USING EVIDENCE TO DRIVE HEALTH INTERVENTIONS:  THE CASE OF HOUSEHOLD WATER TREATMENT Thomas Clasen, JD, PhD Department of ...
Disclosure/Conflicts <ul><li>Unicef </li></ul><ul><li>WHO </li></ul><ul><li>Unilever </li></ul><ul><li>PATH </li></ul><ul>...
Leading Causes of Deaths from Infectious Diseases Lower  Respiratory Infections HIV/AIDS Diarrhoeal Diseases Tuberculosis ...
Childhood Mortality by Cause WHO/UNICEF 2009
Water Supply Coverage
Global Distribution of <5 deaths from diarrhoea  Petri WA, Miller M, Binder HJ et al. (2008). Enteric infections, diarrhoe...
Environmental Barriers  to Faecal-Oral Transmission <ul><li>Primary Barrier </li></ul><ul><ul><li>Sanitation (proper excre...
Interventions at Source
Benefits of Source-Based Improvements <ul><li>Improve water quality </li></ul><ul><ul><li>Reduce water-borne diseases </li...
<ul><li>An estimated 250,000 hand pumps installed in Africa in 1981-2000 </li></ul><ul><li>Surveys suggest that less than ...
Improved Source ≠ Safe WHO (2005-6) Rapid Assessment of Drinking Water Quality (n≈1600) Results of multi-country  Rapid As...
Systematic Review—Wright et al.* <ul><li>Systematic review and meta-analysis of 57 studies measuring bacteria counts for s...
Interventions at the Household
Challenge #1 Assessing Efficacy/Effectiveness
Systematic Review:  Fewtrell et al. Fewtrell L, Kaufmann R, Kay D, Enanoria W, Haller L, Colford J (2005). Water, sanitati...
Systematic Review: Clasen et al. (2006) Clasen T, Roberts I, Rabie T, Schmidt W, Cairncross S. Interventions to improve wa...
Waddington et al. (2009) Waddington H, Snilstveit, White H, Fewtrell L (2009).  Water, sanitation and hygiene intervention...
Methodological Quality:  Blinding Clasen et al. 2006
Jain et al. (2009) <ul><li>Double-blinded, randomized controlled trial of 240 households (3,240 persons) in Ghana using Na...
Colford et al. (2009) <ul><li>Randomized, triple-blinded, crossover trial in 714 households (988 individuals) among older ...
Boisson et al. 2010 <ul><li>Double-blinded, placebo-controlled RCT among 1144 persons in 240 households in Congo DRC using...
Pending Trial (Clasen et al.) <ul><li>Double blinded, placebo-controlled RCT in India among 2000 rural/urban HH with <5s u...
Challenge #2 Correct, consistent use
Compliance <ul><li>In a systematic systematic review of all HWT intervention trials, the pooled RR was 0.46 (95%CI:0.25-0....
Filter use: LifeStraw Personal <ul><li>171/200 (85%) participants (from 122 households) </li></ul><ul><li>  interviewed </...
Filter use: LifeStraw Family <ul><li>Assessed use at month 8 and 14 following deployment in a RCT in Congo DRC </li></ul><...
Programme Assessment: Guatemala  <ul><li>Effectiveness study of a 3-year programme by NGOs in Guatemala to promote HWT (bo...
Programme Assement: Bolivia <ul><li>Cluster-randomized controlled trial in 22 rural communities in Bolivia to evaluate the...
Challenge #3 Effective and appropriate HWT
Interventions at the Household
What about boiling? <ul><li>Sub-optimal microbiological performance, probably due to recontamination after boiling </li></...
 
 
The Need for a  Technological Breakthrough <ul><li>Highly effective against all categories of microbial pathogens </li></u...
Challenge #4 Targeting the vulnerable population
Diarrhoea Morbidity Kosek 2003
Boschi-Pinto 2009
Current Scale of Reported HWT In an evaluation of JMP household survey data from 67 low and medium-income countries, 33% o...
Reported microbiologically adequate HWT-use increases with wealth Rosa G, Clasen T (2010). Estimating the scope of househo...
SHG leaders attend information sessions conducted by MFI
 
Challenge #5 Achieving long-term and sustainable uptake
Sustainability:  Arnold et al. The effect of point-of-use chlorine treatment on child diarrhea by length of intervention. ...
