Hindawi Publishing Corporation
International Journal of Microbiology
Volume 2016, Article ID 2617473, 8 pages
http://dx.doi.org/10.1155/2016/2617473
Research Article
Microbial Content of (Bowl Water) Used for Communal
Handwashing in Preschools within Accra Metropolis, Ghana
Patience B. Tetteh-Quarcoo,1 Isaac Anim-Baidoo,2 Simon Kwaku Attah,1
Bawa Abdul-Latif Baako,2 Japheth A. Opintan,1 Andrew A. Minamor,3
Mubarak Abdul-Rahman,4 and Patrick F. Ayeh-Kumi1,2
1Department of Medical Microbiology, School of Biomedical and Allied Health Sciences, University of Ghana, Accra, Ghana
2Department of Medical Laboratory Science, School of Biomedical and Allied Health Sciences, University of Ghana, Accra, Ghana
3Department of Science Laboratory Technology, Accra Polytechnic, Accra, Ghana
4Department of Immunology, School of Biomedical and Allied Health Sciences, University of Ghana, Accra, Ghana
Correspondence should be addressed to Patience B. Tetteh-Quarcoo; patborket2002@yahoo.com
Received 31 May 2016; Accepted 10 July 2016
Academic Editor: Karl Drlica
Copyright © 2016 Patience B. Tetteh-Quarcoo et al. This is an open access article distributed under the Creative Commons
Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is
properly cited.
Objective. This study aimed at determining the microbial content of “bowl water” used for communal handwashing in preschools
within the Accra Metropolis. Method. Six (6) preschools in the Accra Metropolis were involved in the study. Water samples and
swabs from the hands of the preschool children were collected. The samples were analysed and tested for bacteria, fungi, parasites,
and rotavirus. Results. Eight different bacteria, two different parasites, and a fungus were isolated while no rotavirus was detected.
Unlike the rest of the microbes, bacterial isolates were found among samples from all the schools, with Staphylococcus species being
themost prevalent (40.9%). Out of the three schools that had parasites in their water, two of themhadCryptosporidium parvum.The
fungus isolated from twoout of the six schoolswasAspergillus niger. All bacteria isolatedwere found to be resistant to cotrimoxazole,
ciprofloxacin, and ampicillin and susceptible to amikacin and levofloxacin. Conclusion. Although handwashing has the ability to
get rid of microbes, communal handwashing practices using water in bowls could be considered a possible transmission route and
may be of public concern.
1. Introduction “Bowl water” (water in a basin/bowl) has been adapted to
serve this purpose whenever the flow of running tap water is
Provision of a bowl of water for handwashing in preschools is interrupted.
an intervention by childcare facilities in Ghana, to maintain Handwashing has been regarded as a significant preven-
hygienic practices and prevent transmission of microbes. In tive measure against diarrhoeal diseases [2]. It is an effective
the year 2005, the Ghana School Feeding Programme (GSFP) [2], feasible [2–5], and cost-effective [6] means of preventing
was implemented as one of the most important social inter- gastroenteric infection worldwide. Recently, there has been
ventions by the government, to help boost public basic school growing awareness of its importance not only as a diarrhoeal
enrolments [1]. The programme offers one meal each day for disease preventive measure [2, 7], but also as part of a wider
all government preschoolers and primary school children. public health effort to reduce the disease burden of acute
This provision is to reduce hunger andmalnutrition, increase respiratory infections worldwide [2, 8–10]. The importance
schoolenrolmentandattendance,andstimulate local foodpro- of handwashing has also been underlined in a recent review
duction. Similarly, many privately owned preschools provide of measures to control the spread of pandemic influenza [11].
meals for their pupils. This has therefore necessitated the The two leading causes of disease burden globally, respiratory
provision of water for handwashing before and after meals. infections and diarrhoeal diseases, are responsible for half
2 International Journal of Microbiology
of all childhood deaths each year [12]. Therefore, good and made from each resuspended sediment. Two out of the three
adequate handwashing practice is a prerequisite to disease slides were stained, one with iodine and the other with
control and child’s survival [2, 13]. modified Z-N stain, and the third was examined directly as
With reference to an appropriate handwashing procedure wet mount using standard procedures [19].
