Interventions to improve sanitation for preventing diarrhoea

This is a protocol for a Cochrane Review (Intervention). The objectives are as follows: To assess the effectiveness of sanitation interventions for preventing diarrhoeal disease

Health risks of solid waste management practices in rural Ghana: A semi-quantitative approach toward a solid waste safety plan

Inadequate solid waste management (SWM) can lead to environmental contamination and human health risks. The health risks from poor SWM can vary based on specific practices and exposure pathways. Thus, it is necessary to adequately understand the local context. This information, however, is rarely available in low-resource settings, particularly in rural areas. A solid waste safety plan could be helpful in these settings for gathering necessary data to assess and minimize health risks. As a step in developing such a tool, a semi-quantitative health risk analysis of SWM practices in nine Ghanaian rural villages was undertaken. Data on SWM in each village were collected through qualitative field observations and semi-structured interviews with local stakeholders. SWM-related health risks were assessed using the collected data, similar case studies in the scientific literature and dialogue among an assembled team of experts. The analysis identified context-specific practices and exposure pathways that may present the most substantial health risks as well as targeted solutions for mitigation risks. A risk assessment matrix was developed to quantify SWM risks as low, medium, high, or very high based on the likelihood and severity of identified hazards. The highest SWM risks were identified from dumpsites and uncontrolled burying of solid waste. More specifically, a very high or high risk of infectious and vector-borne diseases from SWM in the villages was identified, both in the disposal of solid waste in dumpsites and uncontrolled burying of solid waste. Additionally, a very high or high risk of inhalation, ingestion or dermal contact with contaminants was found in the disposal of solid waste in dumpsites, open burning of waste and reuse of waste from dumpsites as compost. The results demonstrate the potential value of a solid waste safety plan and a parsimonious approach to collect key local data to inform its contents

Child feces management practices and fecal contamination: A cross-sectional study in rural Odisha, India.

Safe child feces management (CFM) is likely critical for reducing exposure to fecal pathogens in and around the home, but the effectiveness of different CFM practices in reducing fecal contamination is not well understood. We conducted a cross-sectional study of households with children <6 years in rural Odisha, India, using household surveys (188 households), environmental sample analysis (373 samples for 80 child defecation events), and unstructured observation (33 households) to characterize practices and measure fecal contamination resulting from CFM-related practices, including defecation, feces handling and disposal, defecation area or tool cleaning, anal cleansing, and handwashing. For environmental sampling, we developed a sampling strategy that involved collecting samples at the time and place of child defecation to capture activity-level fecal contamination for CFM practices. Defecating on the floor or ground, which was practiced by 63.7% of children <6 years, was found to increase E. coli contamination on finished floors (p < 0.001) or earthen ground surfaces (p = 0.008) after feces were removed, even if paper was laid down prior to defecation. Use of unsafe tools (e.g., paper, plastic bag, straw/hay) to pick up child feces increased E. coli contamination on caregiver hands after feces handling (p < 0.0001), whereas the use of safe tools (e.g., potty, hoe, scoop) did not increase hand contamination. Points of contamination from cleaning CFM hardware and anal cleansing were also identified. The most common disposal location for feces of children <6 years was to throw feces into an open field (41.6%), with only 32.3% disposed in a latrine. Several households owned scoops or potties, but use was low and we identified shortcomings of these CFM tools and proposed alternative interventions that may be more effective. Overall, our results demonstrate the need for CFM interventions that move beyond focusing solely on feces disposal to address CFM as a holistic set of practices

Child Defecation and Feces Disposal Practices and Determinants among Households after a Combined Household-Level Piped Water and Sanitation Intervention in Rural Odisha, India.

Latrine access alone may be insufficient to encourage households to dispose of young children's feces safely in a latrine, and little is known about the determinants of improved child feces disposal. We used longitudinal data collected at up to three timepoints for children less than 5 years of age from households in Odisha, India, which received a combined household-level piped water supply and sanitation intervention, but did not specifically promote the safe disposal of child feces. Among the 85% of intervention households who reported access to improved sanitation, we characterized child defecation and feces disposal practices by age, across time, and season, and assessed determinants of improved disposal. Feces from children less than 3 years of age was commonly picked up by caregivers but disposed of unsafely with garbage into open areas (56.3% of households) or in a drain/ditch (6.2%). Although children 3 and 4 years were more likely to use a latrine than younger children, their feces was also more likely to be left in the open if they did not defecate in a latrine. For children less than 5 years of age, most (84.7%) children's feces that was safely disposed of in a latrine was because of the children defecating in the latrine directly. Significant predictors for disposing of child feces in an improved latrine were the primary female caregiver reporting using a latrine to defecate, the child's age, and water observed at place for handwashing. These findings suggest that child feces interventions should focus on encouraging children to begin using a toilet at a younger age and changing the common behavior of disposing of young child's feces into open areas

