Environmental enteric dysfunction and child stunting.

To characterize the relationship between child faeces disposal and child growth in low- and middle-income countries. We analysed caregiver responses and anthropometric data from Demographic and Health Surveys (2005-2014) for 202614 children under five and 82949 children under two to examine the association between child faeces disposal and child growth. Child faeces disposal in an improved toilet was associated with reduced stunting for children under five [adjusted prevalence ratio (aPR)=0.90, 95% confidence interval (CI) 0.89-0.92] and a 0.12 increase in height-for-age z-score (HAZ; 95% CI: 0.10-0.15) among all households. Among households with improved sanitation access, practicing improved child faeces disposal was still associated with a decrease in stunting (aPR=0.94, 95% CI: 0.91-0.96) and a 0.09 increase in HAZ (95% CI: 0.06-0.13). Improved child faeces disposal was also associated with reductions in underweight and wasting, and an increase in weight-for-age z-score (WAZ), but not an increase in weight-for-height z-score (WHZ). Community coverage level of improved child faeces disposal was also associated with stunting, with 75-100% coverage associated with the greatest reduction in stunting. Child faeces disposal in an unimproved toilet was associated with reductions in underweight and wasting, but not stunting. Improved child faeces disposal practices could achieve greater reductions in child undernutrition than improving toilet access alone. Additionally, the common classification of child faeces disposal as 'safe' regardless of the type of toilet used for disposal may underestimate the benefits of disposal in an improved toilet and overestimate the benefits of disposal in an unimproved toilet.

ObjectiveThis study aimed to provide clarification on the benefits of water, sanitation and hygiene (WASH) alone separately and combined with nutrition in improving child growth outcomes.DesignSystematic review and meta-analysis.MethodsWe conducted...

The sustainable success of water, sanitation, and hygiene (WASH) interventions to reduce waterborne disease and promote public health in low‐income regions is uncertain. Recent large randomized controlled trials in Bangladesh, Kenya, and Zimbabwe revealed that traditional household WASH interventions are unlikely to reduce diarrhea or improve linear growth (i.e., reduce stunting) in infants and children—two important indicators of the effectiveness of WASH interventions. A possible factor contributing to the null results is that traditional WASH interventions control microbial pathogens but do not remove chemical toxicants. Exposure to many organic and inorganic chemical toxicants is associated with diarrheal symptoms, as well as with preterm birth and stunting. Many chemical toxicants have deleterious effects on the immune system, impairing the body's response to infectious diseases, and reducing the effectiveness of vaccinations. Globalization has led to rapid and largely unregulated import, production, use, and disposal without adequate treatment of large quantities of hazardous chemicals throughout the developing world, with profound effects on the environment and human health. Literature evidence from the past 10 to 15 years on putative and demonstrated chemical exposures in Bangladesh, Kenya, and Zimbabwe and the regions within the countries where the large WASH trials took place supports potential contribution(s) from chemical toxicants in the failure of traditional WASH interventions to relieve diarrhea and stunting. Mitigating exposures to organic and inorganic chemical immunotoxins through drinking water and other routes is likely to be a necessary‐but‐insufficient criterion for the sustainable success of WASH interventions.This article is categorized under: Engineering Water > Water, Health, and Sanitation Engineering Water > Sustainable Engineering of Water

Growing evidence highlights the gender-transformative potential of water, sanitation, and hygiene (WASH) interventions, which can shape gender equality and social inclusion alongside and through improvements in WASH practices, service delivery, and governance. This paper presents results from a quasi-experimental evaluation of the gender-transformative impacts of WASH interventions in the districts of Dailekh and Sarlahi in Nepal between 2020 and 2022. This timeframe also overlapped with the COVID-19 pandemic. The evaluation utilized propensity-score-matching and difference-in-difference techniques with the 16-theme water, sanitation, and hygiene – gender equality measure (WASH-GEM) to differentiate results between women and men of varying levels of program involvement. Average scores increased in 10 of the 16 themes for men, while decreasing in 10 themes for women; suggesting that men experienced greater improvements in gendered outcomes. Nonetheless, active participation in the program led to higher benefits or mitigated negative impacts in 15 themes, and women had better outcomes than men in 13 of these. These results suggest that active participation in the program had a positive net benefit for women participants, mitigating the negative gender impacts of the pandemic. This study illustrates the value of gender-transformative WASH programming as a pathway not only to improved WASH but also advancing equality.

