Estimating Health Risks

Estimating Health Risks A Secondary Report of a Parallel Survey of Four Communities in Tola,

Rivas, Nicaragua.

Project Duration: 1 June, 2015 – 24 July, 2015 Submitted to: Foundation for International Medical Relief of Children Submitted by: Sanjay Gadi and Anna Dodson

FIMRC Interns FIMRC Nicaragua – Project Limón

Estimating Health Risks Page 1

Table of Contents Section Title Page(s) Executive Summary……………………………………………………………………………………….……………….2

Methodology………………………………………………………………………………………..……….……………….2

Ethics and Confidentiality………………………………………………………………….……………………………2

Major Findings……………………………………………………………………………………..………………………..3

Child Nutrition………………………………………………………………….……………………………………….3

Children’s Health Services……………………………….…………………………………….………………….6

Female Reproductive Health….…………………………………………………….………………………..7

Statistical Description of the Survey…………………………………………………………..…………………10

Population………………………………………………………………………………..…………………………….10

Income……………………………………………………………………………………..…………………………….10

Overcrowding…………………………………………………………………………..…………………………….11

Household Health Factors……………………………………………………………………………………….12

New Barriers of Health Analysis…………………………………………………………..……………………....15

Dental Health…………………………………………………………………………..……………………………..15

Mental Health……………………………………..…………………………………..……………………………..18

Conclusions and Recommendations.……………………………………………..…………………………….20

Acknowledgements…………..………………………………………………………………………………………….20

References……………………………………………………………………………………..…………………………….21

Appendix A – Survey…………………………………………………………………………………………………....22


Executive Summary The communities of La Virgen Morena, Las Salinas, Limón II, and Limón I, located in Tola, Rivas, Nicaragua, were surveyed in order to learn more regarding their health status so that Foundation for International Medical Relief of Children (FIMRC) could better attend to the population and their health care needs. The survey was performed on a total of 118 households, 97 children aged 0-5 years, and 120 women aged 15-50 years. Background In August, 2009, an initial report on the health status in the communities of Limón I, Limón II, Cuascoto Asentamiento, and Cuascoto Adentro was performed in order to identify areas of focus for FIMRC during its formal partnership with the Roberto Clemente Santa Ana Health Clinic in Limón I. However, in 2010, this partnership ended and FIMRC moved its Nicaraguan site to Las Salinas, thereby changing the communities it reached to those surveyed in this report. Now, in 2015, this report aims to renew FIMRC’s understanding of the health status of these four communities so that existing areas of focus can be reassessed and newly identified necessities can established. Methodology The survey was performed by walking house-to-house and interviewing available participants in each of the four communities in both the morning and afternoon. Though 118 households were visited (La Virgen = 24, Las Salinas = 27, Limón II = 39, Limón I = 27), only 81 were asked all questions included in the survey. All surveys were performed in Spanish. In houses 56-70, only children were surveyed. After visiting house 87, questions regarding mental health were no longer asked. After visiting house 97, questions regarding dental health, socioeconomic indicators, and children’s health services were no longer asked. This shortening of the survey was performed in order to increase our sample size for female reproductive health and child nutrition, sections that would be compared with data from the 2009 report. Children’s nutritional assessment z-scores, which included weight-for-age (WAZ), height-for-age (HAZ), weight-for-height (WHZ), and body-mass index (BMIZ), were calculated using graphs specific to both sexes and each measurement provided by the Nicaraguan Ministry of Health. Data was entered into and statistics were completed on a Microsoft Excel spreadsheet. Ethics and Confidentiality The purpose of this survey and the manner it will be used was explained to and understood by all participants. All respondents verbally agreed to participate in the survey and maintained consent throughout. They were allowed to withdraw their consent at anytime during or after the survey. Respondents’ names have been removed from this publication, as randomized numerical identifiers will be used instead. The documents that contain names and other personal information are filed confidentially at the Roberto Clemente Santa Ana Health Clinic.

