Microbiological evaluation of the efficacy of soapy water to clean hands: a randomized, non-inferiority field trial

Effect of handwashing on the reduction of Escherichia coli on children's hands in an urban slum Indonesia

Poor hand hygiene practice has been linked to an increase in the number of infections among children in urban slums. Hands are considered an intersection for bacterial transmission, but it is unclear whether the handwashing technique affects bacteria elimination. This study investigated the effect of handwashing on the concentration of Escherichia coli (E. coli) and factors related to its reduction among children in an urban slum in Bandung, Indonesia. We observed handwashing and conducted repeated hand swabs before and after handwashing among 137 participants. The mean E. coli concentration on the hands decreased after handwashing, with a higher reduction in E. coli count among students who used soap and had soap contact for more than 10 s during handwashing. Cleaning in-between fingers, using soap, soap contact for more than 10 s, and drying hands with a single-use towel were effective factors for reducing E. coli concentration after handwashing (p < 0.05). More than half of the swab samples (59%) tested positive for E. coli after handwashing, indicating that the children's handwashing technique was not effective in completely removing E. coli from the hands. Moreover, sustained and consistent handwashing practice as a daily behavior in children would maximize the effect.

Recommendations for hand hygiene in community settings: a scoping review of current international guidelines

BACKGROUND

Hand hygiene is an important measure to prevent disease transmission.

OBJECTIVE

To summarise current international guideline recommendations for hand hygiene in community settings and to assess to what extent they are consistent and evidence based.

ELIGIBILITY CRITERIA

We included international guidelines with one or more recommendations on hand hygiene in community settings-categorised as domestic, public or institutional-published by international organisations, in English or French, between 1 January 1990 and 15 November 2021.

DATA SOURCES

To identify relevant guidelines, we searched the WHO Institutional Repository for Information Sharing Database, Google, websites of international organisations, and contacted expert organisations and individuals.

CHARTING METHODS

Recommendations were mapped to four areas related to hand hygiene: (1) effective hand hygiene; (2) minimum requirements; (3) behaviour change and (4) government measures. Recommendations were assessed for consistency, concordance and whether supported by evidence.

RESULTS

We identified 51 guidelines containing 923 recommendations published between 1999 and 2021 by multilateral agencies and international non-governmental organisations. Handwashing with soap is consistently recommended as the preferred method for hand hygiene across all community settings. Most guidelines specifically recommend handwashing with plain soap and running water for at least 20 s; single-use paper towels for hand drying; and alcohol-based hand rub (ABHR) as a complement or alternative to handwashing. There are inconsistent and discordant recommendations for water quality for handwashing, affordable and effective alternatives to soap and ABHR, and the design of handwashing stations. There are gaps in recommendations on soap and water quantity, behaviour change approaches and government measures required for effective hand hygiene. Less than 10% of recommendations are supported by any cited evidence.

CONCLUSION

While current international guidelines consistently recommend handwashing with soap across community settings, there remain gaps in recommendations where clear evidence-based guidance might support more effective policy and investment.

Food Safety Controls during Bulk Food Preparation-An Observational Analysis

Seeing the palpable impact of food poisoning associated with catering operations, we surveyed caterers with and without past hygiene violations to examine staffing, food safety practices and correlations with microbial counts in food and the processing environment. Past infringements did not negatively impact the current execution of food safety measures nor the microbial quality of food. In preference to added stringencies for errant operators, we discuss alternative efforts to augment food safety, as well as the policy implications thereof.

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

OBJECTIVE

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

DESIGN, SETTING AND PARTICIPANTS

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

OUTCOME MEASURES

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

RESULTS

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

CONCLUSION

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

Boehm A, K. Wolfe M. Investigating the Efficacy of Various Handwashing Methods against Enveloped and Non-Enveloped Viruses

Respiratory and diarrheal diseases are leading causes of death worldwide. Handwashing may reduce disease; however, recommended methods (soap and water for 20 seconds) are not always possible, particularly in low-resource settings. The aim of this study is to evaluate handwashing when recommended methods are not feasible, including washing with water only, washing with soapy water, washing for a short duration, using alcohol-based hand sanitizer (ABHS), and cleaning hands with towels. To evaluate laboratory efficacy, we seeded MS2 (a non-enveloped virus) and Phi6 (an enveloped virus) onto the hands of volunteers who then washed their hands. Viruses remaining were recovered and quantified using culture-based and molecular methods to determine the log reduction value (LRV) after washing. Results indicated that washing with water only and with soapy water were similar to washing with soap and water for 20 seconds for both viruses (median LRV for MS2 = 2.8; Phi6 = 3.2). Most towel alternative conditions had LRVs significantly smaller than LRVs from washing with soap and water for either virus. LRVs of ABHS and soap and water for 5 seconds were similar to soap and water for 20 seconds for Phi6 but less for MS2 (median MS2 LRV differences = 2.5 and 0.51 for ABHS and soap and water for 5 seconds, respectively). Additionally, LRVs determined using molecular methods were in agreement with those obtained using culture-based methods. These results suggest some handwashing alternatives were as effective as recommended methods whereas others were not, and inform recommendations and future research on handwashing alternatives in low-resource settings.

Dependency of sanitation infrastructure on the discharge of faecal coliform and SARS-CoV-2 viral RNA in wastewater from COVID and non-COVID hospitals in Dhaka, Bangladesh

The detection of severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2) RNA in wastewater can be used as an indicator of the presence of SARS-CoV-2 infection in specific catchment areas. We conducted a hospital-based study to explore wastewater management in healthcare facilities and analyzed SARS-CoV-2 RNA in the hospital wastewater in Dhaka city during the Coronavirus disease (COVID-19) outbreak between September 2020-January 2021. We selected three COVID-hospitals, two non-COVID-hospitals, and one non-COVID-hospital with COVID wards, conducted spot-checks of the sanitation systems (i.e., toilets, drainage, and septic-tank), and collected 90 untreated wastewater effluent samples (68 from COVID and 22 from non-COVID hospitals). E. coli was detected using a membrane filtration technique and reported as colony forming unit (CFU). SARS-CoV-2 RNA was detected using the iTaq Universal Probes One-Step kit for RT-qPCR amplification of the SARS-CoV-2 ORF1ab and N gene targets and quantified for SARS-CoV-2 genome equivalent copies (GEC) per mL of sample. None of the six hospitals had a primary wastewater treatment facility; two COVID hospitals had functional septic tanks, and the rest of the hospitals had either broken onsite systems or no containment of wastewater. Overall, 100 % of wastewater samples were positive with a high concentration of E. coli (mean = 7.0 log10 CFU/100 mL). Overall, 67 % (60/90) samples were positive for SARS-CoV-2. The highest SARS-CoV-2 concentrations (median: 141 GEC/mL; range: 13-18,214) were detected in wastewater from COVID-hospitals, and in non-COVID-hospitals, the median SARS-CoV-2 concentration was 108 GEC/mL (range: 30-1829). Our results indicate that high concentrations of E. coli and SARS-CoV-2 were discharged through the hospital wastewater (both COVID and non-COVID) without treatment into the ambient water bodies. Although there is no evidence for transmission of SARS-CoV-2 via wastewater, this study highlights the significant risk posed by wastewater from health care facilities in Dhaka for the many other diseases that are spread via faecal oral route. Hospitals in low-income settings could function as sentinel sites to monitor outbreaks through wastewater-based epidemiological surveillance systems. Hospitals should aim to adopt the appropriate wastewater treatment technologies to reduce the discharge of pathogens into the environment and mitigate environmental exposures.

