Effects of an urban sanitation intervention on childhood enteric infection and diarrhea in Maputo, Mozambique: a controlled before-and-after trial

  1. Jackie Knee
  2. Trent Sumner
  3. Zaida Adriano
  4. Claire Anderson
  5. Farran Bush
  6. Drew Capone
  7. Veronica Casmo
  8. David A Holcomb
  9. Pete Kolsky
  10. Amy MacDougall
  11. Evgeniya Molotkova
  12. Judite Monteiro Braga
  13. Celina Russo
  14. Wolf Peter Schmidt
  15. Jill Stewart
  16. Winnie Zambrana
  17. Valentina Zuin
  18. Rassul Nalá
  19. Oliver Cumming
  20. Joe Brown  Is a corresponding author
  1. London School of Hygiene and Tropical Medicine, United Kingdom
  2. Georgia Institute of Technology, United States
  3. WE Consult, Mozambique
  4. Instituto Nacional de Saúde, Mozambique
  5. University of North Carolina at Chapel Hill, United States
  6. Yale-NUS College, Singapore

Abstract

We conducted a controlled before-and-after trial to evaluate the impact of an onsite urban sanitation intervention on the prevalence of enteric infection, soil transmitted helminth re-infection, and diarrhea among children in Maputo, Mozambique. A non-governmental organization replaced existing poor-quality latrines with pour-flush toilets with septic tanks serving household clusters. We enrolled children aged 1-48 months at baseline and measured outcomes before and 12 and 24 months after the intervention, with concurrent measurement among children in a comparable control arm. Despite nearly exclusive use, we found no evidence that intervention affected the prevalence of any measured outcome after 12 or 24 months of exposure. Among children born into study sites after intervention, we observed a reduced prevalence of Trichuris and Shigella infection relative to the same age group at baseline (<2 years old). Protection from birth may be important to reduce exposure to and infection with enteric pathogens in this setting.

Data availability

All data generated or analysed during this study are included in the manuscript and supporting files. Source data files and code have been provided for all analyses and specifically for Figure 1 and Tables 1, 2, and 3. Additionally, we have archived all data and code at Open Science Framework (https://osf.io/me2tx, DOI 17605/OSF.IO/ME2TX).

The following data sets were generated

Article and author information

Author details

  1. Jackie Knee

    Department of Disease Control, London School of Hygiene and Tropical Medicine, London, United Kingdom
    Competing interests
    Jackie Knee, As we have indicated on the ICMJE COI form, attached, this authors's time working on this study was funded in part by the study's funders, the United States Agency for International Development and the Bill and Melinda Gates Foundation..
    ORCID icon "This ORCID iD identifies the author of this article:" 0000-0002-0834-8488
  2. Trent Sumner

    School of Civil and Environmental Engineering, Georgia Institute of Technology, Atlanta GA, United States
    Competing interests
    Trent Sumner, As we have indicated on the ICMJE COI form, attached, this authors's time working on this study was funded in part by the study's funders, the United States Agency for International Development and the Bill and Melinda Gates Foundation..
  3. Zaida Adriano

    ltd, WE Consult, Maputo, Mozambique
    Competing interests
    Zaida Adriano, As we have indicated on the ICMJE COI form, attached, this authors's time working on this study was funded in part by the study's funders, the United States Agency for International Development and the Bill and Melinda Gates Foundation..
  4. Claire Anderson

    School of Civil and Environmental Engineering, Georgia Institute of Technology, Atlanta, United States
    Competing interests
    Claire Anderson, As we have indicated on the ICMJE COI form, attached, this authors's time working on this study was funded in part by the study's funders, the United States Agency for International Development and the Bill and Melinda Gates Foundation..
  5. Farran Bush

    School of Civil and Environmental Engineering, Georgia Institute of Technology, Atlanta GA, United States
    Competing interests
    Farran Bush, As we have indicated on the ICMJE COI form, attached, this authors's time working on this study was funded in part by the study's funders, the United States Agency for International Development and the Bill and Melinda Gates Foundation..
  6. Drew Capone

    School of Civil and Environmental Engineering, Georgia Institute of Technology, Atlanta GA, United States
    Competing interests
    Drew Capone, As we have indicated on the ICMJE COI form, attached, this authors's time working on this study was funded in part by the study's funders, the United States Agency for International Development and the Bill and Melinda Gates Foundation..
  7. Veronica Casmo

