Abstract Book

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Table of Contents
Verbal Abstracts......................................................................................................................... 3
Poster Abstracts ....................................................................................................................... 51
Virtual Poster Abstracts ......................................................................................................... 131

Welcome to the 2022 UNC Water and Health Conference! For ease of use, the abstracts of
presenting authors have been sorted into verbal, in-person poster, and virtual poster
abstracts. The abstracts in each section are listed alphabetically. Abstracts are marked as
follows:

Top 20 Abstract

WaterAid Sanitation Award Winner and First Runner-Up

Due to back-ups at embassies caused by Covid-19, many of

our top presenters were unable to secure travel to the US and
are instead presenting virtual posters. We encourage you to
register for the virtual conference (free!) and log on in order
to see these additional presentations.

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 Verbal Abstracts

Verbal Abstracts
Alphabetical by title

A Cost-Benefit Analysis of Menstrual Health and Hygiene Improvements in Private Sector Workplaces
Aditi Krishna, Iris Group
Additional Authors: Mary Kincaid, Michelle Bronsard, Michal Avni, Jake Eaton

Overall purpose of study:

Women and girls across the globe experience challenges managing their periods, especially those who live and work in
environments that do not support adequate menstrual health and hygiene (MHH). The costs and benefits of achieving a
supportive environment for MHH are poorly understood and almost no research has been conducted in workplaces.
This study reports on the cost-benefit analysis (CBA) of the “Menstrual Health Management in the Workplace” action
research. It addresses the question: What are the financial and social costs and benefits – both for women employees
and the employing companies – of improving MHH in private sector workplaces?
Study Design:
The intervention was conducted over a 9–11-month period in four workplaces in Kenya and Nepal. It included the
provision of menstrual products and infrastructure upgrades, changes in workplace policies, and education and behavior
change communication.
The cost-benefit analysis component collected main categories of variables: 1) market variables (valued by market
prices, such as the cost of one day’s labor); and 2) non-market variables, measured by willingness to pay for the
intervention. Total costs of the project were tracked across implementation; they included the total costs of menstrual
materials, updates to workplace infrastructure, and labor required to conduct the intervention or participate in
intervention activities. Benefits included reductions in absences due to menstruation, savings in healthcare expenditures
due to menstruation-related complications, and an overall valuation of the social benefits of the intervention as
measured through a willingness-to-pay survey.
Key Findings:
CBA: On average, the benefits of implementing the program outweighed the costs: every $1 invested returned $1.40 in
benefits. When projected to 24 months, every $1 invested would return $2.19 in benefits.
Over 10 months, the intervention broke even at 3 out of 4 workplaces. The benefit-cost ratio (BCR) varied from 0.5 to
2.0. When projected over two years, the intervention would break even at all 4 workplaces, with BCRs ranging from 1.1
to 3.0. Results were robust across both an optimistic and conservative scenario. The cost with the largest impact on BCR
was infrastructural improvements; calculated benefits were roughly equivalent across contexts and appeared to be
independent of infrastructural upgrades, which ranged from $0 to >$6,000.
Discussion of how findings inform science, policy, and our practice:
To our knowledge, this is the first CBA of the impacts of achieving adequate MHH in private sector workplaces. The
positive results suggest a favorable rationale for businesses to implement MHH programming, though further research is
required to verify across contexts. Our findings also suggest that menstrual products and workplace culture changes are
instrumental in reducing absences and menstruation-related healthcare expenses. These results suggest that future
workplace interventions, if unable to scale infrastructure improvements, may still benefit markedly from the provision of
menstrual products.

Accelerating sustainability in WASH Services through Business Centers in Ethiopia

Abiy Tafesse Hadera, World Vision Ethiopia
Additional Authors: James B. Tidwell; Desalegn Ayalew Sewagegn

Highlights:
• WASH Business Centre initiative in Ethiopia provide desirable, affordable, and accessible products and services
• Those who know of the centres are more than twice as likely to have improved sanitation

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• Coverage gaps mostly from lack of awareness, with a financing gap to reach the poorest households
Introduction and Objectives:
The sustainability of water, sanitation, and hygiene has emerged as a challenge in Ethiopia. World Vision Ethiopia
introduced the WASH Business Centres (WBCs) initiative at the end of 2017 to address these challenges, a one stop
center for production, sales, and distribution of WASH products and services to communities, schools, and health care
facilities. Products include spare parts for water schemes, latrine slabs, handwashing facilities, and soap. Rigorous study
of such approaches has been rare, so we set out to assess coverage taps as well as whether awareness, marketing,
location, or financing were the larger barriers to higher coverage rates.
Methodology Approach:
We conducted a survey of almost 1600 households within 5km of the WBCs to understand their impact on their local
communities. We had enumerators ask about household demographics and WASH characteristics and awareness and
use of the WBCs. We also randomly gave households discount vouchers for 10%, 30%, or 50% discounts on improved
slabs and separately for handwashing facilities modelled after contextually appropriate water pots to ensure we had
valid data on consumer willingness to pay. We used spatial analysis along with the voucher data to ascertain what was
driving low rates of coverage. We also assessed WBCs financial records.
Analysis and Results:
The 16 WBCs have been established for 3 years on average and have cumulatively reached more than 88,000
households in total, with a total operating profit of more than $40,000. However, while 81% of respondents had a toilet,
only 11% had an improved toilet and 12% had a place for hand washing. Only 1/3 of respondents had heard of the
WBCs, but half of those had made a purchase, and those who had heard of the centers were more than twice as likely to
have an improved toilet. For households within 5km of the centres, 65% traveled to within 1km or less of the center on a
monthly or more frequent basis, and no differences in prior awareness or voucher redemption were observed based on
distance from the center. Redemption rates within one month were very low for the 10% discount, designed to assess
the impact of marketing alone, but rates for 30% and 50% discounts demonstrated that sanitation coverage rates would
double within a only month if financing and marketing gaps were addressed. We found that such gains would be
inequitably realized across wealth quintiles without such financing considerations, so the equity of market-based
approaches should be carefully considered.
Conclusions and recommendations:
This study demonstrates the promise of combined retail and wholesale approaches to improving supply and delivering
gains in WASH coverage. Challenges of marketing and financing remain. While reaching a broader audience to raise
awareness may be straightforward, developing and introducing more affordable products and financing options is
significantly harder, but will be needed to ensure equitable coverage gains. This approach of combining household
survey data with real-life purchase data to facilitate modelling of business decisions needed to reach high coverage
levels is useful to inform entrepreneurs directly and how governments and CSOs can support them to reach universal
WASH coverage.

Access to water in northern remote communities in Canada: Are we missing something?

Alexandra Cassivi, Université Laval
Additional Authors: Manuel Rodriguez; Stephanie Guilherme

Whilst focus is often turned on the most disadvantaged regions, more than 50 million people in Europe and North
America live without safely managed drinking water (WHO/UNICEF, 2019). In Inuit Nunangat (homeland of the Inuit in
Canada), water provision and sewage collection are, in 80% of the communities, operationalized through truck-to-
cistern systems. Problems with operations and maintenance of water and sewage services, including climatic constraints
and mechanical failures, results in intermittency, frequent boil-water advisories, and interrupted services in households
(e.g., hydrocarbons contamination led to emergency in Iqaluit in 2021). Likewise, water trucking complexifies monitoring
and compliance with water quality standards and guidelines to ensure safety from the point of entry into the
distribution system to the point of use (i.e., household tap). In view of increasing resilience, there is a need to better
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understand overall domestic access to water and the risks associated with water truck-to-cistern supply in northern
communities. A case study was organized, with local partners guidance and community approval, in the northern village
of Kangiqsualujjuaq, Nunavik (Quebec, Canada) in August 2021. A household survey (n=65), using a paper-based
questionnaire, and water quality testing (i.e., microbiological, and physicochemical parameters) from the water sources
to the point of use (i.e., household taps) were conducted in the community. Results show that households reporting a
shortage (i.e., at least once when their households did not have water from the tap of water) in the previous week (33%)
were more likely to report being unsatisfied or very unsatisfied with the quantity of water delivered, compared to
households that did not report a water shortage (rs 0.395, p=0.004). The size of the households did not significantly
increase the likeliness of reporting water shortage. In terms of consumption, many households (37%) reported not
drinking tap water provided from truck-to-cistern. Taste of chlorine was reported as a recurrent concern in the
community, and households that reported being concerned about it were significantly less likely to drink water directly
from the tap (p=0.002). Level of free chlorine residual at the point of use (range bdl to 0.2 mg/L; mean 0.1 mg/L) was,
however, generally below recommended Regulation respecting the quality of drinking water (RQEP) (≥ 0.2 mg/L in the
tank truck). Insufficiencies and dissatisfaction of the water supply, as well as individual preferences, support the fact that
most households (77%) rather use alternative water sources for drinking purposes, i.e., public tap at the water
treatment plant, natural sources or purchasing bottled water. Results from the survey shows that Inuit were more likely
to rely on additional sources (p<0.001) compared to non-resident population and that an increase in the household’s
size also increased the likeliness of using alternative water sources (rs 0.3722, p=0.005). Various organizational factors
that relate to supply and water quality as well as socioeconomic and housing conditions influence household practices
and perceptions. Better understanding of overall access provide evidence to directed efforts toward mitigating risks
associated to service disruptions, use of alternative sources for drinking purposes as well as maintenance of water
quality in decentralized truck-to-cistern system.

Adaptive Strategies to Enhance Water Security and Resilience in Low- and Middle-income Countries: A Critical
Review
Allison Lee, UNC-Chapel Hill
Additional Authors: Sarah Lebu, Valerie Bauza, Aaron Salzberg

Background:
The water sector is facing unprecedented pressures as increased environmental and anthropogenic challenges, such as
climate change and rapid urbanization, impact the availability and predictability of safe drinking water. Water security
and resilience (WS&R) describes the capacity of drinking water systems to withstand and adapt to these unexpected
stresses that may threaten water service and supplies. There is a need for practitioners and policymakers to integrate
WS&R factors into programming to sustain investments in drinking water systems to support associated economic,
security, and public health benefits. In response to intensifying impacts from WS&R risks, communities and drinking
water systems around the world are developing adaptive strategies, and a critical review of these strategies may provide
lessons that can be implemented at scale.
Objectives:
We conducted a critical assessment of existing WS&R adaptations in low- and middle-income countries (LMICs) and
evaluated the suitability of each adaptation for different contexts. We created a portfolio of adaptive strategies to
inform practitioner and policymaker efforts in enhancing resilience of drinking water systems.
Methods:
This critical review analyzes existing literature on adaptive strategies for achieving water security in response to WS&R
risks and impacts in LMICs. We systematically screened over 9,000 peer-reviewed and grey literature articles and
extracted data from relevant studies that propose, pilot, and/or evaluate adaptations in LMICs. Based on results from
data extraction, we created portfolios of complementary adaptations, synthesizing associated strengths, weaknesses,
and implementation lessons for each adaptation. We developed a decision-tree framework that provides a consistent
and replicable process for informing investment and policy choices around WS&R.
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Results:
Literature identified an assortment of adaptations from over 75 LMICs, developed in response to WS&R risks and
impacts experienced around the world. Over 20 adaptations were identified, including strategies such as stormwater
management, wastewater reuse, non-revenue water reductions, water pricing, and public awareness campaigns. We
categorized adaptations by function (improving water management, augmenting existing supplies, reducing water
demand) and scale (household, municipal, regional) to better target recommendations to local challenges. For each
adaptation, we highlighted associated strengths, weaknesses, barriers to adoption, successes, and challenges in
implementation, and enabling environments. We developed a decision-tree tool to recommend a portfolio of
adaptations for practitioners and policymakers to enhance resilience, according to the risks, scale, geography, and
climate experienced by the area of interest. The portfolio includes combinations of adaptations that may apply to the
area of interest since many adaptations in tandem build resilience more holistically. We propose an assortment of
complementary adaptations based on a criterion of risks addressed, scale of implementation, and suitable climate.
Conclusion:
Water security and resilience is critical to sustain water services and supply amidst growing challenges. This critical
review presents recommendations for practitioners and policymakers to invest in WS&R adaptations, catered to shared
risks and contexts. As communities and drinking water systems in LMICs adapt to unprecedented pressures, their
successes and challenges can be harnessed and tailored for future implementation in similar contexts.

Antimicrobial Resistance and Environmental Health: A Water Stewardship Framework for Global and National
Action
Rachel Kaiser, Tennessee Technological University
Additional Authors: Lina Taing, Himesh Bhatia

Antimicrobial resistance (AMR) is a global health crisis that affects all life on Earth. In 2015, the World Health
Organization developed guidance to combat AMR in accordance with a One Health framework considering human,
animal, and environmental sectors of planetary health. This study reviewed global guidance and 25 National Action Plans
to evaluate thematic priorities in One Health AMR approaches using a novel framework that additionally facilitated the
identification of water-related stewardship gaps, as water resources are recognized as the primary environmental AMR
reservoir and dissemination pathway. This review found that global and national stewardship primarily focuses on
mitigating antibiotic use in the human and animal sectors, overlooking environmental drivers, particularly diverse
environmental waters. The findings of this study highlight the need to broaden the scope of water-related AMR
concerns beyond water, sanitation, and hygiene (WASH) infrastructure for water supply and wastewater treatment, and
account for environmental waters in AMR development and dissemination, particularly in low-income countries where
half a billion people rely on environmental waters to meet daily needs. Equitably accounting for water environments,
supplies, and waste in AMR prevention, mitigation, surveillance, and innovation can significantly enhance the integration
of environmental objectives in One Health AMR stewardship.

Assessing the sustained effects of a water filter intervention in Rwamagana, Rwanda: a 30-month longitudinal study
Sabrina Haque, Emory
Additional Authors: Miles A. Kirby, Alemayehu Gebremariam, Howard H. Chang, Matthew Freeman, Thomas Clasen

An estimated 2 billion people use drinking water contaminated with indicators of fecal bacteria, with the majority
residing in sub-Saharan Africa, Central America, and South Asia. Household water treatment and safe storage
interventions have been shown to improve microbial water quality and reduce diarrheal disease in areas lacking access
to safe water, at least in the short term. However, little is known about their sustainability, with few studies evaluating
their effectiveness for over a year. We aimed to assess the longer-term uptake and effects of a household-based filter
with safe storage delivered and promoted through Community Health Clubs in Rwanda’s national environmental health
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program. We undertook a 30-month longitudinal study in Rwamagana District, following 608 households across 30
villages receiving the intervention. We conducted four unannounced follow-up visits and measured filter coverage,
condition, and use, drinking water quality, and child diarrhea prevalence at ~6, 15, 24, and 30 months since the delivery
of the intervention. Coverage of the water filter remained high throughout the follow-up period, with 94% of
households observed to have the filter by the 30-month visit. Compared to the 6-month visit, the households with filters
in good condition declined by 12% at the 30 month-visit, adjusting for seasonal and household characteristics. Filter use
was comparable between the 6- and 15-month visits but fell by the 24- and 30-month visits. About 84% of households
reported using the filter, and 59% had filters with observed water in the storage container by the end of the follow-up.
Water quality did not deteriorate over the duration of the study visits, and child diarrhea prevalence did not increase
after the 6-month visit. These findings suggest coverage, condition, and use of a household water filter delivered using
Community Health Clubs in Rwanda declined only modestly over time. The effects on drinking water quality and child
diarrhea were sustained even 30 months post-implementation.

Assessment of existing mechanization solutions in ensuring occupational safety and health of sanitation workers
Meghna Malhotra, Urban Management Centre
Additional Authors: Meghna Malhotra, Jay Shah, Manvita Baradi

The objectives of the study are as follows:

● Developing a framework to evaluate efficiency and efficacy of existing technologies available for sanitation
service delivery
● Assess if mechanization eliminates sanitation workers’ contact with fecal matter during mechanical cleaning of
sanitation appurtenances
● Identify and recommend suitable machines for cleaning of sanitation infrastructure to enable urban local bodies,
parastatal and private agencies make an informed decision during procurement of machines

The Prohibition of Employment as Manual Scavengers and their Rehabilitation Act, 2013 passed by the Government of
India prohibits entry into maintenance holes and septic tanks to ensure the safety of sanitation workers. Hence, there is
a need to expedite the process of mechanization in sewer line/septic tank maintenance.
Owing to factors like terrain, budget, distribution of sanitation facilities etc., ULBs require a single machine or a
combination of two or more. The choice of proper mechanical equipment is a challenge for most ULBs as they are
unaware of existing technological options and their application under varied situations. This research aims to develop a
framework to evaluate existing technologies for sanitation service delivery, identify suitable machines from existing
options for procurement and understand if mechanization eliminates sanitation workers’ contact with fecal matter
during mechanical cleaning.
The study involved development of a framework that assesses machines on parameters like application, HR and training
requirement, safety of sanitation workers, services provided by the machines, effectiveness, and efficiency in
performance of work, services provided by the machines, technical support required for maintenance and capex and
opex. The framework was further used to develop questionnaires for qualitative data collection by interviewing
sanitation officials from urban local bodies (ULBs) and parastatal agencies, private agencies, and sanitation workers. In
addition, we observed the machines during operations in the field.
The preliminary findings suggest that machines are effective in cleaning if the site of operations is easy to access and the
sanitation infrastructure is fairly new and built as per standards. However, as most sanitation infrastructure in India is
several decades old and located in either very busy or narrow lanes, the machines are not able to entirely serve their
purpose. If the drains are permanently covered or the sewer lines are laid too deep, the machines do not have sufficient
suction power to clean these. The municipal officials and private agencies also faced procurement and maintenance
challenges if the machines were manufactured in distant regions of India.
Lack of guidance system in machines is another challenge that prevents effective cleaning. Spillage of waste during
operation and transportation was another common problem. In both cases, sanitation workers inadvertently come in
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contact with fecal matter. It was also noticed that lack of adequate training on use of personal protective equipment and
operation of the machines led to exposure of sanitation workers to sludge and harmful gases.
We will present detailed results of our primary data analysis and observational research to highlight challenges in
mechanization of sanitation sector. Our findings will identify most user-friendly machines and lead to recommendations
for ULBs to procure relevant machines suiting their local context and available budget. The study will also nudge
innovation in right directions for developing better technological solutions for mechanization of sanitation sector. The
study will also highlight capacity building initiatives required to ensure that sanitation workers come in no contact with
fecal matter while using these machines.

Availability of multiple hand hygiene technology options increases practice: Findings from a trial in Kenya
Victoria Trinies, CDC
Additional Authors: Lorna Maru, Alex Mwaki3, Aloyce Odhiambo, Isaac Ngere, David Berendes

Key learning objectives:

- Understand the effect of having both handwashing stations and alcohol-based handrub available versus handwashing
stations only on hand hygiene practice among people in community locations
- Understand the limitations of technology choice on promoting practice
Background:
Interventions supporting hand hygiene (HH) in community settings are key components of community mitigation
response for COVID-19 and other infectious disease outbreaks. However, little is known about the effect having a choice
of HH technology options has on HH practice. We implemented an observational trial in Kisumu County, Kenya, to
determine if having multiple HH technology options (handwashing stations (HWS) and alcohol-based handrub (ABHR))
improved HH practice among visitors to community settings compared to provision of HWS alone.
Methods:
In December 2021, 18 locations were purposively selected based on suitability for maintaining HH interventions from
among 37 priority community sites with high levels of population mixing identified for HH interventions by the county
government and situation assessments. These included public service offices, community organization offices,
transportation booking offices, and markets. Pairs of locations were matched by sub-county, location type, and daily
number of visitors. Within each pair, locations were randomly allocated to either receive a HWS only (Arm A) or receive
a HWS plus ABHR (Arm B) to be placed at the entrance. All locations were provided with soap throughout the trial.
Enumerators conducted observations of visitor HH practices (use of water only, water and soap, ABHR, or none) upon
entering each location once every two weeks. Observations ended once the enumerators observed 10 visitors or 2 hours
had passed. After 6 observation rounds, a cross-over occurred; ABHR was provided to Arm A sites and removed from
Arm B sites and observations continued for an additional 3 rounds. HH practice between study arms was assessed
through logistic regression controlling for observation round with generalized estimating equations to account for
clustering within locations.
Results:
HH practices were observed for 1731 visitors entering the 18 locations across 9 observation rounds. A HWS with water
and soap was available at 99% (n= 1721) of observations and ABHR was available at 48% (n=834) of observations.
Overall, visitors performed HH, defined as washing hands with soap and water or using ABHR, at 10% (n=173) of
observations. Visitors performed hand hygiene more often upon entry when both ABHR and a HWS were available
(n=105, 13%) compared to when only a HWS was available (n=68, 8%; OR 1.76, 95% CI 1.09–2.83). When both ABHR and
HWS were available, 30% of HH practitioners used ABHR, 66% washed hands with soap, and 4% did both.
Conclusion:
We observed that people performed HH upon entering public locations more often when multiple HH technology
options were available compared to when only HWS were available. However, HH performance remained low even
when both HWS and ABHR were present; this may reflect the novelty of entrances as a key location for HH introduced in
response to the COVID-19 pandemic. Although providing multiple HH options can improve HH performance, additional
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approaches are needed to ensure frequent HH performance. We also observed that even when ABHR was available
most HH practitioners used water and soap, indicating that HWS are the preferred HH option in this population and
should be consistently available.

Barriers to using PPEs by waste and sanitation workers in seven Bangladeshi cities
Tanvir Ahmed, BUET
Additional Authors: Mahbub-Ul Alam, Mehedi Hasan, Dewan Muhammad Shoaib, Kazy Farhat Tabassum, Makfie Farah

Background
Inadequate use of personal protective equipment (PPEs) among waste and sanitation workers is commonly seen in low-
and middle-income countries, making the workers vulnerable to diverse injuries and diseases, especially during COVID-
19. To improve the workers’ practice of wearing PPEs at the workplace, an intervention was designed in seven cities of
Bangladesh to ensure their access to PPEs with a practical demonstration of their proper use. We explored the barriers
and suggestions for improvement of using the PPEs, particularly for reflective apron/jacket, gumboot, hand gloves, and
masks from the waste and sanitation workers and their managers.
Methodology
A qualitative study was carried out in the selected cities. We purposively selected two waste management officials for
key informant interviews (KIIs) and three frontline waste and sanitation workers for In-depth Interviews (IDIs) from each
of the seven intervention areas, counting a total of 14 KIIs and 21 IDIs. Following an informed consent process, the
interviews were recorded, transcribed, translated, and then thematically analyzed.
Results
The provision of PPEs by the authorities can significantly increase the workers’ job satisfaction (mentioned by 16 out of
21 respondents) as it enhances their social acceptance and gives them some form of identity (mentioned by 9 out of 21),
and altogether, this can result in improved usage practices of PPEs (mentioned by 16 out of 21 KI). However, most
respondents were concerned about the quality of the protective materials. The materials of the reflective jackets should
be comfortable to wear (mentioned by 18 out of 21 respondents), reflect heat, and prevent excessive sweating
considering the hot and humid weather. The Jackets can also be made colorful, which some workers prefer. The
gumboots should be light, strong, durable, and proper-sized which was mentioned by a few workers. Hand gloves should
be thick, durable, sweat-reducing, and usable multiple times, as suggested strongly by all the workers. Also, PPEs that
are used multiple times must be washable. Seasonal variations (mentioned by 6 out of 21) and gender issues (mentioned
by 11 out of 21 respondents) need to be considered while choosing the raw materials and design of the PPEs. Frequent
supply of the PPEs, including reusable masks (mentioned by 17 out of 21 respondents and 4 KI out of 14), needs to be
ensured. Provision of at least two sets of PPEs is preferred to ensure usability when those get wet or dirty. Moreover, to
sustain the PPE use, regular refresher training (mentioned by 4 out of 21 respondents and 7 out of 14 KI) and monitoring
by the local waste management authority (mentioned by 10 out of 14 KI) will be required.
Conclusion
A proper set of PPEs are not merely protective equipment; it also can increase social acceptance and enhance the
workers’ engagement with the work and job satisfaction. The designing of PPEs should prioritize the user’s perspective.
The availability and comfortability of the PPEs at the end-user level, regular refresher training, and monitoring will
increase their use.

Beyond COVID-19: simultaneous quantification of many pathogens in wastewater to inform public health response
Gouthami Rao, University of North Carolina - Chapel Hill
Additional Authors: Drew Capone, Kevin Zhu, and Joe Brown

Wastewater-based epidemiology has emerged as a critical tool for public health surveillance, with broad application in
SARS-CoV-2 monitoring and building on decades of work on other specific pathogens including poliovirus. Work to date
has been limited to monitoring a single pathogen or small numbers of pathogens in targeted studies. We developed a
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novel quantitative multi-pathogen surveillance tool (36 pathogen targets including bacteria, viruses, protozoa, and
helminths) using Taqman Array Cards (RT-qPCR) and applied the method on concentrated wastewater samples collected
at four wastewater treatment plants in Atlanta, GA in February to October of 2020. From these sewersheds serving
approximately 2 million people, we detected a wide range of targets including many we expected to find in wastewater
(e.g., enterotoxigenic E. coli and Giardia in 100% of 32 samples at stable concentrations) as well as unexpected targets
including Strongyloides stercolaris (i.e., human threadworm, a neglected tropical disease rarely found in the USA). Other
notable detections included several pathogen targets that are not commonly included in wastewater surveillance like
Acanthamoeba spp., Balantidium coli, Entamoeba histolytica, astrovirus, norovirus, and sapovirus. Our data suggest
broad utility in expanding the scope of pathogen surveillance in wastewaters, with potential for application in a variety
of settings where pathogen quantification in fecal waste streams can inform public health surveillance and selection of
control measures to limit infections.

Building public toilets has reduced enteric pathogen hazards in San Francisco, but potential risks remain
Troy Barker, Department of Environmental Science and Engineering, Gillings School of Global Public Health, University of
North Carolina at Chapel Hill
Additional Authors: Drew Capone, Heather Amato, Jay Graham, Joe Brown

People experiencing homelessness lack consistent access to sanitation facilities causing some individuals to resort to
open defecation. In urban centers with high population densities, untreated feces in the environment may contain
enteric pathogens, which pose infection risks. These risks are highest for people experiencing homelessness who have
the most frequent exposures and pose risks to the housed community. Our research aim was to determine the sources
of freshly discarded feces in San Francisco, California (i.e., human, or non-human) and to identify which enteric
pathogens were present.
We systematically collected freshly discarded feces from 20 city blocks in San Francisco, California from September to
October 2019. Samples were collected on four Wednesday mornings before street cleaning began. We extracted total
nucleic acids from the collected stools. Then we used digital PCR to determine the concentration of human
mitochondrial DNA (mtDNA), which enabled differentiation between human and non-human samples. In addition, we
used a custom TaqMan Array Card (TAC) – a reverse transcription quantitative PCR platform – to test all samples for 35
enteric pathogens.
We collected 59 freshly discarded stool samples in our study area and found that 20% (12/59) were human and 80%
(47/59) were non-human. Half of the human stools (50%, [6/12]) and 32% (15/47) of non-human stools were positive for
≥1 of the pathogens assessed. Among the human stools, we most frequently detected enteropathogenic E. coli (38%,
[5/12]), followed by Acanthamoeba spp. (17%, [2/12]), Helicobacter pylori (17%, [2/12]), Blastocystis spp. (8.3%, [1/12]),
Enteroaggregative E. coli (8.3%, [1/12]), Enterotoxigenic E. coli (8.3%, [1/12]), Plesiomonas shigelloides (8.3%, [1/12]),
Shigella/Enteroinvasive E. coli (8.3%, [1/12]), Trichuris spp. (8.3%, [1/12]), and Yersinia enterocolitica (8.3%, [1/12]).
Our results indicate that people experiencing homelessness in San Francisco, California may be exposed to enteric
pathogens in the environment. Increased access to sanitation, including public toilets and housing programs, is needed
to reduce exposure. Further, efforts to improve sanitation access in US cities should also increase the hygienic disposal
of animal feces, which can be a source of zoonotic pathogens.

Building-level wastewater-based epidemiology for COVID-19 surveillance on a university campus

Ryan Julien, Michigan State University
Additional Authors: Jade Mitchell

The COVID-19 pandemic has caused over 500 million infections, six million deaths, and countless disruptions to social
and economic functions across the globe. Disease surveillance is typically conducted on an individual basis, which is
costly and presents issues with the privacy of sensitive health records. Wastewater-Based Epidemiology (WBE) is a
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promising tool used to surveil a larger population by instead monitoring biomarkers found in human sewage. WBE has
previously been used to monitor for diseases, such the poliovirus, and has since been recently deployed to monitor the
SARS-CoV-2 virus, the causative agent for COVID-19.
However, sewer systems are not specifically designed to support WBE and present a multitude of complications to
disease surveillance which often go unaddressed. These include uncertainty associated with wastewater composition
and dilution of human waste; variability in fecal concentrations of the virus; sewer geometry and the sample location’s
sewer shed boundaries; and temporal relationships between defecation events, hydraulic mixing, and sample collection.
These factors are thought to have a more pronounced impact on a smaller scale (e.g., at building-level) where smaller
populations lead to increased granularity of individual infections and hydraulic events.
This study relies on a rich data set of more than 1500 wastewater samples collected from a university campus and
analyzed for SARS-CoV-2 gene targets using ddPCR. Data also include building-level measurements for water
consumption, occupancy, vaccine status. Previous analyses on these data, such as cross-correlation, proportion tests,
and Poisson regression have revealed that wastewater gives an early warning of cases compared to weekly
asymptomatic screenings, composite samples are more likely to identify positive cases than grab samples, and that
building occupancy, sample temperature and pH, daily building-level water use, and viral concentrations are all
statistically significant in predicting positive cases.
This study expands on previous work. Multiple mechanistic models will be evaluated stochastically to explore the
impacts of measured and unmeasured variables. Results of this study will clarify the relationship between wastewater
concentrations measured at building-level and the number of people actively shedding virus and will identify variables
which have a disproportionate effect on that relationship. These results may assist in interpreting data from similar
COVID-19 surveillance and further develop WBE modeling for use in future outbreaks.

Characteristics of hand hygiene in healthcare settings in Central America and East Africa—2020–2021
Denisse Vega Ocasio, Centers for Disease Control and Prevention
Additional Authors: Maureen Kesande, Paulina Garzaro, Nicholas Bivens, Dan Schnorr, Evelyn Mugambi

Introduction:
Hand hygiene (HH) can reduce transmission of many diarrheal and respiratory diseases. In low- and middle-income
countries, an estimated 50% of health care facilities (HCFs) lack piped water and 39% have inadequate handwashing
facilities. Limitations in healthcare water, sanitation, and hygiene (WASH) infrastructure increase the risk of healthcare
associated infections that can increase morbidity and mortality. We conducted a multi-site evaluation in select HCFs
across five countries to assess HH practices during the COVID-19 pandemic.
Methods:
During December 2020–June 2021, we observed HH practices among healthcare workers in 88 government HCFs in five
countries (Belize, Dominican Republic, Guatemala, Uganda, and Kenya), including HCFs classified at primary, secondary,
and tertiary care levels. Healthcare workers who had regular contact with patients were selected randomly as subjects
of observation for HH adherence, defined as using alcohol-based hand rub (ABHR) or handwashing with soap and water
(HWS). Enumerators observed and recorded healthcare worker HH practices (used ABHR, HWS, or none) before and
after patient contact during routine patient care. We also recorded available HH materials in patient care areas at the
time of observation in Belize, Uganda, and Kenya. Unadjusted analyses used correlations and chi-square to compare
proportions.
Results:
In total, 4052 HH observations were completed in Belize (n=742; 19%), Dominican Republic (n=1414; 35%), Guatemala
(n=488; 12%), Uganda (n=1066; 26%), and Kenya (n=342; 8%). Overall, HH adherence was 29%. ABHR was used 19% of
the time, HWS 9%, and both were performed 1% of the time. HH adherence was highest in Belize (49%), followed by
Guatemala (39%), Uganda (28%), Kenya (22%), and Dominican Republic (16%). ABHR was used more often than HWS in
all countries except Dominican Republic, where HWS was more common than ABHR use (14% vs 2%, respectively). In
aggregate, HH adherence was higher after vs. before patient contact (39% vs. 20%, respectively; P <0.0001). HH
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adherence was similar across facility levels: 33% in secondary HCFs, 32% in primary HCFs, and 27% in hospitals. HH
adherence was highest among doctors (32%), followed by nurses (28%), while lab technicians had the lowest rates (26%)
(P<0.001). Among HCFs in Belize, Uganda, and Kenya, ABHR was available during 81% of HH observations compared to
47% for water and soap. Overall, HH adherence was higher when both ABHR and water and soap were available (45%)
compared to when only ABHR (36%) or water and soap (26%) were available (P <0.0001).
Conclusion:
Preliminary analysis shows that HH adherence varied across countries and was more common after patient contact than
before. Doctors were more likely to perform HH than other healthcare workers. ABHR was more frequently available,
which may be because the study was conducted during the COVID-19 pandemic. Findings indicate that ABHR use was
more common than HWS; ABHR availability was associated with higher HH adherence, suggesting a need for sustained
production and access to ABHR. Results from this evaluation can facilitate prioritization of interventions to address gaps
in access to HH resources and ways to improve HH adherence.
Themes: Hand Hygiene, Handwashing facilities, healthcare facilities
Key learning objectives
- To evaluate hand hygiene practices in healthcare facilities across countries
- Assessments of hand hygiene materials available in healthcare facilities
- Guide implementation of sustainable improvements related to hand hygiene adherence

Climate change and waterborne infectious disease: evidence from a global scoping review
Jesse Limaheluw, National Institute for Public Health, and the Environment (RIVM)
Additional Authors: Fabio Serafim, Rebecca Niese, Lucie Vermeulen, Ana Maria de Roda Husman

The scientific evidence base on the human health impacts of climate change is rapidly growing. However, because of this
increased research output finding relevant information can be challenging. The aim of our work was to systematically
identify and review studies that quantified human health impacts of climate change. We developed a review protocol,
formulating in- and exclusion criteria and defining the boundaries of our review. We then conducted a broad search for
English language scientific literature, collecting all studies published between January 2000 and July 2021 that made
reference to climate change and human health in their text fields. Here we specifically present the outcomes on
waterborne infectious disease.
From an initial selection of 36,956 records, we identified 307 studies that quantified climate change impacts on
pathogens, disease vectors, hosts, or infectious disease. Of these studies, 33 specifically studied waterborne infectious
disease, or health outcomes and pathogens associated with waterborne transmission. Twenty-six studies quantified an
effect of climate change on a specific health outcome, and five studies assessed risks associated with specific outcomes.
Diarrheal diseases were the most commonly studied outcome, followed by schistosomiasis. Vibrio spp. were the most
studied pathogens. The World Health Organization’s Western Pacific region was the most studied region.
Four retrospective studies provide some quantitative evidence that climate change has already impacted waterborne
infectious disease risk. Increasing sea surface temperatures have been linked to increased Vibrio spp. abundance and
associated infections in the Northern Hemisphere. Individual studies demonstrated that observed climate change has
likely contributed to an expansion of suitable habitat of an intermediate host of Schistosoma japonicum in China, and an
increase in legionellosis incidence in the United States.
There is moderate agreement that climate change will worsen waterborne infectious disease risk and burden in the
future, however results are not uniform. Geographical variability in the outcomes is common, indicating that climate
change impacts differ between and within countries. Studies on schistosomiasis in Africa and one study on fasciolosis in
Europe demonstrated that more extreme levels of climate change could lead to a decrease in disease risk over time, as
regions become climatically unsuitable for pathogens or host species. For diarrheal disease greater increases are
generally projected for more intense climate change.
Ten studies present results for lower- or lower-middle income economies, which currently carry the largest burden of
waterborne disease, also in relation to climate change. For these regions, quantitative projections indicate that climate
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change will likely exacerbate diarrheal disease risks but could have beneficial effects on the burden of schistosomiasis.
An important variable that has only been considered by one study is the interaction with socio-economic development.
As climate change occurs concurrently with, for example, efforts to improve access to adequate water, sanitation, and
hygiene (WASH), an important effect may be that it slows down WASH progress. Based on the quantitative evidence
presented, it is recommended that future research examines additional waterborne disease etiologies including
emerging diseases and provides more detailed assessments of the combined effects of climate change and other
developments.

Collective Action in WASH for Improving Animal Feces Management through Nurturing Care Groups
Bismark Dwumfour-Asare, AAM-University of Skills Training and Entrepreneurial Development (AAMUSTED)
Additional Authors: James Tidwell, Eugene Appiah-Effah

Background:
Recent large scale, rigorous trials of sanitation interventions have suggested that households constructing and using a
latrine may not be sufficient to reduce diarrheal disease burdens. Reducing non-human fecal material in the
environment may be essential to see health gains (Pickering et al., 2019). Nearly two-thirds of human pathogens and
three-quarters of emerging pathogens are zoonotic, and one-third of deaths due to diarrhea among children under 5 are
due to diseases transmitted through animal feces (Ercumen et al., 2017). However, raising animals is an important
source of income and improved nutrition for many families in LMICs and is associated with many positive health and
developmental outcomes, and thus methods of separating animal excrement from human contact are urgently needed.
Disease caused by exposure to even a small amount of animal feces in the environment may limit the effectiveness of
these post-contamination approaches, so controlling the spaces where animals are allowed to roam is likely a key
intervention in reducing the disease burden in young children driven by contact with animal feces (Monira et al., 2020).
Methods:
We evaluated the effectiveness of Nurturing Care Group (NCGs) in improving animal feces management, a model where
10-12 women chosen by groups of 10-15 neighboring households each meet with health promoters, and then relay the
messages back to their neighbors. We conducted a controlled before-and-after trial in two districts of Ghana from June
2019 to December 2020. We collected data from individuals in program areas (n=324) and neighboring areas (n=430)
before and after the intervention. Follow-up focus group discussions (n=12) and in-depth individual interviews (n=20)
were conducted in communities and households that saw significant improvements and those that didn’t to understand
key facilitators or barriers to success.
Results:
We observed a 22%pp greater increase in animals enclosed during the day beyond the reach of households’ drinking
water (difference-in-differences in treatment vs. control areas) and a 14%pp greater increase at night. There was a
27%pp greater reduction in visible animal feces, with a 16%pp increase in animal feces managed through composting
and a 22%pp point decrease in feces “thrown elsewhere on the plot.” Qualitative interviews showed that some aspects
of culture not considered by the program played a significant role in programmatic success—where men could be
invited to the group meetings, decisions related to livestock and construction could be made in the joint setting,
whereas a lack of acceptable venues in other locations made even those interested in making changes unable to do so.
Furthermore, those who had long wished to see community-wide improvements were encouraged to leverage the
collective approach of the program to achieve their vision.
Conclusions:
This program demonstrated that low-cost, collective approaches to behavior change can be effective in reducing
childhood exposures to pathogens, though more research is needed to understand what additional barriers limit the
potential to achieve higher impacts.

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Developing a Novel Approach for Addressing Environmental Justice in North Carolina

Kauleen S. Proctor, UNC Gillings Department of Environmental Sciences and Engineering
Additional Authors: Cassidy Rice, Samantha Feinstein, and Howard Weinberg.

The Alcoa Badin Business Park (BBP) is the site of a shuttered aluminum smelting facility in Badin, North Carolina. During
the smelter’s period of operation, from 1917 to 2007, spent pot liner and other waste was disposed of in unlined
landfills. Though the North Carolina Department of Environmental Quality (NCDEQ) enforced implementation of
corrective measures, surrounding community groups and environmental law and advocacy organizations are concerned
about levels of environmental cyanide and fluoride contamination leaching from these landfills. Badin, NC is like other
communities impacted by Environmental Injustices as the bulk of solid waste landfills are located in the historically Black
area of West Badin. Many of the community members also experience disproportionate health impacts as a result of
working at the smelter and would be further burdened by hazardous contamination of their community water bodies.
Beginning in May 2021, our research team collected publicly available documents provided by NCDEQ, Duke
Environmental Law and Policy Clinic, and the Yadkin Riverkeeper to determine the extent to which the cyanide
contamination of recreational waters may be hazardous to the health of surrounding community members, what was
already done to address the contamination, and what has yet to be achieved. Through analyzing quantitative monitoring
reports, conducting interviews, evaluating legal documents, and reviewing previous studies of the area, our research
team identified three key findings: (1) Concerned residents of West Badin feel they were routinely excluded from
conversations and processes regarding management and previous remediation of landfills and waste water systems; (2)
The NCDEQ cyanide reporting requirements for BBP’s National Pollutant Discharge Elimination System permit are
outdated and no longer supported by evidence regarding cyanide toxicity. These findings resulted in our collaboration
with the Yadkin Riverkeeper to deliver a public comment to NCDEQ during a Triennial Review, resulting in a NCDEQ
proposal. An NCDEQ proposal to modify and update cyanide monitoring requirements is currently under review by the
NC Environmental Management Commission. Submission of this comment also resulted in our last key finding. (3) A
review of other public comments during the Triennial Review revealed common ground between industry
representatives and environmental advocates, which informed a second phase of our project, namely planning,
organizing, and preparation of educational materials for a Stakeholder Workshop held on March 23, 2022. The
Stakeholder Workshop gathered representatives from Alcoa, the Yadkin Riverkeeper, NCDEQ, community groups, local
environmental organizations, and local government in a neutral location to promote transparency and encourage new
partnerships. As a result of the Workshop, our team is now planning a third phase, which entails a water sampling and
monitoring campaign aiming to, first and foremost, engage and center excluded community members, and to provide a
more accurate assessment of fluoride and cyanide contamination resulting from landfill leaching at the facility. While
Badin and other Alcoa sites are perhaps not generalizable to other industrial contamination cases, successful sampling
coupled with previous phases of this study could be referenced as a new and novel framework for approaching and
addressing Environmental Justice conflicts.

Development and validation of a highly accurate TLF sensor coupled with a machine leaning model for the
detection of fecal contamination risk
Emily Bedell, Virridy

As many as two billion people worldwide use a drinking water source that is contaminated with feces. Drinking fecally
contaminated water causes adverse health effects including diarrhea and stunting, particularly among children under 5
in low- and middle-income countries. Diarrheal diseases are the fifth leading cause of morbidity for people of all ages
and the third leading cause for children ages 0-9. Although, incidences of diarrhea are most frequent in low- and middle-
income countries, outbreaks are common in high-income countries as well. At least 40 million people in the United
States rely on domestic wells for their drinking water supply, where the water quality is not regulated by the U.S.
Environmental Protection Agency (EPA). Between 1971 and 2008, 30% of all waterborne outbreaks in the U.S. were
associated with the consumption of untreated groundwater.
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In both academic research and professional practice, estimates of contamination are mostly based on infrequent point
measurements with small sample sizes. More frequent testing is often limited by the established methods used to
identify fecal contamination that are expensive, time consuming, and have high training requirements.
We designed and validated a highly sensitive, continuous monitoring, in-situ, remotely reporting tryptophan-like
fluorescence (TLF) sensor and coupled it with a machine learning (ML) model to predict high-risk fecal contamination in
water (>10 colony forming units (CFU)/100mL E. coli). A major challenge to continuously monitoring aquatic sensors is
the formation of biofilms or mineral scaling on the sensor’s lenses that can impact the output signal, leading to a high
false positive or false negative rate. We characterized the sensor's response to multiple fluorescence interferents
through benchtop analysis. The sensor's minimum detection limit (MDL) of the correlation to E. coli present in
wastewater effluent dilutions was 10 CFU/100 mL (p < 0.01). Biofouling was demonstrated to increase the fluorescence
signal by approximately 82% in a certain context, while mineral scaling reduced the sensitivity of the sensor by
approximately 5%. An ML model was developed, with TLF measurements as the primary feature, to output fecal
contamination risk levels established by the World Health Organization. A training and validation data set for the model
was built by installing four sensors on Boulder Creek, Colorado for 88 days and enumerating 298 grab samples for E. coli
with membrane filtration. The ML model incorporated a proxy feature for fouling (time since last cleaning) which
improved model performance. A binary classification model was able to predict high risk fecal contamination with 83%
accuracy (95% CI: 78% - 87%), sensitivity of 80%, and specificity of 86%. A model distinguishing between all World Health
Organization established risk categories performed with an overall accuracy of 64%. Integrating TLF measurements into
an ML model allows for anomaly detection and noise reduction, permitting contamination prediction in real-time,
despite multiple environmental and physical interferents on the signal. Real-time detection of fecal contamination in
drinking water could contribute to more informed decision making by water service providers and consumers. This
technology has the potential to be a major step forward in terms of microbial water quality monitoring for human health
worldwide.

Disinfection of Surfaces Using Locally Available Disinfectants

Gabrielle String, Lehigh University
Additional Authors: Mitchell White, Yarmina Kamal, David Gute, Elke Mühlberger, Daniele Lantagne

Key Learning Objectives

• Understand the efficacy of locally available disinfectants against enveloped and non-enveloped viruses and
bacteria in surface disinfection
• Summarize the results of three laboratory studies that evaluate 0.5% soapy water, 0.5% NaOCl, and natural
sunlight as disinfectants.
• Review the recommendations for surface disinfection protocols stemming from the outcomes of these studies.
Introduction:
During outbreaks, disinfecting surfaces in households, community structures, and health-care facilities is commonly
completed to interrupt disease transmission. To complete surface disinfection, the WHO and the CDC recommend using
soap to pre-clean a surface and applying an appropriate disinfectant. With guidance from the experts of our external
Technical Advisory Group, we conducted three linked laboratory-based efficacy studies on three locally-available
disinfectants – soapy water, chlorine, and sunlight. Our goal was to address responder questions on surface disinfection
practices in COVID-19 and Ebola contexts.
Methods:
All three studies were conducted using a factorial experimental design using ASTM modified test methods. Study 1
determined if a 0.5% soapy water solution could inactivate SARS-CoV-2 in suspension and on a steel surface and if Phi6
or MS2 were appropriate SARS-CoV-2 surrogates for soapy water disinfection. Study 2 investigated the impact of
chlorine disinfection after drying seven porous and non-porous surfaces in varied environmental conditions
(temperature, relative humidity, and soil load) against Phi6, a SARS-CoV-2 and Ebola surrogate. Study 3 evaluated the

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efficacy of natural sunlight (Full Sun, Partial Sun, Cloudy) against Phi6, MS2, and E. coli – models for pathogenic
organisms – on healthcare surfaces (steel, nitrile, tarp, cloth) as recommended in Ebola response.
Results:
In Study 1, after contact with 0.5% soapy water Phi6 was reduced ≥4 LRV in 1 minute on both steel and in suspension,
SARS-CoV-2 was reduced ≥4 LRV in suspension and 0.5 LRV on steel in 10 minutes, and MS2 was not reduced in 20
minutes. In Study 2, infective Phi6 was recovered after 1 hour for all environmental conditions. Additionally, 0.5%
chlorine reduced Phi6 ≥4 LRV after 1 and 5 minutes on non-porous surfaces more than porous surfaces (p<0.001,
respectively). In Study 3, after exposure to varied light conditions only Phi6 achieved ≥4 LRV and only after exposure to
Full Sun (average 737 W/m2 solar radiation).
Conclusions:
Overall, surface disinfection efficacy is dependent on the organism of interest, surface of deposition, and the
disinfectant used. From Study 1, we do not recommend changes to the current WHO and CDC surface disinfection
protocols which recommend using soap to pre-clean a surface and then applying an appropriate disinfectant. From
Study 2, we recommend using a 0.5% chlorine solution for at least 1 minute of contact on non-porous and most porous
surfaces and note that disinfection of enveloped viruses on concrete and wood is challenging. From Study 3, for sunlight
disinfection with contact times up to 1 hour, we recommend future research evaluating Full Sun light conditions for
enveloped viruses (SARS-CoV-2, Ebola). Furthermore, we do not recommend sunlight exposure for less than one hour or
use of sunlight as a disinfectant for non-enveloped viruses or bacteria. As previously proposed surrogate models for
human pathogens, our Phi6, MS2, and E. coli data contributes to the literature base in preparing for future outbreaks in
humanitarian and LMIC contexts by informing disinfection recommendations.

Drinking Water & Health in Appalachia: Initial Findings from a Small-scale Cohort Study in Rural Virginia
Alasdair Cohen, Virginia Tech
Additional Authors: Md Rasheduzzaman, Leigh-Anne Krometis, Teresa Brown, Elizabeth Rogawski McQuade, Mami
Taniuchi

Background:
Consumption of unsafe drinking water is associated with a substantial burden of disease globally. In the US, ~1.8 million
people in rural areas lack reliable access to safe drinking water, a problem that is particularly acute in many rural areas
of Appalachia. However, our understanding of which regions and populations have higher risks of exposure to
contaminated water is hampered by a lack of data, and even less is known about water-associated health impacts.
Objectives:
Our objective was to better understand potential exposures to microbiological and chemical contaminants in drinking
water by assessing the use and quality of primary household-level drinking water sources as well as associated health
outcomes, poverty-related indicators, and sociocultural factors in lower-income households without utility-supplied
water in rural southwest Virginia.
Methods:
In 2021, with support from a public water and sewer utility in southwest Virginia, we initiated a cohort study open to all
households in a small, lower-income, rural community the utility was considering for a water supply extension project.
We collected survey data (face-to-face interviews) and multiple sets of water samples (tap, source, and bottled water)
from consenting households. Field measurements were taken for pH, temperature, conductivity, and dissolved oxygen.
Water samples were tested for E. coli, total coliforms, nitrate, sulfate, heavy metals such as arsenic, cadmium, and lead
(via ICP-MS), and for 30+ enteric pathogens (via RT-qPCR). Our study was approved by Virginia Tech’s IRB (#21-763).
(Initial) Results:
Among the 69% (n=9) eligible and non-vacant homes that agreed to participate at baseline, all had piped well water,
though 67% (n=6) used bottled water as their primary source of drinking water. The majority of household (67%, n=6)
reported incomes of <$43,000/year. Total coliforms were detected in samples from 44.4% (n=4) of households, E. coli
was detected in one home, and enteric pathogens (Aeromonas, Campylobacter, Enterobacter) were detected in 33%
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(n=3) of homes. Tap water samples from 44% (n=4) of homes exceeded ½ the US EPA MCL for nitrate, and 56% (n=5)
exceeded ½ the US EPA SMCL for iron. Sodium concentrations in source water samples ranged from 3.3 – 110.0 mg/L
(mean=66.0, SD=36.0, median=76.4, n=9). Reported diarrhea was 25% more likely in homes with measured E. coli
and/or specific pathogens (Risk Ratio=1.25, cluster-robust standard error=1.64, p=0.865).
Broader Significance:
Although our sample size was relatively small, our findings indicate that microbiological and/or chemical contamination
in drinking water is not uncommon for lower-income residents without utility-supplied water in rural areas of southwest
Virginia, and that many, if not most, such rural households rely on bottled water as their primary source of drinking
water. Our detection of specific enteric pathogens and relatively high concentrations of contaminants such as nitrate
and iron in water samples indicates that additional research and surveillance data are needed to better understand
which regions, communities, and populations in Central Appalachia may be exposed to contaminated water sources, the
nature and extent of associated adverse health outcomes, and what interventions might be implemented to expand safe
water access.

Effect of a behavior change and hardware intervention on safe child feces management practices in rural
Odisha, India
Valerie Bauza, Emory University
Additional Authors: Gloria D. Sclar, Alokananda Bisoyi, Fiona Majorin, Hans-Joachim Mosler, Thomas F. Clasen

Background:
Poor child feces management (CFM) practices may contribute to a large disease burden in low-income settings through
exposure to enteric pathogens. Although India has seen substantial increases in sanitation coverage, child feces are
often unsafely managed. We aimed to evaluate a behavior change and hardware intervention designed to improve
caregiver safe disposal of child feces and child latrine use.
Methods:
We conducted a cluster-randomized controlled trial among 74 rural villages in Ganjam and Gajapati districts, Odisha,
India between November 2019, and September 2021. Villages were eligible for inclusion if they had previously
participated in a community-based water and sanitation program. All latrine-owning households with a child under 5
years old were eligible. Following a baseline survey and using stratified randomization, 37 villages were assigned to the
intervention and 37 to control. The intervention focused on primary caregivers and consisted of five behavior change
strategies together with provision of hardware: wash basin and bucket with lid to aid safe management of soiled nappies
and latrine training mat with tray to aid safe disposal and latrine training. A follow-up survey was administered four to
six months after delivery. Neither participants nor surveyors were masked to study assignment. The primary outcome
was safe disposal of child feces as defined by Joint Monitoring Programme (JMP), which encompasses caregiver safe
disposal of child’s feces into a latrine and child latrine use. We did intention-to-treat (ITT) and per-protocol (PP) analyses
of the follow-up sample. This trial is registered at ISRCTN (15831099).
Findings:
There were 662 caregivers (841 children) in intervention villages and 631 caregivers (785 children) in control villages at
follow-up. For the ITT analysis, prevalence of JMP-defined safe disposal was 1.15 times greater in the intervention arm
compared to control (77.7% vs. 65.9%; prevalence ratio [PR] 1.15, 95% CI 1.03-1.29), with improvements specifically in
prevalence of caregiver safe disposal (45.5% vs. 28.5%; PR 1.76, 95% CI 1.33-2.33), but no difference in child latrine use
(59.1% vs. 52.2%; PR 1.08, 95% CI 0.95-1.22). When restricted to the PP sample, the prevalence of JMP-defined safe
disposal slightly improved among the intervention arm compared to control (PR 1.22; 95% CI 1.08 – 1.36), caregiver safe
disposal was twice as high in the intervention arm (PR 2.02; 95% CI 1.50 – 2.72), and child latrine use was 1.18 times
greater (95% CI 1.04 – 1.33). Mediation analyses revealed the intervention had an indirect effect on caregiver safe
disposal through influencing attitudes, norms, and behavioral intention but only had an indirect effect on child latrine
training through influencing risk perceptions of child open defecation. We also report impacts of the intervention on

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other CFM practices including child defecation on a safe material and caregiver use of a safe material to handle child
feces, with these improvements linked to use of the latrine training mat with tray.
Implications:
The behavior changes and hardware intervention greatly increased caregiver safe disposal and modestly improved child
latrine use. This study addresses a crucial knowledge gap in sanitation by developing and evaluating an intervention
focused on safe CFM practices, including a novel CFM hardware (latrine training mat with tray). Elements of this
intervention could be scaled up in India’s national sanitation programming and considered in similar contexts with poor
CFM.

Effective, Contextualized Behavior Change at Scale: Assessment of the Rapid Behavior Centered Design Toolkit
Sidney Shea, World Vision U.S.
Additional Authors: James B. Tidwell

Background:
Many behaviors change design processes are costly and time-consuming. Contextual differences within implementation
areas require tailored approaches, limiting the applicability and scalability of a centrally designed approach. We
developed a practical toolkit that is sufficiently generic to address a wide range of behaviors, synthesizes existing
knowledge to reduce the burden on design teams, and directs implementers to the most relevant tools and resources to
inform contextualized tailoring of interventions.
Methods:
Drawing on the principles of Behavior Centered Design (BCD), we developed a suite of tools and a process to address the
barriers identified above. First, the Behavior Change Practical Implementation Guide contains educational content to
strengthen the capacity of front-line field staff. Second, behavior-specific guides synthesize public health evidence,
behavioral science findings, and monitoring and evaluation recommendations for priority behaviors. Next, the RapidBCD
tool adapts information into the BCD categories of grabbing attention, causing revaluation, and facilitating performance
of a chosen behavior among a target population. A typology of behaviors based on the type of action, benefit, and
beneficiary informs this by identifying where in this process interventions should address different kinds of behaviors.
Finally, a formative research flow chart guides the staff in how to fill any gaps identified by the RapidBCD tool. These
tools were piloted with staff in three countries through interactive workshops that walked through practical examples.
We delivered training to local teams and collected outputs from the process (completed tools) and conducted
qualitative interviews with capital-based and field staff to understand the benefits and challenges of the approach.
Results:
El Salvador explored how to identify target behaviors related to WASH in Schools; Indonesia designed formative
research to address child feces disposal; Sudan implemented a Nurturing Care Group program where the delivery
mechanism was already identified, but they needed to create the messages to complete the handwashing curriculum.
Results will be collected over the next five months using a case-study approach. We will assess completed formative
research tools and final intervention designs and conduct interviews with country staff about the ease of use of this
guidance as well as any needed improvements. In Sudan, pre/post quantitative surveys of knowledge, attitudes, and
practices will be used to assess programmatic impacts. This process is informing more general learnings around behavior
change capacity building in local contexts within our organization and with partners.
Conclusion:
Our system of rigorous, contextually adaptable behavior change tools are scalable across an organization and across a
wide range of behaviors and sectors. A combination of synthesized evidence, local expertise, formative research
guidance, and an iterative learning process has led to a useful, but not overwhelming capacity building approach. Such a
design process can itself be evaluated, so that rather than just gathering isolated behavioral insights, learning in the field
can be structured around evidence of the broad effectiveness of applying behavior change processes, rather than
evidence tied to specific behavioral determinants or behavior change techniques. This will accelerate and refine practical
behavior change both in the WASH sector and more broadly.
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Effectiveness of a financial support program in increasing access to water, sanitation, and hygiene among residents of
coastal areas in Bangladesh
Tarique Nurul Huda, icddr, b
Additional Authors: Jesmin Sultana; AKM Shoab; Zillur Rahman; Mahbubur Rahman; Akramul Islam

Background:
Improving WASH access in hard-to-reach areas (HtRAs), including coastal areas, is challenging considering the
geographical location, frequent natural disasters, and salinity. BRAC, an international NGO based in Bangladesh,
implemented a water, sanitation, and hygiene (WASH) program from 2016 to 2020 in 48 coastal sub-districts. The
program focused on an inclusive financing model to provide financial and technical support to the non-poor, poor, and
ultra-poor population in improving WASH access through individual, community, and entrepreneur-level approaches.
This study evaluated the impact of the WASH program in improving access to improved sanitation facilities and drinking
water sources.
Evaluation methodology:
icddr, b team evaluated the program using a post-interventional cross-sectional study design. We used a multi-stage
sampling strategy to select the study households from both intervention and matched comparison areas. We matched
the intervention and comparison groups at both union and household levels. Unions are the lowest rural administrative
unit in Bangladesh. This study was conducted among 435 households in intervention and 435 households from
comparison areas. Trained field staff from icddr, b conducted questionnaire surveys and spot-check of WASH facilities
using structured questionnaire and observation checklist to assess the access to WASH facilities and the use of those by
the household members. We used mixed-effect logistic regression modeling to assess the effect of the intervention.
Results:
The respondents in the comparison areas were poorer and had fewer years of formal education compared to the
respondents from the intervention areas. Significantly more households in the intervention group compared to the
comparison group received financial or technical support from an NGO (40% vs. 16%). The proportion of households
with individual ownership of water sources was higher among the intervention households (34% vs. 11%) compared to
the comparison households (adjusted odds ratio (AOR): 3.23; 95% CI: 1.8, 5.82). Intervention areas had more households
with access to safely managed sanitation facilities (58% vs. 41%; AOR: 1.57; 95% CI: 1.00, 2.36) and improved sanitation
facilities accessible to all age groups (82% vs. 69%; AOR: 1.60; 95% CI: 1.01, 2.52) compared to the comparison group. In
the intervention areas, 49% (n=213) of the households had access to a handwashing facility with soap and water
available for handwashing compared to only 30% in the comparison area (AOR: 1.48; 95% CI: 1.00, 2.19). The proportion
of respondents who reported washing hands with soap before eating (51% vs 43%) or preparing food (14% vs 6%) was
higher in the intervention villages than in the comparison villages. The intervention areas had a higher proportion of
households, building water points (48% vs. 40%; AOR: 1.32; 95% CI: 0.6, 2.99) and sanitation facilities (68% vs. 53%; AOR:
1.47; 95% CI: 0.93, 2.31) above the usual flood line, compared to those in comparison areas.
Conclusion:
Our study findings suggest that financial support alone may help in increasing access to water and sanitation facilities.
These findings indicate that the intervention positively impacted access to WASH facilities among residents of coastal
communities in Bangladesh.

Effectiveness of a novel HWTS system that delivers tap water: a stepped wedge randomized trial
Ane Galdos Balzategui, Cantaro Azul /Ulster University
Additional Authors: John A. Byrne, Pilar Fernandez Ibanez, Fermín Reygadas

In low and middle-income countries, there are still great inequalities in water supply between regions and between rural
and urban areas. Household water treatment and safe storage (HWTS) provides a solution and for many contexts remain
the only medium-term alternative. Many different HWTS technologies exist, they are widely used and there is evidence
of their positive impacts. However, most of the HWTS systems are designed to treat around 20 liters per day. Therefore,
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their use is reduced to drinking water and few other domestic uses. Since not all the water in the household is treated,
exposure and consumption of unsafe water remains a common practice that limits the effectiveness of most HWTS
technologies.
The objective of our study is to measure the effectiveness of a HWTS system in a rural, indigenous region of Mexico in
achieving the quality of drinking water and the exclusive consumption of safe water. The intervention combined the
installation of a novel point-of-entry (POE) technology with behavior change and community water management
strategies. The HWTS provides a minimum of 50 liters per person per day of disinfected water. It includes the
distribution of water through pipes and taps to key points within the household where water is used directly, avoiding
the need for additional storage at those points. In short, it is a household solution that provides safe, running tap water.
We conducted a randomized stepped wedge trial where 187 households, located in 4 communities, participated. At
baseline, all households started in the control arm and, in a random sequence, ""crossed over"" to the intervention arm
during one of seven ""steps"" after baseline. Surveillance was performed in all households to measure outcomes at each
step. Escherichia coli (E. coli) was quantified using Aquagenx CBT EC MPN in water from those points in the households
where informants identified having drank more recently. A tour was carried out in each household to characterize all the
points in the household's where water was available and questions were asked to evaluate practices associated with
household water management (e.g., water consumption, storage of post-treatment water). The study began in February
2021 and will end in May 2022.
To date we have implemented the intervention in all the households and six surveillance visits have been completed. A
partial analysis has led to encouraging results. The intervention increased the percentage of households where the
water consumed is free from E. coli (from 15 to 68%) and 78% of households in the intervention arm reported that the
last point from which they consumed water was directly from the system tap, without additional storage of post-
treatment water.
The results so far show that the availability of safe and running water at different points in the household (1) reduces
post-treatment water storage and, (2) allows the use of safe water for a greater diversity of uses, creating a more
hygienic environment and reducing the recontamination of water in the household. The distribution network within the
household is something to take into consideration for HWTS solutions.

Enhanced efficiency of 222 nm over 254 nm on antibiotic resistant bacteria inactivation, resistance gene
damage, and inhibition of resistance gene transfer
Yijing Liu, The Ohio State University
Additional Authors: Natalie Hull

The presence of antibiotic resistant bacteria (ARB) and the horizontal gene transfer (HGT) of antibiotic resistant genes
(ARG) in water environments pose a threat to human health. The hospitalization and mortality rate due to ARB infection
is rising. ARB and ARGs have been detected in tap and bottled water as well as in untreated water sources. Concerns
about quality of water have led to investigations of the presence and removal of ARB and ARG in water engineered
system. Ultraviolet (UV) irradiation is an advantageous disinfection method because it produces fewer potentially toxic
disinfection byproducts than oxidative technologies, and it damages nucleic acids which can inhibit HGT of ARG. This
work was therefore undertaken to provide a comprehensive investigation of the fundamental kinetic parameters and
compares the treatment efficiency of different UV wavelengths (222 nm KrCl excimer lamp and 254 nm low pressure Hg
lamp) for inactivating multidrug antibiotic resistant B. subtilis strain 1A189, damaging intracellular and extracellular ARG,
and inhibiting HGT of intracellular and extracellular ARG using non-resistant strain 1A1 as the recipient. Additionally,
impact of ARG amplicon length (266 bp, 832 bp, 870 bp and 1070 bp) on ability to detect DNA damage. Disinfection
efficiency increased with UV dose for both wavelengths, but the 222 nm wavelength was more effective than 254
(pseudo first order rate constant k = 0.0318 cm2/mJ and 0.0298 cm2/mJ respectively). ARG damage quantified by
polymerase chain reaction (qPCR) increased with UV dose and amplicon length for both UV wavelengths. Although
extracellular ARG damage was similar between wavelengths, intracellular ARG damage was greater by 222 nm than 254
nm. For HGT of extracellular ARG, log10 reduction of HGT increased with UV dose, and the inhibition effect was stronger
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 Verbal Abstracts

by 222 nm (k = 0.0139 cm2/mJ at 222 nm and k = 0.0091 cm2/mJ at 254 nm). Overall, these comparisons demonstrate
the superior mechanistic efficacy of 222 nm over 254 nm UV for disinfecting ARB and for damaging and inhibiting
transfer of ARG. By understanding the UV impacts for disinfecting ARB and for damaging and inhibiting transfer of ARG,
we can progress to the next step of optimizing UV-based disinfection application strategies and explore how to employ
the UV irradiation in water treatment and distribution systems.

Environmental surveillance for SARS-COV-2 in the Greater Accra Region, Ghana: A proof of concept study
Habib Yakubu, Center for Global Safe WASH, Emory University
Additional Authors: Center for Global Safe WASH, Emory University-Working Group, Council for Scientific and
Industrial Research- Water Research Institute- Working Group, TREND Group-Working Group, Ghana Health Service-
Working Group

Several high-resource countries are using environmental surveillance (ES) to supplement COVID-19 surveillance based
on diagnostic testing. ES has the potential to provide early warning of community outbreaks and as a convenient,
sensitive, low-cost, and rapid method to estimate COVID-19 prevalence, especially resource-challenged populations
where clinical testing is limited. In high-resource countries, most ES has been conducted in communities with sewerage
systems. However, there are few ES studies in low-resource settings that typically have a mix of sewered and non-
sewered sanitation systems. We explored the feasibility of environmental surveillance for SARS-COV-2 as an early
warning system in Ghana’s epicenter, the Greater Accra region.
In the Greater Accra region of Ghana, about 9.4% of households are connected to a sewerage network, 75.2% use
improved on-site sanitation systems including shared latrines, and about 40% rely on non-sewered public latrine
facilities. Stakeholder analysis and mapping was used to identify and convene key national stakeholders in order to
institutionalize ES to inform the government of Ghana’s COVID risk mitigation strategy. A national expert committee, led
by the Ghana Health Service, guided the selection of the study sites. Tema (pop. 374,148) and Osu Alata (pop. 68,633)
were selected based on COVID-19 hotspot data and the mix of sanitation solutions they represent. Tema is primarily
served by a sewer system, whilst Osu Alata is served by shared non-sewered public latrines. The study sites were
mapped to inform decision-making by the municipal COVID 19 committee. From January-May 2021, samples were
collected from 3 locations in Tema and from 6 shared public latrines in Osu Alata. A total of 208 weekly grab and Moore
swab samples were collected at these sites and processed by either membrane filtration or skim milk flocculation
method, RNA extraction, and then analyzed by quantitative multiplex RT-PCR using commercially available kits.
Corresponding physical parameters (temperature, pH, total dissolved solids, and turbidity) were also measured per
sample. Additionally, weekly data on reported cases from the two sites were collected.
Of the 134 samples collected from the Osu Alata public latrines, 11.2% tested positive for SARS CoV-2 RNA. Of the 74
samples collected from the Tema, 35.1% tested positive for SARS-CoV-2 RNA. To our knowledge, this is the first time
SARS COV-2 RNA has been detected from fecal sludge from an on-site public latrine system in a low-resource setting.
Initial analyses show a temporal trend and credible variation in the strength of the PCR signal corresponding with
reported COVID-19 cases in Tema and Osu Alata. These results have been shared during the monthly stakeholder
meetings to inform decision-making for COVID-19 risk mitigation.
The Ghana Health Service is planning to use ES: 1) in 6 districts that have not reported any cases of COVID-19, 2) to
monitor COVID-19 variants in Ghana, 3) to monitor COVID-19 in key institutions, and 4) to integrate into the national
polio ES system and the national SORMAS COVID-19 dashboard. These findings demonstrate that ES for COVID 19 is
feasible in low-resource settings as a complementary tool to measure COVID-19 burden and mitigate risk.

Evaluation of a Water Arsenic Filter in a Participatory Intervention to Reduce Arsenic Exposure in American
Indian Communities: Strong Heart Water Study
Christine Marie George, Johns Hopkins Bloomberg School of Public Health
Additional Authors: Tracy Zacher, Kelly Endres, Francine Richards, Lisa Bear Robe, Ana Navas-Acien
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 Verbal Abstracts

Many rural populations, including American Indian communities, using private wells for their drinking and cooking water
are disproportionately exposed to elevated levels of arsenic. However, programs aimed at reducing arsenic in American
Indian communities are limited. The Strong Heart Water Study (SHWS) is a randomized controlled trial aimed at reducing
arsenic exposure among private well users in American Indian Northern Great Plains communities. The community led
SHWS program installed point of use (POU) arsenic filters in the kitchen sink of households, and health promoters
delivered an arsenic health communication program. In this study we evaluated the efficacy of these POU arsenic filters
in removing arsenic during the two-year installation period. Participants were randomized into two arms. In the first arm
households received a POU arsenic filter, and 3 calls promoting filter use (SHWS mobile health(mHealth) and filter only
arm). The second arm received the same filter and phone calls, and 3 in-person home visits and 3 Facebook messages
(SHWS intensive arm) for program delivery. Temporal variability in water arsenic concentrations from the main kitchen
faucet was also evaluated. A total of 283 water samples were collected from 50 households with private wells (139 filter
and 144 kitchen faucet samples). Ninety-three percent of households followed after baseline had filter faucet water
arsenic concentrations below the arsenic maximum contaminant level of 10 μg/L (98% in the intensive arm vs. 94% in
the mHealth and filter only arm). No significant temporal variation in kitchen arsenic concentration was observed over
the study period (intraclass correlation coefficient = 0.99). This study demonstrates that POU arsenic filters installed for
the community participatory SHWS program were effective in reducing water arsenic concentration in study households
in both arms. Furthermore, we found that there was limited temporal variability in water arsenic concentrations.

