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ABSTRACT: The study examined the impact of in-situ climatic and marine environmental variability on cholera incidence in an endemic area of Bangladesh and developed a forecasting model for understanding the magnitude of incidence. Diarrhoea surveillance data collected between 1988 and 2001 were obtained from a field research site in Matlab, Bangladesh. Cholera cases were defined as Vibrio cholerae O1 isolated from faecal specimens of patients who sought care at treatment centres serving the Matlab population. Cholera incidence for 168 months was correlated with remotely-sensed sea-surface temperature (SST) and in-situ environmental data, including rainfall and ambient temperature. A seasonal autoregressive integrated moving average (SARIMA) model was used for determining the impact of climatic and environmental variability on cholera incidence and evaluating the ability of the model to forecast the magnitude of cholera. There were 4,157 cholera cases during the study period, with an average of 1.4 cases per 1,000 people. Since monthly cholera cases varied significantly by month, it was necessary to stabilize the variance of cholera incidence by computing the natural logarithm to conduct the analysis. The SARIMA model shows temporal clustering of cholera at one- and 12-month lags. There was a 6% increase in cholera incidence with a minimum temperature increase of one degree celsius in the current month. For increase of SST by one degree celsius, there was a 25% increase in the cholera incidence at currrent month and 18% increase in the cholera incidence at two months. Rainfall did not influenc to cause variation in cholera incidence during the study period. The model forecast the fluctuation of cholera incidence in Matlab reasonably well (Root mean square error, RMSE: 0.108). Thus, the ambient and sea-surface temperature-based model could be used in forecasting cholera outbreaks in Matlab.
Journal of Health Population and Nutrition 03/2013; 31(1):11-9. · 0.95 Impact Factor
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ABSTRACT: Objectives. We investigated whether deep tube wells installed to provide arsenic-free groundwater in rural Bangladesh have the added benefit of reducing childhood diarrheal disease incidence. Methods. We recorded cases of diarrhea in children younger than 5 years in 142 villages of Matlab, Bangladesh, during monthly community health surveys in 2005 and 2006. We surveyed the location and depth of 12 018 tube wells and integrated these data with diarrhea data and other data in a geographic information system. We fit a longitudinal logistic regression model to measure the relationship between childhood diarrhea and deep tube well use. We controlled for maternal education, family wealth, year, and distance to a deep tube well. Results. Household clusters assumed to be using deep tube wells were 48.7% (95% confidence interval = 27.8%, 63.5%) less likely to have a case of childhood diarrhea than were other household clusters. Conclusions. Increased access to deep tube wells may provide dual benefits to vulnerable populations in Matlab, Bangladesh, by reducing the risk of childhood diarrheal disease and decreasing exposure to naturally occurring arsenic in groundwater. (Am J Public Health. Published online ahead of print February 14, 2013: e1-e5. doi:10.2105/AJPH.2012.300975).
American Journal of Public Health 02/2013; · 3.93 Impact Factor
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Guillaume Constantin de Magny,
Raghu Murtugudde,
Mathew R P Sapiano,
Azhar Nizam,
Christopher W Brown,
Antonio J Busalacchi, Mohammad Yunus,
G Balakrish Nair,
Ana I Gil,
Claudio F Lanata,
John Calkins,
Byomkesh Manna,
Krishnan Rajendran,
Mihir Kumar Bhattacharya,
Anwar Huq,
R Bradley Sack,
Rita R Colwell
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Annals of the Association of American Geographers 01/2013; 103(2):299-308. · 2.17 Impact Factor
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ABSTRACT: Arsenic in drinking water was associated with increased risk of all-cause, cancer, and cardiovascular death in adults. However, the extent to which exposure is related to all-cause and deaths from cancer and cardiovascular condition in young age is unknown. Therefore, we prospectively assessed whether long-term and recent arsenic exposures are associated with all-cause and cancer and cardiovascular mortalities in Bangladeshi childhood population.
