Does clean water matter? An updated meta-analysis of water supply and sanitation interventions and diarrhoeal diseases

June 24, 2013 · 0 comments

Does clean water matter? An updated meta-analysis of water supply and sanitation interventions and diarrhoeal diseases. Lancet, June 17, 2013.

Rebecca E Engell, Stephen S Lim

Background – There is conflicting evidence on the effect of water and sanitation interventions on diarrhoeal diseases. Quantification of their impact is complicated by the different comparison groups used across epidemiological studies and the combination of interventions examined under the umbrella of improved water or sanitation.

Methods – We conducted an updated review of epidemiological studies on the effect of water and sanitation interventions on self-reported diarrhoea episodes. We supplemented existing reviews with a Google Scholar search for studies published between 2010 and March, 2012. 84 studies were used in a meta-analysis that was designed to adjust for intervention and baseline group characteristics. First, we compared indicator variables for each intervention component (improved sanitation, hygiene, point-of-use water treatment, source water treatment, and piped water) with a reference category (improved water source). Second, we also included indicator variables for the baseline characteristics—ie, whether the baseline was an unimproved or improved water source or sanitation—as covariates to account for the heterogeneous control groups. Subanalyses were conducted to investigate differential effects by type of intervention and age.

Findings – Significant effects were found for both improved water and improved sanitation relative risks: 1·34 (95% CI 1·02—1·72) and 1·33 (1·02—1·74), respectively. We did not find significantly greater effects of piped water or source water treatment compared with improved water supply (p=0·50 and p=0·65, respectively) or significant effects by age (p=0·19). Furthermore, we found no difference in point-of-use interventions when blinding was taken into account (p=0·08). Unimproved water and sanitation together accounted for 0·9% (0·4—1·6) of global disability-adjusted life-years in 2010, ranking 22nd and 26th, respectively, in terms of top global risks. These proportions are substantially smaller than 6·8% in 1990, and 3·7% in 2000, estimated in previous Global Burden of Disease studies for water, sanitation, and hygiene combined.

Interpretation – Our reanalysis of quasi-experimental and experimental studies suggests much smaller impacts of water and sanitation interventions than previously thought. Given the emphasis placed on these interventions in improving livelihood, continued epidemiological research to assess the full effects of such interventions remains imperative.

Chris Holmes – Water: A Unifying Issue: USAID’s New Global Water Strategy

June 21, 2013 · 0 comments

Chris Holmes – Water: A Unifying Issue: USAID’s New Global Water Strategy | Source: USAID IMPACT Blog, June 19, 2013 |

In late May, when USAID launched its first global water strategy, Administrator Shah, Democrats and Republicans alike agreed on the message: solving the water and sanitation crises is critical. The goal of the USAID Water and Development Strategy is to save lives and improve development in a world where practically 800 million people are without adequate water and 2.5 billion people are without access to adequate sanitation. To achieve its goal, the strategy sets out two overarching strategic objectives: improve global health and strengthen global food security through USAID-supported water programs.

Chris Holmes serves as USAID’s Global Water Coordinator.

Partnering with faith-based and community organizations—as well as other stakeholders – is critical to meeting these objectives. It is through partnerships that we combine the resources, expertise and wisdom necessary to meet the needs of literally billions of people.

Last week I had the opportunity to participate in a conference call hosted by Ms. Melissa Rogers, Executive Director of the White House Office of Faith-based and Neighborhood Partnerships. Participants on the call included WASH Advocates, Blood: Water Mission, the Millennium Water Alliance, EROD, PATH, American Jewish Joint Distribution Committee, World Vision, International Orthodox Christian Charities, Episcopal Relief and Development, Catholic Relief Services, Engineering Ministries International and Lifewater International.  During our call, we covered a wide range of activities—partnerships— to save and improve lives.  One participant noted that it was exciting to see the strategy’s emphasis on women, in particular engaging women in WASH programming and leadership as well as focusing the strategy on countries and regions where we can have greatest impact.  Others on the call addressed such matters as watershed management, evaluation, and the impact on NGOs of channeling development resources through national governments.

