Tuesday, December 5, 2023
| Variable and response | Value |
|---|---|
| Race | |
| Black or African American | 444 (91) |
| White | 9 (1.8) |
| Prefer not to answer | 6 (1.2) |
| Black and White | 2 (0.4) |
| Unsure | 2 (0.4) |
| No response | 25 (5.1) |
| Ethnicity | |
| Not Hispanic or Latino | 407 (83) |
| Prefer not to answer | 16 (3.3) |
| Hispanic or Latino | 7 (1.4) |
| Unknown | 6 (1.2) |
| No response | 52 (11) |
| County | |
| Wilcox | 237 (56) |
| Lowndes | 101 (21) |
| Perry | 86 (17) |
| No response | 66 (14) |
| Household receives water bill | |
| Yes | 385 (79) |
| No | 67 (14) |
| Don’t know | 6 (1.2) |
| No response | 430 (6.1) |
| Household sanitation | |
| Septic tank | 207 (42) |
| Sewer connection | 111 (23) |
| Don’t know | 80 (16) |
| Straight pipe | 56 (11) |
| Cesspit | 2 (0.4) |
| Other | 1 (0.1) |
| No response | 31 (6.3) |
| Raw sewage in yard or home in past year | |
| No | 400 (82) |
| Yes | 38 (7.8) |
| No response | 50 (10) |
| History of international travel in past year | |
| No | 448 (92) |
| Yes | 13 (2.7) |
| No response | 27 (5.5) |
| Sex | |
| M | 236 (48) |
| F | 229 (47) |
| No response | 23 (4.7) |
| Daily screen time, h | |
| <2 | 72 (15) |
| 2–4 | 182 (37) |
| >4 | 203 (42) |
| No response | 31 (6.4) |
| Age, y | |
| Mean (SD) | 11 (4.1) |
| Median (interquartile range) | 11 (8–14) |
| Range | 2–18 |
| No response | 37 (17.6) |
| Ever treated for an intestinal parasite | |
| No | 418 (86) |
| Don’t know | 45 (9.2) |
| Yes | 12 (2.5) |
| No response | 13 (2.7) |
Table 1. Demographic characteristics of 488 children and water infrastructure summary based on self-administered surveys conducted in Lowndes, Wilcox, and Perry Counties, Alabama, USA, January 2019–December 2021*
*Values are no. (%) except as indicated.
| Type and pathogen | Prevalence, no. (%) |
|---|---|
| Any | |
| ≥1 pathogen gene detected | 127 (26) |
| Bacteria | |
| Clostridioides difficile | 32 (6.6) |
| EPEC (atypical) | 30 (6.1) |
| EAEC | 19 (3.9) |
| Helicobacter pylori | 11 (2.3) |
| EPEC (typical) | 7 (1.4) |
| Yersinia enterocolitica | 5 (1.0) |
| E. coli O157:H7 | 4 (0.8) |
| Plesiomonas shigelloides | 2 (0.4) |
| ETEC | 2 (0.4) |
| Shigella or EIEC | 1 (0.2) |
| Salmonella | 1 (0.2) |
| STEC | 1 (0.2) |
| Campylobacter jejuni or coli | 0 |
| Fungus/algae | |
| Blastocystis | 18 (3.7) |
| Enterocytozoon bieneusi | 0 |
| Encephalitozoon intestinalis | 0 |
| Protozoa | |
| Balantidium coli | 3 (0.6) |
| Acanthamoeba | 2 (0.4) |
| Giardia spp. | 2 (0.4) |
| Entamoeba hystolytica | 1 (0.2) |
| Cystoisospora belli | 0 |
| Cyclospora cayetanensi | 0 |
| Cryptosporidium | 0 |
| Entamoeba | 0 |
| Virus | |
| Norovirus GI or GII | 7 (1.4) |
| SARS-CoV-2 | 3 (0.6) |
| Rotavirus | 2 (0.4) |
| Sapovirus | 2 (0.4) |
| Astrovirus | 1 (0.2) |
Table 2. Prevalence of enteric pathogens in stool specimens of children in a study conducted in Lowndes, Wilcox, and Perry Counties, Alabama, USA, January 2019–December 2021*
*EAEC, enteroaggregative Escherichia coli; EIEC, enteroinvasive E. coli; EPEC, enteropathogenic E. coli; ETEC, enterotoxigenic E. coli; GI/GII, genotype group I and II; STEC, Shiga toxin–producing E. coli.