Inequality of handwashing practice using antimicrobial agents in Bangladesh: a household level analyses

OBJECTIVES

About 2.3 billion individuals worldwide are still deprived of the amenity of handwashing with antimicrobial agents. The progress of handwashing with antimicrobial agents in Bangladesh is relatively slower than in many developing countries. The objective of this study was to capture the inequality of the prevalence of handwashing with antimicrobial agents and to identify the factors that are potentially contributing to socio-economic inequalities of handwashing practice in Bangladesh.

STUDY DESIGN

Cross-sectional study.

METHODS

The present study used the nationally representative cross-sectional data from the latest Bangladesh Demographic and Health Survey (BDHS) 2017-18. A total of 19,457 households were included in the analysis of this study. A regression-based decomposition method was applied to assess the socio-economic contributors of inequality.

RESULTS

This study showed that only 38% of Bangladeshi households wash their hands with antimicrobial agents while a pro-rich socio-economic inequality was observed. Household's wealth index was responsible for about 46% of the overall inequality of handwashing with antimicrobial agents while the type of place for handwashing variable contributed 38% of total inequalities. Hygienic toilet facilities (12%) and exposure to mass media (7.4%) are other determinants of total inequalities of handwashing with antimicrobial agents.

CONCLUSIONS

Despite recent declines in attributable mortality, handwashing with antimicrobial agents remains an important determinant of public health problems in many developing countries like Bangladesh. The regular programs aimed at promoting best hand hygiene practices and ensuring the availability of the necessary infrastructure at the community level will be important measures to eliminate this inequality at the population level.

Formative Research for the Development of the CHoBI7 Cholera Rapid Response Program for Cholera Hotspots in Bangladesh

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.

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

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.

Water, Sanitation, and Hygiene and Nutritional Risk Factors for Acute Respiratory Illness in the Democratic Republic of the Congo: REDUCE Prospective Cohort Study

The objective of this cohort study was to examine the prevalence of acute respiratory illness among children under 5 years of age and to identify water, sanitation, and hygiene (WASH) and nutritional risk factors. This prospective cohort study was conducted in Walungu Territory, South Kivu, and Democratic Republic of the Congo (DRC), and enrolled 512 participants. Spot checks of the household environment were conducted at baseline. Baseline minimum dietary diversity (MDD) was defined by consumption of five or more of the following food groups: 1) breast milk; 2) grains, roots, and tubers; 3) legumes and nuts; 4) dairy products; 5) flesh foods; 6) eggs; 7) vitamin A rich fruits and vegetables; and 8) other fruits and vegetables. Acute respiratory illness was defined as caregiver reported rapid breathing, difficulty breathing, lower chest wall in drawing, or coughing in the previous 2 weeks obtained at a 6-month follow-up based on the use of this definition in previous studies in Bangladesh and Kenya. A total of 58% of children had acute respiratory illness, 19% had soap present in the cooking area, and 4% in the defecation area, and 21% of children met MDD. A decreased odds of acute respiratory illness was associated with soap being present in the cooking area (odds ratio [OR]: 0.49, 95% confidence interval [CI]: 0.38-0.88) and MDD (OR: 0.62, 95% CI: 0.38-1.00). These findings highlight the need for interventions targeting hygiene and improved dietary diversity among rural DRC households to reduce the rate of respiratory illnesses in children under 5 years.

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

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.

Field Trial of an Automated Batch Chlorinator System at Two Shared Shallow Tubewells among Camps for Forcibly Displaced Myanmar Nationals (FDMN) in Cox's Bazar, Bangladesh

Chlorination of shallow tubewell water is challenging due to various iron concentrations. A mixed-method, small-scale before-and-after field trial assessed the accuracy and consistency of an automated chlorinator, Zimba, in Rohingya camp housing, Cox’s Bazar. From August–September 2018, two shallow tubewells (iron concentration = 6.5 mg/L and 1.5 mg/L) were selected and 20 households were randomly enrolled to participate in household surveys and water testing. The field-team tested pre-and post-treated tubewell and household stored water for iron, free and total chlorine, and E. coli. A sub-set of households (n = 10) also received safe storage containers (5 L jerry cans). Overall mean iron concentrations were 5.8 mg/L in Zimba water, 1.9 mg/L in household storage containers, and 2.8 mg/L in the project-provided safe storage containers. At baseline, 0% samples at source and 60% samples stored in household vessels were contaminated with E. coli (mean log₁₀ = 0.62 MPN/100 mL). After treatment, all water samples collected from source and project-provided safe storage containers were free from E. coli, but 41% of post-treated water stored in the household was contaminated with E. coli. E. coli concentrations were significantly lower in the project-provided safe storage containers (log₁₀ mean difference = 0.92 MPN, 95% CI = 0.59–1.14) compared with baseline and post-treated water stored in household vessels (difference = 0.57 MPN, 95% CI = 0.32–0.83). Zimba is a potential water treatment technology for groundwater extracted through tubewells with different iron concentrations in humanitarian settings.

Relationships Among Toilet Sharing, Water Source Locations, and Handwashing Places Without Observed Soap: A Cross-Sectional Study of the Richest Households in Bangladesh

BACKGROUND

A high percentage of the richest households in Bangladesh lack soap at their handwashing places, a problem that is typically considered to be one of the poor.

OBJECTIVE

We investigated toilet sharing practices, locations of water sources, and relevant sociodemographic factors associated with the observed handwashing places that lack soap in the richest (ninth wealth decile) households in Bangladesh.

METHODS

We used data from the 2017-18 Bangladesh Demographic and Health Survey (BDHS). Logistic regression technique was used to investigate how toilet sharing practices, water source locations, and different sociodemographic factors were associated with observed handwashing places without soap.

RESULTS

We found that 25.8% of the richest households were observed to have no soap at their handwashing places. Of these households, those that shared their toilets with another household were 4.6 times (95% CI 3.15-6.60) more likely to observe handwashing places without soap as compared with those that did not share their toilets. Further, the richest households were 4.2 times (95% CI 2.38-7.33) more likely to observe handwashing places without soap if they collected water from their own yard or plot, and 7.1 times (95% CI 3.61-13.97) more likely to observe handwashing places without soap if they collected water from elsewhere in comparison to the reference group that collected water from their own dwelling.

CONCLUSION

Sharing toilet with other households and location of main water source are associated with handwashing places without observed soap in the richest households in Bangladesh. These results can inform discussions of water availability and soap-handwashing-related policy and program development.

Efficacy of Removing Bacteria and Organic Dirt from Hands-A Study Based on Bioluminescence Measurements for Evaluation of Hand Hygiene When Cooking

The objective of this study was to evaluate the efficacy of dirt removal (bacteria and organic matter) of several hand-cleaning procedures. The results from the hand hygiene experiment indicated that washing hands with warm water and soap for 20 s is the most effective method investigated when hands are either dirty or greasy. Even if not proper washing, rinsing under running water for 5 s is a cleaning procedure that may significantly reduce the probability of cross-contamination, as it removes 90% of the hands’ dirt. Although less effective than water and soap, the usage of antibacterial wipes was significantly more effective than wet wipes, indicating that they are a better choice when water and soap are not available. The results of this study enable us to inform consumers about the effectiveness of hand-cleaning procedures applied in their homes when cooking. Moreover, it can make consumers understand why, during the COVID-19 pandemic, authorities recommended washing hands as a preventive measure of infection and using an anti-bacterial hand gel or wiping hands with an antimicrobial wipe if water and soap are not available.

