Association of Supply Type with Fecal Contamination of Source Water and Household Stored Drinking Water in Developing Countries: A Bivariate Meta-analysis

Prevalence and epidemiological distribution of indicators of pathogenic bacteria in households drinking water in Ethiopia: a systematic review and meta-analysis

BACKGROUND

Ensuring the availability of safe drinking water remains a critical challenge in developing countries, including Ethiopia. Therefore, this paper aimed to investigate the prevalence of fecal coliform and E. coli bacteria and, geographical, children availability, and seasonal exposure assessment through a meta-analysis.

METHODS

Two independent review groups extensively searched internet databases for English-language research articles published between 2013 and 2023. This systematic review and meta-analysis followed PRISMA guidelines. The methodological quality of each included study was evaluated using the STROBE guidelines. Publication bias was assessed by visual inspection of a funnel plot and then tested by the Egger regression test, and meta-analysis was performed using DerSimonian and Laird random-effects models with inverse variance weighting. Subgroup analyses were also conducted to explore heterogeneity.

RESULTS

Out of 48 potentially relevant studies, only 21 fulfilled the inclusion criteria and were considered for meta-analysis. The pooled prevalence of fecal coliform and E. coli was 64% (95% CI: 56.0-71.0%, I2 = 95.8%) and 54% (95% CI: 45.7-62.3%, I2 = 94.2%), respectively. Subgroup analysis revealed that the prevalence of fecal coliform bacteria increased during the wet season (70%) compared to the dry season (60%), particularly in households with under-five children (74%) compared to all households (61%), in rural (68%) versus urban (66%) areas, and in regions with high prevalence such as Amhara (71%), Gambela (71%), and Oromia (70%). Similarly, the prevalence of E. coli was higher in households with under-five children (66%) than in all households (46%).

CONCLUSIONS

The analysis highlights the higher prevalence of fecal coliform and E. coli within households drinking water, indicating that these bacteria are a significant public health concern. Moreover, these findings emphasize the critical need for targeted interventions aimed at improving drinking water quality to reduce the risk of fecal contamination and enhance public health outcomes for susceptible groups, including households with under-five children, in particular geographical areas such as the Amhara, Gambela, and Oromia regions, as well as rural areas, at point-of-use, and during the rainy season.

REGISTRATION

This review was registered on PROSPERO (registration ID - CRD42023448812).

Identifying predictors of E. coli in rural household water in sub-Saharan Africa using elimination regression

Exposure to fecally contaminated drinking water contributes to the global disease burden, especially in sub-Saharan Africa (SSA). We used cross-sectional data and elimination regression analysis to examine factors influencing E. coli contamination in household drinking water samples from 4,499 rural households in nine countries in SSA (Malawi, Mozambique, and Zambia in Southern Africa; Ghana, Mali, and Niger in Western Africa; and Kenya, Rwanda, and Tanzania in Eastern Africa). The proportion of household water samples containing E. coli was 71%, ranging from 45% (Malawi) to 89% (Tanzania). Pooled and multi-country predictive logistic regression models showed that using an unimproved-type water source, the absence of a community water committee, and domestic animal ownership were significantly associated with household drinking water contamination. Household water treatment and storage practices, sanitation and hygiene practices, and payment for drinking water were not significantly associated with E. coli contamination in any model. The season was a significant predictor of E. coli in the pooled model; samples collected in the rainy season were 2.3 [2.0, 2.7] times as likely to be contaminated with E. coli. Practitioners and policymakers should prioritize implementing piped on-plot water services, establishing effective local water source management structures, and incorporating animal husbandry practices into water, sanitation, and hygiene interventions.

Seasonal Variations in Household Water Use, Microbiological Water Quality, and Challenges to the Provision of Adequate Drinking Water: A Case of Peri-urban and Informal Settlements of Hosanna Town, Southern Ethiopia

Several studies have been conducted on household water use and microbial water quality globally. However, studies that considered seasonal variability of household water use and microbial water quality were limited. Therefore, this study investigated the seasonal variability of household water use, microbiological water quality, and challenges to the provision of adequate water in the peri-urban and informal settlements of Hosanna town, Southern Ethiopia. A longitudinal study was conducted on 288 households. The data was gathered using a pretested structured questionnaire, laboratory-analysis, interviews, storage-container inventories, focus group discussions, key-informant interviews, and an observational checklist. The data was analyzed using stepwise-multiple linear regression, bivariate and multivariable logistic regression, thematic-analysis, t-tests, and non-parametric-tests. Households were visited for 7 consecutive days during the dry and rainy seasons to account for changes in daily and seasonal variation of water use. 440 stored water and 12 source samples were analyzed for E. coli presence during dry and rainy seasons. The prevalence of stored water contamination with E. coli was 43.2% and 34.5% during the dry and rainy seasons, respectively. The per capita water consumption was 19.4 and 20.3 l during the dry and rainy seasons, respectively. Piped water on-premises, small family size, volume, and number of water storage containers were significant predictors of per capita water consumption in both seasons. Piped water off-premises, storing water for more than 3 days, uncovered, and wide-mouthed water storage containers were significantly associated with the presence of E. coli in water in both seasons. Seasonal variability of household water use and microbiological water quality was statistically significant, which is a significant public health concern and needs intervention to enhance water quantity and quality to mitigate the risk of waterborne diseases. Findings also suggest seasonal monitoring of the safety of drinking water to ensure that the water is safe and healthy.

Assessment of current water, sanitation, and hygiene (WASH) practices in the third and ninth districts of N'Djamena, Chad

Access to safe drinking water, sanitation, and hygiene in Chad's cities, especially N'Djamena, is a persistent and significant challenge. This study aimed to assess current practices in water, sanitation, and hygiene in N'Djamena's third and ninth districts. We surveyed 395 households, conducted water source identification, and analyzed seven water samples at the National Water Laboratory. Temperature, ammonium, total coliforms, and aerobic flora values exceeded World Health Organization (WHO) guidelines. Ammonium and temperature averaged 0.7 mg/L and 30.1-31.93 °C, respectively. Bacterial contamination (>100 MPN/100 mL) exceeded the WHO's 0 MPN/100 mL guidelines, rendering the water unfit for consumption. Survey results indicate that 78.7% use hand pumps, 21.1% have tap water access, and 0.2% rely on rivers for water. Regarding toilets, 92.8% have traditional models, 2.9% have modern facilities, and 4.3% practice open defecation. 95% dispose of untreated wastewater into nature, with only 5% using septic tanks. For solid waste, 72% use illegal dumpsites, 18% rely on public services, and 10% burn waste. Finally, 95.5% of households wash their hands with clean water and soap after using the toilet. It is crucial to treat drinking water and implement proper hygiene and sanitation measures to safeguard the population's health in the studied area.

Factors that influence safe water drinking practices among older persons in slums of Kampala: Analyzing disparities in boiling water

INTRODUCTION

Safe drinking water practice is a key public health promotion strategy for reducing the spread of waterborne diseases. The purpose of this study was to investigate the factors that influence boiling water practice among older persons in informal settlements of Kampala.

METHODS

We collected primary data on "Access to safe water and health services among older persons in informal settlements of Kampala in October 2022. The study interviewed 593 men and women aged 60 years and older. The Complementary log-log multivariable technique was used to establish the association between boiling water practice and selected independent variables.

RESULTS

The results show that nearly 8% of the respondents did not boil their water for drinking. The findings show that the female older persons had increased odds of boiling water to make it safe for drinking compared to their male counterparts (OR = 1.859, 95% CI = 1.384-2.495). Other factors associated with boiling water practice among older persons in the informal settlements of Kampala were; living alone, quality of house, and type of water source.

CONCLUSION

Basing on our findings, we find that older women are more likely to use safe drinking water practice (boiling) compared to the male older persons. Health education majorly targeting older men about the importance and health benefits associated with safe water drinking practices should be prioritized by policy makers. There is need to improve housing conditions of older persons to minimize typhoid, diarrhea and other health risks associated with drinking unsafely managed water.

Multiscalar Evaluation of the Water Distribution System and Diarrheal Disease Risk in Addis Ababa, Ethiopia

Despite growing urbanization, our understanding of the impacts of water and sanitation on human health has largely come from studies in rural sectors. To this end, we collected data at both regional (water quality measures from water treatment systems) and community (cross-sectional surveys) scales to examine determinants of enteric pathogen infection and diarrheal disease among infants in Addis Ababa, Ethiopia. Regionally, the Legedadi water treatment plant had significantly lower heterotrophic plate counts, total coliform counts, and fecal coliform counts compared with the Gefersa water treatment plant. The number of pathogen types in infant stool also differed by plant. Decreases in chlorine levels and increases in the relative abundance of Gammaproteobacteria with distance from treatment plants suggest a compromised water distribution system. In communities, infants in households that obtained water from yard pipes or public taps had significantly lower odds of diarrhea compared to households that had water piped into their dwellings (OR = 0.35, 95% CI 0.16, 0.76, and OR = 0.39, 95% CI 0.15, 1.00, respectively). Similarly, infants in households that boiled or filtered water had significantly lower odds of diarrhea compared to households that did not treat water (OR = 0.40, 95% CI 0.19, 0.86 and OR = 0.23, 95% CI 0.06, 0.84, respectively). Integrating multiscalar data better informs the health impacts of water in urban settings.

