Diarrhoea and respiratory infections remain the biggest killers of children under 5 years in developing countries. We conducted a 5-month household randomised controlled trial among 566 households in rural Rwanda to assess uptake, compliance and impact on environmental exposures of a combined intervention delivering high-performance water filters and improved stoves for free. Compliance was measured monthly by self-report and spot-check observations. Semi-continuous 24-h PM_2.5 monitoring of the cooking area was conducted in a random subsample of 121 households to assess household air pollution, while samples of drinking water from all households were collected monthly to assess the levels of thermotolerant coliforms. Adoption was generally high, with most householders reporting the filters as their primary source of drinking water and the intervention stoves as their primary cooking stove. However, some householders continued to drink untreated water and most continued to cook on traditional stoves. The intervention was associated with a 97.5% reduction in mean faecal indicator bacteria (Williams means 0.5 vs. 20.2 TTC/100 mL, p<0.001) and a median reduction of 48% of 24-h PM_2.5 concentrations in the cooking area (p = 0.005). Further studies to increase compliance should be undertaken to better inform large-scale interventions. Trial registration: Clinicaltrials.gov; NCT01882777; http://clinicaltrials.gov/ct2/results?term=NCT01882777&Search=Search

The United Nations Sustainable Development Goals (SDGs), announced in September 2015, present a vision of achieving a higher level of human health and well-being worldwide by the year 2030. The SDG targets specific to water and sanitation call for more detailed monitoring and response to understand the coverage and quality of safely managed sources. It is hoped that improved monitoring of water and sanitation interventions will reveal more cost-effective and efficient ways of meeting the SDGs. In this paper, we review the landscape of approaches that can be used to support and improve on the water and sanitation targets SDG 6.1, “By 2030, achieve universal and equitable access to safe and affordable drinking water for all”, and SDG 6.2, “By 2030, achieve access to adequate and equitable sanitation and hygiene for all and end open defecation, paying special attention to the needs of women and girls and those in vulnerable situations”.

Unsafe drinking water and household air pollution (HAP) are major causes of morbidity and mortality among children under 5 in low and middle-income countries. Household water filters and higher-efficiency biomass-burning cookstoves have been widely promoted to improve water quality and reduce fuel use, but there is limited evidence of their health effects when delivered programmatically at scale. In a large-scale program in Western Province, Rwanda, water filters and portable biomass-burning natural draft rocket-style cookstoves were distributed between September and December 2014 and promoted to over 101,000 households in the poorest economic quartile in 72 (of 96) randomly selected sectors in Western Province. To assess the effects of the intervention, between August and December, 2014, we enrolled 1,582 households that included a child under 4 years from 174 randomly selected village-sized clusters, half from intervention sectors and half from nonintervention sectors. At baseline, 76% of households relied primarily on an improved source for drinking water (piped, borehole, protected spring/well, or rainwater) and over 99% cooked primarily on traditional biomass-burning stoves. We conducted follow-up at 3 time-points between February 2015 and March 2016 to assess reported diarrhea and acute respiratory infections (ARIs) among children <5 years in the preceding 7 days (primary outcomes) and patterns of intervention use, drinking water quality, and air quality. The intervention reduced the prevalence of reported child diarrhea by 29% (prevalence ratio [PR] 0.71, 95% confidence interval [CI] 0.59-0.87, p = 0.001) and reported child ARI by 25% (PR 0.75, 95% CI 0.60-0.93, p = 0.009). Overall, more than 62% of households were observed to have water in their filters at follow-up, while 65% reported using the intervention stove every day, and 55% reported using it primarily outdoors. Use of both the intervention filter and intervention stove decreased throughout follow-up, while reported traditional stove use increased. The intervention reduced the prevalence of households with detectable fecal contamination in drinking water samples by 38% (PR 0.62, 95% CI 0.57-0.68, p < 0.0001) but had no significant impact on 48-hour personal exposure to log-transformed fine particulate matter (PM2.5) concentrations among cooks (β = -0.089, p = 0.486) or children (β = -0.228, p = 0.127). The main limitations of this trial include the unblinded nature of the intervention, limited PM2.5 exposure measurement, and a reliance on reported intervention use and reported health outcomes. Our findings indicate that the intervention improved household drinking water quality and reduced caregiver-reported diarrhea among children <5 years. It also reduced caregiver-reported ARI despite no evidence of improved air quality. Further research is necessary to ascertain longer-term intervention use and benefits and to explore the potential synergistic effects between diarrhea and ARI. Clinical Trials.gov NCT02239250.

Infections with enteric pathogens impose a heavy disease burden, especially among young children in low-income countries. Recent findings from randomized controlled trials of water, sanitation and hygiene interventions have raised questions about current methods for assessing environmental exposure to enteric pathogens. Approaches for estimating sources and doses of exposure suffer from a number of shortcomings, including reliance on imperfect indicators of fecal contamination instead of actual pathogens and estimating exposure indirectly from imprecise measurements of pathogens in the environment and human interaction therewith. These shortcomings limit the potential for effective surveillance of exposures, identification of important sources and modes of transmission, and evaluation of the effectiveness of interventions. In this review, we summarize current and emerging approaches used to characterize enteric pathogen hazards in different environmental media as well as human interaction with those media (external measures of exposure), and review methods that measure human infection with enteric pathogens as a proxy for past exposure (internal measures of exposure). We draw from lessons learned in other areas of environmental health to highlight how external and internal measures of exposure can be used to more comprehensively assess exposure. We conclude by recommending strategies for advancing enteric pathogen exposure assessments.

Millions of people in the arid regions of Kenya and Ethiopia face water scarcity and frequent drought. Water resource forecasting and reliable operation of groundwater distribution systems may improve drought resilience. In this study, we examined three remote sensing data sets against in-situ sensor-collected groundwater extraction data from 221 water points serving over 1.34 million people across northern Kenya and Afar, Ethiopia between January 1, 2017 and August 31, 2018. In models containing rainfall as a binary variable, we observed an overall 23% increase in borehole runtime following weeks with no rainfall compared to weeks preceded by some rainfall. Further, a 1 mm increase in rainfall was associated with a 1% decrease in borehole use the following week. When surface water availability is reduced during the dry seasons, groundwater demand increases. Our findings emphasize the imperative to maintain functionality of groundwater boreholes in these regions which often suffer drought related emergencies. Funding provided by the United States Agency for International Development, the World Bank, the National Science Foundation, and the Cisco Foundation. The views expressed in this article do not necessarily reflect the views of the United States Agency for International Development or the United States Government.