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Meta-Analysis
. 2015 Oct 20;2015(10):CD004794.
doi: 10.1002/14651858.CD004794.pub3.

Interventions to improve water quality for preventing diarrhoea

Thomas F Clasen  1 , Kelly T Alexander, David Sinclair, Sophie Boisson, Rachel Peletz, Howard H Chang, Fiona Majorin, Sandy Cairncross
Affiliations
Meta-Analysis

Interventions to improve water quality for preventing diarrhoea

Thomas F Clasen et al. Cochrane Database Syst Rev. .

Abstract

Background: Diarrhoea is a major cause of death and disease, especially among young children in low-income countries. In these settings, many infectious agents associated with diarrhoea are spread through water contaminated with faeces.In remote and low-income settings, source-based water quality improvement includes providing protected groundwater (springs, wells, and bore holes), or harvested rainwater as an alternative to surface sources (rivers and lakes). Point-of-use water quality improvement interventions include boiling, chlorination, flocculation, filtration, or solar disinfection, mainly conducted at home.

Objectives: To assess the effectiveness of interventions to improve water quality for preventing diarrhoea.

Search methods: We searched the Cochrane Infectious Diseases Group Specialized Register (11 November 2014), CENTRAL (the Cochrane Library, 7 November 2014), MEDLINE (1966 to 10 November 2014), EMBASE (1974 to 10 November 2014), and LILACS (1982 to 7 November 2014). We also handsearched relevant conference proceedings, contacted researchers and organizations working in the field, and checked references from identified studies through 11 November 2014.

Selection criteria: Randomized controlled trials (RCTs), quasi-RCTs, and controlled before-and-after studies (CBA) comparing interventions aimed at improving the microbiological quality of drinking water with no intervention in children and adults.

Data collection and analysis: Two review authors independently assessed trial quality and extracted data. We used meta-analyses to estimate pooled measures of effect, where appropriate, and investigated potential sources of heterogeneity using subgroup analyses. We assessed the quality of evidence using the GRADE approach.

Main results: Forty-five cluster-RCTs, two quasi-RCTs, and eight CBA studies, including over 84,000 participants, met the inclusion criteria. Most included studies were conducted in low- or middle-income countries (LMICs) (50 studies) with unimproved water sources (30 studies) and unimproved or unclear sanitation (34 studies). The primary outcome in most studies was self-reported diarrhoea, which is at high risk of bias due to the lack of blinding in over 80% of the included studies. Source-based water quality improvementsThere is currently insufficient evidence to know if source-based improvements such as protected wells, communal tap stands, or chlorination/filtration of community sources consistently reduce diarrhoea (one cluster-RCT, five CBA studies, very low quality evidence). We found no studies evaluating reliable piped-in water supplies delivered to households. Point-of-use water quality interventionsOn average, distributing water disinfection products for use at the household level may reduce diarrhoea by around one quarter (Home chlorination products: RR 0.77, 95% CI 0.65 to 0.91; 14 trials, 30,746 participants, low quality evidence; flocculation and disinfection sachets: RR 0.69, 95% CI 0.58 to 0.82, four trials, 11,788 participants, moderate quality evidence). However, there was substantial heterogeneity in the size of the effect estimates between individual studies.Point-of-use filtration systems probably reduce diarrhoea by around a half (RR 0.48, 95% CI 0.38 to 0.59, 18 trials, 15,582 participants, moderate quality evidence). Important reductions in diarrhoea episodes were shown with ceramic filters, biosand systems and LifeStraw® filters; (Ceramic: RR 0.39, 95% CI 0.28 to 0.53; eight trials, 5763 participants, moderate quality evidence; Biosand: RR 0.47, 95% CI 0.39 to 0.57; four trials, 5504 participants, moderate quality evidence; LifeStraw®: RR 0.69, 95% CI 0.51 to 0.93; three trials, 3259 participants, low quality evidence). Plumbed in filters have only been evaluated in high-income settings (RR 0.81, 95% CI 0.71 to 0.94, three trials, 1056 participants, fixed effects model).In low-income settings, solar water disinfection (SODIS) by distribution of plastic bottles with instructions to leave filled bottles in direct sunlight for at least six hours before drinking probably reduces diarrhoea by around a third (RR 0.62, 95% CI 0.42 to 0.94; four trials, 3460 participants, moderate quality evidence).In subgroup analyses, larger effects were seen in trials with higher adherence, and trials that provided a safe storage container. In most cases, the reduction in diarrhoea shown in the studies was evident in settings with improved and unimproved water sources and sanitation.

Authors' conclusions: Interventions that address the microbial contamination of water at the point-of-use may be important interim measures to improve drinking water quality until homes can be reached with safe, reliable, piped-in water connections. The average estimates of effect for each individual point-of-use intervention generally show important effects. Comparisons between these estimates do not provide evidence of superiority of one intervention over another, as such comparisons are confounded by the study setting, design, and population.Further studies assessing the effects of household connections and chlorination at the point of delivery will help improve our knowledge base. As evidence suggests effectiveness improves with adherence, studies assessing programmatic approaches to optimising coverage and long-term utilization of these interventions among vulnerable populations could also help strategies to improve health outcomes.