Assessing surface water pollution in Hanoi, Vietnam, using remote sensing and machine learning algorithms

Rapid urbanization led to significant land-use changes and posed threats to surface water bodies worldwide, especially in the Global South. Hanoi, the capital city of Vietnam, has been facing chronic surface water pollution for more than a decade. Developing a methodology to better track and analyze pollutants using available technologies to manage the problem has been imperative. Advancement of machine learning and earth observation systems offers opportunities for tracking water quality indicators, especially the increasing pollutants in the surface water bodies. This study introduces machine learning with the cubist model (ML-CB), which combines optical and RADAR data, and a machine learning algorithm to estimate surface water pollutants including total suspended sediments (TSS), chemical oxygen demand (COD), and biological oxygen demand (BOD). The model was trained using optical (Sentinel-2A and Sentinel-1A) and RADAR satellite images. Results were compared with field survey data using regression models. Results show that the predictive estimates of pollutants based on ML-CB provide significant results. The study offers an alternative water quality monitoring method for managers and urban planners, which could be instrumental in protecting and sustaining the use of surface water resources in Hanoi and other cities of the Global South.

Isolation and Identification of Coliform Bacteria and Multidrug-Resistant Escherichia coli from Water Intended for Drug Compounding in Community Pharmacies in Jordan

(1) Background: Water is necessary for the preparation of some medicines found in pharmacies where the local water source does not meet the required purity. This study aimed to investigate the presence of coliform contamination in water used for drug reconstitution in community pharmacies in Jordan. (2) Methods: Two water samples from 50 randomly selected community pharmacies representing all Jordanian governorates were filtered and then cultured in plate count agars to determine total microbial count, and in m-Endo Agar Les and Eosin Methylene Blue (EMB) agar to cultivate Escherichia coli (E. coli). The presence of E. coli was further characterized with gram stains, biochemical tests, and Polymerase chain reaction (PCR). Antibiotic susceptibility of isolated E. coli was tested against a variety of standard antibiotics. (3) Results: Community pharmacies used droppers filled with water from coolers (62%), bottled water (20%), boiled tap water (16%) and tap water (2%). The majority of the sampled water contained coliform bacteria (88%), and E. coli was isolated from 26% of all samples. Statistical analysis showed no significant difference in the percentage of contaminated water samples based on its source location. Nonetheless, the results showed a tendency for higher proportions of contamination in droppers filled from boiled tap water (37.5%; SE: 17.1), followed by water from water coolers (25.8%; SE: 7.9), and then from bottled water (20%; SE: 12.7). All of the isolated E. coli were sensitive to gentamycin, ciprofloxacin and levofloxacin. The susceptibility of the isolates to ceftazidime, doxycycline, tetracycline, azithromycin and amoxicillin/clavulanic acid were 92%, 61%, 46%, 23% and 15%, respectively. (4) Conclusions: This study confirms the widespread presence of multidrug-resistant bacteria in water intended for reconstituting drugs in local pharmacies. These findings expose an alarming situation that needs special attention by the acting pharmacists and competent authorities. Higher levels of personal hygiene in the pharmacies coupled with regular inspection of water quality may reduce the risk of microbial contamination in compounded products, especially multidrug-resistant strains of E. coli and other index microorganisms.

Global occurrence of SARS-CoV-2 in environmental aquatic matrices and its implications for sanitation and vulnerabilities in Brazil and developing countries

This paper includes a systematic review of the SARS-CoV-2 occurrence in environmental aquatic matrices and a critical sanitation analysis. We discussed the interconnection of sanitation services (wastewater, water supply, solid waste, and stormwater drainage) functioning as an important network for controlling the spread of SARS-CoV-2 in waters. We collected 98 studies containing data of the SARS-CoV-2 occurrence in aquatic matrices around the world, of which 40% were from developing countries. Alongside a significant number of people infected by the virus, developing countries face socioeconomic deficiencies and insufficient public investment in infrastructure. Therefore, our study focused on highlighting solutions to provide sanitation in developing countries, considering the virus control in waters by disinfection techniques and sanitary measures, including alternatives for the vulnerable communities. The need for multilateral efforts to improve the universal coverage of sanitation services demands urgent attention in a pandemic scenario.

Monitoring Drinking Water Quality in Nationally Representative Household Surveys in Low- and Middle-Income Countries: Cross-Sectional Analysis of 27 Multiple Indicator Cluster Surveys 2014-2020

BACKGROUND

The 2030 Sustainable Development Goals (SDGs) set an ambitious new benchmark for safely managed drinking water services (SMDWs), but many countries lack national data on the availability and quality of drinking water.

OBJECTIVES

We quantified the availability and microbiological quality of drinking water, monitored SMDWs, and examined risk factors for Escherichia coli (E. coli) contamination in 27 low-and middle-income countries (LMICs).

METHODS

A new water quality module for household surveys was implemented in 27 Multiple Indicator Cluster Surveys. Teams used portable equipment to measure E. coli at the point of collection (PoC, n=61,170) and at the point of use (PoU, n=64,900) and asked respondents about the availability and accessibility of drinking water. Households were classified as having SMDW services if they used an improved water source that was free of E. coli contamination at PoC, accessible on premises, and available when needed. Compliance with individual SMDW criteria was also assessed. Modified Poisson regression was used to explore household and community risk factors for E. coli contamination.

RESULTS

E. coli was commonly detected at the PoC (range 16-90%) and was more likely at the PoU (range 19-99%). On average, 84% of households used an improved drinking water source, and 31% met all of the SMDW criteria. E. coli contamination was the primary reason SMDW criteria were not met (15 of 27 countries). The prevalence of E. coli in PoC samples was lower among households using improved water sources [risk ratio (RR)=0.74; 95% confidence interval (CI): 0.64, 0.85] but not for households with water accessible on premises (RR=0.99; 95% CI: 0.94, 1.05) or available when needed (RR=0.95; 95% CI: 0.88, 1.02). E. coli contamination of PoU samples was less common for households in the richest vs. poorest wealth quintile (RR=0.70; 95% CI: 0.55, 0.88) and in communities with high (>75%) improved sanitation coverage (RR=0.94; 95% CI: 0.90, 0.97). Livestock ownership (RR=1.08; 95% CI: 1.04, 1.13), rural vs. urban residence (RR=1.10; 95% CI: 1.04, 1.16), and wet vs. dry season sampling (RR=1.07; 95% CI: 1.01, 1.15) were positively associated with contamination at the PoU.

DISCUSSION

Cross-sectional water quality data can be collected in household surveys and can be used to assess inequalities in service levels, to track the SDG indicator of SMDWs, and to examine risk factors for contamination. There is an urgent need for better risk management to reduce widespread exposure to fecal contamination through drinking water services in LMICs. https://doi.org/10.1289/EHP8459.

A baseline study of spatial variability of bacteria (total coliform, E. coli, and Enterococcus spp.) as biomarkers of pollution in ten tropical Atlantic beaches: concern for environmental and public health

Coastal water quality in urban cities is increasingly impacted by human activities such as agricultural runoff, sewage discharges, and poor sanitation. However, environmental factors controlling bacteria abundance remain poorly understood. The study employed multiple indicators to assess ten beach water qualities in Ghana during minor wet seasons. Environmental parameters (e.g. temperature, electrical conductivity, total dissolved solids) were measured in situ using the Horiba multiple parameter probe. Surface water samples were collected to measure total suspended solids, nutrients, and chlorophyll-a via standard methods and bacteria determination through membrane filtration. Environmental parameters measured showed no significant variation for the sample period. However, bacteria loads differ significantly (p = 0.024) among the beaches and influenced significantly by nitrate (55.3%, p = 0.02) and total dissolved solids (17.1%, p = 0.017). The baseline study detected an increased amount of total coliforms and faecal indicator bacteria (Escherichia coli and Enterococcus spp.) in beach waters along the coast of Ghana, suggesting faecal contamination, which can pose health risks. The mean ± standard deviations of bacteria loads in beach water are total coliforms (4.06 × 10³ ± 4.16 × 10³ CFU/100 mL), E. coli (7.06 × 10² ± 1.72 × 10³ CFU/100 mL), and Enterococcus spp. (6.15 × 10² ± 1.75 × 10³ CFU/100 mL). Evidence of pollution calls for public awareness to prevent ecological and health-related risks and policy reforms to control coastal water pollution. Future research should focus on identifying the sources of contamination in the tropical Atlantic region.

