***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: BACKGROUND Cholera is endemic in Bangladesh with epidemics occurring each year . The decision to use a cheap oral killed whole-cell cholera vaccine to control the disease depends on the feasibility and effectiveness of vaccination when delivered in a public health setting . We therefore assessed the feasibility and protective effect of delivering such a vaccine through routine government services in urban Bangladesh and evaluated the benefit of adding behavioural interventions to encourage safe drinking water and h and washing to vaccination in this setting . METHODS We did this cluster-r and omised open-label trial in Dhaka , Bangladesh . We r and omly assigned 90 clusters ( 1:1:1 ) to vaccination only , vaccination and behavioural change , or no intervention . The primary outcome was overall protective effectiveness , assessed as the risk of severely dehydrating cholera during 2 years after vaccination for all individuals present at time of the second dose . This study is registered with Clinical Trials.gov , number NCT01339845 . FINDINGS Of 268,896 people present at baseline , we analysed 267,270 : 94,675 assigned to vaccination only , 92,539 assigned to vaccination and behavioural change , and 80,056 assigned to non-intervention . Vaccine coverage was 65 % in the vaccination only group and 66 % in the vaccination and behavioural change group . Overall protective effectiveness was 37 % ( 95 % CI lower bound 18 % ; p=0·002 ) in the vaccination group and 45 % ( 95 % CI lower bound 24 % ; p=0·001 ) in the vaccination and behavioural change group . We recorded no vaccine-related serious adverse events . INTERPRETATION Our findings provide the first indication of the effect of delivering an oral killed whole-cell cholera vaccine to poor urban population s with endemic cholera using routine government services and will help policy makers to formulate vaccination strategies to reduce the burden of severely dehydrating cholera in such population s. FUNDING Bill & Melinda Gates Foundation This paper analyzes a r and omized experiment that uses novel strategies to promote h and washing with soap at critical points in time in Peru . It evaluates a large-scale comprehensive initiative that involved both community and school activities in addition to communication campaigns . The analysis indicates that the initiative was successful in reaching the target audience and in increasing the treated population 's knowledge about appropriate h and washing behavior . These improvements translated into higher self-reported and observed h and washing with soap at critical junctures . However , no significant improvements in the health of children under the age of 5 years  were observed . Copyright © 2015 John Wiley & Sons , Summary Background Diarrhoea and growth faltering in early childhood are associated with subsequent adverse outcomes . We aim ed to assess whether water quality , sanitation , and h and washing interventions alone or combined with nutrition interventions reduced diarrhoea or growth faltering . Methods The WASH Benefits Bangladesh cluster-r and omised trial enrolled pregnant women from villages in rural Bangladesh and evaluated outcomes at 1-year and 2-years ' follow-up . Pregnant women in geographically adjacent clusters were block-r and omised to one of seven clusters : chlorinated drinking water ( water ) ; up grade d sanitation ( sanitation ) ; promotion of h and washing with soap ( h and washing ) ; combined water , sanitation , and h and washing ; counselling on appropriate child nutrition plus lipid-based nutrient supplements ( nutrition ) ; combined water , sanitation , h and washing , and nutrition ; and control ( data collection only ) . Primary outcomes were caregiver-reported diarrhoea in the past 7 days among children who were in utero or younger than 3 years at enrolment and length-for-age Z score among children born to enrolled pregnant women . Masking was not possible for data collection , but analyses were masked . Analysis was by intention to treat . This trial is registered at Clinical Trials.gov , number NCC01590095 . Findings Between May 31 , 2012 , and July 7 , 2013 , 5551 pregnant women in 720 clusters were r and omly allocated to one of seven groups . 1382 women were assigned to the control group ; 698 to water ; 696 to sanitation ; 688 to h and washing ; 702 to water , sanitation , and h and washing ; 699 to nutrition ; and 686 to water , sanitation , h and washing , and nutrition .  331 ( 6 % ) women were lost to follow-up . Data on diarrhoea at year 1 or year 2 ( combined ) were available for 14 425 children ( 7331 in year 1 , 7094 in year 2 ) and data on length-for-age Z score in year 2 were available for 4584 children ( 92 % of living children were measured at year 2 ) . All interventions had high adherence . Compared with a prevalence of 5·7 % ( 200 of 3517 child weeks ) in the control group , 7-day diarrhoea prevalence was lower among index children and children under 3 years at enrolment who received sanitation ( 61 [ 3·5 % ] of 1760 ; prevalence ratio 0·61 , 95 % CI 0·46–0·81 ) , h and washing ( 62 [ 3·5 % ] of 1795 ; 0·60 , 0·45–0·80 ) , combined water , sanitation , and h and washing ( 74 [ 3·9 % ] of 1902 ; 0·69 , 0·53–0·90 ) , nutrition ( 62 [ 3·5 % ] of 1766 ; 0·64 , 0·49–0·85 ) , and combined water , sanitation , h and washing , and nutrition ( 66 [ 3·5 % ] of 1861 ; 0·62 , 0·47–0·81 ) ; diarrhoea prevalence was not significantly lower in children receiving water treatment ( 90 [ 4·9 % ] of 1824 ; 0·89 , 0·70–1·13 ) . Compared with control ( mean length-for-age Z score −1·79 ) , children were taller by year 2 in the nutrition group ( mean difference 0·25 [ 95 % CI 0·15–0·36 ] ) and in the combined water , sanitation , h and washing , and nutrition group ( 0·13 [ 0·02–0·24 ] ) . The individual water , sanitation , and h and washing groups , and combined water , sanitation , and h and washing group had no effect on linear growth . Interpretation Nutrient supplementation and counselling  modestly improved linear growth , but there was no benefit to the integration of water , sanitation , and h and washing with nutrition . Adherence was high in all groups and diarrhoea prevalence was reduced in all intervention groups except water treatment . Combined water , sanitation , and h and washing interventions provided no additive benefit over single interventions . Funding Bill & Melinda Gates Foundation BACKGROUND Child malnutrition is an important indicator