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Health Impact of Community-Based Water Treatment Systems in Honduras

Health Impact of Community-Based Water Treatment Systems in Honduras Hindawi Publishing Corporation Journal of Anthropology Volume 2011, Article ID 929860, 5 pages doi:10.1155/2011/929860 Research Article Health Impact of Community-Based Water Treatment Systems in Honduras Jeffery Deal Health Studies at Water Missions International, 2049 Savannah Highway, Charleston, SC 29407, USA Correspondence should be addressed to Jeffery Deal, jdeal@watermissions.org Received 1 November 2011; Accepted 30 November 2011 Academic Editor: Kaushik Bose Copyright © 2011 Jeffery Deal. This is an open access article distributed under the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. This paper provides a followup on a previous report in this journal on the health impact of providing access to water treatment and flush toilets to region of Honduras. Significant reductions were found in the one-year incidence of positive test results for the three protozoan species tested. This finding combined with the previously reported ethnographic and medical chart review data provides compelling evidence that such interventions significantly reduce the disease load from waterborne pathogens within this population. Furthermore, the finding that initial results are significantly different, even in the initial round of testing, if individuals who are not followed up are eliminated from the analysis has profound methodological implications which warrant further investigation and demonstrates the need for precise definitions of community in future studies. 1. Introduction on diarrhea and water interventions [7]. Whilesomeof these deficiencies may be reduced by shortening recall time A key component of the United Nations Millennium Devel- to seventy-two hours or less, potentially profound observer opment Goal Number 7 states “halve, by 2015 the proportion effects remain. Estimates of disease load changes are further of the population (global) without sustainable access to impeded by researchers’ concentration on known users of safe drinking water and basic sanitation.” Most waterborne water systems rather than measurements on community dis- diseases result in diarrhea which continues to be a leading ease levels of disease changes regardless of compliance, thus cause of morbidity and mortality worldwide. According to making extrapolations of disease rate changes inappropriate. World Health Organization data, using existing technologies In 2006, Water Missions International (WMI) received approximately ten percent of the worldwide burden of a grant from the Pentair Foundation to provide improved disease would be removed by the water supply, sanitation, water source access and toilet systems to all of the people hygiene, and management of water resources, making water- in the district of Colon, Honduras, an area that contains related diseases arguably the most manageable set of health approximately 340,000 people. The goal of 100% cover- problems affecting humans [1]. age utilizes a combination of solutions including home- A great deal of work has been done attempting to based filtration systems (provided by a different NGO) for measure the impact of interventions to provide improved communities with less than 300 people, and a variety of water sources at the household level, and less frequently at high-capacity treatment systems for larger communities. In the community level. The overwhelming majority of these the initial phase of the study, all 604 water sources for studies have also used either key informant or self-reporting the control and test communities were tested by pressure of diarrhea (defined as three or more loose stools per day) filtration methods, and all failed quality testing by being as the measure of disease burden [2–4]. Reliance upon positive for coliform bacterial growth. For all households such nonobjective measures introduces a host of potentially that lacked adequate sanitation facilities and agreed to assist confounding variables [2, 5, 6]and yetappears to have in installation, sanitary pit latrines with pour-flush toilet been used in all of the 2,120 published studies reviewed in (toilets with water traps and no reservoir that are flushed by a far reaching meta-analysis produced for the World Bank pouring a bucket of water into the basin) were also provided. 2 Journal of Anthropology Water treatment systems and pour-flush toilets deployed dose, which in management of Giardia has been shown to be during the present study were developed and manufactured highly effective without the additional doses. No side effects by Water Missions International, a nonprofit organization of treatment were reported. One hundred and sixty-three of based in Charleston, SC, that works to provide sustainable the 200 subjects in the final round of testing in 2010 had also water treatment capacities and sanitation facilities for people participated in the prior studies conducted 12 months earlier. in developing countries. The technology uses a combination The effect of previous medical treatment of subjects upon of multimedia, multistage filters, and chlorination to provide the present study is to provide a population that either tested treated water for drinking and cooking that meets the most negative or were given highly effective treatment in 2009— stringent class of WHO drinking water standards as well thus providing a subpopulation which was believed to have as passed present US standards from the EPA—specifically, begun the 12-month test period free of any of the three tested tests on treated water grew no coliform bacteria on repeated, protozoans. The results among the subjects tested both times, monthly testing during the period of this study. In addition, therefore, may be regarded as the rates of reinfection over the WMI provides community development programs that 12-month period (or a one-year incidence rate) for all three include education and microenterprise strategies to assure groups. sustainability of these interventions. Recent advances in highly sensitive and specific rapid In the baseline study phase of