Evaluation of an innovative, nature-based approach to decentralized wastewater treatment in urban informal

settlements
Allison Salinger, Emory University
Additional Authors: Thomas F. Clasen, Kerrie Burge, Peter Breen, Maghfira Saifuddaolah, Tony Wong

Background:
Globally, 3 billion are projected to live in urban informal settlements by 2050. Due to their complex sociocultural and
biophysical characteristics, sanitation management in informal settlements poses many challenges. There is an urgent
need to identify technical solutions for providing safe sanitation and disrupting fecal-oral contamination pathways in
these contexts. Water-sensitive cities (WSC) is an innovative approach that employs ‘nature-based’ technologies, in
hybrid green-grey infrastructure, to manage wastewater and environmental contamination through decentralized
bioremediation. WSCs have been effective in high-income settings, but have not been attempted in informal
settlements, which introduce several unique challenges including housing density, ill-defined tenure, and hazardous
environmental conditions such as flooding. This study is an evaluation of a demonstration site to inform intervention
design in an ongoing randomized controlled trial, which will ultimately assess the effect of WSCs on environmental fecal
contamination, human health, and wellbeing. This study aimed to demonstrate feasibility of construction, system
performance, cost-effectiveness, and acceptability of implementing WSC technologies in informal settlements.
Methods:
The demonstration project was constructed in 2020 in Makassar, Indonesia to service 22 dwellings. The system was co-
designed with residents and included communal septic tanks and drains, precinct-scale pressure sewers, constructed
wastewater treatment wetlands, and biofilters. A total of 317 water samples were collected over 57 weeks at five
locations throughout the treatment system and one in the receiving environment. Samples were analyzed for
physiochemical and microbiological parameters. Simplified lifecycle cost analysis was used to calculate estimated
planning, operation, and maintenance costs and actual construction costs; estimates were compared to costs of a
conventional system in South Sumatra, Indonesia. To evaluate acceptability, in-depth interviews were conducted with
residents and analyzed to capture perceived benefits and consequences of specific intervention components.
Results:
Analysis of water samples indicated that, except for ammonia, the system met all Indonesian discharge standards for
domestic wastewater, including pH, BOD, TSS, COD, oil and grease and total coliforms. Ammonia remained non-
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 Verbal Abstracts

compliant (inflow 181.4mg/L, effluent 35.2mg/L, standard <10mg/L), possibly due to non-dilution with greywater and
requiring additional aeration. Mean total coliforms were reduced by 99.3% (from 308,900 to 2,100 CFU/100ml) and E.
coli by 99.7% (from 195,150 to 650 CFU/100ml). The total system cost was $5,153 USD/household, which compared
favorably to the conventional system in South Sumatra estimated at $6,670 USD/connection. The comparison is against
a typical conventional system consisting of a wastewater treatment plant, pump station, pressure mains, and gravity
sewers, but not the toilet renovations, rainwater harvesting, improved drainage and flood control included in the WSC
approach. Interviews demonstrated acceptability among diverse residents who cited major benefits related to
accessways and improved flood resilience.
Conclusions:
Results suggest that the nature-based solutions introduced by the trial’s implementation can effectively substitute for
conventional wastewater treatment while being appropriate for densely populated, low-income settings. Having
demonstrated the feasibility, performance, cost-competitiveness, and acceptability of implementing the WSC approach
in this context, this study provides a compelling solution for practitioners interested in implementing fit-for-purpose
systems in urban informal settlements that address residents’ sanitation needs whilst also providing multiple co-
benefits.

Expanding sanitary sewer infrastructure amidst uncertain rates of urbanization and climate change
Gabrielle Marega, University of Toronto
Additional Authors: David Meyer

Background:
Achieving sustainable universal access to water and sanitation under the influence of climate change has been described
as the “defining challenge for the SDG period” [1]. The latest Intergovernmental Panel on Climate Change reports states:
“key infrastructure systems including sanitation… will be increasingly vulnerable if design standards do not account for
changing climate conditions” [2]. Yet, the literature on how climate change will impact sanitation infrastructure is sparse
[3]. In this study, we create a parsimonious model of piped sewer performance to quantitatively identify the largest
uncertainty-induced threats to safely managed sanitation in rapidly urbanizing cities under the influence of climate
change.
Methods:
To identify threats to safely managed piped sanitation, we contrasted current sewer design guidelines with the load
sewers are likely to experience in an urbanized 2050 scenario, including climate change effects. Flows through a sanitary
sewer include sewage, groundwater infiltration, and some stormwater. We consider how each of these flows varies
under urbanization and climate change explicitly by modelling changes in population growth rate, sewage production
per capita, impervious areas, interconnections between sanitary and stormwater systems, and rainfall intensity. Our
model also considers sewer performance before 2050, highlighting more immediate opportunities for adaptation and
mitigation. We applied our model to three case study cities in different climatic zones of Brazil: Recife (in the Northeast),
Manaus (in the Amazon Basin), and Curitiba (in the South).
Results:
In all three cities, one-way sensitivity analyses of our 2050 scenario found that the interconnection rate between
sanitary and storm systems is at least 2.1 times more influential than other considered variables and at least 2.8 times
more significant than climate change. This result demonstrates that sanitary sewer infrastructure in Brazil is highly
vulnerable to stormwater entering the sanitary sewers. This vulnerability will be magnified as rainfall events intensify
due to climate change. During a sewer’s lifetime, utility managers can learn about their climate change readiness by
comparing sewage flows before and during rainfall events. We find that reducing the amount of stormwater that enters
sanitary sewers is a highly effective method of both increasing sewer capacity and mitigating the effects of climate
change on piped sewers.
Conclusions:

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 Verbal Abstracts

To ensure reliable sewer performance, uncertainty must be considered at the design stage, especially in low- and
middle-income countries with sparse or unreliable historical data. When building or expanding sanitary sewers,
inaccurate estimates of how much stormwater will enter the sanitary system can lead to sewage overflow resulting in
health, environmental and economic hazards. Our parsimonious model provides policymakers and utilities with the high-
level insights needed to measure and mitigate five key sources of uncertainty affecting sanitary sewer design and
expansion. Our model highlights that stormwater entering sanitary sewers poses the largest threat to urban sanitation
and sewer network performance; this threat is intensified where extreme rainfall events will increase due to climate
change.
References
[1] G. Howard, R. Calow, A. Macdonald, and J. Bartram, “Climate Change and Water and Sanitation: Likely Impacts and
Emerging Trends for Action,” Annu. Rev. Environ. Resour., vol. 41, no. 1, pp. 253–276, Nov. 2016, doi: 10.1146/annurev-
environ-110615-085856.
[2] IPCC (2022) Climate change 2022: impacts, adaptation, and vulnerability: contribution of Working Group II to the
sixth assessment report of the Intergovernmental Panel on Climate Change. Cambridge, UK; New York: Cambridge
University Press, 2022.
[3] Mikhael, G., Hyde-Smith, L., Twyman, B., Trancón, D. S., Jabagi, E., & Bamford, E. (2021). Climate Resilient Urban
Sanitation - Accelerating the Convergence of Sanitation and Climate Action. Deutsche Gesellschaft für Internationale
Zusammenarbeit (GIZ) GmbH

Filling the Buried Sanitation Infrastructure Data Gap in the United States
Nelson da Luz, University of Massachusetts Amherst
Additional Authors: Emily Kumpel, Jay Taneja

Background:
There has not been a national effort to collect detailed data on the sanitation infrastructure systems serving the United
States population since the 1990 US Census when at least 20% of the population were served by septic systems.
Sanitation systems can be centralized (e.g., sewer systems) or decentralized (e.g., on-site wastewater treatment systems
(OWTS) or septic systems). With a large portion of the population served by on-site systems, it is important to quantify
where these systems are located, how prevalent they are, if they serve their purpose, and what populations are served
by them. We propose the creation of a national inventory of buried sanitation infrastructure to fill the gap in recent
nationally available data on who in the US is served by different types of buried sanitation infrastructure.
Methods:
We present a framework for processing publicly available datasets and then using that processed data with machine
learning models (e.g., classification trees, random forests, and neural networks) to predict prevalence of sanitation
infrastructure types. Datasets including building footprints, roads, land cover, wastewater treatment plant locations, tax
assessments, US Census places, and US Census American Community Survey data are acquired and then processed using
geospatial data processing techniques to assign characteristics of these datasets to individual land parcels. The
processed data is then used as input features for machine learning models. Ground truth data from the state of Florida’s
Florida Water Management Inventory is used to create labels of parcel requires sanitation infrastructure (Yes/No) and
labels of on-site system or sewer connection. The input features and ground truth data are used to train random forest
models to make predictions for the label classes described (Requires sanitation infrastructure: Yes/No, Infrastructure
Type: On-Site/Sewer).
Results:
Results thus far demonstrate that a method using two random forest models serially is effective for making predictions
of sanitation infrastructure coverage in four counties in the state of Florida (>80% correct classification with models
trained with data from two of the counties). “In sample” prediction performance for the portion of data reserved for
testing in two of the counties exceeds 95% accuracy. For out of sample predictions in the other two counties, the
performance accuracies were approximately 80% and 90%. Adding a small fraction of county specific labels (1% of
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 Verbal Abstracts

known labels) for the out of sample county with poorer performance led to an increase from approximately 80%
accuracy to 92% accuracy. Future work will encompass analysis of all counties in Florida and some counties in Virginia to
demonstrate model generalizability and potential for method scaling to other regions of the United States.
Conclusions:
Machine learning methods such as random forest can provide reasonable estimates of sanitation infrastructure
coverage in counties in different regions of the US state of Florida. Adding additional county specific labels during model
training can significantly increase performance potential. An inventory of buried sanitation infrastructure can be used by
engineers and planners to aid in evaluating risk of failure of on-site sanitation systems and evaluating feasibility of
sanitation infrastructure centralization.

Household self-supply: an immense but overlooked contributor to SDG6 in the Asia-Pacific region
Tim Foster, University of Technology Sydney
Additional Authors: Diana Gonzalez Botero, Peter Harvey

This study characterizes the extent of household investment in self-supply in the Asia-Pacific and its contribution to SDG
target 6.1. Global cost estimates for SDG6 assume that a piped connection is the only means for accessing a safely
managed service. However, in low- and middle-income countries (LMICs) in the Asia-Pacific region, it is common for
households to instead invest in their own well or rainwater tank (i.e., household self-supply). Given these systems are
typically available on the premises, they are capable of providing a safely managed service.
Focusing on South Asia, Southeast Asia and the Pacific, the objective of this study was to (a) estimate the number of
people relying on self-supply, (b) characterize the wealth status of self-supplying households, and (c) quantify the
contribution of self-supply to coverage of safely managed water services. National policies and plans were also reviewed
to assess how governments recognize and respond to self-supply. Analysis was conducted on >80 nationally
representative datasets (e.g., Multiple Indicator Cluster Surveys, Demographic and Health Surveys, Censuses) from 23
LMICs in the Asia-Pacific region. Self-supply was defined as a non-piped water source located on the premises of a
respondent (e.g., borehole/tubewell, protected well, unprotected well or rainwater tank). Country-level results from the
most recent surveys were pooled to estimate region-wide coverage levels.
Our results show that around one-third of the population – or ~800 million people – in Asia-Pacific LMICs self-supply
their drinking water, and an additional 75 million self-supply their water for other domestic needs. The population
relying on self-supply is increasing by ~10 million each year. Self-supplying households are distributed across the wealth
spectrum and include both the poorest and wealthiest households. Among the 9 countries with available data on both
water quality and availability, 57.5% of households with improved self-supply receive a safely managed service,
compared with 44.1% of households supplied through a piped connection. Of the 13 countries with data on water
availability, self-supply provides a more reliable service than piped supply in 10 countries. In contrast, self-supply is more
likely to be contaminated with E. coli in 6 out of 9 countries with available data. In these 9 countries, the number of
households receiving safely managed water through self-supply is around 2.7 times the number of households receiving
safely managed water through a piped supply. Current self-supply assets represent USD 10-40 billion in household
investment, with households spending a further USD125-500 million on self-supply every year. Despite this, self-supply
receives little recognition in national policy documents or sector plans.
Contrary to widespread assumptions, our results show that self-supply can – and commonly does – provide a safely
managed water service. Despite significant levels of expenditure on water supply infrastructure by governments and
development partners in LMICs in the Asia-Pacific region, it is household investment that has delivered the majority of
safely managed water services in numerous countries. Yet self-supply remains underappreciated, with policy documents
in many countries failing to acknowledge its existence. Recognizing and harnessing these hidden investments could
accelerate progress towards the SDG target 6.1, which governments and development partners alone may not reach by
2030.

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 Verbal Abstracts

How Technology Innovation & Social Marketing Converge for Impactful Behavior Change: Pb Mitigation in
Madagascar
Adaline Buerck, Mercer University
Additional Authors: James R. Mihelcic, Mahmooda Khaliq, Luke John Paul Barrett, Lova Navalona Rakotoarisoa, Rinah
Rakotondrazaka

Background:
Toamasina, Madagascar presents a unique challenge when examining the abundant use of hand pumps locally
manufactured with lead (Pb) parts that has resulted in unsafe drinking water. Toamasina is a coastal city of over 300,000
people where centralized piped water is not always affordable or reliable, creating a demand for supplemental
decentralized self-supply water systems, such as hand pumps, common in low-income countries. Challenges for this
system come from a unique market for hand-driven wells, the many water contaminants found (Pb being one concern
due to its toxic nature), and the lack of understanding of the health effects of Pb on Malagasy children. Researchers have
identified a simple solution to retrofit the pumps with non-leaded components. However, the question remains whether
the population will adopt the solution. This convergent research integrates engineering, social marketing, and public
health to assess and develop a sustainable solution to reducing Pb contamination.
Objective:
Demonstrate how decision modification (i.e., use of non-leaded components) informed by social marketing can reduce
exposure to chemical pollution such as lead in water, thereby improving community health outcomes.
Methods:
Using a social marketing framework, a behavioral focus was selected (use of non-leaded components), priority audience
identified (hand pump technicians), and formative research was conducted, which led to a communication/skill-based
intervention targeting knowledge, attitudes, and practices of technicians, who manufacture and repair pumps. The
sought-after behavior change was to replace and no longer use Pb components in the pump by way of an engineered
substitute (i.e., non-leaded components). Evaluation methods included informal interviews with technicians, water
quality testing, and assessing blood lead level concentrations of children prior to and following remediation (removal of
Pb components and replacement of non-Pb components) of pumps.
Results:
This research remediated over 500 pumps, tested blood lead levels in more than 300 children, and developed and
implemented a social marketing campaign developed for pump technicians. In total, 21 technicians participated in some
portion of remediation work. Findings indicate that removing lead from the pumps results in a statistically significant
decrease in aqueous Pb levels (t(35)= 3.78, p < 0.001; 95% CI[6.75,22.42]) and blood Pb level concentrations (t(54)= 6.15,
p < 0.001) of children indicating a positive impact on health from the remediation efforts. Interviews with technicians,
skill checks, and observing technicians while working indicate a sustainable behavior change within the technician
population to use Pb free components.
Impact:
A major contribution of this work includes support for utilizing convergent research methods to examine complex
problems such as chemical contamination. To the authors knowledge no BLLs had previously been measured in LMICs
for relations to aqueous lead exposure. Our analysis of water and blood lead levels shows the significance of aqueous
lead exposure in LMICs. Furthermore, to the authors knowledge social marketing has not been used to reduce lead
exposure within LMICs. This research shows sustainable uptake of engineered solutions is possible by behavior change
of midstream players facilitated by social marketing. The methods used are adaptable and applicable for other
geographic areas and toxins.

How well do point-of-use water treatment devices really “work”? A novel in-situ evaluation method
Camille Zimmer, University of Victoria
Additional Authors: Alice Gentleman, Caetano C. Dorea

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 Verbal Abstracts

Point of use water treatment (POUWT) technologies are the final and sometimes only barrier against waterborne illness
in contexts where there is insufficient or non-existent access to a safely managed on-premises water supply.
Microbiological effectiveness of POUWT devices is currently evaluated under controlled laboratory conditions using
water spiked with virus, bacteria, and/or protozoa or their surrogates to measure log10 reduction values or LRVs, in a
process called challenge testing. However, laboratory-based POUWT challenge tests do not assess microbe reduction
under real-use conditions, thus omitting user behaviors and water quality.
The objective of this work was to develop and pilot a field challenge test protocol using previously validated food-safe
spike microorganisms. These objective addresses recent calls for POUWT methods to be evaluated while in operation by
their owners in situ (as opposed to idealized laboratory conditions).
In summer 2021, 144 one-on-one surveys were conducted of backcountry campers in the Juan de Fuca provincial park in
British Columbia, Canada (University of Victoria ethical approval #21-0092; BC Parks authorization #98700-20). Each
survey consisted of a challenge test of the participants’ own water treatment device (topic of this abstract), a
questionnaire, a 100 mL grab sample of the participants’ drinking water, and a hand rinse sample measuring
microbiological hand contamination (outside the scope of this abstract). The challenge test consisted of spiking a 1 L
sample of water (taken from the stream at the campsite) with probiotic supplement Mutaflor® and baker’s yeast, food-
safe surrogates for pathogenic E. coli and protozoans, respectively. Participants treated the spiked water as normal,
using their own POUWT device. Post-treatment water samples were enumerated in comparison to the original spike to
calculate LRVs.
Field challenge tests proved a feasible way to assess POUWT methods in situ. In the field, POUWT devices achieved on
average 3.1 LRVs (95% CI 2.9-3.3) and 3.7 LRVs (95% CI 3.5-3.9) for bacteria and protozoan surrogates, respectively.
Field-generated LRV data were compared to LRVs reported by the manufacturer or by the WHO International Scheme to
Evaluate Household Water Treatment Technologies (the “laboratory” data) where available, using multiple one-sample
t-tests (α = 0.05, with a post hoc Bonferroni correction). Many technologies performed worse relative to laboratory data,
however some methods performed better, highlighting the importance of in situ evaluations, especially in view of
decision-making based on such data.
Six out of eight brands (75%) for which data was available had significantly lower bacterial reduction (poorer
performance) in the field compared to reported laboratory data; these brands showed an average field
underperformance of 3.0 LRV compared to the laboratory. Four out of eight brands (50%) had significantly higher
protozoan surrogate reduction in the field than that reported in the lab, with an average overperformance of 1.6 LRV.
Two out of the eight brands (25%) had significantly lower protozoan surrogate reduction in the field, with an average
underperformance of 2.0 LRV. The pilot study results point to the need to assess microbial reduction under conditions
that are representative of real-life situations, including user conditions and water quality.

Impact of a sanitation intervention on infection risk from fly contaminated foods in Maputo, Mozambique
Drew Capone, Indiana University
Additional Authors: Joe Brown

Synanthropic filth flies feed on feces and can transport enteric pathogens in their alimentary canal and on their body.
When these flies land on food, they may vomit, defecate, or deposit enteric pathogens from their body onto food
surfaces. The presence of enteric pathogens in food then poses an infection risk to individuals upon consumption. Our
research aims were to: (1) assess the prevalence of 22 enteric pathogens in individual flies; and (2) evaluate if a shared
onsite sanitation intervention in Maputo, Mozambique reduced a person’s estimated annual risk of infection from
consuming fly contaminated food compared to a control group.
We collected flies at compounds which received a shared onsite sanitation intervention and at control compounds that
did not receive the intervention. We used Compact Dry™ EC plates to measure culturable E. coli from 46 flies, dPCR to
quantify gene copies (ybbW) of E. coli from 19 flies, and RT-qPCR to quantify gene copies specific to 22 enteric
pathogens from 168 flies. We found 50% (23/46) of individual flies were positive for culturable E. coli and 100% for the

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E. coli gene ybbW. We detected ≥1 pathogen gene from 47% (79/168) of flies, including enteropathogenic E. coli
(37/168), pan-adenovirus (25/168), Giardia spp. (13/168), and Trichuris trichiura (12/168).
We combined experimental data with probabilistic distributions from the peer reviewed literature to develop stochastic
quantitative microbial risk assessment (QMRA) models for the eight most frequently detected pathogens. Using our
QMRA estimated annual infection risk for consumption of fly contaminated food as the outcome variable and the
intervention as our exposure variable, we fit Poisson regression models to generate risk ratios.
We estimated that intervention reduced the annual risk of infection attributable to fly contaminated food for Giardia
spp. (RR = 0.41, [0.18, 0.96]), but had no impact on enteropathogenic E. coli (RR = 1.1, [0.48, 2.7]), pan-adenovirus (RR =
0.60, [0.33, 1.1]), enteroaggregative E. coli (RR = 0.76, [0.49, 1.2]), enterotoxigenic E. coli (RR = 0.92, [0.0.72, 1.2]),
Trichuris trichiura (RR = 0.66, [0.19, 2.3]), Shigella spp. (RR = 0.96, [0.28, 3.3]), and norovirus (RR = 0.98, [0.77, 1.3]). The
protective effect observed for Giardia spp. may be a result of the sanitation intervention design – a pour flush toilet to
septic tank – which created a physical barrier and may have better prevented flies from breeding in fecal sludge
compared to controls. However, our results suggest that the intervention did not substantially reduce the risk of enteric
pathogen infection from fly contaminated food.

Impact of Better Sanitation on Quality of Life: Evidence from Rural Zambia, Ethiopia, and Malawi
James B. Tidwell, World Vision
Additional Authors: Jenala Chipungu, Abiy Tefasse, Ian Ross

Background:
Recent trials have called into question the direct child health benefits of basic WASH services and many programs only
evaluate the benefits of WASH across indicators like reductions in diarrhea, stunting, and wasting. However, an
extensive (mostly qualitative) literature shows there are broad benefits of WASH including time and cost savings,
impacts on livelihoods (especially important in the COVID-19 era), and privacy, safety, and dignity, but tools for
capturing these benefits in a rigorous, quantitative, easy-to-deploy-in-programming manner are lacking. Some work has
been done to develop a Sanitation-Related Quality of Life (SanQoL) measure in peri-urban contexts, but the concerns
and capabilities of those in rural areas are likely to differ significantly. Such a measure could be useful both as an
outcome measure and a tool for planning sanitation promotion campaigns.
Methods:
We sought to adapt the SanQoL measure to rural settings in Zambia, Ethiopia, and Malawi. We conducted a series of
qualitative interviews to understand the unique challenges faced related to sanitation in rural settings with special
attention paid to issues of gender, physical disability, and vulnerability in general. Based on the quality-of-life priorities
associated with sanitation identified in the qualitative work (n=30 interviews and n=20 FGDs) and cognitive interviews to
ensure that constructs were being adequately conveyed to respondents, a quantitative survey was deployed in Zambia
(n=500) across 25 villages in 5 districts, in Ethiopia (n=1,500) across 6 woredas in 3 regions, and in Malawi (n=4,500) all
10 traditional authorities of the Chiradzulu district, capturing basic demographics, detailed measures of objective
sanitation characteristics, quality-of-life indicators, and a ranking exercise to produce indicator-associated weights
derived from users themselves. Data collection from Malawi is almost complete will be finished by May 15, 2022, but
both other data sets are complete and so their results are described here (Malawi will be included in the presentation).
Results:
Open defecation was relatively rare even in relatively poor, rural areas in Zambia (7%), while Ethiopia had higher rates of
OD (31%). Despite some studies suggesting that some people prefer open defecation, there were few practicing OD who
reported high SanQoL scores, with a mean score (on a scale from 0 to 1) of 0.57 for OD vs 0.75 for having any kind of
toilet (even unimproved) in Zambia (p=.037), and 0.29 for OD vs 76% for having any kind of toilet (even unimproved) in
Ethiopia (p<.001). In both settings, the six attributes were ranked, in order from most to least important, as (avoiding)
disgust, privacy, convenience, safety, (avoiding) shame, and health, with health notably the lowest ranked category.
Finally, while these data indicated that non-health approaches to sanitation promotion would be the most effective,
28% of the variation in sanitation status was associated with the level of wealth of households, indicating that beyond
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promotional approaches, a significant gap in sanitation promotion will result if only demand-side characteristics are
considered.
Conclusion:
The SanQoL measure is a low-burden, informative way to measure the impact of sanitation programs and to understand
how programs differentially population sub-groups. Simple measures to understand both the importance of sanitation
for quality of life in rural contexts as well as preferences for kinds of sanitation technology to inform promotion efforts
may lead to more effective and equitable sanitation programs.

Impact of changes in WASH practices and nutrition Pre-/Post COVID-19 pandemic on child health
Bal Mukund Kunwar, Helvetas/EAWAG
Additional Authors: Regula Meierhofer and Akina Shrestha

Background:
Achham and Dailekh are remote hilly districts in Nepal. Subsistence agriculture and foreign migration are the most
important sources of income. Due to lockdowns during the COVID-19 pandemic, migrant workers returned home, and
income levels were reduced. This increased household’s food insecurity. To prevent the spread of the SARS-CoV-2 virus
hygiene measures were promoted by the health authorities and media. However, inadequate water supply in these
regions may have limited adequate hygiene behaviors. The objective of this study therefore was to understand the
impact of the COVID-19 pandemic on changes in water, sanitation, and hygiene (WASH) related practices, nutritional
and other health outcomes among children.
Methods:
A longitudinal and mixed method study was conducted using data from a cross-sectional study conducted in spring 2018
for baseline and follow-up data collected in November-December 2021. We involved 490 children aged 0-14 years at
follow-up. Structured interviews were conducted to collect information on WASH practices, the availability of WASH
infrastructure at household level, child health and dietary intake. Water quality at the source and point of consumption
was assessed using membrane filtration. Stool samples were analyzed via a suite of copro-microscopic diagnostic
methods for the detection of intestinal protozoa and helminths. Anthropometry and clinical signs of nutritional
deficiencies were assessed during health examinations. In addition, we conducted 10 in-depth interviews with children’s
caregivers and local stakeholders to understand major problems the local community faced in relation to COVID-19. The
changes in key indicators between the baseline and follow-up surveys were analyzed by mixed logistic and linear
regression models.
Results:
Most respondents (94.2%) heard about COVID-19, however, did not wear masks nor comply with any social distancing
protocols. 94.2% of households’ self-reported handwashing with soap 5-10 times per day at follow-up, especially after
defecation compared to 19.6% at baseline. However, the adequacy of the handwashing was reduced by interruptions in
the water supply and limited availability and high cost of soap. Water quality was better at follow-up than at baseline
with median 12 vs 29 CFU E. coli/100mL (interquartile range at baseline (IQR) = 4-101) at the point of collection and 34
vs 51.5 CFU E. coli/100mL (IQR=8-194) at the point of consumption. We found a decreased prevalence of various
infections at follow up: fever (41.1% to 16.8%; p=0.48), respiratory illness (14.3% to 4.3%; p=0.58), diarrhea (19.6% to
9.5%; p= 0.97) and Giardia lamblia infections (34.2% to 6.5%, p=0.33). Contrary to this, we found a higher prevalence of
nutritional deficiencies at follow-up: bitots’ spots (26.7% to 40.2%; p=0.69), pale conjunctiva (47.0% to 63.3%; p=0.60)
and dermatitis (64.8% to 81.4%; p=0.64). Inadequacy household income to secure nutritional needs increased from
35.0% to 94.2% (p=0.61).
Conclusions:
Intensified hygiene promotion and the threat of infection during the COVID-19 pandemic facilitated the frequency
handwashing, while the prevalence of infectious diseases decreased. At the same time measures to prevent the
pandemic reduced food security resulting in a high prevalence of nutritional deficiencies. Our findings underline that
disaster preparedness should pay attention to adequate WASH, nutrition, and health supplies.
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Improving Treatment of Container-Based Sanitation via Windrow Composting in Haiti

Patrick Ward, Sustainable Organic Integrated Livelihoods (SOIL) - Haiti
Additional Authors: Julie Jeliazovski

Background:
Sustainable Organic Integrated Livelihoods (SOIL) operates a household container-based sanitation and composting
waste treatment service in urban and peri-urban Cap-Haitien, Haiti. SOIL’s services meet a demand for safely managed
sanitation and addresses a myriad of interconnected challenges: environmental degradation, waterborne illness,
economic disempowerment, climate change, and food insecurity.
SOIL historically employed a composting system that contained and treated the collected waste in a 12 m3 bin for 2
months and then turned the waste monthly for an additional 4.5 months in piles until reaching maturity. This process
was appropriate at a small scale because small quantities of waste could achieve requisite temperatures for killing
pathogens. Now serving 1,600 households, bin composting presents an expensive challenge: every 120 additional
households require an additional bin and turning space.
Preparing for the projected scale-up to 8,000 households in five years, SOIL has the opportunity to re-envision the
treatment and transformation process. SOIL explored the viability of replacing the current bin composting process with
windrow composting. Our findings validate this transition which will begin in the coming months.
Methods:
Seven pilot windrow piles were created between May and September 2021. All piles were subject to regular turning,
watering, temperature checks, and E. Coli testing. Non-woven geotextile was used to preclude vectors and maintain pile
humidity. Once the transformation from waste to compost was complete, compost quality was assessed with pH and
conductivity analyses. The estimated process cost, time to maturation, and amount of compost yielded were calculated
for both bin composting and windrow composting.
Results:
The windrow compost met safety and maturity requirements in 3.2 months compared to 6.5 months for bin composting
(P-value: <0.001). The windrow composting yield was on average 10% higher than bin composting’s (P-value: 0.008). Due
to the increased turning frequency, windrow composting is more labor-intensive. However, windrow composting’s
efficiency and minimal infrastructure requirement make it 57% less expensive than bin composting at our current scale,
about $2,000 a month for windrow versus $3,000 for bin composting, and 64% less expensive at our 5-year objective of
8,000 households at $14,400 versus $22,400, respectively.
Conclusion:
Windrow composting represents a more efficient treatment process, increases waste treatment capacity of SOIL’s site,
improves compost yield (which has potential to increase compost revenue), and is more cost-effective than bin
composting per ton of waste treated. Additionally, SOIL is considering mechanizing operations with a large-scale
compost turner. This degree of mechanization, and its economies of scale, was not possible with bin composting.
Next steps include transitioning the whole facility to windrow composting without disrupting service through a phased
approach and further research to optimize compost yield and improve worker ergonomics. Additional safety measures
have already been incorporated through the feedback from compost workers. The implications of this transition are
significant: by adopting a more cost-effective process that is equally effective for the protection of public health, SOIL is
demonstrating a model for the provision of safely managed sanitation that is both ecological and inclusive of the urban
poor.

Individual risk perception to antimicrobial resistance (AMR) through environmental pathways in Malawi
Kondwani Chidziwisano, Malawi University of Business and Applied Sciences
Additional Authors: Tracy Morse, Dereck Cooker and Nicholas Feasey

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Introduction:
Exposures associated with human and environmental interaction are integral to enteric bacteria transmission, including
those with antimicrobial resistance (AMR). AMR elements have been found in water, feces, food, and wastewater in
household and environmental settings in Low- and Middle-Income Countries. However, individual perception to AMR –
bacteria risk and the behaviors that bring people into contact with the environment (i.e., animal feces, drain and river
water) have not been fully assessed. We conducted a study to identify individual risk perceptions to AMR through
specific environmental pathways and its associated behavioral determinants; to support the design of an intervention to
improve human and environmental interaction to reduce AMR exposure at household level in Malawi.
Method:
The cross-sectional research was grounded in the RANAS (Risk, Attitude, Norms, Ability and Self – regulation) Model of
behavior change and assessed risk perception of AMR exposure via three key targeted behaviors: use of river water, use
of drain water and contact with animal feces. In total, we conducted interviews with head of households in 300
households: 100 households in each study location i.e., urban, peri-urban, and rural settings. A quantitative
questionnaire based on the RANAS model was used to assess psychosocial factors underlying AMR exposure via animal
feces, river and drain water. T - test was used to assess AMR risk perception via the selected three environmental
parameters among the study participants while ANOVA was conducted to estimate differences in means between
performers and non–performers of the targeted behaviors across the three study locations.
Results:
Personal risk evaluation for AMR exposure was low (41%) among the study population and the perception of risk
between the study locations was not different (p=0.189). In terms of the behaviors that were linked with AMR
transmission, the study participants perceived that being in contact with animal feces contributes to the onset of AMR
while they expressed low perception on being in contact with drain and river water as risk factors to AMR transmission.
Further ANOVA mean comparison analysis revealed significant differences between urban and rural participants
(p=.001). Specifically, urban participants reported significantly more at risk to AMR via the selected environmental
parameters than their rural counterparts. Importantly, the study participants expressed limited knowledge on how such
human – environmental interaction facilitates the transmission of AMR as they only expressed being aware of general
disease transmission. Perception of social norms was favorable for the targeted behaviors (p=0.001). Self – reported
attitude and ability estimates (self – efficacy) were also significant (p=0.023).
Conclusion:
The findings suggest that factual knowledge should be targeted with an information-based intervention to raise
awareness on the role of environmental factors in AMR transmission. The study indicated the role of psychosocial
factors in influencing the human – environment interaction in AMR transmission cycle. Normative behavior changes
techniques (e.g., use of role models), combined with one-to-one meetings focused on targeting attitude and ability
factors are essential.

Laboratory evaluation of portable water quality testing kits

Rick Johnston, World Health Organization

Many low- and middle-income countries lack national data on drinking-water quality, in part because of difficulties in
collecting and analyzing samples in rural areas, or from privately owned supplies such as boreholes. One tactic to
overcome the problem of long travel times to laboratories has been to make use of portable water quality testing kits,
that allow for sample processing and incubation to be done in the field, with relatively little technical expertise.
Increasingly, chromogenic or fluorogenic growth media are used which allow measurement of E. coli instead of the
broader class of thermotolerant coliforms. One application has been the use of membrane filtration and chromogenic
media in household surveys, such as the Multiple Indicator Cluster Surveys (MICS), which have now been implemented
in nearly 50 settings.
A wide range of portable testing kits and growth media are now available and not all have been rigorously evaluated by
independent laboratories or certified by regulatory authorities.
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WHO has developed a laboratory protocol that assesses a product’s performance in defined water solutions and under
different conditions, ensuring that manufacturer claims can be verified. The protocol is based on existing E. coli
regulation certificates (USEPA and ISO) but specifically tailored to UNICEF and WHO use cases for field testing of water
quality.
In 2020/21 WHO supported a laboratory assessment at the KWR of 20 portable test kits, including products used in the
MICS as well as other materials available in WHO and UNICEF supply catalogues. Thirteen kits passed an initial screening
using a known strain of E. coli (ATCC 29522) in laboratory waters and were further evaluated using a range of natural
waters and high, medium, and low loadings of wild E. coli. Kits were assessed at different incubation temperatures, and
results were read at different times (typically 24, 48 and 72 hours).
Some of the technologies assessed relied on counting colonies, including Delagua and Wagtech portable kits, a new
Aquagenx gel bag, and a portable membrane filtration manifold (Millipore) combined with different chromogenic media
(Compact Dry ECO plates, 3M Petrifilm SEC plates, and Sartorius Chromocult Nutrient Pads). Other technologies relied
on Most Probable Number (MPN) methods. The Aquagenx Compartment Bag Tests and Palintest Colitag MPN Plate
made use of proprietary MPN systems, while 99-well plates were used to assess other chromogenic media (HiMedia
HiSelective, Hach Pathoscreen, and resorufin). One novel product (Fluidion Alert Lab) performs a multispectral optical
analysis, turbidity correction, signal analysis, and bacterial quantification of culturable E. coli with a time to result
ranging between 2 and 12 hours.
Preliminary results were shared at the UNC Water and Health 2021 conference, without identifying individual products;
results from the individual test kits will be presented at the 2022 conference. Kits are not given pass/fail marks, but the
results of the different challenges are presented quantitatively using regression analysis and nonparametric statistics for
goodness-of-fit.

Longitudinal effects of a cluster-randomized sanitation intervention on diarrhea and respiratory infection in rural
Bangladesh
Jesse Contreras, University of Michigan
Additional Authors: Mahfuza Islam, Benjamin F. Arnold, Stephen P. Luby, John M. Colford Jr, Ayse Ercumen

Background:
Diarrhea and acute respiratory infection (ARI) are leading causes of death in children. The WASH Benefits Bangladesh
trial implemented a sanitation intervention that reduced diarrhea by 39% and ARI by 25% among children, measured 1-2
years after intervention implementation. We measured longer-term intervention effects on these outcomes between 1-
3.5 years after intervention implementation, including periods with differing intensity of behavioral promotion.
Methods and Findings:
WASH Benefits Bangladesh was a cluster-randomized controlled trial of water, sanitation, hygiene, and nutrition
interventions (NCT01590095). The sanitation intervention included provision of or upgrades to improved latrines, sani-
scoops for feces removal, children’s potties, and in-person behavioral promotion. Promotion was intensive up to 2 years
after intervention initiation, decreased in intensity between years 2-3, and stopped after 3 years. Access to and reported
use of latrines was high in both arms, and latrine quality was significantly improved by the intervention, while use of
child feces management tools was low. We enrolled a random subset of households from the sanitation and control
arms into a longitudinal sub study, which measured child health with quarterly visits between 1-3.5 years after
intervention implementation. The study period therefore included approximately one year of high-intensity promotion,
one year of low-intensity promotion, and six months with no promotion. We assessed intervention effects on diarrhea
and ARI prevalence among children <5 years through intention-to-treat analysis using generalized linear models with
robust standard errors. Masking was not possible during data collection, but data analysis was masked. We enrolled 720
households (360 per arm) from the parent trial and made 9,088 child observations between June 2014 and December
2016. Over the entire study period, diarrheal prevalence was lower among children in the sanitation arm (11.9%)
compared to the control arm (14.5%) (prevalence ratio [PR] = 0.81, 95% CI 0.66, 1.00, p = .05: prevalence difference [PD]
= -0.027, 95% CI -0.053, 0.000, p = .05). ARI prevalence did not differ between sanitation (21.3%) and control (22.7%)
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arms (PR=0.93, 95% CI 0.82, 1.05, p = .23: PD=-0.016, 95% CI -0.043, 0.010, p = .23). There were no significant
differences in intervention effects between periods with high-intensity vs. low-intensity/no promotion. Study limitations
include use of caregiver-reported symptoms to define health outcomes and limited data collected after promotion
ceased.
Conclusions:
The observed effect of the WASH Benefits Bangladesh sanitation intervention on diarrhea in children was sustained for
at least 3.5 years after implementation, including 1.5 years after heavy promotion ceased. Existing latrine access was
high in the study setting, suggesting that improving on-site latrine quality can deliver health benefits when latrine use
practices are in place. Further work is needed to understand how latrine adoption can be achieved and sustained in
settings with low existing access, and how sanitation programs can adopt transformative approaches of excreta
management, including safe disposal of child and animal feces, to generate a hygienic home environment.

Making progress on national-level monitoring of menstrual health and hygiene: Priority indicators and related
measures
Marni Sommer, Columbia University
Additional Authors: Lead from each institution: Bethany Caruso (Emory University); Julie Hennegan (Burnett Institute);
Therese Mahon (WaterAid); Penelope Phillips-Howard (Liverpool School of Tropical Medicine); Jackie Haver (Save the
Children)

Problems Addressed/Purpose:
There is growing global recognition of menstrual health and hygiene (MHH) as an important health, education, rights,
and gender equality issue, but the lack of adequate validated indicators with related measures impedes progress.
Specifically, at the national level, the absence of standardized indicators and related measures curbs understanding of
MHH across populations and over time, and limits national evaluation of policies and programs designed to improve
MHH.
Overall Purpose:
Working in collaboration with key stakeholders and leaders from four exemplar countries and input from global
monitoring and MHH experts, we aimed to co-create a priority list of recommended indicators and related measures to
support national level monitoring of MHH for adolescent girls in and out of school.
Study Design:
Development of the indicator list involved a five-phase approach. First, we determined priority domains for monitoring,
considering definitions of MHH, past research, and operational guidelines for policy and programming. Second, existing
indicators, measures, and data sources were identified through a desk review, interviews with stakeholders in exemplar
countries, and review of policy guidance where available. Third, we mapped existing indicators and measures against the
priority domains to create an initial list, with consideration to quality, feasibility, and what indicators and measures were
already in use. Fourth, national stakeholders and global monitoring experts reviewed and rated the initial list of
indicators and measures based on relevance, usefulness, and feasibility, which then informed discussions across a two-
day online meeting. Finally, input from the virtual meeting, and repeated core group meetings, informed the final,
refined shortlist.
Key Findings:
Launched in 2022, we developed the “Priority List of Indicators for Girls MHH: Technical Guidance for National Level
Monitoring” guidance notes to present the selected indicators, supporting evidence, and considerations for future use.
Sufficient evidence was available to recommend a shortlist of priority indicators and related measures for seven priority
domains, extending across the WASH, Health (SRHR and psychosocial health), Education, and Gender sectors. Some
indicators could be drawn from existing national surveys, while others needed to be adapted. Not all domains relevant
to MHH are included because measures require further development before recommendation at scale. Future work is
needed to validate the adapted indicators and measures, to expand the current shortlist to a more comprehensive list,
and to support the use of the indicators at scale.
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Discussion:
Use of the recommended indicators will enable countries to identify unmet MHH needs across their populations, track
progress towards better supporting the needs of those who menstruate and set targets for improvement. Country
uptake will require addressing capacity needs around training for expanded data collection, analysis, and reporting, and
identifying country-level champions for incorporating MHH into national-level monitoring systems. While targeting
national level monitoring, MHH indicators can be used in research and programming to support and evaluate MHH.

Mechanisms for engagement of diverse people in participatory design for urban WASH, Indonesia, and Fiji
Naomi Francis, Monash University
Additional Authors: Audra Bass, Sheela S Sinharoy, Sudirman Nasir, Litea Meo-Sewabu, Becky Batagol

Globally, more than 1-billion people live in urban informal settlements and experience suboptimal access to safe water,
sanitation, and hygiene (WASH). Participatory approaches are increasingly being promoted as part of ‘transformative’
WASH interventions, but the key elements of these approaches are not well-defined. The Revitalizing Informal
Settlements and their Environments (RISE) program launched in 2017 and uses a participatory approach to co-design
water-sensitive infrastructure with residents of 24 urban informal settlements in Makassar, Indonesia and Suva, Fiji. Our
objective was to identify key mechanisms of a gender and socially inclusive participatory approach for engaging diverse
people in RISE.
We conducted semi-structured in-depth interviews (IDIs) with 49 RISE program staff (based in Indonesia, Fiji, Australia,
and the USA); IDIs with 42 residents from RISE settlements in Indonesia and Fiji; and 12 focus group discussions (FGDs)
with RISE settlement residents in Fiji in 2020-2021, after participatory design activities were complete. Resident
participants were purposively selected for representation of women and men; high and low participation in RISE; and
different levels of disability/impairment.
The question guides were informed by the Consolidated Framework for Implementation Research (CFIR), which defines
39 constructs (grouped into 5 domains) that describe an intervention. The IDI and FGD transcripts were analyzed
thematically with deductive codes based on the CFIR. For each of the 5 CFIR domains, the construct that provided the
most relevant findings pertaining to mechanisms for the engagement of diverse people was used for the final analysis.
The findings suggested that the key mechanism for engaging diverse residents in the RISE program was frequent
household visits by the staff for both assessment and intervention activities because this served to include those who
could not participate in group or public activities (e.g., due to mobility impairments) Another key mechanism was the
flexibility of the RISE program to prioritize resident needs outside of the program’s original mandate (e.g. providing food
aid during the pandemic). This responsiveness to the residents’ needs-built trust and interest in the program and
consequently encouraged residents to positively engage. The responsiveness of the program to local cultural norms and
organizational structures and residents’ schedules by offering activities at different times, with different combinations of
participants (e.g., women-/men-only/children-only activities) served to engage diverse participants also. Having a
diverse implementing team (with respect to gender, age and languages spoken) meant that diverse residents felt
comfortable engaging with them.
A key learning from this study is that interventions that aim to improve health in urban informal settlements through
participatory design of WASH infrastructure should engage with residents at least at the household level if they are to be
inclusive of diverse people. Future research should further explore the role of intra-household dynamics on the inclusion
of diverse individuals in participatory activities. Future scale-ups of programs like RISE should include budgets for
adapting engagement activities to the context of the participating settlements as well as flexibility to meet some of the
needs of residents outside the original program goals.

Microbial Source Tracking and Enteric Pathogen Detection in Humans and Domestic Animals in Urban Kenya
Sean Daly, North Carolina State University
Additional Authors: Swarthout, Jenna M.; Pickering, Amy J.; Harris, Angela R.
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Diarrheal illness remains a predominant contributor to the global disease burden and preventable death. Various
bacteria, viruses, protists, and helminths cause diarrhea, and can interact with humans through various environmental
pathways, with a common pathway being drinking water. Human feces (n=22), domestic animal feces (n=111), and
source (n=13) and stored (n=46) drinking water samples were collected in low-income areas near Nairobi, Kenya in 2019.
Nucleic acid from these samples was extracted and analyzed using microbial source tracking (MST) qPCR (quantitative
polymerase chain reaction) assays, including indicators for human, ruminant, and avian feces, and enteric pathogen
TaqMan Array Cards (TAC). TACs are 384-well singleplex real time PCR technologies, which allowed for the simultaneous
detection of up to 43 enteric pathogens via PCR amplification. From highest to lowest mean number of pathogens
detected per sample, the feces sources were dog (21.6), duck (16.2), goat (13.7), chicken (11.2), human (9.6), and cow
(8.9). The most common pathogens detected across hosts were Escherichia coli O157:H7 (most common in chickens,
dogs, ducks, and goats), Entamoeba histolytica (most common in cows and goats), and enteroinvasive E. coli (most
common in humans). Conducting MST will allow for identifying the source of fecal contamination in drinking water,
providing more specific insights for disrupting contamination pathways compared to using fecal indicator bacteria (FIB),
which are not disease-causing or host-specific organisms. These results will be presented in full following completion of
laboratory analysis. Using TACs provides information regarding specific pathogen density in environmental samples,
relieving some of the limitations of using more conventional FIB methods. This work will be helpful in identifying the
health risks associated with different host feces, and when coupled with environmental surveillance and observational
data, it can inform the dominant transmission pathways for pathogens in these settings.

Modeling groundwater use with satellite data, in-situ sensors, and machine learning toward drought early action
Katie Fankhauser, University of Colorado Boulder
Additional Authors: Denis Macharia, Evan Thomas

Groundwater is an important source of water for people, livestock, and agriculture during drought in the Horn of Africa.
In this work, areas of high groundwater use and demand in drought-prone Kenya were identified and forecasted prior to
the dry season. Estimates of groundwater use were extended from a sentinel network of 69 in-situ sensored mechanical
boreholes to the region with satellite data and a machine learning model. The sensors contributed 756 site-month
observations from June 2017 to September 2021 for model building and validation at a density of approximately one
sensor per 3700 km2. An ensemble of 19 parameterized algorithms was informed by features including satellite-derived
precipitation, surface water availability, vegetation indices, hydrologic land surface modeling, and site characteristics to
dichotomize high groundwater pump utilization. Three operational definitions of high demand on groundwater
infrastructure were considered: 1) mechanical runtime of pumps greater than a quarter of a day (6+ hr) and daily per
capita volume extractions indicative of 2) domestic water needs (35+ L), and 3) intermediate needs including livestock
(75+ L). Gridded interpolation of localized groundwater use and demand was provided from 2017 to 2020 and
forecasted for the 2021 dry season, June–September 2021. Cross-validated skill for contemporary estimates of daily
pump runtime and daily volume extraction to meet domestic and intermediate water needs was 68%, 69%, and 75%,
respectively. Forecasts were externally validated with an accuracy of at least 56%, 70%, or 72% for each groundwater
use definition. The groundwater maps are accessible to stakeholders including the Kenya National Drought Management
Authority (NDMA) and the Famine Early Warning Systems Network (FEWS NET). These maps represent the first
operational spatially explicit sub-seasonal to seasonal (S2S) estimates of groundwater use and demand in the literature.
Knowledge of historical and forecasted groundwater use is anticipated to improve decision-making and resource
allocation for a range of early warning early action applications.

Piloting Smart and Targeted Sanitation Subsidies in Ethiopia

Lars Osterwalder, USAID Transform WASH / IRC WASH
Additional Authors: Monte Achenbach, Ekram Redwan, Dagim Demirew, Shegaw Fentaye and Ephraim Mebrate
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 Verbal Abstracts

In rural Ethiopia, the richest are much less likely to practice open defection (11%) than the poorest (46%) according to
JMP estimates (JMP, 2017). The richest are also more likely to have access to basic sanitation services (10%) than the
poorest (5%). The Government of Ethiopia is promoting a market-based sanitation (MBS) approach to help households
move up the sanitation ladder, but affordability of sanitation products and services is recognized as a key barrier,
especially among the poorest (MoH, 2020).
It is estimated that potentially up to 40% of the population might need financial support for the construction of
improved toilet facilities (WASHPaLS, 2021). Therefore, the Ministry of Health (MoH) has developed a sanitation subsidy
protocol to guide the implementation of sanitation subsidies. They must be SMART to ensure that they do not distort or
hamper MBS and CLTSH approaches but rather contribute to overall expansion of sanitation markets. They also must be
TARGETED so that the subsidies address the most vulnerable population groups, who are not able to construct improved
sanitation facilities on their own due to their extreme poverty and/or impeding environmental factors.
The protocol is based on five principles: subsidies must be well-targeted, subsidies should only target latrine sub-
structures (including flooring), subsidies should only cover a proportion of the overall cost, subsidies should only be
introduced in places with a well-established supply chain, and these guiding principles must apply to everyone.
USAID Transform WASH, a project aimed at building a sustainable and thriving WASH market in Ethiopia, agreed to
support the MoH by piloting sanitation subsidies that adhere to the national protocol to generate evidence for further
adaptation and strengthening of the methodology. The pilot will be implemented in four woredas (districts) in Oromia
and SNNP regions. To be TARGETED, households eligible for subsidies are those exempted from paying for the recently
introduced community-based health insurance scheme. To be SMART, a voucher system will be used for eligible
households to procure installation services from nearby businesses that offer sanitation products and services.
A pre-implementation household survey was carried out in April 2022, including eligible (n = 532) and non-eligible
households (n = 359). Fifty-two percent of the subsidy-eligible households were found to have no own toilet facility, 47
percent to own an unimproved dry pit latrine, and only one percent to own an improved pit latrine. The sanitation
service levels of non-eligible households were found to be higher (31% no facility, 60% unimproved and 9% improved).
These findings confirm that additional support is needed for the eligible households to construct new pit latrines or to
upgrade existing unimproved latrines. However, the findings also show that non-eligible households need to invest in
improving their sanitation facilities and that there is a risk that sanitation subsides could discourage them from making
these investments.
The sanitation subsidy pilot will be implemented in May to July and a post-implementation survey conducted in August.
Findings of the pilot will be available for presentation at the UNC conference in October 2022.
MoH 2020 National Market-Based Sanitation Implementation Guideline. Ministry of Health/ Ethiopia, Addis Ababa,
November 2020.
JMP 2017 Inequality chart for Ethiopia in 2017 retrieved from washdata.org (on 30/04/2022). World Health Organization
(WHO) and the United Nations Children’s Fund (UNICEF). Geneva and New York.
WASHPaLS 2021 Assessment of tax exemptions policy for plastic sanitation products in Ethiopia - updated results based
on revised costing data. USAID Transform WASH & WASHPaLS projects, September 2021.

Process evaluation of a multi-modal hand hygiene intervention feasibility study in healthcare facilities in Cambodia
Robert Dreibelbis, London School of Hygiene and Tropical Medicine
Additional Authors: Elisabeth Tadiri, Yolisa Nalule, Channa Samol, Alison Macintyre, Supheap Leang

The CHAMP intervention is a multi-modal intervention designed to improve hand hygiene (HH) behaviors along the
continuum of care for mothers and neonates. For childbirth, the intervention targeted midwives with a two-day, digitally
delivered, interactive training session, cues, and nudges to trigger HH, and systems to allow reflection and feedback on
hygiene practices. For post-natal care (PNC), new handwashing infrastructure for patients and visitors was installed and
alcohol-based hand rub (ABHR) made accessible. Midwives were tasked with introducing the PNC spaces as a “clean
hands zone” and messages were reinforced with color-coded iconography. Mothers were given a personal bottle of
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ABHR and a baby hat with the words “wash your hands” knitted in Khmer. The intervention was implemented over a 3-
month period from April 2020 with routine process data collected monthly until an endline evaluation in November
2020. Results of the feasibility study have been previously reported. In brief: after adjusting for baseline differences, the
CHAMP intervention was associated with increased odds that midwives in intervention facilities would follow proper HH
protocol prior to the start of key procedures during childbirth compared to midwives in control facilities (aOR: 4.7, 95%
CI: 2.9 – 7.7), but there was no evidence that HH during procedures differed between control and intervention facilities.
In PNC spaces, the odds of HH associated with a critical moment were nine times higher in intervention compared to
control facilities (aOR: 9.2, 95% CI: 1.3 – 66.2). Despite large relative improvements, the intervention was associated
with only modest absolute changes in HH behavior: midwives’ adherence to HH protocol prior to childbirth procedures
increased from 16% to 27% in intervention facilities and only 9% of hand hygiene opportunities (42 / 461) in intervention
facility PNC wards were associated with handwashing with soap.
Our prospective process evaluation explored intervention fidelity, reach, comprehension, compliance, and acceptability.
Midwives were considered both an intervention target group and the individuals responsible for delivering key messages
to patients and visitors. Intervention fidelity was high for childbirth components of the intervention. Midwives
understood and accepted the digital training system but requested that future training include face-to-face sessions and
that more frequent refresher trainings be offered. Information on recontamination of hands during childbirth
procedures remained unclear to midwives after the training, helping to explain the lack of observed effect on HH during
procedures. Midwives delayed in introducing the clean hands zone to patients and visitors, particularly due to facility
load or childbirth timing, impacting intervention reach, as many patients and visitors did not receive detailed
explanations of the intervention before facility discharge. Patients and visitors reported that handwashing infrastructure
was not always accessible and preferred not to use the provided baby hats due to low literacy levels among family
members.
Simple, theoretically informed domains of process evaluation helped to understand ways in which the CHAMP
intervention reached and engaged with intended users. Modifications to the intervention are currently being tested in a
second feasibility study, including the incorporation of low-dose, high-frequency training models and strengthened
engagement of patients and visitors around HH.

Quantifying the viral reduction achieved using ash and sand as handwashing agents
Winnie Zambrana, Stanford University
Additional Authors: Jingyan Tong, Claire E. Anderson, Elana M. G. Chan, Alexandria B. Boehm, Marlene K. Wolfe

Good hand hygiene can prevent transmission of pathogens, including transmission of respiratory and enteric viruses.
Both the World Health Organization (WHO) and the US Centers for Disease Control and Prevention (CDC) recommend
that soap and water be used for handwashing for 40 seconds and 20 seconds, respectively. However, soap and water are
not always available. In some cases, where handwashing products or alternatives such as alcohol-based hand sanitizer
are not available, ash or sand are used for handwashing; the WHO supports this practice when other options are not
available. However, no study has quantified the efficacy of these materials for handwashing against the reduction of
viruses. The purpose of this study was to evaluate the efficacy of ash and sand as handwashing agents in the removal of
enveloped and non-enveloped viruses, and to compare their efficacy against well-established handwashing methods
such as soap and water. To determine the efficacy of the handwashing agents of interest, we performed a volunteer
study to estimate the log reduction value (LRV) of model organisms Phi6 and MS2 on hands after washing with ash and
water, sand and water, soap and water, and water-only for 20 seconds each, and after washing with ash and water, and
sand and water for 5 seconds each. Phi6 and MS2 are bacteriophages that are not pathogenic in humans and can
provide representative information on enveloped and non-enveloped viruses. The hands of volunteers were seeded with
Phi6 and MS2, and then volunteers proceeded to wash their hands using each handwashing method in turn. After
handwashing, any viruses remaining on volunteers’ hands were recovered by rinsing in an eluent solution and were
quantified using plaque assays. The results from each handwashing test were compared against a no handwashing
condition to determine LRV attributable to the use of the handwashing method. We used Kruskal-Walli’s test followed
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by a Conover-Iman post-hoc test to determine which conditions were significantly different. We found that LRVs across
all handwashing conditions were significantly higher for Phi6 (enveloped) than MS2 (non-enveloped). Handwashing with
any of the handwashing agents for 20 seconds, including ash and sand, resulted in greater than 2-log reduction for both
Phi6 and MS2. Soap and water resulted in significantly greater log reduction than washing with ash or sand for 5 seconds
for both viruses, and water-only resulted in significantly higher log reductions than all ash and sand conditions for MS2.
These results suggest that using ash or sand as hand washing agents can be effective in the reduction of enveloped and
non-enveloped viruses, but they may be less efficacious than recommended handwashing agents, especially when used
for a short duration. Further research should consider the potential harmful impact on skin of ash and sand and the
likelihood that these media could introduce contamination in a real-world setting.

Reducing ergonomic risk in container-based sanitation collection services to improve safety for sanitation
workers
Eric Muchira, Sanergy
Additional Authors: Ricky Ojwang, Anne Aol, Lauren Trondsen, Ruthie Rosenberg

Container-based sanitation (CBS) provides toilets that collect waste in sealable containers that are exchanged for clean
containers when full. This system provides an affordable and effective sanitation solution, particularly in dense urban
areas and informal settlements that are otherwise inaccessible to safely managed sanitation. To operate successfully,
our CBS service employs a team of 88 employees to replace full containers and transport them for treatment. To
maximize the impact of ongoing efforts to improve the safety of our team while also increasing the efficiency of our
collection service, we conducted an ergonomic risk assessment to quantitatively measure risk and prioritize risk
reduction efforts.
We divided the collection process into five activities: lifting and removing full containers from toilets, carrying containers
to handcarts, loading, and unloading containers on handcarts, pulling handcarts to consolidation centers, and
consolidating contents of full containers into larger containers for transportation to the treatment site. For tasks that
involved lifting, we used the US National Institute of Occupational Safety and Health (NIOSH) Lifting Equation to
determine the lifting risk index (LI). For all activities, we used Liberty Mutual’s Manual Handling Equations to identify the
percent of the population expected to perform the task without overexertion. It should be noted that these percentiles
were developed in the US, and both the demographic profile and the weights and forces resulting in “overexertion” may
vary considerably in Kenya. Despite this limitation, these tools allowed us to quantify the ergonomic risk from each
activity, and to prioritize interventions to reduce risk.
From the NIOSH equation, lifting containers from toilets, loading and unloading from handcarts, and consolidating waste
had LIs of 2.03, 2.43, and 2.93, respectively, which are all above the maximum desirable threshold of 1. Based on the
Liberty Mutual equations, carrying containers from toilets to handcarts was acceptable for 85% of the male population
and 38% of the female population, while all other activities were acceptable to less than 1% of either male or female
populations. Factors that increased risk for each activity included frequency, duration, posture, and height or distance.
Several interventions were designed and are now being tested to improve each of the activities, such as a portable lifting
device to remove containers from toilets, replacing handcarts with mechanized tractors, optimizing routes to reduce
carrying distances, and training on improved postures and techniques that reduce strain. We will evaluate successes and
challenges for all interventions and iterate on designs where needed. Particularly for interventions that require behavior
change, we will observe preferences from the team and any barriers to adoption. We will conclude with an endline
evaluation to determine new risk levels. Standard targets are LI less than 1 and acceptability for 75% of the female
population, although it is acknowledged that some jobs are inherently challenging to design for that target. Although we
have prioritized employee safety and risk reduction since beginning operations, this work allows us to objectively
measure risk for the first time and to prioritize interventions using an evidence-based approach.

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Revenue patterns of piped water services in rural Africa

Andrew Armstrong, University of Oxford
Additional Authors: Rob Hope, Johanna Koehler, Ellen Dyer

Rural water infrastructure investments are often predicated on uninformed assumptions of demand and revenue
response to changes in service levels, tariffs, and seasonal rainfall. This evidence gaps limits financial viability and
hinders progress towards universal access to safely managed services. We present findings from an empirical analysis of
a multi-country, longitudinal dataset to answer three questions. First, how do rates of revenue generated from user
payments differ across rural piped water connection types? Second, how does seasonal rainfall influence rural piped
water revenue? Third, what implications do these findings hold for piped water investments in rural Africa?
We clean 4,888 monthly revenue records corresponding to rural piped schemes in Ghana, Rwanda, and Uganda.
Revenue changes in the service areas are quantified over 635 transitions between dry and wet seasons identified using
geospatial rainfall estimates and evaluated against key rainfall metrics. Service area archetypes are constructed from
records clustered at multi- and single country operational scales and based on whether the investment was led by the
state or a private enterprise. Parameters from generalized estimating equations are estimated to determine associations
between waterpoint connection type, revenue in each archetype, and seasonal revenue variability while controlling for
tariff level.
Higher volumetric revenue rates are observed for on premises connections than waterpoints located off premises in all
service area archetypes. However, off premises standpipes and kiosks facilitate more water usage per waterpoint and
provide an aggregate revenue benefit in three of the four archetypes. When tariff levels are controlled, on premises
connections are not associated with significantly different revenue rates than off premises connections (p < 0.05) in any
archetype across the entire range of observed tariff levels. These patterns are recurrent at multi- and single country
scales and across service areas where public and enterprise-led investment approaches to infrastructure development
are taken.
Results also show operators experience revenue variability at regional and intra-seasonal scales. Revenues fall by an
average of 30 percent during the wettest months of the year in climate regimes with consistent wet season rainfall.
However, seasonally stable revenues are observed in areas where consecutive dry days are common during the wet
season, potentially reflecting a dependency on reliable services. We find changes in tariff level and waterpoint
connection type do not consistently prevent or increase seasonal revenue variability.
Local revenue generation underpins delivery of drinking water services. Our analysis offers several insights regarding
viable and equitable investment strategies to enhance piped water revenue and achieve SDG 6.1 in rural Africa. First,
revenue and equity goals can be promoted through sequenced and optimized investments in on- and off-site piped
water. Second, intra-seasonal rainfall analysis offers localized insight into water demand dynamics and reveals where
climate variability may increase dependence on reliable services. Third, the revenue patterns we identify are recurrent
across operating contexts and investment approaches, suggesting our findings are applicable beyond the study domain.

Stabilized soil lining for pit latrines in sandy soil conditions: Baseline findings from Sembehum, Liberia
Taya Raine, CAWST
Additional Authors: Samson G Neese, Karen Joe

Background:
Latrine ownership in coastal communities of Liberia remains challenging due to historical pit collapse in the unstable,
sandy soil formations. Stabilized soil lining, using the principles of rammed earth construction and a small amount of
cement, creates a lining to support pit walls against collapse. To explore the durability of this lining, 23 latrines were
constructed in Sembehum, Liberia.
While Community Led Total Sanitation (CLTS) succeeded in raising awareness of open defecation, it failed to address the
widespread lack of access to adequate sanitation. A recent Sanitation Market Assessment of Liberia noted ‘toilets
constructed under the CLTS initiative have collapsed or gotten damaged over time, as they were built using poor quality,
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 Verbal Abstracts

non-durable materials. This same report found 39% of households that reverted back to open defecation did so due to
structural damage to their latrine, including pit collapse. Previous attempts by NGOs to provide latrines in Sembehum
resulted in pit collapse within 1-2 months. CLTS is entering a new phase, with a renewed focus on sanitation marketing
to improve access to toilets and related infrastructure. If this pit lining technique proves successful it could serve as a
viable option for scale up across the country.
Methods:
Twenty-three stabilized soil latrines were constructed from October-December 2021 in the coastal community of
Sembehum. In March 2022, the team conducted an initial evaluation of this pilot project. The cost of constructing the
pits (~$2USD/ft) and slabs ($23-$28USD) was provided on the condition that households built their own superstructures.
Three community members (2M/1F) were trained on the construction methods. Household surveys were conducted
with 22/23 homes to assess user satisfaction, perceived costs, and collect overall feedback on the latrines. Two focus
group discussions were conducted to complement survey findings and gain a deeper understanding of the community’s
perceptions. Observational assessments of the superstructures, handwashing stations, and pits were done including
measurement of the fecal sludge levels.
Results:
Pit depths ranged from 3-6.6ft, based on the water table level, with an average depth of 5.8ft. The average cost to build
the superstructures was $30USD, a cost deemed acceptable to the community. Overall feedback was positive, all survey
participants reported satisfaction with their latrines. Open defecation has been drastically reduced; no feces was
spotted during the visit. The majority of latrines (21/22) were in good, clean condition. The average depth of fecal sludge
across the 23 pits was 3.4cm, after 3 months of use.
Conclusions:
This evaluation set the baseline for future follow-up and monitoring of the pit lining technique. The latrines had only
been in use for approximately 3 months prior to this visit however, results appear promising as satisfaction levels are
high, and pits have already lasted longer than previous constructions. Before recommending this technology for scale-up
in sandy soil communities a second evaluation will be conducted following the rainy season, one-year post-construction.
This will provide more insight into the durability of the pits following heavy rains and rising water tables.

State of Affairs of Open Defecation Free (ODF) Status in Flood-Prone Regions of Southern Nepal
Sital Uprety, Swiss Federal Institute of Aquatic Science and Technology (Eawag)
Additional Authors: Anjil Adhikari, Abhinay Man Shrestha, Sanjeena Sainju, Sara Marks

The sanitation campaign in Nepal, which officially started in the 1980s, later initiated the Open Defecation Free (ODF)
campaign that led to the country being declared an ODF zone in 2019. However, just three years after the declaration,
there are concerns regarding slippage in the ODF status, especially in South-Eastern Nepal. In addition, the impact of
frequent flooding events in the region on these toilets is still unknown. To address this knowledge gap, we conducted
the assessment of ODF toilets in the flood-affected regions of Southeastern Nepal, focusing on four districts, to
understand and reflect on how ODF toilets have been operating and what should be done further to reduce slippage and
move towards the national goal on total sanitation. Key Informant Interviews (n = 16), Household (HHs) surveys (n =
1,018) along with water quality sampling for E. coli counts were conducted to obtain information on a
partial/completeness of toilet structures, household, water supply, sanitation management, and hygiene aspects.
Descriptive and bivariate analyses were conducted to identify key predictors associated with sub-optimal use,
partial/complete toilet structures, and water quality. Finally, a national-level stakeholder consultation (n = 25) was
conducted to translate the research results into policy recommendations.
Out of the HHs surveyed, 21% did not have toilets, predominantly due to a lack of budget and lack of spare land. Among
HHs having toilets (76%), around 16% toilets were being sub-optimally used which was significantly influenced by
functionality of toilets (χ2 = <0.001, ρ= -0.348), location of toilet facility (χ2 = 0.001, ρ= 0.125) and wealth quintile (χ2 =
0.008, ρ= -0.098), among other variables. Moreover, 26% of toilets were found to be partially structured. Flooding
damages and impacts were reported in 35% of toilets which significantly contributed to the toilets being partially
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structured (χ2<0.001, ρ= 0.203). HHs having educated members tended to have complete toilet structures as against
those having uneducated members (χ2<0.001, ρ= -0.188). Also, HHs which received construction incentives tended to
have partial toilet structures (χ2<0.001, ρ= 0.119) due to a perceived lesser sense of ownership. Water samples were
collected from either point of collection, POC (n = 736) which included handpumps and taps, or from storage containers
SC (n = 280) which included utensils and bottles. 78% of POC and 77% of SC samples were free from E. coli
contamination while no particular association was found between water quality and any independent variable.
This study highlighted the current and future state of ODF toilets in vulnerable areas of Nepal and identified key
predictors associated with the nationally pressing issues of sub-optimal use and partially structured toilets. Key
recommendations include sound policy and strategy level reformation initiated through local and federal governments
that understand the local context better than the central government to bring about an effective behavior change. This
also includes technologically upgrading the sanitation system focusing more on flood resiliency, capacity building, and
the creation of appropriate market demand for it.

