Enterococcus contamination of infant foods and implications for exposure to foodborne pathogens in peri-urban neighbourhoods of Kisumu, Kenya

We collected infant food samples from 714 households in Kisumu, Kenya, and estimated the prevalence and concentration of Enterococcus, an indicator of food hygiene conditions. In a subset of 212 households, we quantified the change in concentration in stored food between a morning and afternoon feeding time. In addition, household socioeconomic characteristics and hygiene practices of the caregivers were documented. The prevalence of Enterococcus in infant foods was 50% (95% confidence interval: 46.1 - 53.4), and the mean log10 colony-forming units (CFUs) was 1.1 (SD + 1.4). No risk factors were significantly associated with the prevalence and concentration of Enterococcus in infant foods. The mean log10 CFU of Enterococcus concentration was 0.47 in the morning and 0.73 in the afternoon foods with a 0.64 log10 mean increase in matched samples during storage. Although no factors were statistically associated with the prevalence and the concentration of Enterococcus in infant foods, household flooring type was significantly associated with an increase in concentration during storage, with finished floors leading to 1.5 times higher odds of concentration increase compared to unfinished floors. Our study revealed high prevalence but low concentration of Enterococcus in infant food in low-income Kisumu households, although concentrations increased during storage implying potential increases in risk of exposure to foodborne pathogens over a day. Further studies aiming at investigating contamination of infant foods with pathogenic organisms and identifying effective mitigation measures are required to ensure infant food safety.

Protocol for the PATHOME study: a cohort study on urban societal development and the ecology of enteric disease transmission among infants, domestic animals and the environment

INTRODUCTION

Global morbidity from enteric infections and diarrhoea remains high in children in low-income and middle-income countries, despite significant investment over recent decades in health systems and water and sanitation infrastructure. Other types of societal development may be required to reduce disease burden. Ecological research on the influence of household and neighbourhood societal development on pathogen transmission dynamics between humans, animals and the environment could identify more effective strategies for preventing enteric infections.

METHODS AND ANALYSIS

The 'enteric pathome'-that is, the communities of viral, bacterial and parasitic pathogens transmitted from human and animal faeces through the environment is taxonomically complex in high burden settings. This integrated cohort-exposure assessment study leverages natural socioeconomic spectrums of development to study how pathome complexity is influenced by household and neighbourhood infrastructure and hygiene conditions. We are enrolling under 12-month-old children in low-income and middle-income neighbourhoods of two Kenyan cities (Nairobi and Kisumu) into a 'short-cohort' study involving repeat testing of child faeces for enteric pathogens. A mid-study exposure assessment documenting infrastructural, behavioural, spatial, climate, environmental and zoonotic factors characterises pathogen exposure pathways in household and neighbourhood settings. These data will be used to inform and validate statistical and agent-based models (ABM) that identify individual or combined intervention strategies for reducing multipathogen transmission between humans, animals and environment in urban Kenya.

ETHICS AND DISSEMINATION

The protocols for human subjects' research were approved by Institutional Review Boards at the University of Iowa (ID-202004606) and AMREF Health Africa (ID-ESRC P887/2020), and a national permit was obtained from the Kenya National Commission for Science Technology and Innovation (ID# P/21/8441). The study was registered on Clinicaltrials.gov (Identifier: NCT05322655) and is in pre-results stage. Protocols for research on animals were approved by the University of Iowa Animal Care and Use Committee (ID 0042302).

Development of Shortened Enrichment Methods for Detection of Salmonella Typhimurium Spiked in Milk

Rapid and accurate testing of pathogenic Salmonella enterica in dairy products could reduce the risk of exposure to the bacterial pathogens for consumers. This study aimed to reduce the assessment time needed for enteric bacteria recovery and quantification in food using the natural growth properties of Salmonella enterica Typhimurium (S. Typhimurium) in cow's milk and efficiently using rapid PCR methods. Over 5 h of 37 °C enrichment, culture and PCR methods measured increases in the non-heat-treated S. Typhimurium concentration at similar rates, with an average increase of 2.7 log10 CFU/mL between the start of enrichment and 5 h. In contrast, no bacteria were recovered by culture after S. Typhimurium in milk received heat treatment, and the number of gene copies of heat-treated Salmonella detected by PCR did not increase with the enrichment time. Thus, comparing culture and PCR data over just 5 h of enrichment time can detect and differentiate between replicating bacteria and dead bacteria.

A Mixed Methods Process Evaluation of a Food Hygiene Intervention in Low-Income Informal Neighbourhoods of Kisumu, Kenya

OBJECTIVES

Diarrhoea is a leading cause of infant mortality with the main transmission pathways being unsafe water and contaminated food, surfaces and hands. The 'Safe Start' trial evaluated a food hygiene intervention implemented in a peri-urban settlement of Kisumu, Kenya, with the aim of reducing diarrhoeagenic enteric infections among infants. Four food hygiene behaviours were targeted: handwashing with soap before preparation and feeding, boiling infant food before feeding, storing infant food in sealed containers, and exclusive use of designated utensils during feeding.

METHODS

A process evaluation of the intervention was guided by a theory of change describing the hypothesised implementation and receipt of the intervention, mechanisms of change, and the context. These were assessed by qualitative and quantitative data that included debriefing sessions with the delivery teams and Community Health Volunteers (CHVs), and structured observations during food preparation.

RESULTS

The intervention achieved high coverage and fidelity with over 90% of 814 eligible caregivers participating in the intervention. Caregivers in the intervention arm demonstrated an understanding of the intervention messages, and had 1.38 (95% CI: 1.02-1.87) times the odds of washing hands before food preparation and 3.5 (95% CI: 1.91-6.56) times the odds of using a feeding utensil compared to caregivers in the control group. Contextual factors, especially the movement of caregivers within and outside the study area and time constraints faced by caregivers influenced uptake of some intervention behaviours.

CONCLUSION

Future interventions should seek to explicitly target contextual factors such as secondary caregivers and promote food hygiene interventions as independent of each other.

Environmental and behavioural exposure pathways associated with diarrhoea and enteric pathogen detection in 5-month-old, periurban Kenyan infants: a cross-sectional study

OBJECTIVES

The aim of this study was to test whether household environmental hygiene and behavioural conditions moderated associations between diarrhoea and enteric pathogen detection in infants 5 months of age in Kenya and pathogen sources, including latrine access, domestic animal co-habitation and public food sources.

DESIGN

Cross-sectional study utilising enrolment survey data of households participating in the Safe Start cluster-randomised controlled trial .

SETTING

Kisumu, Kenya.

PARTICIPANTS

A total of 898 caregivers with 5-month (22 week ± 1 week) aged infants were enrolled in the study and completed the enrolment survey.

PRIMARY AND SECONDARY OUTCOME MEASURES

Outcomes were (1) caregiver-reported 7-day diarrhoea prevalence and (2) count of types of enteric viruses, bacteria and parasites in infant stool. Exposures and effect modifiers included water access and treatment, cohabitation with domestic animals, sanitation access, handwashing practices, supplemental feeding, access to refrigeration and flooring.

RESULTS

Reported handwashing after handling animals (adjusted odds ratio (aOR)=0.20; 95% CI=0.06 to 0.50) and before eating (aOR=0.44; 95% CI=0.26 to 0.73) were strongly associated with lower risk of caregiver-reported diarrhoea, while cohabitation with animals (aOR=1.54; 95% CI=1.01 to 2.34) living in a household with vinyl-covered dirt floors (aOR=0.60; 95% CI=0.45 to 0.87) were strongly associated with pathogen codetection in infants. Caregiver handwashing after child (p=0.02) or self-defecation (p=0.03) moderated the relationship between shared sanitation access and infant exposure to pathogens, specifically private latrine access was protective against pathogen exposure of infants in households, where caregivers washed hands after defecation. In the absence of handwashing, access to private sanitation posed no benefits over shared latrines for protecting infants from exposure.