Progress toward achieving Sustainable Development Goal 6, clean water and sanitation for all, is behind schedule and faces substantial financial challenges. Rigorous water, sanitation, and hygiene (WASH) interventions have underperformed, casting doubt on their efficacy and potentially undermining confidence in WASH funding and investments. But these interventions have leaned on a narrow set of WASH indicators—linear growth and diarrhea—that reflect a 20th‐century prioritization of microbiological water quality as the most important measurement of WASH intervention success. Even when water is microbiologically safe, hundreds of millions of people face harassment, assault, injury, poisoning, anxiety, exhaustion, depression, social exclusion, discrimination, subjugation, hunger, debt, or work, school, or family care absenteeism when retrieving or consuming household water. Measures of WASH intervention success should incorporate these impacts to reinforce the WASH value proposition. We present a way forward for implementing a monitoring and evaluation paradigm shift that can help achieve transformative WASH.This article is categorized under: Engineering Water > Water, Health, and Sanitation Human Water > Value of Water Human Water > Methods

IntroductionHealthcare-associated infections (HCAIs) are the most frequent adverse event compromising patient safety globally. Patients in healthcare facilities (HCFs) in low-income and middle-income countries (LMICs) are most at risk. Although water,...

Household-level water, sanitation, and hygiene (WASH) interventions do not always achieve sustainable uptake. Research that considers WASH within a socioecological framework, where multi-level factors are interconnected in influencing choices, can inform more effective interventions. To understand WASH preferences and priorities under different socioeconomic and community contexts, we conducted in-depth interviews and freelisting activities with 33 mothers of children under age two participating in the ECoMiD study in northwest Ecuador. Data were inductively coded and connected thematically to the socioecological framework. Select survey data from ECoMiD were analyzed to provide additional context. Maternal WASH choices are driven by factors at each level of the framework. Climatic: seasonal flooding decreases the appeal of WASH investments like cisterns, and household wealth facilitates access in times of climatic stress. Geographic: benefits of WASH access via proximity to piped systems are complicated by quality and consistency concerns, while access from proximity to rivers is complicated by labor requirements. Community: local infrastructure dictates individual options for accessing WASH, and local conditions are dictated by national sociopolitical context and policy decisions. Household: consistent, quality piped water for drinking and chores is the most common maternal WASH preference. WASH choices respond to financial and labor constraints. Individual: mothers value time-savings associated with WASH technologies and access. Maternal decision making operates at the terminus of a chain of broader and interconnected socioecological conditions. The burden of obtaining WASH access is greatest for the poorest households with the least community infrastructure, compounded by seasonal conditions. This contextually grounded study draws attention to how socio-spatial, economic, and environmental constraints interact in the Ecuadorian context to shape lived experience. Improving community-level WASH and taking a multisectoral approach to health interventions would better address barriers to WASH access, and support mothers in making WASH-related choices that can ultimately improve child health and wellbeing.

Water, sanitation, and hygiene (WASH) interventions have been proposed as an important complement to deworming programs for sustainable control of soil-transmitted helminth (STH) infections. We aimed to determine whether a community-based WASH program had additional benefits in reducing STH infections compared with community deworming alone. We conducted the WASH for WORMS cluster-randomized controlled trial in 18 rural communities in Timor-Leste. Intervention communities received a WASH intervention that provided access to an improved water source, promoted improved household sanitation, and encouraged handwashing with soap. All eligible community members in intervention and control arms received albendazole every 6 months for 2 years. The primary outcomes were infection with each STH, measured using multiplex real-time quantitative polymerase chain reaction. We compared outcomes between study arms using generalized linear mixed models, accounting for clustering at community, household, and individual levels. At study completion, the integrated WASH and deworming intervention did not have an effect on infection with Ascaris spp. (relative risk [RR] 2.87, 95% confidence interval [CI]: 0.66-12.48, P = 0.159) or Necator americanus (RR 0.99, 95% CI: 0.52-1.89, P = 0.987), compared with deworming alone. At the last follow-up, open defecation was practiced by 66.1% (95% CI: 54.2-80.2) of respondents in the control arm versus 40.2% (95% CI: 25.3-52.6) of respondents in the intervention arm (P = 0.005). We found no evidence that the WASH intervention resulted in additional reductions in STH infections beyond that achieved with deworming alone over the 2-year trial period. The role of WASH on STH infections over a longer period of time and in the absence of deworming remains to be determined.

