Effects of water quality, sanitation, handwashing and nutritional interventions on enteric pathogen seroconversion in rural Bangladesh: a cluster randomised trial
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).
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BibTeX
@misc{rahman2026effects,
title = {{Effects of water quality, sanitation, handwashing and nutritional interventions on enteric pathogen seroconversion in rural Bangladesh: a cluster randomised trial}},
author = {Mahbubur Rahman and Pearl Anne Ante-Testard and Richelle W. Kihoro and Henry Kanyi and Henry Emisiko and Huiyu Hu and Everlyn Kamau and E. Brook Goodhew and Chabier Coleman and Shahjahan Ali and Md Ziaur Rahman and Abul Kasham Shoab and Md. Rana Miah and Sania Ashraf and Sarker M Parvez and Md. Mostofa Shakil and Samantha J. Bents and Julianna Colado and Nikolina Walas and Jessica A. Grembi and Richelle C. Charles and Edward T. Ryan and Claire Munroe and Robert L. Atmar and Jade Benjamin-Chung and Ayse Ercumen and Andrew N. Mertens and Audrie Lin and Patrick J. Lammie and Christine P. Stewart and John M. Colford and Stephen P. Luby and Sammy M. Njenga and Rashidul Haque and Jeffrey W. Priest and Benjamin F. Arnold},
howpublished = {medRxiv},
year = {2026},
month = oct,
doi = {10.64898/2026.10.30.26366885},
url = {https://www.medrxiv.org/content/10.64898/2026.10.30.26366885v1},
note = {CC BY},
}
RIS
TY - UNPB
TI - Effects of water quality, sanitation, handwashing and nutritional interventions on enteric pathogen seroconversion in rural Bangladesh: a cluster randomised trial
AU - Mahbubur Rahman
AU - Pearl Anne Ante-Testard
AU - Richelle W. Kihoro
AU - Henry Kanyi
AU - Henry Emisiko
AU - Huiyu Hu
AU - Everlyn Kamau
AU - E. Brook Goodhew
AU - Chabier Coleman
AU - Shahjahan Ali
AU - Md Ziaur Rahman
AU - Abul Kasham Shoab
AU - Md. Rana Miah
AU - Sania Ashraf
AU - Sarker M Parvez
AU - Md. Mostofa Shakil
AU - Samantha J. Bents
AU - Julianna Colado
AU - Nikolina Walas
AU - Jessica A. Grembi
AU - Richelle C. Charles
AU - Edward T. Ryan
AU - Claire Munroe
AU - Robert L. Atmar
AU - Jade Benjamin-Chung
AU - Ayse Ercumen
AU - Andrew N. Mertens
AU - Audrie Lin
AU - Patrick J. Lammie
AU - Christine P. Stewart
AU - John M. Colford
AU - Stephen P. Luby
AU - Sammy M. Njenga
AU - Rashidul Haque
AU - Jeffrey W. Priest
AU - Benjamin F. Arnold
PY - 2026
DA - 2026/10/30
PB - medRxiv
DO - 10.64898/2026.10.30.26366885
UR - https://www.medrxiv.org/content/10.64898/2026.10.30.26366885v1
AB - 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).
ER -