Solar disinfection of water for diarrhoeal prevention in southern India

Randomized controlled trial in rural Ethiopia to assess a portable water treatment device

We conducted a randomized controlled trial to assess the Lifestraw Personal pipe-style water treatment device among a rural population in Ethiopia. A total of 313 households (including 1516 persons) were randomly assigned either to an intervention group in which each householder received a Lifestraw Personal or a control. Households were visited fortnightly over a five-month intervention period and asked to report any episode of diarrhea during the previous week. A random sample of 160 devices was tested each month to assess the presence of thermotolerant coliforms (TTC) and residual iodine in treated water and to measure flow rate under simulated use. Members of the intervention group had 25% fewer weeks with diarrhea than those of the control group (longitudinal prevalence ratio = 0.75; 95% CI 0.60; 0.95). All 718 filtered water samples were free of TTC, were free of detectable iodine disinfectant, and showed a constant flow rate over time. After the five-month intervention period, 34% of participants reported use of device in the preceding week and 13% reported consistent use. While the device was associated with a 25% reduction in longitudinal prevalence of diarrhea, low levels of use suggest that much of this effect is likely to be attributable to reporting bias that is common in open trials with nonobjective outcomes.

Solar drinking water disinfection (SODIS) to reduce childhood diarrhoea in rural Bolivia: a cluster-randomized, controlled trial

BACKGROUND

Solar drinking water disinfection (SODIS) is a low-cost, point-of-use water purification method that has been disseminated globally. Laboratory studies suggest that SODIS is highly efficacious in inactivating waterborne pathogens. Previous field studies provided limited evidence for its effectiveness in reducing diarrhoea.

METHODS AND FINDINGS

We conducted a cluster-randomized controlled trial in 22 rural communities in Bolivia to evaluate the effect of SODIS in reducing diarrhoea among children under the age of 5 y. A local nongovernmental organisation conducted a standardised interactive SODIS-promotion campaign in 11 communities targeting households, communities, and primary schools. Mothers completed a daily child health diary for 1 y. Within the intervention arm 225 households (376 children) were trained to expose water-filled polyethyleneteraphtalate bottles to sunlight. Eleven communities (200 households, 349 children) served as a control. We recorded 166,971 person-days of observation during the trial representing 79.9% and 78.9% of the total possible person-days of child observation in intervention and control arms, respectively. Mean compliance with SODIS was 32.1%. The reported incidence rate of gastrointestinal illness in children in the intervention arm was 3.6 compared to 4.3 episodes/year at risk in the control arm. The relative rate of diarrhoea adjusted for intracluster correlation was 0.81 (95% confidence interval 0.59-1.12). The median length of diarrhoea was 3 d in both groups.

CONCLUSIONS

Despite an extensive SODIS promotion campaign we found only moderate compliance with the intervention and no strong evidence for a substantive reduction in diarrhoea among children. These results suggest that there is a need for better evidence of how the well-established laboratory efficacy of this home-based water treatment method translates into field effectiveness under various cultural settings and intervention intensities. Further global promotion of SODIS for general use should be undertaken with care until such evidence is available.

TRIAL REGISTRATION

www.ClinicalTrials.govNCT00731497 Please see later in the article for Editors' Summary.

Solar disinfection (SODIS) and subsequent dark storage of Salmonella typhimurium and Shigella flexneri monitored by flow cytometry

Pathogenic enteric bacteria are a major cause of drinking water related morbidity and mortality in developing countries. Solar disinfection (SODIS) is an effective means to fight this problem. In the present study, SODIS of two important enteric pathogens, Shigella flexneri and Salmonella typhimurium, was investigated with a variety of viability indicators including cellular ATP levels, efflux pump activity, glucose uptake ability, and polarization and integrity of the cytoplasmic membrane. The respiratory chain of enteric bacteria was identified to be a likely target of sunlight and UVA irradiation. Furthermore, during dark storage after irradiation, the physiological state of the bacterial cells continued to deteriorate even in the absence of irradiation: apparently the cells were unable to repair damage. This strongly suggests that for S. typhimurium and Sh. flexneri, a relatively small light dose is enough to irreversibly damage the cells and that storage of bottles after irradiation does not allow regrowth of inactivated bacterial cells. In addition, we show that light dose reciprocity is an important issue when using simulated sunlight. At high irradiation intensities (>700 W m(-2)) light dose reciprocity failed and resulted in an overestimation of the effect, whereas reciprocity applied well around natural sunlight intensity (<400 W m(-2)).

