Genetically Altered Mosquitoes: Way to Control Dengue?

Aedes aegypti mosquito (cdc.gov)

Here is an interesting article published online in Time that outlines how genetically altered mosquitoes are being used in some parts of the world to control dengue. In a lab setting, mosquitoes are altered such that males become either infertile or carry genes that decrease longevity; the infertile males are then released into the environment and either fail to impregnate female mosquitoes or pass on genes that decrease the lifespan of the next generation of mosquitoes.

This approach was used in Malaysia in 2011 and is now being employed in Brazil. Although the long-term environmental effects of this approach are uncertain, it is clear that new technologies and approaches need to be deployed to combat dengue.

Pork: Contaminated with Antibiotic Resistant Bacteria?

wikipedia.org

Here is a study published in Consumer Reports that looked at the presence of antibiotic resistant bacteria in pork. They tested 198 samples of ground pork and pork chops, all consumer products, and found that 69% were contaminated with Yersinia enterocolitica, 11% were contaminated with Enterococcus, 7% were contaminated with Staphylococcus aureus and 4% were contaminated with Salmonella.

Of the whopping 69% of products contaminated with Yersinia enterocolitica, 39% were resistant to 2-3 antibiotics. Sixty-four percent of the Staphylococcus aureus isolates were resistant to 2-4 antibiotics and 38% of the Salmonella isolates were resistant to 5 antibiotics.

These findings highlight the issue of antibiotic use in the food industry driving antibiotic resistance in general. As antibiotics are used in a population of animals (pigs, for instance), antibiotic susceptible bacteria are killed off (thus 'selecting out' resistant bacteria); these bacteria are then shed into the environment, contaminate fertilizer and can contaminate food products such as the pork noted in this study. Humans then can become colonized or sick when they come in contact with these organisms. A person who ingests undercooked pork contaminated with bacteria such as Yersinia enterocolitica could develop a severe diarrheal illness that would be more difficult to treat as the organism is already resistant to multiple antibiotics.

This report highlights key things consumers can do to protect themselves, such as ensuring meat is cooked appropriately (thus killing any bacterial contaminants), keeping raw meat separate from other foods and good hand washing.

This report is a disturbing real-time reminder that non-human antibiotic use is an important component of the current antibiotic resistance crisis; this is especially important when one considers that approximately 80% of all antibiotics used in the United States are used in food-production animals. Efforts to combat antibiotic resistance must account for the large percentage of antibiotic use in the food industry, and true solutions to this problem will require coordinated efforts across multiple disciplines.

Neglected Tropical Diseases: Becoming Less Neglected?

Ascaris lumbricoides (the "large common roundworm"),
a soil-transmitted helminth; cdc.gov

Here is a nice article outlining the global problem of neglected tropical diseases, or "NTDs." These are a group of seventeen tropical infections, mostly worms, that are associated with high morbidity (things such as poor growth and mental development in children, pregnancy complications) but low mortality. Despite their major negative effects on health they do not receive much "press" (as opposed to better known diseases such as malaria, HIV and tuberculosis).

It is estimated that 1 in 6 people in the world currently suffer from an NTD. 

The article links to the "END7" campaign that has some great resources about NTDs, including a two minute long YouTube video that is worth checking out. Some nice general information about the seven most common NTDs can be found here.

In our work in Honduras we focus on decreasing the burden of NTDs, specifically, soil-transmitted helminths (intestinal worms). We estimate that somewhere between 30-70% of the patients we see are infected with one or more of these worms. We provide anti-helminthic therapy according to WHO guidelines, with the hopes of decreasing the overall burden of these infections in the population at large. According to the WHO, "deworming school-aged children is probably the most economically efficient public health activity that can be implemented in any low-income country."

The overall tone of the Guardian article is hopeful, noting that the movement to combat NTDs has gained momentum. However, as emphasized in the article, efforts to combat these diseases should be inter-disciplinary and address both environmental health issues in addition to eradicating disease at the individual level.

Global Warming: Promoting Mosquito Expansion?

Aedes aegypti mosquito; cdc.gov

Here is an interesting study by Lozano-Fuentes and colleagues that was just published in this month's American Journal of Tropical Medicine and Hygiene. They looked at the presence of Aedes aegypti mosquitoes across a number of communities at different elevations in Mexico and found that the mosquitoes were present at elevations as high as 2,130 meters, over 300 meters higher than previously described in Mexico. The authors posit that global warming may increase the geographic range of Aedes aegypti mosquitoes, thereby putting previously protected populations at risk of mosquito-borne illnesses. Their results are intriguing (although by no means conclusive) and contribute to the growing body of literature examining the effects of climate change on emerging infectious diseases.