A place-based analysis of COVID-19 risk factors in Bangladesh urban slums: a secondary analysis of World Bank microdata

BACKGROUND

There is a lack of research investigating the confluence of risk factors in urban slums that may make them accelerators for respiratory, droplet infections like COVID-19. Our working hypothesis was that, even within slums, an inverse relationship existed between living density and access to shared or private WASH facilities.

METHODS

In an exploratory, secondary analysis of World Bank, cross-sectional microdata from slums in Bangladesh we investigated the relationship between intra-household population density (crowding) and access to private or shared water sources and toilet facilities.

RESULTS

The analysis showed that most households were single-room dwellings (80.4%). Median crowding ranged from 0.55 m² per person up to 67.7 m² per person. The majority of the dwellings (83.3%), shared both toilet facilities and the source of water, and there was a significant positive relationship between crowding and the use of shared facilities.

CONCLUSION

The findings highlight the practical constraints on implementing, in slums, the conventional COVID19 management approaches of social distancing, regular hand washing, and not sharing spaces. It has implications for the management of future respiratory epidemics.

Could Alcohol-Based Hand Sanitizer Be an Option for Hand Hygiene for Households in Rural Bangladesh?

In low- and middle-income countries (LMICs), hand sanitizer may be a convenient alternative to soap and water to increase hand hygiene practices. We explored perceptions, acceptability, and use of hand sanitizer in rural Bangladesh. We enrolled 120 households from three rural villages. Promoters distributed free alcohol-based hand sanitizer, installed handwashing stations (bucket with tap, stand, basin, and bottle for soapy water), and conducted household visits and community meetings. During Phase 1, promoters recommended handwashing with soap or soapy water, or hand sanitizer after defecation, after cleaning a child's anus/feces, and before food preparation. In Phase 2, they recommended separate key times for hand sanitizer: before touching a child ≤ 6 months and after returning home. Three to 4 months after each intervention phase, we conducted a survey, in-depth interviews, and group discussions with child caregivers and male household members. After Phase 1, 82/89 (92%) households reported handwashing with soap after defecation versus 38 (43%) reported hand sanitizer use. Participants thought soap and water removed dirt from their hands, whereas hand sanitizer killed germs. In Phase 2, 76/87 (87%) reported using hand sanitizer after returning home and 71/87 (82%) before touching a child ≤ 6 months. Qualitative study participants reported that Phase 2-recommended times for hand sanitizer use were acceptable, but handwashing with soap was preferred over hand sanitizer when there was uncertainty over choosing between the two. Hand sanitizer use was liked by household members and has potential for use in LMICs, including during the coronavirus pandemic.

Effects of Hand-Washing Facilities with Water and Soap on Diarrhea Incidence among Children under Five Years in Lao People's Democratic Republic: A Cross-Sectional Study

Diarrhea is a leading cause of death among children under five (U5) in Lao People’s Democratic Republic (PDR). This study assessed the association between the presence of household hand-washing facilities with water and soap and diarrhea episodes among children U5 in Lao PDR. Data from the Lao Social Indicator Survey II were used. The outcome variable was diarrhea episodes in the two weeks preceding the survey. The main predictor variable was the presence of household hand-washing facilities with or without water and/or soap. Mixed-effect logistic regression analysis was used to assess the association, controlling for clustering, and other predictor variables. Of the 8640 households surveyed with 11,404 children, 49.1% possessed hand-washing facilities with both water and soap and 34.7% possessed hand-washing facilities with water alone. Children whose households possessed hand-washing facilities with water alone were significantly more likely to have a diarrhea episode compared to children whose households possessed hand-washing facilities with both water and soap (8.1% vs. 5.9%; odds ratio, 1.49; 95% confidence interval, 1.22–1.81). The association remained significant even after adjusting for other predictors. The absence of soap in hand-washing facilities was associated with higher odds of having a diarrhea episode among children U5 in Lao PDR.

Pathogen flows from on-site sanitation systems in low-income urban neighborhoods, Dhaka: A quantitative environmental assessment

BACKGROUND

Despite wide usage of on-site sanitation, there is limited field-based evidence on the removal or release of pathogens from septic tanks and other primary treatment systems, such as anaerobic baffled reactors (ABR). In two low-income areas in Dhaka, we conducted a cross-sectional study to explore pathogen loads discharged from commonly used on-site sanitation-systems and their transport in nearby drains and waterways.

METHODS

We collected samples of drain water, drain sediment, canal water, and floodwater from April-October 2019. Sludge, supernatant, and effluent samples were also collected from septic tanks and ABRs. We investigated the presence and concentration of selected enteric pathogens (Shigella, Vibrio cholerae (V. cholerae), Salmonella Typhi (S. Typhi), Norovirus Genogroup-II (NoV-GII), and Giardia) and presence of Cryptosporidium in these samples using quantitative polymerase chain reaction (qPCR).The equivalent genome copies (EGC) of individual pathogens were estimated in each sample by interpolation of the mean Ct value to the corresponding standard curve and the dilution factor for each sample type. Absolute quantification was expressed as log₁₀ EGC per 100 mL for the water samples and log₁₀ EGC per gram for the sediment samples.

RESULTS

Among all samples tested (N = 151), 89% were contaminated with Shigella, 68% with V. cholerae and NoV-GII, 32% with Giardia, 17% with S. Typhi and 6% with Cryptosporidium. A wide range of concentration of pathogens [range: mean log₁₀ concentration of Giardia = 0.74 EGC/100 mL in drain ultrafiltration samples to mean log₁₀ concentration of NoV-GII and Giardia = 7.11 EGC/100 mL in ABR sludge] was found in all environmental samples. The highest pathogen concentrations were detected in open drains [range: mean log₁₀ concentration = 2.50-4.94 EGC/100 mL], septic tank effluent [range: mean log₁₀ concentration = 3.32-4.65 EGC/100 mL], and ABR effluent [range: mean log₁₀ concentration = 2.72-5.13 EGC/100 mL].

CONCLUSIONS

High concentrations of pathogens (particularly NoV-GII, V.cholerae and Shigella) were frequently detected in environmental samples from two low-income urban neighbourhoods of Dhaka city. The numerous environmental exposure pathways for children and adults make these findings of public health concern. These results should prompt rethinking of how to achieve safe sanitation solutions that protect public health in dense low-income areas. In particular, improved management and maintenance regimes, further treatment of liquid effluent from primary treatment processes, and appropriate application of onsite, decentralised and offsite sanitation systems given the local context.

A 3D-printed, touch-activated, sanitizer dispensing device for reducing healthcare-acquired infections

Aim: We present a touch-activated, sanitizer dispensing (TSD) device, intended to be mounted on high-touch surfaces, that aims to reduce nosocomial infections. It disinfects the person’s hand touching its surface while being self-sterilizing. Materials & methods: The TSD device consists of an array of 3D-printed, passive, miniaturized, mechanical valves that dispense a small amount of liquid sanitizer when touched. Its mechanical performance and disinfecting efficiency were quantified using simulations and experimental tests. Results & conclusion: The TSD device has a disinfecting efficiency comparable to the standard hand sanitizing approach, reducing the microbiological load by approximately 30-times. It can be easily mounted on high-touch surfaces in a healthcare setting and it is expected to greatly reduce the spread of nosocomial infections.

