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Crocker J, Ogutu EA, Snyder J, Freeman MC. The state of reporting context and implementation in peer-reviewed evaluations of water, sanitation, and hygiene interventions: A scoping review. Int J Hyg Environ Health 2024; 259:114363. [PMID: 38604106 DOI: 10.1016/j.ijheh.2024.114363] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2023] [Revised: 02/05/2024] [Accepted: 03/26/2024] [Indexed: 04/13/2024]
Abstract
INTRODUCTION To accurately assess evidence from environmental and public health field trials, context and implementation details of the intervention must be weighed with trial results; yet these details are under and inconsistently reported for water, sanitation, and hygiene (WASH), limiting the external validity of the evidence. METHODS To quantify the level of reporting of context and implementation in WASH evaluations, we conducted a scoping review of the 40 most cited evaluations of WASH interventions published in the last 10 years (2012-2022). We applied criteria derived from a review of existing reporting guidance from other sectors including healthcare and implementation science. We subsequently reviewed main articles, supplements, protocols, and other associated resources to assess thoroughness of context and implementation reporting. RESULTS Of the final 25 reporting items we searched for, four-intervention name, approach, location, and temporality-were reported by all studies. Five items-theory, implementer qualifications, dose intensity, targeting, and measured fidelity-were not reported in over a third of reviewed articles. Only two studies (5%) reported all items in our checklist. Only 74% of items were found in the main article, while the rest were found in separate papers (7%) or not at all (19%). DISCUSSION Inconsistent reporting of WASH implementation illustrates a major challenge in the sector. It is difficult to know what interventions are actually being evaluated and how to compare evaluation results. This inconsistent and incomplete implementation reporting limits the ability of programmers and policy makers to apply the available evidence to their contexts. Standardized reporting guidelines would improve the application of the evidence for WASH field evaluations.
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Affiliation(s)
- Jonny Crocker
- Gangarosa Department of Environmental Health, Emory University, Atlanta, Georgia, USA.
| | - Emily A Ogutu
- Gangarosa Department of Environmental Health, Emory University, Atlanta, Georgia, USA
| | - Jedidiah Snyder
- Gangarosa Department of Environmental Health, Emory University, Atlanta, Georgia, USA
| | - Matthew C Freeman
- Gangarosa Department of Environmental Health, Emory University, Atlanta, Georgia, USA
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OKeeffe J, Salem-Bango L, Desjardins MR, Lantagne D, Altare C, Kaur G, Heath T, Rangaiya K, Obroh POO, Audu A, Lecuyot B, Zoungrana T, Ihemezue EE, Aye S, Sikder M, Doocy S, Wang Q, Xiao M, Spiegel PB. Case-area targeted interventions during a large-scale cholera epidemic: A prospective cohort study in Northeast Nigeria. PLoS Med 2024; 21:e1004404. [PMID: 38728366 PMCID: PMC11149837 DOI: 10.1371/journal.pmed.1004404] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/12/2024] [Revised: 06/04/2024] [Accepted: 04/17/2024] [Indexed: 05/12/2024] Open
Abstract
BACKGROUND Cholera outbreaks are on the rise globally, with conflict-affected settings particularly at risk. Case-area targeted interventions (CATIs), a strategy whereby teams provide a package of interventions to case and neighboring households within a predefined "ring," are increasingly employed in cholera responses. However, evidence on their ability to attenuate incidence is limited. METHODS AND FINDINGS We conducted a prospective observational cohort study in 3 conflict-affected states in Nigeria in 2021. Enumerators within rapid response teams observed CATI implementation during a cholera outbreak and collected data on household demographics; existing water, sanitation, and hygiene (WASH) infrastructure; and CATI interventions. Descriptive statistics showed that CATIs were delivered to 46,864 case and neighbor households, with 80.0% of cases and 33.5% of neighbors receiving all intended supplies and activities, in a context with operational challenges of population density, supply stock outs, and security constraints. We then applied prospective Poisson space-time scan statistics (STSS) across 3 models for each state: (1) an unadjusted model with case and population data; (2) an environmentally adjusted model adjusting for distance to cholera treatment centers and existing WASH infrastructure (improved water source, improved latrine, and handwashing station); and (3) a fully adjusted model adjusting for environmental and CATI variables (supply of Aquatabs and soap, hygiene promotion, bedding and latrine disinfection activities, ring coverage, and response timeliness). We ran the STSS each day of our study period to evaluate the space-time dynamics of the cholera outbreaks. Compared to the unadjusted model, significant cholera clustering was attenuated in the environmentally adjusted model (from 572 to 18 clusters) but there was still risk of cholera transmission. Two states still yielded significant clusters (range 8-10 total clusters, relative risk of 2.2-5.5, 16.6-19.9 day duration, including 11.1-56.8 cholera cases). Cholera clustering was completely attenuated in the fully adjusted model, with no significant anomalous clusters across time and space. Associated measures including quantity, relative risk, significance, likelihood of recurrence, size, and duration of clusters reinforced the results. Key limitations include selection bias, remote data monitoring, and the lack of a control group. CONCLUSIONS CATIs were associated with significant reductions in cholera clustering in Northeast Nigeria despite operational challenges. Our results provide a strong justification for rapid implementation and scale-up CATIs in cholera-response, particularly in conflict settings where WASH access is often limited.
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Affiliation(s)
- Jennifer OKeeffe
- Center for Humanitarian Health, Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, United States of America
| | - Lindsay Salem-Bango
- Center for Humanitarian Health, Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, United States of America
| | - Michael R. Desjardins
- Spatial Science for Public Health Center, Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, United States of America
| | - Daniele Lantagne
- Lancon Environmental, LLC, Somerville, Massachusetts, United States of America
| | - Chiara Altare
- Center for Humanitarian Health, Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, United States of America
| | - Gurpreet Kaur
- Center for Humanitarian Health, Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, United States of America
| | | | | | | | | | | | | | | | - Solomon Aye
- Solidarités International, Maiduguri, Nigeria
| | - Mustafa Sikder
- Center for Humanitarian Health, Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, United States of America
| | - Shannon Doocy
- Center for Humanitarian Health, Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, United States of America
| | - Qiulin Wang
- Center for Humanitarian Health, Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, United States of America
| | - Melody Xiao
- Center for Humanitarian Health, Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, United States of America
| | - Paul B. Spiegel
- Center for Humanitarian Health, Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, United States of America
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Endres K, Mwishingo A, Thomas E, Boroto R, Ntumba Nyarukanyi W, Bisimwa JC, Sanvura P, Perin J, Bengehya J, Maheshe G, Cikomola C, George CM. A Quantitative and Qualitative Program Evaluation of a Case-Area Targeted Intervention to Reduce Cholera in Eastern Democratic Republic of the Congo. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2023; 21:27. [PMID: 38248491 PMCID: PMC10815631 DOI: 10.3390/ijerph21010027] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/16/2023] [Revised: 11/30/2023] [Accepted: 12/13/2023] [Indexed: 01/23/2024]
Abstract
Individuals living near cholera patients have an increased risk of cholera infections. Case-area targeted interventions (CATIs) promoting improved water, sanitation, and hygiene (WASH) present a promising approach to reducing cholera for those residing near cholera cases. However, there is limited evidence on the effectiveness and implementation of this approach in increasing WASH behaviors. We conducted a mixed-methods program evaluation in rural and urban eastern Democratic Republic of the Congo. The quantitative component included household structured observations and spot checks in CATI and control areas to assess WASH conditions and behaviors. The qualitative component included semi-structured interviews with CATI recipients, non-recipients, and implementers to assess CATI implementation. A total of 399 participants were enrolled in the quantitative evaluation conducted within 1 month of CATI delivery. For the qualitative evaluation, 41 semi-structured interviews were conducted, 30 with individuals in CATI areas (recipients and non-recipients) and 11 with CATI implementers. Handwashing with soap was low among both CATI and control area participants (1% vs. 2%, p = 0.89). Significantly more CATI area households (75%) had chlorine tablets present compared to control area households (0%) (p < 0.0001); however, the percentage of households with stored water free chlorine concentrations > 0.2 mg/L was low for both CATI and control area households (11% vs. 6%, p = 0.45). Implementers reported an insufficient supply of soap for distribution to recipients and mistrust in the community of their activities. CATI recipients demonstrated low knowledge of the correct preparation and use of chlorine for water treatment. Recipients also indicated a need for CATI implementers to engage community leaders. As CATIs are part of cholera control plans in many cholera-endemic countries, it is important to evaluate existing programs and develop evidence-based approaches to deliver CATIs that are both tailored to the local context and engage affected communities to increase WASH behaviors to reduce the spread of cholera.
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Affiliation(s)
- Kelly Endres
- Department of International Health, Program in Global Disease Epidemiology and Control, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD 21205, USA; (K.E.); (E.T.); (J.P.)
| | - Alain Mwishingo
- Center for Tropical Diseases & Global Health, Université Catholique de Bukavu, Bukavu B.P 265, Democratic Republic of the Congo; (A.M.); (R.B.); (W.N.N.); (J.-C.B.); (P.S.); (C.C.)
| | - Elizabeth Thomas
- Department of International Health, Program in Global Disease Epidemiology and Control, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD 21205, USA; (K.E.); (E.T.); (J.P.)
| | - Raissa Boroto
- Center for Tropical Diseases & Global Health, Université Catholique de Bukavu, Bukavu B.P 265, Democratic Republic of the Congo; (A.M.); (R.B.); (W.N.N.); (J.-C.B.); (P.S.); (C.C.)
| | - Wivine Ntumba Nyarukanyi
- Center for Tropical Diseases & Global Health, Université Catholique de Bukavu, Bukavu B.P 265, Democratic Republic of the Congo; (A.M.); (R.B.); (W.N.N.); (J.-C.B.); (P.S.); (C.C.)
| | - Jean-Claude Bisimwa
- Center for Tropical Diseases & Global Health, Université Catholique de Bukavu, Bukavu B.P 265, Democratic Republic of the Congo; (A.M.); (R.B.); (W.N.N.); (J.-C.B.); (P.S.); (C.C.)
| | - Presence Sanvura
- Center for Tropical Diseases & Global Health, Université Catholique de Bukavu, Bukavu B.P 265, Democratic Republic of the Congo; (A.M.); (R.B.); (W.N.N.); (J.-C.B.); (P.S.); (C.C.)
| | - Jamie Perin
- Department of International Health, Program in Global Disease Epidemiology and Control, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD 21205, USA; (K.E.); (E.T.); (J.P.)
| | - Justin Bengehya
- Bureau de l’Information Sanitaire, Surveillance Epidémiologique et Recherche Scientifique Division Provinciale de la Santé/Sud Kivu, Ministère de la Santé Publique, Hygiène et Prévention, Bukavu B.P 1899, Democratic Republic of the Congo;
| | - Ghislain Maheshe
- Faculty of Medicine, Université Catholique de Bukavu, Bukavu B.P 265, Democratic Republic of the Congo;
| | - Cirhuza Cikomola
- Center for Tropical Diseases & Global Health, Université Catholique de Bukavu, Bukavu B.P 265, Democratic Republic of the Congo; (A.M.); (R.B.); (W.N.N.); (J.-C.B.); (P.S.); (C.C.)
- Faculty of Medicine, Université Catholique de Bukavu, Bukavu B.P 265, Democratic Republic of the Congo;
| | - Christine Marie George
- Department of International Health, Program in Global Disease Epidemiology and Control, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD 21205, USA; (K.E.); (E.T.); (J.P.)
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Monira S, Barman I, Jubyda FT, Ali SI, Islam A, Rahman KMZ, Rashid MU, Johura FT, Sultana M, Zohura F, Bhuyian SI, Parvin T, Sack D, Ahmed T, Saif-Ur-Rahman KM, Hossain M, Watanabe H, George CM, Alam M. Gut microbiota shifts favorably with delivery of handwashing with soap and water treatment intervention in a prospective cohort (CHoBI7 trial). JOURNAL OF HEALTH, POPULATION, AND NUTRITION 2023; 42:146. [PMID: 38129922 PMCID: PMC10740293 DOI: 10.1186/s41043-023-00477-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/18/2022] [Accepted: 11/21/2023] [Indexed: 12/23/2023]
Abstract
BACKGROUND Cholera can result in the expulsion of important microbiota from the gut and result in death if left untreated. The disease transmits mainly via drinking water carrying Vibrio cholerae; and household contacts (HHC) of cholera patients are at elevated risk during the first week of infection. The gut microbiota profiles of HHC-children of cholera patients at Dhaka city slums were investigated before (day 0) and after (day 8) delivery of chlorinated water as part of the major study 'CHoBI7 trial (cholera-hospital-based intervention for 7 days)'. RESULT Results of sequencing and analysis of bacterial community DNA revealed the predominance of two bacterial phyla: Bacteroidetes and Firmicutes at day 0 with a relative abundance of 62 ± 6 (mean ± SEM%) and 32 ± 7, respectively. The pattern reversed at day 8 with a decreased relative abundance of Bacteroidetes (39 ± 12; p = 0.034) and an increased abundance of Firmicutes (49 ± 12; p = 0.057). Of 65 bacterial families confirmed at day 0, six belonging to Proteobacteria including Vibrionaceae disappeared at day 8. Interestingly, the relative abundance of four Firmicutes families-Lachnospiraceae, Bifidobacteriaceae, Clostridiaceae, and Ruminococcaceae was increased in all five study children at day 8. CONCLUSION The observed exclusion of pathogenic Proteobacteria and enhancement of beneficial Firmicutes in the gut of children delivered with chlorinated water as part of WASH intervention reflect a great promise of the CHoBI7 program in preventing cholera and improving child health.
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Affiliation(s)
- Shirajum Monira
- Molecular Ecology and Metagenomics Laboratory, Infectious Diseases Division, icddr,b, (International Centre for Diarrhoeal Diseases Research Bangladesh), Dhaka, Bangladesh
| | - Indrajeet Barman
- Molecular Ecology and Metagenomics Laboratory, Infectious Diseases Division, icddr,b, (International Centre for Diarrhoeal Diseases Research Bangladesh), Dhaka, Bangladesh
| | - Fatema Tuz Jubyda
- Molecular Ecology and Metagenomics Laboratory, Infectious Diseases Division, icddr,b, (International Centre for Diarrhoeal Diseases Research Bangladesh), Dhaka, Bangladesh
| | - Sk Imran Ali
- Molecular Ecology and Metagenomics Laboratory, Infectious Diseases Division, icddr,b, (International Centre for Diarrhoeal Diseases Research Bangladesh), Dhaka, Bangladesh
| | - Aminul Islam
- Molecular Ecology and Metagenomics Laboratory, Infectious Diseases Division, icddr,b, (International Centre for Diarrhoeal Diseases Research Bangladesh), Dhaka, Bangladesh
| | - Kazi Mohammad Zillur Rahman
- Molecular Ecology and Metagenomics Laboratory, Infectious Diseases Division, icddr,b, (International Centre for Diarrhoeal Diseases Research Bangladesh), Dhaka, Bangladesh
| | - Mahamud-Ur Rashid
- Molecular Ecology and Metagenomics Laboratory, Infectious Diseases Division, icddr,b, (International Centre for Diarrhoeal Diseases Research Bangladesh), Dhaka, Bangladesh
| | - Fatema-Tuz Johura
- Molecular Ecology and Metagenomics Laboratory, Infectious Diseases Division, icddr,b, (International Centre for Diarrhoeal Diseases Research Bangladesh), Dhaka, Bangladesh
| | - Marzia Sultana
- Molecular Ecology and Metagenomics Laboratory, Infectious Diseases Division, icddr,b, (International Centre for Diarrhoeal Diseases Research Bangladesh), Dhaka, Bangladesh
| | - Fatema Zohura
- Molecular Ecology and Metagenomics Laboratory, Infectious Diseases Division, icddr,b, (International Centre for Diarrhoeal Diseases Research Bangladesh), Dhaka, Bangladesh
| | - Sazzadul Islam Bhuyian
- Molecular Ecology and Metagenomics Laboratory, Infectious Diseases Division, icddr,b, (International Centre for Diarrhoeal Diseases Research Bangladesh), Dhaka, Bangladesh
| | - Tahmina Parvin
- Molecular Ecology and Metagenomics Laboratory, Infectious Diseases Division, icddr,b, (International Centre for Diarrhoeal Diseases Research Bangladesh), Dhaka, Bangladesh
| | - David Sack
- Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
| | - Tahmeed Ahmed
- Molecular Ecology and Metagenomics Laboratory, Infectious Diseases Division, icddr,b, (International Centre for Diarrhoeal Diseases Research Bangladesh), Dhaka, Bangladesh
| | - K M Saif-Ur-Rahman
- Molecular Ecology and Metagenomics Laboratory, Infectious Diseases Division, icddr,b, (International Centre for Diarrhoeal Diseases Research Bangladesh), Dhaka, Bangladesh
- Evidence Synthesis Ireland and Cochrane Ireland, College of Medicine, Nursing, and Health Sciences, University of Galway, Galway, Ireland
| | - Maqsud Hossain
- NSU Genome Research Institute, North South University, Dhaka, Bangladesh
| | - Haruo Watanabe
- National Institutes of Infectious Diseases (NIID), Tokyo, Japan
| | - Christine Marie George
- Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
| | - Munirul Alam
- Molecular Ecology and Metagenomics Laboratory, Infectious Diseases Division, icddr,b, (International Centre for Diarrhoeal Diseases Research Bangladesh), Dhaka, Bangladesh.
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Wiens KE, Xu H, Zou K, Mwaba J, Lessler J, Malembaka EB, Demby MN, Bwire G, Qadri F, Lee EC, Azman AS. Estimating the proportion of clinically suspected cholera cases that are true Vibrio cholerae infections: A systematic review and meta-analysis. PLoS Med 2023; 20:e1004286. [PMID: 37708235 PMCID: PMC10538743 DOI: 10.1371/journal.pmed.1004286] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/25/2022] [Revised: 09/28/2023] [Accepted: 08/25/2023] [Indexed: 09/16/2023] Open
Abstract
BACKGROUND Cholera surveillance relies on clinical diagnosis of acute watery diarrhea. Suspected cholera case definitions have high sensitivity but low specificity, challenging our ability to characterize cholera burden and epidemiology. Our objective was to estimate the proportion of clinically suspected cholera that are true Vibrio cholerae infections and identify factors that explain variation in positivity. METHODS AND FINDINGS We conducted a systematic review of studies that tested ≥10 suspected cholera cases for V. cholerae O1/O139 using culture, PCR, and/or a rapid diagnostic test. We searched PubMed, Embase, Scopus, and Google Scholar for studies that sampled at least one suspected case between January 1, 2000 and April 19, 2023, to reflect contemporary patterns in V. cholerae positivity. We estimated diagnostic test sensitivity and specificity using a latent class meta-analysis. We estimated V. cholerae positivity using a random-effects meta-analysis, adjusting for test performance. We included 119 studies from 30 countries. V. cholerae positivity was lower in studies with representative sampling and in studies that set minimum ages in suspected case definitions. After adjusting for test performance, on average, 52% (95% credible interval (CrI): 24%, 80%) of suspected cases represented true V. cholerae infections. After adjusting for test performance and study methodology, the odds of a suspected case having a true infection were 5.71 (odds ratio 95% CrI: 1.53, 15.43) times higher when surveillance was initiated in response to an outbreak than in non-outbreak settings. Variation across studies was high, and a limitation of our approach was that we were unable to explain all the heterogeneity with study-level attributes, including diagnostic test used, setting, and case definitions. CONCLUSIONS In this study, we found that burden estimates based on suspected cases alone may overestimate the incidence of medically attended cholera by 2-fold. However, accounting for cases missed by traditional clinical surveillance is key to unbiased cholera burden estimates. Given the substantial variability in positivity between settings, extrapolations from suspected to confirmed cases, which is necessary to estimate cholera incidence rates without exhaustive testing, should be based on local data.
