Medicine and Health Sciences Commons^™

Quantification And Analysis Of Micro-Level Activities Data From Children Aged 1-12 Years Old For Use In The Assessments Of Exposure To Recycled Tire On Turf And Playgrounds., Nicolas Lopez-Galvez, Jocelyn Claude, Patty Wong, Asa Bradman, Carly Hyland, Rosemary Castorina, Robert A Canales, Dean Billheimer, Elmira Torabzadeh, James O Leckie, Paloma I Beamer

Environmental and Occupational Health Faculty Publications

BACKGROUND: There are growing health concerns about exposure to toxicants released from recycled tire rubber, which is commonly used in synthetic turf and playground mats. To better estimate children's exposure and risk from recycled tire rubber used in synthetic turf and playground mats, there is a need to collect detailed accurate information on mouthing activity and dermal contact behaviors. The objective of this study was to quantify and analyze micro-level activity time series (MLATS) data from children aged 1-12 years old while playing (non-sport-related games) at turf-like locations and playgrounds. Another objective was to estimate the incidental ingestion rate of …

Association Between Increasing Agricultural Use Of 2,4-D And Population Biomarkers Of Exposure: Findings From The National Health And Nutrition Examination Survey, 2001-2014., Marlaina S. Freisthler, C Rebecca Robbins, Charles M Benbrook, Heather A. Young, David M Haas, Paul D Winchester, Melissa J Perry

Environmental and Occupational Health Faculty Publications

BACKGROUND: 2,4-Dichlorophenoxyacetic acid (2,4-D) is one of the most extensively used herbicides in the United States. In 2012, 2,4-D was the most widely used herbicide in non-agricultural settings and the fifth most heavily applied pesticide in the US agricultural sector. The objective of this study was to examine trends in 2,4-D urinary biomarker concentrations to determine whether increases in 2,4-D application in agriculture are associated with increases in biomonitoring levels of urine 2,4-D.

METHODS: Data from the National Health and Nutrition Examination Survey (NHANES) with available urine 2,4-D biomarker measurements from survey cycles between 2001 and 2014 were utilized. Urine …

Global Pediatric Pulmonology Alliance (Gppa) Proposal For Covid-19 Vaccination In Children., Lance E Rodewald, Kun-Ling Shen, Yong-Hong Yang, Gary Wing-Kin Wong, Leyla Namazova-Baranova, Lanny J Rosenwasser, Adel S Alharbi, Anne B Chang, Jim Buttery, Basil Elnazir, Ruth A. Etzel, Anne Goh, Hilary Hoey, Rosemary Horne, Eitan Kerem, Antonella Muraro, Chris O'Callaghan, Kazunobu Ouchi, Varinder Singh, Jiu-Yao Wang, Spencer Li, Yu Guan, Yue-Jie Zheng, Zhengde Xie, Gen Lu, Yi Jiang, Xing-Wang Li, Rong-Meng Jiang, Xiao-Chuan Wang, Ji-Kui Deng, Xiao-Xia Lu, Bao-Ping Xu, Zhuang Wei, Lu-Zhao Feng, Zheng-Yan Zhao

Environmental and Occupational Health Faculty Publications

No abstract provided.

The Ramazzini Institute 13-Week Study On Glyphosate-Based Herbicides At Human-Equivalent Dose In Sprague Dawley Rats: Study Design And First In-Life Endpoints Evaluation., Simona Panzacchi, Daniele Mandrioli, Fabiana Manservisi, Luciano Bua, Laura Falcioni, Melissa J Perry, +Several Additional Authors

Environmental and Occupational Health Faculty Publications

BACKGROUND: Glyphosate-based herbicides (GBHs) are the most widely used pesticides worldwide, and glyphosate is the active ingredient of such herbicides, including the formulation known as Roundup. The massive and increasing use of GBHs results in not only the global burden of occupational exposures, but also increased exposure to the general population. The current pilot study represents the first phase of a long-term investigation of GBHs that we are conducting over the next 5 years. In this paper, we present the study design, the first evaluation of in vivo parameters and the determination of glyphosate and its major metabolite aminomethylphosphonic acid …

Occupational Exposure To Solvents And Associated Neurotoxicity In Construction Painters: A Systematic Review, Allison Cailliau

