Diarrhoeal disease knowledge among diarrhoea patient housholds: findings from the randomised controlled trial of the Cholera-Hospital-Based-Intervention-for-7-days (CHoBI7) mobile health program.

OBJECTIVE: The objective of this study was to evaluate the impact of the Cholera-Hospital-Based-Intervention-for-7-days (CHoBI7) handwashing with soap and water treatment mobile health (mHealth) program on diarrhoeal disease knowledge among diarrhoea patients and their household members in urban Dhaka, Bangladesh. METHODS: A cluster-randomised controlled trial of the CHoBI7 mHealth program was conducted among diarrhoea patient households in Dhaka, Bangladesh. Patients were randomised to three arms: standard recommendation on oral rehydration solution use; health facility delivery of CHoBI7 plus mHealth (weekly voice and text messages) (no home visits); and health facility delivery of CHoBI7 plus two home visits and mHealth. An open-ended questionnaire was administered to 1468 participants 12 years of age or older on diarrhoeal disease transmission and prevention. These items were combined to form a diarrhoeal disease knowledge score measured at baseline and at a 1 week, 6 month and 12 month follow-up. RESULTS: At baseline, when participants were asked to report three ways diarrhoeal diseases were spread 37% (546/1468) of participants reported by water, 13% (187/1468) by lack of handwashing and 4% (53/1468) by food not being covered properly. At baseline when asked to name three ways diarrhoeal diseases could be prevented, 35% (515/1468) of participants reported safe water, and 16% (228/1468) reported handwashing with soap. At the 12-month follow-up, the overall diarrhoeal disease knowledge score was significantly higher in the mHealth with no home visits arm (score coefficient: 0.69, 95% Confidence Interval: 0.36, 1.01, P < 0.0001) and the mHealth with two home visits arm (score coefficient: 1.18, 95% CI: 0.87, 1.49, P < 0.0001) compared with the standard recommendation arm. CONCLUSION: The CHoBI7 mHealth program significantly increased knowledge of diarrhoeal disease transmission and prevention among diarrhoea patients and their household members 12 months after in-person visits for program delivery were conducted.

OBJECTIF: L'objectif de cette étude était d'évaluer l'impact du programme CHoBI7 (Cholera-Hospital-Based-Intervention-for-7-days) de santé mobile (mHealth) sur la connaissance sur les maladies diarrhéiques chez les patients atteints de diarrhée et les membres de leur ménage dans la ville de Dhaka, au Bangladesh. MÉTHODES: Un essai contrôlé randomisé par grappes du programme mHealth CHoBI7 a été mené auprès de ménages de patients atteints de diarrhée à Dhaka, au Bangladesh. Les patients ont été randomisés dans trois groupes: recommandation standard sur l'utilisation de solutions de réhydratation orale; délivrance du programme CHoBI7 dans les services de santé plus mHealth (pas de visites à domicile); et délivrance du programme CHoBI7 dans les services de santé plus deux visites à domicile et mHealth. Un questionnaire ouvert a été administré à 1.468 participants âgés de 12 ans ou plus sur la transmission et la prévention des maladies diarrhéiques. Ces éléments ont été combinés pour former un score de connaissance sur les maladies diarrhéiques mesuré au départ et à 1 semaine, 6 mois et 12 mois. RÉSULTATS: Au départ, lorsqu'il a été demandé aux participants d'indiquer trois modes de propagation des maladies diarrhéiques, 37% (546/1468) des participants ont indiqué que ces maladies étaient transmises par l'eau, 13% (187/1468) par le manque de lavage des mains et 4% (53/1468) par le fait que les aliments n'étaient pas correctement couverts. Au départ, lorsqu'on leur a demandé de citer trois moyens de prévention des maladies diarrhéiques, 35% (515/1468) des participants ont cité l'accès à l'eau potable et 16% (228/1468) ont cité le lavage des mains avec du savon. Lors du suivi à 12 mois, le score global de connaissance sur la diarrhée était significativement plus élevé dans le bras mHealth sans visites à domicile (coefficient de score: 0,69, intervalle de confiance à 95%: 0,36-1,01; P < 0,0001) et le volet mHealth avec deux visites à domicile (coefficient de score: 1,18; IC 95%: 0,87-1,50; P < 0,0001) par rapport au bras de recommandation standard. CONCLUSION: Ces résultats suggèrent que le programme mHealth de CHoBI7 présente une approche prometteuse pour accroître les connaissances sur les maladies diarrhéiques dans les ménages de patients atteints de diarrhée.

Effect of a water, sanitation and hygiene program on handwashing with soap among household members of diarrhoea patients in healthcare facilities in Bangladesh: a cluster-randomised controlled trial of the CHoBI7 mobile health program.

OBJECTIVE: The Cholera-Hospital-Based-Intervention-for-7-days (CHoBI7) is a water treatment and handwashing with soap intervention for diarrhoea patients and their household members which is initially delivered in a healthcare facility setting. This study evaluated the effectiveness of CHoBI7 program delivery in increasing handwashing with soap in a healthcare facility setting among diarrhoea patients and their household members. METHODS: A randomised controlled trial of the CHoBI7 program was conducted among 404 diarrhoea patients and their accompanying household members in healthcare facilities in Dhaka, Bangladesh. The 'Standard Message' Arm received the standard message given in Bangladesh to diarrhoea patients on the use of oral rehydration solution. The 'Health Facility Visit + Soapy Water' Arm received the standard message, the CHoBI7 communication module delivered bedside to the patient; and a soapy water bottle in the healthcare facility. The 'Health Facility Visit + Handwashing Station' Arm received this same intervention plus a small plastic handwashing station. Within 24 h of intervention delivery, three-hour structured observation of handwashing practices at stool/vomit- and food-related events (key events) was conducted in healthcare facilities of diarrhoea patients and their accompanying household members. RESULTS: Compared to the Standard Message Arm, there was significantly more handwashing with soap at key events in both the Health Facility Visit + Soapy Water Arm (51% vs. 25 %) (Odds Ratio: 3.02; (95% Confidence Interval (CI): 1.41, 6.45) and the Health Facility Visit + Handwashing Station Arm (58% vs. 25%) OR: 4.12; (95% CI: 1.86, 9.14). CONCLUSION: These findings demonstrate that delivery of the CHoBI7 communication module and provision of a soapy water bottle to diarrhoea patients and their accompanying household members presents a promising approach to increase handwashing with soap among this high risk population in a healthcare facility setting in Bangladesh.

