The American Journal of Tropical Medicine and Hygiene - Volume 95, Issue 1, July 2016

Hepatitis E virus (HEV) is an emerging infectious agent in developed countries. HEV genotypes 1 (G1) and 3 (G3) have been identified in environmental and clinical samples in Europe. In Israel, the overall prevalence of anti-HEV IgG antibodies was found to be 10.6%; however, reports of HEV infection are scarce. In this study, the presence of HEV in Israel was investigated using 169 sewage samples from 32 treatment facilities and 49 samples from acute hepatitis patients, all collected between 2013 and 2015. Fourteen sewage samples, from Haifa (11/18 samples), Tel Aviv (2/29 samples), and Beer Sheva (1/17 samples), regions with good sanitary conditions and middle-high socioeconomic populations, were HEV positive. Among the patient samples, 6.1% (3/49) were HEV positive, all returning travelers from India. Genotype analysis revealed G1 HEV in patients and G3 HEV sequences in sewage. Evidence that HEV could be establishing itself in our region may justify more active surveillance to monitor its spread.

In south Asia, where diarrhea is common and antibiotics are accessible without prescription, antimicrobial resistance is an emerging and serious problem. However, beliefs and behaviors related to antimicrobial resistance are poorly understood. We explored laypersons' and health-care providers' (HCP) awareness and perceptions of antimicrobial resistance in the context of treatment of adult diarrheal disease in Karachi, Pakistan. In-depth, open-ended interviews were conducted with 40 laypersons and 45 HCPs in a lower-middle-class urban neighborhood. Interviews conducted in Urdu were audiotaped, transcribed, translated, and coded using applied thematic analysis. Slightly over half of laypersons and two-thirds of HCPs were aware that antimicrobial medication could lose effectiveness, but misperceptions were common. Laypersons and HCPs often believed that “the body becomes immune” or “bacteria attack more strongly” if medications are taken “improperly.” Another prevalent theme was that causes and effects of antimicrobial resistance are limited to the individual taking the antimicrobial medication and to the specific diarrheal episode. Participants often attributed antimicrobial resistance to patient behaviors; HCP behavior was rarely discussed. Less than half of the HCPs were aware of treatment guidelines. To combat antimicrobial resistance in urban Pakistan, a health systems strategy and community-supported outreach campaigns on appropriate antimicrobial use are needed.

Establishing and maintaining public water services in fragile states is a significant development challenge. In anticipation of water infrastructure investments, this study compares drinking water sources and quality between Port Harcourt, Nigeria, and Monrovia, Liberia, two cities recovering from political and economic instability. In both cities, access to piped water is low, and residents rely on a range of other private and public water sources. In Port Harcourt, geographic points for sampling were randomly selected and stratified by population density, whereas in Monrovia, locations for sampling were selected from a current inventory of public water sources. In Port Harcourt, the sampling frame demonstrated extensive reliance on private boreholes and a preference, in both planned and unplanned settlements, for drinking bottled and sachet water. In Monrovia, sample collection focused on public sources (predominantly shallow dug wells). In Port Harcourt, fecal indicator bacteria (FIB) were detected in 25% of sources (N = 566), though concentrations were low. In Monrovia, 57% of sources contained FIB and 22% of sources had nitrate levels that exceeded standards (N = 204). In Monrovia, the convenience of piped water may promote acceptance of the associated water tariffs. However, in Port Harcourt, the high prevalence of self-supply and bottled and sachet drinking water suggests that the consumer's willingness to pay for ongoing municipal water supply improvements may be determined by service reliability and perceptions of water quality.

Use of drinking water sold in plastic bags (sachet water) is growing rapidly in west Africa. The impact on water consumption and child health remains unclear, and a debate on the taxation and regulation of sachet water is ongoing. This study assessed the feasibility of providing subsidized sachet water to low-income urban households in Accra and measured the resultant changes in water consumption. A total of 86 children, 6–36 months of age in neighborhoods lacking indoor piped water, were randomized to three study arms. The control group received education about diarrhea. The second arm received vouchers for 15 L/week/child of free water sachets (value: $0.63/week) plus education. The third arm received vouchers for the same water sachet volume at half price plus education. Water consumption was measured at baseline and followed for 4 months thereafter. At baseline, 66 of 81 children (82%) drank only sachet water. When given one voucher/child/week, households redeemed an average 0.94 vouchers/week/child in the free-sachet-voucher arm and 0.82 vouchers/week/child in the half-price arm. No change in water consumption was observed in the half-price arm, although the study was not powered to detect such differences. In the free-sachet-voucher arm, estimated sachet water consumption increased by 0.27 L/child/day (P = 0.03). The increase in sachet water consumption by children in the free-sachet-voucher arm shows that provision of fully subsidized water sachets might improve the quality of drinking water consumed by children. Further research is needed to quantify this and any related child health impacts.