BACKGROUND:Healthcare workers play an important role in administering COVID-19 vaccines, particularly in conflict-affected settings. Syria has endured a protracted conflict for over a decade and while most of the healthcare workers in the country have been vaccinated with at least one COVID-19 vaccine dose, vaccinating all of them would reduce their risk of COVID-19 complications, given their daily interactions with patients. METHODS:The goal of this study was to better understand the main barriers to uptake of COVID-19 vaccines among female healthcare workers in Syria. Using data from a wider national survey of 17,000 respondents conducted between October and November 2022, we analysed a sub-sample of 4136 responses from female healthcare workers, across 14 Governorates. The main outcome of interest was vaccination status, (vaccinated, willing (but not yet vaccinated), unsure about vaccination and finally, those unwilling to receive a COVID-19 vaccine). We present descriptive information about the sample and conduct a multivariate logistic regression analysis to shed light on some of the barriers preventing COVID-19 vaccination uptake. RESULTS:We find that the vast majority (93.7%) of female healthcare workers have received at least one COVID-19 vaccination dose. We find that attitudes and beliefs around COVID-19 vaccines impact upon the decision to get a vaccination-positive attitudes around effectiveness and safety of the vaccines increase the likelihood of being vaccinated or willing to be vaccinated. More specifically, healthcare workers which believe in the safety of the vaccines are twice as likely to get vaccinated relative to those who don't. By contrast, we find that neutral attitudes regarding the vaccines are associated with vaccine indecision among female healthcare workers. In addition, we also find that female healthcare workers tend to trust COVID-19 vaccine information from their peers-close to 99% of vaccinated female healthcare workers tend to trust the vaccine information received from their peers. IMPLICATIONS:While the vaccination rates among healthcare workers are high, the results could further help in devising strategies for tackling the structural and individual barriers towards vaccine uptake among healthcare workers.

Access to safe drinking water is a recognized human right and a policy priority, reflected in the United Nations’ Sustainable Development Goals (SDGs). To monitor progress on SDG Target 6.1—safely managed drinking water services—many countries now incorporate Escherichia coli water quality testing into nationally representative household surveys, including UNICEF’s Multiple Indicator Cluster Surveys (MICS). The objective of this study was to evaluate multiple aspects of existing MICS water quality testing techniques. A low-cost filtration kit (~$60 compared to ~$1200 for the standard kit) was piloted during a water quality study in Southern Malawi. The low-cost filtration kit performed well with no breakage, leakage or stability issues reported. An existing MICS quality control measure was also assessed. Results support the current practice of using pre-tested locally purchased bottled water to undertake “blank” negative quality control testing. The current practice of having enumerators count E. coli colonies was investigated and was found to be acceptable and valid. To increase the storage capacity of the belt incubation method, a reduced (18- vs. 24-hour) incubation time was investigated. If the purpose is to classify results by risk categories, it would be advisable to incubate samples for the additional 6 hours if after 18 hours a count is observed of only 1 or 2 CFU/100 mL lower than the cut-off for the next highest risk category. Overall, results were encouraging and support the widespread use of the low-cost filtration kit, with potentially significant cost savings. However, we recommend further research to investigate and quantify the impacts of an abbreviated incubation time on water quality results.