OBJECTIF: Le programme (CHoBI7Cholera-Hospital-Based-Intervention-for-7-days) est une intervention de traitement de l'eau et de lavage des mains avec du savon pour les patients et les membres de leur famille qui est initialement administrée dans un établissement de santé. Cette étude a évalué l'efficacité du programme CHoBI7 pour augmenter le lavage des mains au savon dans les établissements de santé. MÉTHODES: Un essai contrôlé randomisé du programme CHoBI7 a été mené auprès de 404 patients atteints de diarrhée et des membres de leur famille qui les accompagnent dans des établissements de santé à Dhaka, au Bangladesh. Le bras "Message standard" a reçu le message standard donné au Bangladesh aux patients atteints de diarrhée sur l'utilisation de la solution de réhydratation orale. Le bras "Visite de l'établissement de santé + eau savonneuse" a reçu le message standard, le module de communication CHoBI7 a été délivré au chevet du patient et une bouteille d'eau savonneuse dans l'établissement de santé. Le bras "Visite de l'établissement de santé + station de lavage des mains" a reçu la même intervention, ainsi qu'une petite station de lavage des mains en plastique. Dans les 24 heures suivant l'intervention, une observation structurée de trois heures des pratiques de lavage des mains lors d'événements liés aux selles/vomis et à la nourriture (événements clés) a été menée dans les établissements de santé. RÉSULTATS: Par rapport au bras 'Message standard', le lavage des mains au savon était significativement plus fréquent lors des événements clés dans le bras 'Visite de l'établissement de santé + Station de lavage des mains' (58% contre 25%) (rapport de cotes (OR): 4,12 ; (intervalle de confiance (IC) de 95%: 1,86-9,14) et dans le bras 'Visite de l'établissement de santé + Eau savonneuse' (51% contre 25%) (OR: 3,02 ; (IC95% : 1,41-6,45). CONCLUSION: Ces résultats démontrent que l'implémentation du module CHoBI7 constitue une approche prometteuse pour augmenter le lavage des mains au savon dans un établissement de santé au Bangladesh.

Prospective cohort study of child mouthing of faeces and fomites in Dhaka, Bangladesh (CHoBI7 Program).

OBJECTIVE: To characterise childhood mouthing and handling behaviours and to assess the association between hand-to-object and object-to-mouth contacts and diarrhoea prevalence in young children in urban Dhaka, Bangladesh. METHODS: A prospective cohort study was conducted among 494 children under 5 years of age in Dhaka, Bangladesh. This study was nested within the randomised controlled trial of the Cholera Hospital-Based Intervention for 7 Days (CHoBI7) mobile health (mHealth) program. The CHoBI7 mHealth program focuses on promoting handwashing with soap and water treatment to diarrhoea patients and their household members through mobile messages and a single in person visit. Mouthing and handling of faeces and fomites among young children was measured by five-hour structured observation and caregiver reports. Diarrhoea surveillance data was collected monthly for 12 months. RESULTS: Fifty five percent of caregivers reported that their child put a visibly dirty fomite (object or soil) in their mouth in the past week. Caregivers reported that 50% of children had mouthed visibly dirty objects, 26% had mouthed dirt, and 2% had mouthed faeces. Forty five percent of children were observed mouthing a visibly dirty fomite during structured observation, 40% of children were observed mouthing a visibly dirty object, 10% were observed mouthing soil, and one child (0.2%) was observed mouthing faeces. Mouthing of visibly dirty fomites was highest for children 12-18 months of age with 69% of these children having caregiver reports and 54% having observed events. Children with caregiver reports of mouthing faeces had a significantly higher odds of diarrhoea over the subsequent month (Odds Ratio: 4.54; 95% Confidence Interval: 1.06, 19.48). CONCLUSION: These findings demonstrate that mouthing of contaminated fomites among young children is frequent in urban environments in Bangladesh, and that mouthing faeces is associated with a significantly higher odds of diarrhoea. Interventions are urgently needed to protect young children from faecal pathogens in their play spaces.

