Water disconnection and disease

Water disconnection and disease SiR-Fewtrell and colleagues (May 28, p 1370) show no evidence linking disconnection with notified hepatitis A and shigellosis. They suggest that any association is an effect of poverty and more strongly predicted by other indicators of social deprivation. Many UK water companies exceed the legal requirement to notify disconnections of inhabited properties, by more than 24 hours. This practice might mask the true effects of disconnection. Fewer than 1 in 10 dysentery cases might be notified. Notification requires an affected individual to attend a doctor, the doctor must suspect a notifiable infection and notify, a sample must be collected, and laboratory diagnosis must be confirmed. An individual whose water supply has been disconnected, might not seek medical advice while he is trying to overcome more compelling problems. Disconnected families might also be "reluctant to flaunt their poverty to anyone" (West Smethwick community safety initiative, personal communication). Furthermore, disconnected households have been resourceful in getting alternative water supplies. Any ill-health effects from disconnection would thus be prevented, or hidden. Disconnection cannot be a causal factor for these infections, but would influence the magnitude of an outbreak and secondary spread. Disconnection also places households at particular risk where there are existing health problems and greater need for water including families with small children, people who are housebound, bedbound, incontinent, or others requiring frequent baths for symptomatic relief. Some case studies in Birmingham are illustrative: two patients with diarrhoeal illness, which were not notified, after disconnection; people unable to take prescribed tablets without water; one family with two children with sickle-cell anaemia who were disconnected twice in six months; one household infested with rats and the family was unable to wash themselves clean of rat poison.’I The importance of such individual health problems to the general public health cannot be assessed without a prospective case-control study based on disconnected households. There is a clear need for prospective studies of physical and psychological morbidity, especially with respect to methods of paying for water. The debate in the UK seems to be shifting from disconnection to water metering, which is seen by some to encourage water conservation and help consumers’ budgets. However, McNeish reports metered families rationing their use of baths, toilet flushes, and hand washing, and being unable to follow instructions for use of scabicides.2 Pre-payment meters might reduce notified disconnections but not actual disconnections. In a prepayment pilot study, 110 (27-5%) of the study group selfdisconnected in nine months, compared with 0-03% overall disconnection rate.3 It is vital that the public health consequences of water disconnection are thoroughly

explored. Middleton, Pat Saunders, Jayne Corson

JD

Sandwell Health Authority, PO Box 1953, West Bromwich, West Midlands B71 4NA, UK; West Midlands Regional Health Authority; and Institute of Public and Environmental Health, Birmingham University

1

Corson J. Water disconnections of domestic premises and the possible link with Shigella infections. A literature review and investigative research. Birmingham: Birmingham University, 1993, MSc Thesis.

2

McNeish D. Liquid gold: the cost of water in the nineties. Ilford: Barnardo’s Publicity Services, 1993.

3

Figures from Severn Trent Water. Cited in: Early day motion 2515. London: Houses of Parliament, notice of motions, 1994, no 227: 10804.

62

Compulsory

measures

to combat

spread of

HIV in Sweden

SiR-Voluntary testing for HIV infection has been strongly encouraged in nationwide campaigns in Sweden, and vigorous testing of persons has been done since the HIV-test became available. Sweden’s health strategy to contain the spread of AIDS has been voluntary routine testing, compulsory contact, and partner tracing and subsequent

testing. HIV is a notifiable disease in Sweden, and according to the Communicable Diseases Law, 1989, an individual infected with HIV can be detained in hospital if he or she poses a threat of spreading the infection to others. The patient’s physician is obliged to report a case of HIV to the County Council medical health officer in charge of the control of communicable diseases. The report includes a coded (anonymous) case-number and provides information on sex, year, and country of birth; risk category and, if possible, time and place of transmission. The patient should be reported as soon as the HIV diagnosis is verified and when the criteria for AIDS are fulfilled. The consulting physician is responsible for seeing the patient regularly and informing them of binding regulations to prevent further spread of infection. The regulations require individuals: (1) to inform the sexual partner about their HIV infection before having intercourse; (2) to practise safe sex (ie, use condoms); (3) not to share needles or syringes; and (4) not to engage in prostitution. It is also mandatory for the patient to inform medical personnel before receiving treatment that could involve blood contact. If the patient does not adhere to these rules, the physician has to report their identity to the medical officer. He then contacts the patient and additional counselling is given, which is usually sufficient to alter highrisk behaviour. An administrative court decides about detainment. The patient has the right to a lawyer and to

appeal. In Sweden there are almost 4000 HIV-infected individuals. Of these, about 3000 live in Stockholm county. During the past 5 years, about 40 persons with HIV have been detained after decision by the administrative courts, 30 of whom are from the Stockholm area. Thus, 1% of HIVinfected persons have been subject to isolation. The duration of the first detainment ruled by the court is limited to 3 months. Subsequent rulings may be for up to 6 months. Every detainment has to be decided by the administrative court, with right of appeal. Much effort is put into

counselling, promoting drug treatment programmes, or referring patients for psychiatric treatment before compulsory measures are undertaken. Brith

Christenson, Staffan Sylvan, Per Lundbergh

Department of Environmental Health and Infectious Diseases Control, Stockholm County Council, Karolinska Hospital, S-171 76 Stockholm, Sweden

Control of iodine

deficiency in India

SiR-Imam’s April 23 (p 1031) news item records efforts to control the iodine deficiency disorders in India through the National Iodine Deficiency Disorders Control Programme (NIDDCP), and draws attention to the non-availability of iodised salt to about half the Indian population of about 900 million. Although it is true that the non-availability of adequate amounts of iodised salt is a major constraint in the successful implementation of the NIDDCP, other factors are also implicated. It is well known that even where the iodised salt has been made available as a priority-eg, in sub-Himalayan areas-not everyone is compliant. The main reason is the