Influence of climate and environment on the efficacy of water, sanitation, and handwashing interventions on diarrheal disease in rural Bangladesh: a re-analysis of a randomized control trial


Background: Climate change may influence the effectiveness of environmental interventions. We investigated if climate and environment modified the effect of low-cost, point-of-use water, sanitation, and handwashing (WASH) interventions on diarrhea and predicted intervention effectiveness under climate change scenarios. Methods: We analyzed data from a cluster-randomized trial in rural Bangladesh that measured diarrhea prevalence in children 0-2 years from 2012-2016. We matched remote sensing data on temperature, precipitation, humidity, and surface water to households by location and measurement date. We estimated prevalence ratios (PR) for WASH interventions vs. control stratified by environmental factors using generative additive models and targeted maximum likelihood estimation. We estimated intervention effects under predicted precipitation in the study region in 2050 for climate change scenarios from different Shared Socioeconomic Pathways (SSPs). Findings: WASH interventions more effectively prevented diarrhea under higher levels of total precipitation in the previous week and when there was heavy rain in the previous week (heavy rainfall PR = 0.38, 95% CI 0.23-0.62 vs. no heavy rainfall PR = 0.77, 0.60-0.98). We did not detect substantial effect modification by other environmental variables. WASH intervention effectiveness increased under most climate change scenarios; in a fossil-fueled development scenario (SSP5), the PR was 0.46 (0.44-0.48) compared to 0.67 (0.65-0.68) in the study. Interpretation: WASH interventions had the strongest effect on diarrhea under higher precipitation, and effectiveness may increase under climate change without sustainable development. WASH interventions may improve population resilience to climate-related health risks. Funding: Bill & Melinda Gates Foundation, National Institute of Allergy and Infectious Diseases, National Heart, Lung, And Blood Institute

Competing Interest Statement

The authors have declared no competing interest.

Clinical Trial


Funding Statement

This study was supported by the Gates Foundation (grant number OPPGD759 to the University of California, Berkeley) and the Task Force for Global Health (grant number NTDSC 088G to Innovations for Poverty Action, and grant number NTDSC 089G to the University of California, Berkeley). Research reported in this publication was supported in part by the National Institute of Allergy And Infectious Diseases of the National Institutes of Health under Award Numbers K01AI141616 (PI: Benjamin-Chung) and R01AI166671 (PI: Arnold), the National Heart, Lung, And Blood Institute of the National Institutes of Health under award number T32HL151323 (Nguyen), and a Stanford University School of Medicine Dean's Postdoctoral Fellowship (Grembi). The content is solely the responsibility of the authors and does not necessarily represent the official views of the National Institutes of Health. Jade Benjamin-Chung is a Chan Zuckerberg Biohub Investigator. We also acknowledge the Stanford Research Computing Center for computational resources at the Sherlock high-performance cluster. The funders of the study had no role in study design, data analysis, interpretation, writing of the manuscript, or the decision to submit the manuscript for publication.

Author Declarations

I confirm all relevant ethical guidelines have been followed, and any necessary IRB and/or ethics committee approvals have been obtained.


The details of the IRB/oversight body that provided approval or exemption for the research described are given below:

The original trial protocol was approved by the Ethical Review Committee at The International Centre for Diarrhoeal Disease Research, Bangladesh (PR-11063), the Committee for the Protection of Human Subjects at the University of California, Berkeley (2011-09-3652), and the institutional review board at Stanford University (25863). 

I confirm that all necessary patient/participant consent has been obtained and the appropriate institutional forms have been archived, and that any patient/participant/sample identifiers included were not known to anyone (e.g., hospital staff, patients or participants themselves) outside the research group so cannot be used to identify individuals.


I understand that all clinical trials and any other prospective interventional studies must be registered with an ICMJE-approved registry, such as I confirm that any such study reported in the manuscript has been registered and the trial registration ID is provided (note: if posting a prospective study registered retrospectively, please provide a statement in the trial ID field explaining why the study was not registered in advance).


I have followed all appropriate research reporting guidelines and uploaded the relevant EQUATOR Network research reporting checklist(s) and other pertinent material as supplementary files, if applicable.


Data Availability

Individual participant data and metadata for this study will be made available at the time of publication and posted here: The pre-analysis plan and ancillary results are also available at the same URL. To protect participant privacy, household geocoordinates will not be included in the public dataset.

Comments (0)

No login