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Water, sanitation, hygiene and enteric infections in children
  1. Joe Brown,
  2. Sandy Cairncross,
  3. Jeroen H J Ensink
  1. Environmental Health Group, Faculty of Infectious and Tropical Diseases, London School of Hygiene and Tropical Medicine, London, UK
  1. Correspondence to Dr Jeroen H J Ensink, Environmental Health Group, Faculty of Infectious and Tropical Diseases, London School of Hygiene and Tropical Medicine, Keppel Street, London WC1E 7HT, UK; Jeroen.ensink{at}

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In 2007, readers of the British Medical Journal voted that the introduction of clean water and sewerage—the ‘sanitation revolution’ of the Victorian era—was the most important medical milestone since the 1840s,1 over anaesthesia, antibiotics, or vaccines. These improvements led to a dramatic reduction in morbidity and mortality associated with faecal-oral infections, such as typhoid fever and cholera. Today, water, sanitation and hygiene (WSH) measures remain critically important to global public health, especially among children in lower income countries, who are at greatest risk from enteric infections and their associated symptoms, complications and sequelae.

In this article, we review the evidence linking WSH measures to faecal-oral diseases in children. Although continued research is needed, existing evidence from the last 150 years supports extending life-saving WSH measures to at-risk populations worldwide.2 One recent estimate3 held that 95% of diarrhoeal deaths in children under 5 years of age could be prevented by 2025, at a cost of US$6.715 billion, through targeted scale-up of proven, cost-effective, life-saving interventions. These include access to safe and accessible excreta disposal, support for basic hygiene practices such as hand washing with soap, and provision of a safe and reliable water supply. We present estimates of the burden of WSH-related disease followed by brief overviews of water, sanitation and hygiene-related transmission routes and control measures.i We conclude with a summary of current international targets and progress.

Transmission routes and health impact

Human excreta can contain over 50 known bacterial, viral, protozoan and helminthic pathogens. The majority of excreta-related infections are obtained through ingestion, less often through inhalation. Excreta-related infections travel through a variety of routes from one host to the next, either as a result of direct transmission through contaminated hands, or indirect transmission via contamination of drinking water, soil, utensils, food and flies (figure 1). The importance of each transmission route …

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  • Contributors All authors wrote and reviewed the paper, JHJE acts as guarantor of the content.

  • Funding SC's and JHJE's time was funded by the DFID research programme consortium on Sanitation and Hygiene (SHARE: grant no. P04990).

  • Competing interests None.

  • Provenance and peer review Commissioned; externally peer reviewed.

  • i Although we do cite pooled estimates of effect for WSH interventions on child health from a number of systematic reviews, readers should note that there is a rich emerging literature that attempts comparisons of impact between water supply, water quality, hygiene and sanitation; Waddington et al 2009 provides a good summary that is still current. WSH interventions are not very amenable to randomisation (in the case of infrastructure) and are almost never blinded in trials, with the exception of a minority of water quality intervention trials. Therefore, randomised, controlled trials (RCTs) may be subject to significant bias, and RCTs constitute the majority of studies included in systematic reviews of WSH interventions. We cite these reviews where appropriate as important but potentially flawed estimates that may be considered suggestive only. A broader perspective on the evidence base may be more helpful.