Household Water Storage Management, Hygiene Practices, and Associated Drinking Water Quality in Rural India.

Household drinking water storage is commonly practiced in rural India. Fecal contamination may be introduced at the water source, during collection, storage, or access. Within a trial of a community-level water supply intervention, we conducted five quarterly household-level surveys to collect information about water, sanitation, and hygiene practices in rural India. In a random subsample of households, we tested stored drinking water samples for Escherichia coli, concurrently observing storage and access practices. We conducted 9961 surveys and collected 3296 stored water samples. Stored water samples were frequently contaminated with E. coli (69%), and E. coli levels were the highest during the wet season. Most households contributing two or more drinking water samples had detectable E. coli in some (47%) or all (44%) samples. Predictors of stored water contamination with E. coli included consumption of river water and open defecation; consumption of reverse osmosis-treated water and safe water access practices appeared to be protective. Until households can be reached with on-premises continuous safe water supplies, suboptimal household water storage practices are likely to continue. Improvements to source water quality alone are unlikely to prevent exposure to contaminated drinking water unless attention is also given to improving household water storage, access, and sanitation practices.

Effect of hygiene interventions on acute respiratory infections in childcare, school and domestic settings in low- and middle-income countries: a systematic review.

OBJECTIVES: Acute respiratory infections (ARIs) disproportionately affect those living in low- and middle-income countries (LMICs). We aimed to determine whether hygiene interventions delivered in childcare, school or domestic settings in LMICs effectively prevent or reduce ARIs. METHODS: We registered our systematic review with PROSPERO (CRD42017058239) and searched MEDLINE, EMBASE, CENTRAL, and Scopus from inception to 17 October 2017 for randomised controlled trials (RCTs) examining the impact of hygiene interventions on ARI morbidity in adults and children in community-based settings in LMICs. We stratified data into childcare, school and domestic settings and used the Grading of Recommendations Assessment, Development and Evaluation approach to assess evidence quality. RESULTS: We identified 14 cluster RCTs evaluating hand-hygiene interventions in LMICs with considerable heterogeneity in setting, size, intervention delivery and duration. We found reduced ARI-related absenteeism and illness in childcare settings (low- to moderate-quality evidence). In school settings, we found reduced ARI-related absenteeism and laboratory-confirmed influenza (moderate- to high-quality evidence), but no reduction in ARI illness (low-quality evidence). In domestic settings, we found reduced ARI illness and pneumonia amongst children in urban settlements (high-quality evidence) but not in rural settlements (low-quality evidence), and no effect on secondary transmission of influenza in households (moderate-quality evidence). CONCLUSIONS: Evidence suggests that hand-hygiene interventions delivered in childcare, school and domestic settings can reduce ARI morbidity, but effectiveness varies according to setting, intervention target and intervention compliance. Further studies are needed to develop, deliver and evaluate targeted and sustainable hygiene interventions in LMICs.

Variability in 24 hour excretion of cyanuric acid: implications for water exposure assessment.

Cyanuric acid (CYA) excretion in urine has been used to estimate the volume of water ingested during swimming and other recreational activities in outdoor pools containing this chemical. These estimates of water ingestion are based on the assumption of 100% excretion within 24 hours, but the supporting evidence for this is scant. While adapting this methodology to investigate other water ingestion scenarios, we observed a high degree of variability in cyanuric acid excretion among experimental subjects, with over 25% of individuals excreting less than 80% of an ingested dose. Use of cyanuric acid to measure inadvertent water ingestion may be a valuable tool to generate data for health risk assessment of non-potable water sources, but our observations indicate that this technique carries an inherent degree of underestimation that should be taken into account when calculating water exposure.

Adoption of a microbial health-based target for Australian drinking water regulation.