Subsewershed SARS-CoV-2 Wastewater Surveillance & COVID-19 Epidemiology Using Building-specific

Occupancy & Case Data
Alasdair Cohen, Virginia Tech
Additional Authors: Ayella Maile-Moskowitz, Carla Finkielstein, Raul Gonzalez, Amy Pruden, Peter Vikesland

Background:
Wastewater-based surveillance has long been used as a supplement to clinical surveillance for diseases such as polio
(since the 1940s), as well as for other purposes such as monitoring illicit drug use and supporting vaccination campaigns
aimed at eradicating poliomyelitis and vaccine-derived poliovirus outbreaks. SARS-CoV-2 may be quantified in clinical or
wastewater samples through the detection of viral RNA via nucleic acid amplification methods that target regions on the
nucleocapsid gene (N), envelope (E) and spike protein (S) genes.
Objectives:
The overarching objective of this research was to improve our understanding of the relationships between SARS-CoV-2
detected in sewage and COVID-19 case data at building-scales, and to improve guidance on sub-sewershed sample
collection and analysis strategies. With regard to specific research objectives, we sought to evaluate whether analysis of
unadjusted and population-adjusted SARS-CoV-2 viral concentrations in wastewater samples could be used to reliably
predict cases of COVID-19 at building-specific scales using pre-specified lead times from sample collection to case
identification.
Methods:
Over the 2020-2021 academic year we collected wastewater samples twice weekly from 17 manholes across Virginia
Tech’s main campus (Blacksburg, VA) covering multiple sites/buildings, as well as the university’s primary wastewater
outflow. We used data from external door swipe card readers and student isolation/quarantine status to estimate
building-specific occupancy and COVID-19 case counts at a daily resolution. After analyzing 673 wastewater samples
using RT-qPCR, we re-analyzed 329 samples from isolation- and non-isolation dormitories and the campus sewage
outflow using RT-ddPCR. Our study was approved by VT’s IRB (#21-110).
Results:
Population-adjusted viral copy means from COVID-19 isolation dormitory wastewater samples were 48% and 66% higher
than unadjusted viral copy means for N and E genes (1,846 to 2,733/100mL/100people, and 2,312 to
3,828/100mL/100people, respectively; n=46). Pre-specified analyses with random-effects Poisson regression and
dormitory/cluster-robust standard errors showed that detection of N and E genes were associated with increases of 85%
and 99% in the likelihood of COVID-19 cases eight days later (IRR=1.845, p=0.013, and IRR=1.994, p=0.007, respectively;
n=215), and one-log increases in swipe card normalized viral copies (copies/100mL/100people) for N and E were
associated with increases of 21% and 27% in the likelihood of observing COVID-19 cases eight days following sample
collection (IRR=1.206, p<0.001, n=211 for N; and IRR=1.265, p<0.001, n=211 for E). One-log increases in swipe

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normalized copies were also associated with 40% and 43% increases in the likelihood of observing COVID-19 cases five
days after sample collection (IRR=1.403, p=0.002, n=212 for N; and IRR=1.426, p<0.001, n=212 for E).
Broader Significance:
Our findings highlight the use of building-specific occupancy data and add to evidence on the potential of wastewater-
based epidemiology for predicting COVID-19 trends at sub-sewershed scales. As far as we are aware, among recently
published SARS-CoV-2 wastewater surveillance studies, our study appears to be relatively unique with respect to our use
of building-specific occupancy and COVID-19 case data to calculate population-adjusted SARS-CoV-2 results, as well as
our use of statistical modeling for wastewater-based epidemiology to assess associations between SARS-CoV-2 signals
from wastewater samples and likelihoods of subsequent COVID-19 infection.

The accuracy and usability of point-of-use fluoride biosensors: a field study in Nakuru County, Kenya
Sera Young, Northwestern University
Additional Authors: Walter Thavarajah, Patrick Mbullo Owuor, Diana Awuor, Karlmax Kiprotich, Julius B. Lucks.

Dental and skeletal fluorosis caused by geogenic fluoride in drinking water is a critical public health issue. As such, there
is a pressing need to prevent or mitigate exposure to dangerous levels of fluoride. However, the difficulty of identifying
contaminated water sources is a major obstacle to doing so. Gold standard analytical equipment offers reliable results at
a relatively low cost, but these technologies are limited by the infrastructure for transport and communication.
Currently available field deployable technologies can provide measurements onsite, but have other limitations including
cost, operating complexity, and/or accuracy. To obtain high resolution data on global fluoride contamination and track
process towards SDG 6.1, a simple, inexpensive, rapid, and accurate diagnostic is needed at the point-of-use.
Engineering biological systems (sometimes referred to as synthetic biology) is a promising strategy for developing such
tests. Indeed, a naturally occurring fluoride sensing mechanism from Bacillus cereus has been successfully engineered
into a fluoride sensor and incorporated into a rapid (3 hour) diagnostic for geogenic fluoride in water that costs less than
USD 1 per test. This suggested field suitability, but it was unclear if this bioengineered rapid test could be successfully
used by non-scientists.
To understand the suitability of this test, we recruited adults from 36 households in Nakuru County, Kenya, an area
known to have high levels of geogenic fluoride. We used bioengineering and public health techniques to assess how 1)
participants experienced the usability and interpretation of the test and 2) how the accuracy of the rapid tests compared
to a fluoride photometer, a gold-standard field deployable method. We first surveyed participants about their
knowledge, attitudes, and behaviors related to fluoride, then asked them to test water samples from their household
with the rapid test. After test completion, we surveyed them again about their experiences with the test and cross-
validated the test results with a fluoride photometer, a gold standard colorimetric test.
To aim 1, 90.4% of users understood the relationship between fluoride contamination of drinking water and fluorosis,
though only 48.1% reported a correct understanding of how to prevent fluorosis. The majority (94.2%) reported no
difficulty with test operation or interpretation, with no significant differences by age, gender, or education. To aim 2, the
rapid test correctly classified the fluoride content of 89.5% of samples tested, with a sensitivity (true positive) of 93.3%
(95% CIs 81.7% to 98.6%) and a specificity (true negative) of 75% (95% CI 42.8% to 95.5%).
To our knowledge, this is the first study to describe field deployment and operation of any bioengineered water test in
the general population. These findings suggest that such tests satisfy an unmet need for the simple, rapid, and accurate
detection of geogenic fluoride; they are now ready for large-scale implementation. Moving forward, bioengineering
sensors for water contaminants could yield a suite of tests that permit the rapid, accurate, and cost-effective onsite
detection of myriad priority and emerging contaminants in any setting.

The impact of water, sanitation, and hygiene interventions by season: a systematic review and meta-analysis
Sydney Hubbard, Emory University
Additional Authors: Hemali Oza, Jennyfer Wolf, Benjamin Arnold, Matthew Freeman, Karen Levy
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 Verbal Abstracts

Severe weather, driven increasingly by climate change, can promote infectious disease transmission. Diarrheal diseases
are particularly sensitive to environmental drivers- including ambient temperature and precipitation- with seasonal
peaks typically occurring during rainy seasons. Water, sanitation, and hygiene (WASH) interventions that aim to disrupt
transmission of enteric pathogens have, at times, failed to reveal impacts on diarrheal disease; however, the seasonal-
specific impacts of these interventions have not been well studied. We conducted a systematic review of the available
literature spanning from 1970 to 2021 to explore whether the impact of WASH interventions on diarrheal diseases varies
by season, or periods of higher meteorological exposures. We found 126 published WASH studies that met our inclusion
criteria and identified meteorological data for the study time period using proximate land weather station data from the
NOAA Global Surface Summary of the Day catalogue of weather datasets. We created data-driven seasons for each
study using principal component analysis and k-means clustering on precipitation, temperature, and humidity values. Of
the 126 studies, 29 studies contained disaggregated diarrheal results that occurred across our data-driven seasons and
20 were contained entirely in one season (n=15 in dry season only and n=5 in rainy season only). Random effects meta-
analysis of all 49 studies yielded a pooled relative risk of 0.71 (0.64, 0.79), indicating a 29% reduction of diarrhea. In rainy
seasons, the pooled relative risk was 0.82 (0.71, 0.95) and in dry seasons the pooled relative risk was 0.65 (0.57, 0.74),
suggesting seasonal differences in the protectiveness of WASH interventions, with the effect of WASH interventions
~17% stronger in dry seasons compared to rainy seasons. These results suggest that the impact of WASH interventions
can vary substantially depending on season, possibly due to the dominance of different pathways of infection, dominant
pathogens, or overall infection pressure. Our findings point to the need to consider how to design WASH interventions
that are resilient to future climatic changes.

The Role of Race in Access to Public Water and Sewer Service in Halifax County, NC
Banks Grubbs, North Carolina State University
Additional Authors: Jacqueline MacDonald Gibson

A number of studies have shown that Black people on the fringes of Southern towns and cities have been systematically
denied access to public drinking water and sewer services. This paper analyzes the role of race in access to public water
and sewer access within the extraterritorial jurisdictions of and the areas within one mile of municipal boundaries in
Halifax County, North Carolina.
Utilizing publicly available tax data and census records, we quantified the proportion of people identifying as Black in
Halifax County census blocks and identified which tax parcels had access to public water and/or sewer service. We then
utilized a two-stage least squares regression to quantify the relationship between the proportion of Black people in a
census block and the odds of a tax parcel in that block having access to public water and sewer, as mediated by the
effect of population density. We found that, within ETJs, for every 10% increase in the proportion of people identifying
as Black in a census block, the odds of a parcel in that same census block having public water service decreases by
12.3%, and the odds of having sewer service decreases by 8.3%. The same trend is found in the areas within one mile of
town boundaries, where the odds of public water service decreases by 6.6% and odds of sewer service decreases by
5.1% for every 10% increase in the Black population proportion.
These results suggest that Black communities in these settings are more likely to be excluded from public water and
sewer and show the need for further research to understand the health impacts of this exclusion.

Two-Year Evaluation of Legionella in an Aging Residential Building: Assessment of Multiple Water Treatment
Approaches
Monica Lee-Masi, Johns Hopkins University
Additional Authors: Natalie G. Exum, Kellogg J. Schwab

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 Verbal Abstracts

Aging drinking water infrastructure in the United States in conjunction with challenges in premise plumbing within
residential buildings often reintroduce contamination and increase microbial growth in potable water. Along with these
influences, the COVID-19 pandemic shutdowns have impacted building premise plumbing systems due to water
stagnation. Prolonged water stagnation can negatively impact water quality due to reduction in residual chlorine, biofilm
formation, and growth of opportunistic premise plumbing pathogens, particularly Legionella pneumophila (Lp). This
study characterized the microbial water quality over two years in a three-story residential building located within an
aging potable water urban infrastructure that was subjected to a six-month shutdown as well as limited occupancy
before returning to full occupancy. In addition to monthly hot water sampling, water samples were collected pre and
post premise pluming water treatment approaches which included intensive water flushing, hot water heat shocks,
chlorine shock treatment, and intermittent chlorine dioxide treatment.
Water samples (n=648) were collected at a minimum of monthly intervals over two years from hot water lines at
proximal and distal sites within the three building risers following removal of showerheads or aerators. Timing of water
collection allowed samples to be taken during complete building shutdown after a period of six months of stagnation as
well as during subsequent partial and full reoccupation. At each sampling location 1L was collected from a first draw
(Time=0) and after a five-minute flush (Time =5). Lp was quantified via most probable number (MPN) culture and
characterized by subsequent molecular detection. Additional physical and chemical parameters including free chlorine,
temperature, pH, total organic carbon, and turbidity were measured at each collection site and time (T0 and T5).
The Lp concentrations varied by sampling location and time of collection as well as following each treatment. The Lp
concentrations from individual shower hot water sites were highly variable, ranging from 0 to 64,690 MPN/100mL
across all sampling locations, time points, and draws. Lp concentrations were notably higher at showers of a particular
wing (Riser A) compared to the other wings of the building (Riser B & C). After each heat shock treatment (n=3), Lp
concentrations decreased one order of magnitude or remained constant. “Bounce back” to initial concentrations or
higher were observed in the following weeks after heat shock. After each chlorine shock disinfection treatment (n=3), Lp
concentrations decreased two to three orders of magnitude, but gradually increased back to pre-shock concentrations
by one month. After intermittent chlorine dioxide treatment was initiated, Lp concentrations remained constant, but Lp
levels subsequently increased weeks afterwards.
These results indicate that all the implemented treatments can initially reduce Lp concentrations but result in Lp levels
rebounding within weeks to months after each treatment approach. This two-year study highlights the difficulty of full
eradication of Lp in aging water systems and variable Lp colonization within specific parts of an aging premise plumbing.
These data reflect the need for continuous monitoring and robust water management plans for all buildings to maintain
Lp at safe levels within complex building water systems.

Understanding the WASH Benefits Bangladesh trial results: hypotheses and estimates from a disease
transmission model
Andrew F. Brouwer, University of Michigan
Additional Authors: Marisa C. Eisenberg, Kevin M. Bakker, Mondal H. Zahid, Matthew C. Freeman, Joseph N.S. Eisenberg

Background:
Recent large-scale, well-powered intervention randomized controlled trials (RCTs) in low-income settings have not found
the expected health benefits of water, sanitation, and hygiene (WASH) interventions, including on reduced diarrhea.
There has been a robust discourse about the potential reasons for these underwhelming impacts, addressing issues of
completeness, coverage, compliance, and baseline WASH/disease conditions, among others. However, an RCT, which
evaluates a hypothesis in a specific context, cannot easily generalize to other contexts, so that counterfactual questions
of “what would have happened if…” are hard to address. Mechanistic models are a widely used to generalize findings
between contexts but have not been previously applied to RCTs. The purpose of this study was to 1) develop a modeling
framework to explain relative risk outcomes in an RCT and 2) to generalize the RCT results to other contexts and
conditions.
Methods:
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 Verbal Abstracts

Our model accounts for i) transmission across multiple environmental pathways, ii) multiple interventions applied
individually and in combination, iii) adherence to interventions, and iv) the impact of individuals not enrolled in the
study. A Bayesian sampling approach was used to obtain posterior estimates of mechanistic parameters and their
uncertainties for the WASH Benefits Bangladesh RCT (n=17,187), reproducing reported diarrheal prevalence.
Results:
The baseline estimate of the basic reproduction number R0 for the control arm was 1.15, (95% CI: 1.09, 1.27) in the
absence of intervention or preexisting WASH conditions. No single pathway—water, fomites, or all other pathways—
was likely able to sustain transmission as pathway-specific R0s were each below 1 (0.49 (95% CI: 0.07, 0.99), 0.26 (95%
CI: 0.04, 0.57), and 0.40 (95% CI: 0.02, 0.88), respectively). In our counterfactual simulations, completeness, and
coverage, rather than compliance, efficacy, or baseline conditions, were most strongly associated with intervention
effectiveness.
Conclusion:
Our approach can aid in understanding the contentious findings of the WASH-Benefits trial but also enhance analysis of
empirical RCT data for program decision-making.

Washing hands in a common bowl before eating is part of our tradition: A qualitative study of communal
handwashing practice in urban and rural Mali, West Africa
Evans Asamane, University of Birmingham, UK
Additional Authors: Cheick Sidibe, Hawa Diarra, Youssouf Diarra, Ousmane Toure, Semira Manaseki-Holland

What and why:

Proper handwashing practices are the most cost-effective method of promoting health through the reduction in
transmission of microorganisms. Communal handwashing (C-HW) is where two or more people wash hands in one
shared container of water usually without soap and without changing the water between individuals. This practice, often
conducted before meals when food is eaten by hand, poses a risk as the contaminated water in the common bowl acts
as a route for spreading diseases and microbes. As the order of washing in the common bowl ends with the youngest,
this exposes young children to a high risk of diarrhea, which may also influence malnutrition through enteropathies. Our
systematic review of the published literature found scarce evidence about the extent to which African communities
practice C-HW, the motivations underpinning the continual practice of this behavior, or interventions addressing this
practice. The present study aims to investigate the motivation and method of this practice in Mali, to promote and co-
create targeted interventions to successfully curb this food hygiene related practice.
How:
As a sub-objective of two separate mixed-methods studies in Mali to understand the drivers of C-HW. Qualitative data
from these studies related to C-HW is presented below. The first study was a qualitative nested study in a randomized
control trial, in three rural and four low-socioeconomic urban communities. In this study, semi-structured interviews
were conducted with 30 mothers and 30 household heads. In the second study, we conducted one separate focus group
discussion each with mothers (average n=8) and fathers (average n=8), grandmothers (average n=8) and community
elders (average n=8) in four low-socioeconomic urban and three rural communities (total=28 FGDs). Participants in both
studies were conveniently selected. All interviews were conducted in French, transcribed verbatim and translated into
English Language. Thematic analysis was used to analyze the data adopting an inductive and deductive approach.
Results:
All participant households in both studies practiced C-HW. Most participants revealed that the use of the shared
container (communal bowl) to wash hands “strengthens family solidarity”. They further explained that the custom of
this form of handwashing has been passed over generations and families that wash hands together in the common bowl
have “fewer disagreements and disunity”. Some participants insisted that it was important to continue C-HW for
improving family unity, although some participants acknowledged that it was not the most hygienic practice. C-HW was
also practiced by the order of age in the family, where the youngest are often the last to wash their hands in the
common bowl. This makes young children most vulnerable to transmission of infection and diarrheal diseases from older
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 Verbal Abstracts

members who may have become immune to severe diarrhea. Only a few participants mentioned the scarcity of soap
and water as factors influencing the practice of C-HW.
Conclusion:
C-HW was commonly practiced in both rural and urban Mali, and this was largely motivated by traditional or cultural
beliefs. Designing culturally acceptable interventions specifically targeting C-HW in consideration of these cultural
motivations, are urgently needed. Such interventions, if co-created with communities will ensure maximum impact.

Water and Hygiene Intervention to Combat Childhood Diarrhea Hot Spot Areas in Ethiopia
Bezuayehu Alemayehu Shimo, Mizan-Tepi University
Additional Authors: Argaw Ambelu

Introduction:
Effective water and hygiene intervention is needed to reduce childhood diarrhea (CHD), a major cause of morbidity and
mortality in low-income countries. This intervention aimed to evaluate the effectiveness of handwashing with soap at
critical times, home-based water treatment, and both combinations to reduce CHD, in hotspot areas of southwestern
Ethiopia.
Methods:
Community randomized control with the factorial design was conducted in southwestern Ethiopia, from July to October
30/2020. About 720 households were maintained and equally allocated for handwashing with soap at critical times,
home-based water treatment, and both combined interventions having 180 households, that were followed up for four
months. Baseline data were collected during the first two weeks from 720 households. Data processed and entered EPI
data version 3.02. Homogeneity of the baseline characteristics of the participant in both groups was checked at a p-
value less or equal to 0.05. The incidence of CHD per 100 per two weeks was measured in both groups. Mann-Kendall
trend test was performed to check the statistical significance patterns of CHD. Intention-to-treat analysis was used to
compare the incidence of CHD for both groups. A generalized estimating equation with a logit-link Poisson distribution
family and the exchangeable working correlation, with robust standard error estimation, was used for the analysis of
repeated observations of the incidence of CHD in individuals over time. The unadjusted and adjusted incidence rate
along with the corresponding 95% CI was analyzed by using a multivariable analysis to control potential confounders on
Stata 14 software.
Result:
Water and Hygiene intervention significantly decreased CHD, as compared with non-water and sanitation interventions,
that increased in control groups. Particularly, handwashing with soap at critical times has reduced the incidence of
diarrhea by 45% (IRR= 0.55, 0.48, 0.61, P<0.001). Similarly home-based water treatment reduced by 52% (IRR= 0.48,
0.42, 0.54, P<0.001). Likewise, both integrated handwashing with soap and home-based water treatment have reduced
CHD by 60% (AOR=0.40, 0.36, 0.47, P<0.001) after adjusting potential confounders.
Conclusion:
This study indicated single and combined interventions reduced CHD. Promoting this effective intervention in rural
communities would save many lives of children from diarrhea.
Keywords: Childhood diarrhea, handwashing, Home-based water treatment, RCT

Water Insecurity and Unpaid Labor: Quantifying burdens and musculoskeletal health outcomes among rural
Nigerian women
Abisola Osinuga, University of North Carolina at Chapel Hill
Additional Authors: Nathan B. Fethke; Segun E. Ibitoye and Kelly K. Baker

Women living in rural areas of developing countries engage in physically demanding domestic labor (PDDL), which places
them at an increased risk of experiencing musculoskeletal pain (MSP). The impact of PDDL on women’s health may be
46
 Verbal Abstracts

especially severe among water stressed women. The biomechanical and physiological demands of PDDL have mostly
been estimated using relatively crude self-report methods. Combining metrics from instrument-based methods with
task-level information from observation-based measures can improve the accuracy and precision of exposure measures
and identify populations at risk for MSP. This study examined the relationship between water fetching and carriage and
self-reported pain in the back (BP), neck/shoulder (NSP), and elbow/hand/wrist regions (EHWP), then characterized
PDDL by measuring the postures, movements speeds, and level of physical activity across tasks over time among women
selected by level of water stress and pregnancy status.
Survey data were collected from 356 women in rural communities of Ibadan, Nigeria and modeled using logistic
regression to examine the association between exposure to PDDL, including water stress (frequent water fetching and
carriage over long distance and time), and MSP (BP, NSP and EHWP). An exploratory repeated-measures study among 37
women (109 recordings, 111 hours of observation), purposively selected based on level of water stress and pregnancy
status, estimated metrics of trunk and arm postures, movement speeds and physical activity from accelerometers and
observation data across a range of common domestic tasks. Linear mixed-effect models were used to determine the
effects of water stress and pregnancy status on exposure levels. Fixed-effect repeated measures models were used to
examine the difference in exposure levels by task.
Women reporting frequent fetching and carrying of water over long distances and time were more likely to experience
BP [(OR= 1.31; 95% CI = 1.09-1.79) and NSP (OR= 1.20; 95% CI = 1.08-1.76). In the exploratory study, women who were
water stressed experienced more extreme trunk and arm postures and spent longer time performing domestic labor in
those postures compared to women who were less water stressed. Characterizing exposure by task revealed that
carrying water and fetching water were each associated with a higher frequency and duration of extreme arm postures
and vigorous physical activity compared to other domestic tasks. There was no statistically significant difference in most
exposure metrics by pregnancy status.
The new instrument- and observation-based PDDL exposure assessment methods developed in this study strengthen the
evidence of risks from water stress for MSP in women and add new quantitative evidence linking water stress to
biomechanical exposures. Our survey, accelerometer, and observed data agree that women experiencing water stress
are more vulnerable to working in extreme trunk and upper arm postures over long periods. Pregnant women may be
uniquely vulnerable to harm from PDLL exposures. Larger prospective studies are needed to rigorously estimate the
association between water stress and MSPs and to identify preventive interventions targeted at ergonomic
improvement in domestic work exposure behaviors, including water supply interventions that reduce the burden of
domestic labor.

Water insecurity is associated with lower dietary diversity: Longitudinal data from four countries
Joshua Miller, UNC Chapel Hill
Additional Authors: Sera L. Young, Elizabeth Bryan, Claudia Ringler

Objectives:
The COVID-19 pandemic and associated mobility restrictions have resulted in supply chain disruptions and financial
instability that present substantial barriers to reliably acquiring food and water, both at the household and national
level. Inadequate access to these essential resources causes psychosocial distress and may increase the risk of both
communicable and non-communicable diseases, potentially through impacts on diet. Despite the interlinkages between
water insecurity, food insecurity, and diet quality, and evidence that issues with food and water often co-occur and
mutually exacerbate each other, few studies have concurrently collected data on these three indicators, and even fewer
have looked at their relationships longitudinally. We therefore used data from a study conducted among adults living in
Ghana, Niger, Nigeria, and Senegal to assess, for the first time, the role of water insecurity in diet quality across time.
Methods:
Data are from panel phone surveys that were conducted between October 2020 and May 2021 by the International
Food Policy Research Institute. A random subsample of men and women (n=1909) enrolled in ongoing projects were
invited to participate in a sub-study examining the gendered impacts of the COVID-19 pandemic. Surveys lasted 20-30
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 Verbal Abstracts

minutes and included information about respondent and household characteristics; experiences with household water
insecurity [using the Household Water Insecurity Experiences Scale-4 (HWISE-4), range: 0-12] and food insecurity (using
a subset of five items from the Food Insecurity Experiences Scale) in the prior 2 weeks; and diet in the prior 24 hours
(range: 0-10 food groups). We assessed the relationship between water insecurity and both food insecurity and dietary
diversity using multilevel mixed-effects regression models that account for clustering by site and adjust for putative
confounders.
Results:
Almost all individuals (93.3%) were engaged in smallholder agriculture. Among sampled households, the prevalence of
water insecurity (HWISE-4 scores >3) ranged from 8.9% in Nepal to 47.4% in Ghana. In general, greater water insecurity
was associated with lower dietary diversity. Relative to individuals living in water-secure households, water-insecure
individuals were estimated to consume 0.53 fewer food groups (95% CI: -0.64, -0.41). Water-insecure individuals had
lower odds of consuming animal-source foods (OR: 0.64; 95% CI: 0.56, 0.74), grains and pulses (OR: 0.46; 95% CI: 0.36,
0.59), and fruits and vegetables (OR: 0.58; 95% CI: 0.48, 0.69) compared to water-secure individuals. In each site, greater
water insecurity was associated with higher odds of affirming more food insecurity experiences. In aggregate, water-
insecure individuals had 1.55 (95% CI: 1.40, 1.72) higher odds of reporting any food insecurity experience compared to
their water-secure counterparts.
Conclusions:
Water insecurity is experienced by many households and may be an important determinant of nutritional and physical
well-being. This is important given that most nutrition interventions do not consider water access and use, meaning that
meaningful barriers to good nutrition and health are commonly overlooked. Promoting reliable access to adequate
water for all household activities, including producing and preparing nutrient-dense foods, has the potential to advance
progress toward food and water security Sustainable Development Goals (SDGs 2 and 6).

Water insecurity is positively associated with food insecurity in low- and middle-income countries
Hilary J. Bethancourt, Northwestern University
Additional Authors: Edward A. Frongillo, Sara Viviani, Carlo Cafiero, Sera L. Young

Objective:
Although water insecurity and food insecurity may be related via various pathways, this relationship has received little
attention. Knowing where and among whom water and food insecurities coexist is critical for developing nutrition
interventions and policies that are not undermined by concurrent problems with water. The objective of this study,
therefore, was to investigate the relationship between water and food insecurities in low- and middle-income countries
(LMICs).
Methods:
In 2020, Gallup World Poll administered the Individual Water Insecurity Experiences Scale (IWISE, score range 0-36) and
the Food Insecurity Experiences Scale (FIES, score range 0-8) to measure water and food insecurities in nationally
representative samples from 25 LMICs in four global regions: sub-Saharan Africa, North Africa, Asia, and Latin America.
As a preliminary analysis, we estimated the odds of food insecurity (FIES score ≥4) in relation to water insecurity (IWISE
score ≥12) for each country and region separately using multivariable logistic regression models adjusted for key
covariates including income, urbanicity, gender, and extent to which respondents’ lives were affected by the COVID-19
situation (n=31,755).
Results:
The prevalence of water insecurity in the full pooled sample was 18.3% (95% CI: 17.1, 19.4), ranging from 14.8% (95% CI:
13.9, 15.7) in the pooled Asia sample to 34.4% (95% CI: 32.9, 35.9) in the pooled sub-Saharan Africa sample. Of those
who were water insecure in the full pooled sample, 68.9% (95% CI: 66.7, 73.8) experienced concurrent food insecurity.
Adjusting for covariates water insecurity was associated with higher odds of food insecurity in 21 of the 25 countries. In
the pooled regional models adjusted for country fixed-effects, the odds of food insecurity in sub-Saharan Africa were
2.70-fold higher (95% CI: 2.39, 3.06) among those with water insecurity. The magnitude of this association was similar in
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 Verbal Abstracts

the pooled samples for North Africa (OR: 3.05, 95% CI: 2.30, 4.04), Asia (OR: 3.17, 95% CI: 2.15, 4.67), and Latin America
(OR: 2.52, 95% CI: 1.87, 3.40).
Conclusions:
In most of the LMICs in our sample, water insecurity was positively associated with food insecurity independently of
socioeconomic covariates and self-reported impact from the COVID-19 pandemic. These findings have important
implications for how we approach policies and programs aimed at improving global food security and nutrition, as they
suggest the need to consider the water problems that exist alongside and potentially exacerbate food insecurity.
Unpacking how and why food and water insecurity relate and how their relationships differ across contexts will be an
important next step to developing more comprehensive policies and interventions that work to address water and food
insecurities in concert.

Water, sanitation, and hygiene (WASH) research in humanitarian crises: the Child Health & Nutrition Research
Initiative (CHNRI) prioritization exercise
Daniele Lantagne, Tufts University
Additional Authors: Elsa Rohm, Camille Heylen, Monica Ramos, Lauren D'Mello-Guyett

Background:
Humanitarian emergencies are predicted to occur more frequently and affect larger numbers of people due to climate
change. With a growing number of people at risk, evidence-based strategies to provide interventions to affected
populations are needed to prevent and control communicable diseases. While water, sanitation, and hygiene (WASH)
interventions are commonly implemented as part of humanitarian response activities to disrupt the transmission routes
of bacteria, viruses, and parasites that threaten human health, evidence gap in humanitarian WASH persists, particularly
as there are important questions that can only be addressed by conducting research in humanitarian settings. Setting a
consensus-based research agenda to guide the WASH in humanitarian crises field is key to progress in global health. This
work aims to identify consensus-based priority areas of research for the next ten years by involving practitioners, policy
makers, researchers, donors, and others involved in WASH and humanitarian programs.
Methods:
Following the Child Health and Nutrition Research Initiative (CHNRI) methodology, research questions were developed
through a literature review, and key informant interviews. In the literature review, research questions were first
extracted from previous systematic reviews (2015, 2019), and then new searchers were completed, and research gaps
extracted from recently published literature. Key informant interviews were conducted with stakeholders with expertise
in the humanitarian WASH sector, and then transcribed and research questions extracted. Research questions were
refined by a group of technical experts for wider dissemination and scoring according to five criteria from those
recommended by the CHNRI process and selected by the process managers. Practitioners, policy makers, researchers,
donors, and others involved in WASH and humanitarian programs were asked to judge each research question according
to the five criteria via an online survey hosted on Qualtrics. From this, an overall research prioritization score for each
question will be computed and a prioritized research gap produced.

Results:
Overall, 404 research articles were reviewed and 23 key informant interviews were conducted. This resulted in a
combined 934 research questions. After duplicates and questions not related to humanitarian emergencies were
removed, 555 research questions remained. After cleaning and removing questions not WASH-relevant, a list of 250
research questions was refined by 11 academic and technical experts to 130 questions. In parallel, the process managers
selected five criteria to judge the research questions, including: Impact, Answerability, Relevancy, Potential for
translation, and Implement ability. The online survey has been developed to ask participants to judge how each question
may meet each of the five criteria (by indicating “Yes” (1 point), “Maybe” (0.5 points), “No” (0 points), or ""Not my area
of expertise” (no input)). The survey is now being tested through academic experts for adjustments before
dissemination.
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 Verbal Abstracts

Discussion:
Work is currently ongoing, and the survey link will be shortly circulated during the 2022 EEHF and GWC annual meeting
conferences and via existing networks. A research prioritization score of 0-100% will be calculated for each criterion for
each research question, and from this, an overall research prioritization score for each question will be computed.
Results will be presented in October.

Workplace Menstrual Health and Hygiene in the Private Sector: Results from a Pilot Study in Kenya and Nepal
D. Maneshka Eliatamby, Iris Group
Additional Authors: Aditi Krishna, Whitney Fry, Michal Avni

Overall purpose of study, including RQs addressed:

Women and girls across the globe experience challenges managing their periods, especially those who live and work in
environments that do not support adequate menstrual health and hygiene (MHH). For working women, these challenges
may have critical implications for their health, well-being, and economic empowerment.
This workplace action research examined the efficacy of an MHH intervention on improving women’s experience
managing menstruation at work. Key outcomes included menstrual stigma, psychosocial stress, self-efficacy, and
supportive workplace culture.
Study Design:
This intervention was conducted over a ~10-month period in four workplaces (two each in Kenya and Nepal). It included
the following components:
1. Products & Infrastructure: free menstrual products (reusable and disposable) and upgraded workplace WASH
infrastructure
2. Workplace Policies & Guidance: a more supportive working environment for menstruating employees
3. Education & Behavior Change Communication (BCC): improved workplace culture through custom-designed
products and sessions
The project used a mixed-methods approach to evaluate changes between baseline and endline. A pre-post quantitative
survey provided data on key variables related to women’s experience managing menstruation. Focus group discussions
(FGDs), key informant interviews (KIIs), observation and process monitoring data, and an infrastructure assessment
provided complementary qualitative data to the research.
Key Findings:
Overall, the intervention showed substantial improvements across most indicators of women’s workplace experience.
These included statistically significant increases in women’s knowledge of MHH, satisfaction with menstrual materials,
and confidence at work. For example, the percentage of women who strongly agreed they felt confident in managing
menstruation increased from 41% to 98% in Kenya and from 62% to 72% in Nepal, while the percentage of women who
reported improved job satisfaction from the previous year increased by 39% in Kenya and 27% in Nepal.
There were also improvements in key objective metrics of workplace performance and women’s health. The average
time absent from work was reduced by roughly 1.5 hours per month in both countries. Average expenditures for
menstruation-related care were also significantly reduced, from ~$2 to $0.18 per woman per month in Kenya and from
~$12 to $4.60 per woman per month in Nepal.
Discussion of how findings inform science, policy, and or practice:
This study provides much needed data on the association between workplace MHH and women’s economic
empowerment; this effort provides clear and compelling evidence that links improved workplace MHH with both
women’s and business outcomes. This study informs the private sector of novel approaches that improve working
conditions for women (e.g., reduced stress and increased access to products and supplies), while also advancing
business outcomes (e.g., increased attendance and improved worker satisfaction). Researchers may leverage findings
from this pilot study to consider effects of MHH in other workplace environments (e.g., informal sector) and other
countries, understand linkages between MHH and corporate characteristics and culture, and apply new metrics and
tools.
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 Poster Abstracts

Poster Abstracts
Alphabetical by title
A Framework for Understanding and Modeling Health Risks from Intermittent Water Supplies
Emily Kumpel, University of Massachusetts Amherst
Additional Authors: Sally Weston; Karina Chavarria

More than one billion people receive Intermittent Water Supply (IWS), in which water is provided for a limited number
of hours through a piped network. Although there is substantial work on IWS that have shown it leads to degradation of
water quality through stagnation when supply is off, intrusion of contamination during low pressure, and the
necessitation of household storage, there has been limited exploration comparing the relative importance of these
different mechanisms to water quality. Similarly, while health studies have linked IWS to increased diarrheal illness, the
main routes of pathogen transmission to these individuals served by IWS has not been isolated. Modeling studies, such
as through Quantitative Microbial Risk Assessment (QMRA), can aid in exploring these tradeoffs, however, prior QMRAs
for IWS have lacked fine consideration of spatial and temporal variability in IWS, particularly during the first flush when
water is first turned on, and have lacked the critical component of consumer household behavior. A key aspect of
intermittency is household coping strategies – strategies that households employ to compensate for having intermittent
water supply, such as use of alternative and often lower-quality water sources or use of household water treatment.
We have developed a novel conceptual model of the risks posed by IWS to potential water consumers, and identify
assumptions, data gaps, and important considerations in modeling this risk. Overall, this framework enables QMRAs of
IWS. Critically, our research provides a model that can be used to simulate strategies for improving IWS systems,
furthering our understanding of the spatial and temporal risk of microbial intrusion at the pipe-level and the impacts of
household storage and coping solutions.
In this model, we cover and attempt to quantify risks from the operation of a distribution system intermittently. This
includes modeling the risks from the environment or context, including intrusion from outside pipes (accounting for the
presence of external contaminants, pathways for entry, and adverse pressure gradients, ultimately estimating intrusion
volumes entering), as well as treatment plant failures and external factors more commonly co-located with IWS, such as
pump failures and high temperatures. The potential for pathogen entry or growth also exists inside the pipes while
supply is off, during flushing when supply is first turned back on, and during the often-low-pressure supply period. These
insights are paired with an understanding of how consumers draw water to the tap in a supply driven IWS, which is
fundamentally different than most models of consumer tap withdrawals from continuous water supply systems. Finally,
we develop a framework and provide values relevant for modeling the potential pathogen risks of household-level
coping with IWS that includes consumer water behaviors of collection, storage, use of alternative sources, and use of
household water treatment. Finally, we present a series of case study scenarios, covering extreme intermittency (5
hours every 5 days), moderate intermittency (7 hours daily), and mostly continuous (3 days on/ 3 days off) in three
regions (South Asia, Southern Africa, Latin America) that provides examples of how to apply the framework in these
example contexts.

A nationwide analysis of college and university campus wastewater-based epidemiology practices in response to
COVID-19
Raeann Leal, Loma Linda University
Additional Authors: Deborah Sumatri, Michael Pecolar, Cameron Rull, Sarah Teague, and Ryan Sinclair

Wastewater Based Epidemiology (WBE) can be used as a rapid, sensitive, and cost-efficient surveillance system for the
SARS-CoV-2 in cities, neighborhoods, campuses, and buildings. An examination was completed of 177 U.S. private and
public college and universities' response to the COVID-19 global pandemic using an innovative surveillance method to
monitor wastewater for SARS-CoV-2. We developed a WBE scorecard to reflect readiness, response, and adaptability. To
do this we examined several campus approaches, collaborations, results, and resources used to activate a surveillance
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 Poster Abstracts

system. The analysis of the scorecard and various lessons learned will aid in future research, development, and
implementation of a rapid disaster response protocol for college and university campuses. Striking differences were
noted among colleges and universities across the US. As a case study, we self-scored and analyzed the approaches,
results, and resources that Loma Linda University used to activate its student body in the COVID-19 emergency
response. This presentation examined and compared the challenges, successes, and lessons learned from the WBE rapid
response from a private university system to the variety of responses seen in our nationwide analysis of college and
university practices of WBE.

A Participatory Science Approach to Evaluating Factors Associated with the Occurrence of Metals and PFAS in
Guatemala City Tap Water
Jennifer Hoponick Redmon, RTI International
Additional Authors: Erica Wood, AJ Kondash, Edwin Castellanos, Maria Andrea Najera Acevedo

Limited information is available regarding chemical water quality at the tap in Central America, preventing data-driven
decision-making by individuals, water utilities, and public health authorities. To address this need, 113 participants
among households served by a range of water providers across the Guatemala City metropolitan area were recruited as
citizen scientists to collect first-draw and flushed tap water samples at their residence. Samples were transported to the
U.S. and analyzed for 20 metals and 25 per- and polyfluoroalkyl substances (PFAS). At least one metal exceeded the
Guatemalan Maximum Permissible Limit (MPL) for drinking water in 63% of households (n=71). Arsenic and lead
exceeded the MPL in 33.6% (n=38) and 8.9% (n=10) of samples, respectively. Arsenic was strongly associated with
groundwater while lead occurrence was randomly distributed. One or more PFAS were detected in 19% of samples
(n=21, range 2.1–64.2 ppt). PFAS were significantly associated with the use of plastic water storage tanks but not with
location, water source, or provider. The high prevalence of arsenic above the MPL in Guatemala City tap water
represents a potential health risk associated with natural groundwater contamination that current water treatment
processes are not optimized to remove. Contaminants from premise plumbing and storage, including lead and possibly
PFAS, represent additional risks requiring further investigation and public engagement.

Access to Water, Sanitation and Hygiene Services and Other Preventive Measures against COVID-19 among People
with Disabilities, Dodoma, Tanzania
Hussein Mohamed, Department of Environmental Health, Muhimbili University of Health and Allied Sciences, Dar es
Salaam, Tanzania
Additional Authors: Elizabeth Wamera, Wilhelmina Malima

Access to Water, Sanitation and Hygiene (WASH) among people with disabilities is a great concern in many developing
countries despite being one of the commonest strategies to prevent and control many infectious diseases. During the
first wave of COVID-19 pandemic in 2020, in addition to other preventive measures the government of Tanzania
invested heavily on hand washing stations in public places where locally manufactured hand wash facilities such as
plastic containers fixed with a tap were placed. However, the interventions were mostly for the general population. A
big question was the appropriateness of the WASH facilities to suite different kinds of disabilities. The study was
conducted to assess access to WASH and other preventive measures against COVID-19 among people with disabilities.
This was mixed method study where data were collected both qualitatively and quantitatively. The main study
population of was people with disabilities in each district who vision impairment, deaf or hard of hearing, and physical
disability. The study was conducted in seven districts of Dodoma region, Tanzania.
A total of 16 key informant interviews (KIIs) and 9 focus group discussions (FGDs) were conducted. KIIs were carried out
at national level targeting officials responsible with persons with disabilities at the Prime Minister’s Office and at the
Council level where environmental health officers and social welfare officers whose roles include health education and
promotion in councils were included. FGD were conducted to a total of 102 people with disabilities.
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Findings show that there were inadequate WASH and other COVID-19 preventive measures designed specifically for
people with disabilities against the pandemic. Many people with disabilities reported challenges in accessing water for
hand washing and using hand washing facilities installed for general population. Other challenges include inadequate
health education and timely communication; failure to keep distance, access and use of face masks and sanitizers
depending on the kinds of disabilities. People with mobility, hearing, and vision impairments were mostly affected.
There was no representation of people with disability at the national COVID-19 task force.
On the other side KII revealed that health education officers reported to experience budget constrains to reach people
with disabilities. It was sometimes costly to hire an interpreter who could assist to communicate to people who had
hearing and talking disabilities; likewise, it was regarded expensive to prepare Braille letters for people with vision
disability when preparing information education and communication materials, they reiterated. Same findings were
reported by policy makers that financial constraint was the main limitation because it was not possible to have specific
COVID-19 measures for people with disabilities.
The study has reported an important public health issue with regard to COVID-19 preventive measures among people
with disabilities who are reported to face many challenges even during the times when there is no outbreak of the
disease.
The report calls for public health a policy that recognizes the need to have specific programs to address access to WASH,
timely communication, other preventive measures against COVID-19 and other social welfare services among people
with disabilities.

AI and HCD: the dual key to improving handwashing in public hospitals

Stephen Sara, USAID/Momentum Country & Global Leadership project
Additional Authors: Arshmeen Baveja, Niyoshi Shah, Shreya Mukta Gupta, Surendra Sharma, Pooja Sharma, Deborah
Sitrin

Background & Problem Statement:

Though hand hygiene is crucial in preventing hospital-acquired infections, health workers do not follow requisite
protocols. The global average compliance rate for handwashing is about 38.7%.
Direct supervision and feedback can help in behavior change but are difficult to sustain in resource-constrained settings.
Some studies indicate that artificial intelligence (AI) can be used instead. But it must be deployed with care in countries
like India where the risk of digital harm is higher because the public health system is riddled with power asymmetries.
Objective:
We employed human-centered design (HCD) with a particular focus on ethnography, co-creation, and iteration to
explore how AI may be implemented in settings where hierarchy is rife.
Methods:
The main interventions of this project were based on extensive fieldwork. A two-part AI-enabled system was installed in
seven public facilities. Health workers received live feedback on their hand washes through a display monitor at the
basin. This data was anonymized, aggregated, and made available to the management through a dashboard.
Research:
We conducted in-depth interviews and focused discussions with 30+ stakeholders across all staff categories to learn
about their handwashing practices and their initial experience of the AI system.
Ideation, Prototyping:
We identified the key drivers of behavior change from this inquiry to guide our brainstorming, using the Manoff Group’s
Toolkit for Behavior Integration. Our ideas were opened to the end users right from the start to ensure that our
interventions grew in a desirable and feasible way.

Delivery:
We re-designed the display to enable self-learning through gamification. With the new interface, users can simply follow
a series of GIFs to get a perfect score on their hand wash. This can be empowering for those who are scared to practice
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the right technique with their higher-ups. This product change was supported by a bundle of non-digital interventions on
team cohesion, motivation, and right data practices to ensure sustainability.
Results:
Preliminary results show that our poorest performing site has made a significant improvement in compliance, from
2.54% to 18.41%, indicating that contextualized AI can improve handwashing.
Conclusion:
Below are a few actionable insights that can be applied by other projects in this domain.
Feedback is better received when it is culturally resonant. We used a friendly mascot, and positive messaging in the local
language to make our AI system more acceptable.
People with low digital literacy automatically equate a camera-based technology with surveillance so a holistic
onboarding kit is essential, to explain machine learning in a jargon-free way.
Anonymous, aggregated data can be misused to blame others for low performance and reinforce hierarchy. So, it is
crucial to study the end impact group’s privacy preferences before setting up an AI system.
The administration is often pressed for time, so it helps to provide a mobile-friendly performance report, with data
visualization, for better decision-making.
In the long run, product upkeep; grievance redressal; data quality, and completeness are crucial to ensure that a
machine ages gracefully after it assimilates into a public facility.

Amplifying voices: Climate Impacts on rural Sanitation and Hygiene in eastern Burkina Faso
Jamie Myers, Sanitation Learning Hub
Additional Authors: Lea PareToe, Ruhil Iyer, Yagouba Diallo, Daphney Richardson, Karim Savadogo

Background:
Climate change is a leading concern in the sanitation sector that deepens existing vulnerabilities with access and use.
There is limited actionable guidance for programming and the voices of the most vulnerable are absent from this
discussion.
Burkina Faso faces a major sanitation and hygiene burden with over 63% of rural people practicing open defecation in
2015 (IRC, 2019). This study explores direct and indirect impacts of climate hazards on sanitation and hygiene practices
and programming in 4 villages in the East Region to provide evidence informed actionable recommendations for
programming. It focuses on community voices and social dimensions of impacts, exploring variabilities and behavioral
aspects to sanitation access and use.
Methodology:
The study drew on participatory rural appraisal methods. It included 20 participatory group discussions with impact
diagram, transect walks and hazard mapping activities with households. These discussions captured and unpacked tacit
knowledge and experiences of climate impacts on sanitation and hygiene practices. Separate focus group discussions
were held for women, men, and community leaders. Additionally, 32 semi structured key informant interviews were
undertaken with village elders, practitioners (UNICEF, SNV and Plan International) and local government officials in the
East region to understand climate considerations within programming.
Findings:
1)Impacts on sanitation and hygiene practices: Major climate hazards reported were irregular and heavy rainfall, and dry
spells and droughts. Direct impacts during irregular and heavy rainfall included significant damage to infrastructure as
most latrines made with wood, earth and straw are unable to withstand heavy rains and face rot and termite damage.
Containment pits overflowed and collapsed with excessive rains, reducing functionality of latrines and safe management
of excreta. People faced mental fatigue having to repair facilities frequently. Partial damage caused people to stop using
facilities for fear of further damage. Indirect impacts - loss of livelihoods (crop damage/failure, illness/death of cattle)
caused cascading deprioritization of sanitation through reduced investments.
During droughts and dry spells, the lack of water challenged cleaning and maintaining latrines, maintaining handwashing
and menstrual hygiene practices. Decreased bush cover perversely led to reduced spaces for open defecation and
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increased demand towards latrines. Indirect impacts - women faced increased burdens to manage domestic work
(cooking, cleaning, and washing) with reduced water availability.
2)Impacts on programming: Reduced water availability during dry conditions made it difficult for practitioners to
encourage communities to build latrines, especially in households lacking borewells. Since emptying services are
expensive, households’ resort to digging another pit when their first pits fill up. Full pits are inundated with water during
floods become a major hazard, adding to existing risks of unsafely managed facilities. Rains and flood also led to
increased fatigue with behavior change programming with frequent breakdown of infrastructure.
3)Local coping mechanisms: Various community and household led coping and adaptive mechanisms emerged. These
included rebuilding of latrines with available material after monsoons and relocating latrines to better protect them,
rallying as a community to help affected households rebuild toilets, barricading yards to reduce stormwater inundation,
investing small pots of money during the dry season to make toilets more resilient and using toilets to wash in the dry
season so the water could be reused to clean toilets.
Key Takeaways:
1. Nuanced formative research capturing community voices on localized climate impacts on sanitation and hygiene
are crucial to identify threats to sanitation and hygiene progress
2. Climate factors can be integrated into existing sanitation interventions through building on local coping
mechanisms to strengthen programmatic interventions and sustain outcomes

An Assessment of Integrated Approaches in Eliminating Open Defecation at the District-level in Madagascar”

Harisoa Rasamoelina, CARE International RANO WASH Project
Additional Authors: Avo Ratoarijaona; Sara Hoffman; Kelly Alexander

Open defecation remains a significant challenge in Madagascar; currently, 40% of the country still practices open
defecation. As part of the national initiative “Clean Madagascar,” the government set a goal to reduce open defecation
to 10% by 2023.
To support this initiative, the USAID-funded RANO WASH project (2018-2023) tested different combinations of
approaches to assist communes in reaching Open Defecation Free (ODF) status. The RANO WASH strategy used the
commune government as an entry point as it is the decentralized authority closest to the population and has greatest
potential to scale lessons learned. Rather than focus solely on ODF status at the village (fokontany) level as traditional
CLTS and ODF approaches have done, RANO WASH focused on achieving ODF at the much larger commune-scale,
encompassing an average population of 16,000 people in each commune. The RANO WASH strategy mobilized
commune governments, formal and informal leaders, women’s rights organizations, schools, health facilities and
community members through group meetings and dialogues. One key approach was combining triggering at
institutional and community levels and having vocal and supportive leadership from the commune Mayor and their
team. The strategy also addressed multiple factors beyond basic triggering for behavior change, and tested the layering
of approaches, such as market-based sanitation and the availability of latrine inputs and designs, discussing and
addressing resource-based and cultural barriers to use, going beyond basic triggering for behavior change. As a result, 37
communes eliminated open defecation in two and a half years, impacting more than 500,000 people. This experience
revealed the importance of a multi-stakeholder and multi-level approach to achieving sustainable sanitation change at
scale.
In this presentation, we will describe the rationale for a commune-level ODF strategy (vs village-level) and compare the
layering and sequencing of behavior change, market-based, and governance approaches that led to ODF status at the
commune-scale across 37 communes. We will describe overall impacts in terms of sanitation coverage, commune, and
community-level investment, and sustained ODF status. We will also identify key factors of success, including the
leadership of local authorities, reinforcing behavior change through institutions such schools and health facilities, and
the integration of sanitation and wider governance approaches. Finally, we will provide recommendations for
practitioners and policymakers in Madagascar and other similar settings to support elimination of open defecation at
scale.
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An Evaluation of Rotary-Funded Water Systems in Honduras - Study Results and Recommendations

Victoria M. Cuéllar, Desert Research Institute
Additional Authors: Braimah Apambire, Omar Núñez, Steve Werner, Tony Medina

Background:
Rotary International, a service organization with an international network of volunteer clubs has targeted Water,
Sanitation and Hygiene (WASH) provision as one of its seven areas of focus to improve the lives of people and
strengthen international relations globally. Total Rotary WASH funding has doubled over the last sixteen years and
understanding and supporting the long-term sustainability of these systems is integral to ensuring the value of these
investments is fully realized. Over 90 Rotary-sponsored water systems had been constructed over the last 30+ years with
grants from The Rotary Foundation and at the time of the study in Honduras those projects totaled an investment of
more than US$ 5 million. Little was known about the functionality of the Rotary-funded WASH projects post-
construction, or about the technical support and training needs to sustain them over the long-term for maximum
community benefit. As a result, Rotary partnered with the Desert Research Institute (DRI) and the Honduran
organization, Asociación Hondureña de Juntas Administradoras de Agua (AHJASA) to learn about the functionality of
these projects over the years.
Methods:
In 2018, DRI designed a study that would evaluate water system sustainability and develop recommendations for
repairs, training, and technical support. DRI and AHJASA worked together to complete an assessment of functionality of
34 Rotary-sponsored WASH systems in eight western Departments (out of the 90 projects supported by The Rotary
Foundation) Honduras. Two survey tools were used: an in-depth Water Board survey and a water system inspection
tool. DRI tested the survey tools with AHJASA technicians, and the latter conducted the survey and inspection of water
systems. Water quality samples were also taken.
Results:
Key findings included the age of water systems, which ranged from one year to 37 years at the time of the study. Only
27% of systems treated water centrally, even though 66% were equipped with chlorinators. Sixty-five percent of the
current water board members had not been trained. The majority of the communities do not have their water
distribution networks mapped. Less than half of all water boards reported that their tariffs were sufficient to meet their
operation and maintenance needs. Only a third of water boards had a life cycle costing plan.
Conclusion:
Overall, the study found that many of the challenges and repairs needed are due to normal wear and tear of the systems
over time; lack of post-construction support; and deterioration of water quality. Though significant challenges to long-
term water system functionality persist among Rotary-sponsored systems, these challenges can be resolved with a
robust capacity building program. Rotary, DRI and AHJASA have planned, in the next year, to conduct repairs and
upgrading of water infrastructure and using the Circuit Rider Methodology to provide ongoing technical and
administrative capacity building needs to these communities. Rotary, DRI, and AHJASA hope that the lessons learned
from this study will inform others implementing WASH programs about the need for post-construction support and urge
others to evaluate their work so that they may learn from it and share their lessons learned.

Assessing the Challenges to Improving Water Access for Navajo Nation Households Without Piped Drinking Water
David Harvey, Indian Health Service
Additional Authors: Ashley Lee, Natalie G. Exum, Nikki Tulley, Karletta Chief, and Crystal Tulley-Cordova

US Census data shows Native American households are 3.7 times more likely to live in a home without access to indoor
plumbing compared to households not identifying as Native American. In April 2020, the Indian Health Service estimated
that around 9,600 tribal homes or 37,000 people lacked access to in-home piped water on the Navajo Nation,
representing about 21% of the Navajo Nation population. The Navajo Water Access Project commenced in April 2020 to

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increase water access for homes without piped water by implementing safe water collection and storage of hauled
water at Chapter operated water points.
There is inconsistent data that relates to Navajo Nation water access and current estimates for the number of homes
not connected to piped water are as high as 40%. More comprehensive studies are needed to understand the total
number of homes lacking access and the challenges facing Navajo households to obtain access to an adequate quantity
and quality drinking water. This study will report on data collected from Chapter Officials through the Navajo Water
Access Project via focus groups and key informant interviews.
The project constructed 59 transitional water points (TWPs) connected to public water systems, shortening the travel
distance between these points and homes with no piped water from 52 to 17 miles round trip. The project also
subsidized water supply cost at these points and 48 Chapters with existing permanent water points (PWPs). Additionally,
over 37,000 5-gallon water storage containers and as needed water disinfection tablets, were provided to Chapters for
distribution to residents with no in home piped water to facilitate safe drinking water hauling and storage practices.
Water meter data from TWP and PWP shows only 2% and 29% respectively of the estimated volume of water have been
supplied and only 64% of the supplied water storage containers have been distributed.
Preliminary reports from Chapter Officials involved with the project describe the main challenges as: limited hours of
operation associated with the water points, residents lacking the ability to haul sufficient quantity of water needed to
protect public health, transportation challenges associated with poor road conditions, low flow rates from the water
points, and continued reliance on other traditional water sources closer to their homes.
Findings from this work will highlight: 1) the challenges associated with increasing access to drinking water from
regulated water sources in the Navajo Nation and 2) the steps being taken by the Navajo Nation supported by other
stakeholders to reduce these barriers including the delivery of safe water. The presentation will also highlight future
work to study water access and summarize how the collaborative efforts undertaken will make these data actionable to
develop policy recommendations to improve water access on the Navajo Nation.

Assessment of institutional mechanism for safe confined space entry of sanitation workers in India
Meghna Malhotra, Urban Management Centre
Additional Authors: Prerana Somani, Manvita Baradi, Jay Shah, Abhijit Namboothiri

The objectives of the study are as following:

● To assess the institutional arrangements undertaken by ULBs to establish and institutionalize Emergency
Response Sanitation Unit for ensuring safe confined space entry
● To understand the interventions undertaken by ULBs to develop a team of trained sewer entry professionals and
provide access to necessary infrastructure for safe cleaning of sewers and septic tanks
Sanitation workers engaged in cleaning of confined spaces like sewer line and septic tanks in India work in unsafe
environment with no safety devices or training. Despite legislations and guidelines issued by the Government of India
(GOI), lack of regulatory mechanisms has led to minimal compliance. As per the GOI, 340 sanitation workers died during
the last five years while cleaning confined spaces. The number of deaths and injuries due to manual scavenging maybe
be higher than what is reported.
While there is a strong focus on mechanization of sanitation services, mechanical cleaning isn’t feasible always.
Recognizing this, the GOI published an advisory in 2019 on establishing Emergency Response Sanitation Unit (ERSU) in
urban local bodies (ULBs), to put systemic frameworks in place for institutionalizing safety practices and mitigating the
risk and hazards. This research aims to study the implementation of ERSU and assess the interventions undertaken by
ULBs to make manual cleaning of sewer and septic tanks fatality-free.
The study is being conducted in five cities of India having varying coverage of sewerage system from 33% to over 99%.
We adopted qualitative approach; primary data collection was done by conducting key informant interviews of
stakeholders including ULB staff and private contractors. Focused group discussion with sanitation workers involved in
manual cleaning of confined spaces was conducted. We gathered information related to resource allocation, training &

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capacity building of stakeholders and monitoring & reporting systems adopted to ensure adherence to laws. Relevant
official documents were also collected for secondary data analysis.
Preliminary data suggests that ULBs have issued orders to set up ERSU and nominated officials for handling charge of the
day-to-day operations of the ERSU. However, it was observed that no standard operating protocols have been put in
place to establish processes that stakeholders should followed. Most ULB staff and contractors are not fully aware of
their responsibilities, nor have they received training on confined space entry. The ULBs have imparted trainings to
sanitation workers, however the quality is compromised. The ULBs have procured some safety devices and personal
protective equipment to use during safe confined space entry. Modality adopted for empanelment of private
contractors has significant impact on monitoring and compliance. Since the establishment of ERSU, except
Bhubaneswar, no city has officially recorded any manual entry in septic tank or sewer line. However, the sanitation
workers shared that unsafe manual entry in confined space still exists.
We will present the results of our primary and secondary data analysis, and the extent to which ERSU has been able to
ensure safe manual entry of sanitation workers in confined spaces. Current approaches by ULBs to reducing unsafe
manual entry focus on stopping formal sanitation workers from undertaking such jobs; however, this approach
promotes unsafe manual cleaning by informal workers. Based on the results, the study will recommend strategic
changes that can be adopted by ULBs to reduce fatalities and make confined space entry safer.

Assessment of tap water quality in Mobile Homes in the Eastern Coachella Valley, California
Thomas Hile, Loma Linda University
Additional Authors: Ryan G. Sinclair, Stephen G. Dunbar, Nataly Escobedo Garcia.

Very few studies have been undertaken on water quality from mobile homes, with most information coming from press
and policy reports suggesting that people living in mobile homes in the US have poor water quality. Our goal was to
evaluate resident exposure to microbes at the point of use of tap water sourced from the Oasis Mobile Homes Park
(OMHP), using physico-chemical parameters, concentrations of target cultivatable microbes, and quantitative
polymerase chain reaction (qPCR) analyses. In this study, we found arsenic concentrations to be 4-8 times above the
acceptable EPA standard of 10 ppm. Our qPCR demonstrated high concentrations of gene targets for Salmonella spp, L.
monocytogenes, P. aeruginosa, C. jejuni, E. faecalis, and E. coli in one or more of our sampled mobile homes (MHs).
Except for MH4, which had the highest concentration of L. monocytogenes and E. faecalis, all MHs had different
predominant microorganisms. Based on the physico-chemical parameters and our microbiological analysis, we conclude
that drinking water from MH taps in the OMHP is unsafe for consumption.

Assessment of Vulnerability for Vulnerable Group (Sanitation Worker) during a Vulnerable (pandemic) Time
Tahmidul Islam, WaterAid
Additional Authors: Hossain Ishrath Adib, Babul Bala, Imamur Rahman, Saief Manzoor-Al-Islam, Hasin Jahan

Bangladesh, due to its high population density and inadequate health infrastructure characterized in a highly vulnerable
and fragile country on the brink of a major crisis like pandemic, with severe ramifications for public health, the economy
and social cohesion. One of the key tactics applied by governments during pandemic to break the chain of infection was
to restrict the movement of people out of their homes barring people delivering essential services. One of the categories
of workers covered under essential services are sanitation workers as they deal with waste collection and management,
cleaning of public places, and maintaining sanitation services.
Sanitation workers in Bangladesh are vulnerable groups, especially people living in poverty, from lower caste and
religious minorities are more likely to engage in these types of work and are discriminated and stigmatized because of
their profession. This study was intended do a rapid assessment of the situation of sanitation workers during COVID-19
pandemic in Bangladesh. The objective of the study was to understand their knowledge, practices, and concerns
regarding the COVID-19 pandemic and to find out the gaps to improve their health and safety. A total of 123 sanitation
workers from five major cities of Bangladesh were interviewed with support of city authorities, institutional and private
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employers. Interviews were held from 8-16 May 2020 over telephone and recorded data on mWater platform and later
analyzed on the same platform.
Sanitation workers are one of the prime vulnerable groups during this unprecedented period of coronavirus pandemic.
This assessment suggests that they seriously lack information, knowledge, training, essential supplies of safety materials,
knowledge about how to handle the safety gears, and access to facilities to keep them protected. However, all the
interviewees had already heard about COVID-19 and most of them know at least three basic safety measures to prevent
spread of infection. Almost 87% respondents mentioned that use of masks, 69% mentioning frequent washing of hands
with soap, while 41% was maintaining social distance. Although, 37% workers do not know where to go for testing if
they have symptoms, or how to access treatment.
As they live in congested areas, use shared facilities, handle high-risk materials, and serve a wide range of people in their
work, they are highly exposed to risk of infection. Most of the waste workers those were interviewed use shared water
points, which are usually unimproved and illegally accessed. In over 30% of cases, the ratio between a water point and
users is over 100 while in 11% cases, a facility is used by over 300 people. In 60% of cases, a single toilet is being used by
average 25 users while in over 15% of cases, a toilet is being used by average 50 people.
Despite their apprehensions about working during COVID-19, economic hardship is forcing them to continue working,
many workers also experience reduced income and increased expenditure, which has increased their hardship manifold.
There was also clear acknowledgment that’s sanitation workers are not covered under any insurance scheme or other
benefit packages.

Associations between maternal nutritional status, inflammation, stress, and estriol during pregnancy and child stress
response
Ziaur Rahman, International Centre for Diarrhoeal Disease Research, Bangladesh
Additional Authors: Alexis Silvera, Zachary Butzin-Dozier, Stephen P. Luby, Mahbubur Rahman, Audrie Lin

Maternal prenatal well-being, which can be measured through stress, immune status, nutrition, and estriol biomarkers,
affects child health in the short and long term. In a child’s developing brain, chronic stress can adversely affect the
neuroendocrine-immune network by perpetually activating the hypothalamic-pituitary-adrenal axis and the sympathetic
adrenomedullary axis. Maternal stress, inflammation, nutrition, and estriol may contribute to poor child health
outcomes, however, there is little research analyzing the relationship between these maternal exposures and child
stress biomarkers. This study aims to determine the association between maternal stress biomarkers, inflammation,
nutrition, and estriol during pregnancy and subsequent measures of child stress. The WASH Benefits Bangladesh cluster-
randomized controlled trial enrolled 5,551 pregnant women in the first or second trimester of their pregnancy. We
assessed the following maternal blood biomarkers during the first two trimesters of pregnancy at baseline: cortisol, C-
reactive protein (CRP), alpha-1-acid glycoprotein, 13 cytokines (including IFN-γ), vitamin D (25-hydroxy-D [25(OH)D]),
ferritin, soluble transferrin receptor, retinol binding protein, and estriol. In children, we measured urinary F2-
isoprostanes at age 14 months. At age 28 months, we measured salivary alpha-amylase (sAA) and cortisol reactivity to a
venipuncture stressor, methylation of the glucocorticoid receptor gene (including the nerve growth factor-inducible
protein A (NGFI-A) binding site) on saliva samples, resting heart rate, and mean arterial pressure. We estimated
associations using generalized additive models, adjusting for potential confounders, and including a random effect for
cluster membership. We reported estimated differences and confidence intervals between the 25th percentile and 75th
percentile of each exposure distribution. This sub study measured outcomes in 493 children at age 14 months and 542
at age 28 months. F2-isoprostanes were not associated with child stress biomarkers at 14 months. Maternal cortisol,
estriol, IFN-γ, and the cytokine sum score during pregnancy were negatively associated with child resting heart rate at
age 28 months. Maternal cortisol was negatively associated with post-stressor salivary cortisol [-0.26 log μg/dl (95% CI -
0.47, -0.05)] in children at 28 months. Maternal CRP was positively associated with child mean arterial pressure, and
maternal IFN-γ was negatively associated with sAA reactivity and methylation of NGFI-A in children at 28 months.
Maternal vitamin D was negatively associated with child mean arterial pressure [-1.26 mmHg (95% CI -1.98, -0.53)], and
maternal ferritin was negatively associated with mean change in sAA [-1.23 log U/ml (95% CI -2.33, -0.13)] in children at
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28 months. The neuroendocrine-immune profile and nutritional status during the first two trimesters of pregnancy
affect child stress physiology, which may have implications for development.

ATP-based assessments of cleanliness for shared toilets in Western Kenya

Graeme Prentice-Mott, Centers for Disease Control and Prevention
Additional Authors: Lorna Maru, Alexandra Kossik, Cynthia Ombok, Isaac Ngere, David Berendes

Key Learning Objectives:

Share results from assessment of shared toilets in dense urban neighborhoods in Western Kenya
-Understand toilet conditions, user experiences, and cleaning management gaps in low-resource neighborhoods where
private household sanitation is limited
-Measure levels of organic surface contamination on high-touch surfaces in shared toilets, and identify factors
associated with higher levels, to inform how COVID-19 mitigation guidance for daily cleaning can be assessed

Background:
Residents of dense urban neighborhoods in low-income settings rely on shared toilets that are often poorly managed.
Guidance and training for managing shared toilets is often limited to fecal sludge management. With the onset of the
COVID-19 pandemic, mitigation guidance for low-resource settings recommends daily cleaning of high-touch surfaces in
toilets, a cleaning surface not previously recommended.
Luminometers measure adenosine triphosphate (ATP), a marker for general (organic) contamination, on surfaces. They
have been used to monitor effective cleaning, such as in hospitals settings using a threshold value of ≤250 relative light
units (RLU) as a cleaning efficacy standard. Luminometer-based ATP testing may be an effective approach for assessing
cleanliness of high-touch surfaces in toilets.
Methods:
In November 2021, we assessed 32 shared toilet sites in two suburbs of Kisumu, Kenya, from a census of commercial
and institutional (church, community center) sites and a convenience sample of high-use residential compound sites.
Observations of toilets included visual inspections paired with luminometer testing of door handles (high-touch
surfaces). Surveys of toilet conditions and management were conducted with users and operators, respectively. To
identify characteristics associated with levels of organic surface material on high-touch surfaces, we conducted log-
linear regression for RLU, with generalized estimating equations, controlling for time of day, toilet conditions (presence
of feces, urine/water pooling, rubbish, and clogging), and toilet site, design, and sex designation
Results:
We interviewed 224 toilet users: 96% reported toilets were acceptable for use, 83% rated toilets as in “very good”
condition, and 64% indicated toilets were “always clean.” However, of 209 interviewees who reported study toilet use in
the past 24 hours, 8% reported feces on the floor, 17% reported bad odor, and 15% reported urine puddling on the
floor.
We conducted 5 repeated observational visits in 73 toilets for a total of 365 observations. Geometric mean RLU from
high-touch surfaces was 1,941 (geometric standard deviation factor: 4.81). High-touch surfaces in commercial toilets had
115.0% (95% CI: 15.1-301.8) higher RLU compared with residential toilets, with an adjusted mean RLU of 2,933 (95% CI:
1,345-6,396) in commercial toilets and 1,364 (95% CI: 655-2,842) in residential toilets. No specific toilet conditions were
associated with higher RLU; conversely, high-touch surfaces in toilets with rubbish present had 28.9% (95% CI: 7.6-45.2)
lower RLU compared with no rubbish present. Only 3 of 32 site operators reported additional cleaning of toilet doors or
doors handles during or following waves of COVID-19. Limited availability and expense of cleaning materials and
dedicated toilet cleaners were reported as primary challenges to keeping toilets clean.
Conclusion:
Even if users report shared toilets as acceptable, feces, odor, urine, and other poor toilet conditions may be present.
Shared toilet management protocols and increased access to cleaning materials could help address cleanliness; yet
guidance and training often do not address high touch surfaces relevant for transmission of disease. Luminometer
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testing may be a useful tool for monitoring or evaluating the cleanliness of high-touch surfaces in public toilets,
however, more data are needed to determine cutoff standards for acceptable cleaning.

