PresentationPresentation from the 2008 World Water Week in StockholmPresentation from the 2008 World Water Week  in Stockholm©The Author(s), all rights reserved

Household Water Treatment:effectiveness, cost-effectiveness

and the challenges and policy i f liissues of scaling up

Thomas Clasen JD PhDThomas Clasen, JD, PhDDisease Control & Vector Biology Unit

Department Infectious & Tropical DiseasesLondon School of Hygiene & Tropical Medicine

thomas.clasen@lshtm.ac.uk

Leading Causes of Deaths from Infectious DiseasesLeading Causes of Deaths from Infectious Diseasesgg

2004 World Health Report

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Tuberc

ulosi

Malari

Measle

Respir

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Diarrhoe T

Childhood Mortality by Causey y

Black RE, Morris SS & Bryce J (2003). Where and why are 10 million children dying every year? Lancet 361:2226-34.

Environmental Barriers to Faecal-Oral Transmission

• Primary Barrier– Sanitation (proper

excreta disposal)excreta disposal)– Hygiene (hand washing)

• Secondary Barriersy– Water quality

(treatment & safe storage)storage)

– Water quantity (personal and domestic hygiene)

– Hygiene (especially hand washing)hand washing)

– Proper cooking/food handing practices

Reduction in Diarrhoea from Improvements in Water Quality

Expected reduction in diarrhoeal disease morbidity from improvements in Expected reduction in diarrhoeal disease morbidity from improvements in one or more components of water and sanitation (Esrey, 1991)one or more components of water and sanitation (Esrey, 1991)

All StudiesAll Studies Rigorous StudiesRigorous Studies

No. No. No. No. StudiesStudies ReductionReduction StudiesStudies Reduction Reduction

Water and SanitationWater and Sanitation 77 20%20% 22 30%30%

S nit ti nS nit ti n 1111 22%22% 55 36%36%SanitationSanitation 1111 22%22% 55 36%36%

Water Quality and Water Quality and QuantityQuantity 2222 16%16% 22 17%17%yy

Water QualityWater Quality 77 17%17% 44 15%15%

Water QuantityWater Quantity 77 27%27% 55 20%20%

HygieneHygiene 66 33%33% 66 33%33%

Systematic Review—Wright et al.*• Systematic review and meta-analysis

of 57 studies measuring bacteria counts for source water and stored water in the home.

• Results: The bacteriological quality of drinking water significantly g g ydeclined after collection in many settings.

• Conclusion: Policies that aim to improve water quality through source improvements may be compromised by post-collection contamination. Safer household water storage and treatment is recommended to prevent this, together with point-of-use water quality monitoring.

*Wright J, Gundry S, Conroy R (2004). Householdd i ki t i d l i t i t tidrinking water in developing countries: a systematicreview of microbiological contamination betweensource and point-of-use. Tropical Med. Int’l Health9(1): 106-117

Interventions at Source

“Safe”-Microbiological Qualityg Q yResults of eight-country (Bangladesh, China, Jordon, Tajikistand, India, Nicaragua,

Nigeria, Ethiopia) Rapid Assessment of Drinking Water Quality (RADWQ)

Water supply technology Mean portion of samples complying with WHO guideline value for TTCwith WHO guideline value for TTC

Protected dug well 43% (range 19% to 56%)

Protected springs 63% (Ethiopia 43%, Tajikistan 82%)82%)

Boreholes 69% (range 39%-99%)

Utility piped water supplies

89% (range 39%-99%)

JMP RADWQ (in press)

Interventions at the Household

What about boiling?g• Sub-optimal microbiological performance, probably due

to recontamination after boiling (Gupta 2006; Handzel to eco ta at o a te bo g (Gupta 006; a d e2007; Oswald 2007; Clasen 2008; Clasen 2008a).

