Last data update: Jan 27, 2025. (Total: 48650 publications since 2009)
Records 1-30 (of 30 Records) |
Query Trace: Handzel T[original query] |
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An environmental evaluation of urine-diverting dry toilets in Hiloweyn Camp, Dollo Ado, Ethiopia
Brown TW , Murphy JL , Akers P , Patrick M , Hill V , Mattioli M , Tsige Y , Adow A , Abdirashid M , Mohamed MN , Githiri D , Handzel T . Sci Total Environ 2024 926 171838 Safe and hygienic management of human waste is essential in humanitarian settings. Urine-diverting dry toilets (UDDTs) can enable this management in some humanitarian emergency settings. A seeded, longitudinal environmental study was conducted in Hiloweyn refugee camp, Dollo Ado, Ethiopia, to measure Escherichia coli and Ascaris suum ova inactivation within closed UDDT vaults and to document environmental conditions (temperature, moisture content, and pH) that could influence inactivation. Hiloweyn camp represented an optimal location for a desiccation-based sanitation technology such as the UDDT. E. coli and Ascaris ova inactivation was observed in UDDTs under warm, dry, alkaline conditions at 6, 9, and 12 months of storage; UDDTs with samples containing <1000 E. coli/g total solids increased from 30 % to 95 % over 12 months, and a >2.8-log(10) reduction in Ascaris ova viability was observed after 6 months. Additional laboratory-based studies were conducted to provide insights into the field study findings and study the impact of hydrated lime on E. coli and Ascaris ova inactivation. Results suggest that adding hydrated lime to elevate pH > 12 may increase inactivation and decrease storage time. Overall, UDDTs could contribute to the safe and hygienic management of human waste in comparable warm and dry humanitarian settings. |
Improving water, sanitation, and hygiene (WASH), with a focus on hand hygiene, globally for community mitigation of COVID-19
Berendes D , Martinsen A , Lozier M , Rajasingham A , Medley A , Osborne T , Trinies V , Schweitzer R , Prentice-Mott G , Pratt C , Murphy J , Craig C , Lamorde M , Kesande M , Tusabe F , Mwaki A , Eleveld A , Odhiambo A , Ngere I , Kariuki Njenga M , Cordon-Rosales C , Contreras APG , Call D , Ramay BM , Ramm RES , Paulino CJT , Schnorr CD , Aubin M , Dumas D , Murray KO , Bivens N , Ly A , Hawes E , Maliga A , Morazan GH , Manzanero R , Morey F , Maes P , Diallo Y , Ilboudo M , Richemond D , Hattab OE , Oger PY , Matsuhashi A , Nsambi G , Antoine J , Ayebare R , Nakubulwa T , Vosburgh W , Boore A , Herman-Roloff A , Zielinski-Gutierrez E , Handzel T . PLOS Water 2022 1 (6) Continuity of key water, sanitation, and hygiene (WASH) infrastructure and WASH practices-for example, hand hygiene-are among several critical community preventive and mitigation measures to reduce transmission of infectious diseases, including COVID-19 and other respiratory diseases. WASH guidance for COVID-19 prevention may combine existing WASH standards and new COVID-19 guidance. Many existing WASH tools can also be modified for targeted WASH assessments during the COVID-19 pandemic. We partnered with local organizations to develop and deploy tools to assess WASH conditions and practices and subsequently implement, monitor, and evaluate WASH interventions to mitigate COVID-19 in low- and middle-income countries in Latin America and the Caribbean and Africa, focusing on healthcare, community institution, and household settings and hand hygiene specifically. Employing mixed-methods assessments, we observed gaps in access to hand hygiene materials specifically despite most of those settings having access to improved, often onsite, water supplies. Across countries, adherence to hand hygiene among healthcare providers was about twice as high after patient contact compared to before patient contact. Poor or non-existent management of handwashing stations and alcohol-based hand rub (ABHR) was common, especially in community institutions. Markets and points of entry (internal or external border crossings) represent congregation spaces, critical for COVID-19 mitigation, where globally-recognized WASH standards are needed. Development, evaluation, deployment, and refinement of new and existing standards can help ensure WASH aspects of community mitigation efforts that remain accessible and functional to enable inclusive preventive behaviors. |
Implementation of maternal and perinatal death surveillance and response (MPDSR) in humanitarian settings: insights and experiences of humanitarian health practitioners and global technical expert meeting attendees
Russell N , Tappis H , Mwanga JP , Black B , Thapa K , Handzel E , Scudder E , Amsalu R , Reddi J , Palestra F , Moran AC . Confl Health 2022 16 (1) 23 BACKGROUND: Maternal and perinatal death surveillance and response (MPDSR) is a system of identifying, analysing and learning lessons from such deaths in order to respond and prevent future deaths, and has been recommended by WHO and implemented in many low-and-middle income settings in recent years. However, there is limited documentation of experience with MPDSR in humanitarian settings. A meeting on MPDSR in humanitarian settings was convened by WHO, UNICEF, CDC and Save the Children, UNFPA and UNHCR on 17th-18th October 2019, informed by semi-structured interviews with a range of professionals, including expert attendees. CONSULTATION FINDINGS: Interviewees revealed significant obstacles to full implementation of the MPDSR process in humanitarian settings. Many obstacles were familiar to low resource settings in general but were amplified in the context of a humanitarian crisis, such as overburdened services, disincentives to reporting, accountability gaps, a blame approach, and politicisation of mortality. Factors more unique to humanitarian contexts included concerns about health worker security and moral distress. There are varying levels of institutionalisation and implementation capacity for MPDSR within humanitarian organisations. It is suggested that if poorly implemented, particularly with a punitive or blame approach, MPDSR may be counterproductive. Nevertheless, successes in MPDSR were described whereby the process led to concrete actions to prevent deaths, and where death reviews have led to improved understanding of complex and rectifiable contextual factors leading to deaths in humanitarian settings. CONCLUSIONS: Despite the challenges, examples exist where the lessons learnt from MPDSR processes have led to improved access and quality of care in humanitarian contexts, including successful advocacy. An adapted approach is required to ensure feasibility, with varying implementation being possible in different phases of crises. There is a need for guidance on MPDSR in humanitarian contexts, and for greater documentation and learning from experiences. |
