Enterococcus contamination of infant foods and implications for exposure to foodborne pathogens in peri-urban neighbourhoods of Kisumu, Kenya.

We collected infant food samples from 714 households in Kisumu, Kenya, and estimated the prevalence and concentration of Enterococcus, an indicator of food hygiene conditions. In a subset of 212 households, we quantified the change in concentration in stored food between a morning and afternoon feeding time. In addition, household socioeconomic characteristics and hygiene practices of the caregivers were documented. The prevalence of Enterococcus in infant foods was 50% (95% confidence interval: 46.1 - 53.4), and the mean log10 colony-forming units (CFUs) was 1.1 (SD + 1.4). No risk factors were significantly associated with the prevalence and concentration of Enterococcus in infant foods. The mean log10 CFU of Enterococcus concentration was 0.47 in the morning and 0.73 in the afternoon foods with a 0.64 log10 mean increase in matched samples during storage. Although no factors were statistically associated with the prevalence and the concentration of Enterococcus in infant foods, household flooring type was significantly associated with an increase in concentration during storage, with finished floors leading to 1.5 times higher odds of concentration increase compared to unfinished floors. Our study revealed high prevalence but low concentration of Enterococcus in infant food in low-income Kisumu households, although concentrations increased during storage implying potential increases in risk of exposure to foodborne pathogens over a day. Further studies aiming at investigating contamination of infant foods with pathogenic organisms and identifying effective mitigation measures are required to ensure infant food safety.

Protocol for the PATHOME study: a cohort study on urban societal development and the ecology of enteric disease transmission among infants, domestic animals and the environment.

INTRODUCTION: Global morbidity from enteric infections and diarrhoea remains high in children in low-income and middle-income countries, despite significant investment over recent decades in health systems and water and sanitation infrastructure. Other types of societal development may be required to reduce disease burden. Ecological research on the influence of household and neighbourhood societal development on pathogen transmission dynamics between humans, animals and the environment could identify more effective strategies for preventing enteric infections. METHODS AND ANALYSIS: The 'enteric pathome'-that is, the communities of viral, bacterial and parasitic pathogens transmitted from human and animal faeces through the environment is taxonomically complex in high burden settings. This integrated cohort-exposure assessment study leverages natural socioeconomic spectrums of development to study how pathome complexity is influenced by household and neighbourhood infrastructure and hygiene conditions. We are enrolling under 12-month-old children in low-income and middle-income neighbourhoods of two Kenyan cities (Nairobi and Kisumu) into a 'short-cohort' study involving repeat testing of child faeces for enteric pathogens. A mid-study exposure assessment documenting infrastructural, behavioural, spatial, climate, environmental and zoonotic factors characterises pathogen exposure pathways in household and neighbourhood settings. These data will be used to inform and validate statistical and agent-based models (ABM) that identify individual or combined intervention strategies for reducing multipathogen transmission between humans, animals and environment in urban Kenya. ETHICS AND DISSEMINATION: The protocols for human subjects' research were approved by Institutional Review Boards at the University of Iowa (ID-202004606) and AMREF Health Africa (ID-ESRC P887/2020), and a national permit was obtained from the Kenya National Commission for Science Technology and Innovation (ID# P/21/8441). The study was registered on Clinicaltrials.gov (Identifier: NCT05322655) and is in pre-results stage. Protocols for research on animals were approved by the University of Iowa Animal Care and Use Committee (ID 0042302).

Development of Shortened Enrichment Methods for Detection of Salmonella Typhimurium Spiked in Milk.

