Liquefied petroleum gas or biomass for cooking and effects on birth weight

BACKGROUND: Exposure during pregnancy to household air pollution caused by the burning of solid biomass fuel is associated with adverse health outcomes, including low birth weight. Whether the replacement of a biomass cookstove with a liquefied petroleum gas (LPG) cookstove would result in an increase in birth weight is unclear. METHODS: We performed a randomized, controlled trial involving pregnant women (18 to \u3c35 years of age and at 9 to \u3c20 weeks\u27 gestation as confirmed on ultrasonography) in Guatemala, India, Peru, and Rwanda. The women were assigned in a 1:1 ratio to use a free LPG cookstove and fuel (intervention group) or to continue using a biomass cookstove (control group). Birth weight, one of four prespecified primary outcomes, was the primary outcome for this report; data for the other three outcomes are not yet available. Birth weight was measured within 24 hours after birth. In addition, 24-hour personal exposures to fine particulate matter (particles with a diameter of ≤2.5 μm [PM RESULTS: A total of 3200 women underwent randomization; 1593 were assigned to the intervention group, and 1607 to the control group. Uptake of the intervention was nearly complete, with traditional biomass cookstoves being used at a median rate of less than 1 day per month. After randomization, the median 24-hour personal exposure to fine particulate matter was 23.9 μg per cubic meter in the intervention group and 70.7 μg per cubic meter in the control group. Among 3061 live births, a valid birth weight was available for 94.9% of the infants born to women in the intervention group and for 92.7% of infants born to those in the control group. The mean (±SD) birth weight was 2921±474.3 g in the intervention group and 2898±467.9 g in the control group, for an adjusted mean difference of 19.6 g (95% confidence interval, -10.1 to 49.2). CONCLUSIONS: The birth weight of infants did not differ significantly between those born to women who used LPG cookstoves and those born to women who used biomass cookstoves. (Funded by the National Institutes of Health and the Bill and Melinda Gates Foundation; HAPIN ClinicalTrials.gov number, NCT02944682.)

Assessing the Health Impact of Water Quality Interventions in Low-Income Settings: Concerns Associated with Blinded Trials and the Need for Objective Outcomes.

BACKGROUND: A dramatic disparity between the results of blinded versus open trial designs has raised questions about the effectiveness of water quality interventions and other environmental interventions to prevent diarrhea, a leading killer of young children in low-income countries. OBJECTIVES: We summarize the results of blinded versus open trials of water quality interventions, describe evidence from a recent placebo-controlled trial in India suggesting that control households were put at risk from their participation, and suggest alternatives to blinded trials that could resolve continued uncertainty about the magnitude of the protective effect of water, sanitation, and hygiene (WASH) interventions without presenting ethical questions. DISCUSSION: Concerns about reporting bias in open trial designs continue to cause uncertainty about the effectiveness of WASH interventions. However, evidence suggests that despite instructions to the contrary, placebos may encourage control group participants in blinded trials to cease practicing traditional water treatment practices in the mistaken belief that they are protected by an active intervention. Although objective outcomes such as pathogen incrimination, seroconversion, biomarkers, and anthropometry can be helpful, these are often costly, nonspecific, and unsuitable for evaluating programmatic interventions. CONCLUSIONS: Unless researchers can be assured that a placebo will not cause those in a control group to change their behavior in a manner that increases their risk, it is incumbent on researchers to use alternatives. Validated objective measures are needed for assessing the health impact of WASH interventions that are reliable, affordable, and suitable both for research and program evaluation. CITATION: Clasen T, Boisson S. 2016. Assessing the health impact of water quality interventions in low-income settings: concerns associated with blinded trials and the need for objective outcomes. Environ Health Perspect 124:886-889; http://dx.doi.org/10.1289/ehp.1510532

Assessing Latrine Use in Rural India: A Cross-Sectional Study Comparing Reported Use and Passive Latrine Use Monitors.

