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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
  1. Joe Brown1,
  2. Oliver Cumming2,
  3. Jamie Bartram3,
  4. Sandy Cairncross2,
  5. Jeroen Ensink2,
  6. David Holcomb3,
  7. Jackie Knee1,
  8. Peter Kolsky3,
  9. Kaida Liang3,
  10. Song Liang4,
  11. Rassul Nala5,
  12. Guy Norman6,
  13. Richard Rheingans4,
  14. Jill Stewart3,
  15. Olimpio Zavale7,
  16. Valentina Zuin8,
  17. Wolf-Peter Schmidt2
  1. 1School of Civil & Environmental Engineering, Georgia Institute of Technology, Atlanta, Georgia, USA
  2. 2Department of Disease Control, London School of Hygiene and Tropical Medicine, London, UK
  3. 3Department of Environmental Sciences and Engineering, Gillings School of Global Public Health, University of North Carolina—Chapel Hill, Chapel Hill, North Carolina, USA
  4. 4Department of Environmental and Global Health, University of Florida, Gainesville, Florida, USA
  5. 5Ministry of Health, Republic of Mozambique, Maputo, Mozambique
  6. 6Water and Sanitation for the Urban Poor, London, UK
  7. 7Health Research for Development, Maputo, Mozambique
  8. 8Emmett Interdisciplinary Program in Environment and Resources, Stanford University, Palo Alto, California, USA
  1. Correspondence to Dr Brown Joe; joe.brown{at}


Introduction 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 and analysis 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.

Ethics 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.

Trial registration number NCT02362932.


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