[Show abstract][Hide abstract] ABSTRACT: In an earlier study in rural Guatemala, 257 households that received flocculant-disinfectant to treat their drinking water had 39% less diarrhea than 257 control households. Three weeks after completion of the study, national marketing of the flocculant-disinfectant was extended into the study communities. Six months later, we assessed frequency of and characteristics associated with purchase and use of the flocculant-disinfectant by revisiting the original study households and administering a questionnaire. Four hundred sixty-two households (90%) completed the follow-up survey; 22 households (5%) purchased the flocculant-disinfectant within the preceding 2 weeks and used it within the last week. Neither being randomized to the intervention group during the efficacy study nor combined spending on laundry soap, toothpaste, and hand soap in the preceding week was associated with active repeat use. Even after efficacy was demonstrated within their community and an aggressive sophisticated marketing approach, few households purchased flocculant-disinfectant for point-of-use water treatment.
The American journal of tropical medicine and hygiene 04/2008; 78(3):382-7. · 2.70 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: Endosymbionic Wolbachia bacteria inside adult Onchocerca volvulus worms (causing river blindness) are necessary for female worm fertility. We evaluated whether rifampin and/or azithromycin used in a five-day course could kill Wolbachia. In an open-label trial in Guatemala, 73 patients with 134 palpable onchocercal nodules were randomized into four treatment groups: rifampin, azithromycin, a combination of the two drugs, and controls (multivitamins). After five days of antibiotic treatment, all participants received a single dose of ivermectin on day 6. Nine months after treatment, the nodules were removed and the worms were examined. Skin snips to determine microfilariae were obtained at baseline and nine months. There were no significant differences between any of the treatment groups in the condition of the worms in the nodules, the presence of Wolbachia surface protein, or the number of microfilariae in skin. Short courses with these antibiotics will not clear Wolbachia from O. volvulus.
The American journal of tropical medicine and hygiene 12/2007; 77(5):878-82. · 2.70 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: We evaluated enteric infection serology as an alternative outcome measure to diarrhea prevalence in a randomized controlled trial of household-based drinking water treatment; 492 households were randomly assigned to 5 household-based water treatment interventions or control. Individuals were followed weekly over 52 weeks to measure diarrhea prevalence. Study subjects of age <or= 6 months and < 24 months had blood drawn at entry and exit from the study or age cohort. Serologic assays for Cryptosporidium parvum, Giardia intestinalis, enterotoxigenic Escherichia coli (ETEC), and Norovirus were done. Of 343 subjects eligible for the study, the proportions of subjects experiencing serologic responses were 56% for Norovirus, 24% for C. parvum, 10% for ETEC, and 16% for G. intestinalis. Serologic response was associated with increased diarrhea prevalence only for G. intestinalis (P = 0.0134). Serologic response to the antigens tested for G. intestinalis but not for Norovirus, C. parvum, and ETEC may be a useful health-effect measure. Larger intervention studies that yield a more marked effect on diarrheal disease, use additional and improved serologic assays, and that collect serum samples at more frequent intervals are needed.
The American journal of tropical medicine and hygiene 08/2007; 77(1):136-41. · 2.70 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: World Health Organization certification criteria for onchocerciasis elimination use anterior segment eye lesion prevalence as an indicator of mass ivermectin treatment program success. Lesions either contain visible microfilaria (noninflammatory punctate keratitis [PK] or microfilariae in anterior chamber [MFAC]), or microfilaria obscured by inflammation (inflammatory PK). To assess the utility of these disease indicators, two experienced ophthalmologists independently examined persons from endemic (N = 325) and nonendemic (N = 348) Guatemalan communities. Thirty-six (11.1%) and nine (2.6%) persons from endemic and nonendemic areas respectively had lesions found by either ophthalmologist (prevalence ratio = 4.3, 95% CI 2.1-8.8, P < 0.001). All lesions in nonendemic areas were inflammatory PK in whom no persons were seropositive for onchocerciasis. Overall, observer agreement was moderate (Kappa = 0.49), and most (61%) discordance occurred with inflammatory PK lesions. Our findings suggest that inflammatory punctate keratitis is neither a specific nor a reliable indicator of onchocercal eye disease. Future prevalence surveys should rely upon noninflammatory lesions as disease indicators.
