Effects of water quality, sanitation, handwashing, and nutritional interventions on diarrhoea and child growth in rural Kenya: a cluster-randomised controlled trial

Child hand contamination is associated with subsequent pediatric diarrhea in rural Democratic Republic of the Congo (REDUCE Program)

OBJECTIVE

The Reducing Enteropathy, Undernutrition, and Contamination in the Environment (REDUCE) program focuses on identifying exposure pathways to faecal pathogens for young children in the Democratic Republic of the Congo (DRC) and on developing scalable interventions to reduce faecal contamination from these pathways.

METHODS

A prospective cohort study of 690 participants was conducted to investigate the association between hand, food, and environmental faecal contamination and diarrhoeal disease prevalence among young children in Walungu Territory, South Kivu, DRC. A total of 1923 hand rinse, soil, food, object, surface, stored water and water source samples were collected during unannounced spot checks after baseline enrolment and analysed for Escherichia coli. Caregiver reports of diarrhoea were obtained from children < 5 years at a 6-month follow-up.

RESULTS

E.coli was detected in 73% of child and caregiver hand-rinse samples, 69% of soil samples from child play spaces, 54% of child food samples, 38% of objects and surfaces children were observed putting in their mouths, 74% of stored water samples, and 40% of source water samples. Children < 5 years with E. coli on their hands had significantly higher odds of diarrhoea at the 6-month follow-up (odds ratio: 2.03 (95% confidence interval: 1.05, 3.92)).

CONCLUSION

The cohort study findings from the REDUCE program have shown that child hand contamination is associated with diarrhoeal disease in rural DRC, and that there is high faecal contamination in child plays spaces and food. These findings provide evidence demonstrating the urgent need to provide clean play spaces for young children and interventions targeting hand hygiene to reduce paediatric exposure to faecal pathogens.

Improving nutritional status among urban poor children in sub-Saharan Africa: An evidence-informed Delphi-based consultation

In sub‐Saharan Africa (SSA), rapid urbanisation coupled with the high prevalence of infant and young child (IYC) undernutrition in low‐income settings means that interventions to support IYC nutrition are a priority. Little is known about how urbanisation influences IYC feeding (IYCF) practices, and evidence‐based interventions to improve IYC health/nutrition in the urban poor are lacking. Therefore, this research aimed to (a) systematically review evidence on interventions for improving the nutritional status of IYC aged 6–23 months living in urban poor areas (PROSPERO CRD42018091265) and (b) engage stakeholders to identify the highest ranking evidence gaps for improving IYCF programmes/policies. First, a rapid systematic review was conducted. This focused on the literature published regarding nutrition‐specific and nutrition‐sensitive complementary feeding interventions in urban poor areas, specifically low‐income informal settlements, in low‐ and middle‐income countries (LMICs). Six intervention studies met the review inclusion criteria. Intervention adherence was generally high, and indicators of maternal knowledge and IYC nutritional intake typically increased because of the interventions, but the impact on anthropometric status was small. Second, stakeholders working across SSA were engaged via a Delphi‐based approach to identify priority areas for future intervention. Stakeholders reported that a situational analysis was required to better understand IYCF in urban poor areas, particularly the causes of IYC undernutrition, and highlighted the need to involve local communities in defining how future work should proceed. Together, these findings indicate a need for more evidence regarding IYCF and the factors that drive it in urban poor areas across LMIC settings, but particularly in SSA.

Ingestion of Fecal Bacteria along Multiple Pathways by Young Children in Rural Bangladesh Participating in a Cluster-Randomized Trial of Water, Sanitation, and Hygiene Interventions (WASH Benefits)

Quantifying the contribution of individual exposure pathways to a child's total ingestion of fecal matter could help prioritize interventions to reduce environmental enteropathy and diarrhea. This study used data on fecal contamination of drinking water, food, soil, hands, and objects and second-by-second data on children's contacts with these environmental reservoirs in rural Bangladesh to assess the relative contribution of different pathways to children's ingestion of fecal indicator bacteria and if ingestion decreased with the water, sanitation, and hygiene interventions implemented in the WASH Benefits Trial. Our model estimated that rural Bangladeshi children <36 months old consume 3.6-4.9 log₁₀ most probable number E. coli/day. Among children <6 months, placing objects in the mouth accounted for 60% of E. coli ingested. For children 6-35 months old, mouthing their own hands, direct soil ingestion, and ingestion of contaminated food were the primary pathways of E. coli ingestion. The amount of E. coli ingested by children and the predominant pathways of E. coli ingestion were unchanged by the water, sanitation, and hygiene interventions. These results highlight contaminated soil, children's hands, food, and objects as primary pathways of E. coli ingestion and emphasize the value of intervening along these pathways.

Associations between Household-Level Exposures and All-Cause Diarrhea and Pathogen-Specific Enteric Infections in Children Enrolled in Five Sentinel Surveillance Studies

Diarrheal disease remains a major cause of childhood mortality and morbidity causing poor health and economic outcomes. In low-resource settings, young children are exposed to numerous risk factors for enteric pathogen transmission within their dwellings, though the relative importance of different transmission pathways varies by pathogen species. The objective of this analysis was to model associations between five household-level risk factors-water, sanitation, flooring, caregiver education, and crowding-and infection status for endemic enteric pathogens in children in five surveillance studies. Data were combined from 22 sites in which a total of 58,000 stool samples were tested for 16 specific enteropathogens using qPCR. Risk ratios for pathogen- and taxon-specific infection status were modeled using generalized linear models along with hazard ratios for all-cause diarrhea in proportional hazard models, with the five household-level variables as primary exposures adjusting for covariates. Improved drinking water sources conferred a 17% reduction in diarrhea risk; however, the direction of its association with particular pathogens was inconsistent. Improved sanitation was associated with a 9% reduction in diarrhea risk with protective effects across pathogen species and taxa of around 10-20% risk reduction. A 9% reduction in diarrhea risk was observed in subjects with covered floors, which were also associated with decreases in risk for zoonotic enteropathogens. Caregiver education and household crowding showed more modest, inconclusive results. Combining data from diverse sites, this analysis quantified associations between five household-level exposures on risk of specific enteric infections, effects which differed by pathogen species but were broadly consistent with hypothesized transmission mechanisms. Such estimates may be used within expanded water, sanitation, and hygiene (WASH) programs to target interventions to the particular pathogen profiles of individual communities and prioritize resources.

A pilot project: handwashing educational intervention decreases incidence of respiratory and diarrheal illnesses in a rural Malawi orphanage

Children who live in orphanages represent a population particularly vulnerable to transmissible diseases. Handwashing interventions have proven efficacy for reducing the rate of transmission of common infectious diseases. Few studies have analyzed the delivery of health interventions for children in orphanages in sub-Saharan Africa. To address this gap, we conducted an ecological assessment and piloted a handwashing intervention in an orphanage in rural Malawi, focusing on caregiver knowledge and behaviors, child handwashing behaviors, and disease incidence. A secondary study aim was to demonstrate program feasibility for a future randomized controlled trial. Orphanage caregivers participated in a three-module educational intervention on handwashing based on WHO recommendations and workshops on how to teach the curriculum to children. Seventeen orphanage caregivers and 65 children were monitored for handwashing behavior and child disease incidence. Friedman's tests were conducted to compare changes in caregiver knowledge and behaviors. Child handwashing behaviors and surveillance of child disease incidence were measured pre- and post-intervention. There were significant increases in caregiver hand hygiene knowledge. At six months post-intervention, handwashing with soap increased significantly among caregivers (p < 0.001) and was observed in children. The incidence of acute respiratory infections decreased from 30% to 6% post-intervention, resulting in an 80% decrease. The incidence of diarrhea decreased from 9.2% to 6.2% post-intervention, resulting in a 33% decrease. A brief educational intervention may improve handwashing knowledge and behaviors and help to decrease the incidence of common infectious diseases in an orphanage in rural Malawi. In addition, the caregiver uptake of the intervention demonstrated feasibility for future studies.

Measuring Environmental Exposure to Enteric Pathogens in Low-Income Settings: Review and Recommendations of an Interdisciplinary Working Group

Infections with enteric pathogens impose a heavy disease burden, especially among young children in low-income countries. Recent findings from randomized controlled trials of water, sanitation, and hygiene interventions have raised questions about current methods for assessing environmental exposure to enteric pathogens. Approaches for estimating sources and doses of exposure suffer from a number of shortcomings, including reliance on imperfect indicators of fecal contamination instead of actual pathogens and estimating exposure indirectly from imprecise measurements of pathogens in the environment and human interaction therewith. These shortcomings limit the potential for effective surveillance of exposures, identification of important sources and modes of transmission, and evaluation of the effectiveness of interventions. In this review, we summarize current and emerging approaches used to characterize enteric pathogen hazards in different environmental media as well as human interaction with those media (external measures of exposure), and review methods that measure human infection with enteric pathogens as a proxy for past exposure (internal measures of exposure). We draw from lessons learned in other areas of environmental health to highlight how external and internal measures of exposure can be used to more comprehensively assess exposure. We conclude by recommending strategies for advancing enteric pathogen exposure assessments.

Systems Science Approaches for Global Environmental Health Research: Enhancing Intervention Design and Implementation for Household Air Pollution (HAP) and Water, Sanitation, and Hygiene (WASH) Programs

BACKGROUND

Two of the most important causes of global disease fall in the realm of environmental health: household air pollution (HAP) and poor water, sanitation, and hygiene (WASH) conditions. Interventions, such as clean cookstoves, household water treatment, and improved sanitation facilities, have great potential to yield reductions in disease burden. However, in recent trials and implementation efforts, interventions to improve HAP and WASH conditions have shown few of the desired health gains, raising fundamental questions about current approaches.

OBJECTIVES

We describe how the failure to consider the complex systems that characterize diverse real-world conditions may doom promising new approaches prematurely. We provide examples of the application of systems approaches, including system dynamics, network analysis, and agent-based modeling, to the global environmental health priorities of HAP and WASH research and programs. Finally, we offer suggestions on how to approach systems science.

METHODS

Systems science applied to environmental health can address major challenges by a) enhancing understanding of existing system structures and behaviors that accelerate or impede aims; b) developing understanding and agreement on a problem among stakeholders; and c) guiding intervention and policy formulation. When employed in participatory processes that engage study populations, policy makers, and implementers, systems science helps ensure that research is responsive to local priorities and reflect real-world conditions. Systems approaches also help interpret unexpected outcomes by revealing emergent properties of the system due to interactions among variables, yielding complex behaviors and sometimes counterintuitive results.

