Water, sanitation, hygiene practices, health and nutritional status among children before and during the COVID-19 pandemic: longitudinal evidence from remote areas of Dailekh and Achham districts in Nepal.

BACKGROUND: The COVID-19 pandemic drew hygiene to the center of disease prevention. The provision of adequate water, sanitation, and hygiene (WASH) services is crucial to protect public health during a pandemic. Yet, access to levels of water supply that support adequate hygiene measures are deficient in many areas in Nepal. We examined WASH practices and their impact on child health and nutritional status in two districts before and during the COVID-19 pandemic. METHODS: A longitudinal and mixed method study was conducted in March-May 2018 and November-December 2021. In total, 715 children aged 0-10 years were surveyed at baseline. Of these, 490 children were assessed at endline. Data collection methods included observations, a questionnaire, stool analysis, anthropometric measurements, water quality analysis, and an assessment of clinical signs of nutritional deficiencies. We conducted 10 in-depth interviews to understand major problems related to COVID-19. RESULTS: Most respondents (94.2%) had heard about COVID-19; however, they did not wear face masks or comply with any social distancing protocols. Almost 94.2% of the households self-reported handwashing with soap 5-10 times per day at endline, especially after defecation, compared to 19.6% at baseline. Water quality was better at endline than at baseline with median 12 to 29 CFU Escherichia coli/100 mL (interquartile range at baseline [IQR] = 4-101) at the point of collection and 34 to 51.5 CFU Escherichia coli/100 mL (IQR = 8-194) at the point of consumption. Fever (41.1-16.8%; p = 0.01), respiratory illness (14.3-4.3%; p = 0.002), diarrhea (19.6-9.5%; p = 0.01), and Giardia lamblia infections (34.2-6.5%, p = 0.01) decreased at endline. In contrast, nutritional deficiencies such as bitot's spots (26.7-40.2%; p = 0.01), pale conjunctiva (47.0-63.3%; p = 0.01), and dermatitis (64.8-81.4%; p = 0.01) increased at endline. The inadequacy of the harvest and the lack of household income to meet households' nutritional needs increased drastically (35.0-94.2%; p = 0.01). CONCLUSION: We found that improved water quality and handwashing practices were associated with a decrease in infectious diseases. However, food security also decreased resulting in a high prevalence of nutritional deficiencies. Our findings underline that disaster preparedness should consider access to adequate WASH, nutrition, and health supplies.

Assessing Access to WASH in Urban Schools during COVID-19 in Kazakhstan: Case Study of Central Kazakhstan.

The WHO/UNICEF Joint Monitoring Program (JMP) for Water Supply, Sanitation and Hygiene (WASH) produces global estimates of the real situation of access to water, sanitation and hygiene services, and sanitation and hygiene in households, educational institutes and health care facilities; however it is lacking data on schools in Kazakhstan. Thus, the aim of this research was to assess access to WASH in schools of urban area in Kazakhstan. The study was conducted in seven schools of Central Kazakhstan during the COVID-19 pandemic and restrictive measures. Three data collection methods were used: a questionnaire for administrative staff, a questionnaire for parents and observation. Parents of offline study pupils (only second and third grades due to the pandemic) were included in the survey. Students had access to in-building toilets in all schools connected to the centralized sewer. The number of school toilets varied from 7 (KAZ200085) to 61 (KAZ200089). The average amount of toilets was 28.08 ± 16.97. Only two out of seven schools complied with the requirements of Kazakhstan national sanitary standards for the ratio of school toilets to the number of students. From the questionnaire with the school administrations, it was defined that the primary source of drinking water was the public water supply. All schools regularly disinfect and check the water supply system. At the same time, the results also revealed discrepancies in the answers between administration and parents (2.6% of parents showed that their children have rare access to drinking water), and insufficient monitoring of implementation of WASH services. This study also confirmed that the full provision of access to water and water services in the structure of educational institutions solves several SDG targets.

Access to and challenges in water, sanitation, and hygiene in healthcare facilities during the early phase of the COVID-19 pandemic in Ethiopia: A mixed-methods evaluation.

