Access to safe drinking-water at home is essential during the outpatient treatment of children with acute malnutrition due to their increased vulnerability to infections and disease. The study aimed to evaluate the effectiveness of ceramic water filters with safe storage in preventing diarrhoea and acute malnutrition among under-five children in Kassala state, Sudan. It was designed as an open-label randomized controlled trial, comparing two study groups. Data was collected through face-to-face interviews and direct observations, then processed and analysed using Epi Info 7.2.0.1. Use of water filters is a potential predictor of number of diarrhoea episodes per child (P < 0.001). The intervention group had a lower diarrhoea occurrence (P < 0.001), better monthly average weight gain (P = 0.012) and average mid-upper arm circumference increase (P = 0.001), and lower prevalence of acute malnutrition at the end of the study (P = 0.001) compared with the control group. Ceramic water filters with safe storage can be effective in preventing diarrhoea and acute malnutrition, and beneficial to children admitted to Community Management of Acute Malnutrition programmes in Kassala state. More research is needed to understand the pathways to achieving these outcomes. Other WASH interventions may be needed to interrupt the primary vectors of diarrhoea disease transmission in this setting.

Altmann, M., Altare, C., van der Spek, N., Barbiche, J.C., Dodos, J., Bechir, M., Ait Aissa, M. and Kolsteren, P. (2018) ‘Effectiveness of a household water, sanitation and hygiene package on an outpatient program for severe acute malnutrition: a pragmatic cluster-randomized controlled trial in Chad’. The American Journal of Tropical Medicine and Hygiene 98(4): 1005–12 <http://dx.doi.org/10.4269/ajtmh.17-0699>.

Central Bureau of Statistics (CBS)/UNICEF Sudan (2016) Sudan: Multiple Indicator Cluster Survey 2014: Key Findings [online], UNICEF and Central Bureau of Statistics (CBS), Khartoum, Sudan <https://reliefweb.int/report/sudan/sudan-multiple-indicator-cluster-survey-2014-key-findings> [accessed 15 December 2019].

Clasen, T., Schmidt, W-P., Rabie, T., Roberts, I. and Cairncross, S. (2007) ‘Interventions to improve water quality for preventing diarrhoea: systematic review and meta-analysis’, BMJ 334(7597): 782 <https://doi.org/10.1136/bmj.39118.489931.BE>.

Clasen, T.F., Alexander, K.T., Sinclair, D., Boisson, S., Peletz, R., Chang, H.H., Majorin, F. and Cairncross, S. (2015) ‘Interventions to improve water quality for preventing diarrhoea’, Cochrane Database of Systematic Reviews 10: CD004794 <http://dx.doi.org/10.1002/14651858.CD004794.pub3>.

Darvesh, N., Das, J.K., Vaivada, T., Gaffey, M.F., Rasanathan, K. and Bhutta, Z.A. (2017) ‘Water, sanitation and hygiene interventions for acute childhood diarrhea: a systematic review to provide estimates for the Lives Saved Tool’, BMC Public Health 17: 776 <http://dx.doi.org/10.1186/s12889-017-4746-1>.

Dewey, K.G. and Mayers, D.R. (2011) ‘Early child growth: how do nutrition and infection interact?’ Maternal and Child Nutrition 7(Suppl 3): 129–42 <http://dx.doi.org/10.1111/j.1740-8709.2011.00357.x>.

Dodos, J., Altare, C., Bechir, M., Myatt, M., Pedro, B., Bellet, F., Lapegue, J., Peeters, J. and Altmann, M. (2018) ‘Individual and household risk factors of severe acute malnutrition among under-five children in Mao, Chad: a matched case-control study’, Archives of Public Health 76: 35 <http://dx.doi.org/10.1186/s13690-018-0281-5>.

Doocy, S., Tappis, H., Villeminot, N., Suk, A., Kumar, D., Fazal, S. and Pietzsch, S. (2018) ‘Point-of-use water treatment improves recovery rates among children with severe acute malnutrition in Pakistan: results from a site-randomized trial’, Public Health Nutrition 21(16): 3080–90 <http://dx.doi.org/10.1017/S1368980018001647>.

