Impact of COVID-19 Health Precautions on Asymptomatic Streptococcus pyogenes Carriage in Palestinian Children: A Before and After Study

Impact of COVID-19 Health Precautions on Asymptomatic Streptococcus pyogenes Carriage in Palestinian Children: A Before and After Study | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Impact of COVID-19 Health Precautions on Asymptomatic Streptococcus pyogenes Carriage in Palestinian Children: A Before and After Study Ibrahim Amer Ghannam, Rana Mahmoud Maraqa, Duha Shokri Qawasmeh, and 4 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-4599563/v1 This work is licensed under a CC BY 4.0 License Status: Published Journal Publication published 04 Oct, 2024 Read the published version in BMC Infectious Diseases → Version 1 posted 13 You are reading this latest preprint version Abstract Background Streptococcus pyogenes (Group A Streptococcus, GAS) is a significant pathogen that causes diverse infections, ranging from pharyngitis to severe invasive diseases. Asymptomatic carriage in children is pivotal for transmission. The COVID-19 pandemic's health measures, including mask wearing and enhanced hand hygiene, likely influenced GAS transmission dynamics. This study evaluated the impact of these precautions on the prevalence of asymptomatic pharyngeal GAS carriage among schoolchildren in the southern West Bank, Palestine. Methods This cross-sectional study was conducted in two phases: pre-COVID-19 (November 2019 - January 2020) and post-COVID-19 (November 2023 - April 2024). Throat swabs from 701 children (345 pre-COVID-19, 356 post-COVID-19) were collected using cluster sampling. The samples were tested using the ABON Strep A rapid test and confirmed by culture. Sociodemographic, health, and household data were gathered. The statistical analyses included descriptive statistics, chi-square tests, and binary logistic regression. Results The prevalence of asymptomatic GAS carriage significantly decreased from 15.7% in 2019 to 10.4% in 2024 (p = 0.038). The gender distribution remained stable (p = 0.662), while urban residence increased significantly from 34.5–41.6% (p = 0.050). The use of private wells for drinking water increased from 17.7–32.0% (p < 0.001), with private well users having greater odds of GAS carriage than municipal water users (adjusted OR = 4.128, 95% CI: 2.175–7.830, p < 0.001). Consistent hand hygiene was associated with lower odds of carriage (adjusted OR = 0.367, 95% CI: 0.184–0.730, p < 0.001), and regular teeth brushing also significantly reduced odds (adjusted OR for brushing twice daily = 0.055, 95% CI: 0.019–0.157, p < 0.001). Conclusions COVID-19-related health precautions were correlated with a significant reduction in asymptomatic GAS carriage among Palestinian children. These findings suggest that public health measures, such as mask wearing and hand hygiene, can influence the transmission of respiratory pathogens. Ongoing surveillance and targeted interventions are essential for managing GAS infections, particularly in resource-limited settings. Asymptomatic GAS carriage COVID-19 precautions Schoolchildren Southern West Bank Palestine. Figures Figure 1 Background Streptococcus pyogenes , also known as Group A Streptococci (GAS), is a common human pathogen responsible for a wide range of infections, from uncomplicated pharyngitis to life-threatening invasive diseases such as necrotizing fasciitis and streptococcal toxic shock syndrome [ 1 , 2 ]. Severe GAS infections cause approximately 500,000 fatalities per year, creating a major global health burden, especially in resource-limited settings [ 3 , 4 ]. The morbidity and mortality linked to these infections highlight how crucial it is to understand the dynamics of GAS transmission, risk factors, and epidemiology. GAS pharyngitis, often known as strep throat, is a frequent illness that mostly affects children [ 4 , 5 ]. Differentiating it from viral pharyngitis, which is more prevalent and typically self-limiting, is crucial for accurate diagnosis [ 6 ]. Prompt antibiotic treatment of GAS pharyngitis is essential to prevent complications such as rheumatic fever and acute glomerulonephritis and to reduce transmission [ 7 ]. Asymptomatic GAS carriage, defined as the presence of GAS in the nasopharynx or oropharynx without signs of acute infection, is a significant reservoir for transmission and a known precursor to invasive disease [ 8 ]. The southern West Bank region of Palestine faces unique healthcare challenges. High population density, limited healthcare infrastructure, and geographic barriers contribute to a higher incidence of infectious diseases, including GAS infections [ 9 ]. The region's socioeconomic conditions and environmental factors further complicate efforts to manage and control these infections. Previous studies have estimated that 5–15% of school children worldwide develop GAS pharyngitis annually [ 10 , 11 ]. However, data on the prevalence and determinants of asymptomatic GAS carriage in this region remain sparse. When the COVID-19 pandemic broke out, the West Bank was among the many places in the world where public health initiatives were implemented with the goal of preventing the spread of the virus. These precautions, which included mask usage, hand washing, social separation, and temporary school closures, were implemented. [ 12 ]. The dynamics of the transmission of other infectious agents, such as GAS, have been altered by these measures in addition to the spread of SARS-CoV-2. Closing schools and imposing social distancing measures, for instance, may have changed the exposure patterns of children, whereas mask use and better hand hygiene may have decreased the spread of respiratory diseases. [ 13 ]. This cross-sectional study investigated the potential influence of COVID-19 public health measures on the asymptomatic carriage of Group A Streptococcus (GAS) in the pharynx of healthy schoolchildren residing in the southern West Bank, Palestine. The project originated prior to the COVID-19 pandemic, aiming to assess the baseline prevalence and risk factors associated with asymptomatic GAS carriage. However, the study was necessarily halted due to the emergence of COVID-19 in 2020. We have now resumed the study with the added objective of exploring whether the implemented public health measures have impacted GAS carriage rates. We will also continue to examine potential contributing factors such as socioeconomic status, household characteristics, and past medical history. This research has substantial public health implications. Understanding these mechanisms is critical for designing targeted strategies to prevent GAS infections. This project will provide vital information about GAS epidemiology in an area with specific healthcare problems, eventually guiding efforts to improve children's health. Materials and methods Study design and setting: This study employed a two-stage cross-sectional design, encompassing the Hebron and Bethlehem governorates in the southern West Bank, Palestine. The first stage occurred between November 2019 and January 2020, while the second stage occurred from November 2023 to April 2024. In 2019, there were 770 schools in this region, with a total student population of 211,025 children. By 2023, the number of schools had increased to 807, and the total number of children had risen to 230,463. [ 14 , 15 ]. Participants : The study included a total of 701 children divided into two time intervals. During the first interval, 345 children without symptoms of sore throat were sampled and tested. The study was put on hold in January 2020 due to the spread of the COVID-19 pandemic and resumed in late 2023, with a second stage in which 356 children without symptoms of sore throat were sampled. Schools and participants were selected using a cluster sampling method. Throat swab samples were collected from school-aged children between 5 and 12 years of age from various kindergartens and primary schools within the region, encompassing cities, villages, and refugee camps. Sample Size Calculation: The sample size for this study was initially calculated based on an estimated 15% prevalence of asymptomatic GAS carriage in school-aged children from previous studies [ 10 , 11 ]. Assuming a desired precision of ± 5% with a 95% confidence interval, the required sample size was determined to be 196 participants. To further increase the statistical power, additional participants were recruited beyond the calculated sample size. After the onset of the COVID-19 pandemic and the subsequent adjustment of the study aims, the sample size was recalculated for each time interval (pre-COVID-19 and post-COVID-19). Ultimately, 345 and 356 participants were recruited during the pre-COVID-19 and post-COVID-19 intervals, respectively, to enhance the statistical power and ensure robust results. Inclusion criteria All students aged 5 to 12 years who were enrolled in the selected classes of the chosen schools and who were present during the sampling period were eligible for inclusion in the study. However, their participation was contingent upon providing signed written consent from their parents or legal guardians. Exclusion criteria To ensure a representative sample of asymptomatic carriers, we excluded children who presented with symptoms suggestive of upper respiratory tract infection (URTI) at enrollment and those with a history of tonsillectomy or recent antibiotic use within one week of sample collection. Additionally, children who were diagnosed with chronic medical conditions and who were older than 12 years of age were excluded from the study. Information collection: All participating children provided a detailed medical history, either directly or through their parents or guardians. This information included age, gender, school name and location, place of residence, province, and parental socioeconomic status. The medical history also included the frequency and severity of sore throat episodes over the past year and any current symptoms, such as fever, sore throat, difficulty swallowing, ear pain, or skin rash. Additionally, data were collected on recent contacts with individuals experiencing sore throats. The inquiry further extended to family and environmental factors, such as the number of siblings, the number of rooms in the household, the water supply system, the number of people sharing the child's room, and personal hygiene practices, including the frequency of tooth brushing and hand washing. Sample collection and group A Streptococcus (GAS) identification Sterile cotton swabs and tongue depressors were used for primary throat swab collection from participants. The research team adhered to rigorous hygiene protocols, utilizing personal protective equipment, including gloves, to mitigate the risk of cross-contamination. During the initial rapid testing phase, the ABON Strep A throat swab rapid test kit was utilized (ABON, lot number IST-502, Germany). Sample processing followed the manufacturer's instructions. This rapid antigen detection test (RADT) served as an indicator of asymptomatic Streptococcus carriage, consistent with previous studies reporting a 91% concordance between RADTs and culture results at the 21-day follow-up [ 16 ]. For samples yielding positive results in the rapid test, a second set of sterile swabs was obtained to collect specimens for culture testing. These swabs were transported to the microbiology laboratory using appropriate transport media to maintain the viability of the microorganisms. Subsequently, the throat swabs were inoculated onto commercially available 5% sheep blood agar plates and incubated for 24 hours under optimal conditions (37°C, 5–10% CO 2 ). After the incubation period, suspected colonies exhibiting beta-hemolysis were identified, subcultured onto fresh 5% blood agar plates, and incubated for an additional 24 hours. The hemolysis pattern was then evaluated in these subcultures. Plates displaying beta-hemolysis were subjected to Gram staining and catalase testing. If the bacteria were identified as gram-positive cocci arranged in chains and catalase negative, they were subcultured onto another 5% blood agar plate for bacitracin and trimethoprim-sulfamethoxazole (SXT) susceptibility testing. The presence of Streptococcus pyogenes (Group A Streptococcus; GAS) was confirmed in bacitracin-sensitive and SXT-resistant isolates. Statistical analysis: Data analysis was performed using IBM SPSS version 27 and MedCalc® Statistical Software version 22.0. Descriptive statistics, including means and standard deviations, were employed to summarize quantitative variables, while frequencies and percentages were utilized to present categorical variables. The chi-square test was used to assess the existence of associations and to evaluate the statistical significance of the results. Additionally, binary logistic regression analysis was conducted to determine the effect of independent variables. We quantified risk using odds ratios (ORs) with 95% confidence intervals. A p value less than or equal to 0.05 was considered to indicate statistical significance. Ethical considerations: After receiving ethical approval from the Deanship of Scientific Research at Al-Quds University and participating school principals, the study adhered to ethical guidelines by obtaining written informed consent from parents or guardians and verbal assent from the children themselves. Results Prevalence of asymptomatic group A Streptococcus (GAS) carriage The study examined a total of 701 children from the southwest Bank region of Palestine, with data collected in 2019 and 2024. A notable decrease in the prevalence of asymptomatic GAS carriage among these children was observed between the two time points. In 2019, 15.7% (54 out of 345) of the children were asymptomatic carriers of GAS, with a 95% confidence interval (CI) ranging from 12.1–19.8%. However, by 2024, this prevalence had dropped to 10.4% (37 out of 356), with a 95% CI of 7.5–13.9% (Fig. 1 ). Statistical analysis confirmed that this reduction in the prevalence of asymptomatic GAS carriage was statistically significant (p = 0.038). Sociodemographic Characteristics of Study Participants: The gender distribution remained stable (p = 0.662). While there was a slight but not significant increase in the number of participants under 7 years of age in 2024 (41.6% vs . 