PubMed Disclaimer

Conflict of interest statement

TC, KA, SB, and SC have provided research or consulting services for Unilever, Ltd., Medentech, Ltd., DelAgua Health and Science, Ltd., and Vestergaard‐Frandsen SA who manufacture or sell household‐based water treatment devices.

Figures

1
1
Study flow diagram.
2
2
Risk of bias graph: summary of authors' judgements about each 'Risk of bias' item presented as percentages across all included studies.
3
3
Forest plot of comparison: 2 Source: water supply improvement versus control, outcome: 2.1 Diarrhoea: CBA studies subgrouped by age.
4
4
Forest plot of comparison: 3 POU: water chlorination versus control, outcome: 3.3 Diarrhoea: cluster‐RCTs; subgrouped by adherence.
5
5
Funnel plot of comparison: 3 POU: water chlorination versus control, outcome: 3.1 Diarrhoea: subgrouped by study design.
6
6
Forest plot of comparison: 4 POU: filtration versus control, outcome: 4.2 Diarrhoea: cluster‐RCTs: subgrouped by type of filtration.
1.1
1.1. Analysis
Comparison 1 Water quality intervention versus control, Outcome 1 Diarrhoea: all ages.
1.2
1.2. Analysis
Comparison 1 Water quality intervention versus control, Outcome 2 Diarrhoea: children < 5 years.
2.1
2.1. Analysis
Comparison 2 Source: water supply improvement versus control, Outcome 1 Diarrhoea: CBA studies subgrouped by age.
2.2
2.2. Analysis
Comparison 2 Source: water supply improvement versus control, Outcome 2 Diarrhoea: CBA studies subgrouped by age.
3.1
3.1. Analysis
Comparison 3 POU: water chlorination versus control, Outcome 1 Diarrhoea: subgrouped by study design.
3.2
3.2. Analysis
Comparison 3 POU: water chlorination versus control, Outcome 2 Diarrhoea: cluster‐RCTs: subgrouped by age.
3.3
3.3. Analysis
Comparison 3 POU: water chlorination versus control, Outcome 3 Diarrhoea: cluster‐RCTs; subgrouped by adherence.
3.4
3.4. Analysis
Comparison 3 POU: water chlorination versus control, Outcome 4 Diarrhoea: cluster‐RCTs by risk of bias by blinding of participants.
3.5
3.5. Analysis
Comparison 3 POU: water chlorination versus control, Outcome 5 Diarrhoea: cluster‐RCTs; subgrouped by additional water storage intervention.
3.6
3.6. Analysis
Comparison 3 POU: water chlorination versus control, Outcome 6 Diarrhoea: cluster‐RCTs: subgrouped by sufficiency of water quantity.
3.7
3.7. Analysis
Comparison 3 POU: water chlorination versus control, Outcome 7 Diarrhoea: cluster‐RCTs: subgrouped by water source.
3.8
3.8. Analysis
Comparison 3 POU: water chlorination versus control, Outcome 8 Diarrhoea: cluster‐RCTs: subgrouped by sanitation level.
3.9
3.9. Analysis
Comparison 3 POU: water chlorination versus control, Outcome 9 Diarrhoea: cluster‐RCTs; subgrouped by length of follow‐up.
4.1
4.1. Analysis
Comparison 4 POU: flocculation and disinfection versus control, Outcome 1 Diarrhoea: cluster‐RCTs.
4.2
4.2. Analysis
Comparison 4 POU: flocculation and disinfection versus control, Outcome 2 Diarrhoea: cluster‐RCTs: subgrouped by age; excluding Doocy 2006 LBR.
4.3
4.3. Analysis
Comparison 4 POU: flocculation and disinfection versus control, Outcome 3 Diarrhoea: cluster‐RCTs: subgrouped by adherence.
4.4
4.4. Analysis
Comparison 4 POU: flocculation and disinfection versus control, Outcome 4 Diarrhoea: cluster‐RCTs: subgrouped by additional storage container.
