WASH and Child Growth & Development

1. Clean, Fed & Nurtured: Joining forces to promote child growth and development WASH andChild Growth & Development Washington, DC | May 2-3, 2013 Val Curtis London School Of Hygiene and Tropical Medicine & Alan Dangour, Oliver Cumming, SHARE, DFID

2. WASH basics • Water • quantity and quality • Sanitation • Faecal waste disposal • Hygiene • Hand, Food, Environment

3. 0.85m deaths a year 2-3.5bn episodes Source: Liu et al, Lancet 2012

4. Fluids Fields New Host Faeces Foods Flies Fingers

5. Fluids Fields New Host Faeces Foods Flies Fingers

6. Fluids Fields New Host Faeces Foods Flies Fingers

7. Fluids Fields New Host Faeces Foods Flies Fingers

8. Fluids Fields New Host Faeces Foods Flies Fingers

9. Fluids Fields New Host Faeces Foods Flies Fingers

10. Fluids Fields New Host Faeces Foods Flies Fingers

12. 2.6bn have no safe toilet 0.8bn have no safe drinking water 20%?? HWWS Source: Global Water Supply and Sanitation Assessment 2010 Report: WHO and UNICEF, 2012

13. WASH and nutrition Poor WASH Faecal-oral exposure Nematode infection Diarrhoeal Diseases Environmental Enteropathy Poor nutritional status

15. Cochrane Public Health Group • Includes • RCTs • non-randomised controlled studies • interrupted time series studies • WASH included as one intervention

16. Review protocol • All included studies to have controlled design • Participants: children < 18 years old • Intervention types • Improving access to facilities which ensure the hygienic separation of human excreta from human contact • Promotion of hand washing with soap • Introducing a new/improved water supply and/or improved distribution • Improving the microbiological quality of drinking water

17. Outcomes, search strategy • Primary outcomes (z-scores) • Weight-for-height (wasting) • Weight-for-age (underweight) • Height-for-age (stunting) • Secondary outcomes • All other child anthropometric measures • Biochemical measures of micronutrient status • 6 databases searched; keyword and MeSH terms • 3 main Chinese databases searched

18. Search results

19. Included studies • 12 studies from 10 countries • Bangladesh (1989; 1993) • Guatemala (1968; 2009) • Pakistan (2012) • Kenya (2011) • Ethiopia (2012) • Nigeria (1990) • Nepal (2011) • Chile (1983) • South Africa (2010) • Cambodia (2011) • Duration: 6 mo to 5 years • Sample: n=8,500; all <5 years

20. Interventions • Studies included from 1 to 4 WASH interventions • Interventions • Provision of flocculent water disinfectant • Provision of a protected water supply • Installation of boreholes and hand pumps • Solar water disinfection (SODIS) • Sanitation education • Construction of sanitary facilities • Provision of soap • Promotion of hand washing with soap

21. Study designs • Multiple designs • Randomised controlled trials (3) • Follow-up of cluster randomised controlled trial (1) • Longitudinal study with control group (3) • Repeat cross-sectional with control group (3) • Controlled before-and-after study (1) • Cross-sectional with intervention and historic control group matched by propensity score matching (1) • No study considered high quality according to Cochrane criteria

22. Results table n=8,500

23. HAZ (all studies)

24. HAZ meta-analysis n=1,603 I2 = 0%

25. WAZ meta-analysis n=1,616 I2 = 5%

26. WHZ meta-analysis n=1,605 I2 = 0%

27. Interpretation Number of children included in studies reasonable Quality of studies is limited Cochrane meta-analysis suggests that WASH improves HAZ by ~0.15 SD Supported by IPD analysis “Suggestive evidence of benefit”

28. Concerns Publication bias Quality of studies Links in the pathway?

29. Conclusions of Cochrane review First systematic review of WASH and nutrition 12 studies (of mixed quality) provide data for analysis Suggestive evidence of benefit of WASH on linear growth More evidence on the way And still more needed!

30. WASH and nutrition Poor WASH Faecal-oral exposure Nematode infection Diarrhoeal Diseases Environmental Enteropathy Poor nutritional status

31. Diarrhoea and stunting • Diarrhoea associated with poor nutritional status but causal link hard to demonstrate • Poor nutritional status associated with greater risk of diarrhoea (Briend, 1990; Checkley et al, 2002) • Recent analysis of 9 studies with daily diarrhoea morbidity data and longitudinal anthropometry (Checkley et al, 2008): • Odds of stunting at age 24 mo increased with each diarrhoeal episode before 24 mo (P<0.001) • Odds of stunting at age 24 mo increased by 1.13 (95% C.I. 1.07, 1.19) for every five episodes • Consistent with hypothesis that higher cumulative burden of diarrhoea increases risk of stunting

32. WASH and nutrition Poor WASH Faecal-oral exposure Time, costs, workload Nematode infection Diarrhoeal Diseases Environmental Enteropathy Other Diseases Poor nutrition

33. WASH and ECD Poor WASH Faecal-oral exposure Time, costs, workload Nematode infection Diarrhoeal Diseases Environmental Enteropathy Other Diseases Poor ECD

34. Diarrhoea/Giardia and ECD High diarrheal disease burdens before 2 years of age linked with delayed school entry and poorer performance on intelligence tests • Patrick et al 2005. • Lorntz et al 2006 Multiple infections with Giardia associated with a 4-point (0.27 SD) deficit on a standardized intelligence test at 9 years of age. • Berkman et al 2002

35. Bowen et al 2012... “At 5 to 7 years of age, children randomized to home-based handwashing promotion during their first 30 months of life attained global developmental quotients more than 6 points (0.4 SD) greater than control children. The effect size was similar across all 5 domains (adaptive, personalsocial, communication, cognitive, and motor) ...and is comparable to gains after participation in the US publicly funded Head Start preschool program for poor children (SD, 0.33-0.46 compared with parental care) and early intervention programs for premature infants (SD, 0.46) Such an effect size is regarded as clinically meaningful and some estimate that a societal shift of this magnitude would yield trillions of dollars in increased productivity.”