OBJECTIF: Caractériser les comportements de mâchouillement et de manipulation par les enfants et évaluer l'association entre les contacts main-objet et objet-bouche et la prévalence de la diarrhée chez les jeunes enfants dans la ville de Dhaka, au Bangladesh. MÉTHODES: Une étude de cohorte prospective a été menée auprès de 494 enfants de moins de 5 ans à Dhaka, au Bangladesh. Cette étude s'inscrivait dans le cadre de l'essai contrôlé randomisé du programme CHoBI7 (Cholera-Hospital-Based-Intervention-for-7-days) de santé mobile (mHealth. Le programme de santé mobile CHoBI7 se concentre sur la promotion du traitement de l'eau et du lavage des mains avec à l'eau et au savon aux patients atteints de diarrhée et aux membres de leur foyer par le biais de messages mobiles et de visites de face à face. Le mâchouillement et la manipulation des excréments et des fomites chez les jeunes enfants ont été mesurés par des observations structurées de cinq heures et par les rapports des personnes s'occupant d'enfants (soignants). Les données de surveillance de la diarrhée ont été recueillies chaque mois pendant 12 mois. RÉSULTATS: 55% des soignants ont déclaré que leur enfant avait mis un fomite visiblement sale (objet ou terre) dans sa bouche au cours de la semaine précédente. Les soignants ont indiqué que 50% des enfants avaient mâchouillé des objets visiblement sales, 26% avaient mâchouillé de la terre et 2% avaient mâchouillé des excréments. 45% des enfants ont été observés en train de mâchouiller un fomite visiblement sale au cours d'une observation structurée. 40% des enfants ont été observés en train de mâchouiller un objet, 10% ont été observés en train de mâchouiller de la terre et un enfant (0,2%) a été observé en train de mâchouiller des excréments. Le mâchouillement de fomites visiblement sales était le plus fréquent chez les enfants de 12 à 18 mois; 69% de ces enfants ont été signalés par les soignants et 54% ont été observés en train de le faire. Les enfants dont les soignants avaient signalé un mâchouillement d'excréments présentaient un risque de diarrhée nettement plus élevé au cours du mois suivant (rapport de cotes: 4,54; intervalle de confiance à 95%: 1,06-19,48). CONCLUSION: Ces résultats démontrent que le fait de mâchouiller des fomites contaminés chez les jeunes enfants est fréquent en milieu urbain au Bangladesh et que le fait de mâchouiller des excréments est associé à un risque de diarrhée nettement plus élevé. Des interventions sont urgemment nécessaires pour protéger les jeunes enfants des agents pathogènes fécaux dans leurs espaces de jeu.

Process evaluation for the delivery of a water, sanitation and hygiene mobile health program: findings from the randomised controlled trial of the CHoBI7 mobile health program.

OBJECTIVE: The Cholera-Hospital-Based Intervention for 7-days (CHoBI7) mobile health (mHealth) program delivers mobile messages to diarrhoea patient households promoting water treatment and handwashing with soap. The randomised controlled trial (RCT) of the CHoBI7 mHealth program demonstrated this intervention was effective in significantly reducing diarrhoea and stunting amoung young children. The objective of this study was to assess the implementation of the CHoBI7 mHealth program in delivering mHealth messages during this RCT. METHODS: 517 diarrhoea patient households with 1777 participants received weekly text, voice and interactive voice response (IVR) messages from the CHoBI7 mHealth program over the 12-month program period. The program process evaluation indicators were the following: the percentage of CHoBI7 mHealth messages received and fully listened to by program households (program fidelity and dose), and household members reporting receiving and sharing an mHealth message from the program in the past two weeks (program reach). RESULTS: Ninety two percent of text messages were received by program households. Eighty three percent of voice and 86% of IVR messages sent were fully listened to by at least one household member. Eighty one percent of IVR quiz responses from households were answered correctly. Program households reported receiving a CHoBI7 mHealth message in the past two weeks at 79% of monthly household visits during the 12-month program. Seventy seven percent of participants reported sharing a program message with a spouse, 55% with a neighbour and 49% with a child during the program period. CONCLUSION: There was high fidelity, dose and reach of mobile messages delivered for the CHoBI7 mHealth program. This study presents an approach for process evaluation that can be implemented to evaluate future mHealth programs.

OBJECTIF: Le programme CHoBI7 (Cholera-Hospital-Based-Intervention-for-7-days) de santé mobile (mHealth) délivre des messages mobiles aux ménages avec patients atteints de diarrhée pour promouvoir le traitement de l'eau et le lavage des mains au savon. L'essai contrôlé randomisé (ECR) du programme mHealth CHoBI7 a démontré que cette intervention était efficace pour réduire de manière significative la diarrhée et le retard de croissance chez les jeunes enfants. L'objectif de cette étude était d'évaluer la mise en œuvre du programme CHoBI7 mHealth dans la diffusion des messages mHealth au cours de cet ECR. MÉTHODES: 517 ménages avec des patients atteints de diarrhée ont reçu chaque semaine des messages SMS, vocaux et de réponse vocale interactive (RVI) du programme mHealth de CHoBI7 pendant les 12 mois du programme. Les indicateurs d'évaluation du processus du programme étaient les suivants: le pourcentage de messages mHealth du programme CHoBI7 reçus (fidélité au programme et dose) et entièrement écoutés par les ménages participant au programme (fidélité au programme et dose) et les bénéficiaires déclarant avoir reçu et partagé un message mHealth du programme (portée du programme) au cours des deux dernières semaines. RÉSULTATS: 92% des SMS ont été reçus par les ménages participant au programme. 83% des messages vocaux et 86% des messages RVI envoyés ont été entièrement écoutés par au moins un membre du ménage. 81% des réponses aux quiz RVI des ménages ont été correctement répondues. Les ménages du programme ont déclaré avoir reçu un message CHoBI7 mHealth au cours des deux dernières semaines dans 79% des visites mensuelles des ménages pendant les 12 mois du programme. 77% des participants ont déclaré avoir partagé un message du programme avec un conjoint, 55% avec un voisin et 49% avec un enfant pendant la durée du programme. CONCLUSION: La dose et les messages délivrés dans le cadre du programme mHealth de CHoBI7 l'ont été avec une fidélité élevée. Cette étude présente une approche d'évaluation des processus qui peut être mise en œuvre pour évaluer les futurs programmes mHealth.