The data used for this report and subsequent information contained is intended to be sent to national and international agencies and organizations concerned with the main areas of interest including child welfare, women’s health, mental health, and dental health


Major Findings Child Nutrition Compared to the data from 2009, current data (Table 1) demonstrates consistent improvement in male children and worsening among female children across all four anthropometric measurements. Failure is defined as a z-score of -2 or lower. Table 1: Change in male and female rates of failure between 2009 and 2015. Measurement Failure 2009 (%) Failure 2015 (%) Classification of

Failure Male Female Male Female WAZ 9.0 12.0 5.0 24.1 Underweight HAZ 9.0 9.0 2.5 9.6 Stunting WHZ 13.0 17.0 5.6 19.2 Wasting BMIZ 8.0 8.0 5.0 23.1 Underweight

Moreover, using the Composite Index of Anthropometric Failure (CIAF), in 2009, it was determined that 23.6% of children experienced some form of failure. In the 2015 sample population, 22.8% experienced some form of failure (Table 2). Table 2: Change in CIAF failure between 2009 and 2015.

Failure Experienced

Number of Children Percent Children (%) 2009 2015 2009 2015

No Failure 42 71 76.4 77.2 Some Failure 13 21 23.6 22.8

Wasting 2 5 3.6 5.4 Wasting and Underweight 2 8 3.6 8.7 Wasting, Stunting, and Underweight

0 0 0.0 0.0

Stunting and Underweight 3 4 5.5 4.3 Stunting 6 2 10.9 2.2 Underweight 0 2 0.0 2.2

Total 55 92 100 100 As a visual representation of the changes in rates of underweight observed since 2009 (Table), Figure 1 demonstrates the shift of the WAZ distribution for female children towards the negative z-scores and the shift of the WAZ distribution for male towards the positive z-scores. This trend persists for the other three measurements as well. Though the negative shift in female HAZ distribution is less severe (Figure 2), female WHZ shift is significant (Figure 3). The negative shift in female BMIZ distribution is especially severe (Figure 4).


Figure 1: Weight-for-age z-scores (WAZ) in male and female children.

Figure 2: Height-for-age z-scores (HAZ) in male and female children.

-‐5.0

0.0

5.0

10.0

15.0

20.0

25.0

30.0

35.0

40.0

45.0

-‐4 -‐2 0 2 4

Frequency (%)

Z-‐Score

Male (n=40)

Female (n=54)

0.0

10.0

20.0

30.0

40.0

50.0

60.0

-‐4 -‐2 0 2 4

Frequency (%)

Z-‐Score

Male (n=40)

Female (n=52)


Figure 3: Weight-for-height z-scores (WHZ) in male and female children.

Figure 4: Body mass index z-scores (BMIZ) in male and female children. It was reported in 2009 data that 13% of both male and female children were overweight, defined as having a BMIZ of 2 or greater. Now, 2015 data shows that 20.0% of male children and 9.6% of female children are overweight.

0.0

5.0

10.0

15.0

20.0

25.0

30.0

35.0

40.0

45.0

-‐4 -‐2 0 2 4

Frequency (%)

Z-‐Score

Male (n=36)

Female (n=52)

0.0

5.0

10.0

15.0

20.0

25.0

30.0

35.0

40.0

45.0

-‐4 -‐2 0 2 4

Frequency (%)

Z-‐Score

Male (n=40)

Female (n=52)


Children’s Health Services Households were asked when a child’s last visit to a general doctor and pediatrician, in that order, was. Figures 5 and 6 display this data, showing that a majority of children in the four communities visit the general doctor, while only half of surveyed children in Limón I reported visiting the general doctor. A majority of children in all four communities visit the pediatrician.

Figure 5: Time since last visit to a general doctor.

Figure 6: Time since last visit to a pediatrician. Households were next asked whether they were aware of the pediatric services provided by FIMRC. Limón I was least aware of the FIMRC pediatrician.

0 0.1 0.2 0.3 0.4 0.5 0.6 0.7 0.8 0.9 1

La Virgen (n=21)

Las Salinas (n=7)

Limon II (n=19)

Limon I (n=14)

Frequency (%)

Community

Never

≥37 Months Ago

25-‐36 Months Ago

13-‐24 Months Ago

0-‐12 Months Ago

0 0.1 0.2 0.3 0.4 0.5 0.6 0.7 0.8 0.9 1

La Virgen (n=23)

Las Salinas (n=9)

Limon II (n=20)

Limon I (n=15)

Frequency (%)

Community

Never

≥37 Months Ago

25-‐36 Months Ago

13-‐24 Months Ago

0-‐12 Months Ago


Figure 7: Awareness of FIMRC pediatric services. Female Reproductive Health Women were asked how long ago their last past smear and gynecological appointments were, in that order. Women in all four communities reported attending pap smear visits and gynecological appointments at much higher rates than those in 2009, though women of Limón I reported the lowest rates of attendance in both measures (Figures 8, 9).

