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Zika virus infection in Mexico

27 January 2016 16:48 (America/New_York)

Reposted from the Government of Mexico in January The prevention and control actions “Wash, Cover, Flip and Throw out” remain essential for the prevention of Dengue, Chikungunya and Zika in Mexico.

Zika virus infection is a disease caused by a virus that is transmitted through the bite of the Aedes aegypti mosquito, transmitter of the same vector of Dengue and Chikungunya. It was first isolated in a monkey in the Zika forest in Entebbe, Uganda (Africa); since 1968 outbreaks have been reported from this disease in tropical Africa and parts of Southeast Asia.

In March 2014, was identified the presence of Zika virus infection in the Americas, and in November 2015 was confirmed the first indigenous case of Zika virus infection in Mexico.

In Mexico, January 8, 2016 have been confirmed 15 indigenous cases of infection Zika virus in the states of Chiapas (10), Jalisco (1) and Nuevo Leon (4), while there have been three cases imported in Queretaro (1), Nuevo Leon (1) and Tamaulipas (1).

On January 17, 2016, the Pan American Health Organization has reported that there are 18 countries that have confirmed indigenous circulation of Zika virus (ZIKV) between 2015 and 2016: Brazil, Barbados, Colombia, Ecuador, El Salvador, Guatemala, Guyana, French Guyana, Haiti, Honduras, Martinique, Mexico, Panama, Paraguay, Puerto Rico, St. Martin, Suriname and Venezuela.

Zika virus infection is characterized by:

  • Fever.
  • Conjunctivitis.
  • Headache.
  • Muscle pain.
  • Rash.
  • Itch.
  • Shaking chills.

There is no specific treatment and as for Dengue and Chikungunya, the treatment is only symptomatic and for relieve pain and fever. There is no vaccine to prevent the infection of this virus.

It is important to note that Brazil has reported an association between microcephaly and Zika virus infection in pregnant women. Microcephaly is a neurological disorder in which the circumference of the head is less than average for a baby of their size or age. This country has reported the occurrence of three deaths attributed by Zika virus infection.

Since May 2014 in Mexico have taken steps to prevent Zika virus infection through prevention campaigns and health promotion, preventive travel advisories, warnings and epidemiological actions for vector control.

Mexico´s Epidemiological Surveillance System is ready for diagnosis of infections by Zika virus.

In addition to the prevention and control of the vector, in the coming days it will spread a campaign in media about the importance of preventing Zika virus infection especially among pregnant women, to prevent complications such as microcephaly.

It is necessary to continue spreading the following recommendations:

Recommendations to the public:

  • Wear long sleeves, trousers and repellent.
  • Wash the containers in which you save water and cover them.
  • Turn buckets and bottles and strip what you do not use and can accumulate water
  • Keep doors and windows closed, place mosquito nets and sleeping pavilions.

Pregnant women besides these recommendations should attend prenatal checkups.

We hope that in the coming weeks or months the disease will disperse in the country.

 

Solar-powered ATM delivers safe drinking water to Ugandan community

8 January 2016 14:55 (America/New_York)

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.

SUWASA Pathway for Urban Water

7 January 2016 16:25 (America/New_York)

The SUWASA Pathway is a tool developed to share experiences, deliver key messages and provide links to useful resources such as manuals, case studies, templates and reports. The SUWASA Pathway was developed by the SUWASA team in consultation with project partners including officials from government ministries, municipalities and regulatory agencies, utility managers, managers of dedicated funding units, private operators, commercial bank representatives, civil society and development partners. The objective of the Pathway is to communicate complicated reform topics in a highly accessible manner to a broad range of sector stakeholders and to assist with envisioning and sequencing reform efforts. There are many possible reform paths, but the SUWASA Pathways offer viable reform routes.

Available for download and viewing:

Performance Pathway for Water Utilities

Household water treatment and safe storage – effectiveness and economics

9 November 2015 13:02 (America/New_York)

Household water treatment and safe storage – effectiveness and economics. Drink. Water Eng. Sci. Discuss., 8, 143–176, 2015.