37.7% in 2019, p = 0.101), there was a shift in the number of residents, with a significant increase in city dwellers (p = 0.050) from 34.5% in 2019 to 41.6% in 2024. The governorate distribution remained consistent (p = 0.311), with Hebron as the majority. The patients’ socioeconomic status was stable, with more than 92% in the medium category in both years (p = 0.240) (Table 1 ). Table 1 Demographic and Socioeconomic Information (2019 vs. 2024) Variable Category 2019 (n = 345) (n, %) 2024 (n = 356) (n, %) Total (n = 701) (n, %) P Value Sex Male 161 (46.7) 172 (48.3) 333 (47.5) 0.662 Female 184 (53.3) 184 (51.7) 368 (52.5) Age Groups < 7 130 (37.7) 148 (41.6) 278 (39.7) 0.101 7–8 136 (39.4) 113 (31.7) 249 (35.5) 9+ 79 (22.9) 95 (26.7) 174 (24.8) Place of Residence City 119 (34.5) 148 (41.6) 267 (38.1) 0.050 Village 184 (53.3) 157 (44.1) 341 (48.6) Camp 42 (12.2) 51 (14.3) 93 (13.3) Governorate Hebron 234 (67.8) 254 (71.3) 488 (69.6) 0.311 Bethlehem 111 (32.3) 102 (28.7) 213 (30.4) Family Socioeconomic Status Low 12 (3.5) 18 (5.1) 30 (4.3) 0.240 Medium 319 (92.5) 330 (92.7) 649 (92.6) High 14 (4.1) 8 (2.2) 22 (3.1) Health and Household Characteristics There were notable changes in health and household characteristics over the study period. The frequency of sore throats and their severity did not significantly differ (p = 0.519 and p = 0.407, respectively). However, the source of drinking water and the type of residence were significantly different between 2019 and 2024. A greater proportion of children used private wells in 2024 (32.0%) than in 2019 (17.7%) (p < 0.001). Additionally, there was an increase in the number of children living in houses (from 28.1% in 2019 to 50.1% in 2024) and a decrease in those living in apartments (p < 0.001) (Table 2 ). Table 2 Health and Household Information (2019 vs. 2024) Variable Category 2019 (n = 345) (n, %) 2024 (n = 356) (n, %) Total (n = 701) (n, %) P Value Sore Throat Frequency Never 56 (16.2) 60 (16.9) 116 (16.5) 0.519 Once 119 (34.5) 119 (33.4) 238 (34.0) Two to three 153 (44.3) 150 (42.1) 303 (43.2) More than three 17 (4.9) 27 (7.6) 44 (6.3) Sore Throat Severity Mild 58 (20.1) 67 (22.6) 125 (21.4) 0.407 Moderate 174 (60.2) 162 (54.7) 336 (57.4) Severe 57 (19.7) 67 (22.6) 124 (21.2) Drinking Water Source Municipal 267 (77.4) 222 (62.4) 489 (69.8) < 0.001 Private well 61 (17.7) 114 (32.0) 175 (25.0) Bottled 17 (4.9) 20 (5.6) 37 (5.3) Type of House Apartment 247 (71.6) 174 (49.0) 421 (60.1) < 0.001 House 97 (28.1) 178 (50.1) 275 (39.3) Other 1 (0.3) 3 (0.8) 4 (0.6) Contact with Sore Throat Yes 30 (8.7) 20 (5.6) 50 (7.1) 0.182 No 299 (86.7) 313 (87.9) 612 (87.3) Do not Know 16 (4.6) 23 (6.5) 39 (5.6) BMI Categories < 18.50 45 (16.1) 49 (14.0) 94 (14.9) 0.011 18.50–24.99 199 (71.1) 281 (80.1) 480 (76.1) 25.00–29.99 29 (10.4) 19 (5.4) 48 (7.6) 30.00–34.99 7 (2.5) 2 (0.6) 9 (1.4) Number of Siblings < 3 120 (34.8) 132 (37.1) 252 (35.9) 0.049 3–5 172 (49.9) 191 (53.7) 363 (51.8) 6+ 53 (15.4) 33 (9.3) 86 (12.3) People in Household < 3 4 (1.2) 3 (0.8) 7 (1.0) 0.159 3–5 111 (32.2) 139 (39.0) 250 (35.7) 6+ 230 (66.7) 214 (60.1) 444 (63.3) Rooms in House < 3 37 (10.7) 56 (15.7) 93 (13.3) 0.141 3–5 279 (80.9) 274 (77.0) 553 (78.9) 6+ 29 (8.4) 26 (7.3) 55 (7.8) Number of other people sleeping in your room 0 49 (14.2) 88 (24.7) 137 (19.5) < 0.001 1 171 (49.6) 140 (39.3) 311 (44.4) 2+ 125 (36.2) 128 (36.0) 253 (36.1) Bivariate and multivariate analysis Demographic and Household Factors According to the bivariate analysis, factors such as higher BMI (25.00-29.99) and living in a city were significantly associated with greater odds of GAS carriage. Children with a BMI of 25.00-29.99 had significantly greater odds of GAS carriage (crude OR = 17.2, 95% CI: 8.85–33.46, p < 0.001; adjusted OR = 17.68, 95% CI: 9.03–34.61, p < 0.001) (Table 3 ). Living in a village was associated with lower odds of GAS carriage than living in a city (adjusted OR = 0.505, 95% CI: 0.280–0.909, p = 0.023). Table 3 Bivariate and multivariate analyses of demographic and household factors associated with the prevalence of GAS Variable Category Crude Odds Ratio (OR) 95% CI for OR P Value Adjusted OR* 95% CI for Adjusted OR P Value Sex Male (reference) 1 - - 1 - - Female 0.959 0.651–1.573 0.879 1.04 0.626–1.73 0.879 BMI < 18.5 0.311 0.095–1.02 0.054 0.31 0.095–1.03 0.055 18.5-24.99 (reference) 1 - - 1 - - 25-29.99 17.2 8.85–33.46 < 0.001 17.68 9.03–34.61 < 0.001 30+ 11.79 3.06–45.46 0.003 12.71 3.24–49.85 < 0.001 Age 5–6 Years (reference) 1 - - 1 - - 7–8 Years 0.626 0.389–1.008 0.054 1.215 0.685–2.155 0.506 9–12 Years 0.49 0.276–0.868 0.015 1.261 0.635–2.506 0.507 Number of Siblings < 3 (reference) 1 - - 1 - - 3–5 1.27 0.769–2.097 0.351 1.104 0.627–1.945 0.731 6+ 1.905 0.971–3.737 0.061 1.758 0.804–3.843 0.157 Number of people living in your home < 3 (reference) 1 - - 1 - - 3–5 0.341 0.063–1.836 0.21 1.007 0.117–8.673 0.995 6+ 0.383 0.073–2.02 0.258 0.863 0.102–7.276 0.892 Number of rooms in your home < 3 (reference) 1 - - 1 - - 3–5 0.529 0.304–0.921 0.024 0.585 0.31–1.103 0.097 6+ 0.068 0.009–0.519 0.01 0 0–0 0.997 Number of other people sleeping in your room 0 (reference) 1 - - 1 - - 1 0.869 0.442–1.708 0.684 0.553 0.259–1.178 0.125 2+ 2.11 1.119–3.981 0.021 1.572 0.778–3.173 0.207 Place of Residence City (reference) 1 - - 1 - - Village 0.539 0.331–0.880 0.013 0.505 0.280–0.909 0.023 Camp 1.082 0.577–2.032 0.805 1.31 0.653–2.628 0.448 Governorate Hebron (reference) 1 - - 1 - - Bethlehem 1.359 0.857–2.156 0.192 1.303 0.763–2.551 0.333 *: adjusted for age and BMI group Environmental and Behavioral Factors Environmental and behavioral factors also play a significant role in GAS carriage. The odds of GAS carriage were significantly greater for children who drank from private wells than for those who drank from municipal water (adjusted OR = 3.989, 95% CI: 2.32–6.858, p < 0.001). Inconsistent handwashing with soap and water was associated with increased odds of GAS carriage (adjusted OR = 2.723, 95% CI: 1.631–4.544, p < 0.001) (Table 4 ). Hygiene practices Frequent teeth brushing was associated with lower odds of GAS carriage. Brushing teeth once or twice daily significantly reduced the odds ratio (adjusted OR for brushing twice: 0.055, 95% CI: 0.019–0.157, p < 0.001). Children who reported always washing their hands with soap and water also had lower odds of GAS carriage (adjusted OR = 0.367, 95% CI: 0.220–0.613, p < 0.001). Table 4 Bivariate and multivariate analyses of environmental and behavioral factors associated with the prevalence of GAS Variable Category Crude Odds Ratio (OR) 95% CI for OR P Value Adjusted OR 95% CI for Adjusted OR P Value Family Socioeconomic Status Low (reference) 1 - - 1 - - Medium 0.713 0.265–1.915 0.502 0.8 0.251–2.551 0.707 High 1.471 0.368–5.87 0.585 2.293 0.47–11.188 0.305 Frequency of Sore Throat in the Past Year Never (reference) 1 - - 1 - - Once 0.776 0.406–1.485 0.444 0.685 0.334–1.404 0.302 Two to three times 0.835 0.451–1.547 0.567 0.808 0.408–1.6 0.541 More than three times 1.294 0.514–3.257 0.584 1.584 0.541–4.639 0.402 Severity of Sore Throats Mild (reference) 1 - - 1 - - Moderate 0.669 0.377–1.188 0.17 0.765 0.401–1.46 0.417 Severe 0.58 0.276–1.218 0.15 0.53 0.222–1.27 0.155 Source of Drinking Water Municipal water system (reference) 1 - - 1 - - Private well 4.615 2.892–7.366 < 0.001 3.989 2.32–6.858 < 0.001 Bottled mineral water 1.439 0.484–4.275 0.513 1.648 0.453–5.998 0.449 Type of Residence Apartment (reference) 1 - - 1 - - House 1.024 0.651–1.609 0.919 1.179 0.703–1.978 0.533 Other 2.265 0.231–22.173 0.482 1.525 0.123–18.842 0.742 Washing Hands Regularly with Soap and Water Sometimes (reference) 1 - - 1 - Always 0.326 0.208–0.513 < 0.001 0.367 0.220–0.613 < 0.001 Frequency of Brushing Teeth 0 (reference) 1 - - 1 - - 1 0.188 0.113–0.311 < 0.001 0.219 0.123–0.391 < 0.001 2 0.08 0.036–0.18 < 0.001 0.055 0.019–0.157 < 0.001 3 0.24 0.052–1.112 0.068 0.274 0.054–1.384 0.117 Close Contact with Someone with Sore Throat Yes (reference) 1 - - 1 - - No 2.527 0.769–8.301 0.127 3.037 0.578–15.971 0.19 Do not Know 1.306 0.249–6.854 0.753 1.37 0.177–10.633 0.763 Discussion Effects of COVID-19 Health Prevention on Asymptomatic GAS Carriage The implementation of COVID-19 health precautions appears to have significantly reduced the prevalence of asymptomatic Group A Streptococcus (GAS) carriage among Palestinian children, decreasing from 15.7% in 2019 to 10.4% in 2024 (p = 0.038). This reduction likely results from pandemic measures disrupting GAS transmission pathways. Public health strategies such as increased hand hygiene, mask wearing, and social distancing, primarily aimed at controlling SARS-CoV-2, also impact the transmission of other pathogens, including GAS. Enhanced hand hygiene practices were particularly crucial, aligning with previous research that demonstrated the effectiveness of hand hygiene in reducing the transmission of respiratory and other infectious diseases [ 13 , 17 ]. Sociodemographic and Household Characteristics Changes in sociodemographic and household characteristics were also found to be significant factors influencing GAS carriage[ 6 ]. While demographic characteristics, such as sex and age distribution, did not change significantly between 2019 and 2024 (p = 0.662 and p = 0.101, respectively), there were notable shifts in living environments and water sources. The proportion of children residing in urban areas increased significantly from 34.5% in 2019 to 41.6% in 2024 (p = 0.050), indicating a shift in population distribution. Despite this increase, living in urban areas did not significantly impact the prevalence of GAS carriage. In contrast, the use of private wells for drinking water increased from 17.7% in 2019 to 32.0% in 2024 (p < 0.001). Residents of households utilizing private wells displayed a 4.1-fold increased risk of GAS carriage compared to those with municipal water access (adjusted OR = 4.128, 95% CI: 2.175–7.830, p < 0.001). This suggests a potential disparity in water quality between private wells and municipal systems, which may contribute to a heightened risk of infections such as GAS [ 18 ]. Despite this, the overall prevalence of GAS decreased, likely due to improved hygiene practices and other pandemic-related measures. The reliance on private wells increased because municipal water availability decreased annually due to chronic shortages, particularly in the southwest bank region, which is considered a water-poor area. This scarcity has forced residents to increasingly depend on private wells for their water supply [ 19 , 20 ]. Hygiene Practices and Infection Control Improved hygiene behaviors were associated with a lower likelihood of GAS carriage. Frequent handwashing with soap and water, as well as daily toothbrushing, was linked to reduced GAS carriage [ 21 ]. Children who reported consistently washing their hands with soap and water had a significantly lower chance of carrying GAS (odds ratio (OR) = 0.367, 95% CI: 0.184–0.730, p < 0.001). Similarly, daily toothbrushing significantly reduced the odds of carriage (OR for brushing twice = 0.055, 95% CI: 0.019–0.157, p < 0.001). These findings emphasize the importance of personal hygiene in controlling infections. Handwashing with soap and water is a well-established, simple yet highly effective way to prevent the spread of numerous pathogens, including GAS. The emphasis on hand hygiene during the COVID-19 pandemic likely played a role in the observed decrease in GAS carriage. Interestingly, the link between teeth brushing and lower GAS carriage highlights the potential benefits of oral hygiene for preventing respiratory infections. Poor oral hygiene might create an environment favorable for bacterial growth, increasing the risk of infection [ 4 ]. Comparison with Similar Studies The observed reduction in GAS carriage aligns with reports of decreased respiratory infections associated with pandemic control measures [ 22 – 24 ]. For example, a Taiwanese study documented significant declines in common respiratory illnesses, including streptococcal pharyngitis, during the COVID-19 pandemic, which was attributed to intensified public health interventions [ 25 ]. Similarly, research from several European countries revealed lower rates of respiratory infections in primary care settings, further suggesting broader benefits of COVID-19 prevention for infectious disease control [ 26 , 27 ]. However, maintaining consistent public health measures presents distinct challenges in conflict settings such as Palestine. A study on healthcare in conflict zones emphasized the difficulties in securing reliable water quality and consistent public health practices, which can have variable effects on infectious disease transmission [ 28 ]. Conclusion Our study demonstrated a significant reduction in asymptomatic GAS carriage among Palestinian children following the implementation of COVID-19 health precautions. This finding suggested that improved hygiene practices and pandemic-related measures, despite potential counteracting factors such as reliance on private wells, had a net positive impact on GAS prevalence. These results underscore the importance of sustained public health efforts and personal hygiene in curbing the spread of infectious diseases. It is crucial for public health strategies to focus on maintaining and promoting these hygiene practices beyond the pandemic to mitigate the burden of GAS and other infectious diseases. Abbreviations OR Odds Ratio BMI Body Mass Index GAS Group A Streptococcus. Declarations Acknowledgements We gratefully acknowledge the Al-Quds University Health Research Ethical Review Committee for providing ethical clearance for this research. We also extend our sincere thanks to the study participants and everyone who, in any way, supported the completion of this project. In the preparation of this manuscript, AI-assisted language tools were employed to ensure the text is free from language errors and to enhance the overall clarity and readability of the document. These tools were used to check grammar, spelling, and syntax while maintaining the integrity and originality of the authors' work. Authors’ contributions I.G. initiated the study in 2019 and collected data at that time. All authors collected data in 2024. I.G. and Y.G. processed and analyzed the data. All authors contributed to the conceptualization, study design, execution, data acquisition, and interpretation. Each author participated in drafting, revising, or critically reviewing the article. All authors approved the final version for publication and consented to the journal selected for submission. Funding The authors self-funded the financial costs associated with collecting the research data. Availability of data and materials The researchers are willing to provide the data sets generated and/or analyzed as part of this study to interested parties upon reasonable request made to the corresponding author. Competing interests The authors declare no competing interests. Ethics approval and consent to participate This research received ethical approval from the Al-Quds University Research Ethics Committee and adhered to the principles of the Declaration of Helsinki. Data collectors and/or the investigator thoroughly explained the study's purpose and the significance of participation to each child's parent/guardian. Written informed consent was obtained from all parents/guardians, and assent was obtained from the children themselves before the study began. Participation was entirely voluntary. Consent for publication Not applicable. Conflicts of interests There were no conflicts of interest. Author details 1 Department of Medical Laboratory Sciences, Al-Quds University, Faculty of Health professions, Abu Dis, Palestine. 