CONCLUSION

Our evidence highlights eliminating animal cohabitation and improving flooring, postdefecation and food-related handwashing, and safety and use of cow milk sources as interventions to prevent enteric pathogen exposure of young infants in Kenya.

TRIAL REGISTRATION NUMBER

NCT03468114.

Milk Product Safety and Household Food Hygiene Influence Bacterial Contamination of Infant Food in Peri-Urban Kenya

Background

Milk is a common infant food in peri-urban Kenya that can transmit diarrhea-causing enteric pathogens. Little is known about how contamination of milk at point of purchase and household handling of milk-based infant foods contribute to infant exposure to enteric pathogens.

Objective

To compare the prevalence and concentrations of bacterial indicator organisms and enteric pathogens in unpackaged, fresh pasteurized, and ultra-high temperature (UHT) treated milk at purchase and assess the influence of the type of milk used to prepare infant food on contamination of this food.

Methods

Paired samples of purchased milk and infant food prepared with this milk were obtained from 188 households in low-income neighborhoods in Kisumu, Kenya. Samples were cultured on selective media to isolate Salmonella enterica, Shigella spp., Klebsiella aerogenes, Proteus spp., and Escherichia coli, with pathogens validated by PCR. Probability of detection of these bacteria was compared by milk product treatment and packaging method, and between milk at point of purchase vs. food at point of infant consumption.

Results

Unpackaged milk was most contaminated at point of purchase, but bacterial contamination was also present in pasteurized and UHT milk at purchase. Presence of bacteria in UHT and fresh pasteurized milk at purchase predicted presence of the same bacteria type in infant food. Prevalence of bacterial contamination and concentration level for bacterial indicators generally increased between point of purchase and consumption in UHT and fresh pasteurized milk-based food but decreased in unpackaged milk-based food. Prevalence of the four fecal bacteria were similar in infant foods prepared with each type of milk.

Conclusion

Both pre-market contamination and post-purchase handling influence the likelihood of infants ingesting foods contaminated by diarrheal pathogens.

Inclusion of environmentally themed search terms improves Elastic net regression nowcasts of regional Lyme disease rates

Lyme disease is the most widely reported vector-borne disease in the United States. 95% of confirmed human cases are reported in the Northeast and upper Midwest (25,778 total confirmed cases from Northeast and upper Midwest / 27,203 total US confirmed cases). Human cases typically occur in the spring and summer months when an infected nymph Ixodid tick takes a blood meal. Current federal surveillance strategies report data on an annual basis, leading to nearly a year lag in national data reporting. These lags in reporting make it difficult for public health agencies to assess and plan for the current burden of Lyme disease. Implementation of a nowcasting model, using historical data to predict current trends, provides a means for public health agencies to evaluate current Lyme disease burden and make timely priority-based budgeting decisions. The objective of the study was to develop and compare the performance of nowcasting models using free data from Google Trends and Centers of Disease Control and Prevention surveillance reports. We developed two sets of elastic net models for five regions of the United States: 1. Using only monthly proportional hit data from the 21 disease symptoms and tick related terms, and 2. Using monthly proportional hit data from terms identified via Google correlate and the disease symptom and vector terms. Elastic net models using the full-term list were highly accurate (Root Mean Square Error: 0.74, Mean Absolute Error: 0.52, R2: 0.97) for four of the five regions of the United States and improved accuracy 1.33-fold while reducing error 0.5-fold compared to predictions from models using disease symptom and vector terms alone. Many of the terms included and found to be important for model performance were environmentally related. These models can be implemented to help local and state public health agencies accurately monitor Lyme disease burden during times of reporting lag from federal public health reporting agencies.

Bacteroides Microbial Source Tracking Markers Perform Poorly in Predicting Enterobacteriaceae and Enteric Pathogen Contamination of Cow Milk Products and Milk-Containing Infant Food

Consumption of microbiologically contaminated food is one of the leading causes of diarrheal diseases. Understanding the source of enteric pathogens in food is important to guide effective interventions. Enterobacteriaceae bacterial assays typically used to assess food safety do not shed light on the source. Source-specific Bacteroides microbial source tracking (MST) markers have been proposed as alternative indicators for water fecal contamination assessment but have not been evaluated as an alternative fecal indicator in animal-derived foods. This study tested various milk products collected from vendors in urban Kenyan communities and infant foods made with the milk (n = 394 pairs) using conventional culture methods and TaqMan qPCR for enteric pathogens and human and bovine-sourced MST markers. Detection profiles of various enteric pathogens and Bacteroides MST markers in milk products differed from that of milk-containing infant foods. MST markers were more frequently detected in infant food prepared by caregivers, indicating recent contamination events were more likely to occur during food preparation at home. However, Bacteroides MST markers had lower sensitivity in detecting enteric pathogens in food than traditional Enterobacteriaceae indicators. Bacteroides MST markers tested in this study were not associated with the detection of culturable Salmonella enterica and Shigella sonnei in milk products or milk-containing infant food. The findings show that while Bacteroides MST markers could provide valuable information about how foods become contaminated, they may not be suitable for predicting the origin of the enteric pathogen contamination sources.

Understanding Rural Women's Domestic Work Experiences (DWE) in Ibadan, Nigeria: Development of a Measurement Tool Using Confirmatory Factor Analysis

Gender norms prescribe domestic labor as primarily a female's responsibility in developing countries. Many domestic tasks depend on access to water, so the physical, emotional, and time demands of domestic labor may be exacerbated for women living in water-insecure environments. We developed a set of domestic work experience (DWE) measures tailored to work in rural areas in developing countries, assessed rural Nigerian women's DWE, and examined relationships among the measures. Interviewer-administered survey data were collected between August and September from 256 women in four rural Nigerian communities. Latent factors of DWE were identified by analyzing survey items using confirmatory factor analysis. Pearson's correlation was used to examine relationships among latent factor scores, and multivariate linear regression models were used to determine if factor scores significantly differed across socio-demographic characteristics. The DWE measures consisted of latent factors of the physical domain (frequency of common domestic tasks, water sourcing and carriage, experience of water scarcity), the psychosocial domain (stress appraisal and demand-control), and the social domain (social support). Significant correlations were observed among the latent factors within and across domains. Results revealed the importance of measuring rural Nigerian women's DWE using multiple and contextual approaches rather than relying solely on one exposure measure. Multiple inter-related factors contributed to women's DWE. Water insecurity exacerbated the physical and emotional demands of domestic labor DWE varied across age categories and pregnancy status among rural Nigerian women.

A meta-analysis of the association between physical demands of domestic labor and back pain among women

Background

Back pain (BP) is among the most common musculoskeletal problems globally and is a leading contributor to disability among adults. Millions of women especially those in low-income settings, engage in strenuous domestic activities that may increase their risk of BP. The purpose of this meta-analysis was to estimate the association between physically demanding domestic labor (PDDL) which is characterized as intensity, frequency, duration of work and biomechanical risk factors of work and BP among women.

Methods

Five databases were searched for records published from January 1991 to March 2020; and results from 11studies were included in the meta-analysis. A random effects model and the generic inverse-variance method was used to estimate the pooled odds ratio (OR), 95% confidence interval (CI), and the degree of heterogeneity among studies (I²). Stratified and sensitivity analyses were conducted to identify the influence of outliers and identify the sources of heterogeneity.

Results

Exposure to high PDDL was significantly associated with BP (OR = 1.63; 95% CI 1.30, 2.04; I² = 70%). The odds of back pain were highest among the following groups: women performing domestic labor in non-neutral postures (OR = 2.30; 95% CI = 1.75–3.04; I² = 0%; N = 4 studies) and among women from low- and middle-income countries (OR = 1.98; 95% CI = 1.58–2.49; I² = 29%; N = 5 studies). We found no evidence of publication bias (Egger’s test p-value = 0.15).

Conclusions

PDDL may significantly increase a woman’s risk of experiencing BP, but larger prospective studies are needed to further investigate the association. Presenting data on how domestic work affects the musculoskeletal health of women will be important in designing future interventions (behavioral, infrastructural, and ergonomic) that can reduce the burdens from domestic labor.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12905-021-01294-5.