4.5
4.5. Analysis
Comparison 4 POU: flocculation and disinfection versus control, Outcome 5 Diarrhoea: cluster‐RCTs: subgrouped by sufficiency of water quantity.
4.6
4.6. Analysis
Comparison 4 POU: flocculation and disinfection versus control, Outcome 6 Diarrhoea: cluster‐RCTs: subgrouped by water source.
4.7
4.7. Analysis
Comparison 4 POU: flocculation and disinfection versus control, Outcome 7 Diarrhoea: cluster‐RCTs: subgrouped by sanitation level.
4.8
4.8. Analysis
Comparison 4 POU: flocculation and disinfection versus control, Outcome 8 Diarrhoea: cluster‐RCTs: subgrouped by length of follow‐up.
5.1
5.1. Analysis
Comparison 5 POU: filtration versus control, Outcome 1 Diarrhoea: cluster‐RCTs: subgrouped by age.
5.2
5.2. Analysis
Comparison 5 POU: filtration versus control, Outcome 2 Diarrhoea: cluster‐RCTs: subgrouped by type of filtration.
5.3
5.3. Analysis
Comparison 5 POU: filtration versus control, Outcome 3 Diarrhoea: cluster‐RCTs: subgrouped by blinding of participants.
5.4
5.4. Analysis
Comparison 5 POU: filtration versus control, Outcome 4 Diarrhoea: ceramic filter studies subgrouped by water source.
5.5
5.5. Analysis
Comparison 5 POU: filtration versus control, Outcome 5 Diarrhoea: ceramic filter studies subgrouped by sanitation level.
5.6
5.6. Analysis
Comparison 5 POU: filtration versus control, Outcome 6 Diarrhoea: sand filter studies: subgrouped by water source.
5.7
5.7. Analysis
Comparison 5 POU: filtration versus control, Outcome 7 Diarrhoea: sand filter studies: subgrouped by sanitation level.
5.8
5.8. Analysis
Comparison 5 POU: filtration versus control, Outcome 8 Diarrhoea: cluster‐RCTs: subgrouped by adherence.
5.9
5.9. Analysis
Comparison 5 POU: filtration versus control, Outcome 9 Diarrhoea: cluster‐RCTs: subgrouped by additional water storage intervention.
5.10
5.10. Analysis
Comparison 5 POU: filtration versus control, Outcome 10 Diarrhoea: cluster‐RCTs; subgrouped by length of follow‐up.
6.1
6.1. Analysis
Comparison 6 POU: solar disinfection versus control, Outcome 1 Diarrhoea: subgrouped by study design.
6.2
6.2. Analysis
Comparison 6 POU: solar disinfection versus control, Outcome 2 Diarrhoea: cluster‐RCTs; subgrouped by age.
6.3
6.3. Analysis
Comparison 6 POU: solar disinfection versus control, Outcome 3 Diarrhoea: cluster‐RCTs; subgrouped by adherence.
6.4
6.4. Analysis
Comparison 6 POU: solar disinfection versus control, Outcome 4 Diarrhoea: cluster‐RCTs; subgrouped by sufficiency of water supply level.
6.5
6.5. Analysis
Comparison 6 POU: solar disinfection versus control, Outcome 5 Diarrhoea: cluster‐RCTs; subgrouped by water source.
6.6
6.6. Analysis
Comparison 6 POU: solar disinfection versus control, Outcome 6 Diarrhoea: cluster‐RCTs; subgrouped by sanitation level.
6.7
6.7. Analysis
Comparison 6 POU: solar disinfection versus control, Outcome 7 Diarrhoea: cluster‐RCTs; subgrouped by length of follow‐up.
7.1
7.1. Analysis
Comparison 7 POU: UV disinfection versus control, Outcome 1 Diarrhoea: cluster‐RCT.
8.1
8.1. Analysis
Comparison 8 POU: improved storage versus control, Outcome 1 Diarrhoea: cluster‐RCTs: subgrouped by age.
See this image and copyright information in PMC