Sustainability: (Waddington et al.)
Hunter (2009) Hunter P (2009). Household water treatment in developing countries: comparing different intervention types u...
Driving HWT Policy  with Evidence of Impact* <ul><li>Input-based strategy for water (e.g., “improved water supplies”) has ...
Driving HWT Policy  with Evidence of Impact <ul><li>HWT policy should be assessed on  impact  (long-term outcomes), partic...
Acknowledgements <ul><li>CDC (S. Luby, R. Quick J. Crump, T. Chiller, E. Mintz, D. Lantagne) </li></ul><ul><li>Proctor & G...
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Using Evidence to Drive Health Interventions: The Case of Household Water Treatment - Dr Thomas Clasen

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  • and
  • Overall: 33% of households reporting treating there water. Substantial differences by country and geographical region. Most common in Western Pacific&gt; 66.8%. Least common in EASTERN MED and AFRICA &gt; 13.6% and 18.2%.
  • Overall, ADEQUATE hwt INCREASED with WEALTH. However, there are exceptions to the rule, : Benin, Guatemala, Macedonia= NO DIFFERENCE In certain countries the OPPSITE TREND was observed: LAO, Indonesia and Panama used DECREASED with INC wealth.
  • Using Evidence to Drive Health Interventions: The Case of Household Water Treatment - Dr Thomas Clasen

    1. 1. USING EVIDENCE TO DRIVE HEALTH INTERVENTIONS: THE CASE OF HOUSEHOLD WATER TREATMENT Thomas Clasen, JD, PhD Department of Disease Control Faculty of Infectious & Tropical Diseases London School of Hygiene & Tropical Medicine [email_address]
    2. 2. Disclosure/Conflicts <ul><li>Unicef </li></ul><ul><li>WHO </li></ul><ul><li>Unilever </li></ul><ul><li>PATH </li></ul><ul><li>PSI </li></ul><ul><li>Medentech </li></ul><ul><li>ICDDR,B </li></ul><ul><li>UC Berkeley </li></ul><ul><li>Vestergaard Frandsen </li></ul><ul><li>Procter & Gamble </li></ul><ul><li>USAID </li></ul><ul><li>3ie </li></ul><ul><li>Wellcome Trust </li></ul><ul><li>Bill & Melinda Gates Foundation </li></ul><ul><li>American Chemistry Council </li></ul>
    3. 3. Leading Causes of Deaths from Infectious Diseases Lower Respiratory Infections HIV/AIDS Diarrhoeal Diseases Tuberculosis Malaria Measles Deaths in millions Source: WHO 2004 0.0 0.5 1.0 1.5 2.0 2.5 3.0 3.5 4.0 3.9 2.8 1.8 1.6 1.3 0.6 Over age 5 Under age 5
    4. 4. Childhood Mortality by Cause WHO/UNICEF 2009
    5. 5. Water Supply Coverage
    6. 6. Global Distribution of <5 deaths from diarrhoea Petri WA, Miller M, Binder HJ et al. (2008). Enteric infections, diarrhoea, and their impact on function and development. J. Clinical Investigation 118:1277-90
    7. 7. Environmental Barriers to Faecal-Oral Transmission <ul><li>Primary Barrier </li></ul><ul><ul><li>Sanitation (proper excreta disposal) </li></ul></ul><ul><ul><li>Hygiene (hand washing) </li></ul></ul><ul><li>Secondary Barriers </li></ul><ul><ul><li>Water quality (treatment & safe storage) </li></ul></ul><ul><ul><li>Water quantity (personal and domestic hygiene) </li></ul></ul><ul><ul><li>Hygiene (especially hand washing) </li></ul></ul><ul><ul><li>Proper cooking/food handing practices </li></ul></ul>
    8. 8. Interventions at Source
