Cholera Platform Webinar In 2018 we conducted systematic
Cholera Platform Webinar • In 2018, we conducted systematic reviews of: Welcome! – WASH in outbreaks & emergencies • Identified eight CISUR interventions – Commonly Implemented but Severely Under. Researched Today we will present research from three studies conducted at • Three of which were: – Household spraying Tufts University with R 2 HC and – Household disinfection kits – Bucket chlorination OFDA funding. • Received funding from OFDA and R 2 HC to investigate efficacy / effectiveness of these three CISUR interventions
Household Spraying in Cholera Outbreaks: Evaluation of Three Programs K. Gallandat, J. Rayner, A. Huang, G. String, D. Lantagne Webinar with the Regional Cholera Platforms Central & West Africa June 27, 2019
Background Objectives Methods Results Conclusions Household Spraying • Sprayers apply chlorine on surfaces in cholera-affected households • “Not recommended” in 4 guidelines – – – No evidence for efficacy or effectiveness Timeliness of the intervention? Limited coverage (asymptomatic) Stigmatization concerns Prioritization of interventions • But commonly implemented in outbreak response Kalemie, DRC, June 2018 3
Background Objectives Methods Results Conclusions Objectives a. Determine where V. cholerae is found in households b. Evaluate the effectiveness of household spraying c. Identify opportunities and challenges of the intervention 4
Background Objectives Methods Results Conclusions Evaluation Methods • Chlorine solution testing (titration) • Sampling of surfaces by swabbing – Before spraying – 30 minutes & 24 hours after spraying – Detection of V. cholerae, E. coli, total coliforms • Key informant interview(s) • Household surveys • 3 programs evaluated – 4 -5 HH in each evaluation – 1 more pending evaluation Mbuji-Mayi, DRC, July 2018 5
Background Objectives Methods Results Conclusions Program Characteristics Program A Program B Program C Urban (DRC) (Semi-)urban (DRC) Urban (Haiti) Endemic Epidemic Endemic 2008 April 2018 2014 # Spraying agents 3 (+6 “back-up”) 9 11 Supervision Local health auth. NGO Team base CTC/hospital CTC/CTU, ORP NGO office Case HH + 5 latrines Case HH + 20 HH Case HH + ≤ 30 HH Environment Cholera context Program start Coverage objectives Chlorine type Target chlorine concentrations Calcium hypochlorite (HTH) 0. 2% for HH surfaces, 2. 0% for latrines & soiled surfaces 6
Background Objectives Methods Results Conclusions Kalemie, DRC, June 2018 Mbuji-Mayi, DRC, July 2018 Chlorine Preparation Dosage of HTH powder with spoons in all programs At the household for Program A, at the CTC/base for Programs B & C Use of container / spraying equipment to estimate volumes 7
Background Objectives Methods Results Conclusions Chlorine Dosage HTH dosage (0. 2%) HTH dosage (2. 0%) 3500 25000 3000 2000 mg/L 2500 10000 500 0 15000 1 2 3 A 4 5 6 7 8 B 9 10 11 12 13 14 C Dosage with spoons in all programs Dosage more accurate at 0. 2% compared to 2. 0%, and consistently lower than target in Program C 8
Background Objectives Methods Results Conclusions V. cholerae on Selected Household Surfaces PROGRAM A Systematic 5 -10 L/HH 5 -10 min/HH (■) High: ≥ 5, 000 CFU/100 cm 2 PROGRAM B (■) Intermediate: 200 -5, 000 CFU/100 cm 2 (■) Low: <200 CFU/100 cm 2 (■) Not detected Ad hoc 0. 2 L/HH 2 -5 min/HH 9
Background Objectives Methods Results Conclusions V. cholerae on Selected Household Surfaces PROGRAM C (■) High: ≥ 5, 000 CFU/100 cm 2 Ad hoc 2 (■) Intermediate: 200 -5, 000 CFU/100 cm 2 -5 L/HH Time not recorded 2 (■) Low: <200 CFU/100 cm (■) Not detected HH 13 -14: no suspected cholera case (AWD) Consistent inactivation of V. cholerae after spraying was seen in Program A only Some recontamination was observed after 24 hours 10
Background Objectives Methods Results Conclusions # positive samples Detection of V. cholerae 10 9 8 7 6 5 4 3 2 1 0 1 2 3 4 5 6 7 A 8 9 B BEFORE 30 MIN 10 11 12 13 14 C 24 HRS More HH surfaces initially contaminated in Program B Reduction in # of contaminated after 30 minutes in 13/14 HH (93%) Recontamination after 24 hours observed in 10/14 HH (71%) 11
