Background: With the MDG 7 target deadline approaching to halve the global population lacking access to improved water and sanitation by 2015, many nations find the need to explore alternative water sources. Rainwater may be a viable alternative water source. However, there have been concerns raised in recent decades as to the quality of rainwater harvested for potable use. Methods: Data from the Demographic and Health Surveys database which included 50,579 household surveys between 2002 and 2007 from the Dominican Republic were examined. STATA 8 was used for data analysis. Descriptive statistics were computed, and logistic regression analysis was used to compare toilet type, water source, and type of place of residence with prevalence of diarrheal disease in children under five. Results: This study found that rainwater presents less risk for diarrheal disease when compared to all other water sources (excluding bottled water). In 2002, people who consumed all other sources of water (excluding bottled) were 1.28 times more likely to have diarrhea in children under 5 (95% CI 1.05-1.57) compared to those who consumed rainwater. They were 1.33 times more likely to have diarrhea in children under 5 (95% CI 1.08-1.65) in 2007 and 1.31 times more likely in both years combined (95% CI 1.13-1.51). Discussion: This study concluded that consuming rainwater presents a decreased risk for diarrheal disease compared to all other sources (excluding bottled water). More studies are needed to add more evidence to the existing literature regarding health risks associated with rainwater consumption.

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Diarrheal diseases are a leading cause of childhood morbidity and mortality globally and in East Africa. Determining diarrheal disease risk factors and their strength of association to diarrheal disease in this region is necessary to identify and prioritize future research questions and interventions. Demographic and Health Surveys (DHS) Program Data on child health in Burundi, Rwanda, and Tanzania from 2010 were used and simple and multiple logistic regressions were completed to determine factors that predicted diarrheal disease. Diarrhea that occurred in the two weeks prior to data collection was reported for 24.80% of Burundian, 13.1% of Rwandan, and 13.91% of Tanzanian children under five. In Burundian children, increased risk of diarrhea was associated with unimproved sanitation, young mothers, and the mother’s education level (secondary school or less). In Rwandan children, increased risk of diarrhea was associated with more than 30-minute travel time to water source, rainy season, young mothers, mother’s lack of education, and low wealth index. In Tanzanian children, increased risk of diarrhea was associated with rainy season and young mothers. The impact of improved water source and sanitation facility on diarrheal disease is not consistent across the literature or results of this study. Future research should include information on hygiene practices, type of water storage container and types of household water treatment. Further, pathogen specific research, such as molecular fingerprinting, would assist to link the source to the disease. These additions would provide a more comprehensive understanding of risk factors for and sources of diarrheal disease globally and in East Africa.

Abstract Objectives: Diarrheal disease is a global health challenge that assumes gigantic importance with regard to child health in developing countries like Pakistan. Prompt medical attention and proper use of Oral Re-hydration Therapy (ORT) by mothers helps prevent dehydration and secondary complications among affected children. However, ORT use among mothers in Pakistan is low. This study seeks to examine how various socio-demographic factors impact the use of ORT and dispensary treatment among mothers of children affected with diarrhea. Methods:Data from Pakistan Demographic Health Survey (2012-2013) was used for the study. The study sample consisted of women aged 15-49 years old resident in Punjab region (N= 505) with children under five years old who had diarrhea within two weeks of the survey. Chi-square tests and logistic regression analyses were used to determine relationships between maternal socio-demographic characteristics and use of ORT and dispensary care. P-values Results: After controlling for place of residence, educational level and frequency of watching television, caregivers whose children had fever with diarrheal episodes had nearly two-fold increased odds of using ORT treatment [OR= 1.9, (95% CI: 1.28-2.82)], compared to those whose children did not have fever. Similarly poor and middle class socioeconomic status (SES) participants had 3 times increased odds [OR= 2.76, [95% CI: 1.1 -6.89)] of using dispensary treatment when compared to upper class mothers. Place of residence was not a significant predictor of ORT or dispensary use. Discussion: These findings are consistent with other studies that show that mothers’ socioeconomic status are a good indicator of their knowledge about ORT use, and health care seeking behavior. On the other hand, maternal place of residence was not a significant predictor of ORT use, or consultation at a dispensary, even though other studies have found significant associations. Conclusion: Interventions aimed at improving low-income mothers’ knowledge about diarrhea management can include lay medical personnel, such as dispensers, who are often the easily accessible medical resource to this population. Therefore, dispensers should be provided with further training to increase their knowledge and skills in treating children with diarrhea. Future studies that are more rigorous should be conducted to examine this public health issue.

