Water Supply Interruptions Are Associated with More Frequent Stressful Behaviors and Emotions but Mitigated by Predictability: A Multisite Study.

Water supply interruptions contribute to household water insecurity. Unpredictable interruptions may particularly exacerbate water insecurity, as uncertainty limits households' ability to optimize water collection and storage or to modify other coping behaviors. This study used regression models of survey data from 2873 households across 10 sites in 9 middle-income countries to assess whether water supply interruptions and the predictability of interruptions were related to composite indicators of stressful behaviors and emotional distress. More frequent water service interruptions were associated with more frequent emotional distress (ß = 0.49, SE = 0.05, P < 0.001) and stressful behaviors (ß = 0.39, SE = 0.06, P < 0.001). Among households that experienced interruptions, predictability mitigated these respective relationships by approximately 25 and 50%. Where the provision of continuous water supplies is challenged by climate change, population growth, and poor management, water service providers may be able to mitigate some psychosocial consequences of intermittency through scheduled intermittency and communication about water supply interruptions. Service providers unable to supply continuous water should optimize intermittent water delivery to reduce negative impacts on users, and global monitoring regimes should account for intermittency and predictability in post-2030 water service metrics to better reflect household water insecurity experiences.

Water use behaviors and water access in intermittent and continuous water supply areas during the COVID-19 pandemic.

More than one billion people worldwide receive intermittent water supply (IWS), in which water is delivered through a pipe network for fewer than 24 h/day, limiting the quantity and accessibility of water. During the COVID-19 pandemic, stay-at-home orders and efforts to limit contact with others can affect water access for those with unreliable home water supplies. We explored whether water service delivery and household water-use behaviors changed during the COVID-19 pandemic in Hubballi-Dharwad, India, and whether they differed if households had IWS or continuous (24×7) water supply through a longitudinal household survey in 2020-2021. We found few perceived differences in water service delivery or water access, although one-quarter of all households reported insufficient water for handwashing, suggesting an increased demand for water that was not satisfied. Many households with 24×7 supply reported water outages, necessitating the use of alternative water sources. These findings suggest that water demand at home increased and households with IWS and 24×7 both lacked access to sufficient water. Our findings indicate that water insecurity negatively affected households' ability to adhere to protective public health measures during the COVID-19 pandemic and highlight the importance of access to uninterrupted, on-premise water during public health emergencies.

Optimizing Household Water Decisions for Managing Intermittent Water Supply in Mexico City.

One billion people worldwide experience intermittent water supply (IWS), in which piped water is delivered for limited durations. Households with IWS must invest in water storage infrastructure and often rely on multiple sources of water; therefore, these household-level purchasing and infrastructure decisions is a critical component of water access. Informed by interviews with IWS households, we use radial basis function networks, a type of artificial neural network, to determine optimal household water management decisions that maximize reliability of water supply while minimizing costs for a representative household in Mexico City that uses municipal piped water, trucked water, and rainwater. We find that securing reliable water supply for IWS households is greatly assisted by installation of household storage tanks of at least 2500 L. In the case of IWS households with limited storage options, the overall cost for water supply is reduced by scheduling water deliveries on nonconsecutive days. Rainwater harvesting systems were shown to be economically viable for households with limited water supply. This study demonstrates the importance of considering the management of multiple sources and household storage infrastructure when evaluating water investments in cities with IWS.

The effect of sodium thiosulfate dechlorination on fecal indicator bacteria enumeration: laboratory and field data.

