• Acting on an Environmental Health Disaster: The Case of the Aral Sea.

      Small, I; van der Meer, J; Upshur, R; Uzbekistan/Turkmenistan and the Aral Sea Area Program, Medecins Sans Frontieres, Tashkent, Uzbekistan. msfh-tashkent@amsterdam.msf.org (Published by National Institute of Environmental Health Sciences, 2001-06)
      The Aral Sea area in Central Asia has been encountering one of the world's greatest environmental disasters for more than 15 years. During that time, despite many assessments and millions of dollars spent by large, multinational organizations, little has changed. The 5 million people living in this neglected and virtually unknown part of the world are suffering not only from an environmental catastrophe that has no easy solutions but also from a litany of health problems. The region is often dismissed as a chronic problem where nothing positive can be achieved. Within this complicated context, Medecins Sans Frontieres, winner of the Nobel Peace Prize in 1999, is actively trying to assess the impact of the environmental disaster on human health to help the people who live in the Aral Sea area cope with their environment. Medecins Sans Frontieres has combined a direct medical program to improve the health of the population while conducting operational research to gain a better understanding of the relationship between the environmental disaster and human health outcomes. In this paper we explore the health situation of the region and the broader policy context in which it is situated, and present some ideas that could potentially be applied to many other places in the world that are caught up in environmental and human health disasters.
    • Biodegradable bags as emergency sanitation in urban settings: the field experience

      Coloni, F; van den Bergh, R; Sittaro, F; Giandonato, S; Loots, G; Maes, P (2012-01)
    • Does Village Water Supply Affect Children's Length of Stay in a Therapeutic Feeding Program in Niger? Lessons from a Médecins Sans Frontières Program.

      Dorion, C; Hunter, P R; Van den Bergh, R; Roure, C; Delchevalerie, P; Reid, T; Maes, P; Médecins Sans Frontières, Operational Center Barcelona, Barcelona, Spain. (2012-12)
      With an increasing move towards outpatient therapeutic feeding for moderately and severely malnourished children, the home environment has become an increasingly important factor in achieving good program outcomes. Infections, including those water-borne, may significantly delay weight gain in a therapeutic feeding program. This study examined the relationship between adequacy of water supply and children's length of stay in a therapeutic feeding program in Niger.
    • Effectiveness of Emergency Water Treatment Practices in Refugee Camps in South Sudan

      Ali, SI; Ali, SS; Fesselet, JF (World Health Organization, 2015-08-01)
      To investigate the concentration of residual chlorine in drinking water supplies in refugee camps, South Sudan, March-April 2013.
    • Evaluation and use of surveillance system data toward the identification of high-risk areas for potential cholera vaccination: a case study from Niger.

      Guerra, J; Mayana, B; Djibo, A; Manzo, M L; Llosa, A E; Grais, R; Epicentre-8, Rue St-Sabin, 75011 Paris, France; Direction régionale de la Santé Publique, Maradi, Niger; Faculté des sciences de la santé, Université de Niamey, Niamey, Niger. (2012-05)
      In 2008, Africa accounted for 94% of the cholera cases reported worldwide. Although the World Health Organization currently recommends the oral cholera vaccine in endemic areas for high-risk populations, its use in Sub-Saharan Africa has been limited. Here, we provide the principal results of an evaluation of the cholera surveillance system in the region of Maradi in Niger and an analysis of its data towards identifying high-risk areas for cholera.
    • Factors affecting continued use of ceramic water purifiers distributed to Tsunami-affected Communities in Sri Lanka