Child mouthing of soil and presence of animals in child sleeping spaces are associated with growth faltering among young children in Dhaka, Bangladesh (CHoBI7 Program).

OBJECTIVE: The objective of the study was to investigate potential risk factors for growth faltering among children under 5 years of age. METHOD: We conducted a prospective cohort study of 553 children under 5 years from diarrhoea patient households in urban Dhaka, Bangladesh. Height and weight measurements were obtained at baseline and at a 12-month follow-up. Caregivers of young children were administered a monthly questionnaire on household sociodemographic characteristics and hygiene practices. RESULTS: Children with caregiver reports of mouthing soil at the majority of household visits had a significant reduction in their height-for-age z-scores (HAZ) from baseline to the 12-month follow-up (ΔHAZ: -0.28 (95% confidence interval (CI): -0.51, -0.05)). A significant reduction in HAZ was also observed for children in households with animals in their sleeping space (ΔHAZ: -0.37 (95% CI: -0.71, -0.04)). CONCLUSION: These findings provide further evidence to support the hypothesis that child mouthing of soil and the presence of animals in the child's sleeping space are potential risk factors for growth faltering among young children. Interventions are urgently needed to provide clean play and sleeping spaces for young children to reduce exposure to faecal pathogens through child mouthing.

OBJECTIF: L'objectif de l'étude était d'examiner les facteurs de risque potentiels de retard de croissance chez les enfants de moins de 5 ans. MÉTHODE: Nous avons mené une étude de cohorte prospective sur 553 enfants de moins de 5 ans provenant de ménages avec des patients diarrhéiques dans la ville de Dhaka, au Bangladesh. Les mesures de taille et de poids ont été obtenues au départ et à 12 mois de suivi. Les personnes s'occupant de jeunes enfants (les gardiens) ont reçu un questionnaire mensuel sur les caractéristiques sociodémographiques des ménages et les pratiques d'hygiène. RÉSULTATS: Les enfants pour lesquels les gardiens ont déclaré qu'ils mâchouillaient de la terre lors de la majorité des visites à domicile présentaient une diminution du score Z de taille pour l'âge (TAZ) de manière significative de l'âge de référence au 12 mois de suivi (ΔTAZ −0,28 (intervalle de confiance (IC) à 95%: −0,51, −0,05)). Une réduction significative des TAZ a également été observée pour les enfants des ménages ayant des animaux dans leur espace de couchage (ΔTAZ −0,37 (IC95%: −0,71, −0,04)). CONCLUSION: Ces résultats apportent des données supplémentaires pour appuyer l'hypothèse selon laquelle le fait que l'enfant mâchouille de la terre et la présence d'animaux dans son espace de couchage sont des facteurs de risque potentiels de retard de croissance chez les jeunes enfants. Des interventions sont urgemment nécessaires pour fournir des espaces de jeu et de sommeil sains aux jeunes enfants afin de réduire l'exposition aux agents pathogènes fécaux par le mâchouillement des enfants.

Effectiveness of a large-scale handwashing promotion intervention on handwashing behaviour in Dhaka, Bangladesh.

OBJECTIVE: The behavioural effect of large-scale handwashing promotion programmes has been infrequently evaluated, and variation in the effect over time has not been described. We assess the effect of a large-scale handwashing promotion programme on handwashing outcomes in a community setting in Dhaka, Bangladesh. METHODS: We analysed data from a cluster-randomised trial that included three arms: vaccine-and-behaviour-change intervention (VBC), vaccine-only (V) and no intervention (Control). Data collectors randomly selected different subsets of households each month during the study period and assessed: (i) temporal variation in availability of soap and water at handwashing place; (ii) the use of water and soap by participants when asked to demonstrate handwashing, and; (iii) handwashing behaviour according to structured observation. We used log-binomial regression analyses to calculate prevalence ratios (PRs) and 95% confidence intervals and compare outcomes by study arms. RESULTS: Data collectors surveyed 9325 households over 28 months. In VBC, there was a significant positive trend on availability of water and soap from baseline to 9 months after the start of the intervention (P-for-trends <0.001), and no significant trend during months 10-28 (P-for-trend = 0.297). In the entire study period, availability of water and soap was higher in VBC (43%) than in V (23%) (PR = 1.92; CI = 1.72, 2.15) and Control (28%) (PR = 1.53; CI = 1.38, 1.69) households. There were no differences between study arms with regard to use of soap during handwashing demonstrations. Observed handwashing with soap after toilet use was higher in VBC (17%) than in V (8%) (PR = 1.47, CI = 0.58, 3.75) and Control (2%) (PR = 3.47, CI = 0.48, 23.33) groups. At other possible pathogen transmission events, the prevalence of handwashing with soap was ≤3%. CONCLUSION: VBC households maintained soap and water for handwashing, but the prevalence of observed handwashing was low in all study arms. The results underscore the need to strengthen scalable behaviour change approaches.

