Care-Seeking for Diarrhoea in Southern Malawi: Attitudes, Practices and Implications for Diarrhoea Control.

This paper examined care-seeking behaviour and its associated risk factors when a family member had diarrhoea. Data was obtained from a survey conducted in Chikwawa, a district in Southern Malawi. Chikwawa is faced with a number of environmental and socioeconomic problems and currently diarrhoea morbidity in the district is estimated at 24.4%, statistically higher than the national average of 17%. Using hierarchically built data from a survey of 1403 households nested within 33 communities, a series of two level binary logistic regression models with Bayesian estimation were used to determine predictors of care-seeking behaviour. The results show that 68% of mothers used oral rehydration solutions (ORS) the last time a child in their family had diarrhoea. However, when asked on the action they take when a member of their household has diarrhoea two thirds of the mothers said they visit a health facility. Most respondents (73%) mentioned distance and transport costs as the main obstacles to accessing their nearest health facility and the same proportion of respondents mentioned prolonged waiting time and absence of health workers as the main obstacles encountered at the health facilities. The main predictor variables when a member of the family had diarrhoea were maternal age, distance to the nearest health facility, school level, and relative wealth, household diarrhoea endemicity, and household size while the main predictor variables when a child had diarrhoea were existence of a village health committee (VHC), distance to the nearest health facility, and maternal age. Most households use ORS for the treatment of diarrhoea and village health committees and health surveillance assistants (HSAs) are important factors in this choice of treatment. Health education messages on the use and efficacy of ORS to ensure proper and prescribed handling are important. There is need for a comprehensive concept addressing several dimensions of management and proper coordination of delivery of resources and services; availability of adequate healthcare workers at all levels; affordability to accessibility of healthcare resources and services to all communities; acceptability and quality of care; intensification of health education messages on the use and management of ORS, and prompt and timely treatment of diarrhoeal illness.

The Pattern of Variation between Diarrhea and Malaria Coexistence with Corresponding Risk Factors in, Chikhwawa, Malawi: A Bivariate Multilevel Analysis.

Developing countries face a huge burden of infectious diseases, a number of which co-exist. This paper estimates the pattern and variation of malaria and diarrhea coexistence in Chikhwawa, a district in Southern Malawi using bivariate multilevel modelling with Bayesian estimation. A probit link was employed to examine hierarchically built data from a survey of individuals (n = 6,727) nested within households (n = 1,380) nested within communities (n = 33). Results show significant malaria [σ²µ1=0.901 (95% CI:0.746,1.056)] and diarrhea [σ²µ2=1.009 (95% CI:0.860,1.158)] variations with a strong correlation between them [r(¹,²)µ=0.565] at household level. There are significant malaria [σ²ν1=0.053 (95% CI: 0.018,0.088)] and diarrhea [σ²ν2=0.099(95% CI : 0.030,0.168) ] variations at community level but with a small correlation [r(¹,²) ν=0.124] between them. There is also significant correlation between malaria and diarrhea at individual level [ r(¹,²) e=0.241]. These results suggest a close association between reported malaria-like illness and diarrheal illness especially at household and individual levels in Southern Malawi.

Knowledge, awareness and practice of the importance of hand-washing amongst children attending state run primary schools in rural Malawi.

A study was undertaken to determine the efficacy of hygiene practices in 2 primary schools in Malawi. The study determined: (1) presence of Escherichia coli on the hands of 126 primary school pupils, (2) knowledge, awareness and hygiene practices amongst pupils and teachers and (3) the school environment through observation. Pupil appreciation of hygiene issues was reasonable; however, the high percentage presence of E. coli on hands (71%) and the evidence of large-scale open defaecation in school grounds revealed that apparent knowledge was not put into practice. The standard of facilities for sanitation and hygiene did not significantly impact on the level of knowledge or percentage of school children's hands harbouring faecal bacteria. Evidence from pupils and teachers indicated a poor understanding of principles of disease transmission. Latrines and hand-washing facilities constructed were not child friendly. This study identifies a multidisciplinary approach to improve sanitation and hygiene practices within schools.

