Disinfection of Phi6, MS2, and Escherichia coli by Natural Sunlight on Healthcare Critical Surfaces.

Ultraviolet (UV) radiation systems, commonly used to disinfect surfaces, drinking water, and air, stem from historical practice to use sunlight to disinfect household items after contagious illness. Currently, it is still recommended in viral outbreak contexts such as COVID-19, Ebola, and Marburg to expose soft surfaces to sunlight after washing with detergent or disinfecting with chlorine. However, sunlight that reaches the Earth's surface is in the UVA/UVB wavelengths, whereas UV disinfection systems typically rely on biocidal UVC. Our goal was to fill the evidence gap on the efficacy of sunlight disinfection on surface materials common in low-resource healthcare settings by seeding four surfaces (stainless steel, nitrile, tarp, cloth) with three microorganisms (viral surrogate bacteriophages Phi6 and MS2 and Escherichia coli bacteria), with and without soil load, and exposing to three sunlight conditions (full sun, partial sun, cloudy). We conducted 144 tests in triplicate and found: solar radiation averaged 737 W/m2 (SD = 333), 519 W/m2 (SD = 65), and 149 W/m2 (SD = 24) for full sun, partial sun, and cloudy conditions; significantly more surfaces averaged ≥ 4 log10 reduction value (LRV) for Phi6 than MS2 and E. coli (P < 0.001) after full sun exposure, and no samples achieved ≥ 4 LRV for partial sun or cloudy conditions. On the basis of our results, we recommend no change to current protocols of disinfecting materials first with a 0.5% chlorine solution then moving to sunlight to dry. Additional field-based research is recommended to understand sunlight disinfection efficacy against pathogenic organisms on healthcare relevant surfaces during actual outbreak contexts.

Chlorine efficacy against bacteriophage Phi6, a surrogate for enveloped human viruses, on porous and non-porous surfaces at varying temperatures and humidity.

While efficacy of chlorine against Phi6, a widely-used surrogate for pathogenic enveloped viruses, is well-documented, surfaces common to low-resource contexts are under-researched. We evaluated seven surfaces (stainless steel, plastic, nitrile, tarp, cloth, concrete, wood) and three environmental conditions-temperature (4, 25, 40 °C), relative humidity (RH) (23, 85%), and soiling-to determine Phi6 recoverability and the efficacy of disinfection with 0.5% NaOCl. Overall, Phi6 recovery was >4 log10 PFU/mL on most surfaces after drying 1 hour at all temperature/humidity conditions. After disinfection, all non-porous test conditions (48/48) achieved ≥4 LRV at 1 and 5 minutes of exposure; significantly more non-porous surfaces met ≥4 LRV than porous (p < 0.001). Comparing porous surfaces, significantly fewer wood samples met ≥4 LRV than cloth (p < 0.001); no differences were observed between concrete and either wood (p = 0.083) or cloth (p = 0.087). Lastly, no differences were observed between soil and no-soil conditions for all surfaces (p = 0.712). This study highlights infectious Phi6 is recoverable across a range of surfaces and environmental conditions, and confirms the efficacy of chlorine disinfection. We recommend treating all surfaces with suspect contamination as potentially infectious, and disinfecting with 0.5% NaOCl for the minimum contact time required for the target enveloped virus (e.g. Ebola, SARS-CoV-2).

Passive In-Line Chlorination for Drinking Water Disinfection: A Critical Review.

The world is not on track to meet Sustainable Development Goal 6.1 to provide universal access to safely managed drinking water by 2030. Removal of priority microbial contaminants by disinfection is one aspect of ensuring water is safely managed. Passive chlorination (also called in-line chlorination) represents one approach to disinfecting drinking water before or at the point of collection (POC), without requiring daily user input or electricity. In contrast to manual household chlorination methods typically implemented at the point of use (POU), passive chlorinators can reduce the user burden for chlorine dosing and enable treatment at scales ranging from communities to small municipalities. In this review, we synthesized evidence from 27 evaluations of passive chlorinators (in 19 articles, 3 NGO reports, and 5 theses) conducted across 16 countries in communities, schools, health care facilities, and refugee camps. Of the 27 passive chlorinators we identified, the majority (22/27) were solid tablet or granular chlorine dosers, and the remaining devices were liquid chlorine dosers. We identified the following research priorities to address existing barriers to scaled deployment of passive chlorinators: (i) strengthening local chlorine supply chains through decentralized liquid chlorine production, (ii) validating context-specific business models and financial sustainability, (iii) leveraging remote monitoring and sensing tools to monitor real-time chlorine levels and potential system failures, and (iv) designing handpump-compatible passive chlorinators to serve the many communities reliant on handpumps as a primary drinking water source. We also propose a set of reporting indicators for future studies to facilitate standardized evaluations of the technical performance and financial sustainability of passive chlorinators. In addition, we discuss the limitations of chlorine-based disinfection and recognize the importance of addressing chemical contamination in drinking water supplies. Passive chlorinators deployed and managed at-scale have the potential to elevate the quality of existing accessible and available water services to meet "safely managed" requirements.