Given nearly one third of sub-Saharan Africa’s population lack access to an improved water source that is available when needed, service continuity restricts access to safely managed services. Household surveys, water regulators, and utilities all gather data on service continuity, but few studies have integrated these disparate datasets to quantify continuity-related risk factors and inequalities. This study aimed to assess the added value of utility and regulator data for international monitoring by assessing factors affecting piped water availability in urban and peri-urban Zambia. Household ‘user’ data from the 2018 Demographic and Health Survey (n = 3047) were spatially linked to provider data from an international utility database and regulator reports. Multilevel modelling quantified provider-related and socio-economic risk factors for households reporting water being unavailable for at least one day in the previous fortnight. 47% (95% CI: 45%, 49%) of urban and peri-urban households reported water being unavailable for at least one full day, ranging from 18% (95% CI: 14%, 23%) to 76% (95% CI: 70%, 81%) across providers. Controlling for provider, home ownership (odds ratio (OR) = 1.31; p <0.01), speaking Luvale, Kaonde, Lunda (OR = 2.06; p <0.05) or Tonga (OR = 1.78; p <0.1) as an ethnicity proxy, and dry season interview dates (OR = 1.91; p <0.05) were associated with household-reported interruptions. Households using a neighbour’s tap (OR = 1.33; p <0.1) and in mid-wealth neighbourhoods (OR = 4.31; p <0.1) were more likely to report interruptions. For every $1000 increase in utility-level GDP per capita, the odds of an interruption were 0.51 times less (p<0.01). Substantial inequalities in drinking-water availability were found between provider coverage areas. Spatial integration of user, provider and regulator data enriches analysis, providing a finer-scale perspective than otherwise possible. However, wider use of utility or regulator data requires investment in monitoring of small-scale community supply intermittency and utility coverage area data.

Background: Understanding the main determinants of COVID-19 vaccine uptake is critical to increasing vaccine coverage. This is particularly important for COVID-19 vaccine uptake, which has been affected by both demand and supply issues. Aim: To understand the links between vaccine uptake and demand and supply issues in the WHO Eastern Mediterranean and UNICEF Middle East and North Africa regions. Methods: We collected data through 2 rounds of a repeated cross-sectional phone survey from 11 000 individuals across 16 low-and middle-income countries. We used logit modelling to distil the main characteristics of the 4 vaccination categories (vaccinated, unvaccinated but willing, unvaccinated and undecided, and unvaccinated and unwilling) while also considering vaccine availability. We conducted sub-regional analysis to account for differences in level of development between the low-and middle-income countries. Results: Despite the increase in vaccination coverage from 60.9% at the end of 2021 to 78.3% by August 2022, about 9% were not willing and were not vaccinated during the two rounds of interviews. Our modelling analysis revealed that positive beliefs about safety, effectiveness and side effects of the COVID-19 vaccines were associated with increased odds of being vaccinated or willingness to be vaccinated. Those who did not believe in the safety of the vaccines were less likely to be vaccinated than those who believed in the safety of the vaccines (OR: 0.56; 95% CI: 0.46-0.67). By contrast, negative beliefs about the COVID-19 vaccines increased the probability of being unwilling to be vaccinated. Conclusion: The results from this research offer useful insights into tackling the supply and demand related barriers to COVID-19 vaccination uptake and provides lessons for future health threats.

Safe drinking water access is a human right, but data on safely managed drinking water services (SMDWS) is lacking for more than half of the global population. We estimate SMDWS use in 135 low- and middle-income countries (LMICs) at subnational levels with a geospatial modeling approach, combining existing household survey data with available global geospatial datasets. We estimate that only one in three people used SMDWS in LMICs in 2020 and identified fecal contamination as the primary limiting factor affecting almost half of the population of LMICs. Our results are relevant for raising awareness about the challenges and limitations of current global monitoring approaches and demonstrating how globally available geospatial data can be leveraged to fill data gaps and identify priority areas in LMICs.

Disposable diaper use is widespread in many low- and middle-income countries whilst waste collection services are scarce. Despite the potential environmental and public health impacts of disposable diaper consumption by households lacking waste services, an international system for monitoring such consumption is lacking. This study therefore aims to develop and evaluate a method for estimating disposable diaper use based on secondary data, specifically nationally representative household expenditure surveys. Disposable diaper expenditure reported via household expenditure surveys for Nigeria (from 2018–19), Kenya (2015–16) and Ghana (2016–17) was used to estimate national disposable diaper consumption among households lacking waste collection services. To assess plausibility of reported expenditure, consumption-smoothing was examined, and Receiver Operating Curve analysis was used to infer mean toilet-training age. In Ghana, Kenya and Nigeria, households lacking appropriately managed waste services consumed an estimated 19 million, 210 million and 285 million disposable diapers per year (292 child/year, 433 child/year and 59 child/year among nappy-consuming households), respectively. Mean toilet-training ages were 24 to 30 months. Disposable diaper purchasing patterns showed evidence of consumption-smoothing among poorer households. Where commodity coding allows, household expenditure surveys can be used to construct internationally comparable indicators depicting disposable diaper consumption among households lacking waste services. Such indicators could be used to advocate for accelerated diaper product innovation, and target areas with high disposable diaper consumption but low waste service coverage.

