Effective use of household water treatment and safe storage in response to the 2010 Haiti earthquake

Systematic Review of the Microbiological Performance of Household Water Treatment Technologies

Household water treatment (HWT) is a prevalent method for improving the safety of drinking-water. We conducted a systematic review of peer-reviewed literature from 1997 to 2021 on microbiological performance of common HWT technologies including porous ceramic filters, carbon block or membrane filtration, granular media filtration, thermal treatment, solar disinfection, UV irradiation, chemical disinfection, and combined coagulation-disinfectant products. We used the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) best practices and searched SCOPUS, Web of Science, PubMed, and Agricola and further consulted an expert working group to add relevant publications reporting microbial performance of HWT (n = 396 peer-reviewed studies). Reported log10 reduction values (LRVs) varied widely across and within technology categories. We summarize microbial performance by technology type; pathogen class (bacteria, virus, protozoa); and study setting (field or laboratory). Combined coagulation-disinfectant products had the highest LRV performance for bacterial (6.3) and viral (5.3) classes, and porous ceramic had the highest LRV for protozoa (3) when n > 3. Findings can inform the selection of candidate HWT options, but factors such as product design, time burden of use, cost, and long-term maintenance requirements are important considerations in technological performance. Microbiological performance is meaningless if the technology is not used consistently, correctly, and sustainably.

Pricing drinking water testing in northern Haiti: Financial sensitivity to operating costs, user demand, and economic conditions

Safe drinking water availability is a concern in Haiti. Public systems have limited coverage and reliability. Private wells and local water sources are often of unknown or poor quality. Public health events, such as the 2010 cholera outbreak, demonstrate vulnerability to water contamination. To address these concerns, a drinking water laboratory was established at the Campus Henri Christophe in Limonade, a branch of the State University of Haiti, to meet water testing demands from local clients such as for-profit kiosks, institutions, industries, and municipal water systems. This study assessed the financial viability of a university-based drinking water laboratory in Haiti by calculating Internal Rate of Return and Net Present Value. Sensitivity analysis was used to identify the range of conditions under which laboratory revenues would cover operating costs. To achieve an acceptable profitability level, the laboratory must perform microbiological testing for routine monitoring samples and test an average of five samples per day. Price-based incentives for new clients have relatively small impacts on profitability. Finally, international and Haitian inflation cause some variation in profitability. These economic factors will be among the key drivers of laboratory operation costs. The results underscore the main factors that must be considered to make the laboratory successful and the importance of strategic marketing for laboratory managers to encourage clients to regularly test drinking water and emphasize microbiological testing.

Determinants of adoption of household water treatment in Haiti using two analysis methods: logistic regression and machine learning

Household water treatment (HWT) is recommended when safe drinking water is limited. To understand determinants of HWT adoption, we conducted a cross-sectional survey with 650 households across different regions in Haiti. Data were collected on 71 demographic and psychosocial factors and 2 outcomes (self-reported and confirmed HWT use). Data were transformed into 169 possible determinants of adoption across nine categories. We assessed determinants using logistic regression and, as machine learning methods are increasingly used, random forest analyses. Overall, 376 (58%) respondents self-reported treating or purchasing water, and 123 (19%) respondents had residual chlorine in stored household water. Both logistic regression and machine learning analyses had high accuracy (area under the receiver operating characteristic curve (AUC): 0.77-0.82), and the strongest determinants in models were in the demographics and socioeconomics, risk belief, and WASH practice categories. Determinants that can be influenced inform HWT promotion in Haiti. It is recommended to increase access to HWT products, provide cash and education on water treatment to emergency-impacted populations, and focus future surveys on known determinants of adoption. We found both regression and machine learning methods need informed, thoughtful, and trained analysts to ensure meaningful results and discuss the benefits/drawbacks of analysis methods herein.

Wilderness Medical Society Clinical Practice Guidelines on Water Treatment for Wilderness, International Travel, and Austere Situations: 2024 Update

To provide guidance to medical providers, wilderness users, and travelers, the Wilderness Medical Society convened an expert panel to develop evidence-based guidelines for treating water in situations where the potability of available water is not assured, including wilderness and international travel, areas impacted by disaster, and other areas without adequate sanitation. The guidelines present the available methods for reducing or eliminating microbiological contamination of water for individuals, groups, or households; evaluation of their effectiveness; and practical considerations. The evidence base includes both laboratory and clinical publications. The panel graded the recommendations based on the quality of supporting evidence and the balance between benefits and risks/burdens according to the criteria published by the American College of Chest Physicians.

