Legionellosis on the rise: A scoping review of sporadic, community-acquired incidence in the United States

Over the past two decades, the incidence of legionellosis has been steadily increasing in the United States though there is noclear explanation for the main factors driving the increase. While legionellosis is the leading cause of waterborne outbreaks in the US, most cases are sporadic and acquired in community settings where the environmental source is never identified. This scoping review aimed to summarise the drivers of infections in the USA and determine the magnitude of impact each potential driver may have. A total of 1,738 titles were screened, and 18 articles were identified that met the inclusion criteria. Strong evidence was found for precipitation as a major driver, and both temperature and relative humidity were found to be moderate drivers of incidence. Increased testing and improved diagnostic methods were classified as moderate drivers, and the ageing U.S. population was a minor driver of increasing incidence. Racial and socioeconomic inequities and water and housing infrastructure were found to be potential factors explaining the increasing incidence though they were largely understudied in the context of non-outbreak cases. Understanding the complex relationships between environmental, infrastructure, and population factors driving legionellosis incidence is important to optimise mitigation strategies and public policy.

Two-Year Evaluation of Legionella in an Aging Residential Building: Assessment of Multiple Potable Water Remediation Approaches

Legionella is an opportunistic waterborne pathogen that is difficult to eradicate in colonized drinking water pipes. Legionella control is further challenged by aging water infrastructure and lack of evidence-based guidance for building treatment. This study assessed multiple premise water remediation approaches designed to reduce Legionella pneumophila (Lp) within a residential building located in an aging, urban drinking water system over a two-year period. Samples (n=745) were collected from hot and cold-water lines and quantified via most probable number culture. Building-level treatment approaches included three single heat shocks (HS), three single chemical shocks (CS), and continuous low-level chemical disinfection (CCD) in the potable water system. The building was highly colonized with Lp with 71% Lp positivity. Single HS had a statistically significant Lp reduction one day post treatment but no significant Lp reduction one, two, and four weeks post treatment. The first two CS resulted in statistically significant Lp reduction at two days and four weeks post treatment, but there was a significant Lp increase at four weeks following the third CS. CCD resulted in statistically significant Lp reduction ten weeks post treatment implementation. This demonstrates that in a building highly colonized with Lp, sustained remediation is best achieved using CCD.

The association between menstrual hygiene, workplace sanitation practices and self-reported urogenital symptoms in a cross-sectional survey of women working in Mukono District, Uganda

BACKGROUND

Women worldwide experience challenges managing their periods. Menstrual and genital hygiene behaviours have been linked to negative health outcomes, including urogenital symptoms and confirmed infections. However, evidence testing this association has been limited and mixed. This study aimed to (1) describe the menstrual care practices and prevalence of self-reported urogenital symptoms among working women in Mukono District, Uganda, and (2) test the associations between menstrual and genital care practices, and urogenital symptoms.

METHODOLOGY

We undertook a cross-sectional survey of women aged 18-45 working in markets, schools, and healthcare facilities in Mukono District, with 499 participants who had menstruated in the past two months included in this analysis. We developed an aggregated measure of menstrual material cleanliness, incorporating material type and laundering practices. Associations with urogenital symptoms were tested using the aggregated material cleanliness measure alongside the frequency of changing materials, handwashing before menstrual tasks, and sanitation practices.

RESULTS

Among our sample, 41% experienced urogenital symptoms in the past month. Compared to women exclusively using disposable pads, using appropriately cleaned or non-reused improvised materials (PR = 1.33, 95%CI 1.04-1.71), or inadequately cleaned materials (improvised or commercially produced reusable pads) (PR = 1.84, 95%CI 1.46-3.42) was associated with an increased prevalence of self-reported urogenital symptoms in the last month. There was no difference between those using disposable pads and those using clean reusable pads (PR = 0.98; 95%CI 0.66-1.57). Infrequent handwashing before changing materials (PR 1.18, 95%CI: 0.96-1.47), and delaying urination at work (PR = 1.37, 95%CI: 1.08-1.73) were associated with an increased prevalence of self-reported symptoms.