    9. 9. Benefits of Source-Based Improvements <ul><li>Improve water quality </li></ul><ul><ul><li>Reduce water-borne diseases </li></ul></ul><ul><li>Improve water quantity and access </li></ul><ul><ul><li>Reduce water washed diseases </li></ul></ul><ul><ul><li>Improve personal hygiene </li></ul></ul><ul><ul><ul><li>Reduce reported diarrhoea by 30%-45% (Curtis 2005) </li></ul></ul></ul><ul><ul><ul><li>Reduce respiratory infections by 25% (Rabie 2006) </li></ul></ul></ul><ul><ul><li>Improve domestic hygiene </li></ul></ul><ul><ul><li>Reduce time spent collecting water </li></ul></ul><ul><ul><li>Potential for productive/economic use of water </li></ul></ul>
    10. 10. <ul><li>An estimated 250,000 hand pumps installed in Africa in 1981-2000 </li></ul><ul><li>Surveys suggest that less than half were still in use in 2004 </li></ul><ul><li>Harvey and Drouin (2006 ) </li></ul>
    11. 11. Improved Source ≠ Safe WHO (2005-6) Rapid Assessment of Drinking Water Quality (n≈1600) Results of multi-country Rapid Assessment of Drinking Water Quality (RADWQ) Percentage of samples from “improved water sources” that comply with WHO DWQG values by country and technology type (compiled from RADWQ reports) Utility piped water Community piped Boreholes/Tubewells Protected Springs Protected wells Total Jordon 99.9% 99.9% Ethiopia 87.6% 67.9% 43.3% 54.9% 72.0% Nicaragua 89.9% 39.1% 45.7% 19.3% 46.7% Nigeria 77.0% 94.0% 56.0% 75.7% Tajikistan 88.6% 82.0% 87.2%
    12. 12. Systematic Review—Wright et al.* <ul><li>Systematic review and meta-analysis of 57 studies measuring bacteria counts for source water and stored water in the home. </li></ul><ul><li>Results: The bacteriological quality of drinking water significantly declined after collection in many settings. </li></ul><ul><li>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. </li></ul>*Wright J, Gundry S, Conroy R (2004). Household drinking water in developing countries: a systematic review of microbiological contamination between source and point-of-use. Tropical Med. Int’l Health 9(1): 106-117
    13. 13. Interventions at the Household
    14. 14. Challenge #1 Assessing Efficacy/Effectiveness
    15. 15. Systematic Review: Fewtrell et al. Fewtrell L, Kaufmann R, Kay D, Enanoria W, Haller L, Colford J (2005). Water, sanitation, and hygiene interventions to reduce diarrhoea in developing countries: a systematic review and meta-analysis. Lancet Infect. Dis 5: 42-52.
    16. 16. Systematic Review: Clasen et al. (2006) Clasen T, Roberts I, Rabie T, Schmidt W, Cairncross S. Interventions to improve water quality for preventing diarrhoea (A Cochrane Review). In: The Cochrane Library, Issue 3, 2006. Intervention Type (no. trials) Estimate (random) % Δ (1-RR) 95% CI of Estimate Source (6) 0.73 27% 0.53 to 1.01 Household (32) 0.53 47% 0.39 to 0.73 Filtration (6) 0.37 63% 0.28 to 0.49 Chlorination (16) 0.63 37% 0.52 to 0.75 Solar Disinfection (2) 0.69 31% 0.63 to 0.74 Flocc/Disinfection (7) 0.48 52% 0.20 to 1.16 Flocc/Disinfection (ex Doocy) 0.69 31% 0.58 to 0.82 Impr. Storage (1) 0.79 21% 0.61 to 1.03
    17. 17. Waddington et al. (2009) Waddington H, Snilstveit, White H, Fewtrell L (2009). Water, sanitation and hygiene interventions to combat childhood diarrhoea in developing countries. Delhi: International Initiative for Impact Evaluation.
