SuSanA - Forum Kunena Site Syndication http://forum.susana.org/ Tue, 21 Oct 2014 00:31:39 +0000 Kunena 1.6 http://forum.susana.org/components/com_kunena/template/default/images/icons/rss.png SuSanA - Forum http://forum.susana.org/ en-gb Re: Sanitation interventions during Ebola epidemic - by: arno http://forum.susana.org/forum/categories/26-health-hygiene-and-disability-issues/10359-sanitation-interventions-during-ebola-epidemic?limit=12&start=24#10614 http://forum.susana.org/forum/categories/26-health-hygiene-and-disability-issues/10359-sanitation-interventions-during-ebola-epidemic?limit=12&start=24#10614 Ebola Outbreak: NEJM Live Audio Webcast.

click2.nejm.org/cts/click?q=66666779%3B6...BrvS9GG5aww20Dc%2Bfa

A special invitation for valued readers of the New England Journal of Medicine, a publication of NEJM Group.

NEJM Live Audio Webcast:
Ebola Outbreak
Experts discuss virology, epidemiology, and clinical care
October 22, 2014 | 2:00 pm - 3:30 pm ET

What Clinicians Need to Know
International experts with hands-on experience provide the latest information on the Ebola outbreak, including recent events in the U.S., protection for health care professionals and the general public, and projections for the future.

Learn more about this free live audio webcast hosted by the New England Journal of Medicine, including the full agenda and guest speakers. Webcast participants will also have an opportunity to submit questions live or in advance by sending their questions to This e-mail address is being protected from spambots. You need JavaScript enabled to view it .

GUEST SPEAKERS & MODERATORS
Christopher Dye, D.Phil.
World Health Organization

Paul Farmer, M.D.,Ph.D.
Partners in Health

Jeremy Farrer, M.D.,Ph.D.
Wellcome Trust

Armand Sprecher, M.D.
Médecins Sans Frontières

Moderators
Jeffrey M. Drazen, M.D.
Editor-in-Chief The New England Journal of Medicine

Lindsey Baden, M.D.
Deputy Editor The New England Journal of Medicine

Follow the live event on Twitter: #NEJMEbola]]>
Health, hygiene and disability issues Mon, 20 Oct 2014 20:28:02 +0000
Re: Sanitation interventions during Ebola epidemic - by: joeturner http://forum.susana.org/forum/categories/26-health-hygiene-and-disability-issues/10359-sanitation-interventions-during-ebola-epidemic?limit=12&start=24#10609 http://forum.susana.org/forum/categories/26-health-hygiene-and-disability-issues/10359-sanitation-interventions-during-ebola-epidemic?limit=12&start=24#10609
Tuladhar, Era, et al. "Residual viral and bacterial contamination of surfaces after cleaning and disinfection." Applied and environmental microbiology 78.21 (2012): 7769-7775.

Full text: aem.asm.org/content/78/21/7769.full

Abstract:

Environmental surfaces contaminated with pathogens can be sources of indirect transmission, and cleaning and disinfection are common interventions focused on reducing contamination levels. We determined the efficacy of cleaning and disinfection procedures for reducing contamination by noroviruses, rotavirus, poliovirus, parechovirus, adenovirus, influenza virus, Staphylococcus aureus, and Salmonella enterica from artificially contaminated stainless steel surfaces. After a single wipe with water, liquid soap, or 250-ppm free chlorine solution, the numbers of infective viruses and bacteria were reduced by 1 log10 for poliovirus and close to 4 log10 for influenza virus. There was no significant difference in residual contamination levels after wiping with water, liquid soap, or 250-ppm chlorine solution. When a single wipe with liquid soap was followed by a second wipe using 250- or 1,000-ppm chlorine, an extra 1- to 3-log10 reduction was achieved, and except for rotavirus and norovirus genogroup I, no significant additional effect of 1,000 ppm compared to 250 ppm was found. A reduced correlation between reduction in PCR units (PCRU) and reduction in infectious particles suggests that at least part of the reduction achieved in the second step is due to inactivation instead of removal alone. We used data on infectious doses and transfer efficiencies to estimate a target level to which the residual contamination should be reduced and found that a single wipe with liquid soap followed by a wipe with 250-ppm free chlorine solution was sufficient to reduce the residual contamination to below the target level for most of the pathogens tested.
]]>
Health, hygiene and disability issues Mon, 20 Oct 2014 14:50:15 +0000
Re: Sanitation interventions during Ebola epidemic - by: joeturner http://forum.susana.org/forum/categories/26-health-hygiene-and-disability-issues/10359-sanitation-interventions-during-ebola-epidemic?limit=12&start=24#10608 http://forum.susana.org/forum/categories/26-health-hygiene-and-disability-issues/10359-sanitation-interventions-during-ebola-epidemic?limit=12&start=24#10608 www.processcleaningsolutions.com/pdf/3_norovirus-barker.pdf

The paper seems to make clear that wiping and the use of detergent is not enough to clean surfaces of the virus. The use of a bleach, preferably with surfaces wiped beforehand, seems to be the advice given in this paper to reduce risks.]]>
Health, hygiene and disability issues Mon, 20 Oct 2014 14:32:50 +0000
Re: Sanitation interventions during Ebola epidemic - by: arno http://forum.susana.org/forum/categories/26-health-hygiene-and-disability-issues/10359-sanitation-interventions-during-ebola-epidemic?limit=12&start=24#10607 http://forum.susana.org/forum/categories/26-health-hygiene-and-disability-issues/10359-sanitation-interventions-during-ebola-epidemic?limit=12&start=24#10607 Here is a paper on Noroviruses transferred via faeces on environmental surfaces. Drawing parallels with Filoviruses isn't really a long shot. Protecting against the highly contagious and persistent Noroviruses should provide the proper safety to protect against Ebola.

