As the first article in a four-part PLoS Medicine series on water and sanitation, Jamie Bartram and Sandy Cairncross argue that the massive burden of ill health associated with poor hygiene, sanitation, and water supply demands more attention from health professionals and policymakers.

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Hygiene, sanitation, and water: forgotten foundations of health.

Background
In countries of high endemicity of the soil-transmitted helminth parasites Ascaris lumbricoides, Trichuris trichiura, and hookworm, preventive chemotherapy (i.e., repeated administration of anthelmintic drugs to at-risk populations) is the main strategy to control morbidity. However, rapid reinfection of humans occurs after successful deworming, and therefore effective preventive measures are required to achieve public health goals with optimal efficiency and sustainability.

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Effect of Sanitation on Soil-Transmitted Helminth Infection: Systematic Review and Meta-Analysis

The world is becoming more urban every day, and the process has been ongoing since the industrial revolution in the 18th century. The United Nations now estimates that 3.9 billion people live in urban centres. The rapid influx of residents is however not universal and the developed countries are already urban, but the big rise in urban population in the next 30 years is expected to be in Asia and Africa. Urbanization leads to many challenges for global health and the epidemiology of infectious diseases. New megacities can be incubators for new epidemics, and zoonotic diseases can spread in a more rapid manner and become worldwide threats. Adequate city planning and surveillance can be powerful tools to improve the global health and decrease the burden of communicable diseases.

How urbanization affects the epidemiology of emerging infectious diseases.

Poor sanitation is thought to be a major cause of enteric infections among young children. However, there are no previously published randomized trials to measure the health impacts of large-scale sanitation programs. India’s Total Sanitation Campaign (TSC) is one such program that seeks to end the practice of open defecation by changing social norms and behaviors, and providing technical support and financial subsidies. The objective of this study was to measure the effect of the TSC implemented with capacity building support from the World Bank’s Water and Sanitation Program in Madhya Pradesh on availability of individual household latrines (IHLs), defecation behaviors, and child health (diarrhea, highly credible gastrointestinal illness [HCGI], parasitic infections, anemia, growth). The authors conducted a cluster-randomized, controlled trial in 80 rural villages. The study enrolled a random sample of 5,209 children less than 5 years old from 3,039 households that had at least one child less than 24 months at the beginning of the study. A random subsample of 1,150 children less than 24 months at enrollment were tested for soil transmitted helminth and protozoan infections in stool. The randomization successfully balanced intervention and control groups, and the authors estimated differences between groups in an intention to treat analysis. The intervention led to modest increases in availability of IHLs and even more modest reductions in open defecation. These improvements were insufficient to improve child health outcomes (diarrhea, HCGI, parasite infection, anemia, growth). The results underscore the difficulty of achieving adequately large improvements in sanitation levels to deliver expected health benefits within large-scale rural sanitation programs.

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The effect of India's total sanitation campaign on defecation behaviors and child health in rural Madhya Pradesh: a cluster randomized controlled trial.

Public health practitioners increasingly agree that it is not enough to provide people with water and sanitation hardware. Numerous approaches are used to tackle the “software” which means to ensur...

A systematic approach to behavior change interventions for the water and sanitation sector in developing countries: a conceptual model, a review, and a guideline

As one article in a four-part PLoS Medicine series on water and sanitation, David Trouba and colleagues discuss the importance of improved sanitation to health and the role that the health sector can play in its advocacy.

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Jon Lane

Papers

Sanitation and health.