Evaluation of a rapid diagnostic test for detection of Vibrio cholerae O1 in the Democratic Republic of the Congo: Preventative intervention for cholera for 7 days (PICHA7 program)

OBJECTIVE

Globally, there are estimated to be 2.9 million cholera cases annually. Early detection of cholera outbreaks is crucial for resource allocation for case management and for targeted interventions to be delivered to stop the spread of cholera. In resource limited settings such as Eastern Democratic Republic of the Congo (DRC), there is often limited laboratory capacity for analysing stool samples for cholera by bacterial culture. Therefore, rapid diagnostic tests (RDTs) for cholera present a promising tool to rapidly test stool samples in a health facility setting for cholera. Our objective is to evaluate the Crystal VC O1 RDT for cholera detection compared with bacterial culture and polymerase chain reaction (PCR) for Vibrio cholerae.

METHODS

From March 2020 to December 2022, stool samples were collected from 644 diarrhoea patients admitted to 94 health facilities in Bukavu in Eastern DRC. Patient stool samples were analysed by Crystal VC O1 RDT for cholera and by bacterial culture and PCR for V. cholerae O1.

RESULTS

Twenty six percent of diarrhoea patients (166/644) had stool samples positive for cholera by RDT, and 24% (152/644) had stool samples positive for V. cholerae O1 by bacterial culture or PCR. The overall specificity and sensitivity of the Crystal VC O1 RDT by direct testing was 94% (95% confidence interval [CI]: 92%-96%) and 90% (95% CI, 84%-94%), respectively, when compared with either a positive result by bacterial culture or PCR.

CONCLUSION

Our findings suggest that the Crystal VC O1 RDT presents a promising tool for cholera surveillance in this cholera endemic setting in sub-Saharan Africa.

Effect of an Arsenic Mitigation Program on Arsenic Exposure in American Indian Communities: A Cluster Randomized Controlled Trial of the Community-Led Strong Heart Water Study Program

BACKGROUND

Chronic arsenic exposure has been associated with an increased risk of cardiovascular disease; diabetes; cancers of the lung, pancreas and prostate; and all-cause mortality in American Indian communities in the Strong Heart Study.

OBJECTIVE

The Strong Heart Water Study (SHWS) designed and evaluated a multilevel, community-led arsenic mitigation program to reduce arsenic exposure among private well users in partnership with Northern Great Plains American Indian Nations.

METHODS

A cluster randomized controlled trial (cRCT) was conducted to evaluate the effectiveness of the SHWS arsenic mitigation program over a 2-y period on a) urinary arsenic, and b) reported use of arsenic-safe water for drinking and cooking. The cRCT compared the installation of a point-of-use arsenic filter and a mobile Health (mHealth) program (3 phone calls; SHWS mHealth and Filter arm) to a more intensive program, which included this same program plus three home visits (3 phone calls and 3 home visits; SHWS Intensive arm).

RESULTS

A 47% reduction in urinary arsenic [geometric mean  ( GM ) = 13.2  to  7.0 μ g / g creatinine] was observed from baseline to the final follow-up when both study arms were combined. By treatment arm, the reduction in urinary arsenic from baseline to the final follow-up visit was 55% in the mHealth and Filter arm (GM = 14.6  to  6.55 μ g / g creatinine) and 30% in the Intensive arm (GM = 11.2  to  7.82 μ g / g creatinine). There was no significant difference in urinary arsenic levels by treatment arm at the final follow-up visit comparing the Intensive vs. mHealth and Filter arms: GM ratio of 1.21 (95% confidence interval: 0.77, 1.90). In both arms combined, exclusive use of arsenic-safe water from baseline to the final follow-up visit significantly increased for water used for cooking (17% to 53%) and drinking (12% to 46%).

DISCUSSION

Delivery of the interventions for the community-led SHWS arsenic mitigation program, including the installation of a point-of-use arsenic filter and a mHealth program on the use of arsenic-safe water (calls only, no home visits), resulted in a significant reduction in urinary arsenic and increases in reported use of arsenic-safe water for drinking and cooking during the 2-y study period. These results demonstrate that the installation of an arsenic filter and phone calls from a mHealth program presents a promising approach to reduce water arsenic exposure among private well users. https://doi.org/10.1289/EHP12548.

A Quantitative and Qualitative Program Evaluation of a Case-Area Targeted Intervention to Reduce Cholera in Eastern Democratic Republic of the Congo

Individuals living near cholera patients have an increased risk of cholera infections. Case-area targeted interventions (CATIs) promoting improved water, sanitation, and hygiene (WASH) present a promising approach to reducing cholera for those residing near cholera cases. However, there is limited evidence on the effectiveness and implementation of this approach in increasing WASH behaviors. We conducted a mixed-methods program evaluation in rural and urban eastern Democratic Republic of the Congo. The quantitative component included household structured observations and spot checks in CATI and control areas to assess WASH conditions and behaviors. The qualitative component included semi-structured interviews with CATI recipients, non-recipients, and implementers to assess CATI implementation. A total of 399 participants were enrolled in the quantitative evaluation conducted within 1 month of CATI delivery. For the qualitative evaluation, 41 semi-structured interviews were conducted, 30 with individuals in CATI areas (recipients and non-recipients) and 11 with CATI implementers. Handwashing with soap was low among both CATI and control area participants (1% vs. 2%, p = 0.89). Significantly more CATI area households (75%) had chlorine tablets present compared to control area households (0%) (p < 0.0001); however, the percentage of households with stored water free chlorine concentrations > 0.2 mg/L was low for both CATI and control area households (11% vs. 6%, p = 0.45). Implementers reported an insufficient supply of soap for distribution to recipients and mistrust in the community of their activities. CATI recipients demonstrated low knowledge of the correct preparation and use of chlorine for water treatment. Recipients also indicated a need for CATI implementers to engage community leaders. As CATIs are part of cholera control plans in many cholera-endemic countries, it is important to evaluate existing programs and develop evidence-based approaches to deliver CATIs that are both tailored to the local context and engage affected communities to increase WASH behaviors to reduce the spread of cholera.

Gut microbiota shifts favorably with delivery of handwashing with soap and water treatment intervention in a prospective cohort (CHoBI7 trial)

BACKGROUND

Cholera can result in the expulsion of important microbiota from the gut and result in death if left untreated. The disease transmits mainly via drinking water carrying Vibrio cholerae; and household contacts (HHC) of cholera patients are at elevated risk during the first week of infection. The gut microbiota profiles of HHC-children of cholera patients at Dhaka city slums were investigated before (day 0) and after (day 8) delivery of chlorinated water as part of the major study 'CHoBI7 trial (cholera-hospital-based intervention for 7 days)'.

RESULT

Results of sequencing and analysis of bacterial community DNA revealed the predominance of two bacterial phyla: Bacteroidetes and Firmicutes at day 0 with a relative abundance of 62 ± 6 (mean ± SEM%) and 32 ± 7, respectively. The pattern reversed at day 8 with a decreased relative abundance of Bacteroidetes (39 ± 12; p = 0.034) and an increased abundance of Firmicutes (49 ± 12; p = 0.057). Of 65 bacterial families confirmed at day 0, six belonging to Proteobacteria including Vibrionaceae disappeared at day 8. Interestingly, the relative abundance of four Firmicutes families-Lachnospiraceae, Bifidobacteriaceae, Clostridiaceae, and Ruminococcaceae was increased in all five study children at day 8.

CONCLUSION

The observed exclusion of pathogenic Proteobacteria and enhancement of beneficial Firmicutes in the gut of children delivered with chlorinated water as part of WASH intervention reflect a great promise of the CHoBI7 program in preventing cholera and improving child health.

Behavioral determinants of arsenic-safe water use among Great Plains Indian Nation private well users: results from the Community-Led Strong Heart Water Study Arsenic Mitigation Program

BACKGROUND

The objective of this study was to evaluate the behavioral determinants associated with exclusive use of arsenic-safe water in the community-led Strong Heart Water Study (SHWS) arsenic mitigation program.

METHODS

The SHWS is a randomized controlled trial of a community-led arsenic mitigation program designed to reduce arsenic exposure among private well users in American Indian Great Plains communities. All households received point-of-use (POU) arsenic filters installed at baseline and were followed for 2 years. Behavioral determinants selected were those targeted during the development of the SHWS program, and were assessed at baseline and follow-up.

RESULTS

Among participants, exclusive use of arsenic-safe water for drinking and cooking at follow-up was associated with higher self-efficacy for accessing local resources to learn about arsenic (OR: 5.19, 95% CI: 1.48-18.21) and higher self-efficacy to resolve challenges related to arsenic in water using local resources (OR: 3.11, 95% CI: 1.11-8.71). Higher commitment to use the POU arsenic filter faucet at baseline was also a significant predictor of exclusive arsenic-safe water use for drinking (OR: 32.57, 95% CI: 1.42-746.70) and cooking (OR: 15.90, 95% CI: 1.33-189.52) at follow-up. From baseline to follow-up, the SHWS program significantly increased perceived vulnerability to arsenic exposure, self-efficacy, descriptive norms, and injunctive norms. Changing one's arsenic filter cartridge after installation was associated with higher self-efficacy to obtain arsenic-safe water for drinking (OR: 6.22, 95% CI: 1.33-29.07) and cooking (OR: 10.65, 95% CI: 2.48-45.68) and higher perceived vulnerability of personal health effects (OR: 7.79, 95% CI: 1.17-51.98) from drinking arsenic-unsafe water.

