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Kerr M, Cardinale V, De Vito C, Khanolkar AR. Lifestraw Family water filters in low- and middle-income countries: a systematic review and meta-analysis to define longer-term public health impact against childhood diarrhoea and inform scale-up. J Glob Health 2024; 14:04018. [PMID: 38939952 PMCID: PMC11215800 DOI: 10.7189/jogh.14.04018] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/29/2024] Open
Abstract
Background Diarrhoeal disease disproportionately affects children <5 years in low- and middle-income countries (LMICs). The pathogens responsible for diarrhoea are commonly transmitted through faecally-contaminated drinking water. Lifestraw Family point-of-use water filters have been the subject of intervention studies for over a decade and were the first filters evaluated by the World Health Organization in its water treatment evaluation scheme to provide comprehensive protection against many diarrhoea-causing pathogens. This systematic review aimed to: 1) report on aspects related to physical environment and implementation and 2) conduct an updated meta-analysis on Lifestraw Family filter effectiveness against childhood diarrhoea based on studies with ≥12 months of follow-up. Methods We conducted a literature search in November 2022 using MEDLINE, Embase, Cochrane, and CINAHL databases. Inclusion criteria were: 1) RCTs, cluster-RCTs, quasi-experimental, or matched cohort studies on 2) Lifestraw Family 1.0 or 2.0 filters 3) conducted in LMICs 4) that evaluated filter effectiveness against diarrhoea in children <5 and 5) analysed ≥12 months of follow-up data on clinical effectiveness against diarrhoea and were 6) published from 2010 with 7) full-text availability in English. A modified Newcastle-Ottawa Scale was used to assess risk of bias. Relative risk (RR) and 95% confidence intervals (CIs) were extracted and analysed using a random-effects meta-analysis. Results We included 6 studies in LMICs involving 4740 children <5. Of the four clinically-effective interventions, common characteristics were access to improved water sources (75%), the 2.0 version of the filter or the 1.0 version with additional water storage (100%), use of behaviour change theory, community engagement, and health messaging (75%), local filter repair-and-replace mechanisms (75%), and specially-trained local interventionists (100%). The meta-analysis showed a 30% reduction in diarrhoea risk in the intervention group (RR = 0.69; 95% CI = 0.52-0.91, P = 0.01). Conclusions Lifestraw Family water filters can be effective interventions to reduce diarrhoea in vulnerable paediatric populations for at least one year, though certain aspects related to physical environment and implementation may increase their public health impact. The findings of this study suggest considerations for scale-up that can be applied in settings in need of longer-term interim solutions until universal access to safe drinking water is achieved.
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Affiliation(s)
- Melissa Kerr
- Department of Population Health Sciences, King’s College London, Guy’s Campus, London, England, UK
- Department of Public Health and Infectious Diseases, Sapienza University of Rome, Rome, Italy
| | - Vincenzo Cardinale
- Department of Medico-Surgical Sciences and Biotechnologies, Sapienza University of Rome, Latina, Italy
| | - Corrado De Vito
- Department of Public Health and Infectious Diseases, Sapienza University of Rome, Rome, Italy
| | - Amal R Khanolkar
- Department of Population Health Sciences, King’s College London, Guy’s Campus, London, England, UK
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Haque S, Kirby MA, Iyakaremye L, Gebremariam A, Tessema G, Thomas E, Chang HH, Clasen T. Effects of adding household water filters to Rwanda's Community-Based Environmental Health Promotion Programme: a cluster-randomized controlled trial in Rwamagana district. NPJ CLEAN WATER 2022; 5:42. [PMID: 36118619 PMCID: PMC9464616 DOI: 10.1038/s41545-022-00185-y] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 10/05/2021] [Accepted: 08/19/2022] [Indexed: 06/15/2023]
Abstract
Unsafe drinking water remains a major cause of mortality and morbidity. While Rwanda's Community-Based Environmental Health Promotion Programme (CBEHPP) promotes boiling and safe storage, previous research found these efforts to be ineffective in reducing fecal contamination of drinking water. We conducted a cluster randomized control led trial to determine if adding a household water filter with safe storage to the CBEHPP would improve drinking water quality and reduce child diarrhea. We enrolled 1,199 households with a pregnant person or child under 5 across 60 randomly selected villages in Rwamagana district. CBEHPP implementers distributed and promoted water purifiers to a random half of villages. We conducted two unannounced follow-up visits over 13-16 months after the intervention delivery. The intervention reduced the proportions of households with detectable E. coli in drinking water samples (primary outcome) by 20% (PR 0.80, 95% CI 0.74-0.87, p < 0.001) and with moderate and higher fecal contamination (≥10 CFU/100 mL) by 35% (PR 0.65, 95% CI 0.57-0.74, p < 0.001). The proportion of children under 5 experiencing diarrhea in the last week was reduced by 49% (aPR 0.51, 95%CI 0.35-0.73, p < 0.001). Our findings identify an effective intervention for improving water quality and child health that can be added to the CBEHPP.
