Volume 90, Issue 4
  • ISSN: 0002-9637
  • E-ISSN: 1476-1645



Diarrheal disease remains a leading cause of morbidity in areas with limited access to safe water and sanitation. As water and sanitation interventions continue to be implemented, it will be important to understand the ecological context in which they can prevent diarrhea. We conducted six serial case control studies in Ecuador to estimate the risk of diarrhea from unimproved water and sanitation and the potential for effect modification by rainfall. Unimproved water source and unimproved sanitation increased the adjusted odds of diarrhea (odds ratio [OR] = 3.6, 95% confidence interval [95% CI] = 1.7–7.8 and OR = 1.7, 95% CI = 1.2–2.5, respectively). The OR associated with an unimproved water source was highest after maximum rainfall (OR = 6.8, 95% CI = 1.9–24.5), whereas the OR associated with unimproved sanitation was highest after minimal rainfall (OR = 2.9, 95% CI = 1.3–6.6). Our finding that use of safe water sources and improved sanitation facilities are most protective under opposing rainfall conditions highlights the need for integrated interventions to reduce the burden of diarrheal disease.


Article metrics loading...

The graphs shown below represent data from March 2017
Loading full text...

Full text loading...



  1. Boschi-Pinto C, Velebit L, Shibuya K, , 2008. Estimating child mortality due to diarrhoea in developing countries. Bull World Health Organ 86: 710717.[Crossref] [Google Scholar]
  2. Fink G, Gunther I, Hill K, , 2011. The effect of water and sanitation on child health: evidence from the demographic and health surveys 1986–2007. Int J Epidemiol 40: 11961204.[Crossref] [Google Scholar]
  3. Kosek M, Bern C, Guerrant RL, , 2003. The global burden of diarrhoeal disease, as estimated from studies published between 1992 and 2000. Bull World Health Organ 81: 197204. [Google Scholar]
  4. Pruss A, Kay D, Fewtrell L, Bartram J, , 2002. Estimating the burden of disease from water, sanitation, and hygiene at a global level. Environ Health Perspect 110: 537542.[Crossref] [Google Scholar]
  5. UN, 2011. United Nations, The Millennium Development Goals Report 2011. Available at: http://www.un.org/millenniumgoals/pdf/(2011_E)%20MDG%20Report%202011_Book%20LR.pdf. Accessed November 17, 2011. [Google Scholar]
  6. Cairncross S, Blumenthal U, Kolsky P, Moraes L, Tayeh A, , 1996. The public and domestic domains in the transmission of disease. Trop Med Int Health 1: 2734.[Crossref] [Google Scholar]
  7. Nmorsi OP, Agbozele G, Ukwandu NC, , 2007. Some aspects of epidemiology of filth flies: Musca domestica, Musca domestica vicina, Drosophilia melanogaster and associated bacteria pathogens in Ekpoma, Nigeria. Vector Borne Zoonotic Dis 7: 107117.[Crossref] [Google Scholar]
  8. Thomas KM, Charron DF, Waltner-Toews D, Schuster C, Maarouf AR, Holt JD, , 2006. A role of high impact weather events in waterborne disease outbreaks in Canada, 1975–2001. Int J Environ Health Res 16: 167180.[Crossref] [Google Scholar]
  9. Auld H, MacIver D, Klaassen J, , 2004. Heavy rainfall and waterborne disease outbreaks: the Walkerton example. J Toxicol Environ Health A 67: 18791887.[Crossref] [Google Scholar]
  10. Chou WC, Wu JL, Wang YC, Huang H, Sung FC, Chuang CY, , 2010. Modeling the impact of climate variability on diarrhea-associated diseases in Taiwan (1996–2007). Sci Total Environ 409: 4351.[Crossref] [Google Scholar]
  11. Drayna P, McLellan SL, Simpson P, Li SH, Gorelick MH, , 2010. Association between rainfall and pediatric emergency department visits for acute gastrointestinal illness. Environ Health Perspect 118: 14391443.[Crossref] [Google Scholar]