Rapid and accurate testing of pathogenic Salmonella enterica in dairy products could reduce the risk of exposure to the bacterial pathogens for consumers. This study aimed to reduce the assessment time needed for enteric bacteria recovery and quantification in food using the natural growth properties of Salmonella enterica Typhimurium (S. Typhimurium) in cow's milk and efficiently using rapid PCR methods. Over 5 h of 37 °C enrichment, culture and PCR methods measured increases in the non-heat-treated S. Typhimurium concentration at similar rates, with an average increase of 2.7 log10 CFU/mL between the start of enrichment and 5 h. In contrast, no bacteria were recovered by culture after S. Typhimurium in milk received heat treatment, and the number of gene copies of heat-treated Salmonella detected by PCR did not increase with the enrichment time. Thus, comparing culture and PCR data over just 5 h of enrichment time can detect and differentiate between replicating bacteria and dead bacteria.

A Mixed Methods Process Evaluation of a Food Hygiene Intervention in Low-Income Informal Neighbourhoods of Kisumu, Kenya.

OBJECTIVES: Diarrhoea is a leading cause of infant mortality with the main transmission pathways being unsafe water and contaminated food, surfaces and hands. The 'Safe Start' trial evaluated a food hygiene intervention implemented in a peri-urban settlement of Kisumu, Kenya, with the aim of reducing diarrhoeagenic enteric infections among infants. Four food hygiene behaviours were targeted: handwashing with soap before preparation and feeding, boiling infant food before feeding, storing infant food in sealed containers, and exclusive use of designated utensils during feeding. METHODS: A process evaluation of the intervention was guided by a theory of change describing the hypothesised implementation and receipt of the intervention, mechanisms of change, and the context. These were assessed by qualitative and quantitative data that included debriefing sessions with the delivery teams and Community Health Volunteers (CHVs), and structured observations during food preparation. RESULTS: The intervention achieved high coverage and fidelity with over 90% of 814 eligible caregivers participating in the intervention. Caregivers in the intervention arm demonstrated an understanding of the intervention messages, and had 1.38 (95% CI: 1.02-1.87) times the odds of washing hands before food preparation and 3.5 (95% CI: 1.91-6.56) times the odds of using a feeding utensil compared to caregivers in the control group. Contextual factors, especially the movement of caregivers within and outside the study area and time constraints faced by caregivers influenced uptake of some intervention behaviours. CONCLUSION: Future interventions should seek to explicitly target contextual factors such as secondary caregivers and promote food hygiene interventions as independent of each other.

Assessing the relationship between domestic work experience and musculoskeletal health among rural Nigerian women.

BACKGROUND: Women performing strenuous domestic tasks (especially those in developing countries) are at risk of experiencing musculoskeletal pain (MSP). Physical, psychosocial, and social conditions of work in rural environments contribute to women's domestic work experiences (DWEs) and the risk of MSP. The impact of DWEs on women's health is especially severe in water-insecure countries like Nigeria. This study examines the relationship between a recently developed measure of DWEs and self-reported pain in the lower back (LBP), neck/shoulder (NSP), and elbow/hand/wrist regions (EHWP) among rural Nigerian women. METHODS: Interviewer-administered survey data were collected from 356 women in four rural communities of Ibadan, Nigeria. Binary and ordinal logistic regression models were used to examine the relationship between DWE factor scores, sociodemographic characteristics, and musculoskeletal pain symptoms and severity after controlling for sociodemographic covariates. Effect estimates of association were presented using the odds ratio (OR), and the corresponding 95% confidence interval (CI) at p-value of 0.05. FINDINGS: Among 356 participants, the 2-month prevalence of LBP was 58%, NSP was 30%, and EWHP 30%. High DWE scores were significantly associated with higher odds of experiencing and having more severe LBP, NSP, and EHWP. Specifically, the odds of LBP [(OR = 2.88; 95% CI = 1.64-5.11), NSP (OR = 4.58; 95% CI = 2.29-9.40) and EHWP (OR = 1.88; 95% CI = 1.26-3.77)] were significantly higher among women who perceived their domestic work responsibilities as very stressful (i.e., 'high stress appraisal') compared to those with lower stress appraisal scores. Those who were time-pressured and had less autonomy over familial duties (i.e., 'high demand/low control') had significantly higher odds of LBP [(OR = 2.58; 95% CI = 1.64-4.09) and NSP (OR = 1.49; 95% CI = 1.24-2.58)]. Frequently fetching and carrying water over long distances and time (i.e., 'high water sourcing and carriage') was also associated with higher odds of LBP [(OR = 1.31; 95% CI = 1.09-1.79) and NSP (OR = 1.20; 95% CI = 1.08-1.76). CONCLUSION: Strenuous and stressful DWEs were associated with MSP among rural Nigerian women. This study provides new evidence on how the physical, social, and psychosocial factors of domestic work can increase women's risk of MSP.

