Lessons learned from fifteen drinking water treatment program evaluations in Haiti

Providing safe drinking water is a priority in emergencies. The 2010 earthquake in Haiti and subsequent cholera outbreak thus led to the implementation of numerous point-of-collection (PoC) and point-of-use (PoU) water treatment programs. We propose to present a synthesis of lessons learned from fifteen evaluations conducted in Haiti between 2010 and 2016, including four PoC and eleven PoU water treatment programs, to better understand which strategies have helped make programs effective and sustainable. Overall, it appears that PoU water treatment technologies were more effective than PoC water treatment programs in the Haitian context. Additionally, evaluation results suggest that programs achieving sustained effectiveness were those that:1) promoted technologies that were effective and familiar to beneficiaries; 2) had reliable supply chains for water treatment products; 3) worked with local partners; and, 4) included monitoring

Evaluating the sustained health impact of household chlorination of drinking water in rural Haiti.

The Jolivert Safe Water for Families program has sold sodium hypochlorite solution (chlorine) and conducted household visits in rural Haiti since 2002. To assess the impact of the program on diarrheal disease, in 2010 we conducted a survey and water quality testing in 201 program participants and 425 control households selected at random. Fifty-six percent of participants (versus 10% of controls) had free chlorine residuals between 0.2 and 2.0 mg/L, indicating correct water treatment. Using intention-to-treat analysis, we found that significantly fewer children < 5 in participant households had an episode of diarrhea in the previous 48 hours (32% versus 52%; P < 0.001) with 59% reduced odds (odds ratio = 0.41, 95% confidence interval = 0.21-0.79). Treatment-on-treated estimates of the odds of diarrhea indicated larger program effects for participants who met more stringent verifications of participation. Diarrheal disease reduction in this long-term program was comparable with that seen in short-term randomized, controlled interventions, suggesting that household chlorination can be an effective long-term water treatment strategy

Trihalomethane formation in rural household water filtration systems in Haiti

Thesis (M.Eng.)--Massachusetts Institute of Technology, Dept. of Civil and Environmental Engineering, 2001.Includes bibliographical references (p. 123-131).by Daniele S. Lantagne.M.Eng

Sustained effectiveness of chlorinators installed in community-scale water distribution systems in Haiti

In 2012 and 2013, Child Relief International (CRI) partnered with Haiti Philanthropy to install “Chlorinators” in 79 gravity-fed water distribution systems in Southeast Haiti as an emergency response project, followed by a sustainability plan. We carried out an independent evaluation to assess the extent to which Chlorinators were operational and providing safe water approximately two years after installation. We completed 18 randomly selected site assessments, 180 household surveys, water quality testing for Free Chlorine Residual (FCR) and Escherichia coli on water samples from reservoirs, taps, and household stored water, and 24 key informant interviews. None of the systems were functioning 2 years after installation, 3% of household respondents had received information about the Chlorinators, and no community or household water samples had detectable FCR from Chlorinators. However, key informants were largely supportive of the systems. Reasons for non-operation and challenges associated with achieving sustainability are discussed

A systematic review of chlorine-based surface disinfection efficacy to inform recommendations for low-resource outbreak settings

BACKGROUND: Infectious diseases can be transmitted via fomites (contaminated surfaces/objects); disinfection can interrupt this transmission route. However, disinfection guidelines for low-resource outbreak settings are inconsistent and not evidence-based. METHODS: A systematic review of surface disinfection efficacy studies was conducted to inform low-resource outbreak guideline development. Due to variation in experimental procedures, outcomes were synthesized in a narrative summary focusing on chlorine-based disinfection against seven pathogens with potential to produce outbreaks in low-resource settings (Mycobacterium tuberculosis, Vibrio cholerae, Salmonella spp., hepatitis A virus, rotavirus, norovirus, Ebola virus). RESULTS: Data were extracted from 89 laboratory studies and made available, including 20 studies on relevant pathogens used in combination with surrogate data to determine minimum target concentrationxtime ("CT") factors. Stainless steel (68%) and chlorine-based disinfectants (56%) were most commonly tested. No consistent trend was seen in the influence of chlorine concentration and exposure time on disinfection efficacy. Disinfectant application mode; soil load; and surface type were frequently identified as influential factors in included studies. CONCLUSIONS: This review highlights that surface disinfection efficacy estimates are strongly influenced by each study's experimental conditions. We therefore recommend laboratory testing to be followed by field-based testing/monitoring to ensure effectiveness is achieved in situ

WASH interventions in emergencies and outbreaks: two systematic reviews and impact analyses