CONCLUSION

Prevalence of self-reported urogenital symptoms was associated with the type and cleanliness of menstrual material used as well as infrequent handwashing and urinary restriction. There is a need for interventions to enable women to maintain cleanliness of their menstrual materials and meet their menstruation, urination and hand washing needs at home and work.

Revalidation and adaptation of the Menstrual Practice Needs Scale (MPNS) in a cross-sectional survey to measure the menstrual experiences of adult women working in Mukono District, Uganda

OBJECTIVES

The Menstrual Practice Needs Scale (MPNS) is a comprehensive measure of menstrual self-care experience including access to sufficient, comfortable materials to catch or absorb bleeding, supportive spaces for managing menstruation and for disposal and laundering of used materials. It addresses a critical measurement gap to improve quantitative menstrual health research and programme evaluation. The scale was validated in a population of adolescent schoolgirls. This study appraises its performance among adult women.

DESIGN

Cross-sectional survey.

SETTING AND PARTICIPANTS

Seven cognitive interviews provided insights into the interpretability of scale items. A survey of 525 working women who had menstruated in the past 6 months (435 working in markets, 45 in schools and 45 working in healthcare facilities) in Mukono District, Uganda was used to test the dimensionality, reliability and validity of the measure.

RESULTS

The 36 scale items were well understood by the study population. Dimensionality was tested for the 28 items relevant to women disposing of menstrual materials and 32 items relevant to those washing and reusing materials. The original subscale structure fit with the data, however, fell short of recommended thresholds for those disposing of materials (root mean squared error of approximation, RMSEA=0.069; Comparative Fit Index, CFI=0.840; Trucker-Lewis Index, TLI=0.824). An alternative subscale structure was an acceptable fit for those disposing (RMSEA=0.051; CFI=0.911; TLI=0.897) and reusing materials (RMSEA=0.053; CFI=0.915; TLI=0.904). MPNS total and subscale scores demonstrated acceptable internal consistency. Higher scores reflected more positive menstrual experiences and were associated with well-being (total score r=0.24, p<0.001), not missing work due to the last menstrual period (total score OR=2.47 95% CI 1.42 to 4.30) and confidence to manage menstruation.

CONCLUSIONS

The MPNS offers a valid and reliable way to assess menstrual health needs. The revised factor structure can be used for samples of adult workers. Findings also highlight challenges in assessing the variety of experiences relevant to managing menstrual bleeding.

Menstrual health challenges in the workplace and consequences for women's work and wellbeing: A cross-sectional survey in Mukono, Uganda

This study describes women's menstrual health needs at work in Uganda and explores the associations between unmet needs and women's work and wellbeing. We undertook a cross-sectional survey of women working in marketplaces, public primary schools, and health care facilities in Mukono district, central Uganda. Survey questions were designed to capture women's experiences of managing menstrual bleeding, pain, social support, and the social environment. A total 435 women working in markets, 45 teachers and 45 health care facility workers participated. Of these, 15% missed work due to their last period, and 41% would prefer not to work during menstruation. Unmet menstrual health needs were associated with consequences for women's work and psychological wellbeing. Experiencing menstrual pain (aPR 3.65 95%CI 1.48-9.00), along with the use of improvised menstrual materials (aPR 1.41 95%CI 1.08-1.83), not feeling comfortable to discuss menstruation at work (aPR 1.54 95%CI 1.01-2.34) and the expectation that women should stay home when menstruating (aPR 2.44 95%CI 1.30-4.60) were associated with absenteeism due to menstruation. In contrast, not having menstrual management needs met (aPR 1.45 95%CI 1.17-1.79) and the attitude that menstruating women are dirty (aPR 1.94 95%CI 1.50-2.51), along with pain (aPR 1.59 95%CI 1.12-2.24) and norms around absenteeism were associated with wanting to miss work. After adjustment for age and poverty, unmet menstrual management needs (b = -5.97, 95%CI -8.89, -2.97), pain (b = -3.89, 95%CI -7.71, -0.08) and poor social support (b = -5.40, 95%CI -9.22, -1.57) were associated with lower wellbeing measured using the WHO-5. Attitudes that menstruation should be kept secret (b = 4.48, 95%CI 0.79, 8.17) and is dirty (b = 4.59, 95%CI 0.79, 8.40) were associated with higher wellbeing. Findings suggest that supporting care for menstrual pain, addressing secrecy surrounding menstruation and the perception of menstruation as dirty, and improving access to materials and facilities for managing menstrual bleeding are avenues for programs and policies to support working women.