Selection of a SARS-CoV-2 Surrogate for Use in Surface Disinfection Efficacy Studies with Chlorine and Antimicrobial Surfaces.

Initial recommendations for surface disinfection to prevent SARS-CoV-2 transmission were developed using previous evidence from potential surrogates. To the best of our knowledge, no appropriate surrogate for SARS-CoV-2 has been identified or confirmed for chlorine and antimicrobial surface disinfection. We completed a study to evaluate the efficacy of two hypothesized antimicrobial surfaces, and four chlorine solutions on nonporous and porous surfaces, against SARS-CoV-2 and three potential SARS-CoV-2 surrogates [coronavirus mouse hepatitis virus (MHV) and bacteriophages Phi6 and MS2], to identify a BSL-1 or BSL-2 virus to use in future studies. We found SARS-CoV-2 can be reduced >4 log10 on porous and nonporous surfaces within 30 s upon exposure to 0.5% NaOCl. The results indicate coronavirus MHV-GFP is inactivated faster than SARS-CoV-2 (MHV-GFP ≥ 6.08 log10; SARS-CoV-2 = 0.66 log10 at 30 s with 0.05% NaOCl on steel) and MS2 is inactivated more slowly. Phi6 is inactivated like SARS-CoV-2, and we propose Phi6 as a slightly conservative surrogate for SARS-CoV-2 chlorine disinfection. Additionally, disinfection of bacteriophages on wood was challenging, and exposure to antimicrobial surfaces had no disinfection efficacy as tested. We recommend using 0.5% chlorine on surfaces for a minimum of 30 s of contact to disinfect SARS-CoV-2 and recommend additional research on Phi6 disinfection with varied surfaces and conditions.

A systematic review of chlorine-based surface disinfection efficacy to inform recommendations for low-resource outbreak settings.

BACKGROUND: Infectious diseases can be transmitted via fomites (contaminated surfaces/objects); disinfection can interrupt this transmission route. However, disinfection guidelines for low-resource outbreak settings are inconsistent and not evidence-based. METHODS: A systematic review of surface disinfection efficacy studies was conducted to inform low-resource outbreak guideline development. Due to variation in experimental procedures, outcomes were synthesized in a narrative summary focusing on chlorine-based disinfection against 7 pathogens with potential to produce outbreaks in low-resource settings (Mycobacterium tuberculosis, Vibrio cholerae, Salmonella spp., hepatitis A virus, rotavirus, norovirus, and Ebola virus). RESULTS: Data were extracted from 89 laboratory studies and made available, including 20 studies on relevant pathogens used in combination with surrogate data to determine minimum target concentration × time ("CT") factors. Stainless steel (68%) and chlorine-based disinfectants (56%) were most commonly tested. No consistent trend was seen in the influence of chlorine concentration and exposure time on disinfection efficacy. Disinfectant application mode; soil load; and surface type were frequently identified as influential factors in included studies. CONCLUSIONS: This review highlights that surface disinfection efficacy estimates are strongly influenced by each study's experimental conditions. We therefore recommend laboratory testing to be followed by field-based testing/monitoring to ensure effectiveness is achieved in situ.

Laboratory efficacy of surface disinfection using chlorine against Vibrio cholerae.

