Evidence map›Paper›PMID 35780792›Full record

SynthesisLancet (London, England)2022

Effectiveness of interventions to improve drinking water, sanitation, and handwashing with soap on risk of diarrhoeal disease in children in low-income and middle-income settings: a systematic review and meta-analysis.

Jennyfer Wolf, Sydney Hubbard, Michael Brauer, Argaw Ambelu, Benjamin F Arnold, Robert Bain, Valerie Bauza, Joe Brown, Bethany A Caruso, Thomas Clasen and 11 more

Erratum issuedOpen access · hybridAbstract readMeta-AnalysisSystematic Review
PubMed Full text at PMC Publisher
In one paragraph

Synthesis in Lancet (London, England), 2022. The graph could read no effect estimate from its abstract, so it casts no vote on the map. An erratum has been issued. Cited by 153 papers, 24 of them syntheses that pooled it.

0numbers the graph read from it
0cells of the map it votes in
153citing papers in PubMed, 24 pooled it
32.5field-weighted citation impact, top 1% of its field
1 · What the graph read from it

What it found

Each row is one number read from the abstract, on the scale the paper reported it, with its interval. Left of the dashed line favours the treatment, right favours the comparator. Under each row is the sentence it came from. New to these charts? A ten-minute tutorial.

The abstract states no effect estimate the extractor could read, or names no intervention and outcome on the map, so this paper lights no cell and moves no belief. It is still indexed, cited and linked below.

2 · The registry

The trial behind it

Trials whose registry record cites this paper, or whose number appears in the abstract. A trial that started after this paper was published is citing it as background, not reporting it.

Neither the registry nor the abstract names a trial number. If this is a trial report, that itself is worth knowing.

3 · Its place in the literature

Who cites it

153 citing papers in PubMed, 24 syntheses or guidelines pooled it, 320 citations in OpenAlex.

  1. Pooled it
  2. Pooled it
  3. Safe Drinking Water and Its Impact on Children's Growth and Development: A Systematic Review.International journal of environmental research and public health · 2026
    Pooled it
  4. Pooled it
  5. Pooled it
  6. Pooled it
  7. Pooled it
  8. Pooled it
  9. Pooled it
  10. Pooled it
  11. Pooled it
  12. Pooled it
  13. Pooled it
  14. Pooled it
  15. Pooled it
  16. Pooled it
  17. Pooled it
  18. Pooled it
  19. Pooled it
  20. Pooled it

93 more citing papers are in PubMed but not listed here.

4 · The record

Corrections and comments

5 · Who and what money

Authors and funding

21 authors at 8 institutions in 5 countries.

Jennyfer WolfDepartment of Environmental, Climate Change and Health, WHO, Geneva, Switzerland. Electronic address: wolfj@who.int.
Sydney HubbardGangarosa Department of Environmental Health, Rollins School of Public Health, Emory University, Atlanta, GA, USA.
Michael BrauerInstitute for Health Metrics and Evaluation, University of Washington, Seattle, WA, USA; School of Population and Public Health, University of British Columbia, Vancouver, BC, Canada.
Argaw AmbeluDepartment of Environmental Health Sciences and Technology, Faculty of Public Health, Jimma University, Jimma, Ethiopia.
Benjamin F ArnoldDivision of Epidemiology and Biostatistics, School of Public Health, University of California, Berkeley, CA, USA.
Robert BainUNICEF Middle East and North Africa, Amman, Jordan.
Valerie BauzaGangarosa Department of Environmental Health, Rollins School of Public Health, Emory University, Atlanta, GA, USA.
Joe BrownDepartment of Environmental Sciences and Engineering, Gillings School of Global Public Health, University of North Carolina at Chapel Hill, NC, USA.
Bethany A CarusoThe Hubert Department of Global Health, Rollins School of Public Health, Emory University, Atlanta, GA, USA.
Thomas ClasenGangarosa Department of Environmental Health, Rollins School of Public Health, Emory University, Atlanta, GA, USA.
John M ColfordDivision of Epidemiology and Biostatistics, School of Public Health, University of California, Berkeley, CA, USA.
Matthew C FreemanGangarosa Department of Environmental Health, Rollins School of Public Health, Emory University, Atlanta, GA, USA.
Bruce GordonDepartment of Environmental, Climate Change and Health, WHO, Geneva, Switzerland.
Richard B JohnstonDepartment of Environmental, Climate Change and Health, WHO, Geneva, Switzerland.
Andrew MertensDivision of Epidemiology and Biostatistics, School of Public Health, University of California, Berkeley, CA, USA.
Annette Prüss-UstünDepartment of Environmental, Climate Change and Health, WHO, Geneva, Switzerland.
Ian RossDepartment of Disease Control, Faculty of Infectious Tropical Disease, London School of Hygiene & Tropical Medicine, London, UK.
Jeffrey StanawayInstitute for Health Metrics and Evaluation, University of Washington, Seattle, WA, USA.
Jeff T ZhaoInstitute for Health Metrics and Evaluation, University of Washington, Seattle, WA, USA.
Oliver CummingDepartment of Disease Control, Faculty of Infectious Tropical Disease, London School of Hygiene & Tropical Medicine, London, UK.
Sophie BoissonDepartment of Environmental, Climate Change and Health, WHO, Geneva, Switzerland.
Emory University · USWorld Health Organization · CHUniversity of California, Berkeley · USInstitute for Health Metrics and Evaluation · USLondon School of Hygiene & Tropical Medicine · GBJimma University · ETUniversity of British Columbia · CAUniversity of North Carolina at Chapel Hill · US

