Assessment of Water, Sanitation, and Hygiene Interventions in Response to an Outbreak of Typhoid Fever in Neno District, Malawi

Assessment of Water, Sanitation, and Hygiene Interventions in Response to an Outbreak of Typhoid Fever in Neno District, Malawi Sarah D. Bennett, MD, MPH Lieutenant, U.S. Public Health Service April 13, 2011 Division of Foodborne, Waterborne, and Environmental Diseases National Center for Emerging and Zoonotic Infectious Diseases Division of Foodborne, Waterborne, and Environmental Diseases

Typhoid Fever Salmonella enterica serovar Typhi 21 million illnesses and 200,000 deaths Humans are the only known reservoir Infection through contact with contaminated food or water

Outbreak Timeline Onset Neno District Malawi Tsangano District Mozambique May 2009 Aug Oct April June Aug Sept

Outbreak Timeline Onset Multinational investigation May June Aug Oct Dec Feb April 2009 2010 June Aug Sept 302 cases

Outbreak Timeline Onset Multinational investigation May June Aug Oct Dec Feb April 2009 2010 June Aug Sept Prevention interventions

Outbreak Timeline Multinational investigation Onset Rainy season May June Aug Oct Dec Feb April 2009 2010 June Aug Sept Prevention interventions

Interventions Community meetings or Typhoid Talks Cause, treatment and prevention of typhoid fever Household stored water treatment Distribution of WaterGuard Locally produced Dilute sodium hypochlorite solution Infrastructural improvements Boreholes Pit latrines

Outbreak Timeline Multinational investigation Onset Rainy season 784 cases 44 deaths May June Aug Oct Dec Feb April 2009 2010 June Aug Sept Prevention interventions

Outbreak Timeline Multinational investigation Onset Rainy season WASH Survey May June Aug Oct Dec Feb April 2009 2010 June Aug Sept Prevention interventions

Impact of prevention interventions on WASH Survey Objectives Knowledge of cause and prevention of typhoid fever Knowledge, attitudes and practices regarding safe water Receipt and use of WaterGuard

17 villages Methods: WASH Survey Neno District, Malawi Reported cases in 2009 and 2010 10-12 female heads of household per village Randomly selected

Methods: Household Stored Water Testing Free residual chlorine testing

Response Rate 393 households visited 202 households enrolled

Response Rate 393 households visited 187 unavailable 4 refused 202 households enrolled

Demographics All Respondents (n=202) Mean age (range) 35 (18-83) Mean persons per household (range) 5 (1-12) No education 25% Self-reported literacy 57%

Attendance at a Typhoid Talk 56% reported attending a Typhoid Talk Talks led by Community Health Workers Clinicians NGO s

Reported Causes of Typhoid Fever Total (n=202) Poor hygiene 73% Drinking bad water 47% Eating bad food 27%

Reported Causes of Typhoid Fever Typhoid Talk (n=111) No Typhoid Talk (n=87) p-value Poor hygiene 85% 64% < 0.01 Drinking bad water 55% 42% 0.02 Eating bad food 34% 21% 0.13

Reported Methods of Prevention Total (n=202) Treat water 65% Wash hands 50% Clean cooking utensils / vessels 36% Cook food thoroughly 34%

Reported Methods of Prevention Typhoid Talk (n=111) No Typhoid Talk (n=87) p-value Treat water 70% 63% 0.30 Hand washing 52% 51% 0.89 Clean cooking utensils / vessels 44% 26% 0.04 Cook food thoroughly 32% 38% 0.55

Impact of Typhoid Talks on Knowledge of Cause and Prevention of Typhoid Fever Household understanding of causes and methods of preventing typhoid fever are low Attendance at a Typhoid Talk Improved knowledge of hygiene and water as causes Did not improve knowledge of food as a potential cause Did not significantly improve knowledge of prevention methods

Sources of Household Water 4% Rivers 48% Boreholes 46% Unprotected wells 2% Public Taps

Additional Sources of Household Water 57% Unprotected wells 6% Rivers Primary borehole users 3% Another borehole

Treatment of Household Stored Water 70% reported treating water in preceding 2 weeks Most common reasons for not treating water Lack of WaterGuard (57%) or 1% stock chlorine solution (40%) Current water is safe (18%) Too busy (12%) Bad taste or smell associated with treatment (2%)