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A cluster-randomized trial assessing the impact of school water, sanitation and hygiene improvements

June 18, 2013 · 0 comments

Journal of Water, Sanitation and Hygiene for Development In Press, 2013

A cluster-randomized trial assessing the impact of school water, sanitation and hygiene improvements on pupil enrolment and gender parity in enrolment

Joshua V. Garn, Leslie E. Greene, Robert Dreibelbis, Shadi Saboori, Richard D. Rheingans and Matthew C. Freeman
E-mail: mcfreem@emory.edu

Abstract – We employed a cluster-randomized trial design to measure the impact of a school-based water, sanitation and hygiene (WASH) improvement on pupil enrolment and on gender parity in enrolment, in primary schools in Nyanza Province, Kenya (2007–2009). Among schools with poor water access during the dry season, those that received a water supply, hygiene promotion and water treatment (HP&WT) and sanitation improvement demonstrated increased enrolment (β = 0.091 [0.009, 0.173] p = 0.03), which translates to 26 additional pupils per school on average. The proportion of girls enrolled in school also increased by 4% (prevalence ratio (PR) = 1.04 [1.00, 1.07] p = 0.02). Among schools with better baseline water access during the dry season (schools that didn’t receive a water source), we found no evidence of increased enrolment in schools that received a HP&WT intervention (β = 0.016 [–0.039, 0.072] p = 0.56) or the HP&WT and sanitation intervention (β = 0.027 [–0.028, 0.082] p = 0.34), and there was no evidence of improved gender parity (PR = 0.99 [0.96, 1.02] p = 0.59, PR = 1.00 [0.97, 1.02] p = 0.75, respectively). Our findings suggest that increased school enrolment and improved gender parity may be influenced by a comprehensive WASH programme that includes an improved water source; schools with poor water access during the dry season may benefit most from these interventions.

An innovative approach to sharing knowledge about drinking water practices

June 18, 2013 · 1 comment

Journal of Water, Sanitation and Hygiene for Development, in Press, 2013

Returning knowledge to the community: an innovative approach to sharing knowledge about drinking water practices in a peri-urban community

C. Furlong,  and J. Tippett.
Email:  claire.furlong@ymail.com

During previous research into water quality in Peru, it was found that drinking water was becoming contaminated in households, and there was a lack of understanding surrounding this contamination. It was felt that returning these findings to the community could build capacity, enabling people to make more informed choices about drinking water practices. Several participatory methods were explored. Ketso®, a hands-on kit for engagement, was thought to provide the most appropriate approach, and was used to deliver several workshops in the community. Thirty-five participants explored their understanding of drinking water and factors that caused contamination. The method allowed them to explore these factors in depth and to develop several practical and simple solutions. One solution capitalized on a novel finding; participants associated the taste of chlorine with clean water, but were unaware that household bleach could be used as a cost-effective water treatment. Feedback was excellent, with Ketso seen as giving participants space to better understand and question their practices, whilst building capacity for change. This co-production of knowledge also allowed the researcher to gain a better understanding of local knowledge and perceptions. Such innovative knowledge exchange has important implications for future implementation of new water technologies and engineering projects.

Use of Certeza point-of-use water treatment product in Mozambique

June 18, 2013 · 2 comments

Journal of Water, Sanitation and Hygiene for Development, In Press, 2013

Use of Certeza point-of-use water treatment product in Mozambique

Jennifer Wheeler and Sohail Agha

Certeza, a branded and socially marketed point-of-use water treatment product consisting of diluted sodium hypochlorite solution, was launched in Mozambique by Population Services International (PSI) in 2004. Certeza is sold in 150-mL bottles at subsidized prices through the private sector and distributed for free during emergency situations. PSI also implements behavior change communication (BCC) activities to promote healthy behaviors related to water treatment. In 2007 and 2012, two large-scale, population-based surveys were conducted in selected districts to collect information from caregivers of children under the age of five on knowledge and use of water treatment products.

This study presents changes in water treatment indicators between 2007 and 2012 and an assessment of the effects of exposure to BCC interventions on water treatment behaviors in 2012. The findings show improvement in most water treatment behaviors, after controlling for differences in the two surveys. Notably, ever-use of Certeza increased from 17 to 30% and current use increased from 10 to 25%. These improvements were accompanied by improved social norms, knowledge, and self-efficacy relating to water treatment. Moreover, exposure to PSI interventions was associated with practicing water treatment behaviors (those specific to Certeza use and also general water treatment behaviors).