Improving rural water supply sustainability in sub-Saharan Africa remains a major challenge. This study analysed five-years of cross-sectional sustainability check data collected annually between 2011 and 2016 (except 2015) to investigate factors influencing the operational performance of community-managed handpumps in rural Mozambique. Logistic and negative binomial regression was performed using multiple outcome measures of functionality, reliability and continuity. Average marginal effects (AMEs) were estimated to assess the effects of the predictors and mediation analysis was conducted to examine the role of women's participation.Higher levels of handpump performance were associated with financial records quality and update frequency, water committees with spare parts in stock, and committee annual revenue. The AME of high quality or recently updated financial records for non-functionality was estimated to be −0.40 (95% confidence interval [CI], −0.25 to −0.56), which is interpreted as a 40% lower probability of a water point being non-functional compared to the reference group. Annual committee revenue up to 2000 MZN (50 USD) reduced the probability of non-functionality by 25% (AME, 95% CI, −0.05 to −0.45). Water committees with a spare part stock exhibited a preventive effect on both non-functionality and breakdowns in the past 12 months, reducing their probability by 10% (AME, 95% CI, −0.03 to −0.17) and by 18% (AME, 95% CI, −0.05 to −0.30), respectively. Handpumps were 10% (AME, 95% CI, 0.03 to 0.17) more likely to be non-functional when women were in the committee management positions. Conversely, female maintenance group members were associated with reduced breakdowns in the multivariate regression analysis (odds ratio, 0.48; 95% CI, 0.24 to 0.95).Increasing outreach of post-construction support on capacity building for water committees, particularly on user fee collection, maintaining financial records, replenishing spare parts, and increased participation of women in the maintenance group, may contribute to greater sustainability of rural water points.

Exposure to fecally contaminated drinking water contributes to the global disease burden, especially in sub-Saharan Africa (SSA). We used cross-sectional data and elimination regression analysis to examine factors influencing E. coli contamination in household drinking water samples from 4499 rural households in nine countries in SSA (Malawi, Mozambique, and Zambia in Southern Africa; Ghana, Mali, and Niger in Western Africa; and Kenya, Rwanda, and Tanzania in Eastern Africa). The proportion of household water samples containing E. coli was 71%, ranging from 45% (Malawi) to 89% (Tanzania). Pooled and multi-country predictive logistic regression models showed that using an unimproved-type water source, the absence of a community water committee, and domestic animal ownership were significantly associated with household drinking water contamination. Household water treatment and storage practices, sanitation and hygiene practices, and payment for drinking water were not significantly associated with E. coli contamination in any model. The season was a significant predictor of E. coli in the pooled model; samples collected in the rainy season were 2.3 [2.0, 2.7] times as likely to be contaminated with E. coli. Practitioners and policymakers should prioritize implementing piped on-plot water services, establishing effective local water source management structures, and incorporating animal husbandry practices into water, sanitation, and hygiene interventions.

Objective To study the link between coronavirus disease 2019 (COVID-19) vaccination status and adherence to public health and social measures in Members of the Eastern Mediterranean Region and Algeria. Methods We analysed two rounds of a large, cross-country, repeated cross-sectional mobile phone survey in June-July 2021 and October-November 2021. The rounds included 14 287 and 14 131 respondents, respectively, from 23 countries and territories. Questions covered knowledge, attitudes and practices around COVID-19, and demographic, employment, health and vaccination status. We used logit modelling to analyse the link between self-reported vaccination status and individuals' practice of mask wearing, physical distancing and handwashing. We used propensity score matching as a robustness check. Findings Overall, vaccinated respondents (8766 respondents in round 2) were significantly more likely to adhere to preventive measures than those who were unvaccinated (5297 respondents in round 2). Odds ratios were 1.5 (95% confidence interval, CI: 1.3-1.8) for mask wearing; 1.5 (95% CI: 1.3-1.7) for physical distancing; and 1.2 (95% CI: 1.0-1.4) for handwashing. Similar results were found on analysing subsamples of low- and middle-income countries. However, in high-income countries, where vaccination coverage is high, there was no significant link between vaccination and preventive practices. The association between vaccination status and adherence to public health advice was sustained over time, even though self-reported vaccination coverage tripled over 5 months (19.4% to 62.3%; weighted percentages). Conclusion Individuals vaccinated against COVID-19 maintained their adherence to preventive health measures. Nevertheless, reinforcement of public health messages is important for the public's continued compliance with preventive measures.