36. Conclusions Systematic reviews are blunt instruments but the best we have All studies need publishing Ever more evidence to collect? Should that hold us back? Is this about competition?

37. Clean, Fed & Nurtured: Joining forces to promote child growth and development NUTRITION andChild Growth & Development Washington, DC | May 2-3, 2013 Kay Dewey UC-Davis and Alive & Thrive

38. Nutrition Basics • IYCF = infant and young child feeding, to 2 years • WHO-recommended feeding practices for: • Breastfeeding (early initiation; exclusive BF; continued BF) • Complementary feeding (e.g. amount, consistency, frequency, diversity & types of foods), including: • Safe preparation & storage of complementary foods (relevant to WASH) • Responsive feeding practices (relevant to ECD) • Established indicators: • Feeding practices (8 core WHO/UNICEF indicators) • Anthropometric measures (e.g., weight for age, height for age, weight for height, arm circumference) • Reduction in stunting (very short height for age) is a key goal

39. Key window for nutrition interventions Preconception through pregnancy 0-6 mo: Exclusive breastfeeding 6-24 mo: Complementary feeding Guiding principles for complementary feeding (2003; 2005)

40. Outline Impact of nutrition interventions on linear growth (child’s height) Impact of nutrition on child development The need for combined interventions

41. Impact of nutrition on child growth

42. Iron & folic acid supplements Multiple micronutrient supplements Balanced protein-energy supplements Fortified foods for pregnant women Potential for major impact on stunting, but evidence is mixed Prenatal nutrition interventions

43. Prenatal nutrition interventions • Multiple micronutrient supplements (usually compared with iron & folic acid) Meta-analysis in 2009 (Fall et al.): • Small but significant increase in birth weight (+22 g) but not birth length (+0.06 cm) • Measurement issues? • 11-17% reduction in low birth weight • Impact only evident in mothers with higher BMI Meta-analysis in 2012 (Ramakrishnan et al.): • Increase in mean birth weight (+53 g); data on birth length not presented • 14% reduction in low birth weight

44. Prenatal nutrition interventions B. Balanced protein-energy supplementation Meta-analysis in 2003 (Kramer & Kakuma): • Increase in mean birth weight (+38 g) but not birth length (+0.1 cm) • 32% reduction in small-for-gestational-age births • Larger effect on birth weight in hungry season and in undernourished women Meta-analysis in 2012 (Imdad & Bhutta): • Increase in mean birth weight (+73 g); did not report birth length • 32% reduction in LBW and 34% reduction in SGA births • Larger effect on birth weight in undernourished women

45. Prenatal nutrition interventions C. Fortified foods for pregnant women Lipid-based nutrient supplement (LNS) (Huybregtset al. Am J ClinNutr2009), Burkina Faso • LNS: 373 kcal/d & similar micronutrients as MMN tablets • LNS group (compared to MMN): • Birth weight +31 g (p=0.2) • Birth length +0.46 cm (p=0.001) • effect greater in mothers with BMI < 18.5 (+1.2 cm) • Same research group previously showed that MMN (vs. control) increased birth length by 0.36 cm; thus predicted impact of LNS vs. control would be 0.46 + 0.36 = 0.82 cm (effect size 0.33)

46. Exclusive breastfeeding 0-6 mo • Large impact on infant survival • Little evidence of impact on stunting • Effect may be more likely in populations with high rates of infection during the first 6 mo postpartum, where promotion of exclusive breastfeeding may reduce infection and thus be more likely to promote linear growth than in populations where such infections are less common • Insufficient evidence to evaluate this question at present 46

47. Complementary feeding 6-24 mo 6-24 mo: Complementary feeding Guiding principles for complementary feeding (2003; 2005) • Several strategies: • Educational approaches • Increasing energy density of complementary foods • Provision of complementary food • Fortification • Potential for major impact on stunting but evidence is mixed 47

48. Complementary Feeding - 1 • Educational approaches – mixed results • Most showed little or no impact • Peru study illustrated substantial potential to improve linear growth (Effect size=0.5): emphasized consumption of nutrient-rich animal-source foods & was conducted in a population where animal-source foods were available & affordable • Two recent studies (Shi et al.; Vazir et al.) show modest impact (Effect size ~0.2): both emphasized key messages including dietary diversity and animal-source foods

49. Complementary Feeding - 2 • Interventions to increase energy density – mixed results • Of 5 studies, 2 had positive impact but 3 had no impact on energy intake or growth • May be effective when traditional complementary food has low energy density & infant unable to compensate by increasing volume of food consumed or feeding frequency

50. Complementary Feeding - 3 • Provision of complementary food – mixed results • Average effect size ~0.2-0.3, but wide range • May depend on food security of target population • May depend on nutrient quality of food provided • Two studies directly compared food + education vs. education only (both in S Asia): somewhat greater impact when food included