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Joseph N.S. Eisenberg, PhD, MPH, James C. Scott, MPH and Travis Porco, PhD, MPH

Joseph N.S. Eisenberg is with the School of Public Health, University of Michigan, Ann Arbor. James C. Scott is with the School of Public Health, University of California, Berkeley. Travis Porco is with the California Department of Health Services, Richmond, and the Center for Infectious Disease Preparedness, University of California, Berkeley.

Correspondence: Requests for reprints should be sent to Joseph N.S. Eisenberg, PhD, 611 Church St, Department of Epidemiology, School of Public Health, University of Michigan, Ann Arbor, MI 48104-3028 (e-mail: jnse{at}umich.edu).

Objectives. Although the burden of diarrheal disease resulting from inadequate water quality, sanitation practices, and hygiene remains high, there is little understanding of the integration of these environmental control strategies. We tested a modeling framework designed to capture the interdependent transmission pathways of enteric pathogens.

Methods. We developed a household-level stochastic model accounting for 5 different transmission pathways. We estimated disease preventable through water treatment by comparing 2 scenarios: all households fully exposed to contaminated drinking water and all households receiving the water quality intervention.

Results. We found that the benefits of a water quality intervention depend on sanitation and hygiene conditions. When sanitation conditions are poor, water quality improvements may have minimal impact regardless of amount of water contamination. If each transmission pathway alone is sufficient to maintain diarrheal disease, single-pathway interventions will have minimal benefit, and ultimately an intervention will be successful only if all sufficient pathways are eliminated. However, when 1 pathway is critical to maintaining the disease, public health efforts should focus on this critical pathway.

Conclusions. Our findings provide guidance in understanding how to best reduce and eliminate diarrheal disease through integrated control strategies.

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