Water, sanitation, hygiene and enteric infections in children

Correlating Cases of Soil-Transmitted Helminths and Remote Sensing Covariates: A Case Study Utilizing 2015, 2017, and 2019 Metadata of Camarines Sur, Philippines

INTRODUCTION

Soil-transmitted helminth (STH) is a group of helminths that are considered to be neglected tropical diseases (NTDs) and, globally, affect more than 1.5 to 2.6 million people yearly. Depending on the species, they can be acquired by ingesting embryonated eggs from contaminated matter or by skin penetration. Most species of STH are found in the tropics, such as the Philippines. Despite the Mass Drug Administration (MDA), the cases of STH infection continue to rise in the country. Surveys from the Research Institute of Tropical Medicine (RITM) indicate that a high prevalence of STH (Ascaris lumbricoides, Trichuris trichiura, and Necator americanus) was primarily observed in the provinces of the country, such as in Camarines Sur.

OBJECTIVES

To correlate remote sensing covariates such as Normalized Difference Vegetation Index (NDVI) and Normalized Difference Built-up Index (NDBI) - to STH-infected cases of the 37 municipalities of Camarines Sur.

METHODOLOGY

The available public health record of STH cases from 2015 to 2019 were calculated using the Quantum Geographic Information System (QGIS)and correlated using Pearson Correlation Coefficient.

RESULTS

The results showed that infection was higher in children than adults, and A. lumbricoides caused 60% of infection. No correlation of indices with infection cases during 2015 and 2017 was observed; however, 2019 showed a moderate strength (p = 0.037) in correlation.

CONCLUSION

This indicates that infection relied not mainly on vegetation and urbanization but on additional environmental factors and non-environmental variables.

Response of soil microbial community structure and function to the sewage leakage: A case study of a 25-year-old cesspool

Providing many millions of rural households with decentralized sanitation facilities remains challenging. In undeveloped areas, cesspools have still been widely used due to technologically simple and low-cost. However, the influence of cesspools on the surrounding soil remains unclear. In this study, we investigated the influence of a 25-year-old household cesspool on soil physicochemical factors, microbial community composition and function, pathogens and antibiotic resistance genes (ARGs). Soil at the depth around the sewage liquid level (D70) was mostly disturbed where TOC, NO3-N and TP was increased to 16.8 g/kg, 18.2 mg/kg and 1.02 mg/kg respectively. Correspondingly, the element cycling genes of carbon fixation, methanotrophy, nitrogen fixation, ammonia oxidation, and nitrate reduction etc., were increased at D70. Notably, human derived pathogens such as Enterobacter, Salmonella, Pseudomonas aeruginosa, Klebsiella pneumoniae, Prevotella, and Vibrio were highly enriched by 5-10 folders in D70, indicating the potential health risk to human. Mantel tests suggested that EC, TP, pH, NH3-N and particularly NO3-N are important factors that influence the microbial community and element cycling genes in cesspool-affected soil. Overall, this study revealed the impact of household cesspool leakage on the surrounding soil and provided information for the selection and construction of basic sanitation facilities in poor regions.

Individual and community level factors of safe child feces disposal among youngest children in East Africa: a multilevel modeling analysis using recent national demography and health survey data

BACKGROUND

The Joint Monitoring Program (JMP) for water supply and sanitation developed by the WHO and UNICEF defines safe child feces disposal practices as either burial or defecation into a toilet. Children become exposed to fecal-oral illnesses when their stools are not disposed of appropriately, and this vulnerability persists until all children's stools are properly disposed of. Data on the elements influencing child feces disposal in East Africa is scarce. Hence, this study aimed to assess the prevalence and associated factors of safe child feces disposal in East Africa.

METHODS

Data from the Demographic and Health Surveys, which were collected between 2015 and 2022 in 10 East African nations, were used in this analysis. For a weighted 44,821 children under the age of two, we examined additional features as well as how child feces were disposed of. Both bivariable and multivariable multilevel logistic regression were carried out to choose potential components and identify important explanatory variables connected to the outcome variable. With 95% confidence intervals, adjusted odd ratios (AORs) were used to present the results. P values of ≤ 0.2 and < 0.05 were used to investigate significant factors in the binary and multivariable multilevel logistic regression models respectively.

RESULTS

Approximately 65.54% (95% CI: 65.10, 65.98) of children's waste was disposed of properly. Women age from 35 to 49 years (AOR = 1.12, 95% CI: 1.05-1.19) 15-24 years old, primary (AOR = 1.62, 95% CI, 1.53,1.72), and secondary/higher education (AOR = 1.22, 95% CI, 1.14,1.31), women from highly educated community (AOR = 1.33, 95% CI, 1.22,1.46), employed (AOR = 1.29, 95% CI, 1.24,1.35), poorer(AOR = 1.51,95% CI, 1.42,1.61), middle(AOR = 1.67, 95% CI, 1.56,1.78), richer(AOR = 1.96,95% CI, 1.82,2.11), and richest(AOR = 2.08, 95% CI, 1.91,2.27), mass media exposure (AOR = 1.37,95% CI,1.31,1.44), community level mass media exposure (AOR = 1.23, 95% CI, 1.34,1.34), had ANC visit(AOR = 1.71, 95% CI, 1.55,1.88), modern contraceptive(AOR = 1.17, 95% CI, 1.12,1.23), health institution delivery (AOR = 2.22, 95% CI, 2.09,2.34), had an improved toilet facility (AOR = 1.12, 95% CI, 1.07,1.17), children who's their age group from 6 to 11 months old, (AOR = 2.12, 95% CI, 2.01,2.25) and 12-23 months old (AOR = 3.10,95% CI, 2.94,3.27) were the factors associated with higher odds of safe child feces disposal as compared to less than six months old children respectively. Finally, women from high community poverty level (AOR = 0.87, 95% CI, 0.79,0.95), and rural women were the factors associated with lower odds of safe child feces disposal (AOR = 0.91, 95% CI 0.85-0.98) compared to their counterparts respectively.

CONCLUSIONS

East Africa has a Slightly lower proportion of properly disposing of child feces. There was a strong correlation between characteristics such as residence, mother's age, education level, work status, place of delivery, ANC visit, child's age, wealth index, media exposure, and poverty. Acting on these factors and strengthening and using links between mother and child health care is, thus, strongly advocated.

Prevalence of Open Defecation Practice and Associated Factors Among Households in Geshiyaro Project Implementation Sites in Ethiopia: A Cross-Sectional Study

Background

Open defecation is a significant global challenge, impacting public health, environmental sanitation, and social well-being, especially in low- and middle-income countries like Ethiopia. It is the second-largest cause of disease burden worldwide by facilitating the spread of germs that cause diarrhea diseases. Studies examining open defecation practices are insufficient, especially in areas implementing Ethiopia's Geshiyaro project. Therefore, this study aimed to assess the status of open defecation practice and associated factors in the study area.

Method

A community-based cross-sectional study was conducted from June to July 2023. The total number of households included in this study was 7995. A structured questionnaire and observational checklist were used to collect data. Descriptive and multivariate logistic regression analyses were performed using STATA version 16.

Results

The study found that 16.5% of households practiced open defecation. The following factors were significantly associated with the occurrence of open defecation: residence (AOR = 1.56, 95% CI: 1.26-1.92), education (AOR = 0.59, 95% CI: 0.49-0.72), age (AOR = 0.53, 95% CI: 0.41-0.69), knowledge on diarrhea prevention (AOR = 1.32, 95% CI: 1.17-1.50), marital status (AOR = 1.61, 95% CI: 1.32-1.97), and awareness creation about WASH services (AOR = 1.96, 95% CI: 1.71-2.25). On the other hand, no significant association was observed between the occurrence of open defecation and the household's income (AOR = 1.07, 95% CI: 0.93-1.23) or the head of household sex (AOR = 0.94, 95% CI: 0.78-1.12).

Conclusion

Open defecation remains a critical public health concern in Ethiopia's Geshiyaro project sites. Various factors influencing this practice have been identified. Targeted interventions are needed to enhance access to safe sanitation facilities and promote awareness of WASH services, aligning with SDG 3 target 3, and SDG 6 target 2.

Decomposing rural-urban gap in unsafe disposal practice of child stool in India using nationwide sample survey data

A significant rural-urban disparity in unsafe child stool disposal practices exists in India, yet existing research falls short in identifying the contributing factors to this gap. This study addresses the research gap by contextualizing the rural-urban divide in unsafe child stool disposal using data from the fifth round of the National Family Health Survey (NFHS-5, 2019-21). In particular, the study examines the prevalence and predictors of unsafe disposal practices, exploring associated contributing factors to this gap. The study involves a sample of 78,074 women aged 15-49 with a living child under 2 years, without any missing data related to the study interest. Employing descriptive statistics, the Pearson chi-square test, multilevel logistic regression, and the Fairlie decomposition model, the research aims to fulfill its objectives. The rural-urban gap in unsafe child stool disposal practices among the study participants was 22.3 percentage points (pp), with a more pronounced gap among the Scheduled Tribes (ST). Notably, the gap was particularly wide in Madhya Pradesh (33.9 pp), Telangana (27.5 pp), Gujarat (26.1 pp), and Rajasthan (25.8 pp). Predictors such as mother's education, mass media exposure, household wealth quintile, and sanitation facilities proved significant irrespective of residence. However, religion, social group, and water facility on household premises emerged as significant factors in rural areas only. The study identified that 67% of the explained gap in unsafe child stool disposal practices was attributed to the rural-urban difference in household wealth. Other noteworthy contributors were 'household sanitation facility' (21.3%), 'mother's education level' (3.9%), and 'water facility on household premises' (3.9%). These findings underscore the need for population and area-specific policy interventions, especially for individuals from socio-economically disadvantaged backgrounds, those with lower education levels, and limited exposure to mass media, particularly in states with a high prevalence of unsafe disposal practices. Such interventions are crucial to mitigating the existing rural-urban gap in unsafe child stool disposal practices.