Estimating stillbirth and neonatal mortality rate among Rohingya refugees in Bangladesh, September 2017 to December 2018: a prospective surveillance
Amsalu R , Costello J , Hasna Z , Handzel E . BMJ Glob Health 2022 7 (4) INTRODUCTION: There is limited literature on neonatal mortality in humanitarian emergencies. We estimated neonatal mortality and stillbirth rates; determined whether an association exists between proximity to a secondary health facility and neonatal mortality or stillbirth; and tested the correlation between the number of health facilities in a camp and neonatal mortality or stillbirth rates in Rohingya refugee camps in Bangladesh. METHODS: We conducted a prospective community-based mortality surveillance in 29 out of 34 Rohingya refugee camps between September 2017 and December 2018, covering approximately 811 543 Rohingya refugees with 19 477 estimated live births. We linked mortality surveillance data with publicly available information on camp population, number of functional health facilities and camp and health facility geospatial coordinates. Using descriptive statistics and spatial analyses, we estimated the mortality rate and tested for correlations. RESULTS: Overall, the estimated neonatal mortality rate was 27.0 (95% CI: 22.3 to 31.8) per 1000 live births, and the stillbirth rate was 15.2 (95% CI: 10.8 to 19.6) per 1000 total births. The majority of neonatal deaths (76.3%, n=405/531) and stillbirths (72.1%, n=202/280) occurred at home or in the community. A positive correlation existed between the camp population size and number of health facilities inside the camp (Spearman's rho=0.56, p value<0.01). No statistically significant correlation existed between the camp neonatal mortality rate or stillbirth rate and number of health facilities inside the camp. Camps that were located closer to a secondary health facility as compared with a labour room/sexual and reproductive health unit had a lower neonatal mortality rate (p value<0.01). CONCLUSIONS: The results provide insight into the neonatal mortality and stillbirth rates in Rohingya refugees camps in Bangladesh during 2017-2018. Prospective community-based mortality surveillance may be a feasible method to evaluate the effectiveness of humanitarian responses in improving neonatal survival and preventing stillbirths. |
Acceptability of urine diversion dry toilets in Dollo Ado refugee camp, Ethiopia
Patrick M , Tsige Y , Adow A , Abdirashid M , Yunis H , Githiri D , Hulland E , Murphy J , Akers P , Brown TW , Blanton C , Handzel T . Int J Hyg Environ Health 2021 234 113745 Given the increasing frequency and duration of humanitarian emergencies worldwide, there is a need to identify a greater range of effective and contextually appropriate water, sanitation and hygiene (WASH) interventions. Typical sanitation systems may be poorly suited for some of the conditions in which humanitarian emergencies can occur, such as in drought-prone regions. Urine-diversion dry toilets (UDDTs) are one potential alternative sanitation option which can be used in these conditions. Between 2014 and 2016, the U.S. Centers for Disease Control and Prevention (CDC) partnered with local agencies to evaluate the acceptability of UDDTs in a refugee camp in Ethiopia. The overall goals were to provide evidence regarding the level of adoption and satisfaction with UDDTs in this emergency context and the factors associated with satisfaction. Two cross-sectional surveys were conducted 18-months apart, using a stratified design to sample UDDT and latrine users for comparison. The proportion who reported to use their UDDT consistently was 88.8% (95% CI 85.1-92.5) in the first survey and 93.4% (95% CI 90.6-96.2) in the second survey. Reported satisfaction levels were significantly higher among respondents in the second survey (p < 0.0001), where 97.0% (95% CI 95.1-98.9) of respondents stated either that they were mostly or very satisfied with their UDDT. There was no significant difference detected in satisfaction between UDDT and latrine users (p = 0.28). Using a multivariable logistic regression model, we identified several factors associated with a higher level of satisfaction with UDDTs. Those who had previously (before coming to the camp) used a pit latrine (AOR = 4.2; 95% CI 1.4-12.7) or had no sanitation system (AOR = 2.4; 95% CI 1.3-4.4) relative to a pour-flush toilet, had a clean UDDT (AOR = 2.8; 95% CI 1.7-4.6), had been in the camp for a longer time period (AOR = 2.3; 95% CI 1.7-3.0), did not share their UDDT (AOR = 1.8; 95% CI 1.0-3.0) and had used their UDDT for a longer time period (AOR = 1.7; 95% CI 1.2-2.4) had higher odds of satisfaction. The findings demonstrate that UDDTs have been effectively introduced and utilized in this context and this may have implications for other humanitarian settings where they can be similarly managed. |
Backpack use as an alternative water transport method in Kisumu, Kenya
