Efficiency of a multi-barrier household system for surface water treatment combining a household slow sand filter to a Mesita Azul® ultraviolet disinfection device.

Low-cost household technologies for water treatment are crucial to improving drinking water quality and preventing health, social and economic impacts, mostly in middle- and low-income regions. This work assessed the removal efficiency of physical-chemical and bacteriological parameters from river water by a multi-barrier household water treatment system for 113 consecutive days. This system combines a pre-treatment step through a non-woven synthetic blanket, filtration by an intermittent household slow sand filter (HSSF) and a Mesita Azul® ultraviolet disinfection device. In general, the water quality was improved by the evaluated system. Turbidity was removed by an average of 73% (ranging from 33 to 94%), total coliforms (TC) of 3.88 log10 (ranging from 2.22 to 5.16 log10) and E. coli of 2.49 log10 (ranging from 1.81 to 3.30 log10). Filtration improvement was mostly correlated to HSSF biofilm development and influent water quality. Characterisation of HSSF schmutzdecke demonstrated a predominance of organic content, and a higher presence of carbohydrates than proteins on the sand and the blanket. Ultraviolet disinfection with Mesita Azul® inactivated most of the remaining bacteria after filtration and no regrowth was observed after 15 days of disinfection. In conclusion, the multi-barrier household water treatment system was efficient in treating river water, reducing risks of microbial contamination to achieve safe drinking water.

UVC inactivation of MS2-phage in drinking water - Modelling and field testing.

UVC disinfection has been recognised by the WHO as an effective disinfection treatment to provide decentralized potable water. Under real conditions there are still unknowns that limit this application including the influence of suspended solids and natural organic matter. This work aims to investigate the influence of two key parameters, suspended solids and natural organic matter, on the efficiency of UVC disinfection of surface water to achieve the drinking water quality requirements established by the WHO for point of use (POU) technologies. Kaolinite (turbidity agent) and humic acids (HA, model of organic matter) were used in a factorial design of experiments (Turbidity from 0 to 5 NTU, and HA from 0 to 3.5 mg/L) to investigate their effect on UVC inactivation of MS2 phage in surface water. A collimated beam (12 W) and a commercial UVC disinfection flow system (16 W) designed to provide drinking water at households were used. The UVC flow system both in the laboratory and in the field was able to achieve the reduction requirements established by WHO (LRV >3.5 for all tested conditions), confirming the good performance of the studied UVC disinfection system. The results found in the lab were used to establish a numerical model that predicts the disinfection rate constant as a function of water turbidity and transmittance at 254 nm (confidence level>95%). The model permitted to elucidate the critical effect of low concentrations of HA in reducing the inactivation rate by 40% for 3.5 mg/L-HA compared with 0, the non-significant detrimental effect of turbidity lower than 5 NTU, and the lack of synergistic effects between both parameters at these levels. The UVC flow system was also tested in the field, in Tzabalho, Chiapas (Mexico), and Antioquia (Colombia), with spiked MS2 into natural surface water. This investigation opens a potential application to monitor the performance of UVC systems with surface water by monitoring transmittance at 254 nm as a tool to control UVC domestic systems to deliver safe drinking water in a household without the need of expensive and laborious biological monitoring tools.

Measuring User Compliance and Cost Effectiveness of Safe Drinking Water Programs: A Cluster-Randomized Study of Household Ultraviolet Disinfection in Rural Mexico.

Low adoption and compliance levels for household water treatment and safe storage (HWTS) technologies have made it challenging for these systems to achieve measurable health benefits in the developing world. User compliance remains an inconsistently defined and poorly understood feature of HWTS programs. In this article, we develop a comprehensive approach to understanding HWTS compliance. First, our Safe Drinking Water Compliance Framework disaggregates and measures the components of compliance from initial adoption of the HWTS to exclusive consumption of treated water. We apply this framework to an ultraviolet (UV)-based safe water system in a cluster-randomized controlled trial in rural Mexico. Second, we evaluate a no-frills (or "Basic") variant of the program as well as an improved (or "Enhanced") variant, to test if subtle changes in the user interface of HWTS programs could improve compliance. Finally, we perform a full-cost analysis of both variants to assess their cost effectiveness (CE) in achieving compliance. We define "compliance" strictly as the habit of consuming safe water. We find that compliance was significantly higher in the groups where the UV program variants were rolled out than in the control groups. The Enhanced variant performed better immediately postintervention than the Basic, but compliance (and thus CE) degraded with time such that no effective difference remained between the two versions of the program.

Field efficacy evaluation and post-treatment contamination risk assessment of an ultraviolet disinfection and safe storage system.

