Diffusion of Handwashing Knowledge and Water Treatment Practices From Mothers in an Antenatal Hygiene Promotion Program to Nonpregnant Friends and Relatives, Machinga District, Malawi.

Access to safe drinking water and improved hygiene are essential for preventing diarrheal diseases in low- and middle-income countries. Integrating water treatment and hygiene products into antenatal clinic care can motivate water treatment and handwashing among pregnant women. Free water hygiene kits (water storage containers, sodium hypochlorite water treatment solution, and soap) and refills of water treatment solution and soap were integrated into antenatal care and delivery services in Machinga District, Malawi, resulting in improved water treatment and hygiene practices in the home and increased maternal health service use. To determine whether water treatment and hygiene practices diffused from maternal health program participants to friends and relatives households in the same communities, we assessed the practices of 106 nonpregnant friends and relatives of these new mothers at baseline and 1-year follow-up. At follow-up, friends and relatives were more likely than at baseline to have water treatment products observable in the home (33.3% vs. 1.2%, p < 0.00001) and detectable free chlorine residual in their water, confirming water treatment (35.7% vs. 1.4%; p < 0.00001). Qualitative data from in-depth interviews also suggested that program participants helped motivate adoption of water treatment and hygiene behaviors among their friends and relatives.

Comparison of indoor air quality in smoke-permitted and smoke-free multiunit housing: findings from the Boston Housing Authority.

INTRODUCTION: Secondhand smoke remains a health concern for individuals living in multiunit housing, where smoke has been shown to easily transfer between units. Building-wide smoke-free policies are a logical step for minimizing smoke exposure in these settings. This evaluation sought to determine whether buildings with smoke-free policies have less secondhand smoke than similar buildings without such policies. Furthermore, this study assessed potential secondhand smoke transfer between apartments with and without resident smokers. METHODS: Fine particulate matter (PM2.5), airborne nicotine, and self-reported smoking activity were recorded in 15 households with resident smokers and 17 households where no one smoked in 5 Boston Housing Authority developments. Of these, 4 apartment pairs were adjacent apartments with and without resident smokers. Halls between apartments and outdoor air were also monitored to capture potential smoke transfer and to provide background PM2.5 concentrations. RESULTS: Households within buildings with smoke-free policies showed lower PM2.5 concentrations compared to buildings without these policies (median: 4.8 vs 8.1 µg/m(3)). Although the greatest difference in PM2.5 between smoking-permitted and smoke-free buildings was observed in households with resident smokers (14.3 vs 7.0 µg/m(3)), households without resident smokers also showed a significant difference (5.1 vs 4.0 µg/m(3)). Secondhand smoke transfer to smoke-free apartments was demonstrable with directly adjacent households. CONCLUSION: This evaluation documented instances of secondhand smoke transfer between households as well as lower PM2.5 measurements in buildings with smoke-free policies. Building-wide smoke-free policies can limit secondhand smoke exposure for everyone living in multiunit housing.

Evaluating the impact of environmental interventions across 2 countries: the International Bikeshare Impacts on Cycling and Collisions Study (IBICCS) Study protocol.

BACKGROUND: Few international studies examine public bicycle share programs (PBSP) health impacts. We describe the protocol for the International Bikeshare Impacts on Cycling and Collisions Study (IBICCS). METHODS: A quasi-experimental non-equivalent groups design was used. Intervention cities (Montreal, Toronto, Boston, New York and Vancouver) were matched to control cities (Chicago, Detroit, and Philadelphia) on total population, population density, cycling rates, and average yearly temperature. The study used three repeated, cross-sectional surveys in intervention and control cities in Fall 2012 (baseline), 2013 (year 1), and 2014 (year 2). A non-probabilistic online panel survey with a sampling frame of individuals residing in and around areas where PBSP are/would be implemented was used. A total of 12,000 respondents will be sampled. In each of the 8 cities 1000 respondents will be sampled with an additional 4000 respondents sampled based on the total population of the city. Survey questions include measures of self-rated health, and self-reported height and weight, knowledge and experience using PBSP, physical activity, bicycle helmet use and history of collisions and injuries while cycling, socio-demographic questions, and home/workplace locations. Respondents could complete questionnaires in English, French, and Spanish. Two weights will be applied to the data: inverse probability of selection and post-stratification on age and sex.A triple difference analysis will be used. This approach includes in the models, time, exposure, and treatment group, and interaction terms between these variables to estimate changes across time, between exposure groups and between cities. DISCUSSION: There are scientific and practical challenges in evaluating PBSP. Methodological challenges included: appropriate sample recruitment, exchangeability of treatment and control groups, controlling unmeasured confounding, and specifying exposure. Practical challenges arise in the evaluation of environmental interventions such as a PBSP: one of the companies involved filed for bankruptcy, a Hurricane devastated New York City, and one PBSP was not implemented. Overall, this protocol provides methodological and practical guidance for researchers wanting to study PBSP impacts on health.