  12. Curriero FC, Patz JA, Rose JB, Lele S, , 2001. The association between extreme precipitation and waterborne disease outbreaks in the United States, 1948–1994. Am J Public Health 91: 11941199.[Crossref] [Google Scholar]
  13. Hashizume M, Armstrong B, Hajat S, Wagatsuma Y, Faruque AS, Hayashi T, Sack DA, , 2007. Association between climate variability and hospital visits for non-cholera diarrhoea in Bangladesh: effects and vulnerable groups. Int J Epidemiol 36: 10301037.[Crossref] [Google Scholar]
  14. Singh RB, Hales S, de Wet N, Raj R, Hearnden M, Weinstein P, , 2001. The influence of climate variation and change on diarrheal disease in the Pacific Islands. Environ Health Perspect 109: 155159.[Crossref] [Google Scholar]
  15. Gascon J, , 2006. Epidemiology, etiology and pathophysiology of traveler's diarrhea. Digestion 73 (Suppl 1): 102108.[Crossref] [Google Scholar]
  16. Bhavnani D, Goldstick JE, Cevallos W, Trueba G, Eisenberg JN, , 2012. Synergistic effects between rotavirus and coinfecting pathogens on diarrheal disease: evidence from a community-based study in northwestern Ecuador. Am J Epidemiol 176: 387395.[Crossref] [Google Scholar]
  17. WHO/UNICEF, 2011. WHO/UNICEF Joint Monitoring Programme (JMP) for Water Supply and Sanitation. Types of Drinking-Water Sources and Sanitation. Available at: http://www.wssinfo.org/definitions-methods/watsan-categories/. Accessed November 17, 2011. [Google Scholar]
  18. Zeger SL, Liang KY, , 1986. Longitudinal data analysis for discrete and continuous outcomes. Biometrics 42: 121130.[Crossref] [Google Scholar]
  19. Ochoa TJ, Ecker L, Barletta F, Mispireta ML, Gil AI, Contreras C, Molina M, Amemiya I, Verastegui H, Hall ER, Cleary TG, Lanata CF, , 2009. Age-related susceptibility to infection with diarrheagenic Escherichia coli among infants from Periurban areas in Lima, Peru. Clin Infect Dis 49: 16941702.[Crossref] [Google Scholar]
  20. Qadri F, Svennerholm AM, Faruque AS, Sack RB, , 2005. Enterotoxigenic Escherichia coli in developing countries: epidemiology, microbiology, clinical features, treatment, and prevention. Clin Microbiol Rev 18: 465483.[Crossref] [Google Scholar]
  21. Yeager BA, Lanata CF, Lazo F, Verastegui H, Black RE, , 1991. Transmission factors and socioeconomic status as determinants of diarrhoeal incidence in Lima, Peru. J Diarrhoeal Dis Res 9: 186193. [Google Scholar]
  22. Strina A, Rodrigues LC, Cairncross S, Ferrer SR, Fialho AM, Leite JP, Ribeiro HC, Jr Barreto ML, , 2012. Factors associated with rotavirus diarrhoea in children living in a socially diverse urban centre in Brazil. Trans R Soc Trop Med Hyg 106: 445451.[Crossref] [Google Scholar]
  23. Nundy S, Gilman RH, Xiao L, Cabrera L, Cama R, Ortega YR, Kahn G, Cama VA, , 2011. Wealth and its associations with enteric parasitic infections in a low-income community in Peru: use of principal component analysis. Am J Trop Med Hyg 84: 3842.[Crossref] [Google Scholar]
  24. Eisenberg JN, Scott JC, Porco T, , 2007. Integrating disease control strategies: balancing water sanitation and hygiene interventions to reduce diarrheal disease burden. Am J Public Health 97: 846852.[Crossref] [Google Scholar]
  25. VanDerslice J, Briscoe J, , 1995. Environmental interventions in developing countries: interactions and their implications. Am J Epidemiol 141: 135144.[Crossref] [Google Scholar]
  26. Saidi SM, Iijima Y, Sang WK, Mwangudza AK, Oundo JO, Taga K, Aihara M, Nagayama K, Yamamoto H, Waiyaki PG, Honda T, , 1997. Epidemiological study on infectious diarrheal diseases in children in a coastal rural area of Kenya. Microbiol Immunol 41: 773778.[Crossref] [Google Scholar]
  27. Levy K, Hubbard AE, Nelson KL, Eisenberg JN, , 2009. Drivers of water quality variability in northern coastal Ecuador. Environ Sci Technol 43: 17881797.[Crossref] [Google Scholar]
