Category Archives: Research

Sanitation and Hygiene-Specific Risk Factors for Moderate-to-Severe Diarrhea in Young Children in the Global Enteric Multicenter Study

The current issue of PLoS Medicine has an important review on sanitation and hygiene and also below is an analysis of the review by Jonny Crocker and Jamie Bartram.

Sanitation and Hygiene-Specific Risk Factors for Moderate-to-Severe Diarrhea in Young Children in the Global Enteric Multicenter Study, 2007–2011: Case-Control Study. PLoS Med, May 2016. Authors: Kelly K. Baker, Ciara E. O’Reilly, Myron M. Levine, Karen L., et al.

Full text:

Background – Diarrheal disease is the second leading cause of disease in children less than 5 y of age. Poor water, sanitation, and hygiene conditions are the primary routes of exposure and infection. Sanitation and hygiene interventions are estimated to generate a 36% and 48% reduction in diarrheal risk in young children, respectively. Little is known about whether the number of households sharing a sanitation facility affects a child’s risk of diarrhea. The objective of this study was to describe sanitation and hygiene access across the Global Enteric Multicenter Study (GEMS) sites in Africa and South Asia and to assess sanitation and hygiene exposures, including shared sanitation access, as risk factors for moderate-to-severe diarrhea (MSD) in children less than 5 y of age.

Methods/Findings – The GEMS matched case-control study was conducted between December 1, 2007, and March 3, 2011, at seven sites in Basse, The Gambia; Nyanza Province, Kenya; Bamako, Mali; Manhiça, Mozambique; Mirzapur, Bangladesh; Kolkata, India; and Karachi, Pakistan. Data was collected for 8,592 case children aged <5 y old experiencing MSD and for 12,390 asymptomatic age, gender, and neighborhood-matched controls. An MSD case was defined as a child with a diarrheal illness <7 d duration comprising ≥3 loose stools in 24 h and ≥1 of the following: sunken eyes, skin tenting, dysentery, intravenous (IV) rehydration, or hospitalization. Site-specific conditional logistic regression models were used to explore the association between sanitation and hygiene exposures and MSD. Most households at six sites (>93%) had access to a sanitation facility, while 70% of households in rural Kenya had access to a facility. Practicing open defecation was a risk factor for MSD in children <5 y old in Kenya. Sharing sanitation facilities with 1–2 or ≥3 other households was a statistically significant risk factor for MSD in Kenya, Mali, Mozambique, and Pakistan. Among those with a designated handwashing area near the home, soap or ash were more frequently observed at control households and were significantly protective against MSD in Mozambique and India.

Conclusions – This study suggests that sharing a sanitation facility with just one to two other households can increase the risk of MSD in young children, compared to using a private facility. Interventions aimed at increasing access to private household sanitation facilities may reduce the burden of MSD in children. These findings support the current World Health Organization/ United Nations Children’s Emergency Fund (UNICEF) system that categorizes shared sanitation as unimproved.

Interpreting the Global Enteric Multicenter Study (GEMS) Findings on Sanitation, Hygiene, and Diarrhea. PLoS Med, May 2016. Author: Jonny Crocker, Jamie Bartram

Full text:

The draft sanitation ladder for measuring SDG progress allows sharing of improved facilities by fewer than five households to count towards ending open defecation [19]. Higher rungs refer to private facilities and safe excreta management. The indicators also interpret access as including use, which was not included in GEMS. Future research should include indicators on use of facilities and excreta management.

Baker and colleagues provide valuable evidence that confirms that private sanitation often provides greater benefits than shared sanitation. Prior evidence suggests health benefits for use of any sanitation facility (including shared) when compared to open defecation [8–10]. This study will inform policy and programming, yet shared facilities may still have a role in addressing open defecation in challenging settings. For reasons beyond just health such as dignity and gender equity [20,21], we should advocate for private access whenever possible.