El Samani, E.F.Z., Willet, W.C. and Ware, J.H. (1988) ‘Association of malnutrition and diarrhoea in children aged under 5 years: a prospective follow-up study in a rural Sudanese community’, American Journal of Epidemiology 128: 93-105.

Federal Ministry of Health (FMoH) (2014) ‘Regulations of Drinking Water Safety Control, 2014, Republic of Sudan, Federal Ministry of Health, Environmental Health & Food Control Department’, under the Environmental Health Act 2009.

Federal Ministry of Health (FMoH)/Central Bureau of Statistics (2010) Sudan Household Health Survey Second Round 2010: Summary Report [online], ReliefWeb <https://reliefweb.int/report/sudan/sudan-household-and-health-survey-second-round-2010-summary-report> [accessed 15 December 2019].

Fisher, R.A. (1935) ‘The logic of inductive inference (with discussion)’, Journal of the Royal Statistical Society 98: 39–82 <http://dx.doi.org/10.2307/2342435>.

Levy, K. (2015) ‘Does poor water quality cause diarrheal disease?’ The American Journal of Tropical Medicine and Hygiene 93(5): 899–900 <http://dx.doi.org/10.4269/ajtmh.15-0689>.

Nel, E.D. (2010) ‘Diarrhoea and malnutrition’, South African Journal of Clinical Nutrition 23(suppl 1): 15–8 <https://doi.org/10.1080/16070658.2010.11734262>.

Oloruntoba, E.O., Folarin, T.B. and Ayede, A.I. (2014) ‘Hygiene and sanitation risk factors of diarrhoeal disease among under-five children in Ibadan, Nigeria’, African Health Sciences 14(4) <https://doi.org/10.4314/ahs.v14i4.32>.

Prüss-Ustün, A., Bartram, J., Clasen, T., Colford, J.M. Jr, Cumming, O., Curtis, V., Bonjour, S., Dangour, A.D., De France, J., Fewtrell, L., Freeman, M.C., Gordon, B., Hunter, P.R., Johnston, R.B., Mathers, C., Mäusezahl, D., Medlicott, K., Neira, M., Stocks, M., Wolf, J. and Cairncross, S. (2014) ‘Burden of disease from inadequate water, sanitation and hygiene in low- and middle-income settings: a retrospective analysis of data from 145 countries’, Tropical Medicine & International Health 19(8): 894–905 <http://dx.doi.org/10.1111/tmi.12329>.

Schmidt, W.P. and Cairncross, S. (2009) ‘Household water treatment in poor populations: is there enough evidence for scaling up now?’ Environmental Science & Technology 43: 986–92 <http://dx.doi.org/10.1021/es802232w>.

Tshishonga, M. and Gumbo, J.R. (2017) ‘The use of ceramic water filters in improving the microbial quality of drinking water’, paper presented at the 9th International Conference on Advances in Science, Engineering, Technology & Waste Management (ASETWM-17), 27–28 November 2017, Parys, South Africa.

UNICEF (2013) Annual Report 2013 – Sudan [online] <https://www.unicef.org/about/annualreport/files/Sudan_COAR_2013.pdf> [accessed 15 December 2019].

UNICEF/WHO/World Bank Group (2019) Levels and Trends in Child Malnutrition [pdf], UNICEF, New York; WHO, Geneva; World Bank, Washington, DC <https://www.who.int/nutgrowthdb/estimates/en/> [accessed 16 December 2019].

WHO (2011) Guidelines for Drinking-Water Quality, 4th edn [online], WHO, Geneva <https://www.who.int/water_sanitation_health/publications/dwq-guidelines-4/en/> [accessed 19 December 2019].

WHO (2018) ‘Malnutrition – key facts’ [online] <https://www.who.int/news-room/fact-sheets/detail/malnutrition> [accessed 19 December 2019].

WHO/UNICEF/JMP (2017) Progress on Drinking Water, Sanitation and Hygiene: 2017 Update and SDG Baselines [pdf], WHO, Geneva; UNICEF, New York; Join Monitoring Programme, New York <https://www.who.int/water_sanitation_health/publications/jmp-2017/en/> [accessed 19 December 2019].

