Radically cleaner environment may be essential to cut childhood stunting

Improved drinking water, sanitation and handwashing (WASH) interventions reduced child diarrhoea in rural Bangladesh, but contrary to expectations, did not impact child growth - indicates findings from new study by icddr,b and US collaborators.

Published in the Lancet Global Health, finding from the WASH Benefits study conducted by icddr,b researchers with support from a broad range of international collaborators explored how a combination of chlorinated drinking water, upgraded sanitation and handwashing promotion with nutritional supplements coupled with dietary counseling altogether or individually affects the health and wellbeing of children under 2 years of age.

Partial improvements in WASH may be insufficient to affect childhood stunting. Photo: GMB Akash / icddr,b 

The study achieved high uptake of the water, sanitation, handwashing and nutrition interventions, with a clear interruption of pathogen transmission, illustrated by the reduction in diarrhoea.

The nutrition intervention modestly improved child’s height, but none of the WASH interventions improved height or reduced stunting, that is being short for age.

Scientists from Stanford University; University of California, Berkeley; Johns Hopkins Bloomberg School of Public Health; the University of California, Davis; the University of Buffalo and Emory University were co-investigators and authors of the research supported by the Bill & Melinda Gates Foundation.


Why no effect on stunting?

Children in the Bangladesh trial who received nutritional supplements in addition to WASH interventions did grow taller and were 38 percent less likely to die during the study, but WASH interventions alone without nutrition did not improve growth.

The intervention reduced contamination of food and water, resulting in fewer flies and improved diet, nevertheless soil in the study area was still heavily contaminated.

“Even with high uptake, these interventions apparently did not clean the environment enough to impact child growth. If we want children in the most resource-constrained environments to thrive, we may need to make their environments radically cleaner,” observed Stanford Professor Stephen Luby, senior author of the study.

Slide by Ayse Ercumen. Courtesy of Prof Steven Luby / Stanford

Prof Luby is one of the first epidemiologists to examine WASH interventions as a way of improving children’s growth in resource-limited communities. He observes that the findings help to inform future efforts, by focusing on strategies that can provide more than modest improvements to environments.

It is imperative to reduce children’s exposure to fecal contamination. Photo: Emdadul Islam Bitu / icddr,b

Commenting on the findings, Dr Md. Mahbubur Rahman, icddr,b principal investigator of the study in Bangladesh, said, “It was shown again that conventional WASH intervention strategies are insufficient to improve stunting in children living in WASH-compromised settings.”

He feels it is the time to think about more comprehensive strategies for WASH interventions that can better ensure clean and safe environments for growing children.

Future studies need to examine ways to reduce children’s exposure to fecal contamination in and around the home, recommends Dr Rahman, who also leads the environmental health & interventions unit at icddr,b as a project coordinator.

“We also need to learn how to effectively integrate these WASH interventions with other interventions for maternal and child health nutrition, and psychosocial stimulation to product the very best outcomes for our children,” he adds.

Muhamamd Zahir Hassan Nabil