The American journal of tropical medicine and hygiene 01/2007; 75(6):1058-62. · 2.70 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: To examine the effect of a new point-of-use treatment for drinking-water, a commercially developed flocculant-disinfectant, on the prevalence of diarrhoea in children.
We conducted a randomized controlled trial among 514 rural Guatemalan households, divided into 42 neighbourhood clusters, for 13 weeks, from 4 November 2002 through 31 January 2003. Clusters assigned to water treatment with the flocculant-disinfectant were compared with those using their usual water-handling practices. The longitudinal prevalence of diarrhoea was calculated as the proportion of total days with diarrhoea divided by the total number of days of observation. The prevalence of diarrhoea was compared using the Wilcoxon rank-sum test.
The 1702 people in households receiving the disinfectant had a prevalence of diarrhoea that was 40% lower than that among the 1699 people using standard water-handling practices (0.9% versus 1.5%; P = 0.001). In households using the flocculant-disinfectant, children < 1 year of age had a 39% lower prevalence of diarrhoea than those in households using their standard practices (3.7% versus 6.0%; P = 0.005).
In settings where families rarely treat drinking-water, we introduced a novel flocculant-disinfectant that reduced the longitudinal prevalence of diarrhoea, especially among children aged < 1 year, among whom diarrhoea has been strongly associated with mortality. Successful introduction and use of this product could contribute to preventing diarrhoeal disease globally.
Bulletin of the World Health Organisation 02/2006; 84(1):28-35. DOI:10.2471/BLT.04.016980 · 5.09 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: Background
Point-of-use water treatment prevents diarrhea in families in developing countries who lack access to potable water. A 13-week controlled intervention trial provided free flocculant-disinfectant product for water treatment to 257 households that as a result experienced 40% less diarrhea than 257 control households. We conducted a post-study survey six months after the intervention, to determine factors associated with subsequent purchase and use of the product.
A standardized questionnaire was administered to rural Guatemalan households that participated in the 13-week study. Confirmed users were defined as households that used the product in the previous week, had purchased product in the previous four weeks, and had the product at time of interview. We calculated adjusted odd ratios using logistic regression.
In August 2003, 472 (92%) of 514 households completed the six month post-study questionnaire; 259 (55%) knew where to purchase the product and 25 (10%) were confirmed users. Compared to non-users, confirmed users were more likely to believe drinking water makes their family sick (Adjusted Odds Ratio [AOR]=5.0, 95% Confidence Interval [CI] =1.1-22.5) and were 5.8 times more likely to own a refrigerator (AOR=5.8, 95% CI=1.9-18.2). Compared to non-users, confirmed users were equally likely to have purchased laundry detergent (96%vs.99%, OR=0.31, p=0.33) and toothpaste (64%vs.58%, OR=1.28, p=0.58) in the previous week. Confirmed users were equally likely to have been in the intervention or control group during the 13-week trial (13%vs.15%, OR=0.84, p=0.68).
Beliefs about drinking water safety was the primary difference between households who purchased and used flocculant-disinfectant and non-users. Effective communication of the health risks of unsafe drinking water could motivate point-of-use water treatment.
