A Cluster-Randomized Controlled Trial to Reduce Diarrheal Disease and Dengue Entomological Risk Factors in Rural Primary Schools in Colombia

Impact of a school-based water and hygiene intervention on child health and school attendance in Addis Ababa, Ethiopia: a cluster-randomised controlled trial

BACKGROUND

School-based water, sanitation and hygiene (WASH) may improve the health and attendance of schoolchildren, particularly post-menarcheal girls, but existing evidence is mixed. We examined the impact of an urban school-based WASH programme (Project WISE) on child health and attendance.

METHODS

The WISE cluster-randomised trial, conducted in 60 public primary schools in Addis Ababa, Ethiopia over one academic year, enrolled 2-4 randomly selected classes per school (~ 100 pupils) from grades 2 to 8 (aged 7-16) in an 'open cohort'. Schools were assigned 1:1 by stratified randomisation to receive the intervention during the 2021/2022 or the 2022/2023 academic year (waitlist control). The intervention included improvements to drinking water storage, filtration and access, handwashing stations and behaviour change promotion. Planned sanitation improvements were not realised. At four unannounced classroom visits post-intervention (March-June 2022), enumerators recorded primary outcomes of roll-call absence, and pupil-reported respiratory illness and diarrhoea in the past 7 days among pupils present. Analysis was by intention-to-treat.

RESULTS

Of 83 eligible schools, 60 were randomly selected and assigned. In total, 6229 eligible pupils were enrolled (median per school 101.5; IQR 94-112), 5987 enrolled at study initiation (23rd November-22nd December 2021) and the remaining 242 during follow-up. Data were available on roll-call absence for 6166 pupils (99.0%), and pupil-reported illness for 6145 pupils (98.6%). We observed a 16% relative reduction in odds of pupil-reported respiratory illness in the past 7 days during follow-up in intervention vs. control schools (aOR 0.84; 95% CI 0.71-1.00; p = 0.046). There was no evidence of effect on pupil-reported diarrhoea in the past 7 days (aOR 1.15; 95% CI 0.84-1.59; p = 0.39) nor roll-call absence (aOR 1.07; 95% 0.83-1.38; p = 0.59). There was a small increase in menstrual care self-efficacy (aMD 3.32 on 0-100 scale; 95% CI 0.05-6.59), and no evidence of effects on other secondary outcomes.

CONCLUSIONS

This large-scale intervention to improve school WASH conditions city-wide had a borderline impact on pupil-reported respiratory illness but no effect on diarrhoeal disease nor pupil absence. Future research should establish relationships between WASH-related illness, absence and other educational outcomes.

TRIAL REGISTRATION

ClinicalTrials.gov, number NCT05024890.

Systematic Review of Impacts of Educational Interventions to Control Breeding Sites of Aedes aegypti and Aedes albopictus Mosquitoes

Community participation is a critical element in the management of Aedes aegypti and Aedes albopictus breeding sites. Many educational interventions have been conducted to encourage prevention and elimination of breeding sites among different community actors, such as government-run programs for vector surveillance aimed at preventing and eliminating breeding sites at the household level within a community. Getting people involved in prevention and elimination of vector breeding sites in their communities requires communication and social mobilization strategies to promote and reinforce those prevention actions that, in turn, should be effective from the entomological standpoint. Articles published in English, Spanish, and Portuguese, were reviewed to assess whether educational interventions targeting Ae. aegypti and Ae. albopictus were effective in reducing entomological indicators or in improving practices to prevent the presence of or eliminate breeding sites. The most widely used indicators were larval indices and the practices associated with reducing/eliminating breeding sites. We found that using a community-based approach adapted to eco-epidemiological and sociocultural scenarios explains the reduction of entomological indicators by educational interventions. Those who design or implement educational interventions should strengthen the evaluation of those interventions using qualitative approaches that provide a more complete picture of the social context and the barriers and facilitators to implementing vector control. Engaging school children in cross-sectorial collaboration involving the health and education spheres promotes the participation of the community in vector surveillance and reduces the risk of arboviral disease transmission.

Effectiveness of a Nursing Educational Intervention in Adults to Promote Control Behaviors Against Dengue: Protocol for a Randomized Controlled Trial

BACKGROUND

The increase in dengue cases can be attributed to social, demographic, environmental changes, or community-driven factors. In this regard, different strategies have been established in health education, using educational interventions as necessary tools for the reduction of the disease with the aim of reinforcing and stimulating the prevention and control of dengue.

OBJECTIVE

This study aims to evaluate the effectiveness of a nursing educational intervention for dengue control.

METHODS

A randomized controlled trial will be conducted with adults living in rural areas and participating in health promotion and disease prevention programs. We will enroll 116 adults. Adults will be randomized 1:1, with 58 adults assigned to the educational intervention group and 58 to the usual care group. Participants will receive 4 sessions over the course of a month, 1 week apart, and will be followed up for 1 month after the end of the educational intervention. Nursing Outcome Classification labels will be used to measure the outcomes: risk control (1902) and participation in health care decisions (1606).

RESULTS

The participants in the intervention group are expected to achieve better dengue control behaviors than those in the usual care group.

CONCLUSIONS

Risk factors are fostered by the community, largely caused by artificial reservoirs or unprotected tanks in homes; also, the lack of information hinders the identification of symptomatology and the poor implementation of effective measures, and the development of standardized educational strategies can contribute to efficient and cost-effective control of the disease.

TRIAL REGISTRATION

ClinicalTrials.gov NCT05321264; https://clinicaltrials.gov/study/NCT05321264.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

PRR1-10.2196/54286.

School and community driven dengue vector control and monitoring in Myanmar: Study protocol for a cluster randomized controlled trial

Background

Dengue is the most common and widespread mosquito-borne arboviral disease globally estimated to cause >390 million infections and >20,000 deaths annually. There are no effective preventive drugs and the newly introduced vaccines are not yet available. Control of dengue transmission still relies primarily on mosquito vector control. Although most vector control methods currently used by national dengue control programs may temporarily reduce mosquito populations, there is little evidence that they affect transmission. There is an urgent need for innovative, participatory, effective, and locally adapted approaches for sustainable vector control and monitoring in which students can be particularly relevant contributors and to demonstrate a clear link between vector reduction and dengue transmission reduction, using tools that are inexpensive and easy to use by local communities in a sustainable manner.