Pattern of maternal knowledge and its implications for diarrhoea control in Southern Malawi: multilevel thresholds of change analysis.

A survey was conducted in Southern Malawi to examine the pattern of mothers' knowledge on diarrhoea. Diarrhoea morbidity in the district is estimated at 24.4%, statistically higher than the national average at 17%. Using hierarchically built data from a survey, a multilevel threshold of change analysis was used to determine predictors of knowledge about diarrhoeal aetiology, clinical features, and prevention. The results show a strong hierarchical structured pattern in overall maternal knowledge revealing differences between communities. Responsible mothers with primary or secondary school education were more likely to give more correct answers on diarrhoea knowledge than those without any formal education. Responsible mothers from communities without a health surveillance assistant were less likely to give more correct answers. The results show that differences in diarrhoeal knowledge do exist between communities and demonstrate that basic formal education is important in responsible mother's understanding of diseases. The results also reveal the positive impact health surveillance assistants have in rural communities.

Community Knowledge Variation; Bed-Net Coverage and the Role of a District Healthcare System; and their Implications for Malaria Control in Southern Malawi

This paper presents data on the pattern of knowledge of caregivers; bed-net coverage and the role of a rural district healthcare system; and their implications for malaria transmission; treatment; prevention and control in Chikhwawa; southern Malawi; using multi-level logistic regression modelling with Bayesian estimation. The majority of caregivers could identify the main symptoms of malaria; that the mosquito was the vector; and that insecticide-treated nets (ITN) could be used to cover beds as an effective preventative measure; although cost was a prohibitive factor. Use of bed nets displayed significant variation between communities. Groups that were more knowledgeable on malaria prevention and symptoms included young mothers; people who had attended school; wealthy individuals; those residing closest to government hospitals and health posts; and communities that had access to a health surveillance assistant (HSA). HSAs should be trained on malaria intervention programmes; and tasked with the responsibility of working with village health committees to develop community-based malaria intervention programmes. These programmes should include appropriate and affordable household improvement methods; identification of high-risk groups; distribution of ITNs and the incorporation of larval control measures; to reduce exposure to the vector and parasite. This would reduce the transmission and prevalence of malaria at community level

Microbiological hazard identification and exposure assessment of food prepared and served in rural households of Lungwena, Malawi.

The presence of food-borne pathogens, Escherichia coli 0157:H7, Staphylococcus aureus, Salmonella species, Campylobacter jejuni and non-pathogenic E. coli, in 132 home cooked food samples consisting of maize flour porridge (MFP), (n=41), fish (n=37), vegetables (n=28), beans (n=13) and "Others" (n=13), collected from 6 villages in Lungwena, Malawi was investigated. It was found that 35% of the food samples were contaminated with one or more pathogens; with 48%, 8%, 61% and 23% of the food samples being found to harbour E. coli, pathogenic E. coli 0157: H7, S aureus and Salmonella species, respectively. C. jejuni was not detected in any food sample. Using a 95% level of significance, pathogen concentration among food categories demonstrated a statistical difference (p=0.001). Distribution of pathogens among villages was also found to be significant (p=0.03). MFP was the most contaminated food. Practices that promote the spread of the pathogens in the rural household kitchens were investigated. Food was thought to be contaminated as a result of poor food handling, preparation and storage practices.

Cryptosporidium excystation and invasion: getting to the guts of the matter.

Cryptosporidium parvum excystation and host cell invasion have been characterized in some detail ultrastructurally. However, until recently, the biochemical and molecular basis of host-parasite interactions and parasite- and host-specific molecules involved in excystation, motility and host cell invasion have been poorly understood. This article describes our understanding of Cryptosporidium excystation and the events leading to host cell invasion, and draws from information available about these processes in other apicomplexans. Many questions remain but, once the specific mechanisms are identified, they could prove to be novel targets for drug delivery.

Determination of amoebicidal activities of multipurpose contact lens solutions by using a most probable number enumeration technique.

