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The nêhiyawêwin (Plains Cree language) Cree word, miskâsowin, relates to the sacred teachings of Treaty Elders of Saskatchewan as a concept pertaining to wellness of “finding one’s sense of belonging”—a process integral in the aftermath of colonial disruption. Métis educator and performance artist Moe Clark offers an approach to healing and well-being, which is imparted through movement, flux and through musical and performance-based engagement. Moe works with tools of embodiment in performance and circle work contexts, including song creation, collaborative performance, participatory youth expression and land-based projects as healing art. She shares her process for re-animating these relationships to land, human kin, and other-than-human kin through breath-work, creative practice and relationality as part of a path to wholeness. The authors document Moe’s approach to supporting the identity, growth, healing and transformation of others.

Background: Acute gastroenteritis (AGE) is a major medical condition for travellers worldwide, particularly travellers to low- and middle-income countries. Norovirus (NoV) is the most common cause of viral AGE in older children and adults, but data on prevalence and impact amongst travellers is limited., Methods: Prospective, multi-site, observational cohort study conducted 2015-2017, amongst adult international travellers from the US and Europe to areas of moderate to high risk of travel-acquired AGE. Participants provided self-collected pre-travel stool samples and self-reported AGE symptoms whilst travelling. Post-travel stool samples were requested from symptomatic subjects and a sample of asymptomatic travellers within 14 days of return. Samples were tested for NoV by RT-qPCR, genotyped if positive and tested for other common enteric pathogens by Luminex xTAG GPP., Results: Of the 1109 participants included, 437 (39.4%) developed AGE symptoms resulting in an overall AGE incidence of 24.7 per 100 person-weeks [95% confidence interval (CI): 22.4; 27.1]. In total, 20 NoV-positive AGE cases (5.2% of those tested) were identified at an incidence of 1.1 per 100 person-weeks (95% CI: 0.7; 1.7). NoV-positive samples belonged mostly to genogroup GII (18, 85.7%); None of the 13 samples sequenced belonged to genotype GII.4. Clinical severity of AGE was higher for NoV-positive than for NoV-negative cases (mean modified Vesikari Score 6.8 vs 4.9) with more cases classified as severe or moderate (25% vs 6.8%). In total, 80% of NoV-positive participants (vs 38.9% in NoV-negative) reported at least moderate impact on travel plans., Conclusions: AGE is a prevalent disease amongst travellers with a small proportion associated with NoV. Post-travel stool sample collection timing might have influenced the low number of NoV cases detected; however, NoV infections resulted in high clinical severity and impact on travel plans. These results may contribute to targeted vaccine development and the design of future studies on NoV epidemiology., (© International Society of Travel Medicine 2023. Published by Oxford University Press. All rights reserved. For Permissions, please e-mail: journals.permissions@oup.com.)

Since the coronavirus disease 2019 (COVID-19) pandemic, wastewater-based epidemiology (WBE) has been widely applied in many countries and regions for monitoring COVID-19 transmission in the population through testing severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) in wastewater. However, the amount of virus shed by individuals over time based on the stage of infection and accurate number of infections in the community creates challenges in predicting COVID-19 prevalence in the population and interpreting WBE results. In this study, we measured SARS-CoV-2, pepper mild mottle virus (PMMoV), and human mitochondrial DNA (mtDNA) in longitudinal fecal samples collected from 42 COVID-19 patients for up to 42 days after diagnosis. SARS-CoV-2 RNA was detected in 73.1% (19/26) of inpatient study participants in at least one of the collected fecal specimens during the sampling period. Most participants shed the virus within 3 weeks after diagnosis, but five inpatient participants still shed the virus between 20 and 60 days after diagnosis. The median concentration of SARS-CoV-2 in positive fecal samples was 1.08 × 10 5 genome copies (GC)/gram dry fecal material. PMMoV and mtDNA were detected in 99.4% (154/155) and 100% (155/155) of all fecal samples, respectively. The median concentrations of PMMoV RNA and mtDNA in fecal samples were 1.73 × 10 7 and 2.49 × 10 8 GC/dry gram, respectively. These results provide important information about the dynamics of fecal shedding of SARS-CoV-2 and two human fecal indicators in COVID-19 patients. mtDNA showed higher positive rates, higher concentrations, and less variability between and within individuals than PMMoV, suggesting that mtDNA could be a better normalization factor for WBE results than PMMoV., Competing Interests: The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest., (Copyright © 2024 Liu, Sablon, Wang, Hilton, Khalil, Ingersoll, Truell, Edupuganti, Alaaeddine, Naji, Monarrez, Wolfe, Rouphael, Kraft and Moe.)

Background: Hand hygiene is known to reduce healthcare-associated infections. However, it remains suboptimal among healthcare providers. In this study, we used the Behaviour-centered Design approach to explore the facilitators and deterrents to hand hygiene among healthcare providers in the Kampala Metropolitan area, Uganda., Methods: We conducted a formative qualitative study as part of a cluster randomised trial in 19 healthcare facilities (HCFs). The study used 19 semi-structured and 18 key informant interviews to collect data on hand hygiene status and facilitators and deterrents of hand hygiene. Research assistants transcribed verbatim and used a thematic framework aided by Nvivo 14.0. to undertake analysis. We used thick descriptions and illustrative quotes to enhance the credibility and trustworthiness of our findings., Results: About 47.4% of the HCFs had sufficient hand hygiene infrastructure, and 57.9% did not report total compliance with hand hygiene during patient care. The physical facilitator for hand hygiene was the presence of constant reminders such as nudges, while the biological included the frequency of patient contact and the nature of clinical work. The only biological deterrent was the heavy workload in HCFs. The executive brain facilitators included knowledge of workplace health risks, infection prevention and control (IPC) guidelines, and a positive attitude. A negative attitude was the executive brain deterrent to hand hygiene. Recognition, rewards, and fear of infections were the only motivated brain facilitators. Behavioural setting facilitators included proximity to functional hand hygiene infrastructure, the existence of active IPC committees, good leadership, and the availability of a budget for hand hygiene supplies. Behavioural setting deterrents included the non-functionality and non-proximity to hand hygiene infrastructure and inadequate supplies., Conclusions: The study revealed low compliance with hand hygiene during the critical moments of patient care and inadequacy of hand hygiene infrastructure. The deterrents to hand hygiene included a heavy workload, negative attitude, inadequate supplies, non-functionality, and long distance to hand washing stations. Facilitators included constant reminders, fear of infections, frequency of patient contact and nature of clinical work, positive attitude, knowledge of IPC guidelines, recognition and reward, good leadership, availability of budgets for hand hygiene supplies, availability and proximity to hand hygiene supplies and infrastructure and active IPC committees., Trial Registration: ISRCTN Registry with number ISRCTN98148144. The trial was registered on 23/11/2020., (© 2024. The Author(s).)

Institution-level wastewater-based surveillance was implemented during the COVID-19 pandemic, including in carceral facilities. We examined the relationship between COVID-19 diagnostic test results of residents in a jail in Atlanta, Georgia, USA (average population ≈2,700), and quantitative reverse transcription PCR signal for SARS-CoV-2 in weekly wastewater samples collected during October 2021‒May 2022. The jail offered residents rapid antigen testing at entry and periodic mass screenings by reverse transcription PCR of self-collected nasal swab specimens. We aggregated individual test data, calculated the Spearman correlation coefficient, and performed logistic regression to examine the relationship between strength of SARS-CoV-2 PCR signal (cycle threshold value) in wastewater and percentage of jail population that tested positive for COVID-19. Of 13,745 nasal specimens collected, 3.9% were COVID-positive (range 0%-29.5% per week). We observed a strong inverse correlation between diagnostic test positivity and cycle threshold value (r = -0.67; p<0.01). Wastewater-based surveillance represents an effective strategy for jailwide surveillance of COVID-19.

Background: Noroviruses (NoVs) are a leading cause of non-bacterial gastroenteritis in young children and adults worldwide. Snow Mountain Virus (SMV) is the prototype of NoV GII genotype 2 (GII.2) that has been developed as a viral model for human challenge models, an important tool for studying pathogenesis and immune response of NoV infections and for evaluating NoV vaccine candidates. Previous studies have identified blockade antibodies that block the binding of NoV virus-like particles (VLPs) to histo-blood group antigens (HBGAs) as a surrogate for neutralization in human Norwalk virus and GII.4 infections but little is known about SMV blockade antibodies., Methods: In this secondary data analysis study, blockade antibodies were characterized in pre-challenge and post-challenge serum samples from human subjects challenged with a new SMV inoculum. The correlation between blockade antibody geometric mean antibody titers (GMTs) and SMV-specific serum IgG/IgA GMTs were examined after stratifying the subjects by infection status. A linear mixed model was applied to test the association between HBGA blockade antibody concentrations and post-challenge days accounting for covariates and random effects., Results: Laboratory results from 33 SMV inoculated individuals were analyzed and 75.7% (25/33) participants became infected. Serum SMV-specific blockade antibodies, IgA, and IgG were all significantly different between infected and uninfected individuals beginning day 15 post-challenge. Within infected individuals, a significant correlation was observed between both IgG and IgA and blockade antibody concentration as early as day 6 post-challenge. Analysis of blockade antibody using the linear mixed model showed that infected individuals, when compared to uninfected individuals, had a statistically significant increase in blockade antibody concentrations across the post-challenge days. Among the post-challenge days, blockade antibody concentrations on days 15, 30, and 45 were significantly higher than those observed pre-challenge. The intraclass correlation coefficient (ICC) analysis indicated that the variability of blockade antibody titers is more observed between individuals rather than observations within subjects., Conclusions: These results indicate that HBGA-blockade antibody GMTs are generated after SMV challenge and the blockade antibodies were still detectable at day 45 post-challenge. These data indicate that the second generation of SMV inoculum is highly effective.