Household water treatment in poor populations: is there enough evidence for scaling up now?

Point-of-use water treatment (household water treatment, HWT) has been advocated as a means to substantially decrease the global burden of diarrhea and to contribute to the Millennium Development Goals. To determine whether HWT should be scaled up now, we reviewed the evidence on acceptability, scalability, adverse effects, and nonhealth benefits as the main criteria to establish how much evidence is needed before scaling up. These aspects are contrasted with the evidence on the effect of HWT on diarrhea. We found that the acceptability and scalability of HWT is still unclear, and that there are substantial barriers making it difficult to identify populations that would benefit most from a potential effect. The nonhealth benefits of HWT are negligible. Health outcome trials suggest that HWT may reduce diarrhea by 30-40%. The problem of bias is discussed. There is evidence that the estimates may be strongly biased. Current evidence does not exclude that the observed diarrhea reductions are largely or entirely due to bias. We conclude that widespread promotion of HWT is premature given the available evidence. Further acceptability studies and large blinded trials or trials with an objective health outcome are needed before HWT can be recommended to policy makers and implementers.

Water disinfection and hygiene behaviour in an urban slum in Kenya: impact on childhood diarrhoea and influence of beliefs

In this research project, we studied factors that presumably affect the incidence of diarrhoea among young children in urban slums in developing countries: consumption of safe drinks, hygiene behaviour, cleanliness of household surroundings and the quality of raw water. Beliefs concerning the causes of diarrhoea were also related to health-improving behaviour, namely the application of the water-treatment method SODIS (solar water disinfection) and hygiene behaviour. We conducted a survey in a shanty town in Nairobi, Kenya. Field workers interviewed 500 households. Analysis with regression models revealed that two out of the four postulated factors were significant: children have a lower risk of contracting diarrhoea when they consume high percentages of safe drinks and live in households with good hygiene. As regards beliefs, we found that biomedical knowledge of children's diarrhoea as well as the perceived social norm for treating water was associated with the use of SODIS and good hygiene.

Point of use household drinking water filtration: A practical, effective solution for providing sustained access to safe drinking water in the developing world

The lack of safe water creates a tremendous burden of diarrheal disease and other debilitating, life-threatening illnesses for people in the developing world. Point-of-use (POU) water treatment technology has emerged as an approach that empowers people and communities without access to safe water to improve water quality by treating it in the home. Several POU technologies are available, but, except for boiling, none have achieved sustained, large-scale use. Sustained use is essential if household water treatment technology (HWT) is to provide continued protection, but it is difficult to achieve. The most effective, widely promoted and used POU HWTs are critically examined according to specified criteria for performance and sustainability. Ceramic and biosand household water filters are identified as most effective according to the evaluation criteria applied and as having the greatest potential to become widely used and sustainable for improving household water quality to reduce waterborne disease and death.

Disinfection of drinking water contaminated with Cryptosporidium parvum oocysts under natural sunlight and using the photocatalyst TiO2

The results of a batch-process solar disinfection (SODIS) and solar photocatalytic disinfection (SPCDIS) on drinking water contaminated with Cryptosporidium are reported. Cryptosporidium parvum oocyst suspensions were exposed to natural sunlight in Southern Spain and the oocyst viability was evaluated using two vital dyes [4',6-diamidino-2-phenylindole (DAPI) and propidium iodide (PI)]. SODIS exposures (strong sunlight) of 8 and 12h reduced oocyst viability from 98% (+/-1.3%) to 11.7% (+/-0.9%) and 0.3% (+/-0.33%), respectively. SODIS reactors fitted with flexible plastic inserts coated with TiO2 powder (SPCDIS) were found to be more effective than those which were not. After 8 and 16 h of overcast and cloudy solar irradiance conditions, SPCDIS reduced oocyst viability from 98.3% (+/-0.3%) to 37.7% (+/-2.6%) and 11.7% (+/-0.7%), respectively, versus to that achieved using SODIS of 81.3% (+/-1.6%) and 36.0% (+/-1.0%), respectively. These results confirm that solar disinfection of drinking water can be an effective household intervention against Cryptosporidium contamination.