Disinfecting surfaces with chlorine is commonly conducted in cholera outbreaks to prevent ongoing fomite-based transmission, yet evidence gaps have led to contradictory guidance. In this study, we tested the efficacy of spraying and wiping chlorine on five representatives non-porous and five porous surfaces to remove Vibrio cholerae. In total, 120 disinfection tests were run in replicate on carriers inoculated with 1.02 × 107-1.73 × 108 V. cholerae CFU/cm2. Surfaces disinfected by spraying 0.2% chlorine had >3 log reduction value (LRV) on 7/10 and 9/10 surfaces at 1 and 10 min, respectively; and 2.0% chlorine on 9/10 and 10/10 surfaces at 1 and 10 min, respectively. Surfaces disinfected by wiping 0.2% chlorine had >3 LRV on 3/10 and 7/10 surfaces at 1 and 10 min, respectively; and 2.0% chlorine on 8/10 surfaces at 1 and 10 min. We found no significant differences between chlorine types (p < 0.05), higher reductions with spraying compared to wiping (p = 0.001), and lower reductions on porous compared to non-porous surfaces (p = 0.006 spraying and p < 0.001 wiping). Our results support using 0.2% chlorine sprayed on all surfaces, or wiped on most non-heavily soiled surfaces, and a 2.0% concentration on contaminated porous surfaces; and emphasize surfaces must be visibly wetted to achieve disinfection.

Household spraying in cholera outbreaks: Insights from three exploratory, mixed-methods field effectiveness evaluations.

Household spraying is a commonly implemented, yet an under-researched, cholera response intervention where a response team sprays surfaces in cholera patients' houses with chlorine. We conducted mixed-methods evaluations of three household spraying programs in the Democratic Republic of Congo and Haiti, including 18 key informant interviews, 14 household surveys and observations, and 418 surface samples collected before spraying, 30 minutes and 24 hours after spraying. The surfaces consistently most contaminated with Vibrio cholerae were food preparation areas, near the patient's bed and the latrine. Effectiveness varied between programs, with statistically significant reductions in V. cholerae concentrations 30 minutes after spraying in two programs. Surface contamination after 24 hours was variable between households and programs. Program challenges included difficulty locating households, transportation and funding limitations, and reaching households quickly after case presentation (disinfection occurred 2-6 days after reported cholera onset). Program advantages included the concurrent deployment of hygiene promotion activities. Further research is indicated on perception, recontamination, cost-effectiveness, viable but nonculturable V. cholerae, and epidemiological coverage. We recommend that, if spraying is implemented, spraying agents should: disinfect surfaces systematically until wet using 0.2/2.0% chlorine solution, including kitchen spaces, patients' beds, and latrines; arrive at households quickly; and, concurrently deploy hygiene promotion activities.

Operational research on rural, community-managed Water Safety Plans: Case study results from implementations in India, DRC, Fiji, and Vanuatu.

Water Safety Plans (WSPs) are internationally recommended risk assessment and management strategies for water delivery. However, documented outcomes and impacts from implementing WSPs are lacking, particularly for community-managed supplies. In this research, previously implemented, community-managed WSPs were evaluated in four countries through a mixed-methods protocol assessing: WSP implementation quality, WSP management via key informant interviews (KII) and focus group discussions (FGD), household characteristics, and collection-point and stored household water quality in WSP and non-WSP communities. Overall, 256 KIIs and FGDs, 816 household surveys, and 1,099 water quality samples were completed. The quality of WSP implementations scored 6-13 out of 18 possible points. KIIs and FGDs found WSP communities had improved capacity to manage water supplies and identify key risks to safe water delivery. Fewer non-WSP community households reported paying for water in DRC and Vanuatu (p < 0.001). WSP community water collection-points had more E. coli contamination than non-WSP community collection-points in DRC (p = 0.009), Fiji (p = 0.020), and Vanuatu (p = 0.004); household results varied, although exploratory analysis revealed that non-WSP communities were imperfectly matched to WSP communities. Overall, we found: 1) incomplete WSP implementations; 2) small improvements in water supply operations; and, 3) no documented microbiological water quality improvements from WSPs. These results highlight that WSPs implemented in rural, community-managed supplies are challenging and question their effectiveness; if implemented additional technical and financial resources are necessary to support community-managed WSPs.

Evaluation of consistent use, barriers to use, and microbiological effectiveness of three prototype household water treatment technologies in Haiti, Kenya, and Nicaragua.

