Predictors of diarrhea and respiratory disease and use of serological markers to assess the health impact of a household filtration intervention among young children in Western Province, Rwanda Open Access

Zambrano, Laura Divens (2016)

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Diarrhea and acute lower respiratory infection (ALRI) are the two largest contributors to childhood morbidity and mortality in Sub-Saharan Africa and are primarily attributable to poor water quality, inadequate sanitation and hygiene and exposure to household air pollution from cooking with biomass fuels. Household filtration interventions significantly reduce diarrheal disease, even in the absence of any improvements to sanitation facilities. Interventions addressing household air pollution exposures have had varying degrees of success given the substantial reductions in fine particulate matter exposure (e.g., PM2.5) required to have a measurable health effect. This dissertation leverages the baseline round of a large cluster-randomized controlled trial of a household water filter and a wood-burning rocket stove to characterize household characteristics and environmental exposures that are associated with diarrhea and ALRI. Seroconversion between baseline and follow-up against various enteropathogens was also assessed relative to study arm assignment and recent diarrheal disease. Multilevel analyses accounting for the complex survey design of the two cross-sectional studies of the baseline data revealed several household characteristics that were associated with diarrhea and ALRI. Compared to protected spring water sources, piped water sources and dug wells were protective against diarrheal disease while standpipes, boreholes and surface water sources were associated with excess risk. Compared with pit latrines, diarrhea prevalence was higher in households that had shared sanitation and non-shared household composting toilets. Drinking water quality was not associated with diarrheal disease. While ALRI was not affected by household stove and cooking characteristics, PM2.5 exposures varied significantly by cooking location, fuel use and stove type. The third study examining seroconversion against various enteropathogens found that the water filter intervention significantly decreased Cryptosporidium seroconversion, that both Giardia and Cryptosporidium were associated with recent diarrheal disease and that seroconversion peaked after 12 months of age. This dissertation outlines particular household exposures that are disproportionately linked to childhood diarrhea and respiratory diseases, which should be useful to organizations and stakeholders working in this field. It also generates future directions for this research, particularly in the application of serological markers to the evaluation of water and sanitation interventions.

Table of Contents

Chapter 1 - Introduction. 1

Aims of Dissertation. 5

Chapter 2 - Diarrheal Disease and WASH. 9

Global Burden of Disease. 9

Access to Improved Water. 9

Access to Improved Sanitation. 10

Background of Methods to Assess Exposures and Disease. 10

Justification of nested seroconversion study within the RCT. 12

Chapter 3 - Pneumonia and Household Air Pollution. 18

Global Burden of Disease. 18

Hazards of PM2.5 exposure.18

Cooking habits and fuel sources. 19

Background for household air pollution exposure methods. 20

Biological mechanisms of HAP-associated pneumonia. 22

Chapter 4 - Study Context, Preliminary Data and Unifying Methods. 32

Study Site, Population and Household Characteristics. 32

Intervention information. 33

Preliminary Data from Pilot Phase and Phase 1. 34

Unifying Methods for Dissertation Aims. 37

Chapter 5 - Predictors of diarrhea and coliform contamination of drinking water; a cross-sectional study in Western Province, Rwanda. 44

Chapter 6 - Predictors of acute respiratory infection, pneumonia and household air pollution; a cross sectional study in Western Province, Rwanda. 100

Chapter 7 - Assessing seroconversion against enteropathogens relative to reported diarrhea and the receipt of a point-of-use water filter in Western Province, Rwanda. 158

Chapter 8 - Conclusion. 199

References. 207

Appendix 1 - IRB Documentation. 228

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