      Casanova, L M; Walters, A; Naghawatte, A; Sobsey, M D; Institute of Public Health, Georgia State University, Atlanta, GA, USA  Medecins Sans Frontieres, New York, NY, USA  Department of Microbiology, Faculty of Medicine, University of Ruhuna, Galle, Sri Lanka  Department of Environmental Sciences and Engineering, University of North Carolina Chapel Hill, Chapel Hill, NC, USA. (2012-09-24)
      Objectives  There is little information about continued use of point-of-use technologies after disaster relief efforts. After the 2004 tsunami, the Red Cross distributed ceramic water filters in Sri Lanka. This study determined factors associated with filter disuse and evaluate the quality of household drinking water. Methods  A cross-sectional survey of water sources and treatment, filter use and household characteristics was administered by in-person oral interview, and household water quality was tested. Multivariable logistic regression was used to model probability of filter non-use. Results  At the time of survey, 24% of households (107/452) did not use filters; the most common reason given was breakage (42%). The most common household water sources were taps and wells. Wells were used by 45% of filter users and 28% of non-users. Of households with taps, 75% had source water Escherichia coli in the lowest World Health Organisation risk category (<1/100 ml), vs. only 30% of households reporting wells did. Tap households were approximately four times more likely to discontinue filter use than well households. Conclusion  After 2 years, 24% of households were non-users. The main factors were breakage and household water source; households with taps were more likely to stop use than households with wells. Tap water users also had higher-quality source water, suggesting that disuse is not necessarily negative and monitoring of water quality can aid decision-making about continued use. To promote continued use, disaster recovery filter distribution efforts must be joined with capacity building for long-term water monitoring, supply chains and local production.
    • Household fish preparation hygiene and cholera transmission in Monrovia, Liberia.

      Scheelbeek, P; Treglown, S; Reid, T; Maes, P; Médecins Sans Frontières Belgium, Brussels, Belgium. Pauline.Scheelbeek@gmail.com (2009-07)
      BACKGROUND: In the 1980s Vibrio cholerae was found to be an autochthonous resident of aquatic environments. As result, ingestion of undercooked, contaminated fish has been associated with cholera transmission. An alternative mechanism of transmission associated with fish was hypothesised by Schürmann et al. in 2002. He described a cholera case that was more likely to have been infected by contamination on the patient's hands rather than by ingestion of contaminated fish. METHODOLOGY: With fish being the main diet in Liberia, we decided to examine fish samples and preparation techniques in Monrovia. Excreta of 15 fish, caught in the estuarine waters of Monrovia, were analysed for V. cholerae. In addition, fish preparation methods were observed in 30 households. RESULTS: Two fish samples were found positive. Observations revealed that hygiene measures during the gutting process of fish were limited; although hands were usually rinsed, in all cases soap was not used. Furthermore, contaminated water was frequently reused during food preparation. CONCLUSIONS: Since the cooking process of fish (and thus elimination of bacteria) in Monrovia usually consists of both frying and boiling, it seems plausible that in this context, the hypothesis by Schürmann et al. could be applicable. Further research is necessary to confirm this association, which could be a starting point for more context-specific health education campaigns addressing food preparation hygiene as risk factor for cholera.
    • Learning from water treatment and hygiene interventions in response to a hepatitis E outbreak in an open setting in Chad

      Spina, A; Beversluis, D; Irwin, A; Chen, A; Nassariman, JN; Ahamat, A; Noh, I; Oosterloo, J; Alfani, P; Sang, S; Lenglet, A; Taylor, DL (IWA Publishing, 2018-04)
      In September 2016, Médecins Sans Frontières responded to a hepatitis E (HEV) outbreak in Chad by implementing water treatment and hygiene interventions. To evaluate the coverage and use of these interventions, we conducted a cross-sectional study in the community. Our results showed that 99% of households interviewed had received a hygiene kit from us, aimed at improving water handling practice and personal hygiene and almost all respondents had heard messages about preventing jaundice and handwashing. Acceptance of chlorination of drinking water was also very high, although at the time of interview, we were only able to measure a safe free residual chlorine level (free chlorine residual (FRC) ≥0.2 mg/L) in 43% of households. Households which had refilled water containers within the last 18 hours, had sourced water from private wells or had poured water into a previously empty container, were all more likely to have a safe FRC level. In this open setting, we were able to achieve high coverage for chlorination, hygiene messaging and hygiene kit ownership; however, a review of our technical practice is needed in order to maintain safe FRC levels in drinking water in households, particularly when water is collected from multiple sources, stored and mixed with older water.
    • Minimizing the Risk of Disease Transmission in Emergency Settings: Novel In Situ Physico-Chemical Disinfection of Pathogen-Laden Hospital Wastewaters

