WASH &UndernutritionOliver CummingLondon School of Hygiene and Tropical MedicineSHARE Consortium
Key points1. Background2. Evidence3. Disparities/equity4. Implications for policy
UndernutritionPrevalence of stunting (> 2 SD HAZ)Source: Black et al. 2008
UndernutritionIt is estimated that undernutrition causes 2.2 million deaths and21% of global disease burden for children y...
Growth falteringMean height for age z-scores by age by regionSource: Victora et al 2010
WASH• Review of 42 studies for food programmes inAfrica found the best result was 0.7 z-score• Average growth deficit for ...
Systematic Review1. To evaluate the strength ofevidence on theeffectiveness of water,sanitation and hygieneinterventions i...
Hypothesis• Evidence that WASH interventions positively impact prevalence ofchildhood disease3 4 5• Diseases such as diarr...
Low water quantityWater source far from homeInadequate storagecapacityPoor water qualityUnprotected water sourceLess time ...
Three key pathways1.Repeated bouts of diarrhoea2. Intestinal worm infection(hookworm, ascaris)3. Environmental enteropathy...
Methods• Primary outcomes:– weight-for-height (wasting)– weight-for-age (underweight)– height-for-age (stunting)• Secondar...
Method• Study design: intervention with control arm• Participants: children < 18 years old from both low and high incomeco...
Preliminary ResultsFew high quality interventions studies <10Most studies included ranked as poor quality by CochraneOne r...
DisparitiesSanitation progress 1995-2008 by wealth quintileSource: UNICEF 2011
All toilets are equal?• 2.5 billion people without toilet• Every toilet built (used!) is progress• But, need to get toilet...
So what?
“If preventable, whynot prevented?”(1891)
Key messages1. New research but WASH a cause of undernutrition2. Undernutrition increases risk of infection & death3. Need...
Concluding footnoteEdwin Chadwick (1847)Sanitary reform to improve nutritionof urban poorMills-Reinicke (McNutt 1901)“The ...
Thank youwww.SHAREresearch.orgoliver.cumming@lshtm.ac.uk
WASH & Undernutrition
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The seminar will examine the widely neglected and underestimated adverse nutritional impact of lack of safe water, sanitation and hygiene (WASH). It makes apparent how governments struggling to feed their citizens can make a substantial contribution to food and nutrition security by making WASH investments. Reducing faecal infections through sanitation and hygienic behaviour is a major means for reducing the undernutrition of children, enhancing the wellbeing of children, women and men, and achieving the MDGs. Approaches for scaling-up WASH like Conditional Cash Transfers (CCT) as well as approaches to improve food and nutrition security through productive sanitation will be presented using regional case studies. Together with the participants the potentials and challenges of these approaches will be discussed in rotating discussion groups facilitated by distinguished sector experts. The goal is to get an in-depth understanding of this neglected link and to provide constructive impulses for promising ways forward to strengthen this nexus at scale and push towards fulfilment of the human right to water and sanitation. This seminar was part of World Water Week, 2012.

