Menstrual hygiene management (MHM) practices vary worldwide and depend on the individual’s socioeconomic status, personal preferences, local traditions and beliefs, and access to water and sanitation resources. MHM practices can be particularly unhygienic and inconvenient for girls and women in poorer settings. Little is known about whether unhygienic MHM practices increase a woman’s exposure to urogenital infections, such as bacterial vaginosis (BV) and urinary tract infection (UTI). This study aimed to determine the association of MHM practices with urogenital infections, controlling for environmental drivers. A hospital-based case-control study was conducted on 486 women at Odisha, India. Cases and controls were recruited using a syndromic approach. Vaginal swabs were collected from all the participants and tested for BV status using Amsel’s criteria. Urine samples were cultured to assess UTI status. Socioeconomic status, clinical symptoms and reproductive history, and MHM and water and sanitation practices were obtained by standardised questionnaire. A total of 486 women were recruited to the study, 228 symptomatic cases and 258 asymptomatic controls. Women who used reusable absorbent pads were more likely to have symptoms of urogenital infection (AdjOR=2.3, 95%CI1.5-3.4) or to be diagnosed with at least one urogenital infection (BV or UTI) (AdjOR=2.8, 95%CI1.7-4.5), than women using disposable pads. Increased wealth and space for personal hygiene in the household were protective for BV (AdjOR=0.5, 95%CI0.3-0.9 and AdjOR=0.6, 95%CI0.3-0.9 respectively). Lower education of the participants was the only factor associated with UTI after adjusting for all the confounders (AdjOR=3.1, 95%CI1.2-7.9). Interventions that ensure women have access to private facilities with water for MHM and that educate women about safer, low-cost MHM materials could reduce urogenital disease among women. Further studies of the effects of specific practices for managing hygienically reusable pads and studies to explore other pathogenic reproductive tract infections are needed.

Studies have suggested that CMV infection may influence cardiovascular disease (CVD) risk and mortality. However, there have been no large-scale examinations of these relationships among demographically diverse populations. The inflammatory marker C-reactive protein (CRP) is also linked with CVD outcomes and mortality and may play an important role in the pathway between CMV and mortality. We utilized a U.S. nationally representative study to examine whether CMV infection is associated with all-cause and CVD-related mortality. We also assessed whether CRP level mediated or modified these relationships. Data come from subjects ≥25 years of age who were tested for CMV and CRP level and were eligible for mortality follow-up on December 31^st, 2006 (N = 14153) in the National Health and Nutrition Examination Survey (NHANES) III (1988–1994). Cox proportional hazard models were used to estimate hazard ratios (HR) and 95% confidence intervals (CI) for all-cause and CVD-related mortality by CMV serostatus. After adjusting for multiple confounders, CMV seropositivity remained statistically significantly associated with all-cause mortality (HR 1.19, 95% CI: 1.01, 1.41). The association between CMV and CVD-related mortality did not achieve statistical significance after confounder adjustment. CRP did not mediate these associations. However, CMV seropositive individuals with high CRP levels showed a 30.1% higher risk for all-cause mortality and 29.5% higher risk for CVD-related mortality compared to CMV seropositive individuals with low CRP levels. CMV was associated with a significant increased risk for all-cause mortality and CMV seropositive subjects who also had high CRP levels were at substantially higher risk for both for all-cause and CVD-related mortality than subjects with low CRP levels. Future work should target the mechanisms by which CMV infection and low-level inflammation interact to yield significant impact on mortality.

Summary: Aging is a major risk factor for chronic disease in the human population, but there are little human data on gene expression alterations that accompany the process. We examined human peripheral blood leukocyte in‐vivo RNA in a large‐scale transcriptomic microarray study (subjects aged 30–104 years). We tested associations between probe expression intensity and advancing age (adjusting for confounding factors), initially in a discovery set (n = 458), following‐up findings in a replication set (n = 240). We confirmed expression of key results by real‐time PCR. Of 16 571 expressed probes, only 295 (2%) were robustly associated with age. Just six probes were required for a highly efficient model for distinguishing between young and old (area under the curve in replication set; 95%). The focused nature of age‐related gene expression may therefore provide potential biomarkers of aging. Similarly, only 7 of 1065 biological or metabolic pathways were age‐associated, in gene set enrichment analysis, notably including the processing of messenger RNAs (mRNAs); [P < 0.002, false discovery rate (FDR) q < 0.05]. This is supported by our observation of age‐associated disruption to the balance of alternatively expressed isoforms for selected genes, suggesting that modification of mRNA processing may be a feature of human aging.

