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Ballard AM, Corozo Angulo B, Laramee N, Pace Gallagher J, Haardörfer R, Freeman MC, Trostle J, Eisenberg JNS, Lee GO, Levy K, Caruso BA. Multilevel factors drive child exposure to enteric pathogens in animal feces: A qualitative study in northwestern coastal Ecuador. PLOS GLOBAL PUBLIC HEALTH 2024; 4:e0003604. [PMID: 39292655 PMCID: PMC11410186 DOI: 10.1371/journal.pgph.0003604] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/05/2024] [Accepted: 08/26/2024] [Indexed: 09/20/2024]
Abstract
Exposure to animal feces and associated enteric pathogens poses significant risks to child health. However, public health strategies to mitigate enteric infections among children largely aim to reduce exposure to human feces, overlooking transmission pathways related to animal feces. In this study we examine if and how children are exposed to enteric pathogens in animal feces in northwestern coastal Ecuador. We conducted qualitative interviews with mothers of children aged 10-18 months that owned (n = 32) and did not own (n = 26) animals in urban and rural communities. Using thematic analysis, we identified community, household, and child behavioral factors that influence exposure. We also compared child exposure by household animal ownership. Our findings revealed myriad opportunities for young children to be exposed to enteric pathogens in many locations and from multiple animal sources, regardless of household animal ownership. Animal feces management practices (AFM) used by mothers, such as rinsing feces into ditches and throwing feces into surrounding areas, may increase environmental contamination outside their homes and in their communities. Unsafe AFM practices were similar to unsafe child feces management practices reported in other studies, including practices related to defecation location, feces removal and disposal, environmental contamination cleaning, and handwashing. Findings suggest that animal feces may contaminate the environment along similar pathways as human feces. Identification and incorporation of safe AFM practices, similar to those developed for child feces management, would 1) mitigate child exposure to enteric pathogens by reducing animal feces contamination in domestic and public spaces; and 2) enable an integrated approach to address enteric pathogen exposure pathways related to animal and child feces.
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Affiliation(s)
- April M Ballard
- Department of Population Health Sciences, Georgia State University School of Public Health, Atlanta, Georgia, United States of America
- Gangarosa Department of Environmental Health, Emory University Rollins School of Public Health, Atlanta, Georgia, United States of America
| | | | - Nicholas Laramee
- Hubert Department of Global Health, Emory University Rollins School of Public Health, Atlanta, Georgia, United States of America
| | - Jayden Pace Gallagher
- Gangarosa Department of Environmental Health, Emory University Rollins School of Public Health, Atlanta, Georgia, United States of America
| | - Regine Haardörfer
- Department of Behavioral, Social, and Health Education Sciences, Emory University Rollins School of Public Health, Atlanta, Georgia, United States of America
| | - Matthew C Freeman
- Gangarosa Department of Environmental Health, Emory University Rollins School of Public Health, Atlanta, Georgia, United States of America
| | - James Trostle
- Department of Anthropology, Trinity College, Hartford, Connecticut, United States of America
| | - Joseph N S Eisenberg
- Department of Epidemiology, University of Michigan School of Public Health, Ann Arbor, Michigan, United States of America
| | - Gwenyth O Lee
- Rutgers Global Health Institute and Department of Biostatistics and Epidemiology, Rutgers School of Public Health, Piscataway, New Jersey, United States of America
| | - Karen Levy
- Department of Environmental and Occupational Health Sciences, University of Washington School of Public Health, Seattle, Washington, United States of America
| | - Bethany A Caruso
- Gangarosa Department of Environmental Health, Emory University Rollins School of Public Health, Atlanta, Georgia, United States of America
- Hubert Department of Global Health, Emory University Rollins School of Public Health, Atlanta, Georgia, United States of America
- Department of Behavioral, Social, and Health Education Sciences, Emory University Rollins School of Public Health, Atlanta, Georgia, United States of America
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Ballard AM, Haardörfer R, Angulo BC, Freeman MC, Eisenberg JNS, Lee GO, Levy K, Caruso BA. The development and validation of a survey to measure fecal-oral child exposure to zoonotic enteropathogens: The FECEZ Enteropathogens Index. PLOS GLOBAL PUBLIC HEALTH 2024; 4:e0002690. [PMID: 39255298 PMCID: PMC11386431 DOI: 10.1371/journal.pgph.0002690] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/29/2023] [Accepted: 06/10/2024] [Indexed: 09/12/2024]
Abstract
Child exposure to animal feces and associated enteropathogens contribute to a significant burden of disease in low- and middle-income countries. However, there are no standardized, validated survey-based approaches to enable accurate assessment of child exposure to zoonotic enteropathogens. We developed and validated a survey-based measure of exposure, the fecal-oral child exposure to zoonotic enteropathogens Index (the FECEZ Enteropathogens Index). First, we identified critical attributes of child exposure through in-depth interviews (IDIs) in Ecuador among individuals who care for animals (n = 29) and mothers of children under two years old (n = 58), and through a systematic review of existing exposure measures. Second, based on these findings, we developed a 105-question survey and administered it to 297 mothers with children under age five. Third, we refined the survey, using principal component analysis to determine the optimal number of components. The final index consisted of 34 items across two sub-domains: the child Environment and child Behavior. Lastly, we compared index scores to two commonly used, unvalidated measures of child exposure-maternal reported household animal ownership and presence of animal feces. Using the FECEZ Enteropathogens Index revealed varying degrees of exposure in our study population, with only two children having no exposure. In contrast, if we had used animal ownership or the presence of animal feces as a measure of exposure, 44% and 33% of children would have been classified as having no exposure, respectively. These common binary exposure measures may be inadequate because they do not provide sufficient information to identify the relative risk of zoonotic pathogen exposure. The FECEZ Enteropathogens Index overcomes this limitation, advancing our ability to assess exposure by quantifying the multiple components of child exposure to zoonotic enteropathogens with higher resolution. Additional testing and evaluation of the index is needed to ensure its reliability, validity, and cross-cultural equivalence in other contexts.
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Affiliation(s)
- April M. Ballard
- Department of Population Health Sciences, Georgia State University School of Public Health, Atlanta, Georgia, United States of America
- Gangarosa Department of Environmental Health, Emory University Rollins School of Public Health, Atlanta, Georgia, United States of America
| | - Regine Haardörfer
- Department of Behavioral, Social and Health Education Sciences, Emory University Rollins School of Public Health, Atlanta, Georgia, United States of America
| | | | - Matthew C. Freeman
- Gangarosa Department of Environmental Health, Emory University Rollins School of Public Health, Atlanta, Georgia, United States of America
- Hubert Department of Global Health, Emory University Rollins School of Public Health, Atlanta, Georgia, United States of America
| | - Joseph N. S. Eisenberg
- Department of Epidemiology, University of Michigan School of Public Health, Ann Arbor, Michigan, United States of America
| | - Gwenyth O. Lee
- Rutgers Global Health Institute and Department of Biostatistics and Epidemiology, Rutgers School of Public Health, Piscataway, New Jersey, United States of America
| | - Karen Levy
- Department of Environmental and Occupational Health Sciences, University of Washington School of Public Health, Seattle, Washington, United States of America
| | - Bethany A. Caruso
- Gangarosa Department of Environmental Health, Emory University Rollins School of Public Health, Atlanta, Georgia, United States of America
- Department of Behavioral, Social and Health Education Sciences, Emory University Rollins School of Public Health, Atlanta, Georgia, United States of America
- Hubert Department of Global Health, Emory University Rollins School of Public Health, Atlanta, Georgia, United States of America
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Chakrabarti S, Gune S, Bruckner TA, Strominger J, Singh P. Toilet construction under the Swachh Bharat Mission and infant mortality in India. Sci Rep 2024; 14:20340. [PMID: 39223201 PMCID: PMC11369168 DOI: 10.1038/s41598-024-71268-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/04/2023] [Accepted: 08/26/2024] [Indexed: 09/04/2024] Open
Abstract
Improvement of water and sanitation conditions may reduce infant mortality, particularly in countries like India where open defecation is highly prevalent. We conducted a quasi-experimental study to investigate the association between the Swachh Bharat Mission (SBM)-a national sanitation program initiated in 2014-and infant (IMR) and under five mortality rates (U5MR) in India. We analyzed data from thirty-five Indian states and 640 districts spanning 10 years (2011-2020), with IMR and U5MR per thousand live births as the outcomes. Our main exposure was the district-level annual percentage of households that received a constructed toilet under SBM. We mapped changes in IMR and U5MR and toilet access at the district level over time. We fit two-way fixed effects regression models controlling for sociodemographic, wealth, and healthcare-related confounders at the district-level to estimate the association between toilets constructed and child mortality. Toilet access and child mortality have a historically robust inverse association in India. Toilets constructed increased dramatically across India following the implementation of SBM in 2014. Results from panel data regression models show that districts with > 30% toilets constructed under SBM corresponds with 5.3 lower IMR (p < 0.05), and 6.8 lower U5MR (p < 0.05). Placebo, falsification tests and robustness checks support our main findings. The post-SBM period in India exhibited accelerated reductions in infant and child mortality compared to the pre-SBM years. Based on our regression estimates, the provision of toilets at-scale may have contributed to averting approximately 60,000-70,000 infant deaths annually. Our findings show that the implementation of transformative sanitation programs can deliver population health benefits in low- and middle-income countries.
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Affiliation(s)
- Suman Chakrabarti
- Nutrition, Diets and Health Unit, International Food Policy Research Institute, Washington, DC, USA
| | - Soyra Gune
- Nutrition, Diets and Health Unit, International Food Policy Research Institute, New Delhi, India
| | - Tim A Bruckner
- Program in Public Health, University of California, Irvine, CA, USA
| | - Julie Strominger
- Division of Epidemiology, College of Public Health, The Ohio State University, 338 Cunz Hall, 1841 Neil Avenue, Columbus, OH, 43210, USA
| | - Parvati Singh
- Division of Epidemiology, College of Public Health, The Ohio State University, 338 Cunz Hall, 1841 Neil Avenue, Columbus, OH, 43210, USA.
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Denno DM, Ahmed S, Ahmed T, Ali SA, Amadi B, Kelly P, Lawrence S, Mahfuz M, Marie C, Moore SR, Nataro JP, Petri WA, Sullivan PB, Tarr PI. The Environmental Enteric Dysfunction Biopsy Initiative (EEDBI) Consortium: mucosal investigations of environmental enteric dysfunction. Am J Clin Nutr 2024; 120 Suppl 1:S4-S14. [PMID: 39300662 DOI: 10.1016/j.ajcnut.2024.02.003] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/06/2023] [Accepted: 02/01/2024] [Indexed: 09/22/2024] Open
Abstract
Environmental enteric dysfunction (EED) is an asymptomatic acquired disorder characterized by upper small bowel inflammation, villus blunting, and gut permeability. It is a major contributor to poor growth in childhood as well as other highly consequential outcomes such as delayed neuorcognitive development. After decades of intermittent interest in this entity, we are now seeing a resurgence in the field of EED. However, recent studies have been hampered by a lack of investigation of the target tissue-the upper small bowel. In 2016, the EEDBI (Environmental Enteric Dysfunction Biopsy Initiative) Consortium was established as a common scientific platform across 3 independent EED biopsy cohort studies in Bangladesh, Pakistan, and Zambia. Two centers in the United States recruited comparison groups of children undergoing endoscopy for clinical indications. The EEDBI Consortium goal was to augment the contributions of the individual centers and answer high-level questions amenable to analysis and interpretation across the studies. Here, we describe the Consortium and its cohorts and recruitment procedures across studies. We also offer details applicable to all papers in this supplement, which describe EED mucosal histology, morphometry, immunohistochemistry, and transcriptomics as well as histology relationship to pathogens and biomarkers.
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Affiliation(s)
- Donna M Denno
- Department of Pediatrics, University of Washington, Seattle, WA, United States.
| | - Sheraz Ahmed
- Department of Paediatrics and Child Health, Aga Kahn University, Karachi, Pakistan
| | - Tahmeed Ahmed
- Nutrition Research Division, International Centre for Diarrhoeal Disease Research, Bangladesh, Dhaka, Bangladesh
| | - S Asad Ali
- Department of Paediatrics and Child Health, Aga Kahn University, Karachi, Pakistan
| | - Beatrice Amadi
- Tropical Gastroenterology & Nutrition Group, University of Zambia, Lusaka, Zambia
| | - Paul Kelly
- Blizard Institute, Barts & The London School of Medicine, Queen Mary University of London, London, United Kingdom
| | - Sarah Lawrence
- Department of Pediatrics, University of Washington, Seattle, WA, United States
| | - Mustafa Mahfuz
- Nutrition Research Division, International Centre for Diarrhoeal Disease Research, Bangladesh, Dhaka, Bangladesh
| | - Chelsea Marie
- Department of Medicine, University of Virginia, Charlottesville, VA, United States
| | - Sean R Moore
- Department of Pediatrics, University of Virginia, Charlottesville, VA, United States
| | - James P Nataro
- Department of Pediatrics, University of Virginia, Charlottesville, VA, United States
| | - William A Petri
- Department of Medicine, University of Virginia, Charlottesville, VA, United States
| | - Peter B Sullivan
- Department of Paediatrics, Children's Hospital, University of Oxford, Oxford, United Kingdom
| | - Phillip I Tarr
- Department of Pediatrics, Washington University, St. Louis, MO, United States
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Muriithi B, Wandera EA, Takeuchi R, Mutunga F, Kathiiko C, Wachira M, Tinkoi J, Meiguran M, Akumu P, Ndege V, Mochizuki R, Kaneko S, Morita K, Ouma C, Ichinose Y. Impact of integrated WASH and maternal and child health interventions on diarrhea disease prevalence in a resource-constrained setting in Kenya. Trop Med Health 2024; 52:56. [PMID: 39215357 PMCID: PMC11363663 DOI: 10.1186/s41182-024-00616-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2024] [Accepted: 07/15/2024] [Indexed: 09/04/2024] Open
Abstract
BACKGROUND Water, sanitation and hygiene (WASH) and child health interventions are proven simple and cost-effective strategies for preventing diarrhea and minimizing excess mortality. Individually, they are able to prevent diarrhea though sub-optimally, and their effectiveness when combined may be higher. This study examined the effect of integrated WASH and maternal and child health (MCH) interventions on prevalence of diarrhea, in a resource-limited setting in Kenya. METHODS A controlled intervention was implemented in Narok County. The interventions included WASH interventions integrated with promotion of MCH. A structured questionnaire was used to collect data on targeted indicators before and after the interventions. Data were analyzed using descriptive statistics and Chi-square to establish the impact of the interventions. RESULTS A total of 431and 424 households and 491 and 487 households in intervention and control sites, respectively, participated in the baseline and endline surveys. Following implementation of the interventions, prevalence of diarrhea decreased by 69.1% (95% CI: 49.6-87.1%) and 58.6% (95% CI: 26.6-82.4%) in the intervention and control site, respectively. Treatment of drinking water and animal husbandry practices were significantly associated with diarrhea post-interventions. CONCLUSIONS Integrating WASH interventions with other diarrhea control strategies and contextualizing them to meet site-specific needs may effectively prevent diarrhea.
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Affiliation(s)
- Betty Muriithi
- Institute of Tropical Medicine, Nagasaki University-Kenya Medical Research Institute, P.O. Box 19993-00202, Nairobi, Kenya
| | - Ernest Apondi Wandera
- Institute of Tropical Medicine, Nagasaki University-Kenya Medical Research Institute, P.O. Box 19993-00202, Nairobi, Kenya.
- Centre for Virus Research, Kenya Medical Research Institute, Nairobi, Kenya.
| | - Rie Takeuchi
- Department of Public Health, International University of Health and Welfare, Otawara, Japan
| | - Felix Mutunga
- Institute of Tropical Medicine, Nagasaki University-Kenya Medical Research Institute, P.O. Box 19993-00202, Nairobi, Kenya
| | - Cyrus Kathiiko
- Institute of Tropical Medicine, Nagasaki University-Kenya Medical Research Institute, P.O. Box 19993-00202, Nairobi, Kenya
| | - Mary Wachira
- Institute of Tropical Medicine, Nagasaki University-Kenya Medical Research Institute, P.O. Box 19993-00202, Nairobi, Kenya
| | | | | | | | | | | | - Satoshi Kaneko
- Institute of Tropical Medicine, Nagasaki University-Kenya Medical Research Institute, P.O. Box 19993-00202, Nairobi, Kenya
| | - Kouichi Morita
- Institute of Tropical Medicine, Nagasaki University-Kenya Medical Research Institute, P.O. Box 19993-00202, Nairobi, Kenya
| | - Collins Ouma
- Department of Biomedical Sciences and Technology, Maseno University, Maseno, Kenya
| | - Yoshio Ichinose
- Institute of Tropical Medicine, Nagasaki University-Kenya Medical Research Institute, P.O. Box 19993-00202, Nairobi, Kenya
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Sclar GD, Bauza V, Bisoyi A, Majorin F, Mosler HJ, Clasen TF. Effect of a behavior change and hardware intervention on safe child feces management practices in rural Odisha, India: a cluster-randomized controlled trial. BMC Public Health 2024; 24:2327. [PMID: 39192252 PMCID: PMC11351010 DOI: 10.1186/s12889-024-19272-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/14/2023] [Accepted: 06/25/2024] [Indexed: 08/29/2024] Open
Abstract
BACKGROUND Poor child feces management contributes to enteropathogen exposure and, consequently, is associated with diarrheal disease and negative impacts on child growth. Despite high latrine coverage, only 37% of Indian households safely dispose of their child's feces into a latrine or have the child use the latrine, with the lowest rate in the state of Odisha at 12%. We evaluated a behavior change and hardware intervention designed to improve caregiver safe disposal of child feces and child latrine use. METHODS We conducted a cluster-randomized controlled trial among 74 villages in rural Odisha, India. Eligible villages previously participated in a water and sanitation infrastructure program. Following a baseline survey, half the villages were assigned to intervention and half to control. Caregivers of children < 5 years old from households with a latrine were eligible to participate. The intervention included five behavior change activities. Hardware was provided at the first activity, based on child age, to aid safe disposal and latrine training (wash basin and bucket with lid for children < 7 months old; latrine training mat platform with removable tray for children 7 to 48 months old). The primary outcome was caregiver reported 'safe disposal' as defined by the WHO/UNICEF Joint Monitoring Programme (JMP) which encompasses two behaviors: caregiver disposal of child's feces into a latrine and child latrine use. Safe disposal was measured four to six months after intervention delivery (endline). RESULTS Endline analysis included 665 intervention caregivers (840 children) and 634 control caregivers (785 children). Prevalence of JMP-defined safe disposal was 1.16 times greater in the intervention arm compared to control (77.7% vs. 65.9%; prevalence ratio [PR] 1.16, 95% CI 1.04-1.29), with higher prevalence of caregiver safe disposal (18.6% vs. 13.6%; PR 1.46, 95% CI 1.12-1.92) but no significant difference in child latrine use (59.0% vs. 52.2%; PR 1.06, 95% CI 0.95-1.18). When restricted to children < 3 years old, JMP-defined safe disposal was 1.42 times greater (67.5% vs. 46.7%; PR 1.42 95% CI 1.21-1.67) with higher prevalence of both caregiver safe disposal (34.6% vs. 25.7%; PR 1.44, 95% CI 1.11-1.86) and child latrine use (32.9% vs. 20.9%; PR 1.41, 95% CI 1.08-1.83). CONCLUSIONS The intervention increased JMP-defined safe disposal, with substantial improvements in both caregiver safe disposal and child latrine use among children < 3 years old. While future research is needed to demonstrate sustainability of these effects, our results suggest a potentially scalable intervention for improving child feces disposal and reducing disease. TRIAL REGISTRATION This trial was retrospectively registered at ISRCTN15831099 on 18/02/2020, which was approximately two months after the first participant was recruited for the baseline survey on 02/12/2019.
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Affiliation(s)
- Gloria D Sclar
- Gangarosa Department of Environmental Health, Rollins School of Public Health, Emory University, Atlanta, GA, USA.