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Affiliation(s)
- Sabrina Haque
- Gangarosa Department of Environmental Health, Emory University Rollins School of Public Health, Atlanta, GA USA
| | - Miles A. Kirby
- Gangarosa Department of Environmental Health, Emory University Rollins School of Public Health, Atlanta, GA USA
- Department of Global Health and Population, Harvard T.H. Chan School of Public Health, Boston, MA USA
| | | | | | | | - Evan Thomas
- Mortenson Center in Global Engineering, University of Colorado, Boulder, CO USA
| | - Howard H. Chang
- Gangarosa Department of Environmental Health, Emory University Rollins School of Public Health, Atlanta, GA USA
| | - Thomas Clasen
- Gangarosa Department of Environmental Health, Emory University Rollins School of Public Health, Atlanta, GA USA
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Kann S, Concha G, Hartmann M, Köller T, Alker J, Schotte U, Kreienbrock L, Frickmann H, Warnke P. Only Low Effects of Water Filters on the Enteric Carriage of Gastrointestinal Pathogen DNA in Colombian Indigenous People. Microorganisms 2022; 10:microorganisms10030658. [PMID: 35336233 PMCID: PMC8955181 DOI: 10.3390/microorganisms10030658] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/26/2022] [Revised: 02/28/2022] [Accepted: 03/17/2022] [Indexed: 12/18/2022] Open
Abstract
Water filtration is a common strategy of water sanitation in resource-poor tropical settings. Here, we assessed the intermediate term effect of this preventive procedure including specific filter-related as well as general hygiene training on the molecular detection of enteric pathogens in stool samples from Colombian Indigenous people. From a total of 89 individuals from an Indigenous tribe called Wiwa, stool samples were assessed by real-time PCR for enteropathogenic microorganisms prior to the implementation of water filtration-based infection prevention. Three years after the onset of the preventive strategy, a follow-up assessment was performed. A significantly beneficial effect of water filtration could be shown for Ascaris spp. only (p = 0.035) and a tendency (p = 0.059) for Hymenolepis nana. No hints for effects on the gastrointestinal shedding of Giardia duodenalis, Entamoeba histolytica, Cryptosporidium spp., Campylobacter spp., Shigella spp./enteroinvasive Escherichia coli, Necator americanus, Strongyloides stercoralis, Trichuris trichiura, and Taenia spp. were seen. In conclusion, the study indicates that water filtration can only be an element of a multi-modal hygiene concept to reduce enteric pathogen carriage in inhabitants of resource-poor tropical settings in spite of tendencies of beneficial effects.
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Affiliation(s)
- Simone Kann
- Medical Mission Institute, 97074 Würzburg, Germany
- Correspondence: (S.K.); (P.W.)
| | - Gustavo Concha
- Organization Wiwa Yugumaiun Bunkauanarrua Tayrona (OWYBT), Department Health Advocacy, Valledupar 2000001, Colombia;
| | - Maria Hartmann
- Institute for Biometry, Epidemiology and Information Processing, Veterinary Medical University Hannover, 30559 Hannover, Germany; (M.H.); (L.K.)
| | - Thomas Köller
- Institute for Medical Microbiology, Virology and Hygiene, University Medicine Rostock, 18057 Rostock, Germany; (T.K.); (H.F.)
| | - Juliane Alker
- Department A-Veterinary Medicine, Central Institute of the Bundeswehr Medical Service Kiel, 24119 Kronshagen, Germany; (J.A.); (U.S.)
| | - Ulrich Schotte
- Department A-Veterinary Medicine, Central Institute of the Bundeswehr Medical Service Kiel, 24119 Kronshagen, Germany; (J.A.); (U.S.)
| | - Lothar Kreienbrock
- Institute for Biometry, Epidemiology and Information Processing, Veterinary Medical University Hannover, 30559 Hannover, Germany; (M.H.); (L.K.)
| | - Hagen Frickmann
- Institute for Medical Microbiology, Virology and Hygiene, University Medicine Rostock, 18057 Rostock, Germany; (T.K.); (H.F.)
