03450nas a2200349   4500000000100000008004100001653003600042653002200078653000800100653002900108653001500137653001300152100001400165700002100179700001300200700001000213700001500223700001400238700001300252700001400265700001400279700001300293700001200306700001400318700001100332245019400343856007900537300001300616490000700629520245000636022001403086       2019                            d10aSoil-transmitted helminth (STH)10aWaSH intervention10aMDA10aCluster randomized trial10aBangladesh10aChildren1 aErcumen A1 aBenjamin-Chung J1 aArnold B1 aLin A1 aHubbard AE1 aStewart C1 aRahman Z1 aParvez SM1 aUnicomb L1 aRahman M1 aHaque R1 aColford J1 aLuby S00aEffects of water, sanitation, handwashing and nutritional interventions on soil-transmitted helminth infections in young children: A cluster-randomized controlled trial in rural Bangladesh.  uhttps://journals.plos.org/plosntds/article?id=10.1371/journal.pntd.0007323  ae00073230 v133 a<p><strong>BACKGROUND: </strong>Soil transmitted helminths (STH) infect &gt;1.5 billion people. Mass drug administration (MDA) effectively reduces infection; however, there is evidence for rapid reinfection and risk of potential drug resistance. We conducted a randomized controlled trial in Bangladesh (WASH Benefits, NCT01590095) to assess whether water, sanitation, hygiene and nutrition interventions, alone and combined, reduce STH in a setting with ongoing MDA.</p>

<p><strong>METHODOLOGY/PRINCIPAL FINDINGS: </strong>In 2012-2013, we randomized 720 clusters of 5551 pregnant women into water treatment, sanitation, handwashing, combined water+sanitation+handwashing (WSH), nutrition, nutrition+WSH (N+WSH) or control arms. In 2015-2016, we enrolled 7795 children, aged 2-12 years, of 4102 available women for STH follow-up and collected stool from 7187. We enumerated STH infections with Kato-Katz. We estimated intention-to-treat intervention effects on infection prevalence and intensity. Participants and field staff were not blinded; laboratory technicians and data analysts were blinded. Prevalence among controls was 36.8% for A. lumbricoides, 9.2% for hookworm and 7.5% for T. trichiura. Most infections were low-intensity. Compared to controls, the water intervention reduced hookworm by 31% (prevalence ratio [PR] = 0.69 (0.50,0.95), prevalence difference [PD] = -2.83 (-5.16,-0.50)) but did not affect other STH. Sanitation improvements reduced T. trichiura by 29% (PR = 0.71 (0.52,0.98), PD = -2.17 (-4.03,-0.38)), had a similar borderline effect on hookworm and no effect on A. lumbricoides. Handwashing and nutrition interventions did not reduce any STH. WSH and N+WSH reduced hookworm prevalence by 29-33% (WSH: PR = 0.71 (0.52,0.99), PD = -2.63 (-4.95,-0.31); N+WSH: PR = 0.67 (0.50,0.91), PD = -3.00 (-5.14,-0.85)) and marginally reduced A. lumbricoides. Effects on infection intensity were similar.</p>

<p><strong>CONCLUSIONS/SIGNIFICANCE: </strong>In a low-intensity infection setting with MDA, we found modest but sustained hookworm reduction from water treatment and combined WSH interventions. Impacts were more pronounced on STH species with short vs. long-term environmental survival. Our findings suggest possible waterborne transmission for hookworm. Water treatment and sanitation improvements can augment MDA to interrupt STH transmission.</p>

<p><strong>TRIAL REGISTRATION: </strong>NCT01590095.</p>
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