Household Drinking Water Quality Updates
PLOS Medicine and Water, Sanitation, and Hygiene: A Committed Relationship. PLoS Medicine, March 2014.
The PLOS Medicine Editors.
PLOS Medicine has long been committed to highlighting the key role of WASH in improving health. In 2009, we argued that clean water should be recognized as a human right . We maintain our stance that ensuring access to clean water could substantially reduce the global burden of disease; that the privatization of water—which exploits the view that water is a commodity rather than a public good—does not result in equitable access; and that climate change, population growth, agricultural development, and industrial pollution are all leading to increasing water scarcity, threatening the quality of the current water supply. We remain of the view that a human rights framework could galvanize international recognition, concerted action, and targeted funding to help ensure that water is safe, affordable, and accessible to everyone.
Then in 2010 we published our landmark series (organized by Jamie Bartram, Sandy Cairncross, and colleagues) on water and sanitation (http://plos.io/1dvtfOy). The series highlighted that although water, sanitation, and hygiene are development priorities, the ambition of international policy on drinking water and sanitation was inadequate and that the active involvement of health professionals in hygiene, sanitation, and water supply was crucial to accelerating and consolidating progress for health , factors still pertinent to 2014. The series concluded with a rallying call for all to recognize WASH as one of the key intervention strategies for reducing morbidity, mortality, and health care costs . The series also gave some targeted action points, such as how research funding agencies should consider how they could improve their support for critical research on WASH and health , a point that still holds true.
Assessing the Impact of Water Filters and Improved Cook Stoves on Drinking Water Quality and Household Air Pollution
Assessing the Impact of Water Filters and Improved Cook Stoves on Drinking Water Quality and Household Air Pollution: A Randomised Controlled Trial in Rwanda. PLoS One, March 2014.
Ghislaine Rosa, Fiona Majorin, et al.
Diarrhoea and respiratory infections remain the biggest killers of children under 5 years in developing countries. We conducted a 5-month household randomised controlled trial among 566 households in rural Rwanda to assess uptake, compliance and impact on environmental exposures of a combined intervention delivering high-performance water filters and improved stoves for free. Compliance was measured monthly by self-report and spot-check observations. Semi-continuous 24-h PM2.5 monitoring of the cooking area was conducted in a random subsample of 121 households to assess household air pollution, while samples of drinking water from all households were collected monthly to assess the levels of thermotolerant coliforms.
Adoption was generally high, with most householders reporting the filters as their primary source of drinking water and the intervention stoves as their primary cooking stove. However, some householders continued to drink untreated water and most continued to cook on traditional stoves. The intervention was associated with a 97.5% reduction in mean faecal indicator bacteria (Williams means 0.5 vs. 20.2 TTC/100 mL, p<0.001) and a median reduction of 48% of 24-h PM2.5 concentrations in the cooking area (p = 0.005). Further studies to increase compliance should be undertaken to better inform large-scale interventions.
Water Distribution System Deficiencies and Gastrointestinal Illness: A Systematic Review and Meta-Analysis
Water Distribution System Deficiencies and Gastrointestinal Illness: A Systematic Review and Meta-Analysis. Env Health Perspec, Mar 2014.
Authors: Ayse Ercumen, Joshua S. Gruber, and John M. Colford Jr.
Background: Water distribution systems are vulnerable to performance deficiencies that can cause (re)contamination of treated water and plausibly lead to increased risk of gastrointestinal illness (GII) in consumers.
Objectives: It is well established that large system disruptions in piped water networks can cause GII outbreaks. We hypothesized that routine network problems can also contribute to background levels of waterborne illnessand conducted a systematic review and meta-analysis to assess the impact of distribution system deficiencies on endemic GII.
Methods: We reviewed published studies that compare direct tap water consumption to consumption of tap water re-treated at the point of use (POU) and studies of specific system deficiencies such as breach of physical or hydraulic pipe integrity and lack of disinfectant residual.