We assembled a cohort of 58406 children aged 5-18 years from the Health and Demographic Surveillance System of icddrb in Bangladesh and followed during 2003-2010. There were 185 non-accidental deaths registered in-about 0.4 million person-years of observation. We calculated hazard ratios for cause-specific death in relation to exposure at baseline (µg/L), time-weighted lifetime average (µg/L) and cumulative concentration (µg-years/L). After adjusting covariates, hazard ratios (HRs) for all-cause childhood deaths comparing lifetime average exposure 10-50.0, 50.1-150.0, 150.1-300.0 and ≥300.1µg/L were 1.37 (95% confidence interval [CI], 0.74-2.57), 1.44 (95% CI, 0.88-2.38), 1.22 (95% CI, 0.75-1.98) and 1.88 (95% CI, 1.14-3.10) respectively. Significant increased risk was also observed for baseline (P for trend = 0.023) and cumulative exposure categories (P for trend = 0.036). Girls had higher mortality risk compared to boys (HR for girls 1.79, 1.21, 1.64, 2.31; HR for boys 0.52, 0.53, 1.14, 0.99) in relation to baseline exposure. For all cancers and cardiovascular deaths combined, multivariable adjusted HRs amounted to 1.53 (95% CI 0.51-4.57); 1.29 (95% CI 0.43-3.87); 2.18 (95%CI 1.15-4.16) for 10.0-50.0, 50.1-150.0, and ≥150.1, comparing lowest exposure as reference (P for trend = 0.009). Adolescents had higher mortality risk compared to children (HRs = 1.53, 95% CI 1.03-2.28 vs. HRs = 1.30, 95% CI 0.78-2.17).
Arsenic exposure was associated with substantial increased risk of deaths at young age from all-cause, and cancers and cardiovascular conditions. Girls and adolescents (12-18 years) had higher risk compared to boys and child.
PLoS ONE 01/2013; 8(1):e55014. · 4.09 Impact Factor
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ABSTRACT: There has been little evidence of a decline in the global burden of cholera in recent years as the number of cholera cases reported to WHO continues to rise. Cholera remains a global threat to public health and a key indicator of lack of socioeconomic development. Overall socioeconomic development is the ultimate solution for control of cholera as evidenced in developed countries. However, most research has focused on cross-county comparisons so that the role of individual- or small area-level socioeconomic status (SES) in cholera dynamics has not been carefully studied. Reported cases of cholera in Matlab, Bangladesh have fluctuated greatly over time and epidemic outbreaks of cholera continue, most recently with the introduction of a new serotype into the region. The wealth of longitudinal data on the population of Matlab provides a unique opportunity to explore the impact of socioeconomic status and other demographic characteristics on the long-term temporal dynamics of cholera in the region. In this population-based study we examine which factors impact the initial number of cholera cases in a bari at the beginning of the 0139 epidemic and the factors impacting the number of cases over time. Cholera data were derived from the ICDDR,B health records and linked to socioeconomic and geographic data collected as part of the Matlab Health and Demographic Surveillance System. Longitudinal zero-inflated Poisson (ZIP) multilevel regression models are used to examine the impact of environmental and socio-demographic factors on cholera counts across baris. Results indicate that baris with a high socioeconomic status had lower initial rates of cholera at the beginning of the 0139 epidemic (γ(01) = -0.147, p = 0.041) and a higher probability of reporting no cholera cases (α(01) = 0.156, p = 0.061). Populations in baris characterized by low SES are more likely to experience higher cholera morbidity at the beginning of an epidemic than populations in high SES baris.
PLoS Neglected Tropical Diseases 01/2013; 7(1):e1997. · 4.69 Impact Factor
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ABSTRACT: We develop novel methods for conceptualizing geographic space and social networks to evaluate their respective and combined contributions to childhood diarrheal incidence. After defining maternal networks according to direct familial linkages between females, and road networks using satellite imagery of the study area, we use a spatial econometrics model to evaluate the significance of correlation terms relating childhood diarrheal incidence to the incidence observed within respective networks. Disease was significantly clustered within road networks across time, but only inconsistently correlated within maternal networks. These methods could be widely applied to systems in which both social and spatial processes jointly influence health outcomes.
