Poor sanitation remains a major public health concern linked to several important health outcomes; emerging evidence indicates a link to childhood stunting. In India over half of the population ...defecates in the open; the prevalence of stunting remains very high. Recently published data on levels of stunting in 112 districts of India provide an opportunity to explore the relationship between levels of open defecation and stunting within this population. We conducted an ecological regression analysis to assess the association between the prevalence of open defecation and stunting after adjustment for potential confounding factors. Data from the 2011 HUNGaMA survey was used for the outcome of interest, stunting; data from the 2011 Indian Census for the same districts was used for the exposure of interest, open defecation. After adjustment for various potential confounding factors--including socio-economic status, maternal education and calorie availability--a 10 percent increase in open defecation was associated with a 0.7 percentage point increase in both stunting and severe stunting. Differences in open defecation can statistically account for 35 to 55 percent of the average difference in stunting between districts identified as low-performing and high-performing in the HUNGaMA data. In addition, using a Monte Carlo simulation, we explored the effect on statistical power of the common practice of dichotomizing continuous height data into binary stunting indicators. Our simulation showed that dichotomization of height sacrifices statistical power, suggesting that our estimate of the association between open defecation and stunting may be a lower bound. Whilst our analysis is ecological and therefore vulnerable to residual confounding, these findings use the most recently collected large-scale data from India to add to a growing body of suggestive evidence for an effect of poor sanitation on human growth. New intervention studies, currently underway, may shed more light on this important issue.
Water, sanitation and hygiene (WASH) are essential for a healthy and dignified life. International targets to reduce inadequate WASH coverage were set under the Millennium Development Goals (MDGs, ...1990-2015) and now the Sustainable Development Goals (SDGs, 2016-2030). The MDGs called for halving the proportion of the population without access to adequate water and sanitation, whereas the SDGs call for universal access, require the progressive reduction of inequalities, and include hygiene in addition to water and sanitation. Estimating access to complete WASH coverage provides a baseline for monitoring during the SDG period. Sub-Saharan Africa (SSA) has among the lowest rates of WASH coverage globally.
The most recent available Demographic Household Survey (DHS) or Multiple Indicator Cluster Survey (MICS) data for 25 countries in SSA were analysed to estimate national and regional coverage for combined water and sanitation (a combined MDG indicator for 'improved' access) and combined water with collection time within 30 minutes plus sanitation and hygiene (a combined SDG indicator for 'basic' access). Coverage rates were estimated separately for urban and rural populations and for wealth quintiles. Frequency ratios and percentage point differences for urban and rural coverage were calculated to give both relative and absolute measures of urban-rural inequality. Wealth inequalities were assessed by visual examination of coverage across wealth quintiles in urban and rural populations and by calculating concentration indices as standard measures of relative wealth related inequality that give an indication of how unevenly a health indicator is distributed across the wealth distribution.
Combined MDG coverage in SSA was 20%, and combined basic SDG coverage was 4%; an estimated 921 million people lacked basic SDG coverage. Relative measures of inequality were higher for combined basic SDG coverage than combined MDG coverage, but absolute inequality was lower. Rural combined basic SDG coverage was close to zero in many countries.
Our estimates help to quantify the scale of progress required to achieve universal WASH access in low-income countries, as envisaged under the water and sanitation SDG. Monitoring and reporting changes in the proportion of the national population with access to water, sanitation and hygiene may be useful in focusing WASH policy and investments towards the areas of greatest need.
