Association of Water, Sanitation, Hygiene and Animal Ownership With Relapse to Acute Malnutrition Among Children Aged 6–59 Months in Mali, South Sudan and Somalia: A Multi‐Site Prospective Cohort Study

Children successfully treated through community-based management of acute malnutrition (CMAM) frequently relapse to acute malnutrition (AM) following recovery and discharge. This prospective cohort study examined associations between relapse and household water, sanitation and hygiene (WASH) conditions, as well as animal ownership, in Mali, South Sudan and Somalia. Between April 2021 and June 2022, 1115 children were enrolled, with 964 children followed for 6 months, 242 in Mali, 488 in South Sudan and 234 in Somalia. Relapse to AM occurred in 32%, 63% and 21% of children in Mali, South Sudan and Somalia, respectively. In Mali, relapse risk was higher in households using multiple drinking water sources (aRR 1.71, 95% CI: 1.21-2.43, p = 0.003) or lacking soap (aRR 1.71, 95% CI: 1.03-2.82, p = 0.037). In South Sudan, inadequate drinking water sources, open defecation and the presence of animal faeces in the compound were associated with an increased risk of relapse (aRR 1.20, 95% CI: 1.04-1.38, p = 0.010; aRR 1.16, 95% CI: 1.03-1.30, p = 0.016; aRR 1.13, 95% CI: 1.02-1.26, p = 0.019, respectively). Sheep ownership in Mali (aRR 0.57, 95% CI: 0.40-0.81, p = 0.002) and cattle ownership in South Sudan (aRR 0.78, 95% CI: 0.71-0.85, p = < 0.001) were protective. No significant WASH or animal-related factors were associated with relapse in Somalia. As nearly all household drinking water samples were contaminated across settings and time points, no association could be detected between measured water quality and relapse. While many WASH indicators were not associated with relapse, some inadequate WASH conditions were identified as risk factors for relapse, although heterogeneous across contexts. These findings may help to identify at-risk children during treatment and inform strategies to reduce relapse post-recovery.