201
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Levy K. Reducing Health Regrets in a Changing Climate. J Infect Dis 2016; 215:14-16. [PMID: 27811321 DOI: 10.1093/infdis/jiw522] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2016] [Accepted: 10/24/2016] [Indexed: 12/29/2022] Open
Affiliation(s)
- Karen Levy
- Department of Environmental Health, Emory University, Rollins School of Public Health, Atlanta, Georgia
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202
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Larson KL, Hansen C, Ritz M, Carreño D. Acceptance and Impact of Point-of-Use Water Filtration Systems in Rural Guatemala. J Nurs Scholarsh 2016; 49:96-102. [DOI: 10.1111/jnu.12260] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/19/2016] [Indexed: 11/29/2022]
Affiliation(s)
- Kim L. Larson
- Beta Nu , Associate Professor; East Carolina University; Greenville NC USA
| | - Corrie Hansen
- Beta Nu , Staff Nurse; Duke University Medical Center; Durham NC USA
| | - Michala Ritz
- Research Assistant, Spectrum Clinical Research; Inc; Baltimore MD USA
| | - Diego Carreño
- Student, East Carolina University; Greenville NC USA
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203
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Hunter PR, Prüss-Ustün A. Have We Substantially Underestimated the Impact of Improved Sanitation Coverage on Child Health? A Generalized Additive Model Panel Analysis of Global Data on Child Mortality and Malnutrition. PLoS One 2016; 11:e0164571. [PMID: 27783646 PMCID: PMC5081205 DOI: 10.1371/journal.pone.0164571] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/11/2016] [Accepted: 09/27/2016] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND Although widely accepted as being one of the most important public health advances of the past hundred years, the contribution that improving sanitation coverage can make to child health is still unclear, especially since the publication of two large studies of sanitation in India which found no effect on child morbidity. We hypothesis that the value of sanitation does not come directly from use of improved sanitation but from improving community coverage. If this is so we further hypothesise that the relationship between sanitation coverage and child health will be non-linear and that most of any health improvement will accrue as sanitation becomes universal. METHODS We report a fixed effects panel analysis of country level data using Generalized Additive Models in R. Outcome variables were under 5 childhood mortality, neonatal mortality, under 5 childhood mortality from diarrhoea, proportion of children under 5 with stunting and with underweight. Predictor variables were % coverage by improved sanitation, improved water source, Gross Domestic Product per capita and Health Expenditure per capita. We also identified three studies reporting incidence of diarrhoea in children under five alongside gains in community coverage in improved sanitation. FINDINGS For each of the five outcome variables, sanitation coverage was independently associated with the outcome but this association was highly non-linear. Improving sanitation coverage was very strongly associated with under 5 years diarrhoea mortality, under 5years all-cause mortality, and all-cause neonatal mortality. There was a decline as sanitation coverage increased up to about 20% but then no further decline was seen until about 70% (60% for diarrhoea mortality and 80% for neonatal mortality, respectively). The association was less strong for stunting and underweight but a threshold about 50% coverage was also seen. Three large trials of sanitation on diarrhoea morbidity gave results that were similar to what would have been predicted by our model. CONCLUSIONS Improving sanitation coverage may be one of the more effective means to reduce childhood mortality, but only if high levels of community coverage are achieved. Studies of the impact of sanitation that focus on the individual's use of improved sanitation as the predictor variable rather than community coverage is likely to severely underestimate the impact of sanitation.
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Affiliation(s)
- Paul R. Hunter
- Department of Public Health, Environment and Social Determinants of Health, World Health Organization, Geneva, Switzerland
- The Norwich School of Medicine, University of East Anglia, Norwich, UK
- Department of Environmental Health, Tshwane University of Technology, Pretoria, South Africa
| | - Annette Prüss-Ustün
- Department of Public Health, Environment and Social Determinants of Health, World Health Organization, Geneva, Switzerland
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204
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Sonego IL, Mosler HJ. Spot-checks to measure general hygiene practice. INTERNATIONAL JOURNAL OF ENVIRONMENTAL HEALTH RESEARCH 2016; 26:554-571. [PMID: 27666296 DOI: 10.1080/09603123.2016.1217314] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/10/2016] [Accepted: 05/17/2016] [Indexed: 06/06/2023]
Abstract
A variety of hygiene behaviors are fundamental to the prevention of diarrhea. We used spot-checks in a survey of 761 households in Burundi to examine whether something we could call general hygiene practice is responsible for more specific hygiene behaviors, ranging from handwashing to sweeping the floor. Using structural equation modeling, we showed that clusters of hygiene behavior, such as primary caregivers' cleanliness and household cleanliness, explained the spot-check findings well. Within our model, general hygiene practice as overall concept explained the more specific clusters of hygiene behavior well. Furthermore, the higher general hygiene practice, the more likely children were to be categorized healthy (r = 0.46). General hygiene practice was correlated with commitment to hygiene (r = 0.52), indicating a strong association to psychosocial determinants. The results show that different hygiene behaviors co-occur regularly. Using spot-checks, the general hygiene practice of a household can be rated quickly and easily.
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Affiliation(s)
- Ina L Sonego
- a Environmental Social Sciences , Eawag: Swiss Federal Institute of Aquatic Science and Technology , Dübendorf , Switzerland
| | - Hans-Joachim Mosler
- a Environmental Social Sciences , Eawag: Swiss Federal Institute of Aquatic Science and Technology , Dübendorf , Switzerland
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205
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Hodge J, Chang HH, Boisson S, Collin SM, Peletz R, Clasen T. Assessing the Association between Thermotolerant Coliforms in Drinking Water and Diarrhea: An Analysis of Individual-Level Data from Multiple Studies. ENVIRONMENTAL HEALTH PERSPECTIVES 2016; 124:1560-1567. [PMID: 27164618 PMCID: PMC5047765 DOI: 10.1289/ehp156] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/11/2015] [Revised: 02/02/2016] [Accepted: 04/27/2016] [Indexed: 05/22/2023]
Abstract
BACKGROUND Fecally contaminated drinking water is believed to be a major contributor to the global burden of diarrheal disease and a leading cause of mortality among young children. However, recent systematic reviews and results from blinded studies of water quality interventions have raised questions about the risk associated with fecally contaminated water, particularly as measured by thermotolerant coliform (TTC) bacteria, a WHO-approved indicator of drinking water quality. OBJECTIVES We investigated the association between TTC in drinking water and diarrhea using data from seven previous studies. METHODS We obtained individual-level data from available field studies that measured TTC levels in household-drinking water and reported prevalence of diarrhea among household members during the days prior to the visit. RESULTS The combined data set included diarrhea prevalence for 26,518 individuals and 8,000 water samples from 4,017 households, yielding 45,052 observations. The odds of diarrhea increased for each log10 increase in TTC/100 mL by 18% (95% CI: 11, 26%) for children < 5 years old and 12% (95% CI: 8, 18%) for all ages. For all ages, the odds of diarrhea increased by 21%, 35% and 49% for those whose household water samples were from 11-100, 101-1,000, and > 1,000 TTC/100 mL, respectively compared to < 1 TTC/100 mL. We found no evidence of increased odds of diarrhea with contamination levels below 11 TTC/100 mL, either in adults or children. CONCLUSIONS Our analysis of individual-level data shows increased risk of diarrhea with increasing levels of TTC in drinking water. These results suggest an association between fecally contaminated water and diarrheal disease and provides support for health-based targets for levels of TTC in drinking water and for interventions to improve drinking water quality to prevent diarrhea. CITATION Hodge J, Chang HH, Boisson S, Collin SM, Peletz R, Clasen T. 2016. Assessing the association between thermotolerant coliforms in drinking water and diarrhea: an analysis of individual level data from multiple studies. Environ Health Perspect 124:1560-1567; http://dx.doi.org/10.1289/EHP156.
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Affiliation(s)
| | - Howard H. Chang
- Department of Biostatistics and Bioinformatics, Rollins School of Public Health, Emory University, Atlanta, Georgia, USA
| | - Sophie Boisson
- Faculty of Infectious Diseases, London School of Hygiene and Tropical Medicine, London, United Kingdom
| | - Simon M. Collin
- School of Social and Community Medicine, University of Bristol, Bristol, United Kingdom
| | | | - Thomas Clasen
- Department of Environmental Health, and
- Faculty of Infectious Diseases, London School of Hygiene and Tropical Medicine, London, United Kingdom
- Address correspondence to T. Clasen, Rollins School of Public Health, Emory University, 1518 Clifton Rd., NE, Atlanta, GA 30322 USA. Telephone: (404) 727-3480. E-mail:
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206
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Gon G, Restrepo-Méndez MC, Campbell OMR, Barros AJD, Woodd S, Benova L, Graham WJ. Who Delivers without Water? A Multi Country Analysis of Water and Sanitation in the Childbirth Environment. PLoS One 2016; 11:e0160572. [PMID: 27532291 PMCID: PMC4988668 DOI: 10.1371/journal.pone.0160572] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/12/2016] [Accepted: 07/21/2016] [Indexed: 12/02/2022] Open
Abstract
Background and Objectives Hygiene during childbirth is essential to the health of mothers and newborns, irrespective of where birth takes place. This paper investigates the status of water and sanitation in both the home and facility childbirth environments, and for whom and where this is a more significant problem. Methods We used three datasets: a global dataset, with information on the home environment from 58 countries, and two datasets for each of four countries in Eastern Africa: a healthcare facility dataset, and a dataset that incorporated information on facilities and the home environment to create a comprehensive description of birth environments in those countries. We constructed indices of improved water, and improved water and sanitation combined (WATSAN), for the home and healthcare facilities. The Joint Monitoring Program was used to construct indices for household; we tailored them to the facility context–household and facility indices include different components. We described what proportion of women delivered in an environment with improved WATSAN. For those women who delivered at home, we calculated what proportion had improved WATSAN by socio-economic status, education and rural-urban status. Results Among women delivering at home (58 countries), coverage of improved WATSAN by region varied from 9% to 53%. Fewer than 15% of women who delivered at home in Sub-Saharan Africa, had access to water and sanitation infrastructure (range 0.1% to 37%). This was worse among the poorest, the less educated and those living in rural areas. In Eastern Africa, where we looked at both the home and facility childbirth environment, a third of women delivered in an environment with improved water in Uganda and Rwanda; whereas, 18% of women in Kenya and 7% in Tanzania delivered with improved water and sanitation. Across the four countries, less than half of the facility deliveries had improved water, or improved water and sanitation in the childbirth environment. Conclusions Access to water and sanitation during childbirth is poor across low and middle-income countries. Even when women travel to health facilities for childbirth, they are not guaranteed access to basic WATSAN infrastructure. These indicators should be measured routinely in order to inform improvements.
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Affiliation(s)
- Giorgia Gon
- Infectious Disease Epidemiology Department, London School of Hygiene and Tropical Medicine, London, UK
- * E-mail:
| | | | - Oona M. R. Campbell
- Infectious Disease Epidemiology Department, London School of Hygiene and Tropical Medicine, London, UK
| | - Aluísio J. D. Barros
- International Center for Equity in Health, Federal University of Pelotas, Pelotas, Brazil
| | - Susannah Woodd
- Infectious Disease Epidemiology Department, London School of Hygiene and Tropical Medicine, London, UK
| | - Lenka Benova
- Infectious Disease Epidemiology Department, London School of Hygiene and Tropical Medicine, London, UK
| | - Wendy J. Graham
- Infectious Disease Epidemiology Department, London School of Hygiene and Tropical Medicine, London, UK
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207
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Bresee S, Caruso BA, Sales J, Lupele J, Freeman MC. 'A child is also a teacher': exploring the potential for children as change agents in the context of a school-based WASH intervention in rural Eastern Zambia. HEALTH EDUCATION RESEARCH 2016; 31:521-534. [PMID: 27206442 DOI: 10.1093/her/cyw022] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/23/2015] [Accepted: 04/15/2016] [Indexed: 06/05/2023]
Abstract
As part of water, sanitation and hygiene interventions in low-income settings, it is frequently assumed that pupils can disseminate information and catalyze change at home, yet this assumption has not been rigorously assessed. We employed qualitative research methods in two phases to assess the potential for children to be change agents in five schools in rural Zambia. Phase 1 included role-play and focus group discussions among pupils on their percieved ability to serve as change agents. Children were then given 'homework' that included information on health messages and on how to build a handwashing station, and were encouraged to engage their family. In Phase 2, we conducted separate focus group discussions with pupils and mothers on their experiences with the 'homework'. We found that, in general, pupils were enthusiastic about engaging with parents-typically male heads of household-and were successful at constructing handwashing stations. Mothers reported high levels of trust in children to relay health information learned at school. Pupils were able to enact small changes to behavior, but not larger infrastructure changes, such as construction of latrines. Pupils are capable of communicating knowledge and behaviors to family members; however, discrete activities and guidance is required.
