Study design and rationale for a cluster randomized trial of a safe child feces management intervention in rural Odisha, India

Background Poor child feces management (CFM) is believed to be an important source of exposure to enteric pathogens that contribute to a large disease burden in low-income settings. While access to sanitation facilities is improving, national surveys indicate that even households with latrines often do not safely dispose of their child’s feces. Working with caregivers in rural Odisha, India, we co-developed an intervention aimed at improving safe disposal of child feces and encouraging child latrine use at an earlier age. We describe the rationale for the intervention and summarize the protocol for a cluster randomized trial (CRT) to evaluate its effectiveness at changing CFM practices. Methods The intervention consists of six behavior change strategies together with hardware provision: wash basin and bucket with lid to aid safe management of soiled nappies and a novel latrine training mat to aid safe disposal and latrine training. The intervention will be offered at the village level to interested caregivers of children < 5 years of age by a community-based organization. Following a baseline survey, 74 villages were randomly allocated to either intervention or control arm. The primary outcome is caregiver reported safe disposal of child feces after last defecation, either by the caregiver disposing of the child’s feces into the latrine or the child using the latrine, measured approximately four to six months following intervention delivery. Secondary outcomes include fecal contamination of household drinking water and the childs’ hands. A process evaluation will also be conducted to assess intervention fidelity and reach, and explore implementer and participant feedback. Discussion This study addresses a crucial knowledge gap in sanitation by developing a scalable intervention to improve safe management of child feces. The behavior change strategies were designed following the Risks, Attitudes, Norms, Abilities and Self-Regulation (RANAS) approach, which has shown to be effective for other environmental behavior change interventions in low-income settings. The latrine training mat hardware is a novel design developed cooperatively and manufactured locally. The evaluation follows a rigorous CRT study design assessing the impact of the intervention on CFM behavior change, as well as fecal contamination of two sources of potential exposure. Trial registration This trial is registered at ISRCTN: ISRCTN15831099.

Microbial source tracking and antimicrobial resistance in one river system of a rural community in Bahia, Brazil

Use of antibiotics inevitably leads to antimicrobial resistance. Selection for resistance occurs primarily within the gut of humans and animals as well as in the environment through natural resistance and residual antibiotics in streams and soil. We evaluated antimicrobial resistance in Gram negative bacteria from a river system in a rural community in Bahia, Brazil. Water was collected from the Jiquiriçá and Brejões rivers and the piped water supply. Additionally, stools were collected from a random sample of residents, cows, pigs and horses near the river. The samples were screened for bacteria resistant to ciprofloxacin, cefotaxime, and meropenem and identified biochemically at the genus and species levels. Microbial source tracking demonstrated that ruminant and human fecal contamination increased as the rivers neared the village center and decreased after the last residence. Antibiotic bacteria were identified from all samples (n = 32). No bacteria were resistant to carbapenems, but the majority of the enterobacteria were resistant to ciprofloxacin, even though this class of antibiotics is not commonly used in food animals in this region. Considering these facts, together with the pattern of human fecal contamination, a human source was considered most likely for these resistant isolates.

The impact of on-premises piped water supply on fecal contamination pathways in rural Zambia

Reliable access to water, sanitation, and hygiene (WASH) services is a critical component of child health and development. However, as piped water systems with taps conveniently close to households are rare in rural, sub-Saharan Africa, there is limited evidence of their impact. We conducted a quasi-experimental study in four rural villages of southern Zambia between April 2018 and May 2019 in which we measured the impact of installing on-premises piped water systems on fecal contamination of stored water and caregivers’ hands. Gaining access to piped water was associated with a 0.5 log10 reduction of E. coli concentration in drinking water (p < 0.05) but no changes in hand contamination. The piped water systems in this study reduced the median distance to a safe drinking water source by over 90%, but we measured only small improvements in microbiological outcomes and no changes in the duration of self-reported, in-home water storage. These findings emphasize the need for future impact assessments of piped water systems to measure a comprehensive set of indicators directly linked to human well-being such as time savings.

Transcriptomic and rRNA:rDNA Signatures of Environmental versus Enteric Enterococcus faecalis Isolates under Oligotrophic Freshwater Conditions

Enterococci are commonly used worldwide to monitor environmental fecal contamination and public health risk for waterborne diseases. However, closely related enterococci strains adapted to living in the extraenteric environment may represent a lower public health risk and confound water quality estimates.

