Household spraying in cholera outbreaks: Insights from three exploratory, mixed-methods field effectiveness evaluations.

Household spraying is a commonly implemented, yet an under-researched, cholera response intervention where a response team sprays surfaces in cholera patients' houses with chlorine. We conducted mixed-methods evaluations of three household spraying programs in the Democratic Republic of Congo and Haiti, including 18 key informant interviews, 14 household surveys and observations, and 418 surface samples collected before spraying, 30 minutes and 24 hours after spraying. The surfaces consistently most contaminated with Vibrio cholerae were food preparation areas, near the patient's bed and the latrine. Effectiveness varied between programs, with statistically significant reductions in V. cholerae concentrations 30 minutes after spraying in two programs. Surface contamination after 24 hours was variable between households and programs. Program challenges included difficulty locating households, transportation and funding limitations, and reaching households quickly after case presentation (disinfection occurred 2-6 days after reported cholera onset). Program advantages included the concurrent deployment of hygiene promotion activities. Further research is indicated on perception, recontamination, cost-effectiveness, viable but nonculturable V. cholerae, and epidemiological coverage. We recommend that, if spraying is implemented, spraying agents should: disinfect surfaces systematically until wet using 0.2/2.0% chlorine solution, including kitchen spaces, patients' beds, and latrines; arrive at households quickly; and, concurrently deploy hygiene promotion activities.

Evaluation of consistent use, barriers to use, and microbiological effectiveness of three prototype household water treatment technologies in Haiti, Kenya, and Nicaragua.

Household water treatment (HWT) can improve drinking water quality and reduce diarrheal disease. New HWT technologies are typically evaluated under ideal conditions; however, health gains depend on consistent, effective household use, which is less often evaluated. We conducted four evaluations of three prototype HWT technologies: two filters and one electrochlorinator. Evaluations consisted of a baseline survey, HWT distribution to households (ranging from 60 to 82), and four visits (ranging from 1 week-14 months after distribution). Each visit included a survey, observation of treated water presence (confirmed use), and microbiological analysis of treated and untreated samples for E. coli. Consistent use was defined as the proportion of total visits with confirmed use. Overall, confirmed use declined 2.54% per month on average, and 2-72% of households demonstrated 100% consistent use. Consistent use was positively associated with baseline HWT knowledge and practice and belief that drinking water was unsafe, and negatively associated with technological problems. Reported barriers to use were behavioral, such as forgetting or when outside the home, and technological failures. Technologies demonstrated 68-96% E. coli reductions, with 18-70% of treated samples having detectable E. coli. Results highlight the importance of household use evaluations within prototype HWT technology design cycles, the need for standard evaluation metrics, and difficulties in achieving both consistent use and microbiological effectiveness with HWT technologies.

Impact of chlorination on silver elution from ceramic water filters.

Applying silver nanoparticles (nAg) or silver nitrate (AgNO3) to ceramic water filters improves microbiological efficacy, reduces biofilm formation, and protects stored water from recontamination. A challenge in ceramic filter production is adding sufficient silver to achieve these goals without exceeding the maximum recommended silver concentration in drinking water. Silver release is affected by silver type, application method, and influent water chemistry. Despite a lack of data, there is an assumption that chlorinated water should not be used as influent water because it may increase silver elution. Thus, the objective of this work was to systematically evaluate the impact of chlorinated water (0-4 mg/L free chlorine residual, FCR) on silver release from ceramic filter disks painted with casein-coated nAg, painted with AgNO3, or containing fired-in nAg over a range of ionic strength (IS = 0-10 mM as NaNO3) in the presence or absence of natural organic matter (NOM). Influent deionized water containing chlorine increased silver release 2-5-fold compared to controls. However, this effect of chlorine was mitigated at higher IS (≥1 mM) or in the presence of NOM (3 mg C/L). For filter disks painted with nAg or AgNO3, silver release increased with increasing IS (with or without chlorine), and effluent concentrations remained above the World Health Organization (WHO) guideline of 0.1 mg/L even after 30 h (80 pore volumes, PVs) of flow with a background solution of 10 mM NaNO3. Silver speciation (nAg vs. Ag+) was monitored in effluent samples from painted or fired-in nAg filter disks. Results indicated that in general, greater than 90% of the eluted silver was due to Ag+ dissolution rather than nAg release. Additionally, a filter disk prepared with fired-in nAg exhibited a lower % released in the nanoparticle form (nAg = 5% of total Ag in effluent) compared to painted on nAg (nAg = 14% of total Ag in effluent). The findings of this study suggest that chlorinated influent water has minimal impact on silver elution from ceramic filters under simulated natural water conditions, and thus, the recommendation to avoid the use of chlorinated water with ceramic filters is not necessary under most conditions.