Aedes aegypti mosquitoes are an important vector for a number of viruses, including dengue, chikungunya and yellow fever. Conceivably, if the geographic range of Aedes aegypti mosquitoes expands more people will be at risk for these serious infections. The ongoing dengue outbreak in Madeira and recent reports of infections in the United States illustrate the need for further research into the relationship between climate change and emerging infectious diseases, and underscores the need for robust surveillance for all emerging mosquito-borne infections.

Where Is Flu Occurring? "Google" It!

Here is a link to a Los Angeles Times story that highlights work by Jeffrey Shaman and others on a new influenza prediction model using Google search data. These researchers created a new influenza tracking model that pulls data from the Google Flu Trends project and utilizes methodology from weather forecasting. They applied their model retrospectively to flu data from New York City from 2003-2008 and found that they were able to predict the peak of influenza activity over seven weeks before this actually occurred. 

This new study builds on work by Ginsberg and colleagues published in Nature in 2009 (full text available here). These authors created an influenza-like illness (ILI) surveillance model that utilized Google search data. This model correlated closely with ILI surveillance by the CDC, and predicted ILI nationally 1-2 weeks ahead of the CDC surveillance mechanism. 

The work by Shaman and colleagues illustrates that ILI surveillance models based on search engines such as Google can be refined using techniques from other disciplines (in this case weather forecasting). 

Other technologies such as Twitter and Facebook have also piqued interest as potential resources for disease surveillance, as well as for the real-time dissemination of information in the setting of disasters. 

For certain, influenza surveillance models utilizing internet search platforms such as Google are powerful tools, and as these models become more refined and are validated they will provide useful data that will give the medical and public health communities a real-time "heads up" when influenza activity is occurring. It is unclear how other technologies (such as Twitter and Facebook) can best be leveraged for disease surveillance and health communication, but these modalities also represent powerful potential tools. 

Update on Ebola Outbreak in Uganda




wikipedia.org

 
Here is an update from the WHO on the Ebola outbreak in Uganda; as of November 23rd there have been 10 cases with 5 deaths in Luweero and Kampala. What is worrisome about this outbreak is that the disease made it as far as the capitol city. Although this current outbreak appears to be contained, this is a good reminder that a disease that emerges in a remote jungle today can spread to anywhere in the world in a very short period of time.

Antibiotic Resistance: Why Is This a Big Deal?

cdc.gov

Here is a nice article published online in American Medical News that provides a very nice overview of the problem of antibiotic resistance. The article also links to a consensus statement by 26 major health groups (including the CDC, Infectious Diseases Society of America and American Academy of Pediatrics, to name a few) that outlines the nature of the problem and commits to begin combatting the issue more aggressively, in a coordinated fashion, via promoting improved utilization of antibiotics, calling for new antibiotics to treat resistant infections and raising awareness about this issue in general. This is an excellent "call to arms" that both raises awareness about this issue and commits to a coordinated approach to addressing it.

Notably missing from the list of organizations that signed this statement, however, are major agricultural groups; as previously discussed, the majority of antibiotics are used in animal husbandry. The problem of antibiotic resistance truly crosses disciplines, and solutions to this issue will accordingly need to involve professionals across diverse fields such as agriculture, medicine, public health, economics, sociology, et cetera (the previously mentioned "One Health" approach to addressing issues with global impact).

Fake Drugs: A Global Problem

www.wikipedia.org

In my travel clinic I regularly counsel patients who are traveling abroad that they need to carry a full supply of any prescription medications they regularly take with them, and bring a small cache of over-the-counter medications they might need, as well. In the few instances patients have asked me whether it is safe to purchase a portion of their anti-malarial medications abroad (as the drugs are often much cheaper) I have recommended against this over fear of the quality of the medications they would purchase. Although my practice is consistent with guidance provided by the CDC, we don't know the true scope or nature of this problem.

Here is a link to a nice New York Times article discussing the issue of fake and substandard drugs. This article links to a detailed analysis of this subject by Attaran and colleagues that appeared in this month's BMJ (the full text of this paper is available here).

