title: A controlled, before-and-after trial of an urban sanitation intervention to reduce enteric infections in children: research protocol for the Maputo Sanitation (MapSan) study, Mozambique.
abstract: BACKGROUND
  Access to safe sanitation in low-income, informal settlements of Sub-Saharan Africa has not significantly improved since 1990. The combination of a high faecal-related disease burden and inadequate infrastructure suggests that investment in expanding sanitation access in densely populated urban slums can yield important public health gains. No rigorous, controlled intervention studies have evaluated the health effects of decentralised (non-sewerage) sanitation in an informal urban setting, despite the role that such technologies will likely play in scaling up access.
  
  
  METHODS
  We have designed a controlled, before-and-after (CBA) trial to estimate the health impacts of an urban sanitation intervention in informal neighbourhoods of Maputo, Mozambique, including an assessment of whether exposures and health outcomes vary by localised population density. The intervention consists of private pour-flush latrines (to septic tank) shared by multiple households in compounds or household clusters. We will measure objective health outcomes in approximately 760 children (380 children with household access to interventions, 380 matched controls using existing shared private latrines in poor sanitary conditions), at 2 time points: immediately before the intervention and at follow-up after 12 months. The primary outcome is combined prevalence of selected enteric infections among children under 5 years of age. Secondary outcome measures include soil-transmitted helminth (STH) reinfection in children following baseline deworming and prevalence of reported diarrhoeal disease. We will use exposure assessment, faecal source tracking, and microbial transmission modelling to examine whether and how routes of exposure for diarrhoeagenic pathogens and STHs change following introduction of effective sanitation.
  
  
  METHODS
  Study protocols have been reviewed and approved by human subjects review boards at the London School of Hygiene and Tropical Medicine, the Georgia Institute of Technology, the University of North Carolina at Chapel Hill, and the Ministry of Health, Republic of Mozambique.
  
  
  BACKGROUND
  NCT02362932.
authors.affiliation: School of Civil & Environmental Engineering, Georgia Institute of Technology, Atlanta, Georgia, USA.
authors.forename: Joe
authors.initials: J
authors.lastname: Brown
authors.affiliation: Department of Disease Control, London School of Hygiene and Tropical Medicine, London, UK.
authors.forename: Oliver
authors.initials: O
authors.lastname: Cumming
authors.affiliation: Department of Environmental Sciences and Engineering, Gillings School of Global Public Health, University of North Carolina-Chapel Hill, Chapel Hill, North Carolina, USA.
authors.forename: Jamie
authors.initials: J
authors.lastname: Bartram
authors.affiliation: Department of Disease Control, London School of Hygiene and Tropical Medicine, London, UK.
authors.forename: Sandy
authors.initials: S
authors.lastname: Cairncross
authors.affiliation: Department of Disease Control, London School of Hygiene and Tropical Medicine, London, UK.
authors.forename: Jeroen
authors.initials: J
authors.lastname: Ensink
authors.affiliation: Department of Environmental Sciences and Engineering, Gillings School of Global Public Health, University of North Carolina-Chapel Hill, Chapel Hill, North Carolina, USA.
authors.forename: David
authors.initials: D
authors.lastname: Holcomb
authors.affiliation: School of Civil & Environmental Engineering, Georgia Institute of Technology, Atlanta, Georgia, USA.
authors.forename: Jackie
authors.initials: J
authors.lastname: Knee
authors.affiliation: Department of Environmental Sciences and Engineering, Gillings School of Global Public Health, University of North Carolina-Chapel Hill, Chapel Hill, North Carolina, USA.
authors.forename: Peter
authors.initials: P
authors.lastname: Kolsky
authors.affiliation: Department of Environmental Sciences and Engineering, Gillings School of Global Public Health, University of North Carolina-Chapel Hill, Chapel Hill, North Carolina, USA.
authors.forename: Kaida
authors.initials: K
authors.lastname: Liang
authors.affiliation: Department of Environmental and Global Health, University of Florida, Gainesville, Florida, USA.
authors.forename: Song
authors.initials: S
authors.lastname: Liang
authors.affiliation: Ministry of Health, Republic of Mozambique, Maputo, Mozambique.
authors.forename: Rassul
authors.initials: R
authors.lastname: Nala
authors.affiliation: Water and Sanitation for the Urban Poor, London, UK.
authors.forename: Guy
authors.initials: G
authors.lastname: Norman
authors.affiliation: Department of Environmental and Global Health, University of Florida, Gainesville, Florida, USA.
authors.forename: Richard
authors.initials: R
authors.lastname: Rheingans
authors.affiliation: Department of Environmental Sciences and Engineering, Gillings School of Global Public Health, University of North Carolina-Chapel Hill, Chapel Hill, North Carolina, USA.
authors.forename: Jill
authors.initials: J
authors.lastname: Stewart
authors.affiliation: Health Research for Development, Maputo, Mozambique.
authors.forename: Olimpio
authors.initials: O
authors.lastname: Zavale
authors.affiliation: Emmett Interdisciplinary Program in Environment and Resources, Stanford University, Palo Alto, California, USA.
authors.forename: Valentina
authors.initials: V
authors.lastname: Zuin
authors.affiliation: Department of Disease Control, London School of Hygiene and Tropical Medicine, London, UK.
authors.forename: Wolf-Peter
authors.initials: WP
authors.lastname: Schmidt
mesh_terms: D002675:Child, Preschool; D002985:Clinical Protocols; D003967:Diarrhea / Q000453:epidemiology / Q000209:etiology / Q000517:prevention & control*; D005260:Female; D005500:Follow-Up Studies; D006373:Helminthiasis / Q000150:complications / Q000453:epidemiology / Q000517:prevention & control*; D006801:Humans; D007223:Infant; D007231:Infant, Newborn; D008297:Male; D009073:Mozambique / Q000453:epidemiology; D011203:Poverty; D011315:Preventive Medicine / Q000458:organization & administration*; D011634:Public Health; D012499:Sanitation / Q000592:standards*; D012987:Soil / Q000469:parasitology*; D014038:Toilet Facilities / Q000592:standards*; D014505:Urban Population
chemical_list: D012987:Soil
keywords: EPIDEMIOLOGY