Last data update: May 13, 2024. (Total: 46773 publications since 2009)
Records 1-16 (of 16 Records) |
Query Trace: Ram PK[original query] |
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Pilot intervention study of household ventilation and fine particulate matter concentrations in a low-income urban area, Dhaka, Bangladesh
Weaver AM , Parveen S , Goswami D , Crabtree-Ide C , Rudra C , Yu J , Mu L , Fry AM , Sharmin I , Luby SP , Ram PK . Am J Trop Med Hyg 2017 97 (2) 615-623 Fine particulate matter (PM2.5) is a risk factor for pneumonia; ventilation may be protective. We tested behavioral and structural ventilation interventions on indoor PM2.5 in Dhaka, Bangladesh. We recruited 59 good ventilation (window or door in ≥ 3 walls) and 29 poor ventilation (no window, one door) homes. We monitored baseline indoor and outdoor PM2.5 for 48 hours. We asked all participants to increase ventilation behavior, including opening windows and doors, and operating fans. Where permitted, we installed windows in nine poor ventilation homes, then repeated PM2.5 monitoring. We estimated effects using linear mixed-effects models and conducted qualitative interviews regarding motivators and barriers to ventilation. Compared with poor ventilation homes, good ventilation homes were larger, their residents wealthier and less likely to use biomass fuel. In multivariable linear mixed-effects models, ventilation structures and opening a door or window were inversely associated with the number of hours PM2.5 concentrations exceeded 100 and 250 mug/m3. Outdoor air pollution was positively associated with the number of hours PM2.5 concentrations exceeded 100 and 250 mug/m3. Few homes accepted window installation, due to landlord refusal and fear of theft. Motivators for ventilation behavior included cooling of the home and sunlight; barriers included rain, outdoor odors or noise, theft risk, mosquito entry, and, for fan use, perceptions of wasting electricity or unavailability of electricity. We concluded that ventilation may reduce indoor PM2.5 concentrations but, there are barriers to increasing ventilation and, in areas with high ambient PM2.5 concentrations, indoor concentrations may remain above recommended levels. |
Household-level risk factors for secondary influenza-like illness in a rural area of Bangladesh
Weaver AM , Khatun EJannat K , Cercone E , Krytus K , Sohel BM , Ahmed M , Rahman M , Azziz-Baumgartner E , Yu J , Fry AM , Luby SP , Ram PK . Trop Med Int Health 2016 22 (2) 187-195 OBJECTIVE: To describe household-level risk factors for secondary Influenza-like illness (ILI), an important public health concern in the low-income population of Bangladesh. METHODS: Secondary analysis of control participants in a randomized controlled trial evaluating the effect of handwashing to prevent household ILI transmission. We recruited index-case patients with ILI-fever (<5 years); fever, cough or sore throat (≥5 years)-from health facilities, collected information on household factors, and conducted syndromic surveillance among household contacts for 10 days after resolution of index-case patients' symptoms. We evaluated the associations between household factors at baseline and secondary ILI among household contacts using negative binomial regression, accounting for clustering by household. RESULTS: Our sample was 1491 household contacts of 184 index-case patients. 71% reported that smoking occurred in their home, 27% shared a latrine with 1 other household, and 36% shared a latrine with >1 other household. A total of 114 household contacts (7.6%) had symptoms of ILI during follow-up. Smoking in the home (RRadj 1.9, 95% CI 1.2, 3.0) and sharing a latrine with 1 household (RRadj 2.1, 95% CI 1.2, 3.6) or >1 household (RRadj 3.1, 95% CI 1.8-5.2) were independently associated with increased risk of secondary ILI. CONCLUSION: Tobacco use in homes could increase respiratory illness in Bangladesh. The mechanism between use of shared latrines and household ILI transmission is not clear. It is possible that respiratory pathogens could be transmitted through fecal contact or contaminated fomites in shared latrines. This article is protected by copyright. All rights reserved. |
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. |
