op één lijn 51 1 e uitgave 2015 Promotie Mahmud Abdulkader Mahmud Hand hygiene in Ethiopia – clipping the soap bubble? DOOR LUC GIDDING, REDACTIE On March 11 2015 Mahmud successfully defended his PhD thesis in Maastricht. Mahmud was one of the external PhD students at our department supervised by Geert-Jan Dinant and Mark Spigt, in a joined PhD trajectory with the University of Alcala Madrid, Spain. His thesis titled ‘Intestinal Parasitosis and Under-nutrition in Ethiopia: Prevalence, Risk factors and Prevention’ describes how intestinal parasitic infections (IPIs) and under‐nutrition remain major health and socioeconomic challenges among underserved populations worldwide. Diseases caused by IPIs and under‐nutrition are of particular importance in terms of global burden, and their control has been recently recognised as a priority for achieving the United Nations Millennium Development Goals (MDGs). IPIs and under‐nutrition show similar geographic distribution, usually among poor populations which suffer from their combined effects. In such settings, infection and undernutrition are highly interlinked. Children, particularly those of school‐age, are heavily burdened by IPIs and malnutrition. In a preliminary study, Mahmud and his team studied 600 school children from 12 primary schools and found a high prevalence of parasitic infections (72%) and protein-energy malnutrition, including stunting (35%) and thinness (34%). Anaemia prevalence in the study group was of a mild public health importance (11%). Although there were slight differences between urban and rural schools, problems of infection and undernutrition were of the same magnitude. Overall, children with poor personal hygiene habits had higher prevalence of intestinal parasitosis. Similarly, the prevalence of anaemia and protein‐energy malnutrition was higher among unhygienic children. Because of these preliminary results, Mahmud identified a need for randomised trials to address the causal relationship between personal hygiene, parasitic infection, and malnutrition. Therefore the team conducted a randomised controlled 18 trial among rural school‐aged children to assess the impact of hand‐washing with soap and nail clipping in the prevention of intestinal parasite re‐infection, reduction of worm burden and anaemia prevalence. 367 children aged 6‐15 who screened negative for IPIs were randomised to one of four groups: hand‐washing with soap; nail clipping; hand-washing with soap and nail clipping; or standard habit and practice controls. Children were monitored for six months. The primary hypothesis of the study stated that hand‐washing with soap and nail clipping would significantly reduce the prevalence of intestinal parasite re‐infection rates and worm burden among the study population of school‐aged children. Regarding the study’s primary outcome, only 14% (26/185) of children in the hand-washing with soap intervention were re‐infected compared to 29% (53/182) of children in the control group (Odds Ratio (OR) 0.32). Similarly, the prevalence of re‐infection was lower among children in the nail clipping group, at 17% (33/189), compared to 26% (46/178) of children in the control arm (OR 0.51). Further, a significant reduction in worm burden was observed among children in the hand‐washing group than the control group. At the end of the trial, 13% (24/185) of children in the hand‐washing intervention were anaemic compared to 23% (41/182) in the control group (OR 0.39). There was also a reduction in the prevalence of anaemia among children of the nail clipping intervention; however the observed difference did not reach statistical significance. In summary, the six‐month hand‐washing with soap and weekly nail clipping interventions demonstrated a significant reduction in intestinal parasite re‐infection rates and the size of worm burden acquired after a successful treatment. A significant reduction in the prevalence of anaemia was also observed in children of the hand‐washing with soap intervention. Given that school‐aged children bear peak worm intensity in a community and that the size of the worm burden is the central determinant of transmission dynamics, proper hand‐washing with soap and weekly nail trimming could have potential flow‐on benefits to the community by reducing parasite transmission, in addition to immediate benefits in improving the health of children.
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