Monday 22 nd March 2004, “World Water Day” was marked by a range of events across the world.

In London, the UN Association hosted a conference to launch “Listening” a new publication by the Water Supply and Sanitation Collaborative Council.

“Listening” argues that the failure to provide “water, sanitation and hygiene for all” represents one of the greatest failures of national and international development efforts in the last 50 years”. Some of the key points, made in the document
( http://www.wsscc.org/listening/ ) were:

• To be effective in reducing the infectious disease burden, programmes of water and sanitation must be accompanied by the promotion of hygiene practice
• The main barrier to “water, sanitation and hygiene for all” is not lack of financial resources, but lack of willingness to learn from past failures, and listen to those who have pioneered new approaches
• Success in the future depends on radically different approaches, which involve “igniting demand and participation” from within communities rather than imposing solutions from outside
• This means persuading governments and aid agencies to divert precious resource from the task of “installing hardware” (i.e water and sanitation) to supporting communication projects which mobilise communities and create community demand – and supporting the “thousands of NGOs, community organisations and inspired individuals” who are needed to work in the community if this is to be achieved.

The Stanier Institute held a two day meeting in February to consider the impact of hygiene on Canada. The first day took the form of a workshop roundtable on the Status of Hygiene and the second day was an open discussion with "Focus on Hygiene". Topics and speakers included: Emergent and re-emergent infections (Harvey Artsob), food and water infection control (Judith Isaac-Renton), communicable disease control (Claudia Kurzac), hospital infection control (Mary McNaughton), air pollution control and health policy (David Pengelly), medical microbiology and hospital infection control (Diane Roscoe), the use of physical, chemical and biological agents for prevention of spread of disease in the environment (Syed Sattar) and home and community hygiene (Liz Scott). The audiotaped proceedings will be published by the Stanier Society.

In Germany the Robert-Koch-Institut (RKI) has recently issued revised recommendations on cleaning and surface disinfection in hospital housekeeping (Bundesgesundheitsblatt, 2004;47). Based on new insights and new experimental data, the guidelines now recommend the use of disinfectants for hand contact surfaces in patient areas, and floor disinfection in high risk areas. The evidence base for these new guidelines is presented by Exner et al. in the April issue of the Journal of Hospital Infection (2004, vol 56, supplement 2, pp70-75). The paper also describes a new test method which was used by the authors to compare the efficacy of disinfection versus detergent-based cleaning procedures in reducing the microbial load on a contaminated surface and preventing the spread of pathogens to other surfaces. Under the conditions of the test it was found that, where water or detergent only was used, the test organism Staphylococcus aureus was not eliminated from a contaminated surface, and where the mop was then used to wipe another surface, the contamination was transferred to that surface . In order to eliminate contamination from the surface and prevent spread, it was necessary to use an effective disinfectant product.

Professor Exner said “These new guidelines have important implications for the care of at risk groups in the home as well as in hospitals. In Germany, as in other European countries, demographic changes and changes in Public Health mean that the number of people in the home needing special care, because they are at particular risk of infection, has significantly increased and will continue to do so. The largest proportion of these people are the elderly who have generally reduced immunity to infection which is often exacerbated by other basic illnesses like diabetes mellitus, malignant illnesses, etc. The number of ambulant operations and other medical procedures whereby patients are discharged to their homes immediately or on the same day has also significantly increased. A significant proportion of this group are patients who have a bladder catheter or other invasive systems such as PEG probes, intravasal catheters or endotracheal tubes. An important part of the new German health policy is a commitment to ensure that the increase in ambulant provision in the home is not accompanied by increased infectious disease risks, otherwise cost savings gained by care in the community are likely to be overridden by additional costs of re-hospitalisation”.

In the next months, IFH members of the Scientific Advisory Board will be available to meet you at the following events

• 5 th World Congress on Food Borne Infections, Berlin, Germany, 5-11 June 2003.
• APIC meeting, Phoenix, Arizona, 6 – 10 June 2004. The IFH and the new Simmons Center for Hygiene and Health will have an exhibition stand.
• 5 th Congress of the International Federation on Infection Control (IFIC), Porec, Croatia, 9 – 12 October 2004.
  
• Water Supply and Santiation Collaborative Council „ WASH Forum“, Dakar, Senegal, 22-26 November 2004.

