Gates Foundation awards $10.9 million to study impacts of sanitation on diseases

Researchers at the University of California, Berkeley, have received a five-year, $10.9 million grant from the Bill & Melinda Gates Foundation to evaluate several interventions to combat diarrheal disease in developing countries.

Dr. Jack Colford

Dr. Jack Colford, professor of epidemiology at UC Berkeley’s School of Public Health, will coordinate the project, working with the International Centre for Diarrhoeal Disease Research, Bangladesh (ICDDR,B) and Innovations for Poverty Action (IPA).

An estimated 2.2 million children under the age of 5 die from diarrheal diseases each year, according to the World Health Organization. Most of these diseases are thought to be preventable with improvements in sanitation, water quality and hygiene.

Due to the high cost of developing and maintaining large infrastructure projects, such as networked water, there is now a movement toward simpler, alternative methods to improve health in rural areas. However, there is almost no evidence that allows direct comparison of the health benefits or cost effectiveness of these simpler interventions, such as improved latrines, household water treatment and hand washing with soap.

The goal of the new project is to determine how sanitation interventions, delivered alone or as part of combined intervention packages, impact child health and well-being. In addition to improved sanitation, the intervention packages will include drinking water improvements and hand washing solutions. The results have the potential to influence how billions of dollars are directed towards long-term improvements in health and economic outcomes for millions of children each year, said Colford.

“Increasingly, foundations, governments, the World Bank and development agencies such as the MCC (Millennium Challenge Corporation) are demanding evidence of effectiveness when awarding development funds,” said Colford. “Right now, it is unknown whether single interventions are as cost effective as combinations of these interventions. This grant will fund the first large-scale, randomized impact evaluation designed to gather rigorous evidence about this question.”

The study will test the impact of these sanitation, water and hygiene interventions using a large-scale, randomized impact evaluation in Bangladesh and Kenya. These two countries are representative of the two regions that account for the majority of the world’s gastrointestinal disease burden: Southeast Asia and sub-Saharan Africa. The researchers expect to enroll a total of 23,000 children in the trials, which will be monitored by several institutional review boards.

Of the $10.9 million, about $7.9 million will be subcontracted out to the two field sites. Dr. Stephen Luby, head of the Programme on Infectious Diseases and Vaccine Sciences with ICDDR,B, and Michael Kremer, Ph.D., a research affiliate with IPA, will lead the trials in Bangladesh and Kenya, respectively. They will be joined by a team of experts from various disciplines, including public health, economics, behavioral change, nutrition, cognitive development and tropical enteropathy.

Source: Linda Anderberg, UC Berkely News, 05 Nov 2009

Water, sanitation and hygiene interventions to combat childhood diarrhoea in developing countries

Water, sanitation and hygiene interventions to combat childhood diarrhoea in developing countries

Hugh Waddington, Birte Snilstveit, Howard White, and Lorna Fewtrell
Corresponding author email: hwaddington [at] 3ieimpact.org
August 2009
Synthetic review 001
International Initiative for Impact Evaluation (3ie).

Full text

Summary

This report is a synthetic review of impact evaluations examining effectiveness of water, sanitation and hygiene (WSH) interventions in reducing childhood diarrhoea.

The review has been conducted to Campbell/Cochrane Collabo ration standards of systematic review, as well as employing mixed methods of data analysis to assess not only which interventions are effective, or not, but why and under what circumstances. The review provides an update of previous reviews conducted in this area, notably Fewtrell and Colford (2004).

A comprehensive search was conducted of published and unpublished materials. Studies were identified for inclusion which employed rigorous impact evaluation techniques, using experimental (randomised assignme nt) and quasi-experimental methods, and which evaluated the impact of water, sanitation and/or hygiene interventions on diarrhoea morbidity among children in low- and middle-income countries. 65 rigorous impact evaluations were identified for quantitative synthesis, covering 71 distinct interventions assessed across 130,000 children in 35 developing countries during the past three decades. Each study was coded for a range of variables relating to type of intervention, effect size and precision, internal validity (relating to evaluation quality) and external validity (relating to context and behavioural mechanisms). Interventions were grouped into five categories: water supply improvements, water quality, sanitation, hygiene and multiple interventions involving a combination of water and sanitation and/or hygiene. Data were collected and synthesised on both quantitative and qualitative information presented in the evaluations.