Inconsistent use of household water treatment and safe storage (HWTS) systems reduces their potential health benefits. Ultraviolet (UV) disinfection is more convenient than some existing HWTS systems, but it does not provide post-treatment residual disinfectant, which could leave drinking water vulnerable to recontamination. In this paper, using as-treated analyses, we report on the field efficacy of a UV disinfection system at improving household drinking water quality in rural Mexico. We further assess the risk of post-treatment contamination from the UV system, and develop a process-based model to better understand household risk factors for recontamination. This study was part of a larger cluster-randomized stepped wedge trial, and the results complement previously published population-level results of the intervention on diarrheal prevalence and water quality. Based on the presence of Escherichia coli (proportion of households with ≥ 1 E. coli/100 mL), we estimated a risk difference of -28.0% (95% confidence interval (CI): -33.9%, -22.1%) when comparing intervention to control households; -38.6% (CI: -48.9%, -28.2%) when comparing post- and pre-intervention results; and -37.1% (CI: -45.2%, -28.9%) when comparing UV disinfected water to alternatives within the household. We found substantial increases in post-treatment E. coli contamination when comparing samples from the UV system effluent (5.0%) to samples taken from the storage container (21.1%) and drinking glasses (26.0%). We found that improved household infrastructure, additional extractions from the storage container, additional time from when the storage container was filled, and increased experience of the UV system operator were associated with reductions in post-treatment contamination. Our results suggest that the UV system is efficacious at improving household water quality when used as intended. Promoting safe storage habits is essential for an effective UV system dissemination. The drinking glass appears to represent a small but significant source of recontamination that is likely to impact all HWTS systems.

Estimation of treatment efficacy with complier average causal effects (CACE) in a randomized stepped wedge trial.

Complier average causal effects (CACE) estimate the impact of an intervention among treatment compliers in randomized trials. Methods used to estimate CACE have been outlined for parallel-arm trials (e.g., using an instrumental variables (IV) estimator) but not for other randomized study designs. Here, we propose a method for estimating CACE in randomized stepped wedge trials, where experimental units cross over from control conditions to intervention conditions in a randomized sequence. We illustrate the approach with a cluster-randomized drinking water trial conducted in rural Mexico from 2009 to 2011. Additionally, we evaluated the plausibility of assumptions required to estimate CACE using the IV approach, which are testable in stepped wedge trials but not in parallel-arm trials. We observed small increases in the magnitude of CACE risk differences compared with intention-to-treat estimates for drinking water contamination (risk difference (RD) = -22% (95% confidence interval (CI): -33, -11) vs. RD = -19% (95% CI: -26, -12)) and diarrhea (RD = -0.8% (95% CI: -2.1, 0.4) vs. RD = -0.1% (95% CI: -1.1, 0.9)). Assumptions required for IV analysis were probably violated. Stepped wedge trials allow investigators to estimate CACE with an approach that avoids the stronger assumptions required for CACE estimation in parallel-arm trials. Inclusion of CACE estimates in stepped wedge trials with imperfect compliance could enhance reporting and interpretation of the results of such trials.

A stepped wedge, cluster-randomized trial of a household UV-disinfection and safe storage drinking water intervention in rural Baja California Sur, Mexico.

In collaboration with a local non-profit organization, this study evaluated the expansion of a program that promoted and installed Mesita Azul, an ultraviolet-disinfection system designed to treat household drinking water in rural Mexico. We conducted a 15-month, cluster-randomized stepped wedge trial by randomizing the order in which 24 communities (444 households) received the intervention. We measured primary outcomes (water contamination and diarrhea) during seven household visits. The intervention increased the percentage of households with access to treated and safely stored drinking water (23-62%), and reduced the percentage of households with Escherichia coli contaminated drinking water (risk difference (RD): -19% [95% CI: -27%, -14%]). No significant reduction in diarrhea was observed (RD: -0.1% [95% CI: -1.1%, 0.9%]). We conclude that household water quality improvements measured in this study justify future promotion of the Mesita Azul, and that future studies to measure its health impact would be valuable if conducted in populations with higher diarrhea prevalence.

Assessment of a low-cost, point-of-use, ultraviolet water disinfection technology.

We describe a point-of-use (POU) ultraviolet (UV) disinfection technology, the UV Tube, which can be made with locally available resources around the world for under $50 US. Laboratory and field studies were conducted to characterize the UV Tube's performance when treating a flowrate of 5 L/min. Based on biological assays with MS2 coliphage, the UV Tube delivered an average fluence of 900+/-80 J/m(2) (95% CI) in water with an absorption coefficient of 0.01 cm(-1). The residence time distribution in the UV Tube was characterized as plug flow with dispersion (Peclet Number = 19.7) and a mean hydraulic residence time of 36 s. Undesirable compounds were leached or produced from UV Tubes constructed with unlined ABS, PVC, or a galvanized steel liner. Lining the PVC pipe with stainless steel, however, prevented production of regulated halogenated organics. A small field study in two rural communities in Baja California Sur demonstrated that the UV Tube reduced E. coli concentrations to less than 1/100 ml in 65 out of 70 samples. Based on these results, we conclude that the UV Tube is a promising technology for treating household drinking water at the point of use.