GW Research Days 2016 - 2020

Background

Existing evidence suggests that occupational exposure to solvents can have devastating and adverse effects on cognitive function. Individuals in the construction industry, specifically construction painters, often come in contact with these harmful chemicals on a regular basis. A solvent is a liquid that can dissolve, suspend, or extract other materials without chemical change to the solvent itself. They are present in a wide range of industries and can be used for extraction of fats and oils, degreasing, or manufacturing of paints and plastics. Their main routes of exposure are through inhalation and skin absorption, and they have a tendency …

(Video) Dirty Cotton: Occupational Pesticide Exposure And Elevated Suicide Risk Among Male Cotton Farmers In India, Bethany Natalia Kondavaty

GW Research Days 2016 - 2020

Purpose: The aim of this critical analysis was to examine the association (or lack thereof) of occupational pesticide exposure and elevated suicide risk among male cotton farmers in India.

Methods: A literature review was performed using Scopus, PubMed, and Google Scholar databases. The review included documents published before and after year 2002. Children were excluded from the search as well as women, with exception to research on gender differences in suicide.

Results: Studies outside India show a positive correlation between work-related pesticide exposure and suicide. Animal studies have shown that pesticides, as organophosphates, are toxic, …

Occupational Exposure To Organophosphate Pesticides And Its Effects On Human Sperm Parameters: A Systematic Review, Roxana E. Amaya-Fuentes, Melissa J. Perry

GW Research Days 2016 - 2020

Background

Previous research has indicated there is a decrease in sperm quality in the last 40 years. There have been a few reports that have associated occupational exposure to Organophosphate pesticides with a decrease in sperm count, abnormalities in the head or tail, and motility leading to infertility over time. Organophosphates are the most common pesticides used in the United States and have been classified as toxic to bees, wildlife, and humans by the EPA even at low exposures. Furthermore, Organophosphates are considered endocrine disrupting chemicals altering the normal function of the endocrine system. This occurs by interfering with the …

Does Occupational Exposure To Swine Increase The Risk Of Influenza? A Systematic Literature Review, Courtney Youngbar, Lance Price

GW Research Days 2016 - 2020

Background Workers who have an occupational exposure to swine may have an increased risk of influenza infection.

Objective We conducted a systematic review regarding occupational exposure to swine and influenza infection in humans.

Methods We searched articles published within the past ten years at the time of writing, and included original studies that quantified exposures to swine and resulting influenza infections in swine farm workers, including veterinarians. We evaluated the risk of bias of individual studies and the overall quality and strength of the evidence according to the Navigation Guide systematic review methodology. Twelve studies met the inclusion criteria. We …

Systematic Literature Review Of Indoor School Exposure To Pm2.5 In Children, Brittany Wagner, Ami Zota

GW Research Days 2016 - 2020

Asthma is a chronic respiratory disease that puts a strain on lung function and breathing. It is the leading cause of school absenteeism and hospitalization for American children. Genetics play a major role in allergy related disease development such as asthma, but environmental exposures are proving to be a potential contributor to childhood asthma. Despite the sufficient data regarding air pollution, there is a huge knowledge gap regarding indoor air quality and its relationship with health outcomes such as asthma. Many of the studies available only look at outdoor air pollution levels, while children spend the majority of their time …

Combining Community Engagement And Scientific Approaches In Next-Generation Monitor Siting: The Case Of The Imperial County Community Air Network., Michelle Wong, Esther Bejarano, Graeme Carvlin, Katie Fellows, Galatea King, Humberto Lugo, Michael Jerrett, Dan Meltzer, Amanda Northcross, Luis Olmedo, Edmund Seto, Alexa Wilkie, Paul English

Environmental and Occupational Health Faculty Publications

Air pollution continues to be a global public health threat, and the expanding availability of small, low-cost air sensors has led to increased interest in both personal and crowd-sourced air monitoring. However, to date, few low-cost air monitoring networks have been developed with the scientific rigor or continuity needed to conduct public health surveillance and inform policy. In Imperial County, California, near the U.S./Mexico border, we used a collaborative, community-engaged process to develop a community air monitoring network that attains the scientific rigor required for research, while also achieving community priorities. By engaging community residents in the project design, monitor …

Genomic Differences Between Nasal Staphylococcus Aureus From Hog Slaughterhouse Workers And Their Communities., Yaqi You, Li Song, Bareng A S Nonyane, Lance B Price, Ellen K Silbergeld

