Studies on sanitation, hygiene & water quality

Below are citations to 12 recently published or forthoming reports and articles. Links are included to the full-text when available.

These Environmental Health Updates can also be found on the Environmental Health at USAID website at: http://www.ehproject.org/eh/eh_topics.html

New Reports

1 – USAID Hygiene Improvement Project, 2009 – Assessment of Hygiene Promotion in Madagascar 2007-2008: Comparisons for Households, Schools, and Health Facilities. This report presents comparative findings of the USAID Hygiene Improvement Project’s annual behavioral outcome monitoring of hygiene practices measured in 2007 and again in 2008 in the four regions in central, south central, and eastern Madagascar where HIP is operational.

2 – USAID Hygiene Improvement Project – Lessons Learned to Improve Basic Sanitation (World Water Week 2009). Author: Merri Weinger.

3 – WHO, 2009 – Scaling Up Household Water Treatment Among Low-Income Populations. Authors: Thomas Clasen (London School of Hygiene & Tropical Medicine). This report examines the evidence to date regarding the scalability of HWTS. It seeks to consolidate existing knowledge and experience and distill the lessons learnt. Its primary aims are to 1) review the development and evolution of leading household water treatment technologies in their efforts to achieve scale, 2) identify the main constraints that they have encountered and 3) recommend ways forward.

4 – Water and Sanitation Program (WSP), 2009 – Study for Financial and Economic Analysis of Ecological Sanitation in Sub-Saharan Africa. This study on financial and economic analysis of ecological sanitation (ecosan) in Sub-Saharan Africa was financed by the Water and Sanitation Program (WSP). It focused on a comparison of sanitation technologies suitable for urban settlements. The aim of the study was to compare ecosan with conventional sanitation systems in terms of financial and economic costs and benefits, in order to assist decision-makers and sponsors of development programs to make informed decisions about relative merits of different types of sanitation.

Recently Published or Forthcoming Articles

5 – Tropical Medicine & International Health, forthcoming article

The effect of a soap promotion and hygiene education campaign on handwashing behaviour in rural India: a cluster randomised trial

Adam Biran, Wolf-Peter Schmidt, Richard Wright, Therese Jones, M Seshadri, Pradeep Isaac, N. A. Nathan, Peter Hall, Joeleen McKenna, Stewart Granger, Pat Bidinger and Val Curtis.

Objective – To investigate the effectiveness of a hygiene promotion intervention based on germ awareness in increasing handwashing with soap on key occasions (after faecal contact and before eating) in rural Indian households.

Methods – Cluster randomised trial of a hygiene promotion intervention in five intervention and five control villages. Handwashing was assessed through structured observation in a random sample of 30 households per village. Additionally, soap use was monitored in a sub-sample of 10 households per village using electronic motion detectors embedded in soap bars.

Results – The intervention reached 40% of the target population. Germ awareness increased as well as reported handwashing (a possible indicator of perceived social norms). Observed handwashing with soap on key occasions was rare (6%), especially after faecal contact (2%). Observed handwashing with soap on key occasions did not change 4 weeks after the intervention in either the intervention arm (−1%, 95% CI −2%/+0.3%), or the control arm (+0.4%, 95% CI −1%/+2%). Data from motion detectors indicated a significant but small increase in overall soap use in the intervention arm. We cannot confidently identify the nature of this increase except to say that there was no change in a key measure of handwashing after defecation.

Conclusion – The intervention proved scalable and effective in raising hygiene awareness. There was some evidence of an impact on soap use but not on the primary outcome of handwashing at key times. However, the results do not exclude that changes in knowledge and social norms may lay the foundations for behaviour change in the longer term.

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6 – Epidemiology and Infection, forthcoming article

Dirty hands: bacteria of faecal origin on commuters’ hands

JUDAH,G., DONACHIE,P., COBB,E., SCHMIDT,W., HOLLAND,M., CURTIS,V.

