Evaluation of Student Handwashing Practices During a School-Based Hygiene Program in Rural Western Kenya, 2007.

Unsafe drinking water and inadequate handwashing facilities in primary schools increase the risk of absenteeism due to diarrhea and respiratory infections. To mitigate these risks, we provided 28 schools in rural Western Kenya with handwashing and drinking water stations (containers with lids and taps on metal stands), bleach for water treatment, soap for handwashing, and educational materials. We observed the use of the water stations and assessed teachers' attitudes toward the intervention. Of 151 total handwashing stations, 69 (59%) were observed to have soap and water and treated drinking water 4 months after implementation; observations of pupils showed an increase in handwashing behavior in water stations located < 10 m, as compared with those >10 m, from latrines ( p < .02). In focus groups, teachers reported improved cleanliness and decreased illness in pupils. Teacher training and installation of water stations resulted in observed improvements in pupils' hygiene, particularly when water stations were located <10 m from latrines.

A Qualitative Inquiry About Pruno, an Illicit Alcoholic Beverage Linked to Botulism Outbreaks in United States Prisons.

OBJECTIVES: Since 2011, 3 outbreaks of botulism in US prisons have been attributed to pruno, which is an alcoholic beverage made by inmates. Following 1 outbreak, we conducted a qualitative inquiry to understand pruno brewing and its social context to inform outbreak prevention measures. METHODS: We interviewed staff, inmates, and parolees from 1 prison about pruno production methods, the social aspects of pruno, and strategies for communicating the association between botulism and pruno. RESULTS: Twenty-seven inmates and parolees and 13 staff completed interviews. Pruno is fermented from water, fruit, sugar, and miscellaneous ingredients. Knowledge of pruno making was widespread among inmates; staff were familiar with only the most common ingredients and supplies inmates described. Staff and inmates described inconsistent consequences for pruno possession and suggested using graphic health messages from organizations external to the prison to communicate the risk of botulism from pruno. CONCLUSIONS: Pruno making was frequent in this prison. Improved staff recognition of pruno ingredients and supplies might improve detection of brewing activities in this and other prisons. Consistent consequences and clear messages about the association between pruno and botulism might prevent outbreaks.

Emergency water treatment with bleach in the United States: the need to revise EPA recommendations.

During emergencies in the United States, the Environmental Protection Agency (EPA) currently recommends using bottled water, or boiling or treating water by adding 1/8 teaspoon (or 8 drops) of bleach to 1 gal of water. This bleach recommendation is internally inconsistent, a relatively high chlorine dose (5.55-8.67 mg/L), and unsupported by evidence. In this study, bleach was added in three different dosages to six waters available to emergency-affected populations in each of six states; free chlorine residual (FCR) and Escherichia coli/total coliforms were measured 1-24 h after treatment. Data were analyzed using four efficacy criteria. Results indicated the dosages in the current EPA recommendation are unnecessarily high to ensure (1) maintenance of FCR for 24 h after treatment, (2) absence of E. coli/total coliforms, and (3) establishment of a CT-factor sufficient to inactivate Giardia lamblia and enteric viruses 1 h after treatment. Additionally, emergency-prone populations did not have the materials to complete treatment with bleach in their household. Therefore, we recommend EPA review and revise the current recommendation to establish an internally consistent, criteria-based recommendation that is usable by emergency-affected populations. We also recommend investigating the use of new or commercially available water treatment products for emergency response in the United States.

Evaluation of a rapid cholera response activity--Nyanza Province, Kenya, 2008.

BACKGROUND: In response to recurrent cholera outbreaks in Nyanza Province, Kenya, a local nongovernmental organization assisted the Ministry of Health by providing cholera education activities to some cholera-affected communities. We evaluated the impact on cholera prevention knowledge and practices. METHODS: In November-December 2008, we conducted a cross-sectional household survey and tested stored water for chlorine in 6 cholera-affected enumeration areas (intervention-EAs) where response activities had occurred between March-September 2008, and 6 comparison-EAs with no known reports of cholera outbreaks or response activities. RESULTS: We enrolled 358 individuals from intervention-EAs and 365 from comparison-EAs. Overall, >80% knew cholera symptoms and over 60% knew that water treatment prevented diarrhea; <20% had chlorine residual in stored water. More intervention-EA respondents than comparison-EA respondents recalled a cholera outbreak in their community (52% vs 19%, P < .0001), and of those, 51% versus 39%, respectively, had attended a cholera response event. Detectable chlorine residuals in stored water were found in a higher percentage of intervention-EA and comparison-EA event attendees (21% and 25%, respectively) than nonattendees (17% and 8%, respectively). CONCLUSIONS: There was a gap between knowledge and practice of water treatment as a cholera preventive measure. Cholera event attendance may have modestly motivated increased household water treatment.

