Study design and rationale for the PAASIM project: a matched cohort study on urban water supply improvements and infant enteric pathogen infection, gut microbiome development and health in Mozambique
Thomas F Clasen,
Matthew C Freeman,
Rassul Nala,
Joe Brown,
Courtney Victor,
Konstantinos T Konstantinidis,
Karen Levy,
Joshua V Garn,
Zaida Adriano Cumbe,
Bacelar Muneme,
Christine S Fagnant-Sperati,
Sydney Hubbard,
Antonio Júnior,
João Luís Manuel,
Magalhães Mangamela,
Sandy McGunegill,
Molly K Miller-Petrie,
Jedidiah S Snyder,
Lance A Waller
Affiliations
Thomas F Clasen
Gangarosa Department of Environmental Health, Rollins School of Public Health, Emory University, Atlanta, Georgia, USA
Matthew C Freeman
Gangarosa Department of Environmental Health, Rollins School of Public Health, Emory University, Atlanta, Georgia, USA
Rassul Nala
Division of Parasitology, Instituto Nacional de Saúde, Maputo, Mozambique
Joe Brown
Department of Environmental Sciences and Engineering, Gillings School of Global Public Health, University of North Carolina, Chapel Hill, North Carolina, USA
Courtney Victor
Gangarosa Department of Environmental Health, Rollins School of Public Health, Emory University, Atlanta, Georgia, USA
Konstantinos T Konstantinidis
School of Civil and Environmental Engineering, Georgia Institute of Technology, Atlanta, Georgia, USA
Karen Levy
Gangarosa Department of Environmental Health, Rollins School of Public Health, Emory University, Atlanta, Georgia, USA
Joshua V Garn
Division of Biostatistics, Epidemiology and Environmental Health, School of Public Health, University of Nevada Reno, Reno, Nevada, USA
Zaida Adriano Cumbe
WE Consult, Maputo, Mozambique
Bacelar Muneme
WE Consult, Maputo, Mozambique
Christine S Fagnant-Sperati
Department of Environmental and Occupational Health Sciences, University of Washington School of Public Health, Seattle, Washington, USA
Sydney Hubbard
Gangarosa Department of Environmental Health, Rollins School of Public Health, Emory University, Atlanta, Georgia, USA
Antonio Júnior
WE Consult, Maputo, Mozambique
João Luís Manuel
Beira Operations Research Center, National Health Institute (INS), Ministry of Health of Mozambique, Beira, Mozambique
Magalhães Mangamela
Autoridade Reguladora de Água, Instituto Público, Maputo, Mozambique
Sandy McGunegill
Gangarosa Department of Environmental Health, Rollins School of Public Health, Emory University, Atlanta, Georgia, USA
Molly K Miller-Petrie
Department of Environmental and Occupational Health Sciences, University of Washington School of Public Health, Seattle, Washington, USA
Jedidiah S Snyder
Gangarosa Department of Environmental Health, Rollins School of Public Health, Emory University, Atlanta, Georgia, USA
Lance A Waller
Department of Biostatistics and Bioinformatics, Rollins School of Public Health, Emory University, Atlanta, Georgia, USA
Introduction Despite clear linkages between provision of clean water and improvements in child health, limited information exists about the health impacts of large water infrastructure improvements in low-income settings. Billions of dollars are spent annually to improve urban water supply, and rigorous evaluation of these improvements, especially targeting informal settlements, is critical to guide policy and investment strategies. Objective measures of infection and exposure to pathogens, and measures of gut function, are needed to understand the effectiveness and impact of water supply improvements.Methods and analysis In the PAASIM study, we examine the impact of water system improvements on acute and chronic health outcomes in children in a low-income urban area of Beira, Mozambique, comprising 62 sub-neighbourhoods and ~26 300 households. This prospective matched cohort study follows 548 mother–child dyads from late pregnancy through 12 months of age. Primary outcomes include measures of enteric pathogen infections, gut microbiome composition and source drinking water microbiological quality, measured at the child’s 12-month visit. Additional outcomes include diarrhoea prevalence, child growth, previous enteric pathogen exposure, child mortality and various measures of water access and quality. Our analyses will compare (1) subjects living in sub-neighbourhoods with the improved water to those living in sub-neighbourhoods without these improvements; and (2) subjects with household water connections on their premises to those without such a connection. This study will provide critical information to understand how to optimise investments for improving child health, filling the information gap about the impact of piped water provision to low-income urban households, using novel gastrointestinal disease outcomes.Ethics and dissemination This study was approved by the Emory University Institutional Review Board and the National Bio-Ethics Committee for Health in Mozambique. The pre-analysis plan is published on the Open Science Framework platform (https://osf.io/4rkn6/). Results will be shared with relevant stakeholders locally, and through publications.