BACKGROUND: Inadequate water, sanitation, and hygiene (WASH) in healthcare facilities (HCFs) have an impact on the transmission of infectious diseases, including COVID-19 pandemic. But, there is limited data on the status of WASH facilities in the healthcare settings of Ethiopia. Therefore, this study aimed to assess WASH facilities and related challenges in the HCFs of Northeastern Ethiopia during the early phase of COVID-19 pandemic. METHODS: An institution-based cross-sectional study was conducted from July to August 2020. About 70 HCFs were selected using a simple random sampling technique. We used a mixed approach of qualitative and quantitative study. The quantitative data were collected by an interviewer-administered structured questionnaire and observational checklist, whereas the qualitative data were collected using a key-informant interview from the head of HCFs, janitors, and WASH coordinator of the HCFs. The quantitative data were entered in EpiData version 4.6 and exported to Statistical Package for Social Sciences (SPSS) version 25.0 for data cleaning and analysis. The quantitative data on access to WASH facilities was reported using WHO ladder guidelines, which include no access, limited access, and basic access, whereas the qualitative data on challenges to WASH facilities were triangulated with the quantitative result. RESULTS: From the survey of 70 HCFs, three-fourths 53 (75.7%) were clinics, 12 (17.2%) were health centers, and 5 (7.1%) were hospitals. Most (88.6%) of the HCFs had basic access to water supply. The absence of a specific budget for WASH facilities, non-functional water pipes, the absence of water-quality monitoring systems, and frequent water interruptions were the major problems with water supply, which occurred primarily in clinics and health centers. Due to the absence of separate latrine designated for disabled people, none of the HCFs possessed basic sanitary facilities. Half (51.5%) of the HCFs had limited access to sanitation facilities. The major problems were the absence of separate latrines for healthcare workers and clients, as well as female and male staffs, an unbalanced number of functional latrines for the number of clients, non-functional latrines, poor cleanliness and misuse of the latrine. Less than a quarter of the HCFs 15 (21.4%) had basic access to handwashing facilities, while half 35 (50%) of the HCFs did not. The lack of functional handwashing facilities at expected sites and misuse of the facilities around the latrine, including theft of supplies by visitors, were the two most serious problems with hygiene facilities. CONCLUSION: Despite the fact that the majority of HCFs had basic access to water, there were problems in their sanitation and handwashing facilities. The lack of physical infrastructure, poor quality of facilities, lack of separate budget to maintain WASH facilities, and inappropriate utilization of WASH facilities were the main problems in HCFs. Further investigation should be done to assess the enabling factors and constraints for the provision, use, and maintenance of WASH infrastructure at HCFs.

Stakeholder Perspectives on COVID-19 and Household Water Access in Vulnerable Communities in the Mekong Region.

The COVID-19 pandemic has underlined the importance of safe access to sufficient clean water in vulnerable communities, renewing interest in water, sanitation and hygiene (WASH) programs and related targets under Sustainable Development Goal 6 (SDG 6). The purpose of this study was to better understand the obstacles to water access in vulnerable communities and identify ways they might be addressed in five countries in the Mekong Region (Cambodia, Laos, Myanmar, Thailand, Vietnam). To this end, qualitative interviews with 50 government officials and development or health experts were complimented with a quantitative survey of the experiences and views of individuals in 15 vulnerable communities. There were several key findings. First, difficulties in accessing sufficient clean water for drinking and hygiene persist in certain vulnerable communities, including informal urban settlements, remote minority villages, and migrant worker camps. Second, limited rights, high prices, and remote locations were common obstacles to household access to improved water sources. Third, seasonal differences in the availability of clean water, alongside other disruptions to supply such as restrictions on movement in COVID-19 responses, drove households towards lower quality sources. Fourth, there are multiple threats to water quality from source to consumption that should be addressed by monitoring, treatment, and watershed protection. Fifth, stakeholder groups differ from each other and residents of vulnerable communities regarding the significance of water access, supply and quality difficulties, and how they should be addressed. The paper ends with a set of program suggestions addressing these water-related difficulties.

Assessment of water and sanitation systems at Palestinian healthcare facilities: pre- and post-COVID-19.