The challenge of promoting interventions to prevent disease in impoverished populations in rural western Kenya.

Poverty is a critical social determinant of health. A particular approach toward mitigating inequitable access to health services in Kenya has been through a community-based distribution program implemented by the Safe Water and AIDS Project (SWAP) that has achieved modest uptake of public health interventions. To explore reasons for modest uptake, we asked program participants about child health problems, daily tasks, household expenditures, and services needed by their communities. Respondents identified child health problems consistent with health data and reported daily tasks, expenses, and needed services that were more related to basic needs of life other than health. These findings highlight the challenges of implementing potentially self-sustaining preventive interventions at scale in poor populations in the developing world.

Perspectives of men on antenatal and delivery care service utilisation in rural western Kenya: a qualitative study.

BACKGROUND: Poor utilisation of facility-based antenatal and delivery care services in Kenya hampers reduction of maternal mortality. Studies suggest that the participation of men in antenatal and delivery care is associated with better health care seeking behaviour, yet many reproductive health programs do not facilitate their involvement. This qualitative study conducted in rural Western Kenya, explored men's perceptions of antenatal and delivery care services and identified factors that facilitated or constrained their involvement. METHODS: Eight focus group discussions were conducted with 68 married men between 20-65 years of age in May 2011. Participants were of the Luo ethnic group residing in Asembo, western Kenya. The area has a high HIV-prevalence and polygamy is common. A topic guide was used to guide the discussions and a thematic framework approach for data analysis. RESULTS: Overall, men were positive in their views of antenatal and delivery care, as decision makers they often encouraged, some even 'forced', their wives to attend for antenatal or delivery care. Many reasons why it was beneficial to accompany their wives were provided, yet few did this in practice unless there was a clinical complication. The three main barriers relating to cultural norms identified were: 1) pregnancy support was considered a female role; and the male role that of provider; 2) negative health care worker attitudes towards men's participation, and 3) couple unfriendly antenatal and delivery unit infrastructure. CONCLUSION: Although men reported to facilitate their wives' utilisation of antenatal and delivery care services, this does not translate to practice as adherence to antenatal-care schedules and facility based delivery is generally poor. Equally, reasons proffered why they should accompany their wives are not carried through into practice, with barriers outweighing facilitators. Recommendations to improve men involvement and potentially increase services utilisation include awareness campaigns targeting men, exploring promotion of joint HIV testing and counselling, staff training, and design of couple friendly antenatal and delivery units.

Study and implementation of urogenital schistosomiasis elimination in Zanzibar (Unguja and Pemba islands) using an integrated multidisciplinary approach.

