An assessment of microbiological water quality of six water source categories in north-east Uganda

Using intersectionality to study gender and antimicrobial resistance in low- and middle-income countries

Different sexes and genders experience differentiated risks of acquiring infections, including drug-resistant infections, and of becoming ill. Different genders also have different health-seeking behaviours that shape their likelihood of having access to and appropriately using and administering antimicrobials. Consequently, they are distinctly affected by antimicrobial resistance (AMR). As such, it is crucial to incorporate perspectives on sex and gender in the study of both AMR and antimicrobial use in order to present a full picture of AMR's drivers and impact. An intersectional approach to understanding gender and AMR can display how gender and other components 'intersect' to shape the experiences of individuals and groups affected by AMR. However, there are insufficient data on the burden of AMR disaggregated by gender and other socio-economic characteristics, and where available, it is fragmented. For example, to date, the best estimate of the global burden of bacterial AMR published in The Lancet does not consider gender or other social stratifiers in its analysis. To address this evidence gap, we undertook a scoping review to examine how sex and gender compounded by other axes of marginalization influence one's vulnerability and exposure to AMR as well as one's access to and use of antimicrobials. We undertook a gendered analysis of AMR, using intersectionality as a concept to help us understand the multiple and overlapping ways in which different people experience exposure vulnerability to AMR. This approach is crucial in informing a more nuanced view of the burden and drivers of AMR. The intersectional gender lens should be taken into account in AMR surveillance, antimicrobial stewardship, infection prevention and control and public and professional awareness efforts, both donor and government funded, as well as national and international policies and programmes tackling AMR such as through national action plans.

Acute health risks to community hand-pumped groundwater supplies following Cyclone Idai flooding

This longitudinal flood-relief study assessed the impact of the March 2019 Cyclone Idai flood event on E. coli contamination of hand-pumped boreholes in Mulanje District, Malawi. It established the microbiological water-quality safety of 279 community supplies over three phases, each comprising water-quality survey, rehabilitation and treatment verification monitoring. Phase 1 contamination three months after Idai was moderate, but likely underestimated. Increased contamination in Phase 2 at 9 months and even greater in Phase 3, a year after Idai was surprising and concerning, with 40% of supplies then registering E. coli contamination and 20% of supplies deemed 'unsafe'. Without donor support for follow-up interventions, this would have been missed by a typical single-phase flood-relief activity. Contamination rebound at boreholes successfully treated months earlier signifies a systemic problem from persistent sources intensified by groundwater levels likely at a decade high. Problem extent in normal, or drier years is unknown due to absence of routine monitoring of water point E. coli in Malawi. Statistical analysis was not conclusive, but was indicative of damaged borehole infrastructure and increased near-borehole pit-latrine numbers being influential. Spatial analysis including groundwater flow-field definition (an overlooked sector opportunity) revealed 'hit-and-miss' contamination of safe and unsafe boreholes in proximity. Hydrogeological control was shown by increased contamination near flood-affected area and in more recent recharge groundwater otherwise of good quality. Pit latrines are presented as credible e-coli sources in a conceptual model accounting for heterogeneous borehole contamination, wet season influence and rebound behavior. Critical to establish are groundwater level - flow direction, hand-pump plume draw, multiple footprint latrine sources - 'skinny' plumes, borehole short-circuiting and fast natural pathway (e.g. fracture flow) and other source influences. Concerted WASH (Water, Sanitation and Hygiene) sector investment in research and policy driving national water point based E. coli monitoring programs are advocated.

