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. 2019 Aug 28;17(1):173.
doi: 10.1186/s12916-019-1410-x.

The implications of three major new trials for the effect of water, sanitation and hygiene on childhood diarrhea and stunting: a consensus statement

Oliver Cumming  1 , Benjamin F Arnold  2 , Radu Ban  3 , Thomas Clasen  4 , Joanna Esteves Mills  5 , Matthew C Freeman  4 , Bruce Gordon  6 , Raymond Guiteras  7 , Guy Howard  8 , Paul R Hunter  9 , Richard B Johnston  6 , Amy J Pickering  10 , Andrew J Prendergast  11 , Annette Prüss-Ustün  6 , Jan Willem Rosenboom  3 , Dean Spears  12 , Shelly Sundberg  3 , Jennyfer Wolf  6 , Clair Null  13 , Stephen P Luby  14 , Jean H Humphrey  15 , John M Colford Jr  2
Affiliations

The implications of three major new trials for the effect of water, sanitation and hygiene on childhood diarrhea and stunting: a consensus statement

Oliver Cumming et al. BMC Med. .

Abstract

Background: 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.

Main body: 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.

Conclusion: 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.

Keywords: Diarrhea; Hygiene; Sanitation; Stunting; Undernutrition; Water.

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Conflict of interest statement

CN receives funding through grants from the Bill and Melinda Gates Foundation and the United States Agency for International Development. JHH receives funding from the Bill and Melinda Gates Foundation, the UK Department for International Development, the European Union, and the Nestle Nutrition Institute. AJP receives funding from the Bill and Melinda Gates Foundation. All other authors declare that they have no competing interests.

Figures

Fig. 1
Fig. 1
Cochrane risk of bias assessment for the WASH-Benefits and SHINE trials
Fig. 2
Fig. 2
Summary of key reported results for the WASH-B and SHINE trials
See this image and copyright information in PMC

Comment in

References

    1. Luby SP, Rahman M, Arnold BF, Unicomb L, Ashraf S, Winch PJ, et al. Effects of water quality, sanitation, handwashing, and nutritional interventions on diarrhoea and child growth in rural Bangladesh: a cluster randomised controlled trial. Lancet Glob Health. 2018;6(3):e302–e315. - PMC - PubMed
    1. Null C, Stewart CP, Pickering AJ, Dentz HN, Arnold BF, Arnold CD, et al. Effects of water quality, sanitation, handwashing, and nutritional interventions on diarrhoea and child growth in rural Kenya: a cluster-randomised controlled trial. Lancet Glob Health. 2018;6(3):e316–e329. - PMC - PubMed
    1. Humphrey JH, Mbuya MN, Ntozini R, Moulton LH, Stoltzfus RJ, Tavengwa NV, et al. Independent and combined effects of improved water, sanitation, and hygiene, and improved complementary feeding, on child stunting and anaemia in rural Zimbabwe: a cluster-randomised trial. Lancet Glob Health. 2019;7(1):e132–e147. - PMC - PubMed
    1. Schulz KF, Altman DG, Moher D. CONSORT 2010 statement: updated guidelines for reporting parallel group randomised trials. BMC Med. 2010;8(1):18. - PMC - PubMed
    1. Arnold BF, Null C, Luby SP, Unicomb L, Stewart CP, Dewey KG, et al. Cluster-randomised controlled trials of individual and combined water, sanitation, hygiene and nutritional interventions in rural Bangladesh and Kenya: the WASH benefits study design and rationale. BMJ Open. 2013;3(8):e003476. - PMC - PubMed

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