Update of

References

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    1. Quick RE, Kimura A, Thevos A, Tembo M, Shamputa I, Hutwagner L, et al. Diarrhea prevention through household‐level water disinfection and safe storage in Zambia. American Journal of Tropical Medicine and Hygiene 2002;66(5):584‐9. - PubMed
Reller 2003a GTM {published data only}
    1. Reller ME, Mendoza CE, Lopez MB, Alvarez M, Hoekstra AR, Olson CA, et al. A randomized controlled trial of household‐based flocculant‐disinfectant drinking water treatment for diarrhoea prevention in rural Guatemala. American Journal of Tropical Medicine and Hygiene 2003;69(4):411‐9. - PubMed
Reller 2003b GTM {published data only}
    1. Reller ME, Mendoza CE, Lopez MB, Alvarez M, Hoekstra AR, Olson CA, et al. A randomized controlled trial of household‐based flocculant‐disinfectant drinking water treatment for diarrhoea prevention in rural Guatemala. American Journal of Tropical Medicine and Hygiene 2003;69(4):411‐9. - PubMed
Reller 2003c GTM {published data only}
    1. Reller ME, Mendoza CE, Lopez MB, Alvarez M, Hoekstra AR, Olson CA, et al. A randomized controlled trial of household‐based flocculant‐disinfectant drinking water treatment for diarrhoea prevention in rural Guatemala. American Journal of Tropical Medicine and Hygiene 2003;69(4):411‐9. - PubMed
Reller 2003d GTM {published data only}
    1. Reller ME, Mendoza CE, Lopez MB, Alvarez M, Hoekstra AR, Olson CA, et al. A randomized controlled trial of household‐based flocculant‐disinfectant drinking water treatment for diarrhoea prevention in rural Guatemala. American Journal of Tropical Medicine and Hygiene 2003;69(4):411‐9. - PubMed
Roberts 2001 MWI {published data only}
    1. Roberts L, Chartier Y, Chartier O, Malenga G, Toole M, Rodka H. Keeping clean water clean in a Malawi refugee camp: a randomized intervention trial. Bulletin of the World Health Organization 2001;79(4):280‐7. - PMC - PubMed
Rodrigo 2011 AUS {published data only}
    1. Rodrigo S, Sinclair M, Forbes A, Cunliffe D, Leder K. Drinking rainwater: a double‐blinded, randomized controlled study of water treatment filters and gastroenteritis incidence. American Journal of Public Health 2011;101(5):842‐7. - PMC - PubMed
Semenza 1998 UZB {published data only}
    1. Semenza JC, Roberts L, Henderson A, Bogan J, Rubin CH. Water distribution system and diarrheal disease transmission: a case study in Uzbekistan. American Journal of Tropical Medicine and Hygiene 1998;59(6):941‐6. - PubMed
Stauber 2009 DOM {published and unpublished data}
    1. Stauber CE, Ortiz GM, Loomis DP, Sobsey MD. A randomized controlled trial of the concrete Biosand filter and its impact on diarrheal disease in Bonao, Dominican Republic. American Journal of Tropical Medicine and Hygiene 2009;80(2):286‐93. - PubMed
Stauber 2012a KHM {published data only}
    1. Stauber CE, Printy ER, McCarty FA, Liang KR, Sobsey MD. Cluster randomized controlled trial of the plastic BioSand water filter in Cambodia. Environmental Science & Technology 2012;46(2):722‐8. - PubMed
Stauber 2012b GHA {published and unpublished data}
    1. Stauber C, Kominek B, Liang K, Osman M, Sobsey M. Evaluation of the impact of the plastic BioSand filter on health and drinking water quality in rural Tamale, Ghana. International Journal of Environmental Research and Public Health 2012;9(11):3806‐23. - PMC - PubMed
Tiwari 2009 KEN {published data only}
    1. Tiwari SS, Schmidt WP, Darby J, Kariuki ZG, Jenkins MW. Intermittent slow sand filtration for preventing diarrhoea among children in Kenyan households using unimproved water sources: randomized controlled trial. Tropical Medicine & International Health 2009;14(11):1374‐82. - PubMed
Torun 1982 GTM {published data only}
    1. Torun B. Environmental and educational interventions against diarrhea in Guatemala. In: Chen LC, Scrimshaw NS editor(s). Diarrhea and Malnutrition: Interactions, Mechanisms and Interventions. New York: Plenum Press, 1982:235‐66.
URL 1995a GTM {published data only}
    1. Universidad Rafael Landivar. Preventing infant morbidity: artisanal filters and education [Contra la morbilidad infantil: filtros artesanales y education]. Revista de Estudios Sociales 1995;IV(53):1‐66.
URL 1995b GTM {published data only}
    1. Universidad Rafael Landivar. Preventing infant morbidity: artisanal filters and education [Contra la morbilidad infantil: filtros artesanales y education]. Revista de Estudios Sociales 1995;IV(53):1‐66.
Xiao 1997 CHN {published data only}
    1. Xiao S, Lin C, Chen K. Evaluation of effectiveness of comprehensive control for diarrhea diseases in rural areas of east Fujian and analysis of its cost‐benefit [Chinese]. Zhonghua Yu Fang Yi Xue Za Zhi [Chinese Journal of Preventive Medicine] 1997;31(1):40‐1. - PubMed