Impact of intensive handwashing promotion on secondary household influenza-like illness in rural Bangladesh: findings from a randomized controlled trial
Ram PK , DiVita MA , Khatun EJannat K , Islam M , Krytus K , Cercone E , Sohel BM , Ahmed M , Rahman AM , Rahman M , Yu J , Brooks WA , Azziz-Baumgartner E , Fry AM , Luby SP . PLoS One 2015 10 (6) e0125200 RATIONALE: There is little evidence for the efficacy of handwashing for prevention of influenza transmission in resource-poor settings. We tested the impact of intensive handwashing promotion on household transmission of influenza-like illness and influenza in rural Bangladesh. METHODS: In 2009-10, we identified index case-patients with influenza-like illness (fever with cough or sore throat) who were the only symptomatic person in their household. Household compounds of index case-patients were randomized to control or intervention (soap and daily handwashing promotion). We conducted daily surveillance and collected oropharyngeal specimens. Secondary attack ratios (SAR) were calculated for influenza and ILI in each arm. Among controls, we investigated individual risk factors for ILI among household contacts of index case-patients. RESULTS: Among 377 index case-patients, the mean number of days between fever onset and study enrollment was 2.1 (SD 1.7) among the 184 controls and 2.6 (SD 2.9) among 193 intervention case-patients. Influenza infection was confirmed in 20% of controls and 12% of intervention index case-patients. The SAR for influenza-like illness among household contacts was 9.5% among intervention (158/1661) and 7.7% among control households (115/1498) (SAR ratio 1.24, 95% CI 0.92-1.65). The SAR ratio for influenza was 2.40 (95% CI 0.68-8.47). In the control arm, susceptible contacts <2 years old (RRadj 5.51, 95% CI 3.43-8.85), those living with an index case-patient enrolled ≤24 hours after symptom onset (RRadj 1.91, 95% CI 1.18-3.10), and those who reported multiple daily interactions with the index case-patient (RRadj 1.94, 95% CI 1.71-3.26) were at increased risk of influenza-like illness. DISCUSSION: Handwashing promotion initiated after illness onset in a household member did not protect against influenza-like illness or influenza. Behavior may not have changed rapidly enough to curb transmission between household members. A reactive approach to reduce household influenza transmission through handwashing promotion may be ineffective in the context of rural Bangladesh. TRIAL REGISTRATION: ClinicalTrials.gov NCT00880659. |
Household-level risk factors for influenza among young children in Dhaka, Bangladesh: a case-control study
Doshi S , Silk BJ , Dutt D , Ahmed M , Cohen AL , Taylor TH , Brooks WA , Goswami D , Luby SP , Fry AM , Ram PK . Trop Med Int Health 2015 20 (6) 719-29 OBJECTIVES: To identify household-level factors associated with influenza among young children in a crowded community in Dhaka, Bangladesh. METHODS: We conducted a case-control study using existing active surveillance for respiratory illness. Cases were children aged 12-59 months with laboratory-confirmed influenza. Controls were children frequency-matched by age group with no respiratory illness in the prior six months. We interviewed caregivers and observed household handwashing behavior. Soap consumption was estimated by summing weight differences of three bars of soap sequentially left in each household. We measured concentrations of airborne particulate matter <2.5 mug in diameter (PM2.5 ) in a subset of households. We used logistic regression to estimate adjusted odds ratios (aOR) and 95% confidence intervals (CI). RESULTS: We enrolled 145 cases and 341 controls between March 2009 and April 2010. Case and control household members were observed to wash hands with similar frequency during a five-hour period (mean, 0.64 events vs. 0.63, p=0.87), and similar daily soap consumption per capita (mean 2.92 grams vs. 2.93, p=0.92). Case households were more likely than controls to have crowded (≥4 persons) sleeping areas (aOR=1.67, CI: 1.06-2.63) and cross-ventilated cooking spaces (aOR=1.75, CI: 1.16-2.63). Case and control households had similar median 24-hour geometric mean PM2.5 concentrations in the cooking (69.2 vs. 69.6 mcg/m3 , p=0.45) and sleeping (65.4 vs. 67.4 mcg/m3 , p=0.19) spaces. CONCLUSIONS: Handwashing with soap was practiced infrequently, and was not associated with pediatric influenza in this community. Interventions aimed at crowded households may reduce influenza incidence in young children. |