Measuring and monitoring progress toward health equity: local challenges for public health.

To address health disparities, local health departments need high-resolution data on subpopulations and geographic regions, but the quality and availability of these data are often suboptimal. The Boston Public Health Commission and the Los Angeles County Department of Public Health faced challenges in acquiring and using community-level data essential for the design and implementation of programs that can improve the health of those who have social or economic disadvantages. To overcome these challenges, both agencies used practical and innovative strategies for data management and analysis, including augmentation of existing population surveys, the use of combined data sets, and the generation of small-area estimates. These and other strategies show how community-level health data can be analyzed, expanded, and integrated into existing public health surveillance and program infrastructure to inform jurisdictional planning and tailoring of interventions aimed at achieving optimal health for all members of a community.

Impact of integration of hygiene kit distribution with routine immunizations on infant vaccine coverage and water treatment and handwashing practices of Kenyan mothers.

Integration of immunizations with hygiene interventions may improve use of both interventions. We interviewed 1361 intervention and 1139 comparison caregivers about hygiene practices and vaccination history, distributed water treatment and hygiene kits to caregivers during infant vaccination sessions in intervention clinics for 12 months, and conducted a followup survey of 2361 intervention and 1033 comparison caregivers. We observed significant increases in reported household water treatment (30% vs 44%, P < .0001) and correct handwashing technique (25% vs 51%, P < .0001) in intervention households and no changes in comparison households. Immunization coverage improved in both intervention and comparison infants (57% vs 66%, P = .04; 37% vs 53%, P < .0001, respectively). Hygiene kit distribution during routine immunizations positively impacted household water treatment and hygiene without a negative impact on vaccination coverage. Further study is needed to assess hygiene incentives, implement alternative water quality indicators, and evaluate the impact of this intervention in other settings.

Integration of routine vaccination and hygiene interventions: a comparison of 2 strategies in Kenya.

BACKGROUND: Hygiene interventions reduce child mortality from diarrhea. Vaccination visits provide a platform for delivery of other health services but may overburden nurses. We compared 2 strategies to integrate hygiene interventions with vaccinations in Kenya's Homa Bay district, 1 using community workers to support nurses and 1 using nurses. METHODS: Homa Bay was divided into 2 geographical areas, each with 9 clinics. Each area was randomly assigned to either the nurse or community-assisted strategy. At infant vaccination visits hygiene kits were distributed by the nurse or community member. Surveys pre- and post-intervention, measured hygiene indicators and vaccination coverage. Interviews and focus groups assessed acceptability. RESULTS: Between April 2009 and March 2010, 39 158 hygiene kits were distributed. Both nurse and community-assisted strategies were well-accepted. Hygiene indicators improved similarly in nurse and community sites. However, residual chlorine in water changed in neither group. Vaccination coverage increased in urban areas. In rural areas coverage either remained unchanged or increased with 1 exception (13% third dose poliovirus vaccine decrease). CONCLUSIONS: Distribution of hygiene products and education during vaccination visits was found to be feasible using both delivery strategies. Additional studies should consider assessing the use of community members to support integrated service delivery.

Referral Strategies to a Tobacco Quitline and Racial and/or Ethnic Differences in Participation.

