The World Health Organization recommends healthcare workers (HCWs) practice hand hygiene (HH) while providing care. Making alcohol-based hand rub (ABHR) available at points of care is recommended during times of high patient volume, such as the COVID-19 pandemic. In low- and middle-income countries, such as Belize, there may be limited access to HH materials within healthcare facilities (HCF). This paper examines the motivators and barriers to HH among HCWs in the 11 largest public healthcare facilities in Belize and HCWs' experiences with an intervention. In 2021, focus group discussions (FGDs) gathered HCWs' HH perceptions and preferences. An intervention was then implemented to increase ABHR access and HH training for HCWs. Post-intervention endpoint FGDs in 2022 documented HCWs' experiences with interventions. Baseline FGDs revealed that self-protection and protection of one's household members from illness were key motivators for HCWs' HH practice. Insufficient time, inadequate access to HH supplies, and gaps in education were barriers to practicing HH. At endpoint, participants appreciated increased access to ABHR and its convenience but did not like ABHR's effect on hands. Experiences with the training were mixed. To improve HCWs' HH practices, HH interventions should be tailored to HCWs' context and learning preferences.

Disparities in access to water, sanitation, and hygiene within high-income countries are common and often occur across racial/ethnic lines. The Arab-Bedouins in Israel, a formerly nomadic ethno-national minority, have experienced displacement, forced sedentarization, and poverty since Israel was founded. Land disputes with the government have led to precarious living arrangements, including unrecognized villages that the government considers illegal. We administered a structured questionnaire in one government-planned, two legally recognized, and two unrecognized Bedouin communities in the Negev (190 households). Only 44% (95% CI 37%, 51%) of households had access to both safely managed drinking water and sanitation; nationally Israel reports over 99% coverage for each. In one unrecognized village, only 15% of households had access to safely managed water and sanitation, comparable to low-income countries. The overall 1-week prevalence of diarrhea in children under 5 years of age was 22% (95% CI 17%, 27%), with substantial variation between communities. These results highlight that universal access to safely managed drinking water and sanitation remains a relevant goal, not only for low- and middle-income countries but for high-income countries. Bedouin communities in the Negev are a prime example, emphasizing that historic gains in global development have not uniformly reached marginalized groups within high-income countries.

Safe water storage protects household drinking water from microbial contamination, maintaining water quality and preventing diarrhea and other water-borne diseases. However, achieving high adoption and sustained use of safe storage is challenging. Systematic adaptation can address these challenges by improving contextual fit while retaining core functionality to protect water quality. We applied Plan-Do-Study-Act (PDSA) cycles to systematically adapt a safe water storage container (SWSC) intervention for implementation in rural Burkina Faso. This study describes the adaptation process and the impacts of the SWSC on contamination in household stored water in a cluster-randomized trial with 49 intervention villages (274 households) and 50 no-intervention control villages (290 households). SWSC adoption among intervention households was high (88.9%). The intervention achieved approximately a 0.4 log reduction in contamination. Intervention impact was likely moderated by differential changes in improved source use across intervention and control households. Safe storage improves water quality when used consistently. PDSA frameworks can guide the adaptation of safe storage interventions to optimize adoption and sustained use in new contexts while preserving core functions that protect water quality.

As factors influencing the health and well-being of children are complex and cross-sectoral, integrated interventions are required to improve child health and hence address the Sustainable Development Goals. This paper explores linkages between environmental factors, feeding practices and potential infection pathways in India. The PANChSHEEEL project is a participatory interdisciplinary study, designed to explore HEEE (Health, Education, Engineering and Environment) factors influencing Infant and Young Child Feeding practices. This study uses data from observational transect walks and 445 household interviews from nine villages in Banswara district in India. Using the socio-ecological model, this study demonstrates how the lack of access to and quality of water resources, poor access to sanitation and hygiene practices, access to cooking fuels and flooding can influence feeding practices. The study finds that access to water, sanitation and cooking fuels can affect the preparation of food, contaminate water and food and place added time burden on caregivers. For infants, insufficient and contaminated water can lead to a higher risk of infection, diarrhoea and ultimately malnutrition. Recommendations include efforts to address waterlogging, promote safe storage of water, establish a water quality regime with stakeholders and develop appropriate, affordable and acceptable sanitation solutions.