Factors associated with rural-urban safe disposal of children stools in Ghana

INTRODUCTION

The burden of children's disease in many low-and middle-income countries is associated with poor sanitation, including unsafe disposal of children's stool. Infants and toddler stools pose a greater public health risk than adults. Studies on stool disposal in Sub-Saharan Africa (SSA) and Ghana have focused on prevalence, patterns, and associated factors. Nevertheless, these studies have not focused on factors that independently influence rural and/or urban child stool disposal. This study, therefore, examines factors associated with safe child stool disposal in rural areas separately from urban areas towards Ghana's readiness for ending open defaecation by 2030.

METHODOLOGY

We examined young children's faecal disposal drawing on the sixth round of the nationally-representative Ghana Multiple Indicator Cluster Survey (MICS) conducted in 2017/18. This study was restricted to children under two years, yielding a sub-sample of 3,476. Responses of caregivers or mothers who disposed of children less than two years faecal matter, their characteristics in addition to the child's age in months were analysed. A binary logistic regression was used to examine the factors associated with the safe disposal of young children's stools.

RESULTS

In the aggregated data, only 22% of households, regardless of their residence, dispose of their young children less than two years stools safely. From the disaggregated data, the rural analysis shows that 26% of young children's stools were safely disposed of, compared to 16% in the urban analysis. The urban analysis shows that the child's age, sex and caregiver's marital status were significantly associated with safe disposal of stools. On the other hand, child's age, caregiver listening to radio and household access to improved toilet facilities were significant in the rural analysis.

CONCLUSION

The safe practice of stool disposal was very low. The results of this study show that urgent and different policies and strategies are needed to address child stool disposal in urban residences compared to rural residences if we are to meet SDG targets of ending open defaecation.

No Child's Play: Under-five Child Feces Management in a Rural Area of Bengaluru Urban District, India

Background

Inappropriate feces disposal leads to environmental contamination, and increases the risk of exposure to children. We aimed to estimate the proportion of rural households with knowledge and practice of safe management of feces (SMoF) among under-five children and to identify associated factors.

Materials and Methods

A cross-sectional study was conducted in eight villages in Bengaluru Urban district over 2 months, using a face-validated semi-structured interview schedule. SMoF was defined based on five criteria - defecation site, transport tool, feces disposal, cleaning of transport tool, and hand washing.

Results

Out of 320 under-five children surveyed, 15.7% were pre-ambulatory and 84.3% were ambulatory. The majority of the caregivers (92.5%) felt that children should defecate in the latrine and only 23.7% were aware that child feces were more infectious than adult feces. SMoF was only practiced by caregivers of ambulatory children (52.6%). Households with older caregivers (P = 0.01) and those living in a pucca house (P = 0.02) with a latrine inside (P = 0.04) were found to practice SMoF. Children of households that practiced unsafe disposal of child feces experienced more diarrheal episodes (P = 0.04). Caregivers >20 years were found to have better odds of SMoF [20-25 years (adjusted odds ratio, aOR: 9.02), 26-30 years (aOR: 12.17), >30 years (aOR: 8.93)] compared to those <20 years.

Conclusion

The proportion of households with knowledge and practice of SMoF was low. Awareness of SMoF is essential to reduce the incidence of diarrheal diseases and improve sanitation. Our findings also call for awareness building at schools and colleges.

Effect of Positive Deviance Approach on Promotion of Safe Disposal of Child's Feces in Rural Tamil Nadu: A Community-Based Quasi-Experimental Study

Introduction

Safe disposal of feces is ensured when it is deposited into a toilet, whereas unsafe disposal of child's feces plays a crucial role in disease transmission and environmental pollution. These areas are overlooked by many sanitation promotion interventions.

Objective

To determine the effect of positive deviance (PD) approach on safe disposal of child's feces among households who owned a toilet.

Materials and Methods

A community-based quasi-experimental study was conducted in the four field practice villages of the Urban Health Training Center, Villupuram, for 18 months. Households who owned a toilet and had a child less than 5 years old were included. After IEC clearance, information was collected from a representative sample of 100 households before intervention and another 100 households after intervention. PD approach was applied for 6 months to promote safe disposal practices in the study villages. Data were analyzed using the Statistical Package for the Social Sciences (SPSS) software (version 24). The Chi-square test was used to determine the significance of difference between baseline and endline data. The effect size was calculated to estimate the magnitude of difference between baseline and endline data.

Results

Before intervention, only 3% of households disposed the feces into a toilet, while after intervention, almost 38% of households disposed in the toilet (χ2 = 37.39; df = 1; P = 0.001). The effect size (Cramer's V) was found to be 0.43.

Conclusion

PD approach demonstrated considerable improvements in safe disposal of child's feces in rural settings. Further, to sustain the behavior change, frequent reinforcement of key messages at frequent intervals needs to be emphasized.

Evidence of waste management impacting severe diarrhea prevalence more than WASH: An exhaustive analysis with Brazilian municipal-level data

Adequate housing protects from diarrhea, which is a substantial health concern in low- and middle-income countries. The purpose of this study was to quantify the relationship between severe diarrhea and housing features at the municipal level to help in public health planning. Regression analyses were performed on annual (2000-2012) datasets on Brazilian municipalities (5570) in six household feature categories (e.g., waste management) and four severe diarrhea outcomes (e.g., diarrhea deaths of under-5 children). Household data were not available elsewhere of this magnitude and granularity, highlighting the scientific value-add of this study. Municipalities were clustered prior to regression analysis because of data heterogeneity. The compositional household feature data were also subjected to principal component analysis to diminish feature variable multicollinearity. The highest explanatory power was found for diarrhea deaths of under-5 children (R2 = 10-22 %), while those in the over-5 population were the least best explained (R2 = 0.3-7 %). Household features predicted diarrhea outcomes more accurately in the "advanced" housing municipality cluster (R2 = 16-22 %) than in the "mid-level" (R2 = 7-20 %) and "basic" (R2 = 6-12 %) ones (over-5 diarrhea deaths excluded). Under-5 children's diarrhea death prevalence was three times higher in the "basic" cluster than in the "advanced" cluster. Importantly, the impact of waste management was overall the largest of all household features, even larger than those of WASH, i.e., water supply, sanitation, and household drinking water treatment. This is surprising in the context of existing literature because WASH is generally regarded as the most important household factor affecting gastrointestinal health. In conclusion, public health interventions could benefit from customizing interventions for diarrhea outcomes, municipality types, and household features. Waste management's identified stronger association with diarrhea compared to WASH may have important implications beyond the water field and Brazil.

Hygienic Disposal of Children's Stools Practices Among Women of Children With Diarrhoea in Sub-Saharan Africa

Background

Diarrhoea stools contain infectious agents and pose a public health threat to children and members of the entire family when exposed to them. Therefore, their hygienic disposal is essential. Empirical data are needed to stir the needed public health interventions to encourage or enforce proper disposal practices to curb associated clinical issues. This study assessed the prevalence and correlates of hygienic stool disposal practices by mothers of children with diarrhoea in sub-Saharan Africa (SSA).

Methods

The Demographic and Health Surveys (DHS) data of 16 sub-Saharan African countries from 2015 to 2021 involving 22 590 mother-child pairs were analysed. Multilevel binary logistic analysis was conducted to assess the individual- and household-level factors associated with the hygienic disposal of stool practices by mothers of children with diarrhoea. The results were presented using adjusted odds ratios (AOR) and 95% confidence intervals (CI) at a statistical significance of P < .05.

Results

The overall prevalence of hygienic disposal of children's stools among women of children with diarrhoea was 49.01% (95% CI: 48.40-49.62) and ranged from 15.70% in Liberia to 86.6% in Rwanda. The practice of hygienic disposal of stools of children with diarrhoea was likely to increase among mothers who are working (AOR: 1.19; 95% CI: 1.09-1.30), those with partners with primary level of education (AOR: 1.18; 95% CI: 1.06-1.31), Muslims (AOR: 1.69; 95% CI: 1.49-1.91) and widowed/divorced (AOR: 8.94, 95% CI: 3.55-22.53). Again, mothers in the richer (AOR: 1.23; 95% CI: 1.08-1.39) wealth index had increased odds of disposing of stools hygienically compared to those in the poorest wealth index. Women who were 20 years and above, to who belonged to Traditional Religions (AOR: 0.57; 95% CI: 0.43-0.74), and those with unimproved sources of water (AOR: 0.89; 95% CI: 0.82-0.98) and toilet facilities (AOR: 0.63; 95% CI: 0.58-0.69) were less likely to dispose of child's diarrhoea stool hygienically than their counterparts.

Conclusion

The study reveals that the unhygienic disposal of the stool of children with diarrhoea is prevalent in SSA and requires a concerted effort to curb it. Sanitation practices such as educating mothers about hygienic disposal of children's stool and improving water and sanitation facilities are crucial in lowering the high prevalence of unhygienic disposal of the diarrhoeic stool of children. Additional country-level research is needed to assess children's defecation behaviours and the disposal of diarrhoeic stools using different methodologies.

Unimproved source of drinking water and its associated factors: a spatial and multilevel analysis of Ethiopian demographic and health survey

BACKGROUND

Drinking water quality has been a major public health concern in lower and middle income countries where access to improved water supplies is limited. Ethiopia is thought to have one of the worst drinking water infrastructures in the world. This study aimed to assess the spatial variation and determinants of using unimproved sources of drinking water in Ethiopia using recent nationally representative data.

METHODS

A population-based cross-sectional study was employed with the recent EDHS data of 2019. A total of 8663 households were sampled using a stratified two-stage cluster sampling method. Kuldorff's SaTScan version 9.6 software was used to generate spatial scan statistics. ArcGIS version 10.7 software was used to visualize the spatial patterns of unimproved drinking water sources. A multilevel multivariable mixed-effect logistic regression was used to identify factors associated with the use of an unimproved drinking water source. In the multivariable multilevel analysis, those variables with a p-value < 0.05 were considered to be significant predictors of using an unimproved source of drinking water.