Methods

Here we describe a cluster randomized controlled trial to be conducted in 46 school catchment areas in two townships in Yangon, Myanmar. The outcome measures are dengue cases confirmed by rapid diagnostic test in the townships, dengue incidence in schools, entomological indices, knowledge, attitudes and practice, behavior, and engagement.

Conclusions

The trial involves middle school students that positions them to become actors in dengue knowledge transfer to their communities and take a leadership role in the delivery of vector control interventions and monitoring methods. Following this rationale, we believe that students can become change agents of decentralized vector surveillance and sustainable disease control in line with recent new paradigms in integrated and participatory vector surveillance and control. This provides an opportunity to operationalize transdisciplinary research towards sustainable health development. Due to the COVID-19 pandemic and political instability in Myanmar the project has been terminated by the donor, but the protocol will be helpful for potential future implementation of the project in Myanmar and/or elsewhere.Registration: This trial was registered in the ISRCTN Registry on 31 May 2022 ( https://doi.org/10.1186/ISRCTN78254298).

The application of environmental management methods in combating dengue: a systematic review

Among several vector control methods commonly used, environmental management is one of the control measures to mitigate dengue in such vulnerable communities. Since there is no curative treatment for dengue yet, targeted environmental and ecosystem management is increasingly relevant. Hence, this review was conducted to identify the effectiveness of environmental management intervention strategy to reduce dengue cases. We searched PUBMED, CENTRAL, SCOPUS, Web of Science, CIJE, WHO ICTRP, and ClinicalTrials.gov up to January 2021. A total of 521 articles were screened. Only 16 studies were included in this review. There were 6 studies that applied all three types of environmental management interventions (manipulation, modification and behavior), 8 studies applied two types of interventions (manipulation and behavior) and 2 studies applied one type of intervention (manipulation or behavior). All included studies reported reduction of Aedes entomological indices. The studies showed reduction in dengue cases and density of Aedes population through environmental interventions. It is recommended for the health authority to incorporate environmental management intervention in dengue control activities and enhanced the community involvement to ensure sustainability with high impact on dengue reduction.

Characterizing dengue transmission in rural areas: A systematic review

Dengue has historically been considered an urban disease associated with dense human populations and the built environment. Recently, studies suggest increasing dengue virus (DENV) transmission in rural populations. It is unclear whether these reports reflect recent spread into rural areas or ongoing transmission that was previously unnoticed, and what mechanisms are driving this rural transmission. We conducted a systematic review to synthesize research on dengue in rural areas and apply this knowledge to summarize aspects of rurality used in current epidemiological studies of DENV transmission given changing and mixed environments. We described how authors defined rurality and how they defined mechanisms for rural dengue transmission. We systematically searched PubMed, Web of Science, and Embase for articles evaluating dengue prevalence or cumulative incidence in rural areas. A total of 106 articles published between 1958 and 2021 met our inclusion criteria. Overall, 56% (n = 22) of the 48 estimates that compared urban and rural settings reported rural dengue incidence as being as high or higher than in urban locations. In some rural areas, the force of infection appears to be increasing over time, as measured by increasing seroprevalence in children and thus likely decreasing age of first infection, suggesting that rural dengue transmission may be a relatively recent phenomenon. Authors characterized rural locations by many different factors, including population density and size, environmental and land use characteristics, and by comparing their context to urban areas. Hypothesized mechanisms for rural dengue transmission included travel, population size, urban infrastructure, vector and environmental factors, among other mechanisms. Strengthening our understanding of the relationship between rurality and dengue will require a more nuanced definition of rurality from the perspective of DENV transmission. Future studies should focus on characterizing details of study locations based on their environmental features, exposure histories, and movement dynamics to identify characteristics that may influence dengue transmission.

Interventions to improve sanitation for preventing diarrhoea

BACKGROUND

Diarrhoea is a major contributor to the global disease burden, particularly amongst children under five years in low- and middle-income countries (LMICs). As many of the infectious agents associated with diarrhoea are transmitted through faeces, sanitation interventions to safely contain and manage human faeces have the potential to reduce exposure and diarrhoeal disease.

OBJECTIVES

To assess the effectiveness of sanitation interventions for preventing diarrhoeal disease, alone or in combination with other WASH interventions.

SEARCH METHODS

We searched the Cochrane Infectious Diseases Group Specialized Register, CENTRAL, MEDLINE, Embase, LILACS, and Chinese language databases available under the China National Knowledge Infrastructure (CNKI-CAJ). We also searched the metaRegister of Controlled Trials (mRCT) and conference proceedings, contacted researchers, and searched references of included studies. The last search date was 16 February 2022.

SELECTION CRITERIA

We included randomized controlled trials (RCTs), quasi-RCTs, non-randomized controlled trials (NRCTs), controlled before-and-after studies (CBAs), and matched cohort studies of interventions aimed at introducing or expanding the coverage and/or use of sanitation facilities in children and adults in any country or population. Our primary outcome of interest was diarrhoea and secondary outcomes included dysentery (bloody diarrhoea), persistent diarrhoea, hospital or clinical visits for diarrhoea, mortality, and adverse events. We included sanitation interventions whether they were conducted independently or in combination with other interventions.

DATA COLLECTION AND ANALYSIS

Two review authors independently assessed eligible studies, extracted relevant data, assessed risk of bias, and assessed the certainty of evidence using the GRADE approach. We used meta-analyses to estimate pooled measures of effect, described results narratively, and investigated potential sources of heterogeneity using subgroup analyses.

