Waterborne exposure during non-consumptive domestic use of surface water: a population study across WASH service levels in rural India.

Exposure to pathogens from domestic use of surface water is understudied. In many low- and middle-income countries, surface water is used for hygiene, sanitation, amenity, and recreational purposes. In this study, self-reported use of and structured observations at community ponds were collected to measure waterborne exposure across water and sanitation service levels in a rural population of Khorda District, India.

Estimating Cryptosporidium and Giardia disease burdens for children drinking untreated groundwater in a rural population in India.

Background: In 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 Findings: We studied a population of 3,385 children < 5 years of age in 100 communities of Puri District, Odisha, India.

Processes and challenges of community mobilisation for latrine promotion under Nirmal Bharat Abhiyan in rural Odisha, India.

Background: Despite efforts to eradicate it, open defecation remains widely practiced in India, especially in rural areas. Between 2013 and 2014, 50 villages in one district of Odisha, India, received a sanitation programme under the Nirmal Bharat Abhiyan (NBA - "Clean India Campaign"), the successor of India's Total Sanitation Campaign. This paper documents the strategies and processes of NBA community mobilisation for latrine promotion in these villages and assesses the strengths and limitations of the mobilisation activities.

Adopt or Adapt: Sanitation Technology Choices in Urbanizing Malawi.

This paper presents the results of a mixed-methods study examining adaptation strategies that property owners in low-income, rapidly urbanizing areas in Malawi adopt to address the limitations of pit latrines, the most common method of disposing human excreta. A particular challenge is lack of space for constructing new latrines as population density increases: traditional practice has been to cap full pits and simply move to a new site, but increasing demands on space require new approaches to extend the service life of latrines. In this context, we collected data on sanitation technology choices from January to September 2013 through 48 in-depth interviews and a stated preference survey targeting 1,300 property owners from 27 low-income urban areas.

Modeling Cryptosporidium and Giardia in Ground and Surface Water Sources in Rural India: Associations with Latrines, Livestock, Damaged Wells, and Rainfall Patterns.

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).

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

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.

Infant and Young Child Feces Management and Enabling Products for Their Hygienic Collection, Transport, and Disposal in Cambodia.

In Cambodia, children's feces are rarely disposed of in an improved sanitation facility. This study examines current practices and the role that enabling products may play in increasing hygienic management of infant and young child (IYC) feces in households with access to improved sanitation. A survey was conducted with the primary caregiver of a child under 5 years of age in 130 homes with an improved latrine in 21 villages across two provinces in Cambodia.

Development of A Multidimensional Scale to Assess Attitudinal Determinants of Sanitation Uptake and Use.

Over 1 billion people still practice open defecation. Low uptake and use of new sanitation technologies in a number of settings has underscored our current limited understanding of the complex attitudinal factors that influence a household's decision to adopt and use new sanitation technologies. Mokken scaling techniques were applied to series of population-based surveys in Odisha, India between September 2011 and October 2013 (sample sizes 120, 500, 2200).

Socio-cultural and behavioural factors constraining latrine adoption in rural coastal Odisha: an exploratory qualitative study.

Background: Open defecation is widely practiced in India. To improve sanitation and promote better health, the Government of India (GOI) has instituted large scale sanitation programmes supporting construction of public and institutional toilets and extending financial subsidies for poor families in rural areas for building individual household latrines. Nevertheless, many household latrines in rural India, built with government subsidies and the facilitation and support of non-government organizations (NGO), remain unused.

Human and Animal Fecal Contamination of Community Water Sources, Stored Drinking Water and Hands in Rural India Measured with Validated Microbial Source Tracking Assays.

We examined pathways of exposure to fecal contamination of human and animal origin in 24 villages in Odisha, India. In a cross-sectional study during the monsoon season, fecal exposure via community water sources (N = 123) and in the home (N = 137) was assessed using human- and nonhuman-associated Bacteroidales microbial source tracking (MST) markers and fecal coliforms (FCs). Detection rates and marker concentrations were examined to pinpoint pathways of human fecal exposure in the public and domestic domains of disease transmission in study communities.

Cryptosporidium and Giardia in Humans, Domestic Animals, and Village Water Sources in Rural India.

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.

Pit latrine emptying behavior and demand for sanitation services in Dar Es Salaam, Tanzania.

