Three large new trials of unprecedented scale and cost, which included novel factorial designs, have found no effect of basic water, sanitation and hygiene (WASH) interventions on childhood stunting, and only mixed effects on childhood diarrhea. Arriving at the inception of the United Nations’ Sustainable Development Goals, and the bold new target of safely managed water, sanitation and hygiene for all by 2030, these results warrant the attention of researchers, policy-makers and practitioners. Here we report the conclusions of an expert meeting convened by the World Health Organization and the Bill and Melinda Gates Foundation to discuss these findings, and present five key consensus messages as a basis for wider discussion and debate in the WASH and nutrition sectors. We judge these trials to have high internal validity, constituting good evidence that these specific interventions had no effect on childhood linear growth, and mixed effects on childhood diarrhea. These results suggest that, in settings such as these, more comprehensive or ambitious WASH interventions may be needed to achieve a major impact on child health. These results are important because such basic interventions are often deployed in low-income rural settings with the expectation of improving child health, although this is rarely the sole justification. Our view is that these three new trials do not show that WASH in general cannot influence child linear growth, but they do demonstrate that these specific interventions had no influence in settings where stunting remains an important public health challenge. We support a call for transformative WASH, in so much as it encapsulates the guiding principle that – in any context – a comprehensive package of WASH interventions is needed that is tailored to address the local exposure landscape and enteric disease burden.

Climate change represents the most significant challenge of the twenty-first century and poses risks to water and sanitation services. Concerns for water supply include damage to infrastructure from flooding, loss of water sources due to declining rainfall and increasing demand, and changes in the water quality of water sources and within distribution of water. Sanitation concerns include damage and loss of services from floods and reduced carrying capacity of waters receiving wastewater. Key actions to reduce climate risks include the integration of measures of climate resilience into water safety plans, as well as improved accounting and management of water resources. Policy prescriptions on technologies for service delivery and changes in management models offer potential to reduce risks, particularly in low-income settings. Water and sanitation services contribute to greenhouse gas emissions. Choice of wastewater treatment technologies, improved pumping efficiency, use of renewable sources of energy, and within-system generation of energy offer potential for reducing emissions. Overall, greater attention and research are required to understand, plan for, and adapt to climate change in water and sanitation services. As with many other climate change adaptations, the likely benefits from no-regrets solutions are likely to outweigh the costs of investment.

Intermittent water supply (IWS) is prevalent throughout low and middle-income countries. IWS is associated with increased microbial contamination and potentially elevated risk of waterborne illness. We used existing data sets to estimate the population exposed to IWS, assess the probability of infection using quantitative microbial risk assessment, and calculate the subsequent burden of diarrheal disease attributable to consuming fecally contaminated tap water from an IWS. We used reference pathogens Campylobacter, Cryptosporidium, and rotavirus as conservative risk proxies for infections via bacteria, protozoa, and viruses, respectively. Results indicate that the median daily risk of infection is an estimated 1 in 23 500 for Campylobacter, 1 in 5 050 000 for Cryptosporidium, and 1 in 118 000 for rotavirus. Based on these risks, IWS may account for 17.2 million infections causing 4.52 million cases of diarrhea, 109 000 diarrheal DALYs, and 1560 deaths each year. The burden of diarrheal disease associated with IWS likely exceeds the WHO health-based normative guideline for drinking water of 10^–6 DALYs per person per year. Our results underscore the importance water safety management in water supplies and the potential benefits of point-of-use treatment to mitigate risks.

The aim of building climate resilient and environmentally sustainable health care facilities is: (a) to enhance their capacity to protect and improve the health of their target communities in an unstable and changing climate; and (b) to empower them to optimize the use of resources and minimize the release of pollutants and waste into the environment. Such health care facilities contribute to high quality of care and accessibility of services and, by helping reduce facility costs, also ensure better affordability. They are an important component of universal health coverage. Action is needed in at least four areas which are fundamental requirements for providing safe and quality care: having adequate numbers of skilled human resources, with decent working conditions, empowered and informed to respond to these environmental challenges; sustainable and safe management of water, sanitation and health care waste; sustainable energy services; and appropriate infrastructure and technologies, including all the operations that allow for the efficient functioning of a health care facility. Importantly, this work contributes to promoting actions to ensure that health care facilities are constantly and increasingly strengthened and continue to be efficient and responsive to improve health and contribute to reducing inequities and vulnerability within their local settings. To this end, we propose a framework to respond to these challenges.

In the 3rd edition of its Guidelines for Drinking-Water Quality (2004) (GDWQ) the World Health Organization (WHO) promotes the use of risk assessment coupled with risk management for the control of water safety in drinking water supplies. Quantitative microbial risk assessment (QMRA) provides a tool for estimating the disease-burden from pathogenic microorganisms in water using information about the distribution and occurrence of the pathogen or an appropriate surrogate. This information may then be used to inform decisions about appropriate management of the water supply system. Although QMRA has been used to estimate disease burden from water supplies in developed countries, the method has not been evaluated in developing countries where relevant data may be scarce. In this paper, we describe a simplified risk assessment procedure to calculate the disease burden from three reference pathogens – pathogenic Escherichia coli, Cryptosporidium parvum and rotavirus – in water supplies in Kampala, Uganda. The study shows how QMRA can be used in countries with limited data, and that the outcome can provide valuable information for the management of water supplies.