[14], communal handwashing from a bowl of water is not the
best practice. A handwashing facility, even with soap, on a
communal basis, where the same water is used by more than 2.3. Isolation, Enumeration, and Identification of Bacteria
one person, does not constitute an adequate handwashing and Fungi. The water samples were well mixed and using
facility [15, 16].This practice, especially when the water in the disposable sterile loops (2mm inside diameter) each of the
bowl is not changed frequently, could increase the exchange samples was inoculated onto MacConkey agar (MA) and
of microbes among the children when the goal is to get blood agar (BA) (Oxoid Ltd., Basingstoke, UK). The swabs
rid of them. Therefore, this study aimed at determining the were also inoculated (directly) onto MA and BA. The plates
microbial content of “bowl water” used for handwashing in were incubated at 37
∘C for 24 hours. The number of colonies
preschools within Accra Metropolis. This will help in the seen was counted using a colony counter and recorded
understanding of the possible role that “bowl water” could as colony forming unit per gram (cfu/g) for swabs and
play in the transmission of infectious agents. It will also colony forming unit permillilitre (cfu/mL) for water samples.
help appreciate whether, in the absence of flowing tap water, Bacteria colonies were further subcultured onto MA and BA,
washing from a bowl of water could serve as an alternative to obtain pure cultures and primary identification done using
way of getting rid of most microbes among children. colonial morphology. Further identification was done basedon a number of procedures including microscopy, Gram
staining, oxidation-fermentation tests, and other biochemical
2. Methods tests such as urease test, catalase test, citrate utilization test,
indole test, and triple sugar iron test [20–23].
2.1. Study Site and Sample Collection. Preschools within Similarly, the water samples and swabs were inoculated
Accra, the capital of Ghana, that either are under the on Sabouraud agar (Oxoid Ltd., Basingstoke, UK) for fungal
Ghana School Feeding Programme or are private schools growth and subsequent identification using standard proto-
that provide meals for children were selected for the current col [19].
study. To maintain anonymous identity of the schools and
confidentiality, the schools were coded as SA, SB, SC, SD,
SE, and SF. Sterile plastic bottles were used to aseptically 2.4. Susceptibility Testing of Bacteria. Susceptibility test for
collect 1000mL each of water samples used for handwashing identified bacteria was determined using a modified form of
and rinsing. Three water samples were taken from each the Kirby Bauer method.The antimicrobials tested with their
school; one sample was taken from their main source, such disk concentrations in micrograms (𝜇g) were gentamicin
as water storage tanks, commonly called “poly tank,” tap, (15), amikacin (30), tetracycline (30), cotrimoxazole (25),
and well, and labelled as “source.” Another sample was cefotaxime (30), meropenem (10), ampicillin (10), ceftriaxone
taken from the basins containing water for handwashing (30), chloramphenicol (30), cefuroxime (30), levofloxacin (5),
and labelled as “soapy water” and a third sample was taken and ciprofloxacin (5) (Oxoid Ltd., Basingstoke, UK). These
from the basin containing water for rinsing and labelled antimicrobials are among the common drugs found on the
as “rinse.” After a brief interview using a questionnaire, Ghanaian market. Briefly, on the procedure for antibiotic
swabs were obtained from three randomly selected pupils susceptibility testing, the test organism was emulsified in
from each school, before they washed their hands and after peptone water until the suspension was comparable with 0.5
handwashing. The collected samples (both the water and the McFarland’s standard. A sterile cotton swab was dipped into
swabs) were transported on ice packs, to the laboratories the suspension and drained by pressing the swab against the
at the Departments of Medical Microbiology and Medical inside of the bottle. The swab was then used to streak the
Laboratory Sciences, all of the School of Biomedical and entire surface of a Mueller-Hinton agar plate (Oxoid Ltd.,
AlliedHealth Sciences, University of Ghana, for examination. Basingstoke, UK). The moisture was allowed to be absorbed
for at least 15 minutes and sterile forceps were used to apply
the antibiotic discs to the surface of the agar plates. The plate
∘
2.2. Parasitological Examination. One hundred millilitres was kept at 4 C for 4–6 hours, so that the antibiotic can
(100mL) of each water sample was centrifuged at 5000 rpm diffuse on the agar media after which it was incubated at 37
∘C
for 10 minutes. The supernatant was discarded and the for 18–24 hours. Zone diameters around the antibiotic discs
remaining sediments were resuspended and examined by were measured and later classified as susceptible or resistant
the direct wet mount and concentration techniques [17, 18]. based on the Clinical Laboratory Standards Institute (CLSI)
Briefly, a drop of the sediment was placed on two clean criteria [24]. Control strain used for the susceptibility test was
grease-free microscope slides. To one, a drop of iodine Escherichia coli NCTC 10418.
was added and both were covered with coverslips. Each
slide was then examined under a light microscope for the 2.5. Virological Examination. The water samples were tested
presence of life forms of protozoans and helminths. Formol- for rotavirus using the ProSpecT Rotavirus ELISA kit
ether concentration method was employed on the rest of (Oxoid Ltd., UK). The process was carried out using the
the sediments [17, 18]. After concentration, three slides were protocol designed by the manufacturer (Oxoid Ltd., UK).
