Effect of handwashing on child health: a randomised controlled trial

Streptococcus pyogenes carriage and infection within households in The Gambia: a longitudinal cohort study

BACKGROUND

Streptococcus pyogenes causes more than 500 000 deaths per year globally, which occur disproportionately in low-income and middle-income countries. The roles of S pyogenes skin and pharyngeal carriage in transmission are unclear. We aimed to investigate the clinical epidemiology and household transmission dynamics of both S pyogenes asymptomatic carriage and infection in a high-burden setting.

METHODS

We did a 1-year prospective, longitudinal, household cohort study, recruiting healthy participants from households in Sukuta, The Gambia. Households were eligible if they comprised at least three members, including one child younger than 18 years, and were excluded if more than half of household members declined to participate. Households were identified by random GPS coordinates derived from census data. At monthly visits, pharyngeal and normal skin swabs were collected for S pyogenes culture, and sociodemographic data were recorded by interview. Incident pharyngitis and pyoderma infections were captured. Cultured isolates underwent emm genotyping. The primary outcome measures were incidence of S pyogenes carriage and disease. Additional outcomes were prevalence of S pyogenes skin and pharyngeal carriage, S pyogenes skin and pharyngeal clearance time, S pyogenes emm type, risk factors for carriage and disease events, household secondary attack rate, and emm-linked household transmission events. The study is registered on ClinicalTrials.gov, NCT05117528.

FINDINGS

Between July 27, 2021, and Sept 28, 2022, 442 participants were enrolled from 44 households. The median age was 15 years (IQR 6-28) and 233 (53%) were female. We identified 17 pharyngitis and 99 pyoderma events and 49 pharyngeal and 39 skin S pyogenes carriage acquisition events. Mean monthly prevalence was 1·4% (95% CI 1·1-1·9) for S pyogenes pharyngeal carriage and 1·2% (0·9-1·6) for S pyogenes skin carriage. Incidence was 120 per 1000 person-years (95% CI 87-166) for S pyogenes pharyngeal carriage, 124 per 1000 person-years (90-170) for S pyogenes skin carriage, 51 per 1000 person-years (31-84) for S pyogenes pharyngitis, and 263 per 1000 person-years (212-327) for S pyogenes pyoderma. Pharyngeal carriage risk was higher during the rainy season (HR 5·67, 95% CI 2·19-14·69) and in larger households (per additional person: 1·03, 1·00-1·05), as was pharyngitis risk (rainy season: 3·00, 1·10-8·22; household size: 1·04, 1·02-1·07). Skin carriage risk was not affected by season or household size, but was lower in female than in male participants (0·45, 0·22-0·92) and highest in children younger than 5 years compared with adults (22·69, 3·08-167·21), with similar findings for pyoderma (female sex: 0·34, 0·19-0·61; age <5 years: 7·00, 2·78-17·64). Median clearance time after carriage acquisition was 4·0 days for both skin (IQR 3·5-7·0) and pharynx (3·5-7·3). The mean household secondary attack rate was 4·9 (95% CI 3·5-6·3) for epidemiologically linked S pyogenes events and 0·74 (0·3-1·2) for emm-linked S pyogenes events. Of the 204 carriage and disease events, emm types were available for 179 (88%). Only 18 emm-linked between-visit household transmission events were identified. Pyoderma was the most common source of S pyogenes household transmissions in 11 (61%) of 18 emm-linked transmissions. Both pharynx to skin and skin to pharynx transmission events were observed.

INTERPRETATION

S pyogenes carriage and infection are common in The Gambia, particularly in children. Most events are non-household acquisitions, but skin carriage and pyoderma have an important role in S pyogenes household transmission and bidirectional transmission between skin and pharynx occurs.

FUNDING

Wellcome Trust, Chadwick Trust, Fonds National de la Recherche Scientifique (Belgium), European Society for Paediatric Infectious Diseases, and Medical Research Council (UK).

Prevalence and determinants of impetigo in Ghana: a cross-sectional study

INTRODUCTION

Skin diseases such as impetigo pose a significant public health challenge in low resource settings. Despite this, there is a dearth of epidemiological data on the prevalence of this condition in Ghana.

METHODS

We conducted a cross sectional study in three settings in Ghana: community members in East Mamprusi district in the North East region, a secondary school in Sekyere East district, and inmates of the Kumasi central prisons both in the Ashanti region. Following a period of training, we performed a standardised skin examination on each participant to assess for scabies and impetigo. We calculated the prevalence of each skin condition and investigated determinants of impetigo.

RESULTS/ FINDINGS

Of the 1327 participants [males 64.1% and median age 22 (16-29) years], 746 (56.2%) had scabies and 186 (14%) had impetigo which was usually very mild or mild in severity. Most participants with impetigo also had scabies (161/186, 86.6%). Having an itch [RR 6.05 (95% CI 2.53-14.47)], presence of scabies burrows [RR 1.99 (95% CI 1.54-2.59)], clinical scabies [RR 3.15 (2.11-4.72)] or being in preschool [RR 4.56 (1.78-11.67)] increased the risk for impetigo. A combination of the presence of clinical scabies, age, sex and itch most accurately predicted the odds of having impetigo.

CONCLUSIONS

There is substantial burden of impetigo and scabies in Ghana. There is a need to institute measures to improve detection and control of these common dermatoses as part of Universal Health Coverage package to reduce the scourge of the diseases in this setting.

Childcare centre attendance and health, growth, and development among children aged 0-3 years in low- and middle-income countries: A systematic review

Background

Lack of childcare for children aged 0-3 years has emerged as a global crisis, accentuated by women's increasing workforce participation and recognition that young children require nurturing care. Through this systematic review, we sought to examine associations between childcare centre attendance in low- and middle-income countries (LMICs) and children's health, growth, and development, and to generate childcare centre programmatic and research recommendations for children aged 0-3 years.

Methods

We systematically searched PsycINFO, MEDLINE, PubMed, and Cochrane for articles on centre-based childcare for children aged 0-3 years in LMICs, published between 2000 and 2021 in English (or which were translated into English). We excluded articles on specialised subgroups or interventions. We imported the retrieved articles into Covidence for review and assessed them for bias using the National Institutes of Health (NIH) quality assessment tool.

Results

Twenty-two articles (24 studies) met the inclusion criteria, encompassing 36 927 children from 10 countries across Mexico and South America (n = 12), Africa (n = 5), and Asia (n = 5). Outcomes included health (n = 12), growth/nutrition (n = 6), and development (n = 6). Study quality assessments were low; 41% exceeded 50% of quality criteria and 45% adjusted for confounders. Associations between childcare attendance and outcome measures were primarily negative for health (n/N = 7/12) and positive for growth/nutrition (n/N = 5/6) and development (n/N = 4/6). Childcare centre programmatic recommendations for children aged 0-3 years included: age-specific policies; program quality, including safety, hygiene, nutrition, and curriculum; access and affordability; parent engagement; financial support; and workforce development. Research recommendations included: study design, including enrolment age, frequency, duration, childcare type, home and childcare sociodemographic and cultural environments, child and caregiver outcomes, and analytical approaches; longitudinal studies; and implementation research.

Conclusions

Rigorous primary research in global childcare for young children is urgently needed. Policies, programmes, and investments in high-quality childcare can promote nurturing care for young children, enabling mothers to participate in the workforce.

Registration

PROSPERO: CRD42018105576.

The Social and Home Environment: Impacts of Determinants of Health on Atopic Dermatitis, Pathways Toward Solutions, and Unique Considerations for Rural and Remote North American Indigenous Populations

Disparities in environmental and social determinants of health (DOH) are associated with morbidity in atopic dermatitis (AD). The socioecological model (SEM) is a framework that can be applied to better understand how such DOH impacts patients with AD. We include a case scenario of a remote Indigenous patient reflective of real-world situations of living with AD and examine relevant impact, gaps in knowledge, and further research needs. This review highlights a variety of social and environmental exposures as important DOH which must be addressed to achieve optimal management in AD. The "rainbow model" is a modified framework to help illustrate how complex environmental and social forces impact both AD presentation and therapeutic success. However, practical applications and outcome metrics for health promotion are limited. An inter- and transdisciplinary approach is paramount to address the complex challenges associated with AD care, as well as multistakeholder approach integrating culturally-competent equitable health frameworks. This review underscores the importance of expanding the focus of AD management beyond basic science and clinical trials to recognize and address health disparities and to promote optimal health and well-being in patients with AD, and contributes a working approach to mapping the complex interventions and patient-oriented research needed using a focus on remote North American Indigenous patients affected by AD.

Is the impact of paid maternity leave policy on the prevalence of childhood diarrhoea mediated by breastfeeding duration? A causal mediation analysis using quasi-experimental evidence from 38 low-income and middle-income countries

OBJECTIVES

Quasi-experimental evidence suggests that extending the duration of legislated paid maternity leave is associated with lower prevalence of childhood diarrhoea in low-income and middle-income countries (LMICs). This could be due to a variety of mechanisms. This study examines whether this effect is mediated by changes in breastfeeding duration.

DESIGN AND SETTING

Difference-in-difference approach and causal mediation analysis were used to perform secondary statistical analysis of cross-sectional data from Demographic and Health Surveys (DHSs) in 38 LMICs.

PARTICIPANTS

We merged longitudinal data on national maternity leave policies with information on childhood diarrhoea related to 639 153 live births between 1996 and 2014 in 38 LMICs that participated in the DHS at least twice between 1995 and 2015.

PRIMARY OUTCOME MEASURE

Our outcome was whether the child had bloody stools in the 2 weeks prior to the interview. This measure was used as an indicator of severe diarrhoea because the frequency of loose stools in breastfed infants can be difficult to distinguish from pathological diarrhoea based on survey data.

RESULTS

A 1-month increase in the legislated duration of paid maternity leave was associated with a 34% (risk ratio 0.66, 95% CI 0.47 to 0.91) reduction in the prevalence of bloody diarrhoea. Breast feeding for at least 6 months and 12 months mediated 10.6% and 7.4% of this effect, respectively.

CONCLUSION

Extending the duration of paid maternity leave appears to lower diarrhoea prevalence in children under 5 years of age in LMICs. This effect is slightly mediated by changes in breastfeeding duration.

Estimating spatially disaggregated probability of severe COVID-19 and the impact of handwashing interventions: The case of Zimbabwe

INTRODUCTION

The severity of COVID-19 disease varies substantially between individuals, with some infections being asymptomatic while others are fatal. Several risk factors have been identified that affect the progression of SARS-CoV-2 to severe COVID-19. They include age, smoking and presence of underlying comorbidities such as respiratory illness, HIV, anemia and obesity. Given that respiratory illness is one such comorbidity and is affected by hand hygiene, it is plausible that improving access to handwashing could lower the risk of severe COVID-19 among a population. In this paper, we estimate the potential impact of improved access to handwashing on the risk of respiratory illness and its knock-on impact on the risk of developing severe COVID-19 disease across Zimbabwe.