Although many studies have investigated bacteria on the hands of health-care workers and caregivers, few have looked at microbiological contamination on the hands of the general adult public. This study investigated faecal bacteria on the hands of commuters in five UK cities. Of the 404 people sampled 28% were found to have bacteria of faecal origin on their hands. A breakdown by city showed that the proportion of people with contaminated hands increased the further north the city of investigation (P<0·001), an effect which was due in large part to a significant trend in men but not in women. Bus users were more contaminated than train users. The results of this exploratory study indicate that hand hygiene practices in the UK may be inadequate and that faecal indicator bacteria on hands may be used to monitor the effect of hand-washing promotion campaigns.

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7 – Epidemiology and Infection, forthcoming article

Recall errors in a weekly survey of diarrhoea in Guatemala: determining the optimal length of recall

ZAFAR,S. N., LUBY,S. P., MENDOZA,C.

We measured the recall error, optimal recall length and factors associated with diarrhoea in a weekly survey. Data was taken from a year-long randomized controlled trial in which characteristics of diarrhoeal episodes were recorded weekly. We labelled the recall period as days 1–6; day 1 being the day before the visit. Recall error was the percentage difference between the number of episodes reported to begin on a particular day and the mean for days 1 and 2. Generalized estimating equations were used to determine associations. Recall error was 37% on day 3 and 51% on day 5. The error was less in younger children (by 10%), severe episodes (by 29%) and when blood was present in the stool (by 18%). Diarrhoea was underreported when the recall period extended beyond 2 days. Surveys that use longer recall periods risk underestimating diarrhoea incidence and selectively capturing more severe episodes.

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8 – Journal of Water and Health Vol 07 No 3 pp 380–391

Environmental risk factors for diarrhoea among male schoolchildren in Jeddah City, Saudi Arabia.

Mansour A. Al-Ghamdi, Graham Bentham and Paul R. Hunter

Diarrhoeal disease is still one of the major causes of mortality and morbidity of children in developing countries. Our objective was to assess the prevalence of diarrhoeal disease among male schoolchildren in Jeddah and to identify the associated risk factors, especially those related to drinking water and sanitation disposal. This cross-sectional study was conducted randomly where self-administered questionnaires were issued to parents through the schools. The data were collected from 1,064 respondents indicating that 14.9% of the children had diarrhoea during the previous month. The main risk factors were: the number of children under five years living in the same house (OR per child 1.34, 95% confidence intervals 1.15–1.56), being of Saudi nationality (OR 1.75, 1.08–2.84), reporting sewage spillage near the home (OR 1.69, 1.14–2.53), eating out after school hours (OR 1.74, 1.16–2.60), not drying hands after washing them (OR 1.66, 1.10–2.51), using reusable cloths or sponges to dry dishes (OR 1.70, 1.14–2.52).

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9 – Journal of Water and Health Vol 07 No 2 pp 259–266

Child dysentery in the Limpopo Valley: a cohort study of water, sanitation and hygiene risk factors

Stephen W. Gundry, James A. Wright, Ronán M. Conroy, Martella Du Preez, Bettina Genthe, Sibonginkosi Moyo, Charles Mutisi and Natasha Potgieter

The objective of this cohort study was to assess risk factors for child dysentery and watery diarrhoea. The study participants consisted of 254 children aged 12–24 months in rural South Africa and Zimbabwe in households where drinking water was collected from communal sources. The main outcome measure was the most severe diarrhoea episode: dysentery, watery diarrhoea or none. For dysentery, drinking water from sources other than standpipes had a relative risk ratio of 3.8 (95% CI 1.5–9.8). Poor source water quality, as indicated by Escherichia coli counts of 10 or more cfu 100 ml-1, increased risk by 2.9 (1.5–5.7). There were no other significant risk factors for dysentery and none for watery diarrhoea. In this study, endemic dysentery is associated only with faecal contamination of source water. Sources other than standpipes, including improved groundwater, are of greater risk. Remediation of water quality by treatment at source or in the household will be required to achieve access to safe drinking water in accordance with the 7th Millennium Development Goal.

