Global VAX: A U.S. contribution to global COVID-19 vaccination efforts, 2021-2023.

In December 2021 the U.S. Government announced a new, whole-of-government $1.8 billion effort, the Initiative for Global Vaccine Access (Global VAX) in response to the global COVID-19 pandemic. Using the foundation of decades of U.S. government investments in global health and working in close partnership with local governments and key global and multilateral organizations, Global VAX enabled the rapid acceleration of the global COVID-19 vaccine rollout in selected countries, contributing to increased COVID-19 vaccine coverage in some of the world's most vulnerable communities. Through Global VAX, the U.S. Government has supported 125 countries to scale up COVID-19 vaccine delivery and administration while strengthening primary health care systems to respond to future health crises. The progress made by Global VAX has paved the way for a stronger global recovery and improved global health security.

The Impact of Water Sanitation and Hygiene (WASH) Improvements on Hand Hygiene at Two Liberian Hospitals during the Recovery Phase of an Ebola Epidemic.

Fourteen years of civil war left Liberia with crumbling infrastructure and one of the weakest health systems in the world. The 2014-2015 Ebola virus disease (EVD) outbreak exposed the vulnerabilities of the Liberian health system. Findings from the EVD outbreak highlighted the lack of infection prevention and control (IPC) practices, exacerbated by a lack of essential services such as water, sanitation, and hygiene (WASH) in healthcare facilities. The objective of this intervention was to improve IPC practice through comprehensive WASH renovations conducted at two hospitals in Liberia, prioritized by the Ministry of Health (MOH). The completion of renovations was tracked along with the impact of improvements on hand hygiene (HH) practice audits of healthcare workers pre- and post-intervention. An occurrence of overall HH practice was defined as the healthcare worker practicing compliant HH before and after the care for a single patient encounter. Liberia Government Hospital Bomi (LGH Bomi) and St. Timothy Government Hospital (St. Timothy) achieved World Health Organization (WHO) minimum global standards for environmental health in healthcare facilities as well as Liberian national standards. Healthcare worker (HCW) overall hand hygiene compliance improved from 36% (2016) to 89% (2018) at LGH Bomi hospital and from 86% (2016) to 88% (2018) at St. Timothy hospital. Improved WASH services and IPC practices in resource-limited healthcare settings are possible if significant holistic WASH infrastructure investments are made in these settings.

"Back to the Future": Time for a Renaissance of Public Health Engineering.

Public health has always been, and remains, an interdisciplinary field, and engineering was closely aligned with public health for many years. Indeed, the branch of engineering that has been known at various times as sanitary engineering, public health engineering, or environmental engineering was integral to the emergence of public health as a distinct discipline. However, in the United States (U.S.) during the 20th century, the academic preparation and practice of this branch of engineering became largely separated from public health. Various factors contributed to this separation, including an evolution in leadership roles within public health; increasing specialization within public health; and the emerging environmental movement, which led to the creation of the U.S. Environmental Protection Agency (EPA), with its emphasis on the natural environment. In this paper, we consider these factors in turn. We also present a case study example of public health engineering in current practice in the U.S. that has had large-scale positive health impacts through improving water and sanitation services in Native American and Alaska Native communities. We also consider briefly how to educate engineers to work in public health in the modern world, and the benefits and challenges associated with that process. We close by discussing the global implications of public health engineering and the need to re-integrate engineering into public health practice and strengthen the connection between the two fields.

Applying a New Framework for Public Health Systems Recovery following Emergencies and Disasters: The Example of Haiti following a Major Earthquake and Cholera Outbreak.

Emergencies can often directly impact health systems of an affected region or country, especially in resource-constrained areas. Health system recovery following an emergency is a complex and dynamic process. Health system recovery efforts have often been structured around the World Health Organization's health systems building blocks as demonstrated by the Post-Disaster Needs Assessment. Although this structure is valuable and well known, it can overlook the intricacies of public health systems. We retrospectively examine public health systems recovery, a subset of the larger health system, following the 2010 Haiti earthquake and cholera outbreak, through the lens of the 10 essential public health services. This framework illustrates the comprehensive nature of and helps categorize the activities necessary for a well-functioning public health system and can complement other assessments. Outlining the features of a public health system for recovery in structured manner can also help lay the foundation for sustainable long-term development leading to a more robust and resilient health system.