Infant Food Hygiene and Childcare Practices in Context: Findings from an Urban Informal Settlement in Kenya

Complementary food hygiene is important to reduce infant exposures to enteric pathogens; however, interventions to improve food hygiene in low- and middle-income countries often ignore the larger context in which childcare occurs. In this study, we explore on observational and qualitative information regarding childcare in an informal community in Kenya. Our findings demonstrate that behaviors associated with food contamination, such as hand feeding and storing food for extended periods, are determined largely by the larger social and economic realities of primary caretakers. Data also show how caregiving within an informal settlement is highly dynamic and involves multiple individuals and locations throughout the day. Findings from this study will help inform the development and implementation of food hygiene interventions in informal urban communities.

Environmental and spatial determinants of enteric pathogen infection in rural Lao People's Democratic Republic: A cross-sectional study

TRIAL REGISTRATION

clinicaltrials.gov (NCT02342860).

Risk factors for child food contamination in low-income neighbourhoods of Maputo, Mozambique: An exploratory, cross-sectional study

In low‐ and middle‐income countries, food may be a critical transmission route for pathogens causing childhood diarrhoea, but basic food hygiene is often overlooked in public health strategies. Characterising child food contamination and its risk factors could help prioritise interventions to reduce foodborne diarrhoeal disease, especially in low‐income urban areas where the diarrhoeal disease burden is often high. This cross‐sectional study comprised a caregiver questionnaire coupled with food sampling, and food preparation observations, among the study population of an ongoing sanitation trial in Maputo. The aim was to determine the prevalence of child food contamination and associated risk factors. The prevalence of Enterococcus spp., as an indicator of faecal contamination, was estimated in food samples. Risk factor analyses were performed through zero‐inflated negative binomial regression on colony counts. A modified hazard analysis and critical control point approach was used to determine critical control points (CCPs) that might effectively reduce risk. Fifty‐eight linked caregiver questionnaires and food samples were collected, and 59 food preparation observations were conducted. The prevalence of enterococci in child foods exceeding 10 colony forming units per gram was 53% (95% confidence interval [40%, 67%]). Risk factors for child food contamination were identified, including type of food, food preparation practices, and hygiene behaviours. CCPs included cooking/reheating of food and food storage and handling. This exploratory study highlights the need for more research into diarrhoeagenic pathogens and foodborne risks for children living in these challenging urban environments.

Designing a Food Hygiene Intervention in Low-Income, Peri-Urban Context of Kisumu, Kenya: Application of the Trials of Improved Practices Methodology

Food contamination during weaning and complementary feeding can result in high diarrheal incidence among infants. Caregiver practices are important determinants of exposure to foodborne pathogens, and can therefore play a role in reduction in infant food contamination. Through a qualitative approach, we used the Trials of Improved Practices methodology to design a food hygiene intervention in a low-income settlement of Kisumu city in Kenya. These settlements in Kisumu city host a large portion of the city’s population and are faced with a high diarrheal disease burden. Caregivers were selected if they had a child aged 6–9 months, and together, we codesigned a combination of hardware and messaging components targeting handwashing with soap, hygienic feeding, reheating, and hygienic storage of infant food. Caregivers received up to six engagement visits with the research team. The visits were aimed at improving the designed hardware and messaging components. Results showed that feeding items were easily adopted by caregivers, whereas reheating of food was less observed. Households reportedly improved their food storage and handwashing practices. As a result, the hardware components were further refined and tested among the caregivers. Messaging components spurred the aspirations that caregivers had for their children and acted as reminders of practicing good food hygiene. The outcomes of the codesign process provided valuable insights on the knowledge of caregivers, a delivery approach for implementing the intervention, and further informed a subsequent trial that adopted the designed intervention to target early childhood exposure to enteric pathogens through contaminated food.

Gender-based differences in water, sanitation and hygiene-related diarrheal disease and helminthic infections: a systematic review and meta-analysis

BACKGROUND

Qualitative evidence suggests that inadequate water, sanitation and hygiene (WASH) may affect diarrheal and helminthic infection in women disproportionately. We systematically searched PubMed in June 2014 (updated 2016) and the WHO website, for relevant articles.

METHODS

Articles dealing with the public health relevance of helminthic and diarrheal diseases, and highlighting the role of gender in WASH were included. Where possible, we carried out a meta-analysis.

RESULTS

In studies of individuals 5 years or older, cholera showed lower prevalence in males (OR 0.56; 95% CI 0.34-0.94), while Schistosoma mansoni (1.38; 95% CI 1.14-1.67), Schistosoma japonicum (1.52; 95% CI 1.13-2.05), hookworm (1.43; 95% CI 1.07-1.89) and all forms of infectious diarrhea (1.21; 95% CI 1.06-1.38) showed a higher prevalence in males. When studies included all participants, S. mansoni and S. japonicum showed higher prevalence with males (OR 1.40; 95% CI 1.27-1.55 and 1.84; 95% CI 1.27-2.67, respectively). Prevalence of Trichiuris and hookworm infection showed effect modification with continent.

CONCLUSIONS

Evidence of gender differences in infection may reflect differences in gender norms, suggesting that policy changes at the regional level may help ameliorate gender related disparities in helminthic and diarrheal disease prevalence.

The Safe Start trial to assess the effect of an infant hygiene intervention on enteric infections and diarrhoea in low-income informal neighbourhoods of Kisumu, Kenya: a study protocol for a cluster randomized controlled trial

BACKGROUND

Symptomatic and asymptomatic enteric infections in early childhood are associated with negative effects on childhood growth and development, especially in low and middle-income countries, and food may be an important transmission route. Although basic food hygiene practices might reduce exposure to faecal pathogens and resulting infections, there have been few rigorous interventions studies to assess this, and no studies in low income urban settings where risks are plausibly very high. The aim of this study is to evaluate the impact of a novel infant food hygiene intervention on infant enteric infections and diarrhoea in peri-urban settlements of Kisumu, Kenya.

METHODS

This is a cluster randomized control trial with 50 clusters, representing the catchment areas of Community Health Volunteers (CHVs), randomly assigned to intervention or control, and a total of 750 infants recruited on a rolling basis at 22 weeks of age and then followed for 15 weeks. The intervention targeted four key caregiver behaviours related to food hygiene: 1) hand washing with soap before infant food preparation and feeding; 2) bringing all infant food to the boil before feeding, including when reheating or reserving; 3) storing all infant food in sealed containers; and, 4) using only specific utensils for infant feeding which are kept separate and clean.

RESULTS

The primary outcome of interest is the prevalence of one or more of 23 pre-specified enteric infections, determined using quantitative real-time polymerase chain reaction for enteric pathogen gene targets. In addition, infant food samples were collected at 33 weeks, and faecal indicator bacteria (Enterococcus) isolated and enumerated to assess the impact of the intervention on infant food contamination.

CONCLUSION

To our knowledge this is the first randomized controlled trial to assess the effect of an infant food hygiene intervention on enteric infections in a high burden, low income urban setting. Our trial responds to growing evidence that food may be a key pathway for early childhood enteric infection and disease and that basic food hygiene behaviours may be able to mitigate these risks. The Safe Start trial seeks to provide new evidence as to whether a locally appropriate infant food hygiene intervention delivered through the local health extension system can improve the health of young children.

TRIAL REGISTRATION

The trial was registered at clinicaltrial.gov on March 16th 2018 before enrolment of any participants (https://clinicaltrials.gov/ct2/show/NCT03468114).

Frequency and determinants of health care utilization for symptomatic reproductive tract infections in rural Indian women: A cross-sectional study

Introduction

The public health burden of reproductive tract infections (RTIs) among women in rural areas of low-income countries is poorly addressed because health care seeking for treatment of RTIs is inadequate. There are gaps in knowledge about whether low care seeking behavior stems from challenges in accessing health care versus women's recognition of and response to RTI-specific disease symptoms. We aim to identify determinants of care seeking behavior and analyze the difference in utilization of health care resources in response to symptoms of an RTI versus non-RTI disease symptoms in rural India. This will aid in the design of interventions that promote RTI care seeking behavior.

