Objectives: We assessed the impact of water, hygiene and sanitation (WASH), maternal, new-born and child health (MNCH), nutrition and early childhood development (ECD) on diarrhoea and microbial quality of water in a resource-constrained rural setting in Kenya. Methods: Through a controlled intervention study, we tested faecal and water samples collected from both the intervention and control sites before and after the interventions using microbiological, immunological and molecular assays to determine the prevalence of diarrhoeagenic agents and microbial quality of water. Data from the hospital registers were used to estimate all-cause diarrhoea prevalence. Results: After the interventions, we observed a 58.2% (95% CI: 39.4–75.3) decline in all-cause diarrhoea in the intervention site versus a 22.2% (95% CI: 5.9–49.4) reduction of the same in the control site. Besides rotavirus and pathogenic Escherichia coli, the rate of isolation of other diarrhoea-causing bacteria declined substantially in the intervention site. The microbial quality of community and household water improved considerably in both the intervention (81.9%; 95% CI: 74.5%–87.8%) and control (72.5%; 95% CI: 64.2%–80.5%) sites with the relative improvements in the intervention site being slightly larger. Conclusions: The integrated WASH, MNCH, nutrition and ECD interventions resulted in notable decline in all-cause diarrhoea and improvements in water quality in the rural resource-limited population in Kenya. This indicates a direct public health impact of the interventions and provides early evidence for public health policy makers to support the sustained implementation of these interventions.
This was a controlled intervention study conducted in Narok County, Kenya between 2018 and 2021. Narok County is situated in the southern part of Kenya bordering the Republic of Tanzania. The County’s population was 1130 million in 2018 [20]. The dominant tribe is Maasai. The main economic activities in the county include pastoralism, crop farming and tourism from the Maasai Mara Game Reserve. Elangata‐Enterit, a resource‐constrained sub‐location in Narok County, was the intervention site whereas Maji‐Moto sub‐location which neighbours Elangata‐Enterit was the control site. The control site was selected based on its similarity with the intervention site in terms of socio‐economic status, demography and geological formation. We conducted a baseline survey in both the intervention and control sites from January to April 2018 to establish the burden of diarrhoeal disease through an active hospital‐based surveillance. The Elangata‐Enterit Health Centre, which was the only health facility serving the residents of Elangata‐Enterit sub‐location, served as the intervention study facility while the Maji‐Moto Dispensary, which was the only health facility serving the residents of Maji‐Moto sub‐location, served as the control study facility. After the implementation of the WASH, MNCH, nutrition and ECD interventions, we carried out an endline survey between January and May 2021 in both sites to evaluate the impact of these interventions. An approach of integrated intervention of WASH, MNCH, nutrition and ECD was implemented in Elangata‐Enterit sub‐location [19]. Briefly, to improve access to water, sanitation and hygiene, a mega borehole was sunk and water extended with pipelines to various water distribution points in the target community. Latrines were constructed by community members with the support of Community Health Volunteers (CHVs) and the project staff after extensive public sensitization in schools and within the community. Clean and hygienic practices were taught and promoted through delivery of key hygiene messages on hand washing, environmental hygiene and sanitation, and water and food safety to children and the general public. To improve MNCH, the project promoted at least four antenatal clinic (ANC) visits by expectant mothers; delivery at a health facility; clean and hygienic birth practices for mothers, caregivers and birth attendants; early initiation of breast feeding and exclusive breastfeeding for 6 months; timely and complete immunisation; hand washing, environmental sanitation and water and food safety to children, mothers and caregivers. Nutritional interventions included promotion of continued breastfeeding for up to 2 years and beyond; fresh hygienically prepared complementary food; clean and hygienic child‐eating area and food preparation area; and provision of micronutrients, and supplementary or therapeutic food for malnourished children. Lastly, ECD focused on provision of age appropriate and environmental hygienic play spaces; and education on improved caregiver‐child interactions. This study was reviewed and approved by the Masino University Ethics Review Committee (MSU/DRPI/MUERC/00492/17). Informed written consent was sought from all the participating adults and from the caregivers of all participating children. The study subjects for diarrhoeal disease surveillance were persons of all ages attending either Elangata‐Enterit Health Centre or Maji‐Moto Dispensary with acute gastroenteritis and having experienced an episode of 3 looser than normal or watery stools within a 24‐h period for not more than 7 days with or without episodes of vomiting [21]. The patients came directly from the community. Decisions on treatment were at the discretion of the clinicians attending to the patients. Demographic and clinical data were collected from the study participants. After written informed consent had been granted, whole stool and/or anal swab samples were collected in clean sterile containers. Each sample was labelled with the date of collection and a sample number assigned. The samples were kept at 4°C at the health facilities before being transported to the Nagasaki University Institute of Tropical Medicine‐Kenya Medical Research Institute (NUITM‐KEMRI) laboratories in Nairobi for processing. A total of 416 faecal