RotaFlash, April 2016
Water, sanitation and hygiene (WASH) interventions are key to preventing diarrheal diseases. Handwashing is an easy way to prevent diarrhea, but is not always practiced. How can we improve the practices of people in countries where diarrheal diseases remain prevalent? To get some answers, we spoke with Dr. Emily Gurley, an infectious disease epidemiologist who is currently acting as the director of icddr,b’s Centre for Communicable Diseases.
Why is icddr,b’s WASH work significant in the context of Bangladesh? And globally?
The burden in Bangladesh from diseases and conditions that can be prevented by WASH interventions is considerable—everything from diarrhea to respiratory illness could be prevented through more sanitary and clean environments. While diarrhea may be a minor inconvenience in some places, in many countries it kills. Bangladesh is infamous for its high burden of diarrheal disease.
icddr,b’s WASH research is committed to finding and testing interventions such as handwashing and other good hygiene practices that can drastically improve health outcomes in Bangladesh and beyond, by creating evidence that WASH interventions work, and how they can be brought to scale in setting where people don’t always have access to safe water. Even at the global level, the evidence generated by our research could help identify key interventions to improve global health outcomes. This is particularly relevant in the new Sustainable Development Framework where one of the Global Goals is dedicated to ensuring access to water and sanitation for all.
Research doesn’t always prove the success of an intervention: we also have conducted research which proves that interventions in WASH aren’t always as effective as initially thought. This does, however, not mean that the intervention was a failure! There are valuable lessons learned that we can take home from this type of research, and that helps us develop interventions which are more effective and scalable.
What makes handwashing so important?
According to the WHO, each year there are an estimated 1.7 billion cases of childhood diarrhea worldwide. Handwashing with soap before preparing and eating a meal is the best way to keep families safe and healthy. Our studies on handwashing practices in Bangladesh have shown that the presence of water in close proximity to the home doubles the probability of handwashing. We know that washing your hands – even briefly – with water before handling, preparing and eating food can significantly reduce the incidence of diarrhea. Incidence is even further reduced when there is also soap available: almost 50% according to some estimates! In addition, handwashing can also prevent the spread of other diseases, if done properly.
Given its effectiveness, why is handwashing still not common practice in many rural areas?
We have a study going on right now in an urban area north of Dhaka – our experiences there build upon the evidence that, while there is knowledge about the importance of handwashing, it is still far from becoming a habit. The point of the study is to look at how households cope with water scarcity, and how their access to water is related to hygiene-related behavior, not just hand washing, but also bathing, washing clothes and dishes, cleaning households etc. If you have a ready access in at least one part of
your house to a tap that always has clean running water, and you can afford a bar of soap, why wouldn’t you clean your house every time it is dirty? If you have to bring water by bucket into your house to use for everything, you probably want to use that water for handwashing less often because it is so precious.
How can we use that knowledge to change behavior?
Education of the persons preparing and providing the food – in particular mothers, is very important. By demonstrating good hygiene practices, they will also teach their children and other people in the household to practice handwashing and other good hygiene habits. However, there is still the question of access to water and soap. Despite there being broad knowledge of the benefits of hand-washing, it is still not widely practiced if access to water and soap is limited. Our studies show that the best indicator for frequent handwashing is if they actually have a place in their house that has clean water and soap.
What are some key hygiene and sanitation messages you would like to share with our readers to encourage handwashing interventions?
WASH interventions are particularly important in those areas where environmental factors make it difficult to maintain a high standard of sanitation. At the same time, they are an essential component of an improved quality of life where, as countries progress from low-income to middle-income societies, the sanitation and hygiene conditions improve—as with Bangladesh over the years.
There is also a strong need for promoting the measurement of effectiveness of WASH interventions. By generating evidence of the benefits of WASH in combination with other interventions such as in nutrition, we hope that we can encourage policy and decision makers as well as implementers to adopt integrated policies and programs to maximize health outcomes.
All humans need fresh, clean water - reduced access to it leads to disease, forced migration, loss of crops and food security. It is just so central to everything that a society needs to thrive.Read more
Outbreak and emergency situations often raise the specter of cholera and the very real danger it poses. But many communities throughout the world also face the silent, but no less deadly, burden of endemic cholera. Earlier this year, results from a groundbreaking study showed the promise and potential of using cholera vaccines for prevention in endemic settings. DefeatDD talked with Dr. John Clemens, Executive Director of icddr,b, which conducted this large scale study in Dhaka, Bangladesh.