The importance of maternal sanitation behaviour during pregnancy for birth outcomes remains unclear. Poor sanitation practices can promote infection and induce stress during pregnancy and may contribute to adverse pregnancy outcomes (APOs). We aimed to assess whether poor sanitation practices were associated with increased risk of APOs such as preterm birth and low birth weight in a population-based study in rural India. A prospective cohort of pregnant women (n = 670) in their first trimester of pregnancy was enrolled and followed until birth. Socio-demographic, clinical, and anthropometric factors, along with access to toilets and sanitation practices, were recorded at enrolment (12th week of gestation). A trained community health volunteer conducted home visits to ensure retention in the study and learn about study outcomes during the course of pregnancy. Unadjusted odds ratios (ORs) and adjusted odds ratios (AORs) and 95% confidence intervals for APOs were estimated by logistic regression models. Of the 667 women who were retained at the end of the study, 58.2% practiced open defecation and 25.7% experienced APOs, including 130 (19.4%) preterm births, 95 (14.2%) births with low birth weight, 11 (1.7%) spontaneous abortions, and six (0.9%) stillbirths. Unadjusted ORs for APOs (OR: 2.53; 95% CI: 1.72–3.71), preterm birth (OR: 2.36; 95% CI: 1.54–3.62), and low birth weight (OR: 2.00; 95% CI: 1.24–3.23) were found to be significantly associated with open defecation practices. After adjustment for potential confounders such as maternal socio-demographic and clinical factors, open defecation was still significantly associated with increased odds of APOs (AOR: 2.38; 95% CI: 1.49–3.80) and preterm birth (AOR: 2.22; 95% CI: 1.29–3.79) but not low birth weight (AOR: 1.61; 95% CI: 0.94–2.73). The association between APOs and open defecation was independent of poverty and caste. Even though we accounted for several key confounding factors in our estimates, the possibility of residual confounding should not be ruled out. We did not identify specific exposure pathways that led to the outcomes. This study provides the first evidence, to our knowledge, that poor sanitation is associated with a higher risk of APOs. Additional studies are required to elucidate the socio-behavioural and/or biological basis of this association so that appropriate targeted interventions might be designed to support improved birth outcomes in vulnerable populations. While it is intuitive to expect that caste and poverty are associated with poor sanitation practice driving APOs, and we cannot rule out additional confounders, our results demonstrate that the association of poor sanitation practices (open defecation) with these outcomes is independent of poverty. Our results support the need to assess the mechanisms, both biological and behavioural, by which limited access to improved sanitation leads to APOs. Pregnancy is usually a happy time for women and their families. But, for some women, pregnancy ends unhappily. Some women lose their baby during early pregnancy (spontaneous abortion or miscarriage) or during late pregnancy (stillbirth). Others have their baby earlier than expected (preterm birth) or have a baby with low birth weight, two outcomes that adversely affect the baby’s survival and long-term health. The burden of adverse pregnancy outcomes (low birth weight, preterm birth, stillbirth, and spontaneous abortion) is substantial across the world but is particularly high in resource-limited settings. More than 60% of all preterm births take place in Asia and sub-Saharan Africa, and in India alone nearly 13 million babies (47% of all births) had a low birth weight in 2010. Many risk factors for adverse pregnancy outcomes have been identified, including infection, diabetes, poor antenatal care, and other socio-economic factors, but a clear causal mechanism for adverse pregnancy outcomes has not been established. One potential risk factor for adverse pregnancy outcomes, particularly in resource-limited settings, is poor sanitation—the inadequate provision of facilities and services for the safe disposal of human urine and feces. The WHO/UNICEF Joint Monitoring Programme for Water Supply and Sanitation estimates that, globally, 1.1 billion people defecate in the open, a practice that can expose individuals to contact with human feces containing infectious organisms and that can contaminate food and water. Poor sanitation might contribute to adverse pregnancy outcomes by promoting infection or by causing stress during pregnancy. Women might, for example, limit their intake of food and water to avoid having to use inadequate toilet facilities, thereby adversely affecting the health of their unborn child. Here, the researchers assess whether poor sanitation practices are associated with an increased risk of adverse pregnancy outcomes by undertaking a population-based prospective study in two rural areas of Odisha state, India. Odisha has a high infant death rate (57 deaths per 1,000 live births), only 18.2% of households have access to an improved latrine (a facility such as a flush toilet that hygienically prevents human contact with human excreta), and 75% of households practice open defecation. For their study, the researchers enrolled 670 women during the first trimester of their pregnancy. They recorded socio-demographic data (for example, age, level of education, and household assets), clinical data, weight and height, and toilet access and sanitation practices for each woman at enrollment and followed them through pregnancy until birth. Nearly two-thirds of the women practiced open defecation, and a quarter experienced an adverse pregnancy outcome, most commonly a preterm birth and/or having a baby with low birth weight. After adjustment for potential confounding factors (factors that might affect outcomes, such as socio-demographic characteristics), open defecation was significantly associated with adverse pregnancy outcomes (all four adverse outcomes considered together) and with preterm birth, but not with low birth weight (a significant association is one that is unlikely to have happened by chance). Specifically, the adjusted odds ratios (an indicator of the strength of association between an exposure and an outcome; an odds ratio of more than one indicates that an exposure increases the risk of an outcome) of adverse pregnancy outcomes and preterm birth among women practicing open defecation compared with women with access to a latrine were 2.38 and 2.22, respectively. Notably, these associations were independent of poverty, caste, and religion. These findings indicate that, among women in Odisha, defecation in the open (poor sanitation) during pregnancy is associated with a higher risk of any adverse pregnancy outcome and of preterm birth than the use of a latrine. Counterintuitively, these findings also suggest that the association between open defecation and adverse pregnancy outcomes is not explained by poverty. Although the researchers adjusted for numerous confounding factors in their analysis, the women who defecated in the open may have shared some other unknown characteristic (residual confounding) that was actually responsible for their increased risk of an adverse pregnancy outcome. Further studies are now needed to determine the socio-behavioral and/or biological basis of the association between poor sanitation and adverse pregnancy outcomes. Appropriate public health interventions can then be designed to reduce the burden of adverse pregnancy outcomes among women living in settings where there is limited access to adequate sanitation. This list of resources contains links that can be accessed when viewing the PDF on a device or via the online version of the article at http://dx.doi.org/10.1371/journal.pmed.1001828.

