• 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)
    • Distribution of hygiene kits during a cholera outbreak in Kasaï-Oriental, Democratic Republic of Congo: a process evaluation.

      D'Mello-Guyett, L; Greenland, K; Bonneville, S; D'hondt, R; Mashako, M; Gorski, A; Verheyen, D; Van den Bergh, R; Maes, P; Checchi, F; et al. (BioMed Central, 2020-07-24)
      Background: Cholera remains a leading cause of infectious disease outbreaks globally, and a major public health threat in complex emergencies. Hygiene kits distributed to cholera case-households have previously shown an effect in reducing cholera incidence and are recommended by Médecins Sans Frontières (MSF) for distribution to admitted patients and accompanying household members upon admission to health care facilities (HCFs). Methods: This process evaluation documented the implementation, participant response and context of hygiene kit distribution by MSF during a 2018 cholera outbreak in Kasaï-Oriental, Democratic Republic of Congo (DRC). The study population comprised key informant interviews with seven MSF staff, 17 staff from other organisations and a random sample of 27 hygiene kit recipients. Structured observations were conducted of hygiene kit demonstrations and health promotion, and programme reports were analysed to triangulate data. Results and conclusions: Between Week (W) 28-48 of the 2018 cholera outbreak in Kasaï-Oriental, there were 667 suspected cholera cases with a 5% case fatality rate (CFR). Across seven HCFs supported by MSF, 196 patients were admitted with suspected cholera between W43-W47 and hygiene kit were provided to patients upon admission and health promotion at the HCF was conducted to accompanying household contacts 5-6 times per day. Distribution of hygiene kits was limited and only 52% of admitted suspected cholera cases received a hygiene kit. The delay of the overall response, delayed supply and insufficient quantities of hygiene kits available limited the coverage and utility of the hygiene kits, and may have diminished the effectiveness of the intervention. The integration of a WASH intervention for cholera control at the point of patient admission is a growing trend and promising intervention for case-targeted cholera responses. However, the barriers identified in this study warrant consideration in subsequent cholera responses and further research is required to identify ways to improve implementation and delivery of this intervention.
    • Does community-wide water chlorination reduce hepatitis E virus infections during an outbreak? A geospatial analysis of data from an outbreak in Am Timan, Chad (2016–2017)

      Lenglet, A; Ehlkes, L; Taylor, D; Fesselet, J-F; Nassariman, JN; Ahamat, A; Chen, A; Noh, I; Moustapha, A; Spina, A (IWA Publishing, 2020-06-02)
      Hepatitis E Virus (HEV) genotype 1 and 2 infect an estimated 20 million people each year, via the faecal-oral transmission route. An urban outbreak of HEV occurred in Am Timan, Chad, between September 2016 and April 2017. As part of the outbreak response, Médecins Sans Frontières and the Ministry of Health implemented water and hygiene interventions, including the chlorination of town water sources. We aimed to understand whether these water treatment activities had any impact on the number of HEV infections, using geospatial analysis of epidemiological and water treatment monitoring data. By conducting cluster analysis we investigated whether there were areas of particularly high and low infection risk during the outbreak and explored the reasons for this. We observed two high-risk spatial clusters of suspected cases and one high-risk cluster of confirmed cases. Our main finding was that confirmed HEV cases had a higher median number of days of exposure to unsafe water compared to suspected and non-confirmed cases (Kruskal-Wallis Chi Square: 15.5; p < 0.001). Our study confirms the mixed, but shifting, transmission routes during this outbreak. It also highlights the spatial and temporal analytical methods, which can be employed in future outbreaks to improve understanding of HEV transmission.
    • Does community-wide water chlorination reduce hepatitis E virus infections during an outbreak? a geospatial analysis of data from an outbreak in Am Timan, Chad (2016–2017)