Assessment of Decontamination and Reuse of Disposable Filter Funnels Used in Microbiological Water Quality Tests

To monitor safely managed drinking water services, an increasing number of countries have integrated water quality testing for Escherichia coli into nationally-representative household surveys such as the Multiple Indicator Cluster Surveys (MICS). However, plastic waste generated during such water quality testing programs, mostly through the use of pre-sterilized disposable materials, is non-negligible. The objective of this study was to evaluate several re-use protocols for disposable filter funnels used by the MICS water quality test kits. Decontamination and re-use protocols were assessed in centralized laboratory and decentralized field settings and neither yielded positive results. Re-use of 100 mL sterile funnels decontaminated with an alcohol wipe resulted in a higher incidence of false positive results (i.e., positive contamination when processing sterile water), both in the laboratory and field; therefore, a higher proportion of positives tests can be expected if these components are re-used. Further improvements to the decontamination technique and training are needed before material re-use can be reliably adopted. Autoclaving the funnels for re-use is feasible, provided that there is capacity to re-package and distribute funnels in a sterile manner.

Large-scale survey of seasonal drinking water quality in Malawi using in situ tryptophan-like fluorescence and conventional water quality indicators

Faecally-contaminated drinking water is a risk to human health, with the greatest risks to those living in developing countries. UN Sustainable Development Goal 6 aims to address this issue. Tryptophan-like fluorescence (TLF) shows potential as a rapid method for detecting microbial contamination in drinking water, which could reduce the spread of waterborne diseases. This study is the first to investigate the effectiveness of TLF for a large-scale survey using a randomised, spot-sampling approach. The large-scale survey took place in Malawi, sub-Saharan Africa, in the dry season (n = 183). A subset of sources were revisited at the end of the following wet season (n = 41). The effectiveness of TLF was assessed by comparing TLF results to thermotolerant coliforms (TTC), humic-like fluorescence (HLF), inorganic hydrochemical data and sanitary risk scores. The most prominent differences in microbial water quality were observed between source types, with little variation between districts and seasons. TLF, TTCs, turbidity and sanitary risk scores were all elevated at alternative sources (shallow wells and tap stands) compared to hand-pumped boreholes. In the dry season, 18% of hand-pumped boreholes showed TTC contamination, which increase to 21% in the wet season. Groundwater recharge processes are likely responsible for seasonal variability of inorganic hydrochemistry at hand-pumped boreholes. TLF was able to distinguish no and low WHO risk classes (TTC 0-9 cfu/100 mL) from medium, high and very high risk classes (TTC 10 - >1000 cfu/100 mL). TLF failed to distinguish between no and low risk classes, which limits the use of TLF for assessing water quality to drinking water standards. This dataset indicates that HLF may raise baseline TLF for samples with low TLF values, increasing false positives. Therefore, TLF is better suited as a rapid high-level water quality screening tool to assess moderate and high levels of faecal contamination.

Coliform bacteria and salt content as drinking water challenges at sand dams in Kenya

Sand dams can be an effective community-scale solution to increasing water supplies in some arid and semi-arid regions, but there are few studies that have investigated water quality at sand dams. This study investigated the levels of coliform bacteria and salt content as parameters of potential concern. Most water taken from sand dam sources had fecal coliforms present. Median fecal coliforms were in the range of 150-800 cfu/100 ml for unprotected sources (scoop holes, surface water or hand dug wells), levels which are considered high or very high health risk. Pump wells had less contamination, with fecal coliforms detected in one-third of samples in the dry season. Despite this contamination, user surveys indicated that 74% of communities generally view water as clean for drinking, and 72% reported that no or few people in their community treat their water. Salt content in the dry season was in the poor or unacceptable range (above 900 ppm as total dissolved solids) in 33% of water samples. Results suggest that fecal coliforms and salt content represent two types of challenges to water quality at sand dams: fecal coliforms are a health hazard, whereas high salt content potentially reduces the amount of usable water that is available.

Comparative performance of rural water supplies during drought

As rural African communities experience more frequent and extreme droughts, it is increasingly important that water supplies are climate resilient. Using a unique temporal dataset we explore rural water supply (n = 5196) performance during the 2015-16 drought in Ethiopia. Mean functionality ranged from 60% for motorised boreholes to 75% for hand-pumped boreholes. Real-time monitoring and responsive operation and maintenance led to rapid increases in functionality of hand-pumped and, to a lesser extent, motorised boreholes. Increased demand was placed on motorised boreholes in lowland areas as springs, hand-dug-wells and open sources failed. Most users travelled >1 h to access motorised boreholes but <30 min, increasing to 30-60 mins, for hand-pumped boreholes. Boreholes accessing deep (>30 m) groundwater performed best during the drought. Prioritising access to groundwater via multiple improved sources and a portfolio of technologies, such as hand-pumped and motorised boreholes, supported by responsive and proactive operation and maintenance, increases rural water supply resilience.

