ii When a Vaccine Alone is not Enough: An Assessment of Effective Point-of-Use Water Treatment and Hand Washing Among Cholera-Vaccinated and Unvaccinated Inhabitants in Mirpur Slum, Dhaka, Bangladesh Open Access
Schaeffner, Danielle McFall (2012)
Abstract
Abstract
When a Vaccine Alone is not Enough:
An Assessment of Effective Point-of-Use Water Treatment and Hand
Washing
Among Cholera-Vaccinated and Unvaccinated Inhabitants in Mirpur
Slum,
Dhaka, Bangladesh
Background: Cholera prevention and control includes vaccines
and improved water,
sanitation and hygiene (WASH). In endemic regions, vaccination may
provide time to
improve WASH infrastructure and behaviors in high-risk populations.
While there is
debate about the role of cholera vaccination because of the modest
efficacy and limited
duration of protection, it will not be a cost-effective
intervention without proper
messaging and good WASH practices.
Objective: To examine the impact of cholera vaccination on
WASH-related behavior by
comparing vaccinated and unvaccinated populations.
Methods: 728 households (HHs) were recruited from
cholera-vaccinated and
unvaccinated groups in Mirpur slum, Dhaka, Bangladesh.
Approximately 100 HHs were
surveyed every month for 4 key WASH outcomes: household water
contamination, self-
reported household water treatment, and self-reported and observed
hand washing, with
and without soap. The first four months of data were examined for
an association
between WASH outcomes and vaccination.
Results: There were no significant differences in the 4 WASH
outcomes between the
vaccinated and unvaccinated groups. The adjusted odds ratios ranged
from 1.10 to 1.57,
and included the null value in the 95% CI. In the vaccinated group,
53% reported that
they felt protected by the cholera vaccine. There were no
significant differences in
WASH outcomes for vaccine recipients who felt protected versus
those who did not. No
consistent time trends in WASH practices were observed over the
4-month study period.
Discussion: Cholera vaccination alone did not change
WASH-related behavior.
Because vaccination was implemented without providing information
on efficacy and
duration of protection, it is not possible to determine the impact
an effective message
may have had on WASH practices. Future studies should examine
whether a clear,
culturally-appropriate message provided with the cholera vaccine
could influence WASH-
practices in endemic areas.
Table of Contents
Table of Contents
Background
................................................................................................................................
1
History of Cholera
........................................................................................................................
1
Figure I. Spread of Cholera
............................................................................................................
3
Biological Aspects
........................................................................................................................
4
Bangladesh
.................................................................................................................................
5
Cholera Prevention and Treatment
...................................................................................................
6
Vaccines
....................................................................................................................................
8
Behavioral Influence
....................................................................................................................
10
Study Objectives
........................................................................................................................
15
Manuscript
.................................................................................................................................
16
Title
..........................................................................................................................................
16
Author
.......................................................................................................................................
16
Abstract
....................................................................................................................................
17
Introduction
...............................................................................................................................
18
Figure II. Pathogen Transmission Pathways
.......................................................................................
19
Methods
....................................................................................................................................
22
Study Site
.................................................................................................................................
22
Figure III. Mirpur, Dhaka: Study Site
...............................................................................................
22
Study Design
..............................................................................................................................
23
Sample Size
................................................................................................................................
24
Household Data Collection
.............................................................................................................
25
Water Quality Assessment
.............................................................................................................
26
Hand Washing Assessment
.............................................................................................................
27
Data Analyses
.............................................................................................................................
27
Results
......................................................................................................................................
29
Table I. Behaviors and Perceptions by Vaccination Status, Combined
Over four months
since vaccination
........................................................................................................................
30
Table II. Behaviors across Perceptions of Vaccine Protection within
Vaccinated Study Arm
................................................................................................................................................
31
Figure V. Household Water Contamination
.........................................................................................
32
Figure VI. Household Hand Washing: With or Without Soap
..................................................................
33
Table III. Behaviors across Study Arms over Time
...............................................................................
34
Table IV. The Odds of Contaminated Household Water by Vaccination
Status: Combined
over Time and Controlling for Time
...................................................................................................
35
Table V. The Odds of handwashing Behavior by Vaccination Status:
Combined over Time
and Controlling for Time
.................................................................................................................
36
Table VI. The Odds of Hand Washing with Soap by Vaccination Status:
Combined over
Time and Controlling for Time
..........................................................................................................
36
Table VII. The Odds of Self-Reported Water Treatment by Vaccination
Status: Combined
over Time and Controlling for Time
....................................................................................................
37
Table VIII. Odds Ratios by Months since Vaccination: Considering
Interaction between
Time and Vaccination
.....................................................................................................................
38
Figure VI. Odds Ratios of Behaviors since Vaccination: Considering
Interaction between
Time and Vaccination
.....................................................................................................................
39
Discussion
....................................................................................................................................
40
Main Findings
................................................................................................................................
41
Self-reported water treatment and household water quality
...................................................................
41
Self-reported hand washing and observed hand washing behavior
...........................................................
43
Differences in WASH Behavior over Follow-up: Was there a Change
over Time? ......................................... 45
Perceptions of vaccine protection
.....................................................................................................
46
Strengths and Limitations of this Study
..............................................................................................
47
Randomized Design
.........................................................................................................................
47
Short Follow-Up Period
....................................................................................................................
47
Different Subsets of Households
........................................................................................................
48
No baseline data on WASH behavior
...................................................................................................
48
Difficult to measure WASH behaviors
..................................................................................................
49
H2S Test Inaccuracies
.....................................................................................................................
49
Lack of data on health messages
.......................................................................................................
50
Conclusions and Recommendations
.....................................................................................................
51
Conclusions:
...................................................................................................................................
51
Recommendations:
...........................................................................................................................
52
References
......................................................................................................................................
55
Appendices
.....................................................................................................................................
60
Appendix A: IRB Letter of Exemption
....................................................................................................
60
Appendix B: International Center for Diarrheal Disease Research,
Bangladesh: Letter of
Permission
......................................................................................................................................
61
Appendix C: ICVB Study Questionnaire
.................................................................................................
62
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