***TASK*** the task is to summarize an input biomedical literature in six sentences 
    ***INPUT*** the input is a biomedical literature 
    ***OUTPUT*** the output is the summary of an input biomedical literature in six sentences 
    ***DOCUMENTATION*** 
    ***EXAMPLES*** 
    Input: The impact of improved water , sanitation , and hygiene ( WASH ) access on mitigating illness is well documented , although impact of school-based WASH on school-aged children has not been rigorously explored . We conducted a cluster-r and omized trial in Nyanza Province , Kenya to assess the impact of a school-based WASH intervention on diarrhoeal disease in primary -school pupils . Two study population s were used : schools with a nearby dry season water source and those without . Pupils attending ' water-available ' schools that received hygiene promotion and water treatment ( HP&WT ) and sanitation improvements showed no difference in period prevalence or duration of illness compared to pupils attending control schools . Those pupils in schools that received only the HP&WT showed similar results . Pupils in ' water-scarce ' schools that received a water-supply improvement , HP&WT and sanitation showed a reduction in diarrhoea incidence and days of illness . Our study revealed mixed results on the impact of improvements to school WASH improvements on pupil diarrhoea Background The SAFE strategy aims to reduce transmission of Chlamydia trachomatis through antibiotics , improved hygiene , and sanitation . We integrated assessment of intestinal parasites into large-scale trachoma impact surveys to determine whether documented environmental improvements promoted by a trachoma program had collateral impact on intestinal parasites . Methodology We surveyed 99 communities for both trachoma and intestinal parasites ( soil-transmitted helminths , Schistosoma mansoni , and intestinal protozoa ) in South Gondar , Ethiopia . One child aged 2–15 years per household was r and omly selected to provide a stool sample of which about 1 g was fixed in sodium acetate-acetic acid-formalin , concentrated with ether , and examined under a microscope by experienced laboratory technicians . Principal Findings A total of 2,338 stool specimens were provided , processed , and linked to survey data from 2,657 r and omly selected children ( 88 % response ) . The zonal-level prevalence of Ascaris lumbricoides , hookworm , and Trichuris trichiura was 9.9 % ( 95 % confidence interval ( CI ) 7.2–12.7 % ) , 9.7 % ( 5.9–13.4 % ) , and 2.6 % ( 1.6–3.7 % ) , respectively . The prevalence of S. mansoni was 2.9 % ( 95 % CI 0.2–5.5 % ) but infection was highly focal ( range by community from 0–52.4 % ) . The prevalence of any of these helminth infections was 24.2 % ( 95 % CI 17.6–30.9 % ) compared to 48.5 % as found in a previous study in 1995 using the Kato-Katz technique . The pathogenic intestinal protozoa Giardia intestinalis and Entamoeba histolytica/E. dispar were found in 23.0 % ( 95 % CI 20.3–25.6 % ) and 11.1 % ( 95 % CI 8.9–13.2 % ) of the surveyed children , respectively . We found statistically significant increases in household latrine ownership , use of an improved water source , access to water , and face washing behavior over the past 7 years . Conclusions Improvements in hygiene and sanitation promoted both by the SAFE strategy for trachoma and health extension program combined with preventive chemotherapy during enhanced outreach services are plausible explanations for the changing patterns of intestinal parasite prevalence . The extent of intestinal protozoa infections suggests poor water quality or unsanitary water collection and storage practice s and warrants targeted intervention Background To control soil-transmitted helminth ( STH ) infections , the World Health Organization recommends school-based deworming programs with a health hygiene education component . The effect of such health hygiene interventions , however , has not been adequately studied . The objective of the present study was to determine the effectiveness of a health hygiene education intervention on the occurrence of STH re-infection four months post-de-worming . Methodology /Principal Findings An open-label pair-matched cluster-r and omized trial was conducted in Grade 5 schoolchildren of 18 primary schools ( 9 intervention and 9 control ) in the Peruvian Amazon . Baseline assessment included interview with a pre-tested question naire and collection of single stool specimens that were examined using the single Kato-Katz