Background: Ebola virus disease (EVD) is highly transmissible and has a high mortality rate. During outbreaks, EVD can spread across international borders. Inadequate hand hygiene places healthcare workers (HCWs) at increased risk for healthcare-associated infections, including EVD. In high-income countries, alcohol-based hand rub (ABHR) can improve hand hygiene compliance among HCWs in healthcare facilities (HCF). We evaluated local production and district-wide distribution of a WHO-recommended ABHR formulation and associations between ABHR availability in HCF and HCW hand hygiene compliance. Methods: The evaluation included 30 HCF in Kabarole District, located in Western Uganda near the border with the Democratic Republic of the Congo, where an EVD outbreak has been ongoing since August 2018. We recorded baseline hand hygiene practices before and after patient contact among 46 healthcare workers across 20 HCFs in August 2018. Subsequently, in late 2018, WHO/UNICEF distributed commercially produced ABHR to all 30 HCFs in Kabarole as part of Ebola preparedness efforts. In February 2019, our crossover evaluation distributed 20 L locally produced ABHR to each of 15 HCFs. From June 24–July 5, 2019, we performed follow-up observations of hand hygiene practices among 68 HCWs across all 30 HCFs. We defined hand hygiene as handwashing with soap or using ABHR. We conducted focus groups with healthcare workers at baseline and follow-up. Results: We observed hand hygiene compliance before and after 203 and 308 patient contacts at baseline and follow-up, respectively. From baseline to follow-up, hand hygiene compliance before patient contact increased for ABHR use (0% to 17%) and handwashing with soap (0% to 5%), for a total increase from 0% to 22% (P < .0001). Similarly, hand hygiene after patient contact increased from baseline to follow-up for ABHR use (from 3% to 55%), and handwashing with soap decreased (from 12% to 7%), yielding a net increase in hand hygiene compliance after patient contact from 15% to 62% (P < .0001). Focus groups found that HCWs prefer ABHR to handwashing because it is faster and more convenient. Conclusions: In an HCF in Kabarole District, the introduction of ABHR appeared to improve hand hygiene compliance. However, the confirmation of 3 EVD cases in Uganda 120 km from Kabarole District 2 weeks before our follow-up hand hygiene observations may have influenced healthcare worker behavior and hand hygiene compliance. Local production and district-wide distribution of ABHR is feasible and may contribute to improved hand hygiene compliance among healthcare workers.Funding: NoneDisclosures: Mohammed Lamorde, Contracted Research - Janssen Pharmaceutica, ViiV, Mylan

Household water chlorination has been shown to reduce diarrhea incidence among people living with Human Immunodeficiency Virus (PLHIV). Some HIV programs in Ethiopia previously provided a socially marketed chlorination product (brand name WuhaAgar) to prevent diarrhea. To evaluate the program, we compared WuhaAgar use and water treatment practices between 795 clients from 20 antiretroviral therapy (ART) clinics and 795 community members matched by age, sex, and neighborhood. Overall, 19% of study participants reported water treatment with WuhaAgar. Being an ART clinic client was associated with reported treatment of drinking water (matched odds ratios (mOR): 3.8, 95% confidence interval (CI): 2.9–5.0), reported current water treatment with WuhaAgar (mOR: 5.5, 95% CI 3.9–7.7), and bottles of WuhaAgar observed in the home (mOR: 8.8, 95% CI 5.4–14.3). Being an ART clinic client was also associated with reported diarrhea among respondents (mOR: 4.8, 95% CI 2.9–7.9) and household members (mOR:2.8, 95% CI: 1.9–4.2) in the two weeks preceding the survey. Results suggest that promoting and distributing water chlorination products in ART clinics was effective in increasing access to and use of water treatment products among PLHIV. The positive association between ART clinic attendees and diarrhea likely resulted from the immunocompromised status of ART clinic clients.

