Building on a decade of progress in water, sanitation and hygiene to control, eliminate and eradicate neglected tropical diseases.

Water, sanitation and hygiene (WASH) are essential for the control and elimination of neglected tropical diseases (NTDs). The forthcoming NTD road map 'Ending the neglect to attain the Sustainable Development Goals: a road map for neglected tropical diseases 2021-2030' encourages cross-sectoral collaboration and includes cross-cutting targets on WASH. This commentary reflects on collaborative efforts between the NTD and WASH sectors over the past years and encourages strengthened partnerships to support the new road map and achieve the 2030 agenda ambition of leaving no one behind.

Animal influence on water, sanitation and hygiene measures for zoonosis control at the household level: A systematic literature review.

INTRODUCTION: Neglected zoonotic diseases (NZDs) have a significant impact on the livelihoods of the world's poorest populations, which often lack access to basic services. Water, sanitation and hygiene (WASH) programmes are included among the key strategies for achieving the World Health Organization's 2020 Roadmap for Implementation for control of Neglected Tropical Diseases (NTDs). There exists a lack of knowledge regarding the effect of animals on the effectiveness of WASH measures. OBJECTIVES: This review looked to identify how animal presence in the household influences the effectiveness of water, hygiene and sanitation measures for zoonotic disease control in low and middle income countries; to identify gaps of knowledge regarding this topic based on the amount and type of studies looking at this particular interaction. METHODS: Studies from three databases (Medline, Web of Science and Global Health) were screened through various stages. Selected articles were required to show burden of one or more zoonotic diseases, an animal component and a WASH component. Selected articles were analysed. A narrative synthesis was chosen for the review. RESULTS: Only two studies out of 7588 met the inclusion criteria. The studies exemplified how direct or indirect contact between animals and humans within the household can influence the effectiveness of WASH interventions. The analysis also shows the challenges faced by the scientific community to isolate and depict this particular interaction. CONCLUSION: The dearth of studies examining animal-WASH interactions is explained by the difficulties associated with studying environmental interventions and the lack of collaboration between the WASH and Veterinary Public Health research communities. Further tailored research under a holistic One Health approach will be required in order to meet the goals set in the NTDs Roadmap and the 2030 Agenda for Sustainable Development.

Tailoring Water, Sanitation, and Hygiene (WASH) Targets for Soil-Transmitted Helminthiasis and Schistosomiasis Control.

The World Health Organization's (WHO) 2015-2020 Global Strategy on water, sanitation, and hygiene (WASH) and neglected tropical diseases (NTDs) encourages integration, whilst maintaining existing structured NTD investments, and acceleration towards Sustainable Development Goal (SDG) targets. Accordingly, SDG-associated and WASH-NTD indicators have been developed, commencing important intersectoral dialogue, alongside opportunities for future disease-specific refinements. The rationale for soil-transmitted helminthiasis (STH)- and schistosomiasis-specific WASH considerations, and a traffic-light figure, are presented here to indicate where current international definitions may, or may not, suffice. Certain unique aspects in control dynamics and parasitic lifecycles, however, necessitate additional implementation research with more appropriate measurement indicators developed to record programmatic interventions and to define strategic priorities more effectively.

Unpacking the enabling factors for hand, cord and birth-surface hygiene in Zanzibar maternity units.

Recent national surveys in The United Republic of Tanzania have revealed poor standards of hygiene at birth in facilities. As more women opt for institutional delivery, improving basic hygiene becomes an essential part of preventative strategies for reducing puerperal and newborn sepsis. Our collaborative research in Zanzibar provides an in-depth picture of the state of hygiene on maternity wards to inform action. Hygiene was assessed in 2014 across all 37 facilities with a maternity unit in Zanzibar. We used a mixed methods approach, including structured and semi-structured interviews, and environmental microbiology. Data were analysed according to the WHO 'cleans' framework, focusing on the fundamental practices for prevention of newborn and maternal sepsis. For each 'clean' we explored the following enabling factors: knowledge, infrastructure (including equipment), staffing levels and policies. Composite indices were constructed for the enabling factors of the 'cleans' from the quantitative data: clean hands, cord cutting, and birth surface. Results from the qualitative tools were used to complement this information.Only 49% of facilities had the 'infrastructural' requirements to enable 'clean hands', with the availability of constant running water particularly lacking. Less than half (46%) of facilities met the 'knowledge' requirements for ensuring a 'clean delivery surface'; six out of seven facilities had birthing surfaces that tested positive for multiple potential pathogens. Almost two thirds of facilities met the 'infrastructure (equipment) requirement' for 'clean cord'; however, disposable cord clamps being frequently out of stock, often resulted in the use of non-sterile thread made of fabric. This mixed methods approach, and the analytical framework based on the WHO 'cleans' and the enabling factors, yielded practical information of direct relevance to action at local and ministerial levels. The same approach could be applied to collect and analyse data on infection prevention from maternity units in other contexts.