behavior change, diarrhea, flocculation, Guatemala, water purification, water supply
AMERICAN JOURNAL OF TROPICAL MEDICINE AND HYGIENE; 12/2005
[Show abstract][Hide abstract] ABSTRACT: The prevalence of Toxoplasma gondii in free-ranging chickens is a good indicator of the prevalence of T. gondii oocysts in the soil because chickens feed from the ground. The prevalence of T. gondii in 50 free-range chickens (Gallus domesticus) from Guatemala was determined. Antibodies to T. gondii were assayed by the modified agglutination test (MAT). Antibodies were found in 37 (74%) chickens with titers of 1:5 (11), 1:10 (7), 1:20 (11), 1:40 (1), 1:80 (1), 1:160 (3), 1:1,280 (2), and 1:2,560 (1). Hearts, pectoral muscles, and brains of 19 chickens with MAT titers of 1:20 or more were bioassayed individually in mice. Tissues from the remaining 31 chickens with titers of 1:10 or lower were pooled and fed to 4 T. gondii-free cats (13 chickens with titers of less than 1:5 to 1 cat, 11 chickens with titers of 1:5 to 2 cats, and 7 chickens with titers of 1:10 to 1 cat). Feces of cats were examined for oocysts; they did not shed oocysts. Toxoplasma gondii was isolated from 8 chickens with MAT titers of 1:20 or more (from 1 of 11 chickens with a titer of 1:20 and all 7 chickens with a titer of 1:80 or more) from the heart, brain, and pectoral muscle (3); heart and pectoral muscle (1); and heart alone (4). Genotyping of these 8 isolates with the SAG2 locus indicated that 5 were type III and 3 were type 1. This is the first report of isolation of T. gondii from chickens from Guatemala.
Journal of Parasitology 09/2005; 91(4):955-7. DOI:10.1645/GE-493R.1 · 1.23 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: Water and sanitation interventions in developing countries have historically been difficult to evaluate. We conducted a seroepidemiologic study with the following goals: 1) to determine the feasibility of using antibody markers as indicators of waterborne pathogen infection in the evaluation of water and sanitation intervention projects; 2) to characterize the epidemiology of waterborne diarrheal infections in rural Guatemala, and 3) to measure the age-specific prevalence of antibodies to waterborne pathogens. Between September and December 1999, all children 6-36 months of age in 10 study villages were invited to participate. We collected sufficient serum from 522 of 590 eligible children, and divided them into six-month age groups for analysis (6-12, 13-18, 19-24, 25-30, and 31-36 months). The prevalence of antibodies was lowest in children 6-12 months old compared with the four older age groups for the following pathogens: enterotoxigenic Escherichia coli (48%, 81%, 80%, 77%, and 83%), Norwalk virus (27%, 61%, 83%, 94%, and 94%), and Cryptosporidium parvum (27%, 53%, 70%, 67%, and 73%). The prevalence of total antibody to hepatitis A virus increased steadily in the three oldest age groups (40%, 28%, 46%, 60%, and 76%). In contrast, the prevalence of antibody to Helicobacter pylori was relatively constant in all five age groups (20%, 19%, 21%, 25%, and 25%). Serology appears to be an efficient and feasible approach for determining the prevalence of infection with selected waterborne pathogens in very young children. Such an approach may provide a suitable, sensitive, and economical alternative to the cumbersome stool collection methods that have previously been used for evaluation of water and sanitation projects.
The American journal of tropical medicine and hygiene 02/2004; 70(1):83-8. · 2.70 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: We conducted a study to determine if use of a new flocculant-disinfectant home water treatment reduced diarrhea. We randomly assigned 492 rural Guatemalan households to five different water treatment groups: flocculant-disinfectant, flocculant-disinfectant plus a customized vessel, bleach, bleach plus a vessel, and control. During one year of observation, residents of control households had 4.31 episodes of diarrhea per 100 person-weeks, whereas the incidence of diarrhea was 24% lower among residents of households receiving flocculant-disinfectant, 29% lower among those receiving flocculant-disinfectant plus vessel, 25% lower among those receiving bleach, and 12% lower among households receiving bleach plus vessel. In unannounced evaluations of home drinking water, free chlorine was detected in samples from 27% of flocculant-disinfectant households, 35% of flocculant-disinfectant plus vessel households, 35% of bleach households, and 43% of bleach plus vessel households. In a setting where diarrhea was a leading cause of death, intermittent use of home water treatment with flocculant-disinfectant decreased the incidence of diarrhea.
