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Background Typhoid fever contributes to approximately 135 000 deaths annually. Achievable improvements in household water, sanitation, and hygiene (WASH) combined with vaccination using typhoid conjugate vaccines (TCVs) may be an effective preventive strategy. However, little is known about how improved WASH and vaccination interact to lower the risk of typhoid. Methods A total of 61 654 urban Bangladeshi children aged 9 months to Results The adjusted reduced risk of typhoid among all residents living in the clusters assigned to TCV was 55% (95% confidence interval [CI], 43%–65%; P < .001), and that of living in Better WASH households, regardless of cluster, was 37% (95% CI, 24%–48%; P < .001). The highest risk of typhoid was observed in persons living in households with Not Better WASH in the JE clusters. In comparison with these persons, those living in households with Better WASH in the TCV clusters had an adjusted reduced risk of 71% (95% CI, 59%–80%; P < .001). Conclusions Implementation of TCV programs combined with achievable and culturally acceptable household WASH practices were independently associated with a significant reduction in typhoid risk. Clinical Trials Registration ISRCTN11643110.

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Cholera poses a substantial health burden in the developing world due to both epidemic and endemic diseases. The World Health Organization recommends oral cholera vaccines for mass vaccination campaigns in addition to traditional prevention practices and treatments in resource-poor settings. In many developing countries like Bangladesh, the major challenge behind implementing mass vaccination campaigns concerns the affordability of the oral cholera vaccine (OCV). Vaccination of children with OCV is not only an impactful approach for controlling cholera at the population level and reducing childhood morbidity but is also considered more cost-effective than vaccinating all ages. The aim of the study was to estimate the cost of an OCV campaign for children from a societal perspective using empirical study. A total of 66,311 children aged 1 to 14 years old were fully vaccinated with two doses of the OCV Shanchol while 9,035 individuals received one dose of this vaccine. The estimated societal cost per individual for full vaccination was US$ 6.11, which includes the cost of vaccine delivery estimated at US$ 1.95. The cost per single dose was estimated at US$ 2.86. The total provider cost for full vaccination was estimated at US$ 6.01 and the recipient cost at US$ 0.10. Our estimation of OCV delivery costs for children was relatively higher than what was found in a similar mass OCV campaign for all age groups, indicating that there may be additional cost factors to consider in targeted vaccine campaigns. This analysis provides useful benchmarks for the possible costs related to delivery of OCV to children and future OCV cost-effectiveness models should factor in these possible cost disparities. Attempts to reduce the cost per dose are likely to have a greater impact on the cost of similar vaccination campaigns in many resource-poor settings.

Peer reviewed: True, Acknowledgements: Icddr,b is grateful to the Governments of Bangladesh, Canada, Sweden and the UK for providing unrestricted support. The authors would like to thank Dr Nigel McMillan (Griffith University) for his scientific and technical support in the manuscript., OBJECTIVE: To investigate the association between existing household water quality, sanitation and hygiene (WASH) practices and severe cholera risk in a dense urban slum where cholera is highly endemic. DESIGN, SETTING AND PARTICIPANTS: We assembled a large prospective cohort within a cluster randomised trial evaluating the effectiveness of oral cholera vaccine. Our dynamic cohort population (n=193 576) comprised individuals living in the 'non-intervention' clusters of the trial, and were followed over 4 years. This study was conducted in a dense urban slum community of Dhaka, Bangladesh and cholera surveillance was undertaken in 12 hospitals serving the study area. PRIMARY OUTCOME MEASURE: First severe cholera episode detected during follow-up period. METHODS: We applied a machine learning algorithm on a training subpopulation (n=96 943) to develop a binary ('better', 'not better') composite WASH variable predictive of severe cholera. The WASH rule was evaluated for performance in a separate validation subpopulation (n=96 633). Afterwards, we used Cox regression models to evaluate the association between 'better' WASH households and severe cholera risk over 4 years in the entire study population. RESULTS: The 'better' WASH rule found that water quality and access were the most significant factors associated with severe cholera risk. Members of 'better' WASH households, constituting one-third of the population, had a 47% reduced risk of severe cholera (95% CI: 29 to 69; p

Drawing on interviews with 74 South Korean (hereafter Korean) students and 34 parents at ten elite U.S. colleges, I examine how elite Korean parents seek to reproduce and extend their family privilege through children’s transnational education. I analyze how each group – children, mothers, and fathers – interprets and represents their views of the elite transnational parenting they experienced or practiced. By triangulating the narratives of three groups, I explore the family dynamics of the transnational families of high-achieving Korean students abroad. Well-educated yet opt-out mothers intensively managed their children’s early education, often relying on gender-segregated networks. In contrast, cosmopolitan professional fathers heavily engaged in guiding their children’s education and career preparation abroad, using their class resources, such as English proficiency, professional careers, and social networks of other elites. In children’s narratives, mothers’ lifelong care for their private life was undervalued and criticized, while fathers’ growing involvement in their later education was highly valued and appreciated. Across employment statuses, mothers in this dissertation shared and internalized the notion of “intensive mothering.” Mothers with professional occupations extended the meaning of being a “good” transnational mother by providing their children with both motherly care and academic support. In contrast, less-transnational opt-out mothers limited the scope of their involvement in their children’s lives abroad due to their lack of transnational resources, such as English proficiency and knowledge about elite education and careers abroad. Elite fathers in this dissertation pursued extensive transnational fatherhood, an extended version of engaging fatherhood. Studied- or worked-abroad fathers emphasized their effort for both academic and emotional support for their children. While they shared a great deal of joy and a sense of fulfillment from their fatherhood, less-affluent, never-studied-abroad fathers undervalued their fatherhood, doubting their capability to help their high-achieving children abroad. Class privilege, or transnational mobility, is being reproduced based on the gender achievement gap within elite families. My findings contextualize the discourse of Asian high achievement, which has been racialized and gendered, reflecting the notions of “model minority” and “tiger mother.” This study re-writes the stereotypical dichotomy between intense mothers and distant fathers in Korean or Asian families.