Adoption of Point-of-Use Chlorination for Household Drinking Water Treatment: A Systematic Review

BACKGROUND

Centralized chlorination of urban piped water supplies has historically contributed to major reductions in waterborne illness. In locations without effective centralized water treatment, point-of-use (POU) chlorination for households is widely promoted to improve drinking water quality and health. Realizing these health benefits requires correct, consistent, and sustained product use, but real-world evaluations have often observed low levels of use. To our knowledge, no prior reviews exist on adoption of chlorine POU products.

OBJECTIVES

Our objectives were to identify which indicators of adoption are most often used in chlorine POU studies, summarize levels of adoption observed, understand how adoption changes over time, and determine how adoption is affected by frequency of contact between participants and study staff.

METHODS

We conducted a systematic review of household POU chlorination interventions or programs from 1990 through 2021 that reported a quantitative measure of adoption, were conducted in low- and middle-income countries, included data collection at households, and reported the intervention start date.

RESULTS

We identified 36 studies of household drinking water chlorination products that met prespecified eligibility criteria and extracted data from 46 chlorine intervention groups with a variety of chlorine POU products and locations. There was no consensus definition of adoption of household water treatment; the most common indicator was the proportion of household stored water samples with free chlorine residual > 0.1  or   0.2 mg / L . Among studies that reported either free or total chlorine-confirmed adoption of chlorine POU products, use was highly variable (across all chlorine intervention groups at the last time point measured in each study; range: 1.5%-100%; sample size-weighted median = 47 % ; unweighted median = 58 % ). The median follow-up duration among intervention groups was 3 months. On average, adoption declined over time and was positively associated with frequency of contact between respondents and study staff.

DISCUSSION

Although prior research has shown that POU chlorine products improve health when correctly and consistently used, a reliance on individual adoption for effective treatment is unlikely to lead to the widespread public health benefits historically associated with pressurized, centralized treatment of piped water supplies. https://doi.org/10.1289/EHP10839.

Chlorination for low-cost household water disinfection - A critical review and status in three Latin American countries

Chlorination has historically provided microbiologically safe drinking water in public water supplies. Likewise, chlorine has also been introduced as a low-cost disinfection method in rural and marginalized communities, both at community and household level, as well as during emergencies. Although this practice is common and well established for use as a household water treatment technology in the Global South, several challenges in effective and efficient implementation still need to be addressed. Here, we explored these issues by a literature review and narrowed them to the status of three Latin American countries (Mexico, Colombia, and Brazil). Overall, it was found that although guidance on household-based chlorination includes information on health risks and hygiene, this may not create enough incentive for the user to adapt the method satisfactorily. Physicochemical quality of the water influences chlorination efficiency and it is found that variations in quality are rarely considered when recommending chlorine doses during implementation. These are far more often based on a few measurements of turbidity, thereby not considering dissolved organic matter, or seasonal and day-to-day variations. Other factors such as user preferences, chlorine product quality and availability also represent potential barriers to the sustainable use of chlorination. For chlorination to become a sustainable household water treatment, more focus should therefore be given to local conditions prior to the intervention, as well as support and maintenance of behavioural changes during and after the intervention.

Feasibility, acceptability, and effectiveness of non-pharmaceutical interventions against infectious diseases among crisis-affected populations: a scoping review

BACKGROUND

Non-pharmaceutical interventions (NPIs) are a crucial suite of measures to prevent and control infectious disease outbreaks. Despite being particularly important for crisis-affected populations and those living in informal settlements, who typically reside in overcrowded and resource limited settings with inadequate access to healthcare, guidance on NPI implementation rarely takes the specific needs of such populations into account. We therefore conducted a systematic scoping review of the published evidence to describe the landscape of research and identify evidence gaps concerning the acceptability, feasibility, and effectiveness of NPIs among crisis-affected populations and informal settlements.

METHODS

We systematically reviewed peer-reviewed articles published between 1970 and 2020 to collate available evidence on the feasibility, acceptability, and effectiveness of NPIs in crisis-affected populations and informal settlements. We performed quality assessments of each study using a standardised questionnaire. We analysed the data to produce descriptive summaries according to a number of categories: date of publication; geographical region of intervention; typology of crisis, shelter, modes of transmission, NPI, research design; study design; and study quality.

