Impact of Low-Cost Point-of-Use Water Treatment Technologies on Enteric Infections and Growth among Children in Limpopo, South Africa.

Enteric infections early in life have been associated with poor linear growth among children in low-resource settings. Point-of-use water treatment technologies provide effective and low-cost solutions to reduce exposure to enteropathogens from drinking water, but it is unknown whether the use of these technologies translates to improvements in child growth. We conducted a community-based randomized controlled trial of two water treatment technologies to estimate their effects on child growth in Limpopo, South Africa. We randomized 404 households with a child younger than 3 years to receive a silver-impregnated ceramic water filter, a silver-impregnated ceramic tablet, a safe-storage water container alone, or no intervention, and these households were followed up quarterly for 2 years. We estimated the effects of the interventions on linear and ponderal growth, enteric infections assessed by quantitative molecular diagnostics, and diarrhea prevalence. The silver-impregnated ceramic water filters and tablets consistently achieved approximately 1.2 and 3 log reductions, respectively, in total coliform bacteria in drinking water samples. However, the filters and tablets were not associated with differences in height (height-for-age z-score differences compared with no intervention: 0.06, 95% CI: -0.29, 0.40, and 0.00, 95% CI: -0.35, 0.35, respectively). There were also no effects of the interventions on weight, diarrhea prevalence, or enteric infections. Despite their effectiveness in treating drinking water, the use of the silver-impregnated ceramic water filters and tablets did not reduce enteric infections or improve child growth. More transformative water, sanitation, and hygiene interventions that better prevent enteric infections are likely needed to improve long-term child growth outcomes.

Analytical scaling relations to evaluate leakage and intrusion in intermittent water supply systems.

Intermittent water supplies (IWS) deliver piped water to one billion people; this water is often microbially contaminated. Contaminants that accumulate while IWS are depressurized are flushed into customers' homes when these systems become pressurized. In addition, during the steady-state phase of IWS, contaminants from higher-pressure sources (e.g., sewers) may continue to intrude where pipe pressure is low. To guide the operation and improvement of IWS, this paper proposes an analytic model relating supply pressure, supply duration, leakage, and the volume of intruded, potentially-contaminated, fluids present during flushing and steady-state. The proposed model suggests that increasing the supply duration may improve water quality during the flushing phase, but decrease the subsequent steady-state water quality. As such, regulators and academics should take more care in reporting if water quality samples are taken during flushing or steady-state operational conditions. Pipe leakage increases with increased supply pressure and/or duration. We propose using an equivalent orifice area (EOA) to quantify pipe quality. This provides a more stable metric for regulators and utilities tracking pipe repairs. Finally, we show that the volume of intruded fluid decreases in proportion to reductions in EOA. The proposed relationships are applied to self-reported performance indicators for IWS serving 108 million people described in the IBNET database and in the Benchmarking and Data Book of Water Utilities in India. This application shows that current high-pressure, continuous water supply targets will require extensive EOA reductions. For example, in order to achieve national targets, utilities in India will need to reduce their EOA by a median of at least 90%.

Efficacy of microbial sampling recommendations and practices in sub-Saharan Africa.

Current guidelines for testing drinking water quality recommend that the sampling rate, which is the number of samples tested for fecal indicator bacteria (FIB) per year, increases as the population served by the drinking water system increases. However, in low-resource settings, prevalence of contamination tends to be higher, potentially requiring higher sampling rates and different statistical methods not addressed by current sampling recommendations. We analyzed 27,930 tests for FIB collected from 351 piped water systems in eight countries in sub-Saharan Africa to assess current sampling rates, observed contamination prevalences, and the ability of monitoring agencies to complete two common objectives of sampling programs: determine regulatory compliance and detect a change over time. Although FIB were never detected in samples from 75% of piped water systems, only 14% were sampled often enough to conclude with 90% confidence that the true contamination prevalence met an example guideline (≤5% chance of any sample positive for FIB). Similarly, after observing a ten percentage point increase in contaminated samples, 43% of PWS would still require more than a year before their monitoring agency could be confident that contamination had actually increased. We conclude that current sampling practices in these settings may provide insufficient information because they collect too few samples. We also conclude that current guidelines could be improved by specifying how to increase sampling after contamination has been detected. Our results suggest that future recommendations should explicitly consider the regulatory limit and desired confidence in results, and adapt when FIB is detected.