Literature Review of Associations among Attributes of Reported Drinking Water Disease Outbreaks

Waterborne disease outbreaks attributed to various pathogens and drinking water system characteristics have adversely affected public health worldwide throughout recorded history. Data from drinking water disease outbreak (DWDO) reports of widely varying breadth and depth were synthesized to investigate associations between outbreak attributes and human health impacts. Among 1519 outbreaks described in 475 sources identified during review of the primarily peer-reviewed, English language literature, most occurred in the U.S., the U.K. and Canada (in descending order). The outbreaks are most frequently associated with pathogens of unknown etiology, groundwater and untreated systems, and catchment realm-associated deficiencies (i.e., contamination events). Relative frequencies of outbreaks by various attributes are comparable with those within other DWDO reviews, with water system size and treatment type likely driving most of the (often statistically-significant at p < 0.05) differences in outbreak frequency, case count and attack rate. Temporal analysis suggests that while implementation of surface (drinking) water management policies is associated with decreased disease burden, further strengthening of related policies is needed to address the remaining burden attributed to catchment and distribution realm-associated deficiencies and to groundwater viral and disinfection-only system outbreaks

Fecal contamination of drinking-water in low- and middle-income countries: a systematic review and meta-analysis

Background: access to safe drinking-water is a fundamental requirement for good health and is also a human right. Global access to safe drinking-water is monitored by WHO and UNICEF using as an indicator “use of an improved source,” which does not account for water quality measurements. Our objectives were to determine whether water from “improved” sources is less likely to contain fecal contamination than “unimproved” sources and to assess the extent to which contamination varies by source type and setting.Methods and findings: studies in Chinese, English, French, Portuguese, and Spanish were identified from online databases, including PubMed and Web of Science, and grey literature. Studies in low- and middle-income countries published between 1990 and August 2013 that assessed drinking-water for the presence of Escherichia coli or thermotolerant coliforms (TTC) were included provided they associated results with a particular source type. In total 319 studies were included, reporting on 96,737 water samples. The odds of contamination within a given study were considerably lower for “improved” sources than “unimproved” sources (odds ratio [OR] = 0.15 [0.10–0.21], I2 = 80.3% [72.9–85.6]). However over a quarter of samples from improved sources contained fecal contamination in 38% of 191 studies. Water sources in low-income countries (OR = 2.37 [1.52–3.71]; p&lt;0.001) and rural areas (OR = 2.37 [1.47–3.81] p&lt;0.001) were more likely to be contaminated. Studies rarely reported stored water quality or sanitary risks and few achieved robust random selection. Safety may be overestimated due to infrequent water sampling and deterioration in quality prior to consumption.Conclusion: access to an “improved source” provides a measure of sanitary protection but does not ensure water is free of fecal contamination nor is it consistent between source types or settings. International estimates therefore greatly overstate use of safe drinking-water and do not fully reflect disparities in access. An enhanced monitoring strategy would combine indicators of sanitary protection with measures of water qualit

Sustainability of community-led total sanitation outcomes: Evidence from Ethiopia and Ghana

We conducted a study to evaluate the sustainability of community-led total sanitation (CLTS) outcomes in Ethiopia and Ghana. Plan International, with local actors, implemented four CLTS interventions from 2012 to 2014: health extension worker-facilitated CLTS and teacher-facilitated CLTS in Ethiopia, and NGO-facilitated CLTS with and without training for natural leaders in Ghana. We previously evaluated these interventions using survey data collected immediately after implementation ended, and concluded that in Ethiopia health extension workers were more effective facilitators than teachers, and that in Ghana training natural leaders improved CLTS outcomes. For this study, we resurveyed 3831 households one year after implementation ended, and analyzed latrine use and quality to assess post-intervention changes in sanitation outcomes, to determine if our original conclusions were robust. In one of four interventions evaluated (health extension worker-facilitated CLTS in Ethiopia), there was an 8 percentage point increase in open defecation in the year after implementation ended, challenging our prior conclusion on their effectiveness. For the other three interventions, the initial decreases in open defecation of 8–24 percentage points were sustained, with no significant changes occurring in the year after implementation. On average, latrines in Ethiopia were lower quality than those in Ghana. In the year following implementation, forty-five percent of households in Ethiopia repaired or rebuilt latrines that had become unusable, while only 6% did in Ghana possibly due to higher latrine quality. Across all four interventions and three survey rounds, most latrines remained unimproved. Regardless of the intervention, households in villages higher latrine use were more likely to have sustained latrine use, which together with the high latrine repair rates indicates a potential social norm. There are few studies that revisit villages after an initial evaluation to assess sustainability of sanitation outcomes. This study provides new evidence that CLTS outcomes can be sustained in the presence of training provided to local actors, and strengthens previous recommendations that CLTS is not appropriate in all settings and should be combined with efforts to address barriers households face to building higher quality latrines

