Graeme Prentice-Mott’s research while affiliated with Centers for Disease Control and Prevention and other places

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Publications (10)


Hand Hygiene Knowledge and Hand Dirtiness Assessment to Inform Alcohol-Based Hand Rub Appropriateness in Community Settings in Uganda and Kenya
  • Article

December 2024

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5 Reads

The American journal of tropical medicine and hygiene

Christiana Hug

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Evelyn Makena Mugambi

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[...]

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During the coronavirus disease 2019 pandemic, alcohol-based hand rub (ABHR) availability and use increased as a prevention measure. ABHR is a convenient, effective way to kill microbes on hands but is hampered by the presence of organic material, whereas handwashing with water and soap (HWWS) can physically remove microbes and dirt. Although ABHR is preferred in most health care settings, the suitability of ABHR use in community settings has not been measured. We compared characteristics between community members and health care personnel (HCP) to inform considerations for promoting ABHR in community settings. We included data from community locations and health care facilities in Kenya and Uganda collected between 2021 and 2022. Hand dirtiness swabs were measured using the Quantitative Personal Hygiene Assessment Tool (qPHAT), a visual scale where 0 is very visibly dirty and 10 is no visible dirt. Participants were also asked about the appropriate method to use when hands were visibly dirty. Hand swabs were collected from HCP and community members. Both groups had median qPHAT scores of five. Neither the adjusted odds of having a qPHAT score less than or equal to five (1.4, 95% CI: 0.8–2.2) nor the adjusted odds of responding correctly to the knowledge question (0.8, 95% CI: 0.4–1.4) differed significantly by setting. People in community settings may, therefore, have comparable hand dirtiness and knowledge of appropriate hand hygiene practices to use ABHR as a HWWS complement. Further investigation into guidance and use of supportive messaging should be considered as completed elsewhere.


Fig. 1 | Map of shared toilet sites, Kisumu, Kenya. Locations of toilet sites are shown by dots, with colors by type of site. Streets, buildings, and water features retrieved from https://www.openstreetmap.org. Map created using R version 4.2.1 and the 'sf' package.
ATP-based assessments of recent cleaning and disinfection for high-touch surfaces in low-resource shared toilets
  • Article
  • Full-text available

September 2024

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23 Reads

npj Clean Water

Quality improvements and reduction of disease risk for low-resource shared sanitation facilities require cleanliness assessment approaches that are both rigorous and practical. Using Adenosine Triphosphate (ATP) bioluminescence testing, we assessed contamination on high-touch (HT) surfaces (inner door handles) at 32 shared toilet sites in Kisumu, Kenya. In public toilets, contamination was lowest after cleaning and disinfection (C&D) with 0.5% chlorine solution (adjusted difference in mean log 10 Relative Light Units per 100 cm ² (aDiff): −1.61; CI: −2.43, −0.59), followed by C&D with 0.1% chlorine solution (aDiff: −1.16; CI: −1.77, −0.55). ATP levels were not associated with overall observable toilet cleanliness and had poor agreement with visually assessed HT surface cleanliness. Our findings demonstrate the utility of this field-feasible method for detecting the impact of recent C&D in low-resource shared toilets, a novel setting for ATP cleanliness testing, while also highlighting the importance of using effective C&D procedures and addressing HT surfaces within cleaning protocols.

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Study flow diagram of installation of SaTo pans in healthcare facility pit latrines and assessment visits.
Odds ratio of patient acceptability (a) and prevalence ratio of latrine conditions (b) (fly, odour, puddle or faeces) at endline to baseline, by intervention and control groups.
Evaluation of SaTo pans as a new latrine technology in Kisumu County healthcare facilities, Kenya