Barriers and facilitators to implementing a multi-level arsenic mitigation intervention in American Indian communities
Darcy Anderson, Johns Hopkins University
Additional Authors: Annabelle Black Bear, Tracy Zacher, Kelly Endres, Francine Richards, Christine Marie George

Arsenic is a naturally occurring toxicant in ground water, which increases risk of a cancer and cardiovascular disease. In
the United States, arsenic in private household wells is unregulated. American Indians populations are
disproportionately exposed, in part due to lack of mitigation programs on Indian reservations. The Strong Heart Water
Study delivered a multi-level intervention to reduce arsenic exposure among private well users in three Great Plains
tribal nations. Households were randomized to two arms: mobile health (mHealth) and filter installation and intensive
intervention. Both arms received water testing, a point-of-use filter, and behavior change messaging by phone and SMS-
messages. The intensive arm received additional in-person behavior change messages and intervention materials to
encourage use (e.g., branded cups, window stickers). In this study, we (1) assessed barriers and facilitators to
implementing the multi-layer intervention, and (2) assessed barriers and facilitators to use and maintenance of the filter
faucets among recipient households. We conducted in-depth interviews with implementers (a local American Indian
owned medical firm, tribal housing authorities, and the Indian Health Service) and recipient households. We analyzed
barriers and facilitators using the Consolidated Framework for Implementation Research (CFIR) at the implementer-level
and the Risks, Attitudes, Norms, Abilities, and Self-regulation (RANAS) model at the household-level. At the
implementer-level, barriers included remoteness of households, identifying plumbers for installation of arsenic filters,
and difficulty securing a local supplier for filter cartridges. Facilitators included rapport building and trust between
individual implementation staff members and households. At the household-level, facilitators included knowledge of the
health risks of arsenic, perceived credibility of test results showing filter effectiveness, and visual cues to promote habit
formation (intensive arm only). Barriers at the household-level were attitudes towards water taste and temperature and
ability to change the filter cartridge. This study offers new insights on the successes and challenges of implementation in
American Indian communities that can inform future health communication programs in partnership with these
communities. Our study suggests that building credibility and trust between implementers and households is important
for successful program implementation.

Building evidence in Kyaka II refugee settlement (Uganda) to support scaling of the Safe Water Optimization Tool
Camille Heylen, Tufts University
Additional Authors: Gabrielle String, Vincent Ogira, Syed Imran Ali, James Brown, and Daniele Lantagne

Background:
Centralized batch chlorination is the most widely used method of water treatment disinfection during emergencies.
While water treatment guidelines stipulate what free residual chlorine (FRC) levels should be at water distribution points
in humanitarian settings to protect against microbiological contamination, previous studies showed these guidelines fail
to ensure adequate FRC levels at the point-of-consumption, which is necessary for preventing microbiological
recontamination of stored water. In response, the Safe Water Optimization Tool (SWOT) has been developed to
generate site-specific, evidence-based point-of-distribution FRC targets that maximize the proportion of water users
having safe water at the point-of-consumption. While the SWOT has been previously validated in ‘traditional’ camp
settings dependent primarily on groundwater, this work seeks to gather evidence on the effectiveness and feasibility of
the SWOT in other humanitarian contexts, as well as on previously identified concerns, including the formation of
disinfection by-products (DBP) and chlorine taste and odor acceptance thresholds. Overall, this study aims to encourage
the SWOT innovation scaling to improve water safety in humanitarian contexts.
Methods:
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To do so, a mixed-method approach was used in the Kyaka II refugee settlement in Uganda to gather evidence using the
SWOT at a surface water treatment plant, including: 1) survey with water users to understand water storage and use
practices; 2) water quality testing at users’ points-of-distribution and points-of-consumption to collect FRC, E. coli, and
DBP measurements before (baseline) and after (endline) SWOT implementation; 3) taste and odor acceptance tests to
determine chlorine flavor detection and acceptability thresholds among different population groups; and, 4) key
informant interviews with response organization staff to understand chlorination protocols. We intend to conduct 450
user surveys, collect 1350 FRC, 50 E. coli, and 50 DBP measurements, run 150 chlorine flavor detection and acceptability
threshold tests, and interview 10 operators and decision makers. Baseline data will be triangulated and analyzed to
provide an evidence-based and site-specific water chlorination target for the SWOT. The SWOT will then be
implemented for one month, after which endline data will be collected and analyzed to inform and improve the SWOT.
Results and Discussion:
Data collection began in April 2022 and concludes August 2022. Surface collected water is pumped to the water
treatment plant for aeration and clarification via coagulation and settling. It is then pumped to three 100 m3 reservoirs,
treated with a chlorine solution made on-site, and then released to tapstands. To date, 105 water users from 7
tapstands have been surveyed and 210 water quality measurements taken as part of the baseline. Initial results indicate
fluctuating FRC at the taps and low FRC levels at the point-of-consumption compared to water treatment guidelines
targets.

Challenges in developing a results-based financing contract for container-based sanitation in Haiti

Claire Remington, SOIL Haiti
Additional Authors: Sasha Kramer, Edwige Petit

Introduction:
The aim of this study is to identify the challenges and roadblocks faced in developing a results-based financing (RBF)
pilot contract for container-based sanitation (CBS) in Haiti. DINEPA, the Haitian sanitation authority, is interested in
piloting an RBF framework to achieve its directive of eliminating open defecation and increasing access to safely
managed sanitation. DINEPA partnered with Sustainable Organic Integrated Livelihoods (SOIL) to develop a contractual
arrangement to implement the RBF pilot and expand SOIL’s household container-based sanitation service, EkoLakay. The
proposed objectives of the contract are to incentive an increase in household safely served and to reduce the required
subsidy per household. An international development bank that helped develop the idea was identified as an outcome
funder and earmarked a disbursement of US$1.05 mn for the contract.
RBF contracts are widely recognized to be complex and expensive to set-up, and the recommendation for first-time
contracts is to “learn by doing.” The stakeholders on this project have spent over three years discussing the launch and
execution of a pilot RBF contract; they remain at an impasse. The RBF framework could serve as a model for how to
build a bridge to public sector financing for essential sanitation services in fragile states, but so far has failed to do so.
This study, via a qualitative case study methodology consisting of informal stakeholder interviews, shares in what ways
have we learned by “not doing.”
Findings:
We have found that designing an achievable and measurable outcome payment metric is a crucial component of RBF
contracts – and represents the primary obstacle in advancing the RBF pilot. Both DINEPA, as the government
stakeholder, and SOIL, as the service provider, reached consensus regarding the structure of the outcome payment
metric. DINEPA drafted a term of reference (TOR) wherein they proposed two outcome payment metrics: 1) additional
number of households served by SOIL’s CBS service and 2) additional tons of waste collected and safely treated through
the service. Based on financial modelling work done in collaboration with Social Finance UK, a disbursement of
US$1.05mn would support the growth of the service 2.5-fold from 1,480 households to 3,528 households over a 1.5-
year pilot RBF contract.
However, the donor outcome funder objected to the scope of the TOR and insisted upon the following:

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- A target financial cost recovery of 50-80% by end of the pilot contract period (even though the financial modelling work
suggested a more realistic achievement of 30% cost recovery);
- An abandonment of the composting site in preference of an unspecified and more cost-effective treatment technology
alternative; and
- A broader engagement in the provision of FSM services (e.g., pit latrine waste emptying, transport, and treatment) in
the city of Cap-Haitien, Haiti.
In response to these objections and in discussion with DINEPA, SOIL agreed to engage with stakeholders in discussion
about broader participation in the provision of FSM services but refused to compromise on the other two points as they
represent unacceptable risks: 1) the public and environmental risk of inadequate treatment of collected waste and 2)
the uncertain and ethical morass of improving the service’s financial cost recovery by either decreasing costs by cutting
quality of service or increasing the price of service so as to be unaffordable to low-income households.

Discussion:
Inconsistent government stakeholder engagement and interest have been identified as a principal cause of failure in
launching RBF-style contracts in other contexts. In this case, it seems that the cause of failure is a lack of an achievable
compromise between the outcome funder, SOIL, and DINEPA with regards to the scale of improved cost recovery. This
cause of failure is tied to a lack of shared understanding about the subsidy required to finance sanitation for low-income
households.
To overcome this lack of understanding, SOIL is pursuing a willingness-to-pay analysis to better understand 1) the price
at which low-income households are willing and able to pay for the CBS service; 2) the gap between price and costs of
service provision (i.e. the required subsidy); 3) the price that the Haitian government is willing to pay in the future for
safe sanitation on a per capita basis; and 4) the price outcome funders are willing to pay for safe sanitation on a per
capita basis in the near term. In parallel, SOIL is pursuing revenue diversification strategies like carbon credits, sale of
alternative waste reuse products like black soldier fly larvae, and cross-subsidization of the household service by
commercial customers. However, revenue diversification is unlikely to make the service fully profitable as desired by
some donor outcome funders.
It is unacceptable that increasing access to safely managed sanitation for low-income households in Haiti is dependent
on donor expectations that service providers achieve an unrealistic cost recovery. The challenges of this experience have
connected us to work, and research being done globally to shift the conversation away from “you should achieve x cost
recovery” to “how much money do we need now to provide safely managed sanitation services?”
In this case, DINEPA’s leadership is evident, exciting, and represents the centering of government in ownership of the
RBF contract as a potential tool to achieving their overarching sanitation directive. Ultimately, DINEPA and SOIL remain
committed in their partnership, aligned in their goals, and are prepared to seek out a like-minded funder.

Comparative case study on increasing data-driven water resources decision-making: Lessons from South Sudan and
Somalia
Justine Lee, World Vision, Inc.
Additional Authors: Peter Hynes, Mulatu Kassa, Isaiah Odhiambo Sei

Climate change, degraded watersheds, and groundwater over-abstraction are jeopardizing decades of progress towards
universal access to clean water. Notably, water resources management in resource-constrained settings are further
hampered by a broader lack of information on the quantity, quality, and use of water resources. Motivated by these
risks, a comparative case study examining the use of hydrometeorological data for water resources management was
launched in two of the most climate-vulnerable countries in the world–South Sudan and Somalia. There are three key
learning objectives:
1. To examine whether and how improving access to hydrometeorological data impacts water resources decision-
making.
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2. To identify the relative importance of water security attributes to households, to help inform weighting of the novel
Brief Household Water Insecurity Experience (BWISE) scale.
3. To suggest entry points for practitioners and policy makers in contexts with varying baseline levels of data use in
water resources management.
The study compares learnings from two pilot projects with different starting points. The first pilot is in South Sudan
(Upper Nile), in two counties where there was no prior hydrometeorological database nor sensor network. The second
pilot is in Somalia (Puntland, Southwest, Jubaland, and Somaliland) where there was already a small, existing network of
23 sensors and several unintegrated databases. This network has been expanded with an additional 20 sensors over the
project term. Interventions in both pilots include the installation of hydrometeorological instruments that collect real-
time remote water parametric data that is sent using a 3G enabled mobile network, as well as support for government
on data management and interpretation. The hydrometeorological instruments make it possible to monitor the effects
of water abstraction, seasonal variations on water levels, and water quality within aquifer systems.
A total of 12 water security stakeholder groups were selected for key informant interview (KIIs) for the two projects.
Interview guides were informed by principles from the Water Security Improvement process developed by USAID and
the Sustainable Water Partnership in 2017. KIIs have already been conducted in South Sudan and will being conducted in
Somalia in May 2022. 361 household surveys have also been conducted in South Sudan, including questions that focused
on the four attributes in BWISE and a rank sum valuation exercise. Results from the survey is currently being analyzed
and will be available at the time of the conference. During the poster session, attendees will also be able to view live
hydrometeorological data from both project sites via scanning a QR code on the poster.
This study yields practical learnings for implementing organizations and policy makers on establishing a
hydrometeorological network and database from the ground up versus expanding upon an existing sensor network and
data structure. It also produced a field-tested interview guide based on sound water security improvement principles
that other practitioners can adapt and use. Finally, this study informs the continued development of a novel measure of
water security (BWISE). Each of these findings help accelerate and refine approaches to water security improvement in
resource-constrained settings.

Comparing Triple Bottom Line of treatment alternatives in very small communities in the US
Kaycie Lane, University of Massachusetts Amherst
Additional Authors: Emily Kumpel, John Tobiason, David Reckhow

In very small drinking water systems in the US, financing sustainable improvements requires balancing economic, public
health, and environmental factors. When seeking to improve water quality and meet regulations, traditional
approaches may include adding to or optimizing treatment trains, replacing assets, or seeking out new or blended water
sources. However, point-of-use (POU) and point-of-entry (POE) treatment devices, installed at consumer residences, can
provide an alternative option for reducing concentrations of contaminants of health concern. While POU and POE
devices can be used as a compliance option for certain contaminants, barriers to successful implementation such as
device certification, 100% customer participation, and state-level permitting have made POU/POE devices a last resort
option for under-performing small water systems. Data from four case study community water systems with either
arsenic or nitrate regulation violations in EPA Regions 1, 5, 7 and 9 with populations of <500 people were used to model
the costs and benefits of using POU/POEs as a compliance strategy compared to upgrading the centralized water system.
To determine which contexts POU/POE devices provide a viable alternative to upgrading centralized treatment in small
community water systems, we use a Triple Bottom Line approach to evaluate public health, environmental
sustainability, and economic trade-offs. Public health impacts were evaluated using exposure assessment to determine
chronic intake of a contaminant, maximum likelihoods of exposure and the estimated exposure duration possible at the
current contaminant concentration. Initial exposure assessment results indicate a maximum exposure duration of 4-6
years at the current concentration of arsenic will result in the lowest observable adverse effect to the population served.
These values were compared to an implementation timeline for POU/POE devices and an implementation timeline for
centralized upgrades to determine which alternative can be implemented prior to see observable health impacts in a
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very small system. Life cycle costing and life cycle analysis were used to evaluate economic costs and environmental
impacts, respectively. EPA Cost models were adapted to inform a model of cost for improving centralized treatment and
POU/POE units for several different treatment technology options.
Through these three analyses we discovered that a POU adsorptive media device removes the most arsenic
contamination in regions 1 and 9 but compromises elements of cost and sustainability. In Regions 5 and 7, a centralized
improvement provides a more cost-effective alternative over 30 years but compromises removal efficiency of nitrate in
region 7 and arsenic in region 5. Working with case study CWSs revealed the importance of actions such as permitting
and piloting POU/POE devices on exposure and how sampling frequency for SDWA compliance increases the cost of
POU/POEs over time. We present recommendations for both improvements to each analysis in the triple bottom line
approach and to state administrators, POU/POE device manufacturers and CWS stakeholders based on the assumptions
we uncovered during the modeling process to improve the viability and reliability of POU/POE devices as a long-term
SDWA compliance strategy.

Comparison of ATP-based and traditional culture swabs for environmental surface sampling in Kisumu, Kenya
Alexandra Kossik, Waterborne Disease Prevention Branch, Division of Foodborne, Waterborne, and Environmental
Diseases, Centers for Disease Control and Prevention
Additional Authors: Graeme Prentice-Mott, Isaac Ngere, Jared Oremo, Lauren Trondsen, Jennifer Murphy

Key Learning Objectives:

1) Learn about the novel approach for ATP-based swabs that was used in the method comparison and how it differs
from traditional surface swabbing methods.
2) Understand how and why an ATP-based swab method could be beneficial in low-resource settings.
3) Comprehend why future research steps need to be conducted to validate ATP-based swabs for environmental surface
sampling.
Background:
Luminometers have been used to read swabs containing adenosine triphosphate (ATP) as an indicator of general
cleanliness in clinical and food production settings. In these instances, the threshold for a passing measurement is
generally ≤250 relative light units (RLU, the unit of measure for the overall burden of organic material on a surface).
Standard environmental microbiological surface sampling methods are laboratory-based swabbing methods for
culturing microorganisms. However, these methods are challenging to execute in low-resource settings due to
limitations in laboratory, equipment, and technical capacity.
Given the importance of environmental cleaning for infectious disease prevention, this study aimed to determine how
swabs measuring ATP compare to culture swab methods for environmental surface analysis, specifically the surfaces of
latrines, in low-resource settings.
Methods:
In November 2021, field studies were conducted at shared latrines in densely populated neighborhoods in Kisumu,
Kenya. High-touch (HT) (e.g., door handles) and low-touch (LT) (e.g., upper walls) surfaces were selected for swabbing at
each latrine. Each surface had both an ATP swab (3M™ Clean-Trace™ Surface ATP Test Swab) and a culture swab
(Sanigen macrofoam swabs) collected from adjacent ~50 cm2 surfaces using a crosshatch pattern. ATP swabs were
immediately analyzed using the 3M™ Clean-Trace™ Luminometer LX25; culture swabs were transported to a laboratory
at 4 °C for same-day processing.
Culture swabs were eluted with 5 ml 0.05% phosphate buffered saline (PBS)-Tween solution and membrane filtered at
three dilution levels (10 µl, 100 µl, and 1 ml) with the addition of sterile PBS to account for necessary filtration volume.
Membrane filtration was conducted using nitrocellulose filters (0.45 µm, 47 mm) (Millipore) and incubated at 35°C for
up to 48 hours on Plate Count Agar (BD Difco™).
Results:
A total of 132 swabs were collected from 33 latrines. ATP measurements from HT surfaces (n=33) ranged from 733 to
56,652 RLU (mean: 6188, median: 2117, IQR: 5179) and measurements from LT surfaces (n=32) ranged from 104 to
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21,219 RLU (mean: 1541, median: 537, IQR: 1057). Colony forming units (CFU) for swabs cultured from HT surfaces
(n=30) ranged from 123 to 28,910 (mean: 4564, median: 1250, IQR: 2579) and CFUs from LT surfaces (n=32) ranged from
14 to 1850 (mean: 457, median: 242, IQR: 369). Samples that were overgrown (n=1) or too numerous to count (n=3)
were excluded. Comparing swab types, there was an association between log10 transformed ATP and culture swab
values with a regression coefficient of 0.395 (P=0.0098).
Conclusion:
Based on this method comparison, ATP swabs seem to be a faster, less resource intensive measure that can be
implemented in the field. However, additional data are needed to validate the use of ATP-based methods on
environmental surfaces in low resource settings. Laboratory studies are ongoing to determine the appropriate
interpretation of RLU values and to understand where the cleanliness threshold should be set for ATP swabs in this type
of field setting.

Critical Review on Theory, Current Practices, and Recommendations on Contextualizing the Measurement of
Resilience
Hemali Oza, Rollins School of Public Health at Emory University
Additional Authors: Anuj Nanavati, Sophie Anthony, Alyssa Clausen, Matthew Freeman, Sheela Sinharoy

Introduction:
With climate change resulting in increasingly severe weather events and socio-economic challenges, there has been a
push for humanitarian aid to contribute to building more resilient populations, particularly in low- and middle-income
country (LMIC) settings. Resilience is generally defined as the capacity to absorb, cope with, or adapt to a changing
environment while maintaining the principal factors of structure, function, and identity. Building resilience among
individuals, households, and communities can help populations recover from or avoid shocks and stressors. However,
few validated and user-friendly tools exist to measure resilience in relation to environmental shocks such as floods,
droughts, or disease outbreaks.
Methods:
As a first step in developing tools to measure resilience in relation to environmental shocks, we conducted a scoping
review of the literature. The objective of this review was to 1. elucidate the underpinnings of resilience measurement
theory as it relates to water, sanitation and hygiene (WaSH); 2. summarize the evidence base related to WaSH and
resilience; 3. identify tools (quantitative and qualitative) used to measure WaSH resilience in different contexts (e.g.,
study design, populations, regions, etc.); and 4. provide guidance on better aligning application and empirical studies
with theory and how to contextualize measurement based on location, vulnerabilities, regional capacities, and available
infrastructure. We searched six databases (i.e., PubMed, EMBASE, Web of Science, PsycINFO, Global Health, and
CINAHL) for eligible studies from inception through November 2021. We included studies that used a conceptual
understanding of resilience and either presented a framework or tool to measure household or community WaSH
resilience to environmental shocks in LMICs.
Results:
We identified approximately 7,400 articles through database searches and included 169 studies in our review,
representing a variety of contexts among LMICs. We found that few studies included informal populations, physical
WaSH infrastructure resilience was often excluded in measurement tools, and cross-sectional study designs were
predominantly used versus the preferred longitudinal study design.
Finally, we developed a framework of WaSH resilience, which comprises three domains and 13 sub-domains. We
collated and synthesized the frameworks and tools and developed guidance for measurement of WaSH resilience by
types of environmental shocks and stressors (i.e., climate and non-climate related), regional conditions and geographic
contexts, and community conditions such as population density and formal vs. informal housing status. The framework
includes sub-domains that are common across various populations (e.g., Water Security) and others that are more
specific to regions or types of shocks (e.g., Coastal Protection).
Conclusions:
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This work builds on existing research and provides a practical solution to the challenge of measuring WaSH resilience –
an increasingly important and globally relevant construct. Through improved measurement and understanding of WaSH
resilience, we can better inform interventions and humanitarian aid for researchers and practitioners who aim to
strengthen the resilience of households and communities to environmental shocks.

Defining performance at the nexus of development and humanitarian response

Claire Remington, SOIL Haiti
Additional Authors: Sasha Kramer, Tanvi Nagpal, Edwige Petit, Alyse Schrecongost

Introduction:
Stakeholders generally differentiate between development and humanitarian contexts when creating performance
indicators, but many service providers operate in contexts that oscillate between the two. Haiti is one such
environment, with several recent acute climate, public health, and political crises that periodically interrupted most
essential services. As a safely managed sanitation service provider to informal urban households in Cap-Haitien, SOIL is
developing a framework to help guide and communicate its performance on service continuity, inclusivity, and efficiency
under a range of operating scenarios. This work is relevant to service providers increasingly tasked with humanitarian
response and basic service continuity.
Study Design:
To set performance targets for development and humanitarian scenarios, SOIL is doing a post hoc review of how its
requirements and performance varied during acute emergencies over the past eight years. Acute emergencies are
defined as days when it has been necessary to halt all non-essential operations, focusing solely on providing
uninterrupted services to existing customers, pausing on growth and optimization efforts pursued under status quo
conditions. In partnership with the operations team, the SOIL Board is working to define KPIs for both scenarios to
improve planning, support and motivate staff, and communicate realistic expectations to external stakeholders.
Key Findings:
During status quo conditions, SOIL is able to prioritize growth of the service (i.e. increasing the number of households in
the service), improved financial viability of the service through payment collection and economization of costs, and non-
essential research and systems strengthening work (e.g. government relations work). However, during acute crises, SOIL
must deprioritize these objectives and instead dedicate the organizations resources to ensuring employee safety and
maintaining essential operations (collection, transport, and treatment of waste for 100% of current customers) in the
context of the crisis. Because SOIL crafts performance indicators that are intended to be ambitious but achievable in
status quo conditions, they are impossible to meet during acute crises. This has negative impacts on donor relations and
staff morale. By developing an appropriate set of indicators for crisis and status quo conditions, we are able to celebrate
the excellence and resilience of our staff, our customers, and our service as a whole while continuing to push towards
our scaling objectives when possible. Using thorough research and analysis to develop the two sets of indicators will
ensure a solid foundation for asking external stakeholders to understand the realities of providing access to essential
human rights under extremely challenging conditions.
Discussion:
In an increasingly unpredictable world, evaluating services as development OR humanitarian may not accurately reflect
reality. SOIL’s presentation will focus on the research used to develop different sets of indicators for development and
humanitarian conditions. It is critical that actors set reasonable expectations rooted in rigorous research and that
stakeholders have empathy for both service providers and clients struggling to access to basic human rights under
extremely challenging conditions. We will present a framework for how stakeholders can evaluate service providers in
the context of a rapidly changing climate, increasing socioeconomic inequality, and political unrest.

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Degradation of bleach produced for disinfection in Kenyan healthcare facilities using novel technology
Rodney Herrington and Chris Dunston, Aqua Research
Additional Authors: Jared Oremo, Sunkyung Kim, Lois Warren, Alex Mwaki

Healthcare associated infections (HAI) are common in developing countries. Water, sanitation, and hygiene (WASH)
improvements in developing country healthcare facilities (HCF) can help prevent HAI, and surface disinfection is an
important WASH component. Although disinfection with bleach is recommended, supplies are often inadequate in
developing country settings because of budget shortfalls, inadequate supply chains, poor-quality commercial bleach,
and degradation of bleach over time, which can reduce disinfection effectiveness. Aqua Research, a company that
produces technology (STREAM) that generates bleach electrolytically from salt solution at a concentration of 5,000 mg/l
(0.5%) free available chlorine (FAC), meeting WHO standards for contaminated medical settings, partnered with a
Kenyan NGO, the Safe Water and AIDS Project (SWAP), and the Kenyan Ministry of Health to determine whether bleach
production by STREAM in HCFs was feasible and the shelf life of bleach solution adequate to justify wider deployment.
We produced bleach with STREAM equipment in two hospitals (HCF A and B), and stored bleach in two 20-liter plastic
containers in each HCF which were all transported to the SWAP water laboratory. Sodium hydroxide was added to
stabilize bleach in one container in each HCF by raising pH to 12; non-stabilized bleach was stored in the other container.
We determined bleach degradation by testing FAC in bleach samples upon arrival at the SWAP laboratory, then every
three days for a three-week period, and weekly for another three weeks. At each time point, we filled three one-liter
opaque bottles with bleach from each 20-liter container, for a total of 12 bottles. We pipetted three one-ml samples
from each bottle, added each sample to a beaker with 999ml of chlorine-demand-free diluent. We added N,N-diethyl-p-
phenylenediamine reagent to each of 36 beakers, and determined FAC concentration in mg/l with a HACH colorimeter.
At each time point, FAC results were averaged from 9 samples from each of two lots of bleach from HCF A and B, and we
determined average percent degradation per time-period for non-stabilized and stabilized bleach. At time 0, average
FAC was 0.5200 mg/l and 0.6144 mg/l, respectively, for non-stabilized bleach from HCFs A and B, and 0.5778 mg/l and
0.6267 mg/l, respectively, for stabilized bleach from HCFs A and B. By day 20, average FAC in non-stabilized bleach
decreased by 13.9% to 0.4478 mg/l in HCF A and by 10.8% to 0.5478 mg/l in HCF B; average FAC for stabilized bleach
was unchanged in HCF A (0.5289 mg/l) and decreased by 11.2% in HCF B (0.5567 mg/l). In HCF A, which began bleach
production 3 weeks before HCF B, average FAC at 44 days for non-stabilized bleach decreased by over 65% (0.1789 mg/l)
and decreased by 7.8% for stabilized bleach (0.4867 mg/l). Bleach production proved feasible in HCFs A and B, and FAC
of both non-stabilized and stabilized bleach was adequate for surface disinfection after 3 weeks in both HCFs. Stabilized
bleach concentration remained adequate for disinfection for 6 weeks in HCF A. Bleach stored >3 weeks should be
stabilized to ensure adequate concentration for effective disinfection.

Designing for Deficiency or Sufficiency? Drinking Water Service Provision in Tribal Communities in the US
Catherine McManus, UNC
Additional Authors: Dale Whittington, Michael Hanemann

Introduction:
It is a myth that residents of the United States have universal access to safely managed drinking water; many Tribal
communities in the US have inadequate access to drinking water infrastructure. Members of these communities have
disproportionately less drinking water, often of lower quality, relative to non-indigenous communities in the US. The
Indian Health Service (IHS), the federal agency responsible for environmental service delivery, has an infrastructure
needs assessment protocol which quantifies deficiency, and is limited in scope to addressing those deficiencies rather
than providing infrastructure which allows development. This ongoing work explores the engineering impacts of this
deficiency-minded approach and the historical decision-making which has led to it.
Methods:
This study aims to answer the question, “how have historic engineering decisions affected the quality of drinking water
infrastructure for Tribal communities?” To do so, I use archival data collection methods to construct a discursive
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narrative surrounding the provision of drinking water service by US federal agencies. Historical design guidelines and
project details will be compared to those used in Tribal communities and non-Tribal communities today.
Expected Results:
Initial findings display an evolution in IHS standards of service. For example, a 1951 report on a Navajo drinking water
system reports an average daily consumption of water of 70 gallons per person. In contrast, the current IHS assessment
protocol includes in the lowest deficiency categorization a threshold of consumption of less than 5 gallons per capita per
day. Through the continuation of archival research, I will collect more information about the historic and current
engineering decision-making which has led to the disparity in drinking water service level.
Detection of SARS-CoV-2 in wastewater and comparison to COVID-19 cases in two sewersheds, North Carolina
Connor LaMontagne, University of North Carolina at Chapel Hill
Additional Authors: Alyssa M. Grube, Nikhil Kothegal, Megan E. Miller, David A. Holcomb, Jill R. Stewart

Wastewater surveillance of SARS-CoV-2 may be useful for monitoring population-wide COVID-19 infections, especially
given asymptomatic infections and limitations in diagnostic testing. We aimed to detect SARS-CoV-2 RNA in wastewater
and compare viral concentrations to COVID-19 case numbers in the respective counties and sewersheds. Batched 24-
hour composite wastewater samples were collected from July to December 2020 from two municipal wastewater
treatment plants serving different population sizes in Chatham and Orange Counties in North Carolina. After a
concentration step via HA filtration, SARS-CoV-2 RNA was detected and quantified by reverse transcription droplet
digital polymerase chain reaction (RT-ddPCR) and quantitative PCR (RT-qPCR), targeting the N1 and N2 nucleocapsid
genes. SARS-CoV-2 RNA was detected by RT-ddPCR in 100% (24/24) and 79% (19/24) of influent wastewater samples
from the larger and smaller plants, respectively. In comparison, viral RNA was detected by RT-qPCR in 41.7% (10/24) and
8.3% (2/24) of samples from the larger and smaller plants, respectively. Positivity rates and method agreement further
increased for the RT-qPCR assay when samples with positive signals below the limit of detection were counted as
positive. The wastewater data from the larger plant generally correlated (⍴ ~0.5, p<0.05) with, and even anticipated, the
trends in reported COVID-19 cases, with a notable spike in measured viral RNA preceding a spike in cases when students
returned to a college campus in the Orange County sewer shed. Correlations were generally higher when using
estimates of sewer shed-level case data rather than county-level data. This work supports use of wastewater
surveillance for tracking COVID-19 disease trends, especially in identifying spikes in cases. Wastewater-based
epidemiology can be a valuable resource for tracking disease trends, allocating resources, and evaluating policy in the
fight against current and future pandemics.

Development of a horizontal constructed wetland for safe agricultural household greywater reuse in rural Burkina
Faso
James Mihelcic, University Joseph KI-ZERBO
Additional Authors: Cheik Omar Tidiane Compaoré, Martine Diallo/Koné, Seyram Sossou, Aboubakar S. Outattara,
Ynoussa Maiga

The development of efficient sanitation technologies and practices can enhance the resilience of local populations from
adverse consequences of inappropriate sanitation. For example, greywater (which represents as much as 60% of total
generated wastewater) can be an alternative source of water for agriculture in arid regions like Burkina Faso. However,
it may contain chemical and microbial pollutants that can limit its safe reuse. Many imported water and sanitation
technologies have failed in regions like Sub-Saharan Africa because they were not adapted to local conditions or do not
correspond to the needs of end users.
Accordingly, we developed in a participatory manner, a horizontal constructed wetland for greywater treatment and
reuse that utilizes all sources of a household’s greywater in a rural area typical of Sub-Saharan Africa. An extensive
literature review, site observations, and preliminary results obtained from pilot tests were used to develop the
greywater treatment unit. Our project is supported by the U.S. Agency for International Development through the

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Partnerships for Enhanced Engagement in Research (PEER) program, a competitive grant program that supports
research in developing countries with strong potential for development impact.
From the site observations, greywater production and management were similar to literature findings with three main
sources identified: laundry (11%), dishwashing (18%) and shower (70%) for a daily production of 13 L per capita per day.
Laundry and dishwashing activities (30% of greywater production) were performed using containers that allow direct
collection of greywaters. Shower greywater, which contributed up to 70% of the total volume, was historically poured
directly onto the ground, causing health and aesthetic concerns.
With the final objective of reusing the treated greywater for household gardening, some important points were
addressed during the developing of the treatment unit: (1) the treatment system is made of locally available materials
(plastic tanks, local plants, concrete, filter materials made of sand and gravel); (2) the shower room is adapted to allow
the collection of shower greywater, which contributes up to 70% of the total water; (3) the problem of laundry and
dishwashing greywater collection observed in our previous studies was solved by integrating a receiving basin located
inside the home that is connected to the shower room. From this basin, greywater can be drained to the treatment
system located outside the houses; (4) the treatment unit is composed of four sections: an upper receiving basin, lower
basin, planted basin, and sunlight exposed basin; and (5) a receiving tank is placed after the treatment system for the
collection of treated greywaters for reuse in gardening.
The greywater unit-shower was constructed at four different households growing two local plant species with ongoing
efficiency assessment being performed that will be compared to World Health Organization (WHO) reuse guidelines.
With the different sections and the filter media used, we expect to have treated greywater compliant with the WHO
reuse guidelines. Our study supports WHO’s realization that it has become apparent that new and innovative methods
are needed to ensure more sustainable management of water resources that incorporate health considerations.

Development of viability PCR for detection of Campylobacter and Shigella in water and raw cow milk
Tahmina Ahmed, University of Virginia
Additional Authors: Suporn Pholwat, Erin G. Wettstone, James A. Platts-Mills, James A. Smith, and Mami Taniuchi

Background:
Campylobacter and Shigella are common enteric pathogens, and the major modes of transmission include consumption
of contaminated food, milk, and water. The range of infectious doses of Campylobacter and Shigella are approximately
800 to 104 CFU (colony forming units) and 10 to 500 viable organisms, respectively. Conventional culture methods have
been used to count viable microorganisms but are less sensitive, while molecular methods including qPCR allow
increased sensitivity but cannot differentiate between viable and non-viable pathogens. We evaluated laboratory
methods to detect these pathogens from water and raw cow milk as well as to differentiate between viable and non-
viable bacteria.
Methods:
To optimize sample processing and extraction, we compared nine water concentration methods, two water DNA
extraction protocols, eight milk concentration methods and nine milk DNA extraction protocols. Water and milk were
spiked with known amounts of bacteria and then underwent concentration, DNA extraction and qPCR. After choosing
the optimal approach, the limit of detection (LOD), linearity, and precision (repeatability and reproducibility) were
determined. The viability PCR (vPCR) involved the qPCR along with the use of PMAxx, a DNA intercalating dye, which can
penetrate the compromised cell membrane and block PCR amplification. The differences in the threshold cycle (dCt)
between vPCR and normal qPCR were compared for water and milk spiked with heat-killed and live bacteria. The
percentage of live bacteria was calculated as 100 divided by 2dCt.
Results:
The lowest threshold cycle (Ct) values for water were obtained by using Concentrating pipette (CP Select™, Drexel, MO,
USA) and QIAamp Fast DNA Stool Mini Kit (Qiagen, USA). The method-1 (1.5 ml of milk centrifuged at 16,000xg for
20min) and QIAamp DNA Mini kit (Qiagen, USA) showed the lowest threshold cycle (Ct) values for milk. Thus, these
methods were used for the vPCR experiments. The LOD of Campylobacter and Shigella were 103.7 CFU/ml and 102.6
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CFU/ml, respectively. The Ct values of the assays had within-run variance of 1.8% to 2.3% (repeatability, n=10) and
between-run variance of 1.6% to 2.4% (reproducibility, n=10). The optimal concentration of PMAxx was 25µM and 75
µM for water and milk, respectively (P < 0.001, by ANOVA). The PMAxx treated dead bacteria showed later Ct values
than the viable bacteria (average dCt ≥ 4).
Conclusions:
We identified an optimal approach for concentration and DNA extraction for detection of Campylobacter and Shigella
from milk and water. The optimized vPCR differentiated between live and dead bacteria in both liquids.

Different people have different problems”: motives, facilitators, and constraints to building an improved poultry shed
Liz Thomas
Additional Authors: Jesmin Sultana, Mohammad Rofi Uddin, Laura H. Kwong, Tarique Nurul Huda, Peter J. Winch

Background:
Backyard poultry production is an important livelihood strategy for households in rural Bangladesh. However, exposure
to poultry feces is a risk factor for child health. This study explored motives, facilitators, and constraints to building
improved poultry housing as part of a pilot study to prevent overnight housing of poultry inside the household dwelling.
Methods:
We enrolled 80 poultry-raising households in rural Mymensingh, Bangladesh into a pilot study of a behavior change
intervention promoting construction of an improved poultry shed. Thirty-seven households also received monetary
support (USD 23) for construction costs. Prior to intervention delivery, we quantitatively assessed motives and
constraints to building a poultry shed. Following intervention implementation, we conducted semi-structured interviews
with 16 pilot study participants who had built a shed (doers) and 14 with those who had not (non-doers) to explore their
experiences with the intervention.
Results:
At baseline, poultry-raisers’ motivations to build a shed were mostly cleanliness-related, though few mentioned health
risks to themselves or their children. During follow-up interviews, almost all participants mentioned child or family
health as their motivation for building or planning to build a shed, along with other motivations, such as poultry health
and aesthetic appeal. Most doers we interviewed had to obtain the money and materials to build a shed from multiple
sources, including by taking out loans, even if they had received monetary support from the study. Family and
intervention group support and access to financing options emerged as facilitators to building a shed. Financial
constraints, lack of family support, and the short intervention timeline (3 months) were notable constraints to building a
shed during the intervention period. Follow-up interviews also underscored the importance of monitoring equity during
interventions, as female-headed households faced difficulty securing the resources to build a shed.
Conclusion:
Promotion of improved poultry-housing practices to separate backyard poultry from the human living space at night is a
promising intervention approach, though longer timelines (>6 months), increased financing options, and targeted
support for the poorest of households will likely be required.

Disrupting the transmission of mosquito-borne diseases through treatment of water storage containers
Sydney Turner, University of Virginia
Additional Authors: Jim Smith

Background:
For communities without access to uninterrupted, piped water, home water storage can lead to adverse public health
outcomes caused by water degradation and mosquito proliferation. Higher prevalence of dengue and chikungunya,
mosquito-borne diseases, has been correlated with unsafe household water storage (HWS) (Vannavong et al., 2017).
Mosquitoes are the most prolific, invasive species contributing to disease (Lounibos, 2002) and as of late have received
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increased attention for their observed resistance to insecticides, such as temephos, that are commonly employed in
HWS containers (Guedes et al., 2020). Thus, the objective of this study is to identify alternative chemicals that effectively
mitigate larval growth at concentrations still safe for human consumption.
Methods:
This lab-study is designed to assess the larvicidal effects of juvenile Aedes aegypti after their aquatic growth
environment is dosed with silver, copper, and chlorine, individually and in tandem, at concentrations within drinking
water quality guidelines. Efficacy of the disinfectants is determined by the decreased emergence of adult mosquitoes
and mortality of larvae when compared to the controls.
Per experiment, three target concentrations of the water disinfectant are tested alongside a control in triplicate.
Twenty-five larvae are inserted into 200mL of solution. This process is then repeated for a total of 3 trials, resulting in
225 larvae tested per concentration. For the larvicidal bioassays, 1st/2nd and 3rd/4th instar larvae are tested separately.
Larvae observations are made at 24hr increments. Evaluations of the chemical effects (e.g., synergistic) of using silver,
copper, and/or chlorine in tandem are also being examined.
The protocol for the experiments follows methods outlined by WHO (2005) and Reza et al. (2020). Due to focus on the
specific application, adaptation of the WHO method included longer experimental periods, addition of a feeding
regiment, and a novel analysis approach to compare the inhibition of emergence. To understand the mode of action by
which chemicals inhibit development, a stereo microscope is used to determine the morphological defects of the dead
Ae. aegypti.
Data analysis methods include percent reduction of emergence, statistical analysis (i.e. probit analysis, two tail t-test,
Mann-Whitney U test), and Abbott’s correction formula (1925).
Preliminary Results:
Preliminary results show that all three disinfectants inhibit the growth of the juvenile Aedes aegypti, though at varying
efficiencies and via different modes of action. Results thus far have shown that when the water disinfectants are
compared based on a relative percentage to their drinking water standard (e.g., 20%, 40%, 80%), silver is notably the
most effective in terms of both larval mortality and inhibiting emergence, followed by chlorine. Younger instar larvae are
much more susceptible to these low concentration treatments then older instar larvae. Specific results for this study will
be completed by the date of the conference, including experiments considering chemical affects when using multiple
chemicals in tandem.
Conclusions:
Preliminary results from this lab-based study have shown the potential for providing communities access to clean water
while simultaneously disrupting the transmission of mosquito-borne diseases through treatment of water storage
containers. This work will provide guidance for future mosquito mitigation efforts.
Presentation Learning Objectives:
1.) Report on current large-scale mosquito mitigation strategies used around the world, highlighting the successes,
shortcomings, and the setbacks.
2.) Explore and compare alternative methods for treating household water storage containers based on results from
study that identify water treatment disinfectants as potential effective alternatives.
3.) Propose new strategies and guidance for large-scale mosquito mitigation strategies. Consider the role in which
treating household water storage plays within this broader effort.

Drinking water contamination and associated health outcomes in rural Appalachia: a systematic review and meta-
analysis
Amanda Darling, Virginia Tech
Additional Authors: Hannah Patton, Rasheduzzaman, Joshua McCray, Leigh-Anne Krometis, Alasdair Cohen

Background:
Of the approximately two million Americans who still lack reliable access to safe drinking water, many live in low-income
rural areas of the Appalachian Region of the USA. Limited evidence suggests health-related impacts associated with
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exposures to contaminated water may be disproportionately common in rural Appalachia. Aside from media coverage of
high-profile instances of drinking water contamination events in the region, data on the nature and extent of drinking
water contamination and associated health outcomes in rural Appalachia is starkly limited.
Objectives:
The objective of this study was to comprehensively review and synthesize published research findings on drinking water
contamination and associated health outcomes in the Appalachian region.
Methods:
We conducted a systematic review of drinking water contaminants – both microbiological and chemical – and drinking
water related health outcomes in the Appalachian region. We pre-registered our study protocols, limiting eligibility to
studies that collected primary data in Appalachian counties, as defined by the Appalachian Regional Commission (ARC).
We searched four databases to identify eligible papers (PubMed, EMBASE, Web of Science, and the Cochrane Library)
published over a 20-year period from January 1, 2000, to December 31, 2019. In addition to qualitative summary, meta-
analysis was used to summarize mean concentrations and detection frequencies for contaminants across studies (using
sample size-based weighting). We also performed a meta-regression analysis using a generalized linear model with a
logit link, binomial distribution, and cluster-robust standardized errors to assess the relationship between predictor
variables and the likelihood of chemical contaminants being reported above US Environmental Protection Agency (EPA)
Maximum Contaminant Limits (MCL).
Results:
We identified 3,452 records for screening; of these, 85 met our eligibility criteria and reported sufficient data for
extraction. Close to half of the eligible publications reported results from studies conducted in Northern (32%, n=27) and
North Central (24%, n=20) Appalachia, with only five eligible studies (6%) identified from the Central Appalachia region.
Of the eligible records, only 32% (n=27) addressed water-associated health outcomes specifically, and of these only four
used case-control or cohort study designs. 93% of studies (n=79) used cross-sectional designs. Though sample size and
source water varied across studies, most of the reported chemical contaminant mean concentrations were below EPA
MCLs, though this was not the case for lead (mean=0.0702 mg/L) or uranium (mean=3.99 mg/L). The weighted sample
means for E. coli and total coliform were 12.8 MPN/100 mL and 105 MPN/100mL, respectively. Of the health outcomes
reported, the most common were gastrointestinal illness (19%, n=5), concentrations of per-fluorinated compounds in
blood serum (48%, n=13), and cardiovascular outcomes (15%, n=4).
Conclusions:
Our results indicate that more epidemiologic-based research is needed to better understand the nature and extent of
contaminated drinking water and associated exposures and health outcomes in rural regions of Appalachia, particularly
in Central Appalachia. Overall, aside from some extensive analysis of chemical contaminants in groundwater, the extent
of drinking water contamination and access issues in low-income areas of rural Appalachia appears to be relatively
underrepresented in the broader water and health research literature.

Effective targeting of water connection subsidies to low-income households in Uganda

Diana Keesiga, Tetra Tech (USAID Funded Uganda Sanitation for Health Activity)
Additional Authors: Annis Jonathan, Reinold Seidelmann, Herbert Nuwamanya, Reinold Seidelmann, Herbert
Nuwamanya

Six regional parastatal utilities, the Umbrella Authorities for Water and Sanitation (UAs), operate most piped water
supply systems (WSS) serving rural areas in Uganda where 54 percent of households earn $55 or less per month and
access to safely managed drinking water stands at eight percent. UAs seek to promote new water connections as part of
a broader strategy to increase revenue and improve scheme-level financial viability. Most households living near a WSS
wish to connect and can afford a monthly water bill but cannot meet the upfront connection cost without a subsidy.
With technical support from the USAID Uganda Sanitation for Health Activity, in March 2021, two UAs began piloting
three “pro poor” interventions aimed at equitably increasing access to water connections by disadvantaged households
at five WSS: (i) an inverted block tariff for the first cubic meter, (ii) using socio-economic surveys to inform allocation of
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water connection subsidies (iii) socially marketing water connections to low-income households. Studies conducted to
inform the development of the “pro poor” strategy and early results of applying the block tariff were presented at last
year’s conference. This year we propose to focus on ii and iii.
Socio-economic household surveys using the EquityTool questions were conducted among 2,021 existing consumers and
3,584 potential customers. Factor weights, quintile cut-offs, and relative wealth of the respondents to the national
population were generated. A distribution of wealth quintiles specific to each WSS service area was also determined.
Community meetings to activate demand for subsidized connections were conducted (the level of subsidy offered at
each WSS was determined by willingness and ability to pay surveys). Households were given 30 days to apply. Applicants
were plotted on their scheme-specific wealth distribution index to establish if households in the lowest two quintiles
were signing-up. Targeted social marketing was done to increase participation in the lowest two quintiles.
Results show that all intervention towns are comparatively wealthy on a national scale. For example, in Kamengo,
Central Region, 97% of the 671 unconnected households fall in the wealthiest two quintiles nationally. However,
scheme-specific wealth distribution curves indicate that few households in the bottom two locally representative
quintiles are currently connected. In Kamengo, no household in the poorest quintile is connected and only 2% of
customers lie in the second quintile. Across three schemes, 69% of unconnected households lie in the bottom two
service area quintiles, yet only 26% of the initial 805 applications received were from these segments. Targeted social
marketing and offering a payment by installment option later increased the application rate of households in these
groups.
These results, which will be updated in July to include all five towns, demonstrate a) very few poor households are
connected to WSSs indicating the UA’s traditional approach of allocating water connection subsidies has not been
equitable, b) the need to generate scheme-specific wealth quintiles to effectively target water connection subsidies, and
c) the impact of targeted marketing and offering flexible payment terms to encourage the poorest households to apply
for subsidized connections.

Effectiveness of Free Chlorine and Chloramine to Control Legionella in Building Water Systems
Rasheduzzaman, Virginia Tech
Additional Authors: Rajveer Singh, Patrick L. Gurian

Legionella spp. is the most recognized pathogen present in premise plumbing systems, and the number of Legionella
cases is rising worldwide. Chemical disinfectants such as chlorine and chloramine in premise plumbing systems are
known to be effective and are commonly used to control Legionella. This study performed a systematic review and
meta-analyses of existing evidence on the relationship between disinfectant residual concentrations (i.e., chlorine and
chloramine) and Legionella contamination to identify the effective disinfectant residual concentration in premise
plumbing systems to control Legionella. A total of 29 studies met our inclusion criteria and were included in our
qualitative synthesis and quantitative analyses to identify the effect of disinfectant residual concentrations. For chlorine
and chloramine, the Receiver Operating Characteristic (ROC) curve identified 0.2 mg/L and 2.5 mg/L, respectively, as a
cutoff point for the required disinfectant residual concentration with Area Under the Curve (AUC) values of 0.642 and
0.650. The effect of a unit change in chlorine residual on the odds ratio (OR) for Legionella occurrence was found to be
0.016 while the effect for chloramine was higher (i.e., 0.172). Both effects indicate the decreased occurrence of positive
Legionella colonization with increased disinfectant residual concentrations. For chlorine residual, our logistic regression
found a residual concentration of 1 mg/L associated with a 2% probability of detectable Legionella while for chloramine,
a residual concentration of 2.5 mg/L was associated with a 10% probability of detectable Legionella. Further research or
a more thorough reporting of existing datasets is needed to assess if Legionella contamination can be restricted below
specific concentration targets at disinfectant residual concentrations.

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Effects of Extreme Flooding on Water Quality in Areas of Dense Food Animal Production
Nikhil Kothegal, UNC Chapel Hill
Additional Authors: Elizabeth Christenson-Diver; Jill Stewart; Marc Serre; Collin K. Coleman; Connor LaMontagne

Storm events are expected to increase with climate change, with the potential to adversely impact environmental
quality and public health. This study assessed impacts of Hurricane Florence on water quality in areas of dense food
animal production. Twelve surface water sites in rural, eastern North Carolina were sampled before and after Hurricane
Florence to assess storm effects and duration of impacts. Concentrations of fecal indicator bacteria Escherichia coli were
not significantly different in our first sampling event, conducted 10 days after Hurricane Florence. Instead, the
longitudinal data show that first runoff events, defined as rainfall following a dry period, are associated with increased
concentrations of fecal indicator bacteria in these watersheds. Additionally, watersheds with larger commercial hog
operations (CHOs) and CHOs closer to sampling sites, as well as sites with larger number of households closer to
sampling sites had increased E. coli concentrations. Unlike E. coli concentrations, we found that mean ranks of microbial
source tracking markers associated with swine wastes (pig-2-bac) and human wastes (HF183) were higher immediately
after Florence (Mann Whitney U p=0.009, p=0.0003 respectively). The swine MST marker was markedly elevated at
several sites in watersheds with CHOs, while the human MST marker suggested diffuse human contamination across
study sites. Antimicrobial resistance among E. coli isolated from study waters was also higher in watersheds with CHOs.
Resistant E. coli was detected in 46% (n=147) of samples collected downstream of CHOs compared to 22% (n=94) of
samples collected in watersheds without CHOs, resulting in a relative risk of 1.47 (95% CI: 1.21, 1.78). Bacteria with
multiple antibiotic resistance was isolated in 15 of the CHO-associated samples and 1 background sample. Occurrence of
AMR does not appear to be driven by precipitation, suggesting other dynamics such as spray events or antibiotic use
practices may better explain contributions to resistant bacteria to surface waters. These results help clarify the effects of
extreme flooding on microbial contamination of surface waters and can inform strategies for waste management,
antibiotic use, and one health surveillance. Ultimately, this work contributes information to build more resilient
agricultural systems and communities better prepared to weather the storms that frequent the North Carolina coast.

Efficacy evaluation of geotextile and non-geotextile membranes to treat simulant sludge

Marine Ricau, Tufts University
Additional Authors: Gabrielle String and Daniele Lantagne

Key Learning Objectives:

• Overall, the woven geotextiles are more appropriate than non-woven geotextiles for fecal sludge treatment,
especially if multiple layers of sludge are added on the membrane and consistent results overtime are necessary.
• Fishnet membranes have better removal of helminth eggs than the geotextiles, but they have highly inconsistent
results overtime, for the filtrate, solid sludge, and dewatering flow.
• Mixing lime prior to filtration results in clogging of the membrane or severe slowdown of the dewatering flow,
so it is not recommended for all three membranes.
Introduction:
Treatment of human excreta in humanitarian contexts is still rare. Often, untreated sludge is disposed of into the
environment, posing a serious environmental and public health risk. Geotextiles are permeable fabrics used to retain
soils and have been adapted for sanitation use. Fecal sludge dewatering geotextile plants are a promising treatment
solution for humanitarian contexts; however, data on their efficacy is limited. To address this knowledge gap, we
compared the efficacy of three types of permeable membranes, geotextile, and non-geotextile, in the laboratory using
simulated fecal sludge.
Methods:
We evaluated three membranes: one woven geotextile designed for fecal sludge dewatering; one non-woven geotextile;
and one non-geotextile membrane mimicking locally available material (100 µm fishnet). For one layer, we prepared and
filtered 1L of simulant sludge (with and without lime) through each membrane and measured chemical oxygen demand
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(COD), E. Coli, total suspended solids (TSS), volatile suspended solids (VSS), and fluorescent beads (as Helminth eggs
surrogate) in the influent and effluent. Over 48h of filtering, we measured the flow rate. For influent without lime, this
was repeated a total of five times, with sludge accumulating on the membrane surface. At the end of the experiment,
we measured the total solids and total volatile solids of the unfiltered sludge cake.
Results:
Woven geotextile membranes have the most consistent results across all outcomes, and their dewatering flow improves
with the addition of layers. Non-woven geotextiles clog faster than the other membranes and their dewatering flow
decreases with the addition of layers. Fishnet membranes have the highest results for the removal of helminth eggs and
have similar results than the geotextiles for other outcomes. However, they have highly variable results, and their
dewatering flow is slower than the geotextile membranes. Adding layers of sludge without cleaning the membrane have
no effect on all outcomes but the dewatering flow of the non-woven geotextiles. Mixing lime with the sludge prior to
filtration results in clogging for the woven geotextile membranes and high decrease of dewatering flow for the other
two membranes. Using lime results in inactivation of E. Coli, but in lower removal for all other outcomes.
Conclusions:
Overall, each membrane is more appropriate depending on the objective of treatment. Woven geotextiles are more
appropriate if consistent results overtime is necessary, especially for dewatering flow. Fishnet membranes may be
appropriate if inconsistent results are not a problem, if helminth eggs removal is the objective, or for economic reasons.
Non-woven geotextiles are appropriate if a limited number of sludge layers are going to be added, but they are overall
less appropriate than the woven geotextiles for the treatment of sludge. Mixing lime prior to filtration is not appropriate
for all membranes.

Electronic Sensors to Monitor Functionality and Usage Trends of Rural Water Infrastructure in Plateau State, Nigeria
Taylor Sharpe, University of Colorado Boulder
Additional Authors: Chantal Iribagiza, Emmanuel Iorkumbur, Jeremy Coyle, Crystal Fenwick, Ellen Greggio

Recently, IoT technologies have been used to monitor critical infrastructure in remote settings. Prior research has
supported active O\&M campaigns, quantified groundwater extraction rates, and evaluated service delivery approaches.
In this study, continuous data collection was used to examine the operating characteristics of rural water infrastructure.
Three research questions motivated this work: (1) What are the operating characteristics and trends of these pumps? (2)
Can water point functionality be predicted? (3) Does the instrumented water point sample accurately represent overall
water system functionality in this setting? 397 randomly selected groundwater pump sites were observed within Plateau
State, Nigeria over 12 months in 2021. 200 of these sites were instrumented with in-situ sensor systems, including 100
handpump sensors, 50 AC electrical sensors, and 50 water level cistern sensors. Bi-monthly phone calls and site visits
were used to observe pump functionality statuses and served as ground-truth data over the study period. An automated
expert classifier system generated statuses for instrumented pumps on a weekly basis. The classifier was able to
accurately detect running pumps but did not perform well in detecting failures. Varied responses were seen in pump
usage as a function of rainfall, with handpump use decreasing significantly, AC pump usage decreasing to a lesser
degree, and DC pump usage increasing in response to local rainfall. A statistical comparison of the 200 instrumented to
197 non-instrumented sites showed significant overall functionality level differences due to a baseline functionality
criterion for sensor installation, but similar repair and failure rates on a bi-monthly basis. This suggests that in terms of
functional change, the sensor-enabled group statistically represented the larger group of water points in Plateau State.

Encouraging Favorable Payment Behavior for Container-Based Sanitation in Haiti

Maya Lubeck-Schricker, SOIL
Additional Authors: Claire Remington, Jessica Laporte, Sasha Kramer

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Background:
SOIL provides container-based sanitation (CBS) services to households in Cap-Haitien, Haiti. CBS is a user-approved, low-
cost sanitation option particularly in low-income urban areas where demand for sanitation services is high and other on-
site sanitation systems and sewerage are not feasible, safe, or cost-effective. SOIL collects a nominal monthly service
fee—equivalent to $3.34—that contributes to operational cost recovery and establishes the provision of sanitation as an
essential basic service rather than a charity.
Problem Statement:
Customers who subscribe to SOIL but fail to pay the monthly fee get uninstalled from the service. SOIL applies resource-
intensive tactics such as home visits to encourage customers to make on-time payments and therefore retain access to
safe sanitation. SOIL has also made payment structure changes and offered special deals in an effort to improve cost
recovery and favorable payment behavior. However, the impacts of these interventions have not previously been
evaluated.
Objective:
This analysis aims to explore whether the previously implemented payment interventions are associated with improved
customer payment behavior, which will inform future organizational tactics to promote favorable payment behavior and
thereby retain customers in the service.
Methods:
SOIL’s database of historic customer bills and payment records was used to assess five interventions implemented
between 2018 and 2021. For each intervention, the proportion of favorable payment behavior practiced (i.e., payments
made on time or in advance) was calculated for each active customer for the 6 months prior to the intervention and the
6 months following the intervention. A paired t-test was run for each intervention to assess whether there was an
associated significant difference in favorable payment behavior.
Results:
A price increase in 2018 significantly decreased favorable payment behavior by 19%. Conversely, favorable payment
behavior significantly increased by 2% after a price increase in 2021. A long-term debt management intervention starting
in 2019 that entered customers with 3 months of accumulated debt into a period of service suspension prior to
uninstallation significantly increased favorable payment behavior by 7%. Two special offers that conditionally gave
customers a free month of service also significantly increased favorable payment behavior, one by 23% and the other by
13%
Conclusion:
All interventions were significantly associated with a change in favorable payment behavior with the September 2018
price increase as the only change that was associated with a decrease in favorable payments. Some of the interventions
overlapped and other potential related factors such as income and household size cannot not be controlled for in t-test
analyses. SOIL is building on these findings with more rigorous payment behavior change research to better understand
strategies to improve favorable payment behavior and therefore customer retention in the service. In contexts where
the target population for basic utility services are informal workers earning daily income, paying regularly monthly fees
does not align with their other typical payment patterns. It is important to understand who can afford to pay but
requires encouragement to adapt their payment behavior, and who simply cannot afford the service and requires other
interventions, such as additional subsidies, to retain access to safe sanitation.

Establishing a Strong Foundation for Governance: 17-Country Evaluation to Improve WASH Implementation and
Quality Control
Adam Questad, World Vision
Additional Authors: Justine Lee

Background:
The United Nations estimated that only 30% of the population in Sub-Saharan Africa was using safely managed drinking
water services in 2020. The WASH sector has, for many good reasons, shifted focus towards governance and post-
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construction operation; however, there lacks adequate consideration for proper quality control procedures, resources,
and tools to design and implement well-designed infrastructure that sets a strong foundation for future governance and
management. In response, World Vision has initiated a 17-country survey of current engineering, design, procurement,
management, and quality control procedures to identify the most critical capacity gaps and outline a strategy to
promote quality as piped water systems grow in number and complexity.
Methods:
World Vision has initiated formative research to assess the current state of technical qualitatively and quantitatively,
engineering, procurement and administrative practices when implementing water systems globally. Countries were
selected to provide diversity in geography, fragility, and current WASH capacity representing East Africa, South Africa,
West Africa, Latin America, and Asia Pacific regions. The survey includes four categories to be completed by different
technical specialists including technical (hardware), non-technical (software), management/leadership, and
procurement. In total, at least 68 respondents will be included (4 technical specialties from 17 countries). The survey
includes qualitative questions requesting information on current practices, documents, and procedures and also
quantitative questions such as the percentage of source water types used, water quality analytes assessed, or the
frequency of government and private sector involvement during the design process. As of May 2, 2022, we have
received 80% of the survey results and are beginning to synthesize and develop findings to inform strategies for
improving quality and reliability.
Results:
Preliminary findings showed that 94% of respondents indicated water systems are analyzed for E. coli whereas only 50-
60% analyze for toxic metals. In addition, 69% stated that biological water quality contamination is the most common
concern, but only 53% said that disinfection is always provided for water systems and only 18% said disinfection is
always provided at the household level. In addition, 94% of respondents indicated a contractor performs drilling, but
only 63% stated that an inspector is present from start to finish to oversee quality and compliance. Our team will assess
global, regional, and country-specific trends to identify needs and opportunities to modify current procedures and
develop new resources or training to improve quality and reliability of water systems implemented.
Conclusion:
Quality and reliability of water systems is a growing concern and there is a need to not only quantify the occurrence of
non-functional systems but identify programming strategies to improve the quality of these systems. Our
recommendations are likely to include the need for more oversight during all phases of design and construction,
expanded and more frequent water quality monitoring, a better framework for assessing treatment needs, and quality
control guidance that can be adapted locally and within existing governmental frameworks. Recommendations will be
presented as an opportunity for WASH sector practitioners to identify their own strategies for quality infrastructure to
set a strong foundation for governance.

Estimating the Global Target Market for Passive Chlorination

Katya Cherukumilli, UC Berkeley
Additional Authors: Robert Bain, Yiru Chen, Amy Pickering

Two billion people currently lack access to safely managed drinking water sources, which are defined by UN SDG 6.1 as
being accessible on premises, available when needed, and from an improved source free from contamination. Reducing
microbial contamination in drinking water supplies is necessary to protect long-term public health, substantially reduce
child mortality, support child growth and development, and improve school attendance. Deployment of passive
chlorinators, which can automatically disinfect water without electricity or daily user input at the point of collection,
offers one strategy for advancing access to safely managed drinking water services. By combining and leveraging data on
household water usage, treatment, and quality from the Joint Monitoring Programme’s (JMP) WASH database and
UNICEF’s Multiple Indicator Cluster Surveys (MICS), we estimate that 5.7 billion people in low- and middle-income
countries (LMICs) are currently using drinking water sources that are either directly or potentially compatible with
passive chlorinators (e.g., piped water, kiosks, packaged or delivered water, stored rainwater, tubewells, boreholes,
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protected springs). Within this LMIC population, we estimate a target market of approximately 2.2 billion people using
microbially contaminated compatible (1.39B) or potentially compatible (786M) drinking water sources. The largest
target market for passive chlorinators is in South Asia (549.4M rural users and 399.3M urban users), where over 77% of
regional drinking water sources compatible with passive chlorinators are also contaminated. Self-reported household
water treatment practices in LMICs suggest that chlorination is a more common practice in African regions and Latin
America and the Caribbean than compared to Asian regions (where filtering is more common, especially in urban areas),
highlighting a potential barrier to user acceptance of chlorinated water in Asia. To reach the full target market for
passive chlorinators in LMICs, future work must establish device compatibility with diverse water infrastructure,
including handpumps and protected springs, characterize the type and size of storage tanks used with water sources,
and identify financially sustainable strategies to scale up user adoption and consistent device use.

Evaluation of occupational health and safety intervention for waste and sanitation workers in Bangladesh during
COVID-19
Tanvir Ahmed, BUET
Additional Authors: Mahbub-Ul Alam, Dewan Muhammad Shoaib, Kazy Farhat Tabassum, Makfie Farah, Alauddin Ahmed

Background:
Waste and sanitation workers in South Asian countries live in resource-poor settings and handle hazardous waste
without adequate personal protective equipment, making them vulnerable to injuries and diseases, including COVID-19.
To reduce their occupational health risk, an intervention was made during the pandemic in 10 cities in Bangladesh that
included training and PPEs distribution among the workers. We conducted a randomized cluster trial to evaluate the
impact of the intervention in improving occupational health and safety-related knowledge, attitude, and practices of the
workers.
Methods:
We conducted the study in 10 cities in Bangladesh that included seven intervention areas (cities) and three control
areas. For the baseline assessment, we conducted 499 in-person surveys (Control-152, Intervention-347) with waste and
sanitation workers and made 47 structured observations (Control-15, Intervention-32) of their routine activities. The
endline evaluation (after intervention) was based on 499 surveys (Control-150, Intervention-349), and 50 structured
observations (Control-15, Intervention-35). To evaluate the impact of the intervention at endline, we used the difference
in difference (DID) method after adjusting for education, religion, caste, accommodation, and monthly income.
Results:
The intervention has more likely improved the workers’ knowledge of using/maintaining protective equipment (DID:
21%, CI: 8, 33), major COVID-19 transmission causes (DID: 27%, CI: 14, 40), and preventive measures (DID: 12%, CI: -0.6,
25). However, it has not changed the workers’ understanding about social distancing (DID: 4%, CI: -8, 16), quarantine
(DID: 3%, CI: -20, 26), and isolation (DID: 5%, CI: -31, 41). The intervention has also improved attitude of the workers
regarding using PPEs (DID: 36%, CI: 22, 49), washing PPEs (DID: 20%, CI: 8, 32), and cleaning working equipment (DID:
20%, CI: 7, 33). The intervention seems to have improved workers’ practice of taking adequate precautions after getting
back home from work (DID: 37%, CI: 27, 47) and the practice of changing/cleaning masks every day (DID: 47%, CI: 0.03,
94). The practice of using PPEs among the workers (who had PPEs available) was similar in both intervention and control
areas. There was an improvement in handwashing practices of the workers before wearing PPEs (DID: 27%, CI: 2, 52),
after finishing work (DID: 31%, CI: -7, 69), during work intervals (DID: 30%, CI: -33, 93) in the intervention areas although
there was not much improvement in handwashing practices before having meals (DID: 2%, CI: -61, 65), and after using
the toilet (DID: 7%, CI: -41, 55). Improvement was observed in maintaining coughing etiquette (DID: 20%, CI: 0.2, 40) and
social distancing (DID: 13%, CI: -19, 46), while practice of using mask had limited impact (DID: 1%, CI: -40, 42) from the
intervention.
Conclusion:
The intervention appeared to have effectively improved the workers' knowledge, attitude, and practice about critical
occupational health risks and mitigation measures. Workers’ understanding of social distancing, isolation, quarantine,
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and practices of mask use, and handwashing before a meal and after the toilet had limited improvement which clearly
indicates the need for further intervention.

Evaluation of on-site wastewater testing for SARS-CoV-2 in US correctional facilities

Anna Mehrotra, Water Environment Federation
Additional Authors: Shellie Chard, Travis Herrian, Justine Hutchinson, Lara Strick, Carley Truyens

During the COVID-19 pandemic, the benefits of wastewater disease surveillance (WDS)—or the systematic testing,
analysis, and interpretation of wastewater data to inform public health practice—have accrued mainly to larger
communities with easy access to third party laboratories. Analytical technologies configured for on-site wastewater
testing for SARS-CoV-2 and other pathogen targets may be suitable for institutions, small towns, Tribal nations, and
other settings for which sample shipment logistics make reliance on outside laboratories challenging. Questions remain
about the feasibility of running on-site WDS programs, given existing demands on water and health professionals in
these locations and the nascent nature of these testing technologies.
To evaluate the feasibility of on-site wastewater testing in institutional settings, we implemented a SARS-CoV-2
wastewater testing pilot program in US correctional facilities. Our objectives for the pilot, which was funded by the US
CDC, were to (1) assess the conditions required for initiation of an on-site testing program; (2) identify barriers to use of
the testing technology and acceptance of the data produced; and (3) analyze the correlation between the wastewater
SARS-CoV-2 concentrations and COVID-19 incidence in the institution.
On-site wastewater testing for SARS-CoV-2 was performed in 18 correctional facilities across four states (California,
Oklahoma, Virginia, and Washington) using the GeneCount Q16 quantitative polymerase chain reaction technology and
associated test kits (Hach Company, Colorado USA and LuminUltra, New Brunswick Canada). Testing was performed by
staff and/or inmates at each facility, many of whom had no prior laboratory experience. Untreated wastewater samples
(either grab or composite) were collected for 12 weeks or more and analyzed for SARS-CoV-2 (N2 target). Quality
assurance (QA) procedures included negative and positive controls, sample and extraction replicates, and matrix spikes.
Data quality was regularly checked, and virtual meetings were used to discuss the facilities’ experiences implementing
the testing program and how the wastewater data compared to reported COVID-19 incidence for the facility.
A total of 581 test results have been reported to date, with samples collected and analyzed every 1.4 to 10 days,
depending on the facility. Most of the results (444 out of 581 [76%]) have been below the limit of detection (5 x 104
gene copies per L), and the highest wastewater result reported was 3 x 1010 gene copies per L. Preliminary analyses
suggest that SARS-CoV-2 concentrations in wastewater are consistent with facility COVID-19 incidence. Pilot participants
have reported that the data are helpful for informing COVID-19 mitigation strategies, with more frequent sampling
associated with greater data utility.
Upon the pilot’s conclusion in June 2022, we will perform a complete analysis of the data and a thorough evaluation of
lessons learned. To date, the pilot has demonstrated that non-detect wastewater levels are common in institutional
settings. Although learning the analytical technique was challenging for some staff without laboratory experience, all
testing teams were ultimately able to generate data that passed QA metrics. Close communication between those
performing the testing and those using the data will be critical if wastewater data are to inform institution-level public
health actions.