In microbiological water quality testing, sample dechlorination with sodium thiosulfate is recommended to ensure that results accurately reflect the water quality at sample collection. Nevertheless, monitoring institutions in low-resource settings do not always dechlorinate samples, and there is limited research describing how this practice impacts drinking water quality results. The effect of dechlorination on indicator bacteria counts was evaluated by spiking laboratory water with five Escherichia coli (E. coli) concentrations (104-108 CFU/100 mL), chlorinating at six doses (0-0.6 mg/L), holding samples with and without sodium thiosulfate for 5-7 hours, and enumerating E. coli by membrane filtration with m-lauryl sulfate media. Additionally, sub-Saharan African water suppliers enumerated thermotolerant coliform by membrane filtration in paired chlorinated water samples collected with and without sodium thiosulfate. Across all E. coli and chlorine doses in the laboratory, and all field tests, samples held without sodium thiosulfate had lower bacteria counts (p < 0.001). Additionally, chlorinated water supply samples held without sodium thiosulfate had an 87.5% false negative rate. Results indicate the importance of dechlorinating microbiological water quality samples, discarding data from chlorinated samples collected without dechlorination, and reinforcing dechlorination recommendations in resource-limited environments to improve water safety management.

How Much Will It Cost To Monitor Microbial Drinking Water Quality in Sub-Saharan Africa?

Microbial water quality monitoring is crucial for managing water resources and protecting public health. However, institutional testing activities in sub-Saharan Africa are currently limited. Because the economics of water quality testing are poorly understood, the extent to which cost may be a barrier to monitoring in different settings is unclear. This study used cost data from 18 African monitoring institutions (piped water suppliers and health surveillance agencies in six countries) and estimates of water supply type coverage from 15 countries to assess the annual financial requirements for microbial water testing at both national and regional levels, using World Health Organization recommendations for sampling frequency. We found that a microbial water quality test costs 21.0 ± 11.3 USD, on average, including consumables, equipment, labor, and logistics, which is higher than previously calculated. Our annual cost estimates for microbial monitoring of piped supplies and improved point sources ranged between 8 000 USD for Equatorial Guinea and 1.9 million USD for Ethiopia, depending primarily on the population served but also on the distribution of piped water system sizes. A comparison with current national water and sanitation budgets showed that the cost of implementing prescribed testing levels represents a relatively modest proportion of existing budgets (<2%). At the regional level, we estimated that monitoring the microbial quality of all improved water sources in sub-Saharan Africa would cost 16.0 million USD per year, which is minimal in comparison to the projected annual capital costs of achieving Sustainable Development Goal 6.1 of safe water for all (14.8 billion USD).

Estimating Infection Risks and the Global Burden of Diarrheal Disease Attributable to Intermittent Water Supply Using QMRA.

Intermittent water supply (IWS) is prevalent throughout low and middle-income countries. IWS is associated with increased microbial contamination and potentially elevated risk of waterborne illness. We used existing data sets to estimate the population exposed to IWS, assess the probability of infection using quantitative microbial risk assessment, and calculate the subsequent burden of diarrheal disease attributable to consuming fecally contaminated tap water from an IWS. We used reference pathogens Campylobacter, Cryptosporidium, and rotavirus as conservative risk proxies for infections via bacteria, protozoa, and viruses, respectively. Results indicate that the median daily risk of infection is an estimated 1 in 23 500 for Campylobacter, 1 in 5 050 000 for Cryptosporidium, and 1 in 118 000 for rotavirus. Based on these risks, IWS may account for 17.2 million infections causing 4.52 million cases of diarrhea, 109 000 diarrheal DALYs, and 1560 deaths each year. The burden of diarrheal disease associated with IWS likely exceeds the WHO health-based normative guideline for drinking water of 10-6 DALYs per person per year. Our results underscore the importance water safety management in water supplies and the potential benefits of point-of-use treatment to mitigate risks.

Intermittent Water Supply: Prevalence, Practice, and Microbial Water Quality.