'I do what a woman should do': a grounded theory study of women's menstrual experiences at work in Mukono District, Uganda

Menstrual health has received increasing recognition as an essential issue for public health and gender equality. A growing body of research has elucidated adolescent girls’ menstrual needs and informed policy and practice responses. However, the experiences of adult women have received little attention, particularly in the workplace where many spend a significant proportion of their lives. To address this gap, we took a grounded theory approach to generate a nuanced understanding of working women’s menstrual experiences, and the impact of menstruation on their work and health in Mukono District, Uganda. In-depth interviews were undertaken with 35 women aged 18–49. This included 21 women working in markets, 7 teachers and 7 healthcare facility workers. Frequent collaborative analysis sessions throughout data collection, coding of interview transcripts, and generation of participant, workplace, and category memos facilitated analysis. Our core category and underlying theory, ‘being a responsible woman’, underpinned women’s experiences. ‘Being responsible’ meant keeping menstruation secret, and the body clean, at all times. These gendered expectations meant that any difficulty managing menses represented a failure of womanhood, met with disgust and shame. Difficulties with menstrual pain and heavy bleeding were excepted from these expectations and perceived as requiring compassion. Commercial menstrual products were expensive for most women, and many expressed concerns about the quality of cheaper brands. Workplace infrastructure, particularly unreliable water supply and cleanliness, was problematic for many women who resorted to travelling home or to other facilities to meet their needs. Menstruation presented a burden at work, causing some women to miss work and income, and many others to endure pain, discomfort and anxiety throughout their day. Our findings can inform norm and resource-focused responses to improve experiences and should provoke critical reflection on the discourse used in menstrual health advocacy in Uganda.

Comparison of 1-week and 2-week recall periods for caregiver-reported diarrhoeal illness in children, using nationally representative household surveys

BACKGROUND

Diarrhoeal outcomes in children are often ascertained using caregiver-reported symptoms, which are subject to a variety of biases and methodological challenges. One source of bias is the time window used for reporting diarrhoeal illness and the ability of caregivers to accurately recall episodes in children.

METHODS

Diarrhoea period prevalence in children under five was determined using two similarly administered, nationally representative household surveys: Performance Monitoring and Accountability 2020 (PMA2020) (1-week recall, N = 14 603) and Demographic and Health Surveys (DHS) (2-week recall, N = 66 717). Countries included in the analysis were the Democratic Republic of the Congo, Ethiopia, Ghana, Kenya and Uganda. Diarrhoea period prevalence estimates were compared and water, sanitation and hygiene risk factors were analysed.

RESULTS

Childhood diarrhoea prevalence using 1-week recall (PMA2020) pooled across countries was 21.4% [95% confidence interval (CI): 19.9%, 22.9%] versus 16.0% using 2-week recall (DHS) (95% CI: 15.4%, 16.5%). In stratified analyses for all five countries, the number of diarrhoea cases detected was consistently higher using 1-week recall versus 2-week recall. The key risk factors identified in the PMA2020 data that were not associated with diarrhoeal episodes or were attenuated in the DHS data included: the main sanitation classifications for households, disposal method used for child faeces, number of household members and wealth quintiles.