Five Years of Promoting Market-Based Sanitation in Ethiopia: Lessons Learned from USAID Transform WASH
Monte Achenbach, Population Services International
Additional Authors: Michael Negash, Dagim Demirew, Getachew Asradew, Shegaw Fentaye, and Lars Osterwalder

Introduction:
The majority of Ethiopia’s population uses dry pit latrines. Most of these latrines are classified as unimproved (EDHS,
2016; JMP, 2021). An active private sector is needed for efficient and sustainable expansion of household access to
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improved sanitation facilities, including a well-functioning supply chain. Market-based sanitation (MBS) is a development
approach to improve household facilities by building the market for affordable sanitation products and services for
which the customer is willing to make a full or partial monetary purchase. Services include construction, upgrade, and/or
maintenance of toilets offered by nearby businesses (UNICEF, 2020).
USAID Transform WASH (T/WASH) is a six-year project (2017 to 2022) financed by USAID and awarded to PSI and
consortium partners SNV, IRC and Plan International to test and develop market-based models designed to increase
demand for and supply of quality, affordable WASH products and services in Ethiopia, with an emphasis on sanitation.
Results:
In close collaboration with the Government of Ethiopia’s One WASH National Program and the Ministry of Health,
T/WASH has introduced 20 new/innovative WASH products and service packages for sanitation, household water
treatment and hand washing, and developed and tested four business models. More than 530 business partners have
been engaged as part of the supply chain, 95% of which remain operational. Since 2017, T/WASH business partners have
sold 81,699 improved sanitation products. Further, Ethiopia’s national MBS guidelines were revised with the support of
T/WASH, and an MBS training manual developed and cascaded to 300 woredas (districts).
Major Lessons Learned:
• Simple latrine upgrades to spark demand for improved sanitation. The T/WASH approach started with providing
cement slabs through pre-existing businesses but diversified quickly to include a broader range of business models with
products/services that better met consumer needs. Of these approaches “skirting” (installation of a SATO pan on a
durable traditional unimproved pit latrine with cement plastering of the latrine floor) was found to be a desirable low-
cost option to upgrade latrines to “improved” status and provide better consumer experiences.
• Door-to-door promotion and installation to reach more households. A ‘decision quotient’, problem-led sales approach
was introduced and proved that ‘deskilled’ start-up entrepreneurs can generate demand for their products and services
to a level that ensures financial viability of the businesses’ operation. This service delivery model can encourage about
25 to 30% of households reached to improve their sanitation facilities and minimizes the households’ burden of
improving their own toilets through self-installation.
• SATO pans as unique selling point. While a SATO pan alone does not necessarily upgrade a pit latrine to “improved”
status, it offers a new solution around which additional latrine upgrades can be framed. The supply chains established by
T/WASH, using pre-existing businesses, have proven to be sustainable and resilient.
• Close collaboration with government at all levels to prepare for scale-up. Close collaboration helped to integrate MBS
into key government strategies and to harmonize the MBS approach for scale-up and leveraging of government finance.
Health extension workers were found to be valuable in linking customers with T/WASH business partners.
EDHS 2016 Ethiopia Demographic and Health Survey 2016. Report of the Central Statistical Agency (CSA) [Ethiopia] and
ICF. Addis Ababa, Ethiopia, and Rockville, Maryland USA.
JMP 2021 Progress on household drinking water, sanitation, and hygiene 2000-2020: Five years into the SDGs. Report of
the World Health Organization (WHO) and the United Nations Children’s Fund (UNICEF). Geneva and New York.
UNICEF 2020 Guidance on Market-Based Sanitation. Report of the United Nations Children’s Fund (UNICEF), New York.

Food Hygiene and Fecal Contamination on the Household Compound are Associated with increased Pediatric Diarrhea
in Urban Bangladesh (CHoBI7 Program)
Ismat Uddin, icddrb
Additional Authors: Tahmina Pervin, Sazzadul Islam Bhuyian, Kelly Endess, Jamie Perin, Christine Marie George

Diarrheal disease is a leading cause of death in children globally. In this prospective cohort study, we explored individual
and household-level risk factors associated with diarrheal diseases among 251 children under 5 years of age in slum
areas of urban Dhaka, Bangladesh. During the 3-month study period, diarrhea surveillance was collected monthly, with
diarrhea defined as caregiver-reported diarrhea in the past 2 weeks (>3 loose stools over a 24-hour period).
Unannounced spot checks of the household compound were performed at 7 days, 1 month, and 3-months after
enrollment to assess the presence of feces (animal or human) on the household compound and in cooking and food
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storage areas, and to assess if cooked food was covered and refrigerated. Children living in households with feces within
10 steps of cooking and food storage areas(Odds Ratio (OR): 8.43; 95% Confidence Interval (CI): 1.01, 70.18), those with
visible feces found on the ground of the household compound(OR: 4.05; 95% (CI):1.24, 13.22), and those in households
found to keep cooked food uncovered and without refrigeration(OR: 6.16; 95% (CI): 1.11, 34.25) during unannounced
spot checks had a significantly higher odds of diarrhea for children under 5 years over the 3-month study period. These
study findings demonstrate that presence of visible feces on the household compound and within 10 steps of cooking
and food storage areas, and poor food hygiene practices were significant risk factors for diarrheal disease among young
children in Dhaka, Bangladesh. Health communication programs are needed to target these exposure routes to fecal
pathogens.

From Poop to Chicken Feed – Growing Black Soldier Fly Larvae on Waste from Container-based sanitation in Haiti
Michèle Heeb, Sustainable Organic Integrated Livelihoods (SOIL)

Background:
Sustainable Organic Integrated Livelihoods (SOIL) operates a household container-based sanitation (CBS) and
composting waste treatment service in urban and peri-urban Cap-Haitien, Haiti. SOIL’s services meet a demand for
safely managed sanitation and address a myriad of interconnected challenges: environmental degradation, waterborne
illness, economic disempowerment, climate change, and food insecurity. SOIL is interested in diversifying its waste-to-
resource products by producing Black Soldier Fly Larvae (BSFL) in addition to compost.
The black soldier fly (BSF), Hermetia illucens, is endemic to Haiti. During its unusually long larval stage (2-3 weeks), it
feeds on organic waste, more than doubling its weight. BSFL are rich in protein and can serve as animal feed, increasing
food security in the region. With the integration of a BSFL processing step prior to composting, SOIL could generate
revenue from BSFL sales to financially support ongoing waste treatment operations. To determine whether BSFL
production is feasible, SOIL has researched:
1) Are we able to establish and maintain a BSF colony such that we have a constant supply of larvae?
2) Can BSFL grow on the waste we collect through our CBS service and if so, how efficiently do they transform it?
Methods:
To establish a BSFL larvae colony, wild BSF eggs were collected from around SOIL’s composting site. The eggs were
placed on a mix of water and chickenfeed for the freshly hatched larvae to feed on.
In addition to maintaining the BSF colony, experiments on waste treatment by BSFL were performed by adding 5000 5-
to-7-day old larvae to 6 kg of CBS waste with a moisture content adjusted to 75 %. The larval growth rate and waste
reduction were observed for 14 days.
Results:
We were able to breed from the wild BSF eggs collected from the site and have successfully maintained a BSF colony
grown from these eggs.
Preliminary results of the waste experiments show a bioconversion rate of 6% and a final larval weight of 0.094 g. A yield
of 130 kg of larvae per ton of waste treated was calculated (before adjustment of moisture content). Waste wet weight
and volume was reduced by 27 % and 23 %, respectively. No statistical analysis has been done as the experiments have
not been concluded yet.
Conclusion:
Waste transformation and resource recovery through BSFL is feasible for SOIL. We are able to continuously breed BSF
and have built a rearing unit to facilitate further expansion of the BSF colony. Furthermore, we have demonstrated that
BSFL grow on our waste, and this reduces its mass and volume. The residuals from BSF processing can be composted in
SOIL’s existing composting infrastructure. Next steps include expanding the BSF colony to produce enough larvae for a
small-scale pilot and assessing product quality and safety.
Incorporating BSFL in SOIL’s waste-to-resource strategy will not only increase operational cost recovery at the treatment
site but also greatly benefit the region of Northern Haiti by providing local and readily accessible animal feed and safe
sanitation, thus improving food security and public health at the same time.
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Global WASH: Raising the prominence of a neglected global health issue

Rick Gelting, US Centers for Disease Control and Prevention (CDC)

Waterborne and water-related diseases, principally diarrhea, are the second leading cause of childhood mortality
worldwide after acute respiratory infections. These diseases, which are directly related to inadequate water, sanitation,
and hygiene (WASH) conditions, kill nearly 200 million children annually, more than HIV/AIDS, malaria, and measles
combined. Globally, over 2 billion people lack safely managed drinking water and over 4 billion lack safely managed
sanitation. Poor WASH conditions also contribute to waterborne disease outbreaks, which continue to cause major and
widespread health crises around the world. Cholera, for example, causes an estimated 2.9 million cases and 95,000
deaths worldwide every year. Rapid urbanization, natural disasters, changing weather patterns, conflict, and
displacement further complicate WASH challenges. Lack of WASH in healthcare facilities and schools are also a serious
public health issue.
Yet, this massive global health challenge does not receive as much attention as others with lesser health burdens.
Vertical disease-specific programs such as the President’s Emergency Plan for AIDS Relief (PEPFAR) and The Global Fund
tend to dominate global public health programming. More recently, several large, cross-cutting public health initiatives
such as the Global Health Security Agenda are broader, but WASH is not a principal element, and is subordinated within
other programs such as anti-microbial resistance (AMR).
Various reasons likely account for this sparse attention to WASH. Those causes include WASH is spread across
disciplines, sometimes without consistent understanding of where responsibility lies; a perception that the problem is
too large or expensive to tackle; or a lack of awareness of the true scale of the issue. In addition, the burden falls largely
on marginalized populations predominantly residing in low-income countries.
The negative impacts resulting from a lack of WASH are persistent and well-studied, yet this relative lack of attention
remains. Therefore, this presentation will explore the policy environment surrounding global WASH issues. This will
include an in-depth discussion of the reasons why WASH issues do not have a higher profile within global public health
and other related disciplines. Potential policy levers to raise the profile of global WASH issues will also be explored,
including such mechanisms as:
• incentives, including for governments
• changing perceptions by raising policy maker awareness
• structural changes within global health and development programs, such as integrating WASH as a principal
element into larger initiatives like Global Health Security
• financing, including alternatives such as private sector support, and outcome based funding
• use of outcome and impact-based measurement
This presentation will be relevant to a variety of stakeholders including public health professionals, policy makers, non-
governmental organizations, the private sector, and the general public.

Groundwater data improves localized water resource management in the Sahel

Alex Loken, Winrock International
Additional Authors: Judith Lenti-Sidibe

Background:
In Niger and Burkina Faso, access to water, especially groundwater, remains critical for domestic and economic uses.
Local water resource management actors lack access to localized data on water resources, limiting information, tools, or
knowledge on how to best access, distribute, and monitor this resource. The USAID-funded TerresEauVie Activity,
implemented by Winrock International, commissioned groundwater studies in 21 municipalities to identify the quantity

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and quality of groundwater resources available, and used the results to inform local plans and policies to better target
water points, investment, and sustainability.
Methodology:
The project surveyed 142 villages in 3 communes in Centre-Nord and Est regions of Burkina Faso and 2,660 villages
across 18 communes in Maradi and Zinder regions of Niger between October 2020 and June 2021. TerresEauVie worked
with local universities to staff the teams who surveyed 5,008 water points, collecting samples from 2,613 water points.
Water samples were tested for bacteriological and chemical contamination, including a random selection of samples
counter-analyzed by official laboratories. TerresEauVie collected hydrological and geophysical data to estimate quantity
and location of aquifers and mapped these resources along with water extraction infrastructure. The studies were
reviewed by a steering committee and shared with local, regional, and national government representatives.
TerresEauVie conducted follow-up trainings, interviews, and consultations with these policymakers to assess uptake of
the study results.
Results:
Aquifers were characterized for each commune with maps of their potential, a water balance, and water quality that
showed bacteriological and chemical contamination as a result of water point design, lack of hygiene,
agriculture/livestock contamination, and geological features of the reservoirs with 66% of samples positive for coliforms,
12% with high arsenic levels and 4% with fluoride levels above the norm. TerresEauVie found that this localized data at
the village-level was utilized by decision-makers. Local technical services used the data to inform their communal
development plans which guide resource allocation. In Zinder, local government identified 11 water points with
sufficient water yield, according to the data, to upgrade them to autonomous water stations serving more residents.
Regional institutions are better equipped to plan new infrastructure where high quality water is available. In Niger, the
Departmental and Regional Directorates of Hydraulics disinfected waterpoints in flood-affected areas based on the
study results, providing safe water to 12,232 people. Ministries are institutionalizing geospatial data on groundwater,
and in Niger groundwater management is now officially incorporated in the policy document guiding municipal
development plans.
Conclusion:
Generating evidence on village-level groundwater resources is vital for improved planning and is particularly effective
when paired with training of local actors that are involved throughout the study. Governments are more likely to use the
data when they understand the science and numbers, but also the potential impact it could have on public health,
agriculture, financial resources, and sustainability. Systematic surveying of groundwater exploitation and potential needs
to be continued for more locations in Niger and Burkina Faso, and the data needs to flow down to municipal and local
decision-makers in link with regional and national institutions.

Hand Hygiene Knowledge and Cleanliness Assessment to Inform Alcohol-Based Hand Rub Appropriateness in
Community Settings.
Christiana Hug, Global WASH Epidemiology Team, Waterborne Disease Prevention Branch, Division of Foodborne,
Waterborne and Environmental Diseases, Centers for Disease Control and Prevention
Additional Authors: Evelyn Mugambi, Issac Ngere, Maureen Kesande, Mohammed Lamorde, David Berendes

Background:
Alcohol-based hand rub (ABHR) is an effective way to kill microbes on hands but is less effective when visible dirt is
present. While ABHR is the preferred method in most clinical settings for routine hand antisepsis, it can complement
handwashing with soap (HWS) to improve hand hygiene access in community settings in low- and middle-income
countries. However, specific scenarios for successful ABHR roll-out have not been assessed and may depend on both
individuals’ knowledge of appropriate use of different hand hygiene technologies and present hand dirtiness. We
compared hand dirtiness and knowledge of best hand hygiene practices between community and healthcare settings (as
a reference where ABHR is widely used) and assessed variations between community settings to inform future
considerations for ABHR roll-out.
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Methods:
To quantify hand dirtiness, we used the Quantitative Personal Hygiene Assessment Tool (qPHAT), which collects a hand
swab by tracing a saline wipe in a standardized pattern over one hand. Hand swabs were collected among visitors to 38
community locations (e.g., markets, schools, churches) and healthcare workers (HCWs) in 40 healthcare facilities (HCFs)
in Uganda and Kenya from November 2021–March 2022. Hand swabs were scored by two researchers on a scale from
zero (very visibly dirty) to ten (no visible dirt). Participants were asked, “When hands are visibly dirty, which hand
hygiene technology (HWS or ABHR) should be used, or are both equally effective?” Data was analyzed using SAS to
compare hand dirtiness and hand hygiene knowledge by location type (community vs HCF) and between community
settings.
Results:
Overall, 613 hand swabs were collected: 228 from HCFs and 385 from community locations. Most community hand
swabs were collected at public service offices (n=146, 38%) and markets (n=67, 17%). In Kenya, 332 hand swabs were
collected (129 from HCFs, 203 from community locations). In Uganda, 281 hand swabs were collected (99 from HCFs,
182 from community locations). The median qPHAT scores were equal (median=5), but qPHAT score distributions
skewed towards zero in community locations. In unadjusted analysis, risk of having a qPHAT score less than five (more
visible dirt) did not differ significantly (RR: 1.2; 95% confidence interval: 1.0, 1.4) between location types. Visitors to
churches (median=6) and community-based organizations (median=6) had higher qPHAT scores while visitors at check
points (median=4), rice processing plants (median=4), and markets (median=4) had lower scores overall. In both HCFs
and community locations, HWS was the most common response to the knowledge question (n=191, 83%; n=296, 77%,
respectively), but more respondents selected ABHR in community locations (n=65, 17%) compared with HCFs (n=6, 3%)
(p<0.05). Among community locations, churches (100%) and community-based organizations (90%) had the highest
correct response (HWS) to the knowledge question while lodges (60%) and checkpoints (68%) had the lowest.
Conclusion:
Findings suggest a potential difference in visible hand dirtiness and knowledge of suitable hand hygiene technology
when hands are visibly dirty between healthcare workers and visitors to community locations. ABHR may therefore be
appropriate in community settings alongside educational campaigns to promote appropriate use.

Human Rights Implications of Container-based Sanitation in urban Haiti

Jessica Laporte and Froggi VanRiper, Sustainable Organic Integrated Livelihoods (SOIL)

Health, sanitation, and livelihoods are interrelated human rights and essential components of community wellbeing.
Despite the United Nations recognizing the human right to sanitation, one-third of the world’s population lacks access to
improved sanitation. In Haiti 19% of urban households lack improved sanitation access. Furthermore, in many low- and
middle-income countries like Haiti, urban latrines are excavated manually without physical or regulatory protections.
Container-based sanitation (CBS) has promise as a component of Citywide Inclusive Sanitation (CWIS) in densely
populated, low-resource environments to meet sanitation needs that include protective mechanisms for sanitation
systems and workers.
Before investing in CBS, however, governments and funders require evidence of user acceptance, public demand, and
fair labor aspects of service delivery. To provide this evidence base, we completed 633 interviews with active and former
users of EkoLakay, a CBS service in Cap Haïtien, Haiti. This study used a mixed methodology approach, deriving
qualitative and quantitative data from EkoLakay subscriber records and structured interviews. As one of the longest-
running household CBS services, EkoLakay provides an ideal case for exploring CBS and its role in urban sanitation
systems of low-income cities. Based on household interviews with EkoLakay users in Cap Haïtien, this study addresses
two main research questions:
1) What are the characteristics of households that subscribe to the EkoLakay CBS system?
2) What are the implications of a CBS-integrated urban sanitation system on the exposure risk, labor hours, and
livelihoods of northern Haiti’s bayakou (professionals who manually excavate latrines and cesspits)?
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Through this survey we created a profile of the user base including household demographics, payment patterns, and
sanitation access before and after (for former customers) subscribing to the service. We also compiled and analyzed
secondary data to determine the impacts of widespread CBS expansion in northern Haiti. Results reveal that CBS
presently serves a geographical subset of Haiti’s most resource-insecure residents. Haitian CBS users had above-average
rates of open defecation and limited sanitation access pre-CBS.
In addition, CBS significantly reduces the unsafe handling of untreated excreta in Haiti’s Nord Department, while
doubling livelihood opportunities through safe and dignified jobs.We found that if CBS were to take the place of pit
latrines in northern Haiti, it would replace 1 million hours of unsafe excreta-handling labor annually with 500 safer jobs.
If CBS was only extended to the 20% of Haitian households who currently lack sanitation altogether an additional 100
livelihoods would be created. Many previous international efforts to improve the working conditions of manual
excavators have been deemed unsuccessful and abandoned. While political systems in Haiti and elsewhere lack the
enforcement resources to protect independent workers like the bayakou, CBS services provide a structure compatible
with safety monitoring and worker protection and therefore lead to higher quality livelihoods as employees. While SOIL
does not currently employ bayakou the expansion of CBS services would likely increase the overlap and potential to
transition former bayakou in new, safer sanitation jobs. Given its cost-effectiveness, CBS provides an opportunity to
achieve widespread sanitation coverage by integrating and cross-subsidizing CBS within a CWIS strategy.

Identifying Characteristics Affecting Rainwater Tank Management in Western Kenya Schools

Harnoor Kaur, The Water Project
Additional Authors: Allison Gregory, Iboko Samuel Ngidiwe, Joan Were, Mwandije Victor Daniel, Humphrey Buradi Zadok

Introduction:
Access to clean and reliable water supply in schools has shown to improve education and health benefits for children in
Kenya. However, only 40.9% of public primary schools in Kenya are connected to safe water supplies (WHO and UNICEF,
2020). In Kenyan schools with improved water sources, rainwater harvesting is a common on-site source. The Water
Project (TWP), Western Water and Sanitation Forum, and Friends of Timothy Foundation have been working with
schools in Western Kenya to install rainwater harvesting tanks since 2011. Management of school water points can help
ensure students access clean drinking water, but this topic has not been studied as extensively as community
management. To strengthen understanding of rainwater tank management in rural schools, this study will explore the
following objectives:
Objectives:
To determine the characteristics of rainwater tank management in schools.
To identify challenges to effective rainwater tank management.
To understand the impact of seasonality, multiple water sources on-premises, and school population size on rainwater
tank sufficiency and management.
Methods:
The study has adopted a mixed method-grounded theory research design. Qualitative data will be collected through
focus-group discussions and key-informant interviews with school water managers, school staff, and partner
organization monitoring and evaluation staff. We will collect qualitative data on water management practices, decision-
making practices, and the impact of seasonal anomalies. The quantitative data from Mobi-Water tank sensors and a
short management survey will help us understand water availability, usage patterns, and repairs and maintenance
practices.
Purposeful sampling will be used to gather information-rich cases, primarily criterion sampling. Based on the focus of the
study, the schools recruited will have a TWP-funded rainwater tank (50,000 or 75,000 liters) installed in Lurambi, Hamisi,
Malava, or Mumias East sub-county. Rainwater tanks that do not have a Mobi-Water tank volume sensor installed will
be excluded from the study. TWP has 197 rainwater tanks installed in the study area, and 70 of them have Mobi-Water
sensors.

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TWP will conduct a minimum of twenty focus groups, fifteen key informant interviews, and fifteen short management
surveys to understand the divergent rainwater tank management practices across schools in Western Kenya. The true
sample size (theoretical saturation) might emerge later based on the information gathered. Qualitative data from the
interviews, discussions, and surveys will be analyzed using theoretical coding (memos and code-lists). The characteristics
of school water management revealed through the coding process will then be analyzed with the tank volume data,
which will be used to measure the reliability of rainwater tanks. Logistic regression will be used to explore the
relationships between management characteristics and rainwater tank reliability.
Conclusion:
Overall, insights from this study will help us comprehend how rainwater harvesting systems can be part of a wider
approach to increasing water security in rural schools. Identifying challenges - vandalism, lack of preventative
maintenance, unauthorized use, and seasonal insufficiency - to effective rainwater tank management will help recognize
areas for improvement in design, maintenance system, and monitoring.

Identifying characteristics that lead to a perceived ""modern"" bathroom in the rural Peruvian context
Rebecca Ventura, University of Colorado Boulder
Additional Authors: Amy Javernick-Will

Most households want a toilet for more than the infrastructure; they desire the additional benefits that come with it,
like privacy, safety, and perceived modernness. As households adapt and invest in their sanitation systems through self-
construction, they work to improve the quality of their bathroom and gain these benefits. Therefore, it is crucial to
understand how desired aspects, such as a feeling of having a “modern” bathroom, are realized and how they may
increase improved sanitation use. Yet no previous studies have evaluated what combinations of characteristics lead to a
“modern” bathroom and how benefits are linked specifically to these “modern” characteristics. In addition, as some
households desire sewered bathrooms which are technologically infeasible in the study’s context, it’s important to know
how sanitation can be adapted to provide the same benefits as their ideal “modern” bathrooms. To that end, this study
investigates two questions: What makes a bathroom modern? and How can household sanitation aspirations be met
when the desired modern design is not feasible?”.
To answer these questions, we surveyed 305 households across 9 rural communities near Cascas, Peru and
quantitatively and qualitatively analyzed the responses to 1) identify the bathroom characteristics that are most often
associated with a “modern” bathroom, 2) identify contextual and demographic factors that shape this definition of
modern, and 3) document what benefits are gained from these “modern” characteristics and how current sanitation
systems can be adapted to better meet these modern ideals. At each sampled house, we surveyed either the household
head or spouse and took two pictures of the bathroom. Multilevel logistic regression analyses and qualitative content
analyses were performed to identify local definitions of “modern” and the ways in which modern has been successfully
achieved in the study’s context.
Our results show that, while a majority of the households had improved sanitation systems, most did not have a modern
bathroom. “Modern” bathrooms were most often defined as spaces that have all accessories (sink, shower, and sitting
style toilet). Few households mentioned sanitation system type when discussing modern, and statistical analyses found
sanitation system type to not be a significant predictor of having a “modern” bathroom. This points towards the
possibility of “modern” being achievable independent of the below ground system type.
In this presentation we will discuss the results of this analysis and how identified characteristics can be used to inform
both future adaptable sanitation designs and community-level programming in Peru. We will also invite conference
attendees to discuss and reflect on how modern may be defined in other contexts and how meeting more household-
level sanitation preferences can improve the motivation for, and therefore accessibility of, improved sanitation services.
By the end of the presentation, we hope audience members will be able to 1) identify characteristics that are often
associated with “modern” sanitation, 2) apply the methods described in this study to their own sanitation work, and 3)
reflect on how their own sanitation work could be improved to better meet household preferences for “modern”.

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Impact of an urban onsite sanitation intervention on antimicrobial resistance in flies

Drew Capone, Indiana University
Additional Authors: Drew Capone, Abeoseh Flemister, Victor Ilevbare, Joe Brown

Antimicrobial resistance (AMR) is a serious and growing public health threat. Current predictions suggest that 10 million
deaths annually may be attributable to AMR by 2050. Antimicrobial stewardship and research have historically focused
on clinical settings and animal husbandry, while the environmental transmission of antimicrobial resistance genes (ARG)
due to poor sanitation infrastructure has received less attention.
Synanthropic filth flies – including house flies (Musca domestica) and greenbottle flies (Lucilia sericata) – feed on fecal
wastes. This enables flies to transport antimicrobial resistant organisms and genes from feces to the environment. Safely
managed sanitation may enable improved antimicrobial stewardship by reducing the risk of enteric infections that
require antibiotics for treatments and by preventing the dissemination of ARGs to the environment. Our research aims
were to: (1) assess the impact of an urban onsite sanitation intervention on the number of antimicrobial resistant genes
(ARGs) detected in flies from low-income neighborhoods in Maputo, Mozambique, and (2) to assess if
Enterobacteriaceae isolates from flies expressed phenotypic resistance to ten antibiotics.
We collected flies at compounds which received a shared onsite sanitation intervention and at control compounds that
did not receive the intervention. We used a custom TaqMan Array Card (qPCR) to quantify gene copies specific to 28
ARGs from 168 flies and performed Kirby Bauer Disk Diffusion on 48 Enterobacteriaceae isolates to assess phenotypic
resistance. Compounds enrolled in the trial were not randomized, so we used a difference-in-difference approach to
evaluate the impact of the intervention – the exposure variable – on the number of ARGs detected per fly, which was
the outcome variable in our Poisson regression model.
We detected a mean of 11 ARGs (standard deviation = 4.7) per fly out of the 28 genes measured. Adjusting for
covariates, we found that the intervention reduced the number of ARGs per fly by 31% (aRR = 0.69, [0.52, 0.92])
compared to the control group. The median number of antibiotics that Enterobacteriaceae isolates were resistant to
was three. These results suggest that improving onsite sanitation infrastructure in low-income informal settlements may
help reduce the fly mediated transmission of ARGs to the environment.

Impacts of COVID-19 pandemic on child mortality, health, schooling, and food security in rural Kenya
Julie Powers, UC Berkeley
Additional Authors: Cecilia Nekesa, Blastus Bwire, Katie Liu, Andrew Mertens, Amy J. Pickering

Background:
COVID-19 related lockdown measures and disruptions have affected life in Kenya and throughout the world but impacts
on child health in low- and middle- income countries have not been well documented. Economic impacts (e.g., job
losses) could mean less money available for food and healthcare. However, COVID-19 response measures (e.g., masking,
and social distancing) could have also reduced transmission of infectious diseases. Understanding impacts of the COVID-
19 pandemic on child health, mortality, and schooling is critical for informing response measures.
Methods:
We leveraged a large ongoing study on water treatment and child survival to understand the impacts of the COVID-19
pandemic on mothers and their children in rural Kenya. We used in-person data collected before (N = 34,052, July 2019
to March 2020) and during (N = 12, 068, January 2021 to May 2021) the COVID-19 pandemic to assess impacts on child
mortality, diarrhea, fever, cough, school enrollment, and attendance. We performed modified Poisson regression for
binary outcomes and linear regression for continuous outcomes. For mortality, we calculated hazard ratios using the Cox
proportional hazards model. We followed up with a subset of enrolled women (N = 10,503) by phone during COVID-19
shutdowns (June 2020 to December 2020) and asked respondents about COVID-19 perceptions, behaviors, and
household food security.

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Preliminary Results:
In phone surveys, 94.5% of respondents reported that they would be willing to get vaccinated for COVID-19. When
asked what they would do if they developed any COVID-19 symptoms, most (85.8%) reported that they would seek
medical care, but relatively few (5.6%) reported that they would stay at home/isolate. When asked about measures
taken to reduce the risk of contracting COVID-19, handwashing and masking were most frequently reported. Prevalence
of moderate or severe hunger was higher than that reported in the same study area in 2013.
Considering in-person data, child health improved after the COVID-19 pandemic began. Among under 5 children, 7-day
prevalence of diarrhea decreased from 11.5% to 5.9%, cough decreased from 20.4% to 16.3%, and fever decreased from
8.6% to 7.1%. School enrollment decreased after the pandemic began among children 3-5 years old (pre-primary),
perhaps due to reduced ability to pay school fees or concerns about COVID-19. Changes were statistically significant
(p<0.05) in adjusted models. Full results (including mortality) are forthcoming.
Conclusion:
These results will inform COVID-19 response measures in Kenya as policymakers consider the consequences to-date.
Reduced diarrhea and respiratory illness suggest that COVID-19 response measures such as masking may have
interrupted transmission of infectious diseases and could be used to improve child health beyond the pandemic.
Additional work should be done to understand the mechanisms behind reduced diarrhea and respiratory illness, and
weight these against potential negative impacts (e.g., reduced social stimulation when children are wearing masks).
Decreased school enrollment among pre-primary children could leave children less prepared to start primary school and
suggests the need for potential intervention.

Improving rural water functionality through community-led financial institutions

Chris Prottas, The Water Trust
Additional Authors: Bena Nakabiri, Enock Obwon, Pheona Ayomirwothjamony, Simon Mugume

In 2022, The Water Trust conducted a water point census and functionality survey across three districts in western
Uganda, covering 4,862 publicly accessible water points. The study population of interest consisted of all protected and
unprotected water sources reported by local village chiefs as sources for drinking water across Masindi, Kiryandongo,
and Kikuube districts. This study provides insight into limitations in the quality and completeness of government data
rural water sources, as well as a descriptive comparison of water points with and without a Self-Help Group (SHG).
Ministry officials acknowledge challenges with maintaining the water atlas. This study finds significant variances related
to these challenges. For example, Kikuube District reports the highest rural water functionality rate of the three districts,
reporting 93% rural water functionality across 890 domestic water sources. The Water Trust identified 1,587 protected
water sources in the district, with only 58% having water available. Across the district’s, observed functionality was
lower than reported functionality, with a larger number of water sources present than recorded. In addition, the
survey’s area of focus included Masindi and Kiryandongo districts, where The Water Trust has trained SHGs to improve
water point management and availability of funds for maintenance and repair. SHGs are savings and credit cooperatives
formed in a water point catchment that maintain a reserve fund to pay for water point maintenance and repair, as well
as provide general access to savings and credit. These groups support water points both constructed by The Water Trust
as well as water points constructed by third parties, including government and NGOs. This survey allowed for
comparative analysis of water points with and without SHGs in the same region across a number of measures related to
water point functionality and reliability, water point management composition and behaviors, as well as funds available
for repairs. Of protected water points without SHGs, the survey found that across the three districts 58% to 67% had any
water available at the time of the survey, and 57% to 61% were functional. Of the 744 water points with a SHG in
Masindi and Kiryandongo districts, 92% to 96% had any water available and 90% to 94% were functional. The latter
water points also reported significantly more active water point management and funds available for water point repair.
For example, more than 90% of water points had a committee with funds available for repair, had records of fees
collected, and completed at least one water point management task in the past year. Of water points without SHGs, less
than one-third achieved these outcomes. The results suggest additional investment is needed in improving government
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capacity to monitor rural water access and functionality, and that SHGs may be effective in addressing the institutional
and financial vacuum that constrains water point maintenance and long-term functionality.

Improving the lives of older people - Understanding barriers to inclusion of older people with incontinence in
humanitarian WASH programming
Jamie Myers, Institute of Development Studies
Additional Authors: Diana Hiscock, Marion Staunton, Michelle Farrington, Caroline Muturi, Amita Bhakta

Incontinence is a complex health issue involving lack of bladder and bowel control. Many older people struggle with
incontinence, needing more privacy, access to facilities and time for daily hygiene activities. Reduced mobility may lead
to problems accessing latrine facilities safely and urgently. There is limited sector awareness of the scope and
implications of the problem, and a dearth of evidence to guide appropriate responses. To address this, the aims of the
research were to:
1. Investigate how the WASH sector can better engage with and support people with incontinence
2. Identify the needs and priorities of people with incontinence
3. Understand coping mechanisms
Field work was undertaken in Gambella, Ethiopia, and in Blantyre, Chicwawa and and Nsanje, Malawi, by staff from
Oxfam, HelpAge and the Malawi Network of Older Persons' Organisations (MANEPO) . Data collection methods included
focus group discussions (9 in Malawi and 13 in Ethiopia), small group discussions led by older people (5 in Malawi and 3
in Ethiopia), household visits and facility audits (18 in Malawi and 18 in Ethiopia), key informant interviews (5 in Malawi
and 6 in Ethiopia) and quantitative needs assessments (41 in Malawi and 39 in Ethiopia).
Data collected was added to a standardized research summary sheet before being coded using NVivo. Workshops in
both Ethiopia and Malawi were held with WASH, Health, and Protection stakeholders to share findings and discuss
potential actions.
Key findings included:
- Very few informants interviewed in Ethiopia had heard of the term or considered incontinence within the context of
the refugee camps. In Malawi, it was seen by many of the health professionals interviewed as a chronic problem for
which there was little that could be done.
- Incontinence has a psychological impact on older people and their caregivers. Suicide was mentioned frequently as a
result of incontinence and neglect, and many caregivers noted feelings of guilt and loneliness.
- Coping mechanism include using cow skins as mattress protectors, using available containers as make-shift bed pans
and urinals; using pieces of cloth in underwear and piles of blankets to protect bedding and clothes from leaks; regularly
changing clothes and bedding when they have leaks, resulting sometimes in not having clean clothes or bedding to use.
Also withdrawing from society, not leaving the house, and not socializing with others.
- In both Chichewa and Nuer languages there is no word for incontinence, while in Ethiopia being bed-bound was often
used interchangeable with being incontinent.
- Older people living with incontinence recommended their situation would be improved by improved access to WASH
facilities, non-food item and food items, financial support and assistive products alongside training for caregivers,
psychological support for those living with incontinence and caregivers, palliative care and increased awareness to
change attitudes of those within their communities.
To conclude, living with incontinences without appropriate support creates multiple barriers to maintaining
independence, dignity, psychosocial wellbeing and an active role in family and community life and in many cases leads
to increased stigma, discrimination, and exclusion.

Improving WASH in Health Care Facilities: An assessment of the STREAMS innovation in Northern Malawi
Sean Irwin, Royal Roads University
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Additional Authors: Victoria Cuellar; Nancy Gilbert; Braimah Apambire; Daniel Nyirenda; Flument Mkinga

Background:
Improving WASH in health care facilities (HCFs) in the global South is critical for reducing the spread of hospital acquired
infections, which can include Ebola and Covid-19, and has an outsized role in improving women’s health. Despite an
emergent literature on the challenges of poor WASH in HCFs, few comprehensive approaches have been devised,
implemented, and rigorously evaluated.
In response to this problem, the STREAMS (Systems, TRaining, Empowerment and Monitoring Support) innovation was
developed; a holistic approach to addressing the technical and behavioral barriers that limit the availability of good
WASH in HCFs. STREAMS uses a paired circuit rider (CR) approach, one technical CR and one quality of care CR, to
provide WASH training, monitoring and services to HCFs on a monthly basis in a designated region. The approach is
designed to be low cost, comprehensive, and sustainable.
In 2021 the STREAMS innovation was implemented in Rumphi district, Malawi, in tandem with a project to assess its
efficacy. The objective of this presentation, therefore, is to present the findings of the research and outline lessons
learned from a complex intervention to address WASH challenges in HCFs in low asset settings.
Methods:
This study uses pre and post implementation data from the target region of Rumphi district and the neighboring district
of Nkhata Bay to serve as a control. Baseline data collection in June 2021 consisted of in-person surveys with patients
(n= 134, convenience sample), guardians – people who stay at HCFs and care for friends or family members who are
patients (n= 121, convenience sample), staff (n= 80, random sample), and managers (n= 18, complete sample) from the
18 HCFs in Rumphi district. A similar number were carried out with the same groups at the 21 HCFs in Nkhata Bay.
Endline data collection in June 2022 will collect a similar number of surveys from the same groups along with key
informant interviews.
Results:
Due to the pre-post nature of the study, details on the efficacy and sustainability of the program will only be clear after
data collection and analysis is conducted over summer 2022. However, preliminary work has revealed a significant
dearth of functioning WASH systems and WASH knowledge. Key barriers are related to lack of assets and governance,
and effects and perspectives differ somewhat across groups (women/men, able bodied/disabled and others).
Implementation has led to changes in the availability of water, training (cleaning, handwashing, waste disposal), and
management tools (job descriptions, task management skills), but to what degree these have driven improved
outcomes, and if they will be sustained, is yet to be determined.
Conclusion:
This research is one of the first attempts, we are aware of, to empirically evaluate the efficacy of a comprehensive
WASH improvement program for health care facilities in low-asset settings. It will provide insight into pathways to good
WASH and thus improve the health of women, men, and communities. Furthermore, the research contributes to our
understanding of complex system interventions, which are increasingly recognized as necessary for development
interventions in WASH and beyond.

Inclusive and sustainable sanitation in African cities - interpretation, barriers and opportunities
Kondwani Chidziwisano, WASHTED, Malawi university of Business and Applied Sciences
Additional Authors: Kondwani Luwe; Rebecca Sindall; Hans C Komakech; Annatoria Chinyama; Huda Lohiya; Tracy Morse

Background:
Sub-Saharan Africa’s (SSA) urban population continues to grow and will double by 2050. This anticipated increase will
pose tremendous strain on cities, which already have poorly resourced sanitation services. To address this current and
impending challenge, issues of inclusion and sustainability in sanitation programmes have become paramount. However,
as experts in the field advocate for interdisciplinary or multi-sectoral approaches in the development of sanitation
solutions, challenges are arising where actors have different understandings of the concepts of inclusion and
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sustainability. This research was aimed to examine current perceptions of inclusion and sustainability of sanitation
stakeholders in sub-Saharan African cities in Malawi (Blantyre), Tanzania (Arusha and Dar es Salaam), Zimbabwe
(Bulawayo), and South Africa (Durban).
Methods:
The study was a cross sectional which mainly utilized qualitative methods. A total of 78 WASH professionals involved in
urban sanitation in the identified cities were interviewed using a standardized tool across all sites. Individuals were
recruited through purposive sampling and represented local donors, private, public, non-governmental, civil society and
academic stakeholders in urban sanitation. Data was analyzed using NVIVO version 12, where themes were identified
and coded to reveal any trends in responses.
Results:
Definitions for sustainability and inclusion were shown to be context specific with observed differences between
countries and sectors. Three main interpretations of inclusion were emphasized: (1) a holistic approach to sanitation, (2)
the engagement of all stakeholders, and (3) consideration of different groups (e.g., women, people with disabilities and
the poor) in sanitation. Catch phrases used in defining inclusion i.e., “leaving no one behind” or “everyone” took away
focus on the specifics of who should be included, why and how. Definitions for sustainability generally revolved around
the term’s “longevity” and “continuity” of sanitation programs, with all three of the pillars of sustainability (economic,
social & environment) being referenced. The three pillars of sustainability also gave rise to differences in interpretations
for sustainability; especially where different countries, organizations or sectors emphasize different aspects in coming
up with urban sanitation solutions in reference to their priorities. Political barriers (e.g., political interference and
corruption), private sector involvement, social (e.g., community involvement and education) and environmental
(reducing, reusing, and recycling) opportunities were said to have significance in the achievement of urban sanitation
that is both inclusive and sustainable.
Conclusion:
The study provided a baseline interpretation of inclusion and sustainability on the ground; revealing potential loopholes
and issues to be considered in actualization of inclusive and sustainable urban sanitation. Differences in interpretations
that may result from differences in professional backgrounds, country or sector priorities should be anticipated. An
approach to inclusive and sustainable urban sanitation where stakeholders in different projects meet and discuss what
these terms mean beforehand is paramount, ensuring use of agreed language, and allowing for contextualization as
appropriate.

Influence of community-level sanitation coverage on environmental fecal contamination and child health in rural
Bangladesh
Jesse Contreras, University of Michigan
Additional Authors: Mahfuza Islam, Andrew Mertens, Amy J. Pickering, Laura H. Kwong, Ayse Ercumen

Background:
Household-level sanitation interventions have had limited effects on child health or environmental contamination,
potentially due to low community coverage. Higher community-level coverage with safely managed sanitation can
reduce opportunities for disease transmission.
Methods:
We estimated associations between community sanitation coverage, environmental fecal contamination, and child
health among 360 compounds in the control arm of the WASH Benefits trial in rural Bangladesh (NCT01590095). In each
compound, we enumerated E. coli in environmental samples and recorded the 7-day prevalence of caregiver-reported
diarrheal disease and acute respiratory infections (ARI) in children under five. We observed indicators of latrine access
and quality among all neighboring compounds within 100 m of study compounds. We defined community coverage as
the proportion of neighboring compounds with (1) at least one latrine, and (2) exclusively hygienic latrines (improved
facility observed to safely contain feces), within both 50 m and 100 m of study compounds. We assessed effect
modification by population density and season.
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Results:
Adjusted for confounders, study compounds surrounded by 100% coverage of at least one latrine per compound within
50 m had slightly lower log10 E. coli counts in stored water (∆log = -0.13, 95% CI -0.26, -0.01), child hand rinses (∆log = -
0.13, 95% CI -0.24, -0.02), and caregiver hand rinses (∆log = -0.16, 95% CI -0.29, -0.03) and marginally lower prevalence
of diarrheal disease (prevalence ratio [PR] = 0.82, 95% CI 0.64, 1.04) and ARI (PR = 0.84, 95% CI 0.69, 1.03). Effects were
similar but less pronounced at 100 m. At higher population densities, community latrine coverage was associated with
larger reductions in E. coli on caregiver hands and prevalence of diarrheal disease. Coverage with exclusively hygienic
latrines was not associated with any outcome.
Conclusion:
Higher community sanitation coverage was associated with reduced pathogen transmission, with stronger effects at
highly local scales (50m) and at high population densities. Our findings indicate that the relationship between
community sanitation coverage, environmental contamination, and child health varies by definition of coverage,
distance, and population density. More research is needed to uncover relevant sanitation coverage metrics across
different scales of community.

Integrating WASH and Nutrition for maximum, cost-effective impact on stunting

Joke Le Poole, Max Foundation
Additional Authors: Remco Geervliet, Riad Imam Mahmud, Kazal Ahidul Islam

Background:
Due to COVID-19 related disruptions, there could be an additional 2.6 million stunted children in the world by 2022
(Osendarp et al., 2021). Using the most cost-effective approaches to reduce undernutrition in children under 5 therefore
has renewed relevance. However, there are few programmes that report data on their cost effectiveness, meaning
research is largely based on theoretical estimates. We use data from Max Foundation’s integrated Healthy Village
approach (WASH, nutrition, and essential mother/childcare) in Bangladesh to estimate its cost effectiveness and
contrast it with other estimates.
Methods:
The programme collected 355,000 anthropometric measurements on 77,000 children over a 3-year period. Though a
participatory approach was used for data collection, there are no strong signs of bias in the data, and over 80% of
children in the area were included in the study.
To calculate cost-benefit ratios, we used the methodologies of Galasso & Wagstaff (2019) and Hoddinot et al. (2013).
Both calculate country-level cost-benefit ratios using a list of high-impact nutrition interventions based on Bhutta et al.
(2013). They discount future earnings from employment to their net present value and compare this with
implementation costs. Following their procedures with our programme data, we create cost-benefit estimates that can
be directly compared to the ones provided in these papers.
Results:
The stunting rate in our dataset halved from 51% to 25%, meaning that around 19,000 children moved from being
stunted to healthy growth. Considering non-stunted children are expected to see their lifetime earnings increase by
15.8%, this translates into a total economic benefit of over €280 million. Set against the programme’s cost (€9 million)
the cost-benefit ratio is 29:1, 25% higher than Galasso & Wagstaff’s (2019) estimate of 23:1.
Hoddinot et al. (2013) follow a different methodology but find a similar cost-benefit ratio of 18.4:1. As they assume a
larger increase in income from not being stunted, taking this increase into account almost doubles the ratio of the
Healthy Village approach to 36.5:1.
These findings stand in stark contrast with Pickering et al. (2019) and show not only that integrating in particular WASH
with nutrition leads to further improvements in child health, and also improves cost-effectiveness by between 25 and
100%.
Conclusions:

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How can we cost-effectively ensure a healthy start in life for every child? Our data show the cost-benefit ratio of an
integrated WASH-nutrition-care approach to be between 25 and 100% higher than single-focus interventions. Even
though integrated interventions are, unsurprisingly, more costly, they are better able to tackle the multifaceted root
causes of stunting.
Donors and practitioners alike should identify and scale the most cost-effective approaches to maximise their impact.
Sometimes complex problems need multipronged solutions, and we show that the exponential increase in impact makes
this added investment worthwhile in tackling undernutrition (stunting) in children under 5.
References:
Bhutta, Zulfiqar A, Jai K Das, Arjumand Rizvi, Michelle F Gaffey, Neff Walker, Susan Horton, Patrick Webb, et al. 2013.
“Evidence-Based Interventions for Improvement of Maternal and Child Nutrition: What Can Be Done and at What Cost?”
The Lancet 382 (9890): 452–77.
Galasso, Emanuela, and Adam Wagstaff. 2019. “The Aggregate Income Losses from Childhood Stunting and the Returns
to a Nutrition Intervention Aimed at Reducing Stunting.” Economics & Human Biology 34: 225–38.
Hoddinott, John, Harold Alderman, Jere R Behrman, Lawrence Haddad, and Susan Horton. 2013. “The Economic
Rationale for Investing in Stunting Reduction.” Maternal & Child Nutrition 9: 69–82.
Pickering, Amy J, Clair Null, Peter J Winch, Goldberg Mangwadu, Benjamin F Arnold, Andrew J Prendergast, Sammy M
Njenga, et al. 2019. “The WASH Benefits and SHINE Trials: Interpretation of WASH Intervention Effects on Linear Growth
and Diarrhoea.” The Lancet Global Health 7 (8): e1139–46.

Inter- and intra-rater reliability of handpump functionality field tests in Uganda

Daniel W. Smith and Samantha Wind, Stanford University (now at USAID)
Additional Authors: Igor Markov, Stephen Atwii Ongom, Jennifer Davis

Background and problem statement:

One fourth of rural drinking water points in sub-Saharan Africa, and over 40% in some countries in Asia and the Pacific,
are not working, negatively affecting health. Growing awareness of this sustainability problem has motivated increased
attention to validly and reliably measuring water point functionality. Yet the most widely used indicator of water point
functionality, whether it provides water, does not produce consistent measurements. Nor does it generate actionable
information for water points deemed functional. Objective, reliable, and diagnostic indicators would enhance the
comparability and actionability of water point functionality data in research and practice. We focused on handpumps,
the most common rural water infrastructure in sub-Saharan Africa and South Asia.
Objective:
We aimed to determine the inter- and intra-rater reliability of three physical tests of handpump functionality: pump
capacity (volume discharged per pumping cycle), 10-minute leakage rate (volumetric loss from the pumping column),
and flowrate (volume obtained per unit time). One person equipped with a stopwatch and a 20-liter container can
complete the tests for one handpump in 15 minutes. The reliability of these tests when conducted by different people
and repeatedly by the same person is unknown.
Methods:
We conducted the study on 60 boreholes with India Mark II handpumps across two districts in northern Uganda. The
same three or four raters each conducted the tests three times on 28 handpumps selected for convenience. Different
sets of four or five raters each conducted the tests once on 32 handpumps representative of the districts. Intraclass
correlation coefficients (ICCs) were estimated to indicate inter-rater reliability using two-way random effects and one-
way random effects models for the sets of 28 and 32 handpumps, respectively. ICCs were estimated to indicate intra-
rater reliability using two-way mixed-effects models. Following convention, ICC values less than 0.5, between 0.5 and
0.75, between 0.75 and 0.90, and greater than 0.90 were interpreted to represent poor, moderate, good, and excellent
reliability, respectively.
Results:

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Ten-minute leakage rate had the highest inter-rater reliability, followed by pump capacity and flowrate. ICCs for 10-
minute leakage rate indicated good to excellent inter-rater reliability (0.79-0.98) (p<0.05). ICCs for pump capacity
indicated moderate to good inter-rater reliability (0.68-0.87) (p<0.05). ICCs for flowrate suggested moderate inter-rater
reliability (0.54-0.62) but were not significantly greater than 0.5. Intra-rater reliability for all tests was good to excellent
(0.87-0.99) (p<0.05).
Conclusions:
Ten-minute leakage rate and pump capacity are reliable measurements of handpump functionality that provide more
actionable information than the conventional binary indicator. Ten-minute leakage rate may detect leaks before they
cause complete failure. Pump capacity indicates wear in pump components over time. Based on our results, we propose
that 10-minute leakage greater than 200 mL/minute and pump capacity less than 200 mL/stroke indicate urgent need
for repair. These two quick and simple tests can be standardized in preventive maintenance services, surveys,
crowdsourced datasets, and as outcomes in research to enhance the objectivity, comparability, and value of handpump
functionality measurements. Handpump flowrates measured by different people are unreliable and should be
interpreted with caution.
Investigating Temporal and spatial variability of GHG emissions from on-site sanitation systems in Senegal
Baba Ngom, Ecole Polytechnique de Thies
Additional Authors: Mamadou Matar Dramé, Rose Dianga Tine, Olivia Reddy, Nathalie Andre, Guy Howard.

Senegal is on the western coastline of Africa, bordering the Atlantic Ocean from 12 to 17 °N. It has a tropical climate
with pleasant heat throughout the year with well-defined dry and humid seasons that result from northeast winter
winds and southwest summer winds. The country experiences a dry season from November to May dominated by a
northeastern wind pattern, and a wet season from June to October with a southwesterly wind pattern. rainfall increases
substantially farther south, exceeding 1,500 mm (59.1 in) annually in some areas. As well as being susceptible to the
impacts of precipitation and temperature changes caused by climate change, Senegal is vulnerable to sea level rise,
groundwater level variability.
All these temporal and spatial changes may have great impact in greenhouse gas emissions from onsite sanitation
systems. The proportion of these systems is significantly higher in low– and middle– income countries (LMICS) in
comparison to the global average, for instance in Senegal it represents over 80% of used sanitation systems. The
widespread use of on-site sanitation system provides one example showing the importance of deepening our
understanding on factors influencing GHG productions in such sanitation facilities.
In this work we study impacts of climate (temperature) and geophysical characteristics on GHG emissions. 20
households were selected in two different Senegalese cities (Tivaouane and Kaolack), and an initial survey to collect data
related to onsite sanitation system typology, design and management were conducted. After that, direct analysis of
containment effluent and gas emissions were operated using flux chamber. These measurements were made in four
different seasonal contexts: [1] Middle of the dry season (~ March), [2] end of the dry season (~ June), [3] middle of the
rainy season (~ August), and [4] end of the rainy season (~ November). It is planned to choose 10 sanitation facilities
located in low land and 10 others in high land.
The preliminary results showed that Senegalese households use almost similar design and management of sanitation
systems. Interestingly, a high variability of gases compositions and emissions rate were recorded over time and space.
This ongoing study will identify the main factors associated with GHG emissions from on-site sanitation systems. To our
knowledge this study design is the first of its kind that is applied in western Africa to investigate the impacts of climate
and geophysical characteristics on GHG emissions in on-site sanitation systems. The results of this study will be
instrumental to better inform policy makers and program designers to reduce GHG emissions.

Investigating the efficacy of commonly used handwashing methods against enveloped and non-enveloped viruses
Claire Anderson, Stanford University
Additional Authors: Jingyan Tong, Winnie Zambrana, Alexandria Boehm, Marlene Wolfe

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Respiratory infections and diarrheal diseases are two leading causes of death worldwide. Handwashing with soap and
water is a well-established intervention and has been proven to reduce both pathogen concentration on hands and the
incidence rate of many diseases, including respiratory diseases like COVID-19. Despite this, limited resources among
people in low- and middle-income regions, people in remote areas, refugees, internally displaced people, and those
experiencing homelessness, may prevent individuals from using handwashing methods recommended by the CDC or
WHO (soap and water for 20+ seconds). When handwashing with soap and water for 20s is not feasible, individuals may
turn to handwashing alternatives. Some alternatives, like using alcohol-based hand sanitizer (ABHS), are well
characterized for bacterial and non-enveloped virus removal. However, there are many alternatives which are
understudied, particularly for enveloped virus removal. The aim of this study is to evaluate the efficacy of handwashing
alternatives, including washing with water only, washing with soapy water, washing for a short duration, using alcohol-
based hand sanitizer (ABHS), and washing with towels against enveloped and non-enveloped viruses. To evaluate the
efficacy of the handwashing methods, we seeded MS2 (a non-enveloped virus) and Phi6 (an enveloped virus) onto the
hands of 26 volunteers who then used a handwashing method. Viruses remaining were recovered and quantified using
culture-based methods and molecular methods to determine the log reduction value (LRV) after washing. Friedman
tests followed by post-hoc tests (Wilcoxon signed-rank tests with a Bonferroni correction) were used to determine if
there were any significant differences in LRVs between the 12 handwashing methods studied. A significance level of 0.05
and 80% power were used to determine significant results. Results indicated that washing with water only and with
soapy water were like washing with soap and water for 20 s for both viruses. Most towel alternative conditions had LRVs
significantly smaller than LRVs from washing with soap and water for either virus. LRVs of ABHS and soap and water for
5 s were similar to soap and water for 20 s for Phi6, but less for MS2. Additionally, LRVs determined using molecular
methods were in agreement with those obtained using culture-based methods. This study provides foundational data to
ensure handwashing promoted in humanitarian crises is effective for important outbreak diseases. These results show
that some handwashing alternatives were as efficacious as recommended methods while others were not and inform
both recommendations and future research on handwashing alternatives in low resource settings.

It's like there's salt in the water: African Immigrants' Knowledge, Attitude and Practices around Water Quality in
North Carolina, USA
Love Odetola, University of North Carolina Greensboro
Additional Authors: Sharon Morrison

Background:
Exposure to lead has been linked to a variety of irreversible poor health outcomes, including lower IQ. Black children,
including African immigrant children, are almost three times more likely to have elevated blood-lead levels, when
compared to white children.
Aim:
This pilot study seeks to qualitatively assess African immigrant participants’ knowledge, perceptions and practices
around their tap water quality and lead exposure.
Methods:
We used a multistage approach that included delineation of immigrant-rich neighborhoods, community engagement for
recruitment and citizen science approaches to increase response rate. We have conducted semi-structured interviews
with 8 African immigrant households. We will be interviewing 10-15 more households during summer 2022. These
additional interviews will be analyzed via Inductive & Deductive Data Analysis, incorporating Ziebland & McPherson’s
‘One Sheet of Paper’ analysis method.
Results:
Thus far, we have identified a knowledge gap on lead exposure, mistrust of tap water and health-compromising
practices among African immigrants.
Implications:

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Community-based methods are allowing us to overcome the current gap in knowledge of household-level lead levels,
thereby opening new horizons for more effective interventions and policies aimed at reducing exposure to lead among
African immigrant populations.

Leveraging Village Savings and Loan Associations (VSLAs) to collect water user fees in rural Uganda
Caroline Delaire, The Aquaya Institute
Additional Authors: Katherine Marshall, Allan Mutegeki, Rachel Peletz, Ranjiv Khush

Background:
In rural Uganda, poor transparency and repeated misuse of community water point funds erodes trust in and authority
of voluntary management committees tasked with collecting user fees. Water users hesitate to make regular payments
to committees that have largely proven ineffective. Most rural communities are therefore left unable to pay for water
point repairs and can face extended periods without service. Village Savings and Loans Associations (VSLAs) are
community-based groups primarily intended to allow members to save money and access low-interest loans. VSLAs
typically have robust accountability mechanisms that reinforce trust among members.
Research objective:
We hypothesized that VSLAs would be more effective than existing committees at collecting and managing water fees.
This study evaluated VSLAs in ten communities of Kabarole District, Uganda.
Methods:
In January 2021, we rehabilitated ten shallow well handpumps and supported water users to form VSLAs with a
dedicated savings account for water system management, called the “water fund.” VSLA members committed to make
monthly contributions to the water fund. We then collected information on VSLA members and data on monthly
financial transactions for approximately one year. We also conducted in-depth qualitative interviews with 290 VSLA
members, non-members, community leaders, and local government officials at baseline and eight months after the
beginning of the intervention. This study was funded by the Conrad N. Hilton Foundation and implemented in
consultation with Kabarole’s District Water Office.
Results:
VSLAs had 54–92 members (median=68). A majority of members (median=76%) deposited savings each month, and
VSLAs gave out 69–233 loans in the first annual cycle, indicative of vitality. Contributions to the water funds were
reasonably regular (35–95% of members each month) and almost tripled in the last month of the annual cycle.
Over the first 12-month cycle, the VSLAs collected an average of 149 USD in water funds (range: 83-218 USD), an
amount typically enough to cover annual handpump maintenance expenses. During this first annual cycle, several
groups appropriately used water funds for source protection measures, such as fencing (n=9) and minor handpump
repairs (n=2). Qualitative data revealed instances where water point management committees effectively collaborated
with VSLAs to increase community motivation for maintenance. After using VSLAs to manage fees, communities felt
more confident in their ability to quickly pay for water point repairs when needed.
Size and membership composition of VSLAs did not seem to influence performance, which was likely driven primarily by
communities' income levels. Regular third-party financial audits likely promoted accountability and helped dissuade
fears of misappropriation. All the ten VSLAs have rolled into a second annual cycle.
Implications for policy and practice: The largely positive study results speak in favor of innovative approaches to collect
water user fees in rural Uganda. Given these findings, the Kabarole District Water Office has decided to replicate the
approach in 25 additional communities.
Learning objectives:
1) Share the practical modalities of using VSLAs to collect water user fees.
2) Demonstrate how innovative financial approaches can more effectively elicit regular payments when the ""pay-as-
you-fetch"" model falls short.

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Leveraging Water and Sanitation for Health Facility Improvement Tool (WASH FIT) to establish five model healthcare
facilities— Kabarole District, Uganda
Carrie Ripkey, CDC Foundation
Additional Authors: Martin Watsisi, Ayoreka Mary Concepta, Moses Asiimwe, Victoria Trinies, Matt Lozier

Background:
Proper water, sanitation, and hygiene (WASH) in healthcare facilities (HCFs) is essential for provision of safe healthcare.
However, recent global assessments indicate large gaps remain in WASH infrastructure and services in HCFs, particularly
in low-and-middle-income countries. The WASH Facility Improvement Tool (WASH FIT) is one promising method to
address these gaps through empowering facilities to identify challenges and develop strategies to meet WASH
standards. To better understand the impact of this approach, we aim to analyze 1) changes in WASH status associated
with implementing WASH FIT and 2) acceptability of this approach as part of the formation of five model HCFs in
Kabarole District, Uganda.
Methods:
In August 2021, five Health Center IIIs in Kabarole District, Uganda, providing basic in- and out-patient services, were
selected to serve as model facilities to promote learning throughout the district and a district WASH FIT team was
formed and trained on WASH FIT methodology. In September 2021, the district team conducted baseline assessments at
each model facility using a modified WASH FIT assessment. The team then supported formation of facility WASH FIT
teams comprised of the in-charge, IPC focal person, WASH technician, a member of Health Unit Management
Committee (HUMCs), and maintenance/cleaning personnel. Facility and district WASH FIT teams used baseline
assessment results to develop five Facility Improvement Plans to address prioritized gaps within each domain. Facilities
then carried out improvement activities in line with their respective plans. Follow-up WASH FIT assessments of these
model HCFs were completed in January 2022. We used paired sample t-tests to compare baseline average scores for the
7 WASH FIT domains from all five model HCFs with follow-up scores. This was complemented by review of associated
planning and program documents, including meeting minutes and training reports, to explore acceptability.
Results:
Baseline data showed that among model facilities, average scores were the highest in management and workforce
(mean=80%) and energy and environment (mean=75%) domains, with environmental cleaning (mean=48%) and hand
hygiene (mean=27%) scoring lowest. At the four-month follow-up, average scores improved in 5 of 7 domains and
decreased in two domains. The average hand hygiene domain score increased from 27% (standard deviation (SD)=9%) at
baseline to 50% (SD=17%) at follow-up (p=0.025). Changes in the other 6 domains were not statistically significant at
α=0.05. Review of planning and program documents indicated positive perception of WASH FIT along with increased
motivation of HUMCs to make requisite changes.
Conclusion:
The modified WASH FIT approach implemented in five model HCFs identified gaps in WASH services and management,
particularly in hand hygiene, informed Facility Improvement Plans, and documented a significant improvement in hand
hygiene services. The methodology has been well received by facility and district partners, showing promise for
improving WASH status at primary HCFs in Kabarole District. Additional planned work in 2022 includes continued repeat
use of WASH FIT Assessment to monitor performance and sustainability of improvements at model HCFs as well as
conducting in-depth interviews with relevant actors to better understand how contextual factors impact
implementation and WASH status changes.

(Mis)Perceptions of Tap Water for Home Medical Devices – PNView 360+ Survey, United States, August 2021
Shanna Miko, U.S. Centers for Disease Control and Prevention
Additional Authors: WDPB PN View 360+ Workgroup

Background:

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Seven million waterborne-related infections occur in the US each year. Tap water that is safe to drink is not sterile.
When used for medical purposes (e.g., nasal irrigation) unsterile tap water can result in infections from high
consequence waterborne pathogens like nontuberculous mycobacteria and free-living amebae. We examined
population perceptions of water sterility and use of water at home.
Methods:
Porter Novelli Public Services and ENGINE Insights administered the PN View 360+ survey (August 2021, n=1,004 US
panel members aged ≥18 years). The survey was weighted to be representative of the US population by gender, age,
region, race/ethnicity, and education. We used weighted SAS survey procedures to assess proportions of response
variables by demographics. We tested associations of responses with demographic variables using Chi-square tests and
used post hoc Wald F tests to compare subgroups for demographic variables with more than two levels.
Results:
Most respondents (62.9% (95% CI: 59.8–66.1)) answered that “sterile water” means absence of bacteria or living
organisms, 32.9% (30.0–36.2) agreed tap water does not contain bacteria or organisms, and 26% (23.1–28.9) answered
that water filters sterilize water. More than half (62.4% (58.9–65.8)) agreed tap water could safely be used for sinus
rinsing, 50.1% (46.5–53.6), for rinsing contact lenses, and 41.5% (37.9–45.1), for filling medical respirator devices and
humidifiers. When asked about usage, 24% (21.2–26.8) reported filling respiratory devices, 12.7% (10.6–14.9) rinsed
their sinuses, and 8.9% (7.0–10.7) rinsed their contact lenses with tap water.

Conclusion:
Tap water is commonly misperceived to be sterile and used for home medical purposes. Clear messaging and
educational campaigns could improve public knowledge and help healthcare providers communicate recommendations.
Improved communications and awareness may help reduce high consequence infections associated with non-sterile
water for home medical uses.

Market Based Sanitation Implementation Approach to Unlock Household Investment in Basic Sanitation in Rural
Uganda
Patricia Namakula, USAID - Uganda Sanitation for Health Activity (USHA)
Additional Authors: Jonathan Annis

Despite steady progress eliminating open defecation, only 20% of households in Uganda have access to basic sanitation,
a figure that is largely unchanged over the past 20 years. The country is well off track to meet their national
development goal of 40% of the population having basic sanitation by 2025. Historically, market-based sanitation
interventions have achieved low levels of product uptake and scale in sub-Saharan African contexts.
In early 2019, the USAID Uganda Sanitation for Health Activity (USHA) applied key intervention themes described within
the Ministry of Health’s National Sanitation Market Guidelines for Basic Sanitation (NSMG) to design a novel
intervention aimed at increasing household investment in basic sanitation in two priority customer segments. Coined
the Market Based Sanitation Implementation Approach (MBSIA), the intervention has since been refined and rolled out
in 13 districts in the Central and Eastern regions, targeting 219,843 households within 1,958 villages. MBSIA is broadly
defined as facilitated community collective action that encourages household investment in basic sanitation products
delivered through a network model characterized by sales agents linked with capable masons and supported by local
government structures.
USHA’s robust M&E system captures household baseline sanitation status and longitudinally tracks the processes that
underpin the intervention. The database currently has over half a million household records with more data being added
daily. We also conducted over 800 learning visits with actors involved in the model (masons, sales promoters,
households, hardware stores) to gather qualitative information about how and why the model was working, or not. An
endline survey done with each household that makes an investment captures information including attendance at
community sensitization meetings, interactions with sanitation promoters and masons, access to products, engagement
of women in decision making processes, among other variables.
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As of 7 March 2022, the model has resulted in the unsubsidized construction or upgrade of over 64,000 basic toilets and
a total household investment of over five million USD, nearly three times what USHA has invested in rolling out the
intervention. Using data through September 2022, the results section of the presentation will focus on both qualitative
and quantitative aspects of MBSIA implementation, including the a) overall impact of the model in terms of number and
types of toilets constructed b) level and household investments c) varying effectiveness of the model across geographic
scales and customer segments and d) household engagement with the value chain actors.
MBSIA has proven that a rural sanitation intervention that uses customer segmentation and value chain insights within
the government of Uganda’s NSMG (i.e., product design, use of sales agents, a network delivery model), coupled with a
robust a M&E system that can longitudinally capture household interaction with value chain actors, can unlock
substantial household investment in basic sanitation. USHA’s experience offers the government of Uganda and other
implementers a roadmap that can be applied to other market segments to accelerate progress towards achieving
national and international goals for basic and safely managed sanitation.

Measurement of Human-Environment Behaviors and Fecal Contamination for Assessing Risk of Cholera in Urban
Kenya
Cecilia Mbae, Kenya Medical Research Institute
Additional Authors: Aniruddha Deshpande, Habib Yakubu, Sam Kariuki, Christine Moe

Cholera is endemic in Kenya and the East Africa region accounting for nearly 10% of all cases reported from sub-Saharan
Africa. The case-fatality rates remain above 2.5%, which is unacceptably high. Cholera can be spread through multiple
pathways, including consumption of fecal-contaminated water and food. Developing effective strategies to reduce
cholera transmission in Kenya requires identifying hotspots and investigating the relationship between the built
environment, fecal contamination in the environment, and human exposure behavior. To study cholera hotspots
identified from previous and ongoing outbreaks and quantify exposure to environmental pathways of cholera
transmission via human behavior and characteristics of the built environment. High-resolution satellite imaging was
used to map cholera hotspots and WASH infrastructure. Household surveys measured demographic characteristics of
the population in these hotspots and exposure to different environmental transmission pathways such as food, drinking
water, and flood water. Environmental samples were analyzed for E. coli and V. cholerae. Five low-income
neighborhoods in Nairobi, Kenya were surveyed each containing 100-250 houses in the sample. Most houses in the
study area were compound residences with concrete floors and iron sheets for roofing and walls. Shared sanitation was
common across all neighborhoods with most residents relying on public toilets, shared flush toilets, or shared pit
latrines. Municipal water supply was the most common source of drinking water (>80%). Drinking water sources were
within 20 meters of toilets or flooding zones for half of the households, and in two neighborhoods we observed much
closer proximity of drinking water to contamination. These two neighborhoods reported to have less frequent contact
with flood water for both adults and children but had similar exposure frequency to street food and surface water.
Preliminary microbial analyses of >400 environmental samples indicate that open drains (97%, 57%), surface water
(100%, 67%), flood waters (97%, 43%), and raw produce (80%, 23%) were frequently contaminated with E. coli and V.
cholerae, respectively. Despite the heterogeneity across neighborhoods, 2-week diarrhea prevalence amongst children
under 5 was similar across the neighborhoods (20-25%). This suggests that there are heterogeneities in fecal
contamination across neighborhoods and pathways. Further quantitative analysis of fecal contamination in the
environment is ongoing and will provide insights about dominant exposure pathways for cholera and other fecal-oral
diseases. This information, combined with results from genotyping of cholera strains, will be used to guide WASH and
vaccine interventions for cholera prevention and preparedness.

