Relative and absolute addressability of global disease burden in maternal and perinatal health by investment in R&D

Maternal and perinatal disease accounts for nearly 10% of the global burden of disease, with only modest progress towards achievement of the Millennium Development Goals. Despite a favourable new global health landscape in research and development (R&D) to produce new drugs for neglected diseases, R&D investment in maternal/perinatal health remains small and non-strategic. Investment in obstetric R&D by industry or the not-for-profit sector has lagged behind other specialties, with the number of registered pipeline drugs only 1-5% that for other major disease areas. Using a Delphi exercise with maternal/perinatal experts in global and translational research, we estimate that equitable pharmaceutical R&D and public sector research funding over the next 10-20 years could avert 1.1% and 1.9% of the global disease burden, respectively. In contrast, optimal uptake of existing research would prevent 3.0%, justifying the current focus on health service provision. Although R&D predominantly occurs in high-income countries, more than 98% of the estimated reduction in disease burden in this field would be in developing countries. We conclude that better pharmaceutical and public sector R&D would prevent around 1/3 and 2/3, respectively, of the disease burden addressable by optimal uptake of existing research. Strengthening R&D may be an important complementary strategy to health service provision to address global maternal and perinatal disease burden.     

Assessing the impact of a school-based water treatment, hygiene and sanitation programme on pupil absence in Nyanza Province, Kenya: a cluster-randomized trial

Objectives There has been increased attention to access to water, sanitation and hygiene (WASH) at schools in developing countries, but a dearth of empirical studies on the impact. We conducted a cluster‐randomized trial of school‐based WASH on pupil absence in Nyanza Province, Kenya, from 2007 to 2008. Methods Public primary schools nested in three geographical strata were randomly assigned and allocated to one of three study arms [water treatment and hygiene promotion (WT & HP), additional sanitation improvement, or control] to assess the effects on pupil absence at 2‐year follow‐up. Results We found no overall effect of the intervention on absence. However, among schools in two of the geographical areas not affected by post‐election violence, those that received WT and HP showed a 58% reduction in the odds of absence for girls (OR 0.42, CI 0.21–0.85). In the same strata, sanitation improvement in combination with WT and HP resulted in a comparable drop in absence, although results were marginally significant (OR 0.47, 0.21–1.05). Boys were not impacted by the intervention. Conclusion School WASH improvements can improve school attendance for girls, and mechanisms for gendered impacts should be explored. Incomplete intervention compliance highlights the challenges of achieving consistent results across all settings.     

Direct observation of hygiene in a Peruvian shantytown: not enough handwashing and too little water

Objective To document frequency of hygiene practices of mothers and children in a shantytown in Lima, Peru. Methods Continuous monitoring over three 12‐h sessions in households without in‐house water connections to measure: (i) water and soap use of 32 mothers; (ii) frequency of interrupting faecal‐hand contamination by washing; and (iii) the time until faecal‐hand contamination became a possible transmission event. Results During 1008 h of observation, 55% (65/119) of mothers’ and 69% (37/54) of children’s faecal‐hand contamination events were not followed within 15 min by handwashing or bathing. Nearly 40% (67/173) of faecal‐hand contamination events became possible faecal‐oral transmission events. There was no difference in the time‐until‐transmission between mothers and children (P = 0.43). Potential transmission of faecal material to food or mouth occurred in 64% of cases within 1 h of hand contamination. Mean water usage (6.5 l) was low compared to international disaster relief standards. Conclusions We observed low volumes of water usage, inadequate handwashing, and frequent opportunities for faecal contamination and possible transmission in this water‐scarce community.     

Examining time‐dependent effects of water,sanitation, and hygiene (WASH) interventions using an agent‐based model

The effects of water, sanitation, and hygiene (WASH) interventions have been well acknowledged to reduce the risk from diarrheal disease‐causing pathogens. In spite of the recognized importance of WASH interventions on the reduction of diarrheal disease, there are still gaps in the understanding of the time‐varying effects of interventions. To bridge this research gap, we developed agent‐based models (ABMs) of diarrheal disease transmission in a community context. In the model, infections occur via two pathways: (i) between household members within the household environment and (ii) from the community environment outside the household. To measure the effectiveness of WASH interventions, we performed global sensitivity analysis (GSA) at the macro and micro temporal scales, varying the level of intervention coverage in the community. We simulated three intervention strategies, implemented separately in the experiments. The clean drinking water intervention, sanitation intervention, and hand washing intervention had similar success rates in the long‐term. The handwashing intervention had the largest immediate effect. This highlights that proper short‐ and long‐term intervention strategies need to be considered for disease control and the effective management of limited resources.