OBJECTIF: L'effet sur le comportement des programmes de promotion du lavage des mains à grande échelle a été rarement évalué et aucune variation de cet effet dans le temps n'a été décrite. Nous évaluons les effets d'un programme de promotion du lavage des mains à grande échelle sur les résultats dans un cadre communautaire à Dhaka, au Bangladesh. MÉTHODES: Nous avons analysé les données d'un essai randomisé par grappes comprenant 3 groupes: intervention vaccin-changement de comportement (VBC), vaccin uniquement (V) et aucune intervention (contrôle). Les collecteurs de données ont sélectionné au hasard différents sous-ensembles de ménages chaque mois au cours de la période d'étude et ont évalué: 1) la variation temporelle de la disponibilité de savon et d'eau sur le lieu de lavage des mains, 2) l'utilisation d'eau et de savon par les participants lorsqu'on leur a demandé de faire la démonstration du lavage des mains, 3) le comportement du lavage des mains selon une observation structurée. Nous avons utilisé des analyses de régression log-binomiales pour calculer les ratios de prévalence (PR) et les intervalles de confiance à 95%, ainsi que pour comparer les résultats par groupe d'étude. RÉSULTATS: Les collecteurs de données ont interrogé 9325 ménages au cours de 28 mois. Dans le groupe VBC, il y avait une tendance positive significative sur la disponibilité d'eau et de savon de la ligne de base à 9 mois après le début de l'intervention (p-pour-tendances <0,001) et aucune tendance significative au cours des mois 10 à 28 (p-pour- tendance = 0,297). Sur l'ensemble de la période d'étude, la disponibilité en eau et en savon était plus élevée dans le groupe VBC (43%) que dans le groupe V (23%) (PR = 1,92; IC: 1,72 - 2,15) et dans le groupe contrôle (28%) (PR = 1,53; IC: 1,38 - 1,69). Il n'y avait pas de différence entre les groupes d'étude en ce qui concerne l'utilisation de savon lors de démonstrations de lavage des mains. Le lavage des mains observé avec du savon après l'utilisation des toilettes était plus élevé dans le groupe VBC (17%) que dans le groupe V (8%) (PR = 1,47; IC: 0,58 - 3,75) et dans le groupe témoin (2%) (PR = 3,47, IC: 0,48 - 23,33). Lors d'autres événements possibles de transmission d'agents pathogènes, la fréquence du lavage des mains au savon était ≤ 3%. CONCLUSION: Les ménages du groupe VBC ont maintenu du savon et de l'eau pour se laver les mains, mais la prévalence du lavage des mains observé était faible dans tous les groupes de l'étude. Les résultats soulignent la nécessité de renforcer les approches évolutives de changement de comportement.

Enteric Infections in Young Children are Associated with Environmental Enteropathy and Impaired Growth.

OBJECTIVE: To investigate the relationship between faecal contamination in child play spaces, enteric infections, environmental enteropathy (EE) and impaired growth among young children. METHODS: A prospective cohort study was conducted of 203 children 6-30 months of age in rural Bangladesh. Stool samples were analysed by quantitative PCR for Shigella, Enterotoxigenic Escherichia coli (ETEC), Campylobacter jejuni, Giardia intestinalis and Cryptosporidium spp. Four faecal markers of intestinal inflammation were also measured: alpha-1-antitrypsin, myeloperoxidase, neopterin and calprotectin. Child growth was measured at baseline and 9 months after enrolment. E. coli was measured in soil in child play spaces. RESULTS: Forty-seven percent of study children had three or more enteric pathogens in their stool. Thirty five percent (71/203) of children had Shigella, 30% (61/203) had ETEC, 73% (148/203) had C. jejuni, 79% (160/203) had Giardia intestinalis and none had Cryptosporidium. Children with ETEC had significantly higher calprotectin concentrations (Coefficient: 1.35, 95% Confidence Interval [CI]: 1.005, 1.82). Children with Shigella had a significantly higher odds of being stunted at our 9-month follow-up (OR: 2.01, 95% CI: 1.02, 3.93). Children with Giardia intestinalis had significantly higher E.coli counts in the soil collected from their play spaces (OR: 1.23, 95% CI: 1.02, 1.48). CONCLUSION: Enteric infections were significantly associated with EE and impaired growth in rural Bangladesh. These findings provide further evidence to support the hypothesis that contaminated soil in child play spaces can lead to enteric infections, many of which are likely subclinical, resulting in EE and impaired growth in young children.

Mouthing of Soil Contaminated Objects is Associated with Environmental Enteropathy in Young Children.

OBJECTIVE: To characterise childhood mouthing behaviours and to investigate the association between object-to-mouth and food-to-mouth contacts, diarrhoea prevalence and environmental enteropathy. METHODS: A prospective cohort study was conducted of 216 children ≤30 months of age in rural Bangladesh. Mouthing contacts with soil and food and objects with visible soil were assessed by 5-h structured observation. Stool was analysed for four faecal markers of intestinal inflammation: alpha-1-antitrypsin, myeloperoxidase, neopterin and calprotectin. RESULTS: Overall 82% of children were observed mouthing soil, objects with visible soil, or food with visible soil during the structured observation period. Sixty two percent of children were observed mouthing objects with visible soil, 63% were observed mouthing food with visible soil, and 18% were observed mouthing soil only. Children observed mouthing objects with visible soil had significantly elevated faecal calprotectin concentrations (206.81 µg/g, 95% confidence interval [CI]: 6.27, 407.36). There was also a marginally significant association between Escherichia coli counts in soil from a child's play space and the prevalence rate of diarrhoea (diarrhoea prevalence ratio: 2.03, 95% CI 0.97, 4.25). CONCLUSION: These findings provide further evidence to support the hypothesis that childhood mouthing behaviour in environments with faecal contamination can lead to environmental enteropathy in susceptible paediatric populations. Furthermore, these findings suggest that young children mouthing objects with soil, which occurred more frequently than soil directly (60% vs. 18%), was an important exposure route to faecal pathogens and a risk factor for environmental enteropathy.

Randomized Controlled Trial of Hospital-Based Hygiene and Water Treatment Intervention (CHoBI7) to Reduce Cholera.