BACKGROUND: Tobacco use inflicts a disproportionate burden of disease on people of color. We evaluated the reach among African American and Hispanic smokers in Boston of 2 referral strategies to the Massachusetts quitline: (1) a provider-referred strategy based in pediatric and dental clinics and (2) a targeted media campaign to promote self-referral to the quitline. METHODS: Selected demographic characteristics of Boston quitline participants during the study period (2010-2012) were compared between strategies. Self-referred smoker characteristics were also compared in the years before and after the media campaign. Finally, the characteristics of quitline participants were compared with smokers in the 2010 Boston Behavioral Risk Factor Surveillance Survey. RESULTS: During the study period, 4066 smokers received cessation services from the quitline; 3722 (91.5%) were self-referred, and 344 (8.5%) were referred by pediatric and dental providers. The proportion of black (31.6%) and Hispanic (20.3%) participants referred by providers was higher than among self-referred participants (18.3% and 7.8%, respectively; P <.001). Overall, provider-referred participants were less likely to be white (17.9%) than to be people of color. Self-referred smokers were more likely to be white (68.0%) than the estimated population of Boston smokers overall (62.9%; P <.001). CONCLUSIONS: The large-scale media campaign, which promoted self-referral, was associated with higher quitline participation overall, but the provider-referred strategy based in community health centers yielded participation from a greater proportion of smokers of color. The 2 strategies reached different subpopulations of smokers, and their combined reach enhanced access to cessation services among smokers from different racial and ethnic backgrounds.

No-cost gym visits are associated with lower weight and blood pressure among non-Latino black and Latino participants with a diagnosis of hypertension in a multi-site demonstration project.

Well documented, persistent racial/ethnic health disparities in obesity and hypertension in the US demonstrate the continued need for interventions that focus on people of color who may be at higher risk. We evaluated a demonstration project funded by the CDC's Racial/Ethnic Approaches to Community Health (REACH) program at four federally qualified health centers (FQHC) and YMCA fitness and wellness centers in Boston. No-cost YMCA memberships were offered from June 2014 to June 2015 to non-Latino black and Latino adults with a diagnosis of hypertension. YMCA visit data were merged with health data for 224 participants (n = 1265 health center visits). We assessed associations between gym visit frequency and weight, body mass index (BMI), systolic blood pressure (SBP), and diastolic blood pressure (DBP) using longitudinal time-varying linear fixed-effects models. The total number of gym visits over the entire program duration was 5.5, while the conditional total number of visits (after the first gym visit has been made) was 17.3. Having visited the gym at least 10 times before an FQHC exam was, on average, associated with lower weight (1.19 kg, p = 0.01), lower BMI (0.43 kg/m2, p = 0.01) and reductions in SBP (-3.20 mm Hg, p = 0.01) and DBP (-2.06 mm Hg p = 0.01). Having visited the gym an average of 1.4 times per month (study average) was associated with reductions in weight, BMI, and DBP. No-cost gym visits were associated with improved weight and blood pressure in hypertensive non-Latino black and Latino adults in this program. Additional evaluation is necessary to assess the sustainability of these effects.

The Authors Respond: Reframing the Value of Treatments for Relapsed Refractory Multiple Myeloma.

DISCLOSURES: Funding for the Carlson et al. study was provided in part by the Institute for Clinical and Economic Review. Ollendorf, Synnott, Chapman, and Pearson disclosed grants from Blue Shield of California Foundation, California Health Care Foundation, Laura and John Arnold Foundation, Aetna, AHIP, Anthem, Blue Shield of California, CVS Caremark, Express Scripts, Harvard Pilgrim Health Care, OmedaRx, United Healthcare, Kaiser Permanente, Premera, AstraZeneca, Genentech, GlaxoSmithKline, Johnson & Johnson, Merck, National Pharmaceutical Council, Takeda, Pfizer, Novartis, Lilly, Spark Therapeutics, Sanofi, Prime Therapeutics, and Health Care Service Corporation. Carlson disclosed grants from the Institute for Clinical and Economic Review and personal fees from Seattle Genetics, Genentech, and Pfizer. Russo, Guzauskas, Liu, and Brouwer have nothing to disclose.

Cost-effectiveness of Drugs to Treat Relapsed/Refractory Multiple Myeloma in the United States.

