Reducing Sexual Violence by Increasing the Supply of Toilets in Khayelitsha,South Africa: A Mathematical Model

Background

Sexual violence is a major public health issue, affecting 35% of women worldwide. Major risk factors for sexual assault include inadequate indoor sanitation and the need to travel to outdoor toilet facilities. We estimated how increasing the number of toilets in an urban township (Khayelitsha, South Africa) might reduce both economic costs and the incidence and social burden of sexual assault.

Methods

We developed a mathematical model that links risk of sexual assault to the number of sanitation facilities and the time a woman must spend walking to a toilet. We defined a composite societal cost function, comprising both the burden of sexual assault and the costs of installing and maintaining public chemical toilets. By expressing total social costs as a function of the number of available toilets, we were able to identify an optimal (i.e., cost-minimizing) social investment in toilet facilities.

Findings

There are currently an estimated 5600 toilets in Khayelitsha. This results in 635 sexual assaults and US$40 million in combined social costs each year. Increasing the number of toilets to 11300 would minimize total costs ($35 million) and reduce sexual assaults to 446. Higher toilet installation and maintenance costs would be more than offset by lower sexual assault costs. Probabilistic sensitivity analysis shows that the optimal number of toilets exceeds the original allocation of toilets in the township in over 80% of the 5000 iterations of the model.

Interpretation

Improving access to sanitation facilities in urban settlements will simultaneously reduce the incidence of sexual assaults and overall cost to society. Since our analysis ignores the many additional health benefits of improving sanitation in resource-constrained urban areas (e.g., potential reductions in waterborne infectious diseases), the optimal number of toilets identified here should be interpreted as conservative.     

Screening of vision in school: could we do better by doing less?

Assessment of vision in schoolchildren is routinely performed, but the effectiveness of the screening programmes has not been reviewed. A survey of health district screening programmes for vision in schools was performed at the end of 1984. The response rate from districts in England and Wales was 81%. All 165 of the districts that responded screened for loss of distant visual acuity; 96% screened for loss of colour vision, 73% for squint, and 67% for loss of near visual acuity. The frequency with which districts screened varied considerably. Some districts screened yearly, and various different types of tests were used. In many districts children were screened in unsuitable places, such as corridors, assembly halls, and toilets. Criteria for referral varied from one district to another, and few districts collected data appropriate for monitoring their screening programmes. Many districts screened more intensively than could be justified on the basis of the conditions tested for and the likely benefit of remedial treatment.     

Use of Electronic Loggers to Measure Changes in the Rates of Hand Washing with Soap in Low-Income Urban Households in India

We evaluated the utility of electronic loggers to measure the effects of a simple intervention designed to influence the rates of hand washing with soap within enclosed toilets and bathrooms in low-income urban households in Kerala, India. 58 households were given three items with embedded electronic loggers for a period of 2-5 days. Two logged soaps tracked hand and body washing in the bathroom. The third logged item was a water vessel used for flushing the toilet and for post-defecation anal cleansing; this served as a marker of toilet use. In addition, 28 households in a Soap by toilet arm were given an additional logged soap, to be kept by the toilet, and used for hand washing. Compared with the Soap in bathroom arm, the loggers in the Soap by toilet households recorded 73% greater daily use of soaps designated for hand washing (t(36)=2.92, p<0.01) and 172% greater use within 2 minutes of the use of the water vessel (t(36)=3.51, p = 0.001). We conclude that the loggers were capable of detecting changes in the rates of hand washing with soap and changes in hand washing with soap after use of the toilet. Further adoption of logger technologies would enable more insightful studies of hand washing within urban environments.     

A bacteriological investigation of the effectiveness of cleaning and disinfection procedures for toilet hygiene

S cott , E. & B loomfield , S.F. 1985. A bacteriological investigation of the effectiveness of cleaning and disinfection procedures for toilet hygiene, Journal of Applied Bacteriology 59 , 291–297.
The bacterial contamination of hospital and institutional toilets and toilet areas which were cleaned daily was investigated. The effect of daily disinfection with hypochlorite or a quaternary ammonium product, or with a continuous-release hypochlorite disinfectant system, based on the chlorine-releasing agent trichloro-isocyanuric acid, was determined. The continuous release system produced substantial and sustained reduction in contamination of the toilet itself (water, toilet bowl and rim) and some reduction in contamination of sites surrounding the toilet (seat, floor, and air). By contrast, although daily disinfection produced some reduction in contamination compared with daily cleaning, the reductions were less than that associated with the continuous release system and indicated the inadequacy of daily disinfection and/or cleaning for toilets where effective procedures are required.     