Environmental health services (EHS) are critical for safe and functional healthcare facilities (HCFs). Understanding costs is important for improving and sustaining access to EHS in HCFs, yet the understanding of costs is poor and no tools exist to specifically support costing EHS in HCFs in low- and middle-income countries. We developed a toolkit to guide the following steps of costing EHS in HCFs: defining costing goals, developing and executing a data collection plan, calculating costs, and disseminating findings. The costing toolkit is divided into eight step-by-step modules with instructions, fillable worksheets, and guidance for effective data collection. It is designed for use by diverse stakeholders involved in funding, implementation, and management of EHS in HCFs and can be used by stakeholders with no prior costing experience. This paper describes the development, structure, and functionality of the toolkit; provides guidance for its application; and identifies good practices for costing, including pilot testing data collection tools and iterating the data collection process, involving diverse stakeholders, considering long-term costs, and disaggregating environmental costs in records to facilitate future costing. The toolkit itself is provided in the Supplementary Material.

The eggs of parasitic helminth worms are incredibly resilient - possessing the ability to survive changing environmental factors and exposure to chemical treatments - which has restricted the efficacy of wastewater sanitation. This research reports on the effectiveness of electroporation to permeabilize ova of , a helminth surrogate, for parasite deactivation. This technique utilizes electric pulses to increase cell membrane permeability in its conventional application, but herein is used to open pores in nonparasitic nematode eggshells - the first report of such an application to the best knowledge of the authors. A parametric evaluation of electric field strength and total electroporation duration of eggs and worms in phosphate-buffered saline was performed using a 1 Hz pulse train of 0.01% duty cycle. The extent of pore formation was determined using a fluorescent label, propidium iodide, targeting C. elegans embryonic DNA. The results of this research demonstrate that electroporation increases eggshell permeability. This treatment, coupled with existing methods of electrochemical disinfection, could improve upon current attempts at the deactivation of helminth eggs. We discuss electroporation treatment conditions and likely modification of the lipid-rich permeability barrier within the eggshell strata.

For fecal sludge from households in low- and middle-income countries to be treated offsite it needs to be removed, which can be greatly affected by the pit latrine floor design. However, it is unclear whether precast pit latrine concrete floors (latrine slabs) can withstand emptiers and their equipment. To investigate this issue, 28 prefabricated latrine slabs were purchased in two cities of Malawi. They were first visually evaluated, and then their compression strength was tested. Additionally, each seller was asked a series of questions to better understand their business, training, and construction practices. Results showed that households should perform due diligence to ensure that they are purchasing a safe precast latrine slab. Commonly reported problems included nonstandard reinforcement material and spacing, in addition to slabs that were not thick enough or were not large enough in diameter. The results of this research illustrate the inherent complexity in ensuring high-quality decentralized sanitation solutionsand how one component, the user interface, if implemented poorly, can affect the rest of the value chain. The findings from this work can help inform training and initiatives that engage artisans and suppliers who play a role in the provision of onsite sanitation service delivery.

sp. is the most prominent and resilient helminth of human health importance found in faecal sludge, making sp. an ideal index organism for inactivation testing. Heat treatment destroys helminths,allowingfor safe handling and possible reuse of sludge. Technology developmentfocuses on rapid heating to minimize equipment size and cost. This study evaluates viability with short heating time. were placed in a water bath at temperatures from 60 to 80 °C for various exposure times (5 seconds to 4 minutes) and were immediately processed and analysed via light microscopy. For all samples within these temperature and time ranges, less than 10% viable eggs were recovered. For 70, 75 and 80 °C, complete inactivation was observed for exposure time of 5 seconds and above.