There is a lack of evidence-base for WASH interventions in emergencies, although many agencies collect various types of evidence that is not formally published or widely shared. The aim of this work is to help provide policy relevant evidence of WASH interventions by summarizing the information collected by NGOs, UN agencies, or local governments responding to humanitarian emergencies and disease outbreaks. A systematic search covered academic databases, agency websites, and direct solicitation of humanitarian actors. Qualitative and quantitative research methodologies, as well as, both published and grey literature were eligible for review. More than 15,000 manuscripts were identified, 1,500 abstracts assessed, and 500 full texts reviewed. Final included manuscripts will be summarized using the GRADE summary of findings around the themes of: use of service; health-related outcomes; non-health related outcomes; barriers and facilitators to implementation; and cost-effectiveness. This work will establish a real-world evidence-base for humanitarian WASH policy

Surface Cleaning and Disinfection: Efficacy Assessment of Four Chlorine Types Using Escherichia coli and the Ebola Surrogate Phi6.

In the 2014 West African Ebola outbreak, international organizations provided conflicting recommendations for disinfecting surfaces contaminated by uncontrolled patient spills. We compared the efficacy of four chlorine solutions (sodium hypochlorite, sodium dichloroisocyanurate, high-test hypochlorite, and generated hypochlorite) for disinfection of three surface types (stainless steel, heavy-duty tarp, and nitrile) with and without pre-cleaning practices (prewiping, covering, or both) and soil load. The test organisms were Escherichia coli and the Ebola surrogate Phi6. All tests achieved a minimum of 5.9 and 3.1 log removal in E. coli and Phi6, respectively. A 15 min exposure to 0.5% chlorine was sufficient to ensure <8 Phi6 plaque-forming unit (PFU)/cm2 in all tests. While chlorine types were equally efficacious with and without soil load, variation was seen by surface type. Wiping did not increase disinfection efficacy and is not recommended because it generates infectious waste. Covering spills decreased disinfection efficacy against E. coli on heavy-duty tarp but does prevent splashing, which is critical in Ebola contexts. Our results support the recommendation of a 15 min exposure to 0.5% chlorine, independently of chlorine type, surface, pre-cleaning practices, and organic matter, as an efficacious measure to interrupt disease transmission from uncontrolled spills in Ebola outbreaks

Surface Cleaning and Disinfection: Efficacy Assessment of Four Chlorine Types Using Escherichia coli and the Ebola Surrogate Phi6.

In the 2014 West African Ebola outbreak, international organizations provided conflicting recommendations for disinfecting surfaces contaminated by uncontrolled patient spills. We compared the efficacy of four chlorine solutions (sodium hypochlorite, sodium dichloroisocyanurate, high-test hypochlorite, and generated hypochlorite) for disinfection of three surface types (stainless steel, heavy-duty tarp, and nitrile) with and without pre-cleaning practices (prewiping, covering, or both) and soil load. The test organisms were Escherichia coli and the Ebola surrogate Phi6. All tests achieved a minimum of 5.9 and 3.1 log removal in E. coli and Phi6, respectively. A 15 min exposure to 0.5% chlorine was sufficient to ensure <8 Phi6 plaque-forming unit (PFU)/cm2 in all tests. While chlorine types were equally efficacious with and without soil load, variation was seen by surface type. Wiping did not increase disinfection efficacy and is not recommended because it generates infectious waste. Covering spills decreased disinfection efficacy against E. coli on heavy-duty tarp but does prevent splashing, which is critical in Ebola contexts. Our results support the recommendation of a 15 min exposure to 0.5% chlorine, independently of chlorine type, surface, pre-cleaning practices, and organic matter, as an efficacious measure to interrupt disease transmission from uncontrolled spills in Ebola outbreaks

A cross-sectional study on water access within the Healthy Villages and Schools (VEA) program in the DRC

In DRC, the Healthy Villages and Schools (VEA) National Program consists of a community participatory process towards sustainable access to improved water services, hygiene and sanitation where villages and schools are certified “healthy” once they comply with 7 WASH specific norms. Through a mixed-methods survey of household questionnaires, water quality testing of source and stored water samples, mapping of water sources, and discussions with key informants, this study looked at VEA implementation in the Katana health zone, South Kivu province, to ascertain lessons learnt from the program. From 206 household surveys and 71 focus group discussions, it was determined that there are two primary barriers to effective water supply coverage: accessibility to a source within 30 minutes and delivery of water that conforms to WHO guidelines of <1 E. coli CFU/100mL. Additional demographic and WASH knowledge, attitudes, and practices outcomes as well as challenges associated with the VEA are discussed