Effects of water quality, sanitation, handwashing and nutritional interventions on enteric pathogen seroconversion in rural Kenya: a cluster randomised trial
- 1University of California, San Francisco
Abstract
Background: We evaluated whether water, sanitation, and handwashing (WASH) and nutrition interventions reduced enteric pathogen seroprevalence during the first two years of life among children in rural Kenya. Methods: We analysed the 2x2 factorial subset of the WASH Benefits Kenya cluster-randomised trial (control, WASH, nutrition, and WASH plus nutrition). Dried blood spots were collected from all children in the birth cohort after two years of intervention and at 6 and 12 months within a longitudinal substudy. Immunoglobulin G (IgG) responses were measured using a multiplex bead assay that included 12 viral, bacterial, protozoan, and helminth pathogens. The primary outcome was IgG seroprevalence at 2 years. We estimated intention-to-treat differences, comparing WASH with no WASH and nutrition with no nutrition across the factorial design. The trial is registered with ClinicalTrials.gov (NCT01704105). Findings: The primary analysis included 3030 children in 384 of 391 clusters (median age 23 months). Seroprevalence increased rapidly with age and exceeded 90% for norovirus, Campylobacter, and LT-ETEC by the final visit, with several pathogens at more moderate prevalences (24% of children were seropositive to typhoidal S. enterica HlyE). Differences between intervention groups were small: lower T. solium (-3.3 percentage points [95% CI -6.3 to -0.2]) and higher E. histolytica (3.2 [0.1 to 6.3]) with WASH versus control, and lower V. cholerae (-1.1 [-1.8 to -0.3]) and Shigella/EIEC (-2.7 [-5.5 to 0.0]) with nutrition versus no nutrition. No comparison met the 5% Benjamini-Hochberg false discovery rate threshold. Secondary analyses and age-seroprevalence curves suggested modest reductions in seroprevalence for some pathogens but an increase in norovirus at approximately 12 months when intervention adherence was highest. Interpretation: At the levels of adherence achieved, household-level WASH and nutrition interventions were insufficient to reduce widespread early-life enteric pathogen exposure in this high-transmission setting, supporting development of complementary vaccine and transmission-control strategies. Funding: National Institutes of Health (R01AI166671, R01AI106878, R01AI134814). The original WASH Benefits trial was funded by the Gates Foundation (OPPGD759).
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BibTeX
@misc{kanyi2026effects,
title = {{Effects of water quality, sanitation, handwashing and nutritional interventions on enteric pathogen seroconversion in rural Kenya: a cluster randomised trial}},
author = {H. Kanyi and R. W. Kihoro and H. Hu and H. Emisiko and B. Goodhew and C. Coleman and R. C. Charles and E. T. Ryan and C. Munroe and R. L. Atmar and P. A. Ante-Testard and E. Kamau and S. J. Bents and B. S. Achando and A. N. Mertens and H. N. Dentz and G. Rao and M. K. Wolfe and C. P. Stewart and A. J. Pickering and C. Null and A. Lin and J. M. Colford and P. J. Lammie and J. W. Priest and B. F. Arnold and S. M. Njenga},
howpublished = {medRxiv},
year = {2026},
month = oct,
doi = {10.64898/2026.10.30.26366882},
url = {https://www.medrxiv.org/content/10.64898/2026.10.30.26366882v1},
note = {CC BY},
}
RIS
TY - UNPB
TI - Effects of water quality, sanitation, handwashing and nutritional interventions on enteric pathogen seroconversion in rural Kenya: a cluster randomised trial
AU - H. Kanyi
AU - R. W. Kihoro
AU - H. Hu
AU - H. Emisiko
AU - B. Goodhew
AU - C. Coleman
AU - R. C. Charles
AU - E. T. Ryan
AU - C. Munroe
AU - R. L. Atmar
AU - P. A. Ante-Testard
AU - E. Kamau
AU - S. J. Bents
AU - B. S. Achando
AU - A. N. Mertens
AU - H. N. Dentz
AU - G. Rao
AU - M. K. Wolfe
AU - C. P. Stewart
AU - A. J. Pickering
AU - C. Null
AU - A. Lin
AU - J. M. Colford
AU - P. J. Lammie
AU - J. W. Priest
AU - B. F. Arnold
AU - S. M. Njenga
PY - 2026
DA - 2026/10/30
PB - medRxiv
DO - 10.64898/2026.10.30.26366882
UR - https://www.medrxiv.org/content/10.64898/2026.10.30.26366882v1
AB - Background: We evaluated whether water, sanitation, and handwashing (WASH) and nutrition interventions reduced enteric pathogen seroprevalence during the first two years of life among children in rural Kenya. Methods: We analysed the 2x2 factorial subset of the WASH Benefits Kenya cluster-randomised trial (control, WASH, nutrition, and WASH plus nutrition). Dried blood spots were collected from all children in the birth cohort after two years of intervention and at 6 and 12 months within a longitudinal substudy. Immunoglobulin G (IgG) responses were measured using a multiplex bead assay that included 12 viral, bacterial, protozoan, and helminth pathogens. The primary outcome was IgG seroprevalence at 2 years. We estimated intention-to-treat differences, comparing WASH with no WASH and nutrition with no nutrition across the factorial design. The trial is registered with ClinicalTrials.gov (NCT01704105). Findings: The primary analysis included 3030 children in 384 of 391 clusters (median age 23 months). Seroprevalence increased rapidly with age and exceeded 90% for norovirus, Campylobacter, and LT-ETEC by the final visit, with several pathogens at more moderate prevalences (24% of children were seropositive to typhoidal S. enterica HlyE). Differences between intervention groups were small: lower T. solium (-3.3 percentage points [95% CI -6.3 to -0.2]) and higher E. histolytica (3.2 [0.1 to 6.3]) with WASH versus control, and lower V. cholerae (-1.1 [-1.8 to -0.3]) and Shigella/EIEC (-2.7 [-5.5 to 0.0]) with nutrition versus no nutrition. No comparison met the 5% Benjamini-Hochberg false discovery rate threshold. Secondary analyses and age-seroprevalence curves suggested modest reductions in seroprevalence for some pathogens but an increase in norovirus at approximately 12 months when intervention adherence was highest. Interpretation: At the levels of adherence achieved, household-level WASH and nutrition interventions were insufficient to reduce widespread early-life enteric pathogen exposure in this high-transmission setting, supporting development of complementary vaccine and transmission-control strategies. Funding: National Institutes of Health (R01AI166671, R01AI106878, R01AI134814). The original WASH Benefits trial was funded by the Gates Foundation (OPPGD759).
ER -