- Department of Psychology, University of Zürich, Zürich, Switzerland.
| | - Valerie Bauza
- Gangarosa Department of Environmental Health, Rollins School of Public Health, Emory University, Atlanta, GA, USA
| | | | - Fiona Majorin
- Department of Disease Control, Faculty of Infectious and Tropical Diseases, London School of Hygiene and Tropical Medicine, London, UK
| | | | - Thomas F Clasen
- Gangarosa Department of Environmental Health, Rollins School of Public Health, Emory University, Atlanta, GA, USA
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Fink G, Locks LM, Lauer JM, Chembe M, Henderson S, Sikazwe D, Billima-Mulenga T, Parkerson D, Rockers PC. The impact of home-installed growth charts and small-quantity lipid-based nutrient supplements (SQ-LNS) on child growth in Zambia: a four-arm parallel open-label cluster randomised controlled trial. BMJ Glob Health 2024; 9:e015438. [PMID: 39153751 PMCID: PMC11331861 DOI: 10.1136/bmjgh-2024-015438] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/29/2024] [Accepted: 07/09/2024] [Indexed: 08/19/2024] Open
Abstract
BACKGROUND Childhood stunting remains common in many low-income settings and is associated with increased morbidity and mortality, as well as impaired child development. METHODS The main objective of the study was to assess whether home-installed growth charts as well as small-quantity lipid-based nutrient supplements (SQ-LNS) can reduce growth faltering among infants. All caregivers of infants between 2 and 10 months of age at baseline, and at least 6 months old at the beginning of the interventions, in 282 randomly selected enumeration areas in Choma, Mansa and Lusaka districts in Zambia were invited to participate in the study. Cluster randomisation was stratified by district. A software-generated random number draw was used to assign clusters to one of four arms: (1) no intervention (control); (2) home installation of a wall chart that contained a growth monitoring tool along with key messages on infant and young child feeding and nutrition (growth charts only); (3) 30 sachets of SQ-LNS delivered each month (SQ-LNS only) or (4) growth charts+SQ LNS. The primary outcomes were children's height-for-age z-score (HAZ) and stunting (HAZ <-2) after 18 months of intervention. Secondary outcomes were haemoglobin (Hb), anaemia (Hb<110.0 g/L), weight-for-height, weight-for-age z-score (WAZ), underweight (WAZ<-2) and child development measured by the Global Scales of Early Development (GSED). Outcomes were analysed intention to treat using adjusted linear and logistic regression models and compared each of the three interventions to the control group. Assessors and analysts were blinded to the treatment-blinding of participating families was not possible. RESULTS A total of 2291 caregiver-child dyads across the 282 study clusters were included in the study. 70 clusters (557 dyads) were assigned to the control group, 70 clusters (643 dyads) to growth charts only, 71 clusters (525 dyads) to SQ-LNS and 71 clusters (566 dyads) to SQ-LNS and growth charts. SQ-LNS improved HAZ by 0.21 SD (95% CI 0.06 to 0.36) and reduced the odds of stunting by 37% (adjusted OR, aOR 0.63, 95% CI (0.46 to 0.87)). No HAZ or stunting impacts were found in the growth charts only or growth charts+SQ LNS arms. SQ-LNS only improved WAZ (mean difference, MD 0.17, 95% CI (0.05 to 0.28). No impacts on WAZ were seen for growth charts and the combined intervention. Child development was higher in the growth charts only (MD 0.18, 95% CI (0.01 to 0.35)) and SQ-LNS only arms (MD 0.28, 95% CI (0.09 to 0.46). SQ-LNS improved average haemoglobin levels (MD 2.9 g/L (0.2, 5.5). The combined intervention did not have an impact on WAZ, Hb or GSED but reduced the odds of anaemia (aOR 0.72, 95% CI (0.53 to 0.97)). No adverse events were reported. INTERPRETATION SQ-LNS appears to be effective in reducing growth faltering as well as improving anaemia and child development. Growth charts also show the potential to reduce anaemia and improve child development but do not seem as effective in addressing growth faltering. Further research is needed to better understand reduced effectiveness when both interventions are combined. TRIAL REGISTRATION NUMBER NCT051204272.
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Affiliation(s)
- Günther Fink
- University of Basel, Basel, Switzerland
- Epidemiology and Public Health, Swiss Tropical and Public Health Institute, Allschwil, Switzerland
| | - Lindsey M Locks
- Department of Global Health, Boston University School of Public Health, Boston, Massachusetts, USA
- Department of Health Sciences, Sargent College of Health and Rehabilitation Sciences, Boston University, Boston, Massachusetts, USA
| | - Jacqueline M. Lauer
- Department of Health Sciences, Sargent College of Health and Rehabilitation Sciences, Boston University, Boston, Massachusetts, USA
| | - Mpela Chembe
- Innovations for Poverty Action Zambia, Lusaka, Zambia
| | - Savanna Henderson
- Innovations for Poverty Action, Washington, District of Columbia, USA
| | | | | | - Doug Parkerson
- Innovations for Poverty Action, Washington, District of Columbia, USA
| | - Peter C Rockers
- Department of Global Health, Boston University School of Public Health, Boston, Massachusetts, USA
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Long KZ, Gunanti IR, Stride C, Sanchez J, Sur D, Manna B, Ramamurthy T, Kanungo S, Nataro JP, Powell H, Roose A, Nasrin D, Sommerfelt H, Levine M, Kotloff K. Identification of Enteric Pathogen Reservoirs and Transmission Pathways Associated with Short Childhood Stature in the Kolkata Indian Site of the Global Enteric Multicenter Study. Nutrients 2024; 16:2733. [PMID: 39203869 PMCID: PMC11357064 DOI: 10.3390/nu16162733] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2024] [Revised: 08/08/2024] [Accepted: 08/13/2024] [Indexed: 09/03/2024] Open
Abstract
Age-stratified path analyses modeled associations between enteric pathogen reservoirs, transmission pathways and height-for-age z-scores (HAZ) to identify determinants of childhood growth in the Kolkata, India site of the Global Enteric Multicenter Study (GEMS). Models tested direct associations of potential pathogen reservoirs with HAZ at 60-day follow-up in separate moderate and severe diarrhea (MSD) case and control cohorts or indirectly when mediated by enteric infections. In the MSD cohort, rotavirus and typical EPEC (tEPEC) infections among children 0-11 months of age and ST-ETEC infections among children 12-23 months of age were associated with lower HAZ. Handwashing after defecating and before cooking reduced impaired growth through reductions in rotavirus and tEPEC infections. Water storage increased rotavirus and ST-ETEC infection risks, resulting in increased impaired growth, but was reduced with reported child feces disposal. The GII norovirus variant was inversely associated with HAZ among children 12-59 months of age in the control cohort. Reported handwashing before the handling of children reduced GII infections and impaired growth. Boiling water and the disposal of children's feces mediated by stored water were positively associated with HAZ. The targeting of pathogen-specific reservoirs and transmission pathways may more effectively improve childhood linear growth in South Asian urban communities.
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Affiliation(s)
- Kurt Z. Long
- Epidemiology and Public Health, Swiss Tropical and Public Health Institute, 4123 Allschwil, Switzerland
- Faculty of Medicine, University of Basel, Peterplatz 1, 4003 Basel, Switzerland
- The Child Health Research Centre, Faculty of Medicine and Biomedical Sciences, The University of Queensland, Brisbane 4101, Australia
| | - Inong R. Gunanti
- The Child Health Research Centre, Faculty of Medicine and Biomedical Sciences, The University of Queensland, Brisbane 4101, Australia
| | - Chris Stride
- The Institute of Work Psychology, University of Sheffield, Sheffield S10 2TN, UK;
| | - Johanna Sanchez
- The Child Health Research Centre, Faculty of Medicine and Biomedical Sciences, The University of Queensland, Brisbane 4101, Australia
| | - Dipika Sur
- ICMR—National Institute for Research in Bacterial Infections, Kolkata 700010, India
| | - Byomkesh Manna
- ICMR—National Institute for Research in Bacterial Infections, Kolkata 700010, India
| | | | - Suman Kanungo
- ICMR—National Institute for Research in Bacterial Infections, Kolkata 700010, India
| | - James P. Nataro
- Department of Pediatrics, University of Virginia School of Medicine, Charlottesville, VA 22903, USA
| | - Helen Powell
- Department of Pediatrics, Center for Vaccine Development and Global Health, University of Maryland School of Medicine, Baltimore, MD 21201, USA
| | - Anna Roose
- Department of Medicine Center for Vaccine Development and Global Health, University of Maryland School of Medicine, Baltimore, MD 21201, USA
| | - Dilruba Nasrin
- Department of Medicine Center for Vaccine Development and Global Health, University of Maryland School of Medicine, Baltimore, MD 21201, USA
| | - Halvor Sommerfelt
- Centre for Intervention Science in Maternal and Child Health, Centre for International Health, University of Bergen and the Norwegian Institute of Public Health, NO-5020 Bergen, Norway
| | - Myron Levine
- Department of Pediatrics, Center for Vaccine Development and Global Health, University of Maryland School of Medicine, Baltimore, MD 21201, USA
- Department of Medicine Center for Vaccine Development and Global Health, University of Maryland School of Medicine, Baltimore, MD 21201, USA
| | - Karen Kotloff
- Department of Pediatrics, Center for Vaccine Development and Global Health, University of Maryland School of Medicine, Baltimore, MD 21201, USA
- Department of Medicine Center for Vaccine Development and Global Health, University of Maryland School of Medicine, Baltimore, MD 21201, USA
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9
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Yazawa T, Rubite KJG, Macabata-Rubite PE. How does the citizens' choice of water use actions based on their empirical knowledge affect the water quality in a rural community of the Philippines? JOURNAL OF WATER AND HEALTH 2024; 22:1541-1555. [PMID: 39212286 DOI: 10.2166/wh.2024.177] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/25/2024] [Accepted: 07/24/2024] [Indexed: 09/04/2024]
Abstract
This research assessed water quality, based on the purpose of water consumption, in households in the municipality of Barbaza, the Province of Antique, Philippines, according to the national water quality guidelines. The effects of the empirical/traditional water use actions taken by local people on the quality of the water they use were investigated through a descriptive study using water quality measurements. Most of the drinking water in the community did not meet the required standards of pH, total dissolved solids (TDS), or coliform. Tap water and well water samples generally met the pH and TDS standards. However, Escherichia coli (E. coli) and coliform were detected, and nitrogen pollution in well water was also confirmed. Local practices, such as using old clothes as filters for well pumps, increased the coliform concentration from 0-10 CFU/mL to too numerous to count (TNTC) levels of more than 100 CFU/mL. Storing well water in a bucket also affected both E. coli and coliform concentrations. Such empirical/traditional water use actions create a high risk of exposing local people to harmful microorganisms. This research integrated citizen science into the methodology for local water management, which could assist governors, practitioners, and citizens, particularly in Southeast Asia, where strong community relationships exist.
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Affiliation(s)
- Taishi Yazawa
- Institute of Industrial Science, The University of Tokyo, 4-6-1 Komaba, Meguro, Tokyo 153-8505, Japan E-mail:
| | - Kenn Joshua Geroy Rubite
- Binangbang Centro, Municipality of Barbaza, The Province of Antique, Republic of The Philippines
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10
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Lui JC, Palmer AC, Christian P. Nutrition, Other Environmental Influences, and Genetics in the Determination of Human Stature. Annu Rev Nutr 2024; 44:205-229. [PMID: 38759081 DOI: 10.1146/annurev-nutr-061121-091112] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/19/2024]
Abstract
Linear growth during three distinct stages of life determines attained stature in adulthood: namely, in utero, early postnatal life, and puberty and the adolescent period. Individual host factors, genetics, and the environment, including nutrition, influence attained human stature. Each period of physical growth has its specific biological and environmental considerations. Recent epidemiologic investigations reveal a strong influence of prenatal factors on linear size at birth that in turn influence the postnatal growth trajectory. Although average population height changes have been documented in high-income regions, stature as a complex human trait is not well understood or easily modified. This review summarizes the biology of linear growth and its major drivers, including nutrition from a life-course perspective, the genetics of programmed growth patterns or height, and gene-environment interactions that determine human stature in toto over the life span. Implications for public health interventions and knowledge gaps are discussed.
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Affiliation(s)
- Julian C Lui
- Section on Growth and Development, Eunice Kennedy Shriver National Institute of Child Health and Human Development, Bethesda, Maryland, USA
| | - Amanda C Palmer
- Center for Human Nutrition, Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA;
| | - Parul Christian
- Center for Human Nutrition, Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA;
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11
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MacLeod C, Ngabirano L, N'Diaye DS, Braun L, Cumming O. Household-level water, sanitation and hygiene factors and interventions and the prevention of relapse after severe acute malnutrition recovery: A systematic review. MATERNAL & CHILD NUTRITION 2024; 20:e13634. [PMID: 38372439 PMCID: PMC11168358 DOI: 10.1111/mcn.13634] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/09/2023] [Revised: 01/29/2024] [Accepted: 01/31/2024] [Indexed: 02/20/2024]
Abstract
Severe acute malnutrition (SAM) is the most serious form of acute malnutrition and is associated with high mortality risk among children under 5. While the Community-based Management of Acute Malnutrition (CMAM) approach, recommended for treating cases of uncomplicated SAM, has increased treatment coverage and recovery outcomes, high relapse rates have been reported. Several risk factors for SAM relapse, such as insufficient food intake and high infectious disease burden in the community, have been identified. However, the role of household water, sanitation and hygiene (WASH) conditions remains unclear. This systematic review: (1) assesses the effectiveness of WASH interventions on preventing SAM relapse and (2) identifies WASH-related conditions associated with relapse to SAM among children aged 6-59 months discharged as recovered following SAM CMAM treatment. We performed electronic searches of six databases to identify relevant studies published between 1 January 2000 and 6 November 2023 and assessed their quality. After deduplication, 10,294 documents were screened by title and abstract, with 13 retrieved for full-text screening. We included three studies ranging from low- to medium-quality. One intervention study found that providing a WASH kit during SAM outpatient treatment did not reduce the risk of relapse to SAM. Two observational studies found inconsistent associations between household WASH conditions-unimproved sanitation and unsafe drinking water-and SAM relapse. Despite the paucity of evidence, the hypothesised causal pathways between WASH conditions and the risk of relapse remain plausible. Further evidence is needed to identify interventions for an integrated postdischarge approach to prevent relapse.
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Affiliation(s)
- Clara MacLeod
- Department of Disease ControlLondon School of Hygiene and Tropical MedicineLondonUnited Kingdom
| | | | | | - Laura Braun
- Department of Disease ControlLondon School of Hygiene and Tropical MedicineLondonUnited Kingdom
| | - Oliver Cumming
- Department of Disease ControlLondon School of Hygiene and Tropical MedicineLondonUnited Kingdom
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12
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Choudhary N, Brewis A, Schuster RC, Wutich A. Beyond WASH: Testing Additional Connections Between Household Water Insecurity and Child Nutrition Outcomes in Multi-Country Contexts. Ecol Food Nutr 2024; 63:435-468. [PMID: 38889358 DOI: 10.1080/03670244.2024.2366913] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/20/2024]
Abstract
This study identifies multiple pathways connecting household water insecurity with child nutrition. Using nationally representative samples for 18 countries, we examine the mediating role of child's dietary diversity as a function of household water status, while also accounting for sanitation. We construct a latent household water insecurity score (HWI) and use Structural Equation approach to model underlying pathways. HWI affected child's HAZ score and hemoglobin both directly and indirectly, with a mediation from child feeding alongside effects from sanitation. Broadening the conception of household water insecurity and accommodating the indirect effects of water could improve explanations of child under-nutrition.
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Affiliation(s)
- Neetu Choudhary
- School of Human Evolution and Social Change, Arizona State University, Tempe
| | - Alexandra Brewis
- School of Human Evolution and Social Change, Arizona State University, Tempe
| | - Roseanne C Schuster
- School of Human Evolution and Social Change, Arizona State University, Tempe
| | - Amber Wutich
- School of Human Evolution and Social Change, Arizona State University, Tempe
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13
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Girma M, Hussein A, Norris T, Genye T, Tessema M, Bossuyt A, Hadis M, van Zyl C, Goyol K, Samuel A. Progress in Water, Sanitation and Hygiene (WASH) coverage and potential contribution to the decline in diarrhea and stunting in Ethiopia. MATERNAL & CHILD NUTRITION 2024; 20 Suppl 5:e13280. [PMID: 34738323 PMCID: PMC11258769 DOI: 10.1111/mcn.13280] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/23/2021] [Revised: 08/23/2021] [Accepted: 09/16/2021] [Indexed: 12/20/2022]
Abstract
Inadequate safe water supply and poor sanitation and hygiene continue to be important risk factors for diarrhoea and stunting globally. We used data from the four rounds of the Ethiopian Demographic and Health Survey and applied the new World Health Organization (WHO)/UNICEF Joint Monitoring Program (JMP) service standards to assess progress in water, sanitation and hygiene (WASH) coverage between 2000 and 2016. We also performed an age-disaggregated pooled linear probability regression analysis followed by a decomposition analysis to determine whether changes in WASH practices have contributed to the changing prevalence of diarrhoea and stunting in children under 5 years of age. We observed a significant increase in the coverage of safe drinking water and adequate sanitation facilities over the period. At the national level, the use of a basic water source increased from 18% in 2000 to 50% in 2016. Open defecation declined from 82% to 32% over the same period. However, in 2016, only 6% of households had access to a basic sanitation facility, and 40% of households had no handwashing facilities. The reduction in surface water use between 2000 and 2016 explained 6% of the decline in diarrhoea observed among children aged 0-5 months. In children aged 6-59 months, between 7% and 9% of the reduction in stunting were attributable to the reduction in open defecation over this period. Despite progress, improvements are still needed to increase basic WASH coverage in Ethiopia. Our findings showed that improvements in water and sanitation only modestly explained reductions in diarrhoea and stunting.
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Affiliation(s)
- Meron Girma
- National Information Platforms for Nutrition (NIPN)Ethiopian Public Health InstituteArbegnoch StreetAddis Ababa1242Ethiopia
| | - Alemayehu Hussein
- National Information Platforms for Nutrition (NIPN)Ethiopian Public Health InstituteArbegnoch StreetAddis Ababa1242Ethiopia
| | - Tom Norris
- National Information Platforms for Nutrition (NIPN) CollaboratorInternational Food Policy Research InstituteAddis AbabaEthiopia
| | - Tirsit Genye
- National Information Platforms for Nutrition (NIPN)International Food Policy Research InstituteAddis AbabaEthiopia
| | - Masresha Tessema
- National Information Platforms for Nutrition (NIPN)Ethiopian Public Health InstituteArbegnoch StreetAddis Ababa1242Ethiopia
| | - Anne Bossuyt
- National Information Platforms for Nutrition (NIPN)International Food Policy Research InstituteAddis AbabaEthiopia
| | - Mamuye Hadis
- Knowledge Translation DirectorateEthiopian Public Health InstituteAddis AbabaEthiopia
| | - Cornelia van Zyl
- National Information Platforms for Nutrition (NIPN)International Food Policy Research InstituteAddis AbabaEthiopia
| | - Kitka Goyol
- Water, Sanitation and Hygiene (WASH)UNICEFAddis AbabaEthiopia
| | - Aregash Samuel
- National Information Platforms for Nutrition (NIPN)Ethiopian Public Health InstituteArbegnoch StreetAddis Ababa1242Ethiopia
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14
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Swarthout J, Mureithi M, Mboya J, Arnold BF, Wolfe MK, Dentz HN, Lin A, Arnold CD, Rao G, Stewart CP, Clasen T, Colford JM, Null C, Pickering AJ. Addressing Fecal Contamination in Rural Kenyan Households: The Roles of Environmental Interventions and Animal Ownership. ENVIRONMENTAL SCIENCE & TECHNOLOGY 2024; 58:9500-9514. [PMID: 38760010 PMCID: PMC11155254 DOI: 10.1021/acs.est.3c09419] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/11/2023] [Revised: 04/17/2024] [Accepted: 04/18/2024] [Indexed: 05/19/2024]
Abstract
Combined water, sanitation, and handwashing (WSH) interventions could reduce fecal contamination along more transmission pathways than single interventions alone. We measured Escherichia coli levels in 3909 drinking water samples, 2691 child hand rinses, and 2422 toy ball rinses collected from households enrolled in a 2-year cluster-randomized controlled trial evaluating single and combined WSH interventions. Water treatment with chlorine reduced E. coli in drinking water. A combined WSH intervention improved water quality by the same magnitude but did not affect E. coli levels on hands or toys. One potential explanation for the limited impact of the sanitation intervention (upgraded latrines) is failure to address dog and livestock fecal contamination. Small ruminant (goat or sheep) ownership was associated with increased E. coli levels in stored water and on child hands. Cattle and poultry ownership was protective against child stunting, and domesticated animal ownership was not associated with child diarrhea. Our findings do not support restricting household animal ownership to prevent child diarrheal disease or stunting but do support calls for WSH infrastructure that can more effectively reduce household fecal contamination.
