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Baker KK, Simiyu S, Busienei P, Gutema FD, Okoth B, Agira J, Amondi CS, Ziraba A, Kapanka AG, Osinuga A, Ouma C, Sewell DK, Gaire S, Tumwebaze IK, Mberu B. Protocol for the PATHOME study: a cohort study on urban societal development and the ecology of enteric disease transmission among infants, domestic animals and the environment. BMJ Open 2023; 13:e076067. [PMID: 38000826 PMCID: PMC10680014 DOI: 10.1136/bmjopen-2023-076067] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/26/2023] [Accepted: 10/25/2023] [Indexed: 11/26/2023] Open
Abstract
INTRODUCTION Global morbidity from enteric infections and diarrhoea remains high in children in low-income and middle-income countries, despite significant investment over recent decades in health systems and water and sanitation infrastructure. Other types of societal development may be required to reduce disease burden. Ecological research on the influence of household and neighbourhood societal development on pathogen transmission dynamics between humans, animals and the environment could identify more effective strategies for preventing enteric infections. METHODS AND ANALYSIS The 'enteric pathome'-that is, the communities of viral, bacterial and parasitic pathogens transmitted from human and animal faeces through the environment is taxonomically complex in high burden settings. This integrated cohort-exposure assessment study leverages natural socioeconomic spectrums of development to study how pathome complexity is influenced by household and neighbourhood infrastructure and hygiene conditions. We are enrolling under 12-month-old children in low-income and middle-income neighbourhoods of two Kenyan cities (Nairobi and Kisumu) into a 'short-cohort' study involving repeat testing of child faeces for enteric pathogens. A mid-study exposure assessment documenting infrastructural, behavioural, spatial, climate, environmental and zoonotic factors characterises pathogen exposure pathways in household and neighbourhood settings. These data will be used to inform and validate statistical and agent-based models (ABM) that identify individual or combined intervention strategies for reducing multipathogen transmission between humans, animals and environment in urban Kenya. ETHICS AND DISSEMINATION The protocols for human subjects' research were approved by Institutional Review Boards at the University of Iowa (ID-202004606) and AMREF Health Africa (ID-ESRC P887/2020), and a national permit was obtained from the Kenya National Commission for Science Technology and Innovation (ID# P/21/8441). The study was registered on Clinicaltrials.gov (Identifier: NCT05322655) and is in pre-results stage. Protocols for research on animals were approved by the University of Iowa Animal Care and Use Committee (ID 0042302).
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Affiliation(s)
- Kelly K Baker
- Department of Occupational and Environmental Health, The University of Iowa College of Public Health, Iowa City, Iowa, USA
| | - Sheillah Simiyu
- Division of Population Dynamics and Urbanization, African Population and Health Research Center, Nairobi, Kenya
| | - Phylis Busienei
- Division of Population Dynamics and Urbanization, African Population and Health Research Center, Nairobi, Kenya
| | - Fanta D Gutema
- Department of Occupational and Environmental Health, The University of Iowa College of Public Health, Iowa City, Iowa, USA
| | - Bonphace Okoth
- Division of Population Dynamics and Urbanization, African Population and Health Research Center, Nairobi, Kenya
| | - John Agira
- Division of Population Dynamics and Urbanization, African Population and Health Research Center, Nairobi, Kenya
| | - Christine S Amondi
- Division of Population Dynamics and Urbanization, African Population and Health Research Center, Nairobi, Kenya
| | - Abdhalah Ziraba
- Division of Health and Wellbeing, African Population and Health Research Center, Nairobi, Kenya
| | - Alexis G Kapanka
- Department of Occupational and Environmental Health, The University of Iowa College of Public Health, Iowa City, Iowa, USA
| | - Abisola Osinuga
- Department of Occupational and Environmental Health, The University of Iowa College of Public Health, Iowa City, Iowa, USA
- The University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
| | | | - Daniel K Sewell
- Department of Biostatistics, The University of Iowa College of Public Health, Iowa City, Iowa, USA
| | - Sabin Gaire
- Department of Biostatistics, The University of Iowa College of Public Health, Iowa City, Iowa, USA
| | - Innocent K Tumwebaze
- Division of Population Dynamics and Urbanization, African Population and Health Research Center, Nairobi, Kenya
| | - Blessing Mberu
- Division of Population Dynamics and Urbanization, African Population and Health Research Center, Nairobi, Kenya
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Workman CL, Stoler J, Harris A, Ercumen A, Kearns J, Mapunda KM. Food, water, and sanitation insecurities: Complex linkages and implications for achieving WASH security. Glob Public Health 2022; 17:3060-3075. [PMID: 34506263 DOI: 10.1080/17441692.2021.1971735] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
Food, water and sanitation insecurities are complex, multi-dimensional phenomena that entail more than availability and access; food, water, and sanitation resources must be safe and culturally appropriate. Researchers and implementers concerned with these insecurities have demonstrated that there are notable interactions between them resulting in significant psychological and biological outcomes. Recent randomised controlled trials (RCTs) in Bangladesh, Kenya (WASH Benefits) and Zimbabwe (SHINE) demonstrated no effect from water, sanitation and hygiene (WASH) interventions on linear growth, and mixed evidence on enteropathogen burden and risk of diarrhoea in young children. These data suggest a need for a more comprehensive understanding of WASH security. The risks posed by multiple resource insecurities shift depending on the individual, their movement throughout their day, their economically and socially prescribed roles, and ecological features such as seasonality and precipitation. By more fully integrating food, water and sanitation security in interventions and subsequent impact evaluations, we can achieve WASH security-one that addresses myriad transmission pathways and co-occurring diseases-that ultimately would improve health outcomes throughout the world. In this critical review, we outline the complexity of combined resource insecurities as a step towards transformative WASH.
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Affiliation(s)
| | | | - Angela Harris
- North Carolina State University, Raleigh, North Carolina
| | - Ayse Ercumen
- North Carolina State University, Raleigh, North Carolina
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Rego R, Watson S, Alam MAU, Abdullah SA, Yunus M, Alam IT, Chowdhury AK, Haider S, Faruque ASG, Khan AI, Hofer T, Gill P, Islam MS, Lilford R. A comparison of traditional diarrhoea measurement methods with microbiological and biochemical indicators: A cross-sectional observational study in the Cox's Bazar displaced persons camp. EClinicalMedicine 2021; 42:101205. [PMID: 34849477 PMCID: PMC8608865 DOI: 10.1016/j.eclinm.2021.101205] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/23/2021] [Revised: 10/29/2021] [Accepted: 11/01/2021] [Indexed: 12/18/2022] Open
Abstract
BACKGROUND Water, Sanitation, and Hygiene (WASH) systems aim to reduce the spread of enteric pathogens, particularly amongst children under five years old. The most common primary outcome of WASH trials is carer-reported diarrhoea. We evaluate different diarrhoea survey instruments as proxy markers of enteric pathogen presence in stool. METHODS We recruited 800 community-based participants from the Cox's Bazar Displaced Person's Camp in Bangladesh, split evenly between the rainy (July/August 2020) and dry (November/December 2020) periods. Participants were randomized evenly into either a standard survey asking carers if their child under five years old has had diarrhoea in the past fortnight, or a pictorial survey asking carers to pick from a pictorial chart which stools their child under five years old has had in the past fortnight. We collected stools from a random sub-sample of 120. Stools were examined visually, and tested for proteins associated with enteric infection and 16 enteric pathogens. We calculated sensitivities and specificities for each survey type, visual examination, and proteins with respect to enteric pathogen presence. FINDINGS The sensitivity of the standard survey for enteric pathogen presence was 0.49[95%CI:0.32,0.66] and the specificity was 0.65[0.41,0.85]. Similar sensitivities and specificities were observed for pictorial survey, visual inspection, and proteins. INTERPRETATION While diarrhoea is an important sign in clinical practice it appears that it is a poor proxy for enteric pathogen presence in stool in epidemiological surveys. When enteric infection is of interest, this should be measured directly. FUNDING The project was funded by the National Institutes for Health Research Global Health Research Unit on Improving Health in Slums (16/136/87) and by the University of Warwick.