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Affiliation(s)
- S Bresee
- Department of Behavioral Sciences and Health Education, Rollins School of Public Health, Emory University, Atlanta, Georgia, USA
| | - B A Caruso
- Department of Behavioral Sciences and Health Education, Rollins School of Public Health, Emory University, Atlanta, Georgia, USA
| | - J Sales
- Department of Behavioral Sciences and Health Education, Rollins School of Public Health, Emory University, Atlanta, Georgia, USA
| | - J Lupele
- Schools Promoting Learning Acheivement through Sanitation and Hygiene (SPLASH), Lusaka, Zambia
| | - M C Freeman
- Department of Environmental Health, Rollins School of Public Health, Emory University, Atlanta, Georgia, USA
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208
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Assessing reliability, change after intervention, and performance of a water insecurity scale in rural Ethiopia. Food Secur 2016. [DOI: 10.1007/s12571-016-0599-1] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
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209
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Wade R, Sideris E, Paton F, Rice S, Palmer S, Fox D, Woolacott N, Spackman E. Graduated compression stockings for the prevention of deep-vein thrombosis in postoperative surgical patients: a systematic review and economic model with a value of information analysis. Health Technol Assess 2016; 19:1-220. [PMID: 26613365 DOI: 10.3310/hta19980] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/03/2023] Open
Abstract
BACKGROUND Deep-vein thrombosis (DVT) can occur in surgical patients. Routine prophylaxis can be pharmacological and/or mechanical [e.g. graduated compression stockings (GCSs)]. GCSs are available in knee length or thigh length. OBJECTIVE To establish the expected value of undertaking additional research addressing the relative effectiveness of thigh-length GCSs versus knee-length GCSs, in addition to pharmacoprophylaxis, for prevention of DVT in surgical patients. DESIGN Systematic review and economic model, including value of information (VOI) analysis. REVIEW METHODS Randomised controlled trials (RCTs) assessing thigh- or knee-length GCSs in surgical patients were eligible for inclusion. The primary outcome was incidence of DVT. DVT complications and GCSs adverse events were assessed. Random-effects meta-analysis was performed. To draw on a wider evidence base, a random-effects network meta-analysis (NMA) was undertaken for the outcome DVT. A review of trials and observational studies of patient adherence was also conducted. A decision-analytic model was developed to assess the cost-effectiveness of thigh- and knee-length GCSs and the VOI. RESULTS Twenty-three RCTs were included in the review of effectiveness. There was substantial variation between trials in terms of the patient characteristics, interventions and methods of outcome assessment. Five trials comparing knee-length with thigh-length GCSs with or without pharmacoprophylaxis were pooled; the summary estimate of effect indicated a non-significant trend favouring thigh-length GCSs [odds ratio (OR) 1.48, 95% confidence interval (CI) 0.80 to 2.73]. Thirteen trials were included in the NMA. In the base-case analysis, thigh-length GCSs with pharmacoprophylaxis were more effective than knee-length GCSs with pharmacoprophylaxis (knee vs. thigh OR 1.76, 95% credible interval 0.82 to 3.53). Overall, thigh-length stockings with pharmacoprophylaxis was the most effective treatment, with a 0.73 probability of being the most effective treatment in a new trial of all the treatments. Patient adherence was generally higher with knee-length GCSs, and patients preferred knee-length GCSs. Thigh-length GCSs were found to be cost-effective in all but the subgroup with the lowest baseline risk, although the absolute differences in costs and effects were relatively small. The expected value of perfect information ranged from £0.2M to £178.0M depending on the scenario and subgroup. The relative effect parameters had the highest expected value of partial perfect information and ranged from £2.0M to £39.4M. The value of further research was most evident in the high-risk subgroups. LIMITATIONS There was substantial variation across the included trials in terms of patient and intervention characteristics. Many of the included trials were old and poorly reported, which reduces the reliability of the results of the review. CONCLUSIONS Given that the results from both the standard meta-analysis and the NMA lacked precision (CIs were wide) owing to the heterogeneous evidence base, a new definitive trial in high-risk patients may be warranted. However, the efficiency of any further research (i.e. whether this represents value for money) is dependent on several factors, including the acquisition price of GCSs, expected compliance with thigh-length GCSs wear, and whether or not uncertainty can be resolved around possible effect modifiers, as well as the feasibility and actual cost of undertaking the proposed research. STUDY REGISTRATION This study is registered as PROSPERO CRD42014007202. FUNDING The National Institute for Health Research Health Technology Assessment programme.
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Affiliation(s)
- Ros Wade
- Centre for Reviews and Dissemination, University of York, York, UK
| | | | - Fiona Paton
- Centre for Reviews and Dissemination, University of York, York, UK
| | - Stephen Rice
- Centre for Reviews and Dissemination, University of York, York, UK
| | - Stephen Palmer
- Centre for Health Economics, University of York, York, UK
| | - Dave Fox
- Centre for Reviews and Dissemination, University of York, York, UK
| | - Nerys Woolacott
- Centre for Reviews and Dissemination, University of York, York, UK
| | - Eldon Spackman
- Centre for Health Economics, University of York, York, UK
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210
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Clasen T, Boisson S. Assessing the Health Impact of Water Quality Interventions in Low-Income Settings: Concerns Associated with Blinded Trials and the Need for Objective Outcomes. ENVIRONMENTAL HEALTH PERSPECTIVES 2016; 124:886-9. [PMID: 26685286 PMCID: PMC4937874 DOI: 10.1289/ehp.1510532] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/25/2015] [Accepted: 12/01/2015] [Indexed: 05/10/2023]
Abstract
BACKGROUND A dramatic disparity between the results of blinded versus open trial designs has raised questions about the effectiveness of water quality interventions and other environmental interventions to prevent diarrhea, a leading killer of young children in low-income countries. OBJECTIVES We summarize the results of blinded versus open trials of water quality interventions, describe evidence from a recent placebo-controlled trial in India suggesting that control households were put at risk from their participation, and suggest alternatives to blinded trials that could resolve continued uncertainty about the magnitude of the protective effect of water, sanitation, and hygiene (WASH) interventions without presenting ethical questions. DISCUSSION Concerns about reporting bias in open trial designs continue to cause uncertainty about the effectiveness of WASH interventions. However, evidence suggests that despite instructions to the contrary, placebos may encourage control group participants in blinded trials to cease practicing traditional water treatment practices in the mistaken belief that they are protected by an active intervention. Although objective outcomes such as pathogen incrimination, seroconversion, biomarkers, and anthropometry can be helpful, these are often costly, nonspecific, and unsuitable for evaluating programmatic interventions. CONCLUSIONS Unless researchers can be assured that a placebo will not cause those in a control group to change their behavior in a manner that increases their risk, it is incumbent on researchers to use alternatives. Validated objective measures are needed for assessing the health impact of WASH interventions that are reliable, affordable, and suitable both for research and program evaluation. CITATION Clasen T, Boisson S. 2016. Assessing the health impact of water quality interventions in low-income settings: concerns associated with blinded trials and the need for objective outcomes. Environ Health Perspect 124:886-889; http://dx.doi.org/10.1289/ehp.1510532.
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Affiliation(s)
- Thomas Clasen
- Department of Environmental Health, Rollins School of Public Health, Emory University, Atlanta, Georgia, USA
- Faculty of Infectious and Tropical Diseases, London School of Hygiene & Tropical Medicine, London, United Kingdom
- Address correspondence to T. Clasen, Department of Environmental Health, Rollins School of Public Health, Emory University, 1518 Clifton Rd. NE, Atlanta, GA 30322 USA. Telephone: (404) 727-3480. E-mail:
| | - Sophie Boisson
- Faculty of Infectious and Tropical Diseases, London School of Hygiene & Tropical Medicine, London, United Kingdom
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211
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The Life-Cycle Costs of School Water, Sanitation and Hygiene Access in Kenyan Primary Schools. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2016; 13:ijerph13070637. [PMID: 27355962 PMCID: PMC4962178 DOI: 10.3390/ijerph13070637] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 04/11/2016] [Revised: 05/20/2016] [Accepted: 06/15/2016] [Indexed: 11/25/2022]
Abstract
Water, Sanitation and Hygiene (WASH) programs in schools can increase the health, dignity and comfort of students and teachers. Understanding the costs of WASH facilities and services in schools is one essential piece for policy makers to utilize when budgeting for schools and helping to make WASH programs more sustainable. In this study we collected data from NGO and government offices, local hardware shops and 89 rural primary schools across three Kenyan counties. Current expenditures on WASH, from school and external (NGO, government, parent) sources, averaged 1.83 USD per student per year. After reviewing current expenditures, estimated costs of operations and maintenance for bringing schools up to basic WASH standards, were calculated to be 3.03 USD per student per year. This includes recurrent costs, but not the cost of installing or setting up WASH infrastructure, which was 18,916 USD per school, for a school of 400 students (4.92 USD per student, per year). These findings demonstrate the need for increases in allocations to schools in Kenya, and stricter guidance on how money should be spent on WASH inputs to enable all schools to provide basic WASH for all students.
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212
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Hutton G, Chase C. The Knowledge Base for Achieving the Sustainable Development Goal Targets on Water Supply, Sanitation and Hygiene. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2016; 13:ijerph13060536. [PMID: 27240389 PMCID: PMC4923993 DOI: 10.3390/ijerph13060536] [Citation(s) in RCA: 67] [Impact Index Per Article: 8.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 02/29/2016] [Revised: 05/16/2016] [Accepted: 05/18/2016] [Indexed: 02/07/2023]
Abstract
Safe drinking water, sanitation, and hygiene (WASH) are fundamental to an improved standard of living. Globally, 91% of households used improved drinking water sources in 2015, while for improved sanitation it is 68%. Wealth disparities are stark, with rural populations, slum dwellers and marginalized groups lagging significantly behind. Service coverage is significantly lower when considering the new water and sanitation targets under the sustainable development goals (SDGs) which aspire to a higher standard of ‘safely managed’ water and sanitation. Lack of access to WASH can have an economic impact as much as 7% of Gross Domestic Product, not including the social and environmental consequences. Research points to significant health and socio-economic consequences of poor nutritional status, child growth and school performance caused by inadequate WASH. Groundwater over-extraction and pollution of surface water bodies have serious impacts on water resource availability and biodiversity, while climate change exacerbates the health risks of water insecurity. A significant literature documents the beneficial impacts of WASH interventions, and a growing number of impact evaluation studies assess how interventions are optimally financed, implemented and sustained. Many innovations in behavior change and service delivery offer potential for scaling up services to meet the SDGs.
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Affiliation(s)
- Guy Hutton
- United Nations Children's Emergency Fund (UNICEF), New York, NY 10017, USA.
- Water and Sanitation Program, The World Bank, Washington, DC 20433, USA.
| | - Claire Chase
- Water and Sanitation Program, The World Bank, Washington, DC 20433, USA.
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213
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Azage M, Kumie A, Worku A, Bagtzoglou AC. Childhood diarrhea in high and low hotspot districts of Amhara Region, northwest Ethiopia: a multilevel modeling. JOURNAL OF HEALTH, POPULATION, AND NUTRITION 2016; 35:13. [PMID: 27184552 PMCID: PMC5025988 DOI: 10.1186/s41043-016-0052-2] [Citation(s) in RCA: 37] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/14/2015] [Accepted: 05/11/2016] [Indexed: 05/15/2023]
Abstract
BACKGROUND Childhood diarrhea is one of the major public health problems in Ethiopia. Multiple factors at different levels contribute to the occurrence of childhood diarrhea. The objective of the study was to identify the factors affecting childhood diarrhea at individual and community level. METHODS A cross-sectional study design was employed from February to March 2015 in high and low hotspot districts of Awi and West and East Gojjam zones in Amhara Region, northwest Ethiopia. Districts with high and low hotspots with childhood diarrhea were identified using SaTScan spatial statistical analysis. A total of 2495 households from ten (five high and five low hotspot) randomly selected districts were included in the study. A semi-structured questionnaire was used to collect data. Data were entered and cleaned in Epi Info 3.5.2 version and analyzed using Stata version 12. A multilevel logistic regression was used to identify factors associated with childhood diarrhea. RESULTS The prevalence of childhood diarrhea was 13.5 % and did not show significant variation between high [14.3 % (95 % CI 12.3-16.2 %)] and low [12.7 % (95 % CI 10.9-14.6 %)] hotspot districts. Individual- and community-level factors accounted for 35 % of childhood diarrhea variation across the communities in the full model. Age of children (6-35 months), complementary feeding initiation below 6 months, inadequate hand washing practices, limited knowledge of mothers on diarrhea, lowest wealth status of households, and longer time interval to visit households by health extension workers were factors for increasing the odds of childhood diarrhea at the individual level. At the community level, lack of improved water supply and sanitation and unvaccinated children with measles and rotavirus vaccine were the factors associated with childhood diarrhea. CONCLUSIONS In this study, childhood diarrhea occurrences remained high. Both individual- and community-level factors determined the occurrence of diarrhea. Interventions should consider both individual- and community-level factors to reduce the occurrence of childhood diarrhea.
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Affiliation(s)
- Muluken Azage
- Ethiopian Institute of Water Resources, Addis Ababa University, Addis Ababa, Ethiopia.
| | - Abera Kumie
- School of Public Health, College of Health Sciences, Addis Ababa University, Addis Ababa, Ethiopia
| | - Alemayehu Worku
- School of Public Health, College of Health Sciences, Addis Ababa University, Addis Ababa, Ethiopia
| | - Amvrossios C Bagtzoglou
- Department of Civil and Environmental Engineering, School of Engineering, University of Connecticut, Storrs, CT, 06269-3037, USA
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Overbo A, Williams AR, Evans B, Hunter PR, Bartram J. On-plot drinking water supplies and health: A systematic review. Int J Hyg Environ Health 2016; 219:317-30. [PMID: 27118130 DOI: 10.1016/j.ijheh.2016.04.008] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2015] [Revised: 02/26/2016] [Accepted: 04/14/2016] [Indexed: 10/21/2022]
Abstract
Many studies have found that household access to water supplies near or within the household plot can reduce the probability of diarrhea, trachoma, and other water-related diseases, and it is generally accepted that on-plot water supplies produce health benefits for households. However, the body of research literature has not been analyzed to weigh the evidence supporting this. A systematic review was conducted to investigate the impacts of on-plot water supplies on diarrhea, trachoma, child growth, and water-related diseases, to further examine the relationship between household health and distance to water source and to assess whether on-plot water supplies generate health gains for households. Studies provide evidence that households with on-plot water supplies experience fewer diarrheal and helminth infections and greater child height. Findings suggest that water-washed (hygiene associated) diseases are more strongly impacted by on-plot water access than waterborne diseases. Few studies analyzed the effects of on-plot water access on quantity of domestic water used, hygiene behavior, and use of multiple water sources, and the lack of evidence for these relationships reveals an important gap in current literature. The review findings indicate that on-plot water access is a useful health indicator and benchmark for the progressive realization of the Sustainable Development Goal target of universal safe water access as well as the human right to safe water.
