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Greenhalgh T, MacIntyre CR, Baker MG, Bhattacharjee S, Chughtai AA, Fisman D, Kunasekaran M, Kvalsvig A, Lupton D, Oliver M, Tawfiq E, Ungrin M, Vipond J. Masks and respirators for prevention of respiratory infections: a state of the science review. Clin Microbiol Rev 2024; 37:e0012423. [PMID: 38775460 DOI: 10.1128/cmr.00124-23] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/14/2024] Open
Abstract
SUMMARYThis narrative review and meta-analysis summarizes a broad evidence base on the benefits-and also the practicalities, disbenefits, harms and personal, sociocultural and environmental impacts-of masks and masking. Our synthesis of evidence from over 100 published reviews and selected primary studies, including re-analyzing contested meta-analyses of key clinical trials, produced seven key findings. First, there is strong and consistent evidence for airborne transmission of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) and other respiratory pathogens. Second, masks are, if correctly and consistently worn, effective in reducing transmission of respiratory diseases and show a dose-response effect. Third, respirators are significantly more effective than medical or cloth masks. Fourth, mask mandates are, overall, effective in reducing community transmission of respiratory pathogens. Fifth, masks are important sociocultural symbols; non-adherence to masking is sometimes linked to political and ideological beliefs and to widely circulated mis- or disinformation. Sixth, while there is much evidence that masks are not generally harmful to the general population, masking may be relatively contraindicated in individuals with certain medical conditions, who may require exemption. Furthermore, certain groups (notably D/deaf people) are disadvantaged when others are masked. Finally, there are risks to the environment from single-use masks and respirators. We propose an agenda for future research, including improved characterization of the situations in which masking should be recommended or mandated; attention to comfort and acceptability; generalized and disability-focused communication support in settings where masks are worn; and development and testing of novel materials and designs for improved filtration, breathability, and environmental impact.
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Affiliation(s)
- Trisha Greenhalgh
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, United Kingdom
| | - C Raina MacIntyre
- Biosecurity Program, The Kirby Institute, University of New South Wales, Sydney, Australia
| | - Michael G Baker
- Department of Public Health, University of Otago, Wellington, New Zealand
| | - Shovon Bhattacharjee
- Biosecurity Program, The Kirby Institute, University of New South Wales, Sydney, Australia
- School of Mechanical and Manufacturing Engineering, University of New South Wales, Sydney, Australia
| | - Abrar A Chughtai
- School of Population Health, University of New South Wales, Sydney, Australia
| | - David Fisman
- Dalla Lana School of Public Health, University of Toronto, Toronto, Ontario, Canada
| | - Mohana Kunasekaran
- Biosecurity Program, The Kirby Institute, University of New South Wales, Sydney, Australia
| | - Amanda Kvalsvig
- Department of Public Health, University of Otago, Wellington, New Zealand
| | - Deborah Lupton
- Centre for Social Research in Health and Social Policy Research Centre, Faculty of Arts, Design and Architecture, University of New South Wales, Sydney, Australia
| | - Matt Oliver
- Professional Standards Advocate, Edmonton, Canada
| | - Essa Tawfiq
- Biosecurity Program, The Kirby Institute, University of New South Wales, Sydney, Australia
| | - Mark Ungrin
- Faculty of Veterinary Medicine; Department of Biomedical Engineering, Schulich School of Engineering; Alberta Children's Hospital Research Institute, University of Calgary, Calgary, Alberta, Canada
| | - Joe Vipond
- Department of Emergency Medicine, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
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Hu W, Shi Y, Chen C, Chen Z. Optimal strategic pandemic control: human mobility and travel restriction. MATHEMATICAL BIOSCIENCES AND ENGINEERING : MBE 2021; 18:9525-9562. [PMID: 34814357 DOI: 10.3934/mbe.2021468] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/13/2023]
Abstract
This paper presents a model for finding optimal pandemic control policy considering cross-region human mobility. We extend the baseline susceptible-infectious-recovered (SIR) epidemiology model by including the net human mobility from a severely-impacted region to a mildly-affected region. The strategic optimal mitigation policy combining testing and lockdown in each region is then obtained with the goal of minimizing economic cost under the constraint of limited resources. We parametrize the model using the data of the COVID-19 pandemic and show that the optimal response strategy and mitigation outcome greatly rely on the mitigation duration, available resources, and cross-region human mobility. Furthermore, we discuss the economic impact of travel restriction policies through a quantitative analysis.