Although large-scale programs, like India's Total Sanitation Campaign (TSC), have improved latrine coverage in rural settings, evidence suggests that actual use is suboptimal. However, the reliability of methods to assess latrine use is uncertain. We assessed the reliability of reported use, the standard method, by comparing survey-based responses against passive latrine use monitors (PLUMs) through a cross-sectional study among 292 households in 25 villages in rural Odisha, India, which recently received individual household latrines under the TSC. PLUMs were installed for 2 weeks and householders responded to surveys about their latrine use behavior. Reported use was compared with PLUM results using Bland-Altman (BA) plots and concordance statistics. Reported use was higher than corresponding PLUM-recorded events across the range of comparisons. The mean reported "usual" daily events per household (7.09, 95% confidence interval [CI] = 6.51, 7.68) was nearly twice that of the PLUM-recorded daily average (3.62, 95% CI = 3.29, 3.94). There was poor agreement between "usual" daily latrine use and the average daily PLUM-recorded events (ρc = 0.331, 95% CI = 0.242, 0.427). Moderate agreement (ρc = 0.598, 95% CI = 0.497, 0.683) was obtained when comparing daily reported use during the previous 48 hours with the average daily PLUM count. Reported latrine use, though already suggesting suboptimal adoption, likely exaggerates the actual level of uptake of latrines constructed under the program. Where reliance on self-reports is used, survey questions should focus on the 48 hours prior to the date of the survey rather than asking about "usual" latrine use behavior

Use, microbiological effectiveness and health impact of a household water filter intervention in rural Rwanda-A matched cohort study.

Unsafe drinking water is a substantial health risk contributing to child diarrhoea. We investigated impacts of a program that provided a water filter to households in rural Rwandan villages. We assessed drinking water quality and reported diarrhoea 12-24 months after intervention delivery among 269 households in the poorest tertile with a child under 5 from 9 intervention villages and 9 matched control villages. We also documented filter coverage and use. In Round 1 (12-18 months after delivery), 97.4% of intervention households reported receiving the filter, 84.5% were working, and 86.0% of working filters contained water. Sensors confirmed half of households with working filters filled them at least once every other day on average. Coverage and usage was similar in Round 2 (19-24 months after delivery). The odds of detecting faecal indicator bacteria in drinking water were 78% lower in the intervention arm than the control arm (odds ratio (OR) 0.22, 95% credible interval (CrI) 0.10-0.39, p<0.001). The intervention arm also had 50% lower odds of reported diarrhoea among children <5 than the control arm (OR=0.50, 95% CrI 0.23-0.90, p=0.03). The protective effect of the filter is also suggested by reduced odds of reported diarrhoea-related visits to community health workers or clinics, although these did not reach statistical significance

Assessing patterns and determinants of latrine use in rural settings: A longitudinal study in Odisha, India.

INTRODUCTION: Monitoring of sanitation programs is often limited to sanitation access and coverage, with little emphasis on use of the facilities despite increasing evidence of widespread non-use. OBJECTIVES: We assessed patterns and determinants of individual latrine use over 12 months in a low- income rural study population that had recently received latrines as part of the Government of India's Total Sanitation Campaign (TSC) in coastal Puri district in Odisha, India. MATERIALS AND METHODS: We surveyed 1938 individuals (>3years) in 310 rural households with latrines from 25 villages over 12 months. Data collection rounds were timed to correspond with the seasons. The primary outcome was reported use by each member of the household over the prior 48h. We classified use into three categories-"never", "sometimes" and "always/usually". We also assessed consistency of use over six days across the three seasons (dry cold, dry hot, rainy). We explored the association between individual and household-level variables and latrine use in any given season and longitudinally using multinomial logistic regression. We also inquired about reasons for non-use. RESULTS: Overall, latrine use was poor and inconsistent. The average response probability at any given round of never use was 43.5% (95% CI=37.9, 49.1), sometimes use was 4.6% (95% CI=3.8, 5.5), and always/usual use was 51.9% (95% CI=46.2, 57.5). Only two-thirds of those who reported always/usually using a latrine in round one reported the same for all three rounds. Across all three rounds, the study population was about equally divided among those who reported never using the latrine (30.1%, 95% CI=23.0, 37.2), sometimes using the latrine (33.2%, 95% CI=28.3, 38.1) and always/usually using the latrine (36.8%, 95% CI=31.8, 41.8). The reported likelihood of always/usually versus never using the latrine was significantly greater in the dry cold season (OR=1.50, 95% CI=1.18, 1.89, p=0.001) and in the rainy season (OR=1.34, 95% CI=1.07, 1.69, p=0.012), than in the dry hot season. Across all three seasons, there was increased likelihood of always/usually and sometimes using the latrine versus never using it among females and where latrines had a door and roof. Older age groups, including those aged 41-59 years and 60+ years, and increase in household size were associated with a decreased likelihood of always/usually using the latrine versus never using it. The leading reason for non-use was a preference for open defecation. CONCLUSION: Results highlight the low and inconsistent use of subsidized latrines built under the TSC in rural Odisha. This study identifies individual and household levels factors that may be used to target behavior change campaigns to drive consistent use of sanitation facilities by all

Modeling the Impact of an Indoor Air Filter on Air Pollution Exposure Reduction and Associated Mortality in Urban Delhi Household.