Kim S , Curran K , Deng L , Odhiambo A , Oremo J , Otieno R , Omore R , Handzel T , Quick R . J Water Sanit Hyg Dev 2020 10 (4) 986-995 In developing countries, most households transport water from distant sources, placing physical burdens on women and children, who commonly carry water on their heads. A lightweight backpack was developed to alleviate physical stress from water carriage and provide a safe storage container. In 2015, we conducted a baseline survey among 251 Kenyan households with children <5 years old, distributed one backpack per household, and made 6 monthly home visits to ask about backpack use. At baseline, the median reported water collection time was 40 minutes/round trip; 80% of households reported collecting water daily (median 3 times/day). At follow-up visits, respondents reported backpack use to carry water ranged from 4% to 20% in the previous day; reported backpack use for water storage in the previous day ranged from 31% to 67%. Pain from water carriage was reported at 9% of all follow-up visits. The odds of backpack use in the past day to collect water were lower during rainy season (OR: 0.3, 95% CI: 0.2–0.3) and not associated with reported pain (OR: 1.7, 95% CI: 0.9–3.3). Our study suggests that participants preferred using the backpacks for storage rather than transport of water. Further dissemination of the backpacks is not recommended because of modest use for transport. |
Improved chlorination and rapid water quality assessment in response to an outbreak of acute watery diarrhea in Somali region, Ethiopia
Rajasingham A , Harvey B , Taye Y , Kamwaga S , Martinsen A , Sirad M , Aden M , Gallagher K , Handzel T . J Water Sanit Hyg Dev 2020 10 (3) 596-602 The Somali Region of Ethiopia has been affected by drought for several years. Drought conditions have led to food and water scarcity and a humanitarian crisis in the region. In January 2017, an outbreak of acute watery diarrhea (AWD) was declared in the region. AWD prevention and control activities include strengthening water, sanitation, and hygiene (WASH) services. Access to safe drinking water is critical in preventing transmission of AWD and chlorine is an effective chemical to disinfect water supplies. The US Centers for Disease Control and Prevention collaborated with the WASH Cluster and the United Nations Children’s Fund, Ethiopia, to provide technical assistance to the Somali Regional Water Bureau to improve chlorination of drinking water supplies and quickly assess water quality improvements in Jijiga town, Fafan Zone. Timely sharing of surveillance and case investigation data allowed for the identification of gaps within the water supply system in Jijiga and implementation of centralized and decentralized chlorination interventions and monitoring systems. Pilot use of a rapid assessment to determine residual chlorine levels at various points in the city helped improve chlorination intervention impact. This work illustrates that rapid community-level water quality improvements can be implemented and assessed quickly to improve interventions during outbreaks. |
Notes from the field: Nationwide hepatitis E outbreak concentrated in informal settlements - Namibia, 2017-2020
Bustamante ND , Matyenyika SR , Miller LA , Goers M , Katjiuanjo P , Ndiitodino K , Ndevaetela EE , Kaura U , Nyarko KM , Kahuika-Crentsil L , Haufiku B , Handzel T , Teshale EH , Dziuban EJ , Nangombe BT , Hofmeister MG . MMWR Morb Mortal Wkly Rep 2020 69 (12) 355-357 In September 2017, Namibia’s Ministry of Health and Social Services (MoHSS) identified an increase in cases of acute jaundice in Khomas region, which includes the capital city of Windhoek. Hepatitis E is a liver disease caused by hepatitis E virus, which is transmitted by the fecal-oral route, causing symptoms consistent with acute jaundice syndrome (1). Hepatitis E is rarely fatal; however, the disease can be severe in pregnant women, resulting in fulminant hepatic failure and death (2). |
Systematic identification of facility-based stillbirths and neonatal deaths through the piloted use of an adapted RAPID tool in Liberia and Nepal
Greene-Cramer B , Boyd AT , Russell S , Hulland E , Tromble E , Widiati Y , Sharma S , Pun A , Roth Allen D , Dokubo EK , Handzel E . PLoS One 2019 14 (9) e0222583 Maternal, fetal, and neonatal health outcomes are interdependent. Designing public health strategies that link fetal and neonatal outcomes with maternal outcomes is necessary in order to successfully reduce perinatal and neonatal mortality, particularly in low- and middle- income countries. However, to date, there has been no standardized method for documenting, reporting, and reviewing facility-based stillbirths and neonatal deaths that links to maternal health outcomes would enable a more comprehensive understanding of the burden and determinants of poor fetal and neonatal outcomes. We developed and pilot-tested an adapted RAPID tool, Perinatal-Neonatal Rapid Ascertainment Process for Institutional Deaths (PN RAPID), to systematically identify and quantify facility-based stillbirths and neonatal deaths and link them to maternal health factors in two countries: Liberia and Nepal. This study found an absence of stillbirth timing documented in records, a high proportion of neonatal deaths occurring within the first 24 hours, and an absence of documentation of pregnancy-related and maternal factors that might be associated with fetal and neonatal outcomes. The use of an adapted RAPID methodology and tools was limited by these data gaps, highlighting the need for concurrent strengthening of death documentation through training and standardized record templates. |
Hypertensive disorders in pregnancy and maternal and neonatal outcomes in Haiti: the importance of surveillance and data collection
Bridwell M , Handzel E , Hynes M , Jean-Louis R , Fitter D , Hogue C , Grand-Pierre R , Pierre H , Pearce B . BMC Pregnancy Childbirth 2019 19 (1) 208 BACKGROUND: This study aims to determine reported prevalence of hypertensive disorders in pregnancy (HDP) and maternal and neonatal outcomes associated with these disorders among women delivering at selected hospitals across Haiti. METHODS: A retrospective review of 8822 singleton deliveries between January 2012 and December 2014 was conducted at four hospitals in separate Departments across Haiti. Researchers examined the proportion of women with reported HDP (hypertension, preeclampsia, eclampsia) and the association between women with HDP and three neonatal outcomes: low birth weight, preterm birth, and stillbirths; and two maternal outcomes: placental abruption and maternal death in Hopital Albert Schweitzer (HAS). Odds ratios for associations between HDP and perinatal outcomes at HAS were assessed using logistic regression, adjusting for potential confounders. RESULTS: Of the 8822 singleton births included in the study, 510 (5.8%) had a reported HDP (including 