References to studies excluded from this review

Ahoyo 2011 {published data only}
    1. Ahoyo TA, Fatombi KJ, Boco M, Aminou T, Dramane KL. Impact of water quality and environmental sanitation on the health of schoolchildren in a suburban area of Benin: findings in the Savalou‐Banté and Dassa‐Glazoué sanitary districts [Impact de la qualité de l'eau et de l'assainissement sur la santé des enfants en milieu périurbain au Bénin: cas des zones sanitaires Savalou‐Banté et Dassa‐Glazoué]. Médecine tropicale 2011;71(3):281‐5. - PubMed
Aiken 2011 {published data only}
    1. Aiken BA, Stauber CE, Ortiz GM, Sobsey MD. An assessment of continued use and health impact of the concrete biosand filter in Bonao, Dominican Republic. American Journal of Tropical Medicine & Hygiene 2011;85(2):309‐17. - PMC - PubMed
Alexander 2013 {published data only}
    1. Alexander KT, Dreibelbis R, Freeman MC, Ojeny B, Rheingans R. Improving service delivery of water, sanitation, and hygiene in primary schools: a cluster‐randomized trial in western Kenya. Journal of Water and Health 2013;11(3):507‐19. - PubMed
Arnold 2009 {published data only}
    1. Arnold B, Arana B, Mäusezahl D, Hubbard A, Colford JM Jr. Evaluation of a pre‐existing, 3‐year household water treatment and handwashing intervention in rural Guatemala. International Journal of Epidemiology 2009;38(6):1651‐61. - PMC - PubMed
Arnold 2012a {published data only}
    1. Arnold BF, Mäusezahl D, Schmidt WP, Christen A, Colford, JM. Comment on randomized intervention study of solar disinfection of drinking water in the prevention of dysentery in Kenyan children aged under 5 years. Environmental Science & Technology 2012;46(5):3031‐2. - PubMed
Arnold 2013 {published data only}
    1. Arnold BF, Null C, Luby SP, Unicomb L, Stewart CP, Dewey KG, et al. Cluster‐randomised controlled trials of individual and combined water, sanitation, hygiene and nutritional interventions in rural Bangladesh and Kenya: the WASH Benefits study design and rationale. BMJ Open 2013;3(8):e003476. - PMC - PubMed
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Aziz 1990 BGD {published data only}
    1. Aziz KM, Hoque BA, Hasan KZ, Patwary MY, Huttly SR, Rahaman MM, et al. Reduction in diarrhoeal diseases in children in rural Bangladesh by environmental and behavioural modifications. Transactions of the Royal Society of Tropical Medicine and Hygiene 1990;84(3):433‐8. - PubMed
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Barzilay 2011 {published data only}
    1. Barzilay EJ, Aghoghovbia TS, Blanton EM, Akinpelumi AA, Coldiron ME, Akinfolayan O, et al. Diarrhea prevention in people living with HIV: an evaluation of a point‐of‐use water quality intervention in Lagos, Nigeria. AIDS Care 2011;23(3):330‐9. - PubMed
Bersh 1985 {published data only}
    1. Bersh D, Osorio MM. Studies of diarrhoea in Quindio (Colombia): problems related to water treatment. Social Science & Medicine 1985;21(1):31‐9. - PubMed
Boubacar 2014 {published data only}
    1. Boubacar Maïnassara H, Tohon Z. Assessing the health impact of the following measures in schools in Maradi (Niger): construction of latrines, clean water supply, establishment of hand washing stations, and health education. Journal of Parasitology Research 2014;2014:190451. - PMC - PubMed
Brown 2012a {published data only}
    1. Brown J, Clasen T. High adherence is necessary to realize health gains from water quality interventions. PLoS One 2012;7(5):e36735. - PMC - PubMed
Capuno 2011 {published data only}
    1. Capuno JJ, Tan CAR Jr, Fabella VM. Do piped water and flush toilets prevent child diarrhea in rural Philippines?. Asia‐Pacific Journal of Public Health 2011;December:1‐11. - PubMed
Cavallaro 2011 {published data only}
    1. Cavallaro EC, Harris JR, Goia MS, dos Santos Barrado JC, Alves da Nóbrega A, Carvalho de Alvarenga Júnior I, et al. Evaluation of pot‐chlorination of wells during a cholera outbreak, Bissau, Guinea‐Bissau, 2008. Journal of Water and Health 2011;9(2):394‐402. - PubMed
Chang 2012 {published data only}
    1. Chang WK, Ryu J, Yi Y, Lee W‐C, Lee C‐W, Kang D, et al. Improved water quality in response to pollution control measures at Masan Bay, Korea. Marine Pollution Bulletin 2012;64(2):427‐35. - PubMed
Chongsuvivatwong 1994 {published data only}
    1. Chongsuvivatwong V, Mo‐suwan L, Chompikul J, Vitsupakorn K, McNeil D. Effects of piped water supply on the incidence of diarrhoeal diseases in children in southern Thailand. Southeast Asian Journal of Tropical Medicine and Public Health 1994;25(4):628‐32. - PubMed
Christen 2011 {published data only}
    1. Christen A, Duran Pancheco G, Hattendorf J, Arnold BF, Cevallos M, Indergand S, et al. Factors associated with compliance among users of solar water disinfection in rural Bolivia. BMC Public Health 2011;11:210. - PMC - PubMed
Clasen 2012 {published data only}
    1. Clasen T, Boisson S, Routray P, Cumming O, Jenkins M, Ensink JHJ, et al. The effect of improved rural sanitation on diarrhoea and helminth infection: design of a cluster‐randomized trial in Orissa, India. Emerging Themes in Epidemiology 2012;9:7. - PMC - PubMed
Colford 2005 {published data only}
