Introduction to Household Water Treatment and Safe Storage, Module 5.3
Dr. Sophie Boisson, London School of Hygiene & Tropical Medicine Unsafe water Consistent Use Effective Option Introduction
Introduction to HWTS | 2 Transmission for fecal-oral pathogens is complex
HWTS addresses only one pathway
How much diarrhoea can be prevented by improving water quality alone?
Transmission of faecal-oral pathogens Source: WEDC, Adapted from Wagner & Lanoix (1958) Introduction to HWTS | 3 Systematic reviews on health impact 0 20 40 60 80 100 Flocculation/disinfection Solar disinfection Filtration Chlorination Household Source Water supply Water quality % Reduction in diarrhea Fewtrell 2005 Clasen 2006 Waddington 2009 Introduction to HWTS | 4 Intervention studies Randomised control trials Unit of randomisation can be household or village Outcome can be blinded
Observational studies Before/ After Case control studies Ecological studies
Modelling studies Measuring impact: evaluation designs Introduction to HWTS | 5 Function of stool consistency and frequency WHO definition: passase of 3 or more loose stools within 24-h period
Potential issues Reporting bias Placebo effect Hawthorne effect Respondent fatigue Measuring impact: outcome is diarrhoea Boisson et al (2013) Introduction to HWTS | 6 Different magnitude of effect Open trials report diarrhea reductions in the range of 30-40% Blinded trial report no effect
Lack of blinding of subjective outcomes risk exaggerating magnitude of impact by 25% (Wood 2008)
Adjusting for bias (Hunter 2009) Went from 44% to 15% reduction after adjustment
Blinded versus non-blinded trials Clasen et al (2006) Introduction to HWTS | 7 Setting with different transmission dynamics Transmission routes Pathogens Treatment methods not effective against all class of pathogens Different levels of compliance Impact on diarrhea diminishes over time (Arnold 2006, Hunter 2009) Efficacy versus effectiveness trials Evaluation of 3-year HWT and HWWS in Guatemala Residual chlorine 9% intervention vs 3% in control (Arnold 2009) CRT of SODIS among 22 rural communities in Bolivia 32% (Mausezhal 2009)
Potential explanation for variability Introduction to HWTS | 8 Blinded RCTs Challenges to blind effectively Potentially unethical
Alternative health outcomes Nutritional indicators Weight-for-age (malnutrition, diarrhoea) Height-for-age (stunting) Environmental enteropathy Pathogen identification
Alternatives to improve measurement? Schmidt et al (2010) Introduction to HWTS | 9 Significant health gains, 30-40% reductions in diarrhoea but may be an overestimation
Measuring impact on health is possible but can be complicated and expensive
Routine monitoring and evaluation should focus on use before attempting to measure health impact
Conclusion Introduction to HWTS | 10 Systematic reviews
Arnold, B. F. & J. M. Colford, Jr. (2007) Treating water with chlorine at point-of- use to improve water quality and reduce child diarrhea in developing countries: a systematic review and meta-analysis. Am J Trop Med Hyg, 76, 354-64.
Clasen, T., I. Roberts, T. Rabie, W. Schmidt & S. Cairncross (2006) Interventions to improve water quality for preventing diarrhoea. Cochrane Database Syst Rev, 3, CD004794.
Esrey, S. A., R. G. Feachem & J. M. Hughes (1985) Interventions for the control of diarrhoeal diseases among young children: improving water supplies and excreta disposal facilities. Bulletin of the World Health Organization, 63, 757-72.
Fewtrell, L., R. B. Kaufmann, D. Kay, W. Enanoria, L. Haller & J. M. Colford, Jr. (2005) Water, sanitation, and hygiene interventions to reduce diarrhoea in less developed countries: a systematic review and meta-analysis. Lancet Infect Dis, 5, 42-52.
Waddington, H. S., B. White, H. Fewtrell, L. 2009. Water, Sanitation and Hygiene Interventions to Combat Childhood Diarrhoea in Developing Countries. International Initiative for Impact Evaluation (3ie).
Further discussions about evidence for health impact of HWTS
Clasen T, Bartram J, Colford J, Luby S, Quick R, et al. (2009) Comment on Household water treatment in poor populations: is there enough evidence for scaling up now?. Environ Sci Technol 43: 55425544; author reply 55455546. doi: 10.1021/es9008147
Hunter, P. R. (2009) Household Water Treatment in Developing Countries: Comparing Different Intervention Types Using Meta-Regression. Environ Sci Technol. 43(23):8991-7
Schmidt, W. P. & S. Cairncross (2009) Household water treatment in poor populations: is there enough evidence for scaling up now? Environ Sci Technol, 43, 986-92. Additional ressources: Reviews Introduction to HWTS | 11
Arnold, B., B. Arana, D. Mausezahl, A. Hubbard & J. M. Colford, Jr. (2009) Evaluation of a pre-existing, 3-year household water treatment and handwashing intervention in rural Guatemala. Int J Epidemiol.
Boisson S, Stevenson M, Shapiro L, Kumar V, Singh LP, et al. (2013) Effect of Household-Based Drinking Water Chlorination on Diarrhoea among Children under Five in Orissa, India: A Double-Blind Randomised Placebo- Controlled Trial. PLoS Med 10(8): e1001497. doi:10.1371/journal.pmed.1001497
Boisson S, Kiyombo M, Sthreshley L, Tumba S, Makambo J, et al. (2010) Field assessment of a novel household-based water filtration device: a randomised, placebo-controlled trial in the Democratic Republic of Congo. PLoS One 5: e12613 doi:10.1371/journal.pone.0012613
Mausezahl, D., A. Christen, G. D. Pacheco, F. A. Tellez, M. Iriarte, M. E. Zapata, M. Cevallos, J. Hattendorf, M. D. Cattaneo, B. Arnold, T. A. Smith & J. M. Colford, Jr. (2009) Solar drinking water disinfection (SODIS) to reduce childhood diarrhoea in rural Bolivia: a cluster-randomized, controlled trial. PLoS Med, 6, e1000125.
Schmidt, W. P., S. Boisson, B. Genser, M. L. Barreto, K. Baisley, S. Filteau & S. Cairncross (2010) Weight-for- age z-score as a proxy marker for diarrhoea in epidemiological studies. J Epidemiol Community Health, 64, 1074-9.
Schmidt, W. P., B. F. Arnold, S. Boisson, B. Genser, S. P. Luby, M. L. Barreto, T. Clasen & S. Cairncross (2011) Epidemiological methods in diarrhoea studies--an update. Int J Epidemiol, 40, 1678-92.
.
Additional ressources: studies cited Introduction to HWTS | 12