Alternative Water Transport and Storage Containers: Assessing Sustained Use of the PackH2O in Rural Haiti.

The PackH2O water backpack carrier was developed to provide safe storage and relieve stress of head-loading during water transport with traditional containers such as buckets and jerry cans. We conducted an evaluation to assess both self-reported and observed use over a 6-month period between November 2014 and May 2015. A total of 866 packs were distributed to 618 households in six communities in rural Haiti, and 431 and 441 households were surveyed at midline and end line, respectively. We performed linear regression to assess change of self-reported use over time. Although 79.3% of respondents reported continued use of the 20-L pack after 6 months, other measures of self-reported use were low, with only 16.8% reporting to have used the pack the last time they collected water and 10.3% preferring the pack over other water collection containers. In addition, only 10.2% of all people collecting water at community sources were observed using packs and 12.0% of all households surveyed had water in the pack at the time of visit. Pack use varied by community and demographics. Although women were targeted during distribution, men preferred the pack and were more commonly observed using it at the community water sources. In conclusion, the use of the PackH2O was not widely adopted in rural Haiti; however, further research is needed to assess the pack acceptance in areas where back-loading is more common and in emergency settings.

Notes from the Field: Chlorination Strategies for Drinking Water During a Cholera Epidemic - Tanzania, 2016.

Since August 2015, the Ministry of Health, Community Development, Gender, Elderly and Children (MoHCDGEC) of Tanzania has been leading the response to a widespread cholera outbreak. As of June 9, 2016, cholera had affected 23 of 25 regions in Tanzania, with 21,750 cumulative cases and 341 deaths reported (Ally Nyanga, MoHCDGEC Emergency Operations Center, personal communication, June 2016). Approximately one fourth of all cases occurred in the Dar es Salaam region on the east coast. Regions surrounding Lake Victoria, in the north, also reported high case counts, including Mwanza with 9% (Ally Nyanga, MoHCDGEC Emergency Operations Center, personal communication, June 2016). Since the start of the outbreak, MoHCDGEC and the Ministry of Water (MOW) have collaborated with the Tanzania Red Cross Society, United Nations Children's Fund (UNICEF), World Health Organization (WHO), and CDC to enhance the water, sanitation, and hygiene (WASH) response to prevent the further spread of cholera.

Effects of community-based sales of micronutrient powders on morbidity episodes in preschool children in Western Kenya.

BACKGROUND: Although the use of micronutrient powders (MNPs) is considered the preferred approach for childhood anemia control, concerns about iron-related morbidity from clinical trials have challenged programmatic scale-up. OBJECTIVE: We aimed to measure the effects of community-based sales of MNPs on diarrhea-, fever-, cough-, and malaria-morbidity episodes in children 6-35 mo of age. DESIGN: We conducted a cluster-randomized trial in rural Western Kenya where 60 villages were randomly assigned to either intervention or control groups. MNPs (containing iron, vitamin A, zinc, and 11 other micronutrients) and other health products (e.g., insecticide-treated bednets, soap, and water disinfectant) were marketed in 30 intervention villages from June 2007 to March 2008. Household visits every 2 wk were used to monitor self-reported MNP use and morbidity (illness episodes in the previous 24 h and hospitalizations in the previous 2 wk) in both groups. Iron, vitamin A, anemia, malaria, and anthropometric measures were assessed at baseline and at 12 mo of follow-up. Data were analyzed by intent-to-treat analyses. RESULTS: Of 1062 children enrolled in the study, 1038 children (97.7%) were followed (a total of 14,204 surveillance visits). Mean MNP intake in intervention villages was 0.9 sachets/wk. Children in intervention villages, compared with children in control villages, had ~60% fewer hospitalizations for diarrhea (0.9% compared with 2.4%, respectively; P = 0.03) and 70% fewer hospitalizations for fever (1.8% compared with 5.3%, respectively; P = 0.003) but no significant differences in hospitalizations for respiratory illness (1.1% compared with 2.2%, respectively; P = 0.11) or malaria (3.1% compared with 2.9%, respectively; P = 0.82). There were no differences between groups in the numbers of episodes of diarrhea, cough, or fever. CONCLUSIONS: MNP use in Western Kenya through market-based community sales was not associated with increased infectious morbidity in young children and was associated with decreased hospitalizations for diarrhea and fever. An integrated distribution of MNPs with other health interventions should be explored further in settings with a high child malnutrition and infection burden. This trial was registered at clinicaltrials.gov as NCT01088958.