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Affiliation(s)
- Kirsten E. Wiens
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Johns Hopkins University, Baltimore, Maryland, United States of America
- Department of Epidemiology and Biostatistics, College of Public Health, Temple University, Philadelphia, Pennsylvania, United States of America
| | - Hanmeng Xu
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Johns Hopkins University, Baltimore, Maryland, United States of America
| | - Kaiyue Zou
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Johns Hopkins University, Baltimore, Maryland, United States of America
| | - John Mwaba
- Centre for Infectious Disease Research in Zambia (CIDRZ), Lusaka, Zambia
- Department of Biomedical Sciences, School of Health Sciences, University of Zambia, Lusaka, Zambia
- Department of Pathology and Microbiology, University Teaching Hospital, Lusaka, Zambia
| | - Justin Lessler
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Johns Hopkins University, Baltimore, Maryland, United States of America
- Department of Epidemiology, Gillings School of Global Public Health, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, United States of America
- Carolina Population Center, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, United States of America
| | - Espoir Bwenge Malembaka
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Johns Hopkins University, Baltimore, Maryland, United States of America
- Center for Tropical Diseases and Global Health (CTDGH), Université Catholique de Bukavu, Bukavu, Democratic Republic of the Congo
| | - Maya N. Demby
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Johns Hopkins University, Baltimore, Maryland, United States of America
| | - Godfrey Bwire
- Division of Public Health Emergency Preparedness and Response, Ministry of Health, Kampala, Uganda
| | - Firdausi Qadri
- Infectious Diseases Division, International Centre for Diarrhoeal Disease Research Bangladesh (icddr,b), Dhaka, Bangladesh
| | - Elizabeth C. Lee
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Johns Hopkins University, Baltimore, Maryland, United States of America
| | - Andrew S. Azman
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Johns Hopkins University, Baltimore, Maryland, United States of America
- Geneva Centre for Emerging Viral Diseases, Geneva University Hospitals, Geneva, Switzerland
- Division of Tropical and Humanitarian Medicine, Geneva University Hospitals, Geneva, Switzerland
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Sarker MHR, Das SK, Sujon H, Moriyama M, Rahman MM, Uzzaman MN, Banu S, Shahid ASMSB, Das J, Khan SH, Chisti MJ, Faruque ASG, Ahmed T. Changing Water-Sanitation Determinants of Cholera over Two Decades in Bangladesh. Am J Trop Med Hyg 2023; 109:368-375. [PMID: 37277103 PMCID: PMC10397457 DOI: 10.4269/ajtmh.22-0575] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/04/2022] [Accepted: 03/10/2023] [Indexed: 06/07/2023] Open
Abstract
Cholera is a leading global public health threat, especially in developing countries. This study aimed to determine the changing determinants of cholera related to water-sanitation practices between 1994-1998 and 2014-2018 in Dhaka, Bangladesh. Data of all cause diarrhea cases were extracted from the Diarrheal Disease Surveillance System of the International Centre for Diarrhoeal Disease Research, Bangladesh, Dhaka, and analysis was performed among three groups: Vibrio cholerae detected as sole pathogen, V. cholerae detected as mixed infection, and detection of no common enteropathogen in stool specimens (reference). Using sanitary toilet, drinking tap water, drinking boiled water, family size greater than five, and slum dwelling were the main exposures. Overall, 3,380 (20.30%) and 1,290 (9.69%) patients were positive for V. cholerae during 1994-1998 and 2014-2018, respectively. In 1994-1998, use of sanitary toilet (adjusted odds ratio [aOR]: 0.86, 95% CI: 0.76-0.97) and drinking tap water (aOR: 0.81, 95% CI: 0.72-0.92) were found to be negatively associated and in 2014-2018, drinking tap water (aOR: 1.47, 95% CI: 1.21-1.78) and slum dwelling (aOR: 1.43, 95% CI: 1.10-1.86) were found to be positively associated with V. cholerae infection after adjusting for age, sex, monthly income, and seasonality. Because the determinants of cholera such as drinking tap water can change over time in developing cities, ameliorating the water, sanitation, and hygiene (WASH) situation is of paramount importance. In addition, in settings such as urban slums, where long-term WASH monitoring might be difficult to achieve, mass vaccination with oral cholera vaccine should be introduced to control cholera.
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Affiliation(s)
| | - Sumon Kumar Das
- Menzies School of Health Research, Charles Darwin University, Darwin, Australia
| | - Hasnat Sujon
- International Centre for Diarrhoeal Disease Research, Bangladesh, Dhaka, Bangladesh
- Infectious Disease and One Health Program, Hannover Medical School, Hannover, Germany
| | - Michiko Moriyama
- Graduate School of Biomedical and Health Sciences, Hiroshima University, Hiroshima, Japan
| | - Md Moshiur Rahman
- Graduate School of Biomedical and Health Sciences, Hiroshima University, Hiroshima, Japan
| | - Md. Nazim Uzzaman
- International Centre for Diarrhoeal Disease Research, Bangladesh, Dhaka, Bangladesh
- Usher Institute, University of Edinburgh, Edinburgh, United Kingdom
| | - Shakila Banu
- International Centre for Diarrhoeal Disease Research, Bangladesh, Dhaka, Bangladesh
| | - Abu SMSB Shahid
- International Centre for Diarrhoeal Disease Research, Bangladesh, Dhaka, Bangladesh
| | - Jui Das
- Institute for Social Science Research, The University of Queensland, Brisbane, Australia
| | - Soroar Hossain Khan
- International Centre for Diarrhoeal Disease Research, Bangladesh, Dhaka, Bangladesh
| | | | - ASG Faruque
- International Centre for Diarrhoeal Disease Research, Bangladesh, Dhaka, Bangladesh
| | - Tahmeed Ahmed
- International Centre for Diarrhoeal Disease Research, Bangladesh, Dhaka, Bangladesh
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7
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Uddin IM, Endres K, Parvin T, Bhuyian MSI, Zohura F, Masud J, Monira S, Hasan MT, Biswas SK, Sultana M, Thomas ED, Perin J, Sack DA, Faruque A, Alam M, George CM. Food Hygiene and Fecal Contamination on the Household Compound are Associated with Increased Pediatric Diarrhea in Urban Bangladesh (CHoBI7 Program). Am J Trop Med Hyg 2023; 108:524-529. [PMID: 36746654 PMCID: PMC9978565 DOI: 10.4269/ajtmh.22-0129] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2022] [Accepted: 08/27/2022] [Indexed: 02/08/2023] Open
Abstract
In this prospective cohort study, we explored individual- and household-level risk factors associated with diarrheal diseases among 251 children younger than 5 years in slum areas of urban Dhaka, Bangladesh. During the 3-month study period, diarrhea surveillance was conducted monthly, and spot checks of the household compound were performed at baseline to assess the presence of feces (animal or human) in the household compound and in cooking and food storage areas, and to assess whether cooked food was covered and refrigerated. We also collected caregiver reports on child mouthing behaviors. Children living in households with feces within 10 steps of cooking and food storage areas (odds ratio [OR], 8.43; 95% CI, 1.01-70.18), those with visible feces found on the ground of the household compound (OR, 4.05; 95% CI, 1.24-13.22), and those in households found to keep cooked food uncovered and without refrigeration (OR, 6.16; 95% CI, 1.11-34.25) during spot checks had a significantly greater odds of diarrhea. There was no significant association between pediatric diarrhea and caregiver-reported child mouthing behaviors or presence of animals in the cooking area. These study findings demonstrate that presence of visible feces in the household compound and near cooking and food storage areas, and poor household food hygiene practices, were significant risk factors for diarrheal disease among young children in Dhaka, Bangladesh. Health communication programs are needed to target these exposure pathways to fecal pathogens.
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Affiliation(s)
- Ismat Minhaj Uddin
- International Centre for Diarrhoeal Disease Research, Bangladesh, Dhaka, Bangladesh
| | - Kelly Endres
- Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland
| | - Tahmina Parvin
- International Centre for Diarrhoeal Disease Research, Bangladesh, Dhaka, Bangladesh
| | | | - Fatema Zohura
- International Centre for Diarrhoeal Disease Research, Bangladesh, Dhaka, Bangladesh
| | - Jahed Masud
- International Centre for Diarrhoeal Disease Research, Bangladesh, Dhaka, Bangladesh
| | - Shirajum Monira
- International Centre for Diarrhoeal Disease Research, Bangladesh, Dhaka, Bangladesh
| | - M. Tasdik Hasan
- International Centre for Diarrhoeal Disease Research, Bangladesh, Dhaka, Bangladesh
| | - Shwapon Kumar Biswas
- International Centre for Diarrhoeal Disease Research, Bangladesh, Dhaka, Bangladesh
| | - Marzia Sultana
- International Centre for Diarrhoeal Disease Research, Bangladesh, Dhaka, Bangladesh
| | - Elizabeth D. Thomas
- Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland
| | - Jamie Perin
- Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland
| | - David A. Sack
- Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland
| | - A.S.G. Faruque
- International Centre for Diarrhoeal Disease Research, Bangladesh, Dhaka, Bangladesh
| | - Munirul Alam
- International Centre for Diarrhoeal Disease Research, Bangladesh, Dhaka, Bangladesh
| | - Christine Marie George
- Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland
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Bhuyian MSI, Perin J, Endres K, Zohura F, Masud J, Parvin T, Uddin IM, Hasan T, Monira S, Sack DA, Faruque ASG, Alam M, George CM. Reduced Diarrhea Prevalence and Improvements in Handwashing with Soap and Stored Drinking Water Quality Associated with Diarrheal Disease Awareness Measured by Interactive Voice Response Messages in the CHoBI7 Mobile Health Program. Am J Trop Med Hyg 2023; 108:530-535. [PMID: 36746653 PMCID: PMC9978569 DOI: 10.4269/ajtmh.22-0273] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2022] [Accepted: 08/15/2022] [Indexed: 02/08/2023] Open
Abstract
The Cholera-Hospital-Based-Intervention-for-7-Days (CHoBI7) mobile health program promotes water, sanitation, and hygiene (WASH) behaviors through interactive voice response (IVR), voice, and text messages to reduce diarrheal diseases in Bangladesh. The objective of this study was to investigate the relationship between responses to CHoBI7 WASH IVR quiz messages and subsequent diarrhea and WASH behaviors. Fourteen CHoBI7 IVR quiz messages on handwashing with soap and treatment of stored water were sent to 517 households with 1,777 participants during the 12-month program period. IVR message responses were classified as correct answer, incorrect answer, no response (did not press 1 or 2), and failed (did not answer the phone). Diarrhea prevalence was assessed through self-reported monthly clinical surveillance visits. Handwashing with soap was assessed by a 5-hour structured observation, and stored water quality was defined by Escherichia coli concentration. Households that responded correctly to a CHoBI7 IVR quiz message had significantly lower odds of diarrhea for all age groups (adults and children) at the subsequent visit 1 month later (odds ratio [OR], 0.73; 95% CI, 0.54-0.98), and significantly greater odds of handwashing with soap after stool-related events (OR, 2.48; 95% CI, 1.12-5.49) and E. coli levels < 100 colony forming units (CFU)/100 mL (World Health Organization high-risk cutoff) in the stored household water (OR, 2.04; 95% CI, 1.25-3.33) compared with households that did not answer CHoBI7 IVR quiz calls. Correct responses to CHoBI7 IVR quizzes were associated with decreased diarrhea prevalence and improved stored drinking water quality and handwashing with soap behaviors at the subsequent visits. These findings suggest engagement in the CHoBI7 mobile health (mHealth) program and awareness of diarrheal disease prevention can reduce diarrhea and facilitate changes in WASH behaviors.
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Affiliation(s)
| | - Jamie Perin
- Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland
| | - Kelly Endres
- Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland
| | - Fatema Zohura
- International Center for Diarrheal Disease Research, Bangladesh, Dhaka, Bangladesh
| | - Jahed Masud
- International Center for Diarrheal Disease Research, Bangladesh, Dhaka, Bangladesh
| | - Tahmina Parvin
- International Center for Diarrheal Disease Research, Bangladesh, Dhaka, Bangladesh
| | - Ismat Minhaj Uddin
- International Center for Diarrheal Disease Research, Bangladesh, Dhaka, Bangladesh
| | - Tasdik Hasan
- International Center for Diarrheal Disease Research, Bangladesh, Dhaka, Bangladesh
| | - Shirajum Monira
- International Center for Diarrheal Disease Research, Bangladesh, Dhaka, Bangladesh
| | - David A. Sack
- Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland
| | - Abu S. G. Faruque
- International Center for Diarrheal Disease Research, Bangladesh, Dhaka, Bangladesh
| | - Munirul Alam
- International Center for Diarrheal Disease Research, Bangladesh, Dhaka, Bangladesh
| | - Christine Marie George
- Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland
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Bauza V, Ye W, Liao J, Majorin F, Clasen T. Interventions to improve sanitation for preventing diarrhoea. Cochrane Database Syst Rev 2023; 1:CD013328. [PMID: 36697370 PMCID: PMC9969045 DOI: 10.1002/14651858.cd013328.pub2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/26/2023]
Abstract
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.
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Affiliation(s)
- Valerie Bauza
- Department of Environmental Health, Rollins School of Public Health, Emory University, Atlanta, GA, USA
| | - Wenlu Ye
- Department of Environmental Health, Rollins School of Public Health, Emory University, Atlanta, GA, USA
- Division of Environmental Health Sciences, School of Public Health, University of California, Berkeley, CA, USA
| | - Jiawen Liao
- Department of Environmental Health, Rollins School of Public Health, Emory University, Atlanta, GA, USA
- Department of Population and Public Health Sciences, Keck School of Medicine of the University of Southern California, Los Angeles, CA, USA
| | - Fiona Majorin
- Faculty of Infectious and Tropical Diseases, London School of Hygiene & Tropical Medicine, London, UK
| | - Thomas Clasen
- Department of Environmental Health, Rollins School of Public Health, Emory University, Atlanta, GA, USA
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Crider YS, Tsuchiya M, Mukundwa M, Ray I, Pickering AJ. Adoption of Point-of-Use Chlorination for Household Drinking Water Treatment: A Systematic Review. ENVIRONMENTAL HEALTH PERSPECTIVES 2023; 131:16001. [PMID: 36715546 PMCID: PMC9885856 DOI: 10.1289/ehp10839] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 12/21/2021] [Revised: 12/20/2022] [Accepted: 12/23/2022] [Indexed: 06/18/2023]
Abstract
BACKGROUND Centralized chlorination of urban piped water supplies has historically contributed to major reductions in waterborne illness. In locations without effective centralized water treatment, point-of-use (POU) chlorination for households is widely promoted to improve drinking water quality and health. Realizing these health benefits requires correct, consistent, and sustained product use, but real-world evaluations have often observed low levels of use. To our knowledge, no prior reviews exist on adoption of chlorine POU products. OBJECTIVES Our objectives were to identify which indicators of adoption are most often used in chlorine POU studies, summarize levels of adoption observed, understand how adoption changes over time, and determine how adoption is affected by frequency of contact between participants and study staff. METHODS We conducted a systematic review of household POU chlorination interventions or programs from 1990 through 2021 that reported a quantitative measure of adoption, were conducted in low- and middle-income countries, included data collection at households, and reported the intervention start date. RESULTS We identified 36 studies of household drinking water chlorination products that met prespecified eligibility criteria and extracted data from 46 chlorine intervention groups with a variety of chlorine POU products and locations. There was no consensus definition of adoption of household water treatment; the most common indicator was the proportion of household stored water samples with free chlorine residual > 0.1 or 0.2 mg / L . Among studies that reported either free or total chlorine-confirmed adoption of chlorine POU products, use was highly variable (across all chlorine intervention groups at the last time point measured in each study; range: 1.5%-100%; sample size-weighted median = 47 % ; unweighted median = 58 % ). The median follow-up duration among intervention groups was 3 months. On average, adoption declined over time and was positively associated with frequency of contact between respondents and study staff. DISCUSSION Although prior research has shown that POU chlorine products improve health when correctly and consistently used, a reliance on individual adoption for effective treatment is unlikely to lead to the widespread public health benefits historically associated with pressurized, centralized treatment of piped water supplies. https://doi.org/10.1289/EHP10839.
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Affiliation(s)
- Yoshika S. Crider
- Energy and Resources Group, University of California, Berkeley (UC Berkeley), Berkeley, California, USA
- Division of Epidemiology and Biostatistics, UC Berkeley, Berkeley, California, USA
- King Center on Global Development, Stanford University, Stanford, California, USA
| | - Miki Tsuchiya
- Master of Development Practice Program, UC Berkeley, Berkeley, California, USA
| | - Magnifique Mukundwa
- Department of Civil and Environmental Engineering, Tufts University, Medford, Massachusetts, USA
| | - Isha Ray
- Energy and Resources Group, University of California, Berkeley (UC Berkeley), Berkeley, California, USA
| | - Amy J. Pickering
- Department of Civil and Environmental Engineering, UC Berkeley, Berkeley, California, USA
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11
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White S, Jain A, Bangura A, Farrington M, Mekonen M, Nhial BC, Hoque E, Moniruzzaman M, Namegabe P, Walassa J, Majorin F. Facilitating hand hygiene in displacement camps during the COVID-19 pandemic: a qualitative assessment of a novel handwashing stand and hygiene promotion package. Confl Health 2022; 16:65. [PMID: 36527055 PMCID: PMC9756724 DOI: 10.1186/s13031-022-00492-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2022] [Accepted: 10/31/2022] [Indexed: 12/23/2022] Open
Abstract
BACKGROUND Handwashing with soap is critical for the prevention of diarrhoeal diseases and outbreak related diseases, including interrupting the transmission of COVID-19. People living in large displacement settings are particularly vulnerable to such outbreaks, however, practicing handwashing is typically challenging in these contexts. METHODS We conducted a qualitative assessment of the implementation of a combined intervention to facilitate handwashing behaviour in displacement camps and in surrounding communities in Bangladesh, Ethiopia and the Democratic Republic of Congo during the COVID-19 pandemic. The intervention comprised a 'hardware' infrastructural component (provision of the Oxfam Handwashing Station) and a 'software' hygiene promotion package (Mum's Magic Hands). We used programmatic logbooks, interviews with implementation staff and focus group discussions with crisis-affected populations to assess the use, feasibility and acceptability of the intervention. RESULTS Both components of the intervention were viewed as novel and appealing by implementing staff and crisis-affected populations across the study sites. The acceptability of the handwashing station could be improved by redesigning the tap and legs, exploring local supply chain options, and by providing a greater number of facilities. The implementation of the hygiene promotion package varied substantially by country making it challenging to evaluate and compare. A greater focus on community engagement could address misconceptions, barriers related to the intuitiveness of the handwashing station design, and willingness to participate in the hygiene promotion component. CONCLUSIONS The combination of a 'hardware' and 'software' intervention in these settings appeared to facilitate both access and use of handwashing facilities. The acceptability of the combined intervention was partially because a great deal of effort had been put into their design. However, even when delivering well-designed interventions, there are many contextual aspects that need to be considered, as well as unintended consequences which can affect the acceptability of an intervention.
