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Linking toilets to stunting
Sanitation and Stunting Conference, Delhi School of Economics
July 2013
Oliver Cumming
Environ...
Stunting – a global challenge
Short-term
• ↑ risk of mortality
• ↑ susceptibility to infections/morbidity
Long-term
• Educ...
Growth faltering
Mean height for age z-scores by age by region
Source: Victora et al 2010
Age 2
And, in India
SOURCE: Reproductive health, and child health and
nutrition in India: meeting the challenge. Paul et al (Lan...
A tough nut to crack
SOURCE: Lancet Series on Maternal and Child Undernutrition and
Overweight (Black et al, 2013)
Nutrition-specific interventions
If 10 core nutrition specific interventions were
scaled up at 90% coverage, could reduce
...
Nutrition-sensitive
interventions
What is the
contribution of
sanitation and
water…
and hygiene?
Linking WASH to undernutrition
Faecal-oral exposure
Diarrhoeal
Diseases
Environmental
Enteropathy
Nematode
infection
Poor ...
Diarrhoea and stunting
Diarrhoea is associated with poor
nutritional status but causal link is
hard to demonstrate
Recent ...
Nematode infections
Parasitic worm infections associated with
poor sanitation that limit growth and
cognitive development:...
Environmental Enteropathy
• Villous atrophy
• Crypt hyperplasis
• Increased gut permeability
• Inflammatory cell infiltrat...
What does this mean for
India?
Diarrhoea
A leading cause of child
deaths (13% of all u-5)
Nematode infections
284 million ...
1. Stunting is very important and a major public health challenge in India
1. Scaling up nutrition-specific interventions ...
What did we review?
• All included studies had an intervention and control
– RCTs, BACC, ITS
• Participants: children < 5
...
Search results - HAZ
Included studies
• 14 studies from 10 countries (but not India)
• 5 appropriate for meta-analysis
• Duration: 6 months to ...
HAZ meta-analysis
Supported by a separate individual participant data analysis (IPD):
HAZ: Mean Diff 0.11 z-score (95% CI:...
Interpretation
• Cochrane meta-analysis suggests effect of WASH of mean
difference 0.08 HAZ z-score (borderline significan...
Sanitation and stunting in India
1. Stunting is an enduring challenge in India with far-reaching
consequences and f/o expo...
Acknowledgements
Collaborators:
Dr Alan Dangour, Louise Watson and other co-authors
Funders:
UK Department for Internation...
Thank you!
Ollie   stunting & sanitation conference oliver cumming
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Ollie stunting & sanitation conference oliver cumming

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Ollie stunting & sanitation conference oliver cumming

  1. 1. Linking toilets to stunting Sanitation and Stunting Conference, Delhi School of Economics July 2013 Oliver Cumming Environmental Health Group London School of Hygiene and Tropical Medicine
  2. 2. Stunting – a global challenge Short-term • ↑ risk of mortality • ↑ susceptibility to infections/morbidity Long-term • Educational achievement • Work capacity • Economic productivity 34 countries which account for 90% of undernutrition. Source: Bhutta et al, 2013
  3. 3. Growth faltering Mean height for age z-scores by age by region Source: Victora et al 2010 Age 2
  4. 4. And, in India SOURCE: Reproductive health, and child health and nutrition in India: meeting the challenge. Paul et al (Lancet 2011)
  5. 5. A tough nut to crack SOURCE: Lancet Series on Maternal and Child Undernutrition and Overweight (Black et al, 2013)
  6. 6. Nutrition-specific interventions If 10 core nutrition specific interventions were scaled up at 90% coverage, could reduce stunting by 20% (Bhutta et al 2013) How do we close the gap?
  7. 7. Nutrition-sensitive interventions What is the contribution of sanitation and water… and hygiene?
  8. 8. Linking WASH to undernutrition Faecal-oral exposure Diarrhoeal Diseases Environmental Enteropathy Nematode infection Poor WASH Poor nutritional status
  9. 9. Diarrhoea and stunting Diarrhoea is associated with poor nutritional status but causal link is hard to demonstrate Recent analysis of 9 studies with daily diarrhoea morbidity data and longitudinal anthropometry (Checkley et al, 2008): Odds of stunting at age 24 months increased by 1.13 (95% C.I. 1.07, 1.19) for every five episodes Consistent with a hypothesis that higher cumulative burden of diarrhoea increases risk of stunting
  10. 10. Nematode infections Parasitic worm infections associated with poor sanitation that limit growth and cognitive development: • Ascaris lumbricoides (Roundworm) Intestinal obstruction & Vit A malabsorption • Trichuris trichiura (Whipworm) Dysentery syndrome, colitis • N. americanus & A. duodenale (Hookworm) Intestinal blood loss, iron deficiency, PEM SOURCE: Bethony et al, 2006
  11. 11. Environmental Enteropathy • Villous atrophy • Crypt hyperplasis • Increased gut permeability • Inflammatory cell infiltration • Malabsorption • Blunted immune function • Oral vaccine failure SOURCES: Images - Garcia, 1968; Histology – Humphrey 2009; Korpe & Petri
  12. 12. What does this mean for India? Diarrhoea A leading cause of child deaths (13% of all u-5) Nematode infections 284 million nematode infections Environmental enteropathy Plausibly high prevalence but not measured SOURCE: Reproductive health, and child health and nutrition in India: meeting the challenge. Paul et al (Lancet 2011)
  13. 13. 1. Stunting is very important and a major public health challenge in India 1. Scaling up nutrition-specific interventions alone not sufficient 3. Plausible that limiting faecal-oral exposure will reduce stunting 4. What evidence is there that WASH is effective in reducing stunting? Recap…
  14. 14. What did we review? • All included studies had an intervention and control – RCTs, BACC, ITS • Participants: children < 5 • All WASH interventions • Outcomes: z-scores and other anthropometric and bio-markers • 6 databases searched; keyword and MeSH terms • 3 main Chinese databases searched
  15. 15. Search results - HAZ
  16. 16. Included studies • 14 studies from 10 countries (but not India) • 5 appropriate for meta-analysis • Duration: 6 months to 5 years • Sample: n=11,611; all children <5 years • Multiple WASH interventions • Multiple study designs (including 5 RCTs) • No study considered to be “high quality”
  17. 17. HAZ meta-analysis Supported by a separate individual participant data analysis (IPD): HAZ: Mean Diff 0.11 z-score (95% CI: 0.03, 0.18)
  18. 18. Interpretation • Cochrane meta-analysis suggests effect of WASH of mean difference 0.08 HAZ z-score (borderline significant) • Approx. equivalent to 0.5 cm at 5 years of age • Approx. equivalent to a relative decline in stunting of as much as 15%* (absolute decline of 4.5%) • No sanitation, no water supply…
  19. 19. Sanitation and stunting in India 1. Stunting is an enduring challenge in India with far-reaching consequences and f/o exposure may be an important factor 2. Suggestive evidence that WASH is effective in reducing stunting 1. Rethink design and targeting of some environmental (‘WASH’) interventions 1. New evidence will help strengthen our response (Orissa RCT) 1. Don’t forget the basics – people need to own and use toilets!
  20. 20. Acknowledgements Collaborators: Dr Alan Dangour, Louise Watson and other co-authors Funders: UK Department for International Development Further information: www.SHAREresearch.org http://onlinelibrary.wiley.com/doi/10.1002/14651858.CD0 09382.pub2/full
  21. 21. Thank you!

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