• Potentially high cost: US$7.99 to US$8.34 per household per year in India (McLaughlin 2006); US$3.24 to $20.16, in Vietnam) (do Hoang 2007)

• Indoor air poll tion from cooking ith biomass• Indoor air pollution from cooking with biomass associated with reduced birth weight, respiratory infections, anemia, stunting (Retherford 2006), , g ( )

• Boiling water at home is also associated with higher levels of burn accidents . In Sao Paulo, Brazil, boiling

ibl f 9% f b idwater was responsible for 59% of burn accidents among children under 3 years (Rossi 1998).

• Other issues: Suitability environmental sustainability• Other issues: Suitability, environmental sustainability

Cochrane ReviewCochrane Review

Clasen T, Roberts I, Rabie T, Schmidt Clasen T, Roberts I, Rabie T, Schmidt W C i S I iW C i S I iW, Cairncross S. Interventions to W, Cairncross S. Interventions to

improve water quality for preventing improve water quality for preventing diarrhoea (A Cochrane Review). In: The diarrhoea (A Cochrane Review). In: The

Cochrane Library, Issue 3, 2006. Cochrane Library, Issue 3, 2006.

Effectiveness: Intervention Type (all age)

Summary of Effectiveness—All agesIntervention Type Intervention Type

(no. trials)(no. trials)

EstimateEstimate

(random)(random)

% % ΔΔ

(1(1--RR)RR)

95% CI of 95% CI of EstimateEstimate

Heterogeneity*Heterogeneity*

(Chi(Chi--square)square)

Source (6)Source (6) 0.730.73 27%27% 0.53 to 1.010.53 to 1.01 p<0.00001p<0.00001

Household (32)Household (32) 0.530.53 47%47% 0.39 to 0.730.39 to 0.73 p<0.00001p<0.00001Household (32)Household (32) 0.530.53 47%47% 0.39 to 0.730.39 to 0.73 p<0.00001p<0.00001

Filtration (6)Filtration (6) 0.370.37 63%63% 0.28 to 0.490.28 to 0.49 p=0.56p=0.56

Chlorination (16)Chlorination (16) 0.630.63 37%37% 0.52 to 0.750.52 to 0.75 p<0.00001p<0.00001

Solar Disinfection (2)Solar Disinfection (2) 0.690.69 31%31% 0.63 to 0.740.63 to 0.74 p=0.73p=0.73

Flocc/Disinfection (7)Flocc/Disinfection (7) 0.480.48 52%52% 0.20 to 1.160.20 to 1.16 p<0.0001p<0.0001

Flocc/Disinfection Flocc/Disinfection (ex (ex 0.690.69 31%31% 0.58 to 0.820.58 to 0.82 p=0.08p=0.08Doocy)Doocy)

Impr. Storage (1)Impr. Storage (1) 0.790.79 21%21% 0.61 to 1.030.61 to 1.03 n.a.n.a.

*N h i f h i l l ( <0 10) l d l i*Note that in a test for heterogeneity, a low p-value (eg <0.10) suggests an actual underlyingdifference in effect between studies that is unlikely to be attributable to chance.

Summary of Effectiveness—Under 5sIntervention Type Intervention Type

(no. trials)(no. trials)

EstimateEstimate

(random)(random)

% % ΔΔ

(1(1--RR)RR)

95% CI of 95% CI of EstimateEstimate

HeterogeneityHeterogeneity

(Chi(Chi--square)square)( )( ) ( )( ) (( )) (( q )q )

SourceSource ((44)) 00..8585 1515%% 00..7171 toto 11..0202 p=p=..007007

Household (25)Household (25) 00..5656 4444%% 00..3939 toto 00..8181 p<p<00..0000100001

Filtration (5)Filtration (5) 00..3636 6464%% 00..2424 toto 00..5353 p=p=00..3737

Chlorination (12)Chlorination (12) 00..7676 2424%% 00..6767 toto 00..8686 p=p=00..004004

Solar Disinfection (0)Solar Disinfection (0) nana nana nana nana

Flocc/Disinfection (7)Flocc/Disinfection (7) 00..5252 4848%% 00..2020 toto 11..3737 p<p<00..0000100001

Flocc/Disinfection (6) (Flocc/Disinfection (6) (ex ex Doocy)Doocy)

00..7171 2929%% 00..6161 toto 00..8484 p=p=00..1010

Impr. Storage (1)Impr. Storage (1) 0.690.69 31%31% 0.47 to 0.810.47 to 0.81 n.a.n.a.

