Determinants of drinking water quality in rural Nicaragua.

One hundred and fifty-three water samples from rural Nicaragua were examined for the presence of faecal coliforms during both wet and dry periods. A linear model was fitted by analysis of covariance with the logarithm of the faecal coliform count as the dependent variable. As expected, traditional water sources were grossly contaminated at all times whereas piped water sources were much cleaner. Hand-dug protected wells had significantly higher levels of faecal contamination than unprotected riverside wells and springs during the dry season. The possible reasons for this unexpected finding are discussed. A close association between rainfall and faecal contamination was demonstrated but the effect of rainfall depended on the type of water source. An association between water quality and the size of the community served by the source was also detected. The finding that stored water was usually more contaminated than fresh water samples is consistent with the results from other studies. Since it is unusual for water quality to be inversely correlated with accessibility, this study site would be suitable for investigating the relative importance of water-borne versus water-washed transmission mechanisms in childhood diarrhoea.

Outbreak of Clostridium difficile diarrhoea in an orthopaedic unit: evidence by phage-typing for cross-infection.

In a three-week period five patients had diarrhoea in an orthopaedic unit. The first case was clinically diagnosed as pseudomembranous colitis but the causative agent was not sought. Of the remaining cases, two were Clostridium difficile positive. The outbreak then apparently ceased, but during the following several days two of seven stool samples taken at random from asymptomatic patients yielded C. difficile. Phage-typing of the isolates showed that all apparently belonged to the same strain.

The value of water supply and sanitation in development: an assessment.

The attractiveness of oral rehydration therapy (ORT), a new and simple ministration that averts many child deaths from diarrhea among children, is diverting attention among donor agencies from the importance of water supply and sanitation (WS&S) in developing nations. The principal factor that led to the adoption of ORT is its apparent low cost per diarrheal death averted in children when compared with WS&S. However, WS&S provides many more benefits that are essential to sustaining the lives saved by ORT and vital to maintaining and enhancing the lives of adults and children. Among many other benefits WS&S prevents spread of the causes of diarrhea, controls many other water- and sanitation-related diseases, releases women from the heavy and time-consuming burden of carrying water from distant sources, and improves the quality of life in the community. Cost comparisons between WS&S and ORT are misleading. WS&S is a long-term investment in preventive health while ORT is a response to an immediate life-threatening situation. WS&S interventions eliminate unsanitary conditions leading to illness and death while ORT has no effect on the causes of diarrheal morbidity. The costs of WS&S are not high: $5 to $10 per capita annually. Without WS&S and hygiene education ORT programs are not likely to effect long-term improvement in child health status. ORT and WS&S programs are complementary; one should not displace the other.

Aeromonas-associated diarrhea in children.

In a 27-month prospective study, Aeromonas spp. were isolated from 7.3% of children with diarrhea and from 2.2% of controls. In 32 patients with diarrhea, ranging in age from 1 to 27 months old, Aeromonas spp. were the only potential bacterial enteropathogens isolated. Principal symptoms of Aeromonas-associated diarrhea were vomiting, fever and bloody stools. Diarrhea was often self-limiting and lasted for 10 days or less in 90% of patients. No secondary spread of diarrhea among close contacts was observed and no clear-cut seasonal patterns of Aeromonas isolation were found. Aeromonas caviae was the most frequently isolated species in fecal samples of patients (24 of 29 isolates) as well as controls (5 of 7 isolates). Cholera toxin cross-reactive cytotoxic enterotoxin was produced by a vast majority of Aeromonas isolates, as compared to a non-cholera toxin cross-reactive cytotonic enterotoxin. In addition no significant correlation was observed between severity of the diarrheal disease and different Aeromonas or the quantity of enterotoxins produced. In our geographic area Aeromonas spp., and A. caviae in particular, seem to be an important and frequent cause of diarrhea in young children.

Evidence for cross-infection in an outbreak of Clostridium difficile-associated diarrhoea in a surgical unit.

Environmental studies were performed in a hospital outbreak of Clostridium difficile-associated diarrhoea. Transmission was associated with the sluice room and the storage room where medical equipment was found to be contaminated with C.difficile. Typing of isolates by antibiotic-susceptibility patterns and profiles of EDTA-extracted proteins showed the presence of an "epidemic" strain common to the majority of patients and environmental sites. Control of the outbreak was achieved by improvement of environmental hygiene and use of disposable equipment.

Diarrheal illness among infants and toddlers in day care centers: effects of active surveillance and staff training without subsequent monitoring.