Pit latrines are the main form of sanitation in unplanned areas in many rapidly growing developing cities. Understanding demand for pit latrine fecal sludge management (FSM) services in these communities is important for designing demand-responsive sanitation services and policies to improve public health. We examine latrine emptying knowledge, attitudes, behavior, trends and rates of safe/unsafe emptying, and measure demand for a new hygienic latrine emptying service in unplanned communities in Dar Es Salaam (Dar), Tanzania, using data from a cross-sectional survey at 662 residential properties in 35 unplanned sub-wards across Dar, where 97% had pit latrines.

Effectiveness of a rural sanitation programme on diarrhoea, soil-transmitted helminth infection, and child malnutrition in Odisha, India: a cluster-randomised trial.

Background: A third of the 2·5 billion people worldwide without access to improved sanitation live in India, as do two-thirds of the 1·1 billion practising open defecation and a quarter of the 1·5 million who die annually from diarrhoeal diseases. We aimed to assess the effectiveness of a rural sanitation intervention, within the context of the Government of India's Total Sanitation Campaign, to prevent diarrhoea, soil-transmitted helminth infection, and child malnutrition.

Methods: We did a cluster-randomised controlled trial between May 20, 2010, and Dec 22, 2013, in 100 rural villages in Odisha, India.

Validation of Bacteroidales quantitative PCR assays targeting human and animal fecal contamination in the public and domestic domains in India.

We compared host-associated Bacteroidales qPCR assays developed in the continental United States and Europe for the purpose of measuring the effect of improved sanitation on human fecal exposure in rural Indian communities where both human and animal fecal loading are high. Ten candidate Bacteroidales qPCR assays were tested against fecal samples (human, sewage, cow, buffalo, goat, sheep, dog and chicken) from a test set of 30 individual human, 5 sewage, and 60 pooled animal samples collected in coastal Odisha, India. The two universal/general Bacteroidales assays tested (BacUni, GenBac3) performed equally well, achieving 100% sensitivity on the test set.

Measuring the safety of excreta disposal behavior in India with the new Safe San Index: reliability, validity and utility.

Methods to assess household excreta disposal practices are critical for informing public health outcomes of efforts to improve sanitation in developing countries. We present a new metric, the Safe San Index (SSI), to quantify the hygienic safety of a household's defecation and human feces disposal practices in India, where behavioral outcomes from on-going public expenditures to construct household sanitation facilities and eliminate open defecation are poorly measured. We define hygienic safety of feces disposal as capture in a hygienic sanitation facility.

Opportunities to improve domestic hygiene practices through new enabling products: a study of handwashing practices and equipment in rural Cambodia.

Background: Lack of a dedicated place and equipment for handwashing has been associated with poor practice of handwashing with soap in the home in developing communities where the practice is needed to reduce diarrhea diseases and respiratory infections.

Methods: We conducted formative research on handwashing knowledge, attitudes, practices and equipment and investigated the need and demand for dedicated handwashing equipment to enable improved hygiene practices and enhance handwashing performance for health in rural Cambodian homes where water is collected and stored. Responses to closed and open-ended questions and structured observation of a demonstration of handwashing by the mother or another female adult child caretaker in 79 households were used to identify handwashing occasions, evaluate handwashing equipment and competency, investigate attitudes and structural barriers to handwashing with soap, and assess use of and interest in dedicated handwashing equipment.

The effect of improved rural sanitation on diarrhoea and helminth infection: design of a cluster-randomized trial in Orissa, India.

Background: Infectious diseases associated with poor sanitation such as diarrhoea, intestinal worms, trachoma and lymphatic filariasis continue to cause a large disease burden in low income settings and contribute substantially to child mortality and morbidity. Obtaining health impact data for rural sanitation campaigns poses a number of methodological challenges. Here we describe the design of a village-level cluster-randomised trial in the state of Orissa, India to evaluate the impact of an ongoing rural sanitation campaign conducted under the umbrella of India's Total Sanitation Campaign (TSC).

Relative benefits of on-plot water supply over other 'improved' sources in rural Vietnam.

Objective: Access to improved water sources is rapidly expanding in rural central Vietnam. We examined one NGO-led piped water supply programme to assess the drinking water quality and health impacts of piped water systems where access to 'improved' water sources is already good.

