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UNC-Chapel Hill ENVR 890 - Water, sanitation, and hygiene interventions to reduce diarrhoea in less developed countries

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Water, sanitation, and hygiene interventions to reduce diarrhoea in less developed countries: a systematic review and meta-anMethodsSearch strategyInitial selection criteria and data extractionInterventionsMeta-analysisResultsHygieneSanitationWater supplyWater qualityMultiple interventionsResults summaryDiscussionConclusionsAcknowledgmentsReferencesReviewDiarrhoeal disease is one of the leading causes ofmorbidity and mortality in less developed countries,especially among children aged under 5 years.1,2Sincethe seminal reviews of Esrey and colleagues in 1985,1986, and 1991,3–5additional studies have beenpublished on various water, hygiene, and sanitation-related interventions aimed at population healthimprovements. The original reviews,3–5and a study byBlum and Feachem,6have led to a better understandingof methodological issues in this area. The reviews byEsrey and colleagues3–5included studies that measureddifferences in health outcomes between groups that haddifferent water or sanitation conditions. Since these original reviews, many studies havereported additional results of interventions to reduceillness through improvements in drinking water,sanitation facilities, and hygiene practices in the lessdeveloped world. There has, however, been no formalsystematic review and meta-analysis comparing therelative evidence on the effectiveness of theseinterventions. We present a systematic review of allpublished studies and, where appropriate, meta-analysis of studies that reported interventions (plannedor occurring as natural experiments) in water quality,water supply, hygiene, and sanitation in less developedcountries. Less developed countries are defined here asany country not within a class A region under theWHO comparative risk assessment (class A countrieshave very low child and adult mortality). The meta-analyses focus on the evidence for any changearising from the interventions in diarrhoeal diseaseoccurrence in non-outbreak conditions. MethodsSearch strategyDatabase searches of the Cochrane Library, Embase,LILACS, Medline, and Pascal Biomed were done withkeyword searches that paired aspects of “water”,“sanitation”, and “hygiene” with “diarrhoea”, and,separately, with “intervention”. The Cochrane CentralRegister of Controlled Trials was particularly useful foridentifying intervention studies; Embase and Medlineprovided very good coverage of English languagepapers; and LILACS and Pascal Biomed providedcoverage of foreign language, Latin American, andCaribbean papers. Searches were limited to articlespublished before June 26, 2003 (when the search wasdone), and to articles about human beings. The reviewsby Esrey and colleauges3–5were used as an additionalsource to identify early studies, and author-basedsearches were used to identify subsequent work by theprimary investigators, with additional information. Alltitles and abstracts (if available) from each of thesearches were examined and then the relevant articleswere obtained for review. Bibliographies of thosearticles were examined for additional references. Norestrictions were put on study design, location, orlanguage of publication. Initial selection criteria and data extractionTwo selection criteria were used to identify articles: (1)description of specific water, sanitation, or hygieneinterventions, or some combination of such interventions;and (2) diarrhoea morbidity reported as the healthoutcome, measured under endemic (non-outbreak)Lancet Infect Dis 2005; 5: 42–52LF and DK are at the Centre forResearch into Environment andHealth, University of Wales,Aberystwyth, UK; RBK is at theWorld Bank, Washington DC, andCenters for Disease Control andPrevention, Atlanta, GA, USA;WE and JMCJr are at theUniversity of California, School ofPublic Health, Berkeley, CA, USA;and LH and JMCJr are at theWorld Health Organization,Water, Sanitation and HygieneUnit, Geneva, Switzerland.Correspondence to:Lorna Fewtrell, Centre forResearch into Environment andHealth, University of Wales,Aberystwyth, Ceredigion SY23 2DB, UKTel +44 (0)1270 250583; fax +44 (0)1270 589761;[email protected] http://infection.thelancet.com Vol 5 January 2005Lorna Fewtrell, Rachel B Kaufmann, David Kay, Wayne Enanoria, Laurence Haller, and John M Colford JrMany studies have reported the results of interventions to reduce illness through improvements in drinking water,sanitation facilities, and hygiene practices in less developed countries. There has, however, been no formalsystematic review and meta-analysis comparing the evidence of the relative effectiveness of these interventions. Wedeveloped a comprehensive search strategy designed to identify all peer-reviewed articles, in any language, thatpresented water, sanitation, or hygiene interventions. We examined only those articles with specific measurementof diarrhoea morbidity as a health outcome in non-outbreak conditions. We screened the titles and, wherenecessary, the abstracts of 2120 publications. 46 studies were judged to contain relevant evidence and werereviewed in detail. Data were extracted from these studies and pooled by meta-analysis to provide summaryestimates of the effectiveness of each type of intervention. All of the interventions studied were found to reducesignificantly the risks of diarrhoeal illness. Most of the interventions had a similar degree of impact on diarrhoealillness, with the relative risk estimates from the overall meta-analyses ranging between 0·63 and 0·75. The resultsgenerally agree with those from previous reviews, but water quality interventions (point-of-use water treatment)were found to be more effective than previously thought, and multiple interventions (consisting of combined water,sanitation, and hygiene measures) were not more effective than interventions with a single focus. There is someevidence of publication bias in the findings from the hygiene and water treatment interventions.Water, sanitation, and hygiene interventions to reducediarrhoea in less developed countries: a systematic reviewand meta-analysisReviewconditions. In addition, only published studies were used,to maintain quality (via peer review) and transparency.Data on intervention effectiveness were extracted,tabulated, and, if appropriate, pooled using meta-analysis to estimate summary measures ofeffectiveness, expressed as the relative risk of areduction in illness resulting from a specific type ofintervention. If many articles reported results from thesame


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UNC-Chapel Hill ENVR 890 - Water, sanitation, and hygiene interventions to reduce diarrhoea in less developed countries

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