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Braun L, MacDougall A, Sumner T, Adriano Z, Viegas E, Nalá R, Brown J, Knee J, Cumming O. Associations between Shared Sanitation, Stunting and Diarrhoea in Low-Income, High Density Urban Neighbourhoods of Maputo, Mozambique - a Cross-Sectional Study. Matern Child Health J 2024; 28:775-784. [PMID: 38427278 DOI: 10.1007/s10995-024-03924-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/15/2024] [Indexed: 03/02/2024]
Abstract
INTRODUCTION Shared sanitation facilities are used by over 500 million people around the world. Most research evidence indicates that shared sanitation conveys higher risk than household sanitation for many adverse health outcomes. However, studies often fail to account for variation between different types of shared facilities. As informal housing development outpaces sanitation infrastructure, it is imperative to understand which components of shared facilities may mitigate the health risks of shared sanitation use. METHODS This cross-sectional study determines whether sanitation improvement or compound hygiene were associated with stunting or diarrhoeal prevalence in children under five living in Maputo, Mozambique who rely on shared sanitation facilities. The study uses logistic and linear multivariable regression analysis to search for associations and control for potential confounding factors. RESULTS 346 children (43.9%) in the study population were stunted. Each unit increase in sanitation score was associated with an approximate decrease of 22% in the odds of stunting (OR: 0.78, CI: 0.66, 0.92), and an increase in height of 0.23 height-for-age z-scores (CI: 0.10, 0.36). There was no evidence that the compound hygiene score was associated with height as measured by stunting (OR: 1.05, CI: 0.87, 1.26) or z-score (-0.06, CI: -0.21, 0.09). Neither sanitation nor compound hygiene score were associated with diarrhoea in the population. CONCLUSIONS Use of an improved shared latrine is associated with decreased odds of stunting. There is no evidence of an association between latrine improvement and diarrhoea. Further investigation is necessary to isolate attributes of shared sanitation facilities that may reduce health risks.
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Affiliation(s)
- Laura Braun
- Department of Disease Control, London School of Hygiene and Tropical Medicine, London, UK.
| | - Amy MacDougall
- Department of Medical Statistics, London School of Hygiene and Tropical Medicine, London, UK
| | - Trent Sumner
- School of Civil and Environmental Engineering, Georgia Institute of Technology, Atlanta, USA
| | | | - Edna Viegas
- Instituto Nacional de Saúde Maputo, Maputo, Mozambique
| | - Rassul Nalá
- Instituto Nacional de Saúde Maputo, Maputo, Mozambique
| | - Joe Brown
- Department of Environmental Sciences and Engineering, Gillings School of Public Health, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Jackie Knee
- Department of Disease Control, London School of Hygiene and Tropical Medicine, London, UK
| | - Oliver Cumming
- Department of Disease Control, London School of Hygiene and Tropical Medicine, London, UK
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Capone D, Cumming O, Flemister A, Ilevbare V, Irish SR, Keenum I, Knee J, Nala R, Brown J. Sanitation in urban areas may limit the spread of antimicrobial resistance via flies. PLoS One 2024; 19:e0298578. [PMID: 38507457 PMCID: PMC10954131 DOI: 10.1371/journal.pone.0298578] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2023] [Accepted: 01/28/2024] [Indexed: 03/22/2024] Open
Abstract
Synanthropic filth flies are common where sanitation is poor and fecal wastes are accessible to them. These flies have been proposed as mechanical vectors for the localized transport of fecal microbes including antimicrobial resistant (AMR) organisms and associated antimicrobial resistance genes (ARGs), increasing exposure risks. We evaluated whether an onsite sanitation intervention in Maputo, Mozambique reduced the concentration of enteric bacteria and the frequency of detection of ARGs carried by flies collected in household compounds of low-income neighborhoods. Additionally, we assessed the phenotypic resistance profile of Enterobacteriaceae isolates recovered from flies during the pre-intervention phase. After fly enumeration at study compounds, quantitative polymerase chain reaction was used to quantify an enteric 16S rRNA gene (i.e., specific to a cluster of phylotypes corresponding to 5% of the human fecal microflora), 28 ARGs, and Kirby Bauer Disk Diffusion of Enterobacteriaceae isolates was utilized to assess resistance to eleven clinically relevant antibiotics. The intervention was associated with a 1.5 log10 reduction (95% confidence interval: -0.73, -2.3) in the concentration of the enteric 16S gene and a 31% reduction (adjusted prevalence ratio = 0.69, [0.52, 0.92]) in the mean number of ARGs per fly compared to a control group with poor sanitation. This protective effect was consistent across the six ARG classes that we detected. Enterobacteriaceae isolates-only from the pre-intervention phase-were resistant to a mean of 3.4 antibiotics out of the eleven assessed. Improving onsite sanitation infrastructure in low-income informal settlements may help reduce fly-mediated transmission of enteric bacteria and the ARGs carried by them.