thick smear . All schoolchildren were then treated with single-dose albendazole ( 400 mg ) . Schoolchildren in intervention schools then received 1 ) an initial one hour in-class activity on health hygiene and sanitation and 30-minute refresher activities every two weeks over four months ; and 2 ) a half-day workshop for teachers and principals , while children in control schools did not . Four months later , STH infection was re-assessed in all schools by laboratory technologists blinded to intervention status . From April 21–October 20 , 2010 , a total of 1,089 schoolchildren ( 518 and 571 from intervention and control schools , respectively ) participated in this study . Intervention children scored significantly higher on all aspects of a test of STH-related knowledge compared with control children ( aOR = 18·4 ; 95 % CI : 12·7 to 26·6 ) . The intensity of Ascaris lumbricoides infection at follow-up was statistically significantly lower ( by 58 % ) in children in intervention schools compared with children in control schools ( aIRR = 0·42 ; 95 % CI = 0·21 to 0·85 ) . No significant changes in hookworm or Trichuris trichiura intensity were observed . Conclusions / Significance A school-based health hygiene education intervention was effective in increasing STH knowledge and in reducing Ascaris lumbricoides infection . The benefits of school-based periodic deworming programs are likely to be enhanced when a sustained health hygiene education intervention is integrated into school curricula OBJECTIVES Improving school water , sanitation and hygiene ( WASH ) conditions reduces pupil absence and illness . However , these benefits may depend on the conditions of the latrines and availability of consumables . We sought to determine whether a low-cost , policy-relevant , environmental-level latrine cleaning intervention could improve latrine cleanliness , increase its use and reduce absenteeism . METHODS In a three-arm , cluster-r and omized trial we assessed absence via periodical roll-call among 17 564 pupils in 60 schools that had previously received WASH improvements as part of the SWASH+ project .  Latrine conditions and use were also assessed using structured observation . Latrine cleanliness increased significantly during the post-intervention period among schools receiving the latrine cleaning package compared to controls , as did h and washing with soap . We found no difference in latrine use and absence across arms . CONCLUSIONS The additive impact of cleaning may not have been strong enough to impact absence above and beyond reductions attributable to the original WASH infrastructure improvements and basic hygiene education the schools previously received . Improving latrine conditions is important for the dignity and well-being of pupils , and investments and strategies are necessary to ensure that school toilets are clean and pupil-friendly BACKGROUND Community-led total sanitation ( CLTS ) uses participatory approaches to mobilise communities to build their own toilets and stop open defecation . Our aim was to undertake the first r and omised trial of CLTS to assess its effect on child health in Koulikoro , Mali . METHODS We did a cluster-r and omised trial to assess a CLTS programme  implemented by the Government of Mali . The study population included households in rural villages ( clusters ) from the Koulikoro district of Mali ; every household had to have at least one child aged younger than 10 years . Villages were r and omly assigned ( 1:1 ) with a computer-generated sequence by a study investigator to receive CLTS or no programme . Health outcomes included diarrhoea ( primary outcome ) , height for age , weight for age , stunting , and underweight . Outcomes were measured 1·5 years after intervention delivery ( 2 years after enrolment ) among children younger than 5 years . Participants were not masked to intervention assignment . The trial is registered with Clinical Trials.gov , number NCT01900912 . FINDINGS We recruited participants between April 12 , and June 23 , 2011 . We assigned 60 villages ( 2365 households ) to receive the CLTS intervention and 61 villages ( 2167 households ) to the control group . No differences were observed in terms of diarrhoeal prevalence among children in CLTS and control villages ( 706 [ 22 % ] of 3140 CLTS children vs 693 [ 24 % ] of 2872 control children ; prevalence ratio [ PR ] 0·93 , 95 % CI 0·76 - 1·14 ) . Access to private latrines was almost twice as high in intervention villages ( 1373 [ 65 % ] of 2120 vs 661 [ 35 % ] of 1911 households ) and reported open defecation was reduced in female ( 198 [ 9 % ] of 2086 vs 608 [ 33 % ] of 1869 households ) and in male ( 195 [ 10 % ] of 2004 vs 602 [ 33 % ] of 1813 households ) adults . Children in CLTS villages were taller ( 0·18 increase in height-for-age Z score , 95 % CI 0·03 - 0·32 ; 2415 children ) and less likely to be stunted ( 35 % vs 41 % , PR 0·86 , 95 % CI 0·74 - 1·0 ) than children in control villages . 