Operational research on rural, community-managed Water Safety Plans: Case study results from implementations in India, DRC, Fiji, and Vanuatu

Water Safety Plans (WSPs) are internationally recommended risk assessment and management strategies for water delivery. However, documented outcomes and impacts from implementing WSPs are lacking, particularly for community-managed supplies. In this research, previously implemented, community-managed WSPs were evaluated in four countries through a mixed-methods protocol assessing: WSP implementation quality, WSP management via key informant interviews (KII) and focus group discussions (FGD), household characteristics, and collection-point and stored household water quality in WSP and non-WSP communities. Overall, 256 KIIs and FGDs, 816 household surveys, and 1,099 water quality samples were completed. The quality of WSP implementations scored 6-13 out of 18 possible points. KIIs and FGDs found WSP communities had improved capacity to manage water supplies and identify key risks to safe water delivery. Fewer non-WSP community households reported paying for water in DRC and Vanuatu (p < 0.001). WSP community water collection-points had more E. coli contamination than non-WSP community collection-points in DRC (p = 0.009), Fiji (p = 0.020), and Vanuatu (p = 0.004); household results varied, although exploratory analysis revealed that non-WSP communities were imperfectly matched to WSP communities. Overall, we found: 1) incomplete WSP implementations; 2) small improvements in water supply operations; and, 3) no documented microbiological water quality improvements from WSPs. These results highlight that WSPs implemented in rural, community-managed supplies are challenging and question their effectiveness; if implemented additional technical and financial resources are necessary to support community-managed WSPs.

An Assessment of Inter-Observer Agreement in Water Source Classification and Sanitary Risk Observations

Sanitary risk inspection, an observation protocol for identifying contamination hazards around water sources, is promoted for managing rural water supply safety. However, it is unclear how far different observers consistently identify contamination hazards and consistently classify water source types using standard typologies. This study aimed to quantify inter-observer agreement in hazard identification and classification of rural water sources. Six observers separately visited 146 domestic water sources in Siaya County, Kenya, in wet and dry seasons. Each observer independently classified the source type and conducted a sanitary risk inspection using a standard protocol. Water source types assigned by an experienced observer were cross-tabulated against those of his colleagues, as were contamination hazards identified, and inter-observer agreement measures calculated. Agreement between hazards observed by the most experienced observer versus his colleagues was significant but low (intra-class correlation = 0.49), with inexperienced observers detecting fewer hazards. Inter-observer agreement in classifying water sources was strong (Cohen's kappa = 0.84). However, some source types were frequently misclassified, such as sources adapted to cope with water insecurity (e.g. tanks drawing on both piped and rainwater). Observers with limited training and experience thus struggle to consistently identify hazards using existing protocols, suggesting observation protocols require revision and their implementation should be supported by comprehensive training. Findings also indicate that field survey teams struggle to differentiate some water source types based on a standard water source classification, particularly sources adapted to cope with water insecurity. These findings demonstrate uncertainties underpinning international monitoring and analyses of safe water access via household surveys.