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Affiliation(s)
- Wentao Hu
- Institute for Financial Studies and School of Mathematics, Shandong University, Shandanan Road, Jinan 250100, China
| | - Yufeng Shi
- Institute for Financial Studies and School of Mathematics, Shandong University, Shandanan Road, Jinan 250100, China
- Shandong Big Data Research Association, Jinan 250100, China
| | - Cuixia Chen
- Hebei Finance University, Baoding City, Hebei 071051, China
| | - Ze Chen
- School of Finance, Renmin University of China, Beijing 100872, China
- China Insurance Institute, Renmin University of China, Beijing 100872, China
- China Financial Policy Research Center, Renmin University of China, Beijing 100872, China
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Skarp JE, Downey LE, Ohrnberger JWE, Cilloni L, Hogan AB, Sykes AL, Wang SS, Shah HA, Xiao M, Hauck K. A Systematic Review of the Costs Relating to Non-pharmaceutical Interventions Against Infectious Disease Outbreaks. APPLIED HEALTH ECONOMICS AND HEALTH POLICY 2021; 19:673-697. [PMID: 34114184 PMCID: PMC8192223 DOI: 10.1007/s40258-021-00659-z] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Accepted: 04/23/2021] [Indexed: 06/12/2023]
Abstract
BACKGROUND Non-pharmaceutical interventions (NPIs) are the cornerstone of infectious disease outbreak response in the absence of effective pharmaceutical interventions. Outbreak strategies often involve combinations of NPIs that may change according to disease prevalence and population response. Little is known with regard to how costly each NPI is to implement. This information is essential to inform policy decisions for outbreak response. OBJECTIVE To address this gap in existing literature, we conducted a systematic review on outbreak costings and simulation studies related to a number of NPI strategies, including isolating infected individuals, contact tracing and quarantine, and school closures. METHODS Our search covered the MEDLINE and EMBASE databases, studies published between 1990 and 24 March 2020 were included. We included studies containing cost data for our NPIs of interest in pandemic, epidemic, and outbreak response scenarios. RESULTS We identified 61 relevant studies. There was substantial heterogeneity in the cost components recorded for NPIs in outbreak costing studies. The direct costs of NPIs for which costing studies existed also ranged widely: isolating infected individuals per case: US$141.18 to US$1042.68 (2020 values), tracing and quarantine of contacts per contact: US$40.73 to US$93.59, social distancing: US$33.76 to US$167.92, personal protection and hygiene: US$0.15 to US$895.60. CONCLUSION While there are gaps and heterogeneity in available cost data, the findings of this review and the collated cost database serve as an important resource for evidence-based decision-making for estimating costs pertaining to NPI implementation in future outbreak response policies.
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Affiliation(s)
- Janetta E Skarp
- Imperial College London, MRC Centre for Global Infectious Disease Analysis, Abdul Latif Jameel Institute for Disease and Emergency Analytics (J-IDEA), London, UK.
| | - Laura E Downey
- Imperial College London, MRC Centre for Global Infectious Disease Analysis, Abdul Latif Jameel Institute for Disease and Emergency Analytics (J-IDEA), London, UK
- The George Institute for Global Health, School of Public Health, Imperial College London, London, UK
| | - Julius W E Ohrnberger
- Imperial College London, MRC Centre for Global Infectious Disease Analysis, Abdul Latif Jameel Institute for Disease and Emergency Analytics (J-IDEA), London, UK
| | - Lucia Cilloni
- Imperial College London, MRC Centre for Global Infectious Disease Analysis, Abdul Latif Jameel Institute for Disease and Emergency Analytics (J-IDEA), London, UK
| | - Alexandra B Hogan
- Imperial College London, MRC Centre for Global Infectious Disease Analysis, Abdul Latif Jameel Institute for Disease and Emergency Analytics (J-IDEA), London, UK
| | - Abagael L Sykes
- Imperial College London, MRC Centre for Global Infectious Disease Analysis, Abdul Latif Jameel Institute for Disease and Emergency Analytics (J-IDEA), London, UK
| | - Susannah S Wang
- Imperial College London, MRC Centre for Global Infectious Disease Analysis, Abdul Latif Jameel Institute for Disease and Emergency Analytics (J-IDEA), London, UK
| | - Hiral Anil Shah
- Imperial College London, MRC Centre for Global Infectious Disease Analysis, Abdul Latif Jameel Institute for Disease and Emergency Analytics (J-IDEA), London, UK
| | - Mimi Xiao
- Imperial College London, MRC Centre for Global Infectious Disease Analysis, Abdul Latif Jameel Institute for Disease and Emergency Analytics (J-IDEA), London, UK
| | - Katharina Hauck
- Imperial College London, MRC Centre for Global Infectious Disease Analysis, Abdul Latif Jameel Institute for Disease and Emergency Analytics (J-IDEA), London, UK
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Wang F, Wei J, Shi X. Compliance with recommended protective actions during an H7N9 emergency: a risk perception perspective. DISASTERS 2018; 42:207-232. [PMID: 28799670 DOI: 10.1111/disa.12240] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/07/2023]
Abstract
This study investigates the factors determining an individual's response to official recommended protective measures, based on the Health Belief Model and the Protective Action Decision Model, to understand the adoption of protective behaviour during an H7N9 (Avian Influenza A) emergency. A public survey involving 1,375 respondents was conducted in Anhui Province, China, during the 2013 H7N9 outbreak to test the research model and hypotheses. The results indicate that protective, stakeholder, and risk perceptions influence positively an individual's willingness to take recommended actions. Protective and stakeholder perceptions also have a positive bearing on lay people's risk perceptions. A stakeholder perception is a vital determinant of a protective perception. More importantly, the effects of protective and stakeholder perceptions on behavioural responses to recommendations are mediated in part by risk perception. These findings can help public health officials to develop messages to encourage members of the population to protect themselves effectively during an influenza crisis.