CONCLUSIONS

For nationally representative household surveys assessing childhood diarrhoea period prevalence, a 2-week recall period may underestimate diarrhoea prevalence compared with a 1-week period. The household sanitation facility and practices remain key risk factors for diarrhoeal disease in children under five.

Evaluating the declarations of open defecation free status under the Swachh Bharat (‘Clean India’) Mission: repeated cross-sectional surveys in Rajasthan, India

Background

The most ambitious sanitation campaign to end open defecation (OD) in India came to a close on 2 October 2019 and there are limited independent, robust data to measure its success. We aimed to evaluate Rajasthan’s claim of open defecation free status in March 2018 under the Swachh Bharat Mission (SBM) or ‘Clean India Mission’ by measuring OD trends from 2016 to 2018.

Methods

We used publicly available data from Performance Monitoring and Accountability 2020, a representative survey with two-stage stratified cluster sampling. Enumeration areas were the primary sampling units selected by the probability proportional ­to ­size method. The repeated cross-sectional surveys independently collected household water and sanitation data in Rajasthan (n=20 485). Among households reporting toilet access, the data were pooled across the four rounds for an observational analysis using logistic regression. The primary outcome measure was regular OD among households with access to toilet facilities.

Findings

Between October 2016 and July 2018 main OD practices in rural Rajasthan households decreased from 63.3% (95% CI 57.0% to 69.6%) to 45.8% (95% CI 38.4% to 53.2%) and in urban households from 12.6% (95% CI 6.0% to 19.1%) to 9.4% (95% CI 4.0% to 14.7%). Households with regular OD occurring despite access to a toilet made up 21.7% (95% CI 16.9% to 26.6%) of rural and 12.1% (95% CI 3.6% to 20.7%) of urban Rajasthan as of July 2018. The multivariate logistic regression revealed that factors related to water stress and sanitation sharing were associated with household members regularly practising OD.

Conclusions

These data highlight the importance of a continued focus on constructing toilets that are affordable with low water requirements during the next phase of SBM. An independent survey that can provide robust estimates of OD is needed to monitor progress of toilet construction and use.

The prevalence of schistosomiasis in Uganda: A nationally representative population estimate to inform control programs and water and sanitation interventions

Background

To improve schistosomiasis control programs in Uganda, where intestinal schistosomiasis is a widespread public health problem, a country-wide assessment of the disease prevalence among all age ranges is needed. Few studies have aimed to quantify the relationships between disease prevalence and water and sanitation characteristics across Uganda to understand the potential to interrupt disease transmission with an integrated package of interventions.

Methodology/Principal findings

A nationally representative survey was undertaken that included a household and individual questionnaire followed by disease testing based on detection of worm antigens (circulating cathodic antigen–CCA), diagnosis and treatment. A comprehensive set of questions was asked of randomly sampled individuals, two years of age and above, to understand their water and sanitation infrastructure, open defecation behaviors, exposure to surface water bodies, and knowledge of schistosomiasis. From a set of 170 randomly sampled, geographically diverse enumeration areas, a total of 9,183 study participants were included. After adjustment with sample weights, the national prevalence of schistosomiasis was 25.6% (95% confidence interval (CI): 22.3, 29.0) with children ages two to four most at risk for the disease with 36.1% infected (95% CI: 30.1, 42.2). The defecation behaviors of an individual were more strongly associated with infection status than the household water and sanitation infrastructure, indicating the importance of incorporating behavior change into community-led total sanitation coverage.

Conclusions/Significance

Our results highlight the importance of incorporating monitoring and evaluation data into control programs in Uganda to understand the geographic distribution of schistosomiasis prevalence outside of communities where endemicity is known to be high. The high prevalence of schistosomiasis among the youngest age group, ineligible to receive drug treatment, shows the imperative to develop a child-appropriate drug protocol that can be safely administered to preschool-aged children. Water and sanitation interventions should be considered an essential investment for elimination alongside drug treatment.

