Interventions to improve water quality for preventing diarrhoea
Thomas Clasen,Kelly T. Alexander,David Sinclair,Sophie Boisson,Rachel Peletz,Howard H. Chang,Fiona Majorin,Sandy Cairncross +7 more
TLDR
There was substantial heterogeneity in the size of the effect estimates between individual studies, and 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.Abstract:
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.read more
Citations
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Journal ArticleDOI
Interventions to improve water quality for preventing diarrhoea: systematic review and meta-analysis
TL;DR: Significant heterogeneity among the trials suggests that the level of effectiveness may depend on a variety of conditions that research to date cannot fully explain.
Journal ArticleDOI
Water, Sanitation, Hygiene, and Soil-Transmitted Helminth Infection: A Systematic Review and Meta-Analysis
Eric C. Strunz,David G. Addiss,Meredith E. Stocks,Stephanie Ogden,Jürg Utzinger,Matthew C. Freeman +5 more
TL;DR: Whether improvements in water, sanitation, and hygiene (WASH) practices are associated with reduced risk of infections with soil-transmitted helminths is examined.
Journal ArticleDOI
Effects of water quality, sanitation, handwashing, and nutritional interventions on diarrhoea and child growth in rural Bangladesh: a cluster randomised controlled trial.
Stephen P. Luby,Mahbubur Rahman,Benjamin F. Arnold,Leanne Unicomb,Sania Ashraf,Peter J. Winch,Christine P. Stewart,Farzana Begum,Faruqe Hussain,Jade Benjamin-Chung,Elli Leontsini,Abu Mohd Naser,Sarker Masud Parvez,Alan Hubbard,Audrie Lin,Fosiul A. Nizame,Kaniz Jannat,Ayse Ercumen,Pavani K. Ram,Kishor K. Das,Jaynal Abedin,Thomas Clasen,Kathryn G. Dewey,Lia C. H. Fernald,Clair Null,Tahmeed Ahmed,John M. Colford +26 more
TL;DR: The WASH Benefits Bangladesh cluster-randomised trial as mentioned in this paper enrolled pregnant women from villages in rural Bangladesh and evaluated outcomes at 1-year and 2-years' follow-up to assess whether water quality, sanitation, and handwashing interventions alone or combined with nutrition interventions reduced diarrhoea or growth faltering.
Journal ArticleDOI
Fecal Contamination of Drinking-Water in Low- and Middle-Income Countries: A Systematic Review and Meta-Analysis
TL;DR: It is found that access to an “improved source” provides a measure of sanitary protection but does not ensure water is free of fecal contamination.
Journal ArticleDOI
Solar water disinfection (SODIS): A review from bench-top to roof-top
Kevin G. McGuigan,Ronan M. Conroy,Hans-Joachim Mosler,Martella du Preez,Eunice Ubomba-Jaswa,Pilar Fernández-Ibáñez +5 more
TL;DR: This review attempts to revise all relevant knowledge about solar disinfection from microbiological issues, laboratory research, solar testing, up to and including real application studies, limitations, factors influencing adoption of the technique and health impact.
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Phillips,Hwee Pin Phua,Dietrich Plass,Dan Poenaru,Guilherme V. Polanczyk,Suzanne Polinder,Constance D. Pond,C. Arden Pope,Daniel Pope,Svetlana Popova,Farshad Pourmalek,John Powles,Dorairaj Prabhakaran,Noela M Prasad,Dima M. Qato,Amado D Quezada,D. Alex Quistberg,Lionel Racapé,Anwar Rafay,Kazem Rahimi,Vafa Rahimi-Movaghar,Sajjad Ur Rahman,Murugesan Raju,Ivo Rakovac,Saleem M Rana,Mayuree Rao,Homie Razavi,K. Srinath Reddy,Amany H Refaat,Amany H Refaat,Jürgen Rehm,Giuseppe Remuzzi,Antônio Luiz Pinho Ribeiro,Patricia