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Affiliation(s)
- Sian White
- grid.8991.90000 0004 0425 469XDepartment of Disease Control, London School of Hygiene and Tropical Medicine, Keppel Street, London, UK
| | | | - Abie Bangura
- grid.437028.a0000 0004 0450 9859Oxfam, John Smith Drive, Oxford, UK
| | | | | | - Bang Chuol Nhial
- Department of Public Health, Gambella University, Gambella Town, Gambella, Ethiopia
| | - Enamul Hoque
- Oxfam in Bangladesh, RAOWA Complex, VIP Road, Dhaka, 1206 Bangladesh
| | - Md. Moniruzzaman
- Oxfam in Bangladesh, RAOWA Complex, VIP Road, Dhaka, 1206 Bangladesh
| | | | - John Walassa
- Oxfam in DRC, Goma, Democratic Republic of Congo
| | - Fiona Majorin
- grid.8991.90000 0004 0425 469XDepartment of Disease Control, London School of Hygiene and Tropical Medicine, Keppel Street, London, UK
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12
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Nalule Y, Pors P, Samol C, Ret S, Leang S, Ir P, Macintyre A, Dreibelbis R. A controlled before-and-after study of a multi-modal intervention to improve hand hygiene during the peri-natal period in Cambodia. Sci Rep 2022; 12:19646. [PMID: 36385113 PMCID: PMC9666993 DOI: 10.1038/s41598-022-23937-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/15/2021] [Accepted: 11/08/2022] [Indexed: 11/17/2022] Open
Abstract
Adequate hand hygiene practices throughout the continuum of care of maternal and newborn health are essential for infection prevention. However, the hand hygiene compliance of facility-based birth attendants, parents and other caregivers along this continuum is low and behavioural-science informed interventions targeting the range of caregivers in both the healthcare facility and home environments are scarce. We assessed the limited efficacy of a novel multimodal behaviour change intervention, delivered at the facility, to improve the hand hygiene practices among midwives and caregivers during childbirth through the return to the home environment. The 6-month intervention was implemented in 4 of 8 purposively selected facilities and included environmental restructuring, hand hygiene infrastructure provision, cues and reminders, and participatory training. In this controlled before-and-after study, the hand hygiene practices of all caregivers present along the care continuum of 99 women and newborns were directly observed. Direct observations took place during three time periods; labour, delivery and immediate aftercare in the facility delivery room, postnatal care in the facility ward and in the home environment within the first 48 h following discharge. Multilevel logistic regression models, adjusted for baseline measures, assessed differences in hand hygiene practices between intervention and control facilities. The intervention was associated with increased odds of improved practice of birth attendants during birth and newborn care in the delivery room (Adjusted odds ratio [AOR] = 4.7; 95% confidence interval [CI] = 2.7, 7.7), and that of parental and non-parental caregivers prior to newborn care in the post-natal care ward (AOR = 9.2; CI = 1.3, 66.2); however, the absolute magnitude of improvements was limited. Intervention effects were not presented for the home environment due COVID-19 related restrictions on observation duration at endline which resulted in too low observation numbers to warrant testing. Our results suggest the potential of a facility-based multimodal behaviour change intervention to improve hand hygiene practices that are critical to maternal and neonatal infection along the continuum of care.
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Affiliation(s)
- Yolisa Nalule
- grid.8991.90000 0004 0425 469XDisease Control Department, London School of Hygiene and Tropical Medicine, London, WC1E 7HT UK
| | | | | | | | - Supheap Leang
- grid.436334.5National Institute of Public Health, Phnom Penh, Cambodia
| | - Por Ir
- grid.436334.5National Institute of Public Health, Phnom Penh, Cambodia
| | | | - Robert Dreibelbis
- grid.8991.90000 0004 0425 469XDisease Control Department, London School of Hygiene and Tropical Medicine, London, WC1E 7HT UK
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Zohura F, Thomas ED, Masud J, Bhuyian MSI, Parvin T, Monira S, Faruque ASG, Alam M, George CM. Formative Research for the Development of the CHoBI7 Cholera Rapid Response Program for Cholera Hotspots in Bangladesh. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2022; 19:13352. [PMID: 36293930 PMCID: PMC9603179 DOI: 10.3390/ijerph192013352] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/17/2022] [Revised: 09/25/2022] [Accepted: 09/29/2022] [Indexed: 06/16/2023]
Abstract
Cholera is a severe form of acute watery diarrhea that if left untreated can result in death. Globally, there are 2.9 million cholera cases annually. Individuals living in close proximity to cholera cases are at a higher risk for developing cholera compared to the general population. Targeted water, sanitation, and hygiene (WASH) interventions have the potential to reduce cholera transmission in cholera hotspots around cholera cases. The objective of this study was to expand the scope of the Cholera-Hospital-Based-Intervention-for-7-Days (CHoBI7) program, focused on cholera patient households, for delivery in cholera hotspots in urban slums in Dhaka, Bangladesh. Thirty-one semi-structured interviews were conducted in cholera hotspots around cholera patients, and three intervention planning workshops were conducted to inform modifications needed to the CHoBI7 program. After exploratory interviews, a two-phase, iterative pilot study was conducted for 9 months to test the developed CHoBI7 Cholera Rapid Response program among 180 participants to further inform modifications to intervention content and delivery. Findings from pilot participant interviews highlighted the need to adapt intervention content for delivery at the compound-rather than household-level, given an environment with multiple households sharing a water source, toilets, and kitchen facilities. This was addressed by conducting a "ring session" for intervention delivery in cholera hotspots for households to discuss how to improve their shared facilities together and encourage a compound-level commitment to promoted WASH behaviors and placement of soapy water bottles in shared spaces. Based on the low number of soapy water bottles observed in communal spaces during the first iteration of the pilot, we also added context-specific examples using the narratives of families in mobile messages to encourage WASH behavioral recommendations. Formative research identified important considerations for the modifications needed to tailor the CHoBI7 program for delivery in cholera hotspots in urban Bangladesh.
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Affiliation(s)
- Fatema Zohura
- Research, Training and Management International, Dhaka 1216, Bangladesh
- International Centre for Diarrhoeal Disease Research, icddr,b, Dhaka 1212, Bangladesh
| | - Elizabeth D. Thomas
- Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD 21205, USA
| | - Jahed Masud
- Research, Training and Management International, Dhaka 1216, Bangladesh
- International Centre for Diarrhoeal Disease Research, icddr,b, Dhaka 1212, Bangladesh
| | - Md Sazzadul Islam Bhuyian
- Research, Training and Management International, Dhaka 1216, Bangladesh
- International Centre for Diarrhoeal Disease Research, icddr,b, Dhaka 1212, Bangladesh
| | - Tahmina Parvin
- Research, Training and Management International, Dhaka 1216, Bangladesh
- International Centre for Diarrhoeal Disease Research, icddr,b, Dhaka 1212, Bangladesh
| | - Shirajum Monira
- International Centre for Diarrhoeal Disease Research, icddr,b, Dhaka 1212, Bangladesh
| | - Abu S. G. Faruque
- International Centre for Diarrhoeal Disease Research, icddr,b, Dhaka 1212, Bangladesh
| | - Munirul Alam
- International Centre for Diarrhoeal Disease Research, icddr,b, Dhaka 1212, Bangladesh
| | - Christine Marie George
- Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD 21205, USA
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George CM, Parvin T, Bhuyian MSI, Uddin IM, Zohura F, Masud J, Monira S, Sack DA, Perin J, Alam M, Faruque ASG. Randomized Controlled Trial of the Cholera-Hospital-Based-Intervention-for-7-Days (CHoBI7) Cholera Rapid Response Program to Reduce Diarrheal Diseases in Bangladesh. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2022; 19:12905. [PMID: 36232205 PMCID: PMC9566036 DOI: 10.3390/ijerph191912905] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 08/15/2022] [Revised: 09/09/2022] [Accepted: 09/19/2022] [Indexed: 06/16/2023]
Abstract
(a) Objective: To build an evidence base on effective water, sanitation, and hygiene interventions to reduce diarrheal diseases in cholera hotspots, we developed the CHoBI7 Cholera Rapid Response Program. (b) Methods: Once a cholera patient (confirmed by bacterial culture) is identified at a health facility, a health promoter delivers a targeted WASH intervention to the cholera hotspot (households within 20 m of a cholera patient) through both in-person visits during the first week and bi-weekly WASH mobile messages for the 3-month program period. A randomized controlled trial of the CHoBI7 Cholera Rapid Response Program was conducted with 284 participants in 15 cholera hotspots around cholera patients in urban Dhaka, Bangladesh. This program was compared to the standard message in Bangladesh on the use of oral rehydration solution for dehydration. Five-hour structured observation of handwashing with soap and diarrhea surveillance was conducted monthly. (c) Findings: Handwashing with soap at food- and stool-related events was significantly higher in the CHoBI7 Cholera Rapid Response Program arm compared to the standard message arm at all timepoints (overall 54% in the CHoBI7 arm vs. 23% in the standard arm, p < 0.05). Furthermore, there was a significant reduction in diarrheal prevalence for all participants (adults and children) (Prevalence Ratio (PR) 0.35, 95% CI: 0.14-0.85) and for children under 5 years of age (PR: 0.27, 95% CI: 0.085-0.87) during the 3-month program. (d) Conclusions: These findings demonstrate that the CHoBI7 Cholera Rapid Response Program is effective in lowering diarrhea prevalence and increasing handwashing with soap for a population at high risk of cholera.
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Affiliation(s)
- Christine Marie George
- Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD 21205-2103, USA
| | - Tahmina Parvin
- Research Training and Management International, Dhaka 1216, Bangladesh
- International Centre for Diarrhoeal Disease Research, Bangladesh (icddr,b), Dhaka 1212, Bangladesh
| | - Md. Sazzadul Islam Bhuyian
- Research Training and Management International, Dhaka 1216, Bangladesh
- International Centre for Diarrhoeal Disease Research, Bangladesh (icddr,b), Dhaka 1212, Bangladesh
| | - Ismat Minhaj Uddin
- Research Training and Management International, Dhaka 1216, Bangladesh
- International Centre for Diarrhoeal Disease Research, Bangladesh (icddr,b), Dhaka 1212, Bangladesh
| | - Fatema Zohura
- Research Training and Management International, Dhaka 1216, Bangladesh
- International Centre for Diarrhoeal Disease Research, Bangladesh (icddr,b), Dhaka 1212, Bangladesh
| | - Jahed Masud
- Research Training and Management International, Dhaka 1216, Bangladesh
- International Centre for Diarrhoeal Disease Research, Bangladesh (icddr,b), Dhaka 1212, Bangladesh
| | - Shirajum Monira
- International Centre for Diarrhoeal Disease Research, Bangladesh (icddr,b), Dhaka 1212, Bangladesh
| | - David A. Sack
- Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD 21205-2103, USA
| | - Jamie Perin
- Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD 21205-2103, USA
| | - Munirul Alam
- International Centre for Diarrhoeal Disease Research, Bangladesh (icddr,b), Dhaka 1212, Bangladesh
| | - A. S. G. Faruque
- International Centre for Diarrhoeal Disease Research, Bangladesh (icddr,b), Dhaka 1212, Bangladesh
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Bisimwa L, Williams C, Bisimwa JC, Sanvura P, Endres K, Thomas E, Perin J, Cikomola C, Bengehya J, Maheshe G, Mwishingo A, George CM. Formative Research for the Development of Evidence-Based Targeted Water, Sanitation, and Hygiene Interventions to Reduce Cholera in Hotspots in the Democratic Republic of the Congo: Preventative Intervention for Cholera for 7 Days (PICHA7) Program. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2022; 19:12243. [PMID: 36231546 PMCID: PMC9566157 DOI: 10.3390/ijerph191912243] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 07/18/2022] [Revised: 08/18/2022] [Accepted: 09/05/2022] [Indexed: 06/16/2023]
Abstract
Compared to the general public, household members of cholera patients are at a 100 times higher risk of contracting cholera during the 7-day high-risk period after a cholera patient has been admitted to a health facility for treatment. The Preventative-Intervention-for-Cholera-for-7-days (PICHA7) program aims to reduce household transmission of cholera during this 7-day high-risk period through a health facility-initiated water, sanitation, and hygiene (WASH) program promoting handwashing with soap, water treatment, and safe water storage. The PICHA7 program is delivered to cholera patient households through: (1) a pictorial flipbook delivered by a health promoter; (2) a cholera prevention package (handwashing station, drinking water vessel with lid and tap, and chlorine tablets); and (3) weekly WASH mobile messages sent to patient households in the Democratic Republic of the Congo (DRC). The objectives of this study were to conduct formative research to identify facilitators and barriers of the promoted WASH behaviors for cholera patient households and to tailor the PICHA7 program to target these facilitators and barriers. Formative research included 93 semi-structured interviews with diarrhea patient households and healthcare workers during exploratory research and a pilot study of 518 participants. Barriers to the promoted WASH behaviors identified during exploratory and pilot study interviews included: (1) low awareness of cholera transmission and prevention; (2) unaffordability of soap for handwashing; and (3) intermittent access to water limiting water for handwashing. For intervention development, narratives of the lived experiences of patient households in our study were presented by health promoters to describe cholera transmission and prevention, and soapy water and ash were promoted in the program flipbook and mobile messages to address the affordability of soap for handwashing. A jerry can was provided to allow for additional water storage, and a tap with a slower flow rate was attached to the handwashing station to reduce the amount of water required for handwashing. The pilot findings indicate that the PICHA7 program has high user acceptability and is feasible to deliver to cholera patients that present at health facilities for treatment in our study setting. Formative research allowed for tailoring this targeted WASH program for cholera patient households in the DRC.
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Affiliation(s)
- Lucien Bisimwa
- Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD 21205-2103, USA
- Center for Tropical Diseases & Global Health, Université Catholique de Bukavu, Bukavu B.P 265, Democratic Republic of the Congo
| | - Camille Williams
- Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD 21205-2103, USA
| | - Jean-Claude Bisimwa
- Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD 21205-2103, USA
- Center for Tropical Diseases & Global Health, Université Catholique de Bukavu, Bukavu B.P 265, Democratic Republic of the Congo
| | - Presence Sanvura
- Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD 21205-2103, USA
- Center for Tropical Diseases & Global Health, Université Catholique de Bukavu, Bukavu B.P 265, Democratic Republic of the Congo
| | - Kelly Endres
- Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD 21205-2103, USA
| | - Elizabeth Thomas
- Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD 21205-2103, USA
| | - Jamie Perin
- Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD 21205-2103, USA
| | - Cirhuza Cikomola
- Center for Tropical Diseases & Global Health, Université Catholique de Bukavu, Bukavu B.P 265, Democratic Republic of the Congo
| | - Justin Bengehya
- Bureau de l’Information Sanitaire, Surveillance Epidémiologique et Recherche Scientifique Division Provinciale de la Santé/Sud Kivu, Ministère de la Santé Publique, Hygiène et Prévention, Bukavu B.P 265, Democratic Republic of the Congo
| | - Ghislain Maheshe
- Faculty of Medicine, Université Catholique de Bukavu, Bukavu B.P 265, Democratic Republic of the Congo
| | - Alain Mwishingo
- Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD 21205-2103, USA
- Center for Tropical Diseases & Global Health, Université Catholique de Bukavu, Bukavu B.P 265, Democratic Republic of the Congo
| | - Christine Marie George
- Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD 21205-2103, USA
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Kang S, Chowdhury F, Park J, Ahmed T, Tadesse BT, Islam MT, Kim DR, Im J, Aziz AB, Hoque M, Pak G, Khanam F, Ahmmed F, Liu X, Zaman K, Khan AI, Kim JH, Marks F, Qadri F, Clemens JD. Are better existing WASH practices in urban slums associated with a lower long-term risk of severe cholera? A prospective cohort study with 4 years of follow-up in Mirpur, Bangladesh. BMJ Open 2022; 12:e060858. [PMID: 36130764 PMCID: PMC9494564 DOI: 10.1136/bmjopen-2022-060858] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
OBJECTIVE To investigate the association between existing household water quality, sanitation and hygiene (WASH) practices and severe cholera risk in a dense urban slum where cholera is highly endemic. DESIGN, SETTING AND PARTICIPANTS We assembled a large prospective cohort within a cluster randomised trial evaluating the effectiveness of oral cholera vaccine. Our dynamic cohort population (n=193 576) comprised individuals living in the 'non-intervention' clusters of the trial, and were followed over 4 years. This study was conducted in a dense urban slum community of Dhaka, Bangladesh and cholera surveillance was undertaken in 12 hospitals serving the study area. PRIMARY OUTCOME MEASURE First severe cholera episode detected during follow-up period. METHODS We applied a machine learning algorithm on a training subpopulation (n=96 943) to develop a binary ('better', 'not better') composite WASH variable predictive of severe cholera. The WASH rule was evaluated for performance in a separate validation subpopulation (n=96 633). Afterwards, we used Cox regression models to evaluate the association between 'better' WASH households and severe cholera risk over 4 years in the entire study population. RESULTS The 'better' WASH rule found that water quality and access were the most significant factors associated with severe cholera risk. Members of 'better' WASH households, constituting one-third of the population, had a 47% reduced risk of severe cholera (95% CI: 29 to 69; p<0.001), after adjusting for covariates. The protective association between living in a 'better' WASH household and severe cholera persisted in all age groups. CONCLUSIONS Salutary existing household WASH practices were associated with a significantly reduced long-term risk of severe cholera in an urban slum of Dhaka. These findings suggest that WASH adaptations already practised in the community may be important for developing and implementing effective and sustainable cholera control programmes in similar settings. TRIAL REGISTRATION NUMBER This article is a re-analysis of data from a cluster randomized trial; can be found on ClinicalTrials.gov NCT01339845.
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Affiliation(s)
- Sophie Kang
- Epidemiology, Public Health, and Impact Unit, International Vaccine Institute, Gwanak-gu, The Republic of Korea
| | - Fahima Chowdhury
- Infectious Diseases Division, International Centre for Diarrhoeal Disease Research, Dhaka, Bangladesh
- Griffith University Menzies Health Institute Queensland, Nathan, Queensland, Australia
| | - Juyeon Park
- Epidemiology, Public Health, and Impact Unit, International Vaccine Institute, Gwanak-gu, The Republic of Korea
| | - Tasnuva Ahmed
- Infectious Diseases Division, International Centre for Diarrhoeal Disease Research, Dhaka, Bangladesh
| | - Birkneh Tilahun Tadesse
- Epidemiology, Public Health, and Impact Unit, International Vaccine Institute, Gwanak-gu, The Republic of Korea
| | - Md Taufiqul Islam
- Infectious Diseases Division, International Centre for Diarrhoeal Disease Research, Dhaka, Bangladesh
| | - Deok Ryun Kim
- Epidemiology, Public Health, and Impact Unit, International Vaccine Institute, Gwanak-gu, The Republic of Korea
| | - Justin Im
- Epidemiology, Public Health, and Impact Unit, International Vaccine Institute, Gwanak-gu, The Republic of Korea
| | - Asma Binte Aziz
- Epidemiology, Public Health, and Impact Unit, International Vaccine Institute, Gwanak-gu, The Republic of Korea
| | - Masuma Hoque
- Infectious Diseases Division, International Centre for Diarrhoeal Disease Research, Dhaka, Bangladesh
| | - Gideok Pak
- Epidemiology, Public Health, and Impact Unit, International Vaccine Institute, Gwanak-gu, The Republic of Korea
| | - Farhana Khanam
- Infectious Diseases Division, International Centre for Diarrhoeal Disease Research, Dhaka, Bangladesh
| | - Faisal Ahmmed
- Infectious Diseases Division, International Centre for Diarrhoeal Disease Research, Dhaka, Bangladesh
| | - Xinxue Liu
- Oxford Vaccine Group, Department of Paediatrics, University of Oxford, Oxford, UK
| | - K Zaman
- Infectious Diseases Division, International Centre for Diarrhoeal Disease Research, Dhaka, Bangladesh
| | - Ashraful Islam Khan
- Infectious Diseases Division, International Centre for Diarrhoeal Disease Research, Dhaka, Bangladesh
| | - Jerome H Kim
- International Vaccine Institute, Gwanak-gu, The Republic of Korea
| | - Florian Marks
- Epidemiology, Public Health, and Impact Unit, International Vaccine Institute, Gwanak-gu, The Republic of Korea
- Department of Medicine, University of Cambridge, Cambridge, UK
| | - Firdausi Qadri
- Infectious Diseases Division, International Centre for Diarrhoeal Disease Research, Dhaka, Bangladesh
| | - John D Clemens
- Infectious Diseases Division, International Centre for Diarrhoeal Disease Research, Dhaka, Bangladesh
- International Vaccine Institute, Gwanak-gu, The Republic of Korea
- Fielding School of Public Health, University of California, Los Angeles, California, USA
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Ratnayake R, Peyraud N, Ciglenecki I, Gignoux E, Lightowler M, Azman AS, Gakima P, Ouamba JP, Sagara JA, Ndombe R, Mimbu N, Ascorra A, Welo PO, Mukamba Musenga E, Miwanda B, Boum Y, Checchi F, Edmunds WJ, Luquero F, Porten K, Finger F. Effectiveness of case-area targeted interventions including vaccination on the control of epidemic cholera: protocol for a prospective observational study. BMJ Open 2022; 12:e061206. [PMID: 35793924 PMCID: PMC9260795 DOI: 10.1136/bmjopen-2022-061206] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
INTRODUCTION Cholera outbreaks in fragile settings are prone to rapid expansion. Case-area targeted interventions (CATIs) have been proposed as a rapid and efficient response strategy to halt or substantially reduce the size of small outbreaks. CATI aims to deliver synergistic interventions (eg, water, sanitation, and hygiene interventions, vaccination, and antibiotic chemoprophylaxis) to households in a 100-250 m 'ring' around primary outbreak cases. METHODS AND ANALYSIS We report on a protocol for a prospective observational study of the effectiveness of CATI. Médecins Sans Frontières (MSF) plans to implement CATI in the Democratic Republic of the Congo (DRC), Cameroon, Niger and Zimbabwe. This study will run in parallel to each implementation. The primary outcome is the cumulative incidence of cholera in each CATI ring. CATI will be triggered immediately on notification of a case in a new area. As with most real-world interventions, there will be delays to response as the strategy is rolled out. We will compare the cumulative incidence among rings as a function of response delay, as a proxy for performance. Cross-sectional household surveys will measure population-based coverage. Cohort studies will measure effects on reducing incidence among household contacts and changes in antimicrobial resistance. ETHICS AND DISSEMINATION The ethics review boards of MSF and the London School of Hygiene and Tropical Medicine have approved a generic protocol. The DRC and Niger-specific versions have been approved by the respective national ethics review boards. Approvals are in process for Cameroon and Zimbabwe. The study findings will be disseminated to the networks of national cholera control actors and the Global Task Force for Cholera Control using meetings and policy briefs, to the scientific community using journal articles, and to communities via community meetings.
