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In response to the recent cholera outbreak, a public health response targeted high-risk communities, including resource-poor communities in Port-au-Prince, Haiti. A survey covering knowledge and practices indicated that hygiene messages were received and induced behavior change, specifically related to water treatment practices. Self-reported household water treatment increased from 30.3% to 73.9%. [ABSTRACT FROM AUTHOR]

The article reports on the health needs of people affected by the 2004 Indian Ocean tsunami. The report, a joint effort of the Cooperative for Assistance and Relief Everywhere, Inc. International Indonesia and the Centers for Disease Control, surveyed survivors in three districts in Aceh Province: Aceh Besar, Banda Aceh and Simeulue. Participants were classified as either internally displaced persons or non-displaced populations. The study assessed weight and height of children, malarial infection and anemia, food assistance received, malnutrition, access to a measles vaccination campaign and other public health services, access to drinking water and toilets and damage to homes.

Safe and hygienic management of human waste is essential in humanitarian settings. Urine-diverting dry toilets (UDDTs) can enable this management in some humanitarian emergency settings. A seeded, longitudinal environmental study was conducted in Hiloweyn refugee camp, Dollo Ado, Ethiopia, to measure Escherichia coli and Ascaris suum ova inactivation within closed UDDT vaults and to document environmental conditions (temperature, moisture content, and pH) that could influence inactivation. Hiloweyn camp represented an optimal location for a desiccation-based sanitation technology such as the UDDT. E. coli and Ascaris ova inactivation was observed in UDDTs under warm, dry, alkaline conditions at 6, 9, and 12 months of storage; UDDTs with samples containing <1000 E. coli/g total solids increased from 30 % to 95 % over 12 months, and a >2.8-log 10 reduction in Ascaris ova viability was observed after 6 months. Additional laboratory-based studies were conducted to provide insights into the field study findings and study the impact of hydrated lime on E. coli and Ascaris ova inactivation. Results suggest that adding hydrated lime to elevate pH > 12 may increase inactivation and decrease storage time. Overall, UDDTs could contribute to the safe and hygienic management of human waste in comparable warm and dry humanitarian settings., Competing Interests: Declaration of competing interest The authors declare the following financial interests/personal relationships which may be considered as potential competing interests: Thomas Handzel reports financial support was provided by Research for Health in Humanitarian Crises. If there are other authors, they declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (Published by Elsevier B.V.)

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., Competing Interests: Competing Interests: The authors have declared that no competing interests exist.

Given the increasing frequency and duration of humanitarian emergencies worldwide, there is a need to identify a greater range of effective and contextually appropriate water, sanitation and hygiene (WASH) interventions. Typical sanitation systems may be poorly suited for some of the conditions in which humanitarian emergencies can occur, such as in drought-prone regions. Urine-diversion dry toilets (UDDTs) are one potential alternative sanitation option which can be used in these conditions. Between 2014 and 2016, the U.S. Centers for Disease Control and Prevention (CDC) partnered with local agencies to evaluate the acceptability of UDDTs in a refugee camp in Ethiopia. The overall goals were to provide evidence regarding the level of adoption and satisfaction with UDDTs in this emergency context and the factors associated with satisfaction. Two cross-sectional surveys were conducted 18-months apart, using a stratified design to sample UDDT and latrine users for comparison. The proportion who reported to use their UDDT consistently was 88.8% (95% CI 85.1-92.5) in the first survey and 93.4% (95% CI 90.6-96.2) in the second survey. Reported satisfaction levels were significantly higher among respondents in the second survey (p < 0.0001), where 97.0% (95% CI 95.1-98.9) of respondents stated either that they were mostly or very satisfied with their UDDT. There was no significant difference detected in satisfaction between UDDT and latrine users (p = 0.28). Using a multivariable logistic regression model, we identified several factors associated with a higher level of satisfaction with UDDTs. Those who had previously (before coming to the camp) used a pit latrine (AOR = 4.2; 95% CI 1.4-12.7) or had no sanitation system (AOR = 2.4; 95% CI 1.3-4.4) relative to a pour-flush toilet, had a clean UDDT (AOR = 2.8; 95% CI 1.7-4.6), had been in the camp for a longer time period (AOR = 2.3; 95% CI 1.7-3.0), did not share their UDDT (AOR = 1.8; 95% CI 1.0-3.0) and had used their UDDT for a longer time period (AOR = 1.7; 95% CI 1.2-2.4) had higher odds of satisfaction. The findings demonstrate that UDDTs have been effectively introduced and utilized in this context and this may have implications for other humanitarian settings where they can be similarly managed., (Published by Elsevier GmbH.)