CONCLUSIONS

The community-led SHWS program conducted a theory-driven approach for intervention development and evaluation that allowed for behavioral determinants to be identified that were associated with the use of arsenic safe water and changing one's arsenic filter cartridge. These results demonstrate that theory-driven, context-specific formative research can influence behavior change interventions to reduce water arsenic exposure. The SHWS can serve as a model for the design of theory-driven intervention approaches that engage communities to reduce arsenic exposure.

TRIAL REGISTRATION

The SHWS is registered with ClinicalTrials.gov (Identifier: NCT03725592).

Vibrio cholerae O1 associated with recent endemic cholera shows temporal changes in serotype, genotype, and drug-resistance patterns in Bangladesh

BACKGROUND

Despite the advancement in our understanding of cholera and its etiological agent, Vibrio cholerae, the prevention and treatment of the disease are often hindered due to rapid changes in drug response pattern, serotype, and the major genomic islands namely, the CTX-prophage, and related genetic characteristics. In the present study, V. cholerae (n = 172) associated with endemic cholera in Dhaka during the years 2015-2021 were analyzed for major phenotypic and genetic characteristics, including drug resistance patterns.

RESULTS

Results revealed that the V. cholerae strains belonged to serogroup O1 biotype El Tor carrying El Tor -specific genes rtxC, tcpA El Tor, and hlyA El Tor, but possessed classical-biotype cholera toxin. Serotypes of V. cholerae strains differed temporally in predominance with Inaba during 2015-2017, and again in 2020-2021, while Ogawa was the predominant serotype in 2018-2019. Also, ctxB1 was predominant in V. cholerae associated with cholera during 2015-2017, while ctxB7 was predominant in 2018, and in the subsequent years, as observed until 2021. V. cholerae strains differed in their antibiotic resistance pattern with a majority (97%) being multi-drug resistant (MDR) and belonging to six sub-groups. Notably, one of these MDR strains was resistant to eleven of the eighteen antibiotics tested, with resistance to fourth-generation cephalosporin (cefepime), and aztreonam. This extreme drug resistant (XDR) strain carried resistance-related genes namely, extended-spectrum β-lactamases (ESBL), blaOXA-1 and blaPER-3.

CONCLUSION

The observed temporal switching of serotypes, as well as the ctxB genotype, and the emergence of MDR/XDR V. cholerae and their association with endemic cholera in Dhaka underscore the need for routine monitoring of the pathogen for proper patient management.

Food Hygiene and Fecal Contamination on the Household Compound are Associated with Increased Pediatric Diarrhea in Urban Bangladesh (CHoBI7 Program)

In this prospective cohort study, we explored individual- and household-level risk factors associated with diarrheal diseases among 251 children younger than 5 years in slum areas of urban Dhaka, Bangladesh. During the 3-month study period, diarrhea surveillance was conducted monthly, and spot checks of the household compound were performed at baseline to assess the presence of feces (animal or human) in the household compound and in cooking and food storage areas, and to assess whether cooked food was covered and refrigerated. We also collected caregiver reports on child mouthing behaviors. Children living in households with feces within 10 steps of cooking and food storage areas (odds ratio [OR], 8.43; 95% CI, 1.01-70.18), those with visible feces found on the ground of the household compound (OR, 4.05; 95% CI, 1.24-13.22), and those in households found to keep cooked food uncovered and without refrigeration (OR, 6.16; 95% CI, 1.11-34.25) during spot checks had a significantly greater odds of diarrhea. There was no significant association between pediatric diarrhea and caregiver-reported child mouthing behaviors or presence of animals in the cooking area. These study findings demonstrate that presence of visible feces in the household compound and near cooking and food storage areas, and poor household food hygiene practices, were significant risk factors for diarrheal disease among young children in Dhaka, Bangladesh. Health communication programs are needed to target these exposure pathways to fecal pathogens.

Evaluation of a water arsenic filter in a participatory intervention to reduce arsenic exposure in American Indian communities: The Strong Heart Water Study

Many rural populations, including American Indian communities, that use private wells from groundwater for their source of drinking and cooking water are disproportionately exposed to elevated levels of arsenic. However, programs aimed at reducing arsenic in American Indian communities are limited. The Strong Heart Water Study (SHWS) is a randomized controlled trial aimed at reducing arsenic exposure among private well users in American Indian Northern Great Plains communities. The community-led SHWS program installed point-of-use (POU) arsenic filters in the kitchen sink of households, and health promoters delivered arsenic health communication programs. In this study we evaluated the efficacy of these POU arsenic filters in removing arsenic during the two-year installation period. Participants were randomized into two arms. In the first arm households received a POU arsenic filter, and 3 calls promoting filter use (SHWS mobile health (mHealth) & filter arm). The second arm received the same filter and phone calls, and 3 in-person home visits and 3 Facebook messages (SHWS intensive arm) for program delivery. Temporal variability in water arsenic concentrations from the main kitchen faucet was also evaluated. A total of 283 water samples were collected from 50 households with private wells from groundwater (139 filter and 144 kitchen faucet samples). Ninety-three percent of households followed after baseline had filter faucet water arsenic concentrations below the arsenic maximum contaminant level of 10 μg/L at the final visit during our 2 year study period with no difference between study arms (98 % in the intensive arm vs. 94 % in the mHealth & filter arm). No significant temporal variation in kitchen arsenic concentration was observed over the study period (intraclass correlation coefficient = 0.99). This study demonstrates that POU arsenic filters installed for the community participatory SHWS program were effective in reducing water arsenic concentration in study households in both arms, even with delivery of the POU arsenic filter and mHealth program only. Furthermore, we observed limited temporal variability of water arsenic concentrations from kitchen faucet samples collected over time from private wells in our study setting.

Reduced Diarrhea Prevalence and Improvements in Handwashing with Soap and Stored Drinking Water Quality Associated with Diarrheal Disease Awareness Measured by Interactive Voice Response Messages in the CHoBI7 Mobile Health Program

The Cholera-Hospital-Based-Intervention-for-7-Days (CHoBI7) mobile health program promotes water, sanitation, and hygiene (WASH) behaviors through interactive voice response (IVR), voice, and text messages to reduce diarrheal diseases in Bangladesh. The objective of this study was to investigate the relationship between responses to CHoBI7 WASH IVR quiz messages and subsequent diarrhea and WASH behaviors. Fourteen CHoBI7 IVR quiz messages on handwashing with soap and treatment of stored water were sent to 517 households with 1,777 participants during the 12-month program period. IVR message responses were classified as correct answer, incorrect answer, no response (did not press 1 or 2), and failed (did not answer the phone). Diarrhea prevalence was assessed through self-reported monthly clinical surveillance visits. Handwashing with soap was assessed by a 5-hour structured observation, and stored water quality was defined by Escherichia coli concentration. Households that responded correctly to a CHoBI7 IVR quiz message had significantly lower odds of diarrhea for all age groups (adults and children) at the subsequent visit 1 month later (odds ratio [OR], 0.73; 95% CI, 0.54-0.98), and significantly greater odds of handwashing with soap after stool-related events (OR, 2.48; 95% CI, 1.12-5.49) and E. coli levels < 100 colony forming units (CFU)/100 mL (World Health Organization high-risk cutoff) in the stored household water (OR, 2.04; 95% CI, 1.25-3.33) compared with households that did not answer CHoBI7 IVR quiz calls. Correct responses to CHoBI7 IVR quizzes were associated with decreased diarrhea prevalence and improved stored drinking water quality and handwashing with soap behaviors at the subsequent visits. These findings suggest engagement in the CHoBI7 mobile health (mHealth) program and awareness of diarrheal disease prevention can reduce diarrhea and facilitate changes in WASH behaviors.

Implementing a Community-Led Arsenic Mitigation Intervention for Private Well Users in American Indian Communities: A Qualitative Evaluation of the Strong Heart Water Study Program

Arsenic is a naturally occurring toxicant in groundwater, which increases cancer and cardiovascular disease risk. American Indian populations are disproportionately exposed to arsenic in drinking water. The Strong Heart Water Study (SHWS), through a community-centered approach for intervention development and implementation, delivered an arsenic mitigation program for private well users in American Indian communities. The SHWS program comprised community-led water arsenic testing, point-of-use arsenic filter installation, and a mobile health program to promote sustained filter use and maintenance (i.e., changing the filter cartridge). Half of enrolled households received additional in-person behavior change communication and videos. Our objectives for this study were to assess successes, barriers, and facilitators in the implementation, use, and maintenance of the program among implementers and recipients. We conducted 45 semi-structured interviews with implementers and SHWS program recipients. We analyzed barriers and facilitators using the Consolidated Framework for Implementation Research and the Risks, Attitudes, Norms, Abilities, and Self-regulation model. At the implementer level, facilitators included building rapport and trust between implementers and participating households. Barriers included the remoteness of households, coordinating with community plumbers for arsenic filter installation, and difficulty securing a local supplier for replacement filter cartridges. At the recipient level, facilitators included knowledge of the arsenic health risks, perceived effectiveness of the filter, and visual cues to promote habit formation. Barriers included attitudes towards water taste and temperature and inability to procure or install replacement filter cartridges. This study offers insights into the successes and challenges of implementing an arsenic mitigation program tailored to American Indian households, which can inform future programs in partnership with these and potentially similar affected communities. Our study suggests that building credibility and trust between implementers and participants is important for the success of arsenic mitigation programs.