Health & Place 10/2012; 19C:45-52. · 2.67 Impact Factor
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Andrew S Ferguson,
Alice C Layton,
Brian J Mailloux,
Patricia J Culligan,
Daniel E Williams,
Abby E Smartt,
Gary S Sayler,
John Feighery,
Larry D McKay,
Peter S K Knappett,
Ekaterina Alexandrova,
Talia Arbit,
Michael Emch,
Veronica Escamilla,
Kazi Matin Ahmed,
Md Jahangir Alam,
P Kim Streatfield, Mohammad Yunus,
Alexander van Geen
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ABSTRACT: Groundwater is routinely analyzed for fecal indicators but direct comparisons of fecal indicators to the presence of bacterial and viral pathogens are rare. This study was conducted in rural Bangladesh where the human population density is high, sanitation is poor, and groundwater pumped from shallow tubewells is often contaminated with fecal bacteria. Five indicator microorganisms (E. coli, total coliform, F+RNA coliphage, Bacteroides and human-associated Bacteroides) and various environmental parameters were compared to the direct detection of waterborne pathogens by quantitative PCR in groundwater pumped from 50 tubewells. Rotavirus was detected in groundwater filtrate from the largest proportion of tubewells (40%), followed by Shigella (10%), Vibrio (10%), and pathogenic E. coli (8%). Spearman rank correlations and sensitivity-specificity calculations indicate that some, but not all, combinations of indicators and environmental parameters can predict the presence of pathogens. Culture-dependent fecal indicator bacteria measured on a single date did not predict total bacterial pathogens, but annually averaged monthly measurements of culturable E. coli did improve prediction for total bacterial pathogens. A qPCR-based E. coli assay was the best indicator for the bacterial pathogens. F+RNA coliphage were neither correlated nor sufficiently sensitive towards rotavirus, but were predictive of bacterial pathogens. Since groundwater cannot be excluded as a significant source of diarrheal disease in Bangladesh and neighboring countries with similar characteristics, the need to develop more effective methods for screening tubewells with respect to microbial contamination is necessary.
Science of The Total Environment 06/2012; 431:314-22. · 3.29 Impact Factor
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ABSTRACT: The population dynamics of endemic cholera in urban environments--in particular interannual variation in the size and distribution of seasonal outbreaks--remain poorly understood and highly unpredictable. In part, this situation is due to the considerable demographic, socioeconomic, and environmental heterogeneity of large and growing urban centers. Despite this heterogeneity, the influence of climate variability on the population dynamics of infectious diseases is considered a large-scale, regional, phenomenon, and as such has been previously addressed for cholera only with temporal models that do not incorporate spatial structure. Here we show that a probabilistic spatial model can explain cholera dynamics in the megacity of Dhaka, Bangladesh, and afford a basis for cholera forecasts at lead times of 11 mo. Critically, we find that the action of climate variability (El Niño southern oscillation and flooding) is quite localized: There is a climate-sensitive urban core that acts to propagate risk to the rest of the city. The modeling framework presented here should be applicable to cholera in other cities, as well as to other infectious diseases in urban settings and other biological systems with spatiotemporal interactions.
Proceedings of the National Academy of Sciences 02/2012; 109(6):2033-6. · 9.68 Impact Factor
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Annals of the Association of American Geographers 01/2012; 102(5):1004-1015. · 2.17 Impact Factor
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Jianyong Wu,
Alexander van Geen,
Kazi Matin Ahmed,
Yasuyuki Akita,
Janahgir Alam,
Patricia J Culligan,
Veronica Escamilla,
John Feighery,
Andrew S Ferguson,
Peter Knappett,
Brian J Mailloux,
Larry D McKay,
Marc L Serre,
P Kim Streatfield, Mohammad Yunus,
Michael Emch
PLoS ONE 01/2012; 7(1). · 4.09 Impact Factor
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ABSTRACT: During the past three decades in Bangladesh, millions of tubewells have been installed to reduce the prevalence of diarrheal disease. This study evaluates the impacts of tubewell access and tubewell depth on childhood diarrhea in rural Bangladesh.
A total of 59,796 cases of diarrhea in children under 5 were recorded in 142 villages of Matlab, Bangladesh during monthly community health surveys between 2000 and 2006. The location and depth of 12,018 tubewells were surveyed in 2002-04 and integrated with diarrhea and other data in a geographic information system. A proxy for tubewell access was developed by calculating the local density of tubewells around households. Logistic regression models were built to examine the relationship between childhood diarrhea, tubewell density and tubewell depth. Wealth, adult female education, flood control, population density and the child's age were considered as potential confounders.