the project, water sources immunoassays for waterborne parasite diseases have made for 613 communities were identified. Various water quality field testing of individual fecal specimens now possible tests were conducted on the community water sources by [9, 10]. These devices test for species-specific antigens of standard membrane filter test. High counts of coliform common parasites known to be primarily waterborne. The bacteria indicative of fecal contamination were found in device chosen for this study tested for three protozoan 100% of the water sources. As previously published [8], parasites: Giardia lamblia (now widely known as Giardia initial stool tests also showed that 29.3% (53 of 181) of the intestinalis), Entamoeba histolytica/Entamoeba dispar,and volunteer subjects from the twelve communities that had Cryptosporidium parvum antigens. Previous work has shown been randomly selected from the state of Colon carried at these tests to have both specificity and sensitivity in excess of least one of the three tested protozoan parasites. Also as 96% for the aforementioned pathogens. reported previously, the prevalence of positive protozoan Immunoassay of stool for these waterborne parasites was parasite levels was significantly lower in the intervention used as an indicator that the subject had been exposed to groups as compared to the test group. Even greater reduc- waterborne pathogens and was therefore at risk of these and tions of disease rates (at least 52%) were noted in the other infectious waterborne illnesses. A separate subset of medical chart reviews of visits to the local health facility for 163 subjects from the three groups who also gave specimens diarrhea and dysentery as well as self-reporting of the same twelve months earlier was analyzed as a separate subgroup. diseases via ethnographic interviews. Ethnographic data Given the highly effective cure rates of tinidazole for Giardia further suggested widespread acceptance and community- and Entameba and the fact that the vast majority of non- wide reproduction of the awareness of health benefits derived immunocompromised subjects will clear Cryptosporidium from consuming treated water. The present paper is a infections spontaneously, this subset is thought to represent followup to that report primarily looking at the development recolonization rates with waterborne protozoan during the of positive parasite stool tests in the same communities year after the initial round of testing and treatment. All twelve months after the initial round of tests with an specimens were tested within 12 hours of collection using expanded study population. the Triage Micro Parasite Panel manufactured by Biosite Incorporated. Further information regarding diarrhea and dysentery 2. Methods rates was obtained by reviewing medical records from a public health clinic in a community where a water treatment Twelve communities from three different categories were system had been previously installed. Ethnographic data was randomly selected from the Colon district. Four commu- collected using a combination of KAP surveys and guided nities had not yet obtained a water treatment system and interviews. The medical records review and the majority of were used collectively as the Control Group. Four other the ethnographic data have been previously reported in this communities where water systems (Water Only Group) had journal [8]. been deployed were entered into the study as were four more communities where both water systems and sanitary flush latrines had been installed (Water and Sanitation Group). 3. Role of the Funding Source and Ethics Review For both the initial tests in 2009 and the final round of tests in 2010, volunteers were recruited by poster advertising Water Missions International maintains a country program in Honduras whose staff provided support and significant and via community leaders. Methods of recruitment were identical in all communities. All subjects who tested positive amount of labor for this project. The study design, collection, and analysis of data and interpretation of the data were the for protozoan antigens in either study (2009 or 2010) were sole responsibility of the author. treated with an appropriate dose of tinidazole (500 mgs per day for three days for adults with weight adjusted dosing for Prior to initiation of the study, the Colon Minister children). Subjects were directly observed to take the initial of Health and the Institutional Review Board of Water Journal of Anthropology 3 Results of 2009 and 2010 Table 1: Age distribution of all subjects in all groups. parasite tests positivity Min. Max. Mean Std. deviation 35.9% Age 2 82 23.06 19.143 27.5% 25% 21.6% Table 2: Mean age distribution by group. Mean (years) N Std. deviation 3.8% 4.5% Control group 22.67 67 18.806 Control group Water only group Water and sanitation Water only group 24.79 68 20.662 group (n = 51) (n = 78) (n = 51) Water and sanitation group 21.66 65 17.959 Inital round of tests (2009) Table 3: Gender by intervention group. Second round data (2010) Water only Water and Control group Totals Figure 1 Group sanitation group Female 125 44 42 39 Male 75 23 26 26 2009 data by gender Total 200 67 68 65 33.3% 37.9% 31% Table 4: 2010 data comparing control group to the combination of water only group and water and sanitation group. 