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    Detectable E. coli and chlorine residuals in source and stored drinking water, health-care facility evaluation, Siaya County, Kenya, 2016.

  • 1.

    Cronk R, Bartram J, 2018. Environmental conditions in health care facilities in low- and middle-income countries: coverage and inequalities. Int J Hyg Environ Health 221: 409422.

    • Search Google Scholar
    • Export Citation
  • 2.

    Pittet D, Allegranzi B, Storr J, Bagheri Nejad S, Dziekan G, Leotsakos A, Donaldson L, 2008. Infection control as a major World Health Organization priority for developing countries. J Hosp Infect 68: 285292.

    • Search Google Scholar
    • Export Citation
  • 3.

    Kilmarx PH et al. Centers for Disease Control and Prevention (CDC), 2014. Ebola virus disease in health care workers–Sierra Leone, 2014. MMWR Morb Mortal Wkly Rep 63: 11681171.

    • Search Google Scholar
    • Export Citation
  • 4.

    Grinnell M, Dixon MG, Patton M, Fitter D, Bilivogui P, Johnson C, Dotson E, Diallo B, Rodier G, Raghunathan P, 2015. Ebola virus disease in health care workers–Guinea, 2014. MMWR Morb Mortal Wkly Rep 64: 10831087.

    • Search Google Scholar
    • Export Citation
  • 5.

    UN Sustainable Development Knowledge Platform, 2018. Sustainable Development Goal 6. Available at: https://sustainabledevelopment.un.org/sdg6. Accessed August 21, 2018.

    • Search Google Scholar
    • Export Citation
  • 6.

    World Health Organization, 2017. Guidelines for Drinking Water Quality, Fourth Edition, Incorporating the First Addendum. Available at: https://www.who.int/water_sanitation_health/publications/drinking-water-quality-guidelines-4-including-1st-addendum/en/. Accessed June 25, 2019.

    • Search Google Scholar
    • Export Citation
  • 7.

    Sreenivasan N, Gotestrand SA, Ombeki S, Oluoch G, Fischer TK, Quick R, 2015. Evaluation of the impact of a simple hand-washing and water-treatment intervention in rural health facilities on hygiene knowledge and reported behaviours of health workers and their clients, Nyanza Province, Kenya, 2008. Epidemiol Infect. 143: 873880.

    • Search Google Scholar
    • Export Citation
  • 8.

    Bennett SD, Otieno R, Ayers TL, Odhiambo A, Faith SH, Quick R, 2015. Acceptability and use of portable drinking water and hand washing stations in health care facilities and their impact on patient hygiene practices, western Kenya. PLoS One 10: e0126916.

    • Search Google Scholar
    • Export Citation
  • 9.

    Rajasingham A, Leso M, Ombeki S, Ayers T, Quick R, 2018. Water treatment and handwashing practices in rural Kenyan health care facilities and households six years after the installation of portable water stations and hygiene training. J Water Health 16: 263274.

    • Search Google Scholar
    • Export Citation
  • 10.

    Guo A, Bowling JM, Bartram J, Kayser G, 2017. Water, sanitation, and hygiene in rural health-care facilities: a cross-sectional study in Ethiopia, Kenya, Mozambique, Rwanda, Uganda, and Zambia. Am J Trop Med Hyg 97: 10331042.

    • Search Google Scholar
    • Export Citation
  • 11.

    Puchalski Ritchie LM et al. 2016. Low- and middle-income countries face many common barriers to implementation of maternal health evidence products. J Clin Epidemiol 76: 229237.

    • Search Google Scholar
    • Export Citation
  • 12.

    Murphy JL, Ayers TL, Knee J, Oremo J, Odhiambo A, Faith SH, Nyagol RO, Stauber CE, Lantagne DS, Quick RE, 2016. Evaluating four measures of water quality in clay pots and plastic safe storage containers in Kenya. Water Res 104: 312319.

    • Search Google Scholar
    • Export Citation
  • 13.

