Ayse Ercumen

Enteric infections and diarrhea are responsible for a large burden of morbidity and mortality among children under 5 years and are associated with increased growth faltering, anemia, impaired child development, and mortality. The primary public health interventions to prevent enteric infections are household water, sanitation, and hygiene (WASH) interventions. However, recent WASH intervention trials found only modest impacts on enteric infection prevalence in children. Observational studies have found that children in households with concrete floors have lower prevalence of diarrhea, soil-transmitted helminth infection, and Giardia infection than those in households with soil floors. However, these findings may be strongly confounded by household wealth. We propose a randomized trial in rural Bangladesh to measure whether installing concrete floors in households with soil floors reduces child enteric infection. We will randomize 800 eligible households with pregnant women and install concrete floors before index children are born. We will collect follow-up measurements when children are ages 6, 12, 18, and 24 months. Our team is comprised of experts in environmental and infectious disease epidemiology, including Bangladeshi scientists. We have extensive experience implementing large-scale health intervention trials in Bangladesh and other low resource settings. Aim 1 is to determine the effect of household concrete floors on child enteric illness in households. The primary endpoint is Ascaris lumbricoides prevalence at any follow-up measurement. Secondary endpoints include prevalence of other soil-transmitted helminths, Giardia duodenalis and diarrhea. Aim 2 is to measure effects of household concrete floors on household fecal contamination over time. In a subset, we will detect molecular markers of enteric bacteria (N=200) and parasites (N=800) in floors, child hands, and sentinel toy samples. Aim 3 is to assess whether household concrete floors reduce child soil contact and ingestion. We will conduct video observations in a subsample (N=60) to estimate the frequency of child activities inside vs. outside the home each day. This trial will determine whether concrete floors reduce enteric infection, and further determine how concrete floors reduce enteric infection or if they do not, why. Our findings will provide rigorous, policy-relevant evidence about whether concrete flooring installation should be delivered as a public health intervention to reduce child enteric infection. More broadly, this study marks a paradigm shift in intervention design for improving child health by expanding its scope to include housing improvements.