Akkermansia muciniphila Associated with Improved Linear Growth among Young Children, Democratic Republic of the Congo

To investigate the association between enteric pathogens, fecal microbes, and child growth, we conducted a prospective cohort study of 236 children <5 years of age in rural eastern Democratic Republic of the Congo. We analyzed baseline fecal specimens by quantitative PCR and measured child height and weight at baseline and growth at a 6-month follow-up. At baseline, 66% (156/236) of children had >3 pathogens in their feces. We observed larger increases in height-for-age-z-scores from baseline to the 6-month follow-up among children with Akkermansia muciniphila in their feces (coefficient 0.02 [95% CI 0.0001-0.04]; p = 0.04). Children with Cryptosporidium in their feces had larger declines in weight-for-height/length z-scores from baseline to the 6-month follow-up (coefficient -0.03 [95% CI -0.05 to -0.005]; p = 0.02). Our study showed high prevalence of enteric pathogens among this pediatric cohort and suggests A. muciniphila can potentially serve as a probiotic to improve child growth.

A Qualitative Evaluation of COVID-19 Preventative Response Activities in South Kivu, Democratic Republic of the Congo

OBJECTIVE

In this evaluation of COVID-19 preventative response programs in South Kivu, Democratic Republic of the Congo (DRC), we aimed to explore community understandings of COVID-19, assess operational successes and challenges of COVID response activities, and identify barriers to practicing COVID-19 preventative behaviors.

METHODS

Thirty-one semi-structured interviews were conducted from April to September 2021 in South Kivu, DRC, with community members (n = 16) and programmatic stakeholders (n = 15) (healthcare providers, government officials, and developmental and NGO staff engaged in COVID-19 response).

FINDINGS

Most community members were aware of COVID-19 and its global burden, but few were aware of local transmission in their area. Some community members attributed COVID-19 to actions of malevolent neighbors, miasma ("bad air"), or spirits. Awareness of COVID-19 preventative measures was widespread, largely because of radio and TV health promotion programs. Community members and programmatic stakeholders both said community-level non-compliance to COVID-19 preventative measures was high despite high awareness of preventative methods. Community members expressed concern that face masks distributed as part of preventative programs contained the COVID-19 virus. Programmatic stakeholders emphasized the need for broader health system strengthening with improved coordination, provision of resources to health facilities at the provincial level, and prioritization of research. Lessons learned from addressing Ebola were leveraged for COVID-19 health promotion, rapid training of healthcare personnel, and surveillance.

CONCLUSIONS

Community-informed approaches are needed for effective COVID-19 preventative response programs in South Kivu, DRC. Our study identified successes and challenges in COVID-19 response activities. Future research should assess the effectiveness of integrating preventive programs with COVID-19 vaccination efforts.

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.

Tapwater Exposures, Effects Potential, and Residential Risk Management in Northern Plains Nations

In the United States (US), private-supply tapwater (TW) is rarely monitored. This data gap undermines individual/community risk-management decision-making, leading to an increased probability of unrecognized contaminant exposures in rural and remote locations that rely on private wells. We assessed point-of-use (POU) TW in three northern plains Tribal Nations, where ongoing TW arsenic (As) interventions include expansion of small community water systems and POU adsorptive-media treatment for Strong Heart Water Study participants. Samples from 34 private-well and 22 public-supply sites were analyzed for 476 organics, 34 inorganics, and 3 in vitro bioactivities. 63 organics and 30 inorganics were detected. Arsenic, uranium (U), and lead (Pb) were detected in 54%, 43%, and 20% of samples, respectively. Concentrations equivalent to public-supply maximum contaminant level(s) (MCL) were exceeded only in untreated private-well samples (As 47%, U 3%). Precautionary health-based screening levels were exceeded frequently, due to inorganics in private supplies and chlorine-based disinfection byproducts in public supplies. The results indicate that simultaneous exposures to co-occurring TW contaminants are common, warranting consideration of expanded source, point-of-entry, or POU treatment(s). This study illustrates the importance of increased monitoring of private-well TW, employing a broad, environmentally informative analytical scope, to reduce the risks of unrecognized contaminant exposures.

Randomized Controlled Trial of the Cholera-Hospital-Based-Intervention-for-7-Days (CHoBI7) Cholera Rapid Response Program to Reduce Diarrheal Diseases in Bangladesh

(a) Objective: To build an evidence base on effective water, sanitation, and hygiene interventions to reduce diarrheal diseases in cholera hotspots, we developed the CHoBI7 Cholera Rapid Response Program. (b) Methods: Once a cholera patient (confirmed by bacterial culture) is identified at a health facility, a health promoter delivers a targeted WASH intervention to the cholera hotspot (households within 20 m of a cholera patient) through both in-person visits during the first week and bi-weekly WASH mobile messages for the 3-month program period. A randomized controlled trial of the CHoBI7 Cholera Rapid Response Program was conducted with 284 participants in 15 cholera hotspots around cholera patients in urban Dhaka, Bangladesh. This program was compared to the standard message in Bangladesh on the use of oral rehydration solution for dehydration. Five-hour structured observation of handwashing with soap and diarrhea surveillance was conducted monthly. (c) Findings: Handwashing with soap at food- and stool-related events was significantly higher in the CHoBI7 Cholera Rapid Response Program arm compared to the standard message arm at all timepoints (overall 54% in the CHoBI7 arm vs. 23% in the standard arm, p < 0.05). Furthermore, there was a significant reduction in diarrheal prevalence for all participants (adults and children) (Prevalence Ratio (PR) 0.35, 95% CI: 0.14-0.85) and for children under 5 years of age (PR: 0.27, 95% CI: 0.085-0.87) during the 3-month program. (d) Conclusions: These findings demonstrate that the CHoBI7 Cholera Rapid Response Program is effective in lowering diarrhea prevalence and increasing handwashing with soap for a population at high risk of cholera.

Methods to Evaluate COVID-19 Preventive Hygiene Programs: Observed Mask Wearing, Handwashing, and Physical Distancing Behaviors in Public Indoor Spaces in Democratic Republic of the Congo

The objective of our study was to develop and test observational methods to evaluate COVID-19 preventive hygiene behaviors and physical distancing, and to evaluate the effectiveness of a government mandate on indoor fully covered mask wearing. An observational study was conducted of 4,736 individuals from April to October 2021 using 5-hour and rapid (10-minute) structured observations and spot checks to evaluate mask-wearing, handwashing, and physical-distancing behaviors, and the functionality of handwashing stations in 161 indoor public spaces across Bukavu, Democratic Republic of the Congo (DRC). Sixteen percent of individuals entering indoor public spaces were wearing a mask that fully covered their nose and mouth (fully covered mask wearing). Fully covered mask wearing was lowest inside schools (1%), universities (2%), religious establishments (22%), and health facility wards (28%). Overall physical distancing of more than 1-m inside indoor public spaces was 22%, and was lowest inside schools and religious establishments (7%). Thirty-nine percent of handwashing stations had water and a cleansing agent present. Ten percent of individuals washed their hands with a cleansing agent before entering an indoor space. Overall, fully covered mask wearing was similar for 5-hour and rapid structured observations (16% versus 15%). The odds of fully covered mask wearing was significantly greater with increased government enforcement of mask wearing in public spaces through fines (odds ratio, 2.72; 95% CI, 1.02-7.30). This study presents rigorous methods using structured observations to assess government mandates and programs on COVID-19 preventive hygiene behaviors in indoor public spaces in settings globally.

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.

Fecal Sampling of Soil, Food, Hand, and Surface Samples from Households in Urban Slums of Dhaka, Bangladesh: An Evidence-Based Development of Baby Water, Sanitation, and Hygiene Interventions

The aim of this study was to identify the exposure pathways of fecal pathogens for a pediatric population living in the urban slums of Bangladesh. A total of 252 soil, food, surface, and hand rinse samples were collected from the pilot households with children less than 5 years of age. All samples were analyzed using the IDEXX Quanti-Tray System (Colilert-18) to enumerate fecal indicator bacteria Escherichia coli. Escherichia coli was detected in all soil samples collected from children play spaces (N = 46), 35% of objects and surfaces children frequently put in their mouths, and 31% of child food samples. Thirty-three percent of hand samples from the child and 46% of hand samples from the caregiver had detectable E. coli. These findings showed high fecal contamination of soil, food, and on hands and surfaces in households with young children and demonstrate the need for interventions reducing these exposure pathways for susceptible pediatric populations.