M. Riccio,Lee Richardson,Anne M. Riederer,Margaret Robinson,Anna Roca,Alina Rodriguez,David Rojas-Rueda,Isabelle Romieu,Luca Ronfani,Robin Room,Nobhojit Roy,George Mugambage Ruhago,Lesley Rushton,Nsanzimana Sabin,Ralph L. Sacco,Sukanta Saha,Ramesh Sahathevan,Mohammad Ali Sahraian,Joshua A. Salomon,Deborah Salvo,Uchechukwu K.A. Sampson,Juan Sanabria,Juan Sanabria,Luz Maria Sanchez,Tania G Sánchez-Pimienta,Lidia Sanchez-Riera,Logan Sandar,Itamar S. Santos,Amir Sapkota,Maheswar Satpathy,James E. Saunders,Monika Sawhney,Mete Saylan,Peter Scarborough,Jürgen C Schmidt,Ione Jayce Ceola Schneider,Ben Schöttker,David C. Schwebel,James Scott,Soraya Seedat,Sadaf G. Sepanlou,Berrin Serdar,Edson Serván-Mori,Gavin Shaddick,Saeid Shahraz,Teresa Shamah Levy,Siyi Shangguan,Jun She,Sara Sheikhbahaei,Kenji Shibuya,Hwashin H. Shin,Yukito Shinohara,Rahman Shiri,Kawkab Shishani,Ivy Shiue,Inga Dora Sigfusdottir,Donald H. Silberberg,Edgar P. Simard,Shireen Sindi,Abhishek Singh,Gitanjali M. Singh,Jasvinder A. Singh,Vegard Skirbekk,Karen Sliwa,Michael Soljak,Samir Soneji,Kjetil Søreide,Sergey Soshnikov,Luciano A. Sposato,Chandrashekhar T Sreeramareddy,Nicolas J. C. Stapelberg,Vasiliki Stathopoulou,Nadine Steckling,Dan J. Stein,Murray B. Stein,Natalie Stephens,Heidi Stöckl,Kurt Straif,Konstantinos Stroumpoulis,Lela Sturua,Bruno F. Sunguya,Soumya Swaminathan,Mamta Swaroop,Bryan L. Sykes,Karen M. Tabb,Ken Takahashi,Roberto Tchio Talongwa,Nikhil Tandon,David Tanne,Marcel Tanner,Mohammad Tavakkoli,Braden Te Ao,Carolina Maria Teixeira,Martha M Téllez Rojo,Abdullah Sulieman Terkawi,Abdullah Sulieman Terkawi,José Luis Texcalac-Sangrador,Sarah V Thackway,Blake Thomson,Andrew L. Thorne-Lyman,Amanda G. Thrift,George D. Thurston,Taavi Tillmann,Myriam Tobollik,Marcello Tonelli,Fotis Topouzis,Jeffrey A. Towbin,Hideaki Toyoshima,Jefferson Traebert,Bach Xuan Tran,Leonardo Trasande,Matias Trillini,Ulises Trujillo,Zacharie Tsala Dimbuene,Miltiadis K. Tsilimbaris,Emin Murat Tuzcu,Uche S. Uchendu,Kingsley N. Ukwaja,Selen Begüm Uzun,Steven van de Vijver,Rita Van Dingenen,Coen H. Van Gool,Jim van Os,Yuri Y Varakin,Tommi Vasankari,Ana Maria Nogales Vasconcelos,Monica S. Vavilala,Lennert J. Veerman,Gustavo Velasquez-Melendez,Narayanaswamy Venketasubramanian,Lakshmi Vijayakumar,Salvador Villalpando,Francesco Saverio Violante,Vasiliy Victorovich Vlassov,Stein Emil Vollset,Gregory R. Wagner,Gregory R. Wagner,Stephen G Waller,Mitchell T. Wallin,Xia Wan,Haidong Wang,JianLi Wang,Linhong Wang,Wenzhi Wang,Yanping Wang,Tati S. Warouw,Charlotte Watts,Charlotte Watts,Scott Weichenthal,Elisabete Weiderpass,Robert G. Weintraub,Andrea Werdecker,K. Ryan Wessells,Ronny Westerman,Harvey Whiteford,James D. Wilkinson,Hywel C Williams,Thomas N. Williams,Solomon Meseret Woldeyohannes,Charles D.A. Wolfe,John Q. Wong,Anthony D. Woolf,Jonathan L. Wright,Jonathan L. Wright,Brittany Wurtz,Gelin Xu,Lijing L. Yan,Gonghuan Yang,Yuichiro Yano,Pengpeng Ye,Muluken Azage Yenesew,Gokalp Kadri Yentur,Paul S. F. Yip,Naohiro Yonemoto,Seok Jun Yoon,Mustafa Z. Younis,Zourkaleini Younoussi,Chuanhua Yu,Maysaa El Sayed Zaki,Yong Zhao,Yingfeng Zheng,Maigeng Zhou,Jun Zhu,Shankuan Zhu,Xiaonong Zou,Joseph R. Zunt,Alan D. Lopez,Theo Vos,Christopher J L Murray +736 more
TL;DR: The Global Burden of Disease, Injuries, and Risk Factor study 2013 (GBD 2013) as discussed by the authors provides a timely opportunity to update the comparative risk assessment with new data for exposure, relative risks, and evidence on the appropriate counterfactual risk distribution.