Eff i d i di iEffectiveness under various conditions

Compliance Compliance (use of (use of the intervention)the intervention)

>50% Compliance (n=16*)>50% Compliance (n=16*)

0.46 (0.32 to 0.83)0.46 (0.32 to 0.83)

<50% Compliance (n=5)<50% Compliance (n=5)

0.75 (0.63 to 0.90)0.75 (0.63 to 0.90)))P<0.0001P<0.0001 P=0.06P=0.06

SanitationSanitation(( HO/UNICEFHO/UNICEF

Improved (n=11)Improved (n=11)

0 48 (0 38 to 0 62)0 48 (0 38 to 0 62)

Unimproved (n=8*)Unimproved (n=8*)

0 67 (0 55 to 0 81)0 67 (0 55 to 0 81)((WHO/UNICEF WHO/UNICEF definitions)definitions)

0.48 (0.38 to 0.62)0.48 (0.38 to 0.62)

P=0.02P=0.02

0.67 (0.55 to 0.81)0.67 (0.55 to 0.81)

P<0.00001P<0.00001

Water SupplyWater Supply Improved (n=11)Improved (n=11) Unimproved (n=24*)Unimproved (n=24*)Water Supply Water Supply ((WHO/UNICEF WHO/UNICEF definitions)definitions)

0.57 (0.46 to 0.72)0.57 (0.46 to 0.72)

P=0.01P=0.01

0.66 (0.55 to 0.72)0.66 (0.55 to 0.72)

P<0.00001P<0.00001

Water Quantity Water Quantity (Sphere Project (Sphere Project minimums)minimums)

15L/person/day(n=7)15L/person/day(n=7)

0.56 (0.44 to 0.71)0.56 (0.44 to 0.71)

P=0.005P=0.005

<15L/person/day (n=3*)<15L/person/day (n=3*)

0.880.88 (0.(0.772 to 1.2 to 1.0808) ) PP=0.01=0.01))

*Excludes Doocy, 2006

QualificationsQualifications• While two single blinded trials showed effectiveness (pooled

estimate, 0.69; 95%CI: 0.63-0.75), four double blinded trials showed no statistically significant protective effect (0.92; 95%CI: 0.65-1.30). WE NEED MORE BLINDED TRIALS TO RULE IDENTIFY EXTENT OF REPORTING BIASTO RULE IDENTIFY EXTENT OF REPORTING BIAS.

• Studies of source-based interventions were substantially longer (median 36 months, range 12 to 60 months) than studies of ( , g )household interventions (5 months, 9.5 weeks to 12 months). WE NEED LONGER TRIALS OF HOUSEHOLD INTERVENTIONS.

• Trials of household interventions were more likely to be research-driven and may have greater susceptibility to Hawthorne effect, site selection and other biases that may Hawthorne effect, site selection and other biases that may overstate their effectiveness when compared with actual programs. WE NEED TO STUDY AND REPORT ON ACTUAL INTEVENTION PROGRAMS OVER THE LONG TERM.

Cost-Effectiveness• A comparison of various

interventions on a sector-wide basisbasis.

• Unlike cost-benefit analysis (where all benefits—improved

d ti it i d h lproductivity, increased school time, etc.—are included in the calculus), CEA is concerned

ith th li ti f i lwith the realization of a social objective, such as the prevention of disease

• The output of a CEA is a ratio (the cost-effectiveness ratio) between the cost of the intervention the disability adjusted life years (DALYs) averted as a result of theaverted as a result of the intervention.