Campylobacter at home:
microbiological risks and interventions to reduce them

Wageningen University (Social Sciences Group, Marketing and Consumer Behaviour Group) and the National Institute for Public Health and the Environment (RIVM, Bilthoven, The Netherlands; Microbiological Laboratory for Health Protection) are co-operating in a project called “Food: microbial risk, consumer behaviour and the potential for positive health interventions.” This project aims to study the potential for reducing the risk of food borne illness for consumers who prepare their food at home. This will be achieved by integrating food microbiology, microbiological risk assessment, consumer behaviour, and risk communication.

The researchers say “We will conduct a case study on cross contamination and survival of an indicator-microorganism in the kitchen during preparation of a chicken salad. In this study, a group of consumers will be observed during the preparation of the chicken salad by use of a video camera. Simultaneously, the transfer of the indicator-microorganism, which was spiked on the raw chicken, to the salad will be studied. In the laboratory, we will mimic consumer behaviour by preparing the same salad with a mix of the indicator-microorganism and Campylobacter jejuni. Data from this laboratory study will be used in a quantitative microbiological risk assessment (QMRA) to assess the critical control point(s) of the salad processing and for translating the results with the indicator-microorganism to C. jejuni. The QMRA model, which is based on laboratory data, will be validated with the data from the consumer study; both the behavioural data and microbiological data will be used. The combination of consumer experiments, laboratory research, and QMRA makes this project unique from a food microbiological point of view”.

Next to these ‘natural science’ experiments, the consumer study will be used for ‘social science’ research as well. After preparation of the salad, the participants will be interviewed and these data will be used to assess consumer’s risk perceptions about the transmission of food borne illness. These data on how consumers think they behave will be coupled to the observed behaviour and the microbiological data.

In a follow up case study, consumers will be provided with risk information salient to self-protective behaviour, before preparing the same salad as in the first consumer study. The type of information to be provided will be based on the critical control point(s) assessed by microbiological data. The way to submit the information will be based on the outcome of the social science research. The impact of this information on behavioural intention and actual behaviours will be analysed and described both in terms of behaviour, microbiological contamination, and microbiological health risks. The results of this unique social-natural science based project can be used by risk managers in deciding upon interventions to reduce food borne illness in the consumer phase.

The IFH Infectious Disease Briefing Documents, formerly focused on the UK situation, have been updated with recent global data and information. The documents, included under ‘infectious diseases in the home’ section, are:

• Infectious Intestinal Disease / Gut infections
• Foodborne Disease/Food poisoning
• Respiratory infections/colds & flu
• Salmonella
• Campylobacter
• Rotavirus
• Norovirus
• E. coli O157
• SARS

A new study, carried out in Denmark, has been published (British Medical Journal 30th April 2004) which helps to further unravel the link between infectious diease, microbial exposure and atopic disease.
The study was carried out with 24.341 mother-child pairs to determine whether a protective effect of infectious disease during the first 6 months of life could explain the association between markers of microbial exposure (such as family size etc) and development of atopic dermatitis before 18 months of age.
Although the results of the study confirm previous findings, namely that larger family sizes, early childcare, pet keeping and farm living is correlated with decreased risk of atopic dermatitis in children before 18 months, contrary to previous belief, the data also suggest that, as far as clinical infection is concerned, development of infectious disease in early life is associated with increased atopic dermatitis risk.
The results thus suggest that although microbial exposure may be protective against atopic disease the development of clinically apparent infectious disease is not a prerequisite.

Salmonella enteritidis infections, United States 1985–1999 . Patrick, M.E., Adcock, P.M., Gomez, T.M., Altekruse, S.F., Holland, B.H., Tauxe, R.V. and Swerdlow, D.L. Emerg Infect Dis 2004;10:1-7.

This papers examines the trends in S. enteritidis infection in the US from 1985 to 1999 based on surveillance data for sporadic infections and outbreaks reported to the Centers for Disease Control and Prevention (CDC). Overall, rates of sporadic S. enteritidis infection, outbreaks, and deaths have declined. Prevention and control strategies along the entire farm-to-table continuum, and a plan for further reduction of S. enteritidis infections are suggested.

Risk factors for infection with Giardia duodenalis in pre-school children in the city of Salvador, Brazil. Prado, M.S., Strina, A., Barreto, M.L., Olivera-Assis, A.M., Paz, L.M. and Cairncross, S. Epidemiol Infect 2003;130:1-8.