- Department of Microbiology and Hospital Hygiene, Bundeswehr Hospital Hamburg, 20359 Hamburg, Germany
| | - Philipp Warnke
- Department of Microbiology and Hospital Hygiene, Bundeswehr Hospital Hamburg, 20359 Hamburg, Germany
- Correspondence: (S.K.); (P.W.)
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Pi SY, Wang Y, Lu YW, Liu GL, Wang DL, Wu HM, Chen D, Liu H. Fabrication of polypyrrole nanowire arrays-modified electrode for point-of-use water disinfection via low-voltage electroporation. WATER RESEARCH 2021; 207:117825. [PMID: 34763279 DOI: 10.1016/j.watres.2021.117825] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/06/2021] [Revised: 10/09/2021] [Accepted: 10/29/2021] [Indexed: 06/13/2023]
Abstract
Still ∼10% of world's population has no sustainable access to centralized water supply system, causing millions of deaths annually by waterborne diseases. Here, we develop polypyrrole nanowire arrays (PPyNWs)-modified electrodes by polymerization of pyrrole on graphite felt for point-of-use water disinfection via low-voltage electroporation. A flow-through mode is specially applied to alleviate diffusion barrier of pyrrole in the porous graphite felt for uniform PPyNWs growth. The flow-through disinfection device using the optimized PPyNWs electrode achieves above 4-log removal for model virus (MS2) and gram-positive/negative bacteria (E. faecalis and E. coli) at applied voltage of 1.0 V and fluxes below 1000 and 2500 L/m2/h. Electroporation is recognized as the dominant disinfection mechanism by using square-wave alternating voltage of ±1.0 V to eliminate the electrochemical reactions. In-situ sampling experiments reveal that anode acts as the main disinfection function due to its electric field attraction with negatively charged E. coli cells. The live/dead baclight staining experiments indicate an adsorption-desorption process of E. coli cells on anode, and the adsorption-desorption balance determines the disinfection abilities of PPyNWs anode. Under 1.0 V and 2000 L/m2/h, the disinfection device enables above 4-log E. coli removal in tap water within 7-day operation with energy consumption below 20 mJ/L, suggesting its sound application potential for point-of-use water disinfection.
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Affiliation(s)
- Shuang-Yu Pi
- School of Environment, Guangzhou Key Laboratory of Environmental Exposure and Health, and Guangdong Key Laboratory of Environmental Pollution and Health, Jinan University, Guangzhou 510632, China
| | - Yang Wang
- School of Environment, Guangzhou Key Laboratory of Environmental Exposure and Health, and Guangdong Key Laboratory of Environmental Pollution and Health, Jinan University, Guangzhou 510632, China
| | - Ying-Wen Lu
- School of Environment, Guangzhou Key Laboratory of Environmental Exposure and Health, and Guangdong Key Laboratory of Environmental Pollution and Health, Jinan University, Guangzhou 510632, China
| | - Guang-Li Liu
- Guangdong Provincial Key Laboratory of Environmental Pollution Control and Remediation Technology, Sun Yat-sen University, Guangzhou 510275, China
| | - Da-Li Wang
- School of Environment, Guangzhou Key Laboratory of Environmental Exposure and Health, and Guangdong Key Laboratory of Environmental Pollution and Health, Jinan University, Guangzhou 510632, China
| | - Hai-Ming Wu
- Shandong Key Laboratory of Water Pollution Control and Resource Reuse, School of Environmental Science and Engineering, Shandong University, Qingdao 266237, China
| | - Da Chen
- School of Environment, Guangzhou Key Laboratory of Environmental Exposure and Health, and Guangdong Key Laboratory of Environmental Pollution and Health, Jinan University, Guangzhou 510632, China
| | - Hai Liu
- School of Environment, Guangzhou Key Laboratory of Environmental Exposure and Health, and Guangdong Key Laboratory of Environmental Pollution and Health, Jinan University, Guangzhou 510632, China; Guangdong Provincial Key Laboratory of Environmental Pollution Control and Remediation Technology, Sun Yat-sen University, Guangzhou 510275, China
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Chirgwin H, Cairncross S, Zehra D, Sharma Waddington H. Interventions promoting uptake of water, sanitation and hygiene (WASH) technologies in low- and middle-income countries: An evidence and gap map of effectiveness studies. CAMPBELL SYSTEMATIC REVIEWS 2021; 17:e1194. [PMID: 36951806 PMCID: PMC8988822 DOI: 10.1002/cl2.1194] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/25/2023]
Abstract
Background Lack of access to and use of water, sanitation and hygiene (WASH) cause 1.6 million deaths every year, of which 1.2 million are due to gastrointestinal illnesses like diarrhoea and acute respiratory infections like pneumonia. Poor WASH access and use also diminish nutrition and educational attainment, and cause danger and stress for vulnerable populations, especially for women and girls. The hardest hit regions are sub-Saharan Africa and South Asia. Sustainable Development Goal (SDG) 6 calls for the end of open defecation, and universal access to safely managed water and sanitation facilities, and basic hand hygiene, by 2030. WASH access and use also underpin progress in other areas such as SDG1 poverty targets, SDG3 health and SDG4 education targets. Meeting the SDG equity agenda to "leave none behind" will require WASH providers prioritise the hardest to reach including those living remotely and people who are disadvantaged. Objectives Decision makers need access to high-quality evidence on what works in WASH promotion in different contexts, and for different groups of people, to reach the most disadvantaged populations and thereby achieve universal targets. The WASH evidence