The results challenge the notion that water quality treatment in the household (at point -of-use) and sanitation ‘software’ (hygiene) interventions are necessarily the most efficacious and sustainable interventions for promoting reduction of diarrhoea.

While point-of-use water quality interventions appear to be highly effective – and indeed, more effective than water supply or source treatment in reducing diarrhoea – much of the evidence is from trials conducted over small populations and short time periods. More evidence is needed on sustainability, as water quality interventions conducted over longer periods tend to show smaller effectiveness, while compliance rates, and therefore impact, appear to fall markedly over time.

Hygiene interventions, particularly provision of soap for hand-washing, are effective in reducing diarrhoea morb idity, and there does not appear to be evidence that compliance falls over time. The analysis suggests that sanitation ‘hardware’ interventions are also highly effective. However, relatively few studies have been conducted in this area to-date and studies are particularly needed that quantify the possible environmental spillovers from sanitation provision.

Evidence on the combined impact of multiple interventions is mixed. Further primary studies employing factorial design – that is, comparing different interventions using multiple treatment arms – are needed for more conclusiveness on whether water and sanitation/hygiene interventions are substitutes or complements in the health production function.

The study highlights the importance of behavioural factors in determining up-take and sustainable adoption of WSH technologies. Insights from diffusion theory suggest that preventive interventions tend to be adopted more slowly as benefits are difficult to observe and users presumably discontinue treatment as they perceive that the costs of using the intervention outweigh the benefits. These problems are more relevant for interventions aiming to reduce disease prevalence which do not have additional benefits, for example time savings. Unfortunately, few impact evaluations addressing sustainability collect data on the reasons for the levels of compliance and acceptance found among beneficiaries. This information is an essential guide to fostering long-term impact.

Intermittent slow sand filtration for preventing diarrhoea among children in Kenyan households using unimproved water sources

Intermittent slow sand filtration for preventing diarrhoea among children in Kenyan households using unimproved water sources: randomized controlled trial
doi:10.1111/j.1365-3156.2009.02381.x
Published Online: 4 Sep 2009

Sangya-Sangam K. Tiwari 1 , Wolf-Peter Schmidt 2 , Jeannie Darby 1 , Z. G. Kariuki 3 and Marion W. Jenkins 1
1 Department of Civil and Environmental Engineering, University of California, Davis, CA, USA
2 Department of Infectious and Tropical Diseases, London School of Hygiene and Tropical Medicine, London, UK
3 Ministry of Health, Nakuru District, Nakuru, Kenya

Objective Measure effectiveness of intermittent slow sand filtration for reducing child diarrhoea among households using unimproved water sources in rural Kenya.

Methods A randomized controlled trail was conducted among populations meeting a high-risk profile for child diarrhoea from drinking river water in the River Njoro watershed. Intervention households (30) were provided the concrete BioSand Filter and instructed on filter use and maintenance. Control households (29) continued normal practices. Longitudinal monthly monitoring of diarrhoea (seven-day daily prevalence recall) and of influent, effluent, and drinking water quality for fecal coliform was conducted for 6 months.

Results Intervention households had better drinking water quality than control households (fecal coliform geometric mean, 30.0 CFU vs. 89.0 CFU/100 ml, P < 0.001) and reported significantly fewer diarrhoea days (86 days over 626 child-weeks) compared to controls (203 days over 558 child-weeks) among children up to 15 (age-adjusted RR 0.46; 95 % CI = 0.22, 0.96). Greater child diarrhoea reduction due to the intervention (age-adjusted RR 0.23, 95 % CI = 0.10, 0.51) was observed among the sub-group using unimproved water sources all of the time.

Conclusion Intermittent slow sand filtration, a non-commercial technology, produces similar observed effects on child diarrhoea as commercial POU products, adding to the range of effective options for poor populations (chlorination, ceramic filtration, solar disinfection, flocculation/disinfection).

Uganda: Water is Life Programme to start PhD research in 2010

‘Water is Life: Amazzi Bulamu’ (2007-2011) is a large multi-disciplinary project comprising a partnership of Irish Higher Education Institutions, Makerere University in Uganda and various NGOs.

The Irish Institutes involved are Dundalk Institute of Technology, NUI Maynooth, Dublin City University, Trinity College Dublin, Dublin Institute of Technology Bolton St., The Royal College of Surgeons in Ireland, University College Dublin and Queens University Belfast.