Methods of Treating Household Stored Water 100% 98% 2009 89% 2010 79% 80% Reported Frequency 60% 40% 20% 47% 48% 23% 36% 16% 0% Any chlorine product WaterGuard 1% stock chlorine solution Boiling

WaterGuard in the Home 84% received free WaterGuard 53% had WaterGuard observed in the home 33% used to treat currently stored water

Free Residual Chlorine Testing Adequate Free Residual Chlorine* All households with stored water 15% (n=152) Households who reported treating water with WaterGuard 63% (n=38) *Adequate free residual chlorine defined as 0.2 milligrams per liter

Impact of Interventions on Knowledge, Attitudes and Practices of Safe Water Most households use unimproved sources of water WaterGuard was distributed Few used it to treat stored water Supply insufficient to treat all stored water Adequate chlorine levels in few households Most households do not have safe drinking water

Limitations of WASH Survey Lack of a baseline evaluation for comparison Challenges in typhoid fever surveillance Ongoing prevention activities during survey High rate of unavailable target respondents

Conclusions Knowledge of relationship between unsafe water, food and typhoid fever remains low Typhoid Talks improved knowledge of poor hygiene and unsafe water as causes Did not improve knowledge of food as cause Did not improve knowledge of prevention methods WaterGuard was distributed, but use is low Many households remain without safe drinking water

Recommendations Improve attendance and effectiveness of educational campaigns or Typhoid Talks Increase knowledge of typhoid fever Emphasize importance of household stored water treatment Improve delivery and promote use of WaterGuard Sustainable access to WaterGuard at household level Continue improvement of water and sanitation infrastructure in Neno District

Acknowledgements WHO Ministry of Health, Malawi Neno District Health Office UNICEF Partners in Health USAID PSI Action Aid All the staff, enumerators and drivers who participated in planning, logistics and data collection CDC Lauren Blum Cheryl Bopp Linda Capewell Austin Demby Holly Dentz Leonard Floyd Mike Humphreys Sara Lowther Eric Mintz Benjamin Nygren Michele Parsons Jim Sejvar Ethel Taylor Tom Warne

Thank you! For more information please contact Centers for Disease Control and Prevention 1600 Clifton Road NE, Atlanta, GA 30333 Telephone, 1-800-CDC-INFO (232-4636)/TTY: 1-888-232-6348 E-mail: cdcinfo@cdc.gov Web: www.cdc.gov The findings and conclusions in this report are those of the authors and do not necessarily represent the official position of the Centers for Disease Control and Prevention. National Center for Emerging and Zoonotic Infectious Diseases Division of Foodborne, Waterborne and Environmental Diseases

ADDITIONAL SLIDES

Outbreak Timeline Multinational investigation Onset Rainy season WASH Survey 784 cases 44 deaths May June Aug Oct Dec Feb April 2009 2010 302 cases June Aug Sept Prevention interventions

Epidemic Curve for Typhoid Fever Outbreak Number of Cases 100 90 80 70 60 50 40 30 20 10 0 Active Surveillance (Outbreak investigation) Mar Apr May June July Aug Sept Oct Nov Dec Jan Feb Mar Apr May June July Aug Sept 2009 2010 Passive Surveillance Laboratory Capacity Building Month and Year Suspected Probable Confirmed

Early Intervention Late Intervention Nsambe Clinic Neno District Hospital

Attendance at a Typhoid Talk by Village Village Targeted Education "Typhoid Talk" Attendance Chakulembera Yes 64% Chikalema No 36% Chimbalanga I Yes 36% Chimbalanga II Yes 33% Chiyembekeza Yes 82% Kagudza Yes 58% Kaingilira Yes 58% Kalimedzako Yes 33% Kamoto No 33% Kumbwani Yes 33% Kundembo Yes 45% Kweneza Yes 92% Masamba Yes 67% Moffat Yes 67% Mposadala Yes 67% Mtemankhawa Yes 83% Nseula Yes 64%

Results: Products Received at Typhoid Talk 100% 80% 84% 78% Reported Frequency 60% 40% 30% 20% 14% 11% 5% 0% WaterGuard Soap Advice or information 1% stock chlorine solution Print materials T-shirt

