Abstract. We conducted a matched-control trial in Mali to assess the effectiveness of a comprehensive school-based water, sanitation, and hygiene (WASH) intervention on pupil absence, diarrhea, and respiratory infections. After completion of the intervention, data were collected from 100 beneficiary schools and 100 matched comparison schools in 5-6 sessions over a 14-month period. Data collection included roll calls to assess absenteeism and interviews with a subset of pupils to assess recent absence and disease symptoms. The odds of pupils being absent at roll call were 23% higher in beneficiary schools than in comparison schools (odds ratio [OR]: 1.23, 95% confidence interval [CI]: 1.06, 1.42). The odds of pupils reporting being absent due to diarrhea (OR: 0.73, 95% CI: 0.56, 0.94) or having had diarrhea (OR: 0.71, 95% CI: 0.60, 0.85) or respiratory infection symptoms (OR: 0.75, 95% CI: 0.65, 0.86) in the past week were lower in beneficiary schools compared with comparison schools. We found that a school-based WASH intervention can have a positive effect on reducing rates of illness, as well as absence due to diarrhea. However, we did not find evidence that these health impacts led to a reduction in overall absence. Higher absence rates are less likely attributable to the intervention than the result of an imbalance in unobserved confounders between study groups.

Abstract. Malaria serology through assaying for IgG against Plasmodium spp. antigens provides evidence into the infection history for an individual. The multiplex bead assay (MBA) allows for detection of IgG against multiple Plasmodium spp., and can be especially useful in many regions where Plasmodium falciparum is of primary clinical focus, but other species are co-endemic. Dried blood spots were collected from 805 Malian children attending 42 elementary schools in the regions of Mopti, Sikasso, Koulikoro, and Bamako capital district, and IgG assayed by MBA. As southern Mali is known to be holoendemic for P. falciparum, merozoite surface protein 1 19-kDa subunit (MSP-1 42 ) and apical membrane antigen 1 (AMA-1) antigens were included for serology against this parasite. Responses to these antigens both provided high estimates for lifetime exposure, with 730 (90%) children with IgG antibodies for MSP-1 42 , 737 (91%) for AMA-1, and 773 (96%) positive for either or both. Also included was the antigen Plasmodium vivax MSP-1 19 , against which 140 (17.4%) children were found to have antibodies. Increases in antibody titers with older age were clearly seen with the P. falciparum antigens, but not with the P. vivax antigen, likely indicating more of a sporadic, rather than sustained transmission for this species. The MBA provides effective opportunities to evaluate malaria transmission through serological analysis for multiple Plasmodium species.

There is a well-established link between hydration and improved cognitive performance among adults, with evidence of similar findings among children. No trials have investigated the impact of water provision on cognitive performance among schoolchildren in hot and arid low-resource settings. We conducted a randomized-controlled trial in five schools with limited water access in Chipata district in Eastern province, Zambia, to assess the efficacy of water provision on cognition. Pupils in grades 3–6 were randomly assigned to either receive a bottle of drinking water that they could refill throughout the day (water group, n = 149) or only have access to drinking water that was normally available at the school (control group, n = 143). Hydration was assessed in the morning before provision of water and in the afternoon through urine specific gravity (Usg) measured with a portable refractometer. In the afternoon we administered six cognitive tests to assess short-term memory, concentration, visual attention, and visual motor skills. Morning prevalence of dehydration, defined as Usg≥1.020, was 42%. Afternoon dehydration increased to 67% among the control arm and dropped to 10% among the intervention arm. We did not find that provision of water or hydration impacted cognitive test scores, although there were suggestive relationships between both water provision and hydration and increased scores on tests measuring visual attention. We identified key improvements to the study design that are warranted to further investigate this relationship.Trial Registration: ClinicalTrials.gov NCT01924546

Abstract. Studies assessing the impacts of school-based water, sanitation, and hygiene (WASH) interventions have revealed inconsistent improvements in pupils' health and educational outcomes. This may be in part due to suboptimal project fidelity or adherence. As part of a matched-control trial of a comprehensive school-based WASH project in Mali, we measured the degree to which schools met four prespecified WASH targets, comprised of 15 criteria, 0-3 years after program implementation. We compared achievement of the targets and criteria between beneficiary and matched control schools, and compared achievement within beneficiary schools at baseline and at follow-up visits. We assessed the "as-treated" associations between WASH target achievement and pupil diarrhea, respiratory symptoms, and absence. Between 44% and 81% of beneficiary schools achieved each target. Although adherence was inconsistent across schools, beneficiary schools, on average, met more WASH targets than matched control schools, and beneficiary schools also met more WASH targets at follow-up than at baseline. Very few of the targets were individually associated with health and absenteeism outcomes. Increasing achievement of multiple WASH targets together was associated with a lower odds of pupils having diarrhea (P trend < 0.01) and having respiratory symptoms (P trend < 0.01), but was not associated with roll-call absence (P trend = 0.14) or pupil-reported absence (P trend = 0.41). These results indicate that a comprehensive WASH intervention and a focus on increasing adherence may help maximize the health effects of school WASH programs, but that WASH alone might not be sufficient to decrease pupils' absenteeism.

Adequate provision of safe water, basic sanitation, and hygiene (WASH) facilities and behavior change can reduce pupil absence and infectious disease. Increased drinking water quantity may also improve educational outcomes through the effect of hydration on attention, concentration, and short-term memory. A pilot study was conducted to adapt field measures of short-term cognitive performance and hydration, to evaluate levels of hydration, and to investigate the impact of providing supplementary drinking water on the cognitive performance of pupils attending water-scarce schools in rural Mali. Using a cross-over trial design, data were collected under normal school conditions (control condition) on one visit day; on the other, participants were given a bottle of water that was refilled throughout the day (water condition). Morning and afternoon hydration was assessed using specific gravity and urine color. Cognitive performance was evaluated using six paper-based tests. Three percent of pupils were dehydrated on the morning of each visit. The prevalence of dehydration increased in the afternoon, but was lower under the water condition. Although there was a trend indicating drinking water may improve cognitive test performance, as has been shown in studies in other settings, results were not statistically significant and were masked by a “practice effect.”