2 Faculty of Medicine, Al-Quds University, Abu Dis, Palestine. References Pallon J, Roost M, Sundqvist M, Hedin K: The aetiology of pharyngotonsillitis in primary health care: a prospective observational study . BMC Infect Dis 2021, 21 (1):971. Nayiga I, Okello E, Lwabi P, Ndeezi G: Prevalence of group a streptococcus pharyngeal carriage and clinical manifestations in school children aged 5-15 yrs in Wakiso District, Uganda . BMC Infect Dis 2017, 17 (1):248. Increased incidence of scarlet fever and invasive Group A Streptococcus infection - multi-country. [https://www.who.int/emergencies/disease-outbreak-news/item/2022-DON429] Avire NJ, Whiley H, Ross K: A Review of Streptococcus pyogenes: Public Health Risk Factors, Prevention and Control . Pathogens 2021, 10 (2). Robinson JL: Paediatrics: how to manage pharyngitis in an era of increasing antimicrobial resistance . Drugs Context 2021, 10 . Oliver J, Malliya Wadu E, Pierse N, Moreland NJ, Williamson DA, Baker MG: Group A Streptococcus pharyngitis and pharyngeal carriage: A meta-analysis . PLoS Negl Trop Dis 2018, 12 (3):e0006335. Spinks A, Glasziou PP, Del Mar CB: Antibiotics for treatment of sore throat in children and adults . Cochrane Database Syst Rev 2021, 12 (12):CD000023. Vijaya D, Sathish J, Janakiram K: The prevalence of group a streptococci carriers among asymptomatic school children . J Clin Diagn Res 2013, 7 (3):446-448. Organization WH: Health conditions in the occupied Palestinian territory, including east Jerusalem, and in the occupied Syrian Golan . In . ; 2023. Luo R, Sickler J, Vahidnia F, Lee YC, Frogner B, Thompson M: Diagnosis and Management of Group a Streptococcal Pharyngitis in the United States, 2011-2015 . BMC Infect Dis 2019, 19 (1):193. Cohen JF, Tanz RR, Shulman ST: Group A Streptococcus pharyngitis in Children: New Perspectives on Rapid Diagnostic Testing and Antimicrobial Stewardship . J Pediatric Infect Dis Soc 2024, 13 (4):250-256. AlKhaldi M, Kaloti R, Shella D, Al Basuoni A, Meghari H: Health system's response to the COVID-19 pandemic in conflict settings: Policy reflections from Palestine . Glob Public Health 2020, 15 (8):1244-1256. Lee HH, Lin SH: Effects of COVID-19 Prevention Measures on Other Common Infections, Taiwan . Emerg Infect Dis 2020, 26 (10):2509-2511. Distribution of Schools in Palestine by Supervising Authority, Region and Governorate, for Scholastic Years 2011/2012-2022/2023 [https://www.pcbs.gov.ps/Portals/_Rainbow/Documents/Schools_en.html] Distribution of Basic Stage Students* in Schools in Palestine by Supervising Authority, Region and Governorate and sex for Scholastic Years 2011/2012-2022/2023. [https://www.pcbs.gov.ps/Portals/_Rainbow/Documents/Basic_Students_en.html] Rystedt K, Hedin K, Tyrstrup M, Skoog-Stahlgren G, Edlund C, Giske CG, Gunnarsson R, Sundvall PD: Agreement between rapid antigen detection test and culture for group A streptococcus in patients recently treated for pharyngotonsillitis - a prospective observational study in primary care . Scand J Prim Health Care 2023, 41 (1):91-97. Jefferson T, Del Mar CB, Dooley L, Ferroni E, Al-Ansary LA, Bawazeer GA, van Driel ML, Nair S, Jones MA, Thorning S et al : Physical interventions to interrupt or reduce the spread of respiratory viruses . Cochrane Database Syst Rev 2011, 2011 (7):CD006207. Woolf AD, Stierman BD, Barnett ED, Byron LG, Council On Environmental H, Climate C, Committee On Infectious D: Drinking Water From Private Wells and Risks to Children . Pediatrics 2023, 151 (2). Zohud A, Alam L: A Review of Groundwater Contamination in West Bank, Palestine: Quality, Sources, Risks, and Management . Water 2022, 14 (21). WorldBank: Securing water for development in West Bank and Gaza . In . Washington, DC.; 2018. DeMuri GP, Wald ER: The Group A Streptococcal Carrier State Reviewed: Still an Enigma . J Pediatric Infect Dis Soc 2014, 3 (4):336-342. Zuo Z, Yang C, Ye F, Wang M, Wu J, Tao C, Xun Y, Li Z, Liu S, Huang J et al : Trends in respiratory diseases before and after the COVID-19 pandemic in China from 2010 to 2021 . BMC Public Health 2023, 23 (1):217. Nguyen JL, Benigno M, Malhotra D, Khan F, Angulo FJ, Hammond J, Swerdlow DL, Reimbaeva M, Emir B, McLaughlin JM: Pandemic-related declines in hospitalization for non-COVID-19-related illness in the United States from January through July 2020 . PLoS One 2022, 17 (1):e0262347. Kadambari S, Goldacre R, Morris E, Goldacre MJ, Pollard AJ: Indirect effects of the covid-19 pandemic on childhood infection in England: population based observational study . BMJ 2022, 376 :e067519. Yang MC, Su YT, Chen PH, Tsai CC, Lin TI, Wu JR: Changing patterns of infectious diseases in children during the COVID-19 pandemic . Front Cell Infect Microbiol 2023, 13 :1200617. Wanat M, Hoste ME, Gobat NH, Anastasaki M, Bohmer F, Chlabicz S, Colliers A, Farrell K, Hollerbach S, Karkana MN et al : Patients' and clinicians' perspectives on the primary care consultations for acute respiratory infections during the first wave of the COVID-19 pandemic: an eight-country qualitative study in Europe . BJGP Open 2022, 6 (2). van der Velden AW, Bax EA, Bongard E, Munck Aabenhus R, Anastasaki M, Anthierens S, Balan A, Bohmer F, Bruno P, Chlabicz S et al : Primary care for patients with respiratory tract infection before and early on in the COVID-19 pandemic: an observational study in 16 European countries . BMJ Open 2021, 11 (7):e049257. Marou V, Vardavas CI, Aslanoglou K, Nikitara K, Plyta Z, Leonardi-Bee J, Atkins K, Condell O, Lamb F, Suk JE: The impact of conflict on infectious disease: a systematic literature review . Confl Health 2024, 18 (1):27. Additional Declarations No competing interests reported. Cite Share Download PDF Status: Published Journal Publication published 04 Oct, 2024 Read the published version in BMC Infectious Diseases → Version 1 posted Editorial decision: Revision requested 06 Aug, 2024 Reviews received at journal 05 Aug, 2024 Reviews received at journal 30 Jul, 2024 Reviews received at journal 29 Jul, 2024 Reviewers agreed at journal 15 Jul, 2024 Reviewers agreed at journal 14 Jul, 2024 Reviewers agreed at journal 12 Jul, 2024 Reviewers agreed at journal 25 Jun, 2024 Reviewers invited by journal 24 Jun, 2024 Editor invited by journal 20 Jun, 2024 Editor assigned by journal 19 Jun, 2024 Submission checks completed at journal 19 Jun, 2024 First submitted to journal 18 Jun, 2024 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-4599563","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":320634619,"identity":"3ab5e37d-c558-423c-b53b-a80bbea9530c","order_by":0,"name":"Ibrahim Amer Ghannam","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAABFUlEQVRIiWNgGAWjYBACNgYeCIMfRFTYMDDwAWkJIGZsIKRFsoGZgeFMGkiEgBYGmBaDA8Rq4eNfe/Bz4Q67aOPz5w9+OJDAIM/GnmN48weDjeyGAzgcJvEuWXrmmeTcbTeSmSWAWgzbeN4YW/MwpBnj1nLGQJq3jRmohZlB+uMPBsY2iRwzaQaGw4l4tBj/5m2rz93cf5j5B9AWe5AWyR8M/3Fr4e8xA9pyOHcDQzIbyGGJIC0SPAwH8NjCY2bN23Y8d8aNZDOLAwkSyW08z4qteQySjWfi0CLff8b4Nm9bdW5//8HHNw4k2Nj2sydvvPmjwk62D4cWBokEVC4Qg0QMcCgHAX5MsxIwREbBKBgFo2BkAwBmkFsOCtH90AAAAABJRU5ErkJggg==","orcid":"","institution":"Al-Quds University","correspondingAuthor":true,"submittingAuthor":false,"prefix":"","firstName":"Ibrahim","middleName":"Amer","lastName":"Ghannam","suffix":""},{"id":320634620,"identity":"38387e83-dae7-473e-8064-ca1f809d1fe4","order_by":1,"name":"Rana Mahmoud Maraqa","email":"","orcid":"","institution":"Al-Quds University","correspondingAuthor":false,"submittingAuthor":false,"prefix":"","firstName":"Rana","middleName":"Mahmoud","lastName":"Maraqa","suffix":""},{"id":320634621,"identity":"045215ed-9a13-4715-b06c-7926379c081c","order_by":2,"name":"Duha Shokri Qawasmeh","email":"","orcid":"","institution":"Al-Quds University","correspondingAuthor":false,"submittingAuthor":false,"prefix":"","firstName":"Duha","middleName":"Shokri","lastName":"Qawasmeh","suffix":""},{"id":320634622,"identity":"e199bc64-d2d5-4c9a-8b40-cb8e49c42a5e","order_by":3,"name":"Rania Khalil Alsous","email":"","orcid":"","institution":"Al-Quds University","correspondingAuthor":false,"submittingAuthor":false,"prefix":"","firstName":"Rania","middleName":"Khalil","lastName":"Alsous","suffix":""},{"id":320634623,"identity":"08accdf6-cdf4-48df-bb88-bcaf05a34319","order_by":4,"name":"Sakra Mohammad Abu Jaber","email":"","orcid":"","institution":"Al-Quds University","correspondingAuthor":false,"submittingAuthor":false,"prefix":"","firstName":"Sakra","middleName":"Mohammad Abu","lastName":"Jaber","suffix":""},{"id":320634624,"identity":"9338f998-5f05-4044-a1c4-86d937cd0ad5","order_by":5,"name":"Iman Abd Almuti Ghatasha","email":"","orcid":"","institution":"Al-Quds University","correspondingAuthor":false,"submittingAuthor":false,"prefix":"","firstName":"Iman","middleName":"Abd Almuti","lastName":"Ghatasha","suffix":""},{"id":320634625,"identity":"5064e530-f3cb-4e12-9986-2b019595f581","order_by":6,"name":"Yahya Ibrahim Ghannam","email":"","orcid":"","institution":"Al-Quds University","correspondingAuthor":false,"submittingAuthor":false,"prefix":"","firstName":"Yahya","middleName":"Ibrahim","lastName":"Ghannam","suffix":""}],"badges":[],"createdAt":"2024-06-18 11:17:23","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-4599563/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-4599563/v1","draftVersion":[],"editorialEvents":[{"content":"https://doi.org/10.1186/s12879-024-10023-w","type":"published","date":"2024-10-04T15:57:35+00:00"}],"editorialNote":"","failedWorkflow":false,"files":[{"id":60446946,"identity":"8a1f0e64-1f26-4745-960a-feca67099e02","added_by":"auto","created_at":"2024-07-16 21:58:13","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":6271,"visible":true,"origin":"","legend":"\u003cp\u003ePrevalence of Group A Streptococcus Asymptomatic Carriage Among Palestinian Children (2019 vs. 2024)\u003c/p\u003e","description":"","filename":"1.png","url":"https://assets-eu.researchsquare.com/files/rs-4599563/v1/2c93a73e6ddbcf2099ce8acf.png"},{"id":66096804,"identity":"34aac5d1-ad13-4968-b878-849af6b062b0","added_by":"auto","created_at":"2024-10-07 16:10:20","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":1806363,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-4599563/v1/b255e5d2-770c-48c3-af04-169673b063e2.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Impact of COVID-19 Health Precautions on Asymptomatic Streptococcus pyogenes Carriage in Palestinian Children: A Before and After Study","fulltext":[{"header":"Background","content":"\u003cp\u003e \u003cem\u003eStreptococcus pyogenes\u003c/em\u003e, also known as Group A Streptococci (GAS), is a common human pathogen responsible for a wide range of infections, from uncomplicated pharyngitis to life-threatening invasive diseases such as necrotizing fasciitis and streptococcal toxic shock syndrome [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e, \u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e]. Severe GAS infections cause approximately 500,000 fatalities per year, creating a major global health burden, especially in resource-limited settings [\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e, \u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e]. The morbidity and mortality linked to these infections highlight how crucial it is to understand the dynamics of GAS transmission, risk factors, and epidemiology.\u003c/p\u003e \u003cp\u003eGAS pharyngitis, often known as strep throat, is a frequent illness that mostly affects children [\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e, \u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e]. Differentiating it from viral pharyngitis, which is more prevalent and typically self-limiting, is crucial for accurate diagnosis [\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e]. Prompt antibiotic treatment of GAS pharyngitis is essential to prevent complications such as rheumatic fever and acute glomerulonephritis and to reduce transmission [\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e]. Asymptomatic GAS carriage, defined as the presence of GAS in the nasopharynx or oropharynx without signs of acute infection, is a significant reservoir for transmission and a known precursor to invasive disease [\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eThe southern West Bank region of Palestine faces unique healthcare challenges. High population density, limited healthcare infrastructure, and geographic barriers contribute to a higher incidence of infectious diseases, including GAS infections [\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e]. The region's socioeconomic conditions and environmental factors further complicate efforts to manage and control these infections. Previous studies have estimated that 5\u0026ndash;15% of school children worldwide develop GAS pharyngitis annually [\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e, \u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e]. However, data on the prevalence and determinants of asymptomatic GAS carriage in this region remain sparse.