Monitoring access to safely managed drinking water services requires information on water quality. An increasing number of countries have integrated water quality testing in household surveys however it is not anticipated that such tests will be included in all future surveys. Using water testing data from the 2016 Ethiopia Socio-Economic Survey (ESS) we developed predictive models to identify households using contaminated (≥1 E. coli per 100 mL) drinking water sources based on common machine learning classification algorithms. These models were then applied to the 2013–2014 and 2018–2019 waves of the ESS that did not include water testing. The highest performing model achieved good accuracy (88.5%; 95% CI 86.3%, 90.6%) and discrimination (AUC 0.91; 95% CI 0.89, 0.94). The use of demographic, socioeconomic, and geospatial variables provided comparable results to that of the full features model whereas a model based exclusively on water source type performed poorly. Drinking water quality at the point of collection can be predicted from demographic, socioeconomic, and geospatial variables that are often available in household surveys.

We used three rounds of a repeated cross-sectional survey on COVID-19 vaccination conducted throughout the entire territory of Yemen to: (i) describe the demographic and socio-economic characteristics associated with willingness to be vaccinated; (ii) analyse the link between beliefs associated with COVID-19 vaccines and willingness to be vaccinated; and (iii) analyse the potential platforms that could be used to target vaccine hesitancy and improve vaccine coverage in Yemen. Over two-thirds of respondents were either unwilling or unsure about vaccination across the three rounds. We found that gender, age, and educational attainment were significant correlates of vaccination status. Respondents with better knowledge about the virus and with greater confidence in the capacity of the authorities (and their own) to deal with the virus were more likely to be willing to be vaccinated. Consistent with the health belief model, practising one (or more) COVID-19 preventative measures was associated with a higher willingness to get a COVID-19 vaccination. Respondents with more positive views towards COVID-19 vaccines were also more likely to be willing to be vaccinated. By contrast, respondents who believed that vaccines are associated with significant side effects were more likely to refuse vaccination. Finally, those who relied on community leaders/healthcare workers as a trusted channel for obtaining COVID-19-related information were more likely to be willing to be vaccinated. Strengthening the information about the COVID-19 vaccination (safety, effectiveness, side effects) and communicating it through community leaders/healthcare workers could help increase the COVID-19 vaccine coverage in Yemen.

Achieving a high level of COVID-19 vaccination coverage in a conflict-affected setting is challenging. The objective of this paper is to shed further light on the main determinants of vaccination coverage using a large, cross-sectional sample (October–November 2022) of over 17,000 adults in Syria. We find evidence that certain demographic and socioeconomic characteristics describe a core set of vaccination personas. Men, older respondents, and those who are more educated and trust information received from healthcare authorities are more likely to be vaccinated. Healthcare workers in this sample are highly vaccinated. Furthermore, respondents with more positive views towards COVID-19 vaccines are also more likely to be willing to be vaccinated. By contrast, respondents who believe that vaccines are associated with significant side effects are also more likely to refuse vaccination. In addition, younger respondents and women, as well as those with a lower level of education, are more likely to refuse to be vaccinated. Respondents with a neutral attitude towards vaccines are also more likely to be undecided, whereas respondents who are refusing to get vaccinated are more likely to trust the information received from private doctors, private clinics, as well as social media and, more broadly, the internet.