Microbiological evaluation of the efficacy of soapy water to clean hands: a randomized, non-inferiority field trial
Amin N , Pickering AJ , Ram PK , Unicomb L , Najnin N , Homaira N , Ashraf S , Abedin J , Islam MS , Luby SP . Am J Trop Med Hyg 2014 91 (2) 415-23 We conducted a randomized, non-inferiority field trial in urban Dhaka, Bangladesh among mothers to compare microbial efficacy of soapy water (30 g powdered detergent in 1.5 L water) with bar soap and water alone. Fieldworkers collected hand rinse samples before and after the following washing regimens: scrubbing with soapy water for 15 and 30 seconds; scrubbing with bar soap for 15 and 30 seconds; and scrubbing with water alone for 15 seconds. Soapy water and bar soap removed thermotolerant coliforms similarly after washing for 15 seconds (mean log10 reduction = 0.7 colony-forming units [CFU], P < 0.001 for soapy water; mean log10 reduction = 0.6 CFU, P = 0.001 for bar soap). Increasing scrubbing time to 30 seconds did not improve removal (P > 0.05). Scrubbing hands with water alone also reduced thermotolerant coliforms (mean log10 reduction = 0.3 CFU, P = 0.046) but was less efficacious than scrubbing hands with soapy water. Soapy water is an inexpensive and microbiologically effective cleansing agent to improve handwashing among households with vulnerable children. |
Impact of neighborhood biomass cooking patterns on episodic high indoor particulate matter concentrations in clean fuel homes in Dhaka, Bangladesh
Salje H , Gurley ES , Homaira N , Ram PK , Haque R , Petri W , Moss WJ , Luby SP , Breysse P , Azziz-Baumgartner E . Indoor Air 2014 24 (2) 213-20 Exposure to particulate matter (PM2.5 ) from the burning of biomass is associated with increased risk of respiratory disease. In Dhaka, Bangladesh, households that do not burn biomass often still experience high concentrations of PM2.5 , but the sources remain unexplained. We characterized the diurnal variation in the concentrations of PM2.5 in 257 households and compared the risk of experiencing high PM2.5 concentrations in biomass and non-biomass users. Indoor PM2.5 concentrations were estimated every minute over 24 h once a month from April 2009 through April 2010. We found that households that used gas or electricity experienced PM2.5 concentrations exceeding 1000 mug/m(3) for a mean of 35 min within a 24-h period compared with 66 min in biomass-burning households. In both households that used biomass and those that had no obvious source of particulate matter, the probability of PM2.5 exceeding 1000 mug/m(3) were highest during distinct morning, afternoon, and evening periods. In such densely populated settings, indoor pollution in clean fuel households may be determined by biomass used by neighbors, with the highest risk of exposure occurring during cooking periods. Community interventions to reduce biomass use may reduce exposure to high concentrations of PM2.5 in both biomass and non-biomass using households. |
Indoor exposure to particulate matter and age at first acute lower respiratory infection in a low-income urban community in Bangladesh
Gurley ES , Salje H , Homaira N , Ram PK , Haque R , Petri WA Jr , Bresee J , Moss WJ , Luby SP , Breysse P , Azziz-Baumgartner E . Am J Epidemiol 2014 179 (8) 967-73 The timing of a child's first acute lower respiratory infection (ALRI) is important, because the younger a child is when he or she experiences ALRI, the greater the risk of death. Indoor exposure to particulate matter less than or equal to 2.5 microm in diameter (PM2.5) has been associated with increased frequency of ALRI, but little is known about how it may affect the timing of a child's first ALRI. In this study, we aimed to estimate the association between a child's age at first ALRI and indoor exposure to PM2.5 in a low-income community in Dhaka, Bangladesh. We followed 257 children from birth through age 2 years to record their age at first ALRI. Between May 2009 and April 2010, we also measured indoor concentrations of PM2.5 in children's homes. We used generalized gamma distribution models to estimate the relative age at first ALRI associated with the mean number of hours in which PM2.5 concentrations exceeded 100 microg/m(3). Each hour in which PM2.5 levels exceeded 100 microg/m(3) was independently associated with a 12% decrease (95% confidence interval: 2, 21; P = 0.021) in age at first ALRI. Interventions to reduce indoor exposure to PM2.5 could increase the ages at which children experience their first ALRI in this urban community. |