The health-based targets of 1 in 10,000 for infection and 10(-6) disability adjusted life years (DALYs) per person per year are increasingly being considered, or have already been adopted, to define microbial safety targets for water. The aim of this paper is to convey information about how these two targets compare by converting each of the target values to a common metric. The metric chosen for viral (rotavirus and norovirus) and protozoan (Cryptosporidium) reference pathogens is the estimated maximum number of annual drinking water-associated cases of acute diarrhoeal disease tolerated. For the reference bacterial pathogen Campylobacter, sequelae to acute diarrhoeal illness have also been considered in estimating the tolerable number of cases for the DALY target. Also investigated is whether non-compliance with targets would be detected as a waterborne disease outbreak by the health surveillance system in an extreme hypothetical situation whereby all tolerable cases per annum occurred as a single event. The paper highlights that verification of compliance with targets cannot be demonstrated by the absence of reported drinking water-associated outbreaks alone and concludes that introduction of a quantitative health-based outcome for drinking water in Australia would help improve water quality management by providing a common goal directly linked to health outcomes.

Evolution of regulatory targets for drinking water quality.

The last century has been marked by major advances in the understanding of microbial disease risks from water supplies and significant changes in expectations of drinking water safety. The focus of drinking water quality regulation has moved progressively from simple prevention of detectable waterborne outbreaks towards adoption of health-based targets that aim to reduce infection and disease to a level well below detection limits at the community level. This review outlines the changes in understanding of community disease and waterborne risks that prompted development of these targets, and also describes their underlying assumptions and current context. Issues regarding the appropriateness of selected target values, and how continuing changes in knowledge and practice may influence their evolution, are also discussed.

Advice to risk assessors modeling viral health risk associated with household graywater.

Quantitative microbial risk assessment (QMRA) is a valuable tool that can be used to predict the risk associated with human exposure to specific microbial contaminants in water sources. The transparency inherent in the QMRA process benefits discussions between multidisciplinary teams because members of such teams have different expertise and their confidence in the risk assessment output will depend upon whether they regard the selected input data and assumptions as being suitable and/or plausible. Selection of input data requires knowledge of the availability of appropriate data sets, the limitations of using a particular data set, and the logic of using alternative approaches. In performing QMRA modeling and in the absence of directly relevant data, compromises must be made. One such compromise made is to use available Escherichia coli data and apply a ratio of enteric viruses to indicator E. coli in wastewater obtained from prior studies to estimate the concentration of enteric viruses in other wastewater types/sources. In this article, we have provided an argument for why we do not recommend the use of a pathogen to E. coli ratio to estimate virus concentrations in single household graywater and additionally suggested circumstances in which use of such a ratio may be justified.

Comparison of response rates and cost-effectiveness for a community-based survey: postal, internet and telephone modes with generic or personalised recruitment approaches.

BACKGROUND: Epidemiological research often requires collection of data from a representative sample of the community or recruitment of specific groups through broad community approaches. The population coverage of traditional survey methods such as mail-outs to residential addresses, and telephone contact via public directories or random-digit-dialing is declining and survey response rates are falling. There is a need to explore new sampling frames and consider multiple response modes including those offered by changes in telecommunications and internet technology. METHODS: We evaluated response rates and cost-effectiveness for three modes of survey administration (postal invitation/postal survey, postal invitation/internet survey and postal invitation/telephone survey) and two styles of contact approach (personalised and generic) in a community survey of greywater use. Potential respondents were contacted only once, with no follow up of non-responders. RESULTS: The telephone survey produced the highest adjusted response rate (30.2%), followed by the personalised postal survey (10.5%), generic postal survey (7.5%) and then the internet survey (4.7% for the personalised approach and 2.2% for the generic approach). There were some differences in household characteristics and greywater use rates between respondents to different survey modes, and between respondents to personalised and generic approaches. These may be attributable to the differing levels of motivations needed for a response, and varying levels of interest in the survey topic among greywater users and non-users. The generic postal survey had the lowest costs per valid survey received (Australian $22.93), followed by the personalised postal survey ($24.75). CONCLUSIONS: Our findings suggest that postal surveys currently remain the most economic option for population-based studies, with similar costs for personalised and generic approaches. Internet surveys may be effective for specialised groups where email lists are available for initial contact, but barriers other than household internet access still exist for community-based surveys. Given the increasing recruitment challenges facing community-based studies, there is an imperative to gather contemporary comparative data on different survey modes and recruitment approaches in order to determine their strengths, limitations and costs. Researchers also need to document and report on the potential biases in the target and respondent populations and how this may affect the data collected.

Monitoring of diverse enteric pathogens across environmental and host reservoirs with TaqMan array cards and standard qPCR: a methodological comparison study.