Monitoring SARS-CoV-2 in wastewater is a valuable approach to track COVID-19 transmission. Designing wastewater surveillance (WWS) with representative sampling sites and quantifiable results requires knowledge of the sewerage system and virus fate and transport. We developed a multi-level WWS system to track COVID-19 in Atlanta using an adaptive nested sampling strategy. From March 2021 to April 2022, 868 wastewater samples were collected from influent lines to wastewater treatment facilities and upstream community manholes. Variations in SARS-CoV-2 concentrations in influent line samples preceded similar variations in numbers of reported COVID-19 cases in the corresponding catchment areas. Community sites under nested sampling represented mutually-exclusive catchment areas. Community sites with high SARS-CoV-2 detection rates in wastewater covered high COVID-19 incidence areas, and adaptive sampling enabled identification and tracing of COVID-19 hotspots. This study demonstrates how a well-designed WWS provides actionable information including early warning of surges in cases and identification of disease hotspots., Competing Interests: The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (© 2022 The Author(s).)

Background: Genogroup II noroviruses are the most common cause of acute infectious gastroenteritis. We evaluated the use of a new GII.2 inoculum in a human challenge., Methods: Forty-four healthy adults (36 secretor-positive and 8 secretor-negative for histo-blood group antigens) were challenged with ascending doses of a new safety-tested Snow Mountain virus (SMV) GII.2 norovirus inoculum (1.2 × 104 to 1.2 × 107 genome equivalent copies [GEC]; n = 38) or placebo (n = 6). Illness was defined as diarrhea and/or vomiting postchallenge in subjects with evidence of infection (defined as GII.2 norovirus RNA detection in stool and/or anti-SMV immunoglobulin G [IgG] seroconversion)., Results: The highest dose was associated with SMV infection in 90%, and illness in 70% of subjects with 10 of 12 secretor-positive (83%) and 4 of 8 secretor-negative (50%) becoming ill. There was no association between prechallenge anti-SMV serum IgG concentration, carbohydrate-binding blockade antibody, or salivary immunoglobulin A and infection. The median infectious dose (ID50) was 5.1 × 105 GEC., Conclusions: High rates of infection and illness were observed in both secretor-positive and secretor-negative subjects in this challenge study. However, a high dose will be required to achieve the target of 75% illness to make this an efficient model for evaluating potential norovirus vaccines and therapeutics., Clinical Trials Registration: NCT02473224., Competing Interests: Potential conflicts of interest. N. R. has research support from Merck, Sanofi Pasteur, Lilly, Quidel, Pfizer and do not pose a conflict of interest for this paper. M. J. M. has research support from Lilly, Pfizer, Sanofi; personal fees from Pfizer and Meissa Vaccines and do not pose a conflict of interest for this paper. L. C. L. and R. S. B. have ongoing collaborations with Hillvax, VaxArt and Takeda that are unrelated and do not pose conflicts of interest with this report. C.L.M has collaborations with Takeda that are unrelated and do not pose conflicts of interest with this report. V. R. has research support from Sanofi Pasteur, unrelated, no conflict of interest with this report. E. J. A. has consulted for Pfizer, Sanofi Pasteur, Janssen, and Medscape, and his institution receives funds to conduct clinical research unrelated to this manuscript from MedImmune, Regeneron, PaxVax, Pfizer, GSK, Merck, Sanofi-Pasteur, Janssen, and Micron. He also serves on a safety monitoring board for Kentucky BioProcessing, Inc. and Sanofi Pasteur. No conflict of interest with this report. C. P., J. E. K., A. E. K., A. B., P. L., M. S. N., L. L., V. P., J. W., M. H. C., T. G., A. A., N. B., V. K., J. A. R., Y. W., and S. B. have no competing interests to declare. All authors have submitted the ICMJE Form for Disclosure of Potential Conflicts of Interest. Conflicts that the editors consider relevant to the content of the manuscript have been disclosed., (© The Author(s) 2022. Published by Oxford University Press for the Infectious Diseases Society of America. All rights reserved. For permissions, e-mail: journals.permissions@oup.com.)

An end goal of fecal source tracking (FST) is to provide information on risk of transmission of waterborne illnesses associated with fecal contamination. Ideally, concentrations of FST markers in ambient waters would reflect exposure risk. Human mtDNA is an FST marker that is exclusively human in origin and may be elevated in feces of individuals experiencing gastrointestinal inflammation. In this study, we examined whether human mtDNA is elevated in fecal samples from individuals with symptomatic norovirus infections using samples from the United States (US), Mozambique, and Bangladesh. We quantified hCYTB484 (human mtDNA) and HF183/BacR287 (human-associated Bacteroides ) FST markers using droplet digital polymerase chain reaction. We observed the greatest difference in concentrations of hCYTB484 when comparing samples from individuals with symptomatic norovirus infections versus individuals without norovirus infections or diarrhea symptoms: log 10 increase of 1.42 in US samples (3,820% increase, p -value = 0.062), 0.49 in Mozambique (308% increase, p -value = 0.061), and 0.86 in Bangladesh (648% increase, p -value = 0.035). We did not observe any trends in concentrations of HF183/BacR287 in the same samples. These results suggest concentrations of fecal mtDNA may increase during symptomatic norovirus infection and that mtDNA in environmental samples may represent an unambiguously human source-tracking marker that correlates with enteric pathogen exposure risk., Competing Interests: The authors declare no competing financial interest., (© 2022 The Authors. Published by American Chemical Society.)

The ongoing pandemic of the coronavirus disease 2019 (COVID-19) is a public health crisis of global concern. The progression of the COVID-19 pandemic has been monitored in the first place by testing symptomatic individuals for SARS-CoV-2 virus in the respiratory samples. Concurrently, wastewater carries feces, urine, and sputum that potentially contains SARS-CoV-2 intact virus or partially damaged viral genetic materials excreted by infected individuals. This brings significant opportunities for understanding the infection dynamics by environmental surveillance. It has advantages for the country, especially in densely populated areas where individual clinical testing is difficult. However, there are several challenges including: 1) establishing a sampling plan and schedule that is representative of the various catchment populations 2) development and validation of standardized protocols for the laboratory analysis 3) understanding hydraulic flows and virus transport in complex wastewater drainage systems and 4) collaborative efforts from government agencies, NGOs, public health units and academia., Competing Interests: The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (© 2022 Published by Elsevier B.V.)

SARS-CoV-2 is a respiratory virus, but it is also detected in a significant proportion of fecal samples from COVID-19 cases. Recent studies have shown that wastewater surveillance can be a low-cost tool compared to massive diagnostic testing for tracking COVID-19 outbreaks in communities, but most studies have focused on sampling from wastewater treatment plants. Institutional level wastewater surveillance may serve well for early warning purposes because specific geographic areas/populations with emerging cases can be tracked and immediate action can be executed in the event of a positive wastewater signal. In this study, a novel Moore swab method was developed and used for wastewater surveillance of COVID-19 at an institutional level. Of the 442 swab samples tested, 148 (33.5%) swabs collected from the three campuses and two buildings were positive for SARS-CoV-2 RNA. Further study of the quarantine building with a known number of cases indicated that this method was sensitive enough to detect few cases in the building. In addition, comparison between grab samples and Moore swab samples from the hospital sewage line indicated that Moore swabs were more sensitive than grab samples and offer a simple, inexpensive method for obtaining a composite sample of virus in wastewater over a 24-48 h period. These results suggest that collection and analyses of Moore swabs for SARS-CoV-2 RNA detection is a sensitive, low-cost, and easy to use tool for COVID-19 surveillance that is useful for institutional settings and could be deployed in low-resource settings to identify emerging COVID-19 clusters in communities., Competing Interests: Declaration of competing interest The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (Copyright © 2021 Elsevier B.V. All rights reserved.)