Faecal contamination of groundwater self-supply in low- and middle income countries: Systematic review and meta-analysis

Self-supply is a ubiquitous response by households to the public water supply inadequacies found worldwide. Self-supply is invested in and managed by an individual household, accessible on-premises and unregulated. Vulnerability to faecal contamination is a concern due to reliance on low-cost technologies and shallow groundwater. This review aims to evaluate the evidence base on the safety of groundwater self-supply in low- and middle income countries in relation to faecal contamination. Differences in microbial water quality between source types, settings, countries and ownership were investigated. A search of peer-reviewed studies in low- and middle income countries was conducted in online databases, including PubMed, Web of Science, ProQuest and Environmental Complete. Studies were included if they had sufficient detail about the water samples to be related to groundwater self-supply, contained extractable data on faecal indicator bacteria (FIB) including thermotolerant coliform or Escherichia coli and were published in English between 1990 and April 2020. A total of 30 studies were included, resulting in 100 datasets and 26,981 water samples across the studies. FIB were present in 36% self-supply samples. The odds of FIB being detected was significantly higher for unimproved sources (OR=8.19, 95% CI [4.04-16.59], p<0.001) and for sources in low income countries (OR=3.85, 95% CI [1.85-7.69], p<0.001). Self-supply was significantly more likely to be contaminated than piped supply (OR=3.45, 95% CI [1.52-7.82], p=0.003). However, water quality was highly heterogeneous (I²=90.9%). Egger's test found no evidence of small study publication bias for self-supply compared to public supply. No evidence of bias due to lack of randomization or season was found, but study design and quality could potentially bias the results. To achieve Sustainable Development Goal 6.1 on safe drinking water for all, more attention is needed from governments to engage with self-supply and formulate balanced policy responses.

The efficiency of natural-ecofriendly clay filters on water purification for improving performance and immunity in broiler chickens

Background

Innovative water treatments and purification processes have become a point of interest to provide solutions and meet the basic water requirements and demands. Clay plays a key role in environmental protection from pollutants through ion exchange and/or adsorption.

Aim

The study evaluated the adsorption and antimicrobial efficiency of clay in purifying polluted water, as well as the influence of clay-purified water on performance, immunity, and microbial counts.

Methods

The experimented 280 one-day-old Hubbard broilers were divided into seven groups on a deep litter system. Polluted water (lead nitrate; 500 mg/l, calcium sulfate; 80 mg/l, yeast extract 5%; 5 mg/l, diazinon; 2.5 ml/l, Salmonella Typhimurium; 1.5 × 106 CFU/ml, and Eimeria tenella; 1 × 105 OPG/ml) was filtered using plastic basins of 1 m3 supplied with 60 cm layer of clay. Broiler groups (G1 to G6) were supplied with clay-filtered and G7 with control tape water. A total of 2,182 samples, including 54 water samples, 266 sera, 266 duodenal swabs, 266 breast muscles, 266 fecal samples, and 1,064 organs including liver, spleen, heart, and bursa of Fabricius were collected.

Results

Weight gains, performance indices, water intakes, water/feed intake ratios, live body weights, carcasses weights, edible and immune organs' weights, immunoglobulin G and M, total antioxidant capacity, lactate dehydrogenase, malondialdehyde, and superoxide dismutase revealed highly significant (p < 0.01) increases in all broiler groups supplemented with clay-filtered water compared to the control group. Meanwhile, total protein, alanine aminotransferase, creatinine, glucose, triglycerides, total cholesterol, cortisol hormone, total bacterial and Enterobacteriaceae counts, total Salmonella counts, and E. tenella counts revealed highly significant (p < 0.01) declines in all broiler groups supplemented with clay-filtered water compared to the control group.

Conclusion

Clay filters provided high filtration, adsorption, and antimicrobial efficiency against polluted water, enhanced water quality, and improved performance and immunity in broiler chickens.

Attributes of drinking water, sanitation, and hygiene associated with microbiological water quality of stored drinking water in rural schools in Mozambique and Uganda

Contaminated drinking water causes morbidity and mortality worldwide, especially in low- and middle-income countries. Drinking water quality has been studied extensively in household settings, but little research is available on drinking water quality in schools. School settings are of particular importance, because children are more susceptible than adults to a variety of diseases from contaminated drinking water. Many school water, sanitation and hygiene (WaSH) interventions have been studied for their efficacy to reduce diarrheal disease incidence, but few have evaluated drinking water quality, which reflects an important exposure pathway between WaSH services and health outcomes. Using school surveys developed from internationally established WaSH indicators and field microbiological water quality tests, we studied 374 rural schools in Mozambique and Uganda to understand the association between specific WaSH services and drinking water microbiological contamination, specifically testing most probable number (MPN) of Escherichia coli, an indicator of fecal contamination, per 100 mL. In Mozambique and Uganda, 71% and 83% respectively of rural schools had low risk drinking water quality (<1 E. coli/100 mL); thirteen percent and seven percent had very high-risk water quality (≥100 E. coli/100 mL). When accounting for all WaSH services studied, schools that used an improved-type water source had 0.22 times less E. coli in stored drinking water in Mozambique (95% CI: 0.07, 0.65) and 0.12 times less E. coli in Uganda (95% CI: 0.02, 0.80). In Mozambique, use of a water source within 30 minutes for travel and collection and the presence of water and soap/ash for handwashing were also significantly associated with less E. coli in drinking water. The findings of this study provide public health practitioners with implementable WaSH services to improve school drinking water quality, which has implications for the health, learning environment, and cognitive development of school children in rural Mozambique and Uganda.

The challenges of monitoring and controlling drinking-water quality in dispersed rural areas: a case study based on two settlements in the Colombian Caribbean

Water quality surveillance systems are hardly applied in rural contexts. To provide a comprehensive analysis of drinking-water quality in two rural settlements in the Colombian Caribbean drinking-water samples were collected and analyzed from storage containers in 42 homes. The results of physical, chemical, and microbiological analyses of the water samples were compared with values established by the World Health Organization (WHO) Guidelines for Drinking-water Quality, and Colombian regulations. The Kruskal-Wallis test was applied to compare each parameter for supply source, season (rainy or dry), settlement, and types of storage. Drinking-water Quality Risk Index (IRCA) was calculated for each of the samples. The water supply sources were varied: well (33.3%), rainwater (23.8%), artificial pond (23.8%), and river (19.0%). One-hundred percent of the samples contained Escherichia coli and total coliforms. The IRCA varied between 57.3 and 83.9, with a median of 72.9. Eighty-eight percent of the samples exhibited high risk levels (35.1 < IRCA < 80.0) and 12% were unsanitary (80.1 < IRCA < 100.0). Artificial pond water was the source of supply with the worst IRCA (83.79). Drinking water in the El Cascajo and La Delfina settlements does not meet international and national drinking-water standards. A change is required whereby monitoring and quality control policies take into account the reality of rural settings.

Factors associated with water quality, sanitation, and hygiene in rural schools in 14 low- and middle-income countries

Improving access to water, sanitation, and hygiene (WaSH) and menstrual hygiene management (MHM) in schools is important to achieve Sustainable Development Goals (SDGs) 3 and 6. Inadequate WaSH and MHM in schools adversely affect student health and educational performance, as well as teacher satisfaction. However, there is little evidence describing factors associated with WaSH services and MHM in schools. We conducted 2690 surveys and collected 1946 water samples at randomly selected schools in rural areas of 14 low- and middle-income countries (LMICs). We developed multilevel mixed-effects logistic regression models to identify factors associated with basic water services, water quality, basic sanitation facilities, basic handwashing facilities, and availability of MHM materials. We found that 51% of schools had at least a basic, on-premises water service. Twenty-eight percent of schools had at least basic sanitation services, 12% had at least a basic handwashing facility, and 26% had MHM materials available. Four percent of schools had all basic WaSH services. Half (52%) of schools had drinking water compliant with the WHO guideline value for E. coli. In regression models, we found that schools that did not share their water point with a community, had a parent-teacher association that supported WaSH, or had support from an external WaSH program were more likely to have access to basic, continuous, on-premises water service versus worse access. Schools with an on-premises water point, water available on the day of survey, a health club, or handwashing stations near toilets were more likely to have a basic sanitation service versus a lower service. Schools with limited or basic sanitation, health clubs, an MHM curriculum, a designated MHM focal person, or school funds for WaSH were more likely to have MHM materials. We conclude that improved institutional management and external support, accountability mechanisms, and enhanced training and hygiene curriculum will support sustained WaSH service delivery in schools in LMICs.