BACKGROUND: Schistosomiasis is a parasitic infection that continues to be a major public health problem in many developing countries being responsible for an estimated burden of at least 1.4 million disability-adjusted life years (DALYs) in Africa alone. Importantly, morbidity due to schistosomiasis has been greatly reduced in some parts of the world, including Zanzibar. The Zanzibar government is now committed to eliminate urogenital schistosomiasis. Over the next 3-5 years, the whole at-risk population will be administered praziquantel (40 mg/kg) biannually. Additionally, snail control and behaviour change interventions will be implemented in selected communities and the outcomes and impact measured in a randomized intervention trial. METHODS/DESIGN: In this 5-year research study, on both Unguja and Pemba islands, urogenital schistosomiasis will be assessed in 45 communities with urine filtration and reagent strips in 4,500 schoolchildren aged 9-12 years annually, and in 4,500 first-year schoolchildren and 2,250 adults in years 1 and 5. Additionally, from first-year schoolchildren, a finger-prick blood sample will be collected and examined for Schistosoma haematobium infection biomarkers. Changes in prevalence and infection intensity will be assessed annually. Among the 45 communities, 15 were randomized for biannual snail control with niclosamide, in concordance with preventive chemotherapy campaigns. The reduction of Bulinus globosus snail populations and S. haematobium-infected snails will be investigated. In 15 other communities, interventions triggering behaviour change have been designed and will be implemented in collaboration with the community. A change in knowledge, attitudes and practices will be assessed annually through focus group discussions and in-depth interviews with schoolchildren, teachers, parents and community leaders. In all 45 communities, changes in the health system, water and sanitation infrastructure will be annually tracked by standardized questionnaire-interviews with community leaders. Additional issues potentially impacting on study outcomes and all incurring costs will be recordedand monitored longitudinally. DISCUSSION: Elimination of schistosomiasis has become a priority on the agenda of the Zanzibar government and the international community. Our study will contribute to identifying what, in addition to preventive chemotherapy, needs to be done to prevent, control, and ultimately eliminate schistosomiasis, and to draw lessons for current and future schistosomiasis elimination programmes in Africa and elsewhere. TRIAL REGISTRATION: ISRCTN48837681.

A strategy to increase adoption of locally-produced, ceramic cookstoves in rural Kenyan households.

BACKGROUND: Exposure to household air pollutants released during cooking has been linked to numerous adverse health outcomes among residents of rural areas in low-income countries. Improved cookstoves are one of few available interventions, but achieving equity in cookstove access has been challenging. Therefore, innovative approaches are needed. To evaluate a project designed to motivate adoption of locally-produced, ceramic cookstoves (upesi jiko) in an impoverished, rural African population, we assessed the perceived benefits of the cookstoves (in monetary and time-savings terms), the rate of cookstove adoption, and the equity of adoption. METHODS: The project was conducted in 60 rural Kenyan villages in 2008 and 2009. Baseline (n = 1250) and follow-up (n = 293) surveys and a stove-tracking database were analyzed. RESULTS: At baseline, nearly all respondents used wood (95%) and firepits (99%) for cooking; 98% desired smoke reductions. Households with upesi jiko subsequently spent <100 Kenyan Shillings/week on firewood more often (40%) than households without upesi jiko (20%) (p = 0.0002). There were no significant differences in the presence of children <2 years of age in households using upesi jiko (48%) or three-stone stoves (49%) (p = 0.88); children 2-5 years of age were less common in households using upesi jiko versus three-stone stoves (46% and 69%, respectively) (p = 0.0001). Vendors installed 1,124 upesi jiko in 757 multi-family households in 18 months; 68% of these transactions involved incentives for vendors and purchasers. Relatively few (<10%) upesi jiko were installed in households of women in the youngest age quartile (<22 years) or among households in the poorest quintile. CONCLUSIONS: Our strategy of training of local vendors, appropriate incentives, and product integration effectively accelerated cookstove adoption into a large number of households. The strategy also created opportunities to reinforce health messages and promote cookstoves sales and installation. However, the project's overall success was diminished by inequitable and incomplete adoption by households with the lowest socioeconomic status and young children present. Additional evaluations of similar strategies will be needed to determine whether our strategy can be applied equitably elsewhere, and whether reductions in fuel use, household air pollution, and the incidence of respiratory diseases will follow adoption of improved cookstoves.

A descriptive qualitative case study of the experiences, perceptions and attitudes of pregnant women on Unguja island, Zanzibar, towards antischistosomal treatment.