School-based, blacklight handwashing program can improve handwashing quality and knowledge among pre-school aged children

In the United States, lack of proper handwashing is associated with respiratory and gastrointestinal illnesses. Interventions to improve handwashing practices have led to an increase in handwashing knowledge and behavior, and decreases in gastrointestinal illnesses. Most studies have evaluated their interventions in the context of reported handwashing rates by observation, reduction of illnesses, as well as reduced absences, however none of these studies examined handwashing quality or knowledge as outcome measures. The objective of this paper is to present the results from a handwashing program with a special focus on the evaluation methods. A pre-post design was used to evaluate a handwashing program that took place in two pre-schools the northeast of the United States. The program utilized a black light technology to demonstrate to children the importance of good quality. The evaluation consisted of assessing knowledge and quality of handwashing using a linear puzzle and individual handwashing observation, respectively. Students from both schools improved on both knowledge and quality over time (p-values 0.071 and <0.001, respectively). The present study demonstrates that the use of black light technology as an educational tool may help to improve handwashing quality among pre-school aged children, even after only one instructional session.

Inconsistency in Diarrhea Measurements when Assessing Intervention Impact in a Non-Blinded Cluster-Randomized Controlled Trial

To explore the consistency in impact evaluation based on reported diarrhea, we compared diarrhea data collected through two different surveys and with observed diarrhea-associated hospitalization for children aged ≤ 5 years from a non-blinded cluster-randomized trial conducted over 2 years in urban Dhaka. We have previously reported that the interventions did not reduce diarrhea-associated hospitalization for children aged ≤ 5 years in this trial. We randomly allocated 90 geographic clusters comprising > 60,000 low-income households into three groups: cholera vaccine only, vaccine plus behavior change (cholera vaccine and handwashing plus drinking water chlorination promotion), and control. We calculated reported diarrhea prevalence within the last 2 days using data collected from two different survey methods. The "census" data were collected from each household every 6 months for updating household demographic information. The "monthly survey" data were collected every month from a subset of randomly selected study households for monitoring the uptake of behavior change interventions. We used binomial regression with a logarithmic link accounting for clustering to compare diarrhea prevalence across intervention and control groups separately for both census and monthly survey data. No intervention impact was detected in the census (vaccine only versus control: 2.32% versus 2.53%; P = 0.49; vaccine plus behavior change versus control: 2.44% versus 2.53%; P = 0.78) or in the vaccine only versus control in the monthly survey (3.39% versus 3.80%; P = 0.69). However, diarrhea prevalence was lower in the vaccine-plus-behavior-change group than control in the monthly survey (2.08% versus 3.80%; P = 0.02). Although the reasons for different observed treatment effects in the census and monthly survey data in this study are unclear, these findings emphasize the importance of assessing objective outcomes along with reported outcomes from non-blinded trials.

Quantitative assessment of fecal contamination in multiple environmental sample types in urban communities in Dhaka, Bangladesh using SaniPath microbial approach

Rapid urbanization has led to a growing sanitation crisis in urban areas of Bangladesh and potential exposure to fecal contamination in the urban environment due to inadequate sanitation and poor fecal sludge management. Limited data are available on environmental fecal contamination associated with different exposure pathways in urban Dhaka. We conducted a cross-sectional study to explore the magnitude of fecal contamination in the environment in low-income, high-income, and transient/floating neighborhoods in urban Dhaka. Ten samples were collected from each of 10 environmental compartments in 10 different neighborhoods (4 low-income, 4 high-income and 2 transient/floating neighborhoods). These 1,000 samples were analyzed with the IDEXX-Quanti-Tray technique to determine most-probable-number (MPN) of E. coli. Samples of open drains (6.91 log10 MPN/100 mL), surface water (5.28 log10 MPN/100 mL), floodwater (4.60 log10 MPN/100 mL), produce (3.19 log10 MPN/serving), soil (2.29 log10 MPN/gram), and street food (1.79 log10 MPN/gram) had the highest mean log10 E. coli contamination compared to other samples. The contamination concentrations did not differ between low-income and high-income neighborhoods for shared latrine swabs, open drains, municipal water, produce, and street foodsamples. E. coli contamination levels were significantly higher (p <0.05) in low-income neighborhoods compared to high-income for soil (0.91 log10 MPN/gram, 95% CI, 0.39, 1.43), bathing water (0.98 log10 MPN/100 mL, 95% CI, 0.41, 1.54), non-municipal water (0.64 log10 MPN/100 mL, 95% CI, 0.24, 1.04), surface water (1.92 log10 MPN/100 mL, 95% CI, 1.44, 2.40), and floodwater (0.48 log10 MPN/100 mL, 95% CI, 0.03, 0.92) samples. E. coli contamination were significantly higher (p<0.05) in low-income neighborhoods compared to transient/floating neighborhoods for drain water, bathing water, non-municipal water and surface water. Future studies should examine behavior that brings people into contact with the environment and assess the extent of exposure to fecal contamination in the environment through multiple pathways and associated risks.

Formative research for the design of a scalable water, sanitation, and hygiene mobile health program: CHoBI7 mobile health program

Background

The Cholera-Hospital-Based-Intervention-for-7-Days (CHoBI7) is a handwashing with soap and water treatment intervention program delivered by a health promoter bedside in a health facility and through home visits to diarrhea patients and their household members during the 7 days after admission to a health facility. In a randomized controlled trial among cholera patient households in Bangladesh, the 7-day CHoBI7 program resulted in a significant reduction in cholera among household members of cholera patients and sustained improvements in drinking water quality and handwashing with soap practices 12 months post-intervention. In an effort to take this intervention to scale across Bangladesh in partnership with the Bangladesh Ministry of Health and Family Welfare, this study evaluates the feasibility and acceptability of mobile health (mHealth) programs as a low-cost, scalable approach for CHoBI7 program delivery.

Methods

Formative research for the development of the CHoBI7 mHealth intervention included 40 semi-structured interviews, 4 mHealth workshops, 2 group discussions, and a pilot study of 52 households to assess the feasibility and acceptability of the developed mHealth program. Thematic analysis of the interviews and group discussions was conducted by two individuals separately based on emergent themes, and then themes were compared and discussed.

Results

A theory- and evidence-based approach using qualitative research methods was implemented to design the CHoBI7 mHealth program. Semi-structured interviews with government stakeholders identified perceptions and preferences for scaling the CHoBI7 mHealth program. Group discussions and semi-structured interviews with diarrhea patients and their family members identified beneficiary perceptions of mHealth and preferences for CHoBI7 mHealth program delivery. mHealth workshops were conducted as an interactive approach to draft and refine mobile message content based on stakeholder preferences. The pilot findings indicate that the CHoBI7 mHealth program has high user acceptability and is feasible to deliver to diarrhea patients that present at health facilities for treatment in Bangladesh. Both text and voice messages were recommended for program delivery. Dr. Chobi, the sender of mHealth messages, was viewed as a credible source of information that could be shared with others.

Conclusion

This study presents a theory- and evidence-based approach that can be implemented for the development of future water, sanitation, and hygiene mHealth programs in low-resource settings.

Electronic supplementary material

The online version of this article (10.1186/s12889-019-7144-z) contains supplementary material, which is available to authorized users.

Hygiene in Restaurants and among Street Food Vendors in Bangladesh

Poor hand hygiene and food handling put consumers of restaurant and street food at risk of enteric disease, especially in low-income countries. This study aimed to collect hygiene indicators from a nationally representative sample of restaurants and street food vendors. The field team collected data from 50 rural villages and 50 urban administrative units (mahallas). We explored restaurant service staff, cook, and food vendor hygiene practices (N = 300 restaurants and 600 street food vendors), by observing hygiene facilities, food handling, and utensil cleaning. A qualitative assessment explored perceptions of hygiene related to food handling. During restaurant spot checks, 91% (273/300) had soap and water at handwashing location for customers but in only 33% (100) at locations convenient for restaurant staff. Among street food-vending stalls, 11% (68/600) had soap and water when observed. During 90-minute structured observations, cooks used soap to wash hands on 14/514 (3%) of occasions before food preparation, 6/82 (8%) occasions after cutting fish/meat/vegetables, 3/71 (4%) occasions before serving food, and 0/49 (0%) occasions) before hand-mashing food/salad preparation; no street food vendors washed hands with soap during these food-handling events. Most of the qualitative study participants perceived that customers select a vendor based on tastiness of the food, whereas no one mentioned the importance of food hygiene. The study demonstrates widespread poor hygiene and food-handling practices in restaurants and among food vendors. Based on our study findings, we proposed a food premises Hygiene Investigation Model to create action plans to improve food safety.