BACKGROUND:Assessments of disease burden are important to inform national, regional, and global strategies and to guide investment. We aimed to estimate the drinking water, sanitation, and hygiene (WASH)-attributable burden of disease for diarrhoea, acute respiratory infections, undernutrition, and soil-transmitted helminthiasis, using the WASH service levels used to monitor the UN Sustainable Development Goals (SDGs) as counterfactual minimum risk-exposure levels. METHODS:We assessed the WASH-attributable disease burden of the four health outcomes overall and disaggregated by region, age, and sex for the year 2019. We calculated WASH-attributable fractions of diarrhoea and acute respiratory infections by country using modelled WASH exposures and exposure-response relationships from two updated meta-analyses. We used the WHO and UNICEF Joint Monitoring Programme for Water Supply, Sanitation and Hygiene public database to estimate population exposure to different WASH service levels. WASH-attributable undernutrition was estimated by combining the population attributable fractions (PAF) of diarrhoea caused by unsafe WASH and the PAF of undernutrition caused by diarrhoea. Soil-transmitted helminthiasis was fully attributed to unsafe WASH. FINDINGS:We estimate that 1·4 (95% CI 1·3-1·5) million deaths and 74 (68-80) million disability-adjusted life-years (DALYs) could have been prevented by safe WASH in 2019 across the four designated outcomes, representing 2·5% of global deaths and 2·9% of global DALYs from all causes. The proportion of diarrhoea that is attributable to unsafe WASH is 0·69 (0·65-0·72), 0·14 (0·13-0·17) for acute respiratory infections, and 0·10 (0·09-0·10) for undernutrition, and we assume that the entire disease burden from soil-transmitted helminthiasis was attributable to unsafe WASH. INTERPRETATION:WASH-attributable burden of disease estimates based on the levels of service established under the SDG framework show that progress towards the internationally agreed goal of safely managed WASH services for all would yield major public-health returns. FUNDING:WHO and Foreign, Commonwealth & Development Office.

Deploying passive (in-line) chlorinators is one strategy for improving access to microbially safe drinking water without requiring electricity or daily user input. Using Joint Monitoring Programme data, we calculate the population in low-and middle-income countries (n = 135 LMICs) using drinking water sources that are compatible (piped water and kiosks) or potentially compatible (packaged and/or delivered water, rainwater, boreholes and/or tube wells, and protected springs) with passive chlorinators. Leveraging water quality data from the Multiple Indicator Cluster Surveys (n = 37 LMICs), we estimate that 2.32 [95% confidence interval (CI): 2.19, 2.46] billion people use microbially contaminated water sources that are compatible [1.51 (1.42, 1.60) billion] or potentially compatible [817 (776, 858) million] with passive chlorinators. The largest target market for passive chlorinators is in South Asia [551 (532, 571) million rural users and 401 (384, 417) million urban users], where >77% of compatible drinking water sources are contaminated. However, self-reported household water treatment practices (n = 54 LMICs) indicate that chlorination is more common in the African and Latin American regions, suggesting passive chlorination would have higher acceptance in these regions than in Asia. Reaching the full potential of passive chlorinators will require establishing compatability of technologies with hand pump chlorination and identifying financially viable implementation models.

Sustainable Development Goal target 6.2 calls for universal access to adequate and equitable sanitation, setting a more ambitious standard for ‘safely managed sanitation services’. On-site sanitation systems (e.g., septic tanks) are widely used in low- and middle-income countries (LMICs). However, the lack of indicators for assessing fecal exposure risks presents a barrier to monitoring safely managed services. Furthermore, geographic diversity and frequency of disasters require a more nuanced approach to risk-informed decision-making. Taking Indonesia as an example, the purpose of this paper is to provide insights into current status and practices for on-site sanitation services in the contexts of LMICs. Using a dataset from a national socio-economic survey (n = 295,155) coupled with village census (n = 83,931), we assessed (1) household sanitation practices across Indonesia stratified by city-level population density and meteorological factors, (2) factors associated with septic tank emptying practice, and (3) inequalities in potential fecal exposure as measured by population density and WASH access by wealth quintile. We found a high reliance on on-site sanitation facilities (80.0%), almost half of which are assumed to be ‘uncontained’ septic tanks and one in ten facilities discharging untreated waste directly into the environment. The most densely populated areas had the highest rates of septic tank emptying, though emptying rates were just 17.0%, while in the lowest population density group, emptying was rarely reported. Multivariate regression analysis demonstrated an association between flooding and drought occurrence and septic tank emptying practice. Higher groundwater usage for drinking among poorer households suggests unsafe sanitation may disproportionally affect the poor. Our study underscores the urgent need to strengthen the monitoring of on-site sanitation in LMICs by developing contextualized standards. Furthermore, the inequalities in potential fecal exposure require greater attention and tailored support mechanisms to ensure the poorest gain access to safely managed sanitation services.

