Cochrane Evidence Aid: resources for flooding and poor water sanitation

thumbnail image: Cochrane Evidence Aid: resources for flooding and poor water sanitation

In times of natural disaster, having access to safe and clean water is essential. Water polluted by faecal matter can lead to the spread of diarrhoeal diseases such as cholera, and water polluted by animal waste can spread other diseases, such as leptospirosis. Natural disasters can also result in an increase in water-based insect vectors that can spread disease (such as malaria), and a lack of clean water for personal hygiene can result in an increase in diseases such as conjunctivitis and scabies. These outcomes are outlined in the World Health Organization’s field manual for ‘Communicable disease control in emergencies’,1 and have informed the preparation of this Special Collection.

The burden caused by natural disasters adds to the existing burden of morbidity and mortality from diarrhoeal diseases. According to the World Health Organization, diarrhoeal disease is the second leading cause of death in children under five years old and kills 1.5 million children each year.2

Cochrane systematic reviews can contribute to the use of effective interventions to prevent and treat water-related diseases, and they have also examined interventions to improve sanitation and promote hand washing. This Special Collection presents the Cochrane Reviews that summarize the available evidence around water safety and water-related diseases. Where available, links to Evidence Update summaries are provided.

This Special Collection concludes with a list of additional resources and guidelines, recommended by the contributors to this Special Collection, likely to be of relevance and interest to those working in disaster relief.

New: Japanese translation prepared by Kyoto University School of Public Health.

Note from the publisher, Wiley-Blackwell: As part of our Evidence Aid programme, we have granted all people in Japan access to all databases in The Cochrane Library, including the Cochrane Database of Systematic Reviews.

Water-related diseases caused by faecal pollution: general diarrhoea prevention, management, & treatment

Diarrhoea prevention: water quality & hand washing

Diarrhoea is a common cause of morbidity and a leading cause of death among children aged less than five years, particularly in low- and middle-income countries. Persistent diarrhoea can also contribute to malnutrition, reduced resistance to infections, and sometimes impaired growth and development. Many of the infectious agents are transmitted by ingesting contaminated food or drink, by direct person-to-person contact, or from contaminated hands.

Interventions to improve water quality for preventing diarrhoea

“Interventions to improve water quality are generally effective in preventing diarrhoea, and interventions to improve water quality at the household level are more effective than those at the source.”

Diarrhoeal diseases are a leading cause of mortality and morbidity, especially among young children in developing countries. While many of the infectious agents associated with diarrhoeal disease are potentially waterborne, the evidence for reducing diarrhoea in settings where it is endemic by improving the microbiological quality of drinking water has been equivocal. This review assesses the effectiveness of interventions to improve water quality for preventing diarrhoea. These include conventional improvements at the water source (eg protected wells, bore holes, and stand posts) and point-of-use interventions at the household level (eg chlorination, filtration, solar disinfection, and combined flocculation and disinfection). [Download PDF] [Evidence Update summary]

Interventions to improve disposal of human excreta for preventing diarrhoea

“This review provides some evidence that interventions to improve excreta disposal are effective in preventing diarrhoeal disease.”

Over a third of the world’s population lacks access to improved facilities for the disposal of human excreta, such as a basic pit latrine, a toilet connected to a septic tank or piped sewer system, or a composting toilet. This puts many people at risk of exposure to human excreta, which can lead to the transmission of diarrhoeal diseases. This review assesses the effectiveness of interventions to improve the disposal of human excreta for preventing diarrhoeal diseases. [Download PDF]

Hand washing for preventing diarrhoea

“Interventions that promote hand washing can reduce diarrhoea episodes by about one-third. This significant reduction is comparable to the effect of providing clean water in low-income areas.”

Hand washing after defecation and handling faeces, and before preparing and eating food, is one of a range of hygiene promotion interventions that can interrupt the transmission of diarrhoea-causing pathogens. This review evaluates the effects of interventions to promote hand washing on diarrhoeal episodes in children and adults. [Download PDF] [Evidence Update summary]

Diarrhoea management: oral rehydration solution (ORS)

Reduced osmolarity oral rehydration solution for treating dehydration caused by acute diarrhoea in children

“In children admitted to hospital with diarrhoea, reduced osmolarity ORS [oral rehydration solution] [total osmolarity ≤ 250 mmol/L with reduced sodium] when compared to WHO [World Health Organization] standard ORS [90 mmol/L sodium, 111 mmol/L glucose, total osmolarity 311 mmol/L] is associated with fewer unscheduled intravenous fluid infusions, lower stool volume post randomization, and less vomiting. No additional risk of developing hyponatraemia when compared with WHO standard ORS was detected.”

