Médecins Sans Frontières-Operational Centre Amsterdam piloted the distribution of household disinfection kits (HDKs) and health promotion sessions for cholera prevention in households of patients admitted to their cholera treatment centres in Carrefour, Port au Prince, Haiti, between December 2010 and February 2011. We conducted a follow-up survey with 208 recipient households to determine the uptake and use of the kits and understanding of the health promotion messages. In 61% of surveyed households, a caregiver had been the recipient of the HDK and 57.7% of households had received the HDKs after the discharge of the patient. Among surveyed households, 97.6% stated they had used the contents of the HDK after receiving it, with 75% of these reporting using five or more items, with the two most popular items being chlorine and soap. A significant (p < 0.05) increase in self-reported use items in the HDK was observed in households that received kits after 24 January 2011 when the education messages were strengthened. To our knowledge, this is the first time it has been demonstrated that during a large-scale cholera outbreak, the distribution of simple kits, with readily available cleaning products and materials, combined with health promotion is easy, feasible, and valued by the target population.

ObjectiveTo investigate the concentration of residual chlorine in drinking water supplies in refugee camps, South Sudan, March–April 2013.MethodsFor each of three refugee camps, we measured physical and chemical characteristics of water supplies at four points after distribution: (i) directly from tapstands; (ii) after collection; (iii) after transport to households; and (iv) after several hours of household storage. The following parameters were measured: free and total residual chlorine, temperature, turbidity, pH, electrical conductivity and oxidation reduction potential. We documented water handling practices with spot checks and respondent self-reports. We analysed factors affecting residual chlorine concentrations using mathematical and linear regression models.FindingsFor initial free residual chlorine concentrations in the 0.5–1.5 mg/L range, a decay rate of ~5x10-3 L/mg/min was found across all camps. Regression models showed that the decay of residual chlorine was related to initial chlorine levels, electrical conductivity and air temperature. Covering water storage containers, but not other water handling practices, improved the residual chlorine levels.ConclusionThe concentrations of residual chlorine that we measured in water supplies in refugee camps in South Sudan were too low. We tentatively recommend that the free residual chlorine guideline be increased to 1.0 mg/L in all situations, irrespective of diarrhoeal disease outbreaks and the pH or turbidity of water supplies. According to our findings, this would ensure a free residual chlorine level of 0.2 mg/L for at least 10 hours after distribution. However, it is unknown whether our findings are generalizable to other camps and further studies are therefore required.

Purpose -To document the drinking water component of the humanitarian response to the Great Sumatra-Andaman earthquake of December 26, 2004, including a focus on the promotion of household water treatment (HHWT)/safe storage to minimize the spread of diarrhoeal disease. Design/methodology/approach -Firsthand accounts of the response effort, interviews, and literature review. Findings -The combined efforts to mobilize a drinking water response were timely, comprehensive and effective. HHWT/safe storage efforts (other than the continued promotion of boiling) appeared to play only a secondary role in the initial response to the disaster for a variety of reasons. Practical implications -The enormity of this disaster and the unprecedented scale of the relief effort limit the broad lessons that can be learned at this time. Originality/value -Shows that there is a clear need to continue to take steps to minimize the risks of waterborne diseases following natural disasters, develop and disseminate practical solutions for the special circumstances associated with tsunamis, including saline water intrusion, clarify the conditions under which proven approaches to HHWT may be useful in emergencies and assess their role in the medium-and long-term response, improve water quality and surveillance without compromising emphasis on water quantity, take advantage of the enormous resources committed to the tsunami response to make effective and sustainable improvements in water, sanitation and hygiene in the affected areas, and document experiences from the tsunami response, distil the lessons learned, disseminate the results and develop guidelines to inform future actions.

The operation of a health care facility, such as a cholera or Ebola treatment center in an emergency setting, results in the production of pathogen-laden wastewaters that may potentially lead to onward transmission of the disease. The research presented here evaluated the design and operation of a novel treatment system, successfully used by Médecins Sans Frontières in Haiti to disinfect CTC wastewaters in situ, eliminating the need for road haulage and disposal of the waste to a poorly-managed hazardous waste facility, thereby providing an effective barrier to disease transmission through a novel but simple sanitary intervention. The physico-chemical protocols eventually successfully treated over 600 m3 of wastewater, achieving coagulation/flocculation and disinfection by exposure to high pH (Protocol A) and low pH (Protocol B) environments, using thermotolerant coliforms as a disinfection efficacy index. In Protocol A, the addition of hydrated lime resulted in wastewater disinfection and coagulation/flocculation of suspended solids. In Protocol B, disinfection was achieved by the addition of hydrochloric acid, followed by pH neutralization and coagulation/flocculation of suspended solids using aluminum sulfate. Removal rates achieved were: COD >99%; suspended solids >90%; turbidity >90% and thermotolerant coliforms >99.9%. The proposed approach is the first known successful attempt to disinfect wastewater in a disease outbreak setting without resorting to the alternative, untested, approach of ‘super chlorination’ which, it has been suggested, may not consistently achieve adequate disinfection. A basic analysis of costs demonstrated a significant saving in reagent costs compared with the less reliable approach of super-chlorination. The proposed approach to in situ sanitation in cholera treatment centers and other disease outbreak settings represents a timely response to a UN call for onsite disinfection of wastewaters generated in such emergencies, and the ‘Coalition for Cholera Prevention and Control’ recently highlighted the research as meriting serious consideration and further study. Further applications of the method to other emergency settings are being actively explored by the authors through discussion with the World Health Organization with regards to the ongoing Ebola outbreak in West Africa, and with the UK-based NGO Oxfam with regards to excreta-borne disease management in the Philippines and Myanmar, as a component of post-disaster incremental improvements to local sanitation chains.

Waterborne illnesses are a leading health concern in refugee and internally displaced person (IDP) settlements where waterborne pathogens often spread through household recontamination of stored water. Ensuring sufficient chlorine residual is important for protecting drinking water against recontamination and ensuring water remains safe up to the point-of-consumption. We used ensembles of artificial neural networks (ANNs) to probabilistically forecast the point-of-consumption free residual chlorine (FRC) concentration and to develop point-of-distribution FRC targets based on the risk of insufficient FRC at the point-of consumption. We built ANN ensemble models using data from three refugee settlements and found that the risk-based FRC targets generated by the ensemble models were consistent with an empirical water safety evaluation, indicating that the models accurately predicted the risk of low point-of-consumption FRC despite all ensemble forecasts being underdispersed even after post-processing. This demonstrates the usefulness of ANN ensembles for generating risk-based point-of-distribution FRC targets to ensure safe drinking water in humanitarian operations.