Assessing Progress towards Public Health, Human Rights, and International Development Goals Using Frontier Analysis

Indicators to measure progress towards achieving public health, human rights, and international development targets, such as 100% access to improved drinking water or zero maternal mortality ratio, generally focus on status (i.e., level of attainment or coverage) or trends in status (i.e., rates of change). However, these indicators do not account for different levels of development that countries experience, thus making it difficult to compare progress between countries. We describe a recently developed new use of frontier analysis and apply this method to calculate country performance indices in three areas: maternal mortality ratio, poverty headcount ratio, and primary school completion rate. Frontier analysis is used to identify the maximum achievable rates of change, defined by the historically best-performing countries, as a function of coverage level. Performance indices are calculated by comparing a country’s rate of change against the maximum achievable rate at the same coverage level. A country’s performance can be positive or negative, corresponding to progression or regression, respectively. The calculated performance indices allow countries to be compared against each other regardless of whether they have only begun to make progress or whether they have almost achieved the target. This paper is the first to use frontier analysis to determine the maximum achievable rates as a function of coverage level and to calculate performance indices for public health, human rights, and international development indicators. The method can be applied to multiple fields and settings, for example health targets such as cessation in smoking or specific vaccine immunizations, and offers both a new approach to analyze existing data and a new data source for consideration when assessing progress achieved

FoodAuthent – Developing a System for Food Authenticity by Collecting, Analyzing and Utilizing Product Data

The research project FoodAuthent aims at providing the technical framework and incentives for the routine use of “fingerprinting” to secure and monitor food quality. The planned system captures, analyses and processes data on the chemical fingerprint of food and can prove its authenticity. For this purpose, cloud-based fingerprinting databases are combined with methods of data analysis and batch-specific product information. The project focuses on proof of origin and fraud detection of food as well as on analytical methods for the product categories cheese, oil and spirits

Predicting critical power in elite cyclists: questioning validity of the 3-min All-out test

Purpose: New applications of the critical power concept, such as the modelling of intermittent work capabilities, are exciting prospects for elite cycling. However, accurate calculation of the required parameters is traditionally time invasive and somewhat impractical. An alternative single test protocol (3-min All-out) has recently been proposed, but validation in an elite population is lacking. The traditional approach for parameter establishment, but with fewer tests, could also prove an acceptable compromise. Methods: Six senior Australian endurance track cycling representatives completed six efforts to exhaustion on two separate days over a three week period. These included 1, 4, 6, 8 and 10 minute self-paced efforts, plus the 3-min All-out protocol. Traditional work versus time calculations of CP and W’ using the five self-paced efforts were compared to calculations from the 3-min All-out protocol. The impact of using just two or three self-paced efforts for traditional CP and W’ estimation were also explored using thresholds of agreement (8W, 2.0kJ respectively). Results: CP estimated from the 3-min All-out approach was significantly higher than from the traditional approach (402±33W, 351±27W, p<0.001), whilst W’ was lower (15.5±3.0kJ, 24.3±4.0kJ, p=0.02). Five different combinations of two or three self-paced efforts led to CP estimates within the threshold of agreement, with only one combination deemed accurate for W’. Conclusions: In elite cyclists the 3-min All-out approach is not suitable to estimate CP when compared to the traditional method. However, reducing the number of tests used in the traditional method lessens testing burden whilst maintaining appropriate parameter accuracy.Jason C Bartram, Dominic Thewlis, David T Martin, Kevin I Norto

The true costs of participatory sanitation: Evidence from community-led total sanitation studies in Ghana and Ethiopia

Evidence on sanitation and hygiene program costs is used for many purposes. The few studies that report costs use top-down costing methods that are inaccurate and inappropriate. Community-led total sanitation (CLTS) is a participatory behavior-change approach that presents difficulties for cost analysis. We used implementation tracking and bottom-up, activity-based costing to assess the process, program costs, and local investments for four CLTS interventions in Ghana and Ethiopia. Data collection included implementation checklists, surveys, and financial records review. Financial costs and value-of-time spent on CLTS by different actors were assessed. Results are disaggregated by intervention, cost category, actor, geographic area, and project month. The average household size was 4.0 people in Ghana, and 5.8 people in Ethiopia. The program cost of CLTS was $30.34–$81.56 per household targeted in Ghana, and $14.15–$19.21 in Ethiopia. Most program costs were from training for three of four interventions. Local investments ranged from $7.93–$22.36 per household targeted in Ghana, and $2.35–$3.41 in Ethiopia. This is the first study to present comprehensive, disaggregated costs of a sanitation and hygiene behavior-change intervention. The findings can be used to inform policy and finance decisions, plan program scale-up, perform cost-effectiveness and benefit studies, and compare different interventions. The costing method is applicable to other public health behavior-change programs

