Investigating the effect of a school-based WASH intervention on soil-transmitted helminth and schistosome infections and nutritional status of school children in Ethiopia: a quasi-experimental study.

BACKGROUND: The impact of access to improved water, sanitation and hygiene (WASH) and health education on large-scale deworming programs aimed at controlling soil-transmitted helminth (STH) and schistosome (SCH) infections has not been well studied. We assessed the additional impact of improved WASH infrastructure and health education at schools on STH and SCH infections in Ethiopia. METHODS: The study used a quasi-experimental design under which 30 schools were assigned to either an intervention (15 schools) or control (15 schools) arm. Both arms received a standard deworming treatment and lunch. In the intervention arm, improved WASH and health education were provided. At three consecutive time points (baseline in 2013, 2014 and 2015), the prevalence and intensity of STH and SCH infections and the nutritional status [hemoglobin concentrations and physical growth (height and weight)] were determined. To verify whether interventions were successfully implemented, the WASH status at school and the student knowledge, attitudes and practices related to WASH (WASH-KAP) were recorded. Differences in metrics between arms at baseline (2013) and follow-up (2015) were assessed both within and between the arms. RESULTS: A significant increase in scores for both the school WASH and student KAP was found in the intervention arm, indicating successful implementation of the intervention. The prevalence of any STH infection was significantly reduced in the intervention arm but not in the control arm (F = 4.486, p = 0.034). There was a significantly greater reduction in the intensity of infection of hookworm and Ascaris lumbricoides compared to baseline in both arms. The intervention did not affect school children's height-for-age z-score (intervention arm * time coef = 0.12, p = 0.400) and body mass index-for-age z-scores (intervention * time coef = - 0.06, p = 0.526). Hemoglobin concentrations increased significantly more in the control than the intervention arm (coef = - 0.16, p = 0.006). CONCLUSIONS: Although the intervention did increase school WASH and student WASH-KAP, our study found poor evidence of the additional benefit of improved WASH and health education to deworming and school food programs on parasite re-infection and the health outcomes of children.

Contextual factors affecting integration of eye health into school health programme in Zanzibar: a qualitative health system research.

BACKGROUND: Short-term school eye health programmes supported by external funders have sustainability issues. This study aimed to understand the contextual factors affecting integrating eye health into the school health programme. METHODS: We elicited responses from 83 respondents, purposefully selected from the Ministry of Health (n = 7), Ministry of Education and Vocational Training (n = 7), hospitals/eye centres (n = 5), master trainers (4) and schools (n = 60) who participated in in-depth interviews. Their responses were analysed and grouped into contextual factors according to the WHO Consolidated Framework for Implementation Research: stakeholders/political, institutional, physical, cultural, delivery system and others. Themes were then generated, and quotations were presented to illustrate the findings. RESULTS: The six contextual factors affecting the integration of eye health into the school eye health programme were i) Stakeholders/political (Good ministry coordination, defined departmental roles and resource mobilisation from multiple stakeholders; Good stakeholder synergies and address current gaps); ii) Institutional (Institutional coordination and adequate clinic space; Securing human and financial resources; Strategic advocacy for institutional resources); iii) Physical (Long travel distance to service points); vi) Cultural (low eye health awareness among parents, teachers and children); iv) Delivery system (Practical approach to increase screening coverage using teachers as screeners; Balance teachers' workload, increase screening sensitivity and follow up and; v) Others (Comprehensive training material and effective training delivery; Improved curriculum, teacher selection and supervision and incentives). CONCLUSION: Integrated school eye health delivery is generally well-received by stakeholders in Zanzibar, with the caveat that investment is required to address the six contextual factors identified in the study.

Precision mapping of schistosomiasis and soil-transmitted helminthiasis among school age children at the coastal region, Kenya.

