Effect of intensive handwashing in the prevention of diarrhoeal illness among patients with AIDS: a randomized controlled study

Effects of local handwashing agents on microbial contamination of the hands in a rural setting in Northwest Ethiopia: a cluster randomised controlled trial

OBJECTIVE

To evaluate the effectiveness of handwashing with water and wood ash in reducing faecal contamination of the hands.

DESIGN

A cluster randomised controlled trial was employed with two arms: handwashing with water and wood ash versus handwashing with water alone.

SETTING

Rural households of East Dembiya District, Central Gondar Zone, Amhara National Regional State, Ethiopia.

PARTICIPANTS

440 mothers and caregivers of children younger than 5 years assigned (1:1, 220 in each group) in clusters, with buffer zones between each cluster.

INTERVENTION

Health education on effective handwashing was given to the intervention and control groups. Participants in the intervention group used wood ash of the same quantity (ie, one closed palm).

OUTCOME MEASURES

The primary outcome was microbial contamination of the hands, measured by means of Escherichia coli counts before and after handwashing.

RESULTS

At baseline, 75.9% and 67.7% of the participants in the intervention and control groups, respectively, had dirt on their fingernails, and the hands of all participants in both groups were contaminated with E. coli. The mean E. coli counts recovered at baseline were 3.07 log10 colony forming unit (CFU)/swab in the intervention group and 3.03 log10 CFU/swab in the control group, while at endline it was 1.4 log10 CFU/swab in the intervention group and 3.02 log10 CFU/swab in the control group. The mean E.coli counts was reduced by 1.65 log10 due to the intervention (difference-in-differences: β= -1.65, 95% CI= -1.84 to -1.46).

CONCLUSION

Two-thirds of the swab samples tested positive for E. coli after handwashing with water and wood ash, which indicates wood ash is not very effective in terms of completely removing micro-organisms on the hands. However, wood ash was significantly better than water alone in reducing the concentration of faecal coliform organisms on the hands. Local health authorities should primarily promote handwashing with soap. However, in the absence of soap, use of wood ash over water alone might be appropriate.

TRIAL REGISTRATION NUMBER

PACTR202011855730652.

Associations of infection control measures and norovirus outbreak outcomes in healthcare settings: a systematic review and meta-analysis

BACKGROUND

Although most norovirus outbreaks in high-income countries occur in healthcare facilities, information on associations between control measures and outbreak outcomes in these settings is lacking.

METHODS

We conducted a systematic review/meta-analysis to assess associations between norovirus outbreak control measures and outcomes in hospitals and long-term care facilities (LTCFs), globally. Using regression analyses stratified by setting (hospital/LTCF), we compared durations, attack rates, and case counts for outbreaks in which control measures were reportedly implemented to those in which they were not.

RESULTS

We identified 102 papers describing 162 norovirus outbreaks. Control measures were reportedly implemented in 118 (73%) outbreaks and were associated with 0.6 (95% CI: 0.3-1.1) times smaller patient case counts and 0.7 (95% CI: 0.4, 1.0) times shorter durations in hospitals but 1.5 (95% CI: 1.1-2.2), 1.5 (95% CI: 1.0-2.1) and 1.6 (95% CI: 1.0-2.6) times larger overall, resident and staff case counts, respectively, and 1.4 (95% CI: 1.0-2.0) times longer durations in LTCFs.

CONCLUSIONS

Reported implementation of control measures was associated with smaller/shorter outbreaks in hospitals but larger/longer outbreaks in LTCFs. Control measures were likely implemented in response to larger/longer outbreaks in LTCFs, rather than causing them. Prospective observational or intervention studies are needed to determine effectiveness.

Effects of local handwashing agents on microbial contamination of hands in the rural settings of northwest Ethiopia: protocol for a two-arm, clustered-randomised controlled trial

INTRODUCTION

Hands play a part in the transmission of infections. Handwashing with soap sufficiently reduces the level of hand contamination and the spread of infections. As soap is not usually available due to cost, ash is often used as a zero-cost alternative to soap in the rural settings of developing countries. However, there is limited evidence on the effectiveness of ash to reduce microbial contamination of hands. This study is, therefore, designed to assess the effect of ash on microbial contamination of hands in the rural settings of northwest Ethiopia.

