Cholera Platform Webinar

1. Cholera Platform Webinar Welcome! Today we will present research from three studies conducted at Tufts University with R2HC and OFDA funding. • In 2018, we conducted systematic reviews of: • WASH in outbreaks & emergencies • Identified eight CISUR interventions • Commonly Implemented but Severely Under-Researched • Three of which were: • Household spraying • Household disinfection kits • Bucket chlorination • Received funding from OFDA and R2HC to investigate efficacy / effectiveness of these three CISUR interventions

2. Household Spraying in Cholera Outbreaks: Evaluation of Three Programs K. Gallandat, J. Rayner, A. Huang, G. String, D. LantagneWebinar with the Regional Cholera Platforms Central & West AfricaJune 27, 2019

3. BackgroundObjectives Methods Results Conclusions Household Spraying • Sprayers apply chlorine on surfaces in cholera-affected households • “Not recommended” in 4 guidelines • No evidence for efficacy or effectiveness • Timeliness of the intervention? • Limited coverage (asymptomatic) • Stigmatization concerns • Prioritization of interventions • But commonly implemented in outbreak response Kalemie, DRC, June 2018 3

4. BackgroundObjectives Methods Results Conclusions Objectives • a. Determine where V. cholerae is found in households • b. Evaluate the effectiveness of household spraying • c. Identify opportunities and challenges of the intervention 4

5. BackgroundObjectives Methods Results Conclusions Evaluation Methods • Chlorine solution testing (titration) • Sampling of surfaces by swabbing • Before spraying • 30 minutes & 24 hours after spraying • Detection of V. cholerae, E. coli, total coliforms • Key informant interview(s) • Household surveys • 3 programs evaluated • 4-5 HH in each evaluation • 1 more pending evaluation Mbuji-Mayi, DRC, July 2018 5

6. BackgroundObjectives Methods Results Conclusions Program Characteristics 6

7. BackgroundObjectives MethodsResults Conclusions Chlorine Preparation Mbuji-Mayi, DRC, July 2018 Kalemie, DRC, June 2018 Dosage of HTH powder with spoons in all programs At the household for Program A, at the CTC/base for Programs B & C Use of container / spraying equipment to estimate volumes 7

8. BackgroundObjectives MethodsResults Conclusions Chlorine Dosage Dosage with spoons in all programs Dosage more accurate at 0.2% compared to 2.0%, and consistently lower than target in Program C 8

9. BackgroundObjectives MethodsResults Conclusions V. cholerae on Selected Household Surfaces PROGRAM A Systematic 5-10 L/HH 5-10 min/HH (■) High: ≥5,000 CFU/100 cm2 (■) Intermediate: 200-5,000 CFU/100 cm2 (■) Low: <200 CFU/100 cm2 (■) Not detected PROGRAM B Ad hoc 0.2 L/HH 2-5 min/HH 9

10. BackgroundObjectives Methods Results Conclusions V. cholerae on Selected Household Surfaces PROGRAM C (■) High: ≥5,000 CFU/100 cm2 (■) Intermediate: 200-5,000 CFU/100 cm2 (■) Low: <200 CFU/100 cm2 (■) Not detected Ad hoc 2-5 L/HH Time not recorded HH13-14: no suspected cholera case (AWD) Consistent inactivation of V. cholerae after spraying was seen in Program A only Some recontamination was observed after 24 hours 10

11. BackgroundObjectives MethodsResults Conclusions Detection of V. cholerae More HH surfaces initially contaminated in Program B Reduction in # of contaminated after 30 minutes in 13/14 HH (93%) Recontamination after 24 hours observed in 10/14 HH (71%) 11

12. BackgroundObjectives Methods Results Conclusions Selected Survey Results Intervention timing: long time to reach households Among survey participants … • 50-80% found HH spraying “very useful” • 40-100% appreciated a “clean house” • 100% had nothing to report when asked what they did NOT like • Highlights the risk of bias; further qualitative research needed