Perceived water insecurity among adults from urban and peri-urban Haiti: A qualitative study

Water and sanitation services are fundamental in preventing the spread of waterborne and hygiene-related diseases. However, in developing countries, such as Haiti, access to clean water continues to pose major challenges despite efforts to improve quality and reduce distance. With Léogâne being the epicenter of the earthquake in Haiti in 2010, there were dozens of interventions aimed to improve access to clean water, specifically well construction and use of water treatment strategies. Using the socioecological framework, this study collected qualitative data to supplement a household water insecurity experiences (HWISE) survey in order to fully understand the narratives around water in Léogâne (urban) and its neighboring commune Gressier (peri-urban). The inclusion criteria for this study was that the participant must be a resident of either site, at least 18 years or older, and a female. Only females were included in this study so that researchers could better understand how perceived water insecurity impacts reproductive health, specifically gynecological infections. This cross-sectional study yielded 61 total in-depth interviews using a semi-structured open ended questionnaire to allow participants the ability to elaborate. Results suggest that there are common misconceptions about water and reproductive health specifically that engaging in sexual intercourse in saltwater will not result in pregnancy. Relevant narratives among the two communes included water acquisition, use of water, and bathing practices, among several others. Through understanding the local Haitian perspective and practices that surround water insecurity, we can better tailor public health interventions to improve access to water, female hygiene practices, and ultimately lower and prevent disease transmission.

Contamination Potentials of Household Water Handling and Storage Practices in Kirundo Subcounty, Kisoro District, Uganda

Introduction

Waterborne diseases constitute a major public health burden in developing and underdeveloped countries. Consumption of contaminated water causes health risk to the public, and the situation is alarming in rural areas. The objective of this study was to assess the contamination potentials of different house water handling and storage practices in the Kirundo subcounty, Kisoro District, Uganda.

Material and Methods

A cross-sectional and descriptive study in which 344 water samples were collected randomly and analysed for bacteriological contamination, total coliforms (TCs) and Escherichia coli per 100 ml, using the Most Probable Number (MPN) technique and reported in terms of CFU/100 ml.

Results

The 43.2% samples from unprotected water sources had total coliforms and 34.1% had Escherichia coli. In analysed household drinking water, 25% had total coliforms and 8.7% had Escherichia coli. Most drinking water sources were found to have coliform counts above the recommended national and international guidelines. There was a statistically significant difference among water sources with respect to total coliforms and Escherichia coli (p < 0.05).

Conclusion

The overall results indicated that there is a strong linkage between microbiological water quality and water source sanitation; hence, the protected water source was safer than unprotected water sources. For the unprotected water sources, protection strategies as well as monitoring are recommended for this community.

A Comparative Overview of the Livestock-Environment Interactions in Asia and Sub-saharan Africa

Understanding the interactions between livestock and the environment in Asia and Sub-Saharan Africa is essential to sustainable livestock sector development. In this comparative overview, we review the available evidence on the extent of grassland degradation, land, and water pollution by nutrients and microorganisms, water stress, biodiversity loss, and greenhouse gas emissions and their relation to livestock production in Asia and Sub-Saharan Africa. We also draw on Asia's past livestock development trajectories and their impacts to provide guidance for future sustainable livestock development in Sub-Saharan Africa. Forward-looking policies and programs that anticipate long-term changes in the livestock sector and that assess trade-offs between policies and investments in multiple environmental domains in Sub-Saharan Africa are required to support sustainable development and guide policy decisions in the years ahead, from an environmental, social and public health perspective.

An assessment of the replicability of a standard and modified sanitary risk protocol for groundwater sources in Greater Accra

Sanitary risk inspection, the systematic observation of contamination hazards, is often used to manage safety of water sources such as wells and boreholes. However, the replicability of sanitary risk inspections undertaken by different observers has not been studied. This study aimed to assess the replicability of sanitary risk inspections by two different observers in urban and peri-urban neighbourhoods of Greater Accra, Ghana. Two observers independently used a standard protocol to record contamination hazards around 62 groundwater sources, additionally recording urban-specific hazards such as damaged sewage pipes via a modified protocol. We calculated risk scores as the proportion of hazards observed at each source, separately for each observer. Linn's concordance correlation coefficient indicated very high agreement between the two observers' risk scores (n = 62; c = 0.949, 95% confidence limits 0.917-0.968). However, risk scores from urban-specific observations were uncorrelated with those from the standard protocol (r = 0.11, p = 0.41 for observer 1; r = 0.16, p = 0.22 for observer 2). Ours is the first study of replicability of sanitary risk observations and suggests high inter-observer agreement. However, urban contamination hazards were not captured using the standard protocol. In the future, assessment of inter-observer agreement and observations of urban-specific hazards could be incorporated into nationwide or regional sanitary risk surveys.

