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POSTER PRESENTATIONS – 2018 Water & Health Conference of 52

2018 Water & Health Conference Where Science Meets Policy

October 28 – November 2, 2018

University of North Carolina at Chapel Hill

POSTER ABSTRACTS (Alpha Order by Title)

Updated 10-10-18 Title: A New Approach to Measuring Household Water Insecurity Experiences (HWISE): Highlights and Opportunities from the HWISE Network

Authors: Justin Stoler, University of Miami, Sera Young, Northwestern University, Wendy Jepson, Texas A&M, Amber Wutich, Arizona State University, Joshua Miller, Northwestern University, HWISE Consortium

Submission: The Household Water InSecurity Experiences (HWISE) network is a consortium of over 50 water researchers and practitioners. HWISE is a community of practice and collaboration that fosters key analytics and theoretical advances coupled with the development of research protocols and standardized assessments to document, benchmark, and understand the causes and outcomes of water insecurity at the household scale. The network also supports conceptual advances in the study of household water provision and water insecurity in relation to broader social and environmental challenges. HWISE partners have completed (or have underway) standardized water insecurity assessments at 28 sites on 4 continents, and already have cleaned data from over 6,000 households across 20 sites. We present the highlights of several recent cross-cultural studies using harmonized HWISE data to understand the broad consequences of water insecurity on issues such as coping through water sharing, concomitant psychosocial stress, infant and young child feeding, water fetching injuries, the financial strain of buying water, and the relationship with food insecurity. The network presents rich opportunities for interdisciplinary collaboration and practitioner engagement to meet household water provision goals across diverse socio-cultural and political-economic contexts. Note: abstract is intended to be paired with a related submission by Sera Young, Northwestern University.

Title: Microbial and Turbidity Removal by Chitosan Coagulation in Natural Waters to Optimize Various Point-of-Use Filtration Technologies for Household Drinking Water Treatment

Author: Eleanor Holmes, University of north Carolina at Chapel Hill

Submission: Critical performance challenges still exist in technologies employing filtration as a contaminant removal mechanism for drinking water. Coagulation-flocculation pretreatment is often applied to overcome these limitations. While inorganic coagulants are commonly used, there has been limited research to explore alternative, environmentally-friendly coagulants that may be more effective against pathogenic microorganism such as viruses. We identified a novel and flexible alternative pretreatment approach employing chitosan as a “green alternative” which has demonstrated effectiveness over a range of temperature and pH values. In this study, we aimed to investigate the turbidity and microbial reductions associated with chitosan coagulation combined with various filtration technologies. Previous studies have evaluated medical grade chitosans with high purity that are expensive and difficult to source. We compared food and medical grade chitosans in order to determine whether an alternative grade of chitosan that is more cost-effective achieves comparable reductions. To examine microbial removal, surface waters were spiked with E. coli KO11 bacteria and MS2 bacteriophages as bacterial and viral surrogates. Membrane filtration, spread plate, double agar layer and single agar layer assays were used for enumeration. Log10 values and percent reductions were calculated for surrogate microbes and turbidity, respectively. Results varied significantly between different types of filtration technologies. For ceramic filters,


preliminary results indicate that food and medical grade chitosans achieved similar average log10 reductions for both bacteria and viruses, exceeding 8 and 6, respectively, while average percent turbidity reductions exceeded 85%. The use of medical grade chitosan acetate, in conjunction with cloth filters, did not achieve extensive reductions in bacteria or viruses to meet WHO performance targets for HWT technologies. Sand filters are still under evaluation but preliminary results have produced variable reductions. Results indicate that food grade chitosan products offer a more cost-effective and easily-sourced means for water treatment compared to medical grade products and achieve similar log10 reductions for surrogate microbes. Further optimization of dose is required before this innovation can be applied for water treatment purposes.

Title: A Novel Approach for Detecting Cryptosporidium Contamination in Surface Water Supplies

Authors: Kristen Jellison, Lehigh University, Sabrina Jedlicka, Lehigh University

Submission: EPA methodology for Cryptosporidium monitoring in water relies on filtering 10 L of water, providing a snapshot of river conditions. A negative sample does not mean that oocysts are not (or have not recently been) present in the water supply, only that no oocysts were detected in that 10-L water sample. We have shown that biofilm sampling provides comparable oocyst detection to filtration-based methods. We deployed glass slides (substrates for biofilm growth) at a water treatment plant (WTP) intake and a sewage-contaminated creek for 2-week intervals over one year; we also filtered water at these locations every two weeks. Biofilms were scraped from slides and filters were eluted; oocysts were detected by immunomagnetic separation (IMS) and an immunofluorescent assay (IFA). At the WTP, oocysts were detected in 36% of slides and 32% of filters; at the creek, oocysts were detected in 56% of slides and 59% of filters. Biofilm sampling is cheaper than filtration ($3/set of slides vs. $110/filter) and could thus be performed more frequently and at more locations. Benthic rock biofilm sampling was also tested. Rock scrapings collected upstream and downstream of a sewage outfall were processed by IMS and IFA; 5 oocysts were counted upstream compared to 19 downstream. At a second outfall, oocysts were detected in 16% and 50% of upstream and downstream rock scrapings, respectively. Despite these data, the use of biofilms for standardized detection of Cryptosporidium is contraindicated due to variation in biofilm composition and development across seasons and geographic locations. Thus, we are working to develop an inexpensive, biomimetic substrate that will permit oocyst attachment similar to that observed in biofilms. Water sampling with the biomimetic substrate could supplement filtration-based Cryptosporidium monitoring, and these substrates could be strategically placed throughout a watershed to identify point sources of oocyst contamination which require intervention.

Title: A Novel Lactic Acid Bacteria Based Method to Sanitize Synthetic Wastewater of Escherichia Coli

Authors: Walter Chingwaru, Bindura University of Science Education, Tatenda Jambo, Bindura University of Science Education, Richwell Alufasi, Bindura University of Science Education

Submission: Zimbabwe's population is affected by erratic outbeaks of diarrhoea. The country has recorded at least 200 cases of typhoid fever during the first 3 weeks of 2018 alone. Our ongoing research continues to identify poor water quality and the release of wastewaters into the countries freshwater channels as the major risk factors for the burden of diarrhoeal diseases. Bioremediation is widely praised as a sustainable and cheap way to treat wastewaters particularly in resource limited settings. We tested the removal of strains of Escherichia coli (saprophytic / environmental and O157:H7) by a number of putative lactic acid bacteria and standard probiotic bacteria from synthetic wastewater. Furthermore, we tested the cidal / static activities of the LABs using the well diffusion assay. A number of treatments with LAB led to significant reductions (p < 0.05) in loads and shorter survival times in the two strains of E. coli in synthetic water and showed high antimicrobial activities (zone of inhibition at least 12mm – comparable to that of kanamycin, ≥ 15mm). The LABs survived for a longer period in the synthetic water than both strains of E. coli. Given the high cidal / static effects of the selected probiotic strains in wastewater medium, we propose a method that employs LABs as novel tools for the removal of E. coli from wastewater with potential for use as an ecologically acceptable method to sanitise wastewaters of enteropathogens in low and high income countries.