RESULT

Around 31% (95% CI: 30%, 32%) of the population in Ethiopia uses unimproved sources of drinking water with significant spatial variation across the country. Households aged 41-60 [AOR = 0.69; 95%CI; 0.53, 0.89] as compared to the households aged 10-25, households having middle wealth index [AOR = 0.48; 95%CI; 0.40, 0.59], and households having a rich wealth index [AOR = 0.31; 95%CI; 0.25, 0.39] as compared to the poor households, living in high community literacy level [AOR = 0.36; 95%CI; 0.16, 0.80], living in high-level community poverty [AOR = 3.03; 95%CI; 1.32, 6.98], rural residence [AOR = 7.88; 95%CI; 2.74, 22.67] were significant predictors of use of unimproved source of drinking water. Hot spot areas of use of unimproved drinking water sources were observed in Amhara, Afar, and Somalia regions and some parts of SNNPR and Oromia regions in Ethiopia. The primary clusters were found in Ethiopia's Somalia and Oromia regions.

CONCLUSION

Around one third of the Ethiopian population utilizes unimproved source of drinking water and it was distributed non-randomly across regions of Ethiopia. The age of the household head, wealth status of the household, residence, community poverty level, and community literacy level were found to be significantly associated with utilizing unimproved drinking water source. State authorities, non-governmental organizations and local health administrators should work to improve the quality of drinking water particularly for high risk groups such as communities living in high poverty and low literacy, poor households, rural residents, and hot spot areas to decrease the adverse consequences of using unimproved drinking water source.

Microscopic and Molecular Identification of Cyclospora cayetanensis and Cystoisospora belli in HIV-Infected People in Tabriz, Northwest of Iran

Opportunistic pathogens such as Cryptosporidium, Cystoisospora belli, and Cyclospora cayetanensis cause various gastrointestinal and non-digestive disorders in people with HIV/AIDS. These symptoms are especially severe in HIV-infected people who have a CD4+ count of less than 200 cells/mL. This study aimed to determine the prevalence of C. belli and C. cayetanensis infections among people living with HIV in Tabriz, northwest of Iran. This descriptive study was performed on 137 people with HIV who had been referred to behavioral disease counseling centers in Tabriz. Then, after receiving written consent, fecal samples were collected and evaluated for the detection of parasitic infections using direct methods and modified acid fast staining, as well as polymerase chain reaction (PCR).From the 137 fecal samples collected (98 males and 39 females, between 20 and 40 years old), 1.5% were positive for C. cayetanensis and 2.9% were positive for C. belli. Due to the prevalence of C. cayetanensis and C. belli in people with HIV in Tabriz, essential measures, including personal hygiene training for infection control and prevention, seem necessary.

Association of access to water, sanitation and handwashing facilities with undernutrition of children below 5 years of age in Bangladesh: evidence from two population-based, nationally representative surveys

OBJECTIVE

To examine the association between household access to water, sanitation and handwashing (WaSH) facilities and child undernutrition in Bangladesh.

DESIGN, SETTING AND PARTICIPANTS

Cross-sectional study of children less than 5 years using data collected from the 2019 Multiple Indicator Cluster Survey (MICS) and the 2017-2018 Bangladesh Demographic and Health Survey (BDHS).

OUTCOME MEASURES

Stunting, wasting and underweight, defined as a Z-score <-2 SD for height-for-age, weight-for-height and weight-for-age, respectively. We applied hierarchical multiple binary logistic regression models.

RESULTS

Among 30 514 children 0-59 months, there was a high prevalence of child undernutrition (MICS: 28.0% stunted, 9.8% wasted, 22.6% underweight; BDHS: 30.8% stunted, 8.4% wasted, 21.7% underweight). Most children came from households lacking basic sanitation (MICS: 39.1%, BDHS: 55.3%) or handwashing facilities (MICS: 43.8%, BDHS: 62.6%). Children from households without access to WaSH facilities experienced the highest rates of undernutrition. Exposure-specific adjusted logistic regression models showed that a lack of access to improved water sources was associated with greater odds of wasting (MICS: adjusted OR (AOR) 1.36, 95% CI 1.00 to 1.85, p<0.05); basic sanitation facility with higher rates of stunting (MICS: 1.13, 1.04 to 1.23, p<0.01) and underweight (BDHS: 1.18, 1.02 to 1.37, p<0.05); and a lack of handwashing facilities with stunting (BDHS: 1.27, 1.10 to 1.48, p<0.01) and underweight (MICS: 1.10, 1.01 to 1.19, p<0.05). In fully adjusted models, no basic sanitation facility was associated with higher odds of stunting (MICS: AOR 1.12, 1.03 to 1.22, p<0.01) and a lack of handwashing facilities with higher odds of underweight (BDHS: AOR 1.30, 1.10 to 1.54, p<0.01;MICS: AOR 1.09, 1.01 to 1.19, p<0.05).

CONCLUSION

These findings demonstrate a significant association between poor household WaSH facilities and high prevalence of child undernutrition. Improving WaSH may help reduce child undernutrition in Bangladesh.

Assessing sustained uptake of latrine and child feces management interventions: Extended follow-up of a cluster-randomized controlled trial in rural Bangladesh 1-3.5 years after intervention initiation

BACKGROUND

Sanitation interventions typically result in modest increases in latrine access, and any gains in latrine access and use are often not sustained over time. Sanitation programs also rarely include child-focused interventions such as potties. We aimed to assess the sustained effect of a multi-component sanitation intervention on access to and use of latrines and child feces management tools in rural Bangladesh.

METHODS

We conducted a longitudinal substudy nested within the WASH Benefits randomized controlled trial. The trial provided latrine upgrades, child potties and sani-scoops for feces removal, along with behavior change promotion to encourage use of the delivered hardware. Promotion visits to intervention recipients were frequent during the first 2 years after intervention initiation, decreased in frequency between years 2-3, and ceased after 3 years. We enrolled a random subset of 720 households from the sanitation and control arms of the trial in a substudy and visited them quarterly between 1 and 3.5 years after intervention initiation. At each visit, field staff recorded sanitation-related behaviors through spot-check observations and structured questionnaires. We assessed intervention effects on observed indicators of hygienic latrine access, potty use and sani-scoop use and investigated whether these effects were modified by duration of follow-up, ongoing behavior change promotion and household characteristics.

RESULTS

The intervention increased hygienic latrine access from 37% among controls to 94% in the sanitation arm (p < 0.001). Access among intervention recipients remained high 3.5 years after intervention initiation, including periods with no active promotion. Gains in access were higher among households with less education, less wealth and larger number of residents. The intervention increased availability of child potties from 29% among controls to 98% in the sanitation arm (p < 0.001). However, fewer than 25% of intervention households reported exclusive child defecation in a potty or had observed indicators of potty and sani-scoop use, and gains in potty use declined over the follow-up period, even with ongoing promotion.

CONCLUSION

Our findings from an intervention that provided free products and intensive initial behavior change promotion suggest a sustained increase in hygienic latrine access up to 3.5 years after intervention initiation but infrequent use of child feces management tools. Studies should investigate strategies to ensure sustained adoption of safe child feces management practices.

Influence of Seasonal Hazards on Water, Sanitation, and Hygiene-Related Behavior and Implications for Cholera Transmission in Bangladesh

Most cholera outbreaks in Bangladesh are seasonal, peaking in the dry and post-monsoon periods. Therefore, we investigated whether changes in water, sanitation, and hygiene (WASH) behavior in three populations in Bangladesh during the year could help explain why these two periods are particular to cholera transmission. The study used a mixed-method design, including a repeated cross-sectional study, focus group discussions, and key informant interviews. Through a repeated cross-sectional study, WASH-related variables were assessed during the dry, monsoon, and control seasons in 600 households from coastal Satkhira, inland Sirajganj, and the Dhaka slums. Seasonal behavioral changes were observed in all study areas. Dhaka and Satkhira had an increased mean distance to water sources during the dry and monsoon seasons (Dhaka: control season, 12 m [95% CI, 11-13]; dry season, 36 m [95% CI, 18-55]; and monsoon season, 180 m [95% CI, 118-243]; Satkhira: control season, 334 m [95% CI, 258-411]; dry season, 669 m [95% CI, 515-822]; and monsoon season, 2,437 m [95% CI, 1,665-3,209]). The participants attributed this to pollution of the usual water source. Perceived water quantity was lowest during the dry season in Dhaka and Sirajganj, and during the monsoon season in Satkhira. Handwashing with soap declined in all areas during the dry and monsoon seasons. Open defecation was frequent among children younger than 5 years, increasing during seasonal climate hazards. Results show that WASH-related behavior changed seasonally, increasing the risk of cholera transmission through multiple hygiene-related transmission pathways. Future research would benefit by ensuring that the length of studies covers all seasons throughout the year and also by looking in more detail at people's behavior and hygiene practices.

Relapse of acute malnutrition and associated factors after discharge from nutrition stabilization centers among children in Eastern Ethiopia

Background

Acute malnutrition is a major global health problem primarily affecting under-five children. In sub-Saharan Africa, children treated for severe acute malnutrition (SAM) at an inpatient have high case fatality rate and is associated with relapse of acute malnutrition after discharge from inpatient treatment programs. However, there is limited data on the rate of relapse of acute malnutrition in children after discharge from stabilization centers in Ethiopia. Hence, this study aimed to assess the magnitude and predictors of relapse of acute malnutrition among children aged 6-59 months discharged from stabilization centers in Habro Woreda, Eastern Ethiopia.

Methods

A cross-sectional study was conducted among under-five children to determine the rate and predictors of relapse of acute malnutrition. A simple random sampling method was used to select participants. All randomly selected children aged 6-59 months discharged from stabilization centers between June 2019 and May 2020 were included. Data were collected using pretested semi-structured questionnaires and standard anthropometric measurements. The anthropometric measurements were used to determine relapse of acute malnutrition. Binary logistic regression analysis was used to identify factors associated with relapse of acute malnutrition. An odds ratio with 95% CI was used to estimate the strength of the association and a p-value less than 0.05 was considered statistically significant.

Results

A total of 213 children with mothers/caregivers were included in the study. The mean age in months of children was 33.9 ± 11.4. More than half (50.7%) of the children were male. The mean duration of children after discharge was 10.9 (± 3.0 SD) months. The magnitude of relapse of acute malnutrition after discharge from stabilization centers was 36.2% (95% CI: 29.6,42.6). Several determinant factors were identified for relapse of acute malnutrition. Mid-upper arm circumference less than 110 mm at admission (AOR = 2.80; 95% CI: 1.05,7.92), absence of latrine (AOR = 2.50, 95% CI: 1.09,5.65), absence of follow-up visits after discharge (AOR = 2.81, 95% CI: 1.15,7.22), not received vitamin A supplementation in the past 6 months (AOR = 3.40, 95% CI: 1.40,8.09), household food insecurity (AOR = 4.51, 95% CI: 1.40,15.06), poor dietary diversity (AOR = 3.10, 95% CI: 1.31,7.33), and poor wealth index (AOR = 3.90, 95% CI: 1.23,12.43) were significant predictors of relapse of acute malnutrition.