The availability of safe drinking water and the proper management of wastewater in healthcare facilities are important pillars for maintaining safety of workers, patients, and visitors and protecting human health and environment. Water and sanitation services at 495 healthcare facilities in the West Bank of Palestine are assessed using the results of PCBS and MoH (2014) survey study. Services are reassessed after the COVID-10 pandemic using personal interviews with experts from healthcare facilities, regulatory authorities, and service providers. The results show that 92.1% of healthcare facilities were connected to public water networks, 12.9% of them purchased water tanks, and 10.8% of them depended on harvested rainwater which may cause contamination and waterborne diseases. Regardless the source of freshwater, the water quality has to be regularly examined and compared to local guidelines and international standards for health promotion. Almost 63.4% of healthcare facilities were not connected to wastewater networks and used either tight or porous cesspits. Once these cesspits are filled off, wastewater is randomly disposed into nearby valleys causing adverse environmental impacts on air, water, and land resources. Medical wastewater of hazardous substances should be treated before discharged to wastewater networks. Experts assured that although heightened procedures have been made by service providers to curb the spread of the COVID-19 disease, yet, more consistent protocols and stringent procedures are crucial. There have not been any new directives or procedures regarding the management of water supplies and wastewater services in the healthcare facilities. Stakeholder collaboration can help prevent the COVID-19 disease.

Flushing of Stagnant Premise Water Systems after the COVID-19 Shutdown Can Reduce Infection Risk by Legionella and Mycobacterium spp.

There is concern about potential exposure to opportunistic pathogens when reopening buildings closed due to the COVID-19 pandemic. In this study, water samples were collected before, during, and after flushing showers in five unoccupied (i.e., for ∼2 months) university buildings with quantification of opportunists via a cultivation-based assay (Legionella pneumophila only) and quantitative PCR. L. pneumophila were not detected by either method; Legionella spp., nontuberculous mycobacteria (NTM), and Mycobacterium avium complex (MAC), however, were widespread. Using quantitative microbial risk assessment (QMRA), the estimated risks of illness from exposure to L. pneumophila and MAC via showering were generally low (i.e., less than a 10-7 daily risk threshold), with the exception of systemic infection risk from MAC exposure in some buildings. Flushing rapidly restored the total chlorine (as chloramine) residual and decreased bacterial gene targets to building inlet concentrations within 30 min. During the postflush stagnation period, the residual chlorine dissipated within a few days and bacteria rebounded, approaching preflush concentrations after 6-7 days. These results suggest that flushing can quickly improve water quality in unoccupied buildings, but the improvement may only last a few days.

No place to shelter: ethnography of the homeless population in the COVID-19 pandemic.

OBJECTIVE: to analyze how homeless people live, in times of COVID-19 pandemic, in the city of Rio de Janeiro. METHOD: an ethnographic research that used interviews and observations and articles published in newspapers and magazines of great circulation, using domain analysis. RESULTS: the results tell how the COVID-19 pandemic emerged for the homeless population. Isolation led to emptying the streets and reducing passers-by, damaging their ways of living and their survival tactics. Hunger, thirst, absence of places for bathing and for fulfilling physiological needs became part of their daily lives. FINAL CONSIDERATIONS: given the impossibility of having a place to shelter, acquiring food and water and the limitations in carrying out preventive measures, care actions offered by managers to limit the virus to spread, even in this population, are ineffective.

Assessment of socioeconomic inequality based on virus-contaminated water usage in developing countries: A review.

Water is an essential resource required for various human activities such as drinking, cooking, and other recreational activities. While developed nations have made significant improvement in providing adequate quality water and sanitation devoid of virus contaminations to a significant percentage of the residences, many of the developing countries are still lacking in these regards, leading to many death cases among the vulnerable due to ingestion of virus-contaminated water and other waterborne pathogens. However, the recent global pandemic of COVID-19 seems to have changed the paradigm by reawakening the importance of water quality and sanitation, and focusing more attention on the pervasive effect of the use of virus-contaminated water as it can be a potential driver for the spread of the virus and other waterborne diseases, especially in developing nations that are characterized by low socioeconomic development. Therefore, this review assessed the socioeconomic inequalities related to the usage of virus-contaminated water and other waterborne pathogens in developing countries. The socioeconomic factors attributed to the various waterborne diseases due to the use of virus-contaminated water in many developing countries are poverty, the standard of living, access to health care facilities, age, gender, and level of education. Some mitigation strategies to address the viral contamination of water sources are therefore proposed, while future scope and recommendations on tackling the essential issues related to socioeconomic inequality in developing nations are highlighted.

