Associations of water, sanitation, and hygiene with typhoid fever in case-control studies: a systematic review and meta-analysis

Abstract

Background: Water, sanitation, and hygiene (WASH) play a pivotal role in controlling typhoid fever, as it is primarily transmitted through oral-fecal pathways. Given our constrained resources, staying current with the most recent research is crucial. This ensures we remain informed about practical insights regarding effective typhoid fever control strategies across various WASH components. We conducted a systematic review and meta-analysis of case-control studies to estimate the associations of water, sanitation, and hygiene exposures with typhoid fever.

Methods: We updated the previous review conducted by Brockett et al. We included new findings published between June 2018 and October 2022 in Web of Science, Embase, and PubMed. We used the Risk of Bias in Non-Randomized Studies of Interventions (ROBINS-I) tool for risk of bias (ROB) assessment. We classified WASH exposures according to the classification provided by the WHO/UNICEF Joint Monitoring Programme for Water Supply, Sanitation, and Hygiene (JMP) update in 2015. We conducted the meta-analyses by only including studies that did not have a critical ROB in both Bayesian and frequentist random-effects models.

Results: We identified 8 new studies and analyzed 27 studies in total. Our analyses showed that while the general insights on the protective (or harmful) impact of improved (or unimproved) WASH remain the same, the pooled estimates of OR differed. Pooled estimates of limited hygiene (OR = 2.26, 95% CrI: 1.38 to 3.64), untreated water (OR = 1.96, 95% CrI: 1.28 to 3.27) and surface water (OR = 2.14, 95% CrI: 1.03 to 4.06) showed 3% increase, 18% decrease, and 16% increase, respectively, from the existing estimates. On the other hand, improved WASH reduced the odds of typhoid fever with pooled estimates for improved water source (OR = 0.54, 95% CrI: 0.31 to 1.08), basic hygiene (OR = 0.6, 95% CrI: 0.38 to 0.97) and treated water (OR = 0.54, 95% CrI: 0.36 to 0.8) showing 26% decrease, 15% increase, and 8% decrease, respectively, from the existing estimates.

Conclusions: The updated pooled estimates of ORs for the association of WASH with typhoid fever showed clear changes from the existing estimates. Our study affirms that relatively low-cost WASH strategies such as basic hygiene or water treatment can be an effective tool to provide protection against typhoid fever in addition to other resource-intensive ways to improve WASH.

Trial registration: PROSPERO 2021 CRD42021271881.

Keywords: Bayesian meta-analysis; Case-control study; Intervention strategy; Typhoid fever; Water, sanitation, and hygiene (WASH).

Fig. 1

PRISMA flow diagram. The PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) flow diagram shows the number of articles at the different phases of identification, screening, and inclusion in the systematic review and meta-analysis

Fig. 2

Risk of bias assessment using the Cochrane ROBINS-I tool. The studies included in the systematic review were assessed for risk of bias due to 1) confounding, 2) selection, 3) intervention classification, 4) intervention deviation, 5) missing data, 6) outcome measurement, and 7) selective reporting

Fig. 3

Association between water source and typhoid fever. The forest plot illustrates the association between water source and typhoid fever. Filled circles are posterior median values. Thick and thin black lines show 80% and 95% credible intervals, respectively

Fig. 4

Association between water treatment and typhoid fever. The forest plot illustrates the association between water treatment and typhoid fever. Filled circles are posterior median values. Thick and thin black lines show 80% and 95% credible intervals, respectively

Fig. 5

Association between sanitation and typhoid fever. The forest plot illustrates the association between sanitation and typhoid fever. Filled circles are posterior median values. Thick and thin black lines show 80% and 95% credible intervals, respectively

Fig. 6

Association between hygiene and typhoid fever. The forest plot illustrates the association between hygiene and typhoid fever. Filled circles are posterior median values. Thick and thin black lines show 80% and 95% credible intervals, respectively