Microbial Groundwater Quality Status of Hand-Dug Wells and Boreholes in the Dodowa Area of Ghana

To assess the suitability of water sources for drinking purposes, samples were taken from groundwater sources (boreholes and hand-dug wells) used for drinking water in the Dodowa area of Ghana. The samples were analyzed for the presence of fecal indicator bacteria (Escherichia coli) and viruses (Adenovirus and Rotavirus), using membrane filtration with plating and glass wool filtration with quantitative polymerase chain reaction (PCR), respectively. In addition, sanitary inspection of surroundings of the sources was conducted to identify their vulnerability to pollution. The presence of viruses was also assessed in water samples from the Dodowa River. More than 70% of the hand-dug wells were sited within 10 m of nearby sources of contamination. All sources contained E. coli bacteria, and their numbers in samples of water between dug wells and boreholes showed no significant difference (p = 0.48). Quantitative PCR results for Adenovirus indicated 27% and 55% were positive for the boreholes and hand-dug wells, respectively. Samples from all boreholes tested negative for the presence of Rotavirus while 27% of the dug wells were positive for Rotavirus. PCR tests of 20% of groundwater samples were inhibited. Based on these results we concluded that there is systemic microbial and fecal contamination of groundwater in the area. On-site sanitation facilities, e.g., pit latrines and unlined wastewater drains, are likely the most common sources of fecal contamination of groundwater in the area. Water abstracted from groundwater sources needs to be treated before use for consumption purposes. In addition, efforts should be made to delineate protected areas around groundwater abstraction points to minimize contamination from point sources of pollution.

Open Defaecation and Its Effects on the Bacteriological Quality of Drinking Water Sources in Isiolo County, Kenya

BACKGROUND INFORMATION

The post-2015 Sustainable Development Goals for sanitation call for universal access to adequate and equitable sanitation and an end to open defaecation by 2030. In Isiolo County, a semi-arid region lying in the northern part of Kenya, poor sanitation and water shortage remain a major problem facing the rural communities.

OBJECTIVE

The overall aim of the study was to assess the relationship between sanitation practices and the bacteriological quality of drinking water sources. The study also assessed the risk factors contributing to open defaecation in the rural environments of the study area.

METHODS

A cross-sectional study of 150 households was conducted to assess the faecal disposal practices in open defaecation free (ODF) and open defaecation not free (ODNF) areas. Sanitary surveys and bacteriological analyses were conducted for selected community water sources to identify faecal pollution sources, contamination pathways, and contributory factors. Analysis of data was performed using SPSS (descriptive and inferential statistics at α = .05 level of significance).

RESULTS

Open defaecation habit was reported in 51% of the study households in ODNF villages and in 17% households in ODF villages. Higher mean colony counts were recorded for water samples from ODNF areas 2.0, 7.8, 5.3, and 7.0 (×10³) colony-forming units (CFUs)/100 mL compared with those of ODF 1.8, 6.4, 3.5, and 6.1 (×10³) areas for Escherichia coli, faecal streptococci, Salmonella typhi, and total coliform, respectively. Correlation tests revealed a significant relationship between sanitary surveys and contamination of water sources (P = .002).

CONCLUSIONS

The water sources exhibited high levels of contamination with microbial pathogens attributed to poor sanitation. Practising safe faecal disposal in particular is recommended as this will considerably reverse the situation and thus lead to improved human health.