Background Objectives Methods Results Conclusions Selected Survey Results Intervention timing: long time to reach households Mean (range) # days since cholera onset Program A Program B 3. 4 (2 -5) 3. 2 (2 -4) Program C 4. 5 (4 -5) Among survey participants … • 50 -80% found HH spraying “very useful” • 40 -100% appreciated a “clean house” • 100% had nothing to report when asked what they did NOT like – Highlights the risk of bias; further qualitative research needed
Background Objectives Methods Results Conclusions • Timeliness • Household identification (all programs) Ø Use cell phones / radios Ø Travel with patient relatives • Resource-intensive (all programs) Ø Use as platform for sensitization, active case searching, outbreak monitoring (GPS) • Mostly appreciated by beneficiaries (all programs), with occasional refusals reportedly due to fear of stigmatization and religious beliefs (programs A, C) Mbuji-Mayi, DRC, July 2018 Challenges & Opportunities from KII
Background Objectives Methods Results Conclusions Key results § Spraying can reduce contamination on HH surfaces if implemented properly § Intervention coverage is limited (asymptomatic & community cases) § Challenge: identification of HH § VBNC V. cholerae not detected in this work; their relevance remains unclear Recommendations (if HH spraying is implemented) § Systematic procedure to ensure complete coverage § Spray until surface is wet § Kitchen area is critical (2. 0%) § Prioritize approaches that increase community coverage § Use HH spraying opportunities for hygiene promotion § Travel w/ patient’s relative and give sprayers phones/radio 14
Background Objectives Methods Results Conclusions Acknowledgements • Partner organizations: AIDES, Solidarites International • Interpretors: François Mitima, Eddy Mbuyamba Kashala, Miché Payen • Study participants: program staff & beneficiaries • Funding: Research for Heatlh in Humanitarian Crises, Swiss National Science Foundation, PEO Foundation 15
Thank you Contact: karin. gallandat@lshtm. ac. uk
Identifying barriers to adoption of Household Disinfection Kits for environmental infection control of cholera transmission Camille Heylen and Daniele Lantagne Department of Civil and Environmental Engineering, Tufts University, Medford, MA, USA
Background Photo credit: IFRC and MSF • Environmental infection control interventions • Key to interrupting within household cholera transmission • Two approaches: - Household Spraying - Household Disinfection Kit • International recommendations for HDK, but… no one implementing. 18
Objectives & Methods • Identify barriers to adopting HDKs • Evaluate one barrier of HDK beneficiaries’ training on HDK use Response agency staff Beneficiaries (Haiti) Trainings on the use; Environmental sampling; and Household surveys Key informant interview (KII) Quantitative aspect of HDK/Insight on the training needed Qualitative aspect of HDK Trial in Haiti in August 2019 14 KIIs done (February-April 2019) 19
Results (I) 14 KIIs conducted Main results : - Question on priority of disinfection interventions - Gap of evidence on the effectiveness of both measures - Confusion between HDK and hygiene kit of HDK - Huge divide between international staff and national staff (HDK > < HS) 20
Results (I) – (Perceived) Benefits & Drawbacks of HDK’s Benefits of HDKs: – People know how to use items – Time wise “We did see that there was a very good use of the kit” “HDK with the right support is more appropriate than spraying, given all the delays in providing data” – Increase of awareness of the population Drawbacks of HDKs: Composition of the kit varies “HDK gives a lot of more control to the people in the household to really target their cleaning appropriately and immediately” “ There as many kits and names as there are countries or partners, even though the clusters are trying to align the composition “ “ It is important that partners have a same understanding for the composition of the kit” Coordination with decision-makers Resale of items “The greatest failure is the resale of the items and it is a big issue. Because we can’t ignore it: the priority is the food” 21
