Prevalent high-risk respiratory hygiene practices in urban and rural Bangladesh

Objectives To identify existing respiratory hygiene risk practices, and guide the development of interventions for improving respiratory hygiene. Methods We selected a convenience sample of 80 households and 20 schools in two densely populated communities in Bangladesh, one urban and one rural. We observed and recorded respiratory hygiene events with potential to spread viruses such as coughing, sneezing, spitting and nasal cleaning using a standardized assessment tool. Results In 907 (81%) of 1122 observed events, households’ participants coughed or sneezed into the air (i.e. uncovered), 119 (11%) into their hands and 83 (7%) into their clothing. Twenty-two per cent of women covered their coughs and sneezes compared to 13% of men (OR 2.6, 95% CI 1.6–4.3). Twenty-seven per cent of persons living in households with a reported monthly income of >72.6 US$ covered their coughs or sneezes compared to 13% of persons living in households with lower income (OR 3.2, 95% CI 1.6–6.2). In 956 (85%) of 1126 events, school participants coughed or sneezed into the air and 142 (13%) into their hands. Twenty-seven per cent of coughs/sneezes in rural schools were covered compared to 10% of coughs/sneezes in urban schools (OR 2.3, 95% CI 1.5–3.6). Hand washing was never observed after participants coughed or sneezed into their hands. Conclusion There is an urgent need to develop culturally appropriate, cost-effective and scalable interventions to improve respiratory hygiene practices and to assess their effectiveness in reducing respiratory pathogen transmission. Pratiques d’hygiène respiratoire à haut risque répandues en milieu urbain et rural au Bangladesh Objectifs: Identifier les pratiques existantes d’hygiène respiratoire à risque et guider dans le développement d’interventions visant à améliorer l’hygiène respiratoire. Méthodes: Nous avons sélectionné un échantillon convenable de 80 ménages et 20 écoles dans deux communautés densément peuplées du Bangladesh; une urbaine et une rurale. Nous avons observé et enregistré les événements d’hygiène respiratoire pouvant mener à la propagation des virus tels que la toux, les éternuements, les crachats et le nettoyage du nez, en utilisant un outil d’évaluation standardisé. Résultats: Sur 1122 événements observés, 907 (81%) participants toussaient ou éternuaient dans l’air (i.e., sans protection), 119 (11%) dans leurs mains et 83 (7%) dans leurs vêtements. 22% des femmes couvraient leurs toux et éternuements, comparéà 13% des hommes (OR= 2,6; IC95%: 1,6-4,3). 27% des personnes vivant dans des ménages avec un revenu mensuel déclaré > 72,6 $ US couvraient leurs toux ou éternuements, comparéà 13% des personnes vivant dans des ménages à faible revenu (OR= 3,2; IC95%: 1,6 - 6,2). Sur 1126 événements observés dans les écoles, 956 (85%) participants toussaient ou éternuaient dans l’air et 142 (13%) dans leurs mains. 27% des toux/éternuements dans les écoles rurales étaient couverts, contre 10% dans les écoles urbaines (OR= 2,3; IC95%: 1,5- 3,6). Le lavage des mains par les participants n’a jamais été observé après la toux ou l’éternuement dans les mains. Conclusion: Il y a un besoin urgent de développer des interventions culturellement appropriées, rentables et déployables pour améliorer les pratiques d’hygiène respiratoire et évaluer leur efficacitéà réduire la transmission des pathogènes des voies respiratoires. Prácticas de higiene respiratoria de alto riesgo prevalentes en la Bangladesh urbana y rural Objetivos: Identificar prácticas existentes de higiene respiratoria y guiar en el desarrollo de intervenciones para mejorar la higiene respiratoria. Métodos: Seleccionamos una muestra conveniente de 80 hogares y 20 colegios en dos comunidades con una alta densidad poblacional en Bangladesh, una urbana y una rural. Observamos y documentamos eventos de higiene respiratoria que tienen el potencial de extender virus, tales como toser, estornudar, escupir así como la limpieza nasal utilizando una herramienta estandarizada de evaluación. Resultados: En 907 (81%) de 1,122 eventos observados, los participantes tosieron o estornudaron al aire (es decir, sin cubrirse), 119 (11%) lo hicieron entre sus manos y 83 (7%) en su ropa. 22% de las mujeres se cubrieron mientras tosían o estornudaban, en comparación a un 13% de los hombres (OR 2.6, 95% IC 1.6–4.3). Un 27% de las personas que viven en hogares con un ingreso mensual reportado >72.6 US$ se cubrieron al toser o estornudar, comparado con un 13% de las personas viviendo en hogares con un menor ingreso (OR 3.2, 95% CI 1.6–6.2). En 956 (85%) de los 1126 eventos, los escolares que participaban en el estudio tosieron o estornudaron en el aire y 142 (13%) lo hicieron cubriéndose con las manos. Un 27% del toser/estornudar entre escolares de zonas rurales se realizó cubriéndose, comparado con 10% del toser/estornudar en escuelas urbanas (OR, 2.3, 95% CI 1.5–3.6). Nunca se observó un lavado de manos después de que los participantes hubiesen estornudado/tosido cubriéndose con las manos. Conclusión: Hay una necesidad urgente de desarrollar intervenciones culturalmente apropiadas, costo-efectivas y que puedan llevarse a escala para mejorar las prácticas de higiene respiratoria y para evaluar su efectividad en reducir la transmisión de patógenos respiratorios. Pandemic (H1N1) 2009 spread rapidly throughout the world during 2009, affecting more than 