285 (55.9%) preeclampsia, 119 (23.3%) eclampsia, and 106 (20.8%) hypertension). Prevalence of HDP among each hospital was: HAS (13.5%), Hopital Immaculee Conception des Cayes (HIC) (3.2%), Fort Liberte (4.3%), and Hopital Sacre Coeur de Milot (HSC) (3.0%). Among women at HAS with HDP, the adjusted odds of having a low birth weight baby was four times that of women without HDP (aOR 4.17, 95% CI 3.19-5.45), more than three times that for stillbirths (aOR 3.51, 95% CI 2.43-5.06), and five times as likely to result in maternal death (aOR 5.13, 95% CI 1.53-17.25). Among the three types of HDP, eclampsia was associated with the greatest odds of adverse events with five times the odds of having a low birth weight baby (aOR 5.00, 95% CI 2.84-8.79), six times the odds for stillbirths (aOR 6.34, 95% CI 3.40-11.82), and more than twelve times as likely to result in maternal death (aOR 12.70, 95% CI 2.33-69.31). CONCLUSIONS: A high prevalence of HDP was found among a cohort of Haitian mothers. HDP was associated with higher rates of adverse maternal and neonatal outcomes in HAS, which is comparable to studies of HDP conducted in high-income countries. |
Evaluation of an emergency bulk chlorination project targeting drinking water vendors in cholera-affected wards of Dar es Salaam and Morogoro, Tanzania
Rajasingham A , Hardy C , Kamwaga S , Sebunya K , Massa K , Mulungu J , Martinsen A , Nyasani E , Hulland E , Russell S , Blanton C , Nygren B , Eidex R , Handzel T . Am J Trop Med Hyg 2019 100 (6) 1335-1341 In August 2015, an outbreak of cholera was reported in Tanzania. In cholera-affected areas of urban Dar es Salaam and Morogoro, many households obtained drinking water from vendors, who sold water from tanks ranging in volume from 1,000 to 20,000 L. Water supplied by vendors was not adequately chlorinated. The Tanzanian Ministry of Health, Community Development, Gender, Elderly and Children and the U.N. Children's Fund, Tanzania, collaborated to enroll and train vendors to treat their water with 8.68-g sodium dichloroisocyanurate tablets. The CDC provided monitoring and evaluation support. Vendors were provided a 3-month supply of chlorine tablets. A baseline assessment and routine monitoring were conducted by ward environmental health officers. Approximately 3 months after chlorine tablet distribution, an evaluation of the program was conducted. The evaluation included a full enumeration of all vendors, an in-depth survey with half of the vendors enumerated, and focus group discussions. In total, 797 (88.9%) vendors were included in the full enumeration and 392 in the in-depth survey. Free residual chlorine (FRC) was detected in 12.0% of tanks at baseline and 69.6% of tanks during the evaluation; however, only 17.4% of these tanks had FRC >/= 0.5 mg/L. The results suggest high acceptability and use of the chlorine tablets by water vendors. However, given variation in the water source used and longer storage times, dosing could be increased in future programming. Bulk chlorination using chlorine tablets offers an efficient community-level approach to treating water closer to the point of use. |
Alternative water transport and storage containers: Assessing sustained use of the PackH2O in rural Haiti
Martinsen A , Hulland E , Phillips R , Darius JA , Felker-Kantor E , Simpson D , Stephens M , Thomas E , Quick R , Handzel T . Am J Trop Med Hyg 2019 100 (4) 981-987 The PackH2O 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 PackH2O 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. |
Setting priorities for humanitarian water, sanitation and hygiene research: A meeting report
D'Mello-Guyett L , Yates T , Bastable A , Dahab M , Deola C , Dorea C , Dreibelbis R , Grieve T , Handzel T , Harmer A , Lantagne D , Maes P , Opryszko M , Palmer-Felgate S , Reed B , Van Den Bergh R , Porteaud D , Cumming O . Confl Health 2018 12 (1) Recent systematic reviews have highlighted a paucity of rigorous evidence to guide water, sanitation and hygiene (WASH) interventions in humanitarian crises. In June 2017, the Research for Health in Humanitarian Crises (R2HC) programme of Elrha, convened a meeting of representatives from international response agencies, research institutions and donor organisations active in the field of humanitarian WASH to identify research priorities, discuss challenges conducting research and to establish next steps. Topics including cholera transmission, menstrual hygiene management, and acute undernutrition were identified as research priorities. Several international response agencies have existing research programmes; however, a more cohesive and coordinated effort in the WASH sector would likely advance this field of research. This report shares the conclusions of that meeting and proposes a research agenda with the aim of strengthening humanitarian WASH policy and practice. |
Centers for Disease Control and Prevention public health response to humanitarian emergencies, 2007-2016
Boyd AT , Cookson ST , Anderson M , Bilukha OO , Brennan M , Handzel T , Hardy C , Husain F , Cardozo BL , Colorado CN , Shahpar C , Talley L , Toole M , Gerber M . Emerg Infect Dis 2017 23 (13) S196-202 Humanitarian emergencies, including complex emergencies associated with fragile states or areas of conflict, affect millions of persons worldwide. Such emergencies threaten global health security and have complicated but predictable effects on public health. The Centers for Disease Control and Prevention (CDC) Emergency Response and Recovery Branch (ERRB) (Division of Global Health Protection, Center for Global Health) contributes to public health emergency responses by providing epidemiologic support for humanitarian health interventions. To capture the extent of this emergency response work for the past decade, we conducted a retrospective review of ERRB's responses during 2007-2016. Responses were conducted across the world and in collaboration with national and international partners. Lessons from this work include the need to develop epidemiologic tools for use in resource-limited contexts, build local capacity for response and health systems recovery, and adapt responses to changing public health threats in fragile states. Through ERRB's multisector expertise and ability to respond quickly, CDC guides humanitarian response to protect emergency-affected populations. |