Low dietary diversity is associated with linear growth faltering and subsequent adverse child developmental outcomes in rural Democratic Republic of the Congo (REDUCE program)

The objective of this study was to investigate the association between dietary diversity, child growth and child developmental outcomes. This was a prospective cohort study. Developmental outcomes were assessed by communication, fine motor, gross motor, personal social, problem solving and combined developmental scores measured by the Extended Ages and Stages Questionnaire (EASQ) at a 6‐month follow‐up visit. Height and weight were measured at baseline and a 6‐month follow‐up. Baseline minimum dietary diversity (MDD) for children 6–23 months old 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. Participants were 117 children 6–23 months of age. Linear growth faltering was defined as a significant decline (p < 0.05) in length‐for‐age Z‐scores (LAZ) between baseline and follow‐up. Regression models were performed. The study was conducted in rural eastern Democratic Republic of the Congo (DRC). MDD was positively associated with change in LAZ (coefficient: 0.87 [95% confidence interval [CI]: 0.33, 1.40]), and a reduced odds of stunting (LAZ < −2) (odds ratio: 0.21 [95% CI: 0.07, 0.61]). MDD was also associated with a significantly higher combined EASQ‐Z‐scores (coefficient: 0.34 [95% CI: 0.003, 0.68], higher communication EASQ‐Z‐scores [0.50 {95% CI: 0.14, 0.85}], and higher personal social EASQ‐Z‐scores [0.46 {95% CI: 0.11, 0.82}]). This study provides further evidence demonstrating the need for interventions to improve dietary diversity among young children.

Dietary diversity was low among young children in our study setting in rural eastern Democratic Republic of the Congo.

Low dietary diversity was associated with linear growth faltering and lower child developmental outcomes.

This study provides further evidence demonstrating the need for interventions to improve dietary diversity among young children to improve child health.

Low Fruit and Vegetable Consumption Associated with Linear Growth Faltering among Children in Urban Bangladesh

The objective of this study was to examine the association between dietary diversity and child growth among children 6 to 23 months of age in urban slums of Bangladesh. This prospective cohort study enrolled 192 participants 6 to 23 months of age in Dhaka, Bangladesh. A total of 170 children with follow-up anthropometric data were included in the analysis. To collect dietary intake information for children 6 to 23 months of age, consumption of five or more of the following eight minimum dietary diversity food groups was recorded using 24-hour dietary recall at enrollment provided by the child's caregiver: 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. Height and weight were measured at baseline and at a 12-month follow-up. Fifty-five percent of children (106 of 192) consumed five or more of the eight minimum dietary diversity food groups during their first visit to assess dietary intake. Eighty-two percent of children (157 of 192) had a report of consuming an animal source of food (e.g., eggs, diary, flesh foods) in the past 24 hours, 85% (164 of 192) consumed any source of protein (e.g., eggs, diary, flesh foods, nuts, and legumes), and 65% of children (125 of 192) were reported to consume any fruits and vegetables. Child consumption of fruits and vegetables was associated positively with change in length-for-age z-scores from baseline to the 12-month follow-up (coefficient, 0.86; 95% CI, 0.03-1.68). Inadequate fruit and vegetable consumption was associated with linear growth faltering among the young children residing in urban Dhaka, Bangladesh. These findings demonstrate the need for effective interventions to increase fruit and vegetable consumption in this susceptible pediatric population.

Fecal Contamination in Child Play Spaces and on Child Hands Are Associated with Subsequent Adverse Child Developmental Outcomes in Rural Democratic Republic of the Congo: REDUCE Prospective Cohort Study

The objective of the Reducing Enteropathy, Undernutrition, and Contamination in the Environment (REDUCE) program is to identify exposure pathways to fecal pathogens that are significant contributors to morbidity among young children in the Democratic Republic of the Congo (DRC), and on developing and evaluating scalable interventions to reduce fecal contamination from these pathways. This prospective cohort study of 270 children under 5 years of age was conducted in rural South Kivu, DRC, to investigate the association between Escherichia coli in hand rinse, soil, food, object, surface, stored water, and water source samples and child developmental outcomes. Child developmental outcomes were assessed by communication, fine motor, gross motor, personal social, problem-solving, and combined scores measured by the Extended Ages and Stages Questionnaire (EASQ) at a 6-month follow-up. Children having E. coli present in the soil in their play spaces had significantly lower combined EASQ z scores (coefficient: -0.38 (95% CI: -0.73, -0.03)). E. coli on children's hands was associated with lower communication EASQ z scores (-0.37 (95% CI: -0.0.10, -0.01), and E. coli in stored drinking water was associated with lower gross motor EASQ z scores (-0.40 (95% CI: -0.68, -0.12). In the REDUCE cohort study, E. coli in soil in child play spaces, on children's hands, and in stored drinking water was associated with lower developmental outcome scores (communication, gross motor, fine motor, and problem-solving skills). These results suggest the need for interventions to reduce fecal contamination in the household environment to protect the cognitive development of susceptible pediatric populations in rural DRC.

Diarrheal Disease Awareness Is Associated with Caregiver Handwashing with Soap in the Democratic Republic of the Congo (REDUCE Program)

Diarrhea is one of the leading causes of childhood illness and a major cause of infant and child mortality globally. In the Reducing Enteropathy, Undernutrition, and Contamination in the Environment (REDUCE) prospective cohort study, we investigated the association between diarrheal disease awareness and handwashing with soap among caregivers of children under 5 years of age. A total of 259 caregivers of children under 5 years of age in Walungu Territory, South Kivu, Democratic Republic of the Congo (DRC), were administered an open-ended questionnaire assessing awareness of diarrheal disease transmission and prevention, and key times to wash hands with soap. An overall diarrhea awareness score was developed based on the responses to these items. Five-hour structured observation of handwashing behaviors was conducted at the 6-month follow-up. Diarrheal disease awareness among caregivers was low. Only 32% of caregivers were able to correctly identify a method of diarrhea prevention. The median diarrhea awareness score was three out of 10 (SD: 1.7, range: 0-9). During structured observation, 9% of caregivers washed their hands with soap at a food-related event and 9% washed their hands with soap at a stool-related event. Higher diarrheal disease awareness was associated with an increased odds of handwashing with soap at food-related events (odds ratio: 1.40, 95% confidence interval: 1.03, 1.90). Our findings emphasize the need for targeted water, sanitation, and hygiene interventions to increase diarrhea awareness to facilitate handwashing with soap among caregivers of children under 5 years in rural 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.

Household Bird Ownership is Associated with Respiratory Illness among Young Children in Urban Bangladesh (CHoBI7 Program)

There is limited evidence on the association between animal ownership and respiratory illness among young children in low- and middle-income countries. In this study, we examined the association between animal ownership and respiratory illness among children younger than 5 years of age enrolled in a prospective cohort study in urban Bangladesh. This prospective cohort study enrolled 884 participants younger than 5 years of age in Dhaka, Bangladesh. At baseline, trained research assistants administered caregivers of children younger than 5 years of age a questionnaire on household animal ownership. Animal ownership was defined as owning chickens, birds other than chickens, cats, and dogs. Respiratory surveillance was conducted monthly for children based on caregiver-reported coughing, rapid breathing, and difficulty breathing in the past 2 weeks during the 12-month study period. At baseline, 48% of children (424 of 884) had reports of coughing, 5% (40 of 884) had difficulty breathing, 3% (25 of 884) had rapid breathing, and 49% (431 of 884) had reports of any of these three respiratory symptoms. Seventeen percent of children (151 of 884) resided in a household that owned an animal. Children residing in households reporting bird ownership had a significantly greater odds of coughing (odds ratio, 1.14; 95% CI, 1.02-1.28) and any of the three respiratory symptoms in the past 2 weeks (odds ratio, 1.14; 95% CI, 1.02-1.28). Household bird ownership was associated with respiratory illness in young children. These findings suggest that interventions aiming to reduce young children's exposure to domestic animals should extend to include birds other than chickens.

Linear Growth Faltering Is Associated with Subsequent Adverse Child Cognitive Developmental Outcomes in the Democratic Republic of the Congo (REDUCE Program)

Globally, 140 million children under 5 years of age are estimated to be stunted. Previous studies have found an association between stunting and poor cognitive outcomes. However, there is limited evidence of this association in sub-Saharan African settings, such as the Democratic Republic of the Congo (DRC). This prospective cohort study of 286 children under 5 years was conducted in rural DRC to investigate the association between diarrhea prevalence, child growth, and child cognitive developmental outcomes. Developmental outcomes were assessed by communication, fine motor, gross motor, personal social, problem-solving, and combined developmental scores measured by the Extended Ages and Stages Questionnaire (EASQ) at a 6-month follow-up visit. Height and weight were measured at baseline and a 6-month follow-up. Diarrhea prevalence was assessed through surveillance visits. Diarrhea prevalence was not associated with follow-up combined EASQ Z-scores at the 6-month follow-up (coefficient: -0.06 [95% CI: -0.29, 0.17]). Each additional standard deviation (SD) increase in height-for-age Z-scores from baseline to the 6-month follow-up increased combined EASQ Z-scores by 0.22 (95%: 0.14, -0.31) SDs. Each additional SD increase in weight-for-age Z-scores from baseline to the 6-month follow-up increased combined EASQ Z-scores by 0.21 (95%: 0.10, -0.32) SDs. Linear growth faltering and reduced weight gain were associated with reduced cognitive developmental outcomes among children residing in rural DRC. Interventions are urgently needed for this susceptible pediatric population to improve child growth and cognitive developmental outcomes.