for monitoring progress towards the Millennium Development Goals ( MDG ) . This paper describes the methodology developed by the World Health Organization ( WHO ) to derive global and regional trends of child stunting and underweight , and reports trends in prevalence and numbers affected for 1990 - 2005 . METHODS National prevalence data from 139 countries were extracted from the WHO Global Data base on Child Growth and Malnutrition . A total of 419 and 388 survey data points were available for underweight and stunting , respectively . To estimate trends we used linear mixed-effect models allowing for r and om effects at country level and for heterogeneous covariance structures . One model was fitted for each United Nation 's region using the logit transform of the prevalence and results back-transformed to the original scale . Best models were selected based on explicit statistical and graphical criteria . RESULTS During 1990 - 2000 global stunting and underweight prevalences declined from 34 % to 27 % and 27 % to 22 % , respectively . Large declines were achieved in Eastern and South-eastern Asia , while South- central Asia continued to suffer very high levels of malnutrition . Substantial improvements were also made in Latin America and the Caribbean , whereas in Africa numbers of stunted and underweight children increased from 40 to 45 , and 25 to 31 million , respectively . CONCLUSION Linear mixed-effect models made best use of all available information . Trends are uneven across regions , with some showing a need for more concerted and efficient interventions to meet the MDG of reducing levels of child malnutrition by half between 1990 and 2015 Background We analyzed data from the baseline assessment of a large intervention project to describe typical h and washing practice s in rural Bangladesh , and compare measures of h and cleanliness with household characteristics . Methods We r and omly selected 100 villages from 36 districts in rural Bangladesh . Field workers identified 17 eligible households per village using systematic sampling . Field workers conducted 5-hour structured observations in 1000 households , and a cross-sectional assessment in 1692 households that included spot checks , an evaluation of h and cleanliness and a request that residents demonstrate their usual  h and washing practice s after defecation . Results Although 47 % of caregivers reported and 51 % demonstrated washing both h and s with soap  after defecation , in structured observation , only 33 % of caregivers and 14 % of all persons observed washed both h and s with soap after defecation . Less than 1 % used  soap and water  for h and washing  before eating and /or feeding a child . More commonly people washed their h and s only with water , 23 % after defecation and 5 % before eating . Spot checks during the cross sectional survey classified 930 caregivers ( 55 % ) and 453 children ( 28 % ) as having clean appearing h and s. In multivariate analysis economic status and water available at h and washing locations were significantly associated with h and cleanliness among both caregivers and children . Conclusions A minority of rural Bangladeshi residents  washed both h and s with soap  at key h and washing times , though rinsing h and s with only water was more common . To realize the health benefits of h and washing , efforts to improve h and washing in these communities should target adding soap to current h and rinsing practice Summary Background Poor nutrition and exposure to faecal contamination are associated with diarrhoea and growth faltering , both of which have long-term consequences for child health . We aim ed to assess whether water , sanitation , h and washing , and nutrition interventions reduced diarrhoea or growth faltering . Methods The WASH Benefits cluster-r and omised trial enrolled pregnant women from villages in rural Kenya and evaluated outcomes at 1 year and 2 years of follow-up . Geographically-adjacent clusters were block-r and omised to active control ( household visits to measure mid-upper-arm circumference ) , passive control ( data collection only ) , or compound-level interventions including household visits to promote target behaviours : drinking chlorinated water ( water ) ; safe sanitation consisting of disposing faeces in an improved latrine ( sanitation ) ; h and washing with soap ( h and washing ) ; combined water , sanitation , and h and washing ; counselling on appropriate maternal , infant , and young child feeding plus small-quantity lipid-based nutrient supplements from 6–24 months ( nutrition ) ; and combined water , sanitation , h and washing , and nutrition . Primary outcomes were caregiver-reported diarrhoea in the past 7 days and length-for-age Z score at year 2 in index children born to the enrolled pregnant women . Masking was not possible for data collection , but analyses were masked . Analysis was by intention to treat . This trial is registered with Clinical Trials.gov , number NCT01704105 . Findings Between Nov 27 , 2012 , and May 21 , 2014 , 8246 women in 702 clusters were enrolled and r and omly assigned an intervention or control group . 1919 women were assigned to the active control group  ; 938 to passive control ; 904 to water ; 892 to sanitation ; 917 to h and washing ; 912 to combined water , sanitation , and h and washing ; 843 to nutrition ; and 921 to combined water , sanitation , h and washing , and nutrition .  Data on diarrhoea at year 1 or year 2 were available for 6494 children and data on length-for-age Z score in year 2 were available for 6583 children ( 86 % of living children were measured at year 2 ) . Adherence indicators for sanitation , h and washing , and nutrition were more than 70 % at year 1 , h and washing fell to less than 25 % at year 2 , and for water was less than 45 % at year 1 and less than 25 % at year 2 ; combined groups were comparable to single groups . None of the interventions reduced diarrhoea prevalence compared with the active control . Compared with active control ( length-for-age Z score −1·54 ) children in nutrition and combined water , sanitation , h and washing , and nutrition  were taller by year 2 ( mean difference 0·13 [ 95 % CI 0·01 
    Output:
    
Conclusions Many people lack a design ated h and washing facility , but even among those with access , HWWS is poorly practised .
People with access to design ated h and washing facilities are about twice as likely to wash their h and s with soap after potential faecal contact as people who lack a facility .