      Lenglet, A; Ehlkes, L; Taylor, D; Fesselet, JF; Nassariman, JN; Ahamat, A; Chen, A; Noh, I; Moustapha, A; Spina, A; et al. (IWA Publishing, 2020-06-02)
      Hepatitis E Virus (HEV) genotype 1 and 2 infect an estimated 20 million people each year, via the faecal-oral transmission route. An urban outbreak of HEV occurred in Am Timan, Chad, between September 2016 and April 2017. As part of the outbreak response, Médecins Sans Frontières and the Ministry of Health implemented water and hygiene interventions, including the chlorination of town water sources. We aimed to understand whether these water treatment activities had any impact on the number of HEV infections, using geospatial analysis of epidemiological and water treatment monitoring data. By conducting cluster analysis we investigated whether there were areas of particularly high and low infection risk during the outbreak and explored the reasons for this. We observed two high-risk spatial clusters of suspected cases and one high-risk cluster of confirmed cases. Our main finding was that confirmed HEV cases had a higher median number of days of exposure to unsafe water compared to suspected and non-confirmed cases (Kruskal-Wallis Chi Square: 15.5; p < 0.001). Our study confirms the mixed, but shifting, transmission routes during this outbreak. It also highlights the spatial and temporal analytical methods, which can be employed in future outbreaks to improve understanding of HEV transmission.
    • 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.
    • Early detection of cholera epidemics to support control in fragile states: estimation of delays and potential epidemic sizes

      Ratnayake, R; Finger, F; Edmunds, WJ; Checchi, F (BMC, 2020-12-15)
      Background Cholera epidemics continue to challenge disease control, particularly in fragile and conflict-affected states. Rapid detection and response to small cholera clusters is key for efficient control before an epidemic propagates. To understand the capacity for early response in fragile states, we investigated delays in outbreak detection, investigation, response, and laboratory confirmation, and we estimated epidemic sizes. We assessed predictors of delays, and annual changes in response time. Methods We compiled a list of cholera outbreaks in fragile and conflict-affected states from 2008 to 2019. We searched for peer-reviewed articles and epidemiological reports. We evaluated delays from the dates of symptom onset of the primary case, and the earliest dates of outbreak detection, investigation, response, and confirmation. Information on how the outbreak was alerted was summarized. A branching process model was used to estimate epidemic size at each delay. Regression models were used to investigate the association between predictors and delays to response. Results Seventy-six outbreaks from 34 countries were included. Median delays spanned 1–2 weeks: from symptom onset of the primary case to presentation at the health facility (5 days, IQR 5–5), detection (5 days, IQR 5–6), investigation (7 days, IQR 5.8–13.3), response (10 days, IQR 7–18), and confirmation (11 days, IQR 7–16). In the model simulation, the median delay to response (10 days) with 3 seed cases led to a median epidemic size of 12 cases (upper range, 47) and 8% of outbreaks ≥ 20 cases (increasing to 32% with a 30-day delay to response). Increased outbreak size at detection (10 seed cases) and a 10-day median delay to response resulted in an epidemic size of 34 cases (upper range 67 cases) and < 1% of outbreaks < 20 cases. We estimated an annual global decrease in delay to response of 5.2% (95% CI 0.5–9.6, p = 0.03). Outbreaks signaled by immediate alerts were associated with a reduction in delay to response of 39.3% (95% CI 5.7–61.0, p = 0.03). Conclusions From 2008 to 2019, median delays from symptom onset of the primary case to case presentation and to response were 5 days and 10 days, respectively. Our model simulations suggest that depending on the outbreak size (3 versus 10 seed cases), in 8 to 99% of scenarios, a 10-day delay to response would result in large clusters that would be difficult to contain. Improving the delay to response involves rethinking the integration at local levels of event-based detection, rapid diagnostic testing for cluster validation, and integrated alert, investigation, and response.
    • 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.
    • Epidemiological, clinical, and public health response characteristics of a large outbreak of diphtheria among the Rohingya population in Cox's Bazar, Bangladesh, 2017 to 2019: A retrospective study.

