Effect of household water treatment with chlorine on diarrhea among children under the age of five years in rural areas of Dire Dawa, eastern Ethiopia: a cluster randomized controlled trial

Abstract

Background Diarrheal disease is a leading cause of child mortality and morbidity worldwide. Household water treatment with chlorine significantly reduces morbidity due to waterborne diseases. However, the effect of point-of-use (POU) water treatment in improving the quality of water in areas where POU is not provided free of charge and the effectiveness of home visits in inspiring household members to use POU regularly have not been studied. The objective of this study was to evaluate the effectiveness of drinking water disinfection by chlorination on diarrheal disease reduction among children under the age of 5 years in rural eastern Ethiopia. Methods A cluster randomized controlled trial was carried out in rural Dire Dawa from October 2018 through January 2019. The 405 households were randomized to intervention and control arms and intervention materials were distributed after conducting a baseline survey. This trial evaluated the effectiveness of household drinking water disinfection by chlorination in reducing incidence of diarrhea among children under the age of 5 years. Intervention households received 1.2% sodium hypochlorite with demonstration of its proper use. Participants in the control households continued with their usual habits of water collection and water storage. Generalized estimation equations (GEE) with log link Poisson distribution family and exchangeable correlation matrix was used to compute crude incidence rate ratio (IRR), adjusted IRR and the corresponding 95% confidence intervals. Results In the intervention households, in total, 281 cases of diarrhea were documented (8.7 cases per 100 person-weeks observation); in the control households, in total 446 cases of diarrhea were documented (13.8 cases per 100 person-weeks observation). A 36.0% (adjusted IRR = 0.64, 95% CI: 0.57–0.73) reduction in incidence of diarrhea was observed in the intervention arm when compared with the control arm. The highest and the lowest reductions were obtained in children of age ranges 1 to 2 years and 3 to 4 years, 42.7 and 30.4%, respectively. Adherence to the intervention was 81.3% as measured by free residual chlorine test. Conclusions In rural areas where diarrhea is the second leading cause of morbidity, water chlorination at the household level using liquid bleach considerably reduced episodes of diarrhea among children under the age of 5 years. Therefore, chlorinating drinking water at the household level may be a valuable interim solution for reducing the incidence of diarrheal diseases until potable water is made accessible to the majority of the population in Dire Dawa Administration and other Ethiopian communities. Trial registration PACTR, PACTR201807815961394. Registered 16 July 2018, www.pactr.org

Effect of handwashing with soap at crtitical times and home based water treatment in combating hot spot areas of childhood diarrhea in Ethiopia

“…Our result suggested a 52% (IRR = 0.48, 0.42, 0.54, P < 0.001) reduction in CHD from home based water treatment households, which is comparable to the ndings of a 48.0% reduction in Zambia [41], but higher than a 36% reduction in Dire Dawa, eastern Ethiopia [42]. It is evidenced that home based water treatment minimizes the risk of recontamination despite the improved water supply system [43][44][45].…”

“…Likewise, there might be the presence of chlorine-resistant parasitic protozoa such as oocysts of the Cryptosporidium species and cysts of Giardia lamblia [55]. In other parts, discontinuous use of the water treatment product due to the odor and taste of sodium hypochlorite may be a reason for these disparities in magnitude of the reduction [42]. Moreover, the correct and consistent usage of treated water relies almost exclusively on the consumer behavior [43].…”

A Qualitative Analysis of Factors Influencing Household Water Treatment Practices Among Consumers of Self-Supplied Water in Rural Ethiopia

“…26 It should be noted that the chlorine taste and smell of chlorine-based water treatment products are not insurmountable obstacles to its use, particularly if people are encouraged to use it until they grow accustomed to the smell. 27 In the study area, widespread civic disillusionment was seen as leading to the community's failure to sustain safe water practices. Participants raised concerns about the genuineness of the training they are given at different times.…”

“…26 It should be noted that the chlorine taste and smell of chlorine-based water treatment products are not insurmountable obstacles to its use, particularly if people are encouraged to use it until they grow accustomed to the smell. 27 …”

Factors affecting under-five diarrhea in households with dirt floors: a multilevel mixed-effects analysis from a national survey of Ethiopia

“…Almost 88% of diarrhea-associated deaths are attributable to unsafe water, inadequate sanitation, and insu cient hygiene [9]. Several studies explore the effect of single and combined water, sanitation, and hygiene (WASH) intervention in the reduce risk of diarrheal morbidity [8, [10][11][12][13][14]. For example, a systematic review for the effect of WASH interventions for acute childhood diarrhea found that various WASH interventions show diarrhea risk reductions between 27% and 53% in children under ve years old, depending on intervention type [11].…”