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Affiliation(s)
- Alycia Overbo
- The Water Institute, University of North Carolina at Chapel Hill, United States.
| | - Ashley R Williams
- The Water Institute, University of North Carolina at Chapel Hill, United States
| | - Barbara Evans
- Institute of Public Health and Environmental Engineering, University of Leeds,United Kingdom
| | - Paul R Hunter
- Norwich Medical School, University of East Anglia, United Kingdom
| | - Jamie Bartram
- The Water Institute, University of North Carolina at Chapel Hill, United States.
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215
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Mellor JE, Levy K, Zimmerman J, Elliott M, Bartram J, Carlton E, Clasen T, Dillingham R, Eisenberg J, Guerrant R, Lantagne D, Mihelcic J, Nelson K. Planning for climate change: The need for mechanistic systems-based approaches to study climate change impacts on diarrheal diseases. THE SCIENCE OF THE TOTAL ENVIRONMENT 2016; 548-549:82-90. [PMID: 26799810 PMCID: PMC4818006 DOI: 10.1016/j.scitotenv.2015.12.087] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/26/2015] [Revised: 12/18/2015] [Accepted: 12/18/2015] [Indexed: 05/20/2023]
Abstract
Increased precipitation and temperature variability as well as extreme events related to climate change are predicted to affect the availability and quality of water globally. Already heavily burdened with diarrheal diseases due to poor access to water, sanitation and hygiene facilities, communities throughout the developing world lack the adaptive capacity to sufficiently respond to the additional adversity caused by climate change. Studies suggest that diarrhea rates are positively correlated with increased temperature, and show a complex relationship with precipitation. Although climate change will likely increase rates of diarrheal diseases on average, there is a poor mechanistic understanding of the underlying disease transmission processes and substantial uncertainty surrounding current estimates. This makes it difficult to recommend appropriate adaptation strategies. We review the relevant climate-related mechanisms behind transmission of diarrheal disease pathogens and argue that systems-based mechanistic approaches incorporating human, engineered and environmental components are urgently needed. We then review successful systems-based approaches used in other environmental health fields and detail one modeling framework to predict climate change impacts on diarrheal diseases and design adaptation strategies.
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Affiliation(s)
- Jonathan E Mellor
- Department of Civil and Environmental Engineering, University of Connecticut, 261 Glenbrook Road, Storrs, CT 06269-3037, USA.
| | - Karen Levy
- Department of Environmental Health, Rollins School of Public Health, Emory University, Atlanta, GA, USA
| | - Julie Zimmerman
- Department of Chemical and Environmental Engineering, School of Engineering & Applied Science, Yale University, New Haven, CT, USA
| | - Mark Elliott
- Department of Civil, Construction and Environmental Engineering, The College of Engineering, University of Alabama, Tuscaloosa, AL, USA
| | - Jamie Bartram
- Water Institute, Environmental Sciences and Engineering, Gillings School of Global Public Health, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Elizabeth Carlton
- Department of Environmental and Occupational Health, Colorado School of Public Health, University of Colorado at Denver, Aurora, CO, USA
| | - Thomas Clasen
- Department of Environmental Health, Rollins School of Public Health, Emory University, Atlanta, GA, USA
| | - Rebecca Dillingham
- The Center for Global Health, University of Virginia, Charlottesville, VA, USA
| | - Joseph Eisenberg
- School of Public Health, University of Michigan, Ann Arbor, MI, USA
| | - Richard Guerrant
- The Center for Global Health, University of Virginia, Charlottesville, VA, USA
| | - Daniele Lantagne
- Department of Civil and Environmental Engineering, School of Engineering, Tufts University, Medford, MA, USA
| | - James Mihelcic
- Department of Civil and Environmental Engineering, The College of Engineering, University of South Florida, Tampa, FL, USA
| | - Kara Nelson
- Department of Civil and Environmental Engineering, University of California, Berkeley, CA, USA
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Cronin AA, Sebayang SK, Torlesse H, Nandy R. Association of Safe Disposal of Child Feces and Reported Diarrhea in Indonesia: Need for Stronger Focus on a Neglected Risk. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2016; 13:E310. [PMID: 26978379 PMCID: PMC4808973 DOI: 10.3390/ijerph13030310] [Citation(s) in RCA: 32] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 11/21/2015] [Revised: 01/18/2016] [Accepted: 01/19/2016] [Indexed: 11/17/2022]
Abstract
Indonesia still faces several challenges in the areas of water, sanitation, and hygiene (WASH). Diarrhea remains a major killer of children and it is important to understand the local diarrhea transmission pathways to prioritise appropriate WASH interventions to reduce diarrhea burden. This study used a cross-sectional data set from a recent national household survey (the 2012 Indonesia Demographic and Health Survey) to examine the associations between diarrhea in children aged less than 24 months with WASH interventions and population characteristics. Unsafe disposal of child feces was strongly associated with an increased odds of child diarrhea (OR: 1.46; 95% CI: 1.18-1.82, p = 0.001). However, other WASH practices were not found to be associated. The findings underline the dangers of unsafe disposal of child feces and highlight the need for strengthening the related policies and program strategies and their implementation.
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Affiliation(s)
- Aidan A Cronin
- UNICEF Indonesia, World Trade Center 6, Jalan Jenderal Sudirman Kav. 31, Jakarta 12920, Indonesia.
| | - Susy Katikana Sebayang
- Faculty of Public Health, Universitas Airlangga, Banyuwangi Campus, Jalan Wijaya Kusuma No 113, Banyuwangi 68414, Indonesia.
| | - Harriet Torlesse
- UNICEF Indonesia, World Trade Center 6, Jalan Jenderal Sudirman Kav. 31, Jakarta 12920, Indonesia.
| | - Robin Nandy
- UNICEF Indonesia, World Trade Center 6, Jalan Jenderal Sudirman Kav. 31, Jakarta 12920, Indonesia.
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217
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Philipsborn R, Ahmed SM, Brosi BJ, Levy K. Climatic Drivers of Diarrheagenic Escherichia coli Incidence: A Systematic Review and Meta-analysis. J Infect Dis 2016; 214:6-15. [PMID: 26931446 DOI: 10.1093/infdis/jiw081] [Citation(s) in RCA: 39] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/25/2015] [Accepted: 02/22/2016] [Indexed: 11/12/2022] Open
Abstract
BACKGROUND Positive associations have been noted between temperature and diarrhea incidence, but considerable uncertainty surrounds quantitative estimates of this relationship because of pathogen-specific factors and a scarcity of data on the influence of meteorological factors on the risk of disease. Quantifying these relationships is important for disease prevention and climate change adaptation. METHODS To address these issues, we performed a systematic literature review of studies in which at least 1 full year of data on the monthly incidence of diarrheagenic Escherichia coli were reported. We characterized seasonal patterns of disease incidence from 28 studies. In addition, using monthly time- and location-specific weather data for 18 studies, we performed univariate Poisson models on individual studies and a meta-analysis, using a generalized estimating equation, on the entire data set. RESULTS We found an 8% increase in the incidence of diarrheagenic E. coli (95% confidence interval, 5%-11%; P < .0001) for each 1°C increase in mean monthly temperature. We found a modest positive association between 1-month-lagged mean rainfall and incidence of diarrheagenic E. coli, which was not statistically significant when we controlled for temperature. CONCLUSIONS These results suggest that increases in ambient temperature correspond to an elevated incidence of diarrheagenic E. coli and underscore the need to redouble efforts to prevent the transmission of these pathogens in the face of increasing global temperatures.
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Affiliation(s)
| | - Sharia M Ahmed
- Department of Environmental Health, Rollins School of Public Health
| | - Berry J Brosi
- Department of Environmental Sciences, Emory University, Atlanta, Georgia
| | - Karen Levy
- Department of Environmental Health, Rollins School of Public Health
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Clasen T. Household Water Treatment and Safe Storage to Prevent Diarrheal Disease in Developing Countries. Curr Environ Health Rep 2016; 2:69-74. [PMID: 26231243 DOI: 10.1007/s40572-014-0033-9] [Citation(s) in RCA: 61] [Impact Index Per Article: 7.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
Household water treatment and safe storage (HWTS), such as boiling, filtering, or chlorinating water at home, have been shown to be effective in improving the microbiological quality of drinking water. However, estimates of their protective effect against diarrhea, a major killer, have varied widely. While results may be exaggerated because of reporting bias, this heterogeneity is consistent with other environmental interventions that are implemented with varying levels of coverage and uptake in settings where the source of exposure represents one of many transmission pathways. Evidence suggests that the effectiveness of HWTS can be optimized by ensuring that the method is microbiologically effective; (2) making it accessible to an exposed population; and (3) securing their consistent and long-term use.
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Affiliation(s)
- Thomas Clasen
- Department of Environmental Health, Rollins School of Public Health, Emory University, 1518 Clifton Road NE, Atlanta, GA, 30322, USA,
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Forouzanfar MH, Alexander L, Anderson HR, Bachman VF, Biryukov S, Brauer M, Burnett R, Casey D, Coates MM, Cohen A, Delwiche K, Estep K, Frostad JJ, Astha KC, Kyu HH, Moradi-Lakeh M, Ng M, Slepak EL, Thomas BA, Wagner J, Aasvang GM, Abbafati C, Abbasoglu Ozgoren A, Abd-Allah F, Abera SF, Aboyans V, Abraham B, Abraham JP, Abubakar I, Abu-Rmeileh NME, Aburto TC, Achoki T, Adelekan A, Adofo K, Adou AK, Adsuar JC, Afshin A, Agardh EE, Al Khabouri MJ, Al Lami FH, Alam SS, Alasfoor D, Albittar MI, Alegretti MA, Aleman AV, Alemu ZA, Alfonso-Cristancho R, Alhabib S, Ali R, Ali MK, Alla F, Allebeck P, Allen PJ, Alsharif U, Alvarez E, Alvis-Guzman N, Amankwaa AA, Amare AT, Ameh EA, Ameli O, Amini H, Ammar W, Anderson BO, Antonio CAT, Anwari P, Argeseanu Cunningham S, Arnlöv J, Arsenijevic VSA, Artaman A, Asghar RJ, Assadi R, Atkins LS, Atkinson C, Avila MA, Awuah B, Badawi A, Bahit MC, Bakfalouni T, Balakrishnan K, Balalla S, Balu RK, Banerjee A, Barber RM, Barker-Collo SL, Barquera S, Barregard L, Barrero LH, Barrientos-Gutierrez T, Basto-Abreu AC, Basu A, Basu S, Basulaiman MO, Batis Ruvalcaba C, Beardsley J, Bedi N, Bekele T, Bell ML, Benjet C, Bennett DA, Benzian H, Bernabé E, Beyene TJ, Bhala N, Bhalla A, Bhutta ZA, Bikbov B, Bin Abdulhak AA, Blore JD, Blyth FM, Bohensky MA, Bora Başara B, Borges G, Bornstein NM, Bose D, Boufous S, Bourne RR, Brainin M, Brazinova A, Breitborde NJ, Brenner H, Briggs ADM, Broday DM, Brooks PM, Bruce NG, Brugha TS, Brunekreef B, Buchbinder R, Bui LN, Bukhman G, Bulloch AG, Burch M, Burney PGJ, Campos-Nonato IR, Campuzano JC, Cantoral AJ, Caravanos J, Cárdenas R, Cardis E, Carpenter DO, Caso V, Castañeda-Orjuela CA, Castro RE, Catalá-López F, Cavalleri F, Çavlin A, Chadha VK, Chang JC, Charlson FJ, Chen H, Chen W, Chen Z, Chiang PP, Chimed-Ochir O, Chowdhury R, Christophi CA, Chuang TW, Chugh SS, Cirillo M, Claßen TKD, Colistro V, Colomar M, Colquhoun SM, Contreras AG, Cooper C, Cooperrider K, Cooper LT, Coresh J, Courville KJ, Criqui MH, Cuevas-Nasu L, Damsere-Derry J, Danawi H, Dandona L, Dandona R, Dargan PI, Davis A, Davitoiu DV, Dayama A, de Castro EF, De la Cruz-Góngora V, De Leo D, de Lima G, Degenhardt L, del Pozo-Cruz B, Dellavalle