Title: A Preventative Maintenance Business Model: Lessons from Rural Uganda

Authors: Alison Filler, International Lifeline Fund, Igor Markov, International Lifeline Fund, Emmanuel Sunday Ojara, International Lifeline Fund


Submission: Efforts to improve access to water in rural Uganda are failing over the long-term when as many as 30-50% of water projects fail within two to five years. After thoroughly engaging the local government and communities for buy-in, International Lifeline Fund has been piloting a preventative maintenance and repair business model in rural Uganda since August 2017 to address this challenge. This model offers three key advantages over business as usual. First, a professional business removes the burden of maintenance and repair from the users - the community simply pays for a service. Second, continuous monitoring of engineering parameters and a toll-free hotline allow for early detection of mechanical issues to reduce the frequency of breakdowns and downtime. Finally, at an average price of less than $1 per user per year, it reduces cost barriers for communities to subscribe to a maintenance contract. At the 2017 UNC conference, Lifeline demonstrated the initial findings of how this project has laid the foundation for a community-funded, centralized maintenance infrastructure at the district level that can sustain the functionality of community managed boreholes. First quarter results included 99.4% functionality of serviced boreholes, an average of 8.9 months between pump failures, and 100% on-time delivery of maintenance services. Since then, Lifeline has partnered with other WASH actors to boost its M&E capacity and transition the business from manual paper-based tracking to a cloud-based platform. In doing so, Lifeline intends to turns this business over to local Ugandan entrepreneurs for long-term ownership and operation.In this presentation, Lifeline will discuss one year of findings, challenges, and lessons learned since the launch of its borehole maintenance business, including the power of sector partnership to share the benefits of comparative expertise, and what this means for improving rural water access across sub-Saharan Africa and the globe.

Title: A Systematic Literature Review of Systems Tools and Approaches for WaSH

Authors: Nicholas Valcourt, Department of Civil, Environmental and Architectural Engineering. University of Colorado Boulder, Amy Javernick-Will, University of Colorado Boulder, Jeffrey Walters, Department of Civil Engineering. Universidad Diego Portales, Karl Linden, University of Colorado Boulder

Submission: The WASH sector has begun to embrace systems thinking approaches in recognition that sustaining services to achieve the SDGs will require a more actionable understanding of complex, dynamic and context-specific local systems. Despite a substantial number of systems tools and approaches proposed for improving WASH outcomes, there is currently no knowledge base of these approaches or their efficacy. This lack of a clear evidence base presents a barrier for uptake of these tools in planning and implementation because development practitioners have no metrics to compare and vet one approach against another.To address this gap, USAID’s Sustainable WASH Systems Learning Partnership has begun a comprehensive, systematic review of the current state of, and evidence for, systems approaches in WASH. The analysis will synthesize current trends in methodologies, applications, and evidence of systems approaches. Since much of this information has been developed outside of academia, the review will examine grey and organizational literature in addition to peer-reviewed journals. Initial findings highlight an important divide across the sector in how systems approaches are conceptualized. Grey literature tends to describe these approaches as frameworks for engaging in local systems or networks, whereas peer-reviewed literature typically focuses on singular applications of a specific analytical methodology. The most prominent gap identified to date is the broad spectrum of definitions for basic elements of a system such as ‘factors’ or ‘interconnections’, and fundamentally, what constitutes a ‘systems approach’. Thus, this review has identified notable issues in how different actors in the WASH sector frame and implement systems thinking activities. Bridging these gaps and working towards a common, shared language of systems can help the sector better understand the utility and efficacy of these approaches in helping to achieve the SDGs.

Title: A Systematic Review of Environmental Health Conditions in Institutional Care Settings for Orphaned and Abandoned Children

Authors: Michelle Moffa, Duke University, Ryan Cronk, UNC Water Institute, Leslie Padilla, Sarah Dancausse

Submission: Background: Safe environmental health conditions and good hygiene behaviors are fundamental for the provision of adequate housing and are important for children’s health, development, and well-being. This is especially important in institutional care settings for orphaned and abandoned children, a particularly vulnerable population whose basic needs are often not met. The objectives of this systematic review were to report on the status of environmental health conditions and exposures in institutional care settings and associated health outcomes; interventions to improve these conditions and outcomes; and obstacles that prevent these improvements. Methods: We searched PubMed, Web of Science, Scopus, and EBSCOhost for peer-reviewed studies, and additional sources for grey literature. Studies were


included if they reported primary data or observations on one or more environmental health condition or exposure in an institutional care setting for orphaned and abandoned children.Results: Forty-seven studies were included. The most common environmental health concerns included overcrowding, sharing of personal items, insufficient hygiene, improper hand-washing practices, and inadequate or contaminated water supply. Scabies, malnutrition, protozoan parasites, and other infections were commonly correlated with these poor living conditions and behaviors. Discussion/conclusion: Adequate environmental health conditions and good hygiene behaviors in children’s institutional care settings and successful environmental health interventions can serve as positive examples to improve the health and development of orphaned and abandoned children worldwide.

Title: A Systematic Review of Environmental Health Conditions in Penal Institutions

Authors: Wilson Guo, The Water Institute, Department of Environmental Sciences and Engineering, Ryan Cronk, UNC Water Institute, Elissa Scherer, Annie Oommen

Submission: Background: Penal institutions play an important role in addressing the basic health needs of prisoners. Adequate environmental health conditions in penal institutions are necessary to protect and promote the health of prison populations. Our objectives through this systematic review were to determine the status of environmental health conditions in penal institutions and the associated exposures and health outcomes, investigate strategies effective in controlling and preventing current and prospective environmental health concerns, and identify evidence gaps within the literature on environmental exposure in penal institution populations.Methods: PubMed, Web of Science, EBSCOhost, Scopus, and ProQuest were searched. Peer-reviewed studies that contained original data and reported on environmental health conditions and/or exposures in penal institutions were included.Results: Seventy-three studies were included. The most common risk factor identified was the intake of food and/or beverages prepared and handled in the penal institutions kitchen facility. Overcrowding, inadequate ventilation, lack or sharing of soap and other sanitary products, and poor environmental health conditions increased the risk of adverse health outcomes. Common control strategies included isolating affected patients, educating prisoners and prison staff on improved sanitation and hygiene practices, improving ventilation, and disinfecting contaminated surfaces and/or water sources. Discussion/Conclusion: Inadequate environmental health conditions in penal institutions are common and preventable, yet adversely impact the health of prisoners and prison staff. Environmental health conditions affecting prison populations can be improved through enhanced implementation of control measures and prevention strategies and vigilant monitoring of environmental health conditions.

Title: Advancing the Safistation Chlorine Generator forInfection Prevention and Control in Health Care Facilities

Authors: Chelsea Schiller, PATH, Adam Drolet, PATH

Submission: Health care facility-acquired infections (HCAIs) negatively affect hundreds of millions of individuals worldwide. Patients in low- and middle-income countries face an increased risk of exposure to HCAIs: 3‒20 times higher than patients in similar settings in high-income countries. A recent World Health Organization survey of health care facility conditions in low- and middle-income countries revealed 36.4% lacked chlorine solution for decontamination. Causes of limited chlorine solution availability and stockouts include weak supply chains, burdensome procurement processes, and logistical complexities involved in chlorine product distribution. PATH and MSR® Global Health developed the SafiStationTM Chlorine Generator, an innovative and easy-to-use chlorine generator designed primarily for infection prevention and control in low- and middle-income country health facilities. The device uses commonly available consumables—salt, water, and electricity—to produce 3 liters per hour of 1% chlorine solution onsite through the process of electrolysis. From September through November 2018, PATH will conduct an operational study to analyze quantitative and qualitative data regarding the performance, acceptability, and health system fit of the SafiStation in up to 40 health facilities in Ghana and Uganda. Study results will validate the technical performance of the SafiStation, generate a summative acceptability measure of the device, and identify changes in chlorine availability and distribution within health facilities and operational cost and potential cost savings resulting from the use of the SafiStation. Along with preliminary findings on these study endpoints, market validation results and market introduction strategies will be presented.


