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Randomized Controlled Trial
. 2020 Mar 28;221(8):1379-1386.
doi: 10.1093/infdis/jiz179.

Impact of Water Quality, Sanitation, Handwashing, and Nutritional Interventions on Enteric Infections in Rural Zimbabwe: The Sanitation Hygiene Infant Nutrition Efficacy (SHINE) Trial

Elizabeth T Rogawski McQuade  1   2 , James A Platts-Mills  2 , Jean Gratz  2 , Jixian Zhang  2 , Lawrence H Moulton  3   4 , Kuda Mutasa  3 , Florence D Majo  3 , Naume Tavengwa  3 , Robert Ntozini  3 , Andrew J Prendergast  3   5 , Jean H Humphrey  3   4 , Jie Liu  2 , Eric R Houpt  2
Affiliations
Randomized Controlled Trial

Impact of Water Quality, Sanitation, Handwashing, and Nutritional Interventions on Enteric Infections in Rural Zimbabwe: The Sanitation Hygiene Infant Nutrition Efficacy (SHINE) Trial

Elizabeth T Rogawski McQuade et al. J Infect Dis. .

Abstract

Background: We assessed the impact of water, sanitation, and hygiene (WASH) and infant and young child feeding (IYCF) interventions on enteric infections in the Sanitation Hygiene Infant Nutrition Efficacy (SHINE) trial in rural Zimbabwe.

Methods: We tested stool samples collected at 1, 3, 6, and 12 months of age and during diarrhea using quantitative molecular diagnostics for 29 pathogens. We estimated the effects of the WASH, IYCF, and combined WASH + IYCF interventions on individual enteropathogen prevalence and quantity, total numbers of pathogens detected, and incidence of pathogen-attributable diarrhea.

Results: WASH interventions decreased the number of parasites detected (difference in number compared to non-WASH arms, -0.07 [95% confidence interval, -.14 to -.02]), but had no statistically significant effects on bacteria, viruses, or the prevalence and quantity of individual enteropathogens after accounting for multiple comparisons. IYCF interventions had no significant effects on individual or total enteropathogens. Neither intervention had significant effects on pathogen-attributable diarrhea.

Conclusions: The WASH interventions implemented in SHINE (improved pit latrine, hand-washing stations, liquid soap, point-of-use water chlorination, and clean play space) did not prevent enteric infections. Transformative WASH interventions are needed that are more efficacious in interrupting fecal-oral microbial transmission in children living in highly contaminated environments.

Keywords: enteric infections; environmental enteric dysfunction; hygiene; sanitation; stunting.

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Figures

Figure 1.
Figure 1.
Enteropathogen prevalence in stool samples collected from 996 children in the Sanitation Hygiene Infant Nutrition Efficacy (SHINE) trial. High prevalence of rotavirus at 1 and 3 months of age may be due to shedding of rotavirus vaccine. Abbreviations: aEPEC, atypical enteropathogenic Escherichia coli; EAEC, enteroaggregative Escherichia coli; ETEC, enterotoxigenic Escherichia coli; STEC, Shiga toxin–producing Escherichia coli; tEPEC, typical enteropathogenic Escherichia coli.
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