Environmental and Occupational Health Faculty Publications

New human pathogens can emerge from the livestock-human interface and spread into human populations through many pathways including livestock products. Occupational contact with livestock is a risk factor for exposure to those pathogens and may cause further spreading of those pathogens in the community. The current study used whole genome sequencing to explore nasal Staphylococcus aureus obtained from hog slaughterhouse workers and their community members, all of whom resided in a livestock-dense region in rural North Carolina. Sequence data were analyzed for lineage distribution, pathogenicity-related genomic features, and mobile genetic elements. We observed evidence of nasal S. aureus differences between …

Colonizing Opportunistic Pathogens (Cops): The Beasts In All Of Us., Lance B Price, Bruce A Hungate, Benjamin J Koch, Gregg S Davis, Cindy M Liu

Environmental and Occupational Health Faculty Publications

Colonizing opportunistic pathogens (COPs) are microbes that asymptomatically colonize the human body and, when the conditions are right, can cause infections. Their ability to persist indefinitely and to be transmitted without detection [1] gives COPs a unique epidemiology that warrants special consideration. There are examples of COPs among bacteria, fungi (e.g., Candida albicans [2]), protozoa (e.g., Blastocystis [3, 4]), and viruses (e.g., Rhinovirus [5]), but bacterial COPs are of particular relevance because of their major contribution to today’s antibiotic resistance crisis. The COPs include a long list of notorious bacteria that …

Colonizing Opportunistic Pathogens (Cops): The Beasts In All Of Us., Lance B Price, Bruce A Hungate, Benjamin J Koch, Gregg S Davis, Cindy M Liu

Environmental and Occupational Health Faculty Publications

Colonizing opportunistic pathogens (COPs) are microbes that asymptomatically colonize the human body and, when the conditions are right, can cause infections. Their ability to persist indefinitely and to be transmitted without detection [1] gives COPs a unique epidemiology that warrants special consideration. There are examples of COPs among bacteria, fungi (e.g., Candida albicans [2]), protozoa (e.g., Blastocystis [3, 4]), and viruses (e.g., Rhinovirus [5]), but bacterial COPs are of particular relevance because of their major contribution to today’s antibiotic resistance crisis. The COPs include a long list of notorious bacteria that …

The Imperial County Community Air Monitoring Network: A Model For Community-Based Environmental Monitoring For Public Health Action., Paul B English, Luis Olmedo, Ester Bejarano, Humberto Lugo, Eduardo Murillo, Edmund Seto, Michelle Wong, Galatea King, Alexa Wilkie, Dan Meltzer, Graeme Carvlin, Michael Jerrett, Amanda Northcross

Environmental and Occupational Health Faculty Publications

The Imperial County Community Air Monitoring Network (the Network) is a collaborative group of community, academic, nongovernmental, and government partners designed to fill the need for more detailed data on particulate matter in an area that often exceeds air quality standards. The Network employs a community-based environmental monitoring process in which the community and researchers have specific, well-defined roles as part of an equitable partnership that also includes shared decision-making to determine study direction, plan research protocols, and conduct project activities. The Network is currently producing real-time particulate matter data from 40 low-cost sensors throughout Imperial County, one of the …

Heat Exposure And Maternal Health In The Face Of Climate Change., Leeann Kuehn, Sabrina Mccormick

Environmental and Occupational Health Faculty Publications

Climate change will increasingly affect the health of vulnerable populations, including maternal and fetal health. This systematic review aims to identify recent literature that investigates increasing heat and extreme temperatures on pregnancy outcomes globally. We identify common research findings in order to create a comprehensive understanding of how immediate effects will be sustained in the next generation. Following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guide, we systematically reviewed articles from PubMed and Cochrane Reviews. We included articles that identify climate change-related exposures and adverse health effects for pregnant women. There is evidence that temperature extremes adversely …

Reducing Chemical Exposures At Home: Opportunities For Action., Ami R Zota, Veena Singla, Gary Adamkiewicz, Susanna D Mitro, Robin E Dodson