    Kotlarz N, Lantagne D, Preston K, Jellison K, 2009. Turbidity and chlorine demand reduction using locally available physical water clarification mechanisms before household chlorination in developing countries. J Water Health 7: 497506.

    • Search Google Scholar
    • Export Citation
  • 14.

    Garrett V, Ogutu P, Mabonga P, Ombeki S, Mwaki A, Aluoch G, Phelan M, Quick RE, 2008. Diarrhoea prevention in a high-risk rural Kenyan population through point-of-use chlorination, safe water storage, sanitation, and rainwater harvesting. Epidemiol Infect 136: 14631471.

    • Search Google Scholar
    • Export Citation
  • 15.

    Wright J, Gundry S, Conroy R, 2004. Household drinking water in developing countries: a systematic review of microbiological contamination between source and point-of-use. Trop Med Int Health 9: 106117.

    • Search Google Scholar
    • Export Citation
  • 16.

    Clasen T, 2015. Household water treatment and safe storage to prevent diarrheal disease in developing countries. Curr Environ Health Rep 2: 6974.

    • Search Google Scholar
    • Export Citation
  • 17.

    World Health Organization, UNICEF. Core Questions and Indicators for Monitoring WASH in Health Care Facilities in the Sustainable Development Goals. Available at: http://www.who.int/water_sanitation_health/publications/core-questions-and-indicators-for-monitoring-wash/en/. Accessed June 25, 2019.

    • Search Google Scholar
    • Export Citation
  • 18.

    Albert J, Luoto J, Levine D, 2010. End-user preferences for and performance of competing POU water treatment technologies among the rural poor of Kenya. Environ Sci Technol 44: 44264432.

    • Search Google Scholar
    • Export Citation
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Evaluation of a Water and Hygiene Project in Health-Care Facilities in Siaya County, Kenya, 2016

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  • 1 Centers for Disease Control and Prevention, Waterborne Diseases Prevention Branch, Atlanta, Georgia;
  • | 2 Safe Water and AIDS Project, Kisumu, Kenya;
  • | 3 Centers for Disease Control and Prevention, Emergency Recovery and Response Branch, Atlanta, Georgia;
  • | 4 Centers for Disease Control and Prevention, Biostatistics and Information Management Office, Atlanta, Georgia

To address water and hygiene infrastructure deficiencies in health-care facilities (HCFs) in Siaya County, Kenya, portable water stations, soap, and water treatment products were provided to 109 HCFs in 2005. In 2011 and again in 2016, we interviewed staff in 26 randomly selected HCFs, observed water sources, water stations, and tested source and stored water for chlorine residual and Escherichia coli. Of 26 HCFs, 22 (85%) had improved water supplies, and 22 (85%) had functioning handwashing and drinking water stations, but < 50% provided soap or water treatment. Thirteen (50%) of 26 source water samples yielded E. coli; 24 (92%) of 26 stored water samples yielded no E. coli, including nine with residual chlorine and nine untreated samples from sources yielding no E. coli. Eleven years after implementation, 85% of HCFs continued to use water stations that protected water from recontamination. Sustainable provision of soap and water treatment products could optimize intervention use.

Many HCFs in developing countries lack access to water, sanitation, and hygiene (WASH) infrastructure.1 These deficiencies place patients at risk of health-care–associated infections (HAIs), which have two to 20 times higher incidence than in developed countries.2 Poor WASH infrastructure also contributes to HAIs in health-care workers, who experienced a 42- to 103-fold greater risk of confirmed Ebola infection during the West African epidemic than the general population.3,4

In recognition of this crisis, in 2014, the WHO and United Nations Children’s Fund (UNICEF) launched a global initiative on WASH in HCFs that aims to achieve universal basic WASH coverage by 2030 as part of Sustainable Development Goal 6 (SDG6).5 Even if this ambitious goal is met, millions of patients will be at risk of HAIs in the intervening years.