Baker and colleagues present the best dataset yet on diarrheal disease associated with sanitation and hygiene. They provide compelling evidence on sanitation and hygiene risk factors for MSD and variability in that risk. Importantly, they also demonstrate the feasibility and value of rigorous data collection on health outcomes, something that future studies should develop yet further.

Recent studies on sanitation acess & violence,and others

Below are links to the abstracts or full text of recently published articles:

Access to sanitation and violence against women: evidence from Demographic Health Survey (DHS) data in Kenya. Int J Environ Health Res. 2016 June.

This study analyzed 2008 Kenya Demographic Health Survey’s data and found women who primarily practice open defecation (OD), particularly in disorganized communities, had higher odds of experiencing recent non-partner violence

Untangling the Impacts of Climate Change on Waterborne Diseases: a Systematic Review of Relationships between Diarrheal Diseases and Temperature, Rainfall, Flooding, and Drought. Environ Sci Technol. 2016 Apr 25.

Key areas of agreement include a positive association between ambient temperature and diarrheal diseases, with the exception of viral diarrhea and an increase in diarrheal disease following heavy rainfall and flooding events. Insufficient evidence was available to evaluate the effects of drought on diarrhea. There is evidence to support the biological plausibility of these associations, but publication bias is an ongoing concern.

The Impact of a School-Based Water, Sanitation, and Hygiene Program on Absenteeism, Diarrhea, and Respiratory Infection: A Matched–Control Trial in Mali. Amer Jnl Trop Med Hyg, Current issue
Abstract –

We found that a school-based WASH intervention can have a positive effect on reducing rates of illness, as well as absence due to diarrhea. However, we did not find evidence that these health impacts led to a reduction in overall absence. Higher absence rates are less likely attributable to the intervention than the result of an imbalance in unobserved confounders between study groups.

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Links to recent sanitation research

Research Updates

Exploring the Potential of Antimicrobial Hand Hygiene Products in Reducing the Infectious Burden in Low-Income Countries: An Integrative ReviewAmerican Journal of Infection Control, April 2016. The study looks at whether adding antimicrobial agents to hand hygiene products increases the health benefits of handwashing with plain soap in low-income settings.

What is Sanitation Success? Improve International, April 2016. This desk review found there was not one widely accepted definition of sanitation success, even for broadly used approaches like community-led total sanitation.

Ruminants Contribute Fecal Contamination to the Urban Household Environment in Dhaka, BangladeshEnvironmental Science & Technology, April 2016. Results suggest that effective household fecal management should account not only for human sources of contamination, but also for animal sources.

Can Behavior Change Approaches Improve the Cleanliness and Functionality of Shared Toilets? Water and Sanitation for the Urban Poor, 2016. A research project in Dhaka looks at whether behavior change strategies help users keep their toilets clean and functional.

Urban Solutions: Metropolitan Approaches, Innovation in Urban Water and Sanitation, and Inclusive Smart Cities: A New Generation of Ideas. Wilson Center, March 2016. The Wilson Center’s Urban Sustainability Laboratory, Cities Alliance, Global Coalition for Inclusive Housing and Sustainable Cities, USAID, and the World Bank are cosponsoring the Reducing Urban Poverty Paper Competition for advanced graduate students. The competition seeks to encourage a new generation of urban policymakers and promote early career research.

Innovation in Scaling Up Access to Water and Sanitation Services in Kenya. Water and Sanitation Program (WSP), 2015. An analysis and summary of the World Bank WSP’s technical assistance to five cities in Kenya. The objective of this technical assistance was to increase access to water and sanitation services by the urban poor in peri-urban areas.

Innovation in the Sanitation Sector: e-Catalogue for Individual Household Toilets.Water for People, 2016. The e-Catalogue, developed in India, is a flash-based software application for desktops and laptops, and an Android application for tablets and smartphones. With the e-Catalogue, a family or customer can design their own toilet based on their individual budget. The e-Catelogue also helps generate demand among households to choose and construct their desired toilet models.

9 WASH open access articles – March 2016

Below are links to the full-text of 9 peer-review WASH studies that were published in March 2016. Click on the titles to go to the abstract and full-text.