RP, Deribe K, Derrett S, Des Jarlais DC, Dessalegn M, deVeber GA, Devries KM, Dharmaratne SD, Dherani MK, Dicker D, Ding EL, Dokova K, Dorsey ER, Driscoll TR, Duan L, Durrani AM, Ebel BE, Ellenbogen RG, Elshrek YM, Endres M, Ermakov SP, Erskine HE, Eshrati B, Esteghamati A, Fahimi S, Faraon EJA, Farzadfar F, Fay DFJ, Feigin VL, Feigl AB, Fereshtehnejad SM, Ferrari AJ, Ferri CP, Flaxman AD, Fleming TD, Foigt N, Foreman KJ, Paleo UF, Franklin RC, Gabbe B, Gaffikin L, Gakidou E, Gamkrelidze A, Gankpé FG, Gansevoort RT, García-Guerra FA, Gasana E, Geleijnse JM, Gessner BD, Gething P, Gibney KB, Gillum RF, Ginawi IAM, Giroud M, Giussani G, Goenka S, Goginashvili K, Gomez Dantes H, Gona P, Gonzalez de Cosio T, González-Castell D, Gotay CC, Goto A, Gouda HN, Guerrant RL, Gugnani HC, Guillemin F, Gunnell D, Gupta R, Gupta R, Gutiérrez RA, Hafezi-Nejad N, Hagan H, Hagstromer M, Halasa YA, Hamadeh RR, Hammami M, Hankey GJ, Hao Y, Harb HL, Haregu TN, Haro JM, Havmoeller R, Hay SI, Hedayati MT, Heredia-Pi IB, Hernandez L, Heuton KR, Heydarpour P, Hijar M, Hoek HW, Hoffman HJ, Hornberger JC, Hosgood HD, Hoy DG, Hsairi M, Hu G, Hu H, Huang C, Huang JJ, Hubbell BJ, Huiart L, Husseini A, Iannarone ML, Iburg KM, Idrisov BT, Ikeda N, Innos K, Inoue M, Islami F, Ismayilova S, Jacobsen KH, Jansen HA, Jarvis DL, Jassal SK, Jauregui A, Jayaraman S, Jeemon P, Jensen PN, Jha V, Jiang F, Jiang G, Jiang Y, Jonas JB, Juel K, Kan H, Kany Roseline SS, Karam NE, Karch A, Karema CK, Karthikeyan G, Kaul A, Kawakami N, Kazi DS, Kemp AH, Kengne AP, Keren A, Khader YS, Khalifa SEAH, Khan EA, Khang YH, Khatibzadeh S, Khonelidze I, Kieling C, Kim D, Kim S, Kim Y, Kimokoti RW, Kinfu Y, Kinge JM, Kissela BM, Kivipelto M, Knibbs LD, Knudsen AK, Kokubo Y, Kose MR, Kosen S, Kraemer A, Kravchenko M, Krishnaswami S, Kromhout H, Ku T, Kuate Defo B, Kucuk Bicer B, Kuipers EJ, Kulkarni C, Kulkarni VS, Kumar GA, Kwan GF, Lai T, Lakshmana Balaji A, Lalloo R, Lallukka T, Lam H, Lan Q, Lansingh VC, Larson HJ, Larsson A, Laryea DO, Lavados PM, Lawrynowicz AE, Leasher JL, Lee JT, Leigh J, Leung R, Levi M, Li Y, Li Y, Liang J, Liang X, Lim SS, Lindsay MP, Lipshultz SE, Liu S, Liu Y, Lloyd BK, Logroscino G, London SJ, Lopez N, Lortet-Tieulent J, Lotufo PA, Lozano R, Lunevicius R, Ma J, Ma S, Machado VMP, MacIntyre MF, Magis-Rodriguez C, Mahdi AA, Majdan M, Malekzadeh R, Mangalam S, Mapoma CC, Marape M, Marcenes W, Margolis DJ, Margono C, Marks GB, Martin RV, Marzan MB, Mashal MT, Masiye F, Mason-Jones AJ, Matsushita K, Matzopoulos R, Mayosi BM, Mazorodze TT, McKay AC, McKee M, McLain A, Meaney PA, Medina C, Mehndiratta MM, Mejia-Rodriguez F, Mekonnen W, Melaku YA, Meltzer M, Memish ZA, Mendoza W, Mensah GA, Meretoja A, Mhimbira FA, Micha R, Miller TR, Mills EJ, Misganaw A, Mishra S, Mohamed Ibrahim N, Mohammad KA, Mokdad AH, Mola GL, Monasta L, Montañez Hernandez JC, Montico M, Moore AR, Morawska L, Mori R, Moschandreas J, Moturi WN, Mozaffarian D, Mueller UO, Mukaigawara M, Mullany EC, Murthy KS, Naghavi M, Nahas Z, Naheed A, Naidoo KS, Naldi L, Nand D, Nangia V, Narayan KMV, Nash D, Neal B, Nejjari C, Neupane SP, Newton CR, Ngalesoni FN, Ngirabega JDD, Nguyen G, Nguyen NT, Nieuwenhuijsen MJ, Nisar MI, Nogueira JR, Nolla JM, Nolte S, Norheim OF, Norman RE, Norrving B, Nyakarahuka L, Oh IH, Ohkubo T, Olusanya BO, Omer SB, Opio JN, Orozco R, Pagcatipunan RS, Pain AW, Pandian JD, Panelo CIA, Papachristou C, Park EK, Parry CD, Paternina Caicedo AJ, Patten SB, Paul VK, Pavlin BI, Pearce N, Pedraza LS, Pedroza A, Pejin Stokic L, Pekericli A, Pereira DM, Perez-Padilla R, Perez-Ruiz F, Perico N, Perry SAL, Pervaiz A, Pesudovs K, Peterson CB, Petzold M, Phillips MR, Phua HP, Plass D, Poenaru D, Polanczyk GV, Polinder S, Pond CD, Pope CA, Pope D, Popova S, Pourmalek F, Powles J, Prabhakaran D, Prasad NM, Qato DM, Quezada AD, Quistberg DAA, Racapé L, Rafay A, Rahimi K, Rahimi-Movaghar V, Rahman SU, Raju M, Rakovac I, Rana SM, Rao M, Razavi H, Reddy KS, Refaat AH, Rehm J, Remuzzi G, Ribeiro AL, Riccio PM, Richardson L, Riederer A, Robinson M, Roca A, Rodriguez A, Rojas-Rueda D, Romieu I, Ronfani L, Room R, Roy N, Ruhago GM, Rushton L, Sabin N, Sacco RL, Saha S, Sahathevan R, Sahraian MA, Salomon JA, Salvo D, Sampson UK, Sanabria JR, Sanchez LM, Sánchez-Pimienta TG, Sanchez-Riera L, Sandar L, Santos IS, Sapkota A, Satpathy M, Saunders JE, Sawhney M, Saylan MI, Scarborough P, Schmidt JC, Schneider IJC, Schöttker B, Schwebel DC, Scott JG, Seedat S, Sepanlou SG, Serdar B, Servan-Mori EE, Shaddick G, Shahraz S, Levy TS, Shangguan S, She J, Sheikhbahaei S, Shibuya K, Shin HH, Shinohara Y, Shiri R, Shishani K, Shiue I, Sigfusdottir ID, Silberberg DH, Simard EP, Sindi S, Singh A, Singh GM, Singh JA, Skirbekk V, Sliwa K, Soljak M, Soneji S, Søreide K, Soshnikov S, Sposato LA, Sreeramareddy CT, Stapelberg NJC, Stathopoulou V, Steckling N, Stein DJ, Stein MB, Stephens N, Stöckl H, Straif K, Stroumpoulis K, Sturua L, Sunguya BF, Swaminathan S, Swaroop M, Sykes BL, Tabb KM, Takahashi K, Talongwa RT, Tandon N, Tanne D, Tanner M, Tavakkoli M, Te Ao BJ, Teixeira CM, Téllez Rojo MM, Terkawi AS, Texcalac-Sangrador JL, Thackway SV, Thomson B, Thorne-Lyman AL, Thrift AG, Thurston GD, Tillmann T, Tobollik M, Tonelli M, Topouzis F, Towbin JA, Toyoshima H, Traebert J, Tran BX, Trasande L, Trillini M, Trujillo U, Dimbuene ZT, Tsilimbaris M, Tuzcu EM, Uchendu US, Ukwaja KN, Uzun SB, van de Vijver S, Van Dingenen R, van Gool CH, van Os J, Varakin YY, Vasankari TJ, Vasconcelos AMN, Vavilala MS, Veerman LJ, Velasquez-Melendez G, Venketasubramanian N, Vijayakumar L, Villalpando S, Violante FS, Vlassov VV, Vollset SE, Wagner GR, Waller SG, Wallin MT, Wan X, Wang H, Wang J, Wang L, Wang W, Wang Y, Warouw TS, Watts CH, Weichenthal S, Weiderpass E, Weintraub RG, Werdecker A, Wessells KR, Westerman R, Whiteford HA, Wilkinson JD, Williams HC, Williams TN, Woldeyohannes SM, Wolfe CDA, Wong JQ, Woolf AD, Wright JL, Wurtz B, Xu G, Yan LL, Yang G, Yano Y, Ye P, Yenesew M, Yentür GK, Yip P, Yonemoto N, Yoon SJ, Younis MZ, Younoussi Z, Yu C, Zaki ME, Zhao Y, Zheng Y, Zhou M, Zhu J, Zhu S, Zou X, Zunt JR, Lopez AD, Vos T, Murray CJ. Global, regional, and national comparative risk assessment of 79 behavioural, environmental and occupational, and metabolic risks or clusters of risks in 188 countries, 1990-2013: a systematic analysis for the Global Burden of Disease Study 2013. Lancet 2015; 386:2287-323. [PMID: 26364544 PMCID: PMC4685753 DOI: 10.1016/s0140-6736(15)00128-2] [Citation(s) in RCA: 1719] [Impact Index Per Article: 191.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
BACKGROUND The Global Burden of Disease, Injuries, and Risk Factor study 2013 (GBD 2013) is the first of a series of annual updates of the GBD. Risk factor quantification, particularly of modifiable risk factors, can help to identify emerging threats to population health and opportunities for prevention. The GBD 2013 provides a timely opportunity to update the comparative risk assessment with new data for exposure, relative risks, and evidence on the appropriate counterfactual risk distribution. METHODS Attributable deaths, years of life lost, years lived with disability, and disability-adjusted life-years (DALYs) have been estimated for 79 risks or clusters of risks using the GBD 2010 methods. Risk-outcome pairs meeting explicit evidence criteria were assessed for 188 countries for the period 1990-2013 by age and sex using three inputs: risk exposure, relative risks, and the theoretical minimum risk exposure level (TMREL). Risks are organised into a hierarchy with blocks of behavioural, environmental and occupational, and metabolic risks at the first level of the hierarchy. The next level in the hierarchy includes nine clusters of related risks and two individual risks, with more detail provided at levels 3 and 4 of the hierarchy. Compared with GBD 2010, six new risk factors have been added: handwashing practices, occupational exposure to trichloroethylene, childhood wasting, childhood stunting, unsafe sex, and low glomerular filtration rate. For most risks, data for exposure were synthesised with a Bayesian meta-regression method, DisMod-MR 2.0, or spatial-temporal Gaussian process regression. Relative risks were based on meta-regressions of published cohort and intervention studies. Attributable burden for clusters of risks and all risks combined took into account evidence on the mediation of some risks such as high body-mass index (BMI) through other risks such as high systolic blood pressure and high cholesterol. FINDINGS All risks combined account for 57·2% (95% uncertainty interval [UI] 55·8-58·5) of deaths and 41·6% (40·1-43·0) of DALYs. Risks quantified account for 87·9% (86·5-89·3) of cardiovascular disease DALYs, ranging to a low of 0% for neonatal disorders and neglected tropical diseases and malaria. In terms of global DALYs in 2013, six risks or clusters of risks each caused more than 5% of DALYs: dietary risks accounting for 11·3 million deaths and 241·4 million DALYs, high systolic blood pressure for 10·4 million deaths and 208·1 million DALYs, child and maternal malnutrition for 1·7 million deaths and 176·9 million DALYs, tobacco smoke for 6·1 million deaths and 143·5 million DALYs, air pollution for 5·5 million deaths and 141·5 million DALYs, and high BMI for 4·4 million deaths and 134·0 million DALYs. Risk factor patterns vary across regions and countries and with time. In sub-Saharan Africa, the leading risk factors are child and maternal malnutrition, unsafe sex, and unsafe water, sanitation, and handwashing. In women, in nearly all countries in the Americas, north Africa, and the Middle East, and in many other high-income countries, high BMI is the leading risk factor, with high systolic blood pressure as the leading risk in most of Central and Eastern Europe and south and east Asia. For men, high systolic blood pressure or tobacco use are the leading risks in nearly all high-income countries, in north Africa and the Middle East, Europe, and Asia. For men and women, unsafe sex is the leading risk in a corridor from Kenya to South Africa. INTERPRETATION Behavioural, environmental and occupational, and metabolic risks can explain half of global mortality and more than one-third of global DALYs providing many opportunities for prevention. Of the larger risks, the attributable burden of high BMI has increased in the past 23 years. In view of the prominence of behavioural risk factors, behavioural and social science research on interventions for these risks should be strengthened. Many prevention and primary care policy options are available now to act on key risks. FUNDING Bill & Melinda Gates Foundation.
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Mohamed H, Clasen T, Njee RM, Malebo HM, Mbuligwe S, Brown J. Microbiological effectiveness of household water treatment technologies under field use conditions in rural Tanzania. Trop Med Int Health 2015; 21:33-40. [PMID: 26505903 DOI: 10.1111/tmi.12628] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
OBJECTIVES To assess the microbiological effectiveness of several household water treatment and safe storage (HWTS) options in situ in Tanzania, before consideration for national scale-up of HWTS. METHODS Participating households received supplies and instructions for practicing six HWTS methods on a rotating 5-week basis. We analysed 1202 paired samples (source and treated) of drinking water from 390 households, across all technologies. Samples were analysed for thermotolerant (TTC) coliforms, an indicator of faecal contamination, to measure effectiveness of treatment in situ. RESULTS All HWTS methods improved microbial water quality, with reductions in TTC of 99.3% for boiling, 99.4% for Waterguard™ brand sodium hypochlorite solution, 99.5% for a ceramic pot filter, 99.5% for Aquatab® sodium dichloroisocyanurate (NaDCC) tablets, 99.6% for P&G Purifier of Water™ flocculent/disinfectant sachets, and 99.7% for a ceramic siphon filter. Microbiological performance was relatively high compared with other field studies and differences in microbial reductions between technologies were not statistically significant. CONCLUSIONS Given that microbiological performance across technologies was comparable, decisions regarding scale-up should be based on other factors, including uptake in the target population and correct, consistent, and sustained use over time.
