Evidence map›Paper›PMID 36889861›Full record

SynthesisThe Lancet. Planetary health2023

Effects of water, sanitation, and hygiene interventions on detection of enteropathogens and host-specific faecal markers in the environment: a systematic review and individual participant data meta-analysis.

Andrew Mertens, Benjamin F Arnold, Jade Benjamin-Chung, Alexandria B Boehm, Joe Brown, Drew Capone, Thomas Clasen, Erica Fuhrmeister, Jessica A Grembi, David Holcomb and 17 more

Open access · goldFull text readSystematic ReviewMeta-Analysis
PubMed Full text at PMC Publisher
In one paragraph

Synthesis in The Lancet. Planetary health, 2023. The graph could read no effect estimate from its abstract, so it casts no vote on the map. Cited by 16 papers, 1 of them a synthesis that pooled it.

0numbers the graph read from it
0cells of the map it votes in
16citing papers in PubMed, 1 pooled it
3.5field-weighted citation impact, top 7% 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

16 citing papers in PubMed, 1 synthesis or guideline pooled it, 22 citations in OpenAlex.

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  13. Associations between floor material andbioRxiv : the preprint server for biology · 2025
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4 · The record

Corrections and comments

PubMed lists nothing against this paper. Absence here is not a guarantee, only a check that was made.

5 · Who and what money

Authors and funding

27 authors at 13 institutions in 3 countries.

Andrew MertensDivision of Epidemiology and Biostatistics, University of California, Berkeley, CA, USA. Electronic address: amertens@berkeley.edu.
Benjamin F ArnoldFrancis I Proctor Foundation and Department of Ophthalmology, University of California, San Francisco, CA, USA.
Jade Benjamin-ChungDepartment of Epidemiology and Population Health, Stanford University, Stanford, CA, USA.
Alexandria B BoehmDepartment of Civil and Environmental Engineering, Stanford University, Stanford, CA, USA.
Joe BrownDepartment of Environmental Science and Engineering, Gillings School of Global Public Health, Michael Hooker Research Center, University of North Carolina, Chapel Hill, NC, USA.
Drew CaponeDepartment of Environmental and Occupational Health, Indiana University Bloomington, Bloomington, IN, USA.
Thomas ClasenDepartment of Environmental Health, Rollins School of Public Health, Emory University, NE, Atlanta, GA, USA.
Erica FuhrmeisterDepartment of Environmental and Occupational Health Sciences, University of Washington, Seattle, WA, USA.
Jessica A GrembiDepartment of Medicine, Stanford University, Stanford, CA, USA.
David HolcombDepartment of Environmental Science and Engineering, Gillings School of Global Public Health, Michael Hooker Research Center, University of North Carolina, Chapel Hill, NC, USA.
Jackie KneeDepartment of Disease Control, London School of Tropical Medicine & Hygiene, London, UK.
Laura H KwongDivision of Environmental Health Sciences, University of California, Berkeley, CA, USA.
Audrie LinDepartment of Biobehavioral Health, Pennsylvania State University, PA, USA.
Stephen P LubyDivision of Infectious Diseases and Geographic Medicine, Stanford University, Stanford, CA, USA.
Rassul NalaMinistério da Saúde, Instituto Nacional de Saúde Maputo, Maputo, Mozambique.
Kara NelsonDepartment of Civil and Environmental Engineering, College of Engineering, University of California, Berkeley, CA, USA.
Sammy M NjengaKenya Medical Research Institute, Nairobi, Kenya.
Clair NullMathematica, Princeton, NJ, USA.
Amy J PickeringDepartment of Civil and Environmental Engineering, College of Engineering, University of California, Berkeley, CA, USA.
Mahbubur RahmanEnvironmental Interventions Unit, Infectious Diseases Division, Dhaka, Bangladesh.
Heather E ReeseDepartment of Environmental Health, Rollins School of Public Health, Emory University, NE, Atlanta, GA, USA.
Lauren SteinbaumCenter for the Ecology of Infectious Diseases, University of Georgia, Athens, GA, USA.
Jill StewartDepartment of Environmental Science and Engineering, Gillings School of Global Public Health, Michael Hooker Research Center, University of North Carolina, Chapel Hill, NC, USA.
Ruwan ThilakaratneDivision of Epidemiology and Biostatistics, University of California, Berkeley, CA, USA.
Oliver CummingDepartment of Disease Control, London School of Tropical Medicine & Hygiene, London, UK.
John M ColfordDivision of Epidemiology and Biostatistics, University of California, Berkeley, CA, USA.
Ayse ErcumenDepartment of Forestry and Environmental Resources, North Carolina State University, Raleigh, NC, USA.
University of California, Berkeley · USStanford University · USUniversity of North Carolina at Chapel Hill · USEmory University · USIndiana University Bloomington · USKenya Medical Research Institute · KEMathematica Policy Research · USMinistry of Health · MZNorth Carolina State University · USPennsylvania State University · USSan Francisco Foundation · USUniversity of Georgia · USUniversity of Washington · US

