Combined Handwashing and Drinking Water Treatment for Diarrhea Prevention, a Randomized Control Trial. Steve Luby, Centers for Disease Control

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1 Combined Handwashing and Drinking Water Treatment for Diarrhea Prevention, a Randomized Control Trial Steve Luby, Centers for Disease Control

2 Bleach treatment of home drinking water Setting year Diarrhea reduction Montero, Bolivia % Nukkus, Uzbekistan % Kitwe, Zambia % Karachi, Pakistan %

3 Flocculant-Disinfectant (PūR ) Developed by Procter & Gamble Combines Precipitation Coagulation Flocculation Disinfection

4 Piped Drinking Water Karachi, July 2003

5 Piped Drinking Water Karachi, July 2003

6 Handwashing reduces diarrhea 47% Meta- analysis of handwashing studies (Curtis, V. Lancet Infectious Diseases, 2003; 3: )

7 Study Objectives Evaluate the effectiveness of flocculantdisinfectant in reducing diarrhea Measure the marginal health benefit in reducing diarrhea by adding handwashing with soap to improved drinking water.

8 Karachi Squatter Settlements Sewage contaminated drinking water 10,900 colony forming units of fecal coliforms per 100 ml Feces contaminated environment

9 Disease Setting 10% of children die before their 5 th birthday 40% from diarrhea 40% of children are malnourished

10 Cluster randomized study Study area divided into 47 neighborhoods Randomly assigned to Bleach Flocculant-disinfectant Soap Flocculant-disinfectant + Soap Control

11 Study Groups Intervention neigborhoods households Flocculent-disinfectant Handw ashing w ith soap Flocculant-disinfectant + Handw ashing w ith soap Bleach Control 9 282

12 Community based behavior change HOPE Local nongovernment organization Provide community based health care and development

13 Bleach Group Provided Local vessel Dilute bleach weekly Instructions: Add one bottle of dilute bleach per vessel Wait 30 minutes Drink only bleach treated water

14 Flocculent-disinfectant Group Provided bucket spoon cloths local vessel flocculent-disinfectant weekly

15 Use Instructions

16 Handwashing Promotion Households visits, at least weekly Discussions in households native language Pictures used to promote discussions about handwashing Questions answered Diarrhea data collected Soap re-supplied

17 Soap group instructions Wash hands thoroughly lathering with soap After Defecation Cleaning an infant Before Preparing food Eating Feeding an infant

18 Primary Outcome Diarrhea : 3 or more loose stools in a 24 hour period Longitudinal prevalence of diarrhea: Number of days with diarrhea Number of days of observation

19 Baseline Household Characteristics Bleach Floc Floc + Soap Control Soap Persons per household Children <5 yrs per house Maternal literacy 35% 30% 30% 32% 37% Income < $60 per month 51% 51% 56% 51% 56% Handwash station with soap observed Bar soaps bought last 2 weeks 24% 23% 21% 22% 24%

20 Primary Drinking Water Source Bleach (%) Floc (%) Floc + Soap (%) Soap (%) Control (%) Municipal supply in house Municipal supply at com mcommunity tap Tanker truck Water bearer Tubewell

21 Precipitation in Karachi 2003 Rainfall (mm) year mean July rainfall Apr May Jun Jul Aug Sep Oct Nov Dec USDA Weekly Weather and Crop Bulletin, 2003

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23 Diarrhea longitudinal prevalence by week and intervention % person days with diarrhea Apr May Jun July Aug Sep Oct Nov Dec Control

24 Diarrhea longitudinal prevalence by week and intervention % person days with diarrhea Apr May Jun July Aug Sep Oct Nov Dec Control Bleach

25 Diarrhea longitudinal prevalence by week and intervention % person days with diarrhea Apr May Jun July Aug Sep Oct Nov Dec Control Bleach Floc

26 Diarrhea longitudinal prevalence by week and intervention % person days with diarrhea Apr May Jun July Aug Sep Oct Nov Dec Control Bleach Floc Soap

27 Diarrhea longitudinal prevalence by week and intervention % person days with diarrhea Apr May Jun July Aug Sep Oct Nov Dec Control Bleach Floc Soap Soap+Floc

28 Diarrhea longitudinal prevalence by treatment group Floc+Soap Soap Floc Bleach Control -55% (-17%, -80%)* -51% -64% (-12%, -76%) (-29%, -90%) -55% (-18%, -80%) % person days with diarrhea *95% CI Karachi Floc Health Study, 2003

29 Diarrhea longitudinal prevalence by treatment group Floc+Soap Soap Floc Bleach Control -55% (-17%, -80%)* -51% -64% (-12%, -76%) (-29%, -90%) -55% (-18%, -80%) % person days with diarrhea *95% CI Karachi Floc Health Study, 2003

30 Diarrhea longitudinal prevalence by age and treatment group % person days with diarrhea < > Control Bleach Floc Soap Soap+Floc Years Karachi Floc Health Study, 2003

31 Diarrhea longitudinal prevalence by age and treatment group % person days with diarrhea % < > Control Bleach Floc Soap Soap+Floc Years Karachi Floc Health Study, 2003

32 Diarrhea longitudinal prevalence by age and treatment group % person days with diarrhea % 73% < > Control Bleach Floc Soap Soap+Floc Years Karachi Floc Health Study, 2003

33 Conclusions Flocculant-disinfectant water treatment markedly reduced diarrhea in this vulnerable population Handwashing with soap markedly reduced diarrhea in this vulnerable population Adding handwashing with soap to improved drinking water, did not further reduce diarrhea No single intervention was significantly more effective in reducing diarrhea than any other

34 Limitations Courtesy bias possible Interventions were not blinded Diarrhea was based on self report People use products differently when they are not in a study It is possible that with less regular use of water treatment and handwashing there could be an additive benefit

35 Next Steps Work to bring effective interventions to scale PuR is being sold in Pakistan Follow sales for sustainability Assess health impact among users Evaluate combined interventions in other settings

36 Acknowledgements Health Oriented Preventive Education Dr. Mubina Agboatwalla Faisal Sawari Aga Khan University Arshad Altaf Procter & Gamble Bruce Keswick Ward Billhimer Centers for Disease Control & Prevention Steve Luby, R Mike Hoekstra, John Painter