Many countries exclude pregnant and lactating women from mass drug administration (MDA) programmes with praziquantel against schistosomiasis due to historic safety concerns over drug use during gestation and breast feeding. More than 10 years of empirical evidence from the field and a growing body of dedicated research has prompted the World Health Organisation and schistosomiasis control initiatives to advocate the inclusion of this vulnerable group into MDA. This qualitative descriptive case study explored, over a five-week period, the subjective experiences, perceptions, opinions, and attitudes of pregnant women attending government supported clinics on Unguja island, United Republic of Tanzania, towards praziquantel use during pregnancy in MDA programmes. The aim of the study was to identify and determine how to overcome potential barriers to effective use of MDA medications during pregnancy. Additionally, it was to determine trusted communication channels for future messaging and discover behavioural and community opportunities to increase participation of pregnant women in future MDA efforts. A 60 min, semi-structured qualitative interview was undertaken with 25 pregnant women recruited from 4 health centres on Unguja along with testing for Schistosoma haematobium infection. Using a modified-grounded theory approach, narrative data were transcribed, coded and analysed using a thematic analysis of the emergent themes. Women reported that they rely on traditional home remedies to stay healthy during pregnancy. Influenced by their mothers, husbands and neighbours, women predominately made medication choices during pregnancy and breastfeeding based on what they heard at home. Most women had been excluded from government MDA programmes in the past due to pregnancy. Women valued healthcare services for antenatal education and pregnancy advice. Women reported they would trust and follow direction from healthcare providers about taking praziquantel during pregnancy. Antenatal clinics offer an excellent opportunity to educate and expand praziquantel treatment to this cohort. Efforts should be augmented with training for providers and behavioural education for the community as a whole and family members of pregnant women.

Cholera prevention training materials for community health workers, Haiti, 2010­2011.

Stopping the spread of the cholera epidemic in Haiti required engaging community health workers (CHWs) in prevention and treatment activities. The Centers for Disease Control and Prevention collaborated with the Haitian Ministry of Public Health and Population to develop CHW educational materials, train >1,100 CHWs, and evaluate training efforts.

Evaluation of a urogenital schistosomiasis behavioural intervention among students from rural schools in Unguja and Pemba islands, Zanzibar.

Urogenital schistosomiasis is a common experience among children in Zanzibar. There is a paucity of behavioural science-based, health education and behaviour change (HEBC) interventions for school-aged children, those at greatest risk for urogenital schistosomiasis. We assessed the influence of a HEBC intervention, guided by the Health Belief model, among rural schoolchildren on Pemba and Unguja islands in Zanzibar, Tanzania. From 2012 to 2016, a cluster-randomized trial to assess three different interventions against urogenital schistosomiasis was conducted in 90 schools and shehias across Zanzibar. The HEBC intervention was implemented in 15 schools per island. In 2017, at the trial conclusion, we administered written questionnaires to schoolchildren from 4 HEBC intervention schools and 4 not HEBC exposed schools on each island, respectively. Responses were compared between students that were exposed or not exposed to the HEBC intervention using a Fisher's exact test. A total of 1451 students, 708 from intervention and 743 from non-intervention schools completed the questionnaire. Noting some between island differences, students who had received the HEBC interventions reported significant improvements in knowledge about Schistosoma haematobium transmission and personal risk, strategies for schistosomiasis prevention, and self-reported changes in risk behaviours: stopped washing laundry/dishes 49.4% (350/708) versus 5.8% (43/743), stopped bathing in streams/ponds 49.4% (350/708) versus 4.2% (31/743), and stopped playing in streams/ponds 40.8% (289/708) versus 10.8% (80/743). HEBC exposed children also reported a significant increase in swallowing tablets during mass drug administration (MDA) campaigns (when they had not before) 30.2% (214/708) versus 4.6% (34/743). The school based HEBC interventions were associated with desirable positive behaviour change among students. Data suggest that scaling up HEBC interventions to all schools in high-risk areas, augmented with bi-annual MDA, can help to reduce prevalence of urogenital schistosomiasis in Zanzibar, strengthening the possibility for future disease elimination.

A Cluster Randomized Trial of the Impact of Education through Listening (a Novel Behavior Change Technique) on Household Water Treatment with Chlorine in Vihiga District, Kenya, 2010-2011.

Despite multiple studies demonstrating the effectiveness of household water treatment with chlorine in disinfecting water and preventing diarrhea, social marketing of this intervention in low- and middle-income countries has resulted in only modest uptake. In a cluster randomized trial in Vihiga district, western Kenya, we compared uptake of household water treatment with chlorine among six villages served by community vendors trained in standard social marketing plus education through listening (ETL), an innovative behavior change method, and six villages served by community vendors trained in standard social marketing only. Water treatment uptake, water quality, and childhood diarrhea were measured over 6 months and compared between the two groups of villages. During the 6-month period, we found no association between ETL exposure and reported and confirmed household water treatment with chlorine. In both groups (ETL and comparison), reported use of water treatment was low and did not change during our 6-month follow-up. However, persons confirmed to have chlorinated water had improved bacteriologic water quality. Study findings suggest that ETL implementation was suboptimal, which, along with unexpected changes in the supply and price of chlorine, may have prevented an accurate assessment of the potential impact of ETL on water treatment behavior. Taken together, these observations exemplify the complexities of habits, practices, attitudes, and external factors that can create challenging conditions for implementing behavioral interventions. As a consequence, in this trial, ETL had no measurable impact on water treatment behavior.

