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Cited by 95Parasites and Host InteractionsChild Nutrition and Water AccessParasitic Infections and Diagnostics

Effects of single and integrated water, sanitation, handwashing, and nutrition interventions on child soil-transmitted helminth and Giardia infections: A cluster-randomized controlled trial in rural Kenya

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Pickering, Amy J., Njenga, Sammy M., Steinbaum, Lauren, Swarthout, Jenna, Lin, Audrie, Arnold, Benjamin F., Stewart, Christine P., Dentz, Holly N. +14 more·2019·PLOS Medicine
DOI 10.1371/journal.pmed.1002841PMC PMC6594579

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Abstract

BACKGROUND: Helminth and protozoan infections affect more than 1 billion children globally. Improving water quality, sanitation, handwashing, and nutrition could be more sustainable control strategies for parasite infections than mass drug administration, while providing other quality of life benefits. METHODS AND FINDINGS: We enrolled geographic clusters of pregnant women in rural western Kenya into a cluster-randomized controlled trial (ClinicalTrials.gov NCT01704105) that tested 6 interventions: water treatment, improved sanitation, handwashing with soap, combined water treatment, sanitation, and handwashing (WSH), improved nutrition, and combined WSH and nutrition (WSHN). We assessed intervention effects on parasite infections by measuring Ascaris lumbricoides, Trichuris trichiura, hookworm, and Giardia duodenalis among children born to the enrolled pregnant women (index children) and their older siblings. After 2 years of intervention exposure, we collected stool specimens from 9,077 total children aged 2 to 15 years in 622 clusters, including 2,346 children in an active control group (received household visits but no interventions), 1,117 in the water treatment arm, 1,160 in the sanitation arm, 1,141 in the handwashing arm, 1,064 in the WSH arm, 1,072 in the nutrition arm, and 1,177 in the WSHN arm. In the control group, 23% of children were infected with A. lumbricoides, 1% with T. trichiura, 2% with hookworm, and 39% with G. duodenalis. The analysis included 4,928 index children (median age in years: 2) and 4,149 older siblings (median age in years: 5); study households had an average of 5 people, <10% had electricity access, and >90% had dirt floors. Compared to the control group, Ascaris infection prevalence was lower in the water treatment arm (prevalence ratio [PR]: 0.82 [95% CI 0.67, 1.00], p = 0.056), the WSH arm (PR: 0.78 [95% CI 0.63, 0.96], p = 0.021), and the WSHN arm (PR: 0.78 [95% CI 0.64, 0.96], p = 0.017). We did not observe differences in Ascaris infection prevalence between the control group and the arms with the individual interventions sanitation (PR: 0.89 [95% CI 0.73, 1.08], p = 0.228), handwashing (PR: 0.89 [95% CI 0.73, 1.09], p = 0.277), or nutrition (PR: 86 [95% CI 0.71, 1.05], p = 0.148). Integrating nutrition with WSH did not provide additional benefit. Trichuris and hookworm were rarely detected, resulting in imprecise effect estimates. No intervention reduced Giardia. Reanalysis of stool samples by quantitative polymerase chain reaction confirmed the reductions in Ascaris infections measured by microscopy in the WSH and WSHN groups. Trial limitations included imperfect uptake of targeted intervention behaviors, limited power to detect effects on rare parasite infections, and that it was not feasible to blind participants and sample collectors to treatment status. However, lab technicians and data analysts were blinded to treatment status. The trial was funded by the Bill & Melinda Gates Foundation and the United States Agency for International Development. CONCLUSIONS: Integration of improved water quality, sanitation, and handwashing could contribute to sustainable control strategies for Ascaris infections, particularly in similar settings with recent or ongoing deworming programs. Combining nutrition with WSH did not provide further benefits, and water treatment alone was similarly effective to integrated WSH. Our findings provide new evidence that drinking water should be given increased attention as a transmission pathway for Ascaris. TRIAL REGISTRATION: ClinicalTrials.gov NCT01704105.

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  • Previous water treatment and sanitation intervention trials conducted in urban informal settlements or peri-urban settings have typically only based effectiveness on demonstrated reductions in child diarrhea and/or improvements in child growth.

    “Previous water treatment and sanitation intervention trials conducted in urban informal settlements or peri-urban settings have typically only based effectiveness on demonstrated reductions in child diarrhea and/or improvements in child growth 110,112-114 .”