Wright, J., Gundry, S. and Conroy, R. (2004) ‘Household drinking water in developing countries: a systematic review of microbiological contamination between source and point-of-use’, Tropical Medicine & International Health 9: 106–17 <http://dx.doi.org/10.1046/j.1365-3156.2003.01160.x>.

Zinn, C., Bailey, R., Barkley, N., Walsh, M.R., Hynes, A., Coleman, T., Savic, G., Soltis, K., Primm, S. and Haque, U. (2018) ‘How are water treatment technologies used in developing countries and which are the most effective? An implication to improve global health’, Journal of Public Health and Emergency 2: 25 <http://dx.doi.org/10.21037/jphe.2018.06.02>.

Altmann, M., Altare, C., van der Spek, N., Barbiche, J.C., Dodos, J., Bechir, M., Ait Aissa, M. and Kolsteren, P. (2018) ‘Effectiveness of a household water, sanitation and hygiene package on an outpatient program for severe acute malnutrition: a pragmatic cluster-randomized controlled trial in Chad’. The American Journal of Tropical Medicine and Hygiene 98(4): 1005–12 <http://dx.doi.org/10.4269/ajtmh.17-0699>.

Central Bureau of Statistics (CBS)/UNICEF Sudan (2016) Sudan: Multiple Indicator Cluster Survey 2014: Key Findings [online], UNICEF and Central Bureau of Statistics (CBS), Khartoum, Sudan <https://reliefweb.int/report/sudan/sudan-multiple-indicator-cluster-survey-2014-key-findings> [accessed 15 December 2019].

Clasen, T., Schmidt, W-P., Rabie, T., Roberts, I. and Cairncross, S. (2007) ‘Interventions to improve water quality for preventing diarrhoea: systematic review and meta-analysis’, BMJ 334(7597): 782 <https://doi.org/10.1136/bmj.39118.489931.BE>.

Clasen, T.F., Alexander, K.T., Sinclair, D., Boisson, S., Peletz, R., Chang, H.H., Majorin, F. and Cairncross, S. (2015) ‘Interventions to improve water quality for preventing diarrhoea’, Cochrane Database of Systematic Reviews 10: CD004794 <http://dx.doi.org/10.1002/14651858.CD004794.pub3>.

Darvesh, N., Das, J.K., Vaivada, T., Gaffey, M.F., Rasanathan, K. and Bhutta, Z.A. (2017) ‘Water, sanitation and hygiene interventions for acute childhood diarrhea: a systematic review to provide estimates for the Lives Saved Tool’, BMC Public Health 17: 776 <http://dx.doi.org/10.1186/s12889-017-4746-1>.

Dewey, K.G. and Mayers, D.R. (2011) ‘Early child growth: how do nutrition and infection interact?’ Maternal and Child Nutrition 7(Suppl 3): 129–42 <http://dx.doi.org/10.1111/j.1740-8709.2011.00357.x>.

Dodos, J., Altare, C., Bechir, M., Myatt, M., Pedro, B., Bellet, F., Lapegue, J., Peeters, J. and Altmann, M. (2018) ‘Individual and household risk factors of severe acute malnutrition among under-five children in Mao, Chad: a matched case-control study’, Archives of Public Health 76: 35 <http://dx.doi.org/10.1186/s13690-018-0281-5>.

Doocy, S., Tappis, H., Villeminot, N., Suk, A., Kumar, D., Fazal, S. and Pietzsch, S. (2018) ‘Point-of-use water treatment improves recovery rates among children with severe acute malnutrition in Pakistan: results from a site-randomized trial’, Public Health Nutrition 21(16): 3080–90 <http://dx.doi.org/10.1017/S1368980018001647>.

El Samani, E.F.Z., Willet, W.C. and Ware, J.H. (1988) ‘Association of malnutrition and diarrhoea in children aged under 5 years: a prospective follow-up study in a rural Sudanese community’, American Journal of Epidemiology 128: 93-105.