This study of 694 children (aged 2-45mths) was carried out to identify environmental risk factors for infections with Giardia duodenalis. Variables studied included 3 social and demographic factors, 5 factors relating to the peri-domestic environment, 7 relating to the home and a score for hygiene behaviour based on structured observation. Prevalence of infection with G. duodenalis was nearly 14% (as identified from stool samples). Only 4 significant risk factors were found (i) number of children under 5yrs old in the household, (ii) rubbish not collected from the house, (iii) presence of visible sewage nearby, and (iv) absence of a toilet.

Food safety and foodborne disease in 21st century homes. Scott, E. Can J Infect Dis 2003;14:277-280

It is now accepted that many cases of foodborne illness occur because of improper handling and preparation of food by consumers in their own kitchens. This paper gives an overview of the role of the home in the transmission and acquisition of foodborne disease. It describes the increasing incidence of foodborne disease globally and the factors that impact food safety in the home. Measures on how to improve food safety in the home are outlined.

Risk Factors for Norovirus, Sapporo-like Virus, and Group A Rotavirus Gastroenteritis . de Wit, M.A.S., Koopmans, M.P.G. and van Duynhoven, Y.T.H.P. Emerg Infect Dis 2003;9:1563-1570.

This study identified risk factors, modes of transmission, and opportunities for prevention for gastroenteritis attributable to norovirus, Sapporo-like virus (SLV), and rotavirus. The main risk factor for viral gastroenteritis was contact with other persons with gastroenteritis, supporting the hypothesis that these viruses are mainly transmitted from person to person. However, for NV gastroenteritis, foodborne transmission seems to play an important role. Hygienic food-handling procedures can therefore further prevent the infection spreading from one person to another.

Helicobacter pylori risk associated with childhood home environment . Ueda, M., Kikuchi, S., Kasugai, T., Shunichi, T. and Miyake, C. Cancer Sci;94:914-918.

The aim of this Japanese study was to assess the relationship between the establishment of persistent Helicobacter pylori infection, and factors such as sanitary conditions or home environment during childhood. Almost 6000 participants completed a questionnaire and H. pylori antibody test. Associations between the 6 factors in the questionnaire and infection were calculated. Drinking water, type of toilet, residential area, number of people in the house and birth order showed significant correlation with H. pylori infection.

A comparison of the bacteria found on the hands of ‘homemakers’ and neonatal intensive care nurses. Aiello, A.E., Cimiotti, J., Della-Latta, P. and Larson, E.L. J Hosp Infect 2003;54:310-315.

The counts, types and antimicrobial resistance of bacteria on the hands of 204 individuals in the community (homemakers) was compared to that of 119 nurses at a university teaching hospital. The mean total log counts of bacteria was 5.73 and 5.24 for the homemakers and nurse hands, respectively. There was a higher proportion of antibiotic resistant bacteria on the hands of the nurses. This study demonstrates differences in prevalence, bacterial composition and antimicrobial resistance of hand flora of hospital personnel compared with homemakers.

Bioluminescence ATP monitoring as a surrogate marker for microbial load on hands and surfaces in the home. Larson, E.L., Aiello, A.E., Gomez-Duarte, C., Lin, S.X., Lee, L., Della-Latta, P. and Lindhardt, C. Food Microbiol 2003;20:735-739.

The kitchen table surface in 225 US homes was sampled by microbiologic culture and by two biomass-monitoring systems. Hands of homemakers were also cultured and sampled with the ATP monitoring system immediately after handwashing. Log microbial counts on hands ranged from 3.2-7.0 and from, 1.0-5.5 on the table. There was no significant correlation between the ATP monitor readings and the cfu counts on either the hands or the table. The authors conclude that such biomass measurements are not a substitute for quantitation of microbial load.

The effect of container-biofilm on the microbiological quality of water used from plastic household containers. Jagals, P., Jagals, C. and Bokako, T.C. J Water Health 2003;1(3):101-108.

In developing countries, microbial contamination of water for human consumption may occur during the fetching of water from the supply source or during storage at home. This study investigated whether biofilms occurred in PVC storage containers and to determine the effect of the biofilm on the microbial quality of the water. The results show that contaminant build-up on inner container walls contained microorganisms. The biofilm harbours heterotrophic bacteria, total coliforms and C. perfringens. When dislodged with the biofilm, these bacteria contributed substantially to the deterioration of the microbiological quality of supplied water stored in plastic containers.