A qualitative evaluation of hand drying practices among Kenyans.

BACKGROUND: Recommended disease prevention behaviors of hand washing, hygienic hand drying, and covering one's mouth and nose in a hygienic manner when coughing and sneezing appear to be simple behaviors but continue to be a challenge to successfully promote and sustain worldwide. We conducted a qualitative inquiry to better understand current hand drying behaviors associated with activities of daily living, and mouth and nose covering practices, among Kenyans. METHODS AND FINDINGS: We conducted 7 focus group discussions; 30 in-depth interviews; 10 structured household observations; and 75 structured observations in public venues in the urban area of Kisumu; rural communities surrounding Kisumu; and a peri-urban area outside Nairobi, Kenya. Using a grounded theory approach, we transcribed and coded the narrative data followed by thematic analysis of the emergent themes. Hand drying, specifically on a clean towel, was not a common practice among our participants. Most women dried their hands on their waist cloth, called a leso, or their clothes whether they were cooking, eating or cleaning the nose of a young child. If men dried their hands, they used their trousers or a handkerchief. Children rarely dried their hands; they usually just wiped them on their clothes, shook them, or left them wet as they continued with their activities. Many people sneezed into their hands and wiped them on their clothes. Men and women used a handkerchief fairly often when they had a runny nose, cold, or the flu. Most people coughed into the air or their hand. CONCLUSIONS: Drying hands on dirty clothes, rags and lesos can compromise the benefits of handwashing. Coughing and sneezing in to an open hand can contribute to spread of disease as well. Understanding these practices can inform health promotion activities and campaigns for the prevention and control of diarrheal disease and influenza.

A recurrent, multistate outbreak of salmonella serotype agona infections associated with dry, unsweetened cereal consumption, United States, 2008.

An outbreak of Salmonella enterica serotype Agona infections associated with nationwide distribution of cereal from Company X was identified in April 2008. This outbreak was detected using PulseNet, the national molecular subtyping network for foodborne disease surveillance, which coincided with Company X's voluntary recall of unsweetened puffed rice and wheat cereals after routine product sampling yielded Salmonella Agona. A case patient was defined as being infected with the outbreak strain of Salmonella Agona, with illness onset from 1 January through 1 July 2008. Case patients were interviewed using a standard questionnaire, and the proportion of ill persons who reported eating Company X puffed rice cereal was compared with Company X's market share data using binomial testing. The Minnesota Department of Agriculture inspected the cereal production facility and collected both product and environmental swab samples. Routine surveillance identified 33 case patients in 17 states. Of 32 patients interviewed, 24 (83%) reported eating Company X puffed rice cereal. Company X puffed rice cereal represented 0.063% of the total ready-to-eat dry cereal market share in the United States at the time of the investigation. Binomial testing suggested that the proportion of exposed case patients would not likely occur by chance (P < 0.0001). Of 17 cereal samples collected from case patient homes for laboratory testing, 2 (12%) yielded Salmonella Agona indistinguishable from the outbreak strain. Twelve environmental swabs and nine product samples from the cereal plant yielded the outbreak strain of Salmonella Agona. Company X cereal was implicated in a similar outbreak of Salmonella Agona infection in 1998 with the same outbreak strain linked to the same production facility. We hypothesize that a recent construction project at this facility created an open wall near the cereal production area allowing reintroduction of Salmonella Agona into the product, highlighting the resilience of Salmonella in dry food production environments.