BACKGROUND: Accurate mapping of schistosomiasis (SCH) and soil transmitted helminths (STH) is a prerequisite for effective implementation of the control and elimination interventions. A precision mapping protocol was developed and implemented in the coastal region of Kenya by applying the current World Health Organization (WHO) mapping guide at a much lower administrative level (ward). METHODS: A two-stage cluster survey design was undertaken, with 5 villages in each ward selected. From within each village 50 households were randomly selected, and a single child between the ages of 8 and 14 sampled following appropriate assent. The prevalence and intensity of infection of Schistosoma mansoni and STH were determined using the Kato-Katz method (single stool, duplicate slides) and urine filtration for S. haematobium. RESULTS: Of the 27,850 school age children sampled, 6.9% were infected with at least one Schistosoma species, with S. haematobium being the most common 6.1% (95% CI: 3.1-11.9), and Tana River County having highest prevalence 19.6% (95% CI: 11.6-31.3). Prevalence of any STH infection was 5.8% (95% CI: 3.7-8.9), with Lamu County having the highest prevalence at 11.9% (95% CI: 10.0-14.1). The most prevalent STH species in the region was Trichuris trichiura at 3.1% (95% CI: 2.0-4.8). According to the WHO threshold for MDA implementation, 31 wards (in 15 sub-Counties) had a prevalence of ≥10% for SCH and thus qualify for annual MDA of all age groups from 2 years old. On the other hand, using the stricter Kenya BTS MDA threshold of ≥2%, 72 wards (in 17 sub-Counties) qualified for MDA and were targeted for treatment in 2021. CONCLUSIONS: The precision mapping at the ward level demonstrated the variations of schistosomiasis prevalence and endemicity by ward even within the same sub-counties. The data collected will be utilized by the Kenyan Ministry of Health to improve targeting.

Responding to the cuts in UK AID to neglected tropical diseases control programmes in Africa.

The early termination of the Accelerating the Sustainable Control and Elimination of Neglected Tropical Diseases (Ascend) programme by the UK government in June 2021 was a bitter blow to countries in East and West Africa where no alternative source of funding existed. Here we assess the potential impact the cuts may have had if alternative funding had not been made available by new development partners and outline new strategies developed by affected countries to mitigate current and future disruptions to neglected tropical disease control programmes.

Precision and geographical prevalence mapping of schistosomiasis and soil-transmitted helminthiasis among school-aged children in selected districts of north-western Tanzania.

BACKGROUND: The identification and mapping of at-risk populations at a lower administrative level than the district are prerequisites for the planning, resource allocation and design of impactful control intervention measures. Thus, the objective of the current study was to conduct sub-district precision mapping of soil-transmitted helminthiasis (STH) and schistosomiasis in 29 districts of north-western Tanzania using the current recommended World Health Organization criteria. METHODS: A cross-sectional survey was conducted in 145 schools between March and May 2021. A urine filtration technique was used for the quantification of Schistosoma haematobium eggs, whereas quantification of Schistosoma mansoni and STH eggs was done using the Kato-Katz technique. Microhaematuria was examined using a urine dipstick. RESULTS: The overall prevalences of any STH and schistosome infections were 9.3% [95% confidence interval (95%CI) 8.6-9.9] and 14.6% (95%CI 13.9-15.4), respectively. The overall prevalence of S. mansoni was 8.7% (95%CI 8.1-9.3), and 36.4%, 41.6%, and 21.9% of the children had low, moderate, and heavy infections, respectively. The overall prevalence of S. haematobium was 6.1% (95%CI 5.5-6.5), and 71.7% and 28.3% of the infected children had light and heavy intensity infections, respectively. The prevalence of microhaematuria was 7.3% (95%CI 6.7-7.8), with males having the highest prevalence (8.4%, P < 0.001). The prevalences of Trichuris trichiura, Ascaris lumbricoides and hookworm were, respectively, 1.3% (95%CI 0.1-1.5), 2.9% (95%CI 2.5-3.3) and 6.2% (95%CI 5.7-6.7). Most of the children infected with STH had light to moderate intensities of infection. The overall prevalence of co-infection with STH and schistosomiasis was 19.1%. The prevalence of schistosomiasis (P < 00.1) and STH (P < 0.001) varied significantly between schools and sub-districts. Schistosoma mansoni and S. haematobium were observed in 60 and 71 schools, respectively, whereas any STH was observed in 49 schools. In schools where schistosomiasis was observed, prevalence was < 10% in 90.8% of them, and ranged from ≥ 10% to < 50% in the other 9.2%. In schools where any STH was observed, the prevalence was < 10% in 87.7% of them. CONCLUSIONS: The data reported here show that schistosomiasis and STH are widely distributed around Lake Victoria. In most of the schools where schistosomiasis and STH occurred the transmission thresholds were low. These data are important and need to be taken into consideration when decisions are made on the implementation of the next round of mass chemotherapies for schistosomiasis and STH in Tanzania.