RESULTS

Our review included 158 studies published in 85 peer-reviewed articles. Most research used low quality study designs. The acceptability, feasibility, and effectiveness of NPIs was highly context dependent. In general, simple and cost-effective interventions such as community-level environmental cleaning and provision of water, sanitation and hygiene services, and distribution of items for personal protection such as insecticide-treated nets, were both highly feasible and acceptable. Logistical, financial, and human resource constraints affected both the implementation and sustainability of measures. Community engagement emerged as a strong factor contributing to the effectiveness of NPIs. Conversely, measures that involve potential restriction on personal liberty such as case isolation and patient care and burial restrictions were found to be less acceptable, despite apparent effectiveness.

CONCLUSIONS

Overall, the evidence base was variable, with substantial knowledge gaps which varied between settings and pathogens. Based on the current landscape, robust evidence-based guidance is not possible, and a research agenda is urgently required that focusses on these specific vulnerable populations. Although implementation of NPIs presents unique practical challenges in these settings, it is critical that such an agenda is put in place, and that the lessons learned from historical and present experiences are documented to build a firm evidence base.

Field Trial of an Automated Batch Chlorinator System at Two Shared Shallow Tubewells among Camps for Forcibly Displaced Myanmar Nationals (FDMN) in Cox's Bazar, Bangladesh

Chlorination of shallow tubewell water is challenging due to various iron concentrations. A mixed-method, small-scale before-and-after field trial assessed the accuracy and consistency of an automated chlorinator, Zimba, in Rohingya camp housing, Cox’s Bazar. From August–September 2018, two shallow tubewells (iron concentration = 6.5 mg/L and 1.5 mg/L) were selected and 20 households were randomly enrolled to participate in household surveys and water testing. The field-team tested pre-and post-treated tubewell and household stored water for iron, free and total chlorine, and E. coli. A sub-set of households (n = 10) also received safe storage containers (5 L jerry cans). Overall mean iron concentrations were 5.8 mg/L in Zimba water, 1.9 mg/L in household storage containers, and 2.8 mg/L in the project-provided safe storage containers. At baseline, 0% samples at source and 60% samples stored in household vessels were contaminated with E. coli (mean log₁₀ = 0.62 MPN/100 mL). After treatment, all water samples collected from source and project-provided safe storage containers were free from E. coli, but 41% of post-treated water stored in the household was contaminated with E. coli. E. coli concentrations were significantly lower in the project-provided safe storage containers (log₁₀ mean difference = 0.92 MPN, 95% CI = 0.59–1.14) compared with baseline and post-treated water stored in household vessels (difference = 0.57 MPN, 95% CI = 0.32–0.83). Zimba is a potential water treatment technology for groundwater extracted through tubewells with different iron concentrations in humanitarian settings.

Community health workers in humanitarian settings: Scoping review

BACKGROUND

There is a need for greater understanding of experiences implementing community-based primary health care in humanitarian settings and of the adjustments needed to ensure continuation of essential services and utilization of services by the population, and to contribute to effective emergency response. We reviewed the evidence base on community health workers (CHWs) in humanitarian settings, with the goal of improving delivery of essential services to the most vulnerable populations.

METHODS

We conducted a scoping review of published and grey literature related to health and nutrition services provided by CHWs in humanitarian settings. Extracted data from retained documents were analyzed inductively for key themes.

RESULTS

Of 3709 documents screened, 219 were included in the review. Key findings from the literature include: 1) CHWs were often able to continue providing services during acute and protracted crises, including prolonged periods of conflict and insecurity and during population displacement. 2) CHWs carried out critical emergency response activities during acute crises. 3) Flexible funding facilitated transitions between development and humanitarian programming. 4) Communities that did not have a locally-resident CHW experienced reduced access to services when travel was limited. 5) Community selection of CHWs and engagement of respected local leaders were crucial for community trust and acceptance and high utilization of services. 6) Selection of local supervisors and use of mobile phones facilitated continued supervision. 7) Actions taken to maintain supplies included creating parallel supply chains, providing buffer stocks to CHWs, and storing commodities in decentralized locations. 8) When travel was restricted, reporting and data collection were continued using mobile phones and use of local data collectors. 9) CHWs and supervisors faced security threats and psychological trauma as a result of their work.