Women face greater challenges than men in accessing water, sanitation, and hygiene (WASH) resources to address their daily needs, and may respond to these challenges by adopting unsafe practices that increase the risk of reproductive tract infections (RTIs). WASH practices may change as women transition through socially-defined life stage experiences, like marriage and pregnancy. Thus, the relationship between WASH practices and RTIs might vary across female reproductive life stages. This cross-sectional study assessed the relationship between WASH exposures and self-reported RTI symptoms in 3,952 girls and women from two rural districts in India, and tested whether social exposures represented by reproductive life stage was an effect modifier of associations. In fully adjusted models, RTI symptoms were less common in women using a latrine without water for defecation versus open defecation (Odds Ratio (OR) = 0.69; Confidence Interval (CI) = 0.48, 0.98) and those walking shorter distances to a bathing location (OR = 0.79, CI = 0.63, 0.99), but there was no association between using a latrine with a water source and RTIs versus open defecation (OR = 1.09; CI = 0.69, 1.72). Unexpectedly, RTI symptoms were more common for women bathing daily with soap (OR = 6.55, CI = 3.60, 11.94) and for women washing their hands after defecation with soap (OR = 10.27; CI = 5.53, 19.08) or ash/soil/mud (OR = 6.02; CI = 3.07, 11.77) versus water only or no hand washing. WASH practices of girls and women varied across reproductive life stages, but the associations between WASH practices and RTI symptoms were not moderated by or confounded by life stage status. This study provides new evidence that WASH access and practices are associated with self-reported reproductive tract infection symptoms in rural Indian girls and women from different reproductive life stages. However, the counterintuitive directions of effect for soap use highlights that causality and mechanisms of effect cannot be inferred from this study design. Future research is needed to understand whether improvements in water and sanitation access could improve the practice of safe hygiene behaviors and reduce the global burden of RTIs in women.

Extreme heat and heat waves have been established as disasters which can lead to a great loss of life. Several studies over the years, both within and outside of India, have shown how extreme heat events lead to an overall increase in mortality. However, the impact of extreme heat, similar to other disasters, depends upon the vulnerability of the population. This study aims to assess the extreme heat vulnerability of the population of four cities with different characteristics across India. This cross-sectional study included 500 households from each city across the urban localities (both slum and non-slum) of Ongole in Andhra Pradesh, Karimnagar in Telangana, Kolkata in West Bengal and Angul in Odisha. Twenty-one indicators were used to construct a household vulnerability index to understand the vulnerability of the cities. The results have shown that the majority of the households fell under moderate to high vulnerability level across all the cities. Angul and Kolkata were found to be more highly vulnerable as compared to Ongole and Karimnagar. Further analysis also revealed that household vulnerability is more significantly related to adaptive capacity than sensitivity and exposure. Heat Vulnerability Index can help in identifying the vulnerable population and scaling up adaptive practices.