Does an integrated school eye health delivery model perform better than a vertical model in a real-world setting? A non-randomised interventional comparative implementation study in Zanzibar.

BACKGROUND: Few studies on school eye health programmes have shown they were cost-effective. We compared the performance (Reach, Effectiveness, Adoption, Implementation and Maintenance (RE-AIM)) between an integrated model (IM) and a vertical model (VM) of school eye health delivery in Zanzibar. METHODS: The set of RE-AIM performance indicators of the IM (n=9) and VM (n=10) cohorts was compared. The VM implemented only the eye health interventions, while the IM had the eye health interventions conducted within the school feeding programme. Semistructured interviews were conducted with 36 stakeholders to understand the challenges and outcomes experienced when implementing both models. RESULTS: The IM achieved higher screening coverage, voluntary follow-up rate, screening validity and spectacle compliance than VM. This was due to effective coordination between implementers, motivated teachers to prevent vision problems and related negative impacts in children, and activities implemented timeously post-training. Both models recorded low wearing compliance. All schools in the IM cohort completed screening activities, but two schools in the VM cohort did not. Both models ceased activities after the funding stopped. Local stakeholders emphasised that evidence from this study can be used to advocate for more resources for children's eye health. CONCLUSIONS: The IM cohort achieved better reach, effectiveness, adoption rate and implementation performance than the VM cohort. The poor maintenance performance indicators in both arms postfunding call for improvement to the implementation strategy to ensure the sustainability of school eye health. In the optics of scaling up, an integrated approach is recommended.

Factors associated with soil-transmitted helminths infection in Benin: Findings from the DeWorm3 study.

BACKGROUND: Despite several years of school-based MDA implementation, STH infections remain an important public health problem in Benin, with a country-wide prevalence of 20% in 2015. The DeWorm3 study is designed to assess the feasibility of using community-based MDA with albendazole to interrupt the transmission of STH, through a series of cluster-randomized trials in Benin, India and Malawi. We used the pre-treatment baseline survey data to describe and analyze the factors associated with STH infection in Comé, the study site of the DeWorm3 project in Benin. These data will improve understanding of the challenges that need to be addressed in order to eliminate STH as a public health problem in Benin. METHODS: Between March and April 2018, the prevalence of STH (hookworm spp., Ascaris and Trichuris trichiura) was assessed by Kato-Katz in stool samples collected from 6,153 residents in the community of Comé, Benin using a stratified random sampling procedure. A standardized survey questionnaire was used to collect information from individual households concerning factors potentially associated with the presence and intensity of STH infections in pre-school (PSAC, aged 1-4), school-aged children (SAC, aged 5-14) and adults (aged 15 and above). Multilevel mixed-effects models were used to assess associations between these factors and STH infection. RESULTS: The overall prevalence of STH infection was 5.3%; 3.2% hookworm spp., 2.1% Ascaris lumbricoides and 0.1% Trichuris. Hookworm spp. were more prevalent in adults than in SAC (4.4% versus 2.0%, respectively; p = 0.0001) and PSAC (4.4% versus 1.0%, respectively; p<0.0001), whilst Ascaris lumbricoides was more prevalent in SAC than in adults (3.0% versus 1.7%, respectively; p = 0.004). Being PSAC (adjusted Odds Ratio (aOR) = 0.2, p< 0.001; adjusted Infection Intensity Ratio (aIIR) = 0.1, p<0.001) or SAC (aOR = 0.5, p = 0.008; aIIR = 0.3, p = 0.01), being a female (aOR = 0.6, p = 0.004; aIIR = 0.3, p = 0.001), and having received deworming treatment the previous year (aOR = 0.4, p< 0.002; aIIR = 0.2, p<0.001) were associated with a lower prevalence and intensity of hookworm infection. Lower income (lowest quintile: aOR = 5.0, p<0.001, 2nd quintile aOR = 3.6, p = 0.001 and 3rd quintile aOR = 2.5, p = 0.02), being a farmer (aOR = 1.8, p = 0.02), medium population density (aOR = 2.6, p = 0.01), and open defecation (aOR = 0.5, p = 0.04) were associated with a higher prevalence of hookworm infection. Lower education-no education, primary or secondary school- (aIIR = 40.1, p = 0.01; aIIR = 30.9, p = 0.02; aIIR = 19.3, p = 0.04, respectively), farming (aIIR = 3.9, p = 0.002), natural flooring (aIIR = 0.2, p = 0.06), peri-urban settings (aIIR = 6.2, 95%CI 1.82-20.90, p = 0.003), and unimproved water source more than 30 minutes from the household (aIIR = 13.5, p = 0.02) were associated with a higher intensity of hookworm infection. Improved and unshared toilet was associated with lower intensity of hookworm infections (aIIR = 0.2, p = 0.01). SAC had a higher odds of Ascaris lumbricoides infection than adults (aOR = 2.0, p = 0.01) and females had a lower odds of infection (aOR = 0.5, p = 0.02). CONCLUSION: Hookworm spp. are the most prevalent STH in Comé, with a persistent reservoir in adults that is not addressed by current control measures based on school MDA. Expanding MDA to target adults and PSAC is necessary to substantially impact population prevalence, particularly for hookworm. TRIAL REGISTRATION: ClinicalTrials.gov NCT03014167.

