Using a knowledge, attitudes and practices survey to supplement findings of an outbreak investigation: cholera prevention measures during the 1991 epidemic in Peru.

BACKGROUND: To assess the effectiveness of the cholera prevention activities of the Peruvian Ministry of Health, we conducted a knowledge, attitudes, and practices (KAP) survey in urban and rural Amazon communities during the cholera epidemic in 1991. METHODS: We surveyed heads of 67 urban and 61 rural households to determine diarrhoea rates, sources of cholera prevention information, and knowledge, attitudes, and practices regarding ten cholera prevention measures. RESULTS: Twenty-five per cent of 482 urban and 11% of 454 rural household members had diarrhoea during the first 3-4 months of the epidemic. Exposure to mass media education was greater in urban areas, and education through interpersonal communication was more prevalent in rural villages. Ninety-three per cent of rural and 67% of urban respondents believed they could prevent cholera. The mean numbers of correct responses to ten knowledge questions were 7.8 for urban and 8.2 for rural respondents. Practices lagged behind knowledge and attitudes (mean correct response to ten possible: urban 4.9, rural 4.6). Seventy-five per cent of respondents drank untreated water and 91% ate unwashed produce, both of which were identified as cholera risk factors in a concurrently conducted case-control study. CONCLUSIONS: The cholera prevention campaign successfully educated respondents, but did not cause many to adopt preventive behaviours. Direct interpersonal education by community-based personnel may enhance the likelihood of translating education into changes in health behaviours. Knowledge, attitudes, and practices surveys conducted with case-control studies during an epidemic can be an effective method of refining education/control programmes.

PIP: The authors conducted a knowledge, attitudes, and practices (KAP) survey in urban and rural Amazon communities during the 1991 cholera epidemic to assess the effectiveness of the Peruvian Ministry of Health's cholera prevention activities. Diarrhea rates, sources of cholera prevention information, and knowledge, attitudes, and practices regarding 10 cholera prevention measures were determined by surveying the heads of 67 urban and 61 rural households. 25% of 482 urban and 11% of 454 rural household members had diarrhea during the first 3-4 months of the epidemic. Exposure to mass media education was greater in urban areas, while education through interpersonal communication prevailed in rural villages. 93% of rural and 67% of urban respondents believed they could prevent cholera. Rural respondents were slightly more knowledgeable than urban respondents about cholera. Overall, however, practices did not reflect their knowledge and attitudes; 75% of respondents drank untreated water and 91% ate unwashed produce.

Epidemic cholera in the Amazon: the role of produce in disease risk and prevention.

Epidemic cholera struck Peru in January 1991 and spread within a month to the Amazon headwaters. A case-control study was done in the Amazonian city of Iquitos, Peru. Cholera-like illness was associated with eating unwashed fruits and vegetables (odds ratio [OR] = 8.0; 95% confidence limits [CL] = 2.2, 28.9) and drinking untreated water (OR = 2.9; 95% CL = 1.3, 6.4). Consumption of a drink made from toronja, a citrus fruit, was protective against illness (OR = 0.4; 95% CL = 0.2, 0.7). Illness was inversely associated with the quantity of toronja drink consumed (P < .01). Produce has not previously been convincingly documented as a risk factor for cholera; this study underscores the importance of washing produce before eating it. Acidic juices, such as toronja drink (pH 4.1), inhibit vibrio growth and may make contaminated water safer. Wild citrus fruits such as toronja are abundant, cheap, and popular in the Amazon region. Promoting the consumption of toronja drink may be a useful cholera prevention strategy in this region.

Epidemic cholera in the Amazon: the challenge of preventing death.

Epidemic cholera struck Peru in January 1991, and spread rapidly. The national cholera case-fatality rate (CFR) was less than 1% in the first six months of the epidemic, but in some rural areas, the CFR exceeded 10%. We investigated cholera mortality in the rural Amazon region, an area with a CFR of 6.3%. We conducted a case-control study, comparing 29 decedents with 61 survivors of recent cholera-like diarrheal illness in 12 villages with a combined CFR of 13.5%. Of 29 decedents, 28 (96%) died in the village or en route to a health facility. Death occurred within 36 hours of illness onset for 83% of the decedents. In 11 (92%) villages, the first or second recognized case was fatal. Death was associated with receiving treatment only at home (odds ratio indeterminate; 95% confidence interval 3.5, indeterminate). Treatment with oral rehydration salts (ORS) was not protective against death for patients who received treatment only at home. Treatment with homemade sugar-salt solution (SSS) was also not protective; fewer than one-third of respondents knew the correct SSS recipe. Most decedents experienced multiple barriers to health care. Cholera victims died rapidly and early in village outbreaks, and few patients had access to health care. Provision of threatened villages with ORS supplies and education in their use before cholera strikes is essential to reducing cholera mortality in this region.

Cholera in Piura, Peru: a modern urban epidemic.