Baris (patrilineally-related clusters of households) with greater tubewell density were associated with significantly less diarrhea (OR (odds ratio) = 0.87, 95% confidence interval (CI): 0.85-0.89). Tubewell density had a greater influence on childhood diarrhea in areas that were not protected from flooding. Baris using intermediate depth tubewells (140-300 feet) were associated with more childhood diarrhea (OR = 1.24, 95% CI: 1.19-1.29) than those using shallow wells (10-140 feet). Baris using deep wells (300-990 feet) had less diarrheal disease than those using shallow wells, however, the difference was significant only when population density was low (< 1000 person/km(2)) or children were at the age of 13-24 months.
Increased access to tubewells is associated with a lower risk of childhood diarrhea. Intermediate- depth wells are associated with more childhood diarrhea compared to shallower or deeper wells. These findings may have implications for on-going efforts to reduce exposure to elevated levels of arsenic contained in groundwater that is pumped in this study area primarily from shallow tubewells.
Environmental Health 12/2011; 10:109. · 2.65 Impact Factor
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Anisur Rahman,
Allisyn Moran,
Jesmin Pervin,
Aminur Rahman,
Monjur Rahman,
Sharifa Yeasmin,
Hosneara Begum,
Harunor Rashid, Mohammad Yunus,
Daniel Hruschka,
Shams E Arifeen,
Peter K Streatfield,
Lynn Sibley,
Abbas Bhuiya,
Marge Koblinsky
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ABSTRACT: Improving perinatal health is the key to achieving the Millennium Development Goal for child survival. Recently, several reviews suggest that scaling up available effective perinatal interventions in an integrated approach can substantially reduce the stillbirth and neonatal death rates worldwide. We evaluated the effect of packaged interventions given in pregnancy, delivery and post-partum periods through integration of community- and facility-based services on perinatal mortality.
This study took advantage of an ongoing health and demographic surveillance system (HDSS) and a new Maternal, Neonatal and Child Health (MNCH) Project initiated in 2007 in Matlab, Bangladesh in half (intervention area) of the HDSS area. In the other half, women received usual care through the government health system (comparison area). The MNCH Project strengthened ongoing maternal and child health services as well as added new services. The intervention followed a continuum of care model for pregnancy, intrapartum, and post-natal periods by improving established links between community- and facility-based services. With a separate pre-post samples design, we compared the perinatal mortality rates between two periods--before (2005-2006) and after (2008-2009) implementation of MNCH interventions. We also evaluated the difference-of-differences in perinatal mortality between intervention and comparison areas.
Antenatal coverage, facility delivery and cesarean section rates were significantly higher in the post- intervention period in comparison with the period before intervention. In the intervention area, the odds of perinatal mortality decreased by 36% between the pre-intervention and post-intervention periods (odds ratio: 0.64; 95% confidence intervals: 0.52-0.78). The reduction in the intervention area was also significant relative to the reduction in the comparison area (OR 0.73, 95% CI: 0.56-0.95; P = 0.018).
The continuum of care approach provided through the integration of service delivery modes decreased the perinatal mortality rate within a short period of time. Further testing of this model is warranted within the government health system in Bangladesh and other low-income countries.
BMC Public Health 12/2011; 11:914. · 2.00 Impact Factor
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ABSTRACT: Little is known about the variation in exposure to toxic metals by age and gender and other potential modifying factors. We evaluated age and gender differences by measurements of metal/element concentrations in urine in a rural population in Matlab, Bangladesh, in three age groups: 8-12 (N=238), 14-15 (N=107) and 30-88 (N=710) years of age, living in an area with no point sources of metal exposure but where elevated water arsenic concentrations are prevalent.
We found marked differences in urine concentrations of metals and trace elements by gender, age, tobacco use, socioeconomic and nutritional status. Besides a clearly elevated urinary arsenic concentration in all age groups (medians 63-85 μg As/L), and despite the low degree of contamination from industries and traffic, the urine concentrations of toxic metals such as cadmium and lead were clearly elevated, especially in children (median 0.31 μg Cd/L and 2.9 μg Pb/L, respectively). In general, women had higher urinary concentrations of toxic metals, especially Cd (median 0.81 μg/L) compared to men (0.66 μg/L) and U (median 10 ng/L in women, compared to 6.4 ng/L in men), while men had higher urinary concentrations of the basic and essential elements Ca (69 mg/L in men, 30-50 years, compared to 52 mg/L in women), Mg (58 mg/L in men compared to 50 mg/L in women), Zn (182 μg/L in men compared to 117 μg/L in women) and Se (9.9 μg/L in men compared to 8.7 μg/L in women). Manganese was consistently higher in females than in males in all age groups, suggesting a biological difference between females and males in Mn metabolism. Increasing socioeconomic status decreased the toxic metal exposure significantly in children and especially in men. Poor iron status was detected in 17% of children, adolescents and women, but only in 6% of men. Also zinc deficiency was more prevalent in females than in males.