A bacteriological investigation of the effectiveness of cleaning and disinfection procedures for toilet hygiene

The bacterial contamination of hospital and institutional toilets and toilet areas which were cleaned daily was investigated. The effect of daily disinfection with hypochlorite or a quaternary ammonium product, or with a continuous-release hypochlorite disinfectant system, based on the chlorine-releasing agent trichloroisocyanuric acid, was determined. The continuous release system produced substantial and sustained reduction in contamination of the toilet itself (water, toilet bowl and rim) and some reduction in contamination of sites surrounding the toilet (seat, floor, and air). By contrast, although daily disinfection produced some reduction in contamination compared with daily cleaning, the reductions were less than that associated with the continuous release system and indicated the inadequacy of daily disinfection and/or cleaning for toilets where effective procedures are required.     

Medical schools seeking new ways to cope with funding cutbacks

Cuts in government funding mean that Canada''s medical schools have to seek new ways to raise funds. Susan Thorne examines some of the ways faculties of medicine are coping with change. In the brave new world of medical education, schools are combining classes for medical students and other health professionals, seeking business alliances, encouraging attendance by full-tuition students from other countries and diversifying revenue bases through new programs, such as McGill''s new 5-year MD-MBA degree.     

Survival of Salmonella in bathrooms and toilets in domestic homes following salmonellosis

The survival and environmental spread of Salmonella bacteria from domestic toilets was examined in homes, where a family member had recently suffered an attack of salmonellosis. In four out of six households tested, Salmonella bacteria persisted in the biofilm material found under the recess of the toilet bowl rim which was difficult to remove with household toilet cleaners. In two homes Salmonella bacteria became incorporated into the scaly biofilm adhering to the toilet bowl surface below the water line. Salmonella enteritidis persisted in one toilet for 4 weeks after the diarrhoea had stopped, despite the use of cleaning fluids. Salmonellas were not isolated from normally dry areas such as, the toilet seat, the flush handle and door handle. Toilet seeding experiments were set up with Salmonella enteritidis PT4 to mimic environmental conditions associated with acute diarrhoea. Flushing the toilet resulted in contamination of the toilet seat and the toilet seat lid. In one out of three seedings, Salmonella bacteria were also isolated from an air sample taken immediately after flushing, indicating that airborne spread of the organism could contaminate surfaces in the bathroom. In the seeded toilet Salmonella bacteria were isolated from the biofilm in the toilet bowl below the waterline for up to 50 d after seeding, and also on one occasion from the bowl water. The results suggest that during diarrhoeal illness, there is considerable risk of spread of Salmonella infection to other family members via the environment, including contaminated hands and surfaces in the toilet area.     

Asthma in primary schools.

Seven schools in the Lewes area were visited to identify which children were using inhalational treatment for asthma. The attitudes of the parents and schools were assessed, as was the children''s skill in using inhalers. Five per cent of all children were receiving inhalational treatment with bronchodilator drugs. On average they had missed seven school days in the past year. The opinions of the parents about treatment appeared to be determined by the severity of the child''s asthma. Most schools coped well with giving bronchodilators, though there was no real understanding of the nature of the disease or treatment. Most children who had received pressurised inhalers could not use them satisfactorily.     

Health checks on patients 75 years and over in Nottinghamshire after the new GP contract.

OBJECTIVE--To investigate annual health checks for patients of 75 years and over required by the 1990 contract for general practitioners. DESIGN--Visits to practices to collect information on how assessments were organised and carried out; completion of questionnaires for every patient who had been assessed in a sample month, using information provided by the practice records. SETTING--20 general practices in one family health services authority. SUBJECTS--Patients of 75 years and over in 20 general practices. RESULTS--Three practices (15%) had not performed checks. Thirteen practices sent a letter to invite patients to undergo a check. Of these practices, seven followed up non-responders. Two practices visited patients'' homes unannounced, and two did checks on an opportunistic basis only. Sixteen practices used a checklist. Sixteen practices involved their practice nurses; at eight of these, doctors also performed checks; in six practices the nurses undertaking the checks had no training in assessing old people. Ten practices assessed more than 75% of their old people in the first year of the new contract. Practices that did not follow up patients who had not responded to the invitation for assessment completed significantly fewer checks. During the sample month, 331 patients were assessed in the 17 practices. 204 new problems were discovered in 143 patients. Significantly more problems per patient were found in inner city areas. CONCLUSIONS--The way health checks were performed varied greatly, both in their organisation and the practices'' attitudes. Many old people did not respond to letters asking if they wanted an assessment but very few refused one if followed up. Forty three per cent of those assessed had some unmet need. The number of new problems found per patient may reduce over the next few years if the assessments are successful. The need for annual assessment should be kept under review and adequate resources made available for the needs uncovered. Improved training for practice nurses in assessment is needed. Effectiveness of the checks must be monitored. If most unmet need falls in particular high risk groups it would seem sensible to modify the annual check to target these groups.     

