Effects of water quality, sanitation, handwashing and nutritional interventions on enteric pathogen seroconversion in rural Bangladesh: a cluster randomised trial

Background: Improvements to water quality, sanitation, handwashing (WASH) and nutrition may prevent enteric pathogen infection during the first two years of life. Few randomised controlled trials have measured pathogen-specific effects of WASH and nutritional interventions. Methods: Within a 2x2 factorial cluster-randomized trial of WASH and nutritional interventions in Bangladesh, we tested dried blood spot specimens with multiplex assay for IgG responses to 12 enteric pathogens: Norovirus, Campylobacter, LT-producing enterotoxigenic E. coli (LT-ETEC), Shigella, non-typhoidal and typhoidal Salmonella enterica, Vibrio cholerae, Cryptosporidium, Giardia, Entamoeba histolytica, Taenia solium, and Strongyloides stercoralis. Primary analysis included children with IgG measurements at ~24 months, and secondary analysis assessed early effects in a sub-study at ~14 months. We estimated age-specific seroprevalence and marginal seroprevalence differences for WASH and nutrition effects. Trial is registered with ClinicalTrials.gov ( NCT01590095 ). Findings: Across the four arms (450 clusters), 4817 samples were tested for IgG responses, 2453 samples at the primary endpoint. Seroprevalence increased with age, consistent with intense early-life transmission. For highest transmission pathogens, >94% of children had seroconverted to norovirus, LT-ETEC and Campylobacter by 12-18 months. WASH effects were modest and pathogen-specific but generally protective. At 24 months, children that received WASH interventions had less antibody against Shigella (-4.5%, 95% CI -7.6% to -1.5%), non-typhoidal S. enterica (-4.0%, 95% CI -6.5% to -1.5%), and Giardia (-3.4%, 95% CI -6.7% to -0.2%), although not after multiple-testing correction. Nutrition had limited effects on most enteric pathogens, but reduced non-typhoidal S. enterica at 14 months (-6.4%, 95% CI: -9.8% to -3.0%). Interpretation: Multiplex serology provided evidence that WASH may modestly reduce cumulative exposure to selected enteric pathogens, but household-level interventions were insufficient to substantially disrupt transmission in this high-exposure setting. Funding: National Institutes of Health (R01AI166671, R01AI106878, R01AI134814). The original WASH Benefits trial was funded by Gates Foundation (OPPGD759).

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Journal
medRxiv
Published
2026-11-01
DOI
https://doi.org/10.64898/2026.10.30.26366885
Primary Topic
Child Nutrition and Water Access
Type
preprint

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preprint

Effects of water quality, sanitation, handwashing and nutritional interventions on enteric pathogen seroconversion in rural Bangladesh: a cluster randomised trial

Robert L. Atmar, Benjamin F. Arnold, Ayşe Ercümen, Andrew N. Mertens et al.
1 links
medRxiv
Child Nutrition and Water Access
preprint

Effects of water quality, sanitation, handwashing and nutritional interventions on enteric pathogen seroconversion in rural Bangladesh: a cluster randomised trial

Robert L. Atmar, Benjamin F. Arnold, Ayşe Ercümen, Andrew N. Mertens, Pearl Anne Ante-Testard, Richelle C. Charles, Jessica A. Grembi, Nikolina Walas, Md Ziaur Rahman, Erica Brook Goodhew, Samantha J. Bents, Stephen P. Luby, Henry Muriuki Kanyi, Sammy M. Njenga, John M. Colford, Edward Thomas Ryan, Audrie Lin, Md. Rana Miah, Jeffrey W. Priest, Claire Munroe, Abul Kashem Shoab, Christine P. Stewart, Rashidul Haque, Sania Ashraf, Patrick J. Lammie, Shahjahan Ali, Richelle W. Kihoro, Jade Benjamin‐Chung, Sarker Masud Parvez, Everlyn Kamau, Henry Emisiko, Huiyu Hu, C. Norman Coleman, Julianna Colado, Md. Mostofa Shakil, Mahbubur Rahman
preprint en

Abstract

Background: Improvements to water quality, sanitation, handwashing (WASH) and nutrition may prevent enteric pathogen infection during the first two years of life. Few randomised controlled trials have measured pathogen-specific effects of WASH and nutritional interventions. Methods: Within a 2x2 factorial cluster-randomized trial of WASH and nutritional interventions in Bangladesh, we tested dried blood spot specimens with multiplex assay for IgG responses to 12 enteric pathogens: Norovirus, Campylobacter, LT-producing enterotoxigenic E. coli (LT-ETEC), Shigella, non-typhoidal and typhoidal Salmonella enterica, Vibrio cholerae, Cryptosporidium, Giardia, Entamoeba histolytica, Taenia solium, and Strongyloides stercoralis. Primary analysis included children with IgG measurements at ~24 months, and secondary analysis assessed early effects in a sub-study at ~14 months. We estimated age-specific seroprevalence and marginal seroprevalence differences for WASH and nutrition effects. Trial is registered with ClinicalTrials.gov ( NCT01590095 ). Findings: Across the four arms (450 clusters), 4817 samples were tested for IgG responses, 2453 samples at the primary endpoint. Seroprevalence increased with age, consistent with intense early-life transmission. For highest transmission pathogens, >94% of children had seroconverted to norovirus, LT-ETEC and Campylobacter by 12-18 months. WASH effects were modest and pathogen-specific but generally protective. At 24 months, children that received WASH interventions had less antibody against Shigella (-4.5%, 95% CI -7.6% to -1.5%), non-typhoidal S. enterica (-4.0%, 95% CI -6.5% to -1.5%), and Giardia (-3.4%, 95% CI -6.7% to -0.2%), although not after multiple-testing correction. Nutrition had limited effects on most enteric pathogens, but reduced non-typhoidal S. enterica at 14 months (-6.4%, 95% CI: -9.8% to -3.0%). Interpretation: Multiplex serology provided evidence that WASH may modestly reduce cumulative exposure to selected enteric pathogens, but household-level interventions were insufficient to substantially disrupt transmission in this high-exposure setting. Funding: National Institutes of Health (R01AI166671, R01AI106878, R01AI134814). The original WASH Benefits trial was funded by Gates Foundation (OPPGD759).

medRxiv
Pennsylvania State University (US), North Carolina State University (US), Queensland University of Technology (AU), University of California, San Francisco (US), Baylor College of Medicine (US), University of California, Santa Cruz (US), International Centre for Diarrhoeal Disease Research (BD), Kenya Medical Research Institute (KE), Massachusetts General Hospital (US), The Task Force for Global Health (US), University of California, Davis (US), University of Colorado Denver (US), University of California, Berkeley (US), Stanford University (US)
International Centre for Diarrhoeal Disease Research, Bangladesh, Centers for Disease Control and Prevention
Good health and well-being, Zero hunger, Clean water and sanitation
Child Nutrition and Water Access
DOIOpen Access PDFOpenAlex
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