A systems analysis of irrigation water quality in an environmental assessment of an E. coli O157:H7 outbreak in the United States linked to iceberg lettuce.

A foodborne Escherichia coli O157:H7 outbreak in December 2006 included 77 illnesses reported in Iowa and Minnesota. Epidemiologic investigations by health departments in those states and the U.S. Centers for Disease Control and Prevention (CDC) identified shredded iceberg lettuce (Lactuca sativa L.) as the vehicle of transmission. The U.S. Food and Drug Administration (FDA) and Minnesota and California public health agencies traced the lettuce to several growing regions in California based on information from a lettuce processor in Minnesota. Samples from an environmental investigation initiated by the California Food Emergency Response Team (CalFERT) revealed a genetic match between the outbreak strain and environmental samples from a single farm, leading to an in-depth systems-based analysis of the irrigation water system on that farm. This paper presents findings from that systems-based analysis, which assessed conditions on the farm potentially contributing to contamination of the lettuce. The farm had three sources of irrigation water: groundwater from onsite wells, surface water delivered by a water management agency and effluent from wastewater lagoons on nearby dairy farms. Wastewater effluent was blended with the other sources and used only to irrigate animal feed crops. However, water management on the farm, including control of wastewater blending, appeared to create potential for cross-contamination. Pressure gradients and lack of backflow measures in the irrigation system might have created conditions for cross-contamination of water used to irrigate lettuce. The irrigation network on the farm had evolved over time to meet various needs, without an overall analysis of how that evolution potentially created vulnerabilities to contamination of irrigation water. The type of systems analysis described here is one method for helping to ensure that such vulnerabilities are identified and addressed. A preventive, risk-based management approach, such as the Water Safety Plan process for drinking water, may also be useful in managing irrigation water quality.

Sustainability of water, sanitation and hygiene interventions in Central America.

The American Red Cross and U.S. Centers for Disease Control and Prevention collaborated on a sustainability evaluation of post-hurricane water, sanitation and hygiene (WASH) interventions in Central America. In 2006 and 2009, we revisited six study areas in rural El Salvador, Guatemala, Honduras and Nicaragua to assess sustainability of WASH interventions finalized in 2002, after 1998's Hurricane Mitch. We used surveys to collect data, calculate indicators and identify factors that influence sustainability. Regional sustainability indicator results showed there was a statistically significant decline in access to water. The presence of sanitation facilities had not changed since the beginning of the project; however, maintenance and use of latrines declined but continued to meet the goal of 75% use after 7 years. The hygiene indicator, hand washing, initially declined and then increased. Declines in water access were due to operational problems related to storm events and population changes. Sanitation facilities were still present and sometimes used even though they reached or surpassed their original design life. Changes in hygiene practices appeared related to ongoing hygiene promotion from outside organizations. These results provide useful input for making WASH programs more sustainable and informing future, more in-depth research into factors influencing sustainability.

Development of indicators for measuring outcomes of water safety plans.

Water safety plans (WSPs) are endorsed by the World Health Organization as the most effective method of protecting a water supply. With the increase in WSPs worldwide, several valuable resources have been developed to assist practitioners in the implementation of WSPs, yet there is still a need for a practical and standardized method of evaluating WSP effectiveness. In 2012, the Centers for Disease Control and Prevention (CDC) published a conceptual framework for the evaluation of WSPs, presenting four key outcomes of the WSP process: institutional, operational, financial and policy change. In this paper, we seek to operationalize this conceptual framework by providing a set of simple and practical indicators for assessing WSP outcomes. Using CDC's WSP framework as a foundation and incorporating various existing performance monitoring indicators for water utilities, we developed a set of approximately 25 indicators of institutional, operational, financial and policy change within the WSP context. These outcome indicators hold great potential for the continued implementation and expansion of WSPs worldwide. Having a defined framework for evaluating a WSP's effectiveness, along with a set of measurable indicators by which to carry out that evaluation, will help implementers assess key WSP outcomes internally, as well as benchmark their progress against other WSPs in their region and globally.

Development of Haiti's rural water, sanitation and hygiene workforce.