The American journal of tropical medicine and hygiene 11/2003; 69(4):411-9. · 2.70 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: Human enteropathogenic microsporidia (HEM), Cryptosporidium parvum, Cyclospora cayetanesis, and Giardia lamblia are associated with gastrointestinal disease in humans. To date, the mode of transmission and environmental occurrence of HEM (Encephalitozoon intestinalis and Enterocytozoon bieneusi) and Cyclospora cayetanesis have not been fully elucidated due to lack of sensitive and specific environmental screening methods. The present study was undertaken with recently developed methods, to screen various water sources used for public consumption in rural areas around the city of Guatemala. Water concentrates collected in these areas were subjected to community DNA extraction followed by PCR amplification, PCR sequencing and computer database homology comparison (CDHC). All water samples screened in this study had been previously confirmed positive for Giardia spp. by immunofluorescent assay (IFA). Of the 12 water concentrates screened, 6 showed amplification of microsporidial SSU-rDNA and were subsequently confirmed to be Encephalitozoon intestinalis. Five of the samples allowed for amplification of Cyclospora 18S-rDNA; three of these were confirmed to be Cyclospora cayetanesis while two could not be identified because of inadequate sequence information. Thus, this study represents the first confirmed identification of Cyclospora cayetanesis and Encephalitozoon intestinalis in source water used for consumption. The fact that the waters tested may be used for human consumption indicates that these emerging protozoa may be transmitted by ingestion of contaminated water.
Journal of Water and Health 10/2003; 1(3):117-23. · 1.46 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: Over 75% of the world's.population lives in underdeveloped areas without access to safe drinking water. Water sources are scarce and frequently heavily contaminated. This has been linked to severe health problems, including diarrheal disease which causes an estimated 2.2 million deaths per year. In Latin America, it is estimated that 40% of households receive water inadequately treated or not treated at all. Water treatment to assure safe drinking water is not routinely performed in rural areas of Guatemala although municipal governments are compelled by law to disinfect water. Even though local villagers consider their water to be clean, it is generally thought by the scientific community that water in rural areas is unsafe. We studied the quality of the water sources of ten rural communities of San Juan Sacatepequez, located 30 kilometers from Guatemala City. The sources selected were available most of the year and frequently used. Initial water samples were collected during 1999 from a cross-sectional pilot study. These samples were analyzed for water quality for presence of bacteria, parasites and viruses. The samples screened for bacteria were processed using a modification of the most probable number method and tested with Colilert Quanti-tray(R) to quantify total coliforms and Escherichia coli. Water samples were collected using the USEPA Information Collection Rule (ICR) method for concentration and detection of protozoan parasites and viruses and measured by immunofluorescent assay (IFA) and cell culture assays, respectively. Additionally, the concentrates were subjected to community DNA extraction followed by PCR amplification and sequencing to identify the presence of Cyclospora cayetanensis and Microsporidia. Of a total of 35 water samples screened for bacteria, 25 (77%) showed presence of E. coli with an average contamination level of 2 x 103 UFC/100 ml. Ten of the most contaminated sources, with the highest levels of total coliforms and E. coli were examined for parasites and viruses. Of the 10 sample sites, seven were confirmed positive for Giardia lamblia and three for Cryptosporidium parvum. Enteroviruses were found in three out of the 10 sample sites. Six samples showed positive amplification for Microsporidial DNA and three were confirmed for C. cayetanensis. The most effective microbiological monitoring of water sources and drinking water in general is the determination of the presence of bacteria, especially E. coli, but water might contain a range of pathogens which would represent different risks. The non-bacterial pathogens found are the first documented reports of parasite and viruses found in drinking water in the country. Giardia and Cryptosporidium are not sensitive to regular disinfection by chlorine, its finding draws attention to the need of identifying other intervention strategies for their elimination. The results of this study demonstrate high levels of bacterial, parasitic and viral contamination on water sources in these rural communities. Water sources in these areas consist of reservoirs fed by springs or wells and available water is frequently contaminated by both human and animal feces.