Low-cost, household-level water, sanitation, and hygiene (WASH) and nutrition interventions can reduce pediatric antibiotic use, but the mechanism through which interventions reduce antibiotic use has not been investigated. We conducted a causal mediation analysis using data from the WASH Benefits Bangladesh cluster-randomized trial (NCT01590095). Among a subsample of children within the WSH, nutrition, nutrition+WSH, and controls arms (N=1,409), we recorded caregiver-reported antibiotic use at ages 14 and 28 months and collected stool at age 14 months. Mediators included caregiver-reported child diarrhea, acute respiratory infection (ARI), and fever; and enteric pathogen carriage in stool measured by qPCR. Models controlled for mediator-outcome confounders. The receipt of any WSH or nutrition intervention reduced antibiotic use in the past month by 5.5 percentage points (95% CI 1.2, 9.9) through all pathways, from 49.5% (95% CI 45.9%, 53.0%) in the control group to 45.0 % (95% CI 42.7%, 47.2%) in the pooled intervention group. Interventions reduced antibiotic use by 0.6 percentage points (95% CI 0.1, 1.3) through reduced diarrhea, 0.7 percentage points (95% CI 0.1, 1.5) through reduced ARI with fever, and 1.8 percentage points (95% CI 0.5, 3.5) through reduced prevalence of enteric viruses. Interventions reduced antibiotic use through any mediator by 2.5 percentage points (95% CI 0.2, 5.3). Our findings bolster a causal interpretation that WASH and nutrition interventions reduced pediatric antibiotic use through reduced infections in a rural, low-income population. Bill & Melinda Gates Foundation, National Institute of Allergy and Infectious Diseases.

Environmental Enteric Dysfunction (EED) is a subclinical condition of the gut characterized by changes in gut morphology and function with underlying chronic inflammatory responses. EED affects more than two-thirds of young children living in low-income settings. EED has been linked with growth faltering in young children living in low-income settings, however, the mechanisms by which EED impacts growth are not well defined. A proposed pathway suggests that ingestion of enteric pathogens and toxins, through contaminated food and water, changes gut microbiota composition and function. This results in intestinal inflammation and changes in the intestinal epithelium structure. There is limited data examining the association between the gut microbiota and EED. The present work was nested in a cluster-randomized trial of mass drug administration of azithromycin and was carried out to characterize composition and diversity of the gut microbiota in rural Malawian children with and without signs of EED. The work also tested for associations between the gut microbiota and stunting. Proteins were extracted from fecal samples and used for the quantification, by ELISA, of neopterin, myeloperoxidase and alpha-1 antitrypsin, which are biomarkers of intestinal inflammation and permeability that have been proposed as potential proxies of EED. Concentrations of the three biomarkers were combined to form a proxy EED score using principal component analysis. Total genomic DNA was also extracted from the fecal samples for V4-16SrRNA sequencing and for species-specific PCR to determine intestinal carriage of bacteria that have previously been shown to be associated with growth in a mouse model. All three biomarkers decreased with age. Faecalibacterium prausnitzii and Dorea formicigenerans were prevalent in over 70% of children while Bifidobacterium longum was the least prevalent of the bacteria assayed. No associations were found between fecal biomarkers of EED or intestinal bacteria carriage and stunting, however, intestinal carriage of D. formicigenerans was associated with normal biomarker concentration. Increased fecal microbiota diversity was associated with a reduction in neopterin concentration. Increased abundance of Succinivibrio was associated with reduced EED scores. Mass treatment with azithromycin appeared to have no long-term impact on alpha diversity of fecal samples but was weakly associated with increased abundance of Prevotella at 24-months follow-up. A negative correlation between age and the three biomarkers of EED was found and confirms trends shown in other children living in similar low-income settings. The association between D. formicigenerans and normal biomarker concentration suggests a potential beneficial role of the bacterium in gut health. An increase in microbiota diversity is potentially associated with reduced intestinal inflammation, but larger studies are needed to confirm this. The association between Succinivibrio and biomarkers of EED shown here is consistent with recent data from another study conducted in Malawi. Succinivibrio plays a role in fiber-degradation and metabolites of fiber-degradation have been shown to inhibit intestinal colonization by pathogenic bacteria, therefore, further studies are needed to investigate the significance of this bacterium in EED. Mass treatment with azithromycin may have long-lasting effects on the abundance of defined bacterial taxa but not overall microbiota diversity.