Title: Africasan - Measuring Progress Toward SDG 6

Authors: Alayne Potter, DAI - Water for Africa through Leadership and Institutional Support (WALIS)

Submission: The AfricaSan Movement is a pan-African political initiative started in 2002 to build momentum to address safe sanitation and hygiene across Africa. AfricaSan serves as the African-led leader in thinking on and around sanitation monitoring against SDG 6.2, building consensus with varying actors on these topics. After the adoption of the SDGs in 2015, the African Ministers in charge of sanitation and other representatives of African governments made a landmark decision during the AfricaSan 4 conference with the ‘’Ngor Commitments on Sanitation and Hygiene’’. The Ngor Commitments aim to achieve universal access to adequate and sustainable sanitation and hygiene services and eliminate open defecation by 2030 through strong monitoring, improved budgeting, and leveraging resources to bridge the funding gap.Supported by USAID WALIS, the African Ministers Council on Water (AMCOW) spearheads the AfricaSan process. During this session, participants will learn about what Africa is doing to lead the monitoring and evaluation progress against SDG 6.2 and the Ngor Commitments. This will include information on new AfricaSan indicator reporting guidance, Africa’s first-ever country-by-country baseline monitoring, and get a sneak-peek of the upcoming Joint AfricaSan/Fecal Sludge Management Conference taking place in Abidjan in February 2019. We’ll also be sharing the challenges that AMCOW has faced in getting national level buy-in for monitoring and evaluation, the funding gap that Africa continues to face on SDG 6.2, the trajectory Africa is on in meeting the SDG 6.2, and what needs to change to meet our targets.

Title: Airborne Antimicrobial Resistance Genes Near Open Wastewater Drains in Kanpur, Uttar Pradesh, India

Authors: Olivia Ginn, School of Civil and Environmental Engineering, Georgia Institute of Technology, David Berendes, Anna Wood, Georgia Institute of Technology, Sachchida Nand Tripathi

Submission: Understanding environmental transmission of antimicrobial resistance genes (ARGs) is critical to limiting the spread of antimicrobial resistance. To assess potential for ARG transport via the aeromicrobiologic pathway in cities with poor sanitation, we quantified fecal indicator bacteria and ARGs in 11 open drains with concentrated fecal waste flows and nearby ambient air (n=68) in Kanpur, India over two months spanning dry and rainy seasons. ARGs represented major antibiotic groups—tetracyclines (tetA), fluoroquinolines (qnrB), and beta-lacatams (blaTEM)—and a mobile genetic element (intI1). Samples of drain water (11/11) and air (39/53) had detectable ARGs. Drain samples analyzed contained all ARGs tested. Of 53 air samples analyzed, tetA (60%) and intI1 (65%) were most prevalent, followed by blaTEM (23%) and qnrB (2%). While average ARG concentrations in positive drain samples were high (1.14 x 106-3.34 x 108 gc/m3 water), concentrations in positive air samples were lower but detectable (28.8 to 405 gc/m3 air). Bioaerosols may play a role in the fate and transport of ARGs in highly contaminated, urban environments.

Title: An Evaluation of a Novel Hand Hygiene Education Program in Philadelphia Pre-K Schools

Authors: Heather Murphy, Water Health and Applied Microbiology Lab (WHAM Lab) Temple University, Jingwei Wu, Temple University, Michael Pietrowski, Temple University, Deirdre Ann Dingman, Temple University

Submission: Handwashing interventions reduce both gastrointestinal and respiratory illnesses in children under the age of 5 (Freeman et al. 2014). The purpose of this study was to evaluate a novel handwashing program targeted at preschool aged children (3-4 years old) in the Philadelphia School District. A private global hygiene and health company, with an office in Philadelphia, created a handwashing program using a black light technology to illustrate correct hand hygiene practices to preschool aged children in hopes to spur a behavior change and improve handwashing knowledge and practices. The research team conducted a waitlist control study in two Pre-k schools (10 classrooms, 200 students) to evaluate this program. The intervention school design was o x o o and the waitlist control was o o x o, such that three observations occur at each school (o= observation; x= intervention). To measure handwashing knowledge, students were asked to place 5 handwashing steps presented as puzzle pieces in sequential order (score 1 point for each correct step). To measure handwashing practices, students were observed washing their hands and received points for each correct handwashing step (e.g., wet hands, apply soap). In addition to these direct observations, parents of participants were sent a survey to document the number of gastrointestinal or respiratory illnesses and absences students had experienced in the past 7 days. Lastly, we collected 30-day absence lists from the central office. At the time of this submission, data are being analyzed. Findings from this study will inform practice and may be used to modify the program so it can be further studied and scaled-up for use in schools in both developed and developing countries.


Title: An Investigation of Community Pooled Resources for Sustainable Handpump Maintenance: The Relationship Between Water User Participation and Saline Water

Authors: Jonathan Truslove, University of Strathclyde, Andrea Coulson, University of Strathclyde, Robert Kalin, University of Strathclyde, Muthi Nhlema, BASEFlow

Submission: In rural Malawi, the responsibility of water supply management is decentralised through the Community-Based Management (CBM) approach. Since the implementation of CBM, it has been widely recognised that this approach has various failings. To address these issues, a community pooled resource approach has been piloted in a catchment area of Chikwawa, Malawi. This approach utilises financial contributions from multiple communities for the maintenance of Afridev handpumps in the catchment area. A field investigation and SWOT analysis was conducted into the operations and maintenance procedures of the community pooled resource approach and the participating local water point committees (WPC). Observations during this study found that the pilot model has similar failings as CBM. Over a 12-month period there was a marked reduction from 58 WPCs that participated to only 8 WPCs. Poor water quality was observed to influence water user participation with the WPCs, and WPC participation with the pilot model. Thus, handpump breakdowns were often left unresolved. Electrical Conductivity (EC) data was recorded from the 24 WPCs reporting water salinity, in the range of 1183μS/cm to 11810μS/cm. Out of those supplies, 12 were below the Malawian minimum standard for EC (3500μS/cm), while 12 were above the minimum standard. Water users also stated they prefer using other handpumps with less saline water, or unimproved sources, than using the saline supplies. Salinity will continue to be a burden to sustainable service provision by negatively impacting financial resources towards the water point. This will result in a lack of safe drinking water availability which poses a risk to the health of the community. In order for Malawi to fulfil its SDG targets, it is recommended that water quality is appropriately investigated at the commission stage of water provision.