Competing Interests: All authors have completed and submitted the International Committee of Medical Journal Editors form for disclosure of potential conflicts of interest. No potential conflicts of interest were disclosed.

Background: Diarrhea and acute respiratory infections (ARI) account for 30% of deaths among children displaced due to humanitarian emergencies. A wealth of evidence demonstrates that handwashing with soap prevents both diarrhea and ARI. While socially- and emotionally-driven factors are proven motivators to handwashing in non-emergency situations, little is known about determinants of handwashing behavior in emergency settings., Methods: We conducted a qualitative investigation from June to August 2015 in a camp for internally displaced persons with a population of 6360 in the war-torn eastern region of the Democratic Republic of Congo. We held key informant interviews with 9 non-governmental organizations and camp officials, in-depth interviews and rating exercises with 18 mothers of children < 5 years, and discussions with 4 groups of camp residents and hygiene promoters to identify motivators and barriers to handwashing., Results: At the time of the study, hygiene promotion activities lacked adequate resources, cultural acceptability, innovation, and adaptation for sustained behavioral change. Lack of ongoing provision of hygiene materials was a major barrier to handwashing behavior. When hygiene materials were available, camp residents reported that the primary motivator to handwashing was to prevent illness, particularly diarrheal disease, with many mentioning an increased need to wash hands during diarrhea outbreaks. Emotionally- and socially-related motivators such as "maintaining a good image" and social pressure to follow recommended camp hygiene practices were also reported to motivate handwashing with soap. Residents who engaged in day labor outside the camp had limited exposure to hygiene messages and handwashing facilities. Interviewees indicated that the harsh living conditions forced residents to prioritize obtaining basic survival needs over good hygiene., Conclusions: Hygiene promotion in camp settings must involve preparedness of adequate resources and supplies and ongoing provision of hygiene materials so that vulnerable populations affected by emergencies can apply good hygiene behaviors for the duration of the camp's existence. Compared to non-emergency contexts, illness-based messages may be more effective in emergency settings where disease poses a current and ongoing threat. However, failure to use emotive and social drivers that motivate handwashing may present missed opportunities to improve handwashing in camps., Competing Interests: Competing interestsThe authors declare that they have no competing interests., (© The Author(s). 2019.)

In August 2015, an outbreak of cholera was reported in Tanzania. In cholera-affected areas of urban Dar es Salaam and Morogoro, many households obtained drinking water from vendors, who sold water from tanks ranging in volume from 1,000 to 20,000 L. Water supplied by vendors was not adequately chlorinated. The Tanzanian Ministry of Health, Community Development, Gender, Elderly and Children and the U.N. Children's Fund, Tanzania, collaborated to enroll and train vendors to treat their water with 8.68-g sodium dichloroisocyanurate tablets (Medentech, Ireland). The Centers for Disease Control and Prevention (CDC) provided monitoring and evaluation support. Vendors were provided a 3-month supply of chlorine tablets. A baseline assessment and routine monitoring were conducted by ward environmental health officers. Approximately 3 months after chlorine tablet distribution, an evaluation of the program was conducted. The evaluation included a full enumeration of all vendors, an in-depth survey with half of the vendors enumerated, and focus group discussions. In total, 797 (88.9%) vendors were included in the full enumeration and 392 in the in-depth survey. Free residual chlorine (FRC) was detected in 12.0% of tanks at baseline and 69.6% of tanks during the evaluation; however, only 17.4% of these tanks had FRC ≥ 0.5 mg/L. The results suggest high acceptability and use of the chlorine tablets by water vendors. However, given variation in the water source used and longer storage times, dosing could be increased in future programming. Bulk chlorination using chlorine tablets offers an efficient community-level approach to treating water closer to the point of use.