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Affiliation(s)
- Jenna
M. Swarthout
- Department
of Civil and Environmental Engineering, Tufts University, Medford, Massachusetts 02155, United States
| | | | - John Mboya
- Innovations
for Poverty Action, Nairobi 00200, Kenya
- Department
of Civil and Environmental Engineering, University of California, Berkeley, Berkeley, California 94720, United States
| | - Benjamin F. Arnold
- Francis
I. Proctor Foundation, Department of Ophthalmology and Institute for
Global Health Sciences, University of California,
San Francisco, San Francisco, California 94158, United States
| | - Marlene K. Wolfe
- Gangarosa
Department of Environmental Health, Emory
University, Atlanta, Georgia 30322, United States
| | - Holly N. Dentz
- Institute
for Global Nutrition, University of California,
Davis, Davis, California 95616, United States
| | - Audrie Lin
- Department
of Microbiology and Environmental Toxicology, University of California, Santa Cruz, Santa Cruz, California 95064, United States
| | - Charles D. Arnold
- Institute
for Global Nutrition, University of California,
Davis, Davis, California 95616, United States
| | - Gouthami Rao
- Department
of Environmental Sciences and Engineering, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina 27599, United States
| | - Christine P. Stewart
- Institute
for Global Nutrition, University of California,
Davis, Davis, California 95616, United States
| | - Thomas Clasen
- Gangarosa
Department of Environmental Health, Emory
University, Atlanta, Georgia 30322, United States
| | - John M. Colford
- School
of Public Health, Division of Epidemiology, University of California, Berkeley, Berkeley, California 94720, United States
| | - Clair Null
- Mathematica, Washington, District of
Columbia 20002, United States
| | - Amy J. Pickering
- Department
of Civil and Environmental Engineering, Tufts University, Medford, Massachusetts 02155, United States
- Department
of Civil and Environmental Engineering, University of California, Berkeley, Berkeley, California 94720, United States
- Chan
Zuckerberg Biohub San Francisco, San Francisco, California 94158, United States
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15
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Laauwen M, Nowicki S. Reinforcing Feedbacks for Sustainable Implementation of Rural Drinking-Water Treatment Technology. ACS ES&T WATER 2024; 4:1763-1774. [PMID: 38633363 PMCID: PMC11019543 DOI: 10.1021/acsestwater.3c00779] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 12/04/2023] [Revised: 02/09/2024] [Accepted: 03/06/2024] [Indexed: 04/19/2024]
Abstract
Progress toward universal access to safe drinking water depends on rural water service delivery models that incorporate water safety management. Water supplies of all types have high rates of fecal contamination unless water safety risks are actively managed through water source protection, treatment, distribution, and storage. Recognizing the role of treatment within this broader risk-based framework, this study focuses on the implementation of passive chlorination and ultraviolet (UV) disinfection technologies in rural settings. These technologies can reduce the health risk from microbiological contaminants in drinking water; however, technology-focused treatment interventions have had limited sustainability in rural settings. This study examines the requirements for sustainable implementation of rural water treatment through qualitative content analysis of 26 key informant interviews, representing passive chlorination and UV disinfection projects in rural areas in South America, Africa, and Asia. The analysis is aligned with the RE-AIM framework and delivers insight into 18 principal enablers and barriers to rural water treatment sustainability. Analysis of the interrelationships among these factors identifies leverage points and encourages fit-for-purpose intervention design reinforced by collaboration between facilitating actors through hybrid service delivery models. Further work should prioritize health impact evidence, water quality reporting guidance, and technological capabilities that optimize trade-offs in fit-for-purpose treatment design.
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Affiliation(s)
- Merel Laauwen
- School
of Geography and the Environment, University
of Oxford, South Parks Road, Oxford OX1 3QY, U.K.
| | - Saskia Nowicki
- School
of Geography and the Environment, University
of Oxford, South Parks Road, Oxford OX1 3QY, U.K.
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16
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Serrano Matos YA, Cano J, Shafiq H, Williams C, Sunny J, Cowardin CA. Colonization during a key developmental window reveals microbiota-dependent shifts in growth and immunity during undernutrition. MICROBIOME 2024; 12:71. [PMID: 38589975 PMCID: PMC11003143 DOI: 10.1186/s40168-024-01783-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/20/2023] [Accepted: 02/28/2024] [Indexed: 04/10/2024]
Abstract
BACKGROUND Childhood undernutrition is a major global health challenge with devastating lifelong consequences. Linear growth stunting due to undernutrition has been linked to poor health outcomes, and mothers who experience growth stunting in childhood are more likely to give birth to stunted children later in life. Based on these findings, we hypothesized that intergenerational colonization of mice with microbiota from human donors with undernutrition may recapitulate certain immune and growth changes observed in this disorder. RESULTS To test this hypothesis, we developed a gnotobiotic murine model of undernutrition using microbiota from human infants with healthy or stunted growth trajectories. Intergenerational colonization with microbiota derived from children with growth stunting lead to less linear growth and the development of immune features of undernutrition and enteropathy, including intestinal villus blunting, lower liver IGF-1 and accumulation of intraepithelial lymphocytes and plasma cells in the small intestine. In contrast, colonization after weaning lead to fewer host phenotypic changes between these distinct microbial communities. CONCLUSIONS These results are broadly consistent with previous findings demonstrating that exposure of the immune system to microbial products during the weaning phase is a critical determinant of later life immune function. Overall, our results suggest intergenerational colonization with human microbiota samples is a useful approach with which to investigate microbiota-dependent changes in growth and immunity in early life. Murine models that capture the intergenerational and multifactorial nature of undernutrition are critical to understanding the underlying biology of this disorder. Video Abstract.
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Affiliation(s)
- Yadeliz A Serrano Matos
- Division of Pediatric Gastroenterology & Hepatology, Department of Pediatrics, University of Virginia School of Medicine, Charlottesville, VA, 22908, USA
- Department of Microbiology, Immunology and Cancer Biology, University of Virginia School of Medicine, Charlottesville, VA, 22908, USA
| | - Jasmine Cano
- Division of Pediatric Gastroenterology & Hepatology, Department of Pediatrics, University of Virginia School of Medicine, Charlottesville, VA, 22908, USA
| | - Hamna Shafiq
- Division of Pediatric Gastroenterology & Hepatology, Department of Pediatrics, University of Virginia School of Medicine, Charlottesville, VA, 22908, USA
| | - Claire Williams
- Division of Pediatric Gastroenterology & Hepatology, Department of Pediatrics, University of Virginia School of Medicine, Charlottesville, VA, 22908, USA
- Department of Microbiology, Immunology and Cancer Biology, University of Virginia School of Medicine, Charlottesville, VA, 22908, USA
| | - Julee Sunny
- Division of Pediatric Gastroenterology & Hepatology, Department of Pediatrics, University of Virginia School of Medicine, Charlottesville, VA, 22908, USA
| | - Carrie A Cowardin
- Division of Pediatric Gastroenterology & Hepatology, Department of Pediatrics, University of Virginia School of Medicine, Charlottesville, VA, 22908, USA.
- Department of Microbiology, Immunology and Cancer Biology, University of Virginia School of Medicine, Charlottesville, VA, 22908, USA.
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17
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Addae HY, Sulemana M, Yakubu T, Atosona A, Tahiru R, Azupogo F. Low birth weight, household socio-economic status, water and sanitation are associated with stunting and wasting among children aged 6-23 months: Results from a national survey in Ghana. PLoS One 2024; 19:e0297698. [PMID: 38547113 PMCID: PMC10977686 DOI: 10.1371/journal.pone.0297698] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2023] [Accepted: 01/11/2024] [Indexed: 04/02/2024] Open
Abstract
BACKGROUND Stunting and wasting are key public health problems in Ghana that are significantly linked with mortality and morbidity risk among children. However, information on their associated factors using nationally representative data is scanty in Ghana. This study investigated the influence of Infant and Young Child Feeding (IYCF) indicators, socio-demographic and economic related factors, and water and sanitation on stunting and wasting, using nationally representative data in Ghana. METHODS This is a secondary data analysis of the most recent (2017/2018) Ghana Multi-Indicator Cluster Survey (MICS) datasets. The multi-indicator cluster survey is a national cross-sectional household survey with rich data on women of reproductive age and children under the age of five. The survey used a two-stage sampling method in the selection of respondents and a computer-assisted personal interviewing technique to administer structured questionnaires from October 2017 to January 2018. The present study involved 2529 mother-child pairs, with their children aged 6 to 23 months. We used the Complex Sample procedures in SPSS, adjusting for clustering and stratification effects. In a bivariate logistic regression, variables with P-values ≤ 0.05 were included in a backward multivariate logistic regression to identify the significant factors associated with stunting and wasting. RESULTS The mean age of children was 14.32 ± 0.14 months, with slightly more being males (50.4%). About 12% and 16% of the children were wasted and stunted, respectively. There were 39.4%, 25.9%, and 13.7% of children who, respectively, satisfied the minimum meal frequency (MMF), minimum dietary diversity (MDD), and minimum acceptable diet (MAD). None of the IYCF indicators was significantly associated with stunting or wasting in the multivariate analysis but low socio-economic status, low birth weight, being a male child and unimproved toilet facilities were significantly associated with both wasting and stunting. CONCLUSION Our findings suggest that aside from the pre-natal period, in certain contexts, household factors such as low socio-economic status and poor water and sanitation, may be stronger predictors of undernutrition. A combination of nutrition-specific and nutrition-sensitive interventions including the pre-natal period to simultaneously address the multiple determinants of undernutrition need strengthening.
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Affiliation(s)
- Hammond Yaw Addae
- Nursing & Midwifery Training College, Kpembe, Salaga, Ghana
- Department of Biochemistry and Biotechnology, College of Science, Kwame Nkrumah University of Science and Technology, Kumasi, Ghana
| | | | - Taminu Yakubu
- Department of Biochemistry and Biotechnology, College of Science, Kwame Nkrumah University of Science and Technology, Kumasi, Ghana
- Department of Nutrition & Dietetics, Tamale Technical University, Tamale, Ghana
| | - Ambrose Atosona
- Department of Biochemistry and Biotechnology, College of Science, Kwame Nkrumah University of Science and Technology, Kumasi, Ghana
- Department of Nutritional Sciences, School of Allied Health Sciences, University for Development Studies, Tamale, Ghana
| | - Rafatu Tahiru
- Department of Biochemistry and Biotechnology, College of Science, Kwame Nkrumah University of Science and Technology, Kumasi, Ghana
- Community Health Nurse Training College, Tamale, Ghana
| | - Fusta Azupogo
- Faculty of Agriculture, Food and Consumer Sciences, Department of Family and Consumer Sciences, University for Development Studies, Tamale, Ghana
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18
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Butzin-Dozier Z, Ji Y, Coyle J, Malenica I, McQuade ETR, Grembi JA, Platts-Mills JA, Houpt ER, Graham JP, Ali S, Rahman MZ, Alauddin M, Famida SL, Akther S, Hossen MS, Mutsuddi P, Shoab AK, Rahman M, Islam MO, Miah R, Taniuchi M, Liu J, Alauddin S, Stewart CP, Luby SP, Colford JM, Hubbard AE, Mertens AN, Lin A. Treatment Heterogeneity of Water, Sanitation, Hygiene, and Nutrition Interventions on Child Growth by Environmental Enteric Dysfunction and Pathogen Status for Young Children in Bangladesh. MEDRXIV : THE PREPRINT SERVER FOR HEALTH SCIENCES 2024:2024.03.21.24304684. [PMID: 38585931 PMCID: PMC10996736 DOI: 10.1101/2024.03.21.24304684] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 04/09/2024]
Abstract
Background Water, sanitation, hygiene (WSH), nutrition (N), and combined (N+WSH) interventions are often implemented by global health organizations, but WSH interventions may insufficiently reduce pathogen exposure, and nutrition interventions may be modified by environmental enteric dysfunction (EED), a condition of increased intestinal permeability and inflammation. This study investigated the heterogeneity of these treatments' effects based on individual pathogen and EED biomarker status with respect to child linear growth. Methods We applied cross-validated targeted maximum likelihood estimation and super learner ensemble machine learning to assess the conditional treatment effects in subgroups defined by biomarker and pathogen status. We analyzed treatment (N+WSH, WSH, N, or control) randomly assigned in-utero, child pathogen and EED data at 14 months of age, and child LAZ at 28 months of age. We estimated the difference in mean child length for age Z-score (LAZ) under the treatment rule and the difference in stratified treatment effect (treatment effect difference) comparing children with high versus low pathogen/biomarker status while controlling for baseline covariates. Results We analyzed data from 1,522 children, who had median LAZ of -1.56. We found that myeloperoxidase (N+WSH treatment effect difference 0.0007 LAZ, WSH treatment effect difference 0.1032 LAZ, N treatment effect difference 0.0037 LAZ) and Campylobacter infection (N+WSH treatment effect difference 0.0011 LAZ, WSH difference 0.0119 LAZ, N difference 0.0255 LAZ) were associated with greater effect of all interventions on growth. In other words, children with high myeloperoxidase or Campylobacter infection experienced a greater impact of the interventions on growth. We found that a treatment rule that assigned the N+WSH (LAZ difference 0.23, 95% CI (0.05, 0.41)) and WSH (LAZ difference 0.17, 95% CI (0.04, 0.30)) interventions based on EED biomarkers and pathogens increased predicted child growth compared to the randomly allocated intervention. Conclusions These findings indicate that EED biomarker and pathogen status, particularly Campylobacter and myeloperoxidase (a measure of gut inflammation), may be related to impact of N+WSH, WSH, and N interventions on child linear growth.
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Affiliation(s)
| | - Yunwen Ji
- School of Public Health, University of California, Berkeley, Berkeley, CA USA
| | - Jeremy Coyle
- School of Public Health, University of California, Berkeley, Berkeley, CA USA
| | - Ivana Malenica
- School of Public Health, University of California, Berkeley, Berkeley, CA USA
| | | | - Jessica Anne Grembi
- Division of Infectious Diseases and Geographic Medicine, Stanford University, Stanford, CA USA
| | | | - Eric R. Houpt
- School of Medicine, University of Virginia, Charlottesville, VA, USA
| | - Jay P. Graham
- School of Public Health, University of California, Berkeley, Berkeley, CA USA
| | - Shahjahan Ali
- International Centre for Diarrhoeal Disease Research, Bangladesh, Dhaka, Bangladesh
| | - Md Ziaur Rahman
- International Centre for Diarrhoeal Disease Research, Bangladesh, Dhaka, Bangladesh
| | - Mohammad Alauddin
- International Centre for Diarrhoeal Disease Research, Bangladesh, Dhaka, Bangladesh
| | - Syeda L. Famida
- International Centre for Diarrhoeal Disease Research, Bangladesh, Dhaka, Bangladesh
| | - Salma Akther
- International Centre for Diarrhoeal Disease Research, Bangladesh, Dhaka, Bangladesh
| | - Md. Saheen Hossen
- International Centre for Diarrhoeal Disease Research, Bangladesh, Dhaka, Bangladesh
| | - Palash Mutsuddi
- International Centre for Diarrhoeal Disease Research, Bangladesh, Dhaka, Bangladesh
| | - Abul K. Shoab
- International Centre for Diarrhoeal Disease Research, Bangladesh, Dhaka, Bangladesh
| | - Mahbubur Rahman
- International Centre for Diarrhoeal Disease Research, Bangladesh, Dhaka, Bangladesh
| | - Md. Ohedul Islam
- International Centre for Diarrhoeal Disease Research, Bangladesh, Dhaka, Bangladesh
| | - Rana Miah
- International Centre for Diarrhoeal Disease Research, Bangladesh, Dhaka, Bangladesh
| | - Mami Taniuchi
- School of Medicine, University of Virginia, Charlottesville, VA, USA
| | - Jie Liu
- School of Public Health, Qingdao University, Qingdao, China
| | | | | | - Stephen P. Luby
- Division of Infectious Diseases and Geographic Medicine, Stanford University, Stanford, CA USA
| | - John M. Colford
- School of Public Health, University of California, Berkeley, Berkeley, CA USA
| | - Alan E. Hubbard
- School of Public Health, University of California, Berkeley, Berkeley, CA USA
| | - Andrew N. Mertens
- School of Public Health, University of California, Berkeley, Berkeley, CA USA
| | - Audrie Lin
- Department of Microbiology and Environmental Toxicology, University of California, Santa Cruz, Santa Cruz, CA USA
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Mertens A, Arnold BF, Benjamin-Chung J, Boehm AB, Brown J, Capone D, Clasen T, Fuhrmeister ER, Grembi JA, Holcomb D, Knee J, Kwong LH, Lin A, Luby SP, Nala R, Nelson K, Njenga SM, Null C, Pickering AJ, Rahman M, Reese HE, Steinbaum L, Stewart JR, Thilakaratne R, Cumming O, Colford JM, Ercumen A. Is detection of enteropathogens and human or animal faecal markers in the environment associated with subsequent child enteric infections and growth: an individual participant data meta-analysis. Lancet Glob Health 2024; 12:e433-e444. [PMID: 38365415 PMCID: PMC10882208 DOI: 10.1016/s2214-109x(23)00563-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/06/2023] [Revised: 11/13/2023] [Accepted: 11/28/2023] [Indexed: 02/18/2024]
Abstract
BACKGROUND Quantifying contributions of environmental faecal contamination to child diarrhoea and growth faltering can illuminate causal mechanisms behind modest health benefits in recent water, sanitation, and hygiene (WASH) trials. We aimed to assess associations between environmental detection of enteropathogens and human or animal microbial source tracking markers (MSTM) and subsequent child health outcomes. METHODS In this individual participant data meta-analysis we searched we searched PubMed, Embase, CAB Direct Global Health, Agricultural and Environmental Science Database, Web of Science, and Scopus for WASH intervention studies with a prospective design and concurrent control that measured enteropathogens or MSTM in environmental samples, or both, and subsequently measured enteric infections, diarrhoea, or height-for-age Z-scores (HAZ) in children younger than 5 years. We excluded studies that only measured faecal indicator bacteria. The initial search was done on Jan 19, 2021, and updated on March 22, 2023. One reviewer (AM) screened abstracts, and two independent reviewers (AM and RT) examined the full texts of short-listed articles. All included studies include at least one author that also contributed as an author to the present Article. Our primary outcomes were the 7-day prevalence of caregiver-reported diarrhoea and HAZ in children. For specific enteropathogens in the environment, primary outcomes also included subsequent child infection with the same pathogen ascertained by stool testing. We estimated associations using covariate-adjusted regressions and pooled estimates across studies. FINDINGS Data from nine published reports from five interventions studies, which included 8603 children (4302 girls and 4301 boys), were included in the meta-analysis. Environmental pathogen detection was associated with increased infection prevalence with the same pathogen and lower HAZ (ΔHAZ -0·09 [95% CI -0·17 to -0·01]) but not diarrhoea (prevalence ratio 1·22 [95% CI 0·95 to 1·58]), except during wet seasons. Detection of MSTM was not associated with diarrhoea (no pooled estimate) or HAZ (ΔHAZ -0·01 [-0·13 to 0·11] for human markers and ΔHAZ -0·02 [-0·24 to 0·21] for animal markers). Soil, children's hands, and stored drinking water were major transmission pathways. INTERPRETATION Our findings support a causal chain from pathogens in the environment to infection to growth faltering, indicating that the lack of WASH intervention effects on child growth might stem from insufficient reductions in environmental pathogen prevalence. Studies measuring enteropathogens in the environment should subsequently measure the same pathogens in stool to further examine theories of change between WASH, faecal contamination, and health. Given that environmental pathogen detection was predictive of infection, programmes targeting specific pathogens (eg, vaccinations and elimination efforts) can environmentally monitor the pathogens of interest for population-level surveillance instead of collecting individual biospecimens. FUNDING The Bill & Melinda Gates Foundation and the UK Foreign and Commonwealth Development Office.