20.8% Combined water Controls only and water and Totals 15% 13% sanitation Negative for any parasite 50 126 176 Positive for any parasite 17 7 24 5 Total 67 133 200 Control group Water only group Water and sanitation group Missions International reviewed and gave approval and Females consent for the project and study. Consistent with this Males review, no information from medical chart reviews which Figure 2 could identify subjects of the study was retained outside of the local healthcare facility. Under the supervision of a licensed physician, all individuals in whom potential access to water and flush toilets both in the initial survey of pathologic parasites were found were given free treatment 2009 and in the 2010 followup (P< .005). These finding are with regimens previously approved by the Colon Minister of summarized in Figure 1. Health. The control communities where no water treatment or sanitation facilities existed were selected from a preexisting In 2009, a comparison of the rate of positive parasite construction queue and intervention was not withheld as tests appeared to demonstrate that, while access to a water a result of this study. Verbal consent was obtained and treatment system reduced parasite levels, communities that recorded from all subjects. had both treatment systems and installed flush toilets demonstrated a higher rate of positive parasite tests. These findings show a distinct gender bias toward women and are 4. Results summarized in Figure 2. Additional ethnographic witnessing suggested that this finding may possibly be explained by Age distributions within the three groups are seen in the fact that women exclusively cleaned the toilets, often Tables 1 and 2. Gender distribution is seen in Table 3.Par- with inadequate supplies and protection. Water Missions asite test results for the control group compared to the International responded to this suggestion with additional combined water only group and water and sanitation group training and supplies. In the followup parasite survey of are seen in Table 4. Giardia and Entameba accounted for 2010, what had appeared to have been a negative effect of all but one positive test in all categories. Giardia accounted the toilet systems was no longer present, as seen in Figure 2. for 46% and Entameba 48% of the positive tests while Cryptosporidium remained rare at 6% of the totals. A separate analysis of parasite test results including Subjects living in communities that did not have access to only subjects who were available in both 2009 and 2010 water systems had significantly higher rates of positive tests is summarized in Figure 3. Of interest is that the apparent than subjects who had either access to water or who had negative effect of the toilets in the 2009 data (Figure 1) (%) (%) 4 Journal of Anthropology Only subjects who provided specimens in in none of the four focus groups) and for no one were they 2009 and 2010 the basis for a preferred method of treatment. Immunoassay evidence of decreased prevalence of water- 38.9% borne parasites strongly supports the contention that community-based water treatment facilities reduce the over- 25% all stool parasite load, at least of the three protozoan 16.4% species tested. Since all subjects who tested positive for 11.5% either Giardia or Entameba were treated with three doses 3.8% 4.5% of tinidazole adjusted for age and weight, the follow-up study of all subjects who submitted stool samples initially is Group 1 Group 2 Group 3 (water felt to represent the reinfection rates, in essence eliminating (no intervention) (water system only) system and toilets) concerns regarding residual colonization from exposures that 72 subjects 67 subjects 78 subjects occurred prior to initiation of this study. Previous treatment of subjects who tested positive for any parasite creates the 2009 data 2010 data potential for a Hawthorne effect; however, the elevated number of positive tests initially found within the control Figure 3 communities would potentially bias this group more than the test groups and would tend to lessen rather than strengthen the differences found. completely vanishes when subjects lost to follow up in 2010 Also, as previously reported [8], when parasite antigens are removed from the 2009 analysis. were detected in stool samples of individuals who had access to improved water sources, ethnographic investigation revealed lapses of behavior in spite of the high level of 5. Discussion understanding of the risks associated with drinking from untreated sources. Further analysis of the interviews of The present paper is a followup of the research previously reported [8] and adds support to the conclusion that subjects whose stool was positive for potential waterborne access to community-based water treatment systems and parasites suggests that risk and time management deci- sions rather than cultural or knowledge-based differences flush toilets reduced the disease load in this region of Honduras. To our knowledge, these are the first studies to accounted for lapses in behavior and willingness to drink combine self-reported data, medical chart review, and stool untreated water. Subjects reported that the time required immunoassays as an indicator of exposure to potential water- to obtain treated water, sometimes a difference of only a borne pathogens. The triangulation of these methodologies minute or less, was too great to overcome their concerns with provides powerful support to what are otherwise strongly potential health risks associated with untreated tap water. subjective and questionable measures of disease loads from Multiple pathogens and inflammatory conditions cause waterborne pathogens. diarrhea, making monitoring this symptom alone an inex- act measure of the disease load related to water quality. The previously reported ethnographic data from these communities suggests a high level of understanding of the Worldwide, the most common causes of diarrhea are viral causes and prevention of diarrhea among the communities infections such as the rotavirus, an ubiquitous infection that may be transmitted by personal contact. Food contamination studied. The overwhelming majority (130 of 142) of the people interviewed attributed the majority of their diarrheal and noninfectious inflammatory diseases add to the diarrhea diseases to water and sanitation issues and improvement prevalence. Though not precisely known, the number of of the condition to improved water sources and access to diarrhea cases unrelated to waterborne pathogens is likely flush toilets. There were also significant signs of a shift substantial. This means that the 52% drop in diarrhea rates noted in the previously reported community chart reviews of ideations regarding drinking untreated water toward an appreciation of the importance of purified water and may represent an even greater majority of the cases that prohibitions against drinking untreated water with the could possibly be related to potential water and sanitation issues. This follow-up study strongly supports this