In 2009 the Haitian Directorate of Potable Water and Sanitation (DINEPA) identified an inadequately trained and under-staffed rural workforce as one of their main institutional challenges. Plans to address this challenge were impacted by the devastating earthquake of January 12, 2010 and the cholera outbreak of October 2010, both of which further complicated Haiti's already poor water and sanitation conditions. Recognizing the importance of DINEPA's institutional priorities, donor and technical assistance groups provided needed support to improve the country's conditions and build the rural water and sanitation workforce. This report describes how DINEPA and the US Centers for Disease Control and Prevention (CDC) collaborated to design and implement a training program for 264 potable water and sanitation technicians for rural areas. The paper also describes the initial field activities of the newly trained technicians and the immediate impact of their work in the rural water, sanitation and hygiene sector.

Water, sanitation and hygiene in Haiti: past, present, and future.

Haiti has the lowest rates of access to improved water and sanitation infrastructure in the western hemisphere. This situation was likely exacerbated by the earthquake in 2010 and also contributed to the rapid spread of the cholera epidemic that started later that same year. This report examines the history of the water, sanitation, and hygiene (WASH) sector in Haiti, considering some factors that have influenced WASH conditions in the country. We then discuss the situation sine the earthquake and subsequent cholera epidemic, and the responses to those events. Finally, drawing on Haiti's National Plan of Action for the Elimination of Cholera in Haiti 2013-2022, we suggest some actions that could help bring about long-term WASH improvements for the future. Because the current WASH situation has evolved over decades of limited attention and resources, it will take a long-term, sustained effort to improve the situation.

Awareness, adoption and implementation of the water safety plan methodology: insights from five Latin American and Caribbean experiences.

Considerable effort has been made worldwide to disseminate information and provide technical assistance to encourage the adoption and implementation of the water safety plan (WSP) methodology. Described since the third edition of the World Health Organization (WHO) Guidelines for Drinking-water Quality, a WSP provides guidance for water utilities to ensure the delivery of safe drinking water and protect health. Attention is now being given to understand the success of efforts to advance adoption of the WSP methodology in the Latin America and Caribbean (LAC) region. More specifically, there is interest in knowing how early adopters developed strategies to implement the WSP methodology and what challenges exist for further implementation. To better understand adoption and implementation trends, key informants from five LAC countries were interviewed and case studies were developed to reveal the diversity of WSP approaches applied in the region. Results indicate that WSP implementation is more widespread than previously reported. Respondents affirmed that the WHO Guidelines for Drinking-water Quality are routinely used as a model for country-level drinking-water regulations, which has led to uptake of the WSP methodology. Interview respondents also revealed innovative national strategic approaches for WSP implementation.

A conceptual framework to evaluate the outcomes and impacts of water safety plans.

A Water Safety Plan (WSP) is a preventive, risk management approach to ensure drinking water safety. The World Health Organization (WHO) guidelines place WSPs within a larger 'framework for safe drinking-water' that links WSPs to health, creating an implicit expectation that implementation of WSPs will safeguard health in areas with acceptable drinking water quality. However, many intervening factors can come between implementation of an individual WSP and ultimate health outcomes. Evaluating the impacts of a WSP, therefore, requires a much broader analysis than simply looking at health improvements. Until recently, little guidance for the monitoring and evaluation of WSPs existed. Drawing examples from existing WSPs in various regions, this paper outlines a conceptual framework for conducting an overall evaluation of the various outcomes and impacts of a WSP. This framework can provide a common basis for implementers to objectively monitor and evaluate the range of outcomes and impacts from WSPs, as well as a common understanding of the time frames within which those results may occur. As implementers understand the various outcomes and impacts of WSPs beyond health, a strong evidence base for the effectiveness of WSPs will develop, further enabling the scaling up of WSP implementation and provision of better quality water.

A community demand-driven approach toward sustainable water and sanitation infrastructure development.

In September 2001, Cooperative Assistance and Relief Everywhere, Peru Country Office (CARE Peru), obtained funding from the United States Agency for International Development (USAID) to implement community-supported, condominial water and sanitation interventions in Manuel Cardozo Dávila, a settlement in Iquitos, Peru. With technical support from the Centers for Disease Control and Prevention (CDC), CARE Peru's Urban Environmental Health Models (Modelos Urbanos de Salud Ambiental [MUSA]) project built on previous work from implementing the Protocol for Assessing Community Excellence in Environmental Health in this same community. The project led to the municipal water supply distribution system being extended 1.3 kilometers into the Southern zone of Iquitos, where it connected to the condominial water system. Altogether, 1030 households were connected to the water supply system after the installation of a condominial water and sewerage system in Cardozo. Diarrheal disease decreased by 37% for children less than 5 years of age from 2003 to 2004. This paper illustrates the strategy used by CARE Peru in conjunction with the Cardozo community to assure that the local demand for improved water and sanitation was met.