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Affiliation(s)
- Fei Wang
- Postdoctoral Fellow, School of Management, University of Science and Technology of China, China
| | - Jiuchang Wei
- Professor, School of Management, University of Science and Technology of China, and Research Fellow, Center for Crisis Management Research, School of Public Policy and Management, Tsinghua University, China
| | - Xing Shi
- PhD Candidate, Economics Business School, University of Western Australia, Australia
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Mukerji S, MacIntyre CR, Seale H, Wang Q, Yang P, Wang X, Newall AT. Cost-effectiveness analysis of N95 respirators and medical masks to protect healthcare workers in China from respiratory infections. BMC Infect Dis 2017; 17:464. [PMID: 28673259 PMCID: PMC5496227 DOI: 10.1186/s12879-017-2564-9] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/10/2016] [Accepted: 06/23/2017] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND There are substantial differences between the costs of medical masks and N95 respirators. Cost-effectiveness analysis is required to assist decision-makers evaluating alternative healthcare worker (HCW) mask/respirator strategies. This study aims to compare the cost-effectiveness of N95 respirators and medical masks for protecting HCWs in Beijing, China. METHODS We developed a cost-effectiveness analysis model utilising efficacy and resource use data from two cluster randomised clinical trials assessing various mask/respirator strategies conducted in HCWs in Level 2 and 3 Beijing hospitals for the 2008-09 and 2009-10 influenza seasons. The main outcome measure was the incremental cost-effectiveness ratio (ICER) per clinical respiratory illness (CRI) case prevented. We used a societal perspective which included intervention costs, the healthcare costs of CRI in HCWs and absenteeism costs. RESULTS The incremental cost to prevent a CRI case with continuous use of N95 respirators when compared to medical masks ranged from US $490-$1230 (approx. 3000-7600 RMB). One-way sensitivity analysis indicated that the CRI attack rate and intervention effectiveness had the greatest impact on cost-effectiveness. CONCLUSIONS The determination of cost-effectiveness for mask/respirator strategies will depend on the willingness to pay to prevent a CRI case in a HCW, which will vary between countries. In the case of a highly pathogenic pandemic, respirator use in HCWs would likely be a cost-effective intervention.
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Affiliation(s)
- Shohini Mukerji
- School of Public Health and Community Medicine, The University of New South Wales, Sydney, NSW 2052 Australia
| | - C. Raina MacIntyre
- School of Public Health and Community Medicine, The University of New South Wales, Sydney, NSW 2052 Australia
- National Centre for Immunisation Research and Surveillance of Vaccine Preventable Diseases (NCIRS), University of Sydney, Westmead, NSW Australia
| | - Holly Seale
- School of Public Health and Community Medicine, The University of New South Wales, Sydney, NSW 2052 Australia
| | - Quanyi Wang
- The Beijing Centre for Disease Control and Prevention, Beijing, China
| | - Peng Yang
- The Beijing Centre for Disease Control and Prevention, Beijing, China
| | - Xiaoli Wang
- The Beijing Centre for Disease Control and Prevention, Beijing, China
| | - Anthony T. Newall
- School of Public Health and Community Medicine, The University of New South Wales, Sydney, NSW 2052 Australia
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Gao X, Wei J, Cowling BJ, Li Y. Potential impact of a ventilation intervention for influenza in the context of a dense indoor contact network in Hong Kong. THE SCIENCE OF THE TOTAL ENVIRONMENT 2016; 569-570:373-381. [PMID: 27351145 DOI: 10.1016/j.scitotenv.2016.06.179] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/05/2016] [Revised: 06/21/2016] [Accepted: 06/21/2016] [Indexed: 05/25/2023]
Abstract
Emerging diseases may spread rapidly through dense and large urban contact networks. We constructed a simple but novel dual-contact network model to account for both airborne contact and close contact of individuals in the densely populated city of Hong Kong. The model was then integrated with an existing epidemiological susceptible-exposed-infectious-recovered (SEIR) model, and we used a revised Wells-Riley model to estimate infection risks by the airborne route and an exponential dose-response model for risks by the contact and droplet routes. A potential outbreak of partially airborne influenza was examined, assuming different proportions of transmission through the airborne route. Our results show that building ventilation can have significant effects in airborne transmission-dominated conditions. Moreover, even when the airborne route only contributes 20% to the total infection risk, increasing the ventilation rate has a strong influence on transmission dynamics, and it also can achieve control effects similar to those of wearing masks for patients, isolation and vaccination.