Summary Background A third of the 2·5 billion people worldwide without access to improved sanitation live in India, as do two-thirds of the 1·1 billion practising open defecation and a quarter of the ...1·5 million who die annually from diarrhoeal diseases. We aimed to assess the effectiveness of a rural sanitation intervention, within the context of the Government of India's Total Sanitation Campaign, to prevent diarrhoea, soil-transmitted helminth infection, and child malnutrition. Methods We did a cluster-randomised controlled trial between May 20, 2010, and Dec 22, 2013, in 100 rural villages in Odisha, India. Households within villages were eligible if they had a child younger than 4 years or a pregnant woman. Villages were randomly assigned (1:1), with a computer-generated sequence, to undergo latrine promotion and construction or to receive no intervention (control). Randomisation was stratified by administrative block to ensure an equal number of intervention and control villages in each block. Masking of participants was not possible because of the nature of the intervention. However, households were not told explicitly that the purpose of enrolment was to study the effect of a trial intervention, and the surveillance team was different from the intervention team. The primary endpoint was 7-day prevalence of reported diarrhoea in children younger than 5 years. We did intention-to-treat and per-protocol analyses. This trial is registered with ClinicalTrials.gov , number NCT01214785. Findings We randomly assigned 50 villages to the intervention group and 50 villages to the control group. There were 4586 households (24 969 individuals) in intervention villages and 4894 households (25 982 individuals) in control villages. The intervention increased mean village-level latrine coverage from 9% of households to 63%, compared with an increase from 8% to 12% in control villages. Health surveillance data were obtained from 1437 households with children younger than 5 years in the intervention group (1919 children younger than 5 years), and from 1465 households (1916 children younger than 5 years) in the control group. 7-day prevalence of reported diarrhoea in children younger than 5 years was 8·8% in the intervention group and 9·1% in the control group (period prevalence ratio 0·97, 95% CI 0·83–1·12). 162 participants died in the intervention group (11 children younger than 5 years) and 151 died in the control group (13 children younger than 5 years). Interpretation Increased latrine coverage is generally believed to be effective for reducing exposure to faecal pathogens and preventing disease; however, our results show that this outcome cannot be assumed. As efforts to improve sanitation are being undertaken worldwide, approaches should not only meet international coverage targets, but should also be implemented in a way that achieves uptake, reduces exposure, and delivers genuine health gains. Funding Bill & Melinda Gates Foundation, International Initiative for Impact Evaluation (3ie), and Department for International Development-backed SHARE Research Consortium at the London School of Hygiene & Tropical Medicine.
The extent to which reproductive tract infections (RTIs) are associated with poor menstrual hygiene management (MHM) practices has not been extensively studied. We aimed to determine whether poor ...menstrual hygiene practices were associated with three common infections of the lower reproductive tract; Bacterial vaginosis (BV), Candida, and Trichomonas vaginalis (TV).
Non-pregnant women of reproductive age (18-45 years) and attending one of two hospitals in Odisha, India, between April 2015 and February 2016 were recruited for the study. A standardized questionnaire was used to collect information on: MHM practices, clinical symptoms for the three infections, and socio-economic and demographic information. Specimens from posterior vaginal fornix were collected using swabs for diagnosis of BV, Candida and TV infection.
A total of 558 women were recruited for the study of whom 62.4% were diagnosed with at least one of the three tested infections and 52% presented with one or more RTI symptoms. BV was the most prevalent infection (41%), followed by Candida infection (34%) and TV infection (5.6%). After adjustment for potentially confounding factors, women diagnosed with Candida infection were more likely to use reusable absorbent material (aPRR = 1.54, 95%CI 1.2-2.0) and practice lower frequency of personal washing (aPRR = 1.34, 95%CI 1.07-1.7). Women with BV were more likely to practice personal washing less frequently (aPRR = 1.25, 95%CI 1.0-1.5), change absorbent material outside a toilet facility (aPRR = 1.21, 95%CI 1.0-1.48) whilst a higher frequency of absorbent material changing was protective (aPRR = 0.56, 95%CI 0.4-0.75). No studied factors were found to be associated with TV infection. In addition, among women reusing absorbent material, Candida but not BV or TV - infection was more frequent who dried their pads inside their houses and who stored the cloth hidden in the toilet compartment.
The results of our study add to growing number of studies which demonstrate a strong and consistent association between poor menstrual hygiene practices and higher prevalence of lower RTIs.
Safe drinking water and sanitation are important determinants of human health and wellbeing and have recently been declared human rights by the international community. Increased access to both were ...included in the Millennium Development Goals under a single dedicated target for 2015. This target was reached in 2010 for water but sanitation will fall short; however, there is an important difference in the benchmarks used for assessing global access. For drinking water the benchmark is community-level access whilst for sanitation it is household-level access, so a pit latrine shared between households does not count toward the Millennium Development Goal (MDG) target. We estimated global progress for water and sanitation under two scenarios: with equivalent household- and community-level benchmarks. Our results demonstrate that the "sanitation deficit" is apparent only when household-level sanitation access is contrasted with community-level water access. When equivalent benchmarks are used for water and sanitation, the global deficit is as great for water as it is for sanitation, and sanitation progress in the MDG-period (1990-2015) outstrips that in water. As both drinking water and sanitation access yield greater benefits at the household-level than at the community-level, we conclude that any post-2015 goals should consider a household-level benchmark for both.
In the final article in a four-part PLoS Medicine series on water and sanitation, Sandy Cairncross and colleagues outline what needs to be done to make significant progress in providing more and ...better hygiene, sanitation, and water for all.