Results: In settings with network malfunction, consumers of tap versus POU-treated water had increased GII (incidence density ratio (IDR) = 1.34; 95% CI: 1.00, 1.79). The subset of non-blinded studies showed a significant association between GII and tap versus POU-treated water consumption (IDR = 1.52; 95% CI: 1.05, 2.20), but there was no association based on studies that blinded participants to their POU water treatment status (IDR = 0.98; 95% CI: 0.90, 1.08). Among studies focusing on specific network deficiencies, GII was associated with temporary water outages (relative risk = 3.26; 95% CI: 1.48, 7.19) as well as chronic outages in intermittently operated distribution systems (odds ratio = 1.61; 95% CI: 1.26, 2.07).
Conclusions: Tap water consumption is associated with GII in malfunctioning distribution networks. System deficiencies such as water outages also are associated with increased GII, suggesting a potential health risk for consumers served by piped water networks.
A critique of boiling as a method of household water treatment in South India. Journal of Water and Health In Press, 2014 | doi:10.2166/wh.2014.010
Authors: Luke Juran and Morgan C. MacDonaldDepartment of Geography and Virginia Water Resources Research Center, Virginia Tech, 125 Major Williams Hall, Blacksburg, VA 24061, USA E-mail: email@example.com; firstname.lastname@example.org. School of Engineering, University of Guelph, 3120 Thornbrough, Guelph, ON N1G 2W1, Canada
This article scrutinizes the boiling of water in Tamil Nadu and Puducherry, India. Boiling, as it is commonly practiced, improves water quality, but its full potential is not being realized. Thus, the objective is to refine the method in practice, promote acceptability, and foster the scalability of boiling and household water treatment (HWT) writ large. The study is based on bacteriological samples from 300 households and 80 public standposts, 14 focus group discussions (FGDs), and 74 household interviews. Collectively, the data fashion both an empirical and ethnographic understanding of boiling. The rate and efficacy of boiling, barriers to and caveats of its adoption, and recommendations for augmenting its practice are detailed. While boiling is scientifically proven to eliminate bacteria, data demonstrate that pragmatics inhibit their total destruction. Furthermore, data and the literature indicate that a range of cultural, economic, and ancillary health factors challenge the uptake of boiling. Fieldwork and resultant knowledge arrive at strategies for overcoming these impediments. The article concludes with recommendations for selecting, introducing, and scaling up HWT mechanisms. A place-based approach that can be sustained over the long-term is espoused, and prolonged exposure by the interveners coupled with meaningful participation of the target population is essential.
Going to scale with safe water – what changes are needed to remove the barriers to scale? 2014.
By Urs Heierli and Paul Osborn, Discussion paper for 300in6.
Event the most successful projects – as described in the Hystra study: “Access to Safe Water for the Base of the Pyramid” look more like oases in the middle of a huge desert. It is unlikely that scaling these projects will lead to universal access. What is badly needed are not more oasis, but a greening of the desert in-between, and this requires significant changes from business as usual.
This discussion paper attempts to sketch out a change agenda and will describe what is needed to go to scale. Scaling-up is not a linear process of replicating successful models or pilot projects at a larger scale: it means to apply a much more holistic, better coordinated and orchestrated approach involving not only project partners but mainstream institutions of the society.
Evidence-based tailoring of behavior-change campaigns: increasing fluoride-free water consumption in rural Ethiopia
Evidence-based tailoring of behavior-change campaigns: increasing fluoride-free water consumption in rural Ethiopia with persuasion. Appl Psychol Health Well Being. 2014 Mar;6(1):96-118. doi: 10.1111/aphw.12018.
Authors: Huber AC1, Tobias R, Mosler HJ.
Two hundred million people worldwide are at risk of developing dental and skeletal fluorosis due to excessive fluoride uptake from their water. Since medical treatment of the disease is difficult and mostly ineffective, preventing fluoride uptake is crucial. In the Ethiopian Rift Valley, a fluoride-removal community filter was installed. Despite having access to a fluoride filter, the community used the filter sparingly. During a baseline assessment, 173 face-to-face interviews were conducted to identify psychological factors that influence fluoride-free water consumption. Based on the results, two behavior-change campaigns were implemented: a traditional information intervention targeting perceived vulnerability, and an evidence-based persuasion intervention regarding perceived costs.