finding addition of water treatment facilities and community edu- cation. and suggests that the effect where water treatment systems Ethnographic data found during this study suggests are maintained may even increase over time. that, consistent with other similar work, the availability of A comparison of the 2009 parasite test data excluding improved water is felt by its recipients to improve a general those lost to follow up a year later was dramatically different sense of health and well-being. High levels of knowledge from when these individual tests were included (Figure 3). related to water issues exist in this area of Honduras which This suggests that the population that was lost to follow up could be attributed to many factors including sophisticated significantly added to the initial rate of positive tests. This public health efforts, high literacy rates comparable to the phenomenon deserves future scrutiny and incorporation region, widespread health education in public schools, and into discussions of the idea of community as a social the training offered by Water Missions International and construct. If community is defined as those present at a given other NGOs. Local indigenous belief systems appear uncom- point in time, we see a negative impact from presence of the monly (mentioned in only 6 of 46 individual interviews and toilets. When we define community as those who reside in (%) Journal of Anthropology 5 the geographic area for at least one year we find the exact Description of the project, evaluation methods, and impact on intervening variables,” Transactions of the Royal Society of opposite as this apparent negative impact is not detected. Tropical Medicine and Hygiene, vol. 84, no. 2, pp. 309–315, As this finding demonstrates, the unit of analysis remains paramount in such studies. [6] T. Clasen, I. Roberts, T. Rabie, W. Schmidt, and S. Cairncross, This combination of qualitative data, health records “Interventions to improve water quality for preventing diar- reviews, and immunoassays provides compelling evidence rhoea,” Cochrane Database of Systematic Reviews, vol. 3, p. that community-based water treatment facilities with or CD004794, 2006. without providing flush toilets significantly reduced the [7] L. Fewtrell and J. M. Colford Jr., “Water, sanitation, and burden of diseases in the communities of Colon, Honduras. hygiene interventions to reduce diarrhoea in less developed We further validate with objective measures prior work countries: a systematic review and meta-analysis,” The Lancet based upon self-reporting of diarrhea rates. Finally, this data Infectious Diseases, vol. 5, no. 1, pp. 42–52, 2005. suggests that interventions to provide potable water access [8] Jeffery L. Deal et al., “A multidimensional measure of diarrheal disease load changes resulting from access to improved water on a community level when combined with community sources in honduras,” Practicing Anthropologist, vol. 32, no. 1, development efforts and sanitation can play a significant role pp. 15–20, 2010. in the reduction of mortality and morbidity from waterborne [9] L. S. Garcia, R. Y. Shimizu, and C. N. Bernard, “Detection diseases and associated comorbidities. of Giardia lamblia, Entamoeba histolytica/Entamoeba dispar, and Cryptosporidium parvum antigens in human fecal spec- 6. Conclusion imens using the triage parasite panel enzyme immunoassay,” Journal of Clinical Microbiology, vol. 38, no. 9, pp. 3337–3340, Providing access to water treatment or water treatment and flush toilets significantly reduced the one-year incidence [10] S. E. Sharp, C. A. Suarez, Y. Duran, and R. J. Poppiti, “Evaluation of the Triage Micro Parasite Panel for detection of positive test results for the three protozoan species of Giardia lamblia, Entamoeba histolytica/Entamoeba dispar, tested. This finding combined with the previously reported and Cryptosporidium parvum in patient stool specimens,” ethnographic and medical chart review data provides com- Journal of Clinical Microbiology, vol. 39, no. 1, pp. 332–334, pelling evidence that such interventions significantly reduce the disease load from waterborne pathogens within this population. Furthermore, the finding that initial results are significantly different, even in the initial round of testing, if individuals who are not followed up are eliminated from the analysis has profound methodological implications which warrant further investigation. Adding a temporal definition of community resulted in a completely different finding regarding the impact of supplying flush toilets, demonstrating the need for precise definitions of community in future studies. The method used here where objective measurements of health effects are coupled with more traditional anthropolog- ical tools may serve as a template for future studies in medical anthropology. References [1] A. Pruss- ¨ Ustun, ¨ R. Bos, F. Gore, and J. Bartram, Safer Water, Better Health: Costs, Benefits and Sustainability of Interventions to Protect and Promote Health, World Health Organization, Geneva, Switzerland, 2008. [2] S. Boisson, W. P. Schmidt, T. Berhanu, H. Gezahegn, and T. Clasen, “Randomized controlled trial in rural Ethiopia to assess a portable water,” Environmental Science and Technology, vol. 43, no. 15, pp. 5934–5939, 2009. [3] R. J. Gelting and L. Ortolano, “A model describing per- formance of rural drinking water systems in Honduras,” International Journal of Water Resources Development, vol. 14, no. 2, pp. 199–215, 1998. [4] U. D. Parashar, E. G. Hummelman, J. S. Bresee, M. A. Miller, and R. I. Glass, “Global illness and deaths caused by rotavirus disease in children,” Emerging Infectious Diseases, vol. 9, no. 5, pp. 565–572, 2003. [5] D. Blum, R. N. Emeh, S. R. Huttly et al., “The Imo State (Nigeria) Drinking Water Supply and Sanitation Project, 1. 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Health Impact of Community-Based Water Treatment Systems in Honduras

Journal of Anthropology , Volume 2011 – Dec 25, 2011

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Copyright © 2011 Jeffery Deal. This is an open access article distributed under the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.