Funding

Graduate and Postdoctoral Training in ToxicologyT32ES012870 · NIEHS · EMORY UNIVERSITY · PI Carmen Joseph Marsit · 2004 to 2026
$9.1M
NIEHS NIH HHS T32 ES012870World Health Organization 001
6 · The paper itself

Abstract

backgroundEstimates of the effectiveness of water, sanitation, and hygiene (WASH) interventions that provide high levels of service on childhood diarrhoea are scarce. We aimed to provide up-to-date estimates on the burden of disease attributable to WASH and on the effects of different types of WASH interventions on childhood diarrhoea in low-income and middle-income countries (LMICs).

methodsIn this systematic review and meta-analysis, we updated previous reviews following their search strategy by searching MEDLINE, Embase, Scopus, Cochrane Library, and BIOSIS Citation Index for studies of basic WASH interventions and of WASH interventions providing a high level of service, published between Jan 1, 2016, and May 25, 2021. We included randomised and non-randomised controlled trials conducted at household or community level that matched exposure categories of the so-called service ladder approach of the Sustainable Development Goal (SDG) for WASH. Two reviewers independently extracted study-level data and assessed risk of bias using a modified Newcastle-Ottawa Scale and certainty of evidence using a modified Grading of Recommendations, Assessment, Development, and Evaluation approach. We analysed extracted relative risks (RRs) and 95% CIs using random-effects meta-analyses and meta-regression models. This study is registered with PROSPERO, CRD42016043164.

findings19 837 records were identified from the search, of which 124 studies were included, providing 83 water (62 616 children), 20 sanitation (40 799 children), and 41 hygiene (98 416 children) comparisons. Compared with untreated water from an unimproved source, risk of diarrhoea was reduced by up to 50% with water treated at point of use (POU): filtration (n=23 studies; RR 0·50 [95% CI 0·41-0·60]), solar treatment (n=13; 0·63 [0·50-0·80]), and chlorination (n=25; 0·66 [0·56-0·77]). Compared with an unimproved source, provision of an improved drinking water supply on premises with higher water quality reduced diarrhoea risk by 52% (n=2; 0·48 [0·26-0·87]). Overall, sanitation interventions reduced diarrhoea risk by 24% (0·76 [0·61-0·94]). Compared with unimproved sanitation, providing sewer connection reduced diarrhoea risk by 47% (n=5; 0·53 [0·30-0·93]). Promotion of handwashing with soap reduced diarrhoea risk by 30% (0·70 [0·64-0·76]).

interpretationWASH interventions reduced risk of diarrhoea in children in LMICs. Interventions supplying either water filtered at POU, higher water quality from an improved source on premises, or basic sanitation services with sewer connection were associated with increased reductions. Our results support higher service levels called for under SDG 6. Notably, no studies evaluated interventions that delivered access to safely managed WASH services, the level of service to which universal coverage by 2030 is committed under the SDG.

fundingWHO, Foreign, Commonwealth & Development Office, and National Institute of Environmental Health Sciences.

Indexed as

Drinking WaterSanitationChildDiarrheaHand DisinfectionHumansSoapsDrinking WaterSoaps

Identifiers

PMID35780792
PMCPMC9251635
OpenAlexW4283761346

What OpenQuestion holds

Textmetadata
LicenceCC BY
Read underepoch 390

Registered trials

None linked

Read under generation 80e0d062 · epoch 390. Bibliography from PubMed, PubMed Central and OpenAlex; grants from NIH RePORTER; trial links from ClinicalTrials.gov; estimates, votes and beliefs from the OpenQuestion graph.