www.sciencedirect.com/science/article/pii/S0195670104002087

Effects of cleaning and disinfection in reducing the spread of Norovirus contamination via environmental surfaces by J. Barker, I.B. Vipond, S.F. Bloomfield.
Journal of Hospital Infection. Volume 58, Issue 1, September 2004, Pages 42–49

Abstract
A reverse transcriptase polymerase chain reaction assay was used to study the transfer of Norovirus (NV) from contaminated faecal material via fingers and cloths to other hand-contact surfaces. The results showed that, where fingers come into contact with virus-contaminated material, NV is consistently transferred via the fingers to melamine surfaces and from there to other typical hand-contact surfaces, such as taps, door handles and telephone receivers. It was found that contaminated fingers could sequentially transfer virus to up to seven clean surfaces. The effectiveness of detergent– and disinfectant-based cleaning regimes typical of those that might be used to decontaminate faecally contaminated surfaces and reduce spread of NV was also compared. It was found that detergent-based cleaning with a cloth to produce a visibly clean surface consistently failed to eliminate NV contamination. Where there was faecal soiling, although a combined hypochlorite/detergent formulation at 5000 ppm of available chlorine produced a significant risk reduction, NV contamination could still be detected on up to 28% of surfaces. In order consistently to achieve good hygiene, it was necessary to wipe the surface clean using a cloth soaked in detergent before applying the combined hypochlorite/detergent. When detergent cleaning alone or combined hypochlorite/detergent treatment failed to eliminate NV contamination from the surface and the cleaning cloth was then used to wipe another surface, the virus was transferred to that surface and to the hands of the person handling the cloth. In contrast, were surfaces where contaminated with NV-infected faecal suspension diluted to 1 in 10 and 1 in 80, intended to simulate surfaces that have become contaminated after secondary transfer, treatment with a combined bleach/detergent formulation, without prior cleaning, was sufficient to decontaminate surfaces and prevent transfer.]]>
Health, hygiene and disability issues Mon, 20 Oct 2014 14:22:46 +0000
Re: Sanitation interventions during Ebola epidemic - by: Sowmya http://forum.susana.org/forum/categories/26-health-hygiene-and-disability-issues/10359-sanitation-interventions-during-ebola-epidemic?limit=12&start=24#10586 http://forum.susana.org/forum/categories/26-health-hygiene-and-disability-issues/10359-sanitation-interventions-during-ebola-epidemic?limit=12&start=24#10586 [Start of Page 3 of the discussion]


I think your point is very important. In Ebola containment, we need to think of toilets that may be in bad condition also (built too long ago or not constructed properly, etc.,) - cleaning / disinfecting would be all the more difficult in such cases. If it is not possible to use disinfectant chemicals (because the discharge might get mixed with the compost / fertilizer to be added to the fields), there could be a risk of infection.

Taking all these factors into consideration, it might be best to adopt the normal cleaning procedure for the toilet with the proviso that users wash their hands and feet thoroughly with soap and water outside the toilet (preferably with the water going into a small hole in the ground so that there is no unsightly pool of dirty water stagnating near the toilet) and, after drying, to dust their hands and feet with antiseptic / germicidal powder.

The small hole should probably be not more than 1-1.5 feet deep and 1-1.5 feet diameter as the hole should not be large enough to allow children or small animals to get hurt while running and preferably be kept closed with a lid that will not break into sharp shards if someone stamps on it accidentally - maybe a plastic / rubber ring (eg., a used pressure cooker gasket) with brightly-colored plastic cover on it. Or, can always use bamboo like the ones used for making baskets to make the ring. Probably better solutions are available but I am just thinking of the most resource scarce situation possible and without the possibility of quickly distributing required materials.

A germicidal solution, like Dettol or Savlon, could also be used instead of germicidal powder (I do not have scientific evidence but if other proven options are not available, this could probably be used). Further, for public toilets, a good solution could be the arrangements MSF had made for the hospital in Kitwit (please see article referred by Joe) to have a footbath. Individuals going from one area to the other had to wade through a tray filled with disinfectant (Pedi-Luve or foot bath). The material used had been developed, adapted and tested by MSF during previous emergency situations. 0.2% Calcium Hypochlorite solution 70% was used for the footbath. Something similar could also be used in households, if possible.

Warm regards,

Sowmya]]>
Health, hygiene and disability issues Fri, 17 Oct 2014 13:59:56 +0000
Re: Sanitation interventions during Ebola epidemic - by: joeturner http://forum.susana.org/forum/categories/26-health-hygiene-and-disability-issues/10359-sanitation-interventions-during-ebola-epidemic?limit=12&start=24#10578 http://forum.susana.org/forum/categories/26-health-hygiene-and-disability-issues/10359-sanitation-interventions-during-ebola-epidemic?limit=12&start=24#10578
We have been talking about the risks of stored faeces, should we also be thinking about the risks associated with 'fresh' faeces from ebola victims?

It seems that there is little information about the risks of infection from faeces, but it also seems that one does not need to be exposed much of the virus to get infected.

Should we, therefore, be also talking about the risks of the toilet (delivery) part of sanitation systems?