The interventions were tailored to household characteristics. The campaigns were evaluated with a survey and analyzed in terms of their effectiveness in changing behavior and targeted psychological factors. While the intervention targeting perceived vulnerability showed no desirable effects, cost persuasion decreased the perceived costs and increased the consumption of fluoride-free water. This showed that altering subjective perceptions can change behavior even without changing objective circumstances. Moreover, interventions are more effective if they are based on evidence and tailored to specific households.
Designing and Piloting a Program to Provide Water Filters and Improved Cookstoves in Rwanda. PLoS One, March 2014.
Authors: Christina K. Barstow, Fidele Ngabo, Ghislaine Rosa, Fiona Majorin, Sophie Boisson, Thomas Clasen, Evan A. Thomas
Background – In environmental health interventions addressing water and indoor air quality, multiple determinants contribute to adoption. These may include technology selection, technology distribution and education methods, community engagement with behavior change, and duration and magnitude of implementer engagement. In Rwanda, while the country has the fastest annual reduction in child mortality in the world, the population is still exposed to a disease burden associated with environmental health challenges. Rwanda relies both on direct donor funding and coordination of programs managed by international non-profits and health sector businesses working on these challenges.
Methods and Findings – This paper describes the design, implementation and outcomes of a pilot program in 1,943 households across 15 villages in the western province of Rwanda to distribute and monitor the use of household water filters and improved cookstoves. Three key program design criteria include a.) an investment in behavior change messaging and monitoring through community health workers, b.) free distributions to encourage community-wide engagement, and c.) a private-public partnership incentivized by a business model designed to encourage “pay for performance”. Over a 5-month period of rigorous monitoring, reported uptake was maintained at greater than 90% for both technologies, although exclusive use of the stove was reported in only 28.5% of households and reported water volume was 1.27 liters per person per day. On-going qualitative monitoring suggest maintenance of comparable adoption rates through at least 16 months after the intervention.
Conclusion – High uptake and sustained adoption of a water filter and improved cookstove was measured over a five-month period with indications of continued comparable adoption 16 months after the intervention. The design attributes applied by the implementers may be sufficient in a longer term. In particular, sustained and comprehensive engagement by the program implementer is enabled by a pay-for-performance business model that rewards sustained behavior change.
Video Surveillance Captures Student Hand Hygiene Behavior, Reactivity to Observation, and Peer Influence in Kenyan Primary Schools
Video Surveillance Captures Student Hand Hygiene Behavior, Reactivity to Observation, and Peer Influence in Kenyan Primary Schools. PLoS One, March 2014.
Authors: Amy J. Pickering, Annalise G. Blum, Robert F. Breiman, Pavani K. Ram, Jennifer Davis
Background – In-person structured observation is considered the best approach for measuring hand hygiene behavior, yet is expensive, time consuming, and may alter behavior. Video surveillance could be a useful tool for objectively monitoring hand hygiene behavior if validated against current methods.
Methods – Student hand cleaning behavior was monitored with video surveillance and in-person structured observation, both simultaneously and separately, at four primary schools in urban Kenya over a study period of 8 weeks.
Findings – Video surveillance and in-person observation captured similar rates of hand cleaning (absolute difference <5%, p = 0.74). Video surveillance documented higher hand cleaning rates (71%) when at least one other person was present at the hand cleaning station, compared to when a student was alone (48%; rate ratio = 1.14 [95% CI 1.01–1.28]). Students increased hand cleaning rates during simultaneous video and in-person monitoring as compared to single-method monitoring, suggesting reactivity to each method of monitoring. This trend was documented at schools receiving a handwashing with soap intervention, but not at schools receiving a sanitizer intervention.
Conclusion – Video surveillance of hand hygiene behavior yields results comparable to in-person observation among schools in a resource-constrained setting. Video surveillance also has certain advantages over in-person observation, including rapid data processing and the capability to capture new behavioral insights. Peer influence can significantly improve student hand cleaning behavior and, when possible, should be exploited in the design and implementation of school hand hygiene programs.
Solar Disinfection of Pseudomonas aeruginosa in Harvested Rainwater: A Step towards Potability of Rainwater. PLoS One, Mar 2014.