November 2023

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87 Reads

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1 Citation

Objectives Innovations to improve public sanitation facilities, especially in healthcare facilities (HCFs) in low‐income countries, are limited. SaTo pans represent novel, largely untested, modifications to reduce odour and flies and improve acceptability of HCF sanitation facilities. We conducted a pilot project to evaluate acceptability, cleanliness, flies and odour within latrines in 37 HCFs in Kisumu, Kenya, randomised into intervention (SaTo pan modifications) and control arms by sub‐county and HCF level. Methods At baseline (pre‐intervention) and endline (>3 months after completion of SaTo pan installations in latrines in intervention HCFs), we surveyed users, cleaners and in‐charges, observed odour and cleanliness, and assessed flies using fly tape. Unadjusted difference‐in‐difference analysis compared changes from baseline to endline in patient‐reported acceptability and observed latrine conditions between intervention and control HCFs. A secondary assessment compared patient‐reported acceptability following use of SaTo pan versus non‐SaTo pan latrines within intervention HCFs. Results Patient‐reported acceptability of latrines was higher following the intervention (baseline: 87%, endline: 96%, p = 0.05). However, patient‐reported acceptability was also high in the control arm (79%, 86%, p = 0.34), and the between‐arm difference‐in‐difference was not significant. Enumerator‐observed odour declined in intervention latrines (32%–14%) compared with controls (36%–51%, difference‐in‐difference ratio: 0.32, 95% confidence interval: 0.12–0.84), but changes in flies, puddling of urine and visible faeces did not differ between arms. In the secondary assessment, fewer intervention than control latrines had patient‐reported flies (0% vs. 26%) and odour (18% vs. 50%), and reported satisfaction was greater. Most cleaners reported dropholes and floors were easier to clean in intervention versus controls; limited challenges with water for flushing were reported. Conclusions Our results suggest SaTo pans may be acceptable by cleaners and users and reduce odour in HCF sanitation facilities, though challenges exist and further evaluation with larger sample sizes is needed.


Access to and Use of Hand Hygiene Resources during the COVID-19 Pandemic in Two Districts in Uganda, January–April 2021

August 2023

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39 Reads

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1 Citation

The American journal of tropical medicine and hygiene

To understand access to and use of hand hygiene in healthcare facilities (HCFs) and community locations during the COVID-19 pandemic, we evaluated factors associated with hand hygiene in 60 priority HCFs and community locations in two border districts in Uganda. We assessed water and hand hygiene resource availability and observed hand hygiene practice by staff or patrons. Regression modeling estimated factors associated with the availability or use of hand hygiene. In HCFs, most inpatient (61%), outpatient (71%), and laboratory or staff (90%) rooms contained hand hygiene materials. Only 38% of community locations had hand hygiene materials at all entrances and exits, 35% of congregation areas had hand hygiene materials. Overall, 38% of healthcare staff, 48% of patrons post-latrine use, and 21% of patrons entering or exiting community locations practiced hand hygiene. HCF hand hygiene access was lower in inpatient rooms (odds ratio [OR] = 0.17, 95% CI: 0.06–0.45) and outpatient rooms (OR = 0.23, 95% CI: 0.07–0.70) compared with laboratory/staff rooms. HCF hand hygiene practice was higher for doctors than nurses (OR = 3.58, 95% CI: 1.15–11.14) and with new versus existing patient encounters (OR = 2.27, 95% CI: 1.20–4.27); it was lower before versus after patient contact for both invasive (OR = 0.03, 95% CI: 0.00–0.20) and noninvasive (OR = 0.66, 95% CI: 0.45–0.95) procedures. In community settings, hand hygiene practice after using the latrine was higher than at an entrances/exits (OR = 3.39, 95% CI: 2.08–5.52). Hand hygiene rates were relatively low in healthcare and community settings. Greater emphasis on hand hygiene before patient interactions (at HCFs) and at community entrances/exits for patrons is also needed.


Water, Sanitation, and Animals Among Enrollees in the Vaccine Impact on Diarrhea in Africa Study: Overall and by Site
Exploring Survey-Based Water, Sanitation, and Animal Associations With Enteric Pathogen Carriage: Comparing Results in a Cohort of Cases With Moderate-to-Severe Diarrhea to Those in Controls in the Vaccine Impact on Diarrhea in Africa (VIDA) Study, 2015-2018

April 2023

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48 Reads

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5 Citations

Clinical Infectious Diseases

Background: The magnitude of pediatric enteric pathogen exposures in low-income settings necessitates substantive water and sanitation interventions, including animal feces management. We assessed associations between pediatric enteric pathogen detection and survey-based water, sanitation, and animal characteristics within the Vaccine Impact on Diarrhea in Africa case-control study. Methods: In The Gambia, Kenya, and Mali, we assessed enteric pathogens in stool of children aged <5 years with moderate-to-severe diarrhea and their matched controls (diarrhea-free in prior 7 days) via the TaqMan Array Card and surveyed caregivers about household drinking water and sanitation conditions and animals living in the compound. Risk ratios (RRs) and 95% confidence intervals (CIs) were calculated using modified Poisson regression models, stratified for cases and controls and adjusted for age, sex, site, and demographics. Results: Bacterial (cases, 93%; controls, 72%), viral (63%, 56%), and protozoal (50%, 38%) pathogens were commonly detected (cycle threshold <35) in the 4840 cases and 6213 controls. In cases, unimproved sanitation (RR, 1.56; 95% CI, 1.12-2.17), as well as cows (RR, 1.61; 95% CI, 1.16-2.24) and sheep (RR, 1.48; 95% CI, 1.11-1.96) living in the compound, were associated with Shiga toxin-producing Escherichia coli. In controls, fowl (RR, 1.30; 95% CI, 1.15-1.47) were associated with Campylobacter spp. In controls, surface water sources were associated with Cryptosporidium spp., Shigella spp., heat-stable toxin-producing enterotoxigenic E. coli, and Giardia spp. Conclusions: Findings underscore the importance of enteric pathogen exposure risks from animals alongside more broadly recognized water and sanitation risk factors in children.