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Affiliation(s)
- Andrew Mertens
- Division of Epidemiology, University of California, Berkeley, CA, USA; Division of Biostatistics, University of California, Berkeley, CA, USA.
| | - Benjamin F Arnold
- Francis I Proctor Foundation and Department of Ophthalmology, University of California, San Francisco, CA, USA
| | - Jade Benjamin-Chung
- Department of Epidemiology and Population Health, Stanford University, Stanford, CA, USA
| | - Alexandria B Boehm
- Department of Civil and Environmental Engineering, Stanford University, Stanford, CA, USA
| | - Joe Brown
- Department of Environmental Science and Engineering, University of North Carolina, Gillings School of Global Public Health, Michael Hooker Research Center, Chapel Hill, NC, USA
| | - Drew Capone
- Department of Environmental and Occupational Health, Indiana University, Bloomington, IN, USA
| | - Thomas Clasen
- Department of Environmental Health, Rollins School of Public Health, Emory University, Atlanta, GA, USA
| | - Erica R Fuhrmeister
- Department of Environmental & Occupational Health Sciences, University of Washington, Seattle, WA, USA
| | | | - David Holcomb
- Department of Environmental Science and Engineering, University of North Carolina, Gillings School of Global Public Health, Michael Hooker Research Center, Chapel Hill, NC, USA
| | - Jackie Knee
- Department of Disease Control, London School of Tropical Medicine & Hygiene, London, UK
| | - Laura H Kwong
- Division of Environmental Health Sciences, University of California, Berkeley, CA, USA
| | - Audrie Lin
- Department of Microbiology and Environmental Toxicology, University of California, Santa Cruz, CA, USA
| | - Stephen P Luby
- Division of Infectious Diseases and Geographic Medicine, Stanford University, Stanford, CA, USA
| | - Rassul Nala
- Ministério da Saúde, Instituto Nacional de Saúde Maputo, Maputo, Mozambique
| | - Kara Nelson
- Department of Civil and Environmental Engineering, College of Engineering, University of California, Berkeley, CA, USA
| | | | | | - Amy J Pickering
- Department of Civil and Environmental Engineering, College of Engineering, University of California, Berkeley, CA, USA
| | - Mahbubur Rahman
- Environmental Interventions Unit, Infectious Diseases Division, Dhaka, Bangladesh
| | - Heather E Reese
- Department of Environmental Health, Rollins School of Public Health, Emory University, Atlanta, GA, USA
| | - Lauren Steinbaum
- California Department of Toxic Substances Control, Sacramento, CA, USA
| | - Jill R Stewart
- Department of Environmental Science and Engineering, University of North Carolina, Gillings School of Global Public Health, Michael Hooker Research Center, Chapel Hill, NC, USA
| | | | - Oliver Cumming
- Department of Disease Control, London School of Tropical Medicine & Hygiene, London, UK
| | - John M Colford
- Division of Epidemiology, University of California, Berkeley, CA, USA
| | - Ayse Ercumen
- Department of Forestry and Environmental Resources, North Carolina State University, Raleigh, NC, USA
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20
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Chen D, Havelaar AH, Platts-Mills JA, Yang Y. Acquisition and clearance dynamics of Campylobacter spp. in children in low- and middle-income countries. Epidemics 2024; 46:100749. [PMID: 38367286 PMCID: PMC10944168 DOI: 10.1016/j.epidem.2024.100749] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/28/2023] [Revised: 11/08/2023] [Accepted: 02/06/2024] [Indexed: 02/19/2024] Open
Abstract
The prevalence of Campylobacter infection is generally high among children in low- and middle-income countries (LMIC), but the dynamics of its acquisition and clearance are understudied. We aim to quantify this process among children under two years old in eight LMIC using a statistical modeling approach, leveraging enzyme-immunoassay-based Campylobacter genus data and quantitative-PCR-based Campylobacter jejuni/coli data from the MAL-ED study. We developed a Markov model to compare the dynamics of acquisition and clearance of Campylobacter across countries and to explore the effect of antibiotic usage on Campylobacter clearance. Clearance rates were generally higher than acquisition rates, but their magnitude and temporal pattern varied across countries. For C. jejuni/coli, clearance was faster than acquisition throughout the two years at all sites. For Campylobacter spp., the acquisition rate either exceeded or stayed very close to the clearance rate after the first half year in Bangladesh, Pakistan and Tanzania, leading to high prevalence. Bangladesh had the shortest (28 and 57 days) while Brazil had the longest (328 and 306 days) mean times from last clearance to acquisition for Campylobacter spp. and C. jejuni/coli, respectively. South Africa had the shortest (10 and 8 days) while Tanzania had the longest (53 and 41 days) mean times to clearance for Campylobacter spp. and C. jejuni/col, respectively. The use of Macrolide accelerated clearance of C. jejuni/coli in Bangladesh and Peru and of Campylobacter spp. in Bangladesh and Pakistan. Fluoroquinolone showed statistically meaningful effects only in Bangladesh but for both Campylobacter groups. Higher prevalence of Campylobacter infection was mainly driven by a high acquisition rate that was close to or surpassing the clearance rate. Acquisition rate usually peaked in 11-17 months of age, indicating the importance of targeting the first year of life for effective interventions to reduce exposures.
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Affiliation(s)
- Dehao Chen
- Department of Environmental and Global Health, College of Public Health and Health Professions, University of Florida, Gainesville, FL, USA; Emerging Pathogens Institute, University of Florida, Gainesville, FL, USA; Department of Epidemiology, Emory University, Atlanta, GA, USA
| | - Arie H Havelaar
- Emerging Pathogens Institute, University of Florida, Gainesville, FL, USA; Department of Animal Sciences, Institute of Food and Agricultural Sciences, University of Florida, Gainesville, FL, USA; Global Food Systems Institute, University of Florida, Gainesville, FL, USA
| | - James A Platts-Mills
- Division of Infectious Diseases and International Health, University of Virginia Health System, Charlottesville, VA, USA
| | - Yang Yang
- Department of Statistics, Franklin College of Arts and Sciences, University of Georgia, Athens, GA, USA.
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21
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Dominguez-Salas P, Waddington HS, Grace D, Bosire C, Moodley A, Kulkarni B, Dasi T, Banjara SK, Kumar RN, Fahmida U, Htet MK, Sudibya ARP, Faye B, Tine RC, Heffernan C, Saxena D, Dreibelbis R, Häsler B. Understanding the role of household hygiene practices and foodborne disease risks in child stunting: a UKRI GCRF Action Against Stunting Hub protocol paper. BMJ Paediatr Open 2024; 8:e001695. [PMID: 38417924 PMCID: PMC10900323 DOI: 10.1136/bmjpo-2022-001695] [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: 10/04/2022] [Accepted: 03/20/2023] [Indexed: 03/01/2024] Open
Abstract
INTRODUCTION Environmental hygiene and food safety are important determinants of child stunting. This research aims to explore the relationship between child stunting and household hygiene practices and behaviours, including the availability of water, sanitation and hygiene (WASH) facilities; the use of safe food and good quality drinking water (especially when used for complementary feeding); hygienic practices in food transport, storage and preparation and the control of cross-contamination from animals, their produce and waste. METHODS AND ANALYSIS This study is part of a wider observational study which aims to investigate the interdisciplinary factors contributing to child stunting using a 'whole child' paradigm. The observational study recruits women during pregnancy in Hyderabad, India, Lombok, Indonesia and Kaffrine, Senegal, and dyads (ie, 500 mother-infant pairs per country) are followed longitudinally up to 24 months after birth. Within the interdisciplinary niche, the study here has developed tools to investigate the potential exposure pathways to environmental pathogen contamination of foods and water. Holistic WASH and food safety data collection tools have been developed to explore exposure pathways at the household level, including: (1) survey questionnaires; (2) spot-checks; (3) biological sampling of drinking water, food and domestic surfaces and (4) direct observation. An integrated analytical approach will be used to triangulate the evidence in order to examine the relationships between child stunting, WASH and food safety behaviours. ETHICS AND DISSEMINATION Ethical approval of the study was granted by the ethics committee of the LSHTM, RVC, ILRI, ICMR, IIPHG, SEAMEO-RECFON, University of Cheikh Anta Diop. Findings of the study will be disseminated through publication in peer-reviewed journals, relevant international conferences, public engagement events, and policy-maker and stakeholder events.
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Affiliation(s)
- Paula Dominguez-Salas
- National Resources Institute, University of Greenwich, London, UK
- Policies, Institutions and Livelihoods Programme, International Livestock Research Institute (ILRI), Nairobi, Kenya, Nairobi, Kenya
| | - Hugh Sharma Waddington
- Department of Disease Control, London School of Hygiene and Tropical Medicine, London, UK
| | - Delia Grace
- National Resources Institute, University of Greenwich, London, UK
- Animal and Human Health Programme, International Livestock Research Institute (ILRI), Nairobi, Kenya
| | - Caroline Bosire
- Animal and Human Health Programme, International Livestock Research Institute (ILRI), Nairobi, Kenya
| | - Arshnee Moodley
- CGIAR Antimicrobial Resistance Hub, International Livestock Research Institute (ILRI), Nairobi, Kenya
| | - Bharati Kulkarni
- National Institute of Nutrition, Indian Council of Medical Research, Hyderabad, Telangana, India
| | - Teena Dasi
- National Institute of Nutrition, Indian Council of Medical Research, Hyderabad, Telangana, India
| | | | | | - Umi Fahmida
- Southeast Asian Ministry of Education Organisation Regional Centre for Food and Nutrition (SEAMEO RECFON), East Jakarta, Indonesia
| | - Min Kyaw Htet
- Southeast Asian Ministry of Education Organisation Regional Centre for Food and Nutrition (SEAMEO RECFON), East Jakarta, Indonesia
| | - Arienta R P Sudibya
- Southeast Asian Ministry of Education Organisation Regional Centre for Food and Nutrition (SEAMEO RECFON), East Jakarta, Indonesia
| | - Babacar Faye
- Department of Parasitology, Université Cheikh Anta Diop (UCAD), Dakar, Senegal
| | - Roger C Tine
- Department of Parasitology-Mycology, University of Cheikh Anta DIOP, Dakar, Senegal
| | - Claire Heffernan
- Department of Pathobiology and Population Sciences, University of London, London, UK
- London International Development Centre, London, UK
| | - Deepak Saxena
- Public Health Foundation, Indian Institute of Public Health Gandhinagar (IIPHG), New Delhi, Delhi, India
| | - Robert Dreibelbis
- Department of Disease Control, London School of Hygiene and Tropical Medicine, London, UK
| | - B Häsler
- Department of Pathobiology and Population Sciences, Royal Veterinary College (RVC), Hatfield, UK
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22
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Ante-Testard PA, Rerolle F, Nguyen AT, Ashraf S, Parvez SM, Naser AM, Benmarhnia T, Rahman M, Luby SP, Benjamin-Chung J, Arnold BF. WASH interventions and child diarrhea at the interface of climate and socioeconomic position in Bangladesh. Nat Commun 2024; 15:1556. [PMID: 38378704 PMCID: PMC10879131 DOI: 10.1038/s41467-024-45624-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/09/2023] [Accepted: 01/30/2024] [Indexed: 02/22/2024] Open
Abstract
Many diarrhea-causing pathogens are climate-sensitive, and populations with the lowest socioeconomic position (SEP) are often most vulnerable to climate-related transmission. Household Water, Sanitation, and Handwashing (WASH) interventions constitute one potential effective strategy to reduce child diarrhea, especially among low-income households. Capitalizing on a cluster randomized trial population (360 clusters, 4941 children with 8440 measurements) in rural Bangladesh, one of the world's most climate-sensitive regions, we show that improved WASH substantially reduces diarrhea risk with largest benefits among children with lowest SEP and during the monsoon season. We extrapolated trial results to rural Bangladesh regions using high-resolution geospatial layers to identify areas most likely to benefit. Scaling up a similar intervention could prevent an estimated 734 (95% CI 385, 1085) cases per 1000 children per month during the seasonal monsoon, with marked regional heterogeneities. Here, we show how to extend large-scale trials to inform WASH strategies among climate-sensitive and low-income populations.
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Affiliation(s)
- Pearl Anne Ante-Testard
- Francis I. Proctor Foundation and Department of Ophthalmology, University of California, San Francisco, San Francisco, CA, USA.
| | - Francois Rerolle
- Francis I. Proctor Foundation and Department of Ophthalmology, University of California, San Francisco, San Francisco, CA, USA
- Scripps Institution of Oceanography, University of California, San Diego, San Diego, CA, USA
| | - Anna T Nguyen
- Department of Epidemiology and Population Health, Stanford University, Stanford, CA, USA
| | - Sania Ashraf
- Environmental Health and WASH, Health System and Population Studies Division, icddr,b, Dhaka, 1212, Bangladesh
| | - Sarker Masud Parvez
- Environmental Health and WASH, Health System and Population Studies Division, icddr,b, Dhaka, 1212, Bangladesh
- Child Health Research Centre, The University of Queensland, South Brisbane, QLD, Australia
| | - Abu Mohammed Naser
- Division of Epidemiology, Biostatistics, and Environmental Health, School of Public Health, University of Memphis, Memphis, TN, USA
| | - Tarik Benmarhnia
- Scripps Institution of Oceanography, University of California, San Diego, San Diego, CA, USA
| | - Mahbubur Rahman
- Environmental Health and WASH, Health System and Population Studies Division, icddr,b, Dhaka, 1212, Bangladesh
| | - Stephen P Luby
- Division of Infectious Diseases and Geographic Medicine, Stanford University, Stanford, CA, USA
| | - Jade Benjamin-Chung
- Department of Epidemiology and Population Health, Stanford University, Stanford, CA, USA
- Chan Zuckerberg Biohub, San Francisco, CA, 94158, USA
| | - Benjamin F Arnold
- Francis I. Proctor Foundation and Department of Ophthalmology, University of California, San Francisco, San Francisco, CA, USA
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23
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Mwangome M, Ngari M, Brals D, Bawhere P, Kabore P, McGrath M, Berkley JA. Stunting in the first year of life: Pathway analysis of a birth cohort. PLOS GLOBAL PUBLIC HEALTH 2024; 4:e0002908. [PMID: 38363746 PMCID: PMC10871522 DOI: 10.1371/journal.pgph.0002908] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/07/2023] [Accepted: 01/20/2024] [Indexed: 02/18/2024]
Abstract
Malnutrition among infants aged below 6 months has been largely overlooked creating gaps in our understanding of factors underlying stunting in early infancy. Recent evidence suggests that pre-natal and early childhood factors may contribute more to driving childhood stunting than previously appreciated. The study was set up to examine pathways including parental and household characteristics, birth size and gestation, and illness in infancy with stunting at birth and months 3, 6 and 12 using an a priori hypothesized framework. It was a secondary analysis of a birth cohort of 1017 infants recruited from four health facilities in Burkina Faso and followed up for one year. Structural equation models (SEM) were generated to explore pathways to stunting at birth and months 3, 6 and 12. The prevalence of being stunted at birth and months 3, 6 and 12 was 7.4%, 23%, 20% and 18% respectively. The fractions of month 12 stunting attributable to being stunted at birth, months 3 and 6 were 11% (95%CI 5.0‒16%), 32% (95%CI 22‒41%) and 40% (95%CI 31‒49%) respectively. In the structural equation model, male sex and maternal characteristics had direct effects on stunting at birth and at 3 months, but not subsequently. Premature birth, twin birth and being stunted at a previous time point were directly associated with stunting at months 3, 6 and 12. Both maternal and paternal characteristics were directly associated with preterm birth. Non-exclusive breastfeeding had borderline positive direct effect on stunting at month 6 but not at month 12. The direct and indirect pathways identified in this study highlight the complex interlinks between child, maternal, paternal and household characteristics. Interventions tackling preterm birth, in utero growth, exclusive breastfeeding and maternal wellbeing may reduce stunting in the first year of life.
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Affiliation(s)
- Martha Mwangome
- KEMRI/Wellcome Trust Research Programme, Kilifi, Kenya
- The Childhood Acute Illness and Nutrition Network, Nairobi, Kenya
| | - Moses Ngari
- KEMRI/Wellcome Trust Research Programme, Kilifi, Kenya
- The Childhood Acute Illness and Nutrition Network, Nairobi, Kenya
| | - Daniella Brals
- The Childhood Acute Illness and Nutrition Network, Nairobi, Kenya
- Amsterdam Centre for Global Child Health, Emma Children’s Hospital, Amsterdam University Medical Centres, Amsterdam, Netherlands
| | - Paluku Bawhere
- School of Public Health, Center of Research in Epidemiology Biostatistics and Clinical Research, Université Libre de Bruxelles, Brussels, Belgium
| | - Patrick Kabore
- Africa Regional office, World Health Organisation, Brazzaville, Republic of Congo
| | - Marie McGrath
- Emergency Nutrition Network (ENN), Kidlington, Oxfordshire, United Kingdom
| | - James A. Berkley
- KEMRI/Wellcome Trust Research Programme, Kilifi, Kenya
- The Childhood Acute Illness and Nutrition Network, Nairobi, Kenya
- Centre for Clinical Vaccinology & Tropical Medicine, University of Oxford, Oxford, United Kingdom
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24
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Salinger AP, Charles I, Francis N, Batagol B, Meo-Sewabu L, Nasir S, Bass A, Habsji H, Malumu L, Marzaman L, Prescott MF, Jane Sawailau M, Syamsu S, Taruc RR, Tela A, Vakarewa I, Wilson A, Sinharoy SS. "People are now working together for a common good": The effect on social capital of participatory design for community-level sanitation infrastructure in urban informal settlements. WORLD DEVELOPMENT 2024; 174:106449. [PMID: 38304853 PMCID: PMC10759637 DOI: 10.1016/j.worlddev.2023.106449] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Accepted: 10/26/2023] [Indexed: 02/03/2024]
Abstract
Communities with higher levels of social capital perform better than communities with lower social capital in community-level water and sanitation interventions and have better health outcomes. Although research recommends bolstering social capital to improve intervention outcomes, few studies provide empirical evidence on the effect of intervention activities on social capital. This study aimed to evaluate the effect of participatory design and community engagement activities on social capital among urban informal settlements in Suva, Fiji and Makassar, Indonesia enrolled in the Revitalizing Informal Settlements and their Environments trial using the Short Adapted Social Capital Assessment Tool. We performed confirmatory factor analyses (CFA) to test tool performance and built structural equation models to assess intervention effect on CFA-informed, sub-scale scores for cognitive and structural social capital. Qualitative in-depth interviews in Fiji and Indonesia and focus group discussions in Fiji provided nuanced understanding of intervention effects on social capital from residents' perspectives. Results confirmed the hypothesized two-factor solution but revealed differences by country and by gender in Indonesia. The intervention appeared positively related to cognitive social capital among men and women in Indonesia and negatively related to cognitive and structural social capital among men and women in Fiji. While effect sizes were small and cluster-adjustment for a small number of settlements yielded non-significant effects, trends were consistent across models and bivariate analyses and were corroborated by qualitative findings. Several contextual factors may explain these results, including timing and duration of intervention activities and influence of COVID-19. Qualitative data suggested that the relationship between participatory design and social capital may be bidirectional, helping to explain why certain settlements appeared to be better equipped to benefit from intervention activities. Practitioners and program designers should carefully consider the social pre-conditions of communities in which they intend to work to optimize program outcomes and avoid unintended consequences.
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Affiliation(s)
| | - Isabel Charles
- Rollins School of Public Health, Emory University, Atlanta, GA, USA
| | - Naomi Francis
- Monash Sustainable Development Institute, Monash University, Melbourne, VIC, Australia
| | - Becky Batagol
- Monash Sustainable Development Institute, Monash University, Melbourne, VIC, Australia
- Faculty of Law, Monash University, Melbourne, VIC, Australia
| | - Litea Meo-Sewabu
- School of Law & Social Sciences, The University of the South Pacific, Suva, Fiji
- School of Social Sciences, Western Sydney University, Pernith, NSW, Australia
| | - Sudirman Nasir
- Faculty of Public Health, Universitas Hasanuddin, Makassar, Indonesia
- Universitas Hasanuddin, Centre of Excellence for Interdisciplinary and Sustainability Sciences, Makassar, Indonesia
| | - Audra Bass
- Rollins School of Public Health, Emory University, Atlanta, GA, USA
| | - Hamdan Habsji
- Monash Sustainable Development Institute, Monash University, Melbourne, VIC, Australia
- Indonesia Team, Revitalizing Informal Settlements and their Environments (RISE), Makassar, Indonesia
| | - Losalini Malumu
- Monash Sustainable Development Institute, Monash University, Melbourne, VIC, Australia
- Live & Learn Environmental Education, Suva, Fiji
| | - Liza Marzaman
- Monash Sustainable Development Institute, Monash University, Melbourne, VIC, Australia
- Indonesia Team, Revitalizing Informal Settlements and their Environments (RISE), Makassar, Indonesia
| | - Michaela F. Prescott
- Monash Art, Design, & Architecture, Monash University, Melbourne, VIC, Australia
| | - Mere Jane Sawailau
- Monash Sustainable Development Institute, Monash University, Melbourne, VIC, Australia
- Live & Learn Environmental Education, Suva, Fiji
| | - Syaidah Syamsu
- Monash Sustainable Development Institute, Monash University, Melbourne, VIC, Australia
- Indonesia Team, Revitalizing Informal Settlements and their Environments (RISE), Makassar, Indonesia
| | - Ruzka R. Taruc
- Monash Sustainable Development Institute, Monash University, Melbourne, VIC, Australia
- Indonesia Team, Revitalizing Informal Settlements and their Environments (RISE), Makassar, Indonesia
| | - Autiko Tela
- Monash Sustainable Development Institute, Monash University, Melbourne, VIC, Australia
- School of Public Health and Primary Care, Fiji National University, Suva, Fiji
| | - Isoa Vakarewa
- Monash Sustainable Development Institute, Monash University, Melbourne, VIC, Australia
- Live & Learn Environmental Education, Suva, Fiji
| | - Alexander Wilson
- Monash Sustainable Development Institute, Monash University, Melbourne, VIC, Australia
- Live & Learn Environmental Education, Suva, Fiji
| | | | - on behalf of the RISE Consortium
- Rollins School of Public Health, Emory University, Atlanta, GA, USA
- Monash Sustainable Development Institute, Monash University, Melbourne, VIC, Australia
- Faculty of Law, Monash University, Melbourne, VIC, Australia
- School of Law & Social Sciences, The University of the South Pacific, Suva, Fiji
- Faculty of Public Health, Universitas Hasanuddin, Makassar, Indonesia
- Universitas Hasanuddin, Centre of Excellence for Interdisciplinary and Sustainability Sciences, Makassar, Indonesia
- Indonesia Team, Revitalizing Informal Settlements and their Environments (RISE), Makassar, Indonesia
- Live & Learn Environmental Education, Suva, Fiji
- Monash Art, Design, & Architecture, Monash University, Melbourne, VIC, Australia
- School of Public Health and Primary Care, Fiji National University, Suva, Fiji
- School of Social Sciences, Western Sydney University, Pernith, NSW, Australia
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25
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Beatty A, Borkum E, Leith W, Null C, Suriastini W. A cluster randomized controlled trial of a community-based initiative to reduce stunting in rural Indonesia. MATERNAL & CHILD NUTRITION 2024; 20:e13593. [PMID: 38041533 PMCID: PMC10750001 DOI: 10.1111/mcn.13593] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/11/2023] [Revised: 09/29/2023] [Accepted: 11/03/2023] [Indexed: 12/03/2023]
Abstract
We evaluate the impacts of a $120 million project in Indonesia conducted between 2014 and 2018 that sought to reduce stunting through a combination of (1) community-driven development grants targeted at health and education outcomes, (2) training for health providers on infant and young child feeding and growth monitoring and (3) training for sanitarians on a local variation of community-led total sanitation. This cluster randomized controlled trial involved 95 treatment and 95 control subdistricts across South Sumatra, West Kalimantan, and Central Kalimantan provinces. Overall, we find no significant impacts on stunting, the study's primary outcome measure (0.5 pp; 95% confidence interval [CI]: -3.0 to 4.1 percentage points [pp]), or other longer-term undernutrition outcomes about 1 year after the end of the project. The project had a modest impact on some secondary, more proximal outcomes related to maternal and child nutrition, including the percentage of mothers consuming the recommended number of iron-folic acid pills during pregnancy (8.7 pp; 95% CI: 4.1-13.3 pp), 0-5-month-olds being exclusively breastfed (8.7 pp; 95% CI: 1.8-15.6 pp) and 6-23-month-olds receiving the number of recommended meals per day (8.5 pp; 95% CI: 3.8-13.2 pp). However, there were no significant impacts on other proximal outcomes like the number of pre-natal and post-natal checkups, child dietary diversity, child vitamin A receipt or the incidence of child diarrhoea. Our findings highlight that successfully implementing an integrated package of interventions to reduce child stunting may be challenging in practice. Project design needs to consider implementation reality along with best practice-for example, by piloting the synchronous implementation of multifaceted interventions or phasing them in more gradually over a longer timeframe.