Effect of an equipment-behavior change intervention on handwashing behavior among primary school children in Kenya: the Povu Poa school pilot study

BACKGROUND

Handwashing prevalence in schools in Kenya is low due to lack of access to water and soap and lack of drive for handwashing. Soapy water made from detergent powder is an inexpensive alternative to bar soap and disgust and social norms change can be powerful drivers of handwashing, but their effectiveness has not been assessed in school setting. In Kenyan public schools, we evaluated an equipment-behavior change intervention's effect on handwashing outcomes. We also monitored functionality of the Povu Poa prototypes to identify design improvements necessary for continued high usage in institutional settings.

METHODS

The intervention included the "Povu Poa", a new type of handwashing station that dispensed foaming soap and rinse water, combined with school-wide behavior change promotion based on disgust and social norms. In this stepped-wedge cluster-randomized trial, we randomly selected 30 schools and divided them into 3 groups of 10. Following baseline data collection, we delivered the intervention sequentially (Group 1: 3-5 weeks after baseline; Group 2: 6-8 weeks; Group 3: 19-24 weeks). We observed outcomes [1] availability of handwashing materials at handwashing places, and; 2) observed handwashing behavior after toilet use among schoolchildren) at baseline and in three follow-up rounds. We compared the outcomes between schools that had received the intervention and schools that had not yet received the intervention.

RESULTS

Water and soap/soapy water were available at 2% of school visits before intervention, and at 42% of school visits after intervention.. Before intervention, we observed handwashing with water after 11% of 461 toilet use events; no one was observed to wash hands with soap/soapy water. After intervention, we observed handwashing after 62% of 383 toilet use events (PR = 5.96, 95% CI = 3.02, 11.76) and handwashing with soap/soapy water after 26% of events (PR incalculable). Foaming soap dispenser caps were cracked in 31% of all observations, but were typically still functional.

CONCLUSIONS

Our combined equipment-behavior intervention increased availability of handwashing materials and improved the compliance with handwashing after using the toilet, but handwashing with soap was still rare. Equipment durability must be improved for deployment in schools at scale. American Economic Association's Registry for Randomized Controlled Trials; Trial Registry Number (TRN): AEARCTR-0000662; Date of Registry: April 14, 2015.

Microbial Quality and Safety of Sushi Prepared with Gloved or Bare Hands: Food Handlers' Impact on Retail Food Hygiene and Safety

Food handlers play an important role in retail food hygiene and safety. This study was conducted to better understand the impact of food handlers on the microbiological quality and safety of sushi and ingredients handled by gloved and bare hands. At retail premises, food handlers were asked to prepare a batch of sushi with raw fish followed by a batch of sushi with cooked ingredients. Food (sushi and ready-to-eat ingredients), hand, and glove samples were collected for analysis of overall microorganisms (standard plate counts) and targeted foodborne bacteria: Staphylococcus aureus, Bacillus cereus, Escherichia coli, Salmonella, and Listeria monocytogenes. Results suggested that cross-contamination was more prevalent at premises where bare hands were used to prepare sushi. When bare hands were used, significantly higher standard plate counts were obtained from samples of cooked rice (2.3 to 4.9 log CFU/g) and sushi (2.8 to 6.9 log CFU/g) and the prevalence of S. aureus in samples was higher on food (21.7%, 28 of 129 samples) and hands (30%, 18 of 60 samples) ( P < 0.05). Glove changing in combination with hand washing minimized cross-contamination during sushi preparation as indicated by the lower prevalence of S. aureus (0%, 0 of 28 samples) and total targeted foodborne bacteria (3.6%, 1 of 28 samples) on the gloves of food handlers who changed gloves and washed their hands compared with those handlers who did not don new gloves. Repeated use of dishcloths could be a cause of cross-contamination, and the prevalence of total targeted foodborne bacteria was significantly higher on hands dried with dishcloths (64.7%, 11 of 17 samples) than on hands dried with paper towels (12.5%, 1 of 8 samples) ( P < 0.05). The prevalences of B. cereus, L. monocytogenes, and Salmonella in the 356 food samples were 5.1% (18 samples), 0.8% (3 samples), and 0%, respectively. Improvements to hand washing, hand drying, and glove changing practices are needed to lower the occurrence of cross-contamination during sushi preparation.

Impact of a Large-Scale Handwashing Intervention on Reported Respiratory Illness: Findings from a Cluster-Randomized Controlled Trial

We assessed the impact of handwashing promotion on reported respiratory illness as a secondary outcome from among > 60,000 low-income households enrolled in a cluster-randomized trial conducted in Bangladesh. Ninety geographic clusters were randomly allocated into three groups: cholera-vaccine-only; vaccine-plus-behavior-change (handwashing promotion and drinking water chlorination); and control. Data on respiratory illness (fever plus either cough or nasal congestion or breathing difficulty within previous 2 days) and intervention uptake (presence of soap and water at handwashing station) were collected through monthly surveys conducted among a different subset of randomly selected households during the intervention period. We determined respiratory illness prevalence across groups and used log-binomial regression to examine the association between respiratory illness and presence of soap and water in the handwashing station. Results were adjusted for age, gender, wealth, and cluster-randomized design. The vaccine-plus-behavior-change group had more handwashing stations with soap and water present than controls (45% versus 25%; P < 0.001). Reported respiratory illness prevalence was similar across groups (vaccine-plus-behavior-change versus control: 2.8% versus 2.9%; 95% confidence interval [CI]: -0.008, 0.006; P = 0.6; cholera-vaccine-only versus control: 3.0% versus 2.9%; 95% CI: -0.006, 0.009; P = 0.4). Irrespective of intervention assignment, respiratory illness was lower among people who had soap and water present in the handwashing station than among those who did not (risk ratioadjusted: 0.82; 95% CI: 0.69-0.98). With modest uptake of the handwashing intervention, we found no impact of this large-scale intervention on respiratory illness. However, those who actually had a handwashing station with soap and water had less illness. This suggests improving the effectiveness of handwashing promotion in achieving sustained behavior change could result in health benefits.

Complementary feeding practices among rural Bangladeshi mothers: Results from WASH Benefits study

Inappropriate complementary feeding contributes to linear growth faltering in early childhood. Behaviour change interventions have been effective at improving practice, but few studies have investigated the effects of multicomponent integrated interventions. We conducted a cluster‐randomized controlled trial in rural Bangladesh in which geographic clusters were randomized into seven arms: water treatment (W), sanitation (S), handwashing (H), water, sanitation, and handwashing (WSH), improved nutrition with infant and young child feeding messages and lipid‐based nutrient supplementation for 6‐ to 24‐month olds (N), N+WSH, and control. The objective of this paper was to examine the independent and combined effects of interventions on indicators of complementary feeding. Approximately 1 and 2 years after initiation of the intervention, research assistants surveyed mothers about infant feeding practices. Complementary feeding was examined using the World Health Organization indicators of infant and young child feeding practices. We used Poisson regression models to estimate prevalence ratios and linear regression models for prevalence differences with clustered sandwich estimators to adjust for clustering. A total of 4,718 households from 720 clusters were surveyed at year 1 and 4,667 at year 2. The children in the nutrition arms had a higher prevalence of meeting the minimum dietary diversity score compared with controls (year 1: N: 66.4%; N+WSH: 65.0% vs. C:32.4%; year 2: N: 91.5%; N+WSH: 91.6% vs. C:77.7%). Children in the nutrition arms received diverse food earlier than the children in control arm. In addition, the average consumption of lipid‐based nutrient supplementation was >90% in each follow‐up. Nutrition‐specific interventions could be integrated with nutrition‐sensitive interventions such as WSH without compromising the uptake of the nutrition intervention.