BACKGROUND: Multiple bacteria, viruses, protists, and helminths cause enteric infections that greatly impact human health and wellbeing. These enteropathogens are transmited via several pathways through human, animal, and environmental reservoirs. Individual qPCR assays have been extensively used to detect enteropathogens within these types of samples, whereas the TaqMan array card (TAC), which allows simultaneous detection of multiple enteropathogens, has only previously been validated in human clinical samples. METHODS: In this methodological comparison study, we compared the performance of a custom 48-singleplex TAC relative to standard qPCR. We established the sensitivity and specificity of each method for the detection of eight enteric targets, by using spiked samples with varying levels of PCR inhibition. We then tested the prevalence and abundance of pathogens in wastewater from Melbourne (Australia), and human, animal, and environmental samples from informal settlements in Suva, Fiji using both TAC and qPCR. FINDINGS: Both methods exhibited similarly h specificity (TAC 100%, qPCR 94%), sensitivity (TAC 92%, qPCR 100%), and quantitation accuracy (TAC 91%, qPCR 99%) in non-inhibited sample matrices with spiked gene fragments. PCR inhibitors substantially affected detection via TAC, though this issue was alleviated by ten-fold sample dilution. Among samples from informal settlements, the two techniques performed similarly for detection (89% agreement) and quantitation (R2 0·82) for the eight enteropathogen targets. The TAC additionally included 38 other enteric targets, enabling detection of diverse faecal pathogens and extensive environmental contamination that would be prohibitively labour intensive to assay by standard qPCR. INTERPRETATION: The two techniques produced similar results across diverse sample types, with qPCR prioritising greater sensitivity and quantitation accuracy, and TAC trading small reductions in these for a cost-effective larger enteropathogen panel enabling a greater number of enteric pathogens to be analysed concurrently, which is beneficial given the abundance and variety of enteric pathogens in environments such as urban informal settlements. The ability to monitor multiple enteric pathogens across diverse reservoirs could allow better resolution of pathogen exposure pathways, and the design and monitoring of interventions to reduce pathogen load. FUNDING: Wellcome Trust Our Planet, Our Health programme.

Study design, rationale and methods of the Revitalising Informal Settlements and their Environments (RISE) study: a cluster randomised controlled trial to evaluate environmental and human health impacts of a water-sensitive intervention in informal settlements in Indonesia and Fiji.

INTRODUCTION: Increasing urban populations have led to the growth of informal settlements, with contaminated environments linked to poor human health through a range of interlinked pathways. Here, we describe the design and methods for the Revitalising Informal Settlements and their Environments (RISE) study, a transdisciplinary randomised trial evaluating impacts of an intervention to upgrade urban informal settlements in two Asia-Pacific countries. METHODS AND ANALYSIS: RISE is a cluster randomised controlled trial among 12 settlements in Makassar, Indonesia, and 12 in Suva, Fiji. Six settlements in each country have been randomised to receive the intervention at the outset; the remainder will serve as controls and be offered intervention delivery after trial completion. The intervention involves a water-sensitive approach, delivering site-specific, modular, decentralised infrastructure primarily aimed at improving health by decreasing exposure to environmental faecal contamination. Consenting households within each informal settlement site have been enrolled, with longitudinal assessment to involve health and well-being surveys, and human and environmental sampling. Primary outcomes will be evaluated in children under 5 years of age and include prevalence and diversity of gastrointestinal pathogens, abundance and diversity of antimicrobial resistance (AMR) genes in gastrointestinal microorganisms and markers of gastrointestinal inflammation. Diverse secondary outcomes include changes in microbial contamination; abundance and diversity of pathogens and AMR genes in environmental samples; impacts on ecological biodiversity and microclimates; mosquito vector abundance; anthropometric assessments, nutrition markers and systemic inflammation in children; caregiver-reported and self-reported health symptoms and healthcare utilisation; and measures of individual and community psychological, emotional and economic well-being. The study aims to provide proof-of-concept evidence to inform policies on upgrading of informal settlements to improve environments and human health and well-being. ETHICS: Study protocols have been approved by ethics boards at Monash University, Fiji National University and Hasanuddin University. TRIAL REGISTRATION NUMBER: ACTRN12618000633280; Pre-results.