Clasen T, Haller L, Walker D, Bartram J, Cairncross S (2007). Cost-effectiveness analysis of water quality interventions for preventing diarrhoeal disease in developing countries. J. Water & Health 5(4):599-608

Hardware CostsProduct Unit Cost Volume of Cost per First Year Three YearProduct Unit Cost Volume of

Water Treated

Cost per 10,000L of Water Treated

First Year Cost1

Three Year Cost1

Gravity filter with two ceramic Stefani® candles3

$15.00 20,000L $7.50 $15.00 $30.00

Locally-fabricated pot-style $7 50 20 000L $7 50 $9 30 $12 90Locally-fabricated pot-style ceramic water purifiers (CWP) 4

$7.50 20,000L $7.50 $9.30 $12.90

Sodis Solar Disinfection5 $0.40 730L $5.48 $0.80 $2.40

Procter & Gamble PUR® Sachet6

$0.10 10L $100.00 $91.25 $273.75

WaterGuard™ (PSI brand of $0.45 1,000 $4.50 $4.10 $12.32WaterGuard (PSI brand of sodium hypochlorite7

$0.45 1,000 $4.50 $4.10 $12.32

1. Based on 25L/day/household, or 9,125L/year.2. 150ml bottle of 1.25% sodium hypochlorite designed to treat 1000L sold at retail in Tanzania and assuming full cost recovery (not subsidized);production cost is $0.17 per bottle (Clasen, 2006a).3$3.75 per candle, plus $7.50 for vessels and valves. 5,000L capacity per candle according to manufacturer. Replace candles each year. Replace vesselsand valve after 3 years. (Clasen 2004)4. $7.50 initial cost, 25L daily capacity, 2% breakage per month (Brown 2007)5 $0 10 per bottle (mean price based data from 6 countries) x recommended 4 bottles per household used for 6 months; capacity based on 2 x 2L5. $0.10 per bottle (mean price based data from 6 countries) x recommended 4 bottles per household, used for 6 months; capacity based on 2 x 2Lbottles (alternate 2 bottles in sun, 2 bottles in household each day) (M. Wegelin personal communication).6. Manufacturer’s suggested retail price of $0.10 per sachet. Assumes no further expenditure for mixing and storing vessels.7. PSI retail target price in Tanzania for strip pack of 10 x 20L tablets.

Summary of Cost EstimatesAnnual cost per person in US$ of source and household interventions

$6.00

Annual cost per person in US$ of source and household interventions (error bars represent range of costs from programmes)

$4.95$5.00

$3.60$4.00

$2.61

$3.03$3.00

Cos

t

$1.88$2.00

$0.66 $0.63

$

$1.00

$-Source-Africa Source-Asia Source-LA&C Chlorination Ceramic

FiltrationSolar

DisinfectionFlocculation-Disinfection

System

Health Cost Offsets*Costs Averted Variable Data Source Data value (and range)

Health sector Unit cost per treatment WHO regional $4 30-$9 70 per visitHealth sector expenses averted due to prevention of diarrhoeal

Unit cost per treatment WHO regional unit cost data

$4.30-$9.70 per visit$16.10-$39.70 per day

Number of cases WHO BoD data Variable by region

disease Visits or days per case Expert opinion 1 outpatient visit per case (0.5-1.5); 5 days for hospitalized casesProbably much less than 0.5.

Hospitalisation rate WHO Data 91.8% ambulatory

Patient (householder)

Transport cost per visit Assumptions $0.50 per visit

% patients using Assumptions 50% of patientscosts averted due to prevention of diarrhoeal disease

% patients using transport

Assumptions 50% of patients

Number of cases WHO BoD data Variable by region

Visits or days per case Expert opinion 1 outpatient visit per case (0.5-1.5); 5 days for hospitalized cases

Hospitalization rate WHO data 91.8% ambulatory

*Adapted from Hutton & Haller (2004). Evaluation of the Costs and Benefits of Water and Sanitation Improvements at the Global Level. Geneva: World Health Organization