\u003c/p\u003e \u003cp\u003eWhen the COVID-19 pandemic broke out, the West Bank was among the many places in the world where public health initiatives were implemented with the goal of preventing the spread of the virus. These precautions, which included mask usage, hand washing, social separation, and temporary school closures, were implemented. [\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e]. The dynamics of the transmission of other infectious agents, such as GAS, have been altered by these measures in addition to the spread of SARS-CoV-2. Closing schools and imposing social distancing measures, for instance, may have changed the exposure patterns of children, whereas mask use and better hand hygiene may have decreased the spread of respiratory diseases. [\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eThis cross-sectional study investigated the potential influence of COVID-19 public health measures on the asymptomatic carriage of Group A Streptococcus (GAS) in the pharynx of healthy schoolchildren residing in the southern West Bank, Palestine. The project originated prior to the COVID-19 pandemic, aiming to assess the baseline prevalence and risk factors associated with asymptomatic GAS carriage. However, the study was necessarily halted due to the emergence of COVID-19 in 2020. We have now resumed the study with the added objective of exploring whether the implemented public health measures have impacted GAS carriage rates. We will also continue to examine potential contributing factors such as socioeconomic status, household characteristics, and past medical history. This research has substantial public health implications. Understanding these mechanisms is critical for designing targeted strategies to prevent GAS infections. This project will provide vital information about GAS epidemiology in an area with specific healthcare problems, eventually guiding efforts to improve children's health.\u003c/p\u003e"},{"header":"Materials and methods","content":"\u003cdiv id=\"Sec3\" class=\"Section2\"\u003e \u003ch2\u003eStudy design and setting:\u003c/h2\u003e \u003cp\u003eThis study employed a two-stage cross-sectional design, encompassing the Hebron and Bethlehem governorates in the southern West Bank, Palestine. The first stage occurred between November 2019 and January 2020, while the second stage occurred from November 2023 to April 2024. In 2019, there were 770 schools in this region, with a total student population of 211,025 children. By 2023, the number of schools had increased to 807, and the total number of children had risen to 230,463. [\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e, \u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e].\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec4\" class=\"Section2\"\u003e \u003ch2\u003e\u003cb\u003eParticipants\u003c/b\u003e:\u003c/h2\u003e \u003cp\u003eThe study included a total of 701 children divided into two time intervals. During the first interval, 345 children without symptoms of sore throat were sampled and tested. The study was put on hold in January 2020 due to the spread of the COVID-19 pandemic and resumed in late 2023, with a second stage in which 356 children without symptoms of sore throat were sampled. Schools and participants were selected using a cluster sampling method. Throat swab samples were collected from school-aged children between 5 and 12 years of age from various kindergartens and primary schools within the region, encompassing cities, villages, and refugee camps.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec5\" class=\"Section2\"\u003e \u003ch2\u003eSample Size Calculation:\u003c/h2\u003e \u003cp\u003eThe sample size for this study was initially calculated based on an estimated 15% prevalence of asymptomatic GAS carriage in school-aged children from previous studies [\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e, \u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e]. Assuming a desired precision of \u0026plusmn;\u0026thinsp;5% with a 95% confidence interval, the required sample size was determined to be 196 participants. To further increase the statistical power, additional participants were recruited beyond the calculated sample size. After the onset of the COVID-19 pandemic and the subsequent adjustment of the study aims, the sample size was recalculated for each time interval (pre-COVID-19 and post-COVID-19). Ultimately, 345 and 356 participants were recruited during the pre-COVID-19 and post-COVID-19 intervals, respectively, to enhance the statistical power and ensure robust results.\u003c/p\u003e \u003cp\u003e \u003cstrong\u003eInclusion criteria\u003c/strong\u003e \u003cp\u003eAll students aged 5 to 12 years who were enrolled in the selected classes of the chosen schools and who were present during the sampling period were eligible for inclusion in the study. However, their participation was contingent upon providing signed written consent from their parents or legal guardians.\u003c/p\u003e \u003c/p\u003e \u003cp\u003e \u003cstrong\u003eExclusion criteria\u003c/strong\u003e \u003cp\u003eTo ensure a representative sample of asymptomatic carriers, we excluded children who presented with symptoms suggestive of upper respiratory tract infection (URTI) at enrollment and those with a history of tonsillectomy or recent antibiotic use within one week of sample collection. Additionally, children who were diagnosed with chronic medical conditions and who were older than 12 years of age were excluded from the study.\u003c/p\u003e \u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec6\" class=\"Section2\"\u003e \u003ch2\u003eInformation collection:\u003c/h2\u003e \u003cp\u003e All participating children provided a detailed medical history, either directly or through their parents or guardians. This information included age, gender, school name and location, place of residence, province, and parental socioeconomic status. The medical history also included the frequency and severity of sore throat episodes over the past year and any current symptoms, such as fever, sore throat, difficulty swallowing, ear pain, or skin rash. Additionally, data were collected on recent contacts with individuals experiencing sore throats. The inquiry further extended to family and environmental factors, such as the number of siblings, the number of rooms in the household, the water supply system, the number of people sharing the child's room, and personal hygiene practices, including the frequency of tooth brushing and hand washing.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec7\" class=\"Section2\"\u003e \u003ch2\u003eSample collection and group A Streptococcus (GAS) identification\u003c/h2\u003e \u003cp\u003e Sterile cotton swabs and tongue depressors were used for primary throat swab collection from participants. The research team adhered to rigorous hygiene protocols, utilizing personal protective equipment, including gloves, to mitigate the risk of cross-contamination. During the initial rapid testing phase, the ABON Strep A throat swab rapid test kit was utilized (ABON, lot number IST-502, Germany). Sample processing followed the manufacturer's instructions. This rapid antigen detection test (RADT) served as an indicator of asymptomatic Streptococcus carriage, consistent with previous studies reporting a 91% concordance between RADTs and culture results at the 21-day follow-up [\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eFor samples yielding positive results in the rapid test, a second set of sterile swabs was obtained to collect specimens for culture testing. These swabs were transported to the microbiology laboratory using appropriate transport media to maintain the viability of the microorganisms. Subsequently, the throat swabs were inoculated onto commercially available 5% sheep blood agar plates and incubated for 24 hours under optimal conditions (37\u0026deg;C, 5\u0026ndash;10% CO\u003csub\u003e2\u003c/sub\u003e). After the incubation period, suspected colonies exhibiting beta-hemolysis were identified, subcultured onto fresh 5% blood agar plates, and incubated for an additional 24 hours. The hemolysis pattern was then evaluated in these subcultures. Plates displaying beta-hemolysis were subjected to Gram staining and catalase testing. If the bacteria were identified as gram-positive cocci arranged in chains and catalase negative, they were subcultured onto another 5% blood agar plate for bacitracin and trimethoprim-sulfamethoxazole (SXT) susceptibility testing. The presence of \u003cem\u003eStreptococcus pyogenes\u003c/em\u003e (Group A Streptococcus; GAS) was confirmed in bacitracin-sensitive and SXT-resistant isolates.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec8\" class=\"Section2\"\u003e \u003ch2\u003eStatistical analysis:\u003c/h2\u003e \u003cp\u003eData analysis was performed using IBM SPSS version 27 and MedCalc\u0026reg; Statistical Software version 22.0. Descriptive statistics, including means and standard deviations, were employed to summarize quantitative variables, while frequencies and percentages were utilized to present categorical variables. The chi-square test was used to assess the existence of associations and to evaluate the statistical significance of the results. Additionally, binary logistic regression analysis was conducted to determine the effect of independent variables. We quantified risk using odds ratios (ORs) with 95% confidence intervals. A p value less than or equal to 0.05 was considered to indicate statistical significance.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec9\" class=\"Section2\"\u003e \u003ch2\u003eEthical considerations:\u003c/h2\u003e \u003cp\u003e After receiving ethical approval from the Deanship of Scientific Research at Al-Quds University and participating school principals, the study adhered to ethical guidelines by obtaining written informed consent from parents or guardians and verbal assent from the children themselves.\u003c/p\u003e \u003c/div\u003e"},{"header":"Results","content":"\u003cdiv id=\"Sec11\" class=\"Section2\"\u003e \u003ch2\u003ePrevalence of asymptomatic group A Streptococcus (GAS) carriage\u003c/h2\u003e \u003cp\u003eThe study examined a total of 701 children from the southwest Bank region of Palestine, with data collected in 2019 and 2024. A notable decrease in the prevalence of asymptomatic GAS carriage among these children was observed between the two time points. In 2019, 15.7% (54 out of 345) of the children were asymptomatic carriers of GAS, with a 95% confidence interval (CI) ranging from 12.1\u0026ndash;19.8%. However, by 2024, this prevalence had dropped to 10.4% (37 out of 356), with a 95% CI of 7.5\u0026ndash;13.9% (Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e). Statistical analysis confirmed that this reduction in the prevalence of asymptomatic GAS carriage was statistically significant (p\u0026thinsp;=\u0026thinsp;0.038).\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec12\" class=\"Section2\"\u003e \u003ch2\u003eSociodemographic Characteristics of Study Participants:\u003c/h2\u003e \u003cp\u003eThe gender distribution remained stable (p\u0026thinsp;=\u0026thinsp;0.662). While there was a slight but not significant increase in the number of participants under 7 years of age in 2024 (41.6% \u003cem\u003evs\u003c/em\u003e. 37.7% in 2019, p\u0026thinsp;=\u0026thinsp;0.101), there was a shift in the number of residents, with a significant increase in city dwellers (p\u0026thinsp;=\u0026thinsp;0.050) from 34.5% in 2019 to 41.6% in 2024. The governorate distribution remained consistent (p\u0026thinsp;=\u0026thinsp;0.311), with Hebron as the majority. The patients\u0026rsquo; socioeconomic status was stable, with more than 92% in the medium category in both years (p\u0026thinsp;=\u0026thinsp;0.240) (Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e).\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eDemographic and Socioeconomic Information (2019 vs. 2024)\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"6\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eVariable\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eCategory\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003e2019 (n\u0026thinsp;=\u0026thinsp;345) (n, %)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003e2024 (n\u0026thinsp;=\u0026thinsp;356) (n, %)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003eTotal (n\u0026thinsp;=\u0026thinsp;701) (n, %)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c6\"\u003e \u003cp\u003eP Value\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003eSex\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eMale\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e161 (46.7)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e172 (48.3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e333 (47.5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003e0.662\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eFemale\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e184 (53.3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e184 (51.7)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e368 (52.5)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"2\" rowspan=\"3\"\u003e \u003cp\u003eAge Groups\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e130 (37.7)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e148 (41.6)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e278 (39.7)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\" morerows=\"2\" rowspan=\"3\"\u003e \u003cp\u003e0.101\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e7\u0026ndash;8\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e136 (39.4)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e113 (31.7)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e249 (35.5)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e9+\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e79 (22.9)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e95 (26.7)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e174 (24.8)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"2\" rowspan=\"3\"\u003e \u003cp\u003ePlace of Residence\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eCity\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e119 (34.5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e148 (41.6)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e267 (38.1)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\" morerows=\"2\" rowspan=\"3\"\u003e \u003cp\u003e0.050\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eVillage\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e184 (53.3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e157 (44.1)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e341 (48.6)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eCamp\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e42 (12.2)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e51 (14.3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e93 (13.3)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003eGovernorate\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eHebron\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e234 (67.8)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e254 (71.3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e488 (69.6)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003e0.311\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eBethlehem\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e111 (32.3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e102 (28.7)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e213 (30.4)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"2\" rowspan=\"3\"\u003e \u003cp\u003eFamily Socioeconomic Status\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eLow\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e12 (3.5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e18 (5.1)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e30 (4.3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\" morerows=\"2\" rowspan=\"3\"\u003e \u003cp\u003e0.240\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eMedium\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e319 (92.5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e330 (92.7)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e649 (92.6)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eHigh\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e14 (4.1)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e8 (2.2)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e22 (3.1)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec13\" class=\"Section2\"\u003e \u003ch2\u003eHealth and Household Characteristics\u003c/h2\u003e \u003cp\u003eThere were notable changes in health and household characteristics over the study period. The frequency of sore throats and their severity did not significantly differ (p\u0026thinsp;=\u0026thinsp;0.519 and p\u0026thinsp;=\u0026thinsp;0.407, respectively). However, the source of drinking water and the type of residence were significantly different between 2019 and 2024. A greater proportion of children used private wells in 2024 (32.0%) than in 2019 (17.7%) (p\u0026thinsp;\u0026lt;\u0026thinsp;0.001). Additionally, there was an increase in the number of children living in houses (from 28.1% in 2019 to 50.1% in 2024) and a decrease in those living in apartments (p\u0026thinsp;\u0026lt;\u0026thinsp;0.001) (Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e).\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab2\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eHealth and Household Information (2019 vs. 2024)\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"6\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eVariable\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eCategory\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003e2019 (n\u0026thinsp;=\u0026thinsp;345) (n, %)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003e2024 (n\u0026thinsp;=\u0026thinsp;356) (n, %)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003eTotal (n\u0026thinsp;=\u0026thinsp;701) (n, %)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c6\"\u003e \u003cp\u003eP Value\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"3\" rowspan=\"4\"\u003e \u003cp\u003eSore Throat Frequency\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eNever\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e56 (16.2)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e60 (16.9)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e116 (16.5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\" morerows=\"3\" rowspan=\"4\"\u003e \u003cp\u003e0.519\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eOnce\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e119 (34.5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e119 (33.4)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e238 (34.0)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eTwo to three\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e153 (44.3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e150 (42.1)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e303 (43.2)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eMore than three\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e17 (4.9)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e27 (7.6)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e44 (6.3)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"2\" rowspan=\"3\"\u003e \u003cp\u003eSore Throat Severity\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eMild\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e58 (20.1)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e67 (22.6)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e125 (21.4)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\" morerows=\"2\" rowspan=\"3\"\u003e \u003cp\u003e0.407\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eModerate\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e174 (60.2)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e162 (54.7)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e336 (57.4)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eSevere\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e57 (19.7)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e67 (22.6)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e124 (21.2)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"2\" rowspan=\"3\"\u003e \u003cp\u003eDrinking Water Source\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eMunicipal\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e267 (77.4)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e222 (62.4)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e489 (69.8)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\" morerows=\"2\" rowspan=\"3\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003ePrivate well\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e61 (17.7)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e114 (32.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e175 (25.0)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eBottled\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e17 (4.9)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e20 (5.6)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e37 (5.3)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"2\" rowspan=\"3\"\u003e \u003cp\u003eType of House\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eApartment\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e247 (71.6)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e174 (49.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e421 (60.1)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\" morerows=\"2\" rowspan=\"3\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eHouse\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e97 (28.1)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e178 (50.1)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e275 (39.3)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eOther\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e1 (0.3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e3 (0.8)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e4 (0.6)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"2\" rowspan=\"3\"\u003e \u003cp\u003eContact with Sore Throat\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e30 (8.7)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e20 (5.6)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e50 (7.1)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\" morerows=\"2\" rowspan=\"3\"\u003e \u003cp\u003e0.182\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eNo\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e299 (86.7)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e313 (87.9)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e612 (87.3)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eDo not Know\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e16 (4.6)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e23 (6.5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e39 (5.6)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"3\" rowspan=\"4\"\u003e \u003cp\u003eBMI Categories\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;18.50\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e45 (16.1)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e49 (14.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e94 (14.9)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\" morerows=\"3\" rowspan=\"4\"\u003e \u003cp\u003e0.011\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e18.50\u0026ndash;24.99\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e199 (71.1)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e281 (80.1)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e480 (76.1)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e25.00\u0026ndash;29.99\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e29 (10.4)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e19 (5.4)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e48 (7.6)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e30.00\u0026ndash;34.99\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e7 (2.5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e2 (0.6)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e9 (1.4)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"2\" rowspan=\"3\"\u003e \u003cp\u003eNumber of Siblings\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e120 (34.8)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e132 (37.1)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e252 (35.9)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\" morerows=\"2\" rowspan=\"3\"\u003e \u003cp\u003e0.049\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e3\u0026ndash;5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e172 (49.9)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e191 (53.7)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e363 (51.8)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e6+\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e53 (15.4)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e33 (9.3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e86 (12.3)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"2\" rowspan=\"3\"\u003e \u003cp\u003ePeople in Household\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e4 (1.2)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e3 (0.8)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e7 (1.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\" morerows=\"2\" rowspan=\"3\"\u003e \u003cp\u003e0.159\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e3\u0026ndash;5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e111 (32.2)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e139 (39.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e250 (35.7)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e6+\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e230 (66.7)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e214 (60.1)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e444 (63.3)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"2\" rowspan=\"3\"\u003e \u003cp\u003eRooms in House\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e37 (10.7)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e56 (15.7)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e93 (13.3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\" morerows=\"2\" rowspan=\"3\"\u003e \u003cp\u003e0.141\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e3\u0026ndash;5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e279 (80.9)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e274 (77.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e553 (78.9)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e6+\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e29 (8.4)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e26 (7.3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e55 (7.8)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"2\" rowspan=\"3\"\u003e \u003cp\u003eNumber of other people sleeping in your room\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e49 (14.2)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e88 (24.7)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e137 (19.5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\" morerows=\"2\" rowspan=\"3\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e171 (49.6)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e140 (39.3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e311 (44.4)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e2+\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e125 (36.2)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e128 (36.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e253 (36.1)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec14\" class=\"Section2\"\u003e \u003ch2\u003eBivariate and multivariate analysis\u003c/h2\u003e \u003cdiv id=\"Sec15\" class=\"Section3\"\u003e \u003ch2\u003eDemographic and Household Factors\u003c/h2\u003e \u003cp\u003eAccording to the bivariate analysis, factors such as higher BMI (25.00-29.99) and living in a city were significantly associated with greater odds of GAS carriage. Children with a BMI of 25.00-29.99 had significantly greater odds of GAS carriage (crude OR\u0026thinsp;=\u0026thinsp;17.2, 95% CI: 8.85\u0026ndash;33.46, p\u0026thinsp;\u0026lt;\u0026thinsp;0.001; adjusted OR\u0026thinsp;=\u0026thinsp;17.68, 95% CI: 9.03\u0026ndash;34.61, p\u0026thinsp;\u0026lt;\u0026thinsp;0.001) (Table\u0026nbsp;\u003cspan refid=\"Tab3\" class=\"InternalRef\"\u003e3\u003c/span\u003e). Living in a village was associated with lower odds of GAS carriage than living in a city (adjusted OR\u0026thinsp;=\u0026thinsp;0.505, 95% CI: 0.280\u0026ndash;0.909, p\u0026thinsp;=\u0026thinsp;0.023).