Effectiveness of Chlorine Dispensers in Emergencies: Case Study Results from Haiti, Sierra Leone, DRC, and Senegal. Environ. Sci. Technol., March 2015.

Authors: Travis Yates , Elise Armitage , Lilian V. Lehmann , Ariel J. Branz , and Daniele S. Lantagne

Dispensers are a source-based water quality intervention with promising uptake results in development contexts. Dispenser programs include a tank of chlorine with a dosing valve that is installed next to a water source, a local Promoter who conducts community education and refills the Dispenser, and chlorine refills. In collaboration with response organizations, we assessed the effectiveness of Dispensers in four emergency situations.

In the three initial and four sustained response phase evaluations, 70 Dispenser sites were visited, 2,057 household surveys were conducted, and 1,676 water samples were analyzed. Across the evaluations, reported Dispenser use ranged from 9-97%, confirmed Dispenser use (as measured by free chlorine residual) ranged from 5-87%, and effective use (as measured by improvement in household water quality to meet international standards) ranged from 0-81%.

More effective Dispenser interventions installed Dispensers at point-sources, maintained a high-quality chlorine solution manufacturing and distribution chain, maintained Dispenser hardware, integrated Dispensers projects within larger water programs, remunerated Promoters, had experienced project staff, worked with local partners to implement the project, conducted ongoing monitoring, and had a project sustainability plan. Our results indicate that Dispensers can be, but are not always, an appropriate strategy to reduce the risk of waterborne diseases in emergencies.

Effects of Source- versus Household Contamination of Tubewell Water on Child Diarrhea in Rural Bangladesh: A Randomized Controlled Trial. PLoS One, March 2015

Authors: Ayse Ercumen , Abu Mohd. Naser , Leanne Unicomb, Benjamin F. Arnold, John M. Colford Jr., Stephen P. Luby

Background - Shallow tubewells are the primary drinking water source for most rural Bangladeshis. Fecal contamination has been detected in tubewells, at low concentrations at the source and at higher levels at the point of use. We conducted a randomized controlled trial to assess whether improving the microbiological quality of tubewell drinking water by household water treatment and safe storage would reduce diarrhea in children <2 years in rural Bangladesh.

Methods - We randomly assigned 1800 households with a child aged 6-18 months (index child) into one of three arms: chlorine plus safe storage, safe storage and control. We followed households with monthly visits for one year to promote the interventions, track their uptake, test participants’ source and stored water for fecal contamination, and record caregiver-reported child diarrhea prevalence (primary outcome). To assess reporting bias, we also collected data on health outcomes that are not expected to be impacted by our interventions.

Findings - Both interventions had high uptake. Safe storage, alone or combined with chlorination, reduced heavy contamination of stored water. Compared to controls, diarrhea in index children was reduced by 36% in the chlorine plus safe storage arm (prevalence ratio, PR = 0.64, 0.55-0.73) and 31% in the safe storage arm (PR = 0.69, 0.60-0.80), with no difference between the two intervention arms. One limitation of the study was the non-blinded design with self-reported outcomes. However, the prevalence of health outcomes not expected to be impacted by water interventions did not differ between study arms, suggesting minimal reporting bias.

Conclusions - Safe storage significantly improved drinking water quality at the point of use and reduced child diarrhea in rural Bangladesh. There was no added benefit from combining safe storage with chlorination. Efforts should be undertaken to implement and evaluate long-term efforts for safe water storage in Bangladesh.


Sustainability and scale-up of household water treatment and safe storage practices: Enablers and barriers to effective implementation. International Journal of Hygiene and Environmental Health, March 2015.

Authors: Edema Ojomo, Mark Elliott, Lorelei Goodyear, Michael Forson, Jamie Bartram

Household water treatment and safe storage (HWTS) options provide a solution, when employed correctly and consistently, for managing water safety at home. However, despite years of promotion by non-governmental organizations (NGOs), governments and others, boiling is the only method to achieve scale. Many HWTS programs have reported strong initial uptake and use that then decreases over time. This study maps out enablers and barriers to HWTS sustainability and scale-up.

Interviews were carried out with 72 HWTS practitioners who had direct experience with HWTS programs in over 25 countries. A total of 47 enablers and barriers important to sustaining and scaling up HWTS practices were identified. These were grouped into six domains: (1) user guidance on HWTS products; (2) resource availability; (3) standards, certification and regulations; (4) integration and collaboration; (5) user preferences; and (6) market strategies.

Collectively, the six domains cover the major aspects of moving products from development to the consumers. It is important that each domain is considered in all programs that aim to sustain and scale-up HWTS practices. The findings described in this paper can aid governments, NGOs, and other organizations involved in HWTS to approach programs more effectively and efficiently.