It is clear that many of the drugs available to consumers (especially in developing countries) are either fake or substandard. The true scope of this problem is unknown, but it has been estimated that half of some drugs for life-threatening diseases may be fake. The article by Attaran and colleagues cites the following real-world examples: > 120 people dying in Pakistan after receiving tainted medication for heart disease, an anti-cancer drug being distributed throughout the world that had no active ingredient and the distribution of substandard HIV drugs in Kenya.

Although this problem is widespread in developing nations, it is a problem for first-world countries, as well. An example of this is the aforementioned issue with the anti-cancer drug bevacizumab, wherein a fake version of the drug (that contained no active drug) was distributed in the United States.

Attaran and colleagues call for a comprehensive international strategy that universally defines what substandard and fake medications are, and that creates legal consequences for trafficking these products. We also need better information about the true scope of this problem.

European Dengue Outbreak: Etiology & Implications

Here is a link to a Reuters story reporting on the large outbreak of dengue ("breakbone") fever in Madeira (a Portuguese-controlled series of islands in the Atlantic just west of Morocco).  Over 1,300 cases have been reported since the outbreak was first recognized in October; significantly, this is the first sustained European dengue outbreak since the 1920s.

Dengue fever is a viral infection transmitted by Aedes aegypti (and Aedes albopictus) mosquitoes; it is the most common mosquito-borne viral infection. This is a febrile illness associated with high morbidity and low mortality; the disease can be deadly, however, as it can cause shock and an illness characterized by widespread hemorrhaging.

It is believed that the virus crossed species from monkeys to humans in Southeast Asia or Africa sometime in the past 1,000 years, with rapid dissemination of the disease around the world in the 20th century. Per WHO estimates 50-100 million infections occur each year with 22,000 deaths; see the CDC's site for great information about the disease.

Dengue fever is an excellent example of a disease that has emerged and expanded due to globalization; it is believed that rural-urban migration, explosive population growth, increased international trade and poor urban infrastructure all have played roles in the rapid expansion of this disease.

Dengue infections have made a resurgence in the United States as well, with cases reported in Key West in 2009 and recent cases being reported in Hawaii and in Texas, also. There is concern that climate change and global warming are playing a role in the re-emergence of dengue in the US: see a thoughtful commentary on this in the Lancet.

http://www.who.int/csr/disease/dengue/impact/en/; Areas in red
represent areas where dengue has emerged since 1960

What are the implications of the outbreak of dengue in Madeira and the sporadic cases being seen in the United States? It is clear that "tropical" infections can emerge and expand rapidly, and that infectious diseases are affected by globalization and do not respect traditional borders. Any solution to the dengue problem must involve a trans-national approach that emphasizes collaboration and brings together professionals across disciplines.

cdc.gov; Aedes aegypti mosquito

It is also clear that this is not a static issue: the public health community must be vigilant with dengue surveillance and early intervention (such as improved mosquito control) when disease expansion is detected.

Finally, here is a nice CBS News piece with a general discussion of the scope of the dengue problem, as well as an interview with Dr. Anthony Faucci, director of the National Institutes of Allergy and Infectious Diseases.

A "One Health" Approach to Antibiotic Resistance

cdc.gov

This is a nice post highlighting the recent symposium "A One Health Approach to Antimicrobial Use & Resistance: A Dialogue for a Common Purpose" that was coordinated by the National Institute for Animal Agriculture. This meeting brought together experts in antibiotic resistance from numerous disciplines (following the "One Health" approach that emphasizes interdisciplinary coordination to address global health issues). 

The following were the 'take home points' from the conference: antibiotic resistance is not a new phenomenon, the issue is complex and involves more than just its health implications (also has social, political and economic implications); all communities that use antibiotics are responsible for antimicrobial stewardship; people from all disciplines need to work together to address this important issue. 

The call for a coordinated, interdisciplinary response to antibiotic resistance is sound and necessary; improved antibiotic use in humans is important but the issue must also be addressed in animal populations where the majority of antibiotics are used. The One Health approach emphasizes that experts across the board (veterinarians, physicians, economists, et cetera) and around the globe need to work together to address the issue.

One thing is certain: the time to get aggressive with battling antibiotic resistance is now. We have essentially run out of new antibiotics to combat many resistant infections, and perhaps are nearing the dreaded 'post-antibiotic era.' Although a recent survey by the Pew Health Group indicated that many Americans are aware of the issue of antibiotic resistance, this issue is largely not viewed as a major public health crisis (which it is). 

You can test your knowledge about antibiotics here. 