Intermittent water supplies (IWS), in which water is provided through pipes for only limited durations, serve at least 300 million people around the world. However, providing water intermittently can compromise water quality in the distribution system. In IWS systems, the pipes do not supply water for periods of time, supply periods are shortened, and pipes experience regular flow restarting and draining. These unique behaviors affect distribution system water quality in ways that are different than during normal operations in continuous water supplies (CWS). A better understanding of the influence of IWS on mechanisms causing contamination can help lead to incremental steps that protect water quality and minimize health risks. This review examines the status and nature of IWS practices throughout the world, the evidence of the effect of IWS on water quality, and how the typical contexts in which IWS systems often exist-low-income countries with under-resourced utilities and inadequate sanitation infrastructure-can exacerbate mechanisms causing contamination. We then highlight knowledge gaps for further research to improve our understanding of water quality in IWS.

Systems Approach to Climate, Water, and Diarrhea in Hubli-Dharwad, India.

Anthropogenic climate change will likely increase diarrhea rates for communities with inadequate water, sanitation, or hygiene facilities including those with intermittent water supplies. Current approaches to study these impacts typically focus on the effect of temperature on all-cause diarrhea while excluding precipitation and diarrhea etiology while not providing actionable adaptation strategies. We develop a partially mechanistic, systems approach to estimate future diarrhea prevalence and design adaptation strategies. The model incorporates downscaled global climate models, water quality data, quantitative microbial risk assessment, and pathogen prevalence in an agent-based modeling framework incorporating precipitation and diarrhea etiology. It is informed using water quality and diarrhea data from Hubli-Dharwad, India-a city with an intermittent piped water supply exhibiting seasonal water quality variability vulnerable to climate change. We predict all-cause diarrhea prevalence to increase by 4.9% (Range: 1.5-9.0%) by 2011-2030, 11.9% (Range: 7.1-18.2%) by 2046-2065, and 18.2% (Range: 9.1-26.2%) by 2080-2099. Rainfall is an important modifying factor. Rotavirus prevalence is estimated to decline by 10.5% with Cryptosporidium and E. coli prevalence increasing by 9.9% and 6.3%, respectively, by 2080-2099 in this setting. These results suggest that ceramic water filters would be recommended as a climate adaptation strategy over chlorination. This work highlights the vulnerability of intermittent water supplies to climate change and the urgent need for improvements.

Assessing Drinking Water Quality and Water Safety Management in Sub-Saharan Africa Using Regulated Monitoring Data.

Universal access to safe drinking water is prioritized in the post-2015 Sustainable Development Goals. Collecting reliable and actionable water quality information in low-resource settings, however, is challenging, and little is known about the correspondence between water quality data collected by local monitoring agencies and global frameworks for water safety. Using 42 926 microbial water quality test results from 32 surveillance agencies and water suppliers in seven sub-Saharan African countries, we determined the degree to which water sources were monitored, how water quality varied by source type, and institutional responses to results. Sixty-four percent of the water samples were collected from piped supplies, although the majority of Africans rely on nonpiped sources. Piped supplies had the lowest levels of fecal indicator bacteria (FIB) compared to any other source type: only 4% of samples of water piped to plots and 2% of samples from water piped to public taps/standpipes were positive for FIB (n = 14 948 and n = 12 278, respectively). Among other types of improved sources, samples from harvested rainwater and boreholes were less often positive for FIB (22%, n = 167 and 31%, n = 3329, respectively) than protected springs or protected dug wells (39%, n = 472 and 65%, n = 505). When data from different settings were aggregated, the FIB levels in different source types broadly reflected the source-type water safety framework used by the Joint Monitoring Programme. However, the insufficient testing of nonpiped sources relative to their use indicates important gaps in current assessments. Our results emphasize the importance of local data collection for water safety management and measurement of progress toward universal safe drinking water access.

Upgrading a piped water supply from intermittent to continuous delivery and association with waterborne illness: a matched cohort study in urban India.