Diarrhea Prevalence and Child Growth Faltering Are Associated with Subsequent Adverse Child Developmental Outcomes in Bangladesh (CHoBI7 Program)

Millions of young children annually are not meeting their developmental potential in low- and middle-income countries. Previous studies have shown that diarrheal diseases during early life are associated with subsequent malnutrition. This prospective cohort study of 576 children under 5 years was conducted in urban Dhaka, Bangladesh, to investigate the association between diarrhea prevalence, child growth, and child cognitive developmental outcomes. Height and weight were measured at baseline and a 12-month follow-up. Diarrhea prevalence was assessed through monthly surveillance visits. Developmental outcomes were assessed by communication, fine motor, gross motor, personal social, problem-solving, and combined developmental scores measured by the Extended Ages and Stages Questionnaire (EASQ) at the 12-month follow-up visit. To assess the association between diarrhea prevalence, child growth, and child cognitive developmental outcomes, linear regression models were fit using generalized estimating equations to account for clustering at the household level and to approximate 95% CIs. Diarrhea prevalence was negatively associated with change in height-for-age (HAZ) Z-scores from baseline to the 12-month follow-up (coefficient -0.85 [95% CI: -1.42, -0.28]). Diarrhea prevalence was a significant predictor of combined EASQ Z-scores with and without baseline stunting included in the model (-0.89 [95% CI: -1.67, -0.09] [baseline stunting included]) and (-0.88 [95% CI: -1.69, -0.07]). Change in HAZ from baseline to the 12-month follow-up was positively associated with follow-up combined EASQ Z-scores (0.28 [95% CI: 0.15, 0.42]). High diarrhea prevalence and linear growth faltering were associated with negative cognitive developmental outcomes among children residing in urban Dhaka, Bangladesh. Furthermore, high diarrhea prevalence was associated with negative child cognitive developmental outcomes with stunting included in the model, suggesting an effect of diarrhea on cognition independent of stunting.

Contrasting Epidemiology of Cholera in Bangladesh and Africa

In Bangladesh and West Bengal cholera is seasonal, transmission occurs consistently annually. By contrast, in most African countries, cholera has inconsistent seasonal patterns and long periods without obvious transmission. Transmission patterns in Africa occur during intermittent outbreaks followed by elimination of that genetic lineage. Later another outbreak may occur because of reintroduction of new or evolved lineages from adjacent areas, often by human travelers. These then subsequently undergo subsequent elimination. The frequent elimination and reintroduction has several implications when planning for cholera's elimination including: a) reconsidering concepts of definition of elimination, b) stress on rapid detection and response to outbreaks, c) more effective use of oral cholera vaccine and WASH, d) need to readjust estimates of disease burden for Africa, e) re-examination of water as a reservoir for maintaining endemicity in Africa. This paper reviews major features of cholera's epidemiology in African countries which appear different from the Ganges Delta.

Spatial relationship between well water arsenic and uranium in Northern Plains native lands

Arsenic and uranium in unregulated private wells affect many rural populations across the US. The distribution of these contaminants in the private wells of most American Indian communities is poorly characterized, and seldom studied together. Here, we evaluate the association between drinking water arsenic and uranium levels in wells (n = 441) from three tribal regions in North Dakota and South Dakota participating in the Strong Heart Water Study. Groundwater contamination was extensive; 29% and 7% of wells exceeded maximum contaminant levels for arsenic and uranium respectively. 81% of wells had both arsenic and uranium concentrations at one-tenth of their human-health benchmark (arsenic, 1 μg/L; uranium 3 μg/L). Well arsenic and uranium concentrations were uncorrelated (rs = 0.06); however, there appeared to be a spatial correlation of wells co-contaminated by arsenic and uranium associated with flow along a geologic contact. These findings indicate the importance of measuring multiple metals in well water, and to understand underlying hydrogeological conditions. The underlying mechanisms for the prevalence of arsenic and uranium across Northern Plains Tribal Lands in the US, and in particular the occurrence of both elevated arsenic and uranium in drinking water wells in this region, demands further study.

Child Mouthing of Soil and Contaminated Fomites and Unimproved Sanitation are Associated with Subsequent Poor Child Developmental Outcomes in Urban Bangladesh (CHoBI7 Program)

OBJECTIVE

To evaluate the relationship between mouthing of soil and living in unsanitary conditions and child cognitive development in urban Bangladesh.

STUDY DESIGN

This prospective cohort study of 224 children under 5 years of age was conducted in urban Dhaka, Bangladesh. Developmental outcomes were assessed by communication, fine motor, gross motor, personal social, problem solving, and combined developmental scores measured by the Extended Ages and Stages Questionnaire (EASQ) at a 12-month follow-up visit.

RESULTS

Children who had caregiver reports of puting soil in their mouths at the majority of surveillance visits had significantly lower combined EASQ Z scores (coefficient, -0.53; 95% CI, -0.83 to -0.22) at the 12-month follow-up visit. Children who had caregiver reports of putting visibly dirty objects in their mouths at the majority of visits had significantly lower combined EASQ Z scores (-0.50; 95% CI, -0.79 to -0.22). Children in households with unimproved sanitation had significantly lower combined EASQ Z scores (-0.63; 95% CI, -1.11 to -0.16).

CONCLUSIONS

Children found to frequently put soil and visibly dirty objects in their mouths, and those who resided in households using unimproved sanitation, had lower subsequent cognitive developmental outcomes. These findings demonstrate the importance of interventions targeting child mouthing behaviors and sanitation infrastructure to decrease exposure to fecal pathogens and improve child cognitive developmental outcomes.

Fecal Contamination on the Household Compound and in Water Sources are Associated with Subsequent Diarrhea in Young Children in Urban Bangladesh (CHoBI7 Program)

We investigated the environmental and individual-level risk factors for diarrheal disease among young children in slum areas of Dhaka, Bangladesh. A prospective cohort study was conducted among 884 children under 5 years of age. Caregiver reports were collected on sociodemographic factors and hygiene behaviors. Diarrhea surveillance data was collected monthly based on caregiver-reported diarrhea for children in the past 2 weeks during the 12-month study period. Unannounced spot checks of the household compound were performed at 1, 3, 6, 9, and 12 months after enrollment to check for the presence of feces (animal or human) and the presence of animals in the child's sleeping space, to assess child and caregiver hands for the presence of dirt, and to collect samples of the household's source and stored drinking water. Children with feces found on the household compound during spot checks had a significantly higher odds of diarrhea (odds ratio: 1.71; 95% confidence interval: 1.23-2.38). Children residing in households with > 100 colony forming units/100 mL Escherichia coli in source drinking water had a significantly higher odds of diarrhea (OR: 1.43; 95% CI: 1.06-1.92). The presence of feces on the household compound and source drinking water with > 100 colony forming units/100 mL E. coli were significant risk factors for diarrheal disease for children < 5 years of age in slum areas of Dhaka, Bangladesh. These findings demonstrate the urgent need for comprehensive interventions to reduce fecal contamination on the household compound to protect the health of susceptible pediatric populations.

Psychosocial Factors Mediating the Effect of the CHoBI7 Mobile Health Program on Handwashing With Soap and Household Stored Water Quality: A Randomized Controlled Trial

Household members of diarrhea patients are at higher risk of developing diarrheal diseases (>100 times for cholera) than the general population during the 7 days after the diarrhea patient is admitted at a health facility. There is growing evidence demonstrating that theory-driven water, sanitation, and hygiene (WASH) interventions are likely to yield greater behavior change than those based on health education alone. The Cholera Hospital-Based Intervention for 7-Days (CHoBI7) mobile health (mHealth) program is a theory-driven WASH intervention initially delivered to a diarrhea patient by a health promoter during a health facility visit and reinforced through weekly voice and text messages. In the recent randomized controlled trial (RCT) of the CHoBI7-mHealth program in Bangladesh, this intervention significantly reduced diarrheal disease and stunting, and increased handwashing with soap and stored drinking water quality over the 12-month program period. The aim of this study was to assess the underlying mechanism of change of this intervention. Handwashing with soap was measured by 5-hour structured observation. Stored drinking water quality was assessed by the presence of Escherichia coli during unannounced spot checks. Psychosocial factors were measured among 1,468 participants in the CHoBI7-mHealth RCT. Perceived susceptibility, response efficacy, self-efficacy, dirt reactivity, and diarrhea knowledge were mediators of the CHoBI7-mHealth program's effect on stored drinking water quality at the 1-week follow-up. Self-efficacy, response efficacy, and diarrhea knowledge were mediators of the intervention's effect on handwashing with soap habit maintenance and stored drinking water quality at the 12-month follow-up. This study demonstrates how theory-driven approaches for intervention design can facilitate WASH behavior change.

Urinary arsenic is associated with wasting and underweight status in young children in rural Bangladesh

BACKGROUND

Deficits in child growth are associated with poor cognitive outcomes and an increased risk for infection and mortality globally. One hundred forty million people are chronically exposed to arsenic from contaminated drinking water worldwide. While arsenic exposure has been associated with cognitive developmental delays in children, there is limited research on the association between arsenic exposure and growth deficits in young children.