Associations between presence of handwashing stations and soap in the home and diarrhoea and respiratory illness, in children less than five years old in rural western Kenya
Kamm KB , Feikin DR , Bigogo GM , Aol G , Audi A , Cohen AL , Shah MM , Yu J , Breiman RF , Ram PK . Trop Med Int Health 2014 19 (4) 398-406 OBJECTIVE: We tested whether soap presence in the home or a designated handwashing station was associated with diarrhoea and respiratory illness in Kenya. METHODS: In April 2009, we observed presence of a handwashing station and soap in households participating in a longitudinal health surveillance system in rural Kenya. Diarrhoea and acute respiratory illness (ARI) in children < 5 years old were identified using parent-reported syndromic surveillance collected January-April 2009. We used multivariate generalised linear regression to estimate differences in prevalence of illness between households with and without the presence of soap in the home and a handwashing station. RESULTS: Among 2547 children, prevalence of diarrhoea and ARI was 2.3 and 11.4 days per 100 child-days, respectively. Soap was observed in 97% of households. Children in households with soap had 1.3 fewer days of diarrhoea/100 child-days (95% CI -2.6, -0.1) than children in households without soap. ARI prevalence was not associated with presence of soap. A handwashing station was identified in 1.4% of households and was not associated with a difference in diarrhoea or ARI prevalence. CONCLUSIONS: Soap presence in the home was significantly associated with reduced diarrhoea, but not ARI, in children in rural western Kenya. Whereas most households had soap in the home, almost none had a designated handwashing station, which may prevent handwashing at key times of hand contamination. |
Video surveillance captures student hand hygiene behavior, reactivity to observation, and peer influence in Kenyan primary schools
Pickering AJ , Blum AG , Breiman RF , Ram PK , Davis J . PLoS One 2014 9 (3) e92571 BACKGROUND: In-person structured observation is considered the best approach for measuring hand hygiene behavior, yet is expensive, time consuming, and may alter behavior. Video surveillance could be a useful tool for objectively monitoring hand hygiene behavior if validated against current methods. METHODS: Student hand cleaning behavior was monitored with video surveillance and in-person structured observation, both simultaneously and separately, at four primary schools in urban Kenya over a study period of 8 weeks. FINDINGS: Video surveillance and in-person observation captured similar rates of hand cleaning (absolute difference <5%, p = 0.74). Video surveillance documented higher hand cleaning rates (71%) when at least one other person was present at the hand cleaning station, compared to when a student was alone (48%; rate ratio = 1.14 [95% CI 1.01-1.28]). Students increased hand cleaning rates during simultaneous video and in-person monitoring as compared to single-method monitoring, suggesting reactivity to each method of monitoring. This trend was documented at schools receiving a handwashing with soap intervention, but not at schools receiving a sanitizer intervention. CONCLUSION: Video surveillance of hand hygiene behavior yields results comparable to in-person observation among schools in a resource-constrained setting. Video surveillance also has certain advantages over in-person observation, including rapid data processing and the capability to capture new behavioral insights. Peer influence can significantly improve student hand cleaning behavior and, when possible, should be exploited in the design and implementation of school hand hygiene programs. |
Household air quality risk factors associated with childhood pneumonia in urban Dhaka, Bangladesh