| Variable | Reference | Exposure | RR (95% CI) | aRR (95% CI) |
|---|---|---|---|---|
| Pay a water bill | Yes | No | 1.8 (1.2–2.5) | 1.7 (1.1–2.5) |
| Sanitation | Sewer connection | Cesspit | NA | NA |
| Other | 3.4 (0.57–20) | 5.2 (0.88–30) | ||
| Septic tank | 0.89 (0.61–1.3) | 0.95 (0.64–1.4) | ||
| Straight pipe | 0.95 (0.55–1.6) | 0.95 (0.55–1.7) | ||
| Child’s screen time | <2 h | 2–4 h | 0.74 (0.48–1.1) | 0.79 (0.51–1.2) |
| >4 h | 0.74 (0.48–1.1) | 0.73 (0.47–1.1) | ||
| Child’s sex | Male | Female | 0.89 (0.65–1.2) | 0.89 (0.65–1.2) |
| International travel in past year | No | Yes | 0.89 (0.32–2.5) | 0.93 (0.34–2.5) |
| Raw sewage in home or yard in past year | No | Yes | 1.1 (0.68–1.9) | 1.1 (0.66–2.0) |
| Child’s age | <5 y | 5–10 y | 0.71 (0.40–1.3) | 0.76 (0.41–1.4) |
| >10 y | 0.82 (0.47–1.4) | 0.90 (0.49–1.6) |
Table 3. Risk factors for detection of ≥1 enteric pathogen in stool specimens of children in a study conducted in Lowndes, Wilcox, and Perry Counties, Alabama, USA, January 2019–December 2021*
*Unadjusted RRs are from bivariate models, whereas aRRs are from full model including all covariates. aRR, adjusted risk ratio; RR, risk ratio.
Physicians - maximum of 1.00 AMA PRA Category 1 Credit(s)™
ABIM Diplomates - maximum of 1.00 ABIM MOC points
This activity is intended for primary care clinicians, pediatricians, infectious disease specialists, and other healthcare professionals who treat and manage children and adolescents, particularly in poor and rural areas.
The goal of this activity is for members of the healthcare team to be better able to assess the prevalence of and risk factors for positive testing for enteric pathogens among Black children in Alabama.
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CME / ABIM MOC Released: 11/15/2023
Valid for credit through: 11/15/2024, 11:59 PM EST
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We collected stool from school-age children from 352 households living in the Black Belt region of Alabama, USA, where sanitation infrastructure is lacking. We used quantitative reverse transcription PCR to measure key pathogens in stool that may be associated with water and sanitation, as an indicator of exposure. We detected genes associated with ≥1 targets in 26% of specimens, most frequently Clostridioides difficile (6.6%), atypical enteropathogenic Escherichia coli (6.1%), and enteroaggregative E. coli (3.9%). We used generalized estimating equations to assess reported risk factors for detecting ≥1 pathogen in stool. We found no association between lack of sanitation and pathogen detection (adjusted risk ratio 0.95 [95% CI 0.55–1.7]) compared with specimens from children served by sewerage. However, we did observe an increased risk for pathogen detection among children living in homes with well water (adjusted risk ratio 1.7 [95% CI 1.1–2.5]) over those reporting water utility service.
Outside cities and towns served by conventional sewerage, many residents in the rural Black Belt region of Alabama, USA, have failing or inadequate sanitation infrastructure[1,2]. This region was named after its rich black soils, which are typically high in clay content, limiting subsurface infiltration[3] and leading to surface discharge of domestic wastewater. Compounding those challenges is a high rate of poverty; 9 of the 10 poorest counties in Alabama are in the Black Belt region[2,4]. Because common alternatives to septic systems are unaffordable[5,6], many residents use failing systems or lack systems altogether[7,8]. Straight piping (i.e., direct discharge of untreated fecal wastes to the environment) of domestic wastewater is common[7].
When human fecal wastes are not safely managed, they may be transported to the environment through well-understood fecal–oral pathways (i.e., drinking water, soils, flies, food, fomites, and hands)[9,10]. For households reliant on straight pipe discharge of wastewater, direct exposure to this waste may be more likely than for households served by a septic system[8]. Those same households and their communities may also suffer from exposures further downstream. Inadequate treatment of fecal wastes can result in enteric pathogen transport through soil into groundwater and exposure through drinking water (e.g., well water)[11,12]. Other exposures may include fecally contaminated soils[13], flies that feed on and reproduce in human feces[14,15], and contaminated food[10]. Such exposures can result in infection with enteric pathogens, which is a necessary precondition for diarrheal disease and other sequelae, including environmental enteric dysfunction[16], growth deficits[17], cognitive impairment[18], and negative effects on the immune system[19].
Poor sanitation and persistent exposure to fecal wastes, particularly in the context of a state and nation with ample resources to address the issue[20], represents a public policy failure[7,21] affecting human health, dignity, and quality of life. Although the evidence base for public investment in sanitation on health grounds has a long history[22], the health burden attributable to poor rural sanitation in the United States remains poorly characterized, constraining the case for action. To determine the potential roles of rural sanitation improvements or other interventions in controlling disease transmission, a useful first step is estimating prevalence of enteric infections and identifying risk factors associated with them. Because of documented poor sanitation conditions in Alabama’s Black Belt region[5,7,8] and the associated potential persistence of endemic enteric infection[23–25], we conducted a cross-sectional study to assess the prevalence of stool-based enteric pathogen detection in children using molecular methods, as an indicator of previous exposure. We further sought to identify potential household-level environmental risk factors for exposure to those pathogens to understand the potential role of infrastructure in protecting public health in this underserved region.
