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      Impact of an intervention to improve pit latrine emptying practices in low income urban neighborhoods of Maputo, Mozambique

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          Abstract

          Safe fecal sludge management (FSM) – the hygienic emptying, transport, and treatment for reuse or disposal of fecal sludge – is an essential part of safely managed sanitation, especially in towns and cities in low- and middle-income countries with limited sewer coverage. The need for safe and affordable FSM services has become more acute as cities grow and densify. Hygienic pit-emptying uses equipment that limits direct human exposure with fecal sludge and hygienic transport conveys fecal sludge offsite for treatment. We evaluated whether a program of on-site sanitation infrastructure upgrades and FSM capacity development in urban Maputo, Mozambique resulted in more hygienic pit-emptying and safe transportation of fecal sludge. We compared reported emptying practices among multi-household compounds receiving sanitation upgrades with control compounds, both from the Maputo Sanitation (MapSan) trial at 24–36 months after the intervention. Intervention compounds (comprising 1–40 households, median = 3) received a subsidized pour-flush latrine to septic tank system that replaced an existing shared latrine; control compounds continued using existing shared latrines. We surveyed compound residents and analyzed available municipal data on FSM in the city. Due to the recent construction of the intervention, emptying was more frequent in control compounds: 5.6% (15/270) of intervention compounds and 30% (74/247) of controls had emptied their on-site sanitation system in the previous year. Among those compounds which had emptied a sanitation facility in the previous year, intervention compounds were 3.8 (95% CI: 1.4, 10) times more likely to have to done so hygienically. Results suggest that the construction of subsidized pour-flush sanitation systems increased hygienic emptying of fecal sludge in this setting. Further gains in hygienic emptying in urban Maputo may be limited by affordability and physical accessibility.

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          Estimates of the global, regional, and national morbidity, mortality, and aetiologies of diarrhoea in 195 countries: a systematic analysis for the Global Burden of Disease Study 2016

          Summary Background The Global Burden of Diseases, Injuries, and Risk Factors Study (GBD) 2016 provides an up-to-date analysis of the burden of diarrhoea in 195 countries. This study assesses cases, deaths, and aetiologies in 1990–2016 and assesses how the burden of diarrhoea has changed in people of all ages. Methods We modelled diarrhoea mortality with a Bayesian hierarchical modelling platform that evaluates a wide range of covariates and model types on the basis of vital registration and verbal autopsy data. We modelled diarrhoea incidence with a compartmental meta-regression tool that enforces an association between incidence and prevalence, and relies on scientific literature, population representative surveys, and health-care data. Diarrhoea deaths and episodes were attributed to 13 pathogens by use of a counterfactual population attributable fraction approach. Diarrhoea risk factors are also based on counterfactual estimates of risk exposure and the association between the risk and diarrhoea. Each modelled estimate accounted for uncertainty. Findings In 2016, diarrhoea was the eighth leading cause of death among all ages (1 655 944 deaths, 95% uncertainty interval [UI] 1 244 073–2 366 552) and the fifth leading cause of death among children younger than 5 years (446 000 deaths, 390 894–504 613). Rotavirus was the leading aetiology for diarrhoea mortality among children younger than 5 years (128 515 deaths, 105 138–155 133) and among all ages (228 047 deaths, 183 526–292 737). Childhood wasting (low weight-for-height score), unsafe water, and unsafe sanitation were the leading risk factors for diarrhoea, responsible for 80·4% (95% UI 68·2–85·0), 72·1% (34·0–91·4), and 56·4% (49·3–62·7) of diarrhoea deaths in children younger than 5 years, respectively. Prevention of wasting in 1762 children (95% UI 1521–2170) could avert one death from diarrhoea. Interpretation Substantial progress has been made globally in reducing the burden of diarrhoeal diseases, driven by decreases in several primary risk factors. However, this reduction has not been equal across locations, and burden among adults older than 70 years requires attention. Funding Bill & Melinda Gates Foundation.
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            Contingent Valuation: From Dubious to Hopeless

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              Risk factors for childhood enteric infection in urban Maputo, Mozambique: A cross-sectional study

              Background Enteric infections are common where public health infrastructure is lacking. This study assesses risk factors for a range of enteric infections among children living in low-income, unplanned communities of urban Maputo, Mozambique. Methods & findings We conducted a cross-sectional survey in 17 neighborhoods of Maputo to assess the prevalence of reported diarrheal illness and laboratory-confirmed enteric infections in children. We collected stool from children aged 1–48 months, independent of reported symptoms, for molecular detection of 15 common enteric pathogens by multiplex RT-PCR. We also collected survey and observational data related to water, sanitation, and hygiene (WASH) characteristics; other environmental factors; and social, economic, and demographic covariates. We analyzed stool from 759 children living in 425 household clusters (compounds) representing a range of environmental conditions. We detected ≥1 enteric pathogens in stool from most children (86%, 95% confidence interval (CI): 84–89%) though diarrheal symptoms were only reported for 16% (95% CI: 13–19%) of children with enteric infections and 13% (95% CI: 11–15%) of all children. Prevalence of any enteric infection was positively associated with age and ranged from 71% (95% CI: 64–77%) in children 1–11 months to 96% (95% CI: 93–98%) in children 24–48 months. We found poor sanitary conditions, such as presence of feces or soiled diapers around the compound, to be associated with higher risk of protozoan infections. Certain latrine features, including drop-hole covers and latrine walls, and presence of a water tap on the compound grounds were associated with a lower risk of bacterial and protozoan infections. Any breastfeeding was also associated with reduced risk of infection. Conclusions We found a high prevalence of enteric infections, primarily among children without diarrhea, and weak associations between bacterial and protozoan infections and environmental risk factors including WASH. Findings suggest that environmental health interventions to limit infections would need to be transformative given the high prevalence of enteric pathogen shedding and poor sanitary conditions observed. Trial registration ClinicalTrials.gov NCT02362932
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                Author and article information

                Contributors
                Journal
                Int J Hyg Environ Health
                Int J Hyg Environ Health
                International Journal of Hygiene and Environmental Health
                Urban & Fischer
                1438-4639
                1618-131X
                1 May 2020
                May 2020
                : 226
                : 113480
                Affiliations
                [a ]Civil and Environmental Engineering, Georgia Institute of Technology, Atlanta, GA, USA
                [b ]Department of Disease Control, London School of Hygiene and Tropical Medicine, London, UK
                [c ]Ministério da Saúde, Instituto Nacional de Saúde Maputo, Maputo, Mozambique
                Author notes
                []Corresponding author. Civil and Environmental Engineering, Georgia Institute of Technology, 311, Ferst Drive, Atlanta, GA, 30332, USA. joe.brown@ 123456ce.gatech.edu
                Article
                S1438-4639(19)31026-0 113480
                10.1016/j.ijheh.2020.113480
                7184672
                32086016
                6c9af611-7820-4826-bd9a-9a5c9723b781
                © 2020 The Authors

                This is an open access article under the CC BY license (http://creativecommons.org/licenses/by/4.0/).

                History
                : 15 November 2019
                : 3 February 2020
                : 3 February 2020
                Categories
                Article

                fecal sludge management,hygienic pit latrine emptying,on-site sanitation,pour-flush latrines,fecal sludge transport,sanitation intervention

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