Giardia Detection and Codetection With Other Enteric Pathogens in Young Children in the Vaccine Impact on Diarrhea in Africa (VIDA) Case-Control Study: 2015-2018

April 2023

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28 Reads

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2 Citations

Clinical Infectious Diseases

Background: Giardia has been associated with reduced risk of diarrhea in children in low-resource settings, but the mechanism underlying this association is unknown. To assess whether Giardia may shape colonization or infection with other enteric pathogens and impact associations with diarrhea, we examined Giardia and enteric pathogen codetection among children <5 years old in Kenya, The Gambia, and Mali as part of the Vaccine Impact on Diarrhea in Africa study. Methods: We tested for Giardia and other enteric pathogens using enzyme-linked immunosorbent assays and real-time polymerase chain reaction (PCR) on stool, respectively. We evaluated associations between Giardia and enteric pathogen detection using multivariable logistic regression models separately for children with moderate-to-severe diarrhea (MSD, cases) and free of diarrhea (controls). Results: Among 11 039 enrolled children, Giardia detection was more common among controls (35%) than cases (28%, P < .001). Campylobacter coli/jejuni detection was associated with Giardia in controls in The Gambia (adjusted odds ratio [aOR] [95% confidence interval {CI}]: 1.51 [1.22‒1.86]) and cases across all sites (1.16 [1.00‒1.33]). Among controls, the odds of astrovirus (1.43 [1.05‒1.93]) and Cryptosporidium spp. (1.24 [1.06‒1.46]) detection were higher among children with Giardia. Among cases, the odds of rotavirus detection were lower in children with Giardia in Mali (.45 [.30‒.66]) and Kenya (.31 [.17‒.56]). Conclusions: Giardia was prevalent in children <5 years old and was associated with detection of other enteric pathogens, with differing associations in cases versus controls and by site. Giardia may affect colonization or infection by certain enteric pathogens associated with MSD, suggesting an indirect mechanism of clinical impact.


Cholera Outbreak - Haiti, September 2022-January 2023

January 2023

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90 Reads

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13 Citations

MMWR. Morbidity and mortality weekly report

On September 30, 2022, after >3 years with no confirmed cholera cases (1), the Directorate of Epidemiology, Laboratories and Research (DELR) of the Haitian Ministry of Public Health and Population (Ministère de la Santé Publique et de la Population [MSPP]) was notified of two patients with acute, watery diarrhea in the metropolitan area of Port-au-Prince. Within 2 days, Haiti's National Public Health Laboratory confirmed the bacterium Vibrio cholerae O1 in specimens from the two patients with suspected cholera infection, and an outbreak investigation began immediately. As of January 3, 2023, >20,000 suspected cholera cases had been reported throughout the country, and 79% of patients have been hospitalized. The moving 14-day case fatality ratio (CFR) was 3.0%. Cholera, which is transmitted through ingestion of water or food contaminated with fecal matter, can cause acute, severe, watery diarrhea that can rapidly lead to dehydration, shock, and death if not treated promptly (2). Haiti is currently facing ongoing worsening of gang violence, population displacement, social unrest, and insecurity, particularly in the metropolitan area of Port-au-Prince, including Belair, Bas-Delmas, Centre-Ville, Martissant, Cité Soleil, Croix-des Bouquets, and Tabarre, creating an environment that has facilitated the current resurgence of cholera (3). This report describes the initial investigation, ongoing outbreak, and public health response to cholera in Haiti. Cholera outbreak responses require a multipronged, multisectoral approach including surveillance; case management; access to safe water, sanitation, and hygiene (WASH) services; targeted oral cholera vaccine (OCV) campaigns; risk communication; and community engagement. This activity was reviewed by CDC and was conducted consistent with applicable federal law and CDC policy.