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26
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Guga G, Houpt ER, Elwood S, Liu J, Kimathi C, Mosha R, Temu M, Maro A, Mujaga B, Swai N, Pholwat S, McQuade ETR, Mduma ER, DeBoer MD, Platts-Mills J. Impact of azithromycin and nitazoxanide on the enteric infections and child growth: Findings from the Early Life Interventions for Childhood Growth and Development in Tanzania (ELICIT) trial. PLoS One 2023; 18:e0294110. [PMID: 38127924 PMCID: PMC10734999 DOI: 10.1371/journal.pone.0294110] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/11/2023] [Accepted: 10/15/2023] [Indexed: 12/23/2023] Open
Abstract
BACKGROUND Early childhood enteric infection with Shigella/EIEC, enteroaggregative E. coli (EAEC), Campylobacter, and Giardia has been associated with reduced child growth, yet a recent randomized trial of antimicrobial therapy to reduce these infections did not improve growth outcomes. To interrogate this discrepancy, we measured the enteric infections from this study. METHODS We leveraged the Early Life Interventions for Childhood Growth and Development in Tanzania (ELICIT) trial, a randomized double-blind placebo-controlled trial of antimicrobial therapy with azithromycin and nitazoxanide provided quarterly to infants from 6 to 15 months of age. We tested 5,479 stool samples at time points across the study for 34 enteropathogens using quantitative PCR. RESULTS There was substantial carriage of enteropathogens in stool. Azithromycin administration led to reductions in Campylobacter jejuni/coli, enteroaggregative E. coli, and Shigella/EIEC (absolute risk difference ranged from -0.06 to 0.24) 2 weeks after treatment however there was no effect after 3 months. There was no difference in Giardia after nitazoxanide administration (ARR 0.03 at the 12 month administration). When examining the effect of azithromycin versus placebo on the subset of children infected with specific pathogens at the time of treatment, a small increase in weight-for-age Z score was seen only in those infected with Campylobacter jejuni/coli (0.10 Z score, 95% CI -0.01-0.20; length-for-age Z score 0.07, 95% CI -0.06-0.20). CONCLUSION The antimicrobial intervention of quarterly azithromycin plus or minus nitazoxanide led to only transient decreases in enteric infections with Shigella/EIEC, enteroaggregative E. coli (EAEC), Campylobacter, and Giardia. There was a trend towards improved growth in children infected with Campylobacter that received quarterly azithromycin.
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Affiliation(s)
| | - Eric R. Houpt
- University of Virginia Division of Infectious Diseases & International Health, Charlottesville, Virginia, United States of America
| | - Sarah Elwood
- University of Virginia Division of Infectious Diseases & International Health, Charlottesville, Virginia, United States of America
| | - Jie Liu
- School of Public Health, Qingdao University, Qingdao, China
| | | | | | - Mariam Temu
- Haydom Global Health Centre, Haydom, Tanzania
| | - Athanasia Maro
- Biotechnology Laboratory, Kilimanjaro Clinical Research Institute, Moshi, Tanzania
| | - Buliga Mujaga
- Biotechnology Laboratory, Kilimanjaro Clinical Research Institute, Moshi, Tanzania
| | - Ndealilia Swai
- Biotechnology Laboratory, Kilimanjaro Clinical Research Institute, Moshi, Tanzania
| | - Suporn Pholwat
- University of Virginia Division of Infectious Diseases & International Health, Charlottesville, Virginia, United States of America
| | - Elizabeth T. R. McQuade
- Department of Epidemiology, Rollins School of Public Health, Emory University, Atlanta, GA, United States of America
| | | | - Mark D. DeBoer
- Department of Pediatrics, University of Virginia, Charlottesville, Virginia, United States of America
| | - James Platts-Mills
- University of Virginia Division of Infectious Diseases & International Health, Charlottesville, Virginia, United States of America
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Anderson DM, Mahamane E, Bauza V, Mahamadou KOB, Tantum L, Salzberg A. Effects of environmental conditions on healthcare worker wellbeing and quality of care: A qualitative study in Niger. PLOS GLOBAL PUBLIC HEALTH 2023; 3:e0002590. [PMID: 38117837 PMCID: PMC10732385 DOI: 10.1371/journal.pgph.0002590] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/03/2023] [Accepted: 11/21/2023] [Indexed: 12/22/2023]
Abstract
Environmental conditions (water, sanitation, hygiene, waste management, cleaning, energy, building design) are important for a safe and functional healthcare environment. Yet their full range of impacts are not well understood. In this study, we assessed the impact of environmental conditions on healthcare workers' wellbeing and quality of care, using qualitative interviews with 81 healthcare workers at 26 small healthcare facilities in rural Niger. We asked participants to report successes and challenges with environmental conditions and their impacts on wellbeing (physical, social, mental, and economic) and quality of care. We found that all environmental conditions contributed to healthcare workers' wellbeing and quality of care. The norm in facilities of our sample was poor environmental conditions, and thus participants primarily reported detrimental effects. We identified previously documented effects on physical health and safety from pathogen exposure, but also several novel effects on healthcare workers' mental and economic wellbeing and on efficiency, timeliness, and patient centeredness of care. Key wellbeing impacts included pathogen exposure for healthcare workers, stress from unsafe and chaotic working environments, staff dissatisfaction and retention challenges, out-of-pocket spending to avoid stockouts, and uncompensated labor. Key quality of care impacts included pathogen exposure for patients, healthcare worker time dedicated to non-medical tasks like water fetching (i.e., reduced efficiency), breakdowns and spoilage of equipment and supplies, and patient satisfaction with cleanliness and privacy. Inefficiency due to time lost and damaged supplies and equipment likely have substantial economic value and warrant greater consideration in research and policy making. Impacts on staff retention and care efficiency also have implications for health systems. We recommend that future research and decision making for policy and practice incorporate more holistic impact measures beyond just healthcare acquired infections and reconsider the substantial contribution that environmental conditions make to the safety of healthcare facilities and strength of health systems.
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Affiliation(s)
- Darcy M. Anderson
- The Water Institute at UNC, Gillings School of Global Public Health, The University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, United States of America
| | - Ezechiel Mahamane
- World Vision Niger, Nouveau Marche, Boulevard de la Liberté BP 12713, Niamey, Niger
| | - Valerie Bauza
- The Water Institute at UNC, Gillings School of Global Public Health, The University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, United States of America
| | | | - Lucy Tantum
- The Water Institute at UNC, Gillings School of Global Public Health, The University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, United States of America
| | - Aaron Salzberg
- The Water Institute at UNC, Gillings School of Global Public Health, The University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, United States of America
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Zyoud SH, Zyoud AH. Water, sanitation, and hygiene global research: evolution, trends, and knowledge structure. ENVIRONMENTAL SCIENCE AND POLLUTION RESEARCH INTERNATIONAL 2023; 30:119532-119548. [PMID: 37968479 DOI: 10.1007/s11356-023-30813-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/28/2023] [Accepted: 10/29/2023] [Indexed: 11/17/2023]
Abstract
Water, sanitation, and hygiene (WASH) services play a crucial role in promoting public and environmental health as well as social and economic development. At the global level, particularly in the developing world, WASH issues continue to present significant challenges. These challenges have been further intensified by factors such as the COVID-19 pandemic, escalating conflicts, climate change, water scarcity, and rising inequality. The scientific community has actively engaged in constructive discussions on these issues, as evidenced by the notable research findings. Therefore, the aim of this study was to comprehensively examine and evaluate global knowledge on WASH. To search for relevant publications, the Scopus database was utilized using specific terms associated with WASH. VOSviewer 1.6.18 software was employed to generate network visualization maps, which assessed collaborative patterns and research trends in the field of WASH. The research output of countries was adjusted considering their gross domestic product (GDP) and population size. The total number of WASH-related publications, including all types of documents, was 1805. By narrowing the search to articles and reviews, the overall global productivity yielded 1589 documents: 1367 (86.0%) original articles and 222 (14.0%) review articles. The USA had the highest number of WASH publications (n = 668; 42.0%), followed by the UK (n = 396; 24.9%), Switzerland (n = 151; 9.5%), and Australia (n = 141; 8.9%). Ethiopia emerged as the leading country in terms of GDP per capita and the number of publications, followed by Uganda, Malawi, India, and Bangladesh. The USA, the UK, and Switzerland exhibited the most extensive collaboration among countries. The main research areas encompassed the role of WASH in sustainable development, the impacts of inadequate access to WASH services on gender equality, children, infants, and the outbreak of COVID-19 and other diseases, as well as the significance of hygiene practices and community and school-based WASH interventions in reducing infections. This study provides a novel analysis of global WASH-related research and highlights the distribution of outcomes across nations. Continued and increased collaboration between developed and developing nations will facilitate the sharing of responsibility for WASH research outcomes and the implementation of effective policies.
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Affiliation(s)
- Shaher H Zyoud
- Department of Building Engineering & Environment, Department of Civil Engineering & Sustainable Structures, Palestine Technical University (Kadoorie), Tulkarem, Palestine.
| | - Ahed H Zyoud
- Department of Chemistry, College of Sciences, An-Najah National University, Nablus, Palestine
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Schmidt S. When WASHing Is Not Enough: Food Hygiene and Chicken Production in Mozambique. ENVIRONMENTAL HEALTH PERSPECTIVES 2023; 131:124002. [PMID: 38153554 PMCID: PMC10754252 DOI: 10.1289/ehp14175] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/17/2023] [Accepted: 11/27/2023] [Indexed: 12/29/2023]
Abstract
From egg to market, contamination of poultry products with Campylobacter and Salmonella increases along the "value chain," suggesting opportunities to reduce infection with these enteropathogens and complement WASH approaches to sanitation.
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Aunger R. What works in sanitation promotion? Health Promot Int 2023; 38:daad162. [PMID: 38055919 DOI: 10.1093/heapro/daad162] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/08/2023] Open
Abstract
Promotion appears to be the least effective but is nevertheless often the only available, means to achieve increased access to sanitation services, especially at scale, in lower-income countries. A cursory examination of the history of past and present approaches to sanitation promotion, including sanitation marketing, community development, community-led total sanitation and public health, shows that they have a variety of features and characteristics which make them distinctive. Unfortunately, rigorous evaluation has not kept pace with this proliferation of approaches, so it is difficult to recommend any one approach over the others, based on empirical performance in a range of circumstances. However, I argue that a 'hybrid' approach which exhibits a number of salient features from all of the previous approaches is likely to be a good bet. I present a recent example of such a hybrid programme which proved to significantly increase the rate of improved sanitation coverage through promotion (without subsidy of any kind) at scale in Tanzania. I suggest other sanitation promotion programs may want to think about adopting similar practices in their own programming going forward.
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Affiliation(s)
- Robert Aunger
- Department for Disease Control, London School of Hygiene & Tropical Medicine, Keppel St., London, UK, WC1E 7HT
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Harris AR, Daly SW, Pickering AJ, Mrisho M, Harris M, Davis J. Safe Today, Unsafe Tomorrow: Tanzanian Households Experience Variability in Drinking Water Quality. ENVIRONMENTAL SCIENCE & TECHNOLOGY 2023; 57:17481-17489. [PMID: 37922469 DOI: 10.1021/acs.est.3c05275] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/05/2023]
Abstract
Measuring Escherichia coli in a single-grab sample of stored drinking water is often used to characterize drinking water quality. However, if water quality exhibits variability temporally, then one-time measurement schemes may be insufficient to adequately characterize the quality of water that people consume. This study uses longitudinal data collected from 193 households in peri-urban Tanzania to assess variability in stored water quality and to characterize uncertainty with different data collection schemes. Households were visited 5 times over the course of a year. At each visit, information was collected on water management practices, and a sample of stored drinking water was collected for E. coli enumeration. Water quality was poor for households, with 80% having highly contaminated (>100 CFU per 100 mL) water during at least one visit. There was substantial variability of water quality for households, with only 3% of households having the same category (low, medium, or high) of water quality for all five visits. These data suggest a single sample would inaccurately characterize a household's drinking water quality over the course of a year and lead to misestimates of population level access to safe drinking water.
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Affiliation(s)
- Angela R Harris
- Civil, Construction, and Environmental Engineering, North Carolina State University, 915 Partners Way, Campus Box 7908, Raleigh, North Carolina 27606, United States
| | - Sean W Daly
- Civil, Construction, and Environmental Engineering, North Carolina State University, 915 Partners Way, Campus Box 7908, Raleigh, North Carolina 27606, United States
| | - Amy J Pickering
- Civil and Environmental Engineering, University California Berkeley, Berkeley, California 94720, United States
| | | | - Michael Harris
- Civil and Environmental Engineering, University California Berkeley, Berkeley, California 94720, United States
| | - Jennifer Davis
- Environmental Engineering & Science, Department of Civil and Environmental Engineering, Stanford University, Stanford, California 94305, United States
- Woods Institute for the Environment, Stanford University, Stanford, California 94305, United States
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Shioda K, Brouwer AF, Lamar F, Mucache HN, Levy K, Freeman MC. Opportunities to Interrupt Transmission of Enteropathogens of Poultry Origin in Maputo, Mozambique: A Transmission Model Analysis. ENVIRONMENTAL HEALTH PERSPECTIVES 2023; 131:117004. [PMID: 37910131 PMCID: PMC10619637 DOI: 10.1289/ehp12314] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/19/2022] [Revised: 09/09/2023] [Accepted: 10/11/2023] [Indexed: 11/03/2023]
Abstract
BACKGROUND The burden of diarrheal diseases remains high among children in low-income countries. Enteropathogens are challenging to control because they are transmitted via multiple pathways. Chickens are an important animal protein source, but live chickens and their products are often highly contaminated with enteropathogens. OBJECTIVES We conducted this study to a) understand the contribution of multiple transmission pathways to the force of infection of Campylobacter spp. and nontyphoidal Salmonella spp., b) quantify the potential impact of reducing each pathway on human infection, and c) quantify hypothesized pathway reduction from the context of Maputo, Mozambique. METHODS We developed transmission models for Campylobacter and Salmonella that captured person-to-person, water-to-person, food-to-person, soil-to-person, animal-to-person, and all-other-sources-to-person in an urban, low-income setting in Mozambique. We calibrated these models using prevalence data from Maputo, Mozambique and estimates of attributable fraction of transmission pathways for the region. We simulated the prevalence of human infection after reducing transmission through each pathway. RESULTS Simulation results indicated that if foodborne transmission were reduced by 90%, the prevalence of Campylobacter and Salmonella infection would decline by [52.2%; 95% credible interval (CrI): 39.7, 63.8] and (46.9%; 95% CrI: 39, 55.4), respectively. Interruption of any other pathway did not have a substantial impact. Combined with survey and microbiology data, if contamination of broiler chicken meat at informal markets in Maputo could be reduced by 90%, the total infection of Campylobacter and Salmonella could be reduced by 21% (16-26%) and 12% (10-13%), respectively. DISCUSSION Our transmission models showed that the foodborne transmission has to be reduced to control enteropathogen infections in our study site, and likely in other similar contexts, but mitigation of this transmission pathway has not received sufficient attention. Our model can serve as a tool to identify effective mitigation opportunities to control zoonotic enteropathogens. https://doi.org/10.1289/EHP12314.
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Affiliation(s)
- Kayoko Shioda
- Gangarosa Department of Environmental Health, Emory University Rollins School of Public Health, Atlanta, Georgia, USA
- Department of Global Health, Boston University, Boston, MA
- Boston University Center for Emerging Infectious Diseases Policy and Research, Boston, MA
| | - Andrew F Brouwer
- Department of Epidemiology, University of Michigan School of Public Health, Ann Arbor, Michigan, USA
| | - Frederica Lamar
- Gangarosa Department of Environmental Health, Emory University Rollins School of Public Health, Atlanta, Georgia, USA
| | | | - Karen Levy
- Department of Environmental & Occupational Health Sciences, University of Washington School of Public Health, Seattle, Washington, USA
| | - Matthew C Freeman
- Gangarosa Department of Environmental Health, Emory University Rollins School of Public Health, Atlanta, Georgia, USA
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Negussie A, Lejore E, Hailemariam A, Tefera B, Mazengia EM, Dejene T, Tadesse Y, Adane Y, Gugsa K, Banda K, Sharma R, Girma E. BabyWASH and diarrhea prevention practices following multimedia educational intervention in hard-to-reach areas of the Afar and Somali regions of Ethiopia: a mixed-method endline evaluation. BMC Public Health 2023; 23:1998. [PMID: 37833668 PMCID: PMC10576324 DOI: 10.1186/s12889-023-16887-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/17/2023] [Accepted: 10/03/2023] [Indexed: 10/15/2023] Open
Abstract
BACKGROUND Water, sanitation, and hygiene (WASH) interventions, which are specifically targeted towards young children-known as "BabyWASH"-reduce exposure to environmental contamination and prevent microbial burden in their play and feeding environments. The purpose of this endline study was to evaluate the effectiveness and potential sustainability of a multimedia educational intervention in influencing key BabyWASH and diarrhea prevention practices in four hard-to-reach woredas (i.e. administrative districts) of the Afar and Somali regions of Ethiopia. METHODS A mixed-method, comparative cross-sectional study was conducted, which included 457 household surveys, 16 key informant interviews, and 8 focus group discussions. The multimedia educational intervention comprised: broadcasting radio talk shows and radio spot messages, capacity-building training for community health workers and community leaders, community mobilization campaigns, and the distribution of promotional print media materials. Propensity score matching analysis was used to estimate the effect of the multimedia educational intervention on key BabyWASH and diarrhea prevention attitudes and practices, which was then triangulated with qualitative findings. RESULTS The multimedia intervention had a significant positive impact on good BabyWASH and diarrhea prevention practices, including appropriate practices of child feces disposal (t-test = 5.17; p < 0.001), handwashing with soap or ash (t-test = 8.85; p < 0.001), maintaining separate playgrounds for young children (t-test = 2.83; p < 0.001), washing of child's body, hands, and faces (t-test = 15.78; p < 0.001), and food hygiene practices (t-test = 2.74; p < 0.05). The findings of the qualitative assessment also revealed that the multimedia intervention packages and the approaches used were successful in influencing key BabyWASH and diarrhea prevention behaviors in the intervention implementation woredas. In addition, providing capacity building training to local actors and community leaders and recording radio talk shows and sharing them with community members were recognized as effective intervention implementation strategies. CONCLUSION The endline evaluation found that the multimedia educational intervention improved awareness, perception, and practice of BabyWASH and diarrhea prevention behaviors in intervention woredas compared to control woredas. Sanitation and hygiene promotion interventions in pastoralist settings can be effective when using locally and contextually appropriate intervention strategies. However, considerations for integrating both behavioral and structural components in WASH interventions is essential.
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Affiliation(s)
- Abel Negussie
- Department of Social and Population Health, Yirgalem Hospital Medical College, Yirgalem, Ethiopia.
