• Oliver Cumming, Benjamin F Arnold, Radu Ban, Thomas Clasen, Joanna Esteves Mills, Matthew C Freeman, Bruce Gordon, Raymond Guiteras, Guy Howard, Paul R Hunter, Richard B Johnston, Amy J Pickering, Andrew J Prendergast, Annette Prüss-Ustün, Jan Willem Rosenboom, Dean Spears, Shelly Sundberg, Jennyfer Wolf, Clair Null, Stephen P Luby, Jean H Humphrey, and John M Colford.
• Department of Disease Control, Faculty of Infectious Tropical Disease, London School of Hygiene and Tropical Medicine, London, UK. oliver.cumming@lshtm.ac.uk.
• Bmc Med. 2019 Aug 28; 17 (1): 173.

BackgroundThree large new trials of unprecedented scale and cost, which included novel factorial designs, have found no effect of basic water, sanitation and hygiene (WASH) interventions on childhood stunting, and only mixed effects on childhood diarrhea. Arriving at the inception of the United Nations' Sustainable Development Goals, and the bold new target of safely managed water, sanitation and hygiene for all by 2030, these results warrant the attention of researchers, policy-makers and practitioners.Main BodyHere we report the conclusions of an expert meeting convened by the World Health Organization and the Bill and Melinda Gates Foundation to discuss these findings, and present five key consensus messages as a basis for wider discussion and debate in the WASH and nutrition sectors. We judge these trials to have high internal validity, constituting good evidence that these specific interventions had no effect on childhood linear growth, and mixed effects on childhood diarrhea. These results suggest that, in settings such as these, more comprehensive or ambitious WASH interventions may be needed to achieve a major impact on child health.ConclusionThese results are important because such basic interventions are often deployed in low-income rural settings with the expectation of improving child health, although this is rarely the sole justification. Our view is that these three new trials do not show that WASH in general cannot influence child linear growth, but they do demonstrate that these specific interventions had no influence in settings where stunting remains an important public health challenge. We support a call for transformative WASH, in so much as it encapsulates the guiding principle that - in any context - a comprehensive package of WASH interventions is needed that is tailored to address the local exposure landscape and enteric disease burden.

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