    Instituto Nacional de Saúde, Instituto Nacional de Saúde, Maputo, Mozambique
    Competing interests
    Veronica Casmo, As we have indicated on the ICMJE COI form, attached, this authors's time working on this study was funded in part by the study's funders, the United States Agency for International Development and the Bill and Melinda Gates Foundation..
  8. David A Holcomb

    Department of Epidemiology, University of North Carolina at Chapel Hill, Chapel Hill, United States
    Competing interests
    David A Holcomb, As we have indicated on the ICMJE COI form, attached, this authors's time working on this study was funded in part by the study's funders, the United States Agency for International Development and the Bill and Melinda Gates Foundation..
    ORCID icon "This ORCID iD identifies the author of this article:" 0000-0003-4055-7164
  9. Pete Kolsky

    Department of Environmental Sciences and Engineering, University of North Carolina at Chapel Hill, Chapel Hill NC, United States
    Competing interests
    Pete Kolsky, As we have indicated on the ICMJE COI form, attached, this authors's time working on this study was funded in part by the study's funders, the United States Agency for International Development and the Bill and Melinda Gates Foundation..
  10. Amy MacDougall

    Department of Medical Statistics, London School of Hygiene and Tropical Medicine, London, United Kingdom
    Competing interests
    No competing interests declared.
  11. Evgeniya Molotkova

    School of Biological Sciences, Georgia Institute of Technology, Atlanta GA, United States
    Competing interests
    Evgeniya Molotkova, As we have indicated on the ICMJE COI form, attached, this authors's time working on this study was funded in part by the study's funders, the United States Agency for International Development and the Bill and Melinda Gates Foundation..
  12. Judite Monteiro Braga

    Instituto Nacional de Saúde, Instituto Nacional de Saúde, Maputo, Mozambique
    Competing interests
    Judite Monteiro Braga, As we have indicated on the ICMJE COI form, attached, this authors's time working on this study was funded in part by the study's funders, the United States Agency for International Development and the Bill and Melinda Gates Foundation..
  13. Celina Russo

    School of Civil and Environmental Engineering, Georgia Institute of Technology, Atlanta GA, United States
    Competing interests
    Celina Russo, As we have indicated on the ICMJE COI form, attached, this authors's time working on this study was funded in part by the study's funders, the United States Agency for International Development and the Bill and Melinda Gates Foundation..
  14. Wolf Peter Schmidt

    Department of Disease Control, London School of Hygiene and Tropical Medicine, London, United Kingdom
    Competing interests
    Wolf Peter Schmidt, As we have indicated on the ICMJE COI form, attached, this authors's time working on this study was funded in part by the study's funders, the United States Agency for International Development and the Bill and Melinda Gates Foundation..
  15. Jill Stewart

    Department of Environmental Sciences and Engineering, University of North Carolina at Chapel Hill, Chapel Hill NC, United States
    Competing interests
    Jill Stewart, As we have indicated on the ICMJE COI form, attached, this authors's time working on this study was funded in part by the study's funders, the United States Agency for International Development and the Bill and Melinda Gates Foundation..
  16. Winnie Zambrana

    School of Civil and Environmental Engineering, Georgia Institute of Technology, Atlanta GA, United States
    Competing interests
    Winnie Zambrana, As we have indicated on the ICMJE COI form, attached, this authors's time working on this study was funded in part by the study's funders, the United States Agency for International Development and the Bill and Melinda Gates Foundation..
  17. Valentina Zuin

    Division of Social Science, Yale-NUS College, Singapore, Singapore
    Competing interests
    No competing interests declared.
  18. Rassul Nalá

    Instituto Nacional de Saúde, Instituto Nacional de Saúde, Maputo, Mozambique
    Competing interests
    Rassul Nalá, As we have indicated on the ICMJE COI form, attached, this authors's time working on this study was funded in part by the study's funders, the United States Agency for International Development and the Bill and Melinda Gates Foundation..
  19. Oliver Cumming