Typhoid Fever in the Eastern Mediterranean Region: A Systematic Review, 1990–2021

December 2022

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35 Reads

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2 Citations

The American journal of tropical medicine and hygiene

The occurrence and antimicrobial resistance (AMR) of typhoid fever in the WHO Eastern Mediterranean Region (EMR) are poorly characterized. Robust surveillance data are needed to inform strategies for typhoid control and prevention in the region. We conducted a systematic review of typhoid fever occurrence, complications, and AMR patterns in EMR countries. We identified 70 studies published from 1990 to 2021, including a total of 44,541 cases with blood culture confirmed typhoid fever in 12 EMR countries, with 48 (69%) studies and 42,008 cases from Pakistan. Among 56 studies with AMR data, fluroquinolone (68% of 13,013 tested isolates), and multidrug resistance (40% of 15,765 tested isolates) were common. Forty (57%) of the 56 studies were from Pakistan, and all reports of extensively drug resistant Salmonella Typhi (48% of 9,578 tested isolates) were from studies in Pakistan. Our findings support the need for continued efforts to strengthen surveillance and laboratory capacity for blood-culture detection of typhoid fever in the region, including data from an ongoing collaboration among CDC, the American University of Beirut, and the WHO EMR office.


Improving water, sanitation, and hygiene (WASH), with a focus on hand hygiene, globally for community mitigation of COVID-19

June 2022

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198 Reads

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17 Citations

Continuity of key water, sanitation, and hygiene (WASH) infrastructure and WASH practices—for example, hand hygiene—are among several critical community preventive and mitigation measures to reduce transmission of infectious diseases, including COVID-19 and other respiratory diseases. WASH guidance for COVID-19 prevention may combine existing WASH standards and new COVID-19 guidance. Many existing WASH tools can also be modified for targeted WASH assessments during the COVID-19 pandemic. We partnered with local organizations to develop and deploy tools to assess WASH conditions and practices and subsequently implement, monitor, and evaluate WASH interventions to mitigate COVID-19 in low- and middle-income countries in Latin America and the Caribbean and Africa, focusing on healthcare, community institution, and household settings and hand hygiene specifically. Employing mixed-methods assessments, we observed gaps in access to hand hygiene materials specifically despite most of those settings having access to improved, often onsite, water supplies. Across countries, adherence to hand hygiene among healthcare providers was about twice as high after patient contact compared to before patient contact. Poor or non-existent management of handwashing stations and alcohol-based hand rub (ABHR) was common, especially in community institutions. Markets and points of entry (internal or external border crossings) represent congregation spaces, critical for COVID-19 mitigation, where globally-recognized WASH standards are needed. Development, evaluation, deployment, and refinement of new and existing standards can help ensure WASH aspects of community mitigation efforts that remain accessible and functional to enable inclusive preventive behaviors.


Figure 1. Study flow diagram. * Key informant interviews (n = 30) from schools in PSSD arm
Figure 2. Comparisons of sanitation delivery modalities in urban informal settlement schools. (A) Structured observations of private sector sanitation delivery (PSSD) facilities, government standard delivery (GSD) facilities, and other existing facilities from our 20 trial schools. (B) Usable refers to toilets/latrines that are: (C) accessible to students-doors are unlocked or a key is available at all times, (D) functional-the toilet is not broken, the toilet hole is not blocked, and water is available for flush/pour-flush toilets, and (E) private-there are closable doors that lock from the inside and no large gaps in the structure at the time of the observation [17]. (F) Average maintenance scores, ranging from 0 (dirty) to 5 (clean), are composed of the following variables for each facility: availability of cleaning materials, absence of flies, absence of odor, absence of visible feces, and absence of urine/stagnant water.
Summary details of private sector sanitation delivery and government standard delivery of sanitation for trial schools.
The Sustainability and Scalability of Private Sector Sanitation Delivery in Urban Informal Settlement Schools: A Mixed Methods Follow Up of a Randomized Trial in Nairobi, Kenya