Environmental and Occupational Health Faculty Publications

Indoor environments can influence human environmental chemical exposures and, ultimately, public health. Furniture, electronics, personal care and cleaning products, floor coverings and other consumer products contain chemicals that can end up in the indoor air and settled dust. Consumer product chemicals such as phthalates, phenols, flame retardants and per- and polyfluorinated alkyl substances are widely detected in the US general population, including vulnerable populations, and are associated with adverse health effects such as reproductive and endocrine toxicity. We discuss the implications of our recent meta-analysis describing the patterns of chemical exposures and the ubiquity of multiple chemicals in indoor environments. …

Penile Anaerobic Dysbiosis As A Risk Factor For Hiv Infection, Cindy Liu, Jessica Prodger, Aaron Tobian, Alison Abraham, Godfrey Kigozi, Lance B. Price, +Several Additional Authors

Environmental and Occupational Health Faculty Publications

Sexual transmission of HIV requires exposure to the virus and infection of activated mucosal immune cells, specifically CD4⁺ T cells or dendritic cells. The foreskin is a major site of viral entry in heterosexual transmission of HIV. Although the probability of acquiring HIV from a sexual encounter is low, the risk varies even after adjusting for known HIV risk factors. The genital microbiome may account for some of the variability in risk by interacting with the host immune system to trigger inflammatory responses that mediate the infection of mucosal immune cells. We conducted a case-control study of uncircumcised participants …

Emergence Of Livestock-Associated Methicillin-Resistant Staphylococcus Aureus Bloodstream Infections In Denmark., Jesper Larsen, Andreas Petersen, Anders R Larsen, Raphael N Sieber, Marc Stegger, Anders Koch, Frank M Aarestrup, Lance B Price, Robert L Skov

Environmental and Occupational Health Faculty Publications

Background

Livestock-associated methicillin-resistant Staphylococcus aureus clonal complex 398 (LA-MRSA CC398) is causing an increasing number of skin and soft tissue infections (SSTIs) in Denmark and other European countries with industrial pig production. Yet, its impact on MRSA bloodstream infections (BSIs) has not been well studied.

Methods

We investigated the clinical epidemiology of all human cases of LA-MRSA CC398 BSI during 2010–2015. Cases of LA-MRSA CC398 BSI were compared to cases of BSI caused by other types of MRSA and cases of SSTI caused by LA-MRSA CC398. Whole-genome sequence analysis was used to assess the phylogenetic relationship among LA-MRSA CC398 isolates …

Persistent Organic Pollutants And Mortality In The United States, Kristiann Fry, Melinda Power

GW Research Days 2016 - 2020

Background/Objectives: Persistent organic pollutants (POPs) are environmentally and biologically persistent chemicals that include polybrominated diphenyl ethers (PBDEs), per- and polyfluoroalkyl Substances (PFASs), polychlorinated biphenyls (PCBs), and organochlorine (OC) pesticides. Currently, there is limited data on the association between exposure to POPs and the risk of mortality in the general US population. The objective of this study was to determine if higher exposure to POPs are associated with greater risk of all-cause, cancer, heart/cerebrovascular disease, or other-cause mortality in persons aged 60 years and older.

Methods: The analyses included participants aged 60 years and older from the 1999-2006 National Health and …

Implementation Science To Accelerate Clean Cooking For Public Health., Joshua Rosenthal, Kalpana Balakrishnan, Nigel Bruce, David Chambers, Jay Graham, Darby Jack, Lydia Kline, Omar Masera, Sumi Mehta, Ilse Ruiz Mercado, Gila Neta, Subhrendu Pattanayak, Elisa Puzzolo, Helen Petach, Antonello Punturieri, Adolfo Rubinstein, Michael Sage, Rachel Sturke, Anita Shankar, Kenny Sherr, Kirk Smith, Gautam Yadama

Environmental and Occupational Health Faculty Publications

Clean cooking has emerged as a major concern for global health and development because of the enormous burden of disease caused by traditional cookstoves and fires. The World Health Organization has developed new indoor air quality guidelines that few homes will be able to achieve without replacing traditional methods with modern clean cooking technologies, including fuels and stoves. However, decades of experience with improved stove programs indicate that the challenge of modernizing cooking in impoverished communities includes a complex, multi-sectoral set of problems that require implementation research. The National Institutes of Health, in partnership with several government agencies and the …

Clinical And Mucosal Immune Correlates Of Hiv-1 Semen Levels In Antiretroviral-Naive Men., Brendan J W Osborne, Angie K Marsh, Sanja Huibner, Kamnoosh Shahabi, Cindy Liu, Tania Contente, Nico J D Nagelkerke, Colin Kovacs, Erika Benko, Lance Price, Kelly S Macdonald, Rupert Kaul

Environmental and Occupational Health Faculty Publications

Background.

