Compared to the general public, household members of cholera patients are at a 100 times higher risk of contracting cholera during the 7-day high-risk period after a cholera patient has been admitted to a health facility for treatment. The Preventative-Intervention-for-Cholera-for-7-days (PICHA7) program aims to reduce household transmission of cholera during this 7-day high-risk period through a health facility-initiated water, sanitation, and hygiene (WASH) program promoting handwashing with soap, water treatment, and safe water storage. The PICHA7 program is delivered to cholera patient households through: (1) a pictorial flipbook delivered by a health promoter; (2) a cholera prevention package (handwashing station, drinking water vessel with lid and tap, and chlorine tablets); and (3) weekly WASH mobile messages sent to patient households in the Democratic Republic of the Congo (DRC). The objectives of this study were to conduct formative research to identify facilitators and barriers of the promoted WASH behaviors for cholera patient households and to tailor the PICHA7 program to target these facilitators and barriers. Formative research included 93 semi-structured interviews with diarrhea patient households and healthcare workers during exploratory research and a pilot study of 518 participants. Barriers to the promoted WASH behaviors identified during exploratory and pilot study interviews included: (1) low awareness of cholera transmission and prevention; (2) unaffordability of soap for handwashing; and (3) intermittent access to water limiting water for handwashing. For intervention development, narratives of the lived experiences of patient households in our study were presented by health promoters to describe cholera transmission and prevention, and soapy water and ash were promoted in the program flipbook and mobile messages to address the affordability of soap for handwashing. A jerry can was provided to allow for additional water storage, and a tap with a slower flow rate was attached to the handwashing station to reduce the amount of water required for handwashing. The pilot findings indicate that the PICHA7 program has high user acceptability and is feasible to deliver to cholera patients that present at health facilities for treatment in our study setting. Formative research allowed for tailoring this targeted WASH program for cholera patient households in the DRC.

: The objective of our study was to develop and test observational methods to evaluate COVID-19 preventive hygiene behaviors and physical distancing, and to evaluate the effectiveness of a government mandate on indoor fully covered mask wearing. An observational study was conducted of 4,736 individuals from April to October 2021 using 5-hour and rapid (10-minute) structured observations and spot checks to evaluate mask-wearing, handwashing, and physical-distancing behaviors, and the functionality of handwashing stations in 161 indoor public spaces across Bukavu, Democratic Republic of the Congo (DRC). Sixteen percent of individuals entering indoor public spaces were wearing a mask that fully covered their nose and mouth (fully covered mask wearing). Fully covered mask wearing was lowest inside schools (1%), universities (2%), religious establishments (22%), and health facility wards (28%). Overall physical distancing of more than 1-m inside indoor public spaces was 22%, and was lowest inside schools and religious establishments (7%). Thirty-nine percent of handwashing stations had water and a cleansing agent present. Ten percent of individuals washed their hands with a cleansing agent before entering an indoor space. Overall, fully covered mask wearing was similar for 5-hour and rapid structured observations (16% versus 15%). The odds of fully covered mask wearing was significantly greater with increased government enforcement of mask wearing in public spaces through fines (odds ratio, 2.72; 95% CI, 1.02–7.30). This study presents rigorous methods using structured observations to assess government mandates and programs on COVID-19 preventive hygiene behaviors in indoor public spaces in settings globally.

Healthcare-acquired infections are a major problem in healthcare facility settings around the world. The Democratic Republic of the Congo (DRC) has over 2 million diarrhea patients hospitalized each year. These healthcare settings become high-risk environments for spreading diarrheal illnesses such as cholera. The objective of the Preventative Intervention for Cholera for 7 Days (PICHA7) program is to develop evidence-based water, sanitation, and hygiene (WASH) interventions to reduce cholera and other severe diarrheal diseases in the DRC. The study objective was to evaluate the effectiveness of PICHA7 program delivery in increasing handwashing with a cleansing agent at stool/vomit- and food-related events in a healthcare facility setting among diarrhea patients and patient attendants. A pilot of the PICHA7 program was conducted among 284 participants in 27 healthcare facilities from March 2020 to November 2021 in urban Bukavu in the South Kivu Province of the DRC. The standard arm received the standard message provided in the DRC to diarrhea patients on the use of oral rehydration solution and a basic WASH message at healthcare facility discharge. The PICHA7 arm received the PICHA7 WASH pictorial module delivered by a health promoter focused on handwashing with a cleansing agent at the bedside of the diarrhea patient in the healthcare facility and provision of a soapy water bottle (water and detergent powder). Within 24 h of intervention delivery, a three-hour structured observation of handwashing practices at stool/vomit- and food-related events (key events) was conducted in healthcare facilities of diarrhea patients and their attendants. Compared to the standard arm, there was significantly more handwashing with a cleansing agent at key events in the PICHA7 arm (40% vs. 15%) (odds ratio: 5.04; (95% confidence interval (CI): 2.01, 12.7)). These findings demonstrate that delivery of the PICHA7 WASH pictorial module and provision of a soapy water bottle to diarrhea patients and their attendants presents a promising approach to increase handwashing with a cleansing agent among this high-risk population in healthcare facilities in the eastern DRC.