    18. 18. Methodological Quality: Blinding Clasen et al. 2006
    19. 19. Jain et al. (2009) <ul><li>Double-blinded, randomized controlled trial of 240 households (3,240 persons) in Ghana using NaDCC + vessel versus placebo + vessel </li></ul><ul><li>Despite high compliance (measured by residual chlorine) and microbiological efficacy, no difference in episodes of diarrhoea </li></ul><ul><li>Researchers cited comparatively high quality water, low rates of diarrhoea and possible protective effect of the vessel </li></ul>Jain S, Sahanoon OK, Blanton E, Schmitz A, Wannemuehler KA, Hoekstra RM, Quick RE. Sodium dichloroisocyanurate tablets for routine treatment of household drinking water in periurban Ghana: a randomized controlled trial. Am J Trop Med Hyg. 2010 Jan;82(1):16-22
    20. 20. Colford et al. (2009) <ul><li>Randomized, triple-blinded, crossover trial in 714 households (988 individuals) among older adults in California which used active and sham water filtration devices for 6 months each; outcome=HCGI. </li></ul><ul><li>Incidence rate ratio (active versus sham) 0.85 (95% CI = 0.76, 0.94); longitudinal prevalence ratio 0.84 (95% CI = 0.78, 0.90).. </li></ul><ul><li>Conclusion: “We observed reductions in population- and individual-level measures of HCGI associated with use of the active filtration device.” </li></ul>Colford JM Jr, Hilton JF, Wright CC, Arnold BF, Saha S, Wade TJ, Scott J, Eisenberg JN (2009). The Sonoma water evaluation trial: a randomized drinking water intervention trial to reduce gastrointestinal illness in older adults . Am J Public Health. 99(11):1988-95. 

    21. 21. Boisson et al. 2010 <ul><li>Double-blinded, placebo-controlled RCT among 1144 persons in 240 households in Congo DRC using LifeStraw Family Filter for 12 months (11,236 person weeks). </li></ul><ul><li>Despite strong microbiological performance (2.98 LRV) and relatively high uptake (68%), little evidence of protection against diarrhoea (RR 0.85, 95%CI 0.61-1.20). </li></ul><ul><li>Caveats: placebo was not neutral (1.05 LRV), high non-exclusive use (73% adults, 95% <5s), blinding was not fully successful, and post-hoc analysis showed study was underpowered. </li></ul>Boisson S, Kiyombo M, Sthreshley L, Tumba S, Makambo J, Clasen T (2010). Field assessment of a novel household-based water filtration device: a randomised, placebo-controlled trial in the Democratic Republic of Congo PLOS One 5(9): e12613
    22. 22. Pending Trial (Clasen et al.) <ul><li>Double blinded, placebo-controlled RCT in India among 2000 rural/urban HH with <5s using chlorine tablets (NaDCC) for 12 months </li></ul><ul><li>Setting: High prevalence of DD, relying on unimproved sources, ambient water quality >500 TTC/100ml </li></ul><ul><li>Outcomes: 3-day reported diarrhoea (12 monthly visits), WAZ in <5s , TTC and residual free chlorine, school attendance </li></ul><ul><li>Host: PSI. Funding: PATH, USAID, Medentech, American Chemistry Council </li></ul>
    23. 23. Challenge #2 Correct, consistent use
    24. 24. Compliance <ul><li>In a systematic systematic review of all HWT intervention trials, the pooled RR was 0.46 (95%CI:0.25-0.84) among 16 trials reporting compliance >50%, and 0.75 (0.63-0.90) among 5 trials reporting compliance <50% (Clasen 2006). </li></ul><ul><li>Among intervention studies using chlorine, </li></ul><ul><li>effectiveness against DD was enhanced among studies with a larger fraction of water samples with detectable free (Arnold 2007). </li></ul>
    25. 25. Filter use: LifeStraw Personal <ul><li>171/200 (85%) participants (from 122 households) </li></ul><ul><li> interviewed </li></ul><ul><li>Open ended question about last time of use: </li></ul><ul><li>Current user = use in the previous week (34%) </li></ul><ul><li>Consistent user = always drank filtered water + did not drink unfiltered water in previous week (13%) </li></ul>Boisson S, Tadesse G, Gezahegn H, Gerhanu T, Schmidt W-P, Clasen T (2009). A randomized controlled trial in rural Ethiopia to assess the LifeStraw personal water filter. Environmental Sci. & Tech. 43(15):5934–39
