Interventions to improve disposal of child faeces for preventing diarrhoea and soil-transmitted helminth infection.

BACKGROUND: Diarrhoea and soil-transmitted helminth (STH) infections represent a large disease burden worldwide, particularly in low-income countries. As the aetiological agents associated with diarrhoea and STHs are transmitted through faeces, the safe containment and management of human excreta has the potential to reduce exposure and disease. Child faeces may be an important source of exposure even among households with improved sanitation. OBJECTIVES: To assess the effectiveness of interventions to improve the disposal of child faeces for preventing diarrhoea and STH infections. SEARCH METHODS: We searched the Cochrane Infectious Diseases Group Specialized Register, CENTRAL, MEDLINE, Embase, and 10 other databases. We also searched relevant conference proceedings, contacted researchers, searched websites for organizations, and checked references from identified studies. The date of last search was 27 September 2018. SELECTION CRITERIA: We included randomized controlled trials (RCTs) and non-randomized controlled studies (NRS) that compared interventions aiming to improve the disposal of faeces of children aged below five years in order to decrease direct or indirect human contact with such faeces with no intervention or a different intervention in children and adults. DATA COLLECTION AND ANALYSIS: Two review authors selected eligible studies, extracted data, and assessed the risk of bias. We used meta-analyses to estimate pooled measures of effect where appropriate, or described the study results narratively. We assessed the certainty of the evidence using the GRADE approach. MAIN RESULTS: Sixty-three studies covering more than 222,800 participants met the inclusion criteria. Twenty-two studies were cluster RCTs, four were controlled before-and-after studies (CBA), and 37 were NRS (27 case-control studies (one that included seven study sites), three controlled cohort studies, and seven controlled cross-sectional studies). Most study sites (56/69) were in low- or lower middle-income settings. Among studies using experimental study designs, most interventions included child faeces disposal messages along with other health education messages or other water, sanitation, and hygiene (WASH) hardware and software components. Among observational studies, the main risk factors relevant to this review were safe disposal of faeces in the latrine or defecation of children under five years of age in a latrine.Education and hygiene promotion interventions, including child faeces disposal messages (no hardware provision)Four RCTs found that diarrhoea incidence was lower, reducing the risk by an estimated 30% in children under six years old (rate ratio 0.71, 95% confidence interval (CI) 0.59 to 0.86; 2 trials, low-certainty evidence). Diarrhoea prevalence measured in two other RCTs in children under five years of age was lower, but evidence was low-certainty (risk ratio (RR) 0.93, 95% CI 0.84 to 1.04; low-certainty evidence).Two controlled cohort studies that evaluated such an intervention in Bangladesh did not detect a difference on diarrhoea prevalence (RR 0.91, 95% CI 0.64 to 1.28; very low-certainty evidence). Two controlled cross-sectional studies that evaluated the Health Extension Package in Ethiopia were associated with a lower two-week diarrhoea prevalence in 'model' households than in 'non-model households' (odds ratio (OR) 0.26, 95% CI 0.16 to 0.42; very low-certainty evidence).Programmes to end open defecation by all (termed community-led total sanitation (CLTS) interventions plus adaptations)Four RCTs measured diarrhoea prevalence and did not detect an effect in children under five years of age (RR 0.92, 95% CI 0.79 to 1.07; moderate-certainty evidence). The analysis of two trials did not demonstrate an effect of the interventions on STH infection prevalence in children (pooled RR 1.03, 95% CI 0.64 to 1.65; low-certainty evidence).One controlled cross-sectional study compared the prevalence of STH infection in open defecation-free (ODF) villages that had received a CLTS intervention with control villages and reported a higher level of STH infection in the intervention villages (RR 2.51, 95% CI 1.74 to 3.62; very low-certainty evidence).Sanitation hardware and behaviour change interventions, that included child faeces disposal hardware and messagingTwo RCTs had mixed results, with no overall effect on diarrhoea prevalence demonstrated in the pooled analysis (RR 0.79, 95% CI 0.49 to 1.26; very low-certainty evidence).WASH hardware and education/behaviour change interventionsOne RCT did not demonstrate an effect on diarrhoea prevalence (RR 1.15, 95% CI 0.93 to 1.41; very low-certainty evidence).Two CBAs reported that the intervention reduced diarrhoea incidence by about a quarter in children under five years of age, but evidence was very low-certainty (rate ratio 0.77, 95% CI 0.71 to 0.84). Another CBA reported that the intervention reduced the prevalence of STH in an intervention village compared to a control village, again with GRADE assessed at very low-certainty (OR 0.17, 95% CI 0.02 to 0.73).Case-control studiesPooled results from case-control studies that presented data for child faeces disposal indicated that disposal of faeces in the latrine was associated with lower odds of diarrhoea among all ages (OR 0.73, 95% CI: 0.62 to 0.85; 23 comparisons; very low-certainty evidence). Pooled results from case-control studies that presented data for children defecating in the latrine indicated that children using the latrine was associated with lower odds of diarrhoea in all ages (OR 0.54, 95% CI 0.33 to 0.90; 7 studies; very low-certainty evidence). AUTHORS' CONCLUSIONS: Evidence suggests that the safe disposal of child faeces may be effective in preventing diarrhoea. However, the evidence is limited and of low certainty. The limited research on STH infections provides only low and very-low certainty evidence around effects, which means there is currently no reliable evidence that interventions to improve safe disposal of child faeces are effective in preventing such STH infections.While child faeces may represent a source of exposure to young children, interventions generally only address it as part of a broader sanitation initiative. There is a need for RCTs and other rigorous studies to assess the effectiveness and sustainability of different hardware and software interventions to improve the safe disposal of faeces of children of different age groups.