Authors: S. M. L. Stubbé, A. Pelgrim-Adams, G. L. Szanto, and D. van Halem.

Household Water Treatment and safe Storage (HWTS) systems aim to provide safe drinking water in an affordable manner to users where safe piped water supply is either not feasible or not reliable. In this study the effectiveness, costs and cost drivers 5 of three selected HWTS systems were identified. The selected systems are SODIS, ceramic filter and biosand filter.

These options were selected based on their current usage rate, available scientific data, and future potential. Data was obtained through peer-reviewed literature, reports, web-pages and informal sources. The findings show a wide dispersion for log removal of effectiveness of the HWTS systems.

The reported costs of HWTS systems show a wide range as well. The price per cubic 15 meter water is found to be EUR 0–8 (SODIS), EUR 0.37–6.4 (ceramic) and EUR 0.08– 12.3 (biosand). The retail prices found are: negligible (SODIS), USD 1.9–30 (ceramic) and USD 7–100 (biosand). No relationship was observed between removal efficiency and economics of the three systems.

Innovative WASH interventions to prevent cholera

2 October 2015 9:57 (America/New_York)

Innovative WASH interventions to prevent cholera. Source: WHO Wkly Epid Rec, Oct 2, 2015

Authors: Daniele Lantagne, Andy Bastable, Jeroen H. J. Ensink, and Eric Mintz.

In the late 19th and early 20th centuries, epidemic cholera was virtually eliminated in industrialized countries through municipal water supply with treatment and sanitation infrastructure.1 A century later, in 2014, only 58% of the global population had access to piped-on premises water,2 and an estimated 1.8 billion people (28% of the global population) drank microbiologically contaminated water.3 Within this inadequate water and sanitation context, cholera transmission continues.

In 2014, 32 countries – many of which are struggling with poverty, rapid population growth, and instability – reported cholera transmission.4 A recent model found that national improved water access of 71%, and improved sanitation access of 39%, predicted whether a country would have endemic cholera with 62%–65% sensitivity and specificity.5 As progress is made towards universal access to reliable piped-on-premises water, reducing the remaining cholera burden requires a comprehensive strategy. Community- and household level water, sanitation, and hygiene (WASH) interventions are one part of that strategy.

Common cholera-prevention WASH interventions include: water supply, water treatment (well, pot, or bucket chlorination and household treatment); sanitation options (latrines); and, promotion of hand washing and environmental hygiene.6 The effectiveness of these interventions varies7 : water supply and chlorine-based, filtration, and solar disinfection household options have been shown to reduce cholera transmission among users;8, 9, 10, 11, 12 well/pot chlorination effectively treats water only for a few hours,13, 14, 15 unless chlorine is regularly added;16 there is little research on bucket chlorination, sanitation, and hygiene interventions.

Recent innovations in chlorine-prevention WASH include identification of factors leading to programmatic success, and new product design (such as sourcebased water treatment and personal use sanitation options).

An investigation of 14 household treatment programmes implemented in 4 emergencies (including 3 cholera emergencies) found that reported use ranged from 1% to 93% and effective use (the percentage of recipients who improved their drinking water microbiological quality to international standards) ranged from 0 to 68%.17 The most successful programme provided an effective method (chlorine tablets), with the necessary supplies to use it (bucket and tap), and ongoing training by local community health workers to people using contaminated water who were familiar with chlorination before the emergency. Conversely, the least successful programme distributed only chlorine tablets in a relief kit labeled in English to populations without previous chlorination experience.

Similar results were found in an evaluation of dispensers, an innovative source-based intervention that includes a chlorine dispenser and dosing valve installed at water sources, community education, and chlorine refills. Across seven evaluations in four emergencies (including 3 cholera emergencies), reported dispenser use ranged from 9-97% and effective use from 0 to 81%.18 More effective programmes installed dispensers at point-sources, maintained a high-quality chlorine solution manufacturing and distribution chain, maintained hardware, integrated dispenser projects within larger water programmes, compensated promoters, had experienced staff, worked with local partners to implement the project, conducted ongoing monitoring, and had a sustainability plan.