BACKGROUND: Intermittent delivery of piped water can lead to waterborne illness through contamination in the pipelines or during household storage, use of unsafe water sources during intermittencies, and limited water availability for hygiene. We assessed the association between continuous versus intermittent water supply and waterborne diseases, child mortality, and weight for age in Hubli-Dharwad, India. METHODS AND FINDINGS: We conducted a matched cohort study with multivariate matching to identify intermittent and continuous supply areas with comparable characteristics in Hubli-Dharwad. We followed 3,922 households in 16 neighborhoods with children <5 y old, with four longitudinal visits over 15 mo (Nov 2010-Feb 2012) to record caregiver-reported health outcomes (diarrhea, highly credible gastrointestinal illness, bloody diarrhea, typhoid fever, cholera, hepatitis, and deaths of children <2 y old) and, at the final visit, to measure weight for age for children <5 y old. We also collected caregiver-reported data on negative control outcomes (cough/cold and scrapes/bruises) to assess potential bias from residual confounding or differential measurement error. Continuous supply had no significant overall association with diarrhea (prevalence ratio [PR] = 0.93, 95% confidence interval [CI]: 0.83-1.04, p = 0.19), bloody diarrhea (PR = 0.78, 95% CI: 0.60-1.01, p = 0.06), or weight-for-age z-scores (Δz = 0.01, 95% CI: -0.07-0.09, p = 0.79) in children <5 y old. In prespecified subgroup analyses by socioeconomic status, children <5 y old in lower-income continuous supply households had 37% lower prevalence of bloody diarrhea (PR = 0.63, 95% CI: 0.46-0.87, p-value for interaction = 0.03) than lower-income intermittent supply households; in higher-income households, there was no significant association between continuous versus intermittent supply and child diarrheal illnesses. Continuous supply areas also had 42% fewer households with ≥1 reported case of typhoid fever (cumulative incidence ratio [CIR] = 0.58, 95% CI: 0.41-0.78, p = 0.001) than intermittent supply areas. There was no significant association with hepatitis, cholera, or mortality of children <2 y old; however, our results were indicative of lower mortality of children <2 y old (CIR = 0.51, 95% CI: 0.22-1.07, p = 0.10) in continuous supply areas. The major limitations of our study were the potential for unmeasured confounding given the observational design and measurement bias from differential reporting of health symptoms given the nonblinded treatment. However, there was no significant difference in the prevalence of the negative control outcomes between study groups that would suggest undetected confounding or measurement bias. CONCLUSIONS: Continuous water supply had no significant overall association with diarrheal disease or ponderal growth in children <5 y old in Hubli-Dharwad; this might be due to point-of-use water contamination from continuing household storage and exposure to diarrheagenic pathogens through nonwaterborne routes. Continuous supply was associated with lower prevalence of dysentery in children in low-income households and lower typhoid fever incidence, suggesting that intermittently operated piped water systems are a significant transmission mechanism for Salmonella typhi and dysentery-causing pathogens in this urban population, despite centralized water treatment. Continuous supply was associated with reduced transmission, especially in the poorer higher-risk segments of the population.

Mechanisms affecting water quality in an intermittent piped water supply.

Drinking water distribution systems throughout the world supply water intermittently, leaving pipes without pressure between supply cycles. Understanding the multiple mechanisms that affect contamination in these intermittent water supplies (IWS) can be used to develop strategies to improve water quality. To study these effects, we tested water quality in an IWS system with infrequent and short water delivery periods in Hubli-Dharwad, India. We continuously measured pressure and physicochemical parameters and periodically collected grab samples to test for total coliform and E. coli throughout supply cycles at 11 sites. When the supply was first turned on, water with elevated turbidity and high concentrations of indicator bacteria was flushed out of pipes. At low pressures (<10 psi), elevated indicator bacteria were frequently detected even when there was a chlorine residual, suggesting persistent contamination had occurred through intrusion or backflow. At pressures between 10 and 17 psi, evidence of periodic contamination suggested that transient intrusion, backflow, release of particulates, or sloughing of biofilms from pipe walls had occurred. Few total coliform and no E. coli were detected when water was delivered with a chlorine residual and at pressures >17 psi.

Water quality monitoring with purpose: Using a novel framework and leveraging long-term data.