Note: Since the publication of this review, the WHO standard has changed to a reduced osmolarity ORS.

Children with diarrhoea lose body water and sometimes become dehydrated. A solution of sugar and salt dissolved in water (oral rehydration solution - ORS) is widely used to treat dehydration caused by diarrhoea. This review compares two formulations of ORS with different osmolarities in children with acute diarrhoea. [Download PDF] [Evidence Update summary]

Reduced osmolarity oral rehydration solution for treating cholera

“In people with cholera, reduced osmolarity [total osmolarity 250 mmol/L with reduced sodium] ORS [oral rehydration solution] is associated with biochemical hyponatremia when compared with standard ORS [sodium 90 mmol/L, glucose 111 mmol/L, total osmolarity 311 mmol/L], although there are similar benefits in terms of other outcomes.”

Oral rehydration solution (ORS) is used to treat dehydration caused by diarrhoeal diseases, including cholera. Formulations with lower osmolarity are safe and more effective than those with a higher osmolarity for treating non-cholera diarrhoea. As cholera causes rapid electrolyte loss, it is important to know if these benefits are similar for people with cholera. This review compares the safety and efficacy of reduced osmolarity ORS with standard ORS for treating diarrhoea due to cholera. [Download PDF] [Evidence Update summary]

Polymer-based oral rehydration solution for treating acute watery diarrhoea

“Polymer-based ORS [oral rehydration solution] shows some advantages compared to ORS ≥ 310 [the original ORS was based on glucose and had an osmolarity of ≥ 310 mOsm/L] for treating all-cause diarrhoea, and in diarrhoea caused by cholera. Comparisons favoured the polymer-based ORS over ORS ≤ 270 [the currently agreed best formula with ≤ 270 mOsm/L], but the analysis was underpowered.”

Oral rehydration solutions (ORS) have had a massive impact worldwide in reducing the number of deaths related to diarrhoea. Most ORS is in the form of a sugar–salt solution, but over the years people have tried adding a variety of compounds (glucose polymers) such as whole rice, wheat, sorghum, and maize. The aim is to slowly release glucose into the gut and improve the absorption of the water and salt in the solution. This review compares polymer-based ORS with glucose-based ORS for treating acute watery diarrhoea. [Download PDF] [Resumen en español]

Oral versus intravenous rehydration for treating dehydration due to gastroenteritis in children

“There were no important clinical differences between ORT [oral rehydration therapy] and IVT [intravenous rehydration therapy] for rehydration secondary to acute gastroenteritis in children.”

Dehydration associated with gastroenteritis is a serious complication. Dehydration occurs when body water content is reduced causing dry skin, headaches, sunken eyes, dizziness, confusion, and sometimes death. Children with dehydration due to gastroenteritis need rehydrating either by liquids given by mouth or a tube through the nose, or intravenously. This review compares oral with intravenous therapy for treating dehydration due to acute gastroenteritis in children. [Download PDF] [Resumen en español]

Diarrhoea treatment: zinc & probiotics

Oral zinc for treating diarrhoea in children

“In areas where diarrhoea is an important cause of child mortality, research evidence shows zinc is clearly of benefit in children aged six months or more.”

Zinc supplementation could help reduce the duration and severity of diarrhoea, and is recommended by the World Health Organization and UNICEF. This review evaluates oral zinc supplementation for treating children with acute or persistent diarrhoea. [Download PDF]

Probiotics for treating infectious diarrhoea

"Used alongside rehydration therapy, probiotics appear to be safe and have clear beneficial effects in shortening the duration and reducing stool frequency in acute infectious diarrhoea. However, more research is needed to guide the use of particular probiotic regimens in specific patient groups."

