Evaluating the Effectiveness of Safe Drinking Water in SAM Treatment

Grant awarded: £300,000

Lead organisation: Action Against Hunger USA

Partnering organisations: Johns Hopkins Bloomberg School of Public Health

Project length: 2015-2017 (COMPLETED)

Study locations: Pakistan

Principal Investigator: Dr Silke Pietzsch

  • Zameer,1 year, Dadu

  • Dadu nutrition

  • Hygiene Promotion Supervisor Kousar Jahan, 38, delivering hygiene session to a study participant Noor Jahan, 35, at her home in Dadu on 18th May 2016. Noor Jahan’s son Adnan, 6 months old, is a SAM patient.

  • An example of the IEC material used during hygiene promotion sessions.

  • Marvi and Waheed, Hyigene Promoter - Data Gatherers, carry out an indepth interview for qualitative data collection with Ameena and her daughter Aneela, 8 months.

  • Benazir, Hyigene Promoter - Data Gatherer, conducts a session on personal hyigene for Abrab, 35, who has brought her son, Ajeeb, 12 months old, for follow-up at the CMAM site.


Malnutrition contributes to more than half of child deaths in less-developed settings. Severe acute malnutrition (SAM) affects an estimated 20 million children under five worldwide, and contributes to more than 1 million child deaths annually. The development of Ready to Use Therapeutic Foods (RUTFs) has resulted in a huge shift in the treatment of SAM through Community Management of Acute Malnutrition. Waterborne diseases are a major cause of malnutrition and use of unsafe water reduces the efficacy of RUTF. The research aimed to evaluate the effectiveness of introducing water, sanitation and hygiene (WASH) interventions such as safe drinking water into SAM treatment. Point-of-Use water treatments have the potential to decrease exposure to disease and therefore increase speed of recovery of children in SAM treatment.

Progress and outcomes achieved:

The study investigated three household water treatment technologies (a chlorine water treatment called Aquatabs; a flocculent-disinfectant; and ceramic water filters) amongst households where children were being treated for SAM, and made a comparison with a control group of standard SAM treatment plus a basic hygiene education intervention. The impact on the recovery rates, duration of malnutrition treatment and weight gain for children under five years were investigated using an RCT. Qualitative interviews at household level were also undertaken to add context about the participants’ experiences with each of the water treatment methods. The study was undertaken successfully, securing high follow up rates of participants in each study arm. A cost-effectiveness study was also incorporated, investigating the cost per child treated and recovered amongst the 4 treatment groups.

Key findings:

  • Water treatment combined with SAM treatment reduced the time taken for children to recover from SAM, compared with SAM treatment alone. This was particularly the case for Aquatabs and the flocculent disinfectant, whereas the locally available ceramic water filters were found to be less effective.
  • All three water treatment approaches had positive results, suggesting that a context-appropriate household water treatment can be used to deliver improved SAM outcomes.
  • The cost effectiveness studies suggested that the use of Aquatabs led to the most cost effective treatment, and was cheaper per child recovered than SAM treatment alone.

Key outputs:

  • Two peer-reviewed articles are expected to be published on the main study and on the cost-effectiveness element
  • Three dissemination events have been held in Pakistan at national, provincial and district level
  • Presentation of study at Emergency Environmental Health Forum (2016) and University of Oklohoma International WaTER Conference (2017).

Next steps:

The research findings will contribute towards an increased evidence base, alongside parallel ACF-led studies in Chad and DRC, which will be used to influence ACF programming and other actors including the Pakistan Ministry of Health.  Findings will be used to advocate for the inclusion of WASH interventions within treatment for under nutrition, and contribute to work led by other agencies to promote the concept of “WASH in Nut Minimum package”.


 “Yes, there are a lot of advantages to this water. I have been suggesting now to everyone who has a child who is kamzoor [weak] to go to the center [OTP site] and use the kangi ji dawaa [RUTF] and the treated water. My child is not weeping anymore and I am feeling more relaxed in my mind.”  Study participant

“Though both the project and the environment are challenging, the field team has worked together to pursue creative solutions . . . We have maintained close collaboration with staff at CMAM sites, so that the nurses enrolling children in the CMAM program understand the study aims and give vital support to the team in the field.”  Silke Pietzsch, PI


Elrha is a registered charity in England and Wales (1177110).

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