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 PM2.5 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 PM2.5 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

Background 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. Methods and findings 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 (PM 2.5 ) 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 PM 2.5 exposure measurement, and a reliance on reported intervention use and reported health outcomes. Conclusions Our findings indicate that the intervention improved household drinking water quality and reduced caregiver-reported diarrhea among children <5 years...

Remotely reporting electronic sensors offer the potential to reduce bias in monitoring use of environmental health interventions. In the context of a five-month randomized controlled trial of household water filters and improved cookstoves in rural Rwanda, we collected data from intervention households on product compliance using (i) monthly surveys and direct observations by community health workers and environmental health officers, and (ii) sensor-equipped filters and cookstoves deployed for about two weeks in each household. The adoption rate interpreted by the sensors varied from the household reporting: 90.5% of households reported primarily using the intervention stove, while the sensors interpreted 73.2% use, and 96.5% of households reported using the intervention filter regularly, while the sensors interpreted no more than 90.2%. The sensor-collected data estimated use to be lower than conventionally collected data both for water filters (approximately 36% less water volume per day) and cookstoves (approximately 40% fewer uses per week). An evaluation of intrahousehold consistency in use suggests that households are not using their filters or stoves on an exclusive basis, and may be both drinking untreated water at times and using other stoves ("stove-stacking"). These results provide additional evidence that surveys and direct observation may exaggerate compliance with household-based environmental interventions.

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.

In rural sub-Saharan Africa, where handpumps are common, 10-67% are nonfunctional at any one time, and many never get repaired. Increased reliability requires improved monitoring and responsiveness of maintenance providers. In 2014, 181 cellular enabled water pump use sensors were installed in three provinces of Rwanda. In three arms, the nominal maintenance model was compared against a "best practice" circuit rider model, and an "ambulance" service model. In only the ambulance model was the sensor data available to the implementer, and used to dispatch technicians. The study ran for seven months in 2014-2015. In the study period, the nominal maintenance group had a median time to successful repair of approximately 152 days, with a mean per-pump functionality of about 68%. In the circuit rider group, the median time to successful repair was nearly 57 days, with a per-pump functionality mean of nearly 73%. In the ambulance service group, the successful repair interval was nearly 21 days with a functionality mean of nearly 91%. An indicative cost analysis suggests that the cost per functional pump per year is approximately similar between the three models. However, the benefits of reliable water service may justify greater focus on servicing models over installation models.

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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". temporarily and then emptied, transported, and treated off-site; or (iii) transported through a sewer with wastewater and then treated off-site [2]. These additional requirements-i.e., those needed to shift from "improved" to "safely managed" water and sanitation services-would cost approximately $114 billion per year. Hutton and Vergughese [3] estimate the global capital costs of achieving universal access to Water, Sanitation and Hygiene (WASH) services by 2030 are US$ 28.4 billion per year (range: US$13.8 to US$46.7 billion) from 2015 to 2030 for basic WASH (similar to "improved" standard), and $114 billion per year (range: $74 to $166 billion) for safely managed WASH to meet [3]. Monitoring progress toward them, and associated outcomes, is critical to ensure that available funding is spent wisely over time.Against this backdrop emergent technologies, methods, and data-sharing platforms are being used to monitor the impacts of water supply, sanitation, and hygiene (WASH) interventions. These may focus on improving service quality or access to service. The improved monitoring of WASH interventions, it is hoped, will reveal increasingly cost-effective and efficient ways to meet SDG 6. New technologies and methods may facilitate the collection and analysis of increasingly complete and impartial data over time-with significant implications for program improvements. For instance, sensor networks are ubiquitous in most developed markets, where they are used to monitor industrial processes, track products, and organize information services. More recently, many organizations have begun leveraging sensors for supply chain management, remote monitoring, and consumer product testing.Data underpin the governance elements of accountability and transparency. They enable progress to be monitored and service providers, governments and development partners to be held accountable. Many countries lack the financial, institutional and human resources needed to acquire and analyze data to support governance. Less than half of US Member States have comparable data available on progress towards meeting ...

Although large-scale programs, like India's Total Sanitation Campaign (TSC), have improved latrine coverage in rural settings, evidence suggests that actual use is suboptimal. However, the reliability of methods to assess latrine use is uncertain. We assessed the reliability of reported use, the standard method, by comparing survey-based responses against passive latrine use monitors (PLUMs) through a cross-sectional study among 292 households in 25 villages in rural Odisha, India, which recently received individual household latrines under the TSC. PLUMs were installed for 2 weeks and householders responded to surveys about their latrine use behavior. Reported use was compared with PLUM results using Bland–Altman (BA) plots and concordance statistics. Reported use was higher than corresponding PLUM-recorded events across the range of comparisons. The mean reported “usual” daily events per household (7.09, 95% confidence interval [CI] = 6.51, 7.68) was nearly twice that of the PLUM-recorded daily average (3.62, 95% CI = 3.29, 3.94). There was poor agreement between “usual” daily latrine use and the average daily PLUM-recorded events (ρc = 0.331, 95% CI = 0.242, 0.427). Moderate agreement (ρc = 0.598, 95% CI = 0.497, 0.683) was obtained when comparing daily reported use during the previous 48 hours with the average daily PLUM count. Reported latrine use, though already suggesting suboptimal adoption, likely exaggerates the actual level of uptake of latrines constructed under the program. Where reliance on self-reports is used, survey questions should focus on the 48 hours prior to the date of the survey rather than asking about “usual” latrine use behavior.