From tap to table: An assessment of drinking water quality in Perak, Malaysia.

INTRODUCTION: A study on the quality of drinking water was conducted at Air Kuning Treatment Plant In Perak, Malaysia, based on a sanitary survey in 14 sampling points stations from the intake area to the auxiliary points. This was to ensure the continuous supply of clean and safe drinking water to the consumers for public health protection. The objective was to examine the physical, microbiological, and chemical parameters of the water, classification at each site based on National Drinking Water Standards (NDWQS) and to understand the spatial variation using environmetric technique; principal component analysis (PCA). MATERIALS AND METHODS: Water samples were subjected to in situ and laboratory water quality analyses and focused on pH, turbidity, chlorine, Escherichia coli, total coliform, total hardness, iron (Fe), aluminium (Al), zinc (Zn), magnesium (Mg) and sodium (Na). All procedures followed the American Public Health Association (APHA) testing procedures. RESULTS: Based on the results obtained, the values of each parameter were found to be within the safe limits set by the NDWQS except for total coliform and iron (Fe). PCA has indicated that turbidity, total coliform, E. coli, Na, and Al were the major factors that contributed to the drinking water contamination in river water intake. CONCLUSION: Overall, the water from all sampling point stations after undergoing water treatment process was found to be safe as drinking water. It is important to evaluate the drinking water quality of the treatment plant to ensure that consumers have access to safe and clean drinking water as well as community awareness on drinking water quality is essential to promote public health and environmental protection.

Hand washing with soap reduces diarrhoea and spread of bacterial pathogens in a Bangladesh village.

Hand washing with soap and water can prevent the spread of diarrhoeal diseases in areas where comparatively costly interventions, such as supply of safe water and improved sanitation, are not possible. In this study, the practice of hand washing with soap and water was instituted in a periurban slum of Dhaka city, and the surveillance for diarrhoea sustained for a one-year period. Rates of primary and secondary attacks were compared to those of a non-intervention area similar in age structure, economic status, education, and other relevant variables. Rectal swabs of cases and contacts established aetiologies. There was a large (2.6 fold) reduction in diarrhoeal episodes in the intervention area during the observation period. Rates of bacterial pathogens were also lower in the intervention area. Significant reduction in diarrhoeal incidences was observed in all age groups for all pathogens except for rotavirus. These observations if implemented as health policy could reduce the spread of diarrhoeal diseases at low cost in high risk areas.

Serum, breast milk, and infant antibody after maternal immunisation with pneumococcal vaccine.

Pneumococci are a leading cause of severe bacterial disease in infants and children world wide. A possible means of protecting infants in the first few months of life is immunisation of the mother during pregnancy. We prospectively assessed pneumococcal immunisation of pregnant women to determine the amount of pneumococcal antibody transmitted to the infants in serum and milk and the half-life of the passively acquired antibody. Healthy pregnant women in Dhaka, Bangladesh, were randomised to receive pneumococcal or meningococcal vaccine with routine prenatal tetanus immunisation at 30-34 weeks of gestation. Serum and breast milk specimens from the mothers and sera from infants were collected up to 22 weeks of age and assayed for specific serum IgG, IgG1, and IgG2 and for milk IgA antibodies to pneumococcal serotypes 6B and 19F. 55 mothers and 56 infants were followed from birth to five months. Women who received pneumococcal vaccine had geometric mean antibody increases of 2.6 and 3.4 to types 6B and 19F, respectively. The mean infant/maternal antibody ratios were 0.56 and 0.59 (range 0.11-1.46) for these serotypes. Infant cord antibody titres correlated with maternal titres. Infant/maternal IgG ratios correlated with the interval between immunisation and birth and were higher for specific IgG1 than for IgG2. Infants of pneumococcal vaccine recipients had geometric mean antibody concentrations of 6.8 and 7.5 micrograms/mL to serotypes 6B and 19F in cord blood; in cord blood and in all subsequent serum specimens the concentrations were 2-3 fold higher than in control infants. The median half-life of passive antibody was about 35 days; at five months of age 63-71% of infants of pneumococcal vaccine recipients had antibody concentrations greater than 0.15 micrograms/mL. Breast milk IgA antibodies for pneumococcal serotype 19F, but not for type 6B, were significantly higher in vaccine recipients up to five months after delivery. If maternal pneumococcal polysaccharide antibodies do not interfere with active immunisation of the infant with new glycoprotein conjugate pneumococcal vaccines, passive-active immunisation of infants can be a feasible strategy for developing regions.

Enteroaggregative Escherichia coli infections in Bangladeshi children: clinical and microbiological features.