Results (I) – (Perceived) Benefits & Drawbacks of HS Benefits of HS: “With a spraying team, we are sure that the house is disinfected. But if we you give this responsibility to the population, are we sure that they are going to disinfect their house? ” – Certainty of the method – Safety for the household – Mapping Drawbacks of HS: False sense of security Stigmatization Resources consuming/Cost “The use of chlorine is not easy. I do not advise to distribute bleach, it could really lead to bad dosages and bad manipulations as well ” “Spraying allows us to geo locate where sick people come from ” “What's the impact of spraying once a day? It gives a false sense of security. We should reinforce the systematic cleaning that needs to happen every day, multiple times a day” “Spraying is like punishing, it’s like recognizing that something is wrong in that household” “ We see that it has a cost this spray. We see that it is a lot of resources as well. ” 22
Expected results (II) Training (2 different modules) Environmental sampling Initial number of bacteria on surfaces Household survey Knowledge on living conditions and sanitation 1 st household visit Distribution of the kit and use by the beneficiaries Environmental sampling Number of bacteria on surfaces after HDK Household survey Perception of HDK 2 nd household visit 23
Expected results (II) Initial number of bacteria on surfaces Quantitative and qualitative information on logistics and appropriateness of household disinfection kits. Knowledge on living conditions and sanitation + Observation & pictures Number of bacteria on surfaces after HDK Results in Fall 2019 Perception of HDK 24
Expected results Trainings on the use; Environmental sampling; and Household surveys Key informant interview (KII) Qualitative aspect of HDK Quantitative aspect of HDK/Insight on the training needed To compare benefits / challenges of HDK and HS interventions To formulate recommendations on how to use in future Next steps: • Need to finish the analysis of KII • Preparation for the field • Data synthesis and development of recommendations to responders 25
Evaluation of the Effectiveness of Bucket Chlorination Gabrielle String, Mustafa Sikder, Yarmina Kamal, Justine Rayner, and Daniele Lantagne Department of Civil and Environmental Engineering, Tufts University, Medford, MA, USA
Background • Commonly implemented in outbreak response • Lack of quantitative and qualitative evidence • Need to understand chlorine types, concentrations and dosages 27
Methods 28
Results • Four evaluations completed – DRC (2) – Cox’s Bazar (1) – Haiti (1) • 45 program staff and agents interviewed • 40 chlorination points observed • 702 households surveyed • 11 focus group discussions conducted 29
Results: Observation of Chlorination Provision of shade, PPE, and FCR test equipment was most variable. 30
Results: Chlorine Preparation and Dosing Chlorine stock solution preparation, storage, and dosing. No programs adjusted preparation or dosing protocols. Variability in produced stock chlorine concentration when targeting 1%. 31
Results: Source Water Number of users varied widely within and between programs. Testing completed ad-hoc and “jar tests” used at program start. 32 Water from semi- or unprotected sources in Programs 1 and 3 and quality was poor.
Results: Stored Water E. coli reduced ≥ 1 -log in 73% of households with >100 E. coli CFU/100 m. L at source. Variable FCR and high presence of total coliforms indicates risk of recontamination. 33
Key Takeaways • Variation across programs and inexactness in implementations - Management of chlorination points - Chlorine solution concentrations - Dosing protocols - Testing and monitoring protocols • Generally effective at reducing E. coli & providing FCR >0. 2 mg/L • Need to consider beneficiary opinion of programs 34
Preliminary Recommendations 1. Safely store HTH powder and stock solution - Prevents degradation of chlorine concentration 2. Provide shade at chlorination points 3. Conduct more frequent jar tests - Protects agents and chlorine from sun exposure - Ensures proper chlorine dosage of beneficiary containers An additional evaluation will be conducted prior to data synthesis, qualitative data analysis, and development of final recommendations to responders. 35
Acknowledgements Simon Pickard R 2 HC Melissa Opryszko USAID-OFDA In each evaluation context: Response partners, enumerators, and study participants Contributors: Karin Gallandat, Molly Lie, Nicole Masozera, Patrick Mirindi, Magnifique Mukundwa, and Michael Ritter
Thank you and we are happy to take questions! karin. gallandat@lshtm. ac. uk camille. heylen@tufts. edu gabrielle. string@tufts. edu daniele. lantagne@tufts. edu
- Slides: 37