- Ethiopian Health Education and Promotion Professionals Association (EHEPA), Addis Ababa, Ethiopia.
| | - Ephrem Lejore
- School of Public Health, College of Medicine and Health Sciences, Hawassa University, Hawassa, Ethiopia
- Ethiopian Health Education and Promotion Professionals Association (EHEPA), Addis Ababa, Ethiopia
| | - Ariam Hailemariam
- School of Medicine, College of Health Sciences, Addis Ababa University, Addis Ababa, Ethiopia
- Ethiopian Health Education and Promotion Professionals Association (EHEPA), Addis Ababa, Ethiopia
| | - Bereket Tefera
- Department of Public Health, College of Medicine and Health Sciences, Dire Dawa University, Dire Dawa, Ethiopia
- Ethiopian Health Education and Promotion Professionals Association (EHEPA), Addis Ababa, Ethiopia
| | - Elyas Melaku Mazengia
- Department of Public Health, College of Health Sciences, Debre Markos University, Debre Markos, Ethiopia
- Ethiopian Health Education and Promotion Professionals Association (EHEPA), Addis Ababa, Ethiopia
| | - Tariku Dejene
- Center for Population Studies, College of Development Studies, Addis Ababa University, Addis Ababa, Ethiopia
- Ethiopian Health Education and Promotion Professionals Association (EHEPA), Addis Ababa, Ethiopia
| | | | | | - Kalkidan Gugsa
- Social and Behavior Change (SBC) Section, United Nations Children's Fund, Addis Ababa, Ethiopia
| | - Kabuka Banda
- Water, Sanitation and Hygiene (WASH) Section, United Nations Children's Fund, Addis Ababa, Ethiopia
| | - Rachana Sharma
- Social and Behavior Change (SBC) Section, United Nations Children's Fund, Addis Ababa, Ethiopia
| | - Eshetu Girma
- School of Public Health, College of Health Sciences, Addis Ababa University, Addis Ababa, Ethiopia
- Ethiopian Health Education and Promotion Professionals Association (EHEPA), Addis Ababa, Ethiopia
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Deichsel EL, Tickell KD, Rogawski McQuade ET. Minimizing error in estimates of the effect of interventions by accounting for baseline measurements: A simulation study analyzing effects on child growth. MATERNAL & CHILD NUTRITION 2023; 19:e13547. [PMID: 37439573 PMCID: PMC10483953 DOI: 10.1111/mcn.13547] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/29/2023] [Revised: 06/08/2023] [Accepted: 06/22/2023] [Indexed: 07/14/2023]
Abstract
Interventions to reduce childhood stunting burden require clinical trials with a primary outcome of linear growth. When growth is measured longitudinally, there are several options for including baseline measurements in the analysis. This study compares the performance of several methods. Randomized controlled trials evaluating a hypothetical intervention to improve length-for-age z-score (LAZ) from birth through 24 months of age were simulated. The intervention effect was evaluated using linear regression and five methods for handling baseline measurements: comparing final measurements only (FINAL), comparing final measurement adjusted for baseline (ADJUST), comparing the change in the measurement over time (DELTA), adjusting for baseline when comparing the changes over time (DELTA+ADJUST) and adjusting for baseline in two-step residuals approach (RESIDUALS). We calculated bias, precision and power of each method for scenarios with and without a baseline imbalance in LAZ. Using a 0.15 effect size at 18 months, FINAL and DELTA required 1200 and 1500 enroled participants, respectively, to reach 80% power, whereas ADJUST, DELTA+ADJUST and RESIDUALS only required 900 participants. The adjusted models also produced unbiased estimates when there was a baseline imbalance, whereas the FINAL and DELTA methods produced biased estimates, as large as 0.07 lower and higher, respectively, than the true effect. Adjusted methods required smaller sample size and produced more precise results than both DELTA and FINAL methods in all test scenarios. If randomization fails, and there is an imbalance in LAZ at baseline, DELTA and FINAL methods can produce biased estimates, but adjusted models remain unbiased. These results warn against using the FINAL or DELTA methods.
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Affiliation(s)
- Emily L Deichsel
- Center for Vaccine Development and Global Health, University of Maryland School of Medicine, Baltimore, Maryland, USA
| | - Kirkby D Tickell
- Department of Global Health, University of Washington, Seattle, Washington, USA
- Childhood Acute Illness & Nutrition (CHAIN) Network, Nairobi, Kenya
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Lin J, Feng XL. Exploring the impact of water, sanitation and hygiene (WASH), early adequate feeding and access to health care on urban-rural disparities of child malnutrition in China. MATERNAL & CHILD NUTRITION 2023; 19:e13542. [PMID: 37376961 PMCID: PMC10483939 DOI: 10.1111/mcn.13542] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/05/2022] [Revised: 06/01/2023] [Accepted: 06/02/2023] [Indexed: 06/29/2023]
Abstract
To explore the effects of UNICEF-suggested modifiable factors, that is, water, sanitation and hygiene (WASH), early adequate feeding and health care on child malnutrition, and to examine the extent to which each factor contributes to urban-rural disparities of child malnutrition in China. Pooling two waves of regionally representative survey data from Jilin, China, in 2013 and 2018, we report on urban-rural relative risks (RRs) in the prevalence of child stunting, wasting and overweight. We employ Poisson regression to examine the effects of urban-rural setting and the three modifiable factors on the prevalence of each malnutrition outcome, that is, stunting, wasting and overweight. We perform mediation analyses to estimate the extent to which each modifiable factor could explain the urban-rural disparities in each malnutrition outcome. The prevalence of stunting, wasting and overweight were 10.9%, 6.3% and 24.7% in urban, and 27.9%, 8.2% and 35.9% in rural Jilin, respectively. The rural to urban crude RR was 2.55 (95% confidence interval [CI]: 1.92-3.39) for stunting, while the corresponding RRs for wasting and overweight were 1.31 (95% CI: 0.84-2.03) and 1.45 (95% CI: 1.20-1.76), respectively. The rural to urban RR for stunting reduced to 2.01 (95% CI: 1.44-2.79) after adjusting for WASH. The mediation analyses show that WASH could mediate 23.96% (95% CI: 4.34-43.58%) of the urban-rural disparities for stunting, while early adequate feeding and health care had no effects. To close the persistent urban-rural gap in child malnutrition, the specific context of rural China suggests that a multi-sectoral approach is warranted that focuses on the sanitation environment and other wider social determinants of health.
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Affiliation(s)
- Junjie Lin
- Department of Health Policy and Management, School of Public HealthPeking UniversityBeijingChina
| | - Xing Lin Feng
- Department of Health Policy and Management, School of Public HealthPeking UniversityBeijingChina
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Rothstein AP, Jesser KJ, Feistel DJ, Konstantinidis KT, Trueba G, Levy K. Population genomics of diarrheagenic Escherichia coli uncovers high connectivity between urban and rural communities in Ecuador. INFECTION, GENETICS AND EVOLUTION : JOURNAL OF MOLECULAR EPIDEMIOLOGY AND EVOLUTIONARY GENETICS IN INFECTIOUS DISEASES 2023; 113:105476. [PMID: 37392822 PMCID: PMC10599324 DOI: 10.1016/j.meegid.2023.105476] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/07/2023] [Revised: 05/11/2023] [Accepted: 06/28/2023] [Indexed: 07/03/2023]
Abstract
Human movement may be an important driver of transmission dynamics for enteric pathogens but has largely been underappreciated except for international 'travelers' diarrhea or cholera. Phylodynamic methods, which combine genomic and epidemiological data, are used to examine rates and dynamics of disease matching underlying evolutionary history and biogeographic distributions, but these methods often are not applied to enteric bacterial pathogens. We used phylodynamics to explore the phylogeographic and evolutionary patterns of diarrheagenic E. coli in northern Ecuador to investigate the role of human travel in the geographic distribution of strains across the country. Using whole genome sequences of diarrheagenic E. coli isolates, we built a core genome phylogeny, reconstructed discrete ancestral states across urban and rural sites, and estimated migration rates between E. coli populations. We found minimal structuring based on site locations, urban vs. rural locality, pathotype, or clinical status. Ancestral states of phylogenomic nodes and tips were inferred to have 51% urban ancestry and 49% rural ancestry. Lack of structuring by location or pathotype E. coli isolates imply highly connected communities and extensive sharing of genomic characteristics across isolates. Using an approximate structured coalescent model, we estimated rates of migration among circulating isolates were 6.7 times larger for urban towards rural populations compared to rural towards urban populations. This suggests increased inferred migration rates of diarrheagenic E. coli from urban populations towards rural populations. Our results indicate that investments in water and sanitation prevention in urban areas could limit the spread of enteric bacterial pathogens among rural populations.
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Affiliation(s)
- Andrew P. Rothstein
- Department of Environmental and Occupational Health Sciences, School of Public Health, University of Washington, Seattle, WA, USA
| | - Kelsey J. Jesser
- Department of Environmental and Occupational Health Sciences, School of Public Health, University of Washington, Seattle, WA, USA
| | - Dorian J. Feistel
- School of a Biological Sciences, Georgia Institute of Technology, Atlanta, GA, USA
| | - Konstantinos T. Konstantinidis
- School of Civil and Environmental Engineering, Georgia Institute of Technology, Atlanta, GA, USA
- School of a Biological Sciences, Georgia Institute of Technology, Atlanta, GA, USA
| | - Gabriel Trueba
- Instituto de Microbiología, Colegio de Ciencias Biológicas y Ambientales, Universidad San Francisco de Quito, Quito, Pichincha, Ecuador
| | - Karen Levy
- Department of Environmental and Occupational Health Sciences, School of Public Health, University of Washington, Seattle, WA, USA
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Serrano Matos YA, Cano J, Shafiq H, Williams C, Sunny J, Cowardin CA. Colonization during a key developmental window reveals microbiota-dependent shifts in growth and immunity during undernutrition. BIORXIV : THE PREPRINT SERVER FOR BIOLOGY 2023:2023.07.07.547849. [PMID: 37461523 PMCID: PMC10350093 DOI: 10.1101/2023.07.07.547849] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 07/29/2023]
Abstract
Childhood undernutrition is a major global health challenge with devastating lifelong consequences. Linear growth stunting due to undernutrition has been linked to poor outcomes, and mothers who experience stunting are more likely to give birth to stunted children. Murine models that capture the intergenerational and multifactorial nature of undernutrition are critical to understanding the underlying biology of this disorder. Here we report a gnotobiotic mouse model of undernutrition using microbiota from human infants with healthy or stunted growth trajectories. Intergenerational transmission of microbiota from parents to offspring leads to the development of growth and immune features of undernutrition and enteropathy, including reduced linear growth, intestinal villus blunting and accumulation of intraepithelial lymphocytes. In contrast, colonization after weaning reduces sensitivity to detect changes driven by distinct microbial communities. Overall, these results suggest intergenerational colonization is a useful approach with which to investigate microbiota-dependent growth and immunity in early life.
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Affiliation(s)
- Yadeliz A. Serrano Matos
- Division of Pediatric Gastroenterology & Hepatology, Department of Pediatrics, University of Virginia School of Medicine, Charlottesville, Virginia 22908, USA
- Department of Microbiology, Immunology and Cancer Biology, University of Virginia School of Medicine, Charlottesville, Virginia 22908, USA
- These authors contributed equally
| | - Jasmine Cano
- Division of Pediatric Gastroenterology & Hepatology, Department of Pediatrics, University of Virginia School of Medicine, Charlottesville, Virginia 22908, USA
- These authors contributed equally
| | - Hamna Shafiq
- Division of Pediatric Gastroenterology & Hepatology, Department of Pediatrics, University of Virginia School of Medicine, Charlottesville, Virginia 22908, USA
| | - Claire Williams
- Division of Pediatric Gastroenterology & Hepatology, Department of Pediatrics, University of Virginia School of Medicine, Charlottesville, Virginia 22908, USA
- Department of Microbiology, Immunology and Cancer Biology, University of Virginia School of Medicine, Charlottesville, Virginia 22908, USA
| | - Julee Sunny
- Division of Pediatric Gastroenterology & Hepatology, Department of Pediatrics, University of Virginia School of Medicine, Charlottesville, Virginia 22908, USA
| | - Carrie A. Cowardin
- Division of Pediatric Gastroenterology & Hepatology, Department of Pediatrics, University of Virginia School of Medicine, Charlottesville, Virginia 22908, USA
- Department of Microbiology, Immunology and Cancer Biology, University of Virginia School of Medicine, Charlottesville, Virginia 22908, USA
- Senior author
- Lead contact
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Holcomb DA, Monteiro V, Capone D, António V, Chiluvane M, Cumbane V, Ismael N, Knee J, Kowalsky E, Lai A, Linden Y, Mataveia E, Nala R, Rao G, Ribeiro J, Cumming O, Viegas E, Brown J. Long-term impacts of an urban sanitation intervention on enteric pathogens in children in Maputo city, Mozambique: study protocol for a cross-sectional follow-up to the Maputo Sanitation (MapSan) trial 5 years postintervention. BMJ Open 2023; 13:e067941. [PMID: 37290945 PMCID: PMC10254709 DOI: 10.1136/bmjopen-2022-067941] [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: 08/31/2022] [Accepted: 05/24/2023] [Indexed: 06/10/2023] Open
Abstract
INTRODUCTION We previously assessed the effect of an onsite sanitation intervention in informal neighbourhoods of urban Maputo, Mozambique on enteric pathogen detection in children after 2 years of follow-up (Maputo Sanitation (MapSan) trial, ClinicalTrials.gov: NCT02362932). We found significant reductions in Shigella and Trichuris prevalence but only among children born after the intervention was delivered. In this study, we assess the health impacts of the sanitation intervention after 5 years among children born into study households postintervention. METHODS AND ANALYSIS We are conducting a cross-sectional household study of enteric pathogen detection in child stool and the environment at compounds (household clusters sharing sanitation and outdoor living space) that received the pour-flush toilet and septic tank intervention at least 5 years prior or meet the original criteria for trial control sites. We are enrolling at least 400 children (ages 29 days to 60 months) in each treatment arm. Our primary outcome is the prevalence of 22 bacterial, protozoan, and soil transmitted helminth enteric pathogens in child stool using the pooled prevalence ratio across the outcome set to assess the overall intervention effect. Secondary outcomes include the individual pathogen detection prevalence and gene copy density of 27 enteric pathogens (including viruses); mean height-for-age, weight-for-age, and weight-for-height z-scores; prevalence of stunting, underweight, and wasting; and the 7-day period prevalence of caregiver-reported diarrhoea. All analyses are adjusted for prespecified covariates and examined for effect measure modification by age. Environmental samples from study households and the public domain are assessed for pathogens and faecal indicators to explore environmental exposures and monitor disease transmission. ETHICS AND DISSEMINATION Study protocols have been reviewed and approved by human subjects review boards at the Ministry of Health, Republic of Mozambique and the University of North Carolina at Chapel Hill. Deidentified study data will be deposited at https://osf.io/e7pvk/. TRIAL REGISTRATION NUMBER ISRCTN86084138.
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Affiliation(s)
- David A Holcomb
- Department of Environmental Sciences and Engineering, Gillings School of Global Public Health, University of North Carolina, Chapel Hill, North Carolina, USA
- Department of Epidemiology, Gillings School of Global Public Health, University of North Carolina, Chapel Hill, North Carolina, USA
| | - Vanessa Monteiro
- Centro de Investigação e Treino em Saúde da Polana Caniço, Instituto Nacional de Saúde, Maputo, Mozambique
| | - Drew Capone
- Department of Environmental and Occupational Health, School of Public Health, Indiana University, Bloomington, Indiana, USA
| | - Virgílio António
- Division of Biotechnology and Genetics, Instituto Nacional de Saúde, Marracuene, Mozambique
| | - Márcia Chiluvane
- Centro de Investigação e Treino em Saúde da Polana Caniço, Instituto Nacional de Saúde, Maputo, Mozambique
| | - Victória Cumbane
- Centro de Investigação e Treino em Saúde da Polana Caniço, Instituto Nacional de Saúde, Maputo, Mozambique
| | - Nália Ismael
- Division of Biotechnology and Genetics, Instituto Nacional de Saúde, Marracuene, Mozambique
| | - Jackie Knee
- Department of Disease Control, Faculty of Infectious and Tropical Diseases, London School of Hygiene and Tropical Medicine, London, UK
| | - Erin Kowalsky
- Department of Environmental Sciences and Engineering, Gillings School of Global Public Health, University of North Carolina, Chapel Hill, North Carolina, USA
| | - Amanda Lai
- Department of Environmental Sciences and Engineering, Gillings School of Global Public Health, University of North Carolina, Chapel Hill, North Carolina, USA
| | - Yarrow Linden
- Department of Environmental Sciences and Engineering, Gillings School of Global Public Health, University of North Carolina, Chapel Hill, North Carolina, USA
| | - Elly Mataveia
- Centro de Investigação e Treino em Saúde da Polana Caniço, Instituto Nacional de Saúde, Maputo, Mozambique
| | - Rassul Nala
- Division of Parasitology, Instituto Nacional de Saúde, Maputo, Mozambique
| | - Gouthami Rao
- Department of Environmental Sciences and Engineering, Gillings School of Global Public Health, University of North Carolina, Chapel Hill, North Carolina, USA
| | - Jorge Ribeiro
- Centro de Investigação e Treino em Saúde da Polana Caniço, Instituto Nacional de Saúde, Maputo, Mozambique
| | - Oliver Cumming
- Department of Disease Control, Faculty of Infectious and Tropical Diseases, London School of Hygiene and Tropical Medicine, London, UK
| | - Edna Viegas
- Centro de Investigação e Treino em Saúde da Polana Caniço, Instituto Nacional de Saúde, Maputo, Mozambique
| | - Joe Brown
- Department of Environmental Sciences and Engineering, Gillings School of Global Public Health, University of North Carolina, Chapel Hill, North Carolina, USA
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Desye B, Tesfaye AH, Berihun G, Sisay T, Daba C, Berhanu L. Household water treatment practice and associated factors in Ethiopia: A systematic review and meta-analysis. PLoS One 2023; 18:e0285794. [PMID: 37289814 PMCID: PMC10249828 DOI: 10.1371/journal.pone.0285794] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2023] [Accepted: 05/02/2023] [Indexed: 06/10/2023] Open
Abstract
The provision of potable water is crucial to ensuring the health and dignity of individuals. In many developing countries, including Ethiopia, waterborne disease has become a major public health problem. There is a significant gap in accessing comprehensive national-wide evidence on Household Water Treatment (HWT) practices and associated factors in Ethiopia. Therefore, this study aims to assess the pooled HWT practice and associated factors in Ethiopia. A comprehensive search of published studies before October 15, 2022, was identified using databases and other sources. Data were extracted using Microsoft Excel, and analysis was performed using STATA 14/SE software. A random-effects model was used to estimate the pooled proportion of HWT practices and the odds ratio of associated factors. The funnel plot and Egger's regression test were used to assess publication bias, and I2 test statistics was used to assess heterogeneity. Duval and Tweedie's "trim and fill" method was performed to adjust the pooled estimate. A subgroup analysis was also conducted to identify the sources of heterogeneity. In this study, a total of 708 articles were retrieved, and 16 eligible studies were included. The pooled proportion of HWT practice in Ethiopia was found to be 21% (95% CI: 17-24). Having a formal education (OR: 2.42, 95% CI (2.11-2.74)), being male (OR: 1.32, 95% CI (1.13-1.51)), owning radio (OR: 1.33, 95% CI (1.18-1.47)), having a higher income (OR: 1.73, 95% CI (1.41-2.04)), unimproved water source (OR: 1.71, 95% CI (1.41-2.01)), fetching water at more frequently (OR: 3.31, 95% CI (1.99-4.64)), dipping methods of water drawing (OR: 2.08, 95% CI (1.66-2.51)), and taken training of water treatment (OR: 2.15, 95% CI (1.55-2.75)) were all found to be associated with HWT practice. Based on the findings of this study, the pooled proportion of HWT practice in Ethiopia was found to be one-fifth, which indicated that it was significantly low. Therefore, the authors recommend that households could better receive adequate information about HWT practices through strengthened health education and intensive training on HWT.