Assessment of drinking water sold from private sector kiosks in post-earthquake Port-au-Prince, Haiti
Patrick M , Steenland M , Dismer A , Pierre-Louis J , Murphy JL , Kahler A , Mull B , Etheart MD , Rossignol E , Boncy J , Hill V , Handzel T . Am J Trop Med Hyg 2017 97 84-91 Consumption of drinking water from private vendors has increased considerably in Port-au-Prince, Haiti, in recent decades. A major type of vendor is private kiosks, advertising reverse osmosis-treated water for sale by volume. To describe the scale and geographical distribution of private kiosks in metropolitan Port-au-Prince, an inventory of private kiosks was conducted from July to August 2013. Coordinates of kiosks were recorded with global positioning system units and a brief questionnaire was administered with the operator to document key kiosk characteristics. To assess the quality of water originating from private kiosks, water quality analyses were also conducted on a sample of those inventoried as well as from the major provider company sites. The parameters tested were Escherichia coli, free chlorine residual, pH, turbidity, and total dissolved solids. More than 1,300 kiosks were inventoried, the majority of which were franchises of four large provider companies. Approximately half of kiosks reported opening within 12 months of the date of the inventory. The kiosk treatment chain and sales price was consistent among a majority of the kiosks. Of the 757 kiosks sampled for water quality, 90.9% of samples met World Health Organization (WHO) microbiological guideline at the point of sale for nondetectable E. coli in a 100-mL sample. Of the eight provider company sites tested, all samples met the WHO microbiological guideline. Because of the increasing role of the private sector in drinking water provision in Port-au-Prince and elsewhere in Haiti, this assessment was an important first step for government regulation of this sector. |
Use of Rapid Ascertainment Process for Institutional Deaths (RAPID) to identify pregnancy-related deaths in tertiary-care obstetric hospitals in three departments in Haiti
Boyd AT , Hulland EN , Grand'Pierre R , Nesi F , Honore P , Jean-Louis R , Handzel E . BMC Pregnancy Childbirth 2017 17 (1) 145 BACKGROUND: Accurate assessment of maternal deaths is difficult in countries lacking standardized data sources for their review. As a first step to investigate suspected maternal deaths, WHO suggests surveillance of "pregnancy-related deaths", defined as deaths of women while pregnant or within 42 days of termination of pregnancy, irrespective of cause. Rapid Ascertainment Process for Institutional Deaths (RAPID), a surveillance tool, retrospectively identifies pregnancy-related deaths occurring in health facilities that may be missed by routine surveillance to assess gaps in reporting these deaths. METHODS: We used RAPID to review pregnancy-related deaths in six tertiary obstetric care facilities in three departments in Haiti. We reviewed registers and medical dossiers of deaths among women of reproductive age occurring in 2014 and 2015 from all wards, along with any additional available dossiers of deaths not appearing in registers, to capture pregnancy status, suspected cause of death, and timing of death in relation to the pregnancy. We used capture-recapture analyses to estimate the true number of in-hospital pregnancy-related deaths in these facilities. RESULTS: Among 373 deaths of women of reproductive age, we found 111 pregnancy-related deaths, 25.2% more than were reported through routine surveillance, and 22.5% of which were misclassified as non-pregnancy-related. Hemorrhage (27.0%) and hypertensive disorders (18.0%) were the most common categories of suspected causes of death, and deaths after termination of pregnancy were statistically significantly more common than deaths during pregnancy or delivery. Data were missing at multiple levels: 210 deaths had an undetermined pregnancy status, 48.7% of pregnancy-related deaths lacked specific information about timing of death in relation to the pregnancy, and capture-recapture analyses in three hospitals suggested that approximately one-quarter of pregnancy-related deaths were not captured by RAPID or routine surveillance. CONCLUSIONS: Across six tertiary obstetric care facilities in Haiti, RAPID identified unreported pregnancy-related deaths, and showed that missing data was a widespread problem. RAPID is a useful tool to more completely identify facility-based pregnancy-related deaths, but its repeated use would require a concomitant effort to systematically improve documentation of clinical findings in medical records. Limitations of RAPID demonstrate the need to use it alongside other tools to more accurately measure and address maternal mortality. |
Notes from the field: Ongoing cholera epidemic - Tanzania, 2015-2016
Narra R , Maeda JM , Temba H , Mghamba J , Nyanga A , Greiner AL , Bakari M , Beer KD , Chae SR , Curran KG , Eidex RB , Gibson JJ , Handzel T , Kiberiti SJ , Kishimba RS , Lukupulo H , Malibiche T , Massa K , Massay AE , McCrickard LS , McHau GJ , Mmbaga V , Mohamed AA , Mwakapeje ER , Nestory E , Newton AE , Oyugi E , Rajasingham A , Roland ME , Rusibamayila N , Sembuche S , Urio LJ , Walker TA , Wang A , Quick RE . MMWR Morb Mortal Wkly Rep 2017 66 (6) 177-178 On August 15, 2015, the Tanzanian Ministry of Health, Community Development, Gender, Elderly and Children (MOHCDGEC) was notified about a case of acute watery diarrhea with severe dehydration in a patient in Dar es Salaam. Vibrio cholerae O1, biotype El tor, serotype Ogawa, was isolated from the patient’s stool and an investigation was initiated. MOHCDGEC defined a suspected cholera case as the occurrence of severe dehydration or death from acute watery diarrhea in a person aged ≥5 years, or acute, profuse watery diarrhea with or without vomiting in a person aged ≥2 years in a region with an active cholera outbreak. A confirmed cholera case was defined as isolation of V. cholerae O1 from the stool of a person with suspected cholera. Tanzania’s first reported cholera epidemic was in 