Is It Human or Animal? The Origin of Pathogenic E. coli in the Drinking Water of a Low-Income Urban Community in Bangladesh

This study aimed to investigate the origin of diverse pathotypes of E. coli, isolated from communal water sources and from the actual drinking water vessel at the point-of-drinking inside households in a low-income urban community in Arichpur, Dhaka, Bangladesh, using a polymerase chain reaction (PCR). Forty-six percent (57/125, CI 95%: 41−58) of the isolates in the point-of-drinking water and 53% (55/103, CI 95%: 45−64) of the isolates in the source water were diarrheagenic E. coli. Among the pathotypes, enterotoxigenic E. coli (ETEC) was the most common, 81% (46/57) of ETEC was found in the point-of-drinking water and 87% (48/55) was found in the communal source water. Phylogenetic group B1, which is predominant in animals, was the most frequently found isolate in both the point-of-drinking water (50%, 91/181) and in the source (50%, 89/180) water. The phylogenetic subgroup B23, usually of human origin, was more common in the point-of-drinking water (65%, 13/20) than in the source water (35%, 7/20). Our findings suggest that non-human mammals and birds played a vital role in fecal contamination for both the source and point-of-drinking water. Addressing human sanitation without a consideration of fecal contamination from livestock sources will not be enough to prevent drinking-water contamination and thus will persist as a greater contributor to diarrheal pathogens.

Public health risk of Giardia and Cryptosporidium infection from urban wildlife

Introduction/Objective The dedication of large areas in Anchorage for urban park environments encouraged increased interaction between migrating Canadian geese, approximately 1500 moose and humans. Urban wildlife inhabiting public establishments such as parking lots, creeks, playgrounds, and suburban backyards results in significant environmental fecal contamination. Previous studies found varying potential for zoonotic transmission of parasites through direct fecal contact or water contamination. With a significant number of vulnerable unsheltered individuals in Anchorage using public green belts, there is risk of asymptomatic, under diagnosed, parasitic infection due to exposure to fecal contamination. Methods/Case Report To assess environmental risk of parasitic zoonosis from urban wildlife, we surveyed fourteen high impact exposure areas including waterways and green spaces throughout Anchorage with ground collection of 106 fecal samples from moose (n=76) and geese (n=30). Using standard rapid antigen immunoassay detection method, we identified preserved samples for the presence of Cryptosporidium or Giardia. Results (if a Case Study enter NA) Overall evaluation of fecal samples found 23.6% positive for parasitic colonization in 87% of collection sites. Giardia was identified in 10.4% and Cryptosporidium in 13.2%. Comparative evaluation of each species found geese with a higher percentage of Cryptosporidium isolated (30%) when compared to moose (6%). Giardia was predominately found in moose (13%) with very few geese colonized. Conclusion Considering the high population of outdoor enthusiasts and a significant number of unsheltered individuals in Anchorage, discovering nearly a quarter of urban moose and geese colonized with Giardia and/or Cryptosporidium identifies a significant public health risk. Often using creeks and lagoons as their water source Anchorage’s vulnerable population includes a large number of immunocompromised HIV positive individuals in which parasitic infection, especially Cryptosporidium, can cause overall poor health and reduced quality of life. Therefore, active surveillance of parasitic colonization in urban wildlife is essential and continued evaluation necessary to determine public health risk.

Somewhere to go: Assessing the impact of public restroom interventions on reports of open defecation in San Francisco, California from 2014 to 2020

Background Open defecation due to a lack of access to sanitation facilities remains a public health issue in the United States. People experiencing homelessness face barriers to accessing sanitation facilities, and are often forced to practice open defecation on streets and sidewalks. Exposed feces may contain harmful pathogens posing a significant threat to public health, especially among unhoused persons living near open defecation sites. The City of San Francisco’s Department of Public Works implemented the Pit Stop Program to provide the unhoused and the general public with improved access to sanitation with the goal of reducing fecal contamination on streets and sidewalks. The objective of this study was to assess the impact of these public restroom interventions on reports of exposed feces in San Francisco, California. Methods We evaluated the impact of various public restroom interventions implemented from January 1, 2014 to January 1, 2020 on reports of exposed feces, captured through a 311 municipal service. Publicly available 311 reports of exposed feces were spatially and temporally matched to 31 Pit Stop restroom interventions in ten San Francisco neighborhoods. We conducted an interrupted time-series analysis to compare pre- versus post-intervention rates of feces reports near the restrooms. Results Feces reports declined by 12.47 reports per week after the installation of 13 Pit Stop restrooms (p-value = 0.0002). The rate of reports per week declined from the six-month pre-intervention period to the post-intervention period (slope change=-0.024 [95% CI=-0.033, -0.014]). Reports also declined after new restroom installations in the Mission and Golden Gate Park, and after the provision of attendants in the Mission, Castro/Upper Market, and Financial District/South Beach. Conclusions Increased access to public toilets and the addition of restroom attendants reduced fecal contamination in San Francisco, especially in neighborhoods with people experiencing homelessness. Programs that improve access to public restrooms should be evaluated at the neighborhood level in order to tailor sanitation interventions to neighborhood-specific needs.