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      Water, sanitation and hygiene for the prevention of diarrhoea


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          Background Ever since John Snow’s intervention on the Broad St pump, the effect of water quality, hygiene and sanitation in preventing diarrhoea deaths has always been debated. The evidence identified in previous reviews is of variable quality, and mostly relates to morbidity rather than mortality.

          Methods We drew on three systematic reviews, two of them for the Cochrane Collaboration, focussed on the effect of handwashing with soap on diarrhoea, of water quality improvement and of excreta disposal, respectively. The estimated effect on diarrhoea mortality was determined by applying the rules adopted for this supplement, where appropriate.

          Results The striking effect of handwashing with soap is consistent across various study designs and pathogens, though it depends on access to water. The effect of water treatment appears similarly large, but is not found in few blinded studies, suggesting that it may be partly due to the placebo effect. There is very little rigorous evidence for the health benefit of sanitation; four intervention studies were eventually identified, though they were all quasi-randomized, had morbidity as the outcome, and were in Chinese.

          Conclusion We propose diarrhoea risk reductions of 48, 17 and 36%, associated respectively, with handwashing with soap, improved water quality and excreta disposal as the estimates of effect for the LiST model. Most of the evidence is of poor quality. More trials are needed, but the evidence is nonetheless strong enough to support the provision of water supply, sanitation and hygiene for all.

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          Most cited references44

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          Interventions to improve water quality for preventing diarrhoea: systematic review and meta-analysis.

          To assess the effectiveness of interventions to improve the microbial quality of drinking water for preventing diarrhoea. Systematic review. Cochrane Infectious Diseases Group's trials register, CENTRAL, Medline, Embase, LILACS; hand searching; and correspondence with experts and relevant organisations. Randomised and quasirandomised controlled trials of interventions to improve the microbial quality of drinking water for preventing diarrhoea in adults and in children in settings with endemic disease. Allocation concealment, blinding, losses to follow-up, type of intervention, outcome measures, and measures of effect. Pooled effect estimates were calculated within the appropriate subgroups. 33 reports from 21 countries documenting 42 comparisons were included. Variations in design, setting, and type and point of intervention, and variations in defining, assessing, calculating, and reporting outcomes limited the comparability of study results and pooling of results by meta-analysis. In general, interventions to improve the microbial quality of drinking water are effective in preventing diarrhoea. Effectiveness was not conditioned on the presence of improved water supplies or sanitation in the study setting and was not enhanced by combining the intervention with instructions on basic hygiene, a water storage vessel, or improved sanitation or water supplies--other common environmental interventions intended to prevent diarrhoea. Interventions to improve water quality are generally effective for preventing diarrhoea in all ages and in under 5s. Significant heterogeneity among the trials suggests that the level of effectiveness may depend on a variety of conditions that research to date cannot fully explain.
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            Effect of intensive handwashing promotion on childhood diarrhea in high-risk communities in Pakistan: a randomized controlled trial.

            Washing hands with soap prevents diarrhea, but children at the highest risk of death from diarrhea are younger than 1 year, too young to wash their own hands. Previous studies lacked sufficient power to assess the impact of household handwashing on diarrhea in infants. To evaluate the effect of promoting household handwashing with soap among children at the highest risk of death from diarrhea. A cluster randomized controlled trial of 36 low-income neighborhoods in urban squatter settlements in Karachi, Pakistan. Field workers visited participating households at least weekly from April 15, 2002, to April 5, 2003. Eligible households located in the study area had at least 2 children younger than 15 years, at least 1 of whom was younger than 5 years. Weekly visits in 25 neighborhoods to promote handwashing with soap after defecation and before preparing food, eating, and feeding a child. Within intervention neighborhoods, 300 households (1523 children) received a regular supply of antibacterial soap and 300 households (1640 children) received plain soap. Eleven neighborhoods (306 households and 1528 children) comprised the control group. Incidence density of diarrhea among children, defined as the number of diarrheal episodes per 100 person-weeks of observation. Children younger than 15 years living in households that received handwashing promotion and plain soap had a 53% lower incidence of diarrhea (95% confidence interval [CI], -65% to -41%) compared with children living in control neighborhoods. Infants living in households that received handwashing promotion and plain soap had 39% fewer days with diarrhea (95% CI, -61% to -16%) vs infants living in control neighborhoods. Severely malnourished children (weight for age z score, <-3.0) younger than 5 years living in households that received handwashing promotion and plain soap had 42% fewer days with diarrhea (95% CI, -69% to -16%) vs severely malnourished children in the control group. Similar reductions in diarrhea were observed among children living in households receiving antibacterial soap. In a setting in which diarrhea is a leading cause of child death, improvement in handwashing in the household reduced the incidence of diarrhea among children at high risk of death from diarrhea.
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              Combining drinking water treatment and hand washing for diarrhoea prevention, a cluster randomised controlled trial.

              To evaluate the effectiveness of point of use water treatment with flocculent-disinfectant on reducing diarrhoea and the additional benefit of promoting hand washing with soap. The study was conducted in squatter settlements of Karachi, Pakistan, where diarrhoea is a leading cause of childhood death. Interventions were randomly assigned to 47 neighbourhoods. Households in 10 neighbourhoods received diluted bleach and a water vessel; nine neighbourhoods received soap and were encouraged to wash hands; nine neighbourhoods received flocculent-disinfectant water treatment and a water vessel; 10 neighbourhoods received disinfectant-disinfectant water treatment and soap and were encouraged to wash hands; and nine neighbourhoods were followed as controls. Field workers visited households at least once a week from April to December 2003 to promote use of the interventions and to collect data on diarrhoea. Study participants in control neighbourhoods had diarrhoea on 5.2% of days. Compared to controls, participants living in intervention neighbourhoods had a lower prevalence of diarrhoea: 55% (95% CI 17%, 80%) lower in bleach and water vessel neighbourhoods, 51% (95% CI 12%, 76%) lower in hand washing promotion with soap neighbourhoods, 64% lower (95% CI 29%, 90%) in disinfectant-disinfectant neighbourhoods, and 55% (95% CI 18%, 80%) lower in disinfectant-disinfectant plus hand washing with soap neighbourhoods. With an intense community-based intervention and supplies provided free of cost, each of the home-based interventions significantly reduced diarrhoea. There was no benefit by combining hand washing promotion with water treatment.

                Author and article information

                Int J Epidemiol
                International Journal of Epidemiology
                Oxford University Press
                April 2010
                23 March 2010
                23 March 2010
                : 39
                : suppl_1 , Development and use of the Lives Saved Tool (LiST): A model to estimate the impact of scaling up proven interventions on maternal, neonatal and child mortality
                : i193-i205
                1London School of Hygiene & Tropical Medicine, Department of Infectious & Tropical Diseases, London, UK and 2Department of Epidemiology and Biostatistics, College of Public Health, University of Georgia, Athens, GA, USA.
                Author notes
                *Corresponding author. London School of Hygiene & Tropical Medicine, Keppel Street, London WC1E 7HT, UK. E-mail: sandy.cairncross@ 123456lshtm.ac.uk
                Published by Oxford University Press on behalf of the International Epidemiological Association. © The Author 2010; all rights reserved.

                This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License ( http://creativecommons.org/licenses/by-nc/2.5/) which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited.


                Public health
                Public health
                hygiene, diarrhoea, sanitation, water, mortality


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