Effects of Individual and Combined Water, Sanitation, Handwashing, and Nutritional Interventions on Child Respiratory Infections in Rural Kenya: A Cluster-Randomized Controlled Trial

Swarthout, Jenna; Ram, Pavani K.; Dentz, Holly N.; Arnold, Benjamin F.; Kalungu, Stephen; Lin, Audrie; Njenga, Sammy M.; Stewart, Christine P; Colford, John M.; Null, Clair; Pickering, Amy J.

doi:10.4269/ajtmh.19-0779

Cited by 12 publications

(5 citation statements)

References 28 publications

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“…In Kenya, the interventions had no effect on diarrhea 22 , and respiratory infections were reduced by 13% in the nutrition arm during the first year of the trial but not during the full study period and not in the WSH and N+WSH arms 23 . Similarly, in this analysis, total days of antibiotic use was reduced only in the nutrition arm, and only at the first measurement when children were on average 6 months old.…”

Section: Discussionmentioning

confidence: 91%

“…In Bangladesh, children receiving WSH and nutrition interventions had reduced prevalence of diarrhea 20 and respiratory infections 21 compared to controls. In Kenya, children receiving the nutrition intervention had marginally lower prevalence of respiratory infections than controls; there were no other intervention effects 22,23 . In both countries, the nutrition intervention improved child linear growth 20,22 .…”

Section: Introductionmentioning

confidence: 92%

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Can drinking water, sanitation, handwashing, and nutritional interventions reduce antibiotic use in young children?

Ercumen,

Mertens,

Butzin-Dozier

et al. 2024

Preprint

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Frequent antibiotic use in areas with high infection burdens can lead to antimicrobial resistance and microbiome alterations. Reducing pathogen exposure and child undernutrition can reduce infections and subsequent antibiotic use. We assessed effects of water, sanitation, handwashing (WSH) and nutrition interventions on pediatric antibiotic use in Bangladesh and Kenya, using longitudinal data from birth cohorts (at ages 3-28 months) enrolled in the WASH Benefits cluster-randomized trials. Over 50% of children used antibiotics at least once in the last 90 days. In Bangladesh, the prevalence of using antibiotics at least once was 10-14% lower in groups receiving WSH (prevalence ratio [PR]=0.90 (0.82-0.99)), nutrition (PR=0.86 (0.78-0.94)), and nutrition+WSH (PR=0.86 (0.79-0.93)) interventions. The prevalence of using antibiotics multiple times was 24-35% lower in intervention arms. Intervention effects were strongest when the birth cohort was younger. In Kenya, interventions did not affect antibiotic use. Improving WSH and nutrition can reduce antibiotic use in some low- and middle-income settings. Studies should assess whether such reductions translate to reduced carriage of antimicrobial resistance.

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Section: Discussionmentioning

confidence: 91%

Section: Introductionmentioning

confidence: 92%

Can drinking water, sanitation, handwashing, and nutritional interventions reduce antibiotic use in young children?

Ercumen,

Mertens,

Butzin-Dozier

et al. 2024

Preprint

Self Cite

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“…Moreover, the practice of open defecation contributes to repeated faecal contamination of the local environment, exposing affected populations to numerous faecal pathogens responsible for causing diarrhoea. Additionally, inadequate hand hygiene promotes the transmission of faecal and respiratory pathogens through droplets and contaminated objects, increasing the risk of contracting diarrhoea or ARI 27 33–35. Although the potential of WASH interventions to reduce diarrhoea-related morbidity is widely acknowledged, the evidence, particularly for children under 5 years, is poor 36–38.…”

Section: Introductionmentioning

confidence: 99%

Exploring the association between household access to water, sanitation and hygiene (WASH) services and common childhood diseases using data from the 2017–2018 Demographic and Health Survey in Benin: focus on diarrhoea and acute respiratory infection

Gaffan,

Degbey,

Kpozehouen

et al. 2023

BMJ Open

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ObjectiveThe paper aimed to study the association between household access to water, sanitation and hygiene (WASH) services and the occurrence of diarrhoea and acute respiratory infection among children under 5 years in Benin.DesignWe performed secondary analyses using Benin’s Fifth Demographic and Health Survey datasets. The dependent variables were diarrhoea and acute respiratory infection (yes=1, no=0). Among the independent variables were the household access to individual WASH services, grouped as follows: ‘basic’, ‘limited’, ‘unimproved’ and ‘no service’. Multivariate logistic regression was used to determine the association between household access to WASH services and the occurrence of diarrhoea and acute respiratory infection. Results from the multivariate logistic regression were presented using adjusted Odds Ratios (aORs) with 95% Confidence Intervals (95% CIs).SettingBenin.ParticipantsChildren under 5 years successfully surveyed during Benin’s Fifth Demographic and Health Survey.Outcome measuresDiarrhoea and acute respiratory infection.ResultsIn the current study, 12 034 children under 5 years met the selection criteria and were included in the analyses. The prevalence of diarrhoea and acute respiratory infection was 10.5% (95% CI=9.8% to 11.3%) and 2.9% (95% CI=2.5% to 3.4%), respectively. Children living in households without sanitation service, that is, practising open defecation (aOR=1.9, 95% CI=1.4 to 2.6), and with unimproved (aOR=1.9, 95% CI=1.3 to 2.7) and limited (aOR=1.5, 95% CI=1.1 to 2.2) services were more likely to have diarrhoea compared with children with basic sanitation services. Household access to WASH services was not associated with acute respiratory infection.ConclusionWe suggest reinforcing household access to basic sanitation services to combat diarrhoea in children under 5 years. Further research is needed on the effects of WASH interventions on diarrhoea and acute respiratory infection in children under 5 years.

