The Impact of Water, Sanitation, and Hygiene Interventions on the Health and Well-Being of People Living With HIV: A Systematic Review

March 16, 2015 · 0 comments

The Impact of Water, Sanitation, and Hygiene Interventions on the Health and Well-Being of People Living With HIV: A Systematic Review. JAIDS 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 Bangladesh

March 4, 2015 · 0 comments

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.

Safe Water: It’s a Human Right

February 24, 2015 · 0 comments

Safe Water: It’s a Human Right, 2015.

Authors: Syed Emdadul Haque1,2 | Atsuro Tsutsumi1 | Capon Anthony1

1-United Nations University International Institute for Global Health (UNU-IIGH) UNU-IIGH Building, UKM Medical Centre, Jalan Yaacob Latiff, Bandar Tun Razak,Cheras 56000, Kuala Lumpur, MALAYSIA

2-University of Chicago Research Bangladesh, Dhaka, Bangladesh.

Author contact: Dr Syed Emdadul Haque; Email: emdad91@gmail.com

Already 2–3 billion people lack any access to safe drinking water and 884 million more are without sufficient access to a suitable water source, and yet, the situation could worsen still, (link). Indeed, without significant changes, two-thirds of the world’s population is expected to be living under “severe water stress conditions” by 2025, (link). Severe water stress is when there is less than 1,000 cubic meters of water available per person in a given year. This is an alarming prospect for the world’s population.

A recently published article quotes the vice minister at the Ministry of Water Recourses in China who stated that about two-thirds of Chinese cities are “water needy” and nearly 300 million rural people lack access to safe drinking water, (link). In addition, the National Intelligence Council (NIC) reported in “Global Trends 2030: Alternative Worlds” that with regard to China, “climate change, urbanization trends and middle-class lifestyles will create huge water demand and crop shortages by 2030.” 

These issues can create big economic, health, and social problems. According to the Ministry of Supervision, about 60,000 premature deaths already are happening due to water pollution accidents annually. Therefore, experts say that the Chinese government should make more of an effort for the rational use of water and to control its pollution.

Water scarcity continues to pose the greatest challenge in the developing world. Although large infrastructure-intensive water systems are prevalent in industrialized countries, for many developing nations such systems are too expensive to install and operate. For example, the United States spends about US$29 billion every year (link) to maintain its water and wastewater plants and it is obvious that the developing world does not have the kind of money it takes to provide safe water for its population.

Climate change and impacts on safe water

In many countries, climate change is another factor impacting safe water supplies. Water is a key medium through which climate change affects human populations and ecosystems, especially because of expected changes in water quality and quantity, notes the United Nations Expert on Human Rights, Water and Sanitation, (link). Indeed, in many regions of the world, changes to the supply and quality of freshwater resources resulting from climate change may endanger sustainable development, poverty reduction, and child mortality goals, the Intergovernmental Panel on Climate Change (IPCC) has warned, (link).

The IPCC stated that scientists predict nearly one-third of the planet’s land surface will suffer due to extreme drought by the end of this century and 20% of the world population could be affected by severe flooding by 2080. It is therefore essential to consider the direct effects of climate change on water resources as well as its indirect influences on other external drivers of change. Climate change amplifies pressure on governments to deal with the existing threats to the already fragile sustainability of freshwater resources — population growth, socioeconomic and technological changes, and the resulting rising demand for water.

There is considerable variation among the projections and scenarios concerning the impact of climate change on water resources. However, it is clear that it will increase water stress in already dry areas and will undermine water quality in areas flooded by rain or seawater. Also, rising water temperatures, both higher and lower groundwater levels, floods and droughts can all increase the threats from pathogens, chemical substances and radiological hazards in drinking water.

For example, flooding can cause overflows from sewage treatment plants into freshwater sources, which could contaminate certain food crops with pathogen-containing feces, (link). In addition, many scientists predict that sea-level rise can lead to saltwater interruption into groundwater drinking supplies, especially in low-lying, gently sloping coastal areas which will creates scarcity of safe water. On the other hand, droughts affecting agriculture can impact food production and might cause severe malnutrition, (link).

The right to clean water

Access to clean water was declared a human right on 28 July 2010 by the UN General Assembly (A/RES/64/292), receiving 122 votes in favour and zero votes against, (link). The right to water is also implicit in Article 11 of the International Covenant on Economic, Social and Cultural Rights as interpreted by the Committee on Economic, Social and Cultural Rights, which comments that, (link) “the human right to water entitles everyone to sufficient, safe, acceptable, physically accessible and affordable water for personal and domestic uses”.

However, safe water is a vital human rights concern in urban slums worldwide. Rapidly growing urbanization and overcrowding increase already heavy demands for fresh water. The Asia-Pacific region is home to 60 percent of the world’s population but it possesses only 36 percent of Earth’s water resources. Water availability, allocation, and quality remain major issues in the Asian region. Access to safe drinking water is limited and water shortages can pose a real threat to the daily life and the health of communities.

For many of those who have access to water, it is either too expensive or not suitable for consumption and is often exposed to dangerous levels of biological contaminants and chemical pollutants. This is due in part to the inadequate management of urban, industrial, and agricultural wastewater.