Title: A Transdisciplinary Co-Design and Behaviour Change Approach to Introducing Sodis to Rural Communities in Malawi – Formative Research Findings

Authors: Tracy Morse, University of Strathclyde, Kingsley Lungu, Kondwani Luwe, Lyndon Buck, Honor Fagan, Kevin McGuigan, RCSI

Submission: Despite the increasing volume of evidence demonstrating the efficacy of solar water disinfection (SODIS) as a household water treatment technology, there still appear to be significant barriers to uptake in developing countries. SODIS potential is often treated with scepticism both in terms of effective treatment, and safety of the plastics used, and is dismissed in preference for more accepted technologies such as ceramic filters and dose chlorination. As part of WaterSPOUTT (EU H2020 688928), our study is using an integrated transdisciplinary approach to deliver an innovative SODIS system in rural communities in Malawi. These communities currently have no access to protected drinking water, and our formative work initially focussed on identifying specific water needs and challenges, before introducing potential solutions to end users for co-design. This shared dialogue process led to the development of higher volume systems (20 litres) taking into consideration end user preferences for simple systems which are ‘familiar’ and can be constructed locally. Development of potential ‘SODIS bucket’ and ‘combined SODIS ceramic’ systems was then undertaken by design experts with continued input from end users, and then subject to controlled testing to ensure efficacy and safety (E. coli, viruses, Cryptosporidium, leaching of estrogenic and mutagenic compounds). Concurrent formative observations and behaviour change modelling identified the most effective method to introduce and sustain use of the system. These include specific normative, ability and self-regulation factors which will be delivered through existing community structures and household support during a 12 month pilot study of the final prototype systems. The formative process and results will be described.

Title: A Participatory Factor Mapping Process for Understanding the Complexity of Local WASH Systems

Authors: Nicholas Valcourt, Department of Civil, Environmental and Architectural Engineering. University of Colorado Boulder, Jeffrey Walters, Department of Civil Engineering. Universidad Diego Portales, Amy Javernick-Will, University of Colorado Boulder, Karl Linden, University of Colorado Boulder


Submission: Studies have shown that high failure rates of rural water schemes in developing communities are likely the result of a wide range of ‘factors’ which interact in complex, yet unknown and misunderstood, local systems. While this has encouraged WASH sector actors to recognize the need for more systems-based approaches to understand this ‘wicked’ problem, there are few methodologies that explicitly investigate locally-specific interactions and dynamics between these factors. Systems-focused activities and methodologies that have been previously employed in the WASH sector are often too complicated and convoluted to produce salient information for local decision makers. Thus, more accessible, robust and actionable analytical tools are needed to understand and act on the interdependencies and dynamics between important factors to target the underlying system processes that drive service sustainability or failure. To respond to this need, this work employs a Group Model Building (GMB) activity to gain a better understanding of (i) what factors local stakeholders believe to be critical for sustaining services, (ii) how these factors form a dynamic system and, (iii) how similar or divergent these systems appear across contexts. The research also explores how the complex system insights that are produced from these activities can be communicated to, and utilized by, local stakeholders. This work will reflect on experience implementing the GMB activity in eight contexts in rural Ethiopia & Uganda to elicit key insights into local factor interactions. Preliminary results indicate that key system leverage points (feedback loops) vary significantly across seemingly similar contexts as well as between stakeholder groups within the same context. This work also explores the potential for and challenges of engaging local stakeholders in systems thinking activities and communicating complex and nuanced findings to local actors and practitioners.

Title: Approaching Sanitation As a Social-ecological System: A Conceptual Framework to Support Decision-Making

Authors: John Trimmer, University of Illinois at Urbana-Champaign, Diana Byrne, University of Illinois at Urbana-Champaign, Stephanie Houser, University of Illinois at Urbana-Champaign, Hannah Lohman, University of Illinois at Urbana-Champaign, Dan Semakula, Community Integrated Development Initiatives, Daniel Miller, University of Illinois at Urbana-Champaign, Jeremy Guest, University of Illinois at Urbana-Champaign

Submission: Multiple contextual challenges hinder progress toward universal sanitation access. Understanding and overcoming these challenges requires a holistic approach that views sanitation within a broader structure of social, economic, governance, and resource systems. Social-ecological system (SES) frameworks, most often applied to common-pool resources (e.g., fisheries), provide conceptual mechanisms to understand a complex whole by characterizing specific variables and interactions. A framework for resource recovery from sanitation represents a distinct case. Each person forms part of the resource system, contributing flows of resource units (e.g., nutrients, energy) that can be reused. This framework could aid stakeholder communication and support decision-making around technology development and selection, system management, and resource reuse.This work begins to develop such a framework, identifying variables, relationships, and constraints influencing the sanitation SES. Further, we apply it in a specific context – Bwaise, an informal settlement in Kampala, Uganda – as a first step toward developing tools to support communication and decision-making. Findings from 844 household surveys (deployed in partnership with Community Integrated Development Initiatives) provide data and context. Preliminary results suggest most people use shared pit latrines, with sludge emptied and hauled to a management site for a fee. However, household-level sanitation facilities and emptying fees are unaffordable for many, and diarrhea remains a challenge. Alternative sanitation strategies may help address these issues and impact other resource systems. Energy is a major concern, as households spend large fractions of income on cooking fuel. Proximity of local farms suggests nutrient recovery could feasibly generate income and employment. In resource-limited settings like Bwaise, this sanitation SES framework may reveal new opportunities for improving resource access and well-being.

Title: Ascaris Ova and Fecal Coliform Control in the Anaerobic Digestion Pasteurization Latrine

Authors: Aaron Forbis-Stokes, Triangle Environmental Health Initiative, Graham Miller, Duke University Civil & Environmental Engineering, Brandon Hunter, Duke University, Lucas Rocha Melogno, Duke University Civil & Environmental Engineering

Submission: The Anaerobic Digestion Pasteurization Latrine (ADPL) is a self-contained, off-grid, and energy neutral on-site fecal sludge treatment system using anaerobic digestion of human excreta to generate biogas and then uses the biogas to pasteurize the digester effluent at 65-70 °C to produce a safe effluent. The ADPL has been implemented in three countries and has been in continuous operation in the field for 5 years.ADPL research was presented at previous UNC Water and Health Conferences detailing the proof of concept, initial field deployment in Kenya and the Philippines, and findings from


field studies. Since the last conference, greater effort has concentrated on polishing the system effluent and providing greater reliability in pasteurization. A low-cost data acquisition and control system that operates the pasteurizer was improved to regulate flow through the system to ensure pasteurization targets are met. The controller also streams data to a webpage in real-time using local cellular networks. With the controls in place, effluent from the pasteurizer has had no detectable fecal coliform (FC, N=10).Though final effluent had no detectable FC when the heater was set to 62-66 °C for a holding time of >60 min, viable Ascaris ova was discovered. This finding contradicts the classic Feachem et al. curve for pathogen inactivation (WorldBank, 1981) which indicates that inactivation should have occurred in 10 minutes at 60 °C. The heater setpoint was then increased to 65-70 °C. Results are forthcoming from these tests and will be shared at the conference. Other efforts were made to improve the overall efficiency of the pasteurizing system and to expand the window of applicability of the ADPL. These improvements included design, optimization and field assessment of new biogas burners, and solar heating was integrated to provide the additional power necessary to accommodate extra flush and/or wash water. Detailed findings will be presented and discussed at the conference