This study assessed the effects of school-based menstrual hygiene management (MHM) and water, sanitation, and hygiene (WASH) interventions on the empowerment, health, and educational outcomes of menstruating girls using cross-sectional and experimental designs. It examined whether access to MHM education and WASH facilities could enhance girls' self-confidence, physical, emotional, and social health, class attendance, and academic performance. The results showed significant improvements in empowerment at intervention schools, with 54% of girls feeling confident purchasing sanitary products, compared to 18% in control schools, indicating better emotional well-being. Additionally, 21% and 22% of girls in intervention schools felt comfortable discussing MHM with boys and mothers, respectively, compared to just 9% in control schools, reflecting improved social health. Regarding physical health, 51% of menstruating girls in intervention schools practiced genital hygiene three to four times a day, compared to 33% in control schools. Educational outcomes were also improved, with 68% of girls in intervention schools attending class during menstruation, compared to 30% in control schools, and 78% reporting adequate study time at home, compared to 41% in control schools. However, no significant difference in academic performance was found between the two groups. Overall, the findings suggest that school-based MHM and WASH interventions can significantly empower menstruating girls, improve their physical, emotional, and social health, and reduce menstrual-related absenteeism.

This is a protocol for a Cochrane Review (Intervention). The objectives are as follows: Main objective: The main objective is to assess the effect of interventions to improve sanitation, hygiene, water quality and supply within low- and middle-income countries on child development. Secondary objectives: The secondary objectives are to: analyse any measured effect of water, sanitation and hygiene (WASH) interventions on school or preschool enrolment and attendance; examine the feasibility of WASH interventions with regard to their implementation fidelity and participant compliance; evaluate the effect of WASH interventions on intermediary outcomes of environmental contamination, gastrointestinal diseases and reduction in the burden of water collection and water costs; and identify any adverse impact that WASH interventions may have for participants.

BackgroundThe impacts of multicomponent school water, sanitation, and hygiene (WaSH) interventions on children’s health are unclear. We conducted a cluster-randomized controlled trial to test the effects of a school WaSH intervention on children’s malnutrition, dehydration, health literacy (HL), and handwashing (HW) in Metro Manila, Philippines.MethodsThe trial lasted from June 2017 to March 2018 and included children, in grades 5, 6, 7, and 10, from 15 schools. At baseline 756 children were enrolled. Seventy-eight children in two clusters were purposively assigned to the control group (CG); 13 clusters were randomly assigned to one of three intervention groups: low-intensity health education (LIHE; two schools, n = 116 children), medium-intensity health education (MIHE; seven schools, n = 356 children), and high-intensity health education (HIHE; four schools, n = 206 children). The intervention consisted of health education (HE), WaSH policy workshops, provision of hygiene supplies, and WaSH facilities repairs. Outcomes were: height-for-age and body mass index-for-age Z scores (HAZ, BAZ); stunting, undernutrition, overnutrition, dehydration prevalence; HL and HW scores. We used anthropometry to measure children’s physical growth, urine test strips to measure dehydration, questionnaires to measure HL, and observation to measure HW practice. The same measurements were used during baseline and endline. We used multilevel mixed-effects logistic and linear regression models to assess intervention effects.ResultsNone of the interventions reduced undernutrition prevalence or improved HAZ, BAZ, or overall HL scores. Low-intensity HE reduced stunting (adjusted odds ratio [aOR] 0.95; 95% CI 0.93 to 0.96), while low- (aOR 0.57; 95% CI 0.34 to 0.96) and high-intensity HE (aOR 0.63; 95% CI 0.42 to 0.93) reduced overnutrition. Medium- (adjusted incidence rate ratio [aIRR] 0.02; 95% CI 0.01 to 0.04) and high-intensity HE (aIRR 0.01; 95% CI 0.00 to 0.16) reduced severe dehydration. Medium- (aOR 3.18; 95% CI 1.34 to 7.55) and high-intensity HE (aOR 3.89; 95% CI 3.74 to 4.05) increased observed HW after using the toilet/urinal.ConclusionIncreasing the intensity of HE reduced prevalence of stunting, overnutrition, and severe dehydration and increased prevalence of observed HW. Data may be relevant for school WaSH interventions in the Global South. Interventions may have been more effective if adherence was higher, exposure to interventions longer, parents/caregivers were more involved, or household WaSH was addressed.Trial registration numberDRKS00021623.

