By Aparna Rau, Source: UNICEF Media Center : http://www.unicef.org/uganda/media_16796.html

Communities in the Dei fish landing site in the Panyamur Sub County of Uganda’s Nebbi District were falling prey to cholera outbreaks on a daily basis, due to consistently drinking contaminated water from Lake Albert. To tackle this troubling issue Water, Sanitation and Hygiene (WASH) experts at UNICEF Uganda sought to find innovative water solutions far different from those used in the past. Taking India’s idea of the Milk ATM one step further, UNICEF Uganda in partnership with Water Mission Uganda (WMU), created one of the first Water ATM’s in the country, launching the first pilot project in the Dei parish of Panyamur in December of 2013, which serves a population of over 8,000.

LifeLink, the Water ATM designed by the Danish  company Grundfos, enables villagers to purchase between 5 and 20 litres of clean water (100 UGX, or $3 cents for 20 litres), using a water key that allows for both mobile banking and point of sale payment. The ATM machine dispenses safe water. Raw surface water is directly pumped from Lake Albert through a filtered water treatment system, engineered by Water Missions International, which chlorinates to disinfect water from germs that cause water borne diseases; the clean water is then delivered to an elevated gravity pressure water tank, all using solar power technology.

Both a Water Agent and a security guard, selected from Dei parish community, have been trained to manage day-to-day ATM operations. The Water Agent is paid UGX 200,000 (or $58) as a monthly salary and 10 per cent of the sales made from the ATM. A Water Agent Manager from WMU supports the overall running of the system. When a key is used LifeLink automatically captures the data, enabling the system to monitor clean water usage, as well as its own performance from anywhere in the world, using a remote management web application. If an issue occurs that requires maintenance, an SMS and email message is sent to operations services staff to ensure that a consistently reliable water supply is available year round.

With the aim to inspire positive behaviour change, the Water ATM project includes a village health and hygiene promotion component, in which WASH volunteers from the community are trained to go door to door creating awareness on good practices in: hand washing, household and food cleanliness, and latrine usage. Since the introduction of both the Water ATM project and social mobilization campaign, there have been almost no incidents of cholera for the past two years, while over 60 per cent of households in the Dei parish have built and started using latrines.

Association of Supply Type with Fecal Contamination of Source Water and Household Stored Drinking Water in Developing Countries: A Bivariate Meta-analysis. Env Health Perspec, May 2015.

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Authors: Katherine F. Shields, Robert E.S. Bain, Ryan Cronk, Jim A. Wright, and Jamie Bartram

Background: Access to safe drinking water is essential for health. Monitoring access to drinking water focuses on water supply type at the source, but there is limited evidence on whether quality differences at the source persist in water stored in the household.

Objectives: To assess the extent of fecal contamination at the source and in household storedwater (HSW) and explore the relationship between contamination at each of these sampling points and water supply type.

Methods: A bivariate random-effects meta-analysis of 45 studies, identified through asystematic review, that reported either the proportion of samples free of fecal indicator bacteria and/or individual sample bacteria counts for source and HSW, disaggregated by supply type.

Results: Water quality deteriorated substantially between source and stored water. Mean percentage of contaminated samples (noncompliance) at the source was 46% (95% CI: 33, 60%) while mean noncompliance in HSW was 75% (95% CI: 64, 84%). Water supply type was significantly associated with noncompliance at the source (p < .001) and in HSW (p = 0.03). Source water (OR = 0.2; 95% CI: 0.1, 0.5) and HSW (OR = 0.3; 95% CI: 0.2, 0.8) from pipedsupplies had significantly lower odds of contamination when compared to non-piped water,potentially due to residual chlorine.

Conclusions: Piped water is less likely to be contaminated compared to other water supply typesat both the source and in HSW. A focus on upgrading water services to piped supplies may helpimprove safety, including for those drinking stored water.

Microbial quality of domestic water: following the contamination chain in a rural township in Kenya. Journal of Water, Sanitation and Hygiene for Development Vol 5 No 1 pp 39–49 © IWA Publishing 2015 doi:10.2166/washdev.2014.070

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Authors: Pauline W. Macharia, Paul T. Yillia, Wairimu A. Muia, Denis Byamukama and Norbert Kreuzinger

A study was undertaken in Njoro Township, Kenya to evaluate the extent to which drinking water was subjected to post-collection faecal contamination in low-income and high-income households. Boreholes were the main drinking water sources, accounting for roughly 70% singular access. The microbial quality of drinking water from the boreholes deteriorated from the point-of-collection through conveying containers of small-scale water vendors to household storage containers, irrespective of their income status.