samples were collected during the baseline (Elangata‐Enterit‐ 111; Maji‐Moto‐ 148) and endline (Elangata‐Enterit‐ 71; Maji‐Moto‐ 86) survey. To assess the microbial quality of water, water samples were collected from sources and at the point of use (i.e., in the houses) in Elangata‐Enterit and Maji‐Moto sub‐locations once in each of the 4 months of the baseline survey (January–April 2018) and once in each of the 5 months of the follow‐up survey (January–May 2021). The water samples were collected in sterile containers and ferried to the NUITM‐KEMRI laboratories in Nairobi for processing. A total of 139 water samples were collected during the baseline (Elangata‐Enterit‐ 24; Maji‐Moto‐ 23) and endline (Elangata‐Enterit‐ 46; Maji‐Moto‐ 46) survey. Of the 46 water samples collected in Elangata‐Enterit during the endline survey, 8 were obtained from the source (that is at the main borehole and water distribution points), whereas 38 were sampled from the point of use (i.e., from the houses utilising the borehole water). The faecal specimens were cultured on appropriate media for primary isolation of the bacteria as described previously [22]. The media included xylose lysine deoxycholate (XLD) agar (Oxoid Ltd., Basingstoke, Hampshire, UK), deoxycholate hydrogen sulfide lactose (DHL) agar, bromothymol blue (BTB) agar, Salmonella‐Shigella (SS) agar, thiosulfate‐citrate‐bile salt‐sucrose (TCBS) agar (Eiken Chemical Company Ltd. Tochigi, Japan), alkaline peptone water and selenite broth (HiMedia Laboratories Pvt. Ltd., Mumbai, India). The plates and the broth were incubated at 37°C overnight. The isolated bacterial colonies were identified by conventional biochemical identification methods and/or by the VITEK‐2 automated analyser (bioMérieux, Inc., NC, USA). Serologic identification of Escherichia coli isolates was performed by the slide agglutination technique with polyvalent and monovalent antisera for serotype identification of E. coli (Denka Seiken Co. Ltd.) according to the manufacturer’s protocol. Pathogenic E. coli were identified using multiplex polymerase chain reaction (PCR) as described previously [23]. Briefly, bacterial genomic DNA was extracted from three colonies of each E. coli positive sample by the QIAGEN DNA extraction kit (QIAGEN, Hilden, Germany) according to the manufacturer’s instructions. The genomic DNA was subjected to PCR using primers specific for eae gene for enteropathogenic E. coli (EPEC); eae and stx genes for enterohemorrhagic E. coli (EHEC); est and elt genes for enterotoxigenic E. coli (ETEC); ipaH gene for enteroinvasive E. coli (EIEC) and Shigella spp.; and aggR, CVD432 and aspU genes for enteroaggregative E. coli (EAEC). The PCR mixture was prepared with puReTaq Ready‐To‐Go PCR beads kit (GE Healthcare, UK) according to the manufacturer’s instructions. The amplified product was analysed on a 2% agarose gel. For rotavirus detection, about 1 ml of a 10% faecal suspension was prepared from each faecal sample and subjected to an enzyme‐linked immunosorbent assay (ELISA), as described previously [24]. Rotavirus double‐stranded RNA was extracted from the 10% faecal suspensions with ISOGEN‐LS (Nippon Gene Co., Ltd., Toyama, Japan) according to the manufacturer’s protocol. The RNA was reverse transcribed into the complementary DNA (cDNA) using a ReverTra Ace® qPCR RT Kit (Toyobo Biotechnology Co., Ltd., Japan). The cDNA was then amplified in a two‐step multiplexed semi‐nested reverse transcription‐polymerase chain reaction (RT‐PCR) to determine the G and P genotypes of the rotavirus strains using a KOD‐Plus‐Ver.2 high fidelity DNA polymerase kit (Toyobo Biotechnology Co., Ltd.), as described previously [25, 26]. The amplified product was then analysed on a 1.2% agarose gel. The whole stool samples were examined microscopically for diarrhoea‐causing parasites. Briefly, a drop of Lugol’s iodine stain was mixed with a small amount of specimen on the microscope slide using a wire loop and examined under 10× and 40× objectives with the condenser iris closed sufficiently to give a good contrast. Motile trophozoites and egg cysts of the parasitic pathogens were targeted in these examinations. The microbial quality of water was examined using a special fluorescence‐based ES Coli Blue Medium to selectively detect E. coli and total coliforms in water samples as described previously [27]. Briefly, 100 ml of each of the water samples were added into a bottle containing the ES Coli Blue Medium and incubated at 37°C overnight. This was followed by illumination in the dark using a mini fluorescent lamp. Only water samples contaminated with E. coli and other coliform organisms would fluoresce. All the contaminated water samples were cultured on appropriate media for primary isolation and identification of the water contaminant bacteria as described above for the faecal samples. To evaluate the impact of the WASH, MNCH, nutrition and ECD interventions on trends in diarrhoeal disease burden, we reviewed hospital logbooks at Elangata‐Enterit Health Centre and Maji‐Moto Dispensary and recorded the daily all‐cause hospitalizations and all‐cause gastroenteritis at each of the health facilities before (January–April 2018) and after (January–May 2021) the interventions. Using these data, we compared trends in all‐cause gastroenteritis at each facility between the baseline and endline survey. Data were analysed using STATA Version 14 (StataCorp., 2015). Descriptive statistics were used to summarise data and calculate proportions. Isolation rates of diarrhoea‐causing pathogens and hospital visits for all‐cause diarrhoea before and after the interventions were compared using test of proportions. Differences in proportions between two groups were tested using the t‐test where applicable. A p‐value of <0.05 was considered to be significant. Percentage change was calculated to establish increase or decrease in parameters where necessary.
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