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.

BACKGROUND: Child stunting reduces survival and impairs neurodevelopment. We tested the independent and combined effects of improved water, sanitation, and hygiene (WASH), and improved infant and young child feeding (IYCF) on stunting and anaemia in in Zimbabwe. METHODS: We did a cluster-randomised, community-based, 2 × 2 factorial trial in two rural districts in Zimbabwe. Clusters were defined as the catchment area of between one and four village health workers employed by the Zimbabwe Ministry of Health and Child Care. Women were eligible for inclusion if they permanently lived in clusters and were confirmed pregnant. Clusters were randomly assigned (1:1:1:1) to standard of care (52 clusters), IYCF (20 g of a small-quantity lipid-based nutrient supplement per day from age 6 to 18 months plus complementary feeding counselling; 53 clusters), WASH (construction of a ventilated improved pit latrine, provision of two handwashing stations, liquid soap, chlorine, and play space plus hygiene counselling; 53 clusters), or IYCF plus WASH (53 clusters). A constrained randomisation technique was used to achieve balance across the groups for 14 variables related to geography, demography, water access, and community-level sanitation coverage. Masking of participants and fieldworkers was not possible. The primary outcomes were infant length-for-age Z score and haemoglobin concentrations at 18 months of age among children born to mothers who were HIV negative during pregnancy. These outcomes were analysed in the intention-to-treat population. We estimated the effects of the interventions by comparing the two IYCF groups with the two non-IYCF groups and the two WASH groups with the two non-WASH groups, except for outcomes that had an important statistical interaction between the interventions. This trial is registered with ClinicalTrials.gov, number NCT01824940. FINDINGS: Between Nov 22, 2012, and March 27, 2015, 5280 pregnant women were enrolled from 211 clusters. 3686 children born to HIV-negative mothers were assessed at age 18 months (884 in the standard of care group from 52 clusters, 893 in the IYCF group from 53 clusters, 918 in the WASH group from 53 clusters, and 991 in the IYCF plus WASH group from 51 clusters). In the IYCF intervention groups, the mean length-for-age Z score was 0·16 (95% CI 0·08-0·23) higher and the mean haemoglobin concentration was 2·03 g/L (1·28-2·79) higher than those in the non-IYCF intervention groups. The IYCF intervention reduced the number of stunted children from 620 (35%) of 1792 to 514 (27%) of 1879, and the number of children with anaemia from 245 (13·9%) of 1759 to 193 (10·5%) of 1845. The WASH intervention had no effect on either primary outcome. Neither intervention reduced the prevalence of diarrhoea at 12 or 18 months. No trial-related serious adverse events, and only three trial-related adverse events, were reported. INTERPRETATION: Household-level elementary WASH interventions implemented in rural areas in low-income countries are unlikely to reduce stunting or anaemia and might not reduce diarrhoea. Implementation of these WASH interventions in combination with IYCF interventions is unlikely to reduce stunting or anaemia more than implementation of IYCF alone. FUNDING: Bill & Melinda Gates Foundation, UK Department for International Development, Wellcome Trust, Swiss Development Cooperation, UNICEF, and US National Institutes of Health.The SHINE trial is funded by the Bill & Melinda Gates Foundation (OPP1021542 and OPP113707); UK Department for International Development; Wellcome Trust, UK (093768/Z/10/Z, 108065/Z/15/Z and 203905/Z/16/Z); Swiss Agency for Development and Cooperation; US National Institutes of Health (2R01HD060338-06); and UNICEF (PCA-2017-0002)

Cholera case management in Harare City, 2018: are we doing the right things right?

Introduction: On September 6, 2018, a cholera outbreak was declared in Harare City. By September 17,31 deaths out of 3564 cases had occurred with a case fatality rate of 0.9%. Despite having sensitised staff on cholera case management, resources and a rapid response team being in place, 20 of 31 deaths (65%) occurred within cholera treatment centers. A September 12 situation report revealed that the cholera strain was resistant to ceftriaxone and ciprofloxacin and sensitive to azithromycin and imipinem. We assessed the quality of cholera case management. Methods: We carried out a descriptive cross-sectional study of records and observations for case management. Using a data extraction form, we extracted and reviewed 264 records of clients who were treated at major health facility in Harare City. Observations of patient triaging and treatment were done and case management was compared to Zimbabwe Cholera Control Guidelines standards. Data were entered into Epi info 7TM to calculate frequencies, means and proportions. Results: Antibiotic prescribing, fluid management and laboratory investigations were the quality indicators assessed. Intravenous (IV) fluids and oral rehydration solution (ORS) were documented for 73/264 (28%) and 78/264 (29%) of cases respectively. Out of 252 who had prescribed fluids, only 17/252 (7%) of the cases received adequate amount of fluids as prescribed. Ciprofloxacin was prescribed for 166/264 (63%) of cases with only 9/264 (3%) receiving azithromycin. The majority 93/95 (98%) and 69/95 (64%) of cholera case strains were resistant to ceftrioxone and ciprofloxacin respectively. Conclusion: There was over prescription of antibiotics. Fluid management was not according to hydration status and weight as stipulated in the cholera treatment guidelines. The results were shared with Harare City Health department. We recommended strengthening of record documentation, continuous mentorship on case management and use of guidelines to ensure rational drug use