Trop Doct 2008;38:229-231
doi:10.1258/td.2008.070366
© 2008 Royal Society of Medicine Press
Risk perception and water purification practices for water-borne parasitic infections in remote Nepal
Adrienne N Kovalsky MPH MSJ *
Steven E Lacey PhD 
Upendra Raj Kaphle MD 
James M Vaughn PhD *
* University of New England, College of Osteopathic Medicine, Biddeford ME 44613;
University of Illinois at Chicago, School of Public Health, Chicago, USA;
Kathmandu University, College of Medical Sciences, Kathmandu, Nepal
Correspondence to: Adrienne Kovalsky, University of New England, College of Osteopathic Medicine, Biddeford ME 44613 Email: adrienne.nk{at}lycos.com
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SUMMARY
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This study assesses water-borne infection risk perception and
water boiling habits in a remote Sankhuwasava region of Nepal
using a brief interview-style questionnaire. All subjects were
aware of the risks associated with drinking unpurified water,
but a majority (65%) reported they did not boil water regularly,
and almost 60% of villagers interviewed had history of infection
despite their boiling practices. In contrast to reports from
other communities in Nepal, risk awareness was sufficient in
this region. Water boiling alone did not confer protection.
Future efforts should target sanitation, screening, and other
sources of contamination.
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Introduction
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Gastrointestinal parasitic infection is a primary source of
morbidity in Nepal.
1 It contributes to anaemia, malnutrition
and a high six-month infant mortality due to maternal infection.
2–3 However, a clean water supply and good sewage disposal can help
to prevent infection.
The reported prevalence of school children with enteric parasitic infections in rural regions of the Kathmandu Valley was 71%, consistent across sex, age, family size, sewage disposal and water source; prior knowledge of water-borne illnesses has not decreased the prevalence.4 In a nation where enteric parasites are endemic, some communities near Kathmandu consider helminth gastrointestinal inhabitation vital for survival.5 The purpose of this study was to assess water-borne infection risk perception and water boiling habits in the remote Khandbari region of Nepal.
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Subjects and methods
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The target location included two villages (Khandbari and Dhupoo)
of the isolated Sankhuwasava region in far eastern Nepal. Boiling
water is the primary purification method available for villagers.
Neither village has sewage lines – the region uses holding
tanks or pit latrines.
A brief questionnaire assessing the participants' perception of parasitic infection, willingness to accept to treatment, and potential sources of infection was administered during June 2006. The sampling of patients visiting the Khandbari clinic was randomized over a two-week period. Permission was requested before the start of the survey. The instrument was also administered in the neighbouring village of Dhupoo at the village's primary water pump. Each individual who visited the water pump agreed to participate. A history of infection was recorded as positive if the participant had received a confirmed medical diagnosis or had observed worms in the stools. Age, gender and village of residence data were collected without identifiers.
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Results
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Nearly two-thirds of the participants visiting the Khandbari
clinic took precautions before water consumption: 40% (15) regularly
boiled water before drinking; 25% (9) boiled water during sickness
and 5% (2) filtered their water. Women (58%) were more than
twice as likely to drink boiled water than men (25%). Participants
reported inconsistent boiling practices due to time constraints,
the cost of wood or fuel, their belief that boiled water would
lose its natural flavour and minerals and the perception that
their water source was safe.
More than half of the participants (22, 60%) had current or past parasitic infection, either confirmed by a physician or by the presence of worms in their stools. This was independent of their boiling practices. All participants reported they would accept medical treatment for ‘juka’. However, 14% reported they would not take additional precautions such as modifying their hygiene practices or water treatment methods.
Only 15% (3) of Dhupoo households consistently boiled the family water, although an additional 65% (3) boiled water on certain occasions (e.g. during pregnancy, for children and elderly, during sickness or during the rainy season). The remaining 20% (4) did not take any precautions. The primary reasons reported for inconsistent or absent precautions were time constraints, the unnatural or unpleasant flavour of boiled water, the cost and the size of the family. Two-thirds of the villagers who always boiled water had history of infection, as did half of villagers who boiled inconsistently.
