Effects of water quality, sanitation, handwashing and nutritional interventions on enteric pathogen seroconversion in rural Kenya: a cluster randomised trial
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Background
We evaluated whether water, sanitation, and handwashing (WASH) and nutrition interventions reduced enteric pathogen seroprevalence during the first two years of life among children in rural Kenya.
Methods
We analysed the 2×2 factorial subset of the WASH Benefits Kenya cluster-randomised trial (control, WASH, nutrition, and WASH plus nutrition). Dried blood spots were collected from all children in the birth cohort after two years of intervention and at 6 and 12 months within a longitudinal substudy. Immunoglobulin G (IgG) responses were measured using a multiplex bead assay that included 12 pathogens. The primary outcome was IgG seroprevalence at 2 years. We estimated intention-to-treat differences, comparing WASH with no WASH and nutrition with no nutrition across the factorial design. Trial registration: NCT01704105 .
Findings
The primary analysis included 3030 children in 384 clusters (median age 23 months). Seroprevalence increased rapidly with age and exceeded 90% for norovirus, Campylobacter , and LT-ETEC by the final visit, with several pathogens at moderate prevalences (24% were seropositive to typhoidal S. enterica HlyE). Differences between intervention groups were small: lower T. solium (−3.3 percentage points [95% CI −6.3 to −0.2]) and higher E. histolytica (3.2 [0.1 to 6.3]) with WASH versus control, and lower V. cholerae (−1.1 [−1.8 to −0.3]) and Shigella /EIEC (−2.7 [−5.5 to 0.0]) with nutrition versus no nutrition. No comparison met the 5% Benjamini– Hochberg false discovery rate threshold. Secondary analyses and age-seroprevalence curves suggested modest reductions for some pathogens but increased norovirus seroprevalence around 12 months, when intervention adherence was highest.
Interpretation
At achieved adherence levels, household-level WASH and nutrition interventions were insufficient to reduce widespread early-life enteric pathogen exposure in this high-transmission setting, supporting the development of complementary vaccine and transmission-control strategies.
Funding
National Institutes of Health (R01AI166671, R01AI106878, R01AI134814). The original WASH Benefits trial was funded by the Gates Foundation (OPPGD759).