[Show abstract][Hide abstract] ABSTRACT: Exposure to contaminated water through ingestion of drinking water or through recreational activities is a significant mode of transmission of gastrointestinal pathogens that cause death in low income countries. In Guatemala most of the people do not have access to safe drinking water and the development of products to improve quality of drinking water is necessary. To achieve this objective a pilot study testing a new method for the reduction of microbial, organic and heavy metals in water was conducted in rural communities in Guatemala. One hundred randomly selected households were evaluated and randomly assigned in four intervention and one control groups. Three of the intervention groups received flocculant, a new product to be tested that clarifies water through flocculation and disinfects water at the same time; another intervention group received chlorine meanwhile, whereas the control group did not receive an intervention. Baseline household water samples, evaluated for total coliforms, Eschericha coli and turbidity showed no potable water, and high levels of turbidity. The proportion of potable water samples after treatment varied by treatment group, there was a significant improvement in water quality among the four intervention groups, but no a significant difference between the floccutant and the chlorine group. The turbidity decreased significantly in the flocculant users compared to chlorine users. The product showed an improvement in the water potability as well as chlorine bleach, and significantly decreased water turbidity. Based on these findings five hundred households were enrolled and randomly assigned four: flocculant and a water storage vessel, flocculant only, a chlorine solution and chlorine alone. At baseline, one percent of the water samples analyzed was potable, but during fifty two weeks of surveillance up to sixty percent potability was observed in the intervention groups. The turbidity decreased significantly in the water samples treated with the flocculant. This new technology is a functional and inexpensive method to provide safe drinking water in rural communities.
[Show abstract][Hide abstract] ABSTRACT: An estimated 1 billion persons in low-income countries do not have access to improved drinking water. Chlorine, a useful water treatment agent, is less effective in turbid water, and lacks a visible effect, limiting its acceptability. A product incorporating precipitation, coagulation, flocculation, and chlorination technology (combined product) to reduce microbial, organic and heavy metal contaminants in water was evaluated. The combined product's microbiological efficacy in Guatemalan villagers' households was evaluated. One hundred randomly selected households from four neighboring Guatemalan villages were enrolled. Three groups received the combined product and either the Centers for Disease Control (CDC) water storage vessel, a covered bucket with spigot, or no vessel. One group received chlorine bleach and the CDC water storage vessel, and one group no intervention. Household water samples were collected for 4 weeks and Escherichia coli, chlorine, and turbidity levels were measured. Potable water was defined as having less than one E. coli per 100 ml. Eight (8%) baseline water samples were potable. Follow-up water samples were more likely to be potable than control samples (combined product and traditional vessel 83%; combined product and CDC vessel 92%; combined product and covered bucket with spigot 93%; chlorine and CDC vessel 92%; versus control 5%). Among combined product users, 98% reported improved water clarity compared with 45% of chlorine bleach users (p < 0.0001). The combined product technology improved water potability as effectively as chlorine bleach; improved water clarity could motivate more persons to effectively treat their water.
Journal of Water and Health 04/2003; 1(1):15-22. · 1.46 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: A double-blind, randomized trial was undertaken in Guatemala to determine the therapeutic efficacy of an ointment for the treatment of cutaneous leishmaniasis that contained 15% paromomycin and 12% methylbenzethonium chloride and that was applied twice a day for 20 days. The treatment group included 35 patients, and the placebo group included 33 patients. The initial clinical response rate (13 weeks after completing the treatment) was 91.4% in the treatment group and 39.4% in the placebo group. The final clinical response rate at the 12-month follow-up examination was 85.7% (31 of 35) in the treatment group and 39.4% (13 of 33) in the placebo group (P < or = 0.001). In general, the treatment was well tolerated and was never interrupted because of adverse effects. The number of adverse effects reported in the placebo group was lower than in the treatment group (16 events versus 30 events). All adverse effects reported by patients disappeared within 1 week of completing the treatment. Our findings show that the combination of paromomycin with methylbenzethonium chloride for 20 days is a good alternative for antimonial treatments of cutaneous leishmaniasis in Guatemala.
