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WASH & Undernutrition
WASH &
Undernutrition
Oliver Cumming
London School of Hygiene and Tropical Medicine
SHARE Consortium
Key points
1. Background
2. Evidence
3. Disparities/equity
4. Implications for policy
Undernutrition
Prevalence of stunting (> 2 SD HAZ)
Source: Black et al. 2008
Undernutrition
It is estimated that undernutrition causes 2.2 million deaths and
21% of global disease burden for children younger than 5 years
(Black et al 2008)1
30% of children in low-income countries <5 years are chronically
undernourished (UNICEF 2008)2
As diarrhoea causes undernutrition, it also reduces a child’s
resistance 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 – in
early life limits cognitive development and lowers immunity
(Prüss-Üstün & Corvalán 2006)
Growth faltering
Mean height for age z-scores by age by region
Source: Victora et al 2010
WASH
• Review of 42 studies for food programmes in
Africa 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 of
this
Systematic Review
1. To evaluate the strength of
evidence on the
effectiveness of water,
sanitation and hygiene
interventions in improving
child nutritional status
2. To identify current
research gaps
Source: Dangour et al 2011
(Cochrane online)
Hypothesis
• Evidence that WASH interventions positively impact prevalence of
childhood disease3 4 5
• Diseases such as diarrhoea, tropical enteropathy and nematode
infections have negative effects on nutritional status in children6 7 8 9
• WASH interventions could be associated with improved measures
of nutritional status in children.
• Indirect pathways could also contribute:
– time taken to collect water
– the purchase of water
– chemical contamination of water
Low water quantity
Water source far from home
Inadequate storage
capacity
Poor water quality
Unprotected water source
Less time for
food preparation
and meal
supervision
Water pricing
High amount spent on water
DiarrhoeaTropical EnteropathyNematode infection
Contaminated material ingested
Faecal contamination of home
Poor nutritional status
Poor hand-washing
post-defecation
Unimproved sanitation
Less money
for food
Low
quantity and
quality
Conceptual framework
Three key pathways
1.Repeated bouts of diarrhoea
2. Intestinal worm infection
(hookworm, ascaris)
3. Environmental enteropathy***
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
Method
• Study design: intervention with control arm
• Participants: children < 18 years old from both low and high income
countries.
• Intervention types included are those aimed at:
1. improving access to facilities which ensure the hygienic separation of
human excreta from human contact
2. promotion of hand-washing with soap
3. introducing a new/improved water supply and/or improved
distribution
4. improving the microbiological quality of drinking water
Preliminary Results
Few high quality interventions studies <10
Most studies included ranked as poor quality by Cochrane
One 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*
Disparities
Sanitation progress 1995-2008 by wealth quintile
Source: UNICEF 2011
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
So what?
“If preventable, why
not prevented?”
(1891)
Key messages
1. New research but WASH a cause of undernutrition
2. Undernutrition increases risk of infection & death
3. Need food, healthcare access, and WASH
4. Different exposures may mean different interventions
5. Investment case: revalue ‘costs and consequences’
6. Policy coherence – WASH, nutrition, NTD…
7. Another reason to consider disparities/equity/non-
discrimination!
Concluding footnote
Edwin Chadwick (1847)
Sanitary reform to improve nutrition
of urban poor
Mills-Reinicke (McNutt 1901)
“The surprising fact that the
reduction in child mortality
accompanying improvements in
water supply was greater than
what could be accounted for by
the fall in mortality caused by
enteric, waterborne diseases.”
Thank you
www.SHAREresearch.org
oliver.cumming@lshtm.ac.uk

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WASH & Undernutrition

  • 2. WASH & Undernutrition Oliver Cumming London School of Hygiene and Tropical Medicine SHARE Consortium
  • 3. Key points 1. Background 2. Evidence 3. Disparities/equity 4. Implications for policy
  • 4. Undernutrition Prevalence of stunting (> 2 SD HAZ) Source: Black et al. 2008
  • 5. Undernutrition It is estimated that undernutrition causes 2.2 million deaths and 21% of global disease burden for children younger than 5 years (Black et al 2008)1 30% of children in low-income countries <5 years are chronically undernourished (UNICEF 2008)2 As diarrhoea causes undernutrition, it also reduces a child’s resistance 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 – in early life limits cognitive development and lowers immunity (Prüss-Üstün & Corvalán 2006)
  • 6. Growth faltering Mean height for age z-scores by age by region Source: Victora et al 2010
  • 7. WASH • Review of 42 studies for food programmes in Africa 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 of this
  • 8. Systematic Review 1. To evaluate the strength of evidence on the effectiveness of water, sanitation and hygiene interventions in improving child nutritional status 2. To identify current research gaps Source: Dangour et al 2011 (Cochrane online)
  • 9. Hypothesis • Evidence that WASH interventions positively impact prevalence of childhood disease3 4 5 • Diseases such as diarrhoea, tropical enteropathy and nematode infections have negative effects on nutritional status in children6 7 8 9 • WASH interventions could be associated with improved measures of nutritional status in children. • Indirect pathways could also contribute: – time taken to collect water – the purchase of water – chemical contamination of water
  • 10. Low water quantity Water source far from home Inadequate storage capacity Poor water quality Unprotected water source Less time for food preparation and meal supervision Water pricing High amount spent on water DiarrhoeaTropical EnteropathyNematode infection Contaminated material ingested Faecal contamination of home Poor nutritional status Poor hand-washing post-defecation Unimproved sanitation Less money for food Low quantity and quality Conceptual framework
  • 11. Three key pathways 1.Repeated bouts of diarrhoea 2. Intestinal worm infection (hookworm, ascaris) 3. Environmental enteropathy***
  • 12. 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
  • 13. Method • Study design: intervention with control arm • Participants: children < 18 years old from both low and high income countries. • Intervention types included are those aimed at: 1. improving access to facilities which ensure the hygienic separation of human excreta from human contact 2. promotion of hand-washing with soap 3. introducing a new/improved water supply and/or improved distribution 4. improving the microbiological quality of drinking water
  • 14. Preliminary Results Few high quality interventions studies <10 Most studies included ranked as poor quality by Cochrane One 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*
  • 15. Disparities Sanitation progress 1995-2008 by wealth quintile Source: UNICEF 2011
  • 16. 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
  • 18. “If preventable, why not prevented?” (1891)
  • 19. Key messages 1. New research but WASH a cause of undernutrition 2. Undernutrition increases risk of infection & death 3. Need food, healthcare access, and WASH 4. Different exposures may mean different interventions 5. Investment case: revalue ‘costs and consequences’ 6. Policy coherence – WASH, nutrition, NTD… 7. Another reason to consider disparities/equity/non- discrimination!
  • 20. Concluding footnote Edwin Chadwick (1847) Sanitary reform to improve nutrition of urban poor Mills-Reinicke (McNutt 1901) “The surprising fact that the reduction in child mortality accompanying improvements in water supply was greater than what could be accounted for by the fall in mortality caused by enteric, waterborne diseases.”