Sanitation improvements have had limited effectiveness in reducing the spread of fecal pathogens into the environment. We conducted environmental measurements within a randomized controlled trial in Bangladesh that implemented individual and combined water treatment, sanitation, handwashing (WSH) and nutrition interventions (WASH Benefits, NCT01590095). Following approximately 4 months of intervention, we enrolled households in the trial’s control, sanitation and combined WSH arms to assess whether sanitation improvements, alone and coupled with water treatment and handwashing, reduce fecal contamination in the domestic environment. We quantified fecal indicator bacteria in samples of drinking and ambient waters, child hands, food given to young children, courtyard soil and flies. In the WSH arm, Escherichia coli prevalence in stored drinking water was reduced by 62% (prevalence ratio = 0.38 (0.32, 0.44)) and E. coli concentration by 1-log (Δlog10 = −0.88 (−1.01, −0.75)). The interventions did not reduce E. coli along other sampled pathways. Ambient contamination remained high among intervention households. Potential reasons include noncommunity-level sanitation coverage, child open defecation, animal fecal sources, or naturalized E. coli in the environment. Future studies should explore potential threshold effects of different levels of community sanitation coverage on environmental contamination.

The role of ECMO in pregnant and postpartum women with ARDS from H1N1 remains unclear and the benefits suggested from our review should be interpreted with caution.

Prenatal and early childhood lead exposures impair cognitive development. We aimed to evaluate the prevalence of elevated blood lead levels (BLLs) among pregnant women in rural Bangladesh and to identify sources of lead exposure. We analyzed the BLLs of 430 pregnant women randomly selected from rural communities in central Bangladesh. Fifty-seven cases were selected with the highest BLLs, ≥ 7 μg/dL, and 59 controls were selected with the lowest BLLs, < 2 μg/dL. An exposure questionnaire was administered and soil, rice, turmeric, water, traditional medicine, agrochemical, and can samples were analyzed for lead contamination. Of all 430 women, 132 (31%) had BLLs > 5 μg/dL. Most women with elevated BLLs were spatially clustered. Cases were 2.6 times more likely than controls to consume food from a can (95% CI 1.0–6.3, p = 0.04); 3.6 times more likely to use Basudin, a specific brand of pesticide (95% CI 1.6–7.9, p = 0.002); 3.6 times more likely to use Rifit, a specific brand of herbicide (95% CI 1.7–7.9, p = 0.001); 2.9 times more likely to report using any herbicides (95% CI 1.2–7.3, p = 0.02); and 3.3 times more likely to grind rice (95% CI 1.3–8.4, p = 0.01). Five out of 28 food storage cans were lead-soldered. However, there was minimal physical evidence of lead contamination from 382 agrochemical samples and 129 ground and unground rice samples. Among 17 turmeric samples, one contained excessive lead (265 μg/g) and chromium (49 μg/g). Overall, we found evidence of elevated BLLs and multiple possible sources of lead exposure in rural Bangladesh. Further research should explicate and develop interventions to interrupt these pathways.

Fresh water resources are scarce in rural communities in the southern deltaic plains of Bangladesh where both shallow and deep groundwater is frequently brackish, and fresh water ponds have been increasingly salinized by inundation during storm surges and brackishwater aquaculture. Low-cost aquifer storage and recovery (ASR) schemes were constructed at 13 villages in three coastal districts by developing storage in shallow confined fine to medium sand aquifers overlain by variable thicknesses of silt and clay. A typical ASR scheme consisted of a double-chambered graded sand filtration tank with a volume of 19.5 m 3 that feeds filtered pond water to four to six large diameter (d ¼ 30.5 or 56 cm) infiltration wells through PVC pipes fitted with stop valves and flow meters. The infiltration wells were completed at 18-31 m below ground and filled with well-sorted gravel capped with a thin layer of fine sand that acts as a second stage filter. Infiltration rates at 13 sites averaged 3 m 3 =day (range: 3-6 m 3 =day) over one year of operation. At 11 sites where water was abstracted, the recovery rate ranged from 5 to 40%. The source pond source water frequently had turbidity values of ≥ 100 NTU. After sand filtration, the turbidity is typically 5 NTU. Despite this, clogging management involving frequent (monthly to weekly) manual washing to remove fine materials deposited in the sand filtration tank and the infiltration wells is found to be necessary and effective, with post-manual-washing operational infiltration rates restored to annual average values. E. coli counts in recovered water are greatly reduced compared to raw pond water, although E. coli is still detected in about half of the samples. Arsenic in recovered water was detected to be at level of >100 μg=L repeatedly at three sites, suggesting that As risks must be carefully managed and require further investigation.

BackgroundWater, sanitation, and hygiene (WASH) efficacy trials deliver interventions to the target population under optimal conditions to estimate their effects on outcomes of interest, to inform subsequent selection for inclusion in routine programs. A systematic and intensive approach to intervention delivery is required to achieve the high-level uptake necessary to measure efficacy. We describe the intervention delivery system adopted in the WASH Benefits Bangladesh study, as part of a three-paper series on WASH Benefits Intervention Delivery and Performance.MethodsCommunity Health Workers (CHWs) delivered individual and combined WASH and nutrition interventions to 4169 enrolled households in geographically matched clusters. Households were provided with free enabling technologies and supplies, integrated with parallel behaviour-change promotion. Behavioural objectives were drinking treated, safely stored water, safe feces disposal, handwashing with soap at key times, and age-appropriate nutrition behaviours (birth to 24 months). The intervention delivery system built on lessons learned from prior WASH intervention effectiveness, implementation, and formative research studies. We recruited local CHWs, residents of the study villages, through transparent merit-based selection methods, and consultation with community leaders. CHW supervisors received training on direct intervention delivery, then trained their assigned CHWs. CHWs in turn used the technologies in their own homes. Each CHW counseled six to eight intervention households spread across a 0.2–2.2-km radius, with a 1:12 supervisor-to-CHW ratio. CHWs met monthly with supervisor-trainers to exchange experiences and adapt technology and behaviour-change approaches to evolving conditions. Intervention uptake was tracked through fidelity measures, with a priori benchmarks necessary for an efficacy study.ResultsSufficient levels of uptake were attained by the fourth intervention assessment month and sustained throughout the intervention period. Periodic internal CHW monitoring resulted in discontinuation of a small number of low performers.ConclusionsThe intensive intervention delivery system required for an efficacy trial differs in many respects from the system for a routine program. To implement a routine program at scale requires further research on how to optimize the supervisor-to-CHW-to-intervention household ratios, as well as other program costs without compromising program effectiveness.Trial registrationClinicalTrials.gov, ID: NCC01590095. Registered on 2 May 2012.