map is envisioned as a tool for commissioners and researchers to identify existing studies to fill synthesis gaps, as well as helping to prioritise new studies where there are gaps in knowledge. It also supports policymakers and practitioners to navigate the evidence base, including presenting critically appraised findings from existing systematic reviews. Methods This evidence map presents impact evaluations and systematic reviews from the WASH sector, organised according to the types of intervention mechanisms, WASH technologies promoted, and outcomes measured. It is based on a framework of intervention mechanisms (e.g., behaviour change triggering or microloans) and outcomes along the causal pathway, specifically behavioural outcomes (e.g., handwashing and food hygiene practices), ill-health outcomes (e.g., diarrhoeal morbidity and mortality), nutrition and socioeconomic outcomes (e.g., school absenteeism and household income). The map also provides filters to examine the evidence for a particular WASH technology (e.g., latrines), place of use (e.g., home, school or health facility), location (e.g., global region, country, rural and urban) and group (e.g., people living with disability). Systematic searches for published and unpublished literature and trial registries were conducted of studies in low- and middle-income countries (LMICs). Searches were conducted in March 2018, and searches for completed trials were done in May 2020. Coding of information for the map was done by two authors working independently. Impact evaluations were critically appraised according to methods of conduct and reporting. Systematic reviews were critically appraised using a new approach to assess theory-based, mixed-methods evidence synthesis. Results There has been an enormous growth in impact evaluations and systematic reviews of WASH interventions since the International Year of Sanitation, 2008. There are now at least 367 completed or ongoing rigorous impact evaluations in LMICs, nearly three-quarters of which have been conducted since 2008, plus 43 systematic reviews. Studies have been done in 83 LMICs, with a high concentration in Bangladesh, India, and Kenya. WASH sector programming has increasingly shifted in focus from what technology to supply (e.g., a handwashing station or child's potty), to the best way in which to do so to promote demand. Research also covers a broader set of intervention mechanisms. For example, there has been increased interest in behaviour change communication using psychosocial "triggering", such as social marketing and community-led total sanitation. These studies report primarily on behavioural outcomes. With the advent of large-scale funding, in particular by the Bill & Melinda Gates Foundation, there has been a substantial increase in the number of studies on sanitation technologies, particularly latrines. Sustaining behaviour is fundamental for sustaining health and other quality of life improvements. However, few studies have been done of intervention mechanisms for, or measuring outcomes on sustained adoption of latrines to stop open defaecation. There has also been some increase in the number of studies looking at outcomes and interventions that disproportionately affect women and girls, who quite literally carry most of the burden of poor water and sanitation access. However, most studies do not report sex disaggregated outcomes, let alone integrate gender analysis into their framework. Other vulnerable populations are even less addressed; no studies eligible for inclusion in the map were done of interventions targeting, or reporting on outcomes for, people living with disabilities. We were only able to find a single controlled evaluation of WASH interventions in a health care facility, in spite of the importance of WASH in health facilities in global policy debates. The quality of impact evaluations has improved, such as the use of controlled designs as standard, attention to addressing reporting biases, and adequate cluster sample size. However, there remain important concerns about quality of reporting. The quality and usefulness of systematic reviews for policy is also improving, which draw clearer distinctions between intervention mechanisms and synthesise the evidence on outcomes along the causal pathway. Adopting mixed-methods approaches also provides information for programmes on barriers and enablers affecting implementation. Conclusion Ensuring everyone has access to appropriate water, sanitation, and hygiene facilities is one of the most fundamental of challenges for poverty elimination. Researchers and funders need to consider carefully where there is the need for new primary evidence, and new syntheses of that evidence. This study suggests the following priority areas:Impact evaluations incorporating understudied outcomes, such as sustainability and slippage, of WASH provision in understudied places of use, such as health care facilities, and of interventions targeting, or presenting disaggregated data for, vulnerable populations, particularly over the life-course and for people living with a disability;Improved reporting in impact evaluations, including presentation of participant flow diagrams; andSynthesis studies and updates in areas with sufficient existing and planned impact evaluations, such as for diarrhoea mortality, ARIs, WASH in schools and decentralisation. These studies will preferably be conducted as mixed-methods systematic reviews that are able to answer questions about programme targeting, implementation, effectiveness and cost-effectiveness, and compare alternative intervention mechanisms to achieve and sustain outcomes in particular contexts, preferably using network meta-analysis.