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10 – Journal of Water and Health Vol 07 No 3 pp 527–534

Increasing equity of access to point-of-use water treatment products through social marketing and entrepreneurship: a case study in western Kenya.

Matthew C. Freeman, Robert E. Quick, Daniel P. Abbott, Paul Ogutu and Richard Rheingans

Point-of-use water chlorination reduces diarrhoea risk by 25–85%. Social marketing has expanded access to inexpensive sodium hypochlorite for water treatment, at a cost of less than US$0.01 per day, in Kenya. To increase product access, women’s groups in western Kenya were trained to educate neighbours and sell health products to generate income. We evaluated this programme’s impact on equity of access to water treatment products in a cross-sectional survey. We surveyed 487 randomly selected households in eight communities served by the women’s groups. Overall, 20% (range 5–39%) of households in eight communities purchased and used chlorine, as confirmed by residual chlorine observed in stored water. Multivariate models using illiteracy and the poorest socioeconomic status as a referent showed that persons with at least some primary education (OR 2.5, 95% CI 1.8, 3.5) or secondary education (OR 5.4, 95% CI 1.6, 17.5) and persons in the four wealthiest quintiles (OR 2.5, 95% CI 1.0, 6.0) were more likely to chlorinate stored water. While this implementation model was associated with good product penetration and use, barriers to access to inexpensive water treatment remained among the very poor and less educated.

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11 – Jnl Health, Population & Nutrition, August 2009

Capability Development among the Ultra-poor in Bangladesh: A Case Study (pdf, full-text)

Syed Masud Ahmed

Microcredit is advocated as a development tool that has the potential to reduce poverty, empower participants, and improve health. Results of several studies have shown that the extreme poor, or the ultra-poor, often are unable to benefit from traditional microcredit programmes and can, as a result of taking a loan they cannot repay, sink deeper into economic and social poverty. This case study describes an intervention directed at enabling the ultra-poor rural populations to pull themselves out of poverty. The intervention integrates multiple components, including asset grants for income generation, skills training, a time-bound monthly stipend for subsistence, social development and mobilization of local elite, and health support. Results of an evaluation showed that, after 18 months, the programme positively impacted livelihood, economic, social and health status to the extent that 63% of households (n=5,000) maintained asset growth and joined (or intended to join) a regular microcredit programme. Impacts included improved income, improved food security, and improved health knowledge and behaviour. Applying a social exclusion framework to the intervention helps identify the different dynamic forces that can exclude or include the ultra-poor in Bangladesh in development interventions such as microcredit.

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12 – Environmental Health Perspectives, Sept. 2009

Low-Dose Arsenic Compromises the Immune Response to Influenza A Infection in Vivo. (pdf, full-text)

Courtney D. Kozul, Kenneth H. Ely, Richard I. Enelow, and Joshua W. Hamilton

Background: Arsenic exposure is a significant worldwide environmental health concern. We recently reported that 5-week exposure to environmentally relevant levels (10 and 100 ppb) of As in drinking water significantly altered components of the innate immune response in mouse lung, which we hypothesize is an important contributor to the increased risk of lung disease in exposed human populations.

Objectives: We investigated the effects of As exposure on respiratory influenza A (H1N1) virus infection, a common and potentially fatal disease.

Methods: In this study, we exposed C57BL/6J mice to 100 ppb As in drinking water for 5 weeks, followed by intranasal inoculation with a sublethal dose of influenza A/PuertoRico/8/34 (H1N1) virus. Multiple end points were assessed postinfection.

Results: Arsenic was associated with a number of significant changes in response to influenza, including an increase in morbidity and higher pulmonary influenza virus titers on day 7 postinfection. We also found many alterations in the immune response relative to As-unexposed controls, including a decrease in the number of dendritic cells in the mediastinal lymph nodes early in the course of infection.

Conclusions: Our data indicate that chronic As exposure significantly compromises the immune response to infection. Alterations in response to repeated lung infection may also contribute to other chronic illnesses, such as bronchiectasis, which is elevated by As exposure in epidemiology studies.

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