This study was done to characterize parameters associated with semen human immunodeficiency virus (HIV)-1 ribonucleic acid (RNA) viral load (VL) variability in HIV-infected, therapy-naive men. Methods.

Paired blood and semen samples were collected from 30 HIV-infected, therapy-naive men who have sex with men, and 13 participants were observed longitudinally for up to 1 year. Human immunodeficiency virus RNA, bacterial load by 16S RNA, herpesvirus (Epstein-Barr virus and cytomegalovirus [CMV]) shedding, and semen cytokines/chemokines were quantified, and semen T-cell subsets were assessed by multiparameter flow cytometry. Results.

Semen HIV RNA was detected at 93% of visits, with >50% of men …

Use Of A Modified Greenscreen Tool To Conduct A Screening-Level Comparative Hazard Assessment Of Conventional Silver And Two Forms Of Nanosilver., Jennifer Sass, Lauren Heine, Nina Hwang

Environmental and Occupational Health Faculty Publications

BACKGROUND: Increased concern for potential health and environmental impacts of chemicals, including nanomaterials, in consumer products is driving demand for greater transparency regarding potential risks. Chemical hazard assessment is a powerful tool to inform product design, development and procurement and has been integrated into alternative assessment frameworks. The extent to which assessment methods originally designed for conventionally-sized materials can be used for nanomaterials, which have size-dependent physical and chemical properties, have not been well established. We contracted with a certified GreenScreen profiler to conduct three GreenScreen hazard assessments, for conventional silver and two forms of nanosilver. The contractor summarized publicly …

Use Of A Modified Greenscreen Tool To Conduct A Screening-Level Comparative Hazard Assessment Of Conventional Silver And Two Forms Of Nanosilver., Jennifer Sass, Lauren Heine, Nina Hwang

Environmental and Occupational Health Faculty Publications

BACKGROUND: Increased concern for potential health and environmental impacts of chemicals, including nanomaterials, in consumer products is driving demand for greater transparency regarding potential risks. Chemical hazard assessment is a powerful tool to inform product design, development and procurement and has been integrated into alternative assessment frameworks. The extent to which assessment methods originally designed for conventionally-sized materials can be used for nanomaterials, which have size-dependent physical and chemical properties, have not been well established. We contracted with a certified GreenScreen profiler to conduct three GreenScreen hazard assessments, for conventional silver and two forms of nanosilver. The contractor summarized publicly …

Concluding Commentary: Children In All Cancer Prevention Policy Decisions., Cynthia F Bearer, Lynn Goldman

Environmental and Occupational Health Faculty Publications

This interesting series of articles on Opportunities for Cancer Prevention During Early Life brings many ideas for the primary prevention of cancer in childhood, or in adults due to early life events. The economic burden not only of cancer mortality but also of lifelong morbidity among cancer survivors, as shown by Guy et al,1 raises the importance of this critical public health issue. The topics of these articles were developed during online seminars with the pioneers in this area, some of whom authored the articles. They reflect the determinants of health diagrammed so eloquently in Healthy People 2020.2 …

Chemokine Levels In The Penile Coronal Sulcus Correlate With Hiv-1 Acquisition And Are Reduced By Male Circumcision In Rakai, Uganda., Jessica L Prodger, Ronald H Gray, Brett Shannon, Kamnoosh Shahabi, Xiangrong Kong, Kate Grabowski, Godfrey Kigozi, Fred Nalugoda, David Serwadda, Maria J Wawer, Steven J Reynolds, Cindy M. Liu, Aaron A R Tobian, Rupert Kaul

Environmental and Occupational Health Faculty Publications

Individual susceptibility to HIV is heterogeneous, but the biological mechanisms explaining differences are incompletely understood. We hypothesized that penile inflammation may increase HIV susceptibility in men by recruiting permissive CD4 T cells, and that male circumcision may decrease HIV susceptibility in part by reducing genital inflammation. We used multi-array technology to measure levels of seven cytokines in coronal sulcus (penile) swabs collected longitudinally from initially uncircumcised men enrolled in a randomized trial of circumcision in Rakai, Uganda. Coronal sulcus cytokine levels were compared between men who acquired HIV and controls who remained seronegative. Cytokines were also compared within men before …