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Affiliation(s)
- Drew Capone
- Department of Environmental and Occupational Health, Indiana University, Bloomington, Indiana, United States of America
| | - Oliver Cumming
- Department of Disease Control, London School of Hygiene and Tropical Medicine, London, United Kingdom
| | - Abeoseh Flemister
- Roy Blunt NextGen Precision Health, University of Missouri, Columbia, Missouri, United States of America
- Department of Radiology, University of Missouri, Columbia, MO, United States of America
| | - Victor Ilevbare
- Department of Biology, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, United States of America
| | - Seth R. Irish
- Epidemiology and Public Health Department, Swiss Tropical and Public Health Institute, Allschwil, Switzerland
| | - Ishi Keenum
- Department of Civil, Environmental and Geospatial Engineering, Michigan Technological University, Houghton, Michigan, United States of America
| | - Jackie Knee
- Department of Disease Control, London School of Hygiene and Tropical Medicine, London, United Kingdom
| | - Rassul Nala
- Ministério da Saúde de Moçambique, Instituto Nacional de Saúde, Maputo, Mozambique
| | - Joe Brown
- Department of Environmental Sciences and Engineering, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, United States of America
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Holcomb DA, Monteiro V, Capone D, António V, Chiluvane M, Cumbane V, Ismael N, Knee J, Kowalsky E, Lai A, Linden Y, Mataveia E, Nala R, Rao G, Ribeiro J, Cumming O, Viegas E, Brown J. Long-term impacts of an urban sanitation intervention on enteric pathogens in children in Maputo city, Mozambique: study protocol for a cross-sectional follow-up to the Maputo Sanitation (MapSan) trial 5 years postintervention. BMJ Open 2023; 13:e067941. [PMID: 37290945 PMCID: PMC10254709 DOI: 10.1136/bmjopen-2022-067941] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/31/2022] [Accepted: 05/24/2023] [Indexed: 06/10/2023] Open
Abstract
INTRODUCTION We previously assessed the effect of an onsite sanitation intervention in informal neighbourhoods of urban Maputo, Mozambique on enteric pathogen detection in children after 2 years of follow-up (Maputo Sanitation (MapSan) trial, ClinicalTrials.gov: NCT02362932). We found significant reductions in Shigella and Trichuris prevalence but only among children born after the intervention was delivered. In this study, we assess the health impacts of the sanitation intervention after 5 years among children born into study households postintervention. METHODS AND ANALYSIS We are conducting a cross-sectional household study of enteric pathogen detection in child stool and the environment at compounds (household clusters sharing sanitation and outdoor living space) that received the pour-flush toilet and septic tank intervention at least 5 years prior or meet the original criteria for trial control sites. We are enrolling at least 400 children (ages 29 days to 60 months) in each treatment arm. Our primary outcome is the prevalence of 22 bacterial, protozoan, and soil transmitted helminth enteric pathogens in child stool using the pooled prevalence ratio across the outcome set to assess the overall intervention effect. Secondary outcomes include the individual pathogen detection prevalence and gene copy density of 27 enteric pathogens (including viruses); mean height-for-age, weight-for-age, and weight-for-height z-scores; prevalence of stunting, underweight, and wasting; and the 7-day period prevalence of caregiver-reported diarrhoea. All analyses are adjusted for prespecified covariates and examined for effect measure modification by age. Environmental samples from study households and the public domain are assessed for pathogens and faecal indicators to explore environmental exposures and monitor disease transmission. ETHICS AND DISSEMINATION Study protocols have been reviewed and approved by human subjects review boards at the Ministry of Health, Republic of Mozambique and the University of North Carolina at Chapel Hill. Deidentified study data will be deposited at https://osf.io/e7pvk/. TRIAL REGISTRATION NUMBER ISRCTN86084138.