Comment on "A re-assessment of the safety of silver in household water treatment: rapid systematic review of mammalian in vivo genotoxicity studies".

We wish to thank Fewtrell, Majuru, and Hunter for their article highlighting genotoxic risks associated with the use of particulate silver for primary drinking water treatment. The recent promotion of colloidal silver products for household water treatment in developing countries is problematic due to previously identified concerns regarding manufacturing quality and questionable advertising practices, as well as the low efficiency of silver nanoparticles to treat bacteria, viruses, and protozoa in source waters. However, in the conclusion statement of the manuscript, Fewtrell et al. state, "Before colloidal Ag or AgNP are used in filter matrices for drinking water treatment, consideration needs to be given to how much silver is likely to be released from the matrix during the life of the filter." Unfortunately, it appears Fewtrell et al. were unaware that studies of silver nanoparticle and silver ion elution from ceramic filters manufactured and used in developing countries have already been completed. These existing studies have found that: 1) silver ions, not silver nanoparticles, are eluted from ceramic filters treated with silver nanoparticles or silver nitrate; and, 2) silver ions have not been shown to be genotoxic. Thus, the existing recommendation of applying silver nanoparticles to ceramic filters to prevent biofilm formation within the filter and improve microbiological efficacy should still be adhered to, as there is no identified risk to people who drink water from ceramic filters treated with silver nanoparticles or silver nitrate. We note that efforts should continue to minimize exposure to silver nanoparticles (and silica) to employees in ceramic filter factories in collaboration with the organizations that provide technical assistance to ceramic filter factories.

Accuracy, precision, usability, and cost of portable silver test methods for ceramic filter factories.

Locally manufactured ceramic water filters are one effective household drinking water treatment technology. During manufacturing, silver nanoparticles or silver nitrate are applied to prevent microbiological growth within the filter and increase bacterial removal efficacy. Currently, there is no recommendation for manufacturers to test silver concentrations of application solutions or filtered water. We identified six commercially available silver test strips, kits, and meters, and evaluated them by: (1) measuring in quintuplicate six samples from 100 to 1,000 mg/L (application range) and six samples from 0.0 to 1.0 mg/L (effluent range) of silver nanoparticles and silver nitrate to determine accuracy and precision; (2) conducting volunteer testing to assess ease-of-use; and (3) comparing costs. We found no method accurately detected silver nanoparticles, and accuracy ranged from 4 to 91% measurement error for silver nitrate samples. Most methods were precise, but only one method could test both application and effluent concentration ranges of silver nitrate. Volunteers considered test strip methods easiest. The cost for 100 tests ranged from 36 to 1,600 USD. We found no currently available method accurately and precisely measured both silver types at reasonable cost and ease-of-use, thus these methods are not recommended to manufacturers. We recommend development of field-appropriate methods that accurately and precisely measure silver nanoparticle and silver nitrate concentrations.

Silver Dissolution and Release from Ceramic Water Filters.

Application of silver nanoparticles (nAg) or silver nitrate (AgNO3) has been shown to improve the microbiological efficacy of ceramic water filters used for household water treatment. Silver release, however, can lead to undesirable health effects and reduced filter effectiveness over time. The objectives of this study were to evaluate the contribution of nanoparticle detachment, dissolution, and cation exchange to silver elution, and to estimate silver retention under different influent water chemistries. Dissolved silver (Ag(+)) and nAg release from filter disks painted with 0.03 mg/g casein-coated nAg or AgNO3 were measured as a function of pH (5-9), ionic strength (1-50 mM), and cation species (Na(+), Ca(2+), Mg(2+)). Silver elution was controlled by dissolution as Ag(+) and subsequent cation exchange reactions regardless of the applied silver form. Effluent silver levels fell below the drinking water standard (0.1 mg/L) after flushing with 30-42 pore volumes of pH 7, 10 mM NaNO3 at pH 7. When the influent water was at pH 5, contained divalent cations or 50 mM NaNO3, silver concentrations were 5-10 times above the standard. Our findings support regular filter replacement and indicate that saline, hard, or acidic waters should be avoided to minimize effluent silver concentrations and preserve silver treatment integrity.