Methods

Our analysis uses data from a cross-sectional, population-based surveillance survey among rural, non-pregnant women in Odisha, India, from 2013–2014 (n = 3,600). We utilized bivariate logistic regression to determine the degree that certain determinants are associated with a woman’s likelihood to seek RTI treatment, and chi-Squared tests to assess for differences in health care resources used for non-RTI versus RTI symptoms.

Results

Married women were significantly more likely to seek health care for RTI symptoms (Odds Ratio (OR) = 1.9, 95% Confidence Interval (CI): 1.2–3.0) while unmarried adolescents were less likely to seek treatment (OR = 0.4, CI: 0.2–0.6). There was no association between RTI health care seeking with education level, belief about whether symptoms can be treated, or poverty. The majority (73.8%) of women who did not seek treatment for RTI symptoms reported not seeking treatment because they did not know treatment was needed. Women utilized formal health care providers at a higher rate in response to RTI symptoms than in response to their most recent symptoms of any kind (p = 0.003).

Conclusions

Community-based reproductive health education interventions are needed to increase health care seeking behavior for RTIs in rural Indian women. Interventions should target unmarried women and focus on both sexual health education and access to care.

Associations between soil-transmitted helminthiasis and viral, bacterial, and protozoal enteroinfections: a cross-sectional study in rural Laos

Background

Humans are susceptible to over 1400 pathogens. Co-infection by multiple pathogens is common, and can result in a range of neutral, facilitative, or antagonistic interactions within the host. Soil-transmitted helminths (STH) are powerful immunomodulators, but evidence of the effect of STH infection on the direction and magnitude of concurrent enteric microparasite infections is mixed.

Methods

We collected fecal samples from 891 randomly selected children and adults in rural Laos. Samples were analyzed for 5 STH species, 6 viruses, 9 bacteria, and 5 protozoa using a quantitative reverse transcription polymerase chain reaction (qRT-PCR) assay. We utilized logistic regression, controlling for demographics and household water, sanitation, and hygiene access, to examine the effect of STH infection on concurrent viral, bacterial, and protozoal infection.

Results

We found that STH infection was associated with lower odds of concurrent viral infection [odds ratio (OR): 0.48, 95% confidence interval (CI): 0.28–0.83], but higher odds of concurrent bacterial infections (OR: 1.81, 95% CI: 1.06–3.07) and concurrent protozoal infections (OR: 1.50, 95% CI: 0.95–2.37). Trends were consistent across STH species.

Conclusions

The impact of STH on odds of concurrent microparasite co-infection may differ by microparasite taxa, whereby STH infection was negatively associated with viral infections but positively associated with bacterial and protozoal infections. Results suggest that efforts to reduce STH through preventive chemotherapy could have a spillover effect on microparasite infections, though the extent of this impact requires additional study. The associations between STH and concurrent microparasite infection may reflect a reverse effect due to the cross-sectional study design. Additional research is needed to elucidate the exact mechanism of the immunomodulatory effects of STH on concurrent enteric microparasite infection.

Electronic supplementary material

The online version of this article (10.1186/s13071-019-3471-2) contains supplementary material, which is available to authorized users.

Enteric Pathogen Diversity in Infant Foods in Low-Income Neighborhoods of Kisumu, Kenya

Pediatric diarrheal disease remains the second most common cause of preventable illness and death among children under the age of five, especially in low and middle-income countries (LMICs). However, there is limited information regarding the role of food in pathogen transmission in LMICs. For this study, we examined the frequency of enteric pathogen occurrence and co-occurrence in 127 infant weaning foods in Kisumu, Kenya, using a multi-pathogen PCR diagnostic tool, and assessed household food hygiene risk factors for contamination. Bacterial, viral, and protozoan enteric pathogen DNA and RNA were detected in 62% of the infant weaning food samples collected, with 37% of foods containing more than one pathogen type. Multivariable generalized linear mixed model analysis indicated type of infant food best explained the presence and diversity of enteric pathogens in infant food, while most household food hygiene risk factors considered in this study were not significantly associated with pathogen contamination. Specifically, cow’s milk was significantly more likely to contain a pathogen (adjusted risk ratio = 14.4; 95% confidence interval (CI) 1.78–116.1) and more likely to have higher number of enteric pathogen species (adjusted risk ratio = 2.35; 95% CI 1.67–3.29) than porridge. Our study demonstrates that infants in this low-income urban setting are frequently exposed to diarrhoeagenic pathogens in food and suggests that interventions are needed to prevent foodborne transmission of pathogens to infants.

Impact of social capital, harassment of women and girls, and water and sanitation access on premature birth and low infant birth weight in India

BACKGROUND

Globally, preterm birth (PTB) and low infant birth weight (LBW) are leading causes of maternal and child morbidity and mortality. Inadequate water and sanitation access (WASH) are risk factors for PTB and LBW in low-income countries. Physical stress from carrying water and psychosocial stress from addressing sanitation needs in the open may be mechanisms underlying these associations. If so, then living in a community with strong social capital should be able to buffer the adverse effects of WASH on birth outcomes. The objective of this study is to assess the relationships between WASH access and social conditions (including harassment and social capital) on PTB and LBW outcomes among Indian women, and to test whether social conditions modified the association between WASH and birth outcomes.

METHODS AND FINDINGS

This cohort study examined the effect of pre-birth WASH and social conditions on self-reported PTB status and LBW status for 7,926 women who gave birth between 2004/2005 and 2011/2012 Waves of the India Human Development Survey. PTB and LBW occurred in 14.9% and 15.5% of women, respectively. After adjusting for maternal biological and socioeconomic conditions, PTB was associated with sharing a building/compound latrine (Odds Ratio (OR) = 1.55; 95% Confidence Interval (CI) = 1.01, 2.38) versus private latrine access, but suggested an effect in the opposite direction for sharing a community/public latrine (OR = 0.67; CI = 0.45, 1.01). Open defecation, type of drinking water source, minutes per day spent fetching water, and one-way time to a drinking water source were not associated with PTB. LBW was associated with spending more than two hours per day fetching water compared to less than two hours (OR = 1.33; CI = 1.05, 1.70) and suggested an association with open defecation (OR = 1.22; CI = 1.00, 1.48), but was not associated with other types of sanitation, type of drinking water source, or time to a drinking water source. Harassment of women and girls in the community was associated with both PTB (OR = 1.33; CI = 1.09, 1.62) and LBW (OR = 1.26; CI = 1.03, 1.54). The data also showed a possible association of local crime with LBW (OR = 1.30; CI = 1.00, 1.68). Statistically significant (p<0.05) evidence of effect modification was only found for collective efficacy on the association between type of sanitation access and PTB. In addition, stratified analyses identified differences in effect size for walking time to the primary drinking water source and PTB by crime, sanitation access and PTB by harassment, and total hours per day fetching water and LBW by collective efficacy. Limitations of this observational study include risk of bias, inability to confirm causality, reliance on self-reported outcomes, and limited sub-group sample sizes for testing effect modification.

CONCLUSIONS

The relationship between adverse birth outcomes and sanitation access, domestic water fetching, crime, and gender-based harassment suggests physical and psychosocial stress are possible mechanisms by which WASH access affects PTB and LBW among Indian women. Interventions that reduce domestic responsibilities related to water and sanitation and change social norms related to gender-based harassment may reduce rates of PTB and LBW in India.