    Department of Disease Control, London School of Hygiene and Tropical Medicine, London, United Kingdom
    Competing interests
    Oliver Cumming, As we have indicated on the ICMJE COI form, attached, this authors's time working on this study was funded in part by the study's funders, the United States Agency for International Development and the Bill and Melinda Gates Foundation..
  20. Joe Brown

    Department of Environmental Sciences and Engineering, University of North Carolina at Chapel Hill, Chapel Hill NC, United States
    For correspondence
    joebrown@unc.edu
    Competing interests
    Joe Brown, As we have indicated on the ICMJE COI form, attached, this authors's time working on this study was funded in part by the study's funders, the United States Agency for International Development and the Bill and Melinda Gates Foundation..
    ORCID icon "This ORCID iD identifies the author of this article:" 0000-0002-5200-4148

Funding

Bill and Melinda Gates Foundation (OPP1137224)

  • Oliver Cumming
  • Joe Brown

United States Agency for International Development (GHS-A-00-09-00015-00)

  • Oliver Cumming
  • Joe Brown

The funders had no role in study design, data collection and interpretation, or the decision to submit the work for publication.

Ethics

Human subjects: The study protocol was approved by the Comité Nacional de Bioética para a Saúde (CNBS),Ministério da Saúde (333/CNBS/14), the Research Ethics Committee of the London School of Hygiene & Tropical Medicine (reference # 8345), and the Institutional Review Board of theGeorgia Institute of Technology (protocol # H15160).

Reviewing Editor

  1. Joseph Lewnard, University of California Berkeley, United States

Publication history

  1. Received: August 20, 2020
  2. Accepted: April 3, 2021
  3. Accepted Manuscript published: April 9, 2021 (version 1)
  4. Accepted Manuscript updated: April 15, 2021 (version 2)
  5. Version of Record published: May 14, 2021 (version 3)

Copyright

© 2021, Knee et al.

This article is distributed under the terms of the Creative Commons Attribution License permitting unrestricted use and redistribution provided that the original author and source are credited.

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  1. Jackie Knee
  2. Trent Sumner
  3. Zaida Adriano
  4. Claire Anderson
  5. Farran Bush
  6. Drew Capone
  7. Veronica Casmo
  8. David A Holcomb
  9. Pete Kolsky
  10. Amy MacDougall
  11. Evgeniya Molotkova
  12. Judite Monteiro Braga
  13. Celina Russo
  14. Wolf Peter Schmidt
  15. Jill Stewart
  16. Winnie Zambrana
  17. Valentina Zuin
  18. Rassul Nalá
  19. Oliver Cumming
  20. Joe Brown
(2021)
Effects of an urban sanitation intervention on childhood enteric infection and diarrhea in Maputo, Mozambique: a controlled before-and-after trial
eLife 10:e62278.
https://doi.org/10.7554/eLife.62278

Further reading

    1. Epidemiology and Global Health
    Ceereena Ubaida-Mohien et al.
    Research Article Updated

    Background:

    Master athletes (MAs) prove that preserving a high level of physical function up to very late in life is possible, but the mechanisms responsible for their high function remain unclear.

    Methods:

    We performed muscle biopsies in 15 octogenarian world-class track and field MAs and 14 non-athlete age/sex-matched controls (NA) to provide insights into mechanisms for preserving function in advanced age. Muscle samples were assessed for respiratory compromised fibers, mitochondrial DNA (mtDNA) copy number, and proteomics by liquid-chromatography mass spectrometry.

    Results:

    MA exhibited markedly better performance on clinical function tests and greater cross-sectional area of the vastus lateralis muscle. Proteomics analysis revealed marked differences, where most of the ~800 differentially represented proteins in MA versus NA pertained to mitochondria structure/function such as electron transport capacity (ETC), cristae formation, mitochondrial biogenesis, and mtDNA-encoded proteins. In contrast, proteins from the spliceosome complex and nuclear pore were downregulated in MA. Consistent with proteomics data, MA had fewer respiratory compromised fibers, higher mtDNA copy number, and an increased protein ratio of the cristae-bound ETC subunits relative to the outer mitochondrial membrane protein voltage-dependent anion channel. There was a substantial overlap of proteins overrepresented in MA versus NA with proteins that decline with aging and that are higher in physically active than sedentary individuals. However, we also found 176 proteins related to mitochondria that are uniquely differentially expressed in MA.