    1. Colford JM Jr, Wade TJ, Sandhu SK, Wright CC, Lee S, Shaw S, et al. A randomized, controlled trial of in‐home drinking water intervention to reduce gastrointestinal illness. American Journal of Epidemiology 2005;161(5):472‐82. - PubMed
Colwell 2003 {published data only}
    1. Colwell RR, Huq A, Islam MS, Aziz KM, Yunus M, Khan NH, et al. Reduction of cholera in Bangladeshi villages by simple filtration. Proceedings of the National Academy of Sciences of the United States of America 2003;100(3):1051‐5. - PMC - PubMed
Conroy 2001 {published data only}
    1. Conroy RM, Meegan ME, Joyce T, McGuigan K, Barnes J. Solar disinfection of drinking water protects against cholera in children under 6 years of age. Archives of Disease in Childhood 2001;85(4):293‐5. - PMC - PubMed
Coulliette 2013 {published data only}
    1. Coulliette AD, Enger KS, Weir MH, Rose JB. Risk reduction assessment of waterborne Salmonella and Vibrio by a chlorine contact disinfectant point‐of‐use device. International Journal of Hygiene and Environmental Health 2013;216(3):355‐61. - PubMed
Crump 2007 {published data only}
    1. Crump JA, Mendoza CE, Priest JW, Glass RI, Monroe SS, Dauphin LA, et al. Comparing serologic response against enteric pathogens with reported diarrhea to assess the impact of improved household drinking water quality. American Journal of Tropical Medicine and Hygiene 2007;77(1):136‐41. - PubMed
Davis 2011 {published data only}
    1. Davis J, Pickering AJ, Rogers K, Mamuya S, Boehm AB. The effects of informational interventions on household water management, hygiene behaviors, stored drinking water quality, and hand contamination in peri‐urban Tanzania. American Journal of Tropical Medicine and Hygiene 2011;84(2):184‐91. - PMC - PubMed
Deb 1986 {published data only}
    1. Deb BC, Sircar BK, Sengupta PG, De SP, Mondal SK, Gupta DN, et al. Studies on interventions to prevent eltor cholera transmission in urban slums. Bulletin of the World Health Organization 1986;64(1):127‐31. - PMC - PubMed
Denslow 2010 {published data only}
    1. Denslow SA, Edwards J, Horney J, Peña R, Wurzelmann D, Morgan D. Improvements to water purification and sanitation infrastructure may reduce the diarrheal burden in a marginalized and flood prone population in remote Nicaragua. BMC International Health and Human Rights 2010;10:30. - PMC - PubMed
Devoto 2011 {published data only}
    1. Devoto F, Duflo E, Dupas P, Pariente W, Pons V. Happiness on Tap: Piped Water Adoption in Urban Morocco. National Bureau of Economic Research 2011;Working paper: 16933:1‐39.
Dorevitch 2011 {published data only}
    1. Dorevitch S, Doi M, Hsu FC, Lin KT, Roberts JD, Liu LC, et al. A comparison of rapid and conventional measures of indicator bacteria as predictors of waterborne protozoan pathogen presence and density. Journal of Environmental Monitoring 2011;13(9):2427‐35. - PubMed
Dreibelbis 2014a KEN {published data only}
    1. Dreibelbis R, Freeman MC, Greene LE, Saboori S, Rheingans R. The impact of school water, sanitation, and hygiene interventions on the health of younger siblings of pupils: a cluster‐randomized trial in Kenya. American Journal of Public Health 2014;104(1):e91‐7. - PMC - PubMed
Dreibelbis 2014b KEN {published data only}
    1. Dreibelbis R, Freeman MC, Greene LE, Saboori S, Rheingans R. The impact of school water, sanitation, and hygiene interventions on the health of younger siblings of pupils: a cluster‐randomized trial in Kenya. American Journal of Public Health 2014;104(1):e91‐7. - PMC - PubMed
Dreibelbis 2014c KEN {published data only}
    1. Dreibelbis R, Freeman MC, Greene LE, Saboori S, Rheingans R. The impact of school water, sanitation, and hygiene interventions on the health of younger siblings of pupils: a cluster‐randomized trial in Kenya. American Journal of Public Health 2014;104(1):e91‐7. - PMC - PubMed
du Preez 2012 {published data only}
    1. du Preez M, Conroy RM, McGuigan KG. Response to comment on "A randomized intervention study of solar disinfection of drinking water (SODIS) in the prevention of dysentery in Kenyan children aged under 5 years". Environmental Science and Technology 2012;46(5):3036‐7. - PubMed
Eisenberg 2006 {published data only}
    1. Eisenberg JNS, Hubbard A, Wade TJ, Sylvester MD, LeChevallier MW, Levy DA, et al. Inferences drawn from a risk assessment compared directly with a randomized trial of a home drinking water intervention. Environmental Health Perspectives 2006;114(8):1199‐204. - PMC - PubMed
Enger 2012 {published data only}
    1. Enger KS, Nelson KL, Clasen T, Rose JB, Eisenberg JNS. Linking quantitative microbial risk assessment and epidemiological data: informing safe drinking water trials in developing countries. Environmental Science and Technology 2012;46(9):5160‐7. - PubMed
Esrey 1988 {published data only}
    1. Esrey SA, Habicht JJP, Latham MC, Sisler DG, Casella G. Drinking water source, diarrhoeal morbidity, and child growth in villages with both traditional and improved water supplies in rural Lesotho, southern Africa. American Journal of Public Health 1988;78(11):1451‐5. - PMC - PubMed
Fewtrell 1994 {published data only}
    1. Fewtrell L, Kay D, Dunlop J, O'Neill G, Wyer M. Infectious diseases and water‐supply disconnections. Lancet 1994;343(8909):1370. - PubMed
Fewtrell 1997 {published data only}