METHODS AND ANALYSIS

A two-arm clustered-randomised controlled trial will be employed. A total of 11 clusters per arm will be selected using simple random sampling technique. A total of 220 mothers or caregivers of under-5 children will be included in each arm. After providing health education on effective handwashing process, we will ask study subjects to do the usual activities. We will then take swab samples from the dominant hand before washing. After swabbing, participants will be asked to wash their hands with water only and with ash by following effective handwashing procedures. We will again take swab samples from the dominant hand after washing and drying. Finally, we will compare each intervention arm against the control. A generalised estimating equation (GEE) with robust SE estimation will be used to account the cluster nature of data.

ETHICS AND DISSEMINATION

Results will be published in peer-reviewed journal and presented at international conferences. The protocol is approved by the Institutional Review Board of the University of Gondar, Ethiopia.

TRIAL REGISTRATION NUMBER

Pan African Clinical Trial Registry; PACTR202011855730652.

Associations of hand washing frequency with the incidence of illness: a systematic review and meta-analysis

Background

Hand hygiene is one of the ways to prevent the spread of diseases. Our aim was to explore the relationship between hand washing frequency and the impact on disease, and give recommendations on the number of times to wash hands.

Methods

We searched seven electronic databases from their inception to April 11, 2020, and reference lists of related reviews for all studies on hand washing frequency and disease prevention. The Review Manager 5.3. software was used to conduct a meta-analysis. We assessed the risk of bias of included studies, and quality of evidence of the main findings.

Results

A total of eight studies were included. The results of the meta-analysis showed that there was no statistical significance between the effect of disease prevention and washing more than 4 times/day compared to not [odds ratio (OR) =0.61, 95% confidence interval (CI): 0.37 to 1.01]. The results of a case-control study showed that compared with hand washing ≤4 times/day, hand washing 5–10 times/day (OR =0.75, 95% CI: 0.63 to 0.91) and hand washing >10 times/day (OR =0.65, 95% CI 0.53 to 0.80) could reduce the risk of disease infection. There was no statistical significance advantage to hand washing more than 10 times/day compared to 5–10 times/day (OR =0.86, 95% CI: 0.70 to 1.06). Comparing hand washing ≤10 times/day with hand washing >10 times/day, increased hand washing was a protective factor against infection (OR =0.59, 95% CI: 0.36 to 0.97).

Conclusions

The more frequently hands were washed, the lower risk of disease. So far however, there is no high-quality evidence indicating the best range of hand washing frequency for disease prevention.

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.

Adequacy of Improved Sources of Drinking Water, Sanitation, and Hygiene Practice for the Reduction of Diarrheal Disease Among People Living with HIV/AIDS, Harar Region, Ethiopia

Background

Home-based care services like improved water supply, sanitation, and hygiene (WaSH) practice are vital for people living with HIV/AIDS (PLWHA) to improve their quality of life. The negative impact of inadequate WaSH services is more pronounced among HIV-infected individuals leading them to low economic productivity, poor-nourished, immuno-compromised, and death. The aim of this study was to investigate the adequacy of improved sources of drinking water, sanitation, and hygiene practice for the reduction of diarrheal disease among people living with HIV/AIDS, Harar region, Ethiopia.

Methods

A cross-sectional study was conducted on 422 PLWHA in the Harar region related to WaSH as home-based care services and the prevalence of diarrheal disease using a standardized survey questionnaire. Descriptive statistics and multivariate Poisson regressions models were performed by SPSS Version 25. Using generalized linear models, adjusted prevalence ratio (APR) with 95%Cl and p-value were computed to assess the strength of association between the outcome and explanatory variables. A significant association was assured when the p-value is less than 0.05.

Results

In the present study, the two-week prevalence of diarrheal disease was 25%, of which 16% experienced two or more diarrheal episodes. Moreover, 87% of PLWHA used an improved source of drinking water, 66% used improved sanitation facilities, and 68% have good hygiene practices. Only 37% of the respondents acquired a basic water service level (≥20lcd) and 58% of PLWHA acquired the recommended quantity of safe water for drinking (≥1.5lcd). In multivariate analysis, the adjusted prevalence ratio of the 2-week prevalence of diarrhea was lower by 8% (APR =1.08; 95%Cl: 1.02, 1.14), 7% (APR =1.07; 95%Cl: 1.01, 1.14), and 5% (APR =1.05; 95%Cl: 1.00, 1.11) among PLWHA who have good hygiene practice, wash their hand with soap 24 hours before the survey, and used sanitation facility consistently, respectively.