[End of Page 2 of the discussion]]]>
Health, hygiene and disability issues Fri, 17 Oct 2014 10:15:44 +0000
Re: Sanitation interventions during Ebola epidemic - by: joeturner http://forum.susana.org/forum/categories/26-health-hygiene-and-disability-issues/10359-sanitation-interventions-during-ebola-epidemic?limit=12&start=24#10572 http://forum.susana.org/forum/categories/26-health-hygiene-and-disability-issues/10359-sanitation-interventions-during-ebola-epidemic?limit=12&start=24#10572 bloggingonwater.blogspot.co.uk/2014/10/e...and-hygiene.html?m=1]]> Health, hygiene and disability issues Thu, 16 Oct 2014 18:14:20 +0000 Re: Sanitation interventions during Ebola epidemic - by: Sowmya http://forum.susana.org/forum/categories/26-health-hygiene-and-disability-issues/10359-sanitation-interventions-during-ebola-epidemic?limit=12&start=24#10570 http://forum.susana.org/forum/categories/26-health-hygiene-and-disability-issues/10359-sanitation-interventions-during-ebola-epidemic?limit=12&start=24#10570

Please find below some additional points:
  1. Soiled linen (of infected patients) disposal in household / community setting.
  2. (i) Disposal of feces of infants and very small children admitted in isolation wards; (ii) where infants have cloth diapers and not disposable diapers, what is the protocol for management of soiled linen? Low-income households may not have the financial resources to dispose cloth diapers after each use, so soaking the cloth diaper in Dettol or Savlon is good practice (because it is anyway recommended practice)? In case Dettol or Savlon is not available, would phenol or sodium bicarbonate be more easily available and effective? (Please see Wiki page for list of commonly used antiseptics.]
  3. How to ensure sanitation workers are fully informed particularly (i) where sanitation workers are employed by projects which are managed only locally and not connected to a municipal or panchayat committee and (ii) where some people undertake sanitation as a tradition / indigenous occupation? Any other situation where sanitation workers may not be connected to a system that can transfer information?
  4. Information to households that maintain the toilets by themselves (for instance, shift an Arborloo, etc.,), how to ensure the right information reaches them?
  5. The 2014 WHO Interim Guidelines for Management of Ebola does not have a section on sanitation. It would be great to have sanitation guidelines during Ebola epidemic. The guidelines could also have a format of records that could be maintained so that field information gets aggregated (at least for post-epidemic research) with adequate harmonization of terms, etc.
  6. (i) How to clean sanitation equipment after use? (ii) would there be any difference in cleaning protocol for a shovel compared to motorized equipment?
  7. Any factors to be considered with respect to toilets in airplanes and airports? Most planes have chemical toilets. As per the Wiki page on chemical toilets, a chemical toilet deodorizes the waste. Does deodorizing include disinfection? Also, what factors should be considered with respect to faucets in airport toilets ? Though, I guess, even if the faucets are not hands-free, using soap & water and closing the tap after washing hands with a clean paper towel would solve any problems provided there is adequate supply of paper towels.
  8. (i) What factors need to be considered for toilets in train & bus stations which do not have chemical toilets and can have significant usage? (ii) What factors need to be considered in case of gatherings of people (like village shanties, melas, etc.,)?
  9. Not sure if windrows are used in countries currently facing Ebola outbreak but where excreta is taken from the site for community composting elsewhere, how to prevent humans or animals from going near it? This could potentially be a problem if the windrows presently do not have fencing.
  10. Significance of pest control to ensure pests do not carry infected excreta on them?
  11. Any factors to be considered with respect to menstrual hygiene during Ebola outbreak?
  12. Given that sanitation workers may be illiterate or not highly educated (compared to health professionals), should the communication and training strategy for sanitation workers be modified? If so, how?
  13. In some communities, houses may be constructed near trees where fruit bats reside. Stepping barefoot on excreta of fruitbats has been found to be one of the transmission modes. How to clear animal droppings in the area surrounding households? In areas affected by the outbreak, do sanitation workers clean the common areas around houses? Any special considerations relating to handling of domestic animals (to prevent the virus from breaking the species barrier)?

Question 3: What are some options for dealing with excreta and avoiding open defecation / exposed fecal matter?

Instead of incineration, collect feces (in bags and place them without closing the lid) in a container and pour adequate quantities of bleach (or other appropriate disinfectant) into the container to immediately disinfect the excreta. Useful in places with no toilets (ie., only OD) or even in hospital settings where use of common toilets may present additional risk of disease spread. The flip side is that the chemically disinfected excreta cannot be used as organic fertilizer but this solution is only for places with no sanitation or particularly resource-constrained hospital settings. It can also be incinerated later.

Warm regards,

Sowmya]]>
Health, hygiene and disability issues Thu, 16 Oct 2014 14:28:46 +0000
Re: New Lancet study concludes no assumed improvement from TSC (Total Sanitation Campaign, in Odisha, India) - by: Sowmya http://forum.susana.org/forum/categories/26-health-hygiene-and-disability-issues/10437-new-lancet-study-concludes-no-assumed-improvement-from-tsc-total-sanitation-campaign-in-odisha-india#10558 http://forum.susana.org/forum/categories/26-health-hygiene-and-disability-issues/10437-new-lancet-study-concludes-no-assumed-improvement-from-tsc-total-sanitation-campaign-in-odisha-india#10558
Incidence and prevalence:

Incidence is “the number of new cases per population at risk in a given time period” (please see Wiki page on incidence). Prevalence is the “proportion of population found to have a condition ... arrived at by comparing the number of people found to have the condition with the total number of people studied, and is usually expressed as a fraction, as a percentage or as the number of cases per 10,000 or 100,000 people” (please see Wiki page on prevalence).

In other words, prevalence measures the number of children with diarrhoea at a given point of time while incidence measures the number of children who had diarrhoea during a given time period. Since the study talks of incidence, it is “during a given time period” and not “at any point of time”. I was unable to find more details about this report, and so cannot say over what time period this statistic refers to (during a period of one year or six months, etc.,).

When we will reach “dramatic improvement”:

With regard to “dramatic improvement”, I was writing more from the perspective of cost-effectiveness. Think of the technology adoption lifecycle (TALC) and see when the 30%, 95% and 100% coverage is reached.