MAIN RESULTS

Fifty-one studies met our inclusion criteria, with a total of 238,535 participants. Of these, 50 studies had sufficient information to be included in quantitative meta-analysis, including 17 cluster-RCTs and 33 studies with non-randomized study designs (20 NRCTs, one CBA, and 12 matched cohort studies). Most were conducted in LMICs and 86% were conducted in whole or part in rural areas. Studies covered three broad types of interventions: (1) providing access to any sanitation facility to participants without existing access practising open defecation, (2) improving participants' existing sanitation facility, or (3) behaviour change messaging to improve sanitation access or practices without providing hardware or subsidy, although many studies overlapped multiple categories. There was substantial heterogeneity amongst individual study results for all types of interventions. Providing access to any sanitation facility Providing access to sanitation facilities was evaluated in seven cluster-RCTs, and may reduce diarrhoea prevalence in all age groups (risk ratio (RR) 0.89, 95% confidence interval (CI) 0.73 to 1.08; 7 trials, 40,129 participants, low-certainty evidence). In children under five years, access may have little or no effect on diarrhoea prevalence (RR 0.98, 95% CI 0.83 to 1.16, 4 trials, 16,215 participants, low-certainty evidence). Additional analysis in non-randomized studies was generally consistent with these findings. Pooled estimates across randomized and non-randomized studies provided similar protective estimates (all ages: RR 0.79, 95% CI 0.66 to 0.94; 15 studies, 73,511 participants; children < 5 years: RR 0.83, 95% CI 0.68 to 1.02; 11 studies, 25,614 participants).  Sanitation facility improvement Interventions designed to improve existing sanitation facilities were evaluated in three cluster-RCTs in children under five and may reduce diarrhoea prevalence (RR 0.85, 95% CI 0.69 to 1.06; 3 trials, 14,900 participants, low-certainty evidence). However, some of these interventions, such as sewerage connection, are not easily randomized. Non-randomized studies across participants of all ages provided estimates that improving sanitation facilities may reduce diarrhoea, but may be subject to confounding (RR 0.61, 95% CI 0.50 to 0.74; 23 studies, 117,639 participants, low-certainty evidence). Pooled estimates across randomized and non-randomized studies provided similar protective estimates (all ages: RR 0.65, 95% CI 0.55 to 0.78; 26 studies, 132,539 participants; children < 5 years: RR 0.70, 95% CI 0.54 to 0.91, 12 studies, 23,353 participants).  Behaviour change messaging only (no hardware or subsidy provided) Strategies to promote behaviour change to construct, upgrade, or use sanitation facilities were evaluated in seven cluster-RCTs in children under five, and probably reduce diarrhoea prevalence (RR 0.82, 95% CI 0.69 to 0.98; 7 studies, 28,909 participants, moderate-certainty evidence). Additional analysis from two non-randomized studies found no effect, though with very high uncertainty. Pooled estimates across randomized and non-randomized studies provided similar protective estimates (RR 0.85, 95% CI 0.73 to 1.01; 9 studies, 31,080 participants). No studies measured the effects of this type of intervention in older populations.  Any sanitation intervention A pooled analysis of cluster-RCTs across all sanitation interventions demonstrated that the interventions may reduce diarrhoea prevalence in all ages (RR 0.85, 95% CI 0.76 to 0.95, 17 trials, 83,938 participants, low-certainty evidence) and children under five (RR 0.87, 95% CI 0.77 to 0.97; 14 trials, 60,024 participants, low-certainty evidence). Non-randomized comparisons also demonstrated a protective effect, but may be subject to confounding. Pooled estimates across randomized and non-randomized studies provided similar protective estimates (all ages: RR 0.74, 95% CI 0.67 to 0.82; 50 studies, 237,130 participants; children < 5 years: RR 0.80, 95% CI 0.71 to 0.89; 32 studies, 80,047 participants). In subgroup analysis, there was some evidence of larger effects in studies with increased coverage amongst all participants (75% or higher coverage levels) and also some evidence that the effect decreased over longer follow-up times for children under five years. There was limited evidence on other outcomes. However, there was some evidence that any sanitation intervention was protective against dysentery (RR 0.74, 95% CI 0.54 to 1.00; 5 studies, 34,025 participants) and persistent diarrhoea (RR 0.57, 95% CI 0.43 to 0.75; 2 studies, 2665 participants), but not against clinic visits for diarrhoea (RR 0.86, 95% CI 0.44 to 1.67; 2 studies, 3720 participants) or all-cause mortality (RR 0.99, 95% CI 0.89 to1.09; 7 studies, 46,123 participants).

AUTHORS' CONCLUSIONS

There is evidence that sanitation interventions are effective at preventing diarrhoea, both for young children and all age populations. The actual level of effectiveness, however, varies by type of intervention and setting. There is a need for research to better understand the factors that influence effectiveness.

Improving knowledge, attitudes, and practices on dengue and diarrhea in rural primary school students, their parents, and teachers in Colombia: A cluster-randomized controlled trial

BACKGROUND

Improved education on water-related diseases in schools could help to reduce disease burden. This paper presents specific results on knowledge, attitudes and practices (KAP) of a cluster-randomized controlled trial to reduce diarrheal disease and dengue entomological risk factors in rural primary schools in Colombia. The aim was to investigate whether enhanced educational interventions on dengue and diarrheal disease in schools could improve KAP scores related to these diseases in students and teachers in rural primary schools, as well as the students' parents.

METHODOLOGY/PRINCIPAL FINDINGS

A factorial cluster-randomized controlled trial was carried out in 35 rural primary schools in two municipalities in Cundinamarca, central Colombia. Schools were randomized into four arms: interventions related to diarrheal disease (DIA), dengue (DEN), both (DIADEN), or no interventions (control, CON). Both educational and physical interventions to reduce risk factors of dengue and diarrhea were implemented. Comprehensive teachers' manuals were developed and deployed to guide the learning activities. The intervention was carried out over two school years. The knowledge scores of students receiving dengue interventions (DEN, DIADEN) increased by 1.16 point score (0.75-1.56, p<0.001) and those receiving diarrhea interventions (DIA, DIADEN) increased by 1.15 point score (0.67-1.63, p<0.001). The attitude and practice scores of students receiving the diarrhea interventions increased (Attitudes: 0.41 [0.11-0.71, p = 0.01]; Practices: 0.33 [0.01-0.65, p = 0.042]), but not for those receiving the dengue interventions (p = 0.31 and p = 0.08, respectively).

