Lion's mane jellyfish (Cyanea capillata) envenoming presenting as suspected decompression sickness.

Lion's mane jellyfish stings are usually characterised by local inflammation, especially weals. Systemic symptoms are not widely described although there is a well known fictional description of a fatal reaction to envenoming. We describe five divers presenting with suspected decompression sickness, where the probable diagnosis was jellyfish envenoming.

Can child-focused sanitation and nutrition programming improve health practices and outcomes? Evidence from a randomised controlled trial in Kitui County, Kenya.

INTRODUCTION: In Kenya's Kitui County, 46% of children under 5 years are stunted. Sanitation and nutrition programmes have sought to reduce child undernutrition, though they are typically implemented separately. We evaluate the effectiveness of an integrated sanitation and nutrition (SanNut) intervention in improving caregiver sanitation and nutrition knowledge and behaviours. METHODS: We conducted a cluster-randomised controlled trial to evaluate the impact of the SanNut intervention on caregiver knowledge, sanitary and hygiene practices, sanitation outcomes and nutrition outcomes. The evaluation included caregivers of children under 5 years across 604 villages in Kitui County. 309 treatment villages were randomly assigned to receive both the SanNut intervention and the standard Community-Led Total Sanitation (CLTS) intervention, while 295 control villages only received the CLTS intervention. 8 households with children under 5 years were randomly selected from each evaluation village to participate in the endline survey, for a total of 4322 households. RESULTS: SanNut led to modest improvements in sanitary knowledge and practices emphasised by the programme. Caregivers in treatment villages were 3.3 pp (+32%) more likely to mention lack of handwashing after handling child faeces as a potential cause of diarrhoea, and 4.9 pp (+7.8%) more likely to report safe disposal of child faeces than caregivers in control villages. Treatment households were 1.9 pp (+79%) more likely to have a stocked handwashing station and 2.9 pp (-16%) less likely to report incidences of child diarrhoea. However, SanNut appears to have had no impact on nutritional practices, such as breastfeeding, vitamin A supplementation or deworming. Non-child outcomes traditionally associated with CLTS, including latrine use and homestead sanitary conditions, were similar in treatment and control groups. CONCLUSION: Child-focused messaging can potentially be integrated into CLTS programming, though this integration was more successful for topics closer to CLTS objectives (sanitation practices, including limiting faecal contamination and handwashing) than for more disparate topics (nutritional practices). TRIAL REGISTRATION: Pan-African Clinical Trials Registry (PACTR201803003159346) and American Economic Association registry for randomised controlled trials (AEARCTR-0002019).

The psychological impact of accidents on recreational divers: a prospective study.

OBJECTIVE: The present study aimed to examine the medium and long term psychological impact of diving accidents on the victims (n=52), compared with the impact on two control groups: the victim's diving "buddy" (n=40) who simply witnessed the accident, and a second control from the same boat who did not dive with the victim (n=38). METHODS: This was a prospective cohort study of the impact of an accident on the victims who attended the Hyperbaric Unit, in comparison with the two control groups. Pre-accident psychological morbidity was assessed using the General Health Questionnaire. Trauma symptoms were assessed using the Revised Impact of Events Scale at 3, 6 and 12 months post accident. RESULTS: The accident victims endorsed more trauma symptoms and experienced them more intensely and for longer, compared with the two control groups. CONCLUSION: A significant minority of diving accident victims (between 25% and 50%) continued to suffer from the psychological impact of the accident, some for over a year. This has important implications for their future health care, for their safety on subsequent dives, and for dive training.

Targeting appropriate interventions to minimize deterioration of drinking-water quality in developing countries.

In developing countries, it has been observed that drinking-water frequently becomes recontaminated following its collection and during storage in the home. This paper proposes a semi-quantified 'disease risk index' (DRI) designed to identify communities or households that are 'most at risk' from consuming recontaminated drinking-water. A brief review of appropriate physical and educational intervention measures is presented, and their effective use is discussed. It is concluded that incorporating a simple appraisal tool, such as the proposed DRI, into a community water-supply programme would be useful in shaping the overall strategy requiring only a minimum of organizational learning.

The importance of domestic water quality management in the context of faecal-oral disease transmission.

The deterioration of drinking water quality following its collection from a community well or standpipe and during storage in the home has been well documented. However, there is a view that post-supply contamination is of little public health consequence. This paper explores the potential health risk from consuming re-contaminated drinking water. A conceptual framework of principal factors that determine the pathogen load in household drinking water is proposed. Using this framework a series of hypotheses are developed in relation to the risk of disease transmission from re-contaminated drinking water and examined in the light of current literature and detailed field observation in rural Honduran communities. It is shown that considerable evidence of disease transmission from re-contaminated drinking water exists. In particular the type of storage container and hand contact with stored drinking water has been associated with increased incidence of diarrhoeal disease. There is also circumstantial evidence linking such factors as the sanitary conditions in the domestic environment, cultural norms and poverty with the pathogen load of household stored drinking water and hence the risk of disease transmission. In conclusion it is found that re-contaminated drinking water represents a significant health risk especially to infants, and also to those with secondary immunodeficiency.

Mechanisms leading to post-supply water quality deterioration in rural Honduran communities.

Drinking water can become contaminated following its collection from communal sources such as wells and tap stands, as well as during its storage in the home. However, the mechanisms leading to contamination between the points of supply and consumption have not been well documented. This study carried out field-based experiments in three rural Honduran communities to investigate the potential for contamination through hand contact, method used to draw water, and dirty collection containers. The possibility of bacterial growth occurring in stored water was also considered. Hand-water contact was observed frequently during the collection and drawing of drinking water. Faecal contamination was present on 44% of women's fingertips tested during normal household activities, and this faecal material was easily transferred to water. An immediate deterioration in water quality was observed on filling collection containers. Faecal material was detected on cups and beakers used for drawing stored drinking water. Evidence was produced indicating that thermotolerant coliforms remain attached to the inner surface of clay storage containers after rinsing. Drinking-water quality deteriorates during collection and storage as a result of multiple factors linked to hygiene practices and circumstances. However, hands have the greatest potential to introduce contamination because of the constant risk of contact during household water management.

Water quality deterioration: a study of household drinking water quality in rural Honduras.

There is growing awareness that drinking-water can become contaminated following its collection from communal sources such as wells and tap-stands, as well as during its storage in the home. This study evaluated the post-supply drinking-water quality in three rural Honduran communities using either a protected hand-dug well or borehole supply. Water management practices were documented as a basis for further research to improve household drinking-water quality. Membrane filtration was used to compare thermotolerant coliform levels in samples taken from community wells and household drinking-water storage containers. Over a 2-year period, water quality was examined in 43 households and detailed observation made of typical collection, storage and usage practice. Substantial water quality deterioration occurred between the points of supply and consumption. Deterioration occurred regularly and frequently, and was experienced by the majority of study households. Only source water quality appeared to be a significant factor in determining household water quality. None of the storage factors examined, i.e. covering the container, type of container, the material from which the container was made, and hours stored, made any significant difference to the stored water quality. Observation of household water management shows that there are multiple points during the collection to use sequence where pollution could occur. The commonality of water management practice would be an asset in introducing appropriate intervention measures.