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Use of Serologic Responses against Enteropathogens to Assess the Impact of a Point-of-Use Water Filter: A Randomized Controlled Trial in Western Province, Rwanda

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  • 1 Department of Environmental Health, Emory University Rollins School of Public Health, Atlanta, Georgia;
  • | 2 Division of Foodborne, Waterborne and Environmental Diseases, National Center for Zoonotic and Emerging Infectious Diseases, Centers for Disease Control and Prevention, Atlanta, Georgia;
  • | 3 National Reference Laboratory, Rwanda Biomedical Center, Kigali, Rwanda;
  • | 4 OHSU/PSU School of Public Health, Oregon Health and Science University, Portland, Oregon;
  • | 5 Department of Disease Control, London School of Hygiene and Tropical Medicine, London, United Kingdom
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Diarrhea is a leading contributor to childhood morbidity and mortality in sub-Saharan Africa. Given the challenge of blinding most water, sanitation, and hygiene (WASH) interventions, diarrheal disease outcome measures in WASH intervention trials are subject to potential bias and misclassification. Using the platform of a cluster-randomized controlled trial of a household-based drinking water filter in western province, Rwanda, we assessed the impact of the drinking water filter on enteric seroconversion in young children as a health outcome and examined the association between serologic responses and caregiver-reported diarrhea. Among the 2,179 children enrolled in the trial, 189 children 6–12 months of age were enrolled in a nested serology study. These children had their blood drawn at baseline and 6–12 months after the intervention was distributed. Multiplex serologic assays for Giardia, Cryptosporidium, Entamoeba histolytica, norovirus, Campylobacter, enterotoxigenic Escherichia coli and Vibrio cholerae were performed. Despite imperfect uptake, receipt of the water filter was associated with a significant decrease in seroprevalence of IgG directed against Cryptosporidium parvum Cp17 and Cp23 (relative risk [RR]: 0.62, 95% confidence interval [CI]: 0.44–0.89). Serologic responses were positively associated with reported diarrhea in the previous 7 days for both Giardia intestinalis (RR: 1.94, 95% CI: 1.04–3.63) and C. parvum (RR: 2.21, 95% CI: 1.09–4.50). Serologic responses for all antigens generally increased in the follow-up round, rising sharply after 12 months of age. The water filter is associated with reduced serologic responses against C. parvum, a proxy for exposure and infection; therefore, serologic responses against protozoa may be a suitable health outcome measure for WASH trials among children with diarrhea.

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Author Notes

Address correspondence to Laura Divens Zambrano, Department of Environmental Health, Emory University Rollins School of Public Health, 1518 Clifton Road NE, Atlanta, GA 30329. E-mail: laura.zambrano@alumni.emory.edu

Financial support: Funding for this research was provided up front by Delagua Inc., the organization that distributed the intervention. The funding was not contingent upon the delivery of results, nor were any authors employed by Delagua.

Authors’ addresses: Laura Divens Zambrano, Department of Environmental Health, Emory University Rollins School of Public Health, Atlanta, GA, E-mail: laura.zambrano@alumni.emory.edu. Jeffrey W. Priest, Division of Parasitic Diseases and Malaria, Centers for Disease Control and Prevention, Atlanta, GA, E-mail: jip8@cdc.gov. Emil Ivan, National Reference Laboratory, Rwanda Biomedical Center, Kigali, RW, E-mail: emil.ivank@gmail.com. John Rusine, Rwanda Biomedical Center, National Reference Laboratory, Department of Virology, Kigali, RW, E-mail: johnrusine@gmail.com. Corey Nagel, Oregon Health and Science University School of Nursing, Portland, OR, E-mail: nagelc@ohsu.edu. Miles Kirby and Ghislaine Rosa, Department for Disease Control, London School of Hygiene and Tropical Medicine Faculty of Infectious and Tropical Diseases, London, United Kingdom, E-mails: miles.kirby@lshtm.ac.uk and ghislaine.rosa@lshtm.ac.uk. Thomas F. Clasen, Emory University, Rollins School of Public Health, Atlanta, GA, and Department for Disease Control, London School of Hygiene and Tropical Medicine Faculty of Infectious and Tropical Diseases, London, United Kingdom, E-mail: thomas.f.clasen@emory.edu.

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