Non-toxigenic Bacteroides fragilis (NTBF) administration reduces bacteria-driven chronic colitis and tumor development independent of polysaccharide A.

Polysaccharide A (PSA), an immunogenic capsular component of non-toxigenic Bacteroides fragilis (NTBF) strain NCTC 9343, is reported to promote mucosal immune development and suppress colitis. Contrastingly, enterotoxigenic Bacteroides fragilis (ETBF) is highly associated with inflammatory bowel disease (IBD) and colorectal cancer (CRC), rapidly inducing IL-17-dependent murine colitis and tumorigenesis. In specific-pathogen-free (SPF) C57BL/6 wild-type (WT) and multiple intestinal neoplasia (MinApc716+/-) mice, we show that sequential treatment of the NTBF strain, 9343, followed by the ETBF strain, 86-5443-2-2 (86), diminished colitis and tumorigenesis. Mice treated simultaneously with 9343 and 86 exhibited both severe colitis and tumorigenesis. Abrogated disease severity in sequentially treated mice was attributed to 9343 strain dominance and decreased IL-17A, but 86 colonization prior to or simultaneous with 9343 mitigated the anti-inflammatory effect of 9343. Remarkably, 9343-mediated protection was independent of PSA, as sequentially treated mice receiving ΔPSA 9343 exhibited similar protection. Further, SPF WT and Min mice colonized with PSA-competent or PSA-deficient 9343 exhibited similar IL-10, IL-17, and IFN-γ responses. Treatment of 86-colonized mice with 9343 failed to disrupt 86 pathogenesis. Our findings demonstrate that 9343 colonization, independent of PSA, offers prophylaxis against colitis-inducing 86 but may not be a valid therapy once colitis is established.

Shared sanitation versus individual household latrines: a systematic review of health outcomes.

BACKGROUND: More than 761 million people rely on shared sanitation facilities. These have historically been excluded from international sanitation targets, regardless of the service level, due to concerns about acceptability, hygiene and access. In connection with a proposed change in such policy, we undertook this review to identify and summarize existing evidence that compares health outcomes associated with shared sanitation versus individual household latrines. METHODS AND FINDINGS: Shared sanitation included any type of facilities intended for the containment of human faeces and used by more than one household, but excluded public facilities. Health outcomes included diarrhoea, helminth infections, enteric fevers, other faecal-oral diseases, trachoma and adverse maternal or birth outcomes. Studies were included regardless of design, location, language or publication status. Studies were assessed for methodological quality using the STROBE guidelines. Twenty-two studies conducted in 21 countries met the inclusion criteria. Studies show a pattern of increased risk of adverse health outcomes associated with shared sanitation compared to individual household latrines. A meta-analysis of 12 studies reporting on diarrhoea found increased odds of disease associated with reliance on shared sanitation (odds ratio (OR) 1.44, 95% CI: 1.18-1.76). CONCLUSION: Evidence to date does not support a change of existing policy of excluding shared sanitation from the definition of improved sanitation used in international monitoring and targets. However, such evidence is limited, does not adequately address likely confounding, and does not identify potentially important distinctions among types of shared facilities. As reliance on shared sanitation is increasing, further research is necessary to determine the circumstances, if any, under which shared sanitation can offer a safe, appropriate and acceptable alternative to individual household latrines.

