Effect of Water, Sanitation, Handwashing, and Nutrition Interventions on Enteropathogens in Children 14 Months Old: A Cluster-Randomized Controlled Trial in Rural Bangladesh

Abstract

Background We evaluated the impact of low-cost water, sanitation, handwashing (WSH) and child nutrition interventions on enteropathogen carriage in the WASH Benefits cluster-randomized controlled trial in rural Bangladesh. Methods We analyzed 1411 routine fecal samples from children 14±2 months old in the WSH (n = 369), nutrition counseling plus lipid-based nutrient supplement (n = 353), nutrition plus WSH (n = 360), and control (n = 329) arms for 34 enteropathogens using quantitative PCR. Outcomes included the number of co-occurring pathogens; cumulative quantity of four stunting-associated pathogens; and prevalence and quantity of individual pathogens. Masked analysis was by intention-to-treat. Results 326 (99.1%) control children had one or more enteropathogens detected (mean 3.8±1.8). Children receiving WSH interventions had lower prevalence and quantity of individual viruses than controls (prevalence difference for norovirus: -11% [95% confidence interval [CI], -5 to -17%]; sapovirus: -9% [95%CI, -3 to -15%]; and adenovirus 40/41: -9% [95%CI, -2 to - 15%]). There was no difference in bacteria, parasites, or cumulative quantity of stunting-associated pathogens between controls and any intervention arm. Conclusions WSH interventions were associated with fewer enteric viruses in children aged 14 months. Different strategies are needed to reduce enteric bacteria and parasites at this critical young age.

Effects of an urban sanitation intervention on childhood enteric infection and diarrhea in Maputo, Mozambique: A controlled before-and-after trial

“…Most studies of onsite sanitation interventions have occurred in rural areas. Despite good evidence that onsite sanitation is associated with reductions in diarrheal disease ( Freeman et al, 2017a ; Wolf et al, 2018 ), several recent rural trials of basic sanitation and combined WASH interventions with good uptake and use reported mixed effects on child health outcomes including diarrhea, linear growth, and more recently, enteric infection ( Ercumen et al, 2019 ; Grembi et al, 2020 ; Sanitation Hygiene Infant Nutrition Efficacy (SHINE) Trial Team et al, 2019 ; Lin et al, 2018 ; Luby et al, 2018 ; Null et al, 2018 ; Pickering et al, 2019 ; Rogawski McQuade et al, 2020a ).…”

“…The sanitation-only arm had no impact on any parasite measured, although T. trichiura was too infrequently detected to estimate effects ( Pickering et al, 2019 ). An evaluation of a comprehensive suite of 34 enteric pathogens reported reduced prevalence and quantity of enteric viruses, but not bacteria or parasites, among children aged 14 months old in the combined WASH arms in the Bangladesh trial ( Grembi et al, 2020 ). Together with our findings, these results suggest that sanitation and combined WASH interventions can reduce the prevalence of enteric infection in some settings but that effects may vary by pathogen, child age, intervention, and setting.…”

Effect of handwashing with soap at crtitical times and home based water treatment in combating hot spot areas of childhood diarrhea in Ethiopia

“…Evidences noticed that handwashing with soap eliminates transient potentially pathogenic organisms from the hands through the in uences of microbial effectiveness [35], despite a complete change of handwashing behavior remains challenged [37]. Particularly handwashing before preparing food is a mostly imperative opportunity to avert CHD that appears to be a primary means of prevention where intervened households had a lower prevalence of CHD [38,39]. Moreover, compared with controls, children in households with plain soap had a 53% lower incidence of CHD in Karachi, Pakistan [40].…”

Effects of an urban sanitation intervention on childhood enteric infection and diarrhea in Maputo, Mozambique: a controlled before-and-after trial

“…Most studies of onsite sanitation interventions have occurred in rural areas. Despite good evidence that onsite sanitation is associated with reductions in diarrheal disease (M. C. Freeman et al, 2017; Wolf et al, 2018), several recent rural trials of basic sanitation and combined WASH interventions with good uptake and use reported mixed effects on child health outcomes including diarrhea, linear growth, and more recently, enteric infection (Ercumen et al, 2019; Grembi et al, 2020; Humphrey et al, 2019; Lin et al, 2018; Luby et al, 2018; Null et al, 2018; Pickering et al, 2019; Rogawski McQuade, Platts-Mills, et al, 2020).…”

“…The sanitation-only arm had no impact on any parasite measured, though T. trichiura was too infrequently detected to estimate effects (Pickering et al, 2019). An evaluation of a comprehensive suite of 34 enteric pathogens reported reduced prevalence and quantity of enteric viruses, but not bacteria or parasites, among children aged 14 months old in the combined WASH arms in the Bangladesh trial (Grembi et al, 2020). Together with our findings, these results suggest that sanitation and combined WASH interventions can reduce the prevalence of enteric infection in some settings but that effects may vary by pathogen, child age, intervention, and setting.…”