BACKGROUND: The causes of stunting are complex but likely include prenatal effects, inadequate postnatal nutrient intake, and recurrent infections. Low-birth-weight (LBW) infants are at high risk of stunting. More than 25% of live births in low- and middle-income countries are at full term with low birth weight (FT-LBW). Evidence on the efficacy of specific interventions to enhance growth in this vulnerable group remains scant. OBJECTIVE: We investigated the independent and combined effects of a directed use of a water-based hand sanitizer (HS) and a mineraland vitamin-enhanced micronutrient powder (MNP) (22 minerals and vitamins) to prevent infections and improve nutrient intake to reduce stunting in FT-LBW infants. DESIGN: The study was a prospective 2 × 2 factorial, clusterrandomized trial in 467 FT-LBW infants during 2 periods: from 0 to 5 mo postpartum (0–180 d postpartum) and from 6 to 12 mo postpartum (181–360 d postpartum) with the use of 48 clusters. All groups received the same general nutrition, health, and hygiene education (NHHE) at enrollment and throughout the 12 mo. Group assignments initially included the following 2 groups: no HS (control) group or HS from 0 to 5 mo postpartum. These assignments were followed by further divisions into the following 4 groups from 6 to 12 mo postpartum: 1) no HS and no MNP (control), 2) HS only, 3) MNP only, and 4) HS and MNP. RESULTS: When delivered in combination with NHHE, the use of an HS showed no additional benefit in reducing indicators of infection in the first or second half of infancy or the likelihood of stunting at 12 mo postpartum. FT-LBW infants who received the MNP (with or without the HS) were significantly less likely to be stunted at 12 mo than were controls (OR: 0.35; 95% CI: 0.15, 0.84; P = 0.017). CONCLUSIONS: The use of a mineral- and vitamin-enhanced MNP significantly reduced stunting in FT-LBW infants in this high-risk setting. The use of a water-based HS did not have an additive effect. This trial was registered at clinicaltrials.gov as NCT01455636.
<b>BACKGROUND: </b>Diarrhea is one of the leading causes of death, killing 1.3 million in 2013 across the globe, of whom, 0.59 million were children under 5 years of age. Globally, about 1 billion people practice open defecation, and an estimated 2.4 billion people were living without improved sanitation facilities in 2015. Much of the previous research investigating the effect of improved sanitation has been based on observational studies. Recent studies have executed a cluster-randomized controlled trial to investigate the effect of improved sanitation. However, none of these recent studies achieved a sufficient level of latrine coverage. Without universal or at least a sufficient level of latrine coverage, a determination of the effect of improved latrines on the prevention of diarrheal disease is difficult. This cluster-randomized trial aims to explore the net effect of improved latrines on diarrheal prevalence and incidence in children under five and to investigate the effect on the diarrheal duration.<b>Method/design: </b>A phase-in and factorial design will be used for the study. The intervention for improving latrines will be implemented in an intervention arm during the first phase, and the comparable intervention will be performed in the control arm during the second phase. During the second phase, a water pipe will be connected to the gotts (villages) in the intervention arm. After the second phase is completed, the control group will undergo the intervention of receiving a water pipe connection. For diarrheal prevalence, five rounds of surveying will be conducted at the household level. The first four rounds will be carried out in the first phase to explore the effect of improved latrines, and the last one, in the second phase to examine the combined effects of improved water and sanitation. For documentation of diarrheal incidence and duration, the mother or caregiver will record the diarrheal episodes of her youngest child on the "Sanitation Calendar" every day. Of 212 gotts in the project area, 48 gotts were selected for the trial, and 1200 households with a child under 5 will be registered for the intervention or control arm. Informed consent from 1200 households will be obtained from the mother or caregiver in written form.<b>DISCUSSION: </b>To our knowledge, this is the second study to assess the effects of improved latrines on child diarrheal reduction through the application of Community-Led Total Sanitation.<b>Trial Registration: </b>Current Controlled Trials, ISRCTN82492848.