The PackH 2 O water backpack carrier was developed to provide safe storage and relieve stress of head-loading during water transport with traditional containers such as buckets and jerry cans. We conducted an evaluation to assess both self-reported and observed use over a 6-month period between November 2014 and May 2015. A total of 866 packs were distributed to 618 households in six communities in rural Haiti, and 431 and 441 households were surveyed at midline and end line, respectively. We performed linear regression to assess change of self-reported use over time. Although 79.3% of respondents reported continued use of the 20-L pack after 6 months, other measures of self-reported use were low, with only 16.8% reporting to have used the pack the last time they collected water and 10.3% preferring the pack over other water collection containers. In addition, only 10.2% of all people collecting water at community sources were observed using packs and 12.0% of all households surveyed had water in the pack at the time of visit. Pack use varied by community and demographics. Although women were targeted during distribution, men preferred the pack and were more commonly observed using it at the community water sources. In conclusion, the use of the PackH 2 O was not widely adopted in rural Haiti; however, further research is needed to assess the pack acceptance in areas where back-loading is more common and in emergency settings.

Introduction : lack of access to safe water, sanitation, and hygiene (WASH) in healthcare facilities (HCFs) poses health risks to patients and health workers. Universal WASH coverage in HCFs is included among the Sustainable Development Goals (SDGs) for 2030. We evaluated access to safe water, handwashing facilities, and drinking water in HCFs in Kamwenge District, Uganda. Methods : we interviewed HCF staff and conducted environmental assessments of HCFs that included HCF characteristics, water sources and treatment methods, and the availability of hand-washing and drinking-water stations. Additionally, we tested water samples from HCF water sources and drinking water points for Escherichia coli (E. coli) . Results : of the 62 HCFs surveyed, 30 (48%) were public and 32 (52%) were private. Outpatient services were provided by all HCFs and inpatient services by 42 (67%) HCFs. Water supplies were on the premises for 32 (52%). Improved water supplies were the main source for 52 (84%) HCFs. Water was unavailable from the main source for 3 months of the year in 16 (26%) HCFs. Regular interruptions in water supply were reported by 66% of HCFs. Of the 62 HCFs, 41 (66%) had hand-washing facilities with water and soap. While 32 (52%) HCFs reported usually having drinking water for staff and patients, only 23 (37%) had drinking water on interview day. Regular drinking water treatment was reported by 30 (48%) of 62 HCFs. E. coli contamination was found in 18 (49%) of 37 source water samples and 2 (13%) of 16 drinking water samples. Conclusion : most HCFs lacked access to reliable supplies of safe water and had inadequate access to WASH infrastructure. We recommend public and private investment in WASH in Kamwenge District to achieve the SDG for HCFs.

Many health care facilities (HCFs) in developing countries lack adequate infrastructure for handwashing and drinking water, increasing the risk of healthcare-associated infections. Attaining permanent, 24-hour/day piped water access - the long-term goal - is time-consuming and expensive. To address this problem in the short-to medium-term, low-cost portable handwashing water stations (HWSs) and drinking water stations (DWSs) were installed in rural Kenyan HCFs in 2011. Access to HWSs with soap and DWSs with safe water was ascertained at baseline and 1-year follow-up. Cost data were obtained from the program budget and beneficiary data (number of health workers, households, and individuals within HCF catchment areas) from the Ministry of Health. A cost analysis was adjusted for incremental gains from baseline to follow-up in access to improved handwashing and safe DWSs. The cost of improved access to handwashing with soap was $1,527/HCF, $217/health worker, and $0.17/individual, and to safe drinking water was $720/HCF, $103/health worker, and $0.08/individual. The favorable cost of this intervention per beneficiary justifies its use for rapid improvement of handwashing and drinking water access in HCFs during planning and construction of permanent infrastructure.