Measures to Leaving No One Behind in Access to Water, Sanitation and Hygiene (WASH): Gaps, Challenges and Best
Practices in Kenya.
Japheth Mativo Nzioki, College of Health Sciences, Jumeira University, Dubai, UAE
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Background Information:
The system of human rights in the United Nations was introduced by the Universal Declaration of Human Rights (UDHR)
in 1948. Several milestones in the development of Human Rights have taken place over time and in July 2010, UN
General Assembly Resolution A/RES/64/292 formally recognized the right to water and sanitation for the first time and
acknowledged that clean drinking water and sanitation are essential to the realization of all human rights. This study
sought to establish the level of Integration of HRWS and Measures to leaving No One Behind in Access to Water and
Sanitation in Kenya. The study further identified gaps, challenges, and best practices regarding the integration of HRWS
in Kenya.
Materials and Methods:
This was a mixed-method study design that combined both qualitative and quantitative study methods. Qualitative
methods were used to collect data from Key Informants from WASH practitioners (including government, Non-
Governmental Organizations (NGOs), Civil Society Organizations, UN agencies, and donor agencies) and Key informants
selected from vulnerable groups. In addition, a systematic review of literature and Focus Group Discussions were
conducted. 264 Key informants were interviewed. A total of 28 Legislations, 32 strategic Plans, and 8 WASH regulatory
and policy frameworks were systematically reviewed. Three Focus Group Discussions were conducted with technical
WASH teams implementing WASH projects in Kenya.
Results:
The following Kenyan legislations have articles that have integrated HRWS; The Kenyan Constitution 2010, Water Act -
2016, Public Health Act Cap 242, Environmental Management and Coordination act 1999, County Environmental Health
and Sanitation Bill, Basic Education Act of 2017, County Governments Act-2016, and over 50% of County WASH
legislations. The following institutions have policies that support HRWS; The Water Services Regulatory Board (WASREB),
Water Resources Authority (WRA), Water Sector Trust Fund, Water Tribunal, Ministry of Health, Ministry of education,
and County Governments. Lack of good governance, climate change, lack of knowledge of the HRWS, lack of mapping of
vulnerable groups, inadequate knowledge transfer on affordable sanitation technologies designed for the disabled and
poor people, lack of HRWS related performance indicators in WASH service providers, and inadequately resourced
national human rights organizations were among the gaps and challenges observed. Entrenching HRWS into the Bill of
Rights in the constitution of Kenya, application of mobile technology in information sharing between Water service
Providers and consumers, creating of pro-poor Water and Sanitation service provision guidelines, and the water sector
trust fund to finance water services in vulnerable and underserved areas and funding models of key WASH donors
(World Bank and USAID) which promotes the realization of HRWS were among the best practices in the country.
Conclusion and recommendations:
There is overwhelming evidence that Kenya’s legislative, Institutional, Policy, and regulatory frameworks in WASH
service provision have strongly integrated HRWS and measures to LNOB in WASH. Though this has created an enabling
environment to ensure no one is left behind in WASH service provision, millions of Kenyans still lack access to basic
Water and Sanitation services due to the challenges the country is facing in ensuring that every citizen enjoys their right
to water and sanitation. To fast-track the realization of SDG 6, WASH practitioners and stakeholders in Kenya need to
leverage the gains made in realizing the HRWS in the country to improve access to WASH services and ensure no one is
left behind.
Keywords: Human Rights, Water, Sanitation, and Hygiene, Leave No One Behind

Microbiomes and disinfection byproducts in intermittent water supply

Karina Chavarria, University of Massachusetts, Amherst
Additional Authors: Thomas Roberts, David A. Reckhow, Emily Kumpel

In many parts of the world, access to safe water that is sufficient for basic necessities is still a major challenge.
Intermittent water supply (IWS), piped water supply service that delivers water for less than 24 hours a day on average,
is an inconvenience for users, requires consumers to store water, makes it difficult for utilities to deliver an equitable
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water supply and can also pose health risks. IWS has been shown to exhibit poorer microbial water quality than
continuous water supply as is characterized by 1) pressure transients that can lead to intrusion of contaminants into the
drinking water distribution system; 2) periods of water stagnation and drained pipes; 3) first-flush events after service is
returned that can detach biofilms and other particulate into the bulk water; and 4) the need for household storage of
drinking water. These specific characteristics of IWS may result in complex water microbiomes and quality dynamics.
Although we have a robust understanding of the impacts of IWS on microbial water quality, less research emphasis has
been placed on the impact of intermittency on chemical water quality, including the formation of disinfection
byproducts (DBPs). This may be due to the more immediate, acute nature of microbial contamination in a drinking water
system and that microbial water quality should not be compromised in controlling for DBPs. However, it is critical to
understand how IWS affects the formation and characterization of such DBPs to better grasp the health implications of
this substandard yet common water practice.
The overall goal of this research is to investigate microbial communities and DBPs in batch, pilot-scale pipe loop system,
and a full-scale IWS system in Kenya. The main research objectives are: 1) investigate the DBP formation potential under
different IWS conditions and exposed to intrusion; 2) assess microbial community structure in bulk and biofilms exposed
to different IWS cycles and exposed to intrusion; 3) profile microbial communities, the occurrence of DBPs, in a full-scale
IWS system in Kenya; 4) draw conclusions that can aid in the management of IWS systems and identify research
priorities for further understanding IWS. For this work, laboratory-controlled experiments are being carried out using
batch and simulated drinking water distribution systems consisting of two pipe-loop systems located at the University of
Massachusetts, Amherst as well as field surveys in Kenya during 2022 and 2023. Methodology includes high-throughput
sequencing and flow cytometry for assessing microbial communities, ultraviolet absorbance, and gas chromatography
for DBP analysis.
We will present preliminary results from our field work in Kenya and lab-controlled experiments. We will also share
results from a review study conducted regarding DBPs in IWS.

Novel Time-integrated Techniques to Quantify Waterborne Fecal Microorganisms in the Alabama Black Belt
Corinne Baroni, The University of Alabama
Additional Authors: Jillian Maxcy-Brown, Emily Elliott, Elisa Mayerberger, Kristen Jellison, Mark Elliott

In the Alabama Black Belt, widespread rural poverty, limited access to sewer, and shrink-swell clay soils that preclude
the use of conventional septic systems lead to both failing septic systems and the discharge of raw sewage from homes
through “straight pipes.” Sewage that is discharged to the surface typically pools in a ditch or trench until rain flushes
the sewage and sediment into local waterways. The degree to which fecal microbes are associated with the suspended
sediment load (SSL) has important implications for the sustained transport of these contaminants within the waterway,
with ~60% of fecal microbes in surface water during storms associated with particles. Therefore, an accurate and
efficient way of capturing and monitoring suspended sediment and determining the microbial association is critical in
understanding the potential impact that storms have on the fate and transport of fecal pathogens. Sampling surface
water for fecal contamination typically involves collection of grab samples. While this method is technically simple,
microbial surface water quality is highly variable and indicator bacteria are poorly correlated with many waterborne
pathogens including oocysts of Cryptosporidium spp. Therefore, a grab sample tested for fecal indicator bacteria is
inadequate to evaluate potential risk to human health from enteric pathogens in a body of water. There has been little
to no effort to explore time-integrated sampling methods that have been used in sedimentology and incorporate those
into pathogen capture. This project uses novel time-integrated methodologies for capturing suspended sediment and
Cryptosporidium in study three sites along Big Prairie Creek in Newbern, AL. The novel time-integrated sampling
procedure for Cryptosporidium takes advantage of the propensity of oocysts to stick to biofilms; growth of biofilm on
glass slides yields a surface that can capture suspended oocysts, with addition of added calcium ions to enhance
collection. Cryptosporidium oocyst analysis and quantification is conducted at Lehigh University. The time-integrated
mass sediment sampler (TIMS) method that has been used in sedimentology has been applied for the first time to the
challenge of quantifying pathogens and other fecal microbes attached to suspended sediment. TIMS samples are
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currently being analyzed for particle size distributions, with microbial analysis to follow. Current results show that
Cryptosporidium and E. coli levels are higher after large rain events, pointing to increased runoff resulting in more
surface water contamination.
The TIMS and the novel Cryptosporidium samplers are both made of PVC and will provide inexpensive alternatives to
conventional time-integrated or Cryptosporidium sampling methods in surface waters. This work reflects our efforts to
enable affordable time-integrated approaches to the quantify Cryptosporidium in rural streams, differentiate sediment-
associated fecal microbes, assess the potential of in-situ natural and engineered surfaces to capture pathogens as an
alternative to conventional approaches to sampling for Cryptosporidium, and provide water managers with improved
methods for evaluating the safety of water sources for drinking water supply and recreational use.

Occupational Health Risks Prioritization Among Sanitation Workers During Faecal Sludge Emptying in Dar es Salaam.
Raphael Mginga, University of Dar es Salaam
Additional Authors: Richard Kimwaga, Patrick Valimba

Background:
Sanitation workers aspire to achieve safely managed sanitation (SDG 6.2) by 2030 through bridging the gap between
sanitation facilities and fecal sludge emptying services. However, these workers execute this vulnerable work at the cost
of their dignity, safety, and health as they often expose themselves to asphyxiating gases, fecal contact, and detritus
objects with the risk of debilitating infections, injuries, social stigma and even death. Sanitation workers provide a vital
role for public health and SDG 6.2 achievement, but the occupational health risks posed by emptying service to this
workforce is inadequately documented or is totally lacking. Therefore, this study aims to assess and prioritize the risks
and to propose requisite health safety measures that will accelerate achievement of the 2030 targets.
Data collection tools and methods:
This study comprises both qualitative and quantitative data collected in Dar es Salaam Tanzania. Qualitative data were
collected by conducting 30 focus group discussions (FGDs) comprising 8 to 12 participants for both mechanized and
manual sanitation workers, 24 in-depth Interviews (IDIs) were administered to local leaders and the emptiers leaders; to
enhance trust and rapport system. Further 9 key informant interviews (KIIs) were administered to government utilities
and NGOs to validate the information provided by FGDs and IDIs, while quantitative data were collected through
physical observation of practices and safety measures undertaken from 36 emptying events. Furthermore, H2S
concentration was measured from 10 emptying events by using hach spectrophotometer and temperature inside the pit
or septic tank which was measured using a digital thermometer.
Data analysis (in progress):
Monte Carlo Simulation will be used to reduce risks, uncertainty of exposure time for workers and a Risk Matrix Grid will
be used for prioritization of risks observed or reported by sanitation workers and descriptive statistics, bivariate and
multivariate analyses will be performed using SPSS Ver. 20
Preliminary results:
Chemical risks have been reported as the most serious problems faced by emptiers, most of the workers are operating
informally and several emptiers are not using PPE despite being aware of its important to their health and safety.
Conclusion and recommendation:
This will focus on how to improve or mitigate the health risks posed by emptying services by adopting a hierarchy of
controls technique after risks rating and/or prioritizations.
Timeline: (May- June) 2022 data analyses, August 2022 final report submissions.

Opportunities to mitigate infection of enteropathogens of poultry origin: a transmission model analysis

Kayoko Shioda, Emory University
Additional Authors: Andrew Brouwer, Frederica Lamar, Hermógenes Neves Mucache, Karen Levy, Matthew Freeman

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Background:
The burden of diarrheal diseases remains a critical issue among children in low-income countries, but WASH
intervention trials have had limited impacts on diarrhea and child growth. One explanation is that these interventions
focus on interrupting one or more transmission pathways (e.g., water and/or environment), while neglecting other
critical routes of exposure (e.g., food and/or animals). Therefore, we developed an infectious disease transmission
model for children in Maputo, Mozambique to compare the contribution of a comprehensive set of transmission
pathways related to enteropathogens of poultry origin. We then evaluated the potential impact of interrupting these
pathways on childhood infection using these models and interpreted simulation results based on local data in Maputo.
Methods:
We developed infectious disease transmission models for Campylobacter spp. and non-typhoidal Salmonella spp. that
capture not only direct person-to-person transmission but also environmental transmission via food, water, soil, live
chickens, and all other sources. We employed a sampling-importance resampling approach to estimate pathway
contribution based on infection data among children aged 1-48 months from Maputo and WHO estimates of
attributable risk by pathway. To identify effective mitigation opportunities, we simulated the prevalence of infection
among children after reducing each of the estimated transmission rates. We interpreted simulation results based on
locally collected population-based survey data and microbiology data along the poultry value chain in Maputo.
Results:
The simulation analysis revealed that a reduction in foodborne transmission by 50% and 90% yielded declines in the
prevalence of Campylobacter infection among children from 8% (baseline) to 5.8% (95% credible interval: 4.5-7.5%) and
3.5% (2.6-5.2%), respectively. Similarly, a reduction in foodborne transmission by 50% and 90% yielded declines in the
prevalence of Salmonella infection among children from 21.0% (baseline) to 14.2% (13.0-19.8%) and 9.8% (7.5-14.1%),
respectively. Interruption of the remaining pathways - e.g., water, soil - did not have a substantial impact on reducing
infection. Incorporating locally collected data, it suggests that foodborne infection can be reduced by 33% and 41% if we
could eliminate the contamination at corner stores and informal markets, respectively.
Conclusions:
Our models capture a comprehensive set of transmission pathways and highlight the importance of controlling
foodborne transmission. Our model can serve as a tool to generate hypotheses on effective mitigation opportunities to
control zoonotic enteropathogens, which can then be tested empirically through future studies to design actual
intervention strategies.

Periods, Pads, Painkillers, Privacy and School participation in the Philippines and the UK
Rebecca Evans, University of Warwick UK
Additional Authors: Bronwyn Harris, Frances Griffiths

Are the lived menstrual experiences of schoolgirls in a high-income country (HIC) with greater access to resources better
than those in a low-and-middle income (LMIC) country?
It is known that menstruation is a challenge to schoolgirls that can affect both attendance and participation. This
research seeks to understand the factors that affect the quality of the menstrual experience of schoolgirls so that more
supportive policies can be designed.
This was a mixed-methods study which recruited menstruators between the ages of 16 and 19 in the Philippines and in
the UK using Facebook Advertising. Respondents completed an on-line survey in Qualtrics. 14 Likert-style questions
were used to produce a Menstrual Experiences score (max 70) and quantitative analysis looked for associations between
the menstrual experience and demography.
A small group of respondents from each country took place in an asynchronous epistolary Focus Group Discussion via
social media. Qualitative data were imported into Nvivo for Thematic Analysis.
Results:
• 706 menstruators were recruited (Philippines 308 and UK 398). For the focus groups, 12 and 8 respectively.

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• There was no difference between overall menstrual experience score in the Philippines and the UK (36.61+/-
6.11 and 36.60 +/-7.71 respectively).
• In the Philippines there was an association (P<0.05) between menstrual experience and perceived income,
absolute income, number of females per household and access to improved water and sanitation. In the UK,
there was an association with perceived income only.
• There is a significant difference (P<0.01) between the two countries in how girls feel when they are
menstruating. Girls in the UK feel more negative than those in the Philippines.
• Girls in both countries frequently described suffering from Dysmenorrhea.
Conclusion:
Access to menstrual products and adequate Water Sanitation and Hygiene (WASH) facilities is a fundamental
requirement for girls to manage their menstruation at school. Limited access to resources in the Philippines affected
girls’ menstrual experiences, and a few were forced to go home from school to deal with the bleeding. Despite UK
schools providing products and a good standard of facilities, girls in the UK did not rate their menstrual experience any
better than those in the Philippines.
Debilitating dysmenorrhea was very commonly experienced. In the Philippines, girls got support from their peers and
their teachers and could leave the classroom temporarily to change or rest if necessary. In the UK, girls complained
about school policies that did not let them out of the classroom. They routinely took painkillers, and some took the
contraceptive pill, to be able to cope. The menstrual stigma requiring them to ‘put up and shut up’ led to anxiety and
negative feelings around menstruation. These findings concur with what has been called ‘the Menstrual Mandate’ in HIC
in which girls are expected to conceal their menstruation from others.
Girls in LMIC need access to resources including painkillers to enable them to participate in school activities, but in both
LMIC and HIC, policies that remove the menstrual stigma, educate about dysmenorrhea and menstrual disorders, and
promote Menstrual Health more widely need to be developed.

Piloting hand hygiene promotion interventions in rural Malawi Primary Schools

Kondwani Chidziwisano, Malawi University of Business and Applied Sciences-WASHTED Centre
Additional Authors: Tracy Morse, Mindy Panulo

Background:
As a result of the COVID-19 pandemic, the Government of Malawi and its partners prioritized providing handwashing
facilities in primary schools to support handwashing. However, there were no specific hygiene promotion campaigns to
promote usage of the handwashing facilities. Thus, we co-developed and implemented a theory driven behavior change
intervention to promote hand hygiene in schools.
Methods:
We targeted 180 primary schools in Chikwawa district, training one School Health and Nutrition (SHN) teacher per
school. The teacher training sessions used participatory approaches with practical demonstrations to convey the
importance of hand hygiene. With a guided step-by-step manual, teachers then taught learners in the school setting the
importance of handwashing with soap through participatory and practical approaches such as games, demonstrations
and activities. The intervention activities were designed to be fun to grab the attention of the learners. To support
sustainability, the intervention encouraged use of locally available materials. Additionally, a WhatsApp group was
created to serve as a communication platform to maintain collective momentum. Out of the 180 schools, 28 were
followed twice through unannounced visits by the intervention team while 152 schools were followed through the
WhatsApp group and use of Primary Education Advisors.
Results:
Overall, an increase in handwashing with soap practice among the learners was observed between the first and the
second supportive visits, evidenced by increase in number of handwashing facilities present at the school (first visit
average number of handwashing facilities per school = 5 and second visit average number of handwashing facilities per
school = 12); increase in the number of learners observed washing hands with soap at critical times; and 75% increase in
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the number of schools stationing handwashing facilities at an appropriate place. However, challenges were observed
i.e., lack of sufficient hand-washing points to meet the recommended learners to handwashing facility ratio, inadequate
and theft of soap in schools which forced schools to directly add soap into a bucket containing handwashing water which
discouraged handwashing as soap could not be rinsed off leaving both a film, and soap smell on hands. Furthermore,
there was lack of support given to SHN teachers from school leadership and fellow teachers. In the case of shared water
sources, there was conflict between learners and community members. Most importantly, the schools had no specific
plan within the daily school schedule on when to conduct the hygiene promotion activities with the learners.
Conclusion:
Schools are important settings for disease transmission, and school-based interventions should be a priority to reduce
the overall community disease burden. Hygiene promotion targeting schools should be context specific, practical,
participatory, and interesting. Full engagement of school staff is a necessity to reach every learner and sustain change.
Hence, incorporation of such hand hygiene promotion modules in the teacher’s training curriculum is important.
Appropriate handwashing facility designs are needed to meet an increased number of learners in the schools.

Pre- and post- monsoon variation in household water insecurity in rural Bangladesh
Lauren Broyles, Penn State University
Additional Authors: Emily L. Pakhtigian, Sonia Aziz, Ali S. Akanda, Alfonso Mejia

Key Learning Objectives:

(1) Demonstrate statistically significant evidence that HWI in Matlab, Bangladesh is higher pre-monsoon than post-
monsoon
(2) Discuss statistically significant differences in HWI between seasons for those households that pay for drinking water
(3) Analyze likelihoods of HWI among households with higher perceived groundwater arsenic exposure between pre-
and post-monsoon seasons
Background:
It is estimated that billions of people around the globe are at risk for severe water scarcity at some point during the year.
Moreover, as climate change intensifies and weather patterns such as seasonal rains become less predictable, the
severity and scope of those affected by household water insecurity (HWI) are expected to increase. Water insecure
households lack access to safe, affordable, adequate, and reliable water, which negatively affects household health and
wellbeing. Households may need to shift to alternative—and potentially contaminated—water sources, in addition to
overcoming additional mental and physical burdens, such as dehydration. Despite the scope of this challenge, there is
little existing research examining the social, technical, and environmental factors that contribute to intra-annual HWI.
Methods:
We conducted a seasonal cohort study (n=2000) in Matlab, Bangladesh to test for variation in HWI and its determinants
between the pre- (March/April 2021) and post-monsoon (October/November, 2021) seasons using the Household Water
Insecurity Experience Scale (HWISE). The surveys collected information on household water use including HWI, cholera
incidence, and perceived arsenic exposure. Using Poisson regression models, we tested the determinants of HWI during
both seasons, focusing on household water use practices, household characteristics, and experiences with drinking
water health hazards (cholera and arsenic) as key independent variables. Finally, using the two-wave panel, we ran a
household fixed effects model to assess the effect of seasonality on HWI, controlling for household and water use
characteristics.
Results:
We find seasonal variation in the relationship between HWI and household water use variables. Pre-monsoon, we see
that households that pay for drinking water face higher HWI (aPR 1.33, 95% CI [1.01-1.76], p < 0.05); post-monsoon,
households that pay for drinking water report lower HWI (aPR 0.41, 95% CI [0.17-0.91], p < 0.05). This indicates that
households rely on different water sources throughout the year, with implications for their water access and other
consumption abilities. In addition, we find lower likelihoods of HWI among households with higher perceived
groundwater arsenic exposure pre-monsoon (aPR 0.64, 95% CI [0.38-1.07]) and higher, yet insignificant, likelihoods of
HWI among households with higher perceived groundwater arsenic exposure post-monsoon (aPR 1.09, 95% CI [0.57-
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1.93]). Given the health consequences of both HWI and consumption of arsenic-contaminated water, these results
suggest that households may make intra-annual tradeoffs in water-related health risks. Finally, our panel regression with
household fixed effects shows that HWI was lower in the post-monsoon season compared to pre-monsoon (adjusted PR
0.43, 95% CI [0.37-0.50]). This confirms HWI is not static and is influenced by intra-annual environmental seasonality.
Conclusion:
We find that the season of data collection is a significant predictor of HWI in Matlab, Bangladesh, suggesting an annual
measure of HWI is insufficient to fully characterize challenges to household health and wellbeing. The relationship
between HWI and predictors of payment for drinking water and perceived groundwater arsenic exposure also vary
seasonally. These findings suggest that understanding HWI, its determinants, and its relationship with household health
requires investigation of households’ dynamic experiences with water availability throughout the year.

Quantifying the Health Co-Benefits of Improving Flood Resilience in Low- and Middle-Income Settings
Aniruddha Deshpande, International Institute for Applied Systems Analysis
Additional Authors: Josephine Borghi, Finn Laurien

Flooding is one of the most common extreme weather events, posing severe health and economic risks
disproportionately in vulnerable low- and middle-income communities. Flooding due to sea-level rise and extreme
precipitation is poised to worsen in many areas of the world due to anthropogenic climate change. Community resilience
to flooding is a composite of many different variables including physical infrastructure, economic capital, health, and
many other social factors. Furthermore, flooding exposures can vary by location due to each location’s climate and
hydrology. Resilience intervention and adaptation measures have been developed and implemented in many different
settings. The economic impacts of these measures have been characterized in many models, but the health benefits
have not been explicitly linked at scale. In this analysis, we characterized the health co-benefits of improving flood
resilience. The Flood Resilience Measurement for Communities (FRMC) study obtains qualitative assessments of flood
resilience from local experts across low- and middle-income countries. We paired the pre-flood and post-flood
qualitative assessments with corresponding local quantitative metrics from censuses, national surveys, and the Global
Burden of Disease study. In doing so, we can quantify location specific health benefits of improving flood resilience. We
specifically focused on how water and sanitation (WASH) infrastructure improved as part of increasing flood resilience.
Local quantitative estimates of WASH infrastructure from the IHME’s Local Burden of Disease project. Utilizing,
established health risk functions of WASH from the epidemiological literature, we can calculate the health co-benefits as
DALYs averted from the improvement of WASH. In doing so, we capture the health dimension of this sector of climate
change adding to the importance of resilience in the water sector to climate change. We found that each city studied
had varying quantitative levels of WASH that corresponded with each city’s qualitative assessment of WASH. This is vital
in tailoring flood resilience policy locally as levels of adequacy are context specific. Furthermore, investing in climate
resilience initiatives such as flood resilience has substantial indirect effects to generate health benefits. This highlights
that addressing climate and health are not separate but rather intertwined activities with high potential of synergistic
effects. Policymakers should evaluate the benefits holistically before determining the cost-effectiveness of a climate
resilience intervention.

Reduced Diarrhea and Improvements in Handwashing with Soap and Stored Drinking Water Quality Associated with
Diarrheal Disease Awareness Measured by Interactive Voice Response (IVR) Messages in the CHoBI7 Mobile Health
Program.
Sazzadul Bhuyian, icddr, b
Additional Authors: Jamie Perin, Fatema Zohura, Tahmina Parvin, Munirul Alam, Christine Marie George

The Cholera-Hospital-Based-Intervention-for-7-days (CHoBI7) mobile health program promotes water, sanitation, and
hygiene (WASH) behaviors through voice calls and text messages to reduce diarrheal diseases in Bangladesh. The
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objective of this study was to investigate the relationship between responses to CHoBI7 WASH interactive voice
response (IVR) quiz messages and diarrhea and WASH behaviors. Fourteen CHoBI7 IVR quiz messages on handwashing
with soap and water treatment were sent to 517 households with 1777 participants during the 12-month program
period. IVR message responses were classified as “correct answer”, “incorrect answer”, “no response” (not press 1 or 2),
and “failed” (not answer the phone). Diarrhea prevalence was assessed through monthly clinical surveillance.
Handwashing with soap was assessed by 5-hour structured observation, and stored water quality was defined assessed
by E. coli concentration. Households that correctly responded to a CHoBI7 IVR quiz message had a significantly lower
odds of diarrhea for all age groups(adults and children) at the subsequent visit 1 month later(Odds Ratio (OR): 0.73; 95%
Confidence Interval (CI):0.54, 0.98), and significantly higher odds of handwashing with soap at stool related events (OR:
2.33; 95% CI:1.09, 5.01) and E. coli <100 colony forming units /100 mL in the stored household water(OR: 2.04; 95%
CI:1.25, 3.33) compared to households that did not answer CHoBI7 IVR quiz call. Correct responses to CHoBI7 IVR quizzes
were associated with decreased diarrhea prevalence and improved stored drinking water quality and handwashing with
soap. These findings suggest engagement in the CHoBI7 mHealth program and awareness of diarrheal disease
prevention can reduce diarrhea and facilitate changes in WASH behaviors.

Regional scale pathogen concentrations and associated human health risks due to wastewater reuse in the Mezquital
Valley, Mexico
Leon Espira, Department of Epidemiology, University of Michigan of Michigan School of Public Health
Additional Authors: Contreras J.D, Felix-Arellano E.E, Siebe C, Mazari-Hiriart M, Eisenberg J.N.S

Urban wastewater reuse for agriculture is an important climate change adaptation strategy that provides reliable
nutrient-rich water, reduces water stress, and strengthens food systems. Wastewater exposure also presents health
risks to farmers and their communities. These risks can be mitigated by treating the wastewater, however, communities
downstream of treatment plants could recontaminate treated wastewater, negating the benefits of treatment. In 2019,
we collected water samples at various points along irrigation canals carrying treated and untreated wastewater in the
Mezquital Valley and quantified the concentration of a range of bacterial, protozoal, and viral pathogens. Pathogen
concentration data was used to conduct multi-pathogen comparative risk analyses to assess the impact of water
treatment and community recontamination. We found decreases in bacterial pathogen and protozoal gene counts
following water treatment but increases in bacterial pathogen and protozoal gene counts after the treated water passed
through communities. Decreases in viral pathogen gene counts were not as pronounced following water treatment. In
untreated wastewater, bacterial pathogen and protozoal gene counts decreased after transit through communities,
while viral pathogen gene counts increased. Pathogen specific relative risk comparisons between treated and untreated
canals showed that prior to transit through communities, relative risks ranged from 1.09 for norovirus GII to 9.09 for
atypical EPEC. After transit through communities, relative risks diminished, ranging from 1.02 for norovirus GII to 2.15
for Giardia lamblia. The equalization of risks likely results from local community recontamination of the treated water
stream. Understanding the entire wastewater reuse chain provides valuable information for the development of
comprehensive mitigation strategies.

Remote Data Capture and Visualization Frameworks to Support Chlorine Generator Use throughout National
Healthcare Systems
Amanda Miner, Envicom
Additional Authors: Aqua Research, PATH, Catholic Relief Services

Good data architecture is an imperative component of strengthening healthcare systems and evidence-based decision
making. While data in the WASH in HCF sector has become increasingly available, the environmental hygiene service
area remains a clear gap.

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Envicom is collaborating with Aqua Research, Catholic Relief Services (CRS), and PATH to develop and pilot an IoT
solution that can automatically collect and transmit frequent technical performance data from an onsite chlorine
generator—Aqua Research’s STREAM Disinfectant Generator—to cloud-based, end user-centric dashboards. This pilot
project is taking place in Ghana in support of the Ghana Health Service. Data acquired from the STREAM is intended to
provide insights to national and district health leaders regarding HCF-based hygiene services, as well as by STREAM
maintenance service providers to sustain operation. Ten IoT gateway units were deployed to Ghana in December 2021,
with each being assigned to a single Aqua Research STREAM Disinfectant generator. Five of these STREAM/IoT Gateway
Systems are being overseen by PATH, and five by CRS, and are geographically well distributed across Ghana. All of the
components required for installation of the units onsite arrived in Ghana on March 31, 2022. As of April 29, 2022, seven
STREAM/IoT Gateway Systems have been successfully tested in Ghana and two are installed and reporting basic
performance values of pump speed, cell temperature, current, voltage, and total on-time. Device No. 1212376252-0821-
001 has reported no errors, having a total on-time of 1 day, 3 hours, and 37 minutes. The last reported values are: pump
speed 4412 steps/s, cell temperature 113.4 F, current 17 and voltage 11. Device No. 1212376252-0821-009 has reported
no errors, having a total on-time of 1 day, 4 hours, and 2 minutes. The last reported values are: pump speed 4057
steps/s, cell temperature 111.1 F, current 17 and voltage 11.
Greater data visibility from the STREAM devices benefits National, Regional, and District government, as well as
supporting partners PATH and CRS, enabling effective budgeting and operational decision-making, and providing
evidence-based outcomes regarding the efficacy of the STREAM. The data architecture we have set up on the server
allows us to serve the data depending on user roles within the health system. Beyond proving the value of the STREAM
to support hygiene services, this pilot will additionally demonstrate how well-designed data automations can provide
critical support to health systems without requiring effort from staff. Within this pilot project, data dashboards will be
developed and designed specifically for national government decisionmakers and regional biomedical engineers. User-
specific visualizations will contain the following information:
• National Government Decision-Makers
o Volume of chlorine solution produced, Overall Operational Metrics, Costing (Equipment,
Maintenance, Supplies, Energy/Water, Parts, Communications, Cost Savings, Cost per liter)
• Regional Biomedical Engineers
o Per device information: Maintenance/Errors, Run time per use, Frequency/Days/Times of use,
Telemetry.
Ultimately, data architecture strengthens decision-making in healthcare systems through the provision of objective and
complete environmental hygiene data while also generating substantial workflow efficiencies for healthcare staff and
partner organizations through automation.

Risk Factors Associated with Elevated Lead Levels in Drinking Water in Massachusetts Schools and Childcares
Liam Amery, UMass Amherst
Additional Authors: Emily Kumpel and John Tobiason

Exposure to lead through drinking water is of concern for children, particularly at older schools constructed before
restrictions were placed on lead in plumbing materials. In Massachusetts, between 2016 and 2022 1,247 schools and
328 childcare facilities have tested their water for lead and copper contamination, with more than 180,000 test results
reported including first draw and flush samples for lead and copper. 42.5% of schools or childcares tested having at least
one lead sample >15 ppb, and 19.3% of schools had a fixture above 1.3 ppm copper, thresholds used in the Lead and
Copper Rule. We found that remediation techniques such as fixture replacement and daily flushing significantly decrease
lead and copper levels at fixtures. We examined how factors such as building age, source water, and treatment
techniques impact a school's risk to have elevated lead levels. Since there is not a universal threshold for allowable lead
contamination, we used three different indices based on 1 ppb, 5 ppb, and 15 ppb thresholds to categorize a school’s
risk. We found that the greatest predictor for a school’s risk was building age, particularly those constructed before
1987; other factors related to the public water supply serving the facility influence lead levels to a lesser extent. Finally,
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we observed disparities between demographic groups, where schools with >50% African American students or >50%
Asian students had higher median lead levels and a greater percentage of first draw samples above 15 ppb and schools
with >60% low-income students had more fixtures above 15 ppb than schools with <60% low-income students. We used
some of the known characteristics which influence lead levels to identify high-risk schools and childcares in
Massachusetts and present the most significant factors, within the study scope, to guide future monitoring and
remediation programs.

Risk Factors for Enteric Pathogen Carriage Among Children in Rural Alabama
Drew Capone, Indiana University
Additional Authors: Troy Barker, Claudette Pool, Joe Brown

The Alabama Black Belt has soil that is high in clay content and drains poorly, which requires onsite sanitation
technologies that are too expensive for many low-income households. Without affordable sanitation options, some
residents resort to “straight piping”, meaning the direct discharge of untreated fecal wastes to the environment. These
human excreta may contain enteric pathogens, and exposures to pathogens in the environment may result in infection
and illness. We surveyed participants and collected stool from 490 school age children living in the Alabama Black Belt.
Stools were tested for 36 pathogen targets using reverse transcription quantitative PCR. We detected genes associated
with ≥1 enteric pathogen from 27% (140/490) of child stools. The three most frequently detected pathogens were
Clostridium difficile (6.5%, 32/490), atypical enteropathogenic E. coli (6.1%, 30/490), and enteroaggregative E. coli (3.9%,
19/490). We used generalized estimating equations to identify risk factors for the detection of ≥1 pathogen in stool, our
dependent variable. We found no association between straight pipe sanitation and the detection of ≥1 pathogen in stool
(aRR = 0.92, [95% CI: 0.53, 1.6]) compared to a sewer connection. We observed an increased risk of detecting ≥1
pathogen in child stool from households that reported not paying a water bill (aRR = 1.8, [1.2, 2.6]), an indicator of well
water consumption, compared to children from households served by water utilities. Well water consumption in
Alabama’s Black Belt may be associated with increased risk of exposure to enteric pathogens.

Safe and optimized sampling of wastewater RNA for monitoring of SARS-Cov-2 infection waves and variants
Xiaoxiao Cheng, Zymo Research
Additional Authors: Kenneth Day, Michael Lisek, Kris Locken, Liya Zhu, Shuiquan Tang

Wastewater-based epidemiology is an emerging tool for tracking SARS-CoV-2 spread at the community level. Safety and
handling of wastewater containing infectious agents is of concern, along with accurate quantification of viral copies.
SARS-CoV-2 genomes exist within infectious particles, ribonucleoprotein complexes, and as free/unprotected viral RNA.
These states of genome copies are also dependent on such factors as sampling/preservation methods, wastewater
temperatures, duration of transport, total amount of biosolids present, and levels of pharmaceuticals and detergents.
Therefore, a sampling/preservation system is needed to ensure safety and maximize recovery of RNA.
We have developed Wastewater Inactivation and Stabilization Equipment (WISE) designed to collect wastewater from
autosamplers to rapidly inactivate pathogens with a fluorescent safety indicator, preserve and stabilize RNA, and
efficiently extract total RNA from samples. Our stabilizing reagent within a developed purification system paired with an
EUA SARS-CoV-2 qRT-PCR test enabled effective monitoring of pandemic waves. Viral copy numbers per liter reflected
caseload from public clinical testing facilities. Ct values from the qRT-PCR test predicted uniformity of amplicon
sequence (amp-seq) coverage and detection of emerging variants in clinical and wastewater samples. In times of
baseline caseloads, Ct values typically predicted poor SARS-CoV-2 coverage in wastewater and indicated possible carry
over of PCR inhibitors from larger volumes of wastewater required to generate more uniform sequence coverage.
Additional purification steps have removed inhibitors accumulating from the extraction of these larger volumes. The
shifting mutational landscape of SARS-CoV-2 and degraded wastewater RNA size below the range of target PCR
amplicons for sequencing make amp-seq approaches more challenging. Therefore, we developed a targeted
hybridization method (SC2-seq) that gives more consistent and uniform coverage of the SARS-CoV-2 genome. Variants
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called demonstrated 100% agreement between amp-seq and SC2-seq in clinical samples. This approach makes SC2-seq
especially amenable for wastewater monitoring between waves where novel variant frequencies need to be reported at
lower copy number. Our bioinformatic software called VirSieve also removes spurious variants in our wastewater SARS-
CoV-2 genomes.
The WISE system allows for safe wastewater collection by personnel with monitoring of the current pandemic’s variant
landscape and may be expanded to include surveillance of other pathogens in the future.

Same Same, but Different - Innovation in Emergency Fecal Sludge Management

Esther Shaylor, UNICEF
Additional Authors: Cecilie Kolstad, Sylvain Bertrand

Globally Fecal Sludge Management (FSM) has come a long way in the last decade with a number of research projects
and developments in the sector, however this has not focused as much on emergency FSM. There is often a pressure to
rapidly establish sanitation systems in emergencies and protracted crisis to contain feces and prevent health-related
issues (Cholera outbreaks, for example). Among current resources for humanitarian response there is no pre-packaged
easy to deploy FSM system that provides a technical solution that can be quickly implemented in emergencies.
Recognizing there is a potential product gap, UNICEF Supply Division (SD) launched an innovation project to investigate
the potential of an easily deployed (or pre-positioned) FSM solutions in a kit(s).
Using UNICEFs product innovation process (Exploration – Need – R&D – Validation – Transition to Scale) the challenges
of FSM in emergencies were documented and mapped though engagement of country offices who have had emergency
responses requiring FSM interventions, in a series of webinars and interviews. The full sanitation chain was discussed,
and participants identified where they had seen the biggest challenges - treatment. This was then cross referenced with
a series of interviews with other actors in emergency WASH, it was identified the biggest need was in treatment of not
just Fecal Sludge but also waste water.
At the same time SD reached out industry to see what types of products were available along the sanitation chain that
could be quickly deployed in emergencies. Overall, 77 suppliers responded to the online survey, with 33 products for
containment; 27 for emptying; 21 for transportation; and 34 for treatment of fecal sludge suitable for emergency
settings as outlined in the questions. Based on this information we could see there were options on the market but only
a few had been used in emergency or emergency type settings.
As the project moved into the Need phase, the initial survey response, country office feedback and engagement with the
WASH Cluster FSM Technical Working Group, was used to develop a Target Product Profile (TPP) that outlines the
different settings that an FSM and Wastewater ‘kit’ would need to operate in for emergencies, classifications of sludge
characteristics and technical specifications. As this was published a Request for Information (RFI) was also published
through the UN General Marketplace (UNGM) to which 21 suppliers responded. Based on the submitted responses 11
products meet or nearly meet the TPP specifications.
We are now looking to move the project into the Validation phase. This will include releasing a tender that would allow
industry to submit proposals for review and possible inclusion into the UNICEF supply catalogue for emergencies. In
2022 we hope to carry out a tender and product review to see if these products could be added into the UNICEF supply
catalogue, should this be complete we will share the results. However, we still need to work with the sectors to
understand how well these products might perform in emergency settings to contain and treat fecal sludge and
wastewater, and if having them available through SD would mean emergency response would benefit from them.

Sanitation and Hygiene in Early Childhood Development Centres of Low-income Areas of Blantyre, Malawi.
Taonga Mwapasa, Malawi University of Business and Applied Sciences (MUBAS)
Additional Authors: Tracy Morse, Kondwani Chidziwisano, David Lally

At the end of this session, participants should be able to.

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• Understand key areas that pose risk of pathogen transmission through contamination in early childhood
development centre settings.
• Have an insight of the levels of contamination in the key areas.
• Possible behavior changes recommendations that can help limit risk of pathogen transmission in ECDC settings.
Introduction:
Poor water, sanitation, and hygiene (WASH) practices in both domestic and public places in low-income countries
expose children under the age of five to environments with widespread fecal contamination. These environments have
led to high prevalence of diarrhea and other acute and chronic health outcomes such as malnutrition. Over 1.6 million
children aged 2-5 years in Malawi, attend 11,600 Early childhood Development Centres (ECDCs) that are available in the
country. Previous efforts in ECDCs have focused on improving nutritional and educational outcomes in children.
However, being an environment that accommodates young children who are prone to numerous communicable
diseases including diarrhea, ensuring WASH facilities, and associated good hygiene practices in ECDCs is essential. As
such, this formative study aimed to understand hygiene practices in the ECDCs and assess levels of contamination in key
areas of risk, to identify key recommendations for future WASH related interventions in the ECDCs.
Methods:
A mixed-methods design using the convergent-parallel approach was applied to identify key WASH behaviors in 10
ECDCs through; checklist and structured observations (n=849 children; n=33 caregivers), focus group discussions (n=25)
and microbiological sampling (n=261) of drinking water, children, and food handler’s hands, and eating utensils. Source
and stored drinking water were analyzed for presence of E. coli and coliforms using IDEXX ColilertTM test while hands
and utensils were analyzed for general contamination using Adenosine Triphosphate (ATP) swabs with contamination
estimated in Relative Light Units (RLU) using the HygienaTM SystemSURE Plus. Univariate analysis was used to describe
availability of infrastructure while thematic analysis was used to generate themes from observations and focus group
discussions.
Results:
Water sources (80%) and sanitation (100%) infrastructure were available in ECDCs, coupled with lack of supporting
structures such as handwashing facilities, poor hygiene practices and unhygienic environments, increasing the risk of
fecal-oral disease transmission. Few caregivers (30%) and committee members (20%) had received limited training that
focused on childcare, ECDC lessons, food preparation and basic WASH training on how to keep surroundings clean.
Children also lacked proper hand-washing training. There was an increased number of E. coli (up to 105.9MPN/mL) and
coliforms (up to >2420MPN/mL) in stored drinking water compared to source water, which confirmed observed poor
water handling habits by staff and children. Shared cups (88%) for drinking water had the highest contamination
(>30RLU) compared to other utensils which were not shared. Both food handler’s (44%) and children (46%) were
observed to wash hands with water-only and contamination on hands (beyond the safe limit of 60RLU) was recorded in
eight out of nine ECDCs.
Conclusion:
Addressing undesired hygiene practices in ECDCs has the potential of contributing to improved health outcomes of
children in low-income settings. The provisions of infrastructure and knowledge alone cannot ensure that adequate and
appropriate water, sanitation, and hygiene (including food) practices take place. Caregivers and food handlers in ECDCs
need to be trained appropriately using a behavior centered approach, and WASH targeting practical and context
appropriate WASH skills if they are to effectively implement WASH behaviors and train children

Sensor-based monitoring of passive chlorinators in rural Honduras

Megan Lindmark, University of Iowa
Additional Authors: Megan Lindmark, Craig Just, Wesley Meier, Diana Calix, Brayan Lopez

Background + Problem Statement:

Over 2.1 billion people, 25% of the world’s population, lack access to safely managed drinking water. In rural Honduras,
the proportion of the population at risk for waterborne disease due to unsafe drinking water is even greater at 81%.
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Passive chlorinators are a simple and affordable drinking water treatment technology which automatically dose chlorine
into community or institution level water distribution systems without burdening the end user. Over 1,000 communities
across rural Honduras have installed simple PVC passive chlorinators with guidance from EOS International. However,
EOS technicians can often only monitor chlorinators monthly due to systems’ remote-ness and personnel availability. In
turn communities may go weeks at a time lacking access to safe drinking water and to information about their drinking
water.
Objectives:
Our research seeks to evaluate whether surrogate sensor measurements (oxidation reduction potential (ORP), pH, water
level, and temperature) coupled with estimation and anomaly detection algorithms can be used to:
1. Estimate and monitor real-time free chlorine residual (FRC) levels
2. Optimize technician response to system failures
Methods:
We designed and installed solar-powered, sensor-based monitoring systems which include: ORP, pH, temperature, and
water level sensors, at 6 community water tanks with pre-existing passive chlorinators in rural Honduras. Sensor data
was collected every 15 minutes and transmitted hourly via cellular data to a cloud-based data management platform
(Xylem, Hydrosphere). FRC grab samples were collected at each community multiple times weekly throughout the study
period. FRC samples and sensor data were segregated into train and test data sets to generate and evaluate 2
algorithms: an ORP-only anomaly detection algorithm to detect presence/absence of chlorine, and a multivariable
equation-based algorithm to estimate FRC concentration.
Results:
Our preliminary results suggest that it is possible to use surrogate sensors to detect presence/absence of sufficient FRC
and with some certainty quantify free residual chlorine and water safety, without having to use expensive and difficult
to maintain chlorine sensors. A simple ORP only, alarm algorithm estimated presence/absence of FRC, and a more
complex multi-variable equation-based algorithm estimated FRC concentration accurately when compared to manually
collected free chlorine residual measurements. As we continue to collect sensor-based data, combined with free
chlorine grab samples we have been able to steadily improve these algorithms and generate actionable alerts for
technicians and community water system managers.
Conclusions:
As access to internet and communications technologies continues to grow, so has the use of remote monitoring for
WaSH programs and evaluations. But many of these evaluations have focused on monitoring water quantity or program
use. Reaching SDG 6.1 requires drinking water that is located on premises, available when needed, and free from
contamination—therefore we must improve monitoring not just of quantity but also of quality. Our results suggest
sensor-equipped chlorinators can identify lapses in water quality and alert technicians and community members.
Sensor-triggered alerts will allow technicians to visit these sites on an as needed basis rather than in a cyclical basis,
improving availability of safe drinking water and increasing access to critical water safety information.

Small-scale biodigester systems and child diarrhea in semi-rural Nepal

Caitlin Hemlock, University of California, Berkeley
Additional Authors: Heather Amato, Anna-Karin Hess, Jay Graham, Laura Kwong, Amod Pokhrel

Background:
Hundreds of thousands of biodigesters have been constructed in Nepal. These household-level systems use human and
animal waste to produce clean-burning biogas used for cooking, which can reduce household air pollution from
woodburning cookstoves and prevent respiratory illnesses. The biodigesters, typically operated by female caregivers,
require the handling of animal waste, which may increase domestic fecal contamination, exposure to diarrheal
pathogens, and the risk of enteric infections, especially among young children.
Objective:

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We estimated the effect of daily reported biogas cookstove use on incident diarrhea among children <5y old in the
Kavrepalanchok District of Nepal. Secondarily, we assessed effect measure modification and statistical interaction of
individual- and household-level covariates (child sex, child age, birth order, exclusive breastfeeding, proof of vaccination,
roof type, sanitation, drinking water treatment, food insecurity) as well as recent 14-d acute lower respiratory infection
(ALRI) and season.
Methods:
We analyzed 300,133 person-days for 539 children in an observational prospective cohort study to estimate the average
effect of biogas stove use on incident diarrhea using cross-validated targeted maximum likelihood estimation (CV-TMLE).
Results:
Households reported using biogas cookstoves in the past 3 d for 23% of observed person-days. The adjusted relative risk
of diarrhea for children exposed to biogas cookstove use was 1.31 (95% confidence interval (CI): 1.00, 1.71) compared to
unexposed children. The estimated effect of biogas stove use on diarrhea was stronger among breastfed children (2.09;
95% CI: 1.35, 3.25) than for non-breastfed children and stronger during the dry season (2.03; 95% CI: 1.17, 3.53) than in
the wet season. Among children exposed to biogas cookstove use, those with a recent ALRI had the highest mean risk of
diarrhea, estimated at 4.53 events (95% CI: 1.03, 8.04) per 1,000 person-days.
Discussion:
This analysis provides new evidence that child diarrhea may be an unintended health risk of biogas cookstove use.
Additional studies are needed to identify exposure pathways of fecal pathogen contamination associated with
biodigesters to improve the safety of these widely distributed public health interventions.

Spatial Heterogeneity of Neighborhood-Level Water and Sanitation Access in Informal Settlements in Beira,
Mozambique
Courtney Victor, Emory University
Additional Authors: Denisse Vega Ocasio, Sydney Hubbard, Joshua V. Garn, Karen Levy, Matthew C. Freeman
Rapid urbanization, resulting in population growth within informal settlements, has worsened exclusion and inequality
in access to water and sanitation (WASH) services in the poorest and most marginalized communities. In this study, we
describe the heterogeneity in water service satisfaction and WASH access in low-income, peri-urban neighborhoods of
Beira, Mozambique, and examine whether this heterogeneity can be explained by distance to water distribution mains.
Using spatial statistics and regression analyses, we identify spatial heterogeneity in household WASH access, as well as
consumer-reported satisfaction with water services (services, pressure, quality, and sufficient quantity). We find that as
distance from the water main increased, both access to an improved water source at the household and satisfaction
with water pressure decreases, and water supply intermittency increases, controlling for household density and
socioeconomic status. The odds of a household having access to a water source at the household or on the compound
decreases with every 100-meter increase in distance from a water main pipe (odds ratio [OR] 0.87, 95% confidence
interval [CI]: 0.82, 0.92). Satisfaction with water services also decreases with every 100-meter increase in distance from
a water main pipe (OR: 0.80; 95% CI: 0.69, 0.94). Days of availability in the past week decreases by a factor of 0.22 for
every 100-meter increase in distance from the water main (95% CI: -0.29, -0.15). Findings from this study highlight the
unequal household access to water and sanitation in urban informal settlements, even within low-income
neighborhoods. Describing this heterogeneity of access to water services, sanitation, and satisfaction – and the factors
influencing them - can inform stakeholders and guide the development of infrastructural solutions to reduce water
access inequities within urban settings.

Status of WASH Implementation in Fragile Contexts and Emergency Settings

Jonathan Dahlager, World Vision
Additional Authors: James Tidwell

Background:
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WASH interventions in fragile contexts range from covering the needs of vulnerable populations affected by natural
disasters, disease outbreaks, and slow-onset emergencies, to protracted emergencies, extreme poverty, political
instability, and conflict. Recognizing the multifaceted nature of fragility is critical for more responsive programming.
Fragile contexts require very context-driven approaches, which are often more expensive and require greater
adaptability and planning. However, there is limited guidance available for implementers in these wide variety of
contexts and little has been documented about actual adaptations made in such contexts. Therefore, we began by
developing a synthesis of practices, challenges, and successes by implementers on the ground to form the basis for
effective guidance and future learning about what and how to translate across settings.
Methods:
The purpose of this study was to understand the barriers faced and successes achieved on the ground to provide
practical examples for implementers and to inform a synthesized framework to inform programs and planning in other
countries. We began by identifying national and sub-national contexts which fit under different categories of fragility,
with many complex intersections among them. Based upon frameworks in the existing literature, we assessed project
records from projects in six distinct locations to document existing practices across a broad range of WASH activities. We
then compiled a case study documentation protocol including identifying key informants responsible for implementation
as well as additional stakeholders, such as government representatives. We used a comparative case study method to
assess commonalities, key barriers faced, and promising practices for WASH work in fragile contexts.
Results:
The analysis will report on a synthesis of six case studies on notable examples of fragile context WASH responses and
programming from different areas of fragility and emergency interventions, including responses to draught,
floods/cyclones, refugees and displacement, conflict, outbreaks, and natural disasters. Within each case study, we will
specifically identify technical areas of WASH implementation addressed, such as water supply, sanitation, or hygiene.
Each will provide a summary of the contexts being discussed based on our conceptual framework, programmatic
approaches used, and a breakdown of activities undertaken, overall implications of the adapted WASH work in the
country, and a discussion of key successes and failures observed by implementers and other stakeholders.
Conclusions:
There is extensive investment in community-focused WASH interventions in fragile and emergency contexts. However,
to prepare for the inevitable increase of vulnerable people across fragile and emergency-prone contexts, and improve
fragile context responses, documentation of local approaches and adaptations from existing WASH programs of this kind
are an invaluable starting point. This review will simultaneously celebrate innovative responses and adaptations, while
identifying areas of growth to better serve communities in these contexts.

Strengthening WASH services in health care facilities with the STREAM Disinfectant Generator
Adam Drolet, PATH
Additional Authors: Kofi Aburam, Samuel Akoriyea Kaba, Gloria Ntow-Kummi, Thomas Mugumya, Rony Bahatungire;

Water, sanitation, and hygiene (WASH) services are essential for the delivery of quality health services in health care
facilities (HCF), but global estimates show 25% of HCFs have no water services, 33% of HCFs lack proper hand hygiene
services at points of care, and 36% of HCFs lack chlorine for disinfection. Poor WASH and infection prevention and
control IPC) contribute to the spread of pathogens and health care associated infections (HAIs).
Chlorine is an effective chemical disinfectant, widely recommended for IPC practices, yet not consistently available in
HCFs. A PATH analysis of chlorine inventory data across 18 HCFs in Ghana and Uganda found those facilities experienced
an average of 55 to 168 days per year with zero chlorine inventory from November 2019 to November 2020.
PATH is collaborating with the Ghana Health Service (GHS) and Uganda Ministry of Health (MOH) to strengthen WASH
services in HCFs by introducing the Aqua Research STREAM Disinfectant Generator (STREAM) in health facilities. From
December 2020 to June 2021, PATH led an evaluation of 24 STREAM units in 18 HCFs in Ghana and Uganda. The primary
objective of the evaluation was to assess the technical performance, chlorine supply cost, and acceptability of the
STREAM among health care staff. Results showed that 35,248 liters of 0.5% chlorine were produced over the study
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period, with zero health facilities reporting chlorine stockouts. Mechanical failures in three hardware components
(reaction chamber, power supply, control box) led to redesign by the manufacturer, Aqua Research LLC. Cost analyses
found the STREAM generated a per-liter cost savings of 32% to 38% over the minimum five-year life span of the
STREAM, with district hospitals seeing the greatest potential cost savings: $36,278 (70%) in Ghana and $45,998 (119%) in
Uganda. Acceptability data collected from device users (n=16), hospital administrators (n=10), and district health officers
(n=6) found the STREAM easy to use and easy to integrate into IPC practices, and positively contributed to improving IPC
practices in the HCF. Specifically, 100% of district health officers, hospital administrators, and device users reported the
STREAM significantly or moderately improved IPC practices. The STREAM was preferred by 100% of hospital
administrators (n=10) and 94% of device users (n=16) over previous commercial chlorine products, and 83% of district
health officers (n=6) stated they were very supportive of the STREAM introduction. A follow-on evaluation beginning in
June 2022 in 14 HCFs in Ghana will evaluate the reliability, total cost of ownership, and model the cost-effectiveness of
the STREAM on reducing the risk of HAIs and overall, HAI treatment costs for patients. Preliminary results will be ready
by October 2022.
Evidence generated through these studies has instilled confidence and ownership in GHS and Uganda MOH
policymakers. Key policy, regulatory, and health system integration milestones—such as approval by national health
policy committees, market authorization of the STREAM, and training national biomedical staff on STREAM maintenance
and repair—are paving the way toward national introduction of the STREAM in Ghana and Uganda.

Sub-national government leadership for sanitation: experiences and learnings from East and West Africa
Mimi Coultas, Sanitation Learning Hub, Institute of Development Studies

Background:
Sub-national government (SNG) leadership is acknowledged as essential to reach everyone with safely managed
sanitation. WASH systems strengthening approaches recognize the importance of government leadership but much of
the emphasis to date has been on the national level and on water. To help fill this gap, our research investigated what
influences SNGs to increase their sanitation leadership.
Methods:
In 2020/21, the Sanitation Learning Hub (SLH) engaged SNGs and development partners (DPs) from East Africa (Kenya,
Rwanda, Uganda) and West Africa (Benin, Ghana, Guinea, Nigeria) in a virtual participatory process to explore ways to
galvanize SNG sanitation leadership. Areas were identified with DPs based on a demonstrated increase in SNG sanitation
leadership. SNG/DP pairs developed case studies on these increases, using SLH guidance drawing on the participatory
monitoring methods Most Significant Change (MSC) and Outcome Harvesting (OH). Case study teams initially used MSC
to identify the change(s) in sanitation leadership before using OH to work back from the MSC(s) to identify what may
have contributed to them. Case studies were then shared and analyzed by participants in three participatory online
analysis workshops facilitated by SLH. An inductive approach was used to guide the data analysis during the workshops,
with themes emerging from across the case studies. Findings and emerging recommendations were validated by
participants before being published separately for East and West Africa. This paper presents analysis across the regions.
Results:
1. Building and maintaining political will: A supportive national policy environment to enable SNG sanitation leadership
is key. Sub-nationally, engaging elected officials and technical staff is important. Strategic data speaking to different
stakeholders’ motivations can spark discussion and action. Once engaged, SNGs dedicating regular time to sanitation in
meetings helps maintain visibility and momentum. Navigating changing and/or decreasing political will is challenging,
although positive examples exist of written commitments and by-laws enshrining plans.
2. Role of data: Data can help secure and maintain SNG sanitation leadership. Monitoring data is used to trigger
discussions and foster political will, inform programme design, and advocate for resources. Learning activities and
exchanges can support implementation quality and motivation.

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3. Resourcing commitments: Resourcing sanitation is a challenge for SNGs. Inserting sanitation lines in SNG budgets,
mandating sanitation spending, using results-based financing, and developing policies allowing sanitation funds to be
drawn from different sources support resource allocation. However, all participants acknowledged this as problematic.
4. Leave No One Behind (LNOB): Beyond aiming for community-wide outcomes, ways to ensure SNGs reach everyone
with improved sanitation are vital but a significant gap. Ideas for bridging this included fostering LNOB champions,
improving identification of people who may be vulnerable, and allocating budget for LNOB initiatives, although further
research and learning is needed on these.
Conclusions:
Common levers to change were identified across the case studies, including valuable practical recommendations for
sanitation policy makers and practitioners on ways to support SNG sanitation leadership. Participants also benefited
from the cross-learning opportunities afforded by the participatory research. However, common barriers were also
identified, particularly on LNOB, requiring further research.

Supporting Municipalities to Improve the Ownership, Diversity, and Accessibility of Sanitation Data
Maya Gainer, Athena Infonomics and Gather
Additional Authors: Raheema Abdirizaq, John Peter Archer, and Nicolas Radanielina

This presentation will discuss the recommendations that informed a city-wide, cross-sector partnership that is reshaping
data ownership so that local decision makers can collect, share, and analyze data to create geospatial baseline that
informs investment into sanitation infrastructure and services. The lessons are local to the sanitation sector in
Antananarivo, Madagascar but can also be applicable to the global development sector where there is a need to re-
centre local decision makers at the heart of data for development.
This work drew on three routes for our methodology: literature, data assessment and interviews. Within wider
literature, there is a predominant theme of the dominance of the Global North in the ownership, oversight, and
operation of global data for development. Literature and research within the WASH sector focuses on creating a user-
centered data culture from a national level, rather than city-wide level. We focused on the city-level in our research and
wider work in our organization. The city-wide approach encourages synergy and collaboration that better prioritizes low-
income residential areas where the health risks from insufficient sanitation are highest (Wafler, 2020). In our data
assessment work as part of our Benchmark study, we analyzed publicly available sanitation data for fifty countries at the
end of the United Nation’s Human Development Index. A common pattern we found in the majority of the sanitation
datasets within our Benchmark study across the 50 countries were siloed, incomplete or incompatible datasets. Lastly,
we conducted one-on-one interviews with our stakeholders and members of our Antananarivo Sanitation Data Hub. The
goal of our interviews and workshops was to allow municipal decision makers the opportunity to share what systemic
changes they believe are required to increase local leadership in improving the availability, accessibility, and accuracy of
sanitation data. These responses echoed the literature and underlined the need for change. When we asked the
municipality and municipal sanitation company what could help rebalance the unequal power dynamics that continues
to exist between the Global South and Global North, they made three suggestions:
1. Greater data standardization: more local organizations need to be encouraged to collect data that is more easily
available and accessible for their staff to use.
2. Greater transparency: the responsibility for data governance needs to be clearly allocated to local leaders.
3. Greater budget autonomy: local decision makers need to be able to select tools that allow them to retain information
and share data
The recommendations come from interviews with local decision makers and are corroborated by the recent literature
and an assessment of global data imbalances. This work will outline the scale of the problem but also presenting
workable solutions. Organizations and individuals from the Global North working with data for development need to
consider how our behaviors, projects and partnerships can increase local agency instead of reducing it. We will conclude
with encouraging others to start, continue and further the conversation on how to recentre local decision makers and
communities at the heart of data for development projects.
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Sustaining hospital hand hygiene in Liberia through local hand sanitizer production
Lucy Tantum, University of North Carolina at Chapel Hill
Additional Authors: Ronan Arthur, Ashley Styczynski, Amos Tandanpolie, John Gilstad, Stephen Luby

Introduction:
In rural Liberian hospitals, a lack of hand hygiene supplies and infrastructure contributes to increased risk of infection
transmission. As part of a larger study, we conducted a baseline evaluation of hand hygiene at 7 rural Liberian hospitals.
We found that staff preferred to use alcohol-based hand rub (ABHR) for hand hygiene as compared to soap and water or
hypochlorite solution, but ABHR was expensive and inconsistently available. Hospitals had received past hand hygiene
interventions, including staff training in ABHR production and installation of ABHR dispensers onwards. However, these
interventions were reliant on outside funding and ultimately proved unsustainable. Through a qualitative design
process, we created a sustainable financial structure for ABHR production and hospital supply availability by establishing
a market for Liberian-made ABHR.
Problem Statement:
Essential hand hygiene supplies are often unavailable at Liberian hospitals and efforts to improve availability are often
not sustainable, hindering the formation of hand hygiene habits and undermining health facility preparedness for
disease outbreaks.
Objectives:
The objective of this study was to support and evaluate Liberian entrepreneurial development of a local revenue cycle to
sustain hand hygiene supply availability at hospitals.
Methods:
Following a baseline behavior and infrastructure characterization, we designed, piloted, and implemented an ABHR
production intervention at hospitals in rural Bong, Lofa, and Grand Cape Mount Counties, Liberia in October 2021. We
also formed a strategy to sell ABHR to customers in Liberia and use proceeds from sales to support supply availability at
hospitals.
Results:
We established (or re-established) ABHR production at five hospitals in rural Liberia by procuring supplies and
equipment and training teams of hospital staff following a World Health Organization protocol. All production supplies,
except for pump bottles, were procured in Liberia. Production costs were approximately US $3.00 per liter of ABHR. In
collaboration with one facility, we sought to create a local market for ABHR production by approaching institutions in
the hospital catchment area. However, we found that institutions in the region had limited purchasing capacity. Instead,
we shifted to a centralized approach and, as of April 2022, identified a Monrovia-based international organization
interested in buying bulk quantities of ABHR at a cost of $3.50 per bottle. All revenue from sales will be used to purchase
hospital hand hygiene supplies. To our knowledge, this is the first Liberian-made commercial ABHR product.
Discussion:
This study provides a promising model for sustaining supply availability at hospitals while also supporting local
economies. Liberian customers have expressed high willingness to purchase locally produced ABHR, though the cost of
our product is still a barrier for some. Further work to lower production costs, including by manufacturing plastic bottles
in Liberia and utilizing ethanol generated from local feedstocks, could improve our ability to generate revenue and
sustain production systems. Close coordination with government public health stakeholders will also be essential for
integrating ABHR into hospital hand hygiene supply chains.
Learning objectives:
1. Review experience and results from an intervention intended to establish sustained local alcohol-based hand rub
production for Liberian health facilities
2. Propose an entrepreneurial model for sustaining hand hygiene supply availability through self-sustaining hand rub
production
3. Describe current successes and barriers in long-term sustainability of hospital hand hygiene in Liberia.
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The Impact of Persistence Model Selection on the Assessment of Human Health Risks in Surface Waters
Kara Dean, Michigan State University
Additional Authors: Jade Mitchell

Background:
Fecal pollution can introduce pathogens to surface waters that are used as source water for drinking water, for
recreation, and the irrigation of agricultural fields. Characterizing the potential human health risks associated with
pathogen contamination in surface waters requires an understanding of pathogen fate and transport. Some of the
typical assumptions made within quantitative microbial risk assessments for pathogen fate are that i) indicator
organisms have similar fate characteristics as pathogens of concern, and ii) both pathogens and indicators decay at a
constant rate over time. The uncertainty associated with these assumptions is not well understood and may lead to the
mischaracterization of human health risks. This study aimed to challenge traditional assumptions by evaluating the fit of
five different persistence models to a large database of experiments to determine the importance of model selection for
the prediction of decay metrics and the evaluation of uncertainties associated with the indicator-pathogen paradigm.
Methods:
A systematic literature review was conducted to identify available data in the literature that documented the
persistence of pathogens or indicators over time in natural surface waters with varied water quality conditions. There
were 61 studies selected that yielded 629 datasets for subsequent analyses. The five persistence models were fit to each
dataset using Maximum Likelihood Estimation methods and best fitting models were selected using normalized root
mean square error and Bayesian Information Criterion values. Best fitting models were used to predict the time required
for a 1-log reduction (T90), 2-log reduction (T99) and 3-log reduction (T99.9). Factor analyses were completed with the
persistence values as the dependent variables and the water quality conditions as the independent variables.
Results:
Juneja and Marks 2, a two-parameter model, was the best fitting model most frequently. First-order decay kinetics
provided the best fit to less than 20% of the datasets. The Juneja and Marks 2 model accommodates a sigmoidal shape,
accounting for initial periods of minimal decay (shouldering) and decay rates that taper off over time (tailing). The
improved accuracy of the Juneja and Marks 2 model was more pronounced for predicting the time required for higher
log-reductions (>2), with minimal effects observed on the distributions of predicted T90s and T99s. The factor analyses
identified temperature, predation, and water type as key factors influencing the observed persistence behaviors, and
protozoa persistence differed the most from fecal indicator bacteria. The quantification of the difference between fecal
indicator bacteria, bacteriophage, pathogenic bacteria, virus, and protozoa persistence yielded uncertainty factors that
can be applied to improve the utility of the indicator-pathogen paradigm.
Conclusion:
This study highlights the importance of understanding pathogen-specific persistence behaviors and demonstrates that
decay is more dynamic in surface waters than first-order decay kinetics. An improved understanding of persistence
modeling will allow for more accurate predictions of risk, facilitating the optimization of the reliance on natural
attenuation. The models generated through this work can be leveraged to improve risk assessments and decision-
making processes involved in the evaluation of water reuse applications, beach monitoring practices, and water
treatment.
Key Learning Objectives:
Persistence curves for microorganisms can have many features, including tails, shoulders, and linear regions.
The importance of model selection is more pronounced for modeling and predicting higher log-reduction values of
interest (>2).
Uncertainty introduced through over-simplified model selection has implications for human health risks in natural
surface waters.

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The message is the medium: influence of storage media on DNA recovery from stool samples
Troy Barker, Department of Environmental Science and Engineering, Gilling’s School of Global Public Health, University
of North Carolina at Chapel Hill
Additional Authors: Drew Capone, Joe Brown

Analysis of stool samples is critical in WASH: pathogen detection in feces is an unambiguous marker of exposure and
may yield important health information. Analysis of stool for pathogen-associated DNA is now common in health impact
trials, though the wide range of methods used creates challenges in comparing results across studies. Because sample
analysis by advanced molecular methods often occurs far from field sites, stools are commonly preserved in transport
and storage. A wide range of preservation methods are available, and few studies have attempted to compare them for
DNA recovery efficiency. Our study aim was to compare the performance of five commonly used stool preservation
buffers to recover DNA from three pathogen types (helminth, protozoa, and bacteria).
We used hookworm positive (Ancylostoma caninum) canine stools spiked with a high concentration of Giardia
duodenalis and Shigella spp. to each stool. We homogenized and combined each stool 1:1 in the following preservation
buffers: zinc polyvinyl alcohol (Zn-PVA), universal extraction buffer (UNEX), TotalFix, 70% ethanol, and Camacho‐Sanchez
et al. 2013 nucleic acid preservation buffer (NAP). All buffers were stored at ambient conditions, except Zn-PVA which
was stored separately at ambient and at 4°C. We extracted nucleic acids from fresh stools before buffers/fixatives were
added on day 0 (immediately after adding buffers), day 14, day 28, and day 56. Then, we used dPCR to quantify
pathogen gene copies.
We observed differences in recovery over time for the different preservation buffers and conditions. The log10
reduction in gene copy concentration per gram stool between day 0 and day 56 for Ancylostoma caninum in ZnPVA at
ambient temperature was -2.2 log10 [95% CI: -2.5, -1.9], TotalFix at ambient was -1.5 log10 [95% CI: -2.2, -0.79], 70%
ethanol at ambient was -1.3 log10 [95% CI: -1.4, -1.1], ZnPVA at 4°C was -0.73 log10 [95% CI: -1.3, -0.13], UNEX at
ambient was -0.30 log10 [95% CI: -1.0, +0.36], and NAP at ambient was -0.10 log10 [95% CI: -0.54, +0.35]. The analysis
for Giardia duodenalis and Shigella spp. will be completed by June 1st, 2022.
Our results show that ZnPVA at room temperature was the worst-performing preservation buffer and that the NAP
buffer performed the best. These results may help WASH researchers select a preservation buffer to use in future
studies.