This study was unique in its focus on preventing endemic disease, as opposed to halting the outbreaks we commonly associate with cholera. Tell us about the vaccine and the study findings.
The vaccine we studied, Shancol, was developed by the International Vaccine Institute in Korea, Vabiotech in Vietnam, and Shantha Biotech in India, where it has been licensed since 2009. It was created with the intent of affordability, with a low cost-of-goods, and logistic adaptability to the challenging conditions that often occur in cholera epidemics. It is now prequalified by the World Health Organization and is the basis for a stockpile of oral cholera vaccines.
The predominant use of the stockpile has been for outbreaks, yet over 90 percent of the global cholera burden is endemic disease. As is the very nature of endemicity, endemic cholera has a tendency to become perceived as a part of daily life, and does not attract the international attention that outbreaks attract. Shanchol has been very useful in outbreak settings, very feasibly administered and impactful. So we evaluated the vaccine to determine if it is also feasible and impactful when deployed against endemic cholera in an urban, endemic setting.
The endemic cholera burden in an urban, highly populated area like Dhaka must be quite significant.
It is a tremendous burden in Bangladesh. Even though many of the modern approaches to the treatment of diarrhea and cholera were developed here, there are several hundred thousand cases of clinically significant cholera per year, and deaths in the thousands. And in urban areas, cholera burden is growing. Rural populations are moving to the city in great numbers and creating urban squatter settlements that are densely populated, with living conditions that allow diseases like cholera to thrive.
With endemic disease throughout the population, who is the vaccine's target populaton?
Endemic cholera affects all age groups, although it occurs with higher incidence in children. The current thinking is that to immunize pre-emptively against predictable endemic cholera, programs might focus on children under the age of 15 or even an entire population, depending on the strategy that provides the needed level of protection for the population. We are planning to undertake a project with this same vaccine in urban Bangladesh to determine which is the most high-impact, cost-effective, and feasible strategy.
The vaccine is given in two doses, and re-immunization would be required three or up to five years later, depending on the age group. Young children probably will require three-year boosters. Older people seem to be protected longer, to at least five years.
What is the timeline for potentially using this vaccine for pre-emptive protection in endemic communities?
Our project aims to provide the evidence the Government of Bangladesh needs to move forward in deciding whether to incorporate cholera vaccination against endemic disease. The project is two years in duration, and we hope that by its end, we would see decisions about vaccine introduction to be made soon thereafter.
This is very exciting. People have been talking about using oral cholera vaccine in Bangladesh for many years. 30 years ago, icddr,b conducted the world’s first field trial of the efficacy of an oral cholera vaccine against endemic chollera, and there has always been hope that such a vaccine could transition into programs to control the endemic problem, especially among the poor.
So why the gap? What happened in those 30 years that we are only now coming closer to this strategy?
The vaccine that was licensed based on the 1980s field trial was safe and effective, but proved too costly for developing-country programs. Also, because it had to be given with a liquid buffer, it was challenging to administer in some settings. As well, there has been a historical tension between those favoring vaccine strategies and those focusing on controlling cholera through traditional means like improved water and hygiene and improved treatment. Of course in an outbreak, treatment is priority number one.
We have come to realize that, clearly, improved water and sanitation are the ultimate solution to preventing cholera. And vaccines are just one tool to be considered in concert with other approaches. But achievement of the levels of improvement in WASH per se that would be necessary to control cholera is probably not a near-term goal. Urbanization, for example, creates even more challenges for delivering clean water, providing good sanitation, and changing hygienic behaviors. So now there is widespread agreement that we ought to be thinking about using every tool in our toolbox to prevent cholera. In fact, there are good theoretical reasons to believe that even provision of WASH at a level that is not sufficient to control cholera may enhance the performance of oral cholera vaccine. There's inherent synergy between these two approaches.
