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)

Plasma hepcidin concentrations and factors associated with hemoglobin levels in infants and young children in Zimbabwe

Iron metabolism is very dynamic over the first year of life. Anemia is common in sub-Saharan African infants, particularly in the context of HIV infection. Hepcidin, a peptide hormone whose synthesis is simultaneously regulated by iron status and the innate immune system, has evolved as the master regulator of iron metabolism, thereby linking iron homeostasis, inflammation, infection and anemia. However little is known about normal hepcidin values in infancy, its role in the pathogenesis of anemia during infancy or its role in the pathology of HIV infection or exposure. Plasma hepcidin concentrations were higher in 3-month-old (median 9.7 ng/mL [IQR 2.5, 19.3]), than in 6-month-old (4.5 ng/mL [IQR 0.5, 7.3]) and 12-month-old infants (1.9 ng/mL [IQR 0.7, 6.2)]) (p<0.001, Kruskal–Wallis) among healthy, non-anemic Zimbabwean infants with normal iron parameters at 3 (n=60), 6 (n=47) and 12 (n=40) months of age. The correspondingly lower levels of plasma hepcidin at 6 and 12 months in healthy non-anemic infants is likely a physiologic response to mobilize iron stores and increase iron absorption to prevent anemia. Plasma hepcidin concentrations were higher in HIV-infected compared to HIV exposed uninfected (HEU) and HIV-unexposed groups throughout infancy and correlated with levels of plasma ferritin and C- reactive protein (CRP). HEU infants also had higher levels of plasma hepcidin and inflammation (alpha-1-acid glycoprotein (AGP) and CRP) compared to HIV unexposed infants. Overall, anemia had no effect on plasma hepcidin concentrations during infancy except in HIV unexposed infants. Plasma hepcidin declined with age in all groups; girls had higher plasma hepcidin concentrations than boys. Plasma hepcidin concentrations appear to be driven by inflammation in infants, as has been shown in adults. We did not find a significant association between infant and young child feeding (IYCF) indicators and hemoglobin levels in children 6-24 months using data from the 2010-11 Zimbabwe Demographic and Health Survey. However, Water, Sanitation and Hygiene (WASH) practice indicators were associated with hemoglobin levels in young Zimbabwean children adjusting for biological and social factors and warrant further investigation in randomized controlled trials

Relationships between hepcidin and other biomarkers.

<p>Correlations between (A) plasma hepcidin and ferritin and (B) plasma hepcidin and CRP. Values for non-anemic (empty circles) and anemic (solid circles) infants are combined (p<0.001 for all Spearman correlations). Plasma hepcidin, ferritin and CRP are expressed on a log scale.</p

Selection of infants into the hepcidin substudy.

<p>^¶ HIV-unexposed infants with gestational age >37 weeks, birth weight > 2500 g and available plasma samples (>120 μL). *Non anemic infants were selected based on no abnormal iron indicators (defined as hemoglobin < 105 g/L at 3 and 6 months and < 100 g/L at 12 months, serum ferritin < 12 μg/L, sTfR > 8.3 mg/L), no evidence of inflammation (defined as AGP > 1 g/L or CRP > 5 mg/L) and no acute illness (defined as diarrhea or fever in the prior week or measles in the prior 3 months). Anemic infants at each age were randomly selected from 62, 77 and 85 eligible infants at 3, 6 and 12 months based on hemoglobin (defined as <105 g/L at 3 and 6 months, and <100 g/L at 12 months of age.</p

Biomarker concentrations in anemic and non-anemic infants.

<p>Graphs show the plasma concentrations of hepcidin, ferritin, soluble transferrin receptor and C-reactive protein (CRP) in infants at (A) 3 months, (B) 6 months and (C) 12 months of age. The boxes indicate the 25^th and 75^th percentiles and the horizontal line indicates the median. Hepcidin, ferritin and CRP are expressed on a log scale. Full data for each biomarker are also shown in <a href="http://www.plosone.org/article/info:doi/10.1371/journal.pone.0135227#pone.0135227.t002" target="_blank">Table 2</a>.</p