Authors: Muhammad T. Amin, Mohsin Nawaz, Muhammad N. Amin, and Mooyoung Han
Efficiency of solar based disinfection of Pseudomonas aeruginosa (P. aeruginosa) in rooftop harvested rainwater was evaluated aiming the potability of rainwater. The rainwater samples were exposed to direct sunlight for about 8–9 hours and the effects of water temperature (°C), sunlight irradiance (W/m2), different rear surfaces of polyethylene terephthalate bottles, variable microbial concentrations, pH and turbidity were observed on P. aeruginosa inactivation at different weathers. In simple solar disinfection (SODIS), the complete inactivation of P. aeruginosa was obtained only under sunny weather conditions (>50°C and >700 W/m2) with absorptive rear surface. Solar collector disinfection (SOCODIS) system, used to improve the efficiency of simple SODIS under mild and weak weather, completely inactivated the P. aeruginosa by enhancing the disinfection efficiency of about 20% only at mild weather.
Both SODIS and SOCODIS systems, however, were found inefficient at weak weather. Different initial concentrations of P. aeruginosa and/or Escherichia coli had little effects on the disinfection efficiency except for the SODIS with highest initial concentrations. The inactivation of P. aeruginosa increased by about 10–15% by lowering the initial pH values from 10 to 3. A high initial turbidity, adjusted by adding kaolin, adversely affected the efficiency of both systems and a decrease, about 15–25%; in inactivation of P. aeruginosa was observed. The kinetics of this study was investigated by Geeraerd Model for highlighting the best disinfection system based on reaction rate constant. The unique detailed investigation of P. aeruginosa disinfection with sunlight based disinfection systems under different weather conditions and variable parameters will help researchers to understand and further improve the newly invented SOCODIS system.
A global brief on vector-borne diseases, 2014. World Health Organization.
Vector-borne diseases cause more than one million deaths each year. But death counts, though alarming, vastly underestimate the human misery and hardship caused by these diseases, as many people who survive infection are left permanently debilitated, disfigured, maimed, or blind.As vectors thrive under conditions where housing is poor, water is unsafe, and environments are contaminated with filth, these diseases exact their heaviest toll on the poor – the people left behind by development. Measures that control the vectors, the agents of disease, provide an excellent, but underutilized opportunity to help these people catch up.
Why “improved” water sources are not always safe. WHO Bulletin, April 2014.
Authors: Ameer Shaheed, Jennifer Orgill, Maggie A Montgomery, Marc A Jeuland & Joe Brown
Existing and proposed metrics for household drinking-water services are intended to measure the availability, safety and accessibility of water sources. However, these attributes can be highly variable over time and space and this variation complicates the task of creating and implementing simple and scalable metrics. In this paper, we highlight those factors – especially those that relate to so-called improved water sources – that contribute to variability in water safety but may not be generally recognized as important by non-experts.
Problems in the provision of water in adequate quantities and of adequate quality – interrelated problems that are often influenced by human behaviour – may contribute to an increased risk of poor health. Such risk may be masked by global water metrics that indicate that we are on the way to meeting the world’s drinking-water needs. Given the complexity of the topic and current knowledge gaps, international metrics for access to drinking water should be interpreted with great caution. We need further targeted research on the health impacts associated with improvements in drinking-water supplies.
The challenge of global water access monitoring: evaluating straight-line distance versus self-reported travel time among rural households in Mozambique
The challenge of global water access monitoring: evaluating straight-line distance versus self-reported travel time among rural households in Mozambique. Journal of Water and Health, Vol 12 No 1 pp 173–183, 2014.
Jeff C. Ho, Kory C. Russel and Jennifer Davis. Department of Civil and Environmental Engineering, Stanford University, 473 Via Ortega, Stanford, CA 94305, USA. E-mail: email@example.com
Woods Institute for the Environment, Stanford University, 473 Via Ortega, Stanford, CA 94305, USA
ABSTRACT – Support is growing for the incorporation of fetching time and/or distance considerations in the definition of access to improved water supply used for global monitoring. Current efforts typically rely on self-reported distance and/or travel time data that have been shown to be unreliable. To date, however, there has been no head-to-head comparison of such indicators with other possible distance/time metrics. This study provides such a comparison. We examine the association between both straight-line distance and self-reported one-way travel time with measured route distances to water sources for 1,103 households in Nampula province, Mozambique.