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Affiliation(s)
- Ruwan Ratnayake
- Infectious Disease Epidemiology, London School of Hygiene and Tropical Medicine, London, UK
- Epicentre, Paris, France
| | | | | | | | | | - Andrew S Azman
- Médecins Sans Frontières, Geneva, Switzerland
- Epidemiology, Johns Hopkins University Bloomberg School of Public Health, Baltimore, Maryland, USA
| | | | | | | | | | | | | | - Placide Okitayemba Welo
- Programme National d'Elimination du Choléra et de lutte contre les autres Maladies Diarrhéiques, Kinshasa, Congo (the Democratic Republic of the)
| | | | - Berthe Miwanda
- Institut National de Recherche Biologique, Kinshasa, Congo (the Democratic Republic of the)
| | | | - Francesco Checchi
- Infectious Disease Epidemiology, London School of Hygiene and Tropical Medicine, London, UK
| | - W John Edmunds
- Infectious Disease Epidemiology, London School of Hygiene and Tropical Medicine, London, UK
| | - Francisco Luquero
- Epicentre, Paris, France
- GAVI the Vaccine Alliance, Geneva, Switzerland
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18
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White S, Mutula AC, Buroko MM, Heath T, Mazimwe FK, Blanchet K, Curtis V, Dreibelbis R. How does handwashing behaviour change in response to a cholera outbreak? A qualitative case study in the Democratic Republic of the Congo. PLoS One 2022; 17:e0266849. [PMID: 35413080 PMCID: PMC9004767 DOI: 10.1371/journal.pone.0266849] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/02/2021] [Accepted: 03/28/2022] [Indexed: 12/27/2022] Open
Abstract
Background Handwashing with soap has the potential to curb cholera transmission. This research explores how populations experienced and responded to the 2017 cholera outbreak in the Democratic Republic of the Congo and how this affected their handwashing behaviour. Methods Cholera cases were identified through local cholera treatment centre records. Comparison individuals were recruited from the same neighbourhoods by identifying households with no recent confirmed or suspected cholera cases. Multiple qualitative methods were employed to understand hand hygiene practices and their determinants, including unstructured observations, interviews and focus group discussions. The data collection tools and analysis were informed by the Behaviour Centred Design Framework. Comparisons were made between the experiences and practices of people from case households and participants from comparison households. Results Cholera was well understood by the population and viewed as a persistent and common health challenge. Handwashing with soap was generally observed to be rare during the outbreak despite self-reported increases in behaviour. Across case and comparison groups, individuals were unable to prioritise handwashing due to competing food-scarcity and livelihood challenges and there was little in the physical or social environments to cue handwashing or make it a convenient, rewarding or desirable to practice. The ability of people from case households to practice handwashing was further constrained by their exposure to cholera which in addition to illness, caused profound non-health impacts to household income, productivity, social status, and their sense of control. Conclusions Even though cholera outbreaks can cause disruptions to many determinants of behaviour, these shifts do not automatically facilitate an increase in preventative behaviours like handwashing with soap. Hygiene programmes targeting outbreaks within complex crises could be strengthened by acknowledging the emic experiences of the disease and adopting sustainable solutions which build upon local disease coping mechanisms.
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Affiliation(s)
- Sian White
- Department of Disease Control, London School of Hygiene and Tropical Medicine, London, United Kingdom
- * E-mail:
| | - Anna C. Mutula
- Independent Consultant, Goma, Democratic Republic of the Congo
| | | | | | | | - Karl Blanchet
- Geneva Centre of Humanitarian Studies, Université de Genève, Geneva, Switzerland
| | - Val Curtis
- Department of Disease Control, London School of Hygiene and Tropical Medicine, London, United Kingdom
| | - Robert Dreibelbis
- Department of Disease Control, London School of Hygiene and Tropical Medicine, London, United Kingdom
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Kanungo S, Azman AS, Ramamurthy T, Deen J, Dutta S. Cholera. Lancet 2022; 399:1429-1440. [PMID: 35397865 DOI: 10.1016/s0140-6736(22)00330-0] [Citation(s) in RCA: 47] [Impact Index Per Article: 23.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/07/2021] [Revised: 12/14/2021] [Accepted: 02/07/2022] [Indexed: 12/11/2022]
Abstract
Cholera was first described in the areas around the Bay of Bengal and spread globally, resulting in seven pandemics during the past two centuries. It is caused by toxigenic Vibrio cholerae O1 or O139 bacteria. Cholera is characterised by mild to potentially fatal acute watery diarrhoeal disease. Prompt rehydration therapy is the cornerstone of management. We present an overview of cholera and its pathogenesis, natural history, bacteriology, and epidemiology, while highlighting advances over the past 10 years in molecular epidemiology, immunology, and vaccine development and deployment. Since 2014, the Global Task Force on Cholera Control, a WHO coordinated network of partners, has been working with several countries to develop national cholera control strategies. The global roadmap for cholera control focuses on stopping transmission in cholera hotspots through vaccination and improved water, sanitation, and hygiene, with the aim to reduce cholera deaths by 90% and eliminate local transmission in at least 20 countries by 2030.
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Affiliation(s)
- Suman Kanungo
- National Institute of Cholera and Enteric Diseases, Kolkata, India
| | - Andrew S Azman
- Department of Epidemiology, Johns Hopkins University, Baltimore, MD, USA; Institute of Global Health, Faculty of Medicine, University of Geneva, Geneva, Switzerland
| | | | - Jaqueline Deen
- Institute of Child Health and Human Development, National Institutes of Health, University of the Philippines-Manila, Manila, Philippines
| | - Shanta Dutta
- National Institute of Cholera and Enteric Diseases, Kolkata, India.
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D'Mello-Guyett L, Cumming O, Rogers E, D'hondt R, Mengitsu E, Mashako M, Van den Bergh R, Welo PO, Maes P, Checchi F. Identifying transferable lessons from cholera epidemic responses by Médecins Sans Frontières in Mozambique, Malawi and the Democratic Republic of Congo, 2015-2018: a scoping review. Confl Health 2022; 16:12. [PMID: 35351171 PMCID: PMC8966369 DOI: 10.1186/s13031-022-00445-1] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2021] [Accepted: 03/16/2022] [Indexed: 12/03/2022] Open
Abstract
Background Cholera epidemics occur frequently in low-income countries affected by concurrent humanitarian crises. Evaluations of these epidemic response remains largely unpublished and there is a need to generate evidence on response efforts to inform future programmes. This review of MSF cholera epidemic responses aimed to describe the main characteristics of the cholera epidemics and related responses in these three countries, to identify challenges to different intervention strategies based on available data; and to make recommendations for epidemic prevention and control practice and policy. Methods Case studies from the Democratic Republic of Congo, Malawi and Mozambique were purposively selected by MSF for this review due to the documented burden of cholera in each country, frequency of cholera outbreaks, and risk of humanitarian crises. Data were extracted on the characteristics of the epidemics; time between alert and response; and, the delivery of health and water, sanitation and hygiene interventions. A Theory of Change for cholera response programmes was built to assess factors that affected implementation of the responses. Results and conclusions 20 epidemic response reports were identified, 15 in DRC, one in Malawi and four in Mozambique. All contexts experienced concurrent humanitarian crises, either armed conflict or natural disasters. Across the settings, median time between the date of alert and date of the start of the response by MSF was 23 days (IQR 14–41). Almost all responses targeted interventions community-wide, and all responses implemented in-patient treatment of suspected cholera cases in either established health care facilities (HCFs) or temporary cholera treatment units (CTUs). In three responses, interventions were delivered as case-area targeted interventions (CATI) and four responses targeted households of admitted suspected cholera cases. CATI or delivery of interventions to households of admitted suspected cases occurred from 2017 onwards only. Overall, 74 factors affecting implementation were identified including delayed supplies of materials, insufficient quantities of materials and limited or lack of coordination with local government or other agencies. Based on this review, the following recommendations are made to improve cholera prevention and control efforts: explore improved models for epidemic preparedness, including rapid mobilisation of supplies and deployment of trained staff; invest in and strengthen partnerships with national and local government and other agencies; and to standardise reporting templates that allow for rigorous and structured evaluations within and across countries to provide consistent and accessible data. Supplementary Information The online version contains supplementary material available at 10.1186/s13031-022-00445-1.
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Affiliation(s)
- Lauren D'Mello-Guyett
- Department of Disease Control, Faculty of Infectious and Tropical Diseases, London School of Hygiene and Tropical Medicine, London, UK. .,Environmental Health Unit, Médecins Sans Frontières, Brussels, Belgium.
| | - Oliver Cumming
- Department of Disease Control, Faculty of Infectious and Tropical Diseases, London School of Hygiene and Tropical Medicine, London, UK
| | - Elliot Rogers
- Department of Disease Control, Faculty of Infectious and Tropical Diseases, London School of Hygiene and Tropical Medicine, London, UK
| | - Rob D'hondt
- Environmental Health Unit, Médecins Sans Frontières, Brussels, Belgium
| | | | - Maria Mashako
- Médecins Sans Frontières, Kinshasa, Democratic Republic of Congo
| | - Rafael Van den Bergh
- LuxOR, Luxembourg Operational Research Unit, Médecins Sans Frontières, Luxembourg, Luxembourg
| | - Placide Okitayemba Welo
- Programme National d'Elimination du Choléra et de lutte contre les autres Maladies Diarrhéiques, Kinshasa, Democratic Republic of Congo
| | - Peter Maes
- WASH Section, UNICEF, Kinshasa, Democratic Republic of Congo
| | - Francesco Checchi
- Department of Infectious Disease Epidemiology, Faculty of Epidemiology and Population Health, London School of Hygiene and Tropical Medicine, London, UK
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Nasreen T, Hussain NA, Ho JY, Aw VZJ, Alam M, Yanow SK, Boucher YF. Assay for Evaluating the Abundance of Vibrio cholerae and Its O1 Serogroup Subpopulation from Water without DNA Extraction. Pathogens 2022; 11:pathogens11030363. [PMID: 35335687 PMCID: PMC8953119 DOI: 10.3390/pathogens11030363] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2022] [Revised: 03/14/2022] [Accepted: 03/14/2022] [Indexed: 11/16/2022] Open
Abstract
Cholera is a severe diarrheal disease caused by Vibrio cholerae, a natural inhabitant of brackish water. Effective control of cholera outbreaks depends on prompt detection of the pathogen from clinical specimens and tracking its source in the environment. Although the epidemiology of cholera is well studied, rapid detection of V. cholerae remains a challenge, and data on its abundance in environmental sources are limited. Here, we describe a sensitive molecular quantification assay by qPCR, which can be used on-site in low-resource settings on water without the need for DNA extraction. This newly optimized method exhibited 100% specificity for total V. cholerae as well as V. cholerae O1 and allowed detection of as few as three target CFU per reaction. The limit of detection is as low as 5 × 103 CFU/L of water after concentrating biomass from the sample. The ability to perform qPCR on water samples without DNA extraction, portable features of the equipment, stability of the reagents at 4 °C and user-friendly online software facilitate fast quantitative analysis of V. cholerae. These characteristics make this assay extremely useful for field research in resource-poor settings and could support continuous monitoring in cholera-endemic areas.
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Affiliation(s)
- Tania Nasreen
- Department of Biological Sciences, University of Alberta, Edmonton, AB T6G 2E9, Canada; (T.N.); (N.A.S.H.)
| | - Nora A.S. Hussain
- Department of Biological Sciences, University of Alberta, Edmonton, AB T6G 2E9, Canada; (T.N.); (N.A.S.H.)
| | - Jia Yee Ho
- Singapore Centre for Environmental Life Sciences Engineering (SCELSE), National University of Singapore, Singapore 637551, Singapore; (J.Y.H.); (V.Z.J.A.)
- Saw Swee Hock School of Public Health, National University Health System, National University of Singapore, Singapore 117549, Singapore
| | - Vanessa Zhi Jie Aw
- Singapore Centre for Environmental Life Sciences Engineering (SCELSE), National University of Singapore, Singapore 637551, Singapore; (J.Y.H.); (V.Z.J.A.)
- Saw Swee Hock School of Public Health, National University Health System, National University of Singapore, Singapore 117549, Singapore
| | - Munirul Alam
- Centre for Communicable Diseases, International Centre for Diarrhoeal Disease Research, Bangladesh (ICDDR, B), Dhaka 1212, Bangladesh;
| | - Stephanie K. Yanow
- School of Public Health, University of Alberta, Edmonton, AB T6G 2E9, Canada;
- Department of Medical Microbiology and Immunology, University of Alberta, Edmonton, AB T6G 2E9, Canada
| | - Yann F. Boucher
- Singapore Centre for Environmental Life Sciences Engineering (SCELSE), National University of Singapore, Singapore 637551, Singapore; (J.Y.H.); (V.Z.J.A.)
- Saw Swee Hock School of Public Health, National University Health System, National University of Singapore, Singapore 117549, Singapore
- Correspondence:
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22
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George CM, Perin J, Parvin T, Bhuyian S, Thomas ED, Monira S, Zohura F, Hasan T, Sack D, Alam M. Effects of a Water, Sanitation and Hygiene Mobile Health Program on Respiratory Illness in Bangladesh: A Cluster-Randomized Controlled Trial of the CHoBI7 Mobile Health Program. Am J Trop Med Hyg 2022; 106:979-984. [PMID: 35008045 PMCID: PMC8922503 DOI: 10.4269/ajtmh.21-0679] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2021] [Accepted: 10/06/2021] [Indexed: 11/07/2022] Open
Abstract
Acute respiratory infections are a leading cause of morbidity and mortality among young children globally. The objective of this study was to evaluate the impact of the Cholera-Hospital-Based-Intervention-for-7-days (CHoBI7) handwashing with soap and water treatment mobile health (mHealth) program on respiratory illness among diarrhea patients and their household members in urban Dhaka, Bangladesh. A cluster-randomized controlled trial of the CHoBI7 mHealth program was conducted among diarrhea patient households in Dhaka, Bangladesh. Patients were randomized to three arms: standard recommendation on oral rehydration solution use, health facility delivery of CHoBI7 plus mHealth (weekly voice and text messages for 12 months) (no home visits), and health facility delivery of CHoBI7 plus two home visits and mHealth. Respiratory symptoms were assessed during monthly clinical surveillance over the 12-month surveillance period. Respiratory illness was defined as rapid breathing, difficulty breathing, wheezing, or coughing. Two thousand six hundred twenty-six participants in 769 households were randomly allocated to three arms: 849 participants to the standard message arm, 886 to the mHealth with no home visits arm, and 891 to the mHealth with two home visits arm. Compared with the standard message arm, participants in the mHealth with no home visits arm (Prevalence Ratio [PR]: 0.89 [95% CI: 0.80, 0.98]), and the mHealth with two home visits arm (PR: 0.89 [95% CI: 0.81, 0.99]) had significantly lower respiratory illness prevalence over the 12-month program period. Our findings demonstrate that the CHoBI7 mHealth program is effective in reducing respiratory illness among diarrhea patient households.
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Affiliation(s)
- Christine Marie George
- Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland;,Address correspondence to Christine Marie George, Associate Professor, Department of International Health, Program in Global Disease Epidemiology and Control, Johns Hopkins Bloomberg School of Public Health, 615 N. Wolfe Street, Room E5535, Baltimore, MD 21205-2103. E-mail:
| | - Jamie Perin
- Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland
| | - Tahmina Parvin
- International Centre for Diarrhoeal Disease Research, Bangladesh
| | - Sazzadul Bhuyian
- International Centre for Diarrhoeal Disease Research, Bangladesh
| | - Elizabeth D. Thomas
- Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland
| | - Shirajum Monira
- International Centre for Diarrhoeal Disease Research, Bangladesh
| | - Fatema Zohura
- International Centre for Diarrhoeal Disease Research, Bangladesh
| | - Tasdik Hasan
- International Centre for Diarrhoeal Disease Research, Bangladesh
| | - David Sack
- Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland
| | - Munirul Alam
- International Centre for Diarrhoeal Disease Research, Bangladesh
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Biran A, White S, Awe B, Greenland K, Akabike K, Chuktu N, Aunger R, Curtis V, Schmidt W, Van der Voorden C. A cluster-randomised trial to evaluate an intervention to promote handwashing in rural Nigeria. INTERNATIONAL JOURNAL OF ENVIRONMENTAL HEALTH RESEARCH 2022; 32:579-594. [PMID: 32631102 DOI: 10.1080/09603123.2020.1788712] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/08/2019] [Accepted: 06/24/2020] [Indexed: 06/11/2023]
Abstract
Handwashing with soap at critical times helps prevent diarrhoeal diseases. Changing handwashing practices through behaviour change communication remains a challenge. This study designed and tested a scalable intervention to promote handwashing with soap. A cluster-randomised, controlled trial compared our intervention against standard practice. Subjects were men, women and children in 14 villages in Cross-River state, Nigeria. The primary outcome was the proportion of observed key events on which hands were washed with soap. Binomial regression analysis calculated prevalence differences between study arms. The intervention had minimal effect on the primary outcome (+2.4%, p = 0.096). The intervention was associated with increased frequency of handwashes without soap before food contact (+13%, p = 0.017). The intervention failed to produce significant changes in handwashing with soap at key times. The low dose delivered (two contact points) may have increased scalability at the cost of effectiveness, particularly in the challenging context of inconvenient water access.
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Affiliation(s)
- Adam Biran
- Disease Control Department, London School of Hygiene and Tropical Medicine, London, UK
| | - S White
- Disease Control Department, London School of Hygiene and Tropical Medicine, London, UK
| | - B Awe
- United Purpose Nigeria, Calabar, Nigeria
| | - K Greenland
- Disease Control Department, London School of Hygiene and Tropical Medicine, London, UK
| | | | - N Chuktu
- United Purpose Nigeria, Calabar, Nigeria
| | - R Aunger
- Disease Control Department, London School of Hygiene and Tropical Medicine, London, UK
| | - V Curtis
- Disease Control Department, London School of Hygiene and Tropical Medicine, London, UK
| | - W Schmidt
- Disease Control Department, London School of Hygiene and Tropical Medicine, London, UK
| | - C Van der Voorden
- Technical Support Unit, Water Supply and Sanitation Collaborative Council, Geneva, Switzerland
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Sack DA, Debes AK, Ateudjieu J, Bwire G, Ali M, Ngwa MC, Mwaba J, Chilengi R, Orach CC, Boru W, Mohamed AA, Ram M, George CM, Stine OC. Contrasting Epidemiology of Cholera in Bangladesh and Africa. J Infect Dis 2021; 224:S701-S709. [PMID: 34549788 PMCID: PMC8687066 DOI: 10.1093/infdis/jiab440] [Citation(s) in RCA: 18] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022] Open
Abstract
In Bangladesh and West Bengal cholera is seasonal, transmission occurs consistently annually. By contrast, in most African countries, cholera has inconsistent seasonal patterns and long periods without obvious transmission. Transmission patterns in Africa occur during intermittent outbreaks followed by elimination of that genetic lineage. Later another outbreak may occur because of reintroduction of new or evolved lineages from adjacent areas, often by human travelers. These then subsequently undergo subsequent elimination. The frequent elimination and reintroduction has several implications when planning for cholera's elimination including: a) reconsidering concepts of definition of elimination, b) stress on rapid detection and response to outbreaks, c) more effective use of oral cholera vaccine and WASH, d) need to readjust estimates of disease burden for Africa, e) re-examination of water as a reservoir for maintaining endemicity in Africa. This paper reviews major features of cholera's epidemiology in African countries which appear different from the Ganges Delta.