Federal Ministry of Health (FMoH) (2014) ‘Regulations of Drinking Water Safety Control, 2014, Republic of Sudan, Federal Ministry of Health, Environmental Health & Food Control Department’, under the Environmental Health Act 2009.

Federal Ministry of Health (FMoH)/Central Bureau of Statistics (2010) Sudan Household Health Survey Second Round 2010: Summary Report [online], ReliefWeb <https://reliefweb.int/report/sudan/sudan-household-and-health-survey-second-round-2010-summary-report> [accessed 15 December 2019].

Fisher, R.A. (1935) ‘The logic of inductive inference (with discussion)’, Journal of the Royal Statistical Society 98: 39–82 <http://dx.doi.org/10.2307/2342435>.

Levy, K. (2015) ‘Does poor water quality cause diarrheal disease?’ The American Journal of Tropical Medicine and Hygiene 93(5): 899–900 <http://dx.doi.org/10.4269/ajtmh.15-0689>.

Nel, E.D. (2010) ‘Diarrhoea and malnutrition’, South African Journal of Clinical Nutrition 23(suppl 1): 15–8 <https://doi.org/10.1080/16070658.2010.11734262>.

Oloruntoba, E.O., Folarin, T.B. and Ayede, A.I. (2014) ‘Hygiene and sanitation risk factors of diarrhoeal disease among under-five children in Ibadan, Nigeria’, African Health Sciences 14(4) <https://doi.org/10.4314/ahs.v14i4.32>.

Prüss-Ustün, A., Bartram, J., Clasen, T., Colford, J.M. Jr, Cumming, O., Curtis, V., Bonjour, S., Dangour, A.D., De France, J., Fewtrell, L., Freeman, M.C., Gordon, B., Hunter, P.R., Johnston, R.B., Mathers, C., Mäusezahl, D., Medlicott, K., Neira, M., Stocks, M., Wolf, J. and Cairncross, S. (2014) ‘Burden of disease from inadequate water, sanitation and hygiene in low- and middle-income settings: a retrospective analysis of data from 145 countries’, Tropical Medicine & International Health 19(8): 894–905 <http://dx.doi.org/10.1111/tmi.12329>.

Schmidt, W.P. and Cairncross, S. (2009) ‘Household water treatment in poor populations: is there enough evidence for scaling up now?’ Environmental Science & Technology 43: 986–92 <http://dx.doi.org/10.1021/es802232w>.

Tshishonga, M. and Gumbo, J.R. (2017) ‘The use of ceramic water filters in improving the microbial quality of drinking water’, paper presented at the 9th International Conference on Advances in Science, Engineering, Technology & Waste Management (ASETWM-17), 27–28 November 2017, Parys, South Africa.

UNICEF (2013) Annual Report 2013 – Sudan [online] <https://www.unicef.org/about/annualreport/files/Sudan_COAR_2013.pdf> [accessed 15 December 2019].

UNICEF/WHO/World Bank Group (2019) Levels and Trends in Child Malnutrition [pdf], UNICEF, New York; WHO, Geneva; World Bank, Washington, DC <https://www.who.int/nutgrowthdb/estimates/en/> [accessed 16 December 2019].

WHO (2011) Guidelines for Drinking-Water Quality, 4th edn [online], WHO, Geneva <https://www.who.int/water_sanitation_health/publications/dwq-guidelines-4/en/> [accessed 19 December 2019].

WHO (2018) ‘Malnutrition – key facts’ [online] <https://www.who.int/news-room/fact-sheets/detail/malnutrition> [accessed 19 December 2019].

WHO/UNICEF/JMP (2017) Progress on Drinking Water, Sanitation and Hygiene: 2017 Update and SDG Baselines [pdf], WHO, Geneva; UNICEF, New York; Join Monitoring Programme, New York <https://www.who.int/water_sanitation_health/publications/jmp-2017/en/> [accessed 19 December 2019].

Wright, J., Gundry, S. and Conroy, R. (2004) ‘Household drinking water in developing countries: a systematic review of microbiological contamination between source and point-of-use’, Tropical Medicine & International Health 9: 106–17 <http://dx.doi.org/10.1046/j.1365-3156.2003.01160.x>.