Interventions to improve sanitation for preventing diarrhoea

BACKGROUND: Diarrhoea is a major contributor to the global disease burden, particularly amongst children under five years in low- and middle-income countries (LMICs). As many of the infectious agents associated with diarrhoea are transmitted through faeces, sanitation interventions to safely contain and manage human faeces have the potential to reduce exposure and diarrhoeal disease. OBJECTIVES: To assess the effectiveness of sanitation interventions for preventing diarrhoeal disease, alone or in combination with other WASH interventions. SEARCH METHODS: We searched the Cochrane Infectious Diseases Group Specialized Register, CENTRAL, MEDLINE, Embase, LILACS, and Chinese language databases available under the China National Knowledge Infrastructure (CNKI-CAJ). We also searched the metaRegister of Controlled Trials (mRCT) and conference proceedings, contacted researchers, and searched references of included studies. The last search date was 16 February 2022. SELECTION CRITERIA: We included randomized controlled trials (RCTs), quasi-RCTs, non-randomized controlled trials (NRCTs), controlled before-and-after studies (CBAs), and matched cohort studies of interventions aimed at introducing or expanding the coverage and/or use of sanitation facilities in children and adults in any country or population. Our primary outcome of interest was diarrhoea and secondary outcomes included dysentery (bloody diarrhoea), persistent diarrhoea, hospital or clinical visits for diarrhoea, mortality, and adverse events. We included sanitation interventions whether they were conducted independently or in combination with other interventions. DATA COLLECTION AND ANALYSIS: Two review authors independently assessed eligible studies, extracted relevant data, assessed risk of bias, and assessed the certainty of evidence using the GRADE approach. We used meta-analyses to estimate pooled measures of effect, described results narratively, and investigated potential sources of heterogeneity using subgroup analyses. MAIN RESULTS: Fifty-one studies met our inclusion criteria, with a total of 238,535 participants. Of these, 50 studies had sufficient information to be included in quantitative meta-analysis, including 17 cluster-RCTs and 33 studies with non-randomized study designs (20 NRCTs, one CBA, and 12 matched cohort studies). Most were conducted in LMICs and 86% were conducted in whole or part in rural areas. Studies covered three broad types of interventions: (1) providing access to any sanitation facility to participants without existing access practising open defecation, (2) improving participants' existing sanitation facility, or (3) behaviour change messaging to improve sanitation access or practices without providing hardware or subsidy, although many studies overlapped multiple categories. There was substantial heterogeneity amongst individual study results for all types of interventions. Providing access to any sanitation facility Providing access to sanitation facilities was evaluated in seven cluster-RCTs, and may reduce diarrhoea prevalence in all age groups (risk ratio (RR) 0.89, 95% confidence interval (CI) 0.73 to 1.08; 7 trials, 40,129 participants, low-certainty evidence). In children under five years, access may have little or no effect on diarrhoea prevalence (RR 0.98, 95% CI 0.83 to 1.16, 4 trials, 16,215 participants, low-certainty evidence). Additional analysis in non-randomized studies was generally consistent with these findings. Pooled estimates across randomized and non-randomized studies provided similar protective estimates (all ages: RR 0.79, 95% CI 0.66 to 0.94; 15 studies, 73,511 participants; children < 5 years: RR 0.83, 95% CI 0.68 to 1.02; 11 studies, 25,614 participants).  Sanitation facility improvement Interventions designed to improve existing sanitation facilities were evaluated in three cluster-RCTs in children under five and may reduce diarrhoea prevalence (RR 0.85, 95% CI 0.69 to 1.06; 3 trials, 14,900 participants, low-certainty evidence). However, some of these interventions, such as sewerage connection, are not easily randomized. Non-randomized studies across participants of all ages provided estimates that improving sanitation facilities may reduce diarrhoea, but may be subject to confounding (RR 0.61, 95% CI 0.50 to 0.74; 23 studies, 117,639 participants, low-certainty evidence). Pooled estimates across randomized and non-randomized studies provided similar protective estimates (all ages: RR 0.65, 95% CI 0.55 to 0.78; 26 studies, 132,539 participants; children < 5 years: RR 0.70, 95% CI 0.54 to 0.91, 12 studies, 23,353 participants).  Behaviour change messaging only (no hardware or subsidy provided) Strategies to promote behaviour change to construct, upgrade, or use sanitation facilities were evaluated in seven cluster-RCTs in children under five, and probably reduce diarrhoea prevalence (RR 0.82, 95% CI 0.69 to 0.98; 7 studies, 28,909 participants, moderate-certainty evidence). Additional analysis from two non-randomized studies found no effect, though with very high uncertainty. Pooled estimates across randomized and non-randomized studies provided similar protective estimates (RR 0.85, 95% CI 0.73 to 1.01; 9 studies, 31,080 participants). No studies measured the effects of this type of intervention in older populations.  Any sanitation intervention A pooled analysis of cluster-RCTs across all sanitation interventions demonstrated that the interventions may reduce diarrhoea prevalence in all ages (RR 0.85, 95% CI 0.76 to 0.95, 17 trials, 83,938 participants, low-certainty evidence) and children under five (RR 0.87, 95% CI 0.77 to 0.97; 14 trials, 60,024 participants, low-certainty evidence). Non-randomized comparisons also demonstrated a protective effect, but may be subject to confounding. Pooled estimates across randomized and non-randomized studies provided similar protective estimates (all ages: RR 0.74, 95% CI 0.67 to 0.82; 50 studies, 237,130 participants; children < 5 years: RR 0.80, 95% CI 0.71 to 0.89; 32 studies, 80,047 participants). In subgroup analysis, there was some evidence of larger effects in studies with increased coverage amongst all participants (75% or higher coverage levels) and also some evidence that the effect decreased over longer follow-up times for children under five years. There was limited evidence on other outcomes. However, there was some evidence that any sanitation intervention was protective against dysentery (RR 0.74, 95% CI 0.54 to 1.00; 5 studies, 34,025 participants) and persistent diarrhoea (RR 0.57, 95% CI 0.43 to 0.75; 2 studies, 2665 participants), but not against clinic visits for diarrhoea (RR 0.86, 95% CI 0.44 to 1.67; 2 studies, 3720 participants) or all-cause mortality (RR 0.99, 95% CI 0.89 to1.09; 7 studies, 46,123 participants). AUTHORS' CONCLUSIONS: There is evidence that sanitation interventions are effective at preventing diarrhoea, both for young children and all age populations. The actual level of effectiveness, however, varies by type of intervention and setting. There is a need for research to better understand the factors that influence effectiveness