1974 with intermittent outbreaks since then; the largest epidemic occurred in 1997, with 40,249 cases and 2,231 deaths (case fatality rate [CFR] was 5.5%) (1). | As of November 26, 2016, the current epidemic continues, affecting 23 (92%) of 25 regions in mainland Tanzania (excluding the Zanzibar archipelago), with a cumulative reported case count of 23,258 and a cumulative CFR of 1.5%. The median number of reported cholera cases per week was 271 (range = 5–1,240) (Figure). Approximately half of all reported cases have been from four regions: Dar es Salaam (5,104; 22%), Morogoro (3,177; 14%), Mwanza (2,311; 10%), and Mara (2,299; 10%). Of 511 stool specimens tested during August 17, 2015–March 18, 2016 at the National Health Laboratory-Quality Assurance Training Center in Dar es Salaam, 268 (52%) were positive for V. cholerae; all specimens were serogroup O1, biotype El tor, serotype Ogawa. Antimicrobial resistance (AMR) testing revealed sensitivity to cotrimoxazole, ceftriaxone, tetracycline, ciprofloxacin, and chloramphenicol, and resistance to nalidixic acid and ampicillin. |
Soap is not enough: handwashing practices and knowledge in refugee camps, Maban County, South Sudan
Phillips RM , Vujcic J , Boscoe A , Handzel T , Aninyasi M , Cookson ST , Blanton C , SBlum L , Ram PK . Confl Health 2015 9 39 BACKGROUND: Refugees are at high risk for communicable diseases due to overcrowding and poor water, sanitation, and hygiene conditions. Handwashing with soap removes pathogens from hands and reduces disease risk. A hepatitis E outbreak in the refugee camps of Maban County, South Sudan in 2012 prompted increased hygiene promotion and improved provision of soap, handwashing stations, and latrines. We conducted a study 1 year after the outbreak to assess the knowledge, attitudes, and practices of the refugees in Maban County. METHODS: We conducted a cross sectional survey of female heads of households in three refugee camps in Maban County. We performed structured observations on a subset of households to directly observe their handwashing practices at times of possible pathogen transmission. RESULTS: Of the 600 households interviewed, nearly all had soap available and 91 % reported water was available "always" or "sometimes". Exposure to handwashing promotion was reported by 85 % of the respondents. Rinsing hands with water alone was more commonly observed than handwashing with soap at critical handwashing times including "before eating" (80 % rinsing vs. 7 % washing with soap) and "before preparing/cooking food" (72.3 % vs 23 %). After toilet use, 46 % were observed to wash hands with soap and an additional 38 % rinsed with water alone. CONCLUSIONS: Despite intensive messaging regarding handwashing with soap and access to soap and water, rinsing hands with water alone rather than washing hands with soap remains more common among the refugees in Maban County. This practice puts them at continued risk for communicable disease transmission. Qualitative research into local beliefs and more effective messaging may help future programs tailor handwashing interventions. |
Perceptions of health communication, water treatment and sanitation in Artibonite Department, Haiti, March-April 2012
Williams HA , Gaines J , Patrick M , Berendes D , Fitter D , Handzel T . PLoS One 2015 10 (11) e0142778 The international response to Haiti's ongoing cholera outbreak has been multifaceted, including health education efforts by community health workers and the distribution of free water treatment products. Artibonite Department was the first region affected by the outbreak. Numerous organizations have been involved in cholera response efforts in Haiti with many focusing on efforts to improve water, sanitation, and hygiene (WASH). Multiple types of water treatment products have been distributed, creating the potential for confusion over correct dosage and water treatment methods. We utilized qualitative methods in Artibonite to determine the population's response to WASH messages, use and acceptability of water treatment products, and water treatment and sanitation knowledge, attitudes and practices at the household level. We conducted eighteen focus group discussions (FGDs): 17 FGDs were held with community members (nine among females, eight among males); one FGD was held with community health workers. Health messages related to WASH were well-retained, with reported improvements in hand-washing. Community health workers were identified as valued sources of health information. Most participants noted a paucity of water-treatment products. Sanitation, specifically the construction of latrines, was the most commonly identified need. Lack of funds was the primary reason given for not constructing a latrine. The construction and maintenance of potable water and sanitation services is needed to ensure a sustainable change. |
A pilot study of a portable hand washing station for recently displaced refugees during an acute emergency in Benishangul-Gumuz Regional State, Ethiopia
Husain F , Hardy C , Zekele L , Clatworthy D , Blanton C , Handzel T . Confl Health 2015 9 26 BACKGROUND: Diarrheal disease is a common cause of morbidity and mortality. Displaced populations are especially vulnerable due to overcrowded camps and limited access to water and sanitation facilities, increasing the risk for outbreaks. Hand washing with soap is effective against disease transmission, and studies suggest access to a convenient hand washing station may be the key to increasing hand washing behavior. This pilot study evaluated the acceptability, durability and use of a novel hand washing bag (HWB) at the household level among Sudanese refugees immediately following an acute emergency. METHODS: We distributed one HWB to every household (n = 874) in Adamazin Transit Center in western Ethiopia. The evaluation consisted of baseline and endline surveys, three monthly monitoring visits and focus group discussions (FGDs) over a six month period. FGD data were analyzed using the Risk, Attitudes, Norms, Abilities, and Self-Regulatory model. Survey and monitoring data were analyzed using SPSS. Note: Residents were resettled to Bambasi Refugee Camp during the study period where the endline survey was