Gross and Net Costs (50% Coverage)Epidemiological SubEpidemiological Sub--Region (and countries)Region (and countries)

InterventionIntervention Gross Annual Gross Annual Cost (and Cost (and

Annual Annual Health Cost Health Cost

Net Annual Net Annual Cost in US$ Cost in US$

range*) in range*) in US$ millionsUS$ millions

Offsets in Offsets in US$ millionsUS$ millions

millionsmillions

AfrAfr--E (Botswana, E (Botswana, SourceSource 128.4 128.4 121.0121.0 7.37.3Burundi, Central African Burundi, Central African Republic, Congo, Cote Republic, Congo, Cote d’Ivoire, Democratic d’Ivoire, Democratic

(50.6(50.6--336.8)336.8)Household Household chlorinationchlorination

104.7 104.7 (104.7(104.7--599.4)599.4) 229.9229.9 --125.2125.2

Republic of the Congo, Republic of the Congo, Eritrea, Ethiopia, Kenya, Eritrea, Ethiopia, Kenya, Lesotho, Malawi, Lesotho, Malawi,

chlorinationchlorination (104.7(104.7 599.4)599.4) 229.9229.9 125.2125.2Household Household filtrationfiltration

480.5 480.5 (320.3(320.3--610.5)610.5) 391.4391.4 89.189.1

Mozambique, Namibia, Mozambique, Namibia, Rwanda, South Africa, Rwanda, South Africa, Swaziland, Uganda, Swaziland, Uganda, U it d R bli fU it d R bli f

Household Household solar solar disinfectiondisinfection

101.5 101.5 (76.1(76.1--139.5)139.5)

192.6192.6 --91.191.1

United Republic of United Republic of Tanzania, Zambia, Tanzania, Zambia, Zimbabwe)Zimbabwe)

Household Household flocculation flocculation disinfectiondisinfection

785.0 785.0 (157.0(157.0--785.0)785.0)

192192..66 592.4592.4

*Based on range of cost estimates per person per year for each intervention

Cost-effectiveness ratios*Sub-Region

Intervention Cost per DALY averted (and range**) in

Cost effectiveness (CMH Benchmark)

range ) in US$s

Afr-E Source 123 (14-322) Highly cost effectiveAfr E Source 123 (14 322) Highly cost effective

Household chlorination 53 (41-447) Highly cost effective

Household filtration 142 (83-223) Highly cost effective

Household solar disinfection

61 (38-104) Highly cost effective

H h ld fl l ti 472 (70 813) C t ff ti (Hi hlHousehold flocculationdisinfection

472 (70-813) Cost effective (Highly CE at net cost of US$354)

*Gross cost, excluding health cost offsets **Minimum/maximum costs; 95%CI of effectiveness

Expansion Pathp

The InternationalThe International Network to

PromoteHousehold WaterHousehold Water

Treatmentd S f Stand Safe Storage

Secretariat

W ld H lth O i tiWorld Health Organization Geneva

Network Mission

“To contribute to a significant reduction in g fwaterborne disease,

especially amongespecially among vulnerable populations,

by promoting household water treatment and safetreatment and safe storage

k t fas a key component of water, sanitation and hygiene programmes.”

www.who.int/household_water

Scaling Up: Litres Treated 2005-2007*

Clasen T (2008). Scaling up Household Water Treatment and Safe Storage. Geneva: World Health Organization

*Excludes emergencies

Scaling Up: HWTS Users 2005-2007*

*Excludes emergencies

Coverage of 884 million without t i d t liaccess to improved water supplies

60% Coverage60% Coverage

Diffusion Curves

Rogers E (2003). Diffusion of Innovations (5th ed.). New York: Free Press

Adoption of Household Innovationsp

Federal Reserve of Dallas 1996

Scaling Up Insecticide Treated Nets

UNICEF (2007). Malaria and Children: Progress in Intervention Coverage. New York: The United Nations Children’s Fund