Water, Sanitation, and Hygiene Practices and Challenges during the COVID-19 Pandemic: A Cross-Sectional Study in Rural Odisha, India.

Water, sanitation, and hygiene (WASH) practices emerged as a critical component to controlling and preventing the spread of the COVID-19 pandemic. We conducted 131 semistructured phone interviews with households in rural Odisha, India, to understand behavior changes made in WASH practices as a result of the pandemic and challenges that would prevent best practices. Interviews were conducted from May through July 2020 with 73 heads of household, 37 caregivers of children < 5 years old, and 21 members of village water and sanitation committees in villages with community-level piped water and high levels of latrine ownership. The majority of respondents (86%, N = 104) reported a change in their handwashing practice due to COVID-19, typically describing an increase in handwashing frequency, more thorough washing method, and/or use of soap. These improved handwashing practices remained in place a few months after the pandemic began and were often described as a new consistent practice after additional daily actions (such as returning home), suggesting new habit formation. Few participants (13%) reported barriers to handwashing. Some respondents also detailed improvements in other WASH behaviors, including village-level cleaning of water tanks and/or treatment of piped water (48% of villages), household water treatment and storage (17% of respondents), and household cleaning (41% of respondents). However, there was minimal change in latrine use and child feces management practices as a result of the pandemic. We provide detailed thematic summaries of qualitative responses to allow for richer insights into these WASH behavior changes during the pandemic. The results also highlight the importance of ensuring communities have adequate WASH infrastructure to enable the practice of safe behaviors and strengthen resilience during a large-scale health crisis