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Affiliation(s)
- Hannah Chirgwin
- International Initiative for Impact Evaluation (3ie)London International Development CentreLondonUK
| | | | | | - Hugh Sharma Waddington
- London School of Hygiene and Tropical Medicine and International Initiative for Impact Evaluation (3ie)London International Development CentreLondonUK
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Heylen C, Oliveira Aguiar A, String G, Domini M, Goff N, Murray A, Asatekin A, Lantagne D. Laboratory Efficacy of Locally Available Backwashing Methods at Removing Fouling in Hollow-Fiber Membrane Filters Used for Household Water Treatment. MEMBRANES 2021; 11:375. [PMID: 34065587 PMCID: PMC8161404 DOI: 10.3390/membranes11050375] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 03/25/2021] [Revised: 05/10/2021] [Accepted: 05/18/2021] [Indexed: 11/17/2022]
Abstract
Hollow-fiber membrane filters (HFMFs) for household water treatment (HWT) can efficaciously remove disease-causing organisms in laboratory settings. However, lower effectiveness in use in low- and middle-income countries (LMICs) and humanitarian contexts (HCs) has been observed and attributed to membrane fouling and the associated cleaning. In LMICs/HCs, it is not possible to prevent and control fouling using commonly known methods (e.g., testing influent water, maintenance regimes), and the literature on fouling/cleaning of HFMFs distributed in LMICs is scarce. As such, controlled laboratory experiments were conducted to determine the efficacy of locally available (in LMICs/HCs) backwashing solutions at removing fouling using different influent waters and HFMF types. Four commonly distributed HFMFs were selected; fouling layers were developed by filtering three influent water compositions, representing LMIC/HC waters, for 10-days, and bleach, water, or vinegar backwashing solutions were used for daily backwashing. Filter performance indicators included: fiber mechanical properties (strain at break, break force), water quantity performance (flow), water quality performance (turbidity, E. coli), and imaging. The study found fouling developed rapidly and altered mechanical properties and water quantity indicators within 200 h of filtration. Fouling did not decrease water quality indicators. Backwashing improved the filter's mechanical properties and water quantity performance, but it did not fully recover the initial performance. Additionally, recovery differed between backwashing solutions, and no universal cleaning recommendation appropriate for HFMFs in LMICs/HCs was identified. Overall, fouling development and control depended on HFMF type, influent water quality, and backwashing solution type; thus, caution before distributing HFMFs for long-term use in LMICs/HCs is recommended.
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Affiliation(s)
- Camille Heylen
- Department of Civil and Environmental Engineering, Tufts University, Medford, MA 02155, USA; (G.S.); (M.D.); (A.M.); (D.L.)
| | - Alice Oliveira Aguiar
- Department of Chemical and Biological Engineering, Tufts University, Medford, MA 02155, USA; (A.O.A.); (N.G.); (A.A.)
| | - Gabrielle String
- Department of Civil and Environmental Engineering, Tufts University, Medford, MA 02155, USA; (G.S.); (M.D.); (A.M.); (D.L.)
| | - Marta Domini
- Department of Civil and Environmental Engineering, Tufts University, Medford, MA 02155, USA; (G.S.); (M.D.); (A.M.); (D.L.)
| | - Nathaniel Goff
- Department of Chemical and Biological Engineering, Tufts University, Medford, MA 02155, USA; (A.O.A.); (N.G.); (A.A.)
| | - Anna Murray
- Department of Civil and Environmental Engineering, Tufts University, Medford, MA 02155, USA; (G.S.); (M.D.); (A.M.); (D.L.)
| | - Ayse Asatekin
- Department of Chemical and Biological Engineering, Tufts University, Medford, MA 02155, USA; (A.O.A.); (N.G.); (A.A.)
| | - Daniele Lantagne
- Department of Civil and Environmental Engineering, Tufts University, Medford, MA 02155, USA; (G.S.); (M.D.); (A.M.); (D.L.)