      Sozzi, E; Fabre, K; Fesselet, J-F; Ebdon, J E; Taylor, H (Public Library of Science, 2015-06-25)
      The operation of a health care facility, such as a cholera or Ebola treatment center in an emergency setting, results in the production of pathogen-laden wastewaters that may potentially lead to onward transmission of the disease. The research presented here evaluated the design and operation of a novel treatment system, successfully used by Médecins Sans Frontières in Haiti to disinfect CTC wastewaters in situ, eliminating the need for road haulage and disposal of the waste to a poorly-managed hazardous waste facility, thereby providing an effective barrier to disease transmission through a novel but simple sanitary intervention. The physico-chemical protocols eventually successfully treated over 600 m3 of wastewater, achieving coagulation/flocculation and disinfection by exposure to high pH (Protocol A) and low pH (Protocol B) environments, using thermotolerant coliforms as a disinfection efficacy index. In Protocol A, the addition of hydrated lime resulted in wastewater disinfection and coagulation/flocculation of suspended solids. In Protocol B, disinfection was achieved by the addition of hydrochloric acid, followed by pH neutralization and coagulation/flocculation of suspended solids using aluminum sulfate. Removal rates achieved were: COD >99%; suspended solids >90%; turbidity >90% and thermotolerant coliforms >99.9%. The proposed approach is the first known successful attempt to disinfect wastewater in a disease outbreak setting without resorting to the alternative, untested, approach of 'super chlorination' which, it has been suggested, may not consistently achieve adequate disinfection. A basic analysis of costs demonstrated a significant saving in reagent costs compared with the less reliable approach of super-chlorination. The proposed approach to in situ sanitation in cholera treatment centers and other disease outbreak settings represents a timely response to a UN call for onsite disinfection of wastewaters generated in such emergencies, and the 'Coalition for Cholera Prevention and Control' recently highlighted the research as meriting serious consideration and further study. Further applications of the method to other emergency settings are being actively explored by the authors through discussion with the World Health Organization with regards to the ongoing Ebola outbreak in West Africa, and with the UK-based NGO Oxfam with regards to excreta-borne disease management in the Philippines and Myanmar, as a component of post-disaster incremental improvements to local sanitation chains.
    • Risk factors for cholera transmission in Haiti during inter-peak periods: insights to improve current control strategies from two case-control studies

      Grandesso, F; Allan, M; Jean-Simon, P S J; Boncy, J; Blake, A; Pierre, R; Alberti, K P; Munger, A; Elder, G; Olson, D; Porten, K; Luquero, F J; Epicentre, Paris, France. (Cambridge University Press, 2013-10-11)
      SUMMARY Two community-based density case-control studies were performed to assess risk factors for cholera transmission during inter-peak periods of the ongoing epidemic in two Haitian urban settings, Gonaives and Carrefour. The strongest associations were: close contact with cholera patients (sharing latrines, visiting cholera patients, helping someone with diarrhoea), eating food from street vendors and washing dishes with untreated water. Protective factors were: drinking chlorinated water, receiving prevention messages via television, church or training sessions, and high household socioeconomic level. These findings suggest that, in addition to contaminated water, factors related to direct and indirect inter-human contact play an important role in cholera transmission during inter-peak periods. In order to reduce cholera transmission in Haiti intensive preventive measures such as hygiene promotion and awareness campaigns should be implemented during inter-peak lulls, when prevention activities are typically scaled back.
    • Safe Water for the Aral Sea Area: Could it get Any Worse?