Environmental and behavioural exposure pathways associated with diarrhoea and enteric pathogen detection in 5-month-old, periurban Kenyan infants: a cross-sectional study.

OBJECTIVES: The aim of this study was to test whether household environmental hygiene and behavioural conditions moderated associations between diarrhoea and enteric pathogen detection in infants 5 months of age in Kenya and pathogen sources, including latrine access, domestic animal co-habitation and public food sources. DESIGN: Cross-sectional study utilising enrolment survey data of households participating in the Safe Start cluster-randomised controlled trial . SETTING: Kisumu, Kenya. PARTICIPANTS: A total of 898 caregivers with 5-month (22 week ± 1 week) aged infants were enrolled in the study and completed the enrolment survey. PRIMARY AND SECONDARY OUTCOME MEASURES: Outcomes were (1) caregiver-reported 7-day diarrhoea prevalence and (2) count of types of enteric viruses, bacteria and parasites in infant stool. Exposures and effect modifiers included water access and treatment, cohabitation with domestic animals, sanitation access, handwashing practices, supplemental feeding, access to refrigeration and flooring. RESULTS: Reported handwashing after handling animals (adjusted odds ratio (aOR)=0.20; 95% CI=0.06 to 0.50) and before eating (aOR=0.44; 95% CI=0.26 to 0.73) were strongly associated with lower risk of caregiver-reported diarrhoea, while cohabitation with animals (aOR=1.54; 95% CI=1.01 to 2.34) living in a household with vinyl-covered dirt floors (aOR=0.60; 95% CI=0.45 to 0.87) were strongly associated with pathogen codetection in infants. Caregiver handwashing after child (p=0.02) or self-defecation (p=0.03) moderated the relationship between shared sanitation access and infant exposure to pathogens, specifically private latrine access was protective against pathogen exposure of infants in households, where caregivers washed hands after defecation. In the absence of handwashing, access to private sanitation posed no benefits over shared latrines for protecting infants from exposure. CONCLUSION: Our evidence highlights eliminating animal cohabitation and improving flooring, postdefecation and food-related handwashing, and safety and use of cow milk sources as interventions to prevent enteric pathogen exposure of young infants in Kenya. TRIAL REGISTRATION NUMBER: NCT03468114.

Days of Flooding Associated with Increased Risk of Influenza.

Influenza typically causes mild infection but can lead to severe outcomes for those with compromised lung health. Flooding, a seasonal problem in Iowa, can expose many Iowans to molds and allergens shown to alter lung inflammation, leading to asthma attacks and decreased viral clearance. Based on this, the hypothesis for this research was that there would be geographically specific positive associations in locations with flooding with influenza diagnosis. An ecological study was performed using influenza diagnoses and positive influenza polymerase chain reaction tests from a de-identified large private insurance database and Iowa State Hygienic Lab. After adjustment for multiple confounding factors, Poisson regression analysis resulted in a consistent 1% associated increase in influenza diagnoses per day above flood stage (95% confidence interval: 1.00-1.04). This relationship remained after removal of the 2009-2010 influenza pandemic year. There was no associated risk between flooding and influenza-like illness as a nonspecific diagnosis. Associated risks between flooding and increased influenza diagnoses were geographically specific, with the greatest risk in the most densely populated areas. This study indicates that populations who live, work, or volunteer in flooded environments should consider preventative measures to avoid environmental exposures to mitigate illness from influenza in the following year.

