Environmental sanitation and undernutrition among China’s children and adolescents from 1989 to 2011

Hamlet, Leigh C.; Chakrabarti, Suman; Kaminsky, Jessica

doi:10.1038/s44221-023-00112-6

Cited by 5 publications

(2 citation statements)

References 106 publications

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“…suggested critical thresholds at which community-wide sanitation significantly affects nutrition outcomes [47,48]. For example, a recent investigation identified a range of 25% to 50% OD prevalence as being pivotal for child height across 4 countries [49].…”

Section: Plos Medicinementioning

confidence: 99%

“…Cross-sectional studies are subject to systematic errors or biases, and the association between WASH and STH is not consistently supported by the available evidence from randomized controlled trials [52]. Conventional approaches often focus on low-cost household interventions, neglecting broader fecal exposure risks linked to undernutrition [47]. Moreover, to estimate the causal interaction effects of deworming on micronutrient status in different community sanitation contexts would require researchers to randomize deworming treatments and sanitation levels across communities [53].…”

Section: Plos Medicinementioning

confidence: 99%

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Deworming and micronutrient status by community open defecation prevalence: An observational study using nationally representative data from India, 2016–2018

Chakrabarti,

Ajjampur,

Waddington

et al. 2024

PLoS Med

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Background Micronutrient deficiencies are widespread in India. Soil-transmitted helminth (STH) infections are acquired by interaction with soil and water contaminated by human feces and lead to blood loss and poor micronutrient absorption. The current recommendation for control of STH-related morbidity is targeted deworming, yet little is known about the effectiveness of deworming on micronutrient status in varying sanitation contexts. Ranging between 1% and 40% prevalence across Indian states, open defecation (OD) remains high despite India’s investments at elimination by promoting community-wide sanitation. This variation provides an opportunity to study the relationship between deworming, micronutrient status, and OD at-scale. Methods and findings Cross-sectional datasets that were representative for India were obtained the Comprehensive National Nutrition Survey in 2016 to 2018 (n = 105,060 individuals aged 1 to 19 years). Consumption of deworming medication was described by age and community OD level. Logistic regression models were used to examine the relationship between deworming, cluster OD, and their interactions, with anemia and micronutrient deficiencies (iron, zinc, vitamin A, folate, and vitamin B12), controlling for age, sex, wealth, diet, and seasonality. These regression models further allowed us to identify a minimum OD rate after which deworming becomes ineffective. In sensitivity analyses, the association between deworming and deficiencies were tested in subsamples of communities classified into 3 OD levels based on statistical tertiles: OD free (0% of households in the community practicing OD), moderate OD (>0% and <30%), or high OD (at least 30%). Average deworming coverage and OD prevalence in the sample were 43.4% [IQR 26.0, 59.0] and 19.1% [IQR 0, 28.5], respectively. Controlling for other determinants of nutritional status, adolescents living in communities with higher OD levels had lower coverage of deworming and higher prevalence of anemia, zinc, vitamin A, and B12 deficiencies. Compared to those who were not dewormed, dewormed children and adolescents had lower odds of anemia (adjusted odds ratio 0.72, (95% CI [0.67, 0.78], p < 0.001) and deficiencies of iron 0.78, (95% CI [0.74, 0.82], p < 0.001) and folate 0.69, (95% CI [0.64,0.74], p<0.001)) in OD free communities. These protective effects remained significant for anemia but diminished for other micronutrient deficiencies in communities with moderate or high OD. Analysis of community OD indicated a threshold range of 30% to 60%, above which targeted deworming was no longer significantly associated with lower anemia, iron, and folate deficiency. The primary limitations of the study included potential for omitted variables bias and inability to capture longitudinal effects. Conclusions Moderate to high rates of OD significantly modify the association between deworming and micronutrient status in India. Public health policy could involve sequencing interventions, with focus on improving deworming coverage in communities that have achieved minimum thresholds of OD and re- triggering sanitation interventions in high OD communities prior to deworming days, ensuring high coverage for both. The efficacy of micronutrient supplementation as a complementary strategy to improve nutritional outcomes alongside deworming and OD elimination in this age group needs further study.

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Section: Plos Medicinementioning

confidence: 99%