Conclusion

The current study results showed that PLWHA has inadequate access to improved drinking water sources, improved sanitation facilities, and hygienic practice; these triggers stakeholders for proper interventions, effective integration of adequate WaSH services to the HIV/AIDS program to enhance the quality of life of PLWHA.

A case-control study to assess risk factors related to cholera outbreak in Addis Ababa, Ethiopia, July 2016

INTRODUCTION

Suspected cholera cases were reported to the city administration health bureau in Addis-Ababa, Ethiopia on June 5, 2016 and it was laboratory confirmed by culture on 7 June 2016. The outbreak was declared by the government on June 8, 2016. The aim of this study was to rapidly investigate the outbreak epidemiologically and guide response activities in the affected Sub cities of Addis Ababa city administration.

METHODS

An unmatched 1:2 case-control study was conducted in six selected sub-cities of the city administration. Different laboratory tests were also done from suspected possible risk factors identified to support the epidemiological findings. A case was a patient greater than 5 years old, who developed acute watery diarrhea with or without Vomiting. Control was an individual greater than 5 years' old who stayed in the same township and did not suffer from cholera. A structured questionnaire was used to select cases and controls. Epi InfoTM statistical software was used to analyze the data. Results were presented in narratives, figures and tables.

RESULTS

The present study found that, the study participants who used street-vended water (Odds Ratio (OR)=10.4; 95% CI: 1.20-90.9), those who reported holy water sources use (OR=2.7, 95% CI: 1.45-5.04), eating raw meat (OR=7.75; 95% CI: 3.86-15.54) or roasted meat (OR=2.16; 95% CI: 1.19-3.93) and vegetable salad (OR=2.07; 95% CI: 1.14-3.76) were associated with contracting cholera infection. The likelihood of contracting cholera was significantly higher among those who ate food from street vendor sources (OR=5.32; 95% CI: 1.82-15.56) and those who practiced open defecation (OR=8.12; 95% CI (2.20-29.81). Having a latrine (OR=0.29; 95% CI: 0.12-0.69) and proper hand hygiene practice (OR=0.22; 95% CI: 0.14-0.38) were found to be protective against cholera infection.

CONCLUSION

Improving awareness of the community by intensifying social mobilization activities through community participation in proper hygienic practice, proper waste disposal and latrine facility construction and utilization. Provision of safe water for the community by strictly conducting end-point assessment of water points and conducting a KAP assessment among food handlers to explore their knowledge and practices regarding safe food/drink handling and water treatment as well as initiate appropriate PH actions based on the findings which will be necessary for prevention of similar cholera outbreaks in the future.

Water, Sanitation, and Hygiene Characteristics among HIV-Positive Households Participating in the Global Enteric Multicenter Study in Rural Western Kenya, 2008-2012

Diarrheal illness, a common occurrence among people living with human immunodeficiency virus (PLHIV), is largely preventable through access to safe drinking water quality, sanitation, and hygiene (WASH) facilities. We examined WASH characteristics among households with and without HIV-positive residents enrolled in the Global Enteric Multicenter Study (GEMS) in rural Western Kenya. Using univariable logistic regression, we examined differences between HIV-positive and HIV-negative households in regard to WASH practices. Among HIV-positive households, we explored the relationship between the length of time knowing their HIV status and GEMS enrollment. No statistically significant differences were apparent in the WASH characteristics among HIV-positive and HIV-negative households. However, we found differences in the WASH characteristics among HIV-positive households who were aware of their HIV status ≥ 30 days before enrollment compared with HIV-positive households who found out their status < 30 days before enrollment or thereafter. Significantly more households aware of their HIV-positive status before enrollment reported treating their drinking water (odds ratio [OR] confidence interval [CI]: 2.34 [1.12, 4.86]) and using effective water treatment methods (OR [CI]: 9.6 [3.09, 29.86]), and had better drinking water storage practices. This suggests that within this region of Kenya, HIV programs are effective in promoting the importance of practicing positive WASH-related behaviors among PLHIV.