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WASH & Undernutrition

  1. 1. WASH &UndernutritionOliver CummingLondon School of Hygiene and Tropical MedicineSHARE Consortium
  2. 2. Key points1. Background2. Evidence3. Disparities/equity4. Implications for policy
  3. 3. UndernutritionPrevalence of stunting (> 2 SD HAZ)Source: Black et al. 2008
  4. 4. UndernutritionIt is estimated that undernutrition causes 2.2 million deaths and21% of global disease burden for children younger than 5 years(Black et al 2008)130% of children in low-income countries <5 years are chronicallyundernourished (UNICEF 2008)2As diarrhoea causes undernutrition, it also reduces a child’sresistance to subsequent infections creating a vicious circle(Brown et al. 2003)Further evidence suggests that sustained exposure to excreta-related pathogens – including helminths referred to above – inearly life limits cognitive development and lowers immunity(Prüss-Üstün & Corvalán 2006)
  5. 5. Growth falteringMean height for age z-scores by age by regionSource: Victora et al 2010
  6. 6. WASH• Review of 42 studies for food programmes inAfrica found the best result was 0.7 z-score• Average growth deficit for Africa (& Asia) 2.0• So, the best programmes only achieved 33%normalisation• Environmental influences may explain some ofthis
  7. 7. Systematic Review1. To evaluate the strength ofevidence on theeffectiveness of water,sanitation and hygieneinterventions in improvingchild nutritional status2. To identify currentresearch gapsSource: Dangour et al 2011(Cochrane online)
  8. 8. Hypothesis• Evidence that WASH interventions positively impact prevalence ofchildhood disease3 4 5• Diseases such as diarrhoea, tropical enteropathy and nematodeinfections have negative effects on nutritional status in children6 7 8 9• WASH interventions could be associated with improved measuresof nutritional status in children.• Indirect pathways could also contribute:– time taken to collect water– the purchase of water– chemical contamination of water
  9. 9. Low water quantityWater source far from homeInadequate storagecapacityPoor water qualityUnprotected water sourceLess time forfood preparationand mealsupervisionWater pricingHigh amount spent on waterDiarrhoeaTropical EnteropathyNematode infectionContaminated material ingestedFaecal contamination of homePoor nutritional statusPoor hand-washingpost-defecationUnimproved sanitationLess moneyfor foodLowquantity andqualityConceptual framework
  10. 10. Three key pathways1.Repeated bouts of diarrhoea2. Intestinal worm infection(hookworm, ascaris)3. Environmental enteropathy***
  11. 11. Methods• Primary outcomes:– weight-for-height (wasting)– weight-for-age (underweight)– height-for-age (stunting)• Secondary outcomes:– all other child anthropometric measures– biochemical measures of micronutrient status (including EE)• 6 databases searched using a keyword search and MeSH terms
  12. 12. Method• Study design: intervention with control arm• Participants: children < 18 years old from both low and high incomecountries.• Intervention types included are those aimed at:1. improving access to facilities which ensure the hygienic separation ofhuman excreta from human contact2. promotion of hand-washing with soap3. introducing a new/improved water supply and/or improveddistribution4. improving the microbiological quality of drinking water
  13. 13. Preliminary ResultsFew high quality interventions studies <10Most studies included ranked as poor quality by CochraneOne randomised controlled trial:Du Preez (2011)Water treatment median 0.8 cm gain for u5 stunting (0.7 - 1.6 cm; P-0.031)A number of important protocols identified:• Clasen et al – Orissa, India (Z-scores)• Luby et al – Bangladesh (Z-scores, MUAC, EE markers )• Humphrey et al – Zimbabwe ((Z-scores, MUAC, EE ) *from birth/factorial*
  14. 14. DisparitiesSanitation progress 1995-2008 by wealth quintileSource: UNICEF 2011
  15. 15. All toilets are equal?• 2.5 billion people without toilet• Every toilet built (used!) is progress• But, need to get toilets to the most at risk• Sanitation risks is not distributed evenly in populations• RR of fatal diarrhoea higher for u5 with under-nutrition• Nutrition is a high determinant of sanitation health risk
  16. 16. So what?
  17. 17. “If preventable, whynot prevented?”(1891)
  18. 18. Key messages1. New research but WASH a cause of undernutrition2. Undernutrition increases risk of infection & death3. Need food, healthcare access, and WASH4. Different exposures may mean different interventions5. Investment case: revalue ‘costs and consequences’6. Policy coherence – WASH, nutrition, NTD…7. Another reason to consider disparities/equity/non-discrimination!
  19. 19. Concluding footnoteEdwin Chadwick (1847)Sanitary reform to improve nutritionof urban poorMills-Reinicke (McNutt 1901)“The surprising fact that thereduction in child mortalityaccompanying improvements inwater supply was greater thanwhat could be accounted for bythe fall in mortality caused byenteric, waterborne diseases.”
  20. 20. Thank youwww.SHAREresearch.orgoliver.cumming@lshtm.ac.uk
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