Household water treatment (HWT) can improve drinking water quality and reduce diarrheal disease. New HWT technologies are typically evaluated under ideal conditions; however, health gains depend on consistent, effective household use, which is less often evaluated. We conducted four evaluations of three prototype HWT technologies: two filters and one electrochlorinator. Evaluations consisted of a baseline survey, HWT distribution to households (ranging from 60 to 82), and four visits (ranging from 1 week-14 months after distribution). Each visit included a survey, observation of treated water presence (confirmed use), and microbiological analysis of treated and untreated samples for E. coli. Consistent use was defined as the proportion of total visits with confirmed use. Overall, confirmed use declined 2.54% per month on average, and 2-72% of households demonstrated 100% consistent use. Consistent use was positively associated with baseline HWT knowledge and practice and belief that drinking water was unsafe, and negatively associated with technological problems. Reported barriers to use were behavioral, such as forgetting or when outside the home, and technological failures. Technologies demonstrated 68-96% E. coli reductions, with 18-70% of treated samples having detectable E. coli. Results highlight the importance of household use evaluations within prototype HWT technology design cycles, the need for standard evaluation metrics, and difficulties in achieving both consistent use and microbiological effectiveness with HWT technologies.

Impact of chlorination on silver elution from ceramic water filters.

Applying silver nanoparticles (nAg) or silver nitrate (AgNO3) to ceramic water filters improves microbiological efficacy, reduces biofilm formation, and protects stored water from recontamination. A challenge in ceramic filter production is adding sufficient silver to achieve these goals without exceeding the maximum recommended silver concentration in drinking water. Silver release is affected by silver type, application method, and influent water chemistry. Despite a lack of data, there is an assumption that chlorinated water should not be used as influent water because it may increase silver elution. Thus, the objective of this work was to systematically evaluate the impact of chlorinated water (0-4 mg/L free chlorine residual, FCR) on silver release from ceramic filter disks painted with casein-coated nAg, painted with AgNO3, or containing fired-in nAg over a range of ionic strength (IS = 0-10 mM as NaNO3) in the presence or absence of natural organic matter (NOM). Influent deionized water containing chlorine increased silver release 2-5-fold compared to controls. However, this effect of chlorine was mitigated at higher IS (≥1 mM) or in the presence of NOM (3 mg C/L). For filter disks painted with nAg or AgNO3, silver release increased with increasing IS (with or without chlorine), and effluent concentrations remained above the World Health Organization (WHO) guideline of 0.1 mg/L even after 30 h (80 pore volumes, PVs) of flow with a background solution of 10 mM NaNO3. Silver speciation (nAg vs. Ag+) was monitored in effluent samples from painted or fired-in nAg filter disks. Results indicated that in general, greater than 90% of the eluted silver was due to Ag+ dissolution rather than nAg release. Additionally, a filter disk prepared with fired-in nAg exhibited a lower % released in the nanoparticle form (nAg = 5% of total Ag in effluent) compared to painted on nAg (nAg = 14% of total Ag in effluent). The findings of this study suggest that chlorinated influent water has minimal impact on silver elution from ceramic filters under simulated natural water conditions, and thus, the recommendation to avoid the use of chlorinated water with ceramic filters is not necessary under most conditions.

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.

A Method to Test the Efficacy of Handwashing for the Removal of Emerging Infectious Pathogens.

Handwashing is widely recommended to prevent infectious disease transmission. However, little comparable evidence exists on the efficacy of handwashing methods in general. Additionally, little evidence exists comparing handwashing methods to determine which are most efficacious at removing infectious pathogens. Research is needed to provide evidence for the different approaches to handwashing that may be employed during infectious disease outbreaks. Here, a laboratory method to assess the efficacy of handwashing methods at removing microorganisms from hands and their persistence in rinse water is described. Volunteers' hands are first spiked with the test organism and then washed with each handwashing method of interest. Generally, surrogate microorganisms are used to protect human subjects from disease. The number of organisms remaining on volunteers' hands after washing is tested using a modified "glove juice" method: the hands are placed in gloves with an eluent and are scrubbed to suspend the microorganisms and make them available for analysis by membrane filtration (bacteria) or plaque assay (viruses/bacteriophages). Rinse water produced from the handwashing is directly collected for analysis. Handwashing efficacy is quantified by comparing the log reduction value between samples taken after handwashing to samples with no handwashing. Rinse water persistence is quantified by comparing rinse water samples from various handwashing methods to samples collected after handwashing with just water. While this method is limited by the need to use surrogate organisms to preserve the safety of human volunteers, it captures aspects of handwashing that are difficult to replicate in an in vitro study and fills research gaps on handwashing efficacy and the persistence of infectious organisms in rinse water.