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Affiliation(s)
- Hussein Mohamed
- School of Public Health, Muhimbili University of Health and Allied Sciences, Dar es Salaam, Tanzania.,School of Environmental Science and Technology, Ardhi University, Dar es Salaam, Tanzania
| | - Thomas Clasen
- Ministry of Health and Social Welfare, Dar es Salaam, Tanzania
| | | | - Hamisi M Malebo
- Rollins School of Public Health, Emory University, Atlanta, GA, USA
| | - Stephen Mbuligwe
- School of Environmental Science and Technology, Ardhi University, Dar es Salaam, Tanzania
| | - Joe Brown
- School of Civil and Environmental Engineering, Georgia Institute of Technology, Atlanta, GA, USA
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Rosa G, Kelly P, Clasen T. Consistency of Use and Effectiveness of Household Water Treatment Practices Among Urban and Rural Populations Claiming to Treat Their Drinking Water at Home: A Case Study in Zambia. Am J Trop Med Hyg 2015; 94:445-55. [PMID: 26572868 DOI: 10.4269/ajtmh.15-0563] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/05/2015] [Accepted: 09/28/2015] [Indexed: 11/07/2022] Open
Abstract
Household water treatment (HWT) can improve drinking water quality and prevent disease, if used correctly and consistently. While international monitoring suggests that 1.8 billion people practice HWT, these estimates are based on household surveys that may overstate the level of consistent use and do not address microbiological effectiveness. We sought to examine how HWT is practiced among households identified as HWT users according to international monitoring standards. Case studies were conducted in urban and rural Zambia. After a baseline survey (urban: 203 households, rural: 276 households) to identify HWT users, 95 urban and 82 rural households were followed up for 6 weeks. Consistency of HWT reporting was low; only 72.6% of urban and 50.0% of rural households reported to be HWT users in the subsequent visit. Similarly, availability of treated water was low, only 23.3% and 4.2% of urban and rural households, respectively, had treated water on all visits. Drinking water was significantly worse than source water in both settings. Only 19.6% of urban and 2.4% of rural households had drinking water free of thermotolerant coliforms on all visits. Our findings raise questions about the value of the data gathered through the international monitoring of HWT practices as predictors of water quality in the home.
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Affiliation(s)
- Ghislaine Rosa
- Faculty of Infectious and Tropical Diseases, London School of Hygiene and Tropical Medicine, London, United Kingdom; Tropical Gastroenterology and Nutrition Group, Department of Internal Medicine, University of Zambia School of Medicine, Lusaka, Zambia; Blizard Institute, Barts and the London School of Medicine, Queen Mary University of London, London, United Kingdom; Department of Environmental Health, Rollins School of Public Health, Emory University, Atlanta, Georgia
| | - Paul Kelly
- Faculty of Infectious and Tropical Diseases, London School of Hygiene and Tropical Medicine, London, United Kingdom; Tropical Gastroenterology and Nutrition Group, Department of Internal Medicine, University of Zambia School of Medicine, Lusaka, Zambia; Blizard Institute, Barts and the London School of Medicine, Queen Mary University of London, London, United Kingdom; Department of Environmental Health, Rollins School of Public Health, Emory University, Atlanta, Georgia
| | - Thomas Clasen
- Faculty of Infectious and Tropical Diseases, London School of Hygiene and Tropical Medicine, London, United Kingdom; Tropical Gastroenterology and Nutrition Group, Department of Internal Medicine, University of Zambia School of Medicine, Lusaka, Zambia; Blizard Institute, Barts and the London School of Medicine, Queen Mary University of London, London, United Kingdom; Department of Environmental Health, Rollins School of Public Health, Emory University, Atlanta, Georgia
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222
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Clasen TF, Alexander KT, Sinclair D, Boisson S, Peletz R, Chang HH, Majorin F, Cairncross S. Interventions to improve water quality for preventing diarrhoea. Cochrane Database Syst Rev 2015; 2015:CD004794. [PMID: 26488938 PMCID: PMC4625648 DOI: 10.1002/14651858.cd004794.pub3] [Citation(s) in RCA: 123] [Impact Index Per Article: 13.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/18/2023]
Abstract
BACKGROUND Diarrhoea is a major cause of death and disease, especially among young children in low-income countries. In these settings, many infectious agents associated with diarrhoea are spread through water contaminated with faeces.In remote and low-income settings, source-based water quality improvement includes providing protected groundwater (springs, wells, and bore holes), or harvested rainwater as an alternative to surface sources (rivers and lakes). Point-of-use water quality improvement interventions include boiling, chlorination, flocculation, filtration, or solar disinfection, mainly conducted at home. OBJECTIVES To assess the effectiveness of interventions to improve water quality for preventing diarrhoea. SEARCH METHODS We searched the Cochrane Infectious Diseases Group Specialized Register (11 November 2014), CENTRAL (the Cochrane Library, 7 November 2014), MEDLINE (1966 to 10 November 2014), EMBASE (1974 to 10 November 2014), and LILACS (1982 to 7 November 2014). We also handsearched relevant conference proceedings, contacted researchers and organizations working in the field, and checked references from identified studies through 11 November 2014. SELECTION CRITERIA Randomized controlled trials (RCTs), quasi-RCTs, and controlled before-and-after studies (CBA) comparing interventions aimed at improving the microbiological quality of drinking water with no intervention in children and adults. DATA COLLECTION AND ANALYSIS Two review authors independently assessed trial quality and extracted data. We used meta-analyses to estimate pooled measures of effect, where appropriate, and investigated potential sources of heterogeneity using subgroup analyses. We assessed the quality of evidence using the GRADE approach. MAIN RESULTS Forty-five cluster-RCTs, two quasi-RCTs, and eight CBA studies, including over 84,000 participants, met the inclusion criteria. Most included studies were conducted in low- or middle-income countries (LMICs) (50 studies) with unimproved water sources (30 studies) and unimproved or unclear sanitation (34 studies). The primary outcome in most studies was self-reported diarrhoea, which is at high risk of bias due to the lack of blinding in over 80% of the included studies. Source-based water quality improvementsThere is currently insufficient evidence to know if source-based improvements such as protected wells, communal tap stands, or chlorination/filtration of community sources consistently reduce diarrhoea (one cluster-RCT, five CBA studies, very low quality evidence). We found no studies evaluating reliable piped-in water supplies delivered to households. Point-of-use water quality interventionsOn average, distributing water disinfection products for use at the household level may reduce diarrhoea by around one quarter (Home chlorination products: RR 0.77, 95% CI 0.65 to 0.91; 14 trials, 30,746 participants, low quality evidence; flocculation and disinfection sachets: RR 0.69, 95% CI 0.58 to 0.82, four trials, 11,788 participants, moderate quality evidence). However, there was substantial heterogeneity in the size of the effect estimates between individual studies.Point-of-use filtration systems probably reduce diarrhoea by around a half (RR 0.48, 95% CI 0.38 to 0.59, 18 trials, 15,582 participants, moderate quality evidence). Important reductions in diarrhoea episodes were shown with ceramic filters, biosand systems and LifeStraw® filters; (Ceramic: RR 0.39, 95% CI 0.28 to 0.53; eight trials, 5763 participants, moderate quality evidence; Biosand: RR 0.47, 95% CI 0.39 to 0.57; four trials, 5504 participants, moderate quality evidence; LifeStraw®: RR 0.69, 95% CI 0.51 to 0.93; three trials, 3259 participants, low quality evidence). Plumbed in filters have only been evaluated in high-income settings (RR 0.81, 95% CI 0.71 to 0.94, three trials, 1056 participants, fixed effects model).In low-income settings, solar water disinfection (SODIS) by distribution of plastic bottles with instructions to leave filled bottles in direct sunlight for at least six hours before drinking probably reduces diarrhoea by around a third (RR 0.62, 95% CI 0.42 to 0.94; four trials, 3460 participants, moderate quality evidence).In subgroup analyses, larger effects were seen in trials with higher adherence, and trials that provided a safe storage container. In most cases, the reduction in diarrhoea shown in the studies was evident in settings with improved and unimproved water sources and sanitation. AUTHORS' CONCLUSIONS Interventions that address the microbial contamination of water at the point-of-use may be important interim measures to improve drinking water quality until homes can be reached with safe, reliable, piped-in water connections. The average estimates of effect for each individual point-of-use intervention generally show important effects. Comparisons between these estimates do not provide evidence of superiority of one intervention over another, as such comparisons are confounded by the study setting, design, and population.Further studies assessing the effects of household connections and chlorination at the point of delivery will help improve our knowledge base. As evidence suggests effectiveness improves with adherence, studies assessing programmatic approaches to optimising coverage and long-term utilization of these interventions among vulnerable populations could also help strategies to improve health outcomes.
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Affiliation(s)
- Thomas F Clasen
- Rollins School of Public Health, Emory UniversityDepartment of Environmental Health1518 Clifton Road NEAtlantaGAUSA30322
| | - Kelly T Alexander
- Rollins School of Public Health, Emory UniversityDepartment of Environmental Health1518 Clifton Road NEAtlantaGAUSA30322
| | - David Sinclair
- Liverpool School of Tropical MedicineDepartment of Clinical SciencesPembroke PlaceLiverpoolUKL3 5QA
| | - Sophie Boisson
- London School of Hygiene & Tropical MedicineFaculty of Infectious and Tropical DiseasesLondonUK
| | | | - Howard H Chang
- Rollins School of Public Health, Emory UniversityDepartment of Biostatistics and Bioinformatics1518 Clifton Road NEAtlantaGAUSA30322
| | - Fiona Majorin
- London School of Hygiene & Tropical MedicineFaculty of Infectious and Tropical DiseasesLondonUK
| | - Sandy Cairncross
- London School of Hygiene & Tropical MedicineDepartment of Disease Control, Faculty of Infectious and Tropical DiseasesKeppel StreetLondonUKWC1E 7HT
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Levy K. Does Poor Water Quality Cause Diarrheal Disease? Am J Trop Med Hyg 2015; 93:899-900. [PMID: 26438028 PMCID: PMC4703281 DOI: 10.4269/ajtmh.15-0689] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/21/2015] [Accepted: 09/24/2015] [Indexed: 11/17/2022] Open
Affiliation(s)
- Karen Levy
- *Address correspondence to Karen Levy, Department of Environmental Health, Rollins School of Public Health, Emory University, 1518 Clifton Rd NE, Atlanta, GA 30322. E-mail:
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224
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Rodriguez-Alvarez MS, Weir MH, Pope JM, Seghezzo L, Rajal VB, Salusso MM, Moraña LB. Development of a relative risk model for drinking water regulation and design recommendations for a peri urban region of Argentina. Int J Hyg Environ Health 2015; 218:627-38. [PMID: 26190481 PMCID: PMC7187401 DOI: 10.1016/j.ijheh.2015.06.007] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/04/2014] [Revised: 06/25/2015] [Accepted: 06/26/2015] [Indexed: 11/16/2022]
Abstract
Argentina is a developing Latin American nation that has an aim of achieving the United Nations Millennium Development Goals for potable water supplies. Their current regulations however, limit the continued development of improved potable water quality and infrastructure from a microbiological viewpoint. This is since the current regulations are focused solely to pathogenic Eschericia coli (E. coli), Pseudomonas aeruginosa (P. aeruginosa) and fecal indicators. Regions of lower socioeconomic status such as peri-urban areas are particularly at risk due to lessened financial and political ability to influence their environmental quality and infrastructure needs. Therefore, a combined microbiological sampling, analysis and quantitative microbial risk assessment (QMRA) modeling effort were engaged for a peri-urban area of Salta Argentina. Drinking water samples from home taps were analyzed and a QMRA model was developed, results of which were compared against a general 1:10,000 risk level for lack of a current Argentinian standard. This QMRA model was able to demonstrate that the current regulations were being achieved for E. coli but were less than acceptable for P. aeruginosa in some instances. Appropriate health protections are far from acceptable for Giardia for almost all water sources. Untreated water sources were sampled and analyzed then QMRA modeled as well, since a significant number of the community (∼9%) still use them for potable water supplies. For untreated water E. coli risks were near 1:10,000, however, P. aeruginosa and Giardia risks failed to be acceptable in almost all instances. The QMRA model and microbiological analyses demonstrate the need for improved regulatory efforts for the peri-urban area along with improved investment in their water infrastructure.