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Affiliation(s)
- David A Sack
- Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA
| | - Amanda K Debes
- Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA
| | - Jerome Ateudjieu
- Meilleur Acces aux Soins de Sante, and Department of Public Health, Faculty of Medicine and Pharmaceutical Sciences, University of Dschang, and Clinical Research Unit, Division of Health Operations Research, Cameroon Ministry of Public Health, Yaoundé, Cameroon
| | - Godfrey Bwire
- Department of Integrated Epidemiology, Surveillance, and Public Health Emergencies, Ministry of Health, Kampala, Uganda
| | - Mohammad Ali
- Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA
| | - Moise Chi Ngwa
- Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA
| | - John Mwaba
- Centre for Infectious Disease Research in Zambia, Lusaka, Zambia
| | - Roma Chilengi
- Centre for Infectious Disease Research in Zambia, Lusaka, Zambia
| | - Christopher C Orach
- Department of Community Health and Behavioural Sciences, Makerere University School of Public Health, Kampala, Uganda
| | - Waqo Boru
- Ministry of Health and Field Epidemiology and Laboratory Training Program, Nairobi, Kenya
| | - Ahmed Abade Mohamed
- Tanzania Field Epidemiology and Laboratory Training Program, Dar-es-Salaam, Tanzania
| | - Malathi Ram
- Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA
| | - Christine Marie George
- Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA
| | - O Colin Stine
- Department of Epidemiology and Public Health, School of Medicine, University of Maryland, Baltimore, Maryland, USA
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Sikder M, Altare C, Doocy S, Trowbridge D, Kaur G, Kaushal N, Lyles E, Lantagne D, Azman AS, Spiegel P. Case-area targeted preventive interventions to interrupt cholera transmission: Current implementation practices and lessons learned. PLoS Negl Trop Dis 2021; 15:e0010042. [PMID: 34919551 PMCID: PMC8719662 DOI: 10.1371/journal.pntd.0010042] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/28/2021] [Revised: 12/31/2021] [Accepted: 12/01/2021] [Indexed: 11/18/2022] Open
Abstract
BACKGROUND Cholera is a major cause of mortality and morbidity in low-resource and humanitarian settings. It is transmitted by fecal-oral route, and the infection risk is higher to those living in and near cholera cases. Rapid identification of cholera cases and implementation of measures to prevent subsequent transmission around cases may be an efficient strategy to reduce the size and scale of cholera outbreaks. METHODOLOGY/PRINCIPLE FINDINGS We investigated implementation of cholera case-area targeted interventions (CATIs) using systematic reviews and case studies. We identified 11 peer-reviewed and eight grey literature articles documenting CATIs and completed 30 key informant interviews in case studies in Democratic Republic of Congo, Haiti, Yemen, and Zimbabwe. We documented 15 outbreaks in 12 countries where CATIs were used. The team composition and the interventions varied, with water, sanitation, and hygiene interventions implemented more commonly than those of health. Alert systems triggering interventions were diverse ranging from suspected cholera cases to culture confirmed cases. Selection of high-risk households around the case household was inconsistent and ranged from only one case to approximately 100 surrounding households with different methods of selecting them. Coordination among actors and integration between sectors were consistently reported as challenging. Delays in sharing case information impeded rapid implementation of this approach, while evaluation of the effectiveness of interventions varied. CONCLUSIONS/SIGNIFICANCE CATIs appear effective in reducing cholera outbreaks, but there is limited and context specific evidence of their effectiveness in reducing the incidence of cholera cases and lack of guidance for their consistent implementation. We propose to 1) use uniform cholera case definitions considering a local capacity to trigger alert; 2) evaluate the effectiveness of individual or sets of interventions to interrupt cholera, and establish a set of evidence-based interventions; 3) establish criteria to select high-risk households; and 4) improve coordination and data sharing amongst actors and facilitate integration among sectors to strengthen CATI approaches in cholera outbreaks.
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Affiliation(s)
- Mustafa Sikder
- Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, United States of America
- Johns Hopkins Center for Humanitarian Health, Baltimore, Maryland, United States of America
| | - Chiara Altare
- Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, United States of America
- Johns Hopkins Center for Humanitarian Health, Baltimore, Maryland, United States of America
| | - Shannon Doocy
- Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, United States of America
- Johns Hopkins Center for Humanitarian Health, Baltimore, Maryland, United States of America
| | - Daniella Trowbridge
- Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, United States of America
- Johns Hopkins Center for Humanitarian Health, Baltimore, Maryland, United States of America
| | - Gurpreet Kaur
- Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, United States of America
- Johns Hopkins Center for Humanitarian Health, Baltimore, Maryland, United States of America
| | - Natasha Kaushal
- Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, United States of America
- Johns Hopkins Center for Humanitarian Health, Baltimore, Maryland, United States of America
| | - Emily Lyles
- Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, United States of America
- Johns Hopkins Center for Humanitarian Health, Baltimore, Maryland, United States of America
| | - Daniele Lantagne
- Consultant, Public Health Engineer, Boston, Massachusetts, United States of America
| | - Andrew S. Azman
- Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, United States of America
- Johns Hopkins Center for Humanitarian Health, Baltimore, Maryland, United States of America
| | - Paul Spiegel
- Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, United States of America
- Johns Hopkins Center for Humanitarian Health, Baltimore, Maryland, United States of America
- * E-mail:
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Ross I, Esteves Mills J, Slaymaker T, Johnston R, Hutton G, Dreibelbis R, Montgomery M. Costs of hand hygiene for all in household settings: estimating the price tag for the 46 least developed countries. BMJ Glob Health 2021; 6:e007361. [PMID: 34916276 PMCID: PMC8679104 DOI: 10.1136/bmjgh-2021-007361] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/06/2021] [Accepted: 11/19/2021] [Indexed: 11/24/2022] Open
Abstract
INTRODUCTION Domestic hand hygiene could prevent over 500 000 attributable deaths per year, but 6 in 10 people in least developed countries (LDCs) do not have a handwashing facility (HWF) with soap and water available at home. We estimated the economic costs of universal access to basic hand hygiene services in household settings in 46 LDCs. METHODS Our model combines quantities of households with no HWF and prices of promotion campaigns, HWFs, soap and water. For quantities, we used estimates from the WHO/UNICEF Joint Monitoring Programme. For prices, we collated data from recent impact evaluations and electronic searches. Accounting for inflation and purchasing power, we calculated costs over 2021-2030, and estimated total cost probabilistically using Monte Carlo simulation. RESULTS An estimated US$12.2-US$15.3 billion over 10 years is needed for universal hand hygiene in household settings in 46 LDCs. The average annual cost of hand hygiene promotion is US$334 million (24% of annual total), with a further US$233 million for 'top-up' promotion (17%). Together, these promotion costs represent US$0.47 annually per head of LDC population. The annual cost of HWFs, a purpose-built drum with tap and stand, is US$174 million (13%). The annual cost of soap is US$497 million (36%) and water US$127 million (9%). CONCLUSION The annual cost of behavioural change promotion to those with no HWF represents 4.7% of median government health expenditure in LDCs, and 1% of their annual aid receipts. These costs could be covered by mobilising resources from across government and partners, and could be reduced by harnessing economies of scale and integrating hand hygiene with other behavioural change campaigns where appropriate. Innovation is required to make soap more affordable and available for the poorest households.
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Affiliation(s)
- Ian Ross
- Department of Disease Control, London School of Hygiene & Tropical Medicine, London, UK
| | | | | | | | | | - Robert Dreibelbis
- Department of Disease Control, London School of Hygiene & Tropical Medicine, London, UK
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Chirgwin H, Cairncross S, Zehra D, Sharma Waddington H. Interventions promoting uptake of water, sanitation and hygiene (WASH) technologies in low- and middle-income countries: An evidence and gap map of effectiveness studies. CAMPBELL SYSTEMATIC REVIEWS 2021; 17:e1194. [PMID: 36951806 PMCID: PMC8988822 DOI: 10.1002/cl2.1194] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/25/2023]
Abstract
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.
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Affiliation(s)
- Hannah Chirgwin
- International Initiative for Impact Evaluation (3ie)London International Development CentreLondonUK
| | | | | | - Hugh Sharma Waddington
- London School of Hygiene and Tropical Medicine and International Initiative for Impact Evaluation (3ie)London International Development CentreLondonUK
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28
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Syed S, Moore SR. Dialing in Prevention of Childhood Stunting and Diarrhea in Low-Income Countries. Clin Infect Dis 2021; 73:e2569-e2570. [PMID: 32785660 DOI: 10.1093/cid/ciaa1059] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/02/2020] [Accepted: 07/21/2020] [Indexed: 11/13/2022] Open
Affiliation(s)
- Sana Syed
- Division of Pediatric Gastroenterology and Nutrition, Department of Pediatrics, University of Virginia, Charlottesville, Virginia, USA.,Department of Pediatrics and Child Health, Aga Khan University, Karachi, Pakistan
| | - Sean R Moore
- Division of Pediatric Gastroenterology and Nutrition, Department of Pediatrics, University of Virginia, Charlottesville, Virginia, USA
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D'Mello-Guyett L, Cumming O, Bonneville S, D'hondt R, Mashako M, Nakoka B, Gorski A, Verheyen D, Van den Bergh R, Welo PO, Maes P, Checchi F. Effectiveness of hygiene kit distribution to reduce cholera transmission in Kasaï-Oriental, Democratic Republic of Congo, 2018: a prospective cohort study. BMJ Open 2021; 11:e050943. [PMID: 34649847 PMCID: PMC8522665 DOI: 10.1136/bmjopen-2021-050943] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
INTRODUCTION Household contacts of cholera cases are at a greater risk of Vibrio cholerae infection than the general population. There is currently no agreed standard of care for household contacts, despite their high risk of infection, in cholera response strategies. In 2018, hygiene kit distribution and health promotion was recommended by Médecins Sans Frontières for admitted patients and accompanying household members on admission to a cholera treatment unit in the Democratic Republic of Congo. METHODS To investigate the effectiveness of the intervention and risk factors for cholera infection, we conducted a prospective cohort study and followed household contacts for 7 days after patient admission. Clinical surveillance among household contacts was based on self-reported symptoms of cholera and diarrhoea, and environmental surveillance through the collection and analysis of food and water samples. RESULTS From 94 eligible households, 469 household contacts were enrolled and 444 completed follow-up. Multivariate analysis suggested evidence of a dose-response relationship with increased kit use associated with decreased relative risk of suspected cholera: household contacts in the high kit-use group had a 66% lower incidence of suspected cholera (adjusted risk ratio (aRR) 0.34, 95% CI 0.11 to 1.03, p=0.055), the mid-use group had a 53% lower incidence (aRR 0.47, 95% CI 0.17 to 1.29, p=1.44) and low-use group had 22% lower incidence (aRR 0.78, 95% CI 0.24 to 2.53, p=0.684), compared with household contacts without a kit. Drinking water contamination was significantly reduced among households in receipt of a kit. There was no significant effect on self-reported diarrhoea or food contamination. CONCLUSION The integration of a hygiene kit intervention to case-households may be effective in reducing cholera transmission among household contacts and environmental contamination within the household. Further work is required to evaluate whether other proactive localised distribution among patients and case-households or to households surrounding cholera cases can be used in future cholera response programmes in emergency contexts.
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Affiliation(s)
- Lauren D'Mello-Guyett
- London School of Hygiene & Tropical Medicine, London, UK
- Médecins Sans Frontières, Brussels, Belgium
| | - Oliver Cumming
- London School of Hygiene & Tropical Medicine, London, UK
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Mwaba J, Debes AK, Murt KN, Shea P, Simuyandi M, Laban N, Kazimbaya K, Chisenga C, Li S, Almeida M, Meisel JS, Shibemba A, Kantenga T, Mukonka V, Kwenda G, Sack DA, Chilengi R, Stine OC. Three transmission events of Vibrio cholerae O1 into Lusaka, Zambia. BMC Infect Dis 2021; 21:570. [PMID: 34126945 PMCID: PMC8200794 DOI: 10.1186/s12879-021-06259-5] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2021] [Accepted: 05/27/2021] [Indexed: 11/23/2022] Open
Abstract
BACKGROUND Cholera has been present and recurring in Zambia since 1977. However, there is a paucity of data on genetic relatedness and diversity of the Vibrio cholerae isolates responsible for these outbreaks. Understanding whether the outbreaks are seeded from existing local isolates or if the outbreaks represent separate transmission events can inform public health decisions. RESULTS Seventy-two V. cholerae isolates from outbreaks in 2009/2010, 2016, and 2017/2018 in Zambia were characterized using multilocus variable number tandem repeat analysis (MLVA) and whole genome sequencing (WGS). The isolates had eight distinct MLVA genotypes that clustered into three MLVA clonal complexes (CCs). Each CC contained isolates from only one outbreak. The results from WGS revealed both clustered and dispersed single nucleotide variants. The genetic relatedness of isolates based on WGS was consistent with the MLVA, each CC was a distinct genetic lineage and had nearest neighbors from other East African countries. In Lusaka, isolates from the same outbreak were more closely related to themselves and isolates from other countries than to isolates from other outbreaks in other years. CONCLUSIONS Our observations are consistent with i) the presence of random mutation and alternative mechanisms of nucleotide variation, and ii) three separate transmission events of V. cholerae into Lusaka, Zambia. We suggest that locally, case-area targeted invention strategies and regionally, well-coordinated plans be in place to effectively control future cholera outbreaks.
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Affiliation(s)
- John Mwaba
- Centre for Infectious Disease Research in Zambia, Lusaka, Zambia
- Department of Biomedical Sciences, University of Zambia School of Health Sciences, Lusaka, Zambia
- Department of Pathology and Microbiology, University Teaching Hospitals, Lusaka, Zambia
| | - Amanda K Debes
- Johns Hopkins Bloomberg School of Public Health, MD, Baltimore, USA
| | - Kelsey N Murt
- Johns Hopkins Bloomberg School of Public Health, MD, Baltimore, USA
| | - Patrick Shea
- Johns Hopkins Bloomberg School of Public Health, MD, Baltimore, USA
| | | | - Natasha Laban
- Centre for Infectious Disease Research in Zambia, Lusaka, Zambia
| | - Katayi Kazimbaya
- Centre for Infectious Disease Research in Zambia, Lusaka, Zambia
- Department of Biomedical Sciences, University of Zambia School of Health Sciences, Lusaka, Zambia
| | | | - Shan Li
- University of Maryland School of Medicine, Baltimore, MD, USA
| | - Mathieu Almeida
- University of Maryland, College Park, College Park, MD, USA
- Université Paris-Saclay, INRAE, MGP, 78350, Jouy-en-Josas, France
| | | | - Aaron Shibemba
- Department of Pathology and Microbiology, University Teaching Hospitals, Lusaka, Zambia
| | - Timothy Kantenga
- Department of Biomedical Sciences, University of Zambia School of Health Sciences, Lusaka, Zambia
- Department of Pathology and Microbiology, University Teaching Hospitals, Lusaka, Zambia
| | | | - Geoffrey Kwenda
- Department of Biomedical Sciences, University of Zambia School of Health Sciences, Lusaka, Zambia
| | - David A Sack
- Johns Hopkins Bloomberg School of Public Health, MD, Baltimore, USA
| | - Roma Chilengi
- Centre for Infectious Disease Research in Zambia, Lusaka, Zambia
| | - O Colin Stine
- University of Maryland School of Medicine, Baltimore, MD, USA.
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Parvin T, Thomas ED, Bhuyian MSI, Uddin IM, Hasan MT, Rahman Z, Barman I, Zohura F, Masud J, Sultana M, Westin A, Johura FT, Monira S, Biswas SK, Sack DA, Perin J, Alam M, George CM. Fecal Contamination on the Household Compound and in Water Sources are Associated with Subsequent Diarrhea in Young Children in Urban Bangladesh (CHoBI7 Program). Am J Trop Med Hyg 2021; 105:261-266. [PMID: 34097647 DOI: 10.4269/ajtmh.20-1516] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/27/2020] [Accepted: 03/11/2021] [Indexed: 11/07/2022] Open
Abstract
We investigated the environmental and individual-level risk factors for diarrheal disease among young children in slum areas of Dhaka, Bangladesh. A prospective cohort study was conducted among 884 children under 5 years of age. Caregiver reports were collected on sociodemographic factors and hygiene behaviors. Diarrhea surveillance data was collected monthly based on caregiver-reported diarrhea for children in the past 2 weeks during the 12-month study period. Unannounced spot checks of the household compound were performed at 1, 3, 6, 9, and 12 months after enrollment to check for the presence of feces (animal or human) and the presence of animals in the child's sleeping space, to assess child and caregiver hands for the presence of dirt, and to collect samples of the household's source and stored drinking water. Children with feces found on the household compound during spot checks had a significantly higher odds of diarrhea (odds ratio: 1.71; 95% confidence interval: 1.23-2.38). Children residing in households with > 100 colony forming units/100 mL Escherichia coli in source drinking water had a significantly higher odds of diarrhea (OR: 1.43; 95% CI: 1.06-1.92). The presence of feces on the household compound and source drinking water with > 100 colony forming units/100 mL E. coli were significant risk factors for diarrheal disease for children < 5 years of age in slum areas of Dhaka, Bangladesh. These findings demonstrate the urgent need for comprehensive interventions to reduce fecal contamination on the household compound to protect the health of susceptible pediatric populations.