Title: Assessing the Demand for Plastic Latrine Slabs in Rural Kenya

Authors: Rachel Peletz, Aquaya, Ranjiv Khush, Aquaya, Joyce Kisangani, Aquaya, Caroline Delaire, Aquaya, Patrick Ronoh, Aquaya, Alicea Cock-Esteb, Aquaya, Jill Luoto, Rand

Submission: The Selling Sanitation Program, managed by the Water & Sanitation Program of the World Bank and the International Finance Corporation, invested approximately US$2 million to develop and market new plastic slab products to improve sanitation. With a cleanable surface and coverable squat-hole opening, these plastic slabs were designed to provide an affordable, simple option for upgrading traditional pit latrines. The Selling Sanitation program estimated that plastic slabs would have a 34% annual growth with a market size of 2.53 million USD in Kenya by 2017. In this study, we examined the commercial viability of these plastic slabs in 30 villages of rural Kenya by evaluating a financing and distribution model intervention arm of a randomized, controlled trial. We also determined household willingness-to-pay through a real-money auction with 322 households. We found that no households in our study area had purchased the plastic slabs. The primary barriers to slab sales were limited marketing activities and low demand compared to the sales price: households were willing to pay an average of 5 USD compared to a market price of 16 USD. These results confirm our previous analysis in Tanzania that found a similar gap between demand and supply costs for latrine slab products. Therefore, in rural settings, current household demand for the plastic slabs is too low to support commercial distribution.

Title: Assessment of Demand and Supply of Rural Sanitation Services in Rwanda

Authors: Kate Sawyer, Water For People, Dr. Aime Tsinda, Institute of Policy Analysis and Research - Rwanda, Pius Nishimwe, Water For People, Eveline Viegas, SNV USA

Submission: Effective management of faecal sludge emptying, transport and disposal mechanisms from the on-plot latrines in both urban and rural areas is critical for the sustainability of sanitation. Since 2016, the USAID-funded Isuku Iwacu Project directly supports and contributes to Government of Rwanda efforts to improve access to sanitation in Rwanda. One activity of the Isuku Iwacu Project is to promote districtwide, private sector-driven household sanitation and hygiene interventions. To this end, Isuku Iwacu Project commissioned a study to assess sludge management and emptying services in March of 2018. The assessment characterizes both the demand side (households’ needs and preferences) and supply side (service providers) and any other factors or actions shaping the status of sludge management and latrine emptying services. A comparative case study was carried out in seven districts of the Eastern and Southern Provinces of Rwanda, which involved policy analysis, a household stratified probability survey (n=1000) complemented with focus group discussions and interviews. The assessment characterizes households’ demand for improved sanitation facilities using a progressive decision-stage sanitation demand model. Results allow for comparison of a household’s demand stage to various factors such as: socio-economic status; gender/age of head of household; status of home ownership; formal education; facility type; satisfaction with current facility; willingness to pay; education received about sanitation and hygiene; motivating factors to install sanitation facilities; and sanitation sensitization via communication media. Results also characterize availability of providers for sanitation services including materials, labor, emptying services, and financing options. The results paint a full picture of specific opportunities, challenges and needs for private sector-driven household sanitation and hygiene interventions in rural districts of Rwanda.


Title: Assessment of Field Performance and Acceptance of the Sato Pan in Ethiopia

Authors: Abinet Kebede, IRCWASH, John Butterworth, IRC, Monte Achenbach, PSI Ethiopia

Submission: Most of the latrine technology options available to rural households are near the bottom of the sanitation ladder; basic or unimproved. To provide more improved options and encourage movement up the ladder, the Federal Ministry of Health (FMoH) has put in place a national sanitation marketing guideline. This provides directions to establish an appropriate enabling environment for developing, testing and commercialization of appropriate products to meet consumer demand.USAID Transform WASH project has introduced SATO pan to the local market in collaboration with the international manufacturer (Lixil) and local businesses districts. SATO pan is an attractive plastic product intended to create an effective seal and keep out flies and smells. By March 2018, the product has been distributed in nine districts.Although plastic products are included in the On-Site Household Latrine Technology Option Planning, Design and Construction Manual, questions have been raised at federal and regional level regarding the suitability of the product for the local market and rural consumers. This study, in collaboration with the FMoH, RHB, Technical and Vocational Education Training (TVET) office and Hawassa University, was carried out to assess the field performance and acceptability of the SATO pans. The study involved a survey of 100 randomly selected sample households who had purchased and installed SATO pan. Additional qualitative data was be collected through key informant interview techniques from woreda health office, TVET and health extension workers.The paper reports on performance of the technology in the field and consumers acceptance of the product. The paper documents the key prospects, gaps and challenges encountered in the field and identifies practical recommendations on how to improve sanitation marketing initiatives in the region.

Title: Assessment of Water, Sanitation and Hygiene Services in Primary Schools of Pakistan: Addressing Sustainable Development Goal 6

Authors: Jamil Ahmed, US- Pakistan Center for Advanced Studies in Water, Mehran University, Jamshoro, Pakistan., Najeebullah Channa, US- Pakistan Center for Advanced Studies in Water, Mehran University, Jamshoro, Pakistan, James VanDerslice, Department of Family & Preventive Medicine, University of Utah, Salt Lake City, Utah, USA, Joshua Garn, School of Community Health Sciences, University of Nevada - Reno, Reno, Nevada, USA

Submission: Introduction: The United Nation’s Sustainable Development Goals include the target to ensure access to water and sanitation for all, however very few studies have assessed school-based drinking water in Pakistan. The purpose of this study was to characterize water quality in primary schools of Pakistan, and to characterize how recent WASH interventions were associated school water quality.Methods: We conducted a representative cross-sectional study primary schools in Sindh province of Pakistan. We used structured observations and structured interviews to ascertain school’s WASH conditions. Our primary exposures of interest were the implementation of previous WASH interventions in the school, and the water source type. Outcomes of interest included water quality (measured by various chemical and microbiological indicators) and water availability at the school’s primary drinking water source. We used log binomial regression to characterize how WASH exposures were associated with water quality outcomes. Results: We collected data from 256 schools. Ground water was the primary drinking water sources at most schools (87%). Water testing showed that 14% of the school’s water had arsenic above the WHO recommendations, and over 50% of the water samples exceeded recommendations for both lead and cadmium. A majority of the water sources (52%) had fecal coliform contamination. None of the schools had nitrate contamination (0%) and few had fluoride contamination (5%). Regression results indicated that having a recent WASH intervention at the school was not associated with either arsenic contamination (prevalence ratio=0.97; 95% CI: 0.46-2.1) or with fecal coliform contamination (PR=0.88; 95% CI: 0.67-1.17). Conclusions: Our assessment unveiled several water quality gaps that exists, including with high heavy metal and fecal contamination. Our findings will help various stakeholders to take suitable action to improve water quality in Pakistani schools.