Water quality monitoring programs are developed to meet goals including attaining regulatory compliance, evaluating long-term environmental changes, or quantifying the impact of an emergency event. Methods for developing these programs often fail to address multiple aspects of development (hazard identification, parameter selection, monitoring locations/frequency) simultaneously. We develop a framework for monitoring program development that is both versatile and systematic, the Hazard Based Water Quality Monitoring Planning framework, and apply it to the Quabbin watershed in Massachusetts, USA. We use a novel application of dataset deconstruction of long-term water quality datasets and the Seasonal Kendall test for trends to evaluate the effects of sampling frequency on long-term trend detection at several watershed sites. Results showed that when sampling frequency is decreased, ability to detect statistically significant trends often decreases. Absolute error in trend slopes between biweekly (twice monthly) and reduced sampling frequencies was relatively small for specific conductance and turbidity but was high for total coliform, likely due to interannual variation in rainfall and temperature We found that no one sampling reduction method resulted in a consistently lower absolute error compared to the "truth" (biweekly sampling), highlighting the importance of evaluating conditions that may affect water quality at sites in different parts of a watershed. We demonstrate the framework's usefulness, particularly for parameter and sampling frequency selection, using methods that can be readily applied to other watershed systems.

Evaluating the impact of sampling design on drinking water quality monitoring program outcomes.

Drinking water suppliers around the world are required by regulations to sample and test water quality in their distribution systems with the intention of generating information that can be used to protect human health. Requirements for where samples must be collected can vary and guidance on how to select locations to meet these requirements is limited. There is a need to better define and evaluate the meaning of representative in the context of selecting locations for collecting grab samples while considering the regulatory context and resources available to suppliers. We develop sampling programs for monitoring disinfectant residual concentrations and compare the results and efficacy of these programs using synthetic water quality data for two example distribution systems. Results showed that achieving accurate estimates of worst quality conditions in a network was more likely than achieving accurate estimates of systemwide conditions, and that using constant locations makes it difficult to accurately represent systemwide conditions. Results also showed that timing of sample collection is likely important depending on factors such as consumer demand patterns, and that it is inappropriate to make conclusions about systemwide conditions when few samples are taken over an evaluation period. This research has implications for developing recommendations that water suppliers and regulators can use to design and evaluate effective sampling programs.

How we assess water safety: A critical review of sanitary inspection and water quality analysis.

Sanitary inspection is used in low-, medium- and high-income settings to assess the risk of microbial contamination at water sources. However, the relationship between sanitary inspection and water quality is not well understood. We conducted a critical literature review and synthesized the findings of 25 studies comparing the results of sanitary inspection and microbial water quality analysis. Most studies used sub-standard sanitary inspection and water quality analysis methods, and applied simplistic comparisons that do not characterize the complexity of the relationship. Sanitary risk score was used to represent sanitary inspection results in 21 (84%) studies; of which 12 (57%) found a significant association between score and microbial water quality and nine (43%) did not. Participatory sanitary inspection (12%) and reporting results back to communities (24%) were uncommon. Most studies relied on laboratory-based water quality analysis as an independently sufficient measure of safety, but reported inadequate quality control (52%) and/or sub-standard sample processing methods (66%). We found that sanitary inspections could contribute to improving water safety through four mechanisms: guiding remedial action at individual water sources, allowing operators and external support programs to prioritize repairs, identifying programmatic issues, and contributing to research. The purpose of the sanitary inspection should be considered when planning sanitary inspection execution, data analysis, and reporting to ensure appropriate methods are employed and results are fit for purpose. Further exploration should recognize that sanitary risk factors represent sources of contamination, pathways for contaminants to enter water supplies, and breakdowns in barriers to contamination. These different sanitary risk factor types have different and inter-dependent effects on water quality.

Efficacy of microbial sampling recommendations and practices in sub-Saharan Africa.

