Assessing the association between the Escherichia coli counts in household drinking water and other risk factors with the occurrence of diarrhea in children under-five across four countries. Open Access

Ravi Kumar, Vishnu (Spring 2019)

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Background: Diarrhoeal diseases remain an important cause of mortality and morbidity among children, particularly in low- and middle-income countries. Diarrheal disease leads to around 525,000 deaths in the children under the age of five and is the second leading cause of under-five childhood deaths. Water quality is an important determinant of diarrheal disease but is captured in only a limited number of large routine population-based surveys. The aim of this study was to assess the association between E.coli counts in drinking water and the occurrence of diarrhea among children aged 0-5 years.  

Methods:  Multiple Indicator Cluster Surveys (MICS), a cross-sectional household survey, was conducted in Bangladesh, Nepal, Republic of Congo and Paraguay. The survey included an indicator for diarrhoea episodes in the two weeks preceding the survey, as recalled by the primary caregiver, and E.coli counts in drinking water. The sample size was 3609 children, yielding information on sociodemographic, environmental and hygiene related behavioural factors of the household. Mixed univariable and multivariable logistic regression analyses was used to identify the risk factors associated with the occurrence of diarrhoea in children under-five.

Results: The reported prevalence of diarrhoea among children under the age of five during the 2 weeks preceding the survey was 12%. Univariable and the multivariable analysis showed there to be no association between the incidence of diarrhea and the E.coli counts in the drinking water. Multivariable regression revealed an association between the incidence of diarrhea in children under-five and the source of drinking water, wealth index of the household and age (in years) of the child.

Conclusion: The results of this study reveal that there is no association between E.coli-based water quality measures on the day of the survey and the outcome of diarrhea. This may be because both exposure and outcome are imprecise; paternal recall is associated with bias and E.coli counts may not be a good predictor of the full extent of pathogen exposure in the drinking water or the overall environmental exposure. 

Table of Contents


Introduction      2

Water, sanitation and diarrhea  3

Countries            4

Microbiological indicators and Escherichia Coli   6

Risk factors        7

Research question:         9

Objectives:         9

Inclusion criteria:            10


Introduction      12

Methods             14

Results 18

Discussion          20


Table 1: Socio-demographic features of under-five children and households in the four countries that were surveyed.    27

Table 2. Unadjusted Analysis of Risk Factors Associated with Diarrhea in under-five children              29

Table 3. Multivariable Analysis of risk factors associated with diarrhea in under-five children              30

CHAPTER III       31



Table 2a. Bangladesh Unadjusted Analysis of Risk Factors Associated with Diarrhea.          48

Table 2b. Nepal Unadjusted Analysis of Risk Factors Associated with Diarrhea.     49

Table 2c. Paraguay: Unadjusted Analysis of Risk Factors Associated with Diarrhea              50

Table 2d. The Republic of Congo: Unadjusted Analysis of Risk Factors Associated with Diarrhea              51

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