Access to Safe Water, Sanitation, and Hygiene: A Cross-Sectional Study among the Maasai in Tanzania

Safe water supply, sanitation, and hygiene (WaSH) are among key components to prevent and control waterborne diseases such as cholera, schistosomiasis, and other gastrointestinal morbidities in the community. In 2018, there was cholera outbreak in Ngorongoro district that was fueled by inadequate and unsafe water as well as poor sanitation and hygiene. We used an analytical cross-sectional study first to determine the proportion of households with access to WaSH and second to assess factors associated with coverage of household's access to WaSH. Methods included interviewing heads of the household to assess the availability of safe drinking water, use of unshared toilet/latrine by household members only, and the availability of functional handwashing facility. Eight percent of households had access to WaSH. Access to household's WaSH was positively associated with household's monthly income, education of heads of the household, and water use per person per week. To control water-related morbidities, there is a need to improve access to reliable safe drinking water, expand alternatives of households to earn more incomes, and enhance proper sanitation and hygiene services to rural areas and marginalized groups like the Maasai of Ngorongoro in Tanzania.

Housing Quality in a Rural and an Urban Settlement in South Africa

During 2016 to 2018, a prospective household cohort study of influenza and respiratory syncytial virus community burden and transmission dynamics (the PHIRST study) was undertaken to examine the factors associated with influenza and other respiratory pathogen transmissions in South Africa. We collected information on housing conditions in the PHIRST study sites: Rural villages near Agincourt, Bushbuckridge Municipality, Mpumalanga Province, and urban Jouberton Township in North West Province. Survey data were collected from 159 and 167 study households in Agincourt and Jouberton, respectively. Multiple housing-related health hazards were identified in both sites, but particularly in Agincourt. In Agincourt, 75% (119/159) of households reported daily or weekly interruptions in water supply and 98% (154/159) stored drinking water in miscellaneous containers, compared to 1% (1/167) and 69% (115/167) of households in Jouberton. Fuels other than electricity (such as wood) were mainly used for cooking by 44% (70/159) and 7% (11/167) of Agincourt and Jouberton households, respectively; and 67% (106/159) of homes in Agincourt versus 47% (79/167) in Jouberton were located on unpaved roads, which is associated with the generation of dust and particulate matter. This study has highlighted housing conditions in Agincourt and Jouberton that are detrimental to health, and which may impact disease severity or transmission in South African communities.

The utility of Escherichia coli as a contamination indicator for rural drinking water: Evidence from whole genome sequencing

Across the water sector, Escherichia coli is the preferred microbial water quality indicator and current guidance upholds that it indicates recent faecal contamination. This has been challenged, however, by research demonstrating growth of E. coli in the environment. In this study, we used whole genome sequencing to investigate the links between E. coli and recent faecal contamination in drinking water. We sequenced 103 E. coli isolates sampled from 9 water supplies in rural Kitui County, Kenya, including points of collection (n = 14) and use (n = 30). Biomarkers for definitive source tracking remain elusive, so we analysed the phylogenetic grouping, multi-locus sequence types (MLSTs), allelic diversity, and virulence and antimicrobial resistance (AMR) genes of the isolates for insight into their likely source. Phylogroup B1, which is generally better adapted to water environments, is dominant in our samples (n = 69) and allelic diversity differences (z = 2.12, p = 0.03) suggest that naturalised populations may be particularly relevant at collection points with lower E. coli concentrations (<50 / 100mL). The strains that are more likely to have originated from human and/or recent faecal contamination (n = 50), were found at poorly protected collection points (4 sites) or at points of use (12 sites). We discuss the difficulty of interpreting health risk from E. coli grab samples, especially at household level, and our findings support the use of E. coli risk categories and encourage monitoring that accounts for sanitary conditions and temporal variability.

Energy access in Malawian healthcare facilities: consequences for health service delivery and environmental health conditions

Many healthcare facilities (HCFs) in low-income countries experience unreliable connectivity to energy sources, which adversely impacts the quality of health service delivery and provision of adequate environmental health services. This assessment explores the status and consequences of energy access through interviews and surveys with administrators and healthcare workers from 44 HCFs (central hospitals, district hospitals, health centres and health posts) in Malawi. Most HCFs are connected to the electrical grid but experience weekly power interruptions averaging 10 h; less than one-third of facilities have a functional back-up source. Inadequate energy availability is associated with irregular water supply and poor medical equipment sterilization; it adversely affects provider safety and contributes to poor lighting and working conditions. Some challenges, such as poor availability and maintenance of back-up energy sources, disproportionately affect smaller HCFs. Policymakers, health system actors and third-party organizations seeking to improve energy access and quality of care in Malawi and similar settings should address these challenges in a way that prioritizes the specific needs of different facility types.

Seasonality of drinking water sources and the impact of drinking water source on enteric infections among children in Limpopo, South Africa

Enteric infections and water-related illnesses are more frequent during times of relative water abundance, especially in regions that experience bimodal rainfall patterns. However, it is unclear how seasonal changes in water availability and drinking water source types affect enteric infections in young children. This study investigated seasonal shifts in primary drinking water source type and the effect of water source type on enteric pathogen prevalence in stool samples from 404 children below age 5 in rural communities in Limpopo Province, South Africa. From wet to dry season, 4.6% (n = 16) of households switched from a source with a higher risk of contamination to a source with lower risk, with the majority switching to municipal water during the dry season. In contrast, 2.6% (n = 9) of households switched from a source with a lower risk of contamination to a source with higher risk. 74.5% (n = 301) of the total households experienced interruptions in their water supply, regardless of source type. There were no significant differences in enteric pathogen prevalence between drinking water sources. Intermittent municipal water distribution and household water use and storage practices may have a larger impact on enteric infections than water source type. The limited differences in enteric pathogen prevalence in children by water source could also be due to other exposure pathways in addition to drinking water, for example through direct contact and food-borne transmission.

A longitudinal study of the association between domestic contact with livestock and contamination of household point-of-use stored drinking water in rural Siaya County (Kenya)

Background

Emerging evidence suggests close domestic proximity of livestock and humans may lead to microbiological contamination of hands, objects, food and water supplies within domestic environments, adversely impacting public health. However, evidence quantifying the relationship between livestock, domestic animals, humans and microbiological contamination of household stored water remains limited.

Aim

This longitudinal study aimed to examine the relationship between domestic contact with livestock and domestic animals on microbiological contamination of household Point-of-Use (POU) stored drinking water in rural Kenya and assess the influence of choice of faecal indicator on such associations.

Methodology

A survey was performed in 234 households in Siaya county, Kenya, to observe presence of livestock (cattle, goats, poultry) and domestic animals (cats, dogs) in household compounds, alongside other risk factors for contamination of POU stored drinking water such as sanitation, storage conditions and hygiene practices. Samples from water sources (e.g. piped, spring/wells, boreholes, surface and rainwater) and from POU storage containers were tested for E. coli and intestinal enterococci. Livestock-related risk factors for water contamination were examined through multinomial regression, controlling for confounders.

Results

Rainwater was the main POU water source and was found to be highly susceptible to contamination. Multivariate analysis showed greater risk of gross (>100 CFU/100 mL) water contamination (with E. coli) for households where goats were observed, and/or where poultry roosted in proximity to stored household water (relative risk RR = 2.71; p = 0.001 and RR = 2.02; p = 0.012 respectively). Presence of a poultry coop was also associated with elevated intestinal enterococci densities (RR = 4.46; p = 0.001). Associations between contamination and livestock risk factors were thus similar for both bacteria groups, but E. coli counts declined more rapidly following collection from surface waters than enterococci counts (p = 0.024).

Conclusion

The presence of livestock (particularly goats) and poultry within household compounds increases POU water contamination risk, suggesting the need for improved interventions to address cross-contamination within rural domestic settings. Within Siaya county, more effective community education is needed to raise awareness of POU water quality protection, particularly of rainwater.

•

Poultry and goats are risk factors for household stored water contamination.

•

Poultry are risk factors for both enterococci and E. coli contamination.

•

Attenuation of enterococci in household stored water is lower than for E. coli.

•

Residual free chlorine is mostly too low to prevent stored water recontamination.

Application of a Faecalibacterium 16S rDNA genetic marker for species identification of dog fecal waste

A dog-associated 16S rDNA genetic marker (ED-1) was designed to detect dog fecal contamination in water through a comparative bioinformatics analysis of Faecalibacterium sequences. For the dog fecal samples, ED-1 had 100% specificity, a high positive rate (89% in dog feces and 92.3% in dog fecal-contaminated water samples), and a low detection limit (10⁷ copies/100 mL) in dog-contaminated water samples. Detection of water samples from seven provinces or cities of China showed that ED-1 was stable enough to be applied in practice. Furthermore, the abundance and diversity of dog gut microbiota from two private house pets (PHP) and Third Military Medical University (TMMU) dogs were estimated by using operational taxonomic units, and the significant differences of dog feces were found, as the PHP dogs have a more diverse diet and closer contact with human than dogs in TMMU. However, ED-1 could detect the feces from the two regions, indicating that ED-1 has good reliability.