      Polonsky, JA; Ivey, M; Mazhar, MKA; Rahman, Z; le Polain de Waroux, O; Karo, B; Jalava, K; Vong, S; Baidjoe, A; Diaz, J; et al. (Public Library of Science, 2021-04-01)
      Background Unrest in Myanmar in August 2017 resulted in the movement of over 700,000 Rohingya refugees to overcrowded camps in Cox’s Bazar, Bangladesh. A large outbreak of diphtheria subsequently began in this population. Methods and findings Data were collected during mass vaccination campaigns (MVCs), contact tracing activities, and from 9 Diphtheria Treatment Centers (DTCs) operated by national and international organizations. These data were used to describe the epidemiological and clinical features and the control measures to prevent transmission, during the first 2 years of the outbreak. Between November 10, 2017 and November 9, 2019, 7,064 cases were reported: 285 (4.0%) laboratory-confirmed, 3,610 (51.1%) probable, and 3,169 (44.9%) suspected cases. The crude attack rate was 51.5 cases per 10,000 person-years, and epidemic doubling time was 4.4 days (95% confidence interval [CI] 4.2–4.7) during the exponential growth phase. The median age was 10 years (range 0–85), and 3,126 (44.3%) were male. The typical symptoms were sore throat (93.5%), fever (86.0%), pseudomembrane (34.7%), and gross cervical lymphadenopathy (GCL; 30.6%). Diphtheria antitoxin (DAT) was administered to 1,062 (89.0%) out of 1,193 eligible patients, with adverse reactions following among 229 (21.6%). There were 45 deaths (case fatality ratio [CFR] 0.6%). Household contacts for 5,702 (80.7%) of 7,064 cases were successfully traced. A total of 41,452 contacts were identified, of whom 40,364 (97.4%) consented to begin chemoprophylaxis; adherence was 55.0% (N = 22,218) at 3-day follow-up. Unvaccinated household contacts were vaccinated with 3 doses (with 4-week interval), while a booster dose was administered if the primary vaccination schedule had been completed. The proportion of contacts vaccinated was 64.7% overall. Three MVC rounds were conducted, with administrative coverage varying between 88.5% and 110.4%. Pentavalent vaccine was administered to those aged 6 weeks to 6 years, while tetanus and diphtheria (Td) vaccine was administered to those aged 7 years and older. Lack of adequate diagnostic capacity to confirm cases was the main limitation, with a majority of cases unconfirmed and the proportion of true diphtheria cases unknown. Conclusions To our knowledge, this is the largest reported diphtheria outbreak in refugee settings. We observed that high population density, poor living conditions, and fast growth rate were associated with explosive expansion of the outbreak during the initial exponential growth phase. Three rounds of mass vaccinations targeting those aged 6 weeks to 14 years were associated with only modestly reduced transmission, and additional public health measures were necessary to end the outbreak. This outbreak has a long-lasting tail, with Rt oscillating at around 1 for an extended period. An adequate global DAT stockpile needs to be maintained. All populations must have access to health services and routine vaccination, and this access must be maintained during humanitarian crises.
    • 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, RF; 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.
    • Evidence-based chlorination targets for household water safety in humanitarian settings: Recommendations from a multi-site study in refugee camps in South Sudan, Jordan, and Rwanda

      Ali, SI; Ali, SS; Fesselet, JF (Elsevier, 2020-11-16)
      The current Sphere guideline for water chlorination in humanitarian emergencies fails to reliably ensure household water safety in refugee camps. We investigated post-distribution chlorine decay and household water safety in refugee camps in South Sudan, Jordan, and Rwanda between 2013-2015 with the goal of demonstrating an approach for generating site-specific and evidence-based chlorination targets that better ensure household water safety than the status quo Sphere guideline. In each of four field studies we conducted, we observed how water quality changed between distribution and point of consumption. We implemented a nonlinear optimization approach for the novel technical challenge of modelling post-distribution chlorine decay in order to generate estimates on what free residual chlorine (FRC) levels must be at water distribution points, in order to provide adequate FRC protection up to the point of consumption in households many hours later at each site. The site-specific FRC targets developed through this modelling approach improved the proportion of households having sufficient chlorine residual (i.e., ≥0.2 mg/L FRC) at the point of consumption in three out of four field studies (South Sudan 2013, Jordan 2014, and Rwanda 2015). These sites tended to be hotter (i.e., average mid-afternoon air temperatures >30°C) and/or had poorer water, sanitation, and hygiene (WASH) conditions, contributing to considerable chlorine decay between distribution and consumption. Our modelling approach did not work as well where chlorine decay was small in absolute terms (Jordan 2015). In such settings, which were cooler (20 to 30°C) and had better WASH conditions, we found that the upper range of the current Sphere chlorination guideline (i.e., 0.5 mg/L FRC) provided sufficient residual chlorine for ensuring household water safety up to 24 hours post-distribution. Site-specific and evidence-based chlorination targets generated from post-distribution chlorine decay modelling could help improve household water safety and public health outcomes in refugee camp settings where the current Sphere chlorination guideline does not provide adequate residual protection. Water quality monitoring in refugee/IDP camps should shift focus from distribution points to household points of consumption in order to monitor if the intended public health goal of safe water at the point of consumption is being achieved.
    • Evidence-based chlorination targets for household water safety in humanitarian settings: Recommendations from a multi-site study in refugee camps in South Sudan, Jordan, and Rwanda.