CONCLUSIONS

To achieve impact, policy makers and program implementers will have to address the bottlenecks to CHW service delivery common in stable low-income settings as well as the additional challenges unique to humanitarian settings. Future interventions should take into account the lessons learned from years of experience with implementation of community-based primary health care in humanitarian settings. There is also a need for rigorous assessments of community-based primary health care interventions in humanitarian settings.

Efficiency and stability evaluation of Cu2O/MWCNTs filters for virus removal from water

Both multi-walled carbon nanotubes (MWCNTs) and metal or metal oxides have demonstrated virus removal efficacy in drinking water applications. In this study, MWCNTs were coated with copper(I) oxide (Cu₂O) using three distinct synthesis procedures (copper ion attachment, copper hydroxide precipitation, and [Cu(NH₃)₄]²⁺ complex attachment) and virus removal efficacy (using MS2 bacteriophages) was evaluated. All synthesis procedures resulted in the presence of adsorbed, nanosized Cu₂O particles on the MWCNTs, shown using X-ray diffraction. Further, transmission electron microscopy confirmed uniform copper(I) oxide distribution along the MWCNTs for all three materials. Virus removal efficacy was assessed for all three synthesised composites both before and after material conditioning (filtering for at least 24 h/280 mL/h), and accounting for additional MS2 inactivation in the permeate due to continued copper inactivation from dissolved/desorbed copper in permeate (time-control). Material conditioning influenced virus removal, with the first litres of water containing higher concentrations of copper than the sixth litres of water, suggesting excess or non-bonded copper species dissolve from filters. Higher copper dissolution was observed for water at pH 5 than at pH 7, which decreased with time. Copper dissolution most likely caused an associated decrease in copper adsorbed to MWCNTs in the filters, which may explain the observed lower MS2 removal efficacy after conditioning. Additionally, the time-control study (immediately after filtration as compared to 2 h after filtration) highlighted continued MS2 inactivation in the permeate over time. The obtained results indicate that the synthesis procedure influences virus removal efficacy for MWCNTs coated with copper oxides and that virus removal is likely due to not only virus electrostatic adsorption to the coated MWCNTs, but also through antiviral properties of copper which continues to act in the permeate. In conclusion, it is highly important to revise the methods of testing filter materials for virus removal, as well as procedure for virus concentration evaluation.

Delivering Drinking Water by Truck in Humanitarian Contexts: Results from Mixed-Methods Evaluations in the Democratic Republic of the Congo and Bangladesh

Water trucking is a commonly implemented, but severely under-researched, drinking water supply intervention in humanitarian response. To fill this research gap, we conducted three mixed-methods water trucking program evaluations in the Democratic Republic of the Congo and Bangladesh, including interviews, water point observations, household surveys, focus groups, and water quality testing. Results indicated that the programs had complex implementation structures involving multiple agencies and limited infrastructure to properly collect, treat, and deliver water. All programs met queueing time and distance indicators, did not meet water quantity indicators, and inconsistently met water quality indicators. Free chlorine residual (FCR) declined through the water chain, and household water Escherichia coli concentrations were associated with household FCR, receiving behavior change messages, storage container type, and distance from the distribution point. Users appreciated water trucking, especially compared to previous water sources, and expressed desires for increased quantity, improved quality, and consistent delivery. If water trucking programs are implemented, it is recommended to have the financial resources to install sanitary collection and distribution infrastructure, establish a management team of all implementation partners, ensure sufficient water quantity is delivered, ensure recommended FCR levels at distribution points, monitor FCR throughout distribution, and complete behavior change communication activities about the program and safe water storage with users.

Does a Free-Trial Approach Increase Purchase and Use of a Household Water Treatment and Safe Storage Product in Rural Haiti?

A cluster, randomized control trial was conducted to assess the effects of social marketing approach on purchase rates and water treatment behavior of Klorfasil, a chlorine-based household water treatment product among seven villages in Thomassique, Haiti, from May to December 2016. Villages were randomized to the free-trial (257 households) or cost-sharing (240 households) group. Households in the free-trial group were allowed 30 days of free Klorfasil use before purchase decision. Households who purchased Klorfasil were then followed up for 30, 60, and 180 days. At the last follow-up, respondents were asked if they would like to repurchase Klorfasil. Questionnaire survey and water quality assessment by residual-free chlorine were conducted in each survey. Chi-square test, t-test, and logistic regression were applied. The first purchase rate of the cost-sharing group was significantly higher than that of the free-trial group (79.2% versus 67.3%). By contrast, the repurchase rate of the free-trial group was higher (82.9% versus 66.3%). However, the overall repurchase rate was 71.6% and the proportion of long-term users was significantly higher in the cost-sharing group (56% versus 47%). Water treatment rates in the cost-sharing group were significantly higher than those in the free-trial group in the first and final surveys (odds ratio [OR] = 0.15, OR = 0.32). Households with high and medium economic status both had significantly higher purchase rates than low economic status households (OR = 4.40, OR = 1.94). Households with higher educated respondents had significantly better water treatment practices (OR = 2.15). The free-trial approach did not increase the first purchase rate but increased the repurchase rate later. The cost-sharing approach significantly encouraged long-term usage.

