Determining the health and environmental impacts of a neighborhood-wide sanitation intervention in Quelimane, Mozambique

The major goal of this project is to analyze baseline data on and samples from a community that will soon
undergo transformative neighborhood level sanitation infrastructure improvements. The study team is
leveraging preliminary funding to collect data and samples in 2024, but funding for sample analysis is not
available. Infrastructure improvements in Quelimane, Mozambique a cholera-endemic city of 420,000, will be
transformative, as ~20% of people in the city currently practice open defecation. We will leverage this imminent
major infrastructure project – funded by the World Bank and serving 200,000 people – to assess its impacts on
child health, disease transmission, and climate resilience, toward a better understanding of the cost-benefit of
such investments. Safe sanitation is considered one of the greatest public health achievements of the 20th
Century, but three billion people still lack improved sanitation infrastructure. Pathogens in fecal wastes reach the
environment through well-understood pathways, yet evidence for the impact of city-wide sanitation in low-
income urban settings is largely uncharacterized. Rigorous controlled studies of city-wide interventions are
difficult to carry out, as it is often infeasible to randomize and challenging to find opportunities to collect
preliminary data immediately before implementation of a project. This unique opportunity will allow us to
overcome many of these challenges by collecting and analyzing baseline data prior to initiation of
construction of the neighborhood wide sanitation intervention. We will map the urban, informal
neighborhoods in the city and collect baseline data on demographic information, water and sanitation access,
and household conditions and behaviors to establish a robust baseline for young children in future intervention
and matched comparison areas. In a subset of 200 households, we will collect household environmental samples
including domestic soils and synanthropic flies (SA1) and in 600 households we will also measure anthropometry
and collect biological samples from children from one month to five years of age to measure baseline markers
of child health and development (SA2). We propose to analyze environmental and stool samples for
enteropathogens using state-of-the-art molecular methods (SA1 + SA2). This transformational sanitation
intervention is a unique, natural experiment that will allow our team to characterize the living conditions,
exposure risks, and infection rates of children living in low-income neighborhoods in Quelimane, to establish a
robust baseline for future impact analyses, while also understanding the relationship between these factors under
current conditions. Our multidisciplinary research team has decades of experience conducting field studies of
enteric diseases and impact evaluations of water and sanitation interventions in low-income settings, and
specifically in Mozambique. This work elucidating the potential health impacts of community-sanitation
interventions in Quelimane will serve as a model for other highly urbanizing, coastal tropical or subtropical
cities with high vulnerability to climate and extreme weather globally.

Grant Number: 5R21AI185419-02
NIH Institute/Center: NIH
Principal Investigator: Drew Capone