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)

Transcutaneous carbon dioxide monitoring could reduce physical contact with COVID-19 patients

Background: Transcutaneous carbon di-oxide (TcCO2) monitoring can be valuable to allow non-invasive monitoring of plasma carbon dioxide (PaCO2) levels in patients with acute respiratory failure including those with novel coronavirus disease 2019 (COVID-19). Methods: A pilot retrospective chart review was performed on critically-ill, adult patients admitted to the medical intensive care unit to assess correlation between TcCO2 and PaCO2 values. Obtained demographics, diagnoses, acute physiology, and chronic health evaluation II score (APACHE II), and Charlson co-morbidity index. TcCO2 values compared with corresponding blood gas PaCO2 values - including patients requiring inotropic agents. Microsoft Excel 2016 and IBM SPSS Statistics for Windows, version 26 (IBM Corp., Armonk, N.Y., USA) used for statistical analysis. Results: Cohort consisted of 53 patients with acute respiratory failure from a variety of documented overlapping diagnoses. Thirty-one (58.4%) needed invasive mechanical ventilation, 20 (37.7%) required non-invasive ventilation with impending need for intubation and 2 patients (3.8%) who did not require oxygen delivery beyond high flow nasal cannula. Forty patients provided 121 instances of paired measurements of TcCO2 and PaCO2 where values were strongly correlated, r(121)=.90, p[less than]0.001, including 54 instances where patients received one or more inotrope infusions at time of measurement. In the paired measurement cohort, the sum of instances per overlapping diagnosis accounted for 47[38.8%] COVID-19, 20[16.5%] interstitial lung disease, 69[57%] pneumonia, 74[61.2%] septic shock, 23[19%] acute exacerbation of chronic obstructive lung disease, 8[6.6%] pulmonary embolism, 13[10.7%] aspiration pneumonia, 7[5.8%] severe pulmonary hypertension, 10 [8.3%] cardiac arrest, 24[19.8%] congestive heart failure, 1[0.8%] each for neuromuscular respiratory failure and angioedema and 13[10.4%] stroke. Conclusions: Continuous TcCO2 monitoring correlates well with PaCO2 offering opportunities to reduce the need for physical patient contact for frequent arterial punctures and arterial line placement among critically-ill patients with acute respiratory failure. It is a valuable addition to non-invasive monitoring of PaCO2 especially those with COVID-19 and irrespective of shock states.James Carrington, DO (1); Tinashe Maduke, MD, MPH (2); Sarah Steenson, DO (2); Nurjahan Khatun, MD (1); Troy Whitacre, RRT (3); Mohammed Alnijoumi, MD (2), Hariharan Regunath, MD (2,4) ; 1. Department of Medicine, University of Missouri. 2. Department of Medicine – Division of Pulmonary, Critical Care and Environmental Medicine, University of Missouri. 3. Respiratory Therapy Services, University of Missouri Hospital and Clinics. 4. Department of Medicine– Division of Infectious Diseases, University of Missouri.Includes bibliographical reference