Cholera outbreak in a naïve rural community in Northern Nigeria: the importance of hand washing with soap, September 2010

INTRODUCTION

Cholera outbreaks in rural communities are associated with high morbidity and mortality. Effective interventions to control these outbreaks require identification of source and risk factors for infection. In September, 2010 we investigated a cholera outbreak in Bashuri, a cholera naïve rural community in northern Nigeria to identify the risk factors and institute control measures.

METHODS

We conducted an unmatched case-control study. We defined a case as any resident of Bashuri community two years and above with acute watery diarrhea with or without vomiting and a control as any resident two years and above without acute watery diarrhea and vomiting. We recruited 80 hospital-based cases and 80 neighborhood controls. We collected and analyzed data on demographic characteristics, clinical information and risk factors. Laboratory analysis was performed on 10 stool samples and 14 open-well samples.

RESULTS

Mean age was 29 years (± 20 years) for cases and 32 years (± 16 years) for controls; 38 (47.5%) of cases and 60 (75%) of controls were males. Compared to controls, cases were less likely to have washed hands with soap before eating (age-adjusted odds ratio (AAOR) = 0.27, 95% confidence interval (CI): 0.10-0.72) and less likely to have washed hands with soap after using the toilet (AAOR = 0.34, 95% CI: 0.15-0.75). Vibrio cholerae O1 was isolated from six stool samples but not from any open-well samples.

CONCLUSION

Unhygienic hand washing practices was the key risk factor in this outbreak. We educated the community on personal hygiene focusing on the importance of hand washing with soap.

The common enteric bacterial pathogens and their antimicrobial susceptibility pattern among HIV-infected individuals attending the antiretroviral therapy clinic of Hawassa university hospital, southern Ethiopia

Background

The frequent occurrence of bacterial gastroenteritis among HIV-infected individuals together with increased antimicrobial drug resistance pose a significant public health challenge in developing countries. This study aimed to determine the prevalence of enteric bacterial pathogens and their antimicrobial susceptibility pattern among HIV-infected patients in a tertiary hospital in southern Ethiopia.

Methods

A hospital-based cross-sectional study was conducted at Hawassa University Comprehensive Specialized Hospital from February to May, 2016. A consecutive 215 HIV-infected patients, with complaints of gastrointestinal tract disease, were enrolled. Data on socio-demography and related factors was collected using a structured questionnaire. A stool sample was collected from each study participant and cultured to isolate enteric bacterial pathogens; isolates were characterized using biochemical tests. Antimicrobial susceptibility was determined using the Kirby- Bauer disk diffusion technique.

Results

Out of 215 patients, 27(12.6%) were culture positive for various bacterial pathogens. Campylobacter species was the most common bacterial isolate (6.04%), followed by Salmonella species (5.1%). The majority of isolates was sensitive to norfloxacin, nalidixic acid, gentamicin, ceftriaxone and ciprofloxacin and showed resistance to trimethoprim sulfamethoxazole (SXT) and chloramphenicol. Consumption of raw food was the only risk factor found to be significantly associated with enteric bacterial infection (crude odds ratio 3.41 95% CI 1.13–10.3).

Conclusions

The observed rate of enteric bacterial pathogens and their antimicrobial resistance pattern to the commonly prescribed antibiotics highlights the need to strengthen intervention efforts and promote rational use of antimicrobials. In this regard, the need to strengthen antimicrobial stewardship efforts should be emphasized to slow grown antimicrobial resistance among this population group.