30% is reached after the innovators, early adopters and half of the early majority have shifted to indoor sanitation. They are the easiest to reach (compared to other categories) and yet, the diarrhoea incidence rate is around 40%. We should also note that with half of the country's population already having toilets, after taking into account the disparities in sanitation uptake between communities (for instance, villages close to major towns and cities are likely to have larger proportion of households with toilets compared to villages in remote areas and its households scoring low on development indicators), it is likely that, broadly, the innovators and early adopters already have toilets within the existing setup (ie., with thinking that toilets are costly, ability to ensure O&M given that sanitation-related activities are taboo, etc.,).

Therefore, with the same KAP-technology framework*, we would have much higher incremental cost of reaching 95% of the population (which includes till most of long-tail category have taken to indoor sanitation) and yet, 25% of the children would still have diarrhoea episodes.

* KAP - Knowledge, Attitude and Practices, all of which have been found to be critical determinants of sanitation uptake in India and elsewhere.

What is “dramatic”?

Does reduction from 40% to 25% seem dramatic? Yes, it seems dramatic but only if we do not consider the incremental cost (financial resources, time and effort) of getting to 25%. Additionally, from a programme objective & targets point of view, is 25% acceptable? Diarrhoea is a child killer by itself and also results in secondary / long-term consequences (the most discussed consequence being stunting / malnutrition). Reaching 25% means reaching most of the long-tail category and it takes the last 5% (of the same long-tail category most of which should have been already reached) to bring diarrhoeal incidence down to less than 10%. If we can reach out to most of the long-tail category, probably the last 5% will shift in an accelerated manner because of herding effect. We do not have scientific evidence for how the last 5% will behave with respect to toilets, so why leave them out of programme targets? Why give up by not even planning to achieve the goal?

So, yes, I would say that we should aim at 100% ODF communities.

Warm regards,

Sowmya]]>
Health, hygiene and disability issues Thu, 16 Oct 2014 06:05:37 +0000
Re: New Lancet study concludes no assumed improvement from TSC (Total Sanitation Campaign, in Odisha, India) - by: joeturner http://forum.susana.org/forum/categories/26-health-hygiene-and-disability-issues/10437-new-lancet-study-concludes-no-assumed-improvement-from-tsc-total-sanitation-campaign-in-odisha-india#10554 http://forum.susana.org/forum/categories/26-health-hygiene-and-disability-issues/10437-new-lancet-study-concludes-no-assumed-improvement-from-tsc-total-sanitation-campaign-in-odisha-india#10554
I woud assume most people would think that was a dramatic health improvement. Are you saying it is not?

Finally, clearly 100% OD free villages have to be totally free 100% of the time. The problem to me appears to be that a small number of people who are still practicing unsafe sanitation adversely affect the health outcomes for everyone. Hence I think i would say that 95% OD free - perhaps even 99% - is not good enough. Have I understood your point correctly?]]>
Health, hygiene and disability issues Wed, 15 Oct 2014 19:29:48 +0000
Re: New Lancet study concludes no assumed improvement from TSC (Total Sanitation Campaign, in Odisha, India) - by: Sowmya http://forum.susana.org/forum/categories/26-health-hygiene-and-disability-issues/10437-new-lancet-study-concludes-no-assumed-improvement-from-tsc-total-sanitation-campaign-in-odisha-india#10553 http://forum.susana.org/forum/categories/26-health-hygiene-and-disability-issues/10437-new-lancet-study-concludes-no-assumed-improvement-from-tsc-total-sanitation-campaign-in-odisha-india#10553
David, the issue that the study is trying to address is whether having latrines has an effect on health outcomes. I can see that education can dramatically increase the use of the latrines, do you have figures which show that 95% use is enough to dramatically improve the health outcomes?

Please find below excerpt from page 37 (Box 3) of the 'Nirmal Bharat: Rural sanitation and hygiene policy 2012-2022' policy document:
A Rapid Assessment undertaken in Himachal Pradesh in 2005 revealed that in villages with ~30 per cent household toilet use, the incidence of diarrhea was reported as being around 40 per cent. Even in villages with 95 per cent household toilets, still reported around 25 per cent diarrheal incidence. Only open defecation free villages with 100 per cent usage have reported significant drop in diarrhea to less than 10%. In effect, even if a few individual households switch to using toilets, the overall risk of bacteriological contamination and incidence of disease continues to be high." The source is 'formative research by WSP - Knowledge Links for IEC Manual in Himachal Pradesh, 2005'.

There is little option but to aim for 100% ODF communities.

Warm regards,

Sowmya]]>
Health, hygiene and disability issues Wed, 15 Oct 2014 18:56:26 +0000
Re: New Lancet study concludes no assumed improvement from TSC (Total Sanitation Campaign, in Odisha, India) - by: Sowmya http://forum.susana.org/forum/categories/26-health-hygiene-and-disability-issues/10437-new-lancet-study-concludes-no-assumed-improvement-from-tsc-total-sanitation-campaign-in-odisha-india#10552 http://forum.susana.org/forum/categories/26-health-hygiene-and-disability-issues/10437-new-lancet-study-concludes-no-assumed-improvement-from-tsc-total-sanitation-campaign-in-odisha-india#10552 earlier thread where the lack of strong evidence linking Hindu religious beliefs and open defecation in India was discussed.

Generating correct and adequate scientific evidence:

Let’s look at possible religious beliefs-open defecation linkages from the perspective of generating scientific evidence. Statistical analysis of MIS-type data (such as the study by Spears) can bring out the inequalities in outcome (viz., development benefits that we aim for) based on some parameter (socio-cultural, economic, gender, other). In this case, a difference in outcomes was found between Hindu and Muslim population. However, it would be incorrect to immediately conclude that religious belief must the primary cause. While a religious belief could be a cause, it need not necessarily be so – and must be backed by valid and adequate scientific evidence before drawing a conclusion. This is particularly important because interventions are designed to pivot on “key causes” and incorrect identification of “key causes” can result in ineffective outcomes.