Realities and experiences of community health volunteers as agents for behaviour change: evidence from an informal urban settlement in Kisumu, Kenya

BACKGROUND

Community health workers play an important role in health service delivery and are increasingly involved in behaviour change interventions, including for hygiene-related behaviour change. However, their role and capacity to deliver behaviour change interventions, particularly in high-density urban settlements, remain under-researched. This study examines the behaviour change-related activities of community health volunteers (CHVs)-community health workers affiliated with the Kenyan Ministry of Health-in a peri-urban settlement in Kenya, in order to assess their capabilities, opportunities to work effectively, and sources of motivation.

METHODS

This mixed-methods study included a census of 16 CHVs who work in the study area. All CHVs participated in structured observations of their daily duties, structured questionnaires, in-depth interviews, and two focus group discussions. Structured data were analysed descriptively. Thematic content analysis was followed for qualitative data. Results were synthesized and interpreted using the capability, opportunity, motivation for behaviour change framework, COM-B.

RESULTS

In addition to their responsibilities with the Ministry of Health, CHVs partnered with a range of non-governmental organizations engaged in health and development programming, often receiving small stipends from these organizations. CHVs reported employing a limited number of behaviour change techniques when interacting with community members at the household level. Capability: While supervision and support from the MOH was robust, CHV training was inconsistent and inadequate with regard to behaviour change and CHVs often lacked material resources necessary for their work. Opportunity: CHVs spent very little time with the households in their allocated catchment area. The number of households contacted per day was insufficient to reach all assigned households within a given month as required and the brief time spent with households limited the quality of engagement.

MOTIVATION

Lack of compensation was noted as a demotivating factor for CHVs. This was compounded by the challenging social environment and CHVs' low motivation to encourage behaviour change in local communities.

CONCLUSIONS

In a complex urban environment, CHVs faced challenges that limited their capacity to be involved in behaviour change interventions. More resources, better coordination, and additional training in modern behaviour change approaches are needed to ensure their optimal performance in implementing health programmes.

Fecal Fingerprints of Enteric Pathogen Contamination in Public Environments of Kisumu, Kenya, Associated with Human Sanitation Conditions and Domestic Animals

Young children are infected by a diverse range of enteric pathogens in high disease burden settings, suggesting pathogen contamination of the environment is equally diverse. This study aimed to characterize across- and within-neighborhood diversity in enteric pathogen contamination of public domains in urban informal settlements of Kisumu, Kenya, and to assess the relationship between pathogen detection patterns and human and domestic animal sanitation conditions. Microbial contamination of soil and surface water from 166 public sites in three Kisumu neighborhoods was measured by enterococcal assays and quantitative reverse transcription polymerase chain reaction (qRT-PCR) for 19 enteric pathogens. Regression was used to assess the association between observed sanitary indicators of contamination with enterococci and pathogen presence and concentration, and pathogen diversity. Seventeen types of pathogens were detected in Kisumu public domains. Enteric pathogens were codetected in 33% of soil and 65% of surface water samples. Greater pathogen diversity was associated with the presence of domestic animal feces but not with human open defecation, deteriorating latrines, flies, or disposal of human feces. Sanitary conditions were not associated with enterococcal bacteria, specific pathogen concentrations, or "any pathogen". Young children played at 40% of observed sites. Managing domestic animal feces may be required to reduce enteric pathogen environmental contamination in high-burden settings.

Urban sanitation coverage and environmental fecal contamination: Links between the household and public environments of Accra, Ghana

Exposure to fecal contamination in public areas, especially in dense, urban environments, may significantly contribute to enteric infection risk. This study examined associations between sanitation and fecal contamination in public environments in four low-income neighborhoods in Accra, Ghana. Soil (n = 72) and open drain (n = 90) samples were tested for E. coli, adenovirus, and norovirus. Sanitation facilities in surveyed households (n = 793) were categorized by onsite fecal sludge containment ("contained" vs. "uncontained") using previous Joint Monitoring Program infrastructure guidelines. Most sanitation facilities were shared by multiple households. Associations between spatial clustering of household sanitation coverage and fecal contamination were examined, controlling for neighborhood and population density (measured as enumeration areas in the 2010 census and spatially matched to sample locations). E. coli concentrations in drains within 50m of clusters of contained household sanitation were more than 3 log-units lower than those outside of clusters. Further, although results were not always statistically significant, E. coli concentrations in drains showed consistent trends with household sanitation coverage clusters: concentrations were lower in or near clusters of high coverage of household sanitation facilities-especially contained facilities-and vice versa. Virus detection in drains and E. coli concentrations in soil were not significantly associated with clustering of any type of household sanitation and did not exhibit consistent trends. Population density alone was not significantly associated with any of the fecal contamination outcomes by itself and was a significant, yet inconsistent, effect modifier of the association between sanitation clusters and E. coli concentrations. These findings suggest clustering of contained household sanitation, even when shared, may be associated with lower levels of fecal contamination within drains in the immediate public domain. Further research is needed to better quantify these relationships and examine impacts on health.

The impact of shared sanitation facilities on diarrheal diseases with and without an environmental reservoir: a modeling study

Epidemiological studies have identified an increased risk of diarrheal diseases associated with using shared sanitation facilities. We hypothesized that this might be related to differences in transmission routes of pathogens. We proposed a mathematical model of two fictitious pathogens, one transmitted with an environmental reservoir and one without. We assumed that individuals susceptible to one pathogen are not susceptible to the other, and therefore, decoupled the two models. We initialized the model with 99% individuals being susceptible. We sampled the parameter space using Latin Hypercube Sampling. We simulated 10,000 parameter sets. We varied the effective shared sanitation coverage (the product of latrine coverage and users' compliance). Our results show that, in our hypothetical scenario, across all levels of effective coverage of shared sanitation, the median final cumulative incidence of diarrheal disease was higher than that of zero coverage. Our simulation findings suggest that increasing effective coverage of shared sanitation may have limited benefits against diarrhea-causing pathogens with an environmental reservoir and may lack benefit against diarrhea-causing pathogens without an environmental reservoir given increased human contacts if latrines are poorly maintained.

Within-Compound Versus Public Latrine Access and Child Feces Disposal Practices in Low-Income Neighborhoods of Accra, Ghana

In crowded urban settlements in low-income countries, many households rely on shared sanitation facilities. Shared facilities are not currently considered "improved sanitation" because of concerns about whether hygiene conditions sufficiently protect users from the feces of others. Prevention of fecal exposure at a latrine is only one aspect of sanitary safety. Ensuring consistent use of latrines for feces disposal, especially child feces, is required to reduce fecal contamination in households and communities. Household crowding and shared latrine access are correlated in these settings, rendering latrine use by neighbors sharing communal living areas as critically important for protecting one's own household. This study in Accra, Ghana, found that household access to a within-compound basic latrine was associated with higher latrine use by children of ages 5-12 years and for disposal of feces of children < 5 years, compared with households using public latrines. However, within-compound access was not associated with improved child feces disposal by other caregivers in the compound. Feces was rarely observed in household compounds but was observed more often in compounds with latrines versus compounds relying on public latrines. Escherichia coli and human adenovirus were detected frequently on household surfaces, but concentrations did not differ when compared by latrine access or usage practices. The differences in latrine use for households sharing within-compound versus public latrines in Accra suggest that disaggregated shared sanitation categories may be useful in monitoring global progress in sanitation coverage. However, compound access did not completely ensure that households were protected from feces and microbial contamination.

