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.

Exposures

  • 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.

Presence of Pseudomonas aeruginosa in coliform-free sachet drinking water in Ghana. Food Control, 11 March 2015

Authors: Justin Stoler, Hawa Ahmed, Lady Asantewa Frimpong, Mohammed Bello

Highlights
• We tested the microbiological quality of 80 sachet water samples in low-income areas.
• Zero samples tested positive for fecal coliforms or E. coli.
• Poor-reputation brands were associated with higher heterotrophic bacteria plate counts.
• 41% of samples contained P. aeruginosa, regardless of brand reputation.
• The results signal an opportunity to revisit packaged water standards in West Africa.

Sachet water is now an important source of drinking water security in West Africa, and the sachet industry continues to mature as market share increasingly shifts from cottage industry players to high-volume corporate producers. Modern sachet production lines are prone to the development of biofilms, and traditional microbiological indicators of fecal water contamination may not capture all the potential risks to human health in such a widely-consumed product.

This study tested a sample of 80 sachets purchased along two commercial transects in low-income neighborhoods of Accra, Ghana, for total coliforms (TC), fecal coliforms (FC), Escherichia coli (EC), total heterotrophic bacteria (THB), and Pseudomonas aeruginosa (PA), and examined the relationship with brand reputation.

Just 5% of samples tested positive for TC, and none tested positive for FC and EC, yet 41% of samples tested positive for PA. After controlling for one popular brand, a negative brand reputation was associated with both THB presence (P = 0.015) and the number of samples with THB > 500 CFU/mL (P = 0.038), but PA was found in brands of both positive and negative reputations, and was only correlated with THB counts. The emergence of PA presents an opportunity for the re-evaluation of packaged water quality standards in a rapidly-globalizing, urban environment.

The Impact of Water, Sanitation, and Hygiene Interventions on the Health and Well-Being of People Living With HIV: A Systematic ReviewJAIDS Journal of Acquired Immune Deficiency Syndromes: 15 April 2015.

Authors: Yates, Travis MSc*; Lantagne, Daniele PhD*; Mintz, Eric MD†; Quick, Robert MD†

Background: Access to improved water supply and sanitation is poor in low-income and middle-income countries. Persons living with HIV/AIDS (PLHIV) experience more severe diarrhea, hospitalizations, and deaths from diarrhea because of waterborne pathogens than immunocompetent populations, even when on antiretroviral therapy (ART).

Methods: We examined the existing literature on the impact of water, sanitation, and hygiene (WASH) interventions on PLHIV for these outcomes: (1) mortality, (2) morbidity, (3) retention in HIV care, (4) quality of life, and (5) prevention of ongoing HIV transmission. Cost-effectiveness was also assessed. Relevant abstracts and articles were gathered, reviewed, and prioritized by thematic outcomes of interest. Articles meeting inclusion criteria were summarized in a grid for comparison.

Results: We reviewed 3355 citations, evaluated 132 abstracts, and read 33 articles. The majority of the 16 included articles focused on morbidity, with less emphasis on mortality. Contaminated water, lack of sanitation, and poor hygienic practices in homes of PLHIV increase the risk of diarrhea, which can result in increased viral load, decreased CD4 counts, and reduced absorption of nutrients and antiretroviral medication. We found WASH programming, particularly water supply, household water treatment, and hygiene interventions, reduced morbidity. Data were inconclusive on mortality. Research gaps remain in retention in care, quality of life, and prevention of ongoing HIV transmission. Compared with the standard threshold of 3 times GDP per capita, WASH interventions were cost-effective, particularly when incorporated into complementary programs.

Conclusions: Although research is required to address behavioral aspects, evidence supports that WASH programming is beneficial for PLHIV.

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, Mar 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.