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Abstract

Hindawi Publishing Corporation Journal of Anthropology Volume 2011, Article ID 929860, 5 pages doi:10.1155/2011/929860 Research Article Health Impact of Community-Based Water Treatment Systems in Honduras Jeffery Deal Health Studies at Water Missions International, 2049 Savannah Highway, Charleston, SC 29407, USA Correspondence should be addressed to Jeffery Deal, jdeal@watermissions.org Received 1 November 2011; Accepted 30 November 2011 Academic Editor: Kaushik Bose Copyright © 2011 Jeffery Deal. This is an open access article distributed under the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. This paper provides a followup on a previous report in this journal on the health impact of providing access to water treatment and flush toilets to region of Honduras. Significant reductions were found in the one-year incidence of positive test results for the three protozoan species tested. This finding combined with the previously reported ethnographic and medical chart review data provides compelling evidence that such interventions significantly reduce the disease load from waterborne pathogens within this population. Furthermore, the finding that initial results are significantly different, even in the initial round of testing, if individuals who are not followed up are eliminated from the analysis has profound methodological implications which warrant further investigation and demonstrates the need for precise definitions of community in future studies. 1. Introduction on diarrhea and water interventions [7]. Whilesomeof these deficiencies may be reduced by shortening recall time A key component of the United Nations Millennium Devel- to seventy-two hours or less, potentially profound observer opment Goal Number 7 states “halve, by 2015 the proportion effects remain. Estimates of disease load changes are further of the population (global) without sustainable access to impeded by researchers’ concentration on known users of safe drinking water and basic sanitation.” Most waterborne water systems rather than measurements on community dis- diseases result in diarrhea which continues to be a leading ease levels of disease changes regardless of compliance, thus cause of morbidity and mortality worldwide. According to making extrapolations of disease rate changes inappropriate. World Health Organization data, using existing technologies In 2006, Water Missions International (WMI) received approximately ten percent of the worldwide burden of a grant from the Pentair Foundation to provide improved disease would be removed by the water supply, sanitation, water source access and toilet systems to all of the people hygiene, and management of water resources, making water- in the district of Colon, Honduras, an area that contains related diseases arguably the most manageable set of health approximately 340,000 people. The goal of 100% cover- problems affecting humans [1]. age utilizes a combination of solutions including home- A great deal of work has been done attempting to based filtration systems (provided by a different NGO) for measure the impact of interventions to provide improved communities with less than 300 people, and a variety of water sources at the household level, and less frequently at high-capacity treatment systems for larger communities. In the community level. The overwhelming majority of these the initial phase of the study, all 604 water sources for studies have also used either key informant or self-reporting the control and test communities were tested by pressure of diarrhea (defined as three or more loose stools per day) filtration methods, and all failed quality testing by being as the measure of disease burden [2–4]. Reliance upon positive for coliform bacterial growth. For all households such nonobjective measures introduces a host of potentially that lacked adequate sanitation facilities and agreed to assist confounding variables [2, 5, 6]and yetappears to have in installation, sanitary pit latrines with pour-flush toilet been used in all of the 2,120 published studies reviewed in (toilets with water traps and no reservoir that are flushed by a far reaching meta-analysis produced for the World Bank pouring a bucket of water into the basin) were also provided. 2 Journal of Anthropology Water treatment systems and pour-flush toilets deployed dose, which in management of Giardia has been shown to be during the present study were developed and manufactured highly effective without the additional doses. No side effects by Water Missions International, a nonprofit organization of treatment were reported. One hundred and sixty-three of based in Charleston, SC, that works to provide sustainable the 200 subjects in the final round of testing in 2010 had also water treatment capacities and sanitation facilities for people participated in the prior studies conducted 12 months earlier. in developing countries. The technology uses a combination The effect of previous medical treatment of subjects upon of multimedia, multistage filters, and chlorination to provide the present study is to provide a population that either tested treated water for drinking and cooking that meets the most negative or were given highly effective treatment in 2009— stringent class of WHO drinking water standards as well thus providing a subpopulation which was believed to have as passed present US standards from the EPA—specifically, begun the 12-month test period free of any of the three tested tests on treated water grew no coliform bacteria on repeated, protozoans. The results among the subjects tested both times, monthly testing during the period of this study. In addition, therefore, may be regarded as the rates of reinfection over the WMI provides community development programs that 12-month period (or a one-year incidence rate) for all three include education and microenterprise strategies to assure groups. sustainability of these interventions. Recent advances in highly sensitive and specific rapid In the baseline study phase of the project, water sources immunoassays for waterborne