IntroductionFacial hygiene promotion and environmental improvements are central components of the global trachoma elimination strategy despite a lack of experimental evidence supporting the effectiveness of water, sanitation and hygiene (WASH) measures for reducing trachoma transmission. The objective of the WUHA (WASH Upgrades for Health in Amhara) trial is to evaluate if a comprehensive water improvement and hygiene education programme reduces the prevalence of ocular chlamydia infection in rural Africa.Methods and analysisForty study clusters, each of which had received at least annual mass azithromycin distributions for the 7 years prior to the start of the study, are randomised in a 1:1 ratio to the WASH intervention arm or a delayed WASH arm. The WASH package includes a community water point, community-based hygiene promotion workers, household wash stations, household WASH education books, household soap distribution and a primary school hygiene curriculum. Educational activities emphasise face-washing and latrine use. Mass antibiotic distributions are not provided during the first 3 years but are provided annually over the final 4 years of the trial. Annual monitoring visits are conducted in each community. The primary outcome is PCR evidence of ocular chlamydia infection among children aged 0–5 years, measured in a separate random sample of children annually over 7 years. A secondary outcome is improvement of the clinical signs of trachoma between the baseline and final study visits as assessed by conjunctival photography. Laboratory workers and photo-graders are masked to treatment allocation.Ethics and disseminationStudy protocols have been approved by human subjects review boards at the University of California, San Francisco, Emory University, the Ethiopian Food and Drug Authority, and the Ethiopian Ministry of Innovation and Technology. A data safety and monitoring committee oversees the trial. Results will be disseminated through peer-reviewed publications and presentations.Trial registration number(http://www.clinicaltrials.gov): NCT02754583; Pre-results.

Background WHO promotes the SAFE strategy for the elimination of trachoma as a public health programme, which promotes surgery for trichiasis (ie, the S component), antibiotics to clear the ocular strains of chlamydia that cause trachoma (the A component), facial cleanliness to prevent transmission of secretions (the F component), and environmental improvements to provide water for washing and sanitation facilities (the E component). However, little evidence is available from randomised trials to support the efficacy of interventions targeting the F and E components of the strategy. We aimed to determine whether an integrated water, sanitation, and hygiene (WASH) intervention prevents the transmission of trachoma. MethodsThe WASH Upgrades for Health in Amhara (WUHA) was a two-arm, parallel-group, cluster-randomised trial in 40 rural communities in Wag Hemra Zone (Amhara Region, Ethiopia) that had been treated with 7 years of annual mass azithromycin distributions. The randomisation unit was the school catchment area. All households within a 1•5 km radius of a potential water point within the catchment area (as determined by the investigators) were eligible for inclusion. Clusters were randomly assigned (at a 1:1 ratio) to receive a WASH intervention either immediately (intervention) or delayed until the conclusion of the trial (control), in the absence of concurrent antibiotic distributions. Given the nature of the intervention, participants and field workers could not be masked, but laboratory personnel were masked to treatment allocation. The WASH intervention consisted of both hygiene infrastructure improvements (namely, construction of a community water point) and hygiene promotion by government, school, and community leaders, which were implemented at the household, school, and community levels. Hygiene promotion focused on two simple messages: to use soap and water to wash your or your child's face, and to always use a latrine for defecation. The primary outcome was the cluster-level prevalence of ocular chlamydia, measured annually using conjunctival swabs in a random sample of children aged 0-5 years from each cluster at 12, 24, and 36 month timepoints. Analyses were done in an intention-to-treat manner. This trial is ongoing and is registered at ClinicalTrials.gov, NCT02754583.

The difference in prevalence of undernutrition and two-week disease history in women and children in Oromia, Ethiopia was compared between two intervention groups: nutrition only (comparison group) and integrated water, sanitation, and hygiene (WASH) and nutrition (integrated group). In both groups, health care workers were trained in community management of acute malnutrition and infant and young child feeding practices. Health care workers in turn organized events and household visits to identify and treat acutely malnourished infants and children, convey messaging regarding proper infant and young child feeding, and provide vegetable seeds for household gardens. The integrated group additionally received water tap construction and community-led total sanitation and hygiene. Four years post initiation, a household and child anthropometric survey (n=1,007) of mothers of children 0-59 months was conducted in 12 villages (6 per group). Accounting for sample design, logistic regression was used to determine adjusted odds ratios for child nutritional outcomes and child and maternal two-week disease history by intervention group. At follow up, intervention groups were similar in demographics, diet and feeding practices, immunization, supplementation, and access to water and hygiene. Access to an improved sanitation facility was greater in the integrated group (48%) than in the comparison group (28%) (p=0.02). Children from the integrated group had a 16 percentage point (95% CI: 0-32 percentage points) and 14 percentage point (95% CI: 5-22 percentage points) lower prevalence of stunting and fever, respectively, than children from the comparison group. The adjusted odds of stunting and fever in children from the integrated group were 50% (OR: 0.50, 95% CI: 0.26, 0.97) and 49% (OR: 0.51, 95% CI: 0.36, 0.74) lower than the odds of stunting and fever in children from the comparison group. Stratifying by intervention group, mean height-forage Z-score increased with sanitation facility among children from the comparison group only. There was no difference in maternal history of disease between groups. Integration of WASH and nutrition was associated with less stunting and disease in children 0-59 months in a setting with poor WASH conditions. Differences in sanitation may contribute to the gains in growth seen among children in the integrated group.

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