conducted. RESULTS: Baseline data suggested water quantity and availability of soap were below SPHERE standards, however participants responded positively to the HWB. At the end of the monitoring period, 73.9 % of the same households retained their original HWBs and 66.7 % of bags had water at the time of the visit. The mean lifespan of the HWB during the monitoring period was 2.73 months. From a new sample of households selected for the endline evaluation, 93.0 % had an original HWB, but only 39.4 % had water in the bag. Endline FGD participants felt the HWB was useful, but reported insufficient soap and hygiene messaging. CONCLUSION: The HWB performed well during the early phases of the emergency, however longer term results in this setting are unclear. The low levels of reported use measured by proxy indicators at six months indicated decreasing acceptability over time or a reflection of potential differences between the two sites. It is also unknown whether the HWB influenced hand washing behavior. Study findings were shared with the manufacturer in an effort to improve the bag's acceptability, utility, and durability. |
Ascaris and Escherichia coli inactivation in an ecological sanitation system in Port-au-Prince, Haiti
Berendes D , Levy K , Knee J , Handzel T , Hill VR . PLoS One 2015 10 (5) e0125336 The goal of this study was to evaluate the microbial die-off in a latrine waste composting system in Port-au-Prince, Haiti. Temperature data and samples were collected from compost aged 0 - 12+ months. Samples collected from compost bin centers and corners at two depths were assessed for moisture content, E. coli concentration, and Ascaris spp. viability. Center temperatures in compost bins were all above 58 degrees C, while corner temperatures were 10 - 20 degrees C lower. Moisture content was 67 +/- 10% in all except the oldest compost. A 4-log reduction in E. coli was observed over the first sixteen weeks of composting at both locations and depths, after which E. coli was undetectable (LOD: 142 MPN g-1 dry weight). In new compost, 10.4% and 8.3% of Ascaris eggs were viable and fully embryonated, respectively. Percent viability dropped to zero in samples older than six weeks. These findings indicate that the Haitian EcoSan composting process was effective in inactivating E. coli and Ascaris spp. in latrine waste within sixteen weeks. This study is one of the first to document efficacy of an ecological sanitation system under field conditions and provides insight into composting methods and monitoring for other international settings. |
Water, sanitation and hygiene in Haiti: past, present, and future
Gelting R , Bliss K , Patrick M , Lockhart G , Handzel T . Am J Trop Med Hyg 2013 89 (4) 665-70 Haiti has the lowest rates of access to improved water and sanitation infrastructure in the western hemisphere. This situation was likely exacerbated by the earthquake in 2010 and also contributed to the rapid spread of the cholera epidemic that started later that same year. This report examines the history of the water, sanitation, and hygiene (WASH) sector in Haiti, considering some factors that have influenced WASH conditions in the country. We then discuss the situation sine the earthquake and subsequent cholera epidemic, and the responses to those events. Finally, drawing on Haiti's National Plan of Action for the Elimination of Cholera in Haiti 2013-2022, we suggest some actions that could help bring about long-term WASH improvements for the future. Because the current WASH situation has evolved over decades of limited attention and resources, it will take a long-term, sustained effort to improve the situation. |
Access to safe water in rural Artibonite, Haiti 16 months after the onset of the cholera epidemic
Patrick M , Berendes D , Murphy J , Bertrand F , Husain F , Handzel T . Am J Trop Med Hyg 2013 89 (4) 647-53 Haiti has the lowest improved water and sanitation coverage in the Western Hemisphere and is suffering from the largest cholera epidemic on record. In May of 2012, an assessment was conducted in rural areas of the Artibonite Department to describe the type and quality of water sources and determine knowledge, access, and use of household water treatment products to inform future programs. It was conducted after emergency response was scaled back but before longer-term water, sanitation, and hygiene activities were initiated. The household survey and source water quality analysis documented low access to safe water, with only 42.3% of households using an improved drinking water source. One-half (50.9%) of the improved water sources tested positive for Escherichia coli. Of households with water to test, 12.7% had positive chlorine residual. The assessment reinforces the identified need for major investments in safe water and sanitation infrastructure and the importance of household water treatment to improve access to safe water in the near term. |
Hepatitis E outbreak, Dadaab refugee camp, Kenya, 2012
Ahmed JA , Moturi E , Spiegel P , Schilperoord M , Burton W , Kassim NH , Mohamed A , Ochieng M , Nderitu L , Navarro-Colorado C , Burke H , Cookson S , Handzel T , Waiboci LW , Montgomery JM , Teshale E , Marano N . Emerg Infect Dis 2013 19 (6) 1010-1 Hepatitis E virus (HEV) is transmitted through the fecal-oral route and is a common cause of viral hepatitis in developing countries. HEV outbreaks have been documented among forcibly displaced persons living in camps in East Africa, but for >10 years, no cases were documented among Somali refugees (1,2). On August 15, 2012, the US Centers for Disease Control and Prevention (CDC) in Nairobi, Kenya, was notified of a cluster of acute jaundice syndrome (AJS) cases in refugee camps in Dadaab, Kenya. On September 5, a CDC epidemiologist assisted the United Nations High Commissioner for Refugees (UNHCR) and its partners in assessing AJS case-patients in the camp, enhancing surveillance, and improving medical management of case-patients. We present the epidemiologic and laboratory findings for the AJS cases (defined as acute onset of scleral icterus not due to another underlying condition) identified during this outbreak. | Dadaab refugee camp is located in eastern Kenya near the border with Somalia. It has existed since 1991 and is the largest refugee camp in the world. Dadaab is composed of 5 smaller camps: Dagahaley, Hagadera, Ifo, Ifo II, and Kambioos. As of December 2012, a total of 460,000 refugees, mainly Somalians, were living in the camps; >25% were recent arrivals displaced by the mid-2011 famine in the Horn of Africa (3). Overcrowding and poor sanitation have led to outbreaks of enteric diseases, including cholera and shigellosis (4); in September 2012, an outbreak of cholera occurred simultaneously with the AJS outbreak. |