Effects of environmental conditions on healthcare worker wellbeing and quality of care: A qualitative study in Niger

Environmental conditions (water, sanitation, hygiene, waste management, cleaning, energy, building design) are important for a safe and functional healthcare environment. Yet their full range of impacts are not well understood. In this study, we assessed the impact of environmental conditions on healthcare workers’ wellbeing and quality of care, using qualitative interviews with 81 healthcare workers at 26 small healthcare facilities in rural Niger. We asked participants to report successes and challenges with environmental conditions and their impacts on wellbeing (physical, social, mental, and economic) and quality of care. We found that all environmental conditions contributed to healthcare workers’ wellbeing and quality of care. The norm in facilities of our sample was poor environmental conditions, and thus participants primarily reported detrimental effects. We identified previously documented effects on physical health and safety from pathogen exposure, but also several novel effects on healthcare workers’ mental and economic wellbeing and on efficiency, timeliness, and patient centeredness of care. Key wellbeing impacts included pathogen exposure for healthcare workers, stress from unsafe and chaotic working environments, staff dissatisfaction and retention challenges, out-of-pocket spending to avoid stockouts, and uncompensated labor. Key quality of care impacts included pathogen exposure for patients, healthcare worker time dedicated to non-medical tasks like water fetching (i.e., reduced efficiency), breakdowns and spoilage of equipment and supplies, and patient satisfaction with cleanliness and privacy. Inefficiency due to time lost and damaged supplies and equipment likely have substantial economic value and warrant greater consideration in research and policy making. Impacts on staff retention and care efficiency also have implications for health systems. We recommend that future research and decision making for policy and practice incorporate more holistic impact measures beyond just healthcare acquired infections and reconsider the substantial contribution that environmental conditions make to the safety of healthcare facilities and strength of health systems

Eliminating lead exposure from drinking water—A global call to action

Each year, approximately 900,000 people die from exposure to lead [1]. But the full impacts of lead exposure are far more insidious. Lead is a potent neurotoxin that impairs brain function and irreversibly harms children’s cognitive development. Any exposure to lead can be damaging. Recent studies estimate that 800 million children globally (approximately 1 in 3) have blood lead concentrations above 5 micrograms per deciliter and that lead exposure may be responsible for 30% of all intellectual disabilities of unknown origin [2, 3]. Lead exposure increases disease burden, estimated at over 21 million disability-adjusted life years (DALYs) yearly, primarily due to cardiovascular diseases and mental disorders. This disease burden attributed to lead has increased globally since 1990, because of population growth and aging [4]. Additional research has shown evidence of a direct dose-response relationship between children’s blood lead levels and reductions in IQ which decreases lifetime earnings [5, 6]. This makes lead a public health threat and a key environmental risk factor that exacerbates long-term inequalities affecting especially marginalized groups. Important sources of exposure include batteries, paint, food containers, drinking water systems, and leaded gasoline (now banned in all countries)

Elucidating fecal contamination exposure in low-income countries, the contribution from child feces disposal practices and soil ingestion, and links to child health

