Impact of WASH on Nutritional Status of Children in India: What are evidence telling us?

SWACH BharatAbstract

The two-leading cause of under-five mortality is diarrhea and pneumonia accounts for more than 30%. The evidence suggests us that hand washing with soap is cost effective yet very impactful intervention. Hand hygiene promotion interventions has potential to interrupt the transmission of diarrhea-causing pathogens. The Handwashing with soap can reduce significantly the incidence of diarrhea and pneumonia (Luby, 2005). As far as evidences are telling us that handwash is most cost-effective intervention and can reduce morbidity due to diarrhea by 44%. India has high number more than 50% of children’s are malnourished & under-nutrition is quite high in children from 6-24 months. Nevertheless, not only mortality but morbidity due to diarrhea and repeated occurrence in children can lead to severe malnourishment. Even the children’s borne healthy with normal weight nutrition status falls once child reached 6-24 months. Diarrhea is mainly caused by eating infected foods or liquids and person-to-person contact (mainly hand to hand then hand to mouth). Hand washing with soap is one of the most cost effective intervention. Hand wash & hygiene at key occasions specially before eating food and after toilet is important but not easy to practice and this requires behavior change and need to be practiced daily to adopt in routine habit. Children at early age during habit formation or at preschool stage need to taught & also parents need to practice that at household level. Hand wash & hygiene requires sharper behavioural change approach in the community to adopt this behavior and practice it as a daily habit. Sepsis is other leading cause of children within a month they are born and clean cord care & hand hygiene can prevent sepsis in neonate. Under-nutrition is the other leading cause of child death is often masked by the reported disease. Data says that 45% of all under-five mortality (more than 3.1 million per year) are due to diarrheaand pneumonia. (Horton, 2013).

Child malnutrition in India happens very early in life. More than half of children under five years of age in India are stunted and fail to meet their potential for growth and development. Their nutritional status deteriorates rapidly over the first two years of life and once this damage is done, catch up and recovery are almost impossible. Lack of access to WASH can affect a child’s nutritional status in many ways. Existing evidence supports at least three direct pathways: via diarrhoeal diseases, intestinal parasite infections and environmental enteropathy. Generally less evidence and fewer trials exist on the link between WASH and improved nutritional status. Nevertheless, there has been a growing interest in better understanding and measuring the effect of WASH on nutritional outcomes, and new research results provide insights into the relationship. The primary objective of this implementation research is to generate operational evidence on “how” WASH interventions can be integrated to improve nutrition outcomes of children.

In the study done by (Liu, 2012) certain WASH interventions can significantly reduce morbidity and mortality due to diarrhea which is second leading cause of under five child mortality. In this study it came out clearly Handwashing with Soap is 44% effective, household water treatment about 39%, Sanitation 32%, Water supply 25% and source water treatment 11%.(Liu,2012) It would be very important to emphasizes on hand washing interventions in India Nutrition and WASH program. Hand hygiene needs to be integral with all nutrition and health interventions. The need of the hour is to integrate Hand Hygiene in all Nutrition programme and this will certainly result in better Nutritional outcomes in Children. The sustainable Nutrition can be achieved only through integrating Hand hygiene with all nutrition programme in India. This means that the likelihood of the child being born with low birth weight is increase if the mother is undernourished before and during pregnancy. In other words, nutritional deprivations before and during pregnancy can contribute to poor nutrition status of the new born, with poor caring and feeding practices further exacerbating the situation. It is now well established that the consequences of chronic under-nutrition are profound, irreversible and life-long. At least 45 per cent of child mortality is attributable to poor nutrition; those children who survive under-nutrition face a diminished life. Their physical and mental development is likely to be impaired, hence they are less likely to perform well in school, less economically productive in adulthood, and at risk of nutrition related chronic illnesses such as obesity, diabetes and cardiovascular diseases. The underlying reasons for high maternal and child undernutrition, especially in resource poor settings, include poor access to health and environmental services, food insecurity, poor maternal education and caring capacity. The risk of severe stunting was three times higher among children that belong to the poorest as compared to those from the two richest wealth quintiles.

Undernutrition can span across generations and affect all stages of the life cycle. Girls suffering from undernutrition are likely to become undernourished mothers who are, in turn, more likely to give birth to low birth weight infants. For example, severe anaemia during pregnancy increases the risk of preterm delivery and low birth weight babies. Low birth weight babies are, in turn, more likely to die or become stunted. Adolescent girls are particularly vulnerable to undernutrition because they have high nutrient needs due to growth and because they are at risk for becoming pregnant (Black et al., 2013).

Lack of access to WASH can affect a child’s nutritional status in many ways. Existing evidence supports at least three direct pathways: via diarrhoeal diseases, intestinal parasite infections and environmental enteropathy.