The Effectiveness of Sanitary Inspections as a Risk Assessment Tool for Thermotolerant Coliform Bacteria Contamination of Rural Drinking Water: A Review of Data from West Bengal, India

AbstractThe use of sanitary inspections combined with periodic water quality testing has been recommended in some cases as screening tools for fecal contamination. We conducted sanitary inspections and tested for thermotolerant coliforms (TTCs), a fecal indicator bacteria, among 7,317 unique water sources in West Bengal, India. Our results indicate that the sanitary inspection score has poor ability to identify TTC-contaminated sources. Among deep and shallow hand pumps, the area under curve (AUC) for prediction of TTC > 0 was 0.58 (95% confidence interval [CI] = 0.53-0.61) and 0.58 (95% CI = 0.54-0.62), respectively, indicating that the sanitary inspection score was only marginally better than chance in discriminating between contaminated and uncontaminated sources of this type. A slightly higher AUC value of 0.64 (95% CI=0.57-0.71) was observed when the sanitary inspection score was used for prediction of TTC > 0 among the gravity-fed piped sources. Among unprotected springs (AUC = 0.48, 95% CI = 0.38-0.55) and unprotected dug wells (AUC = 0.41, 95% CI = 0.20-0.66), the sanitary inspection score performed more poorly than chance in discriminating between sites with TTC < 1 and TTC > 0. Aggregating over all source types, the sensitivity (true positive rate) of a high/very high sanitary inspection score for TTC contamination (TTC > 1 CFU/100 mL) was 29.4% and the specificity (true negative rate) was 77.9%, resulting in substantial misclassification of the sites when using the established risk categories. These findings suggest that sanitary surveys are inappropriate screening tools for identifying TTC contamination at water points.

Can Sanitary Surveys Replace Water Quality Testing? Evidence from Kisii, Kenya

Information about the quality of rural drinking water sources can be used to manage their safety and mitigate risks to health. Sanitary surveys, which are observational checklists to assess hazards present at water sources, are simpler to conduct than microbial tests. We assessed whether sanitary survey results were associated with measured indicator bacteria levels in rural drinking water sources in Kisii Central, Kenya. Overall, thermotolerant coliform (TTC) levels were high: all of the samples from the 20 tested dug wells, almost all (95%) of the samples from the 25 tested springs, and 61% of the samples from the 16 tested rainwater harvesting systems were contaminated with TTC. There were no significant associations between TTC levels and overall sanitary survey scores or their individual components. Contamination by TTC was associated with source type (dug wells and springs were more contaminated than rainwater systems). While sanitary surveys cannot be substituted for microbial water quality results in this context, they could be used to identify potential hazards and contribute to a comprehensive risk management approach.

Population-based study of intra-household gender differences in water insecurity: reliability and validity of a survey instrument for use in rural Uganda

Hundreds of millions of people worldwide lack adequate access to water. Water insecurity, which is defined as having limited or uncertain availability of safe water or the ability to acquire safe water in socially acceptable ways, is typically overlooked by development organizations focusing on water availability. To address the urgent need in the literature for validated measures of water insecurity, we conducted a population-based study in rural Uganda with 327 reproductive-age women and 204 linked men from the same households. We used a novel method of photo identification so that we could accurately elicit study participants' primary household water sources, thereby enabling us to identify water sources for objective water quality testing and distance/elevation measurement. Our psychometric analyses provided strong evidence of the internal structure, reliability, and validity of a new eight-item Household Water Insecurity Access Scale (HWIAS). Important intra-household gender differences in perceptions of water insecurity were observed, with men generally perceiving household water insecurity as being less severe compared to women. In summary, the HWIAS represents a reliable and valid measure of water insecurity, particularly among women, and may be useful for informing and evaluating interventions to improve water access in resource-limited settings.

