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ObjectiveTo estimate the burden of diarrhoeal diseases from exposure to inadequate water, sanitation and hand hygiene in low- and middle-income settings and provide an overview of the impact on other diseases.MethodsFor estimating the impact of water, sanitation and hygiene on diarrhoea, we selected exposure levels with both sufficient global exposure data and a matching exposure-risk relationship. Global exposure data were estimated for the year 2012, and risk estimates were taken from the most recent systematic analyses. We estimated attributable deaths and disability-adjusted life years (DALYs) by country, age and sex for inadequate water, sanitation and hand hygiene separately, and as a cluster of risk factors. Uncertainty estimates were computed on the basis of uncertainty surrounding exposure estimates and relative risks.ResultsIn 2012, 502 000 diarrhoea deaths were estimated to be caused by inadequate drinking water and 280 000 deaths by inadequate sanitation. The most likely estimate of disease burden from inadequate hand hygiene amounts to 297 000 deaths. In total, 842 000 diarrhoea deaths are estimated to be caused by this cluster of risk factors, which amounts to 1.5% of the total disease burden and 58% of diarrhoeal diseases. In children under 5 years old, 361 000 deaths could be prevented, representing 5.5% of deaths in that age group.ConclusionsThis estimate confirms the importance of improving water and sanitation in low- and middle-income settings for the prevention of diarrhoeal disease burden. It also underscores the need for better data on exposure and risk reductions that can be achieved with provision of reliable piped water, community sewage with treatment and hand hygiene.

Abstractobjective To estimate the global prevalence of handwashing with soap and derive a pooled estimate of the effect of hygiene on diarrhoeal diseases, based on a systematic search of the literature.methods Studies with data on observed rates of handwashing with soap published between 1990 and August 2013 were identified from a systematic search of PubMed, Embase and ISI Web of Knowledge. A separate search was conducted for studies on the effect of hygiene on diarrhoeal disease that included randomised controlled trials, quasi-randomised trials with control group, observational studies using matching techniques and observational studies with a control group where the intervention was well defined. The search used Cochrane Library, Global Health, BIOSIS, PubMed, and Embase databases supplemented with reference lists from previously published systematic reviews to identify studies published between 1970 and August 2013. Results were combined using multilevel modelling for handwashing prevalence and meta-regression for risk estimates.results From the 42 studies reporting handwashing prevalence we estimate that approximately 19% of the world population washes hands with soap after contact with excreta (i.e. use of a sanitation facility or contact with children's excreta). Meta-regression of risk estimates suggests that handwashing reduces the risk of diarrhoeal disease by 40% (risk ratio 0.60, 95% CI 0.53-0.68); however, when we included an adjustment for unblinded studies, the effect estimate was reduced to 23% (risk ratio 0.77, 95% CI 0.32-1.86).conclusions Our results show that handwashing after contact with excreta is poorly practiced globally, despite the likely positive health benefits.

Abstractobjective To assess the impact of inadequate water and sanitation on diarrhoeal disease in lowand middle-income settings.methods The search strategy used Cochrane Library, MEDLINE & PubMed, Global Health, Embase and BIOSIS supplemented by screening of reference lists from previously published systematic reviews, to identify studies reporting on interventions examining the effect of drinking water and sanitation improvements in low-and middle-income settings published between 1970 and May 2013. Studies including randomised controlled trials, quasi-randomised trials with control group, observational studies using matching techniques and observational studies with a control group where the intervention was well defined were eligible. Risk of bias was assessed using a modified OttawaNewcastle scale. Study results were combined using meta-analysis and meta-regression to derive overall and intervention-specific risk estimates.results Of 6819 records identified for drinking water, 61 studies met the inclusion criteria, and of 12 515 records identified for sanitation, 11 studies were included. Overall, improvements in drinking water and sanitation were associated with decreased risks of diarrhoea. Specific improvements, such as the use of water filters, provision of high-quality piped water and sewer connections, were associated with greater reductions in diarrhoea compared with other interventions.conclusions The results show that inadequate water and sanitation are associated with considerable risks of diarrhoeal disease and that there are notable differences in illness reduction according to the type of improved water and sanitation implemented.keywords water, sanitation, diarrhoea, global burden of disease, risk estimates 928