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Affiliation(s)
- Belay Desye
- Department of Environmental Health, College of Medicine and Health Sciences, Wollo University, Dessie, Ethiopia
- Department of Public Health, College of Medicine and Health Sciences, Adigrat University, Adigrat, Ethiopia
| | - Amensisa Hailu Tesfaye
- Department of Environmental and Occupational Health and Safety, Institute of Public Health, College of Medicine and Health Sciences, University of Gondar, Gondar, Ethiopia
| | - Gete Berihun
- Department of Environmental Health, College of Medicine and Health Sciences, Wollo University, Dessie, Ethiopia
| | - Tadesse Sisay
- Department of Environmental Health, College of Medicine and Health Sciences, Wollo University, Dessie, Ethiopia
| | - Chala Daba
- Department of Environmental Health, College of Medicine and Health Sciences, Wollo University, Dessie, Ethiopia
| | - Leykun Berhanu
- Department of Environmental Health, College of Medicine and Health Sciences, Wollo University, Dessie, Ethiopia
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Pras A, Mamane H. Nowcasting of fecal coliform presence using an artificial neural network. ENVIRONMENTAL POLLUTION (BARKING, ESSEX : 1987) 2023; 326:121484. [PMID: 36958657 DOI: 10.1016/j.envpol.2023.121484] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/13/2022] [Revised: 02/28/2023] [Accepted: 03/20/2023] [Indexed: 06/18/2023]
Abstract
At least 2 billion people worldwide use drinking water sources that are contaminated with feces, causing waterborne diseases; poor sanitation, poor hygiene, and unsafe drinking water result in a daily death rate of more than 800 children under 5 years of age from diarrheal diseases. This study shows the feasibility of a novel method to nowcast fecal coliforms' (FC) presence in drinking water sources by applying a multilayer perceptron artificial neuron network (MLP-ANN) model. The model gives a binary answer for FC presence or absence in drinking water sources using a minimum of water quality and geographical parameters, which can be monitored in real-time as predictors with low-cost and in-situ equipment. Using 51,400 samples to train, validate and test the model with temperature, pH, electrical conductivity, turbidity, dissolved oxygen, and total dissolved solids (TDS) as water-quality inputs and the water source type and location (as districts in India) as geographical inputs. The model achieved a total accuracy of 92.8% and a sensitivity of 98.2%, meaning that most FC-contaminated samples were classified correctly. In addition, precision reached 93.1%, meaning that most FC-contamination classifications were actually contaminated. The MLP-ANN performed better than the Linear Regression and K-Nearest Neighbors models, with lower accuracies of 90.2% and 91.0%, respectively. The MLP-ANN model could characterize the water quality geospatially, learn from the parameters whether the water is contaminated by FC, and predict with high accuracy on new testing data. This method can be used as a part of a sensor for FC monitoring and management in water, reducing the time gaps between routine lab testing and thus improving drinking water quality and addressing the SDG 6 targets.
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Affiliation(s)
- Asaf Pras
- School of Mechanical Engineering, Faculty of Engineering, Tel Aviv University, Tel Aviv, 69978, Israel.
| | - Hadas Mamane
- School of Mechanical Engineering, Faculty of Engineering, Tel Aviv University, Tel Aviv, 69978, Israel
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Daniels ME, Pradhan A, Odagiri M, Jenkins MW. Waterborne exposure during non-consumptive domestic use of surface water: a population study across WASH service levels in rural India. JOURNAL OF WATER AND HEALTH 2023; 21:751-762. [PMID: 37387340 PMCID: wh_2023_309 DOI: 10.2166/wh.2023.309] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 07/01/2023]
Abstract
Exposure to pathogens from domestic use of surface water is understudied. In many low- and middle-income countries, surface water is used for hygiene, sanitation, amenity, and recreational purposes. In this study, self-reported use of and structured observations at community ponds were collected to measure waterborne exposure across water and sanitation service levels in a rural population of Khorda District, India. Overall, 86% of households (n = 200) reported using ponds on a regular basis. Among observed people (n = 765), 82% put water into their mouth at least once, with a median frequency of five occurrences per visit. Reported and observation data were combined to estimate the proportion (p) of the population that put water in their mouth at least once per day, and their mean daily rate of oral exposure (OE). These were highest for individuals with neither safely managed water nor basic sanitation access (p = 93%, OE = 14 day-1), but still high among those with both (p = 67%, OE = 6 day-1). The results suggest widespread exposure to waterborne pathogens in settings where non-potable surface water bodies continue to be used for domestic purposes, even among households with access to safely managed drinking water.
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Affiliation(s)
- Miles E Daniels
- Institute of Marine Sciences, Fisheries Collaborative Program, University of California, Santa Cruz, CA 95060, USA E-mail:
| | - Ashirbad Pradhan
- Regional Resource Centre for RMNCH + A, Saheed Laxman Nayak Medical College and Hospital, Koraput, Odisha, India; United Nations Children's Fund (UNICEF), Bhubaneswar, Odisha, India
| | | | - Marion W Jenkins
- Department of Civil and Environmental Engineering, University of California, Davis, CA 95616, USA
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Islam M, Rahman M, Kafi MAH, Unicomb L, Rahman M, Mertens A, Benjamin-Chung J, Arnold BF, Colford JM, Luby SP, Ercumen A. Assessing sustained uptake of latrine and child feces management interventions: Extended follow-up of a cluster-randomized controlled trial in rural Bangladesh 1-3.5 years after intervention initiation. Int J Hyg Environ Health 2023; 250:114149. [PMID: 36913791 PMCID: PMC10186382 DOI: 10.1016/j.ijheh.2023.114149] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/08/2022] [Revised: 01/27/2023] [Accepted: 03/07/2023] [Indexed: 03/15/2023]
Abstract
BACKGROUND Sanitation interventions typically result in modest increases in latrine access, and any gains in latrine access and use are often not sustained over time. Sanitation programs also rarely include child-focused interventions such as potties. We aimed to assess the sustained effect of a multi-component sanitation intervention on access to and use of latrines and child feces management tools in rural Bangladesh. METHODS We conducted a longitudinal substudy nested within the WASH Benefits randomized controlled trial. The trial provided latrine upgrades, child potties and sani-scoops for feces removal, along with behavior change promotion to encourage use of the delivered hardware. Promotion visits to intervention recipients were frequent during the first 2 years after intervention initiation, decreased in frequency between years 2-3, and ceased after 3 years. We enrolled a random subset of 720 households from the sanitation and control arms of the trial in a substudy and visited them quarterly between 1 and 3.5 years after intervention initiation. At each visit, field staff recorded sanitation-related behaviors through spot-check observations and structured questionnaires. We assessed intervention effects on observed indicators of hygienic latrine access, potty use and sani-scoop use and investigated whether these effects were modified by duration of follow-up, ongoing behavior change promotion and household characteristics. RESULTS The intervention increased hygienic latrine access from 37% among controls to 94% in the sanitation arm (p < 0.001). Access among intervention recipients remained high 3.5 years after intervention initiation, including periods with no active promotion. Gains in access were higher among households with less education, less wealth and larger number of residents. The intervention increased availability of child potties from 29% among controls to 98% in the sanitation arm (p < 0.001). However, fewer than 25% of intervention households reported exclusive child defecation in a potty or had observed indicators of potty and sani-scoop use, and gains in potty use declined over the follow-up period, even with ongoing promotion. CONCLUSION Our findings from an intervention that provided free products and intensive initial behavior change promotion suggest a sustained increase in hygienic latrine access up to 3.5 years after intervention initiation but infrequent use of child feces management tools. Studies should investigate strategies to ensure sustained adoption of safe child feces management practices.
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Affiliation(s)
- Mahfuza Islam
- Environmental Intervention Unit, Infectious Disease Division, icddr,b, Dhaka, Bangladesh.
| | - Mahbubur Rahman
- Environmental Intervention Unit, Infectious Disease Division, icddr,b, Dhaka, Bangladesh
| | | | - Leanne Unicomb
- Environmental Intervention Unit, Infectious Disease Division, icddr,b, Dhaka, Bangladesh
| | - Mostafizur Rahman
- Environmental Intervention Unit, Infectious Disease Division, icddr,b, Dhaka, Bangladesh
| | - Andrew Mertens
- Division of Epidemiology and Biostatistics, University of California, Berkeley, CA, USA
| | - Jade Benjamin-Chung
- Division of Epidemiology and Biostatistics, University of California, Berkeley, CA, USA
| | - Benjamin F Arnold
- Francis I. Proctor Foundation, University of California, San Francisco, CA, USA
| | - John M Colford
- Division of Epidemiology and Biostatistics, University of California, Berkeley, CA, USA
| | - Stephen P Luby
- Woods Institute for the Environment, Stanford University, Stanford, USA
| | - Ayse Ercumen
- Department of Forestry and Environmental Resources, North Carolina State University, Raleigh, NC, USA
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Mbabazi J, Pesu H, Mutumba R, Filteau S, Lewis JI, Wells JC, Olsen MF, Briend A, Michaelsen KF, Mølgaard C, Ritz C, Nabukeera-Barungi N, Mupere E, Friis H, Grenov B. Effect of milk protein and whey permeate in large quantity lipid-based nutrient supplement on linear growth and body composition among stunted children: A randomized 2 × 2 factorial trial in Uganda. PLoS Med 2023; 20:e1004227. [PMID: 37220111 DOI: 10.1371/journal.pmed.1004227] [Citation(s) in RCA: 7] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/04/2022] [Accepted: 03/29/2023] [Indexed: 05/25/2023] Open
Abstract
BACKGROUND Despite possible benefits for growth, milk is costly to include in foods for undernourished children. Furthermore, the relative effects of different milk components, milk protein (MP), and whey permeate (WP) are unclear. We aimed to assess the effects of MP and WP in lipid-based nutrient supplement (LNS), and of LNS itself, on linear growth and body composition among stunted children. METHODS AND FINDINGS We performed a randomized, double-blind, 2 × 2 factorial trial among 12 to 59 months old stunted children in Uganda. Children were randomized to 4 formulations of LNS with MP or soy protein isolate and WP or maltodextrin (100 g/day for 12 weeks) or no supplementation. Investigators and outcome assessors were blinded; however, participants were only blinded to the ingredients in LNS. Data were analyzed based on intention-to-treat (ITT) using linear mixed-effects models adjusted for age, sex, season, and site. Primary outcomes were change in height and knee-heel length, and secondary outcomes included body composition by bioimpedance analysis (ISRCTN13093195). Between February and September 2020, we enrolled 750 children with a median age of 30 (interquartile range 23 to 41) months, with mean (± standard deviation) height-for-age z-score (HAZ) -3.02 ± 0.74 and 12.7% (95) were breastfed. The 750 children were randomized to LNS (n = 600) with or without MP (n = 299 versus n = 301) and WP (n = 301 versus n = 299), or no supplementation (n = 150); 736 (98.1%), evenly distributed between groups, completed 12-week follow-up. Eleven serious adverse events occurred in 10 (1.3%) children, mainly hospitalization with malaria and anemia, all deemed unrelated to the intervention. Unsupplemented children had 0.06 (95% confidence interval, CI [0.02, 0.10]; p = 0.015) decline in HAZ, accompanied by 0.29 (95% CI [0.20, 0.39]; p < 0.001) kg/m2 increase in fat mass index (FMI), but 0.06 (95% CI [-0.002; 0.12]; p = 0.057) kg/m2 decline in fat-free mass index (FFMI). There were no interactions between MP and WP. The main effects of MP were 0.03 (95% CI [-0.10, 0.16]; p = 0.662) cm in height and 0.2 (95% CI [-0.3, 0.7]; p = 0.389) mm in knee-heel length. The main effects of WP were -0.08 (95% CI [-0.21, 0.05]; p = 220) cm and -0.2 (95% CI [-0.7; 0.3]; p = 403) mm, respectively. Interactions were found between WP and breastfeeding with respect to linear growth (p < 0.02), due to positive effects among breastfed and negative effects among non-breastfed children. Overall, LNS resulted in 0.56 (95% CI [0.42, 0.70]; p < 0.001) cm height increase, corresponding to 0.17 (95% CI [0.13, 0.21]; p < 0.001) HAZ increase, and 0.21 (95% CI [0.14, 0.28]; p < 0.001) kg weight increase, of which 76.5% (95% CI [61.9; 91.1]) was fat-free mass. Using height-adjusted indicators, LNS increased FFMI (0.07 kg/m2, 95% CI [0.0001; 0.13]; p = 0.049), but not FMI (0.01 kg/m2, 95% CI [-0.10, 0.12]; p = 0.800). Main limitations were lack of blinding of caregivers and short study duration. CONCLUSIONS Adding dairy to LNS has no additional effects on linear growth or body composition in stunted children aged 12 to 59 months. However, supplementation with LNS, irrespective of milk, supports linear catch-up growth and accretion of fat-free mass, but not fat mass. If left untreated, children already on a stunting trajectory gain fat at the expense of fat-free mass, thus nutrition programs to treat such children should be considered. TRIAL REGISTRATION ISRCTN13093195.
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Affiliation(s)
- Joseph Mbabazi
- Department of Nutrition, Exercise and Sports, University of Copenhagen, Copenhagen, Denmark
- Department of Paediatrics and Child Health, Makerere University, Kampala, Uganda
| | - Hannah Pesu
- Department of Nutrition, Exercise and Sports, University of Copenhagen, Copenhagen, Denmark
| | - Rolland Mutumba
- Department of Nutrition, Exercise and Sports, University of Copenhagen, Copenhagen, Denmark
- Department of Paediatrics and Child Health, Makerere University, Kampala, Uganda
| | - Suzanne Filteau
- Department of Population Health, London School of Hygiene and Tropical Medicine, London, United Kingdom
| | - Jack I Lewis
- Department of Nutrition, Exercise and Sports, University of Copenhagen, Copenhagen, Denmark
| | - Jonathan C Wells
- Childhood Nutrition Research Centre, Population Policy and Practice Research and Teaching Department, UCL Great Ormond Street Institute of Child Health, London, United Kingdom
| | - Mette F Olsen
- Department of Nutrition, Exercise and Sports, University of Copenhagen, Copenhagen, Denmark
- Department of Infectious Diseases, Rigshospitalet, Copenhagen, Denmark
| | - André Briend
- Department of Nutrition, Exercise and Sports, University of Copenhagen, Copenhagen, Denmark
- Tampere Center for Child, Adolescent and Maternal Health Research, Faculty of Medicine and Health Technology, Tampere University and Tampere University Hospital, Tampere, Finland
| | - Kim F Michaelsen
- Department of Nutrition, Exercise and Sports, University of Copenhagen, Copenhagen, Denmark
| | - Christian Mølgaard
- Department of Nutrition, Exercise and Sports, University of Copenhagen, Copenhagen, Denmark
| | - Christian Ritz
- The National Institute of Public Health, University of Southern Denmark, Copenhagen, Denmark
| | | | - Ezekiel Mupere
- Department of Paediatrics and Child Health, Makerere University, Kampala, Uganda
| | - Henrik Friis
- Department of Nutrition, Exercise and Sports, University of Copenhagen, Copenhagen, Denmark
| | - Benedikte Grenov
- Department of Nutrition, Exercise and Sports, University of Copenhagen, Copenhagen, Denmark
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Jensen PKM, Hossain ZZ, Sultana R, Ferdous J, Almeida S, Begum A. Introduction of the Personal Domain in Water Sanitation and Hygiene (WASH), a New Approach to Identify Missing Health Impacts. Trop Med Infect Dis 2023; 8:tropicalmed8050252. [PMID: 37235300 DOI: 10.3390/tropicalmed8050252] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2023] [Revised: 04/21/2023] [Accepted: 04/24/2023] [Indexed: 05/28/2023] Open
Abstract
The water sanitation and hygiene (WASH) sector has provided beneficiaries in low and middle-income countries with latrines and clean water for decades. However, we still need good evidence documenting the expected health impact. This paper investigates why we lack this evidence and ways to move forward. Using mTEC agar, we monitored E. coli contamination on selected "hotspot" surfaces within the kitchen environments of 32 low-income households in Dhaka, Bangladesh, every six weeks for two years. Despite being washed, the highest average contamination was found on food plates, at 253 cfu/10 cm2, followed by cutting knives, with 240 cfu/10 cm2. The drinking vessel surfaces and the latrine doorknobs had the lowest contaminations, with E. coli means of 167 and 73 cfu/10 cm2, respectively. These findings imply a need to measure an individual's pathogen exposure as close to the mouth as possible to estimate the true pathogen exposure. The paper proposes introducing the new "personal domain"-the point of consumption-as the physical sphere in which WASH interventions should be assessed. With this approach, we can observe and quantify the different pathogen exposure routes and, with this, further improve WASH interventions.
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Affiliation(s)
- Peter Kjær Mackie Jensen
- Copenhagen Center for Disaster Research, Global Health Section, Department of Public Health, University of Copenhagen, Øster Farimagsgade 5, Building 22, 1014 Copenhagen, Denmark
| | - Zenat Zebin Hossain
- Copenhagen Center for Disaster Research, Global Health Section, Department of Public Health, University of Copenhagen, Øster Farimagsgade 5, Building 22, 1014 Copenhagen, Denmark
- Department of Microbiology, University of Dhaka, Dhaka 1000, Bangladesh
- Department of Public Health, School of Pharmacy and Public Health, Independent University, Dhaka 1229, Bangladesh
| | - Rebeca Sultana
- Copenhagen Center for Disaster Research, Global Health Section, Department of Public Health, University of Copenhagen, Øster Farimagsgade 5, Building 22, 1014 Copenhagen, Denmark
- icddr,b, Dhaka 1212, Bangladesh
- Institute of Health Economics, University of Dhaka, Dhaka 1000, Bangladesh
| | - Jannatul Ferdous
- Department of Microbiology, University of Dhaka, Dhaka 1000, Bangladesh
| | - Sara Almeida
- Copenhagen Center for Disaster Research, Global Health Section, Department of Public Health, University of Copenhagen, Øster Farimagsgade 5, Building 22, 1014 Copenhagen, Denmark
| | - Anowara Begum
- Department of Microbiology, University of Dhaka, Dhaka 1000, Bangladesh
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Berendes DM, Fagerli K, Kim S, Nasrin D, Powell H, Kasumba IN, Tennant SM, Roose A, Jahangir Hossain M, Jones JCM, Zaman SMA, Omore R, Ochieng JB, Verani JR, Widdowson MA, Sow SO, Doh S, Sugerman CE, Mintz ED, Kotloff KL. Survey-Based Assessment of Water, Sanitation, and Animal-Associated Risk Factors for Moderate-to-Severe Diarrhea in the Vaccine Impact on Diarrhea in Africa (VIDA) Study: The Gambia, Mali, and Kenya, 2015-2018. Clin Infect Dis 2023; 76:S132-S139. [PMID: 37074438 PMCID: PMC10116493 DOI: 10.1093/cid/ciac911] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/20/2023] Open
Abstract
BACKGROUND Pediatric exposures to unsafe sources of water, unsafely managed sanitation, and animals are prevalent in low- and middle-income countries. In the Vaccine Impact on Diarrhea in Africa case-control study, we examined associations between these risk factors and moderate-to-severe diarrhea (MSD) in children <5 years old in The Gambia, Kenya, and Mali. METHODS We enrolled children <5 years old seeking care for MSD at health centers; age-, sex-, and community-matched controls were enrolled at home. Conditional logistic regression models, adjusted for a priori confounders, were used to evaluate associations between MSD and survey-based assessments of water, sanitation, and animals living in the compound. RESULTS From 2015 to 2018, 4840 cases and 6213 controls were enrolled. In pan-site analyses, children with drinking water sources below "safely managed" (onsite, continuously accessible sources of good water quality) had 1.5-2.0-fold higher odds of MSD (95% confidence intervals [CIs] ranging from 1.0 to 2.5), driven by rural site results (The Gambia and Kenya). In the urban site (Mali), children whose drinking water source was less available (several hours/day vs all the time) had higher odds of MSD (matched odds ratio [mOR]: 1.4, 95% CI: 1.1, 1.7). Associations between MSD and sanitation were site-specific. Goats were associated with slightly increased odds of MSD in pan-site analyses, whereas associations with cows and fowl varied by site. CONCLUSIONS Poorer types and availability of drinking water sources were consistently associated with MSD, whereas the impacts of sanitation and household animals were context-specific. The association between MSD and access to safely managed drinking water sources post-rotavirus introduction calls for transformational changes in drinking water services to prevent acute child morbidity from MSD.