    1. Fewtrell L, Kay D, Wyer M, O'Neill G. An investigation into the possible links between shigellosis and hepatitis A and public water supply disconnections. Public Health 1997;111(3):179‐81. - PubMed
Firth 2010 {published data only}
    1. Firth J, Balraj V, Muliyil J, Roy S, Rani LM, Chandresekhar R, et al. Point‐of‐use interventions to decrease contamination of drinking water: a randomized, controlled pilot study on efficacy, effectiveness, and acceptability of closed containers, Moringa oleifera, and In‐home chlorination in rural South India. American Journal of Tropical Medicine and Hygiene 2010;82(5):759‐65. - PMC - PubMed
Fisher 2011 {published data only}
    1. Fisher S, Kabir B, Lahiff E, MacLachlan M. Knowledge, attitudes, practices and implications of safe water management and good hygiene in rural Bangladesh: assessing the impact and scope of the BRAC WASH programme. Journal of Water and Health 2011;9(1):80‐93. - PubMed
Freeman 2012 {published data only}
    1. Freeman MC, Greene LE, Dreibelbis R, Saboori S, Muga R, Brumback B, et al. Assessing the impact of a school‐based water treatment, hygiene and sanitation programme on pupil absence in Nyanza Province, Kenya: a cluster‐randomized trial. Tropical Medicine & International Health 2012;17(3):380‐91. - PubMed
Freeman 2014a KEN {published data only}
    1. Freeman MC, Clasen T, Dreibelbis R, Saboori S, Greene L, Brumback B, et al. The impact of a school‐based water supply and treatment, hygiene, and sanitation programme on pupil diarrhoea: a cluster‐randomized trial. Epidemiology and Infection 2014;142(2):340‐51. - PMC - PubMed
Freeman 2014b KEN {published data only}
    1. Freeman MC, Clasen T, Dreibelbis R, Saboori S, Greene L, Brumback B, et al. The impact of a school‐based water supply and treatment, hygiene, and sanitation programme on pupil diarrhoea: a cluster‐randomized trial. Epidemiology and Infection 2014;142(2):340‐51. - PMC - PubMed
Freeman 2014c KEN {published data only}
    1. Freeman MC, Clasen T, Dreibelbis R, Saboori S, Greene L, Brumback B, et al. The impact of a school‐based water supply and treatment, hygiene, and sanitation programme on pupil diarrhoea: a cluster‐randomized trial. Epidemiology and Infection 2014;142(2):340‐51. - PMC - PubMed
Fry 2010 {published data only}
    1. Fry LM, Cowden JR, Watkins DW Jr, Clasen T, Mihelcic JR. Quantifying health improvements from water quantity enhancement: an engineering perspective applied to rainwater harvesting in West Africa. Environmental Science and Technology 2010;44(24):9535‐41. - PubMed
Galiani 2009 {published data only}
    1. Galiani S, Gonzalez‐Rozada M, Schargrodsky E. Water expansions in shantytowns: health and savings. Economica 2009;76(104):607‐22.
Garrett 2008 KEN {published data only}
    1. Garrett V, Ogutu P, Mabonga P, Ombeki S, Mwaki A, Aluoch G, et al. Diarrhoea prevention in a high‐risk rural Kenyan population through point‐of‐use chlorination, safe water storage, sanitation, and rainwater harvesting. Epidemiology and Infection 2008;136(11):1463‐71. - PMC - PubMed
Ghannoum 1981 {published data only}
    1. Ghannoum MA, Moore KE, Al‐Dulaimi M, Nasr M. The incidence of water‐related diseases in the Brak area, Libya from 1977 to 1979, before and after the installation of water treatment plants. Zentralblatt für Bakteriologie, Mikrobiologie und Hygiene. 1. Abt. Originale B, Hygiene 1981;173(6):501‐8. - PubMed
Gómez‐Couso 2012 {published data only}
    1. Gómez‐Couso H, Fontán‐Sainza M, Navntoft C, Fernández‐Ibáñez P, Ares‐Mazás E. Comparison of different solar reactors for household disinfection of drinking water in developing countries: evaluation of their efficacy in relation to the waterborne enteropathogen Cryptosporidium parvum. Transactions of the Royal Society of Tropical Medicine and Hygiene 2012;106(11):645‐52. - PubMed
Gorelick 2011 {published data only}
    1. Gorelick MH, McLellan SL, Wagner D, Klein J. Water use and acute diarrhoeal illness in children in a United States metropolitan area. Epidemiology & Infection 2011;139(2):295‐301. - PubMed
Greene 2012 {published data only}
    1. Greene LE, Freeman MC, Akoko D, Saboori S, Moe C, Rheingans R. Impact of a school‐based hygiene promotion and sanitation intervention on pupil hand contamination in Western Kenya: a cluster randomized trial. American Journal of Tropical Medicine and Hygiene 2012;87(3):385‐93. - PMC - PubMed
Habib 2013 {published data only}
    1. Habib MA, Soofi S, Sadiq K, Samejo T, Hussain M, Mirani M, et al. A study to evaluate the acceptability, feasibility and impact of packaged interventions ("Diarrhea Pack") for prevention and treatment of childhood diarrhea in rural Pakistan. BMC Public Health 2013;13:922. - PMC - PubMed
Harris 2009 {published data only}
    1. Harris JR, Greene SK, Thomas TK, Ndivo R, Okanda J, Masaba R, et al. Effect of a point‐of‐use water treatment and safe water storage intervention on diarrhea in infants of HIV‐infected mothers. Journal of Infectious Diseases 2009;200(8):1186‐93. - PubMed
Harshfield 2012 {published data only}
    1. Harshfield E, Lantagne D, Turbes A, Null C. Evaluating the sustained health impact of household chlorination of drinking water in rural Haiti. American Journal of Tropical Medicine and Hygiene 2012;87(5):786‐95. - PMC - PubMed