DISCUSSION

Systems science offers powerful and underused tools to accelerate our ability to identify barriers and facilitators to success in environmental health interventions. This approach is especially useful in the context of implementation research because it explicitly accounts for the interaction of processes occurring at multiple scales, across social and environmental dimensions, with a particular emphasis on linkages and feedback among these processes. https://doi.org/10.1289/EHP7010.

Water, sanitation, and hygiene (WASH) factors associated with growth between birth and 1 year of age in children in Soweto, South Africa: results from the Soweto Baby WASH study

Interventions to reduce undernutrition and improve child growth have incorporated improved water, sanitation, and hygiene (WASH) as part of disease transmission prevention strategies. Knowledge gaps still exist, namely, when and which WASH factors are determinants for growth faltering, and when WASH interventions are most effective at improving growth. This study drew cross-sectional data from a longitudinal cohort study and used hierarchical regression analyses to assess associations between WASH factors: water index, sanitation, hygiene index, and growth: height-for-age (HAZ), weight-for-age (WAZ), weight-for-height (WHZ) at 1, 6, and 12 months postpartum among infants a priori born healthy in Soweto, Johannesburg. Household access to sanitation facilities that were not safely managed was associated with a decrease in HAZ scores at 1 month (β = -2.24) and 6 months (β = -0.96); a decrease in WAZ at 1 month (β = -1.21), 6 months (β = -1.57), and 12 months (β = -1.92); and finally, with WHZ scores at 12 months (β = -1.94). Counterintuitively, poorer scores on the hygiene index were associated with an increase at 1 month for both HAZ (β = 0.53) and WAZ (β = 0.44). Provision of safely managed sanitation at household and community levels may be required before improvements in growth-related outcomes are obtained.

Reducing malnutrition in Cambodia. A modeling exercise to prioritize multisectoral interventions

Undernutrition is a major contributor to child morbidity and mortality and poses a large burden to the economy, in Cambodia. This study explored factors contributing to child stunting and wasting and their regional inequalities among 1,938 Cambodian children aged 6-23.9 months. Data were drawn from a longitudinal study (year 2017) conducted in six districts of two north-eastern provinces and the capital and used as cross-sectional. Socio-demographic and household characteristics, children's feeding practices during the previous 24 hr, and children's length and weight measurements were collected. Gradient boosting models were used to calculate the contribution of determinants to child undernutrition whereas concentration index was used to assess the impact of those determinants on stunting and wasting inequalities among socioeconomic groups. It was found that low-household wealth could predict 21% to 45% of child stunting and 23% to 36% of wasting across regions. After wealth, source and treatment of drinking water were found the second major predictor for stunting (15%) and wasting (21%). Combining child nutrition and household water, sanitation and hygiene indicators predicted around 30% of child undernutrition, either in the form of stunting or wasting. Mothers' education predicted >30% of stunting in the north-eastern region. Results highlight that a complex interplay of factors contributes to child stunting and wasting. An integrated, intersectoral, equity-focused approach that addresses children's dietary quality, household's water, sanitation and hygiene conditions, mother's education, and poverty is likely to yield the highest impact in achieving further gains in nutritional status among Cambodian children.

Interventions to improve linear growth during complementary feeding period for children aged 6-24 months living in low- and middle-income countries: a systematic review and network meta-analysis

Background: Optimizing linear growth in children during complementary feeding period (CFP) (6-24 months) is critical for their development. Several interventions, such as micronutrient and food supplements, deworming, maternal education, and water, sanitation and hygiene (WASH), could potentially be provided to prevent stunting, but their comparative effectiveness are currently unclear. In this study, we evaluated comparative effectiveness of interventions under these domains on child linear growth outcomes of height-for-age z-score (HAZ) and stunting (HAZ <-2SD) Methods: For this study, we searched for low- and middle-income country (LMIC)-based randomized clinical trials (RCTs) of aforementioned interventions provided to children during CFP. We searched for reports published until September 17, 2019 and hand-searched bibliographies of existing reviews. We performed random-effects network meta-analysis (NMA) for HAZ and stunting. Results: The evidence base for our NMA was based on 79 RCTs (96 papers) involving 81,786 children. Among the micronutrients, compared to standard-of-care, iron + folic acid (IFA) (mean difference =0.08; 95% credible interval [CrI]: 0.01, 0.15) and multiple micronutrients (MMN) (mean difference =0.06; 95%CrI: 0.01, 0.11) showed improvements for HAZ; MMN also reduced the risks for stunting (RR=0.86; 95%Crl: 0.73, 0.98), whereas IFA did not (RR=0.92; 95%Crl: 0.64, 1.23). For food supplements, flour in the caloric range of 270-340 kcal (RR=0.73; 95%Crl: 0.51, 1.00) and fortified lipid-based nutrient supplements (LNS) containing 220-285 kcal (RR=0.80; 95%Crl: 0.66, 0.97) decreased the risk of stunting compared to standard-of-care, but these interventions and other food supplements did not show improvements for HAZ. Deworming, maternal education, and WASH interventions did not show improvements for HAZ nor stunting. Conclusion: While we found micronutrient and food supplements to be effective for HAZ and/or stunting, the evidence base for other domains in this life stage was limited, highlighting the need for more investigation. Registration: PROSPERO CRD42018110449; registered on 17 October 2018.

All Children Thrive: Integration of Nutrition and Early Childhood Development

Building on the successes of child survival, we review the evidence needed to ensure both that children who survive also thrive and that recommendations promote equity, with no child left behind. To illustrate the critical roles played by nutrition and child development, we revise the Conceptual Framework for the Causes of Malnutrition and Death and the Nurturing Care Framework to create the Conceptual Framework of All Children Surviving and Thriving. The revised framework highlights the goals of child growth and development, supported by health, nutrition, learning, responsive caregiving, and security and safety. We review the challenges posed by undernutrition, stunting, micronutrient deficiencies, overweight, and children not reaching their developmental potential. Although integrated nutrition-childhood development interventions have shown promising effects, most have not been implemented at scale. Implementation science that investigates how and why integrated interventions work in real life, along with the acceptability, feasibility, cost, coverage, and sustainability of the interventions, is needed to ensure equity for all children thriving.

The effect of access to water, sanitation and handwashing facilities on child growth indicators: Evidence from the Ethiopia Demographic and Health Survey 2016

INTRODUCTION

Poor access to water, sanitation, and handwashing (WASH) facilities frequently contribute to child growth failure. The role of access to WASH facilities on child growth outcomes in Ethiopia is largely unknown. The aim of this study was to determine individual and combined effects of access to WASH facilities on child growth outcomes.

METHODS

Data for this analysis was sourced from the recent Ethiopia Demographic and Health Survey (EDHS) 2016. A multivariable logistic regression model was applied to identify the separate and combined association of access to WASH facilities with child growth outcomes. Odds ratio (OR) and 95% confidence interval (CI) were estimated. Statistical significance was declared at p < 0.05.

RESULTS

Included in the analyses were data for children 0-59 months of age, which amounted to valid data for 9588 children with a height-for-age z-score (HAZ), 9752 children with a weight-for-age z-score (WAZ) and 9607 children with a weight-for-height z-score (WHZ). Children with access to improved combined sanitation with handwashing facilities had 29% lower odds of linear growth failure (stunting) (adjusted odds ratio (AOR) = 0.71; 95% CI: 0.51-0.99) compared with those with unimproved. Children with access to combined improved WASH facilities were 33% less likely to have linear growth failure (AOR = 0.67; 95% CI: 0.45-0.98). Access to improved handwashing alone reduced the odds of being underweight by 17% (AOR = 0.83; 95% CI: 0.71-0.98) compared with unimproved. Improved water and sanitation separately as well as combined WASH were not associated with decreased odds of underweight and wasting.

CONCLUSIONS

Combined access to improved water, sanitation and handwashing was associated with reduced child linear growth failure. Further research with robust methods is needed to examine whether combined WASH practices have synergistic effect on child growth outcomes.

The Impact of Improved Water, Sanitation, and Hygiene on Oral Rotavirus Vaccine Immunogenicity in Zimbabwean Infants: Substudy of a Cluster-randomized Trial

BACKGROUND

Oral vaccines have lower efficacy in developing compared to developed countries. Poor water, sanitation, and hygiene (WASH) may contribute to reduced oral vaccine immunogenicity.

METHODS

We conducted a cluster-randomized 2 × 2 factorial trial in rural Zimbabwe. Pregnant women and their infants were eligible if they lived in clusters randomized to (1) standard of care (52 clusters); (2) improved infant feeding (53 clusters); (3) WASH: ventilated improved pit latrine, 2 hand-washing stations, liquid soap, chlorine, infant play space, and hygiene counseling (53 clusters); or (4) feeding plus WASH (53 clusters). This substudy compared oral rotavirus vaccine (RVV) seroconversion (primary outcome), and seropositivity and geometric mean titer (GMT) (secondary outcomes), in WASH vs non-WASH infants by intention-to-treat analysis.

RESULTS

We included 801 infants with documented RVV receipt and postvaccine titer measurements (329 from 84 WASH clusters; 472 from 102 non-WASH clusters); 328 infants with prevaccination titers were included in the primary outcome. Thirty-three of 109 (30.3%) infants in the WASH group seroconverted following rotavirus vaccination, compared to 43 of 219 (19.6%) in the non-WASH group (absolute difference, 10.6% [95% confidence interval {CI}, .54%-20.7%]; P = .031). In the WASH vs non-WASH groups, 90 of 329 (27.4%) vs 107 of 472 (22.7%) were seropositive postvaccination (absolute difference, 4.7% [95% CI, -1.4% to 10.8%]; P = .130), and antirotavirus GMT was 18.4 (95% CI, 15.6-21.7) U/mL vs 14.9 (95% CI, 13.2-16.8) U/mL (P = .072).

CONCLUSIONS

Improvements in household WASH led to modest but significant increases in seroconversion to RVV in rural Zimbabwean infants.

CLINICAL TRIALS REGISTRATION

NCT01824940.