Indoor exposure to fine particulate matter (PM2.5) is a prominent health concern. However, few studies have examined the effectiveness of long-term use of indoor air filters for reduction of PM2.5 exposure and associated decrease in adverse health impacts in urban India. We conducted 20 simulations of yearlong personal exposure to PM2.5 in urban Delhi using the National Institute of Standards and Technology's CONTAM program (NIST, Gaithersburg, MD, USA). Simulation scenarios were developed to examine different air filter efficiencies, use schedules, and the influence of a smoker at home. We quantified associated mortality reductions with Household Air Pollution Intervention Tool (HAPIT, University of California, Berkeley, CA, USA). Without an air filter, we estimated an annual mean PM2.5 personal exposure of 103 µg/m3 (95% Confidence Interval (CI): 93, 112) and 137 µg/m3 (95% CI: 125, 149) for households without and with a smoker, respectively. All day use of a high-efficiency particle air (HEPA) filter would reduce personal PM2.5 exposure to 29 µg/m3 and 30 µg/m3, respectively. The reduced personal PM2.5 exposure from air filter use is associated with 8-37% reduction in mortality attributable to PM2.5 pollution in Delhi. The findings of this study indicate that air filter may provide significant improvements in indoor air quality and result in health benefits

User preferences and willingness to pay for safe drinking water: Experimental evidence from rural Tanzania.

Almost half of all deaths from drinking microbiologically unsafe water occur in Sub-Saharan Africa. Household water treatment and safe storage (HWTS) systems, when consistently used, can provide safer drinking water and improve health. Social marketing to increase adoption and use of HWTS depends both on the prices of and preferences for these systems. This study included 556 households from rural Tanzania across two low-income districts with low-quality water sources. Over 9 months in 2012 and 2013, we experimentally evaluated consumer preferences for six "low-cost" HWTS options, including boiling, through an ordinal ranking protocol. We estimated consumers' willingness to pay (WTP) for these options, using a modified auction. We allowed respondents to pay for the durable HWTS systems with cash, chickens or mobile money; a significant minority chose chickens as payment. Overall, our participants favored boiling, the ceramic pot filter and, where water was turbid, PuR™ (a combined flocculant-disinfectant). The revealed WTP for all products was far below retail prices, indicating that significant scale-up may need significant subsidies. Our work will inform programs and policies aimed at scaling up HWTS to improve the health of resource-constrained communities that must rely on poor-quality, and sometimes turbid, drinking water sources

Use of Serologic Responses against Enteropathogens to Assess the Impact of a Point-of-Use Water Filter: A Randomized Controlled Trial in Western Province, Rwanda.

Diarrhea is a leading contributor to childhood morbidity and mortality in sub-Saharan Africa. Given the challenge of blinding most water, sanitation, and hygiene (WASH) interventions, diarrheal disease outcome measures in WASH intervention trials are subject to potential bias and misclassification. Using the platform of a cluster-randomized controlled trial of a household-based drinking water filter in western province, Rwanda, we assessed the impact of the drinking water filter on enteric seroconversion in young children as a health outcome and examined the association between serologic responses and caregiver-reported diarrhea. Among the 2,179 children enrolled in the trial, 189 children 6-12 months of age were enrolled in a nested serology study. These children had their blood drawn at baseline and 6-12 months after the intervention was distributed. Multiplex serologic assays for Giardia, Cryptosporidium, Entamoeba histolytica, norovirus, Campylobacter, enterotoxigenic Escherichia coli and Vibrio cholerae were performed. Despite imperfect uptake, receipt of the water filter was associated with a significant decrease in seroprevalence of IgG directed against Cryptosporidium parvum Cp17 and Cp23 (relative risk [RR]: 0.62, 95% confidence interval [CI]: 0.44-0.89). Serologic responses were positively associated with reported diarrhea in the previous 7 days for both Giardia intestinalis (RR: 1.94, 95% CI: 1.04-3.63) and C. parvum (RR: 2.21, 95% CI: 1.09-4.50). Serologic responses for all antigens generally increased in the follow-up round, rising sharply after 12 months of age. The water filter is associated with reduced serologic responses against C. parvum, a proxy for exposure and infection; therefore, serologic responses against protozoa may be a suitable health outcome measure for WASH trials among children with diarrhea