Is an integrated model of school eye health delivery more cost-effective than a vertical model? An implementation research in Zanzibar.

OBJECTIVE: To review and compare the cost-effectiveness of the integrated model (IM) and vertical model (VM) of school eye health programme in Zanzibar. METHODS AND ANALYSIS: This 6-month implementation research was conducted in four districts in Zanzibar. Nine and ten schools were recruited into the IM and VM, respectively. In the VM, teachers conducted eye health screening and education only while these eye health components were added to the existing school feeding programme (IM). The number of children aged 6-13 years old screened and identified was collected monthly. A review of project account records was conducted with 19 key informants. The actual costs were calculated for each cost categories, and costs per child screened and cost per child identified were compared between the two models. RESULTS: Screening coverage was 96% and 90% in the IM and VM with 297 children (69.5%) from the IM and 130 children (30.5%) from VM failed eye health screening. The 6-month eye health screening cost for VM and IM was US$6 728 and US$7 355. The cost per child screened for IM and VM was US$1.23 and US$1.31, and the cost per child identified was US$24.76 and US$51.75, respectively. CONCLUSION: Both models achieved high coverage of eye health screening with the IM being a more cost-effective school eye health delivery screening compared with VM with great opportunities for cost savings.

Development and application of an electronic treatment register: a system for enumerating populations and monitoring treatment during mass drug administration.

We developed an electronic treatment register for the DeWorm3 Project, a cluster-randomised, controlled trial in Benin, India, and Malawi testing the feasibility of interrupting transmission of soil-transmitted helminths through community-wide mass drug administration. The electronic treatment register was designed in xlsform, deployed via the SurveyCTO mobile data collection platform, and implemented on smartphones running the Android operating system. The versatile system enables collection of census and treatment status information, facilitates data aggregation and visualisation, and permits real-time feedback loops during implementation of mass drug administration. Here we describe the system's design and use within the DeWorm3 Project and key features, and by sharing the register here, we hope our readers will further explore its use within their research and disease-control activities.

Gender norms and mass deworming program access in Comé, Benin: A qualitative assessment of gender-associated opportunities and challenges to achieving high mass drug administration coverage.