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Affiliation(s)
- David M Berendes
- Division of Foodborne, Waterborne, and Environmental Diseases, Centers for Disease Control and Prevention, Atlanta, Georgia, USA
| | - Kirsten Fagerli
- Division of Foodborne, Waterborne, and Environmental Diseases, Centers for Disease Control and Prevention, Atlanta, Georgia, USA
| | - Sunkyung Kim
- Division of Foodborne, Waterborne, and Environmental Diseases, Centers for Disease Control and Prevention, Atlanta, Georgia, USA
| | - Dilruba Nasrin
- Center for Vaccine Development and Global Health, University of Maryland School of Medicine, Baltimore, Maryland, USA
- Department of Medicine, Center for Vaccine Development and Global Health, University of Maryland School of Medicine, Baltimore, Maryland, USA
| | - Helen Powell
- Center for Vaccine Development and Global Health, University of Maryland School of Medicine, Baltimore, Maryland, USA
- Department of Pediatrics, Center for Vaccine Development and Global Health, University of Maryland School of Medicine, Baltimore, Maryland, USA
| | - Irene N Kasumba
- Center for Vaccine Development and Global Health, University of Maryland School of Medicine, Baltimore, Maryland, USA
- Department of Medicine, Center for Vaccine Development and Global Health, University of Maryland School of Medicine, Baltimore, Maryland, USA
| | - Sharon M Tennant
- Center for Vaccine Development and Global Health, University of Maryland School of Medicine, Baltimore, Maryland, USA
- Department of Medicine, Center for Vaccine Development and Global Health, University of Maryland School of Medicine, Baltimore, Maryland, USA
| | - Anna Roose
- Center for Vaccine Development and Global Health, University of Maryland School of Medicine, Baltimore, Maryland, USA
- Department of Pediatrics, Center for Vaccine Development and Global Health, University of Maryland School of Medicine, Baltimore, Maryland, USA
| | - M Jahangir Hossain
- Medical Research Council Unit, The Gambia at the London School of Hygiene and Tropical Medicine, Banjul, The Gambia
| | - Joquina Chiquita M Jones
- Medical Research Council Unit, The Gambia at the London School of Hygiene and Tropical Medicine, Banjul, The Gambia
| | - Syed M A Zaman
- Medical Research Council Unit, The Gambia at the London School of Hygiene and Tropical Medicine, Banjul, The Gambia
| | - Richard Omore
- Center for Global Health Research, Kenya Medical Research Institute, Kisumu, Kenya
| | - John B Ochieng
- Center for Global Health Research, Kenya Medical Research Institute, Kisumu, Kenya
| | - Jennifer R Verani
- Division of Global Health Protection, Centers for Disease Control and Prevention, Nairobi, Kenya
| | - Marc-Alain Widdowson
- Division of Global Health Protection, Centers for Disease Control and Prevention, Nairobi, Kenya
| | - Samba O Sow
- Centre pour le Développement des Vaccins du Mali (CVD-Mali), Bamako, Mali
| | - Sanogo Doh
- Centre pour le Développement des Vaccins du Mali (CVD-Mali), Bamako, Mali
| | - Ciara E Sugerman
- Division of Foodborne, Waterborne, and Environmental Diseases, Centers for Disease Control and Prevention, Atlanta, Georgia, USA
| | - Eric D Mintz
- Division of Foodborne, Waterborne, and Environmental Diseases, Centers for Disease Control and Prevention, Atlanta, Georgia, USA
| | - Karen L Kotloff
- Center for Vaccine Development and Global Health, University of Maryland School of Medicine, Baltimore, Maryland, USA
- Department of Pediatrics, Center for Vaccine Development and Global Health, University of Maryland School of Medicine, Baltimore, Maryland, USA
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Berendes DM, Omore R, Prentice-Mott G, Fagerli K, Kim S, Nasrin D, Powell H, Jahangir Hossain M, Sow SO, Doh S, Jones JCM, Ochieng JB, Juma J, Awuor AO, Ogwel B, Verani JR, Widdowson MA, Kasumba IN, Tennant SM, Roose A, Zaman SMA, Liu J, Sugerman CE, Platts-Mills JA, Houpt ER, Kotloff KL, Mintz ED. Exploring Survey-Based Water, Sanitation, and Animal Associations With Enteric Pathogen Carriage: Comparing Results in a Cohort of Cases With Moderate-to-Severe Diarrhea to Those in Controls in the Vaccine Impact on Diarrhea in Africa (VIDA) Study, 2015-2018. Clin Infect Dis 2023; 76:S140-S152. [PMID: 37074442 PMCID: PMC10116566 DOI: 10.1093/cid/ciac918] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/20/2023] Open
Abstract
BACKGROUND The magnitude of pediatric enteric pathogen exposures in low-income settings necessitates substantive water and sanitation interventions, including animal feces management. We assessed associations between pediatric enteric pathogen detection and survey-based water, sanitation, and animal characteristics within the Vaccine Impact on Diarrhea in Africa case-control study. METHODS In The Gambia, Kenya, and Mali, we assessed enteric pathogens in stool of children aged <5 years with moderate-to-severe diarrhea and their matched controls (diarrhea-free in prior 7 days) via the TaqMan Array Card and surveyed caregivers about household drinking water and sanitation conditions and animals living in the compound. Risk ratios (RRs) and 95% confidence intervals (CIs) were calculated using modified Poisson regression models, stratified for cases and controls and adjusted for age, sex, site, and demographics. RESULTS Bacterial (cases, 93%; controls, 72%), viral (63%, 56%), and protozoal (50%, 38%) pathogens were commonly detected (cycle threshold <35) in the 4840 cases and 6213 controls. In cases, unimproved sanitation (RR, 1.56; 95% CI, 1.12-2.17), as well as cows (RR, 1.61; 95% CI, 1.16-2.24) and sheep (RR, 1.48; 95% CI, 1.11-1.96) living in the compound, were associated with Shiga toxin-producing Escherichia coli. In controls, fowl (RR, 1.30; 95% CI, 1.15-1.47) were associated with Campylobacter spp. In controls, surface water sources were associated with Cryptosporidium spp., Shigella spp., heat-stable toxin-producing enterotoxigenic E. coli, and Giardia spp. CONCLUSIONS Findings underscore the importance of enteric pathogen exposure risks from animals alongside more broadly recognized water and sanitation risk factors in children.
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Affiliation(s)
- David M Berendes
- Division of Foodborne, Waterborne, and Environmental Diseases, US Centers for Disease Control and Prevention, Atlanta, Georgia, USA
| | - Richard Omore
- Kenya Medical Research Institute, Center for Global Health Research, Kisumu, Kenya
| | - Graeme Prentice-Mott
- Division of Foodborne, Waterborne, and Environmental Diseases, US Centers for Disease Control and Prevention, Atlanta, Georgia, USA
| | - Kirsten Fagerli
- Division of Foodborne, Waterborne, and Environmental Diseases, US Centers for Disease Control and Prevention, Atlanta, Georgia, USA
| | - Sunkyung Kim
- Division of Foodborne, Waterborne, and Environmental Diseases, US Centers for Disease Control and Prevention, Atlanta, Georgia, USA
| | - Dilruba Nasrin
- Center for Vaccine Development and Global Health, University of Maryland School of Medicine, Baltimore, Maryland, USA
- Department of Medicine, University of Maryland School of Medicine, Baltimore, Maryland, USA
| | - Helen Powell
- Center for Vaccine Development and Global Health, University of Maryland School of Medicine, Baltimore, Maryland, USA
- Department of Pediatrics, University of Maryland School of Medicine, Baltimore, Maryland, USA
| | - M Jahangir Hossain
- Medical Research Council Unit, The Gambia at the London School of Hygiene and Tropical Medicine; Banjul, The Gambia
| | - Samba O Sow
- Centre pour le Développement des Vaccins du Mali (CVD-Mali), Bamako, Mali
| | - Sanogo Doh
- Centre pour le Développement des Vaccins du Mali (CVD-Mali), Bamako, Mali
| | - Joquina Chiquita M Jones
- Medical Research Council Unit, The Gambia at the London School of Hygiene and Tropical Medicine; Banjul, The Gambia
| | - John B Ochieng
- Kenya Medical Research Institute, Center for Global Health Research, Kisumu, Kenya
| | - Jane Juma
- Kenya Medical Research Institute, Center for Global Health Research, Kisumu, Kenya
| | - Alex O Awuor
- Kenya Medical Research Institute, Center for Global Health Research, Kisumu, Kenya
| | - Billy Ogwel
- Kenya Medical Research Institute, Center for Global Health Research, Kisumu, Kenya
| | - Jennifer R Verani
- Division of Global Health Protection, US Centers for Disease Control and Prevention, Nairobi, Kenya
| | - Marc-Alain Widdowson
- Division of Global Health Protection, US Centers for Disease Control and Prevention, Nairobi, Kenya
| | - Irene N Kasumba
- Center for Vaccine Development and Global Health, University of Maryland School of Medicine, Baltimore, Maryland, USA
- Department of Medicine, University of Maryland School of Medicine, Baltimore, Maryland, USA
| | - Sharon M Tennant
- Center for Vaccine Development and Global Health, University of Maryland School of Medicine, Baltimore, Maryland, USA
- Department of Medicine, University of Maryland School of Medicine, Baltimore, Maryland, USA
| | - Anna Roose
- Center for Vaccine Development and Global Health, University of Maryland School of Medicine, Baltimore, Maryland, USA
- Department of Pediatrics, University of Maryland School of Medicine, Baltimore, Maryland, USA
| | - Syed M A Zaman
- Medical Research Council Unit, The Gambia at the London School of Hygiene and Tropical Medicine; Banjul, The Gambia
| | - Jie Liu
- Division of Infectious Diseases and International Health, University of Virginia, Charlottesville, Virginia, USA
- School of Public Health at Qingdao University, Qingdao, China
| | - Ciara E Sugerman
- Division of Foodborne, Waterborne, and Environmental Diseases, US Centers for Disease Control and Prevention, Atlanta, Georgia, USA
| | - James A Platts-Mills
- Division of Infectious Diseases and International Health, University of Virginia, Charlottesville, Virginia, USA
| | - Eric R Houpt
- Centre pour le Développement des Vaccins du Mali (CVD-Mali), Bamako, Mali
| | - Karen L Kotloff
- Center for Vaccine Development and Global Health, University of Maryland School of Medicine, Baltimore, Maryland, USA
- Department of Pediatrics, University of Maryland School of Medicine, Baltimore, Maryland, USA
| | - Eric D Mintz
- Division of Foodborne, Waterborne, and Environmental Diseases, US Centers for Disease Control and Prevention, Atlanta, Georgia, USA
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Pessoa Colombo V, Chenal J, Orina F, Meme H, Koffi JDA, Koné B, Utzinger J. Environmental determinants of access to shared sanitation in informal settlements: a cross-sectional study in Abidjan and Nairobi. Infect Dis Poverty 2023; 12:34. [PMID: 37038238 PMCID: PMC10084626 DOI: 10.1186/s40249-023-01078-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/02/2023] [Accepted: 03/10/2023] [Indexed: 04/12/2023] Open
Abstract
BACKGROUND Universal access to basic sanitation remains a global challenge, particularly in low- and middle-income countries. Efforts are underway to improve access to sanitation in informal settlements, often through shared facilities. However, access to these facilities and their potential health gains-notably, the prevention of diarrheal diseases-may be hampered by contextual aspects related to the physical environment. This study explored associations between the built environment and perceived safety to access toilets, and associations between the latter and diarrheal infections. METHODS A cross-sectional study was carried out between July 2021 and February 2022, including 1714 households in two informal settlements in Abidjan (Côte d'Ivoire) and two in Nairobi (Kenya). We employed adjusted odds ratios (aORs) obtained from multiple logistic regressions (MLRs) to test whether the location of the most frequently used toilet was associated with a perceived lack of safety to use the facility at any time, and whether this perceived insecurity was associated with a higher risk of diarrhea. The MLRs included several exposure and control variables, being stratified by city and age groups. We employed bivariate logistic regressions to test whether the perceived insecurity was associated with settlement morphology indicators derived from the built environment. RESULTS Using a toilet outside the premises was associated with a perceived insecurity both in Abidjan [aOR = 3.14, 95% confidence interval (CI): 1.13-8.70] and in Nairobi (aOR = 57.97, 95% CI: 35.93-93.53). Perceived insecurity to access toilets was associated with diarrheal infections in the general population (aOR = 1.90, 95% CI: 1.29-2.79 in Abidjan, aOR = 1.69, 95% CI: 1.22-2.34 in Nairobi), but not in children below the age of 5 years. Several settlement morphology features were associated with perceived insecurity, namely, buildings' compactness, the proportion of occupied land, and angular deviation between neighboring structures. CONCLUSIONS Toilet location was a critical determinant of perceived security, and hence, must be adequately addressed when building new facilities. The sole availability of facilities may be insufficient to prevent diarrheal infections. People must also be safe to use them. Further attention should be directed toward how the built environment affects safety.
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Affiliation(s)
| | - Jérôme Chenal
- École Polytechnique Fédérale de Lausanne, Lausanne, Switzerland
- Université Mohammed VI Polytechnique, Ben Guerir, Morocco
| | - Fred Orina
- Kenya Medical Research Institute, Nairobi, Kenya
| | - Hellen Meme
- Kenya Medical Research Institute, Nairobi, Kenya
| | | | - Brama Koné
- Centre Suisse de Recherches Scientifiques en Côte d'Ivoire, Abidjan, Côte d'Ivoire
- Université Péléforo Gon Coulibaly, Korhogo, Côte d'Ivoire
| | - Jürg Utzinger
- Swiss Tropical and Public Health Institute, Allschwil, Switzerland
- University of Basel, Basel, Switzerland
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Changes in water treatment, hygiene practices, household floors, and child health in times of Covid-19: A longitudinal cross-sectional survey in Surkhet District, Nepal. Int J Hyg Environ Health 2023; 249:114138. [PMID: 36821912 PMCID: PMC9925420 DOI: 10.1016/j.ijheh.2023.114138] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2022] [Revised: 01/25/2023] [Accepted: 02/12/2023] [Indexed: 02/16/2023]
Abstract
INTRODUCTION Consistent and effective practice of water treatment, sanitation, and hygiene (WASH) behaviour is an indispensable requisite for realizing health improvements among children living in low-income areas with challenging hygienic conditions. Sustainably achieving such a behaviour change is challenging but more likely to be realized during epidemics, when health threats are high and the dissemination of information on preventative measures is intense. Our study conducted cross-sectional surveys in Surkhet District Nepal, before and during the Covid-19 pandemic to assess the impact of water safety interventions and hygiene training implemented before and during the pandemic on WASH conditions and practices and to assess the association of these changes with child health. METHODS Information on WASH infrastructure, WASH behaviour, nutrition, and child health, including on parasitic infections, was obtained before and during the Covid-19 pandemic in spring 2018 and spring 2021, from 589 children aged between 6 months and 10 years and their caregivers. Data was collected through quantitative, structured face-to-face interviews, observations, health examinations of children including anthropometric measurements, analysis of children's stool, and water quality analysis. The association of changes in WASH factors with changes in child health was analysed using multivariate generalized estimating equations for repeated measures. RESULTS Water safety management was significantly improved by the introduction of chlorination to piped water supply systems, which served 40% of households. In addition, the percentage of households using a ceramic water filter increased from 12.2% to 34.8%. Large and significant changes were observed in handwashing behaviour (frequency, use of soap and washing at critical times) and infrastructure: 35% of households constructed a new handwashing station. Kitchen and household hygiene also improved. An additional 22% of households improved the cleanliness of the toilet. The number of houses with a cemented floor increased by 20%. WASH changes were significantly associated with improved child health: the chlorination of piped water supply reduced odds ratios for diarrhoea (OR = 0.36, 95% CI = 0.15-0.88, p = 0.025), respiratory difficulties (OR = 0.39, 95% CI = 0.16-0.92, p = 0.033), fever (OR = 0.42, 95% CI = 0.26-0.71, p = 0.001) and cough (OR = 0.58, 95% CI = 0.36-0.93, p = 0.024), and. The frequency of handwashing with soap was associated with significantly reduced odds ratios for infections with Giardia lamblia (OR = 0.68, 95% CI = 0.50-0.91, p = 0.011), stunting and wasting (OR = 0.75, 95% CI = 0.66-0.92, p = 0.003) and fever (OR = 0.85, 95% CI = 0.75-0.96, p = 0.008),. The presence of a handwashing station at baseline was associated with significantly reduced odds ratios for respiratory difficulties (OR = 0.45, 95% CI = 0.26-0.78, p = 0.004). The construction of a handwashing station between baseline and endline was significantly associated with reduced odds ratios for pale conjunctiva (OR = 0.32, 95% CI = 0.17-0.60, p < 0.001), which is a clinical sign of iron deficiency and anaemia, respiratory difficulties (OR = 0.39, 95% CI = 0.17-0.89, p = 0.026) and cough (OR = 0.44, 95% CI = 0.26-0.76, p = 0.003). Using a clean container for the transport of drinking water was significantly associated with reduced odds ratios for infections with Giardia lamblia (OR = 0.39, 95% CI = 0.16-0.93, p = 0.033) and diarrhoea (OR = 0.48, 95% CI = 0.24-0.96, p = 0.038). Similarly, a cemented floor in the household was significantly associated with reduced odd ratios for diarrhoea (OR = 0.38, 95% CI = 0.16-0.87, p = 0.022) and infections with Giardia lamblia (OR = 0.44, 95% CI = 0.19-1.02, p = 0.056). CONCLUSION WASH training and the promotion of preventative measures during the Covid-19 pandemic supported improved water safety management and hygiene behaviour, which resulted in a reduction in infectious diseases among children in the study area.
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Stoler J, Guzmán DB, Adams EA. Revisiting transformative WASH: measuring impact. Lancet Glob Health 2023; 11:e493-e494. [PMID: 36690012 DOI: 10.1016/s2214-109x(23)00013-x] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2022] [Accepted: 01/04/2023] [Indexed: 01/22/2023]
Affiliation(s)
- Justin Stoler
- Department of Geography and Sustainable Development, University of Miami, Coral Gables, FL 33146, USA; Department of Public Health Sciences, University of Miami Miller School of Medicine, Miami, FL, USA.
| | - Danice B Guzmán
- Pulte Institute for Global Development, University of Notre Dame, Notre Dame, IN, USA; Keough School of Global Affairs, University of Notre Dame, Notre Dame, IN, USA
| | - Ellis A Adams
- Pulte Institute for Global Development, University of Notre Dame, Notre Dame, IN, USA; Keough School of Global Affairs, University of Notre Dame, Notre Dame, IN, USA; Eck Institute for Global Health, University of Notre Dame, Notre Dame, IN, USA
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Sharma Waddington H, Masset E, Bick S, Cairncross S. Impact on childhood mortality of interventions to improve drinking water, sanitation, and hygiene (WASH) to households: Systematic review and meta-analysis. PLoS Med 2023; 20:e1004215. [PMID: 37079510 PMCID: PMC10118100 DOI: 10.1371/journal.pmed.1004215] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/24/2022] [Accepted: 03/14/2023] [Indexed: 04/21/2023] Open
Abstract
BACKGROUND In low- and middle-income countries (L&MICs), the biggest contributing factors to the global burden of disease in childhood are deaths due to respiratory illness and diarrhoea, both of which are closely related to use of water, sanitation, and hygiene (WASH) services by households. However, current estimates of the health impacts of WASH interventions use self-reported morbidity, which may fail to capture longer-term or more severe impacts. Reported mortality is thought to be less prone to bias than other reported measures. This study aimed to answer the question: What are the impacts of WASH interventions on reported childhood mortality in L&MICs? METHODS AND FINDINGS We conducted a systematic review and meta-analysis, using a published protocol. Systematic searches of 11 academic databases and trial registries, plus organisational repositories, were undertaken to locate studies of WASH interventions, which were published in peer review journals or other sources (e.g., organisational reports and working papers). Intervention studies of WASH improvements implemented under endemic disease circumstances in L&MICs were eligible, which reported findings at any time until March 2020. We used the participant flow data supplied in response to journal editors' calls for greater transparency. Data were collected by two authors working independently. We included evidence from 24 randomized and 11 nonrandomized studies of WASH interventions from all global regions, incorporating 2,600 deaths. Effects of 48 WASH treatment arms were included in analysis. We critically appraised and synthesised evidence using meta-analysis to improve statistical power. We found WASH interventions are associated with a significant reduction of 17% in the odds of all-cause mortality in childhood (OR = 0.83, 95% CI = 0.74, 0.92, evidence from 38 interventions), and a significant reduction in diarrhoea mortality of 45% (OR = 0.55, 95% CI = 0.35, 0.84; 10 interventions). Further analysis by WASH technology indicated interventions providing improved water in quantity to households were most consistently associated with reductions in all-cause mortality. Community-wide sanitation was most consistently associated with reductions in diarrhoea mortality. Around one-half of the included studies were assessed as being at "moderate risk of bias" in attributing mortality in childhood to the WASH intervention, and no studies were found to be at "low risk of bias." The review should be updated to incorporate additional published and unpublished participant flow data. CONCLUSIONS The findings are congruent with theories of infectious disease transmission. Washing with water presents a barrier to respiratory illness and diarrhoea, which are the two biggest contributors to all-cause mortality in childhood in L&MICs. Community-wide sanitation halts the spread of diarrhoea. We observed that evidence synthesis can provide new findings, going beyond the underlying data from trials to generate crucial insights for policy. Transparent reporting in trials creates opportunities for research synthesis to answer questions about mortality, which individual studies of interventions cannot be reliably designed to address.
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Affiliation(s)
- Hugh Sharma Waddington
- Environmental Health Group, Department of Disease Control, London School of Hygiene and Tropical Medicine (LSHTM), London International Development Centre (LIDC), London, United Kingdom
| | - Edoardo Masset
- Department of Public Health, Environments and Society, LSHTM, and Deputy Director, Centre of Excellence for Development Impact and Learning (CEDIL), LIDC, London, United Kingdom
| | - Sarah Bick
- Environmental Health Group, Department of Disease Control, LSHTM, London, United Kingdom
| | - Sandy Cairncross
- Environmental Health Group, Department of Disease Control, LSHTM, London, United Kingdom
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