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A Randomized Controlled Trial to Assess the Impact of Ceramic Water Filters on Prevention of Diarrhea and Cryptosporidiosis in Infants and Young Children—Western Kenya, 2013
Jamae Fontain Morris
Jamae Fontain Morris
Epidemic Intelligence Service, Centers for Disease Control and Prevention, Atlanta, Georgia;
Division of Foodborne, Waterborne and Environmental Diseases, National Center for Emerging and Zoonotic Infectious Diseases, Centers for Disease Control and Prevention, Atlanta, Georgia;
Department of African-American Studies, Georgia State University, Atlanta, Georgia;
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Division of Foodborne, Waterborne and Environmental Diseases, National Center for Emerging and Zoonotic Infectious Diseases, Centers for Disease Control and Prevention, Atlanta, Georgia;
Department of African-American Studies, Georgia State University, Atlanta, Georgia;
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Jennifer Murphy
Jennifer Murphy
Division of Foodborne, Waterborne and Environmental Diseases, National Center for Emerging and Zoonotic Infectious Diseases, Centers for Disease Control and Prevention, Atlanta, Georgia;
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Kirsten Fagerli
Kirsten Fagerli
Division of Foodborne, Waterborne and Environmental Diseases, National Center for Emerging and Zoonotic Infectious Diseases, Centers for Disease Control and Prevention, Atlanta, Georgia;
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Chandra Schneeberger
Chandra Schneeberger
Division of Foodborne, Waterborne and Environmental Diseases, National Center for Emerging and Zoonotic Infectious Diseases, Centers for Disease Control and Prevention, Atlanta, Georgia;
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Peter Jaron
Peter Jaron
Kenya Medical Research Institute, Center for Global Health Research, Kisumu, Kenya;
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Fenny Moke
Fenny Moke
Kenya Medical Research Institute, Center for Global Health Research, Kisumu, Kenya;
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Jane Juma
Jane Juma
Kenya Medical Research Institute, Center for Global Health Research, Kisumu, Kenya;
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John B. Ochieng
John B. Ochieng
Kenya Medical Research Institute, Center for Global Health Research, Kisumu, Kenya;
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Richard Omore
Richard Omore
Kenya Medical Research Institute, Center for Global Health Research, Kisumu, Kenya;
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Dawn Roellig
Dawn Roellig
Division of Foodborne, Waterborne and Environmental Diseases, National Center for Emerging and Zoonotic Infectious Diseases, Centers for Disease Control and Prevention, Atlanta, Georgia;
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Lihua Xiao
Lihua Xiao
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Jeffrey W. Priest
Jeffrey W. Priest
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Jothikumar Narayanan
Jothikumar Narayanan
Division of Foodborne, Waterborne and Environmental Diseases, National Center for Emerging and Zoonotic Infectious Diseases, Centers for Disease Control and Prevention, Atlanta, Georgia;
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Joel M. Montgomery
Joel M. Montgomery
Centers for Disease Control and Prevention, Nairobi, Kenya
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Vince Hill
Vince Hill
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Eric Mintz
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Tracy L. Ayers
Tracy L. Ayers
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Ciara E. O’Reilly
Ciara E. O’Reilly
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Cryptosporidium is a leading cause of diarrhea among Kenyan infants. Ceramic water filters (CWFs) are used for household water treatment. We assessed the impact of CWFs on diarrhea, cryptosporidiosis prevention, and water quality in rural western Kenya. A randomized, controlled intervention trial was conducted in 240 households with infants 4–10 months old. Twenty-six weekly household surveys assessed infant diarrhea and health facility visits. Stool specimens from infants with diarrhea were examined for Cryptosporidium. Source water, filtered water, and filter retentate were tested for Cryptosporidium and/or microbial indicators. To estimate the effect of CWFs on health outcomes, logistic regression models using generalized estimating equations were performed; odds ratios (ORs) and 95% confidence intervals (CIs) are reported. Households reported using surface water (36%), public taps (29%), or rainwater (17%) as their primary drinking water sources, with no differences in treatment groups. Intervention households reported less diarrhea (7.6% versus 8.9%; OR: 0.86 [0.64–1.16]) and significantly fewer health facility visits for diarrhea (1.0% versus 1.9%; OR: 0.50 [0.30–0.83]). In total, 15% of intervention and 12% of control stools yielded Cryptosporidium (P = 0.26). Escherichia coli was detected in 93% of source water samples; 71% of filtered water samples met World Health Organization recommendations of < 1 E. coli/100 mL. Cryptosporidium was not detected in source water and was detected in just 2% of filter rinses following passage of large volumes of source water. Water quality was improved among CWF users; however, the short study duration and small sample size limited our ability to observe reductions in cryptosporidiosis.
Author Notes
Financial support: The study was funded by a grant from the CDC Innovation Fund (iFund), the CDC Waterborne Diseases Prevention Branch program funds, and the U.S. Agency for International Development through an Inter-Agency Agreement with the U.S. Centers for Disease Control and Prevention.