After the 2015 earthquake in Nepal that killed approximately 9,000 people, the country faced an increased risk of cholera outbreaks due to extensive destruction of water and sanitation infrastructure and massive displacement. The disaster revealed long-standing weaknesses in water and sanitation systems in the country. Anticipating a cholera outbreak in 2016, UNICEF, Johns Hopkins University, and the Group for Technical Assistance partnered to support the Government of Nepal to ensure a safe water supply and improve sanitation and hygiene. This article discusses challenges, gaps, lessons learned and recommendations that were drawn from the authors' experience in cholera prevention and control in post-earthquake Nepal. Challenges identified include lack of regular water quality testing and monitoring, inconsistent use of point-of-use water treatment products, and lack of a fast-track mechanism for rapid response. The article argues for building a resilient water and sanitation system to secure sustainable and equitable access to safe drinking water.

This paper discusses the need to incorporate equity assessment into the planning and monitoring of sanitation service delivery to South African informal settlements. Equity assessment criteria were drawn from literature and a study of sanitation service delivery to informal settlements in three South African municipalities (Cape Town, Johannesburg and eThekwini) over the period 2012-2015. Three key dimensions of equity - resource allocation, access and stakeholder perceptions - were identified. These had eight associated criteria: (1) funds allocated for basic sanitation, (2) number of staff allocated to informal settlements, (3) disparities in access, (4) proportion of functioning sanitation facilities, (5) menstrual hygiene management (MHM) inclusion, (6) access to information, (7) meets users' notions of dignity, and (8) integration of the perspectives of key stakeholders. Key findings of the study indicate that the current focus on reducing service backlogs largely ignores equity and there is a need to better address this through the incorporation of: equity assessments, improving access to information, and the inclusion of marginalised communities in the planning of sanitation services.

A time-temperature plot presenting the inactivation of eggs is expanded with additional literature data. The information is of value to designers and operators of sanitation equipment who have inactivation as an objective.

Open defecation and poor fecal management facilitates the spread of disease. Viscous heating can pasteurize fecal sludge by creating a high shear field in the annular gap between a stationary, cylindrical outer shell and a rotating inner core. As sludge flows axially through the annular gap, thorough mixing and frictional heating eliminate cool spots where microbes may survive. A viscous heater (VH) compares favorably to a conventional heat exchanger, where cool slugs may occur. Computational fluid dynamics (CFD) was used to determine the effects of geometry and fluid rheology on VH performance over a range of conditions. A shear-rate and temperature-dependent rheological model was developed from experimental data, using a sludge simulant. CFD of an existing VH used the model to improve the original naïve design by including temperature and shear rate-dependent viscosity. CFD results were compared to experimental data at 132 and 200 L/hr to predict design and operating conditions for 1,000 L/hr. Subsequent experimentation with fecal sludge indicated that the CFD approach was valid for design and operation.

The biogas project for domestic sewage treatment (BPDST) is considered a promising facility for wastewater management in rural areas of China. This paper explores previous experimental works, cost analysis, and BPDST structure and design based on Chinese literature. Opportunities for developing decentralized or neighborhood-based BPDSTs include fulfilling Millennium Development Goals (MDGs) and Sustainable Development Goals (SDGs), the water pollution situation and deficiency of wastewater treatment facilities, the advantages of BPDSTs compared with centralized sewage plant, government support and policy drive for rural wastewater treatment, and reuse demand for resources. Meanwhile, challenges faced are emphasized as follows: uncertain responsibility for BPDSTs under different governmental departments restricts BPDST development and should be specified; uncertain effluent quality due to low efficiency of nutrient removal requires aerobic post-treatment to some extent; rural environmental awareness is still low and should be heightened; more funds should be invested in R&D for improvement of technology innovation; more reuse and resource recovery elements should be considered during implementation; follow-up services are lacking and should be improved; and BPDST maintenance should be trained. This paper could provide valuable reference for other developing countries.

