Water Safety Plan (WSP) implementation has the potential to greatly improve, commonly very challenging and resource limited, small drinking water supplies. Although slower than in urban or high-income settings, the uptake of WSPs in low- and middle-income countries (LMICs) is accelerating. Understanding the factors which will make a WSP successful will further improve efficient uptake and assist with its long-term sustainability. Based on an extensive literature search using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISM-A) methodology, 48 publications, including case studies and guidance documentation, formed the basis of this review. These were analysed using inductive and deductive coding methods to (i) identify the success factors applicable to WSP implementation in small drinking water supplies in LMICs and (ii) to investigate which factors are more or less critical depending on the geography and level of development of the implementing country. Key challenges identified during the review process were also noted. A comparison of these success factors was made with those identified from high-income and urban settings. The three most important success factors identified are the development of technical capacity, community engagement, and monitoring and verification. Factors specific to small drinking water supplies in LMICs include support from non-government organisations, integration into existing water sanitation and hygiene (WASH) programs, simplicity, and community engagement. Certain factors, such as adaptability, the use of guidance documentation, international collaboration, the role of pilot studies, knowledge sharing, and stakeholder involvement are applicable to all WSP settings. Due to the specific challenges faced by small drinking water systems and the limited number of original research publications on this topic, this study highlights the need for further data collection and research focused on success factors in these settings. It is anticipated that the consideration of the success factors identified in this study will assist implementers in improving the uptake and long-term sustainability of WSPs in small drinking water supplies in low- and middle-income settings.

Small drinking-water supplies face particular challenges in terms of their management. Being vulnerable to contamination but often not monitored regularly nor well-maintained, small drinking-water supplies may pose consequences for health of users. Sanitary inspection (SI) is a risk assessment tool to identify and manage observable conditions of the water supply technology or circumstances in the catchment area that may favour certain hazardous events and introduce hazards which may become a risk to health. This qualitative research aimed to identify the strengths and weaknesses of the SI tool as published by the World Health Organisation to inform a review and update of the forms and to improve their robustness. The study identified a number of benefits of the approach, such as its simplicity and ease of use. Challenges were also identified, such as potential for inconsistencies in perception of risk between inspectors, in interpreting questions, and lack of follow-up action. The authors recommend a revision of the existing SI forms to address the identified challenges and development of complementary advice on possible remedial action to address identified risk factors and on basic operations and maintenance.

Installation of technologies to remove or deactivate respiratory pathogens from indoor air is a plausible non-pharmaceutical infectious disease control strategy. We undertook a systematic review of worldwide observational and experimental studies, published 1970-2022, to synthesise evidence about the effectiveness of suitable indoor air treatment technologies to prevent respiratory or gastrointestinal infections. We searched for data about infection and symptom outcomes for persons who spent minimum 20 h/week in shared indoor spaces subjected to air treatment strategies hypothesised to change risk of respiratory or gastrointestinal infections or symptoms. Pooled data from 32 included studies suggested no net benefits of air treatment technologies for symptom severity or symptom presence, in absence of confirmed infection. Infection incidence was lower in three cohort studies for persons exposed to high efficiency particulate air filtration (RR 0.4, 95%CI 0.28-0.58, p < 0.001) and in one cohort study that combined ionisers with electrostatic nano filtration (RR 0.08, 95%CI 0.01-0.60, p = 0.01); other types of air treatment technologies and air treatment in other study designs were not strongly linked to fewer infections. The infection outcome data exhibited strong publication bias. Although environmental and surface samples are reduced after air treatment by several air treatment strategies, especially germicidal lights and high efficiency particulate air filtration, robust evidence has yet to emerge that these technologies are effective at reducing respiratory or gastrointestinal infections in real world settings. Data from several randomised trials have yet to report and will be welcome to the evidence base.

Swimming pools provide an excellent facility for exercise and leisure but are also prone to contamination from microbial pathogens. The study modelled a 50-m × 20-m swimming pool using both a small-scale physical model and computational fluid dynamics to investigate how water and pathogens move around a pool in order to identify potential risk spots. Our study revealed a number of lessons for pool operators, designers and policy-makers: disinfection reaches the majority of a full-scale pool in approximately 16 minutes operating at the maximum permissible inlet velocity of 0.5 m/s. This suggests that where a pool is designed to have 15 paired inlets it is capable of distributing disinfectant throughout the water body within an acceptable time frame. However, the study also showed that the exchange rate of water is not uniform across the pool tank and that there is potential for areas of the pool tank to retain contaminated water for significant periods of time. ‘Dead spots’ exist at either end of the pool where pathogens could remain. This is particularly significant if there is a faecal release into the pool by bathers infected with Cryptosporidium parvum, increasing the potential for waterborne disease transmission.

To achieve Sustainable Development Goals (SDGs) 6, universal and equitable access to safe and affordable drinking-water quality and sanitation for all, and 10, to reduce inequality within and among countries, additional and urgent work is required. Efforts to achieve these Goals in the context of small drinking-water supplies, which are the furthest behind in regards to progress, are of particular need. Reasons for this disparity in progress include the remoteness of access to small drinking-water supplies and the lack of technical and financial capacity for monitoring supplies. The World Health Organization promote the use of Sanitary inspection (SI) as an on-site assessment of risk. Despite the potential to increase the body of knowledge and information on supplies in a region, there has been limited research into the role of citizen science and SIs. To meet SDG targets, we need to improve the reach of SIs. This study uses a mixed methods approach of quantitative on-site SI data collection and remote SI data collection via photographic images, together with qualitative data collection, collected by non-expert students, who are citizens of Malawi, as well as a panel of experts in the field of SI. Results indicate that, although further research into the topic is required prior to widescale implementation, the potential exists for citizens to conduct SI, with remote expert verification of the results using photographic images of supplies. Further documentation or guidance is required to support citizens in this process. The results highlight a critical gap in the availability of appropriate documentation for unprotected spring sources which is urgently required. The use of citizen science for SI data collection is in its infancy. However, this study indicates that there is potential to explore the use of citizen science in this area, which will contribute to achieving SDGs 6 and 10.

Water use is a significant operational cost factor for large swimming pool facilities, however it has been overshadowed by the recent focus on energy consumption and carbon emissions. Currently, it is difficult for operators to make decisions in relation to water efficiency due to the lack of information about the relationship between pool operation and water use. This study has started to address this issue by reviewing water use at a fully operational facility. The analysis of the consumption data has led to a proposal for a new water performance indicator, the water exchange deficit. Modifications to the method of estimating water consumption have also been proposed to enable enhanced water management guidance to be developed.