Authors’ addresses: Jamae Fontain Morris, Epidemic Intelligence Service, Office of Workforce and Career Development, Atlanta, GA, Division of Foodborne, Waterborne and Environmental Diseases, National Center for Emerging and Zoonotic Infectious Diseases, Centers for Disease Control and Prevention, Atlanta, GA, and Department of African-American Studies, Georgia State University, Atlanta, GA, E-mail: jmorris60@gsu.edu. Jennifer Murphy, Kirsten Fagerli, Chandra Schneeberger, Dawn Roellig, Lihua Xiao, Jeffrey W. Priest, Jothikumar Narayanan, Vince Hill, Eric Mintz, Tracy L. Ayers, and Ciara E. O’Reilly, Division of Foodborne, Waterborne and Environmental Diseases, National Center for Emerging and Zoonotic Infectious Diseases, Centers for Disease Control and Prevention, Atlanta, GA, E-mails: iod7@cdc.gov, lmj8@cdc.gov, chandra_schneeberger@yahoo.com, iyd4@cdc.gov, lax0@cdc.gov, jip8@cdc.gov, jin2@cdc.gov, veh2@cdc.gov, edm1@cdc.gov, eyk6@cdc.gov, and bwf1@cdc.gov. Peter Jaron, Fenny Moke, Jane Juma, J. Ben Ochieng, and Richard Omore, Kenya Medical Research Institute, Center for Global Health Research, Kisumu, Kenya, E-mails: pjaron@kemricdc.org, fmoke@kemricdc.org, jjuma@kemricdc.org, bochieng@kemricdc.org, and romore@kemricdc.org. Joel M. Montgomery, Division of Global Health Protection, Center for Global Health, Centers for Disease Control and Prevention, Nairobi, Kenya, E-mail: ztq9@cdc.gov.
ProCite
RefWorks
Reference Manager
BibTeX
Zotero
EndNote
-
1.
Boschi-Pinto C, Young M, Black RE, 2010. The Child Health Epidemiology Reference Group reviews of the effectiveness of interventions to reduce maternal, neonatal and child mortality. Int J Epidemiol 39: i3–i6.
-
2.
UNICEF/WHO, 2009. Diarrhea: Why Children Are Still Dying and What Can Be Done. Geneva, Switzerland: WHO/UNICEF.
-
3.
Black RE et al. Child Health Epidemiology Reference Group of WHO and UNICEF, 2010. Global, regional, and national causes of child mortality in 2008: a systematic analysis. Lancet 375: 1969–1987.
-
4.
GBD 2015 Mortality and Causes of Death Collaborators, 2016. Global, regional, and national life expectancy, all-cause mortality, and cause-specific mortality for 249 causes of death, 1980–2015: a systematic analysis for the Global Burden of Disease Study 2015. Lancet 388: 1459–1544.
-
5.
Lui L et al. Child Health Epidemiology Reference Group of WHO and UNICEF, 2012. Global, regional, and national causes of child mortality: an updated systematic analysis for 2010 with time trends since 2000. Lancet 379: 2151–2161.
-
6.
Kotloff KL et al. 2013. Burden and aetiology of diarrhoeal disease in infants and young children in developing countries (the global enteric multicenter study, GEMS): a prospective, case-control study. Lancet 382: 209–222.
-
7.
O’Reilly CE et al. 2012. Risk factors for death among children less than 5 years old hospitalized with diarrhea in rural western Kenya, 2005–2007: a cohort study. PLoS Med 9: e1001256.
-
8.
Lima AA, Guerrant RL, 1992. Persistent diarrhea in children: epidemiology, risk factors, pathophysiology, nutritional impact, and management. Epidemiol Rev 14: 222–242.
-
9.
Bhutta ZA, Nelson EA, Lee WS, Tarr PI, Zablah R, Phua KB, Lindley D, Bass D, Phillips A, 2008. Recent advances and evidence gaps in persistent diarrhea. J Pediatr Gastroenterol Nutr 47: 260–265.
-
10.
Lima AA et al. 2000. Persistent diarrhea signals a critical period of increased diarrhea burdens and nutritional shortfalls: a prospective cohort study among children in northeastern Brazil. J Infect Dis 181: 1643–1651.
-
11.
Niehaus MD, Moore SR, Patrick PD, Derr LL, Lorntz B, Lima AA, Guerrant RL, 2002. Early childhood diarrhea is associated with diminished cognitive function 4 to 7 years later in children in a northeast Brazilian shantytown. Am J Trop Med Hyg 66: 590–593.
-
12.
Cairncross S, Hunt C, Boisson S, Bostoen K, Curtis V, Fung IC, Schmidt WP, 2010. Water, sanitation and hygiene for the prevention of diarrhoea. Int J Epidemiol 39: i193–i205.
