Impact of water, sanitation, and hygiene indicators on enteric viral pathogens among under-5 children in low resource settings

Poor water, sanitation, and hygiene (WASH) are the primary risks of exposure to enteric viral infection. Our study aimed to describe the role of WASH conditions and practices as risk factors for enteric viral infections in children under 5. Literature on the risk factors associated with all-cause diarrhea masks the taxa-specific drivers of diarrhea from specific pathogens, limiting the application of relevant control strategies. We analyzed data from children enrolled in the Global Enteric Multicenter Study (GEMS) across seven study sites between December 2007 and March 2011 as cases (moderate-to-severe diarrhea: MSD) and asymptomatic controls. MSD was defined as new and acute diarrhea, with at least one of the following criteria for MSD: dehydration based on the study clinician's assessment, dysentery, or hospitalization with diarrhea or dysentery. Multiple logistic regression was used to examine the role of water quality, sanitation access, and hygiene facilities on the enteric viral pathogens adjusted for potential covariates. Among MSD symptomatic children (cases), longer water retrieval time (≥15 vs <15 min) was associated with increased Norovirus (aOR 1.33, 95 % CI 1.08-1.64) and Astrovirus (aOR 1.43, 95 % CI 1.01-2.02); scooping as drinking water retrieval method was associated with lower Rotavirus (aOR 0.77, 95 % CI 0.62-0.96), but higher Adenovirus (aOR 2.3, 95 % CI 1.32-4.11) infection compared to non-users. Among asymptomatic children (controls), consumption of non-tube well drinking water was associated with higher Norovirus infection (aOR 1.38, 95 % CI 1.01-1.89). Longer drinking water retrieval time (≥15 vs <15 min) increased Norovirus (aOR 1.47, 95 % CI 1.21-1.78) and Rotavirus (aOR 1.51, 95 % CI 1.20-1.89) infections. Pouring (aOR 0.51, 95 % CI 0.32-0.83) or scooping drinking water with a cup (aOR: 0.52; 95 % CI: 0.32, 0.86) lower Astrovirus infection; restricted water access (aOR 1.57, 95 % CI 1.21-2.02) higher Rotavirus infection. Handwashing before cooking was associated with lower Astrovirus (aOR 0.64, 95 % CI 0.47-0.88) infection in asymptomatic children. Our analysis did not find a significant effect of poor sanitation on different enteric viral pathogens examined. Norovirus and Astrovirus were detected more commonly in sub-Saharan Africa while Rotavirus was less prevalent than South Asia. Though we found statistically significant associations, we did not observe any overall pattern between WASH and enteric viral pathogens. Our findings provide insights to guide further research on targeted interventions for enteric viral pathogens, responsible for a major burden of pediatric diarrhea globally.