WaSH CQI: Applying continuous quality improvement methods to water service delivery in four districts of rural northern Ghana

Continuous, safely managed water is critical to health and development, but rural service delivery faces complex challenges in low- and middle-income countries (LMICs). We report the first application of continuous quality improvement (CQI) methods to improve the microbial quality of household water for consumption (HWC) and the functionality of water sources in four rural districts of northern Ghana. We further report on the impacts of interventions developed through these methods. A local CQI team was formed and trained in CQI methods. Baseline data were collected and analyzed to identify determinants of service delivery problems and microbial safety. The CQI team randomized communities, developed an improvement package, iteratively piloted it in intervention communities, and used uptake survey data to refine the package. The final improvement package comprised safe water storage containers, refresher training for community WaSH committees and replacement of missing maintenance tools. This package significantly reduced contamination of HWC (p<0.01), and significant reduction in contamination persisted two years after implementation. Repair times in both intervention and control arms decreased relative to baseline (p<0.05), but differences between intervention and control arms were not significant at endline. Further work is needed to build on the gains in household water quality observed in this work, sustain and scale these improvements, and explore applications of CQI to other aspects of water supply and sanitation.

Occurrence and diversity of waterborne fungi and associated mycotoxins in treated drinking water distribution system in South Africa: implications on water quality and public health

Despite increased public health concerns on the occurrences of potentially pathogenic/mycotoxigenic fungi in public drinking water system, dissemination of hygienically relevant fungi and their associated mycotoxins via distribution system under the dual burden of ageing infrastructure and ancillary distribution network lacking infrastructure for high-pressure water delivery systems is unknown. In this study, the diversity of fungi and occurrence of mycotoxins at 30 different points along treated piped water supply and ancillary distribution networks in Johannesburg, South Africa, were monitored for 12 months. Mycological analysis using cultural and molecular methods yielded 282 fungi belonging to phylum Ascomycota, having Aspergillus (91%), Penicillium (65%) and Trichoderma (31%) as dominant genera, with Aspergillus fumigatus, Penicillium citrinum, Purpureocillium lilacinum and Aspergillus flavus as the most prevalent species. Communal standpipe and reservoir outlets had significantly higher prevalence than other water samples. There was no strong correlation between total coliforms (r = 0.4266) and residual chlorine (r = - 0.1937), and fungal prevalence at p < 0.05. LC-MS/MS analysis detected aflatoxins B1, M1, G1 and G2 in 50, 9, 9 and 46% of water samples analysed, respectively, ranging between 0 and 3.18 ng/l. Deoxynivalenol (DON), 3-acetyl DON and 15-acetyl DON levels were between 8.4-96.1, 18.7-145.7 and 15.2-71.6 ng/l, respectively. However, the estimated average daily dose (ADD) for detected mycotoxins was below the tolerable daily intake (TDI), suggesting no toxicological risk. Presence of potentially mycotoxigenic fungi, despite the low toxicological risk, demonstrates a need for appropriate monitoring for fungi and mycotoxins in treated drinking water distribution systems for improved water quality and long-term public health assurance.

Household Water Storage Management, Hygiene Practices, and Associated Drinking Water Quality in Rural India

Household drinking water storage is commonly practiced in rural India. Fecal contamination may be introduced at the water source, during collection, storage, or access. Within a trial of a community-level water supply intervention, we conducted five quarterly household-level surveys to collect information about water, sanitation, and hygiene practices in rural India. In a random subsample of households, we tested stored drinking water samples for Escherichia coli, concurrently observing storage and access practices. We conducted 9961 surveys and collected 3296 stored water samples. Stored water samples were frequently contaminated with E. coli (69%), and E. coli levels were the highest during the wet season. Most households contributing two or more drinking water samples had detectable E. coli in some (47%) or all (44%) samples. Predictors of stored water contamination with E. coli included consumption of river water and open defecation; consumption of reverse osmosis-treated water and safe water access practices appeared to be protective. Until households can be reached with on-premises continuous safe water supplies, suboptimal household water storage practices are likely to continue. Improvements to source water quality alone are unlikely to prevent exposure to contaminated drinking water unless attention is also given to improving household water storage, access, and sanitation practices.

Assessing Drinking Water Quality at the Point of Collection and within Household Storage Containers in the Hilly Rural Areas of Mid and Far-Western Nepal

Accurate assessments of drinking water quality, household hygenic practices, and the mindset of the consumers are critical for developing effective water intervention strategies. This paper presents a microbial quality assessment of 512 samples from household water storage containers and 167 samples from points of collection (POC) in remote rural communities in the hilly area of western Nepal. We found that 81% of the stored drinking water samples (mean log₁₀ of all samples = 1.16 colony-forming units (CFU)/100 mL, standard deviation (SD) = 0.84) and 68% of the POC samples (mean log₁₀ of all samples = 0.57 CFU/100 mL, SD = 0.86) had detectable E. coli. The quality of stored water was significantly correlated with the quality at the POC, with the majority (63%) of paired samples showing a deterioration in quality post-collection. Locally applied household water treatment (HWT) methods did not effectively improve microbial water quality. Among all household sanitary inspection questions, only the presence of livestock near the water storage container was significantly correlated with its microbial contamination. Households' perceptions of their drinking water quality were mostly influenced by the water's visual appearance, and these perceptions in general motivated their use of HWT. Improving water quality within the distribution network and promoting safer water handling practices are proposed to reduce the health risk due to consumption of contaminated water in this setting.

Application of tools to monitor environmental conditions, identify exposures, and inform decision-making to improve infection prevention and control practices in Malawian maternity wards

Healthcare-acquired infections (HAIs) contribute to maternal and neonatal morbidity and mortality, especially in low- and middle-income countries (LMICs). Deficient environmental health (EH) conditions and infection prevention and control (IPC) practices in healthcare facilities (HCFs) contribute to the spread of HAIs, but microbial sampling of sources of contamination is rarely conducted nor reported in low-resource settings. The purpose of this study was to assess EH conditions and IPC practices in Malawian HCFs and evaluate how EH deficiencies contribute to pathogen exposures and HAIs, and to provide recommendations to inform improvements in EH conditions using a mixed-methods approach. Thirty-one maternity wards in government-run HCFs were surveyed in the three regions of Malawi. Questionnaires were administered in parallel with structured observations of EH conditions and IPC practices and microbial testing of water sources and facility surfaces. Results indicated significant associations between IPC practices and microbial contamination. Facilities where separate wards were not available for mothers and newborns with infections and where linens were not used for patients during healthcare services were more likely to have delivery tables with surface contamination (relative risk = 2.23; 1.49, 3.34). E. coli was detected in water samples from seven (23%) HCFs. Our results suggest that Malawian maternity wards could reduce microbial contamination, and potentially reduce the occurrence of HAIs, by improving EH conditions and IPC practices. HCF staff can use the simple, low-cost EH monitoring methods used in this study to incorporate microbial monitoring of EH conditions and IPC practices in HCFs in low-resource settings.

Water insecurity and urban poverty in the Global South: Implications for health and human biology

OBJECTIVES

Over half of the world's population (4 billion people) experience severe water scarcity at least one month per year, while half a billion people experience severe water scarcity throughout the year. Despite progress from national and global interventions, a staggering proportion of the Global South remains water insecure. Rapid urban growth and associated demographic changes, climate change, and governance failure have also fostered the growth and expansion of urban informal settlements and slums where widespread poverty and environmental hazards exacerbate the impact of water insecurity on health. This article reflects on the interactions between water insecurity and urban poverty in the Global South across four categories of health outcomes: gastrointestinal diseases, mosquito-borne diseases, injuries, and mental illness. These examples highlight the mechanisms through which urban poverty exacerbates the adverse health effects of water insecurity.

METHODS

The four selected health outcomes were chosen a priori to represent two communicable conditions with well-developed literatures, and two noncommunicable conditions with newer literatures that have emerged over the last decade. We conducted a narrative literature review of scholarly and gray literature appearing between January 2000 and April 2019 using several online scholarly databases.

RESULTS

Gastrointestinal diseases, mosquito-borne diseases, injuries, and mental illness all exemplified the relationship between water insecurity and urban poverty through human biological pathways. For each of the four health categories, we identified frontiers for human biology research contributions to the water-poverty-health nexus.