: The objective of the Reducing Enteropathy, Undernutrition, and Contamination in the Environment (REDUCE) program is to identify exposure pathways to fecal pathogens that are significant contributors to morbidity among young children in the Democratic Republic of the Congo (DRC), and on developing and evaluating scalable interventions to reduce fecal contamination from these pathways. This prospective cohort study of 270 children under 5 years of age was conducted in rural South Kivu, DRC, to investigate the association between Escherichia coli in hand rinse, soil, food, object, surface, stored water, and water source samples and child developmental outcomes. Child developmental outcomes were assessed by communication, fine motor, gross motor, personal social, problem-solving, and combined scores measured by the Extended Ages and Stages Questionnaire (EASQ) at a 6-month follow-up. Children having E. coli present in the soil in their play spaces had significantly lower combined EASQ z scores (coefficient: −0.38 (95% CI: −0.73, −0.03)). E. coli on children’s hands was associated with lower communication EASQ z scores (−0.37 (95% CI: −0.0.10, −0.01), and E. coli in stored drinking water was associated with lower gross motor EASQ z scores (−0.40 (95% CI: −0.68, −0.12). In the REDUCE cohort study, E. coli in soil in child play spaces, on children’s hands, and in stored drinking water was associated with lower developmental outcome scores (communication, gross motor, fine motor, and problem-solving skills). These results suggest the need for interventions to reduce fecal contamination in the household environment to protect the cognitive development of susceptible pediatric populations in rural DRC.

: Globally, 140 million children under 5 years of age are estimated to be stunted. Previous studies have found an association between stunting and poor cognitive outcomes. However, there is limited evidence of this association in sub-Saharan African settings, such as the Democratic Republic of the Congo (DRC). This prospective cohort study of 286 children under 5 years was conducted in rural DRC to investigate the association between diarrhea prevalence, child growth, and child cognitive developmental outcomes. Developmental outcomes were assessed by communication, fine motor, gross motor, personal social, problem-solving, and combined developmental scores measured by the Extended Ages and Stages Questionnaire (EASQ) at a 6-month follow-up visit. Height and weight were measured at baseline and a 6-month follow-up. Diarrhea prevalence was assessed through surveillance visits. Diarrhea prevalence was not associated with follow-up combined EASQ Z-scores at the 6-month follow-up (coefficient: −0.06 [95% CI: −0.29, 0.17]). Each additional standard deviation (SD) increase in height-for-age Z-scores from baseline to the 6-month follow-up increased combined EASQ Z-scores by 0.22 (95%: 0.14, −0.31) SDs. Each additional SD increase in weight-for-age Z-scores from baseline to the 6-month follow-up increased combined EASQ Z-scores by 0.21 (95%: 0.10, −0.32) SDs. Linear growth faltering and reduced weight gain were associated with reduced cognitive developmental outcomes among children residing in rural DRC. Interventions are urgently needed for this susceptible pediatric population to improve child growth and cognitive developmental outcomes.

Objective: In this evaluation of COVID-19 preventative response programs in South Kivu, Democratic Republic of the Congo (DRC), we aimed to explore community understandings of COVID-19, assess operational successes and challenges of COVID response activities, and identify barriers to practicing COVID-19 preventative behaviors. Methods: Thirty-one semi-structured interviews were conducted from April to September 2021 in South Kivu, DRC, with community members (n = 16) and programmatic stakeholders (n = 15) (healthcare providers, government officials, and developmental and NGO staff engaged in COVID-19 response). Findings: Most community members were aware of COVID-19 and its global burden, but few were aware of local transmission in their area. Some community members attributed COVID-19 to actions of malevolent neighbors, miasma (“bad air”), or spirits. Awareness of COVID-19 preventative measures was widespread, largely because of radio and TV health promotion programs. Community members and programmatic stakeholders both said community-level non-compliance to COVID-19 preventative measures was high despite high awareness of preventative methods. Community members expressed concern that face masks distributed as part of preventative programs contained the COVID-19 virus. Programmatic stakeholders emphasized the need for broader health system strengthening with improved coordination, provision of resources to health facilities at the provincial level, and prioritization of research. Lessons learned from addressing Ebola were leveraged for COVID-19 health promotion, rapid training of healthcare personnel, and surveillance. Conclusions: Community-informed approaches are needed for effective COVID-19 preventative response programs in South Kivu, DRC. Our study identified successes and challenges in COVID-19 response activities. Future research should assess the effectiveness of integrating preventive programs with COVID-19 vaccination efforts.