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Affiliation(s)
- David A Holcomb
- Department of Environmental Sciences and Engineering, Gillings School of Global Public Health, University of North Carolina, Chapel Hill, North Carolina, USA
- Department of Epidemiology, Gillings School of Global Public Health, University of North Carolina, Chapel Hill, North Carolina, USA
| | - Vanessa Monteiro
- Centro de Investigação e Treino em Saúde da Polana Caniço, Instituto Nacional de Saúde, Maputo, Mozambique
| | - Drew Capone
- Department of Environmental and Occupational Health, School of Public Health, Indiana University, Bloomington, Indiana, USA
| | - Virgílio António
- Division of Biotechnology and Genetics, Instituto Nacional de Saúde, Marracuene, Mozambique
| | - Márcia Chiluvane
- Centro de Investigação e Treino em Saúde da Polana Caniço, Instituto Nacional de Saúde, Maputo, Mozambique
| | - Victória Cumbane
- Centro de Investigação e Treino em Saúde da Polana Caniço, Instituto Nacional de Saúde, Maputo, Mozambique
| | - Nália Ismael
- Division of Biotechnology and Genetics, Instituto Nacional de Saúde, Marracuene, Mozambique
| | - Jackie Knee
- Department of Disease Control, Faculty of Infectious and Tropical Diseases, London School of Hygiene and Tropical Medicine, London, UK
| | - Erin Kowalsky
- Department of Environmental Sciences and Engineering, Gillings School of Global Public Health, University of North Carolina, Chapel Hill, North Carolina, USA
| | - Amanda Lai
- Department of Environmental Sciences and Engineering, Gillings School of Global Public Health, University of North Carolina, Chapel Hill, North Carolina, USA
| | - Yarrow Linden
- Department of Environmental Sciences and Engineering, Gillings School of Global Public Health, University of North Carolina, Chapel Hill, North Carolina, USA
| | - Elly Mataveia
- Centro de Investigação e Treino em Saúde da Polana Caniço, Instituto Nacional de Saúde, Maputo, Mozambique
| | - Rassul Nala
- Division of Parasitology, Instituto Nacional de Saúde, Maputo, Mozambique
| | - Gouthami Rao
- Department of Environmental Sciences and Engineering, Gillings School of Global Public Health, University of North Carolina, Chapel Hill, North Carolina, USA
| | - Jorge Ribeiro
- Centro de Investigação e Treino em Saúde da Polana Caniço, Instituto Nacional de Saúde, Maputo, Mozambique
| | - Oliver Cumming
- Department of Disease Control, Faculty of Infectious and Tropical Diseases, London School of Hygiene and Tropical Medicine, London, UK
| | - Edna Viegas
- Centro de Investigação e Treino em Saúde da Polana Caniço, Instituto Nacional de Saúde, Maputo, Mozambique
| | - Joe Brown
- Department of Environmental Sciences and Engineering, Gillings School of Global Public Health, University of North Carolina, Chapel Hill, North Carolina, USA
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Hansen T, Laursen LB, Hansen MS. Early Feasibility of an Activity-Based Intervention for Improving Ingestive Functions in Older Adults with Oropharyngeal Dysphagia. Geriatrics (Basel) 2023; 8:geriatrics8020044. [PMID: 37102970 PMCID: PMC10137850 DOI: 10.3390/geriatrics8020044] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2023] [Revised: 03/26/2023] [Accepted: 04/18/2023] [Indexed: 04/28/2023] Open
Abstract
There is growing awareness about the use of combined strength- and skill-based swallowing training for improving swallowing physiology in the event of dysphagia. Such an approach involves focusing on coordination and timing as well as swallowing strengthening in the context of increased exercise complexity in eating and drinking activities. This study aimed to determine the early feasibility of a newly developed 12-week intervention, named the ACT-ING program (ACTivity-based strength and skill training of swallowing to improve INGestion), in older adults with dysphagia and generalized sarcopenia. In a multiple-case-study design, seven participants above 65 years of age (five women and two men) with slight to severe dysphagia and indications of sarcopenia underwent the intervention during hospitalization and in the community after discharge. The ACT-ING program met most of the feasibility marks in terms of demand (73.3% of those invited accepted participation), safety (100%), no reports of adverse events, tolerance (85.7%), usability (100%), and acceptability (100%). Three putative mediators of change (experienced autonomy support, in-therapy engagement, and perceived improvement in swallowing capacity) appeared to have been best accomplished in participants with slight to moderate dysphagia. The ACT-ING program showed preliminary evidence of early feasibility, warranting further early-phase dose articulation and proof-of-concept trials.