Background: During 2014 to 2019, the SaniPath Exposure Assessment Tool, a standardized set of methods to evaluate risk of exposure to fecal contamination in the urban environment through multiple exposure pathways, was deployed in 45 neighborhoods in ten cities, including Accra and Kumasi, Ghana; Vellore, India; Maputo, Mozambique; Siem Reap, Cambodia; Atlanta, United States; Dhaka, Bangladesh; Lusaka, Zambia; Kampala, Uganda; Dakar, Senegal., Objective: Assess and compare risk of exposure to fecal contamination via multiple pathways in ten cities., Methods: In total, 4053 environmental samples, 4586 household surveys, 128 community surveys, and 124 school surveys were collected. E. coli concentrations were measured in environmental samples as an indicator of fecal contamination magnitude. Bayesian methods were used to estimate the distributions of fecal contamination concentration and contact frequency. Exposure to fecal contamination was estimated by the Monte Carlo method. The contamination levels of ten environmental compartments, frequency of contact with those compartments for adults and children, and estimated exposure to fecal contamination through any of the surveyed environmental pathways were compared across cities and neighborhoods., Results: Distribution of fecal contamination in the environment and human contact behavior varied by city. Universally, food pathways were the most common dominant route of exposure to fecal contamination across cities in low-income and lower-middle-income countries. Risks of fecal exposure via water pathways, such as open drains, flood water, and municipal drinking water, were site-specific and often limited to smaller geographic areas (i.e., neighborhoods) instead of larger areas (i.e., cities)., Conclusions: Knowledge of the relative contribution to fecal exposure from multiple pathways, and the environmental contamination level and frequency of contact for those "dominant pathways" could provide guidance for Water, Sanitation, and Hygiene (WASH) programming and investments and enable local governments and municipalities to improve intervention strategies to reduce the risk of exposure to fecal contamination., Competing Interests: Declaration of competing interest The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (Copyright © 2021 The Authors. Published by Elsevier B.V. All rights reserved.)

Exposure to enteric pathogens in the environment poses a serious risk for infection and disease. The accurate detection and quantification of enteric pathogens in environmental samples is critical for understanding pathogen transport and fate and developing risk assessment models. In this study, we successfully applied TaqMan real-time PCR assays to quantitatively detect five human-specific pathogens (Shigella/EIEC, Salmonella Typhi, Vibrio cholera, Norovirus, and Giardia) in samples from open drains, canals, floodwater, septic tanks, and anaerobic baffled reactors (ABR) collected in Mirpur, Dhaka, Bangladesh from April to October 2019. Overall, the grab and sediment samples showed low inhibition but the ultrafiltration samples collected from open drain had significantly higher (P = 0.0049) degree of PCR inhibition (median Ct = 31.06) compared to the extraction controls (Ct = 28.54). We developed a two-step method to adjust underestimation of pathogen quantities due to PCR inhibition and non-optimum PCR efficiency. Compared to other sample types, ultrafiltration samples demonstrated a wide range of concentration increase (1.0%-182.5%) by pathogens after adjusting for PCR inhibition and non-optimum efficiencies. These quantitative qPCR assays are successful in quantifying multiple enteric pathogens in environmental samples, and the adjustment method would be useful for correcting underestimates of pathogen quantities due to partial PCR inhibition and non-optimum efficiency., (Copyright © 2021 Elsevier B.V. All rights reserved.)

Enteric fever is a severe systemic infection caused by Salmonella enterica serovar Typhi (ST) and Salmonella enterica serovar Paratyphi A (SPA). Detection of ST and SPA in wastewater can be used as a surveillance strategy to determine burden of infection and identify priority areas for water, sanitation, and hygiene interventions and vaccination campaigns. However, sensitive and specific detection of ST and SPA in environmental samples has been challenging. In this study, we developed and validated two methods for concentrating and detecting ST/SPA from wastewater: the Moore swab trap method for qualitative results, and ultrafiltration (UF) for sensitive quantitative detection, coupled with qPCR. We then applied these methods for ST and SPA wastewater surveillance in Kolkata, India and Dhaka, Bangladesh, two enteric fever endemic areas. The qPCR assays had a limit of detection of 17 equivalent genome copies (EGC) for ST and 25 EGC for SPA with good reproducibility. In seeded trials, the Moore swab method had a limit of detection of approximately 0.05-0.005 cfu/mL for both ST and SPA. In 53 Moore swab samples collected from three Kolkata pumping stations between September 2019 and March 2020, ST was detected in 69.8% and SPA was detected in 20.8%. Analysis of sewage samples seeded with known amount of ST and SPA and concentrated via the UF method, followed by polyethylene glycol precipitation and qPCR detection demonstrated that UF can effectively recover approximately 8, 5, and 3 log 10 cfu of seeded ST and SPA in 5, 10, and 20 L of wastewater. Using the UF method in Dhaka, ST was detected in 26.7% (8/30) of 20 L drain samples with a range of 0.11-2.10 log 10 EGC per 100 mL and 100% (4/4) of 20 L canal samples with a range of 1.02-2.02 log 10 EGC per 100 mL. These results indicate that the Moore swab and UF methods provide sensitive presence/absence and quantitative detection of ST/SPA in wastewater samples., Competing Interests: The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest., (Copyright © 2021 Liu, Ibaraki, Kapoor, Amin, Das, Miah, Mukhopadhyay, Rahman, Dutta and Moe.)

Phages, such as those infecting Bacteroides spp., have been proven to be reliable indicators of human fecal contamination in microbial source tracking (MST) studies, and the efficacy of these MST markers found to vary geographically. This study reports the application and evaluation of candidate MST methods (phages infecting previously isolated B. fragilis strain GB-124, newly isolated Bacteroides strains (K10, K29, and K33) and recently isolated Kluyvera intermedia strain ASH-08), along with non-source specific somatic coliphages (SOMCPH infecting strain WG-5) and indicator bacteria ( Escherichia coli ) for identifying fecal contamination pathways in Kolkata, India. Source specificity of the phage-based methods was first tested using 60 known non-human fecal samples from common animals, before being evaluated with 56 known human samples (municipal sewage) collected during both the rainy and dry season. SOMCPH were present in 40-90% of samples from different animal species and in 100% of sewage samples. Phages infecting Bacteroides strain GB-124 were not detected from the majority (95%) of animal samples (except in three porcine samples) and were present in 93 and 71% of the sewage samples in the rainy and dry season (Mean = 1.42 and 1.83 log 10 PFU/100mL, respectively), though at lower levels than SOMCPH (Mean = 3.27 and 3.02 log 10 PFU/100mL, respectively). Phages infecting strain ASH-08 were detected in 89 and 96% of the sewage samples in the rainy and dry season, respectively, but were also present in all animal samples tested (except goats). Strains K10, K29, and K30 were not found to be useful MST markers due to low levels of phages and/or co-presence in non-human sources. GB-124 and SOMCPH were subsequently deployed within two low-income neighborhoods to determine the levels and origin of fecal contamination in 110 environmental samples. E. coli , SOMCPH, and phages of GB-124 were detected in 68, 42, and 28% of the samples, respectively. Analyses of 166 wastewater samples from shared community toilets and 21 samples from sewage pumping stations from the same districts showed that SOMCPH were present in 100% and GB-124 phages in 31% of shared toilet samples (Median = 5.59 and <1 log 10 PFU/100 mL, respectively), and both SOMCPH and GB-124 phages were detected in 95% of pumping station samples (Median = 5.82 and 4.04 log 10 PFU/100 mL, respectively). Our findings suggest that GB-124 and SOMCPH have utility as low-cost fecal indicator tools which can facilitate environmental surveillance of enteric organisms, elucidate human and non-human fecal exposure pathways, and inform interventions to mitigate exposure to fecal contamination in the residential environment of Kolkata, India., Competing Interests: The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest., (Copyright © 2021 Kapoor, Ebdon, Wadhwa, Chowdhury, Wang, Raj, Siesel, Durry, Mairinger, Mukhopadhyay, Kanungo, Dutta and Moe.)

Background: Health facility deliveries are generally associated with improved maternal and child health outcomes. However, in Uganda, little is known about factors that influence use of health facilities for delivery especially in rural areas. In this study, we assessed the factors associated with health facility deliveries among mothers living within the catchment areas of major health facilities in Rukungiri and Kanungu districts, Uganda., Methods: Cross-sectional data were collected from 894 randomly-sampled mothers within the catchment of two private hospitals in Rukungiri and Kanungu districts. Data were collected on the place of delivery for the most recent child, mothers' sociodemographic and economic characteristics, and health facility water, sanitation and hygiene (WASH) status. Modified Poisson regression was used to estimate prevalence ratios (PRs) for the determinants of health facility deliveries as well as factors associated with private versus public utilization of health facilities for childbirth., Results: The majority of mothers (90.2%, 806/894) delivered in health facilities. Non-facility deliveries were attributed to faster progression of labour (77.3%, 68/88), lack of transport (31.8%, 28/88), and high cost of hospital delivery (12.5%, 11/88). Being a business-woman [APR = 1.06, 95% CI (1.01-1.11)] and belonging to the highest wealth quintile [APR = 1.09, 95% CI (1.02-1.17)] favoured facility delivery while a higher parity of 3-4 [APR = 0.93, 95% CI (0.88-0.99)] was inversely associated with health facility delivery as compared to parity of 1-2. Factors associated with delivery in a private facility compared to a public facility included availability of highly skilled health workers [APR = 1.15, 95% CI (1.05-1.26)], perceived higher quality of WASH services [APR = 1.11, 95% CI (1.04-1.17)], cost of the delivery [APR = 0.85, 95% CI (0.78-0.92)], and availability of caesarean services [APR = 1.13, 95% CI (1.08-1.19)]., Conclusion: Health facility delivery service utilization was high, and associated with engaging in business, belonging to wealthiest quintile and having higher parity. Factors associated with delivery in private facilities included health facility WASH status, cost of services, and availability of skilled workforce and caesarean services.