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Affiliation(s)
- Tahmina Parvin
- 1International Centre for Diarrhoeal Disease Research, Bangladesh (icddr,b), Dhaka, Bangladesh
| | - Elizabeth D Thomas
- 2Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland
| | | | - Ismat Minhaj Uddin
- 1International Centre for Diarrhoeal Disease Research, Bangladesh (icddr,b), Dhaka, Bangladesh
| | | | - Zillur Rahman
- 1International Centre for Diarrhoeal Disease Research, Bangladesh (icddr,b), Dhaka, Bangladesh
| | - Indrajeet Barman
- 1International Centre for Diarrhoeal Disease Research, Bangladesh (icddr,b), Dhaka, Bangladesh
| | - Fatema Zohura
- 1International Centre for Diarrhoeal Disease Research, Bangladesh (icddr,b), Dhaka, Bangladesh
| | - Jahed Masud
- 1International Centre for Diarrhoeal Disease Research, Bangladesh (icddr,b), Dhaka, Bangladesh
| | - Marzia Sultana
- 1International Centre for Diarrhoeal Disease Research, Bangladesh (icddr,b), Dhaka, Bangladesh
| | - Anne Westin
- 2Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland
| | - Fatema-Tuz Johura
- 1International Centre for Diarrhoeal Disease Research, Bangladesh (icddr,b), Dhaka, Bangladesh
| | - Shirajum Monira
- 1International Centre for Diarrhoeal Disease Research, Bangladesh (icddr,b), Dhaka, Bangladesh
| | - Shwapon Kumar Biswas
- 1International Centre for Diarrhoeal Disease Research, Bangladesh (icddr,b), Dhaka, Bangladesh.,4Ministry of Health & Family Welfare, Dhaka, Bangladesh
| | - David A Sack
- 2Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland
| | - Jamie Perin
- 2Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland
| | - Munirul Alam
- 1International Centre for Diarrhoeal Disease Research, Bangladesh (icddr,b), Dhaka, Bangladesh
| | - Christine Marie George
- 2Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland
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Roskosky M, Ali M, Upreti SR, Sack D. Spatial clustering of cholera cases in the Kathmandu Valley: implications for a ring vaccination strategy. Int Health 2021; 13:170-177. [PMID: 32761173 PMCID: PMC7902685 DOI: 10.1093/inthealth/ihaa042] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/27/2019] [Revised: 05/26/2020] [Accepted: 07/08/2020] [Indexed: 12/17/2022] Open
Abstract
Background In mid-2016, a cholera outbreak occurred in Kathmandu Valley, Nepal. This retrospective study aims to determine if a reactive, ring vaccination strategy would have been useful in preventing cholera transmission during that outbreak. Methods Data on cholera cases were collected as part of hospital-based surveillance in the Kathmandu Valley in 2016. Global Positioning System (GPS) coordinates were obtained during household visits. Geographic clusters of cases were visually determined and tested statistically for clustering. Cluster size was determined based on the distribution of cases around the index case. Results GPS coordinates for 69 cases were analysed. Six geographic clusters were identified, all of which showed significant clustering of cases. Approximately 85% of cases within a cluster occurred more than 7 d after the index case. The median ring size was 1 km, with a population of 14 000 people. Conclusions Cholera cases were clustered in space and the majority of cases occurred over 1 week after the initial cases in the cluster, allowing for an opportunity to prevent transmission through the use of the vaccine soon after the initial case was identified. A ring vaccination strategy may be especially useful for large urban areas with recurrent seasonal outbreaks but where the specific locations for such outbreaks are not predictable.
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Affiliation(s)
- Mellisa Roskosky
- Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, 615 N Wolfe Street, MD-21205, USA
| | - Mohammad Ali
- Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, 615 N Wolfe Street, MD-21205, USA
| | | | - David Sack
- Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, 615 N Wolfe Street, MD-21205, USA
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Thorseth AH, Heath T, Sisay A, Hamo M, White S. An exploratory pilot study of the effect of modified hygiene kits on handwashing with soap among internally displaced persons in Ethiopia. Confl Health 2021; 15:35. [PMID: 33947443 PMCID: PMC8097963 DOI: 10.1186/s13031-021-00368-3] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2020] [Accepted: 04/19/2021] [Indexed: 11/21/2022] Open
Abstract
Background Internally displaced persons fleeing their homes due to conflict and drought are particularly at risk of morbidity and mortality from diarrhoeal diseases. Regular handwashing with soap (HWWS) could substantially reduce the risk of these infections, but the behaviour is challenging to practice while living in resource-poor, informal settlements. To mitigate these challenges, humanitarian aid organisations distribute hygiene kits, including soap and handwashing infrastructure. Our study aimed to assess the effect of modified hygiene kits on handwashing behaviours among internally displaced persons in Moyale, Ethiopia. Methods The pilot study evaluated three interventions: providing liquid soap; scented soap bar; and the inclusion of a mirror in addition to the standard hygiene kit. The hygiene kits were distributed to four study arms. Three of the arms received one of the interventions in addition to the standard hygiene kit. Three to six weeks after distribution the change in behaviour and perceptions of the interventions were assessed through structured observations, surveys and focus group discussions. Results HWWS was rare at critical times for all study arms. In the liquid soap arm, HWWS was observed for only 20% of critical times. This result was not indicated significantly different from the control arm which had a prevalence of 17% (p-value = 0.348). In the mirror and scented soap bar intervention arms, HWWS prevalence was 11 and 10%, respectively. This was indicated to be significantly different from the control arm. Participants in the focus group discussions indicated that liquid soap, scented soap bar and the mirror made handwashing more desirable. In contrast, participants did not consider the soap bar normally distributed in hygiene kits as nice to use. Conclusion We found no evidence of an increased prevalence of handwashing with soap following distribution of the three modified hygiene kits. However, our study indicates the value in better understanding hygiene product preferences as this may contribute to increased acceptability and use among crisis-affected populations. The challenges of doing research in a conflict-affected region had considerable implications on this study’s design and implementation. Trial registration The trial was registered at www.ClinicalTrials.gov 6 September 2019 (reg no: NCT04078633). Supplementary Information The online version contains supplementary material available at 10.1186/s13031-021-00368-3.
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Affiliation(s)
- Astrid Hasund Thorseth
- Department of Disease Control, London School of Hygiene and Tropical Medicine, London, UK.
| | | | | | - Mare Hamo
- Action Against Hunger, Addis Ababa, Ethiopia
| | - Sian White
- Department of Disease Control, London School of Hygiene and Tropical Medicine, London, UK
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Nalule Y, Buxton H, Macintyre A, Ir P, Pors P, Samol C, Leang S, Dreibelbis R. Hand Hygiene during the Early Neonatal Period: A Mixed-Methods Observational Study in Healthcare Facilities and Households in Rural Cambodia. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2021; 18:4416. [PMID: 33919264 PMCID: PMC8122667 DOI: 10.3390/ijerph18094416] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 03/19/2021] [Revised: 04/16/2021] [Accepted: 04/17/2021] [Indexed: 11/16/2022]
Abstract
BACKGROUND Globally, infections are the third leading cause of neonatal mortality. Predominant risk factors for facility-born newborns are poor hygiene practices that span both facilities and home environments. Current improvement interventions focus on only one environment and target limited caregivers, primarily birth attendants and mothers. To inform the design of a hand hygiene behavioural change intervention in rural Cambodia, a formative mixed-methods observational study was conducted to investigate the context-specific behaviours and determinants of handwashing among healthcare workers, and maternal and non-maternal caregivers along the early newborn care continuum. METHODS Direct observations of hygiene practices of all individuals providing care to 46 newborns across eight facilities and the associated communities were completed and hand hygiene compliance was assessed. Semi-structured interactive interviews were subsequently conducted with 35 midwives and household members to explore the corresponding cognitive, emotional and environmental factors influencing the observed key hand hygiene behaviours. RESULTS Hand hygiene opportunities during newborn care were frequent in both settings (n = 1319) and predominantly performed by mothers, fathers and non-parental caregivers. Compliance with hand hygiene protocol across all caregivers, including midwives, was inadequate (0%). Practices were influenced by the lack of accessible physical infrastructure, time, increased workload, low infection risk perception, nurture-related motives, norms and inadequate knowledge. CONCLUSIONS Our findings indicate that an effective intervention in this context should be multi-modal to address the different key behaviour determinants and target a wide range of caregivers.
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Affiliation(s)
- Yolisa Nalule
- Department of Disease Control, London School of Hygiene and Tropical Medicine, London WC1E 7HT, UK;
| | - Helen Buxton
- Division of Psychiatry, University College London, London W1T 7BN, UK;
| | - Alison Macintyre
- Policy and Programs Division, WaterAid Australia, Melbourne 3002, Australia;
| | - Por Ir
- National Institute of Public Health, Phnom Penh, Cambodia; (P.I.); (S.L.)
| | - Ponnary Pors
- WASH and Health Division, WaterAid Cambodia, Phnom Penh, Cambodia; (P.P.); (C.S.)
| | - Channa Samol
- WASH and Health Division, WaterAid Cambodia, Phnom Penh, Cambodia; (P.P.); (C.S.)
| | - Supheap Leang
- National Institute of Public Health, Phnom Penh, Cambodia; (P.I.); (S.L.)
| | - Robert Dreibelbis
- Department of Disease Control, London School of Hygiene and Tropical Medicine, London WC1E 7HT, UK;
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Ratnayake R, Finger F, Azman AS, Lantagne D, Funk S, Edmunds WJ, Checchi F. Highly targeted spatiotemporal interventions against cholera epidemics, 2000-19: a scoping review. THE LANCET. INFECTIOUS DISEASES 2020; 21:e37-e48. [PMID: 33096017 DOI: 10.1016/s1473-3099(20)30479-5] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/19/2020] [Revised: 04/27/2020] [Accepted: 05/19/2020] [Indexed: 01/12/2023]
Abstract
Globally, cholera epidemics continue to challenge disease control. Although mass campaigns covering large populations are commonly used to control cholera, spatial targeting of case households and their radius is emerging as a potentially efficient strategy. We did a Scoping Review to investigate the effectiveness of interventions delivered through case-area targeted intervention, its optimal spatiotemporal scale, and its effectiveness in reducing transmission. 53 articles were retrieved. We found that antibiotic chemoprophylaxis, point-of-use water treatment, and hygiene promotion can rapidly reduce household transmission, and single-dose vaccination can extend the duration of protection within the radius of households. Evidence supports a high-risk spatiotemporal zone of 100 m around case households, for 7 days. Two evaluations separately showed reductions in household transmission when targeting case households, and in size and duration of case clusters when targeting radii. Although case-area targeted intervention shows promise for outbreak control, it is critically dependent on early detection capacity and requires prospective evaluation of intervention packages.
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Affiliation(s)
- Ruwan Ratnayake
- Department of Infectious Disease Epidemiology, London School of Hygiene & Tropical Medicine, London, UK; Centre for the Mathematical Modelling of Infectious Diseases, London School of Hygiene & Tropical Medicine, London, UK.
| | | | - Andrew S Azman
- Department of Epidemiology and Center for Humanitarian Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA; Médecins Sans Frontières, Geneva, Switzerland
| | - Daniele Lantagne
- Department of Civil and Environmental Engineering, Tufts University, Medford, MA, USA
| | - Sebastian Funk
- Department of Infectious Disease Epidemiology, London School of Hygiene & Tropical Medicine, London, UK
| | - W John Edmunds
- Department of Infectious Disease Epidemiology, London School of Hygiene & Tropical Medicine, London, UK; Centre for the Mathematical Modelling of Infectious Diseases, London School of Hygiene & Tropical Medicine, London, UK
| | - Francesco Checchi
- Department of Infectious Disease Epidemiology, London School of Hygiene & Tropical Medicine, London, UK
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Biswas D, Hossin R, Rahman M, Bardosh KL, Watt MH, Zion MI, Sujon H, Rashid MM, Salimuzzaman M, Flora MS, Qadri F, Khan AI, Nelson EJ. An ethnographic exploration of diarrheal disease management in public hospitals in Bangladesh: From problems to solutions. Soc Sci Med 2020; 260:113185. [PMID: 32712557 PMCID: PMC7502197 DOI: 10.1016/j.socscimed.2020.113185] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Revised: 06/26/2020] [Accepted: 06/29/2020] [Indexed: 01/22/2023]
Abstract
INTRODUCTION Diarrheal disease is one of the most common causes of hospital admission globally. The barriers that influence guideline-adherent care at resource limited hospitals are poorly defined, especially during diarrheal disease outbreaks. The objective of this study was to characterize challenges faced in diarrheal disease management in resource-limited hospitals and identify opportunities to improve care. METHODS The study was conducted during a diarrheal disease outbreak period at ten public district hospitals distributed across Bangladesh. A rapid ethnographic approach included observations and informal interviews with clinicians, staff nurses and patients. In the first phase, observations identified common and unique challenges in diarrheal management at the ten sites. In the second phase, four hospitals were purposively selected for additional ethnographic study. Systematic observations over 420 total hours were collected from patient-clinician interactions (n = 76) and informal interviews (n = 138). Applied thematic analysis identified factors that influenced hospitalbased diarrhea management. RESULTS Normalization of guideline deviation was observed at all ten sites, including prescription of non-indicated antibiotics and intravenous (IV) fluids. Conflict between 'what should be done' and 'what can be done' was the most common challenge identified. Clinical assessments and patient treatment plans were established at admission in a median of 2 minutes (n = 76), often without a physical examination (57%; n=43/76). Factors that prevented adherence to clinical guidelines included human resource constraints, conflicts of interests, overcrowding, and inadequate hygiene and sanitation in the emergency department and wards. CONCLUSION This study identified challenges in hospital-based management of diarrheal disease and opportunities to improve care in seemingly change-resilient hospital settings. The results reveal important areas for intervention and policy engagement that may have additive benefit for both hospitals and their patients. These interventions include targeting barriers to clean-water, sanitation and hygiene that prevent clinicians from adopting guidelines out of concern for hospital acquired infections.
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Affiliation(s)
- Debashish Biswas
- International Centre for Diarrhoeal Disease Research, Bangladesh (icddr,b), Dhaka, Bangladesh
| | - Raduan Hossin
- International Centre for Diarrhoeal Disease Research, Bangladesh (icddr,b), Dhaka, Bangladesh
| | - Mahbubur Rahman
- International Centre for Diarrhoeal Disease Research, Bangladesh (icddr,b), Dhaka, Bangladesh
| | - Kevin Louis Bardosh
- Center for One Health Research, School of Public Health, University of Washington, USA; Department of Anthropology, University of Florida, USA
| | | | - Mazharul Islam Zion
- International Centre for Diarrhoeal Disease Research, Bangladesh (icddr,b), Dhaka, Bangladesh
| | - Hasnat Sujon
- Institute of Epidemiology, Disease Control and Research, Ministry of Health and Family Welfare, Government of Bangladesh, USA
| | - Md Mahbubur Rashid
- International Centre for Diarrhoeal Disease Research, Bangladesh (icddr,b), Dhaka, Bangladesh
| | - M Salimuzzaman
- Institute of Epidemiology, Disease Control and Research, Ministry of Health and Family Welfare, Government of Bangladesh, USA
| | - Meerjady S Flora
- Institute of Epidemiology, Disease Control and Research, Ministry of Health and Family Welfare, Government of Bangladesh, USA
| | - Firdausi Qadri
- International Centre for Diarrhoeal Disease Research, Bangladesh (icddr,b), Dhaka, Bangladesh
| | - Ashraful Islam Khan
- International Centre for Diarrhoeal Disease Research, Bangladesh (icddr,b), Dhaka, Bangladesh
| | - Eric J Nelson
- Departments of Pediatrics and Environmental and Global Health, Emerging Pathogens Institute, University of Florida, USA.
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George CM, Monira S, Zohura F, Thomas ED, Hasan MT, Parvin T, Hasan K, Rashid MU, Papri N, Islam A, Rahman Z, Rafique R, Islam Bhuyian S, Saxton R, Labrique A, Alland K, Barman I, Jubyda FT, Afroze F, Sultana M, Johura FT, Khan MAH, Tahmina S, Munmun F, Sack DA, Perin J, Alam M. Effects of a Water, Sanitation and Hygiene Mobile Health Program on Diarrhea and Child Growth in Bangladesh: A Cluster-Randomized Controlled Trial of the CHoBI7 Mobile Health Program. Clin Infect Dis 2020; 73:e2560-e2568. [PMID: 32761174 PMCID: PMC8563223 DOI: 10.1093/cid/ciaa754] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/12/2020] [Accepted: 07/27/2020] [Indexed: 11/17/2022] Open
Abstract
Background The Cholera Hospital-Based Intervention for 7 Days (CHoBI7) mobile health (mHealth) program was a cluster-randomized controlled trial of diarrhea patient households conducted in Dhaka, Bangladesh. Methods Patients were block-randomized to 3 arms: standard message on oral rehydration solution use; health facility delivery of CHoBI7 plus mHealth (no home visits); and health facility delivery of CHoBI7 plus 2 home visits and mHealth. The primary outcome was reported diarrhea in the past 2 weeks collected monthly for 12 months. The secondary outcomes were stunting, underweight, and wasting at a 12-month follow-up. Analysis was intention-to-treat. Results Between 4 December 2016 and 26 April 2018, 2626 participants in 769 households were randomly allocated to 3 arms: 849 participants to the standard message arm, 886 to mHealth with no home visits arm, and 891 to the mHealth with 2 home visits. Children <5 years had significantly lower 12-month diarrhea prevalence in both the mHealth with 2 home visits arm (prevalence ratio [PR]: 0.73 [95% confidence interval {CI}, .61–.87]) and the mHealth with no home visits arm (PR: 0.82 [95% CI, .69–.97]). Children <2 years were significantly less likely to be stunted in both the mHealth with 2 home visits arm (33% vs 45%; odds ratio [OR]: 0.55 [95% CI, .31–.97]) and the mHealth with no home visits arm (32% vs 45%; OR: 0.54 [95% CI, .31–.96]) compared with children in the standard message arm. Conclusions The CHoBI7 mHealth program lowered pediatric diarrhea and stunting among diarrhea patient households. Clinical Trials Registration NCT04008134.
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Affiliation(s)
- Christine Marie George
- Department of International Health, Johns Hopkins School of Public Health, Baltimore, Maryland, USA
| | - Shirajum Monira
- International Centre for Diarrhoeal Disease Research, Bangladesh, Dhaka, Bangladesh
| | - Fatema Zohura
- International Centre for Diarrhoeal Disease Research, Bangladesh, Dhaka, Bangladesh
| | - Elizabeth D Thomas
- Department of International Health, Johns Hopkins School of Public Health, Baltimore, Maryland, USA
| | - M Tasdik Hasan
- International Centre for Diarrhoeal Disease Research, Bangladesh, Dhaka, Bangladesh
| | - Tahmina Parvin
- International Centre for Diarrhoeal Disease Research, Bangladesh, Dhaka, Bangladesh
| | - Khaled Hasan
- Department of International Health, Johns Hopkins School of Public Health, Baltimore, Maryland, USA
| | - Mahamud-Ur Rashid
- International Centre for Diarrhoeal Disease Research, Bangladesh, Dhaka, Bangladesh
| | - Nowshin Papri
- International Centre for Diarrhoeal Disease Research, Bangladesh, Dhaka, Bangladesh
| | - Aminul Islam
- International Centre for Diarrhoeal Disease Research, Bangladesh, Dhaka, Bangladesh
| | - Zillur Rahman
- International Centre for Diarrhoeal Disease Research, Bangladesh, Dhaka, Bangladesh
| | - Raisa Rafique
- International Centre for Diarrhoeal Disease Research, Bangladesh, Dhaka, Bangladesh
| | | | - Ronald Saxton
- Department of International Health, Johns Hopkins School of Public Health, Baltimore, Maryland, USA
| | - Alain Labrique
- Department of International Health, Johns Hopkins School of Public Health, Baltimore, Maryland, USA
| | - Kelsey Alland
- Department of International Health, Johns Hopkins School of Public Health, Baltimore, Maryland, USA
| | - Indrajeet Barman
- International Centre for Diarrhoeal Disease Research, Bangladesh, Dhaka, Bangladesh
| | - Fatema Tuz Jubyda
- Department of International Health, Johns Hopkins School of Public Health, Baltimore, Maryland, USA
| | - Farzana Afroze
- International Centre for Diarrhoeal Disease Research, Bangladesh, Dhaka, Bangladesh
| | - Marzia Sultana
- International Centre for Diarrhoeal Disease Research, Bangladesh, Dhaka, Bangladesh
| | - Fatema-Tuz Johura
- International Centre for Diarrhoeal Disease Research, Bangladesh, Dhaka, Bangladesh
| | | | - Sanya Tahmina
- Bangladesh Ministry of Health and Family Welfare, Dhaka, Bangladesh
| | - Farzana Munmun
- Bangladesh Ministry of Health and Family Welfare, Dhaka, Bangladesh
| | - David A Sack
- Department of International Health, Johns Hopkins School of Public Health, Baltimore, Maryland, USA
| | - Jamie Perin
- Department of International Health, Johns Hopkins School of Public Health, Baltimore, Maryland, USA
| | - Munirul Alam
- International Centre for Diarrhoeal Disease Research, Bangladesh, Dhaka, Bangladesh
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D'Mello-Guyett L, Greenland K, Bonneville S, D'hondt R, Mashako M, Gorski A, Verheyen D, Van den Bergh R, Maes P, Checchi F, Cumming O. Distribution of hygiene kits during a cholera outbreak in Kasaï-Oriental, Democratic Republic of Congo: a process evaluation. Confl Health 2020; 14:51. [PMID: 32760439 PMCID: PMC7379792 DOI: 10.1186/s13031-020-00294-w] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/21/2020] [Accepted: 07/15/2020] [Indexed: 12/30/2022] Open
Abstract
Background Cholera remains a leading cause of infectious disease outbreaks globally, and a major public health threat in complex emergencies. Hygiene kits distributed to cholera case-households have previously shown an effect in reducing cholera incidence and are recommended by Médecins Sans Frontières (MSF) for distribution to admitted patients and accompanying household members upon admission to health care facilities (HCFs). Methods This process evaluation documented the implementation, participant response and context of hygiene kit distribution by MSF during a 2018 cholera outbreak in Kasaï-Oriental, Democratic Republic of Congo (DRC). The study population comprised key informant interviews with seven MSF staff, 17 staff from other organisations and a random sample of 27 hygiene kit recipients. Structured observations were conducted of hygiene kit demonstrations and health promotion, and programme reports were analysed to triangulate data. Results and conclusions Between Week (W) 28-48 of the 2018 cholera outbreak in Kasaï-Oriental, there were 667 suspected cholera cases with a 5% case fatality rate (CFR). Across seven HCFs supported by MSF, 196 patients were admitted with suspected cholera between W43-W47 and hygiene kit were provided to patients upon admission and health promotion at the HCF was conducted to accompanying household contacts 5-6 times per day. Distribution of hygiene kits was limited and only 52% of admitted suspected cholera cases received a hygiene kit. The delay of the overall response, delayed supply and insufficient quantities of hygiene kits available limited the coverage and utility of the hygiene kits, and may have diminished the effectiveness of the intervention. The integration of a WASH intervention for cholera control at the point of patient admission is a growing trend and promising intervention for case-targeted cholera responses. However, the barriers identified in this study warrant consideration in subsequent cholera responses and further research is required to identify ways to improve implementation and delivery of this intervention.