The risk for cholera infection is >100 times higher for household contacts of cholera patients during the week after the index patient seeks hospital care than it is for the general population. To initiate a standard of care for this high-risk population, we developed Cholera-Hospital-Based-Intervention-for-7-Days (CHoBI7), which promotes hand washing with soap and treatment of water. To test CHoBI7, we conducted a randomized controlled trial among 219 intervention household contacts of 82 cholera patients and 220 control contacts of 83 cholera patients in Dhaka, Bangladesh, during 2013-2014. Intervention contacts had significantly fewer symptomatic Vibrio cholerae infections than did control contacts and 47% fewer overall V. cholerae infections. Intervention households had no stored drinking water with V. cholerae and 14 times higher odds of hand washing with soap at key events during structured observation on surveillance days 5, 6, or 7. CHoBI7 presents a promising approach for controlling cholera among highly susceptible household contacts of cholera patients.

Feasibility and effectiveness of oral cholera vaccine in an urban endemic setting in Bangladesh: a cluster randomised open-label trial.

BACKGROUND: Cholera is endemic in Bangladesh with epidemics occurring each year. The decision to use a cheap oral killed whole-cell cholera vaccine to control the disease depends on the feasibility and effectiveness of vaccination when delivered in a public health setting. We therefore assessed the feasibility and protective effect of delivering such a vaccine through routine government services in urban Bangladesh and evaluated the benefit of adding behavioural interventions to encourage safe drinking water and hand washing to vaccination in this setting. METHODS: We did this cluster-randomised open-label trial in Dhaka, Bangladesh. We randomly assigned 90 clusters (1:1:1) to vaccination only, vaccination and behavioural change, or no intervention. The primary outcome was overall protective effectiveness, assessed as the risk of severely dehydrating cholera during 2 years after vaccination for all individuals present at time of the second dose. This study is registered with ClinicalTrials.gov, number NCT01339845. FINDINGS: Of 268,896 people present at baseline, we analysed 267,270: 94,675 assigned to vaccination only, 92,539 assigned to vaccination and behavioural change, and 80,056 assigned to non-intervention. Vaccine coverage was 65% in the vaccination only group and 66% in the vaccination and behavioural change group. Overall protective effectiveness was 37% (95% CI lower bound 18%; p=0·002) in the vaccination group and 45% (95% CI lower bound 24%; p=0·001) in the vaccination and behavioural change group. We recorded no vaccine-related serious adverse events. INTERPRETATION: Our findings provide the first indication of the effect of delivering an oral killed whole-cell cholera vaccine to poor urban populations with endemic cholera using routine government services and will help policy makers to formulate vaccination strategies to reduce the burden of severely dehydrating cholera in such populations. FUNDING: Bill & Melinda Gates Foundation.

Unsafe Child Feces Disposal is Associated with Environmental Enteropathy and Impaired Growth.

OBJECTIVE: To investigate the relationship between unsafe child feces disposal, environmental enteropathy, and impaired growth, we conducted a prospective cohort study of 216 young children in rural Bangladesh. STUDY DESIGN: Using a prospective cohort study design in rural Bangladesh, unsafe child feces disposal, using the Joint Monitoring Program definition, was assessed using 5-hour structured observation by trained study personnel as well as caregiver reports. Anthropometric measurements were collected at baseline and at a 9-month follow-up. Stool was analyzed for fecal markers of environmental enteropathy: alpha-1-antitrypsin, myeloperoxidase, neopterin (combined to form an environmental enteropathy disease activity score), and calprotectin. FINDINGS: Among 216 households with young children, 84% had an unsafe child feces disposal event during structured observation and 75% had caregiver reported events. There was no significant difference in observed unsafe child feces disposal events for households with or without an improved sanitation option (82% vs 85%, P = .72) or by child's age (P = .96). Children in households where caregivers reported unsafe child feces disposal had significantly higher environmental enteropathy scores (0.82-point difference, 95% CI 0.11-1.53), and significantly greater odds of being wasted (weight-for-height z score <-2 SDs) (9% vs 0%, P = .024). In addition, children in households with observed unsafe feces disposal had significantly reduced change in weight-for-age z-score (-0.34 [95% CI -0.68, -0.01] and weight-for-height z score (-0.52 [95% CI -0.98, -0.06]). CONCLUSION: Unsafe child feces disposal was significantly associated with environmental enteropathy and impaired growth in a pediatric population in rural Bangladesh. Interventions are needed to reduce this high-risk behavior to protect the health of susceptible pediatric populations.

Geophagy Is Associated with Growth Faltering in Children in Rural Bangladesh.

OBJECTIVE: To determine the relationship between geophagy (mouthing of dirt, sand, clay, or mud) and growth faltering in young children. STUDY DESIGN: We examined linear growth as height and weight standardized by age and sex, and weight standardized by height, in a cohort of children aged 6-36 months in rural Mirzapur, Bangladesh. We determined geophagy behavior at baseline through caregiver report. Anthropometric measurements were assessed at baseline and at a 1-year follow-up. RESULTS: We found that among children not stunted at baseline, those with caregiver-reported geophagy at baseline grew less over 1 year compared with their peers, with a difference in the change of standardized height for age and sex of -0.31 (95% CI, -0.61 to -0.01). CONCLUSION: These findings show that caregiver-reported geophagy was associated with growth faltering in a pediatric population in rural Bangladesh. Future studies are needed to learn more about this exposure pathway and its relevance to child growth.

Food Hygiene and Fecal Contamination on the Household Compound are Associated with Increased Pediatric Diarrhea in Urban Bangladesh (CHoBI7 Program).