Background: Hand hygiene (HH) among healthcare workers (HCWs) is critical for infection prevention and control (IPC) in healthcare facilities (HCFs). Nonetheless, it remains a challenge in HCFs, largely due to lack of high-impact and efficacious interventions. Environmental cues and mobile phone health messaging (mhealth) have the potential to improve HH compliance among HCWs, however, these remain under-studied. Our study will determine the impact of mhealth hygiene messages and environmental cues on HH practice among HCWs in the Greater Kampala Metropolitan Area (GKMA)., Methods: The study is a cluster-randomized trial, which will be guided by the behaviour centred design model and theory for behaviour change. During the formative phase, we shall conduct 30 key informants' interviews and 30 semi-structured interviews to explore the barriers and facilitators to HCWs' HH practice. Besides, observations of HH facilities in 100 HCFs will be conducted. Findings from the formative phase will guide the intervention design during a stakeholders' insight workshop. The intervention will be implemented for a period of 4 months in 30 HCFs, with a sample of 450 HCWs who work in maternity and children's wards. HCFs in the control arm will receive innovatively designed HH facilities and supplies. HCWs in the intervention arm, in addition to the HH facilities and supplies, will receive environmental cues and mhealth messages. The main outcome will be the proportion of utilized HH opportunities out of the 9000 HH opportunities to be observed. The secondary outcome will be E. coli concentration levels in 100mls of hand rinsates from HCWs, an indicator of recent fecal contamination and HH failure. We shall run multivariable logistic regression under the generalized estimating equations (GEE) framework to account for the dependence of HH on the intervention., Discussion: The study will provide critical findings on barriers and facilitators to HH practice among HCWs, and the impact of environmental cues and mhealth messages on HCWs' HH practice., Trial Registration: ISRCTN Registry with number ISRCTN98148144 . The trial was registered on 23/11/2020.

Background: Despite wide usage of on-site sanitation, there is limited field-based evidence on the removal or release of pathogens from septic tanks and other primary treatment systems, such as anaerobic baffled reactors (ABR). In two low-income areas in Dhaka, we conducted a cross-sectional study to explore pathogen loads discharged from commonly used on-site sanitation-systems and their transport in nearby drains and waterways., Methods: We collected samples of drain water, drain sediment, canal water, and floodwater from April-October 2019. Sludge, supernatant, and effluent samples were also collected from septic tanks and ABRs. We investigated the presence and concentration of selected enteric pathogens (Shigella, Vibrio cholerae (V. cholerae), Salmonella Typhi (S. Typhi), Norovirus Genogroup-II (NoV-GII), and Giardia) and presence of Cryptosporidium in these samples using quantitative polymerase chain reaction (qPCR).The equivalent genome copies (EGC) of individual pathogens were estimated in each sample by interpolation of the mean Ct value to the corresponding standard curve and the dilution factor for each sample type. Absolute quantification was expressed as log 10 EGC per 100 mL for the water samples and log 10 EGC per gram for the sediment samples., Results: Among all samples tested (N = 151), 89% were contaminated with Shigella, 68% with V. cholerae and NoV-GII, 32% with Giardia, 17% with S. Typhi and 6% with Cryptosporidium. A wide range of concentration of pathogens [range: mean log 10 concentration of Giardia = 0.74 EGC/100 mL in drain ultrafiltration samples to mean log 10 concentration of NoV-GII and Giardia = 7.11 EGC/100 mL in ABR sludge] was found in all environmental samples. The highest pathogen concentrations were detected in open drains [range: mean log 10 concentration = 2.50-4.94 EGC/100 mL], septic tank effluent [range: mean log 10 concentration = 3.32-4.65 EGC/100 mL], and ABR effluent [range: mean log 10 concentration = 2.72-5.13 EGC/100 mL]., Conclusions: High concentrations of pathogens (particularly NoV-GII, V.cholerae and Shigella) were frequently detected in environmental samples from two low-income urban neighbourhoods of Dhaka city. The numerous environmental exposure pathways for children and adults make these findings of public health concern. These results should prompt rethinking of how to achieve safe sanitation solutions that protect public health in dense low-income areas. In particular, improved management and maintenance regimes, further treatment of liquid effluent from primary treatment processes, and appropriate application of onsite, decentralised and offsite sanitation systems given the local context., (Copyright © 2020. Published by Elsevier GmbH.)

Noroviruses are a major public health concern: their high infectivity and environmental persistence have been documented in several studies. Genetic sequencing shows that noroviruses are highly variable, and exhibit rapid evolution. A few human challenge studies have been performed with norovirus, leading to estimates of their infectivity. However, such incidental estimates do not provide insight into the biological variation of the virus and the interaction with its human host. To study the variation in infectivity and pathogenicity of norovirus, multiple challenge studies must be analysed jointly, to compare their differences and describe how virus infectivity and host susceptibility vary. Since challenge studies can only provide a small sample of the diversity in the natural norovirus population, outbreaks should be exploited as an additional source of information. The present study shows how challenge studies and 'natural experiments' can be combined in a multilevel dose response framework. Infectivity and pathogenicity are analysed by secretor status as a host factor, and genogroup as a pathogen factor. Infectivity, characterized as the estimated mean infection risk when exposed to 1 genomic copy (qPCR unit)is 0.28 for GI norovirus, and 0.076 for GII virus, both in Se + subjects. The corresponding risks of acute enteric illness are somewhat lower, about 0.2 (GI) and 0.035 (GII), in outbreaks. Se - subjects are protected, with substantially lower risks of infection (0.00007 and 0.015 at a dose of 1 GC of GI and GII virus, respectively). The present study shows there is considerable variability in risk of infection and especially risk of acute symptoms following infection with norovirus. These challenge and outbreak data consistently indicate high infectivity among secretor positives and protection in secretor negatives., (Copyright © 2020 The Author(s). Published by Elsevier B.V. All rights reserved.)

Inadequate sanitation can lead to exposure to fecal contamination through multiple environmental pathways and can result in adverse health outcomes. By understanding the relative importance of multiple exposure pathways, sanitation interventions can be tailored to those pathways with greatest potential public health impact. The SaniPath Exposure Assessment Tool allows users to identify and quantify human exposure to fecal contamination in low-resource urban settings through a systematic yet customizable process. The Tool includes: a project management platform; mobile data collection and a data repository; protocols for primary data collection; and automated exposure assessment analysis. The data collection protocols detail the process of conducting behavioral surveys with households, school children, and community groups to quantify contact with fecal exposure pathways and of collecting and analyzing environmental samples for E. coli as an indicator of fecal contamination. Bayesian analyses are used to estimate the percentage of the population exposed and the mean dose of fecal exposure from microbiological and behavioral data. Fecal exposure from nine pathways (drinking water, bathing water, surface water, ocean water, open drains, floodwater, raw produce, street food, and public or shared toilets) can be compared through a common metric-estimated ingestion of E. coli units (MPN or CFU) per month. The Tool generates data visualizations and recommendations for interventions designed for both scientific and lay audiences. When piloted in Accra, Ghana, the results of the Tool were comparable with that of an in-depth study conducted in the same neighborhoods and highlighted consumption of raw produce as a dominant exposure pathway. The Tool has been deployed in nine cities to date, and the results are being used by local authorities to design and prioritize programming and policy. The SaniPath Tool is a novel approach to support public-health evidence-based decision-making for urban sanitation policies and investments., Competing Interests: The authors have declared that no competing interests exist.