Simply put, for many people water is not yet a human right within comprehension. In coming years, water challenges will increase significantly as because of population growth and rising incomes will lead to greater water consumption, as well as more waste. According to the UN World Water Development Report, (link), by 2050 at least one in four people are likely to live in a country affected by chronic or recurring shortages of fresh water.

Access to safe water should therefore no longer be seen as a service, but, since it is a human right, states and organizations must work towards using economic resources and technology to provide safe, clean, accessible and affordable water, particularly in developing countries. Thus, it is urgent to think about the national and global water consumption policy for the decision-makers to tackle the future crisis. In addition, policy-driven researchers may introduce low cost solutions through public private partnerships.

Household Water Treatment and Safe Storage to Prevent Diarrheal Disease in Developing Countries

February 18, 2015 · 0 comments

Household Water Treatment and Safe Storage to Prevent Diarrheal Disease in Developing Countries. Current Environmental Health Reports, January 2015

Author: Thomas Clasen JD, PhD

Household water treatment and safe storage (HWTS), such as boiling, filtering, or chlorinating water at home, have been shown to be effective in improving the microbiological quality of drinking water. However, estimates of their protective effect against diarrhea, a major killer, have varied widely.

While results may be exaggerated because of reporting bias, this heterogeneity is consistent with other environmental interventions that are implemented with varying levels of coverage and uptake in settings where the source of exposure represents one of many transmission pathways.

Evidence suggests that the effectiveness of HWTS can be optimized by ensuring that the method

  • is microbiologically effective;
  • making it accessible to an exposed population; and
  • securing their consistent and long-term use.

Water bags as a potential vehicle for transmitting disease in a West African capital, Bissau

February 18, 2015 · 0 comments

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

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.

Biosand water filters for floating villages in Cambodia: safe water does not prevent recontamination

February 18, 2015 · 0 comments

Biosand water filters for floating villages in Cambodia: safe water does not prevent recontamination. Journal of Water, Sanitation and Hygiene for Development, In Press, Uncorrected Proof © IWA Publishing 2015 | doi:10.2166/washdev.2015.120

Authors: K. D. Curry, M. Morgan, S. H. Peang and S. Seang

Bridgewater State University, 131 Summer Street, Bridgewater, MA 02325, USA E-mail: kcurry@bridgew.edu. Water for Cambodia, Siem Reap, Cambodia Mahidol University, Bangkok, Thailand. Kulara Water Co. Ltd., Tbaeng Kaeut Village, Siem Reap Province, Cambodia

Water for Cambodia used biosand filters (BSFs) to provide microbiologically safe drinking water for people in Moat Khla floating village in 2010 and 2011. All 189 families use the lake, which by WHO standards is deemed unsafe for drinking water. Surveys from December 2010 to February 2011 compared 40 families using BSFs and 40 families not using BSFs. Over 92% of BSF households and 90% of non-BSF households were using high-risk lake source water (>100 colonies Escherichia coli/100 mL). Only 2.5% of BSF households had filtered water with bacteria in the high-risk range and only 5% of these 40 households showed recontamination in their storage water.

Forty percent of non-BSF households had high-risk bacteria levels in their stored water, and most used no treatment. Storage water for non-BSF families showed a significant reduction in mean log10 E. coli levels compared to their lake source water. Stored water for non-BSF families showed recontamination even for UV-treated water and boiled river water. Recontamination occurs in both groups but is much less for BSF households highlighting the value of proper storage containers used by BSF households and the need for water and sanitation education for floating villages in Cambodia.

Explaining low rates of sustained use of siphon water filter: evidence from follow-up of a randomised controlled trial in Bangladesh

February 18, 2015 · 0 comments

Explaining low rates of sustained use of siphon water filter: evidence from follow-up of a randomised controlled trial in Bangladesh. Trop Med Intl Health, Jan 2015.

Authors: Nusrat Najnin, Shaila Arman, et al.

Objective – To assess sustained siphon filter usage among a low-income population in Bangladesh and study relevant motivators and barriers.

Methods – After a randomised control trial in Bangladesh during 2009, 191 households received a siphon water filter along with educational messages. Researchers revisited households after 3 and 6 months to assess filter usage and determine relevant motivators and barriers. Regular users were defined as those who reported using the filter most of the time and were observed to be using the filter at follow-up visits. Integrated behavioural model for water, sanitation and hygiene (IBM-WASH) was used to explain factors associated with regular filter use.

Results – Regular filter usage was 28% at the 3-month follow-up and 21% at the 6-month follow-up. Regular filter users had better quality water at the 6-month, but not at the 3-month visit. Positive predictors of regular filter usage explained through IBM-WASH at both times were willingness to pay >US$1 for filters, and positive attitude towards filter use (technology dimension at individual level); reporting boiling drinking water at baseline (psychosocial dimension at habitual level); and Bengali ethnicity (contextual dimension at individual level). Frequently reported barriers to regular filter use were as follows: considering filter use an additional task, filter breakage and time required for water filtering (technology dimension at individual level).

