When water quality crises drive change: a comparative analysis of the policy processes behind major water contamination events

The occurrence of major water contamination events across the world have been met with varying levels of policy responses. Arsenic—a priority water contaminant globally, occurring naturally in groundwater, causing adverse health effects—is widespread in Bangladesh. However, the policy response has been slow, and marked by ineffectiveness and a lack of accountability. We explore the delayed policy response to the arsenic crisis in Bangladesh through comparison with water contamination crises in other contexts, using the Multiple Streams Framework to compare policy processes. These included Escherichia coli O157:H7 and Campylobacter in Walkerton, Canada; lead and Legionella in Flint, Michigan, USA; and chromium-6 contamination in Hinkley, California, USA. We find that, while water contamination issues are solvable, a range of complex conditions have to be met in order to reach a successful solution. These include aspects of the temporal nature of the event and the outcomes, the social and political context, the extent of the public or media attention regarding the crisis, the politics of visibility, and accountability and blame. In particular, contaminants with chronic health outcomes, and longer periods of subclinical disease, lead to smaller policy windows with less effective policy changes. Emerging evidence on health threats from drinking water contamination raise the risk of new crises and the need for new approaches to deliver policy change

Learning opportunities for sanitation improvements in informal settlements of East African cities

Progress towards full sanitation coverage in urban areas is slow, with one of the big challenges in East Africa and many other areas being reaching the large proportion who live in informal settlements. The unique characteristics of informal settlements impose varying challenges in installing adequate sanitation facilities. A comparative case study using mixed methods conducted in three East African cities revealed varied perceptions of the residents on barriers hindering the process of toilet installation. Lack of money, topography, lack of space, siting on marginal land, difficult to access sanitation material and services and lack of information were perceived as barriers by residents, but differed between cities. There are different examples of successful strategies to tackle the barriers to sanitation in each city and these offer some opportunities for each of the study cities, as well as other cities with similar challenges, to learn how the same challenges are tackled elsewhere

Metagenomic next-generation sequencing of samples from pediatric febrile illness in Tororo, Uganda.

Febrile illness is a major burden in African children, and non-malarial causes of fever are uncertain. In this retrospective exploratory study, we used metagenomic next-generation sequencing (mNGS) to evaluate serum, nasopharyngeal, and stool specimens from 94 children (aged 2-54 months) with febrile illness admitted to Tororo District Hospital, Uganda. The most common microbes identified were Plasmodium falciparum (51.1% of samples) and parvovirus B19 (4.4%) from serum; human rhinoviruses A and C (40%), respiratory syncytial virus (10%), and human herpesvirus 5 (10%) from nasopharyngeal swabs; and rotavirus A (50% of those with diarrhea) from stool. We also report the near complete genome of a highly divergent orthobunyavirus, tentatively named Nyangole virus, identified from the serum of a child diagnosed with malaria and pneumonia, a Bwamba orthobunyavirus in the nasopharynx of a child with rash and sepsis, and the genomes of two novel human rhinovirus C species. In this retrospective exploratory study, mNGS identified multiple potential pathogens, including 3 new viral species, associated with fever in Ugandan children

Risk factors for human brucellosis in northern Tanzania

Little is known about the epidemiology of human brucellosis in sub-Saharan Africa. This hampers prevention and control efforts at the individual and population levels. To evaluate risk factors for brucellosis in northern Tanzania, we conducted a study of patients presenting with fever to two hospitals in Moshi, Tanzania. Serum taken at enrollment and at 4–6 week follow-up was tested by Brucella microagglutination test. Among participants with a clinically compatible illness, confirmed brucellosis cases were defined as having a ≥ 4-fold rise in agglutination titer between paired sera or a blood culture positive for Brucella spp., and probable brucellosis cases were defined as having a single reciprocal titer ≥ 160. Controls had reciprocal titers < 20 in paired sera. We collected demographic and clinical information and administered a risk factor questionnaire. Of 562 participants in the analysis, 50 (8.9%) had confirmed or probable brucellosis. Multivariable analysis showed that risk factors for brucellosis included assisting goat or sheep births (Odds ratio [OR] 5.9, 95% confidence interval [CI] 1.4, 24.6) and having contact with cattle (OR 1.2, 95% CI 1.0, 1.4). Consuming boiled or pasteurized dairy products was protective against brucellosis (OR 0.12, 95% CI 0.02, 0.93). No participants received a clinical diagnosis of brucellosis from their healthcare providers. The under-recognition of brucellosis by healthcare workers could be addressed with clinician education and better access to brucellosis diagnostic tests. Interventions focused on protecting livestock keepers, especially those who assist goat or sheep births, are needed

Risk factors for human acute leptospirosis in northern Tanzania

Introduction: Leptospirosis is a major cause of febrile illness in Africa but little is known about risk factors for human infection. We conducted a cross-sectional study to investigate risk factors for acute leptospirosis and Leptospira seropositivity among patients with fever attending referral hospitals in northern Tanzania. Methods: We enrolled patients with fever from two referral hospitals in Moshi, Tanzania, 2012–2014, and performed Leptospira microscopic agglutination testing on acute and convalescent serum. Cases of acute leptospirosis were participants with a four-fold rise in antibody titers, or a single reciprocal titer ≥800. Seropositive participants required a single titer ≥100, and controls had titers <100 in both acute and convalescent samples. We administered a questionnaire to assess risk behaviors over the preceding 30 days. We created cumulative scales of exposure to livestock urine, rodents, and surface water, and calculated odds ratios (OR) for individual behaviors and for cumulative exposure variables. Results: We identified 24 acute cases, 252 seropositive participants, and 592 controls. Rice farming (OR 14.6), cleaning cattle waste (OR 4.3), feeding cattle (OR 3.9), farm work (OR 3.3), and an increasing cattle urine exposure score (OR 1.2 per point) were associated with acute leptospirosis. Conclusions: In our population, exposure to cattle and rice farming were risk factors for acute leptospirosis. Although further data is needed, these results suggest that cattle may be an important source of human leptospirosis. Further investigation is needed to explore the potential for control of livestock Leptospira infection to reduce human disease