Conclusion

The study revealed very high magnitude of relapse of acute malnutrition after discharge from nutrition stabilization centers. One in three children developed relapse after discharge in Habro Woreda. Programmers working on nutrition should design interventions that focus on improving household food insecurity through strengthened public Safety Net programs and emphasis should be given to nutrition counseling and education, as well as to continuous follow-up and periodic monitoring, especially during the first 6 months of discharge, to reduce relapse of acute malnutrition.

Associated factors of safe child feces disposal in sub-Saharan Africa: Evidence from recent demographic and health surveys of 34 sub-Saharan countries

INTRODUCTION

Children's feces are thought to pose a greater public health risk than those of adults' due to higher concentrations of pathogens. The aim of this study was to determine the associated factors of safe child feces disposal among children under two years of age in Sub-Saharan Africa.

METHODS

The most recent demographic and health survey datasets of 34 sub-Saharan countries were used. A total weighted sample of 78, 151 mothers/caregivers of under two children were included in the study. Both bivariable and multivariable multilevel logistic regression were done. The Odds Ratio (OR) with a 95% Confidence Interval (CI) was calculated for each independent variables included in the model.

RESULTS

Those mothers/caregivers from urban residence (AOR = 1.42; CI: 1.36, 1.48), mothers with primary education (AOR = 1.49; CI: 1.44, 1.56), richer (AOR = 1.78; CI: 1.69, 1.88) and richest wealth quintiles (AOR = 2.17; CI: 2.01, 2.31), family size <5 (AOR = 1.06; CI: 1.02-1.09), access to improved water source (AOR = 1.29; CI: 1.25, 1.34), mothers who owned toilet (AOR = 3.09; 2.99-3.19) and who had media exposure (AOR = 1.19; CI: 1.15, 1.24) had higher odds of practicing safe child feces disposal than their counter parts. However, mothers/care givers who are not currently working (AOR = 0.83; CI: 0.80, 0.86), higher education (AOR = 0.85; CI: 0.76-0.94) and from Western region of Africa (AOR = 0.82; CI: 0.79-0.86) had reduced chance of safe child feces disposal as compared to their counter parts.

CONCLUSION

Residence, mothers' level of education, wealth index, water source, toilet ownership and media exposure were factors associated with safe child feces disposal. It is advisable to implement health promotion and behavioral change intervention measures especially for those women /caregivers from rural residence, poor economic status, who cannot access improved water and for those with no media exposure to improve the practice of safe child feces disposal.

Enteric infections and management practices among communities in a rural setting of northwest Ethiopia

Infections with enteric pathogens have a high mortality and morbidity burden, as well as significant social and economic costs. Poor water, sanitation, and hygiene (WASH) conditions are the leading risk factors for enteric infections, and prevention in low-income countries is still primarily focused on initiatives to improve access to improved WASH facilities. Rural communities in developing countries, on the other hand, have limited access to improved WASH services, which may result in a high burden of enteric infections. Limited information also exists about the prevalence of enteric infections and management practices among rural communities. Accordingly, this study was conducted to assess enteric infections and management practices among communities in a rural setting of northwest Ethiopia. A community-based cross-sectional study was conducted among 1190 randomly selected households in a rural setting of northwest Ethiopia. Data were collected using structured and pretested interviewers-administered questionnaire and spot-check observations. We used self-reports and medication history audit to assess the occurrence of enteric infections among one or more of the family members in the rural households. Multivariable binary logistic regression model was used to identify factors associated with enteric infections. Statistically significant association was declared on the basis of adjusted odds ratio with 95% confidence interval and p value < 0.05. Out of a total of 1190 households, 17.4% (95% CI: 15.1, 19.7%) of the households reported that one or more of the family members acquired one or more enteric infections in 12 months period prior to the survey and 470 of 6089 (7.7%) surveyed individuals had one or more enteric infections. The common enteric infections reported at household-level were diarrhea (8.2%), amoebiasis (4.1%), and ascariasis (3.9%). Visiting healthcare facilities (71.7%), taking medications without prescriptions (21.1%), and herbal medicine (4.5%) are the common disease management practices among rural households in the studied region. The occurrence of one or more enteric infections among one or more of the family members in rural households in 12 months period prior to the survey was statistically associated with presence of livestock (AOR: 2.24, 95% CI:1.06, 4.75) and households headed by uneducated mothers (AOR: 1.62, 95% CI: (1.18, 2.23). About one-fifth of the rural households in the studied region reported that one or more of the family members had one or more enteric infections. Households in the study area might acquire enteric infections from different risk factors, mainly poor WASH conditions and insufficient separation of animals including their feces from human domestic environments. It is therefore important to implement community-level interventions such as utilization of improved latrine, protecting water sources from contamination, source-based water treatment, containment of domestic animals including their waste, community-driven sanitation, and community health champion.

Prevalence and risk predictors of childhood stunting in Bangladesh

BACKGROUND

The child nutritional status of a country is a potential indicator of socioeconomic development. Child malnutrition is still the leading cause of severe health and welfare problems across Bangladesh. The most prevalent form of child malnutrition, stunting, is a serious public health issue in many low and middle-income countries. This study aimed to investigate the heterogeneous effect of some child, maternal, household, and health-related predictors, along with the quantiles of the conditional distribution of Z-score for height-for-age (HAZ) of under five children in Bangladesh.

METHODS AND MATERIALS

In this study, a sample of 8,321 children under five years of age was studied from BDHS-2017-18. The chi-square test was mainly used to identify the significant predictors of the HAZ score and sequential quantile regression was used to estimate the heterogeneous effect of the significant predictors at different quantiles of the conditional HAZ distribution.

RESULTS

The findings revealed that female children were significantly shorter than their male counterparts except at the 75th quantile. It was also discovered that children aged 7-47 months were disadvantaged, but children aged 48-59 months were advantaged in terms of height over children aged 6 months or younger. Moreover, children with a higher birth order had significantly lower HAZ scores than 1st birth order children. In addition, home delivery, the duration of breastfeeding, and the BCG vaccine and vitamin A received status were found to have varied significant negative associations with the HAZ score. As well, seven or fewer antenatal care visits was negatively associated with the HAZ score, but more than seven antenatal care visits was positively associated with the HAZ score. Additionally, children who lived in urban areas and whose mothers were over 18 years and either normal weight or overweight had a significant height advantage. Furthermore, parental secondary or higher education had a significant positive but varied effect across the conditional HAZ distribution, except for the mother's education, at the 50th quantile. Children from wealthier families were also around 0.30 standard deviations (SD) taller than those from the poorest families. Religion also had a significant relationship with the conditional HAZ distribution in favor of non-Muslim children.

CONCLUSIONS

To enhance children's nutritional levels, intervention measures should be designed considering the estimated heterogeneous effect of the risk factors. This would accelerate the progress towards achieving the targets of Sustainable Development Goals (SDGs) related to child and maternal health in Bangladesh by 2030.

CO2 in indoor environments: From environmental and health risk to potential renewable carbon source

In the developed world, individuals spend most of their time indoors. Poor Indoor Air Quality (IAQ) has a wide range of effects on human health. The burden of disease associated with indoor air accounts for millions of premature deaths related to exposure to Indoor Air Pollutants (IAPs). Among them, CO₂ is the most common one, and is commonly used as a metric of IAQ. Indoor CO₂ concentrations can be significantly higher than outdoors due to human metabolism and activities. Even in presence of ventilation, controlling the CO₂ concentration below the Indoor Air Guideline Values (IAGVs) is a challenge, and many indoor environments including schools, offices and transportation exceed the recommended value of 1000 ppm_v. This is often accompanied by high concentration of other pollutants, including bio-effluents such as viruses, and the importance of mitigating the transmission of airborne diseases has been highlighted by the COVID-19 pandemic. On the other hand, the relatively high CO₂ concentration of indoor environments presents a thermodynamic advantage for direct air capture (DAC) in comparison to atmospheric CO₂ concentration. This review aims to describe the issues associated with poor IAQ, and to demonstrate the potential of indoor CO₂ DAC to purify indoor air while generating a renewable carbon stream that can replace conventional carbon sources as a building block for chemical production, contributing to the circular economy.

Influence of latrine coverage and usage on diarrhoea incidence among children under 5 living in slum areas of Douala 5th sub-division, Cameroon

Introduction

lack of adequate sanitation facilities remain a major concern in developing countries. While around 41% of Cameroonians lack access to improved sanitation facilities, the 2011 National Survey revealed a diarrhoea incidence rate of 21% in children under five years, two weeks before interview. This study aimed at evaluating the influence of latrine coverage and usage on diarrhoeic disease outcomes among children under 5.

Methods

a cross-sectional study was carried out in March 2016 in pre-selected slums areas of Douala 5^th district. A structured questionnaire was used to collect data from one consenting adult per household. Data analysis was carried out using Epi Info version 7.1.4.0. Pearson's chi-square and Fisher exact test were used to estimate the influence of latrine coverage on the incidence of diarrhoea. Statistical significance was set at p < 0.05.

Results

of the 384 households enrolled, 69.01% had latrine facilities, while 30.99% shared latrines with neighbouring households. Sixty point sixteen percent (60.16%) (231/384) of all households used pit latrines. Although consistent use of latrines by all adults was reported, 20.05% of children under 5 practiced open-air defecation. The incidence of diarrhoea among children under 5 years 2 weeks before interview was 29.25%, of which 26.35% were bloody stools. Diarrhoea outcome was significantly associated with use of pit latrines (p < 0.01); lack of cover on latrines hole (p < 0.0001) and proximity of latrines to household (p=0.01).

