Impact of Rainfall on Diarrheal Disease Risk Associated with Unimproved Water and Sanitation

Darlene Bhavnani Department of Epidemiology, School of Public Health, University of Michigan, Ann Arbor, Michigan; Centro de Biomedicina, Universidad Central del Ecuador, Quito, Ecuador; Microbiology Institute, Universidad San Francisco de Quito, Quito, Ecuador

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Jason E. Goldstick Department of Epidemiology, School of Public Health, University of Michigan, Ann Arbor, Michigan; Centro de Biomedicina, Universidad Central del Ecuador, Quito, Ecuador; Microbiology Institute, Universidad San Francisco de Quito, Quito, Ecuador

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William Cevallos Department of Epidemiology, School of Public Health, University of Michigan, Ann Arbor, Michigan; Centro de Biomedicina, Universidad Central del Ecuador, Quito, Ecuador; Microbiology Institute, Universidad San Francisco de Quito, Quito, Ecuador

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Gabriel Trueba Department of Epidemiology, School of Public Health, University of Michigan, Ann Arbor, Michigan; Centro de Biomedicina, Universidad Central del Ecuador, Quito, Ecuador; Microbiology Institute, Universidad San Francisco de Quito, Quito, Ecuador

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Joseph N. S. Eisenberg Department of Epidemiology, School of Public Health, University of Michigan, Ann Arbor, Michigan; Centro de Biomedicina, Universidad Central del Ecuador, Quito, Ecuador; Microbiology Institute, Universidad San Francisco de Quito, Quito, Ecuador

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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.

Author Notes

* Address correspondence to Darlene Bhavnani, Department of Epidemiology, School of Public Health, University of Michigan, 1415 Washington Heights, Ann Arbor, MI 48109-2029. E-mail: dbhavnan@umich.edu

Financial support: This work was supported by National Institutes of Health Grant R01-AI050038 and the University of Michigan Interdisciplinary Training Program in Infectious Diseases funded by National Institute of Allergy and Infectious Diseases Grant T32AI 049816.

Authors' addresses: Darlene Bhavnani, Jason E. Goldstick, and Joseph N. S. Eisenberg, Department of Epidemiology, School of Public Health, University of Michigan, Ann Arbor, MI, E-mails: dbhavnan@umich.edu, jasoneg@med.umich.edu, and jnse@umich.edu. William Cevallos, Centro de Biomedicina, Universidad Central de Ecuador, Quito, Ecuador, E-mail: wcevallos@uce.edu.ec. Gabriel Trueba, Microbiology Institute, Universidad San Francisco de Quito, Quito, Ecuador, E-mail: gtrueba@usfq.edu.ec.

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