Research Article: Effectiveness of a Household Water, Sanitation and Hygiene Package on an Outpatient Program for Severe Acute Malnutrition: A Pragmatic Cluster-Randomized Controlled Trial in Chad

Date Published: April 26, 2018

Publisher: The American Society of Tropical Medicine and Hygiene

Author(s): Mathias Altmann, Chiara Altare, Nanette van der Spek, Jean-Christophe Barbiche, Jovana Dodos, Mahamat Bechir, Myriam Ait Aissa, Patrick Kolsteren.


Water, sanitation and hygiene (WASH) interventions have a small but measurable benefit on stunting, but not on wasting. Our objective was to assess the effectiveness of a household WASH package on the performance of an Outpatient Therapeutic feeding Program (OTP) for severe acute malnutrition (SAM). We conducted a cluster-randomized controlled trial embedded in a routine OTP. The study population included 20 health centers (clusters) from Mao and Mondo districts in Chad. Both arms received the OTP. The intervention arm received an additional household WASH package (chlorine, soap, water storage container, and promotion on its use). The primary objective measures were the relapse rates to SAM at 2 and 6 months post-recovery. The secondary objectives included the recovery rate from SAM, the time-to-recovery, the weight gain, and the diarrhea longitudinal prevalence in OTP. The study lasted from April 2015 to May 2016. Among the 1,603 recruited children, 845 were in the intervention arm and 758 in the control arm. No differences in the relapse rates were noticed at 2 (−0.4%; P = 0.911) and 6 (−1.0%; P = 0.532) months. The intervention decreased the time-to-recovery (−4.4 days; P = 0.038), improved the recovery rate (10.5%; P = 0.034), and the absolute weight gain (3.0 g/d; P = 0.014). No statistical differences were noticed for the diarrhea longitudinal prevalence (−1.7%; P = 0.223) and the weight gain velocity (0.4 g/kg/d; P = 0.086). Our results showed that adding a household WASH package did not decrease post-recovery relapse rates but increased the recovery rate among children admitted in OTP. We recommend further robust trials in other settings to confirm our results.

Partial Text

It is estimated that 58% of annual deaths caused by diarrhea are attributable to poor water, sanitation and hygiene (WASH) conditions.1 Interventions aiming at improving water quality at household level2,3 or at promoting hand washing with soap significantly reduce diarrhea incidence.4,5 WASH interventions have a small but measurable benefit on linear growth, but not on weight or weight-for-height.6 Improved nutrition can reduce the adverse effects of infections such as diarrhea on growth.7 Yet, little evidence exists as to whether infections hamper the effectiveness of nutrition interventions7 and whether combined nutrition and WASH interventions would be more effective.8

A total of 1,616 children between 6 and 59 months of age were recruited from 20 HC (Figure 1), of which 13 were excluded due to incomplete data at admission. Among the 1,603 children, 845 were in the intervention group and 758 in the control group. Two months after discharge, we followed up on 623 and 484 children (80% and 78% of cured children) in the intervention and the control group, respectively. Six months after discharge, 377 and 293 children remained in the intervention and the control group, respectively (corresponding to 73% and 75% of the children who did not relapse 2 months after discharge).

Our study aimed to assess the effectiveness of a household WASH package on the recovery and relapse rates of SAM children admitted to OTP in the Kanem region of Chad. To our knowledge, this is the first study to investigate the additional benefits of a WASH intervention on a nutrition rehabilitation program in Sahel. Studies published so far were conducted in the general population and did not aim primarily to assess the effect on recovery and relapse rates.6 Our results showed that adding a household WASH package enhanced program performance by increasing the recovery rate and, possibly, by decreasing the time-to-recovery. Relapse rates to SAM were not affected by the intervention either at 2 or at 6 months post-recovery.




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