Interventions to improve disposal of child faeces for preventing diarrhoea and soil‐transmitted helminth infection

Interventions to improve disposal of child faeces for preventing diarrhoea and soil‐transmitted helminth infection. Cochrane Database Syst Rev. 2019 Sep; 2019(9): CD011055.

Authors: Fiona Majorin, Belen Torondel, Gabrielle Ka Seen Chan, and Thomas Clasen

Evidence suggests that the safe disposal of child feces may be effective in preventing diarrhea. However, the evidence is limited and of low certainty. The limited research on STH infections provides only low and very‐low certainty evidence around effects, which means there is currently no reliable evidence that interventions to improve safe disposal of child faeces are effective in preventing such STH infections.

While child feces may represent a source of exposure to young children, interventions generally only address it as part of a broader sanitation initiative. There is a need for RCTs and other rigorous studies to assess the effectiveness and sustainability of different hardware and software interventions to improve the safe disposal of feces of children of different age groups.

Child Defecation and Feces Disposal Practices and Determinants among Households after a Combined Household-Level Piped Water and Sanitation Intervention in Rural Odisha, India

Child Defecation and Feces Disposal Practices and Determinants among Households after a Combined Household-Level Piped Water and Sanitation Intervention in Rural Odisha, India. Am Jnl Trop Med Hyg, Feb 18.

Significant predictors for disposing of child feces in an improved latrine were the primary female caregiver reporting using a latrine to defecate, the child’s age, and water observed at place for handwashing.

These findings suggest that child feces interventions should focus on encouraging children to begin using a toilet at a younger age and changing the common behavior of disposing of young child’s feces into open areas.

Webinar summary: The forgotten juncture? Handwashing and safe management of child feces

On August 22nd, 2018, the Global Handwashing Partnership, in conjunction with USAID, the International Water Center, the Water and Engineering Center for Development, and UNICEF hosted a discussion on the intersection of handwashing and the safe management of child feces. 

Safe disposal of children’s feces is a critical practice, and programs often under-emphasize critical times for handwashing related to infant and child feces. This webinar aimed to:
• Discuss the present status and impact of child feces disposal practices and handwashing,
• Highlight case studies, interventions and evidence,
• Share experiences across regions; and
• Review key considerations for practitioners.

Read the complete article and listen to the webinar.

Unsafe Child Feces Disposal is Associated with Environmental Enteropathy and Impaired Growth

Unsafe Child Feces Disposal is Associated with Environmental Enteropathy and Impaired Growth.  Journal of Pediatrics, June 2016.

• Full text, pdf

Authors: Christine Marie George, Lauren Oldja, Shwapon Biswas, et al.

Objective – To investigate the relationship between unsafe child feces disposal, environmental enteropathy, and impaired growth, we conducted a prospective cohort study of 216 young children in rural Bangladesh.

Study design – Using a prospective cohort study design in rural Bangladesh, unsafe child feces disposal, using the Joint Monitoring Program definition, was assessed using 5-hour structured observation by trained study personnel as well as caregiver reports. Anthropometric measurements were collected at baseline and at a 9-month follow-up. Stool was analyzed for fecal markers of environmental enteropathy: alpha-1-antitrypsin, myeloperoxidase, neopterin (combined to form an environmental enteropathy disease activity score), and calprotectin.

Findings – Among 216 households with young children, 84% had an unsafe child feces disposal event during structured observation and 75% had caregiver reported events. There was no significant difference in observed unsafe child feces disposal events for households with or without an improved sanitation option (82% vs 85%, P = .72) or by child’s age (P = .96). Children in households where caregivers reported unsafe child feces disposal had significantly higher environmental enteropathy scores (0.82-point difference, 95% CI 0.11-1.53), and significantly greater odds of being wasted (weight-for-height z score <2 SDs) (9% vs 0%, P = .024). In addition, children in households with observed unsafe feces disposal had significantly reduced change in weight-for-age z-score (0.34 [95% CI 0.68, 0.01] and weight-for-height z score (0.52 [95% CI 0.98, 0.06]).

