Article Text

Original research
Environmental and behavioural exposure pathways associated with diarrhoea and enteric pathogen detection in 5-month-old, periurban Kenyan infants: a cross-sectional study
  1. Kelly K Baker1,
  2. Jane Awiti Odhiambo Mumma2,
  3. Sheillah Simiyu3,
  4. Daniel Sewell4,
  5. Kevin Tsai1,
  6. John David Anderson5,
  7. Amy MacDougall6,
  8. Robert Dreibelbis6,
  9. Oliver Cumming6
  1. 1Department of Occupational and Environmental Health, The University of Iowa, Iowa City, Iowa, USA
  2. 2Great Lakes University of Kisumu, Kisumu, Kenya
  3. 3African Population and Health Research Center, Nairobi, Kenya
  4. 4Department of Biostatistics, The University of Iowa, Iowa City, Iowa, USA
  5. 5Consultant, Austin, Texas, USA
  6. 6Department of Disease Control, London School of Hygiene & Tropical Medicine, London, UK
  1. Correspondence to Dr Kelly K Baker; kelly-k-baker{at}


Objectives The aim of this study was to test whether household environmental hygiene and behavioural conditions moderated associations between diarrhoea and enteric pathogen detection in infants 5 months of age in Kenya and pathogen sources, including latrine access, domestic animal co-habitation and public food sources.

Design Cross-sectional study utilising enrolment survey data of households participating in the Safe Start cluster-randomised controlled trial .

Setting Kisumu, Kenya.

Participants A total of 898 caregivers with 5-month (22 week ± 1 week) aged infants were enrolled in the study and completed the enrolment survey.

Primary and secondary outcome measures Outcomes were (1) caregiver-reported 7-day diarrhoea prevalence and (2) count of types of enteric viruses, bacteria and parasites in infant stool. Exposures and effect modifiers included water access and treatment, cohabitation with domestic animals, sanitation access, handwashing practices, supplemental feeding, access to refrigeration and flooring.

Results Reported handwashing after handling animals (adjusted odds ratio (aOR)=0.20; 95% CI=0.06 to 0.50) and before eating (aOR=0.44; 95% CI=0.26 to 0.73) were strongly associated with lower risk of caregiver-reported diarrhoea, while cohabitation with animals (aOR=1.54; 95% CI=1.01 to 2.34) living in a household with vinyl-covered dirt floors (aOR=0.60; 95% CI=0.45 to 0.87) were strongly associated with pathogen codetection in infants. Caregiver handwashing after child (p=0.02) or self-defecation (p=0.03) moderated the relationship between shared sanitation access and infant exposure to pathogens, specifically private latrine access was protective against pathogen exposure of infants in households, where caregivers washed hands after defecation. In the absence of handwashing, access to private sanitation posed no benefits over shared latrines for protecting infants from exposure.

Conclusion Our evidence highlights eliminating animal cohabitation and improving flooring, postdefecation and food-related handwashing, and safety and use of cow milk sources as interventions to prevent enteric pathogen exposure of young infants in Kenya.

Trial registration number NCT03468114

  • public health
  • infection control
  • gastrointestinal infections
  • epidemiology

Data availability statement

Data are available upon reasonable request. This study includes enrolment data from a clinical trial. De-identified human data will be made available upon request once the primary results of the trial are published.

This is an open access article distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited, appropriate credit is given, any changes made indicated, and the use is non-commercial. See:

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Data availability statement

Data are available upon reasonable request. This study includes enrolment data from a clinical trial. De-identified human data will be made available upon request once the primary results of the trial are published.

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  • Contributors KKB and OC conceived of this study concept. JAOM, OC, KKB, JDA and RD designed the parent study. SS and KT collected data. JAOM and KKB supervised data collection. JAOM managed data assimilation and curation. KKB and DS performed the analysis and drafted the manuscript. AM provided additional statistical review. All authors reviewed and submitted comments on the final manuscript. KKB is responsible as guarantor for the finished work, including the conduct of the study, access to the data, and the decision to publish.

  • Funding The SHARE Research Consortium (Grant Number ITDCHA2310), funded by the United Kingdom Department for International Development (DFID) funded the Safe Start Trial.

  • Competing interests None declared.

  • Patient and public involvement Patients and/or the public were involved in the design, or conduct, or reporting or dissemination plans of this research. Refer to the Methods section for further details.

  • Provenance and peer review Not commissioned; externally peer reviewed.

  • Supplemental material This content has been supplied by the author(s). It has not been vetted by BMJ Publishing Group Limited (BMJ) and may not have been peer-reviewed. Any opinions or recommendations discussed are solely those of the author(s) and are not endorsed by BMJ. BMJ disclaims all liability and responsibility arising from any reliance placed on the content. Where the content includes any translated material, BMJ does not warrant the accuracy and reliability of the translations (including but not limited to local regulations, clinical guidelines, terminology, drug names and drug dosages), and is not responsible for any error and/or omissions arising from translation and adaptation or otherwise.