Oral Contact Events and Caregiver Hand Hygiene: Implications for Fecal-Oral Exposure to Enteric Pathogens among Infants 3-9 Months Living in Informal, Peri-Urban Communities in Kisumu, Kenya

Childhood diarrhea is one of the leading causes of morbidity and mortality in children under five in low and middle-income countries, second only to respiratory illness. The mouthing behavior that is common in children exposes them to fecal-orally transmitted pathogens that can result in diarrhea; however, there is a need for further evidence on specific exposure routes. This study describes the frequency and diversity of two important routes of enteric pathogen exposure among infants 3-9 months of age: infant oral contact behavior and caregiver handwashing behavior. Data were collected through structured observations of 25 index infants for the oral contact data and 25 households for the caregiver handwashing data in a peri-urban setting in Kisumu (Obunga), Kenya. Breast was the most common type of oral contact event with an average of 3.00 per observation period and 0.5 events per hour. This was followed by a range of physical objects with an average of 2.49 per observation and 0.4 events per hour. The "infant's own hands" was the third most common oral contact, with an average of 2.16 events per hour, and 0.4 oral contact events per hour. Food and liquids were the 4th and 5th most common oral contact events with an average of 1.64 food contacts and 0.52 liquid oral contact events per observation period. Feeding events, including breastfeeding, were the most commonly observed key juncture-71% of total junctures observed were caregivers feeding children. This was followed by child cleaning (23%), caregiver toilet uses at (4%), and lastly food preparation at 2%. HWWS was observed only once before a feeding event (1%), twice after cleaning a child (9%), and twice after caregiver toilet use (40%). The combined implication of data from observing oral contact behavior in children and hand hygiene of caregivers suggests that caregiver hand hygiene prior to feeding events and after cleaning a child are priority interventions.

Multipathway Quantitative Assessment of Exposure to Fecal Contamination for Young Children in Low-Income Urban Environments in Accra, Ghana: The SaniPath Analytical Approach

Lack of adequate sanitation results in fecal contamination of the environment and poses a risk of disease transmission via multiple exposure pathways. To better understand how eight different sources contribute to overall exposure to fecal contamination, we quantified exposure through multiple pathways for children under 5 years old in four high-density, low-income, urban neighborhoods in Accra, Ghana. We collected more than 500 hours of structured observation of behaviors of 156 children, 800 household surveys, and 1,855 environmental samples. Data were analyzed using Bayesian models, estimating the environmental and behavioral factors associated with exposure to fecal contamination. These estimates were applied in exposure models simulating sequences of behaviors and transfers of fecal indicators. This approach allows us to identify the contribution of any sources of fecal contamination in the environment to child exposure and use dynamic fecal microbe transfer networks to track fecal indicators from the environment to oral ingestion. The contributions of different sources to exposure were categorized into four types (high/low by dose and frequency), as a basis for ranking pathways by the potential to reduce exposure. Although we observed variation in estimated exposure (108-1016 CFU/day for Escherichia coli) between different age groups and neighborhoods, the greatest contribution was consistently from food (contributing > 99.9% to total exposure). Hands played a pivotal role in fecal microbe transfer, linking environmental sources to oral ingestion. The fecal microbe transfer network constructed here provides a systematic approach to study the complex interaction between contaminated environment and human behavior on exposure to fecal contamination.

Abstract P4-22-11: Combined targeted therapies for advanced triple negative breast cancer: A phase II trial of nab-paclitaxel and bevacizumab followed by maintenance targeted therapy with bevacizumab and erlotinib

Background: Chemotherapy remains the mainstay of therapy for patients with metastatic triple negative breast cancer (TNBC). We hypothesized that the addition of biologic agents targeting key pathways (bevacizumab targeting angiogenesis and erlotinib directed against EGFR) may prolong progression free survival (PFS) and offer a novel treatment strategy free from chemotherapy for patients with metastatic TNBC.

Methods: Patients with TNBC receiving initial therapy for metastatic disease were eligible for this multicenter phase II trial (NCT00733408) conducted at an academic center and affiliated, community practice sites. Induction therapy included nab-paclitaxel 100 mg/m2 IV Qweek (wk) and Bevacizumab 10 mg/kg IV Q2wks x 24 weeks. Patients free of progression at 24 wks began maintenance therapy with bevacizumab 10 mg/kg IV Q2wks and erlotinib 150 mg po daily until progression with radiographic assessment every 8 wks. Primary objective was PFS with secondary objectives of response rate, overall survival (OS) and safety. All eligible patients were included in the analysis of PFS and OS. Response was evaluated among patients with measurable disease by RECIST 1.1 with central review. Patients with inadequate disease assessments were coded as non-responders. Kaplan-Meier method was used to estimate PFS and OS with patients censored at date of last tumor assessment (PFS) or date of last follow up (OS).

Results: From April 2009 – December 2015, 58 patients (median age 54, range 33-83) were enrolled; 56 (97%) had measurable disease, and all had metastatic TNBC by local assessment. 33 (57%) patients completed induction; 22 (38%) came off study during induction; 3 (5%) continue on maintenance therapy. 4 patients discontinued therapy prior to first assessment. As of June 8, 2016, 53 patients (91%) have progressed. Median follow up for surviving patients is 14.5 months (range 4.1-65.4). Median PFS is 7.7 months (95% CI 5.7, 9.5). Of 56 patients with measurable disease, 38 (66%) had partial response (PR); 10 (17%) with stable disease for clinical benefit rate (CBR) of 86%. Median OS is 18.2 months (95% CI 16.3, 24.5). Most common grade 3-4 toxicities during induction were neutropenia [17 (29%), 1 grade 4], fatigue [13 (22%), all grade 3], leukopenia [7 (12%), all grade 3], and neuropathy [7 (12%), all grade 3]. Rash was most common ≥ grade 3 toxicity during maintenance [4 (7%), grade 3]. One patient experienced clinical CHF during maintenance month 16 requiring bevacizumab discontinuation. Conclusions: Nab-paclitaxel and bevacizumab followed by maintenance targeted therapy with bevacizumab and erlotinib was well tolerated. While the observed PFS did not meet pre-specified criteria of interest, the majority of patients experienced clinical benefit (86%) with 30 (57%) receiving maintenance targeted therapy. Correlative studies are ongoing. Supported by Genentech (OSI4266s), Celegene (AX-CL-BRST-PI-003828) and Janssen.

Citation Format: Specht JM, Gadi VK, Gralow JR, Korde LA, Linden HM, Salazar LG, Rodler ET, Cundy A, Buening BJ, Baker KK, Redman MW, Kurland BF, Garrison MA, Smith JC, vanHaelst C, Anderson JE. Combined targeted therapies for advanced triple negative breast cancer: A phase II trial of nab-paclitaxel and bevacizumab followed by maintenance targeted therapy with bevacizumab and erlotinib [abstract]. In: Proceedings of the 2016 San Antonio Breast Cancer Symposium; 2016 Dec 6-10; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2017;77(4 Suppl):Abstract nr P4-22-11.

Sanitation and Hygiene-Specific Risk Factors for Moderate-to-Severe Diarrhea in Young Children in the Global Enteric Multicenter Study, 2007-2011: Case-Control Study

BACKGROUND

Diarrheal disease is the second leading cause of disease in children less than 5 y of age. Poor water, sanitation, and hygiene conditions are the primary routes of exposure and infection. Sanitation and hygiene interventions are estimated to generate a 36% and 48% reduction in diarrheal risk in young children, respectively. Little is known about whether the number of households sharing a sanitation facility affects a child's risk of diarrhea. The objective of this study was to describe sanitation and hygiene access across the Global Enteric Multicenter Study (GEMS) sites in Africa and South Asia and to assess sanitation and hygiene exposures, including shared sanitation access, as risk factors for moderate-to-severe diarrhea (MSD) in children less than 5 y of age.

METHODS/FINDINGS

The GEMS matched case-control study was conducted between December 1, 2007, and March 3, 2011, at seven sites in Basse, The Gambia; Nyanza Province, Kenya; Bamako, Mali; Manhiça, Mozambique; Mirzapur, Bangladesh; Kolkata, India; and Karachi, Pakistan. Data was collected for 8,592 case children aged <5 y old experiencing MSD and for 12,390 asymptomatic age, gender, and neighborhood-matched controls. An MSD case was defined as a child with a diarrheal illness <7 d duration comprising ≥3 loose stools in 24 h and ≥1 of the following: sunken eyes, skin tenting, dysentery, intravenous (IV) rehydration, or hospitalization. Site-specific conditional logistic regression models were used to explore the association between sanitation and hygiene exposures and MSD. Most households at six sites (>93%) had access to a sanitation facility, while 70% of households in rural Kenya had access to a facility. Practicing open defecation was a risk factor for MSD in children <5 y old in Kenya. Sharing sanitation facilities with 1-2 or ≥3 other households was a statistically significant risk factor for MSD in Kenya, Mali, Mozambique, and Pakistan. Among those with a designated handwashing area near the home, soap or ash were more frequently observed at control households and were significantly protective against MSD in Mozambique and India.