    From Urban informal settlements as hotspots of antimicrobial resistance and the need to curb environmental transmission. (2020) · cites this paper as [112]

    The Methods (Study design) identify diarrhea and growth as primary outcomes, while the Methods (Outcomes) also describe prespecified parasite-infection outcomes. The Introduction discusses earlier water and sanitation trials, but our copy does not establish that trials in urban informal settlements or peri-urban settings typically assessed effectiveness only through diarrhea or child growth. I searched for those settings and for previous trials’ outcomes. (LLM, conf=0.76)

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Authors
Pickering, A. J., Njenga, S. M., Steinbaum, L., Swarthout, J., Lin, A., Arnold, B. F., Stewart, C. P., Dentz, H. N., Mureithi, M., Chieng, B., Wolfe, M., Mahoney, R., Kihara, J., Byrd, K., Rao, G., Meerkerk, T., Cheruiyot, P., Papaiakovou, M., Pilotte, N., Williams, S. A., Colford, J. M., & Null, C.
Affiliations
  • Tufts University (US)
  • Kenya Medical Research Institute (KE)
  • Stanford University (US)
  • University of California System (US)
  • University of California, Davis (US)
  • Smith College (US)
  • Innovations for Poverty Action (US)
  • Natural History Museum (GB)
Corresponding author
  • Pickering, Amy J.
  • Njenga, Sammy M.
  • Steinbaum, Lauren
  • Swarthout, Jenna
  • Lin, Audrie
  • Arnold, Benjamin F.
  • Stewart, Christine P.
  • Dentz, Holly N.
  • Mureithi, MaryAnne
  • Chieng, Benard
  • Wolfe, Marlene
  • Mahoney, Ryan
  • Kihara, Jimmy
  • Byrd, Kendra
  • Rao, Gouthami
  • Meerkerk, Theodora
  • Cheruiyot, Priscah
  • Papaiakovou, Marina
  • Pilotte, Nils
  • Williams, Steven A.
  • Colford, John M.
  • Null, Clair
ORCID
Venue
PLOS Medicine
Publisher
Public Library of Science (PLoS)
Published
2019-06-26
Volume
16
Issue
6
Pages
e1002841
ISSN
  • 1549-1277 (ISSN-L)
  • 1549-1676
DOI
10.1371/journal.pmed.1002841
PMC
PMC6594579
OpenAlex
W2954085063
Cited by
95
References
82
Citations by year
2026: 3 · 2025: 18 · 2024: 13 · 2023: 9 · 2022: 12 · 2021: 18 · 2020: 14 · 2019: 8
FWCI
10.03
Type
journal article
Language
en
Open access
Licence
Locations
  • PLoS Medicine (publishedVersion, cc-by)
  • bioRxiv (Cold Spring Harbor Laboratory) (acceptedVersion)
  • bioRxiv (Cold Spring Harbor Laboratory) (acceptedVersion, cc-by-nd)
  • Europe PMC (PubMed Central) (publishedVersion, cc-by)
  • PubMed Central (publishedVersion, cc-by)
  • PubMed (publishedVersion)
  • Smith ScholarWorks (Smith College) (submittedVersion, cc-by)
  • RePEc: Research Papers in Economics (submittedVersion)
  • DOAJ (DOAJ: Directory of Open Access Journals) (submittedVersion, cc-by-sa)
  • eScholarship (California Digital Library) (submittedVersion)
  • Figshare (submittedVersion, cc-by)
Funders
  • Bill and Melinda Gates Foundation (OPPGD759)
  • USAID (AID-OAA-F-13-00040)
Topics
  • Life Sciences › Immunology and Microbiology › Parasitology › Parasites and Host Interactions
  • Health Sciences › Nursing › Nutrition and Dietetics › Child Nutrition and Water Access
  • Life Sciences › Immunology and Microbiology › Parasitology › Parasitic Infections and Diagnostics
Keywords
soil-transmitted helminths, Giardia lamblia, Ascaris lumbricoides, Trichuris trichiura, hookworm, pediatric parasitic infection, water treatment, improved sanitation, handwashing with soap, child nutrition, rural Kenya, pregnant women
MeSH terms
Adolescent, Animals, Child, Child, Preschool, Female, Giardia, Giardiasis, Hand Disinfection, Helminths, Humans, Male, Rural Population, Sanitation, Soil, Nutrition Assessment, Treatment Outcome, Water Purification

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