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Affiliation(s)
- Xiaolei Gao
- Department of Mechanical Engineering, The University of Hong Kong, Pokfulam, Hong Kong, China
| | - Jianjian Wei
- Department of Mechanical Engineering, The University of Hong Kong, Pokfulam, Hong Kong, China.
| | - Benjamin J Cowling
- WHO Collaborating Centre for Infectious Disease Epidemiology and Control, School of Public Health, The University of Hong Kong, Pokfulam, Hong Kong, China
| | - Yuguo Li
- Department of Mechanical Engineering, The University of Hong Kong, Pokfulam, Hong Kong, China
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Paccha B, Jones RM, Gibbs S, Kane MJ, Torremorell M, Neira-Ramirez V, Rabinowitz PM. Modeling risk of occupational zoonotic influenza infection in swine workers. JOURNAL OF OCCUPATIONAL AND ENVIRONMENTAL HYGIENE 2016; 13:577-587. [PMID: 26950677 DOI: 10.1080/15459624.2016.1159688] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/05/2023]
Abstract
Zoonotic transmission of influenza A virus (IAV) between swine and workers in swine production facilities may play a role in the emergence of novel influenza strains with pandemic potential. Guidelines to prevent transmission of influenza to swine workers have been developed but there is a need for evidence-based decision-making about protective measures such as respiratory protection. A mathematical model was applied to estimate the risk of occupational IAV exposure to swine workers by contact and airborne transmission, and to evaluate the use of respirators to reduce transmission. The Markov model was used to simulate the transport and exposure of workers to IAV in a swine facility. A dose-response function was used to estimate the risk of infection. This approach is similar to methods previously used to estimate the risk of infection in human health care settings. This study uses concentration of virus in air from field measurements collected during outbreaks of influenza in commercial swine facilities, and analyzed by polymerase chain reaction. It was found that spending 25 min working in a barn during an influenza outbreak in a swine herd could be sufficient to cause zoonotic infection in a worker. However, this risk estimate was sensitive to estimates of viral infectivity to humans. Wearing an excellent fitting N95 respirator reduced this risk, but with high aerosol levels the predicted risk of infection remained high under certain assumptions. The results of this analysis indicate that under the conditions studied, swine workers are at risk of zoonotic influenza infection. The use of an N95 respirator could reduce such risk. These findings have implications for risk assessment and preventive programs targeting swine workers. The exact level of risk remains uncertain, since our model may have overestimated the viability or infectivity of IAV. Additionally, the potential for partial immunity in swine workers associated with repeated low-dose exposures or from previous infection with other influenza strains was not considered. Further studies should explore these uncertainties.
