WASH Factors Contributing to Malnutrition, and Interventions to Reduce Their Impact

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1 WASH Factors Contributing to Malnutrition, and Interventions to Reduce Their Impact Daniele Lantagne, Ph.D., P.E. Assistant Professor Tufts University Luke Ascolillo Ph.D. Student Tufts University

2 Stunting, Wasting Stunting (HAZ): long-term malnourishment Wasting (WAZ) short-term malnourishment Just providing increased nutrient-dense food only corrects 1/3 rd of growth faltering / stunting

3 Logical Framework WASH interventions Reduce diarrhea Reduces malnutrition

4 Organisms that Contaminate Water Bacteria Chlorine inactivates ~1 micron (filterable) Cholera, Typhoid Viruses Chlorine inactivates <1 micron (not filterable) Rotavirus, Norovirus Protozoa (Oo)Cyst chlorine resistant 3-10 microns (filterable) Cryptosporidiosis, Giardiasis

5 Moderate-to-severe diarrhea: GEMS Study Estimate the population-based burden, microbiologic etiology, and adverse clinical consequences of MSD among children in developing countries 3 years: 7 sites (Asia, Africa), 3 age strata (infants, toddlers, children) 9,439 cases enrolled, 13,129 controls Results Rotavirus, Cryptosporidium, Shigella, and ST-ETEC significantly associated with MSD across all sites Growth faltering after MSD is significant; odds of death 8.5 times higher ST-ETEC and typical enteropathogenic E. coli associated with death (infants) Cryptosporidium associated with death in toddlers

6 Moderate-to-severe diarrhea: GEMS Recommendations Specifically target these five pathogens Vaccine (Rotavirus) Water interventions (the remainder) Nutritional rehabilitation to be part of case management for MSD

7 Link between GEMS and Malnutrition Exacerbation of malnutrition These 5 pathogens increase growth faltering Lead to increased death Malnutrition development more likely w/: Pathophysical impact on intestine Environmental enteropathy Early exposure in life Longer duration of disease Crypto, Shigella, ETEC have the potential Rotavirus, E. coli do not All 5 most common can exacerbate malnutrition 3 of most common can be cause of malnutrition

8 Interventions to reduce diarrhea

9 WASH and Nutrition Dynamic area, with incredibly active research Results since 2012 Environmental hygiene Open defecation Reduction in time to regain weight

10 SHEWA-B Evaluation (Steve Luby)

11 SHEWA-B (Steve Luby) When adjusted, 41% reduction of stunting, 95% reduction of wasting

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13 Lao PDR WSP (Scaling up Rural Sanitation)

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15 Treatment of acute malnutrition RUTF (control) and RUTF + PuR (intervention) 2004 Ethiopia Observed trend of faster recovery with RUTF and PuR Pakistan MAM intervention group recovery time 3.5 months, compared to 4.15 months in control group 2013 ACF, DRC Intervention group 26.4 day stay (control 30.4 days) Weight gain (g/kg/day): intervention (7.3) / control (6.6)

16 Aflatoxin Exposure Aspergillus in common staple crops can lead to the presence of Aflatoxin Aflatoxin exposure In utero, breastmilk, weaning food Limits IgA response -> increases enteric pathogen impact Causes environmental enteropathy There is sufficient evidence to support considering Aflatoxin exposure as a contributing factor to malnutrition

17 Aspergillus. + moisture + warm = Aflatoxin formation Aflatoxin ingestion: Enteropathy & Immunosuppression Enteropathy: reduced absorption due to inflammation of the gut Leaky intestine Clinical Manifestations: Increased severity infection Worsening nutritional status Low HAZ and WAZ Diet, Societal Conditions Diet: poor diversity, inadequate caloric & micronutrient intake, leading to immunosuppression Pathogen exposure, particularly to pathogens causing long-term disease

18 Aspergillus. + moisture + warm = Aflatoxin formation Aflatoxin ingestion: Enteropathy & Immunosuppression Enteropathy: reduced absorption due to inflammation of the gut Leaky intestine WASH interventions Clinical Manifestations: Increased severity infection Worsening nutritional status Low HAZ and WAZ Diet, Societal Conditions Diet: poor diversity, inadequate caloric & micronutrient intake, leading to immunosuppression Pathogen exposure, particularly to pathogens causing long-term disease

19 WASH interventions to reduce risk Provide sufficient nutrient dense foods With safe drinking water to assist in absorbing that food Also target <2 s who have recently had MSD and are growth faltering Keep the gut healthy (prevent environmental enteropathy) Prevent exposure to enteric pathogens causing long-term damage Cryptosporidium, ETEC, Shigella Pre-natal nutrition, breastfeeding, water supply, water treatment, sanitation Improve environmental hygiene Water supply and treatment, reduction of open defecation, handwashing Reduce exposure to Aflatoxin Pre-harvest or Post-harvest interventions Interventions for chronic should focus on first 1,000 days Conception to age 2

20 WASH-Benefits Trial (BMGF) Single intervention assessments unlikely to show impact WASH-Benefits Trial 2 crcts to measure impact of WASH and Nutrition interventions Enroll >5,000 newborn infants in rural Bangladesh and Kenya Outcomes at age 2 (HAZ, WAZ) 7 arms Water quality, Sanitation, Handwashing, Water quality + sanitation + handwashing, Nutrition, Nutrition + water quality + sanitation + handwashing, Control Nutrition intervention: Breastfeeding, education, and a nutritional supplement

21 Summary The WASH / Nutrition link is complex. We do not yet fully understand it. We have sufficient evidence to support implementing WASH, particularly in the first 1000 days, to reduce stunting; and, some evidence to support water treatment implementations in acute malnutrition.

22 Vietnam WSP (Scaling up Rural Sanitation)