Health impact of water and sanitation infrastructure reconstruction programmes in eight Central American communities affected by Hurricane Mitch.

In response to Hurricane Mitch, which struck Central America in October-November 1998, the American Red Cross (ARC) and the Centers for Disease Control and Prevention (CDC) collaborated on a 3-year evaluation of the public health impact of ARC's water, sanitation and hygiene education activities in eight study areas in Honduras, Nicaragua, El Salvador and Guatemala. The evaluation compared: 1) access to and use of water and sanitation facilities, 2) the use of hygienic behaviours, and 3) diarrhoeal prevalence in children younger than 3 years of age before (February 2000) and after (February 2002) the interventions had been implemented. The evaluation included household and key informant interviews designed to measure these three components. Water quality of community water sources and household water was evaluated by measuring levels of indicator bacteria. During the final survey, an infrastructure evaluation provided a review of the design, construction, and current operation and maintenance of the water systems and latrines. The integrated water and sanitation infrastructure interventions and hygiene education programmes implemented following Hurricane Mitch effectively decreased diarrhoea prevalence in the target communities.

Surveillance for waterborne disease and outbreaks associated with drinking water and water not intended for drinking--United States, 2003-2004.

PROBLEM/CONDITION: Since 1971, CDC, the U.S. Environmental Protection Agency (EPA), and the Council of State and Territorial Epidemiologists have maintained a collaborative Waterborne Disease and Outbreaks Surveillance System for collecting and reporting data related to occurrences and causes of waterborne disease and outbreaks (WBDOs). This surveillance system is the primary source of data concerning the scope and effects of WBDOs in the United States. REPORTING PERIOD: Data presented summarize 36 WBDOs that occurred during January 2003-December 2004 and nine previously unreported WBDOs that occurred during 1982-2002. DESCRIPTION OF SYSTEM: The surveillance system includes data on WBDOs associated with drinking water, water not intended for drinking (excluding recreational water), and water of unknown intent. Public health departments in the states, territories, localities, and Freely Associated States (i.e., the Republic of the Marshall Islands, the Federated States of Micronesia, and the Republic of Palau, formerly parts of the U.S.-administered Trust Territory of the Pacific Islands) are primarily responsible for detecting and investigating WBDOs and voluntarily reporting them to CDC by using a standard form. RESULTS: During 2003-2004, a total of 36 WBDOs were reported by 19 states; 30 were associated with drinking water, three were associated with water not intended for drinking, and three were associated with water of unknown intent. The 30 drinking water-associated WBDOs caused illness among an estimated 2,760 persons and were linked to four deaths. Etiologic agents were identified in 25 (83.3%) of these WBDOs: 17 (68.0%) involved pathogens (i.e., 13 bacterial, one parasitic, one viral, one mixed bacterial/parasitic, and one mixed bacterial/parasitic/viral), and eight (32.0%) involved chemical/toxin poisonings. Gastroenteritis represented 67.7% of the illness related to drinking water-associated WBDOs; acute respiratory illness represented 25.8%, and dermatitis represented 6.5%. The classification of deficiencies contributing to WBDOs has been revised to reflect the categories of concerns associated with contamination at or in the source water, treatment facility, or distribution system (SWTD) that are under the jurisdiction of water utilities, versus those at points not under the jurisdiction of a water utility or at the point of water use (NWU/POU), which includes commercially bottled water. A total of 33 deficiencies were cited in the 30 WBDOs associated with drinking water: 17 (51.5%) NWU/POU, 14 (42.4%) SWTD, and two (6.1%) unknown. The most frequently cited NWU/POU deficiencies involved Legionella spp. in the drinking water system (n = eight [47.1%]). The most frequently cited SWTD deficiencies were associated with distribution system contamination (n = six [42.9%]). Contaminated ground water was a contributing factor in seven times as many WBDOs (n = seven) as contaminated surface water (n = one). INTERPRETATION: Approximately half (51.5%) of the drinking water deficiencies occurred outside the jurisdiction of a water utility in situations not currently regulated by EPA. The majority of the WBDOs in which deficiencies were not regulated by EPA were associated with Legionella spp. or chemicals/toxins. Problems in the distribution system were the most commonly identified deficiencies under the jurisdiction of a water utility, underscoring the importance of preventing contamination after water treatment. The substantial proportion of WBDOs involving contaminated ground water provides support for the Ground Water Rule (finalized in October 2006), which specifies when corrective action is required for public ground water systems. PUBLIC HEALTH ACTIONS: CDC and EPA use surveillance data to identify the types of water systems, deficiencies, and etiologic agents associated with WBDOs and to evaluate the adequacy of current technologies and practices for providing safe drinking water. Surveillance data also are used to establish research priorities, which can lead to improved water-quality regulation development. The growing proportion of drinking water deficiencies that are not addressed by current EPA rules emphasizes the need to address risk factors for water contamination in the distribution system and at points not under the jurisdiction of water utilities.

