Assessment of Water, Sanitation, and Hygiene Interventions in Response to an Outbreak of Typhoid Fever in NenoDistrict, Malawi


Assessment of Water, Sanitation, and Hygiene Interventions in Response to an Outbreak of Typhoid Fever in Neno District, MalawiSarah D. Bennett1,2, S. Lowther3, F. Chingoli4, T. Warne5, T. Ayers6, L. Capewell1,7, E. Taylor1,8, B. Nygren7, E. Mintz71Epidemic Intelligence Service, Scientific Education and Professional Development Program Office, OSELS, CDC, Atlanta, GA2Outbreak Response and Prevention Branch, DFWED, NCEZID, CDC, Atlanta, GA3Global Immunization Division, NCIRD, Atlanta, GA4Neno District Health Office, Neno, Malawi5Global AIDS Program Malawi, DGHA, CGH, CDC, Lilongwe, Malawi6Biostatistics Office, DFWED, NCEZID, CDC, Atlanta, GA7Waterborne Disease and Prevention Branch, DFWED, NCEZID, CDC, Atlanta, GA8Enteric Diseases Epidemiology Branch, DFWED, NCEZID, CDC, Atlanta, GA Background: Typhoid fever, caused by Salmonella enterica serovar Typhi, results in an estimated 21 million cases and 200,000 deaths annually worldwide. On May 2, 2009 an outbreak of typhoid fever began in rural villages along the Malawi-Mozambique border resulting in 748 illnesses and 44 deaths by September 2010. Despite numerous interventions, including distribution of WaterGuard (WG) for in-home water treatment and education on its use, cases of typhoid fever continued. Information on knowledge, attitudes, and practices surrounding typhoid fever, safe water, and hygiene are necessary to plan future interventions. Methods: In September 2010, a survey was administered to female heads in randomly selected households in 17 villages in Neno District, Malawi. Stored household drinking water was tested for free and total residual chlorine. Results: Among 202 households, primary sources of drinking water were unimproved wells (45%), boreholes (42%) and rivers (7%). Households who previously attended a community-wide typhoid talk were more likely to report that typhoid fever is caused by drinking unsafe water compared to households not attending a talk (54.8% vs. 41.6%, P = 0.02). WG was present in 53.4% of households; only 32.8% of those households reported treatment of currently storedwater. Residual free chlorine levels were adequate in stored water samples from 59.1% of households that reported water treatment. Conclusion: Knowledge regarding the association between unsafe water and typhoid fever improved after community-wide education, but remains low. Despite the presence of WG in over half of all households, less than a third were using this method to protect their drinking water. Future interventions should focus on increasing use of WG for all stored water to prevent waterborne illnesses, including typhoid fever. Keywords: typhoid fever, outbreaks, Malawi, water, drinking

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