Sanitation efforts may not be effective at preventing fecal exposure in India

1. Over an 18 month surveillance period after implementing increased latrine coverage throughout villages in rural India, there was no reduction in fecal contamination or rates of diarrhea, helminth infection, or childhood malnutrition.

2. Sanitation studies of this type may need long-term follow up of 5-10 years in order to observe effects due to delivered interventions.

Evidence Rating Level: 2 (Good)

Study Rundown: Adequate sanitation is a major problem in many parts of the world, including rural India. In this area, over 700 million individuals practice open defecation and approximately 375,000 die from diarrheal diseases each year. Furthermore, 19% of all deaths in children under the age of five years in low-income settings are attributed to diarrheal diseases and issues with improper sanitation. The authors of this study set out to determine the effectiveness of household sanitation improvements in rural India at preventing diarrheal diseases, helminth infection, and childhood malnutrition by randomly assigning 100 villages to either latrine promotion and construction or no intervention.

The study showed that installation of household latrines in rural villages had no significant effect on any of the three disease states. This study contradicted the generally held belief that increased household latrine presence has a beneficial effect on health status. The findings here, however, agreed with another recently completed trial in a similar population in rural India. This study was limited by the fact that the follow-up period was only 18 months in duration, which may not have been long enough for differences between intervention and control groups to arise as a product of longstanding effects of poor sanitation such as long-lived cyst forms of helminthes. Additionally, improvements in household sanitation alone may not adequately decrease exposure to fecal-oral pathogens.

This study was funded by the Bill & Melinda Gates Foundation, International Initiative for Impact Evaluation (3ie), and Department for International Development-backed SHARE Research Consortium at the London School of Hygiene & Tropical Medicine.

Click to read the study, published today in The Lancet Global Health

Relevant Reading: Systematic review: Assessing the impact of drinking water and sanitation on diarrhoeal disease in low- and middle-income settings: systematic review and meta-regression

In-Depth [randomized controlled trial]: This study included 100 villages in Odisha, India from 2010-13, in which 50 randomly received intervention in the form of latrine promotion and construction, while the other 50 served as a non-intervention control group. Villages were eligible based on having less than 10% sanitation coverage, improved water supply, and no other water, sanitation, or hygiene intervention planned in the next 30 months. Households were selected if they had a child younger than four years old or had a pregnant woman living there. The primary outcome was 7-day prevalence of diarrhea, defined as 3 or more loose stools in 24 hours, in children under 5 years.

The 50 intervention villages consisted of 1,437 households (10,014 individuals, including 1,919 under age 5) and the 50 control villages consisted of 1,465 households (10,269 individuals, 1,961 under age 5). Latrine presence increased from 9% to 63% in intervention villages while the increase was only from 8% to 12% in control villages. Household water contamination was not different between intervention and control villages (OR 1.06, 95% Confidence Interval [CI] 0.89-1.24, p>0.3), as was child hand contamination (OR 0.85, 95% CI 0.47-1.55, p>0.3), and synanthropic fly count (OR 0.73, 95% CI 0.46-1.16, p>0.3). Furthermore, latrine promotion and construction had no effect on diarrhea prevalence in children under age 5 (8.8% in the intervention group vs. 9.1% in the control group) with a prevalence ratio of 0.97 (95% CI 0.83-1.12). Results were similarly non-significant for soil transmitted helminth infection prevalence, weight for age, and height for age z-scores.

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