What COVID-19 Reveals about the Neglect of WASH within Infection Prevention in Low-Resource Healthcare Facilities.

The highly infectious nature of the SARS-CoV-2 virus requires rigorous infection prevention and control (IPC) to reduce the transmission of COVID-19 within healthcare facilities, but in low-resource settings, the lack of water access creates a perfect storm for low-handwashing adherence, ineffective surface decontamination, and other environmental cleaning functions that are critical for IPC compliance. Data from the WHO/UNICEF Joint Monitoring Programme show that one in four healthcare facilities globally lacks a functional water source on premises (i.e., basic water service); in sub-Saharan Africa, half of all healthcare facilities have no basic water services. But even these data do not tell the whole story, other water, sanitation, and hygiene (WASH) assessments in low-resource healthcare facilities have shown the detrimental effects of seasonal or temporary water shortages, nonfunctional water infrastructure, and fluctuating water quality. The rapid spread of COVID-19 forces us to reexamine prevailing norms within national health systems around the importance of WASH for quality of health care, the prioritization of WASH in healthcare facility investments, and the need for focused, cross-sector leadership and collaboration between WASH and health professionals. What COVID-19 reveals about infection prevention in low-resource healthcare facilities is that we can no longer afford to "work around" WASH deficiencies. Basic WASH services are a fundamental prerequisite to compliance with the principles of IPC that are necessary to protect patients and healthcare workers in every setting.

Impact of lockdown on the microbiological status of the hospital water network during COVID-19 pandemic.

The COVID-19 pandemic started in China in early December 2019, and quickly spread around the world. The epidemic gradually started in Italy at the end of February 2020, and by May 31, 2020, 232,664 cases and 33,340 deaths were confirmed. As a result of this pandemic, the Italian Ministerial Decree issued on March 11, 2020, enforced lockdown; therefore, many social, recreational, and cultural centers remained closed for months. In Apulia (southern Italy), all non-urgent hospital activities were suspended, and some wards were closed, with a consequent reduction in the use of the water network and the formation of stagnant water. This situation could enhance the risk of exposure of people to waterborne diseases, including legionellosis. The purpose of this study was to monitor the microbiological quality of the water network (coliforms, E. coli, Enterococci, P. aeruginosa, and Legionella) in three wards (A, B and C) of a large COVID-19 regional hospital, closed for three months due to the COVID-19 emergency. Our study revealed that all three wards' water network showed higher contamination by Legionella pneumophila sg 1 and sg 6 at T1 (after lockdown) compared to the period before the lockdown (T0). In particular, ward A at T1 showed a median value = 5600 CFU/L (range 0-91,000 CFU/L) vs T0, median value = 75 CFU/L (range 0-5000 CFU/L) (p-value = 0.014); ward B at T1 showed a median value = 200 CFU/L (range 0-4200 CFU/L) vs T0, median value = 0 CFU/L (range 0-300 CFU/L) (p-value = 0.016) and ward C at T1 showed a median value = 175 CFU/L (range 0-22,000 CFU/L) vs T0, median value = 0 CFU/L (range 0-340 CFU/L) (p-value < 0.001). In addition, a statistically significant difference was detected in ward B between the number of positive water samples at T0 vs T1 for L. pneumophila sg 1 and sg 6 (24% vs 80% p-value < 0.001) and for coliforms (0% vs 64% p-value < 0.001). Moreover, a median value of coliform load resulted 3 CFU/100 ml (range 0-14 CFU/100 ml) at T1, showing a statistically significant increase versus T0 (0 CFU/100 ml) (p-value < 0.001). Our results highlight the need to implement a water safety plan that includes staff training and a more rigorous environmental microbiological surveillance in all hospitals before occupying a closed ward for a longer than one week, according to national and international guidelines.

Human development, social vulnerability and COVID-19 in Brazil: a study of the social determinants of health.