Environmental surveillance can be used for monitoring enteric disease in a population by detecting pathogens, shed by infected people, in sewage. Detection of pathogens depends on many factors: infection rates and shedding in the population, pathogen fate in the sewerage network, and also sampling sites, sample size, and assay sensitivity. This complexity makes the design of sampling strategies challenging, which creates a need for mathematical modeling to guide decision making. In the present study, a model was developed to simulate pathogen shedding, pathogen transport and fate in the sewerage network, sewage sampling, and detection of the pathogen. The simulation study used Salmonella enterica serovar Typhi (S. Typhi) as the target pathogen and two wards in Kolkata, India as the study area. Five different sampling strategies were evaluated for their sensitivity of detecting S. Typhi, by sampling unit: sewage pumping station, shared toilet, adjacent multiple shared toilets (primary sampling unit), pumping station + shared toilets, pumping station + primary sampling units. Sampling strategies were studied in eight scenarios with different geographic clustering of risk, pathogen loss (decay, leakage), and sensitivity of detection assays. A novel adaptive sampling site allocation method was designed, that updates the locations of sampling sites based on their performance. We then demonstrated how the simulation model can be used to predict the performance of environmental surveillance and how it is improved by optimizing the allocation of sampling sites. The results are summarized as a decision tree to guide the sampling strategy based on disease incidence, geographic distribution of risk, pathogen loss, and the sensitivity of the detection assay. The adaptive sampling site allocation method consistently outperformed alternatives with fixed site locations in most scenarios. In some cases, the optimum allocation method increased the median sensitivity from 45% to 90% within 20 updates., (Copyright © 2020 The Author(s). Published by Elsevier B.V. All rights reserved.)

Noroviruses are known to bind to histo-blood group antigens (HBGAs) and the specific binding patterns depend on the virus genotype. However, the development of point-of-care diagnostic assays based on this binding has been challenging due to low assay sensitivity. This study utilized a well-defined stool collection from a GII.2 Snow Mountain Virus (SMV) human challenge study to investigate virus recovery from stool and emesis samples using HBGA-coated beads. SMV was recovered from H type III-coated beads for 13 stool specimens out of 27 SMV-positive specimens tested. After adjusting for non-specific binding to PEG-coated beads, the mean percent recovery by H type III-coated beads was 308.11% +/- 861.61. Recovery by H type III ligands was subject-specific and weakly correlated with stool consistency. Input virus titer was not correlated with SMV recovery. The results suggest that the generally low virus recovery we observed may be due to bead saturation or hindrance by existing glycans in the matrix that precluded the virus from being captured by the synthetic glycans. These results indicate a strong role for subject-specific and matrix effects in HBGA binding by SMV. Further investigation of the nature of this interference is needed to facilitate development of high sensitivity diagnostic assays.

Alongside efforts to improve safe management of feces along the entire sanitation chain, including after the toilet, global sanitation efforts are focusing on universal access 'basic' services: onsite facilities that safely contain excreta away from human contact. Although fecal sludge management is improving in urban areas, open drains remain a common fate for feces in these often densely-populated neighborhoods in low-income countries. To-date, it is unclear to what extent complete coverage of onsite sanitation reduces fecal contamination in the urban environment and how fecal contamination varies within urban drains across neighborhoods by sanitation status within a city. We assessed how neighborhood levels of environmental fecal contamination (via spatially-representative sampling of open drains for E. coli) varied across four neighborhoods with varying income, type and coverage of household sanitation facilities, and population density in Accra, Ghana. Neighborhoods with very high sanitation coverage (≥89%) still had high (>4 log 10  CFU/100 mL) E. coli concentrations in drains. Between-neighborhood variation in E. coli levels among the high coverage neighborhoods was significant: drain concentrations in neighborhoods with 93% and 89% coverage (4.7 (95% CI: 4.5, 4.9) & 4.9 (95% CI: 4.5, 5.3) log 10  CFU/100 mL, respectively) were higher than in the neighborhood with 97% coverage (4.1 log 10  CFU/100 mL, 95% CI: 3.8, 4.4 log 10  CFU/100 mL). Compared with the highest coverage neighborhood, the neighborhood with lowest coverage (48%) also had higher E. coli concentrations (5.6 log 10  CFU/100 mL, 95% CI: 5.3, 5.9 log 10  CFU/100 mL). Although fecal contamination in open drains appeared lower in neighborhoods with higher onsite sanitation coverage (and vice versa), other factors (e.g. fecal sludge management, animals, population density) may affect drain concentrations. These results underscore that neighborhood-level onsite sanitation improvements alone may not sufficiently reduce fecal hazards to public health from open drains. These findings supporting the need for integrated, city-level fecal sludge management alongside multifaceted interventions to reduce fecal contamination levels and human exposure., Competing Interests: Declaration of competing interest The authors declare no conflicts of interest. The funders had no role in the design of the study; in the collection, analyses, or interpretation of data; in the writing of the manuscript, or in the decision to publish the results., (Published by Elsevier GmbH.)

Norovirus is the most common cause of epidemic and endemic acute gastroenteritis. However, national estimates of the infection burden are challenging. This study used a nationally representative serum bank to estimate the seroprevalence to five norovirus genotypes including three GII variants: GI.1 Norwalk, GI.4, GII.3, GII.4 US95/96, GII.4 Farmington Hills, GII.4 New Orleans, and GIV.1 in the USA population (aged 16 to 49 years). Changes in seroprevalence to the three norovirus GII.4 variants between 1999 and 2000, as well as 2003 and 2004, were measured to examine the role of population immunity in the emergence of pandemic GII.4 noroviruses. The overall population-adjusted seroprevalence to any norovirus was 90.0% (1999 to 2000) and 95.9% (2003 to 2004). Seroprevalence was highest to GI.1 Norwalk, GII.3, and the three GII.4 noroviruses. Seroprevalence to GII.4 Farmington Hills increased significantly between the 1999 and 2000, as well as the 2003 and 2004, study cycles, consistent with the emergence of this pandemic strain. Seroprevalence to GII.4 New Orleans also increased over time, but to a lesser degree. Antibodies against the GIV.1 norovirus were consistently detected (population-adjusted seroprevalence 19.1% to 25.9%), with rates increasing with age. This study confirms the high burden of norovirus infection in US adults, with most adults having multiple norovirus infections over their lifetime., Competing Interests: The authors declare no conflict of interest.

Rapid urbanization has led to a growing sanitation crisis in urban areas of Bangladesh and potential exposure to fecal contamination in the urban environment due to inadequate sanitation and poor fecal sludge management. Limited data are available on environmental fecal contamination associated with different exposure pathways in urban Dhaka. We conducted a cross-sectional study to explore the magnitude of fecal contamination in the environment in low-income, high-income, and transient/floating neighborhoods in urban Dhaka. Ten samples were collected from each of 10 environmental compartments in 10 different neighborhoods (4 low-income, 4 high-income and 2 transient/floating neighborhoods). These 1,000 samples were analyzed with the IDEXX-Quanti-Tray technique to determine most-probable-number (MPN) of E. coli. Samples of open drains (6.91 log10 MPN/100 mL), surface water (5.28 log10 MPN/100 mL), floodwater (4.60 log10 MPN/100 mL), produce (3.19 log10 MPN/serving), soil (2.29 log10 MPN/gram), and street food (1.79 log10 MPN/gram) had the highest mean log10 E. coli contamination compared to other samples. The contamination concentrations did not differ between low-income and high-income neighborhoods for shared latrine swabs, open drains, municipal water, produce, and street foodsamples. E. coli contamination levels were significantly higher (p <0.05) in low-income neighborhoods compared to high-income for soil (0.91 log10 MPN/gram, 95% CI, 0.39, 1.43), bathing water (0.98 log10 MPN/100 mL, 95% CI, 0.41, 1.54), non-municipal water (0.64 log10 MPN/100 mL, 95% CI, 0.24, 1.04), surface water (1.92 log10 MPN/100 mL, 95% CI, 1.44, 2.40), and floodwater (0.48 log10 MPN/100 mL, 95% CI, 0.03, 0.92) samples. E. coli contamination were significantly higher (p<0.05) in low-income neighborhoods compared to transient/floating neighborhoods for drain water, bathing water, non-municipal water and surface water. Future studies should examine behavior that brings people into contact with the environment and assess the extent of exposure to fecal contamination in the environment through multiple pathways and associated risks., Competing Interests: The authors have declared that no competing interests exist.

Background: Open drains are common methods of transporting solid waste and excreta in low-income urban neighborhoods. Open drains can overflow due to blockages with solid waste and during rainfall, posing exposure risks. The goal of this study was to evaluate whether pediatric enteric infection was associated with open drains and flooding in a dense, low-income, urban neighborhood., Methods: As part of the MAL-ED study in Vellore, India, a cohort of 230 children provided stool specimens at 14-17 scheduled home visits and during diarrheal episodes in the first two years of life. All specimens were analyzed for enteric pathogens. Caregivers in 100 households reported on flooding of drains and households and monthly frequency of contact with open drains and flood water. Household GPS points were collected. Monthly rainfall totals for the Vellore district were collected from the Indian Meteorological Department. Clustering of reported drain and house flooding were identified by Kulldorff's Bernoulli Spatial Scan. Differences in enteric infection were assessed for household responses and spatial clusters, with interactions between reported flooding and rainfall to approximate monthly drain flooding retrospectively, using multivariable, mixed-effects logistic regression models., Results: Coverage of household toilets was low (33%), and most toilets (82%) discharged directly into open drains, suggesting poor neighborhood fecal sludge management. Odds of enteric infection increased significantly with total monthly rainfall for children who lived in households that reported that the nearby drain flooded (4% increase per cm of rain: OR: 1.04, 95% CI: 1.00-1.08) and for children in households in a downstream spatial cluster of reported drain flooding (5% increase per cm of rain: OR: 1.05, 95% CI: 1.01-1.09). There was no association between odds of enteric infection and frequency of reported contact with drain or floodwater., Conclusions: Children in areas susceptible to open drain flooding had increased odds of enteric infection as rainfall increased. Results suggested that infection increased with rainfall due to neighborhood infrastructure (including poor fecal sludge management) and not frequency of contact. Thus, these exposures may not be mitigated by changes in personal behaviors alone. These results underscore the importance of improving the neighborhood environment to improve children's health in low-income, urban settings.