Water, sanitation and hygiene in health care facilities: Status in low- and middle-income countries and way forward, 2015. WHO; United Nations’ Children’s Fund.

The findings in this first multi-country review of water, sanitation and hygiene (WASH) services in health care facilities are sobering. Drawing on data from 54 low- and middle-income countries, the report concludes that 38% lack access to even rudimentary levels of water, 19% lack sanitation and 35% do not have water and soap for handwashing.

When a higher level of service is factored in, the situation deteriorates significantly. A number of areas require urgent action and WHO will work with UNICEF, Governments and other partners to develop a global plan to address the most pressing needs and ensure that all health care facilities have WASH services.

Preventing diarrhoea through better water, sanitation and hygiene: exposures and impacts in low- and middle-income countries, 2014. World Health Organization.


  • Direct use of drinking-water from unimproved sources (without household water treatment)ranged from 3% to 38% by region, with an overall average of 12% among LMICs. Regional averages for access to piped water on premises ranged from 19% to 88%, with an LMIC average of 49% (Table 1), although this figure includes intermittent and poorly managed piped supplies which may be microbially compromised.
  • Use of unimproved sanitation facilities ranged from 13% to 65% by region (Table 2). This proportion includes those who share an improved facility among two or more households.
  • Approximately 19% of the world’s population washes hands with soap after contact with excreta. This proportion is estimated to range between 13% and 17% in LMIC regions, and from 43% to 49% in high-income regions (Figure 13).

Impacts of interventions

  • A modest reduction in diarrhoea (e.g. 11–16%) can be achieved through use of basic improved water or sanitation facilities, such as protected wells or improved latrines (Figures 6 and 11). The health benefit is limited because these drinking-water sources may be microbially contaminated and because basic sanitation may not adequately protect the wider community from exposure to excreta.

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Reducing childhood illness – fostering growth : an integrated home-based intervention package (IHIP) to improve indoor-air pollution, drinking water quality and child nutrition, 2014.

Author: Hartinger Peña.

The goal of this PhD thesis was to assess the efficacy of an Integrated Environmental Home-based-Intervention Package (IHIP), comprised of an improved chimney stoves, access to safe drinking water from solar radiation household water treatment (SODIS), and hygiene education interventions, to reduce morbidity of acute respiratory infections, diarrhoea and poor growth of rural Peruvian children under three years of age. We implemented a community-randomised control field trial (cRCT) in 51 community’s clusters of the San Marcos Province, Cajamarca Region, Peru.

The cRCT was divided as follows: * Set-up, community selection and participatory intervention development: A pilot study was carried out for the selection of the interventions. These were adapted to local customs. The participatory phase is described in detail in Chapters 4 & 5. * Randomization, enrolment and baseline data collection: Chapter 6 describes the randomisation, enrolment and baseline in detail. * Carbon monoxide (CO) and Particulate Matter (PM2.5) household air quality assessment: Chapter 7 & 8 describe the efficacy of the OPTIMA-improved stove in improving household air quality in comparison to traditional open fire stoves. * Morbidity surveillance and field data acquisition: Morbidity data on the daily occurrence of signs and symptoms diarrhoea and respiratory illnesses of children was collected weekly. Anthropometric every two months and microbial data every 6 months. Chapter 9 describes the IHIP impact on morbidity reduction. * Workshops for a community-driven sustainable dessimination: Chapter 10 describes the community workshops and dissemination processes and dynamics within a socio-ecological framework.

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Differences in Field Effectiveness and Adoption between a Novel Automated Chlorination System and Household Manual Chlorination of Drinking Water in Dhaka, Bangladesh: A Randomized Controlled Trial. PLoS One, March 2015.

Authors: Amy J. Pickering , Yoshika Crider, Nuhu Amin, Valerie Bauza, Leanne Unicomb, Jennifer Davis, Stephen P. Luby

The number of people served by networked systems that supply intermittent and contaminated drinking water is increasing. In these settings, centralized water treatment is ineffective, while household-level water treatment technologies have not been brought to scale. This study compares a novel low-cost technology designed to passively (automatically) dispense chlorine at shared handpumps with a household-level intervention providing water disinfection tablets (Aquatab), safe water storage containers, and behavior promotion.

Twenty compounds were enrolled in Dhaka, Bangladesh, and randomly assigned to one of three groups: passive chlorinator, Aquatabs, or control. Over a 10-month intervention period, the mean percentage of households whose stored drinking water had detectable total chlorine was 75% in compounds with access to the passive chlorinator, 72% in compounds receiving Aquatabs, and 6% in control compounds. Both interventions also significantly improved microbial water quality. Aquatabs usage fell by 50% after behavioral promotion visits concluded, suggesting intensive promotion is necessary for sustained uptake. The study findings suggest high potential for an automated decentralized water treatment system to increase consistent access to clean water in low-income urban communities.

