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  • br Should child growth replace

    2019-05-08


    Should child growth replace diarrhoea as the primary child health outcome for sanitation trials? We appreciate Derek Headey\'s comment in relation to our trial that the window of opportunity to plausibly affect growth faltering is from in utero up to 24 months, and therefore that sanitation trials should focus growth assessments in children with exposure to the intervention who are younger than 24 months. Ongoing sanitation trials in rural Kenya (), Bangladesh (), and Zimbabwe () have chosen to enrol target children in utero precisely because of the recognition that child stunting and environmental enteric dysfunction can begin before birth. However, the effect of enteric pathogen exposure—either through reduced acute diarrhoea or asymptomatic infections—is likely to be one of many causes of linear growth faltering. In some settings, competing risks such as poor nutrition and non-enteric infections (eg, malaria) could overshadow improved sanitation\'s contribution to growth. Child growth is also unable to capture potential health benefits of sanitation interventions for children older than 2 years. For these reasons, it could be premature to rely exclusively on anthropometry measurement before additional sanitation intervention trials successfully show an effect on child growth. Although we agree with Headey that caregiver-reported diarrhoea can be a biased outcome, we see value in measuring the effect of sanitation interventions on more objective indicators of enteric infections. Notably, recently developed molecular techniques allow for the simultaneous detection of many relevant diarrhoeal pathogens in stool samples, including bacteria, viruses, protozoans, and soil-transmitted helminths. poly ic measures of infection in saliva, blood, and stools provide additional multiplex opportunities to objectively measure enteric pathogens. Continued advancements in molecular techniques are reducing costs and increasing the feasibility of their use in low-income settings. Although the high incidence of asymptomatic infections precludes the use of pathogen presence as a direct indicator for clinical diarrhoea, enteric pathogen infection status would be a valuable outcome to understand the ability of sanitation interventions to interrupt transmission of diarrhoeal pathogens.
    We are grateful to Buddha Basnyat and colleagues (October, 2015), for drawing attention to the potential infectious consequences of the devastating April 25 Nepalese earthquake and the subsequent aftershocks. The need to “build back better” is imperative.
    Buddha Basnyat and colleagues (December, 2015) emphasise the opportunity for investments in innovative health care in the earthquake-ravaged districts of Nepal and raise concerns about epidemic outbreaks based on the experience of the 2010 Haiti earthquake. Yet, the differing climates of Haiti and Nepal deserve attention; contrary to tropical Haiti, Nepal has five climate zones and winters with temperatures dropping below freezing. This presents a similarity to the climate of Fukushima, which was stricken by the Great East Japan earthquake in 2011. Rather than epidemics, winter-related disease might bring the biggest immediate burden to post-disaster Nepal. It should be recognised true-breeding nearly 59 000 people are still living in 120 displacement sites in 13 districts of Nepal, and that 85% of these shelters are not suitable for winter. The beginning of winter will probably bring about problems of hypothermia, pneumonia, influenza, and even tuberculosis. In Fukushima, more than 450 000 people had to be evacuated, but the Japanese Government successfully provided multiple options for transitional shelter including prefabricated temporary housing, private rental apartments, government-owned accommodations, and public housing, all of which provide safety against winter conditions.
    The London Declaration on Neglected Tropical Diseases marked its fourth year on Jan 30, 2016. The declaration represents a coordinate effort to control or eliminate ten of the neglected diseases by 2020, and has already led to important coordination and partnership, and mobilised considerable resources. Although the progress made so far is to be celebrated, now is the time to count down to 2020 and start monitoring the progress and trends towards achieving the control and elimination targets.