Impact of adding hand-washing and water disinfection promotion to oral cholera vaccination on diarrhoea-associated hospitalization in Dhaka, Bangladesh: evidence from a cluster randomized control trial

Background

Information on the impact of hygiene interventions on severe outcomes is limited. As a pre-specified secondary outcome of a cluster-randomized controlled trial among >400 000 low-income residents in Dhaka, Bangladesh, we examined the impact of cholera vaccination plus a behaviour change intervention on diarrhoea-associated hospitalization.

Methods

Ninety neighbourhood clusters were randomly allocated into three areas: cholera-vaccine-only; vaccine-plus-behaviour-change (promotion of hand-washing with soap plus drinking water chlorination); and control. Study follow-up continued for 2 years after intervention began. We calculated cluster-adjusted diarrhoea-associated hospitalization rates using data we collected from nearby hospitals, and 6-monthly census data of all trial households.

Results

A total of 429 995 people contributed 500 700 person-years of data (average follow-up 1.13 years). Vaccine coverage was 58% at the start of analysis but continued to drop due to population migration. In the vaccine-plus-behaviour-change area, water plus soap was present at 45% of hand-washing stations; 4% of households had detectable chlorine in stored drinking water. Hospitalization rates were similar across the study areas [events/1000 person-years, 95% confidence interval (CI), cholera-vaccine-only: 9.4 (95% CI: 8.3–10.6); vaccine-plus-behaviour-change: 9.6 (95% CI: 8.3–11.1); control: 9.7 (95% CI: 8.3–11.6)]. Cholera cases accounted for 7% of total number of diarrhoea-associated hospitalizations.

Conclusions

Neither cholera vaccination alone nor cholera vaccination combined with behaviour-change intervention efforts measurably reduced diarrhoea-associated hospitalization in this highly mobile population, during a time when cholera accounted for a small fraction of diarrhoea episodes. Affordable community-level interventions that prevent infection from multiple pathogens by reliably separating faeces from the environment, food and water, with minimal behavioural demands on impoverished communities, remain an important area for research.

Acceptability and Feasibility of Sharing a Soapy Water System for Handwashing in a Low-Income Urban Community in Dhaka, Bangladesh: A Qualitative Study

Handwashing with soap at key times is an effective means of reducing pathogen transmission. In a low-income community in urban Dhaka, we piloted and evaluated the acceptability and feasibility of a shared handwashing intervention. This included promotion by community health promoters of a homemade solution of detergent powder mixed with water and stored in a 1.5-L reclaimed mineral water bottle. Community health promoters encouraged sharing of the recurrent detergent cost among compound members. Of 152 participating compounds, fieldworkers randomly selected 60 for qualitative assessment. Fieldworkers conducted 30 in-depth interviews and five focus group discussions among purposively selected compound members. The reclaimed bottles served as an easily accessible dispenser for the soapy water, which could feasibly be retained next to the toilet and kitchen areas for communal use. Bottles functioned as a positive reminder for handwashing at recommended key times. Most compounds (45/60, 75%) shared a common soapy water system and its associated costs. There was reluctance to prepare soapy water for shared use in the remaining 25%. Soapy water was an acceptable hand cleaning agent, with the bottle as a feasible dispenser. It was simple in design, cost-effective, replicable, popular with intervention recipient, and neighboring nonrecipients, and commonly shared among nonrelated households. The need to share expenses and product preparation served as a barrier. Developing a sustainable maintenance system, therefore, is critical to ensuring the public health benefits of handwashing with soap.

Children living in the slums of Bangladesh face risks from unsafe food and water and stunted growth is common

AIM

This study investigated the microbial quality of food and water consumed by children in four slums in Dhaka, the capital of Bangladesh, together with the associated risk factors.

METHODS

This cross-sectional study took place from December 2015 to May 2016 and focused on 360 children under the age of five. We recorded household food security, namely adequate food for a healthy life, socio-economic and nutritional status, hygiene and feeding practices. Food and water samples were analysed.

RESULTS

We found that 63% of the children were malnourished and 58% were stunted. Yeast and moulds were detected in 86% of the food samples and coliforms in 73%. All the water samples were contaminated with faecal coliforms, yeasts and moulds and Staphylococcus. Food insecurity affected 83% of households. Children were twice as likely to be malnourished if they were born with a perceived low birthweight or their mothers did not wash their hands with soap after cleaning the child's bottom following defecation. Exclusively breastfed children were less likely to develop malnutrition.

CONCLUSION

Children from the Dhaka slums were frequently stunted and malnourished and contaminated food and water was common. Integrated efforts are essential to create public awareness about hygiene.

Asymmetric transfer efficiencies between fomites and fingers: Impact on model parameterization

BACKGROUND

Healthcare-associated infections (HAIs) affect millions of patients every year. Pathogen transmission via fomites and healthcare workers (HCWs) contribute to the persistence of HAIs in hospitals. A critical parameter needed to assess risk of environmental transmission is the pathogen transfer efficiency between fomites and fingers. Recent studies have shown that pathogen transfer is not symmetric. In this study,we evaluated how the commonly used assumption of symmetry in transfer efficiency changes the dynamics of pathogen movement between patients and rooms and the exposures to uncolonized patients.

METHODS

We developed and analyzed a deterministic compartmental model of Acinetobacter baumannii describing the contact-mediated process among HCWs, patients, and the environment. We compared a system using measured asymmetrical transfer efficiency to 2 symmetrical transfer efficiency systems.

RESULTS

Symmetric models consistently overestimated contamination levels on fomites and underestimated contamination on patients and HCWs compared to the asymmetrical model. The magnitudes of these miscalculations can exceed 100%. Regardless of the model, relative percent reductions in contamination declined after hand hygiene compliance reached approximately 60% in the large fomite scenario and 70% in the small fomite scenario.

CONCLUSIONS

This study demonstrates how healthcare facility-specific data can be used for decision-making processes. We show that the incorrect use of transfer efficiency data leads to biased effectiveness estimates for intervention strategies. More accurate exposure models are needed for more informed infection prevention strategies.

Antiseptic Agents Elicit Short-Term, Personalized, and Body Site-Specific Shifts in Resident Skin Bacterial Communities

Despite critical functions in cutaneous health and disease, it is unclear how resident skin microbial communities are altered by topical antimicrobial interventions commonly used in personal and clinical settings. Here we show that acute exposure to antiseptic treatments elicits rapid but short-term depletion of microbial community diversity and membership. Thirteen subjects were enrolled in a longitudinal treatment study to analyze the effects of topical treatments (i.e., ethanol, povidone-iodine, chlorhexidine, and water) on the skin microbiome at two skin sites of disparate microenvironment: forearm and back. Treatment effects were highly dependent on personalized and body site-specific colonization signatures, which concealed community dynamics at the population level when not accounted for in this analysis. The magnitude of disruption was influenced by the identity and abundance of particular bacterial inhabitants. Lowly abundant members of the skin microbiota were more likely to be displaced, and subsequently replaced, by the most abundant taxa prior to treatment. Members of the skin commensal family Propionibactericeae were particularly resilient to treatment, suggesting a distinct competitive advantage in the face of disturbance. These results provide insight into the stability and resilience of the skin microbiome, while establishing the impact of topical antiseptic treatment on skin bacterial dynamics and community ecology.