      Small, I; Falzon, D; van der Meer, J; Ford, N; Médecins Sans Frontières, Aral Sea Programme, Tashkent, Uzbekistan. (Published by Oxford University Press, 2003-03)
      The environmental adversities around the Aral Sea in Central Asia have been the subject of recent research. Attempts at sustainable provision of palatable drinking water in low chemical and microbial contaminants for the 4 million people in the two countries around the Aral littoral have been largely unsuccessful. In the last few years, severe drought has further depleted the amount of available water. This shortage has negatively impacted on agriculture, and accentuated the out migration of people. An appeal is made to assist the local population in this arid area to cope with the acute and chronic deterioration of water security.
    • Setting priorities for humanitarian water, sanitation and hygiene research: a meeting report

      D’Mello-Guyett, L; Yates, T; Bastable, A; Dahab, M; Deola, C; Dorea, C; Dreibelbis, R; Grieve, T; Handzel, T; Harmer, A; Lantagne, D; Maes, P; Opryszko, M; Palmer-Felgate, S; Reed, B; Van Den Bergh, R; Porteaud, D; Cumming, O (BioMed Central, 2018-06-15)
    • A tale of two cities: restoring water services in Kabul and Monrovia

      Pinera, J-F; Reed, R A; Médecins Sans Frontières, Amsterdam, Netherlands; Water Engineering and Development Centre, Loughborough University, United Kingdom (2009-01-12)
      Kabul and Monrovia, the respective capitals of Afghanistan and Liberia, have recently emerged from long-lasting armed conflicts. In both cities, a large number of organisations took part in emergency water supply provision and later in the rehabilitation of water systems. Based on field research, this paper establishes a parallel between the operations carried out in the two settings, highlighting similarities and analysing the two most common strategies. The first strategy involves international financial institutions, which fund large-scale projects focusing on infrastructural rehabilitation and on the institutional development of the water utility, sometimes envisaging private-sector participation. The second strategy involves humanitarian agencies, which run community-based projects, in most cases independently of the water utilities, and targeting low-income areas. Neither of these approaches manages to combine sustainability and universal service. The paper assesses their respective strengths and weaknesses and suggests ways of improving the quality of assistance provided.
    • Uptake of household disinfection kits as an additional measure in response to a cholera outbreak in urban areas of Haiti

      Gartley, M; Valeh, P; de Lange, R; DiCarlo, S; Viscusi, A; Lenglet, A; Fesselet, J F (IWA Publishing, 2013-12)
      Médecins Sans Frontières-Operational Centre Amsterdam piloted the distribution of household disinfection kits (HDKs) and health promotion sessions for cholera prevention in households of patients admitted to their cholera treatment centres in Carrefour, Port au Prince, Haiti, between December 2010 and February 2011. We conducted a follow-up survey with 208 recipient households to determine the uptake and use of the kits and understanding of the health promotion messages. In 61% of surveyed households, a caregiver had been the recipient of the HDK and 57.7% of households had received the HDKs after the discharge of the patient. Among surveyed households, 97.6% stated they had used the contents of the HDK after receiving it, with 75% of these reporting using five or more items, with the two most popular items being chlorine and soap. A significant (p < 0.05) increase in self-reported use items in the HDK was observed in households that received kits after 24 January 2011 when the education messages were strengthened. To our knowledge, this is the first time it has been demonstrated that during a large-scale cholera outbreak, the distribution of simple kits, with readily available cleaning products and materials, combined with health promotion is easy, feasible, and valued by the target population.
    • Using Lot Quality Assurance Sampling to Assess Access to Water, Sanitation and Hygiene Services in a Refugee Camp Setting in South Sudan: A Feasibility Study

      Harding, E; Beckworth, C; Fesselet, J; Lenglet, A; Lako, R; Valadez, J (BioMed Central, 2017-08-08)
      Humanitarian agencies working in refugee camp settings require rapid assessment methods to measure the needs of the populations they serve. Due to the high level of dependency of refugees, agencies need to carry out these assessments. Lot Quality Assurance Sampling (LQAS) is a method commonly used in development settings to assess populations living in a project catchment area to identify their greatest needs. LQAS could be well suited to serve the needs of refugee populations, but it has rarely been used in humanitarian settings. We adapted and implemented an LQAS survey design in Batil refugee camp, South Sudan in May 2013 to measure the added value of using it for sub-camp level assessment.