CONCLUSIONS

This study suggests that sharing a sanitation facility with just one to two other households can increase the risk of MSD in young children, compared to using a private facility. Interventions aimed at increasing access to private household sanitation facilities may reduce the burden of MSD in children. These findings support the current World Health Organization/ United Nations Children's Emergency Fund (UNICEF) system that categorizes shared sanitation as unimproved.

Quantification of exposure to fecal contamination in open drains in four neighborhoods in Accra, Ghana

In low-income countries, rapid urbanization adds pressure to already stressed water and sanitation systems that are critical to the health of communities. Drainage networks, designed for stormwater but commonly used for disposing of waste, are rarely covered completely, allowing residents to easily come into contact with their contents. This study used spatial mapping, documentation of physical drain characteristics, microbiological analysis of drain samples, and behavioral observation to comprehensively examine drains as a route of exposure to fecal contamination in four low-income neighborhoods in Accra, Ghana. A stochastic model of six likely exposure scenarios was constructed to estimate children's exposure to drain water. Regardless of the age of the child, any exposure scenario considered resulted in exposure to a high level of fecal contamination. Fecal contamination levels in drains were high (Escherichia coli: geometric mean (GM), 8.60 cfu log(10)/100 mL; coliphage: GM, 5.56 pfu log(10)/100 mL), and did not differ by neighborhood or physical drain characteristics, indicating that frequency of contact with drains, and not drain type or location, drives exposure risk. To mitigate health risks associated with this exposure, drains should be covered, with priority given to large concrete and small to medium dirt-lined drains that children were most commonly observed entering.

Risk of Adverse Pregnancy Outcomes among Women Practicing Poor Sanitation in Rural India: A Population-Based Prospective Cohort Study

BACKGROUND

The importance of maternal sanitation behaviour during pregnancy for birth outcomes remains unclear. Poor sanitation practices can promote infection and induce stress during pregnancy and may contribute to adverse pregnancy outcomes (APOs). We aimed to assess whether poor sanitation practices were associated with increased risk of APOs such as preterm birth and low birth weight in a population-based study in rural India.

METHODS AND FINDINGS

A prospective cohort of pregnant women (n = 670) in their first trimester of pregnancy was enrolled and followed until birth. Socio-demographic, clinical, and anthropometric factors, along with access to toilets and sanitation practices, were recorded at enrolment (12th week of gestation). A trained community health volunteer conducted home visits to ensure retention in the study and learn about study outcomes during the course of pregnancy. Unadjusted odds ratios (ORs) and adjusted odds ratios (AORs) and 95% confidence intervals for APOs were estimated by logistic regression models. Of the 667 women who were retained at the end of the study, 58.2% practiced open defecation and 25.7% experienced APOs, including 130 (19.4%) preterm births, 95 (14.2%) births with low birth weight, 11 (1.7%) spontaneous abortions, and six (0.9%) stillbirths. Unadjusted ORs for APOs (OR: 2.53; 95% CI: 1.72-3.71), preterm birth (OR: 2.36; 95% CI: 1.54-3.62), and low birth weight (OR: 2.00; 95% CI: 1.24-3.23) were found to be significantly associated with open defecation practices. After adjustment for potential confounders such as maternal socio-demographic and clinical factors, open defecation was still significantly associated with increased odds of APOs (AOR: 2.38; 95% CI: 1.49-3.80) and preterm birth (AOR: 2.22; 95% CI: 1.29-3.79) but not low birth weight (AOR: 1.61; 95% CI: 0.94-2.73). The association between APOs and open defecation was independent of poverty and caste. Even though we accounted for several key confounding factors in our estimates, the possibility of residual confounding should not be ruled out. We did not identify specific exposure pathways that led to the outcomes.

CONCLUSIONS

This study provides the first evidence, to our knowledge, that poor sanitation is associated with a higher risk of APOs. Additional studies are required to elucidate the socio-behavioural and/or biological basis of this association so that appropriate targeted interventions might be designed to support improved birth outcomes in vulnerable populations. While it is intuitive to expect that caste and poverty are associated with poor sanitation practice driving APOs, and we cannot rule out additional confounders, our results demonstrate that the association of poor sanitation practices (open defecation) with these outcomes is independent of poverty. Our results support the need to assess the mechanisms, both biological and behavioural, by which limited access to improved sanitation leads to APOs.

Menstrual Hygiene Practices, WASH Access and the Risk of Urogenital Infection in Women from Odisha, India

Menstrual hygiene management (MHM) practices vary worldwide and depend on the individual’s socioeconomic status, personal preferences, local traditions and beliefs, and access to water and sanitation resources. MHM practices can be particularly unhygienic and inconvenient for girls and women in poorer settings. Little is known about whether unhygienic MHM practices increase a woman’s exposure to urogenital infections, such as bacterial vaginosis (BV) and urinary tract infection (UTI). This study aimed to determine the association of MHM practices with urogenital infections, controlling for environmental drivers. A hospital-based case-control study was conducted on 486 women at Odisha, India. Cases and controls were recruited using a syndromic approach. Vaginal swabs were collected from all the participants and tested for BV status using Amsel’s criteria. Urine samples were cultured to assess UTI status. Socioeconomic status, clinical symptoms and reproductive history, and MHM and water and sanitation practices were obtained by standardised questionnaire. A total of 486 women were recruited to the study, 228 symptomatic cases and 258 asymptomatic controls. Women who used reusable absorbent pads were more likely to have symptoms of urogenital infection (AdjOR=2.3, 95%CI1.5-3.4) or to be diagnosed with at least one urogenital infection (BV or UTI) (AdjOR=2.8, 95%CI1.7-4.5), than women using disposable pads. Increased wealth and space for personal hygiene in the household were protective for BV (AdjOR=0.5, 95%CI0.3-0.9 and AdjOR=0.6, 95%CI0.3-0.9 respectively). Lower education of the participants was the only factor associated with UTI after adjusting for all the confounders (AdjOR=3.1, 95%CI1.2-7.9). Interventions that ensure women have access to private facilities with water for MHM and that educate women about safer, low-cost MHM materials could reduce urogenital disease among women. Further studies of the effects of specific practices for managing hygienically reusable pads and studies to explore other pathogenic reproductive tract infections are needed.

Association between moderate-to-severe diarrhea in young children in the global enteric multicenter study (GEMS) and types of handwashing materials used by caretakers in Mirzapur, Bangladesh

Handwashing practices among caretakers of case and control children < 5 years of age enrolled in the Global Enteric Multicenter Study in Mirzapur, Bangladesh were characterized and analyzed for association with moderate-to-severe diarrhea. Soap or detergent ownership was common, yet 48% of case and 47.7% of control caretakers also kept ashes for handwashing, including 36.8% of the wealthiest households. Soap, detergent, and ash were used for multiple hygiene purposes and were kept together at handwashing areas. Caretakers preferred soap for handwashing, but frequently relied on ash, or a detergent/ash mixture, as a low-cost alternative. Moderate-to-severe diarrhea was equally likely for children of caretakers who kept soap versus those who kept ash (matched OR = 0.91; 0.62-1.32). Contact with ash and water reduced concentrations of bacterial enteropathogens, without mechanical scrubbing. Thus, washing hands with ash is a prevalent behavior in Mirzapur and may help diminish transmission of diarrheal pathogens to children.