Accuracy, precision, usability, and cost of portable silver test methods for ceramic filter factories.

Locally manufactured ceramic water filters are one effective household drinking water treatment technology. During manufacturing, silver nanoparticles or silver nitrate are applied to prevent microbiological growth within the filter and increase bacterial removal efficacy. Currently, there is no recommendation for manufacturers to test silver concentrations of application solutions or filtered water. We identified six commercially available silver test strips, kits, and meters, and evaluated them by: (1) measuring in quintuplicate six samples from 100 to 1,000 mg/L (application range) and six samples from 0.0 to 1.0 mg/L (effluent range) of silver nanoparticles and silver nitrate to determine accuracy and precision; (2) conducting volunteer testing to assess ease-of-use; and (3) comparing costs. We found no method accurately detected silver nanoparticles, and accuracy ranged from 4 to 91% measurement error for silver nitrate samples. Most methods were precise, but only one method could test both application and effluent concentration ranges of silver nitrate. Volunteers considered test strip methods easiest. The cost for 100 tests ranged from 36 to 1,600 USD. We found no currently available method accurately and precisely measured both silver types at reasonable cost and ease-of-use, thus these methods are not recommended to manufacturers. We recommend development of field-appropriate methods that accurately and precisely measure silver nanoparticle and silver nitrate concentrations.

Evaluating four measures of water quality in clay pots and plastic safe storage containers in Kenya.

Household water treatment with chlorine can improve microbiological quality and reduce diarrhea. Chlorination is typically assessed using free chlorine residual (FCR), with a lower acceptable limit of 0.2 mg/L, however, accurate measurement of FCR is challenging with turbid water. To compare potential measures of adherence to treatment and water quality, we chlorinated recently-collected water in rural Kenyan households and measured total chlorine residual (TCR), FCR, oxidation reduction potential (ORP), and E. coli concentration over 72 h in clay and plastic containers. Results showed that 1) ORP served as a useful proxy for chlorination in plastic containers up to 24 h; 2) most stored water samples disinfected by chlorination remained significantly less contaminated than source water for up to 72 h, even in the absence of FCR; 3) TCR may be a useful proxy indicator of microbiologic water quality because it confirms previous chlorination and is associated with a lower risk of E. coli contamination compared to untreated source water; and 4) chlorination is more effective in plastic than clay containers presumably because of lower chlorine demand in plastic.

Silver Dissolution and Release from Ceramic Water Filters.

Application of silver nanoparticles (nAg) or silver nitrate (AgNO3) has been shown to improve the microbiological efficacy of ceramic water filters used for household water treatment. Silver release, however, can lead to undesirable health effects and reduced filter effectiveness over time. The objectives of this study were to evaluate the contribution of nanoparticle detachment, dissolution, and cation exchange to silver elution, and to estimate silver retention under different influent water chemistries. Dissolved silver (Ag(+)) and nAg release from filter disks painted with 0.03 mg/g casein-coated nAg or AgNO3 were measured as a function of pH (5-9), ionic strength (1-50 mM), and cation species (Na(+), Ca(2+), Mg(2+)). Silver elution was controlled by dissolution as Ag(+) and subsequent cation exchange reactions regardless of the applied silver form. Effluent silver levels fell below the drinking water standard (0.1 mg/L) after flushing with 30-42 pore volumes of pH 7, 10 mM NaNO3 at pH 7. When the influent water was at pH 5, contained divalent cations or 50 mM NaNO3, silver concentrations were 5-10 times above the standard. Our findings support regular filter replacement and indicate that saline, hard, or acidic waters should be avoided to minimize effluent silver concentrations and preserve silver treatment integrity.

Effectiveness of chlorine dispensers in emergencies: case study results from Haiti, Sierra Leone, Democratic Republic of Congo, and Senegal.