Figure 8: Time since last pap smear.

0 0.1 0.2 0.3 0.4 0.5 0.6 0.7 0.8 0.9 1

La Virgen (n=26)

Las Salinas (n=9)

Limon II (n=24)

Limon I (n=17)

Frequency (%)

Community

Do Not Know

Do Know

0 0.1 0.2 0.3 0.4 0.5 0.6 0.7 0.8 0.9 1

La Virgen (n=31)

Las Salinas (n=29)

Limon II (n=25)

Limon I (n=30)

Frequency (%)

Community

Never

≥37 Months Ago

25-‐36 Months Ago

13-‐24 Months Ago

0-‐12 Months Ago


Figure 9: Time since last visit to a gynecologist. Women were next asked whether they were aware of the gynecological services provided by FIMRC. Knowledge of these services was highest in the communities of La Virgen Morena and Las Salinas, and lowest in Limón I, the community in which gynecological and pap smear attendance was also lowest.

Figure 10: Awareness of FIMRC gynecological services. Lastly, women were asked if they performed breast examinations on themselves. A majority of women in all communities reported not performing self-breast exams. However, rates of self-breast examination have increased since 2009, when approximately 90% of women in every

0 0.1 0.2 0.3 0.4 0.5 0.6 0.7 0.8 0.9 1

La Virgen (n=31)

Las Salinas (n=29)

Limon II (n=25)

Limon I (n=30)

Frequency (%)

Community

Never

≥37 Months Ago

25-‐36 Months Ago

13-‐24 Months Ago

0-‐12 Months Ago

0 0.1 0.2 0.3 0.4 0.5 0.6 0.7 0.8 0.9 1

La Virgen (n=31)

Las Salinas (n=30)

Limon II (n=26)

Limon I (n=32)

Frequency (%)

Community

Do Not Know

Know


community reported never having performed a self-breast exam. It is interesting to note the direct relationship between the geographic location of a community with its rates of self-breast examination.

Figure 11: Self-breast exams performance.

0.0 0.1 0.2 0.3 0.4 0.5 0.6 0.7 0.8 0.9 1.0

La Virgen (n=33)

Las Salinas (n=32)

Limon II (n=27)

Limon I (n=34)

Frequency (%)

Community

Do Not Examine

Do Examine


Statistical Description of the Survey This section describes the survey sample through dimensions vital to data received. It examines population, income, overcrowding, snd household health factors. Furthermore, this statistical description compares disparities between the four main communities included in this survey: La Virgen Morena, Las Salinas, Limón I, and Limón II. Population Figure 12 shows a general population pyramid by sex for all 4 communities combined. The largest age group is between 0 and 9 years old accounting for 13.30% of the population. The general shape of the pyramid suggests a growing population.

Figure 12: Population pyramid of the four communities.

Income Figures 13 displays reported monthly incomes in USD. Average income has risen slightly since 2009 from a daily wage of $5-10 to $8-11 dollars. The cause of this increase can be attributed to the growing tourism along the costal region and increasing job opportunities in connected labor divisions, such as construction and restaurant jobs. Income is also closely tied with community. Households in La Virgen and Limon II reported earning the highest incomes, averaging around ten to eleven dollars daily, whereas Las Salinas and Limon I have average daily incomes of approximately 8-9 daily dollars.

-‐8 -‐6 -‐4 -‐2 0 2 4 6 8 10

0 to 4 5 to 9

10 to 14 15 to 19 20 to 24 25 to 29 30 to 34 35 to 39 40 to 44 45 to 49 50 to 54 55 to 59 60 to 64 65 to 69 70 to 74 75 to 79

80+

Percent Population

Age

Females Males


Figure 13: Average daily wage in USD. Overcrowding Figure 14 shows a bar graph for households that are experiencing overcrowding, defined as 3 or more people sleeping in a single room. In total, 10.3% of the households sampled are overcrowded, which is an improvement from 46% overcrowding calculated in 2009. Limon II showed the most overcrowding although it is the second wealthiest community in the survey. Additionally, Limon I showed no evident overcrowding although it is the second poorest community in the survey.

Figure 14: Percent overcrowding experienced.