METHODS

Spatial generalized additive models were applied to cluster level data from the 2015 Demographic and Health Survey. These models were used to generate continuous (1km resolution) estimates of risk factors for severe COVID-19, including prevalence of major comorbidities (respiratory illness, HIV without viral load suppression, anemia and obesity) and prevalence of smoking, which were aggregated to district level alongside estimates of the proportion of the population under 50 from Worldpop data. The risk of severe COVID-19 was then calculated for each district using published estimates of the relationship between comorbidities, smoking and age (under 50) and severe COVID-19. Two scenarios were then simulated to see how changing access to handwashing facilities could have knock on implications for the prevalence of severe COVID-19 in the population.

RESULTS

This modeling conducted in this study shows that (1) current risk of severe disease is heterogeneous across the country, due to differences in individual characteristics and household conditions and (2) that if the quantifiable estimates on the importance of handwashing for transmission are sound, then improvements in handwashing access could lead to reductions in the risk of severe COVID-19 of up to 16% from the estimated current levels across all districts.

CONCLUSIONS

Taken alongside the likely impact on transmission of SARS-CoV-2 itself, as well as countless other pathogens, this result adds further support for the expansion of access to handwashing across the country. It also highlights the spatial differences in risk of severe COVID-19, and thus the opportunity for better planning to focus limited resources in high-risk areas in order to potentially reduce the number of severe cases.

Particle transfer mediates dermal exposure of consumers to plasticizers in eraser and pen accessories

Dermal exposure to chemicals released from daily consumer products is a rising concern, particularly for children who are susceptible to unintentional hand-to-mouth transfer and related chemical exposure risk. However, chemical transfer induced by tiny particles of intact products has yet to be adequately addressed. The objective of the present study was to determine the potentiality of particles release from intact erasers and pen grips upon dermal contact by measuring the migration rates of the embedded plasticizers (phthalates and its alternatives). The results showed that billions of particles were released from erasers (0.6-1.2 × 109) and pen grips (0.2-1.6 × 108) upon dermal contact at ambient temperature, with sizes mainly smaller than 1 μm. The composition of eraser leachates was identical to that of the corresponding bulk eraser, as confirmed by Fourier-transform infrared spectroscopy and pyrolysis. Migrated hydrophobic plasticizers may be used as indicators of particle release from erasers and pen grips. The potentiality of particle release was negatively correlated with the total plasticizer contents (r = -0.51; p < 0.05) for both erasers and pen grips. These findings indicated that particles directly released from school supplies and accessories could be a non-negligible source of human exposure to plasticizers.

The Impact of Infectious Disease Syndromes on Activities During Military Travel

Background

We evaluated the impact of infectious disease (ID) syndromes on US active duty (AD) servicemembers returning from overseas deployment (DEP), military training exercises (EXR), or short-term military travel (eg, temporary assignment of duty [TDY]).

Methods

We conducted a survey-based assessment of US AD servicemembers returning from DEP, EXR, or TDY between 2015 and 2019. Subjects completed a post-travel survey capturing symptoms of travelers' diarrhea (TD), influenza-like illness (ILI), and febrile illness (FI). Risk factors associated with any ID syndrome (ie, either TD, ILI, or FI) that impacted daily activities were assessed using a logistic regression model with backward selection.

Results

One-third of servicemembers (654/1822) experienced an ID syndrome, and 26% (471/1822) reported a ≥50% reduction in activity level due to an ID syndrome (median duration, 3 days). TD was the most common ID syndrome experienced and accounted for 73% (346/471) of ID syndromes impacting daily activities. The greatest impact of ID syndromes was observed in servicemembers on DEP. Compared with servicemembers on EXR or TDY, those on DEP had a longer duration of travel and a delayed period of risk for ID syndromes. Multivariate analysis identified high-risk exposures (ie, environmental exposures, close contact with locals, consuming food from street vendors) and behaviors (ie, inability to sanitize hands before meals) that could be used to inform mitigation strategies.

Conclusions

ID syndromes result in a significant loss of productivity during military travel. Addressing modifiable risk factors and access to TD self-treatment in high-risk settings may help mitigate the impact of ID threats during military travel.

Effectiveness of handwashing with soap for preventing acute respiratory infections in low-income and middle-income countries: a systematic review and meta-analysis

BACKGROUND

Acute respiratory infection (ARI) is a leading cause of morbidity and mortality globally, with 83% of ARI mortality occurring in low-income and middle-income countries (LMICs) before the COVID-19 pandemic. We aimed to estimate the effect of interventions promoting handwashing with soap on ARI in LMICs.

METHODS

In our systematic review and meta-analysis, we searched MEDLINE, Embase, Web of Science, Scopus, Cochrane Library, Global Health, and Global Index Medicus for studies of handwashing with soap interventions in LMICs from inception to May 25, 2021. We included randomised and non-randomised controlled studies of interventions conducted in domestic, school, or childcare settings. Interventions promoting hand hygiene methods other than handwashing with soap were excluded, as were interventions in health-care facilities or the workplace. The primary outcome was ARI morbidity arising from any pathogen for participants of any age. Secondary outcomes were lower respiratory infection, upper respiratory infection, influenza confirmed by diagnostic test, COVID-19 confirmed by diagnostic test, and all-cause mortality. We extracted relative risks (RRs), using random-effects meta-analysis to analyse study results, and metaregression to evaluate heterogeneity. We assessed risk of bias in individual studies using an adapted Newcastle-Ottawa scale, and assessed the overall body of evidence using a Grading of Recommendations, Assessment, Development, and Evaluation (GRADE) approach. The study is registered with PROSPERO, CRD42021231414.

FINDINGS

26 studies with 161 659 participants met inclusion criteria, providing 27 comparisons (21 randomised). Interventions promoting handwashing with soap reduced any ARI compared with no handwashing intervention (RR 0·83 [95% CI 0·76-0·90], I2 88%; 27 comparisons). Interventions also reduced lower respiratory infections (0·78 [0·64-0·94], I2 64%; 12 comparisons) and upper respiratory infections (0·74 [0·59-0·93], I2 91%; seven comparisons), but not test-confirmed influenza (0·94 [0·42-2·11], I2 90%; three comparisons), test-confirmed COVID-19 (no comparisons), or all-cause mortality (prevalence ratio 0·95 [95% CI 0·71-1·27]; one comparison). For ARI, no heterogeneity covariates were significant at p<0·1 and the GRADE rating was moderate certainty evidence.

INTERPRETATION

Interventions promoting handwashing with soap can reduce ARI in LMICs, and could help to prevent the large burden of respiratory disease.

FUNDING

Bill & Melinda Gates Foundation, Reckitt Global Hygiene Institute, and UK FCDO.

Changes in water treatment, hygiene practices, household floors, and child health in times of Covid-19: A longitudinal cross-sectional survey in Surkhet District, Nepal

INTRODUCTION

Consistent and effective practice of water treatment, sanitation, and hygiene (WASH) behaviour is an indispensable requisite for realizing health improvements among children living in low-income areas with challenging hygienic conditions. Sustainably achieving such a behaviour change is challenging but more likely to be realized during epidemics, when health threats are high and the dissemination of information on preventative measures is intense. Our study conducted cross-sectional surveys in Surkhet District Nepal, before and during the Covid-19 pandemic to assess the impact of water safety interventions and hygiene training implemented before and during the pandemic on WASH conditions and practices and to assess the association of these changes with child health.

METHODS

Information on WASH infrastructure, WASH behaviour, nutrition, and child health, including on parasitic infections, was obtained before and during the Covid-19 pandemic in spring 2018 and spring 2021, from 589 children aged between 6 months and 10 years and their caregivers. Data was collected through quantitative, structured face-to-face interviews, observations, health examinations of children including anthropometric measurements, analysis of children's stool, and water quality analysis. The association of changes in WASH factors with changes in child health was analysed using multivariate generalized estimating equations for repeated measures.

RESULTS

Water safety management was significantly improved by the introduction of chlorination to piped water supply systems, which served 40% of households. In addition, the percentage of households using a ceramic water filter increased from 12.2% to 34.8%. Large and significant changes were observed in handwashing behaviour (frequency, use of soap and washing at critical times) and infrastructure: 35% of households constructed a new handwashing station. Kitchen and household hygiene also improved. An additional 22% of households improved the cleanliness of the toilet. The number of houses with a cemented floor increased by 20%. WASH changes were significantly associated with improved child health: the chlorination of piped water supply reduced odds ratios for diarrhoea (OR = 0.36, 95% CI = 0.15-0.88, p = 0.025), respiratory difficulties (OR = 0.39, 95% CI = 0.16-0.92, p = 0.033), fever (OR = 0.42, 95% CI = 0.26-0.71, p = 0.001) and cough (OR = 0.58, 95% CI = 0.36-0.93, p = 0.024), and. The frequency of handwashing with soap was associated with significantly reduced odds ratios for infections with Giardia lamblia (OR = 0.68, 95% CI = 0.50-0.91, p = 0.011), stunting and wasting (OR = 0.75, 95% CI = 0.66-0.92, p = 0.003) and fever (OR = 0.85, 95% CI = 0.75-0.96, p = 0.008),. The presence of a handwashing station at baseline was associated with significantly reduced odds ratios for respiratory difficulties (OR = 0.45, 95% CI = 0.26-0.78, p = 0.004). The construction of a handwashing station between baseline and endline was significantly associated with reduced odds ratios for pale conjunctiva (OR = 0.32, 95% CI = 0.17-0.60, p < 0.001), which is a clinical sign of iron deficiency and anaemia, respiratory difficulties (OR = 0.39, 95% CI = 0.17-0.89, p = 0.026) and cough (OR = 0.44, 95% CI = 0.26-0.76, p = 0.003). Using a clean container for the transport of drinking water was significantly associated with reduced odds ratios for infections with Giardia lamblia (OR = 0.39, 95% CI = 0.16-0.93, p = 0.033) and diarrhoea (OR = 0.48, 95% CI = 0.24-0.96, p = 0.038). Similarly, a cemented floor in the household was significantly associated with reduced odd ratios for diarrhoea (OR = 0.38, 95% CI = 0.16-0.87, p = 0.022) and infections with Giardia lamblia (OR = 0.44, 95% CI = 0.19-1.02, p = 0.056).

CONCLUSION

WASH training and the promotion of preventative measures during the Covid-19 pandemic supported improved water safety management and hygiene behaviour, which resulted in a reduction in infectious diseases among children in the study area.