Chemical sensitivity: Risks in schools

Congressional interest in the health and safety of school children led to a request for the Congressional Office of Technology Assessment (OTA) to assess the available data on hazards to children in schools in the United States. In this report, OTA identified the major hazards thought to pose a risk of illness in schools. Illnesses were limited to those arising from environmental hazards, which were grouped in this report as school materials and indoor air. Few data have been collected on any of these hazards in school. OTA could not identify a functional national reporting system for environmental ?hazards in schools. The absence of studies documenting in‐school illnesses or exposure in school presents fundamental gaps in the data needed to assess risks nationwide.     

Buffeted by harsh economic winds,medical schools turn a wary eye to the future

All parts of Canada''s health care system are facing fiscal pressures these days, but they are particularly great at Canada''s medical schools. However, Dr. David Hawkins of the Association of Canadian Medical Colleges is optimistic that all 16 of Canada''s medical schools will remain open, mainly because of the huge impact they have on health care in their local communities. “We don''t just turn out students — we raise the standard of health care in a whole community,” he says.     

Palaeoparasitology in Japan--discovery of toilet features

The development of palaeoparasitology in Japan has occurred in recent decades. Despite the fact that archaeology in Japan has been slow to develop techniques for excavating ancient toilets, important information about the development of sanitation has been derived from the analysis of a few sites. This shows that the earliest people had very simple methods of sanitation. As populations increased, sanitation became more complex. Ditches surrounding early towns were used for excrement disposal. Eventually distinct toilets were developed followed by cesspit type toilets and flushing toilets. The parasites recovered from these toilets include many species that infect humans today. These parasite spectra reflect local use of aquatic, marine, and land animals. Fecal borne disease was an increasing problem as represented by whipworm and ascarid roundworm eggs. Interestingly, ascarid roundworms were absent in the earliest cultures and only became common with rice agriculture. Finds of pollen and seeds in toilet sediments reveal the use of medicinal plants to control the emerging problem of parasites.     

我国学校微生物污染状况研究进展与展望

学校环境卫生状况与师生健康密切相关。本文从饮食卫生、公共场所卫生、个人卫生等几个方面对目前我国学校微生物污染状况的研究进展进行了综述,并对未来的研究前景进行了展望,以期为相关部门和个人提供较为全面的学校卫生信息,为学校卫生治理和疾病防控提供参考。     

A glimpse under the rim – the composition of microbial biofilm communities in domestic toilets

Aim: To determine the microbial composition of biofilms in domestic toilets by molecular means. Methods and Results: Genomic DNA was extracted from six biofilm samples originating from households around Düsseldorf, Germany. While no archaeal 16S rRNA or fungal ITS genes were detected by PCR, fingerprinting of bacterial 16S rRNA genes revealed a diverse community in all samples. These communities also differed considerably between the six biofilms. Using the Ribosomal Database Project (RDP) classifier tool, 275 cloned 16S rRNA gene sequences were assigned to 11 bacterial phyla and 104 bacterial genera. Only 15 genera (representing 121 sequences affiliated with Acidobacteria, Actinobacteria, Bacteroidetes, Planctomycetes and Proteobacteria) occurred in at least half of the samples or contributed at least 10% of the sequences in a single biofilm. These sequences were defined as ‘typical’ for toilet biofilms, and they were examined in more detail. On a 97% sequence similarity level, these sequences represented 56 species. Twelve of these were closely related to well‐described bacterial species, and only two of them were categorized as belonging to risk group 2. No 16S rRNA genes of typical faecal bacteria were detected in any sample. Virtually all ‘typical’ clones were found to be closely related to bacteria or to sequences obtained from environmental sources, implicating that the flushing water is the main source of recruitment. Conclusion: In view of the great diversity of mostly yet‐uncultured bacteria and the considerable differences between individual toilets, very general strategies appear to be most suited for the removal and prevention of toilet biofilms. Significance and Impact of the Study: For the first time, a molecular fingerprinting and cloning approach was used to monitor the species composition in biofilm samples taken from domestic toilets. Knowledge about the microbial composition of biofilms in domestic toilets is a prerequisite for developing and evaluating strategies for their removal and prevention.     