Effectiveness of Multilevel Risk Management Emergency Response Activities To Ensure Free Chlorine Residual in Household Drinking Water in Southern Syria

To provide safe drinking water and reduce the risk of disease, emergency responders in southern Syria are implementing a multilevel risk reduction strategy with the aim of ensuring free chlorine residual (FCR) in household drinking water. Responders implemented activities across the water chain (from chlorination station and well operators to water vendors to household members), including distribution of supplies for chlorination and training on chlorine use; activities varied by responder. We evaluated the effectiveness of these interventions in a cross-sectional observation study including interviews and observations with 24 chlorination station operators and 63 well owners/managers; interviews, observations, and water quality testing with 220 water truckers; and surveys and water quality testing with 1006 households. Across all responders, activities successfully ensured FCR in household drinking water (61-96% of households with FCR ≥ 0.1 mg/L compared to 21% in nonintervention households, p < 0.001). Centralized interventions led to the highest FCR results. Household FCR was associated with access to piped water systems (aOR 3.5, 95% CI 1.8-6.7) and chlorine distribution (aOR 6.1, 95% CI 3.4-11.0). We recommend continuing activities, emphasizing central-level activities, and supplementing with household-level activities. These results will help to optimize current interventions and guide future response design in similar contexts.

Adherence to Point-of-Use Water Treatment over Short-Term Implementation: Parallel Crossover Trials of Flocculation-Disinfection Sachets in Pakistan and Zambia

The health benefits of point-of-use (POU) water treatment can only be realized through high adherence: correct, consistent, and sustained use. We conducted parallel randomized, longitudinal crossover trials measuring short-term adherence to two single-use flocculant-disinfectant sachets in Pakistan and Zambia. In both trials, adherence declined sharply for both products over the eight week surveillance periods, with overall lower adherence to both products in Zambia. There was no significant difference in adherence between the two products. Estimated median daily production of treated water dropped over the crossover period from 2.5 to 1.4 L person^-1 day^-1 (46% decline) in Pakistan and from 1.4 to 1.1 L person^-1 day^-1 (21% decline) in Zambia. The percentage of surveillance points with detectable total chlorine in household drinking water declined from 70% to 49% in Pakistan and rose marginally from 28% to 30% in Zambia. The relatively low and decreasing adherence observed in this study suggests that these products would have provided little protection from waterborne disease risk in these settings. Our findings underscore the challenge of achieving high adherence to POU water treatment, even under conditions of short-term adoption with intensive follow-up.

Household and Individual Risk Factors for Cholera among Cholera Vaccine Recipients in Rural Haiti

Oral cholera vaccination was used as part of cholera control in Haiti, but the vaccine does not provide complete protection. We conducted secondary data analyses of a vaccine effectiveness study in Haiti to evaluate risk factors for cholera among cholera vaccine recipients. Individuals vaccinated against cholera that presented with acute watery diarrhea and had a stool sample positive for Vibrio cholerae O1 were included as cases. Up to four vaccinated individuals who did not present for treatment of diarrhea were included as controls for each case, and matched by location of residence, enrollment time, and age. We evaluated sociodemographic characteristics and risk factors for cholera. Univariable and multivariable logistic regression were performed to identify risk factors for cholera among vaccinees. Thirty-three vaccine recipients with culture-confirmed cholera were included as cases. One-hundred-and-seventeen of their matched controls reported receiving vaccine and were included as controls. In a multivariable analysis, self-reporting use of branded household water disinfection products as a means of treating water (adjusted relative risk [aRR] = 44.3, 95% confidence interval [CI] = 4.19-468.05, P = 0.002), and reporting having a latrine as the main household toilet (aRR = 4.22, 95% CI = 1.23-14.43, P = 0.02), were independent risk factors for cholera. Self-reporting always treating water (aRR = 0.09, 95% CI = 0.01-0.57, P = 0.01) was associated with protection against cholera. The field effectiveness of water, sanitation, and hygiene interventions used in combination with cholera vaccination in cholera control should be measured and monitored over time to identify and remediate shortcomings, and ensure successful impact on disease control.