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“…The WASH Benefits Kenya and Bangladesh trials provided latrine upgrades, child feces management tools, and behavioral promotion in rural Kenya and Bangladesh. The Kenya trial found no effect on diarrheal disease [17], soil-transmitted helminth infections [19], and ARI [20] from the sanitation intervention. In Bangladesh, the sanitation intervention led to prevalence reductions of 39% for diarrheal disease, 25% for Giardia infections, 29% for Trichuris trichiura infections, and 25% for ARI [16,[21][22][23].…”

Section: Introductionmentioning

confidence: 99%

Evaluation of an on-site sanitation intervention against childhood diarrhea and acute respiratory infection 1 to 3.5 years after implementation: Extended follow-up of a cluster-randomized controlled trial in rural Bangladesh

et al. 2022

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Background Diarrhea and acute respiratory infection (ARI) are leading causes of death in children. The WASH Benefits Bangladesh trial implemented a multicomponent sanitation intervention that led to a 39% reduction in the prevalence of diarrhea among children and a 25% reduction for ARI, measured 1 to 2 years after intervention implementation. We measured longer-term intervention effects on these outcomes between 1 to 3.5 years after intervention implementation, including periods with differing intensity of behavioral promotion. Methods and findings WASH Benefits Bangladesh was a cluster-randomized controlled trial of water, sanitation, hygiene, and nutrition interventions (NCT01590095). The sanitation intervention included provision of or upgrades to improved latrines, sani-scoops for feces removal, children’s potties, and in-person behavioral promotion. Promotion was intensive up to 2 years after intervention initiation, decreased in intensity between years 2 to 3, and stopped after 3 years. Access to and reported use of latrines was high in both arms, and latrine quality was significantly improved by the intervention, while use of child feces management tools was low. We enrolled a random subset of households from the sanitation and control arms into a longitudinal substudy, which measured child health with quarterly visits between 1 to 3.5 years after intervention implementation. The study period therefore included approximately 1 year of high-intensity promotion, 1 year of low-intensity promotion, and 6 months with no promotion. We assessed intervention effects on diarrhea and ARI prevalence among children <5 years through intention-to-treat analysis using generalized linear models with robust standard errors. Masking was not possible during data collection, but data analysis was masked. We enrolled 720 households (360 per arm) from the parent trial and made 9,800 child observations between June 2014 and December 2016. Over the entire study period, diarrheal prevalence was lower among children in the sanitation arm (11.9%) compared to the control arm (14.5%) (prevalence ratio [PR] = 0.81, 95% CI 0.66, 1.00, p = 0.05; prevalence difference [PD] = −0.027, 95% CI −0.053, 0, p = 0.05). ARI prevalence did not differ between sanitation (21.3%) and control (22.7%) arms (PR = 0.93, 95% CI 0.82, 1.05, p = 0.23; PD = −0.016, 95% CI −0.043, 0.010, p = 0.23). There were no significant differences in intervention effects between periods with high-intensity versus low-intensity/no promotion. Study limitations include use of caregiver-reported symptoms to define health outcomes and limited data collected after promotion ceased. Conclusions The observed effect of the WASH Benefits Bangladesh sanitation intervention on diarrhea in children appeared to be sustained for at least 3.5 years after implementation, including 1.5 years after heavy promotion ceased. Existing latrine access was high in the study setting, suggesting that improving on-site latrine quality can deliver health benefits when latrine use practices are in place. Further work is needed to understand how latrine adoption can be achieved and sustained in settings with low existing access and how sanitation programs can adopt transformative approaches of excreta management, including safe disposal of child and animal feces, to generate a hygienic home environment. Trial registration ClinicalTrials.gov; NCT01590095; https://clinicaltrials.gov/ct2/show/NCT01590095.

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Effects of Individual and Combined Water, Sanitation, Handwashing, and Nutritional Interventions on Child Respiratory Infections in Rural Kenya: A Cluster-Randomized Controlled Trial

Cited by 12 publications

References 28 publications

Can drinking water, sanitation, handwashing, and nutritional interventions reduce antibiotic use in young children?

Can drinking water, sanitation, handwashing, and nutritional interventions reduce antibiotic use in young children?

Exploring the association between household access to water, sanitation and hygiene (WASH) services and common childhood diseases using data from the 2017–2018 Demographic and Health Survey in Benin: focus on diarrhoea and acute respiratory infection

Evaluation of an on-site sanitation intervention against childhood diarrhea and acute respiratory infection 1 to 3.5 years after implementation: Extended follow-up of a cluster-randomized controlled trial in rural Bangladesh

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