Effect of Improved Water Quality, Sanitation, Hygiene and Nutrition Interventions on Respiratory Illness in Young Children in Rural Bangladesh: A Multi-Arm Cluster-Randomized Controlled Trial.

Sania Ashraf,Stephen P Luby,John M Colford,Pavani K Ram,Jade Benjamin-Chung,Benjamin F Arnold,Peter J Winch,Mahfuza Islam,Leanne Unicomb,Mahbubur Rahman

doi:10.4269/ajtmh.19-0769

Abstract

.Acute respiratory infections cause mortality in young children. We assessed the effects of water, sanitation, hygiene (WASH) and nutritional interventions on childhood ARI. Geographic clusters of pregnant women from rural Bangladesh were randomly assigned to receive 1) chlorinated drinking water and safe storage (W); 2) upgraded sanitation (S); 3) handwashing promotion (H); 4) combined water, sanitation, and handwashing (WSH); 5) nutrition intervention including lipid-based nutrient supplements; 6) combined WSH plus nutrition (WSHN); or 7) no intervention (control). Masking of participants was not possible. Acute respiratory illness was defined as caregiver-reported persistent cough, panting, wheezing, or difficulty breathing in the past 7 days among index children, those born to enrolled women. We assessed outcomes at 12 and 24 months of intervention using intention to treat. Compared with children in the control group (ARI prevalence, P: 8.9%), caregivers of index children reported significantly lower ARI in the water (P: 6.3%, prevalence ratio (PR): 0.71; 95% CI: 0.53, 0.96), sanitation (P: 6.4%, PR: 0.75, 95% CI: 0.58, 0.96), handwashing (P: 6.4%, PR: 0.68, 95% CI: 0.50, 0.93), and the combined WSH+N arms (P: 5.9%, PR: 0.67, 95% CI: 0.50, 0.90). Those in the nutrition (P: 7.4%, PR: 0.84, 95% CI: 0.63, 1.10) or the WSH arm (P: 8.9%, PR: 0.99, 95% CI: 0.76, 1.28) reported similar ARI prevalence compared with control children. Single targeted water, sanitation, and hygiene interventions reduced reported respiratory illness in young children. There was no apparent respiratory health benefit from combining WASH interventions.

Highlights

Acute respiratory infections (ARIs) are a leading cause of morbidity and mortality in young children globally.[1]
Treatment groups were balanced at baseline on demographic characteristics, household composition, facilities and practices relating to the use of cooking fuel, drinking water, handwashing, and sanitation (Table 1)
The prevalence of ARI varied over the intervention period (Supplemental Figure 1). In this cluster-randomized trial, reported respiratory illness (ARI) among index children was significantly lower in households that received the sanitation intervention that included regular promotion plus individual latrines, potties, and scoops (28% lower); or chlorinated drinking water intervention (30%), FIGURE 2

Summary

Introduction

Acute respiratory infections (ARIs) are a leading cause of morbidity and mortality in young children globally.[1] Acute respiratory infection and pneumonia cause the majority of hospitalizations and death among children younger than 5 years especially in low-income countries.[2] Risk factors for pneumonia include low birth weight, malnutrition, low exclusive breastfeeding rates, poor handwashing, crowding, use of solid fuels, and low maternal education, all of which are common in poor households.[2] In low-income settings, effective interventions include immunization against respiratory pathogens (measles, Haemophilus influenzae type B, and pneumococcus) and reducing indoor air pollution.[3] poor environmental conditions that support transmission of respiratory pathogens can worsen childhood morbidity.[4] Water, sanitation, hygiene (WASH) interventions that improve these conditions, have the potential to reduce respiratory illness by interrupting pathogen transmission

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