To address the problem of inadequate WASH in HCFs, in 2005, CARE Kenya installed handwashing and drinking water stations (locally produced metal stands, buckets with lids and taps, and washbasins), along with “starter supplies” of soap and water treatment products—(P&G Purifier of Water [Procter & Gamble] and WaterGuard sodium hypochlorite solution)—in 109 HCFs in Siaya County, Kenya.

In 2011, the CDC and CARE evaluated the program in a random sample of 30 HCFs. Results suggested that 6 years after implementation, 97% of health facilities still used the water stations. However, only 12% of water samples obtained from drinking water stations had free chlorine residual (FCR), and 60% had soap at handwashing stations.6 In January 2012, P&G provided support to CARE, including a 6-month supply of P&G Purifier of Water, a flocculant and chlorine-based disinfectant (hereafter referred to as sachets), to resume promotion of safe drinking water and hygiene in 73 Siaya County HCFs. In October 2016, CDC conducted a second evaluation in HCFs visited in 2011.

We selected the same sample of 30 HCFs from the 2011 evaluation, excluding two that received full WASH infrastructure during the intervening 6 years, and two HCFs were not visited for logistical reasons.

During surprise visits, enumerators interviewed HCF staff about water sources and use and maintenance of water stations, observed water stations, and tested source and stored water for free and total chlorine using the N, N-diethyl-1,4 phenylenediamine sulfate method (Hach Co., Loveland, CO) and E. coli using Colilert (IDEXX Laboratories Inc., Westbrook, ME). Colilert test results are reported in most probable number (MPN) of coliforms per 100 mL of water; the WHO guideline value is MPN < 1/100 mL. Because of resource limitations, we tested for E. coli in only one randomly selected drinking water station per HCF.

Data were collected on smartphones using Open Data Kit software (opendatakit.org) and managed with SAS 9.4 software (Cary, NC). To assess any change in the select characteristics between baseline and follow-up for HCFs, McNemar’s test for binary variables and the Wilcoxon signed-rank test for continuous variables were used.

The CDC Institutional Review Board liaison determined that this assessment of public health practice was non-research. The Kenyan Ministry of Health approved this evaluation.

Field teams assessed 16 dispensaries and 10 health centers in 2016 (Table 1). Dispensaries had a median of 60 outpatients per day (range: 20–150), three beds (range: 0–20), and 11 staff (range: 5–16). Health centers had a median of 73 patients per day (range: 43–200), 17 staff (range: 8–28), and 11 beds (range: 4–18). Twenty-one (81%) of 26 HCFs had a water source on premises, and 22 (85%) HCFs had improved water sources. Improved water sources are defined by the WHO as household connection, public standpipe, borehole, protected dug well, protected spring, and rainwater collection.

Table 1

Select characteristics of health-care facilities (HCFs) in Siaya County, Kenya, in 2011 and 2016

Dispensaries (n = 16)Health centers (n = 10)Total (n = 26)P-value‖
2011*20162011*20162011*2016
Services, median (range)
 No. of daily patients20 (6–45)60 (20–150)35 (10–60)73 (43–200)25 (6–60)68 (20–200)< 0.001
 No. of beds0 (0–5)3 (0–20)8 (0–16)11 (4–18)0 (0–16)5 (0–20)0.010
 No. of staff2 (0–4)11 (5–16)5 (2–8)17 (8–28)3 (0–8)12 (5–28)< 0.001
Water handling, n (%)
 Improved water source15 (94)8 (50)9 (90)8 (80)24 (92)22 (85)< 0.001
 Water source on premises11 (69)12 (75)8 (80)9 (90)19 (73)21 (81)0.754
 Have ≥ 1 functional† handwashing stations14 (88)13 (81)7 (70)9 (90)21 (81)22 (85)0.739
 Have ≥ 1 functional† handwashing stations with soap8 (50)6 (38)7 (70)5 (50)15 (58)11 (42)0.248
 Have ≥ 1 functional† drinking water stations12 (75)13 (81)9 (90)9 (90)21 (81)22 (85)0.739
 Have ≥ 1 functional† drinking water stations with positive free chlorine residual0 (0)1 (6)3 (30)0 (0)3 (12)1 (4)0.317
 Reports treating water16 (100)15 (94)10 (100)9 (90)26 (100)24 (92)0.500
 Reports using sachets‡14 (88)7 (44)9 (90)3 (30)23 (88)10 (38)< 0.001
 Reports using WaterGuard§14 (88)13 (100)8 (80)9 (100)22 (85)22 (100)0.125

* 2011 data from Rajasingham et al.9

† Water present in container and working tap.

