Consistent point-of-use water chlorination among households using unimproved water sources and treatment preference in Eastern Ethiopia.

A consistent and correct use of water treatment options is fundamental for health gain from point-of-use water chlorination. In Ethiopia, empirical evidence about the consistent use and preference for by end users is scarce. The current study is intended to explore these issues using Waterguard and Bishan Gari in Kersa Health and Demographic Surveillance Site, Eastern Ethiopia. Data were collected every 2 week for 4 months and analyzed using mixed effects logistic regression. Of 377 households, 31% consistently used Waterguard and Bishan Gari in all the study waves. Product use over time within a household varied based on the perception about the products and the type of products each household received. From the exit assessment, 56% of households stated a preference for Waterguard significantly different from 5.6% of households that stated a preference for Bishan Gari. An intervention for consistent use beyond their availability and accessibility to end users is needed.

Appropriate household water treatment methods in Ethiopia: household use and associated factors based on 2005, 2011, and 2016 EDHS data.

BACKGROUND: Diarrheal disease attributable to water and sanitation can be prevented using point-of-use water treatment. In Ethiopia, a small number of households treat water at point-of-use with appropriate methods. However, evidence on factors associated with household use of these treatment methods is scarce. Therefore, this study is intended to explore the household use of appropriate point-of-use water treatment and associated factors in Ethiopia. METHODS: The data of 2005, 2011, and 2016 Ethiopian demographic and health surveys were used for analysis. Households reportedly treating water with bleach, boiling, filtration, and solar disinfection in each survey are considered as treating with appropriate treatment methods. Household water treatment with these treatment methods and factors associated was assessed using bivariate and multivariable regression. In addition, a region level difference in the treatment use was assessed by using multilevel modeling. RESULTS: The number of households that reported treating water with appropriate water treatment methods was 3.0%, 8.2%, and 6.5% respectively in 2005, 2011, and 2016. Household heads with higher education had 5.99 (95% CI = 3.48, 10.33), 3.61 (95% CI = 2.56, 5.07), and 3.43 (95% CI = 2.19, 6.37) times higher odds of using the treatment methods respectively in 2005, 2011, and 2016 compared to household heads who had no education. There was a significantly high number of households that used appropriate water treatment methods in 2011 (AOR = 2.78, 95% CI = 2.16, 3.57) and 2016 (AOR = 2.18, 95% CI = 1.64, 3.89) compared to 2005 data. In pooled data analysis, the reported use of the treatment methods is associated with household head education, residency, drinking water sources, and owning radio and television. From a multilevel modeling, within-region variation is higher than between-region variations in the use of treatment methods in each survey. CONCLUSIONS: Below 10% of households reportedly treating water at point-of-use in each survey attributable to different factors. Designing intervention strategies for wide-scale use of treatment methods at the country level is fundamental.

Systems Approach to Climate, Water, and Diarrhea in Hubli-Dharwad, India.

Anthropogenic climate change will likely increase diarrhea rates for communities with inadequate water, sanitation, or hygiene facilities including those with intermittent water supplies. Current approaches to study these impacts typically focus on the effect of temperature on all-cause diarrhea while excluding precipitation and diarrhea etiology while not providing actionable adaptation strategies. We develop a partially mechanistic, systems approach to estimate future diarrhea prevalence and design adaptation strategies. The model incorporates downscaled global climate models, water quality data, quantitative microbial risk assessment, and pathogen prevalence in an agent-based modeling framework incorporating precipitation and diarrhea etiology. It is informed using water quality and diarrhea data from Hubli-Dharwad, India-a city with an intermittent piped water supply exhibiting seasonal water quality variability vulnerable to climate change. We predict all-cause diarrhea prevalence to increase by 4.9% (Range: 1.5-9.0%) by 2011-2030, 11.9% (Range: 7.1-18.2%) by 2046-2065, and 18.2% (Range: 9.1-26.2%) by 2080-2099. Rainfall is an important modifying factor. Rotavirus prevalence is estimated to decline by 10.5% with Cryptosporidium and E. coli prevalence increasing by 9.9% and 6.3%, respectively, by 2080-2099 in this setting. These results suggest that ceramic water filters would be recommended as a climate adaptation strategy over chlorination. This work highlights the vulnerability of intermittent water supplies to climate change and the urgent need for improvements.

Planning for climate change: The need for mechanistic systems-based approaches to study climate change impacts on diarrheal diseases.

Increased precipitation and temperature variability as well as extreme events related to climate change are predicted to affect the availability and quality of water globally. Already heavily burdened with diarrheal diseases due to poor access to water, sanitation and hygiene facilities, communities throughout the developing world lack the adaptive capacity to sufficiently respond to the additional adversity caused by climate change. Studies suggest that diarrhea rates are positively correlated with increased temperature, and show a complex relationship with precipitation. Although climate change will likely increase rates of diarrheal diseases on average, there is a poor mechanistic understanding of the underlying disease transmission processes and substantial uncertainty surrounding current estimates. This makes it difficult to recommend appropriate adaptation strategies. We review the relevant climate-related mechanisms behind transmission of diarrheal disease pathogens and argue that systems-based mechanistic approaches incorporating human, engineered and environmental components are urgently needed. We then review successful systems-based approaches used in other environmental health fields and detail one modeling framework to predict climate change impacts on diarrheal diseases and design adaptation strategies.