Community mortality from cholera: urban and rural districts in Zimbabwe
Morof D , Cookson ST , Laver S , Chirundu D , Desai S , Mathenge P , Shambare D , Charimari L , Midzi S , Blanton C , Handzel T . Am J Trop Med Hyg 2013 88 (4) 645-50 In 2008-2009, Zimbabwe experienced an unprecedented cholera outbreak with more than 4,000 deaths. More than 60% of deaths occurred at the community level. We conducted descriptive and case-control studies to describe community deaths. Cases were in cholera patients who died outside health facilities. Two surviving cholera patients were matched by age, time of symptom onset, and location to each case-patient. Proxies completed questionnaires regarding mortality risk factors. Cholera awareness and importance of rehydration was high but availability of oral rehydration salts was low. A total of 55 case-patients were matched to 110 controls. The odds of death were higher among males (adjusted odd ratio [AOR] = 5.00, 95% confidence interval [CI] = 1.54-14.30) and persons with larger household sizes (AOR = 1.21, 95% CI = 1.00-1.46). Receiving home-based rehydration (AOR = 0.21, 95% CI = 0.06-0.71) and visiting cholera treatment centers (CTCs) (AOR = 0.07, 95% CI = 0.02-0.23) were protective. Receiving cholera information was associated with home-based rehydration and visiting CTCs. When we compared cases and controls who did not go to CTCs, males were still at increased odds of death (AOR = 5.00, 95% CI = 1.56-16.10) and receiving home-based rehydration (AOR = 0.14, 95% CI = 0.04-0.53) and being married (AOR = 0.26, 95% CI = 0.08-0.83) were protective. Inability to receive home-based rehydration or visit CTCs was associated with mortality. Community education must reinforce the importance of prompt rehydration and CTC referral. |
Preventing maritime transfer of toxigenic Vibrio cholerae
Cohen NJ , Slaten DD , Marano N , Tappero JW , Wellman M , Albert RJ , Hill VR , Espey D , Handzel T , Henry A , Tauxe RV . Emerg Infect Dis 2012 18 (10) 1680-2 ![]() Organisms, including Vibrio cholerae, can be transferred between harbors in the ballast water of ships. Zones in the Caribbean region where distance from shore and water depth meet International Maritime Organization guidelines for ballast water exchange are extremely limited. Use of ballast water treatment systems could mitigate the risk for organism transfer. |
Toxigenic Vibrio cholerae O1 in water and seafood, Haiti
Hill VR , Cohen N , Kahler AM , Jones JL , Bopp CA , Marano N , Tarr CL , Garrett NM , Boncy J , Henry A , Gomez GA , Wellman M , Curtis M , Freeman MM , Turnsek M , Benner RA Jr , Dahourou G , Espey D , DePaola A , Tappero JW , Handzel T , Tauxe RV . Emerg Infect Dis 2011 17 (11) 2147-2150 During the 2010 cholera outbreak in Haiti, water and seafood samples were collected to detect Vibrio cholerae. The outbreak strain of toxigenic V. cholerae O1 serotype Ogawa was isolated from freshwater and seafood samples. The cholera toxin gene was detected in harbor water samples. |
Knowledge, attitudes, and practices related to treatment and prevention of cholera, Haiti, 2010
Beau De Rochars VEM , Tipret J , Patrick M , Jacobson L , Barbour KE , Berendes D , Bensyl D , Frazier C , Domercant JW , Archer R , Roels T , Tappero JW , Handzel T . Emerg Infect Dis 2011 17 (11) 2158-2161 In response to the recent cholera outbreak, a public health response targeted high-risk communities, including resource-poor communities in Port-au-Prince, Haiti. A survey covering knowledge and practices indicated that hygiene messages were received and induced behavior change, specifically related to water treatment practices. Self-reported household water treatment increased from 30.3% to 73.9%. |
Novel risk factors associated with hepatitis E virus infection in a large outbreak in northern Uganda: results from a case-control study and environmental analysis
Howard CM , Handzel T , Hill VR , Grytdal SP , Blanton C , Kamili S , Drobeniuc J , Hu D , Teshale E . Am J Trop Med Hyg 2010 83 (5) 1170-3 ![]() An outbreak of hepatitis E virus (HEV) began in October 2007 in northern Uganda. To determine risk factors and sources for ongoing transmission, we conducted both a case-control study and an environmental investigation. A case patient was defined as having serologic evidence of HEV infection, whereas controls were seronegative. We identified risk factors for infection by univariable and multivariable analyses using conditional logistic regression. Several water sources were tested for HEV RNA. Among 112 cases and 145 controls, storage of drinking water in large-mouthed vessels (adjusted odds ratios [AOR] = 2.83; 95% confidence interval [CI] = 1.16-6.94) and washing hands in a group basin (AOR = 1.90; 95% CI = 1.07-3.38) were associated with HEV infection. HEV RNA was detected from communal hand-rinse and surface-water samples. The epidemiologic and environmental water-testing results suggest that household-level factors played an important role in the transmission of HEV-modalities that have been previously underappreciated. |
Hepatitis E epidemic, Uganda
Teshale EH , Howard CM , Grytdal SP , Handzel TR , Barry V , Kamili S , Drobeniuc J , Okware S , Downing R , Tappero JW , Bakamutumaho B , Teo CG , Ward JW , Holmberg SD , Hu DJ . Emerg Infect Dis 2010 16 (1) 126-9 In October 2007, an epidemic of hepatitis E was suspected in Kitgum District of northern Uganda where no previous epidemics had been documented. This outbreak has progressed to become one of the largest hepatitis E outbreaks in the world. By June 2009, the epidemic had caused illness in >10,196 persons and 160 deaths. |
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