PDF(Pubmed)
Abstract：
In low- and middle-income countries (L&MICs), the biggest contributing factors to the global burden of disease in childhood are deaths due to respiratory illness and diarrhoea, both of which are closely related to use of water, sanitation, and hygiene (WASH) services by households. However, current estimates of the health impacts of WASH interventions use self-reported morbidity, which may fail to capture longer-term or more severe impacts. Reported mortality is thought to be less prone to bias than other reported measures. This study aimed to answer the question: What are the impacts of WASH interventions on reported childhood mortality in L&MICs?
We conducted a systematic review and meta-analysis, using a published protocol. Systematic searches of 11 academic databases and trial registries, plus organisational repositories, were undertaken to locate studies of WASH interventions, which were published in peer review journals or other sources (e.g., organisational reports and working papers). Intervention studies of WASH improvements implemented under endemic disease circumstances in L&MICs were eligible, which reported findings at any time until March 2020. We used the participant flow data supplied in response to journal editors\' calls for greater transparency. Data were collected by two authors working independently. We included evidence from 24 randomized and 11 nonrandomized studies of WASH interventions from all global regions, incorporating 2,600 deaths. Effects of 48 WASH treatment arms were included in analysis. We critically appraised and synthesised evidence using meta-analysis to improve statistical power. We found WASH interventions are associated with a significant reduction of 17% in the odds of all-cause mortality in childhood (OR = 0.83, 95% CI = 0.74, 0.92, evidence from 38 interventions), and a significant reduction in diarrhoea mortality of 45% (OR = 0.55, 95% CI = 0.35, 0.84; 10 interventions). Further analysis by WASH technology indicated interventions providing improved water in quantity to households were most consistently associated with reductions in all-cause mortality. Community-wide sanitation was most consistently associated with reductions in diarrhoea mortality. Around one-half of the included studies were assessed as being at \"moderate risk of bias\" in attributing mortality in childhood to the WASH intervention, and no studies were found to be at \"low risk of bias.\" The review should be updated to incorporate additional published and unpublished participant flow data.
The findings are congruent with theories of infectious disease transmission. Washing with water presents a barrier to respiratory illness and diarrhoea, which are the two biggest contributors to all-cause mortality in childhood in L&MICs. Community-wide sanitation halts the spread of diarrhoea. We observed that evidence synthesis can provide new findings, going beyond the underlying data from trials to generate crucial insights for policy. Transparent reporting in trials creates opportunities for research synthesis to answer questions about mortality, which individual studies of interventions cannot be reliably designed to address.
We conducted a systematic review and meta-analysis, using a published protocol. Systematic searches of 11 academic databases and trial registries, plus organisational repositories, were undertaken to locate studies of WASH interventions, which were published in peer review journals or other sources (e.g., organisational reports and working papers). Intervention studies of WASH improvements implemented under endemic disease circumstances in L&MICs were eligible, which reported findings at any time until March 2020. We used the participant flow data supplied in response to journal editors\' calls for greater transparency. Data were collected by two authors working independently. We included evidence from 24 randomized and 11 nonrandomized studies of WASH interventions from all global regions, incorporating 2,600 deaths. Effects of 48 WASH treatment arms were included in analysis. We critically appraised and synthesised evidence using meta-analysis to improve statistical power. We found WASH interventions are associated with a significant reduction of 17% in the odds of all-cause mortality in childhood (OR = 0.83, 95% CI = 0.74, 0.92, evidence from 38 interventions), and a significant reduction in diarrhoea mortality of 45% (OR = 0.55, 95% CI = 0.35, 0.84; 10 interventions). Further analysis by WASH technology indicated interventions providing improved water in quantity to households were most consistently associated with reductions in all-cause mortality. Community-wide sanitation was most consistently associated with reductions in diarrhoea mortality. Around one-half of the included studies were assessed as being at \"moderate risk of bias\" in attributing mortality in childhood to the WASH intervention, and no studies were found to be at \"low risk of bias.\" The review should be updated to incorporate additional published and unpublished participant flow data.
The findings are congruent with theories of infectious disease transmission. Washing with water presents a barrier to respiratory illness and diarrhoea, which are the two biggest contributors to all-cause mortality in childhood in L&MICs. Community-wide sanitation halts the spread of diarrhoea. We observed that evidence synthesis can provide new findings, going beyond the underlying data from trials to generate crucial insights for policy. Transparent reporting in trials creates opportunities for research synthesis to answer questions about mortality, which individual studies of interventions cannot be reliably designed to address.