A planetary health model for reducing exposure to faecal contamination in urban informal settlements: Baseline findings from Makassar, Indonesia.

BACKGROUND: The intense interactions between people, animals and environmental systems in urban informal settlements compromise human and environmental health. Inadequate water and sanitation services, compounded by exposure to flooding and climate change risks, expose inhabitants to environmental contamination causing poor health and wellbeing and degrading ecosystems. However, the exact nature and full scope of risks and exposure pathways between human health and the environment in informal settlements are uncertain. Existing models are limited to microbiological linkages related to faecal-oral exposures at the individual level, and do not account for a broader range of human-environmental variables and interactions that affect population health and wellbeing. METHODS: We undertook a 12-month health and environmental assessment in 12 flood-prone informal settlements in Makassar, Indonesia. We obtained caregiver-reported health data, anthropometric measurements, stool and blood samples from children < 5 years, and health and wellbeing data for children 5-14 years and adult respondents. We collected environmental data including temperature, mosquito and rat species abundance, and water and sediment samples. Demographic, built environment and household asset data were also collected. We combined our data with existing literature to generate a novel planetary health model of health and environment in informal settlements. RESULTS: Across the 12 settlements, 593 households and 2764 participants were enrolled. Two-thirds (64·1%) of all houses (26·3-82·7% per settlement) had formal land tenure documentation. Cough, fever and diarrhoea in the week prior to the survey were reported among an average of 34.3%, 26.9% and 9.7% of children aged < 5 years, respectively; although proportions varied over time, prevalence among these youngest children was consistently higher than among children 5-14 years or adult respondents. Among children < 5 years, 44·3% experienced stunting, 41·1% underweight, 12.4% wasting, and 26.5% were anaemic. There was self- or carer-reported poor mental health among 16.6% of children aged 5-14 years and 13.9% of adult respondents. Rates of potential risky exposures from swimming in waterways, eating uncooked produce, and eating soil or dirt were high, as were exposures to flooding and livestock. Just over one third of households (35.3%) had access to municipal water, and contamination of well water with E. coli and nitrogen species was common. Most (79·5%) houses had an in-house toilet, but no houses were connected to a piped sewer network or safe, properly constructed septic tank. Median monthly settlement outdoor temperatures ranged from 26·2 °C to 29.3 °C, and were on average, 1·1 °C warmer inside houses than outside. Mosquito density varied over time, with Culex quinquefasciatus accounting for 94·7% of species. Framed by a planetary health lens, our model includes four thematic domains: (1) the physical/built environment; (2) the ecological environment; (3) human health; and (4) socio-economic wellbeing, and is structured at individual, household, settlement, and city/beyond spatial scales. CONCLUSIONS: Our planetary health model includes key risk factors and faecal-oral exposure pathways but extends beyond conventional microbiological faecal-oral enteropathogen exposure pathways to comprehensively account for a wider range of variables affecting health in urban informal settlements. It includes broader ecological interconnections and planetary health-related variables at the household, settlement and city levels. It proposes a composite framework of markers to assess water and sanitation challenges and flood risks in urban informal settlements for optimal design and monitoring of interventions.

Barriers and Enablers to Intervention Uptake and Health Reporting in a Water Intervention Trial in Rural India: A Qualitative Explanatory Study.

Consumption of unsafe drinking water contributes to the global disease burden, necessitating identification and implementation of effective, acceptable, and sustainable water interventions in resource-limited settings. In a quantitative stepped-wedge cluster randomized trial of a community-based water intervention in rural India, we identified low rates of intervention uptake and reported diarrhea. To better understand and explain these findings, we performed a qualitative study examining barriers and enablers to intervention uptake and health reporting using the COM-B model, where capabilities, opportunities, and motivators interact to generate behavior. We conducted 20 focus groups and one semi-structured interview with participants and four focus groups with data collectors. Multifactorial barriers to intervention uptake included distorted perceptions of water-related health effects, implementation issues that reduced treated water availability; convenience of, and preference for, alternative drinking water sources; delivery of water to plastic storage tanks (perceived as affecting water quality and taste); and resistance to change. Enablers included knowledge of water-related health risks, proximity to tanks, and social opportunity. Barriers to health reporting included variability in interpretation of illness, suspicion regarding the consequences of reporting disease, weariness with repeated questions, and perceived inaction on health data already provided; low survey implementation fidelity was also important. Enablers included surveyor initiatives to encourage reporting and a sense of social responsibility. This qualitative explanatory study allowed better understanding of our quantitative results. It also identified obstacles and facilitators to implementing and evaluating community water interventions, providing insight on how to achieve better intervention uptake and health reporting in future studies.