\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab3\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 3\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eBivariate and multivariate analyses of demographic and household factors associated with the prevalence of GAS\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"8\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c7\" colnum=\"7\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c8\" colnum=\"8\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eVariable\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eCategory\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eCrude Odds Ratio (OR)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003e95% CI for OR\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003eP Value\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c6\"\u003e \u003cp\u003eAdjusted OR*\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c7\"\u003e \u003cp\u003e95% CI for Adjusted OR\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c8\"\u003e \u003cp\u003eP Value\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003eSex\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eMale (reference)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eFemale\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.959\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.651\u0026ndash;1.573\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.879\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e1.04\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e0.626\u0026ndash;1.73\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e0.879\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"3\" rowspan=\"4\"\u003e \u003cp\u003eBMI\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;18.5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.311\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.095\u0026ndash;1.02\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.054\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0.31\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e0.095\u0026ndash;1.03\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e0.055\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e18.5-24.99 (reference)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e25-29.99\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e17.2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e8.85\u0026ndash;33.46\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e17.68\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e9.03\u0026ndash;34.61\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e30+\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e11.79\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e3.06\u0026ndash;45.46\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.003\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e12.71\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e3.24\u0026ndash;49.85\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"2\" rowspan=\"3\"\u003e \u003cp\u003eAge\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e5\u0026ndash;6 Years (reference)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e7\u0026ndash;8 Years\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.626\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.389\u0026ndash;1.008\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.054\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e1.215\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e0.685\u0026ndash;2.155\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e0.506\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e9\u0026ndash;12 Years\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.49\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.276\u0026ndash;0.868\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.015\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e1.261\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e0.635\u0026ndash;2.506\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e0.507\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"2\" rowspan=\"3\"\u003e \u003cp\u003eNumber of Siblings\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;3 (reference)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e3\u0026ndash;5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1.27\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.769\u0026ndash;2.097\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.351\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e1.104\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e0.627\u0026ndash;1.945\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e0.731\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e6+\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1.905\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.971\u0026ndash;3.737\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.061\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e1.758\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e0.804\u0026ndash;3.843\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e0.157\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"2\" rowspan=\"3\"\u003e \u003cp\u003eNumber of people living in your home\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;3 (reference)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e3\u0026ndash;5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.341\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.063\u0026ndash;1.836\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.21\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e1.007\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e0.117\u0026ndash;8.673\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e0.995\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e6+\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.383\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.073\u0026ndash;2.02\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.258\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0.863\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e0.102\u0026ndash;7.276\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e0.892\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"2\" rowspan=\"3\"\u003e \u003cp\u003eNumber of rooms in your home\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;3 (reference)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e3\u0026ndash;5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.529\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.304\u0026ndash;0.921\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.024\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0.585\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e0.31\u0026ndash;1.103\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e0.097\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e6+\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.068\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.009\u0026ndash;0.519\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.01\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e0\u0026ndash;0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e0.997\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"2\" rowspan=\"3\"\u003e \u003cp\u003eNumber of other people sleeping in your room\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0 (reference)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.869\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.442\u0026ndash;1.708\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.684\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0.553\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e0.259\u0026ndash;1.178\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e0.125\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e2+\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e2.11\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e1.119\u0026ndash;3.981\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.021\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e1.572\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e0.778\u0026ndash;3.173\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e0.207\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"2\" rowspan=\"3\"\u003e \u003cp\u003ePlace of Residence\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eCity (reference)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eVillage\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.539\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.331\u0026ndash;0.880\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.013\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0.505\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e0.280\u0026ndash;0.909\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e0.023\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eCamp\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1.082\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.577\u0026ndash;2.032\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.805\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e1.31\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e0.653\u0026ndash;2.628\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e0.448\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003eGovernorate\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eHebron (reference)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eBethlehem\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1.359\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.857\u0026ndash;2.156\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.192\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e1.303\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e0.763\u0026ndash;2.551\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e0.333\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003ctfoot\u003e \u003ctr\u003e\u003ctd colspan=\"8\"\u003e*: adjusted for age and BMI group\u003c/td\u003e\u003c/tr\u003e \u003c/tfoot\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv id=\"Sec16\" class=\"Section2\"\u003e \u003ch2\u003eEnvironmental and Behavioral Factors\u003c/h2\u003e \u003cp\u003eEnvironmental and behavioral factors also play a significant role in GAS carriage. The odds of GAS carriage were significantly greater for children who drank from private wells than for those who drank from municipal water (adjusted OR\u0026thinsp;=\u0026thinsp;3.989, 95% CI: 2.32\u0026ndash;6.858, p\u0026thinsp;\u0026lt;\u0026thinsp;0.001). Inconsistent handwashing with soap and water was associated with increased odds of GAS carriage (adjusted OR\u0026thinsp;=\u0026thinsp;2.723, 95% CI: 1.631\u0026ndash;4.544, p\u0026thinsp;\u0026lt;\u0026thinsp;0.001) (Table\u0026nbsp;\u003cspan refid=\"Tab4\" class=\"InternalRef\"\u003e4\u003c/span\u003e).\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec17\" class=\"Section2\"\u003e \u003ch2\u003eHygiene practices\u003c/h2\u003e \u003cp\u003eFrequent teeth brushing was associated with lower odds of GAS carriage. Brushing teeth once or twice daily significantly reduced the odds ratio (adjusted OR for brushing twice: 0.055, 95% CI: 0.019\u0026ndash;0.157, p\u0026thinsp;\u0026lt;\u0026thinsp;0.001). Children who reported always washing their hands with soap and water also had lower odds of GAS carriage (adjusted OR\u0026thinsp;=\u0026thinsp;0.367, 95% CI: 0.220\u0026ndash;0.613, p\u0026thinsp;\u0026lt;\u0026thinsp;0.001).\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab4\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 4\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eBivariate and multivariate analyses of environmental and behavioral factors associated with the prevalence of GAS\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"8\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c7\" colnum=\"7\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c8\" colnum=\"8\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eVariable\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eCategory\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eCrude Odds Ratio (OR)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003e95% CI for OR\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003eP Value\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c6\"\u003e \u003cp\u003eAdjusted OR\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c7\"\u003e \u003cp\u003e95% CI for Adjusted OR\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c8\"\u003e \u003cp\u003eP Value\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"2\" rowspan=\"3\"\u003e \u003cp\u003eFamily Socioeconomic Status\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eLow (reference)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eMedium\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.713\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.265\u0026ndash;1.915\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.502\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0.8\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e0.251\u0026ndash;2.551\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e0.707\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eHigh\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1.471\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.368\u0026ndash;5.87\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.585\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e2.293\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e0.47\u0026ndash;11.188\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e0.305\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"3\" rowspan=\"4\"\u003e \u003cp\u003eFrequency of Sore Throat in the Past Year\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eNever (reference)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eOnce\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.776\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.406\u0026ndash;1.485\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.444\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0.685\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e0.334\u0026ndash;1.404\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e0.302\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eTwo to three times\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.835\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.451\u0026ndash;1.547\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.567\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0.808\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e0.408\u0026ndash;1.6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e0.541\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eMore than three