Formative research exploring acceptability, utilization, and promotion in order to develop a micronutrient powder (Sprinkles) intervention among Luo families in western Kenya.

BACKGROUND: There is a lack of peer-reviewed literature describing in detail the formative research to develop Sprinkles interventions. OBJECTIVE: To describe community members' reactions to and experiences using Sprinkles, with an emphasis on acceptability, utilization, and promotion. METHODS: Fourteen initial focus group discussions on Sprinkles and a 25-family home study were conducted. For the home study, each child 6 to 59 months of age in the household received 30 sachets (1 per day). The initial 14 focus group discussions included mothers, grandmothers, vendors, women who purchased from vendors, and adults in the general population. Home study families were recruited from participants in the initial 14 focus group discussions who had at least one child 6 to 59 months of age. RESULTS: Sprinkles were highly acceptable to adults and most children; some children thought Sprinkles were sugar. Most home study families prepared and used Sprinkles correctly. All families reported positive effects, particularly increased appetite, and recommended Sprinkles; none experienced major problems. Potential barriers identified were lack of knowledge of and experience with Sprinkles, availability of Sprinkles, and cost. Promotional messages targeted to mothers, fathers, all child-care providers, and doctors focused on the positive health effects of Sprinkles. CONCLUSIONS: Issues related to Sprinkles preparation, use, and barriers required attention before implementation. Locally appropriate visual and written instructions were developed for dissemination. Intervention training sessions and promotions were tailored to answer frequently asked questions, increase knowledge of Sprinkles, and provide tangible evidence of health benefits. Information needs and perceptions changed quickly after use of Sprinkles. Existing levels of Sprinkles awareness and knowledge should be considered when designing interventions.

SCORE Operational Research on Moving toward Interruption of Schistosomiasis Transmission.

As part of its diverse portfolio, the Schistosomiasis Consortium for Operational Research and Evaluation (SCORE) included two cluster-randomized trials evaluating interventions that could potentially lead to interruption of schistosomiasis transmission (elimination) in areas of Africa with low prevalence and intensity of infection. These studies, conducted in Zanzibar and Côte d'Ivoire, demonstrated that multiyear mass drug administration (MDA) with praziquantel failed to interrupt the transmission of urogenital schistosomiasis, even when provided biannually and/or supplemented by small-scale implementation of additional interventions. Other SCORE activities related to elimination included a feasibility and acceptability assessment of test-treat-track-test-treat (T5) strategies and mathematical modeling. Future evaluations of interventions to eliminate schistosomiasis should recognize the difficulties inherent in conducting randomized controlled trials on elimination and in measuring small changes where baseline prevalence is low. Highly sensitive and specific diagnostic tests for use in very low-prevalence areas for schistosomiasis are not routinely available, which complicates accurate measurement of infection rates and assessment of changes resulting from interventions in these settings. Although not encountered in these two studies, as prevalence and intensity decrease, political and community commitment to population-wide MDA may decrease. Because of this potential problem, SCORE developed and funded the T5 strategy implemented in Egypt, Kenya, and Tanzania. It is likely that focal MDA campaigns, along with more targeted approaches, including a T5 strategy and snail control, will need to be supplemented with the provision of clean water and sanitation and behavior change communications to achieve interruption of schistosome transmission.

Health-related stigma among women with lymphatic filariasis from the Dominican Republic and Ghana.