Schistosomiasis is a neglected tropical disease in sub-Saharan Africa that has remained intractable despite efforts to eliminate it through mass drug administration. The transmission cycle is perpetuated when sanitation infrastructure does not adequately capture infected urine or feces and local water bodies, with snail vectors, are contaminated. Schistosomiasis has been linked with stunting and cognitive deficits and there is particular concern for the most vulnerable age group under five years old who are undergoing critical intestinal development but are ineligible to receive drug treatment. Efforts to reduce the disease have focused on children and young adolescents in endemic areas, near water bodies where transmission is known to be high. In Uganda, where fresh water bodies are abundant and intestinal schistosomiasis is endemic, very little is understood about the disease prevalence at a national level. We conducted a large, nationally representative survey and found a national prevalence of 25.6% where the 2–4 year old children had the highest prevalence for schistosomiasis with 36.1% infected. The most significant risk-factor for the disease was an individual’s open defecation behaviors in surface waters. This emphasizes the need to include water and sanitation investments alongside drug treatment and behavior change to control schistosomiasis in Uganda.

Correction to: Extreme Precipitation, Public Health Emergencies, and Safe Drinking Water in the USA

Unfortunately, the original publication of this article contained mistakes. The publisher introduced an error after proofreading where the name of the co-author was mistakenly captured as "David P. E. Harvey". The correct name should be "David E. Harvey".

The Relationship between Household Sanitation and Women's Experience of Menstrual Hygiene: Findings from a Cross-Sectional Survey in Kaduna State, Nigeria

Global efforts to improve sanitation have emphasized the needs of women and girls. Managing menstruation is one such need, yet there is scarce research capturing current practices. This study investigated the relationships between household sanitation and women’s experience of menstrual management. Secondary analyses were undertaken on data from 1994 women and girls collected through the Performance Monitoring and Accountability 2020 survey in Kaduna, Nigeria. In multivariable models, women had higher odds of using the main household sanitation facility for menstrual management when they had access to a basic (OR = 1.76 95%CI 1.26–2.46) or limited (OR = 1.63 95%CI 1.08–2.48) sanitation facility, compared to an unimproved facility. Women with no household sanitation facility had higher odds of using their sleeping area (OR = 3.56 95%CI 2.50–5.06) or having no facility for menstrual management (OR = 9.86 95%CI 5.76–16.87) than women with an unimproved sanitation facility. Menstrual management locations were associated with ratings of their characteristics. Safely managed or basic sanitation facilities were not rated more favorably than unimproved facilities in privacy (OR = 1.02 95%CI 0.70–1.48), safety (OR = 1.45 95%CI 0.98–2.15), access to a lock (OR = 0.93 95%CI 0.62–1.37), or soap and water (OR = 1.04 95%CI 0.70–1.56). Women using their sleeping area had more favorable perceptions of their environment. Findings suggest household sanitation influences women’s choices for menstrual management, but that existing indicators for improvement are not sensitive to menstrual needs.

A Longitudinal Study of Household Water, Sanitation, and Hygiene Characteristics and Environmental Enteropathy Markers in Children Less than 24 Months in Iquitos, Peru

Poor child gut health, resulting from a lack of access to an improved toilet or clean water, has been proposed as a biological mechanism underlying child stunting and oral vaccine failure. Characteristics related to household sanitation, water use, and hygiene were measured among a birth cohort of 270 children from peri-urban Iquitos Peru. These children had monthly stool samples and urine samples at four time points and serum samples at (2–4) time points analyzed for biomarkers related to intestinal inflammation and permeability. We found that less storage of fecal matter near the household along with a reliable water connection were associated with reduced inflammation, most prominently the fecal biomarker myeloperoxidase (MPO) (no sanitation facility compared with those with an onsite toilet had −0.43 log MPO, 95% confidence interval [CI]: −0.74, −0.13; and households with an intermittent connection versus those with a continuous supply had +0.36 log MPO, 95% CI: 0.08, 0.63). These results provide preliminary evidence for the hypothesis that children less than 24 months of age living in unsanitary conditions will have elevated gut inflammation.

