The Impact of Improved Water Supply on Cholera and Diarrhoeal Diseases in Uvira, Democratic Republic of the Congo: A Protocol for a Pragmatic Stepped-Wedge Cluster Randomised Trial and Economic Evaluation

Gallandat, Karin; Jeandron, Aurélie; Ross, Ian; Saidi, Jaime Mufitini; Rumedeka, Baron Bashige; Kapepula, Vercus Lumami; Allen, Elizabeth; MacDougall, Amy; Cumming, Oliver

doi:10.21203/rs.3.rs-61607/v1

Cited by 4 publications

(6 citation statements)

References 44 publications

Supporting

Mentioning

Contrasting

Order By: Relevance

“…There is also a need for more rigorous studies of water supply improvements. Although prospective evaluations of water supply interventions are being done (e.g., [102]), we are only aware of one published randomised field trial of a water supply improvement in Ghana [103] and one study that randomised encouragement of subsidies for household connections in Morocco [104]. If services are allocated by administrative area or according to a threshold rule (e.g., the share of community members currently covered by a service), it may be possible to use a discontinuity design, an approach that has been shown to generate the same effect estimates as RCTs, whether applied prospectively or retrospectively [105].…”

Section: Conclusion and Suggested Research Directionsmentioning

confidence: 99%

Impact on childhood mortality of interventions to improve drinking water, sanitation and hygiene (WASH) to households: systematic review and meta-analysis

Waddington

Masset

Bick³

et al. 2023

Preprint

View full text Add to dashboard Cite

Background In low- and middle-income countries (L&MICs), the biggest contributing factors to the global burden of disease in childhood are deaths due to respiratory illness and diarrhoea, both of which are closely related to use of water, sanitation and hygiene (WASH) services. However, current estimates of the health impacts of WASH improvements use self-reported morbidity, which may fail to capture longer-term or more severe impacts. Moreover, reported mortality is thought to be less prone to bias. This study aimed to answer the question: what are the impacts of WASH intervention improvements on reported childhood mortality in L&MICs? Methods and findings We conducted a systematic review and meta-analysis, using a published protocol. Systematic searches of 11 academic databases and trial registries, plus organisational repositories, were undertaken to locate studies of WASH interventions which were published in peer review journals or other sources (e.g., organisational reports and working papers). Intervention trials of WASH improvements implemented under endemic disease conditions in L&MICs were eligible, from studies which reported findings at any time until March 2020. We used the participant flow data supplied in response to journal editors’ calls for greater transparency. Data were collected by two authors working independently. We included evidence from 24 randomized and 11 non-randomized studies of WASH interventions from all global regions, incorporating 2,600 deaths. Effects of 48 WASH treatment arms were included in analysis. We critically appraised and synthesised evidence using meta-analysis to improve statistical power. We found WASH improvements are associated with a significant reduction of 17 percent in the odds of all-cause mortality in childhood (OR=0.83, 95%CI=0.74, 0.92, evidence from 38 interventions), and a significant reduction in diarrhoea mortality of 45 percent (OR=0.55, 95%CI=0.35, 0.84; 10 interventions). Further analysis by WASH technology suggested interventions providing improved water in quantity to households were most consistently associated with reductions in all-cause mortality. Community-wide sanitation was most consistently associated with reductions in diarrhoea mortality. Around one-half of the included studies were assessed as being at ‘moderate risk of bias’ in attributing mortality in childhood to the WASH intervention, and no studies were found to be at ‘low risk of bias’. The review should be updated to incorporate additional published and unpublished participant flow data. Conclusions The findings are congruent with theories of infectious disease transmission. Washing with water presents a barrier to respiratory illness and diarrhoea, which are the two main components of all-cause mortality in childhood in L&MICs. Community-wide sanitation halts the spread of diarrhoea. We observed that evidence synthesis can provide new findings, going beyond the underlying data from trials to generate crucial insights for policy. Transparent reporting in trials creates opportunities for research synthesis to answer questions about mortality, which individual studies of interventions cannot be reliably designed to address.

show abstract

Section: Conclusion and Suggested Research Directionsmentioning

confidence: 99%

Impact on childhood mortality of interventions to improve drinking water, sanitation and hygiene (WASH) to households: systematic review and meta-analysis

Waddington

Masset

Bick³

et al. 2023

Preprint

View full text Add to dashboard Cite

show abstract

“…An annual average of 1,200 admissions (range: 451-1883) was recorded between 2009 and 2021 at acute diarrhoeal disease treatment facilities managed by the Uvira Health Zone and where data were collected for the health impact evaluation of water supply improvements. The use of rapid diagnostic tests since 2016 suggests that approximately 40% of patients admitted to cholera treatment facilities are cholera cases (16,17).…”