This study was quite large, with 250,000 subjects. Is it typical for icddr,b to conduct studies at this scale? What are the keys to success?
icddrb has a history of conducting very large studies, but this is the largest vaccine study that we have ever undertaken. Proper training, supervision, and quality control are always important. But an essential component is having trusting relationships with the community. Community trust is absolutely essential. And that has been a hallmark of icddrb's work, being able to develop these relationships over the long term.
You've worked in diarrhea research, in Bangladesh, and with iccddr,b for quite a long time. What do the results of this study mean for you?
The results of this study indicate clearly that the evidence base for moving ahead in vaccinating against endemic cholera is now nearly complete. It's a very important step forward.
Photo credit: M.Dorgabekova.Read more
Official movie poster (copyright 20th Century Fox), with a few creative tweaks by Laura Edison.
With the recent NASA discovery of water on Mars, combined with the release of my new favorite movie, The Martian, Mars has been on my mind a lot lately. While watching the movie, I was struck not only by the physical beauty of both Mars and Matt Damon, but also by the incredible amount of coordination and planning that it takes to travel through space. And as a vaccine advocate, that got me thinking.
With space travel—whether fictional or real—the mission is usually to explore something, but most of the investments and planning have to do with getting there. In the case of The Martian, a fictional NASA sends a manned mission to Mars to analyze soil samples. But NASA would never send a crew of astronauts to explore Mars without a high-tech spaceship, a meticulously planned flight trajectory, and a well-trained professional team manning the control center, tracking data sent from the spaceship in order to respond as needed. The vast majority of manpower, time, and resources are spent on the journey—because no matter how exciting the goals are for the exploration of Mars, the astronauts will not be able to accomplish anything if they don’t first get there (and get home, too… cough, Matt Damon).
With immunization, our goals—such as those laid out by the Sustainable Development Goals—are to protect children from deadly and disabling diseases. But just like exploring Mars, we can’t get to that goal without the journey: getting vaccines to the right places, at the right time, and at the right temperature. This is where the supply chain comes in.
The immunization supply chain is the entire system that supports the delivery of vaccines from the manufacturer to communities. To succeed in protecting kids (or “exploring Mars”), you need not only the vaccines themselves but also cold chain equipment (spaceships) to transport them, real-time data to help decision-makers (command center) respond to changing needs, a well-planned supply system design (flight trajectory), and, of course, professionally trained supply chain workers (astronauts) to carry out the mission. Supply chains for other commodities, such as oral rehydration solution and zinc for treating diarrhea, work much the same way.
While the planning and coordination part of space travel may not be the most “exciting” part of The Martian, the mission would have been an immediate failure without it—likely resulting in deaths of the astronauts. In order to end the hundreds of thousands of real deaths of children here on earth from vaccine-preventable illnesses such as rotavirus diarrhea and pneumococcal pneumonia every year, we need to apply these same principles to immunization supply chains. I am currently working on a project that aims to use advocacy to help make that a reality.
Current supply chains are outdated and under-resourced. Problems like lack of electricity, muddy roads, flat tires, untrained and poorly paid workers, malfunctioning equipment, and paper-based data systems prevent vaccines from being delivered efficiently and effectively. By investing in next-generation immunization supply chains that include things like accessible, high-quality data, direct-drive solar-powered refrigerators, integration with other health commodity supply chains, and, where appropriate, outsourcing to the private sector, we can ensure that vaccines are delivered and their lifesaving potential is fulfilled. For example, it is estimated that, if successfully delivered, pneumococcal and rotavirus vaccines could avert more than 11 million child deaths in low- and middle-income countries by 2030.
While the real NASA has not yet succeeded in sending a manned mission to Mars, it is planning to do so in the near future (fingers crossed!). NASA doesn’t expect to get to Mars without significant investment in planning, coordination, data, training, and equipment for the journey—and the global health community shouldn’t, either. To reach our “Mars” of protecting every child everywhere from vaccine-preventable diseases, we need to get to work on the supply chain.
-- Laura Edison is a Scientific Communications Associate at PATH.Read more
On October 2nd, India celebrated its one year anniversary of the launch of the Clean India Mission. When I think about how the Government of India aligned Clean India Mission messages in all its flagship programs over the past year, especially in sanitation, I cannot help but wonder why the connection between environment and public health is so hard for people to understand.