Six multipurpose contact lens solutions [All-in-One, All-in-One (Light), ReNu MultiPlus, Optifree Express, Complete, and Solo-care soft] were tested for their efficacies against Acanthamoeba castellanii trophozoites and cysts by using a most probable number (MPN) technique for amoebic enumeration. Against trophozoites, All-in-One, ReNu Multiplus, and Optifree Express achieved total kill (log reduction of >3) after the manufacturer's minimum recommended disinfection time (MMRDT), with the remaining solutions failing to reach a log reduction of 1. After 24 h of exposure, all solutions proved trophozoiticidal, achieving, with the exception of Complete (log reduction of 3.13), total kill. Against cysts, All-in-One gave a log reduction of >3 within the MMRDT, with all other solutions failing to achieve a log reduction of 1. After 24 h of exposure, All-in-One achieved total kill of cysts (log reduction of 3.74), ReNu MultiPlus gave a log reduction of 3.15, and the remaining solutions reached log reductions of between 1.09 and 2.27. The MPN technique provides a simple, reliable, and reproducible method of amoebic enumeration that depends on simply establishing the presence or absence of growth on culture plates inoculated with a series of dilutions and determining the MPN of amoebae present from statistical tables. By use of this technique, two of the multipurpose solutions tested, ReNu MultiPlus and Optifree Express, demonstrated effective trophozoiticidal activities within the recommended disinfection times; however, only All-in-One proved effective against both trophozoites and cysts over the same time period. This MPN technique, which uses axenically produced trophozoites and mature, double-walled cysts, has the potential to form the basis of a national standard for amoebicidal efficacy testing of multipurpose contact lens disinfecting solutions.

Enhanced attachment of acanthamoeba to extended-wear silicone hydrogel contact lenses: a new risk factor for infection?

PURPOSE: To establish if silicone hydrogel (S-H) contact lenses could be a risk factor for Acanthamoeba infection by facilitating the attachment of trophozoites to their surface and transfer to the cornea and to determine the effect Acanthamoeba culture technique, patient wear, and Pseudomonas biofilm coating have on attachment to the S-H lens. DESIGN: Experimental material study. PARTICIPANTS AND CONTROLS: Attachment to a S-H lens was compared with that of a conventional hydrogel control lens. Sixteen replicates were carried out for both lens types under each test condition. METHODS: Unworn S-H (PureVision; Bausch & Lomb, Kingston-Upon-Thames UK) and conventional hydrogel (Acuvue; Vistakon, Johnson & Johnson, Jacksonville, FL USA) lens quarters were incubated for 90 minutes in suspensions of liquid or plate-cultured Acanthamoeba castellanii trophozoites. Unworn, worn, and Pseudomonas biofilm coated S-H and hydrogel quarters were incubated for 90 minutes with plate-cultured trophozoites. MAIN OUTCOME MEASURES: Trophozoites attached to one surface of each lens quarter were counted by direct light microscopy. Logarithmic transformation of data allowed the use of a parametric analysis of variance. RESULTS: Lens polymer had a significant effect on attachment (P < 0.001), with higher numbers of trophozoites attaching to the S-H lens. Culture technique also had a significant effect on attachment (P = 0.013), with higher numbers of liquid-cultured organisms attaching to both lens types. A significant increase in attachment was demonstrated with worn and Pseudomonas biofilm-coated hydrogel lenses (P < 0.001); however, this difference was not seen with the S-H lens. CONCLUSIONS: Acanthamoebal attachment to the S-H lenses was significantly greater than to the conventional hydrogel. Liquid-cultured trophozoites demonstrated a higher affinity for the lenses tested. Wear and bacterial biofilm coating had no effect on attachment to S-H lenses. The increased attachment found with the S-H lens may be an inherent characteristic of the polymer or a side effect of the surface treatment procedure to which the lenses are exposed. It is possible that S-H lenses are at greater risk of promoting Acanthamoeba infection if exposed to the organism because of the enhanced attachment characteristic of this new material.