Laboratory development and field testing of sentinel toys to assess environmental faecal exposure of young children in rural India. Trans R Soc Trop Med Hyg, March 16, 2015.

Authors: Belen Torondel, Yaw Gyekye-Aboagye, Parimita Routray, Sophie Boisson, Wolf Schimdt and Thomas Clasen

Background – Sentinel toys are increasingly used as a method of assessing young children’s exposure to faecal pathogens in households in low-income settings. However, there is no consensus on the suitability of different approaches.

Methods – We evaluated three types of toy balls with different surfaces (plastic, rubber, urethane) in the laboratory to compare the uptake of faecal indicator bacteria (Escherichia coli) on their surface. We performed bacteria survival analysis under different environmental conditions and tested laboratory methods for bacteria removal and recovery. In a field study we distributed sterile urethane balls to children <5 from 360 households in rural India. After 24 hours, we collected and rinsed the toys in sterile water, assayed for thermotolerant coliforms (TTC) and explored associations between the level of contamination and household characteristics.

Results – In the laboratory, urethane foam balls took up more indicator bacteria than the other balls. Bacteria recovery did not differ based on mechanic vs no agitation. Higher temperatures and moisture levels increased bacterial yield. In the field, the only factor associated with a decreased recovery of TTC from the balls was having a soil (unpaved) floor.

Conclusions – Sentinel toys may be an effective tool for assessing young children’s exposure to faecal pathogens. However, even using methods designed to increase bacterial recovery, limited sensitivity may require larger sample sizes.


Microbial Removals by a Novel Biofilter Water Treatment System. Am Jnl Trop Med Hyg, March 2015.

Authors: Christopher Wendt, Rebecca Ives, Anne L. Hoyt, Ken E. Conrad, Stephanie Longstaff, Roy W.Kuennen, and Joan B. Rose

Two point-of-use drinking water treatment systems designed using a carbon filter and foam material as a possible alternative to traditional biosand systems were evaluated for removal of bacteria, protozoa, and viruses. Two configurations were tested: the foam material was positioned vertically around the carbon filter in the sleeve unit or horizontally in the disk unit. The filtration systems were challenged with Cryptosporidium parvum, Raoultella terrigena, and bacteriophages P22 and MS2 before and after biofilm development to determine ALR for each organism and the role of the biofilm.

There was no significant difference in performance between the two designs,and both designs showed significant levels of removal (at least 4 log10 reduction in viruses, 6 log10 for protozoa, and 8 log10 for bacteria). Removal levels meet or exceeded Environmental Protection Agency (EPA) standards for microbial purifiers. Exploratory test results suggested that mature biofilm formation contributed 1–2 log10 reductions. Future work is recommended to determine field viability.

Monitoring Drinking Water, Sanitation, and Hygiene in Non-Household Settings: Priorities for Policy and Practice. International Journal of Hygiene and Environmental Health, 11 March 2015.

Authors: Ryan Cronk, Tom Slaymaker, Jamie Bartram

Inadequate drinking water, sanitation, and hygiene (WaSH) in non-household settings, such as schools, health care facilities, and workplaces impacts the health, education, welfare, and productivity of populations, particularly in low and middle-income countries. There is limited knowledge on the status of WaSH in non-household settings. To address this gap, we reviewed international standards, international and national actors, and monitoring initiatives; developed the first typology of non-household settings; and assessed the viability of monitoring.

Based on setting characteristics, non-household settings include seven types: schools, health care facilities, workplaces, temporary use settings, mass gatherings, and dislocated populations. To-date national governments and international actors have focused monitoring of non-household settings on schools and health care facilities with comparatively little attention given to other settings such as workplaces and markets. Nationally representative facility surveys and national management information systems are the primary monitoring mechanisms. Data suggest that WaSH coverage is generally poor and often lower than in corresponding household settings.

Definitions, indicators, and data sources are underdeveloped and not always comparable between countries. While not all countries monitor non-household settings, examples are available from countries on most continents suggesting that systematic monitoring is achievable in most countries. Monitoring WaSH in schools and health care facilities is most viable. Monitoring WaSH in other non-household settings would be viable with: technical support from local and national actors in addition to international organizations such as WHO and UNICEF; national prioritization through policy and financing; and including WaSH indicators into monitoring initiatives to improve cost-effectiveness.

International consultations on targets and indicators for global monitoring of WaSH post-2015 identified non-household settings as a priority. National and international monitoring systems will be important to better understand status, trends, to identify priorities and target resources accordingly, and to improve accountability for progressive improvements in WaSH in non-household settings.