People fearful of being stigmatized by a health-related condition often do not embrace prevention behaviors or seek medical help. They may adhere poorly to treatment regimes for disease and abruptly terminate much needed treatment. Globally, 120 million--many poor women--suffer consequences of lymphatic filariasis that include stigmatizing lymphedema or elephantiasis of the leg. We investigated how women with lymphedema from two different cultures experience stigma and its consequences. Our qualitative data were collected from 56 Dominican women and 48 Ghanaian women with lymphedema. A lymphedema-related stigma framework was developed from constructs derived from the literature and emergent themes from the data. Women described a spectrum of enacted, perceived, and internalized stigma experiences, such as being criticized and isolated by the community, health providers, and even by friends and relatives; they were often denied access to education and meaningful work roles. Some antecedents, consequences, coping strategies, and outcomes of these experiences varied across cultures, with Dominican women faring somewhat better than Ghanaians. Poverty, poor access to health care resources, limited education, and diminished social support challenged the coping strategies of many women and exacerbated negative consequences of lymphedema-related stigma.

Evaluation of the impact of antimicrobial hand towels on hand contamination with Escherichia coli among mothers in Kisumu County, Kenya, 2011-2012.

Poor hand hygiene contributes to diarrhea in developing countries. Handwashing with soap reduces diarrhea risk, but drying hands on contaminated towels can compromise the benefits of handwashing. In response to the challenge of keeping hands clean, an antimicrobial hand towel was developed and shown to be promising in the laboratory, but has not been adequately tested in the field. We evaluated the effectiveness of an antimicrobial towel in two randomized, double-blinded crossover trials among mothers with children<5 years old in 125 households in western Kenya. In trial 1, we randomly assigned mothers to use either the treated towel or an identical untreated (placebo) towel and made surprise home visits at random times once a week for three weeks. At each visit, we tested hands for Escherichia coli using sterile hand rinses, then switched towel types in the two groups and repeated three weekly rounds of E. coli testing. In crossover trial 2, we compared E. coli contamination of maternal hands immediately following three different handwashing/drying procedures: soap and water + treated towel, water only + treated towel, and soap and water + air dry. There was no statistically significant difference in the level of E. coli contamination on maternal hands by type of towel used during trial 1 (odds ratio for treated vs untreated towel: 1.14, 95% confidence interval 0.83-1.56). In trial 2, there were no significant differences in E. coli contamination of maternal hands by handwashing/drying procedure. In these trials, use of antimicrobial hand towels did not prevent E. coli contamination of mothers' hands in Kenyan households during random testing and offered no advantages over standard handwashing and drying practices. Handwashing with soap and clean water and drying with clean towels are recommended.

Correction to: Urogenital schistosomiasis elimination in Zanzibar: accuracy of urine filtration and haematuria reagent strips for diagnosing light intensity Schistosoma haematobium infections.

Following publication of the original article [1], the authors flagged that unfortunately an error had been introduced to the Conclusions section of the article's Abstract, during production of the article.

A 5-Year intervention study on elimination of urogenital schistosomiasis in Zanzibar: Parasitological results of annual cross-sectional surveys.

BACKGROUND: The Zanzibar Elimination of Schistosomiasis Transmission (ZEST) project aimed to eliminate urogenital schistosomiasis as a public health problem from Pemba and to interrupt Schistosoma haematobium transmission from Unguja in 5 years. METHODOLOGY: A repeated cross-sectional cluster-randomized trial was implemented from 2011/12 till 2017. On each island, 45 shehias were randomly assigned to receive one of three interventions: biannual mass drug administration (MDA) with praziquantel alone, or in combination with snail control or behavior change measures. In cross-sectional surveys, a single urine sample was collected from ~9,000 students aged 9- to 12-years and from ~4,500 adults aged 20- to 55-years annually, and from ~9,000 1st year students at baseline and the final survey. Each sample was examined for S. haematobium eggs by a single urine filtration. Prevalence and infection intensity were determined. Odds of infection were compared between the intervention arms. PRINCIPAL FINDINGS: Prevalence was reduced from 6.1% (95% confidence interval (CI): 4.5%-7.6%) to 1.7% (95% CI: 1.2%-2.2%) in 9- to 12-year old students, from 3.9% (95% CI: 2.8%-5.0%) to 1.5% (95% CI: 1.0%-2.0%) in adults, and from 8.8% (95% CI: 6.5%-11.2%) to 2.6% (95% CI: 1.7%-3.5%) in 1st year students from 2011/12 to 2017. In 2017, heavy infection intensities occurred in 0.4% of 9- to 12-year old students, 0.1% of adults, and 0.8% of 1st year students. Considering 1st year students in 2017, 13/45 schools in Pemba and 4/45 schools in Unguja had heavy infection intensities >1%. There was no significant difference in prevalence between the intervention arms in any study group and year. CONCLUSIONS/SIGNIFICANCE: Urogenital schistosomiasis was eliminated as public health problem from most sites in Pemba and Unguja. Prevalence was significantly reduced, but transmission was not interrupted. Continued interventions that are adaptive and tailored to the micro-epidemiology of S. haematobium in Zanzibar are needed to sustain and advance the gains made by ZEST.