The densities of Escherichia coli (EC) were relatively low at the point-of-collection – median (M): 18 CFU/100 mL, range (R): 0–220, n = 60 – increasing considerably in the containers of water vendors (M: 290 CFU/100 mL, R: 30–350) and slightly (M: 360 CFU/100 mL, R: 0–520) between vendors and low-income households, many of whom used the services of vendors unlike high-income households who relied on a piped system on premises (M: 40 CFU/100 mL, R: 0–500). Post-collection contamination was high in low-income households compared to high-income households but differences were not significant between the two household categories with and without household water treatment (HWT).

Different HWT methods in the two household categories significantly reduced faecal contamination, but unhygienic handling and poor storage practices afterwards caused recontamination. HWT and behavioural change measures need not selectively target household groups solely on the basis of their income status.

Contextual and sociopsychological factors in predicting habitual cleaning of water storage containers in rural Benin. Water Resour Res, March 2015.

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Authors: Andrea Stocker and Hans-Joachim Mosler

Recontamination of drinking water occurring between water collection at the source and the point of consumption is a current problem in developing countries. The household drinking water storage container is one source of contamination and should therefore be cleaned regularly. First, the present study investigated contextual factors that stimulate or inhibit the development of habitual cleaning of drinking water storage containers with soap and water. Second, based on the Risk, Attitudes, Norms, Abilities, and Self-regulation (RANAS) Model of behavior, the study aimed to determine which sociopsychological factors should be influenced by an intervention to promote habitual cleaning.

In a cross-sectional study, 905 households in rural Benin were interviewed by structured face-to-face interviews. A forced-entry regression analysis was used to determine potential contextual factors related to habitual cleaning. Subsequently, a hierarchical regression was conducted with the only relevant contextual factor entered in the first step (R2 5 6.7%) and the sociopsychological factors added in the second step (R2 5 62.5%).

Results showed that households using a clay container for drinking water storage had a significantly weaker habit of cleaning their water storage containers with soap and water than did households using other types of containers (b 5 20.10). The most important sociopsychological predictors of habitual cleaning were commitment (b 5 0.35), forgetting (b 5 20.22), and self-efficacy (b 5 0.14). The combined investigation of contextual and sociopsychological factors proved beneficial in terms of developing intervention strategies. Possible interventions based on these findings are recommended.

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

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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.

Water bags as a potential vehicle for transmitting disease in a West African capital, Bissau. Int. Health (2015) 7 (1): 42-48. doi: 10.1093/inthealth/ihu056, August 27, 2014

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Authors: Adriano A. Bordaloa,b,* and Ana Machadoa,b

aLaboratory of Hydrobiology and Ecology, Institute of Biomedical Sciences, University of Porto (ICBAS-UP), Rua Jorge Viterbo Ferreira, 228, 4050–313 Porto, Portugal
bCiimar-Centre of Marine and Environmental Research, Porto, Portugal
↵*Corresponding author: Tel: +351 220428181; Fax: +351 222062284; E-mail: bordalo@icbas.up.pt

Background – Street vendors of chilled packaged water have an increasing role in meeting the drinking water demand of people on the move in developing nations. Hygienic conditions can be questionable, and water quality screening scarce or non-existent.

Methods – In order to ascertain the quality of the packaged water sold by street vendors in Bissau, the capital of the Western African country Guinea-Bissau, water bags were screened in 2011 and during the 2012 cholera outbreak for key physical, chemical and microbiological parameters.

Results – Water used to fill the hand-filled hand-tied bags originated from communal tap water and melted ice. All samples (n=36) were microbiologically contaminated, although levels showed a pronounced variability (e.g. 7–493 372 cfu 250 ml−1 for Escherichia coli). In 2012, the fecal contamination levels increased (p<0.05), and Vibrio cholerae was detected in all water bags obtained from the neighborhood where the outbreak started.

Conclusion – Findings showed that all packaged water samples were unfit for human consumption and during the 2012 cholera outbreak represented a potential vehicle for the spread of the disease. The design of measures to decrease the risk associated to the consumption of highly contaminated chilled water is clearly required.