Conclusion – Unsafe child feces disposal was significantly associated with environmental enteropathy and impaired growth in a pediatric population in rural Bangladesh. Interventions are needed to reduce this high-risk behavior to protect the health of susceptible pediatric populations

UNICEF/WSP – Child feces disposal in Bangladesh

Child feces disposal in Bangladesh, 2014. UNICEF; Water and Sanitation Program.

Part 1: Overview of current practices (full text, pdf)
Excerpt – In Bangladesh, in 2006, only 22% of households reported that the feces of their children under three were deposited into a toilet/latrine. Therefore, the stools of over 7.5 million children under three were not disposed safely. Th is includes over 3.5 million children whose feces were left in the open.2 Even among those 22% of households with safe child feces disposal, only half (11% overall) have an improved sanitation facility into which they could easily dispose the feces.  In rural areas of Bangladesh, crawling infants come into contact with animal feces, the baby’s own feces, and those of its brothers and sisters. According to one study, half of the mothers in two villages near Dhaka had also seen their infants eating or touching feces during the previous two weeks.

Part 2 – Interventions and Possible Program Interventions: Ideas from the Field (full text, pdf)
Excerpt –  This brief includes all relevant information that the authors have been able to locate thus far on current interventions to improve children’s sanitation in Bangladesh, as well as collating possible integration ideas from the field. It concludes with an appeal to readers to send in any additional information they may be aware of.

 

WASHplus Weekly – Focus on Child Feces Disposal

Issue 140 April 4, 2014 | Focus on Child Feces Disposal

A recent blog post by the SHARE project states that the feces of children may be particularly important in fecal-oral transmission since children are more susceptible to diseases such as diarrhea and often defecate in areas where other children could be exposed—the ground of a compound or in the house. This issue contains recent studies on child feces disposal practices in India and articles on child-friendly toilets. Also included are studies and reports on how infants and children are affected by fecal contamination caused by domestic animals.

WEBSITES

WASH Benefits Study/Bangladesh & Kenya – (Website)
The WASH Benefits Study, funded by the Bill and Melinda Gates Foundation, will provide rigorous evidence on the health and developmental benefits of water quality, sanitation, hand washing, and nutritional interventions during the first years of life. The study includes two cluster-randomized controlled trials to measure the impact of the intervention among newborn infants in rural Bangladesh and Kenya. Both will be large in scope and measure primary outcomes after two years of intervention. 

2014 STUDIES/PROTOCOLS

Interventions to Improve Disposal of Child Faeces for Preventing Diarrhoea and Soil-Transmitted Helminth Infection. (Protocol). Cochrane Database of Systematic Reviews, Apr 2014. F Majorin. (Order info)
The objectives of this study are to assess the effectiveness of interventions to improve the disposal of child feces for preventing diarrhea and soil-transmitted helminth infections. The interventions can include the provision of hardware (for example, nappies [diapers], potties, fecal collection devices, cleaning products to hygienically remove feces, child-friendly squatting slabs or latrines used by children), software (for example, promotion of safe disposal practices), or both. It will include interventions that combine the safe disposal of child feces with other interventions, such as hygiene promotion interventions, and employ subgroup analysis to investigate the impact of these additional interventions.

Child Feces Disposal Practices in Rural Orissa: A Cross Sectional Study. PLoS One, Feb 2014. F Majorin. (Link)
This study conducted surveys with heads of 136 households in 20 villages. It describes defecation and feces disposal practices and explores associations between safe disposal and risk factors. Respondents reported that children commonly defecated on the ground, either inside the household for pre-ambulatory children or around the compound for ambulatory children. Twenty percent of pre-ambulatory children used potties and nappies; the same percentage of ambulatory children defecated in a latrine. The study concludes that in the area surveyed, India’s Total Sanitation Campaign has not led to high levels of safe disposal of child feces.

Why is Child Faeces Disposal Important? 2014. SHARE. (Link)
Fiona Majorin of the SHARE project is currently conducting formative research in urban and rural settings in Orissa, India. The findings from this work will lead to the design of an intervention that will aim to improve safe child feces disposal.

