin F.","family":"Zaitchik","sequence":"additional","affiliation":[{"name":"Department of Earth and Planetary Sciences, Johns Hopkins Krieger School of Arts and Sciences, Baltimore, MA 21218, USA"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Margaret N.","family":"Kosek","sequence":"additional","affiliation":[{"name":"Division of Infectious Diseases, International Health and Public Health Sciences, Department of Internal Medicine, University of Virginia, Charlottesville, VA 22903, USA"}],"role":[{"vocabulary":"crossref","role":"author"}]}],"member":"1968","published-online":{"date-parts":[[2020,11,2]]},"reference":[{"key":"ref_1","doi-asserted-by":"crossref","first-page":"3027","DOI":"10.1016\/S0140-6736(16)31593-8","article-title":"Global, regional, and national causes of under-5 mortality in 2000\u201315: An updated systematic analysis with implications for the Sustainable Development Goals","volume":"388","author":"Liu","year":"2016","journal-title":"Lancet"},{"key":"ref_2","doi-asserted-by":"crossref","first-page":"209","DOI":"10.1016\/S0140-6736(13)60844-2","article-title":"Burden and aetiology of diarrhoeal disease in infants and young children in developing countries (the Global Enteric Multicenter Study, GEMS): A prospective, case-control study","volume":"382","author":"Kotloff","year":"2013","journal-title":"Lancet"},{"key":"ref_3","doi-asserted-by":"crossref","first-page":"909","DOI":"10.1016\/S1473-3099(17)30276-1","article-title":"Estimates of global, regional, and national morbidity, mortality, and aetiologies of diarrhoeal diseases: A systematic analysis for the Global Burden of Disease Study 2015","volume":"17","author":"Troeger","year":"2017","journal-title":"Lancet Infect. 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