BACKGROUND: New 3-drug regimens have been developed and approved to treat multiple myeloma (MM). The absence of direct comparative data and the high cost of treatment support the need to assess the relative clinical and economic outcomes across all approved regimens. OBJECTIVE: To evaluate the cost-effectiveness of treatments for relapsed and/or refractory MM from a U.S. health system perspective. METHODS: We developed a partition survival model with 3 health states (progression-free, progression, and death) to evaluate the following regimens: carfilzomib (CFZ), elotuzumab (ELO), ixazomib (IX), daratumumab (DAR), and panobinostat (PAN) in combination with lenalidomide (LEN) or bortezomib (BOR) plus dexamethasone (DEX) in the second and/or third line of therapy. To estimate relative treatment effects, we developed a network meta-analysis and applied progression-free survival hazard ratios to baseline parametric progression-free survival functions derived from pooled data on LEN+DEX. We estimated overall survival using data on the relationship between progression-free survival and overall survival from a large meta-analysis of MM patients. Modeled costs included those related to drug treatment, administration, monitoring, adverse events, and progression. Utilities were from publicly available data and manufacturer data, if published sources were unavailable. RESULTS: Model results showed that regimens containing DAR yielded the highest expected life years (DAR range: 6.71-7.38 vs. non-DAR range: 3.25-5.27) and quality-adjusted life-years (QALY; DAR range: 4.38-5.44 vs. non-DAR range: 2.04-3.46), with DAR+BOR+DEX (second line) and PAN+BOR+DEX (third line) as the most cost-effective options (incremental cost-effectiveness ratio: $50,700 and cost saving, respectively). The applicability of the PAN+BOR+DEX result may be challenging, however, because of ongoing toxicity concerns. In the probabilistic sensitivity analysis, second-line DAR+BOR+DEX and third-line PAN+BOR+DEX had an 89% and 87% probability of being cost-effective at the $150,000 per QALY threshold, respectively. CONCLUSIONS: The introduction of newer drugs and regimens to treat second- and third-line relapsed/refractory MM appears to provide clinical benefits by lengthening progression-free and overall survival and improving quality of life. However, only the addition of DAR or PAN may be considered cost-effective options according to commonly cited thresholds, and PAN+BOR+DEX results require cautious interpretation. Achieving levels of value more closely aligned with patient benefit would require substantial discounts from the remaining agents evaluated. DISCLOSURES: Funding for this work was provided in part by the Institute for Clinical and Economic Review, which collaborated on the design, conduct, and reporting of this evaluation. During the conduct of this study, Ollendorf, Synnott, Chapman, and Pearson report grants from Blue Shield of California Foundation, California Health Care Foundation, and Laura and John Arnold Foundation and also report other grants from Aetna, AHIP, Anthem, Blue Shield of California, CVS Caremark, Express Scripts, Harvard Pilgrim Health Care, OmedaRx, United Healthcare, Kaiser Permanente, Premera, AstraZeneca, Genentech, GlaxoSmithKline, Johnson & Johnson, Merck, National Pharmaceutical Council, Takeda, Pfizer, Novartis, Lilly, Spark Therapeutics, Sanofi, Prime Therapeutics, and Health Care Service Corporation outside the submitted work. Carlson reports grants from the Institute for Clinical and Economic Review during the conduct of the study and personal fees from Seattle Genetics, Genentech, and Pfizer outside the submitted work. Russo, Guzauskas, Liu, and Brouwer have nothing to disclose. Study concept and design were contributed by Carlson, Guzauskas, and Ollendorf. Guzauskas, Chapman, Synnott, and Liu collected the data, and Carlson, Guzauskas, Chapman, and Ollendorf contributed to data analysis, along with Synnott and Liu. The manuscript was written by Carlson, Guzauskas, and Brouwer, along with Chapman, Synnott, and Ollendorf, and revised by Carlson, Brouwer, and Guzauskas, along with Chapman, Synnott, and Ollendorf.

Safe Water and Hygiene Integration with Human Immunodeficiency Virus and Antenatal Services: Leveraging Opportunities for Public Health Interventions and Improved Service Uptake.

Integrating public health interventions with antenatal clinic (ANC) visits may motivate women to attend ANC, thereby improving maternal and neonatal health, particularly for human immunodeficiency virus (HIV)-infected persons. In 2009, in an integrated ANC/Preventing Mother-to-Child Transmission program, we provided free hygiene kits (safe storage containers, WaterGuard water treatment solution, soap, and oral rehydration salts) to women at their first ANC visit and refills at subsequent visits. To increase fathers' participation, we required partners' presence for women to receive hygiene kits. We surveyed pregnant women at baseline and at 12-month follow-up to assess ANC service utilization, HIV counseling and testing (HCT), test drinking water for residual chlorine, and observe handwashing. We conducted in-depth interviews with pregnant women, partners, and health workers. We enrolled 106 participants; 97 (92%) were found at follow-up. During the program, 99% of pregnant women and their partners received HCT, and 99% mutually disclosed. Fifty-six percent of respondents had ≥ 4 ANC visits and 90% delivered at health facilities. From baseline to follow-up, the percentage of women who knew how to use WaterGuard (23% versus 80%, P < 0.0001), had residual chlorine in stored water (0% versus 73%, P < 0.0001), had confirmed WaterGuard use (0% versus 70%, P < 0.0003), and demonstrated proper handwashing technique (21% versus 64% P < 0.0001) increased. Program participants showed significant improvements in water treatment and hygiene, and high use of ANC services and HCT. This evaluation suggests that integration of hygiene kits, refills, and HIV testing during ANC is feasible and may help improve household hygiene and increase use of health services.