Conclusion

poor faecal waste management and lack of improved sanitation facilities contribute significantly to diarrhoeal episodes among children under 5. A structured strategy to improve community-based sanitation considering urban planning and sanitation campaigns would promote safer environment and reduce outcome of water-borne and diarrhoeic diseases.

Determinants of diarrhoeal disease in children living in low-income households in a periurban community in Cape Town, South Africa

Background. Water, sanitation and hygiene are critically important in reducing morbidity and mortality from childhood diarrhoeal disease and malnutrition in low-income settings.Objectives. To assess the association of diarrhoeal disease with factors relating to domestic hygiene, the environment, sociodemographic status and anthropometry in children <2 years of age.Methods. This was a case-control study conducted in a periurban community 35 km from the centre of Cape Town, South Africa. The study included 100 children with diarrhoeal disease and 100 age-matched controls without diarrhoea, who were recruited at primary healthcare clinics. Sociodemographic status, environmental factors and domestic hygiene were assessed using a structured questionnaire; anthropometry was assessed using the World Health Organization’s child growth standards. Univariate and multivariate logistic regression analyses were performed to identify the factors associated with diarrhoea. Results. The results of the univariate logistic regression showed significant susceptibility to diarrhoea in study cases compared with controls when the caregiver was ≥25 years old (odds ratio (OR) 1.82; 95% confidence interval (CI) 1.02 - 3.23; p=0.042); when children were in day care or cared for by a family member or a relative than when cared for by their mother (OR 1.97; 95% CI 1.06 - 3.65; p=0.032); and when the mothers were employed rather than at home (OR 2.23; 95% CI 1.21 - 4.12; p=0.01). Multivariate logistic regression analysis was used to identify predictors of diarrhoea, which entailed relaxing the inclusion criteria for the univariate analysis variables (p<0.25). The predictors significantly associated with diarrhoea were household problems relating to rat infestation (OR 2.44; 95% CI 1.13 - 5.28; p=0.027); maternal employment (OR 2.47; 95% CI 1.28 - 4.76; p=0.007); and children in day care or cared for by a relative (OR 2.34; 95% CI 1.21 - 4.54; p=0.01). Significantly more of the mothers who were employed than those who were unemployed had children in day care or cared for by a relative.Conclusion. Practices relating to employment, childcare and the domestic environment were significant predictors of diarrhoea. Effective policy implementation on water, sanitation and domestic hygiene could prevent diarrhoeal disease and reduce its impact on children’s growth, especially during the annual diarrhoeal surge season in this and similar periurban communities.

Exploring the determinants and indicators of poultry feces management behaviors in rural Western Uganda

Animal ownership has reported financial and nutritional benefits but has also been associated with enteric and respiratory infections, and inadequate sanitation and hygiene can lead to children touching and ingesting animal fecal matter. We identified key indicators for poultry feces management and investigated their social determinants using data from a baseline survey of a randomized-controlled trial of a poultry management training program in rural Western Uganda. The baseline survey was conducted in the Masindi and Kiryandongo districts of Uganda in September 2019, and data collected from 609 households were used. We evaluated indicators for poultry feces management behaviors using scale development methods, including descriptive statistics, bivariate correlation analyses, and Factor Analysis of Mixed Data. We also investigated social determinants of key poultry feces management behaviors using logistic and multinomial logistic regression models. A significant increase in odds of having free-roaming poultry was found for each additional poultry owned (OR = 1.18, P < 0.001). The odds of a household having an observed enclosure for poultry increased by 5% with each incremental poultry owned (OR = 1.05, P < 0.001), and by 4% with increasing wealth with each additional point on the poverty probability index score (OR = 1.04, P < 0.001). Our results also suggest enclosures are intermittently used and constructing them without further intervention likely will not be sufficient for effectively managing animal fecal contamination. We recommend that future studies on animal feces management measure indicators for corralling and feces disposal practices and evaluate their relationship to enteric pathogen exposure and health outcomes. Insights from this work can inform the development of robust indicators of poultry feces management behaviors that can be used for monitoring and evaluation purposes.

Formative Research Using Settings and Motives to Explore Child Faeces Disposal and Management in Rural Solomon Islands

Unsafe child faeces management can lead to adverse health and wellbeing outcomes for children. In Solomon Islands, diarrhoeal disease is a leading cause of under-5 mortality, though there is limited research into CFM practices and promotion of safe behaviours. The formative research applied a Behaviour-Centred Design framework to investigate the habits, motives and settings related to child faeces management in rural Solomon Islands villages. Data were collected through structured recall demonstrations by caregivers (n = 61), household infrastructure observations (n = 57), semi-structured interviews with caregivers (n = 121) and community leaders (n = 30), focus group discussions (n = 26), and three participatory activities with caregivers. The findings identified a range of CFM-related behaviours, some of which would be considered safe and some, such as outside defecation and disposal to a waterway, as unsafe. Convenience is important in shaping CFM practice and may help health benefits to be achieved without women bearing the cost of an increased work burden. Nurture and disgust may provide the basis for behaviour change communication in SI as they have elsewhere. Critically, the participation in and promotion of safe CFM by fathers in households should be promoted, and motivating such behaviours might be achieved through focus on nurture as a motive.

Hygienic Child Feces Disposal Practice and Its Associated Factors among Mothers/Caregivers of Under Five Children in West Armachiho District, Northwest Ethiopia

BACKGROUND

Children's feces are 5 times more dangerous than that of adults. Unhygienic disposal of child feces has been reported as one of the major sanitation problems in Sub-Saharan African countries. However, there is a scanty of information in the study area and evidences are insufficient in Ethiopia. Therefore, this study intends to assess child feces disposal practices and associated factors among Mothers/Caregivers of Under Five Children in West Armachiho District, Northwest Ethiopia.

METHODS

A community-based cross-sectional study was conducted in the West Armachho district from March 10, 2019 to April 10, 2019 by using a multistage cluster sampling method. Binary and multivariable logistic regression models were employed to identify factors associated to child faces disposal practice. The adjusted odds ratio with a 95% confidence interval and a P-value of ⩽.05 were used to declare statistical significance.

RESULT

The proportion of safe child feces disposal practice was 37.8% (95% CI: 34.6-40.89). Child feces disposal practice was significantly associated with the age of the child (AOR = 5.07, 95% CI: 2.52-10.21), the educational status of fathers (AOR = 2.34, 95% CI: 1.05-5.25), getting health education (AOR = 2.77, 95% CI: 1.84-4.16), utilization of basic type of latrine (AOR = 2.79, 95% CI: 1.55-5.02), knowledge of feces disposal technology options (AOR = 2.58, 95% CI: 1.88-3.96), and media exposure about child feces (AOR = 1.88, 95% CI: 1.22-2.99).

CONCLUSION

The practice of safe CFD was low. Age of the child, fathers' educational status, receiving health education, basic type of latrine, feces disposal technology options used, and media exposure were independent predictors of safe CFD practice. Interventions need to be designed targeting safe CFD practices taking into account different media outlets and advocacy of improved sanitation technology use by policy makers.

Necessary conditions for sustainable water and sanitation service delivery in schools: A systematic review

Access to water, sanitation, and hygiene (WASH) services confers significant health and economic benefits, especially for children, but only if those services can be delivered on a consistent basis. The challenge of sustainable, school-based WASH service delivery has been widely documented, particularly in resource-constrained contexts. We conducted a systematic review of published research that identifies drivers of, or tests solutions to, this challenge within low- and middle-income countries (PROSPERO 2020 CRD42020199163). Authors in the first group employ cross-sectional research designs and interrogate previously implemented school WASH interventions. Most conclude that dysfunctional accountability and information sharing mechanisms drive school WASH service delivery failures. By contrast, most of the interventions developed and tested experimentally by authors in the second group focus on increasing the financial and material resources available to schools for WASH service delivery. Overall, these authors find negligible impact of such infusions of cash, infrastructure, and supplies across a variety of sustainability outcome metrics. Taken together, the evidence suggests that sustainable service delivery depends on three simultaneously necessary components: resources, information, and accountability. Drawing upon theory and evidence from social psychology, public management, and political science, we identify priority knowledge gaps that can meaningfully improve the design of effective interventions. We also highlight the importance of both interdisciplinary collaboration and local expertise in designing WASH programming that aligns with sociocultural and institutional norms, and is thus more likely to generate sustainable impact.

Detection of Escherichia coli, rotavirus, and Cryptosporidium spp. from drinking water, kitchenware, and flies in a periurban community of Lusaka, Zambia

Fecal contamination with a poor water, sanitation and hygiene environment in urban informal settlements poses diarrhea risks. Little information is available on the contamination of environmental media with enteric pathogens in such settlements. We investigated the contamination of Escherichia coli, rotavirus, and Cryptosporidium spp. in water, on kitchenware, and on flies in urban informal settlements of Chawama and Kanyama, Lusaka, Zambia. These environmental media were examined by XM-G agar cultivation for E. coli and specific real-time RT-PCR assays to detect rotavirus and Cryptosporidium spp. E. coli; rotavirus, and Cryptosporidium spp. were detected in samples of household stored drinking water (6 of 10 samples, 3 of 10 samples, and 2 of 10 samples, respectively), cups (10 of 20 samples, 2 of 13 samples, 1 of 13 samples, respectively), and flies (35 of 55 samples, 5 of 17 samples, 1 of 17 samples, respectively). The ranges of rotavirus concentrations in household stored drinking water, on cups, and flies were 2.9 × 10²-2.2 × 10⁵ copies/L, 1.2 × 10²-4.3 × 10² copies/cup, and 5.0 × 10¹-2.0 × 10² copies/fly, respectively. These results indicate the contribution of drinking water and kitchenware to enteric pathogen exposure and potential role of flies in microbial transmission.

Multidrug-resistant enteric bacteria in Nigeria and potential use of bacteriophages as biocontrol

Enteric bacterial pathogens have been implicated in many cases of gastroenteritis in Nigeria, a West African country. This situation is worsened by some reports of the high prevalence of multidrug-resistant enteric bacteria. To better prepare for situations in which even antibiotics of last resort would fail to treat infections caused by these pathogens, attention should be paid to alternative antimicrobial strategies. Here, we summarize existing reports of multidrug-resistant enteric bacterial infections in Nigeria, and importantly present the use of bacteriophages (viruses of bacteria) as an attractive antimicrobial alternative to combat these pathogens. It is hoped that this review will encourage research into the use of lytic bacteriophages against multidrug-resistant enteric bacteria in Nigeria.