The Risk of Arsenic in Drinking Water in Somotillo Municipality, Nicaragua

Osler Guillen, Living Water International
Additional Authors: Bob Thorp; Maicol Calderón; Osler Guillen; Rob Pettigrew

Even low levels of naturally occurring arsenic in drinking water has been linked to higher risks of cancer, diabetes,
cardiovascular disease, respiratory disease, cutaneous issues, and impaired cognitive development in children. However,
little is known about arsenic concentrations in aquifers in Somotillo Municipality, Nicaragua.
Twenty of the 31 communities in the municipality were selected. A sample from every drinking water source (n=42) in
the 20 communities was taken by Living Water staff. The sampled water sources included 14 deep drilled wells (≥200
feet), 11 shallow drilled wells (<200 feet), 12 hand-dug wells, 3 rivers, and 2 springs. Samples were transported to the
Living Water Nicaragua office and tested to evaluate the presence of arsenic using the HACH Arsenic Low Range Test Kit.
In addition, pH, TDS, hardness, and turbidity were measured as well.
Arsenic was identified in 16 of the 42 water sources tested, including seven of the deep drilled wells (50%), three of the
shallow drilled wells (27%), three of the hand dug wells (25%), and all three rivers (100%). Six of the drilled wells with
arsenic were between 200 and 350 feet deep. No water sample collected from a spring had detectable arsenic. Three
water sources, two drilled wells and a hand-dug well, exceeded the WHO guidelines of 10 ppb. The highest
concentration of Arsenic found was from a thermal drilled well with five times the allowable limit of arsenic, while the
other two wells had double the WHO guidelines for arsenic.

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These results indicate that while there is arsenic present in Somotillo aquifers, it is not exceeding allowable parameters
in most locations. Therefore, Living Water recommends that all water points in the municipality be tested and
monitored for arsenic to evaluate the health risk. We recommend these results inform future water source development
plans. If a water source exceeds the WHO guidelines for arsenic, we recommend avoiding additional water source
development within one kilometer of the location. Further, these results suggest that certain types of water sources
(thermal wells, wells between 200 and 350 feet, and rivers) may be more likely to have arsenic in Somotillo, while
springs may be less susceptible. This information will be useful for Living Water's future programming in the
municipality, as well as for other WASH actors working in areas with naturally occurring arsenic in aquifers.

The Search for Safe Water: Assessing Bottled Water Quality in Rural Southwest Virginia
Rasheduzzaman, Virginia Tech
Additional Authors: Amanda Darling, Rebecca Pioso, Leigh-Anne Krometis, Alasdair Cohen

Background:
Thousands of people in the rural Appalachian region struggle with access to safe drinking water. Many of the people in
the Central Appalachian region rely on community water systems (CWS), but many CWS have histories of Safe Drinking
Water Act violations, and a substantial proportion of rural households rely on private wells. Residents who are
concerned about the water quality of their CWS as well as those who lack access to CWS rely on private wells, bottled
water, and roadside springs. Although bottled water is considered to be safe, previous studies found evidence of
chemical and biological contaminants in bottled water. In 2021, we collected bottled water samples from a cluster of
rural homes in Wise County (for an ongoing cohort study); two-thirds of these households (66.6%, n=6) used bottled
water as their primary drinking water source.
Objectives:
We aim to measure chemical constituents, levels of disinfection byproducts, and microbiological indicators in samples
from all brands of bottled water sold in grocery stores in Wise County, VA, and to report whether or not they meet FDA
and USEPA drinking water standards. In addition, we will compare bottled water testing and analysis results with
publicly available testing results provided by bottled water companies to identify potential inconsistencies in reported
testing results.
Methods:
Bottled water sample sites were selected to ensure geographic coverage of all the municipalities in Wise County with
grocery stores, or other “big-box” retailers that also sell groceries. All available brands of commercially bottled water will
be purchased from the selected stores in Wise and different sizes of available brands will be purchased. Measurements
will be taken for pH, temperature, conductivity, and dissolved oxygen and samples will be also tested for E. coli and total
coliform, nitrate, sulfate, total trihalomethanes (TTHMs), fluoride, and heavy metals such as arsenic, cadmium, and lead
(via ICP-MS).
Initial Results:
A total of seven grocery stores were identified and visited to create a catalog of bottled water brands, sizes sold, and
associated pricing. Based on this effort, we plan to purchase and analyze samples from 64 different brands and bottle
size combinations across all stores (bottled water only, excluding flavored beverages). Bottled water purchasing and
analysis is scheduled to begin in late May 2022, with all results expected and a draft manuscript prepared by September
2022.
Broader Significance:
Our initial literature review also revealed that the bottled water companies do not make the testing results always
available to the public and many companies do not reveal the tap water source of their product. Initial findings from
ongoing fieldwork in the same county also indicate that most rural households may rely on bottled water as their
primary source of drinking water. Our detection of total coliforms (and nitrate exceeding ½ the EPA MCL in three bottled
water samples) indicates that findings from this study will help the residents to understand if drinking bottled water in
preference to water from a typical community water system is justified in terms of biological & chemical characteristics.
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Towards a harmonized approach for COVID-19, Polio, AMR and future hazard wastewater surveillance
Jerome Lock-Wah-Hoon, National Institute for Public Health, and the Environment (RIVM), Netherlands
Additional Authors: Joris Sprokholt, Heike Schmitt, Erwin Duizer, Ana Maria de Roda Husman

Key Words: COVID-19, Polio, AMR, guidance, sewage surveillance, wastewater-based epidemiology
Key learning objectives:
• Understand the notion of harmonizing wastewater surveillance and added value
• Understand key programmatic activities that should be considered under the harmonized approach
• Learn about country case studies
• Suggest how practitioners may implement the harmonized approach
Background:
The COVID-19 pandemic has placed increased attention on wastewater surveillance, and surveillance programs targeting
the virus and its known variants have grown considerably worldwide. The wastewater surveillance approach has already
been used in the past decades for poliovirus surveillance to determine prevalence and inform public health actions,
including vaccination programs. Site selection, sample logistics, and sample (pre)treatment at the laboratory are labor
intensive and costly elements of any wastewater surveillance program. And beyond confirming the technical and
scientific applicability of the approach, the consideration of factors from the public health lens that include governance,
ethics, and logistics are important. Our objective is to develop a multi-pathogen common harmonized approach for
SARS-CoV-2, poliovirus, AMR, and future hazard. We target this approach to environmental scientists, public health
practitioners, and outbreak managers.
Method:
Key information from the literature and resources from national authorities currently implementing wastewater
surveillance programs in Pakistan, Iraq, Canada, South Africa, Australia, and the Netherlands informs this approach.
Country authorities were chosen based on contrasting levels of wastewater surveillance implementation, geographic
location, and governance system.
Key findings:
Under a harmonized approach, we find that sample logistics, sample pre-treatment and sample storage are feasible
targets for harmonization. Harmonization provides cost efficiencies, system simplicity, and increased feasibility, and is
particularly beneficial in low resource settings. We find that multi-pathogen wastewater surveillance programs should
be designed to benefit public health in local communities and designed to inform targeted interventions led by public
health practitioners. We find that current and future health hazards can be added to existing wastewater surveillance
program with the intention to inform public health authorities and outbreak managers.
Conclusions:
The harmonization of wastewater surveillance for SARS-CoV2, poliovirus, AMR and future hazard can optimize the use of
financial resources, contribute to system simplicity, and program feasibility. Identified areas of harmonization can have
implications for wastewater surveillance programs, which may improve the management of those programs for current
and future hazards. These findings may lead to direct policy outcomes to increase opportunities for collaboration
between environmental, public health, and government authorities.

Two systematic reviews investigating drinking water perceptions and health outcomes connected to private water use
in Pennsylvania
Leslie Ford, Pennsylvania State University
Additional Authors: Kaitlyn Barnhart, Siddhi Deshpande, Andrew Warner, Asher Rosinger

While approximately 2-3 million rural Pennsylvanians use private water supplies for domestic purposes, Pennsylvania
has no state-wide well drilling or water quality testing requirements for private water sources. The lack of monitoring
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hides potential water supply and quality issues and may have unintentional effects on water trust. Further, this can lead
to negative health outcomes as well as water insecurity – which is defined as the inability to access and gain adequate,
reliable, and safe water for wellbeing and a healthy lifestyle. To begin addressing this gap, we conducted two systematic
reviews of existing literature to understand 1) social perspectives around water insecurity among those dependent on
private water supplies in Pennsylvania and 2) associations between private water sources and health outcomes. We
used the PRISMA reporting checklist to document the review process and searched in Scopus, Web of Science, PubMed,
ProQuest, Compendex, and Google Scholar. The search period was from January 01, 1970, to June 2020 with only
English-language studies included. The first systematic review found 77 results and identified 10 articles which met the
inclusion criteria. The second systematic review found 154 articles and identified 15 which met the inclusion criteria.
The results of the first review indicated that most papers focus on well water as the primary drinking water source, while
others discussed multiple private water sources being used simultaneously including wells, springs, cisterns, and others.
All 10 papers identified that people use multiple methods of coping with water quality concerns. These included
purchasing bottled water, hauling water from other sources, having in home water treatment, or boiling water, and
purchasing homes away from shale gas drilling sites. The most common views on water discussed were categorized into
economic injustice (n=7), water risk (n=6), water governance (n=5), water equity (n=3), and environmental injustice
(n=2). There were multiple causes identified for water insecurity, including industry and development (n=3), water
management (n=3), and environmental (n=1). Only two of 10 articles explicitly discussed mental health, while others
(n=6) implied or mentioned mental health as a concern related to water.
Of the 15 articles identified through the health impacts review, 80% of the articles (n=12) discussed well water
exclusively. The most common sources of water quality issues identified were chemical contamination (n=8) and
biological contamination (n=7), not exclusive. Seven of the articles discussed the relation between water quality and
acute health conditions, while eight discussed chronic conditions. Acute conditions mentioned included diarrhea,
fatigue, nausea, stomach pain, and skin irritation. Chronic health conditions include Parkinson’s disease, cancer, and
thyroid disease.
These systematic reviews found that research on water insecurity in Pennsylvania is limited, however, there are some
studies which note ongoing water challenges and highlight new areas of concern which require further study. From
these we identified opportunities for new research to further quantify water insecurity, social perspectives, and health
concerns around private water sources in Pennsylvania. Future work should identify appropriate interventions to reduce
these burdens.

Understanding iron concentration and chlorine demand of underground tubewell water at Rohingya camp, Cox's
Bazar
Nuhu Amin, icddr, b
Additional Authors: Ahshanul Haque, Mahbubur Rahman

Background:
Water contamination is one of the most important causes of death globally. A recent estimate suggested that more than
two million deaths occur each year due to water pollution. Water contamination with fecal matter is more serious in
humanitarian settings because of a severe outbreak of water-borne diseases like diarrhea and cholera. Recent evidence
suggests that point-of-use water treatment with chlorine may reduce diarrheal disease. Which ultimately reduces the
number of <5 child death. Chlorination of underground water is challenging due to various iron concentrations.
Understanding iron concentration and appropriate residual chlorine in water are important to achieving the WHO
standard free chlorine residual (FCR: 0.2-2mg/L) within 24h of treatment. We developed an easy and inexpensive
technique to explore iron concentration and assessed the chlorine demand in underground tubewell water at the
Rohingya camp, Cox's Bazar, Bangladesh.
Methodology:
From August to September 2019, we randomly selected 106 shallow-tubewells (<75m depth) from the Kutupalong
Rohingya camp. We pumped out 10L of water from each tubewell into a clean plastic bucket. Then the fieldworkers
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added 3mL of 2.62% commercially available chlorine bleach in the form of sodium hypochlorite solution (NaOCl)
(Clorox®: Clorox-Company, Oakland, CA, USA) and mixed well. Immediately after mixing, the fieldworkers tested the
water for iron (Hach-color-disk test-kit, Loveland, Colorado), total dissolved solids (TDS) (Hanna instruments, California),
turbidity, and FCR in collected water. Similar physiochemical parameters were measured after 10 minutes, 30 minutes,
and 24h of mixing NaOCl. Iron concentrations were categorized into low (<3mg/L), medium (3-5mg/L), and high
(>5mg/L) for analysis and comparison. Odds Ratios were calculated using logistic regression stratified by time periods
(Immediately, 10min, 30min, and 24h) model where the outcome variable was FCR value (1=FCR>0.2; 0=FCR<0.2) and
exposure variable was iron concentration (Ref: iron<3mg/L).
Result:
The overall mean concentration of iron was 2.50mg/L (sd=2.93; range:0-7), turbidity: 1.83 NTU (sd=2.91), and TDS:153.4
PPM (sd=62.32) in tubewell water. More than 70.0% samples had iron concentration <3mg/L, 3.8% samples had iron
concentration between 3-5mg/L and 29.3% samples had iron concentration >5mg/L. With iron concentration <3mg/L in
tubewell water, we achieved a mean of 1.24 mg/L FCR, with iron concentration 3-5mg/L, we achieved a mean of
0.62mg/L FCR, and with iron concentration of >5 mg/L, we achieved a mean of 0.07mg/L FCR within 24h of adding
NaOCl. Odds of having FCR ≥0.2mg/L were 175 times (OR: 175, 95% CI: 21.30-1437) high among the tubewells with iron
concentration <3mg/L compared to tubewells with iron concentration >5mg/L.
Conclusions:
We developed an easy and low-cost method to understand the chlorine demand in underground water with different
iron levels. A high concentration (2.62% NaOCl) of raw chlorine required to achieve WHO recommended FCR in water.
Treatment efficacy was higher with a low iron concentration (<3.0mg/L) in the water. Iron concentration between 3.0-
5.0mg/L was also feasible to treat tubewell water, but when the iron concentration exceeded >5mg/L, WHO
recommended FCR was not achieved within 24h treatment. Future studies should focus on the microbial efficacy and
acceptability (smell/taste) of treated water with high chlorine dosing.

User testing of a NoMix Toilet and sensor-based assessment of hygiene practices

Claire Welling, Duke University
Additional Authors: Prateek Kachoria, Sarani Sasidaran, Lotte Kristoferitsch, Sonia Grego

Urine diversion in a NoMix Toilet is a promising approach for sustainable fertilizers and reducing the nutrient load for
wastewater treatment systems. User adoption of such toilets has been a challenge because dry, waterless toilets offer a
less desirable user experience, while flush based NoMix toilet have been traditionally found cumbersome and unreliable.
This study evaluates the Urine Trap, a novel design for a NoMix flush toilet that achieves passive separation of urine and
flush water in a toilet where the urine stream inlet is invisible to the user and hence causes no user behavior change.
This study installed and evaluated one NoMix flush toilet prototype in a multi-stall bathroom facility in two sites in India.
The system was tested with women users who had free, uncontrolled access to the test stall as well as other bathroom
stalls. The facilities were custom-built to test toilet technologies and feature a separate engineering space to collect and
monitor the two waste streams: urine and feces + flush water.
Over 850 uses were recorded in 50 days in three different testing periods. No maintenance was required on the squat
plate during the study. Analytical characterization of the two waste streams found substantial separation of total
nitrogen (TN), 36%, from the wastewater and 45% TN removal if supernatant is considered. These removal values
represent a valuable reduction for treatment systems that target removing 70% of the influent TN per ISO30500
standards. While effective, the separation efficiency of the NoMix squat plate under this test was significantly lower
than the expected 70-80% TN removal. This unexpected result drove to the development of a method to gain insight
into user behavior that may impact system performance.
We recorded with high temporal resolution from digital scales on waste collection tanks and from sensors monitoring
bathroom door opening and cleansing water use. By using sensors, we demonstrate a method to non-invasively yet
quantitatively gain insights in user behavior in a private act such as toilet use.

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The analysis of this dynamic dataset provided information on user actions and practices. We were able to identify type
of excretion (urination or defecation) and user washing actions such as use of wand bidet, mug cleaning and toilet
flushing. The results show that habits such as wetting the squat plate before use is common. While this practice by itself
does not impact TN separation, it significantly degrades the TN separation if this is carried out while urinating. Also, the
data shows that body position or aiming during a urination has a much wider range of possibilities than originally
envisioned. An understanding of user practices can inform interventions, such as user education, and deployment
strategies to maximize performance.
Adoption of urine diversion may be greatly beneficial to the environment and sustainability. This field-testing study
suggests that the Urine Trap is a promising approach to urine diversion and that its TN removal performance could be
even higher but is impacted by practices of the washer’s culture.

Voices of manual pit emptiers: their crucial role in FSM, challenges faced, and desired support
Dennis Gichimu, Sanergy
Additional Authors: Kelly James, Alidou Bande, Lauren Trondsen, Ruthie Rosenberg, Laura Kohler

The global sanitation crisis poses unique challenges in densely populated urban informal settlements, in which many
residents rely on poorly constructed pit latrines that must be routinely emptied but are inaccessible to vacuum trucks
and other mechanical means of emptying. These unique challenges require-and have engendered-creative solutions,
including manual emptying of pit latrines. While their services often do not meet standards for safe management,
manual pit emptiers (MPEs) provide an essential service by removing sanitation waste from the communities where no
other options exist. MPEs are the ones who ultimately find a way to get waste out of communities, no matter how
inaccessible, unstable, or otherwise suboptimal the containment. Promoting the health, safety, and dignity of sanitation
workers is an increasing priority within the WASH and labor sectors, but the perspective of MPEs is often absent due to
heavy stigmatization and the informal nature of their work.
We developed an MPE-centered approach to bring them directly into the conversation. We conducted six focus group
discussions (FGDs) in Senegal, Burkina Faso, Malawi, Kenya, Cameroon, and Uganda to understand the work MPEs do,
how it impacts their lives, their families, and their communities, and to identify opportunities for support. Local
sanitation workers within each country were trained and supported to facilitate FGDs and leveraged their existing
relationships within manual emptying groups to recruit participants and create a comfortable environment for them to
speak openly. Each FGD had five to seven participants and lasted two to three hours. Detailed notes were recorded and
compiled, and inductive coding analysis was used to analyze the data and to develop themes based on the experiences
and opinions that were shared.
Our analysis yielded three main themes: the life of a manual emptier, manual emptying challenges, and opportunities to
improve working conditions. Key findings in the theme of “a day in the life” included practical understanding of
interactions with customers, methods for assessing pits, determining prices, and details on methods for emptying and
transporting waste. Top challenges identified included stigmatization, risks to their physical health and safety,
uncertainty of payment and lack of affordable and efficient emptying and transport tools. Desired support and
opportunities for collaboration included peer-to-peer learning, training on business skills, developing more gender- and
weather-friendly PPE and establishing professional organizations. Manual emptiers presented the FGD findings to an
audience of global WASH stakeholders in a webinar series in 2021, and actively participated in the resulting
conversation.
The formal WASH sector cannot afford to continue without incorporating the expertise of MPEs. Their nuanced
understanding of the complexities of sanitation service delivery in urban contexts is an irreplaceable asset, and their
creativity, problem-solving skills, and decades of experience position them as invaluable contributors to the design and
scale of the safe, efficient, and sustainable solutions that are necessary to expand access to safely managed sanitation
services to all, including the urban poor. We hope that sharing our methods and results demonstrates the feasibility and
value of incorporating MPE perspectives and encourages increased representation of MPEs.

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Water and sanitation insecurity and COVID-19 prevention behaviors in low-income neighborhoods of Beira,
Mozambique
Rebecca Kann, University of Washington
Additional Authors: Karen Levy, Matthew Freeman, Jedidiah Snyder

Background:
WASH inequalities are important drivers of the global burden of disease, and their impact is exacerbated during
outbreaks and health crises. Water security - as a function of water availability, quality, and accessibility – may
determine the resilience of households and disease risk to household members. In particular, households who lack
direct access to sanitation and water services at their home or compound may be at higher risk of COVID-19 both
because they are forced to leave the home for provision of these services and are unable to adequately practice
mitigation behaviors, such as handwashing. In this study, we explore the interaction of water and sanitation insecurity
with control measures for global health crises.
Methods:
We investigated the relationship of demographic characteristics, risk perceptions, and WASH-related factors on disease
prevention behaviors such as hand hygiene, social distancing, and masking in low-income neighborhoods of Beira,
Mozambique during the COVID-19 pandemic. We utilized data collected from 1762 randomly selected households
during a population-based survey in November to December 2020. We fit multivariable logistic regression models to
examine the associations between various WASH factors and disease prevention outcomes of interest (reported
handwashing, social distancing, and masking), adjusting for individual- and household-level demographic characteristics
and risk perceptions relative to the COVID-19 pandemic.
Results:
There was a high level of reported adherence to disease prevention behaviors and belief in risk perceptions that aligned
with facilitators of disease prevention behaviors among the study population. People with lower levels of water
insecurity had a statistically significantly lower odds of reported handwashing (aOR=0.9; 95% CI: 0.82-0.99) and social
distancing (aOR=0.85; 95% CI: 0.8-0.92). People with a shared sanitation facility had a statistically significantly lower
odds of reporting handwashing (aOR=0.35; 95% CI: 0.16-0.74), and a lower odds of reporting social distancing
(aOR=0.59; 95% CI: 0.34-1.03) and masking (aOR=0.67; 95% CI: 0.39-1.17). People with a basic handwashing station,
compared to no facility or a limited facility, had a statistically significantly higher odds of reporting handwashing
(aOR=4.55; 95% CI: 2.44, 8.82), and those that had a fixed handwashing station, compared to a mobile handwashing
station, had a higher odds of reporting handwashing (aOR=2.25; 95% CI: 0.75-8.78) and social distancing (aOR=2.23; 95%
CI: 1.01-5.58).
Conclusions:
Access to improved handwashing and sanitation services play an important role in enabling people to practice disease
prevention behaviors, including handwashing and social distancing. Policy and investments in low-income settings
should prioritize reducing WASH insecurity as a fundamental strategy for building resilience to future health crises.

Water Journeys: Using Walking Interviews and Videos to Explore Water Fetching Risks in Urban Environments
Anna Mittag, University of Notre Dame
Additional Authors: Ellis Adjei Adams, Sydney Byrns, Save Kumwenda, Richard Quilliam, Heather Price

As the slum population in sub-Saharan Africa rapidly grows, so have the public-health risks associated with unsafe
and/or inadequate water. Most of sub-Saharan Africa’s population lack in-home water access, and so they rely on public
sources. In these settings, women are most often tasked with the job of water fetching, and they are therefore
disproportionately affected by its associated risks. While most of the prior literature has focused on household
experiences of water-insecurity, we focused on understanding how women’s water journeys exposes them to different
environmental risks. We conducted video-recorded walking interviews in Ntopwa, an unplanned urban settlement in
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Blantyre, Malawi. We identified three principal sources of environmental risk— terrain, built environment, and human
behavior—those present challenges for water collectors. These risks illustrate how the practice of water fetching strains
women, not only due to exposure but also because of the compounded stresses of complex decision making and
constant trade-offs. Our findings underscore that interventions seeking to improve household water insecurity must
consider the impact of environmental risks on the burden of water fetching. This study also serves as a template of best
practices for using walking interviews and videos for water and health research.

Water, Sanitation, and Hygiene Among Urban Recreational Vehicle Residents: A Case Study in Seattle, WA USA
Karen Levy, University of Washington (UW)
Additional Authors: Leigh Hamlet, Graham Pruss, April Ballard, Chris Wilkerson, Jessica Kaminsky

Among people experiencing homelessness in the urban United States (US), people living in recreational vehicles (RVs)
are some of the most underserved and understudied. In terms of water, sanitation, and hygiene (WASH), RV residents
are part of the country’s minority without consistent access and are unique in their use of onboard facilities. Though
little is known about the everyday WASH practices of RV residents, it is recognized that unsafe disposal of vehicle
wastewater has increased the risks of disease transmission and infection in densely populated cities. In response to this
public health concern, in 2020 the City of Seattle, WA piloted a first-of-its-kind, door-to-door pump-out program to
collect RV waste free of charge. We leverage the opportunity provided by this program to investigate the WASH
experiences of RV residents in Seattle, in addition to offering a new service delivery model for other cities. Specifically,
our study’s objectives were to: (1) characterize RV residents’ WASH conditions and pilot program experience; (2)
recommend ways to support RV residents’ WASH needs from outreach and government perspectives; and (3) describe
the pilot’s operation and lessons learned to help guide future programs in Seattle and other cities.
All data were collected through semi-structured interviews in the spring and summer of 2021. RV residents (n=32)
participating in the pilot program were recruited for (typically) in-person interviews via convenience sampling and asked
questions about their living situations, WASH, and wastewater disposal knowledge and practices. The outreach and
government interviewees (n=10) were purposively sampled for remote interviews and asked about their work with RV
residents and recommendations for addressing RV residents’ WASH needs. To complete our first objective, we will
analyze the vehicle resident interview data through qualitative content analysis. Drawing on the concept of WASH
security, we will code for themes of accessibility, adequacy, reliability, safety/quality, and acceptability. In addition, we
will perform a class analysis to compare the frequencies of themes across different sub-groups based on age, gender,
and length of RV residency. We plan to conduct an inductive thematic analysis with the professional interview data to
accomplish our second objective. Our third objective will be met by incorporating field work observations and themes
from both sets of interviews that relate to the pilot’s operation or client experience.
Notable trends from preliminary inspection of the data, separated by objective, include (1) the inadequacy of water
available for domestic purposes; (2) the importance of conducting needs assessments prior to funding and implementing
WASH programs for RV residents, a heterogeneous population; and (3) the efficiency of partnering social service delivery
with door-to-door pump-outs.
Overall, this research adds critical information to the understudied issue of WASH provision and access for urban US RV
residents, a population that grew during to the pandemic. This study is a necessary first step in promoting future
investigations into best practices for providing WASH services to RV residents in Seattle and other cities.

Weather dependent pricing of water in rural sub-Saharan Africa to reduce rainfall-related disease
Will Ingram, University of Oxford, REACH Programme
Additional Authors: Patrick Thomson

Across much of rural sub-Saharan Africa households are known to shift water collection during periods of rainfall away
from cleaner groundwater sources towards free alternative sources like surface water or rainwater harvesting. This can
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save household expense, but often increases disease risk and decreases sustainability of service provision. New
approaches to incentivize households to maintain their collection of clean groundwater use could mitigate this
environment-water challenge, and therefore improve community health over the year. ‘Water ATMs’ are increasingly
commonly installed at part of rural piped systems across the region, which remotely monitor volumetric use and
facilitate pre-payment, and as such this technology now opens the door to more nuanced pricing interventions. The
objective of this work is to propose and investigate the potential of a novel pricing mechanism predicated on reducing
water price at water ATMs during periods of rainfall.
To do this, we calculate suitable water price reductions for (generic) water ATMs that we derive from measured
reductions in collection of -20% to -30% over rainfall periods (in Tanzania, The Gambia, Kenya, Malawi, Uganda, Ghana,
and Ethiopia), determined from available satellite-based records and other literature. We apply this price mechanism to
different scenarios based on real communities in Tanzania and The Gambia, and other likely scenarios, across likely
ranges of price elasticity (-0.5 to -1) and relative risks of diarrheal disease from this intervention (0.4 to 0.8), both
determined from representative literature, to estimate the (annual) cost per capita and cost per DALY (disability-
adjusted life year) averted from such an intervention. Sensitivity (one-at-a-time) and uncertainty (Monte Carlo) analysis
is undertaken on the key inputs. We also investigate additional ‘days of free water’ beyond heavy rainfall thresholds.
Across the scenarios studied here, there are estimated to be between 5 and 50 USD per DALY averted. The implication
from these results is that costs would compare favorably against those reported for other water quality interventions
(and against other economic benefits of improved community health). Cost and value would depend on greater
community response to reduced pricing along with greater reduction in disease from maintained use of cleaner water.
At this stage, the uncertainty of inputs manifests in relatively wide probability distributions (relative widths: ~0.51;
~0.74), however, these skew towards lower costs suggesting higher likelihoods of favorability. Pricing and length of
pricing blocks could be tailored to different community settings to minimize cost per DALY averted.
In conclusion, these findings suggest that weather dependent pricing has potential to cheaply mitigate the disease risk
that comes with rainfall. It is envisaged as a flexible intervention for service providers that can piggy-back on existing
water ATM projects without further capital expenditure, moving this increasingly used technology towards more
sophisticated remote management, thus supporting professionality service delivery. Implementation will require
understanding community behavior and context. Subsidizing costs may provide a new avenue for accurate subsidy
transfers to service providers for precisely measured lost revenues at community-scale, and its flexibility to weather may
buffer the water-health impacts of climate change, both relevant for policymakers.

What a difference a day makes – especially in water quality testing

Esther Shaylor, UNICEF
Additional Authors: Rick Johnston

Current options for carrying out microbiological water quality testing in field settings have a number of limitations that
need to be considered; including the cost per test, the size of the equipment and how easy it is for someone to process a
sample and read results. Most existing tests have a time to result of at least 18 hours, which impacts how the
information can be used.
UNICEF and WHO have been working with manufacturers to stimulate innovations in water quality testing equipment
that could allow communities, governments, utilities and other actors to conduct water quality testing more efficiently,
at lower cost, and in much shorter time frames.
A number of candidate products have been identified, using different processes such as Next Generation Sensors (NGS),
Adenosine triphosphate (ATP), immunoassays, Tryptophan Like Fluorescence (TLF) and biomarkers. These do not
necessarily measure the presence of infectious E. coli, which is the indicator of fecal contamination recommended in the
WHO Guidelines for Drinking-Water Quality.
UNICEF developed and released a Target Product Profile giving an overview of use cases, potential market size and
aspirational technical specifications, which has been used to engage and interact with manufacturers to stimulate
innovations to meet the outlined requirements. Since 2020 UNICEF has met with over 30 manufacturers who are
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developing products that could be handheld, cost under $6 per test and give microbiological water quality results in
under 2 hours. UNICEF is working with national partners to explore how these innovative products could be used in
different settings, and the extent to which alternative indicators to risk in drinking water could be used by the water
sector.
A set of field trials are being carried out in Nigeria and Indonesia to understand the benefits of rapid water quality tests
in settings where lab testing is not feasible. Working with potential users like water committees and small-scale utilities,
along with decision-makers on what type of product is acceptable and those who undertake product purchasing, UNICEF
hopes to better understand what a difference a day would make in identifying the risk from drinking water, what users
are willing to pay for this and how results that don’t identify E. coli might be used.
While interest from users and decision-makers is one element to understand, another is how much confidence we have
in the products to product accurate, actionable results. Many of the innovative products do not have reference
standards for validation in field settings. Therefore, WHO has established a partnership with AOAC international to
develop a laboratory-based performance test methodology that will review product performance against different
challenges to understand how well the products identify risk in drinking water.
Through these two pieces of work, we hope to demonstrate how rapid, affordable water quality testing would be useful
to different users, and to feed these experiences back to manufacturers to further incentivize innovation in water
testing equipment and allow national partners to take advantage of the difference a day would make.

Who has sheds? Practices and determinants of overnight housing for backyard poultry in rural Bangladesh
Elizabeth Thomas
Additional Authors: Laura H. Kwong, Shifat Khan, Salma Akter, Tarique Nurul Huda, Peter J. Winch

Background:
Small-scale poultry-rearing contributes to income and food security for most rural households in low- and middle-
income countries. However, poultry are often kept inside the main household dwelling at night, posing health risks to
the people raising them. Housing poultry outside the dwelling overnight is a potential intervention to limit young
children’s exposure to poultry feces. In this study, we describe practices and determinants of overnight poultry housing
in Bangladesh as part of formative research for a hygiene intervention to separate young children from poultry feces.
Methods:
We conducted 19 transect walks in rural poultry-raising villages across the 8 divisions of Bangladesh to identify existing
overnight housing practices among backyard poultry-raisers. We then conducted 27 semi-structured interviews to
explore poultry-raising practices and the poultry housing types and materials identified during transect walks.
Results:
During transect walks, we found overnight housing for poultry both inside and outside the dwelling and found that most
poultry-raisers who kept their birds outside the dwelling overnight were doing so in courtyard sheds. Through
interviews, we found that there was general preference and willingness to house birds outside, provided a shed was
available. In this study, we present a multi-level framework outlining the determinants of poultry-housing practices
important to consider when intervening in small-scale poultry production systems. We found that having a shed was a
function of multiple factors, including characteristics of the environment and community, household resources,
availability and access to materials and skilled labor to build a shed, available physical space, area- and village-wide
trends, and the personal preferences of poultry-raisers.
Conclusion:
Our findings indicate that in this setting the promotion of sheds for overnight housing of backyard poultry may be an
acceptable intervention approach to limit young children’s contacts with poultry. Programs will need to make
recommendations for poultry housing that accommodate the needs, preferences, and constraints of poultry-raisers over
a one-size-fits-all approach.

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Zebrafish as a Model for Drinking Water Monitoring

Melissa Chernick, Duke University
Additional Authors: Remy Babich, Lindsay Jasperse, Prabha Ranasinghe, Richard Di Giulio, and Nishad Jayasundara

Background:
Water contamination is one of the major threats to biota and human health. While tens of thousands of compounds
have been recognized and registered by national and international agencies, only a small fraction has data that can be
used to define permissive limits. These compounds also exist as complex mixtures in the environment, making them
difficult to evaluate. Exposure to mixtures can cause toxicity even if the concentrations of individual contaminants are
very low. We use zebrafish (Danio rerio) as a model organism in controlled exposure experiments to detect potential
pollution, understand toxic mechanisms, identify long-term effects, and determine safe thresholds. Their genetic,
anatomical, and physiological homology to higher vertebrates also allows for the assessment of endpoints important to
human health. Following exposure, resultant phenotypic endpoints are indicative of lethal level changes while behavior
and bioenergetic perturbations are sublethal and emblematic widespread subcellular changes that affect whole
organism health.
Methods:
We used behavior and bioenergetics assays to evaluation toxicity in zebrafish following exposure to well water samples
or common agrochemicals that can potentially contaminate drinking water sources. The first project involved a citizen
science based well water sampling approach throughout Maine and New Hampshire. These wells were known to contain
a mixture of metal contaminants. Zebrafish embryos were exposed to well water for 4 days and then larval behavior
assessed. This behavior assay is a 24-well plate-based approach that quantifies zebrafish movement in response to light
and dark cycles to identify neurologic alterations. The second project examined developmental and bioenergetic
changes associated with various agrochemicals. Embryos were exposed to a range of concentrations of individual
compounds and then observed for developmental alterations. Embryos were also evaluated using the bioenergetics
assay, a 96-well plate-based analysis that enables quantification of fundamental energy metabolic processes in
mitochondria.
Results:
Zebrafish larvae exposed to well water samples showed hyper- or hypoactivity that were then linked to combinations of
specific metals found in some wells based on a multivariate statistical analysis. Exposure to agrochemicals resulted in
dose-dependent developmental deformities, with some compounds causing specific, localized changes. Compounds
such as butafenacil, fludioxonil, and prosulfocarb also altered mitochondrial function as early as 24 hours post-
fertilization, halfway through development.
Conclusion:
Together, these studies demonstrate rapid, high-throughput, and sensitive approaches for drinking water monitoring.
The efficacy of zebrafish as a model in its predictive capacity can be an important tool for use by industry and agencies
to define regulatory limits for contaminant mixtures in water to protect human and environmental health.

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Virtual Poster Abstracts

Alphabetical by title

A framework for assessing the climate resilience of sanitation technologies

Ian Cunningham, University of Technology Sydney
Additional Authors: Jeremy Kohlitz

Climate change has far-reaching potential to drive the failure of sanitation technologies (STs) such as containment units
and fecal sludge treatment technologies. Such failures create public health risks through the release of fecal pathogens,
nutrients, and other pollutants into the environment. As a result, there is interest from the water, sanitation, and
hygiene sector for guidance on designing STs that are resilient to climate hazards like floods, droughts, and sea-level rise,
and to the uncertainty created by climate change.
To address this need, the Institute for Sustainable Futures (ISF), in partnership with the Bill and Melinda Gates
Foundation (BMGF), has developed a framework to assess the resilience of STs to eight climate hazards and to climate
uncertainty, and to facilitate critical thinking on how STs can be designed to be more climate resilient. In developing the
framework, ISF completed a scoping review of theoretical and practical literature on what physical design features
contribute to the resilience of technologies. This review covered climate change and resilience literature related to
sanitation and other technology dependent sectors such as housing, electricity, and water supply. From this review, ISF
distilled 24 design features that can contribute to the climate resilience of STs. For example, the ‘portability’ design
feature enables the ST to be relocated to avoid slow-onset climate hazards. The ‘low/no inputs’ feature reduces the ST’s
exposure to climate-driven disruption of inputs such as water and electricity. ISF then developed an excel-based tool and
guidance material (collectively referred to as the ‘framework’) to support users to assess the extent a ST incorporates
the design features that enable resilience to climate hazards and uncertainty, and to critically reflect on how the ST’s
resilience can be improved through design.
The framework is a self-assessment process whereby the users 1) identify where their ST will be implemented, 2)
identify the climate hazards at that location against which resilience is being assessed, 3) self-assess the extent to which
the ST incorporates design features that avoid, reduce or offset negative impacts of climate hazards and uncertainty, 4)
identify design improvements to increase the ST’s resilience based on their knowledge of the ST, and 5) give an overall
score of the resilience of the ST to each climate hazard and to uncertainty.
The framework has been tested on several STs with different design teams. The STs included two single-user and one
multi-user reinvented toilet, and the Omni Processor sludge treatment plant, supported by the BMGF. The framework
was also used to assess the designs of a septic tank, a container-based solution, and a decentralized wastewater
treatment system. This testing indicated that the framework supported users to identify how a ST may or may not be
resilient to specific climate hazards and uncertainty. Users reported the framework prompted them to consider climate
risks in a more nuanced manner and generate practical ideas for improving resilience. The framework may have wider
applicability for supporting sanitation designers and engineers to design resilient sanitation options in a variety of
climate contexts.

A Pilot Membrane-Based Indirect Potable Reuse Treatment System Effectively Removes Microorganisms from
Recycled Wastewater in Westminster, Maryland, U.S.A.
Leena Malayil, University of Maryland, College Park
Additional Authors: Suhana Chattopadhyay, Padmini Ramachandran, Zohreh Mohaved, Ben Movahed, Amy R. Sapkota

Background:
Over half of the world’s population will face water scarcity for at least one month annually by 2050. To address this
escalating crisis, there is a critical need to employ innovative water reuse strategies. The City of Westminster, Maryland
has been experiencing intermittent droughts resulting in significant strains on its drinking water system. To alleviate this
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stress, the city is planning what will be the first indirect potable reuse facility in Maryland, PUREWater Westminster. The
aim of our overall study was to evaluate the effectiveness of the pilot membrane-based treatment train—that will serve
as the basis for the full-scale indirect potable reuse system—in reducing microbiological and chemical contaminants
from wastewater effluent. Here, we present our microbiological findings.
Methods:
One liter grab water samples were collected (n=85) from September 2021 to February 2022 from raw wastewater
influent and multiple locations along the pilot, membrane-based treatment chain located at the Westminster
wastewater treatment facility. The treatment process utilizes microfiltration/ultrafiltration, reverse osmosis, granular
activated carbon (GAC), and UV/ozone advanced oxidation processes. Samples were analyzed for E. coli and total
coliforms using U.S. EPA standard membrane filtration method 1604. Furthermore, to characterize total bacterial
community composition, genomic DNA was extracted from all samples using an enzymatic/physical lysis process, and
the resulting DNA underwent metagenomic sequencing on the NextSeq2000.
Results:
E. coli and total coliforms were detected in all of the raw wastewater samples, the purification facility influent samples,
and the GAC concentrate samples. We did not detect either E. coli or total coliforms in the final purified water samples.
Mean E. coli and total coliform log reduction values (LRVs) through the entire wastewater treatment plant and pilot
treatment train were 7.81 (S.D. 0.09) and 8.97 (S.D. 0.82) respectively. In addition, our metagenomics data revealed the
presence of Pseudomonas, Acinetobacter, Aeromonas, Klebsiella, and Salmonella, to name a few, in the raw wastewater
and purification facility influent samples. However, the majority of the water samples recovered along the pilot
membrane-based treatment chain had such low levels of genomic DNA that they could not be sequenced. Finally, we
observed a number of antibiotic resistance genes coding against macrolides/lincosamides/streptogramins and beta
lactams in wastewater samples that could be sequenced.
Conclusions:
Our findings suggest that the pilot membrane-based treatment system is highly effective in removing bacterial
contaminants from recycled wastewater. This pilot treatment system will be expanded to full-scale in the coming two
years, enabling the City of Westminster to successfully alleviate its drinking water security challenges.

A Qualitative Evaluation of COVID-19 Preventative Response Activities in South Kivu, Democratic Republic of the
Congo
Matthew Aubourg, Johns Hopkins Bloomberg School of Public Health
Additional Authors: Christine Marie George, Lucien Bisimwa, Jean Claude Bisimwa, Presence Sanvura, Camille Williams

In the Democratic Republic of the Congo (DRC), 86,767 confirmed COVID-19 cases and 1,337 related deaths have been
reported to the World Health Organization as of April 2022. However, this is likely underestimated given limited COVID-
19 testing capacity in most areas of the country. To address the emergent COVID-19 burden, programs related to
handwashing with soap and chlorinated water and mask wearing in South Kivu have been implemented by the Ministry
of Health, community health workers, and developmental and non-governmental organizations (NGOs). Programs
included mobile health messaging, distribution of personal protective equipment (PPE), and communal handwashing
stations. The objectives of our study are: (1) to explore community understandings of COVID-19; (2) to assess
operational successes and challenges associated with the COVID-19 response; and (3) to develop recommendations for
refinement of current programs.
We conducted 32 semi-structured interviews from April to September 2021 in Bukavu, DRC with community members
(N=19) and programmatic stakeholders (N=13) (healthcare providers, government officials, and developmental and NGO
staff engaged in the COVID-19 response). Interviews were analyzed thematically based on the following focal areas: (1)
community understandings of COVID-19, (2) personal impacts of COVID-19 in the community, (3) facilitators and barriers
to performing preventative behaviors, and (4) experiences and lessons learned from the COVID-19 response programs.
Most community members were aware of COVID-19 and its global burden, but few were aware of local transmission in
their area. Knowledge of COVID-19 origin, transmission pathways, and risk factors varied across community participants.
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Some attributed the disease to actions of malevolent neighbors, bad air, or spirits. They also contended that it affected
Caucasian people more than African people. However, awareness of COVID-19 preventative measures (i.e.,
handwashing, masking, physical distancing) was high, largely due to radio and TV health promotion programs. Both
community members and programmatic stakeholders said community-level non-compliance to COVID-19 preventative
measures was high despite high awareness of preventative methods. Community members identified living and working
near to others as a barrier to physical distancing. Some community members expressed concern that masks distributed
contained the COVID-19 virus. Programmatic stakeholders described challenges with coordination of efforts among
partners involved in the COVID-19 response. A lack of PPE and hygiene materials (e.g., handwashing stations, chlorine),
particularly at the beginning of the pandemic, was a significant obstacle to performing preventative hygiene behaviors
for COVID-19. Programmatic stakeholders emphasized the need for broader system strengthening with improved
coordination and provision of resources to health facilities at the provincial level. Lessons learned from addressing Ebola
aided in approaches for effective community engagement and health communication. Rapid training of healthcare
providers with developmental organization and NGO assistance, respect for preventative measures within health
facilities, and community-level distribution of hygiene materials were mentioned as programmatic successes.
Our study identified successes and challenges in COVID-19 response activities in South Kivu from the perspectives of
community members and programmatic stakeholders. Future research should assess the effectiveness of integrating
preventive hygiene programs with COVID-19 vaccination efforts and include perspectives of rural community members
in evaluation of COVID-19 response programs.

A total end-to-end approach showcasing national greenhouse gas emission profiles from sanitation
Olivia Reddy, University of Bristol
Additional Authors: Eleanor Waring, James Mock, India Ross, Barbara Evans

This study attempts to improve the accuracy and reliability of the Nationally Determined Contributions (NDCs),
regarding sanitation, using Nepal, Senegal, and Ethiopia as examples. Due to decomposing waste, sanitation is a
significant source of emissions, the quantity of which depends on technologies and management practices. The current
global estimates of greenhouse gas (GHG) emissions gloss over and ignore the intricacies of sanitation management,
especially in low- and middle-income countries (LMICs). The limited pathways presented by the Intergovernmental Panel
on Climate Change (IPCC) do not capture the mix of on- and off-site technologies, as well as imperfect management.
Given the importance of cutting emissions, together with targets for methane reduction, providing better estimates of
the contribution from sanitation, considering different management methods and technologies is essential for this
sector. These countries were chosen as examples as they are likely to be making big investments in sanitation over the
next 20-40 years.
Based on the current IPCC methods, this method carries out national audits to create probable profiles for each of the
three selected countries. An end-to-end approach is used to determine contributions by each system type. Each element
is assessed in terms of emissions impact from storage and collection through transportation to treatment. Using data
from shit flow diagrams (SFD), the Joint Monitoring Programme (JMP), in-country partners, and other national and
international sources, the total country emissions profile is determined by calculating the proportion of users for
different conditions and types of sanitation systems along the sanitation management chain. Where official figures and
data were not available (such as for emptying practices) and where data was limited, assumptions were made using
existing literature and SFDs. Throughout the audit, different sanitation service chains at varying levels of urbanization
were considered.
Overall, the total emissions for Nepal were 2.42 bn kg CO2e/year, and 1.73 bn kg CO2e/year for Senegal. Containment
was shown to be the primary emitter, with figures from Senegal accounting for 1.2 bn kg CO2e/year. The main sources
are latrines that are never emptied, and those which are submerged. These findings are mirrored in Nepal where 78% of
the population use pour-flush toilets, the moisture resulting in higher CH4 emissions compared to standard pit latrines.
Transportation contributes minimal amounts, with CO2 from emptying trucks in Nepal representing <1% of the total.
Wastewater treatment in Senegal represents 6% of total emissions but an extra 140 kg CO2e/cap/year, indicating that as
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treatment plants develop, GHG emissions will increase. Results from Ethiopia are expected soon and are anticipated to
support these findings.
This end-to-end approach takes into consideration the whole sanitation management chain. Splitting up sanitation types
generates not only clearer information for NDCs but encourages people to truly evaluate every aspect involved.
Exploring exactly how management works on multiple levels can act as a springboard for generating intervention
pathways. Over the next few months, it is expected that this study will provide more details about potential ways of
reducing emissions.

Activating demand for pit emptying services in Kigali, Rwanda

Bruce Rutayisire, Pit Pumpers Ltd
Additional Authors: Rachel Sklar

In a non-sewered context, fecal sludge collection and transportation is a major link in the sanitation service chain.
However, this service is often left to the private sector. The lack of public support for fecal sludge management means
that private providers must charge high prices to assure cost recovery. Increasing service demand and volume of
services delivered can lower costs and make services more affordable for low-income households. This research seeks to
identify the most effective strategies for increasing service demand in low-income households in Kigali, Rwanda.
Pit Vidura, a fecal sludge collection and transportation service provider in Rwanda, was used as a case study. The
objectives were to understand the proportion of salesand customer acquisition costs for different marketing channels
and set strategies to optimize cost-effective and high return demand activating channels. From January 2019 to
December 2020, we trialed different marketing channels including the use of sales agents, duka shops (small kiosks),
repeat customer & customer referrals, employee referrals, truck branding, online and social media, radio ads, and
posters. Information on the effectiveness of each channel was tracked through a customer relationship management
(CRM) system.
At the end of the 24 months study period, Pit Vidura recorded an altogether 67% increase in households served
compared to the period before the trial. The breakdown of sales from each channel is as follows: repeat customers &
customer referrals - 35%; sales agents - 33%; employee referrals - 13%; radio advertisements - 6%; truck branding - 5%;
duka shops - 3%; and others (including online and social media, and posters) - 4%. The customer acquisition cost per sale
in each channel was: radio advertising - $39; duka shops - $17, sales agents - $8, truck branding - $7 and employee
referrals - $7, and others (including repeat customers, customer referrals, online and social media ads, and posters) - <
$2. The number of sales via the sales agents dropped by 35% which can be explained by the effect of COVID-19
lockdowns on door-to-door marketing. During the same period, employee referrals increased by 77% and were aided by
the introduction of commission.
Direct marketing channels that appealed to customers’ loyalty and fostered trusts such as customer referrals & repeat
customers, sales agents, and employee referrals were the high sales generating channels. We anticipate repeat
customer & customer referrals to grow with the total number of customers served over time. Additionally, we will foster
this customer loyalty and satisfaction by continuing to do post-service surveys and leveraging CRM tools to anticipate
full pits for existing customers and send text messages to remind them to empty. For sales agents and employee referral
channels, a commission will continue to be used to incentivize sales. As Pit Vidura employs former manual emptiers, it is
easier for them to encourage the adoption of formal pit emptying services in the community. Online and social media
advertisements have proven to be low-cost and therefore have the potential to drive sales in an efficient way. However,
more work is needed to understand how the targeted low-income market uses social media and how to message across
such platforms.

amaWASHa: A platform for women to share safety issues about WASH facilities in South Africa
Lee Voth-Gaeddert, University of the Witwatersrand
Additional Authors: Douglas Momberg; Bongiwe Nkambule; Alastair Van Heerden; Rihlat Said-Mohamed

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In 2017, the South African Water and Sanitation National Assembly Committee reported that a key national challenge in
water and sanitation was the poor safety for women and lack of proper maintenance due to limited data on latrine and
water source upkeep. Data from our work in Soweto (the largest township in South Africa) suggests these challenges are
also prevalent here. However, the high mobile phone coverage in this region (>90%) suggests that information and
communication (ICT) solutions may be a feasible part of the solution.
Various ICT tools exist which target portions of these issues. Harassmap provides users with geolocated harassment
incidents, Woloo and Public Toilet Bangladesh aim to provide geolocated latrine information while SaniPath and
Cityspec APP attempts to provide WASH risk profiles to policy makers and implementers. However, existing tools either,
do not focus on WASH-specific safety risks or do not target or empower the end-user directly. Therefore, we partnered
with local women in Soweto to build an ICT platform for mobile phones to enable women to empower each other with
information to improve their own safety when using latrines and improve accountability for latrine and water source
maintenance.
amaWASHa was developed using user-centered design principles to build a multi-purpose – text message and
smartphone-based – software platform for women living in informal settlements to report and receive information on
the safety, functionality, and cleanliness of WASH facilities, specifically regarding physical harassment and biological
contamination. Furthermore, leveraging the crowd sourced data, we can provide priority lists of latrine maintenance
needs to local service providers.
For this project, objective one was to improve perceived safety at WASH facilities for women. Objective two was to
leverage crowdsourced data to aid service providers to prioritize unsanitary latrines for maintenance. Our platform
allows for three primary actions: 1) the submission of geospatial information on water source points and latrine safety
from women, 2) providing information on water source and latrine safety to women, and 3) the submission of
information on water and latrine maintenance using a rating system from women targeted to service providers.
The results of the project included the establishment of the amaWASHa platform enrolling 100 women in the beta-
testing program. A progressive web app was used to ensure only a limited amount of additional memory was used on
the phones. In-depth interviews and focus group discussions were held with community members in an iterative design
process. During the beta-testing program, maintenance priority reports were generated, but further engagement with
the local utility is needed to optimize the value of this component.
The aim of the platform structure is to make it customizable to a variety of contexts, without completely rewriting the
platform code. In addition, future versions of the platform will enable integration of third-party data such as water and
latrine sensors or integrate with other platforms (e.g., enterprise resource management systems). We have started
piloting a new version of amaWASHa in Burkina Faso and are aiming to scale up deployment in South Africa in Q4 of
2022.

Assessment of Bacteriological Quality of Water Across Informal Vendors Supply Chains in Lodwar Town, Kenya
Paul Ekwar, Egerton University
Additional Authors: Nzula Kitaka; Anastasia Muia; Peter Edome

Growing urban areas face water access challenges especially in their peri-urban areas in developing countries. This has
been occasioned by inadequate expansion of urban water supply systems against growing demand for water. Water
vending has emerged to meet these water supply needs where water utilities are not able to adequately supply. Water
coverage in Lodwar town, Kenya is at 59% indicating an existing water supply gap among its resident population.
Informal water vendors have boosted supply to the minority peri-urban populations in Lodwar town who have not been
reached by the municipal water utility services. However, the main challenge facing this effort is the uncertainty of the
quality of vended water majorly due to lack of monitoring and regulation. This study aimed at determining the densities
of fecal coliforms in water delivered by water tankers, that in kiosks and piped system across the supply chains from the
source to the consumer endpoints. The study sought to find out if vendors’ activities and water handling across the
supply chains contribute to deterioration of water quality. Contamination pathways across the supply chains were to be

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identified to inform interventions that improves water quality. Such actions will be helpful in preventing waterborne
health risks associated with consumption of contaminated water.
Membrane Filtration Technique (MFT) using Oxfam - DelAqua water testing kit was used to determine fecal coliform
densities in water samples across the supply chains. Results indicated that fecal coliform densities across water tankers
supply chain ranged between 199.4 ± 48.11 CFUs/100mL (highest) at the tankers and 6.4 ± 0.21 CFUs/100mL (lowest) at
the borehole source. Thus, the fecal coliform densities significantly increased across water tankers supply chain between
the source and point of use. On the other hand, the distribution of fecal coliforms across kiosks supply chain ranged
between 340.79 ± 75.39 CFUs/100mL at the point of use being the highest and 88.10 ± 56.97 CFUs/100mL at the
borehole being the lowest. Across piped water supply chain, the fecal coliforms densities ranged between 11.50 ± 2.40
CFUs/100mL at the distribution tank (lowest) and 151.04 ± 40.14 CFUs/100mL at the consumer endpoint (highest).
Therefore, fecal coliform densities significantly increased immediately after the distribution tank towards the consumer
endpoints.
In conclusion, fecal coliform densities were recorded across all supply chains. The vendors’ activities and water handling
across the supply chains presented pathways for possible water quality deterioration. This means the water sources and
supply chains are grossly contaminated as they both recorded values above WHO recommendations of fecal coliforms at
zero CFU/100mL for drinking water. Such water is not suitable for domestic purposes and requires treatment before use
since it poses waterborne health risks. There is urgent need to adopt medium-term targets for progressive improvement
of source water supplies according to WHO guidelines for unchlorinated sources and carry out remedial measures to
improve the water quality failure to which alternative sources should be sought for.

Association of privacy, safety, and health with sanitation-related withholding and suppression among urban women
Elaina Sinclair, Emory University
Additional Authors: Anke Hüls, Sheela Sinharoy, Madeleine Patrick, Bethany A. Caruso

Despite having access to a toilet, women can still face challenges meeting their sanitation needs. To cope with
inadequate sanitation circumstances, qualitative research has found that women may withhold food and water or
suppress the urge to urinate or defecate due to sanitation-related privacy, safety and security, and health concerns.
However, there is a lack of quantitative evidence to identify how prevalent withholding and suppression behaviors are
among urban women and what determines these behaviors. This study aimed to 1) quantitatively describe the
prevalence of both withholding and suppression, and 2) evaluate the associations between withholding and suppression
and privacy, safety and security, and health factors.
This study is a secondary analysis of data collected cross-sectionally in Kampala, Uganda, and Tiruchirappalli (Trichy),
India in 2019 as part of the Measuring Urban Sanitation and Empowerment (MUSE) study. The goal of MUSE was to
create and validate measures of sanitation-related empowerment, collectively called the Agency, Resources,
Institutional Structures for Empowerment (ARISE) Scales.
The MUSE survey included questions about the primary outcomes and exposures of interest. Four questions asked about
withholding. Due to a heavily right-skewed distribution, a dichotomous withholding score was calculated; a woman was
considered to practice withholding if she reported withholding food or water (sometimes, often, or always) on any of
the four relevant questions. Three questions asked about suppression. A suppression score was calculated as a mean
frequency of suppression of urination or defecation across the three questions (1-Never, 2-Sometimes, 3-Often, 4-
Always). Validated ARISE scales and factors were used to derive scores for privacy, safety and security, and health as
exposures. Observations with missing data were excluded from the analysis.
There were 1172 complete observations for withholding (Kampala: 697, Trichy: 475) and 710 for suppression (Kampala:
440, Trichy: 270). Over 99% of women had access to either an improved or basic sanitation facility. Nearly three-
quarters of women in Trichy reported access to a privately owned sanitation facility whereas nearly three-quarters of
women in Kampala shared a facility. Withholding was more common among women in Kampala (38%) than Trichy
(16%). Suppression was reported by more than 93% of women in both populations. By logistic regression, the privacy,
safety and security, and health scores were all significantly associated with the odds of withholding among women in
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both Kampala and Trichy. By linear regression, few significant associations were found between privacy, safety and
security and health scores and the suppression score, indicating difficulty in modeling a ubiquitous outcome and the
possible influence of unaccounted variables.
The extent of withholding and suppression in both cities is concerning, particularly given nearly universal access to a
sanitation facility. Further work is needed to determine the influence of privately owning versus sharing a facility on
withholding and suppression. This study demonstrates that improvements to sanitation circumstances require both
social and structural changes to improve experiences for women.

Behavioral determinants of arsenic-safe water use among Great Plains Indian Nation private well users: results from
the Strong Heart Water Study
Kelly Endres, Johns Hopkins Bloomberg School of Public Health
Additional Authors: Tracy Zacher, Francine Richards, Lisa Bear Robe, Martha Powers, Christine Marie George

Background and aim:

Long-term arsenic exposure in potable water remains a serious public health challenge globally. Rural communities with
a high reliance on private wells, including American Indian communities, are disproportionately impacted by arsenic
contaminated water. However, efforts to decrease arsenic exposure from private wells are limited. The objective of this
study is to evaluate the behavioral determinants associated with exclusive arsenic-safe water use in the Strong Heart
Water Study (SHWS).
Methods:
The SHWS is a randomized controlled trial designed to reduce arsenic exposure in American Indian Great Plains
communities. All households received point-of-use arsenic filters installed at baseline and were followed for up to two
years. At each visit questionnaires were administered evaluating water use and behavioral determinants based on the
Risks, Attitudes, Norms, Abilities, and Self-regulation (RANAS) model of behavior change.
Results:
Among 75 participants, exclusive use of arsenic-safe water for drinking and cooking at follow-up was associated with
higher baseline levels of perceived vulnerability (greater concern for getting sick from arsenic exposure) (OR: 0.22, 95%
CI: 0.06-0.82), higher self-efficacy (belief in one’s capability) to access local resource to learn about arsenic in water (OR:
5.26, 95% CI: 1.48-18.74) and that local arsenic resources will be helpful (OR: 3.16, 95% CI: 1.11-9.04), and lower
prioritization of the arsenic filter (OR: 0.23, 95% CI: 0.05-0.96). Higher commitment to using an arsenic filter was also a
significant predictor of exclusive arsenic-safe water use for drinking (OR: 31.10, 95% CI: 1.29-747.59) and cooking (OR:
15.51, 95% CI: 1.26-191.10) at follow-up. From baseline to follow-up, the SHWS program significantly increased
perceived vulnerability, self-efficacy, descriptive norms, and injunctive norms, and decreased prioritization of the arsenic
filter.
Conclusion:
Future arsenic interventions in our partner communities should target these behavioral determinants of the use of
arsenic safe water. The SHWS can serve as a model for the design of theory driven intervention approaches that engage
communities to reduce their arsenic exposure.

Behaviors, Attitudes, and Perceptions of Menstrual Health Management in Amhara, Ethiopia

Erin Mercado, iDE
Additional Authors: Martha Gebeyehu, Elise Mann, Lauren Riley, Sarah Custer Lalanne, Dawit Shiferaw

Menstrual health management (MHM), the ability to manage menstrual needs safely and with dignity, is increasingly
gaining attention within WASH. The links between WASH and MHM are well-documented but often focus solely on
providing MHM products, education, and resources in schools; yet, school-aged children are only a portion of worldwide
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menstruators, with many of these programs located in urban settings. These trends are similar in Ethiopia with notable
developments in the production of reusable menstrual products and social enterprises. With the Government of
Ethiopia’s commitment to market-based sanitation, this qualitative research aimed to understand if and how MHM
could be integrated into sanitation marketing.
The project initiated with a literature review of MHM in Ethiopia and social enterprise models working within the
thematic and geographic area as well as external interviews. We talked directly to menstruators to understand their
behaviors, attitudes, perceptions, and preferences in the following three rural woredas of Amhara Region: Seqota Zuria,
Meket, and Lay Gayint. Between the in-depth interviews and focus group discussions we talked to around 100
menstruators and their families, which we later synthesized and themed based on the major components of MHM -
education, habits and beliefs, WASH linkages, management of menses, and sexual reproductive health.
The results from this research indicate that rural menstruators in Amhara lack a reliable supply chain of menstrual
products and that they want access to affordable and dependable products and information for work, school, and travel.
In these study sites, education and trusted sources about menstruation was minimal leaving young menstruators feeling
frightened, scared, and isolated at menarche. Furthermore, our results revealed rarely discussed links between
contraceptive use and MHM, the differences of views and needs between generations, and positive perceptions of
menstruation.
WASH and MHM are irrevocably linked but comprehensive models of the role of WASH in that linkage are still
developing, which is why formative studies like ours are important as menstrual needs and opportunities are different
for each community and individual because of the influence of norms, policies, and local infrastructure. The significance
of MHM as a gateway to sexual and reproductive health and as a precursor to achieve gender equity cannot be
overstated. Water and sanitation are pillars of a comprehensive MHM. Thus, iDE Ethiopia is working to find a role for
WASH enterprises that promote healthy, informed choices for the management of menstrual cycles.
This session will provide results as well as recommendations for how to start market based MHM programming and how
they can align with WASH programs. Additional assessment of the existing market at the national level and qualitative
research about MHM is underway, with planned completion in September 2022. These additional findings and lessons
learned will be shared to support MHM advocacy occurring in Ethiopia.

Can Composite WASH Data Assessment and Interpretation Be Achieved? Application of a WASH Index Approach
Enovwo Odjegba, Federal University of AGR
Additional Authors: Adebayo Sadiq, Abayomi Bankole and Barakat O. Layi-Adigun

Water, Sanitation and Hygiene (WASH) are vital components of effective service delivery in healthcare facilities. About
25% of healthcare facilities have no basic water services, about 712 million people lacking access to water when they
visit healthcare facilities. This study focused on designing research driven WASH Index for assessing the status of WASH
in Primary Healthcare Facilities (PHCs) especially for low- and middle-income countries. To assess the effectiveness of
the WASH Index in evaluating the WASH in PHCs, 75 PHCs were selected across 3 Southwestern States (Lagos, Ogun and
Osun) in Nigeria based on functionality, accessibility and spread. The WASH index comprises of the five (5) Joint
Monitoring Programme service ladders as outlined in the World Health Organization Global Baseline Report: water,
sanitation, hygiene, waste management and environmental cleaning. The WASH Index had two phases of assessment:
indicators/sub-indicators and the composite WASH Index assessments. The 5 service ladders (also termed components)
were assessed using 10 indicators and 30 sub-indicators. Each indicator could score a maximum of 2 and minimum of
zero. The sub-indicators were used to categorize the indicator scores into three levels: Optimum (2), Average (1) and
Poor (zero). The total maximum obtainable score for all 10 indicators is 20. The composite WASH index score was
obtained as a percentage of the total scores of the components divided by the maximum obtainable score. The resulting
WASH Index scores were classified as Basic Service (76 – 100%), Semi-Basic Service (51 – 75%), Poor Service (26 – 50%)
and No Service (0 – 25%). The indicators/sub-indicators show that more PHCs scored ‘Optimum’ than ‘Average’ or ‘Poor’
for all indicators of Water component, with Lagos PHCs scoring the highest. Osun had the highest percentage of PHCs
scoring ‘Optimum’ for Toilet facility condition and Toilet facility cleanliness, while Lagos PHCs scored the highest in Toilet
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facility adequacy. Ogun PHCs had the highest Optimum scores for Hygiene component. Osun PHCs had the best
Optimum scores for Waste Management and Lagos PHCs had the best Optimum scores for environmental cleaning. The
composite WASH Index assessment indicates that Lagos had the most PHCs in the Basic Service category, Ogun had the
highest percentage of PHCs in the Semi-Basic Category and Osun had the highest percentage of PHCs that recorded Poor
Service. Only Osun had PHCs in the No Service category. PHCs in Poor and No Service categories are worrisome,
jeopardizing the goal of minimum, affordable and proximal health care provision of PHCs, not thanks in part, to
underfunding. The study concludes that the concise nature and ease of computation of the WASH index could be
applied to data collection in WASH related studies, and the results of the study would further provide baseline
information on the status of WASH in PHCs in the selected States in the quest to achieve the Sustainable Development
Goals (SDGs). This study recommends that the WASH Index could be adopted an assessment tool for evaluating WASH in
PHCs to ensure communication of results to policy makers and other relevant stakeholders.

Case-Area Targeted Interventions (CATIs) to Disrupt Cholera Transmission: A Performance Evaluation in North Kivu,
DRC
Andrea Martinsen, US CDC
Additional Authors: Taylor Osborne, Tom Handzel, Anu Rajasingham

Cholera remains a public health threat in 47 countries, with three million cases and 91,000 deaths estimated worldwide,
of which the Democratic Republic of Congo (DRC) accounts for 5-14%.1,2 Cholera is endemic in DRC, with multiple
health zones in the east identified as priority hotspots.3 In recent outbreaks, a Case Area Targeted Intervention (CATI)
strategy has been implemented to prevent cholera in households at high-risk. This strategy is based on data from
Bangladesh, which estimated that persons living within 50 meters of a cholera case had 36 times higher risk of
contracting cholera within three days.4 In 2020, UNICEF supported the DRC Ministry of Health in implementing CATIs in
four health zones of North Kivu. Multisectoral teams, comprised of the Provincial Health Division (DPS) and DRC Red
Cross, provided hygiene packages and health education to all identified suspect cases and 15-20 surrounding households
within a targeted radius of 250 meters.
The US Centers for Disease Control and Prevention (CDC) and UNICEF conducted an evaluation in North Kivu from
February 26 to April 26, 2021, to document performance and compare knowledge and practices before and after CATIs.
From internal Red Cross monitoring data, CATI teams responded to 194 (73.8%) suspect cases within 24 hours of case
arrival to a cholera treatment center (CTC) or health facility and 253 (96.2%) cases within 48 hours. The mean number
of households and persons reached was 18.7 and 142.5 per CATI visit.
Three rounds of field data collection took place, including a baseline survey during CATI visit and two subsequent
monitoring visits within four weeks. We calculated a sample size of 71 case households and five surrounding households
per case for a total sample size of 426. Heads of households were asked about receipt and use of hygiene kits, and
knowledge, attitudes, and practices. A sample of stored drinking water was tested for free chlorine residual (FCR).
The mean number of reported bars of soap and strips of Aquatabs distributed to households was 1.0 and 3.4. At first
and second monitoring visits, less than 5% of households reported having remaining soap. The number of Aquatabs
remaining dropped by half by first visit but only to 1.3 strips by the second visit. The proportion of households receiving
CATI visit who self-reported treating their drinking water in the past week increased from baseline (12.7%) to first
monitoring visits (76.2%) (p<0.0001) but decreased between first and second visits (67.2%) (p=0.0058). The proportion
of households with FCR also increased from baseline (11.3%), but levels remained lower than self-reported data at first
(41.4%) and second (38.9%) visits. Between baseline and first monitoring visits, all households decreased self-reported
cholera and treatment-seeking behaviors.
In summary, the majority of CATIs took place within the targeted 48 hours from alert. Initial monitoring visits showed
uptake of hygiene package and knowledge and practices; however, use of some products waned over time, suggesting
more systematic follow-up visits may be needed to sustain behavior change. Additional evaluations of CATI strategy are
planned to build on these results.

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1) GTFCC (2021). Cholera Roadmap: Research Agenda. Global Task Force for Cholera Control. Retrieved from: gtfcc-
global-roadmap-research-agenda-full-report-with-methodology.pdf. Accessed on 25 April 2022.
2) Ali M, Nelson AR, Lopez AL, Sack DA (2015). Updated Global Burden of Cholera in Endemic Countries. PLOS
Neglected Tropical Diseases. Vol 9 Issues 6. Doi: 10.1371/journal.pntd.0003832
3) Ministere de la Santé, Secretariat General (2020). Plan Stratégique Mutisectoriel d’Elimination du Choléra en
République Démocratique du Congo 2018-2022 recadré. Ministère de la Santé RDC.
4) Ratnayake R, Finger F, Azman AS, Lantagne D, Funk S, Edmunds WJ, Checchi F (2021). Highly targeted spatiotemporal
interventions against cholera epidemics, 2000-2019: a scoping review. The Lancet Infectious Diseases. Vol 21. Issue 3.
2021. Doi: https://doi.org/10.1016/S1473-3099(20)30479-5

Climate change impacts on urban sanitation: a systematic review and failure mode analysis
Leonie Hyde-Smith, University of Leeds
Additional Authors: Zhe Zhan, Katy Roelich, Anna Mdee, Barbara Evans

Background
Effective sanitation systems are crucial for public and environmental health, particularly in densely populated urban
areas. The impacts of climate change will stress the effective functioning of urban sanitation systems. However, there
has not been a comprehensive summary and assessment of the evidence base for the likely impacts of climate on the
full range of urban sanitation systems or components of such. We conducted a systematic literature review critically
appraising the evidence for climate change impacts on all urban sanitation system types and highlighting the gaps in
knowledge and rigour of assessment of climate impacts along the entire sanitation chain to fill this gap.
Methods
The systematic search aimed to identify original qualitative or quantitative research on the direct impacts of climate
change on urban sanitation. The review populations were systems or their components typically part of urban sanitation
provision, including infrastructure or services. We designed our search criteria to include evidence of climate impacts on
road-based transport networks, an essential part of faecal sludge management systems. We included studies that made
no explicit connection to climate change but presented evidence of direct impacts on sanitation systems related to
hazards likely to be exacerbated by a changing climate. Our analysis overlaid knowledge about the failures of urban
sanitation systems today with the stresses that a future climate will impose.
Results
We screened over 43,000 records and included 99 studies in our analysis and qualitative synthesis. Most research in the
field assessed the impacts of climate change on centralised, highly engineered, high-cost sanitation options in high-
income contexts. We identified only scant data demonstrating how climate change will influence the functioning of
onsite (faecal sludge management / FSM) services. None of the studies investigated the impacts of climate change on a
citywide complex sanitation system featuring a mixture of centralised sewerage and non-sewered decentralised
sanitation systems. Further, most evidence refers to infrastructure rather than operational components. To date, there
is no adequate consideration of interdependencies with other sectors and combinations of climate effects. For instance,
the available evidence for climate change impacts on urban transport systems is poorly connected to potential
disruptions of faecal sludge emptying and transport under climate change. Finally, we found evidence that contradicts
past research suggesting that even poor households are generally able to adapt their onsite sanitation technologies to
changing climate conditions by their own means.
Conclusion
To date, research neither adequately represents the variety of urban sanitation systems nor reflects the operational and
management challenges of already stressed systems. Investments in infrastructure alone will not render a sanitation
system ’climate-resilient’. The current focus of research might influence the focus, quality and robustness of future
adaptation and resilience measures. Limited autonomous household adaptation capacity to the impacts of climate

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change on sanitation systems suggests that a planned public service approach at city level is required to actively manage
and adapt sewered and non-sewered sanitation systems.