CONCLUSIONS/SIGNIFICANCE

There were increases in knowledge scores among students, their teachers and their parents for both diseases. However, the attitudes and practices components were not affected to the same extent. The hypothesis that the students would disseminate knowledge acquired from the educational interventions to their parents was confirmed for dengue, but not for diarrhea.

TRIAL REGISTRATION

ISRCTN40195031 The trial is registered in the Current Controlled Trials under Infections and Infestations category.

Effectiveness of Aedes-borne infectious disease control in Latin America and the Caribbean region: A scoping review

Background

Aedes aegypti and Aedes albopictus are primary vectors of emerging or re-emerging arboviruses that threaten public health worldwide. Many efforts have been made to develop interventions to control these Aedes species populations. Still, countries in the Latin America and the Caribbean (LAC) region struggle to create/design/develop sustainable and effective control strategies. This scoping review synthesises evidence concerning the effectiveness of Ae. aegypti and Ae. albopictus prevention and control interventions performed in LAC (2000–2021). The findings can be used to evaluate, compare and develop more effective control strategies.

Methodology

The review is based on the methodology by Joanna Briggs Institute for conducting a scoping review. The MEDLINE (via PubMed and Web of Science), Cochrane Library, Scopus, EMBASE and ScienceDirect databases were used to search for articles. Grey literature was searched from governmental and non-governmental organisation websites. Four reviewers independently screened all titles and abstracts and full-text of the articles using the Rayyan web application, based on pre-defined eligibility criteria.

Results

A total of 122 publications were included in the review. Most studies focused on dengue virus infection and data on Ae. aegypti. Entomological data were mainly used to determine the intervention’s effectiveness. An integrated control intervention was the most commonly employed strategy in both regions. Biological control measures, environmental management, and health education campaigns on community participation achieved more sustainable results than an intervention where only a chemical control measure was used. Challenges to implementing interventions were insufficient financial support, resources, workforce, intersectoral collaboration and legislation.

Conclusions

Based on the synthesised data, an integrated vector (Aedes) management focused on community participation seems to be the most effective approach to mitigate Aedes-borne infectious diseases. Maintaining the approach’s effect remains challenging as it requires multisectoral and multi-disciplinary team engagement and active community participation. Future research needs to address the barriers to program implementation and maintenance as data on this topic is lacking.

School and community driven dengue vector control and monitoring in Myanmar: Study protocol for a cluster randomized controlled trial

Background. Dengue is the most common and widespread mosquito-borne arboviral disease globally estimated to cause >390 million infections and >20,000 deaths annually. There are no effective vaccines or preventive drugs. Control of dengue transmission relies primarily on mosquito vector control. Although most vector control methods currently used by national dengue control programs may temporarily reduce mosquito populations, there is little evidence that they affect transmission. There is an urgent need for innovative, participatory, effective, and locally adapted approaches for sustainable vector control and monitoring in which students can be particularly relevant contributors and to demonstrate a clear link between vector reduction and dengue transmission reduction, using tools that are inexpensive and easy to use by local communities in a sustainable manner. Methods. Here we describe a cluster randomized controlled trial to be conducted in 46 school catchment areas in two townships in Yangon, Myanmar. The outcome measures are dengue cases confirmed by rapid diagnostic test in the townships, dengue incidence in schools, entomological indices, knowledge, attitudes and practice, behavior, and engagement. Conclusions. The trial involves middle school students that positions them to become actors in dengue knowledge transfer to their communities and take a leadership role in the delivery of vector control interventions and monitoring methods. Following this rationale, we believe that students can become change agents of decentralized vector surveillance and sustainable disease control in line with recent new paradigms in integrated and participatory vector surveillance and control. This provides an opportunity to operationalize transdisciplinary research towards sustainable health development. Due to the COVID-19 pandemic and political instability in Myanmar the project has been terminated by the donor, but the protocol will be helpful for potential future implementation of the project in Myanmar and/or elsewhere. Registration: This trial was registered in the ISRCTN Registry on 31 May 2022 (https://doi.org/10.1186/ISRCTN78254298).

Interventions promoting uptake of water, sanitation and hygiene (WASH) technologies in low- and middle-income countries: An evidence and gap map of effectiveness studies

Background

Lack of access to and use of water, sanitation and hygiene (WASH) cause 1.6 million deaths every year, of which 1.2 million are due to gastrointestinal illnesses like diarrhoea and acute respiratory infections like pneumonia. Poor WASH access and use also diminish nutrition and educational attainment, and cause danger and stress for vulnerable populations, especially for women and girls. The hardest hit regions are sub-Saharan Africa and South Asia. Sustainable Development Goal (SDG) 6 calls for the end of open defecation, and universal access to safely managed water and sanitation facilities, and basic hand hygiene, by 2030. WASH access and use also underpin progress in other areas such as SDG1 poverty targets, SDG3 health and SDG4 education targets. Meeting the SDG equity agenda to "leave none behind" will require WASH providers prioritise the hardest to reach including those living remotely and people who are disadvantaged.

Objectives

Decision makers need access to high-quality evidence on what works in WASH promotion in different contexts, and for different groups of people, to reach the most disadvantaged populations and thereby achieve universal targets. The WASH evidence map is envisioned as a tool for commissioners and researchers to identify existing studies to fill synthesis gaps, as well as helping to prioritise new studies where there are gaps in knowledge. It also supports policymakers and practitioners to navigate the evidence base, including presenting critically appraised findings from existing systematic reviews.

Methods

This evidence map presents impact evaluations and systematic reviews from the WASH sector, organised according to the types of intervention mechanisms, WASH technologies promoted, and outcomes measured. It is based on a framework of intervention mechanisms (e.g., behaviour change triggering or microloans) and outcomes along the causal pathway, specifically behavioural outcomes (e.g., handwashing and food hygiene practices), ill-health outcomes (e.g., diarrhoeal morbidity and mortality), nutrition and socioeconomic outcomes (e.g., school absenteeism and household income). The map also provides filters to examine the evidence for a particular WASH technology (e.g., latrines), place of use (e.g., home, school or health facility), location (e.g., global region, country, rural and urban) and group (e.g., people living with disability). Systematic searches for published and unpublished literature and trial registries were conducted of studies in low- and middle-income countries (LMICs). Searches were conducted in March 2018, and searches for completed trials were done in May 2020. Coding of information for the map was done by two authors working independently. Impact evaluations were critically appraised according to methods of conduct and reporting. Systematic reviews were critically appraised using a new approach to assess theory-based, mixed-methods evidence synthesis.