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Affiliation(s)
- Ryan Rego
- Center for Global Health Equity, University of Michigan at Ann Arbor, USA
- Center for Global Health, University of Warwick, UK
- Institute for Applied Health Research, University of Birmingham, UK
| | - Samuel Watson
- Center for Global Health, University of Warwick, UK
- Institute for Applied Health Research, University of Birmingham, UK
| | | | | | - Mohammad Yunus
- International Center for Diarrhoeal Disease Research, Bangladesh
| | - Imam Taskin Alam
- International Center for Diarrhoeal Disease Research, Bangladesh
| | | | | | - ASG Faruque
- International Center for Diarrhoeal Disease Research, Bangladesh
| | | | - Timothy Hofer
- Center for Global Health Equity, University of Michigan at Ann Arbor, USA
| | - Paramjit Gill
- Center for Global Health, University of Warwick, UK
- Institute for Applied Health Research, University of Birmingham, UK
| | | | - Richard Lilford
- Center for Global Health, University of Warwick, UK
- Institute for Applied Health Research, University of Birmingham, UK
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Singh P, Shah M, Bruckner TA. Child Undernutrition following the Introduction of a Large-Scale Toilet Construction Campaign in India. J Nutr 2021; 151:2455-2464. [PMID: 34143878 PMCID: PMC8436001 DOI: 10.1093/jn/nxab150] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2021] [Revised: 04/01/2021] [Accepted: 04/26/2021] [Indexed: 11/14/2022] Open
Abstract
BACKGROUND Lack of toilets and the widespread practice of open defecation may contribute to India's large burden of child undernutrition. OBJECTIVES We examine whether a large national sanitation campaign launched in 2014, the Swachh Bharat Mission (SBM), precedes a reduction in stunting and wasting among under 5-y-old (u5) children in India. METHODS In this observational study, we used district-level data from before (2013-2014) and after (2015-2016) SBM from 3 national surveys to derive, as our outcomes, the percentage of u5 children per district who are stunted and wasted. We defined our exposures as 1) binary indicator of SBM and 2) percentage of households with toilets per district. Our analytic sample comprised nearly all 640 Indian districts (with ∼1200 rural/urban divisions per district per time point). Linear regression analyses controlled for baseline differences in districts, linear time trends by state, and relevant covariates. RESULTS Relative to pre-SBM, u5 stunting declines by 0.06% (95% CI: -0.10, -0.01; P = 0.009) with every percentage increase in households with toilets post-SBM. Rural regions and districts with higher pre-SBM toilet availability show greater decline in u5 stunting post-SBM. CONCLUSIONS An increase in toilet availability on a national scale, precipitated by the SBM sanitation campaign, is associated with a reduction in undernutrition among u5 children in India over the early phase of the campaign.
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Affiliation(s)
- Parvati Singh
- Program in Public Health, University of
California, Irvine, Irvine, CA,
USA
| | - Manisha Shah
- Department of Public Policy, Luskin School of Public Affairs,
University of California, Los Angeles, Los
Angeles, CA, USA
| | - Tim A Bruckner
- Program in Public Health, University of
California, Irvine, Irvine, CA,
USA
- Center for Population, Inequality and Policy, University of
California, Irvine, Irvine, CA,
USA
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Capone D, Berendes D, Cumming O, Holcomb D, Knee J, Konstantinidis KT, Levy K, Nalá R, Risk BB, Stewart J, Brown J. Impact of an Urban Sanitation Intervention on Enteric Pathogen Detection in Soils. ENVIRONMENTAL SCIENCE & TECHNOLOGY 2021; 55:9989-10000. [PMID: 34236178 PMCID: PMC8327413 DOI: 10.1021/acs.est.1c02168] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/20/2023]
Abstract
Environmental fecal contamination is common in many low-income cities, contributing to a high burden of enteric infections and associated negative sequelae. To evaluate the impact of a shared onsite sanitation intervention in Maputo, Mozambique on enteric pathogens in the domestic environment, we collected 179 soil samples at shared latrine entrances from intervention (n = 49) and control (n = 51) compounds during baseline (preintervention) and after 24 months (postintervention) as part of the Maputo Sanitation Trial. We tested soils for the presence of nucleic acids associated with 18 enteric pathogens using a multiplex reverse transcription qPCR platform. We detected at least one pathogen-associated gene target in 91% (163/179) of soils and a median of 3 (IQR = 1, 5) pathogens. Using a difference-in-difference analysis and adjusting for compound population, visibly wet soil, sun exposure, wealth, temperature, animal presence, and visible feces, we estimate the intervention reduced the probability of detecting ≥1 pathogen gene by 15% (adjusted prevalence ratio, aPR = 0.85; 95% CI: 0.70, 1.0) and the total number of pathogens by 35% (aPR = 0.65; 0.44, 0.95) in soil 24 months following the intervention. These results suggest that the intervention reduced the presence of some fecal contamination in the domestic environment, but pathogen detection remained prevalent 24 months following the introduction of new latrines.
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Affiliation(s)
- Drew Capone
- Department of Environmental Sciences and Engineering, Gillings School of Public Health, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, United States of America
| | - David Berendes
- Waterborne Disease Prevention Branch, Division of Foodborne, Waterborne, and Environmental Diseases, National Center for Emerging Zoonotic and Infectious Diseases, Centers for Disease Control and Prevention, Atlanta, Georgia, United States of America
| | - Oliver Cumming
- Department of Disease Control, London School of Hygiene and Tropical Medicine, London, United Kingdom
| | - David Holcomb
- Department of Epidemiology, Gillings School of Global Public Health, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, United States of America
| | - Jackie Knee
- Department of Disease Control, London School of Hygiene and Tropical Medicine, London, United Kingdom
| | - Konstantinos T. Konstantinidis
- Civil and Environmental Engineering, Georgia Institute of Technology, 311 Ferst Drive, Atlanta, Georgia, United States of America
| | - Karen Levy
- Environmental and Occupational Health Sciences, University of Washington, 2980 15th Ave NE, Seattle, Washington, United States of America
| | - Rassul Nalá
- Ministério da Saúde, Instituto Nacional de Saúde Maputo, Maputo, Mozambique
| | - Benjamin B. Risk
- Department of Biostatistics and Bioinformatics, Emory University, Atlanta, Georgia, United States of America
| | - Jill Stewart
- Department of Environmental Sciences and Engineering, Gillings School of Public Health, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, United States of America
| | - Joe Brown
- Department of Environmental Sciences and Engineering, Gillings School of Public Health, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, United States of America
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Rogawski McQuade ET, Benjamin-Chung J, Westreich D, Arnold BF. Population intervention effects in observational studies to emulate target trial results: reconciling the effects of improved sanitation on child growth. Int J Epidemiol 2021; 51:279-290. [PMID: 34151953 DOI: 10.1093/ije/dyab070] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/21/2020] [Accepted: 03/17/2021] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND Improved sanitation has been associated with improved child growth in observational studies, but multiple randomized trials that delivered improved sanitation found no effect on child growth. We assessed to what extent differences in the effect estimated in the two study designs (the effect of treatment in observational studies and the effect of treatment assignment in trials) could explain the contradictory results. METHODS We used parametric g-computation in five prospective studies (n = 21 524) and 59 cross-sectional Demographic and Health Surveys (DHS; n = 158 439). We compared the average treatment effect (ATE) for improved sanitation on mean length-for-age z-score (LAZ) among children aged <2 years to population intervention effects (PIEs), which are the observational analogue of the effect estimated in trials in which some participants are already exposed. RESULTS The ATE was >0.15 z-scores, a clinically meaningful difference, in most prospective studies but in <20% of DHS surveys. The PIE was always smaller than the ATE, and the magnitude of difference depended on the baseline prevalence of the improved sanitation. Interventions with suboptimal coverage and interventions delivered in populations with higher mean LAZ had a smaller effect on population-level LAZ. CONCLUSIONS Estimates of PIEs corresponding to anticipated trial results were often smaller than clinically meaningful effects. Incongruence between observational associations and null trial results may in part be explained by expected differences between the effects estimated. Using observational ATEs to set expectations for trials may overestimate the impact that sanitation interventions can achieve. PIEs predict realistic effects and should be more routinely estimated.