Health risks of air pollution in Europe – HRAPIE project: new emerging risks to health from air pollution – results from the survey of experts

This document presents the results of a survey of experts developed and conducted as part of the WHO “Health risks of air pollution in Europe – HRAPIE” project. The survey’s objective was to assess and document the views of expert stakeholders regarding “evidence of new emerging issues on risks to health from air pollution, either related to specific source categories (e.g. transport, biomass combustion, metals industry, refineries, power production), specific gaseous pollutants or specific components of particulate matter (e.g. size-range like nano-particles and ultra-fines, rare-earth metals, black carbon (EC/OC))” via an online survey tool. The document describes the methodology applied to develop and implement the survey tool and provides a summary of the findings. The main findings of the survey are that the majority of respondents identified the general categories of “road traffic”, “space heating and air conditioning”, and “shipping” as the top three emission source categories of concern associated with emerging issues for public health. The experts felt that fine and ultra-fine particles and their metal content are of greatest concern in relation to health effects. Some of the issues identified are not new but may not have been sufficiently recognized or given priority in the past, while their significance or importance is now coming to the fore. The experts also felt that many well-known issues still require attention. The views of the experts are generally consistent with the findings of the REVIHAAP evidence review.

Linear and angular measurements from plain film cephalometry, 3DCeph, and CBCT / Medidas angulares e lineares em cefalometria em telerradiografias de norma lateral, cefalometria tridimensional, e em tomografias de feixe em cone

The advent of cone beam computed tomography (CBCT) in orthodontics raises the question of how it compares with existing diagnostic tools in providing useful quantitative measures. This study compared linear and angular measurements from craniometry (Cranio), plain film cephalometry (Ceph), three-dimensional cephalometry (3DCeph), and CBCT. Methods: Sixteen linear and fourteen angular measurements were taken using Cranio, Ceph, 3DCeph, and CBCT in 6”, 9”, and 12” field of views (FOV) from five dry skulls. Cranio values defined the “gold standard” for linear measurements, and Ceph values the angular. Paired t-tests and correlations were used for comparison. Results: For linear measurements, Ceph had the most significant differences, followed by 3DCeph and CBCT. All had high (r>0.75) correlations. Average discrepancies were 4.18 mm for Ceph, 1.32 mm for 3DCeph, and less than 1 mm for CBCT in all three FOVs. For angular measurements, CBCT(9) and CBCT(6) were not considered due to incompleteness. Cranio had 6 significant differences, CBCT had 5, and 3DCeph had 2. Cranio and CBCT had low correlations for FMA and FMIA. Average discrepancies were 2.7O for Cranio, 2.1O for CBCT, and 1.8O for 3DCeph. Conclusions: CBCT compared favorably with craniometry for linear measurements, but not with traditional cephalometrics for angular.

A incorporação da tomografia de feixe em cone (TFC) na ortodontia estimula a pergunta de como esta modalidade se compara com as modalidades já em uso. Este estudo compara medidas lineares e angulares para os métodos de craniometria (Crânio), cefalometria em teleradiografias (Ceph), cefalometria tridimensional (3DCeph), e de tomografia de feixe em cone (TFC). Métodos: 16 medidas lineares e 14 angulares foram feitas usando os métodos Crânio, Ceph, 3DCeph, e TFC nos tamanhos de imagem 15, 23, e 38 cm feitas de 5 crânios secos. O valores do método Crânio representam o padrão-ouro para as medidas lineares, e o método Ceph para as medidas angulares. O teste-t dependente e correlações foram usados para esta comparação. Resultados: Para as medidas lineares, o método Ceph mostrou-se com maiores diferenças, seguido pelos métodos 3DCeph e TFC. Todos os métodos mostraram altas correlações (r>0.75). As discrepâncias médias foram 4,18 mm para o método Ceph, 1,32para o 3DCeph, e menos de 1mm para o método TFC, para todos os tamanhos de imagem. Nas medidas angulares, os tamanhos 15cm e 23 cm não puderam ser incluidos por não poder-se realizar todas as medidas desejadas, sendo que alguns pontos cefalométricos não estavam presentes na imagem. O método Crânio teve 6 medidas significamente diferentes, TFC teve 5, e 3DCeph teve 2. Crânio e TFC tiveram baixa correlação para as medias FMA e FMIA. A discrepância média foi de 2.7O para o método Crânio, 2.1O para o TFC, e para o 3DCeph. Conclusões: O método TFC se compara favoralmente com a craniometria para medidas lineares, mas não tanto com a cefalometria para medidas angulares.