Developing a Prototype of Non-invasive Techniques to Identify Septic Tank Characteristics

Srikanth Guruswamy, FISST
Additional Authors: Manoj Reddy G, Noor Mahammad, Mohan Ram C, Swaathi S

Background:
India has nationwide missions such as Swachh Bharat Mission (SBM) 1 and National Policy on Fecal Sludge and Septage
Management (FSSM) 2 to ensure universal sanitation coverage and safe water supply. These two are interrelated in the
water cycle and interact with geology, hydrology, and population density. The dense habitations and clustering of
households lead to high density, volumes, and impact on the Fecal Sludge and Septage Management (FSSM
systems. With ~500MLD of fecal sludge and septage from over 60 Million toilets connected to off-grid septic tanks, a
large number of such septic tank containments are hidden or unknown, due to the density of settlements. Identification
of hidden septic tanks and assessment of their fill, spill and size are an essential precursor to integrating them into the
FSSM chain in terms of monitoring and evaluation. This pilot project aims to design a non-invasive methodology to
locate the hidden septic tanks, estimate the volume of sludge to be evacuated and identify and locate the containment
leakages. The Proof of concept (POC) will be defined based on the feasibility measurements. For this Pilot study,
containment of individual households, community toilets and public toilets in Tiruchirappalli City have been selected.
The study, a first of its kind, demonstrated a high degree of success in target detection. scale-up, standardization, and
operating system.
Methods:
An electrical resistivity tomography equipment was designed and field-tested to i) detect septic tank containment, ii)
provide the tank dimensions and depth, iii) assess the fill level in the tank, and iv) using the Self-Potential (SP) measures,
investigate the spill or contamination in the vicinity. The device uses up to 16 electrodes planted in a profile, and
an acquisition system to acquire resistivity data in 1) Wenner, 2) Wenner-Schlumberger, and 3) Dipole-Dipole methods.
Data is processed and interpreted using the Res2dInv package. The instrument can acquire Self-Potential (SP) data by
selecting suitable electrodes for investigation of contamination through a map of the area. To establish the
effectiveness of the methodology, a dedicated test bed with five septic tanks were created and more than 500
experiments were conducted in controlled conditions. Additionally, ~200 field experiments were carried out to refine
the acquisition, processing and interpretation workflows.
Results:
The study, a first of its kind, demonstrated a high degree of success in target detection, scale-up, standardization, and
operating system. The instrumentation is under final development and refinement for issue to municipal workers.
Resilience to power fluctuations, insufficient profile space, and inhomogeneous substratum (soil, stone or
cement) are being resolved. A cost-effective, easy to operate method for non-invasive detection and assessment of
hidden septic tanks is now available for WASH programme.
Conclusion:
The Wenner method was found to be most sensitive and specific to the objectives by providing ~95% reliability in
detection of the septic tank (under good data acquisition), determining the size and shape of the septic tank, the shape
of the septic tank, fill level, and leakage. The resolution of Wenner-Schlumberger wasis around 35%, and dipole-dipole
was about 90%.
References:
1. Swachh Bharat Mission(G) India, Ministry of Housing and Affairs, October 2021, www.sbm.gov.in.13.
2. CPHEEO, Manual on Sewage treatment plant, National Policy on Faecal Sludge and Septage
Management.pdf(www.cpheeo.gov.in), 2013.

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Diarrhea Awareness Is Associated with Handwashing with Soap in Democratic Republic of the Congo (REDUCE
Program)
Lucien Bisimwa, John Hopkins University
Additional Authors: Kelly Enders, Camille Williams, Patrick Mirindi, Jamie Perin, Christine Marie George

Diarrhea is one of the leading causes of childhood illness and a major cause of infant and child mortality globally. In the
Reducing Enteropathy, Undernutrition, and Contamination in the Environment (REDUCE) prospective cohort study, we
investigated the association between diarrheal disease awareness and handwashing with soap among caregivers of
children under 5 years of age. A total of 259 caregivers of children under 5 years of age in Walungu Territory, South Kivu,
Democratic Republic of the Congo (DRC), were administered an open-ended questionnaire assessing awareness of
diarrheal disease transmission and prevention, and key times to wash hands with soap. An overall diarrhea awareness
score was developed based on the responses to these items. Five-hour structured observation of handwashing
behaviors was conducted at the 6-month follow-up. Diarrheal disease awareness among caregivers was low. Only 32% of
caregivers were able to correctly identify a method of diarrhea prevention. The median diarrhea awareness score was
three out of 10 (SD: 1.7, range: 0-9). During structured observation, 9% of caregivers washed their hands with soap at a
food-related event and 9% washed their hands with soap at a stool-related event. Higher diarrheal disease awareness
was associated with an increased odds of handwashing with soap at food-related events (odds ratio: 1.40, 95%
confidence interval: 1.03, 1.90). Our findings emphasize the need for targeted water, sanitation, and hygiene
interventions to increase diarrhea awareness to facilitate handwashing with soap among caregivers of children under 5
years in rural DRC.

Diarrheagenic toxins in stool correlate to drinking water from improved water sources in Ethiopia
Shibabaw Tadesse Gemeda, Ethiopian Institute of Water Resources, Addis Ababa University
Additional Authors: Adey Feleke, Sirak Roble, Jana Jass and Desalgne Abeje

Enteric Escherichia coli (E. coli) toxins are the most evident and noticeable virulent factors in the Enterobacteriacea and
are found in basically all pathogenic E. coli transmitted via the orofecal route. The correlation of molecular markers of
enteric E. coli toxins identified in water obtained from ‘improved’ drinking water sources with E. coli toxins identified in
stool samples from diarrhea patients using these ‘improved’ drinking water sources were examined. A correlation
between toxins in water with toxins in stools would suggest that contaminated drinking water is a relevant infection
pathway. Stool samples were collected from people suffering of diarrhea (248 stool samples) and from the drinking
water available in their homes (248 water samples). Only diarrhea patients that reported to use improved drinking water
sources as per the definition of the WHO/UNICEF Joint Monitoring Programme were included in the study. The collected
samples were cultured, and toxins analyzed using the multiplex Polymerase Chain Reaction (mPCR) technique.
Descriptive statistics, Chi-square (?2) test, Fisher's exact, logistic regression, and bivariate Pearson correlation
coefficients were used to exam the association and correlation of enteric E. coli toxins (EAST1, Sta; stx1, stx2, and LT) in
water with the same enterotoxins in the stool samples. A positive correlation with P < 0.05 was found between toxins in
water and toxins in stool (r = 0.412). The presence of enteric diarrheal toxins in drinking water was found to have a
statistically significant association (P=0.0001) with the presence of toxins in the stool. Enteroaggregative E. coli heat-
stable enterotoxin 1 (EAST1) in stool was significantly correlated with overall toxins in water (r = 0.378) and increased
the probability of the occurrence of EAST1 in water (OR=4.96, 95% CI, 2.81–8.74; P=0.000). Of the five toxins detected in
the samples, EAST1 was the most frequently detected with 33% (82/248) in the water and 38% (95/248) in the stool.
Overall, of the 248 households, 24% (59) have positive results in both water and stool samples, 63% [ CI: 55- 67%] have
positive results in water samples only and 46% [CI: 37- 49%] were found to be positive for enterotoxins in stool samples
only. ESAT1, stx1, and LT toxins were the most relevant contaminants found in water from improved water sources.
More studies are recommended to explore the sources of pathogenic microbial markers that result in water-related
diseases like diarrhea and help identify the focus areas of the prevention of water contamination.
Keywords: Correlation; EAST1; Enterotoxin; Escherichia coli; Improved water; LT; Patient stool; Sta; stx; mPCR
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Highlights:
• A positive correlation and a statistically significant association were found between toxins in drinking household
water fetched from improved sources and toxins in patient stools.
• EAST1 was the most frequently detected enterotoxins both in drinking household water fetched from improved
sources and in patient stools.
• ESAT1, stx1, and LT toxins were the most relevant contaminants found in drinking household water fetched from
improved sources.

Enterotoxins as a molecular marker of water quality

Shibabaw Tadesse Gemeda, Ethiopian Institute of Water Resources, Addis Ababa University
Additional Authors: Sirak Robel, Adey Feleke, Jana Jass, Wude Mihert and Misrak Netsere

Safety of improved water supplies using enterotoxins as a molecular marker is evaluated. Water samples were collected
from 248 households and tested for enterotoxins using polymerase chain reaction (PCR). The relationships between the
presence of at least one enterotoxin and independent variables were investigated using Chi-square (χ2), Fisher’s exact
test and binary logistic regression. Some 156 enterotoxin biomarkers were detected, 39% of samples had at least one,
and 17% had multiple varieties. EAST1 was detected in the highest proportion of samples (33%) and Sta in the lowest
(2%). Shallow groundwater sources yielded 18% less enterotoxins than water from piped systems, a statistically
significant result (P=0.031). A lower proportion of enterotoxins was detected in relation to those who did not know and
use cloth filters than those with knowledge of them, and the negative association is statistically significant (P=0.017). It
was shown that water samples in which total coliform (TC) colonies were detected were more likely to contain
enterotoxins than those without (P=0.001). It is concluded that enterotoxin molecular markers can be used to monitor
water safety.
Key words: enterotoxins, Escherichia coli, improved water, molecular marker, water quality
Highlights:
• The quality of ‘improved’ water in Ethiopia was determined, which had not been done before.
• A high proportion of the water samples were shown to contain single or multiple enterotoxins.
• The type of water source, cloth filter water purification and TC were significantly associated with at least one
enterotoxin detected.

Evaluation of low-cost tools for Fecal Indicator monitoring

Timothy Purvis, Water Institute at UNC

Water Quality Monitoring (WQM) is a much-needed component of successful water infrastructure and health programs.
To effectively inform users on the health risks posed by their water, WQM programs must continually collect and share
data on the status of water quality. This is due to the highly varying nature of water, which can shift in quality based on
environmental changes and polluting events. One specific challenge facing WQM is the time-delay between sampling
and results, especially for biological parameters. Standard methods require an incubation period between 18 and 48
hours to produce counts of Fecal Indicators, which indicate if there is a potential health risk from pathogen
contamination. This leaves time for a delay in corrective action if water is seen to be contaminated, or no action if the
monitoring activity is not frequent enough to detect a contamination event. The solution, which is often adopted, of
daily monitoring via standard biologic methods, may not be economically or logistically feasible in rural or low-resource
systems. One possible solution to this is the use of real-time proxy measurements, which measure some other aspect
related to biological contamination of water. While proxy measurements are limited by their sometimes-poor specificity,
they may serve as a useful tool in monitoring programs. Real-time proxy measurements may provide a continuous flow
of data to note where water quality changes, and where more investigation is needed. Further research is needed on if
cost-effective proxy technologies may be suitable for use in water quality monitoring for fecal indicators.
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This study compares readings of low-cost options including Tryptophan-like-Fluorescence (TLF), Adenosine Triphosphate
(ATP) Fluorescence, and a low-cost water quality sensor against Membrane Filtration measurements to determine the
suitability of proxy measurements in water systems. Readings from a low-cost, prototype TLF meter, an off-the-shelf ATP
meter, and a low-cost sensor are compared to the plate counts of E. coli and Total Coliform from Membrane Filtration
on MI agar. Measurements were taken from both tap water and surface water background matrices with raw influent
spiked to introduce fecal contamination.
Initial results suggest that TLF readings are the most successful of the three novel proxy methods evaluated and has a
limit of detection at 8 CFU/100 mL, with a few cases of false negatives. The method is able to detect differences of 10
CFU/100 mL in both tap and surface water spiked samples. However, baseline TLF was seen to be far higher in the
surface water samples. This suggests that TLF may only be a successful proxy when known background TLF values are
known. More work is required on adapting the benchtop prototype to a continuous meter, which would be more useful
in providing monitoring data. However, these results suggest that proxy measurements may soon be a viable, low-cost,
method for determining the risk of water systems from fecal contamination.

Feasibility of Bacteria Inoculum Bio-digester model for Upgrading Onsite Sanitation Systems.
Jeevan Raj, Indian Institute for Human Settlement
Additional Authors: Madhu Sudan Thakar, Ashish Mehrotra, Yohananthan Sukumar, Dhanik Narayan, Dharmadurai
Sangapillai

Background:
Safe disposal of human waste has traditionally had the twin goals of protecting public health and the environment.
Although 2.1 billion people received improved sanitation from 1990 to 2015, 2.4 billion still lack access.1 Another 1.5
billion have access to sanitation facilities that do not treat the excreta before discharge into the environment.2
Developing countries (like India) have constructed millions of toilets with onsite sanitation systems (OSS). Disposal is a
cause of concern in high water table areas. The sanitation upgradation process becomes necessary to ensure that the
existing sanitation facilities which the community can afford, can be further retrofitted according to demand perception,
availability of funds, local materials, skilled manpower and a delivery system that functions properly. This study's
outcomes are important because the number of people who use household sanitation technology is expected to rise
from 2.7 billion to 5 billion by 20303. The key objective of this study is to enhance the performance by introducing a
compact bio-digester-based treatment system into existing OSS. The bacteria inoculum bio-digester is an appropriate
onsite technology for blackwater treatment.
Methods:
The model developed for this study uses the principles of DRDO (The Defense Research and Design Organization, India).
A bio-digester capacity of 1,000 liters made of FRP was designed for a family of six to eight Members. The bio-digester
tank has three compartments. Once the bio-digester is kept inside the containment, the inoculum liquid (30% of the
digester capacity) is poured in the bio-digester. The bio-reactor tank is sealed against ingress of air, which makes it
anaerobic. The bio-digester was installed in the containments of three households. The performance of the three
containments were evaluated based on the treatment efficiency of the bio-digester.
Results:
Specially developed bacteria inoculums consume fecal matter and convert it into water and methane under anaerobic
conditions. During the operation period, the organic loads (COD and BOD) reduce gradually. After the installation, the
outlet BOD values of 12 to 90 mg/l, the COD values of 90 to 300 mg/l and Coliforms values of 700 to 900 MPN/ml against
the DRDO benchmark of 70 to 120mg/l for BOD, 250 to 300 mg/l for COD and 3000 MPN/ml for Coliforms were
achieved. Also, the volume of sludge generated was reduced resulted the reduction in the de-sludging frequency of once
in three months to two years.
Conclusion:

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The bio-digester model would improve de-sludging of septic tank wastewater treatment systems. Moreover, this bio-
digester could play a crucial role in development of an appropriate concept for domestic wastewater treatment systems
especially in low-income communities.
References:
1. R. Baum, J. Luh and J. Bartram, Environ. Sci. Technology., 2013, 47, 1994–2000.
2. L. Strande, M. Ronteltap and D. Brdjanovic, Faecal Sludge Management: Systems Approach for Implementation and
Operation, IWA Publishing, London, 2014, ch. 1–2, pp. 1–44
3. United Nations (UN), http://www.un.org/millenniumgoals/environ.shtml (accessed September 2017).

Fecal Sludge Treatment Effectiveness and Use of Alternating Dual-Pit Latrines in Rural Cambodian Households
James Harper, iDE, Causal Design, and Noble Pursuits, LLC
Additional Authors: Rana Abdel Sattar, Tyler Kozole, Veasna Toeur, Jennifer Rogla, Nate Ives, Marlaina Ross, Hannah
Pruit

Having achieved a marked expansion of basic sanitation coverage over the past decade, Cambodia is now faced with the
urgent challenge of safely managing fecal sludge in rural areas. In 2017, iDE introduced an affordable fecal sludge
management (FSM) product-service combination to the rural Cambodian sanitation market: the alternating dual-pit
latrine upgrade (ADP) with lime treatment. ADPs provide on-site treatment of fecal sludge (human feces and urine) by
storing it underground in a sealed pit for a specific amount of time (a minimum of two years per the World Health
Organization). Called storage treatment, this process inactivates pathogens to levels that reduce the spread of disease
to humans when pits are emptied without specific techniques or equipment, such as protective clothing or vacuum
trucks. Adding lime to fecal sludge has also been shown to inactivate pathogens by increasing the pH of fecal sludge.
Combining these two processes, full pits that are part of ADPs are being treated with lime in rural Cambodia as part of
iDE’s sanitation marketing program to make fecal sludge safe for manual emptying, reducing the household’s, pit
emptier’s and community’s risk of exposure to pathogens: and for potential value extraction as agricultural fertilizer.
With over 17,000 ADPs having now been sold and installed at rural households in Cambodia, ADP treatment
effectiveness can now be evaluated at scale in real-world conditions, which has not been described previously.
In partnership with Causal Design, iDE explores two research topics in this study: ADP biology and related household
FSM behaviors. To describe the biology of full limed pits with regard to public health, we enumerate E. coli and Ascaris
ova (helminth egg) viability in 150 pits used by Cambodian households to test if lime-treated pits can be emptied safely
without specific techniques or equipment after the WHO-recommended two years of storage treatment. The novel
Mini-FLOTAC method is used to enumerate Ascaris ova viability, describing pathogenicity based on viability, not simply
presence, of Ascaris ova. To describe household behaviors related to ADPs, we also survey 765 households to describe
how they operate and maintain their ADPs compared to recommended practices.
From this research, iDE seeks to inform consensus within and between the local Cambodian government and the WASH
sector more generally on the efficacy of onsite FSM products in reducing pathogens to safe emptying levels as well as
their feasibility and value for use by rural households. This research serves as a tool to assess progress towards reaching
UNICEF/WHO’s standards for safely managed sanitation (SMS) using quantitative data and prioritizing user-centered,
context-driven approaches. This research also generates key findings to identify, first, if improvements can be made, and
then which improvements should be made to ADP product implementation and lime treatment service to make them
safer, more appropriate, and more valuable to rural households. Lessons learned also inform local FSM policy and guide
discussion about other potential FSM solutions for rural households, such as off-site pit emptying and safe disposal.
Data collection is currently underway and will be completed in May 2022. Full analysis and results will be presented at
the UNC Water and Health Conference.

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Formative Research for the Development of the CHoBI7 Cholera Rapid Response Program to Reduce Cholera in
Hotspots in Bangladesh
Fatema Zohura, icddr, b & RTM International
Additional Authors: Christine Marie George, Elizabeth Thomas

Background:
There are estimated to be 2.9 million cholera cases and 95,000 deaths in cholera-endemic countries annually worldwide.
Individuals living in close proximity to cholera cases are at an increased risk of developing cholera compared to the
general population. Targeted water, sanitation, and hygiene interventions have the potential to reduce cholera
transmission. The objective of this study was to expand the scope of the current Cholera-Hospital-Based-Intervention-
for-7-Days (CHoBI7) mobile health program focused on diarrhea patient households for delivery in cholera hotspots in
urban slums in Bangladesh.
Methods:
From November 2019 to March 2021, we conducted 31 semi-structured interviews in slum areas with cholera patients
to inform modifications needed to the CHoBI7 program. We also conducted three intervention workshops for
development of voice and text messages for program delivery. After initial exploratory interviews, we conducted a two-
part, iterative pilot study for three months to test the developed CHoBI7 cholera rapid response program with 71
households and inform further modifications to intervention content and delivery. The pilot included structured
observations of handwashing with soap behaviors at stool- and food-related events.
Results:
Findings from the exploratory interviews identified the need to adapt intervention content for delivery at the
compound- rather than household-level, given an environment where multiple households shared a water source,
toilets, and kitchen facilities. This was done by recommending WASH enabling technology at the compound-level,
including encouraging placement of multiple soapy-water bottles in shared spaces to facilitate handwashing with soap,
and discouraging compound members from removing these items. Based on structured observations during the first
phase of the pilot study that indicated low handwashing with soap at food-related events (51% at the 1-month and 37%
at the 3-month follow-up), in the second phase of the pilot study we added context-specific examples to intervention
content to illustrate the importance of washing hands with soap in shared facilities. For example, we showed how
cholera germs can exist on communal surfaces and make household members ill if they are not washing their hands with
soap. We also added a community meeting as part of intervention delivery to give households an opportunity to discuss
how to improve their shared facilities together. A story was told of a family that became ill because their neighbor
served them contaminated food because the household was not practicing the promoted WASH behaviors. To increase
remembering of key WASH behaviors, a puzzle card game was played where household members had to indicate the
key times for handwashing with soap. Weekly mobile phone calls and text messages promoted remembering of
promoted WASH behaviors.
Conclusion:
We observed high acceptability of the CHoBI7 cholera rapid response program, and found this program was feasible to
implement in our study setting.

Formative Research for the Development of PICHA7 to Reduce Cholera in Democratic Republic of the Congo
Lucien Bisimwa, Johns Hopkins School of Public Health
Additional Authors: Camille Williams, Jean-Claude Bisimwa, Presence Sanvura, Alain Mwishingo, Christine Marie George

Household members of a cholera patients are at a 100 times higher risk of contracting cholera in the 7-day high risk
period after a cholera patient has been admitted to a health facility compared to the general public. Despite this
evidence, there are few interventions for this high-risk population. The Prevention-Intervention-for-Cholera-for-7-days
(PICHA7) mobile health (mHealth) program aims to reduce household transmission of cholera during this 7-day high-risk
period through promoting handwashing with soap, water treatment, and safe water storage in the Democratic Republic
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of the Congo (DRC). A theory-driven evidence-based approach guided by IBM-WASH and the Model for Adaptation
Design and Impact (MADI) framework to target identified barriers and facilitators of the promoted WASH behaviors was
conducted for intervention development. Formative research began with exploratory interviews of the promoted WASH
behaviors, and then a pilot study to determine the feasibility and acceptability of the developed PICHA7 mHealth
program. Ninety-three semi-structured interviews were conducted with diarrhea patient households and healthcare
providers. Based on formative research several components were developed for the PICHA7 mHealth program: (1) a
WASH pictorial module on cholera transmission, preparing soapy water, and treating water using chlorine tablets; (2) a
diarrhea prevention package containing chlorine tablets, handwashing station, soapy water bottle, and safe water
storage vessel with lid and tap; and (3) weekly WASH voice calls and text messages. Adaptions to the PICHA7 program
were made in a two-phase pilot study of 443 participants. Exploratory interviews were conducted among 37
participants. Awareness of cholera transmission and prevention was low, and soap for handwashing was unaffordable
for some households. Shared sleeping spaces were identified as a potentially important transmission route for cholera
infections. Soapy water was provided as a low-cost alternative to bar soap, and caregivers were discouraged from having
children with diarrhea sleep in the same bed as healthy children. The pilot included 56 semi-structured interviews.
Participants reported difficulty washing their hands at food and stool related events outside the home. Many
participants didn’t wash hands with soap before eating snacks such as donuts or biscuits. This led to adaptions to the
flipbook and mobile messages to emphasize the importance of washing hands with soap even when snacks were
consumed, and provision of a soapy water bottle to wash hands outside the home. The importance of drinking chlorine-
treated water was generally understood, however some participants believed that drinking chlorine-treated wat would
prevent illness, even if consuming unclean food. To address this, the multiple transmission routes for cholera were
emphasized in the flipbook. Some participants did not know where to purchase chlorine tablets in their area. This led to
the locations where chlorine tablets could be purchased being mentioned in the flipbook and mobile messages. Mobile
messages were valued as important reminders of promoted WASH behaviors; however, adaptations were made to
deliver messages in the evenings to maximize household members present. The pilot study indicated the PICHA7
program had high user acceptability and is feasible to deliver to diarrhea patient households to promote WASH
behaviors among diarrhea patient households.

Gender, WASH, and multiple disasters in South Sudan

Sneha Krishnan, OP Jindal Global University, ETCH Consultancy Services

Purpose of the study:

Floods in South Sudan have become a regular annual phenomenon: Ayod and Fangak counties faced floods in 2020-
2021. While the COVID-19 pandemic hit the country, rural communities were already submerged under floodwaters.
This situation has led to an increase in vulnerabilities among the community members towards hazards that have
ultimately given rise to health issues, shortage of food, drinking water, and WASH (Water, Sanitation, and Hygiene) -
collectively.
Research Question:
“How are women coping with the emerging concerns in WASH and other sectors due to multiple disasters in South
Sudan?”
Study design:
This study was conducted in the two counties of South Sudan- Ayod and Fangak using a mixed-methods approach. Prior
to data collection, investigators provided information on the survey and its purpose in the local language/dialect, and
the data were collected through literature review, qualitative and quantitative via household surveys (n- 462) through
Kobo Software, Focus Group Discussions’ (n- 6), and Key Informant Interviews (KII) (n- 19). The data were analyzed to
understand the access and availability issues related to WASH but also attitudes and perceptions about menstrual
hygiene and other hygiene issues.
Findings:

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The existing WASH situation in the country is highly unsafe for those people who are living in flood areas. Due to floods
all the water resources such as boreholes submerged underwater, so the people of the community were forced to use
flood water as they don't have access to clean water for drinking or domestic use. This has led to several diarrhea cases
along with other waterborne diseases. 94% of the respondents don't have access to a latrine, so they either defecate
directly in the flood water or behind the bushes to relieve themselves. Only 1% had access to tube wells and 56% of
people relied on surface-level or open sources of water for drinking. 94.3% don't have an excess handwashing station
and only 13.71% use soap for handwashing and using flood water to clean themselves is a come practice in men,
women, and children to maintain their hygiene. 60.1% of females don't have access to menstrual hygiene products so
they use old clothes and rags that were thrown to flood water or buried by them after use. Menstrual health was widely
reported as a ‘development needs’ given 60.1% of female respondents said that they did not use any menstrual hygiene
materials while 17.6% reported using old clothes or rags as a substitute for menstrual pads. This is the long-stuck taboos
around the topic of menstrual hygiene which forces women to bury their menstrual waste in order ‘hide’ it from their
men in the family.
To eliminate the said taboos, 23.19% of female respondents suggested that menstrual hygiene awareness provided to
their spouses would help them deal with menstrual hygiene in a ‘culturally’ and ‘respectfully’ open situation. While the
others claimed that the information on usage and disposal of sanitary pads and counseling support might be useful to
better manage their menstrual hygiene needs
Discussions:
This study shows that WASH conditions are very poor in South Sudan and continuous floods combined with COVID-19
only increase the hardships of the community. In practice, humanitarian agencies resort to participatory and localized
approaches to address emerging concerns but these are isolated support mechanisms and cannot be sustained over the
longer run. Flood protection and mitigation measures are of utmost importance if health, water, and sanitation needs
are to be holistically addressed.

Genetic characterization and antimicrobial susceptibility of Escherichia coli isolated from household water sources in
northern Ghana
Elvis Kichana
Additional Authors: Osman Adamu Dufailu, Francis Addy

Microbial quality of household water is an important issue in developing countries, especially in Ghana, where many
people still depend on unimproved sources of water. The present study investigated the prevalence, genetic
characteristics, and antimicrobial resistance profile of E. coli from surface water sources. Fifty-two (52) water samples
were analyzed by spread plate, biochemical test, and multiplex PCRs. E. coli was isolated from each of the 52 water
samples. Of these isolates, 75% were noted to possess virulence genes. Approximately 54% of the isolates were
characterized as; ETEC (10.26%), EPEC (17.95%), VTEC (23.07%), and EIEC (2.57%). Eighteen (18) of the 52 isolates could
not be characterized due to heterogeneity in banding. The disc diffusion method was used to test for antimicrobial
susceptibility.
The isolates were most resistant to ceftazidime, augmentin, and cefuroxime. Multi-drug resistance was recorded in
48.1% of the isolates. In contrast, the isolates were most susceptible to ciprofloxacin (86.5%), nitrofurantoin (84.6%),
and ofloxacin (75%). These results revealed a high diversity and widespread of E. coli in northern Ghana. The study
provides important data for public health nationwide surveillance of E. coli in surface water across the country.
Keywords: Diarrhea, Escherichia coli, multi-drug resistance, surface water, virulence genes

Household Bird Ownership is Associated with Respiratory Illness among Young Children in Urban Bangladesh (CHoBI7
Program)
Tahmina Parvin, RTM International
Additional Authors: Sazzadul Islam Bhuyian, Kelly Endres, Daniel Leung, A S G Faruque, Christine Marie George.
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There is limited evidence on the association between animal ownership and respiratory illness among young children in
low- and middle-income countries. In this study, we examined the association between animal ownership and
respiratory illness among children younger than 5 years of age enrolled in a prospective cohort study in urban
Bangladesh. This prospective cohort study enrolled 884 participants younger than 5 years of age in Dhaka, Bangladesh.
At baseline, trained research assistants administered caregivers of children younger than 5 years of age a questionnaire
on household animal ownership. Animal ownership was defined as owning chickens, birds other than chickens, cats, and
dogs. Respiratory surveillance was conducted monthly for children based on caregiver-reported coughing, rapid
breathing, and difficulty breathing in the past 2 weeks during the 12-month study period. At baseline, 48% of children
(424 of 884) had reports of coughing, 5% (40 of 884) had difficulty breathing, 3% (25 of 884) had rapid breathing, and
49% (431 of 884) had reports of any of these three respiratory symptoms. Seventeen percent of children (151 of 884)
resided in a household that owned an animal. Children residing in households reporting bird ownership had a
significantly greater odds of coughing (odds ratio, 1.14; 95% CI, 1.02-1.28) and any of the three respiratory symptoms in
the past 2 weeks (odds ratio, 1.14; 95% CI, 1.02-1.28). Household bird ownership was associated with respiratory illness
in young children. These findings suggest that interventions aiming to reduce young children's exposure to domestic
animals should extend to include birds other than chickens.

How Sama Sama's Shitmaster Model is Dignifying Work for Pit-Emptiers in Ghana
Ebenezer Atsugah, iDE – Ghana

In 2016, iDE established Sama Sama, a water, sanitation, and hygiene social enterprise in northern Ghana, to fill a gap in
the market and increase access to improved sanitation in rural Ghanaian homes. At the time, there were very few
options for rural Ghanaians to access affordable WASH services and products. Since then, Sama Sama has sold over
10,000 toilets and increased access to sanitation to over 60,000 Ghanaians. For customers who bought these toilets a
few years ago, their latrines are filling quickly, and they are concerned about how to safely evacuate the fecal sludge,
given the lack of affordable, accessible fecal sludge management (FSM) services available on the market. As Sama Sama
reached more customers with toilets, we needed a viable way to efficiently and safely empty fecal waste from our
customers’ latrines to ensure ongoing use. Part of that included a strategy for retention, as the turn-over rate for pit-
emptiers in Ghana is high at 80%.
In reaction, Sama Sama created the “Sama Sama ShitMaster” a pit-emptying service that safely empties the fecal matter
contained in a customer’s pit and transports the waste to a centralized treatment site, ensuring continued latrine use by
the customers and reducing exposure to pathogens for households and operators. The pilot launched in 2019, testing
the impact and demand for the Shitmaster as a smaller, cheaper vacuum-emptying truck while also professionalizing the
role for operators. Sama Sama strives to challenge sector assumptions about FSM and meet customers’ sanitation needs
by ensuring the delivery of high-quality latrine-emptying services with a concerted focus on customers who can’t
traditionally afford the service and for those living in places that are difficult to reach. The Sama Sama team designed
the emptying truck prototype with these objectives in mind, using customer need insights revealed through human
centered design (HCD) research. The ShitMaster truck has since been successfully used in Tamale and Sagnarigu, two
districts where Sama Sama has worked.
In addition to an operational and inexpensive FSM service for rural areas, the Sama Sama business model works with
operators of these pit emptying trucks to professionalize pit emptying. We work with operators of these pit emptying
trucks to ensure proper training and provide protective equipment to increase the safety of both operators and
customers. We also facilitate connections between truck operators and customers by leveraging the customer service
infrastructure where customers can request and schedule pit-emptying by phone. Sama Sama is also challenging gender
perceptions about who works in sanitation because the six male operators of the ShitMaster are supervised by a female
customer service officer.

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Sama Sama’s primary objective is to bolster the sanitation ecosystem in Ghana by building out the rural FSM service
market in order to create a sustainable sanitation strategy. By professionalizing pit emptying, operators are afforded
more safety, dignity, and income, while growing the FSM services at the same time.

Improvement of Household-scale Disinfection of Onsite Sanitation Systems using Chlorine Tablet

Senthil kumar Govindaraj, Indian institute for human settlements
Additional Authors: Yohananthan Sukumar, Kanmani Raja Senthilvel, Jeevanraj, Santhosh Ragavan

Background:
Partially treated wastewater effluent percolating into the soil contaminates groundwater quality. As water percolates
through the soil, some degree of disinfection occurs; however, most soil infiltration systems have been traditionally
designed for treated wastewater disposal and are not designed with disinfection in mind1. In India, households
construct and operate OSS systems in the absence of regulatory supervision and non-compliance with IS 24702 where
onsite disposal of liquid is not possible which poses a risk to public health. IS 2470 part II recommending that the
disposal system shall be either a dispersion trench or soak pit and recommends disinfecting before the OSS effluent is
discharged into the drain. In Tiruchirappalli, Tamil Nadu, nearly two-thirds of the population rely on OSS. Infiltration of
partially treated wastewater effluent into the soil is a common practice for many onsite wastewater management
systems in the city. The objective of the study was to check the feasibility of low cost and efficient disinfection methods
and to determine the performance of disinfection, reliability and constraints in the method, maintenance and
frequency, and estimated cost for installation and operation.
Methods:
A closed loop Chlorine Tablet System (CTS) has a chlorine tablet feeder fitted with a single tablet feed tube with a
contact chamber. The chlorine tablets dissolve as water flows through the chamber. The tablet feeder is typically
installed in the subsurface, such as the effluent line of the septic tank.
Results:
The performance of the tablet chlorinator was evaluated at a free flowrate of effluent discharged from the containment.
The free chlorine dose ranged from 5 mg/L to 50 mg/L. No coliform organisms were detected in the chlorinated effluent.
Even though we specify a contact chamber design, the 120-minutes contact time resulted in high rates of disinfection
due to the high free chlorine concentrations. The requirements for maintenance are minimal and the consumption rate
of chlorine tablet is 7.0 to 8.0 g/day, and the residual chlorine of 2-5 mg/l is maintained.
Conclusion:
The capital cost for the chlorine tablet system was $35 and the cost of a year’s supply of chlorine tablets (a 200g supply,
about 10 tablets) with shipping is $7. Unlike the other disinfection technologies, the chlorination facilities may not
require the expenses associated with a power supply. Upgradation of the system is in place by installing automated
water droplet systems to reduce chlorine consumption. Bulk imports of chlorine tablets will reduce the cost. This will
result in containment improvement as well as scale up the system in the individual household OSS. This system can be
used for disinfection purposes in response to disaster and emergencies.
References:
1. Clifford B. Fedler, Richard Francis, Dhiraj Parekh, and Samir Blanchet, Clifford B. Fedler, Richard Francis, Dhiraj Parekh,
and Samir Blanchet, ‘Final Report to the Texas Commission on Environmental Quality: Texas Onsite Wastewater
Treatment Research Council’, December 2022.
2. IS 2470 Part 1&2, 1985 Indian Standard Code of Practice for Installation of Septic Tanks, October 1993.

Low-cost Domestic Rainwater Harvesting in Rural Southeast Madagascar: A Process and Outcome Evaluation
Jasmine Kelly, SEED Madagascar/Tatirano Social Enterprise
Additional Authors: Andrianarivelo Zafindrazana Charlier, Emilie Kowalczewski, Mamy Andriatsihosena, Harry Chaplin,
Hugo Legge
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Background and Purpose:

Lack of access to safe water is a significant global driver of diarrhea-related morbidity and mortality. Water supply
interventions that promote access to improved community water sources, such as public tap stands, can suffer from
poor long-term functionality. In areas where the climate is suitable, household rainwater harvesting (HRWH) could offer
an alternative to this community supply model, allowing households to manage their own water provision through
supported-self supply. However, HRWH and self-supply interventions generally remain under-researched and there is a
clear need for more studies that evaluate their acceptability and effectiveness.
Methods:
In the Anosy region of rural south-eastern Madagascar, communities are largely dependent on surface water and
unimproved community water sources for their domestic needs. This research follows a two-year intervention in Anosy
that provided households with access to a water source at the home through the sale of a partially subsidized HRWH
system. Systems were installed on both metal and grass household rooves and were sold to users at a cost of 18USD
payable over a 6-month period. Through a controlled before and after study and concurrent process evaluation, we
assessed implementation acceptability and fidelity and whether water access and health related benefits were achieved
through the intervention. Surveys were collected from self-enrolled intervention households (n=138) and matched
control households (n=276), and water quality tests were conducted to compare HRWH systems and public water
sources.
Results:
By project close, of the 73 metal-roof and 75 grass-roof HRWH systems that were installed, 75% were functional with an
average age of 1.25 years. 85 (57%) households had completed their payment plans and 63 (42.6%) of households had
an average of 3.7 USD left to pay. Microbial contamination in metal-roof systems was lower (median TTC/100ml=12.9,
IQR=3.5-22.5) compared with grass-roof systems (median TTC/100ml=29.5, IQR=19-34.5) and existing community
sources (median TTC/100ml=31, IQR=5.5–64.3). Intervention households collected on average 5.3 liters of water per
capita day more than controls (95CI: -0.16 to 11.7, p=0.057) and had 2.2 times the odds of having a handwashing station
compared with control households (95CI: 1.02-4.83, p=0.043). There was no difference in diarrheal prevalence among
children under five between study groups following adjustment for socioeconomic status. Overall, operation and
maintenance of the systems remained high, users demonstrated willingness to pay despite the cost, and there was some
evidence to suggest that water provision at the household increased domestic consumption. However, the systems did
not provide contaminant-free water, suggesting that point-of-use water treatment should be maintained by households.
Conclusions:
Results from this study show that in this setting a partially subsidized, low-cost HRWH system, built using locally
available materials demonstrated high levels of acceptability and long-term functionality in a low-income, water
abundant environment. These results will be of relevance to public health practitioners and policy makers in other low-
resource settings where access to improved water sources is limited.

Metagenomic analysis of differences in microbial community and resistome between pristine and biosolids-amended
soils
John Ste. Marie, Oregon State University
Additional Authors: Catherine Mays, Tyler Radniecki, Joy Waite-Cusic, Bing Guo, Tala Navab-Daneshmand

The spread of antimicrobial resistance – largely driven by the presence and horizontal transfer of antibiotic resistance
genes (ARGs) poses a significant threat to public health and is expected to be a leading cause of death by 2050. The land-
application of ARG-rich biosolids generated during wastewater is known to improve soil properties but provides
opportunity for the naturalization of new bacteria and ARGs into the soil environment, propagating the spread of
antibiotic resistance. However, this remains poorly characterized. In this study, we leveraged metagenomics to
characterize the differences between the microbial community and resistome of pristine soil and biosolids-amended soil
during carrot cultivation in a greenhouse study. Carrots were planted in triplicate pots of pristine and biosolids-amended
soils and grown for 11 weeks. Soil samples were collected at the time of planting, 6 weeks into the cultivation, and at the
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time of harvest in week 11. The environmental DNA from soil samples was extracted and shotgun sequenced. The
microbial community was characterized with the program Kaiju, and ARGs were annotated using the ARGs-OAP pipeline.
The richness of the microbial community was higher in biosolids-amended soils at the time of planting, but this
decreased throughout cultivation. At the time of harvest the richness of amended and pristine soils were comparable.
The relative abundance of proteobacteria increased over time in the biosolids-amended soils, whereas it was relatively
stable throughout cultivation for pristine soils. Bacteroidetes were also enriched in amended soils, though their relative
abundance decreased to comparable levels as pristine soils at the time of harvest. The persistence of proteobacteria in
biosolids-amended soils indicate that some of these bacteria, many of which are pathogenic, may be naturalizing into
the soil and provide opportunity for acquisition of ARGs. 318 unique ARGs were detected in the amended samples, while
only 198 were identified in the pristine samples. The most enriched ARGs in the amended soils confer resistance to
sulfonamides, tetracyclines, and multi-drug resistance. The relative abundance of multi-drug resistance genes increased
in biosolids-amended soils throughout the cultivation, while their abundance in pristine samples was relatively constant.
The diversity of ARGs in the amended soils remained considerably higher in than pristine soils, suggesting that the land-
application may be associated with long-term increases in ARG diversity and multi-drug resistance. The results from this
study indicate that current treatment of biosolids may be insufficient to remove ARGs and the application of these
biosolids to agricultural soils can cause enduring effects that facilitate the proliferation of resistance.

Methods to Evaluate COVID-19 Control Hygiene Programs: Observed Mask Wearing, Handwashing, and Physical
Distancing Behaviors
Alain Mwishingo Namegabe, Johns Hopkins Bloomberg School of Public Health
Additional Authors: Kelly Endres, Presence Sanvura, Justin Bengehya, Cirhuza Cikomola, Christine Marie George

The objective of our study was to develop and test observational methods to evaluate COVID-19 preventative hygiene
behaviors and evaluate the effectiveness of a government mandate on indoor fully covered mask wearing. An
observational study was conducted of 4736 individuals using 5-hour and rapid (10 minute) structured observations and
spots to evaluate mask wearing, handwashing, and physical distancing behaviors, and functionality of handwashing
stations in 161 indoor public spaces across Bukavu, Democratic Republic of the Congo (DRC). Sixteen percent of
individuals entering indoor public spaces were wearing a mask that fully covered their nose and mouth (fully covered
mask wearing). Fully covered mask wearing was lowest inside schools at 1%, in universities at 2%, in religious
establishments at 22%, and in health facility wards at 28%. Overall physical distancing > 1-meter inside indoor public
spaces was 22% and was lowest inside schools and religious establishments at 7%. Thirty-nine percent of handwashing
stations had water and a cleansing agent present. Ten percent of individuals washed their hands with a cleansing agent
before entering an indoor space. Overall, fully covered mask wearing was similar for 5-hour and rapid structured
observations (16% vs. 15%). The odds of fully covered mask wearing were significantly higher with increased
government enforcement of mask wearing through fines in public spaces (Odds Ratio: 2.72 (95% Confidence Interval:
1.02-7.30)). This study presents rigorous methods using structured observations to assess government mandates and
programs on COVID-19 preventative hygiene behaviors in indoor public spaces in settings globally.

Private De-sludging Markets: Does a One-Size Approach Fit All?

Gayathri Pattnam, Indian Institute for Human Settlements
Additional Authors: Rajesh Ramamoorthy, Prithivi Mohan

“I need to maintain a 4-star rating on Google,” Irfan* remarked. “Only then I will get calls!” Irfan runs a de-sludging
business in Chennai, one of India’s metropolitan cities and Tamil Nadu’s capital. Across Tamil Nadu, private markets
have evolved in response to the need for emptying services, filling a critical lacuna in municipal service provision.
Irfan started as a casual laborer, eventually accumulated enough savings to purchase a vacuum truck and now manages
a fleet of 10 trucks. While this is unusual in the larger context of Tamil Nadu, such businesses are common in
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metropolitan areas (28 cities with a population over one lakh). Here, de-sludging operators have an extensive clientele,
professionalized business models, and importantly, access to formal finance which allows for rapid business expansion.
Service calls from households are accorded a lower priority, while bulk generators are the targeted customers.
Accordingly, marketing strategies have moved from dropping business cards to also enlisting on search engines.
Moreover, the nature of jobs has diversified to also include blockage removal from sewerage and drainage systems. In
these locations, the disposal facilities have been designed for a higher number of trucks. For example, Chennai has three
disposal points, with each receiving an average of 100 trucks per day.
In Vickramasingapuram, a municipality in Tamil Nadu, Durai* runs a de-sludging business with one truck and two
workers. He works as a contractual conservancy worker as revenues from the business are insufficient. Operators in this
region provide services across towns, travel longer distances and station themselves near highways to access other
markets. The reported de-sludging rates are also much higher than Chennai or Trichy. The FSTPs in these areas (56 FSTPs
catering to 120 towns) have lower capacities, catering to roughly 4 to 8 trucks a day.
Conversations with de-sludging operators were held at 10 locations across the state from September 2021 to January
2022. This covers two major cities, three medium and five small towns.
These stark differences in operator practices and business models have implications on the types of engagement
required to strengthen de-sludging service provision in the state. Urban local bodies (ULB) of larger towns and cities
have adopted a regulatory approach. Some cities issue desludging licenses upon payment of a fee and/or collect tipping
fees for usage of disposal facilities. Some towns on Chennai’s peripheries have high demand for de-sludging: ULBs have
awarded exclusive rights to one or two private operators through bidding and disallow other players from providing
services.
In smaller towns, operators engage in this work as a form of livelihood. Lower demand, challenges in accessing formal
credit facilities, and lack of linkages with sanitation or entrepreneurial schemes mean that operators rely on
supplementary jobs to make ends meet. There is a clear need for a differentiated approach by state and non-state
actors at regional levels to ensure that their livelihoods are protected. For larger cities, the focus can remain on
regulation and mitigating threats from cities becoming fully sewered by enabling diversification of services.
*Names changed

Randomized Controlled Trial of the Cholera-Hospital-Based-Intervention-for-7-Days (CHoBI7) Cholera Rapid-Response

Program to Reduce Diarrheal Diseases in Bangladesh
Tahmina Parvin, Johns Hopkins Bloomberg School of Public Health
Additional Authors: Christine Marie George, Sazzadul Islam Bhuyian, Ismat Minhaj Uddin, Fatema Zohura, Jahed Masud

Worldwide there are 2.9 million cholera cases annually. Effective targeted water, sanitation, and hygiene (WASH)
interventions are urgently needed to reduce cholera globally. Individuals living within 50 meters of a cholera patient are
at higher risk of developing cholera than the general population during the month after the index patient seeks care at a
health facility. To build an evidence base on effective WASH interventions to reduce diarrheal diseases for this
population, we developed the CHoBI7 cholera rapid response program. Once a cholera patient (confirmed by bacterial
culture) is identified at a health facility, a health promoter delivers a targeted WASH intervention to the cholera hotspot
(households within 50 meters of a cholera patient) through both in-person visits, and weekly WASH mobile messages for
the 3-month program period. A randomized controlled trial of the CHoBI7 cholera rapid response program was
conducted of 261 participants in 15 cholera hotspots in urban Dhaka, Bangladesh. This program was compared to the
standard message in Bangladesh on the use of oral rehydration solution for dehydration. Five-hour structured
observation of handwashing with soap practices, and diarrhea surveillance was conducted monthly for the 3-month
program period. Delivery of the CHoBI7 cholera rapid response program significantly increased handwashing with soap
throughout the 3-month program period (Odds Ratio: 3.96 95% Confidence Interval (CI): 2.35, 6.66, p=0.035) (54% in the
CHoBI7 arm vs. 23% in the standard arm). Furthermore, there was a significant reduction in diarrheal prevalence for all
participants (adults and children) (Prevalence Ratio (PR) 0.35: ,95% CI: 0.128 – 0.99, p = 0.049), and for children under 5
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years of age (PR: 0.21, 95% CI: 0.06 – 0.74, p = 0.015) during the 3-month program. These findings demonstrate that the
CHoBI7 cholera rapid response program is effective in lowering diarrhea prevalence and increasing handwashing with
soap for a population at high risk of cholera.

Reframing photography in WASH: A deep dive into photography-based approaches in the WASH-sector
Jess MacArthur, UTS-ISF
Additional Authors: Naomi Carrard, Juliet Willetts

Inclusion, diversity, and equality within WASH programs continue to be important considerations as the sector strives to
improve services for all. As such, many researchers have engaged novel tools such as photography to see new
perspectives. Photography has been used to explore experiences and needs of marginalized communities and is a
common methodology in researching particularly sensitive topics. However, with a long history of the use of
photography to document, elicit and generate insights in the WASH-sector, it is important to understand the extent to
which photography has been and can be effective, inclusive, and ethical in WASH research. As the sector continues to
critically build on a ‘do-no-harm’ approach to research to strengthen a ‘do-more-good’ approach, it is timely to
investigate how photography’s colonial past can be addressed through participatory modalities, moving from an
extractive paradigm to a generative one.
Building on a novel framework to clarify the breadth of photography approaches in research, this study focused on the
use of participatory photography within the WASH-sector. Participatory photography activities are a methodological
research approach in which participants generate images. Activities vary in the extent to which participants engage in
the stages of image interpretation and use, ultimately influencing the opportunities for transformational participation.
The study was comprised of two components: a literature review of participatory photography activities in the WASH
sector (n=32) and an empirical case of a photovoice evaluation in Cambodia (n=20 participants). Drawing on the two
components, we reflect on the extent to which photography-based approaches in the WASH-sector have been effective,
inclusive, and ethical. Our findings indicate that there are significant, but not always guaranteed opportunities to ‘do-
more-good’ from both the process and the outcomes of participatory photography.
This research considers opportunities to strengthen applications of participatory photography activities within the WASH
sector by 1) purposefully selecting participants, 2) creating engaging orientation opportunities, 3) supporting
participants in ethical image creation, 4) facilitating image interpretation, and 5) progressing photo-stories into
advocacy. This timely work aims to support WASH researchers seeking to actively listen to new voices through more
participatory and innovative forms of research.
This presentation has four learning objectives:
1) Clarify the breadth of research photography in the WASH sector through a novel framework
2) Explore the use of participatory photography in the WASH sector through a literature review and empirical
case
3) Reflect on opportunities to decolonize photography in WASH
4) Suggest implications to ‘do-more-good’ in photography-based WASH research

Shifting humanitarian norms: Menstrual health for people with intellectual disabilities in emergencies
Chloe Morrison, World Vision Vanuatu
Additional Authors: Jane Wilbur, Relvie Poilapa

Introduction:
There is increasing recognition in the humanitarian sector of the need to prioritize menstrual health and hygiene (MHH)
in emergencies. These interventions are tailored to the requirements women without disabilities; the unique MHH
needs of women with disability have only begun to be considered in humanitarian spaces. However, even these limited
considerations have not extended to women with intellectual disabilities who require more holistic, customized support.
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Methods:
The study explores the menstrual experiences of people with intellectual disabilities and their carers in humanitarian
settings in Vanuatu. The study was conducted in the aftermath of Category 5 Tropical Cyclone Harold, and the Amabe
volcano evacuation.
This study follows the Behavior Centered Design (BCD) approach. This approach applies a theory of change, behavioral
determinants and a programme design process and has employed three key research methods; a systematized review,
formative research, and participatory review of the Bishesta campaign to answer four key research questions:
1) What evidence exists about the barriers to, and interventions for MHH for people with disabilities in the
humanitarian context?
2) What are the barriers to MHH for people with intellectual impairments, and their carers in Vanuatu?
3) Are the target behaviors within the Bishesta campaign relevant for the target groups in these settings?
4) How can the Bishesta campaign artwork/components be revised to suit these settings?
Formative research with 17 carers and menstruating people (aged 15-30) with intellectual disabilities investigated the
barriers to MHH for people with intellectual impairments, and their carers, during emergencies. Formative research
included in-depth interviews with carers followed by a structured questionnaire. Additionally, participatory methods to
enable people with intellectual disabilities to respond, including using a large doll to explore their feelings and
experiences of menstruating during emergencies were also used.
The formative research is complimented by a systematic review of literature relating to MHH for people with disabilities
in emergencies.
The Bishesta campaign is an intervention to improve understanding and behaviors around menstrual health and hygiene
for people with intellectual impairments and their carers and was first developed and tested in a development setting in
Nepal. The campaign promotes key target behaviors for people with intellectual impairments and their carers alike and
ultimately aims to support improved menstrual health and hygiene especially in emergencies.
Formative research findings have been used to adapt and contextualize the Bishesta campaign for a Vanuatu emergency
setting.

Results:
Findings illustrated the impact intellectual disability has on a young person to manage their menstruation with dignity
during an emergency. Few carers reported ever receiving support to manage the young person’s menstruation, and
nothing beyond standard hygiene/dignity kits in an emergency. Many young people frequently dispose of sanitary
products in bush toilets/VIP toiles which can be both harmful for sanitation facilities and is not environmentally friendly.
Hygiene kits were welcomed, however too often a “one size fits all approach” was taken, especially in relation to
sanitary products which didn’t consider challenges with safe disposal or ability to wash reusable products, number of
materials required, etc.
For households that were displaced a lack of privacy and stigma about the person's disability meant they face additional
challenges managing menstruation. Key implementing agencies reported a need to address MHH during peace time to
maximize effectiveness of humanitarian interventions including hygiene/dignity kit distributions.
*The Bishesta campaign pilot is ongoing, and findings will be finalized in September 2022.
Conclusions/Recommendations:
In Vanuatu, the emergency compounded pre-existing MHH challenges such as when bathing/toileting facilities were
destroyed and increased financial pressure limiting ability to provide menstrual products.
The study highlights that MHH is not a “one size fits all” intervention and if emergency response activities are to “leave
no-one behind” there must be greater attention paid to nuanced and adapted approaches, especially for people with
intellectual impairments and their carers. The pilot provides a toolkit and guidelines for how humanitarian actors can
better address MHH for people with intellectual disabilities in both disaster recovery and preparedness contexts.

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The Call of Duty: Institutionalising Periodic Desludging of Community and Public Toilets in Trichy
Gayathri Pattnam, Indian Institute for Human Settlements
Additional Authors: Rajesh Ramamoorthy, Sugantha Priscilla, Rajeswari R

Community and public toilets (CT/PT) are essential in widening the access to sanitation facilities and ensure that
marginalized communities, mobile workers, and the general public can access a hygienic, reliable, and dignified space.
Trichy, the fourth largest city in Tamil Nadu, India, with a population of one million, has a network of over 400 public and
community toilets, which cater to around 35,000 households without individual latrines, and to a large floating
population (TNUSSP 2018). Around 40% of these toilets use on-site sanitation systems, typically holding tanks, to
manage fecal waste. Although the Trichy City Corporation (TCC), provides de-sludging services to these toilets using two
vacuum trucks, inconsistent administrative oversight led to gaps in service delivery. Holding tanks require regular
emptying to avoid overflows, therefore a periodic de-sludging model was developed for the CT/PTs. Additionally,
embedding systems of accountability at different levels is required to sustain this model.
Records of service requisition and provision were not being maintained making it difficult to track which toilets had
received service, and when. As a first step, GPS devices were installed in the trucks. The GPS data confirmed that eight
toilets received services at a high frequency, thereby exacerbating inefficiencies in service delivery. This helped in
optimizing routes for expanding service coverage. Simultaneously, an assessment of on-site systems at 166 toilets and
discussions with caretakers at these toilets revealed damages in the containment systems at 17 toilets, and overflows
were observed at 47 locations. Caretakers also reported requesting for de-sludging and not receiving the service. This
can be attributed to the muddled lines of communication between the caretakers, the staff operating the trucks and the
TCC.
Field visits for municipal officers were organized to highlight the need for periodic de-sludging and problems with
containment. Thereafter, based on the findings from the assessment and inputs from the sanitary staff and caretakers, a
trial schedule targeting high-usage (over 50 users) toilets was prepared, covering 40 toilets over a period of three
months from September to December 2020. The trial demonstrated route planning while also allowing emergency
servicing. Importantly, it was an exercise in preparing officers for taking ownership of the process and establishing
reporting practices. Based on the results of the trial, in December 2020, the TCC issued a notification formalizing the
periodic de-sludging of high footfall CT/PTs, which is now being extended to cover all CT/PTs.
While the trial clarified the roles of different cadres, the real challenge lies in sustaining the practice. A mobile
application is being piloted to create and track the de-sludging schedules for the toilets. These will be used by the
sanitary officers and truck staff, enabling a two-way visibility on the de-sludging activities. Additionally, to prevent
slippages and address issues, an escalation matrix has also been envisioned.
The broader model of institutionalizing the periodic de-sludging of CT/PTs in Trichy has numerous insights to offer for
other cities looking to scale FSM, while bringing the focus back on public authorities for delivering inclusive sanitation.

The Development of Programmatic Guidelines for Family Planning and Menstrual Health Integration
Kate Rademacher, FHI 360
Additional Authors: Emily Hoppes, Eva Lathrop, Tanya Dargan Mahajan, Marsden Solomon, Katrina Wilson, and Lucy
Wilson

Background:
Family planning (FP) and menstrual health (MH) are closely related areas that are often not effectively integrated, which
results in missed opportunities to improve sexual and reproductive health. The current literature discusses and explores
the evidence around these important linkages but little to no guidance is available to program implementers who want
to integrate FP and MH effectively during programs.
Methods:
In November 2020, FHI 360 hosted a two-day virtual technical consultation on the topic of contraceptive-induced
menstrual changes (CIMCs), which included presentations and discussions related to programmatic interventions for
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CIMCs and FP-MH integration. Following this meeting, a Task Force was convened to develop a Global CIMC Research
and Learning Agenda (RLA), which was disseminated in November 2021. The Global CIMC RLA includes a research
agenda on programmatic research with a focus on FP-MH integration. Building on the Global CIMC RLA, a subcommittee
of Task Force members drafted and built consensus around programmatic guidelines for FP-MH integration.
Results:
Programmatic interventions should be designed to target girls, women, and people who menstruate at key stages across
the reproductive life course, from menarche to menopause. Priority areas for FP-MH integration include:
• Providing puberty education and comprehensive sexuality education with information about FP and MH, including
information about the menstrual cycle and how it relates to pregnancy and fertility that is delivered using evidence-
based curricula and teaching methods
• Providing services at the same delivery point and by offering referrals. For example, including the provision of
menstrual products as a part of FP counseling, or providing FP services or referrals during community-based menstrual
health education and product distribution events
• Using the Pregnancy Checklist (developed by FHI 360) and low-cost pregnancy tests to eliminate menstrual status as
a barrier to FP access
• Addressing CIMCs among FP users, including through the use of counseling tools such as NORMAL (developed by FHI
360 and PSI)
• Ensuring that both MH and FP needs are adequately addressed when providing services to populations with special
or unique needs (including youth, perimenopausal people, people with disabilities, people living with HIV, postpartum
people, refugees, migrants or other mobile populations, sex workers, people in the LGBTQ community, survivors of
abuse and violence, and those who are incarcerated, among others)
Conclusions:
Stakeholders, including governments, donors, program managers and healthcare providers, can facilitate stronger
linkages between FP and MH, including through integrated service delivery models. The guidance document developed
here provides a structured approach to integrating FP and MH into policies and programs globally.

The impacts of COVID-19 on WASH and menstrual hygiene and health

Rachel Fisher Ingraham, WASH Subgroup, Gender & COVID-19 Working Group
Additional Authors: Karen Joe

Background:
Approximately 300 million women, girls, transgender, and gender non-binary persons menstruate daily, yet menstrual
health and hygiene (MHH) remains a forbidden topic and widely unmet need for many. Public toilets and school latrines
are often unsafe and unsanitary and lack privacy, soap, water, and adequate means for MHH product disposal.
Individuals using reusable MHH products additionally may lack hygienic spaces to dry their products. WASH
infrastructure and resources have the power to impact safe menstrual hygiene management. However, as the COVID-19
pandemic developed, resources were diverted to address the crisis while existing public health challenges grew.
Problem Statement:
The COVID-19 pandemic exposed inequities in WASH, further exacerbating the challenges menstruators face.
Objective:
The objective of our research was to understand the impact of COVID-19 on WASH and MHH to inform future crisis
planning.
Methods:
We engaged in a landscape analysis beginning in 2020 that extended into 2021. Because of the nature of the evolving
pandemic, our meta review of MHH and COVID-19 included gray literature in addition to peer reviewed, academic
articles. Specifically, we were interested in materials that highlighted real time experiences of menstruators. By reading
broadly, we were able to identify themes and challenges within the context of WASH and MHH. Using a feminist,

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gender-transformative approach facilitated a more robust and accurate understanding of the systemic and social
complexities surrounding the intersection of these topics.
Findings:
Gender and social norms perpetuate inequalities women, girls, and others who menstruate experience. The COVID-19
pandemic compounded these inequalities by highlighting the many challenges associated with MHH and exposing
weaknesses in WASH systems, infrastructure, and resources. This stigma may be greater for those already marginalized
because of race, religion, gender identity, social class, or disability status. MHH supplies are often provided free of cost
at school and health centers; their closures during the height of the pandemic led to incidents of transactional sex to
procure sanitary pads or the money to buy them. Lockdown protocols, border closures, and panic buying impacted the
sanitary pad supply chain, constraining markets for both buyers and sellers. Any resulting financial strain
disproportionately impacted women and girls who are frequently not in control of finances, an acute issue for those who
use disposable products that require monthly purchasing. Rates of domestic violence also increased during the
pandemic with incidents reported when women used household products as makeshift pads, an act that could be
viewed as ‘destructive’.
Conclusion:
WASH programs can be powerful catalysts for improving gender equality, health, and education by advancing MHH
infrastructure, resources, and stigma reduction. COVID-19 contributed to the redirection of resources, market
disruptions, and continued lack of access to safe WASH during the pandemic, forcing financial and social constraints
upon menstruators. It is critical and vital that any WASH response to a crisis not only elevates but also advances MHH,
ensuring that policies and protocols promote gender equality and human rights.

WASH Access Among People Who Inject Drugs in Tijuana, Mexico and San Diego, California
Alhelí Calderón-Villarreal, UCSD/SDSU
Additional Authors: Lourdes Johanna Avelar Portillo, Daniela Abramovitz, Gudelia Rangel, Steffanie A. Strathdee, Georgia
Kayser

Background:
Water, sanitation, and hygiene (WASH) constitute basic human rights. People who inject drugs (PWID) experience
stigma and structural violence that may limit WASH access. Yet few studies have assessed WASH among PWID, and none
in the Tijuana (TJ)-San Diego (SD) metropolitan area.
Methods:
A cross-sectional binational study among PWID (18+) in 2020-2021 assessed basic WASH, open defecation, and water
sources for cleaning wounds and preparing drugs. Logistic regressions – adjusted by gender, city of residence, housing
status, and sex work – were used to examine WASH insecurity inequalities.
Results:
Of 586 PWID, 66% lived in SD, 75% were male, 42% were unhoused, and 9% reported sex work. 89% reported basic
access to drinking water, 28% to basic sanitation, 38% to basic hand hygiene, and 38% reported open defecation.
Unhoused participants experienced greater insecurity in accessing basic sanitation (AdjOR: 8.7, 95%CI: 5.6-14.1), and
improved water sources for cleaning wounds (AdjOR: 6.5, 95%CI: 2.5-22.5), and preparing drugs (AdjOR: 5.5, 95%CI: 2.3-
16.5). Participants residing in TJ reported more insecurity in accessing basic drinking water (AdjOR: 1.9, 95%CI: 1.1-3.4),
basic sanitation (AdjOR: 1.6, 95%CI: 1.1-2.3), and basic hygiene (AdjOR: 3.3, 95%CI: 2.2-5.1). Participants who reported
sex work experienced more insecurity in accessing basic hand hygiene (AdjOR: 2.3, 95%CI: 1.1-5.5).
Conclusion:
Despite the development and wealth in TJ-SD, PWID and especially those with intersecting vulnerabilities (e.g.,
unhoused, residing in TJ, sex workers) are excluded from WASH assessments. Concerted efforts are needed from
governmental and non-governmental sectors to ensure WASH security in the urban borderland of TJ-SD.

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Water, Sanitation and Hygiene Experiences and Needs of Women with Obstetric-Fistula-Induced Incontinence in
Ghana
Samuel Adjorlolo, Research and Grant Institute of Ghana
Additional Authors: Obed Asamoah Kissi

Background:
Women with incontinence have limited opportunities to keep clean particularly in settings where water, sanitation, and
hygiene (WASH) services are notably scarce. However, the WASH needs of these women have not been granted the
requisite scholarly attention, globally. The existing knowledge gap is largely hampering efforts to design programs to
support women with incontinence resulting from obstetric fistula to meet their WASH needs. The current study
investigated the lived experiences of women with obstetric fistula-induced incontinence, how they meet their WASH
needs, the barriers they encounter, existing and new interventions to improve their WASH experience
Methods:
A sequential mixed methods design which employed individual interviews, focus group discussion and questionnaires
were used to collect data from women with obstetric fistula. The participants were recruited from Mankessim fistula
treatment center, Ghana, using purposive, convenience and snowball sampling approaches. Qualitative data analysis
was guided by Conroy’s Interpretive Framework, while quantitative data analysis was conducted using descriptive
statistics.
Results:
Participants have profound difficulty assessing sanitary and body care products such as diapers, soap, and Dettol. They
adopt practices such as using drugs and/or food to constipate themselves and used diapers produced from traditional
and household materials such as used clothes and flour sacks to manage incontinence. They also experienced a lot of
discomforts and challenges including pain, incontinence with urine and feces, depression, suicidal ideation, social
isolation, stigmatization, unfulfilled sexual lives, and financial constraints. They also found it challenging to meet their
basic hygiene needs since they were not gainfully employed.

Conclusion:
There is the urgent need to institute measures to improve the WASH experiences of women with incontinence, including
using reusable sanitary pads/ diapers, reintegration, and rehabilitation of women with incontinence, economic
empowerment opportunities and public education, awareness creation and advocacy.

Women Social Entrepreneurs in Water ATMs breaking the gender role and poverty cycle
Poonam Sewak, Safe Water Network and USAID
Additional Authors: Pooja Singh; Karen Klimowski; Mark Tegenefeldt

The authors report from urban India on the women-led social entrepreneurship in safe drinking water through water
ATMs for water sector development, gender inclusion, and poverty reduction. Water ATMs are decentralized safe
drinking water kiosks from where the consumer can buy water in their own container at the drop of coin. The 'Water
Aunties' model builds safe drinking water security, social and economic capital within the community, and promotes
micro-enterprises. It sends more women to work and girl child to school as it assures affordable, 24x7 safe drinking
water availability in the locality. Our 'Water Aunties' are women entrepreneurs, plant operators, water quality testing
and monitoring agents, and community mobilizers. The study shares findings from 23 cities across 11 states of India with
multiple Water ATM implementers who enabled and trained 548 grassroots, semi-literate women from low-income
communities or self-help groups to operate and manage the water ATM.
Core activities included entrepreneurship development, capacity building in operations and management of water ATM,
water quality, and social marketing. In phase one of our project, we identified and solved the barriers against women's
participation in Water ATMs. We developed a "" Gender Toolkit"" that shares the framework used to understand the
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enablers and barriers to the inclusion of women in the hitherto male-dominated Water ATMs program. The strategies
adopted to overcome the women's socio-cultural, educational, and technical challenges for inclusion in the program.
The toolkit outlines the methodology to guide the Master Trainer to operationalize women's entrepreneurship in
gender-related work and Water ATMs. It includes gender-responsive indicators, the imperatives for onboarding,
supporting, and retaining women, engaging with men to break down patriarchal barriers, and teaching women groups
how to plan, design, operate, and monitor Water ATMs. In phase two, we trained 18 master trainers to expand the
program across India. The Water Aunties earn $ 50-70 / month.
'Water Aunties' ATMs resulted in positive ripple effects as various micro-enterprises led by women mushroomed around
these centers, such as tea stalls and street food, earning $40-50 / month. Affordable and assured access to safe water
saved time in water collection and increased productive hours for the local women enabling them to pursue their daily
wages at $ 4-5 / day in the informal market. 'Water Aunties' is a model for enabling livelihoods, public health
improvement, and poverty reduction. It can be scaled globally to accelerate the UN SDG Goal 6.1- Safe Water for All.
During the pandemic COVID, these Water ATMs were leveraged as Water Knowledge Resource Centers. The Water
Aunties expanded their role in spreading awareness on handwash hygiene and COVID care protocols. Now, they
promote rainwater harvesting structures, water meters, microenterprises, and the training of women-based repair
groups too. Water Aunties initiative breaks the poverty cycle by economic empowerment of women.

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