13. BackgroundObjectives Methods Results Conclusions Challenges & Opportunities from KII • Timeliness • Household identification (all programs) • Use cell phones / radios • Travel with patient relatives • Resource-intensive (all programs) • Use as platform for sensitization, active case searching, outbreak monitoring (GPS) • Mostly appreciated by beneficiaries (all programs), with occasional refusals reportedly due to fear of stigmatization and religious beliefs (programs A, C) Mbuji-Mayi, DRC, July 2018

14. BackgroundObjectives Methods Results Conclusions Conclusions Key results Recommendations(if HH spraying is implemented) Systematic procedure to ensure complete coverage Spray until surface is wet Kitchen area is critical (2.0%) Prioritize approaches that increase community coverage Use HH spraying opportunities for hygiene promotion Travel w/ patient’s relative and give sprayers phones/radio • Spraying can reduce contamination on HH surfaces if implemented properly • Intervention coverage is limited (asymptomatic & community cases) • Challenge: identification of HH • VBNC V. cholerae not detected in this work; their relevance remains unclear 14

15. BackgroundObjectives Methods Results Conclusions Acknowledgements • Partner organizations: AIDES, Solidarites International • Interpretors:François Mitima, Eddy MbuyambaKashala, Miché Payen • Study participants: program staff & beneficiaries • Funding: Research for Heatlh in Humanitarian Crises, Swiss National Science Foundation, PEO Foundation 15

16. Thank you Contact: karin.gallandat@lshtm.ac.uk

17. Identifying barriers to adoption of Household Disinfection Kits for environmental infection control of cholera transmission Camille Heylen and Daniele Lantagne Department of Civil and Environmental Engineering, Tufts University, Medford, MA, USA

18. Background • Environmental infection control interventions • Key to interrupting within household cholera transmission • Two approaches: - Household Spraying - Household Disinfection Kit • International recommendations for HDK, but… no one implementing. Photo credit: IFRC and MSF 18

19. Objectives & Methods • Evaluate one barrier of HDK •  beneficiaries’ training on HDK use • Identify barriers to adopting HDKs Beneficiaries (Haiti) Response agency staff Trainings on the use; Environmental sampling; and Household surveys Key informant interview (KII) Quantitative aspect of HDK/Insight on the training needed Qualitative aspect of HDK  Trial in Haiti in August 2019  14 KIIs done (February-April 2019) 19

20. Results (I)  14 KIIs conducted • Main results : • Question on priority of disinfection interventions • Gap of evidence on the effectiveness of both measures • Confusion between HDK and hygiene kit of HDK • Huge divide between international staff and national staff (HDK > < HS) 20

21. Results (I) – (Perceived) Benefits & Drawbacks of HDK’s “We did see that there was a very good use of the kit” Benefits of HDKs: • People know how to use items • Time wise • Increase of awareness of the population “HDK with the right support is more appropriate than spraying, given all the delays in providing data” “HDK gives a lot of more control to the people in the household to really target their cleaning appropriately and immediately” • Drawbacks of HDKs: • Composition of the kit varies • Coordination with decision-makers • Resale of items “ There are as many kits and names as there are countries or partners, even though the clusters are trying to align the composition “ “ It is important that partners have a same understanding for the composition of the kit” “The greatest failure is the resale of the items and it is a big issue. Because we can’t ignore it: the priority is the food” 21

22. Results (I) – (Perceived) Benefits & Drawbacks of HS  “With a spraying team, we are sure that the house is disinfected. But if we you give this responsibility to the population, are we sure that they are going to disinfect their house? ”   Benefits of HS: • Certainty of the method • Safety for the household • Mapping  “The use of chlorine is not easy. I do not advise to distribute bleach, it could really lead to bad dosages and bad manipulations as well ”  “Spraying allows us to geo locate where sick people come from ” • Drawbacks of HS: • False sense of security • Stigmatization • Resources consuming/Cost “What's the impact of spraying once a day? It gives a false sense of security. We should reinforce the systematic cleaning that needs to happen every day, multiple times a day” “Spraying is like punishing, it’s like recognizing that something is wrong in that household” “ We see that it has a cost this spray. We see that it is a lot of resources as well.” 22

