This trial is active, not recruiting.

Conditions growth; stunting, nutritional, anemia
Treatments standard care, wash, nutrition, wash and nutrition
Sponsor Johns Hopkins Bloomberg School of Public Health
Collaborator Ministry of Health and Child Care, Zimbabwe
Start date November 2012
End date March 2017
Trial size 5272 participants
Trial identifier NCT01824940, IRB00004205, R01HD060338


Globally, stunting affects 26% (165 million) of under-5-year children, underlies 15-17% of their mortality and leads to long-term cognitive deficits, fewer years and poorer performance in school, lower adult economic productivity, and a higher risk that their own children will also be stunted, perpetuating the problem into future generations. Stunting begins antenatally and peaks at 18-24 months of postnatal life, when mean length-for-age Z-score (LAZ) is about -2.0 among children living in Africa and Asia. Improving the diets of young children can reduce stunting, though, at best, only by about one-third. Frequent diarrheal illness has also been implicated. However, the effect of diarrhea on permanent stunting is relatively small, maybe because children grow at "catch-up" rates between illness episodes.

The Sanitation Hygiene Infant Nutrition Efficacy (SHINE) trial is motivated by a 2-part premise:

- A major cause of child stunting and anemia is Environmental Enteric Dysfunction (EED). EED is a subclinical disorder of the small intestine, which is virtually ubiquitous among asymptomatic people living in low-income settings throughout the world. EED is characterized by increased permeability which facilitates microbial translocation into the systemic circulation and triggers chronic immune activation.

- The primary cause of EED is infant ingestion of fecal microbes due to living in conditions of poor quality and quantity of water, sanitation, and hygiene (WASH).

United States No locations recruiting
Other Countries No locations recruiting

Study Design

Allocation randomized
Endpoint classification efficacy study
Intervention model factorial assignment
Masking open label
Primary purpose prevention
(Placebo Comparator)
The Standard of Care interventions are the blanket interventions.
standard care
Standard Care: Exclusive breastfeeding promotion for all infants, birth to 6 months Strengthened PMTCT (prevention of mother to child transmission of HIV) services Strengthened Village Health Worker system
(Active Comparator)
One of two active interventions to be studied in this 2X2 (two by two) Factorial trial: Intervention 1: a package of interventions to improve household sanitation and hygiene (WASH)
WASH: Standard care interventions Provide household ventilated pit latrine, water treatment solution, and monthly liquid soap, two hand-washing facilities and protected infant play space Provide interpersonal communication interventions promoting feces disposal in a latrine, HWWS (hand washing with soap), drinking water treatment, hygienic weaning food preparation, and preventing babies from putting dirt and animal feces in their mouths.
(Active Comparator)
One of two active interventions to be studied in this 2X2 Factorial trial: Intervention 2: a package of interventions to improve infant and young child feeding (IYCF)
IYCF: Standard care interventions Provide 20 g/d Nutributter from 6-18 months Provide interpersonal communication interventions promoting optimal use of locally available foods for complementary feeding after 6 months, continued breastfeeding and feeding during illness.
(Active Comparator)
This arm receives a combination of all standard care interventions, all WASH and all IYCF interventions.
wash and nutrition
Sanitation/Hygiene AND Nutrition: Standard care interventions All WASH interventions All IYCF interventions

Primary Outcomes

Infant length at 18 months
time frame: 18 months of age
Infant hemoglobin at 18 months
time frame: 18 months

Secondary Outcomes

Infant environmental enteric dysfunction
time frame: 1, 3, 6, 12 and 18 months of age
Infant weight, mid-upper arm circumference and head circumference
time frame: At 18 months, and (with length) at intermediate time-points of 1, 3, 6 and 12 months
To describe the Program Impact Pathways (PIP) linking implementation of each randomized intervention (WASH and IYCF) with length and hemoglobin concentrations
time frame: Throughout follow-up
Exclusive breastfeeding
time frame: First 6 months of life
To evaluate the effect of the IYCF intervention on uptake of improved infant feeding practices by maternal/infant HIV status
time frame: 6-18 months of age
To evaluate the effect of the WASH intervention on the 5 key behaviors it promotes by maternal/infant HIV status
time frame: Throughout follow-up
Relative contributions of diarrhea vs EED
time frame: Birth to 18 months
To measure the strength of association between other potential causes of stunting and anemia (other than poor WASH or IYCF) with linear growth and hemoglobin
time frame: Throughout follow-up
Infant diarrhea prevalence, incidence and severity
time frame: 1 month to 18 months of age

Eligibility Criteria

Female participants from 15 years up to 49 years old.