Evaluation of the role of school children in the promotion of point-of-use water treatment and handwashing in schools and households--Nyanza Province, Western Kenya, 2007.

We installed drinking water and handwashing stations in 17 rural schools and trained teachers to promote water treatment and hygiene to pupils. We gave schools flocculent-disinfectant powder and hypochlorite solution for water treatment. We conducted a baseline water handling survey of pupils' parents from 17 schools and tested stored water for chlorine. We trained teachers and students about hygiene, installed water stations, and distributed instructional comic books to students. We conducted follow-up surveys and chlorine testing at 3 and 13 months. From baseline to 3-month follow-up, parental awareness of the flocculent-disinfectant increased (49-91%, P < 0.0001), awareness of hypochlorite remained high (93-92%), and household use of flocculent-disinfectant (1-7%, P < 0.0001) and hypochlorite (6-13%, P < 0.0001) increased, and were maintained after 13 months. Pupil absentee rates decreased after implementation by 26%. This school-based program resulted in pupil-to-parent knowledge transfer and significant increases in household water treatment practices that were sustained over 1 year.

Factors associated with E. coli contamination of household drinking water among tsunami and earthquake survivors, Indonesia.

The December 2004 tsunami in Sumatra, Indonesia, destroyed drinking water infrastructure, placing over 500,000 displaced persons at increased risk of waterborne disease. In June 2005, we assessed the relationship of water handling behaviors to household water quality in three districts: Aceh Besar, Simeulue, and Nias. We surveyed 1,127 households from 21 communities and tested stored drinking water. Factors associated with a reduced likelihood of having contaminated stored drinking water included obtaining water from improved sources (Aceh Besar, adjusted odds ratio (aOR) 0.41, P < 0.01; Simeulue, aOR 0.48, P = 0.02), using chlorine solution (Simeulue, aOR 0.41, P < 0.01), and having free chlorine in stored water (Aceh Besar, aOR 0.42, P < 0.01; Nias, aOR 0.28, P < 0.01). Reported boiling, even among those who could describe correct practice, was not associated with improved water quality. Water source improvement and household water chlorination appear to be useful strategies to improve household stored drinking water quality in post-disaster situations.

Description of Babesia duncani n.sp. (Apicomplexa: Babesiidae) from humans and its differentiation from other piroplasms.

The morphologic, ultrastructural and genotypic characteristics of Babesia duncani n.sp. are described based on the characterization of two isolates (WA1, CA5) obtained from infected human patients in Washington and California. The intraerythrocytic stages of the parasite are morphologically indistinguishable from Babesia microti, which is the most commonly identified cause of human babesiosis in the USA. Intraerythrocytic trophozoites of B. duncani n.sp. are round to oval, with some piriform, ring and ameboid forms. Division occurs by intraerythrocytic schizogony, which results in the formation of merozoites in tetrads (syn. Maltese cross or quadruplet forms). The ultrastructural features of trophozoites and merozoites are similar to those described for B. microti and Theileria spp. However, intralymphocytic schizont stages characteristic of Theileria spp. have not been observed in infected humans. In phylogenetic analyses based on sequence data for the complete18S ribosomal RNA gene, B. duncani n.sp. lies in a distinct clade that includes isolates from humans, dogs and wildlife in the western United States but separate from Babesia sensu stricto, Theileria spp. and B. microti. ITS2 sequence analysis of the B. duncani n.sp. isolates (WA1, CA5) show that they are phylogenetically indistinguishable from each other and from two other human B. duncani-type parasites (CA6, WA2 clone1) but distinct from other Babesia and Theileria species sequenced. This analysis provides robust molecular support that the B. duncani n.sp. isolates are monophyletic and the same species. The morphologic characteristics together with the phylogenetic analysis of two genetic loci support the assertion that B. duncani n.sp. is a distinct species from other known Babesia spp. for which morphologic and sequence information are available.