times\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1.294\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.514\u0026ndash;3.257\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.584\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e1.584\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e0.541\u0026ndash;4.639\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e0.402\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"2\" rowspan=\"3\"\u003e \u003cp\u003eSeverity of Sore Throats\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eMild (reference)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eModerate\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.669\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.377\u0026ndash;1.188\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.17\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0.765\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e0.401\u0026ndash;1.46\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e0.417\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eSevere\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.58\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.276\u0026ndash;1.218\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.15\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0.53\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e0.222\u0026ndash;1.27\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e0.155\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"2\" rowspan=\"3\"\u003e \u003cp\u003eSource of Drinking Water\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eMunicipal water system (reference)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003ePrivate well\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e4.615\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e2.892\u0026ndash;7.366\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e3.989\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e2.32\u0026ndash;6.858\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eBottled mineral water\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1.439\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.484\u0026ndash;4.275\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.513\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e1.648\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e0.453\u0026ndash;5.998\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e0.449\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"2\" rowspan=\"3\"\u003e \u003cp\u003eType of Residence\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eApartment (reference)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eHouse\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1.024\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.651\u0026ndash;1.609\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.919\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e1.179\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e0.703\u0026ndash;1.978\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e0.533\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eOther\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e2.265\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.231\u0026ndash;22.173\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.482\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e1.525\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e0.123\u0026ndash;18.842\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e0.742\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003eWashing Hands Regularly with Soap and Water\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eSometimes (reference)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eAlways\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.326\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.208\u0026ndash;0.513\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0.367\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e0.220\u0026ndash;0.613\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"3\" rowspan=\"4\"\u003e \u003cp\u003eFrequency of Brushing Teeth\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0 (reference)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.188\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.113\u0026ndash;0.311\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0.219\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e0.123\u0026ndash;0.391\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.08\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.036\u0026ndash;0.18\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0.055\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e0.019\u0026ndash;0.157\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.24\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.052\u0026ndash;1.112\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.068\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0.274\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e0.054\u0026ndash;1.384\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e0.117\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"2\" rowspan=\"3\"\u003e \u003cp\u003eClose Contact with Someone with Sore Throat\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eYes (reference)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eNo\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e2.527\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.769\u0026ndash;8.301\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.127\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e3.037\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e0.578\u0026ndash;15.971\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e0.19\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eDo not Know\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1.306\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.249\u0026ndash;6.854\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.753\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e1.37\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e0.177\u0026ndash;10.633\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e0.763\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003c/div\u003e"},{"header":"Discussion","content":"\u003cdiv id=\"Sec19\" class=\"Section2\"\u003e \u003ch2\u003eEffects of COVID-19 Health Prevention on Asymptomatic GAS Carriage\u003c/h2\u003e \u003cp\u003eThe implementation of COVID-19 health precautions appears to have significantly reduced the prevalence of asymptomatic Group A Streptococcus (GAS) carriage among Palestinian children, decreasing from 15.7% in 2019 to 10.4% in 2024 (p\u0026thinsp;=\u0026thinsp;0.038). This reduction likely results from pandemic measures disrupting GAS transmission pathways. Public health strategies such as increased hand hygiene, mask wearing, and social distancing, primarily aimed at controlling SARS-CoV-2, also impact the transmission of other pathogens, including GAS. Enhanced hand hygiene practices were particularly crucial, aligning with previous research that demonstrated the effectiveness of hand hygiene in reducing the transmission of respiratory and other infectious diseases [\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e, \u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e].\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec20\" class=\"Section2\"\u003e \u003ch2\u003eSociodemographic and Household Characteristics\u003c/h2\u003e \u003cp\u003eChanges in sociodemographic and household characteristics were also found to be significant factors influencing GAS carriage[\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e]. While demographic characteristics, such as sex and age distribution, did not change significantly between 2019 and 2024 (p\u0026thinsp;=\u0026thinsp;0.662 and p\u0026thinsp;=\u0026thinsp;0.101, respectively), there were notable shifts in living environments and water sources. The proportion of children residing in urban areas increased significantly from 34.5% in 2019 to 41.6% in 2024 (p\u0026thinsp;=\u0026thinsp;0.050), indicating a shift in population distribution. Despite this increase, living in urban areas did not significantly impact the prevalence of GAS carriage.\u003c/p\u003e \u003cp\u003eIn contrast, the use of private wells for drinking water increased from 17.7% in 2019 to 32.0% in 2024 (p\u0026thinsp;\u0026lt;\u0026thinsp;0.001). Residents of households utilizing private wells displayed a 4.1-fold increased risk of GAS carriage compared to those with municipal water access (adjusted OR\u0026thinsp;=\u0026thinsp;4.128, 95% CI: 2.175\u0026ndash;7.830, p\u0026thinsp;\u0026lt;\u0026thinsp;0.001). This suggests a potential disparity in water quality between private wells and municipal systems, which may contribute to a heightened risk of infections such as GAS [\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e]. Despite this, the overall prevalence of GAS decreased, likely due to improved hygiene practices and other pandemic-related measures. The reliance on private wells increased because municipal water availability decreased annually due to chronic shortages, particularly in the southwest bank region, which is considered a water-poor area. This scarcity has forced residents to increasingly depend on private wells for their water supply [\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e, \u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e].\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec21\" class=\"Section2\"\u003e \u003ch2\u003eHygiene Practices and Infection Control\u003c/h2\u003e \u003cp\u003eImproved hygiene behaviors were associated with a lower likelihood of GAS carriage. Frequent handwashing with soap and water, as well as daily toothbrushing, was linked to reduced GAS carriage [\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e]. Children who reported consistently washing their hands with soap and water had a significantly lower chance of carrying GAS (odds ratio (OR)\u0026thinsp;=\u0026thinsp;0.367, 95% CI: 0.184\u0026ndash;0.730, p\u0026thinsp;\u0026lt;\u0026thinsp;0.001). Similarly, daily toothbrushing significantly reduced the odds of carriage (OR for brushing twice\u0026thinsp;=\u0026thinsp;0.055, 95% CI: 0.019\u0026ndash;0.157, p\u0026thinsp;\u0026lt;\u0026thinsp;0.001).\u003c/p\u003e \u003cp\u003eThese findings emphasize the importance of personal hygiene in controlling infections. Handwashing with soap and water is a well-established, simple yet highly effective way to prevent the spread of numerous pathogens, including GAS. The emphasis on hand hygiene during the COVID-19 pandemic likely played a role in the observed decrease in GAS carriage. Interestingly, the link between teeth brushing and lower GAS carriage highlights the potential benefits of oral hygiene for preventing respiratory infections. Poor oral hygiene might create an environment favorable for bacterial growth, increasing the risk of infection [\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e].\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec22\" class=\"Section2\"\u003e \u003ch2\u003eComparison with Similar Studies\u003c/h2\u003e \u003cp\u003eThe observed reduction in GAS carriage aligns with reports of decreased respiratory infections associated with pandemic control measures [\u003cspan additionalcitationids=\"CR23\" citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e]. For example, a Taiwanese study documented significant declines in common respiratory illnesses, including streptococcal pharyngitis, during the COVID-19 pandemic, which was attributed to intensified public health interventions [\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e]. Similarly, research from several European countries revealed lower rates of respiratory infections in primary care settings, further suggesting broader benefits of COVID-19 prevention for infectious disease control [\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e, \u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e]. However, maintaining consistent public health measures presents distinct challenges in conflict settings such as Palestine. A study on healthcare in conflict zones emphasized the difficulties in securing reliable water quality and consistent public health practices, which can have variable effects on infectious disease transmission [\u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e].\u003c/p\u003e \u003c/div\u003e"},{"header":"Conclusion","content":"\u003cp\u003eOur study demonstrated a significant reduction in asymptomatic GAS carriage among Palestinian children following the implementation of COVID-19 health precautions. This finding suggested that improved hygiene practices and pandemic-related measures, despite potential counteracting factors such as reliance on private wells, had a net positive impact on GAS prevalence. These results underscore the importance of sustained public health efforts and personal hygiene in curbing the spread of infectious diseases. It is crucial for public health strategies to focus on maintaining and promoting these hygiene practices beyond the pandemic to mitigate the burden of GAS and other infectious diseases.\u003c/p\u003e"},{"header":"Abbreviations","content":"\u003cdiv class=\"DefinitionList\"\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eOR\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eOdds Ratio\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eBMI\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eBody Mass Index\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eGAS\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eGroup A Streptococcus.\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003c/div\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eAcknowledgements\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eWe gratefully acknowledge the Al-Quds University Health Research Ethical Review Committee for providing ethical clearance for this research. We also extend our sincere thanks to the study participants and everyone who, in any way, supported the completion of this project. In the preparation of this manuscript, AI-assisted language tools were employed to ensure the text is free from language errors and to enhance the overall clarity and readability of the document. These tools were used to check grammar, spelling, and syntax while maintaining the integrity and originality of the authors\u0026apos; work.