Cryptosporidium in humans and animals-a one health approach to prophylaxis

Cryptosporidium is a major cause of moderate-to-severe diarrhoea in humans worldwide, second only to rotavirus. Due to the wide host range and environmental persistence of this parasite, cryptosporidiosis can be zoonotic and associated with foodborne and waterborne outbreaks. Currently, 31 species are recognized as valid, and of these, Cryptosporidium hominis and Cryptosporidium parvum are responsible for the majority of infections in humans. The immune status of the host, both innate and adaptive immunity, has a major impact on the severity of the disease and its prognosis. Immunocompetent individuals typically experience self-limiting diarrhoea and transient gastroenteritis lasting up to 2 weeks and recover without treatment, suggesting an efficient host antiparasite immune response. Immunocompromised individuals can suffer from intractable diarrhoea, which can be fatal. Effective drug treatments and vaccines are not yet available. As a result of this, the close cooperation and interaction between veterinarians, health physicians, environmental managers and public health operators is essential to properly control this disease. This review focuses on a One Health approach to prophylaxis, including the importance of understanding transmission routes for zoonotic Cryptosporidium species, improved sanitation and better risk management, improved detection, diagnosis and treatment and the prospect of an effective anticryptosporidial vaccine.

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 the Cochrane Infectious Diseases Group Specialized Register (27 May 2015); CENTRAL (published in the Cochrane Library 2015, Issue 5); MEDLINE (1966 to 27 May 2015); EMBASE (1974 to 27 May 2015); LILACS (1982 to 27 May 2015); PsycINFO (1967 to 27 May 2015); Science Citation Index and Social Science Citation Index (1981 to 27 May 2015); ERIC (1966 to 27 May 2015); SPECTR (2000 to 27 May 2015); Bibliomap (1990 to 27 May 2015); RoRe, The Grey Literature (2002 to 27 May 2015); World Health Organization (WHO) International Clinical Trial Registry Platform (ICTRP), metaRegister of Controlled Trials (mRCT), and reference lists of articles up to 27 May 2015. We also contacted researchers and organizations in the field.

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 risk of bias. We stratified the analyses for child day-care centres or schools, community, and hospital-based settings. Where appropriate, incidence rate ratios (IRR) were pooled using the generic inverse variance method and random-effects model with 95% confidence intervals (CIs). We used the GRADE approach to assess the quality of evidence.

MAIN RESULTS

We included 22 RCTs: 12 trials from child day-care centres or schools in mainly high-income countries (54,006 participants), nine community-based trials in LMICs (15,303 participants), and one hospital-based trial among people with acquired immune deficiency syndrome (AIDS) (148 participants).Hand washing promotion (education activities, sometimes with provision of soap) at child day-care facilities or schools prevents around one-third of diarrhoea episodes in high income countries (rate ratio 0.70; 95% CI 0.58 to 0.85; nine trials, 4664 participants, high quality evidence), and may prevent a similar proportion in LMICs but only two trials from urban Egypt and Kenya have evaluated this (rate ratio 0.66, 95% CI 0.43 to 0.99; two trials, 45,380 participants, low quality evidence). Only three 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; three trials, 1845 participants, low quality evidence).Hand washing promotion among communities in LMICs probably prevents around one-quarter of diarrhoea episodes (rate ratio 0.72, 95% CI 0.62 to 0.83; eight trials, 14,726 participants, moderate quality evidence). However, six of these eight trials were from Asian settings, with only single trials from South America and sub-Saharan Africa. In six 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: rate ratio 0.66, 95% CI 0.56 to 0.78; six trials, 11,422 participants; education only: rate ratio: 0.84, 95% CI 0.67 to 1.05; two trials, 3304 participants). There was increased hand washing at major prompts (before eating/cooking, after visiting the toilet or cleaning the baby's bottom), and increased compliance to hand hygiene procedure (behavioural outcome) in the intervention groups than the control in community trials (data not pooled: three trials, 3490 participants, high quality evidence).Hand washing promotion for the one trial conducted in a hospital among 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; one trial, 148 participants, moderate quality evidence). There was increase in hand washing frequency, seven times per day in the intervention group versus three times in the control in this hospital trial (one trial, 148 participants, moderate quality evidence).We found no trials evaluating or reporting the effects of hand washing promotions on diarrhoea-related deaths, all-cause-under five mortality, or costs.

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%. However, less is known about how to help people maintain hand washing habits in the longer term.

The impact of water, sanitation, and hygiene interventions on the health and well-being of people living with HIV: a systematic review

BACKGROUND

Access to improved water supply and sanitation is poor in low-income and middle-income countries. Persons living with HIV/AIDS (PLHIV) experience more severe diarrhea, hospitalizations, and deaths from diarrhea because of waterborne pathogens than immunocompetent populations, even when on antiretroviral therapy (ART).