The World Health Organization suggests storing human urine for at least 6 months at 20°C prior to application as fertilizer to reduce the potential health risks from pathogenic organisms. Such a storage condition for human urine,however,not only requires along period of time and large space but also ignores the risk of nitrogen losses. In this study, human urine underwent thermal treatment during storage to improve disinfection and to inhibit urea hydrolysis. Microbial indicators such as and fecal coliforms and the concentration of ammonia/ammonium were investigated in urine samples that were stored at 60°C and 70°C. Both the inactivation of indicators and decomposition of urea improved under storage temperatures of 60°C and 70°C compared with storage under ambient temperature. Therefore, human urine is recommended to be stored at 70°C for 7 days for hygienic and stabilization purposes. Under this storage condition, pH is maintained below 8.0 and ammonia/ammonium content is maintained at approximately 800 mg/L.

Packaged water (as either refill, bottled, or sachet water) has become an important element of water security in many low- and middle-income countries, owing to poor reliability and lack of piped water infrastructure. However, over time and across countries, the Demographic and Health Surveys monitoring program has inconsistently classified packaged water components as either improved or unimproved. Using data collected as part of the Performance Monitoring and Accountability 2020 (PMA2020) surveys on water options in nine study geographies across eight countries, we identified five geographies where packaged water constituted one of several options for 5% or more of users. In this study, four scenarios were designed in which packaged water components were variously classified as either improved or unimproved. Unimproved water use was highest in scenarios where sachet or refill water was classified as an unimproved source. Across the four scenarios, the difference in the use of unimproved water as the main option was highest (65%) in Nigeria (Lagos). That difference increased to 78% when considering all regular options. The development of these scenarios highlights the importance of classifying a source as improved or unimproved in the overall metric that indicates progress at national and international levels.

This study was part of the VUNA project aimed to develop an affordable sanitation system that produces a valuable fertiliser, reduces pollution of water resources and promotes health. Urine diversion dry toilets (UDDTs) simplify the on-site hygienisation of faeces and allow for nutrient recovery from urine. Social acceptance is vital for the implementation of the UDDT, because sanitation is only effective if the system not only provides a well-designed toilet and effective waste management, but also offers users a facility that caters to their needs and is sensitive to their cultural lifestyle. This study used qualitative and quantitative methods to investigate acceptance, use and maintenance of UDDTs. Key findings indicate lower levels of acceptance of UDDTs among the elderly, who are accustomed to traditional pit toilets. The users aspire to own a flush toilet, perceived to be indicative of household wealth. A dominant concern was emptying the pit and the quality of the building material. Community interventions are required that will promote acceptance, understanding and encourage proper use and maintenance of the UDDT, and may need some technology modification. There is an urgent need for increased community participation to address users' perceptions, attitudes and behaviour concerning the UDDT.

Community wells that extend deeper than most private wells are crucial for reducing exposure to groundwater arsenic (As) in rural Bangladesh. This study evaluates the impact on access to safe drinking water of 915 such intermediate (90-150 m) and deep (>150 m) wells across a 180 km area where a total of 48,790 tubewells were tested with field kits in 2012-13. Half the shallow private wells meet the Bangladesh standard of 50 µg/L for As in drinking water, whereas 92% of the intermediate and deep wells meet the more restrictive World Health Organization guideline for As in drinking water of 10 µg/L. As a proxy for water access, distance calculations show that 29% of shallow wells with >50 µg/L As are located within walking distance (100 m) of at least one of the 915 intermediate or deep wells. Similar calculations for a hypothetical more even distribution of deep wells show that 74% of shallow wells with >50 µg/L As could have been located within 100 m of the same number deep wells. These observations and well-usage data suggest that community wells in Araihazar, and probably elsewhere in Bangladesh, were not optimally allocated by the government because of elite capture.