Therefore, we must address this question: what constitutes scientific evidence to support a hypothesis that a religious belief (Hindu or other religion) is currently affecting toilet-use amongst the target population?
  1. This question (though relevant for sanitation from intervention design and implementation perspective) comes under the discipline of cultural anthropology. Therefore, scientific evidence must be generated through applying research methods applicable for cultural anthropology (please see Wiki page on cultural anthropology for further details). While surveys are used in cultural anthropology, it must be supported by other ethnographic and other studies.
  2. The evidence must be adequate to support: (a) origin of belief ie., “OD is healthy / wholesome” comes from religion and (b) the belief persists because of religion and no other reason.

(a) Origin of belief: In this regard, excerpts from the Laws of Manu are inadequate to support origin of belief. It needs to be supported by appropriate and adequate evidence from applying anthropological research methods.

A suggestion: The body of religious beliefs in India is comprised of the formal scriptures (Vedas, vedangas, Laws of Manu, etc.,) as much as mythology, legends and folklore. In other words, mythology has as much importance as scriptures in the common man’s framework of religious and ethical beliefs. For instance, more people draw their set of beliefs from the Ramayan and Mahabharata compared to the Vedas and Laws of Manu.

To understand the above, it must be remembered that, till efforts for abolishment of the caste system gained critical mass (with the efforts of Raja Ram Mohan Roy and Swami Dayananda Saraswati), most of the scriptures were beyond the reach of the general masses. When people do not have knowledge of the scriptures, a belief can be sustained through generations, at best, as a superstition or through mythology (including legends and folklore). For instance, several gender rules in society can be sustained through mythology.

What would be interesting is if we can find legends or stories from mythology (not something obscure in layman’s knowledge – like what happened to Shvetaketu on his journey from Dwaraka to the land of the Nagas while carrying Krsna’s message would be an “obscure” story because most laypersons would not even know who is Shvetaketu) strongly upholding ‘OD is healthy / wholesome’ belief – even if it is not strong as ‘the ideal man is like Rama in the story of Ramayan’.

And, considering that quantitative studies have focused on large parts of India (whole of India / large parts of Northern India, etc.,), this myth upholding ‘OD is healthy / wholesome’ belief should be prevalent across such vast populace (instead of a legend about a deity particular to one or few contiguous villages).

A caveat here being that existence of a legend may not be a usual requirement to establish religious beliefs as the cause of current human action in anthropological studies (I have very little knowledge of anthropology) but just something I would look for given my knowledge (with all its imperfections, which should also be taken into account ) of India.

(b) the belief persists because of religion and no other reason: Human behaviour is influenced by several factors relating to society, including religious beliefs, cultural mores and economic priorities. To prove that OD preference is caused by religious belief, it is necessary to prove 1:1 correlation between religious beliefs and low toilet-use.

This requires a research finding that, for the same study population within the same study: (a) strongly positive association exists between OD preference and religious belief and (b) randomness / no association between OD preference and all other possible factors. In this context, we might also want to explore strength of association between religious beliefs and Knowledge-Attitude-Perceptions (KAP) interventions – for instance, do people hold on to their religious beliefs (even if it were to really exist) even after understanding the linkages between practice and health outcomes (eg., handwashing and diarrhoea).

Discussion on results from current quantitative studies:

I do not have the details of the surveys mentioned in the article, hence giving my views based on the excerpts from the article (excerpts in quotes below):

“A new household survey of nearly 23,000 north Indians offers more evidence, especially from Hindu households. Led by Diane Coffey, an economist at Princeton, it found that even among households with a working latrine, more than 40% reported that at least one family member preferred to defecate in the open. Those with a government-built toilet were especially likely to choose a bush instead.

In an unpublished parallel survey of Hindu-dominated villages in north India and Nepal, respondents lauded open defecation as wholesome, healthy and social. By contrast, latrines were seen as potentially impure, especially if near the home. Men often described them as for use only by women, the infirm and the elderly. In short, demand for latrines is constrained.

This suggests that the mere availability of government-built latrines will not end open defecation for decades yet. What is needed instead are public campaigns, in schools and in the media, to explain the health and economic benefits of using toilets and of better hygiene. Researchers found that only a quarter of rural householders understood that washing hands helps prevent diarrhoea.”

I find these sentences interesting:
  1. “... more than 40% reported that at least one family member preferred to defecate in the open” – does this mean that some members in the same family use toilets while others prefer OD? This is possible, if we draw from the other study mentioned in the article that “Men often described them as for use only by women, the infirm and the elderly”. If this was so, how can members of the same family have different toilet-use behavior if such behavior is a result of a religious belief (and the religious belief does not make gender differences in this respect)?
  2. “Men often described them as for use only by women, the infirm and the elderly” – given that scriptures generally require women to maintain the highest standards of purity, is it likely that when a religious belief is the dominant reason for toilet-use behavior, women would be the ones using the toilets “especially if near the home”?
  3. The statement about the government-built toilets is unclear. Did choice of technology, quality of construction, etc., have any impact? Did people who had toilets connected to municipal sewer lines have the same rates of toilet-use as those with other technologies? Was the complete sanitation chain analyzed for these households as well as the ease of operating and maintaining the toilets? Further questions remain.

On the whole, I reiterate that there is stronger evidence pointing to other factors resulting in low toilet-use than evidence demonstrating religious beliefs deterring toilet use in India. As always, my request is that we put people’s welfare and development at the forefront and so, in all controversial issues, we maintain a balanced view and review the scientific evidence based on which we make statements.

Warm regards,

Sowmya]]>
Health, hygiene and disability issues Wed, 15 Oct 2014 18:32:32 +0000
Re: Sanitation interventions during Ebola epidemic - by: Roslyn http://forum.susana.org/forum/categories/26-health-hygiene-and-disability-issues/10359-sanitation-interventions-during-ebola-epidemic?limit=12&start=24#10549 http://forum.susana.org/forum/categories/26-health-hygiene-and-disability-issues/10359-sanitation-interventions-during-ebola-epidemic?limit=12&start=24#10549
I am also a member of HIFA, and have been following their recent thematic discussion on Ebola entitled: “HIFA discussion on Ebola: How can we more effectively meet the information needs of frontline health workers and the general public?”