Drivers of stunting reduction in Nepal: a country case study

BACKGROUND

Chronic child malnutrition represents a serious global health concern. Over the last several decades, Nepal has seen a significant decline in linear growth stunting - a physical manifestation of chronic malnutrition - despite only modest economic growth and significant political instability.

OBJECTIVE

This study aimed to conduct an in-depth assessment of the determinants of stunting reduction in Nepal from 1996 to 2016, with specific attention paid to national-, community-, household-, and individual-level factors, as well as relevant nutrition-specific and -sensitive initiatives rolled out within the country.

METHODS

Using a mixed-methods approach, 4 types of inquiry were employed: 1) a systematic review of published peer-reviewed and gray literature; 2) retrospective quantitative data analyses using Demographic and Health Surveys from 1996 to 2016; 3) a review of key nutrition-specific and -sensitive policies and programs; and 4) retrospective qualitative data collection and analyses.

RESULTS

Mean height-for-age z-scores (HAZ) improved by 0.94 SDs from 1996 to 2016. Subnational variation and socioeconomic inequalities in stunting outcomes persisted, with the latter widening over time. Decomposition analysis for children aged under 5 y explained 90.9% of the predicted change in HAZ, with key factors including parental education (24.7%), maternal nutrition (19.3%), reduced open defecation (12.3%), maternal and newborn health care (11.5%), and economic improvement (9.0%). Key initiatives focused on decentralizing the health system and mobilizing community health workers to increase accessibility; long-standing nationwide provision of basic health interventions; targeted efforts to improve maternal and child health; and the prioritization of nutrition-sensitive initiatives by both government and donors. National and community stakeholders and mothers at village level highlighted a mixture of poverty reduction, access to health services, improved education, and increased access to water, sanitation, and hygiene as drivers of stunting reduction.

CONCLUSIONS

Improvements in both nutrition-specific and nutrition-sensitive sectors have been critical to Nepal's stunting decline, particularly in the areas of poverty reduction, health, education, and sanitation.

Mapping geographical inequalities in access to drinking water and sanitation facilities in low-income and middle-income countries, 2000-17

BACKGROUND

Universal access to safe drinking water and sanitation facilities is an essential human right, recognised in the Sustainable Development Goals as crucial for preventing disease and improving human wellbeing. Comprehensive, high-resolution estimates are important to inform progress towards achieving this goal. We aimed to produce high-resolution geospatial estimates of access to drinking water and sanitation facilities.

METHODS

We used a Bayesian geostatistical model and data from 600 sources across more than 88 low-income and middle-income countries (LMICs) to estimate access to drinking water and sanitation facilities on continuous continent-wide surfaces from 2000 to 2017, and aggregated results to policy-relevant administrative units. We estimated mutually exclusive and collectively exhaustive subcategories of facilities for drinking water (piped water on or off premises, other improved facilities, unimproved, and surface water) and sanitation facilities (septic or sewer sanitation, other improved, unimproved, and open defecation) with use of ordinal regression. We also estimated the number of diarrhoeal deaths in children younger than 5 years attributed to unsafe facilities and estimated deaths that were averted by increased access to safe facilities in 2017, and analysed geographical inequality in access within LMICs.

FINDINGS

Across LMICs, access to both piped water and improved water overall increased between 2000 and 2017, with progress varying spatially. For piped water, the safest water facility type, access increased from 40·0% (95% uncertainty interval [UI] 39·4-40·7) to 50·3% (50·0-50·5), but was lowest in sub-Saharan Africa, where access to piped water was mostly concentrated in urban centres. Access to both sewer or septic sanitation and improved sanitation overall also increased across all LMICs during the study period. For sewer or septic sanitation, access was 46·3% (95% UI 46·1-46·5) in 2017, compared with 28·7% (28·5-29·0) in 2000. Although some units improved access to the safest drinking water or sanitation facilities since 2000, a large absolute number of people continued to not have access in several units with high access to such facilities (>80%) in 2017. More than 253 000 people did not have access to sewer or septic sanitation facilities in the city of Harare, Zimbabwe, despite 88·6% (95% UI 87·2-89·7) access overall. Many units were able to transition from the least safe facilities in 2000 to safe facilities by 2017; for units in which populations primarily practised open defecation in 2000, 686 (95% UI 664-711) of the 1830 (1797-1863) units transitioned to the use of improved sanitation. Geographical disparities in access to improved water across units decreased in 76·1% (95% UI 71·6-80·7) of countries from 2000 to 2017, and in 53·9% (50·6-59·6) of countries for access to improved sanitation, but remained evident subnationally in most countries in 2017.

INTERPRETATION

Our estimates, combined with geospatial trends in diarrhoeal burden, identify where efforts to increase access to safe drinking water and sanitation facilities are most needed. By highlighting areas with successful approaches or in need of targeted interventions, our estimates can enable precision public health to effectively progress towards universal access to safe water and sanitation.

FUNDING

Bill & Melinda Gates Foundation.

Faecal contamination of the environment and child health: a systematic review and individual participant data meta-analysis

BACKGROUND

Exposure to faecal contamination is believed to be associated with child diarrhoea and possibly stunting; however, few studies have explicitly measured the association between faecal contamination and health. We aimed to assess individual participant data (IPD) across multiple trials and observational studies to quantify the relationship for common faecal-oral transmission pathways.

METHODS

We did a systematic review and meta-analysis of IPD from studies identified in an electronic search of PubMed, Web of Science, and Embase on May 21, 2018. The search was done in English, but full texts published in French, Portuguese, and Spanish were also reviewed. Eligible studies quantified (1) household-level faecal indicator bacteria concentrations along common faecal-oral transmission pathways of drinking water, soil, or food, on children's hands or fomites, or fly densities in food preparation areas; and (2) individual-level diarrhoea or linear growth measures for children younger than 5 years in low-income and middle-income countries. For the diarrhoea analysis, all definitions of diarrhoea were eligible but studies were excluded if they used a recall period longer than 7 days. For the linear growth analysis (using height-for-age Z scores [HAZ]), cross-sectional studies were excluded, because of the absence of longitudinal environmental contamination data measured before the growth outcomes. We used multilevel generalised mixed-effects models to estimate the odds ratio (OR) for diarrhoea and the difference in HAZ scores for individual studies associated with a 1-log₁₀ higher measure of faecal contamination. Estimates from each study were combined under a random-effects meta-analysis framework. The study protocol was pre-registered with PROSPERO (CRD42018102114).

FINDINGS

From 72 eligible studies, we included IPD for 20 studies in the meta-analyses, totalling 54 225 diarrhoea or linear growth observations matched to faecal indicator bacteria concentrations in drinking water, and a further 35 010 observations with faecal contamination data for the other transmission pathways. Child diarrhoea was associated with 1-log₁₀ higher faecal indicator bacteria concentrations in drinking water (OR 1·09, 95% CI 1·04 to 1·13; p=0·0002, I²=34%, 95% CI 0 to 62) and on children's hands (1·11, 1·02 to 1·22; p=0·021, I²=0%, 0 to 71). Lower HAZ scores were associated with 1-log₁₀ higher median faecal indicator bacteria concentrations in drinking water (HAZ -0·04, 95% CI -0·06 to -0·01; p=0·0054; I²=19%, 95% CI 0 to 63) and on fomites (-0·06, -0·12 to 0·00; p=0·044, I²=57%, 0 to 90).

INTERPRETATION

Although summary measures from individual studies often report little or no effect of measured faecal contamination on child health, this multi-study IPD analysis indicates that household faecal indicator bacteria concentrations are associated with important adverse health outcomes in young children. Improved direct measures of exposure and enteric pathogens could help to better characterise the relationship and inform intervention design in future studies.

FUNDING

None.

The WHO and UNICEF Joint Monitoring Programme (JMP) Indicators for Water Supply, Sanitation and Hygiene and Their Association with Linear Growth in Children 6 to 23 Months in East Africa

The slow decrease in child stunting rates in East Africa warrants further research to identify the influence of contributing factors such as water, sanitation, and hygiene (WASH). This study investigated the association between child length and WASH conditions using the recently revised WHO and UNICEF (United Nations Children’s Fund) Joint Monitoring Programme (JMP) indicators. Data from households with infants and young children aged 6–23 months from the Demographic and Health Surveys in Burundi, Ethiopia, Kenya, Malawi, Rwanda, Tanzania, Uganda, and Zambia were used. Associations for each country between WASH conditions and length-for-age z-scores (LAZ) were analyzed using linear regression. Stunting rates were high (>20%) reaching 45% in Burundi. At the time of the most recent Demographic and Health Survey (DHS), more than half of the households in most countries did not have basic or safely managed WASH indicators. Models predicted significantly higher LAZ for children living in households with safely managed drinking water compared to those living in households drinking from surface water in Kenya (β = 0.13, p < 0.01) and Tanzania (β = 0.08, p < 0.05) after adjustment with child, maternal, and household covariates. Children living in households with improved sanitation facilities not shared with other households were also taller than children living in households practicing open defecation in Ethiopia (β = 0.07, p < 0.01) and Tanzania (β = 0.08, p < 0.01) in the adjusted models. All countries need improved WASH conditions to reduce pathogen and helminth contamination. Targeting adherence to the highest JMP indicators would support efforts to reduce child stunting in East Africa.

Association of nutrition, water, sanitation and hygiene practices with children's nutritional status, intestinal parasitic infections and diarrhoea in rural Nepal: a cross-sectional study

Background

Providing universal access to safe water, sanitation and hygiene (WASH) in remote Nepal remains challenging. We investigated WASH conditions and their association with children’s nutritional status, intestinal parasitic infections and diarrhoea.

Methods

Data was collected through a cross-sectional survey of 1427 households, including questionnaires, observations, stool analysis, anthropometry, water quality measurements, and assessment of clinical signs of nutritional deficiencies.