The Dangers of Turkey Fryers: A Cautionary Tale from William Shatner

Happy Thanksgiving!

This one's focused more on (public) health, less so on bugs or drugs.

The now classic video of William Shatner warning about the dangers of using a "turkey fryer" (a gas-fueled frying device wherein a turkey is immersed in hot oil) has been updated and is now auto-tuned, just in time for T-day '12: see it here.

As entertaining as the video is, it draws attention to an important public health issue: the National Fire Protection Association recommends against the use of turkey fryer devices, specifically noting that they can "lead to devastating burns, other injuries and the destruction of property." This group recommends that people who want a 'deep fried turkey' seek out a professional establishment or use an oil-free turkey frying device.

So listen to Shatner's cautionary tale and have a safe, turkey-fryer free Thanksgiving. And good luck getting that song out of your head.

Vitamin D Deficiency: Related to HIV?

wikipedia.org

This is an interesting retrospective cohort study published by Sherwood and colleagues looking at vitamin D deficiency (VDD) in patients with and without HIV in a cohort of military beneficiaries; VDD was defined as having a 25-OH vitamin D level < 20 ng/mL and data were collected in the early 2000s. 165  patients with HIV were matched to controls; overall, 85% of patients were male and 61% were black. Patients with HIV were not significantly more likely to have VDD; VDD was associated with black ethnicity regardless of HIV status. Low bone mineral density (BMD) was associated with low exercise, low BMI and with alcohol use, but not with VDD. Low BMD was not associated with tenofovir or other antiretroviral exposure, although there was little tenofovir exposure in this cohort (data primarily collected in early 2000s). 

On the clinical "front lines" it is often difficult to know how aggressively one should manage low vitamin D levels in HIV positive patients: is the concomitant increase in 'pill burden' and its potential negative impact on long-term compliance worth the possible benefit to bone health? If some studies, such as this one, indicate no relationship between bone mineral density and vitamin D levels, are we treating a lab value and not the patient? If VDD and BMD are not definitively linked, why check vitamin D levels at all? Although this study is valuable it does not answer these critical questions; it would be interesting to see this study repeated in the current practice era (e.g., using modern antiretroviral agents according to current practice standards). 

Using Rapid Diagnostic Testing to Streamline Therapy for Candida Fungemia

This is a before-after study forwarded to me by one of my pharmacy colleagues looking at the effects of using peptide nucleic acid fluorescence in situ hybridization (PNA FISH) technology to rapidly identify Candida species in conjunction with a protocol via which on-call pharmacists then made real-time recommendations to providers according to a pre-determined stewardship program protocol. The authors found that the time to Candida species identification was much faster in the PNA FISH group (0.2 versus 4 days, p < 0.01), and the time to targeted antifungal therapy was significantly reduced, as well. There was no significant difference in hospital length of stay or mortality; actual costs were not measured although the authors postulate a cost savings of over $400.

This is a nice example of how rapid diagnostic testing, when used in conjunction with an antibiotic stewardship program, can lead to rapid antimicrobial narrowing/ streamlining. 

HIV Prevention in Prisons & Jails

wikipedia.org

This is a thoughtful PBS piece on HIV surveillance, prevention and treatment comparing 2 systems in Washington, D.C. and Zimbabwe. The article praises recent changes at the D.C. jail that have provided improved HIV testing and treatment resources, as well as condom access and better transitions to outpatient care for prisoners leaving the facility. In contrast, the article cites a Zimbabwe study indicating 49% of prisoners engage in sexual intercourse, however, they are provided no access to condoms. This occurs because homosexuality is illegal in the country. In terms of HIV prevention efforts, not targeting sexual activity in prisons will propagate the epidemic, as 28% of the Zimbabwean inmates in this story were felt to be HIV positive. Although global efforts to both identify and treat HIV infections in prisons and jails are both necessary and laudable, basic efforts to prevent intra-facility HIV transmission (such as providing access to condoms) should also be emphasized.

New Ebola Outbreak in Uganda

Ebola Virus (www.CDC.gov) 

Here is a link to an ABC news article reporting on a new outbreak of Ebola hemorrhagic fever occurring near the capital in Uganda;  per report this outbreak is not epidemiologically linked to the outbreak of Ebola that occurred over the summer. This outbreak serves as another reminder of the unintended consequences of globalization, as the disease has been linked to increased human activity in forests.