Inclusion of environmentally themed search terms improves Elastic net regression nowcasts of regional Lyme disease rates.

Lyme disease is the most widely reported vector-borne disease in the United States. 95% of confirmed human cases are reported in the Northeast and upper Midwest (25,778 total confirmed cases from Northeast and upper Midwest / 27,203 total US confirmed cases). Human cases typically occur in the spring and summer months when an infected nymph Ixodid tick takes a blood meal. Current federal surveillance strategies report data on an annual basis, leading to nearly a year lag in national data reporting. These lags in reporting make it difficult for public health agencies to assess and plan for the current burden of Lyme disease. Implementation of a nowcasting model, using historical data to predict current trends, provides a means for public health agencies to evaluate current Lyme disease burden and make timely priority-based budgeting decisions. The objective of the study was to develop and compare the performance of nowcasting models using free data from Google Trends and Centers of Disease Control and Prevention surveillance reports. We developed two sets of elastic net models for five regions of the United States: 1. Using only monthly proportional hit data from the 21 disease symptoms and tick related terms, and 2. Using monthly proportional hit data from terms identified via Google correlate and the disease symptom and vector terms. Elastic net models using the full-term list were highly accurate (Root Mean Square Error: 0.74, Mean Absolute Error: 0.52, R2: 0.97) for four of the five regions of the United States and improved accuracy 1.33-fold while reducing error 0.5-fold compared to predictions from models using disease symptom and vector terms alone. Many of the terms included and found to be important for model performance were environmentally related. These models can be implemented to help local and state public health agencies accurately monitor Lyme disease burden during times of reporting lag from federal public health reporting agencies.

Understanding Rural Women's Domestic Work Experiences (DWE) in Ibadan, Nigeria: Development of a Measurement Tool Using Confirmatory Factor Analysis.

Gender norms prescribe domestic labor as primarily a female's responsibility in developing countries. Many domestic tasks depend on access to water, so the physical, emotional, and time demands of domestic labor may be exacerbated for women living in water-insecure environments. We developed a set of domestic work experience (DWE) measures tailored to work in rural areas in developing countries, assessed rural Nigerian women's DWE, and examined relationships among the measures. Interviewer-administered survey data were collected between August and September from 256 women in four rural Nigerian communities. Latent factors of DWE were identified by analyzing survey items using confirmatory factor analysis. Pearson's correlation was used to examine relationships among latent factor scores, and multivariate linear regression models were used to determine if factor scores significantly differed across socio-demographic characteristics. The DWE measures consisted of latent factors of the physical domain (frequency of common domestic tasks, water sourcing and carriage, experience of water scarcity), the psychosocial domain (stress appraisal and demand-control), and the social domain (social support). Significant correlations were observed among the latent factors within and across domains. Results revealed the importance of measuring rural Nigerian women's DWE using multiple and contextual approaches rather than relying solely on one exposure measure. Multiple inter-related factors contributed to women's DWE. Water insecurity exacerbated the physical and emotional demands of domestic labor DWE varied across age categories and pregnancy status among rural Nigerian women.

A meta-analysis of the association between physical demands of domestic labor and back pain among women.