The UNICEF Multiple Indicator Cluster Survey module for water testing was included in the 2016/2017 Afghanistan Living Conditions Survey (ALCS) for 10 of the 34 provinces. The module's impact on the survey implementation was assessed through interviews and focus group discussions with survey teams. To assess the level of fecal contamination, drinking water from the source and at the point of consumption was tested for Escherichia coli using on-site membrane filtration. On-site testing of water generated significant interest from community members to receive water test results and understand how to keep their drinking water safe from contamination. The inclusion of the module in the ALCS facilitated access of the enumerators to both communities and households. Only 21.0% of households used safely managed drinking water services. A majority of households (58.2%) used water sources contaminated with E. coli, while E. coli contamination at the point of consumption was found in 77.0% of households. E. coli were more frequently detected in water sources used by households with unimproved sanitation. Beside improvement and increased protection of the water supply services, water quality deterioration between source and point of consumption calls for the promotion of safe handling and storage of water at the home.

Access to safely managed drinking water (SMDW) remains a global challenge, and affects 2.2 billion people 1,2 . Solar-driven atmospheric water harvesting (AWH) devices with continuous cycling may accelerate progress by enabling decentralized extraction of water from air 3–6 , but low specific yields (SY) and low daytime relative humidity (RH) have raised questions about their performance (in litres of water output per day) 7–11 . However, to our knowledge, no analysis has mapped the global potential of AWH 12 despite favourable conditions in tropical regions, where two-thirds of people without SMDW live 2 . Here we show that AWH could provide SMDW for a billion people. Our assessment—using Google Earth Engine 13 —introduces a hypothetical 1-metre-square device with a SY profile of 0.2 to 2.5 litres per kilowatt-hour (0.1 to 1.25 litres per kilowatt-hour for a 2-metre-square device) at 30% to 90% RH, respectively. Such a device could meet a target average daily drinking water requirement of 5 litres per day per person 14 . We plot the impact potential of existing devices and new sorbent classes, which suggests that these targets could be met with continued technological development, and well within thermodynamic limits. Indeed, these performance targets have been achieved experimentally in demonstrations of sorbent materials 15–17 . Our tools can inform design trade-offs for atmospheric water harvesting devices that maximize global impact, alongside ongoing efforts to meet Sustainable Development Goals (SDGs) with existing technologies.