Title: Can Sampling for Drinking Water Quality be More Effective and Efficient? An Example from Massachusetts

Authors: Nelson da Luz, University of Massachusetts Amherst, Emily Kumpel, Univ. of Massachusetts, Amherst

Submission: Drinking water quality regulations such as the EPA’s Revised Total Coliform Rule often specify that sampling locations should be chosen to be representative of water quality throughout a distribution system, but guidance specifying what makes a sampling location representative is limited. Water utilities are thus challenged with deciding where they


should sample for water quality in their distribution systems. The objective of this study is to investigate these challenges and propose pathways for improvement in the ways that utilities carry out drinking water quality sampling through a cooperative effort with a water utility in Massachusetts.Using 15 months of recent water quality data (1597 observations), results show a mean free chlorine (free Cl) concentration of 0.39 mg/L across 29 sampling locations with a declining trend for free Cl over time. Analysis of sampling location usage shows that the pattern of sampling location combinations used by the utility attempts to use each of the 29 individual locations at least once every two weeks. The utility’s sampling objectives and limiting constraints on the objectives will be identified through an interview with the utility. The current sampling plan will be evaluated to see if desired objectives are met. Additional data from past years will be obtained and underlying statistical distributions of water quality parameters (e.g. free Cl residual) will be investigated across the system. Alternative sampling plans will be developed that offer improvements compared to the current sampling plan based on different sub-objectives. Proposed elements of improved sampling plans include increasing system representativeness, identifying locations with the worst water quality, decreasing costs, and making it easier for operators to carry out the sampling plan. Feasibility of alternatives will be evaluated to determine what options could realistically be applied in carrying out the utility’s sampling plan objectives.

Title: Challenges in Implementation of a Combined Water, Sanitation and Hygiene and Food Hygiene Intervention to Reduce Diarrhoeal Diseases in the Children Under Age of Five Years

Authors: Kumwenda Save, University of Malawi, Kondwani Chidziwisano, University of Malawi, The Polytechnic, Tracy Morse, University of Strathclyde

Submission: An increasing number of intervention studies aimed at improving health outcomes associated with water, sanitation and hygiene (WaSH) are being reported, with both positive and negligible impact on diarrhoeal disease. These studies have recognised the limitations of their study design and settings, however few discuss the specific challenges faced in data collection in the field. Knowledge of challenges and possible solutions will help in planning future related studies. This paper shares the challenges and identified solutions from a combined WaSH and hygiene of weaning foods intervention delivered in rural Malawi, Southern Africa. Data on challenges and solutions employed was collected, reported and recorded routinely by the research team. Diarrhoeal disease (primary outcome) was under-reported by participants in the initial phase. The study had implemented a hierarchal mechanism for reporting diarrhoea to ensure stool samples and diagnosis was undertaken in all cases. This was supported by a self reporting diary (monthly) and household visits (weekly). Investigation of the under-reporting identified that participants felt they would be labelled as ‘unhygienic’ contrary to the intervention objectives should they report diarrhoeal disease. Under-reporting was addressed through additional layers of monitoring through health workers, retraining of community key informants, and improved dialogue with participants on the benefits of reporting. Other challenges to implementation included participant incentives, high levels of poverty, low male participation, and procurement processes. These findings highlight the value of formalizing routine collection of challenges and solutions from the field during implementation, and support the need to report and review these in other studies from similar settings. Continuous monitoring of misconceptions during intervention implementation can minimize the impact they might have on both outcomes and impact of an intervention.

Title: Closing the Gap in Access to WaSH in Refugee Settlements by Financing Innovative Technologies

Authors: Hannah Lohman, University of Illinois at Urbana-Champaign, John Trimmer, University of Illinois at Urbana-Champaign, Noble Banadda, Makerere University, Jeremy Guest, University of Illinois at Urbana-Champaign

Submission: Global humanitarian crises have resulted in the displacement of over 65.6 million people – of whom, 17.2 million refugees fall under the United Nations High Commissioner for Refugees (UNHCR) mandate. UNHCR provides necessities to refugees; however, budget constraints continue to result in unmet water and sanitation standards in camps and low access to energy and fertilizer resources. Innovative technologies that meet multiple needs (e.g., energy, fertilizer) provide an opportunity for UNHCR to achieve the standards for access to improved WASH while providing a financial incentive to sell or use recovered nutrients. The goal of this work was to understand how resource recovery sanitation can impact WASH costs in refugee settlements through a techno-economic analysis framework that incorporates site specific factors influencing decision-making. This objective is achieved through development of a cost model of typical UNHCR water delivery, water storage, and sanitation technologies commonly employed in refugee settlements as well as a resource recovery sanitation technology (i.e., urine diverting dry toilet, UDDT). The cost model


was applied to nine refugee settlements in Uganda by incorporating context-specific inputs such as settlement-level WASH coverage (e.g., refugees per latrine) and country-level material and labor costs. The costs of different WASH technologies are compared (i.e., material, construction labor, operation, and maintenance) of different WASH technologies and to elucidate that material costs are the key contributor to total costs followed by operation and maintenance. Sanitation technology costs are compared to show that through resource recovery, a UDDT becomes more cost-effective than a pit latrine after four years of use. More broadly, this research develops a quantitative sustainable design process to better understand the trade-offs involved in the provision of WASH interventions, applicable in refugee-focused and/or development contexts.

Title: Closing the Knowledge Gaps in Intermittent Water Supply: An Experimental Lab-scale Pipe-loop for the Investigation of Intermittent Water Supply

Author: Mariam Alkattan, University of Massachusetts Amherst

Submission: Piped water connections provide drinking water to 57% of the world’s population, however in low- and middle-income countries intermittent water supply (IWS) can be common. The intermittent nature of the water supply can impact the quality of the water delivered to users and have a negative impact on public health. There are still many gaps in our knowledge of IWS. A better knowledge of the mechanisms that effect water quality in IWS are needed to better understand how IWS can be improved to reduce risks to public health. We will compare options for function, materials, operations, and instrumentation for a proposed testbed for understanding distribution system water quality. Also presented will be results of preliminary experiments using a lab-scale pipe-loop that we ultimately designed and constructed for simulating a full-scale water distribution system. Preliminary-experiments will compare whether the resulting water quality from water stagnation in IWS is similar to water stagnation in continuous water supply, including effects on biofilm from different parts of the pipes.

Title: Commune Action Plan, a Method for Collaborative Strategic Planning on the District Level

Authors: Brian Jensen, Haiti Outreach, K. Neil Van Dine, Haiti Outreach

Submission: Recently, across the development sector, there has been a strong focus on data driven decision making. This has allowed Governments, NGO's and Donors to maximize the impact of their limited resources. The aspect of data that is often left behind is its ability to create alignment between various partners and ownership of interventions on the local level. We present our usage of data to empower Local Authorities, allowing them to lead the development process and guide interventions in their WASH sectors. If the WASH sector has shown any consistent behaviors it is the sustainability of development requires the ownership and leadership of local partners in this process. The SDG’s focus on building the capacity of local monitoring and goal setting, empowering these countries to be able to create, track, and adapt their strategies to achieve universal access. Many countries are working to transform the SDG’s to a locally appropriate, and actionable monitoring framework that produces higher resolution snapshots on the path to universal access. In collaboration with Haiti's WASH agency (DINEPA), Haiti Outreach has implemented a methodology that leverages data tools to create an environment where local partners lead the development process. The core of this process is called the Commune Action Plan, which is a collaborative District Level planning approach. This process uses exhaustive water point, water scheme, and housing data to display information in a simple, easy to understand map. This map is then used by Local Authorities and DINEPA officials through a guided framework to target specific interventions necessary to get to universal basic WASH access. These interventions are then locally prioritized and these partners decide who they need to engage to fulfill their plan. Regular meetings allow Local Authorities to align various partners on the current status of their commune and interventions in progress. During this meeting the data is updated and next steps ar