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Goddard FGB, Pickering AJ, Ercumen A, Brown J, Chang HH, Clasen T. Faecal contamination of the environment and child health: a systematic review and individual participant data meta-analysis. Lancet Planet Health 2020; 4:e405-e415. [PMID: 32918886 PMCID: PMC7653404 DOI: 10.1016/s2542-5196(20)30195-9] [Citation(s) in RCA: 19] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/14/2020] [Revised: 07/21/2020] [Accepted: 07/22/2020] [Indexed: 05/10/2023]
Abstract
BACKGROUND Exposure to faecal contamination is believed to be associated with child diarrhoea and possibly stunting; however, few studies have explicitly measured the association between faecal contamination and health. We aimed to assess individual participant data (IPD) across multiple trials and observational studies to quantify the relationship for common faecal-oral transmission pathways. METHODS We did a systematic review and meta-analysis of IPD from studies identified in an electronic search of PubMed, Web of Science, and Embase on May 21, 2018. The search was done in English, but full texts published in French, Portuguese, and Spanish were also reviewed. Eligible studies quantified (1) household-level faecal indicator bacteria concentrations along common faecal-oral transmission pathways of drinking water, soil, or food, on children's hands or fomites, or fly densities in food preparation areas; and (2) individual-level diarrhoea or linear growth measures for children younger than 5 years in low-income and middle-income countries. For the diarrhoea analysis, all definitions of diarrhoea were eligible but studies were excluded if they used a recall period longer than 7 days. For the linear growth analysis (using height-for-age Z scores [HAZ]), cross-sectional studies were excluded, because of the absence of longitudinal environmental contamination data measured before the growth outcomes. We used multilevel generalised mixed-effects models to estimate the odds ratio (OR) for diarrhoea and the difference in HAZ scores for individual studies associated with a 1-log10 higher measure of faecal contamination. Estimates from each study were combined under a random-effects meta-analysis framework. The study protocol was pre-registered with PROSPERO (CRD42018102114). FINDINGS From 72 eligible studies, we included IPD for 20 studies in the meta-analyses, totalling 54 225 diarrhoea or linear growth observations matched to faecal indicator bacteria concentrations in drinking water, and a further 35 010 observations with faecal contamination data for the other transmission pathways. Child diarrhoea was associated with 1-log10 higher faecal indicator bacteria concentrations in drinking water (OR 1·09, 95% CI 1·04 to 1·13; p=0·0002, I2=34%, 95% CI 0 to 62) and on children's hands (1·11, 1·02 to 1·22; p=0·021, I2=0%, 0 to 71). Lower HAZ scores were associated with 1-log10 higher median faecal indicator bacteria concentrations in drinking water (HAZ -0·04, 95% CI -0·06 to -0·01; p=0·0054; I2=19%, 95% CI 0 to 63) and on fomites (-0·06, -0·12 to 0·00; p=0·044, I2=57%, 0 to 90). INTERPRETATION Although summary measures from individual studies often report little or no effect of measured faecal contamination on child health, this multi-study IPD analysis indicates that household faecal indicator bacteria concentrations are associated with important adverse health outcomes in young children. Improved direct measures of exposure and enteric pathogens could help to better characterise the relationship and inform intervention design in future studies. FUNDING None.
