Water, sanitation, and hygiene (WASH) interventions are key to reducing the burden of disease associated with outbreaks, and are commonly implemented in emergency response. However, there is a lack of summarized evidence on the efficacy and effectiveness of these interventions. We conducted a systematic review of published and grey literature by developing theory of change models, developing inclusion criteria, conducting the search, selecting evaluations for inclusion, assessing the quality of the evidence, and analysing the included evaluations. Overall, 15,026 documents were identified and 51 evaluations from 47 studies met inclusion criteria. Interventions from 19 countries were included, primarily in response to cholera (86 per cent). Most included evaluations (70 per cent) were at high risk of bias and nearly half were from grey literature (49 per cent). We found that WASH interventions consistently reduced both the risk of disease and the risk of transmission in outbreak contexts; however, programme design and beneficiary preferences were important considerations to ensure WASH intervention effectiveness. Critical programme design characteristics included simple interventions that were appropriately timed, community-driven, and had linkages between relief and development. Beneficiary preferences, barriers, and facilitators to WASH interventions in outbreak response were taste and smell of water treatment, communication methods, inaccurate perception of efficacy, and trust/fear. Research on commonly implemented but severely under-researched WASH interventions is recommended. It is also recommended that responders implement interventions that are: efficacious, simple, well-timed, community-driven, link relief and development, and address barriers and facilitators to use with communities.

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The International Initiative for Impact Evaluation (3ie) is an international grant-making NGO promoting evidence-informed development policies and programmes. We are the global leader in funding, producing and synthesising high-quality evidence of what works, for whom, why and at what cost. We believe that better and policy-relevant evidence will help make development more effective and improve people's lives. 3ie systematic reviews 3ie systematic reviews appraise and synthesise the available high-quality evidence on the effectiveness of social and economic development interventions in low-and middleincome countries. These reviews follow scientifically recognised review methods, and are peer-reviewed and quality assured according to internationally accepted standards. 3ie is providing leadership in demonstrating rigorous and innovative review methodologies, such as using theory-based approaches suited to inform policy and programming in the dynamic contexts and challenges of low-and middle-income countries.

In 2012 and 2013, as part of relief-to-recovery programming, Child Relief International partnered with Haiti Philanthropy to install automatic tablet-based chlorinators in 79 gravity-fed water distribution systems in Southeast Department, Haiti. We carried out a mixed methods evaluation to assess sustained effectiveness of chlorinators approximately two years after installation, including 18 site assessments of chlorinators and distribution systems, 180 surveys of households served by those systems and 17 key informant interviews. We tested for free chlorine residual and Escherichia coli in samples collected from sources, reservoirs, water access points, and treated and untreated household stored water. We found: 83% of chlorinators were in operational condition, although water pressure was sufficient to operate chlorinators at only 56% of sites; 0% of chlorinator sites had tablet stock; and, while 86% of households reported using water from distribution systems with a chlorinator, 0% of household drinking water was safe to drink because of chlorinators. Reasons why the chlorinator project did not achieve intended sustained effectiveness included: lack of accountability for infrastructure maintenance; lack of tablet access; and lack of effective community management systems. We recommend future implementers of centralized water treatment systems in relief-to-recovery contexts consider these three components necessary for sustainability. by guest *Pressure was not sufficient for water to flow through the chlorinator diversion pipe. **System turned off to encourage people to pay for water. 606 J. Rayner et al. | Sustained effectiveness of automatic chlorinators in Haiti Journal of Water, Sanitation and Hygiene for Development | 06.4 | 2016 Downloaded from https://iwaponline.com/washdev/article-pdf/6/4/602/386055/washdev0060602.pdf by guest With the recent establishment of DINEPA, ownership and accountability for operation and maintenance of community water systems may not yet be well established. Lack of tablet access Lack of chlorine tablet access was identified as the primary reason for non-use in 61% of sites. During the program, 610 J. Rayner et al. | Sustained effectiveness of automatic chlorinators in Haiti Journal of Water, Sanitation and Hygiene for Development | 06.4 | 2016 Downloaded from https://iwaponline.com/washdev/article-pdf/6/4/602/386055/washdev0060602.pdf by guest

Household water treatment (HWT) can reduce the diarrheal disease burden in populations without access to safe water. We evaluated five programs that distributed biosand, ceramic, or Sawyer filters in Haiti after the 2010 earthquake and cholera outbreak. We conducted household surveys and tested Escherichia coli and turbidity in stored household untreated and treated water in ∼50 randomly selected households from each program. Across programs, self-reported filter use ranged from 27 to 78%; confirmed use (participants with reported use who also showed the filter with water currently in it) ranged from 20 to 76%; and effective use (participants who used the filter to improve water quality to international guideline values) ranged from 0 to 54%. Overall, programs that more successfully met evaluation metrics: (1) distributed an effective technology; (2) provided safe storage; (3) required cash investment; (4) provided initial training; (5) provided follow-up; (6) provided supply-chain access; (7) targeted households relying on contaminated water sources; and, (8) had experience working in the local context. These findings, similar to results of previous research on HWT, suggest that well-implemented programs have the potential to result in sustained household filter use in Haiti.