The PackH 2 O water backpack carrier was developed to provide safe storage and relieve stress of head-loading during water transport with traditional containers such as buckets and jerry cans. We conducted an evaluation to assess both self-reported and observed use over a 6-month period between November 2014 and May 2015. A total of 866 packs were distributed to 618 households in six communities in rural Haiti, and 431 and 441 households were surveyed at midline and end line, respectively. We performed linear regression to assess change of self-reported use over time. Although 79.3% of respondents reported continued use of the 20-L pack after 6 months, other measures of self-reported use were low, with only 16.8% reporting to have used the pack the last time they collected water and 10.3% preferring the pack over other water collection containers. In addition, only 10.2% of all people collecting water at community sources were observed using packs and 12.0% of all households surveyed had water in the pack at the time of visit. Pack use varied by community and demographics. Although women were targeted during distribution, men preferred the pack and were more commonly observed using it at the community water sources. In conclusion, the use of the PackH 2 O was not widely adopted in rural Haiti; however, further research is needed to assess the pack acceptance in areas where back-loading is more common and in emergency settings.

Humanitarian emergencies, including complex emergencies associated with fragile states or areas of conflict, affect millions of persons worldwide. Such emergencies threaten global health security and have complicated but predictable effects on public health. The Centers for Disease Control and Prevention (CDC) Emergency Response and Recovery Branch (ERRB) (Division of Global Health Protection, Center for Global Health) contributes to public health emergency responses by providing epidemiologic support for humanitarian health interventions. To capture the extent of this emergency response work for the past decade, we conducted a retrospective review of ERRB's responses during 2007-2016. Responses were conducted across the world and in collaboration with national and international partners. Lessons from this work include the need to develop epidemiologic tools for use in resource-limited contexts, build local capacity for response and health systems recovery, and adapt responses to changing public health threats in fragile states. Through ERRB's multisector expertise and ability to respond quickly, CDC guides humanitarian response to protect emergency-affected populations.

Consumption of drinking water from private vendors has increased considerably in Port-au-Prince, Haiti, in recent decades. A major type of vendor is private kiosks, advertising reverse osmosis-treated water for sale by volume. To describe the scale and geographical distribution of private kiosks in metropolitan Port-au-Prince, an inventory of private kiosks was conducted from July to August 2013. Coordinates of kiosks were recorded with global positioning system units and a brief questionnaire was administered with the operator to document key kiosk characteristics. To assess the quality of water originating from private kiosks, water quality analyses were also conducted on a sample of those inventoried as well as from the major provider company sites. The parameters tested were Escherichia coli , free chlorine residual, pH, turbidity, and total dissolved solids. More than 1,300 kiosks were inventoried, the majority of which were franchises of four large provider companies. Approximately half of kiosks reported opening within 12 months of the date of the inventory. The kiosk treatment chain and sales price was consistent among a majority of the kiosks. Of the 757 kiosks sampled for water quality, 90.9% of samples met World Health Organization (WHO) microbiological guideline at the point of sale for nondetectable E. coli in a 100-mL sample. Of the eight provider company sites tested, all samples met the WHO microbiological guideline. Because of the increasing role of the private sector in drinking water provision in Port-au-Prince and elsewhere in Haiti, this assessment was an important first step for government regulation of this sector.

Since August 2015, the Ministry of Health, Community Development, Gender, Elderly and Children (MoHCDGEC) of Tanzania has been leading the response to a widespread cholera outbreak. As of June 9, 2016, cholera had affected 23 of 25 regions in Tanzania, with 21,750 cumulative cases and 341 deaths reported (Ally Nyanga, MoHCDGEC Emergency Operations Center, personal communication, June 2016). Approximately one fourth of all cases occurred in the Dar es Salaam region on the east coast. Regions surrounding Lake Victoria, in the north, also reported high case counts, including Mwanza with 9% (Ally Nyanga, MoHCDGEC Emergency Operations Center, personal communication, June 2016). Since the start of the outbreak, MoHCDGEC and the Ministry of Water (MOW) have collaborated with the Tanzania Red Cross Society, United Nations Children's Fund (UNICEF), World Health Organization (WHO), and CDC to enhance the water, sanitation, and hygiene (WASH) response to prevent the further spread of cholera.