Teachers and Sanitation Promotion: An Assessment of Community-Led Total Sanitation in Ethiopia

Community-led total sanitation (CLTS) is a participatory approach to addressing open defecation that has demonstrated success in previous studies, yet there is no research on how implementation arrangements and context change effectiveness. We used a quasi-experimental study design to compare two interventions in Ethiopia: conventional CLTS in which health workers and local leaders provided facilitation and an alternative approach in which teachers provided facilitation. In 2012, Plan International Ethiopia trained teachers from 111 villages and health workers and leaders from 54 villages in CLTS facilitation. The trained facilitators then implemented CLTS in their respective villages for a year. Latrine ownership, use, and quality were measured with household surveys. Differences between interventions were explored using surveys and interviews. The decrease in open defecation associated with teacher-facilitated CLTS was 8.2 percentage points smaller than for conventional CLTS (p = 0.048). Teachers had competing responsibilities and initially lacked support from local leaders, which may have lessened their success. Teachers may be more appropriate for a supporting rather than leading role in sanitation promotion because they did demonstrate ability and engagement. Open defecation decreased by 15.3 percentage points overall but did not change where baseline open defecation was below 30%. Ownership of a latrine with stable flooring increased by 8.7 percentage points overall. Improved latrine ownership did not change during the intervention. CLTS is most appropriate where open defecation is high because there were no significant changes in sanitation practices or latrine upgrades where baseline open defecation was low

Building capacity for water, sanitation, and hygiene programming: Training evaluation theory applied to CLTS management training in Kenya

Training and capacity building are long established critical components of global water, sanitation, and hygiene (WaSH) policies, strategies, and programs. Expanding capacity building support for WaSH in developing countries is one of the targets of the Sustainable Development Goals. There are many training evaluation methods and tools available. However, training evaluations in WaSH have been infrequent, have often not utilized these methods and tools, and have lacked rigor. We developed a conceptual framework for evaluating training in WaSH by reviewing and adapting concepts from literature. Our framework includes three target outcomes: learning, individual performance, and improved programming; and two sets of influences: trainee and context factors. We applied the framework to evaluate a seven-month community-led total sanitation (CLTS) management training program delivered to 42 government officials in Kenya from September 2013 to May 2014. Trainees were given a pre-training questionnaire and were interviewed at two weeks and seven months after initial training. We qualitatively analyzed the data using our conceptual framework. The training program resulted in trainees learning the CLTS process and new skills, and improving their individual performance through application of advocacy, partnership, and supervision soft skills. The link from trainees' performance to improved programming was constrained by resource limitations and pre-existing rigidity of trainees’ organizations. Training-over-time enhanced outcomes and enabled trainees to overcome constraints in their work. Training in soft skills is relevant to managing public health programs beyond WaSH. We make recommendations on how training programs can be targeted and adapted to improve outcomes. Our conceptual framework can be used as a tool both for planning and evaluating training programs in WaSH

Drinking water and sanitation: progress in 73 countries in relation to socioeconomic indicators

Objective To assess progress in the provision of drinking water and sanitation in relation to national socioeconomic indicators. Methods We used household survey data for 73 countries – collected between 2000 and 2012 – to calculate linear rates of change in population access to improved drinking water (n=67) and/or sanitation (n=61). To enable comparison of progress between countries with different initial levels of access, the calculated rates of change were normalized to fall between –1 and 1. In regression analyses, we investigated associations between the normalized rates of change in population access and national socioeconomic indicators: gross national income per capita, government effectiveness, official development assistance, freshwater resources, education, poverty, Gini coefficient, child mortality and the human development index. Findings The normalized rates of change indicated that most of the investigated countries were making progress towards achieving universal access to improved drinking water and sanitation. However, only about a third showed a level of progress that was at least half the maximum achievable level. The normalized rates of change did not appear to be correlated with any of the national indicators that we investigated. Conclusion In many countries, the progress being made towards universal access to improved drinking water and sanitation is falling well short of the maximum achievable level. Progress does not appear to be correlated with a country’s social and economic characteristics. The between-country variations observed in such progress may be linked to variations in government policies and in the institutional commitment and capacity needed to execute such policies effectively