Women and children seemed to be more at risk for toxic metal exposure than men and at the same time more vulnerable to micronutrient deficiency. Higher concentrations of the toxic metals in urine in women are likely to reflect an increased gastrointestinal absorption of these metals at micronutrient deficiency, such as low body iron stores and Zn deficiency. Higher urinary concentrations of the essential elements in men likely reflect a better nutritional status. There is a need for information on exposure, lifestyle and socioeconomic factors, stratified by gender and age, for the purpose of conducting balanced risk assessment and management that considers such differences.
Environmental Research 09/2011; 111(8):1271-9. · 3.40 Impact Factor
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ABSTRACT: Live oral cholera vaccines may protect against cholera in a manner similar to natural cholera infections. However, information on which to base these vaccines is limited.
The study was conducted in a cholera-endemic population in Bangladesh. Patients with cholera (index patients) detected between 1991 and 2000 were age-matched to 4 cholera-free controls and then followed up during the subsequent 3 years.
El Tor cholera was associated with a 65% (95% confidence interval [CI], 37%-81%; P < .001) lower risk of a subsequent El Tor episode. Reduction of the risk of subsequent El Tor cholera was similar for children < 5 years and for older persons and was sustained during all 3 years of follow-up. Having El Tor Inaba cholera was associated with lower risks of both El Tor Inaba and El Tor Ogawa cholera, but having El Tor Ogawa cholera was associated only with a reduced risk of El Tor Ogawa cholera. O139 cholera was associated with a 63% (95% CI, -61% to 92%; P = .18) lower risk of subsequent O139 cholera, but there was no evidence of cross-protection between the O1 and O139 serogroups.
Live oral cholera vaccines designed to protect against the O1 and O139 serogroups should contain at least the Inaba serotype and strains of both serogroups.
The Journal of Infectious Diseases 09/2011; 204(6):912-8. · 6.41 Impact Factor
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ABSTRACT: The recent discovery of large-scale arsenic (As) contamination of groundwater has raised much concern in Bangladesh. Reliable estimates of the magnitude of As exposure and related health problems have not been comprehensively investigated in Bangladesh. A large population-based study on As and health consequences in Matlab (AsMat) was done in Matlab field site where International Centre for Diarrhoeal Disease Research, Bangladesh has maintained a health and demographic surveillance system registering prospectively all vital events. Taking advantage of the health and demographic surveillance system and collecting data on detailed individual level As exposure using water and urine samples, AsMat investigated the morbidity and mortality associated with As exposure. Reviews of findings to date suggest the adverse effects of As exposure on the risk of skin lesions, high blood pressure, diabetes mellitus, chronic disease, and all-cause infant and adult disease mortality. Future studies of clinical endpoints will enhance our knowledge gaps and will give directions for disease prevention and mitigations.
The Kaohsiung journal of medical sciences 09/2011; 27(9):371-6. · 0.61 Impact Factor
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ABSTRACT: This study investigates the impact of tubewell user density on cholera and shigellosis events in Matlab, Bangladesh between 2002 and 2004. Household-level demographic, health, and water infrastructure data were incorporated into a local geographic information systems (GIS) database. Geographically-weighted regression (GWR) models were constructed to identify spatial variation of relationships across the study area. Zero-inflated negative binomial regression models were run to simultaneously measure the likelihood of increased magnitude of disease events and the likelihood of zero cholera or shigellosis events. The aim of this study was to examine the effect of tubewell density on both the occurrence of diarrheal disease and the magnitude of diarrheal disease incidence.
In Matlab, households with greater tubewell density were more likely to report zero cholera or shigellosis events. Results for both cholera and shigellosis GWR models suggest that tubewell density effects are spatially stationary and the use of non-spatial statistical methods is appropriate.
Increasing the amount of drinking water available to households through increased density of tubewells contributed to lower reports of cholera and shigellosis events in rural Bangladesh. Our findings demonstrate the importance of tubewell installation and access to groundwater in reducing diarrheal disease events in the developing world.