Sustainable Hand Surgery: Incorporating Water Efficiency Into Clinical Practice

Introduction Public health and well-being outcomes are intimately connected with the health of our planet. Climate change has numerous far-reaching effects. Managing and mitigating these risks to human health presents one of the next challenges to global healthcare. The current usage of planetary resources is unsustainable. Surgical procedures are particularly resource-intensive, often utilising vast amounts of single-use consumables, like water. In the last 100 years global usage of fresh water has increased six-fold and continues to rise by 1% year on year. It is well established that initial hand sterilization and maintenance of hand sterility during the surgical list are essential for preventing hospital-acquired infections and associated morbidity and mortality. This study aims to estimate the current daily water usage of two typical hand surgery lists from a District General Hospital in North Wales, to determine potential water savings by switching exclusively to an alcohol-based hand rub for subsequent scrubs, in line with current national guidelines. Methods Observational study estimation of water consumption from a temperature-controlled manual tap required using a 1 litre volumetric jug where the time taken to fill was recorded. Three separate observational samples were taken, and a mean was calculated. This mean determined the amount of water dispensed from the tap in a standard 3 min scrub and subsequent 1 min scrub. Two different theatre schedules were analysed: 1. A trauma list (five cases) and 2. A higher volume minor elective procedure schedule (16 cases), in this case a wide-awake local anaesthetic no tourniquet (WALANT) carpal tunnel release (CTR). Results Each case regardless of procedure had approximately three persons scrubbed. 20.57L of water is used for one person to scrub for 3 mins and an extra 6.8574L for each subsequent 1 min scrub. Therefore, current daily water consumption could reach 143.99L during the major hand trauma list and 411.4L during a high-volume carpal tunnel release list. Conclusion Simply following current guidelines by switching to alcohol-based hand rub just for subsequent scrubs could reduce water consumption by 57.2% for hand trauma lists and 70.2% for high-volume CTR lists.

Physical interventions to interrupt or reduce the spread of respiratory viruses

BACKGROUND

Viral epidemics or pandemics of acute respiratory infections (ARIs) pose a global threat. Examples are influenza (H1N1) caused by the H1N1pdm09 virus in 2009, severe acute respiratory syndrome (SARS) in 2003, and coronavirus disease 2019 (COVID-19) caused by SARS-CoV-2 in 2019. Antiviral drugs and vaccines may be insufficient to prevent their spread. This is an update of a Cochrane Review last published in 2020. We include results from studies from the current COVID-19 pandemic.

OBJECTIVES

To assess the effectiveness of physical interventions to interrupt or reduce the spread of acute respiratory viruses.

SEARCH METHODS

We searched CENTRAL, PubMed, Embase, CINAHL, and two trials registers in October 2022, with backwards and forwards citation analysis on the new studies.

SELECTION CRITERIA

We included randomised controlled trials (RCTs) and cluster-RCTs investigating physical interventions (screening at entry ports, isolation, quarantine, physical distancing, personal protection, hand hygiene, face masks, glasses, and gargling) to prevent respiratory virus transmission.  DATA COLLECTION AND ANALYSIS: We used standard Cochrane methodological procedures.

MAIN RESULTS

We included 11 new RCTs and cluster-RCTs (610,872 participants) in this update, bringing the total number of RCTs to 78. Six of the new trials were conducted during the COVID-19 pandemic; two from Mexico, and one each from Denmark, Bangladesh, England, and Norway. We identified four ongoing studies, of which one is completed, but unreported, evaluating masks concurrent with the COVID-19 pandemic. Many studies were conducted during non-epidemic influenza periods. Several were conducted during the 2009 H1N1 influenza pandemic, and others in epidemic influenza seasons up to 2016. Therefore, many studies were conducted in the context of lower respiratory viral circulation and transmission compared to COVID-19. The included studies were conducted in heterogeneous settings, ranging from suburban schools to hospital wards in high-income countries; crowded inner city settings in low-income countries; and an immigrant neighbourhood in a high-income country. Adherence with interventions was low in many studies. The risk of bias for the RCTs and cluster-RCTs was mostly high or unclear. Medical/surgical masks compared to no masks We included 12 trials (10 cluster-RCTs) comparing medical/surgical masks versus no masks to prevent the spread of viral respiratory illness (two trials with healthcare workers and 10 in the community). Wearing masks in the community probably makes little or no difference to the outcome of influenza-like illness (ILI)/COVID-19 like illness compared to not wearing masks (risk ratio (RR) 0.95, 95% confidence interval (CI) 0.84 to 1.09; 9 trials, 276,917 participants; moderate-certainty evidence. Wearing masks in the community probably makes little or no difference to the outcome of laboratory-confirmed influenza/SARS-CoV-2 compared to not wearing masks (RR 1.01, 95% CI 0.72 to 1.42; 6 trials, 13,919 participants; moderate-certainty evidence). Harms were rarely measured and poorly reported (very low-certainty evidence). N95/P2 respirators compared to medical/surgical masks We pooled trials comparing N95/P2 respirators with medical/surgical masks (four in healthcare settings and one in a household setting). We are very uncertain on the effects of N95/P2 respirators compared with medical/surgical masks on the outcome of clinical respiratory illness (RR 0.70, 95% CI 0.45 to 1.10; 3 trials, 7779 participants; very low-certainty evidence). N95/P2 respirators compared with medical/surgical masks may be effective for ILI (RR 0.82, 95% CI 0.66 to 1.03; 5 trials, 8407 participants; low-certainty evidence). Evidence is limited by imprecision and heterogeneity for these subjective outcomes. The use of a N95/P2 respirators compared to medical/surgical masks probably makes little or no difference for the objective and more precise outcome of laboratory-confirmed influenza infection (RR 1.10, 95% CI 0.90 to 1.34; 5 trials, 8407 participants; moderate-certainty evidence). Restricting pooling to healthcare workers made no difference to the overall findings. Harms were poorly measured and reported, but discomfort wearing medical/surgical masks or N95/P2 respirators was mentioned in several studies (very low-certainty evidence).  One previously reported ongoing RCT has now been published and observed that medical/surgical masks were non-inferior to N95 respirators in a large study of 1009 healthcare workers in four countries providing direct care to COVID-19 patients.  Hand hygiene compared to control Nineteen trials compared hand hygiene interventions with controls with sufficient data to include in meta-analyses. Settings included schools, childcare centres and homes. Comparing hand hygiene interventions with controls (i.e. no intervention), there was a 14% relative reduction in the number of people with ARIs in the hand hygiene group (RR 0.86, 95% CI 0.81 to 0.90; 9 trials, 52,105 participants; moderate-certainty evidence), suggesting a probable benefit. In absolute terms this benefit would result in a reduction from 380 events per 1000 people to 327 per 1000 people (95% CI 308 to 342). When considering the more strictly defined outcomes of ILI and laboratory-confirmed influenza, the estimates of effect for ILI (RR 0.94, 95% CI 0.81 to 1.09; 11 trials, 34,503 participants; low-certainty evidence), and laboratory-confirmed influenza (RR 0.91, 95% CI 0.63 to 1.30; 8 trials, 8332 participants; low-certainty evidence), suggest the intervention made little or no difference. We pooled 19 trials (71, 210 participants) for the composite outcome of ARI or ILI or influenza, with each study only contributing once and the most comprehensive outcome reported. Pooled data showed that hand hygiene may be beneficial with an 11% relative reduction of respiratory illness (RR 0.89, 95% CI 0.83 to 0.94; low-certainty evidence), but with high heterogeneity. In absolute terms this benefit would result in a reduction from 200 events per 1000 people to 178 per 1000 people (95% CI 166 to 188). Few trials measured and reported harms (very low-certainty evidence). We found no RCTs on gowns and gloves, face shields, or screening at entry ports.

AUTHORS' CONCLUSIONS

The high risk of bias in the trials, variation in outcome measurement, and relatively low adherence with the interventions during the studies hampers drawing firm conclusions. There were additional RCTs during the pandemic related to physical interventions but a relative paucity given the importance of the question of masking and its relative effectiveness and the concomitant measures of mask adherence which would be highly relevant to the measurement of effectiveness, especially in the elderly and in young children. There is uncertainty about the effects of face masks. The low to moderate certainty of evidence means our confidence in the effect estimate is limited, and that the true effect may be different from the observed estimate of the effect. The pooled results of RCTs did not show a clear reduction in respiratory viral infection with the use of medical/surgical masks. There were no clear differences between the use of medical/surgical masks compared with N95/P2 respirators in healthcare workers when used in routine care to reduce respiratory viral infection. Hand hygiene is likely to modestly reduce the burden of respiratory illness, and although this effect was also present when ILI and laboratory-confirmed influenza were analysed separately, it was not found to be a significant difference for the latter two outcomes. Harms associated with physical interventions were under-investigated. There is a need for large, well-designed RCTs addressing the effectiveness of many of these interventions in multiple settings and populations, as well as the impact of adherence on effectiveness, especially in those most at risk of ARIs.

Global mortality associated with 33 bacterial pathogens in 2019: a systematic analysis for the Global Burden of Disease Study 2019

BACKGROUND

Reducing the burden of death due to infection is an urgent global public health priority. Previous studies have estimated the number of deaths associated with drug-resistant infections and sepsis and found that infections remain a leading cause of death globally. Understanding the global burden of common bacterial pathogens (both susceptible and resistant to antimicrobials) is essential to identify the greatest threats to public health. To our knowledge, this is the first study to present global comprehensive estimates of deaths associated with 33 bacterial pathogens across 11 major infectious syndromes.

METHODS

We estimated deaths associated with 33 bacterial genera or species across 11 infectious syndromes in 2019 using methods from the Global Burden of Diseases, Injuries, and Risk Factors Study (GBD) 2019, in addition to a subset of the input data described in the Global Burden of Antimicrobial Resistance 2019 study. This study included 343 million individual records or isolates covering 11 361 study-location-years. We used three modelling steps to estimate the number of deaths associated with each pathogen: deaths in which infection had a role, the fraction of deaths due to infection that are attributable to a given infectious syndrome, and the fraction of deaths due to an infectious syndrome that are attributable to a given pathogen. Estimates were produced for all ages and for males and females across 204 countries and territories in 2019. 95% uncertainty intervals (UIs) were calculated for final estimates of deaths and infections associated with the 33 bacterial pathogens following standard GBD methods by taking the 2·5th and 97·5th percentiles across 1000 posterior draws for each quantity of interest.

FINDINGS

From an estimated 13·7 million (95% UI 10·9-17·1) infection-related deaths in 2019, there were 7·7 million deaths (5·7-10·2) associated with the 33 bacterial pathogens (both resistant and susceptible to antimicrobials) across the 11 infectious syndromes estimated in this study. We estimated deaths associated with the 33 bacterial pathogens to comprise 13·6% (10·2-18·1) of all global deaths and 56·2% (52·1-60·1) of all sepsis-related deaths in 2019. Five leading pathogens-Staphylococcus aureus, Escherichia coli, Streptococcus pneumoniae, Klebsiella pneumoniae, and Pseudomonas aeruginosa-were responsible for 54·9% (52·9-56·9) of deaths among the investigated bacteria. The deadliest infectious syndromes and pathogens varied by location and age. The age-standardised mortality rate associated with these bacterial pathogens was highest in the sub-Saharan Africa super-region, with 230 deaths (185-285) per 100 000 population, and lowest in the high-income super-region, with 52·2 deaths (37·4-71·5) per 100 000 population. S aureus was the leading bacterial cause of death in 135 countries and was also associated with the most deaths in individuals older than 15 years, globally. Among children younger than 5 years, S pneumoniae was the pathogen associated with the most deaths. In 2019, more than 6 million deaths occurred as a result of three bacterial infectious syndromes, with lower respiratory infections and bloodstream infections each causing more than 2 million deaths and peritoneal and intra-abdominal infections causing more than 1 million deaths.