-
13.
Dangour AD, Watson L, Cumming O, Boisson S, Che Y, Velleman Y, Cavill S, Allen E, Uauy R, 2013. Interventions to improve water quality and supply, sanitation and hygiene practices, and their effects on the nutritional status of children. Cochrane Database Syst Rev 8: CD009382.
-
14.
American Public Health Association, 2015. Cryptosporidiosis. Heyman D, ed. Control of Communicable Diseases Manual, 20th edition. Washington, DC: American Public Health Association.
-
15.
Schilling KA et al. 2017. Factors associated with the duration of moderate-to-severe diarrhea among children in rural western Kenya enrolled in the global enteric multicenter study, 2008–2012. Am J Trop Med Hyg 97: 248–258.
-
16.
Delahoy MJ et al. 2012. Cryptosporidium infection in children less than five years old with moderate-to-severe diarrhea in rural western Kenya, 2008–2011. Am J Trop Med Hyg 87: 154–155.
-
17.
Shirley DAT, Moonah SN, Kotloff KL, 2012. Burden of disease from cryptosporidiosis. Curr Opin Infect Dis 25: 555–563.
-
18.
Ochoa TJ, Salazar-Lindo E, Cleary TG, 2004. Management of children with infection-associated persistent diarrhea. Semin Pediatr Infect Dis 15: 229–236.
-
19.
World Health Organization, 2009. Risk Assessment of Cryptosporidium in Drinking Water. Geneva, Switzerland: WHO.
-
20.
Carey CM, Lee H, Trevors JT, 2004. Biology, persistence and detection of Cryptosporidium parvum and Cryptosporidium hominis oocyst. Water Res 38: 818–862.
-
21.
Speich B, Croll D, Fürst T, Utzinger J, Keiser J, 2016. Effect of sanitation and water treatment on intestinal protozoa infection: a systematic review and meta-analysis. Lancet Infect Dis 16: 87–99.
-
22.
Bielefeldt AR, Kowalski K, Schilling C, Schreier S, Kohler A, Summers RS, 2010. Removal of virus to protozoan sized particles in point-of-use ceramic water filters. Water Res 44: 1482–1488.
-
23.
Sobsey MD, Stauber CE, Casanova LM, Brown JM, Elliott MA, 2008. Point-of-use household drinking water filtration: a practical, effective solution for providing sustained access to safe drinking water in the developing world. Environ Sci Technol 42: 4261–4267.
-
24.
Brown J, Sobsey MD, Loomis D, 2008. Local drinking water filters reduce diarrheal disease in Cambodia: a randomized, controlled trial of the ceramic water purifier. Am J Trop Med Hyg 79: 394–400.
-
25.
Lantagne DS, 2001. Investigation of the Potters for Peace Colloidal Silver Impregnated Ceramic Filter Report 1: Intrinsic Effectiveness. Allston, MA: Alethia Environmental.
-
26.
Abebe LS, Su Y, Guerrant RL, Swami NS, Smith JA, 2015. Point-of-use removal of Cryptosporidium parvum from water: independent effects of disinfection by silver nanoparticles and silver ions and by physical filtration in ceramic porous media. Environ Sci Technol 49: 12958–12967.
-
27.
Oyanedel-Craver VA, Smith JA, 2008. Sustainable colloidal-silver-impregnated ceramic filter for point-of-use water treatment. Environ Sci Technol 42: 927–933.
-
28.
Brown J, Chai R, Wang A, Sobsey MD, 2012. Microbiological effectiveness of mineral pot filters in Cambodia. Environ Sci Technol 46: 12055–12061.
-
29.
Mittelman AM, Lantagne DS, Rayner J, Pennell KD, 2015. Silver dissolution and release from ceramic water filters. Environ Sci Technol 49: 8515–8522.
-
30.
Lemons A, Branz A, Kimirei M, Hawkins T, Lantagne D, 2016. Assessment of the quality, effectiveness, and acceptability of ceramic water filters in Tanzania. J Water Sanit Hyg Dev 6: 195–204.
-
31.
Rayner J, Skinner B, Lantagne D, 2013. Current practices in manufacturing locally-made ceramic pot filters for water treatment in developing countries. J Water Sanit Hyg Dev 3: 252–261.
-
32.
Adazu K et al. 2005. Health and demographic surveillance in rural western Kenya: a platform for evaluating interventions to reduce morbidity and mortality from infectious diseases. Am J Trop Med Hyg 73: 1151–1158.
-
33.
Hawley WA et al. 2003. Implications of the western Kenya permethrin-treated bed net study for policy, program implementation, and future research. Am J Trop Med Hyg 68: 168–173.
-
34.
Lindblade KA et al. 2004. Sustainability of reductions in malaria transmission and infant mortality in western Kenya with use of insecticide-treated bednets: 4 to 6 years of follow-up. JAMA 291: 2571–2580.
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