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Affiliation(s)
- María Soledad Rodriguez-Alvarez
- National Agency for the Advancement of Science and Technology (ANPCyT), Avenida Bolivia 5150, A4408FVY Salta, Argentina; INENCO-CONICET, Universidad Nacional de Salta, Av. Bolivia 5150, A4408FVY Salta, Argentina.
| | - Mark H Weir
- Departments of Epidemiology and Biostatistics and Civil and Environmental Engineering, Temple University, 1301 Cecil B. Moore Ave., Philadelphia, PA 19122, USA; CAMRA Consultants LLC, Lansing, MI, USA.
| | | | - Lucas Seghezzo
- INENCO-CONICET, Universidad Nacional de Salta, Av. Bolivia 5150, A4408FVY Salta, Argentina
| | - Verónica B Rajal
- INIQUI-CONICET, Universidad Nacional de Salta, Av. Bolivia 5150, A4408FVY Salta, Argentina
| | - María Mónica Salusso
- National Agency for the Advancement of Science and Technology (ANPCyT), Avenida Bolivia 5150, A4408FVY Salta, Argentina
| | - Liliana B Moraña
- National Agency for the Advancement of Science and Technology (ANPCyT), Avenida Bolivia 5150, A4408FVY Salta, Argentina
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225
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Jeandron A, Saidi JM, Kapama A, Burhole M, Birembano F, Vandevelde T, Gasparrini A, Armstrong B, Cairncross S, Ensink JHJ. Water supply interruptions and suspected cholera incidence: a time-series regression in the Democratic Republic of the Congo. PLoS Med 2015; 12:e1001893. [PMID: 26506001 PMCID: PMC4624412 DOI: 10.1371/journal.pmed.1001893] [Citation(s) in RCA: 35] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/21/2015] [Accepted: 09/17/2015] [Indexed: 12/22/2022] Open
Abstract
BACKGROUND The eastern provinces of the Democratic Republic of the Congo have been identified as endemic areas for cholera transmission, and despite continuous control efforts, they continue to experience regular cholera outbreaks that occasionally spread to the rest of the country. In a region where access to improved water sources is particularly poor, the question of which improvements in water access should be prioritized to address cholera transmission remains unresolved. This study aimed at investigating the temporal association between water supply interruptions and Cholera Treatment Centre (CTC) admissions in a medium-sized town. METHODS AND FINDINGS Time-series patterns of daily incidence of suspected cholera cases admitted to the Cholera Treatment Centre in Uvira in South Kivu Province between 2009 and 2014 were examined in relation to the daily variations in volume of water supplied by the town water treatment plant. Quasi-poisson regression and distributed lag nonlinear models up to 12 d were used, adjusting for daily precipitation rates, day of the week, and seasonal variations. A total of 5,745 patients over 5 y of age with acute watery diarrhoea symptoms were admitted to the CTC over the study period of 1,946 d. Following a day without tap water supply, the suspected cholera incidence rate increased on average by 155% over the next 12 d, corresponding to a rate ratio of 2.55 (95% CI: 1.54-4.24), compared to the incidence experienced after a day with optimal production (defined as the 95th percentile-4,794 m3). Suspected cholera cases attributable to a suboptimal tap water supply reached 23.2% of total admissions (95% CI 11.4%-33.2%). Although generally reporting less admissions to the CTC, neighbourhoods with a higher consumption of tap water were more affected by water supply interruptions, with a rate ratio of 3.71 (95% CI: 1.91-7.20) and an attributable fraction of cases of 31.4% (95% CI: 17.3%-42.5%). The analysis did not suggest any association between levels of residual chlorine in the water fed to the distribution network and suspected cholera incidence. Laboratory confirmation of cholera was not available for this analysis. CONCLUSIONS A clear association is observed between reduced availability of tap water and increased incidence of suspected cholera in the entire town of Uvira in Eastern Democratic Republic of the Congo. Even though access to piped water supplies is low in Uvira, improving the reliability of tap water supply may substantially reduce the incidence of suspected cholera, in particular in neighbourhoods having a higher access to tap water. These results argue in favour of water supply investments that focus on the delivery of a reliable and sustainable water supply, and not only on point-of-use water quality improvements, as is often seen during cholera outbreaks.
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Affiliation(s)
- Aurélie Jeandron
- Environmental Health Group, Department of Disease Control, Faculty of Infectious and Tropical Diseases, London School of Hygiene & Tropical Medicine, London, United Kingdom
- * E-mail:
| | - Jaime Mufitini Saidi
- Ministère de la Santé Publique, Division Provinciale de la Santé Publique, District Sanitaire d’Uvira, Uvira, Sud-Kivu, République Démocratique du Congo
| | - Alois Kapama
- Ministère de la Santé Publique, Division Provinciale de la Santé Publique, District Sanitaire d’Uvira, Uvira, Sud-Kivu, République Démocratique du Congo
| | - Manu Burhole
- Ministère de la Santé Publique, Division Provinciale de la Santé Publique, Bukavu, Sud-Kivu, République Démocratique du Congo
| | - Freddy Birembano
- Ministère de la Santé Publique, Division Provinciale de la Santé Publique, Bukavu, Sud-Kivu, République Démocratique du Congo
| | | | - Antonio Gasparrini
- Department of Medical Statistics, Faculty of Epidemiology and Population Health, London School of Hygiene & Tropical Medicine, London, United Kingdom
| | - Ben Armstrong
- Department of Social and Environmental Research, Faculty of Public Health and Policy, London School of Hygiene & Tropical Medicine, London, United Kingdom
| | - Sandy Cairncross
- Environmental Health Group, Department of Disease Control, Faculty of Infectious and Tropical Diseases, London School of Hygiene & Tropical Medicine, London, United Kingdom
| | - Jeroen H. J. Ensink
- Environmental Health Group, Department of Disease Control, Faculty of Infectious and Tropical Diseases, London School of Hygiene & Tropical Medicine, London, United Kingdom
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226
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Are Randomized Trials Necessary to Advance Epidemiologic Research on Household Air Pollution? CURR EPIDEMIOL REP 2015. [DOI: 10.1007/s40471-015-0054-4] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
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227
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Cha S, Kang D, Tuffuor B, Lee G, Cho J, Chung J, Kim M, Lee H, Lee J, Oh C. The Effect of Improved Water Supply on Diarrhea Prevalence of Children under Five in the Volta Region of Ghana: A Cluster-Randomized Controlled Trial. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2015; 12:12127-43. [PMID: 26404337 PMCID: PMC4626959 DOI: 10.3390/ijerph121012127] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 07/16/2015] [Revised: 09/08/2015] [Accepted: 09/21/2015] [Indexed: 11/16/2022]
Abstract
Although a number of studies have been conducted to explore the effect of water quality improvement, the majority of them have focused mainly on point-of-use water treatment, and the studies investigating the effect of improved water supply have been based on observational or inadequately randomized trials. We report the results of a matched cluster randomized trial investigating the effect of improved water supply on diarrheal prevalence of children under five living in rural areas of the Volta Region in Ghana. We compared the diarrheal prevalence of 305 children in 10 communities of intervention with 302 children in 10 matched communities with no intervention (October 2012 to February 2014). A modified Poisson regression was used to estimate the prevalence ratio. An intention-to-treat analysis was undertaken. The crude prevalence ratio of diarrhea in the intervention compared with the control communities was 0.85 (95% CI 0.74–0.97) for Krachi West, 0.96 (0.87–1.05) for Krachi East, and 0.91 (0.83–0.98) for both districts. Sanitation was adjusted for in the model to remove the bias due to residual imbalance since it was not balanced even after randomization. The adjusted prevalence ratio was 0.82 (95% CI 0.71–0.96) for Krachi West, 0.95 (0.86–1.04) for Krachi East, and 0.89 (0.82–0.97) for both districts. This study provides a basis for a better approach to water quality interventions.
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Affiliation(s)
- Seungman Cha
- Korea International Cooperation Agency, 825 Daewangpangyo-ro, Sujeong-gu, Seongnam-si, Gyeongo-do 13449, Republic of Korea.
- Department of Disease Control, Faculty of Infectious and Tropical Disease, London School of Hygiene & Tropical Medicine, Keppel Street London WC1E 7HT, London, UK.
| | - Douk Kang
- World Vision Korea, 77-1, Yeouinaru-ro, Yeongdeungpo-gu, Seoul, 07327, Republic of Korea.
| | - Benedict Tuffuor
- Training Research and Networking for Development, Post Office. Box Cantonments 6135, Cantonments, Accra, Ghana.
| | - Gyuhong Lee
- Korea International Cooperation Agency, 825 Daewangpangyo-ro, Sujeong-gu, Seongnam-si, Gyeongo-do 13449, Republic of Korea.
| | - Jungmyung Cho
- Korea International Cooperation Agency, 825 Daewangpangyo-ro, Sujeong-gu, Seongnam-si, Gyeongo-do 13449, Republic of Korea.
| | - Jihye Chung
- World Vision Korea, 77-1, Yeouinaru-ro, Yeongdeungpo-gu, Seoul, 07327, Republic of Korea.
| | - Myongjin Kim
- Korea International Cooperation Agency, 825 Daewangpangyo-ro, Sujeong-gu, Seongnam-si, Gyeongo-do 13449, Republic of Korea.
| | - Hoonsang Lee
- Korea International Cooperation Agency, 825 Daewangpangyo-ro, Sujeong-gu, Seongnam-si, Gyeongo-do 13449, Republic of Korea.
| | - Jaeeun Lee
- Korea International Cooperation Agency, 825 Daewangpangyo-ro, Sujeong-gu, Seongnam-si, Gyeongo-do 13449, Republic of Korea.
| | - Chunghyeon Oh
- Korea International Cooperation Agency, 825 Daewangpangyo-ro, Sujeong-gu, Seongnam-si, Gyeongo-do 13449, Republic of Korea.
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228
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Polman K, Becker SL, Alirol E, Bhatta NK, Bhattarai NR, Bottieau E, Bratschi MW, Burza S, Coulibaly JT, Doumbia MN, Horié NS, Jacobs J, Khanal B, Landouré A, Mahendradhata Y, Meheus F, Mertens P, Meyanti F, Murhandarwati EH, N'Goran EK, Peeling RW, Ravinetto R, Rijal S, Sacko M, Saye R, Schneeberger PHH, Schurmans C, Silué KD, Thobari JA, Traoré MS, van Lieshout L, van Loen H, Verdonck K, von Müller L, Yansouni CP, Yao JA, Yao PK, Yap P, Boelaert M, Chappuis F, Utzinger J. Diagnosis of neglected tropical diseases among patients with persistent digestive disorders (diarrhoea and/or abdominal pain ≥14 days): Pierrea multi-country, prospective, non-experimental case-control study. BMC Infect Dis 2015; 15:338. [PMID: 26282537 PMCID: PMC4539676 DOI: 10.1186/s12879-015-1074-x] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/13/2014] [Accepted: 07/30/2015] [Indexed: 12/22/2022] Open
Abstract
Background Diarrhoea still accounts for considerable mortality and morbidity worldwide. The highest burden is concentrated in tropical areas where populations lack access to clean water, adequate sanitation and hygiene. In contrast to acute diarrhoea (<14 days), the spectrum of pathogens that may give rise to persistent diarrhoea (≥14 days) and persistent abdominal pain is poorly understood. It is conceivable that pathogens causing neglected tropical diseases play a major role, but few studies investigated this issue. Clinical management and diagnostic work-up of persistent digestive disorders in the tropics therefore remain inadequate. Hence, important aspects regarding the pathogenesis, epidemiology, clinical symptomatology and treatment options for patients presenting with persistent diarrhoea and persistent abdominal pain should be investigated in multi-centric clinical studies. Methods/Design This multi-country, prospective, non-experimental case–control study will assess persistent diarrhoea (≥14 days; in individuals aged ≥1 year) and persistent abdominal pain (≥14 days; in children/adolescents aged 1–18 years) in up to 2000 symptomatic patients and 2000 matched controls. Subjects from Côte d’Ivoire, Indonesia, Mali and Nepal will be clinically examined and interviewed using a detailed case report form. Additionally, each participant will provide a stool sample that will be examined using a suite of diagnostic methods (i.e., microscopic techniques, rapid diagnostic tests, stool culture and polymerase chain reaction) for the presence of bacterial and parasitic pathogens. Treatment will be offered to all infected participants and the clinical treatment response will be recorded. Data obtained will be utilised to develop patient-centred clinical algorithms that will be validated in primary health care centres in the four study countries in subsequent studies. Discussion Our research will deepen the understanding of the importance of persistent diarrhoea and related digestive disorders in the tropics. A diversity of intestinal pathogens will be assessed for potential associations with persistent diarrhoea and persistent abdominal pain. Different diagnostic methods will be compared, clinical symptoms investigated and diagnosis-treatment algorithms developed for validation in selected primary health care centres. The findings from this study will improve differential diagnosis and evidence-based clinical management of digestive syndromes in the tropics. Trial registration ClinicalTrials.gov; identifier: NCT02105714.
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Affiliation(s)
- Katja Polman
- Department of Biomedical Sciences, Institute of Tropical Medicine, Antwerp, Belgium.
| | - Sören L Becker
- Department of Epidemiology and Public Health, Swiss Tropical and Public Health Institute, Basel, Switzerland. .,University of Basel, Basel, Switzerland. .,Institute of Medical Microbiology and Hygiene, Saarland University, Homburg/Saar, Germany.
| | - Emilie Alirol
- Division of Tropical and Humanitarian Medicine, Geneva University Hospitals, Geneva, Switzerland.
| | - Nisha K Bhatta
- Department of Paediatrics and Adolescent Medicine, B P Koirala Institute of Health Sciences, Dharan, Nepal.
| | - Narayan R Bhattarai
- Department of Microbiology, B P Koirala Institute of Health Sciences, Dharan, Nepal.
| | - Emmanuel Bottieau
- Department of Clinical Sciences, Institute of Tropical Medicine, Antwerp, Belgium.
| | - Martin W Bratschi
- Department of Epidemiology and Public Health, Swiss Tropical and Public Health Institute, Basel, Switzerland. .,University of Basel, Basel, Switzerland.
| | - Sakib Burza
- London School of Hygiene and Tropical Medicine, London, United Kingdom.
| | - Jean T Coulibaly
- Department of Epidemiology and Public Health, Swiss Tropical and Public Health Institute, Basel, Switzerland. .,University of Basel, Basel, Switzerland. .,Unité de Formation et de Recherche Biosciences, Université Félix Houphouët-Boigny, Abidjan, Côte d'Ivoire. .,Département Environnement et Santé, Centre Suisse de Recherches Scientifiques en Côte d'Ivoire, Abidjan, Côte d'Ivoire.
| | - Mama N Doumbia
- Institut National de Recherche en Santé Publique, Bamako, Mali.
| | - Ninon S Horié
- Division of Tropical and Humanitarian Medicine, Geneva University Hospitals, Geneva, Switzerland.
| | - Jan Jacobs
- Department of Clinical Sciences, Institute of Tropical Medicine, Antwerp, Belgium.
| | - Basudha Khanal
- Department of Microbiology, B P Koirala Institute of Health Sciences, Dharan, Nepal.
| | - Aly Landouré
- Institut National de Recherche en Santé Publique, Bamako, Mali.