parasite diseases have made for 613 communities were identified. Various water quality field testing of individual fecal specimens now possible tests were conducted on the community water sources by [9, 10]. These devices test for species-specific antigens of standard membrane filter test. High counts of coliform common parasites known to be primarily waterborne. The bacteria indicative of fecal contamination were found in device chosen for this study tested for three protozoan 100% of the water sources. As previously published [8], parasites: Giardia lamblia (now widely known as Giardia initial stool tests also showed that 29.3% (53 of 181) of the intestinalis), Entamoeba histolytica/Entamoeba dispar,and volunteer subjects from the twelve communities that had Cryptosporidium parvum antigens. Previous work has shown been randomly selected from the state of Colon carried at these tests to have both specificity and sensitivity in excess of least one of the three tested protozoan parasites. Also as 96% for the aforementioned pathogens. reported previously, the prevalence of positive protozoan Immunoassay of stool for these waterborne parasites was parasite levels was significantly lower in the intervention used as an indicator that the subject had been exposed to groups as compared to the test group. Even greater reduc- waterborne pathogens and was therefore at risk of these and tions of disease rates (at least 52%) were noted in the other infectious waterborne illnesses. A separate subset of medical chart reviews of visits to the local health facility for 163 subjects from the three groups who also gave specimens diarrhea and dysentery as well as self-reporting of the same twelve months earlier was analyzed as a separate subgroup. diseases via ethnographic interviews. Ethnographic data Given the highly effective cure rates of tinidazole for Giardia further suggested widespread acceptance and community- and Entameba and the fact that the vast majority of non- wide reproduction of the awareness of health benefits derived immunocompromised subjects will clear Cryptosporidium from consuming treated water. The present paper is a infections spontaneously, this subset is thought to represent followup to that report primarily looking at the development recolonization rates with waterborne protozoan during the of positive parasite stool tests in the same communities year after the initial round of testing and treatment. All twelve months after the initial round of tests with an specimens were tested within 12 hours of collection using expanded study population. the Triage Micro Parasite Panel manufactured by Biosite Incorporated. Further information regarding diarrhea and dysentery 2. Methods rates was obtained by reviewing medical records from a public health clinic in a community where a water treatment Twelve communities from three different categories were system had been previously installed. Ethnographic data was randomly selected from the Colon district. Four commu- collected using a combination of KAP surveys and guided nities had not yet obtained a water treatment system and interviews. The medical records review and the majority of were used collectively as the Control Group. Four other the ethnographic data have been previously reported in this communities where water systems (Water Only Group) had journal [8]. been deployed were entered into the study as were four more communities where both water systems and sanitary flush latrines had been installed (Water and Sanitation Group). 3. Role of the Funding Source and Ethics Review For both the initial tests in 2009 and the final round of tests in 2010, volunteers were recruited by poster advertising Water Missions International maintains a country program in Honduras whose staff provided support and significant and via community leaders. Methods of recruitment were identical in all communities. All subjects who tested positive amount of labor for this project. The study design, collection, and analysis of data and interpretation of the data were the for protozoan antigens in either study (2009 or 2010) were sole responsibility of the author. treated with an appropriate dose of tinidazole (500 mgs per day for three days for adults with weight adjusted dosing for Prior to initiation of the study, the Colon Minister children). Subjects were directly observed to take the initial of Health and the Institutional Review Board of Water Journal of Anthropology 3 Results of 2009 and 2010 Table 1: Age distribution of all subjects in all groups. parasite tests positivity Min. Max. Mean Std. deviation 35.9% Age 2 82 23.06 19.143 27.5% 25% 21.6% Table 2: Mean age distribution by group. Mean (years) N Std. deviation 3.8% 4.5% Control group 22.67 67 18.806 Control group Water only group Water and sanitation Water only group 24.79 68 20.662 group (n = 51) (n = 78) (n = 51) Water and sanitation group 21.66 65 17.959 Inital round of tests (2009) Table 3: Gender by intervention group. Second round data (2010) Water only Water and Control group Totals Figure 1 Group sanitation group Female 125 44 42 39 Male 75 23 26 26 2009 data by gender Total 200 67 68 65 33.3% 37.9% 31% Table 4: 2010 data comparing control group to the combination of water only group and water and sanitation group. 