Results

We found 55.5% of children were undernourished, 63.9% had clinical signs of nutritional deficiencies, 51.1% had intestinal parasitic infections and 52.2% had diarrhoea. Multivariate mixed logistic regression analysis revealed a statistically significant negative association between undernutrition and socio-economic level, with adjusted odds ratios (AOR) of 0.70 (95%-CI = 0.43–1.11) and 0.43 (95%-CI = 0.25–0.75) for high and intermediate levels compared to the lowest level. Undernutrition was negatively associated with regular deworming of children (AOR = 0.44, 95% CI = 0.20–0.94), food supplements (AOR = 0.57, 95% CI = 0.38–0.84), household’s own food production (AOR = 0.67, 95% CI = 0.46–0.97) and personal hygiene (AOR = 0.83, 95% CI = 0.51–1.35). Nutritional deficiency was negatively associated with handwashing after cleaning a baby’s bottom (AOR = 0.60, 95% CI = 0.40–0.92) and cleanliness of caregiver’s hands (AOR = 0.61, 95% CI = 0.41–0.89) and positively associated with keeping animals inside the house overnight (AOR = 1.71, 95% CI = 1.17–2.51) and the presence of total coliforms in the drinking water source (AOR = 10.44, 95% CI = 1.61–67.4). Diarrhoea was positively associated with intermittent water supply (AOR = 2.72, 95% CI = 1.18–6.31) and the presence of a mud floor (AOR = 2.29, 95% CI = 1.20–4.37) and negatively associated with cleanliness of the toilet (AOR = 0.68, 95% CI = 0.47–0.98), and the cleanliness of children’s hands (AOR = 0.62, 95% CI = 0.40–0.96).

Conclusions

Our study found, more than half of the survey children were in a critical health condition. Results suggest that child health improvements are dependent on multiple public health improvements, including providing better nutrition, promoting adequate hygiene behaviour, such as handwashing, keeping the latrines clean, keeping the household environment free from animal faeces and assuring a reliable supply of safe water.

Effects of a Water, Sanitation and Hygiene Mobile Health Program on Diarrhea and Child Growth in Bangladesh: A Cluster-Randomized Controlled Trial of the CHoBI7 Mobile Health Program

Background

The Cholera Hospital-Based Intervention for 7 Days (CHoBI7) mobile health (mHealth) program was a cluster-randomized controlled trial of diarrhea patient households conducted in Dhaka, Bangladesh.

Methods

Patients were block-randomized to 3 arms: standard message on oral rehydration solution use; health facility delivery of CHoBI7 plus mHealth (no home visits); and health facility delivery of CHoBI7 plus 2 home visits and mHealth. The primary outcome was reported diarrhea in the past 2 weeks collected monthly for 12 months. The secondary outcomes were stunting, underweight, and wasting at a 12-month follow-up. Analysis was intention-to-treat.

Results

Between 4 December 2016 and 26 April 2018, 2626 participants in 769 households were randomly allocated to 3 arms: 849 participants to the standard message arm, 886 to mHealth with no home visits arm, and 891 to the mHealth with 2 home visits. Children <5 years had significantly lower 12-month diarrhea prevalence in both the mHealth with 2 home visits arm (prevalence ratio [PR]: 0.73 [95% confidence interval {CI}, .61–.87]) and the mHealth with no home visits arm (PR: 0.82 [95% CI, .69–.97]). Children <2 years were significantly less likely to be stunted in both the mHealth with 2 home visits arm (33% vs 45%; odds ratio [OR]: 0.55 [95% CI, .31–.97]) and the mHealth with no home visits arm (32% vs 45%; OR: 0.54 [95% CI, .31–.96]) compared with children in the standard message arm.

Conclusions

The CHoBI7 mHealth program lowered pediatric diarrhea and stunting among diarrhea patient households.

Clinical Trials Registration

NCT04008134.

Factors influencing undernutrition among children under 5 years from cocoa-growing communities in Bougainville

Half the children under the age of 5 years in Papua New Guinea (PNG) are undernourished, more than double the global average with rural areas disproportionately affected. This study examines factors associated with stunting, wasting and underweight in cocoa growers' children (<5 years) in the Autonomous Region of Bougainville (ARoB), using data from a comprehensive 2017 cross-sectional livelihoods survey. Sixteen independent predictors for stunting, wasting and underweight were selected based on the UNICEF Conceptual Framework of Determinants of Undernutrition. We used multilevel logistic mixed regression models to measure the association of the explanatory variables with stunting, wasting and underweight. At the household level, the adjusted OR (aOR) of stunting (aOR=1.71,95% CI 1.14 to 2.55) and underweight (aOR=2.11, 95% CI 1.16 to 3.82) increased significantly among children from households with unimproved toilet facilities. The aOR for underweight also increased among children from households without access to clean drinking water (aOR=1.97, 95% CI 1.19 to 3.29). Short maternal stature was significantly associated with child stunting, the odds increased as maternal height decreased (from 150 to <155 cm, aOR=1.52, 95% CI 1.02 to 2.26) (<150 cm, aOR=2.37, 95% CI 1.29 to 4.35). At the individual level, the odds of a child being underweight increased with birth order (second born, aOR=1.92, 95% CI 1.09 to 3.36; third born, aOR=6.77, 95% CI 2.00 to 22.82). Compared with children less than 6 months, children aged 6-23 months and 24-59 months had a higher odds of being stunted (aOR=3.27, 95% CI 1.57 to 6.78 and aOR=2.82, 95% CI 1.40 to 5.67) and underweight (aOR=4.83, 95% CI 1.36 to 17.24 and aOR=4.59, 95% CI 1.29 to 16.26). No variables were found to be significant for wasting. Interventions that simultaneously target key life stages for women and children and the underlying social and environmental determinants are required for sustained improvements to undernutrition.

Impact of Rotavirus Vaccination Varies by Level of Access to Piped Water and Sewerage: An Analysis of Childhood Clinic Visits for Diarrhea in Peru, 2005-2015

BACKGROUND

We conducted a national impact evaluation of routine rotavirus vaccination on childhood diarrhea in Peru, accounting for potential modifying factors.

METHODS

We utilized a dataset compiled from Peruvian governmental sources to fit negative binomial models investigating the impact of rotavirus vaccination, piped water access, sewerage access and poverty on the rate of diarrhea clinic visits in children under 5 years old in 194 Peruvian provinces. We considered the interaction between these factors to assess whether water access, sanitation access, or poverty modified the association between ongoing rotavirus vaccination and childhood diarrhea clinic visits. We compared the "pre-vaccine" (2005-2009) and "post-vaccine" (2010-2015) eras.

RESULTS

The rate of childhood diarrhea clinic visits was 7% [95% confidence interval (CI): 3%-10%] lower in the post-vaccine era compared with the pre-vaccine era, controlling for long-term trend and El Niño seasons. No impact of rotavirus vaccination was identified in provinces with the lowest access to piped water (when <40% of province households had piped water) or in the lowest category of sewerage (when <17% of province households had a sewerage connection). Accounting for long-term and El Niño trends, the rate of childhood diarrhea clinic visits was lower in the post-vaccine era by 7% (95% CI: 2%-12%), 13% (95% CI: 7%-19%) and 15% (95% CI: 10%-20%) in the second, third and fourth (highest) quartiles of piped water access, respectively (compared with the pre-vaccine era); results for sewerage access were similar.

CONCLUSION

Improved water/sanitation may operate synergistically with rotavirus vaccination to reduce childhood clinic visits for diarrhea in Peru.

Benefits and Costs of a Community-Led Total Sanitation Intervention in Rural Ethiopia-A Trial-Based ex post Economic Evaluation

We estimated the costs and benefits of a community-led total sanitation (CLTS) intervention using the empirical results from a cluster-randomized controlled trial in rural Ethiopia. We modelled benefits and costs of the intervention over 10 years, as compared to an existing local government program. Health benefits were estimated as the value of averted mortality due to diarrheal disease and the cost of illness arising from averted diarrheal morbidity. We also estimated the value of time savings from avoided open defecation and use of neighbours' latrines. Intervention delivery costs were estimated top-down based on financial records, while recurrent costs were estimated bottom-up from trial data. We explored methodological and parameter uncertainty using one-way and probabilistic sensitivity analyses. Avoided mortality accounted for 58% of total benefits, followed by time savings from increased access to household latrines. The base case benefit-cost ratio was 3.7 (95% CI: 1.9-5.4) and the net present value was Int'l $1,193,786 (95% CI: 406,017-1,977,960). The sources of the largest uncertainty in one-way sensitivity analyses were the effect of the CLTS intervention and the assumed lifespan of an improved latrine. Our results suggest that CLTS interventions can yield favourable economic returns, particularly if follow-up after the triggering is implemented intensively and uptake of improved latrines is achieved (as opposed to unimproved).

Effect of water, sanitation and hygiene interventions alone and combined with nutrition on child growth in low and middle income countries: a systematic review and meta-analysis

OBJECTIVE

This study aimed to provide clarification on the benefits of water, sanitation and hygiene (WASH) alone separately and combined with nutrition in improving child growth outcomes.

DESIGN

Systematic review and meta-analysis.

METHODS

We conducted a systematic review using the Preferred Reporting Items for Systematic Review and Meta-Analyses guidelines. PubMed, MEDLINE, EMBASE, Scopus, Cochrane Library, Web of Science and Science Direct were searched in May 2018 and last updated in April 2019. We included studies that reported WASH interventions alone separately or combined with nutrition. Fixed and random-effects models were used to estimate pooled effect in mean difference (MD). Heterogeneity and publication bias statistics were performed.

RESULTS

A total of 18 studies were included: 13 cluster randomised controlled trials (RCTs) and 5 non-randomised controlled trials (non-RCTs). Non-RCTs showed effect of WASH interventions alone on height-for-age z-score (HAZ) (MD=0.14; 95% CI 0.08 to 0.21) but RCTs did not. WASH alone of non-RCTs and RCTs that were delivered over 18-60 months indicated an effect on HAZ (MD=0.04; 95% CI 0.01 to 0.08). RCTs showed an effect for children <2 years (MD=0.07; 95% CI 0.01 to 0.13). Non-RCTs of WASH alone and those that included at least two components, improved HAZ (MD=0.15; 95% CI 0.07 to 0.23) but RCTs did not. WASH alone of non-RCTs and RCTs separately or together showed no effect on weight-for-age z-score (WAZ) and weight-for-height z-score (WHZ). Combined WASH with nutrition showed an effect on HAZ (MD=0.13; 95% CI 0.08 to 0.17) and on WAZ (MD=0.09; 95% CI 0.05 to 0.13) and was borderline on WHZ.

CONCLUSIONS

WASH interventions alone improved HAZ when delivered over 18-60 months and for children <2 years. Combined WASH with nutrition showed a strong effect on HAZ and WAZ and a borderline effect on WHZ. Integrated WASH with nutrition interventions may be effective inimproving child growth outcomes.