They are holding the upcoming four webinars which may be of interest:
  • 21st October: "Introduction: Response to learning and information needs for frontline health workers"
  • 23rd October: "The health system: supporting frontline health workers"
  • 28th October: "Community sensitization, mobilization and support; interactions with clients"
  • 30th October: "Data to support effective response and case management"
And are currently discussing the following thematic discussion questions on their d-group:
  • Question 1: What more can be done to ensure FLHWs are fully informed? Is there a role for SMS or short voice messages (e.g. for information and training)?
  • Question 2: FLHWs are part of the local system of care; how can their experience inform health officials so they can respond more effectively and quickly to specific patient and health worker needs?
  • Question 3: Can healthcare organizations design public information campaigns and use FLHWs to provide reliable actionable information for the general public on how to prevent Ebola and what to do in case of symptoms?
I have put together a summary of this SuSanA Forum discussion on Ebola to forward to HIFA, to contribute to their thematic discussion, and bring awareness that SuSanA is currently discussing Ebola from a sanitation perspective, and hopefully bring awareness of the connection to sanitation, as well as potential involvement of HIFA members who may be able to contribute additional information.

I have attached the summary document (also with a section of links to sanitation and Ebola) which I summarized based on this discussion topic (as of 15.10.2014), and focused around 5 questions which I felt have emerged from the posts of this discussion, and which I hope we can continue to discuss on in the forum as they all have a lot of room for expansion and information:

Question 1: What does sanitation have to do with Ebola?
Question 2: What information is available around the persistence of the Ebola virus in human faeces?
Question 3: What are some options for dealing with excreta and avoiding open defecation/ exposed faecal matter?
Question 4: Which factors need to be considered regarding handling of excreta?
Question 5: Which factors should be considered in the discussion of whether municipal sanitation workers at pump stations and at sewage treatment are at risk?


Please let me know if you have additional suggestions with forwarding this summary document on to HIFA. I hope that there may be some continued involvement and input from the sanitation sector in their thematic discussions and webinars, and likewise contributions from some of their members to the ongoing discussions here on SuSanA.
Thank you again for the information that has already been posted, and for additional information, links, articles etc. to come which highlight the role of sanitation in connection to Ebola.

Thank you,

Roslyn]]>
Health, hygiene and disability issues Wed, 15 Oct 2014 15:59:42 +0000
Re: New Lancet study concludes no assumed improvement from TSC (Total Sanitation Campaign, in Odisha, India) - by: shobana http://forum.susana.org/forum/categories/26-health-hygiene-and-disability-issues/10437-new-lancet-study-concludes-no-assumed-improvement-from-tsc-total-sanitation-campaign-in-odisha-india#10546 http://forum.susana.org/forum/categories/26-health-hygiene-and-disability-issues/10437-new-lancet-study-concludes-no-assumed-improvement-from-tsc-total-sanitation-campaign-in-odisha-india#10546
In my opinion, OD in India must be tackled with a multifactorial approach. I cannot see it as something associated with a Hindu tradition. Like the Attachment 1 says, the Manu law is 2000 years old and was valid during the time people had not invented toilets.
I cannot imagine villager telling that they prefer open defaecation because the Hindu -law says so. Lack of maintenance of the built toilets could be one reason. Community toilets need more awarness and education to make people understand that they have to treat the toilet as a part of their homes.

I found an interesting article in the internet explaining why India isn't able to solve this issue.

www.reuters.com/article/2014/09/03/us-ba...dUSKBN0GY1ST20140903

Sowmya here had pointed out a similar thing sometime back.

The study quotes another article, “toilets constructed or paid for by the government often remains unused or repurposed by Hindus” - this paints a starkly different picture compared to the fact only 10% do not want to use a toilet and only 2% repurposed the toilet – close to 2/3rds (41% + 22%) had poor unfinished installation or no superstructure as per a CMS 2010 Study cited in the Working Group Report on WATSAN for the XII Five Year Plan of the Government of India.


Regards,
Shobana]]>
Health, hygiene and disability issues Wed, 15 Oct 2014 12:10:28 +0000
Re: Sanitation interventions during Ebola epidemic - by: Sowmya http://forum.susana.org/forum/categories/26-health-hygiene-and-disability-issues/10359-sanitation-interventions-during-ebola-epidemic?limit=12&start=24#10543 http://forum.susana.org/forum/categories/26-health-hygiene-and-disability-issues/10359-sanitation-interventions-during-ebola-epidemic?limit=12&start=24#10543
I have largely focused on ‘basic science’ related information and included other initiatives which I thought might be of interest to SuSanA members. Further, I might have missed some information resources posted on HIFA2015. My sincere apologies for any omission and please let me know of the same so I can include it in this list. Additionally, much of the descriptive text is copy-pasted from the email messages on HIFA2015 but I have not placed them within quotes, as required under anti-plagiarism guidelines, to make the content more readable.

A special thanks. Access to scientific publications is a much-debated topic in the health sector with strong arguments present for both sides of the debate (subscription versus open access). We owe a special thanks to the several journals and organizations that have responded to the Ebola outbreak by giving open access to Ebola-related scientific information despite the ongoing debate. And, I am sure all of you will be happy to know that UpToDate gave open access to two important articles after Dr. Neil, Moderator, HIFA2015, wrote to them.