Reported Causes of Typhoid Fever Total (n=202) Typhoid Talk (n=111) No Typhoid Talk (n=87) p-value Poor hygiene 73% 85% 64% < 0.01 Drinking bad water 47% 55% 42% 0.02 Eating bad food 27% 34% 21% 0.13 Flies 7% 11% 3% 0.06 Unwashed fruits / vegetables 7% 6% 9% 0.24 Don't know 14% 5% 20% 0.01

Reported Methods of Prevention Total (n=202) Typhoid Talk (n=111) No Typhoid Talk (n=87) p-value Treat water 65% 70% 63% 0.30 Hand washing 50% 52% 51% 0.89 Clean cooking utensils / vessels 36% 44% 26% 0.04 Cook food thoroughly 34% 32% 38% 0.55 Wash fruits / vegetables 18% 13% 25% 0.14 Don t know 7% 1% 10% 0.01

96% would go to a health facility Treatment of Typhoid Fever 3% reported a home remedy Traditional healers were not mentioned by any respondent

Diseases Caused by Drinking Unsafe Water Reported Frequency 100% 80% 60% 40% 20% 0% 89% 37% 44% attending a Typhoid Talk compared to 31% not attending a talk (p = 0.04) 33% 21% 18% 11% Diarrhea Typhoid Cholera Malaria Fever Dysentery Don't know 2%

Storage of Household Water 74% wide-mouthed vessels 57% covered 99% scoop with ladle / cup 27% narrow-mouthed vessels 99% pour water

Uses of Household Stored Water 100% 92% 80% Reported Frequency 60% 40% 66% 57% 39% 30% 20% 0% Cooking Washing cooking utensils / vessels Bathing Washing fruits / vegetables Washing clothes

Markers of Water Safety 100% 80% Reported Frequency 60% 40% 20% 0% 54% Appearance 28% It is protected 35% reported clear water can make them sick 19% 16% 11% Smell Taste Containers are clean / covered 2% People get sick 19% Don't know

Reasons for Treating Household Stored Water Overall Typhoid Talk (n=111) No Typhoid Talk (n=87) p-value Makes water safer 83.4% 81.0% 88.0% 0.10 CHW visited village to talk about it 19.4% 26.3% 11.9% 0.04 Received water treatment for free 7.3% 11.0% 3.4% 0.01 Someone at health facility said important 3.8% 3.3% 2.3% 0.54 Family / friends said important 1.2% 0.0% 2.6% Undefined

Receipt and Observed WaterGuard by Village Village WaterGuard Distribution Reported Receipt of WaterGuard Observed WaterGuard in Home Chakulembera Yes 100% 27% Chikalema No 25% 0% Chimbalanga I Yes 92% 50% Chimbalanga II Yes 100% 92% Chiyembekeza Yes 100% 50% Kagudza Yes 100% 100% Kaingilira Yes 100% 50% Kalimedzako Yes 100% 92% Kamoto No 0% 0% Kumbwani Yes 100% 73% Kundembo Yes 100% 83% Kweneza Yes 100% 58% Masamba Yes 100% 58% Moffat Yes 100% 50% Mposadala Yes 100% 58% Mtemankhawa Yes 100% 33% Nseula Yes 100% 80%

Geographic Receipt of WaterGuard Total (n=202) Early Intervention (n=106) Late Intervention (n=96) p-value Received free WaterGuard 84% 100% 74% undefined Observed WaterGuard 53% 53% 54% 0.99

Number of Times Received Free WaterGuard 100% 80% Reported Frequency 60% 40% 20% 11% 6% 12% 21% 23% 12% 15% 0% Never Once 2 Times 3 Times 4 Times 5 Times > 5 Times

Methods of Treating Household Stored Water Overall Typhoid Talk (n=111) No Typhoid Talk (n=87) p-value WaterGuard 89.3% 94.5% 83.7% < 0.01 1% Stock chlorine solution 23.0% 22.3% 24.1% 0.82 Boiling 16.0% 15.8% 17.4% 0.81

Free Residual Chlorine Testing Adequate Free Residual Chlorine* All households with stored water 15% Households who reported treating water 59% Households who reported treating water with WaterGuard 63% *Adequate free residual chlorine defined as 0.2 milligrams per liter

Free Residual Chlorine Testing Adequate Free Residual Chlorine Overall Typhoid Talk No Typhoid Talk p-value All households with stored water 15% 20% 11% 0.11 Households who reported treating water 59% 64% 49% 0.53 Households who reported treating water with WaterGuard 63% 72% 49% 0.33