Handwashing in 51 Countries: Analysis of Proxy Measures of Handwashing Behavior in Multiple Indicator Cluster Surveys and Demographic and Health Surveys, 2010-2013

In 2009, a common set of questions addressing handwashing behavior was introduced into nationally representative Demographic and Health Surveys (DHS) and Multiple Indicator Cluster Surveys (MICS), providing large amounts of comparable data from numerous countries worldwide. The objective of this analysis is to describe global handwashing patterns using two proxy indicators for handwashing behavior from 51 DHS and MICS surveys conducted in 2010-2013: availability of soap anywhere in the dwelling and access to a handwashing place with soap and water. Data were also examined across geographic regions, wealth quintiles, and rural versus urban settings. We found large disparities for both indicators across regions, and even among countries within the same World Health Organization region. Within countries, households in lower wealth quintiles and in rural areas were less likely to have soap anywhere in the dwelling and at designated handwashing locations than households in higher wealth quintiles and urban areas. In addition, disparities existed among various geographic regions within countries. This analysis demonstrates the need to promote access to handwashing materials and placement at handwashing locations in the dwelling, particularly in poorer, rural areas where children are more vulnerable to handwashing-preventable syndromes such as pneumonia and diarrhea.

Provision versus promotion to develop a handwashing station: the effect on desired handwashing behavior

Background

Diarrhea prevalence increases from around the time that complementary foods are introduced. Improving caregiver’s hand hygiene during food preparation could reduce complementary food contamination and enteric pathogen transmission. Washing hands with soap is more common when water and soap are together at a convenient location. We conducted a three-month pilot intervention to evaluate two options for setting up handwashing stations: i) provide a handwashing station, or ii) help the family to make their own from available materials. Additionally, we assessed the feasibility of this intervention to be integrated with a child feeding program.

Methods

We conducted the intervention among two groups; 40 households received a free of cost handwashing station and another 40 households were motivated to place their own soap/soapy-water and water vessel near the food preparation and child feeding area. Community health workers encouraged caregivers to wash hands with soap/soapy-water before food preparation and feeding a child. They either assisted study participants to install the study-provided handwashing station at the recommended place or encouraged caregivers to develop their own. Field researchers assessed placement and composition of handwashing stations and the feasibility of integrating handwashing and nutrition messages.

Results

By end of the trial, 39/40 households developed their own handwashing station, comprising a bucket, mug and bar soap/soapy-water of which 60% (6/10) households were observed with a functional and complete handwashing station set. Observed handwashing with soap was detected among 8/10 households from the study-provided handwashing station group and 5/10 among households who had made their own handwashing station. Sixty-seven of the 76 caregivers recalled integrated intervention messages on social and health benefits of infant and young child feeding correctly; and all recalled key handwashing with soap times, before food preparation and feeding a child.

Conclusion

Encouraging households to develop their own handwashing station with soap and water to place at a food preparation/child feeding location is feasible over the short term. In the absence of large-scale provision of handwashing stations, caregivers can be encouraged to create and use their own. Integrating handwashing with soap into a nutrition intervention was feasible and acceptable and should be considered by policy makers.

Handwashing, but how? Microbial effectiveness of existing handwashing practices in high-density suburbs of Harare, Zimbabwe

BACKGROUND

Consistent domestic hand hygiene can reduce diarrhea-related morbidity and mortality and the spread of other communicable diseases. However, it remains uncertain which technique of handwashing is most effective and practicable during everyday life. The goal of this study is to determine how the handwashing technique, as performed in the daily life by the participants of this case study in Harare, Zimbabwe, influences microbial handwashing effectiveness.

METHODS

Handwashing technique of 173 primary caregivers was observed in their homes and hand rinse samples were collected before and after handwashing. Samples were analyzed for Escherichia coli and total coliform concentrations. Generalized linear models were used to predict fecal hand contamination after washing from observed handwashing technique.

RESULTS

Cleaning under fingernails, scrubbing the fingertips, using soap, and drying hands through rubbing on clothes or a clean towel statistically significantly reduced E coli contamination of hands after washing. Tap use, scrubbing fingertips, and rubbing hands on clothes to dry them statistically significantly reduced total coliform contamination.

CONCLUSIONS

Recommendations for effective and practicable domestic handwashing in Harare, Zimbabwe, should include performing specific handscrubbing steps (ie, cleaning under the fingernails and rubbing the fingertips), and soap and tap use. This calls for further research to develop behavior change interventions that explicitly promote effective handwashing technique at critical times.

Nonrandomized Trial of Feasibility and Acceptability of Strategies for Promotion of Soapy Water as a Handwashing Agent in Rural Bangladesh

We conducted a nonrandomized trial of strategies to promote soapy water for handwashing in rural Bangladesh and measured uptake. We enrolled households with children < 3 years for three progressively intensive study arms: promotion of soapy water (N = 120), soapy water promotion plus handwashing stations (N = 103), and soapy water promotion, stations plus detergent refills (N = 90); we also enrolled control households (N = 72). Our handwashing stations included tap-fitted buckets and soapy water bottles. Community promoters visited households and held community meetings to demonstrate soapy water preparation and promote handwashing at key times. Field workers measured uptake 4 months later. In-depth interviews and focus group discussions assessed factors associated with uptake. More households had soapy water at the handwashing place in progressively intensive arms: 18% (promotion), 60% (promotion plus station), and 71% (promotion, station with refills). Compared with the promotion-only arm, more households that received stations had soapy water at the primary handwashing station (44%, P ≤ 0.001; 71%, P < 0.001 with station plus detergent refill). Qualitative findings highlighted several dimensions that affected use: contextual (shared courtyard), psychosocial (perceived value), and technology dimensions (ease of use, convenience). Soapy water may increase habitual handwashing by addressing barriers of cost and availability of handwashing agents near water sources. Further research should inform optimal strategies to scale-up soapy water as a handwashing agent to study health impact.

Contextual and Psychosocial Determinants of Effective Handwashing Technique: Recommendations for Interventions from a Case Study in Harare, Zimbabwe

Handwashing has been shown to considerably reduce diarrhea morbidity and mortality. To decontaminate hands effectively, the use of running water, soap, and various scrubbing steps are recommended. This study aims to identify the behavioral determinants of effective handwashing. Everyday handwashing technique of 434 primary caregivers in high-density suburbs of Harare, Zimbabwe, was observed and measured as an 8-point sum score of effective handwashing technique. Multiple linear and logistic regression analyses were performed to predict observed handwashing technique from potential contextual and psychosocial determinants. Knowledge of how to wash hands effectively, availability of a handwashing station with functioning water tap, self-reported frequency of handwashing, perceived vulnerability, and action planning were the main determinants of effective handwashing technique. The models were able to explain 39% and 36% of the variance in overall handwashing technique and thoroughness of handscrubbing. Memory aids and guided practice are proposed to consolidate action knowledge, and personalized risk messages should increase the perceived vulnerability of contracting diarrhea. Planning where, when, and how to maintain a designated place for handwashing with sufficient soap and water is proposed to increase action planning. Since frequent self-reported handwashing was associated with performing more effective handwashing technique, behavior change interventions should target both handwashing frequency and technique concurrently.