International Journal of Microbiology 3
(𝛼) (𝛽)
(a) (b) (a) (b)
Figure 1: Modified ZN stained slides of parasites identified. (𝛼) Oocysts of Cyclospora cayetanensis. (𝛽) Oocyst of Cryptosporidium parvum.
(a) represents magnification of ×1000 while (b) is a zoom-in of the oocyst.
Table 1: Demographic data of schools recruited in the study. and Klebsiella pneumoniae were identified in three different
schools. Klebsiella oxytoca and Klebsiella species were identi-
School ID Location Ownership Type of school fied in two preschools and Proteus mirabiliswas isolated from
SA Arena Government Preschool with only one preschool.primary level Examination of the swabs showed that Staphylococcus
SB Arena Private Preschool up to JHS species was present before handwashing and after handwash-level ing. Escherichia coli, Citrobacter species, Salmonella species,
SC Chorkor Private Preschool only Klebsiella pneumoniae, and Klebsiella oxytoca were only
SD Chorkor Private Preschool with isolated from swabs obtained after handwashing (Table 2).primary level Notably, just a few colonies were observed for most of the
SE Mamprobi Private Preschool with bacterial isolates, for the different sources of water and handprimary level swabs.The ranges of colony forming units of the isolates from
SF Korle Gonno Private Preschool with various samples are as follows: Staphylococcus spp. (1.2 × 102–primary level 1.2 × 103), Salmonella spp. (1.0 × 101–3.2 × 101), E. coli (1.1
× 101–1.7 × 101), Citrobacter spp. (1.4 × 101–4.2 × 101), K.
pneumonia (1.5 × 102–7.0 × 102To ensure quality and accurate results, positive and negative ), K. oxytoca (2.0 × 10
2–4.2 ×
2
controls were run for each test. 10 ),Klebsiella spp. (1.0 × 10
2–3.3 × 102), and P. mirabilis (1.0 ×
103–1.5× 104). Apart from Staphylococcus spp. andP.mirabilis,
all the remaining bacteria recorded cfu below 103 (Table 3).
3. Results The isolated Gram negative bacteria were tested against
A total of 6 preschools were involved in the study.Threewater twelve selected antimicrobial agents. All the organisms tested
samples and six swabs were obtained from each preschool (6/6, 100%) were resistant to cotrimoxazole, ampicillin, and
making a total of 54 samples for the investigation. Five (83%) ciprofloxacin while they were susceptible (100%) to amikacin
of the preschools were privately owned while only one was and levofloxacin. The organisms showed varying percentage
government owned (Table 1).The schools had different stages, resistance to the remaining antibiotics (Figure 2). Notably, for
ranging from preschool to junior high school (JHS) (Table 1). gentamicin, resistance was seen among Salmonella species,
Parasitological investigations identified two different par- Klebsiella pneumoniae,and Klebsiella oxytoca. All bacteria,
asites (Table 2). Cryptosporidium parvum and Cyclospora except for Proteus mirabilis and Escherichia coli,were resis-
cayetanensiswere both found in the rinsingwater of school SB tant to cefuroxime. Similarly, resistance to chlorampheni-
and the soapy water of school SD. Meanwhile, Cryptosporid- col was observed in all the bacteria tested except for
ium parvum was also found in the main water source of Citrobacter speciesand Escherichia coli. Meanwhile, the
school SC (Figure 1). only organism susceptible to tetracycline was Escherichia
Bacteriological investigations identified eight (8) different coli.
bacteria in the different water types (Table 2). The bacteria From the fungal studies, Aspergillus niger was identified
isolates were in the following proportions: Staphylococcus from hand swabs of school children from schools SB and SC
species (40.9%), Escherichia coli (13.6%), Citrobacter species before and after handwashing. The same fungal species was
(13.6%), Klebsiella species (4.6%), Proteus mirabilis (2.3%), also found in the soapy water of school SB (Figure 3).