Title: Community Engagement in WaSH Intervention Development: A Trial of Improved Practice of an Infant Food Hygiene Intervention in Kisumu, Kenya

Authors: Sheillah Simiyu, Great Lakes University of Kisumu, Jane Mumma, Great Lakes University of Kisumu, Alexandra Czerniewska, London School of Hygiene and Tropical Medicine, Kelly K. Baker, University of Iowa, Robert Dreibelbis, London School of Hygiene and Tropical Medicine


Submission: Background:Interventions in water, sanitation and hygiene (WASH) have traditionally been designed by specialists for the community. This lack of community engagement is intervention design can lead to low rates of adoption and poor sustainability. This paper draws lessons from the formative phase of the Safe Start Study – an infant food hygiene intervention developed and trialed in informal settlements of Kisumu city in Kenya. Methods:Intervention development followed a modified Trial of Improved Practices (TIPS) methodology to engage community members in designing and adaptation of a food hygiene intervention at the household level. The aim of the study was to identify existing materials available in local markets that could be used by the household in order to foster safe food hygiene practices as well as test and refine motivational messages that can be understood by the community. Specific methods of community engagement included a ‘market place’ where a range of supplies – such as handwashing storage containers and food storage containers – were presented to caregivers- group discussions, interview sessions, and ‘trying out’ sessions at the household level. Results:By the end of the TIPS methodology, caregivers’ level of knowledge on food hygiene practices increased, with several caregivers mentioning that they understood the link between food hygiene and childhood occurrence of diarrhea. After the end of the TIPS process, visits were made to seventeen of these caregivers and it was noted that the household items were still in use, with a few caregivers purchasing more of the household items as a result of the benefits they experienced. In addition, the benefits of the engagement trickled down to other stakeholders such as the community health volunteers as they were more enlightened about the food hygiene practices. The key lesson is that interventions need to be designed with the community during inception, design and implementation stages

Title: Community Managed Source Point Testing and Treatment in Yemen

Author: Jason Brooks, ADRA International

Submission: Given the difficulty of access in the security challenged governorates of Yemen the ability of communities to manage source point chlorination of rehabilitated rural water supplies through the use of trained water user committees equipped with testing materials and treatment supplies has proven to be essential to reducing cholera and other waterborne disease outbreaks. ADRA Yemen has trained communities in 7 regions and 22 districts to chlorinate their water supplies under the supervision of community water committees. Surveys of stored water at the household level show FRC levels of 0.2 mg/l in over 90% of samples. Compared to chlorine tab distribution this approach shows promise for safe water supply at the community level. The ADRA Yemen cascading training of both water treatment techs and hygiene promoters at the community level has improved the quality of water supplies at the point of use and reduced resistance to chlorination at the same time as the conflict has severely affected the ability of local government and the rural water supply authorities to provide services. Funding for expansion of improved water services will continue into the next year with ongoing research and documentation of best practices for working with communities in conflict area to enable support for source point chlorination supervised by local water user committees. Based on the Yemen programs the approach is now being used in Syria.

Title: Comparative Evaluation of Risk Management Frameworks and Tools for Managing Source Water Risks in the United States (WRF Project 4748)

Authors: Karen Setty, The Water Institute at UNC, Jeanne Luh, ICF, Robert McConnell, Tampa Bay Water, Robert Raucher, Corona Environmental Consulting

Submission: 1996 amendments to the US Safe Drinking Water Act (SDWA) required states to develop Source Water Assessment Programs to identify existing and potential contamination sources to drinking water supplies. While this promotes identification of potential hazards, in practice drinking water utilities are often constrained by limited resources and established regulatory paradigms that limit proactive risk management. Risk management approaches aimed at ensuring drinking water safety are widely used abroad, but have not yet been piloted in a US context. This project assessed which permutation(s) of risk management frameworks and tools might benefit drinking water utilities seeking to actively manage risks for US surface water sources. To evaluate frameworks, we undertook a semi-systematic literature review coupled with international utility interviews and domestic participating utility surveys (to inform and weight evaluation criteria). Qualitative data from each included source provided a basis for categorical assignments of goodness-of-fit with each of 24 criterion across five categories. Quantitative integration across the multi-indicator evaluation matrix allowed synthesis of findings and relative ranking of applicability, followed by participatory validation at a decision-making workshop. Two highly applicable frameworks were identified. The source water protection standard developed by the


American Water Works Association (ANSI/AWWA G-300) was recommended as a starting point for elaborating on the SDWA requirements, and the World Health Organization Water Safety Plan (WSP) guidance was recommended for developing more holistic and comprehensive risk management programs for drinking water sources. To address cost-related aspects of risk management relevant to the US context, components of the Australian Drinking Water Guidelines and Techneau guidance were recommended to incorporate financial considerations into risk ranking and mitigation decisions.

Title: Comparing Drying Kinetics and Characteristics of Human Feces Collected from Different on-site Sanitation Solutions

Authors: Katelyn Sellgren, Duke University, Blessing Makununika, UKZN, Brendon Lynch, Biomass Controls, Santiago Septien, UKZN, Aaron Forbis-Stokes, Triangle Environmental Health Initiative, Jeffrey Piascik, Biomass Controls, Chris Buckley, UKZN

Submission: Sanitation in developing and remote regions presents significant challenges including limited or inconsistent electricity supply, lack of functional sewerage systems, and transport distance to waste disposal facilities. To address these inadequacies, our research is focused on the development and implementation of a decentralized, self-contained toilet systems. Within these systems feces is dried before either being combusted on site or transported to a treatment facility. However, drying is an energy intensive unit operation and the physio-chemical characteristics of fecal sludge varies widely not only from region to region but between individuals in the same region1.Understanding the variability in drying characteristics of human feces is therefore critical to designing robust and energy efficient on site technologies that can be deployed worldwide. This study aims to define the drying kinetics of human feces from the distinct regions around the world: pit sludge from a South African slum, feces collected from a communal toilet in India, and feces samples donated from healthy individuals in the United States.1Rose et al. The Characterization of Feces and Urine: A Review of the Literature to Inform Advanced Treatment Technology. Critical Reviews in Environmental Science and Technology. 45: 1827-1879, 2015.