208 countries and overseas territories or communities. At least 12 220 deaths were reported to WHO in 2009 (World Health Organization (WHO) 2009c). After detection of the first case of H1N1 on 18 June in Bangladesh, 814 laboratory confirmed cases were identified including six deaths from that time until 10 January 2009 (World Health Organization (WHO) 2009d). This virus has higher transmissibility among humans (Fraser et al. 2009; Nishiura et al. 2009a,b) and has demonstrated higher morbidity in ferrets (Maines et al. 2009; Munster et al. 2009) than seasonal influenza. During previous pandemics, higher mortality was observed in developing countries than in industrialized countries. Individual host factors including immunity, nutritional status, co-morbidity and community and environmental factors such as population density, housing conditions, poverty, access to health care, quality of care and public health infrastructure were thought to contribute to this higher mortality (Murray et al. 2006; Oshitani et al. 2008). A cornerstone of the pandemic response in resource-poor settings includes non-pharmaceutical interventions like social distancing, hand washing, cough etiquette and household ventilation (World Health Organization (WHO) 2009a); World Health Organization Writing Group, 2006). Promotion of hand washing and cough etiquette is an important component of seasonal campaigns to prevent influenza. Globally, seasonal influenza results in three to five million severe illness cases leading to 250 000–500 000 deaths annually (World Health Organization (WHO) 2009b). Seasonal influenza with a peak during April to September has been documented in Bangladesh through population-based and hospital-based influenza surveillance; an incidence of 84.5 episodes/1000 children/year was noted in the community, while 117 (11%) of 1045 patients presenting with severe acute respiratory illness and influenza-like illness were influenza positive (ICDDBR: Centre for Health and Population Research, 2006, 2008). With its high population density of 979 persons per square kilometre (Bangladesh Bureau of Statistics (BBS) 2008), where family members customarily live together within 1 m of each other in small dwellings, endure widespread poverty (World Health Organization (WHO) 2008) and malnutrition, have little access to disposable tissues for nasal cleansing, and in the absence of routine seasonal influenza vaccination, Bangladesh is a high-risk country for rapid spread of seasonal and pandemic influenza viruses. Person-to-person transmission of respiratory viruses occurs when virus-laden droplets (>5 μm) expelled from infected persons during coughing and sneezing are propelled a short distance (1 m) and come into contact with another person’s conjunctiva, mouth and nasal mucosa (Collignon & Carnie 2006; Brankston et al. 2007). Studies have detected influenza viruses from fomites (Boone & Gerba 2004; Thomas et al. 2008). Therefore, indirect contact may also be a plausible mode of transmission when surfaces and objects are contaminated by these droplets. Influenza viruses can survive on hard, non-porous surfaces for 24–48 h and on porous materials like cloth, tissue and paper for 8–12 h (Bean et al. 1982). Hands have a potential role in the spread of respiratory viruses (Ansari et al. 1991) through their contact with respiratory droplets when people cover their mouth and nose during coughing and sneezing and touch contaminated objects and surfaces. The viability of the virus on hands is approximately five minutes after transfer from the environmental surfaces (Bean et al. 1982). The U.S. Centers for Disease Control and Prevention (CDC) recommends three measures of respiratory hygiene: covering the nose and mouth with a tissue when coughing or sneezing (or into the upper sleeve if no tissue is available), disposing the used tissues in the nearest waste receptacle and washing hands after contact with respiratory secretions and contaminated objects (Centers for Disease Control and Prevention (CDC) 2003a, 2007). Although there are no reliable data confirming the effectiveness of respiratory hygiene interventions against the spread of influenza or other respiratory viruses, in a meta analysis of published studies hand washing with soap reduced the risk of respiratory disease by an average of 16% (Rabie & Curtis 2006). There is little available evidence to guide the development of interventions to promote respiratory hygiene. In resource-poor settings like Bangladesh, promotion of respiratory hygiene practices may be an appropriate preparedness investment to curtail human-to-human spread of seasonal and pandemic influenza, but such initiatives involve substantial behaviour change, and behaviour change for most public health problems has required carefully designed sustained multilevel efforts aimed at individuals up to policy makers (McLeroy et al. 1988; Stokols 1996). Knowledge of current practices can aid development of non-pharmaceutical respiratory disease prevention interventions. As part of a larger formative research project to improve respiratory hygiene and hand washing practices in Bangladesh, a team of quantitative and qualitative researchers, medical epidemiologists, behavioural scientists and field researchers from the International Centre for Diarrhoeal Disease Research, Bangladesh and Johns Hopkins Bloomberg School of Public Health, USA conducted structured observations to assess current