20.8% Combined water Controls only and water and Totals 15% 13% sanitation Negative for any parasite 50 126 176 Positive for any parasite 17 7 24 5 Total 67 133 200 Control group Water only group Water and sanitation group Missions International reviewed and gave approval and Females consent for the project and study. Consistent with this Males review, no information from medical chart reviews which Figure 2 could identify subjects of the study was retained outside of the local healthcare facility. Under the supervision of a licensed physician, all individuals in whom potential access to water and flush toilets both in the initial survey of pathologic parasites were found were given free treatment 2009 and in the 2010 followup (P< .005). These finding are with regimens previously approved by the Colon Minister of summarized in Figure 1. Health. The control communities where no water treatment or sanitation facilities existed were selected from a preexisting In 2009, a comparison of the rate of positive parasite construction queue and intervention was not withheld as tests appeared to demonstrate that, while access to a water a result of this study. Verbal consent was obtained and treatment system reduced parasite levels, communities that recorded from all subjects. had both treatment systems and installed flush toilets demonstrated a higher rate of positive parasite tests. These findings show a distinct gender bias toward women and are 4. Results summarized in Figure 2. Additional ethnographic witnessing suggested that this finding may possibly be explained by Age distributions within the three groups are seen in the fact that women exclusively cleaned the toilets, often Tables 1 and 2. Gender distribution is seen in Table 3.Par- with inadequate supplies and protection. Water Missions asite test results for the control group compared to the International responded to this suggestion with additional combined water only group and water and sanitation group training and supplies. In the followup parasite survey of are seen in Table 4. Giardia and Entameba accounted for 2010, what had appeared to have been a negative effect of all but one positive test in all categories. Giardia accounted the toilet systems was no longer present, as seen in Figure 2. for 46% and Entameba 48% of the positive tests while Cryptosporidium remained rare at 6% of the totals. A separate analysis of parasite test results including Subjects living in communities that did not have access to only subjects who were available in both 2009 and 2010 water systems had significantly higher rates of positive tests is summarized in Figure 3. Of interest is that the apparent than subjects who had either access to water or who had negative effect of the toilets in the 2009 data (Figure 1) (%) (%) 4 Journal of Anthropology Only subjects who provided specimens in in none of the four focus groups) and for no one were they 2009 and 2010 the basis for a preferred method of treatment. Immunoassay evidence of decreased prevalence of water- 38.9% borne parasites strongly supports the contention that community-based water treatment facilities reduce the over- 25% all stool parasite load, at least of the three protozoan 16.4% species tested. Since all subjects who tested positive for 11.5% either Giardia or Entameba were treated with three doses 3.8% 4.5% of tinidazole adjusted for age and weight, the follow-up study of all subjects who submitted stool samples initially is Group 1 Group 2 Group 3 (water felt to represent the reinfection rates, in essence eliminating (no intervention) (water system only) system and toilets) concerns regarding residual colonization from exposures that 72 subjects 67 subjects 78 subjects occurred prior to initiation of this study. Previous treatment of subjects who tested positive for any parasite creates the 2009 data 2010 data potential for a Hawthorne effect; however, the elevated number of positive tests initially found within the control Figure 3 communities would potentially bias this group more than the test groups and would tend to lessen rather than strengthen the differences found. completely vanishes when subjects lost to follow up in 2010 Also, as previously reported [8], when parasite antigens are removed from the 2009 analysis. were detected in stool samples of individuals who had access to improved water sources, ethnographic investigation revealed lapses of behavior in spite of the high level of 5. Discussion understanding of the risks associated with drinking from untreated sources. Further analysis of the interviews of The present paper is a followup of the research previously reported [8] and adds support to the conclusion that subjects whose stool was positive for potential waterborne access to community-based water treatment systems and parasites suggests that risk and time management deci- sions rather than cultural or knowledge-based differences flush toilets reduced the disease load in this region of Honduras. To our knowledge, these are the first studies to accounted for lapses in behavior and willingness to drink combine self-reported data, medical chart review, and stool untreated water. Subjects reported that the time required immunoassays as an indicator of exposure to potential water- to obtain treated water, sometimes a difference of only a borne pathogens. The triangulation of these methodologies minute or less, was too great to overcome their concerns with provides powerful support to what are otherwise strongly potential health risks associated with untreated tap water. subjective and questionable measures of disease loads from Multiple pathogens and inflammatory conditions cause waterborne pathogens. diarrhea, making monitoring this symptom alone an inex- act measure of the disease load related to water quality. The previously reported ethnographic data from these communities suggests a high level of understanding of the Worldwide, the most common causes of diarrhea are viral causes and prevention of diarrhea among the communities infections such as the rotavirus, an ubiquitous infection that may be transmitted by personal contact. Food contamination studied. The overwhelming majority (130 of 142) of the people interviewed attributed the majority of their diarrheal and noninfectious inflammatory diseases add to the diarrhea diseases to water and sanitation issues and improvement prevalence. Though not precisely known, the number of of the condition to improved water sources and access to diarrhea cases unrelated to waterborne pathogens is likely flush toilets. There were also significant signs of a shift substantial. This means that the 52% drop in diarrhea rates noted in the previously reported community chart reviews of ideations regarding drinking untreated water toward an appreciation of the importance of purified water and may represent an even greater majority of the cases that prohibitions against drinking untreated water with the could