BACKGROUND: Coronavirus disease 2019 (COVID-19) was confirmed in Brazil in February 2020. Since then, the disease has spread throughout the country, reaching the poorest areas. This study analyzes the relationship between COVID-19 and the population's living conditions. We aimed to identify social determinants related to the incidence, mortality, and case fatality rate of COVID-19 in Brazil, in 2020. METHODS: This is an ecological study evaluating the relationship between COVID-19 incidence, mortality, and case fatality rates and 49 social indicators of human development and social vulnerability. For the analysis, bivariate spatial correlation and multivariate and spatial regression models (spatial lag model and spatial error models) were used, considering a 95% confidence interval and a significance level of 5%. RESULTS: A total of 44.8% of municipalities registered confirmed cases of COVID-19 and 14.7% had deaths. We observed that 56.2% of municipalities with confirmed cases had very low human development (COVID-19 incidence rate: 59.00/100 000; mortality rate: 36.75/1 000 000), and 52.8% had very high vulnerability (COVID-19 incidence rate: 41.68/100 000; mortality rate: 27.46/1 000 000). The regression model showed 17 indicators associated with transmission of COVID-19 in Brazil. CONCLUSIONS: Although COVID-19 first arrived in the most developed and least vulnerable municipalities in Brazil, it has already reached locations that are farther from large urban centers, whose populations are exposed to a context of intense social vulnerability. Based on these findings, it is necessary to adopt measures that take local social aspects into account in order to contain the pandemic.

Forecast predictions for the COVID-19 pandemic in Brazil by statistical modeling using the Weibull distribution for daily new cases and deaths.

COVID-19 has killed more than 500,000 people worldwide and more than 60,000 in Brazil. Since there are no specific drugs or vaccines, the available tools against COVID-19 are preventive, such as the use of personal protective equipment, social distancing, lockdowns, and mass testing. Such measures are hindered in Brazil due to a restrict budget, low educational level of the population, and misleading attitudes from the federal authorities. Predictions for COVID-19 are of pivotal importance to subsidize and mobilize health authorities' efforts in applying the necessary preventive strategies. The Weibull distribution was used to model the forecast prediction of COVID-19, in four scenarios, based on the curve of daily new deaths as a function of time. The date in which the number of daily new deaths will fall below the rate of 3 deaths per million - the average level in which some countries start to relax the stay-at-home measures - was estimated. If the daily new deaths curve was bending today (i.e., about 1250 deaths per day), the predicted date would be on July 5. Forecast predictions allowed the estimation of overall death toll at the end of the outbreak. Our results suggest that each additional day that lasts to bend the daily new deaths curve may correspond to additional 1685 deaths at the end of COVID-19 outbreak in Brazil (R2 = 0.9890). Predictions of the outbreak can be used to guide Brazilian health authorities in the decision-making to properly fight COVID-19 pandemic.

Disparate on-site access to water, sanitation, and food storage heighten the risk of COVID-19 spread in Sub-Saharan Africa.

COVID-19 is an active pandemic that likely poses an existential threat to humanity. Frequent handwashing, social distancing, and partial or total lockdowns are among the suite of measures prescribed by the World Health Organization (WHO) and being implemented across the world to contain the pandemic. However, existing inequalities in access to certain basic necessities of life (water, sanitation facility, and food storage) create layered vulnerabilities to COVID-19 and can render the preventive measures ineffective or simply counterproductive. We hypothesized that individuals in households without any of the named basic necessities of life are more likely to violate the preventive (especially lockdown) measures and thereby increase the risk of infection or aid the spread of COVID-19. Based on nationally-representative data for 25 sub-Saharan African (SSA) countries, multivariate statistical and geospatial analyses were used to investigate whether, and to what extent, household family structure is associated with in-house access to basic needs which, in turn, could reflect on a higher risk of COVID-19 infection. The results indicate that approximately 46% of the sampled households in these countries (except South Africa) did not have in-house access to any of the three basic needs and about 8% had access to all the three basic needs. Five countries had less than 2% of their households with in-house access to all three basic needs. Ten countries had over 50% of their households with no in-house access to all the three basic needs. There is a social gradient in in-house access between the rich and the poor, urban and rural richest, male- and female-headed households, among others. We conclude that SSA governments would need to infuse innovative gender- and age-sensitive support services (such as water supply, portable sanitation) to augment the preventive measures prescribed by the WHO. Short-, medium- and long-term interventions within and across countries should necessarily address the upstream, midstream and downstream determinants of in-house access and the full spectrum of layers of inequalities including individual, interpersonal, institutional, and population levels.