Planning for climate change: The need for mechanistic systems-based approaches to study climate change impacts on diarrheal diseases. Authors: Mellor JE, Levy K, et al. Sci Total Environ. 2016 Apr 1.

Indicators for Monitoring Water, Sanitation, and Hygiene: A Systematic Review of Indicator Selection Methods. Authors: Schwemlein S, Cronk R, Bartram J. Int J Environ Res Public Health. 2016 Mar 17.

Association of Safe Disposal of Child Feces and Reported Diarrhea in Indonesia: Need for Stronger Focus on a Neglected Risk. Authors: Cronin AA, Sebayang SK, Torlesse H, Nandy R. Int J Environ Res Public Health. 2016 Mar 11.

Complementary school garden, nutrition, water, sanitation and hygiene interventions to improve children’s nutrition and health status in Burkina Faso and Nepal: a study protocol. Authors: Erismann S, Shrestha A, et al. BMC Public Health. 2016 Mar 9.

Effects of Sachet Water Consumption on Exposure to Microbe-Contaminated Drinking Water: Household Survey Evidence from Ghana. Authors: Wright J, Dzodzomenyo M, et al.
Int J Environ Res Public Health. 2016 Mar 9.

Cluster of Ebola Virus Disease Linked to a Single Funeral – Moyamba District, Sierra Leone, 2014. Authors: Curran KG, Gibson JJ; et al. MMWR Morb Mortal Wkly Rep. 2016 Mar 4.

Are studies underestimating the effects of sanitation on child nutrition? Lancet Glob Health. 2016 Mar.

School Water, Sanitation, and Hygiene, Soil-Transmitted Helminths, and Schistosomes: National Mapping in Ethiopia. Authors: Grimes JE, Tadesse G, et al. PLoS Negl Trop Dis. 2016 Mar.

Risk of Intestinal Parasitic Infections in People with Different Exposures to Wastewater and Fecal Sludge in Kampala, Uganda: A Cross-Sectional Study. Authors: Fuhrimann S, Winkler MS, et al. PLoS Negl Trop Dis. 2016 Mar.

Improving health in cities through systems approaches for urban water management

Improving health in cities through systems approaches for urban water management. Env Health, Mar. 2016.

Authors: L. C. Rietveld, J. G. Siri, et al.

As human populations become more and more urban, decision-makers at all levels face new challenges related to both the scale of service provision and the increasing complexity of cities and the networks that connect them. These challenges may take on unique aspects in cities with different cultures, political and institutional frameworks, and at different levels of development, but they frequently have in common an origin in the interaction of human and environmental systems and the feedback relationships that govern their dynamic evolution.

Accordingly, systems approaches are becoming recognized as critical to understanding and addressing such complex problems, including those related to human health and wellbeing. Management of water resources in and for cities is one area where such approaches hold real promise.

USAID’S Public-Private Partnerships A data picture and review of business engagement

USAID’S Public-Private Partnerships: A data picture and review of business engagement, 2016. Brookings Institution.

Authors: George M. Ingram, Anne E. Johnson, Helen Moser.

This paper provides a quantitative and qualitative presentation of USAID’s public-private partnerships and business sector participation in those PPPs. The analysis offered here is based on USAID’s PPP data set covering 2001-2014 and interviews with executives of 17 U.S. corporations that have engaged in PPPs with USAID.


Unlocking resilience through autonomous innovation

Unlocking resilience through autonomous innovation, 2016. ODI.

Authors: Aditya Bahadur and Julian Doczi

This paper draws on alternative approaches to innovation to present the concept of Autonomous Innovation as an important approach/process for enhancing resilience to range of shocks and stresses, including climate change.

Autonomous innovations have five key characteristics: they are inductive (bottom-up); indigenous and suited to local cultural norms; inexpensive and frugal; developed through subjective processes that rely on the innovator’s intuition; and entail a high degree of iteration through trial and error.

This is in contrast with innovations arising from more structured, expert-led and resource-intensive research and development processes and standardised business procedures.