Evidence on the Effectiveness of Water, Sanitation, and Hygiene (WASH) Interventions on Health Outcomes in Humanitarian Crises: A Systematic Review

BACKGROUND

Water, sanitation, and hygiene (WASH) interventions are amongst the most crucial in humanitarian crises, although the impact of the different WASH interventions on health outcomes remains unclear.

AIM

To examine the quantity and quality of evidence on WASH interventions on health outcomes in humanitarian crises, as well as evaluate current evidence on their effectiveness against health outcomes in these contexts.

METHODS

A systematic literature review was conducted of primary and grey quantitative literature on WASH interventions measured against health outcomes in humanitarian crises occurring from 1980-2014. Populations of interest were those in resident in humanitarian settings, with a focus on acute crisis and early recovery stages of humanitarian crises in low and middle-income countries. Interventions of interest were WASH-related, while outcomes of interest were health-related. Study quality was assessed via STROBE/CONSORT criteria. Results were analyzed descriptively, and PRISMA reporting was followed.

RESULTS

Of 3963 studies initially retrieved, only 6 published studies measured a statistically significant change in health outcome as a result of a WASH intervention. All 6 studies employed point-of-use (POU) water quality interventions, with 50% using safe water storage (SWS) and 35% using household water treatment (HWT). All 6 studies used self-reported diarrhea outcomes, 2 studies also reported laboratory confirmed outcomes, and 2 studies reported health treatment outcomes (e.g. clinical admissions). 1 study measured WASH intervention success in relation to both health and water quality outcomes; 1 study recorded uptake (use of soap) as well as health outcomes. 2 studies were unblinded randomized-controlled trials, while 4 were uncontrolled longitudinal studies. 2 studies were graded as providing high quality evidence; 3 studies provided moderate and 1 study low quality evidence.

CONCLUSION

The current evidence base on the impact of WASH interventions on health outcomes in humanitarian crises is extremely limited, and numerous methodological limitations limit the ability to determine associative, let alone causal, relationships.

Hand-to-mouth contacts result in greater ingestion of feces than dietary water consumption in Tanzania: a quantitative fecal exposure assessment model

Diarrheal diseases kill 1800 children under the age of five die each day, and nearly half of these deaths occur in sub-Saharan Africa. Contaminated drinking water and hands are two important environmental transmission routes of diarrhea-causing pathogens to young children in low-income countries. The objective of this research is to evaluate the relative contribution of these two major exposure pathways in a low-income country setting. A Monte Carlo simulation was used to model the amount of human feces ingested by children under five years old from exposure via hand-to-mouth contacts and stored drinking water ingestion in Bagamoyo, Tanzania. Child specific exposure data were obtained from the USEPA 2011 Exposure Factors Handbook, and fecal contamination was estimated using hand rinse and stored water fecal indicator bacteria concentrations from over 1200 Tanzanian households. The model outcome is a distribution of a child's daily dose of feces via each exposure route. The model results show that Tanzanian children ingest a significantly greater amount of feces each day from hand-to-mouth contacts than from drinking water, which may help elucidate why interventions focused on water without also addressing hygiene often see little to no effect on reported incidence of diarrhea.

Access to safe water in rural Artibonite, Haiti 16 months after the onset of the cholera epidemic

Haiti has the lowest improved water and sanitation coverage in the Western Hemisphere and is suffering from the largest cholera epidemic on record. In May of 2012, an assessment was conducted in rural areas of the Artibonite Department to describe the type and quality of water sources and determine knowledge, access, and use of household water treatment products to inform future programs. It was conducted after emergency response was scaled back but before longer-term water, sanitation, and hygiene activities were initiated. The household survey and source water quality analysis documented low access to safe water, with only 42.3% of households using an improved drinking water source. One-half (50.9%) of the improved water sources tested positive for Escherichia coli. Of households with water to test, 12.7% had positive chlorine residual. The assessment reinforces the identified need for major investments in safe water and sanitation infrastructure and the importance of household water treatment to improve access to safe water in the near term.