From October 1981 to September 1984, the authors conducted a three-year longitudinal study of diarrhea among infants and toddlers attending day care centers in Maricopa County, Arizona. In the third year of study, they evaluated the effects on diarrhea rates of staff training without external monitoring and of active surveillance conducted throughout the study. From 21 study day care centers, they randomly selected 10 ("intervention day care centers") to receive staff training in procedures to reduce transmission of infectious diarrhea. Continuing active surveillance in the 10 intervention and 11 control day care centers found no difference between diarrhea rates in intervention day care centers in the pre- and posttraining years and no difference between diarrhea rates in the two groups of centers either before or after the training intervention. Biweekly family-based surveys during the two months after training also demonstrated no difference between infant-toddler diarrhea rates in intervention and control day care centers. These surveys found the 21 study day care centers to have significantly higher diarrhea rates than did day care homes or households not using day care, but significantly lower rates than day care centers not included in the active surveillance. Continuous surveillance without training was associated with a significant decrease in diarrheal illness during the course of longitudinal study. One-time staff training without subsequent monitoring did not result in additional decreases and did not lower day care center diarrhea rates to the levels observed in day care homes and households not using day care.

Occurrence of rotaviruses in Guangzhou and Hong Kong.

Electropherotypes of human rotavirus (HRV) isolated from Hong Kong and Guangzhou were compared to study the transmission of HRV between the cities. Forty-one electropherotypes were identified from 418 hospitalized patients with HRV infection at the Queen Mary Hospital, and 22 were detected from 66 outpatients in community clinics at a separate area in Hong Kong. Nineteen electropherotypes were detected in 370 hospitalized cases of HRV infection from seven hospitals in Guangzhou. Results showed that HRV electropherotypes appeared to circulate freely within each area, yet the HRV population between the two cities remained different. Six electropherotypes were common to both cities. Three of these were predominant types found in Guangzhou and later detected in Hong Kong. One of these was found to cause an outbreak in Hong Kong. Of the remaining three electropherotypes, two were detected in both cities simultaneously, whereas one was first detected in Hong Kong.

Nosocomial rotaviral diarrhea: pattern of spread on wards in a children's hospital.

Nosocomial gastroenteritis in a 315-bed hospital for children was examined prospectively from January 11 through May 31, 1985. There were 85 cases of nosocomial diarrhea during the study period, and these were identified on each of the 13 hospital wards. Rotavirus was identified in 40% of cases. Incidence of nosocomial rotavirus was highest on wards where most children were less than 2 years of age, except for the infectious diseases (isolation) ward (0.24 versus 2.30 cases per 100 admissions, p = 1.70 x 10(-4), Fisher exact test). The lower incidence on the infectious diseases ward occurred despite the greater potential for exposure to rotavirus, since 70% of children admitted with community-acquired rotavirus diarrhea were placed on the infectious diseases ward. Better infection control, especially hand washing, aided by the structure of the infectious diseases ward, may have been responsible for this difference.

[Rotavirus infection in the older child and adult]. / Die Rotavirusinfektion des älteren Kindes und des Erwachsenen.

Rotaviruses were detected in 1.3% of more than 10,000 stool samples from children--older than 6 years--and adults. Beside rotaviruses the main enteropathogenic agents found were salmonellae (6.3%) and Campylobacter jejuni/coli (1.7%). Similar as the rotavirus infection of infants, in adults symptoms and signs were nearly the same except that the disease was not so severe. A correlation of the rotavirus infection with certain behaviour or eating habits was not found.

Shelters for battered women and their children: an under-recognized source of communicable disease transmission.

A survey of 73 full-time government-funded shelters for battered women and their children from five geographic regions in 15 states provided information on communicable disease problems and control measures (focusing on diarrheal illness). Outbreaks of diarrheal illness involving more than 10 persons were reported by 12 per cent (9/73) of shelter directors. Less than half reported screening potential residents for communicable diseases before admitting them, and the majority reported that most of their staff are trained in basics of first aid, principles of hygiene, and experienced in day care work. More than half of the staff in the majority of shelters are counselors, but only 5 per cent (4/73) of shelters have health care workers. Less than one-fourth of the shelters have areas designated for diapering infants and less than half of the shelter directors knew of specified health regulations applying to their shelter. For most shelters, limitations on staff size, training, and funding may restrict the types of disease control measures they can apply. However, basic hygienic practices, such as strict handwashing and identification and cohorting of sick clients, may be effective in disease prevention.

An outbreak of rotavirus infection in a geriatric hospital.

We describe an outbreak of rotavirus infection in a geriatric hospital. The outbreak lasted for 6 weeks, and affected 14 patients of 68 at risk. Diarrhoea was the main symptom, lasting only 1 day in most patients. Rising or high rotavirus antibody titres were demonstrated in six patients. Of 96 staff only one member was infected.

Potential sources of enterotoxigenic Escherichia coli in homes of children with diarrhoea in Thailand.

