Eff ectiveness of a rural sanitation programme on diarrhoea,soil-transmitted helminth infection, and child malnutrition in Odisha, India: a cluster-randomised trial

摘要

Background A third of the 2·5 billion people worldwide without access to improved sanitation live in India, as doudtwo-thirds of the 1·1 billion practising open defecation and a quarter of the 1·5 million who die annually fromuddiarrhoeal diseases. We aimed to assess the eff ectiveness of a rural sanitation intervention, within the context of theudGovernment of India’s Total Sanitation Campaign, to prevent diarrhoea, soil-transmitted helminth infection, andudchild malnutrition.udMethods We did a cluster-randomised controlled trial between May 20, 2010, and Dec 22, 2013, in 100 rural villages inudOdisha, India. Households within villages were eligible if they had a child younger than 4 years or a pregnant woman.udVillages were randomly assigned (1:1), with a computer-generated sequence, to undergo latrine promotion andudconstruction or to receive no intervention (control). Randomisation was stratifi ed by administrative block to ensure anudequal number of intervention and control villages in each block. Masking of participants was not possible because ofudthe nature of the intervention. However, households were not told explicitly that the purpose of enrolment was to studyudthe eff ect of a trial intervention, and the surveillance team was diff erent from the intervention team. The primaryudendpoint was 7-day prevalence of reported diarrhoea in children younger than 5 years. We did intention-to-treat andudper-protocol analyses. This trial is registered with ClinicalTrials.gov, number NCT01214785.udFindings We randomly assigned 50 villages to the intervention group and 50 villages to the control group. There wereud4586 households (24 969 individuals) in intervention villages and 4894 households (25 982 individuals) in controludvillages. The intervention increased mean village-level latrine coverage from 9% of households to 63%, comparedudwith an increase from 8% to 12% in control villages. Health surveillance data were obtained from 1437 householdsudwith children younger than 5 years in the intervention group (1919 children younger than 5 years), and fromud1465 households (1916 children younger than 5 years) in the control group. 7-day prevalence of reported diarrhoea inudchildren younger than 5 years was 8·8% in the intervention group and 9·1% in the control group (period prevalenceudratio 0·97, 95% CI 0·83–1·12). 162 participants died in the intervention group (11 children younger than 5 years) andud151 died in the control group (13 children younger than 5 years).udInterpretation Increased latrine coverage is generally believed to be eff ective for reducing exposure to faecal pathogensudand preventing disease; however, our results show that this outcome cannot be assumed. As eff orts to improveudsanitation are being undertaken worldwide, approaches should not only meet international coverage targets, butudshould also be implemented in a way that achieves uptake, reduces exposure, and delivers genuine health gains.udFunding Bill & Melinda Gates Foundation, International Initiative for Impact Evaluation (3ie), and Department forudInternational Development-backed SHARE Research Consortium at the London School of Hygiene & TropicaludMedicine