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Affiliation(s)
- Elizabeth T Rogawski McQuade
- Department of Public Health Sciences, University of Virginia, Charlottesville, VA, USA.,Division of Infectious Diseases and International Health, University of Virginia, Charlottesville, VA, USA
| | - Jade Benjamin-Chung
- Department of Epidemiology & Biostatistics, University of California, Berkeley, CA, USA
| | - Daniel Westreich
- Division of Epidemiology, University of North Carolina-Chapel Hill, NC, USA
| | - Benjamin F Arnold
- Francis I. Proctor Foundation, University of California, San Francisco, CA, USA.,Department of Ophthalmology, University of California, San Francisco, CA, USA
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Benjamin-Chung J, Crider YS, Mertens A, Ercumen A, Pickering AJ, Lin A, Steinbaum L, Swarthout J, Rahman M, Parvez SM, Haque R, Njenga SM, Kihara J, Null C, Luby SP, Colford JM, Arnold BF. Household finished flooring and soil-transmitted helminth and Giardia infections among children in rural Bangladesh and Kenya: a prospective cohort study. Lancet Glob Health 2021; 9:e301-e308. [PMID: 33607029 PMCID: PMC7900607 DOI: 10.1016/s2214-109x(20)30523-4] [Citation(s) in RCA: 16] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/24/2020] [Revised: 11/20/2020] [Accepted: 11/30/2020] [Indexed: 12/31/2022]
Abstract
BACKGROUND Soil-transmitted helminths and Giardia duodenalis are responsible for a large burden of disease globally. In low-resource settings, household finished floors (eg, concrete floors) might reduce transmission of soil-transmitted helminths and G duodenalis. METHODS In a prospective cohort of children nested within two randomised trials in rural Bangladesh and Kenya, we estimated associations between household finished flooring and soil-transmitted helminths and G duodenalis prevalence. In 2015-16, we collected stool samples from children aged 2-16 years in rural Bangladesh and Kenya. We detected soil-transmitted helminth infection using quantitative PCR (qPCR; Bangladesh n=2800; Kenya n=3094), and G duodenalis using qPCR in Bangladesh (n=6894) and ELISA in Kenya (n=8899). We estimated adjusted prevalence ratios (aPRs) using log-linear models adjusted for potential confounders. FINDINGS 7187 (92·2%) of 7795 children in Bangladesh and 9077 (93·7%) of 9686 children in Kenya provided stool specimens that were analysed by qPCR. At enrolment, 691 (10%) households in Bangladesh and 471 (5%) households in Kenya had finished floors. In both countries, household finished flooring was associated with lower Ascaris lumbricoides prevalence (Bangladesh aPR 0·33, 95% CI 0·14-0·78; Kenya 0·62, 0·39-0·98) and any soil-transmitted helminths (Bangladesh 0·73, 0·52-1·01; Kenya 0·57, 0·37-0·88). Household finished floors were also associated with lower Necator americanus prevalence in Bangladesh (0·52, 0·29-0·94) and G duodenalis prevalence in both countries (Bangladesh 0·78, 0·64-0·95; Kenya 0·82, 0·70-0·97). INTERPRETATION In low-resource settings, living in households with finished floors over a 2-year period was associated with lower prevalence of G duodenalis and some soil-transmitted helminths in children. FUNDING Bill & Melinda Gates Foundation and Task Force for Global Health.
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Affiliation(s)
- Jade Benjamin-Chung
- Division of Epidemiology & Biostatistics, University of California, Berkeley, Berkeley, CA, USA.
| | - Yoshika S Crider
- Division of Epidemiology & Biostatistics, University of California, Berkeley, Berkeley, CA, USA; Energy & Resources Group, University of California, Berkeley, Berkeley, CA, USA
| | - Andrew Mertens
- Division of Epidemiology & Biostatistics, University of California, Berkeley, Berkeley, CA, USA
| | - Ayse Ercumen
- Department of Forestry and Environmental Resources, North Carolina State University, Raleigh, NC, USA
| | - Amy J Pickering
- Civil and Environmental Engineering, Tufts University, Medford, MA, USA
| | - Audrie Lin
- Division of Epidemiology & Biostatistics, University of California, Berkeley, Berkeley, CA, USA
| | | | - Jenna Swarthout
- Civil and Environmental Engineering, Tufts University, Medford, MA, USA
| | - Mahbubur Rahman
- International Centre for Diarrhoeal Disease Research, Dhaka, Bangladesh
| | - Sarker M Parvez
- International Centre for Diarrhoeal Disease Research, Dhaka, Bangladesh
| | - Rashidul Haque
- International Centre for Diarrhoeal Disease Research, Dhaka, Bangladesh
| | - Sammy M Njenga
- Eastern and Southern Africa Centre of International Parasite Control, Kenya Medical Research Institute, Nairobi, Kenya
| | - Jimmy Kihara
- Eastern and Southern Africa Centre of International Parasite Control, Kenya Medical Research Institute, Nairobi, Kenya
| | - Clair Null
- Center for International Policy Research and Evaluation, Mathematica Policy Research, Washington, DC, USA
| | - Stephen P Luby
- Division of Infectious Diseases and Geographic Medicine, Stanford University, Stanford, CA, USA
| | - John M Colford
- Division of Epidemiology & Biostatistics, University of California, Berkeley, Berkeley, CA, USA
| | - Benjamin F Arnold
- Francis I Proctor Foundation, University of California, San Francisco, CA, USA; Department of Ophthalmology, University of California, San Francisco, CA, USA
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Bountogo M, Ouattara M, Sié A, Compaoré G, Dah C, Boudo V, Zakane A, Lebas E, Brogdon JM, Godwin WW, Lin Y, Arnold BF, Oldenburg CE. Access to Improved Sanitation and Nutritional Status among Preschool Children in Nouna District, Burkina Faso. Am J Trop Med Hyg 2021; 104:1540-1545. [PMID: 33556039 PMCID: PMC8045633 DOI: 10.4269/ajtmh.20-0527] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/21/2020] [Accepted: 10/16/2020] [Indexed: 11/07/2022] Open
Abstract
Access to improved sanitation and hygiene may improve child nutritional status by reducing exposure to enteric pathogens. We evaluated this relationship as part of the Community Health with Azithromycin Trial, a community-randomized trial of azithromycin versus placebo for the prevention of child mortality in rural Burkina Faso. Before the baseline study visit, a door-to-door household survey was conducted for all households in the study area. During the baseline study census, which occurred approximately 9 months after the household survey, a mid-upper arm circumference (MUAC) measurement was obtained from each child. We evaluated the relationship between household improved latrine use compared with unimproved latrines or open defecation and MUAC in children aged 6-59 months. Among 32,172 children with household survey data and MUAC measurements, 931 (2.9%) had an MUAC less than 12.5 cm and were classified as having moderate acute malnutrition (MAM). The odds of MAM were higher in children living in households with an unimproved latrine than those with an improved latrine (adjusted odds ratio: 1.60; 95% CI: 1.11-2.31). Children in households with unimproved latrines and households that practiced open defection had approximate 0.15 cm reduced MUAC compared with those in households with an improved latrine. There was a small, but statistically significant, association between improved latrine and nutritional status in preschool children as measured by MUAC.
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Affiliation(s)
| | | | - Ali Sié
- 1Centre de Recherche en Santé de Nouna, Nouna, Burkina Faso
| | | | - Clarisse Dah
- 1Centre de Recherche en Santé de Nouna, Nouna, Burkina Faso
| | - Valentin Boudo
- 1Centre de Recherche en Santé de Nouna, Nouna, Burkina Faso
| | | | - Elodie Lebas
- 2Francis I Proctor Foundation, University of California, San Francisco, California
| | - Jessica M Brogdon
- 2Francis I Proctor Foundation, University of California, San Francisco, California
| | - William W Godwin
- 2Francis I Proctor Foundation, University of California, San Francisco, California
| | - Ying Lin
- 2Francis I Proctor Foundation, University of California, San Francisco, California
| | - Benjamin F Arnold
- 2Francis I Proctor Foundation, University of California, San Francisco, California.,3Department of Ophthalmology, University of California, San Francisco, California
| | - Catherine E Oldenburg
- 2Francis I Proctor Foundation, University of California, San Francisco, California.,3Department of Ophthalmology, University of California, San Francisco, California.,4Department of Epidemiology and Biostatistics, University of California, San Francisco, California
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Rudolph KE, Díaz I. Efficiently transporting causal direct and indirect effects to new populations under intermediate confounding and with multiple mediators. Biostatistics 2021; 23:789-806. [PMID: 33528006 DOI: 10.1093/biostatistics/kxaa057] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/10/2020] [Revised: 11/16/2020] [Accepted: 11/28/2020] [Indexed: 11/12/2022] Open
Abstract
The same intervention can produce different effects in different sites. Existing transport mediation estimators can estimate the extent to which such differences can be explained by differences in compositional factors and the mechanisms by which mediating or intermediate variables are produced; however, they are limited to consider a single, binary mediator. We propose novel nonparametric estimators of transported interventional (in)direct effects that consider multiple, high-dimensional mediators and a single, binary intermediate variable. They are multiply robust, efficient, asymptotically normal, and can incorporate data-adaptive estimation of nuisance parameters. They can be applied to understand differences in treatment effects across sites and/or to predict treatment effects in a target site based on outcome data in source sites.
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Affiliation(s)
- Kara E Rudolph
- Department of Epidemiology, Mailman School of Public Health, Columbia University; and Division of Biostatistics, Department of Population Health Sciences, Weill Cornell Medicine, New York, NY, USA
| | - Iván Díaz
- Department of Epidemiology, Mailman School of Public Health, Columbia University; and Division of Biostatistics, Department of Population Health Sciences, Weill Cornell Medicine, New York, NY, USA
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10
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Nowicki S, deLaurent ZR, de Villiers EP, Githinji G, Charles KJ. The utility of Escherichia coli as a contamination indicator for rural drinking water: Evidence from whole genome sequencing. PLoS One 2021; 16:e0245910. [PMID: 33481909 PMCID: PMC7822521 DOI: 10.1371/journal.pone.0245910] [Citation(s) in RCA: 17] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2020] [Accepted: 01/09/2021] [Indexed: 12/12/2022] Open
Abstract
Across the water sector, Escherichia coli is the preferred microbial water quality indicator and current guidance upholds that it indicates recent faecal contamination. This has been challenged, however, by research demonstrating growth of E. coli in the environment. In this study, we used whole genome sequencing to investigate the links between E. coli and recent faecal contamination in drinking water. We sequenced 103 E. coli isolates sampled from 9 water supplies in rural Kitui County, Kenya, including points of collection (n = 14) and use (n = 30). Biomarkers for definitive source tracking remain elusive, so we analysed the phylogenetic grouping, multi-locus sequence types (MLSTs), allelic diversity, and virulence and antimicrobial resistance (AMR) genes of the isolates for insight into their likely source. Phylogroup B1, which is generally better adapted to water environments, is dominant in our samples (n = 69) and allelic diversity differences (z = 2.12, p = 0.03) suggest that naturalised populations may be particularly relevant at collection points with lower E. coli concentrations (<50 / 100mL). The strains that are more likely to have originated from human and/or recent faecal contamination (n = 50), were found at poorly protected collection points (4 sites) or at points of use (12 sites). We discuss the difficulty of interpreting health risk from E. coli grab samples, especially at household level, and our findings support the use of E. coli risk categories and encourage monitoring that accounts for sanitary conditions and temporal variability.