Background: Acute gastroenteritis (AGE) is the leading cause of illness among returning travelers seeking medical care. Multiple types of enteric pathogens can cause travel-acquired AGE and, while bacterial pathogens have a predominant role, the importance of viruses, such as norovirus, is increasingly recognized. There is a lack of information on travel-acquired norovirus incidence among symptomatic and asymptomatic individuals irrespective of healthcare-seeking behavior. Our aim is to estimate the incidence of travel-acquired AGE due to norovirus and to characterize the burden of disease among international travelers from the United States and Europe., Methods: We describe a prospective cohort study implemented in five US and European sites to estimate the role of AGE due to norovirus among adult international travelers. We enrolled individuals aged 18 years and older who are traveling to regions of moderate-high risk of AGE, or via cruise ship with an international port stop, with a trip duration of 3-15 days. The study will generate a wide range of health and travel-related data for pre-, during, and up to 6-months post-travel. We will identify laboratory-confirmed travel-acquired norovirus infections among both symptomatic and asymptomatic individuals from self-collected whole stool samples tested via quantitative RT-PCR. Coinfections will be identified in a subset of travelers with AGE using a multiplex molecular-based assay., Discussion: This study is unique in design and breadth of data collected. The prospective collection of health and behavioral data, as well as biologic samples from travelers irrespective of symptoms, will provide useful data to better understand the importance of norovirus AGE among international travelers. This study will provide data to estimate the incidence of norovirus infections and AGE and the risk of post-infectious sequelae in the 6-month post-travel period serving as a baseline for future norovirus AGE vaccination studies. This study will contribute valuable information to better understand the role of norovirus in travel-acquired AGE risk and the impact of these infections on a broad set of outcomes.

In recent decades, quantitative microbial risk assessment (QMRA) has been widely used to assess exposure to fecal microbes and associated health risks. In this study, a multipathway exposure assessment model was developed to evaluate exposure to fecal microbes for children under 5 in highly contaminated urban environments. Children had contact with various environmental compartments. The contamination levels of these compartments were estimated from fecal indicator counts in the environmental samples. Structured observations of child behavior (including activities, locations, and time) were used to model behavioral sequences as a dynamic network. The exposure model combines behavior sequences with environmental contamination, using additional exposure factors when needed, to estimate the number of fecal microbes transferred from environmental sources to human oral ingestion. As fecal exposure in a highly contaminated urban environment consists of contributions from multiple pathways, it is imperative to study their relative importance. The model helps us better understand the characteristics of the exposure pathways that may be driven by variation in contamination and by variable behavior, like hygiene and high-risk activities. Importantly, the model also allows prediction of the quantitative effects of an intervention-the expected reduction in exposure due to infrastructural or behavioral changes-by means of scenario studies. Based on experience with this exposure model, we make specific recommendations for additional studies of child behavior and exposure factors in order to fill critical information gaps and improve the model structure and assumptions., (© 2017 The Authors Risk Analysis published by Wiley Periodicals, Inc. on behalf of Society for Risk Analysis.)

Exposure to fecal contamination in public areas, especially in dense, urban environments, may significantly contribute to enteric infection risk. This study examined associations between sanitation and fecal contamination in public environments in four low-income neighborhoods in Accra, Ghana. Soil (n = 72) and open drain (n = 90) samples were tested for E. coli, adenovirus, and norovirus. Sanitation facilities in surveyed households (n = 793) were categorized by onsite fecal sludge containment ("contained" vs. "uncontained") using previous Joint Monitoring Program infrastructure guidelines. Most sanitation facilities were shared by multiple households. Associations between spatial clustering of household sanitation coverage and fecal contamination were examined, controlling for neighborhood and population density (measured as enumeration areas in the 2010 census and spatially matched to sample locations). E. coli concentrations in drains within 50m of clusters of contained household sanitation were more than 3 log-units lower than those outside of clusters. Further, although results were not always statistically significant, E. coli concentrations in drains showed consistent trends with household sanitation coverage clusters: concentrations were lower in or near clusters of high coverage of household sanitation facilities-especially contained facilities-and vice versa. Virus detection in drains and E. coli concentrations in soil were not significantly associated with clustering of any type of household sanitation and did not exhibit consistent trends. Population density alone was not significantly associated with any of the fecal contamination outcomes by itself and was a significant, yet inconsistent, effect modifier of the association between sanitation clusters and E. coli concentrations. These findings suggest clustering of contained household sanitation, even when shared, may be associated with lower levels of fecal contamination within drains in the immediate public domain. Further research is needed to better quantify these relationships and examine impacts on health., Competing Interests: The authors have declared that no competing interests exist.

In crowded urban settlements in low-income countries, many households rely on shared sanitation facilities. Shared facilities are not currently considered "improved sanitation" because of concerns about whether hygiene conditions sufficiently protect users from the feces of others. Prevention of fecal exposure at a latrine is only one aspect of sanitary safety. Ensuring consistent use of latrines for feces disposal, especially child feces, is required to reduce fecal contamination in households and communities. Household crowding and shared latrine access are correlated in these settings, rendering latrine use by neighbors sharing communal living areas as critically important for protecting one's own household. This study in Accra, Ghana, found that household access to a within-compound basic latrine was associated with higher latrine use by children of ages 5-12 years and for disposal of feces of children < 5 years, compared with households using public latrines. However, within-compound access was not associated with improved child feces disposal by other caregivers in the compound. Feces was rarely observed in household compounds but was observed more often in compounds with latrines versus compounds relying on public latrines. Escherichia coli and human adenovirus were detected frequently on household surfaces, but concentrations did not differ when compared by latrine access or usage practices. The differences in latrine use for households sharing within-compound versus public latrines in Accra suggest that disaggregated shared sanitation categories may be useful in monitoring global progress in sanitation coverage. However, compound access did not completely ensure that households were protected from feces and microbial contamination.

Small water enterprises (SWEs) have lower capital expenditures than centralized systems, offering decentralized solutions for rural markets. This study evaluated SWEs in rural Rwanda, where nine health care facilities (HCF) owned and operated water kiosks supplying water from onsite water treatment systems (WTS). SWEs were monitored for 12 months. Spearman's Rank Correlation Coefficient (r s ) was used to evaluate correlations between demand for kiosk water and community characteristics, and between kiosk profit and factors influencing the cost model. On average, SWEs distributed 15,300 L/month. One SWE ran at a loss, four had profit margins of ≤10% and four had profit margins of 45-75%. Factors influencing SWE performance were intermittent water supply (87% of SWE closures were due to water shortage), consumer demand (demand was high where populations already used improved water sources (r s = 0.81, p = 0.02)), price sensitivity (demand was lower where SWEs had high prices (r s = -0.65, p = 0.08)), and production cost (water utility tariffs negatively impacted SWE profits (r s = -0.52, p < 0.01)). Sustainability was more favorable in circumstances where recovery of capital expenditures was not expected, and the demand for treated water was sufficient to fund operational expenditures. Future research is needed to assess the extent to which kiosk revenue can support ongoing operational costs of WTS and kiosks both at HCF and in other contexts., Competing Interests: The authors declare no conflict of interest.

Rapid urbanization has contributed to an urban sanitation crisis in low-income countries. Residents in low-income, urban neighborhoods often have poor sanitation infrastructure and services and may experience frequent exposure to fecal contamination through a range of pathways. There are little data to prioritize strategies to decrease exposure to fecal contamination in these complex and highly contaminated environments, and public health priorities are rarely considered when planning urban sanitation investments. The SaniPath Study addresses this need by characterizing pathways of exposure to fecal contamination. Over a 16 month period, an in-depth, interdisciplinary exposure assessment was conducted in both public and private domains of four neighborhoods in Accra, Ghana. Microbiological analyses of environmental samples and behavioral data collection techniques were used to quantify fecal contamination in the environment and characterize the behaviors of adults and children associated with exposure to fecal contamination. Environmental samples (n = 1,855) were collected and analyzed for fecal indicators and enteric pathogens. A household survey with 800 respondents and over 500 hours of structured observation of young children were conducted. Approximately 25% of environmental samples were collected in conjunction with structured observations (n = 441 samples). The results of the study highlight widespread and often high levels of fecal contamination in both public and private domains and the food supply. The dominant fecal exposure pathway for young children in the household was through consumption of uncooked produce. The SaniPath Study provides critical information on exposure to fecal contamination in low-income, urban environments and ultimately can inform investments and policies to reduce these public health risks.