Conclusion – The technological, psychosocial and contextual dimensions of IBM-WASH contributed to understanding the factors related to sustained use of siphon filter. Given the low regular usage rate and the hardware-related problems reported, the contribution of siphon filters to improving water quality in low-income urban communities in Bangladesh is likely to be minimal.

Changing handwashing behaviour in southern Ethiopia: A longitudinal study on infrastructural and commitment interventions

February 4, 2015 · 0 comments

Changing handwashing behaviour in southern Ethiopia: A longitudinal study on infrastructural and commitment interventions. Soc Sci Med. 2015 Jan;124:103-14. doi: 10.1016/j.socscimed.2014.11.006.

Authors: Contzen N, Meili IH, Mosler HJ.

Improved hand hygiene efficiently prevents the major killers of children under the age of five years in Ethiopia and globally, namely diarrhoeal and respiratory diseases. Effective handwashing interventions are thus in great demand. Evidence- and theory-based interventions, especially when matched to the target population’s needs, are expected to perform better than common practice. To test this hypothesis, we selected two interventions drawing on a baseline questionnaire-study that applied the RANAS (Risk, Attitudes, Norms, Abilities, Self-regulation) approach and focused on the primary caregivers of households in four rural, water-scarce kebeles (smallest administrative units of Ethiopia) in southern Ethiopia (N = 462).

The two interventions were tested in combination with a standard education intervention in a quasi-experiment, as follows: kebele 1, education intervention, namely an f-diagram exercise, (n = 23); kebele 2, education intervention and public-commitment (n = 122); kebele 3, education intervention and tippy-tap-promotion (i.e. handwashing-station-promotion; n = 150); kebele 4, education intervention, public-commitment and tippy-tap-promotion (n = 113).

In kebeles 3 and 4, nearly 100% of the households followed the promotion and invested material and time to construct for themselves a tippy-tap. Three months after intervention termination, the tippy-taps were in use with water and soap being present in up to 83% of the households (kebele 4). Pre-post data analysis on self-reported handwashing revealed that the population-tailored interventions, and especially the tippy-tap-promotion, performed better than the standard education intervention.

Tendencies in observed behaviour and a recently developed implicit self-measure pointed to similar results. Changing people’s hand hygiene is known to be a challenging task, especially in a water-scarce environment. The present project suggests not only to apply theory and evidence to improve handwashing interventions’ effectiveness, but also emphasizes the relevance of tailoring interventions to the target population.

Reactivity in rapidly collected hygiene and toilet spot check measurements: a cautionary note for longitudinal studies.

February 4, 2015 · 0 comments

Reactivity in rapidly collected hygiene and toilet spot check measurements: a cautionary note for longitudinal studies. Am J Trop Med Hyg. 2015 Jan 7;92(1):159-62. doi: 10.4269/ajtmh.14-0306.

Authors: Arnold BF, Khush RS, et al.

Discreet collection of spot check observations to measure household hygiene conditions is a common measurement technique in epidemiologic studies of hygiene in low-income countries. The objective of this study was to determine whether the collection of spot check observations in longitudinal studies could itself induce reactivity (i.e., change participant behavior). We analyzed data from a 12-month prospective cohort study in rural Tamil Nadu, India that was conducted in the absence of any hygiene or toilet promotion activities.

Our data included hygiene and toilet spot checks from 10,427 household visits. We found substantial evidence of participant reactivity to spot check observations of hygiene practices that were easy to modify on short notice. For example, soap observed at the household’s primary handwashing location increased from 49% at enrollment to 81% by the fourth visit and remained at or above 77% for the remainder of the study.

Comparing willingness to pay for improved drinking-water quality using stated preference methods in rural and urban Kenya

February 4, 2015 · 0 comments

Comparing willingness to pay for improved drinking-water quality using stated preference methods in rural and urban kenya. Appl Health Econ Health Policy. 2015 Feb;13(1):81-94. doi: 10.1007/s40258-014-0137-2.

Authors: Brouwer R1, Job FC, van der Kroon B, Johnston R.

BACKGROUND: Access to safe drinking water has been on the global agenda for decades. The key to safe drinking water is found in household water treatment and safe storage systems.

OBJECTIVE: In this study, we assessed rural and urban household demand for a new gravity-driven membrane (GDM) drinking-water filter.

METHODS: A choice experiment (CE) was used to assess the value attached to the characteristics of a new GDM filter before marketing in urban and rural Kenya. The CE was followed by a contingent valuation (CV) question. Differences in willingness to pay (WTP) for the same filter design were tested between methods, as well as urban and rural samples.

RESULTS: The CV follow-up approach produces more conservative and statistically more efficient WTP values than the CE, with only limited indications of anchoring. The effect of the new filter technology on children with diarrhea is among the most important drivers behind choice behavior and WTP in both areas. The urban sample is willing to pay more in absolute terms than the rural sample irrespective of the valuation method. Rural households are more price sensitive, and willing to pay more in relative terms compared with disposable household income.

CONCLUSION: A differentiated marketing strategy across rural and urban areas is expected to increase uptake and diffusion of the new filter technology.

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