The goal of the partnership, in support of the Government of Ireland’s development goals, is: to build research capacity in Ireland and Africa and to conduct research that supports sustainable water resource management as a catalyst for sustainable economic and social development in rural Uganda.

The project is funded under the Programme for Strategic Cooperation between Irish Aid and Higher-Education and Research Institutes (2007-2011) and is led by Dundalk Institute of Technology.

On 1st January 2010, in collaboration with Makerere University, PhD research will start on the following eight projects:

The eight research projects are:

• Sourcing and distribution of sustainable groundwater supplies for rural water supply;
• Sustainable pump technologies;
• Rainwater harvesting and other appropriate safe water storage mechanisms;
• Solar disinfection of drinking water;
• Water and water management needs: social and health impacts on women and their children;
• Adaptation of water management to climate change;
• The social impact of gendering water resource management;
• Understanding cooperation and conflict in local water governance or Participation and governance in water management systems.

Read more

Cost-benefit analysis: comparisons of investments in improved water supply and cholera vaccination programs

Jeuland, M, and Whittington, D. (2009) Cost-benefit comparisons of investments in improved water supply and cholera vaccination programs. Vaccine ; vol. 27, no. 23 ; p. 3109-3120. doi:10.1016/j.vaccine.2009.02.104

This paper presents the first cost–benefit comparison of improved water supply investments and cholera vaccination programs. Specifically, we compare two water supply interventions – deep wells with public hand pumps and biosand filters (an in-house, point-of-use water treatment technology) – with two types of cholera immunization programs with new-generation vaccines – general community-based and targeted and school-based programs. In addition to these four stand-alone investments, we also analyze five combinations of water and vaccine interventions: (1) borehole + hand pump and community-based cholera vaccination, (2) borehole + hand pump and school-based cholera vaccination, (3) biosand filter and community-based cholera vaccination, (4) biosand filter and school-based cholera vaccination, and (5) biosand filter and borehole + hand pump. Using recent data applicable to developing country locations for parameters such as disease incidence, the effectiveness of vaccine and water supply interventions against diarrheal diseases, and the value of a statistical life, we construct cost–benefit models for evaluating these interventions. We then employ probabilistic sensitivity analysis to estimate a frequency distribution of benefit–cost ratios for all four interventions, given a wide variety of possible parameter combinations. Our results demonstrate that there are many plausible conditions in developing countries under which these interventions will be attractive, but that the two improved water supply interventions and the targeted cholera vaccination program are much more likely to yield attractive cost–benefit outcomes than a community-based vaccination program. We show that implementing community-based cholera vaccination programs after borehole + hand pump or biosand filters have already been installed will rarely be justified. This is especially true when the biosand filters are already in place, because these achieve substantial cholera risk reductions on their own. On the other hand, implementing school-based cholera vaccination programs after the installation of boreholes with hand pump is more likely to be economically attractive. Also, if policymakers were to first invest in cholera vaccinations, then subsequently investing in water interventions is still likely to yield positive economic outcomes. This is because point-of-use water treatment delivers health benefits other than reduced cholera, and deep boreholes + hand pumps often yield non-health benefits such as time savings.

However, cholera vaccination programs are much cheaper than the water supply interventions on a household basis. Donors and governments with limited budgets may thus determine that cholera vaccination programs are more equitable than water supply interventions because more people can receive benefits with a given budget. Practical considerations may also favor cholera vaccination programs in the densely crowded slums of South Asian and African cities where there may be insufficient space in housing units for some point-of-use technologies, and where non-networked water supply options are limited.

Flocculant-disinfectant point-of-use water treatment for reducing arsenic exposure in rural Bangladesh

[Researchers from Bangladesh and the USA] introduced flocculant-disinfectant water treatment for 12 weeks in 103 households in Bangladesh to assess if drinking water would be chemically and microbiologically improved and the body burden of arsenic reduced. The median concentration of arsenic in tubewell water decreased by 88% after introduction of the flocculant-disinfectant from 136 μg/l at baseline to 16 (p < 0.001). The median concentration of total urinary arsenic decreased 42% from 385 μg/g creatinine at baseline to 225 μg/g creatinine after intervention (p < 0.001). Among 206 post-intervention drinking water samples that were reportedly treated on the date the sample was collected, 99 (48%) lacked residual free chlorine and 100 (49%) were contaminated with thermotolerant coliforms. The flocculant-disinfectant markedly reduced arsenic in drinking water, but treated drinking water was frequently contaminated with fecal organisms. The lesser reduction in urinary arsenic compared to water arsenic and the health consequences of this reduction require further research.

