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Meta-Analysis
. 2014 Mar 25;11(3):e1001620.
doi: 10.1371/journal.pmed.1001620. eCollection 2014 Mar.

Water, sanitation, hygiene, and soil-transmitted helminth infection: a systematic review and meta-analysis

Affiliations
Meta-Analysis

Water, sanitation, hygiene, and soil-transmitted helminth infection: a systematic review and meta-analysis

Eric C Strunz et al. PLoS Med. .

Abstract

Background: Preventive chemotherapy represents a powerful but short-term control strategy for soil-transmitted helminthiasis. Since humans are often re-infected rapidly, long-term solutions require improvements in water, sanitation, and hygiene (WASH). The purpose of this study was to quantitatively summarize the relationship between WASH access or practices and soil-transmitted helminth (STH) infection.

Methods and findings: We conducted a systematic review and meta-analysis to examine the associations of improved WASH on infection with STH (Ascaris lumbricoides, Trichuris trichiura, hookworm [Ancylostoma duodenale and Necator americanus], and Strongyloides stercoralis). PubMed, Embase, Web of Science, and LILACS were searched from inception to October 28, 2013 with no language restrictions. Studies were eligible for inclusion if they provided an estimate for the effect of WASH access or practices on STH infection. We assessed the quality of published studies with the Grades of Recommendation, Assessment, Development and Evaluation (GRADE) approach. A total of 94 studies met our eligibility criteria; five were randomized controlled trials, whilst most others were cross-sectional studies. We used random-effects meta-analyses and analyzed only adjusted estimates to help account for heterogeneity and potential confounding respectively. Use of treated water was associated with lower odds of STH infection (odds ratio [OR] 0.46, 95% CI 0.36-0.60). Piped water access was associated with lower odds of A. lumbricoides (OR 0.40, 95% CI 0.39-0.41) and T. trichiura infection (OR 0.57, 95% CI 0.45-0.72), but not any STH infection (OR 0.93, 95% CI 0.28-3.11). Access to sanitation was associated with decreased likelihood of infection with any STH (OR 0.66, 95% CI 0.57-0.76), T. trichiura (OR 0.61, 95% CI 0.50-0.74), and A. lumbricoides (OR 0.62, 95% CI 0.44-0.88), but not with hookworm infection (OR 0.80, 95% CI 0.61-1.06). Wearing shoes was associated with reduced odds of hookworm infection (OR 0.29, 95% CI 0.18-0.47) and infection with any STH (OR 0.30, 95% CI 0.11-0.83). Handwashing, both before eating (OR 0.38, 95% CI 0.26-0.55) and after defecating (OR 0.45, 95% CI 0.35-0.58), was associated with lower odds of A. lumbricoides infection. Soap use or availability was significantly associated with lower infection with any STH (OR 0.53, 95% CI 0.29-0.98), as was handwashing after defecation (OR 0.47, 95% CI 0.24-0.90). Observational evidence constituted the majority of included literature, which limits any attempt to make causal inferences. Due to underlying heterogeneity across observational studies, the meta-analysis results reflect an average of many potentially distinct effects, not an average of one specific exposure-outcome relationship.

Conclusions: WASH access and practices are generally associated with reduced odds of STH infection. Pooled estimates from all meta-analyses, except for two, indicated at least a 33% reduction in odds of infection associated with individual WASH practices or access. Although most WASH interventions for STH have focused on sanitation, access to water and hygiene also appear to significantly reduce odds of infection. Overall quality of evidence was low due to the preponderance of observational studies, though recent randomized controlled trials have further underscored the benefit of handwashing interventions. Limited use of the Joint Monitoring Program's standardized water and sanitation definitions in the literature restricted efforts to generalize across studies. While further research is warranted to determine the magnitude of benefit from WASH interventions for STH control, these results call for multi-sectoral, integrated intervention packages that are tailored to social-ecological contexts.

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Conflict of interest statement

The authors have declared that no competing interests exist.

Figures

Figure 1
Figure 1. PRISMA flow diagram.
Figure 2
Figure 2. Retrieved articles by WASH group.
Figure 3
Figure 3. Meta-analysis of the association between use of treated water and infection with any STH –.
Figure 4
Figure 4. Meta-analysis of the association between use of piped water use and any STH infection ,,–.
Figure 5
Figure 5. Meta-analysis of the association between use of piped water and A. lumbricoides infection ,,,.
Figure 6
Figure 6. Meta-analysis of the association between use of piped water and T. trichiura infection ,,.
Figure 7
Figure 7. Meta-analysis of the association between sanitation access and infection with any STH ,,,,,–.
Figure 8
Figure 8. Meta-analysis of the association between sanitation access and A. lumbricoides infection ,,,,,.
Figure 9
Figure 9. Meta-analysis of the association between sanitation access and T. trichiura infection ,,,,–.
Figure 10
Figure 10. Meta-analysis of the association between sanitation access and hookworm infection ,,–. Note: Chongsuvivatwong et al . reported on two separate studies in their 1996 article.
Figure 11
Figure 11. Meta-analysis of the association between soap use and infection with any STH ,,.
Figure 12
Figure 12. Meta-analysis of the association between handwashing before eating and infection with A. lumbricoides ,,.
Figure 13
Figure 13. Meta-analysis of the association between handwashing after defecation and infection with A. lumbricoides ,,.
Figure 14
Figure 14. Meta-analysis of the association between handwashing after defecation and infection with any STH ,,,,.
Figure 15
Figure 15. Meta-analysis of the association between wearing shoes and hookworm infection ,,,. Note: Chongsuvivatwong et al. reported on two separate studies in their 1996 article.
Figure 16
Figure 16. Meta-analysis of the association between wearing shoes and infection with any STH ,,.

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