Water, sanitation, hygiene and enteric infections in children

June 18, 2013 · 1 comment

Water, sanitation, hygiene and enteric infections in children. Arch Dis Child doi:10.1136/archdischild-2011-301528

Joe Brown, Sandy Cairncross, Jeroen H J Ensink
Correspondence info: Dr Jeroen H J Ensink, Environmental Health Group, Faculty of Infectious and Tropical Diseases, London School of Hygiene and Tropical Medicine, Keppel Street, London WC1E 7HT, UK; Jeroen.ensink@lshtm.ac.uk

In this article, we review the evidence linking WSH measures to faecal-oral diseases in children. Although continued research is needed, existing evidence from the last 150 years supports extending life-saving WSH measures to at-risk populations worldwide. One recent estimate held that 95% of diarrhoeal deaths in children under 5 years of age could be prevented by 2025, at a cost of US$6.715 billion, through targeted scale-up of proven, cost-effective, life-saving interventions. These include access to safe and accessible excreta disposal, support for basic hygiene practices such as hand washing with soap, and provision of a safe and reliable water supply. We present estimates of the burden of WSH-related disease followed by brief overviews of water, sanitation and hygiene-related transmission routes and control measures. We conclude with a summary of current international targets and progress.

Diarrhoea, malnutrition and environmental enteropathy
Although great strides have been made in reducing diarrhoea mortality, especially as a result of the increased use of oral rehydration therapy (ORT), diarrhoea remains the second leading cause of death in children under 5 years of age, after pneumonia. It is responsible for an estimated 1.7 billion cases of diarrhoea, or on average 2.9 episodes/child/year, and an estimated 1.87 million deaths among children under 5 years of age.The highest burden of disease is in children in the age range of 6–11 months: 4.5 episodes/child/year. It has been estimated that 50% of diarrhoea deaths can be attributed to persistent diarrhoea,7 and while ORT can prevent many deaths from acute diarrhoeal diseases,8 access to appropriate treatment is often limited in resource-poor settings.

The relationship between diarrhoeal disease and malnutrition is complex, though it is well accepted that malnourished children suffer more frequent episodes of diarrhoeal disease, while a child’s nutritional status is affected following a diarrhoeal episode. A multiple country study found that 25% of stunting in children aged 24 months could be attributable to five or more diarrhoeal episodes experienced in the first 2 years of life. Malnutrition and stunting can lead to poorer school performance, early school drop-out and, as a result, lower economic well-being in later life. Over 440 million school days are missed annually due to WSH-related illnesses. Extended exposure to faecal pathogens may, in part, cause environmental enteropathy, a postulated condition characterised by malabsorption, villus atrophy, crypt hyperplasia, T-cell infiltration and general inflammation of the jejunum. This chronic infection of the small intestine could explain why sanitation may have a stronger association with gains in growth than with reductions in diarrhoea incidence.

More than a Drop in the Bucket: Decentralized Membrane Based Drinking Water Refill Stations

June 5, 2013 · 1 comment

More than a Drop in the Bucket: Decentralized Membrane Based Drinking Water Refill Stations in Southeast Asia. Environ. Sci. Technol., Publication Date (Web): 31 May 2013.

Laura C Sima, and Menachem Elimelech

Decentralized membrane-based water treatment and refill stations represent a viable and growing business model in Southeast Asia, which rely upon the purchase of water from refill stations by consumers. This feature article discusses these water treatment and refill stations, including the appropriateness of the technology, the suitability of the business models employed, and the long term environmental and operational sustainability of these systems. We also provide an outlook for the sector, highlighting key technical challenges that need to be addressed in order to improve the capacity of these systems, such that they can become an effective and financially viable solution to the clean water crisis

USAID/Kenya – Mobile phones and safe water filters

June 5, 2013 · 0 comments

Using Mobile Money to Make Water Safe | Source: Jill Luoto, The RAND Blog, May 23, 2013 |

Contaminated drinking water contributes to the deaths of some 750,000 children under the age of five every year due to diarrheal disease. As a result, there is a pressing need in the developing world for ways to make water safe to drink that are affordable and widely used.

A RAND project, with USAID funding, is using mobile phones to increase the sales and use of safe-water filters in Kenya. The ceramic filters are microbiologically effective and often preferred by users over chemical disinfection (e.g., adding chlorine to water).

photo by waterdotorg/Flickr.com

The filters, however, are not affordable for all who need them. Costing about $10 each, the filters are still a middle-class technology for the poorest of the poor. Many potential users also do not know if they will like the filter or how it works, which can further drive down their purchases.

To increase purchases and use of the filter, David Levine of UC-Berkeley and I are working with the Safe Water and AIDS Project of Kenya to use mobile banking and text messaging to market durable ceramic safe-water filters. The project combines a free product trial with a “rent to own” payment plan to overcome consumer uncertainty and liquidity constraints.