      Dahdaleh Institute for Global Health Research, York University, 88 The Pond Road, M3J 1P3, Toronto, Canada; Médecins sans Frontières, Plantage Middenlaan 14, 1018 DD Amsterdam, Netherlands; Development Impact Lab, University of California, Berkeley, Blum Hall #5570, Berkeley, CA, USA. Electronic address: siali@yorku.ca. 2Dahdaleh Institute for Global Health Research, York University, 88 The Pond Road, M3J 1P3, Toronto, Canada. 3Médecins sans Frontières, Plantage Middenlaan 14, 1018 DD Amsterdam, Netherland (2020-11-16)
      The current Sphere guideline for water chlorination in humanitarian emergencies fails to reliably ensure household water safety in refugee camps. We investigated post-distribution chlorine decay and household water safety in refugee camps in South Sudan, Jordan, and Rwanda between 2013-2015 with the goal of demonstrating an approach for generating site-specific and evidence-based chlorination targets that better ensure household water safety than the status quo Sphere guideline. In each of four field studies we conducted, we observed how water quality changed between distribution and point of consumption. We implemented a nonlinear optimization approach for the novel technical challenge of modelling post-distribution chlorine decay in order to generate estimates on what free residual chlorine (FRC) levels must be at water distribution points, in order to provide adequate FRC protection up to the point of consumption in households many hours later at each site. The site-specific FRC targets developed through this modelling approach improved the proportion of households having sufficient chlorine residual (i.e., ≥0.2 mg/L FRC) at the point of consumption in three out of four field studies (South Sudan 2013, Jordan 2014, and Rwanda 2015). These sites tended to be hotter (i.e., average mid-afternoon air temperatures >30°C) and/or had poorer water, sanitation, and hygiene (WASH) conditions, contributing to considerable chlorine decay between distribution and consumption. Our modelling approach did not work as well where chlorine decay was small in absolute terms (Jordan 2015). In such settings, which were cooler (20 to 30°C) and had better WASH conditions, we found that the upper range of the current Sphere chlorination guideline (i.e., 0.5 mg/L FRC) provided sufficient residual chlorine for ensuring household water safety up to 24 hours post-distribution. Site-specific and evidence-based chlorination targets generated from post-distribution chlorine decay modelling could help improve household water safety and public health outcomes in refugee camp settings where the current Sphere chlorination guideline does not provide adequate residual protection. Water quality monitoring in refugee/IDP camps should shift focus from distribution points to household points of consumption in order to monitor if the intended public health goal of safe water at the point of consumption is being achieved.
    • 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.
    • Hand hygiene compliance and environmental contamination with gram-negative bacilli in a rural hospital in Madarounfa, Niger