respiratory hygiene practices to aid development of an intervention for promotion of respiratory hygiene. To identify the respiratory hygiene risk practices, we selected two densely populated communities, one urban area, Mirpur, a suburb in the capital city Dhaka, and one rural area, Fulbaria, a sub-district of Mymensingh District. We chose these sites as they had other ongoing ICDDR,B studies that would allow us to build rapport and observe the behaviour unnoticed and unhindered by the community. We selected three areas within urban Mirpur representing people from different socio-economic backgrounds: a slum, a lower-class area and a middle-class area. We included a slum in the urban area because slum areas differ from the non-slum areas in terms of poverty, overcrowding, poor housing, and lack of access to basic infrastructure services (World Bank, 2007). In rural Fulbaria, we conducted the study in four adjacent villages: Andharia para, Chowdar, Ichail and Jorbaria. For logistic considerations, we selected a convenience sample of 40 households and 10 schools in both Mirpur and Fulbaria. The urban Mirpur study area included four distinct communities: the Bawniah Badh; Muchipara; Kolabagan Bosti and Lalmatia E block. The field researchers conducted a door-to-door community survey to identify households with members who suffered from fever or cough or runny nose or had visited any health care provider for treatment for respiratory illness. We selected households with at least one member suffering from these respiratory symptoms. We selected five households from each of the five blocks in Bowniah Badh, each several lanes apart to avoid clustering; five households from Muchipara; six households from Kolabagan Bosti and four households from Lalmatia E block. In the rural Fulbaria study area, we selected 27 households from Chowder and 13 households from Andhariapara as the area and population of Chowder is nearly twice that of Andhariapara. We selected 2–4 households from each of the eight ‘paras’ in Chowder and 1–3 households from each of the seven ‘paras’ in Andhariapara. In both study areas, we prepared a list of all the schools and randomly selected 10 of 14 schools in Mirpur and 10 of 16 schools in Fulbaria. Then, we randomly selected three schools for observation in Class 3; three schools for observation in Class 4 and four schools for observation in Class 5 in each area. The field workers collected data from 18 February to 25 March, 2009, using standardized respiratory hygiene assessment tools. We designed the tools to record observations on episodes of coughing, sneezing, spitting and nasal cleaning (i.e. nose picking) and nose blowing events. For the household observations, we recorded the age and the gender of person that had one of the events of interest and whether the person covered his/her mouth or nose while coughing or sneezing; coughed or sneezed into the air, or used any material for covering coughs and sneezes or for nasal cleaning including a handkerchief, tissue paper, end of sari (i.e. a female garment of long unstitched cloth draped over the body in various styles), orna (i.e. a long scarf worn with traditional women’s clothing), gamcha (i.e. traditional towel) or lungi (i.e. a male garment tied around the waist); spat after coughing or washed their hands after these In we collected including the of for hand washing at the We recorded hand washing as (i.e. most used after to the or as (i.e. most used for other We household monthly income by reported monthly For school observations, the episodes were but were We also recorded the of hand washing in the observations were conducted for three during a time for the We the household participants that the of study was to their practices to respiratory hygiene and that we would observe their household School observations for the of and 4 We the school but or were collected using We the data using for We the of observed coughs and sneezes that were covered and the of coughs and sneezes were by washing of hands. We to the of to and of to the of We logistic to identify covering of coughs or sneezes with different into the and of us to the of because of different households or We on on and from the The study team from the members of the households and the school The study was by The field workers observed 40 urban and 40 rural households that the of the rural household had no of 40 urban households reported >72.6 US$ on monthly household (i.e. approximately while of 40 rural households reported to or US$ The field workers observed episodes of sneezing, coughing, nasal cleaning and spitting among household per cent of episodes were into the air (i.e. uncovered), were covered with hands and with the end of In both urban and rural sneezing episodes were more covered than coughing episodes of sneezes of 95% CI Hands were most used for covering during in Mirpur, while end of sari was most used in Fulbaria. most used or the end of and (7%) to their Hands were washed after covering cough or sneezes 10 of nasal cleaning episodes were by hand was used for of the 10 episodes and in one were both hands were to one of hand washing as they blowing their by the of In the women more covered their coughs and sneezes than men (OR 2.6, 95% CI and participants with >72.6 US$ reported monthly household more covered their coughs or sneezes than participants from households with US$ monthly (OR 3.2, 95% CI 1.6–6.2). There was no the of covering of