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthors\u0026rsquo; contributions\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eI.G. initiated the study in 2019 and collected data at that time. All authors collected data in 2024. I.G. and Y.G. processed and analyzed the data. All authors contributed to the conceptualization, study design, execution, data acquisition, and interpretation. Each author participated in drafting, revising, or critically reviewing the article. All authors approved the final version for publication and consented to the journal selected for submission.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors self-funded the financial costs associated with collecting the research data.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAvailability of data and materials\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe researchers are willing to provide the data sets generated and/or analyzed as part of this study to interested parties upon reasonable request made to the corresponding author.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCompeting interests\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors declare no competing interests.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eEthics approval and consent to participate\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis research received ethical approval from the Al-Quds University Research Ethics Committee and adhered to the principles of the Declaration of Helsinki. \u0026nbsp; Data collectors and/or the investigator thoroughly explained the study\u0026apos;s purpose and the significance of participation to each child\u0026apos;s parent/guardian. Written informed consent was obtained from all parents/guardians, and assent was obtained from the children themselves before the study began. Participation was entirely voluntary.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent for publication\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNot applicable.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConflicts of interests\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThere were no conflicts of interest.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthor details\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e1 Department of Medical Laboratory Sciences, Al-Quds University, Faculty of Health professions, Abu Dis, Palestine.\u003c/p\u003e\n\u003cp\u003e2 Faculty of Medicine, Al-Quds University, Abu Dis, Palestine.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n\u003cli\u003ePallon J, Roost M, Sundqvist M, Hedin K: \u003cstrong\u003eThe aetiology of pharyngotonsillitis in primary health care: a prospective observational study\u003c/strong\u003e. \u003cem\u003eBMC Infect Dis \u003c/em\u003e2021, \u003cstrong\u003e21\u003c/strong\u003e(1):971.\u003c/li\u003e\n\u003cli\u003eNayiga I, Okello E, Lwabi P, Ndeezi G: \u003cstrong\u003ePrevalence of group a streptococcus pharyngeal carriage and clinical manifestations in school children aged 5-15 yrs in Wakiso District, Uganda\u003c/strong\u003e. \u003cem\u003eBMC Infect Dis \u003c/em\u003e2017, \u003cstrong\u003e17\u003c/strong\u003e(1):248.\u003c/li\u003e\n\u003cli\u003e\u003cstrong\u003eIncreased incidence of scarlet fever and invasive Group A Streptococcus infection - multi-country. \u003c/strong\u003e[https://www.who.int/emergencies/disease-outbreak-news/item/2022-DON429]\u003c/li\u003e\n\u003cli\u003eAvire NJ, Whiley H, Ross K: \u003cstrong\u003eA Review of Streptococcus pyogenes: Public Health Risk Factors, Prevention and Control\u003c/strong\u003e. \u003cem\u003ePathogens \u003c/em\u003e2021, \u003cstrong\u003e10\u003c/strong\u003e(2).\u003c/li\u003e\n\u003cli\u003eRobinson JL: \u003cstrong\u003ePaediatrics: how to manage pharyngitis in an era of increasing antimicrobial resistance\u003c/strong\u003e. \u003cem\u003eDrugs Context \u003c/em\u003e2021, \u003cstrong\u003e10\u003c/strong\u003e.\u003c/li\u003e\n\u003cli\u003eOliver J, Malliya Wadu E, Pierse N, Moreland NJ, Williamson DA, Baker MG: \u003cstrong\u003eGroup A Streptococcus pharyngitis and pharyngeal carriage: A meta-analysis\u003c/strong\u003e. \u003cem\u003ePLoS Negl Trop Dis \u003c/em\u003e2018, \u003cstrong\u003e12\u003c/strong\u003e(3):e0006335.\u003c/li\u003e\n\u003cli\u003eSpinks A, Glasziou PP, Del Mar CB: \u003cstrong\u003eAntibiotics for treatment of sore throat in children and adults\u003c/strong\u003e. \u003cem\u003eCochrane Database Syst Rev \u003c/em\u003e2021, \u003cstrong\u003e12\u003c/strong\u003e(12):CD000023.\u003c/li\u003e\n\u003cli\u003eVijaya D, Sathish J, Janakiram K: \u003cstrong\u003eThe prevalence of group a streptococci carriers among asymptomatic school children\u003c/strong\u003e. \u003cem\u003eJ Clin Diagn Res \u003c/em\u003e2013, \u003cstrong\u003e7\u003c/strong\u003e(3):446-448.\u003c/li\u003e\n\u003cli\u003eOrganization WH: \u003cstrong\u003eHealth conditions in the occupied Palestinian territory, including east Jerusalem, and in the occupied Syrian Golan\u003c/strong\u003e. 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In\u003cem\u003e.\u003c/em\u003e Washington, DC.; 2018.\u003c/li\u003e\n\u003cli\u003eDeMuri GP, Wald ER: \u003cstrong\u003eThe Group A Streptococcal Carrier State Reviewed: Still an Enigma\u003c/strong\u003e. \u003cem\u003eJ Pediatric Infect Dis Soc \u003c/em\u003e2014, \u003cstrong\u003e3\u003c/strong\u003e(4):336-342.\u003c/li\u003e\n\u003cli\u003eZuo Z, Yang C, Ye F, Wang M, Wu J, Tao C, Xun Y, Li Z, Liu S, Huang J\u003cem\u003e et al\u003c/em\u003e: \u003cstrong\u003eTrends in respiratory diseases before and after the COVID-19 pandemic in China from 2010 to 2021\u003c/strong\u003e. \u003cem\u003eBMC Public Health \u003c/em\u003e2023, \u003cstrong\u003e23\u003c/strong\u003e(1):217.\u003c/li\u003e\n\u003cli\u003eNguyen JL, Benigno M, Malhotra D, Khan F, Angulo FJ, Hammond J, Swerdlow DL, Reimbaeva M, Emir B, McLaughlin JM: \u003cstrong\u003ePandemic-related declines in hospitalization for non-COVID-19-related illness in the United States from January through July 2020\u003c/strong\u003e. \u003cem\u003ePLoS One \u003c/em\u003e2022, \u003cstrong\u003e17\u003c/strong\u003e(1):e0262347.\u003c/li\u003e\n\u003cli\u003eKadambari S, Goldacre R, Morris E, Goldacre MJ, Pollard AJ: \u003cstrong\u003eIndirect effects of the covid-19 pandemic on childhood infection in England: population based observational study\u003c/strong\u003e. \u003cem\u003eBMJ \u003c/em\u003e2022, \u003cstrong\u003e376\u003c/strong\u003e:e067519.\u003c/li\u003e\n\u003cli\u003eYang MC, Su YT, Chen PH, Tsai CC, Lin TI, Wu JR: \u003cstrong\u003eChanging patterns of infectious diseases in children during the COVID-19 pandemic\u003c/strong\u003e. \u003cem\u003eFront Cell Infect Microbiol \u003c/em\u003e2023, \u003cstrong\u003e13\u003c/strong\u003e:1200617.\u003c/li\u003e\n\u003cli\u003eWanat M, Hoste ME, Gobat NH, Anastasaki M, Bohmer F, Chlabicz S, Colliers A, Farrell K, Hollerbach S, Karkana MN\u003cem\u003e et al\u003c/em\u003e: \u003cstrong\u003ePatients\u0026apos; and clinicians\u0026apos; perspectives on the primary care consultations for acute respiratory infections during the first wave of the COVID-19 pandemic: an eight-country qualitative study in Europe\u003c/strong\u003e. \u003cem\u003eBJGP Open \u003c/em\u003e2022, \u003cstrong\u003e6\u003c/strong\u003e(2).\u003c/li\u003e\n\u003cli\u003evan der Velden AW, Bax EA, Bongard E, Munck Aabenhus R, Anastasaki M, Anthierens S, Balan A, Bohmer F, Bruno P, Chlabicz S\u003cem\u003e et al\u003c/em\u003e: \u003cstrong\u003ePrimary care for patients with respiratory tract infection before and early on in the COVID-19 pandemic: an observational study in 16 European countries\u003c/strong\u003e. \u003cem\u003eBMJ Open \u003c/em\u003e2021, \u003cstrong\u003e11\u003c/strong\u003e(7):e049257.\u003c/li\u003e\n\u003cli\u003eMarou V, Vardavas CI, Aslanoglou K, Nikitara K, Plyta Z, Leonardi-Bee J, Atkins K, Condell O, Lamb F, Suk JE: \u003cstrong\u003eThe impact of conflict on infectious disease: a systematic literature review\u003c/strong\u003e. \u003cem\u003eConfl Health \u003c/em\u003e2024, \u003cstrong\u003e18\u003c/strong\u003e(1):27.\u003c/li\u003e\n\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":true,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"bmc-infectious-diseases","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"infd","sideBox":"Learn more about [BMC Infectious Diseases](http://bmcinfectdis.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/infd","title":"BMC Infectious Diseases","twitterHandle":"#bmcinfectdis","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"Asymptomatic GAS carriage, COVID-19 precautions, Schoolchildren, Southern West Bank, Palestine.","lastPublishedDoi":"10.21203/rs.3.rs-4599563/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-4599563/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cb\u003eBackground\u003c/b\u003e\u003c/p\u003e \u003cp\u003e \u003cem\u003eStreptococcus pyogenes\u003c/em\u003e (Group A Streptococcus, GAS) is a significant pathogen that causes diverse infections, ranging from pharyngitis to severe invasive diseases. Asymptomatic carriage in children is pivotal for transmission. The COVID-19 pandemic's health measures, including mask wearing and enhanced hand hygiene, likely influenced GAS transmission dynamics. This study evaluated the impact of these precautions on the prevalence of asymptomatic pharyngeal GAS carriage among schoolchildren in the southern West Bank, Palestine.\u003c/p\u003e\u003cp\u003e\u003cb\u003eMethods\u003c/b\u003e\u003c/p\u003e \u003cp\u003eThis cross-sectional study was conducted in two phases: pre-COVID-19 (November 2019 - January 2020) and post-COVID-19 (November 2023 - April 2024). Throat swabs from 701 children (345 pre-COVID-19, 356 post-COVID-19) were collected using cluster sampling. The samples were tested using the ABON Strep A rapid test and confirmed by culture. Sociodemographic, health, and household data were gathered. The statistical analyses included descriptive statistics, chi-square tests, and binary logistic regression.\u003c/p\u003e\u003cp\u003e\u003cb\u003eResults\u003c/b\u003e\u003c/p\u003e \u003cp\u003eThe prevalence of asymptomatic GAS carriage significantly decreased from 15.7% in 2019 to 10.4% in 2024 (p\u0026thinsp;=\u0026thinsp;0.038). The gender distribution remained stable (p\u0026thinsp;=\u0026thinsp;0.662), while urban residence increased significantly from 34.5\u0026ndash;41.6% (p\u0026thinsp;=\u0026thinsp;0.050). The use of private wells for drinking water increased from 17.7\u0026ndash;32.0% (p\u0026thinsp;\u0026lt;\u0026thinsp;0.001), with private well users having greater odds of GAS carriage than municipal water users (adjusted OR\u0026thinsp;=\u0026thinsp;4.128, 95% CI: 2.175\u0026ndash;7.830, p\u0026thinsp;\u0026lt;\u0026thinsp;0.001). Consistent hand hygiene was associated with lower odds of carriage (adjusted OR\u0026thinsp;=\u0026thinsp;0.367, 95% CI: 0.184\u0026ndash;0.730, p\u0026thinsp;\u0026lt;\u0026thinsp;0.001), and regular teeth brushing also significantly reduced odds (adjusted OR for brushing twice daily\u0026thinsp;=\u0026thinsp;0.055, 95% CI: 0.019\u0026ndash;0.157, p\u0026thinsp;\u0026lt;\u0026thinsp;0.001).\u003c/p\u003e\u003cp\u003e\u003cb\u003eConclusions\u003c/b\u003e\u003c/p\u003e \u003cp\u003eCOVID-19-related health precautions were correlated with a significant reduction in asymptomatic GAS carriage among Palestinian children. These findings suggest that public health measures, such as mask wearing and hand hygiene, can influence the transmission of respiratory pathogens. Ongoing surveillance and targeted interventions are essential for managing GAS infections, particularly in resource-limited settings.\u003c/p\u003e","manuscriptTitle":"Impact of COVID-19 Health Precautions on Asymptomatic Streptococcus pyogenes Carriage in Palestinian Children: A Before and After Study","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2024-07-16 21:58:08","doi":"10.21203/rs.3.rs-4599563/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Revision requested","date":"2024-08-06T10:25:26+00:00","index":"","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2024-08-05T20:19:45+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2024-07-30T08:42:38+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2024-07-29T14:16:36+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"141511528195906281908189978384607944159","date":"2024-07-15T07:09:09+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"75263361568834245240222803855587500963","date":"2024-07-14T16:23:19+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"161853055542842952545498260517652766155","date":"2024-07-12T12:01:37+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"120291525581563900464113971405374827048","date":"2024-06-25T14:27:17+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2024-06-24T04:47:23+00:00","index":"","fulltext":""},{"type":"editorInvited","content":"","date":"2024-06-20T11:07:10+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2024-06-19T05:22:45+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2024-06-19T05:20:43+00:00","index":"","fulltext":""},{"type":"submitted","content":"BMC Infectious Diseases","date":"2024-06-18T11:16:02+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"bmc-infectious-diseases","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"infd","sideBox":"Learn more about [BMC Infectious Diseases](http://bmcinfectdis.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/infd","title":"BMC Infectious Diseases","twitterHandle":"#bmcinfectdis","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"091e0d38-8acc-4e24-90f1-ff2929746861","owner":[],"postedDate":"July 16th, 2024","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"published-in-journal","subjectAreas":[],"tags":[],"updatedAt":"2024-10-07T16:01:30+00:00","versionOfRecord":{"articleIdentity":"rs-4599563","link":"https://doi.org/10.1186/s12879-024-10023-w","journal":{"identity":"bmc-infectious-diseases","isVorOnly":false,"title":"BMC Infectious Diseases"},"publishedOn":"2024-10-04 15:57:35","publishedOnDateReadable":"October 4th, 2024"},"versionCreatedAt":"2024-07-16 21:58:08","video":"","vorDoi":"10.1186/s12879-024-10023-w","vorDoiUrl":"https://doi.org/10.1186/s12879-024-10023-w","workflowStages":[]},"version":"v1","identity":"rs-4599563","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-4599563","identity":"rs-4599563","version":["v1"]},"buildId":"WrCJVZZCHTDjtuVLN7oU0","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}