Quality of piped and stored water in households with children under five years of age enrolled in the Mali site of the Global Enteric Multi-Center Study (GEMS)

Water, sanitation, and hygiene information was collected during a matched case-control study of moderate and severe diarrhea (MSD) among 4,096 children < 5 years of age in Bamako, Mali. Primary use of piped water (conditional odds ratio [cOR] = 0.45; 0.34-0.62), continuous water access (cOR = 0.30; 0.20-0.43), fetching water daily (cOR = 0.77; 0.63-0.96), and breastfeeding (cOR = 0.65; 0.49-0.88) significantly reduced the likelihood of MSD. Fetching water in > 30 minutes (cOR = 2.56; 1.55-4.23) was associated with MSD. Piped tap water and courier-delivered water contained high (> 2 mg/L) concentrations of free residual chlorine and no detectable Escherichia coli. However, many households stored water overnight, resulting in inadequate free residual chlorine (< 0.2 mg/L) for preventing microbial contamination. Coliforms and E. coli were detected in 48% and 8% of stored household water samples, respectively. Although most of Bamako's population enjoys access to an improved water source, water quality is often compromised during household storage.

CfaE tip mutations in enterotoxigenic Escherichia coli CFA/I fimbriae define critical human intestinal binding sites

Enterotoxigenic Escherichia coli (ETEC) use colonization factors to attach to the human intestinal mucosa, followed by enterotoxin expression that induces net secretion and diarrhoeal illness. ETEC strain H10407 expresses CFA/I fimbriae, which are composed of multiple CfaB structural subunits and a CfaE tip subunit. Currently, the contribution of these individual fimbrial subunits in intestinal binding remains incompletely defined. To identify the role of CfaE in attachment in the native ETEC background, an R181A single-amino-acid substitution was introduced by recombination into the H10407 genome. The substitution of R181A eliminated haemagglutination and binding of intestinal mucosa biopsies in in vitro organ culture assays, without loss of CFA/I fimbriae expression. Wild-type in trans plasmid-expressed cfaE restored the binding phenotype. In contrast, in trans expression of cfaE containing amino acid 181 substitutions with similar amino acids, lysine, methionine and glutamine did not restore the binding phenotype, indicating that the loss of the binding phenotype was due to localized areas of epitope disruption. R181 appears to have an irreplaceable role in the formation of a receptor-binding feature on CFA/I fimbriae. The results specifically indicate that the CfaE tip protein is a required binding factor in CFA/I-mediated ETEC colonization, making it a potentially important vaccine antigen.

Control of vocal loudness in young and old adults

This study examined the effect of aging on respiratory and laryngeal mechanisms involved in vocal loudness control. Simultaneous measures of subglottal pressure and electromyographic (EMG) activity from the thyroarytenoid (TA), lateral cricoarytenoid (LCA), and cricothyroid (CT) muscles were investigated in young and old individuals while they attempted to phonate at three loudness levels, "soft," "comfortable," and "loud." Voice sound pressure level (SPL) and fundamental frequency (F ) measures were also obtained. Across loudness conditions, subglottal pressure levels were similar for both age groups. Laryngeal EMG measures tended to be lower and more variable for old compared with young individuals. These differences were most apparent for the TA muscle. Finally, across the three loudness conditions, the old individuals generated SPLs that were lower overall than those produced by the young individuals but modulated loudness levels in a manner similar to that of the young subjects. These findings suggest that the laryngeal mechanism may be more affected than the respiratory system in these old individuals and that these changes may affect vocal loudness levels.

Continuous double loop closure for midline laparotomy wounds

OBJECTIVE

To determine the efficiency of continuous double loop closure of midline laparotomy wounds and how it prevents and reduces wound dehiscence.

METHODS

A prospective study of one hundred patients who underwent laparotomy through midline incision in Basrah General Hospital over a one year period. This study is designed to compare the difference between 2 suturing techniques for closure of midline laparotomy wounds, one is new and unpopular to use, which is the continuous double loop closure, and the other one is the continuous mass closure technique.

RESULTS

By comparison of the 2 techniques, we found that infection of wounds was less using the continuous double loop closure technique (12%) as compared with the control (18%). We also found that wound dehiscence is nil with the continuous double loop closure technique as compared to 8% with the control.

CONCLUSION

The continuous double loop closure technique is superior in closure of midline laparotomy wounds and prevention of wound dehiscence and we recommend it for closure of these wounds in high risk patients.

Short-latency changes in voice F0 and neck surface EMG induced by mechanical perturbations of the larynx during sustained vowel phonation

Nineteen healthy young adult males with normal voice and speech attempted to sustain the vowel /u/ at a constant pitch (target: 180 Hz) and a constant and comfortable loudness level while receiving a sudden mechanical perturbation to the larynx (thyroid prominence) via a servo-controlled probe. The probe moved toward or away from the larynx in a ramp-and-hold fashion (3.3-mm displacement, 0.7 N force, 20-ms rise time, 250-ms duration) as the subjects attempted to maintain a constant probe-larynx pressure. Eighty stimuli were applied in each direction, one stimulus per phonation. Pairs of surface electromyography (EMG) electrodes were attached to the skin of the anterior neck over laryngeal, infralaryngeal, and supralaryngeal areas. The rectified EMG signals, the voltage analog of the voice fundamental frequency (VAF0), and the voltage analog of the probe displacement were digitized and signal-averaged relative to the onset of the stimulus. Sudden perturbation of the larynx induced an instantaneous decrease or increase in VAF0, depending on the direction of the probe's movement, and a short-latency increase in the EMG (30-35 ms) and VAF0 (55-65 ms). We argue that the instantaneous VAF0 change was related to a mechanical effect, and the short-latency VAF0 and EMG changes to reflexogenic effects-the latter most likely associated with both intrinsic and extrinsic laryngeal sensorimotor mechanisms. Further physiological studies are needed to elucidate the sources of the VAF0 and EMG responses. Once elucidated, the present method may provide a powerful noninvasive tool for studying laryngeal neurophysiology. The theoretical and clinical implications of the present findings are addressed.

Thyroarytenoid muscle activity associated with hypophonia in Parkinson disease and aging

OBJECTIVE

To compare electromyographic (EMG) amplitudes of the thyroarytenoid (TA) muscle in young and older individuals and individuals with idiopathic PD (IPD) under conditions of known vocal loudness (sound pressure level).

BACKGROUND

Voice disorders frequently accompany aging and IPD, but it is unclear how laryngeal muscle physiology is affected by these processes and how changes in laryngeal muscle activity result in characteristic changes of the voice.

METHODS

Absolute and relative (to maximum) EMG amplitudes of the TA muscle were compared during speech and nonspeech tasks. Corresponding sound pressure level (SPL) measures were obtained for the speech tasks.

RESULTS

Absolute TA amplitudes were consistently the highest in the young individuals, lowest in the individuals with IPD, and intermediate in the older individuals. Relative TA amplitudes were generally the highest for the young individuals, lowest for the older individuals, and intermediate for the individuals with IPD. SPL findings showed the older individuals and individuals with IPD produced most of the speech tasks with comparable SPLs, and these levels were consistently lower than those of the young individuals.

CONCLUSIONS

Reduced levels of TA muscle activity may contribute to the characteristic hypophonic voice disorders that frequently accompany IPD and aging.

Preliminary voice and speech analysis following fetal dopamine transplants in 5 individuals with Parkinson disease

A surgical procedure involving transplantation of fetal dopamine cells into the striatum of persons with advanced Parkinson disease (PD) has recently been performed in an attempt to alleviate Parkinsonian and drug-dose related symptoms (e.g., the "on-off" phenomena). Improvements in limb motor and neurological function, as well as less severe and shorter on-off episodes have been reported following fetal cell transplant (FCT) surgery. Acoustic, electroglottographic, and perceptual measures were analyzed pre- and post-surgery to determine if phonotory and articulatory function were affected by this relatively new form of treatment. In addition, speech and motor exam measures were compared to determine if similar directional changes across motor systems were apparent. Findings suggest that FCT surgery did not systematically influence voice and speech production. Also, it appears that FCT surgery may differentially affect phonatory, articulatory, and limb motor systems. Findings are discussed relative to these differential effects.