    26. 26. Filter use: LifeStraw Family <ul><li>Assessed use at month 8 and 14 following deployment in a RCT in Congo DRC </li></ul><ul><li>Current user (previous week): 82.6% (mo. 8) and 86.8% (mo.14) </li></ul><ul><li>However, among current users, 83.2 % (94.6% of children <5) also reported drinking untreated water the previous day </li></ul>Boisson S, Kiyombo M, Sthreshley L, Tumba S, Makambo J, Clasen T. Field assessment of a novel household-based water filtration device: a randomised, placebo-controlled trial in the Democratic Republic of Congo (submitted) Month 8 Month 14 N % N % Filter present at time of visit 197 82 203 85 Had filter at time of visit 183 93% 192 94 Used filter previous day 107 58.5 138 72.6 Used filter previous week 44 24.1 25 14.2 > 1 week since last use of filter 32 17.5 27 13.8
    27. 27. Programme Assessment: Guatemala <ul><li>Effectiveness study of a 3-year programme by NGOs in Guatemala to promote HWT (boiling, Sodis and chlorination) and HWWS </li></ul><ul><li>Six-month study comparing 600 households in 30 matched villages (15 intervention/15 control) </li></ul><ul><li>No statistically meaningful difference in adoption of intervention and control households for HWT (9% vs. 3%) or hand washing with soap (HWWS) </li></ul><ul><li>Consistent with the low sustained behaviour adoption, investigators found no difference between intervention and control villages in child diarrhoea, respiratory infections or growth. </li></ul>Arnold B, Arana B, Mausezahl D, Hubbard A, Colford J (2009). Evaluation of a pre-existing, 3-year household water treatment and handwashing Int’l J Epidemiology 2009;1–11
    28. 28. Programme Assement: Bolivia <ul><li>Cluster-randomized controlled trial in 22 rural communities in Bolivia to evaluate the effect of SODIS in reducing diarrhoea among children under the age of 5. </li></ul><ul><li>A local NGO conducted a standardised interactive SODIS-promotion campaign in 11 communities targeting households, communities, and primary schools. Mothers completed a daily child health diary for 1 year. </li></ul><ul><li>Despite the extensive promotion campaign, investigators found only moderate compliance with the intervention (32% regular uses) and no strong evidence of a substantive reduction in diarrhoea among children: RR 0.81 (95% CI 0.59–1.12). </li></ul>Mausezahl D, Christen A, Duran Pacheco G, Tellez FA, Iriarte M, et al. (2009) Solar Drinking Water Disinfection (SODIS) to Reduce Childhood Diarrhoea in Rural Bolivia: A Cluster-Randomized, Controlled Trial. PLoS Med 6(8): e1000125. doi:10.1371/journal.pmed.1000125
    29. 29. Challenge #3 Effective and appropriate HWT
    30. 30. Interventions at the Household
    31. 31. What about boiling? <ul><li>Sub-optimal microbiological performance, probably due to recontamination after boiling </li></ul><ul><li>Potentially high cost: US$7.99 to US$8.34 per household per year in India; US$3.24 (collect fuel) to US$20.16 (purchase) in Vietnam </li></ul><ul><li>Indoor air pollution from cooking with biomass associated with reduced birth weight, respiratory infections, anemia, stunting (Retherford 2006) </li></ul><ul><li>Boiling water at home is also associated with higher levels of burn accidents (Rossi 1998). </li></ul><ul><li>Other issues: Acceptability, environmental sustainability </li></ul>Distribution of samples by TTC count (log scale) in longitudinal field studies (n=50 HH in Vietnam and Guatemala, 212 HH in India) <1 1 to 10 11-100 >100 Vietnam (Clasen 2008) 71.2 10.7 13.2 4.9 India (Clasen 2009) 37.0 38.3 22.2 2.5 Guatemala (Rosa 2010) 59.6 5.7 9.5 25.1 Zambia (Psutka 2010) 39.3 22.9 17.7 20.0
    32. 34. The Need for a Technological Breakthrough <ul><li>Highly effective against all categories of microbial pathogens </li></ul><ul><li>High capacity (daily and long-term production) </li></ul><ul><li>Easy to deploy, learn, use, maintain </li></ul><ul><li>Operates in high and variable turbidity </li></ul><ul><li>Affordable (up front and long term) </li></ul><ul><li>Portable, robust design </li></ul><ul><li>Improves water aesthetics </li></ul><ul><li>Attractive, aspirational </li></ul><ul><li>Protects against recontamination </li></ul><ul><li>Reduces arsenic and fluoride </li></ul><ul><li>Reduces other chemical contaminants </li></ul>