Sub-Saharan Africa (SSA) has the world’s lowest coverage of safely managed water, sanitation, and hygiene (WASH) services. Numerous global and pan-African systematic reviews exist, but often has limited applicability to this sub-region. This scoping review maps the effectiveness and outcomes of WASH interventions implemented since 2010 in 17 Anglophone SSA - countries. Following JBI methodology and PRISMA-ScR guidelines, through searches of four databases (PubMed, Scopus, Google Scholar, and ResearchGate) and websites of relevant WASH organizations from July to December 2023. Two reviewers independently screened 523 unique records screened, 51 publications reporting 49 interventions. Most interventions (71%) combined all three WASH components and were delivered in rural areas (74%) via community- or school-based platforms. RCTs comprised (76%) of the study design. About 78% of interventions achieved increased latrine coverage, handwashing with soap, or reduced diarrhoeal/helminth infections. Major enablers were community ownership, participatory design, and sustained engagement. Dominant barriers were financial constraints, delayed funding, poor adherence and weak political/institutional support.Equity analyses were rare and showed mixed or pro-rich effects. By focusing exclusively on Anglophone SSA and systematically analyzing contextual and equity dimensions, this review provides implementation-focused evidence to inform more effective, equitable, and sustainable WASH policies.

BackgroundInadequate access to water, sanitation, and hygiene (WASH) is an environmental risk factor for poor health outcomes globally, particularly for children in low- and middle-income countries (LMIC). Despite technological advancements, many interventions aimed at improving WASH access return less than optimal results on long term impact, efficacy and sustainability. Research focus in the ‘WASH sector’ has recently expanded from investigating ‘which interventions work’ to ‘how they are best implemented’. The ‘acceptability’ of an intervention is a key component of implementation that can influence initial uptake and sustained use. Acceptability assessments are increasingly common for health interventions in clinical settings. A broad scale assessment of how acceptability has been measured in the WASH sector, however, has not yet been conducted.Methods/Principal findingsWe conducted a systematic literature review of intervention studies published between 1990 and 2021 that evaluated the acceptability of WASH interventions in LMIC settings. Using an implementation science approach, focused outcomes included how acceptability was measured and defined, and the timing of acceptability assessment. We conducted quality assessment for all included studies using the Cochrane Risk of Bias tool for randomised studies, and the Newcastle-Ottawa Scale for non-randomised studies.Of the 1238 records; 36 studies were included for the analysis, 22 of which were non-randomized interventions and 16 randomized or cluster-randomized trials. We found that among the 36 studies, four explicitly defined their acceptability measure, and six used a behavioural framework to inform their acceptability study design. There were few acceptability evaluations in schools and healthcare facilities. While all studies reported measuring WASH acceptability, the measures were often not comparable or described.ConclusionsAs focus in WASH research shifts towards implementation, a consistent approach to including, defining, and measuring acceptability is needed.