Impact of the Boston Active School Day policy to promote physical activity among children.

PURPOSE: To test effectiveness of Active School Day policy implementation on physical activity outcomes and estimate school-level implementation costs. DESIGN: The design of the study was quasi-experimental (pretest-posttest matched controls). SETTING: The study took place in six elementary schools with three matched pairs in Boston, Massachusetts, February to June 2011. SUBJECTS: Subjects were 455 consenting fourth- and fifth-grade students among 467 eligible. INTERVENTION: Active School Day policy implementation provided equipment, curricular materials, and training to physical educators and school wellness champions to promote 150 weekly minutes of quality physical education, recess, and physical activity integrated into classrooms. MEASURES: Accelerometer assessments of accumulated minutes and bouts of moderate, vigorous, and sedentary physical activity on 5 school days before and after implementation were used. Implementation costs were collected by record review and reported resource utilization. ANALYSIS: Analysis was conducted using multivariate mixed models estimated with repeated measures of daily physical activity, adjusted for student demographics and other confounding and design/clustering variables. RESULTS: Accelerometer data were provided by 201 intervention and 192 comparison students for an average of 4 days per period (84% response). During school time, students in intervention schools demonstrated greater increases in minutes per day of moderate-to-vigorous physical activity (3.9, 95% confidence interval [CI] 1.8-6.0; p < .001) and vigorous physical activity (1.8, 95% CI .7-3.0; p < .001), and greater decreases in minutes per day of sedentary time (-10.6, 95% CI -15.3- -5.8; p < .001) than controls. Ongoing annual implementation costs totaled $4,523/school ($14/student). CONCLUSION: Active School Day implementation increased student moderate-to-vigorous physical activity levels by 24% and decreased sedentary time during school at modest cost.

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

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

Water treatment and handwashing behaviors among non-pregnant friends and relatives of participants in an antenatal hygiene promotion program in Malawi.

Access to safe drinking water and improved hygiene are essential for preventing diarrheal diseases. To integrate hygiene improvement with antenatal care, free hygiene kits (water storage containers, water treatment solution, soap) and educational messages were distributed to pregnant women at antenatal clinics in Malawi. We assessed water treatment and hygiene practices of 275 non-pregnant friends and relatives of the hygiene kit recipients at baseline and follow-up nine months later to measure program impact on non-participants in the same communities. At follow-up, friends and relatives who did not receive kits or education were more likely than at baseline to purchase and use water treatment solution (25% versus 1%; P < 0.0001) and demonstrate correct handwashing practices (60% versus 18%; P < 0.0001). This antenatal clinic-based program resulted in improved water treatment and hygiene behaviors among non-pregnant friends and relatives living in the same communities as hygiene kit recipients, suggesting that program benefits extended beyond direct beneficiaries.

Impact of the integration of water treatment and handwashing incentives with antenatal services on hygiene practices of pregnant women in Malawi.

Access to safe drinking water and improved hygiene are important for reducing morbidity and mortality from diarrhea. We surveyed 330 pregnant women who participated in an antenatal clinic-based intervention in Malawi that promoted water treatment and hygiene through distribution of water storage containers, sodium hypochlorite water treatment solution, soap, and educational messages. Program participants were more likely to know correct water treatment procedures (62% versus 27%, P < 0.0001), chlorinate drinking water (61% versus 1%, P < 0.0001), demonstrate correct handwashing practices (68% versus 22%, P < 0.0001), and purchase water treatment solution after free distribution (32% versus 1%, P < 0.0001). Among participants, 72% had at least three antenatal visits, 76% delivered in a health facility, and 54% had a postnatal check. This antenatal-clinic-based program is an effective new strategy for promoting water treatment and hygiene behaviors among pregnant women. Participants had high use of antenatal, delivery, and postnatal services, which could improve maternal and child health.