    Conclusions:

    We conclude that high function in advanced age is associated with preserving mitochondrial structure/function proteins, with underrepresentation of proteins involved in the spliceosome and nuclear pore complex. Whereas many of these differences in MA appear related to their physical activity habits, others may reflect unique biological (e.g., gene, environment) mechanisms that preserve muscle integrity and function with aging.

    Funding:

    Funding for this study was provided by operating grants from the Canadian Institutes of Health Research (MOP 84408 to TT and MOP 125986 to RTH). This work was supported in part by the Intramural Research Program of the National Institute on Aging, NIH, Baltimore, MD, USA.

    1. Epidemiology and Global Health
    Toby Mansell et al.
    Research Article

    Background:

    The risk of adult onset cardiovascular and metabolic (cardiometabolic) disease accrues from early life. Infection is ubiquitous in infancy and induces inflammation, a key cardiometabolic risk factor, but the relationship between infection, inflammation, and metabolic profiles in early childhood remains unexplored. We investigated relationships between infection and plasma metabolomic and lipidomic profiles at age 6 and 12 months, and mediation of these associations by inflammation.

    Methods:

    Matched infection, metabolomics, and lipidomics data were generated from 555 infants in a pre-birth longitudinal cohort. Infection data from birth to 12 months were parent-reported (total infections at age 1, 3, 6, 9, and 12 months), inflammation markers (high-sensitivity C-reactive protein [hsCRP]; glycoprotein acetyls [GlycA]) were quantified at 12 months. Metabolic profiles were 12-month plasma nuclear magnetic resonance metabolomics (228 metabolites) and liquid chromatography/mass spectrometry lipidomics (776 lipids). Associations were evaluated with multivariable linear regression models. In secondary analyses, corresponding inflammation and metabolic data from birth (serum) and 6-month (plasma) time points were used.

    Results:

    At 12 months, more frequent infant infections were associated with adverse metabolomic (elevated inflammation markers, triglycerides and phenylalanine, and lower high-density lipoprotein [HDL] cholesterol and apolipoprotein A1) and lipidomic profiles (elevated phosphatidylethanolamines and lower trihexosylceramides, dehydrocholesteryl esters, and plasmalogens). Similar, more marked, profiles were observed with higher GlycA, but not hsCRP. GlycA mediated a substantial proportion of the relationship between infection and metabolome/lipidome, with hsCRP generally mediating a lower proportion. Analogous relationships were observed between infection and 6-month inflammation, HDL cholesterol, and apolipoprotein A1.

    Conclusions:

    Infants with a greater infection burden in the first year of life had proinflammatory and proatherogenic plasma metabolomic/lipidomic profiles at 12 months of age that in adults are indicative of heightened risk of cardiovascular disease, obesity, and type 2 diabetes. These findings suggest potentially modifiable pathways linking early life infection and inflammation with subsequent cardiometabolic risk.

    Funding:

    The establishment work and infrastructure for the BIS was provided by the Murdoch Children’s Research Institute (MCRI), Deakin University, and Barwon Health. Subsequent funding was secured from National Health and Medical Research Council of Australia (NHMRC), The Shepherd Foundation, The Jack Brockhoff Foundation, the Scobie & Claire McKinnon Trust, the Shane O’Brien Memorial Asthma Foundation, the Our Women’s Our Children’s Fund Raising Committee Barwon Health, the Rotary Club of Geelong, the Minderoo Foundation, the Ilhan Food Allergy Foundation, GMHBA, Vanguard Investments Australia Ltd, and the Percy Baxter Charitable Trust, Perpetual Trustees. In-kind support was provided by the Cotton On Foundation and CreativeForce. The study sponsors were not involved in the collection, analysis, and interpretation of data; writing of the report; or the decision to submit the report for publication. Research at MCRI is supported by the Victorian Government’s Operational Infrastructure Support Program. This work was also supported by NHMRC Senior Research Fellowships to ALP (1008396); DB (1064629); and RS (1045161) , NHMRC Investigator Grants to ALP (1110200) and DB (1175744), NHMRC-A*STAR project grant (1149047). TM is supported by an MCRI ECR Fellowship. SB is supported by the Dutch Research Council (452173113).