Aflatoxin exposure was not associated with childhood stunting: results from a birth cohort study in a resource-poor setting of Dhaka, Bangladesh

OBJECTIVE

Chronic aflatoxin exposure has been associated with childhood stunting (length-for-age/height-for-age < -2 sd), while data lacks for Bangladesh, a country with substantial burden of childhood stunting. This paper examined the association between aflatoxin exposure and childhood stunting in a slum setting of Dhaka city.

DESIGN

In this MAL-ED aflatoxin birth cohort study, plasma samples were assayed for aflatoxin B1-lysine adduct (AFB1-lys) by MS at 7, 15, 24 and 36 months of age for 208, 196, 173 and 167 children to assess chronic aflatoxin exposure. Relationship between aflatoxin exposure and anthropometric measures was examined by mixed-effects logistic regression models.

SETTING AND PARTICIPANTS

The study was conducted in Mirpur, Dhaka, where children were followed from birth to 36 months.

RESULTS

Prevalence of stunting increased from 21 % at 7 months to 49 % at 36 months of age. Mean AFB1-lys concentrations at 7, 15, 24 and 36 months were 1·30 (range 0·09-5·79), 1·52 (range 0·06-6·35), 3·43 (range 0·15-65·60) and 3·70 (range 0·09-126·54) pg/mg albumin, respectively, and the percentage of children with detectable AFB1-lys was 10, 21, 18 and 62 %, respectively. No association was observed between aflatoxin exposure and stunting in multivariable analyses. Factors associated with childhood stunting were age, low birth weight, maternal height, stool myeloperoxidase and number of people sleeping in one room.

CONCLUSIONS

A relatively lower exposure to aflatoxin may not influence the linear growth of children. This finding indicates a threshold level of exposure for linear growth deficit and further investigation in other areas where higher concentrations of aflatoxin exposure exist.

Practices and Perspectives on Latrine Use, Child Feces Disposal, and Clean Play Environments in Western Kenya

Exposure to fecal pathogens contributes to childhood diarrhea and stunting, causing harmful short- and long-term impacts to health. Understanding pathways of child fecal exposure and nutritional deficiencies is critical to informing interventions to reduce stunting. Our aim was to explore determinants of latrine use, disposal of child feces, and perceptions and provisions of a safe and clean child play environment among families with children under two (CU2) years to inform the design of a behavior change intervention to address water, sanitation, and hygiene (WASH), and nutrition behaviors. In 2016, we conducted a mixed-methods formative research in western Kenya. We conducted 29 key informant interviews with community leaders, health workers, and project staff; 18 focus group discussions with caregivers of CU2 years; and 24 semi-structured household observations of feeding, hygiene, and sanitation behaviors. We used the capability, opportunity, motivation, and behavior model as our theoretical framework to map caregiver behavioral determinants. Latrine use barriers were lack of latrines, affordability of lasting materials, and social acceptability of unobserved open defecation. Barriers to safe disposal of child feces were lack of latrines, time associated with safe disposal practices, beliefs that infant feces were not harmful, and not knowing where children had defecated. Primary barriers of clean play environments were associated with creating and maintaining play spaces, and shared human and animal compounds. The immediate cost to practicing behaviors was perceived as greater than the long-term potential benefits. Intervention design must address these barriers and emphasize facilitators to enable optimal WASH behaviors in this context.

Self-Reported Versus Observed Measures: Validation of Child Caregiver Food Hygiene Practices in Rural Malawi

Few studies have attempted to measure the differences between self-reported and observed food hygiene practices in a household setting. We conducted a study to measure the level of agreement between self-reported and observed food hygiene practices among child caregivers with children under the age of five years in rural Malawi. Fifty-eight child caregivers from an intervention and 29 from a control group were recruited into the study. At the end of a nine-month food hygiene intervention, household observations were conducted followed by self-reported surveys. Overall, practices were found to be more frequently reported than observed in both groups. However, the difference between self-reports and observed practices was minimal in the intervention compared to the control group. The odds ratio results confirm that more desirable practices were observed in the intervention group compared to the control group. Despite the effects of reactivity during observations, the study results imply that the intervention group did not just improve their knowledge, but also translated the messaging into better practice. Researchers and implementing agencies in water, sanitation and hygiene and food hygiene sector should ensure that interventions are context-appropriate, and that effective methods of observation are used to confirm any reported effects of an intervention.

Community Perceptions of a Multilevel Sanitation Behavior Change Intervention in Rural Odisha, India

While latrine coverage is increasing in India, not all household members use their latrines. Cost-effective, culturally appropriate, and theory-informed behavior change interventions are necessary to encourage sustained latrine use by all household members. We qualitatively examined community perceptions of sanitation interventions broadly, along with specific impressions and spillover of community-level activities of the Sundara Grama latrine use behavior change intervention in rural Odisha, India. We conducted sixteen sex-segregated focus group discussions (n = 152) in three intervention and three nonintervention villages and thematically analyzed the data. We found Sundara Grama was well-received by community members and considered educative, but perceptions of impact on latrine use were mixed and varied by activity. Intervention recruitment challenges prevented some, such as women and households belonging to lower castes, from attending activities. Spillover occurred in one of two nonintervention villages, potentially due to positive relations within and between the nonintervention village and nearby intervention village. Community-level sanitation initiatives can be hindered by community divisions, prioritization of household sanitation over community cleanliness, and perceptions of latrine use as a household and individual issue, rather than common good. Community-centered sanitation interventions should assess underlying social divisions, norms, and perceptions of collective efficacy to adapt intervention delivery and activities.

JM, Mertens A, Hubbard AE, Arnold BF. Internal replication of computational workflows in scientific research

Failures to reproduce research findings across scientific disciplines from psychology to physics have garnered increasing attention in recent years. External replication of published findings by outside investigators has emerged as a method to detect errors and bias in the published literature. However, some studies influence policy and practice before external replication efforts can confirm or challenge the original contributions. Uncovering and resolving errors before publication would increase the efficiency of the scientific process by increasing the accuracy of published evidence. Here we summarize the rationale and best practices for internal replication, a process in which multiple independent data analysts replicate an analysis and correct errors prior to publication. We explain how internal replication should reduce errors and bias that arise during data analyses and argue that it will be most effective when coupled with pre-specified hypotheses and analysis plans and performed with data analysts masked to experimental group assignments. By improving the reproducibility of published evidence, internal replication should contribute to more rapid scientific advances.

Determinants of Childhood Zoonotic Enteric Infections in a Semirural Community of Quito, Ecuador

Domestic animals in the household environment have the potential to affect a child's carriage of zoonotic enteric pathogens and risk of diarrhea. This study examines the risk factors associated with pediatric diarrhea and carriage of zoonotic enteric pathogens among children living in communities where smallholder livestock production is prevalent. We conducted an observational study of children younger than 5 years that included the analysis of child (n = 306) and animal (n = 480) fecal samples for Campylobacter spp., atypical enteropathogenic Escherichia coli, Shiga toxin-producing E. coli, Salmonella spp., Yersinia spp., Cryptosporidium parvum, and Giardia lamblia. Among these seven pathogens, Giardia was the most commonly identified pathogen among children and animals in the same household, most of which was found in child-dog pairs. Campylobacter spp. was also relatively common within households, particularly among child-chicken and child-guinea pig pairs. We used multivariable Poisson regression models to assess risk factors associated with a child being positive for at least one zoonotic enteric pathogen or having diarrhea during the last week. Children who interacted with domestic animals-a behavior reported by nearly three-quarters of households owning animals-were at an increased risk of colonization with at least one zoonotic enteric pathogen (prevalence ratio [PR] = 1.56, 95% CI: 1.00-2.42). The risk of diarrhea in the last seven days was elevated but not statistically significant (PR = 2.27, CI: 0.91, 5.67). Interventions that aim to reduce pediatric exposures to enteric pathogens will likely need to be incorporated with approaches that remove animal fecal contamination from the domestic environment and encourage behavior change aimed at reducing children's contact with animal feces through diverse exposure pathways.

Effect of in-line drinking water chlorination at the point of collection on child diarrhoea in urban Bangladesh: a double-blind, cluster-randomised controlled trial

BACKGROUND

Previous blinded trials of household water treatment interventions in low-income settings have failed to detect a reduction in child diarrhoea. Technological advances have enabled the development of automated in-line chlorine dosers that can disinfect drinking water without electricity, while also allowing users to continue their typical water collection practices. We aimed to evaluate the effect of installing novel passive chlorination devices at shared water points on child diarrhoea prevalence in low-income, densely populated communities in urban Bangladesh.

METHODS

In this double-blind cluster-randomised controlled trial, 100 shared water points (clusters) in two low-income urban communities in Bangladesh were randomly assigned (1:1) to have their drinking water automatically chlorinated at the point of collection by a solid tablet chlorine doser (intervention group) or to be treated by a visually identical doser that supplied vitamin C (active control group). The trial followed an open cohort design; all children younger than 5 years residing in households accessing enrolled water points were measured every 2-3 months during a 14-month follow-up period (children could migrate into or out of the cluster). The primary outcome was caregiver-reported child diarrhoea (≥3 loose or watery stools in a 24-h period [WHO criteria]) with a 1-week recall, including all available childhood observations in the analyses. This trial is registered with ClinicalTrials.gov, number NCT02606981, and is completed.

FINDINGS

Between July 5, 2015, and Nov 11, 2015, 100 water points with 920 eligible households were enrolled into the study and randomly assigned to the treatment (50 water points; 517 children at baseline; 2073 child observations included in the primary analysis) or control groups (50; 519; 2154). Children in the treatment group had less WHO-defined diarrhoea than did children in the control group (control 216 [10·0%] of 2154; treatment 156 [7·5%] of 2073; prevalence ratio 0·77, 95% CI 0·65-0·91). Drinking water at the point of collection at treatment taps had detectable free chlorine residual 83% (mean 0·37 ppm) of the time compared with 0% at control taps (0·00 ppm).

INTERPRETATION

Passive chlorination at the point of collection could be an effective and scalable strategy in low-income urban settings for reducing child diarrhoea and for achieving global progress towards Sustainable Development Goal 6.1 to attain universal access to safe and affordable drinking water. Targeting a low chlorine residual (<0·5 ppm) in treated water can increase taste acceptability of chlorinated drinking water while still reducing the risk of diarrhoea.