Cost effectiveness of a targeted disinfection program in household kitchens to prevent foodborne illnesses in the United States, Canada and the United Kingdom. Duff, S.B., Scott, E.A., Mafilios, M.S., Todd, E.C., Krilov, L.R., Geddes, A.M. and Ackerman, S.J. J Food Protect 2003;66:2103-2115.

A computer-based economic model was developed to evaluate the potential cost-effectiveness of a targeted disinfection program for high-risk food preparation in household kitchens. For US, Canada and UK, published literature and expert opinion was used to estimate the cost of the program, the number of cases of Salmonella, Campylobacter, and E. coli O157:H7 infections prevented, and the economic and quality-of-life outcomes. The model estimated that approximately 80,000 infections could be prevented annually in US homes, resulting in $138 million in direct medical cost savings, 15,845 quality-adjusted life-years (QALYs) gained, $788 million in program costs. Results were similar for households in Canada and the UK. Implementing a targeted disinfection program in household kitchens in the US, Canada, and UK appears to be a cost-effective strategy. Didn’t the paper show even bigger savings in homes where there were vulnerable groups?

Tolerance of Salmonella enteritidis and Staphylococcus aureus to surface cleaning and household bleach. Kusumaningrum, H.D., Paltinaite, R., Koomen, A.J., Hazeleger, W.C., Rombouts, F.M. and Beumer, R.R. Journal of Food Protection 2003;66:2289-2295.

The effectiveness of Five cloth types to reduce/eliminate Salmonella enteritidis and Staphylococcus aureus from stainless steel surfaces was compared. In general, S. enteritidis and S. aureus were still found on the surfaces at 0.6-2 log cfu/100cm 2 when the surface had just been cleaned, with the exception of the antibacterial cloth in which bacterial counts were below the detection limit <0.6 cfu/100cm 2. After cleaning the surface, the cloths contained bacteria at 10 4-10 5 cfu/100cm 2 except for the antibacterial-treated cloth in which no bacteria could be detected. The effect of sodium hypochorite in suspension and in cloths was determined. Inactivation of bacteria in cloths required a higher concentration of sodium hypochlorite than in a suspension test. This study highlights the need for a hygiene procedure with cleaning cloths that prevents cross-contamination in the home.

Food safety: the fourth pillar in the strategy to prevent infant diarrhoea. Käferstein, F.K. Bulletin of the World Health Organisation 2003;81:842-843.

This article highlights the importance of incorporating food safety as a fourth strategy to combat infant diarrhoea, with the three traditional strategies for preventing infant diarrhoea as proposed by WHO (promotion of breastfeeding, vaccination against certain childhood diseases and improvements in the communities’ drinking-water supply and sanitation). Analyses of foodborne diseases have shown that 2 main errors in food preparation increase risk; firstly, the preparation of food several hours before consumption, storage at temperatures that favour bacterial growth and formation of toxins and secondly, and insufficient cooking/reheating of food. If these practices are avoided food contaminants can be controlled and a considerable number of foodborne disease episodes can be prevented.

Surely this is hygiene practice – how - Assessment of Acinetobacter baumannii susceptibility to antiseptics and disinfectants. Martro, E., Hernandez, A., Ariza, J., Dominguez, M.A., Matas, L., Argerich, M.J., Martin, R. and Ausina, V. Journal of Hospital Infection 2003;55 (1): 39-46.

Disinfection and antisepsis are of primary importance in controlling outbreaks of Acinetobacter baumannii, a nosocomial pathogen that frequently shows multiple antibiotic resistance. In this study we assessed the susceptibility of nine A. baumannii strains isolated during a sustained intensive care unit outbreak, to several antiseptics and disinfectants based on European Standards. While the tested strains showed diverse antibiotic resistance patterns, they were equally sensitive to the biocides assessed in vitro. We observed neither evidence of development of resistance to biocides over time, nor a correlation between resistance to antibiotics and a decreased susceptibility to antiseptics or disinfectants.

