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Review
. 2010 Apr;39 Suppl 1(Suppl 1):i193-205.
doi: 10.1093/ije/dyq035.

Water, sanitation and hygiene for the prevention of diarrhoea

Sandy Cairncross  1 , Caroline Hunt, Sophie Boisson, Kristof Bostoen, Val Curtis, Isaac C H Fung, Wolf-Peter Schmidt
Affiliations
Review

Water, sanitation and hygiene for the prevention of diarrhoea

Sandy Cairncross et al. Int J Epidemiol. 2010 Apr.

Abstract

Background: Ever since John Snow's intervention on the Broad St pump, the effect of water quality, hygiene and sanitation in preventing diarrhoea deaths has always been debated. The evidence identified in previous reviews is of variable quality, and mostly relates to morbidity rather than mortality.

Methods: We drew on three systematic reviews, two of them for the Cochrane Collaboration, focussed on the effect of handwashing with soap on diarrhoea, of water quality improvement and of excreta disposal, respectively. The estimated effect on diarrhoea mortality was determined by applying the rules adopted for this supplement, where appropriate.

Results: The striking effect of handwashing with soap is consistent across various study designs and pathogens, though it depends on access to water. The effect of water treatment appears similarly large, but is not found in few blinded studies, suggesting that it may be partly due to the placebo effect. There is very little rigorous evidence for the health benefit of sanitation; four intervention studies were eventually identified, though they were all quasi-randomized, had morbidity as the outcome, and were in Chinese.

Conclusion: We propose diarrhoea risk reductions of 48, 17 and 36%, associated respectively, with handwashing with soap, improved water quality and excreta disposal as the estimates of effect for the LiST model. Most of the evidence is of poor quality. More trials are needed, but the evidence is nonetheless strong enough to support the provision of water supply, sanitation and hygiene for all.

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Figures

Figure 1
Figure 1
Synthesis of study identification in review of the effect of handwashing with soap on diarrhoea mortality and morbidity
Figure 2
Figure 2
Forest plots of (a) all studies in handwashing review, and (b) intervention studies only. Numbers on y-axis are references to studies in Supplementary Table 1. The diamond represents the combined relative risk and 95% CI from random effects model
Figure 3
Figure 3
Synthesis of study identification in review of the effect of water quality interventions on diarrhoea mortality and morbidity
Figure 4
Figure 4
Forest plots of (a) all 35 studies in water quality review, and (b) the four blinded studies only
Figure 5
Figure 5
Synthesis of study identification in review of the effect of excreta disposal on diarrhoea morbidity
See this image and copyright information in PMC

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