Key Factors for Creating a Residency Track in Global Health

Dr. Bearman Teaching a Medicine Resident in La Hicaca, Honduras

This is a great article forwarded to me by my pediatric colleague Dr. Pat Mason. This is a study by Campagna et al that surveyed global health education directors at 24 pediatric residencies regarding factors deemed essential to creating global health programs; their response rate was 79% (19 programs). The key factors for creating a dedicated global health tract were: having support of key program and department leadership, resident commitment, protected resident elective time, faculty having protected time/ support and having a dedicated program budget; one of the other key elements outlined was having administrative support. The authors conclude that all of these things should be considered when creating a residency-based global health program. This article provides a nice "roadmap" for educators designing global health programs within residencies.

What is Global Health?

What is Global Health? I give a lecture on global health to second year medical students and always struggle to define this-the definition ends up being a sort of 'catch all' term to describe anything relevant to health that does not respect political boundaries.

Rowson and colleagues explore the evolution of the "global health" concept and definition in their article "Conceptualising global health: theoretical issues and their relevance for teaching" (full text can be found here). They discuss the discipline's roots within 19th century "international health," a construct that largely focused on protecting European and North American infection control and colonial interests. The field evolved in the 20th century to address major public health menaces such as malaria and smallpox, and later became more comprehensive including public health policy, a broader focus on economics as well as other factors.

Rowson and colleagues cite my favorite modern definition of the field: Koplan et al defined global health as: "an area for study, research, and practice that places a priority on improving health and achieving equity in health for all people worldwide. Global health emphasizes transnational health issues, determinants, and solutions; involves many disciplines within and beyond the health sciences and promotes interdisciplinary collaboration; and is a synthesis of population-based prevention with individual-level clinical care."

Rowson and his colleagues do not provide a suggestion for a new definition, however, they discuss definition features that are still being debated. Specifically, they note 3 key things:

1) The "object of knowledge" associated with the field (what topics are covered? what is the scope of coverage?)
2) The "types of knowledge" associated with practitioners in the field
3) The "purpose of knowledge" within the field

Rowson et al argue that any definition of global health should avoid the inclusion of value-laden terms such as "equity." They note that inclusion of values in the definition implies that people who do not ascribe to the defined value are not practicing or studying global health. Although this argument is sound and academically "true," I still prefer the aforementioned Koplan definition that emphasizes health equity.

The article by Rowson and colleagues is an excellent overview of how the field of global health has evolved and what it encompasses; moreover, it succinctly highlights the key features that are still being actively debated.

Investigating Unidentified Liver Disease (ULD) in Ethiopia: a Testament to the “One Health” Approach

http://www.cdc.gov/nceh/stories/Ethiopia.html

According to their website, the “One Health concept is a worldwide strategy for expanding interdisciplinary collaborations and communications in all aspects of health care for humans, animals and the environment.” It is an über-collaboration designed to pull from a host of different disciplines to address health issues that cut across disciplines, and is supported by a number of major organizations. 

An example of a “One Health” approach to addressing health issues is the investigation of Unidentified Liver Disease (ULD) that was first reported in northern Ethiopia in 2002. Epidemiologists and scientists from the CDC, the USDA, the Ethiopian Ministry of Agriculture, Addis Ababa University, the Chinese University of Hong Kong among other groups all worked together to solve this mystery, ultimately finding that the disease was due to toxic pyrrolizidine alkaloids that people were exposed to when their fields were not properly weeded. Grain farmers in this region now have the information they need to prevent this illness. Although this investigation does illustrate remarkable collaboration across multiple organizations and countries, another striking feature is the time it took to identify ULD’s etiology-around 6 years from the initial investigation in 2005 until a firm epidemiologic link was established in 2011. Arguably, however, this link likely would not have been elucidated without the close collaboration of the numerous groups involved in this investigation. 

The “One Health” movement is intriguing and the close collaborations it espouses will be critical to addressing critical health issues that cut across disciplines, such as antibiotic resistance. 

Impact of a Water Sanitation & Hygiene Program in Western Kenya

Latrine in La Hicaca, Honduras

This is an interesting study by Greene and colleagues that examined the impact of a school-based improved water, sanitation and hygiene (WASH) program in Western Kenya on fecal contamination of students’ hands with E. Coli. 17 intervention and 17 control schools were assessed (as a sample of a larger cluster randomized trial of 135 schools). Intervention schools had specialized buckets provided for hand washing and drinking water, as well as a supply of hypochlorite solution provided for water decontamination. Teachers were trained on how to maintain the handwashing equipment. Schools with a high ratio of students to latrines underwent the addition of new latrines to meet a pupil to latrine ratio of 30:1 for boys and 25:1 for girls.