Lack of adequate sanitation results in fecal contamination of the environment and poses a risk of disease transmission via multiple exposure pathways. To better understand how eight different sources contribute to overall exposure to fecal contamination, we quantified exposure through multiple pathways for children under 5 years old in four high-density, low-income, urban neighborhoods in Accra, Ghana. We collected more than 500 hours of structured observation of behaviors of 156 children, 800 household surveys, and 1,855 environmental samples. Data were analyzed using Bayesian models, estimating the environmental and behavioral factors associated with exposure to fecal contamination. These estimates were applied in exposure models simulating sequences of behaviors and transfers of fecal indicators. This approach allows us to identify the contribution of any sources of fecal contamination in the environment to child exposure and use dynamic fecal microbe transfer networks to track fecal indicators from the environment to oral ingestion. The contributions of different sources to exposure were categorized into four types (high/low by dose and frequency), as a basis for ranking pathways by the potential to reduce exposure. Although we observed variation in estimated exposure (10 8 -10 16 CFU/day for Escherichia coli ) between different age groups and neighborhoods, the greatest contribution was consistently from food (contributing > 99.9% to total exposure). Hands played a pivotal role in fecal microbe transfer, linking environmental sources to oral ingestion. The fecal microbe transfer network constructed here provides a systematic approach to study the complex interaction between contaminated environment and human behavior on exposure to fecal contamination.

Several produce-associated outbreaks have been linked to the packing facility. Equipment surfaces may be an important source of contamination. The goal was to assess whether the microbial load of packing facility surfaces is associated with the microbial load of produce. From November 2000 to December 2003, 487 matched produce (14 types) and equipment surfaces (six production steps) were sampled from eight packing facilities in the United States near the border with Mexico and enumerated for aerobic plate counts (APC), Escherichia coli , Enterococcus, and coliforms. Bivariate correlations were assessed by Spearman's ρ, and adjusted associations were assessed by multilevel mixed linear regression models. In general, the microbial load both increased and decreased on produce (0.2 to 1.0 log CFU/g) and equipment surfaces (0.5 to 3.0 log CFU/cm 2 ) across production steps. Equipment surface and produce microbial loads were correlated, but correlations varied from none to high depending on the equipment surface. For example, significant correlations (P < 0.01) included APC (ρ = 0.386) and Enterococcus (ρ = 0.562) with the harvest bin, E. coli (ρ = 0.372) and Enterococcus (ρ = 0.355) with the merry-go-round, Enterococcus (ρ = 0.679) with rinse cycle equipment, APC (ρ = 0.542) with the conveyer belt, and for all indicators with the packing box (ρ = 0.310 to 0.657). After controlling for crop type, sample replicate group, and sample location, there were significant positive associations between the log concentration of Enterococcus on produce and the harvest bin (β = 0.259, P < 0.01) and the rinse cycle (β = 0.010, P = 0.01), and between the log concentration of all indicators on produce and the packing box (β = 0.155 to 0.500, all P < 0.01). These statistically significant associations between microbial loads on packing facility surfaces and fresh produce confirm the importance of packing facility sanitation to protect produce quality and safety.

Objective: To investigate, in Amhara, Ethiopia, the association between prevalence of active trachoma among children aged 1-9 years and community sanitation usage., Methods: Between 2011 and 2014, prevalence of trachoma and household pit latrine usage were measured in five population-based cross-sectional surveys. Data on observed indicators of latrine use were aggregated into a measure of community sanitation usage calculated as the proportion of households with a latrine in use. All household members were examined for clinical signs, i.e. trachomatous inflammation, follicular and/or intense, indicative of active trachoma. Multilevel logistic regression was used to estimate prevalence odds ratios (OR) and 95% confidence intervals (CI), adjusting for community, household and individual factors, and to evaluate modification by household latrine use and water access., Findings: In surveyed areas, prevalence of active trachoma among children was estimated to be 29% (95% CI: 28-30) and mean community sanitation usage was 47% (95% CI: 45-48). Despite significant modification (p < 0.0001), no pattern in stratified ORs was detected. Summarizing across strata, community sanitation usage values of 60 to < 80% and ≥ 80% were associated with lower prevalence odds of active trachoma, compared with community sanitation usage of < 20% (OR: 0.76; 95% CI: 0.57-1.03 and OR: 0.67; 95% CI: 0.48-0.95, respectively)., Conclusion: In Amhara, Ethiopia, a negative correlation was observed between community sanitation usage and prevalence of active trachoma among children, highlighting the need for continued efforts to encourage higher levels of sanitation usage and to support sustained use throughout the community, not simply at the household level.

Background: Globally, in 2010, approximately 1.5 billion people were infected with at least one species of soil-transmitted helminth (STH), Ascaris lumbricoides, Trichuris trichiura, hookworm (Ancylostoma duodenale and Necator americanus). Infection occurs through ingestion or contact (hookworm) with eggs or larvae in the environment from fecal contamination. To control these infections, the World Health Organization recommends periodic mass treatment of at-risk populations with deworming drugs. Prevention of these infections typically relies on improved excreta containment and disposal. Most evidence of the relationship between sanitation and STH has focused on household-level access or usage, rather than community-level sanitation usage. We examined the association between the proportion of households in a community with latrines in use and prevalence of STH infections among school-aged children., Methods: Data on STH prevalence and household latrine usage were obtained during four population-based, cross-sectional surveys conducted between 2011 and 2014 in Amhara, Ethiopia. Multilevel regression was used to estimate the association between the proportion of households in the community with latrines in use and presence of STH infection, indicated by > 0 eggs in stool samples from children 6-15 years old., Results: Prevalence of STH infection was estimated as 22% (95% CI: 20-24%), 14% (95% CI: 13-16%), and 4% (95% CI: 4-5%) for hookworm, A. lumbricoides, and T. trichiura, respectively. Adjusting for individual, household, and community characteristics, hookworm prevalence was not associated with community sanitation usage. Trichuris trichuria prevalence was higher in communities with sanitation usage ≥ 60% versus sanitation usage < 20%. Association of community sanitation usage with A. lumbricoides prevalence depended on household sanitation. Community sanitation usage was not associated with A. lumbricoides prevalence among households with latrines in use. Among households without latrines in use, A. lumbricoides prevalence was higher comparing communities with sanitation usage ≥ 60% versus < 20%. Households with a latrine in use had lower prevalence of A. lumbricoides compared to households without latrines in use only in communities where sanitation usage was ≥ 80%., Conclusions: We found no evidence of a protective association between community sanitation usage and STH infection. The relationship between STH infection and community sanitation usage may be complex and requires further study.

Consumer responses to food product recalls have been documented, but there is little information on how consumers respond to illnesses or outbreaks associated with food service facilities. This study uses an on-line survey of 885 adults conducted in 2012 to determine how respondents changed their dining behavior following personal experiences with and secondhand reports of gastrointestinal illness believed to be associated with food service facilities. In response to personally experiencing gastrointestinal illness that they attributed to a food service facility, 90% of survey participants reported that they avoided the implicated facility for a time following the incident; almost one-half decided to never return to the facility they believed had made them ill. In response to a secondhand report of gastrointestinal illness, 86% of respondents reported they would avoid the implicated facility for a time, and 22% said they would never return to the facility. After both personal experiences of illness and secondhand reports of illness, consumer responses were significantly more severe toward the implicated facility than toward all other food service facilities. Frequent diners avoided facilities for shorter periods of time and were less likely to never go back to a facility than were infrequent diners. The survey results indicate that 24 to 97 fewer meals were purchased per respondent, or a 11 to 20% reduction in meals purchased outside the home, in the year following respondents' illness. Future estimates of the economic burden of foodborne illnesses, including those caused by noroviruses, should consider the impacts on the food service industry attributable to changes in consumer behavior, in addition to health care costs and loss of productivity.

This study developed and validated a model for predicting the probability that communities in Amhara Region, Ethiopia, have low sanitation coverage, based on environmental and sociodemographic conditions. Community sanitation coverage was measured between 2011 and 2014 through trachoma control program evaluation surveys. Information on environmental and sociodemographic conditions was obtained from available data sources and linked with community data using a geographic information system. Logistic regression was used to identify predictors of low community sanitation coverage (< 20% versus ≥ 20%). The selected model was geographically and temporally validated. Model-predicted probabilities of low community sanitation coverage were mapped. Among 1,502 communities, 344 (22.90%) had coverage below 20%. The selected model included measures for high topsoil gravel content, an indicator for low-lying land, population density, altitude, and rainfall and had reasonable predictive discrimination (area under the curve = 0.75, 95% confidence interval = 0.72, 0.78). Measures of soil stability were strongly associated with low community sanitation coverage, controlling for community wealth, and other factors. A model using available environmental and sociodemographic data predicted low community sanitation coverage for areas across Amhara Region with fair discrimination. This approach could assist sanitation programs and trachoma control programs, scaling up or in hyperendemic areas, to target vulnerable areas with additional activities or alternate technologies., (© The American Society of Tropical Medicine and Hygiene.)

