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 yearDiarrhea 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

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 flocculant-disinfectant 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 5th

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 non-

government 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 PromotionHouseholds 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 diarrheaNumber of days of observation

Baseline Household Characteristics

Bleach Floc Floc + Soap

Soap Control

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

24% 23% 21% 22% 24%

Bar soaps bought last 2 weeks

1.1 1.2 1.2 1.2 1.2

Primary Drinking Water SourceBleach

(%)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

020406080

100120140160180200

Apr May Jun Jul Aug Sep Oct Nov Dec

Rai

nfal

l (m

m)

50 year mean July rainfall

USDA Weekly Weather and Crop Bulletin, 2003

Diarrhea longitudinal prevalence by week and intervention

0

2

4

6

8

10

1 3 5 7 9 11 13 15 17 19 21 23 25 27 29 31 33 35 37%

per

son

days

with

dia

rrhe

a

Control

Apr May Jun July Aug Sep Oct Nov Dec

Diarrhea longitudinal prevalence by week and intervention

0

2

4

6

8

10

1 3 5 7 9 11 13 15 17 19 21 23 25 27 29 31 33 35 37%

per

son

days

with

dia

rrhe

a

Control Bleach

Apr May Jun July Aug Sep Oct Nov Dec

Diarrhea longitudinal prevalence by week and intervention

0

2

4

6

8

10

1 3 5 7 9 11 13 15 17 19 21 23 25 27 29 31 33 35 37%

per

son

days

with

dia

rrhe

a

Control Bleach Floc

Apr May Jun July Aug Sep Oct Nov Dec

Diarrhea longitudinal prevalence by week and intervention

0

2

4

6

8

10

1 3 5 7 9 11 13 15 17 19 21 23 25 27 29 31 33 35 37%

per

son

days

with

dia

rrhe

a

Control Bleach Floc Soap

Apr May Jun July Aug Sep Oct Nov Dec

Diarrhea longitudinal prevalence by week and intervention

0

2

4

6

8

10

1 3 5 7 9 11 13 15 17 19 21 23 25 27 29 31 33 35 37%

per

son

days

with

dia

rrhe

a

Control Bleach Floc Soap Soap+Floc

Apr May Jun July Aug Sep Oct Nov Dec

Diarrhea longitudinal prevalence by treatment group

0.00 1.00 2.00 3.00 4.00 5.00 6.00

% person days with diarrhea

Floc+SoapSoapFlocBleachControl

-55%

-51%

-64%

-55% (-17%, -80%)*

*95% CI

(-12%, -76%)

(-29%, -90%)

(-18%, -80%)

Karachi Floc Health Study, 2003

Diarrhea longitudinal prevalence by treatment group

0.00 1.00 2.00 3.00 4.00 5.00 6.00

% person days with diarrhea

Floc+SoapSoapFlocBleachControl

-55%

-51%

-64%

-55% (-17%, -80%)*

*95% CI

(-12%, -76%)

(-29%, -90%)

(-18%, -80%)

Karachi Floc Health Study, 2003

Diarrhea longitudinal prevalence by age and treatment group

0

5

10

1 2 3 4 5Years

% p

erso

n da

ys w

ith d

iarr

hea

ControlBleachFlocSoapSoap+Floc

<1 1-2 2-5 5-15 >15

Karachi Floc Health Study, 2003

Diarrhea longitudinal prevalence by age and treatment group

0

5

10

1 2 3 4 5Years

% p

erso

n da

ys w

ith d

iarr

hea

ControlBleachFlocSoapSoap+Floc

<1 1-2 2-5 5-15 >15

40%

Karachi Floc Health Study, 2003

Diarrhea longitudinal prevalence by age and treatment group

0

5

10

1 2 3 4 5Years

% p

erso

n da

ys w

ith d

iarr

hea

ControlBleachFlocSoapSoap+Floc

<1 1-2 2-5 5-15 >15

40%

73%

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