Preparedness for and impact of COVID-19 on primary health care delivery in urban and rural Malawi: a mixed methods study

OBJECTIVE

Across Africa, the impact of COVID-19 continues to be acutely felt. This includes Malawi, where a key component of health service delivery to mitigate against COVID-19 are the primary healthcare facilities, strategically placed throughout districts to offer primary and maternal healthcare. These facilities have limited infrastructure and capacity but are the most accessible and play a crucial role in responding to the COVID-19 pandemic. This study assessed health facility preparedness for COVID-19 and the impact of the pandemic on health service delivery and frontline workers.

SETTING

Primary and maternal healthcare in Blantyre District, Malawi.

PARTICIPANTS

We conducted regular visits to 31 healthcare facilities and a series of telephone-based qualitative interviews with frontline workers (n=81 with 38 participants) between August 2020 and May 2021.

RESULTS

Despite significant financial and infrastructural constraints, health centres continued to remain open. The majority of frontline health workers received training and access to preventative COVID-19 materials. Nevertheless, we found disruptions to key services and a reduction in clients attending facilities. Key barriers to implementing COVID-19 prevention measures included periodic shortages of resources (soap, hand sanitiser, water, masks and staff). Frontline workers reported challenges in managing physical distancing and in handling suspected COVID-19 cases. We found discrepancies between reported behaviour and practice, particularly with consistent use of masks, despite being provided. Frontline workers felt COVID-19 had negatively impacted their lives. They experienced fatigue and stress due to heavy workloads, stigma in the community and worries about becoming infected with and transmitting COVID-19.

CONCLUSION

Resource (human and material) inadequacy shaped the health facility capacity for support and response to COVID-19, and frontline workers may require psychosocial support to manage the impacts of the COVID-19 pandemic.

Sense and Manner of WASH and Their Coalition With Disease and Nutritional Status of Under-five Children in Rural Bangladesh: A Cross-Sectional Study

This study aimed to assess the knowledge and practice of caregivers and their relationship to the disease and nutritional status of children under 5 years of age in rural areas of Sylhet, Bangladesh. A total of 110 households with at least a child aged 6 to 59 months were selected by simple random method from 10 rural communities of three Upazila of Sylhet from September 2019 to February 2020. Descriptive statistics were used to assess the "Water Access, Sanitation, and Hygiene" (WASH) knowledge and practice, and multivariate chi-square analyses were performed to assess associations among diseases and nutritional status with WASH following a structured questionnaire. The study found a significant association between WASH with childhood disease and nutritional status, and 65% of children were found to be in a diseased state and 35% of children were found in a no exposure of disease state within the last 6 months. The findings sketched that mother with poor WASH knowledge and practice was at greater risk for disease outbreaks, disease frequency, and duration. The highest incidence of diarrhea was 17% in children aged 12 to 23 months. A significant effect of WASH was also found in children's nutritional status, which was reflected in the ratio of stunted, underweight, and wasted children. Integrated convergent work focusing on providing clean water within the household, stopping open defecation, promoting handwashing, behavior change, and poverty alleviation is needed to improve the situation. Health, nutrition, and livelihood programs should be uninterrupted, and mothers or caregivers should be encouraged to participate in these programs.

Assessing Hygienic Status, Sanitation Issues, and Associated Problems in Dambi Dollo Town, Oromia Regional State, Ethiopia

The pollutants discharged untreated into water bodies become a challenge in Ethiopia. This study aims to assess sanitation and hygiene status and the associated problems. A total of 500 households were selected using a systematic random sampling technique. Questionnaires, interviews, and site observation were employed. The absence of public and communal latrines had been seen as the constraint. The present study confirmed that waste disposal management has serious problems. In conclusion, these findings revealed that part of the households are living in communities with the town-owned poor sanitary facilities and that further studies are encouraged on waste disposal management.

Diarrhoeal outcomes in young children depend on diarrhoeal cases of other household members: a cross-sectional study of 16,025 people in rural Uganda

BACKGROUND

There is a limited understanding of how diarrhoeal cases across other household members influence the likelihood of diarrhoea in young children (aged 1-4 years).

METHODS

We surveyed 16,025 individuals from 3421 households in 17 villages in Uganda. Using logistic regressions with standard errors clustered by household, diarrhoeal cases within households were used to predict diarrhoeal outcomes in young children. Regressions were adjusted for socio-demographic, water, sanitation, and hygiene (WASH), and ecological covariates. Selection bias for households with (1632/3421) and without (1789/3421) young children was examined.

RESULTS

Diarrhoeal prevalence was 13.7% (2118/16,025) across all study participants and 18.5% (439/2368) in young children. Young children in households with any other diarrhoeal cases were 5.71 times more likely to have diarrhoea than young children in households without any other diarrhoeal cases (95% CI: 4.48-7.26), increasing to over 29 times more likely when the other diarrhoeal case was in another young child (95% CI: 16.29-54.80). Diarrhoeal cases in older household members (aged ≥ 5 years) and their influence on the likelihood of diarrhoea in young children attenuated with age. School-aged children (5-14 years) had a greater influence on diarrhoeal cases in young children (Odds Ratio 2.70, 95% CI: 2.03-3.56) than adults of reproductive age (15-49 years; Odds Ratio 1.96, 95% CI: 1.47-2.59). Diarrhoeal cases in individuals aged ≥ 50 years were not significantly associated with diarrhoeal outcomes in young children (P > 0.05). These age-related differences in diarrhoeal exposures were not driven by sex. The magnitude and significance of the odds ratios remained similar when odds ratios were compared by sex within each age group. WASH factors did not influence the likelihood of diarrhoea in young children, despite influencing the likelihood of diarrhoea in school-aged children and adults. Households with young children differed from households without young children by diarrhoeal prevalence, household size, and village WASH infrastructure and ecology.

CONCLUSIONS

Other diarrhoeal cases within households strongly influence the likelihood of diarrhoea in young children, and when controlled, removed the influence of WASH factors. Future research on childhood diarrhoea should consider effects of diarrhoeal cases within households and explore pathogen transmission between household members.

Effects of local handwashing agents on microbial contamination of the hands in a rural setting in Northwest Ethiopia: a cluster randomised controlled trial

OBJECTIVE

To evaluate the effectiveness of handwashing with water and wood ash in reducing faecal contamination of the hands.

DESIGN

A cluster randomised controlled trial was employed with two arms: handwashing with water and wood ash versus handwashing with water alone.

SETTING

Rural households of East Dembiya District, Central Gondar Zone, Amhara National Regional State, Ethiopia.

PARTICIPANTS

440 mothers and caregivers of children younger than 5 years assigned (1:1, 220 in each group) in clusters, with buffer zones between each cluster.

INTERVENTION

Health education on effective handwashing was given to the intervention and control groups. Participants in the intervention group used wood ash of the same quantity (ie, one closed palm).

OUTCOME MEASURES

The primary outcome was microbial contamination of the hands, measured by means of Escherichia coli counts before and after handwashing.

RESULTS

At baseline, 75.9% and 67.7% of the participants in the intervention and control groups, respectively, had dirt on their fingernails, and the hands of all participants in both groups were contaminated with E. coli. The mean E. coli counts recovered at baseline were 3.07 log10 colony forming unit (CFU)/swab in the intervention group and 3.03 log10 CFU/swab in the control group, while at endline it was 1.4 log10 CFU/swab in the intervention group and 3.02 log10 CFU/swab in the control group. The mean E.coli counts was reduced by 1.65 log10 due to the intervention (difference-in-differences: β= -1.65, 95% CI= -1.84 to -1.46).

CONCLUSION

Two-thirds of the swab samples tested positive for E. coli after handwashing with water and wood ash, which indicates wood ash is not very effective in terms of completely removing micro-organisms on the hands. However, wood ash was significantly better than water alone in reducing the concentration of faecal coliform organisms on the hands. Local health authorities should primarily promote handwashing with soap. However, in the absence of soap, use of wood ash over water alone might be appropriate.

TRIAL REGISTRATION NUMBER

PACTR202011855730652.

Sanitation and Multiple Micronutrient Supplementation in Pregnancy Outcomes: Literature Review

BACKGROUND: Around 2.6 billion people lack proper sanitation. In addition, nutritional problems such as multiple micronutrient (MMN) deficiency can increase morbidity, mortality, and impaired neurocognitive growth at later stages of life. In addition to the need for a sanitary approach, a globally applicable strategy to prevent micronutrient deficiencies in pregnant women, UNICEF recommends the use of MMN for prenatal supplementation as an initial program in developing countries, to reduce the risk of poor birth outcomes. AIM: The aim of this literature study was to analyze the relationship between sanitation and the multimicronutrient (MMN) approach in pregnancy and birth outcomes. METHODS: This research was conducted using literature review method. Various references were collected from online database including reports, journals, and books. The journals were mostly from the scholarly journals. The articles were screened according to the research objectives. The keywords used are sanitation, pregnancy, and multiple micronutrient approach. RESULTS: Several studies have shown that sanitation and the multi micronutrient (MMN) approach play a role in determining pregnancy outcomes. We conclude that the importance of sanitation on pregnancy outcome is to reduce the chance of infection. The importance of MMN in pregnancy outcomes is that mothers who consume MMN during pregnancy can reduce the risk of poor birth output. The role of stakeholders is needed in the future. CONCLUSIONS: Several studies have shown that sanitation and multi micronutrient (MMN) play a role in determining pregnancy outcome.