Probiotics are microbial cell preparations or components of microbial cells that have a beneficial effect on the health and well-being of the host. Probiotics may offer a safe intervention in acute infectious diarrhoea to reduce the duration and severity of the illness. This review assesses the effects of probiotics in proven or presumed acute infectious diarrhoea. [Download PDF]

Probiotics for treating persistent diarrhoea in children

"There is limited evidence suggesting probiotics may be effective in treating persistent diarrhoea in children."

Persistent diarrhoea (diarrhoea lasting more than 14 days) accounts for one third of all diarrhoea-related deaths in developing countries in some studies, and probiotics may help treatment. This review evaluates probiotics for treating persistent diarrhoea in children. [Download PDF]


Water-related diseases caused by faecal pollution: sorted by disease

Amoebiasis

Amoebic colitis is caused by the parasite Entamoeba histolytica. This protozoan is distributed throughout the world and is commonly acquired by ingestion of contaminated food or water. It is estimated that about 40 to 50 million people infected with E. histolytica develop amoebic colitis or extraintestinal abscesses, which result in up to 100,000 deaths per year. Adequate therapy for amoebic colitis is necessary to reduce the severity of illness, prevent development of complicated disease and extraintestinal spread, and decrease transmission.

Antiamoebic drugs for treating amoebic colitis

“Tinidazole is more effective in reducing clinical failure compared with metronidazole and has fewer associated adverse events. Combination drug therapy is more effective in reducing parasitological failure compared with metronidazole alone. However, these results are based on trials with poor methodological quality so there is uncertainty in these conclusions.”

Metronidazole is currently the drug of choice for treating invasive amoebiasis in adults and children, but it may not be sufficient to eliminate parasite cysts in the intestine. Combinations with other drugs are therefore also used. Also, some unpleasant adverse effects associated with metronidazole in some patients, and the possibility of parasite resistance to metronidazole have to be considered. This review evaluates antiamoebic drugs for treating amoebic colitis. [Download PDF]

Image-guided percutaneous procedure plus metronidazole versus metronidazole alone for uncomplicated amoebic liver abscess

“Therapeutic aspiration in addition to metronidazole to hasten clinical or radiologic resolution of uncomplicated amoebic liver abscesses cannot be supported or refuted by the present evidence.”

The most common complication of amoebiasis is the formation of a pus-filled mass inside the liver (liver abscess). Metronidazole is the drug of choice for treatment of amoebic liver abscesses, and this is followed by a luminal agent to eradicate the asymptomatic carrier state. However, a subset of patients with amoebic liver abscesses remains symptomatic, with a significant risk of rupture of the abscess into the peritoneum. The role of image-guided percutaneous therapeutic aspiration in these patients remains controversial. This review assesses the beneficial and harmful effects of image-guided percutaneous procedure plus metronidazole versus metronidazole alone in patients with uncomplicated amoebic liver abscess. [Download PDF]

Cholera

Cholera is caused by bacteria (Vibrio cholerae) ingested through contaminated food or water, and is commonly found where sanitation measures are poor. It causes severe diarrhoea and vomiting, which can lead to profound dehydration and potentially death.

Polymer-based oral rehydration solution for treating acute watery diarrhoea

“Polymer-based ORS [oral rehydration solution] shows some advantages compared to ORS ≥ 310 [the original ORS was based on glucose and had an osmolarity of ≥ 310 mOsm/L] for treating all-cause diarrhoea, and in diarrhoea caused by cholera. Comparisons favoured the polymer-based ORS over ORS ≤ 270 [the currently agreed best formula with ≤ 270 mOsm/L], but the analysis was underpowered.”

Oral rehydration solutions (ORS) have had a massive impact worldwide in reducing the number of deaths related to diarrhoea. Most ORS is in the form of a sugar–salt solution, but over the years people have tried adding a variety of compounds (glucose polymers) such as whole rice, wheat, sorghum, and maize. The aim is to slowly release glucose into the gut and improve the absorption of the water and salt in the solution. This review compares polymer-based ORS with glucose-based ORS for treating acute watery diarrhoea. [Download PDF] [Resumen en español] 

Reduced osmolarity oral rehydration solution for treating cholera

“In people with cholera, reduced osmolarity [total osmolarity 250 mmol/L with reduced sodium] ORS [oral rehydration solution] is associated with biochemical hyponatremia when compared with standard ORS [sodium 90 mmol/L, glucose 111 mmol/L, total osmolarity 311 mmol/L], although there are similar benefits in terms of other outcomes.”