BACKGROUND: Back pain (BP) is among the most common musculoskeletal problems globally and is a leading contributor to disability among adults. Millions of women especially those in low-income settings, engage in strenuous domestic activities that may increase their risk of BP. The purpose of this meta-analysis was to estimate the association between physically demanding domestic labor (PDDL) which is characterized as intensity, frequency, duration of work and biomechanical risk factors of work and BP among women. METHODS: Five databases were searched for records published from January 1991 to March 2020; and results from 11studies were included in the meta-analysis. A random effects model and the generic inverse-variance method was used to estimate the pooled odds ratio (OR), 95% confidence interval (CI), and the degree of heterogeneity among studies (I2). Stratified and sensitivity analyses were conducted to identify the influence of outliers and identify the sources of heterogeneity. RESULTS: Exposure to high PDDL was significantly associated with BP (OR = 1.63; 95% CI 1.30, 2.04; I2 = 70%). The odds of back pain were highest among the following groups: women performing domestic labor in non-neutral postures (OR = 2.30; 95% CI = 1.75-3.04; I2 = 0%; N = 4 studies) and among women from low- and middle-income countries (OR = 1.98; 95% CI = 1.58-2.49; I2 = 29%; N = 5 studies). We found no evidence of publication bias (Egger's test p-value = 0.15). CONCLUSIONS: PDDL may significantly increase a woman's risk of experiencing BP, but larger prospective studies are needed to further investigate the association. Presenting data on how domestic work affects the musculoskeletal health of women will be important in designing future interventions (behavioral, infrastructural, and ergonomic) that can reduce the burdens from domestic labor.

Milk Product Safety and Household Food Hygiene Influence Bacterial Contamination of Infant Food in Peri-Urban Kenya.

BACKGROUND: Milk is a common infant food in peri-urban Kenya that can transmit diarrhea-causing enteric pathogens. Little is known about how contamination of milk at point of purchase and household handling of milk-based infant foods contribute to infant exposure to enteric pathogens. OBJECTIVE: To compare the prevalence and concentrations of bacterial indicator organisms and enteric pathogens in unpackaged, fresh pasteurized, and ultra-high temperature (UHT) treated milk at purchase and assess the influence of the type of milk used to prepare infant food on contamination of this food. METHODS: Paired samples of purchased milk and infant food prepared with this milk were obtained from 188 households in low-income neighborhoods in Kisumu, Kenya. Samples were cultured on selective media to isolate Salmonella enterica, Shigella spp., Klebsiella aerogenes, Proteus spp., and Escherichia coli, with pathogens validated by PCR. Probability of detection of these bacteria was compared by milk product treatment and packaging method, and between milk at point of purchase vs. food at point of infant consumption. RESULTS: Unpackaged milk was most contaminated at point of purchase, but bacterial contamination was also present in pasteurized and UHT milk at purchase. Presence of bacteria in UHT and fresh pasteurized milk at purchase predicted presence of the same bacteria type in infant food. Prevalence of bacterial contamination and concentration level for bacterial indicators generally increased between point of purchase and consumption in UHT and fresh pasteurized milk-based food but decreased in unpackaged milk-based food. Prevalence of the four fecal bacteria were similar in infant foods prepared with each type of milk. CONCLUSION: Both pre-market contamination and post-purchase handling influence the likelihood of infants ingesting foods contaminated by diarrheal pathogens.

Bacteroides Microbial Source Tracking Markers Perform Poorly in Predicting Enterobacteriaceae and Enteric Pathogen Contamination of Cow Milk Products and Milk-Containing Infant Food.

Consumption of microbiologically contaminated food is one of the leading causes of diarrheal diseases. Understanding the source of enteric pathogens in food is important to guide effective interventions. Enterobacteriaceae bacterial assays typically used to assess food safety do not shed light on the source. Source-specific Bacteroides microbial source tracking (MST) markers have been proposed as alternative indicators for water fecal contamination assessment but have not been evaluated as an alternative fecal indicator in animal-derived foods. This study tested various milk products collected from vendors in urban Kenyan communities and infant foods made with the milk (n = 394 pairs) using conventional culture methods and TaqMan qPCR for enteric pathogens and human and bovine-sourced MST markers. Detection profiles of various enteric pathogens and Bacteroides MST markers in milk products differed from that of milk-containing infant foods. MST markers were more frequently detected in infant food prepared by caregivers, indicating recent contamination events were more likely to occur during food preparation at home. However, Bacteroides MST markers had lower sensitivity in detecting enteric pathogens in food than traditional Enterobacteriaceae indicators. Bacteroides MST markers tested in this study were not associated with the detection of culturable Salmonella enterica and Shigella sonnei in milk products or milk-containing infant food. The findings show that while Bacteroides MST markers could provide valuable information about how foods become contaminated, they may not be suitable for predicting the origin of the enteric pathogen contamination sources.