Klebsiella pneumoniae (9.1%), Salmonella species (9.1%), The rotavirus screening did not detect the presence of the
and Klebsiella oxytoca (6.8%). Staphylococcus specieswas virus in any of the water samples collected from the schools,
the most common isolate from all the preschools except as well as the swabs obtained from the hands of the children
for SF. Salmonella species was isolated from four differ- (Table 2). Other viruses could not be investigated due to
ent preschools, while Escherichia coli, Citrobacter species, inadequate resources.
4 International Journal of Microbiology
Table 2: Microbial contamination of different sources of bowl water and hands of children.
Microorganism Main, 𝑛 (%) Soapy, 𝑛 (%) Rinse, 𝑛 (%) Hand before washing, 𝑛 (%) Hand after washing, 𝑛 (%)
𝑁 = 18 𝑁 = 18 𝑁 = 18 𝑁 = 36 𝑁 = 36
Parasites
C. parvum 1 (12.5) 2 (7.1) 2 (9.1) 0 (0) 0 (0)
C. cayetanensis 0 (0.0) 2 (7.1) 2 (9.1) 0 (0) 0 (0)
Bacteria
Staphylococcus spp. 2 (25.0) 5 (18.0) 5 (22.7) 12 (85.7) 15 (31.2)
Salmonella spp. 0 (0.0) 4 (14.3) 2 (9.1) 0 (0.0) 9 (18.8)
E. coli 2 (25.0) 3 (10.7) 3 (13.6) 0 (0.0) 8 (16.7)
Citrobacter spp. 1 (12.5) 3 (10.7) 3 (13.6) 0 (0.0) 6 (12.5)
K. pneumonia 1 (12.5) 3 (10.7) 2 (9.1) 0 (0.0)
K. oxytoca 0 (0.0) 2 (7.1) 2 (9.1) 0 (0.0) 4 (8.3)
Klebsiella spp. 1 (12.5) 2 (7.1) 1 (4.6) 0 (0.0) 4 (8.3)
P. mirabilis 0 (0.0) 1 (3.6) 0 (0.0) 0 (0.0) 0 (0.0)
Fungus
A. niger 0 (0.0) 1 (3.6) 0 (0.0) 2 (14.3) 2 (4.2)
Virus
Rotavirus 0 (0.0) 0 (0.0) 0 (0.0) 0 (0.0) 0 (0.0)
𝑁 represents the total number of samples used. 𝑛 represents number of particular microbes identified.
Table 3: Bacteria colony count of water samples (cfu/mL) and hand-swab samples (cfu/g).
Bacterial isolates Water sources Swabs
Main Soapy Rinse Hand before washing Hand after washing
Staphylococcus spp. 1.2 × 103 1.5 × 103 1.2 × 103 1.8 × 102 1.2 × 102
Salmonella spp. 3.0 × 101 3.2 × 101 3.0 × 101 1.0 × 101 1.2 × 101
E. coli 1.1 × 101 1.3 × 101 1.1 × 101 1.7 × 101 1.5 × 101
Citrobacter spp. 3.0 × 101 4.2 × 101 1.4 × 101 3.7 × 101 3.0 × 101
K. pneumonia 1.8 × 102 2.3 × 102 1.5 × 102 7.0 × 102 1.8 × 102
K. oxytoca 2.3 × 102 2.2 × 102 2.0 × 102 4.0 × 102 4.2 × 102
Klebsiella spp. 2.0 × 102 1.3 × 102 1.0 × 102 3.3 × 102 3.3 × 102
P. mirabilis 1.5 × 103 1.0 × 103 3.0 × 103 1.5 × 104 4.3 × 103
4. Discussion children. For example, Klebsiella pneumo niae causes pneu-
monia, urinary tract infections, and wound infections [23,
Bacteria isolates from the current study include Salmonella 24]. Studies have shown that individuals with recurrent
species, Citrobacter species, Escherichia coli, Proteusmirabilis, infections and those with structural abnormalities of the
Klebsiella pneumoniae,and Klebsiella oxytoca. Most of these urinary tract have an increased frequency of infection caused
organisms have also been isolated from a work done by by bacteria such as Klebsiella oxytoca [27, 28].