METHODS

We examined the existing literature on the impact of water, sanitation, and hygiene (WASH) interventions on PLHIV for these outcomes: (1) mortality, (2) morbidity, (3) retention in HIV care, (4) quality of life, and (5) prevention of ongoing HIV transmission. Cost-effectiveness was also assessed. Relevant abstracts and articles were gathered, reviewed, and prioritized by thematic outcomes of interest. Articles meeting inclusion criteria were summarized in a grid for comparison.

RESULTS

We reviewed 3355 citations, evaluated 132 abstracts, and read 33 articles. The majority of the 16 included articles focused on morbidity, with less emphasis on mortality. Contaminated water, lack of sanitation, and poor hygienic practices in homes of PLHIV increase the risk of diarrhea, which can result in increased viral load, decreased CD4 counts, and reduced absorption of nutrients and antiretroviral medication. We found WASH programming, particularly water supply, household water treatment, and hygiene interventions, reduced morbidity. Data were inconclusive on mortality. Research gaps remain in retention in care, quality of life, and prevention of ongoing HIV transmission. Compared with the standard threshold of 3 times GDP per capita, WASH interventions were cost-effective, particularly when incorporated into complementary programs.

CONCLUSIONS

Although research is required to address behavioral aspects, evidence supports that WASH programming is beneficial for PLHIV.

Preventing community-wide transmission of Cryptosporidium: a proactive public health response to a swimming pool-associated outbreak--Auglaize County, Ohio, USA

The incidence of recreational water-associated outbreaks in the United States has significantly increased, driven, at least in part, by outbreaks both caused by Cryptosporidium and associated with treated recreational water venues. Because of the parasite's extreme chlorine tolerance, transmission can occur even in well-maintained treated recreational water venues (e.g. pools) and a focal cryptosporidiosis outbreak can evolve into a community-wide outbreak associated with multiple recreational water venues and settings (e.g. childcare facilities). In August 2004 in Auglaize County, Ohio, multiple cryptosporidiosis cases were identified and anecdotally linked to pool A. Within 5 days of the first case being reported, pool A was hyperchlorinated to achieve 99·9% Cryptosporidium inactivition. A case-control study was launched to epidemiologically ascertain the outbreak source 11 days later. A total of 150 confirmed and probable cases were identified; the temporal distribution of illness onset was peaked, indicating a point-source exposure. Cryptosporidiosis was significantly associated with swimming in pool A (matched odds ratio 121·7, 95% confidence interval 27·4-∞) but not with another venue or setting. The findings of this investigation suggest that proactive implementation of control measures, when increased Cryptosporidium transmission is detected but before an outbreak source is epidemiologically ascertained, might prevent a focal cryptosporidiosis outbreak from evolving into a community-wide outbreak.

Water, sanitation, and hygiene interventions to improve health among people living with HIV/AIDS: a systematic review

DESIGN

People living with HIV/AIDS (PLHIV) are at increased risk of diarrhoeal disease and enteric infection. This review assesses the effectiveness of water, sanitation, and hygiene (WASH) interventions to prevent disease among PLHIV.

METHODS

We searched MEDLINE, EMBASE, Global Health, The Cochrane Library, Web of Science, LILACS, Africa-wide, IMEMR, IMSEAR, WPRIM, CNKI, and WanFang. We also hand searched conference proceedings, contacted researchers and organizations, and checked references from identified studies. Eligible studies were those involving WASH interventions among PLHIV that reported on health outcomes and employed a controlled study design. We extracted data, explored heterogeneity, sub-grouped based on outcomes, calculated pooled effects on diarrhoeal disease using meta-analysis, and assessed studies for methodological quality.

RESULTS

Ten studies met the eligibility criteria and are included in the review, of which nine involved water quality interventions and one involved promotion of handwashing. Among eight studies that reported on diarrhoea, water quality interventions (seven studies, pooled RR = 0.57, 95% CI: 0.38-0.86) and the handwashing intervention (one study, RR = 0.42, 95% CI: 0.33-0.54) were protective against diarrhoea. One study reported that household water treatment combined with insecticide treated bednets slowed the progression of HIV/AIDS. The validity of most studies is potentially compromised by methodological shortcomings.