Ram PK , Dutt D , Silk BJ , Doshi S , Rudra CB , Abedin J , Goswami D , Fry AM , Brooks WA , Luby SP , Cohen AL . Am J Trop Med Hyg 2014 90 (5) 968-75 To inform interventions to reduce the high burden of pneumonia in urban settings such as Kamalapur, Bangladesh, we evaluated household air quality risk factors for radiographically confirmed pneumonia in children. In 2009-2010, we recruited children < 5 years of age with pneumonia and controls from a population-based surveillance for respiratory and febrile illnesses. Piped natural gas was used by 85% of 331 case and 91% of 663 control households. Crowding, a tin roof in the living space, low socioeconomic status, and male sex of the child were risk factors for pneumonia. The living space in case households was 28% less likely than in control households to be cross-ventilated. Particulate matter concentrations were not significantly associated with pneumonia. With increasing urbanization and supply of improved cooking fuels to urban areas, the high burden of respiratory illnesses in urban populations such as Kamalapur may be reduced by decreasing crowding and improving ventilation in living spaces. |
Seasonal concentrations and determinants of indoor particulate matter in a low-income community in Dhaka, Bangladesh
Gurley ES , Salje H , Homaira N , Ram PK , Haque R , Petri WA Jr , Bresee J , Moss WJ , Luby SP , Breysse P , Azziz-Baumgartner E . Environ Res 2013 121 11-6 Indoor exposure to particulate matter (PM) increases the risk of acute lower respiratory tract infections, which are the leading cause of death in young children in Bangladesh. Few studies, however, have measured children's exposures to indoor PM over time. The World Health Organization recommends that daily indoor concentrations of PM less than 2.5mcm in diameter (PM(2.5)) not exceed 25mcg/m(3). This study aimed to describe the seasonal variation and determinants of concentrations of indoor PM(2.5) in a low-income community in urban Dhaka, Bangladesh. PM(2.5) was measured in homes monthly during May 2009 to April 2010. We calculated the time-weighted average, 90th percentile PM(2.5) concentrations and the daily hours PM(2.5) exceeded 100mcg/m(3). Linear regression models were used to estimate the associations between fuel use, ventilation, indoor smoking, and season to each metric describing indoor PM(2.5) concentrations. Time-weighted average PM(2.5) concentrations were 190mcg/m(3) (95% CI 170-210). Sixteen percent of 258 households primarily used biomass fuels for cooking and PM(2.5) concentrations in these homes had average concentrations 75mcg/m(3) (95% CI 56-124) greater than other homes. PM(2.5) concentrations were also associated with burning both biomass and kerosene, indoor smoking, and ventilation, and were more than twice as high during winter than during other seasons. Young children in this community are exposed to indoor PM(2.5) concentrations 7 times greater than those recommended by World Health Organization guidelines. Interventions to reduce biomass burning could result in a daily reduction of 75mcg/m(3) (40%) in time-weighted average PM(2.5) concentrations. |
Examining the use of oral rehydration salts and other oral rehydration therapy for childhood diarrhea in Kenya
Blum LS , Oria PA , Olson CK , Breiman RF , Ram PK . Am J Trop Med Hyg 2011 85 (6) 1126-33 Reductions in the use of oral rehydration therapy (ORT) in sub-Saharan Africa highlight the need to examine caregiver perceptions of ORT during diarrheal episodes. Qualitative research involving group discussions with childcare providers and in-depth interviews with 45 caregivers of children < 5 years of age who had experienced diarrhea was conducted in one rural and urban site in Kenya during July-December 2007. Diarrhea was considered a dangerous condition that can kill young children. Caregivers preferred to treat diarrhea with Western drugs believed to be more effective in stopping diarrhea than ORT. Inconsistent recommendations from health workers regarding use of oral rehydration solution (ORS) caused confusion about when ORS is appropriate and whether it requires a medical prescription. In the rural community, causal explanations about diarrhea, beliefs in herbal remedies, cost, and distance to health facilities presented additional barriers to ORS use. Health communication is needed to clarify the function of ORT in preventing dehydration. |
Community case management of childhood diarrhea in a setting with declining use of oral rehydration therapy: findings from cross-sectional studies among primary household caregivers, Kenya, 2007
