Introducing Safe Drinking Water for Children with SAM in Sindh‚ Pakistan

This research study focuses on evaluating the effectiveness of introducing safe drinking water into Community-Managed Acute Malnutrition (CMAM) programs. The partnership between Action Against Hunger (ACF) and the Johns Hopkins Bloomberg School of Public Health (JHSPH) will provide inputs for CMAM program implementation in both development and emergency settings.

In this study supported by R2HC, we will conduct a randomized control trial to compare the effectiveness of three different water treatment methods in a CMAM program that ACF operates in Dadu District of Sindh Province. We have hypothesized that the addition of safe drinking water will reduce the amount of time necessary for children impacted by Severe Acute Malnutrition (SAM) to recover, based on the well-documented cyclical nature of waterborne disease and undernutrition.

Malnutrition contributes to more than half of child deaths in less-developed settings, and SAM affects an estimated 20 million children under five worldwide (1, 2). In the past decade, the development of Ready-to-Use Therapeutic Foods (RUTF) has allowed SAM treatment to be implemented on an outpatient basis through CMAM programs, offering a decentralized approach that generally results in higher coverage rates and lower opportunity costs for families as compared to inpatient programs. The cost to rehabilitate an undernourished child remains high, however, and RUTF is a relatively expensive product. Moreover, resource-poor environments often possess not only high rates of undernutrition among children, but also limited access to safe water. The use of unclean water reduces the efficiency of RUTF and increases morbidity and the risk of poor health outcomes for children with SAM.

For these reasons, this study will evaluate the effectiveness and sustainability of introducing water, sanitation, and hygiene (WASH) interventions such as safe drinking water into the treatment of SAM. Point-of-use (PoU) water treatment has the potential to decrease exposure to pathogens and disease, and increase the speed of recovery of children with SAM. Increasing the rapidity of a child’s recovery from SAM, in addition to immediately benefiting the affected child, has programmatic implications as well. If a child is enrolled in the program for a shorter length of time, there will be less RUTF required for each child’s treatment, lowering the overall treatment cost and enabling the programs to reach more children with SAM.

The study will involve distributing different water treatment devices to parents who bring their children to enroll in ACF’s CMAM program. One group will receive Aquatabs, which purify water by use of chlorine as a disinfectant; another group will receive P&;G Purifier of Water sachets, which treat water through a two-stage coagulation and disinfection process; and a third group will receive ceramic water filters. The research will compare outcomes across these three treatment arms as well as a control arm, considering diarrhea rates and CMAM outcomes among the children enrolled in the study.

The study’s focus areas of undernutrition and WASH-related diseases highlight community needs in Dadu District, which has a high prevalence of acute malnutrition and poor access to safe drinking water. A December 2012 ACF SMART survey estimated prevalence of global acute malnutrition (GAM) and severe acute malnutrition (SAM) in Dadu at 13% and 3.8%, respectively. The same survey showed that 78.8% of children under five had suffered from watery diarrhea in the two weeks preceding the survey, which is indicative of a very high burden of waterborne disease (3).

We are currently in the preparation phase of the project and plan to begin data collection in February 2016.

1. Pelletier DL, Frongillo EA jr, Schroeder DG, Habicht JP. The effects of malnutrition on child mortality in developing countries. Bull World Health Organ 1995; 73(4): 443-8.
2. World Health Organization/World Food Programme/UN Standing Committee on Nutrition/The United Nations Children’s Fund. Community Based Management of Severe Acute Malnutrition (Joint Statement). May, 2007.
3. ACF Report. Integrated SMART Survey. Dadu District, Sindh Province. December 2012.This research study focuses on evaluating the effectiveness of introducing safe drinking water into Community-Managed Acute Malnutrition (CMAM) programs. The partnership between Action Against Hunger (ACF) and the Johns Hopkins Bloomberg School of Public Health (JHSPH) will provide inputs for CMAM program implementation in both development and emergency settings.

In this study supported by R2HC, we will conduct a randomized control trial to compare the effectiveness of three different water treatment methods in a CMAM program that ACF operates in Dadu District of Sindh Province. We have hypothesized that the addition of safe drinking water will reduce the amount of time necessary for children impacted by Severe Acute Malnutrition (SAM) to recover, based on the well-documented cyclical nature of waterborne disease and undernutrition.

Malnutrition contributes to more than half of child deaths in less-developed settings, and SAM affects an estimated 20 million children under five worldwide (1, 2). In the past decade, the development of Ready-to-Use Therapeutic Foods (RUTF) has allowed SAM treatment to be implemented on an outpatient basis through CMAM programs, offering a decentralized approach that generally results in higher coverage rates and lower opportunity costs for families as compared to inpatient programs. The cost to rehabilitate an undernourished child remains high, however, and RUTF is a relatively expensive product. Moreover, resource-poor environments often possess not only high rates of undernutrition among children, but also limited access to safe water. The use of unclean water reduces the efficiency of RUTF and increases morbidity and the risk of poor health outcomes for children with SAM.

For these reasons, this study will evaluate the effectiveness and sustainability of introducing water, sanitation, and hygiene (WASH) interventions such as safe drinking water into the treatment of SAM. Point-of-use (PoU) water treatment has the potential to decrease exposure to pathogens and disease, and increase the speed of recovery of children with SAM. Increasing the rapidity of a child’s recovery from SAM, in addition to immediately benefiting the affected child, has programmatic implications as well. If a child is enrolled in the program for a shorter length of time, there will be less RUTF required for each child’s treatment, lowering the overall treatment cost and enabling the programs to reach more children with SAM.

The study will involve distributing different water treatment devices to parents who bring their children to enroll in ACF’s CMAM program. One group will receive Aquatabs, which purify water by use of chlorine as a disinfectant; another group will receive P&;G Purifier of Water sachets, which treat water through a two-stage coagulation and disinfection process; and a third group will receive ceramic water filters. The research will compare outcomes across these three treatment arms as well as a control arm, considering diarrhea rates and CMAM outcomes among the children enrolled in the study.

The study’s focus areas of undernutrition and WASH-related diseases highlight community needs in Dadu District, which has a high prevalence of acute malnutrition and poor access to safe drinking water. A December 2012 ACF SMART survey estimated prevalence of global acute malnutrition (GAM) and severe acute malnutrition (SAM) in Dadu at 13% and 3.8%, respectively. The same survey showed that 78.8% of children under five had suffered from watery diarrhea in the two weeks preceding the survey, which is indicative of a very high burden of waterborne disease (3).

We are currently in the preparation phase of the project and plan to begin data collection in February 2016.

1. Pelletier DL, Frongillo EA jr, Schroeder DG, Habicht JP. The effects of malnutrition on child mortality in developing countries. Bull World Health Organ 1995; 73(4): 443-8.
2. World Health Organization/World Food Programme/UN Standing Committee on Nutrition/The United Nations Children’s Fund. Community Based Management of Severe Acute Malnutrition (Joint Statement). May, 2007.
3. ACF Report. Integrated SMART Survey. Dadu District, Sindh Province. December 2012.