Oral rehydration solution (ORS) is used to treat dehydration caused by diarrhoeal diseases, including cholera. Formulations with lower osmolarity are safe and more effective than those with a higher osmolarity for treating non-cholera diarrhoea. As cholera causes rapid electrolyte loss, it is important to know if these benefits are similar for people with cholera. This review compares the safety and efficacy of reduced osmolarity ORS with standard ORS for treating diarrhoea due to cholera. [Download PDF] [Evidence Update summary]

Vaccines for preventing cholera: killed whole cell or other subunit vaccines (injected)

“Injected cholera vaccines appear to be safe and relatively more effective than usually realized. Protection against cholera persists for up to two years following a single dose of vaccine, and for three years with an annual booster. However, they have been superseded by oral vaccines.”

Vaccination against cholera was first tested in the nineteenth century and may play a role in controlling epidemics. Injected (parenteral) whole cell vaccines were used in the 1960s and 1970s, but they went out of favour as their efficacy was thought to be low and short-lived, and associated with a high rate of adverse effects. This review evaluates killed whole cell (KWC) cholera vaccines and other inactive subunit vaccines (administered by injection) for preventing cholera and death, and aims to evaluate the adverse effects. A separate Cochrane Review about oral cholera vaccines, which were introduced more recently and are used currently, is in progress. [Download PDF]

Hepatitis A

Immunoglobulins for preventing hepatitis A

“Immunoglobulins seem effective for preventing hepatitis A in both children and adults. However, the evidence, on which the conclusion is based, is not strong as the included trials appear to have risk of bias and their number is insufficient.”

Hepatitis A is a common, contagious viral disease in low-income countries. Hepatitis A is transmitted primarily by faecal-oral spread from person to person. Passive immunoprophylaxis for hepatitis A using immunoglobulin preparations was essential for prevention before the development of a specific hepatitis A vaccine (active immunization). This review assesses the beneficial and harmful effects of the pre- and post-exposure prophylaxis with immunoglobulins for preventing hepatitis A. [Download PDF]

Salmonellosis

Antibiotics for treating salmonella gut infections

“There appears to be no evidence of a clinical benefit of antibiotic therapy in otherwise healthy children and adults with non-severe salmonella diarrhoea. Antibiotics appear to increase adverse effects and they also tend to prolong salmonella detection in stools.”

Non-typhoidal salmonellosis appears to be an important cause of acute diarrhoea in some developing countries. Antibiotic treatment of salmonellosis aims to shorten illness and prevent serious complications. There are also concerns about increasing antibiotic drug resistance. This review assesses the effects of antibiotics in adults and children with diarrhoea who have salmonellosis. [Download PDF]

Vaccines for preventing invasive salmonella infections in people with sickle cell disease

“It is expected that salmonella vaccines may be useful in people with sickle cell disease, especially in resource-poor settings where the majority of those who suffer from the condition are found. Unfortunately, there are no randomized controlled trials on the efficacy and safety of the different types of salmonella vaccines in people with sickle cell disease.”

Salmonella infections are a common bacterial cause of invasive disease in people with sickle cell disease, especially children, and are associated with high morbidity and mortality rates. Although available in some centres, people with sickle cell anaemia are not routinely immunized with salmonella vaccines. This review determines whether routine administration of salmonella vaccines to people with sickle cell disease reduces the morbidity and mortality associated with infection. [Download PDF]

Schistosomiasis

Drugs for treating urinary schistosomiasis

“Praziquantel and metrifonate are effective treatments for urinary schistosomiasis and have few adverse events. Metrifonate requires multiple administrations and is therefore operationally less convenient in community-based control programmes. Evidence on the artemisinin derivatives is currently inconclusive, and further research is warranted on combination therapies.”

Urinary schistosomiasis is caused by the blood fluke, Schistosoma haematobium, which is transmitted upon contact with contaminated water. The worms reside in blood vessels of the bladder and cause urinary schistosomiasis, which can lead to long-term ill-health. The disease is commonly found in African and eastern Mediterranean countries, especially in poor, rural areas. This review evaluates antischistosomal drugs, used alone or in combination, for treating urinary schistosomiasis. [Download PDF]

Interventions for treating schistosomiasis mansoni

“Oxamniquine and praziquantel both appear to be effective for treatment of S. mansoni, although lower doses of oxamniquine (less than 30 mg/kg) may not be as effective in some areas.”

