ObjectiveTo estimate the burden of diarrhoeal diseases from exposure to inadequate water, sanitation and hand hygiene in low- and middle-income settings and provide an overview of the impact on other diseases.MethodsFor estimating the impact of water, sanitation and hygiene on diarrhoea, we selected exposure levels with both sufficient global exposure data and a matching exposure-risk relationship. Global exposure data were estimated for the year 2012, and risk estimates were taken from the most recent systematic analyses. We estimated attributable deaths and disability-adjusted life years (DALYs) by country, age and sex for inadequate water, sanitation and hand hygiene separately, and as a cluster of risk factors. Uncertainty estimates were computed on the basis of uncertainty surrounding exposure estimates and relative risks.ResultsIn 2012, 502 000 diarrhoea deaths were estimated to be caused by inadequate drinking water and 280 000 deaths by inadequate sanitation. The most likely estimate of disease burden from inadequate hand hygiene amounts to 297 000 deaths. In total, 842 000 diarrhoea deaths are estimated to be caused by this cluster of risk factors, which amounts to 1.5% of the total disease burden and 58% of diarrhoeal diseases. In children under 5 years old, 361 000 deaths could be prevented, representing 5.5% of deaths in that age group.ConclusionsThis estimate confirms the importance of improving water and sanitation in low- and middle-income settings for the prevention of diarrhoeal disease burden. It also underscores the need for better data on exposure and risk reductions that can be achieved with provision of reliable piped water, community sewage with treatment and hand hygiene.

In a systematic review and meta-analysis, Eric Strunz and colleagues examine whether improvements in water, sanitation, and hygiene (WASH) practices are associated with reduced risk of infections with soil-transmitted helminths. Please see later in the article for the Editors' Summary

Abstractobjective To estimate the global prevalence of handwashing with soap and derive a pooled estimate of the effect of hygiene on diarrhoeal diseases, based on a systematic search of the literature.methods Studies with data on observed rates of handwashing with soap published between 1990 and August 2013 were identified from a systematic search of PubMed, Embase and ISI Web of Knowledge. A separate search was conducted for studies on the effect of hygiene on diarrhoeal disease that included randomised controlled trials, quasi-randomised trials with control group, observational studies using matching techniques and observational studies with a control group where the intervention was well defined. The search used Cochrane Library, Global Health, BIOSIS, PubMed, and Embase databases supplemented with reference lists from previously published systematic reviews to identify studies published between 1970 and August 2013. Results were combined using multilevel modelling for handwashing prevalence and meta-regression for risk estimates.results From the 42 studies reporting handwashing prevalence we estimate that approximately 19% of the world population washes hands with soap after contact with excreta (i.e. use of a sanitation facility or contact with children's excreta). Meta-regression of risk estimates suggests that handwashing reduces the risk of diarrhoeal disease by 40% (risk ratio 0.60, 95% CI 0.53-0.68); however, when we included an adjustment for unblinded studies, the effect estimate was reduced to 23% (risk ratio 0.77, 95% CI 0.32-1.86).conclusions Our results show that handwashing after contact with excreta is poorly practiced globally, despite the likely positive health benefits.

Matthew Freeman and colleagues identified 86 individual studies that reported a measure of the effect of water, sanitation, and hygiene on trachoma and conducted 15 meta-analyses for specific exposure-outcome pairs. Please see later in the article for the Editors' Summary

BackgroundLymphedema of the leg and its advanced form, known as elephantiasis, are significant causes of disability and morbidity in areas endemic for lymphatic filariasis (LF), with an estimated 14 million persons affected worldwide. The twin goals of the World Health Organization’s Global Program to Eliminate Lymphatic Filariasis include interrupting transmission of the parasitic worms that cause LF and providing care to persons who suffer from its clinical manifestations, including lymphedema—so-called morbidity management and disability prevention (MMDP). Scaling up of MMDP has been slow, in part because of a lack of consensus about the effectiveness of recommended hygiene-based interventions for clinical lymphedema.Methods and FindingsWe conducted a systemic review and meta-analyses to estimate the effectiveness of hygiene-based interventions on LF-related lymphedema. We systematically searched PubMed, Embase, ISI Web of Knowledge, MedCarib, Lilacs, REPIDISCA, DESASTRES, and African Index Medicus databases through March 23, 2015 with no restriction on year of publication. Studies were eligible for inclusion if they (1) were conducted in an area endemic for LF, (2) involved hygiene-based interventions to manage lymphedema, and (3) assessed lymphedema-related morbidity. For clinical outcomes for which three or more studies assessed comparable interventions for lymphedema, we conducted random-effects meta-analyses. Twenty-two studies met the inclusion criteria and two meta-analyses were possible. To evaluate study quality, we developed a set of criteria derived from the GRADE methodology. Publication bias was assessed using funnel plots. Participation in hygiene-based lymphedema management was associated with a lower incidence of acute dermatolymphagioadenitis (ADLA), (Odds Ratio 0.32, 95% CI 0.25–0.40), as well as with a decreased percentage of patients reporting at least one episode of ADLA during follow-up (OR 0.29, 95% CI 0.12–0.47). Limitations included high heterogeneity across studies and variation in components of lymphedema management.ConclusionsAvailable evidence strongly supports the effectiveness of hygiene-based lymphedema management in LF-endemic areas. Despite the aforementioned limitations, these findings highlight the potential to significantly reduce LF-associated morbidity and disability as well as the need to develop standardized approaches to MMDP in LF-endemic areas.