Zinn, C., Bailey, R., Barkley, N., Walsh, M.R., Hynes, A., Coleman, T., Savic, G., Soltis, K., Primm, S. and Haque, U. (2018) ‘How are water treatment technologies used in developing countries and which are the most effective? An implication to improve global health’, Journal of Public Health and Emergency 2: 25 <http://dx.doi.org/10.21037/jphe.2018.06.02>.

Altmann, M., Altare, C., van der Spek, N., Barbiche, J.C., Dodos, J., Bechir, M., Ait Aissa, M. and Kolsteren, P. (2018) ‘Effectiveness of a household water, sanitation and hygiene package on an outpatient program for severe acute malnutrition: a pragmatic cluster-randomized controlled trial in Chad’. The American Journal of Tropical Medicine and Hygiene 98(4): 1005–12 <http://dx.doi.org/10.4269/ajtmh.17-0699>.

Central Bureau of Statistics (CBS)/UNICEF Sudan (2016) Sudan: Multiple Indicator Cluster Survey 2014: Key Findings [online], UNICEF and Central Bureau of Statistics (CBS), Khartoum, Sudan <https://reliefweb.int/report/sudan/sudan-multiple-indicator-cluster-survey-2014-key-findings> [accessed 15 December 2019].

Clasen, T., Schmidt, W-P., Rabie, T., Roberts, I. and Cairncross, S. (2007) ‘Interventions to improve water quality for preventing diarrhoea: systematic review and meta-analysis’, BMJ 334(7597): 782 <https://doi.org/10.1136/bmj.39118.489931.BE>.

Clasen, T.F., Alexander, K.T., Sinclair, D., Boisson, S., Peletz, R., Chang, H.H., Majorin, F. and Cairncross, S. (2015) ‘Interventions to improve water quality for preventing diarrhoea’, Cochrane Database of Systematic Reviews 10: CD004794 <http://dx.doi.org/10.1002/14651858.CD004794.pub3>.

Darvesh, N., Das, J.K., Vaivada, T., Gaffey, M.F., Rasanathan, K. and Bhutta, Z.A. (2017) ‘Water, sanitation and hygiene interventions for acute childhood diarrhea: a systematic review to provide estimates for the Lives Saved Tool’, BMC Public Health 17: 776 <http://dx.doi.org/10.1186/s12889-017-4746-1>.

Dewey, K.G. and Mayers, D.R. (2011) ‘Early child growth: how do nutrition and infection interact?’ Maternal and Child Nutrition 7(Suppl 3): 129–42 <http://dx.doi.org/10.1111/j.1740-8709.2011.00357.x>.

Dodos, J., Altare, C., Bechir, M., Myatt, M., Pedro, B., Bellet, F., Lapegue, J., Peeters, J. and Altmann, M. (2018) ‘Individual and household risk factors of severe acute malnutrition among under-five children in Mao, Chad: a matched case-control study’, Archives of Public Health 76: 35 <http://dx.doi.org/10.1186/s13690-018-0281-5>.

Doocy, S., Tappis, H., Villeminot, N., Suk, A., Kumar, D., Fazal, S. and Pietzsch, S. (2018) ‘Point-of-use water treatment improves recovery rates among children with severe acute malnutrition in Pakistan: results from a site-randomized trial’, Public Health Nutrition 21(16): 3080–90 <http://dx.doi.org/10.1017/S1368980018001647>.

El Samani, E.F.Z., Willet, W.C. and Ware, J.H. (1988) ‘Association of malnutrition and diarrhoea in children aged under 5 years: a prospective follow-up study in a rural Sudanese community’, American Journal of Epidemiology 128: 93-105.

Federal Ministry of Health (FMoH) (2014) ‘Regulations of Drinking Water Safety Control, 2014, Republic of Sudan, Federal Ministry of Health, Environmental Health & Food Control Department’, under the Environmental Health Act 2009.

Federal Ministry of Health (FMoH)/Central Bureau of Statistics (2010) Sudan Household Health Survey Second Round 2010: Summary Report [online], ReliefWeb <https://reliefweb.int/report/sudan/sudan-household-and-health-survey-second-round-2010-summary-report> [accessed 15 December 2019].