Environmental and spatial determinants of enteric pathogen infection in rural Lao People's Democratic Republic: A cross-sectional study.

TRIAL REGISTRATION: clinicaltrials.gov (NCT02342860).

Designing a Food Hygiene Intervention in Low-Income, Peri-Urban Context of Kisumu, Kenya: Application of the Trials of Improved Practices Methodology.

Food contamination during weaning and complementary feeding can result in high diarrheal incidence among infants. Caregiver practices are important determinants of exposure to foodborne pathogens, and can therefore play a role in reduction in infant food contamination. Through a qualitative approach, we used the Trials of Improved Practices methodology to design a food hygiene intervention in a low-income settlement of Kisumu city in Kenya. These settlements in Kisumu city host a large portion of the city's population and are faced with a high diarrheal disease burden. Caregivers were selected if they had a child aged 6-9 months, and together, we codesigned a combination of hardware and messaging components targeting handwashing with soap, hygienic feeding, reheating, and hygienic storage of infant food. Caregivers received up to six engagement visits with the research team. The visits were aimed at improving the designed hardware and messaging components. Results showed that feeding items were easily adopted by caregivers, whereas reheating of food was less observed. Households reportedly improved their food storage and handwashing practices. As a result, the hardware components were further refined and tested among the caregivers. Messaging components spurred the aspirations that caregivers had for their children and acted as reminders of practicing good food hygiene. The outcomes of the codesign process provided valuable insights on the knowledge of caregivers, a delivery approach for implementing the intervention, and further informed a subsequent trial that adopted the designed intervention to target early childhood exposure to enteric pathogens through contaminated food.

Risk factors for child food contamination in low-income neighbourhoods of Maputo, Mozambique: An exploratory, cross-sectional study.

In low- and middle-income countries, food may be a critical transmission route for pathogens causing childhood diarrhoea, but basic food hygiene is often overlooked in public health strategies. Characterising child food contamination and its risk factors could help prioritise interventions to reduce foodborne diarrhoeal disease, especially in low-income urban areas where the diarrhoeal disease burden is often high. This cross-sectional study comprised a caregiver questionnaire coupled with food sampling, and food preparation observations, among the study population of an ongoing sanitation trial in Maputo. The aim was to determine the prevalence of child food contamination and associated risk factors. The prevalence of Enterococcus spp., as an indicator of faecal contamination, was estimated in food samples. Risk factor analyses were performed through zero-inflated negative binomial regression on colony counts. A modified hazard analysis and critical control point approach was used to determine critical control points (CCPs) that might effectively reduce risk. Fifty-eight linked caregiver questionnaires and food samples were collected, and 59 food preparation observations were conducted. The prevalence of enterococci in child foods exceeding 10 colony forming units per gram was 53% (95% confidence interval [40%, 67%]). Risk factors for child food contamination were identified, including type of food, food preparation practices, and hygiene behaviours. CCPs included cooking/reheating of food and food storage and handling. This exploratory study highlights the need for more research into diarrhoeagenic pathogens and foodborne risks for children living in these challenging urban environments.

Infant Food Hygiene and Childcare Practices in Context: Findings from an Urban Informal Settlement in Kenya.

Complementary food hygiene is important to reduce infant exposures to enteric pathogens; however, interventions to improve food hygiene in low- and middle-income countries often ignore the larger context in which childcare occurs. In this study, we explore on observational and qualitative information regarding childcare in an informal community in Kenya. Our findings demonstrate that behaviors associated with food contamination, such as hand feeding and storing food for extended periods, are determined largely by the larger social and economic realities of primary caretakers. Data also show how caregiving within an informal settlement is highly dynamic and involves multiple individuals and locations throughout the day. Findings from this study will help inform the development and implementation of food hygiene interventions in informal urban communities.