A Stepped Wedge Cluster-Randomized Trial Assessing the Impact of a Riverbank Filtration Intervention to Improve Access to Safe Water on Health in Rural India.

Sustainable and low-cost methods for delivery of safe drinking water in resource-limited settings remain suboptimal, which contributes to global diarrhea morbidity. We aimed to assess whether delivery of riverbank filtration-treated water to newly installed water storage tanks (improved quality and access, intervention condition) reduced reported diarrhea in comparison to delivery of unfiltered river water (improved access alone, control condition) in rural Indian villages. We used a stepped wedge cluster-randomized trial (SW-CRT) design involving four clusters (villages). Selection criteria included village size, proximity to a river, and lack of existing or planned community-level safe water sources. All adults and children were eligible for enrollment. All villages started in the control condition and were sequentially randomized to receive the intervention at 3-month intervals. Our primary outcome was 7-day-period prevalence of self- or caregiver-reported diarrhea, measured at 3-month intervals (five time points). Analysis was by intention to treat. Because blinding was not possible, we incorporated questions about symptoms unrelated to water consumption to check response validity (negative control symptoms). We measured outcomes in 2,222 households (9,836 participants). We did not find a measurable reduction in diarrhea post-intervention (RR: 0.98 [95% CI: 0.24-4.09]); possible explanations include low intervention uptake, availability of other safe water sources, low baseline diarrheal prevalence, and reporting fatigue. Our study highlights both the difficulties in evaluating the impact of real-world interventions and the potential for an optimized SW-CRT design to address budgetary, funding, and logistical constraints inherent in such evaluations.

Transfer rates of enteric microorganisms in recycled water during machine clothes washing.

Approximately 15% of overall Australian household water usage is in the laundry; hence, a significant reduction in household drinking water demand could be achieved if potable-quality water used for clothes washing is replaced with recycled water. To investigate the microbiological safety of using recycled water in washing machines, bacteriophages MS-2 and PRD-1, Escherichia coli, and Cryptosporidium parvum oocysts were used in a series of experiments to investigate the transfer efficiency of enteric microorganisms from washing machine water to objects including hands, environmental surfaces, air, and fabric swatches. By determining the transference efficiency, it is possible to estimate the numbers of microorganisms that the user will be exposed to if recycled water with various levels of residual microorganisms is used in washing machines. Results, expressed as transfer rates to a given surface area per object, showed that the mean transfer efficiency of E. coli, bacteriophages MS-2 and PRD-1, and C. parvum oocysts from seeded water to fabric swatches ranged from 0.001% to 0.090%. Greatest exposure to microorganisms occurred through direct contact of hands with seeded water and via hand contact with contaminated fabric swatches. No microorganisms were detected in the air samples during the washing machine spin cycle, and transfer rates of bacteriophages from water to environmental surfaces were 100-fold less than from water directly to hands. Findings from this study provide relevant information that can be used to refine regulations governing recycled water and to allay public concerns about the use of recycled water.

Collecting household water usage data: telephone questionnaire or diary?