Schistosoma mansoni is a parasite carried by freshwater snails. Human infection occurs from contact with contaminated water. The worms travel to the intestine, liver, and spleen, and can be fatal. The disease occurs in the tropics, including countries in South America, the Caribbean, Africa, and the eastern Mediterranean. This review assesses the effects of using oxamniquine and praziquantel for treating S. mansoni infection. [Download PDF]

Shigellosis

Antibiotic therapy for Shigella dysentery

“We recommend the use of antibiotics for moderate to severe Shigella dysentery. The choice of antibiotic to use as first line against Shigella dysentery should be governed by periodically updated local antibiotic sensitivity patterns of Shigella isolates. Other supportive and preventive measures recommended by the WHO [World Health Organization] should also be instituted along with antibiotics (eg health education and hand washing).”

Shigellosis is a bacterial infection of the colon that can cause diarrhoea and dysentery (diarrhoea with blood and/or mucus), and may lead to death. It occurs mainly in low- and middle-income countries where overcrowding and poor sanitation exist, and may lead to around 1.1 million deaths per year globally, mostly in children aged less than five years. Mild symptoms are self-limiting, but in more severe cases, antibiotics are recommended for cure and preventing relapse. The antibiotics recommended are diverse, have regional differences in sensitivity, and have adverse effects. This review evaluates the efficacy and safety of antibiotics for treating Shigella dysentery. [Download PDF]

Typhoid and paratyphoid fever (enteric fever)

Azithromycin for treating uncomplicated typhoid and paratyphoid fever (enteric fever)

“Azithromycin appears better than fluoroquinolone drugs in populations that included participants with drug-resistant strains. Azithromycin may perform better than ceftriaxone.”

Typhoid or paratyphoid fevers (known as enteric fever) are infectious diseases caused by Salmonella bacteria. The infection is usually transmitted by ingestion of food or water contaminated with faeces from people who have the infection. Symptoms include intermittent fever, severe headaches, abdominal discomfort, loss of appetite, malaise, vague abdominal tenderness, and enlarged liver and/or spleen. About 10% to 15% of people get complications, which include bleeding, shock, and inflammation of the pancreas, heart muscles, and the brain. For many years, antibiotics such as chloramphenicol, ampicillin, and cotrimoxazole were used for treating enteric fever. However, multiple-drug resistant strains of the bacteria have now emerged. Other antibiotics like the fluoroquinolones, cephalosporins, and azithromycin are used as well. This review compares azithromycin with other antibiotics for treating uncomplicated enteric fever. [Download PDF] [Evidence Update summary]

Fluoroquinolones for treating typhoid and paratyphoid fever (enteric fever)

“Trials were small and methodological quality varied. In adults, fluoroquinolones may be better for reducing clinical relapse rates compared to chloramphenicol. Data are limited for other comparisons, particularly in children.”

Fluoroquinolones are recommended as first-line therapy for typhoid and paratyphoid fever (enteric fever), but how they compare with other antibiotics and different fluoroquinolones is unclear. This review evaluates fluoroquinolone antibiotics for treating enteric fever in children and adults compared with other antibiotics, different fluoroquinolones, and different durations of fluoroquinolone treatment. [Download PDF] [Evidence Update summary]

Vaccines for preventing typhoid fever

“The licensed Ty21a and Vi polysaccharide vaccines are efficacious. The new and unlicensed Vi-rEPA vaccine is as efficacious and may confer longer immunity.”

Two typhoid vaccines are commercially available, Ty21a (oral) and Vi polysaccharide (parenteral), but neither is used routinely. Other vaccines, such as a new modified, conjugated Vi vaccine called Vi-rEPA, are in development. This review evaluates vaccines for preventing typhoid fever. [Download PDF]


Water-related diseases caused by water-based insect vectors

Dengue fever

Corticosteroids for treating dengue shock syndrome

“There is insufficient evidence to justify the use of corticosteroids in managing dengue shock syndrome. As corticosteroids can potentially do harm, clinicians should not use them unless they are participating in a randomized controlled trial comparing corticosteroids with placebo.”

