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Author Notes:

Anna N. Chard Department of Environmental Health, Rollins School of Public Health, Emory University, Atlanta, Georgia, United States of America achard@emory.edu

ANC: data curation, formal analysis, investigation, methodology, project administration, software, supervision, writing - original draft; VT: data curation, investigation, methodology, project administration, supervision, writing - review and editing; DM: investigation, resources, writing - review and editing; HHC: formal analysis, methodology, writing - review and editing; SD: supervision, writing - review and editing; PJL: resource, writing - review and editing; MCF: conceptualization, funding acquisition, methodology, supervision, writing - review and editing.

We would like to thank the parents, students, and teachers who allowed us to conduct this work, as well as the Government of Mali.

We would also like to thank the research team, including Abdoulaye Sow, Seydou Samaké, Salif Ismaïla Traoré, Fatoumata Habib Traoré, Karim Diamoutene, Yacouba Sogore, Alpha Oumar Haidara, as well as Niélé Hawa Diarra and Samba Diop from the University of Bamako.

Thanks as well to the UNICEF, WaterAid, CARE, Oxfam, and Save the Children teams for their support, specifically Jérémie Toubkiss, Yagouba Diallo, Seydou Niafo, Touréba Keïta, Assitan Sogoré, Salimata Togola, Fatoumata Haïdara, Mamadou Diallo, Zoumana Cissé, Ousmane Haïdara, and Thierno Bocoum.

We thank Dr. Tom Nutman for providing the Wb123 antigen and Dr. Jeffrey Chang for providing the dengue and yellow fever antigens.

Use of trade names is for identification only and does not imply endorsement by the Public Health Service or by the U.S. Department of Health and Human Service.

The findings and conclusions in this report are those of the authors and do not necessarily represent the official position of the Centers for Disease Control and Prevention.


Research Funding:

This study was supported by the Dubai Cares Foundation (http://www.dubaicares.ae/en).

Funding was acquired by MCF (no grant number given).

The funders had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript.

The impact of school water, sanitation, and hygiene improvements on infectious disease using serum antibody detection


Journal Title:

PLoS Neglected Tropical Diseases


Volume 12, Number 4


, Pages e0006418-e0006418

Type of Work:

Article | Final Publisher PDF


Background: Evidence from recent studies assessing the impact of school water, sanitation and hygiene (WASH) interventions on child health has been mixed. Self-reports of disease are subject to bias, and few WASH impact evaluations employ objective health measures to assess reductions in disease and exposure to pathogens. We utilized antibody responses from dried blood spots (DBS) to measure the impact of a school WASH intervention on infectious disease among pupils in Mali. Methodology/Principal findings: We randomly selected 21 beneficiary primary schools and their 21 matched comparison schools participating in a matched-control trial of a comprehensive school-based WASH intervention in Mali. DBS were collected from 20 randomly selected pupils in each school (n = 807). We analyzed eluted IgG from the DBS using a Luminex multiplex bead assay to 28 antigens from 17 different pathogens. Factor analysis identified three distinct latent variables representing vector-transmitted disease (driven primarily by dengue), food/water-transmitted enteric disease (driven primarily by Escherichia coli and Vibrio cholerae), and person-to-person transmitted enteric disease (driven primarily by norovirus). Data were analyzed using a linear latent variable model. Antibody evidence of food/water-transmitted enteric disease (change in latent variable mean (β) = -0.24; 95% CI: -0.53, -0.13) and person-to-person transmitted enteric disease (β = -0.17; 95% CI: -0.42, -0.04) was lower among pupils attending beneficiary schools. There was no difference in antibody evidence of vector-transmitted disease (β = 0.11; 95% CI: -0.05, 0.33). Conclusions/Significance: Evidence of enteric disease was lower among pupils attending schools benefitting from school WASH improvements than students attending comparison schools. These findings support results from the parent study, which also found reduced incidence of self-reported diarrhea among pupils of beneficiary schools. DBS collection was feasible in this resource-poor field setting and provided objective evidence of disease at a low cost per antigen analyzed, making it an effective measurement tool for the WASH field.

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This is an Open Access work distributed under the terms of the Creative Commons Universal : Public Domain Dedication License (http://creativecommons.org/publicdomain/zero/1.0/).

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