Modeling the sustainability of a ceramic water filter intervention.

Ceramic water filters (CWFs) are a point-of-use water treatment technology that has shown promise in preventing early childhood diarrhea (ECD) in resource-limited settings. Despite this promise, some researchers have questioned their ability to reduce ECD incidences over the long term since most effectiveness trials conducted to date are less than one year in duration limiting their ability to assess long-term sustainability factors. Most trials also suffer from lack of blinding making them potentially biased. This study uses an agent-based model (ABM) to explore factors related to the long-term sustainability of CWFs in preventing ECD and was based on a three year longitudinal field study. Factors such as filter user compliance, microbial removal effectiveness, filter cleaning and compliance declines were explored. Modeled results indicate that broadly defined human behaviors like compliance and declining microbial effectiveness due to improper maintenance are primary drivers of the outcome metrics of household drinking water quality and ECD rates. The model predicts that a ceramic filter intervention can reduce ECD incidence amongst under two year old children by 41.3%. However, after three years, the average filter is almost entirely ineffective at reducing ECD incidence due to declining filter microbial removal effectiveness resulting from improper maintenance. The model predicts very low ECD rates are possible if compliance rates are 80-90%, filter log reduction efficiency is 3 or greater and there are minimal long-term compliance declines. Cleaning filters at least once every 4 months makes it more likely to achieve very low ECD rates as does the availability of replacement filters for purchase. These results help to understand the heterogeneity seen in previous intervention-control trials and reemphasize the need for researchers to accurately measure confounding variables and ensure that field trials are at least 2-3 years in duration. In summary, the CWF can be a highly effective tool in the fight against ECD, but every effort should be made by implementing agencies to ensure consistent use and maintenance.

Development of a Spatial and Temporal Agent-Based Model for Studying Water and Health Relationships: The Case Study of Two Villages in Limpopo, South Africa.

Diarrhea, the second leading cause of child morbidity and mortality, can have detrimental effects in the physical and cognitive development of children in developing countries. Health interventions (e.g., increased access to health services and safe water) designed to address this problem are difficult to implement in resource-limited settings. In this paper, we present a tool for understanding the complex relationship between water and public health in rural areas of a developing country. A spatial and temporal agent-based model (ABM) was developed to simulate the current water, sanitation, and health status in two villages in Limpopo Province, South Africa. The model was calibrated using empirical data and published sources. It was used to simulate the effects of poor water quality on the frequency of diarrheal episodes in children, and consequently on child development. Preliminary simulation results show that at the current total coliform levels in the water sources of the studied villages, children are expected to experience stunting by as much as -1.0 standard deviations from the World Health Organization height norms. With minor modifications, the calibrated ABM can be used to design and evaluate intervention strategies for improving child health in these villages. The model can also be applied to other regions worldwide that face the same environmental challenges and conditions as the studied villages.

Coliform Sources and Mechanisms for Regrowth in Household Drinking Water in Limpopo, South Africa.

Resource-limited communities throughout the developing world face significant environmental health problems related to the myriad of coliform sources within those communities. This study comprehensively investigated contamination sources and the biological and chemical mechanisms sustaining them in two adjacent communities in rural Limpopo, South Africa. An 8-month study was conducted of household (n = 14) and source water quality, measurements of biofilm layers on the inside of household water storage containers and water transfer devices, and also hand-based coliforms and hand-washing effectiveness. A 7-day water container incubation experiment was also performed to determine the biological and chemical changes that occur in a household water storage container independent of human interference. Results indicate that household drinking water frequently becomes contaminated after collection but before consumption (197 versus 1,046 colony-forming units/100 mL; n = 266; p < 0.001). The most important contamination sources include biofilm layers on the inside of storage containers (1.85 ± 1.59 colony-forming units/cm2; n = 44), hands (5,097 ± 2,125 colony-forming units/hand; n = 48), and coliform regrowth resulting from high assimilable organic carbon (AOC) levels during storage. A maximum specific growth rate, µmax, of 0.072 ± 0.003 h-1 was determined for total coliform bacteria on AOC, and a high correlation between AOC concentrations and the growth potential of total coliform bacteria was observed. These results support the implementation of point-of-use water treatment and other interventions aimed at maintaining the safe water chain and preventing biological regrowth.

Modeling the complexities of water, hygiene, and health in Limpopo Province, South Africa.

Researchers have long studied the causes and prevention strategies of poor household water quality and early childhood diarrhea using intervention-control trials. Although the results of such trails can lead to useful information, they do not capture the complexity of this natural/engineered/social system. We report on the development of an agent-based model (ABM) to study such a system in Limpopo, South Africa. The study is based on four years of field data collection to accurately capture essential elements of the communities and their water contamination chain. An extensive analysis of those elements explored behaviors including water collection and treatment frequency as well as biofilm buildup in water storage containers, source water quality, and water container types. Results indicate that interventions must be optimally implemented in order to see significant reductions in early childhood diarrhea (ECD). Household boiling frequency, source water quality, water container type, and the biofilm layer contribution were deemed to have significant impacts on ECD. Furthermore, concurrently implemented highly effective interventions were shown to reduce diarrhea rates to very low levels even when other, less important practices were suboptimal. This technique can be used by a variety of stakeholders when designing interventions to reduce ECD incidences in similar settings.