Survey-based assessment of water, sanitation, and animal-associated risk factors for moderate-to-severe diarrhea in the Vaccine Impact on Diarrhea in Africa (VIDA) Study: The Gambia, Mali, and Kenya, 2015-2018

David M Berendes, Kirsten Fagerli, Sunkyung Kim, Dilruba Nasrin, Helen Powell, Irene N Kasumba, Sharon M Tennant, Anna Roose, M Jahangir Hossain, Joquina Chiquita M Jones, Syed M A Zaman, Richard Omore, John B Ochieng, Jennifer R Verani, Marc-Alain Widdowson, Samba O Sow, Sanogo Doh, Ciara E Sugerman, Eric D Mintz, Karen L Kotloff

Research output: Contribution to journalA1: Web of Science-articlepeer-review

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BACKGROUND: Pediatric exposures to unsafe sources of water, unsafely managed sanitation, and animals are prevalent in low- and middle-income countries. In the Vaccine Impact on Diarrhea in Africa case-control study, we examined associations between these risk factors and moderate-to-severe diarrhea (MSD) in children <5 years old in The Gambia, Kenya, and Mali.

METHODS: We enrolled children <5 years old seeking care for MSD at health centers; age-, sex-, and community-matched controls were enrolled at home. Conditional logistic regression models, adjusted for a priori confounders, were used to evaluate associations between MSD and survey-based assessments of water, sanitation, and animals living in the compound.

RESULTS: From 2015 to 2018, 4840 cases and 6213 controls were enrolled. In pan-site analyses, children with drinking water sources below "safely managed" (onsite, continuously accessible sources of good water quality) had 1.5-2.0-fold higher odds of MSD (95% confidence intervals [CIs] ranging from 1.0 to 2.5), driven by rural site results (The Gambia and Kenya). In the urban site (Mali), children whose drinking water source was less available (several hours/day vs all the time) had higher odds of MSD (matched odds ratio [mOR]: 1.4, 95% CI: 1.1, 1.7). Associations between MSD and sanitation were site-specific. Goats were associated with slightly increased odds of MSD in pan-site analyses, whereas associations with cows and fowl varied by site.

CONCLUSIONS: Poorer types and availability of drinking water sources were consistently associated with MSD, whereas the impacts of sanitation and household animals were context-specific. The association between MSD and access to safely managed drinking water sources post-rotavirus introduction calls for transformational changes in drinking water services to prevent acute child morbidity from MSD.

Original languageEnglish
JournalClinical Infectious Diseases
Issue numberSuppl.1
Pages (from-to)S132-S139
Number of pages8
Publication statusPublished - 2023
Externally publishedYes


  • Female
  • Animals
  • Cattle
  • Kenya/epidemiology
  • Sanitation/methods
  • Gambia/epidemiology
  • Mali/epidemiology
  • Drinking Water
  • Case-Control Studies
  • Diarrhea/epidemiology
  • Risk Factors

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