CONCLUSIONS

We discuss our findings in the context of three crosscutting themes that merit innovative research approaches: stressor interactions and trade-offs, exposure thresholds, and intervention efficacy. We reiterate that the global burden of disease associated with water insecurity cannot be addressed in isolation from efforts to alleviate extreme poverty.

Faecal contamination of groundwater in rural Vanuatu: prevalence and predictors

Groundwater is an important source of water for coastal communities in Pacific Island Countries. This study assessed the prevalence and predictors of faecal contamination in groundwater sources across 11 islands in Vanuatu. Escherichia coli was detected in 49% of sources and E. coli concentration exceeded 10 MPN (most probable number)/100 mL for 23% of sources. When adjusting for other variables, the detection of E. coli was significantly associated with severe pump stand corrosion, suggestive of contaminated run-off directly entering boreholes. E. coli concentration >10 MPN/100 mL was also significantly associated with: (i) hand-dug wells (as compared to drilled boreholes); (ii) severe pump stand corrosion; (iii) water points underlain by volcanic rocks (as compared to coral limestone); and (iv) rainfall in the previous 24 h. Encasing pump stands in concrete - as some communities had done - was found to have a significant protective effect. While baseline statistics for Sustainable Development Goal target 6.1 suggest that 87% of Vanuatu's rural population have access to at least a basic (improved) water source, the results from this study point to extensive microbial water quality concerns linked to degraded water supply infrastructure in need of rehabilitation.

Understanding the impacts of intermittent supply on the drinking water microbiome

Increasing access to piped water in low-income and middle-income countries combined with the many factors that threaten our drinking water supply infrastructure mean that intermittent water supply (IWS) will remain a common practice around the world. Common features of IWS include water stagnation, pipe drainage, intrusion, backflow, first flush events, and household storage. IWS has been shown to cause degradation as measured by traditional microbial water quality indicators. In this review, we build on new insights into the microbial ecology of continuous water supply systems revealed by sequencing methods to speculate about how intermittent supply conditions may further influence the drinking water microbiome, and identify priorities for future research.

Perceived water insecurity among adults from urban and peri-urban Haiti: A qualitative study

Water and sanitation services are fundamental in preventing the spread of waterborne and hygiene-related diseases. However, in developing countries, such as Haiti, access to clean water continues to pose major challenges despite efforts to improve quality and reduce distance. With Léogâne being the epicenter of the earthquake in Haiti in 2010, there were dozens of interventions aimed to improve access to clean water, specifically well construction and use of water treatment strategies. Using the socioecological framework, this study collected qualitative data to supplement a household water insecurity experiences (HWISE) survey in order to fully understand the narratives around water in Léogâne (urban) and its neighboring commune Gressier (peri-urban). The inclusion criteria for this study was that the participant must be a resident of either site, at least 18 years or older, and a female. Only females were included in this study so that researchers could better understand how perceived water insecurity impacts reproductive health, specifically gynecological infections. This cross-sectional study yielded 61 total in-depth interviews using a semi-structured open ended questionnaire to allow participants the ability to elaborate. Results suggest that there are common misconceptions about water and reproductive health specifically that engaging in sexual intercourse in saltwater will not result in pregnancy. Relevant narratives among the two communes included water acquisition, use of water, and bathing practices, among several others. Through understanding the local Haitian perspective and practices that surround water insecurity, we can better tailor public health interventions to improve access to water, female hygiene practices, and ultimately lower and prevent disease transmission.

Are piped water services reaching poor households? Empirical evidence from rural Viet Nam

The delivery of water services to the poor is lagging, yet local causes and manifestations of this are not well understood. Better data is needed to identify inequalities where they occur, explore underlying reasons, and develop strategies to achieve more equitable access. A focus on the local scale is important because this is where water services are delivered, and inequalities in access can be best observed. This paper presents a mixed-methods study of poor households' access to piped water in rural Viet Nam, providing insight into local dynamics of the water/poverty nexus. Findings pointed to lower rates of piped water access for poor households across areas served by government, private and community service providers. Connection fees were found to be the primary barrier to poor households accessing available piped services. The study also found that where financial support is provided, poor households can achieve comparable or even higher rates of access. Key implications of the study are the demonstrated value of, and yet challenges associated with, rigorous local-level monitoring to ensure equitable, quality service delivery.

Investigation of the water quality of daily used surface-sources for drinking and irrigation by the population of Segou in the center of Mali

This study evaluates the quality and pollution status of source surface waters in Segou, Mali. The nature, sources, and extent of pollution of Comatex Stream, Cerfitex Pond, and Sonikoura River were studied for a period of twelve months (July 2016-June 2017). Analysis included 209 water samples collected from eleven different locations in the study area. Laboratory and field analysis were realized using the standard methods and concerned eleven parameters including four physicals, six chemicals and one bacteriological. Also, organoleptic parameters were observed. Most of the average values of parameters addressing the quality of water were significantly higher (P < 0.05) in both the stream and river compared to the pond. Fecal coliform counts (FCC) were not in significant correlation with the temperature; pH and turbidity; but had a significant and positive correlation (P < 0.05) with conductivity: total dissolved solids (TDS); total suspended solids (TSS); Cl^-; PO₄ ^-P; NO₃ ^-N and 5-day biochemical oxygen demand (BOD₅). Analysis of samples revealed a level of FCC that is above the permissible limit for both drinking water and of fresh vegetable irrigation water. In all, there is a pressing need to inform the public about the state of water bodies and the application of relevant laws regarding the proper treatment of sewage before it is discharged into surface water.

Understanding the Impacts of Short-Term Climate Variability on Drinking Water Source Quality: Observations From Three Distinct Climatic Regions in Tanzania

Climate change is expected to increase waterborne diseases especially in developing countries. However, we lack understanding of how different types of water sources (both improved and unimproved) are affected by climate change, and thus, where to prioritize future investments and improvements to maximize health outcomes. This is due to limited knowledge of the relationships between source water quality and the observed variability in climate conditions. To address this gap, a 20-month observational study was conducted in Tanzania, aiming to understand how water quality changes at various types of sources due to short-term climate variability. Nine rounds of microbiological water quality sampling were conducted for Escherichia coli and total coliforms, at three study sites within different climatic regions. Each round included approximately 233 samples from water sources and 632 samples from households. To identify relationships between water quality and short-term climate variability, Bayesian hierarchical modeling was adopted, allowing these relationships to vary with source types and sampling regions to account for potentially different physical processes. Across water sources, increases in E. coli/total coliform levels were most closely related to increases in recent heavy rainfall. Our key recommendations to future longitudinal studies are (a) demonstrated value of high sampling frequency and temporal coverage (a minimum of 3 years) especially during wet seasons; (b) utility of the Bayesian hierarchical models to pool data from multiple sites while allowing for variations across space and water sources; and (c) importance of a multidisciplinary team approach with consistent commitment and sharing of knowledge.

Development and field testing of low-cost, quantal microbial assays with volunteer reporting as scalable means of drinking water safety estimation

AIMS

To evaluate a low-cost water quality test for at-scale drinking water safety estimation in rural India.

METHODS AND RESULTS

Within a longitudinal study to characterize variability in household drinking water safety in rural Maharashtra, we piloted a low-cost presence-absence (LCPA) microbial test designed to be used by volunteer residents in rural areas. In comparing the LCPA results with standard laboratory methods for enumeration of Escherichia coli, we found that LCPA tests using modified mTec media were highly sensitive in detecting drinking water of moderate risk (88% of tests were positive at E. coli counts of 11-100 CFU per 100 ml) and high risk (96% of tests were positive at E. coli counts of 101 + CFU per 100 ml). The LCPA tests demonstrated low specificity for E. coli specifically, due to concurrent detection of Klebsiella: 38% of LCPA tests were positive even when E. coli was not detected in a 100 ml sample by membrane filtration, suggesting the test would be conservative in risk estimation. We also found that 47% of participants in rural villages in India were willing to conduct tests and return results after a brief training, with 45% of active participants sending their water testing results via short message service.

CONCLUSIONS

Given their low cost (~US$0.50 as piloted) and open-source format, such tests may provide a compelling alternative to standard methods for rapid water quality assessments, especially in resource-limited settings.

SIGNIFICANCE AND IMPACT OF THE STUDY

The lack of availability of water quality data constrains efforts to monitor, evaluate and improve the safety of water and sanitation infrastructure in underserved settings. Current water testing methods are not scalable because of laboratory and cost constraints. Our findings indicate the LCPA or similar low-cost microbial tests could be useful in rapid water safety estimation, including via crowdsourcing.