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Affiliation(s)
- Frederick G B Goddard
- Gangarosa Department of Environmental Health, Rollins School of Public Health, Emory University, Atlanta, GA, USA; Department of Epidemiology, Harvard TH Chan School of Public Health, Boston, MA, USA.
| | - Amy J Pickering
- Department of Civil and Environmental Engineering, School of Engineering, Tufts University, Medford, MA, USA
| | - Ayse Ercumen
- Department of Forestry and Environmental Resources, North Carolina State University, Raleigh, NC, USA
| | - Joe Brown
- School of Civil and Environmental Engineering, Georgia Institute of Technology, Atlanta, GA, USA
| | - Howard H Chang
- Department of Biostatistics and Bioinformatics, Rollins School of Public Health, Emory University, Atlanta, GA, USA
| | - Thomas Clasen
- Gangarosa Department of Environmental Health, Rollins School of Public Health, Emory University, Atlanta, GA, USA
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Fagerli K, Gieraltowski L, Nygren B, Foote E, Gaines J, Oremo J, Odhiambo A, Kim S, Quick R. Use, Acceptability, Performance, and Health Impact of Hollow Fiber Ultrafilters for Water Treatment in Rural Kenyan Households, 2009-2011. Am J Trop Med Hyg 2020; 103:465-471. [PMID: 32274986 DOI: 10.4269/ajtmh.19-0862] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022] Open
Abstract
Diarrheal illness remains a leading cause of morbidity and mortality in children < 5 years in developing countries, and contaminated water contributes to diarrhea risk. To address this problem, a novel hollow fiber ultrafilter (HFU) was developed for household water treatment. To test its impact on water quality and infant health, we conducted a cluster-randomized longitudinal evaluation in 10 intervention and 10 comparison villages in Kenya, attempting to enroll all households with infants (< 12 months old). We conducted a baseline survey, distributed HFUs to intervention households, made biweekly home visits for 1 year to assess water treatment practices and diarrhea in infants, and tested water samples from both groups every 2 months for Escherichia coli. We enrolled 92 infants from intervention households and 74 from comparison households. During the 1-year study period, 45.7% of intervention households and 97.3% of comparison households had at least one stored water sample test positive for E. coli. Compared with comparison households, the odds of E. coli contamination in stored water was lower for intervention households (odds ratio [OR]: 0.42, 95% CI: 0.24, 0.74), but there was no difference in the odds of reported diarrhea in infants, adjusting for covariates (OR: 1.19, 95% CI: 0.74, 1.90). Although nearly all water samples obtained from unprotected sources and filtered by the HFU were free of E. coli contamination, HFUs alone were not effective at reducing diarrhea in infants.
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Affiliation(s)
- Kirsten Fagerli
- Division of Foodborne, Waterborne, and Environmental Diseases, Centers for Disease Control and Prevention, Atlanta, Georgia
| | - Laura Gieraltowski
- Epidemic Intelligence Service, Centers for Disease Control and Prevention, Atlanta, Georgia
| | - Benjamin Nygren
- Division of Foodborne, Waterborne, and Environmental Diseases, Centers for Disease Control and Prevention, Atlanta, Georgia
| | | | - Joanna Gaines
- Epidemic Intelligence Service, Centers for Disease Control and Prevention, Atlanta, Georgia
| | | | | | - Sunkyung Kim
- Division of Foodborne, Waterborne, and Environmental Diseases, Centers for Disease Control and Prevention, Atlanta, Georgia
| | - Robert Quick
- Division of Foodborne, Waterborne, and Environmental Diseases, Centers for Disease Control and Prevention, Atlanta, Georgia
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Backer HD, Derlet RW, Hill VR. Wilderness Medical Society Clinical Practice Guidelines for Water Disinfection for Wilderness, International Travel, and Austere Situations. Wilderness Environ Med 2019; 30:S100-S120. [PMID: 31668519 PMCID: PMC10961709 DOI: 10.1016/j.wem.2019.06.006] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2018] [Revised: 05/18/2019] [Accepted: 06/14/2019] [Indexed: 11/23/2022]
Abstract
To provide guidance to clinicians, the Wilderness Medical Society convened experts to develop evidence-based guidelines for water disinfection in situations where the potability of available water is not ensured, including wilderness and international travel, areas affected by disaster, and other areas without adequate sanitation. The guidelines present the available methods for reducing or eliminating microbiologic contamination of water for individuals, groups, or households; evaluation of their effectiveness; and practical considerations. The evidence evaluation includes both laboratory and clinical publications. The panel graded the recommendations based on the quality of supporting evidence and the balance between benefits and risks or burdens, according to the criteria published by the American College of Chest Physicians.