Background: Refugees are at high risk for communicable diseases due to overcrowding and poor water, sanitation, and hygiene conditions. Handwashing with soap removes pathogens from hands and reduces disease risk. A hepatitis E outbreak in the refugee camps of Maban County, South Sudan in 2012 prompted increased hygiene promotion and improved provision of soap, handwashing stations, and latrines. We conducted a study 1 year after the outbreak to assess the knowledge, attitudes, and practices of the refugees in Maban County., Methods: We conducted a cross sectional survey of female heads of households in three refugee camps in Maban County. We performed structured observations on a subset of households to directly observe their handwashing practices at times of possible pathogen transmission., Results: Of the 600 households interviewed, nearly all had soap available and 91 % reported water was available "always" or "sometimes". Exposure to handwashing promotion was reported by 85 % of the respondents. Rinsing hands with water alone was more commonly observed than handwashing with soap at critical handwashing times including "before eating" (80 % rinsing vs. 7 % washing with soap) and "before preparing/cooking food" (72.3 % vs 23 %). After toilet use, 46 % were observed to wash hands with soap and an additional 38 % rinsed with water alone., Conclusions: Despite intensive messaging regarding handwashing with soap and access to soap and water, rinsing hands with water alone rather than washing hands with soap remains more common among the refugees in Maban County. This practice puts them at continued risk for communicable disease transmission. Qualitative research into local beliefs and more effective messaging may help future programs tailor handwashing interventions.

The international response to Haiti's ongoing cholera outbreak has been multifaceted, including health education efforts by community health workers and the distribution of free water treatment products. Artibonite Department was the first region affected by the outbreak. Numerous organizations have been involved in cholera response efforts in Haiti with many focusing on efforts to improve water, sanitation, and hygiene (WASH). Multiple types of water treatment products have been distributed, creating the potential for confusion over correct dosage and water treatment methods. We utilized qualitative methods in Artibonite to determine the population's response to WASH messages, use and acceptability of water treatment products, and water treatment and sanitation knowledge, attitudes and practices at the household level. We conducted eighteen focus group discussions (FGDs): 17 FGDs were held with community members (nine among females, eight among males); one FGD was held with community health workers. Health messages related to WASH were well-retained, with reported improvements in hand-washing. Community health workers were identified as valued sources of health information. Most participants noted a paucity of water-treatment products. Sanitation, specifically the construction of latrines, was the most commonly identified need. Lack of funds was the primary reason given for not constructing a latrine. The construction and maintenance of potable water and sanitation services is needed to ensure a sustainable change.

Background: Diarrheal disease is a common cause of morbidity and mortality. Displaced populations are especially vulnerable due to overcrowded camps and limited access to water and sanitation facilities, increasing the risk for outbreaks. Hand washing with soap is effective against disease transmission, and studies suggest access to a convenient hand washing station may be the key to increasing hand washing behavior. This pilot study evaluated the acceptability, durability and use of a novel hand washing bag (HWB) at the household level among Sudanese refugees immediately following an acute emergency., Methods: We distributed one HWB to every household (n = 874) in Adamazin Transit Center in western Ethiopia. The evaluation consisted of baseline and endline surveys, three monthly monitoring visits and focus group discussions (FGDs) over a six month period. FGD data were analyzed using the Risk, Attitudes, Norms, Abilities, and Self-Regulatory model. Survey and monitoring data were analyzed using SPSS. Note: Residents were resettled to Bambasi Refugee Camp during the study period where the endline survey was conducted., Results: Baseline data suggested water quantity and availability of soap were below SPHERE standards, however participants responded positively to the HWB. At the end of the monitoring period, 73.9 % of the same households retained their original HWBs and 66.7 % of bags had water at the time of the visit. The mean lifespan of the HWB during the monitoring period was 2.73 months. From a new sample of households selected for the endline evaluation, 93.0 % had an original HWB, but only 39.4 % had water in the bag. Endline FGD participants felt the HWB was useful, but reported insufficient soap and hygiene messaging., Conclusion: The HWB performed well during the early phases of the emergency, however longer term results in this setting are unclear. The low levels of reported use measured by proxy indicators at six months indicated decreasing acceptability over time or a reflection of potential differences between the two sites. It is also unknown whether the HWB influenced hand washing behavior. Study findings were shared with the manufacturer in an effort to improve the bag's acceptability, utility, and durability.