BACKGROUND: Quantitative Microbial Risk Assessment (QMRA), a modelling approach, is used to assess health risks. Inputs into the QMRA process include data that characterise the intensity, frequency and duration of exposure to risk(s). Data gaps for water exposure assessment include the duration and frequency of urban non-potable (non-drinking) water use. The primary objective of this study was to compare household water usage results obtained using two data collection tools, a computer assisted telephone interview (CATI) and a 7-day water activity diary, in order to assess the effect of different methodological survey approaches on derived exposure estimates. Costs and logistical aspects of each data collection tool were also examined. METHODS: A total of 232 households in an Australian dual reticulation scheme (where households are supplied with two grades of water through separate pipe networks) were surveyed about their water usage using both a CATI and a 7-day diary. Householders were questioned about their use of recycled water for toilet flushing, garden watering and other outdoor activities. Householders were also questioned about their water use in the laundry. Agreement between reported CATI and diary water usage responses was assessed. RESULTS: Results of this study showed that the level of agreement between CATI and diary responses was greater for more frequent water-related activities except toilet flushing and for those activities where standard durations or settings were employed. In addition, this study showed that the unit cost of diary administration was greater than for the CATI, excluding consideration of the initial selection and recruitment steps. CONCLUSION: This study showed that it is possible to successfully 'remotely' coordinate diary completion providing that adequate instructions are given and that diary recording forms are well designed. In addition, good diary return rates can be achieved using a monetary incentive and the diary format allows for collective recording, rather than an individual's estimation, of household water usage. Accordingly, there is merit in further exploring the use of diaries for collection of water usage information either in combination with a mail out for recruitment, or potentially in the future with Internet-based recruitment (as household Internet uptake increases).

The Australian Electoral Commission Roll has good utility for 'niche' household recruitment in population health studies.

OBJECTIVE: To investigate the recruitment of 'niche' household populations, defined by their household characteristics and/or water supply type for health studies. METHODS: The Australian Electoral Commission (AEC) database was used to recruit households for participation in two health-related studies, the first, a recycled water usage study and the second, an epidemiological study investigating household rainwater use. RESULTS: The AEC database facilitated the identification and recruitment of households using a particular water supply from among the general household population. CONCLUSIONS: The good utility of the AEC roll in household recruitment was associated with its coverage, accuracy and the ability to delimit the sampling frame according to the geographical area(s) and household characteristics of interest. Its use also allowed personalised contact to be made with potential survey participants by mail, contact that is not otherwise possible using existing telephone and on-line databases. IMPLICATIONS: The AEC database is a valuable resource for household recruitment in a diversity of health and environmental exposure surveys.

Maximising response rates in household telephone surveys.

BACKGROUND: Epidemiological and other studies that require participants to respond by completing a questionnaire face the growing threat of non-response. Response rates to household telephone surveys are diminishing because of changes in telecommunications, marketing and culture. Accordingly, updated information is required about the rate of telephone listing in directories and optimal strategies to maximise survey participation. METHODS: A total of 3426 households in Sydney, Australia were approached to participate in a computer assisted telephone interview (CATI) regarding their domestic (recycled and/or drinking) water usage. Only randomly selected households in the suburb and postcode of interest with a telephone number listed in the Electronic White Pages (EWP) that matched Australian electoral records were approached. RESULTS: The CATI response rate for eligible households contacted by telephone was 39%. The rate of matching of electoral and EWP records, a measure of telephone directory coverage, was 55%. CONCLUSION: The use of a combination of approaches, such as an advance letter, interviewer training, establishment of researcher credentials, increasing call attempts and targeted call times, remains a good strategy to maximise telephone response rates. However, by way of preparation for future technological changes, reduced telephone number listings and people's increasing resistance to unwanted phone calls, alternatives to telephone surveys, such as internet-based approaches, should be investigated.

Cost of gastroenteritis in Australia: A healthcare perspective.

BACKGROUND: Acute gastroenteritis illness is a common illness that causes considerable morbidity, but current estimates of the cost to the Australian healthcare system are unknown. OBJECTIVE: To estimate the current healthcare utilisation and direct public healthcare system costs attributable to acute gastroenteritis illness in Australia. METHODS: This is an incidence-based cost-of-illness study focused on quantifying direct health care costs using a bottom-up approach. Data on general practitioner consultations, prescribed medications, diagnostic tests, specialist consultations, emergency department visits and hospital admissions were collected from national reports. RESULTS: Using 2016 prices, the estimated annual direct per capita cost of acute gastroenteritis illness was AUD$14.87 (USD$10.71), equating to AUD$20.27 (USD$14.59) per case. The estimated overall economic burden in Australia was AUD$359 million (USD$258 million; AUD$1.5 million per 100,000 people). The major contributors to this cost were hospital admissions (57.1%), emergency department visits (17.7%), and general practitioner consultations (14.0%). Children under five years of age have the highest per capita rates of acute gastroenteritis illness; however, service utilisation rates vary by age group and both young children and older adults accounted for a substantial proportion of the overall economic burden attributable to acute gastroenteritis illness. CONCLUSIONS: Although chronic diseases comprise a large cost burden on the healthcare system, acute illnesses, including acute gastroenteritis illness, also impose substantial direct healthcare system costs. Providing data on current cost estimates is useful for prioritizing public health interventions, with our findings suggesting that it would be ideal if targeted interventions to reduce hospitalisation rates among young children and older adults were available.

