Effects of water quality, sanitation, handwashing, and nutritional interventions on diarrhoea and child growth in rural Bangladesh: a cluster randomised controlled trial.
Effects of water quality, sanitation, handwashing, and nutritional interventions on diarrhoea and child growth in rural Bangladesh: a cluster randomised controlled trial.
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DOI：
10.1016/s2214-109x(17)30490-4
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发表时间：
2018-03
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通讯作者：
Colford JM Jr
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作者：
Luby SP;Rahman M;Arnold BF;Unicomb L;Ashraf S;Winch PJ;Stewart CP;Begum F;Hussain F;Benjamin-Chung J;Leontsini E;Naser AM;Parvez SM;Hubbard AE;Lin A;Nizame FA;Jannat K;Ercumen A;Ram PK;Das KK;Abedin J;Clasen TF;Dewey KG;Fernald LC;Null C;Ahmed T;Colford JM Jr
幼儿期腹泻和生长迟缓与随后的不良后果有关。我们的目的是评估水质、卫生和洗手干预单独或与营养干预相结合是否能减少腹泻或生长迟缓。WASH Benefits Bangladesh分组随机试验招募了来自孟加拉国农村的孕妇，并在1年和2年的随访中评估了结果。地理位置相邻的孕妇被随机分组到七个组之一：氯化饮用水（水）；改善卫生设施（卫生设施）；推广用肥皂洗手（洗手）；将水、卫生设施和洗手结合起来；就适当的儿童营养和以脂质为基础的营养补充剂提供咨询（营养）；结合水、卫生、洗手和营养；和控制（仅收集数据）。主要结局是在过去7天内照顾者报告的入组时在子宫内或小于3岁的儿童腹泻，以及入组孕妇所生儿童的年龄长度Z评分。数据收集无法屏蔽，但分析被屏蔽了。分析的目的是治疗。该试验已在ClinicalTrials.gov注册，编号NCC01590095。在2012年5月31日至2013年7月7日期间，720组的5551名孕妇被随机分配到7组中的一组。1382名女性被分配到对照组；698到水；696美元用于卫生；688到洗手；702到水、卫生和洗手；699要营养；686美元用于水、卫生、洗手和营养。331名（6%）女性失访。有14425名儿童（7331名在1731年，7094名在第二年）在1年级或2年级（合并）的腹泻数据，有4584名儿童（92%的在世儿童在2年级测量）在2年级的Z评分数据。所有干预措施的依从性都很高。与对照组的5.7%（3517个儿童周中的200个）相比，指标儿童和3岁以下儿童入组时接受卫生设施（1760例中的61例[3.5%]，患病率0.61,95% CI 0.46 - 0.81）、洗手（1795例中的62例[3.5%]，0.60例，0.45 - 0.80例）、水、卫生设施和洗手相结合（1902例中的74例[3.9%]，0.69例，0.53 - 0.90例）、营养（1766例中的62例[3.5%]）和营养（1766例中的62例[3.5%]）的7天腹泻患病率较低。0.64, 0.49 - 0.85)，结合水，卫生，洗手和营养（1861年66 [3.5%];0.62,0.47 - 0.81）；接受水处理的儿童腹泻患病率没有显著降低（90[4.9%]/ 1824;0.89,0.70 - 1.13）。与对照组（平均年龄长度Z值为- 1.79）相比，营养组（平均差值为0.25 [95% CI为0.15 - 0.36]）和水、卫生、洗手和营养组合组（平均差值为0.13[0.02 - 0.24]）的儿童在2岁时身高更高。单独的水、卫生设施和洗手组，以及水、卫生设施和洗手组合组对线性增长没有影响。营养补充和咨询适度改善了线性增长，但将水、卫生设施和洗手与营养结合起来没有任何好处。所有组的依从性都很高，除水治疗外，所有干预组的腹泻患病率都有所降低。与单一干预措施相比，水、卫生和洗手联合干预措施没有附加效益。比尔和梅林达·盖茨基金会。
Diarrhoea and growth faltering in early childhood are associated with subsequent adverse outcomes. We aimed to assess whether water quality, sanitation, and handwashing interventions alone or combined with nutrition interventions reduced diarrhoea or growth faltering. The WASH Benefits Bangladesh cluster-randomised trial enrolled pregnant women from villages in rural Bangladesh and evaluated outcomes at 1-year and 2-years' follow-up. Pregnant women in geographically adjacent clusters were block-randomised to one of seven clusters: chlorinated drinking water (water); upgraded sanitation (sanitation); promotion of handwashing with soap (handwashing); combined water, sanitation, and handwashing; counselling on appropriate child nutrition plus lipid-based nutrient supplements (nutrition); combined water, sanitation, handwashing, and nutrition; and control (data collection only). Primary outcomes were caregiver-reported diarrhoea in the past 7 days among children who were in utero or younger than 3 years at enrolment and length-for-age Z score among children born to enrolled pregnant women. Masking was not possible for data collection, but analyses were masked. Analysis was by intention to treat. This trial is registered at ClinicalTrials.gov, number NCC01590095. Between May 31, 2012, and July 7, 2013, 5551 pregnant women in 720 clusters were randomly allocated to one of seven groups. 1382 women were assigned to the control group; 698 to water; 696 to sanitation; 688 to handwashing; 702 to water, sanitation, and handwashing; 699 to nutrition; and 686 to water, sanitation, handwashing, and nutrition. 331 (6%) women were lost to follow-up. Data on diarrhoea at year 1 or year 2 (combined) were available for 14 425 children (7331 in year 1, 7094 in year 2) and data on length-for-age Z score in year 2 were available for 4584 children (92% of living children were measured at year 2). All interventions had high adherence. Compared with a prevalence of 5·7% (200 of 3517 child weeks) in the control group, 7-day diarrhoea prevalence was lower among index children and children under 3 years at enrolment who received sanitation (61 [3·5%] of 1760; prevalence ratio 0·61, 95% CI 0·46–0·81), handwashing (62 [3·5%] of 1795; 0·60, 0·45–0·80), combined water, sanitation, and handwashing (74 [3·9%] of 1902; 0·69, 0·53–0·90), nutrition (62 [3·5%] of 1766; 0·64, 0·49–0·85), and combined water, sanitation, handwashing, and nutrition (66 [3·5%] of 1861; 0·62, 0·47–0·81); diarrhoea prevalence was not significantly lower in children receiving water treatment (90 [4·9%] of 1824; 0·89, 0·70–1·13). Compared with control (mean length-for-age Z score −1·79), children were taller by year 2 in the nutrition group (mean difference 0·25 [95% CI 0·15–0·36]) and in the combined water, sanitation, handwashing, and nutrition group (0·13 [0·02–0·24]). The individual water, sanitation, and handwashing groups, and combined water, sanitation, and handwashing group had no effect on linear growth. Nutrient supplementation and counselling modestly improved linear growth, but there was no benefit to the integration of water, sanitation, and handwashing with nutrition. Adherence was high in all groups and diarrhoea prevalence was reduced in all intervention groups except water treatment. Combined water, sanitation, and handwashing interventions provided no additive benefit over single interventions. Bill & Melinda Gates Foundation.