The effects of cleaning and disinfection in reducing Salmonella contamination in a laboratory model kitchen. Barker, J., Naeeni, M. and Bloomfield, S.F. J Appl Microbiol 2003;95:1351-1360

This study describes a reproducible laboratory method that can be used to differentiate the effectiveness of different hygiene procedures for reducing cross-contamination risks during food handling. During handling of contaminated chickens, Salmonella enteritidis spread to hands, cloths, and hand- and food -contact surfaces. Hygiene procedures were assessed on their ability to reduce the number of salmonellas to <1cfu. Detergent-based cleaning without rinsing was insufficient to consistently restore surfaces to a hygienic state. By combining detergent-based cleaning with a rinsing step, some further reduction in microbial risk was achieved, but was not be considered satisfactory for food hygiene purposes. By contrast the risk reduction produced by hypochlorite at 5000ppm was sufficient to reduce the number of contaminated surfaces to 2.9%. Disinfectant compounds should be considered in order to reduce the potential for foodborne cross infection within the home environment.

Effect of chlorination of drinking-water on water quality and childhood diarrhoea in a village in Pakistan. Jensen, P.K., Ensink, J.H.J., Jayasinghe, G., van der Hoek, W., Cairncross, S. and Dalsgaard, A. J Health Popul Nutr 2003;21:26-31.

An intervention study was carried out which involved chlorinating the public water supply system in a village in Pakistan to evaluate the importance of public-domain transmission of pathogens in drinking water. Drinking water source and the occurrence of diarrhoea were monitored weekly over 6mths among 144 village children aged under 5 years. Despite the improvement in drinking water quality, the incidence of diarrhoea was not lower in a neighbouring village where drinking water was not chlorinated and where water quality was poor. The study was of limited size.

Impact of drainage and sewerage on diarrhoea in poor urban areas of Salvador, Brazil. Moraes, L.R.S., Cancio, J.A., Cairncross, S. and Huttly, S. Trans Royal Soc Trop Med Hyg 2003;97:1-6.

Three areas had benefited from drainage improvements, three from both drainage and sewerage improvements, and three from neither. Mothers recorded diarrhoea in their children (under 5yrs) daily for one year. The incidence of diarrhoea in children with drainage was less than two-thirds, and in areas with drains and sewers less than one-third, of the incidence in areas with neither drains or sewers. The study provides evidence that community sanitation can have an impact on diarrhoeal diseases even without measures to promote hygiene behaviour.

Water, sanitation and hygiene for the health of developing nations. Mara, D.D. Public Health 2003;117:452-456.

An article on water and sanitation needs of the poor in developing countries. To meet the target of water and sanitation for all by the end of 2025, some 2.9 billion people will have to receive improved water supplies, and 4.2billion improved sanitation. The technologies used must be appropriate, simple, affordable and sustainable.

Development of bacterial resistance to several biocides and effects on antibiotic susceptibility. Walsh, S.E., Maillaird, J-Y., Russell, A.D., Catrenich, C.E., Charbonneau , D.L. and Bartolo, R.G. J Hosp Infect 2003;55:98-107.

This study investigated the development of bacterial resistance to eugenol, thymol, trichlorocarbanalide, didecyldimethylammonium chloride (DDDMAC) C10-16-alkyldimethyl, N-oxides and subsequent effects on antibiotic susceptibility. The researchers conclude that under laboratory conditions, bacterial exposure to thymol, eugenol and DDDMAC can lead to reduced susceptibility between selected biocidal agents and antibiotics, more specifically, chloramphenicol. However, further studies are required to determine if this is of clinical significance.

Childhood diarrhoea and observed hygiene behaviour in Salvador, Brazil . Strina, A., Cairncross, S., Barreto, M.L., Larrea, C. and Prado, M.S. Am J Epidemiol 2003;157:1032-1038.

Using structured observation, researchers scored behaviour as either hygienic or unhygienic. Among children with mainly positive hygiene behaviour, the prevalence of diarrhoea was 6.4days/child year, compared with 14.2days/child year for children with mainly unhygienic behaviour (highly significant difference). There was a significant association between a positive hygiene score and the presence of adequate excreta disposal facilitates in the home. The authors concluded that families predisposed to acquire adequate sanitation in their homes have a measurably better awareness of hygiene, which is expressed in their behaviour. The study data is indicative of the important role of hygiene behaviour, as well as water supply and sanitation facilities.