Effects of improved drinking water quality on early childhood growth in rural Uttar Pradesh, India: A propensity-score analysis

Context

Recent randomised controlled trials in Bangladesh and Kenya concluded that household water treatment, alone or in combination with upgraded sanitation and handwashing, did not reduce linear growth faltering or improve other child growth outcomes. Whether these results are applicable in areas with distinct constellations of water, sanitation and hygiene (WaSH) risks is unknown. Analysis of observational data offers an efficient means to assess the external validity of trial findings. We studied whether a water quality intervention could improve child growth in a rural Indian setting with higher levels of circulating pathogens than the original trial sites.

Methods

We analysed a cross-sectional dataset including a microbiological measure of household water quality. All households accessed water from an improved source. We applied propensity score methods to emulate a randomised trial investigating the hypothesis that receipt of drinking water meeting Sustainable Development Goal (SDG) 6.1 quality standards for absence of faecal contamination leads to improved growth. Growth outcomes (stunting, underweight, wasting, and their corresponding Z-scores) were assessed in children 12–23 months of age. For each outcome, we estimated the mean and 95% confidence interval of the absolute risk difference between treatment groups.

Findings

Of 1088 households, 442 (40.62%) received drinking water meeting SDG 6.1 standards. The adjusted risk of child underweight was 7.4% (1.3% to 13.4%) lower among those drinking water satisfying SDG 6.1 norms than among controls. Evidence concerning the relationship of drinking water meeting SDG 6.1 norms to length-for-age and weight-for-age was inconclusive, and there was no apparent relationship with stunting or wasting.

Conclusions

In contexts characterised by high pathogen transmission, water quality improvements have the potential to reduce the proportion of underweight children, but are unlikely to impact stunting or wasting. Further research is required to assess how these modelled benefits can best be achieved in real world settings.

Multiple water source use in rural Vanuatu: are households choosing the safest option for drinking?

Households in low- and middle-income countries commonly make use of multiple water sources. However, it remains unclear to what extent their drinking water choices are optimal from a health perspective. This matched cohort study across 10 islands in Vanuatu examined communities with both a groundwater and rainwater source to determine whether their preferred drinking option was the safest in microbial terms. In communities that preferred to drink rainwater, 56.5% of rainwater sources had 'high-risk' or 'very high risk' Escherichia coli contamination (> 10 MPN/100 mL) compared with 26.1% of groundwater sources (p = 0.092). Moreover, a preference for drinking rainwater was significantly associated with rainwater sources having 'high-risk' or 'very high risk' levels of E. coli contamination (p = 0.045). Results show that communities do not necessarily choose the safest water source for drinking. Findings also highlight the need to bolster local capacity to manage water quality risks and for Sustainable Development Goal monitoring to distinguish between protected and unprotected rainwater tanks.

Impact of wastewater-irrigation on in-household water contamination. A cohort study among urban farmers in Ahmedabad, India

This cohort study explores the contribution of wastewater irrigation, in the context of WASH (Water, Sanitation, Hygiene), on in-household water contamination among urban farming households in Ahmedabad, India. Drinking water samples of 204 households in four peri-urban farming communities were collected from the point-of-source (PoS) and point-of-use (PoU) of each household four times over the 12-month follow-up period. Next to the quantification of E. coli, three household surveys (baseline, hygiene and farm) were conducted. Additionally, an observational spot-check was undertaken in bi-monthly intervals throughout the follow-up period. Significant positive differences in water quality between PoS and PoU samples were identified in 78% of households. During the monsoon, the peak of contamination, only 6% of households had access to safe drinking water at PoU. The Average Treatment Effect (ATE) of wastewater irrigation indicates an adverse effect on in-household water contamination, larger in effect size than the mitigation effect of access to sanitation or personal hygiene. To control transmission of fecal pathogens, effective barriers are required for wastewater irrigation similar to the necessity of ensuring access to sanitation and practicing adequate hygiene behavior.

Risk of Appendicitis among Children with Different Piped Water Supply: A Nationwide Population-Based Study

Appendicitis is a common surgical condition for children. However, environmental effects, such as piped water supply, on pediatric appendicitis risk remain unclear. This longitudinal, nationwide, cohort study aimed to compare the risk of appendicitis among children with different levels of piped water supply. Using data from Taiwan Water Resource Agency and National Health Insurance Research Database, we identified 119,128 children born in 1996–2010 from areas of the lowest piped water supply (prevalence 51.21% to 63.06%) as the study cohort; additional 119,128 children of the same period in areas of the highest piped water supply (prevalence 98.97% to 99.63%) were selected as the controls. Both cohorts were propensity-score matched by baseline variables. We calculated the hazard ratios (HRs) and 95% confidence intervals (CIs) of appendicitis in the study cohort compared to the controls by Cox proportional hazards regression. The study cohort had a raised overall incidence rates of appendicitis compared to the control cohort (12.8 vs. 8.7 per 10,000 person-years). After covariate adjustment, the risk of appendicitis was significantly increased in the study cohort (adjusted HR = 1.46, 95% CI: 1.35, 1.58, p < 0.001). Subgroup and sensitivity analyses showed consistent results that children with low piped water supply had a higher risk of appendicitis than those with high piped water supply. This study demonstrated that children with low piped water supply were at an increased risk of appendicitis. Enhancement of piped water availability in areas lacking adequate, secure, and sanitized water supply may protect children against appendicitis.

Childhood intestinal parasitic infection and sanitation predictors in rural Dembiya, northwest Ethiopia

Background

Intestinal parasites are a common problem in the world. The greater proportion of infections is associated with poor water, sanitation, and hygiene (WASH). This study was conducted to assess intestinal parasites, WASH condition, and their association in rural Dembiya, northwest Ethiopia.

Methods

A cross-sectional study was employed. Two hundred twenty-five children aged 6–59 months were included. Mothers were interviewed using a structured questionnaire, and the living environment was observed using checklists. Kato-Katz technique was used to determine the intensity of parasitic infections. Escherichia coli (E. coli) was used as a biological indicator for drinking water quality. Multivariable binary logistic regression analysis was conducted to identify WASH predictors of parasites on the basis of adjusted odds ratio (AOR) with 95% confidence interval (CI) and p < 0.05.

Results

The prevalence of intestinal parasites was 25.8% (95% CI = 20.3–32.0%). Ascaris lumbricoides (78%), hookworm (12%), Hymenolepis nana (7%), Enterobius vermicularis (5%), Schistosoma mansoni (3%), Giardia lamblia (3%), and Trichuris trichiuria (2%) were identified infections. Intestinal parasites were associated with poor child hand washing practice [AOR = 3.86, 95% CI = 1.53, 9.75], unprotected water sources [AOR = 7.79, 95% CI = 3.30, 18.40], access to water below 20 l/c/d [AOR = 3.05, 95% CI = 1.28, 7.23], poor food safety[AOR = 4.33, 95% CI = 1.62, 11.58], and poor sanitation [AOR = 5.01, 95% CI = 1.56, 16.16].

Conclusion

A. lumbricoides, hookworm, H. nana, E. vermicularis, S. mansoni, G. lamblia, and T. trichiuria were identified. Child hand washing practice, service level of water supply, water sources, food safety, and sanitation were associated with intestinal parasites. WASH promotion is needed to prevent infections.

Unpacking the enabling factors for hand, cord and birth-surface hygiene in Zanzibar maternity units

Recent national surveys in The United Republic of Tanzania have revealed poor standards of hygiene at birth in facilities. As more women opt for institutional delivery, improving basic hygiene becomes an essential part of preventative strategies for reducing puerperal and newborn sepsis. Our collaborative research in Zanzibar provides an in-depth picture of the state of hygiene on maternity wards to inform action. Hygiene was assessed in 2014 across all 37 facilities with a maternity unit in Zanzibar. We used a mixed methods approach, including structured and semi-structured interviews, and environmental microbiology. Data were analysed according to the WHO ‘cleans’ framework, focusing on the fundamental practices for prevention of newborn and maternal sepsis. For each ‘clean’ we explored the following enabling factors: knowledge, infrastructure (including equipment), staffing levels and policies. Composite indices were constructed for the enabling factors of the ‘cleans’ from the quantitative data: clean hands, cord cutting, and birth surface. Results from the qualitative tools were used to complement this information.

Only 49% of facilities had the ‘infrastructural’ requirements to enable ‘clean hands’, with the availability of constant running water particularly lacking. Less than half (46%) of facilities met the ‘knowledge’ requirements for ensuring a ‘clean delivery surface’; six out of seven facilities had birthing surfaces that tested positive for multiple potential pathogens. Almost two thirds of facilities met the ‘infrastructure (equipment) requirement’ for ‘clean cord’; however, disposable cord clamps being frequently out of stock, often resulted in the use of non-sterile thread made of fabric. This mixed methods approach, and the analytical framework based on the WHO ‘cleans’ and the enabling factors, yielded practical information of direct relevance to action at local and ministerial levels. The same approach could be applied to collect and analyse data on infection prevention from maternity units in other contexts.

