Water, sanitation and hygiene for the prevention of diarrhoea
Open accessAbstract
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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The analysis did not find a significantly improved effect of water quality interventions, consistent with Cairncross and colleagues.
“Similarly, we did not find a significantly improved effect of water quality interventions, consistent with the findings reported by Cairncross and colleagues,128”
Risk relations between specific water and sanitation risk factors and diarrhoea morbidity and mortality have been shown, but for some outcomes poor evidence permits only rough estimates.
“Risk relations between specific water and sanitation risk factors (ie, unwashed hands and poor water quality) and diarrhoea morbidity and mortality have been shown, but for some outcomes, such as inappropriate excreta disposal, poor availability of evidence permits only rough estimates of risk.68, 69”
From Global burden of childhood pneumonia and diarrhoea (2013) · cites this paper as [69]
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- Authors
- Cairncross, S., Hunt, C., Boisson, S., Bostoen, K., Curtis, V., Fung, I. C., & Schmidt, W.-P.
- Affiliations
- London School of Hygiene & Tropical Medicine (GB)
- London School of Hygiene & Tropical Medicine, Department of Infectious & Tropical Diseases, London, UK
- Corresponding author
- Cairncross, Sandy
- Venue
- International Journal of Epidemiology
- Publisher
- Oxford University Press (OUP)
- Published
- 2010-03-23
- Volume
- 39
- Issue
- suppl_1
- Pages
- i193-i205
- ISSN
- 0300-5771 (ISSN-L)
- 1464-3685
- PMC
- PMC2845874
- OpenAlex
- W2152057480
- Cited by
- 667
- References
- 43
- Citations by year
- 2026: 16 · 2025: 21 · 2024: 43 · 2023: 40 · 2022: 43 · 2021: 56 · 2020: 48 · 2019: 54 · 2018: 47 · 2017: 55 · 2016: 43 · 2015: 56 · 2014: 48 · 2013: 50 · 2012: 24
- FWCI
- 3.48
- Type
- journal article
- Language
- en
- Open access
- hybrid
- doi.org
- Licence
- Locations
- International Journal of Epidemiology (publishedVersion, cc-by-nc)
- PubMed Central (publishedVersion, cc-by-nc)
- PubMed (publishedVersion)
- LSHTM Research Online (London School of Hygiene and Tropical Medicine) (acceptedVersion)
- Funders
- Bill and Melinda Gates Foundation
- UNICEF
- Topics
- Health Sciences › Nursing › Nutrition and Dietetics › Child Nutrition and Water Access
- Health Sciences › Medicine › Infectious Diseases › Viral gastroenteritis research and epidemiology
- Health Sciences › Medicine › Pediatrics, Perinatology and Child Health › Global Maternal and Child Health
- Keywords
- diarrhea prevention, water quality, handwashing with soap, excreta disposal, sanitation, water supply, diarrhea mortality, quality of evidence
- MeSH terms
- Diarrhea, Drinking, Hand Disinfection, Humans, Hygiene, Risk Factors, Risk Management, Sanitation, Toilet Facilities, Water, Risk Assessment, Evidence-Based Medicine
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