Worldwide diarrheal disease is a leading cause of morbidity and mortality in children less than five years of age. Incidence and disease severity remain the highest in sub-Saharan Africa. Kenya has an estimated 400,000 severe diarrhea episodes and 9,500 diarrhea-related deaths per year in children. Current statistical methods for estimating etiological and exposure risk factors for moderate-to-severe diarrhea (MSD) in children are constrained by the inability to assess a large number of parameters due to limitations of sample size, complex relationships, correlated predictors, and model assumptions of linearity. This dissertation examines machine learning statistical methods to address weaknesses associated with using traditional logistic regression models. The studies presented here investigate data from a 4-year, prospective, matched case-control study of MSD among children less than five years of age in rural Kenya from the Global Enteric Multicenter Study. The three machine learning approaches were used to examine associations with MSD and include: least absolute shrinkage and selection operator, classification trees, and random forest. A principal finding in all three studies was that machine learning methodological approaches are useful and feasible to implement in epidemiological studies. All provided additional information and understanding of the data beyond using only logistic regression models. The results from all three machine learning approaches were supported by comparable logistic regression results indicating their usefulness as epidemiological tools. This dissertation offers an exploration of methodological alternatives that should be considered more frequently in diarrheal disease epidemiology, and in public health in general.

Globally, gastrointestinal (GI) infections by enteric pathogens are the second leading cause of morbidity and mortality in children under the age of five (≤5). While GI pathogen exposure in households has been rigorously examined, there is little data about young children’s exposure in public domains. Public areas in low-income settings are often used for waste disposal practices beyond human feces disposal, including trash dumping in open drainage canals and unused lots. If young children play in public domains unattended, they might be exposed to interrelated and highly concentrated microbial, chemical, and physical hazards. This study performed structured observations at 36 public areas in a transitioning internally displaced persons community in Haiti, to document how often young children play in public areas and to quantify behaviors that might lead to illness and injury. Children ≤5 yrs played at all public sites, including toddlers (92%/sites) and infants (44%/sites). Children touched and mouthed trash (metal, glass, plastic), food and other objects from the ground, ate soil (geophagia), drank surface water; as well as touched latrines, animals, animal feces, and open drainage canals. Hand-to-mouth contact was frequent and significantly different among developmental stages (infants: 18/hr, toddlers: 11/hr, and young children: 9/hr), providing evidence that children could ingest trace amounts of GI pathogens and other contaminants on hands. These findings demonstrate that water, sanitation, and hygiene interventions need to consider the unique risks posed by public domains that contribute to GI infection in young children. Furthermore, this highlights the need for waste related interventions to address the broader set of civil conditions that create unsafe, toxic, and contaminated public environments where young children play.

Water is a primary shared resource that connects all species across the landscape and can facilitate shared exposure to a community of waterborne pathogens. Despite remarkable global progress in sanitation and hygiene development in the past two decades, infectious diarrhea remains a prominent public health threat in sub-Saharan Africa. This thesis identifies and discusses persistent challenges limiting the success of current waterborne disease management strategies and several existing research hurdles that continue to impede characterization of microbial transmission and transport. In this work, the Chobe River watershed in Northern Botswana serves as a target study site for the application of hydrological modeling tools to quantify emergent water quality and health challenges in Southern Africa. A watershed model with extensive data requirements, the Hydrological Simulation Program – Fortran (HSPF), is used to identify primary data gaps and model assumptions that limit the progress of model development, and guide opportunities for data collection, tool development, and research direction. Environmental pathogen exposure risk and epidemiological outbreak dynamics are best described by interactions between the coupled human and environmental processes within a system. The challenge of reducing diarrheal disease incidence strengthens a call for research studies and management plans that join multiple disciplines and consider a range of spatiotemporal scales. / Master of Science