PURPOSE

The objective of this study was to assess the association between chronic arsenic exposure and deficits in growth among children under 5 years in a rural setting in Bangladesh.

METHODS

Urinary arsenic measurements were collected from 465 children between the ages of 28 days-59 months in rural Matlab, Bangladesh, and analyzed by graphite furnace atomic absorption. Height and weight measurements were collected from children according to World Health Organization child growth standards. A z-score cutoff2 standard deviations below the mean was used to define stunting (height-for-age z-score), underweight (weight-for-age z-score), and wasting (weight-for-height z-score).

RESULTS

Children under 5 years with urinary arsenic concentrations in the third tertile (greater than 31 μg per liter (μg/L)) had a two times higher odds of being underweight after adjustment for age, creatinine, paternal education, breastfeeding, number of individuals using the same sleeping room, and physician-diagnosed pneumonia (Odds Ratio (OR): 2.29 (95% Confidence Interval (CI): 1.16, 4.52)). Children under 2 years of age had a two times higher odds of being wasted after adjustment for age, creatinine, paternal education, breastfeeding, number of individuals using the same sleeping room, and physician-diagnosed pneumonia (OR: 2.85 (95% CI: 1.18, 6.89)).

CONCLUSIONS

These findings suggest that arsenic exposure is associated with an increased odds of being wasted and underweight among young children in rural Bangladesh.

Formative Research for the Design of a Baby Water, Sanitation, and Hygiene Mobile Health Program in Bangladesh (CHoBI7 Mobile Health Program)

Poor food hygiene practices, child feces not being disposed of in a latrine, child mouthing of contaminated fomites, and poor hand hygiene of caregivers have been associated with diarrheal diseases, environmental enteropathy, and impaired growth in young children. Mobile health (mHealth) programs present a low-cost approach to delivering water, sanitation, and hygiene (WASH) programs. We conducted a theory-driven and evidence-based approach to formative research and intervention development to design and pilot test a Baby WASH mHealth program targeting food hygiene, child mouthing, and child feces disposal behaviors in urban Dhaka, Bangladesh. Formative research activities included 31 semi-structured interviews, five group discussions, six mHealth workshops, and a three-phase iterative pilot study among 102 households. Findings from semi-structured interviews and group discussions indicate that caregivers of young children have relatively high awareness of the need for safer food hygiene, child mouthing, and child feces disposal practices, but are limited by existing household responsibilities and restricted access to enabling technology that would facilitate practicing recommended behaviors. The piloted Baby WASH mHealth program was well-received by households. This study presents a theory-driven and evidence-based approach for intervention development that can be implemented for the development of future WASH mHealth programs in low-resource settings.

Child Mouthing of Feces and Fomites and Animal Contact are Associated with Diarrhea and Impaired Growth Among Young Children in the Democratic Republic of the Congo: A Prospective Cohort Study (REDUCE Program)

OBJECTIVE

To identify exposure pathways to fecal pathogens that are significant contributors to diarrheal diseases and impaired growth in young children, and to evaluate scalable interventions to reduce fecal contamination from these pathways.

STUDY DESIGN

Reducing Enteropathy, Undernutrition, and Contamination in the Environment (REDUCE) was a prospective cohort study of 370 children <5 years of age was conducted in Walungu Territory, South Kivu, Democratic Republic of the Congo. Child mouthing behaviors were assessed through caregiver reports and 5-hour structured observations. Caregiver reports of child contact with animals and child diarrhea were also obtained. Anthropometric measurements were collected at baseline and at a 6-month follow-up.

RESULTS

Children observed putting soil in their mouth during structured observation at baseline had a significantly higher odds of diarrhea at the 6-month follow-up (OR, 1.79; 95% CI, 1.04 to 3.07). Children observed mouthing feces during structured observation had a significant reduction in height-for-age z-score (HAZ) from baseline to the 6-month follow-up (ΔHAZ, -0.69; 95% CI, -1.34 to -0.04). A significant reduction in HAZ was also observed for children with caregiver reports of touching guinea pigs (-0.33; 95% CI, -0.58 to -0.08) and rabbits (-0.34; 95% CI, -0.64 to -0.04) and children with feces in their sleeping space during unannounced spot checks (-0.41; 95% CI, -0.74 to -0.09).

CONCLUSIONS

These findings emphasize the urgent need for infant water, sanitation, and hygiene interventions targeting child mouthing behaviors, fecal contamination in child living spaces, and child contact with domestic animals to reduce exposure to fecal pathogens among susceptible populations.

Child hand contamination is associated with subsequent pediatric diarrhea in rural Democratic Republic of the Congo (REDUCE Program)

OBJECTIVE

The Reducing Enteropathy, Undernutrition, and Contamination in the Environment (REDUCE) program focuses on identifying exposure pathways to faecal pathogens for young children in the Democratic Republic of the Congo (DRC) and on developing scalable interventions to reduce faecal contamination from these pathways.

METHODS

A prospective cohort study of 690 participants was conducted to investigate the association between hand, food, and environmental faecal contamination and diarrhoeal disease prevalence among young children in Walungu Territory, South Kivu, DRC. A total of 1923 hand rinse, soil, food, object, surface, stored water and water source samples were collected during unannounced spot checks after baseline enrolment and analysed for Escherichia coli. Caregiver reports of diarrhoea were obtained from children < 5 years at a 6-month follow-up.

RESULTS

E.coli was detected in 73% of child and caregiver hand-rinse samples, 69% of soil samples from child play spaces, 54% of child food samples, 38% of objects and surfaces children were observed putting in their mouths, 74% of stored water samples, and 40% of source water samples. Children < 5 years with E. coli on their hands had significantly higher odds of diarrhoea at the 6-month follow-up (odds ratio: 2.03 (95% confidence interval: 1.05, 3.92)).

CONCLUSION

The cohort study findings from the REDUCE program have shown that child hand contamination is associated with diarrhoeal disease in rural DRC, and that there is high faecal contamination in child plays spaces and food. These findings provide evidence demonstrating the urgent need to provide clean play spaces for young children and interventions targeting hand hygiene to reduce paediatric exposure to faecal pathogens.

Effects of a Water, Sanitation and Hygiene Mobile Health Program on Diarrhea and Child Growth in Bangladesh: A Cluster-Randomized Controlled Trial of the CHoBI7 Mobile Health Program

Background

The Cholera Hospital-Based Intervention for 7 Days (CHoBI7) mobile health (mHealth) program was a cluster-randomized controlled trial of diarrhea patient households conducted in Dhaka, Bangladesh.

Methods

Patients were block-randomized to 3 arms: standard message on oral rehydration solution use; health facility delivery of CHoBI7 plus mHealth (no home visits); and health facility delivery of CHoBI7 plus 2 home visits and mHealth. The primary outcome was reported diarrhea in the past 2 weeks collected monthly for 12 months. The secondary outcomes were stunting, underweight, and wasting at a 12-month follow-up. Analysis was intention-to-treat.

Results

Between 4 December 2016 and 26 April 2018, 2626 participants in 769 households were randomly allocated to 3 arms: 849 participants to the standard message arm, 886 to mHealth with no home visits arm, and 891 to the mHealth with 2 home visits. Children <5 years had significantly lower 12-month diarrhea prevalence in both the mHealth with 2 home visits arm (prevalence ratio [PR]: 0.73 [95% confidence interval {CI}, .61–.87]) and the mHealth with no home visits arm (PR: 0.82 [95% CI, .69–.97]). Children <2 years were significantly less likely to be stunted in both the mHealth with 2 home visits arm (33% vs 45%; odds ratio [OR]: 0.55 [95% CI, .31–.97]) and the mHealth with no home visits arm (32% vs 45%; OR: 0.54 [95% CI, .31–.96]) compared with children in the standard message arm.

Conclusions

The CHoBI7 mHealth program lowered pediatric diarrhea and stunting among diarrhea patient households.

Clinical Trials Registration

NCT04008134.

Diarrhoeal disease knowledge among diarrhoea patient housholds: findings from the randomised controlled trial of the Cholera-Hospital-Based-Intervention-for-7-days (CHoBI7) mobile health program

OBJECTIVE

The objective of this study was to evaluate the impact of the Cholera-Hospital-Based-Intervention-for-7-days (CHoBI7) handwashing with soap and water treatment mobile health (mHealth) program on diarrhoeal disease knowledge among diarrhoea patients and their household members in urban Dhaka, Bangladesh.

METHODS

A cluster-randomised controlled trial of the CHoBI7 mHealth program was conducted among diarrhoea patient households in Dhaka, Bangladesh. Patients were randomised to three arms: standard recommendation on oral rehydration solution use; health facility delivery of CHoBI7 plus mHealth (weekly voice and text messages) (no home visits); and health facility delivery of CHoBI7 plus two home visits and mHealth. An open-ended questionnaire was administered to 1468 participants 12 years of age or older on diarrhoeal disease transmission and prevention. These items were combined to form a diarrhoeal disease knowledge score measured at baseline and at a 1 week, 6 month and 12 month follow-up.