Collaborating to develop joint water, sanitation and hygiene (WASH) and neglected tropical disease (NTD) sector monitoring: an expert consultation.

Background: Joint monitoring between the water, sanitation and hygiene (WASH) and neglected tropical disease (NTD) sectors presents an opportunity for enhanced collaboration and progress towards shared objectives. Taking forward outputs from global WASH and NTD Roundtables, we engaged experts in a consultative process of identifying measurable priority indicators for joint monitoring. Methods: We used a Delphi method for conducting expert consultation and developing consensus. Experts were invited to participate through purposive and snowball sampling, and open solicitation at key sector meetings. Participating WASH and NTDs experts represented a diversity of interest groups, including NTD and WASH field staff and government stakeholders from endemic countries, bilateral and multilateral development agencies, non-governmental organizations, and academic institutions. Four rounds of consultation were conducted via online surveys. Results: Between 55 and 69 experts participated in each round of consultation. Seven core measurable indicators emerged as priorities for inclusion in joint monitoring for the NTD sector. Conclusion: Our findings provide insight on the development and implementation of joint monitoring frameworks that can be integrated into existing programme level monitoring.

Water, sanitation and hygiene for accelerating and sustaining progress on neglected tropical diseases: a new Global Strategy 2015-20.

Neglected tropical diseases (NTDs) affect over 1 billion people. Safe water, sanitation and hygiene (WASH) contribute to prevention and management of most NTDs. Linking WASH and NTD interventions has potential to impact on multiple NTDs and can help secure sustainable and equitable progress towards universal access to WASH. The need to address the determinants of NTDs has been acknowledged. In response, WHO has published a new Global Strategy: 'Water, Sanitation and Hygiene for accelerating and sustaining progress on Neglected Tropical Diseases'. The Strategy focuses on cross-cutting actions that benefit disease control and care efforts, and strengthen health systems. Implementation of the strategy and the accompanying action plan can help ensure that the health and development agenda leaves no one behind.

Integration of water, sanitation and hygiene for the control of neglected tropical diseases: a review of progress and the way forward.

A WHO roadmap to control, eliminate and eradicate neglected tropical diseases (NTDs) proposes a public health approach integrating diverse prevention and treatment interventions. Water, sanitation and hygiene (WASH) has long been a recognized, yet under-prioritized intervention of global disease control efforts. Through collaboration with the WASH sector, efforts have been made to integrate WASH in NTD control. This article reviews progress made in recent years, explores mechanisms supporting advances, and identifies priorities and next steps for accelerating WASH integration. This paper reveals advances in collaboration between WASH and NTD sectors, resulting in progress made across areas of programming; research; advocacy and policy; training and capacity building; and mapping, data collection and monitoring. Face to face meetings between WASH and NTD sector experts with a clear purpose of informing wider sector discussions, and the development of actionable joint workplans, have been particularly critical in supporting progress. Priority next steps include building capacity for WASH programming among NTD control teams, coordination at the country level, and strengthening the epidemiological evidence and operational learning for joint WASH and NTD interventions. In order to accelerate WASH integration in NTD control through strong collaborations with the WASH sector, the NTD sector could make use of strong data management skills and advocacy opportunities.

From joint thinking to joint action: a call to action on improving water, sanitation, and hygiene for maternal and newborn health.

Yael Velleman and colleagues argue for stronger integration between the water, sanitation, and hygiene (WASH) and maternal and newborn health sectors. Please see later in the article for the Editors' Summary.

Integration of water, sanitation, and hygiene for the prevention and control of neglected tropical diseases: a rationale for inter-sectoral collaboration.