‡ Procter & Gamble™ Purifier of Water.

§ Corresponding data from four HCFs were missing at follow-up.

‖ Wilcoxon signed-rank test for continuous variables or McNemar test for binary variables.

Compared with 2011 (Table 1), in 2016, a slightly higher percentage of HCFs had at least one functioning handwashing station (85% versus 81%) and drinking water station (85% versus 81%), whereas a lower percentage of HCFs had soap at handwashing stations (42% versus 58%); these differences were not statistically significant. In 2016, HCFs had a median of one drinking water and one handwashing station, and a total of 38 drinking water and 41 handwashing stations, compared with 53 drinking water and 41 handwashing stations observed in 2011.6 Of 26 HCF respondents in 2016, 25 (96%) reported that taps on some containers were broken and 16 (62%) said that containers were broken. Sixteen (62%) of 26 respondents said they replaced broken taps and nine (35%) replaced broken containers. Among nine respondents who reported reasons for not replacing broken parts, seven (78%) indicated cost and four (44%) said parts such as taps or sealant were unavailable.

Nearly all HCFs reported treating water in both evaluations (100% in 2011 and 92% in 2016). Between 2011 and 2016, reported use of sachets decreased (88% versus 38%), whereas reported WaterGuard use increased (85% versus 100%).

At least one current staff member from 16 (62%) HCFs received project training in 2012 on chlorination procedure, proper handwashing technique, water station maintenance, and the importance of WASH in HCFs. Respondents from 19 (73%) HCFs reported that staff who had received project training had trained other staff. Water treatment duties were assigned to support staff only (such as cleaners or gardeners) in seven (27%) HCFs and to a combination of support staff, health workers, community health workers, and volunteers in 19 HCFs. No associations were found between type of staff assignment and proper water station management.

Free chlorine residuals > 0.2 mg/L (the minimum recommended by the WHO)6 were detected in stored drinking water samples from two (8%) HCFs and total chlorine residuals > 0.1 mg/L (an indication of past treatment) in samples from nine (35%) HCFs (Table 2). All samples with chorine residuals greater than the minimum guideline value had undetectable E. coli (estimated MPN < 1/100 mL, the WHO guideline value). Of source water samples from 26 HCFs, 13 (50%) had detectable E. coli (MPN > 1/100 mL) (Figure 1). Stored water samples that had been obtained from two (15%) of 13 sources with detectable E. coli also yielded E. coli. Of 11 stored water samples with undetectable E. coli, five (45%) had FCR > 0.2 mg/L. Of six samples with FCR < 0.2 mg/L, three were reported to have been treated with chlorine > 24 hours previously, after which time chlorine residual would have likely dissipated; two other samples were obtained from source water with an estimated E. coli MPN of 1/100 mL. E. coli was not detected in stored water that had been obtained from any of 13 water sources with undetectable E. coli.