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Affiliation(s)
- Tina Hansen
- Physical Medicine & Rehabilitation Research-Copenhagen (PMR-C), Department of Occupational Therapy and Physiotherapy, Copenhagen University Hospital Amager and Hvidovre, 2650 Hvidovre, Denmark
| | - Louise Bolvig Laursen
- Physical Medicine & Rehabilitation Research-Copenhagen (PMR-C), Department of Occupational Therapy and Physiotherapy, Copenhagen University Hospital Amager and Hvidovre, 2650 Hvidovre, Denmark
| | - Maria Swennergren Hansen
- Physical Medicine & Rehabilitation Research-Copenhagen (PMR-C), Department of Occupational Therapy and Physiotherapy, Copenhagen University Hospital Amager and Hvidovre, 2650 Hvidovre, Denmark
- Department of Orthopedic Surgery, Copenhagen University Hospital Amager and Hvidovre, 2650 Hvidovre, Denmark
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Mertens A, Arnold BF, Benjamin-Chung J, Boehm AB, Brown J, Capone D, Clasen T, Fuhrmeister E, Grembi JA, Holcomb D, Knee J, Kwong LH, Lin A, Luby SP, Nala R, Nelson K, Njenga SM, Null C, Pickering AJ, Rahman M, Reese HE, Steinbaum L, Stewart J, Thilakaratne R, Cumming O, Colford JM, Ercumen A. Effects of water, sanitation, and hygiene interventions on detection of enteropathogens and host-specific faecal markers in the environment: a systematic review and individual participant data meta-analysis. Lancet Planet Health 2023; 7:e197-e208. [PMID: 36889861 PMCID: PMC10009758 DOI: 10.1016/s2542-5196(23)00028-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2022] [Revised: 01/25/2023] [Accepted: 01/31/2023] [Indexed: 06/18/2023]
Abstract
BACKGROUND Water, sanitation, and hygiene (WASH) improvements are promoted to reduce diarrhoea in low-income countries. However, trials from the past 5 years have found mixed effects of household-level and community-level WASH interventions on child health. Measuring pathogens and host-specific faecal markers in the environment can help investigate causal pathways between WASH and health by quantifying whether and by how much interventions reduce environmental exposure to enteric pathogens and faecal contamination from human and different animal sources. We aimed to assess the effects of WASH interventions on enteropathogens and microbial source tracking (MST) markers in environmental samples. METHODS We did a systematic review and individual participant data meta-analysis, which included searches from Jan 1, 2000, to Jan 5, 2023, from PubMed, Embase, CAB Direct Global Health, Agricultural and Environmental Science Database, Web of Science, and Scopus, of prospective studies with water, sanitation, or hygiene interventions and concurrent control group that measured pathogens or MST markers in environmental samples and measured child anthropometry, diarrhoea, or pathogen-specific infections. We used covariate-adjusted regression models with robust standard errors to estimate study-specific intervention effects and pooled effect estimates across studies using random-effects models. FINDINGS Few trials have measured the effect of sanitation interventions on pathogens and MST markers in the environment and they mostly focused on onsite sanitation. We extracted individual participant data on nine environmental assessments from five eligible trials. Environmental sampling included drinking water, hand rinses, soil, and flies. Interventions were consistently associated with reduced pathogen detection in the environment but effect estimates in most individual studies could not be distinguished from chance. Pooled across studies, we found a small reduction in the prevalence of any pathogen in any sample type (pooled prevalence ratio [PR] 0·94 [95% CI 0·90-0·99]). Interventions had no effect on the prevalence of MST markers from humans (pooled PR 1·00 [95% CI 0·88-1·13]) or animals (pooled PR 1·00 [95% CI 0·97-1·03]). INTERPRETATION The small effect of these sanitation interventions on pathogen detection and absence of effects on human or animal faecal markers are consistent with the small or null health effects previously reported in these trials. Our findings suggest that the basic sanitation interventions implemented in these studies did not contain human waste and did not adequately reduce exposure to enteropathogens in the environment. FUNDING Bill and Melinda Gates Foundation and the UK Foreign and Commonwealth Development Office.
