# Urban Water Systems, Enteric Pathogen Distribution & Gut Microbiome Development in Children: A Natural Experiment in Mozambique

> **NIH NIH R01** · EMORY UNIVERSITY · 2022 · $685,694

## Abstract

This study leverages our leadership in the evaluation of a major World Bank (WB)-funded project in four urban
areas of Mozambique. We will test if and how improvements in water supply reduce or delay enteropathogen
infection, and impact associated acute and chronic gastrointestinal-related disorders. We take advantage of
the randomized allocation of access to a new piped water system, adding novel microbial and health
endpoints. This will be the largest water system improvement evaluated using an experimental design and the
first to examine the impact of new household water connections on these health outcomes. While improved
case treatment has reduced mortality from diarrhea in recent decades, morbidity has persisted, with an
estimated four billion diarrhea cases annually worldwide. The deleterious health effects of repeated, cumulative
enteric pathogen infections and diarrhea episodes are especially relevant when they occur during the first two
years of life. Increasing evidence suggests that early infection with enteric pathogens, even in the absence of
diarrhea symptoms, is associated with long-term chronic sequelae, including environmental enteric dysfunction
(EED), growth faltering, and cognitive impairment. Studies of WASH interventions often focus on reducing
diarrhea, and few have examined specific enteric pathogens, nor long-term gastrointestinal-related sequelae.
The study of host-level gastrointestinal conditions, such as gut microbiome composition and EED, may help
explain differential acute responses to enteric infections, as well as the downstream consequences of these
infections. While there is evidence of differences in gut microbiome composition across different cultures,
regions, and populations, to date the environmental determinants of these differences, such as access to piped
water, have not been evaluated experimentally, using explicit counterfactuals. More research is needed to
understand these relationships and how they are affected by community-level interventions such as water
supply provision. We propose to test how provision of piped water to low-income, urban households impacts:
(SA1) acute gastrointestinal conditions (enteric pathogen prevalence, diarrhea prevalence); (SA2) chronic
gastrointestinal conditions (EED, gut microbiome composition, growth faltering); and (SA3) timing of
enteropathogen seroconversion and the association between seroconversion and chronic gastrointestinal
conditions. Our multi-disciplinary team has expertise in impact evaluation, enteric diseases, drinking water
quality, and metagenomics, as well as extensive experience researching enteric diseases in low-income
settings throughout the world. This research will inform decisions on how best to invest resources to provide
essential infrastructure to cope with urban growth globally and improve child health, especially for the
estimated 1.1 billion people worldwide who lack safe drinking water supplies.

## Key facts

- **NIH application ID:** 10322133
- **Project number:** 5R01AI130163-05
- **Recipient organization:** EMORY UNIVERSITY
- **Principal Investigator:** Matthew C Freeman
- **Activity code:** R01 (R01, R21, SBIR, etc.)
- **Funding institute:** NIH
- **Fiscal year:** 2022
- **Award amount:** $685,694
- **Award type:** 5
- **Project period:** 2018-01-16 → 2024-12-31

## Primary source

NIH RePORTER: https://reporter.nih.gov/project-details/10322133

## Citation

> US National Institutes of Health, RePORTER application 10322133, Urban Water Systems, Enteric Pathogen Distribution & Gut Microbiome Development in Children: A Natural Experiment in Mozambique (5R01AI130163-05). Retrieved via AI Analytics 2026-05-23 from https://api.ai-analytics.org/grant/nih/10322133. Licensed CC0.

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