Table 2

Characteristics of water use and quality, HCF evaluation, Siaya County, Kenya, 2016

All HCFs (n = 26), n (%)Dispensaries (n = 16), n (%)Health centers (n = 10), n (%)
Water used per day (L)
 10–3010 (42)7 (47)3 (33)
 31–609 (37)7 (47)2 (22)
 > 605 (21)1 (7)4 (44)
Time since last water treatment (days)
 010 (42)8 (53)2 (22)
 17 (29)4 (27)3 (33)
 26 (25)2 (13)4 (44)
 31 (4)1 (7)0 (0)
 Free chlorine residual (> 0.2 mg/L) in stored water2 (8)2 (13)0 (0)
 Total chlorine residual (> 0.1 mg/L) in stored water9 (35)9 (56)0 (0)
E. coli in source water (MPN/100 mL)
 < 113 (50)7 (44)6 (60)
 1–10010 (39)7 (44)3 (30)
 > 1003 (12)2 (13)1 (10)
E. coli detected in stored water (MPN/100 mL)
 < 124 (92)16 (100)8 (80)
 1–1002 (8)0 (0)2 (20)
 > 1000 (0)0 (0)0 (0)
HCFs with E. coli detected in source water but not in stored water10 (38)8 (50)2 (18)

HCFs = health-care facilities; MPN = most probable number.

Figure 1.
Figure 1.

Detectable E. coli and chlorine residuals in source and stored drinking water, health-care facility evaluation, Siaya County, Kenya, 2016.

Citation: The American Journal of Tropical Medicine and Hygiene 101, 3; 10.4269/ajtmh.18-0945

Findings from this evaluation showed that portable handwashing and drinking water stations were still present and in use in most HCFs, 11 years after initial installation. Most HCFs had repaired or replaced broken containers or taps, suggesting that HCF staff valued the water stations and helping explain the longevity of water station use. At least one other evaluation of water station use in Kenya found that some remained in use after ≥ 4 years.7

Of concern, < 50% of HCFs had soap, a vitally important hygiene item, at handwashing stations. We were unable to determine whether this deficiency stemmed from problems with budgets, supply chains, or competing demands of under-resourced HCFs. A similar lack of soap has been found in other HCF assessments.1,710 Weak procurement and management systems are common in resource-poor settings.11

Similarly, treatment of stored water was deficient in both the 2011 and 2016 evaluations, with detectable FCR observed in 12% and 8% of stored water samples, respectively. The low percentages in 2016 likely underestimated actual treatment, based on reported treatment practices and dissipation of free chorine residual over time. Respondents from > 50% of HCFs reported treating their water, and nine (35%) of 26 stored water samples had detectable total chlorine, an indicator of chlorine use that is associated with improved water quality12; none of these nine samples had detectable E. coli. Overall, respondents from 14 (54%) HCFs reported treating water > 1 day before it was tested. Chlorine demand from organic material in water can consume free chlorine in ≤ 24 hours, leaving combined chlorine—a component of total chlorine.13 Surveyors detected FCR in more dispensaries (13%) than health centers (0%). The small HCF sample size precluded statistical exploration of factors associated with detectable FCR, but anecdotal reports suggested that staff at busier HCFs had less time to perform additional duties, such as chlorinating water.

Although source water samples from 13 of 26 HCFs were contaminated with E. coli, stored water samples from 24 (92%) HCFs had no detectable E. coli. All 13 stored water samples from sources with no detectable E. coli remained free of E. coli, suggesting that the water stations provided safe storage, an important consideration in assuring water quality.1416 Of 13 HCFs that had detectable E. coli in their water sources, only two, both of which were untreated, had detectable E. coli in samples obtained from their stored water. Of 11 stored water samples with no detectable E. coli that were obtained from sources with detectable E. coli, eight were reported or confirmed to have been chlorinated and two of the other three uncontaminated samples were obtained from sources with 1/100 mL MPN E. coli. Together, these findings suggest that, with proper handling and maintenance, simple water stations such as the ones used in these HCFs can provide, and maintain, water of reasonable quality.

This evaluation had several important limitations. Because we used a sample of HCFs in one subcounty, findings are not generalizable. The small sample size in this evaluation limited outcome assessments of use and acceptability of water stations and precluded measurement of significance of changes in use of water stations, water treatment, or soap over time. Although reporting bias could have inflated reported use of water stations, observations of water containers, evidence of chlorination, and reported replacement of broken parts suggested that actual use approximated reported use. Finally, because we could only test stored water quality from one container per HCF, we may have overestimated adherence to recommended use of water treatment products.