| | - Yodi Mahendradhata
- Centre for Tropical Medicine, Faculty of Medicine, Gadjah Mada University, Yogyakarta, Indonesia.
| | - Filip Meheus
- University of Cape Town, Cape Town, South Africa.
| | | | - Fransiska Meyanti
- Centre for Tropical Medicine, Faculty of Medicine, Gadjah Mada University, Yogyakarta, Indonesia.
| | - Elsa H Murhandarwati
- Centre for Tropical Medicine, Faculty of Medicine, Gadjah Mada University, Yogyakarta, Indonesia.
| | - Eliézer K N'Goran
- Unité de Formation et de Recherche Biosciences, Université Félix Houphouët-Boigny, Abidjan, Côte d'Ivoire. .,Département Environnement et Santé, Centre Suisse de Recherches Scientifiques en Côte d'Ivoire, Abidjan, Côte d'Ivoire.
| | - Rosanna W Peeling
- London School of Hygiene and Tropical Medicine, London, United Kingdom.
| | - Raffaella Ravinetto
- Department of Clinical Sciences, Institute of Tropical Medicine, Antwerp, Belgium. .,Department of Pharmaceutical and Pharmacological Sciences, KU Leuven, Leuven, Belgium.
| | - Suman Rijal
- Department of Internal Medicine, B P Koirala Institute of Health Sciences, Dharan, Nepal.
| | - Moussa Sacko
- Institut National de Recherche en Santé Publique, Bamako, Mali.
| | - Rénion Saye
- Institut National de Recherche en Santé Publique, Bamako, Mali.
| | - Pierre H H Schneeberger
- Department of Epidemiology and Public Health, Swiss Tropical and Public Health Institute, Basel, Switzerland. .,University of Basel, Basel, Switzerland. .,Department of Epidemiology and Molecular Diagnostics, Agroscope Changins-Wädenswil ACW, Wädenswil, Switzerland. .,Department of Virology, Spiez Laboratory, Federal Office for Civil Protection, Spiez, Switzerland.
| | - Céline Schurmans
- Department of Clinical Sciences, Institute of Tropical Medicine, Antwerp, Belgium.
| | - Kigbafori D Silué
- Unité de Formation et de Recherche Biosciences, Université Félix Houphouët-Boigny, Abidjan, Côte d'Ivoire. .,Département Environnement et Santé, Centre Suisse de Recherches Scientifiques en Côte d'Ivoire, Abidjan, Côte d'Ivoire.
| | - Jarir A Thobari
- Centre for Tropical Medicine, Faculty of Medicine, Gadjah Mada University, Yogyakarta, Indonesia.
| | | | - Lisette van Lieshout
- Department of Parasitology, Leiden University Medical Center, Leiden, The Netherlands.
| | - Harry van Loen
- Department of Clinical Sciences, Institute of Tropical Medicine, Antwerp, Belgium.
| | - Kristien Verdonck
- Department of Public Health, Institute of Tropical Medicine, Antwerp, Belgium.
| | - Lutz von Müller
- Institute of Medical Microbiology and Hygiene, Saarland University, Homburg/Saar, Germany.
| | - Cédric P Yansouni
- Divisions of Infectious Diseases and Medical Microbiology, J.D. MacLean Centre for Tropical Diseases, McGill University Health Centre, Montreal, Canada.
| | - Joel A Yao
- Unité de Formation et de Recherche Biosciences, Université Félix Houphouët-Boigny, Abidjan, Côte d'Ivoire. .,Département Environnement et Santé, Centre Suisse de Recherches Scientifiques en Côte d'Ivoire, Abidjan, Côte d'Ivoire.
| | - Patrick K Yao
- Unité de Formation et de Recherche Biosciences, Université Félix Houphouët-Boigny, Abidjan, Côte d'Ivoire.
| | - Peiling Yap
- Department of Epidemiology and Public Health, Swiss Tropical and Public Health Institute, Basel, Switzerland. .,University of Basel, Basel, Switzerland.
| | - Marleen Boelaert
- Department of Public Health, Institute of Tropical Medicine, Antwerp, Belgium.
| | - François Chappuis
- Division of Tropical and Humanitarian Medicine, Geneva University Hospitals, Geneva, Switzerland.
| | - Jürg Utzinger
- Department of Epidemiology and Public Health, Swiss Tropical and Public Health Institute, Basel, Switzerland. .,University of Basel, Basel, Switzerland.
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Francis MR, Nagarajan G, Sarkar R, Mohan VR, Kang G, Balraj V. Perception of drinking water safety and factors influencing acceptance and sustainability of a water quality intervention in rural southern India. BMC Public Health 2015; 15:731. [PMID: 26223687 PMCID: PMC4520261 DOI: 10.1186/s12889-015-1974-0] [Citation(s) in RCA: 42] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2015] [Accepted: 06/25/2015] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Acceptance and long-term sustainability of water quality interventions are pivotal to realizing continued health benefits. However, there is limited research attempting to understand the factors that influence compliance to or adoption of such interventions. METHODS Eight focus group discussions with parents of young children--including compliant and not compliant households participating in an intervention study, and three key-informant interviews with village headmen were conducted between April and May 2014 to understand perceptions on the effects of unsafe water on health, household drinking water treatment practices, and the factors influencing acceptance and sustainability of an ongoing water quality intervention in a rural population of southern India. RESULTS The ability to recognize health benefits from the intervention, ease of access to water distribution centers and the willingness to pay for intervention maintenance were factors facilitating acceptance and sustainability of the water quality intervention. On the other hand, faulty perceptions on water treatment, lack of knowledge about health hazards associated with drinking unsafe water, false sense of protection from locally available water, resistance to change in taste or odor of water and a lack of support from male members of the household were important factors impeding acceptance and long term use of the intervention. CONCLUSION This study highlights the need to effectively involve communities at important stages of implementation for long term success of water quality interventions. Timely research on the factors influencing uptake of water quality interventions prior to implementation will ensure greater acceptance and sustainability of such interventions in low income settings.
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Affiliation(s)
- Mark Rohit Francis
- Division of Gastrointestinal Sciences, Christian Medical College, Vellore, TN, 632004, India.
| | - Guru Nagarajan
- Department of Physical Medicine and Rehabilitation, Christian Medical College, Vellore, TN, 632002, India.
| | - Rajiv Sarkar
- Division of Gastrointestinal Sciences, Christian Medical College, Vellore, TN, 632004, India.
| | - Venkata Raghava Mohan
- Department of Community Health, Christian Medical College, Vellore, TN, 632002, India.
| | - Gagandeep Kang
- Division of Gastrointestinal Sciences, Christian Medical College, Vellore, TN, 632004, India.
| | - Vinohar Balraj
- Society for Applied Studies, No 14, Natteri Krishnamachari Street, Krishna Nagar, Vellore, 632001, Tamilnadu, India.
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230
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Sahoo KC, Hulland KRS, Caruso BA, Swain R, Freeman MC, Panigrahi P, Dreibelbis R. Sanitation-related psychosocial stress: A grounded theory study of women across the life-course in Odisha, India. Soc Sci Med 2015; 139:80-9. [PMID: 26164119 DOI: 10.1016/j.socscimed.2015.06.031] [Citation(s) in RCA: 125] [Impact Index Per Article: 13.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2014] [Revised: 06/17/2015] [Accepted: 06/22/2015] [Indexed: 10/23/2022]
Abstract
While sanitation interventions have focused primarily on child health, women's unique health risks from inadequate sanitation are gaining recognition as a priority issue. This study examines the range of sanitation-related psychosocial stressors during routine sanitation practices in Odisha, India. Between August 2013 and March 2014, we conducted in-depth interviews with 56 women in four life stages: adolescent, newly married, pregnant and established adult women in three settings: urban slums, rural villages and indigenous villages. Using a grounded theory approach, the study team transcribed, translated, coded and discussed interviews using detailed analytic memos to identify and characterize stressors at each life stage and study site. We found that sanitation practices encompassed more than defecation and urination and included carrying water, washing, bathing, menstrual management, and changing clothes. During the course of these activities, women encountered three broad types of stressors-environmental, social, and sexual-the intensity of which were modified by the woman's life stage, living environment, and access to sanitation facilities. Environmental barriers, social factors and fears of sexual violence all contributed to sanitation-related psychosocial stress. Though women responded with small changes to sanitation practices, they were unable to significantly modify their circumstances, notably by achieving adequate privacy for sanitation-related behaviors. A better understanding of the range of causes of stress and adaptive behaviors is needed to inform context-specific, gender-sensitive sanitation interventions.
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Affiliation(s)
| | | | - Bethany A Caruso
- Department of Behavioral Science and Health Education and Center for Global Safe Water/Hubert Department of Global Health, Rollins School of Public Health, Emory University, Atlanta, GA, USA
| | - Rojalin Swain
- Asian Institute of Public Health, Bhubaneswar, India
| | - Matthew C Freeman
- Department of Environmental Health, Rollins School of Public Health, Emory University, Atlanta, GA, USA
| | - Pinaki Panigrahi
- Epidemiology and Pediatrics and Center for Global Health and Development, College of Public Health, University of Nebraska Medical Center, Omaha, NE, USA
| | - Robert Dreibelbis
- Center for Applied Social Research, Civil Engineering and Environmental Science, and Department of Anthropology, University of Oklahoma, Norman, OK, USA.
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231
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Brown J, Cumming O, Bartram J, Cairncross S, Ensink J, Holcomb D, Knee J, Kolsky P, Liang K, Liang S, Nala R, Norman G, Rheingans R, Stewart J, Zavale O, Zuin V, Schmidt WP. A controlled, before-and-after trial of an urban sanitation intervention to reduce enteric infections in children: research protocol for the Maputo Sanitation (MapSan) study, Mozambique. BMJ Open 2015; 5:e008215. [PMID: 26088809 PMCID: PMC4480002 DOI: 10.1136/bmjopen-2015-008215] [Citation(s) in RCA: 52] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/18/2023] Open
Abstract
INTRODUCTION Access to safe sanitation in low-income, informal settlements of Sub-Saharan Africa has not significantly improved since 1990. The combination of a high faecal-related disease burden and inadequate infrastructure suggests that investment in expanding sanitation access in densely populated urban slums can yield important public health gains. No rigorous, controlled intervention studies have evaluated the health effects of decentralised (non-sewerage) sanitation in an informal urban setting, despite the role that such technologies will likely play in scaling up access. METHODS AND ANALYSIS We have designed a controlled, before-and-after (CBA) trial to estimate the health impacts of an urban sanitation intervention in informal neighbourhoods of Maputo, Mozambique, including an assessment of whether exposures and health outcomes vary by localised population density. The intervention consists of private pour-flush latrines (to septic tank) shared by multiple households in compounds or household clusters. We will measure objective health outcomes in approximately 760 children (380 children with household access to interventions, 380 matched controls using existing shared private latrines in poor sanitary conditions), at 2 time points: immediately before the intervention and at follow-up after 12 months. The primary outcome is combined prevalence of selected enteric infections among children under 5 years of age. Secondary outcome measures include soil-transmitted helminth (STH) reinfection in children following baseline deworming and prevalence of reported diarrhoeal disease. We will use exposure assessment, faecal source tracking, and microbial transmission modelling to examine whether and how routes of exposure for diarrhoeagenic pathogens and STHs change following introduction of effective sanitation. ETHICS Study protocols have been reviewed and approved by human subjects review boards at the London School of Hygiene and Tropical Medicine, the Georgia Institute of Technology, the University of North Carolina at Chapel Hill, and the Ministry of Health, Republic of Mozambique. TRIAL REGISTRATION NUMBER NCT02362932.
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Affiliation(s)
- Joe Brown
- School of Civil & Environmental Engineering, Georgia Institute of Technology, Atlanta, Georgia, USA
| | - Oliver Cumming
- Department of Disease Control, London School of Hygiene and Tropical Medicine, London, UK
| | - Jamie Bartram
- Department of Environmental Sciences and Engineering, Gillings School of Global Public Health, University of North Carolina-Chapel Hill, Chapel Hill, North Carolina, USA
| | - Sandy Cairncross
- Department of Disease Control, London School of Hygiene and Tropical Medicine, London, UK
| | - Jeroen Ensink
- Department of Disease Control, London School of Hygiene and Tropical Medicine, London, UK
| | - David Holcomb
- Department of Environmental Sciences and Engineering, Gillings School of Global Public Health, University of North Carolina-Chapel Hill, Chapel Hill, North Carolina, USA
| | - Jackie Knee
- School of Civil & Environmental Engineering, Georgia Institute of Technology, Atlanta, Georgia, USA
| | - Peter Kolsky
- Department of Environmental Sciences and Engineering, Gillings School of Global Public Health, University of North Carolina-Chapel Hill, Chapel Hill, North Carolina, USA
| | - Kaida Liang
- Department of Environmental Sciences and Engineering, Gillings School of Global Public Health, University of North Carolina-Chapel Hill, Chapel Hill, North Carolina, USA
| | - Song Liang
- Department of Environmental and Global Health, University of Florida, Gainesville, Florida, USA
| | - Rassul Nala
- Ministry of Health, Republic of Mozambique, Maputo, Mozambique
| | - Guy Norman
- Water and Sanitation for the Urban Poor, London, UK
| | - Richard Rheingans
- Department of Environmental and Global Health, University of Florida, Gainesville, Florida, USA
| | - Jill Stewart
- Department of Environmental Sciences and Engineering, Gillings School of Global Public Health, University of North Carolina-Chapel Hill, Chapel Hill, North Carolina, USA
| | | | - Valentina Zuin
- Emmett Interdisciplinary Program in Environment and Resources, Stanford University, Palo Alto, California, USA
| | - Wolf-Peter Schmidt
- Department of Disease Control, London School of Hygiene and Tropical Medicine, London, UK
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232
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Stelmach RD, Clasen T. Household water quantity and health: a systematic review. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2015; 12:5954-74. [PMID: 26030467 PMCID: PMC4483681 DOI: 10.3390/ijerph120605954] [Citation(s) in RCA: 44] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 02/04/2015] [Revised: 05/18/2015] [Accepted: 05/19/2015] [Indexed: 12/02/2022]
Abstract
While the quantity of water used in the home is thought to be an important determinant of health, much of the evidence relies on using water access as a proxy for quantity. This review examines the health effects of household water quantity using studies that directly measured water quantity. We searched MEDLINE, EMBASE, the Cochrane Library, Web of Science, and article reference lists. Eligible studies included experimental and observational studies that measured a difference in water quantity and quantified an association between water quantity and health outcomes. 21 studies, divided into six of the many possible water-quantity associated outcomes, met the eligibility criteria. Due to heterogeneity in designs, settings, methods, and outcomes, a meta-analysis was inappropriate. Overall results showed a positive association between water quantity and health outcomes, but the effect depended on how the water was used. Increased water usage for personal hygiene was generally associated with improved trachoma outcomes, while increased water consumption was generally associated with reduced gastrointestinal infection and diarrheal disease and improved growth outcomes. In high-income countries, increased water consumption was associated with higher rates of renal cell carcinoma and bladder cancer but not associated with type II diabetes, cardiac-related mortality, or all-cause mortality.