0

2

4

6

8

10

12

Community Average

La Virgen Las Salinas Limon II Limon I

Daily Wage (USD)

Community

0

5

10

15

20

25


Overcrowding (%)

Community


Household Health Factors Figures 15-18 depict household health factors, which are defined as properties of a house that significantly impact health outcomes. Figure 15 shows a surprising discovery that La Virgen has the highest percentage of dirt floors even though it reports highest average income. The other communities show relatively normal data with the lower income communities having a higher percentage of dirt floors than higher income communities. Dirt floors are one of the principal routes of exposure to intestinal parasites, particularly among children, since they play in the dirt and put their hands directly into their mouths.1 Therefore, children who live in houses with dirt floors are at a higher risk for becoming infected with intestinal parasites.

Figure 15: Floor type.

Figure 16 reports the average number of animals owned by households in each community. The poorer communities have, on average, more animals per household than wealthier communities. This relationship can be evidence of poorer supplementing their low income by using personal livestock as a source of resources. However, a family’s risk of contracting zoonotic diseases increases with the number of animals it owns.2 Therefore, households in Las Salinas, Limón II, and Limón I seem to be at a higher risk for contracting zoonotic disease than those in La Virgen Morena, though all four communities are at risk.

0 10 20 30 40 50 60 70 80 90 100


Frequency (%)

Community

Dirt

Other


Figure 16: Average number of animals. Figure 17 shows the percentage of each type of cooking fuel used per community. Cooking fuel is an important household health factor to considering because cooking with wood increases exposure to harmful carcinogens and smoke, which can cause respiratory ailments.3 Households in La Virgen Morena, the wealthiest community, reported the highest usage of gas and electricity and the lowest usage of wood, suggesting that they are the least likely to experience respiratory diseases. On the other hand, a significantly larger percent of households in Limón I use wood than any other community. Limón I households are therefore at the highest risk for respiratory diseases.

Figure 17: Cooking fuel type used.

0

2

4

6

8

10

12


Number of Animals

Community

0

10

20

30

40

50

60


Frequency (%)

Community

Wood

Gas

Both

Electric


Figure 18 shows the methods by which water is treated in each community. La Virgen community members collect water from a community well, which is regularly treated with chloride. However, chloride treatment is not as effective in killing microbes and cleaning the water as filtering or buying bottled water. La Virgen community members are therefore more likely to become sick from inadequate water quality. Limon II is the only community that has a significant percentage of families who buy bottled water. Las Salinas has the highest percentage of filter families.

Figure 18: Water treatment type used.

0 10 20 30 40 50 60 70 80 90

La Virgen

Las Salinas

Limon II Limon I

Frequency (%)

Community

None

Buy Bottled

Chloride

Filter

Chloride and Filter


New Barriers of Health Analysis The data presented in this section of the survey deals with dental and mental health. Although no correlating data was collected in the 2009 survey, the following findings offer a baseline status for mental and dental health off of which future studies can be conducted. The following data also suggests the need for dental and psychological services in the four communities, potential areas for FIMRC Nicaragua’s development. Dental Health A majority of people in all four communities reported brushing at least twice daily, and a majority of people in La Virgen Morena, Las Salinas, and Limón II reported brushing three times a day (Figure 19).

Figure 19: Number of times teeth are brushed per day. Almost all of the households in each community stored toothbrushes away from the toilet or latrine, where contaminated water could otherwise be aerosolized and spread to the toothbrush (Figure 20).4

0

0.1

0.2

0.3

0.4

0.5

0.6

0.7

0.8

La Virgen (n=101)

Las Salinas (n=82)

Limon II (n=80)

Limon I (n=93)

Frequency (%)

Community

1

2

3


Figure 20: Location where toothbrush is stored. Floss is used by approximately half of the households across all four communities. Floss is also interestingly inversely related to community wealth, as Limón I reported the highest usage of floss while La Virgen Morena reported the lowest (Figure 21).

Figure 21: Rates of floss usage.

0 0.1 0.2 0.3 0.4 0.5 0.6 0.7 0.8 0.9 1

La Virgen (n=107)

Las Salinas (n=82)

Limon II (n=80)

Limon I (n=93)

Frequency (%)

Community

Away from Excrement

Near Excrement

0

0.1

0.2

0.3

0.4

0.5

0.6

0.7

0.8

La Virgen (n=107)

Las Salinas (n=82)

Limon II (n=80)

Limon I (n=93)

Frequency (%)

Community

Uses Floss

Does Not Use Floss


Most people have never visited a dentist, but a considerable percentage of people have within the past year (Figure 22).