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Affiliation(s)
- Blanca Paccha
- a Occupational and Environmental Medicine Program , Yale University , New Haven , Connecticut
| | - Rachael M Jones
- b Division of Environmental and Occupational Health Sciences, School of Public Health , University of Illinois at Chicago , Chicago , Illinois
| | - Shawn Gibbs
- c Department of Environmental Health , School of Public Health-Bloomington, Indiana University , Bloomington , Indiana
| | - Michael J Kane
- d Department of Biostatistics , Yale School of Public Health, Yale University , New Haven , Connecticut
| | - Montserrat Torremorell
- e Veterinary Population Medicine Department , College of Veterinary Medicine, University of Minnesota , St. Paul , Minnesota
| | - Victor Neira-Ramirez
- e Veterinary Population Medicine Department , College of Veterinary Medicine, University of Minnesota , St. Paul , Minnesota
| | - Peter M Rabinowitz
- f Department of Environmental and Occupational Health Sciences, Department of Global Health , University of Washington School of Public Health , Seattle , Washington
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Mukerji S, MacIntyre CR, Newall AT. Review of economic evaluations of mask and respirator use for protection against respiratory infection transmission. BMC Infect Dis 2015; 15:413. [PMID: 26462473 PMCID: PMC4605092 DOI: 10.1186/s12879-015-1167-6] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/05/2015] [Accepted: 09/30/2015] [Indexed: 11/29/2022] Open
Abstract
BACKGROUND There has been increasing debate surrounding mask and respirator interventions to control respiratory infection transmission in both healthcare and community settings. As decision makers are considering the recommendations they should evaluate how to provide the most efficient protection strategies with minimum costs. The aim of this review is to identify and evaluate the existing economic evaluation literature in this area and to offer advice on how future evaluations on this topic should be conducted. METHODS We searched the Scopus database for all literature on economic evaluation of mask or respirator use to control respiratory infection transmission. Reference lists from the identified studies were also manually searched. Seven studies met our inclusion criteria from the initial 806 studies identified by the search strategy and our manual search. RESULTS Five studies considered interventions for seasonal and/or pandemic influenza, with one also considering SARS (Severe Acute Respiratory Syndrome). The other two studies focussed on tuberculosis transmission control interventions. The settings and methodologies of the studies varied greatly. No low-middle income settings were identified. Only one of the reviewed studies cited clinical evidence to inform their mask/respirator intervention effectiveness parameters. Mask and respirator interventions were generally reported by the study authors to be cost saving or cost-effective when compared to no intervention or other control measures, however the evaluations had important limitations. CONCLUSIONS Given the large cost differential between masks and respirators, there is a need for more comprehensive economic evaluations to compare the relative costs and benefits of these interventions in situations and settings where alternative options are potentially applicable. There are at present insufficient well conducted cost-effectiveness studies to inform decision-makers on the value for money of alternative mask/respirator options.
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Affiliation(s)
- Shohini Mukerji
- School of Public Health and Community Medicine, Faculty of Medicine, University of New South Wales, Sydney, NSW, Australia.
| | - C Raina MacIntyre
- School of Public Health and Community Medicine, Faculty of Medicine, University of New South Wales, Sydney, NSW, Australia.
| | - Anthony T Newall
- School of Public Health and Community Medicine, Faculty of Medicine, University of New South Wales, Sydney, NSW, Australia.
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Julian TR, Pickering AJ. A Pilot Study on Integrating Videography and Environmental Microbial Sampling to Model Fecal Bacterial Exposures in Peri-Urban Tanzania. PLoS One 2015; 10:e0136158. [PMID: 26295964 PMCID: PMC4546663 DOI: 10.1371/journal.pone.0136158] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/27/2014] [Accepted: 07/31/2015] [Indexed: 11/19/2022] Open
Abstract
Diarrheal diseases are a leading cause of under-five mortality and morbidity in sub-Saharan Africa. Quantitative exposure modeling provides opportunities to investigate the relative importance of fecal-oral transmission routes (e.g. hands, water, food) responsible for diarrheal disease. Modeling, however, requires accurate descriptions of individuals' interactions with the environment (i.e., activity data). Such activity data are largely lacking for people in low-income settings. In the present study, we collected activity data and microbiological sampling data to develop a quantitative microbial exposure model for two female caretakers in peri-urban Tanzania. Activity data were combined with microbiological data of contacted surfaces and fomites (e.g. broom handle, soil, clothing) to develop example exposure profiles describing second-by-second estimates of fecal indicator bacteria (E. coli and enterococci) concentrations on the caretaker's hands. The study demonstrates the application and utility of video activity data to quantify exposure factors for people in low-income countries and apply these factors to understand fecal contamination exposure pathways. This study provides both a methodological approach for the design and implementation of larger studies, and preliminary data suggesting contacts with dirt and sand may be important mechanisms of hand contamination. Increasing the scale of activity data collection and modeling to investigate individual-level exposure profiles within target populations for specific exposure scenarios would provide opportunities to identify the relative importance of fecal-oral disease transmission routes.
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Affiliation(s)
- Timothy R. Julian
- Department of Civil and Environmental Engineering, Stanford University, Stanford, CA, United States of America
- * E-mail:
| | - Amy J. Pickering
- Department of Civil and Environmental Engineering, Stanford University, Stanford, CA, United States of America
- Woods Institute for the Environment, Stanford University, Stanford, CA, United States of America
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