The Peepoo is a personal, single-use, biodegradable selfsanitizing double-plastic bag toilet. Peepoos contain sufficient powdered urea to inactivate harmful pathogens in urine and feces after 4 weeks, at which time the waste can be used as fertilizer. Peepoos have been used where latrines are not feasible due to population density, and to bridge the gap between emergency onset and latrine construction.19 One emergency programme concluded that products should be pre-positioned before the emergency, all products necessary for use (including a sitting/squatting stool) should be provided to recipients, training for community health workers should occur before distribution, compensation for collection activities should be provided, and that the disposal mechanism and exit strategy should be predefined before distribution.

As can be seen, lessons learned from the programmes described above are similar: WASH interventions can successfully improve water quality, isolate feces from the environment, and reduce the potential for cholera transmission if they are wisely implemented and distributed with appropriate supplies and training to at-risk populations.

In 2014, it was declared the 2000–2015 Millennium Development Goal – to reduce by half those without access to “improved” supplies – was met for water, but not for sanitation. The anticipated WASH Sustainable Development Goals (SGD) will focus on increasing piped-on-premises supplies, eliminating open defecation, ensuring microbiological water safety, reducing disparities, and ensuring sustainability in households and institutions.20 The long-term WASH improvements necessary to achieve the SDGs will greatly reduce the global cholera burden. In the interim, community and household-level WASH interventions are one critical part of a comprehensive strategy to reduce cholera transmission. Further innovation (including developing creating hygiene promotion strategies), implementation, evaluation (including disease and water quality outcome metrics), and research, particularly on ensuring adoption and investigating holistic WASH programming, will be needed to realize their full potential.

References

1 Cutler D, Miller G.The role of public health improvements in health advances: the twentieth-century United States. Demography 2005, 42, (1), 1–22.

2 WHO/UNICEF Progress on Drinking Water and Sanitation: 2015 Update and MDG Assessment; World Health Organization and UNICEF: Geneva, Switzerland and New York City, NY, USA, 2015.

3 Onda K., LoBuglio J, Bartram, J. Global access to safe water: accounting for water quality and the resulting impact on MDG progress. Int J Environ Res Public Health 2012, 9, (3), 880–894.

4 See No. 40, 2015, pp. 517–544.

5 Nygren, B, L Blackstock A.J, Mintz E.D. Cholera at the crossroads: the association between endemic cholera and national access to improved water sources and sanitation. Am J Trop Med Hyg 2014, 91, (5), 1023–1028.

6 UNICEF Cholera Toolkit; UNICEF: New York, NY, USA, 2013. 7 Taylor D. N, Kahawita T, Cairncross S, Ensink J. The impact of water, sanitation, and hygiene interventions to control cholera: A systematic review. PloS ONe 2015, 10(8): e0135676. doi:10.1371/journal.pone.0135676.

7 Taylor D. N, Kahawita T, Cairncross S, Ensink J. The impact of water, sanitation, and hygiene interventions to control cholera: A systematic review. PloS ONe 2015, 10(8): e0135676. doi:10.1371/journal.pone.0135676.

8 Colwell, R. R, et al. Reduction of cholera in Bangladeshi villages by simple filtration. Proc Natl Acad Sci U S A 2003, 100, (3), 1051–1055.

9 Conroy R.M, Meegan M. E, Joyce T, McGuigan K, Barnes J. Solar disinfection of drinking water protects against cholera in children under 6 years of age. Arch Dis Child, 2001, 85, (4), 293–295.

10 Deb B. C et al. Studies on interventions to prevent eltor cholera transmission in urban slums. Bull World Health Organ 1986, 64, (1), 127–131.

11 O’Connor K. A, et al. Risk factors early in the 2010 cholera epidemic, Haiti. Emerg Infect Dis 2011, 17, (11), 2136–2138.