Warm regards,

Sowmya



Ebola-related information resources:

I. WHO’s Ebola-related information & information for the public:
1. Information from WHO: URL: www.who.int/csr/disease/ebola/en/ for WHO website on Ebola, www.who.int/csr/disease/ebola/faq-ebola/en/ for WHO FAQs on Ebola and www.who.int/mediacentre/factsheets/fs103/en/ for media FactSheet on Ebola.
2. Ebola topic pages for the general public are available from MedlinePlus in English (www.nlm.nih.gov/medlineplus/ebola.html) and in Spanish (www.nlm.nih.gov/medlineplus/spanish/ebola.html).

II. Open science participative programs:

1. OpenIDEO fighting Ebola in collaboration with the Grand Challenge for Development. URL: openideo.com/content/fighting-ebola

III. Ebola-related information from national public health agencies:

1. Public Health Agency of Canada (PHAC): www.phac-aspc.gc.ca/lab-bio/res/psds-ftss/ebola-eng.php
2. US Center for Disease Control (US CDC): www.cdc.gov/vhf/ebola/
3. European Center for Disease Control (EU ECDC): www.ecdc.europa.eu/en/healthtopics/ebola...eak-west-africa.aspx
4. Informative website from South Africa with maps & graphs: www.ebola.org.za/

IV. Ebola-related information repositories and other information access programs:

1. Medbox: www.medbox.org/ebola-toolbox/viral-haemo...ers/preview?q=manson
2. New platform for Ebola resources: ebolacommunicationnetwork.org/ The site is coordinated by the USAID-funded Health Communication Capacity Collaborative and includes information resources for the general public, health workers and 'leaders'. For example, you can see several infographics of Ebola here:
ebolacommunicationnetwork.org/latest-materials/#!/resource_types=76 The collection includes 113 items in English, 12 in French and 2 in Portuguese. Please see footnote for more detailed description.
3. Please see the guide "Ebola Outbreak 2014: Information Resources" at disasterinfo.nlm.nih.gov/dimrc/ebola_2014.html. The guide is frequently updated and now has a section on "Situation Reports" and has added links to "Free Resources from Publishers."
4. Disaster Lit continues to add guidelines from CDC, World Health Organization and others; reports; government documents; factsheets and more. disasterlit.nlm.nih.gov/search/?searchTe...11&search=Search
5. The National Library of Medicine (NLM) Emergency Access Initiative, eai.nlm.nih.gov/, is available through October 17 for free access to 650 journals, 4,000 reference books and online databases to healthcare professionals and libraries affected by disasters. It serves as a temporary collection replacement and/or supplement for libraries affected by disasters that need to continue to serve medical staff and affiliated users. It is also intended for medical personnel responding to the specified disaster. EAI is not an open access collection. It is only intended for those affected by the disaster or assisting the affected population. If you know of a library or organization involved in healthcare efforts in response to the Ebola outbreak, please let them know of this service. Virology, epidemiology, and infectious disease textbooks have been the most popular.
6. The "Virus Variation: Ebolavirus Resource" for genome and protein sequences is now available from the NLM National Center for Biotechnology Information. www.ncbi.nlm.nih.gov/genome/viruses/variation/ebola/
7. Documents collated by One World Medical Network. URL: www.case.io/Documents-about-Ebola-LJ15xk...jcFSMGnd1JeExrutghEC You can view and download the documents with any computer, laptop, tablet PC and smart phone which is connected to the internet. Case.io works in areas with slow internet connections. Share the documents by using "send case" and add as many email addresses you want. You can use the platform free of charge for distribution of any documents concerning Ebola. Please send email to This e-mail address is being protected from spambots. You need JavaScript enabled to view it if you have further questions or need any further help.
8. Bioline platform (http://www bioline.org br) – research publications from the global south. All articles from journals published in 16 developing countries are free to all users. In the first 6 days of October, 115,082 full text articles were downloaded, showing that research from Africa and the other partner developing countries is very well used and visible world wide. Bioline has been operating for over 20 years and is recognised as a valuable resource for the distribution of quality research information from the developing world. Such data is essential for the advancement of science, since without the unique information from such countries, the global picture is incomplete.
9. HINARI: HINARI (http://extranet.who.int/hinari/en/journals.php) continues to play a major role. HINARI Programme set up by WHO together with major publishers, enables low- and middle- income countries to gain access to one of the world's largest collections of biomedical and health literature. Up to 13,000 journals (in 30 different languages), up to 29,000 e-books, up to 70 other information resources are now available to health institutions in more than 100 countries, areas and territories benefiting many thousands of health workers and researchers, and in turn, contributing to improve world health.
10. Search PubMed.gov Publications on Ebola: www.ncbi.nlm.nih.gov/pubmed/?term=ebola
11. Search ClinicalTrials.gov for Ebola: clinicaltrials.gov/ct2/results?term=ebola&Search=Search
12. Resources from Disaster Lit (including info from CDC and WHO): 1.usa.gov/1oZpqGK

V. Scientific journals that have made their Ebola content open access:

1. Lancet’s Ebola Resource Centre URL: www.thelancet-ebola.com. You are also encouraged to share your front-line experiences at www.thelancet-ebola.com
2. The New England Journal of Medicine (NEJM) Ebola Resources: www.nejm.org/page/ebola-outbreak
3. Two articles from UpToDate: www.uptodate.com/contents/diagnosis-and-...?source=related_link and www.uptodate.com/contents/epidemiology-p...rburg-virus-disease.
4. Global Health Knowledge Base newsletter (September 2014, Issue 56) – Ebola is now FREE online at: dmtrk.net/VZZ-1Q40V-4AY19T-P7X5S-1/c.aspx including a week's free trial to the Global Health database.
5. Content from CellPress: ebola.thelancet.com/cpress
6. Elsevier Virology articles: ebola.thelancet.com/elsevier-articles
7. Journals from Oxford University Press Publications on Ebola: www.oxfordjournals.org/en/our-journals/m...nd-health/ebola.html