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Affiliation(s)
- Saskia Nowicki
- School of Geography and the Environment, University of Oxford, Oxford, United Kingdom
| | - Zaydah R. deLaurent
- KEMRI-Wellcome Trust Research Programme, Centre for Geographic Medicine Research-Coast, Kilifi, Kenya
| | - Etienne P. de Villiers
- KEMRI-Wellcome Trust Research Programme, Centre for Geographic Medicine Research-Coast, Kilifi, Kenya
- Nuffield Department of Medicine, Centre for Tropical Medicine and Global Health, University of Oxford, Oxford, United Kingdom
- Department of Public Health, Pwani University, Kilifi, Kenya
| | - George Githinji
- KEMRI-Wellcome Trust Research Programme, Centre for Geographic Medicine Research-Coast, Kilifi, Kenya
| | - Katrina J. Charles
- School of Geography and the Environment, University of Oxford, Oxford, United Kingdom
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11
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Rah JH, Sukotjo S, Badgaiyan N, Cronin AA, Torlesse H. Improved sanitation is associated with reduced child stunting amongst Indonesian children under 3 years of age. MATERNAL AND CHILD NUTRITION 2020; 16 Suppl 2:e12741. [PMID: 32835453 PMCID: PMC7591307 DOI: 10.1111/mcn.12741] [Citation(s) in RCA: 19] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 06/18/2018] [Revised: 10/06/2018] [Accepted: 10/15/2018] [Indexed: 12/31/2022]
Abstract
Growing evidence suggests that household sanitation is associated with child nutritional status in low‐ and middle‐income countries. This paper examined whether household access to improved sanitation facilities and sources of drinking water was associated with stunting and anaemia amongst children aged 6–35 months of age in Indonesia. The sample for the analysis comprised 1,450 children aged 6–35 months who participated in the end‐line survey of the maternal and young child nutrition security project in Asia, conducted in three selected districts in Indonesia. Logistic regression models were used to determine the association between household sanitation and water source, and stunting and anaemia. Approximately 26% and 56% of children 6–35 months of age were stunted and anaemic, respectively. Children living in a household with improved sanitation facilities had 29% reduced odds of being stunted compared with those in a household with unimproved sanitation facilities, after adjusting for potential confounders including child's age and gender, maternal education, and iron–folic acid supplementation, as well as household wealth status and source of drinking water (OR = 0.68, 95% CI:0.48–0.96). No association between household sanitation and childhood anaemia was observed. Source of drinking water was not associated with stunting or anaemia amongst children. There were no synergistic effects of household sanitation and water supply on stunting and anaemia. This suggests that efforts to improve household sanitation condition may need to be considered an essential, integral part of the programmatic responses by governments and development partners for the prevention of childhood nutritional status. Further randomised research is necessary to determine the causal link.
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Affiliation(s)
- Jee H Rah
- Child Survival and Development Cluster, Nutrition Unit, UNICEF Indonesia, Jakarta, Indonesia
| | - Sri Sukotjo
- Child Survival and Development Cluster, Nutrition Unit, UNICEF Indonesia, Jakarta, Indonesia
| | - Nina Badgaiyan
- Child Survival and Development Cluster, Nutrition Unit, UNICEF Indonesia, Jakarta, Indonesia
| | - Aidan A Cronin
- Water, Sanitation and Hygiene Section, UNICEF Zimbabwe, Harare, Zimbabwe
| | - Harriet Torlesse
- Nutrition Section, UNICEF Regional Office for South Asia, Lekhnath Marg, Kathmandu, Nepal
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12
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Rudolph KE, Levy J, Schmidt NM, Stuart EA, Ahern J. Using Transportability to Understand Differences in Mediation Mechanisms Across Trial Sites of a Housing Voucher Experiment. Epidemiology 2020; 31:523-533. [PMID: 32282407 PMCID: PMC7269870 DOI: 10.1097/ede.0000000000001191] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Randomized trials may have different effects in different settings. Moving to Opportunity (MTO), a housing experiment, is one such example. Previously, we examined the extent to which MTO's overall effects on adolescent substance use and mental health outcomes were transportable across the sites to disentangle the contributions of differences in population composition versus differences in contextual factors to site differences. However, to further understand reasons for different site effects, it may be beneficial to examine mediation mechanisms and the degree to which they too are transportable across sites. METHODS We used longitudinal data from MTO youth. We examined mediators summarizing aspects of the school environment over the 10-15 year follow-up. Outcomes of past-year substance use, mental health, and risk behavior were assessed at the final timepoint when participants were 10-20 years old. We used doubly robust and efficient substitution estimators to estimate (1) indirect effects by MTO site and (2) transported indirect effects from one site to another. RESULTS Differences in indirect effect estimates were most pronounced between Chicago and Los Angeles. Using transport estimators to account for differences in baseline covariates, likelihood of using the voucher to move, and mediator distributions partially to fully accounted for site differences in indirect effect estimates in 10 of the 12 pathways examined. CONCLUSIONS Using transport estimators can provide an evidence-based approach for understanding the extent to which differences in compositional factors contribute to differences in indirect effect estimates across sites, and ultimately, to understanding why interventions may have different effects when applied to new populations.
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Affiliation(s)
- Kara E Rudolph
- From the Department of Epidemiology, Mailman School of Public Health, Columbia University, New York, NY
| | - Jonathan Levy
- Division of Epidemiology and Biostatistics, School of Public Health, University of California, Berkeley, CA
| | - Nicole M Schmidt
- Department of Epidemiology and Community Health, University of Minnesota School of Public Health, Minneapolis, MN
| | - Elizabeth A Stuart
- Department of Mental Health, Johns Hopkins School of Public Health, Baltimore, MD
- Department of Biostatistics, Johns Hopkins School of Public Health, Baltimore, MD
- Department of Health Policy and Management, Johns Hopkins School of Public Health, Baltimore, MD
| | - Jennifer Ahern
- Division of Epidemiology and Biostatistics, School of Public Health, University of California, Berkeley, CA
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13
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Kim C, Mansoor GF, Paya PM, Ludin MH, Ahrar MJ, Mashal MO, Todd CS. Multisector nutrition gains amidst evidence scarcity: scoping review of policies, data and interventions to reduce child stunting in Afghanistan. Health Res Policy Syst 2020; 18:65. [PMID: 32527267 PMCID: PMC7291673 DOI: 10.1186/s12961-020-00569-x] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/10/2019] [Accepted: 05/05/2020] [Indexed: 12/02/2022] Open
Abstract
Background Child health indicators have substantially improved across the last decade, yet Afghanistan has among the highest child stunting and malnutrition rates in Asia. Multisectoral approaches were recently introduced but evidence for this approach to improve support for and implementation of child nutrition programmes is limited compared to other countries. Methods We reviewed policy and programme data to identify best practices and gaps surrounding child malnutrition in Afghanistan. We conducted a scoping review using broad search categories and approaches, including database and website searches, reference hand-searches, purposive policy and programme document request, and key informant interviews. Inclusion and exclusion criteria were developed iteratively, with abstracts and documents assessed against the final criteria. We abstracted documents systematically and summarised and synthesised content to generate the main findings. Results We included 18 policies and strategies, 45 data sources and reports, and 20 intervention evaluations. Movement towards multisectoral efforts to address malnutrition at the policy level has started; however, integrated nutrition-specific and nutrition-sensitive interventions are not yet uniformly delivered at the community level. Many data sources capturing nutrition, food security and WASH (water, sanitation and hygiene) indicators are available but indicator definitions are not standardised and there are few longitudinal nutrition surveys. Political will to improve household nutrition status has shown increased government and donor investments in nutrition-sensitive and nutrition-specific programmes through combined small- and large-scale interventions between 2004 and 2013; however, evidence for interventions that effectively decrease stunting prevalence is limited. Conclusions This review shows a breadth of nutrition programme, policy and data in Afghanistan. Multisector approaches faced challenges of reaching sufficient coverage as they often included a package of food security, livelihoods and health interventions but were each implemented independently. Further implementation evidence is needed to aid policy and programmes on effective integration of nutrition, food security and WASH in Afghanistan.