Dengue virus is an arbovirus transmitted to humans by two species of mosquito, Aedes aegypti and A. albopictus. The four serotypes of dengue virus can cause a wide range of symptoms from mild febrile illness to dengue haemorrhagic fever (severe illness with fever and bleeding), which leads to dengue shock syndrome (shock, collapse, and sometimes death). It is currently estimated that most of the 100 million cases of dengue infection occurring annually are in South-East Asia, although many also occur in the Americas. Dengue shock syndrome is the most severe form of dengue haemorrhagic fever. The current treatment for dengue shock syndrome is to give fluids directly into the bloodstream, but corticosteroids have been suggested as drugs that may help due to their anti-inflammatory properties. This review compares corticosteroids with placebo or no corticosteroids for treating dengue shock syndrome. [Download PDF] [Evidence Update summary]

Malaria

See the ‘Malaria Special Collection’.

Onchocerciasis (river blindness)

Ivermectin for onchocercal eye disease (river blindness)

“Ivermectin can prevent damage to the front of the eye but its effectiveness in preventing blindness remains uncertain.”

Onchocerciasis causes severe itching and thickening of the skin, and damages structures at the front and back of the eye. It also affects the nerve that connects the eye with the brain. Onchocerciasis is caused by tiny worms that are transmitted from person to person by a small biting fly. The fly breeds in fast-flowing rivers and streams mainly in West Africa, although it is also endemic in some countries in the Americas and eastern Mediterranean. It is believed that ivermectin (a microfilaricide) could prevent blindness due to onchocerciasis. This review assesses the effectiveness of ivermectin in preventing visual impairment and visual field loss in onchocercal eye disease. [Download PDF]

Japanese encephalitis

Vaccines for preventing Japanese encephalitis

“It is not possible to compare the effectiveness of currently used vaccines in preventing clinical disease as only one of three vaccines has been directly investigated for effectiveness in a RCT [randomized controlled trial].”

Japanese encephalitis is a viral disease of the central nervous system with general symptoms of headache, fever, vomiting, and diarrhoea. Most people recover within a week without further complications, but approximately 1 in 300 suffers additional and severe symptoms such as disorientation, seizures, paralysis, and coma. Around 30% of the severe cases are fatal, and most survivors are left with serious and often chronic disabilities such as mental impairment, limb paralysis, and blindness. Vaccination is recognized as the only practical measure for preventing Japanese encephalitis, but production shortage, costs, and issues of licensure impair vaccination programmes in many affected countries. Concerns over vaccine effectiveness and safety also have a negative impact on acceptance and uptake. This review evaluates vaccines for preventing Japanese encephalitis in terms of effectiveness, adverse events, and immunogenicity. [Download PDF]


Skin, eye, & louse-borne diseases that can occur when there is a lack of water for personal hygiene

Skin infections: scabies

Interventions for treating scabies

“On the basis of the available evidence from randomized controlled trials, topical permethrin appears to be the most effective treatment for scabies. Ivermectin appears to be an effective oral treatment, but in many countries it is not licensed for this indication.”

Scabies is an intensely itchy parasitic infection of the skin caused by the Sarcoptes scabiei mite. The female mite burrows into the skin to lay eggs, which then hatch out and multiply. The infection can spread from person to person via direct skin contact, including sexual contact. Scabies occurs throughout the world, but it is particularly problematic in areas of poor sanitation, overcrowding, and social disruption, and is endemic in many resource-poor countries. Various drugs have been developed to treat scabies, and herbal and traditional medicines are also used. This review evaluates topical and systemic drugs for treating scabies. [Download PDF]

Skin infections: impetigo

Interventions for impetigo

“Penicillin is not effective for impetigo, while other oral antibiotics can help. However, two antibiotic creams (mupirocin and fusidic acid) are at least as effective as oral antibiotics for limited disease. There is little evidence that using disinfectant solutions improves impetigo.”