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Affiliation(s)
- Howard D Backer
- California Emergency Medical Services Authority, Racho Cordova, CA.
| | - Robert W Derlet
- Emergency Department, University of California, Davis, Sacramento, CA
| | - Vincent R Hill
- Division of Foodborne, Waterborne and Environmental Diseases, Waterborne Disease Prevention Branch, Centers for Disease Control and Prevention, Atlanta, GA
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Kirby MA, Nagel CL, Rosa G, Zambrano LD, Musafiri S, Ngirabega JDD, Thomas EA, Clasen T. Effects of a large-scale distribution of water filters and natural draft rocket-style cookstoves on diarrhea and acute respiratory infection: A cluster-randomized controlled trial in Western Province, Rwanda. PLoS Med 2019; 16:e1002812. [PMID: 31158266 PMCID: PMC6546207 DOI: 10.1371/journal.pmed.1002812] [Citation(s) in RCA: 36] [Impact Index Per Article: 7.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/18/2018] [Accepted: 04/23/2019] [Indexed: 12/26/2022] Open
Abstract
BACKGROUND Unsafe drinking water and household air pollution (HAP) are major causes of morbidity and mortality among children under 5 in low and middle-income countries. Household water filters and higher-efficiency biomass-burning cookstoves have been widely promoted to improve water quality and reduce fuel use, but there is limited evidence of their health effects when delivered programmatically at scale. METHODS AND FINDINGS In a large-scale program in Western Province, Rwanda, water filters and portable biomass-burning natural draft rocket-style cookstoves were distributed between September and December 2014 and promoted to over 101,000 households in the poorest economic quartile in 72 (of 96) randomly selected sectors in Western Province. To assess the effects of the intervention, between August and December, 2014, we enrolled 1,582 households that included a child under 4 years from 174 randomly selected village-sized clusters, half from intervention sectors and half from nonintervention sectors. At baseline, 76% of households relied primarily on an improved source for drinking water (piped, borehole, protected spring/well, or rainwater) and over 99% cooked primarily on traditional biomass-burning stoves. We conducted follow-up at 3 time-points between February 2015 and March 2016 to assess reported diarrhea and acute respiratory infections (ARIs) among children <5 years in the preceding 7 days (primary outcomes) and patterns of intervention use, drinking water quality, and air quality. The intervention reduced the prevalence of reported child diarrhea by 29% (prevalence ratio [PR] 0.71, 95% confidence interval [CI] 0.59-0.87, p = 0.001) and reported child ARI by 25% (PR 0.75, 95% CI 0.60-0.93, p = 0.009). Overall, more than 62% of households were observed to have water in their filters at follow-up, while 65% reported using the intervention stove every day, and 55% reported using it primarily outdoors. Use of both the intervention filter and intervention stove decreased throughout follow-up, while reported traditional stove use increased. The intervention reduced the prevalence of households with detectable fecal contamination in drinking water samples by 38% (PR 0.62, 95% CI 0.57-0.68, p < 0.0001) but had no significant impact on 48-hour personal exposure to log-transformed fine particulate matter (PM2.5) concentrations among cooks (β = -0.089, p = 0.486) or children (β = -0.228, p = 0.127). The main limitations of this trial include the unblinded nature of the intervention, limited PM2.5 exposure measurement, and a reliance on reported intervention use and reported health outcomes. CONCLUSIONS Our findings indicate that the intervention improved household drinking water quality and reduced caregiver-reported diarrhea among children <5 years. It also reduced caregiver-reported ARI despite no evidence of improved air quality. Further research is necessary to ascertain longer-term intervention use and benefits and to explore the potential synergistic effects between diarrhea and ARI. TRIAL REGISTRATION Clinical Trials.gov NCT02239250.
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Affiliation(s)
- Miles A. Kirby
- London School of Hygiene and Tropical Medicine, London, United Kingdom
- Emory University Rollins School of Public Health, Emory University, Atlanta, Georgia, United States of America
| | - Corey L. Nagel
- University of Arkansas for Medical Sciences, Little Rock, Arkansas, United States of America
| | - Ghislaine Rosa
- London School of Hygiene and Tropical Medicine, London, United Kingdom
| | - Laura D. Zambrano
- Emory University Rollins School of Public Health, Emory University, Atlanta, Georgia, United States of America
| | - Sanctus Musafiri
- University of Rwanda School of Medicine and Pharmacy, Butare, Rwanda
| | - Jean de Dieu Ngirabega
- Rwanda Biomedical Center, Kigali, Rwanda
- East African Health Research Commission, Arusha, United Republic of Tanzania
| | - Evan A. Thomas
- Mortenson Center in Global Engineering, University of Colorado Boulder, Boulder, Colorado, United States of America
| | - Thomas Clasen
- London School of Hygiene and Tropical Medicine, London, United Kingdom
- Emory University Rollins School of Public Health, Emory University, Atlanta, Georgia, United States of America
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