Since August 2015, the Ministry of Health, Community Development, Gender, Elderly and Children (MoHCDGEC) of Tanzania has been leading the response to a widespread cholera outbreak. As of June 9, 2016, cholera had affected 23 of 25 regions in Tanzania, with 21,750 cumulative cases and 341 deaths reported (Ally Nyanga, MoHCDGEC Emergency Operations Center, personal communication, June 2016). Approximately one fourth of all cases occurred in the Dar es Salaam region on the east coast. Regions surrounding Lake Victoria, in the north, also reported high case counts, including Mwanza with 9% (Ally Nyanga, MoHCDGEC Emergency Operations Center, personal communication, June 2016). Since the start of the outbreak, MoHCDGEC and the Ministry of Water (MOW) have collaborated with the Tanzania Red Cross Society, United Nations Children's Fund (UNICEF), World Health Organization (WHO), and CDC to enhance the water, sanitation, and hygiene (WASH) response to prevent the further spread of cholera.

BACKGROUND:Although the use of micronutrient powders (MNPs) is considered the preferred approach for childhood anemia control, concerns about iron-related morbidity from clinical trials have challenged programmatic scale-up. OBJECTIVE:We aimed to measure the effects of community-based sales of MNPs on diarrhea-, fever-, cough-, and malaria-morbidity episodes in children 6-35 mo of age. DESIGN:We conducted a cluster-randomized trial in rural Western Kenya where 60 villages were randomly assigned to either intervention or control groups. MNPs (containing iron, vitamin A, zinc, and 11 other micronutrients) and other health products (e.g., insecticide-treated bednets, soap, and water disinfectant) were marketed in 30 intervention villages from June 2007 to March 2008. Household visits every 2 wk were used to monitor self-reported MNP use and morbidity (illness episodes in the previous 24 h and hospitalizations in the previous 2 wk) in both groups. Iron, vitamin A, anemia, malaria, and anthropometric measures were assessed at baseline and at 12 mo of follow-up. Data were analyzed by intent-to-treat analyses. RESULTS:Of 1062 children enrolled in the study, 1038 children (97.7%) were followed (a total of 14,204 surveillance visits). Mean MNP intake in intervention villages was 0.9 sachets/wk. Children in intervention villages, compared with children in control villages, had ~60% fewer hospitalizations for diarrhea (0.9% compared with 2.4%, respectively; P = 0.03) and 70% fewer hospitalizations for fever (1.8% compared with 5.3%, respectively; P = 0.003) but no significant differences in hospitalizations for respiratory illness (1.1% compared with 2.2%, respectively; P = 0.11) or malaria (3.1% compared with 2.9%, respectively; P = 0.82). There were no differences between groups in the numbers of episodes of diarrhea, cough, or fever. CONCLUSIONS:MNP use in Western Kenya through market-based community sales was not associated with increased infectious morbidity in young children and was associated with decreased hospitalizations for diarrhea and fever. An integrated distribution of MNPs with other health interventions should be explored further in settings with a high child malnutrition and infection burden. This trial was registered at clinicaltrials.gov as NCT01088958.

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.

Background Recommended disease prevention behaviors of hand washing, hygienic hand drying, and covering one’s mouth and nose in a hygienic manner when coughing and sneezing appear to be simple behaviors but continue to be a challenge to successfully promote and sustain worldwide. We conducted a qualitative inquiry to better understand current hand drying behaviors associated with activities of daily living, and mouth and nose covering practices, among Kenyans. Methods and Findings We conducted 7 focus group discussions; 30 in-depth interviews; 10 structured household observations; and 75 structured observations in public venues in the urban area of Kisumu; rural communities surrounding Kisumu; and a peri-urban area outside Nairobi, Kenya. Using a grounded theory approach, we transcribed and coded the narrative data followed by thematic analysis of the emergent themes. Hand drying, specifically on a clean towel, was not a common practice among our participants. Most women dried their hands on their waist cloth, called a leso, or their clothes whether they were cooking, eating or cleaning the nose of a young child. If men dried their hands, they used their trousers or a handkerchief. Children rarely dried their hands; they usually just wiped them on their clothes, shook them, or left them wet as they continued with their activities. Many people sneezed into their hands and wiped them on their clothes. Men and women used a handkerchief fairly often when they had a runny nose, cold, or the flu. Most people coughed into the air or their hand. Conclusions Drying hands on dirty clothes, rags and lesos can compromise the benefits of handwashing. Coughing and sneezing in to an open hand can contribute to spread of disease as well. Understanding these practices can inform health promotion activities and campaigns for the prevention and control of diarrheal disease and influenza.