Funding

Translational Research Support CoreP30ES025128 · NIEHS · NORTH CAROLINA STATE UNIVERSITY RALEIGH · PI Andrew R. Binder · 2015 to 2026
$18.3M
NIEHS NIH HHS P30 ES025128
6 · The paper itself

Abstract

backgroundWater, sanitation, and hygiene (WASH) improvements are promoted to reduce diarrhoea in low-income countries. However, trials from the past 5 years have found mixed effects of household-level and community-level WASH interventions on child health. Measuring pathogens and host-specific faecal markers in the environment can help investigate causal pathways between WASH and health by quantifying whether and by how much interventions reduce environmental exposure to enteric pathogens and faecal contamination from human and different animal sources. We aimed to assess the effects of WASH interventions on enteropathogens and microbial source tracking (MST) markers in environmental samples.

methodsWe did a systematic review and individual participant data meta-analysis, which included searches from Jan 1, 2000, to Jan 5, 2023, from PubMed, Embase, CAB Direct Global Health, Agricultural and Environmental Science Database, Web of Science, and Scopus, of prospective studies with water, sanitation, or hygiene interventions and concurrent control group that measured pathogens or MST markers in environmental samples and measured child anthropometry, diarrhoea, or pathogen-specific infections. We used covariate-adjusted regression models with robust standard errors to estimate study-specific intervention effects and pooled effect estimates across studies using random-effects models.

findingsFew trials have measured the effect of sanitation interventions on pathogens and MST markers in the environment and they mostly focused on onsite sanitation. We extracted individual participant data on nine environmental assessments from five eligible trials. Environmental sampling included drinking water, hand rinses, soil, and flies. Interventions were consistently associated with reduced pathogen detection in the environment but effect estimates in most individual studies could not be distinguished from chance. Pooled across studies, we found a small reduction in the prevalence of any pathogen in any sample type (pooled prevalence ratio [PR] 0·94 [95% CI 0·90-0·99]). Interventions had no effect on the prevalence of MST markers from humans (pooled PR 1·00 [95% CI 0·88-1·13]) or animals (pooled PR 1·00 [95% CI 0·97-1·03]).

interpretationThe small effect of these sanitation interventions on pathogen detection and absence of effects on human or animal faecal markers are consistent with the small or null health effects previously reported in these trials. Our findings suggest that the basic sanitation interventions implemented in these studies did not contain human waste and did not adequately reduce exposure to enteropathogens in the environment.

fundingBill and Melinda Gates Foundation and the UK Foreign and Commonwealth Development Office.

Indexed as

Drinking WaterSanitationAnimalsChildDiarrheaHumansHygieneProspective StudiesDrinking Water

Identifiers

PMID36889861
PMCPMC10009758
OpenAlexW4323305621

What OpenQuestion holds

Textfull text, public
LicenceCC BY
reference markers read17
measurements read41
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.