Escherichia coli isolated from 389 children, less than 1-year of age with diarrhoea, were analyzed for the presence of Enteroaggregative E. coli (EAggEC) by their pattern of adherence to HeLa cells. EAggEC were isolated from 58 (14.8%) children either as a sole pathogen or in combination with other enteric pathogens. In 60% of these children EAggEC infection occurred in the second half of infancy (7-12 m). Thirty-eight of 47 children having EAggEC as a sole pathogen had watery diarrhoea along with vomiting (87%) and dehydration (74%). In contrast, 9 of the 47 cases had mucoid diarrhoea with infrequent vomiting and dehydration and frequent abdominal pain. Children infected with EAggEC were successfully rehydrated with oral rehydration solution (ORS) alone. Seventy-one percent of the EAggEC strains were resistant to more than three antibiotics. It was evident by phage pattern that various EAggEC strains were present in the population. The results indicated that infections with EAggEC may have a role in the development of diarrhoea among children less than 1-year of age in Bangladesh.

Rotavirus infection detected in neonates from hospitals in urban Bangladesh.

A study of neonatal group A rotavirus (RV) infection in 3 hospitals of urban Bangladesh identified 60 infected babies of 100 studied in 2 hospitals. Preliminary evidence based on serotyping and electropherotyping suggest that these RVs differ from community strains.

Cryptosporidiosis: a cause of diarrhea in Bangladesh.

Fecal samples from diarrheal patients and non-diarrheal controls were examined for Cryptosporidium oocysts in a year-long prospective study at a diarrhea treatment center in Dhaka, Bangladesh. Cryptosporidium oocysts were detected in 42 (3%) of 1,382 diarrheal patients but in none of 235 non-diarrheal controls. In 32 (76%) of 42 patients, no other enteropathogens were detected. Children less than 5 years of age were more commonly infected than older children (4.8% vs. 1.6%, P greater than 0.05) and adults (4.8% vs. 0.2%, P less than 0.01). A higher number of cases were detected during hot and humid months (April--July). Nineteen children less than 5 years of age (index cases) and their 71 family members were followed for 3 weeks after the release of the index cases from the hospital. Diarrhea continued for greater than 14 days (persistent diarrhea) in 8 (32%) index children. Cryptosporidium oocysts were detected in 1 (12.5%) of 8 family members who developed diarrhea during the follow-up period. Index cases excreted oocysts for 3-28 days (12.37 +/- 8.35 days). Almost all the patients recovered with oral rehydration. Cryptosporidium ssp. cause self-limited diarrhea episodes in children less than 5 years of age in Bangladesh, with a low frequency of intrafamilial transmission.

Risk factors for persistent diarrhoea.

With a systematically sampled population of children aged under 5 attending this centre for diarrhoeal disease research during 1983-5 a retrospective analysis of persistent diarrhoea (defined as greater than 14 days' duration) was performed to identify the possible risk factors for this syndrome. Of the 4155 children included in the analysis, 410 (10%) gave a history of persistent diarrhoea. A comparison with children with acute diarrhoea matched for age showed that 11 factors were correlated with persistent diarrhoea, and strongly associated factors were stools with blood or mucus, or both, lower respiratory tract infection, malnutrition, vitamin A deficiency, and antibiotic use before presentation. The peak age was 2 years, and there was no sex difference. Deaths occurred more often in the group with persistent diarrhoea. Although Shigella spp, Campylobacter jejuni, and Giardia lamblia were frequently identified, their rates of isolation were not significantly higher among patients with persistent diarrhoea. No seasonal variation was observed in the rates of persistent diarrhoea. Although the introduction of family food to the diet was associated with higher rates, this factor was difficult to separate from the age dependent risks.

Serotypes of Campylobacter jejuni isolated from patients attending a diarrhoeal disease hospital in urban Bangladesh.

The serotypes of strains of Campylobacter jejuni isolated from patients attending the International Center for Diarrhoeal Disease Research, Bangladesh (ICDDR, B), Dhaka, and from animals were ascertained by Penner and Hennessy's (1980) serotyping scheme. Of 102 isolates from man, 74% were typable and serotypes 53, 15 and 22 predominated. Of 26 isolates from animals, 65% were typable and serotypes 15 and 53 occurred frequently. The diarrhoeal illnesses associated with different serotypes were similar. In one-third of cases other enteropathogens were present. C. jejuni was isolated from 7% of patients tested in a 4% sampling system during 1983, and the prevalent serotypes appeared in most months. It is concluded that C. jejuni is a common enteropathogen in Bangladesh, that a few serotypes predominate among isolates from both man and animals, and that serotype does not determine clinical symptoms.