Addressing Health Inequalities in the Delivery of the Human Papillomavirus Vaccination Programme: Examining the Role of the School Nurse

Background

HPV immunisation of adolescent girls is expected to have a significant impact in the reduction of cervical cancer. UK The HPV immunisation programme is primarily delivered by school nurses. We examine the role of school nurses in delivering the HPV immunisation programme and their impact on minimising health inequalities in vaccine uptake.

Methods and Findings

A rapid evidence assessment (REA) and semi-structured interviews with health professionals were conducted and analysed using thematic analysis. 80 health professionals from across the UK are interviewed, primarily school nurses and HPV immunisation programme coordinators. The REA identified 2,795 articles and after analysis and hand searches, 34 relevant articles were identified and analysed. Interviews revealed that health inequalities in HPV vaccination uptake were mainly related to income and other social factors in contrast to published research which emphasises potential inequalities related to ethnicity and/or religion. Most school nurses interviewed understood local health inequalities and made particular efforts to target girls who did not attend or missed doses. Interviews also revealed maintaining accurate and consistent records influenced both school nurses'' understanding and efforts to target inequalities in HPV vaccination uptake.

Conclusions

Despite high uptake in the UK, some girls remain at risk of not being vaccinated with all three doses. School nurses played a key role in reducing health inequalities in the delivery of the HPV programme. Other studies identified religious beliefs and ethnicity as potentially influencing HPV vaccination uptake but interviews for this research found this appeared not to have occurred. Instead school nurses stated girls who were more likely to be missed were those not in education. Improving understanding of the delivery processes of immunisation programmes and this impact on health inequalities can help to inform solutions to increase uptake and address health inequalities in childhood and adolescent vaccination programmes.     

Environmental health in primary schools in a developing country

In an effort to elucidate the environmental health in developing countries, the environmental and sanitary conditions of Riyadh primary schools were assessed by use of a scoring evaluation sheet for 20 schools representative of primary schools of Riyadh. 20% of schools have been found to be ideally situated and only one fourth of schools with proper building. As regards class rooms, only 25% of them have adequate floor area, window area and are suitably illuminated. Drinking fountains per pupil were inadequate. Overall, environmental rating of 10% excellent, 30% good, and 60% bad were detected in present study. The bad situation of almost two-thirds of primary school buildings in Riyadh is alarming. Remedial suggestion have been forwarded.     

Integration of mental health into primary care in Kenya

Integration of mental health into primary care is essential in Kenya, where there are only 75 psychiatrists for 38 million population, of whom 21 are in the universities and 28 in private practice. A partnership between the Ministry of Health, the Kenya Psychiatric Association and the World Health Organization (WHO) Collaborating Centre, Institute of Psychiatry, Kings College London was funded by Nuffield Foundation to train 3,000 of the 5,000 primary health care staff in the public health system across Kenya, using a sustainable general health system approach. The content of training was closely aligned to the generic tasks of the health workers. The training delivery was integrated into the normal national training delivery system, and accompanied by capacity building courses for district and provincial level staff to encourage the inclusion of mental health in the district and provincial annual operational plans, and to promote the coordination and supervision of mental health services in primary care by district psychiatric nurses and district public health nurses. The project trained 41 trainers, who have so far trained 1671 primary care staff, achieving a mean change in knowledge score of 42% to 77%. Qualitative observations of subsequent clinical practice have demonstrated improvements in assessment, diagnosis, management, record keeping, medicine supply, intersectoral liaison and public education. Around 200 supervisors (psychiatrists, psychiatric nurses and district public health nurses) have also been trained. The project experience may be useful for other countries also wishing to conduct similar sustainable training and supervision programmes.     

Human Resource and Funding Constraints for Essential Surgery in District Hospitals in Africa: A Retrospective Cross-Sectional Survey

Background

There is a growing recognition that the provision of surgical services in low-income countries is inadequate to the need. While constrained health budgets and health worker shortages have been blamed for the low rates of surgery, there has been little empirical data on the providers of surgery and cost of surgical services in Africa. This study described the range of providers of surgical care and anesthesia and estimated the resources dedicated to surgery at district hospitals in three African countries.