Tetteh-Quarcoo et al., when they investigated microbial car- The isolation of Escherichia coli shows that washing with
riage of cockroaches within the same geographical location as bowl-water is a possible source of transmitting this bac-
this study [25].This shows likelihood of these bacteria species terium, which causes acute diarrhoea, especially in children
circulating within the metropolis. A recent study conducted [29]. Although Escherichia coli is part of the normal flora
by Ayeh-Kumi et al., on tiger nuts which were claimed to of the intestinal tract, certain strains can cause moderate to
have been washed and sold in locations including that of severe gastroenteritis in adults and children [29]. Salmonella
the current study, also found bacterial isolates, including species and Escherichia coli were isolated from even the
Klebsiella oxytoca, suggesting the association of this partic- source where the water used for handwashing was fetched.
ular bacterium with water used within the metropolis [26]. This is not surprising, since even sachet water, regarded as
Most of the bacteria isolated in this study are pathogenic more purified, has been found to contain high levels of bac-
or potentially pathogenic and are therefore of public health teria [30]. Almost all the bacteria isolated in this study are
significance, especially when in connection with preschool mostly responsible for enteric diseases in young children.
International Journal of Microbiology 5
100 this recommendation. Staphylococcus species were isolatedfrom swabs before handwashing and after handwashing.
80 Escherichia coli, Citrobacter species, Salmonella species, Kleb-
60 siella pneumoniae, and Klebsiella oxytoca were only isolated
40 from swabs obtained after handwashing. Another study also
20 isolated Staphylococcus species,Escherichia coli, andKlebsiella
0 from the hands of preschool nurses [35]. Most of the isolates
found on the hand swabs were from the “after handwashing”
samples and therefore it is suggested that the children might
have picked the bacteria during handwashing process. All
the same, it is noteworthy that just a few colonies were
counted for most of the bacteria isolates. This implies that
Antibiotics although pathogenic bacteria were among the agents isolated,
Figure 2: Percentage resistance of antibiotics tested. Six out of the infection from these organisms might mostly be manifested
eight isolates tested, namely, Salmonella species, Citrobacter species, in immunocompromised children who use this handwashing
Escherichia coli, Proteus mirabilis, Klebsiella pneumoniae,and Kleb- process.
siella oxytoca. The values of diameter (mm) measurement that were Cryptosporidium parvum and Cyclospora cayetanensis
considered sensitive are as follows: tetracycline ≥ 26, cefotaxime were present in some of the water samples used for hand-
≥ 26, cotrimoxazole ≥ 24, ampicillin ≥ 17, gentamicin ≥ 20, washing in the preschools. These organisms are potential
ciprofloxacin ≥ 21, cefuroxime ≥ 18, meropenem ≥ 16, amikacin ≥
20, chloramphenicol 30, ceftriaxone 21, and levofloxacin 17. pathogens associated with water related diarrhoea outbreaks≥ ≥ ≥ in healthy people and have devastating presentations in
the immunocompromised individuals, particularly children
[36]. The result of this study supports the findings of Obiri-
Danso et al., when they carried out a study to determine the
All the same, the bacteriological methods used in this study microbial quality of water on the streets of Kumasi [37].These
provided not much quantification of bacterial load, unlike organisms are also notable for the stability of their oocysts in
a study by Hoque et al. [31]. Staphylococcus species was the environment [38]. Hence, the finding of these parasites in
very common in each of the preschools. Infections from the “bowl water” used for handwashing by preschool children
this organism occur when staphylococci enter the body is of public health importance.
through breaks, cuts, and abrasions in the skin or mucous The current study identified Aspergillus niger from the
membranes. Hence, children who have openings such as cuts hands of school children before and after handwashing
and abrasions of the skin have a high risk of getting infection and also from soapy water used for handwashing. This
caused by this organism when they use such handwashing emphasizes the ubiquitous nature of this mould and its
facilities. Isolation of Citrobacter species is a notable observa- association with water [39, 40]. In a study, different species
tion, sinceCitrobacter infections can be community acquired. of fungi were recovered from Dead Sea water, many of
Citrobacter species also cause meningitis, septicaemia, and which belonged to nonhalophilic terrestrial species, known
pulmonary infections in neonates and young children. Most for their diverse distribution [39]. Examples of these species
of these organisms were enteric bacteria which possibly include Aspergillus niger and Cladosporium cladosporioides
found their way through accidentally, due to poor hygiene, [39]. In spite of their widespread occurrence, little attention
suggestive of faecal contamination. has been given to the presence of fungi and their significance
Observation from the antibiotic resistance testing of the in preschool environments. The observation of Aspergillus
current study conforms with the observation by Tetteh- niger fromwater samples used for handwashing suggests that
Quarcoo et al. [25] and reemphasizes the assertion that the communal handwashing facility could be considered a
some antibiotics such as cotrimoxazole, ampicillin, and possible transmission route forthis fungal species. Although
ciprofloxacin have been on the Ghanaian market for a Aspergillus species cause significant pulmonary infections,
long time and therefore might have been subjected to Aspergillus niger has rarely been reported as a cause of
indiscriminate use or abuse leading to the high levels of invasive pulmonary aspergillosis [40]. Therefore, identifying
resistance recorded [32, 33]. Although ciprofloxacin and only this species in the study lowers the possibility of signif-
levofloxacin are both from the same class of antibiotics icant pulmonary infections in the school children, acquired
(fluoroquinolones), there was a notable difference in their through the handwashing process.