The World Health Organization's Neglected Tropical Disease Roadmap has accelerated progress towards eliminating select neglected tropical diseases (NTDs). This momentum has catalyzed research to determine the feasibility of interrupting transmission of soil-transmitted helminths (STH) using community-wide mass drug administration (MDA). This study aims to identify potential gender-specific facilitators and barriers to accessing and participating in community-wide STH MDA, with the goal of ensuring programs are equitable and maximize the probability of interrupting STH transmission. This research was conducted prior to the launch of community-wide MDA for STH in Comé, Benin. A total of 10 focus group discussions (FGDs) were conducted separately among 40 men, 38 women, and 15 community drug distributors (CDDs). Salient themes included: both men and women believe that community-wide MDA would reduce the financial burden associated with self-treatment, particularly for low income adults. Community members believe MDA should be packaged alongside water, sanitation, and other health services. Women feel past community-wide programs have been disorganized and are concerned these distributions will be similar. Women also expressed interest in increased engagement in the implementation of future community-based public health programs. Men often did not perceive themselves to be at great risk for STH infection and did not express a high demand for treatment. Finally, the barriers discussed by CDDs generally did not align with gender-specific concerns, but rather represented concerns shared by both genders. A door-to-door distribution strategy for STH MDA is preferred by women in this study, as this platform empowers women to participate as health decision makers for their family. In addition, involving women in planning and implementation of community-wide programs may help to increase treatment coverage and compliance.

Integrated delivery of school health interventions through the school platform: Investing for the future.

School health and nutrition (SHN) programmes are recognized as a significant contributor to both health and education sector goals. The school system offers an ideal platform from which to deliver basic health interventions that target the most common health conditions affecting school-age children (SAC) in low-income countries, leading to improved participation and learning outcomes. However, governments require evidence to cost, design, and implement these programmes. In Ethiopia, prevalent health conditions affecting SAC's education participation and learning outcomes include infection with soil-transmitted helminths (STHs), hunger, and malnutrition. In recognition of the multiple issues affecting the health and education of SAC, the government has taken a proactive approach, coordinating an integrated SHN programme designed to be implemented in partnership and monitored and financed through a single, integrated mechanism. The programme, known as the Enhanced School Health Initiative (ESHI), integrates three complimentary health interventions: deworming; school feeding; and provision of a water, sanitation, and hygiene (WASH) package in schools, which in delivery aim to maximize the benefits of each of the individual components. Operational research surrounding the ESHI programme includes both qualitative and quantitative analyses. Here, we present an overview of the ESHI programme and its genesis. We also introduce three additional supporting papers that provide in-depth analyses of key findings, including the baseline situational analysis, the costs, and community perceptions of the programme. The findings from ESHI provide initial evidence to develop an understanding of the related costs and synergies of integrating multiple health interventions onto a single platform. The work has translated into strengthened institutional capacity and improved cross-sectoral coordination. The government is now committed to supporting 25 million school children in Ethiopia through SHN. The ESHI model serves as a reference point for other countries looking to scale up targeted SHN interventions.

Assessing the feasibility of interrupting the transmission of soil-transmitted helminths through mass drug administration: The DeWorm3 cluster randomized trial protocol.

Current control strategies for soil-transmitted helminths (STH) emphasize morbidity control through mass drug administration (MDA) targeting preschool- and school-age children, women of childbearing age and adults in certain high-risk occupations such as agricultural laborers or miners. This strategy is effective at reducing morbidity in those treated but, without massive economic development, it is unlikely it will interrupt transmission. MDA will therefore need to continue indefinitely to maintain benefit. Mathematical models suggest that transmission interruption may be achievable through MDA alone, provided that all age groups are targeted with high coverage. The DeWorm3 Project will test the feasibility of interrupting STH transmission using biannual MDA targeting all age groups. Study sites (population ≥80,000) have been identified in Benin, Malawi and India. Each site will be divided into 40 clusters, to be randomized 1:1 to three years of twice-annual community-wide MDA or standard-of-care MDA, typically annual school-based deworming. Community-wide MDA will be delivered door-to-door, while standard-of-care MDA will be delivered according to national guidelines. The primary outcome is transmission interruption of the STH species present at each site, defined as weighted cluster-level prevalence ≤2% by quantitative polymerase chain reaction (qPCR), 24 months after the final round of MDA. Secondary outcomes include the endline prevalence of STH, overall and by species, and the endline prevalence of STH among children under five as an indicator of incident infections. Secondary analyses will identify cluster-level factors associated with transmission interruption. Prevalence will be assessed using qPCR of stool samples collected from a random sample of cluster residents at baseline, six months after the final round of MDA and 24 months post-MDA. A smaller number of individuals in each cluster will be followed with annual sampling to monitor trends in prevalence and reinfection throughout the trial. TRIAL REGISTRATION: ClinicalTrials.gov NCT03014167.