possibly be related to potential water and sanitation issues. This follow-up study strongly supports this finding addition of water treatment facilities and community edu- cation. and suggests that the effect where water treatment systems Ethnographic data found during this study suggests are maintained may even increase over time. that, consistent with other similar work, the availability of A comparison of the 2009 parasite test data excluding improved water is felt by its recipients to improve a general those lost to follow up a year later was dramatically different sense of health and well-being. High levels of knowledge from when these individual tests were included (Figure 3). related to water issues exist in this area of Honduras which This suggests that the population that was lost to follow up could be attributed to many factors including sophisticated significantly added to the initial rate of positive tests. This public health efforts, high literacy rates comparable to the phenomenon deserves future scrutiny and incorporation region, widespread health education in public schools, and into discussions of the idea of community as a social the training offered by Water Missions International and construct. If community is defined as those present at a given other NGOs. Local indigenous belief systems appear uncom- point in time, we see a negative impact from presence of the monly (mentioned in only 6 of 46 individual interviews and toilets. When we define community as those who reside in (%) Journal of Anthropology 5 the geographic area for at least one year we find the exact Description of the project, evaluation methods, and impact on intervening variables,” Transactions of the Royal Society of opposite as this apparent negative impact is not detected. Tropical Medicine and Hygiene, vol. 84, no. 2, pp. 309–315, As this finding demonstrates, the unit of analysis remains paramount in such studies. [6] T. Clasen, I. Roberts, T. Rabie, W. Schmidt, and S. Cairncross, This combination of qualitative data, health records “Interventions to improve water quality for preventing diar- reviews, and immunoassays provides compelling evidence rhoea,” Cochrane Database of Systematic Reviews, vol. 3, p. that community-based water treatment facilities with or CD004794, 2006. without providing flush toilets significantly reduced the [7] L. Fewtrell and J. M. Colford Jr., “Water, sanitation, and burden of diseases in the communities of Colon, Honduras. hygiene interventions to reduce diarrhoea in less developed We further validate with objective measures prior work countries: a systematic review and meta-analysis,” The Lancet based upon self-reporting of diarrhea rates. Finally, this data Infectious Diseases, vol. 5, no. 1, pp. 42–52, 2005. suggests that interventions to provide potable water access [8] Jeffery L. Deal et al., “A multidimensional measure of diarrheal disease load changes resulting from access to improved water on a community level when combined with community sources in honduras,” Practicing Anthropologist, vol. 32, no. 1, development efforts and sanitation can play a significant role pp. 15–20, 2010. in the reduction of mortality and morbidity from waterborne [9] L. S. Garcia, R. Y. Shimizu, and C. N. Bernard, “Detection diseases and associated comorbidities. of Giardia lamblia, Entamoeba histolytica/Entamoeba dispar, and Cryptosporidium parvum antigens in human fecal spec- 6. Conclusion imens using the triage parasite panel enzyme immunoassay,” Journal of Clinical Microbiology, vol. 38, no. 9, pp. 3337–3340, Providing access to water treatment or water treatment and flush toilets significantly reduced the one-year incidence [10] S. E. Sharp, C. A. Suarez, Y. Duran, and R. J. Poppiti, “Evaluation of the Triage Micro Parasite Panel for detection of positive test results for the three protozoan species of Giardia lamblia, Entamoeba histolytica/Entamoeba dispar, tested. This finding combined with the previously reported and Cryptosporidium parvum in patient stool specimens,” ethnographic and medical chart review data provides com- Journal of Clinical Microbiology, vol. 39, no. 1, pp. 332–334, pelling evidence that such interventions significantly reduce the disease load from waterborne pathogens within this population. Furthermore, the finding that initial results are significantly different, even in the initial round of testing, if individuals who are not followed up are eliminated from the analysis has profound methodological implications which warrant further investigation. Adding a temporal definition of community resulted in a completely different finding regarding the impact of supplying flush toilets, demonstrating the need for precise definitions of community in future studies. The method used here where objective measurements of health effects are coupled with more traditional anthropolog- ical tools may serve as a template for future studies in medical anthropology. References [1] A. Pruss- ¨ Ustun, ¨ R. Bos, F. Gore, and J. Bartram, Safer Water, Better Health: Costs, Benefits and Sustainability of Interventions to Protect and Promote Health, World Health Organization, Geneva, Switzerland, 2008. [2] S. Boisson, W. P. Schmidt, T. Berhanu, H. Gezahegn, and T. Clasen, “Randomized controlled trial in rural Ethiopia to assess a portable water,” Environmental Science and Technology, vol. 43, no. 15, pp. 5934–5939, 2009. [3] R. J. Gelting and L. Ortolano, “A model describing per- formance of rural drinking water systems in Honduras,” International Journal of Water Resources Development, vol. 14, no. 2, pp. 199–215, 1998. [4] U. D. Parashar, E. G. Hummelman, J. S. Bresee, M. A. Miller, and R. I. Glass, “Global illness and deaths caused by rotavirus disease in children,” Emerging Infectious Diseases, vol. 9, no. 5, pp. 565–572, 2003. [5] D. Blum, R. N. Emeh, S. R. Huttly et al., “The Imo State (Nigeria) Drinking Water Supply and Sanitation Project, 1. 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Journal of AnthropologyHindawi Publishing Corporation

Published: Dec 25, 2011

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