To assess the health impact of reusable, antimicrobial hand towels, we conducted a cluster randomized, yearlong field trial. At baseline, we surveyed mothers, and gave four towels plus hygiene education to intervention households and education alone to controls. At biweekly home visits, we asked about infections in children < 2 years old and tested post-handwashing hand rinse samples of 20% of mothers for Escherichia coli. At study's conclusion, we tested 50% of towels for E. coli. Baseline characteristics between 188 intervention and 181 control households were similar. Intervention and control children had similar rates of diarrhea (1.47 versus 1.48, P = 0.99), respiratory infections (1.38 versus 1.48, P = 0.92), skin infections (1.76 versus 1.79, P = 0.81), and subjective fever (2.62 versus 3.40, P = 0.04) per 100 person-visits. Post-handwashing hand contamination was similar; 67% of towels exhibited E. coli contamination. Antimicrobial hand towels became contaminated over time, did not improve hand hygiene, or prevent diarrhea, respiratory infections, or skin infections.
Efforts to eradicate open defecation and improve sanitation access are unlikely to achieve health benefits unless interventions reduce microbial exposures. This study assessed human fecal contamination and pathogen exposures in rural India, and the effect of increased sanitation coverage on contamination and exposure rates. In a cross‐sectional study of 60 villages of a cluster‐randomized controlled sanitation trial in Odisha, India, human and domestic animal fecal contamination was measured in community tubewells and ponds (n = 301) and via exposure pathways in homes (n = 354), using Bacteroidales microbial source tracking fecal markers validated in India. Community water sources were further tested for diarrheal pathogens (rotavirus, adenovirus and Vibrio cholerae by quantitative PCR; pathogenic Escherichia coli by multiplex PCR; Cryptosporidium and Giardia by immunomagnetic separation and direct fluorescent antibody microscopy). Exposure pathways in intervention and control villages were compared and relationships with child diarrhea examined. Human fecal markers were rarely detected in tubewells (2.4%, 95%CI: 0.3‐4.5%) and ponds (5.6%, 95%CI: 0.8‐10.3%), compared to homes (35.4%, 95%CI: 30.4‐40.4%). In tubewells, V. cholerae was the most frequently detected pathogen (19.8%, 95%CI: 14.4‐25.2%), followed by Giardia (14.8%, 95%CI: 10.0‐19.7%). In ponds, Giardia was most often detected (74.5%, 95%CI: 65.7‐83.3%), followed by pathogenic E. coli (48.1%, 95%CI: 34.8‐61.5%) and rotavirus (44.4%, 95%CI: 34.2‐54.7%). At village‐level, prevalence of fecal pathogen detection in community drinking water sources was associated with elevated prevalence of child diarrhea within 6 weeks of testing (RR 2.13, 95%CI: 1.25‐3.63) while within homes, higher levels of human and animal fecal marker detection were associated with increased risks of subsequent child diarrhea (P = 0.044 and 0.013, respectively). There was no evidence that the intervention, which increased functional latrine coverage and use by 27 percentage points, reduced human fecal contamination in any tested pathway, nor the prevalence of pathogens in water sources. In conclusion, the study demonstrates that (1) improved sanitation alone may be insufficient and further interventions needed in the domestic domain to reduce widespread human and animal fecal contamination observed in homes, (2) pathogens detected in tubewells indicate these sources are microbiologically unsafe for drinking and were associated with child diarrhea, (3) domestic use of ponds heavily contaminated with multiple pathogens presents an under‐recognized health risk, and (4) a 27 percentage point increase in improved sanitation access at village‐level did not reduce detectable human fecal and pathogen contamination in this setting.
INTRODUCTION: Access to safe sanitation in low-income, informal settlements of Sub-Saharan Africa has not significantly improved since 1990. The combination of a high faecal-related disease burden and inadequate infrastructure suggests that investment in expanding sanitation access in densely populated urban slums can yield important public health gains. No rigorous, controlled intervention studies have evaluated the health effects of decentralised (non-sewerage) sanitation in an informal urban setting, despite the role that such technologies will likely play in scaling up access.