CONCLUSION

No studies assessed the impact of improved water supply or sanitation, the most fundamental of WASH interventions. Despite some evidence that water quality interventions and handwashing are protective against diarrhoea, substantial heterogeneity and the potential for bias raise questions about the actual level of protection.

Systemic shigellosis in South Africa

BACKGROUND

Systemic disease due to shigellae is associated with human immunodeficiency virus (HIV), malnutrition, and other immunosuppressed states. We examined the clinical and microbiologic characteristics of systemic shigellosis in South Africa, where rates of HIV infection are high.

METHODS

From 2003 to 2009, 429 cases of invasive shigellosis were identified through national laboratory-based surveillance. At selected sites, additional information was captured on HIV serostatus and outcome. Isolates were serotyped and antimicrobial susceptibility testing performed.

RESULTS

Most cases of systemic shigellosis were diagnosed on blood culture (408 of 429 cases; 95%). HIV prevalence was 67% (80 of 120 cases), highest in patients aged 5-54 years, and higher among females (55 of 70 cases; 79%) compared with males (25 of 48 cases; 52%; P = .002). HIV-infected people were 4.1 times more likely to die than HIV-uninfected cases (case-fatality ratio, 29 of 78 HIV-infected people [37%] vs 5 of 40 HIV-uninfected people [13%]; P = .008; 95% confidence interval [CI], 1.5-11.8). The commonest serotype was Shigella flexneri 2a (89 of 292 serotypes [30.5%]). Pentavalent resistance occurred in 120 of 292 isolates (41.1%). There was no difference in multidrug resistance between HIV-infected patients (33 of 71 [46%]) and uninfected patients (12 of 33 [36%]; 95% CI, .65--3.55).

CONCLUSIONS

Systemic shigellosis is associated with HIV-infected patients, primarily in older girls and women, potentially due to the burden of caring for sick children in the home; interventions need to be targeted here. Death rates are higher in HIV-infected versus uninfected individuals.

Why disgust matters

The new synthesis about disgust is that it is a system that evolved to motivate infectious disease avoidance. There are vital practical and intellectual reasons why we need to understand disgust better. Practically, disgust can be harnessed to combat the behavioural causes of infectious and chronic disease such as diarrhoeal disease, pandemic flu and smoking. Disgust is also a source of much human suffering; it plays an underappreciated role in anxieties and phobias such as obsessive compulsive disorder, social phobia and post-traumatic stress syndromes; it is a hidden cost of many occupations such as caring for the sick and dealing with wastes, and self-directed disgust afflicts the lives of many, such as the obese and fistula patients. Disgust is used and abused in society, being both a force for social cohesion and a cause of prejudice and stigmatization of out-groups. This paper argues that a better understanding of disgust, using the new synthesis, offers practical lessons that can enhance human flourishing. Disgust also provides a model system for the study of emotion, one of the most important issues facing the brain and behavioural sciences today.

Treatment and prevention of cryptosporidiosis: what options are there for a country like Zambia?

Cryptosporidiosis is a major infection of humans, leading to diarrhoea and growth failure in children, diarrhoea and malnutrition in immunocompromised adults, and is associated with increased mortality in all age groups. Using the country of Zambia as an example, I review the possible approaches to treatment and prevention in a tropical setting. The current optimal therapy for cryptosporidiosis is nitazoxanide which works well in HIV uninfected children, but treatment in patients with HIV infection remains remarkably difficult. No single drug has demonstrated efficacy in a randomised trial. No vaccine is available, so the best option for prevention for the moment is filtration and clean storage of drinking water. This would be expected to reduce cryptosporidiosis dramatically, but this needs to be demonstrated directly. Water filtration would have the added benefit of protection against many other pathogens, but the paucity of alternative approaches highlights the need for a better understanding of this important human pathogen.