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Affiliation(s)
- Christine Kim
- Department of Health Policy and Management, Gillings School of Global Public Health, University of North Carolina at Chapel Hill, Chapel Hill, NC, United States of America.
| | - Ghulam Farooq Mansoor
- FHI 360/Integrated Hygiene, Sanitation, and Nutrition (IHSAN) project, Kabul, Afghanistan
| | - Pir Mohammad Paya
- FHI 360/Integrated Hygiene, Sanitation, and Nutrition (IHSAN) project, Kabul, Afghanistan
| | - Mohammad Homayoun Ludin
- Public Nutrition Directorate, Ministry of Public Health, Islamic Republic of Afghanistan, Kabul, Afghanistan
| | - Mohammad Javed Ahrar
- Rural Water Supply and Irrigation Programme (RuWATSIP) Department, Ministry of Rural Rehabilitation and Development (MRRD), Islamic Republic of Afghanistan, Kabul, Afghanistan
| | - Mohammad Omar Mashal
- FHI 360/Integrated Hygiene, Sanitation, and Nutrition (IHSAN) project, Kabul, Afghanistan
| | - Catherine S Todd
- Division of Reproductive, Maternal, Newborn, and Child Health, Global Health, Population and Nutrition Department, Durham, North, Carolina, United States of America
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14
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Pickering AJ, Null C, Winch PJ, Mangwadu G, Arnold BF, Prendergast AJ, Njenga SM, Rahman M, Ntozini R, Benjamin-Chung J, Stewart CP, Huda TMN, Moulton LH, Colford JM, Luby SP, Humphrey JH. The WASH Benefits and SHINE trials: interpretation of WASH intervention effects on linear growth and diarrhoea. LANCET GLOBAL HEALTH 2020; 7:e1139-e1146. [PMID: 31303300 DOI: 10.1016/s2214-109x(19)30268-2] [Citation(s) in RCA: 185] [Impact Index Per Article: 46.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/23/2018] [Revised: 05/01/2019] [Accepted: 05/07/2019] [Indexed: 12/13/2022]
Abstract
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.
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Affiliation(s)
- Amy J Pickering
- Department of Civil and Environmental Engineering, Tufts University, Medford, MA, USA
| | - Clair Null
- Center of International Policy Research and Evaluation, Mathematica Policy Research, Washington, DC, USA
| | - Peter J Winch
- Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
| | - Goldberg Mangwadu
- Department of Environmental Health, Ministry of Health and Child Care, Harare, Zimbabwe
| | - Benjamin F Arnold
- Division of Epidemiology and Biostatistics, School of Public Health, University of California, Berkeley, CA, USA
| | - Andrew J Prendergast
- Zvitambo Institute for Maternal and Child Health Research, Harare, Zimbabwe; Blizard Institute, Queen Mary University of London, London, UK
| | - Sammy M Njenga
- Eastern and Southern Africa Centre of International Parasite Control, Kenya Medical Research Institute, Nairobi, Kenya
| | - Mahbubur Rahman
- International Centre for Diarrhoeal Disease Research, Dhaka, Bangladesh
| | - Robert Ntozini
- Zvitambo Institute for Maternal and Child Health Research, Harare, Zimbabwe
| | - Jade Benjamin-Chung
- Division of Epidemiology and Biostatistics, School of Public Health, University of California, Berkeley, CA, USA
| | | | - Tarique M N Huda
- International Centre for Diarrhoeal Disease Research, Dhaka, Bangladesh
| | - Lawrence H Moulton
- Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
| | - John M Colford
- Division of Epidemiology and Biostatistics, School of Public Health, University of California, Berkeley, CA, USA
| | - Stephen P Luby
- Department of Infectious Diseases and Geographic Medicine, Stanford University, Stanford, CA, USA
| | - Jean H Humphrey
- Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA; Zvitambo Institute for Maternal and Child Health Research, Harare, Zimbabwe.
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15
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Karinja M, Schlienger R, Pillai GC, Esterhuizen T, Onyango E, Gitau A, Ogutu B. Risk reduction of diarrhea and respiratory infections following a community health education program - a facility-based case-control study in rural parts of Kenya. BMC Public Health 2020; 20:586. [PMID: 32349712 PMCID: PMC7191750 DOI: 10.1186/s12889-020-08728-z] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/03/2019] [Accepted: 04/17/2020] [Indexed: 01/24/2023] Open
Abstract
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.
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Affiliation(s)
- Miriam Karinja
- Swiss Tropical and Public Health Institute (Swiss TPH), Basel, Switzerland. .,University of Basel, Basel, Switzerland. .,Center for Research in Therapeutic Sciences (CREATES), Strathmore University, Nairobi, Kenya.
| | - Raymond Schlienger
- Quantitative Safety and Epidemiology, Chief Medical Office & Patient Safety, Novartis Pharma AG, Basel, Switzerland
| | - Goonaseelan Colin Pillai
- CP+ Associates GmbH, Basel, Switzerland.,Division of Clinical Pharmacology, Department of Medicine, University of Cape Town, Cape Town, South Africa
| | - Tonya Esterhuizen
- Division of Epidemiology and Biostatistics, Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town, South Africa
| | - Evance Onyango
- Center for Research in Therapeutic Sciences (CREATES), Strathmore University, Nairobi, Kenya
| | - Anthony Gitau
- The Children's Investment Fund Foundation, Nairobi, Kenya
| | - Bernhards Ogutu
- Center for Research in Therapeutic Sciences (CREATES), Strathmore University, Nairobi, Kenya.,Centre for Clinical Research, Kenya Medical Research Institute, Nairobi, Kenya
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16
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Valcourt N, Javernick-Will A, Walters J, Linden K. System Approaches to Water, Sanitation, and Hygiene: A Systematic Literature Review. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2020; 17:ijerph17030702. [PMID: 31973179 PMCID: PMC7037755 DOI: 10.3390/ijerph17030702] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 12/04/2019] [Revised: 01/09/2020] [Accepted: 01/14/2020] [Indexed: 01/25/2023]
Abstract
Endemic issues of sustainability in the water, sanitation, and hygiene (WASH) sector have led to the rapid expansion of ‘system approaches’ for assessing the multitude of interconnected factors that affect WASH outcomes. However, the sector lacks a systematic analysis and characterization of the knowledge base for systems approaches, in particular how and where they are being implemented and what outcomes have resulted from their application. To address this need, we conducted a wide-ranging systematic literature review of systems approaches for WASH across peer-reviewed, grey, and organizational literature. Our results show a myriad of methods, scopes, and applications within the sector, but an inadequate level of information in the literature to evaluate the utility and efficacy of systems approaches for improving WASH service sustainability. Based on this analysis, we propose four recommendations for improving the evidence base including: diversifying methods that explicitly evaluate interconnections between factors within WASH systems; expanding geopolitical applications; improving reporting on resources required to implement given approaches; and enhancing documentation of effects of systems approaches on WASH services. Overall, these findings provide a robust survey of the existing landscape of systems approaches for WASH and propose a path for future research in this emerging field.
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Affiliation(s)
- Nicholas Valcourt
- Department of Civil, Environmental, and Architectural Engineering, University of Colorado Boulder, Boulder, CO 80309, USA; (A.J.-W.); (K.L.)
- USAID Sustainable WASH Systems Learning Partnership, United State Agency for International Development, Washington, DC 20004, USA;
- Correspondence:
| | - Amy Javernick-Will
- Department of Civil, Environmental, and Architectural Engineering, University of Colorado Boulder, Boulder, CO 80309, USA; (A.J.-W.); (K.L.)
- USAID Sustainable WASH Systems Learning Partnership, United State Agency for International Development, Washington, DC 20004, USA;
| | - Jeffrey Walters
- USAID Sustainable WASH Systems Learning Partnership, United State Agency for International Development, Washington, DC 20004, USA;
- College of Engineering, George Fox University, Newberg, OR 97132, USA
| | - Karl Linden
- Department of Civil, Environmental, and Architectural Engineering, University of Colorado Boulder, Boulder, CO 80309, USA; (A.J.-W.); (K.L.)