FUNDING

The World Bank.

Effects of nutritional supplementation and home visiting on growth and development in young children in Madagascar: a cluster-randomised controlled trial

BACKGROUND

Evidence from efficacy trials suggests that lipid-based nutrient supplementation (LNS) and home visits can be effective approaches to preventing chronic malnutrition and promoting child development in low-income settings. We tested the integration of these approaches within an existing, large-scale, community-based nutrition programme in Madagascar.

METHODS

We randomly allocated 125 programme sites to five intervention groups: standard-of-care programme with monthly growth monitoring and nutrition education (T0); T0 plus home visits for intensive nutrition counselling through an added community worker (T1); T1 plus LNS for children aged 6-18 months (T2); T2 plus LNS for pregnant or lactating women (T3); or T1 plus fortnightly home visits to promote and encourage early stimulation (T4). Pregnant women (second or third trimester) and infants younger than 12 months were enrolled in the trial. Primary outcomes were child growth (length-for-age and weight-for-length Z scores) and development at age 18-30 months. Analyses were by intention to treat. The trial was registered with the ISRCTN registry, number ISRCTN14393738.

FINDINGS

The study enrolled 3738 mothers: 1248 pregnant women (250 women in each of the T0, T1, T2, and T4 intervention groups and 248 in the T3 intervention group) and 2490 children aged 0-11 months (497 children in T0, 500 in T1, 494 in T2, 499 in T3, and 500 in T4) at baseline who were assessed at 1-year and 2-year intervals. There were no main effects of any of the intervention groups on any measure of anthropometry or any of the child development outcomes in the full sample. However, compared with children in the T0 intervention group, the youngest children (<6 months at baseline) in the T2 and T3 intervention groups who were fully exposed to the child LNS dose had higher length-for-age Z scores (a significant effect of 0·210 SD [95% CI -0·004 to 0·424] for T2 and a borderline effect of 0·216 SD [0·043 to 0·389] for T3) and lower stunting prevalence (-9·0% [95% CI -16·7 to -1·2] for T2 and -8·2% [-15·6 to -0·7] for T3); supplementing mothers conferred no additional benefit.

INTERPRETATION

LNS for children for a duration of 12 months only benefited growth when it began at an early age, suggesting the need to supplement infants at age 6 months in a very low-income context. The lack of effect of the early stimulation messages and home visits might be due to little take-up of behaviour-change messages and delivery challenges facing community health workers.

FUNDING

Eunice Kennedy Shriver National Institutes of Child Health and Human Development, Strategic Impact Evaluation Fund, World Bank Innovation Grant, Early Learning Partnership Grant, World Bank Research Budget, Japan Nutrition Trust Fund, Power of Nutrition, and the National Nutrition Office of Madagascar.

A National Communication Campaign in Indonesia Is Associated with Improved WASH-Related Knowledge and Behaviors in Indonesian Mothers

Background: Water, sanitation, and hygiene (WASH) behaviors play a significant role in stunting. Knowledge and behaviors regarding WASH among caregivers are critical to providing children with chances to survive and thrive. The purpose of this study is to determine if exposure to a national communication campaign using media and interpersonal communication (IPC) is associated with WASH-related knowledge and behaviors among Indonesian mothers with children under the age of two. Methods: Data came from a cross-sectional survey of 1734 mothers with children under the age of two. The measures included exposure to two different interventions: media messages (media) and interpersonal communication strategies (IPC) and WASH-related knowledge and behavior. Multiple logistic regression was used to examine the association between intervention exposure and study variables. Results: Exposure to both media and IPC interventions was associated with participants having a higher knowledge of appropriate defecation practices (p < 0.001), higher knowledge of proper handwashing practices (p < 0.001), and higher self-reported handwashing at critical times (p < 0.001) but was not associated with reported practicing of appropriate defecation (OR = 0.780, 95% CI: 0.566–1.101). Mothers exposed to only media interventions were more likely to have knowledge of appropriate defecation practices (p < 0.001) and to have reported practicing appropriate defecation behaviors (OR = 1.539, 95% CI: 1.173–2.019). Mothers exposed to only IPC interventions were more likely to have reported handwashing at critical times (p = 0.009). Conclusions: Exposure to both media and IPC interventions was associated with increased knowledge and optimal behaviors related to WASH. These findings demonstrate the value of communications campaigns that use mass media coupled with IPC to improve WASH knowledge and behavior.

The WASH Benefits and SHINE trials: interpretation of WASH intervention effects on linear growth and diarrhoea

Child stunting is a global problem and is only modestly responsive to dietary interventions. Numerous observational studies have shown that water quality, sanitation, and handwashing (WASH) in a household are strongly associated with linear growth of children living in the same household. We have completed three randomised efficacy trials testing improved household-level WASH with and without improved infant and young child feeding (IYCF) on stunting and diarrhoea in Bangladesh, Kenya, and Zimbabwe. In all trials, improved IYCF had a statistically significant benefit, but WASH had no effect on linear growth. In observational analyses of data from the control groups of the three trials, baseline sanitation was a strong risk factor for stunting in the study populations, suggesting this frequently reported association might be confounded by unmeasured factors of household wellbeing. WASH interventions reduced diarrhoea in Bangladesh, but not in Kenya or Zimbabwe. Intervention promoters visited participants six times per month in Bangladesh compared with monthly in Kenya and Zimbabwe; a review of the literature shows that virtually all published studies that have reported an effect on diarrhoea through home-based water treatment and handwashing promotion achieved high adherence by visiting participants at daily to fortnightly intervals. Despite achieving substantial behavioural change and significant reduction in infection prevalence for some enteric pathogens, detection of enteropathogens among children in the WASH groups of the trials was typically at ten times higher prevalence compared with high-income countries. Considering these results, we recommend that future research in the WASH sector focus on developing and evaluating interventions that are radically more effective in reducing faecal contamination in the domestic environment than the interventions implemented in these trials.

A Stepped Wedge Cluster-Randomized Trial Assessing the Impact of a Riverbank Filtration Intervention to Improve Access to Safe Water on Health in Rural India

Sustainable and low-cost methods for delivery of safe drinking water in resource-limited settings remain suboptimal, which contributes to global diarrhea morbidity. We aimed to assess whether delivery of riverbank filtration-treated water to newly installed water storage tanks (improved quality and access, intervention condition) reduced reported diarrhea in comparison to delivery of unfiltered river water (improved access alone, control condition) in rural Indian villages. We used a stepped wedge cluster-randomized trial (SW-CRT) design involving four clusters (villages). Selection criteria included village size, proximity to a river, and lack of existing or planned community-level safe water sources. All adults and children were eligible for enrollment. All villages started in the control condition and were sequentially randomized to receive the intervention at 3-month intervals. Our primary outcome was 7-day-period prevalence of self- or caregiver-reported diarrhea, measured at 3-month intervals (five time points). Analysis was by intention to treat. Because blinding was not possible, we incorporated questions about symptoms unrelated to water consumption to check response validity (negative control symptoms). We measured outcomes in 2,222 households (9,836 participants). We did not find a measurable reduction in diarrhea post-intervention (RR: 0.98 [95% CI: 0.24-4.09]); possible explanations include low intervention uptake, availability of other safe water sources, low baseline diarrheal prevalence, and reporting fatigue. Our study highlights both the difficulties in evaluating the impact of real-world interventions and the potential for an optimized SW-CRT design to address budgetary, funding, and logistical constraints inherent in such evaluations.

Maternal profiles and social determinants of severe acute malnutrition among children under-five years of age: A case-control study in Nepal

Background

Addressing the determinants of severe acute malnutrition (SAM) among children remains a challenge in Nepal. This study investigated the effect of maternal and social determinants of SAM among under-five children of Nepal.

Methods

We conducted a hospital-based unmatched case-control study with 256 under-five children (128 cases and 128 controls). The children aged 6–59 months were taken, and the cases and controls were defined based on mid-upper arm circumference (MUAC).

Results

Backward Stepwise logistic regression analysis of 6–59 months children showed that the odds of SAM were lower among male children (AOR = 0.50, 95% CI = 0.27–0.92), mothers from high socioeconomic status (AOR = 0.469, 95% CI = 0.26–0.83), breastfeeding 6–12 months (AOR = 0.21, 95% CI = 0.05–0.68), breastfeeding ≥13 months (AOR = 0.18, 95% CI = 0.05–0.54) and optimal complementary feeding (AOR = 0.40, 95% CI = 0.22–0.70). SAM was significantly higher among children of the age group 6–24 months (AOR = 2.57, 95% CI = 1.30–5.22) and children with a history of diarrhea (AOR = 1.75, 95% CI = 0.92–3.39).

Conclusions

In order to reduce the children's SAM, it is necessary to scale up services to improve the socioeconomic status which includes the education, occupation, and monthly income of the mother. Girls of age group 6–24 months were more likely to develop SAM. Two contributing factors to decrease SAM are the importance of exclusive breastfeeding practices and the availability and usage of soap in hand washing, which are ideal for low cost interventions. To reduce SAM in Nepal, a focus on enhancing complementary feeding through increased affordability of nutritious foods is also needed.

Risk factors and transmission pathways associated with infant Campylobacter spp. prevalence and malnutrition: A formative study in rural Ethiopia

Early infection from enteropathogens is recognised as both a cause and effect of infant malnutrition. Specifically, evidence demonstrates associations between growth shortfalls and Campylobacter infection, endemic across low-income settings, with poultry a major source. Whilst improvements in water, sanitation and hygiene (WASH) should reduce pathogen transmission, interventions show inconsistent effects on infant health. This cross-sectional, formative study aimed to understand relationships between infant Campylobacter prevalence, malnutrition and associated risk factors, including domestic animal husbandry practices, in rural Ethiopia. Thirty-five households were visited in Sidama zone, Southern Nations, Nationalities and Peoples' region. Infant and poultry faeces and domestic floor surfaces (total = 102) were analysed for presumptive Campylobacter spp. using selective culture. Infant anthropometry and diarrhoeal prevalence, WASH facilities and animal husbandry data were collected. Of the infants, 14.3% were wasted, 31.4% stunted and 31.4% had recent diarrhoea. Presumptive Campylobacter spp. was isolated from 48.6% of infant, 68.6% of poultry and 65.6% of floor surface samples. Compared to non-wasted infants, wasted infants had an increased odds ratio (OR) of 1.41 for a Campylobacter-positive stool and 1.81 for diarrhoea. Positive infant stools showed a significant relationship with wasting (p = 0.026) but not stunting. Significant risk factors for a positive stool included keeping animals inside (p = 0.027, OR 3.5), owning cattle (p = 0.018, OR 6.5) and positive poultry faeces (p<0.001, OR 1.34). Positive floor samples showed a significant correlation with positive infant (p = 0.023), and positive poultry (p = 0.013, OR 2.68) stools. Ownership of improved WASH facilities was not correlated with lower odds of positive stools. This formative study shows a high prevalence of infants positive for Campylobacter in households with free-range animals. Findings reaffirm contaminated floors as an important pathway to infant pathogen ingestion and suggest that simply upgrading household WASH facilities will not reduce infection without addressing the burden of contamination from animals, alongside adequate separation in the home.