    33. 35. Challenge #4 Targeting the vulnerable population
    34. 36. Diarrhoea Morbidity Kosek 2003
    35. 37. Boschi-Pinto 2009
    36. 38. Current Scale of Reported HWT In an evaluation of JMP household survey data from 67 low and medium-income countries, 33% of households (36.6% urban vs. 30.1%) report treating their water at home before drinking it. This is equivalent to 1.1 billion people. Rosa G, Clasen T (2010). Estimating the scope of household water treatment in low- and middle-income countries. Am. J. Trop. Med. Hyg. 82(2) 67% 14% 18%
    37. 39. Reported microbiologically adequate HWT-use increases with wealth Rosa G, Clasen T (2010). Estimating the scope of household water treatment in low-and medium-income countries. Am. J. Trop. Med. Hyg. 82(2)
    38. 40. SHG leaders attend information sessions conducted by MFI
    39. 42. Challenge #5 Achieving long-term and sustainable uptake
    40. 43. Sustainability: Arnold et al. The effect of point-of-use chlorine treatment on child diarrhea by length of intervention. (The area of each circle reflects the study weight in the random effects meta-analysis.) Arnold B, Colford J (2007). Treating water with chlorine at point-of-use to improve water quality and reduce child diarrhea in developing countries: A systematic review and meta-analysis. American Journal of Tropical Medicine and Hygiene , 76(2):354–364. Length of Study (weeks)
    41. 44. Sustainability: (Waddington et al.)
    42. 45. Hunter (2009) Hunter P (2009). Household water treatment in developing countries: comparing different intervention types using meta-regression. Environ Sci Technol. 43(23):8991-7
    43. 46. Driving HWT Policy with Evidence of Impact* <ul><li>Input-based strategy for water (e.g., “improved water supplies”) has led to sub-optimal solutions in terms of performance, health impact and sustainability </li></ul><ul><li>Do not aggravate this problem by counting HWT toward the MDG water target (“sustainable access to safe drinking water’) </li></ul><ul><ul><li>HWT does not improve quantity and access, key antecedents to development (and health) </li></ul></ul><ul><ul><li>Current evidence does not demonstrate that HWT can consistently deliver “safe water” (though safer than some conventional supplies that currently do count) </li></ul></ul>*Clasen T. Household water treatment and the Millennium Development Goals: keeping the focus on health. Environmental Sci & Tech. 2010 Aug 30. [Epub ahead of print]
    44. 47. Driving HWT Policy with Evidence of Impact <ul><li>HWT policy should be assessed on impact (long-term outcomes), particularly on its contribution to health (child survival) </li></ul><ul><ul><li>Health-based strategy will require promoters to address key challenges (efficacy, compliance, performance, target population, sustainable uptake) </li></ul></ul><ul><ul><li>Investment (government, funders, householders) will be commensurate with demonstrable returns </li></ul></ul><ul><ul><li>Position HWT policy in health (rather than water) ministry to develop clear policies that do not divert resources from optimal water solutions (household connections) </li></ul></ul><ul><li>“ What gets measured, gets done.” Peter Drucker </li></ul>
    45. 48. Acknowledgements <ul><li>CDC (S. Luby, R. Quick J. Crump, T. Chiller, E. Mintz, D. Lantagne) </li></ul><ul><li>Proctor & Gamble (G. Allgood, B. Keswick) </li></ul><ul><li>WHO (B. Gordon, L. Haller) </li></ul><ul><li>Unicef (C. Brockelhurst, O. Odediran) </li></ul><ul><li>Eawag/Sandec (M. Weglin, R. Maihofer) </li></ul><ul><li>University of Bristol (S. Gundry, J. Wright) </li></ul><ul><li>UC Berkeley (J. Colford, B. Arnold) </li></ul><ul><li>University of Wales (L. Fewtrell) </li></ul><ul><li>University of East Anglia (P. Hunter) </li></ul><ul><li>University of North Carolina (M. Sobsey, J. Bartram, J. Brown) </li></ul><ul><li>LSHTM (S. Cairncross, V. Curtis, I. Roberts, T. Rabie, G. Rosa, L. Smith, W. Schmidt, S. Thomas) </li></ul>

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