- USAID Sustainable WASH Systems Learning Partnership, United State Agency for International Development, Washington, DC 20004, USA;
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17
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Contreras JD, Eisenberg JN. Does Basic Sanitation Prevent Diarrhea? Contextualizing Recent Intervention Trials through a Historical Lens. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2019; 17:E230. [PMID: 31905628 PMCID: PMC6981821 DOI: 10.3390/ijerph17010230] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 11/27/2019] [Revised: 12/19/2019] [Accepted: 12/25/2019] [Indexed: 12/14/2022]
Abstract
Three of four recent major sanitation intervention trials found no effect on diarrhea. These results conflicted with longstanding beliefs from decades of literature. To understand this discordance, we placed recent trials into the historical context that preceded them in two ways. First, we evaluated the history of published literature reviews on sanitation and diarrhea. Second, we conducted meta-analyses on studies from the most recent systematic review to uncover features that predict effectiveness. We found that 13 literature reviews dating to 1983 consistently estimated a significant protective effect of sanitation against diarrhea. However, these were marred by flawed studies and inappropriately averaged effects across widely heterogeneous interventions and contexts. Our meta-analyses highlight that the overall effect of sanitation on diarrhea was largely driven by sewerage and interventions that improved more than sanitation alone. There is no true overall effect of sanitation because variability between intervention types and implementation contexts is too complex to average. Ultimately, the null effects of recent latrine interventions are not surprising. Instead, the one trial that found a strong relative reduction in diarrhea is the historical outlier. The development of transformative sanitation interventions requires a better understanding of the social and environmental contexts that determine intervention effectiveness.
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18
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Anitha S, Muzanila Y, Tsusaka TW, Kachulu L, Kumwenda N, Musoke M, Swai E, Shija J, Siambi M, Monyo ES, Bekunda M, Okori P. Reducing Child Undernutrition through Dietary Diversification, Reduced Aflatoxin Exposure, and Improved Hygiene Practices: The Immediate Impacts in Central Tanzania. Ecol Food Nutr 2019; 59:243-262. [DOI: 10.1080/03670244.2019.1691000] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Affiliation(s)
- Seetha Anitha
- Department of Strategic Marketing and communication, International Crops Research Institute for the Semi-Arid Tropics (ICRISAT), Patancheru, Hyderabad, India
- Department of plant breeding, ICRISAT, Lilongwe, Malawi
| | - Yasinta Muzanila
- Department of Food Science and Technology, Sokoine University of Agriculture, Morogoro, Tanzania
| | | | | | | | - Mike Musoke
- Department of plant breeding, ICRISAT, Lilongwe, Malawi
| | - Elirehema Swai
- Agricultural Research Institute, Hombolo, Central Zone Crop Research, Dodoma, Tanzania
| | - Jackson Shija
- District Agriculture and Irrigation department, Kongwa District Council, Dodoma, Tanzania
| | | | | | - Mateete Bekunda
- Africa RISING East & Southern Africa, International Institute for Tropical Agriculture (IITA), Arusha, Tanzania
| | - Patrick Okori
- Department of plant breeding, ICRISAT, Lilongwe, Malawi
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Budge S, Hutchings P, Parker A, Tyrrel S, Tulu T, Gizaw M, Garbutt C. Do domestic animals contribute to bacterial contamination of infant transmission pathways? Formative evidence from Ethiopia. JOURNAL OF WATER AND HEALTH 2019; 17:655-669. [PMID: 31638018 DOI: 10.2166/wh.2019.224] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/10/2023]
Abstract
Child stunting is associated with poor water, sanitation and hygiene (WASH), partly due to the effect of infection on intestinal nutrient absorption. WASH interventions, however, show little effect on growth. A hypothesis is that bacterial contamination of hands and floors from domestic animals and their faeces, and subsequent ingestion via infant hand-to-mouth behaviours, may explain this. This formative study used microbial testing and survey and observational data from 20 households in Ethiopia to characterise principle bacterial transmission pathways to infants, considering WASH facilities and practices, infant behaviours and animal exposure. Microbial swabbing showed the contamination of hands and floor surfaces from thermotolerant coliform bacteria. Animal husbandry practices, such as keeping animals inside, contributed significantly (all p < 0.005). There was no evidence that latrine facilities mitigated contamination across infant (p = 0.76) or maternal (p = 0.86) hands or floor surfaces (p = 0.36). This small study contributes to the evidence that animal faeces are an important source of domestic bacterial contamination. The results imply that interventions aiming to reduce pathogen transmission to infants should think beyond improving WASH and also consider the need to separate infants and animals in the home. Intervention studies will be required to determine whether this reduces infant infection and improves linear growth.
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Affiliation(s)
| | - Paul Hutchings
- Water Science, Cranfield Water Science Institute, Cranfield University, Vincent Building, Cranfield, Bedford MK43 0AL, UK E-mail:
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20
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Hyun C, Burt Z, Crider Y, Nelson KL, Sharada Prasad CS, Rayasam SDG, Tarpeh W, Ray I. Sanitation for Low-Income Regions: A Cross-Disciplinary Review. ANNUAL REVIEW OF ENVIRONMENT AND RESOURCES 2019; 44:287-318. [PMID: 32587484 PMCID: PMC7316187 DOI: 10.1146/annurev-environ-101718-033327] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/04/2023]
Abstract
Sanitation research focuses primarily on containing human waste and preventing disease; thus, it has traditionally been dominated by the fields of environmental engineering and public health. Over the past 20 years, however, the field has grown broader in scope and deeper in complexity, spanning diverse disciplinary perspectives. In this article, we review the current literature in the range of disciplines engaged with sanitation research in low- and middle-income countries (LMICs). We find that perspectives on what sanitation is, and what sanitation policy should prioritize, vary widely. We show how these diverse perspectives augment the conventional sanitation service chain, a framework describing the flow of waste from capture to disposal. We review how these perspectives can inform progress toward equitable sanitation for all [i.e., Sustainable Development Goal (SDG) 6]. Our key message is that both material and nonmaterial flows-and both technological and social functions-make up a sanitation "system." The components of the sanitation service chain are embedded within the flows of finance, decision making, and labor that make material flows of waste possible. The functions of capture, storage, transport, treatment, reuse, and disposal are interlinked with those of ensuring equity and affordability. We find that a multilayered understanding of sanitation, with contributions from multiple disciplines, is necessary to facilitate inclusive and robust research toward the goal of sanitation for all.
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Affiliation(s)
- Christopher Hyun
- Energy and Resources Group, University of California, Berkeley, California 94720, USA
| | - Zachary Burt
- Department of Environmental Health Sciences, Mailman School of Public Health, Columbia University, New York, NY 10032, USA
| | - Yoshika Crider
- Energy and Resources Group, University of California, Berkeley, California 94720, USA
| | - Kara L Nelson
- Department of Civil and Environmental Engineering, College of Engineering, University of California, Berkeley, California 94720, USA
| | - C S Sharada Prasad
- School of Development, Azim Premji University, Bengaluru, Karnataka 560100, India
| | | | - William Tarpeh
- Chemical Engineering, Stanford University, Stanford, California 94305, USA
| | - Isha Ray
- Energy and Resources Group, University of California, Berkeley, California 94720, USA
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21
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Owino VO, Murphy‐Alford AJ, Kerac M, Bahwere P, Friis H, Berkley JA, Jackson AA. Measuring growth and medium- and longer-term outcomes in malnourished children. MATERNAL & CHILD NUTRITION 2019; 15:e12790. [PMID: 30690903 PMCID: PMC7199054 DOI: 10.1111/mcn.12790] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/09/2018] [Revised: 11/13/2018] [Accepted: 12/12/2018] [Indexed: 12/26/2022]
Abstract
Severe and moderate acute malnutrition are among the leading causes of mortality among children in low- and middle-income countries. There is strong evidence that growth assessed anthropometrically from conception to 2 years of age marks later risk of ill health. This is central to the concept of the developmental origins of adult disease and is presumed to be related to modification of developmental processes during critical "window(s)" of vulnerability. Interventions to treat acute malnutrition have resulted in dramatic increase in the number of affected children surviving. Ensuring that these children thrive to fulfil their full physical and cognitive potential is a new challenge. Integral to this challenge is the need to be able to measure how earlier insults relate to the ability to survive and thrive to productive adulthood. Despite its obvious value, routine anthropometry does not adequately indicate how earlier adverse exposures affect more refined aspects of growth. Anthropometry is inadequate for predicting how disruption of healthy growth might modulate risk of disease or any subsequent interventions that correct this risk. A clear characterisation of healthy child growth is needed for determining which component best predicts later outcomes. The extent to which postnatal acute malnutrition is a consequence of maternal factors acting preconception or in utero and their relationship to postnatal health and long-term risk of non-communicable diseases is not clear. Body-composition measurement has significant untapped potential allowing us to translate and better understand the relationship between early insults and interventions on early growth in the short-term and long-term health outcomes.