The goal of this study was to evaluate the microbial die-off in a latrine waste composting system in Port-au-Prince, Haiti. Temperature data and samples were collected from compost aged 0-12+ months. Samples collected from compost bin centers and corners at two depths were assessed for moisture content, E. coli concentration, and Ascaris spp. viability. Center temperatures in compost bins were all above 58 °C, while corner temperatures were 10 - 20 °C lower. Moisture content was 67 ± 10% in all except the oldest compost. A 4-log reduction in E. coli was observed over the first sixteen weeks of composting at both locations and depths, after which E. coli was undetectable (LOD: 142 MPN g(-1) dry weight). In new compost, 10.4% and 8.3% of Ascaris eggs were viable and fully embryonated, respectively. Percent viability dropped to zero in samples older than six weeks. These findings indicate that the Haitian EcoSan composting process was effective in inactivating E. coli and Ascaris spp. in latrine waste within sixteen weeks. This study is one of the first to document efficacy of an ecological sanitation system under field conditions and provides insight into composting methods and monitoring for other international settings.

Haiti has the lowest improved water and sanitation coverage in the Western Hemisphere and is suffering from the largest cholera epidemic on record. In May of 2012, an assessment was conducted in rural areas of the Artibonite Department to describe the type and quality of water sources and determine knowledge, access, and use of household water treatment products to inform future programs. It was conducted after emergency response was scaled back but before longer-term water, sanitation, and hygiene activities were initiated. The household survey and source water quality analysis documented low access to safe water, with only 42.3% of households using an improved drinking water source. One-half (50.9%) of the improved water sources tested positive for Escherichia coli. Of households with water to test, 12.7% had positive chlorine residual. The assessment reinforces the identified need for major investments in safe water and sanitation infrastructure and the importance of household water treatment to improve access to safe water in the near term.

Haiti has the lowest rates of access to improved water and sanitation infrastructure in the western hemisphere. This situation was likely exacerbated by the earthquake in 2010 and also contributed to the rapid spread of the cholera epidemic that started later that same year. This report examines the history of the water, sanitation, and hygiene (WASH) sector in Haiti, considering some factors that have influenced WASH conditions in the country. We then discuss the situation sine the earthquake and subsequent cholera epidemic, and the responses to those events. Finally, drawing on Haiti's National Plan of Action for the Elimination of Cholera in Haiti 2013-2022, we suggest some actions that could help bring about long-term WASH improvements for the future. Because the current WASH situation has evolved over decades of limited attention and resources, it will take a long-term, sustained effort to improve the situation.

In 2008-2009, Zimbabwe experienced an unprecedented cholera outbreak with more than 4,000 deaths. More than 60% of deaths occurred at the community level. We conducted descriptive and case-control studies to describe community deaths. Cases were in cholera patients who died outside health facilities. Two surviving cholera patients were matched by age, time of symptom onset, and location to each case-patient. Proxies completed questionnaires regarding mortality risk factors. Cholera awareness and importance of rehydration was high but availability of oral rehydration salts was low. A total of 55 case-patients were matched to 110 controls. The odds of death were higher among males (adjusted odd ratio [AOR] = 5.00, 95% confidence interval [CI] = 1.54-14.30) and persons with larger household sizes (AOR = 1.21, 95% CI = 1.00-1.46). Receiving home-based rehydration (AOR = 0.21, 95% CI = 0.06-0.71) and visiting cholera treatment centers (CTCs) (AOR = 0.07, 95% CI = 0.02-0.23) were protective. Receiving cholera information was associated with home-based rehydration and visiting CTCs. When we compared cases and controls who did not go to CTCs, males were still at increased odds of death (AOR = 5.00, 95% CI = 1.56-16.10) and receiving home-based rehydration (AOR = 0.14, 95% CI = 0.04-0.53) and being married (AOR = 0.26, 95% CI = 0.08-0.83) were protective. Inability to receive home-based rehydration or visit CTCs was associated with mortality. Community education must reinforce the importance of prompt rehydration and CTC referral.