Full reference:  Norton, D. … [et al.] (2009). Flocculant-disinfectant point-of-use water treatment for reducing arsenic exposure in rural Bangladesh. International journal of environmental health research ; vol. 19, no. 1 ; p. 17-29. doi:10.1080/09603120802272219

Household water treatment: scaling-up is premature say researchers

A critical review concludes that the widespread promotion of household water treatment (HWT) is premature given the available evidence. Further acceptability studies and large blinded trials or trials with an objective health outcome are needed before HWT can be recommended to policy makers and implementers, say Wolf-Peter Schmidt and Sandy Cairncross of the London School of Hygiene and Tropical Medicine (LSHTM) [1].

Point-of-use water treatment (household water treatment, HWT) has been advocated as a means to substantially decrease the global burden of diarrhea and to contribute to the Millennium Development Goals (MDGs). To determine whether HWT should be scaled up now, the LSHTM researchers reviewed the evidence on acceptability, scalability, adverse effects, and nonhealth benefits as the main criteria to establish how much evidence is needed before scaling up. These aspects are contrasted with the evidence on the effect of HWT on diarrhea. The researchers found that the acceptability and scalability of HWT is still unclear, and that there are substantial barriers making it difficult to identify populations that would benefit most from a potential effect. The nonhealth benefits of HWT are negligible. Health outcome trials suggest that HWT may reduce diarrhea by 30-40%, but current evidence does not exclude that the observed reductions are largely or entirely due to bias.

[1] Schmidt, W. and Cairncross, S. (2009). Household water treatment in poor populations : is there enough evidence for scaling up now? Environmental science & technology ; vol. 43, no. 4 ; p. 986–992. doi:10.1021/es802232w

Read the full review here

South Africa: Joburg Water, University Agree to expand research expertise

Johannesburg Water (JU) and University of Johannesburg (UJ) have signed a Memorandum of Understanding [on collaboration] on water and sanitation research and development projects [...] specifically in water nanotechnologies, water purification, waste water treatment and innovation in water analysis.

Mr Jones Mnisi, Acting Chief Operation Officer, Johannesburg Water (JW). and Prof Derek van der Merwe, Pro Vice-Chancellor and Vice-Principal, University of Johannersburg (UJ) at the signing of the Memorandum of Understanding (MoU) at Johannesburg Water on Friday, 16 January 2009. Photo: UJ.

Read more: Gabi Khumalo, Bua News / allAfrica.com, 16 Jan 2009 ; Johannesburg Water, 16 Jan 2009

India: scientists ‘must prioritise the needs of the poor’

Eminent Indian science and technology experts have called on the country’s premier research institutes to redirect their work towards addressing national development problems and the basic needs of the poor.

Key research issues should include clean water, food and sanitation, as well as global warming, said the country’s National Knowledge Commission chairman Sam Pitroda.

He was speaking at a centenary conference of the Bangalore-based Indian Institute of Science (IISc) (15 December). Pitroda [...] suggested that India appoint at least one senior scientist to work as a chief scientific officer in each of India’s 600 districts, to give the poor greater access to technology.

S. Ramadorai, chief executive officer and managing director of global software company Tata Consultancy Services Limited, said that the country needs a national agenda to [...] address national development problems such as basic healthcare, water purification and clean power generation.

Source: T. V. Padma, SciDev.Net, 17 Dec 2008

Risk perception and water purification practices for water-borne parasitic infections in remote Nepal

Kovalsky, A.N. … [et al.] (2008). Risk perception and water purification practices for water-borne parasitic infections in remote Nepal. Tropical doctor ; vol. 38, no. 4 ; p. 229-231. doi:10.1258/td.2008.070366

Correspondence to: Adrienne Kovalsky, University of New England, College of Osteopathic Medicine, Biddeford ME 44613 Email: adrienne.nk@lycos.com

This study assesses water-borne infection risk perception and water boiling habits in a remote Sankhuwasava region of Nepal using a brief interview-style questionnaire. All subjects were aware of the risks associated with drinking unpurified water, but a majority (65%) reported they did not boil water regularly, and almost 60% of villagers interviewed had history of infection despite their boiling practices. In contrast to reports from other communities in Nepal, risk awareness was sufficient in this region. Water boiling alone did not confer protection. Future efforts should target sanitation, screening, and other sources of contamination.