Planned, motivated and habitual hygiene behaviour: an eleven country review

Handwashing with soap (HWWS) may be one of the most cost-effective means of preventing infection in developing countries. However, HWWS is rare in these settings. We reviewed the results of formative research studies from 11 countries so as to understand the planned, motivated and habitual factors involved in HWWS. On average, only 17% of child caretakers HWWS after the toilet. Handwash 'habits' were generally not inculcated at an early age. Key 'motivations' for handwashing were disgust, nurture, comfort and affiliation. Fear of disease generally did not motivate handwashing, except transiently in the case of epidemics such as cholera. 'Plans' involving handwashing included to improve family health and to teach children good manners. Environmental barriers were few as soap was available in almost every household, as was water. Because much handwashing is habitual, self-report of the factors determining it is unreliable. Candidate strategies for promoting HWWS include creating social norms, highlighting disgust of dirty hands and teaching children HWWS as good manners. Dividing the factors that determine health-related behaviour into planned, motivated and habitual categories provides a simple, but comprehensive conceptual model. The habitual aspects of many health-relevant behaviours require further study.

A social marketing approach to building a behavioral intervention for congenital cytomegalovirus

Congenital cytomegalovirus (CMV) is the most common congenital infection in the United States, causing permanent disabilities in more than 5,500 children born each year. In the absence of a vaccine, a promising means of prevention is through a behavioral intervention that educates women about CMV and promotes adherence to hygiene guidelines during pregnancy. Although effective behavioral interventions have been identified for other infectious diseases with similar transmission modes, current research has not yet identified an effective intervention for CMV. One way to gather evidence and identify key elements of a successful CMV intervention is through a social marketing approach. This article describes a five-step process for applying social marketing principles to the research and development, implementation, and evaluation of a CMV behavioral intervention.

Amebic colitis: new insights into pathogenesis and treatment

Amebiasis, caused by the protozoan parasite Entamoeba histolytica, affects more than 50 million people worldwide, with over 100,000 deaths annually. The majority of cases are asymptomatic; however, significant morbidity and mortality are associated with illness in the remaining 10% of cases. Recent advances in the understanding of the mechanism of infection by E. histolytica, the role of the innate immune system, and the role of genetic disposition to infection will allow the development of novel detection and treatment methods. The disease mechanisms, clinical findings, therapeutic strategies, and important developments regarding amebiasis are discussed here.

Hand washing for preventing diarrhoea

BACKGROUND

Diarrhoea is a common cause of morbidity and a leading cause of death among children aged less than five years, particularly in low- and middle-income countries. It is transmitted by ingesting contaminated food or drink, by direct person-to-person contact, or from contaminated hands. Hand washing is one of a range of hygiene promotion interventions that can interrupt the transmission of diarrhoea-causing pathogens.

OBJECTIVES

To evaluate the effects of interventions to promote hand washing on diarrhoeal episodes in children and adults.

SEARCH STRATEGY

In May 2007, we searched the Cochrane Infectious Diseases Group Specialized Register, CENTRAL (The Cochrane Library 2007, Issue 2), MEDLINE, EMBASE, LILACS, PsycINFO, Science Citation Index and Social Science Citation Index, ERIC (1966 to May 2007), SPECTR, Bibliomap, RoRe, The Grey Literature, and reference lists of articles. We also contacted researchers and organizations in the field.

SELECTION CRITERIA

Randomized controlled trials, where the unit of randomization is an institution (eg day-care centre), household, or community, that compared interventions to promote hand washing or a hygiene promotion that included hand washing with no intervention to promote hand washing.

DATA COLLECTION AND ANALYSIS

Two authors independently assessed trial eligibility and methodological quality. Where appropriate, incidence rate ratios (IRR) were pooled using the generic inverse variance method and random-effects model with 95% confidence intervals (CI).

MAIN RESULTS

Fourteen randomized controlled trials met the inclusion criteria. Eight trials were institution-based, five were community-based, and one was in a high-risk group (AIDS patients). Interventions promoting hand washing resulted in a 29% reduction in diarrhoea episodes in institutions in high-income countries (IRR 0.71, 95% CI 0.60 to 0.84; 7 trials) and a 31% reduction in such episodes in communities in low- or middle-income countries (IRR 0.69, 95% CI 0.55 to 0.87; 5 trials).

AUTHORS' CONCLUSIONS

Hand washing can reduce diarrhoea episodes by about 30%. This significant reduction is comparable to the effect of providing clean water in low-income areas. However, trials with longer follow up and that test different methods of promoting hand washing are needed.