Use of Pathogen-Specific Antibody Biomarkers to Estimate Waterborne Infections in Population-Based Settings

PURPOSE OF REVIEW

This review discusses the utility of pathogen-specific antibody biomarkers for improving estimates of the population burden of waterborne infections, assessing the fraction of infections that can be prevented by specific water treatments, and understanding transmission routes and the natural history and ecology of disease in different populations (including asymptomatic infection rates).

RECENT FINDINGS

We review recent literature on the application of pathogen-specific antibody response data to estimate incidence and prevalence of acute infections and their utility to assess the contributions of waterborne transmission pathways. Advantages and technical challenges associated with the use of serum versus minimally invasive salivary antibody biomarkers in cross-sectional and prospective surveys are discussed. We highlight recent advances and challenges and outline future directions for research, development, and application of antibody-based and other immunological biomarkers of waterborne infections.

Floors and Toilets: Association of Floors and Sanitation Practices with Fecal Contamination in Peruvian Amazon Peri-Urban Households

Over two billion people worldwide lack access to an improved sanitation facility that adequately retains or treats feces. This results in the potential for fecal material containing enteric pathogens to contaminate the environment, including household floors. This study aimed to assess how floor type and sanitation practices impacted the concentration of fecal contamination on household floors. We sampled 189 floor surfaces within 63 households in a peri-urban community in Iquitos, Peru. All samples were analyzed for colony forming units (CFUs) of E. coli, and households were evaluated for their water, sanitation, and hygiene characteristics. Results of multivariate linear regression indicated that households with improved sanitation and cement floors in the kitchen area had reduced fecal contamination to those with unimproved sanitation and dirt floors (Beta: -1.18 log10 E. coli CFU/900 cm(2); 95% confidence interval [CI]: -1.77, -0.60). Households that did not versus did share their sanitation facility also had less contaminated kitchen floors (Beta: -0.65 log10 E. coli CFU/900 cm(2); 95% CI: -1.15, -0.16). These findings suggest that the sanitation facilities of a home may impact the microbial load found on floors, contributing to the potential for household floors to serve as an indirect route of fecal pathogen transmission to children.

Water quality, weather and environmental factors associated with fecal indicator organism density in beach sand at two recreational marine beaches

Recent studies showing an association between fecal indicator organisms (FIOs) in sand and gastrointestinal (GI) illness among beachgoers with sand contact have important public health implications because of the large numbers of people who recreate at beaches and engage in sand contact activities. Yet, factors that influence fecal pollution in beach sand remain unclear. During the 2007 National Epidemiological and Environmental Assessment of Recreational (NEEAR) Water Study, sand samples were collected at three locations (60 m apart) on weekend days (Sat, Sun) and holidays between June and September at two marine beaches - Fairhope Beach, AL and Goddard Beach, RI - with nearby publicly-owned treatment works (POTWs) outfalls. F(+) coliphage, enterococci, Bacteroidales, fecal Bacteroides spp., and Clostridium spp. were measured in sand using culture and qPCR-based calibrator-cell equivalent methods. Water samples were also collected on the same days, times and transects as the 144 sand samples and were assayed using the same FIO measurements. Weather and environmental data were collected at the time of sample collection. Mean FIO concentrations in sand varied over time, but not space. Enterococci CFU and CCE densities in sand were not correlated, although other FIOs in sand were. The strongest correlation between FIO density in sand and water was fecal Bacteroides CCE, followed by enterococci CFU, Clostridium spp. CCE, and Bacteroidales CCE. Overall, the factors associated with FIO concentrations in sand were related to the sand-water interface (i.e., sand-wetting) and included daily average densities of FIOs in water, rainfall, and wave height. Targeted monitoring that focuses on daily trends of sand FIO variability, combined with information about specific water quality, weather, and environmental factors may inform beach monitoring and management decisions to reduce microbial burdens in beach sand. The views expressed in this paper are those of the authors and do not necessarily reflect the views or policies of the U.S. Environmental Protection Agency.