CHoBI7 Trial: A hospital based WASH intervention for households of diarrheal patients in Bangladesh

Burden

Diarrhea is the second most leading causes of deaths in children under 5 years of age globally, with an estimated 800,000 deaths annually. On an average, a child in Bangladesh suffers from 3-5 episodes of diarrhea per year. Children suffering from frequent and recurrent diarrhea suffer from food wasting, and the ultimate result is severe malnutrition and growth stunting. Once stunted, its effects typically become permanent, and children may never regain the height lost as a result of stunting. Previous studies have identified lack of caregiver hand washing with soap and treatment of household drinking water, poor water storage practices, and lack of caregivers knowledge about diarrhea prevention as important risk factors for diarrheal disease in paediatric populations. Water, sanitation, and hygiene (WASH) interventions promoting household chlorination of drinking water and hand washing with soap have the potential to reduce diarrheal disease incidence in children less than five years of age an estimated 30 to 40%. Furthermore, Community Based WASH interventions are expensive and often difficult to implement in an urban context in low resource settings. Our team has recently developed a Hospital Based WASH intervention which is entitled CHoBI7 (Cholera Hospital-Based Intervention for 7 days). The CHoBI7 intervention was initially designed to reduce cholera infection among family members of hospitalized cholera cases during the one week high risk period after the case presents at the hospital. This low cost Hospital Based WASH intervention resulted in a significant reduction in the incidence of symptomatic cholera, and a 47% percent reduction in the incidence of cholera infection among household members of hospitalized cholera cases. Furthermore, we observed sustained uptake of the promoted hand washing with soap and water treatment behaviours among intervention households 6 to 12 months after the intervention was delivered.

Knowledge gap

Despite successful intervention in our just concluded hospital based study we still do not understand if all the procedures involved can be integrated into the services provided for hospitalized diarrhea patients at health facilities of Bangladesh and the promoted hand washing with soap and water and water treatment behaviour would be a long lasting practice in the community.

Hypothesis

Based on what we have learned from our just concluded Hospital Based WASH intervention study entitled “Cholera Hospital-Based Intervention for 7 day” (CHoBI7), we hypothesize that developing and evaluating scalable approaches might help this innovative and low cost CHoBI7 intervention to be integrated into the services provided for hospitalized diarrhea patients at the health facilities of Bangladesh. We also hypothesize that evaluating the ability of the CHoBI7 intervention, which could lead to a sustained uptake of the promoted hand washing with soap and water treatment behaviours might reduce the burden of diarrheal diseases over time.

Objective 1

To Develop scalable approaches to integrate the CHoBI7 intervention in urban health facilities through formative research and engagement of key stakeholders.

Objective 3

Investigate the effectiveness of the developed scalable approaches for program delivery of CHoBI7 in terms of: (1) reductions in diarrheal disease prevalence during the 12 months period after the index diarrhea patient in the health facility receives the intervention; and (2) sustained high uptake of hand washing with soap and water treatment practices at 1 week, 1 month, 3 months, 6 months, 9 months, and 12 months post intervention.

Objective 3

Calculate the cost effectiveness of upscaling the CHoBI7 intervention in terms of cost per Disability Adjusted Life Year (DALY) averted and case and death averted for cholera and moderate to severe diarrhea episodes.

Objective 4

Investigate the feasibility of implementing the proposed low cost approaches for program delivery of CHoBI7 as part of the National Emerging and Re-emerging Diseases Program through identification of potential barriers to successful implementation, and engagement with key government stakeholders.

Objective 5

Disseminate the findings of CHoBI7 intervention implementation and evaluation activities and our recent CHoBI7 efficacy trial at the household, health facility, and national and local government levels through the creation of a website, policy planning workshops with government leaders, development of policy briefs, publishing finding in peer reviewed scientific journals, and presentations at international scientific meetings.

Methods

Diarrheal patients admitted to icddr,b Dhaka Hospital or Mugda General Hospital would be screened and enrolled according to inclusion criteria. Diarrhea patients will be recruited after they received ORS or intravenous rehydration. Household members would be recruited those accompanying the diarrhea patient to the hospital and reside in the home of the enrolled diarrhea patient. Written informed consent would be taken from the patients and their HHC before enrolment. A baseline questionnaire will then be administered to each enrolled diarrhea patient and enrolled accompanying household members (adult and child), stool sample will be collected, and anthropometric measurements will be performed. After the baseline questionnaire is administered to the index diarrhea patient and accompanying household members, they will then be randomized to their respective study arm (Control Arm/Health Facility Based Dissemination Arm / Health Facility Based Dissemination and Home Visits Arm) based on the day they arrive to the hospital. The first arm will receive the standard message given to hospitalized diarrhea patients in health facilities in Bangladesh on the use of oral rehydration solution (ORS) (Control Arm). The second arm will receive the standard message plus Health Facility Based Dissemination of CHoBI 7 (Health Facility Based Dissemination-Only Arm) and bi-weekly (every two weeks) follow-up phone calls or text messaging. The third arm will receive the standard message plus Health Facility Based Dissemination of CHoBI 7 plus two home visits (Health Facility Based Dissemination and Home Visits Arm) and biweekly follow-up phone calls or text messaging. These Randomized Control Trial activities would be 12 Months in duration in each enrolled household. Stool samples would be collected from the HHC on different time period, household drinking water would also be collected and direct observation (5 hr long) would also be performed.

Outcome measures/variables

Develop low cost effective strategies for delivering CHoBI7 in urban health facilities which can be integrated into the National Emerging and Re-emerging Diseases Program.