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    • Many advocates assert that improved sanitation is a basic

    2019-06-12

    Many advocates assert that improved sanitation is a basic human right. The main justification for this assertion is that sanitation is essential for achievement of health and promotion of human dignity. If the justification for investment in sanitation is a right based on privacy and human dignity, then the weakness of the scientific evidence for health benefits of sanitation programmes is less important. However, a justification based solely on dignity provides little guidance about how to optimise interventions to improve health. With the present state of scientific knowledge, it is unclear whether or not changing a longstanding, culturally acceptable community practice of open defecation in an area some distance from human settlement towards concentrated defecation in a makeshift pit latrine located much closer to the households\' food preparation area actually improves the health of household members. Similarly, whether or not marginal investment to improve latrine quality through the addition of a cement slab improves health is also unclear.
    In this issue of , Delan Devakumar and colleagues report on the follow-up of children aged 8·5 years in southern Nepal whose mothers participated in a randomised controlled trial of multiple micronutrient supplementation during pregnancy. Control mothers received standard doses of iron and folic thymidylate synthase inhibitor supplements. The offspring of mothers in the intervention group had significantly higher birthweights and higher weights and lower systolic blood pressures at age 2·5 years than the offspring of control mothers. However, at age 8·5 years, no difference was detected in weight-for-age, height-for-age, body-mass-index-for-age, and systolic blood pressure. This finding is consistent with those of other studies cited by Devakumar and colleagues in Burkina Faso, China, and Bangladesh. The findings add to the mosaic of evidence on the effectiveness of interventions to prevent child undernutrition. Multiple micronutrient supplements during pregnancy were recommended in \'s Series on maternal and child nutrition in June, 2013, in which a meta-analysis was cited that found that such supplements led to a 12% reduction in intrauterine growth restriction.
    Although rates of syphilis in the USA and Europe have increased slightly in the past decade, the greatest burden of syphilis lies in sub-Saharan Africa and Asia, where nearly 10 million cases occur every year, and more than 36 million people globally harbour the disease. Recent studies have estimated that more than 5% of pregnant women in sub-Saharan Africa are infected with the spirochaete bacterium, , which causes syphilis. is mainly spread by sexual contact and disease begins with a painless genital ulcer. However, if untreated, it can cause influenza-like symptoms, a diffuse maculopapular rash, meningoencephalitis, tabes dorsalis, cardiovascular syphilis, and gummatous disease. In pregnancy, untreated early syphilis results in a stillbirth rate of 25% and is responsible for 14% of neonatal deaths, with an overall perinatal mortality of 40%. More than 40 observational studies and three randomised trials have shown that male circumcision reduces HIV acquisition in men by 50–60%, and long-term follow-up studies show even higher efficacy of male circumcision. The randomised trials also showed that male circumcision decreases the risk of men acquiring genital ulcer disease, herpes simplex virus type 2, and oncogenic high-risk human papillomavirus. Additionally, male circumcision has direct benefits for female partners with reduced transmission rates of high-risk human papillomavirus, bacterial vaginosis, and trichomoniasis. Although the data showing male circumcision reduces viral sexually transmitted infections (STIs) in men are clear, observational studies and randomised trials have had conflicting results about bacterial STIs. Some observational studies have shown that male circumcision reduces syphilis, but others have found no association. A meta-analysis of 13 observational studies estimated that male circumcision significantly decreased syphilis by 33%. However, the two randomised trials that assessed incidence in Rakai, Uganda (adjusted hazard ratio 1·10, 95% CI 0·75–1·65) and Kisumu, Kenya (risk ratio 1·23, 95% CI 0·41–3·65) showed that male circumcision had no effect on acquisition of syphilis.