Recycled water and human health effects.

BACKGROUND: Recent drought conditions and diminishing drinking water storage levels in Australian capital cities have led to increasing attention being directed to water recycling and the use of alternative water sources for urban domestic use. Despite the 'in principle' acceptance by the Australian public for water recycling, support for proposed schemes is constrained by public perception of possible adverse health effects from exposure to micro-organisms and chemical contaminants. OBJECTIVE: This article describes current research investigating the health impacts of using recycled water for urban nondrinking purposes. DISCUSSION: Two complementary research approaches, quantitative microbial risk assessment and epidemiology, may be employed to assess health impacts of using recycled water for nondrinking or drinking purposes. The first of these approaches involves water quality monitoring and experimental studies. The second involves disease surveillance in which genera practitioners may play a part.

Burden of Disease Attributed to Waterborne Transmission of Selected Enteric Pathogens, Australia, 2010.

AbstractUniversal access to safe drinking water is a global priority. To estimate the annual disease burden of campylobacteriosis, nontyphoidal salmonellosis, cryptosporidiosis, giardiasis, and norovirus attributable to waterborne transmission in Australia, we multiplied regional World Health Organization (WHO) estimates of the proportion of cases attributable to waterborne transmission by estimates of all-source disease burden for each study pathogen. Norovirus was attributed as causing the most waterborne disease cases (479,632; 95% uncertainty interval [UI]: 0-1,111,874) followed by giardiasis and campylobacteriosis. The estimated waterborne disability-adjusted life year (DALY) burden for campylobacteriosis (2,004; 95% UI: 0-5,831) was 7-fold greater than other study pathogens and exceeded the WHO guidelines for drinking water quality (1 × 10-6 DALY per person per year) by 90-fold. However, these estimates include disease transmitted via either drinking or recreational water exposure. More precise country-specific and drinking water-specific attribution estimates would better define the health burden from drinking water and inform changes to treatment requirements.

Protocol for a cluster randomised stepped wedge trial assessing the impact of a community-level hygiene intervention and a water intervention using riverbank filtration technology on diarrhoeal prevalence in India.

INTRODUCTION: Diarrhoea is a leading cause of death globally, mostly occurring as a result of insufficient or unsafe water supplies, inadequate sanitation and poor hygiene. Our study aims to investigate the impact of a community-level hygiene education program and a water quality intervention using riverbank filtration (RBF) technology on diarrhoeal prevalence. METHODS AND ANALYSIS: We have designed a stepped wedge cluster randomised trial to estimate the health impacts of our intervention in 4 rural villages in Karnataka, India. At baseline, surveys will be conducted in all villages, and householders will receive hygiene education. New pipelines, water storage tanks and taps will then be installed at accessible locations in each village and untreated piped river water will be supplied. A subsequent survey will evaluate the impact of hygiene education combined with improved access to greater water volumes for hygiene and drinking purposes (improved water quantity). Villages will then be randomly ordered and RBF-treated water (improved water quality) will be sequentially introduced into the 4 villages in a stepwise manner, with administration of surveys at each time point. The primary outcome is a 7-day period prevalence of self-reported diarrhoea. Secondary outcomes include self-reported respiratory and skin infections, and reported changes in hygiene practices, household water usage and water supply preference. River, tank and tap water from each village, and stored water from a subset of households, will be sampled to assess microbial and chemical quality. ETHICS AND DISSEMINATION: Ethics approval was obtained from the Monash University Human Research Ethics Committee in Australia and The Energy and Resources Institute Institutional Ethics Committee in India. The results of the trial will be presented at conferences, published in peer-reviewed journals and disseminated to relevant stakeholders. This study is funded by an Australian National Health and Medical Research Council (NHMRC) project grant. TRIAL REGISTRATION NUMBER: ACTRN12616001286437; pre-results.