Study participants will be women who are rural residents of Chirumanzu or Shurugwi districts in Zimbabwe and who become pregnant during the enrollment period of the trial and are identified and consent to participation during pregnancy, and their live born infants. A total of 5272 women will be enrolled. Inclusion Criteria: Women residing in the study districts under monthly prospective pregnancy surveillance of a Village Health Worker, who have a negative pregnancy test followed by a positive pregnancy test. Exclusion Criteria: - Women residing in the study districts who were already pregnant when trial recruitment begins - Women residing in the study districts who become pregnant during the enrollment period but do not consent to join the trial - Women who reside in urban areas of these two districts - Infants with major non-fatal abnormalities will not be excluded from study procedures, but will be excluded from the final analytic sample if the abnormality is likely to directly affect gut health/function or stature (e.g. neural tube defects, cerebral palsy, Down syndrome)

Additional Information

Official title Sanitation, Hygiene, Infant Nutrition Efficacy Project
Principal investigator Jean H Humphrey, ScD
Description The Sanitation Hygiene Infant Nutrition Efficacy ("SHINE") trial will test the effects of two packages of interventions: 1) improved water, sanitation and hygiene (WASH) and 2) improved infant and young child feeding (IYCF) on child stunting and anemia in the first 18 months of life. The trial will be conducted in rural Zimbabwe where WASH is poor, food insecurity high, and where about 15% of pregnant women are infected with HIV. The study will enroll 5270 women early in pregnancy and follow them and their infants until 18 months after delivery. The study will be a cluster-randomized controlled trial: two entire districts in central Zimbabwe have been divided into 212 geographic areas, each of about 100 households. The areas will be randomly allocated (that is, assigned by according to chance like the flip of a coin) to one of four interventions: 1. Improved WASH (a ventilated pit latrine, hand washing facilities with soap, drinking water treatment, a protected play space and health lessons to adopt improved hygiene behaviors) 2. Improved Infant Nutrition (health lessons on best infant feeding practices and a nutritional supplement (Nutributter) to be fed daily to babies from 6 to 18 months). 3. Improved WASH and Infant Nutrition (both interventions) 4. Standard of Care All women living in the two districts who become pregnant during the recruitment period of the study will be invited to enroll. They will receive one of the 4 packages of interventions according to the area where they live. Health lessons will be given by Village Health Workers. Latrines and hand washing facilities will be constructed by building teams. Mothers will be followed up by research nurses at 7 months gestation, and at 1, 3, 6, 12, and 18 months after delivery. Primary outcomes are infant height and hemoglobin at 18 months of age. Within SHINE we will measure two causal pathways: the biomedical pathway and the program impact pathway. The biomedical pathway comprises the infant biologic responses to the WASH and IYCF interventions that ultimately result in attained stature and hemoglobin concentration at 18 months of age; it will be elucidated by measuring biomarkers of intestinal structure and function (inflammation, regeneration, absorption and permeability); microbial translocation; systemic inflammation; and hormonal determinants of growth and anemia among a subgroup of infants enrolled in an EED substudy. The investigators will also ask these mothers to record daily any episodes of diarrhea; blood/mucus in the stool; cough; fast or difficult breathing; fever; and lethargy preventing breastfeeding, that the child has between 1 month and 18 months of age. A subgroup of infants will also have stool samples collected during diarrhoeal episodes to evaluate reductions in pathogen-specific diarrhoea following WASH interventions. Since the mothers enrolled in SHINE will have lived in unsanitary living conditions throughout their lives, it is anticipated that most will have some degree of EED themselves. It is hypothesized that resulting chronic inflammation contributes to adverse birth outcomes, such as prematurity and low birth weight. This question will be investigated through an observational design. For all mothers enrolled in SHINE, the sugar absorption test described above will be conducted and specimens of saliva, stool and blood collected and archived at the 10-12 week gestation visit for subsequent assessment of EED biomarkers. The association of severity of EED with risk of adverse birth outcomes (low birth length and weight; miscarriage, stillbirth, and premature delivery) will be assessed. The program impact pathway comprises the series of processes and behaviors linking implementation of the interventions with the two child health outcomes; it will be modeled using measures of fidelity of intervention delivery and household uptake of promoted behaviors and practices. We will also measure a range of household and individual characteristics, social interactions, and maternal capabilities for childcare, which we hypothesize will explain heterogeneity along these pathways.
Trial information was received from ClinicalTrials.gov and was last updated in September 2015.
Information provided to ClinicalTrials.gov by Johns Hopkins Bloomberg School of Public Health.