Improved yet Unsafe: An Aquatic Perspective of Indian Infant Mortality

Infant mortality rate (IMR) is an important development indicator and a vital component of millennium development goals (MDGs) set by United Nations Development Programme (UNDP). According to UNDP, so far India has only fared moderately in reducing IMR (Goal 4 of MDGs). India (32) ranks 144th among 196 countries regarding IMR as per the 2017 data availed from World Development Indicators. Its adjacent countries such as Bhutan (25.6), Bangladesh (26.9) and Nepal (27.8) have fared much better regarding infant survival. Numbers within the parentheses indicate the IMR of the respective country. The United Nations Children’s Fund (UNICEF) has identified that IMR among families with better access to improved drinking water sources and toilet is much lower than those bereft of the same. This inference has been drawn from National Family Health Survey 3 data (NFHS III). The present study investigates into the aforementioned relation analysing NFHS IV data. The result depicts that contrary to UNICEF’s findings, IMR increases with better accessibility to improved water sources. Further to this, the article shows that an additional aqua-related practice together with improved drinking water sources might lead to the betterment of IMR for India.

Human fecal contamination of water, soil, and surfaces in households sharing poor-quality sanitation facilities in Maputo, Mozambique

Identifying the origin of fecal contamination can support more effective interventions to interrupt enteric pathogen transmission. Microbial source tracking (MST) assays may help to identify environmental routes of pathogen transmission although these assays have performed poorly in highly contaminated domestic settings, highlighting the importance of both diagnostic validation and understanding the context-specific ecological, physical, and sociodemographic factors driving the spread of fecal contamination. We assessed fecal contamination of compounds (clusters of 2-10 households that share sanitation facilities) in low-income neighborhoods of urban Maputo, Mozambique, using a set of MST assays that were validated with animal stool and latrine sludge from study compounds. We sampled five environmental compartments involved in fecal microbe transmission and exposure: compound water source, household stored water and food preparation surfaces, and soil from the entrance to the compound latrine and the entrances to each household. Each sample was analyzed by culture for the general fecal indicator Escherichia coli (cEC) and by real-time PCR for the E. coli molecular marker EC23S857, human-associated markers HF183/BacR287 and Mnif, and GFD, an avian-associated marker. We collected 366 samples from 94 households in 58 compounds. At least one microbial target (indicator organism or marker gene) was detected in 96% of samples (353/366), with both E. coli targets present in the majority of samples (78%). Human targets were frequently detected in soils (59%) and occasionally in stored water (17%) but seldom in source water or on food surfaces. The avian target GFD was rarely detected in any sample type but was most common in soils (4%). To identify risk factors of fecal contamination, we estimated associations with sociodemographic, meteorological, and physical sample characteristics for each microbial target and sample type combination using Bayesian censored regression for target concentration responses and Bayesian logistic regression for target detection status. Associations with risk factors were generally weak and often differed in direction between different targets and sample types, though relationships were somewhat more consistent for physical sample characteristics. Wet soils were associated with elevated concentrations of cEC and EC23S857 and odds of detecting HF183. Water storage container characteristics that expose the contents to potential contact with hands and other objects were weakly associated with human target detection. Our results describe a setting impacted by pervasive domestic fecal contamination, including from human sources, that was largely disconnected from the observed variation in socioeconomic and sanitary conditions. This pattern suggests that in such highly contaminated settings, transformational changes to the community environment may be required before meaningful impacts on fecal contamination can be realized.

Improving Complementary Food Hygiene Behaviors Using the Risk, Attitude, Norms, Ability, and Self-Regulation Approach in Rural Malawi

The study evaluated the effectiveness of an intervention to improve complementary food hygiene behaviors among child caregivers in rural Malawi. Formative research and intervention development was grounded in the risk, attitude, norms, ability, and self-regulation (RANAS) model and targeted washing hands and kitchen utensils with soap, safe utensil storage, reheating of leftover food, and feeding of children by caregivers. Longitudinal research was applied at baseline and follow-up surveys among 320 caregivers. Determinants of selected behaviors were found, and interventions were developed based on the behavior change techniques aligned with these determinants in the RANAS model. The intervention was delivered over 9 months through group (cluster) meetings and household visits and included demonstrations, games, rewards, and songs. We randomly assigned villages to the control or intervention group. Follow-up results indicated a significant increase in three targeted behaviors (washing kitchen utensils with soap, safe utensil storage, and handwashing with soap) among intervention recipients. Several psychosocial factors differed significantly between the intervention and control groups. Mediation results showed that the intervention had a significant effect on these three targeted behaviors. For handwashing, feelings, others' behavior in the household, and remembering; for washing kitchen utensils, others' behavior in the household and difficulty to get enough soap; for safe utensils storage, others' behavior in the village and remembering mediated the effect of the intervention on the targeted behaviors. The study demonstrated that targeting food hygiene behaviors with a theory-driven behavior change approach using psychosocial factors can improve the behavior of child caregivers in rural Malawi.

Indirect health sector actions and supportive strategies to prevent malnutrition

PURPOSE OF REVIEW

Malnutrition is a pervasive problem that causes negative acute, long-term, and intergenerational consequences. As we have begun to move from efficacy to effectiveness trials of nutrition interventions, and further still to more holistic case study approaches to understanding how and why nutrition outcomes change over time, it has become clear that more emphasis on the 'nutrition-sensitive' interventions is required.

RECENT FINDINGS

In this article, we propose recategorizing the nutrition-specific and sensitive terminology into a new framework that includes direct and indirect health sector actions and supportive strategies that exist outside the health sector; an adjustment that will improve sector-specific planning and accountability. We outline indirect health sector nutrition interventions, with a focus on family planning and the evidence to support its positive link with nutrition outcomes. In addition, we discuss supportive strategies for nutrition, with emphasis on agriculture and food security, water, sanitation, and hygiene, and poverty alleviation and highlight some of the recent evidence that has contributed to these fields.

SUMMARY

Indirect health sector nutrition interventions and supportive strategies for nutrition will be critical, alongside direct health sector nutrition interventions, to reach global targets. Investments should be made both inside and outside the health sector.

Protocol for the trial to establish a causal linkage between mycotoxin exposure and child stunting: a cluster randomized trial

Background

The number of stunted children has fallen globally but continues to increase in Africa. Stunting is estimated to contribute to 14–17% of child deaths under 5 years of age and is a risk factor for poor cognitive and motor development and educational outcomes. Inadequate dietary intake and disease are thought to be the immediate causes of undernutrition and stunting. However, improving infant diets through complementary feeding interventions has been shown to only modestly reduce stunting. Multiple observational studies demonstrate a dose response relationship between fetal and post-natal aflatoxin exposure and reduced linear growth.

Methods

This community-based cluster randomized trial will measure the effect of a reduced aflatoxin diet on length-for-age Z scores at 18 months in central Tanzania. All 52 health facilities in the Kongwa District of Dodoma Region were randomized into two groups. Starting at 6 months of age, participants in the intervention group receive a low-aflatoxin pre-blended porridge flour containing maize and groundnut (ratio 4:1 respectively) and low-aflatoxin groundnut flour, whereas in the control group the same porridge mix and groundnut flour are promoted through education but acquired by the household. Both groups will receive the same infant and young child feeding education and a thermos flask. A total of 3120 infants between 6 weeks and 3 months of age will be recruited into the study over 1 year. Data will be collected four times – at recruitment and when the infants are 6, 12 and 18 months of age. In a cohort of 600 infants, additional data will be collected at 9 and 15 months of age. The primary outcome is length-for-age at 18 months. Secondary outcomes include the Z scores for weight-for-age, middle upper arm circumference and head circumference, and the blood biomarker aflatoxin-albumin in the full sample, with the urine biomarker aflatoxin M1 analyzed in the cohort only.

Discussion

Better understanding the etiology of childhood stunting can lead to more appropriate interventions and policies to further reduce linear growth faltering and meet the Sustainable Development Goals.

Trial registration

NCT03940547, (April 24, 2019).

Risk reduction of diarrhea and respiratory infections following a community health education program - a facility-based case-control study in rural parts of Kenya

Background

Diarrheal and acute respiratory infections remain a major cause of death in developing countries especially among children below 5 years of age. About 80% of all hospital attendances in Kenya can be attributed to preventable diseases and at least 50% of these preventable diseases are linked to poor sanitation. The purpose of this study was to assess the impact of a community-based health education program, called Familia Nawiri, in reducing the risk of diarrhea and respiratory infections among people living in three rural Kenyan communities.

Methods

Cases were defined as patients attending the health facility due to diarrhea or a respiratory infection while controls were patients attending the same health facility for a non-communicable disease defined as an event other than diarrhea, respiratory infection. Adjusted odds ratios (ORs) with 95% confidence intervals (CIs) were calculated using a logistic regression model to assess the risk of diarrheal or respiratory infection in association with exposure to the health education program.

Results

There were 324 cases and 308 controls recruited for the study with 57% of the cases and 59% of the controls being male. Overall, 13% of cases vs. 20% of control patients were exposed to the education program. Participants exposed to the program had 38% lower odds of diarrhea and respiratory infections compared to those not exposed to the program (adjusted OR 0.62, 95% CI 0.41–0.96). A similar risk reduction was observed for participants in the study who resided in areas with water improvement initiatives (adjusted OR 0.65, 95% CI 0.47–0.90). Variables in the adjusted model included water improvement projects in the area and toilet facilities.