Hand-to-mouth contacts result in greater ingestion of feces than dietary water consumption in Tanzania: A quantitative fecal exposure assessment model. Environ. Sci. Technol., DOI: 10.1021/es505555f, Publication Date (Web): January 5, 2015

Authors: Mia Catharine Morgan Mattioli , Jennifer Davis , and Alexandria B. Boehm

Diarrheal diseases kill 1800 children under the age of five die each day, and nearly half of these deaths occur in sub-Saharan Africa. Contaminated drinking water and hands are two important environmental transmission routes of diarrhea-causing pathogens to young children in low-income countries. The objective of this research is to evaluate the relative contribution of these two major exposure pathways in a low-income country setting. A Monte Carlo simulation was used to model the amount of human feces ingested by children under five years old from exposure via hand-to-mouth contacts and stored drinking water ingestion in Bagamoyo, Tanzania.

Child specific exposure data were obtained from the USEPA 2011 Exposure Factors Handbook, and fecal contamination was estimated using hand rinse and stored water fecal indicator bacteria concentrations from over 1200 Tanzanian households. The model outcome is a distribution of a child’s daily dose of feces via each exposure route.

The model results show that Tanzanian children ingest a significantly greater amount of feces each day from hand-to-mouth contacts than from drinking water, which may help elucidate why interventions focused on water without also addressing hygiene often see little to no effect on reported incidence of diarrhea.

Microbial quality of domestic water: following the contamination chain in a rural township in Kenya. Journal of Water, Sanitation and Hygiene for Development, In Press, Uncorrected Proof © IWA Publishing 2014 | doi:10.2166/washdev.2014.070

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Authors: Pauline W. Macharia, Paul T. Yillia, Wairimu A. Muia, Denis Byamukama and Norbert Kreuzinger

Department of Biological Sciences, Egerton University, Njoro Campus, P.O. Box 536-20115 Egerton, Kenya E-mail: macharia.pauline@yahoo.com
International Institute for Applied Systems Analysis, Schlossplatz 1, Laxenburg A-2361, Austria
WSS Services (U) Ltd, P.O. Box 27755 Kampala, Uganda
Resources & Waste Management, Vienna University of Technology, Institute for Water Quality, Karlsplatz 13/226 Vienna, Austria

A study was undertaken in Njoro Township, Kenya to evaluate the extent to which drinking water was subjected to post-collection faecal contamination in low-income and high-income households. Boreholes were the main drinking water sources, accounting for roughly 70% singular access. The microbial quality of drinking water from the boreholes deteriorated from the point-of-collection through conveying containers of small-scale water vendors to household storage containers, irrespective of their income status.

The densities of Escherichia coli (EC) were relatively low at the point-of-collection – median (M): 18 CFU/100 mL, range (R): 0–220, n = 60 – increasing considerably in the containers of water vendors (M: 290 CFU/100 mL, R: 30–350) and slightly (M: 360 CFU/100 mL, R: 0–520) between vendors and low-income households, many of whom used the services of vendors unlike high-income households who relied on a piped system on premises (M: 40 CFU/100 mL, R: 0–500).

Post-collection contamination was high in low-income households compared to high-income households but differences were not significant between the two household categories with and without household water treatment (HWT). Different HWT methods in the two household categories significantly reduced faecal contamination, but unhygienic handling and poor storage practices afterwards caused recontamination. HWT and behavioural change measures need not selectively target household groups solely on the basis of their income status.

Safety of packaged water distribution limited by household recontamination in rural Cambodia. J Water Health. 2014 Jun.

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Holman EJ, Brown J.

Packaged water treatment schemes represent a growing model for providing safer water in low-income settings, yet post-distribution recontamination of treated water may limit this approach. This study evaluates drinking water quality and household water handling practices in a floating village in Tonlé Sap Lake, Cambodia, through a pilot cross-sectional study of 108 households, approximately half of which used packaged water as the main household drinking water source.

We hypothesized that households purchasing drinking water from local packaged water treatment plants would have microbiologically improved drinking water at the point of consumption. We found no meaningful difference in microbiological drinking water quality between households using packaged, treated water and those collecting water from other sources, including untreated surface water, however.

Households’ water storage and handling practices and home hygiene may have contributed to recontamination of drinking water. Further measures to protect water quality at the point-of-use may be required even if water is treated and packaged in narrow-mouthed containers.