INTERPRETATION

The 33 bacterial pathogens that we investigated in this study are a substantial source of health loss globally, with considerable variation in their distribution across infectious syndromes and locations. Compared with GBD Level 3 underlying causes of death, deaths associated with these bacteria would rank as the second leading cause of death globally in 2019; hence, they should be considered an urgent priority for intervention within the global health community. Strategies to address the burden of bacterial infections include infection prevention, optimised use of antibiotics, improved capacity for microbiological analysis, vaccine development, and improved and more pervasive use of available vaccines. These estimates can be used to help set priorities for vaccine need, demand, and development.

FUNDING

Bill & Melinda Gates Foundation, Wellcome Trust, and Department of Health and Social Care, using UK aid funding managed by the Fleming Fund.

The Effect of Face Mask, Air Temperature, and Humidity on COVID-19 Transmission: A Systematic Review and Meta-analysis

Context: At the beginning of the COVID-19 pandemic, the effects of personal protective equipment (PPE) such as face masks, as well as environmental conditions, including temperature and humidity changes, were discussed due to the lack of effective medicine. Methods: The preferred reporting items for systematic reviews and meta-analysis (PRISMA) were implemented to conduct the present systematic review. The articles were selected from papers published by May 2020 in PubMed, Web of Science, Science Direct, Scopus, and Google Scholar databases. This meta-analysis estimated relative risk (RR) and pooled mean depicted as effect size (ES) using the random or fixed effects methods. Results: Ten studies met inclusion criteria, four of which addressed the effect of face masks and six of which dealt with temperature and humidity changes. This eta-analysis study showed that wearing face masks against the COVID-19 virus had a remarkable safety impact with RR (%95 CI) 8.56 (2.10 - 34.90), (I2 = %0.0 P = 0.999), and the pooled mean changes in temperature and humidity were estimated to be with ES (%95 CI) 9.03 (4.32 - 13.74), (I2 = %99.7, P = 0.0001) and with ES (%95 CI) 56.82 (46.12 - 67.51), ( I2 = %99.3, P = 0.0001) during the outbreak of the COVID-19. Conclusions: The findings of this systematic review and meta-analysis illustrate the effectiveness of face masks, in general, in preventing the transmission of the COVID-19 virus. According to the findings, temperature and humidity changes do not increase the outbreak of the COVID-19 virus.

Hand washing practice among public primary school children and associated factors in Harar town, eastern Ethiopia: An institution-based cross-sectional study

Background

Hand washing with soap and water reduces the risk of diarrheal episode by 28-48% and acute respiratory infection by 20-50%. However, there is limited evidence on hand washing practices among students in Eastern Ethiopia, particularly in Harari town. Therefore, this study aimed to determine hand washing practice among primary school students and associated factors in Harar town, Eastern Ethiopia.

Methods

An institution-based cross-sectional study was applied among 670 students in Harar town from June 1 to 30, 2021. A multi-stage sampling was employed; 6 out of 20 schools were selected through simple random sampling, while eligible children from each school was selected by probability proportional to size sampling method. Data were collected using a pre-tested questionnaire with a face-to-face interview technique and via observation. The data were analyzed using SPSS software version 23. Binary and mult-variable analysis were used to determine the association between factors and outcome variable. Finally, a p-value of < 0.05 was considered to declare a statistically significant association.

Results

A total of 670 participants were included in the study, of which 248 (37.0%) had washed their hands [95% CI: 33.3-40.06]. Being in grade 8 Adjusted Odd Ratio[AOR = 4.9; 95% Confidence Interval (CI): 2.28-10.52], living in an urban area [AOR = 3.49; 95% CI: 1.29-9.40], having role models (parents [AOR = 4.41; 95% CI: 1.79-10.86], teachers [AOR = 3.69; 95% CI: 1.39-8.81], and health professionals [AOR = 3.17, 95% CI: 1.17-8.63]), availability of hand washing facility [AOR = 3.62; 95% CI: 1.57-8.34], access to soap and water [AOR = 2.89; 95% CI: 1.39-5.98] and being membership of water sanitation and hygiene (WASH) club [AOR = 2.39; 95% CI: 1.41-4.03] were found to be significantly associated with hand washing practice.

Conclusions

The current study found that nearly a third of students practiced proper hand washing. Hand washing practice was influenced by students' grade level, residence, referents (role models for hand washing), presence of a hand washing facility, access to water and soap, and membership of WASH club. Therefore, the finding revealed that there is a need to improve hand-washing practices in schools by concerned agencies.

Risk factors for acute rheumatic fever: A case-control study

BACKGROUND

Acute rheumatic fever (ARF) and rheumatic heart disease (RHD) remain an inequitable cause of avoidable suffering and early death in many countries, including among Indigenous Māori and Pacific populations in New Zealand. There is a lack of robust evidence on interventions to prevent ARF. This study aimed to identify modifiable risk factors, with the goal of producing evidence to support policies and programs to decrease rates of ARF.

METHODS

A case-control study was undertaken in New Zealand using hospitalised, first episode ARF cases meeting a standard case-definition. Population controls (ratio of 3:1) were matched by age, ethnicity, socioeconomic deprivation, location, sex, and recruitment month. A comprehensive, pre-tested questionnaire was administered face-to-face by trained interviewers.

FINDINGS

The study included 124 cases and 372 controls. Multivariable analysis identified strong associations between ARF and household crowding (OR 3·88; 95%CI 1·68-8·98) and barriers to accessing primary health care (OR 2·07; 95% CI 1·08-4·00), as well as a high intake of sugar-sweetened beverages (OR 2·00; 1·13-3·54). There was a marked five-fold higher ARF risk for those with a family history of ARF (OR 4·97; 95% CI 2·53-9·77). ARF risk was elevated following self-reported skin infection (aOR 2·53; 1·44-4·42) and sore throat (aOR 2·33; 1·49-3·62).

INTERPRETATION

These globally relevant findings direct attention to the critical importance of household crowding and access to primary health care as strong modifiable causal factors in the development of ARF. They also support a greater focus on the role of managing skin infections in ARF prevention.

FUNDING

This research was funded by the Health Research Council of New Zealand (HRC) Rheumatic Fever Research Partnership (supported by the New Zealand Ministry of Health, Te Puni Kōkiri, Cure Kids, Heart Foundation, and HRC) award number 13/959.

Nonpharmaceutical interventions to prevent viral respiratory infection in community settings: an umbrella review

Background

Respiratory viruses pose an important public health threat to most communities. Nonpharmaceutical interventions (NPIs) such as masks, hand hygiene or physical distancing, among others, are believed to play an important role in reducing transmission of respiratory viruses. In this umbrella review, we summarise the evidence of the effectiveness of NPIs for the prevention of respiratory virus transmission in the community setting.

Observations

A systematic search of PubMed, Embase, Medline and Cochrane reviews resulted in a total of 24 studies consisting of 11 systematic reviews and meta-analyses, 12 systematic reviews without meta-analyses and one standalone meta-analysis. The current evidence from these data suggests that hand hygiene is protective against respiratory viral infection. The use of hand hygiene and facemasks, facemasks alone and physical distancing were interventions with inconsistent evidence. Interventions such as school closures, oral hygiene or nasal saline rinses were shown to be effective in reducing the risk of influenza; however, the evidence is sparse and mostly of low and critically low quality.

Conclusions

Studies on the effectiveness of NPIs for the prevention of respiratory viral transmission in the community vary in study design, quality and reported effectiveness. Evidence for the use of hand hygiene or facemasks is the strongest; therefore, the most reasonable suggestion is to use hand hygiene and facemasks in the community setting.

Environmental and Behavioral Factors Associated With Handwashing With Soap After Defecation in a Rural Setting of 2 Districts of the Jimma Zone, Ethiopia

BACKGROUND

Handwashing with soap can prevent the spread of fecal oral microbes in the home environment. Despite the lack of water and for a variety of reasons, soap-based handwashing is not practiced in developing countries after defecation.

OBJECTIVE

The objective of the study was to determine the environmental and behavioral factors associated with hand washing with soap after defecation of respondents with children under the age of 5 years in a rural setting.

METHODS

Data used were taken from 756 households with children under the age of 5 that participated in a cross-sectional study conducted from July 22 to August 9, 2018, in 2 selected districts in the Jimma Zone, Southwest Ethiopia. It included post-defecation hand washing with soap and other variables such as sociodemographic information, environmental and behavioral factors. Stata version 16 was used to analyze the data. We use binary logistic regression models. To declare statistical significance, a P-value of less than .05 with an adjusted odds ratio and a confidence interval of 95% was used.

RESULTS

The prevalence of soap-based post defecation hand washing practices among respondents was 64.4%. Hand washing practice after defecation with soap has a significant association with having more than 1 child under 5 years of age (AOR = 1.60; 95% CI: 1.05-2.45), households living with cattle (AOR = 2.00; 95% CI: 1.30-3.07), use of unimproved latrine (AOR = 0.55; 95%CI: 0.31-0.98), with the presence of feces in the compound of the households interviewed (AOR = 7.08; 95% CI: 4.07-12.35) and regular cleaning water containers before filling drinking water (AOR = 2.16; 95% CI: 1.13-4.15).

CONCLUSIONS

Most of the study participants washed their hands with soap after defecation. The presence of feces in the compound, having more than 1 child, living with cattle, and cleaning water containers routinely before filling drinking water all enhanced post-defecation handwashing with soap. However, when using unimproved latrines, respondents' post-defecation handwashing behavior with soap may be significantly reduced.

Exploring the effect of the primary care health workers number on infectious diarrhea morbidity and where the health resources should go

We aimed to explore the association between the number of primary healthcare workers and infectious diarrhea morbidity at community levels and to provide evidence-based implications for optimizing primary healthcare manpower resource allocations. We collected annual infectious diarrhea morbidity and relevant data of 4321 communities in Sichuan Province, China, from 2017 to 2019. Global and local Moran’s I were calculated to detect the spatial clustering of infectious diarrhea morbidity and to identify areas where increased primary healthcare manpower resources should be allocated. The spatial lag fixed effects panel data model was adopted to explore the association between the number of primary healthcare workers per 1000 residents and infectious diarrhea morbidity. Significantly high–high and low–low clusters of infectious diarrhea cases were found to be mainly distributed in underdeveloped and developed areas during the studied period years, respectively. The infectious diarrhea morbidity was found to be statistically negatively associated with the number of primary healthcare workers per 1000 residents with a coefficient of − 0.172, indicating that a 0.172 reduction of infectious diarrhea morbidity (1/10,000) was associated with doubled amounts of primary healthcare workers per 1000 residents. Our findings highlighted the role of primary healthcare in the process of infectious diarrhea prevention and control, and implied that constant efforts should be addressed to facilitate infectious diarrhea prevention and control, especially in the underdeveloped areas.