Conclusion

Findings from this study suggest participants exposed to the education program and those residing in areas with water improvement initiatives have a reduced risk of having diarrhea or respiratory infection.

Handwashing with soap after potential faecal contact: global, regional and country estimates

Background

Limited data have been available on the global practice of handwashing with soap (HWWS). To better appreciate global HWWS frequency, which plays a role in disease transmission, our objectives were to: (i) quantify the presence of designated handwashing facilities; (ii) assess the association between handwashing facility presence and observed HWWS; and (iii) derive country, regional and global HWWS estimates after potential faecal contact.

Methods

First, using data from national surveys, we applied multilevel linear modelling to estimate national handwashing facility presence. Second, using multilevel Poisson modelling on datasets including both handwashing facility presence and observed HWWS after potential faecal contact, we estimated HWWS prevalence conditional on handwashing facility presence by region. For high-income countries, we used meta-analysis to pool handwashing prevalence of studies identified through a systematic review. Third, from the modelled handwashing facility presence and estimated HWWS prevalence conditional on the presence of a handwashing facility, we estimated handwashing practice at country, regional and global levels.

Results

First, approximately one in four persons did not have a designated handwashing facility in 2015, based on 115 data points for 77 countries. Second the prevalence ratio between HWWS when a designated facility was present compared with when it was absent was 1.99 (1.66, 2.39) P <0.001 for low- and middle-income countries, based on nine datasets. Third, we estimate that in 2015, 26.2% (23.1%, 29.6%) of potential faecal contacts were followed by HWWS.

Conclusions

Many people lack a designated handwashing facility, but even among those with access, HWWS is poorly practised. People with access to designated handwashing facilities are about twice as likely to wash their hands with soap after potential faecal contact as people who lack a facility. Estimates are based on limited data.

Household Water Storage Management, Hygiene Practices, and Associated Drinking Water Quality in Rural India

Household drinking water storage is commonly practiced in rural India. Fecal contamination may be introduced at the water source, during collection, storage, or access. Within a trial of a community-level water supply intervention, we conducted five quarterly household-level surveys to collect information about water, sanitation, and hygiene practices in rural India. In a random subsample of households, we tested stored drinking water samples for Escherichia coli, concurrently observing storage and access practices. We conducted 9961 surveys and collected 3296 stored water samples. Stored water samples were frequently contaminated with E. coli (69%), and E. coli levels were the highest during the wet season. Most households contributing two or more drinking water samples had detectable E. coli in some (47%) or all (44%) samples. Predictors of stored water contamination with E. coli included consumption of river water and open defecation; consumption of reverse osmosis-treated water and safe water access practices appeared to be protective. Until households can be reached with on-premises continuous safe water supplies, suboptimal household water storage practices are likely to continue. Improvements to source water quality alone are unlikely to prevent exposure to contaminated drinking water unless attention is also given to improving household water storage, access, and sanitation practices.

Health Outcomes of an Integrated Behaviour-Centred Water, Sanitation, Hygiene and Food Safety Intervention-A Randomised before and after Trial

Diarrhoeal disease in children under five in low income settings has been associated with multiple environmental exposure pathways, including complementary foods. Conducted from February to December 2018 in rural Malawi, this before and after trial with a control used diarrhoeal disease as a primary outcome, to measure the impact of a food hygiene intervention (food hygiene + handwashing) relative to a food hygiene and water, sanitation and hygiene (WASH) intervention (food hygiene + handwashing + faeces management + water management). The 31-week intervention was delivered by community-based coordinators through community events (n = 2), cluster group meetings (n = 17) and household visits (n = 14). Diarrhoeal disease was self-reported and measured through an end line survey, and daily diaries completed by caregivers. Difference-in-differences results show a 13-percentage point reduction in self-reported diarrhoea compared to the control group. There were also significant increases in the presence of proxy measures in each of the treatment groups (e.g., the presence of soap). We conclude that food hygiene interventions (including hand washing with soap) can significantly reduce diarrhoeal disease prevalence in children under five years in a low-income setting. Therefore, the promotion of food hygiene practices using a behaviour-centred approach should be embedded in nutrition and WASH policies and programming.

Effects of Individual and Combined Water, Sanitation, Handwashing, and Nutritional Interventions on Child Respiratory Infections in Rural Kenya: A Cluster-Randomized Controlled Trial

Poor nutrition and hand hygiene are risk factors for acute respiratory infections (ARIs). Safe drinking water and sanitation can reduce exposure to pathogens and encourage healthy immune responses, reducing the risk of ARIs. Within a trial assessing impacts of water, sanitation, and handwashing (WASH), and nutritional interventions, we evaluated effects on ARIs. The WASH Benefits cluster-randomized trial enrolled pregnant women from Kenyan villages and evaluated health outcomes in children born to enrolled mothers 1 and 2 years after intervention delivery. Geographically adjacent clusters were block-randomized into a passive control (no promotional visits), a double-sized active control (monthly visits to measure mid–upper arm circumference), and six intervention groups: chlorinated drinking water (W), improved sanitation (S), handwashing with soap (H), combined WSH, improved nutrition (N) through counseling and lipid-based nutrient supplementation (LNS), and combined WSHN. The main outcome was the prevalence of ARI symptoms (cough, panting, wheezing, or difficulty breathing) in children younger than 3 years. Masking participants was not possible. Analyses were intention-to-treat. Between November 2012 and May 2014, 702 clusters were enrolled, including 6,960 (year 1) and 7,088 (year 2) children with ARI data. The cluster-level intra-cluster correlation coefficient for ARIs was 0.026 across both years. Water, sanitation, and handwashing interventions with behavior change messaging did not reduce ARIs. Nutrition counseling and LNS modestly reduced ARI symptoms compared with controls in year 1 [prevalence ratio (PR): 0.87, 95% confidence interval (CI): 0.77–0.99], but no effect in the combined WSHN group weakens this finding.

Egg intervention effect on linear growth no longer present after two years

The Lulun Project, a randomized controlled trial conducted in 2015, found that one egg per day for 6 months during early complementary feeding reduced stunting by 47% and increased linear growth by 0.63 length-for-age Z (LAZ). This follow-up cohort study (Lulun Project II) aimed to test whether the growth effect remained in the egg intervention group compared with the control group after approximately 2 years. Mothers or caregivers from the Lulun Project were recontacted and recruited for this study. Enumerators collected data on socio-economic and demographic factors, 24-hr frequency of dietary intakes, morbidities, and anthropometric measures of height, weight, and head circumference using World Health Organization protocols. Statistical analyses followed the same analytical plan as Lulun Project, applying generalized linear models and regression modelling to test group differences in height-for-age z (HAZ) from LAZ at Lulun Project endline, and structural equation modelling for mediation. One hundred thirty-five mother-child dyads were included in Lulun II, with 11% losses to follow-up from endline Lulun Project. Growth faltering across all children was evident with HAZ -2.07 ± 0.91 and a stunting prevelance of 50%. Regression modelling showed no difference between egg and control groups for the HAZ outcome and other anthropometric outcomes, and significant declines in HAZ from endline Lulun Project in the egg intervention are compared with control groups. Current dietary egg intake, however, was associated with reduced growth faltering in HAZ from Lulun Project endline to Lulun Project II, independent of group assignment and through mediation, explaining 8.8% of the total effect. Findings suggest the need for a longer intervention period and ongoing nutrition support to young children during early childhood.

Association of Poor Sanitation With Growth Measurements Among Children in India

Importance

Much research on sanitation and linear growth in low- and middle-income countries focuses on children younger than 5 years. However, poor sanitation may be associated with growth faltering during middle and late childhood to a greater extent than previously recognized.

Objective

To characterize the association of poor sanitation with height-for-age z (HAZ) scores in children and adolescents in India aged 0 to 18 years.

Design, Setting, and Participants

This cross-sectional study examined 134 882 children and adolescents aged 0 to 18 years who were surveyed in the fourth round of India's District Level Household and Facilities Survey (survey conducted August 2012 to February 2014). Data were analyzed from June 1, 2019, to August 20, 2019.

Exposures

Proportion of households reporting open defecation at the village level (to account for its high negative externality) and household-level access to boiled or filtered drinking water.

Main Outcomes and Measures

Individual-level HAZ scores were measured in standard deviations. The association of exposures with outcomes was estimated using ordinary least-squares regression stratified by sex (boys and girls) and 4 age groups (≤1, >1 to ≤7, >7 to ≤12, >12 to ≤18 years). Models controlled for parental height and education, socioeconomic status, maternal age at birth, hemoglobin level, and indicators for state and birth year to adjust for regional (state) and temporal (birth year) fixed effects.

Results

The sample comprised 70 463 male (52.5%) and 64 419 female (47.8%) children and adolescents aged 0 to 18 years; 46 722 participants (34.6%) were aged older than 12 to 18 years. Open defecation was inversely associated with HAZ score among all age groups except boys aged 1 year and younger (>1 to ≤7 years: β, -0.22; 95% CI, -0.35 to -0.10; >7 to ≤12 years: β, -0.15; 95% CI, -0.24 to -0.06; >12 to ≤18 years: β, -0.10; 95% CI, -0.19 to -0.01) and among girls aged between 7 and 18 years (>7 to ≤12 years: β, -0.22; 95% CI, -0.33 to -0.12; >12 to ≤18 years: β, -0.16; 95% CI, -0.23 to -0.09). Boiled or filtered drinking water was positively associated with HAZ score among younger girls (≤1 year: β, 0.26; 95% CI, 0.07 to 0.45; >1 to ≤7 years: β, 0.07; 95% CI, 0.01 to 0.14) and across all age groups in boys (≤1 years: β, 0.19; 95% CI, 0.03 to 0.35; >1 to ≤7 years: β, 0.07; 95% CI, 0.00 to 0.14; >7 to ≤12 years: β, 0.08; 95% CI, 0.03 to 0.13; >12 to ≤18 years: β, 0.06; 95% CI, 0.01 to 0.11).

Conclusions and Relevance

In this study, open defecation and lack of boiled or filtered drinking water were inversely associated with height-for-age measures across all ages in children and adolescents in India. Improved sanitation may benefit growth among children and adolescents older than 5 years.