Hartinger 2011 {published data only}
    1. Hartinger SM, Lanata CF, Hattendorf J, Gil AI, Verastegui H, Ochoa T, et al. A community randomised controlled trial evaluating a home‐based environmental intervention package of improved stoves, solar water disinfection and kitchen sinks in rural Peru: rationale, trial design and baseline findings. Contemporary Clinical Trials 2011;32(6):864‐73. - PubMed
Hartinger 2012 {published data only}
    1. Hartinger SM, Lanata CF, Gil AI, Hattendorf J, Verastegui H, Mäusezahl D. Combining interventions: improved chimney stoves, kitchen sinks and solar disinfection of drinking water and kitchen clothes to improve home hygiene in rural Peru. Journal of Field Actions 2012;6:1‐10.
Hellard 2001 {published data only}
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Hoque 1996 {published data only}
    1. Hoque BA, Juncker T, Sack RB, Ali M, Aziz KM. Sustainability of a water, sanitation and hygiene education project in rural Bangladesh: a 5‐year follow‐up. Bulletin of the World Health Organization 1996;74(4):431‐7. - PMC - PubMed
Huda 2012 {published data only}
    1. Huda TMN, Unicomb L, Johnston RB, Halder AK, Yushuf Sharker MA, Luby SP. Interim evaluation of a large scale sanitation, hygiene and water improvement programme on childhood diarrhea and respiratory disease in rural Bangladesh. Social Science and Medicine 2012;75(4):604‐11. - PubMed
Hunter 2010 {published data only}
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Iijima 2001 {published data only}
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Islam 2011 {published data only}
    1. Islam MS, Mahmud ZH, Uddin MH, Islam K, Yunus M, Islam MS, et al. Purification of household water using a novel mixture reduces diarrhoeal disease in Matlab, Bangladesh. Transactions of the Royal Society of Tropical Medicine & Hygiene 2011;105(6):341‐5. - PubMed
Jensen 2002 {published data only}
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Kariuki 2012 {published data only}
    1. Kariuki JG, Magambo KJ, Njeruh MF, Muchiri EM, Nzioka SM, Kariuki S. Effects of hygiene and sanitation interventions on reducing diarrhoea prevalence among children in resource constrained communities: case study of Turkana District, Kenya. Journal of Community Health 2012;37(6):1178‐84. - PubMed
Karon 2011 {published data only}
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Keraita 2007 {published data only}
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Khan 1984 {published data only}
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Luby 2008 {published data only}
    1. Luby SP, Gupta SK, Sheikh MA, Johnston RB, Ram PK, Islam MS. Tubewell water quality and predictors of contamination in three flood‐prone areas in Bangladesh. Journal of Applied Microbiology 2008;105(4):1002‐8. - PubMed
Luoto 2011 {published data only}
    1. Luoto J, Najnin N, Mahmud M, Albert J, Islam MS, Luby SP, et al. What point‐of‐use water treatment products do consumers use? Evidence from a randomized controlled trial among the urban poor in Bangladesh. PLoS One 2011;6(10):e26132. - PMC - PubMed
Luoto 2012 {published data only}
    1. Luoto J, Mahmud M, Albert J, Luby SP, Najnin N, Unicomb L, et al. Learning to dislike safe water products: results from a randomized controlled trial of the effects of direct and peer experience on willingness to pay. Environmental Science & Technology 2012;46(11):6244‐51. - PubMed
Macy 1998 {published data only}
    1. Macy JT, Quick RE. Evaluation of a novel drinking water treatment and storage intervention in Nicaragua. Revista Panamericana de Salud Pública (Pan American Journal of Public Health) 1998;3(2):135‐6. - PubMed
Mäusezahl 2003 {unpublished data only}
    1. Mäusezahl D, Tanner M, Hobbins M. The SODIS health impact study (as supplied 15 March 2004). Data on file.
McCabe 1957 {published data only}
    1. McCabe LJ, Haines TW. Diarrheal disease control by improved human excreta disposal. Public Health Reports 1957;72(10):921‐8. - PMC - PubMed
Mertens 1990 {published data only}
    1. Mertens TE, Cousens SN, Fernando MA, Kirkwood BR, Merkle F, Korte R, et al. Health impact evaluation of improved water supplies and hygiene practices in Sri Lanka: background and methodology. Tropical Medicine and Parasitology 1990;41(1):79‐88. - PubMed
Messou 1997 {published data only}
    1. Messou E, Sangaré SV, Josseran R, Corre C, Guélain J. Effect of hygiene measures, water, sanitation and oral rehydration therapy on diarrhoea in children less than five years old in the south of Ivory Coast [Effet de l'observance des mesures d'hygiene, d'approisionnement en eau et de la therapie par voie orale sur les diarrhees chez les enfants de moins de 5 ans dans le sud de la Cote D'Ivoire]. Bulletin de la Société de Pathologie Exotique (1990) 1997;90(1):44‐7. - PubMed
Nanan 2003 {published data only}
    1. Nanan D, White F, Azam I, Afsar H, Hozhari S. Evaluation of a water, sanitation, and hygiene education intervention on diarrhoea in northern Pakistan. Bulletin of the World Health Organization 2003;81(3):160‐5. - PMC - PubMed
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References to other published versions of this review

Clasen 2006
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Publication types