Rotavirus and norovirus are important etiologies of gastroenteritis among hospitalized children. During 2012-2013, we tested 207 residual stool specimens from children with healthcare-associated vomiting and/or diarrhea for rotavirus and norovirus. Twenty (10%) were rotavirus positive, and 3 (3%) were norovirus positive, stressing the importance of these pathogens in hospitalized children.

Noroviruses (NoV) are the most common cause of epidemic gastroenteritis world-wide. NoV infections are often asymptomatic, although individuals still shed large amounts of NoV in their stool. Understanding the differences between asymptomatic and symptomatic individuals would help in elucidating mechanisms of NoV pathogenesis. Our goal was to compare the serum cytokine responses and faecal viral RNA titres of asymptomatic and symptomatic NoV-infected individuals. We tested serum samples from infected subjects (n = 26; 19 symptomatic, seven asymptomatic) from two human challenge studies of GI.1 NoV for 16 cytokines. Samples from prechallenge and days 1-4 post-challenge were tested for these cytokines. Cytokine levels were compared to stool NoV RNA titres quantified previously by reverse transcription-polymerase chain reaction (RT-qPCR). While both symptomatic and asymptomatic groups had similar patterns of cytokine responses, the symptomatic group generally exhibited a greater elevation of T helper type 1 (Th1) and Th2 cytokines and IL-8 post-challenge compared to the asymptomatic group (all P < 0·01). Daily viral RNA titre was associated positively with daily IL-6 concentration and negatively with daily IL-12p40 concentration (all P < 0·05). Symptoms were not associated significantly with daily viral RNA titre, duration of viral shedding or cumulative shedding. Symptomatic individuals, compared to asymptomatic, have greater immune system activation, as measured by serum cytokines, but they do not have greater viral burden, as measured by titre and shedding, suggesting that symptoms may be immune-mediated in NoV infection., (© 2016 British Society for Immunology.)

Noroviruses are an important cause of gastroenteritis, which can be severe at the extremes of ages. Data documenting the endemic burden of norovirus among children and elderly adults are lacking. Stool specimens submitted for clinical testing were collected from elderly (≥ 65 years) adults and children (<18 years) with acute vomiting and/or diarrhea seeking care at several metropolitan Atlanta adult and pediatric hospitals from January 2013-June 2013. Specimens were tested for norovirus with real-time RT-PCR and sequenced if norovirus was detected. Corresponding clinical and demographic data were abstracted from retrospective chart review. Norovirus was detected in 11% (11/104) of elderly specimens and 11% (67/628) of pediatric, with GII.4 Sydney&#95;2012 detected in 64% (7/11) of elderly norovirus-positive and 11% (8/67) of pediatric specimens, P < 0.001. In comparison to hospitalized children, hospitalized elderly with norovirus were more commonly admitted to the intensive care unit (ICU) (36% vs. 7%, P = 0.02). Norovirus in the elderly can be associated with severe illness requiring ICU admissions. The pediatric group demonstrated greater variability in genotype distribution. Ongoing surveillance of norovirus genotypes is crucial for norovirus vaccine development in understanding circulating and emerging genotypes., (© 2015 Wiley Periodicals, Inc.)

Background: In the US, noroviruses are estimated to cause 21 million cases annually with economic losses reaching $2 billion. Outbreak investigations frequently implicate vomiting as a major transmission risk. However, little is known about the characteristics of vomiting as a symptom or the amount of virus present in emesis., Methodology and Principal Findings: Emesis samples and symptomology data were obtained from previous norovirus human challenge studies with GI.1 Norwalk virus, GII.2 Snow Mountain virus, and a pilot study with GII.1 Hawaii virus. Viral titers in emesis were determined using strain-specific quantitative RT-PCR. In all four studies, vomiting was common with 40-100% of infected subjects vomiting at least once. However, only 45% of subjects with vomiting also had diarrhea. Most of the emesis samples had detectable virus and the mean viral titers were 8.0 x 105 and 3.9 x 104 genomic equivalent copies (GEC)/ml for GI and GII viruses, respectively (p = 0.02). Sample pH was correlated with GII.2 Snow Mountain virus detection., Conclusions and Significance: Half of all subjects with symptomatic infection experienced vomiting and the average subject shed 1.7 x 108 GEC in emesis. Unlike shedding through stool, vomiting is more likely to result in significant environmental contamination, leading to transmission through fomites and airborne droplets. This quantitative data will be critical for risk assessment studies to further understand norovirus transmission and develop effective control measures. The correlation between sample pH and virus detection is consistent with a single site of virus replication in the small intestine and stomach contents becoming contaminated by intestinal reflux. Additionally, the frequency of vomiting without concurrent diarrhea suggests that epidemiology studies that enroll subjects based on the presence of diarrhea may be significantly underestimating the true burden of norovirus disease.

To better understand the risks of exposure for young children to fecal contamination in their environment, we systematically characterized and quantified behaviors of 154 children, 0-5 years old, in four high-density, low-income neighborhoods in Accra, Ghana. A repertoire of six different activities and five different compartments (categories of locations within the household) was developed, and about 500 hours of ordered structured observations of activities and locations of individual children were collected. These records were analyzed using a competing hazards model, estimating (Weibull) hazard rates for each state (activity/compartment combination), dependent on the present state and the preceding state. The estimated rates were used to simulate sequences of behavior and describe days in the life of a child in low-income, urban Africa. Children younger than 1 year spent most time playing or sleeping off the ground, older children frequently played on floors. Relatively little time was spent in drains or wet trash areas. Critical combinations of activities, like handwashing after defecation or before eating were estimated to occur rarely. These quantitative behavior estimates can inform future risk assessments that examine the relative roles of various fecal-oral exposure pathways in low-income urban settings., (© The American Society of Tropical Medicine and Hygiene.)

In low-income countries, rapid urbanization adds pressure to already stressed water and sanitation systems that are critical to the health of communities. Drainage networks, designed for stormwater but commonly used for disposing of waste, are rarely covered completely, allowing residents to easily come into contact with their contents. This study used spatial mapping, documentation of physical drain characteristics, microbiological analysis of drain samples, and behavioral observation to comprehensively examine drains as a route of exposure to fecal contamination in four low-income neighborhoods in Accra, Ghana. A stochastic model of six likely exposure scenarios was constructed to estimate children's exposure to drain water. Regardless of the age of the child, any exposure scenario considered resulted in exposure to a high level of fecal contamination. Fecal contamination levels in drains were high (Escherichia coli: geometric mean (GM), 8.60 cfu log(10)/100 mL; coliphage: GM, 5.56 pfu log(10)/100 mL), and did not differ by neighborhood or physical drain characteristics, indicating that frequency of contact with drains, and not drain type or location, drives exposure risk. To mitigate health risks associated with this exposure, drains should be covered, with priority given to large concrete and small to medium dirt-lined drains that children were most commonly observed entering.

Noroviruses (NoV) are the most common cause of epidemic gastroenteritis worldwide. The acute immune response to NoV in humans is poorly understood, hindering research on prevention and treatment. To elucidate the acute immune response and test for cytokine predictors of susceptibility to infection, serum samples from two human NoV challenge studies were tested for 16 cytokines. Subjects who became infected (n = 26) were age-matched with subjects who remained uninfected following NoV challenge (n = 26). Samples were tested from prechallenge and days 1-4 post-challenge. Cytokine responses were compared between infected and uninfected groups. Overall, infected individuals exhibited an elevation in T helper type 1 (Th1) and Th2 cytokines, as well as chemokines interleukin (IL)-8 and monocyte chemoattractant protein (MCP-1), compared to uninfected individuals (all P < 0.05). Most cytokines peaked on day 2 post-challenge in infected subjects, and tumour necrosis factor (TNF)-α, IL-8, and IL-10 remained elevated to day 3. The only cytokine elevated significantly among infected subjects to day 4 post-challenge was IL-10 (P = 0.021). Prechallenge cytokine concentrations were not predictive of infection status post-challenge. There were no significant changes in serum cytokines among NoV-challenged subjects who remained uninfected. These results suggest that NoV infection elicits a Th1-type response, with some Th2 activation. Persistent elevation of IL-10 among infected subjects is consistent with activation of adaptive immune responses, such as B cell expansion, as well as down-regulation of Th1 cytokines. This study presents the first comprehensive description of the acute cytokine response to GI.1 NoV in humans., (© 2015 British Society for Immunology.)