摘要：
背景：在低收入和中等收入国家(L&MICs)，造成全球儿童疾病负担的最大因素是呼吸道疾病和腹泻导致的死亡，两者都与用水密切相关，卫生，和家庭卫生（WASH）服务。然而,目前对WASH干预措施对健康影响的估计使用自我报告的发病率，这可能无法捕捉到更长期或更严重的影响。报告的死亡率被认为比其他报告的指标更不容易出现偏差。本研究旨在回答以下问题：WASH干预措施对L&MICs报告的儿童死亡率有什么影响？
结果：我们进行了系统评价和荟萃分析，使用已发布的协议。系统检索11个学术数据库和试验登记处,加上组织存储库，进行了定位WASH干预措施的研究，发表在同行评审期刊或其他来源(例如，组织报告和工作文件)。在L&中等收入国家的地方病情况下实施的WASH改善干预研究符合资格，它在2020年3月之前的任何时候报告了调查结果。我们使用了响应期刊编辑要求提高透明度而提供的参与者流量数据。数据由两名独立工作的作者收集。我们纳入了来自全球所有地区的24项随机和11项非随机WASH干预研究的证据。包括2,600人死亡。48个WASH治疗组的效果包括在分析中。我们使用荟萃分析批判性地评估和综合证据，以提高统计能力。我们发现WASH干预措施与儿童全因死亡率的几率显着降低17％相关（OR=0.83，95％CI=0.74，0.92，来自38项干预措施的证据），腹泻死亡率显著降低45%(OR=0.55,95%CI=0.35,0.84;10项干预措施).通过WASH技术进行的进一步分析表明，向家庭提供改善水量的干预措施与降低全因死亡率最为一致。全社区的卫生设施与腹泻死亡率的降低密切相关。在将儿童期死亡率归因于WASH干预措施方面，约有一半的纳入研究被评估为处于“中等偏倚风险”。没有研究发现偏倚风险低。“应更新审查，以纳入其他已发布和未发布的参与者流量数据。
结论：这些发现与传染病传播理论是一致的。用水洗涤是呼吸道疾病和腹泻的屏障，这是L和中等收入国家儿童全因死亡率的两个最大贡献者。全社区的卫生设施阻止了腹泻的传播。我们观察到证据综合可以提供新的发现，超越试验的基础数据，为政策提供关键见解。试验中的透明报告为研究综合提供了机会，以回答有关死亡率的问题。不能可靠地设计干预措施的个别研究来解决这些问题。
结果：我们进行了系统评价和荟萃分析，使用已发布的协议。系统检索11个学术数据库和试验登记处,加上组织存储库，进行了定位WASH干预措施的研究，发表在同行评审期刊或其他来源(例如，组织报告和工作文件)。在L&中等收入国家的地方病情况下实施的WASH改善干预研究符合资格，它在2020年3月之前的任何时候报告了调查结果。我们使用了响应期刊编辑要求提高透明度而提供的参与者流量数据。数据由两名独立工作的作者收集。我们纳入了来自全球所有地区的24项随机和11项非随机WASH干预研究的证据。包括2,600人死亡。48个WASH治疗组的效果包括在分析中。我们使用荟萃分析批判性地评估和综合证据，以提高统计能力。我们发现WASH干预措施与儿童全因死亡率的几率显着降低17％相关（OR=0.83，95％CI=0.74，0.92，来自38项干预措施的证据），腹泻死亡率显著降低45%(OR=0.55,95%CI=0.35,0.84;10项干预措施).通过WASH技术进行的进一步分析表明，向家庭提供改善水量的干预措施与降低全因死亡率最为一致。全社区的卫生设施与腹泻死亡率的降低密切相关。在将儿童期死亡率归因于WASH干预措施方面，约有一半的纳入研究被评估为处于“中等偏倚风险”。没有研究发现偏倚风险低。“应更新审查，以纳入其他已发布和未发布的参与者流量数据。
结论：这些发现与传染病传播理论是一致的。用水洗涤是呼吸道疾病和腹泻的屏障，这是L和中等收入国家儿童全因死亡率的两个最大贡献者。全社区的卫生设施阻止了腹泻的传播。我们观察到证据综合可以提供新的发现，超越试验的基础数据，为政策提供关键见解。试验中的透明报告为研究综合提供了机会，以回答有关死亡率的问题。不能可靠地设计干预措施的个别研究来解决这些问题。