Fisher, R.A. (1935) ‘The logic of inductive inference (with discussion)’, Journal of the Royal Statistical Society 98: 39–82 <http://dx.doi.org/10.2307/2342435>.

Levy, K. (2015) ‘Does poor water quality cause diarrheal disease?’ The American Journal of Tropical Medicine and Hygiene 93(5): 899–900 <http://dx.doi.org/10.4269/ajtmh.15-0689>.

Nel, E.D. (2010) ‘Diarrhoea and malnutrition’, South African Journal of Clinical Nutrition 23(suppl 1): 15–8 <https://doi.org/10.1080/16070658.2010.11734262>.

Oloruntoba, E.O., Folarin, T.B. and Ayede, A.I. (2014) ‘Hygiene and sanitation risk factors of diarrhoeal disease among under-five children in Ibadan, Nigeria’, African Health Sciences 14(4) <https://doi.org/10.4314/ahs.v14i4.32>.

Prüss-Ustün, A., Bartram, J., Clasen, T., Colford, J.M. Jr, Cumming, O., Curtis, V., Bonjour, S., Dangour, A.D., De France, J., Fewtrell, L., Freeman, M.C., Gordon, B., Hunter, P.R., Johnston, R.B., Mathers, C., Mäusezahl, D., Medlicott, K., Neira, M., Stocks, M., Wolf, J. and Cairncross, S. (2014) ‘Burden of disease from inadequate water, sanitation and hygiene in low- and middle-income settings: a retrospective analysis of data from 145 countries’, Tropical Medicine & International Health 19(8): 894–905 <http://dx.doi.org/10.1111/tmi.12329>.

Schmidt, W.P. and Cairncross, S. (2009) ‘Household water treatment in poor populations: is there enough evidence for scaling up now?’ Environmental Science & Technology 43: 986–92 <http://dx.doi.org/10.1021/es802232w>.

Tshishonga, M. and Gumbo, J.R. (2017) ‘The use of ceramic water filters in improving the microbial quality of drinking water’, paper presented at the 9th International Conference on Advances in Science, Engineering, Technology & Waste Management (ASETWM-17), 27–28 November 2017, Parys, South Africa.

UNICEF (2013) Annual Report 2013 – Sudan [online] <https://www.unicef.org/about/annualreport/files/Sudan_COAR_2013.pdf> [accessed 15 December 2019].

UNICEF/WHO/World Bank Group (2019) Levels and Trends in Child Malnutrition [pdf], UNICEF, New York; WHO, Geneva; World Bank, Washington, DC <https://www.who.int/nutgrowthdb/estimates/en/> [accessed 16 December 2019].

WHO (2011) Guidelines for Drinking-Water Quality, 4th edn [online], WHO, Geneva <https://www.who.int/water_sanitation_health/publications/dwq-guidelines-4/en/> [accessed 19 December 2019].

WHO (2018) ‘Malnutrition – key facts’ [online] <https://www.who.int/news-room/fact-sheets/detail/malnutrition> [accessed 19 December 2019].

WHO/UNICEF/JMP (2017) Progress on Drinking Water, Sanitation and Hygiene: 2017 Update and SDG Baselines [pdf], WHO, Geneva; UNICEF, New York; Join Monitoring Programme, New York <https://www.who.int/water_sanitation_health/publications/jmp-2017/en/> [accessed 19 December 2019].

Wright, J., Gundry, S. and Conroy, R. (2004) ‘Household drinking water in developing countries: a systematic review of microbiological contamination between source and point-of-use’, Tropical Medicine & International Health 9: 106–17 <http://dx.doi.org/10.1046/j.1365-3156.2003.01160.x>.

Zinn, C., Bailey, R., Barkley, N., Walsh, M.R., Hynes, A., Coleman, T., Savic, G., Soltis, K., Primm, S. and Haque, U. (2018) ‘How are water treatment technologies used in developing countries and which are the most effective? An implication to improve global health’, Journal of Public Health and Emergency 2: 25 <http://dx.doi.org/10.21037/jphe.2018.06.02>.