Interventions to improve water quality for preventing diarrhoea

Background Diarrhoea is a major cause of death and disease, especially among young children in low-income countries. In these settings, many infectious agents associated with diarrhoea are spread through water contaminated with faeces. In remote and low-income settings, source-based water quality improvement includes providing protected groundwater (springs, wells, and bore holes), or harvested rainwater as an alternative to surface sources (rivers and lakes). Point-of-use water quality improvement interventions include boiling, chlorination, flocculation, filtration, or solar disinfection, mainly conducted at home. Objectives To assess the effectiveness of interventions to improve water quality for preventing diarrhoea. Search methods We searched the Cochrane Infectious Diseases Group Specialized Register (11 November 2014), CENTRAL (the Cochrane Library, 7 November 2014), MEDLINE (1966 to 10 November 2014), EMBASE (1974 to 10 November 2014), and LILACS (1982 to 7 November 2014). We also handsearched relevant conference proceedings, contacted researchers and organizations working in the field, and checked references from identified studies through 11 November 2014. Selection criteria Randomized controlled trials (RCTs), quasi-RCTs, and controlled before-and-after studies (CBA) comparing interventions aimed at improving the microbiological quality of drinking water with no intervention in children and adults. Data collection and analysis Two review authors independently assessed trial quality and extracted data. We used meta-analyses to estimate pooled measures of effect, where appropriate, and investigated potential sources of heterogeneity using subgroup analyses. We assessed the quality of evidence using the GRADE approach. Main results Forty-five cluster-RCTs, two quasi-RCTs, and eight CBA studies, including over 84,000 participants, met the inclusion criteria. Most included studies were conducted in low- or middle-income countries (LMICs) (50 studies) with unimproved water sources (30 studies) and unimproved or unclear sanitation (34 studies). The primary outcome in most studies was self-reported diarrhoea, which is at high risk of bias due to the lack of blinding in over 80% of the included studies. Source-based water quality improvements There is currently insufficient evidence to know if source-based improvements such as protected wells, communal tap stands, or chlorination/filtration of community sources consistently reduce diarrhoea (one cluster-RCT, five CBA studies, very low quality evidence). We found no studies evaluating reliable piped-in water supplies delivered to households. Point-of-use water quality interventions On average, distributing water disinfection products for use at the household level may reduce diarrhoea by around one quarter (Home chlorination products: RR 0.77, 95% CI 0.65 to 0.91; 14 trials, 30,746 participants, low quality evidence; flocculation and disinfection sachets: RR 0.69, 95% CI 0.58 to 0.82, four trials, 11,788 participants, moderate quality evidence). However, there was substantial heterogeneity in the size of the effect estimates between individual studies. Point-of-use filtration systems probably reduce diarrhoea by around a half (RR 0.48, 95% CI 0.38 to 0.59, 18 trials, 15,582 participants, moderate quality evidence). Important reductions in diarrhoea episodes were shown with ceramic filters, biosand systems and LifeStraw® filters; (Ceramic: RR 0.39, 95% CI 0.28 to 0.53; eight trials, 5763 participants, moderate quality evidence; Biosand: RR 0.47, 95% CI 0.39 to 0.57; four trials, 5504 participants, moderate quality evidence; LifeStraw®: RR 0.69, 95% CI 0.51 to 0.93; three trials, 3259 participants, low quality evidence). Plumbed in filters have only been evaluated in high-income settings (RR 0.81, 95% CI 0.71 to 0.94, three trials, 1056 participants, fixed effects model). In low-income settings, solar water disinfection (SODIS) by distribution of plastic bottles with instructions to leave filled bottles in direct sunlight for at least six hours before drinking probably reduces diarrhoea by around a third (RR 0.62, 95% CI 0.42 to 0.94; four trials, 3460 participants, moderate quality evidence). In subgroup analyses, larger effects were seen in trials with higher adherence, and trials that provided a safe storage container. In most cases, the reduction in diarrhoea shown in the studies was evident in settings with improved and unimproved water sources and sanitation. Authors' conclusions Interventions that address the microbial contamination of water at the point-of-use may be important interim measures to improve drinking water quality until homes can be reached with safe, reliable, piped-in water connections. The average estimates of effect for each individual point-of-use intervention generally show important effects. Comparisons between these estimates do not provide evidence of superiority of one intervention over another, as such comparisons are confounded by the study setting, design, and population. Further studies assessing the effects of household connections and chlorination at the point of delivery will help improve our knowledge base. As evidence suggests effectiveness improves with adherence, studies assessing programmatic approaches to optimising coverage and long-term utilization of these interventions among vulnerable populations could also help strategies to improve health outcomes