Evaluating the sustainability, scalability, and replicability of an STH transmission interruption intervention: The DeWorm3 implementation science protocol.

Hybrid trials that include both clinical and implementation science outcomes are increasingly relevant for public health researchers that aim to rapidly translate study findings into evidence-based practice. The DeWorm3 Project is a series of hybrid trials testing the feasibility of interrupting the transmission of soil transmitted helminths (STH), while conducting implementation science research that contextualizes clinical research findings and provides guidance on opportunities to optimize delivery of STH interventions. The purpose of DeWorm3 implementation science studies is to ensure rapid and efficient translation of evidence into practice. DeWorm3 will use stakeholder mapping to identify individuals who influence or are influenced by school-based or community-wide mass drug administration (MDA) for STH and to evaluate network dynamics that may affect study outcomes and future policy development. Individual interviews and focus groups will generate the qualitative data needed to identify factors that shape, contextualize, and explain DeWorm3 trial outputs and outcomes. Structural readiness surveys will be used to evaluate the factors that drive health system readiness to implement novel interventions, such as community-wide MDA for STH, in order to target change management activities and identify opportunities for sustaining or scaling the intervention. Process mapping will be used to understand what aspects of the intervention are adaptable across heterogeneous implementation settings and to identify contextually-relevant modifiable bottlenecks that may be addressed to improve the intervention delivery process and to achieve intervention outputs. Lastly, intervention costs and incremental cost-effectiveness will be evaluated to compare the efficiency of community-wide MDA to standard-of-care targeted MDA both over the duration of the trial and over a longer elimination time horizon.

Sanitation, hookworm, anemia, stunting, and wasting in primary school children in southern Ethiopia: Baseline results from a study in 30 schools.

BACKGROUND: Inadequate nutrition; neglected topical diseases; and insufficient water, sanitation, and hygiene (WASH) are interrelated problems in schools in low-income countries, but are not routinely tackled together. A recent three-year longitudinal study investigated integrated school health and nutrition approaches in 30 government primary schools in southern Ethiopia. Here, we report on baseline associations between sanitation, hookworm infection, anemia, stunting, and wasting. METHODS: In each school, the Schistosoma mansoni, S. haematobium, and soil-transmitted helminth infection intensities; blood hemoglobin concentrations; heights; and weights of approximately 125 students were assessed. Of these 125 students, approximately 20 were randomly selected for student WASH surveys. Of these 20, approximately 15 were randomly selected for household sanitation observations. School WASH was also assessed through a combination of observations and questions to the headteacher. Mixed-effects logistic regression was used to compare household sanitation with hookworm infection (the other parasites being much less prevalent); and hookworm infection with anemia, stunting, and wasting. FINDINGS: Blood, stool, and urine samples were provided by 3,729 children, and student WASH and household WASH surveys were conducted with 596 and 448 of these students, respectively. Hookworm, Ascaris lumbricoides, Trichuris trichiura, and S. mansoni infections had prevalences of 18%, 4.8%, 0.6%, and 0.3%, respectively, and no S. haematobium infections were found. Anemia, stunting, and wasting had prevalences of 23%, 28%, and 14%, respectively. No statistically significant associations were found between latrine absence or evidence of open defecation at home, and hookworm infection (adjusted odds ratio, OR = 1.28, 95% confidence interval, CI: 0.476-3.44; and adjusted OR = 1.21, 95% CI: 0.468-3.12; respectively); or between hookworm infection and anemia, stunting, or wasting (adjusted OR = 1.24, 95% CI: 0.988-1.57; adjusted OR = 0.992, 95% CI: 0.789-1.25; and adjusted OR = 0.969, 95% CI: 0.722-1.30; respectively). CONCLUSIONS: In this setting, no statistically significant associations were found between sanitation and hookworm; or between hookworm and anemia, stunting, or wasting. More evidence on best practices for integrated school health interventions will be gathered from the follow-up surveys in this study.