Over the past year, I revisited places in Uttar Pradesh and Bihar where I had previously supported polio communications, which have become hotbeds of Japanese Encephalitis and Acute Encephalitis Syndrome. The cities began to look the same after a while: between no visible sign of solid waste disposal and the contamination of natural water bodies, these areas are breeding nests for a host of diseases.
The link between the polio virus and open sewage was something drilled into me while working in Uttar Pradesh eight years ago. So what can help more people, communities and governments alike, understand the connection between the environment and public health is a question that is constantly with me. Only a few months ago Delhi’s pollution levels were global news, and now the recent dengue scare has the newly appointed local Government in a twist. None of this is new; it’s just several degrees worse.
In Western India, work travel has also taken me to congested Mumbai, where innovative public health projects are faced with Herculean environment issues, even as they try to detect and treat potential tuberculosis patients.
The Prime Minister has clarified on several occasions that India’s sanitation goals have not been missed because of paucity of funds, but because the shared vision as a nation on this important issue has been missing. If one were to look at the positives, as this year rolls by, the first few critical things are seemingly in place and Clean India has caught the imagination across the country. Organizations across the spectrum have come together to work and the Clean India Mission has the highest political commitment.
Last October – on the occasion of Mahatma Gandhi’s birthday – the Prime Minister nominated well-known personalities across a wide spectrum of politics, films, and sports to be Clean India ambassadors. India has hosted international sanitation summits and these efforts are all to map the way to an ambitious goal – to achieve an open defecation-free India. These efforts will help keep India polio-free, control dengue and Japanese Encephalitis, and curb diarrheal diseases.
Despite the progress, the question still nags: Has India been doing something wrong to still be faced with this situation? What are the barriers to understanding the importance of sanitation?
For more information:
-- VIDEO: See how simple diarrhea prevention and treatment solutions can save lives in low-resource settings.
-- Help us raise awareness about the global burden of diarrheal disease. Caption our Traveling Poo's global adventures for a chance to be featured in our 2016 calendar.
Photo credit: PATH/Adriane Berman.Read more
“The results communicate a clear message: We can choose a better future for the world’s children.”
I love that sentence from UNICEF’s most recent A Promise Renewed progress report. The fact that we have a choice makes two essential points: (1) our investments in maternal and child health are working and (2) continued progress is not inevitable. We, as a global community, have to write this chapter in history for ourselves.
Practically speaking, what does that look like? DefeatDD’s new video shares our vision: Lifesaving interventions to prevent and treat diarrheal disease seamlessly woven into the fabric of healthy communities.
Looking forward begins with looking back, and just because the Millennium Development Goals have expired doesn’t mean obstacles have expired with them. It is true that thanks to progress – like the steady march of rotavirus vaccines in nearly 80 poor countries and the early achievement of the Millennium Development Goal on safe drinking water – deaths from diarrhea and other leading child killers have fallen considerably. But it would be short-sighted to consider our work finished in this arena.
While we’ve decreased the scope of the problem with simple solutions, they are not yet available everywhere, and remaining gaps reveal persistent challenges. In India, for example, while there is strong political will for sanitation through the national Swachh Bharat Mission and the India Sanitation Coalition, it has also shed light on the need for more behavior change education, creative use of limited funds, and a sustainable infrastructure that spans state and local level jurisdictions.
Globally, the changing landscape reveals that while child deaths from diarrhea have declined, a dramatic toll on children and families remains. Half a million children still die from preventable diarrhea each year, and those who do survive often are caught in a vicious cycle of diarrhea and malnutrition, suffering long-term physical and cognitive growth shortfalls. Exclusive breastfeeding and adequate nutrition are examples of simple, proven interventions that can fortify children and help ensure that they thrive, not merely survive. While we know what works, the challenge is equitable application and scale-up.
There’s also an increasing recognition of the interconnected nature of goals that, on the surface, seem unrelated. Our video illustrates how access to basic sanitation has everything to do with the education and empowerment of women and girls, and how preventing repeated diarrheal episodes can help ease families’ economic burden.
These are just a few reasons why I believe interventions to defeat diarrheal disease deserve their place in the Global Goals. Progress against this leading child killer is impressive, but unfinished. And our success here will spill over to other critical areas of health and development as well.
Help ensure that global leaders continue to focus on diarrheal disease by sharing our video.Read more