Potential predictability of the Ethiopian summer rains: understanding local variations and their implications for water management decisions

Understanding the influence of large-scale oceanic and atmospheric variability on rainfall over Ethiopia has huge potential to improve seasonal forecasting and inform crucial water management decisions at local levels, where data is available at appropriate scales for decision makers. In this study, drivers of Ethiopia's main rainy season, July–September (JAS), are investigated using correlation analysis with sea surface temperature (SST). The analy- sis showed local spatial variations in the drivers of JAS rainfall. Moreover, the analysis revealed strong correlation between March to May (MAM) SST and JAS rainfall in particular regions. In addition to the influence of SSTs, we highlighted one of the mechanisms explaining the regional pattern of SST influence on Ethiopian rainfall, the East African Low-Level Jet. Moreover, examining the occurrence of large-scale phenomena provided additional infor- mation, with very strong ENSO and positive IOD events associated with drier conditions in most part of Ethiopia. A sub-national analysis, focused at a scale relevant for water managers, on the Awash basin, highlighted two dis- tinct climate zones with different relationships to SSTs. June was not included as part of the rainy season as in some areas June is a hot, dry month between rainy seasons and in others it can be used to update sub-seasonal forecasts with lead time of one month for JAS rainfall. This highlights the importance of understanding locally rel- evant climate systems and ensuing sub-seasonal to seasonal forecasts are done at the appropriate scale for water management in the complex topography and climatology of Ethiopia

Tryptophan-like fluorescence as a measure of microbial contamination risk in groundwater

Microbial water quality is frequently assessed with a risk indicator approach that relies on Escherichia coli. Relying exclusively on E. coli is limiting, particularly in low-resource settings, and we argue that risk assessments could be improved by a complementary parameter, tryptophan-like fluorescence (TLF). Over two campaigns (June 2016 and March 2017) we sampled 37 water points in rural Kwale County, Kenya for TLF, E. coli and thermotolerant coliforms (total n = 1,082). Using three World Health Organization defined classes (very high, high, and low/intermediate), risk indicated by TLF was not significantly different from risk indicated by E. coli (p=0.85). However, the TLF and E. coli risk classifications did show disagreement, with TLF indicating higher risk for 14% of samples and lower risk for 13% of samples. Comparisons of duplicate/replicate results demonstrated that precision is higher for TLF (average relative percent difference of duplicates = 14%) compared to culture-based methods (average RPD of duplicates >= 26%). Additionally, TLF sampling is more practical because it requires less time and resources. Precision and practicality make TLF well-suited to high-frequency sampling in low resource contexts. Interpretation and interference challenges are minimised when TLF is measured in groundwaters, which typically have low dissolved organic carbon, relatively consistent temperature, negligible turbidity and pH between 5 and 8. TLF cannot be used as a proxy for E. coli on an individual sample basis, but it can add value to groundwater risk assessments by improving prioritization of sampling and by increasing understanding of spatiotemporal variability

The Healthy Lifestyles Programme (HeLP), a novel school-based intervention to prevent obesity in school children: study protocol for a randomised controlled trial

Background: Over the last three decades there has been a substantial increase in the proportion of children who are overweight or obese. The Healthy Lifestyles Programme (HeLP) is a novel school-based intervention, using highly interactive and creative delivery methods to prevent obesity in children. Methods/Design: We describe a cluster randomised controlled trial to evaluate the effectiveness and cost effectiveness of HeLP. The intervention has been developed using intervention mapping (involving extensive stakeholder involvement) and has been guided by the Information, Motivation, Behavioural Skills model. HeLP includes creating a receptive environment, drama activities, goal setting and reinforcement activities and runs over three school terms. Piloting showed that 9 to 10 year olds were the most receptive and participative. This study aims to recruit 1,300 children from 32 schools (over half of which will have ≥19% of pupils eligible for free school meals) from the southwest of England. Participating schools will be randomised to intervention or control groups with baseline measures taken prior to randomisation. The primary outcome is change in body mass index standard deviation score (BMI SDS) at 24 months post baseline. Secondary outcomes include, waist circumference and percent body fat SDS and proportion of children classified as overweight or obese at 18 and 24 months and objectively measured physical activity and food intake at 18 months. Between-group comparisons will be made using random effects regression analysis taking into account the hierarchical nature of the study design. An economic evaluation will estimate the incremental cost-effectiveness of HeLP, compared to control, from the perspective of the National Health Service (NHS)/third party payer. An in-depth process evaluation will provide insight into how HeLP works, and whether there is any differential uptake or engagement with the programme. Discussion: The results of the trial will provide evidence on the effectiveness and cost effectiveness of the Healthy Lifestyles Programme in affecting the weight status of children