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Affiliation(s)
- Lauren D'Mello-Guyett
- Faculty of Infectious and Tropical Diseases, London School of Hygiene and Tropical Medicine, London, UK.,Environmental Health Unit, Médecins Sans Frontières, Brussels, Belgium
| | - Katie Greenland
- Faculty of Infectious and Tropical Diseases, London School of Hygiene and Tropical Medicine, London, UK
| | | | - Rob D'hondt
- Environmental Health Unit, Médecins Sans Frontières, Brussels, Belgium
| | - Maria Mashako
- Médecins Sans Frontières, Kinshasa, Democratic Republic of Congo
| | - Alexandre Gorski
- Médecins Sans Frontières, Kinshasa, Democratic Republic of Congo
| | - Dorien Verheyen
- Médecins Sans Frontières, Kinshasa, Democratic Republic of Congo
| | - Rafael Van den Bergh
- LuxOR, Luxembourg Operational Research Unit, Médecins Sans Frontières, Luxembourg City, Luxembourg
| | - Peter Maes
- Environmental Health Unit, Médecins Sans Frontières, Brussels, Belgium
| | - Francesco Checchi
- Faculty of Epidemiology and Population Health, London School of Hygiene and Tropical Medicine, London, UK
| | - Oliver Cumming
- Faculty of Infectious and Tropical Diseases, London School of Hygiene and Tropical Medicine, London, UK
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Masud J, Islam Bhuyian MS, Kumar Biswas S, Zohura F, Perin J, Papri N, Dil Farzana F, Parvin T, Monira S, Alam M, George CM. Diarrhoeal disease knowledge among diarrhoea patient housholds: findings from the randomised controlled trial of the Cholera-Hospital-Based-Intervention-for-7-days (CHoBI7) mobile health program. Trop Med Int Health 2020; 25:996-1007. [PMID: 32406989 DOI: 10.1111/tmi.13415] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
OBJECTIVE The objective of this study was to evaluate the impact of the Cholera-Hospital-Based-Intervention-for-7-days (CHoBI7) handwashing with soap and water treatment mobile health (mHealth) program on diarrhoeal disease knowledge among diarrhoea patients and their household members in urban Dhaka, Bangladesh. METHODS A cluster-randomised controlled trial of the CHoBI7 mHealth program was conducted among diarrhoea patient households in Dhaka, Bangladesh. Patients were randomised to three arms: standard recommendation on oral rehydration solution use; health facility delivery of CHoBI7 plus mHealth (weekly voice and text messages) (no home visits); and health facility delivery of CHoBI7 plus two home visits and mHealth. An open-ended questionnaire was administered to 1468 participants 12 years of age or older on diarrhoeal disease transmission and prevention. These items were combined to form a diarrhoeal disease knowledge score measured at baseline and at a 1 week, 6 month and 12 month follow-up. RESULTS At baseline, when participants were asked to report three ways diarrhoeal diseases were spread 37% (546/1468) of participants reported by water, 13% (187/1468) by lack of handwashing and 4% (53/1468) by food not being covered properly. At baseline when asked to name three ways diarrhoeal diseases could be prevented, 35% (515/1468) of participants reported safe water, and 16% (228/1468) reported handwashing with soap. At the 12-month follow-up, the overall diarrhoeal disease knowledge score was significantly higher in the mHealth with no home visits arm (score coefficient: 0.69, 95% Confidence Interval: 0.36, 1.01, P < 0.0001) and the mHealth with two home visits arm (score coefficient: 1.18, 95% CI: 0.87, 1.49, P < 0.0001) compared with the standard recommendation arm. CONCLUSION The CHoBI7 mHealth program significantly increased knowledge of diarrhoeal disease transmission and prevention among diarrhoea patients and their household members 12 months after in-person visits for program delivery were conducted.
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Affiliation(s)
- Jahed Masud
- International Centre for Diarrhoeal Disease Research, Bangladesh, Dhaka, Bangladesh
| | | | - Shwapon Kumar Biswas
- International Centre for Diarrhoeal Disease Research, Bangladesh, Dhaka, Bangladesh
| | - Fatema Zohura
- International Centre for Diarrhoeal Disease Research, Bangladesh, Dhaka, Bangladesh
| | - Jamie Perin
- Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
| | - Nowshin Papri
- International Centre for Diarrhoeal Disease Research, Bangladesh, Dhaka, Bangladesh
| | - Fahmida Dil Farzana
- International Centre for Diarrhoeal Disease Research, Bangladesh, Dhaka, Bangladesh
| | - Tahmina Parvin
- International Centre for Diarrhoeal Disease Research, Bangladesh, Dhaka, Bangladesh
| | - Shirajum Monira
- International Centre for Diarrhoeal Disease Research, Bangladesh, Dhaka, Bangladesh
| | - Munirul Alam
- International Centre for Diarrhoeal Disease Research, Bangladesh, Dhaka, Bangladesh
| | - Christine Marie George
- Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
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Monira S, Bhuyian MSI, Parvin T, Uddin IM, Zohura F, Hasan MT, Biswas SK, Hasan K, Masud J, Rashid M, Rahman Z, Papri N, Rafique R, Islam A, Barman I, Jubyda FT, Johura F, Sultana M, Sanin KI, Sack DA, Perin J, Alam M, George C. Child mouthing of soil and presence of animals in child sleeping spaces are associated with growth faltering among young children in Dhaka, Bangladesh (CHoBI7 Program). Trop Med Int Health 2020; 25:1016-1023. [DOI: 10.1111/tmi.13417] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Affiliation(s)
- Shirajum Monira
- International Centre for Diarrhoeal Disease Research, Bangladesh Dhaka Bangladesh
| | | | - Tahmina Parvin
- International Centre for Diarrhoeal Disease Research, Bangladesh Dhaka Bangladesh
| | - Ismat Minhaj Uddin
- International Centre for Diarrhoeal Disease Research, Bangladesh Dhaka Bangladesh
| | - Fatema Zohura
- International Centre for Diarrhoeal Disease Research, Bangladesh Dhaka Bangladesh
| | - M. Tasdik Hasan
- International Centre for Diarrhoeal Disease Research, Bangladesh Dhaka Bangladesh
| | - Shwapon K. Biswas
- International Centre for Diarrhoeal Disease Research, Bangladesh Dhaka Bangladesh
| | - Khaled Hasan
- International Centre for Diarrhoeal Disease Research, Bangladesh Dhaka Bangladesh
| | - Jahed Masud
- International Centre for Diarrhoeal Disease Research, Bangladesh Dhaka Bangladesh
| | - Mahamud‐ur Rashid
- International Centre for Diarrhoeal Disease Research, Bangladesh Dhaka Bangladesh
| | - Zillur Rahman
- International Centre for Diarrhoeal Disease Research, Bangladesh Dhaka Bangladesh
| | - Nowshin Papri
- International Centre for Diarrhoeal Disease Research, Bangladesh Dhaka Bangladesh
| | - Raisa Rafique
- International Centre for Diarrhoeal Disease Research, Bangladesh Dhaka Bangladesh
| | - Aminul Islam
- International Centre for Diarrhoeal Disease Research, Bangladesh Dhaka Bangladesh
| | - Indrajeet Barman
- International Centre for Diarrhoeal Disease Research, Bangladesh Dhaka Bangladesh
| | - Fatema Tuz Jubyda
- International Centre for Diarrhoeal Disease Research, Bangladesh Dhaka Bangladesh
| | - Fatema‐Tuz Johura
- International Centre for Diarrhoeal Disease Research, Bangladesh Dhaka Bangladesh
| | - Marzia Sultana
- International Centre for Diarrhoeal Disease Research, Bangladesh Dhaka Bangladesh
| | - Kazi Istiaque Sanin
- International Centre for Diarrhoeal Disease Research, Bangladesh Dhaka Bangladesh
| | - David A. Sack
- Department of International Health Johns Hopkins Bloomberg School of Public Health Baltimore MD USA
| | - Jamie Perin
- Department of International Health Johns Hopkins Bloomberg School of Public Health Baltimore MD USA
| | - Munirul Alam
- International Centre for Diarrhoeal Disease Research, Bangladesh Dhaka Bangladesh
| | - Christine George
- Department of International Health Johns Hopkins Bloomberg School of Public Health Baltimore MD USA
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Zohura F, Bhuyian MSI, Saxton RE, Parvin T, Monira S, Biswas SK, Masud J, Nuzhat S, Papri N, Hasan MT, Thomas ED, Sack D, Perin J, Alam M, George CM. Effect of a water, sanitation and hygiene program on handwashing with soap among household members of diarrhoea patients in healthcare facilities in Bangladesh: a cluster-randomised controlled trial of the CHoBI7 mobile health program. Trop Med Int Health 2020; 25:1008-1015. [PMID: 32406581 DOI: 10.1111/tmi.13416] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/30/2023]
Abstract
OBJECTIVE The Cholera-Hospital-Based-Intervention-for-7-days (CHoBI7) is a water treatment and handwashing with soap intervention for diarrhoea patients and their household members which is initially delivered in a healthcare facility setting. This study evaluated the effectiveness of CHoBI7 program delivery in increasing handwashing with soap in a healthcare facility setting among diarrhoea patients and their household members. METHODS A randomised controlled trial of the CHoBI7 program was conducted among 404 diarrhoea patients and their accompanying household members in healthcare facilities in Dhaka, Bangladesh. The 'Standard Message' Arm received the standard message given in Bangladesh to diarrhoea patients on the use of oral rehydration solution. The 'Health Facility Visit + Soapy Water' Arm received the standard message, the CHoBI7 communication module delivered bedside to the patient; and a soapy water bottle in the healthcare facility. The 'Health Facility Visit + Handwashing Station' Arm received this same intervention plus a small plastic handwashing station. Within 24 h of intervention delivery, three-hour structured observation of handwashing practices at stool/vomit- and food-related events (key events) was conducted in healthcare facilities of diarrhoea patients and their accompanying household members. RESULTS Compared to the Standard Message Arm, there was significantly more handwashing with soap at key events in both the Health Facility Visit + Soapy Water Arm (51% vs. 25 %) (Odds Ratio: 3.02; (95% Confidence Interval (CI): 1.41, 6.45) and the Health Facility Visit + Handwashing Station Arm (58% vs. 25%) OR: 4.12; (95% CI: 1.86, 9.14). CONCLUSION These findings demonstrate that delivery of the CHoBI7 communication module and provision of a soapy water bottle to diarrhoea patients and their accompanying household members presents a promising approach to increase handwashing with soap among this high risk population in a healthcare facility setting in Bangladesh.
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Affiliation(s)
- Fatema Zohura
- International Centre for Diarrhoeal Disease Research, Bangladesh (icddr,b), Dhaka, Bangladesh
| | | | - Ronald E Saxton
- Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
| | - Tahmina Parvin
- International Centre for Diarrhoeal Disease Research, Bangladesh (icddr,b), Dhaka, Bangladesh
| | - Shirajum Monira
- International Centre for Diarrhoeal Disease Research, Bangladesh (icddr,b), Dhaka, Bangladesh
| | - Shwapon K Biswas
- International Centre for Diarrhoeal Disease Research, Bangladesh (icddr,b), Dhaka, Bangladesh
| | - Jahed Masud
- International Centre for Diarrhoeal Disease Research, Bangladesh (icddr,b), Dhaka, Bangladesh
| | - Sharika Nuzhat
- International Centre for Diarrhoeal Disease Research, Bangladesh (icddr,b), Dhaka, Bangladesh
| | - Nowshin Papri
- International Centre for Diarrhoeal Disease Research, Bangladesh (icddr,b), Dhaka, Bangladesh
| | - M Tasdik Hasan
- International Centre for Diarrhoeal Disease Research, Bangladesh (icddr,b), Dhaka, Bangladesh
| | - Elizabeth D Thomas
- Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
| | - David Sack
- Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
| | - Jamie Perin
- Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
| | - Munirul Alam
- International Centre for Diarrhoeal Disease Research, Bangladesh (icddr,b), Dhaka, Bangladesh
| | - Christine Marie George
- Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
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Thomas ED, Zohura F, Hasan MT, Rana MS, Teman A, Parvin T, Masud J, Bhuyian MSI, Hossain MK, Hasan M, Tahmina S, Munmun F, Khan MAH, Monira S, Sack DA, Leontsini E, Winch PJ, Alam M, George CM. Formative research to scale up a handwashing with soap and water treatment intervention for household members of diarrhea patients in health facilities in Dhaka, Bangladesh (CHoBI7 program). BMC Public Health 2020; 20:831. [PMID: 32487209 PMCID: PMC7268342 DOI: 10.1186/s12889-020-08727-0] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/08/2019] [Accepted: 04/17/2020] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND During the time a diarrhea patient presents at a health facility, the household members of the patient are at higher risk of developing diarrheal diseases (> 100 times for cholera) than the general population. The Cholera-Hospital-based-Intervention-for-7-Days (CHoBI7) is a health facility-initiated water treatment and handwashing with soap intervention designed to reduce transmission of diarrheal diseases between patients and their household members. The present research aimed to (1) develop a scalable approach to integrate the CHoBI7 intervention program into services provided at government and private health facilities in Bangladesh; and (2) tailor the intervention program for the household members of all diarrhea patients, irrespective of the etiology of disease. METHODS We conducted 8 months of formative research, including 60 semi-structured interviews, 2 group discussions, and a pilot study. Thirty-two interviews were conducted with diarrhea patients and their family caregivers, government stakeholders, and health care providers both to explore existing WASH and diarrhea patient care practices in health facilities and to identify considerations for scaling the CHoBI7 program. Fifty-two diarrhea patient households participated in a pilot study of a modified version of the CHoBI7 intervention program for tailoring. Twenty-eight interviews and 2 group discussions were conducted with pilot households to explore experiences with and recommendations for intervention delivery. RESULTS The intervention program was modified based on formative research findings. Pilot study participants recognized the benefits of the CHoBI7 intervention program and made suggestions to improve the acceptability and feasibility of the intervention. Modifications included 1) providing additional pictorial modules, cues to action, enabling technologies, and supplies for safe drinking water and handwashing with soap behaviors in the health facility; 2) switching out technology prone to breaks and leaks as well as sourcing plastic technologies from a high-quality, local manufacturer; and 3) including instructions discouraging the non-use or misuse of technologies and supplies. Considerations for scalability include the local availability and marketing of enabling technologies and supplies, staff for program delivery in health facilities, and potential integration into existing government or health promotion programs. CONCLUSIONS Formative research identified important considerations for the content, delivery, and scalability of the CHoBI7 health facility-initiated WASH intervention program.
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Affiliation(s)
- Elizabeth D. Thomas
- Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD USA
| | - Fatema Zohura
- Infectious Diseases Division, International Centre for Diarrhoeal Disease Research, Bangladesh, Dhaka, Bangladesh
| | - M. Tasdik Hasan
- Infectious Diseases Division, International Centre for Diarrhoeal Disease Research, Bangladesh, Dhaka, Bangladesh
| | - Md. Sohel Rana
- Johns Hopkins Bloomberg School of Public Health, Baltimore, MD USA
| | - Alana Teman
- Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD USA
| | - Tahmina Parvin
- Infectious Diseases Division, International Centre for Diarrhoeal Disease Research, Bangladesh, Dhaka, Bangladesh
| | - Jahed Masud
- Infectious Diseases Division, International Centre for Diarrhoeal Disease Research, Bangladesh, Dhaka, Bangladesh
| | - Md. Sazzadul Islam Bhuyian
- Infectious Diseases Division, International Centre for Diarrhoeal Disease Research, Bangladesh, Dhaka, Bangladesh
| | - Md. Khobair Hossain
- Infectious Diseases Division, International Centre for Diarrhoeal Disease Research, Bangladesh, Dhaka, Bangladesh
| | - Maynul Hasan
- Infectious Diseases Division, International Centre for Diarrhoeal Disease Research, Bangladesh, Dhaka, Bangladesh
| | - Sanya Tahmina
- Department of Communicable Diseases, Ministry of Health and Family Welfare, Dhaka, Bangladesh
| | - Farzana Munmun
- Community Based Health Care, Directorate General of Health Services, Dhaka, Bangladesh
| | - Md. Abul Hashem Khan
- Community Based Health Care, Directorate General of Health Services, Dhaka, Bangladesh
| | - Shirajum Monira
- Infectious Diseases Division, International Centre for Diarrhoeal Disease Research, Bangladesh, Dhaka, Bangladesh
| | - David A. Sack
- Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD USA
| | - Elli Leontsini
- Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD USA
| | - Peter J. Winch
- Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD USA
| | - Munirul Alam
- Infectious Diseases Division, International Centre for Diarrhoeal Disease Research, Bangladesh, Dhaka, Bangladesh
| | - Christine Marie George
- Associate Professor, Department of International Health, Program in Global Disease Epidemiology and Control, Johns Hopkins Bloomberg School of Public Health, 615 N. Wolfe Street, Room E5535, Baltimore, MD 21205-2103 USA
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Mwaba J, Debes AK, Shea P, Mukonka V, Chewe O, Chisenga C, Simuyandi M, Kwenda G, Sack D, Chilengi R, Ali M. Identification of cholera hotspots in Zambia: A spatiotemporal analysis of cholera data from 2008 to 2017. PLoS Negl Trop Dis 2020; 14:e0008227. [PMID: 32294084 PMCID: PMC7159183 DOI: 10.1371/journal.pntd.0008227] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2019] [Accepted: 03/17/2020] [Indexed: 11/17/2022] Open
Abstract
The global burden of cholera is increasing, with the majority (60%) of the cases occurring in sub-Saharan Africa. In Zambia, widespread cholera outbreaks have occurred since 1977, predominantly in the capital city of Lusaka. During both the 2016 and 2018 outbreaks, the Ministry of Health implemented cholera vaccination in addition to other preventative and control measures, to stop the spread and control the outbreak. Given the limitations in vaccine availability and the logistical support required for vaccination, oral cholera vaccine (OCV) is now recommended for use in the high risk areas ("hotspots") for cholera. Hence, the aim of this study was to identify areas with an increased risk of cholera in Zambia. Retrospective cholera case data from 2008 to 2017 was obtained from the Ministry of Health, Department of Public Health and Disease Surveillance. The Zambian Central Statistical Office provided district-level population data, socioeconomic and water, sanitation and hygiene (WaSH) indicators. To identify districts at high risk, we performed a discrete Poisson-based space-time scan statistic to account for variations in cholera risk across both space and time over a 10-year study period. A zero-inflated negative binomial regression model was employed to identify the district level risk factors for cholera. The risk map was generated by classifying the relative risk of cholera in each district, as obtained from the space-scan test statistic. In total, 34,950 cases of cholera were reported in Zambia between 2008 and 2017. Cholera cases varied spatially by year. During the study period, Lusaka District had the highest burden of cholera, with 29,080 reported cases. The space-time scan statistic identified 16 districts to be at a significantly higher risk of having cholera. The relative risk of having cholera in these districts was significantly higher and ranged from 1.25 to 78.87 times higher when compared to elsewhere in the country. Proximity to waterbodies was the only factor associated with the increased risk for cholera (P<0.05). This study provides a basis for the cholera elimination program in Zambia. Outside Lusaka, the majority of high risk districts identified were near the border with the DRC, Tanzania, Mozambique, and Zimbabwe. This suggests that cholera in Zambia may be linked to movement of people from neighboring areas of cholera endemicity. A collaborative intervention program implemented in concert with neighboring countries could be an effective strategy for elimination of cholera in Zambia, while also reducing rates at a regional level.