Diarrhoea: Diarrhoea is a leading cause of mortality and morbidity among children under 5 years of age. Children under 5 years of age in low-income countries experience on average 2.9 episodes of diarrhoea per year, with the highest incidence rates in the first 2 years of life – the critical window for a child’s development (Fischer Walker et al., 2012). Diarrhoea and undernutrition form part of a vicious cycle. Diarrhoea can impair nutritional status through loss of appetite, malabsorption of nutrients and increased metabolism (Caulfield et al., 2004; Petri et al., 2008; Dewey & Mayers, 2011). Frequent episodes of diarrhoea in the first 2 years of life increase the risk of stunting and can impair cognitive development (Grantham-McGregor et al., 2007; Victora et al., 2008). At the same time, undernourished children have weakened immune systems, which make them more susceptible to enteric infections and lead to more severe and prolonged episodes of diarrhoea (Caulfield et al., 2004).

Intestinal parasitic infections: Soil-transmitted helminth infections – roundworm, whipworm and hookworm – affect millions of people worldwide (WHO, 2013c). Soil-transmitted helminth infections are directly caused by poor sanitation. Helminth eggs and larvae can survive for months in the soil and can infect humans when ingested (e.g. via contaminated water or food), by contact with fomites or by direct contact with the skin when walking barefoot on contaminated soil (hookworm larvae). Soil-transmitted helminth infections can affect nutritional status by causing malabsorption of nutrients, loss of appetite and increased blood loss. Heavy infections with whipworm and roundworm can impair growth (O’Lorcain & Holland, 2000). Hookworm infections are a major cause of anaemia in pregnant women and children. As many as one third of pregnant women in Africa are at risk of hookworm-related anaemia (Brooker, Hotez & Bundy, 2008), which in turn increases the risk of preterm delivery and low birth weight babies and, eventually, child undernutrition (Black et al., 2013). Environmental Enteropathy: Enteric pathogens can impair nutritional status even in the absence of symptoms such as diarrhoea. Children living in poor sanitary conditions are exposed to a high load of pathogens, especially between 6 months and 2 years of age, when they start crawling on the floor and putting objects into their mouths (Ngure et al., 2014). Chronic ingestion of pathogens can cause recurring inflammation and damage to the gut, leading to malabsorption of nutrients. This condition is often referred to as environmental enteropathy or environmental enteric dysfunction (Humphrey, 2009). Researchers suggest that environmental enteropathy may be an important cause of poor growth and may compromise the efficacy of nutritional interventions (Humphrey, 2009; Korpe & Petri, 2012). Several reviews highlighting the mounting evidence for links between unhygienic environments and gut dysfunction have recently been published (Humphrey, 2009; Korpe & Petri, 2012; Prendergast & Kelly, 2012). A large number of systematic reviews have been conducted to assess the impact of WASH interventions on diarrhoea incidence and prevalence (Esrey, Feachem & Hughes, 1985; Esrey et al., 1991; Fewtrell et al., 2005; Clasen et al., 2006, 2010; Arnold & Colford, 2007; Ejemot et al., 2008; Waddington et al., 2009; Norman, Pedley& Takkouche, 2010). The magnitude of the effect that WASH interventions have on diarrhoea mortality and morbidity varies depending on a number of factors, including the type and quality of the interventions, populations targeted, pathogens circulating in the environment, study design and methodological quality. According to the most recent global burden of disease estimates, access to improved WASH could prevent 361 000 diarrhoeal deaths per year among children under 5 years of age, representing 58% of the total diarrhoea deaths in this age group. This analysis also suggests that the greatest reductions in diarrhoea mortality (up to 73%) can be achieved through services that provide safe and continuous piped water supply and through sewerage connections that remove excreta from both households and community environments (Pruss-Ustun et al., 2014). Furthermore, recent meta-analyses have found that improving a range of WASH services and practices in households reduces the incidence of soil-transmitted helminth infections by, on average, one third (Ziegelbauer et al., 2012; Strunz et al., 2014).

Hand washing with soap is one of a range of hygiene promotion interventions that can interrupt the transmission of diarrhoea-causing pathogens. The leading cause of child mortality is pneumonia at 18%. Evidence indicates that hand washing with soap can significantly reduce the incidence of pneumonia in addition to diarrhoea (Luby, 2005). Generally,less evidence and fewer trials exist on the link between WASH and improved nutritional status compared with WASH and the incidence of diarrhoea or soil-transmitted helminth infections. Nevertheless, there has been a growing interest in better understanding and measuring the effect of WASH on nutritional outcomes, and new research results provide insights into the relationship.

A Cochrane review identified five cluster randomized controlled trials to measure the effect of WASH interventions on nutritional status (Dangour et al., 2013). These five studies, conducted in low-income settings, found evidence for a small, but statistically significant, effect of WASH interventions on stunting. The interventions were limited to water quality and/or hygiene and were of short duration, and no study considered the effect of a complete package of WASH interventions (Du Preez, McGuigan & Conroy, 2010; Du Preez et al., 2011). Whereas the Cochrane review suggests that WASH interventions can improve nutritional status. The proposed implementation research will provide more robust operational evidence on how and by how much different WASH interventions influence nutritional outcomes and identify the most effective ways of linking WASH with Nutrition.

By Abhijeet P Sinha