RESULTS

At baseline, when participants were asked to report three ways diarrhoeal diseases were spread 37% (546/1468) of participants reported by water, 13% (187/1468) by lack of handwashing and 4% (53/1468) by food not being covered properly. At baseline when asked to name three ways diarrhoeal diseases could be prevented, 35% (515/1468) of participants reported safe water, and 16% (228/1468) reported handwashing with soap. At the 12-month follow-up, the overall diarrhoeal disease knowledge score was significantly higher in the mHealth with no home visits arm (score coefficient: 0.69, 95% Confidence Interval: 0.36, 1.01, P < 0.0001) and the mHealth with two home visits arm (score coefficient: 1.18, 95% CI: 0.87, 1.49, P < 0.0001) compared with the standard recommendation arm.

CONCLUSION

The CHoBI7 mHealth program significantly increased knowledge of diarrhoeal disease transmission and prevention among diarrhoea patients and their household members 12 months after in-person visits for program delivery were conducted.

Process evaluation for the delivery of a water, sanitation and hygiene mobile health program: findings from the randomised controlled trial of the CHoBI7 mobile health program

OBJECTIVE

The Cholera-Hospital-Based Intervention for 7-days (CHoBI7) mobile health (mHealth) program delivers mobile messages to diarrhoea patient households promoting water treatment and handwashing with soap. The randomised controlled trial (RCT) of the CHoBI7 mHealth program demonstrated this intervention was effective in significantly reducing diarrhoea and stunting amoung young children. The objective of this study was to assess the implementation of the CHoBI7 mHealth program in delivering mHealth messages during this RCT.

METHODS

517 diarrhoea patient households with 1777 participants received weekly text, voice and interactive voice response (IVR) messages from the CHoBI7 mHealth program over the 12-month program period. The program process evaluation indicators were the following: the percentage of CHoBI7 mHealth messages received and fully listened to by program households (program fidelity and dose), and household members reporting receiving and sharing an mHealth message from the program in the past two weeks (program reach).

RESULTS

Ninety two percent of text messages were received by program households. Eighty three percent of voice and 86% of IVR messages sent were fully listened to by at least one household member. Eighty one percent of IVR quiz responses from households were answered correctly. Program households reported receiving a CHoBI7 mHealth message in the past two weeks at 79% of monthly household visits during the 12-month program. Seventy seven percent of participants reported sharing a program message with a spouse, 55% with a neighbour and 49% with a child during the program period.

CONCLUSION

There was high fidelity, dose and reach of mobile messages delivered for the CHoBI7 mHealth program. This study presents an approach for process evaluation that can be implemented to evaluate future mHealth programs.

The quality of drinking and domestic water from the surface water sources (lakes, rivers, irrigation canals and ponds) and springs in cholera prone communities of Uganda: an analysis of vital physicochemical parameters

BACKGROUND

Water is the most abundant resource on earth, however water scarcity affects more than 40% of people worldwide. Access to safe drinking water is a basic human right and is a United Nations Sustainable Development Goal (SDG) 6. Globally, waterborne diseases such as cholera are responsible for over two million deaths annually. Cholera is a major cause of ill-health in Africa and Uganda. This study aimed to determine the physicochemical characteristics of the surface and spring water in cholera endemic communities of Uganda in order to promote access to safe drinking water.

METHODS

A longitudinal study was carried out between February 2015 and January 2016 in cholera prone communities of Uganda. Surface and spring water used for domestic purposes including drinking from 27 sites (lakes, rivers, irrigation canal, springs and ponds) were tested monthly to determine the vital physicochemical parameters, namely pH, temperature, dissolved oxygen, conductivity and turbidity.

RESULTS

Overall, 318 water samples were tested. Twenty-six percent (36/135) of the tested samples had mean test results that were outside the World Health Organization (WHO) recommended drinking water range. All sites (100%, 27/27) had mean water turbidity values greater than the WHO drinking water recommended standards and the temperature of above 17 °C. In addition, 27% (3/11) of the lake sites and 2/5 of the ponds had pH and dissolved oxygen respectively outside the WHO recommended range of 6.5-8.5 for pH and less than 5 mg/L for dissolved oxygen. These physicochemical conditions were ideal for survival of Vibrio. cholerae.

CONCLUSIONS

This study showed that surface water and springs in the study area were unsafe for drinking and had favourable physicochemical parameters for propagation of waterborne diseases including cholera. Therefore, for Uganda to attain the SDG 6 targets and to eliminate cholera by 2030, more efforts are needed to promote access to safe drinking water. Also, since this study only established the vital water physicochemical parameters, further studies are recommended to determine the other water physicochemical parameters such as the nitrates and copper. Studies are also needed to establish the causal-effect relationship between V. cholerae and the physicochemical parameters.

Effect of a water, sanitation and hygiene program on handwashing with soap among household members of diarrhoea patients in healthcare facilities in Bangladesh: a cluster-randomised controlled trial of the CHoBI7 mobile health program

OBJECTIVE

The Cholera-Hospital-Based-Intervention-for-7-days (CHoBI7) is a water treatment and handwashing with soap intervention for diarrhoea patients and their household members which is initially delivered in a healthcare facility setting. This study evaluated the effectiveness of CHoBI7 program delivery in increasing handwashing with soap in a healthcare facility setting among diarrhoea patients and their household members.

METHODS

A randomised controlled trial of the CHoBI7 program was conducted among 404 diarrhoea patients and their accompanying household members in healthcare facilities in Dhaka, Bangladesh. The 'Standard Message' Arm received the standard message given in Bangladesh to diarrhoea patients on the use of oral rehydration solution. The 'Health Facility Visit + Soapy Water' Arm received the standard message, the CHoBI7 communication module delivered bedside to the patient; and a soapy water bottle in the healthcare facility. The 'Health Facility Visit + Handwashing Station' Arm received this same intervention plus a small plastic handwashing station. Within 24 h of intervention delivery, three-hour structured observation of handwashing practices at stool/vomit- and food-related events (key events) was conducted in healthcare facilities of diarrhoea patients and their accompanying household members.

RESULTS

Compared to the Standard Message Arm, there was significantly more handwashing with soap at key events in both the Health Facility Visit + Soapy Water Arm (51% vs. 25 %) (Odds Ratio: 3.02; (95% Confidence Interval (CI): 1.41, 6.45) and the Health Facility Visit + Handwashing Station Arm (58% vs. 25%) OR: 4.12; (95% CI: 1.86, 9.14).

CONCLUSION

These findings demonstrate that delivery of the CHoBI7 communication module and provision of a soapy water bottle to diarrhoea patients and their accompanying household members presents a promising approach to increase handwashing with soap among this high risk population in a healthcare facility setting in Bangladesh.

Prospective cohort study of child mouthing of faeces and fomites in Dhaka, Bangladesh (CHoBI7 Program)

OBJECTIVE

To characterise childhood mouthing and handling behaviours and to assess the association between hand-to-object and object-to-mouth contacts and diarrhoea prevalence in young children in urban Dhaka, Bangladesh.

METHODS

A prospective cohort study was conducted among 494 children under 5 years of age in Dhaka, Bangladesh. This study was nested within the randomised controlled trial of the Cholera Hospital-Based Intervention for 7 Days (CHoBI7) mobile health (mHealth) program. The CHoBI7 mHealth program focuses on promoting handwashing with soap and water treatment to diarrhoea patients and their household members through mobile messages and a single in person visit. Mouthing and handling of faeces and fomites among young children was measured by five-hour structured observation and caregiver reports. Diarrhoea surveillance data was collected monthly for 12 months.

RESULTS

Fifty five percent of caregivers reported that their child put a visibly dirty fomite (object or soil) in their mouth in the past week. Caregivers reported that 50% of children had mouthed visibly dirty objects, 26% had mouthed dirt, and 2% had mouthed faeces. Forty five percent of children were observed mouthing a visibly dirty fomite during structured observation, 40% of children were observed mouthing a visibly dirty object, 10% were observed mouthing soil, and one child (0.2%) was observed mouthing faeces. Mouthing of visibly dirty fomites was highest for children 12-18 months of age with 69% of these children having caregiver reports and 54% having observed events. Children with caregiver reports of mouthing faeces had a significantly higher odds of diarrhoea over the subsequent month (Odds Ratio: 4.54; 95% Confidence Interval: 1.06, 19.48).

CONCLUSION

These findings demonstrate that mouthing of contaminated fomites among young children is frequent in urban environments in Bangladesh, and that mouthing faeces is associated with a significantly higher odds of diarrhoea. Interventions are urgently needed to protect young children from faecal pathogens in their play spaces.

Formative research to scale up a handwashing with soap and water treatment intervention for household members of diarrhea patients in health facilities in Dhaka, Bangladesh (CHoBI7 program)

BACKGROUND

During the time a diarrhea patient presents at a health facility, the household members of the patient are at higher risk of developing diarrheal diseases (> 100 times for cholera) than the general population. The Cholera-Hospital-based-Intervention-for-7-Days (CHoBI7) is a health facility-initiated water treatment and handwashing with soap intervention designed to reduce transmission of diarrheal diseases between patients and their household members. The present research aimed to (1) develop a scalable approach to integrate the CHoBI7 intervention program into services provided at government and private health facilities in Bangladesh; and (2) tailor the intervention program for the household members of all diarrhea patients, irrespective of the etiology of disease.