International Journal of Health Geographics 06/2011; 10:41. · 2.62 Impact Factor
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ABSTRACT: We conducted a randomized, double-blind placebo controlled, community trial in rural Bangladesh in children 4-59 mo of age to compare the efficacy of a 5- and 10-d course of zinc therapy on the incidence and duration of diarrhea over the subsequent 90-d follow-up after initial treatment for an acute childhood diarrheal (ACD) episode. Children (n = 1622) with ACD were randomly allocated to either 5 or 10 d of zinc treatment. Female field workers visited each child daily, supervised the administration of zinc, recorded the duration of current episode, and the occurrence and duration of diarrhea over the subsequent 3 mo. The incidence of diarrhea over the 90 d of follow-up did not differ between the 5-d (1.08 ± 1.38 episodes) and 10-d (1.02 ± 1.35 episodes) groups (P = 0.35). Children in both groups experienced a comparable duration of diarrheal episodes (3.1 ± 5.6 d vs. 2.9 ± 5.6 d, 5-d vs. 10-d, respectively; P = 0.64) with a mean difference between groups within the defined range of equivalence. Time to onset of the first episode and the proportion children experiencing diarrhea during the 90-d follow-up also did not differ between groups. These findings suggest that among Bangladeshi children, a 5-d zinc treatment for ACD is as efficacious as 10 d in preventing diarrhea in the subsequent 3 mo.
Journal of Nutrition 02/2011; 141(2):312-5. · 3.92 Impact Factor
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ABSTRACT: This study uses social network and spatial analytical methods simultaneously to understand cholera transmission in rural Bangladesh. Both have been used separately to incorporate context into health studies, but using them together is a new and recent approach. Data include a spatially referenced longitudinal demographic database consisting of approximately 200,000 people and a database of all laboratory-confirmed cholera cases from 1983 to 2003. A complete kinship-based network linking households is created, and distance matrices are also constructed to model spatial relationships. A spatial error-social effects model tested for cholera clustering in socially linked households while accounting for spatial factors. Results show that there was social clustering in five out of twenty-one years while accounting for both known and unknown environmental variables. This suggests that environmental cholera transmission is significant and social networks also influence transmission, but not as consistently. Simultaneous spatial and social network analysis may improve understanding of disease transmission.
Interdisciplinary Perspectives on Infectious Diseases 01/2011; 2011:604372.
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Jianyong Wu,
Alexander van Geen,
Kazi Matin Ahmed,
Yasuyuki Akita Jahangir Alam,
Patricia J Culligan,
Veronica Escamilla,
John Feighery,
Andrew S Ferguson,
Peter Knappett,
Brian J Mailloux,
Larry D McKay,
Marc L Serre,
P Kim Streatfield, Mohammad Yunus,
Michael Emch
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ABSTRACT: Millions of households throughout Bangladesh have been exposed to high levels of arsenic (As) causing various deadly diseases by drinking groundwater from shallow tubewells for the past 30 years. Well testing has been the most effective form of mitigation because it has induced massive switching from tubewells that are high (>50 µg/L) in As to neighboring wells that are low in As. A recent study has shown, however, that shallow low-As wells are more likely to be contaminated with the fecal indicator E. coli than shallow high-As wells, suggesting that well switching might lead to an increase in diarrheal disease.
Approximately 60,000 episodes of childhood diarrhea were collected monthly by community health workers between 2000 and 2006 in 142 villages of Matlab, Bangladesh. In this cross-sectional study, associations between childhood diarrhea and As levels in tubewell water were evaluated using logistic regression models.
Adjusting for wealth, population density, and flood control by multivariate logistic regression, the model indicates an 11% (95% confidence intervals (CIs) of 4-19%) increase in the likelihood of diarrhea in children drinking from shallow wells with 10-50 µg/L As compared to shallow wells with >50 µg/L As. The same model indicates a 26% (95%CI: 9-42%) increase in diarrhea for children drinking from shallow wells with ≤10 µg/L As compared to shallow wells with >50 µg/L As.
Children drinking water from shallow low As wells had a higher prevalence of diarrhea than children drinking water from high As wells. This suggests that the health benefits of reducing As exposure may to some extent be countered by an increase in childhood diarrhea.
PLoS ONE 01/2011; 6(12):e29593. · 4.09 Impact Factor