Organisms, including Vibrio cholerae, can be transferred between harbors in the ballast water of ships. Zones in the Caribbean region where distance from shore and water depth meet International Maritime Organization guidelines for ballast water exchange are extremely limited. Use of ballast water treatment systems could mitigate the risk for organism transfer.

During the 2010 cholera outbreak in Haiti, water and seafood samples were collected to detect Vibrio cholerae. The outbreak strain of toxigenic V. cholerae O1 serotype Ogawa was isolated from freshwater and seafood samples. The cholera toxin gene was detected in harbor water samples.

An outbreak of hepatitis E virus (HEV) began in October 2007 in northern Uganda. To determine risk factors and sources for ongoing transmission, we conducted both a case-control study and an environmental investigation. A case patient was defined as having serologic evidence of HEV infection, whereas controls were seronegative. We identified risk factors for infection by univariable and multivariable analyses using conditional logistic regression. Several water sources were tested for HEV RNA. Among 112 cases and 145 controls, storage of drinking water in large-mouthed vessels (adjusted odds ratios [AOR] = 2.83; 95% confidence interval [CI] = 1.16-6.94) and washing hands in a group basin (AOR = 1.90; 95% CI = 1.07-3.38) were associated with HEV infection. HEV RNA was detected from communal hand-rinse and surface-water samples. The epidemiologic and environmental water-testing results suggest that household-level factors played an important role in the transmission of HEV-modalities that have been previously underappreciated.

There is a global need for software to manage imaging based clinical trials to speed basic research and drug development. Such a system must comply with regulatory requirements. The U.S. Food and Drug Administration (FDA) has regulations regarding software development process controls and data provenance tracking. A key unanswered problem is the identification of which data changes are significant given a workflow model for image trial management. We report on the results of our study of provenance tracking requirements and define an architecture and software development process that meets U.S. regulatory requirements using open source software components.

In early 2006, coinciding with heavy rains, Botswana health facilities reported increases in diarrhea, mortality, and acute malnutrition among young children. Data on diarrhea, human immunodeficiency virus, feeding, mortality, and water/sanitation were collected by random cluster survey. Anthropometric data were measured and drinking water samples were tested. Of 537 surveyed children less than five years of age, one-third experienced >or= 1 episode of diarrhea. Prevalence of acute malnutrition was 7.9%, and the mortality rate for children less than five years of age was 2.6/10,000/day during the outbreak. Significant risk factors for diarrhea included an age less than two years; breastfeeding was protective. Diarrhea lasting for more than 14 days and failure to thrive were risk factors for acute malnutrition. Prevalence of acute malnutrition was higher than previously documented and the mortality rate in children less than five years of age during the outbreak was above the international threshold for emergency action with an estimated 547 excess deaths. This survey highlights the need for safe infant feeding and effective treatment of malnutrition and diarrhea in young children.

American Samoa began a territory-wide mass drug administration (MDA) program with diethylcarbamazine and albendazole in 2000 after baseline surveys indicated that 16.5% of 2,989 residents were infected with Wuchereria bancrofti based on tests for circulating filarial antigen. Follow-up surveys were conducted in 2001, 2003, and 2006, using convenience samples of residents of sentinel villages. Antigenemia prevalence in 2001 (11.5%) and 2003 (13.5%) showed no change. After the 2003 sentinel assessment, improvements were made in the social mobilization and drug distribution strategies. In 2006, after a total of 5 years of MDA and 3 years of improved MDA participation, the antigenemia prevalence dropped from 11.5% (2001) to 0.95% (2006) (P < 0.0001). In 2006, antigenemia prevalence was greater in males (1.5%) than females (0.4%) (P = 0.04). The decline in antigenemia prevalence shows the effectiveness of MDA and changes made in social mobilization and drug distribution.