Cryptosporidium as a pathogen for diarrhoea in Bangladesh.

Cryptosporidiosis, a zoonosis caused by Cryptosporidium species is a newly recognized coccidial protozoan infection causing diarrhoea in humans. Using a modified acid fast technique, the International Centre for Diarrhoeal Disease Research, Bangladesh (ICDDR,B) has been screening a 4% sample of diarrhoea patients attending the ICDDR,B diarrhoea treatment center for Cryptosporidium in their stools as a part of an ongoing surveillance program. Positive specimens were confirmed by the standard Giemsa method. Cryptosporidia were identified predominantly in young children and were associated with watery diarrhoea, vomiting, cough and mild to moderate dehydration. The protozoan had a seasonal pattern with an increase in the hot, humid weather. We conclude that Cryptosporidium infection is relatively common in children in Bangladesh and may be responsible for a significant proportion of diarrhoea in this area.

Follow-up of children discharged from hospital after treatment for diarrhoea in urban Bangladesh.

To determine the subsequent mortality of urban children in Bangladesh after an episode of diarrhoea we visited 74 children aged 2 to 5 years in their homes four months after they had received treatment for diarrhoea at the International Centre for Diarrhoeal Disease Research, Bangladesh (ICDDR,B). Parents and health workers were questioned about their perceptions of the nutritional status of the children at this time. Although 43% of the children were severely malnourished and 28% were moderately malnourished at the time of presentation to ICDDR,B only two deaths (3%) had occurred in the cohort during follow-up. No deaths were noted for the severely malnourished two year old group, which contrasts with the high post-discharge mortality (33%) in similarly malnourished two year old Bangladeshi children living in rural areas (p = 0.004) at the time of follow-up parents were significantly (p = 0.02) less likely than health workers to recognize malnutrition in the children. We suggest that there may be substantial rural-urban differences in the survival of children after receiving treatment for diarrhoea. Further, we note that parental under-recognition of malnutrition may impede the nutritional rehabilitation that is necessary to avert much of the morbidity and mortality that ensues after an episode of diarrhoea.

Breast feeding as a determinant of severity in shigellosis. Evidence for protection throughout the first three years of life in Bangladeshi children.

Little is known about the effect of breast feeding upon the severity of illness due to specific diarrheal pathogens. Using a systematically sampled and evaluated population of children aged less than 3 years, who attended a diarrheal disease hospital in Bangladesh, the authors performed a case-control study that assessed whether breast feeding reduces the severity of illness in shigellosis. From 540 children presenting with shigellosis between 1980-1982, they created a group of cases (n = 53) with severe illness and controls (n = 487) with non-severe illness. Overall, the odds ratio relating breast feeding to the severity of shigellosis (0.49, p = 0.01) suggested a substantial mitigating effect of breast feeding upon clinical severity. The high degree of protection against severe shigellosis was evident for breast-fed children up to 35 months of age, as well as for children at high risk for death because of severe malnutrition or measles. Because shigellosis continues to account for substantial morbidity and mortality in children in developing countries, the results support prolonged breast feeding in these settings.

PIP: The influence of breastfeeding on the severity of illness in shigellosis was assessed in a case-control study involving 540 children presenting with shigellosis to a Bangladesh diarrheal disease hospital in 1980-82. The 53 cases were children under 3 years of age with severe illness (i.e., rectal temperature above 102 F, severe neurologic manifestations, or severe dehydration), while the 487 age-matched controls had non-severe shigellosis. 42% of the cases compared with 59% of controls were breastfed, yielding an odds ratio of 0.49 (95% confidence interval, 0.28-0.86). This finding suggests that breastfeeding substantially shifts the spectrum of severity in Shigella infections from severe to non-severe illness. The high degree of protection against severe shigellosis was also seen in malnourished children and in children reporting a recent history of measles. The protective effect of breastfeeding persisted even when the analysis was corrected for the confounding effects of age, nutritional status, and earlier receipt of medication. These results are consistent with data from both developed and developing countries indicating that breastfeeding reduces the severity of illness in childhood diarrhea. In Bangladesh, about 1/3 of mothers breastfeed for 3 years. In other areas of the developing world, however, breastfeeding beyond infancy is relatively uncommon. Because shigellosis accounts for substantial morbidity and mortality in developing countries, prolonged breastfeeding is recommended.

Morbidity and mortality in a diarrhoeal diseases hospital in Bangladesh.