July 2020

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147 Reads

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5 Citations

There are considerable challenges to achieving the Sustainable Development Goals’ target of universal access to basic sanitation in schools. Schools require safe, clean, and sex-segregated facilities for a large number of students. Robust and affordable solutions are needed to address the economic, spatial, social, institutional, and political factors which contribute to poor sanitary conditions in informal settlements. In 2015, we undertook a randomized controlled trial to assess the feasibility of private sector sanitation delivery (PSSD) in 20 primary schools, in informal settlements of Nairobi, Kenya. Our preliminary evaluation after one year of service delivery suggested that PSSD of urine-diverting dry latrines with routine waste collection and maintenance provided a feasible, lower-cost alternative to the government standard delivery (GSD) of cistern-flush toilets or ventilated improved pit latrines. We conducted a mixed-methods follow-up study to assess sanitation delivery over 3–4 years and investigate prevailing drivers and barriers that may influence the scalability of PSSD. The conditions of newly constructed and rehabilitated GSD facilities diminished quickly, reverting to the conditions of existing facilities, indicating lower sustainability compared to sanitation delivered from the private sector. Barriers in financial aspects related to the ongoing implementation of PSSD emerged, particularly among public schools, and few were able to pay for continued service. Our study demonstrates that the engagement of the private sector may lead to improvements in affordable, safely managed sanitation for schools and their students. Yet, to reach a sustained scale, additional guidance is needed on how to develop these partnerships, streamline procurement and contracting processes, and incorporate appropriate financing mechanisms.

Citations (5)


... These inconsistent results have led to calls for the development of transformational WASH programs that radically reduce fecal contamination and children's exposure in the household environment [8]. To achieve these goals, such programs must identify what pathogen-specific reservoirs and transmission pathways in specific study communities are important in children's exposure to different pathogens and subsequent linear growth impairment [9][10][11][12]. ...

Reference:

Identification of Enteric Pathogen Reservoirs and Transmission Pathways Associated with Short Childhood Stature in the Kolkata Indian Site of the Global Enteric Multicenter Study
Exploring Survey-Based Water, Sanitation, and Animal Associations With Enteric Pathogen Carriage: Comparing Results in a Cohort of Cases With Moderate-to-Severe Diarrhea to Those in Controls in the Vaccine Impact on Diarrhea in Africa (VIDA) Study, 2015-2018

Clinical Infectious Diseases

... Despite the fact that G. duodenalis infections were more frequently identified in individuals presenting with diarrhoea than in those without diarrhoea (7.2% vs. 3.3%), the difference was not statistically significant. Remarkably, large cohort studies conducted in sub-Saharan countries including the Global Enteric Multicenter Study (GEMS) (69), the Malnutrition and Enteric Disease Study (MAL-ED) (70), and the Vaccine Impact on Diarrhea in Africa Case-Control Study (VIDA) (71) have evidenced that G. duodenalis detection was more common among non-diarrheal than diarrheal infected children. The reasons for this trend are unclear, but an indirect mechanism triggered by G. duodenalis leading to changes in colonisation/infection by other enteric pathogens associated with moderate-to-severe-diarrhoea has been suggested (71). ...

Giardia Detection and Codetection With Other Enteric Pathogens in Young Children in the Vaccine Impact on Diarrhea in Africa (VIDA) Case-Control Study: 2015-2018
  • Citing Article
  • April 2023

Clinical Infectious Diseases

... Prognosis in this condition is usually good when treated with specific antimicrobial therapy, generally involving fluoroquinolones, third generation cephalosporins and Azithromycin, though changing trends indicate steady rise in antimicrobial resistance. Resistance against fluoroquinolones such as Ciprofloxacin has been widely recorded, particularly in Pakistan [10]. Resistance to Cephalosporins and Azithromycin is relatively low [11]. ...

Typhoid Fever in the Eastern Mediterranean Region: A Systematic Review, 1990–2021
  • Citing Article
  • December 2022

The American journal of tropical medicine and hygiene

... Handwashing with soap is effective 38 at reducing the risk of infectious diseases, including diarrhoea and respiratory infection (Ross et al., 39 2023;Wolf et al., 2022). Global and regional disease outbreaks, such as COVID-19, cholera and 40 typhoid, have magnified the need for improved hand hygiene practices (Berendes et al., 2022). ...

Improving water, sanitation, and hygiene (WASH), with a focus on hand hygiene, globally for community mitigation of COVID-19

... While private sector sanitation delivery in schools in such areas might seem like a feasible solution, the high capital costs associated with such interventions can be a significant barrier. The balance between the immediate economic challenges and the long-term benefits of sustainability becomes crucial in such scenarios (Snyder et al., 2020). ...

The Sustainability and Scalability of Private Sector Sanitation Delivery in Urban Informal Settlement Schools: A Mixed Methods Follow Up of a Randomized Trial in Nairobi, Kenya