Results

There has been an enormous growth in impact evaluations and systematic reviews of WASH interventions since the International Year of Sanitation, 2008. There are now at least 367 completed or ongoing rigorous impact evaluations in LMICs, nearly three-quarters of which have been conducted since 2008, plus 43 systematic reviews. Studies have been done in 83 LMICs, with a high concentration in Bangladesh, India, and Kenya. WASH sector programming has increasingly shifted in focus from what technology to supply (e.g., a handwashing station or child's potty), to the best way in which to do so to promote demand. Research also covers a broader set of intervention mechanisms. For example, there has been increased interest in behaviour change communication using psychosocial "triggering", such as social marketing and community-led total sanitation. These studies report primarily on behavioural outcomes. With the advent of large-scale funding, in particular by the Bill & Melinda Gates Foundation, there has been a substantial increase in the number of studies on sanitation technologies, particularly latrines. Sustaining behaviour is fundamental for sustaining health and other quality of life improvements. However, few studies have been done of intervention mechanisms for, or measuring outcomes on sustained adoption of latrines to stop open defaecation. There has also been some increase in the number of studies looking at outcomes and interventions that disproportionately affect women and girls, who quite literally carry most of the burden of poor water and sanitation access. However, most studies do not report sex disaggregated outcomes, let alone integrate gender analysis into their framework. Other vulnerable populations are even less addressed; no studies eligible for inclusion in the map were done of interventions targeting, or reporting on outcomes for, people living with disabilities. We were only able to find a single controlled evaluation of WASH interventions in a health care facility, in spite of the importance of WASH in health facilities in global policy debates. The quality of impact evaluations has improved, such as the use of controlled designs as standard, attention to addressing reporting biases, and adequate cluster sample size. However, there remain important concerns about quality of reporting. The quality and usefulness of systematic reviews for policy is also improving, which draw clearer distinctions between intervention mechanisms and synthesise the evidence on outcomes along the causal pathway. Adopting mixed-methods approaches also provides information for programmes on barriers and enablers affecting implementation.

Conclusion

Ensuring everyone has access to appropriate water, sanitation, and hygiene facilities is one of the most fundamental of challenges for poverty elimination. Researchers and funders need to consider carefully where there is the need for new primary evidence, and new syntheses of that evidence. This study suggests the following priority areas:Impact evaluations incorporating understudied outcomes, such as sustainability and slippage, of WASH provision in understudied places of use, such as health care facilities, and of interventions targeting, or presenting disaggregated data for, vulnerable populations, particularly over the life-course and for people living with a disability;Improved reporting in impact evaluations, including presentation of participant flow diagrams; andSynthesis studies and updates in areas with sufficient existing and planned impact evaluations, such as for diarrhoea mortality, ARIs, WASH in schools and decentralisation. These studies will preferably be conducted as mixed-methods systematic reviews that are able to answer questions about programme targeting, implementation, effectiveness and cost-effectiveness, and compare alternative intervention mechanisms to achieve and sustain outcomes in particular contexts, preferably using network meta-analysis.

Integrated disease management: arboviral infections and waterborne diarrhoea

Water-related diseases such as diarrhoeal diseases from viral, bacterial and parasitic organisms and Aedes-borne arboviral diseases are major global health problems. We believe that these two disease groups share common risk factors, namely inadequate household water management, poor sanitation and solid waste management. Where water provision is inadequate, water storage is essential. Aedes mosquitoes commonly breed in household water storage containers, which can hold water contaminated with enteric disease-causing organisms. Microbiological contamination of water between source and point-of-use is a major cause of reduced drinking-water quality. Inadequate sanitation and solid waste management increase not only risk of water contamination, but also the availability of mosquito larval habitats. In this article we discuss integrated interventions that interrupt mosquito breeding while also providing sanitary environments and clean water. Specific interventions include improving storage container design, placement and maintenance and scaling up access to piped water. Vector control can be integrated into sanitation projects that target sewers and drains to avoid accumulation of stagnant water. Better management of garbage and solid waste can reduce the availability of mosquito habitats while improving human living conditions. Our proposed integration of disease interventions is consistent with strategies promoted in several global health frameworks, such as the sustainable development goals, the global vector control response, behavioural change, and water, sanitation and hygiene initiatives. Future research should address how interventions targeting water, sanitation, hygiene and community waste disposal also benefit Aedes-borne disease control. The projected effects of climate change mean that integrated management and control strategies will become increasingly important.

Hand-washing promotion for preventing diarrhoea

BACKGROUND

Diarrhoea accounts for 1.8 million deaths in children in low- and middle-income countries (LMICs). One of the identified strategies to prevent diarrhoea is hand washing.

OBJECTIVES

To assess the effects of hand-washing promotion interventions on diarrhoeal episodes in children and adults.

SEARCH METHODS

We searched CENTRAL, MEDLINE, Embase, nine other databases, the World Health Organization (WHO) International Clinical Trial Registry Platform (ICTRP), and metaRegister of Controlled Trials (mRCT) on 8 January 2020, together with reference checking, citation searching and contact with study authors to identify additional studies.

SELECTION CRITERIA

Individually-randomized controlled trials (RCTs) and cluster-RCTs that compared the effects of hand-washing interventions on diarrhoea episodes in children and adults with no intervention.

DATA COLLECTION AND ANALYSIS

Three review authors independently assessed trial eligibility, extracted data, and assessed risks of bias. We stratified the analyses for child day-care centres or schools, community, and hospital-based settings. Where appropriate, we pooled incidence rate ratios (IRRs) using the generic inverse variance method and a random-effects model with a 95% confidence interval (CI). We used the GRADE approach to assess the certainty of the evidence.