      Tang, K; Berthe, F; Nackers, F; Hanson, K; Mambula, C; Langendorf, C; Marquer, C; Isanaka, S (Oxford University Press, 2019-10-14)
      Background Healthcare-associated infections pose a major, yet often preventable risk to patient safety. Poor hand hygiene among healthcare personnel and unsanitary hospital environments may contribute to this risk in low-income settings. We aimed to describe hand hygiene behaviour and environmental contamination by season in a rural, sub-Saharan African hospital setting. Methods We conducted a concurrent triangulation mixed-methods study combining three types of data at a hospital in Madarounfa, Niger. Hand hygiene observations among healthcare personnel during two seasons contributed quantitative data describing hand hygiene frequency and its variability in relation to seasonal changes in caseload. Semistructured interviews with healthcare personnel contributed qualitative data on knowledge, attitudes and barriers to hand hygiene. Biweekly environmental samples evaluated microbial contamination from October 2016 to December 2017. Triangulation identified convergences, complements and contradictions across results. Results Hand hygiene compliance, or the proportion of actions (handrubbing or handwashing) performed out of all actions required, was low (11% during non-peak and 36% during peak caseload seasons). Interviews with healthcare personnel suggesting good general knowledge of hand hygiene contradicted the low hand hygiene compliance. However, compliance by healthcare activity was convergent with poor knowledge of precise hand hygiene steps and the motivation to prevent personal acquisition of infection identified during interviews. Contamination of environmental samples with gram-negative bacilli was high (45%), with the highest rates of contamination observed during the peak caseload season. Conclusion Low hand hygiene compliance coupled with high contamination rates of hospital environments may increase the risk of hospital-acquired infections in sub-Saharan African settings.
    • Highly targeted spatiotemporal interventions against cholera epidemics, 2000–19: a scoping review

      Ratnayake, R; Finger, F; Azman, AS; Lantagne, D; Funk, S; Edmunds, WJ; Checchi, F (Elsevier, 2020-10-20)
      Globally, cholera epidemics continue to challenge disease control. Although mass campaigns covering large populations are commonly used to control cholera, spatial targeting of case households and their radius is emerging as a potentially efficient strategy. We did a Scoping Review to investigate the effectiveness of interventions delivered through case-area targeted intervention, its optimal spatiotemporal scale, and its effectiveness in reducing transmission. 53 articles were retrieved. We found that antibiotic chemoprophylaxis, point-of-use water treatment, and hygiene promotion can rapidly reduce household transmission, and single-dose vaccination can extend the duration of protection within the radius of households. Evidence supports a high-risk spatiotemporal zone of 100 m around case households, for 7 days. Two evaluations separately showed reductions in household transmission when targeting case households, and in size and duration of case clusters when targeting radii. Although case-area targeted intervention shows promise for outbreak control, it is critically dependent on early detection capacity and requires prospective evaluation of intervention packages.
    • 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.
    • Inclusion of Real-Time Hand Hygiene Observation and Feedback in a Multimodal Hand Hygiene Improvement Strategy in Low-Resource Settings.