School Water, Sanitation, and Hygiene, Soil-Transmitted Helminths, and Schistosomes: National Mapping in Ethiopia.

BACKGROUND: It is thought that improving water, sanitation, and hygiene (WASH) might reduce the transmission of schistosomes and soil-transmitted helminths, owing to their life cycles. However, few large-scale studies have yet assessed the real extent of associations between WASH and these parasites. METHODOLOGY/PRINCIPAL FINDINGS: In the 2013-2014 Ethiopian national mapping of infections with these parasites, school WASH was assessed alongside infection intensity in children, mostly between 10 and 15 years of age. Scores were constructed reflecting exposure to schistosomes arising from water collection for schools, from freshwater sources, and the adequacy of school sanitation and hygiene facilities. Kendall's τb was used to test the WASH scores against the school-level arithmetic mean intensity of infection with each parasite, in schools with at least one child positive for the parasite in question. WASH and parasitology data were available for 1,645 schools. More frequent collection of water for schools, from open freshwater sources was associated with statistically significantly higher Schistosoma mansoni infection intensity (Kendall's τb = 0.097, 95% confidence interval, CI: 0.011 to 0.18), better sanitation was associated with significantly lower Ascaris lumbricoides intensity (Kendall's τb = -0.067, 95% CI: -0.11 to -0.023) and borderline significant lower hookworm intensity (Kendall's τb = -0.039, 95% CI: -0.090 to 0.012, P = 0.067), and better hygiene was associated with significantly lower hookworm intensity (Kendall's τb = -0.076, 95% CI: -0.13 to -0.020). However, no significant differences were observed when comparing sanitation and infection with S. mansoni or Trichuris trichiura, or hygiene and infection with A. lumbricoides or T. trichiura. CONCLUSIONS/SIGNIFICANCE: Improving school WASH may reduce transmission of these parasites. However, different forms of WASH appear to have different effects on infection with the various parasites, with our analysis finding the strongest associations between water and S. mansoni, sanitation and A. lumbricoides, and hygiene and hookworm.

Maternal morbidity in the first year after childbirth in Mombasa Kenya; a needs assessment.

BACKGROUND: In sub-Saharan Africa, few services specifically address the needs of women in the first year after childbirth. By assessing the health status of women in this period, key interventions to improve maternal health could be identified. There is an underutilised opportunity to include these interventions within the package of services provided for woman-child pairs attending child-health clinics. METHODS: This needs assessment entailed a cross-sectional survey with 500 women attending a child-health clinic at the provincial hospital in Mombasa, Kenya. A structured questionnaire, clinical examination, and collection of blood, urine, cervical swabs and Pap smear were done. Women's health care needs were compared between the early (four weeks to two months after childbirth), middle (two to six months) and late periods (six to twelve months) since childbirth. RESULTS: More than one third of women had an unmet need for contraception (39%, 187/475). Compared with other time intervals, women in the late period had more general health symptoms such as abdominal pain, fever and depression, but fewer urinary or breast problems. Over 50% of women in each period had anaemia (Hb <11 g/l; 265/489), with even higher levels of anaemia in those who had a caesarean section or had not received iron supplementation during pregnancy. Bacterial vaginosis was present in 32% (141/447) of women, while 1% (5/495) had syphilis, 8% (35/454) Trichomonas vaginalis and 11% (54/496) HIV infection. CONCLUSION: Throughout the first year after childbirth, women had high levels of morbidity. Interface with health workers at child health clinics should be used for treatment of anaemia, screening and treatment of reproductive tract infections, and provision of family planning counselling and contraception. Providing these services during visits to child health clinics, which have high coverage both early and late in the year after childbirth, could make an important contribution towards improving women's health.