MAIN RESULTS

We included 29 RCTs: 13 trials from child day-care centres or schools in mainly high-income countries (54,471 participants), 15 community-based trials in LMICs (29,347 participants), and one hospital-based trial among people with AIDS in a high-income country (148 participants). All the trials and follow-up assessments were of short-term duration. Hand-washing promotion (education activities, sometimes with provision of soap) at child day-care facilities or schools prevent around one-third of diarrhoea episodes in high-income countries (incidence rate ratio (IRR) 0.70, 95% CI 0.58 to 0.85; 9 trials, 4664 participants, high-certainty evidence) and may prevent a similar proportion in LMICs, but only two trials from urban Egypt and Kenya have evaluated this (IRR 0.66, 95% CI 0.43 to 0.99; 2 trials, 45,380 participants; low-certainty evidence). Only four trials reported measures of behaviour change, and the methods of data collection were susceptible to bias. In one trial from the USA hand-washing behaviour was reported to improve; and in the trial from Kenya that provided free soap, hand washing did not increase, but soap use did (data not pooled; 3 trials, 1845 participants; low-certainty evidence). Hand-washing promotion among communities in LMICs probably prevents around one-quarter of diarrhoea episodes (IRR 0.71, 95% CI 0.62 to 0.81; 9 trials, 15,950 participants; moderate-certainty evidence). However, six of these nine trials were from Asian settings, with only one trial from South America and two trials from sub-Saharan Africa. In seven trials, soap was provided free alongside hand-washing education, and the overall average effect size was larger than in the two trials which did not provide soap (soap provided: RR 0.66, 95% CI 0.58 to 0.75; 7 trials, 12,646 participants; education only: RR 0.84, 95% CI 0.67 to 1.05; 2 trials, 3304 participants). There was increased hand washing at major prompts (before eating or cooking, after visiting the toilet, or cleaning the baby's bottom) and increased compliance with hand-hygiene procedure (behavioural outcome) in the intervention groups compared with the control in community trials (data not pooled: 4 trials, 3591 participants; high-certainty evidence). Hand-washing promotion for the one trial conducted in a hospital among a high-risk population showed significant reduction in mean episodes of diarrhoea (1.68 fewer) in the intervention group (mean difference -1.68, 95% CI -1.93 to -1.43; 1 trial, 148 participants; moderate-certainty evidence). Hand-washing frequency increased to seven times a day in the intervention group versus three times a day in the control arm in this hospital trial (1 trial, 148 participants; moderate-certainty evidence). We found no trials evaluating the effects of hand-washing promotions on diarrhoea-related deaths or cost effectiveness.

AUTHORS' CONCLUSIONS

Hand-washing promotion probably reduces diarrhoea episodes in both child day-care centres in high-income countries and among communities living in LMICs by about 30%. The included trials do not provide evidence about the long-term impact of the interventions.

Schools as centers for health educational initiatives, health behavior research and risk behavior for dengue infection in school children and community members: a systematic review

Dengue virus is the main arboviral disease transmitted by Aedes mosquitoes and affects mainly school-aged children and teens. Many methods have been developed for dengue control, including health education strategies for elementary and high school students. The objective of this study is to provide an update on the status of health education on dengue in schools and provide new perspectives on health behavior research in order to reduce the proliferation of mosquitoes and spread of arboviral diseases among school-aged children and other community members. A systematic review about health educational initiatives was carried out. This research discusses the effectiveness of these strategies in educating students about dengue disease and mosquito control and how the school is relevant for community-based participation in research on dengue education. The study found that employing ludic strategies and directly involving children in mosquito control in their households have been the most attractive and effective strategies for dengue education in children and teens. However, the sustainability of protective behaviors has been poorly evaluated, and new approaches for health behavior research are needed. Inasmuch as, schools are important places for gathering community members, and students can serve as an essential link between educative interventions and the community.

Fostering social innovation and building adaptive capacity for dengue control in Cambodia: a case study

Background

The social-ecological systems theory, with its unique conception of resilience (social-ecological systems & resilience, SESR), provides an operational framework that currently best meets the need for integration and adaptive governance as encouraged by the Sustainable Development Goals. SESR accounts for the complex dynamics of social-ecological systems and operationalizes transdisciplinarity by focusing on community engagement, value co-creation, decentralized leadership and social innovation. Targeting Social Innovation (SI) in the context of implementation research for vector-borne diseases (VBD) control offers a low-cost strategy to contribute to lasting and contextualized community engagement in disease control and health development in low and middle income countries of the global south. In this article we describe the processes of community engagement and transdisciplinary collaboration underpinning community-based dengue management in rural primary schools and households in two districts in Cambodia.

Methods

Multiple student-led and community-based interventions have been implemented focusing on empowering education, communication for behavioral change and participatory epidemiology mapping in order to engage Cambodian communities in dengue control. We describe in particular the significance of the participatory processes that have contributed to the design of SI products that emerged following iterative consultations with community stakeholders to address the dengue problem.

Results

The SI products that emerged following our interaction with community members are 1) adult mosquito traps made locally from solid waste collections, 2) revised dengue curriculum with hands-on activities for transformative learning, 3) guppy distribution systems led by community members, 4) co-design of dengue prevention communication material by students and community members, 5) community mapping.

Conclusions

The initiative described in this article put in motion processes of community engagement towards creating ownership of dengue control interventions tools by community stakeholders, including school children. While the project is ongoing, the project’s interventions so far implemented have contributed to the emergence of culturally relevant SI products and provided initial clues regarding 1) the conditions allowing SI to emerge, 2) specific mechanisms by which it happens and 3) how external parties can facilitate SI emergence. Overall there seems to be a strong argument to be made in supporting SI as a desirable outcome of project implementation towards building adaptive capacity and resilience and to use the protocol supporting this project implementation as an operational guiding document for other VBD adaptive management in the region.