In this prospective cohort study, we explored individual- and household-level risk factors associated with diarrheal diseases among 251 children younger than 5 years in slum areas of urban Dhaka, Bangladesh. During the 3-month study period, diarrhea surveillance was conducted monthly, and spot checks of the household compound were performed at baseline to assess the presence of feces (animal or human) in the household compound and in cooking and food storage areas, and to assess whether cooked food was covered and refrigerated. We also collected caregiver reports on child mouthing behaviors. Children living in households with feces within 10 steps of cooking and food storage areas (odds ratio [OR], 8.43; 95% CI, 1.01-70.18), those with visible feces found on the ground of the household compound (OR, 4.05; 95% CI, 1.24-13.22), and those in households found to keep cooked food uncovered and without refrigeration (OR, 6.16; 95% CI, 1.11-34.25) during spot checks had a significantly greater odds of diarrhea. There was no significant association between pediatric diarrhea and caregiver-reported child mouthing behaviors or presence of animals in the cooking area. These study findings demonstrate that presence of visible feces in the household compound and near cooking and food storage areas, and poor household food hygiene practices, were significant risk factors for diarrheal disease among young children in Dhaka, Bangladesh. Health communication programs are needed to target these exposure pathways to fecal pathogens.

Low Fruit and Vegetable Consumption Associated with Linear Growth Faltering among Children in Urban Bangladesh.

The objective of this study was to examine the association between dietary diversity and child growth among children 6 to 23 months of age in urban slums of Bangladesh. This prospective cohort study enrolled 192 participants 6 to 23 months of age in Dhaka, Bangladesh. A total of 170 children with follow-up anthropometric data were included in the analysis. To collect dietary intake information for children 6 to 23 months of age, consumption of five or more of the following eight minimum dietary diversity food groups was recorded using 24-hour dietary recall at enrollment provided by the child's caregiver: 1) breast milk; 2) grains, roots, and tubers; 3) legumes and nuts; 4) dairy products; 5) flesh foods; 6) eggs; 7) vitamin A-rich fruits and vegetables; and 8) other fruits and vegetables. Height and weight were measured at baseline and at a 12-month follow-up. Fifty-five percent of children (106 of 192) consumed five or more of the eight minimum dietary diversity food groups during their first visit to assess dietary intake. Eighty-two percent of children (157 of 192) had a report of consuming an animal source of food (e.g., eggs, diary, flesh foods) in the past 24 hours, 85% (164 of 192) consumed any source of protein (e.g., eggs, diary, flesh foods, nuts, and legumes), and 65% of children (125 of 192) were reported to consume any fruits and vegetables. Child consumption of fruits and vegetables was associated positively with change in length-for-age z-scores from baseline to the 12-month follow-up (coefficient, 0.86; 95% CI, 0.03-1.68). Inadequate fruit and vegetable consumption was associated with linear growth faltering among the young children residing in urban Dhaka, Bangladesh. These findings demonstrate the need for effective interventions to increase fruit and vegetable consumption in this susceptible pediatric population.

Fecal Sampling of Soil, Food, Hand, and Surface Samples from Households in Urban Slums of Dhaka, Bangladesh: An Evidence-Based Development of Baby Water, Sanitation, and Hygiene Interventions.

The aim of this study was to identify the exposure pathways of fecal pathogens for a pediatric population living in the urban slums of Bangladesh. A total of 252 soil, food, surface, and hand rinse samples were collected from the pilot households with children less than 5 years of age. All samples were analyzed using the IDEXX Quanti-Tray System (Colilert-18) to enumerate fecal indicator bacteria Escherichia coli. Escherichia coli was detected in all soil samples collected from children play spaces (N = 46), 35% of objects and surfaces children frequently put in their mouths, and 31% of child food samples. Thirty-three percent of hand samples from the child and 46% of hand samples from the caregiver had detectable E. coli. These findings showed high fecal contamination of soil, food, and on hands and surfaces in households with young children and demonstrate the need for interventions reducing these exposure pathways for susceptible pediatric populations.

Fecal Contamination on the Household Compound and in Water Sources are Associated with Subsequent Diarrhea in Young Children in Urban Bangladesh (CHoBI7 Program).

We investigated the environmental and individual-level risk factors for diarrheal disease among young children in slum areas of Dhaka, Bangladesh. A prospective cohort study was conducted among 884 children under 5 years of age. Caregiver reports were collected on sociodemographic factors and hygiene behaviors. Diarrhea surveillance data was collected monthly based on caregiver-reported diarrhea for children in the past 2 weeks during the 12-month study period. Unannounced spot checks of the household compound were performed at 1, 3, 6, 9, and 12 months after enrollment to check for the presence of feces (animal or human) and the presence of animals in the child's sleeping space, to assess child and caregiver hands for the presence of dirt, and to collect samples of the household's source and stored drinking water. Children with feces found on the household compound during spot checks had a significantly higher odds of diarrhea (odds ratio: 1.71; 95% confidence interval: 1.23-2.38). Children residing in households with > 100 colony forming units/100 mL Escherichia coli in source drinking water had a significantly higher odds of diarrhea (OR: 1.43; 95% CI: 1.06-1.92). The presence of feces on the household compound and source drinking water with > 100 colony forming units/100 mL E. coli were significant risk factors for diarrheal disease for children < 5 years of age in slum areas of Dhaka, Bangladesh. These findings demonstrate the urgent need for comprehensive interventions to reduce fecal contamination on the household compound to protect the health of susceptible pediatric populations.

Formative Research for the Design of a Baby Water, Sanitation, and Hygiene Mobile Health Program in Bangladesh (CHoBI7 Mobile Health Program).