The Safe Start trial to assess the effect of an infant hygiene intervention on enteric infections and diarrhoea in low-income informal neighbourhoods of Kisumu, Kenya: a study protocol for a cluster randomized controlled trial.

BACKGROUND: Symptomatic and asymptomatic enteric infections in early childhood are associated with negative effects on childhood growth and development, especially in low and middle-income countries, and food may be an important transmission route. Although basic food hygiene practices might reduce exposure to faecal pathogens and resulting infections, there have been few rigorous interventions studies to assess this, and no studies in low income urban settings where risks are plausibly very high. The aim of this study is to evaluate the impact of a novel infant food hygiene intervention on infant enteric infections and diarrhoea in peri-urban settlements of Kisumu, Kenya. METHODS: This is a cluster randomized control trial with 50 clusters, representing the catchment areas of Community Health Volunteers (CHVs), randomly assigned to intervention or control, and a total of 750 infants recruited on a rolling basis at 22 weeks of age and then followed for 15 weeks. The intervention targeted four key caregiver behaviours related to food hygiene: 1) hand washing with soap before infant food preparation and feeding; 2) bringing all infant food to the boil before feeding, including when reheating or reserving; 3) storing all infant food in sealed containers; and, 4) using only specific utensils for infant feeding which are kept separate and clean. RESULTS: The primary outcome of interest is the prevalence of one or more of 23 pre-specified enteric infections, determined using quantitative real-time polymerase chain reaction for enteric pathogen gene targets. In addition, infant food samples were collected at 33 weeks, and faecal indicator bacteria (Enterococcus) isolated and enumerated to assess the impact of the intervention on infant food contamination. CONCLUSION: To our knowledge this is the first randomized controlled trial to assess the effect of an infant food hygiene intervention on enteric infections in a high burden, low income urban setting. Our trial responds to growing evidence that food may be a key pathway for early childhood enteric infection and disease and that basic food hygiene behaviours may be able to mitigate these risks. The Safe Start trial seeks to provide new evidence as to whether a locally appropriate infant food hygiene intervention delivered through the local health extension system can improve the health of young children. TRIAL REGISTRATION: The trial was registered at clinicaltrial.gov on March 16th 2018 before enrolment of any participants (https://clinicaltrials.gov/ct2/show/NCT03468114).

Frequency and determinants of health care utilization for symptomatic reproductive tract infections in rural Indian women: A cross-sectional study.

INTRODUCTION: The public health burden of reproductive tract infections (RTIs) among women in rural areas of low-income countries is poorly addressed because health care seeking for treatment of RTIs is inadequate. There are gaps in knowledge about whether low care seeking behavior stems from challenges in accessing health care versus women's recognition of and response to RTI-specific disease symptoms. We aim to identify determinants of care seeking behavior and analyze the difference in utilization of health care resources in response to symptoms of an RTI versus non-RTI disease symptoms in rural India. This will aid in the design of interventions that promote RTI care seeking behavior. METHODS: Our analysis uses data from a cross-sectional, population-based surveillance survey among rural, non-pregnant women in Odisha, India, from 2013-2014 (n = 3,600). We utilized bivariate logistic regression to determine the degree that certain determinants are associated with a woman's likelihood to seek RTI treatment, and chi-Squared tests to assess for differences in health care resources used for non-RTI versus RTI symptoms. RESULTS: Married women were significantly more likely to seek health care for RTI symptoms (Odds Ratio (OR) = 1.9, 95% Confidence Interval (CI): 1.2-3.0) while unmarried adolescents were less likely to seek treatment (OR = 0.4, CI: 0.2-0.6). There was no association between RTI health care seeking with education level, belief about whether symptoms can be treated, or poverty. The majority (73.8%) of women who did not seek treatment for RTI symptoms reported not seeking treatment because they did not know treatment was needed. Women utilized formal health care providers at a higher rate in response to RTI symptoms than in response to their most recent symptoms of any kind (p = 0.003). CONCLUSIONS: Community-based reproductive health education interventions are needed to increase health care seeking behavior for RTIs in rural Indian women. Interventions should target unmarried women and focus on both sexual health education and access to care.

