1. Daniele Lantagne, PE Centers for Disease Control and Prevention Household Water Treatment in Developing Countries: Successes, Failures, and Way Forward

2. Why do children die of diarrhea? Youngest children –Immature immune system –Less physiologic reserve Multiple physiologic insults –Malnutrition Protein & calorie deficient Micronutrient deficient –Frequent infections Feces contaminated environment –Water, Food, Environment Limited access to effective clinical care

3. How many child deaths are due to unsafe water? Question ignores: –Web of causality –Assumes a single cause of death Risks professional groups –Arguing for resources –Not collaborating to address problem Child mortality from diarrhea is an enormous global public health problem and contaminated water contributes importantly.

4. Q: How much disease could be prevented by better managing water, sanitation and hygiene ? A: 10%  "Almost one tenth of the global disease burden could be prevented by improving water supply, sanitation, hygiene and management of water resources"

5. WSH = disease and poverty ? Inadequate water supply Unsafe water resources Inequitable access Time, financial cost Disease burden Health care costs POVERTY

6. WSH = motor of development Improved water supply Safe water resources Universal access Time, financial savings Averted disease costs Health & education Development

7. What is safe water? Health workers –Water that does not cause morbidity or mortality in children < 5 Engineers –Water without bacterial contamination at exit of plant or pump Millennium Development Goals –Protected Sources –Goal: reduce in half those without access to “improved water” by 2015 Safe water is water that is safe to drink in the users’ cup.

9. The World (seen through the lens of diarrheal deaths) Territories are sized in proportion to the absolute number of people who died from diarrheal diseases in one year Source: http://www.worldmapper.orghttp://www.worldmapper.org

11. Goal: Health Impact Diarrheal Disease Reduction 19922004 Hygiene (handwashing)-33%-42% Sanitation-36%-24% Water Supply-19%-23% Water Treatment-15%-39% ALL are necessary. Start with one. Leverage to others.

12. Proven HWTS Options Ceramic Filtration SWS SODIS Biosand Filtration PuR

13. ChlorineFiltrationSODISPuR 1. Lab Bacteria, Viruses 2. Field Proven 3. Health Proven (sol’n) 4. Scale Africa (East) Cost 0.25 USD / 1000 L (sol’n) 0.50 USD / 1000 L (tabs) Proven Option Comparison Chart

14. ChlorineFiltrationSODISPuR 1. Lab Bacteria, Viruses Bacteria, Protozoa 2. Field Proven 3. Health Proven (sol’n)Proven 4. Scale Africa (East)Cambodia Cost 0.25 USD / 1000 L (sol’n) 0.50 USD / 1000 L (tabs) Ceramic: 8-30 USD Sand: 50-100 USD Proven Option Comparison Chart

15. ChlorineFiltrationSODISPuR 1. Lab Bacteria, Viruses Bacteria, Protozoa Bacteria, Viruses, Protozoa 2. Field Proven 3. Health Proven (sol’n)Proven 4. Scale Africa (East)CambodiaLatin America Cost 0.25 USD / 1000 L (sol’n) 0.50 USD / 1000 L (tabs) Ceramic: 8-30 USD Sand: 50-100 USD Free Proven Option Comparison Chart

16. ChlorineFiltrationSODISPuR 1. Lab Bacteria, Viruses Bacteria, Protozoa Bacteria, Viruses, Protozoa 2. Field Proven 3. Health Proven (sol’n)Proven 4. Scale Africa (East)CambodiaLatin AmericaEmergency Cost 0.25 USD / 1000 L (sol’n) 0.50 USD / 1000 L (tabs) Ceramic: 8-30 USD Sand: 50-100 USD Free 0.10 USD / 10 L Proven Option Comparison Chart

17. Note: Other Options 1. Laboratory Testing 2. Field testing 3. Health Impact Analysis 4. Scalability

18. Safe Rural Water Supply = +

19. +

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21. When does POU not work? Poor product Inappropriate product Unconvinced users ??

22. Poor Product Zambia –Study showed 42% said current users 13% had chlorine residual Quality control issue –Old generators Solution –Stringent quality control –Moving to company production

23. Inappropriate Product A BCDE Influent Holding Tank Pump 1 1 micron bag filter Ozonator Ozone Contact Tank 3 micron Filter UV light Chlorine Flow Meter Chlorine Contact Tank Pump 2 0.2 Micron Filter Effluent

26. Unconvinced Users Nepal –AED study on preference SODIS SWS Ceramic Filtration BioSand Filtration –“SODIS won’t work” Culturally inappropriate Solution: education, other option?

27. What makes HWT work? 1.Quality product 2.Distribution, marketing, profit 3.Behavior change communication 4.User adoption

28. 1. Quality (local) product

29. 2. Distribution, marketing, profit

30. 3. Behavior Change Communication

31. 4. Sustained adoption and monitoring

32. Technological Verification Cost Effective Implementation Consumer Demand Sustainability

33. Combined estimate of home water treatment products T. Clasen, “Scaling Up Household Water Treatment Among Low-Income Populations” (World Health Organization, 2009).

34. Coverage - Sobering Statistics (Clasen) 60% Coverage

35. Nursing Collaboration Nurses recommend WaterGuard to mothers of children with diarrhea Chlorine Residual Results –2 weeks 68% (67/98) –1 year 71% (36/51)

36. Diffusion of Innovations

37. Way Forward Think strategically, assess programs, fix failures. Keep an open-mind. Base research on implementation needs. Think at-scale. Implement and fund proven technologies. We are having impact BUT we can always improve.

38. Key questions for future Can we increase demand for improved water quality among the group in highest need? Can we develop sustainable systems that provide point of use approaches to communities in highest need? Can we reduce the burden of disease, particularly among the poorest with this approach?

39. “The notion that ‘being humanitarian’ and ‘doing good’ are somehow inevitably the same is a hard one to shake off” (Slim, 1997) Thank you. I am happy to take questions. dlantagne@cdc.gov