The use of digital technology to improve and monitor handwashing among children 12 years or younger in educational settings: a scoping review

Our scoping review aimed to identify and describe the application of digital technology in hand hygiene research among children in educational settings. We searched for articles in PubMed, IEEE Xplore, and Web of Science. Original hand hygiene research with a form of digital technology used among children ≤12 years in educational settings was eligible for inclusion. Twelve studies met the eligibility criteria and the data were extracted by two teams of independent co-authors for narrative synthesis. Ten studies used digital technology as an intervention tool and two for monitoring purposes. Three main digital technologies were identified including computer games (n = 2), videos (n = 8), and video cameras (n = 2). Digital technologies found in our scoping review were reported to be effective in hand hygiene studies over short temporal periods especially when used in combination with other measures. Future research may demonstrate the effectiveness of digital technology in helping children develop sustainable handwashing behaviors.

Ordeal mechanisms, information, and the cost-effectiveness of strategies to provide subsidized eyeglasses

The cost-effectiveness of policies providing subsidized health goods is often compromised by limited use of the goods provided. Through a randomized trial involving 251 primary schools in western China, we tested two approaches to improve the cost-effectiveness of a program distributing free eyeglasses to myopic children. Relative to delivery of free eyeglasses to schools, we find that providing vouchers redeemable in local optical shops modestly improved the targeting of eyeglasses to those who would use them without reducing effective coverage. Information provided through a health education campaign increased eyeglass use when eyeglasses were delivered to schools, but had no effect when requiring voucher redemption or when families were only given a prescription for eyeglasses to be purchased on the market. Though most expensive, free delivery to schools with a health education campaign was the most socially cost-effective approach tested and increased effective coverage of eyeglasses by 18.5 percentage points after seven months.

Knowledge, Attitude, and Practice Toward Mask-Wearing Behaviors During Covid-19 Pandemic Among Mangalore Residents: A Cross-Sectional Study

Objectives The objective of this study is to assess the knowledge, awareness, and practice toward mask-wearing behaviors of Mangalore residents during the coronavirus disease 2019 (COVID-19) outbreak.

Materials and Methods This survey was conducted at A B Shetty Memorial Institute of Dental Sciences in Mangalore. The questionnaire consisted of 18 questions that were prepared as an online form (Google Forms), and a total of 172 responses were received among the residents of Mangalore who visited the hospital.

The questions were distributed based on knowledge, attitude, and practice regarding the mask-wearing behaviors, and the distribution of responses was presented as frequency and percentages. Prior to the inception of the study, the nature and purpose of the study were explained to each respondent, and informed consent was obtained by all participants in this study.

Statistical analysis was done using SPSS software version 23.

Results It was evident that the COVID-19 knowledge scores were found to be significantly associated with a lower likelihood of negative attitudes and potentially dangerous practices toward the COVID-19 epidemic in this study. These findings clearly indicate the importance of improving residents' COVID-19 knowledge via health education, which may also result in improvements in their attitudes and practices toward COVID-19.

Conclusion In summary, our findings suggest that Mangalore residents have fair knowledge and optimistic attitudes, despite the current lockdown measures undertaken during the second wave of COVID-19, The positivity rate in Mangalore has not reduced satisfactorily. Self-protection, testing, and vaccination would help to reduce the spread and mortality rate due to coronavirus. The residents of Mangalore should abide by the COVID -19 preventive measures and implement this knowledge into their daily practices.

COVID-19 Lesson for Respiratory Syncytial Virus (RSV): Hygiene Works

Respiratory syncytial virus (RSV) is a leading cause of acute lower respiratory tract infections (LRTIs) in infants worldwide. The global direct medical cost associated with RSV LRTIs reaches billions of dollars, with the highest burden in low–middle-income countries. Many efforts have been devoted to improving its prevention and management, including both non-pharmaceutical and pharmaceutical strategies, often with limited routine use in high-income countries due to high costs. During the ongoing COVID-19 pandemic, a dramatic decrease in RSV infections (up to 70–90%) has been reported around the globe, directly related to the implementation of containment measures (face masks, hand hygiene, and social distancing). Primary prevention has demonstrated the highest cost effectiveness ratio in reducing the burden of a respiratory infection such as RSV, never reached before. Thus, we emphasize the importance of non-pharmaceutical preventive hygiene measures that should be implemented and maintained even after the COVID-19 outbreak.

Interventions promoting uptake of water, sanitation and hygiene (WASH) technologies in low- and middle-income countries: An evidence and gap map of effectiveness studies

Background

Lack of access to and use of water, sanitation and hygiene (WASH) cause 1.6 million deaths every year, of which 1.2 million are due to gastrointestinal illnesses like diarrhoea and acute respiratory infections like pneumonia. Poor WASH access and use also diminish nutrition and educational attainment, and cause danger and stress for vulnerable populations, especially for women and girls. The hardest hit regions are sub-Saharan Africa and South Asia. Sustainable Development Goal (SDG) 6 calls for the end of open defecation, and universal access to safely managed water and sanitation facilities, and basic hand hygiene, by 2030. WASH access and use also underpin progress in other areas such as SDG1 poverty targets, SDG3 health and SDG4 education targets. Meeting the SDG equity agenda to "leave none behind" will require WASH providers prioritise the hardest to reach including those living remotely and people who are disadvantaged.

Objectives

Decision makers need access to high-quality evidence on what works in WASH promotion in different contexts, and for different groups of people, to reach the most disadvantaged populations and thereby achieve universal targets. The WASH evidence map is envisioned as a tool for commissioners and researchers to identify existing studies to fill synthesis gaps, as well as helping to prioritise new studies where there are gaps in knowledge. It also supports policymakers and practitioners to navigate the evidence base, including presenting critically appraised findings from existing systematic reviews.

Methods

This evidence map presents impact evaluations and systematic reviews from the WASH sector, organised according to the types of intervention mechanisms, WASH technologies promoted, and outcomes measured. It is based on a framework of intervention mechanisms (e.g., behaviour change triggering or microloans) and outcomes along the causal pathway, specifically behavioural outcomes (e.g., handwashing and food hygiene practices), ill-health outcomes (e.g., diarrhoeal morbidity and mortality), nutrition and socioeconomic outcomes (e.g., school absenteeism and household income). The map also provides filters to examine the evidence for a particular WASH technology (e.g., latrines), place of use (e.g., home, school or health facility), location (e.g., global region, country, rural and urban) and group (e.g., people living with disability). Systematic searches for published and unpublished literature and trial registries were conducted of studies in low- and middle-income countries (LMICs). Searches were conducted in March 2018, and searches for completed trials were done in May 2020. Coding of information for the map was done by two authors working independently. Impact evaluations were critically appraised according to methods of conduct and reporting. Systematic reviews were critically appraised using a new approach to assess theory-based, mixed-methods evidence synthesis.

Results

There has been an enormous growth in impact evaluations and systematic reviews of WASH interventions since the International Year of Sanitation, 2008. There are now at least 367 completed or ongoing rigorous impact evaluations in LMICs, nearly three-quarters of which have been conducted since 2008, plus 43 systematic reviews. Studies have been done in 83 LMICs, with a high concentration in Bangladesh, India, and Kenya. WASH sector programming has increasingly shifted in focus from what technology to supply (e.g., a handwashing station or child's potty), to the best way in which to do so to promote demand. Research also covers a broader set of intervention mechanisms. For example, there has been increased interest in behaviour change communication using psychosocial "triggering", such as social marketing and community-led total sanitation. These studies report primarily on behavioural outcomes. With the advent of large-scale funding, in particular by the Bill & Melinda Gates Foundation, there has been a substantial increase in the number of studies on sanitation technologies, particularly latrines. Sustaining behaviour is fundamental for sustaining health and other quality of life improvements. However, few studies have been done of intervention mechanisms for, or measuring outcomes on sustained adoption of latrines to stop open defaecation. There has also been some increase in the number of studies looking at outcomes and interventions that disproportionately affect women and girls, who quite literally carry most of the burden of poor water and sanitation access. However, most studies do not report sex disaggregated outcomes, let alone integrate gender analysis into their framework. Other vulnerable populations are even less addressed; no studies eligible for inclusion in the map were done of interventions targeting, or reporting on outcomes for, people living with disabilities. We were only able to find a single controlled evaluation of WASH interventions in a health care facility, in spite of the importance of WASH in health facilities in global policy debates. The quality of impact evaluations has improved, such as the use of controlled designs as standard, attention to addressing reporting biases, and adequate cluster sample size. However, there remain important concerns about quality of reporting. The quality and usefulness of systematic reviews for policy is also improving, which draw clearer distinctions between intervention mechanisms and synthesise the evidence on outcomes along the causal pathway. Adopting mixed-methods approaches also provides information for programmes on barriers and enablers affecting implementation.

Conclusion

Ensuring everyone has access to appropriate water, sanitation, and hygiene facilities is one of the most fundamental of challenges for poverty elimination. Researchers and funders need to consider carefully where there is the need for new primary evidence, and new syntheses of that evidence. This study suggests the following priority areas:Impact evaluations incorporating understudied outcomes, such as sustainability and slippage, of WASH provision in understudied places of use, such as health care facilities, and of interventions targeting, or presenting disaggregated data for, vulnerable populations, particularly over the life-course and for people living with a disability;Improved reporting in impact evaluations, including presentation of participant flow diagrams; andSynthesis studies and updates in areas with sufficient existing and planned impact evaluations, such as for diarrhoea mortality, ARIs, WASH in schools and decentralisation. These studies will preferably be conducted as mixed-methods systematic reviews that are able to answer questions about programme targeting, implementation, effectiveness and cost-effectiveness, and compare alternative intervention mechanisms to achieve and sustain outcomes in particular contexts, preferably using network meta-analysis.

Association between Handwashing Behavior and Infectious Diseases among Low-Income Community Children in Urban New Delhi, India: A Cross-Sectional Study

Diarrheal diseases and respiratory infections (RI) are two leading causes of childhood mortality in low and middle-income countries. Effective handwashing at critical time-points may mitigate these diseases. However, there is a lack of published data investigating this association in school-aged children in India. This study is part of a larger prospective handwashing intervention study in a low-income community in New Delhi, India examining the associations between handwashing behavior and diarrhea and RI in schoolchildren. This current study reports the findings of the baseline survey administered to 272 mother–child dyads. Children aged 8–12 years, and their mothers, were recruited from six schools. A baseline questionnaire was used to collect sociodemographic data, handwash behavior, and mother-reported recent diarrhea and RI incidence among the children. Handwashing before and after preparing food, after defecation, and after cleaning dishes significantly reduced the odds of diarrhea by over 70%, and of RI by over 56%. Using a clean cloth after handwashing lowered odds of diarrhea and RI by 72% and 63% respectively. Around 60% of the participants believed that handwashing could prevent diarrhea and RI in their children. There was a low prevalence of handwashing at critical time-points and a poor perception regarding handwashing benefits. To improve handwashing behavior, hygiene promotion programs need to understand what motivates and hinders handwashing in vulnerable populations.