Associations between soil-transmitted helminthiasis and viral, bacterial, and protozoal enteroinfections: a cross-sectional study in rural Laos.

BACKGROUND: Humans are susceptible to over 1400 pathogens. Co-infection by multiple pathogens is common, and can result in a range of neutral, facilitative, or antagonistic interactions within the host. Soil-transmitted helminths (STH) are powerful immunomodulators, but evidence of the effect of STH infection on the direction and magnitude of concurrent enteric microparasite infections is mixed. METHODS: We collected fecal samples from 891 randomly selected children and adults in rural Laos. Samples were analyzed for 5 STH species, 6 viruses, 9 bacteria, and 5 protozoa using a quantitative reverse transcription polymerase chain reaction (qRT-PCR) assay. We utilized logistic regression, controlling for demographics and household water, sanitation, and hygiene access, to examine the effect of STH infection on concurrent viral, bacterial, and protozoal infection. RESULTS: We found that STH infection was associated with lower odds of concurrent viral infection [odds ratio (OR): 0.48, 95% confidence interval (CI): 0.28-0.83], but higher odds of concurrent bacterial infections (OR: 1.81, 95% CI: 1.06-3.07) and concurrent protozoal infections (OR: 1.50, 95% CI: 0.95-2.37). Trends were consistent across STH species. CONCLUSIONS: The impact of STH on odds of concurrent microparasite co-infection may differ by microparasite taxa, whereby STH infection was negatively associated with viral infections but positively associated with bacterial and protozoal infections. Results suggest that efforts to reduce STH through preventive chemotherapy could have a spillover effect on microparasite infections, though the extent of this impact requires additional study. The associations between STH and concurrent microparasite infection may reflect a reverse effect due to the cross-sectional study design. Additional research is needed to elucidate the exact mechanism of the immunomodulatory effects of STH on concurrent enteric microparasite infection.

The landscape of enteric pathogen exposure of young children in public domains of low-income, urban Kenya: The influence of exposure pathway and spatial range of play on multi-pathogen exposure risks.

Young children are infected by a diverse variety of enteric pathogens in low-income, high-burden countries. Little is known about which conditions pose the greatest risk for enteric pathogen exposure and infection. Young children frequently play in residential public areas around their household, including areas contaminated by human and animal feces, suggesting these exposures are particularly hazardous. The objective of this study was to examine how the dose of six types of common enteric pathogens, and the probability of exposure to one or multiple enteric pathogens for young children playing at public play areas in Kisumu, Kenya is influenced by the type and frequency of child play behaviors that result in ingestion of soil or surface water. Additionally, we examine how pathogen doses and multi-pathogen exposure are modified by spatial variability in the number of public areas children are exposed to in their neighborhood. A Bayesian framework was employed to obtain the posterior distribution of pathogen doses for a certain number of contacts. First, a multivariate mixed effects tobit model was used to obtain the posterior distribution of pathogen concentrations, and their interdependencies, in soil and surface water, based upon empirical data of enteric pathogen contamination in three neighborhoods of Kisumu. Then, exposure doses were estimated using behavioral contact parameters from previous studies and contrasted under different exposure conditions. Pathogen presence and concentration in soil varied widely across local (< 25 meter radius area) and neighborhood-level scales, but pathogens were correlated among distinct surface water samples collected near to each other. Multi-pathogen exposure of children at public play areas was common. Pathogen doses and the probability of multi-pathogen ingestion increased with: higher frequency of environmental contact, especially for surface water; larger volume of soil or water ingested; and with play at multiple sites in the neighborhood versus single site play. Child contact with surface water and soil at public play areas in their neighborhood is an important cause of exposure to enteric pathogens in Kisumu, and behavioral, environmental, and spatial conditions are determinants of exposure.