coughs or sneezes and or of the household A hand washing (i.e. most used after to the was in all 10 schools in Mirpur and schools in was in two of 10 schools in Fulbaria and of soap were in two of 10 schools in Mirpur and three of 10 schools in Fulbaria. In Mirpur and field workers observed a of episodes of sneezing, coughing, nasal cleaning and spitting in the 956 (85%) of 1126 episodes were into the air and 13% of coughs or sneezes were covered with hands. of sneezing episodes were covered compared to (13%) of coughing episodes (OR 95% CI Hand washing was never observed after using hands to cover coughs or were most used for nasal was observed to or hands after nasal cleaning In the the of covering coughs or sneezes to whether participants were or (OR 95% CI or whether they a school at a rural or urban area (OR 2.3, 95% CI We identified two respiratory risk practices in communities: people coughed and sneezed into air and people their hands after covering their mouth or nose while coughing or sneezing or after nasal cleaning using The current practices are to transmission of respiratory viruses. people to cover coughs and sneezes by coughing and sneezing into the upper sleeve may be the most behaviour to Although recommends that the US population tissues to respiratory disposable tissues would be for the of population living the poverty of per (World Health Organization (WHO) 2008). may also be to people to their hands with soap if coughs or sneezes into hands several throughout the during an illness. Although we have other data on hand washing in to respiratory hand washing with soap in rural Bangladesh was to be at such as after cleaning a after a and 2008). reported monthly household was with of covering of coughs and This that the risk practices to transmission of respiratory are among the households living in the most and who are at the risk of respiratory morbidity and mortality et al. et al. of Population and et Although we any existing data on respiratory hygiene and status, several studies have reported as an for hygiene practices et al. et al. & 2008). factors that respiratory hygiene practices were gender and in this study respiratory hygiene compared to A of lower of hand hygiene in men has been noted both in Bangladesh and in other settings et al. et al. The for of covering coughs and sneezes in rural schools can be by people who and people who respiratory hygiene et al. for the 2004; et al. 2006). This analysis may be a to identify and for improving respiratory hygiene We to assess respiratory hygiene using structured of the to respiratory hygiene practices included the of to an of the data be and and can be as part of the of an This study has was conducted in a small sample of selected urban and rural areas of Bangladesh during a short of were of Bangladesh and we that be to other densely populated urban communities and rural areas of the We collected data by structured observations, is and the observed may have been by the of an et al. 1996). structured observation is a of hygiene than in survey et al. 2008). In respiratory hygiene is a area of public health with behaviour change in of the study with respiratory hygiene practices, we household participants to their behaviour during observation after of the of the of by the community that structured observation by and who used structured observations to hand washing practices in rural during the hand washing promotion that structured observation to be a for hygiene practices et have both and the current spread of pandemic influenza and the of a case we need to we can and health to public Promotion of respiratory hygiene may a role in this The of to a to improve respiratory hygiene and the transmission of respiratory viruses. to improve hygiene practices by a of the population would carefully and to respiratory hygiene. The intervention campaigns at for the existing social the most important of hygiene behaviour for the community et al. Individual in is a of has that a case can have a on the of an for any disease with high in et al. & 2008). people who other people have been to an important role in the transmission of other such as severe acute respiratory and virus transmission et al. Centers for Disease and Control Prevention (CDC) et al. 2004; & 2008). For the pandemic (H1N1) in 2009, cases were to have from contact with a et al. transmission of the influenza virus is and person is an have an important role in the of the is that we would be to identify in the population and interventions population-based interventions have higher in disease transmission if the in the community also respiratory hygiene. to change behaviour and the observed results would need to be carefully the of this intervention be a research We also a for behavioural to assess the of these intervention efforts and in respiratory hygiene practices in the community. has been an part of for and et al. et al. For respiratory a assessment to the one used in us to the behaviour change and respiratory hygiene. with behaviour we need to the of respiratory hygiene on the transmission of respiratory viruses. This was by a from Johns Hopkins Bloomberg School of Public Health with by from the US for International are the of the and the of the US for International or The Johns Hopkins Bloomberg School of Public Health or the Centers for Disease Control and ICDDR,B with the of to the research The who on developing the respiratory hygiene assessment tool.