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Affiliation(s)
- Victor O. Owino
- Nutritional and Health Related Environmental Studies Section, Division of HealthInternational Atomic Energy AgencyViennaAustria
| | - Alexia J. Murphy‐Alford
- Nutritional and Health Related Environmental Studies Section, Division of HealthInternational Atomic Energy AgencyViennaAustria
| | - Marko Kerac
- Department of Population HealthLondon School of Hygiene and Tropical MedicineLondonUK
| | - Paluku Bahwere
- Valid InternationalOxfordUK
- Research Centre in Epidemiology, Biostatistics and Clinical Research, School of Public HealthFree University of BrusselsBrusselsBelgium
| | - Henrik Friis
- Department of Nutrition, Exercise and SportsUniversity of CopenhagenFrederiksbergDenmark
| | - James A. Berkley
- DirectorThe Childhood Acute Illness & Nutrition (CHAIN) NetworkNairobiKenya
- Nuffield Department of Medicine, Centre for Tropical Medicine and Global HealthUniversity of OxfordOxfordUK
| | - Alan A. Jackson
- Human Nutrition, International Malnutrition Task ForceSouthampton General HospitalSouthamptonUK
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Brown J, Albert J, Whittington D. Community-Led Total Sanitation Moves the Needle on Ending Open Defecation in Zambia. Am J Trop Med Hyg 2019; 100:767-769. [PMID: 30860017 PMCID: PMC6447111 DOI: 10.4269/ajtmh.19-0151] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2019] [Accepted: 02/20/2019] [Indexed: 01/13/2023] Open
Affiliation(s)
- Joe Brown
- School of Civil and Environmental Engineering, Georgia Institute of Technology, Atlanta, Georgia
| | | | - Dale Whittington
- Department of Environmental Sciences and Engineering, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina
- Department of City and Regional Planning, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina
- Global Research Institute, University of Manchester, Manchester, United Kingdom
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23
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Wolf J, Johnston R, Hunter PR, Gordon B, Medlicott K, Prüss-Ustün A. A Faecal Contamination Index for interpreting heterogeneous diarrhoea impacts of water, sanitation and hygiene interventions and overall, regional and country estimates of community sanitation coverage with a focus on low- and middle-income countries. Int J Hyg Environ Health 2019; 222:270-282. [PMID: 30503228 PMCID: PMC6417992 DOI: 10.1016/j.ijheh.2018.11.005] [Citation(s) in RCA: 28] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/23/2018] [Revised: 10/26/2018] [Accepted: 11/19/2018] [Indexed: 02/06/2023]
Abstract
OBJECTIVES The impact on diarrhoea of sanitation interventions has been heterogeneous. We hypothesize that this is due to the level of prevailing faecal environmental contamination and propose a Faecal Contamination Index (FAECI) of selected WASH indicators (objective 1). Additionally, we provide estimates of the proportion of the population living in communities above certain sanitation coverage levels (objective 2). METHODS Objective 1: Faecal contamination post-intervention was estimated from WASH intervention reports. WASH indicators composing the FAECI included eight water, sanitation and hygiene practice indicators, which were selected for their relevance for health and data availability at study- and country-level. The association between the estimated level of faecal environmental contamination and diarrhoea was examined using meta-regression. Objective 2: A literature search was conducted to identify health-relevant community sanitation coverage thresholds. To estimate total community coverage with basic sanitation in low- and middle-income countries, at relevant thresholds, household surveys with data available at primary sampling unit (PSU)-level were analysed according to the identified thresholds, at country-, regional- and overall level. RESULTS Objective 1: We found a non-linear association between estimated environmental faecal contamination and sanitation interventions' impact on diarrhoeal disease. Diarrhoea reductions were highest at lower faecal contamination levels, and no diarrhoea reduction was found when contamination increased above a certain level. Objective 2: Around 45% of the population lives in communities with more than 75% of coverage with basic sanitation and 24% of the population lives in communities above 95% coverage, respectively. CONCLUSIONS High prevailing faecal contamination might explain interventions' poor effectiveness in reducing diarrhoea. The here proposed Faecal Contamination Index is a first attempt to estimate the level of faecal contamination in communities. Much of the world's population currently lives in faecally contaminated environments as indicated by low community sanitation coverage.
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Affiliation(s)
- Jennyfer Wolf
- Department of Public Health, Environment and Social Determinants of Health, World Health Organization, 20 Avenue Appia, Geneva, Switzerland.
| | - Richard Johnston
- Department of Public Health, Environment and Social Determinants of Health, World Health Organization, 20 Avenue Appia, Geneva, Switzerland.
| | - Paul R Hunter
- The Norwich School of Medicine, University of East Anglia, Norwich, UK; Department of Environmental Health, Tshwane University of Technology, Pretoria, South Africa.
| | - Bruce Gordon
- Department of Public Health, Environment and Social Determinants of Health, World Health Organization, 20 Avenue Appia, Geneva, Switzerland.
| | - Kate Medlicott
- Department of Public Health, Environment and Social Determinants of Health, World Health Organization, 20 Avenue Appia, Geneva, Switzerland.
| | - Annette Prüss-Ustün
- Department of Public Health, Environment and Social Determinants of Health, World Health Organization, 20 Avenue Appia, Geneva, Switzerland.
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24
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Johri M, Sylvestre MP, Koné GK, Chandra D, Subramanian SV. Effects of improved drinking water quality on early childhood growth in rural Uttar Pradesh, India: A propensity-score analysis. PLoS One 2019; 14:e0209054. [PMID: 30620737 PMCID: PMC6324831 DOI: 10.1371/journal.pone.0209054] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/27/2018] [Accepted: 11/27/2018] [Indexed: 12/17/2022] Open
Abstract
Context Recent randomised controlled trials in Bangladesh and Kenya concluded that household water treatment, alone or in combination with upgraded sanitation and handwashing, did not reduce linear growth faltering or improve other child growth outcomes. Whether these results are applicable in areas with distinct constellations of water, sanitation and hygiene (WaSH) risks is unknown. Analysis of observational data offers an efficient means to assess the external validity of trial findings. We studied whether a water quality intervention could improve child growth in a rural Indian setting with higher levels of circulating pathogens than the original trial sites. Methods We analysed a cross-sectional dataset including a microbiological measure of household water quality. All households accessed water from an improved source. We applied propensity score methods to emulate a randomised trial investigating the hypothesis that receipt of drinking water meeting Sustainable Development Goal (SDG) 6.1 quality standards for absence of faecal contamination leads to improved growth. Growth outcomes (stunting, underweight, wasting, and their corresponding Z-scores) were assessed in children 12–23 months of age. For each outcome, we estimated the mean and 95% confidence interval of the absolute risk difference between treatment groups. Findings Of 1088 households, 442 (40.62%) received drinking water meeting SDG 6.1 standards. The adjusted risk of child underweight was 7.4% (1.3% to 13.4%) lower among those drinking water satisfying SDG 6.1 norms than among controls. Evidence concerning the relationship of drinking water meeting SDG 6.1 norms to length-for-age and weight-for-age was inconclusive, and there was no apparent relationship with stunting or wasting. Conclusions In contexts characterised by high pathogen transmission, water quality improvements have the potential to reduce the proportion of underweight children, but are unlikely to impact stunting or wasting. Further research is required to assess how these modelled benefits can best be achieved in real world settings.
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Affiliation(s)
- Mira Johri
- Centre de Recherche du Centre Hospitalier de l’Université de Montréal (CRCHUM), Montreal, Québec, Canada
- Département d’administration de la santé, École de santé publique, Université de Montréal, Montreal, Canada
- * E-mail:
| | - Marie-Pierre Sylvestre
- Centre de Recherche du Centre Hospitalier de l’Université de Montréal (CRCHUM), Montreal, Québec, Canada
- Département de médicine sociale et préventive, École de santé publique, Université de Montréal, Montreal, Canada
| | - Georges Karna Koné
- Abt associates, Health finance and governance (FHG) Project, Port-au-Prince, Haiti
| | - Dinesh Chandra
- Centre de Recherche du Centre Hospitalier de l’Université de Montréal (CRCHUM), Montreal, Québec, Canada
- Independent consultant, New Delhi, India
| | - S. V. Subramanian
- Harvard Center for Population and Development Studies, Cambridge MA, United States of America
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25
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Montealegre MC, Roy S, Böni F, Hossain MI, Navab-Daneshmand T, Caduff L, Faruque ASG, Islam MA, Julian TR. Risk Factors for Detection, Survival, and Growth of Antibiotic-Resistant and Pathogenic Escherichia coli in Household Soils in Rural Bangladesh. Appl Environ Microbiol 2018; 84:e01978-18. [PMID: 30315075 PMCID: PMC6275341 DOI: 10.1128/aem.01978-18] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/13/2018] [Accepted: 10/01/2018] [Indexed: 12/18/2022] Open
Abstract
Soils in household environments in low- and middle-income countries may play an important role in the persistence, proliferation, and transmission of Escherichia coli Our goal was to investigate the risk factors for detection, survival, and growth of E. coli in soils collected from household plots. E. coli was enumerated in soil and fecal samples from humans, chickens, and cattle from 52 households in rural Bangladesh. Associations between E. coli concentrations in soil, household-level risk factors, and soil physicochemical characteristics were investigated. Susceptibility to 16 antibiotics and the presence of intestinal pathotypes were evaluated for 175 E. coli isolates. The growth and survival of E. coli in microcosms using soil collected from the households were also assessed. E. coli was isolated from 44.2% of the soil samples, with an average of 1.95 log10 CFU/g dry soil. Soil moisture and clay content were associated with E. coli concentrations in soil, whereas no household-level risk factor was significantly correlated. Antibiotic resistance and pathogenicity were common among E. coli isolates, with 42.3% resistant to at least one antibiotic, 12.6% multidrug resistant (≥3 classes), and 10% potentially pathogenic. Soil microcosms demonstrate growth and/or survival of E. coli, including an enteropathogenic extended-spectrum beta-lactamase (ESBL)-producing isolate, in some, but not all, of the household soils tested. In rural Bangladesh, defined soil physicochemical characteristics appear more influential for E. coli detection in soils than household-level risk factors. Soils may act as reservoirs in the transmission of antibiotic-resistant and potentially pathogenic E. coli and therefore may impact the effectiveness of water, sanitation, and hygiene interventions.IMPORTANCE Soil may represent a direct source or act as an intermediary for the transmission of antibiotic-resistant and pathogenic Escherichia coli strains, particularly in low-income and rural settings. Thus, determining risk factors associated with detection, growth, and long-term survival of E. coli in soil environments is important for public health. Here, we demonstrate that household soils in rural Bangladesh are reservoirs for antibiotic-resistant and potentially pathogenic E. coli strains and can support E. coli growth and survival, and defined soil physicochemical characteristics are drivers of E. coli survival in this environment. In contrast, we found no evidence that household-level factors, including water, sanitation, and hygiene indicators, were associated with E. coli contamination of household soils.