22 % of children were underweight in CLTS compared with 26 % in control villages ( PR 0·88 , 95 % CI 0·71 - 1·08 ) , and the difference in mean weight-for-age Z score was 0·09 ( 95 % CI -0·04 to 0·22 ) between groups . In CLTS villages , younger children at enrolment ( < 2 years ) showed greater improvements in height and weight than older children . INTERPRETATION In villages that received a behavioural sanitation intervention with no monetary subsidies , diarrhoeal prevalence remained similar to control villages . However , access to toilets substantially increased and child growth improved , particularly in children < 2 years . CLTS might have prevented growth faltering through pathways other than reducing diarrhoea . FUNDING Bill & Melinda Gates Foundation In the GRADE approach , r and omized trials start as high- quality evidence and observational studies as low- quality evidence , but both can be rated down if a body of evidence is associated with a high risk of publication bias . Even when individual studies included in best- evidence summaries have a low risk of bias , publication bias can result in substantial overestimates of effect . Authors should suspect publication bias when available evidence comes from a number of small studies , most of which have been commercially funded . A number of approaches based on examination of the pattern of data are available to help assess publication bias . The most popular of these is the funnel plot ; all , however , have substantial limitations . Publication bias is likely frequent , and caution in the face of early results , particularly with small sample size and number of events , is warranted We conducted a cluster-r and omized trial to assess the impact of a school-based water treatment , hygiene , and sanitation program on reducing infection with soil-transmitted helminths ( STHs ) after school-based deworming . We assessed infection with STHs at baseline and then at two follow-up rounds 8 and 10 months after deworming . Forty government primary schools in Nyanza Province , Kenya were r and omly selected and assigned to intervention or control arms . The intervention reduced reinfection prevalence ( odds ratio [ OR ] 0.56 , 95 % confidence interval [ CI ] 0.31 - 1.00 ) and egg count ( rate ratio [ RR ] 0.34 , CI 0.15 - 0.75 ) of Ascaris lumbricoides . We found no evidence of significant intervention effects on the overall prevalence and intensity of Trichuris trichiura , hookworm , or Schistosoma mansoni reinfection . Provision of school-based sanitation , water quality , and hygiene improvements may reduce reinfection of STHs after school-based deworming , but the magnitude of the effects may be sex- and helminth species-specific Introduction The Tanzania government , working in partnership with other stakeholders implemented a community-based project aim ed at increasing access to clean and safe water basic sanitation and promotion of personal hygiene in Mtwara Rural District . Mid-term evaluation revealed that progress had been made towards improved ventilated latrines ; however , there was no adequate information on utilisation of these latrines and associated factors . This study was therefore conducted to establish the factors influencing the utilisation of these latrines . Methods A cross-sectional study was conducted among 375 r and omly selected households using a pre-tested question naire to determine whether the households owned improved ventilated latrines and how they utilised them . Resuls About half ( 50.5 % ) of the households had an  improved ventilated latrine  and households with earnings of more than 50,000 Tanzanian Shillings  were two times more likely to own an improved latrine than those that earned less ( AOR 2.1 , 95 % CI=1.1 - 4.0 , p= 0.034 ) . The likelihood of owning an improved latrine was reduced by more than 60 percent for female-headed households ( AOR=0.38 ; 95 % CI=0.2 
    Output:
    
Conclusions Our results indicate that most sanitation interventions only had a modest impact on increasing latrine coverage and use .