Methods and Findings

We conducted a retrospective cross-sectional survey of data from eight district hospitals in Mozambique, Tanzania, and Uganda. There were no specialist surgeons or anesthetists in any of the hospitals. Most of the health workers were nurses (77.5%), followed by mid-level providers (MLPs) not trained to provide surgical care (7.8%), and MLPs trained to perform surgical procedures (3.8%). There were one to six medical doctors per hospital (4.2% of clinical staff). Most major surgical procedures were performed by doctors (54.6%), however over one-third (35.9%) were done by MLPs. Anesthesia was mainly provided by nurses (39.4%). Most of the hospital expenditure was related to staffing. Of the total operating costs, only 7% to 14% was allocated to surgical care, the majority of which was for obstetric surgery. These costs represent a per capita expenditure on surgery ranging from US$0.05 to US$0.14 between the eight hospitals.

Conclusion

African countries have adopted different policies to ensure the provision of surgical care in their respective district hospitals. Overall, the surgical output per capita was very low, reflecting low staffing ratios and limited expenditures for surgery. We found that most surgical and anesthesia services in the three countries in the study were provided by generalist doctors, MLPs, and nurses. Although more information is needed to estimate unmet need for surgery, increasing the funds allocated to surgery, and, in the absence of trained doctors and surgeons, formalizing the training of MLPs appears to be a pragmatic and cost-effective way to make basic surgical services available in underserved areas. Please see later in the article for the Editors'' Summary     

Monitoring of arsenic in drinking water of high schools and assessment of carcinogenic health risk in Multan,Pakistan

Abstract

This study was performed to measure arsenic (As) contents in groundwater/drinking water of high schools and its effects on human health. Chronic daily intake, hazardous quotient (HQ), carcinogenic risk (CR), hazardous index (HI), and carcinogenic indices (CI) for oral and dermal exposure to arsenic were calculated. Samples were taken from high schools in four tehsils of Multan. As contents ranged from 3.25 to 184?µg/l and 99% samples exceeded World Health Organization safe limit (10?µg/l). HQ for Multan city (1.70) and for Multan Saddar (1.38) exceeded USEPA permissible toxic risk value (1.0). CR in four tehsils for oral (0.0001–0.0003) and dermal exposure (0.0000049–0.000011) exceeded USEPA limit (10^?6). HI for tehsil Multan city (1.75) and Multan Saddar (1.42) exceeded the limit (1.0). CI for four tehsils ranged from 0.00022 to 0.0008 exceeding USEPA limit (10^?6) indicating high chronic and carcinogenic health risk to exposed population. Results indicated that groundwater of district Multan is not fit for human consumption due to excessive arsenic contamination. It invites attention of water supplying agency and educational authorities to take steps for provision of arsenic free safe drinking water to students and local area peoples.     

Toilet hygiene—review and research needs

The goal of good toilet hygiene is minimizing the potential for pathogen transmission. Control of odours is also socially important and believed to be a societal measure of cleanliness. Understanding the need for good cleaning and disinfecting is even more important today considering the potential spread of emerging pathogens such as SARS-CoV-2 virus. While the flush toilet was a major advancement in achieving these objectives, exposure to pathogens can occur from failure to clean and disinfect areas within a restroom, as well as poor hand hygiene. The build-up of biofilm within a toilet bowl/urinal including sink can result in the persistence of pathogens and odours. During flushing, pathogens can be ejected from the toilet bowl/urinal/sink and be transmitted by inhalation and contaminated fomites. Use of automatic toilet bowl cleaners can reduce the number of microorganisms ejected during a flush. Salmonella bacteria can colonize the underside of the rim of toilets and persist up to 50 days. Pathogenic enteric bacteria appear in greater numbers in the biofilm found in toilets than in the water. Source tracking of bacteria in homes has demonstrated that during cleaning enteric bacteria are transferred from the toilet to the bathroom sinks and that these same bacteria colonize cleaning tools used in the restroom. Quantitative microbial risk assessment has shown that significant risks exist from both aerosols and fomites in restrooms. Cleaning with soaps and detergents without the use of disinfectants in public restrooms may spread bacteria and viruses throughout the restroom. Odours in restrooms are largely controlled by ventilation and flushing volume in toilet/urinals. However, this results in increased energy and water usage. Contamination of both the air and surfaces in restrooms is well documented. Better quantification of the risks of infection are needed as this will help determine what interventions will minimize these risks.