Background: The 2030 Sustainable Development Goals (SDGs) set an ambitious new benchmark for safely managed drinking water services (SMDWs), but many countries lack national data on the availability and quality of drinking water. Objectives: We quantified the availability and microbiological quality of drinking water, monitored SMDWs, and examined risk factors for Escherichia coli (E. coli) contamination in 27 low-and middle-income countries (LMICs). Methods: A new water quality module for household surveys was implemented in 27 Multiple Indicator Cluster Surveys. Teams used portable equipment to measure E. coli at the point of collection (PoC, n=61,170) and at the point of use (PoU, n=64,900) and asked respondents about the availability and accessibility of drinking water. Households were classified as having SMDW services if they used an improved water source that was free of E. coli contamination at PoC, accessible on premises, and available when needed. Compliance with individual SMDW criteria was also assessed. Modified Poisson regression was used to explore household and community risk factors for E. coli contamination. Results: E. coli was commonly detected at the PoC (range 16–90%) and was more likely at the PoU (range 19–99%). On average, 84% of households used an improved drinking water source, and 31% met all of the SMDW criteria. E. coli contamination was the primary reason SMDW criteria were not met (15 of 27 countries). The prevalence of E. coli in PoC samples was lower among households using improved water sources [risk ratio (RR)=0.74; 95% confidence interval (CI): 0.64, 0.85] but not for households with water accessible on premises (RR=0.99; 95% CI: 0.94, 1.05) or available when needed (RR=0.95; 95% CI: 0.88, 1.02). E. coli contamination of PoU samples was less common for households in the richest vs. poorest wealth quintile (RR=0.70; 95% CI: 0.55, 0.88) and in communities with high (>75%) improved sanitation coverage (RR=0.94; 95% CI: 0.90, 0.97). Livestock ownership (RR=1.08; 95% CI: 1.04, 1.13), rural vs. urban residence (RR=1.10; 95% CI: 1.04, 1.16), and wet vs. dry season sampling (RR=1.07; 95% CI: 1.01, 1.15) were positively associated with contamination at the PoU. Discussion: Cross-sectional water quality data can be collected in household surveys and can be used to assess inequalities in service levels, to track the SDG indicator of SMDWs, and to examine risk factors for contamination. There is an urgent need for better risk management to reduce widespread exposure to fecal contamination through drinking water services in LMICs. https://doi.org/10.1289/EHP8459

To monitor safely managed drinking water services, an increasing number of countries have integrated water quality testing for Escherichia coli into nationally-representative household surveys such as the Multiple Indicator Cluster Surveys (MICS). However, plastic waste generated during such water quality testing programs, mostly through the use of pre-sterilized disposable materials, is non-negligible. The objective of this study was to evaluate several re-use protocols for disposable filter funnels used by the MICS water quality test kits. Decontamination and re-use protocols were assessed in centralized laboratory and decentralized field settings and neither yielded positive results. Re-use of 100 mL sterile funnels decontaminated with an alcohol wipe resulted in a higher incidence of false positive results (i.e., positive contamination when processing sterile water), both in the laboratory and field; therefore, a higher proportion of positives tests can be expected if these components are re-used. Further improvements to the decontamination technique and training are needed before material re-use can be reliably adopted. Autoclaving the funnels for re-use is feasible, provided that there is capacity to re-package and distribute funnels in a sterile manner.

Handwashing with water and soap is among the most a cost-effective interventions to improve public health. Yet billions of people globally lacking handwashing facilities with water and soap on premises, with gaps particularly found in low- and middle-income countries. Targeted efforts to expand access to basic hygiene services require data at geospatially explicit scales. Drawing on country-specific cross-sectional Demographic and Health Surveys with georeferenced hygiene data, we developed an ensemble machine learning model to predict the prevalence of basic hygiene facilities in Malawi, Nepal, Nigeria, Pakistan and Uganda. The ensemble model was based on a multiple-level stacking structure, where four predictive modelling algorithms were used to produce sub-models, and a random forest model was used to generalise the final predictions. An inverse distance weighted interpolation was incorporated in the random forest model to account for spatial autocorrelation. Local coverage and a local dissimilarity index were calculated to examine the geographic disparities in access. Our methodology produced robust outputs, as evidenced by performance evaluations (all R2 were above 0.8). Among the five study countries, Pakistan had the highest overall coverage, whilst Malawi had the poorest coverage. Apparent disparities in basic hygiene services measured by local coverage were found across geographic locations and between urban and rural settings. Nigeria had the highest level of inequalities in basic hygiene services measured by a dissimilarity index, whilst Malawi showed the least segregation between populations with and without basic hygiene services. Both educational attainment and wealth were important predictors of the geospatial distribution of basic hygiene services. By producing geospatially explicit estimates of the prevalence of handwashing facilities with water and soap, this study provides a means of identifying geographical disparities in basic hygiene services. The method and outputs can be useful tools to identify areas of low coverage and to support efficient and precise targeting of efforts to scale up access to handwashing facilities and shift social and cultural norms on handwashing.