In summary, more than 40% of HCFs in this program were able to provide a basic level of handwashing services that met the Joint Monitoring Program criterion for SDG6.17 With improved and sustained procurement and placement of soap, percent coverage could increase. Although 81% of HCFs met the SDG6 basic service level for water source (location of improved water supply on HCF premises), half of water sources tested were contaminated with E. coli. To achieve safe water management, which would be considered an advanced service level, reliable treatment at the source or point of use would be required. Effective implementation of water treatment would benefit from a consideration of all locally available treatment options; greater choice has been shown in at least one study to increase the use of water treatment products.18 Maintaining water stations and assuring a steady supply of water treatment commodities would require adequate budgeting and effective management and procurement systems. Engagement with district health offices to strengthen these systems would have the added benefit of optimizing proper operation and maintenance of WASH infrastructure as further improvements are made, and is a necessary precondition for the achievement of SDG6.

Acknowledgments:

We are grateful for the field support received from Job Wasonga of CARE Kenya, and A. M. and Alie Eleveld of the Safe Water and AIDS Project. We appreciate the assistance provided by Kelly Alexander of CARE Headquarters and Allison Tummon of Procter & Gamble (P&G). This evaluation was supported by a grant from the P&G Fund and the U.S. Agency for International Development.

REFERENCES

  • 1.

    Cronk R, Bartram J, 2018. Environmental conditions in health care facilities in low- and middle-income countries: coverage and inequalities. Int J Hyg Environ Health 221: 409422.

    • Search Google Scholar
    • Export Citation
  • 2.

    Pittet D, Allegranzi B, Storr J, Bagheri Nejad S, Dziekan G, Leotsakos A, Donaldson L, 2008. Infection control as a major World Health Organization priority for developing countries. J Hosp Infect 68: 285292.

    • Search Google Scholar
    • Export Citation
  • 3.

    Kilmarx PH et al. Centers for Disease Control and Prevention (CDC), 2014. Ebola virus disease in health care workers–Sierra Leone, 2014. MMWR Morb Mortal Wkly Rep 63: 11681171.

    • Search Google Scholar
    • Export Citation
  • 4.

    Grinnell M, Dixon MG, Patton M, Fitter D, Bilivogui P, Johnson C, Dotson E, Diallo B, Rodier G, Raghunathan P, 2015. Ebola virus disease in health care workers–Guinea, 2014. MMWR Morb Mortal Wkly Rep 64: 10831087.

    • Search Google Scholar
    • Export Citation
  • 5.

    UN Sustainable Development Knowledge Platform, 2018. Sustainable Development Goal 6. Available at: https://sustainabledevelopment.un.org/sdg6. Accessed August 21, 2018.

    • Search Google Scholar
    • Export Citation
  • 6.

    World Health Organization, 2017. Guidelines for Drinking Water Quality, Fourth Edition, Incorporating the First Addendum. Available at: https://www.who.int/water_sanitation_health/publications/drinking-water-quality-guidelines-4-including-1st-addendum/en/. Accessed June 25, 2019.

    • Search Google Scholar
    • Export Citation
  • 7.

    Sreenivasan N, Gotestrand SA, Ombeki S, Oluoch G, Fischer TK, Quick R, 2015. Evaluation of the impact of a simple hand-washing and water-treatment intervention in rural health facilities on hygiene knowledge and reported behaviours of health workers and their clients, Nyanza Province, Kenya, 2008. Epidemiol Infect. 143: 873880.

    • Search Google Scholar
    • Export Citation
  • 8.

    Bennett SD, Otieno R, Ayers TL, Odhiambo A, Faith SH, Quick R, 2015. Acceptability and use of portable drinking water and hand washing stations in health care facilities and their impact on patient hygiene practices, western Kenya. PLoS One 10: e0126916.

    • Search Google Scholar
    • Export Citation
  • 9.