Impetigo is a common superficial bacterial skin infection that is contagious and usually occurs in young children. Impetigo causes blister-like sores, which can fill with pus and form scabs; scratching can spread the infection. Treatment options include disinfectant solutions, antibiotic creams, steroid/antibiotic creams, and oral antibiotics. There is no standard therapy, and guidelines for treatment differ widely. Treatment options include many different oral and topical antibiotics as well as disinfectants. This review assesses the effects of treatments for impetigo, including waiting for natural resolution. [Download PDF]

Ophthalmic infections: conjunctivitis

Antibiotics versus placebo for acute bacterial conjunctivitis

“Acute bacterial conjunctivitis is frequently a self-limiting condition, but the use of antibiotics is associated with significantly improved rates of clinical and microbiological remission.”

Acute bacterial conjunctivitis is an infective condition in which the eyes become red and inflamed. The condition is not normally serious and usually recedes spontaneously within about a week. People with acute conjunctivitis are often given antibiotics, usually as eye drops or ointment, to speed recovery. The benefits of antibiotics to the sufferer of conjunctivitis have been questioned. This review assesses the benefit and harm of antibiotic therapy in the management of acute bacterial conjunctivitis. [Download PDF]

Ophthalmic infections: trachoma

Trachoma is the world’s leading cause of preventable blindness. It is a bacterial infection in the eye caused by Chlamydia trachomatis and is common in underprivileged children living in the poor communities of low-income countries, mainly in Africa, Asia, and the Middle East. Through repeated infections, the eyelashes turn in and brush against the cornea. The contact between the lashes and the surface of the eye results in blindness.

Antibiotics for trachoma

“The review found some evidence that antibiotics reduce trachoma. Ointment is neither better nor worse than tablets.”

In 1997, the World Health Organization launched an initiative on trachoma control based on the “SAFE” strategy (surgery, antibiotics, facial cleanliness, and environmental improvement). This review aims to assess the evidence supporting the antibiotic arm of the SAFE strategy by assessing the effects of antibiotics on both active trachoma and on Chlamydia trachomatis infection of the conjunctiva. [Download PDF]

Environmental sanitary interventions for preventing active trachoma

“The role of insecticide spray as a fly control measure in reducing trachoma remains unclear ... Health education may be effective in reducing trachoma.”

One of the major strategies advocated for the control of trachoma is the application of various environmental sanitary measures to such communities. Environmental sanitation is a package of measures aimed at eliminating factors that encourage proliferation of flies and the spread of the disease. Some of these interventions include provision of water and latrines as well insecticide spray to control flies. This review assesses the evidence for the effectiveness of environmental sanitary measures on the prevalence of active trachoma in endemic areas. [Download PDF]

Face washing promotion for preventing active trachoma

“Evidence from one trial suggests that face washing can be effective in increasing facial cleanliness and in reducing severe trachoma, but its effect in reducing active trachoma is inconclusive. In another trial, there was no evidence of effect of face washing alone or in combination with tetracycline in reducing active trachoma in children with already established disease.”

Face washing is part of the “SAFE” strategy (surgery, antibiotics, facial cleanliness, and environmental improvement) promoted by the World Health Organization programme for the global elimination of trachoma. Face washing should reduce the number of eye-seeking flies and transmission of the trachoma organism from person-to-person. This review assesses the effects of face washing on the prevalence of active trachoma in endemic communities. [Download PDF]

Interventions for trachoma trichiasis

No trials show interventions for trichiasis prevent blindness. Certain interventions have been shown to be more effective at eliminating trichiasis.”

Repeated infections cause scarring of the conjunctiva of the upper eyelid, which causes the eyelid to turn in (entropion) so that the eyelashes touch the cornea at the front of the eye. This is known as trachoma trichiasis. Every movement of the eye or eyelids causes trauma to the corneal surface so that it eventually turns opaque and the person becomes blind. This review assesses the effects of different interventions for trachoma trichiasis (both surgical and non-surgical) to identify the most effective means of eliminating trichiasis and the most acceptable way of delivering these. [Download PDF] [Evidence Update summary]

Louse-borne disease: scrub typhus

Antibiotics for treating scrub typhus

“There are no obvious differences between tetracycline, doxycycline, telithromycin, or azithromycin; rifampicin may be better than tetracycline in areas where scrub typhus appears to respond poorly to standard anti-rickettsial drugs.”