Records of all patients who were admitted to or who died in Dhaka hospital of the International Centre for Diarrhoeal Disease Research, Bangladesh (ICDDR,B) between July 1980 and 30th June 1981 were reviewed to identify epidemiological characters associated with in-hospital diarrhoeal diseases-related deaths. Information on aetiological agents, age, sex, major complications, nutritional status and level of dehydration were analysed. Over the one-year period, 3251 patients were admitted to the medical wards and 400 died. Children under five made up 72% of patients admitted and 77% of those who died. All patients were cultured for enteric vibrios, Salmonella and Shigella; 25% of the patients had at least one of these organisms. Shigella was most common and was isolated from 13% of the patients and 19% of those who died. Case-fatality rates in patients with Shigella and Vibrio cholerae non-OI (NAG) were significantly higher than other enteric pathogens (V. cholerae OI, Salmonella typhi and mixed). Case fatality for Vibrio cholerae non-OI was higher than Shigella (25.8% and 17.2%) but the difference was not statistically significant. Among those who died 21% were severely dehydrated and 50% had various complications. Patients with V. cholerae OI were significantly more dehydrated than other groups (P less than 0.05 by chi 2 test). The patients who died with Shigella were significantly more malnourished and had more frequent associated complications than other non-Shigella diarrhoea patients (P less than 0.01 by chi 2 test). Overall our observations indicate that Shigella and Vibrio cholerae non-OI are associated with unusually high case fatality.(ABSTRACT TRUNCATED AT 250 WORDS)

Changing pattern of resistant Shiga bacillus (Shigella dysenteriae type 1) and Shigella flexneri in Bangladesh.

Shigella dysenteriae type 1 (Shiga bacillus) has made a dramatic comeback in Bangladesh after 10 years when Shigella flexneri was the dominant serogroup. Whereas S. flexneri showed little increase in resistance to the commonly used antimicrobial agents--namely, trimethoprim-sulfamethoxazole (TMP-SMX) and ampicillin-over the years, S. dysenteriae type 1 underwent rapid changes with regard to sensitivity pattern during the last two years. The first TMP-SMX-resistant strain of S. dysenteriae type 1 was detected in September 1982; however, by mid-1984 most strains were resistant while retaining sensitivity to ampicillin. During this period, the ratio of S. flexneri to S. dysenteriae type 1 narrowed from 0.15 to 1. Such propagation of high resistance to TMP-SMX might have been due to widespread use of the drug imported into the country in large quantities. Resistance to ampicillin is increasing rapidly, particularly in S. dysenteriae type 1.

Yersinia enterocolitica infection; a case report from Bangladesh.

While a large number of confirmed cases of Yersinia enterocolitica have been reported in different temperate zones, there is little information on the incidence of this infection in tropical areas. For the first time in Bangladesh, this organism has been isolated from the stool of a diarrhoea patient and, therefore, is recognized as a new enteropathogen in this country. The strain was characterized as biotype I, serotype 0:8 and phage type X2. The patient was a five-year-old girl from a poor Muslim family, and admitted to ICDDR,B's Treatment Centre with complaints of abdominal pain, low-grade fever and diarrhoea.

Risk factors for death in complicated diarrhoea of children.

A total of 1330 children with complicated diarrhoea who were admitted to the general ward of the International Centre for Diarrhoeal Diseases Research, Bangladesh Health Complex, during 1979 were examined. The risk of death by complication of diarrhoea, aetiology, age, and nutritional state was analysed by a logit regression model. Serum sodium concentration and coma were found to be significant predictors of death, death being related directly to coma and inversely to serum sodium concentration. An earlier study had shown that the incidence of hyponatraemia was directly related to the degree of malnutrition, but the results of logit regression analysis did not show the nutritional state to be a predictor of death. Owing to lack of data, however, serum albumin concentration could not be taken as a variable in the logit regression analysis. To determine the relation of serum albumin concentration to hyponatraemia and the cause of death in hyponatraemia further prospective studies would be necessary.

Beliefs and treatment related to diarrhoeal episodes reported in association with measles.

Eighty mothers whose children had measles in the past month were interviewed for beliefs and practices related to the management of measles and measles associated diarrhoea. Beliefs and practices about diarrhoea, associated with measles are described. Diarrhoea during and after measles was considered beneficial by mothers, who believed it helped to flush out impurities from the body. Paradoxically ORS was not used because of an erroneous idea that ORS would stop diarrhoea. Informing mothers that ORS will not stop diarrhoea, but will help in flushing out the impurities, could enhance ORS use, reducing morbidity and mortality. The prevalent belief, that measles patients must be kept in a clean environment is useful and should be encouraged. Other beliefs and practices to hasten the eruption are neutral, but since they encourage cleanliness and isolation, need not be discouraged.