    Rajasingham A, Leso M, Ombeki S, Ayers T, Quick R, 2018. Water treatment and handwashing practices in rural Kenyan health care facilities and households six years after the installation of portable water stations and hygiene training. J Water Health 16: 263274.

    • Search Google Scholar
    • Export Citation
  • 10.

    Guo A, Bowling JM, Bartram J, Kayser G, 2017. Water, sanitation, and hygiene in rural health-care facilities: a cross-sectional study in Ethiopia, Kenya, Mozambique, Rwanda, Uganda, and Zambia. Am J Trop Med Hyg 97: 10331042.

    • Search Google Scholar
    • Export Citation
  • 11.

    Puchalski Ritchie LM et al. 2016. Low- and middle-income countries face many common barriers to implementation of maternal health evidence products. J Clin Epidemiol 76: 229237.

    • Search Google Scholar
    • Export Citation
  • 12.

    Murphy JL, Ayers TL, Knee J, Oremo J, Odhiambo A, Faith SH, Nyagol RO, Stauber CE, Lantagne DS, Quick RE, 2016. Evaluating four measures of water quality in clay pots and plastic safe storage containers in Kenya. Water Res 104: 312319.

    • Search Google Scholar
    • Export Citation
  • 13.

    Kotlarz N, Lantagne D, Preston K, Jellison K, 2009. Turbidity and chlorine demand reduction using locally available physical water clarification mechanisms before household chlorination in developing countries. J Water Health 7: 497506.

    • Search Google Scholar
    • Export Citation
  • 14.

    Garrett V, Ogutu P, Mabonga P, Ombeki S, Mwaki A, Aluoch G, Phelan M, Quick RE, 2008. Diarrhoea prevention in a high-risk rural Kenyan population through point-of-use chlorination, safe water storage, sanitation, and rainwater harvesting. Epidemiol Infect 136: 14631471.

    • Search Google Scholar
    • Export Citation
  • 15.

    Wright J, Gundry S, Conroy R, 2004. Household drinking water in developing countries: a systematic review of microbiological contamination between source and point-of-use. Trop Med Int Health 9: 106117.

    • Search Google Scholar
    • Export Citation
  • 16.

    Clasen T, 2015. Household water treatment and safe storage to prevent diarrheal disease in developing countries. Curr Environ Health Rep 2: 6974.

    • Search Google Scholar
    • Export Citation
  • 17.

    World Health Organization, UNICEF. Core Questions and Indicators for Monitoring WASH in Health Care Facilities in the Sustainable Development Goals. Available at: http://www.who.int/water_sanitation_health/publications/core-questions-and-indicators-for-monitoring-wash/en/. Accessed June 25, 2019.

    • Search Google Scholar
    • Export Citation
  • 18.

    Albert J, Luoto J, Levine D, 2010. End-user preferences for and performance of competing POU water treatment technologies among the rural poor of Kenya. Environ Sci Technol 44: 44264432.

    • Search Google Scholar
    • Export Citation

Author Notes

Address correspondence to William Davis, Centers for Disease Control and Prevention, Waterborne Diseases Prevention Branch, Atlanta, GA. E-mail: lyo0@cdc.gov

Authors’ addresses: William Davis and Robert Quick, Centers for Disease Control and Prevention, Waterborne Diseases Prevention Branch, Atlanta, GA, E-mails: lyo0cdc.gov and rxq1@cdc.gov. Aloyce Odhiambo, Jared Oremo, Ronald Otieno, and Alex Mwaki, Safe Water and AIDS Project, Kisumu, Kenya, E-mails: alloyceodhiambo@swapkenya.org, jared@swapkenya.org, ronotien0@yahoo.com, and alex@swapkenya.org. Anu Rajasingham, Centers for Disease Control and Prevention, Emergency Recovery and Response Branch, Atlanta, GA, E-mail: idb4@cdc.gov. Sunkyung Kim, Centers for Disease Control and Prevention, Biostatistics and Information Management Office, Atlanta, GA, E-mail: wox0@cdc.gov.

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