Water handling, sanitation and defecation practices in rural southern India: a knowledge, attitudes and practices study

Diarrhoea and water-borne diseases are leading causes of mortality in developing countries. To understand the socio-cultural factors impacting on water safety, we documented knowledge, attitudes and practices of water handling and usage, sanitation and defecation in rural Tamilnadu, India, using questionnaires and focus group discussions, in a village divided into an upper caste Main village and a lower caste Harijan colony. Our survey showed that all households stored drinking water in wide-mouthed containers. The quantity of water supplied was less in the Harijan colony, than in the Main village (P<0.001). Residents did not associate unsafe water with diarrhoea, attributing it to 'heat', spicy food, ingesting hair, mud or mosquitoes. Among 97 households interviewed, 30 (30.9%) had toilets but only 25 (83.3%) used them. Seventy-two (74.2%) of respondents defecated in fields, and there was no stigma associated with this traditional practice. Hand washing with soap after defecation and before meals was common only in children under 15 years (86.4%). After adjusting for other factors, perception of quantity of water received (P<0.001), stated causation of diarrhoea (P=0.02) and low socio-economic status (P<0.001) were significantly different between the Main village and the Harijan colony. Traditional practices may pose a significant challenge to programmes aimed at toilet usage and better sanitation.

Factors Affecting the Diffusion of Solar Water Disinfection: A Field Study in Bolivia

This study examines a broad array of theory-based factors derived from diffusion research that affect the current and intended use of solar water disinfection (SODIS), a simple, low-cost technology for treating drinking water at the household level. The perceived attributes of an innovation, the nature of the social system in which it is diffused, the extent of change agents' promotional efforts in diffusing it, and the nature of the communication channels used were operationalized by 16 variables. The aim of the study is to determine the influence of each factor and its predictive power. Eight areas in Bolivia were visited, and 644 families were interviewed on the basis of a structured questionnaire. Simultaneous multiple regression analysis showed that 9 of the 16 factors derived from diffusion research contributed significantly to predicting the current use of SODIS. The implications of the findings for customizing future SODIS diffusion activities are outlined.

Interventions to improve water quality for preventing diarrhoea

BACKGROUND

Diarrhoeal diseases are a leading cause of mortality and morbidity, especially among young children in developing countries. While many of the infectious agents associated with diarrhoeal disease are potentially waterborne, the evidence for reducing diarrhoea in settings where it is endemic by improving the microbiological quality of drinking water has been equivocal.

OBJECTIVES

To assess the effectiveness of interventions to improve water quality for preventing diarrhoea.

SEARCH STRATEGY

We searched the Cochrane Infectious Diseases Group Specialized Register (December 2005), CENTRAL (The Cochrane Library 2005, Issue 4), MEDLINE (December 2005), EMBASE (December 2005), and LILACS (December 2005). We also handsearched relevant conference proceedings, contacted researchers and organizations working in the field, and checked references from identified studies.

SELECTION CRITERIA

Randomized and quasi-randomized controlled trials comparing interventions aimed at improving the microbiological quality of drinking water with no intervention in children and adults living in settings where diarrhoeal disease is endemic.

DATA COLLECTION AND ANALYSIS

Two authors independently assessed trial quality and extracted data. We used meta-analyses to estimate pooled measures of effect, where appropriate, and investigated potential sources of heterogeneity using subgroup analyses.

MAIN RESULTS

Thirty trials (including 38 independent comparisons) covering over 53,000 participants met the inclusion criteria. Differences between the trials limited the comparability of results and pooling by meta-analysis. In general, the evidence suggests that interventions to improve the microbiological quality of drinking water are effective in preventing diarrhoea both for populations of all ages and children less than five years old. Subgroup analyses suggest that household interventions are more effective in preventing diarrhoea than interventions at the water source. Effectiveness was positively associated with compliance. Effectiveness was not conditioned on the presence of improved water supplies or sanitation in the study setting, and was not enhanced by combining the intervention to improve water quality with other common environmental interventions intended to prevent diarrhoea.

AUTHORS' CONCLUSIONS

Interventions to improve water quality are generally effective in preventing diarrhoea, and interventions to improve water quality at the household level are more effective than those at the source. Significant heterogeneity among the trials suggests that the actual level of effectiveness may depend on a variety of conditions that research to date cannot fully explain. Rigorous, blinded, multi-arm randomized controlled trials conducted over a longer duration in a variety if settings may help clarify the potential effectiveness.