Skip to main page content
U.S. flag

An official website of the United States government

Dot gov

The .gov means it’s official.
Federal government websites often end in .gov or .mil. Before sharing sensitive information, make sure you’re on a federal government site.

Https

The site is secure.
The https:// ensures that you are connecting to the official website and that any information you provide is encrypted and transmitted securely.

Access keys NCBI Homepage MyNCBI Homepage Main Content Main Navigation
. 2020 Aug 29;227(3):434-447.
doi: 10.1093/infdis/jiaa549. Online ahead of print.

Effect of water, sanitation, handwashing and nutrition interventions on enteropathogens in children 14 months old: a cluster-randomized controlled trial in rural Bangladesh

Jessica A Grembi  1 , Audrie Lin  2 , Md Abdul Karim  3 , Md Ohedul Islam  3 , Rana Miah  3 , Benjamin F Arnold  4 , Elizabeth T Rogawski McQuade  5 , Shahjahan Ali  3 , Md Ziaur Rahman  3 , Zahir Hussain  3 , Abul K Shoab  3 , Syeda L Famida  3 , Md Saheen Hossen  3 , Palash Mutsuddi  3 , Mahbubur Rahman  3 , Leanne Unicomb  3 , Rashidul Haque  3 , Mami Taniuchi  5 , Jie Liu  5 , James A Platts-Mills  5 , Susan P Holmes  6 , Christine P Stewart  7 , Jade Benjamin-Chung  2 , John M Colford  2 , Eric R Houpt  5 , Stephen P Luby  1
Affiliations

Effect of water, sanitation, handwashing and nutrition interventions on enteropathogens in children 14 months old: a cluster-randomized controlled trial in rural Bangladesh

Jessica A Grembi et al. J Infect Dis. .

Abstract

Background: We evaluated the impact of low-cost water, sanitation, handwashing (WSH) and child nutrition interventions on enteropathogen carriage in the WASH Benefits cluster-randomized controlled trial in rural Bangladesh.

Methods: We analyzed 1411 routine fecal samples from children 14±2 months old in the WSH (n = 369), nutrition counseling plus lipid-based nutrient supplement (n = 353), nutrition plus WSH (n = 360), and control (n = 329) arms for 34 enteropathogens using quantitative PCR. Outcomes included the number of co-occurring pathogens; cumulative quantity of four stunting-associated pathogens; and prevalence and quantity of individual pathogens. Masked analysis was by intention-to-treat.

Results: 326 (99.1%) control children had one or more enteropathogens detected (mean 3.8±1.8). Children receiving WSH interventions had lower prevalence and quantity of individual viruses than controls (prevalence difference for norovirus: -11% [95% confidence interval [CI], -5 to -17%]; sapovirus: -9% [95%CI, -3 to -15%]; and adenovirus 40/41: -9% [95%CI, -2 to - 15%]). There was no difference in bacteria, parasites, or cumulative quantity of stunting-associated pathogens between controls and any intervention arm.

Conclusions: WSH interventions were associated with fewer enteric viruses in children aged 14 months. Different strategies are needed to reduce enteric bacteria and parasites at this critical young age.

Keywords: Bangladesh; and handwashing (WSH); child health; enteric pathogens; nutrition; sanitation; water.

PubMed Disclaimer

Figures

Figure 1.
Figure 1.
Impact of interventions on prevalence ratio of individual pathogens in 14-month-old children from rural Bangladesh. Point estimates and 95% confidence intervals were determined with a generalized linear model adjusting for covariates associated with each pathogen outcome (likelihood ratio test P < .1 in bivariate analysis): household food insecurity, child age, child sex, child birth order, season of sample collection, time between defecation and sample placed on cold chain, mother’s age, mother’s height, mother’s education level, number of children aged <18 years in the household, number of individuals living in the compound, distance in minutes to the primary water source, household floor and wall materials, and household assets. Pathogens significant after correction for false discovery rate are annotated: *P < .05, ***P < .005. Abbreviations: aEPEC, atypical enteropathogenic Escherichia coli; EAEC, enteroaggregative Escherichia coli; EIEC, enteroinvasive Escherichia coli; LT-ETEC, enterotoxigenic Escherichia coli with heat-labile toxin; N+WSH, nutrition plus water, sanitation, and handwashing; STEC, Shiga toxin–producing Escherichia coli; ST-ETEC, enterotoxigenic Escherichia coli with heat-stable toxin; tEPEC, typical enteropathogenic Escherichia coli; WSH, water, sanitation, and handwashing.
Figure 2.
Figure 2.
Impact of interventions on quantity (log10 copies/gram stool) of individual pathogens in 14-month-old rural Bangladeshi children. Point estimates and 95% confidence intervals determined with a parametric g-formula including both logistic and log-linear regression steps with generalized linear models adjusting for covariates associated with each pathogen outcome (likelihood ratio test P < .1 in bivariate analysis): household food insecurity, child age, child sex, child birth order, season of sample collection, time between defecation and sample placed on cold chain, mother’s age, mother’s height, mother’s education level, number of children aged <18 years in the household, number of individuals living in the compound, distance in minutes to the primary water source, household floor and wall materials, and household assets. Pathogens significant after correction for false discovery rate are annotated: *P < .05. Abbreviations: aEPEC, atypical enteropathogenic Escherichia coli; EAEC, enteroaggregative Escherichia coli; EIEC, enteroinvasive Escherichia coli; LT-ETEC, enterotoxigenic Escherichia coli with heat-labile toxin; N+WSH, nutrition plus water, sanitation, and handwashing; STEC, Shiga toxin–producing Escherichia coli; ST-ETEC, enterotoxigenic Escherichia coli with heat-stable toxin; tEPEC, typical enteropathogenic Escherichia coli; WSH, water, sanitation, and handwashing.
See this image and copyright information in PMC

References

    1. Troeger C, Blacker BF, Khalil IA, et al. . Estimates of the global, regional, and national morbidity, mortality, and aetiologies of diarrhoea in 195 countries: a systematic analysis for the Global Burden of Disease Study 2016. Lancet Infect Dis 2018; 18:1211–28. - PMC - PubMed
    1. Black RE, Brown KH, Becker S, Alim AR, Huq I. Longitudinal studies of infectious diseases and physical growth of children in rural Bangladesh. II. Incidence of diarrhea and association with known pathogens. Am J Epidemiol 1982; 115:315–24. - PubMed
    1. Berkman DS, Lescano AG, Gilman RH, Lopez SL, Black MM. Effects of stunting, diarrhoeal disease, and parasitic infection during infancy on cognition in late childhood: a follow-up study. Lancet 2002; 359:564–71. - PubMed
    1. Tarleton JL, Haque R, Mondal D, Shu J, Farr BM, Petri WA. Cognitive effects of diarrhea, malnutrition, and Entamoeba histolytica infection on school age children in Dhaka, Bangladesh. Am J Trop Med Hyg 2018; 74:475–81. - PubMed
    1. Rogawski ET, Liu J, Platts-Mills JA, et al. MAL-ED Network Investigators . Use of quantitative molecular diagnostic methods to investigate the effect of enteropathogen infections on linear growth in children in low-resource settings: longitudinal analysis of results from the MAL-ED cohort study. Lancet Glob Health 2018; 6:e1319–28. - PMC - PubMed