Pit latrines are the main form of sanitation in unplanned areas in many rapidly growing developing cities. Understanding demand for pit latrine fecal sludge management (FSM) services in these ...communities is important for designing demand-responsive sanitation services and policies to improve public health. We examine latrine emptying knowledge, attitudes, behavior, trends and rates of safe/unsafe emptying, and measure demand for a new hygienic latrine emptying service in unplanned communities in Dar Es Salaam (Dar), Tanzania, using data from a cross-sectional survey at 662 residential properties in 35 unplanned sub-wards across Dar, where 97% had pit latrines. A picture emerges of expensive and poor FSM service options for latrine owners, resulting in widespread fecal sludge exposure that is likely to increase unless addressed. Households delay emptying as long as possible, use full pits beyond what is safe, face high costs even for unhygienic emptying, and resort to unsafe practices like 'flooding out'. We measured strong interest in and willingness to pay (WTP) for the new pit emptying service at 96% of residences; 57% were WTP≥U.S. $17 to remove ≥200 L of sludge. Emerging policy recommendations for safe FSM in unplanned urban communities in Dar and elsewhere are discussed.
Objective
To estimate the burden of diarrhoeal diseases from exposure to inadequate water, sanitation and hand hygiene in low‐ and middle‐income settings and provide an overview of the impact on ...other diseases.
Methods
For estimating the impact of water, sanitation and hygiene on diarrhoea, we selected exposure levels with both sufficient global exposure data and a matching exposure‐risk relationship. Global exposure data were estimated for the year 2012, and risk estimates were taken from the most recent systematic analyses. We estimated attributable deaths and disability‐adjusted life years (DALYs) by country, age and sex for inadequate water, sanitation and hand hygiene separately, and as a cluster of risk factors. Uncertainty estimates were computed on the basis of uncertainty surrounding exposure estimates and relative risks.
Results
In 2012, 502 000 diarrhoea deaths were estimated to be caused by inadequate drinking water and 280 000 deaths by inadequate sanitation. The most likely estimate of disease burden from inadequate hand hygiene amounts to 297 000 deaths. In total, 842 000 diarrhoea deaths are estimated to be caused by this cluster of risk factors, which amounts to 1.5% of the total disease burden and 58% of diarrhoeal diseases. In children under 5 years old, 361 000 deaths could be prevented, representing 5.5% of deaths in that age group.
Conclusions
This estimate confirms the importance of improving water and sanitation in low‐ and middle‐income settings for the prevention of diarrhoeal disease burden. It also underscores the need for better data on exposure and risk reductions that can be achieved with provision of reliable piped water, community sewage with treatment and hand hygiene.
Objectif
Estimer la charge des maladies diarrhéiques provenant de l'exposition à l'eau, l'assainissement et l'hygiène des mains inadéquats, dans les pays à revenus faibles et intermédiaires et fournir un aperçu de l'impact sur d'autres maladies.
Méthodes
Pour l'estimation de l'impact de l'eau, de l'assainissement et de l'hygiène sur la diarrhée, nous avons sélectionné des niveaux d'exposition avec à la fois des données suffisantes d'exposition mondiale et une relation exposition‐risque correspondante. Les données d'exposition mondiale ont été estimées pour l'année 2012 et les estimations du risque ont été prises à partir des analyses systématiques les plus récentes. Nous avons estimé les décès attribuables et les années de vie ajustées sur l'incapacité (DALY) par pays, âge et sexe pour l'eau, l'assainissement et l'hygiène des mains, séparément et comme un ensemble de facteurs de risque. Les estimations d'incertitude ont été calculées sur la base de l'incertitude entourant les estimations d'exposition et les risques relatifs.
Résultats
En 2012, une estimation de 502 000 décès par diarrhée causés par l'eau non potable et 280 000 décès dus à un assainissement inadéquat, a été calculée. L'estimation la plus probable de la charge de morbidité due à l'hygiène inadéquate des mains s’élève à 297 000 décès. Un total de 842 000 décès par diarrhée causés par cet ensemble de facteurs de risque a été estimé, ce qui équivaut à 1,5% de la charge de morbidité totale et 58% des maladies diarrhéiques. Chez les enfants de moins de cinq ans, 361 000 décès pourraient être évités, ce qui représente 5,5% des décès dans ce groupe d’âge.
Conclusions
Cette estimation confirme l'importance de l'amélioration de l'eau et de l'assainissement dans les pays à revenus faibles et intermédiaires pour la prévention de la charge des maladies diarrhéiques. Il souligne également la nécessité d'améliorer les données sur l'exposition et les réductions du risque qui peuvent être obtenues grâce à la fourniture de raccordement à l'eau fiable, à des égouts communautaires avec traitement et à l'hygiène des mains.
Objetivo
Calcular la carga de diarreas por exposición a agua, saneamiento e higiene de manos inadecuados en lugares con ingresos bajos y medios, y ofrecer una visión general del impacto sobre otras enfermedades.