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Discussion
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Reported infection was high in both groups, as 60% of Khandbari
clinic patients and 55% of Dhupoo villagers interviewed had
suffered current or past infections. While reporting of past
or current infection was similar in both villages, it is likely
that the true number of those infected was higher due to occult
or latent infection.
Boiling water alone did not confer protection. The rate of infection was similar among all categories of boiling practices, possibly because the families who reportedly boiled all of their drinking water probably drank from other sources when travelling or at their workplace. Other sources of infection include the use of unpurified water for washing dishes or produce. Shedding from infected family members or livestock may also explain similar reporting of current or past infection despite boiling practices. The likelihood of drinking boiled water was twice as high in women; this may be explained by their predominant roles in food preparation and domestic sanitation.
While studies of other regions of Nepal have found that infection by juka was perceived as necessary or harmless, this perception did not overtly exist among visitors to the Khandbari clinic. All participants felt infection by juka was detrimental to health, and all were amenable to treatment and intervention. This may be attributed to the fact that Khandbari is the district headquarters and has more advanced schools and medical services. In the past, it also served as a starting point for many international mountain expeditions. This study did not assess what perceptions may have formerly existed.
It was observed that, in both Khandbari and in Dhupoo, some families had begun an albendazole prophylaxis every six months. Within the last decade a prophylaxis programme has been initiated for all pregnant women, and the medication is available unprescribed in Khandbari's pharmacies.
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Conclusion
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In contrast to some communities near Kathmandu,
5 villagers near
Khandbari are aware of the health risks of enteric parasitic
infection. Despite risk awareness, significant morbidity still
exists, though likely a result of available hygiene habits instead
of inappropriate perception of risk. A targeted educational
intervention explaining the risks of parasitic infection may
not be sufficient to decrease morbidity of enteric parasitic
infection.
Water boiling alone does not confer protection. Lifestyle makes purification of all water consumed virtually impossible. The impracticalities of making available means for purification suggest the need for alternative water purification and self-protection modalities. The identification of other major vectors and the development of alternative purification and self-protection modalities will need to be further studied.
In the interim, the introduction of the periodic screening of children and the elderly to enable treatment of the infection should be considered. While this will not guarantee that re-infection will not occur, it may reduce morbidity from current infection, particularly in children during their developmental years. If resources are insufficient for screening, a targeted prophylaxis for children and an annual disbursal of medication for the treatment of anyone who is symptomatic could decrease morbidity without introducing as much risk of the emergence of resistance caused by arbitrary six-month prophylaxis provided for entire families, a practice that seems to be on the rise.
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References
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- Country Health Profile – Nepal (2004). World Health Organization. See http://www.w3.whosea.org/LinkFiles/Nepal_nepal.pdf (downloaded 17 March 2006)
- Navitsky RC, Dreyfuss ML, Shrestha J, Khatry SK, Stoltzfus RJ, Albonico . Ancylostoma duodenale is responsible for hookworm infections among pregnant women in the rural plains of Nepal. J Parasitol 1998;84:647–51[Medline]
- Christian P, Khatry SK, West KP. Antenatal antihelmintic treatment, birthweight, and infant survival in rural Nepal. Lancet 2004;364:981–3[Medline]
- Rai DR, Rai SK, Sharma BK, Ghimire P, Bhatta DR. Factors associated with intestinal parasitic infection among school children in a rural area of Kathmandu Valley, Nepal. Nepal Med Coll J 2005;7:43–6[Medline]
- Poudyal AK, Jimba M, Murakami I, Sherchand JB, Silwal RC, Wakai S. Community perception and readiness for anti-helminth programmes in rural Nepal. Trop Doct 2004;34:87–9[Medline]
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SUMMARY
Introduction