Scrub typhus is a bacterial infection transmitted by chiggers (mites). The infection causes fever and a typical sore on the skin. Scrub typhus is common in the western Pacific region and many parts of Asia, particularly in agricultural workers and travellers in areas where the disease is common, particularly people camping, rafting, or trekking. Antibiotics (chloramphenicol, tetracycline, and doxycycline) have been used to treat the disease. Resistance to these antibiotics has been reported. This review evaluates antibiotic regimens for treating scrub typhus. [Download PDF]

Skin diseases caused by long-term exposure to water

Skin infections: fungal infections of the skin of the foot (including tinea pedis or athlete’s foot)

Topical treatments for fungal infections of the skin and nails of the foot

"Placebo-controlled trials of allylamines and azoles for athlete's foot consistently produce much higher percentages of cure than placebo. Allylamines cure slightly more infections than azoles and are now available OTC [over the counter]. Further research into the effectiveness of antifungal agents for nail infections is required."

The skin between the toes is a frequent site of fungal infection (athlete's foot or tinea pedis), and this can cause pain and itchiness. The skin may become white and macerated, and vesicles (small blisters) may form. These can erupt and spread to other areas of the foot, especially the soles where the area becomes reddened and raw. Also, patches of hard, thickened skin occur on the soles, heels, and side of the feet. This can lead to splits (fissures) in the skin. Fungal infections of the toenail can affect the entire nail plate, and one, several, or all toenails can be infected simultaneously. This review assesses the effects of topical treatments in successfully treating fungal infections of the skin of the feet and toenails, and in preventing recurrence. [Download PDF]

Oral treatments for fungal infections of the skin of the foot

"The evidence suggests that terbinafine is more effective than griseofulvin and that terbinafine and itraconazole are more effective than no treatment."

About 15% of the population have fungal infections of the feet (tinea pedis or athlete's foot). While there are many clinical presentations of tinea pedis, the most common are between the toes and on the soles, heels, and sides of the foot, which is known as moccasin foot. Once acquired the infection can spread to other sites including the nails, which can be a source of reinfection. Oral therapy is usually used for chronic conditions or when topical treatment has failed. This review assesses the effects and costs of oral treatments for fungal infections of the skin of the foot (tinea pedis). [Download PDF]


Water-related diseases caused by urine of certain mammals

Leptospirosis

Antibiotic prophylaxis for leptospirosis

“Regular use of weekly doxycycline 200 mg oral therapy has increased odds for nausea and vomiting with unclear benefit in reducing Leptospira seroconversion or clinical consequences of infection. If it is efficacious in reducing disease, it may be more so in travellers rather than in residents of an endemic area.”

Leptospira infection is a global zoonosis caused by spirochetes of the genus Leptospira. It causes endemic disease among agricultural workers and others regularly exposed to flooded fields and livestock, or other sources of animal urine. Outbreaks of leptospirosis also occur among immune-naive individuals who may be exposed because of changing environmental conditions, travel, or occupational or recreational activities, for example. This review assesses the evidence for or against use of antibiotic prophylaxis against Leptospira infection. [Download PDF]


Additional resources & guidelines


Acknowledgements

Thank you to Prof Zulfiqar Bhutta, Dr Anita Zaidi, Dr Saeed Farooq, Prof Paul Garner, Ms Bridget Jones, Dr Prathap Tharyan, and Prof Mike Clarke for their input and support in preparing this Special Collection.

References

1. Connolly MA, editor. Communicable Disease Control in Emergencies: A Field Manual. Geneva: World Health Organization, 2005. www.who.int/infectious-disease-news/IDdocs/whocds200527/ISBN_9241546166.pdf (accessed 17 August 2010).

2. World Health Organization. Diarrhoeal disease: key facts. www.who.int/mediacentre/factsheets/fs330/en/index.html (accessed 17 August 2010).

Image credit: Paolo Koch/Science Photo Library, E160/192

Date published: 18 August 2010; updated 25 August 2010 to add a new section for ‘Skin diseases caused by long-term exposure to water’; updated 14 October 2010 to extend the access date for Pakistan to the end of 2010; updated 2 November 2010 to add the PDFs for each Cochrane Review; updated 10 November 2010 to add one new review and one updated review; updated 21 December 2010 to change title.

Contact: Cochrane Editorial Unit (editorial-unit@cochrane.org)


   

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