Poor food hygiene practices, child feces not being disposed of in a latrine, child mouthing of contaminated fomites, and poor hand hygiene of caregivers have been associated with diarrheal diseases, environmental enteropathy, and impaired growth in young children. Mobile health (mHealth) programs present a low-cost approach to delivering water, sanitation, and hygiene (WASH) programs. We conducted a theory-driven and evidence-based approach to formative research and intervention development to design and pilot test a Baby WASH mHealth program targeting food hygiene, child mouthing, and child feces disposal behaviors in urban Dhaka, Bangladesh. Formative research activities included 31 semi-structured interviews, five group discussions, six mHealth workshops, and a three-phase iterative pilot study among 102 households. Findings from semi-structured interviews and group discussions indicate that caregivers of young children have relatively high awareness of the need for safer food hygiene, child mouthing, and child feces disposal practices, but are limited by existing household responsibilities and restricted access to enabling technology that would facilitate practicing recommended behaviors. The piloted Baby WASH mHealth program was well-received by households. This study presents a theory-driven and evidence-based approach for intervention development that can be implemented for the development of future WASH mHealth programs in low-resource settings.

A Retrospective Case-Control Study of the Relationship between the Gut Microbiota, Enteropathy, and Child Growth.

The microbial communities residing in the child gut are thought to play an important role in child growth, although the relationship is not well understood. We examined a cohort of young children from Mirzapur, Bangladesh, prospectively over 18 months. Four fecal markers of environmental enteropathy (EE) (high levels of alpha-1-antitrypsin, calprotectin, myeloperoxidase, and neopterin) were examined and anthropometric measures obtained from a cohort of 68 children. The 16S rRNA gene of bacterial DNA was sequenced from stool samples and used to estimate amplicon sequence variants (ASVs). We age-matched children with poor growth to children with normal growth within 1 month and compared the change in abundance and diversity of ASVs over time. Elevated EE markers and poor linear growth in children were associated with changes in microbial communities in the gut. There were increased amounts of Escherichia/Shigella and Proteobacteria and decreased amounts of Prevotella associated with poorly growing children consistent with the mounting evidence supporting the relationship between intestinal inflammation, child growth, and changes in gut microbiota composition. Future research is needed to investigate this association among young children in low- and middle-income countries.

Impact of a Large-Scale Handwashing Intervention on Reported Respiratory Illness: Findings from a Cluster-Randomized Controlled Trial.

We assessed the impact of handwashing promotion on reported respiratory illness as a secondary outcome from among > 60,000 low-income households enrolled in a cluster-randomized trial conducted in Bangladesh. Ninety geographic clusters were randomly allocated into three groups: cholera-vaccine-only; vaccine-plus-behavior-change (handwashing promotion and drinking water chlorination); and control. Data on respiratory illness (fever plus either cough or nasal congestion or breathing difficulty within previous 2 days) and intervention uptake (presence of soap and water at handwashing station) were collected through monthly surveys conducted among a different subset of randomly selected households during the intervention period. We determined respiratory illness prevalence across groups and used log-binomial regression to examine the association between respiratory illness and presence of soap and water in the handwashing station. Results were adjusted for age, gender, wealth, and cluster-randomized design. The vaccine-plus-behavior-change group had more handwashing stations with soap and water present than controls (45% versus 25%; P < 0.001). Reported respiratory illness prevalence was similar across groups (vaccine-plus-behavior-change versus control: 2.8% versus 2.9%; 95% confidence interval [CI]: -0.008, 0.006; P = 0.6; cholera-vaccine-only versus control: 3.0% versus 2.9%; 95% CI: -0.006, 0.009; P = 0.4). Irrespective of intervention assignment, respiratory illness was lower among people who had soap and water present in the handwashing station than among those who did not (risk ratioadjusted: 0.82; 95% CI: 0.69-0.98). With modest uptake of the handwashing intervention, we found no impact of this large-scale intervention on respiratory illness. However, those who actually had a handwashing station with soap and water had less illness. This suggests improving the effectiveness of handwashing promotion in achieving sustained behavior change could result in health benefits.

Inconsistency in Diarrhea Measurements when Assessing Intervention Impact in a Non-Blinded Cluster-Randomized Controlled Trial.

To explore the consistency in impact evaluation based on reported diarrhea, we compared diarrhea data collected through two different surveys and with observed diarrhea-associated hospitalization for children aged ≤ 5 years from a non-blinded cluster-randomized trial conducted over 2 years in urban Dhaka. We have previously reported that the interventions did not reduce diarrhea-associated hospitalization for children aged ≤ 5 years in this trial. We randomly allocated 90 geographic clusters comprising > 60,000 low-income households into three groups: cholera vaccine only, vaccine plus behavior change (cholera vaccine and handwashing plus drinking water chlorination promotion), and control. We calculated reported diarrhea prevalence within the last 2 days using data collected from two different survey methods. The "census" data were collected from each household every 6 months for updating household demographic information. The "monthly survey" data were collected every month from a subset of randomly selected study households for monitoring the uptake of behavior change interventions. We used binomial regression with a logarithmic link accounting for clustering to compare diarrhea prevalence across intervention and control groups separately for both census and monthly survey data. No intervention impact was detected in the census (vaccine only versus control: 2.32% versus 2.53%; P = 0.49; vaccine plus behavior change versus control: 2.44% versus 2.53%; P = 0.78) or in the vaccine only versus control in the monthly survey (3.39% versus 3.80%; P = 0.69). However, diarrhea prevalence was lower in the vaccine-plus-behavior-change group than control in the monthly survey (2.08% versus 3.80%; P = 0.02). Although the reasons for different observed treatment effects in the census and monthly survey data in this study are unclear, these findings emphasize the importance of assessing objective outcomes along with reported outcomes from non-blinded trials.