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

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

Bleach treatment of home drinking water Setting year Diarrhea reduction Montero, Bolivia 1994 44% Nukkus, Uzbekistan 1995 62% Kitwe, Zambia 1998 48% Karachi, Pakistan 2001 72%

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

Piped Drinking Water Karachi, July 2003

Handwashing reduces diarrhea 47% Meta- analysis of handwashing studies (Curtis, V. Lancet Infectious Diseases, 2003; 3:275-281.)

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.

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

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

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

Study Groups Intervention neigborhoods households Flocculent-disinfectant 9 262 Handw ashing w ith soap 9 262 Flocculant-disinfectant + Handw ashing w ith soap 10 266 Bleach 10 265 Control 9 282

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

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

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

Use Instructions

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

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

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

Baseline Household Characteristics Bleach Floc Floc + Soap Control Soap Persons per household 9.4 10.1 9.3 9.2 8.8 Children <5 yrs per house 1.7 1.8 1.8 1.7 1.8 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% 1.1 1.2 1.2 1.2 1.2

Primary Drinking Water Source Bleach (%) Floc (%) Floc + Soap (%) Soap (%) Control (%) Municipal supply in house 30 37 28 28 33 Municipal supply at com mcommunity tap 29 36 38 42 37 Tanker truck 18 12 14 15 12 Water bearer 13 10 10 11 13 Tubewell 10 5 10 11 13

Precipitation in Karachi 2003 Rainfall (mm) 200 180 160 140 120 100 80 60 40 20 0 50 year mean July rainfall Apr May Jun Jul Aug Sep Oct Nov Dec USDA Weekly Weather and Crop Bulletin, 2003

Diarrhea longitudinal prevalence by week and intervention % person days with diarrhea 10 8 6 4 2 0 1 Apr May Jun July Aug Sep Oct Nov Dec 3 5 7 9 11 13 15 17 19 21 23 25 27 29 31 33 35 37 Control

Diarrhea longitudinal prevalence by week and intervention % person days with diarrhea 10 8 6 4 2 0 1 Apr May Jun July Aug Sep Oct Nov Dec 3 5 7 9 11 13 15 17 19 21 23 25 27 29 31 33 35 37 Control Bleach

Diarrhea longitudinal prevalence by treatment group Floc+Soap Soap Floc Bleach Control -55% (-17%, -80%)* -51% -64% (-12%, -76%) (-29%, -90%) -55% (-18%, -80%) 0.00 1.00 2.00 3.00 4.00 5.00 6.00 % person days with diarrhea *95% CI Karachi Floc Health Study, 2003

Diarrhea longitudinal prevalence by age and treatment group % person days with diarrhea 10 5 0 <1 1-2 2-5 5-15 >15 1 2 3 4 5 Control Bleach Floc Soap Soap+Floc Years Karachi Floc Health Study, 2003

Diarrhea longitudinal prevalence by age and treatment group % person days with diarrhea 10 5 0 40% <1 1-2 2-5 5-15 >15 1 2 3 4 5 Control Bleach Floc Soap Soap+Floc Years Karachi Floc Health Study, 2003

Diarrhea longitudinal prevalence by age and treatment group % person days with diarrhea 10 5 0 40% 73% <1 1-2 2-5 5-15 >15 1 2 3 4 5 Control Bleach Floc Soap Soap+Floc Years Karachi Floc Health Study, 2003

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

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

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

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