Protozoan Parasites in Drinking Water: A System Approach for Improved Water, Sanitation and Hygiene in Developing Countries

Improved water, sanitation and hygiene (WASH) are significant in preventing diarrhea morbidity and mortality caused by protozoa in low- and middle-income countries. Due to the intimate and complex relationships between the different WASH components, it is often necessary to improve not just one but all of these components to have sustainable results. The objective of this paper was to review the current state of WASH-related health problems caused by parasitic protozoa by: giving an overview and classification of protozoa and their effect on people's health, discussing different ways to improve accessibility to safe drinking water, sanitation services and personal hygiene behavior; and suggesting an institutional approach to ensure improved WASH. The findings indicate that Giardia and Cryptosporidium are more often identified during waterborne or water-washed outbreaks and they are less sensitive than most of the bacteria and viruses to conventional drinking water and wastewater treatment methods. There are various institutions of control and prevention of water-related diseases caused by protozoa in developed countries. Unfortunately, the developing regions do not have comparable systems. Consequently, the institutional and systems approach to WASH is necessary in these countries.

Childhood diarrheal morbidity and sanitation predictors in a nomadic community

BACKGROUND

Diarrhea remains a leading killer of young children on the globe despite the availability of simple and effective solutions to prevent and control it. The disease is more prevalent among under - five children (U5C) in the developing world due to lack of sanitation. A child dies every 15 s from diarrheal disease caused largely by poor sanitation. Nearly 90% of diarrheal disease is attributed to inadequate sanitation. Even though, the health burden of diarrheal disease is widely recognized at global level, its prevalence and sanitation predictors among a nomadic population of Ethiopia are not researched. This study was therefore designed to assess the prevalence of childhood diarrheal disease and sanitation predictors among a nomadic people in Hadaleala district, Afar region, Northeast Ethiopia.

METHODS

A community based cross-sectional study design was carried out to investigate diarrheal disease among U5C. A total of 704 households who had U5C were included in this study and the study subjects were recruited by a multistage cluster sampling technique. Data were collected using a structured questionnaire and an observational checklist. All the mothers of U5C found in the selected clusters were interviewed. Furthermore, the living environment was observed. Univariable binary logistic regression analysis was used to choose variables for the multivariable binary logistic regression analysis on the basis of p- value less than 0.2. Finally, multivariable binary logistic regression analysis was used to identify variables associated with childhood diarrhea disease on the basis of adjusted odds ratio (AOR) with 95% confidence interval (CI) and p < 0.05.

RESULTS

The two weeks period prevalence of diarrheal disease among U5C in Hadaleala district was 26.1% (95% CI: 22.9 - 29.3%). Childhood diarrheal disease was statistically associated with unprotected drinking water sources [AOR = 2.449, 95% CI = (1.264, 4.744)], inadequate drinking water service level [AOR = 1.535, 95% CI = (1.004, 2.346)], drinking water sources not protected from animal contact [AOR = 4.403, 95% CI = (2.424, 7.999)], un-availability of any type of latrine [AOR = 2.278, 95% CI = (1.045, 4.965)], presence of human excreta in the compound [AOR = 11.391, 95% CI = (2.100, 61.787)], not washing hand after visiting toilet [AOR = 16.511, 95% CI = (3.304, 82.509)], and live in one living room [AOR = 5.827, 95% CI = (3.208, 10.581)].

CONCLUSION

Childhood diarrheal disease was the common public health problem in Hadaleala district. Compared with the national and regional prevalence of childhood diarrhea, higher prevalence of diarrhea among U5C was reported. Types of drinking water sources, households whose water sources are shared with livestock, volume of daily water collected, availability of latrine, presence of faeces in the compound, hand washing after visiting the toilet and number of rooms were the sanitation predictors associated with childhood diarrhea. Therefore, enabling the community with safe and continuous supply of water and proper disposal of wastes including excreta is necessary with particular emphasis to the rural nomadic communities.

Livestock ownership and microbial contamination of drinking-water: Evidence from nationally representative household surveys in Ghana, Nepal and Bangladesh

•

Owning livestock can increase the risk of drinking-water contamination.

•

Large livestock were associated with water contamination in Ghana and Bangladesh.

•

Poultry were associated with drinking-water contamination in Bangladesh.

•

Livestock were not significantly correlated with water contamination in Nepal.

•

Livestock excreta should be considered for the prevention of water contamination.

Background

Current priorities for diarrhoeal disease prevention include use of sanitation and safe water. There have been few attempts to quantify the importance of animal faeces in drinking-water contamination, despite the presence of potentially water-borne zoonotic pathogens in animal faeces.

Objectives

This study aimed to quantify the relationship between livestock ownership and point-of-consumption drinking-water contamination.

Methods

Data from nationally representative household surveys in Nepal, Bangladesh, and Ghana, each with associated water quality assessments, were used. Multinomial regression adjusting for confounders was applied to assess the relationship between livestock ownership and the level of drinking-water contamination with E. coli.

Results

Ownership of five or more large livestock (e.g. cattle) was significantly associated with drinking-water contamination in Ghana (RRR = 7.9, 95% CI = 1.6 to 38.9 for medium levels of contamination with 1–31cfu/100 ml; RRR = 5.2, 95% CI = 1.1–24.5 for high levels of contamination with >31cfu/100 ml) and Bangladesh (RRR = 2.4, 95% CI = 1.3–4.5 for medium levels of contamination; non-significant for high levels of contamination). Ownership of eight or more poultry (chickens, guinea fowl, ducks or turkeys) was associated with drinking-water contamination in Bangladesh (RRR = 1.5, 95% CI = 1.1–2.0 for medium levels of contamination, non-significant for high levels of contamination).

Conclusions

These results suggest that livestock ownership is a significant risk factor for the contamination of drinking-water at the point of consumption. This indicates that addressing human sanitation without consideration of faecal contamination from livestock sources will not be sufficient to prevent drinking-water contamination.

Water, Sanitation, and Hygiene in Rural Health-Care Facilities: A Cross-Sectional Study in Ethiopia, Kenya, Mozambique, Rwanda, Uganda, and Zambia

Safe and sufficient water, sanitation, and hygiene (WaSH) prevent the spread of disease in health-care facilities (HCFs). Little research has been conducted on WaSH in HCF in sub-Saharan Africa. We carried out a cross-sectional study of WaSH in 1,318 randomly selected rural HCF (hospitals, health centers, health posts, and clinics) in regions throughout Ethiopia, Kenya, Mozambique, Rwanda, Uganda, and Zambia. Methods included questionnaires with head doctors and nurses to document WaSH access, continuity, quality, quantity and reliability, and analysis of drinking water samples for Escherichia coli. We found that fewer than 50% of rural HCFs had access to improved water sources on premises, improved sanitation, and consistent access to water and soap for handwashing (Ethiopia [7%), Kenya [30%], Mozambique [29%], Rwanda [50%], Uganda [30%], and Zambia [21%]). Adequate hand hygiene reduces disease transmission and health-care-acquired infections, but fewer than 25% of HCF in each country reported that a combination of water, soap, and hand-drying materials were always available. Our research points to a lack of basic WaSH services in rural HCFs in regions of sub-Saharan Africa, which poses a threat to the health of patients and health-care workers in these settings.

Physicochemical parameters affecting the perception of borehole water quality in Ghana

Rural Ghanaian communities continue using microbiologically contaminated surface water sources due in part to undesirable organoleptic characteristics of groundwater from boreholes. Our objective was to identify thresholds of physical and chemical parameters associated with consumer complaints related to groundwater. Water samples from 94 boreholes in the dry season and 68 boreholes in the rainy season were analyzed for 18 parameters. Interviews of consumers were conducted at each borehole regarding five commonly expressed water quality problems (salty taste, presence of particles, unfavorable scent, oily sheen formation on the water surface, and staining of starchy foods during cooking). Threshold levels of water quality parameters predictive of complaints were determined using the Youden index maximizing the sum of sensitivity and specificity. The probability of complaints at various parameter concentrations was estimated using logistic regression. Exceedances of WHO guidelines were detected for pH, turbidity, chloride, iron, and manganese. Concentrations of total dissolved solids (TDS) above 172mg/L were associated with salty taste complaints. Although the WHO guideline is 1000mg/L, even at half the guideline, the likelihood of salty taste complaint was 75%. Iron concentrations above 0.11, 0.14 and 0.43mg/L (WHO guideline value 0.3mg/L) were associated with complaints of unfavorable scent, oily sheen, and food staining, respectively. Iron and TDS concentrations exhibited strong spatial clustering associated with specific geological formations. Improved groundwater sources in rural African communities that technically meet WHO water quality guidelines may be underutilized in preference of unimproved sources for drinking and domestic uses, compromising human health and sustainability of improved water infrastructure.