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Health impact

Introduction to Household Water Treatment and Safe Storage, Module 5.3

Dr. Sophie Boisson, London School of Hygiene & Tropical Medicine

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Transmission for fecal-oral
pathogens is complex

HWTS addresses only one

How much diarrhoea can be
prevented by improving water
quality alone?

Transmission of faecal-oral pathogens
Source: WEDC, Adapted from Wagner & Lanoix (1958)
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Systematic reviews on health impact
0 20 40 60 80 100
Solar disinfection
Water supply
Water quality
% Reduction in diarrhea
Fewtrell 2005
Clasen 2006
Waddington 2009
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Intervention studies
Randomised control trials
Unit of randomisation can be
household or village
Outcome can be blinded

Observational studies
Before/ After
Case control studies
Ecological studies

Modelling studies
Measuring impact: evaluation designs
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Function of stool consistency and
WHO definition: passase of 3 or more loose
stools within 24-h period

Potential issues
Reporting bias
Placebo effect
Hawthorne effect
Respondent fatigue
Measuring impact: outcome is diarrhoea
Boisson et al (2013)
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Different magnitude of effect
Open trials report diarrhea reductions in the
range of 30-40%
Blinded trial report no effect

Lack of blinding of subjective
outcomes risk exaggerating
magnitude of impact by 25% (Wood

Adjusting for bias (Hunter 2009)
Went from 44% to 15% reduction after

Blinded versus non-blinded trials
Clasen et al (2006)
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Setting with different transmission dynamics
Transmission routes
Treatment methods not effective against all class
of pathogens
Different levels of compliance
Impact on diarrhea diminishes over time (Arnold 2006, Hunter
Efficacy versus effectiveness trials
Evaluation of 3-year HWT and HWWS in Guatemala Residual
chlorine 9% intervention vs 3% in control (Arnold 2009)
CRT of SODIS among 22 rural communities in Bolivia 32%
(Mausezhal 2009)

Potential explanation for variability
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Blinded RCTs
Challenges to blind effectively
Potentially unethical

Alternative health outcomes
Nutritional indicators
Weight-for-age (malnutrition, diarrhoea)
Height-for-age (stunting)
Environmental enteropathy
Pathogen identification

Alternatives to improve measurement?
Schmidt et al (2010)
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Significant health gains, 30-40%
reductions in diarrhoea but may be
an overestimation

Measuring impact on health is
possible but can be complicated and

Routine monitoring and evaluation
should focus on use before
attempting to measure health impact

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Systematic reviews

Arnold, B. F. & J. M. Colford, Jr. (2007) Treating water with chlorine at point-of-
use to improve water quality and reduce child diarrhea in developing countries:
a systematic review and meta-analysis. Am J Trop Med Hyg, 76, 354-64.

Clasen, T., I. Roberts, T. Rabie, W. Schmidt & S. Cairncross (2006)
Interventions to improve water quality for preventing diarrhoea. Cochrane
Database Syst Rev, 3, CD004794.

Esrey, S. A., R. G. Feachem & J. M. Hughes (1985) Interventions for the control
of diarrhoeal diseases among young children: improving water supplies and
excreta disposal facilities. Bulletin of the World Health Organization, 63, 757-72.

Fewtrell, L., R. B. Kaufmann, D. Kay, W. Enanoria, L. Haller & J. M. Colford, Jr.
(2005) Water, sanitation, and hygiene interventions to reduce diarrhoea in less
developed countries: a systematic review and meta-analysis. Lancet Infect Dis,
5, 42-52.

Waddington, H. S., B. White, H. Fewtrell, L. 2009. Water, Sanitation and
Hygiene Interventions to Combat Childhood Diarrhoea in Developing Countries.
International Initiative for Impact Evaluation (3ie).

Further discussions about evidence
for health impact of HWTS

Clasen T, Bartram J, Colford J, Luby S, Quick R, et al. (2009) Comment
on Household water treatment in poor populations: is there enough
evidence for scaling up now?. Environ Sci Technol 43: 55425544;
author reply 55455546. doi: 10.1021/es9008147

Hunter, P. R. (2009) Household Water Treatment in Developing Countries:
Comparing Different Intervention Types Using Meta-Regression. Environ
Sci Technol. 43(23):8991-7

Schmidt, W. P. & S. Cairncross (2009) Household water treatment in poor
populations: is there enough evidence for scaling up now? Environ Sci
Technol, 43, 986-92.
Additional ressources: Reviews
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Arnold, B., B. Arana, D. Mausezahl, A. Hubbard & J. M. Colford, Jr. (2009) Evaluation of a pre-existing, 3-year
household water treatment and handwashing intervention in rural Guatemala. Int J Epidemiol.

Boisson S, Stevenson M, Shapiro L, Kumar V, Singh LP, et al. (2013) Effect of Household-Based Drinking Water
Chlorination on Diarrhoea among Children under Five in Orissa, India: A Double-Blind Randomised Placebo-
Controlled Trial. PLoS Med 10(8): e1001497. doi:10.1371/journal.pmed.1001497

Boisson S, Kiyombo M, Sthreshley L, Tumba S, Makambo J, et al. (2010) Field assessment of a novel
household-based water filtration device: a randomised, placebo-controlled trial in the Democratic Republic of
Congo. PLoS One 5: e12613 doi:10.1371/journal.pone.0012613

Mausezahl, D., A. Christen, G. D. Pacheco, F. A. Tellez, M. Iriarte, M. E. Zapata, M. Cevallos, J. Hattendorf, M.
D. Cattaneo, B. Arnold, T. A. Smith & J. M. Colford, Jr. (2009) Solar drinking water disinfection (SODIS) to
reduce childhood diarrhoea in rural Bolivia: a cluster-randomized, controlled trial. PLoS Med, 6, e1000125.

Schmidt, W. P., S. Boisson, B. Genser, M. L. Barreto, K. Baisley, S. Filteau & S. Cairncross (2010) Weight-for-
age z-score as a proxy marker for diarrhoea in epidemiological studies. J Epidemiol Community Health, 64,

Schmidt, W. P., B. F. Arnold, S. Boisson, B. Genser, S. P. Luby, M. L. Barreto, T. Clasen & S. Cairncross (2011)
Epidemiological methods in diarrhoea studies--an update. Int J Epidemiol, 40, 1678-92.


Additional ressources: studies cited
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