Special Challenges for Scaling up HWTSSpecial Challenges for Scaling up HWTS• Belief that diarrhoea is not a disease• Scepticism about the effectiveness of water quality interventions• Special challenges associated with uptake

– Technologies shortcomings with the available interventions– Need for correct, consistent, sustained use (contrast

i )vaccines)– Other transmission pathways

Evidence of inequitable uptake (Olembo 2003 DeBois 2004– Evidence of inequitable uptake (Olembo 2003, DeBois 2004, Rheingans 2008)

• Public health suspicion of commercial agenda and lack of p gstandards governing HWTS products

• Orphan status of HWTS at public-sector level• Lack of focused international effort and commitment

HWTS Policy IssuesHWTS Policy Issues

Should effective HWTS be actively promoted?

Pro ConAddresses major disease burden Does not improve water quantitySafe Does not generally improve accessEff i E id f di i i i kEffective Evidence of disparities in uptakeCost-effective Diverts resources from improving

sources (?)sou ces (?)Evidence of scalability and sustainability

Provides only an interim/short-term solution (?)

Affordable (by some)Potential for self-funding (through beneficiary contributions and healthbeneficiary contributions and health sector savings)

What HWTS is “effective” HWTS?What HWTS is effective HWTS?Acceptability Suitable, desirable

Productivity Daily production

Longevity

Performance (lab and field)

Microbiological performance Minimum standards and test procedures

Chemical performanceprocedures

Toxicity/adverse impact

Access/Uptake Supply chain access (procurement)Correct, consistent use

Availability and uptake of consumables

Affordability Up-front cost Who pays?

Long-term cost

Sustainability Long-term use

Environmental impact

How should JMP report on HWTS?How should JMP report on HWTS?• Joint Monitoring Programme organized by WHO g g g y

and UNICEF as successor to Water and Sanitation DecadeP• Purpose– Monitor sector progress toward internationally-

established goals on access to water andestablished goals on access to water and sanitation

– Monitor sector trends and programmesMonitor sector trends and programmes– Build national sector monitoring capacity– Inform national and global policymakers onInform national and global policymakers on

status of the sector • JMP’s “improved water sources” is officially

recognized as the indicator for the MDG water target

JMP Core WatSan Questions • Q1: What is the main source of drinking –

water for members of your household?y

“Improved” sources “Unimproved” sources•Piped water into dwelling (household connection)•Piped water to yard/plot (yard connection)

•Unprotected spring•Unprotected dug wellC i h ll k/d•Piped water to yard/plot (yard connection)

•Public tap or standpipe•Tubewell or boreholde

•Cart with small tank/drum•Tanker-truck•Surface water

•Protected dug well•Protected spring

Surface water

•Bottled water*•Rainwater

**Bottled water is considered an improved source of drinking water only when there is a secondary source of improved water for other uses such as personal hygiene and cooking. For those who respond “bottled water to Q1, Q1A asks about the main source used by household for other purposes.

• *Q4: Do you treat your water in any way to make it safer to drink (Yes, No, Don’t Know)

• *Q5: What do you usually do to the water toQ5: What do you usually do to the water to make it safe to drink? (Record all items mentioned)mentioned)“Adequate” water “Inadequate” water qtreatment

qtreatment

•Boil (bringing water to rolling boil) •Strain it through a cloth( g g g )•Add bleach/chlorine•Use of water filter (ceramic, sand,

it t )

g•Let it stand and settle

composite, etc.)•Solar disinfection

* “The questions are intended to gather information on water treatment practices at* The questions are intended to gather information on water treatment practices at the household level, which provides an indication of the quality of the drinking-water used in the household.” (JMP, Core Questions, 2006)

Global Estimates of HWTS: JMP Data

1000

Estimated Population using HWTS (54 Countries)*

860,81

800

900

1000

ns) “Adequate”

500

600

700

(in M

illio

367,35

216,54 231,52300

400

500

Popu

latio

n

60,58 62,242,84 27,33 22,61

0

100

200P

Type of HWT

*Rosa G , Clasen T (in preparation). The global prevalence of boiling as a means of treating water in the home.