Improvements of water, sanitation, and hygiene (WASH) infrastructure and appropriate health-seeking behavior are necessary for achieving sustained control, elimination, or eradication of many neglected tropical diseases (NTDs). Indeed, the global strategies to fight NTDs include provision of WASH, but few programs have specific WASH targets and approaches. Collaboration between disease control programs and stakeholders in WASH is a critical next step. A group of stakeholders from the NTD control, child health, and WASH sectors convened in late 2012 to discuss opportunities for, and barriers to, collaboration. The group agreed on a common vision, namely "Disease-free communities that have adequate and equitable access to water and sanitation, and that practice good hygiene." Four key areas of collaboration were identified, including (i) advocacy, policy, and communication; (ii) capacity building and training; (iii) mapping, data collection, and monitoring; and (iv) research. We discuss strategic opportunities and ways forward for enhanced collaboration between the WASH and the NTD sectors.

Interventions to improve water quality and supply, sanitation and hygiene practices, and their effects on the nutritional status of children.

BACKGROUND: Water, sanitation and hygiene (WASH) interventions are frequently implemented to reduce infectious diseases, and may be linked to improved nutrition outcomes in children. OBJECTIVES: To evaluate the effect of interventions to improve water quality and supply (adequate quantity to maintain hygiene practices), provide adequate sanitation and promote handwashing with soap, on the nutritional status of children under the age of 18 years and to identify current research gaps. SEARCH METHODS: We searched 10 English-language (including MEDLINE and CENTRAL) and three Chinese-language databases for published studies in June 2012. We searched grey literature databases, conference proceedings and websites, reviewed reference lists and contacted experts and authors. SELECTION CRITERIA: Randomised (including cluster-randomised), quasi-randomised and non-randomised controlled trials, controlled cohort or cross-sectional studies and historically controlled studies, comparing WASH interventions among children aged under 18 years. DATA COLLECTION AND ANALYSIS: Two review authors independently sought and extracted data on childhood anthropometry, biochemical measures of micronutrient status, and adherence, attrition and costs either from published reports or through contact with study investigators. We calculated mean difference (MD) with 95% confidence intervals (CI). We conducted study-level and individual-level meta-analyses to estimate pooled measures of effect for randomised controlled trials only. MAIN RESULTS: Fourteen studies (five cluster-randomised controlled trials and nine non-randomised studies with comparison groups) from 10 low- and middle-income countries including 22,241 children at baseline and nutrition outcome data for 9,469 children provided relevant information. Study duration ranged from 6 to 60 months and all studies included children under five years of age at the time of the intervention. Studies included WASH interventions either singly or in combination. Measures of child anthropometry were collected in all 14 studies, and nine studies reported at least one of the following anthropometric indices: weight-for-height, weight-for-age or height-for-age. None of the included studies were of high methodological quality as none of the studies masked the nature of the intervention from participants.Weight-for-age, weight-for-height and height-for-age z-scores were available for five cluster-randomised controlled trials with a duration of between 9 and 12 months. Meta-analysis including 4,627 children identified no evidence of an effect of WASH interventions on weight-for-age z-score (MD 0.05; 95% CI -0.01 to 0.12). Meta-analysis including 4,622 children identified no evidence of an effect of WASH interventions on weight-for-height z-score (MD 0.02; 95% CI -0.07 to 0.11). Meta-analysis including 4,627 children identified a borderline statistically significant effect of WASH interventions on height-for-age z-score (MD 0.08; 95% CI 0.00 to 0.16). These findings were supported by individual participant data analysis including information on 5,375 to 5,386 children from five cluster-randomised controlled trials.No study reported adverse events. Adherence to study interventions was reported in only two studies (both cluster-randomised controlled trials) and ranged from low (< 35%) to high (> 90%). Study attrition was reported in seven studies and ranged from 4% to 16.5%. Intervention cost was reported in one study in which the total cost of the WASH interventions was USD 15/inhabitant. None of the studies reported differential impacts relevant to equity issues such as gender, socioeconomic status and religion. AUTHORS' CONCLUSIONS: The available evidence from meta-analysis of data from cluster-randomised controlled trials with an intervention period of 9-12 months is suggestive of a small benefit of WASH interventions (specifically solar disinfection of water, provision of soap, and improvement of water quality) on length growth in children under five years of age. The duration of the intervention studies was relatively short and none of the included studies is of high methodological quality. Very few studies provided information on intervention adherence, attrition and costs. There are several ongoing trials in low-income country settings that may provide robust evidence to inform these findings.