Dispensers are a source-based water quality intervention with promising uptake results in development contexts. Dispenser programs include a tank of chlorine with a dosing valve that is installed next to a water source, a local Promoter who conducts community education and refills the Dispenser, and chlorine refills. In collaboration with response organizations, we assessed the effectiveness of Dispensers in four emergency situations. In the three initial and four sustained response phase evaluations, 70 Dispenser sites were visited, 2057 household surveys were conducted, and 1676 water samples were analyzed. Across the evaluations, reported Dispenser use ranged from 9 to 97%, confirmed Dispenser use (as measured by free chlorine residual) ranged from 5 to 87%, and effective use (as measured by improvement in household water quality to meet international standards) ranged from 0 to 81%. More effective Dispenser interventions installed Dispensers at point-sources, maintained a high-quality chlorine solution manufacturing and distribution chain, maintained Dispenser hardware, integrated Dispensers projects within larger water programs, remunerated Promoters, had experienced project staff, worked with local partners to implement the project, conducted ongoing monitoring, and had a project sustainability plan. Our results indicate that Dispensers can be, but are not always, an appropriate strategy to reduce the risk of waterborne diseases in emergencies.

Use of household water treatment and safe storage methods in acute emergency response: case study results from Nepal, Indonesia, Kenya, and Haiti.

Household water treatment (HWTS) methods, such as boiling or chlorination, have long been recommended in emergencies. While there is increasing evidence of HWTS efficacy in the development context, effectiveness in the acute emergency context has not been rigorously assessed. We investigated HWTS effectiveness in response to four acute emergencies by surveying 1521 targeted households and testing stored water for free chlorine residual and fecal indicators. We defined "effective use" as the percentage of the targeted population with contaminated household water who used the HWTS method to improve stored drinking water microbiological quality to internationally accepted levels. Chlorine-based methods were distributed in all four emergencies and filters in one emergency. Effective use ranged widely, from 0-67.5%, with only one pre-existing chlorine program in Haiti and unpromoted boiling use in Indonesia reaching >20%. More successful programs provided an effective HWTS method, with the necessary supplies and training provided, to households with contaminated water who were familiar with the method before the emergency. HWTS can be effective at reducing the risk of unsafe drinking water in the acute emergency context. Additionally, by focusing on whether interventions actually improve drinking water quality in vulnerable households, "effective use" provides an important program evaluation metric.

Final Report of the Independent Panel of Experts on the Cholera Outbreak in Haiti

Afin de déterminer avec certitude la source de l'épidémie, le Secrétaire général des Nations Unies a convoqué le Groupe indépendant d'experts sur ​​l'épidémie de choléra en Haïti en 2010, avec comme mandat d'analyser et chercher à déterminer la source de l'épidémie. Pour cela, ils ont réalisé différents types de recherches : épidémiologique, recherche sur l'eau et l'assainissement, ainsi qu'une analyse moléculaire. Ce document est le rapport écrit demandé par le Secrétaire général. Dans ce document, les méthodes, résultats, conclusions et recommandations de ce travail de recherche sont présentés.

Disinfection by-product formation and mitigation strategies in point-of-use chlorination with sodium dichloroisocyanurate in Tanzania.

Almost a billion persons lack access to improved drinking water, and diarrheal diseases cause an estimated 1.87 million deaths per year. Sodium dichloroisocyanurate (NaDCC) tablets are widely recommended for household water treatment to reduce diarrhea. Because NaDCC is directly added to untreated water sources, concerns have been raised about the potential health impact of disinfection by-products. This study investigated trihalomethane (THM) production in water from six sources used for drinking (0.6-888.5 nephelometric turbidity units) near Arusha, Tanzania. No sample collected at 1, 8, and 24 hours after NaDCC addition exceeded the World Health Organization guideline values for either individual or total THMs. Ceramic filtration, sand filtration, cloth filtration, and settling and decanting were not effective mitigation strategies to reduce THM formation. Chlorine residual and THM formation were not significantly different in NaDCC and sodium hypochlorite treatment. Household chlorination of turbid and non-turbid waters did not create THM concentrations that exceeded health risk guidelines.

Viability of commercially available bleach for water treatment in developing countries.

Treating household water with low-cost, widely available commercial bleach is recommended by some organizations to improve water quality and reduce disease in developing countries. I analyzed the chlorine concentration of 32 bleaches from 12 developing countries; the average error between advertised and measured concentration was 35% (range = -45%-100%; standard deviation = 40%). Because of disparities between advertised and actual concentration, the use of commercial bleach for water treatment in developing countries is not recommended without ongoing quality control testing.