We find straight-line, or Euclidean, distance to be a good proxy for route distance (R2 = 0.98), while self-reported travel time is a poor proxy (R2 = 0.12). We also apply a variety of time- and distance-based indicators proposed in the literature to our sample data, finding that the share of households classified as having versus lacking access would differ by more than 70 percentage points depending on the particular indicator employed. This work highlights the importance of the ongoing debate regarding valid, reliable, and feasible strategies for monitoring progress in the provision of improved water supply services.
Household Water Treatment Uptake during a Public Health Response to a Large Typhoid Fever Outbreak in Harare
Household Water Treatment Uptake during a Public Health Response to a Large Typhoid Fever Outbreak in Harare, Zimbabwe. Am Jnl Trop Med Hyg, Mar 2014.
Authors: Maho Imanishi, et al.
Locally manufactured sodium hypochlorite (chlorine) solution has been sold in Zimbabwe since 2010. During October 1, 2011–April 30, 2012, 4,181 suspected and 52 confirmed cases of typhoid fever were identified in Harare. In response to this outbreak, chlorine tablets were distributed. To evaluate household water treatment uptake, we conducted a survey and water quality testing in 458 randomly selected households in two suburbs most affected by the outbreak.
Although 75% of households were aware of chlorine solution and 85% received chlorine tablets, only 18% had reportedly treated stored water and had the recommended protective level of free chlorine residuals. Water treatment was more common among households that reported water treatment before the outbreak, and those that received free tablets during the outbreak, but was not associated with chlorine solution awareness or use before the outbreak. Outbreak response did not build on pre-existing prevention programs.
Social Marketing of Water and Sanitation Products: A Systematic Review of Peer-reviewed Literature. Soc Sci Med, Mar 2014.
Authors: WD Evans, et al.
• Behaviors such as handwashing, and products such as those for oral rehydration treatment (ORT) can be marketed like commercial products
• There has been no systematic review of theory, research, and practice in this area
• We identified 32 articles over a 22 year period that met search criteria
• Evaluations show consistent improvements in behavioral mediators but mixed results in behavior change
• The quality of evaluations varied and more randomized controlled studies are needed
• Social marketing is a promising strategy to improve water and sanitation programs worldwide
Like commercial marketing, social marketing uses the 4 “Ps” and seeks exchange of value between the marketer and consumer. Behaviors such as handwashing, and products such as those for oral rehydration treatment (ORT), can be marketed like commercial products in developing countries. Although social marketing in these areas is growing, there has been no systematic review of the current state of practice, research and evaluation.
We searched the literature for published peer-reviewed studies available through major online publication databases. We identified manuscripts in the health, social science, and business literature on social marketing that used at least one of the 4 Ps of marketing and had a behavioral objective targeting the behaviors or products related to improving water and sanitation. We developed formalized decision rules and applied them in identifying articles for review. We initially identified 117 articles and reviewed a final set of 32 that met our criteria.
Social marketing is a widespread strategy. Marketing efforts have created high levels of awareness of health threats and solutions, including behavior change and socially marketed products. There is widespread use of the 4 Ps of marketing, with price interventions being the least common. Evaluations show consistent improvements in behavioral mediators but mixed results in behavior change.
Interventions have successfully used social marketing following widely recommended strategies. Future evaluations need to focus on mediators that explain successful behavior change in order to identify best practices and improve future programs. More rigorous evaluations including quasi-experimental designs and randomized trials are needed. More consistent reporting of evaluation results that permits meta-analysis of effects is needed.
Toys and toilets: cross-sectional study using children’s toys to evaluate environmental faecal contamination
Toys and toilets: cross-sectional study using children’s toys to evaluate environmental faecal contamination in rural Bangladeshi households with different sanitation facilities and practices. Trop Med Intl Health, March 2014.
Authors: Jelena Vujcic, et al.
Objective – To evaluate household faecal contamination using children’s toys among 100 rural Bangladeshi households categorised as ‘cleaner’ (toilet that reliably separates faeces from the environment and no human faeces in/around living space) or ‘less clean’ (no toilet or toilet that does not reliably separate faeces from the environment and human faeces in/around living space).
Methods – We distributed toy balls to each household and rinsed each study toy and a toy already owned by the household in 200 ml of Ringer’s solution. We enumerated faecal coliforms and faecal streptococci from each rinse using membrane filtration methods.