Current guidelines for testing drinking water quality recommend that the sampling rate, which is the number of samples tested for fecal indicator bacteria (FIB) per year, increases as the population served by the drinking water system increases. However, in low-resource settings, prevalence of contamination tends to be higher, potentially requiring higher sampling rates and different statistical methods not addressed by current sampling recommendations. We analyzed 27,930 tests for FIB collected from 351 piped water systems in eight countries in sub-Saharan Africa to assess current sampling rates, observed contamination prevalences, and the ability of monitoring agencies to complete two common objectives of sampling programs: determine regulatory compliance and detect a change over time. Although FIB were never detected in samples from 75% of piped water systems, only 14% were sampled often enough to conclude with 90% confidence that the true contamination prevalence met an example guideline (≤5% chance of any sample positive for FIB). Similarly, after observing a ten percentage point increase in contaminated samples, 43% of PWS would still require more than a year before their monitoring agency could be confident that contamination had actually increased. We conclude that current sampling practices in these settings may provide insufficient information because they collect too few samples. We also conclude that current guidelines could be improved by specifying how to increase sampling after contamination has been detected. Our results suggest that future recommendations should explicitly consider the regulatory limit and desired confidence in results, and adapt when FIB is detected.

Measuring the Impacts of Water Safety Plans in the Asia-Pacific Region.

This study investigated the effectiveness of Water Safety Plans (WSP) implemented in 99 water supply systems across 12 countries in the Asia-Pacific region. An impact assessment methodology including 36 indicators was developed based on a conceptual framework proposed by the Center for Disease Control (CDC) and before/after data were collected between November 2014 and June 2016. WSPs were associated with infrastructure improvements at the vast majority (82) of participating sites and to increased financial support at 37 sites. In addition, significant changes were observed in operations and management practices, number of water safety-related meetings, unaccounted-for water, water quality testing activities, and monitoring of consumer satisfaction. However, the study also revealed challenges in the implementation of WSPs, including financial constraints and insufficient capacity. Finally, this study provided an opportunity to test the impact assessment methodology itself, and a series of recommendations are made to improve the approach (indicators, study design, data collection methods) for evaluating WSPs.

Why do water quality monitoring programs succeed or fail? A qualitative comparative analysis of regulated testing systems in sub-Saharan Africa.

BACKGROUND: Water quality testing is critical for guiding water safety management and ensuring public health. In many settings, however, water suppliers and surveillance agencies do not meet regulatory requirements for testing frequencies. This study examines the conditions that promote successful water quality monitoring in Africa, with the goal of providing evidence for strengthening regulated water quality testing programs. METHODS AND FINDINGS: We compared monitoring programs among 26 regulated water suppliers and surveillance agencies across six African countries. These institutions submitted monthly water quality testing results over 18 months. We also collected qualitative data on the conditions that influenced testing performance via approximately 821 h of semi-structured interviews and observations. Based on our qualitative data, we developed the Water Capacity Rating Diagnostic (WaterCaRD) to establish a scoring framework for evaluating the effects of the following conditions on testing performance: accountability, staffing, program structure, finances, and equipment & services. We summarized the qualitative data into case studies for each of the 26 institutions and then used the case studies to score the institutions against the conditions captured in WaterCaRD. Subsequently, we applied fuzzy-set Qualitative Comparative Analysis (fsQCA) to compare these scores against performance outcomes for water quality testing. We defined the performance outcomes as the proportion of testing Targets Achieved (outcome 1) and Testing Consistency (outcome 2) based on the monthly number of microbial water quality tests conducted by each institution. Our analysis identified motivation & leadership, knowledge, staff retention, and transport as institutional conditions that were necessary for achieving monitoring targets. In addition, equipment, procurement, infrastructure, and enforcement contributed to the pathways that resulted in strong monitoring performance. CONCLUSIONS: Our identification of institutional commitment, comprising motivation & leadership, knowledge, and staff retention, as a key driver of monitoring performance was not surprising: in weak regulatory environments, individuals and their motivations take-on greater importance in determining institutional and programmatic outcomes. Nevertheless, efforts to build data collection capacity in low-resource settings largely focus on supply-side interventions: the provision of infrastructure, equipment, and training sessions. Our results indicate that these interventions will continue to have limited long-term impacts and sustainability without complementary strategies for motivating or incentivizing water supply and surveillance agency managers to achieve testing goals. More broadly, our research demonstrates both an experimental approach for diagnosing the systems that underlie service provision and an analytical strategy for identifying appropriate interventions.