Microbiological Effectiveness of Boiling: Vietnam

Source DrinkingGeo

Mean 95% CIGeo

Mean 95%CI

R d 1 164 7 (115 2 235 5) 3 9 (2 5 6 2)Round 1 164.7 (115.2; 235.5) 3.9 (2.5; 6.2)

Round 2 170.1 (111.6; 259.3) 6.5 (4.2; 10.2)

R d 3 106 1 (75 7 148 7) 2 8 (2 1 3 9)Round 3 106.1 (75.7; 148.7) 2.8 (2.1; 3.9)

Round 4 140.6 (103.2; 191.4) 4.4 (2.9; 6.9)

R d 5 132 7 (95 1 185 3) 4 3 (2 8 6 4)Round 5 132.7 (95.1; 185.3) 4.3 (2.8; 6.4)

•Boiling was associated with a 97% reduction in TTC, from 141 TTC/100ml in source water to 4.2 TTC/100ml in drinking water. •Nevertheless, 60.5% of stored water samples were positive for TTC, with 22 2% falling into medium risk (11-100 TTC/100ml)with 22.2% falling into medium risk (11 100 TTC/100ml)

Clasen T, Do Hoang T, Boisson S, Shippin O (2008). Microbiological effectiveness and cost of boiling to disinfect water in rural Vietnam. Environmental Sci. & Tech. 42(12):4255-60

Microbiological Effectiveness of Boiling: IndiaSource Drinking

Mean 95%CI Mean 95%CI p-valueea 95%C ea 95%C p v ue

Round 1 426.2 (261.5; 694.5) 6.1 (4.4; 8.3) <0.001

Round 2 1031.1 (615.4; 1727.5) 6.1 (4.4; 8.3) <0.001

Round 3 823.4 (484.8; 1398.2) 7.2 (5.2; 9.9) <0.001Round 3 823.4 (484.8; 1398.2) 7.2 (5.2; 9.9) 0.001

Round 4 944.9 (566.0;1577.5) 6.0 (4.4; 8.2) <0.001

Round 5 251.8 (144.3; 439.1) 4.0 (3.0; 5.2) <0.001

•Boiling was associated with a 99% reduction in geometric mean EC fromBoiling was associated with a 99% reduction in geometric mean EC, from 612.8 CFU/100ml in source water to 5.8 CFU/100ml in drinking water.•Still, 40.4% of drinking water samples were positive for EC, with 25.1% f lli i hi h i k (101 1000 FC/100 l)falling into high risk (101-1000 FC/100ml) Clasen T, McLaughlin C, Nayaar N, Boisson S, Gupta R, Desai D, Shah N. Microbiological effectiveness and cost of disinfecting water by boiling in semi-urban India. Am J. Trop. Med. Hyg. 79(3)

Drinking Water Ladder

WHO/UNICEF JMP (2008): Progress on Drinking Water and Sanitation

Placing HWTS on the Water LadderPlacing HWTS on the Water Ladder

Regulated piped water supplyRegulated piped water supply

Improved water sourceImproved water source

Improved water source + Improved water source + HWTSHWTS

Improved water source Improved water source

I d h d tI d h d t

U i dU i d HWTSHWTS

Improved shared water sourceImproved shared water source

Unimproved water source + Unimproved water source + HWTSHWTS

Unimproved water sourceUnimproved water source

HWTS and the MDG Water TargetHWTS and the MDG Water Target“Unhygienic handling of water during transport or within thehome can contaminate previously safe water. A high percentage ofpeople could therefore benefit from effective household watert t t d f t ti S h h h ld l ltreatment and safe storage practices. Such household-levelinterventions can be very effective in preventing disease if they areused correctly and consistently. . . .used correctly and consistently. . . .The JMP is currently undertaking an investigation to exploreissues related to household water treatment technologies, with ag ,view to evaluating their potential role in providing measurableaccess to a safe and sustainable drinking water supply.”