Narrative Review of Primary Preventive Interventions against Water-Borne Diseases: Scientific Evidence of Health-EDRM in Contexts with Inadequate Safe Drinking Water

Waterborne diseases account for 1.5 million deaths a year globally, particularly affecting children in low-income households in subtropical areas. It is one of the most enduring and economically devastating biological hazards in our society today. The World Health Organization Health Emergency and Disaster Risk Management (health-EDRM) Framework highlights the importance of primary prevention against biological hazards across all levels of society. The framework encourages multi-sectoral coordination and lessons sharing for community risk resilience. A narrative review, conducted in March 2021, identified 88 English-language articles published between January 2000 and March 2021 examining water, sanitation, and hygiene primary prevention interventions against waterborne diseases in resource-poor settings. The literature identified eight main interventions implemented at personal, household and community levels. The strength of evidence, the enabling factors, barriers, co-benefits, and alternative measures were reviewed for each intervention. There is an array of evidence available across each intervention, with strong evidence supporting the effectiveness of water treatment and safe household water storage. Studies show that at personal and household levels, interventions are effective when applied together. Furthermore, water and waste management will have a compounding impact on vector-borne diseases. Mitigation against waterborne diseases require coordinated, multi-sectoral governance, such as building sanitation infrastructure and streamlined waste management. The review showed research gaps relating to evidence-based alternative interventions for resource-poor settings and showed discrepancies in definitions of various interventions amongst research institutions, creating challenges in the direct comparison of results across studies.

Handwashing Knowledge, Attitudes, and Practices among Students in Eastern Province Schools, Saudi Arabia

Background. Lack of knowledge about appropriate handwashing practices has caused great concerns for human health, especially in the risk of many communicable diseases. The objective of the current study is to determine the level of handwashing knowledge, attitudes, and practices among school students in Eastern Province Schools, Saudi Arabia. A cross-sectional survey was recruited from November 2019 to March 2020 to assess the level of the students' handwashing knowledge. A reliable questionnaire was prepared (Cronbach's alpha = 0.608) and conducted using a two-stage sampling technique. A total of 271 students participated in the study from primary, middle, and high schools; 80% were boys, most of whom displayed an acceptable level of knowledge on hand hygiene. Nearly 75% and 74% of boys and girls, respectively, gained knowledge about hand hygiene practices from their parents. Only 46% of the students thought that handwashing is a potential protective measure against diseases, whereas 34% thought it only removes dirt. Prevalence of handwashing with soap after using the toilet was recognized among 52% of the students. Additionally, 93% of the students used water and soap to wash their hands (p value < 0.001) and 97% suggested that soap and water are the best methods to wash their hands (p value < 0.001). There was a positive correlation between the mother's education and hand hygiene practices (p value = 0.044). Results collectively indicated that handwashing knowledge and practices among school students in the Eastern Province are acceptable interventions in preventing the transmission of infectious diseases such as COVID-19. Indeed, further improvement conducted through specific health education programs to emphasize the role of handwashing in health hygiene is highly recommended.

Lactic acid as a major contributor to hand surface infection barrier and its association with morbidity to infectious disease

Although the surface of the human hands contains high antimicrobial activity, studies investigating the precise components involved and the relationship between natural antimicrobial activity and morbidity in infectious diseases are limited. In this study, we developed a method to quantitatively measure the antimicrobial activity of hand surface components. Using a clinical survey, we validated the feasibility of our method and identified antimicrobial factors on the surface of the human hand. In a retrospective observational study, we compared the medical histories of the participants to assess infectious diseases. We found that the antimicrobial activity on the surface of the hands was significantly lower in the high morbidity group (N = 55) than in the low morbidity group (N = 54), indicating a positive association with the history of infection in individuals. A comprehensive analysis of the hand surface components indicated that organic acids, especially lactic acid and antimicrobial peptides, are highly correlated with antimicrobial activity. Moreover, the application of lactic acid using the amount present on the surface of the hand significantly improved the antimicrobial activity. These findings suggest that hand hygiene must be improved to enhance natural antimicrobial activity on the surface of the hands.

Soap, water, and severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2): an ancient handwashing strategy for preventing dissemination of a novel virus

Public Health Agencies worldwide (World Health Organization, United States Centers for Disease Prevention & Control, Chinese Center for Disease Control and Prevention, European Centre for Disease Prevention and Control, etc.) are recommending hand washing with soap and water for preventing the dissemination of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infections. In this review, we have discussed the mechanisms of decontamination by soap and water (involving both removal and inactivation), described the contribution of the various components of formulated soaps to performance as cleansers and to pathogen inactivation, explained why adherence to recommended contact times is critical, evaluated the possible contribution of water temperature to inactivation, discussed the advantages of antimicrobial soaps vs. basic soaps, discussed the differences between use of soap and water vs. alcohol-based hand sanitizers for hand decontamination, and evaluated the limitations and advantages of different methods of drying hands following washing. While the paper emphasizes data applicable to SARS-CoV-2, the topics discussed are germane to most emerging and re-emerging enveloped and non-enveloped viruses and many other pathogen types.

Establishing Healthy Personal Hygiene Habits with Young Children in Australia: A Cross-Sectional Mixed Methods Study

Effective and consistent engagement in personal hygiene practices is important for preventing the acquisition and transmission of communicable diseases in childhood. This study aimed to investigate trends in adherence to recommended hygiene practices and identify factors contributing to difficulties in establishing good hygiene habits with young children (0–4 years) in Australia. A self-selected community sample of parents (N = 426) completed an online survey assessing children's adherence to recommended hygiene practices and barriers and enablers of establishing good personal hygiene habits. Parents reported interest in receiving information/tips on children's personal hygiene (yes/no) and nominated topics of interest. Less than half of children in any age group consistently (always/almost always) covered coughs and sneezes, washed hands after toileting, or washed hands before meals or when dirty. Children's non-compliance (i.e. resistance, refusal) was the most commonly reported barrier to establishing good personal hygiene habits, while children's compliance (i.e. cooperative behaviour, following or complying with caregivers’ instructions) was the most commonly cited enabler. Despite low levels of adherence, less than half (41.2%) of parents wanted information/tips on children's hygiene. Results suggest a disconnect between parents’ knowledge about recommended hygiene practices and actual behaviour. Development and testing of approaches to behaviour change that incorporate evidence-based strategies to manage children's resistance and support parents to encourage the development of healthy hygiene habits is warranted.

Analysis of hand environment factors contributing to the hand surface infection barrier imparted by lactic acid

BACKGROUND

Organic acids on the surface of human hands contribute to the barrier against transient pathogens. This is the first study to explore the synergistic contribution of lactic acid and other hand environment-related features on the antibacterial properties of the hand surface.

MATERIALS AND METHODS

We estimated the contribution of fingerprint depth, skin pH, stratum corneum water content, skin temperature, and sweat rate of the hands to the infection barrier using an observational survey of 105 subjects. The relationship between each factor and the antibacterial activity of the hands was analyzed using Pearson's correlation coefficient. We performed molecular dynamics simulations to study the interaction between lactic acid and bacterial membranes.

RESULTS

The amount of lactic acid on the hands and skin temperature contributed positively to the antimicrobial activity (r = 0.437 and P = 3.18 × 10^-6 , r = 0.500 and P = 5.66 × 10^-8 , respectively), while the skin pH contributed negatively (r = -0.471, P = 3.99 × 10^-7 ). The predicted value of the combined antimicrobial effect of these parameters was [antimicrobial activity] = 0.21 × [lactic acid] - 0.25 × [skin pH] + 0.26 × [skin temperature] + 0.98. The coefficient of determination (R² ) was 0.50.

CONCLUSION

The increase in the amount of non-ionic lactic acid due to lower pH and improvement in the fluidity of the cell membrane due to higher temperatures enable the efficient transport of lactic acid into cells and subsequent antimicrobial activity. The proposed mechanism could help to develop an effective hand infection barrier technology.

A framework for scabies control

Scabies is a neglected tropical disease (NTD) that causes a significant health burden, particularly in disadvantaged communities and where there is overcrowding. There is emerging evidence that ivermectin-based mass drug administration (MDA) can reduce the prevalence of scabies in some settings, but evidence remains limited, and there are no formal guidelines to inform control efforts. An informal World Health Organization (WHO) consultation was organized to find agreement on strategies for global control. The consultation resulted in a framework for scabies control and recommendations for mapping of disease burden, delivery of interventions, and establishing monitoring and evaluation. Key operational research priorities were identified. This framework will allow countries to set control targets for scabies as part of national NTD strategic plans and develop control strategies using MDA for high-prevalence regions and outbreak situations. As further evidence and experience are collected and strategies are refined over time, formal guidelines can be developed. The control of scabies and the reduction of the health burden of scabies and associated conditions will be vital to achieving the targets set in WHO Roadmap for NTDs for 2021 to 2030 and the Sustainable Development Goals.

COVID-19 knowledge, attitude and frequent hand hygiene practices among taxi drivers and associated factors in urban areas of Ethiopia

BACKGROUND

Although several studies have been conducted on COVID-19 knowledge, attitude and prevention practices among healthcare workers and the general population, there has not been any study among taxi drivers in Ethiopia, including Dessie City and Kombolcha Town, the lack of which hinders providing evidence-based interventions to this target group. Thus, this study was designed to contribute to proper planning of COVID-19 intervention measures among taxi drivers in Dessie City and Kombolcha Town, Ethiopia.

METHODS

A cross-sectional study was conducted among 417 taxi drivers in Dessie City and Kombolcha Town during July to August, 2020. The data was collected using a structured questionnaire and an observational checklist. The collected data was checked, coded and entered to EpiData version 4.6 and exported to Statistical Package for the Social Sciences (SPSS) version 25.0 for data cleaning and analysis. The outcome variables of this study were good or poor knowledge, positive or negative attitude and good or poor frequent hand hygiene practices towards COVID-19. Bivariate (Crude Odds Ratio [COR]) and multivariable (Adjusted Odds Ratio [AOR]) logistic regression analysis were employed to identify factors significantly associated with good knowledge, positive attitude and good frequent hand hygiene practices among taxi drivers. Significance level of variables was declared at a p < 0.05 from the adjusted analysis.

MAIN FINDINGS

Out of the total 417 taxi drivers, 69.8% [95% CI: 65.2-73.9], 67.6% [95%CI: 63.1-72.2] and 66.4% [95% CI: 62.1-71.0] of the drivers had good knowledge, positive attitude and good frequent hand hygiene practices, respectively. Educational level (AOR = 7.55, 95% CI = 4.55-12.54), place of residence (AOR = 5.41, 95% CI = 1.4-20.08) and attitude towards COVID-19 prevention (AOR = 1.67, 95% CI = 1.02-2.74) were factors associated with good knowledge about COVID-19. Further, age of taxi drivers greater than 30 years (AOR = 3.01, 95% CI = 1.76-5.13), educational level of secondary or above (AOR = 3.16, 95% CI = 1.88-5.31), income (AOR = 3.36, 95% CI = 1.48-7.61), and knowledge about COVID-19 (AOR = 2.1, 95% CI = 1.21-3.54) were factors associated with positive attitude towards COVID-19 prevention. In addition, attitude towards COVID-19 (AOR = 5.5, 95% CI = 3.40-8.88) and educational level (AOR = 1.84, 95% CI = 1.15-2.95) were the factors associated with good frequent hand hygiene practices.