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Affiliation(s)
- John Mwaba
- Centre for Infectious Disease Research in Zambia, Lusaka, Zambia
| | - Amanda K Debes
- Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, United States
| | - Patrick Shea
- Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, United States
| | | | - Orbrie Chewe
- Zambia National Public Health Institute, Lusaka, Zambia
| | | | | | - Geoffrey Kwenda
- University of Zambia, School of Health Sciences, Lusaka, Zambia
| | - David Sack
- Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, United States
| | - Roma Chilengi
- Centre for Infectious Disease Research in Zambia, Lusaka, Zambia
| | - Mohammad Ali
- Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, United States
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Bompangue D, Moore S, Taty N, Impouma B, Sudre B, Manda R, Balde T, Mboussou F, Vandevelde T. Description of the targeted water supply and hygiene response strategy implemented during the cholera outbreak of 2017-2018 in Kinshasa, DRC. BMC Infect Dis 2020; 20:226. [PMID: 32183745 PMCID: PMC7079479 DOI: 10.1186/s12879-020-4916-0] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2019] [Accepted: 02/21/2020] [Indexed: 12/16/2022] Open
Abstract
Background Rapid control of cholera outbreaks is a significant challenge in overpopulated urban areas. During late-2017, Kinshasa, the capital of the Democratic Republic of the Congo, experienced a cholera outbreak that showed potential to spread throughout the city. A novel targeted water and hygiene response strategy was implemented to quickly stem the outbreak. Methods We describe the first implementation of the cluster grid response strategy carried out in the community during the cholera outbreak in Kinshasa, in which response activities targeted cholera case clusters using a grid approach. Interventions focused on emergency water supply, household water treatment and safe storage, home disinfection and hygiene promotion. We also performed a preliminary community trial study to assess the temporal pattern of the outbreak before and after response interventions were implemented. Cholera surveillance databases from the Ministry of Health were analyzed to assess the spatiotemporal dynamics of the outbreak using epidemic curves and maps. Results From January 2017 to November 2018, a total of 1712 suspected cholera cases were reported in Kinshasa. During this period, the most affected health zones included Binza Météo, Limeté, Kokolo, Kintambo and Kingabwa. Following implementation of the response strategy, the weekly cholera case numbers in Binza Météo, Kintambo and Limeté decreased by an average of 57% after 2 weeks and 86% after 4 weeks. The total weekly case numbers throughout Kinshasa Province dropped by 71% 4 weeks after the peak of the outbreak. Conclusion During the 2017–2018 period, Kinshasa experienced a sharp increase in cholera case numbers. To contain the outbreak, water supply and hygiene response interventions targeted case households, nearby neighbors and public areas in case clusters using a grid approach. Following implementation of the response, the outbreak in Kinshasa was quickly brought under control. A similar approach may be adapted to quickly interrupt cholera transmission in other urban settings.
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Affiliation(s)
- Didier Bompangue
- Ministry of Health, Kinshasa, Democratic Republic of the Congo.,Faculty of Medicine, University of Kinshasa, Kinshasa, Democratic Republic of the Congo.,Laboratory Chrono-Environnement, UMR 6249, University of Bourgogne Franche-Comté, Bourgogne Franche-Comté, France
| | | | - Nadège Taty
- Ministry of Health, Kinshasa, Democratic Republic of the Congo.,Faculty of Medicine, University of Kinshasa, Kinshasa, Democratic Republic of the Congo
| | - Benido Impouma
- World Health Organization, African Regional Office, Brazzaville, Republic of, Congo
| | - Bertrand Sudre
- Laboratory Chrono-Environnement, UMR 6249, University of Bourgogne Franche-Comté, Bourgogne Franche-Comté, France
| | - Richard Manda
- Ministry of Health, Kinshasa, Democratic Republic of the Congo
| | - Thierno Balde
- World Health Organization, African Regional Office, Brazzaville, Republic of, Congo
| | - Franck Mboussou
- World Health Organization, African Regional Office, Brazzaville, Republic of, Congo
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Kennedy-Shaffer L, Hughes MD. Sample size estimation for stratified individual and cluster randomized trials with binary outcomes. Stat Med 2020; 39:1489-1513. [PMID: 32003492 DOI: 10.1002/sim.8492] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/05/2018] [Revised: 12/12/2019] [Accepted: 01/09/2020] [Indexed: 12/20/2022]
Abstract
Individual randomized trials (IRTs) and cluster randomized trials (CRTs) with binary outcomes arise in a variety of settings and are often analyzed by logistic regression (fitted using generalized estimating equations for CRTs). The effect of stratification on the required sample size is less well understood for trials with binary outcomes than for continuous outcomes. We propose easy-to-use methods for sample size estimation for stratified IRTs and CRTs and demonstrate the use of these methods for a tuberculosis prevention CRT currently being planned. For both IRTs and CRTs, we also identify the ratio of the sample size for a stratified trial vs a comparably powered unstratified trial, allowing investigators to evaluate how stratification will affect the required sample size when planning a trial. For CRTs, these can be used when the investigator has estimates of the within-stratum intracluster correlation coefficients (ICCs) or by assuming a common within-stratum ICC. Using these methods, we describe scenarios where stratification may have a practically important impact on the required sample size. We find that in the two-stratum case, for both IRTs and for CRTs with very small cluster sizes, there are unlikely to be plausible scenarios in which an important sample size reduction is achieved when the overall probability of a subject experiencing the event of interest is low. When the probability of events is not small, or when cluster sizes are large, however, there are scenarios where practically important reductions in sample size result from stratification.
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Affiliation(s)
- Lee Kennedy-Shaffer
- Department of Biostatistics, Harvard T.H. Chan School of Public Health, Boston, Massachusetts
| | - Michael D Hughes
- Department of Biostatistics, Harvard T.H. Chan School of Public Health, Boston, Massachusetts
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Czerniewska A, White S. Hygiene programming during outbreaks: a qualitative case study of the humanitarian response during the Ebola outbreak in Liberia. BMC Public Health 2020; 20:154. [PMID: 32005207 PMCID: PMC6995147 DOI: 10.1186/s12889-020-8240-9] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2019] [Accepted: 01/20/2020] [Indexed: 12/26/2022] Open
Abstract
BACKGROUND Hygiene promotion is a cornerstone of humanitarian response during infectious disease outbreaks. Despite this, we know little about how humanitarian organisations design, deliver or monitor hygiene programmes, or about what works to change hygiene behaviours in outbreak settings. This study describes humanitarian perspectives on changing behaviours in crises, through a case study of hygiene promotion during the 2014-2016 Liberian Ebola outbreak. Our aim was to aid better understanding of decision making in high-stress situations where there is little precedent or evidence, and to prompt reflection within the sector around how to improve and support this. METHODS We conducted in-depth, semi-structured interviews with fourteen purposively-sampled individuals (key informants) from international organisations involved in hygiene behaviour change during the outbreak. Through thematic analysis we identified the decisions that were made and processes that were followed to design, deliver and monitor interventions. We compared our findings with theory-driven processes used to design behaviour change interventions in non-outbreak situations. RESULTS Humanitarians predominantly focussed on providing hygiene products (e.g. buckets, soap, gloves) and delivering messages through posters, radio and community meetings. They faced challenges in defining which hygiene behaviours to promote. Assessments focused on understanding infrastructural needs, but omitted systematic assessments of hygiene behaviours or their determinants. Humanitarians assumed that fear and disease awareness would be the most powerful motivators for behaviour change. They thought that behaviour change techniques used in non-emergency settings were too 'experimental', and were beyond the skillset of most humanitarian actors. Monitoring focussed on inputs and outputs rather than behavioural impact. CONCLUSIONS The experiences of humanitarians allowed us to identify areas that could be strengthened when designing hygiene programmes in future outbreaks. Specifically, we identified a need for rapid research methods to explore behavioural determinants; increased skills training for frontline staff, and increased operational research to explore behaviour change strategies that are suited to outbreak situations.
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Affiliation(s)
- Alexandra Czerniewska
- Department of Disease Control, Faculty of Infectious and Tropical Diseases, London School of Hygiene and Tropical Medicine, London, UK
| | - Sian White
- Department of Disease Control, Faculty of Infectious and Tropical Diseases, London School of Hygiene and Tropical Medicine, London, UK
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D’Mello-Guyett L, Gallandat K, Van den Bergh R, Taylor D, Bulit G, Legros D, Maes P, Checchi F, Cumming O. Prevention and control of cholera with household and community water, sanitation and hygiene (WASH) interventions: A scoping review of current international guidelines. PLoS One 2020; 15:e0226549. [PMID: 31914164 PMCID: PMC6948749 DOI: 10.1371/journal.pone.0226549] [Citation(s) in RCA: 23] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/12/2019] [Accepted: 12/03/2019] [Indexed: 12/13/2022] Open
Abstract
INTRODUCTION Cholera remains a frequent cause of outbreaks globally, particularly in areas with inadequate water, sanitation and hygiene (WASH) services. Cholera is spread through faecal-oral routes, and studies demonstrate that ingestion of Vibrio cholerae occurs from consuming contaminated food and water, contact with cholera cases and transmission from contaminated environmental point sources. WASH guidelines recommending interventions for the prevention and control of cholera are numerous and vary considerably in their recommendations. To date, there has been no review of practice guidelines used in cholera prevention and control programmes. METHODS We systematically searched international agency websites to identify WASH intervention guidelines used in cholera programmes in endemic and epidemic settings. Recommendations listed in the guidelines were extracted, categorised and analysed. Analysis was based on consistency, concordance and recommendations were classified on the basis of whether the interventions targeted within-household or community-level transmission. RESULTS Eight international guidelines were included in this review: three by non-governmental organisations (NGOs), one from a non-profit organisation (NPO), three from multilateral organisations and one from a research institution. There were 95 distinct recommendations identified, and concordance among guidelines was poor to fair. All categories of WASH interventions were featured in the guidelines. The majority of recommendations targeted community-level transmission (45%), 35% targeted within-household transmission and 20% both. CONCLUSIONS Recent evidence suggests that interventions for effective cholera control and response to epidemics should focus on case-centred approaches and within-household transmission. Guidelines did consistently propose interventions targeting transmission within households. However, the majority of recommendations listed in guidelines targeted community-level transmission and tended to be more focused on preventing contamination of the environment by cases or recurrent outbreaks, and the level of service required to interrupt community-level transmission was often not specified. The guidelines in current use were varied and interpretation may be difficult when conflicting recommendations are provided. Future editions of guidelines should reflect on the inclusion of evidence-based approaches, cholera transmission models and resource-efficient strategies.
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Affiliation(s)
- Lauren D’Mello-Guyett
- Department of Disease Control, Faculty of Infectious and Tropical Diseases, London School of Hygiene and Tropical Medicine, London, United Kingdom
- Environmental Health Unit, Médecins Sans Frontières, Brussels, Belgium
| | - Karin Gallandat
- Department of Disease Control, Faculty of Infectious and Tropical Diseases, London School of Hygiene and Tropical Medicine, London, United Kingdom
| | - Rafael Van den Bergh
- LuxOR, Luxembourg Operational Research Unit, Médecins Sans Frontières, Luxembourg
| | - Dawn Taylor
- Public Health Unit, Médecins Sans Frontières, Amsterdam, Netherlands
| | - Gregory Bulit
- Water, Sanitation and Hygiene, UNICEF, New York, New York, United States of America
| | - Dominique Legros
- Global Task Force on Cholera Control, World Health Organization, Geneva, Switzerland
| | - Peter Maes
- Environmental Health Unit, Médecins Sans Frontières, Brussels, Belgium
| | - Francesco Checchi
- Department of Infectious Disease Epidemiology, Faculty of Epidemiology and Population Health, London School of Hygiene and Tropical Medicine, London, United Kingdom
| | - Oliver Cumming
- Department of Disease Control, Faculty of Infectious and Tropical Diseases, London School of Hygiene and Tropical Medicine, London, United Kingdom
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Michel E, Gaudart J, Beaulieu S, Bulit G, Piarroux M, Boncy J, Dely P, Piarroux R, Rebaudet S. Estimating effectiveness of case-area targeted response interventions against cholera in Haiti. eLife 2019; 8:50243. [PMID: 31886768 PMCID: PMC7041943 DOI: 10.7554/elife.50243] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/16/2019] [Accepted: 12/20/2019] [Indexed: 01/24/2023] Open
Abstract
Case-area targeted interventions (CATIs) against cholera are conducted by rapid response teams, and may include various activities like water, sanitation, hygiene measures. However, their real-world effectiveness has never been established. We conducted a retrospective observational study in 2015-2017 in the Centre department of Haiti. Using cholera cases, stool cultures and CATI records, we identified 238 outbreaks that were responded to. After adjusting for potential confounders, we found that a prompt response could reduce the number of accumulated cases by 76% (95% confidence interval, 59 to 86) and the outbreak duration by 61% (41 to 75) when compared to a delayed response. An intense response could reduce the number of accumulated cases by 59% (11 to 81) and the outbreak duration by 73% (49 to 86) when compared to a weaker response. These results suggest that prompt and repeated CATIs were significantly effective at mitigating and shortening cholera outbreaks in Haiti.
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Affiliation(s)
- Edwige Michel
- Ministry of Public Health and Population, Directorate of Epidemiology Laboratory and Research, Port-au-Prince, Haiti
| | - Jean Gaudart
- Aix-Marseille Université, APHM, INSERM, IRD, SESSTIM, Hop Timone, BiSTIC, Biostatistics and ICT, Marseille, France
| | | | - Gregory Bulit
- United Nations Children's Fund, Port-au-Prince, Haiti
| | - Martine Piarroux
- Centre d'Épidémiologie et de Santé Publique des Armées, Service de Santé des Armées, Marseille, France
| | - Jacques Boncy
- Ministry of Public Health and Population, National Laboratory of Public Health, Delmas, Haiti
| | - Patrick Dely
- Ministry of Public Health and Population, Directorate of Epidemiology Laboratory and Research, Port-au-Prince, Haiti
| | - Renaud Piarroux
- Sorbonne Université, Sorbonne Université, INSERM, Institut Pierre-Louis d'Epidémiologie et de Santé Publique (IPLESP), AP-HP, Hôpital Pitié-Salpêtrière, Paris, France
| | - Stanislas Rebaudet
- APHM, Hôpital Européen, Aix Marseille Université, INSERM, IRD, SESSTIM, IPLESP, Marseille, France.,Sorbonne Université, INSERM, Institut Pierre-Louis d'Epidémiologie et de Santé Publique, Paris, France
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Inauen J, Lilje J, Mosler HJ. Refining hand washing interventions by identifying active ingredients: A cluster-randomized controlled trial in rural Zimbabwe. Soc Sci Med 2019; 245:112712. [PMID: 31846857 DOI: 10.1016/j.socscimed.2019.112712] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2018] [Revised: 10/17/2019] [Accepted: 11/30/2019] [Indexed: 11/17/2022]
Abstract
RATIONALE Consistent hand washing with soap can reduce the risk of diarrhea, but changing hand-washing behavior is difficult. Systematic behavior change approaches promise to enhance hand washing with soap effectively, and allow the identification of active intervention ingredients using mediation analysis. This knowledge can then be used to derive hypotheses for systematically refining the intervention. OBJECTIVE We demonstrate this at the example of a behavior change intervention to promote hand washing with soap based on the RANAS approach (risk, attitudes, norms, ability, and self-regulation). METHODS Sixteen wards of Masvingo province in Zimbabwe were randomly allocated to the RANAS-based intervention or a wait-list control group. Hand washing at baseline and follow-up was observed for 224 randomly selected caregivers of young children. They additionally participated in quantitative face-to-face interviews assessing psychosocial factors. RESULTS At baseline, hand washing with soap was <3% on average, and did not differ between groups (p = .526). At follow-up, intervention participants washed hands with soap more frequently than controls (in 29.4% vs. 8.2% of all stool- and food-related situations, B = 1.88, SE = 0.32, OR = 6.6, p < .001). Mediation analyses revealed that the intervention enhanced several of the targeted psychosocial factors; return, descriptive and injunctive norms, action knowledge, action self-efficacy, maintenance self-efficacy, action planning, and remembering. The intervention effect was mediated through increased remembering. CONCLUSION This study supports the efficacy of a systematic approach to behavior change to promote hand washing with soap. The analyses of the mechanisms revealed important insights into the active ingredients of the intervention, which will facilitate its future refinement.
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Affiliation(s)
- Jennifer Inauen
- Institute of Psychology, University of Bern, Bern, Switzerland; Department of Environmental Social Sciences, Eawag: Swiss Federal Institute of Aquatic Science & Technology, Duebendorf, Switzerland.
| | - Jonathan Lilje
- Department of Environmental Social Sciences, Eawag: Swiss Federal Institute of Aquatic Science & Technology, Duebendorf, Switzerland
| | - Hans-Joachim Mosler
- Department of Environmental Social Sciences, Eawag: Swiss Federal Institute of Aquatic Science & Technology, Duebendorf, Switzerland
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Azman AS, Luquero FJ, Salje H, Mbaïbardoum NN, Adalbert N, Ali M, Bertuzzo E, Finger F, Toure B, Massing LA, Ramazani R, Saga B, Allan M, Olson D, Leglise J, Porten K, Lessler J. Micro-Hotspots of Risk in Urban Cholera Epidemics. J Infect Dis 2019; 218:1164-1168. [PMID: 29757428 PMCID: PMC6107744 DOI: 10.1093/infdis/jiy283] [Citation(s) in RCA: 25] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2018] [Accepted: 05/09/2018] [Indexed: 12/05/2022] Open
Abstract
Targeted interventions have been delivered to neighbors of cholera cases in major epidemic responses globally despite limited evidence for the impact of such targeting. Using data from urban epidemics in Chad and Democratic Republic of the Congo, we estimate the extent of spatiotemporal zones of increased cholera risk around cases. In both cities, we found zones of increased risk of at least 200 meters during the 5 days immediately after case presentation to a clinic. Risk was highest for those living closest to cases and diminished in time and space similarly across settings. These results provide a rational basis for rapidly delivering targeting interventions.
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Affiliation(s)
- Andrew S Azman
- Departments of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland
| | - Francisco J Luquero
- Departments of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland.,Epicentre, Paris, France
| | | | - Nathan Naibei Mbaïbardoum
- Epicentre, Paris, France.,Communauté des Amis de l'Informatique pour le Développement, N'Djamena, Chad
| | | | - Mohammad Ali
- Departments of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland
| | - Enrico Bertuzzo
- Department of Environmental Science, Informatics and Statistics, Università Ca' Foscari Venezia, Venice, Italy
| | - Flavio Finger
- Centre for the Mathematical Modelling of Infectious Diseases, London School of Hygiene & Tropical Medicine, United Kingom
| | | | - Louis Albert Massing
- Médecins sans Frontières (France), Kinshasa, The Democratic Republic of the Congo
| | - Romain Ramazani
- Médecins sans Frontières (France), Kalemie, The Democratic Republic of the Congo
| | | | | | | | | | | | - Justin Lessler
- Departments of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland
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