12 Jeandron A, et al. Water supply interruptions and suspected cholera incidence: a time-series regression. PLoS Med [in press]. 13 Cavallaro E. C et al. Evaluation of pot-chlorination of wells during a cholera outbreak, Bissau, Guinea-Bissau, 2008. J Water Health 2011, 9, (2), 394–402.

14 Luby S, Islam M. S, Johnston R. Chlorine spot treatment of flooded tube wells, an efficacy trial. J Appl Microbiol 2006, 100, (5), 1154–1158.

15 Rowe A. K., Angulo F. J. Chlorinating well water with liquid bleach was not an effective water disinfection strategy in Guinea-Bissau. International Journal of Environmental Health Research 1998, (8), 339–340.

16 Godfrey S, McCaffrey L, Obika A, Becks M. The effectiveness of point-source chlorination in improving water quality in internally displaced communities in Angola. UK Journal of the Chartered Institution of Water and Environmental Managers, 2002.

17 Lantagne D, Clasen T. Use of household water treatment and safe storage methods in acute emergency response: case study results from Nepal, Indonesia, Kenya, and Haiti. Environ Sci Technol 2012, 46, (20), 11 352– 11 360.

18 Yates T. M, Armitage E, Lehmann, L.V, Branz, A. J, Lantagne, D. S. Effectiveness of chlorine dispensers in emergencies: case study results from Haiti, Sierra Leone, Democratic Republic of Congo, and Senegal. Environ Sci Technol 2015, 49, (8), 5115–5122.

19 Agung H, Berndtsson M. Oxfam’s first Peepoo intervention in the Philippines; Oxfam, Peepoople: 2014.

20 WSP WASH Post-2015 proposed targets and indicators for drinking-water, sanitation and hygiene; World Bank Water and Sanitation Program: 2014.

Acceptability and Use of Portable Drinking Water and Hand Washing Stations in Health Care Facilities and Their Impact on Patient Hygiene Practices

13 August 2015 12:12 (America/New_York)

Acceptability and Use of Portable Drinking Water and Hand Washing Stations in Health Care Facilities and Their Impact on Patient Hygiene Practices, Western Kenya. PLoS One, May 2015.

Authors: Sarah D. Bennett, Ronald Otieno, Tracy L. Ayers, Aloyce Odhiambo, Sitnah H. Faith, Robert Quick, Hans-Joachim Lehmler

Many health care facilities (HCF) in developing countries lack access to reliable hand washing stations and safe drinking water. To address this problem, we installed portable, low-cost hand washing stations (HWS) and drinking water stations (DWS), and trained healthcare workers (HCW) on hand hygiene, safe drinking water, and patient education techniques at 200 rural HCFs lacking a reliable water supply in western Kenya. We performed a survey at baseline and a follow-up evaluation at 15 months to assess the impact of the intervention at a random sample of 40 HCFs and 391 households nearest to these HCFs. From baseline to follow-up, there was a statistically significant increase in the percentage of dispensaries with access to HWSs with soap (42% vs. 77%, p<0.01) and access to safe drinking water (6% vs. 55%, p<0.01).

Female heads of household in the HCF catchment area exhibited statistically significant increases from baseline to follow-up in the ability to state target times for hand washing (10% vs. 35%, p<0.01), perform all four hand washing steps correctly (32% vs. 43%, p = 0.01), and report treatment of stored drinking water using any method (73% vs. 92%, p<0.01); the percentage of households with detectable free residual chlorine in stored drinking water did not change (6%, vs. 8%, p = 0.14). The installation of low-cost, low-maintenance, locally-available, portable hand washing and drinking water stations in rural HCFs without access to 24-hour piped water helped assure that health workers had a place to wash their hands and provide safe drinking water. This HCF intervention may have also contributed to the improvement of hand hygiene and reported safe drinking water behaviors among households nearest to HCFs.