performance against the bacteria isolates tested. This obser- In relation to rotavirus, all the test resultswere negative. In
vation could be due to the probable indiscriminate use of Ghana, almost half of the diarrhoeal disease hospitalization
ciprofloxacin in Ghana, since it is readily available compared cases of children under 5 years of age are caused by rotavirus
to levofloxacin. Citrobacter species was found to be resistant [41]; hence, this virus was included in the microbes under
to five out of the 12 antibiotics tested. In spite of this, Shih et investigation in the current study.The absence of this virus in
al. [34] found that the combination of a beta-lactam and an the bowl water and hands of school children is a positive and
aminoglycoside had better therapeutic results than a single a comforting finding. In spite of this, the absence of detection
agent alone for Citrobacter bacteremia; hence, children who of rotavirus may be a reflection of the sample size used in the
acquire infection through handwashing can be treated using current study or the season when the samples were collected.
Percentage resistance (%)
Tetracycline
Cotrimoxazole
Gentamicin
Cefuroxime
Chloramphenicol
Ceftriaxone
Cefotaxime
Meropenem
Amikacin
Ampicillin
Levofloxacin
Ciprofloxacin
6 International Journal of Microbiology
(a) (b) (c)
Figure 3: A wet preparation of Aspergillus niger showing “sporing structure.” ((a) and (b)) From hands of school children, (c) from soapy
water.
It is therefore important not to infer that all handwashing GSFP: Ghana School Feeding Programme
bowls are free of rotavirus. CLSI: Clinical and Laboratory Standards
Institute
CFU: Colony forming unit
5. Conclusion JHS: Junior High School.
In the absence of running tap water in most locations,
provision of “bowl water” for handwashing in preschools Competing Interests
has been a common practice within the Accra Metropolis. The authors declare that they have no competing interests.
The current study demonstrated the presence of microbes of
faecal and zoonotic origin in some of the swabs and water
samples examined (except for rotavirus).This can be of public Authors’ Contributions
health concern as some of the organisms identified can cause
diseases especially in immunocompromised individuals and Patience B. Tetteh-Quarcoo conceived and designed the
young children. Although handwashing has the ability to experiments. Andrew A. Minamor, Bawa Abdul-Latif Baako,
get rid of some microbes, this communal handwashing Japheth A. Opintan, and Patience B. Tetteh-Quarcoo partic-
practice using water in a bowl could be considered a possible ipated in collection and analyses of the data and drafting
transmission route and may be of public concern. Even of the paper. Simon Kwaku Attah, Andrew A. Minamor,
though pathogenic bacteria were isolated, the colony forming Isaac Anim-Baidoo, Bawa Abdul-Latif Baako, and Mubarak
units for most of them were low. In spite of the low cfu and Abdul-Rahman contributed to interpretation of the data.
nondetectable rotavirus content of the water samples in the Patience B. Tetteh-Quarcoo, Isaac Anim-Baidoo, and Patrick
current study, adapting an improvised running water system F. Ayeh-Kumi jointly developed the structure and arguments
will be an improvement. Therefore, adapting a system like for the paper. Isaac Anim-Baidoo, Japheth A. Opintan, and
the “tippy-tap” which is already practiced in some schools Patrick F. Ayeh-Kumi made critical revisions and approved
in Ghana and has proven to deliver promising results since the final version. All authors read and approved the final
its introduction in some parts of Uganda [42] is highly paper.
recommended.
Acknowledgments
Abbreviations The authors wish to acknowledge all schools and childrenwho participated in the study. Rotavirus investigation was
K. oxytoca: Klebsiella oxytoca supported by the virology unit of the Department of Medical
E. coli: Escherichia coli Microbiology. The authors therefore wish to thank all the
Citrobacter spp.: Citrobacter species staff of the Departments of Medical Laboratory Sciences and
P. mirabilis: Proteus mirabilis Medical Microbiology (all of SBAHS) for their help.
C. parvum: Cryptosporidium parvum
C. cayetanensis: Cyclospora cayetanensis
Z-N: Ziehl-Neelsen References
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