VI. Ebola-related textbook content that has been made open access:

1. Chapter on Ebola and Marburg viruses in 18th Edition of Harrison’s ‘Principles of internal medicine’ URL: accessmedicine.mhmedical.com/content.asp...p;sectionid=40726956

VII. Universities and organizations that have specific webpages of Ebola related content:

1. Bioethics Research Library at Georgetown University: bioethics.georgetown.edu/ebola/ (Articles describing key health sector discussions on Ebola)
2. Center for Infectious Disease Research and Policy (CIDRAP), University of Minnesota: www.cidrap.umn.edu/infectious-disease-topics/ebola
3. Doctors Without Borders URL: www.doctorswithoutborders.org/our-work/medical-issues/ebola
4. The Network for Public Health Law – Primer: Emergency Legal Preparedness Concerning Ebola Virus Disease: www.networkforphl.org/resources_collecti..._ebola_virus_disease
5. University of Pittsburgh Medical Center (UPMC) UPMC Center for Health Security – SEEK Forum: seekebolainfo.com/

VIII. Information posted by C4D Network (viz., Communication For Development Network)

1. @HealthCommCap: Infographics, prevention tips, key messages + more #health communication materials specific to #Ebola: bit.ly/1t09mbB
2. @claireekt: Register now - free teleclass on #ebola by @WHO expert @Sergey_Eremin 16 Sept 2014tinyurl.com/pdbs57h
3. @CDACN: Providing accurate info about #Ebola in W Africa. Listen 2 @BBCAfrica shows bit.ly/1kV8fed
4. @PStollICRC: #commisaid #ebola: our friends of @BritishRedCross organise a #mapthon to #map4ebola w/@hotosm & @TheMissingMaps - www.eventbrite.co.uk/e/humanitarian-open...-tickets-12691180663 ...
5. @HealthCommCap: Social and behavior change communication resources on #Ebola in the Health COMpass:bit.ly/1sYF2hU " so useful!
6. @BexThomas92 : Take a look at @OnOurRadar's interactive timeline of the story of Ebola, from the perspective of affected communities bit.ly/ebolatimeline
7. @GSMAm4d check out our interactive timeline compiled by SMS reports by our citizen journalists around Sierra Leone www.tiki-toki.com/timeline/entry/315694/...the-Ebola-Epicentre/ ...
8. @HealthCommCap : Together We Can Prevent Ebola by @CDCgov; project materials/examples #Ebola social and behavior change communication bit.ly/1sYF2hU
9. @HealthCommCap : Communication is critical in stemming the #Ebola outbreak; list of publicly available com. materials and resources: bit.ly/1sYF2hU

IX. Media initiatives posted by C4D Network:

1. @bbcmediaaction: New #radio shows join the fight against #Ebola in #SierraLeone: latest blog from @musasangarie in Freetown bbc.in/1t7KfUo #mediadev
2. @bbcmediaaction: Listen: a nurse who survived #Ebola and kept her family safe in #SierraLeone. From our new radio show bbc.in/1lkRlWz #c4d #commisaid
3. @bbcmediaaction: How radio is responding to #Ebola in #SierraLeone: our Africa director Caroline Ford on @bbc_world bbc.in/1lvL7n8 #commisaid
4. @bbcmediaaction: Uplifting account of a nurse's recovery from #ebola in Sierra Leone read:bbc.in/1qUfMXE & listen: bbc.in/1lt9T7k

X. Other initiatives and resources posted by C4D Network:

1. @K4Health: How to Make a Hit Song About #Ebola - theatln.tc/1C27y8j @TheAtlantic
2. @CDACN: Read how @TranslatorsWB helping to save lives with Ebola information in 4 local African languagesbit.ly/1BKx5CM
3. @Internews is working to bridge the gap in information about Ebola in Guinea, Sierra Leone + Liberiagoto.gg/projects/internews-west-africa/updates/ ...
4. Visit C4D Network at: c4dnetwork.ning.com/?xg_source=msg_mes_network

Volunteering:
If you are aware of medical professionals interested in volunteering in response to the Ebola outbreak, please refer them to the following:
U.S. Agency for International Development is registering expressions of interest and contact information from medical professionals. Contact information will be shared with U.S. government and non-governmental organizations.
www.usaid.gov/ebola/volunteers

CDC Safety Training Course for Healthcare Workers Going to West Africa in Response to the 2014 Ebola Outbreak
www.cdc.gov/vhf/ebola/hcp/safety-trainin...x.html?s_cid=cs_3923

Ebola Communication Network (ECN):
(accessible at URL www.ebolacommunicationnetwork.org)
The ECN is an online collection of Ebola resources, materials and tools from and for the global health community.

The ECN (www.ebolacommunicationnetwork.org) is populated with more than 120 resources, including not only SBCC materials like posters, brochures and infographics, but also Demographic and Health Surveys of affected regions, customized maps and peer-reviewed journal articles. The site is responsive to mobile devices and optimized for low bandwidth situations. It includes an RSS feed of Ebola-related news that is updated in real time.

ECN’s faceted search allows users to find materials based on language, type (e.g., public service announcements, posters, and fact sheets), topic (e.g., prevention, treatment, safe burial practices), audience (e.g., community health workers, governments, health care providers) and any other facets deemed necessary. Users can also upload their own materials, which are posted after a brief review process.

ECN continues to expand as new resources are added each day. Because it is built on an open-source platform, ECN can be enhanced with a host of new features as the crisis unfolds.

Those working in the fight against Ebola can use ECN to search and share resources, and help build the collection by uploading quality communication materials they have developed for use in the field.

The ECN was developed by the Health Communication Capacity Collaborative (HC3) with input from UNICEF, CDC, USAID, IFRC and WHO. HC3 is a USAID-funded project designed to strengthen developing country capacity to implement state-of-the-art health communication programs.]]>
Health, hygiene and disability issues Wed, 15 Oct 2014 06:09:40 +0000