Morphology, composition and performance of a ceramic filter for household water treatment in Indonesia

13 August 2015 12:05 (America/New_York)

Morphology, composition and performance of a ceramic filter for household water treatment in Indonesia. Water Practice & Technology Vol 10 No 2 pp 361–370 © IWA Publishing 2015 doi:10.2166/wpt.2015.044.

Authors: K. Matthies, H. Bitter,  et al.

People in rural developing areas often depend on point-of-use water treatment for safe drinking water. A very popular and efficient technology for this is the use of ceramic filters, as promoted by the non-governmental organization Potters for Peace. These filters are already used in many countries worldwide, including Indonesia, where they are manufactured in Bandung, Java by Pelita Indonesia. The filters are made of local clay and combustible material, and coated with silver after firing. However, data available on them are very scarce. The structure, composition, and physico-chemical and microbiological performance of the filter were examined. Pore sizes mostly ranged from 1 to 40 µm and flow rate was about 1.3 L/h. Silver, arsenic and manganese were leaching from the filter in remarkable concentrations. While values for silver were about 0.01–0.02 mg/L, manganese was washed out after a few liters and leaching of arsenic fell below 0.02 mg/L after filtering some liters. With a log reduction of 3–5, efficiency in bacteria reduction was satisfactory in contrast to virus removal which was not sufficient according to the World Health Organization guidelines, with a log reduction below 1.

Perception of drinking water safety and factors influencing acceptance and sustainability of a water quality intervention in rural southern India

13 August 2015 11:54 (America/New_York)

Perception of drinking water safety and factors influencing acceptance and sustainability of a water quality intervention in rural southern India. BMC Public Health, July 30, 2015.

Mark Rohit Francis, Guru Nagarajan,  et al.

Background – Acceptance and long-term sustainability of water quality interventions are pivotal to realizing continued health benefits. However, there is limited research attempting to understand the factors that influence compliance to or adoption of such interventions.

Methods – Eight focus group discussions with parents of young children – including compliant and not compliant households participating in an intervention study, and three key-informant interviews with village headmen were conducted between April and May 2014 to understand perceptions on the effects of unsafe water on health, household drinking water treatment practices, and the factors influencing acceptance and sustainability of an ongoing water quality intervention in a rural population of southern India.

Results – The ability to recognize health benefits from the intervention, ease of access to water distribution centers and the willingness to pay for intervention maintenance were factors facilitating acceptance and sustainability of the water quality intervention. On the other hand, faulty perceptions on water treatment, lack of knowledge about health hazards associated with drinking unsafe water, false sense of protection from locally available water, resistance to change in taste or odor of water and a lack of support from male members of the household were important factors impeding acceptance and long term use of the intervention.

Conclusion – This study highlights the need to effectively involve communities at important stages of implementation for long term success of water quality interventions. Timely research on the factors influencing uptake of water quality interventions prior to implementation will ensure greater acceptance and sustainability of such interventions in low income settings.

 

Safe Water II – The paradigm shift in the approach to household water treatment systems

13 August 2015 11:48 (America/New_York)

The paradigm shift in the approach to household water treatment systems, 2015.

Urs Heierli, social marketing expert and advisor to the Safe Water II project, talks about the necessary paradigm shift to household water treatment systems. Visit: http://www.ircwash.org/projects/safe-… to read more about Safe Water Phase 2, a three year initiative (2015-2018) aiming to increase access to safe water particularly for people living at the base of the economic pyramid (BOP).

Effectiveness of emergency water treatment practices in refugee camps in South Sudan

13 August 2015 11:40 (America/New_York)

Effectiveness of emergency water treatment practices in refugee camps in South Sudan. WHO Bulletin, Aug 2015.

Authors: Syed Imran Ali, Syed Saad Ali & Jean-Francois Fesselet

Objective – To investigate the concentration of residual chlorine in drinking water supplies in refugee camps, South Sudan, March–April 2013.