PIP: A year-long study was performed to identify potential sources of enterotoxigenic Escherichia coli (ETEC) within the homes of children with diarrhea in Bangkok. ETEC was identified in 8% (10 of 130) of the inhabitants of 42 homes with children with ETEC diarrhea and 6% (8 of 137) of their neighbors, but in only 2% (49 of 3077) of those individuals living in 866 homes not associated with children with ETEC diarrhea. While 46% (13 of 28) of the children under age 2 infected with ETEC were identified on home visits as having had a recent history of diarrhea, only 13% (5 of 39) of those over age 2 presented such a history. ETEC was isolated from 14% of the mothers' hands, 13% of the children's hands, and 7% of jars containing bath water that was used for washing the children after defecation. Drinking water was identified as a probable source of infection in 1 of 42 cases. Further studies are needed to determine whether ETEC from water stored in the home can spread and cause secondary infections.^ieng

Personal toilet after defaecation and the degree of hand contamination according to different methods used.

Transmission due to contaminated hands is one of the important routes by which diarrhoea pathogens spread. The hands commonly become contaminated while cleaning the anus after defaecation. This study deals with the commonly used methods of anal cleansing in a low socioeconomic community in Rangoon, Burma and with the degree of hand contamination that results according to the method used. A cross-sectional survey was employed for collection of behavioural and hand contamination data. The incidence of acute diarrhoea and dysentery among under-fives in this community was monitored for 1 month and was correlated with the cleaning method used by their mothers. Water was the principal method used for cleaning the anus in all age groups. No one used toilet paper and only 4 to 9% used paper other than toilet paper. The level of education seemed to be a factor in determining the use of paper or water. The hands of mothers using water were more contaminated than those using paper. However, thorough hand washing with soap and water was found to be effective in decontaminating the hands. Furthermore, there was a relation between the incidence of diarrhoea and dysentery and the method of cleaning.

Cryptosporidiosis in a hospital-associated day care center.

Cryptosporidium was identified in the stools of infants and toddlers during an outbreak of diarrheal illness at a hospital-associated day care center. Stools from 42 of 54 children were examined for parasites, Salmonella, Shigella, Campylobacter and rotavirus; 27 children (64%) had Cryptosporidium. One child also had Salmonella and two other children were also found to have Giardia. Information regarding the severity and duration of symptoms was obtained from parents by means of a questionnaire. The most frequently reported symptoms included diarrhea, fever, anorexia and malaise. Of 9 children whose stools were examined during the time they were reported by parents to be symptomatic, 8 were positive for Cryptosporidium oocysts. Symptoms lasted from 1 day to 4 weeks and children excreted oocysts for up to 48 days after the onset of symptoms. Staff at the facility and family members were also affected. Cryptosporidiosis should be considered in the differential diagnosis of young children with diarrheal illness, especially those attending a day care facility.

Acute infectious diarrhea among children in day care: epidemiology and control.

The incidence of diarrhea among children in day care centers is highest for those under three years of age. Limited studies indicate that diarrhea occurs more frequently among children enrolled at these centers than among age-matched children cared for at home or in family day care. Most reported outbreaks have been caused by rotavirus, Giardia, Shigella, or combinations of these organisms. Children in day care centers commonly excrete enteropathogens in the absence of symptoms; the significance of this phenomenon in transmission is unknown. An association between higher rates of diarrhea and selected characteristics of centers--the most important of which is the presence of non-toilet-trained children--has been shown. The contamination of hands, communal toys, and other classroom objects as well as a lack of infection control measures play a role in the transmission of enteropathogens in outbreaks of diarrhea in day care centers. Spread of infection from non-toilet-trained children in centers to their families is common. Potential ways of dealing with this situation include education; development, implementation, and enforcement of regulations; and use of infection control measures. However, the effectiveness of specific control measures has not been systematically evaluated.

Enzootic bovine rotavirus is not a source of infection in Panamanian cattle ranchers and their families.

Vaccination of humans against rotavirus (RV) diarrhea may be accomplished by oral immunization with attenuated animal strains known to be antigenically very similar to human strains. To define better the degree of infectivity in nature of these animal strains for humans, we conducted surveillance for RV infection/diarrhea in 180 farm workers, their 161 family contacts, and the 566 animals (512 cattle, 35 pigs, and 19 sheep) on 14 farms in rural Panama. No correlation between the high infection rates in farm workers (72%) and their family contacts (78%) and in cattle (56%) could be demonstrated. Heads of families with four or more children with RV infection experienced a twofold greater rate of RV infection compared with heads of families of similar size without RV infection. Despite the close similarity between human and bovine RV, in Panama intrafamilial (particularly child-to-child or child-to-parent) rather than interspecies transmission appeared to be the most important route for the spread of this highly infectious virus.