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Affiliation(s)
- Andrew Mertens
- Division of Epidemiology and Biostatistics, University of California, Berkeley, CA, USA.
| | - Benjamin F Arnold
- Francis I Proctor Foundation and Department of Ophthalmology, University of California, San Francisco, CA, USA
| | - Jade Benjamin-Chung
- Department of Epidemiology and Population Health, Stanford University, Stanford, CA, USA
| | - Alexandria B Boehm
- Department of Civil and Environmental Engineering, Stanford University, Stanford, CA, USA
| | - Joe Brown
- Department of Environmental Science and Engineering, Gillings School of Global Public Health, Michael Hooker Research Center, University of North Carolina, Chapel Hill, NC, USA
| | - Drew Capone
- Department of Environmental and Occupational Health, Indiana University Bloomington, Bloomington, IN, USA
| | - Thomas Clasen
- Department of Environmental Health, Rollins School of Public Health, Emory University, NE, Atlanta, GA, USA
| | - Erica Fuhrmeister
- Department of Environmental and Occupational Health Sciences, University of Washington, Seattle, WA, USA
| | | | - David Holcomb
- Department of Environmental Science and Engineering, Gillings School of Global Public Health, Michael Hooker Research Center, University of North Carolina, Chapel Hill, NC, USA
| | - Jackie Knee
- Department of Disease Control, London School of Tropical Medicine & Hygiene, London, UK
| | - Laura H Kwong
- Division of Environmental Health Sciences, University of California, Berkeley, CA, USA
| | - Audrie Lin
- Department of Biobehavioral Health, Pennsylvania State University, PA, USA
| | - Stephen P Luby
- Division of Infectious Diseases and Geographic Medicine, Stanford University, Stanford, CA, USA
| | - Rassul Nala
- Ministério da Saúde, Instituto Nacional de Saúde Maputo, Maputo, Mozambique
| | - Kara Nelson
- Department of Civil and Environmental Engineering, College of Engineering, University of California, Berkeley, CA, USA
| | | | | | - Amy J Pickering
- Department of Civil and Environmental Engineering, College of Engineering, University of California, Berkeley, CA, USA
| | - Mahbubur Rahman
- Environmental Interventions Unit, Infectious Diseases Division, Dhaka, Bangladesh
| | - Heather E Reese
- Department of Environmental Health, Rollins School of Public Health, Emory University, NE, Atlanta, GA, USA
| | - Lauren Steinbaum
- Center for the Ecology of Infectious Diseases, University of Georgia, Athens, GA, USA
| | - Jill Stewart
- Department of Environmental Science and Engineering, Gillings School of Global Public Health, Michael Hooker Research Center, University of North Carolina, Chapel Hill, NC, USA
| | - Ruwan Thilakaratne
- Division of Epidemiology and Biostatistics, University of California, Berkeley, CA, USA
| | - Oliver Cumming
- Department of Disease Control, London School of Tropical Medicine & Hygiene, London, UK
| | - John M Colford
- Division of Epidemiology and Biostatistics, University of California, Berkeley, CA, USA
| | - Ayse Ercumen
- Department of Forestry and Environmental Resources, North Carolina State University, Raleigh, NC, USA
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Capone D, Barker T, Cumming O, Flemister A, Geason R, Kim E, Knee J, Linden Y, Manga M, Meldrum M, Nala R, Smith S, Brown J. Persistent Ascaris Transmission Is Possible in Urban Areas Even Where Sanitation Coverage Is High. ENVIRONMENTAL SCIENCE & TECHNOLOGY 2022; 56:15969-15980. [PMID: 36288473 PMCID: PMC9671051 DOI: 10.1021/acs.est.2c04667] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 07/01/2022] [Revised: 10/13/2022] [Accepted: 10/14/2022] [Indexed: 06/16/2023]
Abstract