METHODS

We conducted 8 months of formative research, including 60 semi-structured interviews, 2 group discussions, and a pilot study. Thirty-two interviews were conducted with diarrhea patients and their family caregivers, government stakeholders, and health care providers both to explore existing WASH and diarrhea patient care practices in health facilities and to identify considerations for scaling the CHoBI7 program. Fifty-two diarrhea patient households participated in a pilot study of a modified version of the CHoBI7 intervention program for tailoring. Twenty-eight interviews and 2 group discussions were conducted with pilot households to explore experiences with and recommendations for intervention delivery.

RESULTS

The intervention program was modified based on formative research findings. Pilot study participants recognized the benefits of the CHoBI7 intervention program and made suggestions to improve the acceptability and feasibility of the intervention. Modifications included 1) providing additional pictorial modules, cues to action, enabling technologies, and supplies for safe drinking water and handwashing with soap behaviors in the health facility; 2) switching out technology prone to breaks and leaks as well as sourcing plastic technologies from a high-quality, local manufacturer; and 3) including instructions discouraging the non-use or misuse of technologies and supplies. Considerations for scalability include the local availability and marketing of enabling technologies and supplies, staff for program delivery in health facilities, and potential integration into existing government or health promotion programs.

CONCLUSIONS

Formative research identified important considerations for the content, delivery, and scalability of the CHoBI7 health facility-initiated WASH intervention program.

A Retrospective Case-Control Study of the Relationship between the Gut Microbiota, Enteropathy, and Child Growth

The microbial communities residing in the child gut are thought to play an important role in child growth, although the relationship is not well understood. We examined a cohort of young children from Mirzapur, Bangladesh, prospectively over 18 months. Four fecal markers of environmental enteropathy (EE) (high levels of alpha-1-antitrypsin, calprotectin, myeloperoxidase, and neopterin) were examined and anthropometric measures obtained from a cohort of 68 children. The 16S rRNA gene of bacterial DNA was sequenced from stool samples and used to estimate amplicon sequence variants (ASVs). We age-matched children with poor growth to children with normal growth within 1 month and compared the change in abundance and diversity of ASVs over time. Elevated EE markers and poor linear growth in children were associated with changes in microbial communities in the gut. There were increased amounts of Escherichia/Shigella and Proteobacteria and decreased amounts of Prevotella associated with poorly growing children consistent with the mounting evidence supporting the relationship between intestinal inflammation, child growth, and changes in gut microbiota composition. Future research is needed to investigate this association among young children in low- and middle-income countries.

Colistin-resistant Escherichia coli carrying mcr-1 in food, water, hand rinse, and healthy human gut in Bangladesh

BACKGROUND

One of the most significant public health concerns in today's world is the persistent upsurge of infections caused by multidrug resistant bacteria. As a result, clinicians are being forced to intervene with either less effective backup drugs or ones with substantial side-effects. Colistin is a last resort antimicrobial agent for the treatment of infections caused by multi-drug resistant gram-negative bacteria.

METHODS

Escherichia coli (n = 65) isolated from street food (n = 20), hand rinse (n = 15), surface water (n = 10), and healthy human stool (n = 20) were tested for colistin resistance gene mcr-1 and response to antimicrobial agents. Antimicrobial resistance genes and virulence genes were detected by employing polymerase chain reaction. DNA fingerprinting of the strains were determined by pulsed-field gel electrophoresis.

RESULTS

Screening of E. coli allowed us to confirm colistin resistance marker gene mcr-1 in 13 strains (street food, n = 4; hand rinse, n = 2; surface water, n = 4; and stool, n = 3); and two of these E. coli strains carrying mcr-1 harbored bla TEM gene encoding extended spectrum beta lactamase. Antibiotic assay results revealed all 13 E. coli strains carrying mcr-1 to be multi-drug resistant (MDR), including to colistin. The minimum inhibitory concentration (MIC) for colistin ranged from 2 to 6 μg/ml. DNA sequencing confirmed homogeneity of the nucleotide sequence for mcr-1, but the E. coli strains were heterogenous, as confirmed by pulsed-field gel electrophoresis suggesting horizontal transmission of colistin resistance in Bangladesh.

CONCLUSION

Widespread dissemination of E. coli strains carrying mcr-1 encoding resistance to colistin in the present study is alarming as this is the last resort drug for the treatment of infections caused by MDR gram-negative bacteria resistant to almost all drugs used commonly.

Whatman Protein Saver Cards for Storage and Detection of Parasitic Enteropathogens

Current methods to identify the etiology of diarrhea require laboratory facilities for storage of pathogens, which is often challenging in low-resource settings. This study evaluated the efficacy of a low-cost method for preserving stool specimens for the detection of parasitic enteropathogens using Whatman 903 protein saver cards (Sigma-Aldrich, St. Louis, MO). Stool samples known to be positive by multiplex real-time polymerase chain reaction for Giardia lamblia, Cryptosporidium spp., and Entamoeba histolytica parasites were preserved on 232 Whatman cards. DNA was then extracted from cards using Chelex and Qiagen extraction protocols, and tested for these parasites using multiplex real-time PCR. We included stool samples known to have a higher parasite load (cycle threshold [ct]-value < 30) and those with a lower parasite load (ct values 30-35). Sensitivities and specificities were determined using DNA extracted directly from whole stool samples using Qiagen kits (QIAGEN, Hilden, Germany). For whole stool samples with ct values < 30, preserved directly on Whatman 903 protein saver cards for Giardia analysis, the sensitivity was 100% for both Qiagen and Chelex DNA extraction. For E. histolytica, this was 100% for sensitivity for Qiagen and 80% for Chelex DNA extractions, and for Cryptosporidium, this was 80% for Qiagen and 50% for Chelex DNA extraction. The specificity was 100% for all parasites for all extraction procedures. Given the high sensitivity for stool samples with higher parasite loads, we recommend the use of the Whatman 903 protein saver card for preserving fecal specimens for the analysis of Giardia and E. histolytica using Qiagen DNA extractions in low-resource settings.

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.

The Strong Heart Water Study: Informing and designing a multi-level intervention to reduce arsenic exposure among private well users in Great Plains Indian Nations

Elevated arsenic exposure from drinking water is associated with an increased risk of cardiovascular disease, diabetes, kidney disease, and skin, lung, and bladder cancer. Arsenic contamination in groundwater supplies disproportionately affects rural populations using private wells. Arsenic mitigation programs for American Indian communities are limited. There is an urgent need for targeted approaches to reduce arsenic exposure for at-risk communities using private wells. Formative research was conducted to inform and design a community-based arsenic mitigation intervention for Lakota and Dakota Nations in the Great Plains Area of the United States, where, in some communities, one-quarter of private wells are estimated to have elevated arsenic. Formative research included semi-structured interviews, a community workshop, intervention-planning workshops, and a pilot study of the developed intervention. Community members prioritize aesthetic qualities of water (e.g. taste, color), safety, and other situational factors (e.g. cost) when considering their drinking and cooking water. Although water safety is a concern, awareness and concern for arsenic vary substantially within communities. To reduce arsenic exposure, community members recommended communication of water test results, home visits for intervention delivery, and reminders to use arsenic-safe water. Findings informed the development of an intervention to prevent arsenic exposure through drinking water and cooking, including health promotion messages and household items to facilitate use of an arsenic removal device (e.g. tankards to store filtered water). The pilot study indicated promising acceptability and operability of the developed intervention. This research provides a model for the development of environmental health interventions in partnership with American Indian and other private well-using communities.

Arsenic in groundwater in private wells in rural North Dakota and South Dakota: Water quality assessment for an intervention trial

Elevated exposure to arsenic disproportionately affects populations relying on private well water in the United States (US). This includes many American Indian (AI) communities where naturally occurring arsenic is often above 10 µg/L, the current US Environmental Protection Agency safety standard. The Strong Heart Water Study is a randomized controlled trial aiming to reduce arsenic exposure to private well water users in AI communities in North Dakota and South Dakota. In preparation for this intervention, 371 households were included in a community water arsenic testing program to identify households with arsenic ≥10 µg/L by inductively coupled plasma mass spectrometry (ICP-MS). Arsenic ≥10 µg/L was found in 97/371 (26.1%) households; median water arsenic concentration was 6.3 µg/L, ranging from <1-198 µg/L. Silica was identified as a water quality parameter that could impact the efficacy of arsenic removal devices to be installed. A low-range field rapid arsenic testing kit evaluated in a small number of households was found to have low accuracy; therefore, not an option for the screening of affected households in this setting. In a pilot study of the effectiveness of a point-of-use adsorptive media water filtration device for arsenic removal, all devices installed removed arsenic below 1 µg/L at both installation and 9 months post-installation. This study identified a relatively high burden of arsenic in AI study communities as well as an effective water filtration device to reduce arsenic in these communities. The long-term efficacy of a community based arsenic mitigation program in reducing arsenic exposure and preventing arsenic related disease is being tested as part of the Strong Heart Water Study.