METHODS AND ANALYSIS: We have designed a controlled, before-and-after (CBA) trial to estimate the health impacts of an urban sanitation intervention in informal neighbourhoods of Maputo, Mozambique, including an assessment of whether exposures and health outcomes vary by localised population density. The intervention consists of private pour-flush latrines (to septic tank) shared by multiple households in compounds or household clusters. We will measure objective health outcomes in approximately 760 children (380 children with household access to interventions, 380 matched controls using existing shared private latrines in poor sanitary conditions), at 2 time points: immediately before the intervention and at follow-up after 12 months. The primary outcome is combined prevalence of selected enteric infections among children under 5 years of age. Secondary outcome measures include soil-transmitted helminth (STH) reinfection in children following baseline deworming and prevalence of reported diarrhoeal disease. We will use exposure assessment, faecal source tracking, and microbial transmission modelling to examine whether and how routes of exposure for diarrhoeagenic pathogens and STHs change following introduction of effective sanitation.
ETHICS: Study protocols have been reviewed and approved by human subjects review boards at the London School of Hygiene and Tropical Medicine, the Georgia Institute of Technology, the University of North Carolina at Chapel Hill, and the Ministry of Health, Republic of Mozambique.
TRIAL REGISTRATION NUMBER: NCT02362932.
While preventive chemotherapy remains to be a major strategy for the prevention and control of soil-transmitted helminthiases (STH), improvements in water, sanitation, and hygiene (WASH) comprise the long-term strategy to achieve sustained control of STH. This study examined the parasitological and nutritional status of school-age and preschool-age children in four villages in Southern Leyte, Philippines where two of the villages attained Open-Defecation-Free (ODF) status after introduction of Community-Led Total Sanitation (CLTS). A total of 341 children (89.0% of the total eligible population) submitted stool samples which were examined using the Kato-Katz technique. Results showed that 27.9% of the total stool samples examined had at least one type of STH (cumulative prevalence), while 7.9% had moderate-heavy intensity infections. Between the two villages where CLTS was introduced, Buenavista had a significantly higher cumulative prevalence of STH at 67.4% (p<0.001) and prevalence of moderate-heavy intensity STH at 23.5% (p=0.000), while Caubang had a significantly lower cumulative prevalence at 4.9% and prevalence of moderate-heavy intensity at 1.8%. On the other hand, the non-CLTS villages of Bitoon and Saub had similar rates for cumulative prevalence (16.7% and 16.8%, respectively; p=0.984) and prevalence of moderate-heavy intensity STH (2.0% and 3.1%, respectively; p=1.000). The findings may be explained by factors that include possible reversion to open defecation, non-utilization of sanitary facilities, and mass drug administration (MDA) coverage, although further studies that can accurately assess the impact of CLTS are recommended. While this study was descriptive, the data indicate no clear pattern among the parasitological and nutritional parameters, as well as the presence of CLTS in the village, suggesting the need to monitor the ODF status of villages on a regular basis even after the end of CLTS activities to ensure the sustainability of the CLTS approach. In order to achieve effective control of STH, deeper collaboration between the WASH and STH sectors are recommended where partners can work together in the area of monitoring and evaluation that may include improved parasitological and nutritional status in high-risk groups, as well as sustainable behavior change as outcome indicators.
BACKGROUND: Community-led total sanitation (CLTS) uses participatory approaches to mobilise communities to build their own toilets and stop open defecation. Our aim was to undertake the first randomised trial of CLTS to assess its effect on child health in Koulikoro, Mali.
METHODS: We did a cluster-randomised trial to assess a CLTS programme implemented by the Government of Mali. The study population included households in rural villages (clusters) from the Koulikoro district of Mali; every household had to have at least one child aged younger than 10 years. Villages were randomly assigned (1:1) with a computer-generated sequence by a study investigator to receive CLTS or no programme. Health outcomes included diarrhoea (primary outcome), height for age, weight for age, stunting, and underweight. Outcomes were measured 1·5 years after intervention delivery (2 years after enrolment) among children younger than 5 years. Participants were not masked to intervention assignment. The trial is registered with ClinicalTrials.gov, number NCT01900912.