      Lenglet, A; van Deursen, B; Viana, R; Abubakar, N; Hoare, S; Murtala, A; Okanlawon, M; Osatogbe, J; Emeh, V; Gray, N; et al. (JAMA, 2019-08-02)
      IMPORTANCE: Hand hygiene adherence monitoring and feedback can reduce health care-acquired infections in hospitals. Few low-cost hand hygiene adherence monitoring tools exist in low-resource settings. OBJECTIVE: To pilot an open-source application for mobile devices and an interactive analytical dashboard for the collection and visualization of health care workers' hand hygiene adherence data. DESIGN, SETTING, AND PARTICIPANTS: This prospective multicenter quality improvement study evaluated preintervention and postintervention adherence with the 5 Moments for Hand Hygiene, as suggested by the World Health Organization, among health care workers from April 23 to May 25, 2018. A novel data collection form, the Hand Hygiene Observation Tool, was developed in open-source software and used to measure adherence with hand hygiene guidelines among health care workers in the inpatient therapeutic feeding center and pediatric ward of Anka General Hospital, Anka, Nigeria, and the postoperative ward of Noma Children's Hospital, Sokoto, Nigeria. Qualitative data were analyzed throughout data collection and used for immediate feedback to staff. A more formal analysis of the data was conducted during October 2018. EXPOSURES: Multimodal hand hygiene improvement strategy with increased availability and accessibility of alcohol-based hand sanitizer, staff training and education, and evaluation and feedback in near real-time. MAIN OUTCOMES AND MEASURES: Hand hygiene adherence before and after the intervention in 3 hospital wards, stratified by health care worker role, ward, and moment of hand hygiene. RESULTS: A total of 686 preintervention adherence observations and 673 postintervention adherence observations were conducted. After the intervention, overall hand hygiene adherence increased from 32.4% to 57.4%. Adherence increased in both wards in Anka General Hospital (inpatient therapeutic feeding center, 24.3% [54 of 222 moments] to 63.7% [163 of 256 moments]; P < .001; pediatric ward, 50.9% [132 of 259 moments] to 68.8% [135 of 196 moments]; P < .001). Adherence among nurses in Anka General Hospital also increased in both wards (inpatient therapeutic feeding center, 17.7% [28 of 158 moments] to 71.2% [79 of 111 moments]; P < .001; pediatric ward, 45.9% [68 of 148 moments] to 68.4% [78 of 114 moments]; P < .001). In Noma Children's Hospital, the overall adherence increased from 17.6% (36 of 205 moments) to 39.8% (88 of 221 moments) (P < .001). Adherence among nurses in Noma Children's Hospital increased from 11.5% (14 of 122 moments) to 61.4% (78 of 126 moments) (P < .001). Adherence among Noma Children's Hospital physicians decreased from 34.2% (13 of 38 moments) to 8.6% (7 of 81 moments). Lowest overall adherence after the intervention occurred before patient contact (53.1% [85 of 160 moments]), before aseptic procedure (58.3% [21 of 36 moments]), and after touching a patient's surroundings (47.1% [124 of 263 moments]). CONCLUSIONS AND RELEVANCE: This study suggests that tools for the collection and rapid visualization of hand hygiene adherence data are feasible in low-resource settings. The novel tool used in this study may contribute to comprehensive infection prevention and control strategies and strengthening of hand hygiene behavior among all health care workers in health care facilities in humanitarian and low-resource settings.
    • 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; et al. (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.
    • Prevention and control of cholera with household and community water, sanitation and hygiene (WASH) interventions: A scoping review of current international guidelines.

      D'Mello-Guyett, L; Gallandat, K; Van den Bergh, R; Taylor, D; Bulit, G; Legros, D; Maes, P; Checchi, F; Cumming, O (Public Library of Science, 2020-01-08)
      INTRODUCTION: Cholera remains a frequent cause of outbreaks globally, particularly in areas with inadequate water, sanitation and hygiene (WASH) services. Cholera is spread through faecal-oral routes, and studies demonstrate that ingestion of Vibrio cholerae occurs from consuming contaminated food and water, contact with cholera cases and transmission from contaminated environmental point sources. WASH guidelines recommending interventions for the prevention and control of cholera are numerous and vary considerably in their recommendations. To date, there has been no review of practice guidelines used in cholera prevention and control programmes. METHODS: We systematically searched international agency websites to identify WASH intervention guidelines used in cholera programmes in endemic and epidemic settings. Recommendations listed in the guidelines were extracted, categorised and analysed. Analysis was based on consistency, concordance and recommendations were classified on the basis of whether the interventions targeted within-household or community-level transmission. RESULTS: Eight international guidelines were included in this review: three by non-governmental organisations (NGOs), one from a non-profit organisation (NPO), three from multilateral organisations and one from a research institution. There were 95 distinct recommendations identified, and concordance among guidelines was poor to fair. All categories of WASH interventions were featured in the guidelines. The majority of recommendations targeted community-level transmission (45%), 35% targeted within-household transmission and 20% both. CONCLUSIONS: Recent evidence suggests that interventions for effective cholera control and response to epidemics should focus on case-centred approaches and within-household transmission. Guidelines did consistently propose interventions targeting transmission within households. However, the majority of recommendations listed in guidelines targeted community-level transmission and tended to be more focused on preventing contamination of the environment by cases or recurrent outbreaks, and the level of service required to interrupt community-level transmission was often not specified. The guidelines in current use were varied and interpretation may be difficult when conflicting recommendations are provided. Future editions of guidelines should reflect on the inclusion of evidence-based approaches, cholera transmission models and resource-efficient strategies.