Dry Taps? A Synthesis of Alternative "Wash" Methods in the Absence of Water and Sanitizers in the Prevention of Coronavirus in Low-Resource Settings.

Objective: Social distancing and hand washing with soap and water have been advocated as the main proactive measures against the spread of coronavirus. We sought to find out what other alternative materials and methods would be used among populations without running water and who may not afford alcohol-based sanitizers. Results: We reviewed studies that reported use of sand, soil, ash, soda ash, seawater, alkaline materials, and sunlight as possible alternatives to handwashing with soap and water. We identified the documented mechanism of actions of these alternative wash methods on both inanimate surfaces and at cellular levels. The consideration of use of these alternative locally available in situations of unavailability of soap and water and alcohol-based sanitizers is timely in the face of coronavirus pandemic. Further randomized studies need to be carried out to evaluate the effectiveness of these alternatives in management of SARS-Cov-2.

Is There a Role for Environmental and Metabolic Factors Predisposing to Severe COVID-19?

The severe acute respiratory syndrome-coronavirus-2 (SARS-CoV-2) pandemic affects people around the world. However, there have been striking differences in the number of infected individuals and deaths in different countries. Particularly, within Central Europe in countries that are similar in ethnicity, age, and medical standards and have performed similar steps of containment, such differences in mortality rates remain inexplicable. We suggest to consider and explore environmental factors to explain these intriguing variations. Countries like Northern Italy, France, Spain, and UK have suffered from 5 times more deaths from the corona virus infection than neighboring countries like Germany, Switzerland, Austria, and Denmark related to the size of their respective populations. There is a striking correlation between the level of environmental pollutants including pesticides, dioxins, and air pollution such as NO2 known to affect immune function and healthy metabolism with the rate of mortality in COVID-19 pandemic in these European countries. There is also a correlation with the use of chlorination of drinking water in these regions. In addition to the improvement of environmental protective programs, there are possibilities to lower the blood levels of these pollutants by therapeutic apheresis. Furthermore, therapeutic apheresis might be an effective method to improve metabolic inflammation, altered vascular perfusion, and neurodegeneration observed as long-term complications of COVID-19 disease.

Coronavirus in water environments: Occurrence, persistence and concentration methods - A scoping review.

Coronaviruses (CoV) are a large family of viruses causing a spectrum of disease ranging from the common cold to more severe diseases as Middle East Respiratory Syndrome (MERS-CoV) and Severe Acute Respiratory Syndrome (SARS-CoV). The recent outbreak of coronavirus disease 2019 (COVID-19) has become a public health emergency worldwide. SARS-CoV-2, the virus responsible for COVID-19, is spread by human-to-human transmission via droplets or direct contact. However, since SARS-CoV-2 (as well as other coronaviruses) has been found in the fecal samples and anal swabs of some patients, the possibility of fecal-oral (including waterborne) transmission need to be investigated and clarified. This scoping review was conducted to summarize research data on CoV in water environments. A literature survey was conducted using the electronic databases PubMed, EMBASE, and Web Science Core Collection. This comprehensive research yielded more than 3000 records, but only 12 met the criteria and were included and discussed in this review. In detail, the review captured relevant studies investigating three main areas: 1) CoV persistence/survival in waters; 2) CoV occurrence in water environments; 3) methods for recovery of CoV from waters. The data available suggest that: i) CoV seems to have a low stability in the environment and is very sensitive to oxidants, like chlorine; ii) CoV appears to be inactivated significantly faster in water than non-enveloped human enteric viruses with known waterborne transmission; iii) temperature is an important factor influencing viral survival (the titer of infectious virus declines more rapidly at 23°C-25 °C than at 4 °C); iv) there is no current evidence that human coronaviruses are present in surface or ground waters or are transmitted through contaminated drinking-water; v) further research is needed to adapt to enveloped viruses the methods commonly used for sampling and concentration of enteric, non enveloped viruses from water environments. The evidence-based knowledge reported in this paper is useful to support risk analysis processes within the drinking and wastewater chain (i.e., water and sanitation safety planning) to protect human health from exposure to coronavirus through water.