In late January 1991, epidemic cholera appeared in Peru. Within 2 months, 7922 cases and 17 deaths occurred in Piura, a Peruvian city of 361,868. A hospital-based culture survey showed that 79%-86% of diarrhea cases were cholera. High vibriocidal antibody titers were detected in 34% of the asymptomatic population. A study of 50 case-patients and 100 matched controls demonstrated that cholera was associated with drinking unboiled water (odds ratio [OR], 3.9; 95% confidence interval [CI], 1.7-8.9), drinking beverages from street vendors (OR, 14.6; CI, 4.2-51.2), and eating food from street vendors (OR, 24.0; CI, 3.0-191). In a second study, patients were more likely than controls to consume beverages with ice (OR, 4.0; CI, 1.1-18.3). Ice was produced from municipal water. Municipal water samples revealed no or insufficient chlorination, and fecal coliform bacteria were detected in samples from 6 of 10 wells tested. With epidemic cholera spreading throughout Latin America, these findings emphasize the importance of safe municipal drinking water.

Investigación epidemiológica del Cólera en el Perú: Lecciones para un Continente en riesgo / Epidemiological investigation of cholera in Perú; Lessons for a continent in risk

Desde el inicio de la epidemia de cólera en el Perú el Programa de entrenamiento en Epidemiología de Campo de la Oficina General de Epidemiología del Ministerio de Salud ha desarrollado diversas investigaciones con el propósito de mejorar la efectividad de las medidas de intervención para el control del problema. A través de la aplicación y diseños metodológicos estandarizados en las áreas más afectadas, se ha encontrado que la seroprevalencia de infección por Vibrio cholerae alcanza a 25-30 de cada 100 habitantes. Los factores de riesgo más significativos incluyen consumo de agua no tratada y de alimentos sanitariamente deficientes. La severidad de cuadro clínico colérico está asociada significativamente con la presencia de grupo sanguíneo "O". La letalidad del cólera está asociada con el tratamiento intradomiciliario del enfermo y la automedicación familiar. El desconocimiento acerca de los modos de contagio, tratamiento y prácticas preventivas incrementa el riesgo de enfermar con cólera. Finalmente, la magnitud del cólera en la población infantil parece ser mayor en el escenario comunitario que en el hospitalario. Los estudios epidemiológicos en el campo pueden ayudar a identificar medidas de control más específicas y más efectivas

Epidemia de cólera en Perú: estudio caso-control de Piura. febrero-marzo. 1991 / Cholera epidemic in Perú: study of a control case of Piura

El primer estudio de 50 casos y 100 controles pareados, mostró asociación significativa entre enfermedad y los factores siguientes: 1) Consumo de bebidas de vendedores ambulantes (OR=14.6, IC 95 por ciento=4.2-51). 2) Consumo de alimentos de vendedores ambulantes (OR=24.0, IC 95 por ciento=3.0-191) 3) Tomar agua sin hervir (OR=3.9, IC 95 por ciento=1.7-8.9). 4) Consumo de arroz cocinado que permaneció sin consumir 3 horas o más y que no fue recalentado antes de su ingesta (OR=3.1, IC 95 por ciento=1.2-8.4). 5) Introducir las manos dentro del depósito familiar donde se almacena el agua de consumo (OR=2.6, IC 95 por ciento=1.2-5.9). El segundo estudio de 32 casos y controles, quienes habían consumido algún alimento o bebida en vendedores ambulantes, demostró asociación significativa entre la enfermedad y el haber tomado bebidas con hielo en vendedores ambulantes (OR=4.0, IC 95 por ciento=1.04-16.6); no se encontró bebida ni comida particular asociada con la enfermedad. Adicionalmente realizaron una encuesta a 31 vendedores anbulantes de bebida, mostrando que el 90 por ciento de ellos añadían hielo a sus bebidas, el que era adquirido de una de las tres fábricas de hielo existentes en Piura

Cólera en la selva peruana: factores de riesgo y protección / Cholera at peruvian jungle: risk factors and protection

El cólera no ha sido reconocido en Sudamérica desde fines del siglo pasado; sin embargo, desde inicios de 1991 más de 200,000 casos de cólera han sido reportados en Perú. La epidemia alcanzó la región amazónica en febrero de 1991, y se efectuó un estudio Caso Control pareado en habitantes de la ciudad de Iquitos con el propósito de identificar factores de riesgo en la transmisión de la enfermedad en el escenario amazónico. Los casos fueron residentes con diarrea acuosa aguda admitidos a la Unidad de Tratamiento de Cólera de los Hospitales de Salud de la ciudad; los controles fueron residentes sanos pareados por sexo, edad y vecindario. Los factores asociados a cólera fueron los siguientes: consumo de agua cruda (ORm=2,9; IC 95 por ciento=1,3<6,4); consumo de fruta y/o verdura sin lavar (ORm=8,0; IC 95 por ciento=2,2<28,9); consumo de arroz frio (ORm=2,1; IC 95 por ciento=1,1<4,5); consumo de `juane' en adultos de 25 a 44 años (ORm=4,2; IC 95 por ciento=1,1<16,3). Adicionalmente, se encontró que el consumo de jugo de toronja (`toronjada'; pH promedio=2,3) se asoció con un riesgo de enfermedad significativamente disminuido (ORm=0,4; IC 95 por ciento=0,2<0,7). El aparente efecto protectivo asociado al consumo de toronja, independientemente de la fuente de agua pura pudiera deberse a la incapacidad de sobrevivencia del V. cholerae en medios con pH bajo. Los factores de riesgo identificados en esta región de la amazonía sugieren que el consumo de agua hervida (o apropiadamente clorinada), la preparación higiénica y el calentamiento de los alimentos previo a su consumo pueden prevenir la ocurrencia de casos de cólera en otras situaciones epidémicas