Figure 22: Time since last dental visit. Figures 23 and 24 show that a majority of the population surveyed has no cavities and no replaced teeth, and that extremely few people have more than a few cavities or false teeth.

Figure 23: Number of cavities per community.

0 0.1 0.2 0.3 0.4 0.5 0.6 0.7 0.8

La Virgen (n=102)

Las Salinas (n=82)

Limon II (n=80)

Limon I (n=88)

Frequency (%)

Community

Never

≥37 Months Ago

25-‐36 Months Ago

13-‐24 Months Ago

0-‐12 Months Ago

0 0.1 0.2 0.3 0.4 0.5 0.6 0.7 0.8 0.9

La Virgen (n=98)

Las Salinas (n=80)

Limon II (n=81)

Limon I (n=81)

Frequency (%)

Community

0

1 to 3

4 to 6

7+


Figure 24: Number of false teeth per community. While this data may seem to suggest that dental health is currently admirable, with all communities reporting regular brushing, correct storage of toothbrushes, minimal cavities, and few false teeth, the reality is that people are simply not visiting the dentist. In every community, of those who have gone to the dentist within the past twelve months, most have gone as the cause of a dental problem, not a regular checkup. The minimal cavity reporting may be explained through the reality that the closest dentist is a bus ride of several hours away. Individuals are not catching their minor cavities until they develop into more serious issues. Dental care is not covered in the national, free health care, causing many families, especially in poorer communities like those that FIMRC serves, to not go to the dentist. Having a dentist on site at FIMRC would provide a valuable, previously unattainable service to the communities of La Virgen, Las Salinas, Limon I, and Limon II.

Mental Health Figure 25 shows that a significant percentage of the population reports regular stress and times of persistent sadness, conveyed to those interviewed as a time in which they felt sad and as though they could not feel happy again. Figure 26 shows reports on possible symptoms of persistent sadness that were used to infer a more profound sadness than is normal, potentially hinting at depression.

0 0.1 0.2 0.3 0.4 0.5 0.6 0.7 0.8 0.9

La Virgen (n=98)

Las Salinas (n=80)

Limon II (n=81)

Limon I (n=81)

Frequency (%)

Community

0

1 to 3

4 to 6

7+


Figure 25: Mental Health

Figure 26: Determining depression. A stigma exists in Nicaragua that severe depression and anxiety are illnesses that merit institutionalization, not treatment. This method of questioning was the most practical way to reach the more meaningful understanding of these more threatening health concerns. The data suggests a psychologist would be a beneficial addition to this area’s health care system.

0 10 20 30 40 50 60 70 80 90 100

Stress Persistent Sadness

Frequency (%)

Mental Health Measure

0 10 20 30 40 50 60 70 80 90 100

Loss of Interest Loss of Appetite Loss of Energy

Frequency (%)

Mental Health Measure


Conclusions and Recommendations FIMRC’s work has been positively affecting the communities of La Virgen Morena, Las Salinas, Limón II, and Limón I, as evidenced by decreased rates of malnutrition and anthropometric failure in male children, increased performance of pap smears and self-breast exams, and increased attendance to the gynecologist. Furthermore, in spite of increasing rates of underweight and wasting, which are acute measures of malnourishment, have increased since 2009, stunting, a chronic measure of malnourishment, has seen a decrease (Table 2). This trend suggests that children’s long-term health has improved. However, there are still improvements to be had. It is important to note that female children—as opposed to their male counterparts—are severely worsening in health, with all four measures of failure indicating increased rates of malnutrition (Table 1). A new focus on the health of female children is gravely needed in these communities, where male-favoritism is negatively affecting girls’ physical health. The pediatric services provided by FIMRC appear to have been used quite extensively. However, education efforts in Limón I to increase awareness about these services are recommended to continue improving attendance to pediatric visits. Still only about half of the women in these communities get a pap smear performed, visit the gynecologist, and know about the gynecological services provided by FIMRC. Self-breast exams are still alarmingly infrequent, as a majority of women in all four communities do not perform them. Education efforts to increase awareness about the availability of FIMRC’s gynecological services and to teach women how to examine their own breasts can improve these measures as well as overall female reproductive health in these four communities. It is imperative that this report be translated into Spanish and distributed to the Nicaraguan Ministry of Health and any other relevant organization in the area. It is also the community members’ right that these findings be conveyed to them for their personal benefit. Acknowledgements The following people were crucial in gathering and compiling the information for this report: Jessica Southern R.N., Anthony Nardone, and FIMRC interns and volunteers. With the support of these individuals and the welcoming spirit of the community members of La Virgen Morena, Las Salinas, Limon I, and Limon II, this study was made possible.