Enteric pathogens transmitted via fecal-oral pathways cause enteric infections that have substantial health and human capital consequences, making it critical to reduce child exposure to fecal contamination. Current water, sanitation, and hygiene programs in low-income countries often focus on improving water delivery and toilet/latrine infrastructure to reduce pathogen exposure, but child exposure to fecal contamination can remain common after these types of improvements. The overarching goal of this research was to investigate fecal contamination and enteric pathogen transmission in low-income countries, with a focus on young children’s feces as a source of contamination, soil ingestion as an exposure point, and their effects on child health. First, the occurrence, magnitude, and distribution of fecal contamination and enteric pathogens were assessed along multiple transmission pathways for children in a densely-populated urban slum neighborhood of Nairobi, Kenya. There was a high frequency of pathogen detection at several exposure points (including stored drinking water, hands, tables, plates, floors, soil, standing water, open drainage ditches, and streams) despite all households having access to a toilet or latrine. The results also provided evidence that children were exposed to enteric pathogens from several exposure points simultaneously, that there were interactions between different transmission pathways, and that soil could be an important exposure point because of its high levels of enteric pathogens. Next, the role of poor child feces management practices for young children (who are not old enough to use a toilet facility themselves) was evaluated in the context of domestic fecal contamination and child health. A method to track fecal contamination from the feces of young children separately from older children/adults was developed, validated, and then used to analyze environmental samples collected from multiple exposure points inside and outside households. Young children’s feces dominated the human fecal contamination found in the majority of samples taken from the indoor environment (caregiver and child hands, tables, plates), older child/adult feces dominated the human fecal contamination found in the majority of samples taken from standing water and streams in the outdoor environment, and each source dominated the human fecal contamination found in an equal number of samples taken from open drainage ditches. These results provided evidence that young children’s feces substantially contribute to household fecal contamination. Next, nationally representative data from 34 low- and middle-income countries was used to evaluate associations between child feces disposal practices and child health. Disposal of child feces into an improved toilet was found to be strongly associated with improvements in child growth, suggesting that better child feces disposal practices could achieve greater child health benefits than only improving toilet access. Finally, this research investigated soil ingestion as a potential exposure pathway for fecal contamination. There were strong associations between soil ingestion and child diarrhea in an urban slum setting in Kenya and a rural setting in northern Ghana, despite high levels of finished floor in households in both settings. There was also a high prevalence of soil ingestion among children in both settings, indicating this is likely a common exposure pathway for children in low-income countries. Taken together, this work identified high levels of enteric pathogen contamination at numerous indoor and outdoor exposure points in an urban slum environment, performed detailed investigations of poor management of young children’s feces as a contamination source and soil ingestion as an exposure point, and linked both of these practices to negative health consequences in children

Elucidating fecal contamination exposure in low-income countries, the contribution from child feces disposal practices and soil ingestion, and links to child health

Enteric pathogens transmitted via fecal-oral pathways cause enteric infections that have substantial health and human capital consequences, making it critical to reduce child exposure to fecal contamination. Current water, sanitation, and hygiene programs in low-income countries often focus on improving water delivery and toilet/latrine infrastructure to reduce pathogen exposure, but child exposure to fecal contamination can remain common after these types of improvements. The overarching goal of this research was to investigate fecal contamination and enteric pathogen transmission in low-income countries, with a focus on young children’s feces as a source of contamination, soil ingestion as an exposure point, and their effects on child health. First, the occurrence, magnitude, and distribution of fecal contamination and enteric pathogens were assessed along multiple transmission pathways for children in a densely-populated urban slum neighborhood of Nairobi, Kenya. There was a high frequency of pathogen detection at several exposure points (including stored drinking water, hands, tables, plates, floors, soil, standing water, open drainage ditches, and streams) despite all households having access to a toilet or latrine. The results also provided evidence that children were exposed to enteric pathogens from several exposure points simultaneously, that there were interactions between different transmission pathways, and that soil could be an important exposure point because of its high levels of enteric pathogens. Next, the role of poor child feces management practices for young children (who are not old enough to use a toilet facility themselves) was evaluated in the context of domestic fecal contamination and child health. A method to track fecal contamination from the feces of young children separately from older children/adults was developed, validated, and then used to analyze environmental samples collected from multiple exposure points inside and outside households. Young children’s feces dominated the human fecal contamination found in the majority of samples taken from the indoor environment (caregiver and child hands, tables, plates), older child/adult feces dominated the human fecal contamination found in the majority of samples taken from standing water and streams in the outdoor environment, and each source dominated the human fecal contamination found in an equal number of samples taken from open drainage ditches. These results provided evidence that young children’s feces substantially contribute to household fecal contamination. Next, nationally representative data from 34 low- and middle-income countries was used to evaluate associations between child feces disposal practices and child health. Disposal of child feces into an improved toilet was found to be strongly associated with improvements in child growth, suggesting that better child feces disposal practices could achieve greater child health benefits than only improving toilet access. Finally, this research investigated soil ingestion as a potential exposure pathway for fecal contamination. There were strong associations between soil ingestion and child diarrhea in an urban slum setting in Kenya and a rural setting in northern Ghana, despite high levels of finished floor in households in both settings. There was also a high prevalence of soil ingestion among children in both settings, indicating this is likely a common exposure pathway for children in low-income countries. Taken together, this work identified high levels of enteric pathogen contamination at numerous indoor and outdoor exposure points in an urban slum environment, performed detailed investigations of poor management of young children’s feces as a contamination source and soil ingestion as an exposure point, and linked both of these practices to negative health consequences in children