Little is known about the HIV epidemic in conflict-affected southern Sudan. During 2002-2003, we conducted behavioral and biological surveillance surveys and sequential sampling in antenatal clinics in Yei, Western Equatoria, and Rumbek, Bar-el-Ghazal. HIV prevalence among individuals aged 15-49 years ranged between 0.4% in Rumbek town and 4.4% in Yei town, and among pregnant women between 0.8 and 3.0%, respectively. After the recent peace agreement, targeted prevention programmes are urgently needed to prevent further spread.

In August 2000, the Ohio Department of Health requested assistance to investigate a cryptosporidiosis outbreak with more than 700 clinical case-patients. An epidemiologic and environmental investigation was conducted. Stool specimens, pool water, and sand filter samples were analyzed. A community-based case-control study showed that the main risk factor was swimming in pool A (odds ratio [OR] = 42, 95% confidence interval [CI] = 12.3-144.9). This was supported by results of polymerase chain reaction (PCR) analysis, which showed the presence of both the human and bovine genotypes of Cryptosporidium parvum in case-patients and samples from the filter of pool A. A pool-based case-control study indicated that the highest risk was related to exposure to pool water via the mouth (OR = 5.1, 95% CI = 2.1-12.5) or to pool sprinklers (OR = 2.5, 95% CI = 1.3-4.7). Fecal accidents at the pool were documented. Records indicated that the pool met local health regulations. The outbreak, caused by co-infection with two C. parvum genotypes (human and bovine), underscores the need for concerted action to improve public health policies for recreational water facilities and enhanced education regarding the potential for disease transmission through pools.

A survey of 1,246 children 10-12 years old in 32 primary schools in Kenya near Lake Victoria was conducted to determine prevalence and distribution of schistosome and geohelminth infections. Stool and urine samples were collected and examined for eggs of Schistosoma mansoni, S. haematobium, and intestinal helminths. A questionnaire was used to obtain demographic information and to quantify exposure to surface waters. Houses, schools, and water sources were mapped using a geographic information system. The mean school prevalence of S. mansoni infection was 16.3% (range = 0-80%). Proximity to the lake (r = 0.89, P < 0.001) and contact with lake water were associated with infection, as were specific water-related activities including swimming, fishing, and collecting water. Sixty-three percent of students were infected with one or more other geohelminths and these infections were more homogenously distributed. The separate distributions of schistosome and geohelminth infections have important implications for combined mass-treatment programs.

Purpose: LASIK with the Nidek EC-5000 excimer laser was used to treat high astigmatism., Methods: The Nidek EC-5000 excimer laser and ACS microkeratome were used in regular LASIK procedures. Results of 74 eyes with astigmatism of more than 3.50 D and up to 10.00 D were evaluated., Results: With Nidek algorithms, it was possible to eliminate refractive error completely or reduce it to a satisfactory amount, especially in difficult cases of mixed astigmatism with high astigmatic components., Conclusion: The Nidek software for mixed and high astigmatism was efficient, predictable, and produced good results in difficult cases of high astigmatism.

On October 15, 2001, a U.S. Senate staff member opened an envelope containing Bacillus anthracis spores. Chemoprophylaxis was promptly initiated and nasal swabs obtained for all persons in the immediate area. An epidemiologic investigation was conducted to define exposure areas and identify persons who should receive prolonged chemoprophylaxis, based on their exposure risk. Persons immediately exposed to B. anthracis spores were interviewed; records were reviewed to identify additional persons in this area. Persons with positive nasal swabs had repeat swabs and serial serologic evaluation to measure antibodies to B. anthracis protective antigen (anti-PA). A total of 625 persons were identified as requiring prolonged chemoprophylaxis; 28 had positive nasal swabs. Repeat nasal swabs were negative at 7 days; none had developed anti-PA antibodies by 42 days after exposure. Early nasal swab testing is a useful epidemiologic tool to assess risk of exposure to aerosolized B. anthracis. Early, wide chemoprophylaxis may have averted an outbreak of anthrax in this population.