Towards a participatory framework for improving water & health outcomes: A case study with Maasai women in rural Tanzania

Rural communities in sub-Saharan Africa (SSA) are disproportionately burdened by a pervasive lack of access to safe drinking water. Widespread programmatic failure in the water, sanitation, and hygiene (WaSH) sector has resulted in particularly slow progress in alleviating these challenges in the region. Drawing from decolonial and participatory methodological scholarship, this research demonstrates how geographically and demographically specific, locally controlled, and long-term educational programming can improve health and wellness outcomes when associated with a technological intervention. Specifically, consultations between January 2015 and August 2018 were followed by an iterative and community-driven program development process between January and July 2019. Fifty Maasai women were subsequently recruited to participate and were provided with a point-of-use water treatment technology in August 2019. These women engaged in a series of three 14-week WaSH education programs over an 18-month evaluation period. Results showed that 38% of participants reported regular diarrhea at baseline, decreasing to 8%, 0%, and 3% immediately after each of the three WaSH education programs were provided at 3, 12, and 18 months. Interim measurements taken between WaSH programs showed 35% of participants (at 6 months) and 5% of participants (at 15 months) reporting regular diarrhea. A trend of improvement was thus observed over the study period, though the increase in reported diarrhea at 6 months demonstrates the need for long-term commitment on the part of WASH practitioners when engaging with end users to achieve sustained change. Further, this research highlights the importance of participatory program development and pedagogical approaches in WaSH interventions, where local control of study objective determination and implementation, combined with consistent and long-term engagement, can facilitate sustained technology use and associated reductions in diarrhea.

Hygienic disposal of stools and risk of diarrheal episodes among children aged under two years: Evidence from the Ghana Demographic Health Survey, 2003–2014

Background

Most childhood diarrheal illnesses are a result of the faeco-oral transmission of infected food, water, and unclean fingers. The present paper was conducted to estimate the prevalence of hygienic disposal of stools (HDS) and its associated factors, and further quantify the impact of HDS on diarrheal diseases among children under two years.

Methods

A cross-sectional design was used to evaluate three rounds of the Ghana Demographic Health Survey (GDHS) from 2003–2014 involving 4869 women with children aged under two years. The outcomes were prevalence of HDS and diarrheal diseases. Poisson regression model was employed to assess risk factors associated with HDS and dominance analysis was used to rank the important risk factors. Inverse Probability Weighting Poisson Regression Adjustment (IPWPRA) with Propensity Score 1:1 density kernel-based matching was employed to assess impact.

Results

The pooled prevalence rate of HDS was 26.5%(95%CI = 24.6–28.4) and it ranged from 18.7% (95%CI = 16.4–21.2) in 2014 to 38.8%(95%CI = 35.3–42.4) in 2003. Diarrhea diseases pooled prevalence was 17.9%(95%CI = 16.4–19.5) and ranged from 13.3%(95%CI = 11.1–15.9) in 2014 to 25.4%(95%CI = 22.2–28.9) in 2003. The overall growth rate for HDS and prevalence of diarrhea diseases, decreased by 21.6% and 11.4% respectively. The most important risk factors of HDS from dominance analysis included; age of the child, wealth index, and differences in region. From pooled data wealth index, increasing age of the child, and regional disparity constituted approximately 72% of the overall impact (Weighted Standardized Dominance Statistics (WSDS) = 0.30, 0.24, and 0.19 respectively). In 2014, they constituted approximately 79% (WSDS = 0.139, 0.177 and 0.471 respectively). The average prevalence of diarrheal diseases among children of women who practiced HDS reduced over the period of the GDHS compared to those whose mothers did not practice HDS [2008 ATE(95%CI) = -0.09(-0.16–0.02), 2014 ATE(95%CI) = -0.05(-0.09–0.01) and Pooled data ATE(95%CI) = -0.05(-0.09–0.02)].

Conclusion

This analysis has provided empirical evidence of the impact of practicing HDS in Ghana from a national household survey. Implementation of the WASH agenda in this low-income setting requires a synergy of interventions and collaborations of actors (government, private and development partners) to improve water and sanitation facilities and to increase hygiene education to prevent the spread of diseases including diarrhea by 2025.

The risk of water, sanitation and hygiene on diarrhea-related infant mortality in eastern Ethiopia: a population-based nested case-control

BACKGROUND

Diarrhea is still appeared to be as one of the leading global killers and disability-adjusted life-years lost, particularly in the infant and children. As per WHO, about 88% of diarrhea-related deaths are attributable to unsafe water, inadequate sanitation and insufficient hygiene, mainly in developing world. Thus, the main objective of this study was to find out the risk of such factors that contribute for diarrhea-related infant mortality in Eastern Ethiopia.

METHODS

This study employed community based unmatched nested case-control study design in Eastern Ethiopia. The cases were infants who died from diarrheal disease while controls were those who survived their first year of life from September, 2016 to August, 2018. A total of 305 study subjects (61 cases and 244 controls) were included in the study. Infants dying from diarrhea were compared to four neighborhood controls in terms of several risk components of Water, Sanitation and Hygiene. Data were collected from mothers/care takers of infants using pre-tested structured questionnaires, and entered onto CSpro version 5.1 and transform to SPSS version 23 to analyzed potential risk factors.

FINDINGS

Finding of this study revealed that the risk factors that found to be significantly associated with infant death from diarrhoea after adjustment for confounding variables included the age of mother with < 20 years old (P = 0.009, AOR: 0.01, 95% CI: 0.01, 0.47), unsafe drinking water storage (P = 0.013, AOR: 0.4, 95% CI: 0.18, 0.81), infants in households without point-of-use water treatment practices (P = 0.004, AOR: 0.21, 95% CI: 0.08, 0.61), households with unimproved sanitation (P = 0.050, AOR: 0.36, 95% CI: 0.13, 1.00), unsafe disposing of child feces (P = 0.014, AOR: 0.34, 95% CI: 0.15, 0.81), and improper management of solid waste (P = 0.003, AOR: 0.29, 95% CI: 0.13, 0.66). These exposure factors had lower risk for the contribution of infants dying from diarrhoea than those with their reference group in the study area. However, infants in households with improper management of liquid waste management showed strongly significant association which had three times more likely to occur diarrhea-related infant death (P = 0.010, AOR: 3.43, 95% CI: 1.34, 8.76). Similarly, infants whose mother/caretaker practiced hand washing with less critical time (one-two occasions) had three times greater risk to infant death from diarrhea than those who had practice more than three critical times of hand washing (P = 0.027, AOR: 3.04, 95% CI: 1.13, 8.17).

CONCLUSION

This study suggests that infants in households with improper management of liquid waste and hand washing practices with fewer occasions (one-two critical time) are a greater risk of getting a diarrhea-related infant death. Therefore, efforts should be made to ensure intervention taking such risk factors into consideration, typically in the infantile period.

Independent and joint contribution of inappropriate complementary feeding and poor water, sanitation and hygiene (WASH) practices to stunted child growth

The causes of undernutrition are often linked to inappropriate complementary feeding practices and poor households' access to water, sanitation and hygiene (WASH), but limited evidence exists on the combined effect of poor WASH and inappropriate complementary feeding practices on stunted child growth. We assessed the independent and joint contribution of inappropriate complementary feeding and poor WASH practices to stunted growth among children aged 6-23 months in the Jirapa Municipality of Ghana. A community-based cross-sectional analytical study design was used with a sample of 301 mothers/caregivers having children aged 6-23 months. The results indicate that in a multivariable logistic regression model that adjusted for confounders, children receiving both unimproved water and inappropriate complementary feeding had a higher and significant odd of becoming stunted (adjusted odds ratio = 33. 92; 95 % confidence interval 3⋅04, 37⋅17; P = 0⋅004) compared to households having both improved water sources and appropriate complementary feeding practices. Except for unimproved drinking water sources, poor sanitation and hygiene, which comprised the use of unimproved household toilet facilities, washing hands without soap and improper disposal of child faeces were not associated with the risks of stunting among children aged 6-23 months. The combined effect of unimproved water and inappropriate complementary feeding on stunting was greater than either unimproved water only or inappropriate complementary feeding only.

Three-compartment septic tanks as sustainable on-site treatment facilities? Watch out for the potential dissemination of human-associated pathogens and antibiotic resistance

Improved sanitation is critical important to reduce the spread of human deposited pathogens and antibiotic resistance genes (ARGs). In the China's rural "Toilet Revolution", three-compartment septic tanks (SPTs) are widely used as household domestic sewage treatment facilities. The effluents of SPTs are encouraged to be used as fertilizer in agriculture. However, whether SPT could eliminate fecal pathogens and ARGs is still unrevealed which is crucial in risk assessment of SPT effluent utilization. Herein, we employed metagenomic sequencing to investigate the pathogens and ARGs in rural household SPTs from Tianjin, China. We found that rural household SPT effluents conserved pathogens comparable to that of the influents. A total of 441 ARGs conferring resistance to 26 antibiotic classes were observed in rural household SPTs, with the relative abundance ranging from 709 to 1800 ppm. Results of metagenomic assembly indicated that some ARG-MGE-carrying contigs were carried by pathogens, which may pose risk to human and animal health after being introduced to the environment. This study raises the question of SPTs as sustainable on-site treatment facilities for rural domestic sewage and underscores the need for more attention to the propagation and dissemination of antibiotic-resistant pathogens from SPT to the environments, animals, and humans.

Effect of Sewerage on the Contamination of Soil with Pathogenic Leptospira in Urban Slums

Leptospirosis is an environmentally transmitted zoonotic disease caused by pathogenic Leptospira spp. that affects poor communities worldwide. In urban slums, leptospirosis is associated with deficient sanitary infrastructure. Yet, the role of sewerage in the reduction of the environmental contamination with pathogenic Leptospira has not been explored. Here, we conducted a survey of the pathogen in soils surrounding open and closed sewer sections in six urban slums in Brazil. We found that soils surrounding conventionally closed sewers (governmental interventions) were 3 times less likely to contain pathogenic Leptospira (inverse OR 3.44, 95% CI = 1.66-8.33; p < 0.001) and contained a 6 times lower load of the pathogen (0.82 log10 units difference, p < 0.01) when compared to their open counterparts. However, no differences were observed in community-closed sewers (poor-quality closings performed by the slum dwellers). Human fecal markers (BacHum) were positively associated with pathogenic Leptospira even in closed sewers, and rat presence was not predictive of the presence of the pathogen in soils, suggesting that site-specific rodent control may not be sufficient to reduce the environmental contamination with Leptospira. Overall, our results indicate that sewerage expansion to urban slums may help reduce the environmental contamination with the pathogen and therefore reduce the risk of human leptospirosis.