The American journal of tropical medicine and hygiene 11/2001; 65(5):466-70. · 2.70 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: Before recommending the skin-test use at national level in Guatemala of an antigen prepared from Leishmania major (a Leishmania species not found in the New World), we conducted a study in 100 Guatemalans to determine its sensitivity and specificity. The antigen consisted of 0.1 mL of a solution that contained 5 x 10(6) promastigotes of L. major (MRHO/IR/75/VAX). Positive leishmanin skin test (LST) reactions at 48 h were observed in 16 (80%) of 20 patients with proven active cutaneous leishmaniasis (CL), 18 (90%) of 20 with previously treated proven CL, and in 18 (90%) of 20 with a history and compatible scan of previously suspected but unconfirmed CL. None of 20 healthy controls or 20 patients with skin lesions due to causes other than CL had positive reactions to the LST, giving a sensitivity of 85% and specificity of 100%. There were no statistically significant differences in ethnic group, age, duration of the lesion, lesion size or Leishmania species between the 34 persons with true positive reactions. Even though it will be necessary to test this antigen on a larger number of patients, these preliminary results show that this antigen is specific and reasonably sensitive in identifying current or past CL and that it is a reasonable choice for epidemiological studies on CL in Guatemala.
Transactions of the Royal Society of Tropical Medicine and Hygiene 07/1999; 93(4):394-6. DOI:10.1016/S0035-9203(99)90129-3 · 1.84 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: Lack of reliable data about street vendors, who are difficult to survey, has hampered efforts to improve the safety of street-vended food. A two-phase method for sampling vendors, surveying first in areas of concentrated vending activity identified by local authorities and second in randomly selected areas, was developed and implemented in two Guatemalan cities where street-vended food had been implicated in cholera transmission. In a 4-day survey in Escuintla, 59 vendors (42 from phase 1, 17 from phase 2) were interviewed. They demonstrated good knowledge of food safety and cholera but unsafe practices, implying that more effective, practical training was needed. In a 6-day survey in Guatemala City, 78 vendors (77 from phase 1, 1 from phase 2) were interviewed. Sixty-eight (87 %) vendors stored water, usually in wide-mouthed vessels prone to contamination; this led to a field test of a new system for safe water storage. Useful information for public health planning and intervention can be gathered rapidly with this new method for surveying street vendors.
Epidemiology and Infection 07/1999; 122(3):409-16. DOI:10.1017/S095026889900240X · 2.54 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: Lack of reliable data about street vendors, who are difficult to survey, has hampered efforts to
improve the safety of street-vended food. A two-phase method for sampling vendors, surveying
first in areas of concentrated vending activity identified by local authorities and second in
randomly selected areas, was developed and implemented in two Guatemalan cities where
street-vended food had been implicated in cholera transmission. In a 4-day survey in Escuintla,
59 vendors (42 from phase 1, 17 from phase 2) were interviewed. They demonstrated good
knowledge of food safety and cholera but unsafe practices, implying that more effective,
practical training was needed. In a 6-day survey in Guatemala City, 78 vendors (77 from phase
1, 1 from phase 2) were interviewed. Sixty-eight (87%) vendors stored water, usually in wide-mouthed vessels prone to contamination; this led to a field test of a new system for safe water
storage. Useful information for public health planning and intervention can be gathered rapidly
with this new method for surveying street vendors.
[Show abstract][Hide abstract] ABSTRACT: Street-vended foods and beverages, an integral part of urban economies in the developing world, have been implicated in cholera transmission in Latin America. To improve the microbiologic quality of market-vended beverages in Guatemala, we tested a simple system consisting of dilute bleach (4.95% free available chlorine) for water purification, narrow-mouth plastic vessels with spigots for disinfecting and storing water and for preparing and storing beverages, handwashing soap, and education in using the system. We conducted a randomized controlled intervention trial among 41 vendors who received the intervention and 42 control vendors, comparing total and fecal coliform bacteria and Escherichia coli contamination of market-vended beverages, stored water, and vendors' hands. Samples were obtained at baseline and at each of six weekly follow-up visits. At baseline, fecal coliform bacteria were found in 40 (48%) market-vended beverages and E. coli in 14 (17%). When compared with samples from control vendors, a significant decrease in total coliform (P < 0.001) and fecal coliform (P < 0.001) bacteria in samples of stored water and beverages sold by intervention vendors was observed over the course of the study. The vessel system was well accepted by vendors. This simple inexpensive system consisting of hypochlorite disinfectant, plastic vessels, soap, and education can significantly reduce fecal contamination of market-vended beverages.
The American journal of tropical medicine and hygiene 10/1998; 59(3):380-7. · 2.70 Impact Factor