FINDINGS: We recruited participants between April 12, and June 23, 2011. We assigned 60 villages (2365 households) to receive the CLTS intervention and 61 villages (2167 households) to the control group. No differences were observed in terms of diarrhoeal prevalence among children in CLTS and control villages (706 [22%] of 3140 CLTS children vs 693 [24%] of 2872 control children; prevalence ratio [PR] 0·93, 95% CI 0·76-1·14). Access to private latrines was almost twice as high in intervention villages (1373 [65%] of 2120 vs 661 [35%] of 1911 households) and reported open defecation was reduced in female (198 [9%] of 2086 vs 608 [33%] of 1869 households) and in male (195 [10%] of 2004 vs 602 [33%] of 1813 households) adults. Children in CLTS villages were taller (0·18 increase in height-for-age Z score, 95% CI 0·03-0·32; 2415 children) and less likely to be stunted (35% vs 41%, PR 0·86, 95% CI 0·74-1·0) than children in control villages. 22% of children were underweight in CLTS compared with 26% in control villages (PR 0·88, 95% CI 0·71-1·08), and the difference in mean weight-for-age Z score was 0·09 (95% CI -0·04 to 0·22) between groups. In CLTS villages, younger children at enrolment (<2 years) showed greater improvements in height and weight than older children.
INTERPRETATION: In villages that received a behavioural sanitation intervention with no monetary subsidies, diarrhoeal prevalence remained similar to control villages. However, access to toilets substantially increased and child growth improved, particularly in children <2 years. CLTS might have prevented growth faltering through pathways other than reducing diarrhoea.
FUNDING: Bill & Melinda Gates Foundation.
In preparation for a larger trial, the Water, Sanitation, and Hygiene (WASH) Benefits pilot study enrolled 72 villages and 499 subjects in two closely related randomized trials of WASH interventions in rural western Kenya. Intervention households received hardware and promotion for one of the following: water treatment, sanitation and latrine improvements, handwashing with soap, or the combination of all three. Interventions were clustered by village. A follow‐up survey was conducted 4 months after intervention delivery to assess uptake. Intervention households were significantly more likely than controls to have chlorinated stored water (36‐60 percentage point increases), covers over latrine drop holes (55‐75 percentage point increases), less stool visible on latrine floors (16‐47 percentage point reductions), and a place for handwashing (71‐85 percentage point increases) with soap available (49‐66 percentage point increases). The high uptake in all arms shows that combined interventions can achieve high short‐term adoption rates if well‐designed.
The causes of stunting are complex but likely include prenatal effects, inadequate postnatal nutrient intake, and recurrent infections. Low-birth-weight (LBW) infants are at high risk of stunting. More than 25% of live births in low- and middle-income countries are at full term with low birth weight (FT-LBW). Evidence on the efficacy of specific interventions to enhance growth in this vulnerable group remains scant.
OBJECTIVE:
We investigated the independent and combined effects of a directed use of a water-based hand sanitizer (HS) and a mineraland vitamin-enhanced micronutrient powder (MNP) (22 minerals and vitamins) to prevent infections and improve nutrient intake to reduce stunting in FT-LBW infants.
DESIGN:
The study was a prospective 2 × 2 factorial, clusterrandomized trial in 467 FT-LBW infants during 2 periods: from 0 to 5 mo postpartum (0–180 d postpartum) and from 6 to 12 mo postpartum (181–360 d postpartum) with the use of 48 clusters. All groups received the same general nutrition, health, and hygiene education (NHHE) at enrollment and throughout the 12 mo. Group assignments initially included the following 2 groups: no HS (control) group or HS from 0 to 5 mo postpartum. These assignments were followed by further divisions into the following 4 groups from 6 to 12 mo postpartum: 1) no HS and no MNP (control), 2) HS only, 3) MNP only, and 4) HS and MNP.
RESULTS:
When delivered in combination with NHHE, the use of an HS showed no additional benefit in reducing indicators of infection in the first or second half of infancy or the likelihood of stunting at 12 mo postpartum. FT-LBW infants who received the MNP (with or without the HS) were significantly less likely to be stunted at 12 mo than were controls (OR: 0.35; 95% CI.: 0.15, 0.84; P = 0.017).
CONCLUSIONS:
The use of a mineral- and vitamin-enhanced MNP significantly reduced stunting in FT-LBW infants in this high-risk setting. The use of a water-based HS did not have an additive effect. This trial was registered at clinicaltrials.gov as NCT01455636.