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Affiliation(s)
- Rachel D Stelmach
- Department of Global Health, Rollins School of Public Health, Emory University, Atlanta, GA 30322, USA.
| | - Thomas Clasen
- Department of Environmental Health, Rollins School of Public Health, Emory University, Atlanta, GA 30322, USA.
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233
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Hodge JM, Clasen TF. Carbon financing of household water treatment: background, operation and recommendations to improve potential for health gains. ENVIRONMENTAL SCIENCE & TECHNOLOGY 2014; 48:12509-15. [PMID: 25314642 DOI: 10.1021/es503155m] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/03/2023]
Abstract
Household water treatment (HWT) provides a means for vulnerable populations to take charge of their own drinking water quality as they patiently wait for the pipe to finally reach them. In many low-income countries, however, promoters have not succeeded in scaling up the intervention among the target population or securing its consistent and sustained use. Carbon financing can provide the funding for reaching targeted populations with effective HWT solutions and the incentives to ensure their long-term uptake. Nevertheless, programs have been criticized because they do not actually reduce carbon emissions. We summarize the background and operation of carbon financing of HWT interventions, including the controversial construct of "suppressed demand". We agree that these programs have limited potential to reduce greenhouse gas emissions and that their characterization of trading "carbon for water" is misleading. Nevertheless, we show that the Kyoto Protocol expressly encouraged the use of suppressed demand as a means of allowing low-income countries to benefit from carbon financing provided it is used to advance development priorities such as health. We conclude by recommending changes to existing criteria for eligible HWT programs that will help ensure that they meet the conditions of microbiological effectiveness and actual use that will improve their potential for health gains.
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Affiliation(s)
- James M Hodge
- Department of Environmental Health, Rollins School of Public Health, Emory University , Atlanta, Georgia 30322, United States
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234
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Effectiveness of a rural sanitation programme on diarrhoea, soil-transmitted helminth infection, and child malnutrition in Odisha, India: a cluster-randomised trial. LANCET GLOBAL HEALTH 2014; 2:e645-53. [PMID: 25442689 DOI: 10.1016/s2214-109x(14)70307-9] [Citation(s) in RCA: 279] [Impact Index Per Article: 27.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
Abstract
BACKGROUND A third of the 2·5 billion people worldwide without access to improved sanitation live in India, as do two-thirds of the 1·1 billion practising open defecation and a quarter of the 1·5 million who die annually from diarrhoeal diseases. We aimed to assess the effectiveness of a rural sanitation intervention, within the context of the Government of India's Total Sanitation Campaign, to prevent diarrhoea, soil-transmitted helminth infection, and child malnutrition. METHODS We did a cluster-randomised controlled trial between May 20, 2010, and Dec 22, 2013, in 100 rural villages in Odisha, India. Households within villages were eligible if they had a child younger than 4 years or a pregnant woman. Villages were randomly assigned (1:1), with a computer-generated sequence, to undergo latrine promotion and construction or to receive no intervention (control). Randomisation was stratified by administrative block to ensure an equal number of intervention and control villages in each block. Masking of participants was not possible because of the nature of the intervention. However, households were not told explicitly that the purpose of enrolment was to study the effect of a trial intervention, and the surveillance team was different from the intervention team. The primary endpoint was 7-day prevalence of reported diarrhoea in children younger than 5 years. We did intention-to-treat and per-protocol analyses. This trial is registered with ClinicalTrials.gov, number NCT01214785. FINDINGS We randomly assigned 50 villages to the intervention group and 50 villages to the control group. There were 4586 households (24,969 individuals) in intervention villages and 4894 households (25,982 individuals) in control villages. The intervention increased mean village-level latrine coverage from 9% of households to 63%, compared with an increase from 8% to 12% in control villages. Health surveillance data were obtained from 1437 households with children younger than 5 years in the intervention group (1919 children younger than 5 years), and from 1465 households (1916 children younger than 5 years) in the control group. 7-day prevalence of reported diarrhoea in children younger than 5 years was 8·8% in the intervention group and 9·1% in the control group (period prevalence ratio 0·97, 95% CI 0·83-1·12). 162 participants died in the intervention group (11 children younger than 5 years) and 151 died in the control group (13 children younger than 5 years). INTERPRETATION Increased latrine coverage is generally believed to be effective for reducing exposure to faecal pathogens and preventing disease; however, our results show that this outcome cannot be assumed. As efforts to improve sanitation are being undertaken worldwide, approaches should not only meet international coverage targets, but should also be implemented in a way that achieves uptake, reduces exposure, and delivers genuine health gains. FUNDING Bill & Melinda Gates Foundation, International Initiative for Impact Evaluation (3ie), and Department for International Development-backed SHARE Research Consortium at the London School of Hygiene & Tropical Medicine.
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235
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Curtis VA. Infection-avoidance behaviour in humans and other animals. Trends Immunol 2014; 35:457-64. [PMID: 25256957 DOI: 10.1016/j.it.2014.08.006] [Citation(s) in RCA: 156] [Impact Index Per Article: 15.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/29/2014] [Revised: 08/25/2014] [Accepted: 08/25/2014] [Indexed: 12/19/2022]
Abstract
Compared with living free, the parasitic way of life has many attractions. Parasites create problems for all animals. Potential hosts can respond by learning to live with parasites (tolerance), actively fighting them (resistance), or they can avoid becoming infected in the first place (avoidance). I propose here a new classification of avoidance behaviour according to the epidemiology of infection risk, where animals must avoid (i) conspecifics, (ii) parasites and their vectors, (iii) parasite-rich environments, and (iv) niche infestation. I further explore how the disgust adaptive system, which coordinates avoidance behaviour, may form a continuum with the immune system through the sharing of signalling pathways, sites of action, and evolutionary history.
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Affiliation(s)
- Valerie A Curtis
- The Hygiene Centre, London School of Hygiene and Tropical Medicine, Keppel Street, London WC1E 4HT, UK
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236
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Prüss-Ustün A, Bartram J, Clasen T, Colford JM, Cumming O, Curtis V, Bonjour S, Dangour AD, De France J, Fewtrell L, Freeman MC, Gordon B, Hunter PR, Johnston RB, Mathers C, Mäusezahl D, Medlicott K, Neira M, Stocks M, Wolf J, Cairncross S. Burden of disease from inadequate water, sanitation and hygiene in low- and middle-income settings: a retrospective analysis of data from 145 countries. Trop Med Int Health 2014; 19:894-905. [PMID: 24779548 PMCID: PMC4255749 DOI: 10.1111/tmi.12329] [Citation(s) in RCA: 439] [Impact Index Per Article: 43.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/13/2023]
Abstract
OBJECTIVE To estimate the burden of diarrhoeal diseases from exposure to inadequate water, sanitation and hand hygiene in low- and middle-income settings and provide an overview of the impact on other diseases. METHODS For estimating the impact of water, sanitation and hygiene on diarrhoea, we selected exposure levels with both sufficient global exposure data and a matching exposure-risk relationship. Global exposure data were estimated for the year 2012, and risk estimates were taken from the most recent systematic analyses. We estimated attributable deaths and disability-adjusted life years (DALYs) by country, age and sex for inadequate water, sanitation and hand hygiene separately, and as a cluster of risk factors. Uncertainty estimates were computed on the basis of uncertainty surrounding exposure estimates and relative risks. RESULTS In 2012, 502,000 diarrhoea deaths were estimated to be caused by inadequate drinking water and 280,000 deaths by inadequate sanitation. The most likely estimate of disease burden from inadequate hand hygiene amounts to 297,000 deaths. In total, 842,000 diarrhoea deaths are estimated to be caused by this cluster of risk factors, which amounts to 1.5% of the total disease burden and 58% of diarrhoeal diseases. In children under 5 years old, 361,000 deaths could be prevented, representing 5.5% of deaths in that age group. CONCLUSIONS This estimate confirms the importance of improving water and sanitation in low- and middle-income settings for the prevention of diarrhoeal disease burden. It also underscores the need for better data on exposure and risk reductions that can be achieved with provision of reliable piped water, community sewage with treatment and hand hygiene.
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Affiliation(s)
- Annette Prüss-Ustün
- Department of Public Health and Environment, World Health OrganizationGeneva, Switzerland
| | - Jamie Bartram
- Gillings School of Global Public Health, University of North Carolina at Chapel HillChapel Hill, NC, USA
| | - Thomas Clasen
- Rollins School of Public Health, Emory UniversityAtlanta, GA, USA
| | - John M Colford
- School of Public Health, University of California, BerkeleyBerkeley, CA, USA
| | - Oliver Cumming
- London School of Hygiene and Tropical MedicineLondon, UK
| | - Valerie Curtis
- London School of Hygiene and Tropical MedicineLondon, UK
| | - Sophie Bonjour
- Department of Public Health and Environment, World Health OrganizationGeneva, Switzerland
| | - Alan D Dangour
- London School of Hygiene and Tropical MedicineLondon, UK
| | - Jennifer De France
- Department of Public Health and Environment, World Health OrganizationGeneva, Switzerland
| | - Lorna Fewtrell
- Centre for Research into Environment and Health, Aberystwyth UniversityAberystwyth, UK
| | | | - Bruce Gordon
- Department of Public Health and Environment, World Health OrganizationGeneva, Switzerland
| | - Paul R Hunter
- Norwich Medical School, University of East AngliaNorwich, UK
- Department of Environmental Health, Tshware University of TechnologyPretoria, South Africa
| | - Richard B Johnston
- Department of Public Health and Environment, World Health OrganizationGeneva, Switzerland
- EAWAG, Swiss Federal Institute of Aquatic Science and TechnologyDübendorf, Switzerland
| | - Colin Mathers
- Department of Health Statistics and Information Systems, World Health OrganizationGeneva, Switzerland
| | - Daniel Mäusezahl
- Swiss Tropical and Public Health InstituteBasel, Switzerland
- University of BaselBasel, Switzerland
| | - Kate Medlicott
- Department of Public Health and Environment, World Health OrganizationGeneva, Switzerland
| | - Maria Neira
- Department of Public Health and Environment, World Health OrganizationGeneva, Switzerland
| | - Meredith Stocks
- Rollins School of Public Health, Emory UniversityAtlanta, GA, USA
| | - Jennyfer Wolf
- Department of Public Health and Environment, World Health OrganizationGeneva, Switzerland
- Swiss Tropical and Public Health InstituteBasel, Switzerland
- University of BaselBasel, Switzerland
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237
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Freeman MC, Stocks ME, Cumming O, Jeandron A, Higgins JPT, Wolf J, Prüss-Ustün A, Bonjour S, Hunter PR, Fewtrell L, Curtis V. Hygiene and health: systematic review of handwashing practices worldwide and update of health effects. Trop Med Int Health 2014; 19:906-16. [PMID: 24889816 DOI: 10.1111/tmi.12339] [Citation(s) in RCA: 238] [Impact Index Per Article: 23.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Abstract
OBJECTIVE To estimate the global prevalence of handwashing with soap and derive a pooled estimate of the effect of hygiene on diarrhoeal diseases, based on a systematic search of the literature. METHODS Studies with data on observed rates of handwashing with soap published between 1990 and August 2013 were identified from a systematic search of PubMed, Embase and ISI Web of Knowledge. A separate search was conducted for studies on the effect of hygiene on diarrhoeal disease that included randomised controlled trials, quasi-randomised trials with control group, observational studies using matching techniques and observational studies with a control group where the intervention was well defined. The search used Cochrane Library, Global Health, BIOSIS, PubMed, and Embase databases supplemented with reference lists from previously published systematic reviews to identify studies published between 1970 and August 2013. Results were combined using multilevel modelling for handwashing prevalence and meta-regression for risk estimates. RESULTS From the 42 studies reporting handwashing prevalence we estimate that approximately 19% of the world population washes hands with soap after contact with excreta (i.e. use of a sanitation facility or contact with children's excreta). Meta-regression of risk estimates suggests that handwashing reduces the risk of diarrhoeal disease by 40% (risk ratio 0.60, 95% CI 0.53-0.68); however, when we included an adjustment for unblinded studies, the effect estimate was reduced to 23% (risk ratio 0.77, 95% CI 0.32-1.86). CONCLUSIONS Our results show that handwashing after contact with excreta is poorly practiced globally, despite the likely positive health benefits.
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Affiliation(s)
- Matthew C Freeman
- Department of Environmental Health, Rollins School of Public Health, Emory University, Atlanta, GA, USA
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