Results – Study toys from 39 cleaner households had lower mean faecal coliform contamination than toys from 61 less clean households (2.4 log10 colony-forming units (CFU)/200 ml vs. 3.2 log10 CFU/200 ml, P = 0.03). However, wealth measures explained a portion of this relationship. Repeat measures were moderately variable [coefficient of variation (CV) = 6.5 between two toys in the household at the same time, CV = 37.6 between toys in the household at two different times 3–4 days apart]. Too few households owned a non-porous toy to compare groups without risk of bias.
Conclusion – In rural Bangladesh, improved sanitation facilities and practices were associated with less environmental contamination. Whether this association is independent of household wealth and whether the difference in contamination improves child health merit further study. The variation found was typical for measures of environmental contamination, and requires large sample sizes to ascertain differences between groups with statistical significance.
Adaptation to Climate Change in Water, Sanitation and Hygiene Assessing risks and appraising options in Africa
Adaptation to Climate Change in Water, Sanitation and Hygiene: Assessing risks and appraising options in Africa, 2014.
Naomi Oates, et al. Overseas Development Institute.
This report presents the findings of research into the risks to delivery of WASH results posed by climate change in Africa, drawing on rapid case study reviews of WASH programming in Malawi, Sierra Leone and Tanzania. A separate Case Study Report provides further detail on country background and findings.
Water and Development Strategy: Implementation Field Guide, 2014. USAID.
This document is intended to serve as a reference tool to help Operating Units understand and apply the Strategy. The Guide provides an overview of:
- The intended procedures and expectations for operationalizing the Strategy and transitioning the Agency’s water portfolio to align with the Strategy
- Key principles, best practices, and approaches for programming related to the Strategy’s two SOs
- Specific funding parameters related to programming in each of the two SOs, including eligible attribution of water directive funding
- Expectations of Operating Units related to monitoring, evaluation, and reporting, including required indicators, the timing, and procedures for annual performance reporting
- Expected contributions of Operating Units to ongoing Agency knowledge management, collaboration, and learning in the water sector
Below are links to reports on the Sawyer Filter that were selected and reviewed by Ryan Rowe and Daniele Lantagne:
Baker, Derek. (2013). Merits and Limitations of the Sawyer Filter. (PDF, 132KB)
“The Sawyer Squeeze Filter for outdoor travelis convenient for water treatment. I think it would be great as a light‐weight,occasional‐use device. For disaster relief it would also make sense to distribute Sawyerfilters to make drinking water safer until permanent infrastructure can be reestablished.However as a long‐term water treatment device for remote rural areaswhere there is no supply chain and no one to pay for the replacement filter when thedonated one clogs or breaks, I think it would be unsuitable.”
Brune, Lia, et al. (2013). Monitoring and Evaluation of a Point-‐of-‐Use Water Treatment Pilot Project in the Peruvian Amazon. (PDF, 1.9MB)
CONAPAC is currently piloting a point-‐of-use (POU) water treatment system that incorporates a Sawyer membrane filter in three communities located on the Amazon and Napo river, The small population and distance between the homes of these communities has made the installation of water treatment plants an inefficient solution. As a result, these communities were selected for a pilot project to test the effectiveness of POU treatment systems in the area.
CAWST. (n.d.) Household Water Treatment and Safe Storage Product Sheet: Sawyer Point One (TM) Filter. (PDF, 152KB)
The Sawyer Point One® filter is a gravity membrane filtration technology that uses hollow fibre membranes to remove pathogens. It has a pore size of 0.1 microns, making it effective for removing bacteria, protozoa and helminths. The Point One® filter does not remove viruses (see Sawyer Point Zero Two Product Sheet for virus removal).
CAWST. (n.d.) Household Water Treatment and Safe Storage Product Sheet: Sawyer Point Zero Two(TM) Purifier. (PDF, 142KB)
The Sawyer Point Zero Two® filter is a gravity membrane filtration technology that uses hollow fibre membranes to remove pathogens from water. It has a pore size of 0.02 microns, making it effective for removing viruses, bacteria, protozoa and helminths.