23. Expected results (II) Training (2 different modules) Initial number of bacteria on surfaces Environmental sampling 1st household visit Knowledge on living conditions and sanitation Household survey Distribution of the kit and use by the beneficiaries Number of bacteria on surfaces after HDK Environmental sampling 2nd household visit Household survey Perception of HDK 23

24. Expected results (II) Initial number of bacteria on surfaces Quantitative and qualitative information on logistics and appropriateness of household disinfection kits. Results in Fall 2019 Knowledge on living conditions and sanitation + Observation & pictures Number of bacteria on surfaces after HDK Perception of HDK 24

25. Expected results Trainings on the use; Environmental sampling; and Household surveys Key informant interview (KII) Qualitative aspect of HDK Quantitative aspect of HDK/Insight on the training needed • To compare benefits / challenges of HDK and HS interventions • To formulate recommendations on how to use in future • Next steps: • Need to finish the analysis of KII • Preparation for the field • Data synthesis and development of recommendations to responders 25

26. Evaluation of the Effectiveness of Bucket Chlorination Gabrielle String, Mustafa Sikder, Yarmina Kamal, Justine Rayner, and Daniele Lantagne Department of Civil and Environmental Engineering, Tufts University, Medford, MA, USA

27. Background • Commonly implemented in outbreak response • Lack of quantitative and qualitative evidence • Need to understand chlorine types, concentrations and dosages 27

28. Methods 28

29. Results • Four evaluations completed • DRC (2) • Cox’s Bazar (1) • Haiti (1) • 45 program staff and agents interviewed • 40 chlorination points observed • 702 households surveyed • 11 focus group discussions conducted 29

30. Results: Observation of Chlorination Provision of shade, PPE, and FCR test equipment was most variable. 30

31. Results: Chlorine Preparation and Dosing Chlorine stock solution preparation, storage, and dosing. No programs adjusted preparation or dosing protocols. Variability in produced stock chlorine concentration when targeting 1%. 31

32. Results: Source Water Number of users varied widely within and between programs. Water from semi- or unprotected sources in Programs 1 and 3 and quality was poor. Testing completed ad-hoc and “jar tests” used at program start. 32

33. Results: Stored Water E. coli reduced ≥ 1-log in 73% of households with >100 E. coli CFU/100mL at source. Variable FCR and high presence of total coliforms indicates risk of recontamination. 33

34. Key Takeaways • Variation across programs and inexactness in implementations - Management of chlorination points - Chlorine solution concentrations - Dosing protocols - Testing and monitoring protocols • Generally effective at reducing E. coli & providing FCR >0.2 mg/L • Need to consider beneficiary opinion of programs 34

35. Preliminary Recommendations • Safely store HTH powder and stock solution - Prevents degradation of chlorine concentration • Provide shade at chlorination points - Protects agents and chlorine from sun exposure • Conduct more frequent jar tests - Ensures proper chlorine dosage of beneficiary containers An additional evaluation will be conducted prior to data synthesis, qualitative data analysis, and development of final recommendations to responders. 35

36. Acknowledgements Simon Pickard R2HC Melissa Opryszko USAID-OFDA In each evaluation context: Response partners, enumerators, and study participants Contributors: Karin Gallandat, Molly Lie, Nicole Masozera, Patrick Mirindi, MagnifiqueMukundwa, and Michael Ritter

37. Thank you and we are happy to take questions! karin.gallandat@lshtm.ac.uk camille.heylen@tufts.edu gabrielle.string@tufts.edu daniele.lantagne@tufts.edu