Aneuploidy: A Common And Early Evidence-Based Biomarker For Carcinogens And Reproductive Toxicants., Daniele Mandrioli, Fiorella Belpoggi, Ellen K Silbergeld, Melissa J. Perry

Environmental and Occupational Health Faculty Publications

Aneuploidy, defined as structural and numerical aberrations of chromosomes, continues to draw attention as an informative effect biomarker for carcinogens and male reproductive toxicants. It has been well documented that aneuploidy is a hallmark of cancer. Aneuploidies in oocytes and spermatozoa contribute to infertility, pregnancy loss and a number of congenital abnormalities, and sperm aneuploidy is associated with testicular cancer. It is striking that several carcinogens induce aneuploidy in somatic cells, and also adversely affect the chromosome compliment of germ cells. In this paper we review 1) the contributions of aneuploidy to cancer, infertility, and developmental abnormalities; 2) techniques for …

Consumer Product Chemicals In Indoor Dust: A Quantitative Meta-Analysis Of U.S. Studies, Susanna D. Mitro, Robin Dodson, Veena Singla, Gary Adamkiewicz, Angelo F. Elmi, Monica Tilly, Ami R. Zota

Environmental and Occupational Health Faculty Publications

Indoor dust is a reservoir for commercial consumer product chemicals, including many compounds with known or suspected health effects. However, most dust exposure studies measure few chemicals in small samples. We systematically searched the U.S. indoor dust literature on phthalates, replacement flame retardants (RFRs), perfluoroalkyl substances (PFASs), synthetic fragrances, and environmental phenols and estimated pooled geometric means (GMs) and 95% confidence intervals for 45 chemicals measured in ≥3 data sets. In order to rank and contextualize these results, we used the pooled GMs to calculate residential intake from dust ingestion, inhalation, and dermal uptake from air, and then identified hazard …

Public Health Stops At The School House Door., Jerome A. Paulson, Claire L Barnett

Environmental and Occupational Health Faculty Publications

In the United States, all children of appropriate age are required to attend school, and many parents send their children to child care. Many school and day care buildings have been found to have environmental health problems that impact children’s health and diminish their ability to learn. No federal agency has the capacity or authority to identify, track, or remediate these problems. A recent meeting, coordinated by Healthy Schools Network, Inc., has developed a set of recommendations to begin to deal with the issue of environmental health problems in schools.

School Siting Near Industrial Chemical Facilities: Findings From The U.S. Chemical Safety Board's Investigation Of The West Fertilizer Explosion., Veronica A Tinney, Jerad M Denton, Lucy Sciallo-Tyler, Jerome A. Paulson

Environmental and Occupational Health Faculty Publications

BACKGROUND: The U.S. Chemical Safety and Hazard Investigation Board (CSB) investigated the April 17, 2013 explosion at the West Fertilizer Company (WFC) that resulted in 15 fatalities, more than 260 injuries and damage to more than 150 buildings. Among these structures were four nearby school buildings cumulatively housing children in grades K-12, a nursing care facility and an apartment complex. The incident occurred during the evening when school was not in session, which reduced the number of injuries.

OBJECTIVES: The goal of this paper is to illustrate the consequences of siting schools near facilities that store or use hazardous chemicals, …

Exploring Determinants Of Handwashing With Soap In Indonesia: A Quantitative Analysis, Mitsuaki Hirai, Jay P. Graham, Kay Mattson, Andrea Kelsey, Supriya Mukherji, Aidan Cronin

Environmental and Occupational Health Faculty Publications

Handwashing with soap is recognized as a cost-effective intervention to reduce morbidity and mortality associated with enteric and respiratory infections. This study analyzes rural Indonesian households’ hygiene behaviors and attitudes to examine how motivations for handwashing, locations of handwashing space in the household, and handwashing moments are associated with handwashing with soap as potential determinants of the behavior. The analysis was conducted using results from a UNICEF cross-sectional study of 1700 households in six districts across three provinces of Indonesia. A composite measure of handwashing with soap was developed that included self-reported handwashing, a handwashing demonstration, and observed handwashing materials …