MAP International. (2012). . Project 350 Plan: Part 1 of 4 – Safe Water for Rural Communities of Ecuador. (PDF, 5.2MB)
MAP International launched a Pure Water Pilot Project in 2010 to test the effects of filters on the health of rural communities. Communities from each of the three regions of Ecuador, the Coast, the Andes, and the Amazon,were included in this Pilot Project. In each community, ten families were carefully selected to use the filters, and to be community leaders. Each family received one filter, reaching a total of 50 families.
Various. (n.d.) . In Their Own Words: Comments from Around the World on the Use of Sawyer Filters. (PDF, 43KB)
An excerpt: “School attendance was about 72%. After we installed Sawyer filters into the school, the attendance increased to 90%” – Dr. Feroz Ismail, HASWA. HASWA has been providing clean water to families in Pakistan since the flooding occurred. The sharing model we use provides clean water for the children during the school day and at the end of the day each child brings a two liter bottle of clean water home to share with the family.
Effect of Water, Sanitation, and Hygiene on the Prevention of Trachoma: A Systematic Review and Meta-Analysis. PLoS Medicine, Feb 2014.
Authors: Meredith E. Stocks, et al.Background - Trachoma is the world’s leading cause of infectious blindness. The World Health Organization (WHO) has endorsed the SAFE strategy in order to eliminate blindness due to trachoma by 2020 through “surgery,” “antibiotics,” “facial cleanliness,” and “environmental improvement.” While the S and A components have been widely implemented, evidence and specific targets are lacking for the F and E components, of which water, sanitation, and hygiene (WASH) are critical elements. Data on the impact of WASH on trachoma are needed to support policy and program recommendations. Our objective was to systematically review the literature and conduct meta-analyses where possible to report the effects of WASH conditions on trachoma and identify research gaps. Methods and Findings - We systematically searched PubMed, Embase, ISI Web of Knowledge, MedCarib, Lilacs, REPIDISCA, DESASTRES, and African Index Medicus databases through October 27, 2013 with no restrictions on language or year of publication. Studies were eligible for inclusion if they reported a measure of the effect of WASH on trachoma, either active disease indicated by observed signs of trachomatous inflammation or Chlamydia trachomatis infection diagnosed using PCR. We identified 86 studies that reported a measure of the effect of WASH on trachoma. To evaluate study quality, we developed a set of criteria derived from the GRADE methodology. Publication bias was assessed using funnel plots. If three or more studies reported measures of effect for a comparable WASH exposure and trachoma outcome, we conducted a random-effects meta-analysis. We conducted 15 meta-analyses for specific exposure-outcome pairs. Access to sanitation was associated with lower trachoma as measured by the presence of trachomatous inflammation-follicular or trachomatous inflammation-intense (TF/TI) (odds ratio [OR] 0.85, 95% CI 0.75–0.95) and C. trachomatisinfection (OR 0.67, 95% CI 0.55–0.78). Having a clean face was significantly associated with reduced odds of TF/TI (OR 0.42, 95% CI 0.32–0.52), as were facial cleanliness indicators lack of ocular discharge (OR 0.42, 95% CI 0.23–0.61) and lack of nasal discharge (OR 0.62, 95% CI 0.52–0.72). Facial cleanliness indicators were also associated with reduced odds of C. trachomatis infection: lack of ocular discharge (OR 0.40, 95% CI 0.31–0.49) and lack of nasal discharge (OR 0.56, 95% CI 0.37–0.76). Other hygiene factors found to be significantly associated with reduced TF/TI included face washing at least once daily (OR 0.76, 95% CI 0.57–0.96), face washing at least twice daily (OR 0.85, 95% CI 0.80–0.90), soap use (OR 0.76, 95% CI 0.59–0.93), towel use (OR 0.65, 95% CI 0.53–0.78), and daily bathing practices (OR 0.76, 95% CI 0.53–0.99). Living within 1 km of a water source was not found to be significantly associated with TF/TI or C. trachomatis infection, and the use of sanitation facilities was not found to be significantly associated with TF/TI. Conclusions - We found strong evidence to support F and E components of the SAFE strategy. Though limitations included moderate to high heterogenity, low study quality, and the lack of standard definitions, these findings support the importance of WASH in trachoma elimination strategies and the need for the development of standardized approaches to measuring WASH in trachoma control programs.