Public Health and Social Benefits of at-house Water Supplies, 2013. DfID.

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Authors – Barbara Evans, et al.

Abstract – We carried out a mix of secondary and primary research to examine the hypothesis that access to an at-house water supply will deliver significantly greater health, social and economic benefits than those derived from a shared public water supply. Our research was based on a mix of literature review and field-base case studies. Fieldwork was carried out in three countries; Ghana, South Africa and Vietnam and used a mix of data collection methods, specifically a three-part household questionnaire, which included anthropometric measures and the measurement of water collection journeys, natural group discussions, and contextual checklists.

The relationship between water source, water usage and health and social outcomes is complex and mitigated by a range of contextual and intermediate factors. A fundamental challenge in comparing outcomes of at-house supplies with shared supplies lies with wealth as a confounder. In our analysis we were able to account for wealth effects to some extent because of the detailed household information we were able to collect. Nonetheless these challenges are significant.

In our research we focused on a two-step approach, looking at the relationship between distance to source and volumes of water consumed followed by an analysis of volumes of water carried/consumed and the health and social outcomes including hygiene practices. In this way we reduced the effect of wealth and other broader social contextual factors in the analysis. This was supplemented by the analysis of the relationship between source-type and water quality.

From our field data a strong theme was that households often used multiple water sources. This dimension of water usage has received only limited attention from researchers. It is likely that the use of multiple sources of water for different activities is a significant confounder and one of the reasons why research into the relationships between health outcomes and use of specific water sources has been inconclusive. We found a strong link between volumes of water consumed and the at-home-off-plot break point in services, but limited evidence of a distance-volume relationship once households were using off-plot supplies. We also found some evidence to suggest that where reliability of services is poor, the location of the water source may be less
significant than its performance characteristics.

In our study locations we found some evidence of households who access water from both private and public wells collecting higher quantities of water than users who access water from taps. Similarly we found strong evidence of a ‘break point’ in health outcomes between those who carried or who had previously carried water from outside the house and those who did not, relating to musculo-skeletal effects. Water quality was significantly better for those with piped water at home than those who carried water from elsewhere and stored it at home. The evidence on social benefits was limited but points to possible advantages to families who do not have to spend time carrying water but can spend time in leisure activities.

Overall the results from our research indicate that evidence for the detailed water quantity versus distance to source curve previously suggested is tenuous. The conclusion that at-house supplies are associated with higher consumption and health and social benefits is supported, but there is no evidence for the secondary drop in consumption at a fixed distance from home. In reality it seems most likely that the relationship between distance to source and volumes of water consumed is highly mediated by social and geographical factors. This suggests the quantity-distance curve is likely to be ‘displaced’ upwards or downwards in different contexts.

The headline conclusion from our research is that at-home water supply has significant, measurable benefits when compared with shared water supply outside the home provided that the service provided is reliable enough to ensure access to adequate quantities of water when required. Reliable at-home water supply results in higher volumes of water consumed, greater practice of key hygiene behaviours, a reduction in musculo-skeletal impacts associated with carrying water from outside the home, and improved water quality. This suggests a logical policy shift towards the promotion of reliable household access as the international benchmark for water supply.

For many governments, the implications of this are relatively simple. Where most people have access to reasonable quantities of water close to the home, there is a strong and compelling argument to focus investment in getting reliable water supplies into the home. In such cases, the outstanding challenges relate to improving our understanding of the relative risks associated with different dimensions of levels of service. For example, under what circumstances does a tap in the house have significant benefits over a tap in the yard? What is the relative risk associated with intermittent supply or low pressure of at-house piped supplies compared with private wells or shared supplies, if the latter can provide a more reliable service? A pressing gap in the literature relates to the water resources and cost implications of providing 24 hour supply in piped systems.

For some countries however, the challenge of moving to household supply as the benchmark level of service is more significant and will take time. In these locations (typically arid regions with limited water resources and limited access to capital funds) the policy emphasis may change more slowly. The clear policy message is that investments in water supply should be designed to enable a progressive move towards provision of household supplies even if this level of service cannot be achieved immediately. This might mean for example, designing point-source systems in such a way as to facilitate the addition of networks and house connections at a later date. In the post-2015 era, the available evidence suggests that access to reliable water supply at home should be the benchmark for water supply.