Human and Animal Fecal Contamination of Community Water Sources, Stored Drinking Water and Hands in Rural India Measured with Validated Microbial Source Tracking Assays

We examined pathways of exposure to fecal contamination of human and animal origin in 24 villages in Odisha, India. In a cross-sectional study during the monsoon season, fecal exposure via community water sources (N = 123) and in the home (N = 137) was assessed using human- and nonhuman-associated Bacteroidales microbial source tracking (MST) markers and fecal coliforms (FCs). Detection rates and marker concentrations were examined to pinpoint pathways of human fecal exposure in the public and domestic domains of disease transmission in study communities. Human fecal markers were detected much more frequently in the domestic domain (45% of households) than in public domain sources (8% of ponds; 4% of groundwater drinking sources). Animal fecal markers were widely detected in both domains (74% of ponds, 96% of households, 10% of groundwater drinking sources), indicating ubiquitous risks of exposure to animal feces and zoonotic pathogens. This study confirms an often suggested contamination link from hands to stored water in the home in developing countries separately for mothers' and children's hands and both human and animal fecal contamination. In contrast to MST markers, FCs provided a poor metric to assess risks of exposure to fecal contamination of human origin in this rural setting.

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<0.001) and rural areas (OR = 2.37 [1.47-3.81] p<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 quality.

Risk reduction assessment of waterborne Salmonella and Vibrio by a chlorine contact disinfectant point-of-use device

Unsafe drinking water continues to burden developing countries despite improvements in clean water delivery and sanitation, in response to Millennium Development Goal 7. Salmonella serotype Typhi and Vibrio cholerae bacteria can contaminate drinking water, causing waterborne typhoid fever and cholera, respectively. Household water treatment (HWT) systems are widely promoted to consumers in developing countries but it is difficult to establish their benefits to the population for specific disease reduction. This research uses a laboratory assessment of halogenated chlorine beads treating contaminated water to inform a quantitative microbial risk assessment (QMRA) of S. Typhi and V. cholerae disease in a developing country community of 1000 people. Laboratory challenges using seeded well water resulted in log10 reductions of 5.44 (± 0.98 standard error (SE)) and 6.07 (± 0.09 SE) for Salmonella serotype Typhimurium and V. cholerae, respectively. In well water with 10% sewage and seeded bacteria, the log10 reductions were 6.06 (± 0.62 SE) and 7.78 (± 0.11 SE) for S. Typhimurium and V. cholerae, respectively. When one infected individual was contributing to the water contamination through fecal material leaking into the water source, the risk of disease associated with drinking untreated water was high according to a Monte Carlo analysis: a median of 0.20 (interquartile range [IQR] 0.017-0.54) for typhoid fever and a median of 0.11 (IQR 0.039-0.20) for cholera. If water was treated, risk greatly decreased, to a median of 4.1 × 10(-7) (IQR 1.6 × 10(-8) to 1.1 × 10(-5)) for typhoid fever and a median of 3.5 × 10(-9) (IQR 8.0 × 10(-10) to 1.3 × 10(-8)) for cholera. Insights on risk management policies and strategies for public health workers were gained using a simple QMRA scenario informed by laboratory assessment of HWT.

Assessing rural small community water supply in Limpopo, South Africa: water service benchmarks and reliability

Although a number of studies have reported on water supply improvements, few have simultaneously taken into account the reliability of the water services. The study aimed to assess whether upgrading water supply systems in small rural communities improved access, availability and potability of water by assessing the water services against selected benchmarks from the World Health Organisation and South African Department of Water Affairs, and to determine the impact of unreliability on the services. These benchmarks were applied in three rural communities in Limpopo, South Africa where rudimentary water supply services were being upgraded to basic services. Data were collected through structured interviews, observations and measurement, and multi-level linear regression models were used to assess the impact of water service upgrades on key outcome measures of distance to source, daily per capita water quantity and Escherichia coli count. When the basic system was operational, 72% of households met the minimum benchmarks for distance and water quantity, but only 8% met both enhanced benchmarks. During non-operational periods of the basic service, daily per capita water consumption decreased by 5.19l (p<0.001, 95% CI 4.06-6.31) and distances to water sources were 639 m further (p ≤ 0.001, 95% CI 560-718). Although both rudimentary and basic systems delivered water that met potability criteria at the sources, the quality of stored water sampled in the home was still unacceptable throughout the various service levels. These results show that basic water services can make substantial improvements to water access, availability, potability, but only if such services are reliable.