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 Público

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

About this Master's Thesis

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School	Rollins School of Public Health
Department	Epidemiology
Degree	MPH
Submission	Master's Thesis
Language	English
Research Field	Health Sciences, Public Health
Palavra-chave	cholera Bangladesh WASH vaccine
Committee Chair / Thesis Advisor	Moe, Christine L, Emory University
Partnering Agencies	International Non-governmental organization (e.g., CARE, Inc.)

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