Persistent Ascaris Transmission Is Possible in Urban Areas Even Where Sanitation Coverage Is High

In low-income, urban, informal communities lacking sewerage and solid waste services, onsite sanitation (sludges, aqueous effluent) and child feces are potential sources of human fecal contamination in living environments. Working in informal communities of urban Maputo, Mozambique, we developed a quantitative, stochastic, mass-balance approach to evaluate plausible scenarios of localized contamination that could explain why the soil-transmitted helminth <em>Ascaris</em> remains endemic despite nearly universal coverage of latrines that sequester most fecal wastes. We used microscopy to enumerate presumptively viable <em>Ascaris</em> ova in feces, fecal sludges, and soils from compounds (i.e., household clusters) and then constructed a steady-state mass-balance model to evaluate possible contamination scenarios capable of explaining observed ova counts in soils. Observed <em>Ascaris</em> counts (mean = -0.01 log₁₀ ova per wet gram of soil, sd = 0.71 log₁₀) could be explained by deposits of 1.9 grams per day (10th percentile 0.04 grams, 90th percentile 84 grams) of child feces on average, rare fecal sludge contamination events that transport 17 kg every three years (10th percentile 1.0 kg, 90th percentile 260 kg), or a daily discharge of 2.7 kg aqueous effluent from an onsite system (10th percentile 0.09 kg, 90th percentile 82 kg). Results suggest that even limited intermittent flows of fecal wastes in this setting can result in a steady-state density of <em>Ascaris</em> ova in soils capable of sustaining transmission, given the high prevalence of <em>Ascaris</em> shedding by children (prevalence = 25%; mean = 3.7 log₁₀ per wet gram, sd = 1.1 log₁₀), the high <em>Ascaris</em> ova counts in fecal sludges (prevalence = 88%; mean = 1.8 log₁₀ per wet gram, sd = 0.95 log₁₀), and the extended persistence and viability of <em>Ascaris</em> ova in soils. Even near-universal coverage of onsite sanitation may allow for sustained transmission of <em>Ascaris</em> under these conditions.