WHO/UNICEF Joint Monitoring Programme (2008)

WHO/UNICEF Joint Monitoring Programme (2008): Progress in Drinking Water and Sanitation

Should effective HWTS count toward the MDG water target (“sustainable

t f d i ki t ”)?access to safe drinking water”)?Pro ConPro ConExcept perhaps for regulated, piped water supplies, “improved “ ≠ “safe”

Shifts burden (and possibly more cost) of water quality to users

Evidence from boiling studies that HWTS—as actually practiced by vulnerable population-- can substantially improve

Requires correct, consistent action on the part of householders; evidence from boiling studies

drinking water quality (safety) suggests existing practices are sub-optimal

Widespread practice of boiling and other Disparities in uptake likely to p p gHWTS suggests potential for scalability and sustainability

p p ycontinue

Some evidence that HWTS contributes Does not improve quantity orSome evidence that HWTS contributes toward other MDG’s

Does not improve quantity or generally improve access

Potential contribution of water supply andPotential contribution of water supply and effective HWTS to MDG water targetg

Quantity Quality Access Affordability Sustainability

Regulated piped supply, household

connection

+++ +++ +++ +++ +++

connectionOther improved supply + HWTS

++ +++ ++ ++ ?

Other improved supply only

+ + ++ ++ ?

Unimproved Neutral + + + ?Unimproved supply + HWTS

Neutral + + + ?

Unimproved s ppl

Baselinesupply

Potential contribution of waterPotential contribution of water supply and HWTS to other MDGspp y

Reduce Poverty

Reduce Hunger

Increase Primary

Improve Gender

Reduce Child

Reduce Maternal

Reduce Major

Education Equality Mortality Mortality Diseases

Regulated piped supply, household

+++ +++ +++ +++ +++ +++ +++pp y,

connection

Other improved source + HWTS

++ ++ ++ ++ +++ +++ +++

Other improved source only

++ ++ ++ ++ ++ ++ ++

U i d + + + + + ++ + ++Unimproved source + HWTS

+ + + + ++ + ++

Unimproved source Baseline

HWTS and the MDG Water TargetHWTS and the MDG Water Target“Helping households improve and maintain water quality atHelping households improve and maintain water quality athome has proven health benefits, is cost-effective, andcontributes directly to meeting the Millennium Developmentcontributes directly to meeting the Millennium DevelopmentGoals. Household water treatment and safe storage can serveas an immediate mechanism to reduce illness among theunserved. . . . Although there are challenges, particularly withregard to achieving widespread adoption and sustainability ofthe interventions household water treatment offers a rapid andthe interventions, household water treatment offers a rapid andaffordable way of reducing the global burden of waterbornedisease.” (emphasis added)( p )

MDG Task Force on Water and Sanitation (2005)MDG Task Force on Water and Sanitation (2005)

Lenton R, Wright A, Lewis K (2005). Health, dignity, and development: what will it take. London: Earthscan

Acknowledgementsg• CDC (S. Luby, R. Quick J. Crump, T. Chiller, E. ( y, Q p, ,

Mintz, D. Lantagne)• Proctor & Gamble (G. Allgood, B. Keswick)• WHO (J. Bartram, B. Gordon, L. Haller, J. Sims, F.

Properzi, R. Bos)• Johns Hopkins University (M E Figueroa L Kincaid• Johns Hopkins University (M.E. Figueroa, L. Kincaid,

D. Walker, S. Doocy)• UNICEF (C. Brockelhurst, H. van Norden)( , )• University of Bristol (S. Gundry, J. Wright)• UC Berkeley (J. Colford)• University of Wales (L. Fewtrell)• University of North Carolina (M. Sobsey, J. Brown)• LSHTM (S. Cairncross, V. Curtis, I. Roberts, T. Rabie,

L. Smith, W. Schmidt, G. Rosa, S. Boisson)