Use of pyriproxyfen in control of Aedes mosquitoes: A systematic review

Dengue is the most rapidly spreading arboviral disease in the world. The current lack of fully protective vaccines and clinical therapeutics creates an urgent need to identify more effective means of controlling Aedes mosquitos, principally Aedes aegypti, as the main vector of dengue. Pyriproxyfen (PPF) is an increasingly used hormone analogue that prevents juvenile Aedes mosquitoes from becoming adults and being incapable of transmitting dengue. The objectives of the review were to (1) Determine the effect of PPF on endpoints including percentage inhibition of emergence to adulthood, larval mortality, and resistance ratios; and (2) Determine the different uses, strengths, and limitations of PPF in control of Aedes. A systematic search was applied to Pubmed, EMBASE, Web of Science, LILACS, Global Health, and the Cochrane database of Systematic Reviews. Out of 1,369 records, 90 studies met the inclusion criteria. Nearly all fit in one of the following four categories 1) Efficacy of granules, 2) Auto-dissemination/horizontal transfer, 3) use of ultra-low volume thermal fogging (ULV), thermal fogging (TF), or fumigant technologies, and 4) assessing mosquito resistance. PPF granules had consistently efficacious results of 90-100% inhibition of emergence for up to 90 days. The evidence is less robust but promising regarding PPF dust for auto-dissemination and the use of PPF in ULV, TF and fumigants. Several studies also found that while mosquito populations were still susceptible to PPF, the lethal concentrations increased among temephos-resistant mosquitoes compared to reference strains. The evidence is strong that PPF does increase immature mortality and adult inhibition in settings represented in the included studies, however future research should focus on areas where there is less evidence (e.g. auto-dissemination, sprays) and new use cases for PPF. A better understanding of the biological mechanisms of cross-resistance between PPF, temephos, and other insecticides will allow control programs to make better informed decisions.

Knowledge, attitudes, and practices about dengue among pupils from rural schools in an endemic area in Colombia

INTRODUCTION

Dengue is a public health problem in tropical and subtropical regions of the world. Studies on dengue in rural areas are scarce since the disease is considered mainly urban.

OBJECTIVE

To determine the knowledge (K), attitudes (A) and practices (P) of dengue in an endemic area in Colombia.

MATERIALS AND METHODS

We conducted a cross-sectional study with 515 pupils (7-16 years old) in 34 rural schools in Anapoima and La Mesa municipalities during 2011. Each KAP category was evaluated independently by a scoring system and then categorized into high, medium or low.

RESULTS

Pupils recognized knowledge variables such as the symptoms (fever, bone pain), transmission route (mosquito bites), and mosquito breeding sites (uncovered water tanks, solid waste). Average scores on attitude were high in both municipalities indicating a well-developed perception of disease severity. Seeking treatment in medical centers and self-medication for fever management and the use of mosquito net and space-spraying of insecticides were the most frequently identified practices.

DISCUSSION

This is the first KAP dengue study performed in a rural area in Colombia and as such it contributes to the understanding of dengue perceptions by the inhabitants of these areas. It showed a medium level of knowledge about dengue and a lower level of preventive practices in pupils from rural schools. It also showed that pupils considered space-spraying as crucial for vector control. The presence of the vector in rural areas of the country underlines the need to improve surveillance and education to more effectively control the vector and promote prevention methods including community participation.

Environmental methods for dengue vector control - A systematic review and meta-analysis

BACKGROUND

Vector control remains the primary method to prevent dengue infections. Environmental interventions represent sustainable and safe methods as there are limited risks of environmental contamination and toxicity. The objective of this study is to perform a systematic review and meta-analysis of the effectiveness of the following environmental methods for dengue vector control.

METHODOLOGY/PRINCIPAL FINDINGS

Following the PRISMA guidelines, a systematic literature search was conducted using the databases PubMed, EMBASE, LILACS, the Cochrane Library and Google Scholar. Quality assessment was done using the CONSORT 2010 checklist. For the meta-analysis the difference-in-differences (DID) and the difference-of-endlines (DOE) were calculated according to the Schmidt-Hunter method for the Breteau index (BI) and the pupae per person index (PPI). Nineteen studies were eligible for the systematic review, sixteen contributed data to the meta-analysis. The following methods were evaluated: (a) container covers with and without insecticides, (b) waste management and clean-up campaigns, and (c) elimination of breeding sites by rendering potential mosquito breeding sites unusable or by eliminating them. Study quality was highest for container covers with insecticides, followed by waste management without direct garbage collection and elimination of breeding places. Both, systematic review and meta-analysis, showed a weak effect of the interventions on larval populations, with no obvious differences between the results of each individual method. For the meta-analysis, both, container covers without insecticides (BI: DID -7.9, DOE -5) and waste management with direct garbage collection (BI: DID -8.83, DOE -6.2) achieved the strongest reductions for the BI, whereas for the PPI results were almost opposite, with container covers with insecticides (PPI: DID -0.83, DOE 0.09) and elimination of breeding places (PPI: DID -0.95, DOE -0.83) showing the strongest effects.

CONCLUSIONS

Each of the investigated environmental methods showed some effectiveness in reducing larval and pupal densities of Aedes sp. mosquitoes. However, there is a need for more comparable high-quality studies at an adequate standard to strengthen this evidence.

Environmental management for dengue control: a systematic review protocol

INTRODUCTION

Dengue is among the most important mosquito-borne diseases, with more than half of the world's population at risk of infection in dengue endemic countries. Environmental management, which includes any activities that involve environmental modification, environmental manipulation and changes to human behaviour have been used to mitigate the risk of dengue transmission. In this protocol, we will integrate the data from various sources to assess the overall effect of environmental management on the incidence of dengue and other entomological indices.

METHODS AND ANALYSES

We will conduct a systematic review of intervention that assess the effect of environmental management on the incidence of dengue and/or entomological indices. We will include any studies that include intervention through environmental management for dengue control, involving environmental modification, environmental manipulation and changes to human behaviour. A comprehensive search will be performed in electronic databases PUBMED, CENTRAL, SCOPUS, Web of Science and relevant research websites such as PROPSERO, WHO ICTRP and ClinicalTrials.gov to identify studies that meet our inclusion criteria. A systematic approach to searching, screening, reviewing and data extraction will be applied based on Preferred Reporting Items for Systematic reviews and Meta-Analysis. Titles, abstract, keywords for eligibility will be examined independently by researchers. The quality of the included studies will be assessed using quality assessment tool for studies with diverse design and Cochrane risk of bias tool. The characteristics of the selected articles will be described based on the study design, types of intervention and outcomes of the study in various countries. These include the types of environmental management intervention methods and the effectiveness of the intervention in reducing dengue cases or incidence and impact on entomological indices.