Small piped water supply systems are often unable to provide reliable, microbiologically safe, and sustainable service over time, and this has direct impacts on public health. Circuit Rider (CR) post-construction support (PCS) addresses this through the provision of technical, financial, and operational assistance to these systems. CRPCS operates in low and high-income countries; yet, no rigorous studies of CRPCS exist. We measured the impact of CRPCS on 'water quality' and 'sustainability' indicators (technical and administrative capacity, and water supply protection) in El Salvador. In this field-based study, a case-control design was utilized in 60 randomly selected case (28 CR) and comparable control (32 noCR) communities. Microbiological water quality tests and pre-tested structured key-informant interviews were conducted. The operational costs of CRPCS were also assessed. Data were compared using parametric and non-parametric statistical methods. We found communities with CRPCS had significantly lower microbiological water contamination, better disinfection rates, higher water fee payment rates, greater transparency (measured by auditable banking records), greater rates of household metering, and higher spending for repairs and water treatment than comparable control communities. CRPCS is also a low-cost (<$1 per household/year in El Salvador) drinking water intervention.

In 2009 the Haitian Directorate of Potable Water and Sanitation (DINEPA) identified an inadequately trained and under-staffed rural workforce as one of their main institutional challenges. Plans to address this challenge were impacted by the devastating earthquake of January 12, 2010 and the cholera outbreak of October 2010, both of which further complicated Haiti's already poor water and sanitation conditions. Recognizing the importance of DINEPA's institutional priorities, donor and technical assistance groups provided needed support to improve the country's conditions and build the rural water and sanitation workforce. This report describes how DINEPA and the US Centers for Disease Control and Prevention (CDC) collaborated to design and implement a training program for 264 potable water and sanitation technicians for rural areas. The paper also describes the initial field activities of the newly trained technicians and the immediate impact of their work in the rural water, sanitation and hygiene sector.

This study considers potential policy responses to the still very high levels of exposure to arsenic (As) caused by drinking water from shallow tubewells in rural Bangladesh. It examines a survey of 4,109 households in 76 villages of Araihazar upazila conducted two years after a national testing campaign swept through the area. The area is adjacent to the region where a long-term study was initiated in 2000 and where households are periodically reminded of health risks associated with well-water elevated in As. Results confirm that testing spurs switching away from unsafe wells, although the 27% fraction who switched was only about half of that in the long-term study area. By village, the fraction of households that switched varied with the availability of safe wells and the distance from the long-term study area. Lacking follow-up testing, two years only after the campaign 21% of households did not know the status of their well and 21% of households with an unsafe well that switched did so to an untested well. Well testing is again urgently needed in Bangladesh and should be paired with better ways to raise awareness and the installation of additional deep community wells.

In response to the COVID-19 pandemic, we established and sustained local production of alcohol-based handrub (ABHR) at district scale for healthcare facilities and community, public locations in four districts in Uganda. District officials provided space and staff for production units. The project renovated space for production, trained staff on ABHR production, and transported ABHR to key locations. The production officer conducted internal ABHR quality assessments while trained district health inspectors conducted external quality assessments prior to distribution. Information, education, and communication materials accompanied ABHR distribution. Onsite ABHR consumption was monitored by site staff using stock cards. On average, it took 11 days (range: 8-14) and 5,760 USD (range: 4,400-7,710) to set up a production unit. From March-December 2021, 21,600L of quality-controlled ABHR were produced for 111 healthcare facilities and community locations at an average cost of 4.30 USD/L (range: 3.50-5.76). All ABHR passed both internal and external quality control (average ethanol concentration of 80%, range: 78-81%). This case study demonstrated that establishing centralized, local production of quality-controlled, affordable ABHR at a district-wide scale is feasible and strengthens the ability of healthcare workers and community locations to access and use ABHR during infectious disease outbreaks in low-resource countries.