Use of a systems-based approach to an environmental health assessment for a waterborne disease outbreak investigation at a snowmobile lodge in Wyoming.

Investigations into disease outbreaks generally incorporate an epidemiologic investigation, laboratory analysis, and an environmental health assessment. This last component is designed to discover connections between factors in the environment and the outbreak, but is often limited, either by time and resources, or the expertise of the personnel included in outbreak investigation teams. A waterborne Norovirus outbreak investigation in Sheridan County, Wyoming, in 2001 provides an excellent example of the importance of including an in-depth, systems-based environmental health assessment in outbreak investigations. The epidemiologic component of this investigation identified the water supply of a snowmobile lodge in the Bighorn Mountains as the source of the outbreak, a result that was confirmed by laboratory analysis. Including a systems-based environmental health assessment in this investigation also helped to uncover the underlying environmental factors that led to contamination of the water supply. Those factors included an onsite wastewater disposal system that was overloaded by increased use and not well suited to local soil and geologic conditions and a drinking water system with no treatment or disinfection. In addition, heavy precipitation and increased pumping of wells to satisfy higher demands probably facilitated the contamination of the drinking water wells by causing greater movement of wastewater through the soil and underlying bedrock. By focusing on these links between factors in the environment and adverse health outcomes, the systems-based environmental health assessment also helped to highlight prevention strategies for avoiding recurrences.

Community environmental health assessment strengthens environmental public health services in the Peruvian Amazon.

In December 1999, the Centers for Disease Control and Prevention (CDC) and the Cooperative for Assistance and Relief Everywhere, Peru Country Office (CARE Peru), initiated the Urban Environmental Health Project (SAU, in Spanish) to strengthen environmental public health services in urban and periurban settlements in Peru. The project received funding from the Woodruff Foundation as part of the CARE-CDC Health Initiative (CCHI). The "Protocol for Assessing Community Excellence in Environmental Health" (PACE EH) guided the development of a community environmental public health assessment (CEHA) process in Cardozo, a settlement in Iquitos, Peru. The project developed a three-phase process that merged scientific understanding and community perception about local environmental health problems. In phase 1, local environmental health technicians assisted the community in understanding environmental health conditions in Cardozo and selecting priorities. During phase 2, local technicians assessed the community-selected priorities: water and sanitation. Results from recent water quality assessments revealed that 82% (9 of 11) of samples from shallow dug wells, 18% (2 of 11) from deeper drilled wells, and 61% (11/18) from household drinking containers were positive for thermotolerant coliforms. Phase 3 activities produced an action plan and an intervention to mitigate health problems associated with inadequate water and sanitation services in the Cardozo community. As a result of the CEHA process, CARE Peru obtained funding from the United States Agency for International Development (USAID) to develop and implement an environmental health risk monitoring system and the proposed water and sewage intervention in the settlement. CDC continues to provide technical assistance to the local environmental health services groups in Iquitos through an agreement with CARE Peru as part of the USAID-funded Urban Environmental Health Models Project (MUSA). Technical assistance activities and the development of the environmental health risk monitoring system have helped to strengthen the local environmental public health services delivery system.