Evaluation of integrated interventions layered on mass drug administration for urogenital schistosomiasis elimination: a cluster-randomised trial.

BACKGROUND: Elimination of schistosomiasis as a public health problem and interruption of transmission in selected areas are targets set by WHO for 2025. Our aim was to assess biannual mass drug administration (MDA) applied alone or with complementary snail control or behaviour change interventions for the reduction of Schistosoma haematobium prevalence and infection intensity in children from Zanzibar and to compare the effect between the clusters. METHODS: In a 5-year repeated cross-sectional cluster-randomised trial, 90 shehias (small administrative regions; clusters) in Zanzibar eligible owing to available natural open freshwater bodies and public primary schools were randomly allocated (ratio 1:1:1) to receive one of three interventions: biannual MDA with praziquantel alone (arm 1) or in combination with snail control (arm 2), or behaviour change activities (arm 3). Neither participants nor field or laboratory personnel were blinded to the intervention arms. From 2012 to 2017, annually, a single urine sample was collected from approximately 100 children aged 9-12 years in the main public primary school of each shehia. The primary outcome was S haematobium infection prevalence and intensity in 9-12-year-old children after 5 years of follow-up. This study is completed and was registered with the ISRCTN, number 48837681. FINDINGS: The trial was done from Nov 1, 2011, through to Dec 31, 2017 and recruitment took place from Nov 2, 2011, until May 17, 2017. At baseline we enrolled 8278 participants, of whom 2899 (35%) were randomly allocated to arm 1, 2741 (33%) to arm 2, and 2638 (32%) to arm 3. 120 (4·2%) of 2853 in arm 1, 209 (7·8%) of 2688 in arm 2, and 167 (6·4%) of 2613 in arm 3 had S haematobium infections at baseline. Heavy infections (≥50 eggs per 10 mL of urine) were found in 126 (1·6%) of 8073 children at baseline. At the 5-year endline survey, 46 (1·4%) of 3184 in arm 1, 56 (1·7%) of 3217 (odds ratio [OR] 1·2 [95% CI 0·6-2·7] vs arm 1) in arm 2, and 58 (1·9%) of 3080 (1·3 [0·6-2·9]) in arm 3 had S haematobium infections. Heavy infections were detected in 33 (0·3%) of 9462 children. INTERPRETATION: Biannual MDA substantially reduced the S haematobium prevalence and infection intensity but was insufficient to interrupt transmission. Although snail control or behaviour change activities did not significantly boost the effect of MDA in our study, they might enhance interruption of transmission when tailored to focal endemicity and applied for a longer period. It is now necessary to focus on reducing prevalence in remaining hotspot areas and to introduce new methods of surveillance and public health response so that the important gains can be maintained and advanced. FUNDING: University of Georgia Research Foundation Inc and Bill & Melinda Gates Foundation.

"Can it be that god does not remember me": a qualitative study on the psychological distress, suffering, and coping of Dominican women with chronic filarial lymphedema and elephantiasis of the leg.

The psychological states of Dominican women with chronic lymphedema and elephantiasis of the leg and the coping strategies they used to ameliorate the negative psychological effects of this condition were explored using modified precepts of grounded theory method. Qualitative data were gathered through in-depth interviewing and focus group discussions held in the Dominican Republic. Thematic results found that compounding their physical disfigurement, functional limitations, and social losses were feelings of depression, embarrassment, social isolation, and despair. Adaptive problem solving and emotion-focused coping strategies that emerged during analysis also are discussed. It is recommended that management of psychological distress should be a significant component of lymphedema management programs in developing countries.