Appendix A – Survey Conducted By: _______________________ Family Number: ______________________

Date: _______________________________ Community: _________________________

1. ID 2. Name 3. Date of Birth 4. Age 5. Sex 6. Role

Hygienic and Sanitary Characteristics Socioeconomic Status Lifestyle Habits 10. Number of Bedrooms 17. Domestic Animals 20. Floor 27. Smokes, How Often? a. Chickens 11. Cooking Fuel Type b. Pigs 21. Walls c. Cows 28. Drinks, How Often? 12. Indoor/Outdoor Oven? d. Dogs 22. Roof e. Cats 13. Water Source f. Horses 23. Mosquito Nets 29. Exercise, How

Often? g. Other 14. Water Storage Type 18. Garbage Deposit Type 24. Garden 15. Water Treated? How? 19. Excrement Deposit

Type 25. Ventilation (if indoor stove)

30. Hours of Sleep

16. Electricity? 26. Household Income

Dental Health ID 31. # Times

Brush/Day 32. Location Brush Kept

33. Flosses? 34. Dr., How Often/Yr

35. Last Dt. Visit?

36. #Cavities

37. # Teeth Replaced

ID 7. Education 8. Profession 9. Existing Illnesses


Nutritional Status, Children Ages 0-5 Family Nutrition ID 38.

Ht. 39. Wt.

40. Time Breastfed

41. Time Formula

42. How Many Times/Day? 43. Amt./Month a. Rc b. Bn c. Mt d. Vg e. Fr f. Da a. Rice

b. Beans c. Salt d. Sugar e. Oil 44. Income Spent

on Food

Female Reproductive Health, Ages 15 and Older ID 45. Pap

Smear, How Often/Yr.?

46. Last Pap Smear

47. Gyno Visit, How Often/Yr.?

48. Last Gyno Visit

49. Future Visits?

50. FIMRC Gyno?

51. Self-Breast Exam Freq.?

Breastfeeding Behaviors Birth Control Knowledge ID 52. How Learned? 53. How Long? 54. Birth Control: Aware 55. Birth Control: Used

Prenatal Health (Pregnant or Recently Pregnant Women) ID 56. Prenatal Visits,

How Often/Month? 57. Last Prenatal Visit

58. Prenatal Vitamins

59. Pregnancy Illnesses and Complications

Mental Health ID 60. How Often

Stressed/Day? 61. Top Reasons for Stress 62. Persistent

Sadness 63. Loss of Interest

64. Loss of Appetite

65. Loss of Energy

Health Services - Children Health Services ID 66. Dr.,

How Often/Yr.

67. Last Dr. Visit

68. Perceived Efficacy

69. Ped., How Often/Yr.

70. Last Ped. Visit

71. Perceived Efficacy

72. FIMRC Ped.?

73. Closest Clinic

74. Clinic Dist. 75. Cost of Visit


References 1Cattaneo, M. D., Galiani, S., Gertler, P. J., Martinez, S., & Titiunik, R. (2009). Housing, health, and happiness. American Economic Journal: Economic Policy, 75-105.Chicago

2Minnesota Department of Health. (2012). Common Zoonotic Diseases from Farm Animals. Retrieved from http://umash.umn.edu/resources/pdf/UMASH-MDH-Zoonoses.pdf

3Smith, K. R. (2006). Health impacts of household fuelwood use in developing countries. UNASYLVA-FAO-, 57(2), 41.Chicago

4Montero, E. A., Isom, I. B., Fults, J., Cvijanovich, S., Chismark, A., & Tran, B. B. (2012). The Effects of Proximity on Aerosol Distribution of Bacteria on Toothbrushes. Journal of the California Dental Hygienists' Association, 27(2).Chicago

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Estimating Health Risks