BackgroundSupplementation with zinc and vitamin A has been associated with reduced duration and severity of diarrhea and respiratory illness in children.ObjectiveWe measured the association of community‐based sales of Sprinkles with incidence of diarrhea, fever and cough in children 6–59mo.DesignThis was a cluster‐randomized, longitudinal cohort trial in 60 villages for the first 9mo (July 2007–March 2008), and expansion of access to Sprinkles to both study groups in the second 9mo (July 2008–March 2009). Thus, in addition to the experimental analyses using the first year's data, an as‐treated analysis to compare users and non‐users of Sprinkles across all 60 villages using all available data was carried out. The incidence of diarrhea, cough, and fever were compared between children who used Sprinkles and those who did not.ResultsOf the 1079 children enrolled, 78% (n=847) had data on Sprinkles use. Analyses using the experimental design (July 2007–March 2008) suggested null effects on diarrhea and cough. However, children in the intervention villages had 32% reduced fever (relative risk, RR=0.68; 95% CI=0.62, 0.74). Use of Sprinkles was associated with about 30% reduction in diarrhea (RR=0.71; 95% CI=0.55, 0.93) and 18% reduction in fever (RR=0.82; 95% CI=0.72, 0.95).ConclusionSale of Sprinkles may reduce fever and diarrhea incidence among children 6–59mo in western Kenya.Grant Funding Source: NEVIN SCRIMSHAW INTERNATIONAL NUTRITION FOUNDATION

We installed drinking water and handwashing stations in 17 rural schools and trained teachers to promote water treatment and hygiene to pupils. We gave schools flocculent-disinfectant powder and hypochlorite solution for water treatment. We conducted a baseline water handling survey of pupils' parents from 17 schools and tested stored water for chlorine. We trained teachers and students about hygiene, installed water stations, and distributed instructional comic books to students. We conducted follow-up surveys and chlorine testing at 3 and 13 months. From baseline to 3-month follow-up, parental awareness of the flocculent-disinfectant increased (49-91%, P < 0.0001), awareness of hypochlorite remained high (93-92%), and household use of flocculent-disinfectant (1-7%, P < 0.0001) and hypochlorite (6-13%, P < 0.0001) increased, and were maintained after 13 months. Pupil absentee rates decreased after implementation by 26%. This school-based program resulted in pupil-to-parent knowledge transfer and significant increases in household water treatment practices that were sustained over 1 year.

The December 2004 tsunami in Sumatra, Indonesia, destroyed drinking water infrastructure, placing over 500,000 displaced persons at increased risk of waterborne disease. In June 2005, we assessed the relationship of water handling behaviors to household water quality in three districts: Aceh Besar, Simeulue, and Nias. We surveyed 1,127 households from 21 communities and tested stored drinking water. Factors associated with a reduced likelihood of having contaminated stored drinking water included obtaining water from improved sources (Aceh Besar, adjusted odds ratio (aOR) 0.41, P < 0.01; Simeulue, aOR 0.48, P = 0.02), using chlorine solution (Simeulue, aOR 0.41, P < 0.01), and having free chlorine in stored water (Aceh Besar, aOR 0.42, P < 0.01; Nias, aOR 0.28, P < 0.01). Reported boiling, even among those who could describe correct practice, was not associated with improved water quality. Water source improvement and household water chlorination appear to be useful strategies to improve household stored drinking water quality in post-disaster situations.