Water, Sanitation, and Hygiene Practices in Urban Slums of Eastern India

Background

The Sustainable Development Goals identified universal access to water and sanitation facilities as key components for improving health. We assessed water, sanitation, and hygiene (WASH) practices and associated determinants among residents of urban slums in Kolkata, India.

Methods

Information on WASH practices was collected in 2 surveys (2018 and 2019) from participants of a prospective enteric fever surveillance conducted in 2 municipal wards of Kolkata. A composite WASH practice score was computed and a hierarchical stepwise multiple linear regression model constructed to identify key determinants of improved WASH score.

Results

Over 90% of households had access to piped water; 6% reported access to continuous supply. Adult women (61% in 2018; 45% in 2019) spent 20 minutes daily to fetch water. Access to improved latrines was almost universal, although 80% used shared facilities. Unhealthy disposal of children’s stools was reported in both rounds. Food hygiene practices were high, with most (>90%) washing uncooked items before eating; frequent consumption of street food items was reported.

Conclusions

The study area reported high WASH coverage. Unhygienic behavioral patterns predisposing to food- or water-borne diseases were also noted. Awareness building and sustainable community mobilization for food hygiene needs to be emphasized to ensure community well-being.

Detection and Quantification of Enteric Pathogens in Aerosols Near Open Wastewater Canals in Cities with Poor Sanitation

Urban sanitation infrastructure is inadequate in many low-income countries, leading to the presence of highly concentrated, uncontained fecal waste streams in densely populated areas. Combined with mechanisms of aerosolization, airborne transport of enteric microbes and their genetic material is possible in such settings but remains poorly characterized. We detected and quantified enteric pathogen-associated gene targets in aerosol samples near open wastewater canals (OWCs) or impacted (receiving sewage or wastewater) surface waters and control sites in La Paz, Bolivia; Kanpur, India; and Atlanta, USA, via multiplex reverse-transcription qPCR (37 targets) and ddPCR (13 targets). We detected a wide range of enteric targets, some not previously reported in extramural urban aerosols, with more frequent detections of all enteric targets at higher densities in La Paz and Kanpur near OWCs. We report density estimates ranging up to 4.7 × 10² gc per m_air³ across all targets including heat-stable enterotoxigenic Escherichia coli, Campylobacter jejuni, enteroinvasive E. coli/Shigella spp., Salmonella spp., norovirus, and Cryptosporidium spp. Estimated 25, 76, and 0% of samples containing positive pathogen detects were accompanied by culturable E. coli in La Paz, Kanpur, and Atlanta, respectively, suggesting potential for viability of enteric microbes at the point of sampling. Airborne transmission of enteric pathogens merits further investigation in cities with poor sanitation.

Impact of climate change and biodiversity collapse on the global emergence and spread of infectious diseases

The reality of climate change and biodiversity collapse is irrefutable in the 21st century, with urgent action required not only to conserve threatened species but also to protect human life and wellbeing. This existential threat forces us to recognise that our existence is completely dependent upon well-functioning ecosystems that sustain the diversity of life on our planet, including that required for human health. By synthesising data on the ecology, epidemiology and evolutionary biology of various pathogens, we are gaining a better understanding of factors that underlie disease emergence and spread. However, our knowledge remains rudimentary with limited insight into the complex feedback loops that underlie ecological stability, which are at risk of rapidly unravelling once certain tipping points are breached. In this paper, we consider the impact of climate change and biodiversity collapse on the ever-present risk of infectious disease emergence and spread. We review historical and contemporaneous infectious diseases that have been influenced by human environmental manipulation, including zoonoses and vector- and water-borne diseases, alongside an evaluation of the impact of migration, urbanisation and human density on transmissible diseases. The current lack of urgency in political commitment to address climate change warrants enhanced understanding and action from paediatricians - to ensure that we safeguard the health and wellbeing of children in our care today, as well as those of future generations.

Under-5 mortality in sub-Saharan Africa: is maternal age at first childbirth below 20 years a risk factor?

OBJECTIVES

This study aimed at examining the association between young maternal age at first childbirth and under-5 mortality in sub-Saharan Africa (SSA).

DESIGN AND SETTING

This cross-sectional study pooled nationally-representative data from the most recent Demographic and Health Surveys conducted in 30 countries in SSA from 2010 to 2019.

PARTICIPANTS

116 379 mothers of children under 5.

RESULTS

The prevalence of adolescent childbirth and death in children under 5 in SSA were 57.36% (95% CI 53.73% to 60.99%) and 4.10% (95% CI 3.65% to 4.54%), respectively. Children born to mothers whose first childbirth occurred at <20 years were 11% more likely to die before the age of 5 compared with those whose mothers' first childbirth occurred at age ≥20 years (adjusted odds ratio (aOR) 1.11; 95% CI 1.05 to 1.18). In terms of the covariates, the likelihood of under-5 mortality was higher among children born to single (aOR 1.54; 95% CI 1.41 to 1.67) and cohabiting mothers (aOR 1.10; 95% CI 1.01 to 1.21) compared with married mothers. Children born to mothers who were obese were more likely to die before the age of 5 compared with those born to mothers with normal body weight (aOR 1.17; 95% CI 1.09 to 1.26). The odds of under-5 mortality were higher among children whose weight at birth was <2500 g compared with those whose weight was ≥2500 g at birth (aOR 1.83; 95% CI 1.64 to 2.03).

CONCLUSIONS

The findings call for the need to enhance policies aimed at reducing under-5 mortality in SSA by reducing adolescent pregnancy and childbirth through family planning, comprehensive sexuality education, and the elimination of child marriage. Again, Since under-5 mortality among adolescent mothers is linked with their poor socio-economic status, there is the need for government and non-governmental organisations in SSA to introduce poverty alleviation programmes and improve access to both formal and informal education as a way of enhancing the socioeconomic status of adolescent mothers. Public health education, through continuous advocacy programmes should be done to encourage adolescent mothers to access antenatal care and health facility deliveries as a way of enhancing the survival status of their children. These interventions should be implemented, taking into consideration other characteristics of mothers such marital status and BMI and child's characteristics such as child's weight, which were found to be associated with high under-5 mortality.

A multilevel analysis of individual and contextual factors associated with the practice of safe disposal of children's faeces in sub-Saharan Africa

Background

Over the years, sanitation programs over the world have focused more on household sanitation, with limited attention towards the disposal of children’s stools. This lack of attention could be due to the misconception that children’s stools are harmless. The current study examined the individual and contextual predictors of safe disposal of children’s faeces among women in sub-Saharan Africa (SSA).

Methods

The study used secondary data involving 128,096 mother-child pairs of under-five children from the current Demographic and Health Surveys (DHS) in 15 sub-Saharan African countries from 2015 to 2018. Multilevel logistic analysis was used to assess the individual and contextual factors associated with the practice of safe disposal of children’s faeces. We presented the results as adjusted odds ratios (aOR) at a statistical significance of p< 0.05.

Results

The results show that 58.73% (57.79–59.68) of childbearing women in the 15 countries in SSA included in our study safely disposed off their children’s stools. This varied from as high as 85.90% (84.57–87.14) in Rwanda to as low as 26.38% (24.01–28.91) in Chad. At the individual level, the practice of safe disposal of children’s stools was more likely to occur among children aged 1, compared to those aged 0 [aOR = 1.74; 95% CI: 1.68–1.80] and those with diarrhoea compared to those without diarrhoea [aOR = 1.17, 95% CI: 1.13–1.21]. Mothers with primary level of education [aOR = 1.42, 95% CI: 1.30–1.5], those aged 35–39 [aOR = 1.20, 95% CI: 1.12–1.28], and those exposed to radio [aOR = 1.23, 95% CI: 1.20–1.27] were more likely to practice safe disposal of children’s stools. Conversely, the odds of safe disposal of children’s stool were lower among mothers who were married [aOR = 0.74, 95% CI: 0.69–0.80] and those who belonged to the Traditional African Religion [aOR = 0.64, 95% CI: 0.51–0.80]. With the contextual factors, women with improved water [aOR = 1.13, 95% CI: 1.10–1.16] and improved toilet facility [aOR = 5.75 95% CI: 5.55–5.95] had higher odds of safe disposal of children’s stool. On the other hand, mothers who lived in households with 5 or more children [aOR = 0.89, 95% CI: 0.86–0.93], those in rural areas [aOR = 0.86, 95% CI: 0.82–0.89], and those who lived in Central Africa [aOR = 0.19, 95% CI: 0.18–0.21] were less likely to practice safe disposal of children’s stools.

Conclusion

The findings indicate that between- and within-country contextual variations and commonalities need to be acknowledged in designing interventions to enhance safe disposal of children’s faeces. Audio-visual education on safe faecal disposal among rural women and large households can help enhance safe disposal. In light of the strong association between safe stool disposal and improved latrine use in SSA, governments need to develop feasible and cost-effective strategies to increase the number of households with access to improved toilet facilities.

An Assessment of Ambient Water Quality and Challenges with Access to Water and Sanitation Services for Individuals Experiencing Homelessness in Riverine Encampments

Individuals experiencing unsheltered homelessness face significant barriers to accessing water, sanitation, and hygiene services, but the risks associated with this lack of access and barriers to service provision have been largely understudied. We analyzed water samples upstream and downstream of three homeless encampments in the San Diego River watershed and interviewed service providers from public and nonprofit sectors to assess local perceptions about challenges and potential solutions for water and sanitation service provision in this context. Water upstream from encampments contained detectable levels of caffeine and sucralose. Escherichia coli concentrations downstream of the encampments were significantly greater than concentrations upstream, but there was no significant change in the concentrations of other pollutants, including caffeine and sucralose. The HF183 marker of Bacteroides was only detected in one sample upstream of an encampment and was not detected downstream. Overall, there was insufficient evidence to suggest that the encampments studied here were responsible for contributing pollution to the river. Nevertheless, the presence of caffeine, sucralose, and HF183 indicated that there are anthropogenic sources of contamination in the river during dry weather and potential risks associated with the use of this water by encampment residents. Interviews with service providers revealed perceptions that the provision of water and sanitation services for this population would be prohibitively expensive. Interviewees also reported perceptions that most riverbank residents avoided contact with service providers, which may present challenges for the provision of water and sanitation service unless trust is first built between service providers and residents of riverine encampments.