100% 92% Hand Hygiene When should you wash your hands 80% 74% Reported Frequency 60% 40% 50% 38% 20% 13% 0% After using toilet Before eating After cleaning babies Before cooking All 4 recommended

When to Wash Hands Overall (n=202) Typhoid Talk (n=11) No Typhoid Talk (n=87) p-value After using toilet 92% 94% 91% 0.42 Before eating 74% 83% 64% 0.01 After cleaning babies 50% 53% 48% 0.64 Before cooking 38% 41% 37% 0.56 All 4 guidelines 13% 12% 14% 0.71

Hand Washing Stations WATER SOAP 77% reported soap in the home 46% use soap for hand washing Only 1 / 202 households with a functional hand washing station

Reported Latrine Use 100% 80% Reported Frequency 60% 40% 51% 43% 20% 0% 9% Own latrine Shared latrine Open defecation

Latrine Use by Intervention Village Total (n=202) Early Intervention (n=106) Late Intervention (n=96) p-value Own latrine 51% 71% 38% < 0.01 Shared latrine 43% 29% 51% 0.04 Open defecation 9% 2% 12% 0.01

Bacterial coliform and E.coli testing PAIRED SAMPLES 5 out of 9 boreholes and all 3 public taps were positive for bacterial coliforms and E. coli

Malawi-Mozambique Border MALAWI MOZAMBIQUE KWENEZA VILLAGE NSAMBE CLINIC DACKSON CLINIC

Low refusal rate Strengths of WASH Survey Inclusion of all 17 villages affected by 2009-2010 outbreak Observation of reported household practices Residual chlorine testing to confirm WaterGuard use

DELETED SLIDES

Background: Outbreak of mystery illness June 24, 2009: Neno District Health Officer reports cases of mystery illness to Malawi Ministry of Health Cases begin on May 2, 2009 Rapid spread throughout Neno District, Malawi and neighboring Tsangano District, Mozambique High rate of neurologic complications Multinational investigation Salmonella enterica serovar Typhi (Typhoid Fever) September 2010: 784 cases and 44 deaths 2 countries, 3 districts, 8 health facilities, and 47 villages Case-fatality ratio 5.6%

Background: Response to the outbreak July 2009 August 2010 Community education on Typhoid Fever and household safe water, sanitation and hygiene practices Distribution and education on use of WaterGuard for in-home stored water treatment Construction of boreholes and protected spring boxes in the most affected villages Construction of latrines School-based education on hand washing and hygiene Interventions interrupted by the rainy season (November 2009 February 2010) Most villages inaccessible

Demographics All Respondents (n=202) Mean age (range) 35 (18-83) Mean number persons per household (range) 5.14 (1-12) No education 25% Some primary education 70% Self-reported literacy 57%

Results: Reported Source of Typhoid Talks 100% (n=111) 80% Reporting Frequency 60% 40% 20% 63% 27% 16% 0% Community Health Workers Clinicians NGO's (PSI / Unicef) 8% 5% 4% 2% Neighbors / Family / Friends Drama Performance Movie Radio

Results: Reported Causes of Typhoid Fever 100% (n=202) Reporting Frequency 80% 60% 40% 73% 47% 27% 20% 7% 7% 14% 0% Poor hygiene Drinking bad water Eating bad food Flies Unwashed fruits / vegetables Don't know

Results: Reported Methods for Preventing Typhoid Fever 100% (n=202) 80% Reporting Frequency 60% 40% 20% 0% 2% No prevention available 65% Treat water 50% Hand washing 36% 34% Clean cooking utensils / vessels Cook food thoroughly 18% Wash fruits / vegetables 7% Don't know

Results: Primary Source of Household Water 100% (n=202) 80% Reported Frequency 60% 40% 20% 48% 46% 0% 4% 2% Borehole Unprotected well River Public tap

Results: Additional Sources of Household Water 100% Among Primary Borehole Users (n=84) 80% Reported Frequency 60% 40% 57% 20% 0% 6% 3% Unprotected well River Another borehole

Results: Access to Household Stored Water 100% (n=202) 80% 74% Reported Frequency 60% 40% 20% 27% 0% Use a scoop Pour water