Section: Study Settingmentioning

confidence: 99%

“…A stepped-wedge cluster randomised trial was designed specifically to assess the effects of water supply service improvements on cholera and diarrhoeal diseases (19). Given the complexity of both the context and intervention, and challenges faced during implementation, an observational (rather than randomised) approach was adopted for the epidemiological analysis as per the planned study protocol, and this process evaluation is intended to complement the trial (17).…”

Section: Main Studymentioning

confidence: 99%

Process evaluation of an urban piped water supply infrastructure improvement programme in a cholera hotspot

Gallandat,

Hutchins,

Malembaka

et al. 2023

Preprint

View full text Add to dashboard Cite

Large-scale investments in water supply infrastructure will be required to achieve Sustainable Development Goal (SDG) 6. Safely managed water services are also a central element of global strategies to prevent cholera and diarrhoeal diseases. However, evidence remains scarce on how to efficiently improve piped water services in the complex settings that bear high disease burdens and where infrastructure investments are most needed. We conducted a process evaluation of a large-scale water supply infrastructure improvement programme in the town of Uvira, an endemic cholera hotspot in South Kivu, Democratic Republic of the Congo. Considering three evaluation domains – context, implementation of the intervention, and population response –, we assessed the validity of the programme’s theory of change and its underlying assumptions. Information sources included documents related to construction works and to the programme implementation, operational and billing records from the water system operator, and household surveys, covering the period from 2014 until 2021.The programme did not achieve the expected improvements in the water supply service available to the population of Uvira during the evaluation period. Contextual challenges included major events such as extreme flooding in early 2020 and the Covid-19 pandemic. Issues related to the electricity supply and the rise of Lake Tanganyika emphasise the need for cross-sectoral approaches and consideration of climate change in the planning of water supply infrastructure. Implementation challenges underlined a need for capacity strengthening alongside infrastructure improvements. Population response elements revealed the importance of designing affordable interventions and of taking informal practices such as the sharing of household taps into account. The programme was a good example of early engagement with researchers. Pragmatic evaluation approaches combining relevant methods should be adopted for the generation of useful scientific evidence from complex programmes in order to inform and enhance the effectiveness of future infrastructure investments contributing to progress towards SDG6.

show abstract

“…(23,24) In Uvira, South Kivu, DRC, cholera is endemic with stable transmission punctuated by seasonal outbreaks. (18) Using an enhanced clinical surveillance system with rapid diagnostic testing that was setup in Uvira's cholera treatment units to support an impact evaluation of water supply infrastructure improvements (25), we investigate the location, timing, and annual prediction of spatiotemporal clustering and to estimate the extent of spatiotemporal zones of increased cholera risk around incident cases in an endemic setting.…”

Section: (Which Was Not Certified By Peer Review)mentioning

confidence: 99%

“…(18,20,(26)(27)(28) Several city-wide interventions have been implemented including a water supply infrastructure program to improve the production and supply of piped drinking water for which construction started in 2018 and mass vaccination that took place from July to October 2020. (25)…”

Section: Settingmentioning

confidence: 99%

Spatiotemporal modelling of cholera and implications for its control, Uvira, Democratic Republic of the Congo

Ratnayake,

Knee,

Cumming

et al. 2023

Preprint

View full text Add to dashboard Cite

The African Great Lakes region including Eastern Democratic Republic of the Congo is a hotspot for cholera transmission. We evaluated the local and global clustering of cholera using 5 years (2016-2020) of suspected cases positive by rapid diagnostic test in Uvira, South Kivu to detect spatiotemporal clusters and the extent of zones of increased risk around cases. We detected 26 clusters (mean radius 652m and mean duration 24.8 days) which recurred annually in three locations and typically preceded seasonal outbreaks. We found a 1100m zone of increased infection risk around cases during the 5 days following clinic attendance for the 2016-2020 period and a 600m radius risk zone for 2020 alone. These risk zone sizes correspond with the area typically used for targeted intervention in the Democratic Republic of the Congo. Our findings underscore the value of the site-specific evaluation of clustering to guide targeted control efforts.

show abstract

The Impact of Improved Water Supply on Cholera and Diarrhoeal Diseases in Uvira, Democratic Republic of the Congo: A Protocol for a Pragmatic Stepped-Wedge Cluster Randomised Trial and Economic Evaluation

Cited by 4 publications

References 44 publications

Impact on childhood mortality of interventions to improve drinking water, sanitation and hygiene (WASH) to households: systematic review and meta-analysis

Impact on childhood mortality of interventions to improve drinking water, sanitation and hygiene (WASH) to households: systematic review and meta-analysis

Process evaluation of an urban piped water supply infrastructure improvement programme in a cholera hotspot

Spatiotemporal modelling of cholera and implications for its control, Uvira, Democratic Republic of the Congo

Contact Info

Product

Resources

About