CONCLUSION

We concluded that the rates of good knowledge, positive attitude and good frequent hand hygiene practices were relatively low among taxi drivers in Dessie City and Kombolcha Town. We strongly recommended providing training about COVID-19 prevention measures for taxi drivers that considers age, education status and attitude areas essential to improve their knowledge, attitude and frequent hand hygiene practices to prevent the spread of COVID-19.

Relationship between the Toothbrushing Behavior and Hand Hygiene Practices of Korean Adolescents: A Study Focused on the 15th Korea Youth Risk Behavior Survey Conducted in 2019

Hand hygiene is one of the most important measures available to prevent infectious diseases such as COVID-19, and it is recommended that individuals wash their hands periodically before and after meals, after using toilets, before preparing food at home, at schools, and in public places. The aim of this study was to investigate the relationship between oral hygiene and hand hygiene in Korean adolescents. Data from 57,303 adolescents who participated in the 2019 Korea Youth Risk Behavior web-based survey were analyzed to determine the relationship between oral hygiene and hand hygiene. A complex sample logistic regression analysis was performed to determine association between toothbrushing behavior and handwashing practices. According to the results of this study, adolescents who brushed their teeth after lunch were 1.48 times more likely to practice handwashing before lunch than were those who did not brush their teeth after lunch (p < 0.001). In addition, the odds ratios adjusted for gender, grade, school type, and residence were found to be 1.87 (p < 0.001). Moreover, these adjusted odds ratios were higher in students who received personal hygiene education (OR: 1.98, p < 0.001). Oral hygiene practices were found to be related to personal hygiene, as assessed by handwashing, in Korean adolescents. Additional studies are needed to develop ways of improving the hygiene and health of adolescents.

Emerging Treatment Strategies for Impetigo in Endemic and Nonendemic Settings: A Systematic Review

PURPOSE

Impetigo affects approximately 162 million children worldwide at any given time. Lack of consensus on the most effective treatment strategy for impetigo and increasing antibiotic resistance continue to drive research into newer and alternative treatment options. We conducted a systematic review to assess the effectiveness of new treatments for impetigo in endemic and nonendemic settings.

METHODS

We searched PubMed, MEDLINE, CINAHL, Web of Science, and Embase via Scopus for studies that explored treatments for bullous, nonbullous, primary, and secondary impetigo published between August 1, 2011, and February 29, 2020. We also searched online trial registries and hand-searched the reference lists of the included studies. We used the revised Cochrane risk of bias (version 2.0) tool for randomized trials and the National Heart, Lung, and Blood Institute for nonrandomized uncontrolled studies to assess the risk of bias.

FINDINGS

We included 10 studies that involved 6651 participants and reported on 9 treatments in the final analysis. Most clinical trials targeted nonbullous impetigo or did not specify this. The risk of bias varied among the studies. In nonendemic settings, ozenoxacin 1% cream appeared to have the strongest evidence base compared with retapamulin and a new minocycline formulation. In endemic settings, oral co-trimoxazole and benzathine benzylpenicillin G injection were equally effective in the treatment of severe impetigo. Mass drug administration intervention emerged as a promising public health strategy to reduce the prevalence of impetigo in endemic settings.

IMPLICATIONS

This review highlights the limited research into new drugs used for the treatment of impetigo in endemic and nonendemic settings. Limited recent evidence supports the use of topical ozenoxacin or retapamulin for impetigo treatment in nonendemic settings, whereas systemic antibiotics and the mass drug administration strategy have evidence for use in endemic settings. Given the troubling increase in resistance to existing treatments, there is a clear need to ensure the judicious use of antibiotics and to develop new treatments and alternative strategies; this is particularly important in endemic settings. PROSPERO identifier: CRD42020173042.

Formative evaluation of a community-based approach to reduce the incidence of Strep A infections and acute rheumatic fever

OBJECTIVES

To explore the acceptability of a novel, outreached-based approach to improve primary and primordial prevention of Strep A skin sores, sore throats and acute rheumatic fever in remote Aboriginal communities.

METHODS

A comprehensive prevention program delivered by trained Aboriginal Community Workers was evaluated using approximately fortnightly household surveys about health and housing and clinical records.

RESULTS

Twenty-seven primary participants from three remote Aboriginal communities in the Northern Territory consented, providing 37.8 years of retrospective baseline data and 18.5 years of prospective data during the study period. Household members were considered to be secondary participants. Five Aboriginal Community Workers were trained and employed, delivering a range of supports to households affected by acute rheumatic fever including environmental health support and education. Clinical record audit and household self-report of Strep A infections were compared. No association between clinical- and self-report was identified.

CONCLUSIONS

Ongoing participation suggests this outreach-based prevention program was acceptable and associated with improved reporting of household maintenance issues and awareness of prevention opportunities for Strep A infections. Implications for public health: Biomedical, clinic-based approaches to the management of Strep A infections in remote communities can be usefully augmented by outreach-based supports delivered by Aboriginal Community Workers responding to community needs.

Nonpharmacological interventions to reduce respiratory viral transmission: an evidence-based review with recommendations

BACKGROUND

Viral respiratory infections are a leading cause of worldwide mortality and exert the potential to cause global socioeconomic crises. However, inexpensive, efficacious, and rapidly deployable strategies to reduce viral transmission are increasingly important in the setting of an ongoing pandemic, though not entirely understood. This article provides a comprehensive review of commonly employed nonpharmacological interventions to interrupt viral spread and provides evidence-based recommendations for their use.

METHODOLOGY

A systematic review of three databases was performed. Studies with defined endpoints of subjects receiving one of five interventions (nasal washing, gargling, personal protective equipment (PPE), social distancing, and hand hygiene) were included. An evidence-based review of the highest level of evidence, with recommendations, was created in accordance with a previously described, rigorous, iterative process.

RESULTS

Fifty-four primary studies were included. The most commonly studied intervention was hand hygiene, followed by PPE, gargling, saline nasal washing, and social distancing.

CONCLUSIONS

Mask use and hand hygiene are strong recommendations for prevention of viral transmission. Donning gloves, gowns, and eye protection are a recommendation in healthcare settings. Saline nasal washing and gargling are options in selected populations. Although an aggregate level of evidence is not provided, the authors recommend social distancing.

Handwashing effect on diarrheal incidence in children under 5 years old in rural eastern Ethiopia: a cluster randomized controlled trial

BACKGROUND

Handwashing with soap reduces diarrheal diseases burden considerably. However, the importance of handwashing in homes has received little attention in rural eastern Ethiopia. The effectiveness of handwashing may be reduced by lack of information on when and in what event hands must be washed, the frequency of handwashing, the individual who should wash his/her hands, and the procedure of handwashing. In these areas, indicators of adherence to handwashing are yet to be established. This study aimed at assessing the efficiency of handwashing on reducing diarrheal disease in children under 5 years old in rural kebeles of Dire Dawa, east Ethiopia.

METHODS

Community-based cluster randomized controlled trial was conducted in rural kebeles of Dire Dawa for 4 months starting from October 2018 to January 2019. Selected clusters were randomized in intervention and control arms using draw method and data collectors conducted the baseline survey. Households assigned to the intervention group were given two bars of plain soap on a bi-monthly basis together with information promoting hand hygiene. Control households were allowed to continue their habitual handwashing practices. We compared the diarrheal incidences of the intervention and non-intervention households. Generalized estimation equations using Poisson family and log choice of the link was employed to calculate adjusted incidence rate ratio with its 95% confidence interval.

RESULTS

We recorded a significant lesser diarrheal incidence in the handwashing arm than in the non-intervention arm (6.9 versus 13.8 episodes per 100 person weeks of observation). In all, there was a 41% reduction in diarrheal incidence in the intervention arm in relation to the non-intervention arm.

CONCLUSION

Handwashing with soap complemented with hand hygiene promotion significantly decreased diarrheal episodes in children under 5 years old in rural kebeles of Dire Dawa. We recommend the promotion and adaptation of washing hands using soap at recommended times to be an effective means of reducing childhood diarrhea morbidity in rural populations of Ethiopia towards achieving the Sustainable Development Goal 6.

TRIAL REGISTRATION

PACTR, PACTR201807815961394 . Registered 16 July 2018.

Rheumatic heart disease in Indigenous young peoples

Indigenous children and young peoples live with an inequitable burden of acute rheumatic fever and rheumatic heart disease. In this Review, we focus on the epidemiological burden and lived experience of these conditions for Indigenous young peoples in Australia, New Zealand, and Canada. We outline the direct and indirect drivers of rheumatic heart disease risk and their mitigation. Specifically, we identify the opportunities and limitations of predominantly biomedical approaches to the primary, secondary, and tertiary prevention of disease among Indigenous peoples. We explain why these biomedical approaches must be coupled with decolonising approaches to address the underlying cause of disease. Initiatives underway to reduce acute rheumatic fever and rheumatic heart disease in Australia, New Zealand, and Canada are reviewed to identify how an Indigenous rights-based approach could contribute to elimination of rheumatic heart disease and global disease control goals.

Effectiveness of Mass Media Campaigns to Improve Handwashing-Related Behavior, Knowledge, and Practices in Rural Bangladesh

Water, sanitation, and handwashing interventions that use intensive interpersonal communication improve targeted behaviors, but are expensive at scale. Mass media is an alternative that could reach more people at lower cost but has rarely been rigorously evaluated. We assessed the effectiveness of a mass media campaign in improving handwashing knowledge and practices in rural Bangladesh. We conducted a cross-sectional assessment before the campaign among 8,947 households and again after 4 months of the campaign among 8,400 different households in the same areas. Trained enumerators conducted spot checks of water, sanitation, and hygiene facilities, and recorded reported knowledge and practices. We compared these outcomes after versus before the campaign using generalized linear models with robust standard errors. After the media campaign, caregivers were more likely to recall ≥ 3 messages regarding handwashing (prevalence ratio [PR] = 1.44, 1.34-1.55), sanitation (PR = 1.45, 1.35-1.55), and safe water (PR = 1.17, 1.08-1.26). After the campaign, the prevalence of using soap and water during handwashing demonstrations was higher among caregivers (PR = 1.15, 1.12-1.19) and children (PR = 1.31, 1.22-1.41). Hands were more commonly observed to be visibly clean among caregivers (PR = 1.14, 1.07-1.20) and children (PR = 1.13, 1.05-1.21). Soap and water was more commonly observed in handwashing stations near latrines (PR = 1.12, 1.06-1.19) and in cooking/eating places (PR = 1.09, 1.01-1.18). Our findings indicate improved handwashing knowledge and behaviors following a mass media campaign. This promising approach can be deployed to improve water, sanitation, and hygiene practices at scale and should be evaluated in other contexts.