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Background Brucella infections associated with travel to endemic countries or imported unpasteurized dairy products continue to present public health challenges in the United States. Although less than 6 brucellosis cases are typically reported annually in Dallas County, a record of 25 brucellosis cases were diagnosed in 2016, primarily due to large outbreaks from imported unpasteurized cheese.MethodsIn 2016, all Brucella clinical isolates one isolate from cheese were confirmed as B. melitensis by PCR and biochemical testing in the Dallas County laboratory. Case interviews and medical chart reviews were conducted to determine exposures and illness characteristics. Supplemental questionnaires were administered to assess knowledge and practices relevant to brucellosis and pasteurization.ResultsIn 2016, 20 confirmed and 5 probable brucellosis cases were reported in Dallas County. Twenty cases, including 2 residents in an adjacent county, were associated with one of 3 separate epidemiologic clusters linked to unpasteurized goat cheese purchased in Mexico, legally imported for personal use, and distributed domestically to friends and relatives. Of the 27 cases, all were Hispanic, 22% were less than 18 years of age (median age 39 years), 67% were male, and only 59% had recent international travel. Although 50% of interviewed adults demonstrated an understanding of pasteurization, 67% were unaware that the consumed cheese was unpasteurized, and 92% were unaware of any health risks associated with consuming unpasteurized cheese. All adults cited economic consequences of their illness, such as missing work (median 31 days) or significant medical costs (median $4,000).ConclusionThese findings highlight the need to improve awareness about the health risks associated with consuming unpasteurized dairy products. Public health and healthcare providers should consider that brucellosis can occur in persons without travel history or who are unaware that they consumed unpasteurized food. Active public health follow-up conducted for these brucellosis clusters ensured: education of exposed persons with low English literacy rates, prompt referral of symptomatic patients to clinical care, and notification of evaluating clinicians and laboratories of a suspected diagnosis.Disclosures All authors: No reported disclosures.

BackgroundIn February 2017, a mumps outbreak was identified in a large Dallas high school among students who had previously completed the two-dose MMR vaccination series. Early notification of recommendations for third dose MMR and free vaccination clinics provided an opportunity to assess vaccine uptake, efficacy, and parental perceptions of third dose MMR recommendations.MethodsMumps illnesses were classified as probable or confirmed cases using 2012 CSTE case definitions. Information about vaccination status, exposure history, and illness characteristics was collected from case interviews and medical records. A third MMR vaccine was recommended to all noncase students and offered without charge at school-based vaccination clinics. Supplemental questionnaires assessing parental knowledge and attitudes regarding this third MMR recommendation were administered to guardians of a randomly selected sample of 20 students who received third dose MMR and 50 students who did not receive the vaccine. Fishers exact tests and chi-square were used to compare responses. Data analysis was performed using SAS 9.4.ResultsFrom February to May 2017, 28 PCR-confirmed and 12 probable mumps cases were identified in students attending one high school campus (24.3 cases per 1,000 students). Of the 1,646 enrolled students, 99.8% had documentation of at least two doses of MMR prior to the outbreak, including all mumps cases. Three undervaccinated students who declined to receive one dose of MMR were excluded from school during the outbreak. Following public health recommendations for a voluntary third MMR dose, 291 students (17.6%) elected to receive a third MMR. No mumps cases occurred in students who received a third vaccine dose. Parental perception of protective benefit of an additional third dose of MMR was significantly associated with decisions to receive third dose MMR (OR: 4.9; 95% CI = 1.6–15.3).ConclusionResponsiveness to health department recommendations for third MMR vaccination in this outbreak setting was limited, even with broad educational communications and free school-based vaccine clinics. The challenges in achieving robust voluntary uptake of a third MMR dose may not improve substantially despite recent ACIP recommendations, in the absence of school mandates requiring third dose of MMR during outbreaks.Disclosures All authors: No reported disclosures.