ETHICS AND DISSEMINATION

We will register this systematic review with the National Medical Research Register, Ministry of Health Malaysia. This protocol also had been registered with the PROSPERO. No ethical approval is necessary, as there will be no collection of primary data. The results will be disseminated though a peer-reviewed publication and conference presentation.

TRIAL REGISTRATION NUMBER

CRD42018092189.

Global Vector Control Guidelines - The Need For Co-Creation

In response to the global expansion and re-emergence of vector-borne diseases, WHO launched the Global Vector Control Response program in 2017. The aim is to strengthen vector control through increased capacity, innovation, improved surveillance, better coordination, and integrated action. Will this new approach overcome the failings of previous initiatives?

Fly control to prevent diarrhoea in children

BACKGROUND

Diarrhoeal disease accounts for millions of child deaths every year. Although the role of flies as vectors of infectious diarrhoea has been established, fly control is not often mentioned as an approach to decrease childhood diarrhoea. Theoretically, fly control for decreasing diarrhoea incidence can be achieved by intervening at four different levels: reduction or elimination of fly breeding sites; reduction of sources that attract houseflies; prevention of contact between flies and disease-causing organisms; and protection of people, food, and food utensils from contact with flies.

OBJECTIVES

To assess the impact of various housefly control measures on the incidence of diarrhoea and its related morbidity and mortality in children under five years of age.

SEARCH METHODS

We searched electronic databases including the Cochrane Central Register of Controlled Trials (CENTRAL) in the Cochrane Library, MEDLINE, Embase, CINAHL, and LILACS, from database inception to 24 May 2018. We also searched trial registries for relevant grey literature and ongoing trials. We checked the references of the identified studies and reviews. We did not apply any filters for language, publication status (published, unpublished, in press, and ongoing), or publication date.

SELECTION CRITERIA

We planned to include randomized controlled trials (RCTs), quasi-RCTs, and controlled before-and-after studies that studied the effect of fly control on diarrhoea in children under five years of age.

DATA COLLECTION AND ANALYSIS

Two review authors extracted the data and independently assessed the risk of bias in the included study. We planned to contact study authors for additional information, where necessary. We assessed the certainty of the evidence using the GRADE approach.

MAIN RESULTS

We included one cluster-RCT (491 participants) conducted in Pakistan that evaluated insecticide spraying in the first two years and baited fly traps in the third year. Insecticide spraying reduced the fly population (house index) in the intervention group during the four months of the year when both flies and cases of diarrhoea were more common, but not at other times. On average, this was associated with a reduction in the incidence of diarrhoea in the first year (illustrative mean episodes per child-year in the intervention group was 6.3 while in the control group was 7.1) and second year of the intervention (illustrative mean episodes per child‒year in the intervention group was 4.4 while in the control group was 6.5; rate ratio (RaR) 0.77, 95% confidence interval (CI) 0.67 to 0.89, low-certainty evidence). In the third year of the intervention, the baited fly traps did not demonstrate an effect on the fly population or on diarrhoea incidence (RaR 1.15, 95% CI 0.90 to 1.47, low-certainty evidence).

AUTHORS' CONCLUSIONS

The trial, conducted in a setting where there were clear seasonal peaks in fly numbers and associated diarrhoea, shows insecticide spraying may reduce diarrhoea in children. Further research on whether this finding is applicable to other setting is required, as well as work on other fly control methods, their effects, feasibility, costs, and acceptability.

[Sustainability of interventions to prevent dengue and diarrhea in rural schools in two municipalities in Colombia: a two-year post-project evaluation]

This study evaluated the sustainability of a set of interventions to prevent dengue and diarrhea in 33 rural schools in the municipalities (counties) of Anapoima and La Mesa, Colombia, two years post-project. The study measured sustainability in two categories: maintenance of the benefits and the interventions, and institutionalization and community capacity-building. The sustainability of the interventions was compared across four arms: interventions to prevent diarrhea, to prevent dengue, combined interventions to prevent diarrhea and dengue, and control. The final score for each arm was classified in five levels of sustainability: regressive, not sustainable, moderately sustainable, sustainable, and highly sustainable. The arms were compared with ANOVA and Kruskal-Wallis test, with significance set at 0.05. At two years post-project, the overall sustainability for the prevention of diarrhea was moderate in the four arms, while dengue prevention was not sustainable in three of the four arms, without statistically significant differences. Sustainability levels also varied in terms of benefits, interventions, capacity-building, and institutionalization. Maintenance of benefits and interventions in both diseases was more sustainable than institutionalization and capacity-building. The analysis of these variables is important for identifying the different factors that influence projects' sustainability, related to their design and execution, organizational framework, and social context.

[Spatial distribution of Aedes aegypti (Diptera: Culicidae) in the rural area of two municipalities of Cundinamarca, Colombia]

INTRODUCTION

It is difficult to adapt or create new strategies for dengue control in rural areas due to the dispersion of homes and the lack of knowledge about the presence and behavior of the vector in these areas. Spatial data analysis could help understand time and space dynamics related to the transmission of vector-borne diseases in rural areas and, thus, contribute to the prevention and control of dengue.

OBJECTIVE

To determine the probability of the presence of the dengue vector Aedes aegypti in the rural area of the municipalities of Anapoima and La Mesa, in the central area of Colombia.

MATERIALS AND METHODS

The probability of the presence or absence of the vector in the study area was determined by means of the kriging spatial interpolation method.

RESULTS

The region with the highest probability of the presence of the vector was located in the central part, close to the urban centers of both municipalities.

CONCLUSION

This study shows the importance of geostatistics for the surveillance of vector-borne diseases and the analysis of time and space dynamics of vector insects and of diseases transmitted by them.