Safety and Health Measures for COVID-19 Transition Period in the Hotel Industry in Spain

The health crisis caused by the outbreak of the COVID-19 disease has devastated the worldwide hospitality sector. The current situation has led many countries to implement drastic rules to stop the spread of the virus. According to the Spanish health authority decisions need to be made in the context of uncertainty and lack of knowledgeable experiences through a gradual and asymmetric de-escalation process planned in four phases. Although the vast majority of studies refer to economic risks and impacts on tourist flows and economic income, few of them explicitly investigates safety and health measures that hotel managers should implement to their customers. Over a population of 12,740 hotels, 823 Spanish hotel managers have been involved in a participatory study. With the aim of assessing the actions taken to stop the spread of the virus, empirical research was implemented. A model presented four variables and 13 indicators which have been previously tested among hotel managers in the tourism sector. Five conclusions are drawn from the hypotheses: (1) Mass testing surveillance in customers and employees should be quick, affordable, and homogeneous throughout the European Union. (2) Training measures need to be taken by both public authorities and the private sector to reach a knowledgeable crisis management team with high commitment to the customer's health and safety. (3) Protocols established by public authorities should be observed and adjusted gradually not only in hotels but also in tourist arrivals. (4) Healthy measures need to be periodically updated. (5) Each hotel should set up a surveillance process to guarantee the safety to their customers.

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

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

Hand-washing promotion for preventing diarrhoea

BACKGROUND

Diarrhoea accounts for 1.8 million deaths in children in low- and middle-income countries (LMICs). One of the identified strategies to prevent diarrhoea is hand washing.

OBJECTIVES

To assess the effects of hand-washing promotion interventions on diarrhoeal episodes in children and adults.

SEARCH METHODS

We searched CENTRAL, MEDLINE, Embase, nine other databases, the World Health Organization (WHO) International Clinical Trial Registry Platform (ICTRP), and metaRegister of Controlled Trials (mRCT) on 8 January 2020, together with reference checking, citation searching and contact with study authors to identify additional studies.

SELECTION CRITERIA

Individually-randomized controlled trials (RCTs) and cluster-RCTs that compared the effects of hand-washing interventions on diarrhoea episodes in children and adults with no intervention.

DATA COLLECTION AND ANALYSIS

Three review authors independently assessed trial eligibility, extracted data, and assessed risks of bias. We stratified the analyses for child day-care centres or schools, community, and hospital-based settings. Where appropriate, we pooled incidence rate ratios (IRRs) using the generic inverse variance method and a random-effects model with a 95% confidence interval (CI). We used the GRADE approach to assess the certainty of the evidence.

MAIN RESULTS

We included 29 RCTs: 13 trials from child day-care centres or schools in mainly high-income countries (54,471 participants), 15 community-based trials in LMICs (29,347 participants), and one hospital-based trial among people with AIDS in a high-income country (148 participants). All the trials and follow-up assessments were of short-term duration. Hand-washing promotion (education activities, sometimes with provision of soap) at child day-care facilities or schools prevent around one-third of diarrhoea episodes in high-income countries (incidence rate ratio (IRR) 0.70, 95% CI 0.58 to 0.85; 9 trials, 4664 participants, high-certainty evidence) and may prevent a similar proportion in LMICs, but only two trials from urban Egypt and Kenya have evaluated this (IRR 0.66, 95% CI 0.43 to 0.99; 2 trials, 45,380 participants; low-certainty evidence). Only four trials reported measures of behaviour change, and the methods of data collection were susceptible to bias. In one trial from the USA hand-washing behaviour was reported to improve; and in the trial from Kenya that provided free soap, hand washing did not increase, but soap use did (data not pooled; 3 trials, 1845 participants; low-certainty evidence). Hand-washing promotion among communities in LMICs probably prevents around one-quarter of diarrhoea episodes (IRR 0.71, 95% CI 0.62 to 0.81; 9 trials, 15,950 participants; moderate-certainty evidence). However, six of these nine trials were from Asian settings, with only one trial from South America and two trials from sub-Saharan Africa. In seven trials, soap was provided free alongside hand-washing education, and the overall average effect size was larger than in the two trials which did not provide soap (soap provided: RR 0.66, 95% CI 0.58 to 0.75; 7 trials, 12,646 participants; education only: RR 0.84, 95% CI 0.67 to 1.05; 2 trials, 3304 participants). There was increased hand washing at major prompts (before eating or cooking, after visiting the toilet, or cleaning the baby's bottom) and increased compliance with hand-hygiene procedure (behavioural outcome) in the intervention groups compared with the control in community trials (data not pooled: 4 trials, 3591 participants; high-certainty evidence). Hand-washing promotion for the one trial conducted in a hospital among a high-risk population showed significant reduction in mean episodes of diarrhoea (1.68 fewer) in the intervention group (mean difference -1.68, 95% CI -1.93 to -1.43; 1 trial, 148 participants; moderate-certainty evidence). Hand-washing frequency increased to seven times a day in the intervention group versus three times a day in the control arm in this hospital trial (1 trial, 148 participants; moderate-certainty evidence). We found no trials evaluating the effects of hand-washing promotions on diarrhoea-related deaths or cost effectiveness.

AUTHORS' CONCLUSIONS

Hand-washing promotion probably reduces diarrhoea episodes in both child day-care centres in high-income countries and among communities living in LMICs by about 30%. The included trials do not provide evidence about the long-term impact of the interventions.

Water, sanitation, hygiene and waste disposal practices as COVID-19 response strategy: insights from Bangladesh

The COVID-19 pandemic has caused a global emergence, and the absence of a proven vaccine or medicine has led to the implementation of measures to prevent and control the spread of the virus. Wearing protective equipment like mask and gloves, washing hands via soap, frequent use of antiseptic solution and maintaining social distance are being applied globally to reduce the transmission rate. Therefore, this study was intended to investigate water, sanitation and hygienic (WASH) behaviour, protective equipment use and their disposal practices among Bangladeshi residents amid the COVID-19 pandemic. Based on the study aims, data were collected mainly via an online survey and analysed through a set of statistical tools including T test, one-way ANOVA and principal component analysis (PCA). This study found that almost 89.80% of the respondents reported to know about the COVID-19 and its preventive measures. WASH status of the respondents is found quite good, where 94.60% stated to have available potable water, 99% have improved toilet facilities, 95% wash their hands via soap, and 79.80% clean their house and toilets by antiseptic solutions properly. Moreover, nearly 94.50% and 54.80% people reported to use face mask and hand gloves, respectively, but the disposal practice of these protective equipment is inappropriate. More than 50% of people reported disposing of their used mask, gloves and tissue with other household wastes, which is alarming for public health and environmental perspective. Moreover, the WASH and waste disposal practices of the marginal people were found very poor and not at a satisfactory level. The results of statistical analysis focused on WASH and waste disposal practices as well as the factors which influence these practices. It is found that gender, occupation, area of residence, and level of education of the participants mainly influence the WASH and waste disposal practices. It is expected that this study exposed the necessity to introduce proper infectious waste management policy and also the increase in awareness level among mass people regarding the preventive measures of COVID-19 infection to combat against disease transmission and environmental pollution.

SUPPLEMENTARY INFORMATION

The online version of this article (10.1007/s10668-020-01151-9) contains supplementary material, which is available to authorized users.

Ending rheumatic heart disease in Australia: the evidence for a new approach

■The RHD Endgame Strategy: the blueprint to eliminate rheumatic heart disease in Australia by 2031 (the Endgame Strategy) is the blueprint to eliminate rheumatic heart disease (RHD) in Australia by 2031. Aboriginal and Torres Strait Islander people live with one of the highest per capita burdens of RHD in the world. ■The Endgame Strategy synthesises information compiled across the 5-year lifespan of the End Rheumatic Heart Disease Centre of Research Excellence (END RHD CRE). Data and results from priority research projects across several disciplines of research complemented literature reviews, systematic reviews and narrative reviews. Further, the experiences of those working in acute rheumatic fever (ARF) and RHD control and those living with RHD to provide the technical evidence for eliminating RHD in Australia were included. ■The lived experience of RHD is a critical factor in health outcomes. All future strategies to address ARF and RHD must prioritise Aboriginal and Torres Strait Islander people's knowledge, perspectives and experiences and develop co-designed approaches to RHD elimination. The environmental, economic, social and political context of RHD in Australia is inexorably linked to ending the disease. ■Statistical modelling undertaken in 2019 looked at the economic and health impacts of implementing an indicative strategy to eliminate RHD by 2031. Beginning in 2019, the strategy would include: reducing household crowding, improving hygiene infrastructure, strengthening primary health care and improving secondary prophylaxis. It was estimated that the strategy would prevent 663 deaths and save the health care system $188 million. ■The Endgame Strategy provides the evidence for a new approach to RHD elimination. It proposes an implementation framework of five priority action areas. These focus on strategies to prevent new cases of ARF and RHD early in the causal pathway from Streptococcus pyogenes exposure to ARF, and strategies that address the critical systems and structural changes needed to support a comprehensive RHD elimination strategy.

Changes in demand for emergency ambulances during a nationwide lockdown that resulted in elimination of COVID-19: an observational study from New Zealand

OBJECTIVE

To examine the impact of a 5-week national lockdown on ambulance service demand during the COVID-19 pandemic in New Zealand.

DESIGN

A descriptive cross-sectional, observational study.

SETTING

High-quality data from ambulance electronic clinical records, New Zealand.

PARTICIPANTS

Ambulance records were obtained from 588 690 attendances during pre-lockdown (prior to 17 February 2020) and from 36 238 records during the lockdown period (23 March to 26 April 2020).

MAIN OUTCOME MEASURES

Ambulance service utilisation during lockdown was compared with pre-lockdown: (a) descriptive analyses of ambulance events and proportions of event types for each period, (b) absolute rates of ambulance attendance (event types/week) for each period.

RESULTS

During lockdown, ambulance patients were more likely to be attended at home and less likely to be aged between 16 and 25 years. There was a significant increase in the proportion of lower acuity patients (Status 3 and Status 4) attended (p<0.001) and a corresponding increase in patients not transported from scene (p<0.001). Road traffic crashes (p<0.001) and alcohol-related incidents (p<0.001) significantly decreased. There was a decrease in the absolute number of weekly ambulance attendances (ratio (95% CI), 0.89 (0.87 to 0.91), p<0.001), attendances to respiratory conditions (0.74 (0.61 to 0.86), p=0.01), and trauma (0.81 (0.77 to 0.85), p<0.001). However, there was a significant increase in ambulance attendances for mental health conditions (1.37 (1.22 to 1.51), p=0.005).

CONCLUSIONS

Despite the relative absence of COVID-19 in the community during the 5-week nationwide lockdown, there were significant differences in ambulance utilisation during this period. The lockdown was associated with an increase in ambulance attendances for mental health conditions and is of concern. In considering future lockdowns, the potential implications on a population's mental well-being will need to be seriously considered against the benefits of elimination of virus transmission.