Healthcare worker and family caregiver hand hygiene in Bangladeshi healthcare facilities: results from the Bangladesh National Hygiene Baseline Survey

BACKGROUND

Healthcare facility hand hygiene impacts patient care, healthcare worker safety, and infection control, but low-income countries have few data to guide interventions.

AIM

To conduct a nationally representative survey of hand hygiene infrastructure and behaviour in Bangladeshi healthcare facilities to establish baseline data to aid policy.

METHODS

The 2013 Bangladesh National Hygiene Baseline Survey examined water, sanitation, and hand hygiene across households, schools, restaurants and food vendors, traditional birth attendants, and healthcare facilities. We used probability proportional to size sampling to select 100 rural and urban population clusters, and then surveyed hand hygiene infrastructure in 875 inpatient healthcare facilities, observing behaviour in 100 facilities.

FINDINGS

More than 96% of facilities had 'improved' water sources, but environmental contamination occurred frequently around water sources. Soap was available at 78-92% of handwashing locations for doctors and nurses, but just 4-30% for patients and family. Only 2% of 4676 hand hygiene opportunities resulted in recommended actions: using alcohol sanitizer or washing both hands with soap, then drying by air or clean cloth. Healthcare workers performed recommended hand hygiene in 9% of 919 opportunities: more after patient contact (26%) than before (11%). Family caregivers frequently washed hands with only water (48% of 2751 opportunities), but with little soap (3%).

CONCLUSION

Healthcare workers had more access to hand hygiene materials and performed better hand hygiene than family, but still had low adherence. Increasing hand hygiene materials and behaviour could improve infection control in Bangladeshi healthcare facilities.

Handwashing With a Water-Efficient Tap and Low-Cost Foaming Soap: The Povu Poa "Cool Foam" System in Kenya

The new handwashing system, designed with end user input, features an economical foaming soap dispenser and a hygienic, water-efficient tap for use in household and institutional settings that lack reliable access to piped water. Cost of the soap and water needed for use is less than US$0.10 per 100 handwash uses, compared with US$0.20–$0.44 for conventional handwashing stations used in Kenya.

Hygiene Practices During Food Preparation in Rural Bangladesh: Opportunities to Improve the Impact of Handwashing Interventions

This study explored the steps of food preparation, related handwashing opportunities, current practices, and community perceptions regarding foods at high-risk of contamination such as mashed foods and salads. In three rural Bangladeshi villages, we collected qualitative and observational data. Food preparation was a complex and multistep process. Food preparation was interrupted by tasks that could contaminate the preparers' hands, after which they continued food preparation without washing hands. Community members typically ate hand-mixed, uncooked mashed food and salad as accompaniments to curry and rice at meals. Hand-mixed dried foods were mostly consumed as a snack. Observers recorded handwashing during preparation of these foods. Among 24 observed caregivers, of 85 opportunities to wash hands with soap during food preparation, washing hands with soap occurred twice, both times after cutting fish, whereas washing hands with water alone was common. A simple and feasible approach is promotion of handwashing with soap upon entering and re-entering the food preparation area, and ensuring that everything needed for handwashing should be within easy reach.

Mineral- and vitamin-enhanced micronutrient powder reduces stunting in full-term low-birth-weight infants receiving nutrition, health, and hygiene education: a 2 × 2 factorial, cluster-randomized trial in Bangladesh

BACKGROUND

The causes of stunting are complex but likely include prenatal effects, inadequate postnatal nutrient intake, and recurrent infections. Low-birth-weight (LBW) infants are at high risk of stunting. More than 25% of live births in low- and middle-income countries are at full term with low birth weight (FT-LBW). Evidence on the efficacy of specific interventions to enhance growth in this vulnerable group remains scant.

OBJECTIVE

We investigated the independent and combined effects of a directed use of a water-based hand sanitizer (HS) and a mineral- and vitamin-enhanced micronutrient powder (MNP) (22 minerals and vitamins) to prevent infections and improve nutrient intake to reduce stunting in FT-LBW infants.

DESIGN

The study was a prospective 2 × 2 factorial, cluster-randomized trial in 467 FT-LBW infants during 2 periods: from 0 to 5 mo postpartum (0-180 d postpartum) and from 6 to 12 mo postpartum (181-360 d postpartum) with the use of 48 clusters. All groups received the same general nutrition, health, and hygiene education (NHHE) at enrollment and throughout the 12 mo. Group assignments initially included the following 2 groups: no HS (control) group or HS from 0 to 5 mo postpartum. These assignments were followed by further divisions into the following 4 groups from 6 to 12 mo postpartum: 1) no HS and no MNP (control), 2) HS only, 3) MNP only, and 4) HS and MNP.

RESULTS

When delivered in combination with NHHE, the use of an HS showed no additional benefit in reducing indicators of infection in the first or second half of infancy or the likelihood of stunting at 12 mo postpartum. FT-LBW infants who received the MNP (with or without the HS) were significantly less likely to be stunted at 12 mo than were controls (OR: 0.35; 95% CI: 0.15, 0.84; P = 0.017).

CONCLUSIONS

The use of a mineral- and vitamin-enhanced MNP significantly reduced stunting in FT-LBW infants in this high-risk setting. The use of a water-based HS did not have an additive effect. This trial was registered at clinicaltrials.gov as NCT01455636.

Soap is not enough: handwashing practices and knowledge in refugee camps, Maban County, South Sudan

BACKGROUND

Refugees are at high risk for communicable diseases due to overcrowding and poor water, sanitation, and hygiene conditions. Handwashing with soap removes pathogens from hands and reduces disease risk. A hepatitis E outbreak in the refugee camps of Maban County, South Sudan in 2012 prompted increased hygiene promotion and improved provision of soap, handwashing stations, and latrines. We conducted a study 1 year after the outbreak to assess the knowledge, attitudes, and practices of the refugees in Maban County.

METHODS

We conducted a cross sectional survey of female heads of households in three refugee camps in Maban County. We performed structured observations on a subset of households to directly observe their handwashing practices at times of possible pathogen transmission.

RESULTS

Of the 600 households interviewed, nearly all had soap available and 91 % reported water was available "always" or "sometimes". Exposure to handwashing promotion was reported by 85 % of the respondents. Rinsing hands with water alone was more commonly observed than handwashing with soap at critical handwashing times including "before eating" (80 % rinsing vs. 7 % washing with soap) and "before preparing/cooking food" (72.3 % vs 23 %). After toilet use, 46 % were observed to wash hands with soap and an additional 38 % rinsed with water alone.

CONCLUSIONS

Despite intensive messaging regarding handwashing with soap and access to soap and water, rinsing hands with water alone rather than washing hands with soap remains more common among the refugees in Maban County. This practice puts them at continued risk for communicable disease transmission. Qualitative research into local beliefs and more effective messaging may help future programs tailor handwashing interventions.

Observed practices and perceived advantages of different hand cleansing agents in rural Bangladesh: ash, soil, and soap

Bangladeshi communities have historically used ash and soil as handwashing agents. A structured observation study and qualitative interviews on the use of ash/soil and soap as handwashing agents were conducted in rural Bangladesh to help develop a handwashing promotion intervention. The observations were conducted among 1,000 randomly selected households from 36 districts. Fieldworkers observed people using ash/soil to wash their hand(s) on 13% of occasions after defecation and on 10% after cleaning a child's anus. This compares with 19% of people who used soap after defecation and 27% after cleaning a child who defecated. Using ash/soil or soap was rarely (< 1%) observed at other times recommended for handwashing. The qualitative study enrolled 24 households from three observation villages, where high usage of ash/soil for handwashing was detected. Most informants reported that ash/soil was used only for handwashing after fecal contact, and that ash/soil could clean hands as effectively as soap.