In low-income, urban, informal communities lacking sewerage and solid waste services, onsite sanitation (sludges, aqueous effluent) and child feces are potential sources of human fecal contamination in living environments. Working in informal communities of urban Maputo, Mozambique, we developed a quantitative, stochastic, mass-balance approach to evaluate plausible scenarios of localized contamination that could explain why the soil-transmitted helminth Ascaris remains endemic despite nearly universal coverage of latrines that sequester most fecal wastes. We used microscopy to enumerate presumptively viable Ascaris ova in feces, fecal sludges, and soils from compounds (i.e., household clusters) and then constructed a steady-state mass-balance model to evaluate possible contamination scenarios capable of explaining observed ova counts in soils. Observed Ascaris counts (mean = -0.01 log10 ova per wet gram of soil, sd = 0.71 log10) could be explained by deposits of 1.9 grams per day (10th percentile 0.04 grams, 90th percentile 84 grams) of child feces on average, rare fecal sludge contamination events that transport 17 kg every three years (10th percentile 1.0 kg, 90th percentile 260 kg), or a daily discharge of 2.7 kg aqueous effluent from an onsite system (10th percentile 0.09 kg, 90th percentile 82 kg). Results suggest that even limited intermittent flows of fecal wastes in this setting can result in a steady-state density of Ascaris ova in soils capable of sustaining transmission, given the high prevalence of Ascaris shedding by children (prevalence = 25%; mean = 3.7 log10 per wet gram, sd = 1.1 log10), the high Ascaris ova counts in fecal sludges (prevalence = 88%; mean = 1.8 log10 per wet gram, sd = 0.95 log10), and the extended persistence and viability of Ascaris ova in soils. Even near-universal coverage of onsite sanitation may allow for sustained transmission of Ascaris under these conditions.
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Affiliation(s)
- Drew Capone
- Department
of Environmental and Occupational Health, School of Public Health, Indiana University, Bloomington, Indiana47401, United States
| | - Troy Barker
- Department
of Environmental Sciences and Engineering, Gillings School of Public
Health, University of North Carolina at
Chapel Hill, Chapel
Hill, North Carolina27599, United States
| | - Oliver Cumming
- Department
of Disease Control, London School of Hygiene
and Tropical Medicine, LondonWC1E 7HT, U.K.
| | - Abeoseh Flemister
- Department
of Biology, University of North Carolina
at Chapel Hill, Chapel
Hill, North Carolina27599, United States
| | - Riley Geason
- Department
of Biology, University of North Carolina
at Chapel Hill, Chapel
Hill, North Carolina27599, United States
| | - Elizabeth Kim
- Department
of Biology, University of North Carolina
at Chapel Hill, Chapel
Hill, North Carolina27599, United States
| | - Jackie Knee
- Department
of Disease Control, London School of Hygiene
and Tropical Medicine, LondonWC1E 7HT, U.K.
| | - Yarrow Linden
- Department
of Environmental Sciences and Engineering, Gillings School of Public
Health, University of North Carolina at
Chapel Hill, Chapel
Hill, North Carolina27599, United States
| | - Musa Manga
- Department
of Environmental Sciences and Engineering, Gillings School of Public
Health, University of North Carolina at
Chapel Hill, Chapel
Hill, North Carolina27599, United States
| | - Mackenzie Meldrum
- Department
of Civil and Environmental Engineering, Georgia Institute of Technology, Atlanta, Georgia30332, United States
| | - Rassul Nala
- Ministério
da Saúde, Instituto Nacional de Saúde
Maputo, Maputo1102, Mozambique
| | - Simrill Smith
- Department
of Civil and Environmental Engineering, Georgia Institute of Technology, Atlanta, Georgia30332, United States
| | - Joe Brown
- Department
of Environmental Sciences and Engineering, Gillings School of Public
Health, University of North Carolina at
Chapel Hill, Chapel
Hill, North Carolina27599, United States
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