Métodos
Para calcular el impacto del agua, saneamiento e higiene sobre la diarrea, hemos seleccionados niveles de exposición que tuviesen suficientes datos de exposición global y una relación exposición‐riesgo conjunta. Los datos de exposición global se calcularon para el año 2012, y los cálculos de riesgo se obtuvieron de los análisis sistemáticos más recientes. Hemos calculado las muertes atribuibles y los años de vida ajustados por la discapacidad (AVADs) por país, edad y sexo para agua, saneamiento y lavado de manos inadecuados de forma separada, y como un conglomerado de factores de riesgo. Los cálculos de incertidumbre se hicieron basándose en la incerteza alrededor de los cálculos de exposición y los riesgos relativos.
Resultados
En el 2012, se calculó que 502 000 muertes por diarrea estaban causadas por beber un agua inadecuada y 280 000 muertes por un saneamiento inadecuada. El cálculo de carga de enfermedad más probable por una higiene de manos inadecuada es de 297 000 muertes. En total, se calculó que 842 000 de muertes eran causadas por este conglomerado de factores de riesgo, siendo responsables de un 1.5% de la carga total de enfermedades y del 58% de las enfermedades diarreicas. En niños menores de cinco años, 361 000 muertes podrían prevenirse, representando un 5.5% de las muertes en este grupo de edad.
Conclusiones
Este cálculo confirma la importancia de mejorar la calidad del agua y del saneamiento en lugares con ingresos bajos y medios para prevenir la carga de enfermedad por diarreas. También subestima la necesidad de mejores datos sobre exposición y la reducción del riesgo que podría alcanzarse con el suministro de agua fiable mediante redes de tuberías, sistemas de alcantarillado comunitario con tratamiento de residuos e higiene de manos.
More than 761 million people rely on shared sanitation facilities. These have historically been excluded from international sanitation targets, regardless of the service level, due to concerns about ...acceptability, hygiene and access. In connection with a proposed change in such policy, we undertook this review to identify and summarize existing evidence that compares health outcomes associated with shared sanitation versus individual household latrines.
Shared sanitation included any type of facilities intended for the containment of human faeces and used by more than one household, but excluded public facilities. Health outcomes included diarrhoea, helminth infections, enteric fevers, other faecal-oral diseases, trachoma and adverse maternal or birth outcomes. Studies were included regardless of design, location, language or publication status. Studies were assessed for methodological quality using the STROBE guidelines. Twenty-two studies conducted in 21 countries met the inclusion criteria. Studies show a pattern of increased risk of adverse health outcomes associated with shared sanitation compared to individual household latrines. A meta-analysis of 12 studies reporting on diarrhoea found increased odds of disease associated with reliance on shared sanitation (odds ratio (OR) 1.44, 95% CI: 1.18-1.76).
Evidence to date does not support a change of existing policy of excluding shared sanitation from the definition of improved sanitation used in international monitoring and targets. However, such evidence is limited, does not adequately address likely confounding, and does not identify potentially important distinctions among types of shared facilities. As reliance on shared sanitation is increasing, further research is necessary to determine the circumstances, if any, under which shared sanitation can offer a safe, appropriate and acceptable alternative to individual household latrines.
Three large new trials of unprecedented scale and cost, which included novel factorial designs, have found no effect of basic water, sanitation and hygiene (WASH) interventions on childhood stunting, ...and only mixed effects on childhood diarrhea. Arriving at the inception of the United Nations' Sustainable Development Goals, and the bold new target of safely managed water, sanitation and hygiene for all by 2030, these results warrant the attention of researchers, policy-makers and practitioners.
Here we report the conclusions of an expert meeting convened by the World Health Organization and the Bill and Melinda Gates Foundation to discuss these findings, and present five key consensus messages as a basis for wider discussion and debate in the WASH and nutrition sectors. We judge these trials to have high internal validity, constituting good evidence that these specific interventions had no effect on childhood linear growth, and mixed effects on childhood diarrhea. These results suggest that, in settings such as these, more comprehensive or ambitious WASH interventions may be needed to achieve a major impact on child health.
These results are important because such basic interventions are often deployed in low-income rural settings with the expectation of improving child health, although this is rarely the sole justification. Our view is that these three new trials do not show that WASH in general cannot influence child linear growth, but they do demonstrate that these specific interventions had no influence in settings where stunting remains an important public health challenge. We support a call for transformative WASH, in so much as it encapsulates the guiding principle that - in any context - a comprehensive package of WASH interventions is needed that is tailored to address the local exposure landscape and enteric disease burden.
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