Methods – For each of three refugee camps, we measured physical and chemical characteristics of water supplies at four points after distribution: (i) directly from tapstands; (ii) after collection; (iii) after transport to households; and (iv) after several hours of household storage. The following parameters were measured: free and total residual chlorine, temperature, turbidity, pH, electrical conductivity and oxidation reduction potential. We documented water handling practices with spot checks and respondent self-reports. We analysed factors affecting residual chlorine concentrations using mathematical and linear regression models.

Findings – For initial free residual chlorine concentrations in the 0.5–1.5 mg/L range, a decay rate of ~5×10-3 L/mg/min was found across all camps. Regression models showed that the decay of residual chlorine was related to initial chlorine levels, electrical conductivity and air temperature. Covering water storage containers, but not other water handling practices, improved the residual chlorine levels.

Conclusion The concentrations of residual chlorine that we measured in water supplies in refugee camps in South Sudan were too low. We tentatively recommend that the free residual chlorine guideline be increased to 1.0 mg/L in all situations, irrespective of diarrhoeal disease outbreaks and the pH or turbidity of water supplies. According to our findings, this would ensure a free residual chlorine level of 0.2 mg/L for at least 10 hours after distribution. However, it is unknown whether our findings are generalizable to other camps and further studies are therefore required.

Determinants of Caregivers’ Use and Adoption of Household Water Chlorination: A Qualitative Study with Peri-urban Communities in the Peruvian Amazon

30 July 2015 10:29 (America/New_York)

Determinants of Caregivers’ Use and Adoption of Household Water Chlorination: A Qualitative Study with Peri-urban Communities in the Peruvian Amazon. Am Jnl Trop Med Hyg, July 2015.

Authors: Jessica D. Rothstein, Elli Leontsini, et al.

The gap between the efficacy and the effectiveness of household water treatment in reducing diarrhea-related morbidity indicates the need for a better understanding of the determinants of long-term behavior change. To explore the barriers to drinking water chlorination in the Peruvian Amazon, where diarrhea is endemic among under-5 children, we conducted qualitative research with 23 caregivers from peri-urban communities of Iquitos, Peru. Our inquiry drew on the Transtheoretical Model of behavior change and the Integrated Behavioral Model for Water, Sanitation, and Hygiene to identify the most relevant contextual, psychosocial, and technological determinants of initial action and long-term adoption of chlorination.

Our findings suggest that the decision to try out this practice resulted from the combined effect of knowledge of chlorination benefits and product availability and affordability. Progress from action to adoption was influenced by caretakers’ understanding of dosage, the packaging of chlorine products, knowledge and skills for multipurpose laundry bleach, the taste of treated water, and reinforcement. This analysis suggests that a focus on these determinants and the household domain may help to improve the sustainability of future intervention efforts.

 

Coping with household water scarcity in the savannah today: Implications for health and climate change into the future

30 July 2015 10:06 (America/New_York)

Coping with household water scarcity in the savannah today: Implications for health and climate change into the futureEarth Interact. 2015 doi:10.1175/EI-D-14-0039.1, in press.

Authors: Amber L. Pearson, Jonathan D. Mayer, David J. Bradley

Even as millions live without reliable access to water, very little is known about how households cope with scarcity. The aims of this research were to: 1) understand aspects of water scarcity in three rural villages in southwestern Uganda; 2) examine differences by demographics and type of source; 3) assess relationships between different factors related to water access; and 4) explore coping strategies used. Health implications and lessons learned that relate to future climate change are discussed.

Over half of the households relied on seasonal water sources. Of those accessing ‘permanent’ sources, ~30% experienced inaccessibility within the past two weeks. Self-reported better access to water was correlated with minutes spent walking to source and to some degree with the source being more public or shared. Those without access to public sources tended to migrate as the primary coping strategy. Water sharing and reciprocity appears crucial between wealthy and poor households, however, those from outside ethnic groups appear to be partially excluded. Middle income households followed by the poorest had the largest reliance on purchasing water to cope. These findings underscore how access to water resources, particularly in times of insecurity, involves social networks.

 

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