Methods: This longitudinal, prospective cohort study followed 300 households in seven project areas in Da Nang province, Vietnam: 224 households who paid for an on-plot piped water connection and 76 control households from the same areas relying primarily on 'improved' water sources outside the home.

Bacterial, viral and turbidity removal by intermittent slow sand filtration for household use in developing countries: experimental investigation and modeling.

A two-factor three-block experimental design was developed to permit rigorous evaluation and modeling of the main effects and interactions of sand size (d(10) of 0.17 and 0.52 mm) and hydraulic head (10, 20, and 30 cm) on removal of fecal coliform (FC) bacteria, MS2 bacteriophage virus, and turbidity, under two batch operating modes ('long' and 'short') in intermittent slow sand filters (ISSFs).

Interventions to improve disposal of human excreta for preventing diarrhoea.

Background: Diarrhoeal diseases are a leading cause of mortality and morbidity, especially among young children in low-income countries, and are associated with exposure to human excreta.

Objectives: To assess the effectiveness of interventions to improve the disposal of human excreta for preventing diarrhoeal diseases.

Search Strategy: We searched the Cochrane Infectious Disease Group Specialized Register; the Cochrane Central Register of Controlled Trials (CENTRAL), published in The Cochrane Library; MEDLINE; EMBASE; LILACS; the metaRegister of Controlled Trials (mRCT); and Chinese-language databases available under the Wan Fang portal, and the China National Knowledge Infrastructure (CNKI-CAJ).

Modelling latrine diffusion in Benin: towards a community typology of demand for improved sanitation in developing countries.

Latrine diffusion patterns across 502 villages in Benin, West Africa, were analysed to explore factors driving initial and increasing levels of household adoption in low-coverage rural areas of sub-Saharan Africa. Variables explaining adoption related to population density, size, infrastructure/services, non-agricultural occupations, road and urban proximity, and the nearby latrine adoption rate, capturing differences in the physical and social environment, lifestyles and latrine exposure involved in stimulating status/prestige and well-being reasons for latrine adoption. Contagion was most important in explaining adoption initiation.

Intermittent slow sand filtration for preventing diarrhoea among children in Kenyan households using unimproved water sources: randomized controlled trial.

Objective: Measure effectiveness of intermittent slow sand filtration for reducing child diarrhoea among households using unimproved water sources in rural Kenya.

Methods: A randomized controlled trail was conducted among populations meeting a high-risk profile for child diarrhoea from drinking river water in the River Njoro watershed. Intervention households (30) were provided the concrete BioSand Filter and instructed on filter use and maintenance.

Identifying human and livestock sources of fecal contamination in Kenya with host-specific Bacteroidales assays.

Microbial source tracking to distinguish between human, livestock and wildlife fecal pollution using molecular techniques is a rapidly evolving approach in many developed countries, but has not previously been applied on the African continent. DNA extracts from cow, donkey, and human fecal specimens and raw domestic sewage samples collected in Kenya were tested against five existing quantitative PCR assays designed to detect universal (2), human-specific (2), and cow-specific (1) fecal Bacteroidales genetic markers. Water samples from the River Njoro in Kenya were evaluated using the five tested Bacteroidales markers and a multi-species assay for Cryptosporidium in a preliminary exploration of fecal pollution sources and health risks in this watershed.

Behavioral indicators of household decision-making and demand for sanitation and potential gains from social marketing in Ghana.

Household demand for improved sanitation in developing countries is an important social and behavioral process with implications for public health, sanitation policy and planning, and sanitation design and technology development. This paper develops a behavioral approach to assess household demand for improved sanitation in Ghana. Adoption decision stages of preference, intention, and choice to install a toilet in Ghana are defined, measured in a survey, and used to estimate sanitation demand, identify factors affecting demand at each stage, and classify households by adoption stage to identify targeted demand-stimulation strategies.

Achieving the 'good life': why some people want latrines in rural Benin.

Nearly half the world's population lacks basic sanitation to protect their environment from human fecal contamination. Building a latrine is the first step on the sanitation ladder in developing countries where a majority of the population defecates in open or public areas. Public health programs to improve sanitation have consistently framed promotional messages in terms of fecal-oral disease prevention and largely fail to motivate changes in sanitation behavior.