Can Sanitary Surveys Replace Water Quality Testing? Evidence from Kisii, Kenya.

Information about the quality of rural drinking water sources can be used to manage their safety and mitigate risks to health. Sanitary surveys, which are observational checklists to assess hazards present at water sources, are simpler to conduct than microbial tests. We assessed whether sanitary survey results were associated with measured indicator bacteria levels in rural drinking water sources in Kisii Central, Kenya. Overall, thermotolerant coliform (TTC) levels were high: all of the samples from the 20 tested dug wells, almost all (95%) of the samples from the 25 tested springs, and 61% of the samples from the 16 tested rainwater harvesting systems were contaminated with TTC. There were no significant associations between TTC levels and overall sanitary survey scores or their individual components. Contamination by TTC was associated with source type (dug wells and springs were more contaminated than rainwater systems). While sanitary surveys cannot be substituted for microbial water quality results in this context, they could be used to identify potential hazards and contribute to a comprehensive risk management approach.

Seasonal Variation in Drinking and Domestic Water Sources and Quality in Port Harcourt, Nigeria.

We compared dry and rainy season water sources and their quality in the urban region of Port Harcourt, Nigeria. Representative sampling indicated that municipal water supplies represent < 1% of the water sources. Residents rely on privately constructed and maintained boreholes that are supplemented by commercially packaged bottled and sachet drinking water. Contamination by thermotolerant coliforms increased from 21% of drinking water sources in the dry season to 42% of drinking water sources in the rainy season (N = 356 and N = 397). The most significant increase was in sachet water, which showed the lowest frequencies of contamination in the dry season compared with other sources (15%, N = 186) but the highest frequencies during the rainy season (59%, N = 76). Only half as many respondents reported drinking sachet water in the rainy season as in the dry season. Respondents primarily used flush or pour-flush toilets connected to septic tanks (85%, N = 399). The remainder relied on pit latrines and hanging (pier) latrines that drained into surface waters. We found significant associations between fecal contamination in boreholes and the nearby presence of hanging latrines. Sanitary surveys of boreholes showed that more than half were well-constructed, and we did not identify associations between structural or site deficiencies and microbial water quality. The deterioration of drinking water quality during the rainy season is a serious public health risk for both untreated groundwater and commercially packaged water, highlighting a need to address gaps in monitoring and quality control.

To What Extent is Drinking Water Tested in Sub-Saharan Africa? A Comparative Analysis of Regulated Water Quality Monitoring.

Water quality information is important for guiding water safety management and preventing water-related diseases. To assess the current status of regulated water quality monitoring in sub-Saharan Africa, we evaluated testing programs for fecal contamination in 72 institutions (water suppliers and public health agencies) across 10 countries. Data were collected through written surveys, in-person interviews, and analysis of microbial water quality testing levels. Though most institutions did not achieve the testing levels specified by applicable standards or World Health Organization (WHO) Guidelines, 85% of institutions had conducted some microbial water testing in the previous year. Institutions were more likely to meet testing targets if they were suppliers (as compared to surveillance agencies), served larger populations, operated in urban settings, and had higher water quality budgets (all p < 0.05). Our results indicate that smaller water providers and rural public health offices will require greater attention and additional resources to achieve regulatory compliance for water quality monitoring in sub-Saharan Africa. The cost-effectiveness of water quality monitoring should be improved by the application of risk-based water management approaches. Efforts to strengthen monitoring capacity should pay greater attention to program sustainability and institutional commitment to water safety.