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Affiliation(s)
| | - Subarna Roy
- Enteric and Food Microbiology Laboratory, International Centre for Diarrhoeal Disease Research, Bangladesh (icddr,b), Dhaka, Bangladesh
| | - Franziska Böni
- Eawag, Swiss Federal Institute of Aquatic Science and Technology, Dübendorf, Switzerland
| | - Muhammed Iqbal Hossain
- Enteric and Food Microbiology Laboratory, International Centre for Diarrhoeal Disease Research, Bangladesh (icddr,b), Dhaka, Bangladesh
| | - Tala Navab-Daneshmand
- Eawag, Swiss Federal Institute of Aquatic Science and Technology, Dübendorf, Switzerland
| | - Lea Caduff
- Eawag, Swiss Federal Institute of Aquatic Science and Technology, Dübendorf, Switzerland
| | - A S G Faruque
- Nutrition and Clinical Services Division (NCSD), International Centre for Diarrhoeal Disease Research, Bangladesh (icddr,b), Dhaka, Bangladesh
| | - Mohammad Aminul Islam
- Enteric and Food Microbiology Laboratory, International Centre for Diarrhoeal Disease Research, Bangladesh (icddr,b), Dhaka, Bangladesh
| | - Timothy R Julian
- Eawag, Swiss Federal Institute of Aquatic Science and Technology, Dübendorf, Switzerland
- Swiss Tropical and Public Health Institute, Basel, Switzerland
- University of Basel, Basel, Switzerland
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26
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Achoki T, Miller-Petrie MK, Glenn SD, Kalra N, Lesego A, Gathecha GK, Alam U, Kiarie HW, Maina IW, Adetifa IMO, Barsosio HC, Degfie TT, Keiyoro PN, Kiirithio DN, Kinfu Y, Kinyoki DK, Kisia JM, Krish VS, Lagat AK, Mooney MD, Moturi WN, Newton CRJ, Ngunjiri JW, Nixon MR, Soti DO, Van De Vijver S, Yonga G, Hay SI, Murray CJL, Naghavi M. Health disparities across the counties of Kenya and implications for policy makers, 1990-2016: a systematic analysis for the Global Burden of Disease Study 2016. LANCET GLOBAL HEALTH 2018; 7:e81-e95. [PMID: 30482677 PMCID: PMC6293072 DOI: 10.1016/s2214-109x(18)30472-8] [Citation(s) in RCA: 38] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 04/11/2018] [Revised: 08/03/2018] [Accepted: 10/03/2018] [Indexed: 12/21/2022]
Abstract
Background The Global Burden of Diseases, Injuries, and Risk Factors Study (GBD) 2016 provided comprehensive estimates of health loss globally. Decision makers in Kenya can use GBD subnational data to target health interventions and address county-level variation in the burden of disease. Methods We used GBD 2016 estimates of life expectancy at birth, healthy life expectancy, all-cause and cause-specific mortality, years of life lost, years lived with disability, disability-adjusted life-years, and risk factors to analyse health by age and sex at the national and county levels in Kenya from 1990 to 2016. Findings The national all-cause mortality rate decreased from 850·3 (95% uncertainty interval [UI] 829·8–871·1) deaths per 100 000 in 1990 to 579·0 (562·1–596·0) deaths per 100 000 in 2016. Under-5 mortality declined from 95·4 (95% UI 90·1–101·3) deaths per 1000 livebirths in 1990 to 43·4 (36·9–51·2) deaths per 1000 livebirths in 2016, and maternal mortality fell from 315·7 (242·9–399·4) deaths per 100 000 in 1990 to 257·6 (195·1–335·3) deaths per 100 000 in 2016, with steeper declines after 2006 and heterogeneously across counties. Life expectancy at birth increased by 5·4 (95% UI 3·7–7·2) years, with higher gains in females than males in all but ten counties. Unsafe water, sanitation, and handwashing, unsafe sex, and malnutrition were the leading national risk factors in 2016. Interpretation Health outcomes have improved in Kenya since 2006. The burden of communicable diseases decreased but continues to predominate the total disease burden in 2016, whereas the non-communicable disease burden increased. Health gains varied strikingly across counties, indicating targeted approaches for health policy are necessary. Funding Bill & Melinda Gates Foundation.
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Affiliation(s)
- Tom Achoki
- Sloan Management, Massachusetts Institute of Technology, Cambridge, MA, USA; Center for Pharmaceutical Policy and Regulation, Utrecht University, Utrecht, Netherlands
| | - Molly K Miller-Petrie
- Institute for Health Metrics and Evaluation, University of Washington, Seattle, WA, USA
| | - Scott D Glenn
- Institute for Health Metrics and Evaluation, University of Washington, Seattle, WA, USA
| | - Nikhila Kalra
- Institute for Health Metrics and Evaluation, University of Washington, Seattle, WA, USA
| | - Abaleng Lesego
- Strategic Information and Learning, University of Research Company, Gaborone, Botswana
| | | | - Uzma Alam
- International Center for Humanitarian Affairs, Nairobi, Kenya
| | | | - Isabella Wanjiku Maina
- Policy, Planning, and Healthcare Financing Department, Nairobi, Kenya; Institute of Tropical Medicine, Jomo Kenyatta University of Agriculture and Technology, Nairobi, Kenya
| | - Ifedayo M O Adetifa
- Department of Infectious Disease Epidemiology, London School of Hygiene & Tropical Medicine, London, UK; Epidemiology and Demography Department, Kilifi, Kenya
| | - Hellen C Barsosio
- Malaria Branch, Kilifi, Kenya; Department of Clinical Sciences, Liverpool School of Tropical Medicine, Liverpool, UK
| | | | | | | | - Yohannes Kinfu
- Faculty of Health, University of Canberra, Canberra, ACT, Australia; Murdoch Children's Research Institute, Royal Children's Hospital, Melbourne, Vic, Australia
| | - Damaris K Kinyoki
- Institute for Health Metrics and Evaluation, University of Washington, Seattle, WA, USA
| | - James M Kisia
- East Africa Center, Humanitarian Leadership Academy, Nairobi, Kenya
| | - Varsha Sarah Krish
- Institute for Health Metrics and Evaluation, University of Washington, Seattle, WA, USA
| | - Abraham K Lagat
- Department of Health Systems and Research Ethics, KEMRI-Wellcome Research Programme, Nairobi, Kenya
| | - Meghan D Mooney
- Institute for Health Metrics and Evaluation, University of Washington, Seattle, WA, USA
| | | | - Charles Richard James Newton
- Kenya Medical Research Institute (KEMRI)-Wellcome Trust Collaborative Programme, Kilifi, Kenya; Department of Psychiatry, University of Oxford, Oxford, UK
| | | | - Molly R Nixon
- Institute for Health Metrics and Evaluation, University of Washington, Seattle, WA, USA
| | - David O Soti
- Eastern Africa Regional Collaborating Centre, African Centre for Disease Control and Prevention, Nairobi, Kenya
| | | | - Gerald Yonga
- School of Medicine, University of Nairobi, Nairobi, Kenya
| | - Simon I Hay
- Institute for Health Metrics and Evaluation, University of Washington, Seattle, WA, USA; Department of Health Metrics Sciences, University of Washington, Seattle, WA, USA
| | - Christopher J L Murray
- Institute for Health Metrics and Evaluation, University of Washington, Seattle, WA, USA; Department of Health Metrics Sciences, University of Washington, Seattle, WA, USA
| | - Mohsen Naghavi
- Institute for Health Metrics and Evaluation, University of Washington, Seattle, WA, USA; Department of Health Metrics Sciences, University of Washington, Seattle, WA, USA.
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