Olson CK , Blum LS , Patel KN , Oria PA , Feikin DR , Laserson KF , Wamae AW , Bartlett AV , Breiman RF , Ram PK . Am J Trop Med Hyg 2011 85 (6) 1134-1140 We sought to determine factors associated with appropriate diarrhea case management in Kenya. We conducted a cross-sectional survey of caregivers of children < 5 years of age with diarrhea in rural Asembo and urban Kibera. In Asembo, 61% of respondents provided oral rehydration therapy (ORT), 45% oral rehydration solution (ORS), and 64% continued feeding. In Kibera, 75% provided ORT, 43% ORS, and 46% continued feeding. Seeking care at a health facility, risk perception regarding death from diarrhea, and treating a child with oral medications were associated with ORT and ORS use. Availability of oral medication was negatively associated. A minority of caregivers reported that ORS is available in nearby shops. In Kenya, household case management of diarrhea remains inadequate for a substantial proportion of children. Health workers have a critical role in empowering caregivers regarding early treatment with ORT and continued feeding. Increasing community ORS availability is essential to improving diarrhea management. |
Burden of typhoid and paratyphoid fever in a densely populated urban community, Dhaka, Bangladesh
Naheed A , Ram PK , Brooks WA , Hossain MA , Parsons MB , Talukder KA , Mintz E , Luby S , Breiman RF . Int J Infect Dis 2010 14 Suppl 3 e93-9 BACKGROUND: We conducted blood culture surveillance to estimate the incidence of typhoid and paratyphoid fever among urban slum residents in Dhaka, Bangladesh. METHODS: Between January 7, 2003 and January 6, 2004, participants were visited weekly to detect febrile illnesses. Blood cultures were obtained at the clinic from patients with fever (≥38 degrees C). Salmonella isolates were assayed for antimicrobial susceptibility. RESULTS: Forty Salmonella Typhi and eight Salmonella Paratyphi A were isolated from 961 blood cultures. The incidence of typhoid fever was 2.0 episodes/1000 person-years, with a higher incidence in children aged<5 years (10.5/1000 person-years) than in older persons (0.9/1000 person-years) (relative risk=12, 95% confidence interval (CI) 6.3-22.6). The incidence of paratyphoid fever was 0.4/1000 person-years without variation by age group. Sixteen S. Typhi isolates were multidrug-resistant (MDR). All S. Paratyphi isolates were pan-susceptible. The duration of fever among patients with an MDR S. Typhi infection was longer than among patients with non-MDR S. Typhi (16+/-8 vs. 11+/-4 days, p=0.02) and S. Paratyphi (10+/-2 days, p=0.04) infections. CONCLUSIONS: Typhoid fever is more common than paratyphoid fever in the urban Bangladeshi slum; children<5 years old have the highest incidence. Multidrug resistance is common in S. Typhi isolates and is associated with prolonged illness. Strategies for typhoid fever prevention in children aged<5 years in Bangladesh, including immunization, are needed. |
Community perceptions of bloody diarrhoea in an urban slum in South Asia: implications for introduction of a Shigella vaccine
Arvelo W , Blum LS , Nahar N , von Seidlein L , Nahar L , Pack RP , Brooks AW , Pach A , Breiman RF , Luby SP , Ram PK . Epidemiol Infect 2010 139 (4) 1-7 Understanding local perceptions of disease causation could help public health officials improve strategies to prevent bloody diarrhoea. A cross-sectional survey was conducted in Dhaka, Bangladesh to elicit community beliefs about the causes of and prevention strategies for bloody diarrhoea. Between March and June 2003, we interviewed 541 randomly selected respondents. Overall, 507 (93%) respondents perceived that a vaccine could prevent bloody diarrhoea. If a vaccine provided lifetime protection, 445 (83%) respondents stated that they would opt to get the vaccine and would pay a median of $0.05 (range U.S.$0.01-0.15) for it, equivalent to <1% of their median weekly income. There was almost universal perception that an effective vaccine to prevent bloody diarrhoea was highly beneficial and acceptable. While respondents valued a vaccine for prevention of bloody diarrhoea, they were only willing to pay minimally for it. Therefore, achieving a high rate of Shigella vaccine coverage may require subsidy of vaccine purchase. |
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