Child Feces Disposal. A Presentation at the Handwashing Behavior Change Think Tank, 2014. (Link)
This brief presentation, given by the Water and Sanitation Program (WSP) of The World Bank, explores how to safely manage child feces. WSP and UNICEF are collaborating on 25 country profiles focusing on child feces disposal. The presenter appealed to colleagues at the Think Tank and to the WASH community to share any research, programs, or policies they know of that address child feces disposal by emailing them toerand@worldbank.org.

Toys and Toilets: Cross-Sectional Study Using Children’s Toys to Evaluate Environmental Faecal Contamination in Rural Bangladeshi Households with Different Sanitation Facilities and Practices. Trop Med Intl Health, Mar 2014. J Vujcic. (Abstract)
This study examined fecal contamination in 100 rural households with and without access to toilets/latrines using toys to measure the level of contamination. In rural Bangladesh, improved sanitation facilities and practices were associated with less environmental contamination. Whether this association is independent of household wealth and whether the difference in contamination improves child health merit further study. The variation found was typical for measures of environmental contamination, and requires large sample sizes to ascertain differences between groups with statistical significance.

“Cleaner, Healthier, Happier” Campaign Unveils New Muppet in Bangladesh, India, and Nigeria. Sesame Workshop India, Mar 2014. (Link)
Sesame Workshop, the nonprofit educational organization behind Sesame Street, unveils the world’s newest Muppet friend, Raya, who will engage children with important messages surrounding proper latrine use and sanitation throughout Bangladesh, India, and Nigeria as part of its Cleaner, Healthier, Happier campaign.

Interventions to improve disposal of child faeces for preventing diarrhoea and STH infection

Interventions to improve disposal of child faeces for preventing diarrhoea and soil-transmitted helminth infection, (Protocol). Cochrane Database of Systematic Reviews,  2014, Issue 4. Art. No.: CD011055. DOI:10.1002/14651858.CD011055.

• Order information

Authors: Majorin F, Torondel B, Ka Seen Chan G, Clasen TF.

Objectives: To assess the effectiveness of interventions to improve the disposal of child feces for preventing diarrhoea and soil-transmitted helminth infections. 

Interventions: Interventions can include the provision of hardware (for example, nappies (diapers), potties, fecal collection devices, cleaning products to hygienically remove feces, child-friendly squatting slabs or latrines used by children) software (for example, promotion of safe disposal practices), or both. It will include interventions that combine the safe disposal of child feces with other interventions, such as hygiene  promotion interventions, and employ subgroup analysis to investigate the impact of these additional interventions.

Child Feces Disposal Practices in Rural Orissa: A Cross Sectional Study

Child Feces Disposal Practices in Rural Orissa: A Cross Sectional Study. PLoS One, Feb 2014.

• Full text

Fiona Majorin, et al

Background – An estimated 2.5 billion people worldwide lack access to improved sanitation facilities. While large-scale programs in some countries have increased latrine coverage, they sometimes fail to ensure optimal latrine use, including the safe disposal of child feces, a significant source of exposure to fecal pathogens. We undertook a cross-sectional study to explore fecal disposal practices among children in rural Orissa, India in villages where the Government of India’s Total Sanitation Campaign had been implemented at least three years prior to the study.

Methods and Findings – We conducted surveys with heads of 136 households with 145 children under 5 years of age in 20 villages. We describe defecation and feces disposal practices and explore associations between safe disposal and risk factors. Respondents reported that children commonly defecated on the ground, either inside the household (57.5%) for pre-ambulatory children or around the compound (55.2%) for ambulatory children. Twenty percent of pre-ambulatory children used potties and nappies; the same percentage of ambulatory children defecated in a latrine. While 78.6% of study children came from 106 households with a latrine, less than a quarter (22.8%) reported using them for disposal of child feces. Most child feces were deposited with other household waste, both for pre-ambulatory (67.5%) and ambulatory (58.1%) children. After restricting the analysis to households owning a latrine, the use of a nappy or potty was associated with safe disposal of feces (OR 6.72, 95%CI 1.02–44.38) though due to small sample size the regression could not adjust for confounders.

Conclusions – In the area surveyed, the Total Sanitation Campaign has not led to high levels of safe disposal of child feces. Further research is needed to identify the actual scope of this potential gap in programming, the health risk presented and interventions to minimize any adverse effect.