The project began in August 2012 and builds on my previous work regarding consumer preferences in safe water technologies. It takes advantage of new mobile health and banking innovations that have accompanied the exploding growth in mobile-phone access throughout the developing world. In Kenya, the mobile-banking system M-PESA is widespread, with 73 percent of the poor using its services in 2012.

The project includes a randomized control trial of 300 households in rural western Kenya. Half the households were offered the filter through door-to-door marketing and a lump-sum purchase. The other half were offered it through the mobile marketing plan and payments over time.

The mobile marketing plan has had a remarkable effect on initial acceptance of the technology: 52 percent of households accepted the free trial, compared to 16 percent of those reached through the traditional marketing plan.

The project offers several potential ways to sustain use of the filters after purchase, including text messages reminding customers about the benefits of the product while requesting installment payments. Results so far are mixed, in part because of intervening holidays, school sessions, and national elections that have made payment performance difficult for many.

Should the project ultimately be successful, it could expand to other development products and settings. By allowing consumers to pay a little at a time and using mobile phones to collect those payments, this approach can help increase adoption of products for which transaction costs would otherwise be too high.

Jill Luoto is an associate economist at the nonprofit, nonpartisan RAND Corporation.

 

Trial of a Household UV-Disinfection and Safe Storage Drinking Water Intervention

June 5, 2013 · 1 comment

Am J Trop Med Hyg. 2013 Jun 3.

A Stepped Wedge, Cluster-Randomized Trial of a Household UV-Disinfection and Safe Storage Drinking Water Intervention in Rural Baja California Sur, Mexico.

Gruber JS, Reygadas F, Arnold BF, Ray I, Nelson K, Colford JM Jr. University of California, Berkeley, Division of Epidemiology, Berkeley, California; University of California, Berkeley, Energy and Resources Group, Berkeley, California; Fundacion Cantaro Azul, La Paz, Mexico; University of California, Berkeley, Civil and Environmental Engineering, Berkeley, California.

Abstract
In collaboration with a local non-profit organization, this study evaluated the expansion of a program that promoted and installed Mesita Azul, an ultraviolet-disinfection system designed to treat household drinking water in rural Mexico. We conducted a 15-month, cluster-randomized stepped wedge trial by randomizing the order in which 24 communities (444 households) received the intervention. We measured primary outcomes (water contamination and diarrhea) during seven household visits.

The intervention increased the percentage of households with access to treated and safely stored drinking water (23-62%), and reduced the percentage of households with Escherichia coli contaminated drinking water (risk difference (RD): -19% [95% CI: -27%, -14%]). No significant reduction in diarrhea was observed (RD: -0.1% [95% CI: -1.1%, 0.9%]). We conclude that household water quality improvements measured in this study justify future promotion of the Mesita Azul, and that future studies to measure its health impact would be valuable if conducted in populations with higher diarrhea prevalence.

CNN – The link between saris and cholera

June 5, 2013 · 1 comment

The link between saris and cholera | Source: CNN Health, June 5, 2013

(CNN) — Cholera, a deadly diarrheal disease, has been rare in the United States since the early 1900s, but in the developing world, where access to clean drinking water is more difficult, it is still a serious problem.

Dr. Rita Colwell has studied cholera for nearly 50 years, and has written more than 700 publications and received at least 40 honorary degrees. The former director of the National Science Foundation and former president of the American Association for the Advancement of Science, Colwell is currently a distinguished professor at both the University of Maryland, College Park and Johns Hopkins University’s Bloomberg School of Public Health.

CNN spoke with Colwell about her research and how she and her team helped develop an incredibly simple method to help the people of rural Bangladesh have cleaner, safer drinking water. The following is an edited portion of that interview.

Rita Colwell, shown here in the laboratory, helped discover that simple filtration can be a key to reducing cholera

CNN: Tell me about cholera.

Colwell: Cholera is … transmitted by water. The bacteria that causes the disease … (naturally occurs) in the aquatic environment. That’s a discovery that my laboratory made some 25 to 30 years ago. When ingested, it attaches to the intestine and a toxin is most frequently produced. The result is severe vomiting, diarrhea and if a person doesn’t have their fluid replenished, dehydration and eventually death (results).

CNN: Is there an antibiotic for cholera?

Colwell: You can take an antibiotic. It’s generally susceptible to tetracycline, a broad-spectrum antibiotic, and other antibiotics. There’s been a discovery some years ago of what’s called oral rehydration therapy, ORT, whereby a mixture in water of table salt, bicarbonate of soda and table sugar is mixed in appropriate concentration and sipped. This replenishes the fluid loss and is very effective in treating cholera.

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