  28. Howard G, Pedley S, Barrett M, Nalubega M, Johal K, , 2003. Risk factors contributing to microbiological contamination of shallow groundwater in Kampala, Uganda. Water Res 37: 34213429.[Crossref] [Google Scholar]
  29. Cronin AA, Breslin N, Gibson J, Pedley S, , 2006. Monitoring source and domestic water quality in parallel with sanitary risk identification in northern Mozambique to prioritise protection interventions. J Water Health 4: 333345.[Crossref] [Google Scholar]
  30. Hashizume M, Wagatsuma Y, Faruque AS, Hayashi T, Hunter PR, Armstrong B, Sack DA, , 2008. Factors determining vulnerability to diarrhoea during and after severe floods in Bangladesh. J Water Health 6: 323332.[Crossref] [Google Scholar]
  31. Knappett PS, Escamilla V, Layton A, McKay LD, Emch M, Williams DE, Huq R, Alam J, Farhana L, Mailloux BJ, Ferguson A, Sayler GS, Ahmed KM, van Geen A, , 2011. Impact of population and latrines on fecal contamination of ponds in rural Bangladesh. Sci Total Environ 409: 31743182.[Crossref] [Google Scholar]
  32. Khan AE, Xun WW, Ahsan H, Vineis P, , 2011. Climate change, sea-level rise, and health impacts in Bangladesh. Environment: Sci Policy Sustain Dev 53: 1833.[Crossref] [Google Scholar]
  33. Escobar JC, Bhavnani D, Trueba G, Ponce K, Cevallos W, Eisenberg J, , 2012. Plesiomonas shigelloides infection, Ecuador, 2004–2008. Emerg Infect Dis 18: 322324.[Crossref] [Google Scholar]
  34. Albert MJ, Faruque AS, Faruque SM, Sack RB, Mahalanabis D, , 1999. Case-control study of enteropathogens associated with childhood diarrhea in Dhaka, Bangladesh. J Clin Microbiol 37: 34583464. [Google Scholar]
  35. Hasan KZ, Pathela P, Alam K, Podder G, Faruque SM, Roy E, Haque AK, Haque R, Albert MJ, Siddique AK, Sack RB, , 2006. Aetiology of diarrhoea in a birth cohort of children aged 0–2 year(s) in rural Mirzapur, Bangladesh. J Health Popul Nutr 24: 2535. [Google Scholar]
  36. Mukherjee AK, Chowdhury P, Bhattacharya MK, Ghosh M, Rajendran K, Ganguly S, , 2009. Hospital-based surveillance of enteric parasites in Kolkata. BMC Res Notes 2: 110.[Crossref] [Google Scholar]
  37. Harris AM, Chowdhury F, Begum YA, Khan AI, Faruque AS, Svennerholm AM, Harris JB, Ryan ET, Cravioto A, Calderwood SB, Qadri F, , 2008. Shifting prevalence of major diarrheal pathogens in patients seeking hospital care during floods in 1998, 2004, and 2007 in Dhaka, Bangladesh. Am J Trop Med Hyg 79: 708714. [Google Scholar]
  38. deRegnier DP, Cole L, Schupp DG, Erlandsen SL, , 1989. Viability of Giardia cysts suspended in lake, river, and tap water. Appl Environ Microbiol 55: 12231229. [Google Scholar]
  39. Ansari SA, Springthorpe VS, Sattar SA, , 1991. Survival and vehicular spread of human rotaviruses: possible relation to seasonality of outbreaks. Rev Infect Dis 13: 448461.[Crossref] [Google Scholar]
  40. Atchison CJ, Tam CC, Hajat S, van Pelt W, Cowden JM, Lopman BA, , 2010. Temperature-dependent transmission of rotavirus in Great Britain and The Netherlands. Proc Biol Sci 277: 933942.[Crossref] [Google Scholar]
  41. Carlton EJ, Eisenberg JN, Goldstick J, Cevallos W, Trostle J, Levy K, , 2014. Heavy rainfall events and diarrhea incidence: the role of social and environmental factors. Am J Epidemiol 179: 344352.[Crossref] [Google Scholar]

Data & Media loading...

  • Received : 23 Jun 2013
  • Accepted : 13 Jan 2014
  • Published online : 02 Apr 2014

Most Cited This Month

This is a required field
Please enter a valid email address
Approval was a Success
Invalid data
An Error Occurred
Approval was partially successful, following selected items could not be processed due to error