These authors found no difference in E. coli hand contamination for the intervention and the control schools, and curiously found an increased risk of hand contamination for girls in schools where new latrines had been constructed (RR: 2.63, 95% CI 1.29-5.34). Although it is not clear why this occurred, the authors postulate that this increase in contamination may have occurred secondary to increased latrine use in the absence of improvements in hand hygiene. The authors note poor student access to soap, a fact that likely critically undermined the overall sanitation program. In a geographically discrete location such as a school, the introduction of latrines in the absence of mechanisms to improve hand hygiene may actually lead to increased fecal contamination of hands, with the potential for spread of diarrheal illness.

Although improving access to latrines is a critical component of improving the overall health of communities, improving latrine access without improving access to soap may actually be harmful. Mechanisms to assure soap access should be built in to hygiene programs.

Ethical Issues in Global Health Outreach Work: A Call for Formalized Medical Student Education

VCU Medical Students Assessing a Patient in Coyoles, Honduras

This is an interesting article published earlier this year by Timothy Lahey in the journal Academic Medicine. In this perspective piece Lahey discusses some of the ethical issues associated with short-term global health outreach work, especially as faced by medical students. He outlines the key components of a medical school curriculum in global health, noting this is important for all learners as "global rightly includes local because healing the sick has the same worth in inner-city Detroit as it does on the outskirts of Dar es Salaam, even if geography and culture alter the manifestations of illness and need."

Lahey notes that the principles of biomedical research should can be applied to global health outreach work: nonmaleficence, beneficence, patient autonomy and justice. Short-term medical trips are rife with pitfalls in all of these areas, as providers often provide sub-standard care without understanding the health needs of the population they are serving, or the greater context of the health pressures faced by these communities or the health disparities that drive illness.

Lahey notes a medical curriculum for global health must include an exploration of health disparities, and notes that faculty mentorship and post-trip debriefing are important components of medical student education in global health.

Over the past 6 years working on short-term medical relief missions in Honduras I personally have struggled with many of the issues Lahey brings up, and have watched many medical students and residents struggle with these issues, as well. Our group has worked to address these issues via close community partnerships, an emphasis on high-yield public health interventions, and providing logistical support to help bolster the longitudinal health efforts of the local ministry of health (find out more about the evolution of our program here).

 In terms of working with students, we have found the following:

1) Pre-trip counseling/ education of learners is essential
2) Providing learners a context for their work (e.g., how their work contributes to the longitudinal/ overall health work performed by the group) is critical
3) Continuous 'checking in' with learners/ helping learners process their experience before, during and after the brigades is very important

As "global health" truly includes addressing health issues/ disparities both internationally and domestically, Lahey's call for integration of global health education into medical school curricula is an excellent one. This 'call' should be extended to residents' curricula, as well.

Household Chlorination Program to Improve Drinking Water Quality in Rural Haiti

Local creation of sodium hypochlorite solution in Haiti (http://www.cdc.gov/safewater/chlorination.html) 

This is an interesting article on a long-term program in Haiti using household chlorination to improve drinking water quality by Harshfield and colleagues. They evaluated the utility of a Safe Water System (SWS) program that was established in a rural part of Haiti in 2002. In 2010 they conducted a survey with concurrent water testing of 201 SWS program participants as well as 425 control households. These authors found that 56% of participants were correctly treating their water with chlorine (as opposed to 10% of controls) with a 59% odds reduction in diarrheal illness in children under 5 (OR 0.41, 95% confidence interval 0.21-0.79). The interesting thing about this study is the SWS program was sustainable and was having a positive impact 8 years after its creation.

We have been working in the Yoro area of northern Honduras since 2008, with our efforts focused in and around the remote, mountainous village of La Hicaca (find out more about our work here). Our public health work is primarily focused on improving access to clean drinking water via a water filter program. The above study is intriguing in that it could provide an alternative, potentially sustainable mechanism to improve access to safe drinking water for the population we serve. However, Gaby Halder conducted a large survey on access to technologies to treat drinking water in 2011 of our population and found very few people used chlorine. This was largely due to poor chlorine access due to financial and geographic barriers. If a SWS program is to be employed in a rural, remote setting such as the one we practice in, addressing these key barriers will be critical.