Title: Comparing Urban and Rural Wash: Evidence from the Solomon Islands

Authors: Carmen Anthonj, UNC Water Institute, Mamita Bora Thakkar, UNICEF Solomon Islands, Waqairapoa M. Tikoisuva, UNICEF Pacific, Lisa Fleming, UNC Water Institute, Ryan Cronk, UNC Water Institute

Submission: Drinking water, sanitation, and hygiene (WaSH) are important for human health, well-being, and development. Providing such in a Small Island Development State such as the Solomon Islands, which consists of more than 900 islands, however, is challenging. The Solomon Island Government National rural WASH Policy addresses WaSH and aims at providing “easy access to sufficient quantity and quality of water, appropriate sanitation and a safe and hygienic environment to all Islanders by 2024”. To develop baseline estimates for the SDGs and to inform national WaSH policy, strategic planning, and programming in the Solomon Islands, nationally representative WaSH surveys were conducted in rural and urban areas. These revealed that radical change is needed to rapidly scale up access to WaSH in the Solomon Islands to achieve this ambitious vision.Preliminary analysis suggests that 67% of the urban/peri-urban households are provided access to a basic water source and that the most commonly used sources were rainwater and piped water. 68% of households used a basic sanitation service and less than half (43%) of households used a basic hygiene service. Out of the rural households, 55% provided access to a basic water source and mainly relied on public tap water or standpipes. Only 14% of households surveyed reported access to a basic sanitation facility while 79% of households had no facility and practiced open defecation. 17% of the households had access to basic hygiene. Generally, the availability of household WaSH services varied substantially by province. The regression analyses reveal that the access to basic WaSH is determined and challenged by different factors in urban and rural areas of the Solomon Islands.The data highlight several areas for improvement including addressing inequalities in service availability and building more resilient WaSH systems to prevent service disruptions due to extreme weather events and climate change.

Title: Comparison of Food and Medical Grade Chitosans to Identify Cost-Effective Alternative for a Filter Aid that Improves Drinking Water


Authors: Eleanor Holmes, University of North Carolina at Chapel Hill, Hemali Oza, UNC Gillings School of Global Public Health, Megan Miller, Lydia Abebe

Submission: Critical performance challenges still exist in technologies employing filtration as a contaminant removal mechanism for drinking water. Coagulation-flocculation pretreatment is often applied to overcome these limitations. While inorganic coagulants are commonly used, there has been limited research to explore alternative, environmentally-friendly coagulants that may be more effective against pathogenic microorganism such as viruses. We identified a novel and flexible alternative pretreatment approach employing chitosan as a “green alternative” which has demonstrated effectiveness over a range of temperature and pH values. In this study, we aimed to investigate the turbidity and microbial reductions associated with chitosan coagulation combined with filtration. Previous studies have evaluated medical grade chitosans with high purity that are expensive and difficult to source. We compared food and medical grade chitosans in order to determine whether an alternative grade of chitosan that is more cost-effective achieves comparable reductions. To examine microbial removal, surface waters were spiked with E. coli KO11 bacteria and MS2 bacteriophages as bacterial and viral surrogates. Membrane filtration, double agar layer and single agar layer assays were used for enumeration. Log10 values and percent reductions were calculated for surrogate microbes and turbidity, respectively. Preliminary results indicate that food and medical grade chitosans achieved similar average log10 reductions for both bacteria and viruses, exceeding 8 and 6, respectively, while average percent turbidity reductions exceeded 85%. Results indicate that food grade chitosan products offer a more cost-effective and easily-sourced means for water treatment compared to medical grade products and achieve similar log10 reductions for surrogate microbes. Further optimization of dose is required before this innovation can be applied for water treatment purposes.

Title: Construction of a Low-cost Field-robust Incubator

Authors: Ariane Schertenleib, Eawag, Jürg Sigrist, Eawag, Max Friedrich, Eawag, Christian Ebi, Eawag, Sara Marks, Sandec, Eawag

Submission: Incubators are essential for a range of culture-based microbial methods, such as membrane filtration followed by cultivation for assessing drinking water quality. However, commercially available incubators are often costly, difficult to transport, not flexible in terms of volume, and/or poorly adapted to local field conditions where access to electricity is unreliable. The purpose of this study was to develop an adaptable, low-cost and transportable incubator that can be constructed using readily available components. The electronic core of the incubator was first developed. These components were then tested using different materials for the incubator shell under a range of ambient temperature conditions. The electronic core tested within different insulating shells showed good performance in terms of the time required to reach the set temperature and inner temperature stability and spatial dispersion, using any type of insulated shell (Styrofoam box, cardboard box covered with a survival blanket, hard cooler box). The incubator set-ups were also effective at moderate and low ambient temperatures (23 °C and 4 °C). Overall performance compared well with other commercially available incubator options. This incubator prototype is low-cost (< 300 USD) and adaptable to a variety of materials and volumes. Its demountable structure makes it easy to transport. It can be used in both established laboratories with grid power or in remote settings powered by solar energy or a car battery. It is particularly useful as an equipment option in areas with limited resources where there is a need to establish field laboratories.

Title: Cost-effectiveness of Private & Public Channels Used to Improve Access to Roto Septic Tanks for Improved Rural Sanitation Coverage in Tien Giang Province, Vietnam

Authors: Josselyn Neukom, Population Services International-Vietnam, Nguyen Minh Tuan, Population Services International-Vietnam, Ngo Thi Hue, Population Services International-Vietnam

Submission: Despite Vietnam’s recent macro-economic gains, WASH-related diseases continue to limit improvements in health and development. Approximately 71% of the rural population in Vietnam has access to hygienic sanitation—compared to 90% of the urban population (JMP, 2017). Achieving Vietnam’s SDG for rural sanitation will require hygienic sanitation installed for 2 million rural people every year until 2025. (MARD, 2010). Barriers to rural sanitation include accessibility and affordability of quality sanitation products/services as well as limited demand. (WSP,2014 & PSI/Vietnam, 2016). In 2016, PSI partnered with ROTO--the manufacturer of a locally-produced, MOH-approved plastic septic tank to expand ROTO rural market coverage in Tien Giang. PSI analyzed sales MIS data as well as field-level expenditure data


during a 12-month period (January-December 2017) to assess the relative cost-effectiveness of ROTO sales through i) retailers & mason referrals; iii) community toilet sales; iv) sales by community sales agents. Only local, field-level expenditure data was included in the analysis. From January-December 2017, PSI sold 1,898 ROTO tanks in Tien Giang through rural construction retailers and their associated Masons, toilet sales seminars and community sales agents. Assuming an average family size of 4, this translates into an estimated 15,246 people benefitting from improved sanitation. Private retailers with trained masons generated 91% of the total ROTO tank sales. This channel was also the most cost-efficient with an estimated local cost per tank sold of $2.6USD, compared to $54.7 through community champions and $135.2 through toilet sales seminars organized in collaboration with provincial government partners. Sales monitoring and financial data suggest that integrating quality sanitation products, services and information into established retail outlets—accessible to underserved communities-- is a cost-effective strategy to increase sanitation coverage.

Title: Creating a Safe Environment for Newborns: Water Sanitation and Hygiene (WaSH) Improvements in Health Care Facilities (HCFS) in Madhya Pradesh, India

Authors: Pankaj Mathur, UNICEF, Dr. Pankaj Shukla, NHM MP, Dr. Vandana Bhatia, UNICEF, Deepika Sharma, UNICEF

Submission: There are evidences showing that improved WASH in health care facilities (HCFs) can significantly contribute to decreasing the prevalence of health care associated infections (HCAI), thereby ensuring quality and people-centered health care. In India, there’s little data available on status of WASH in HCFs. This paper captures the experiences of WASH in HCFs in the second largest State of India; - Madhya Pradesh (MP), implemented since September 2016. It describes the strategic approach to WASH assessment, improvements and monitoring as a contribution to infection prevention and control in 148 critical HCFs covering over 100,000 newborns each year, in tribal districts. UNICEF supported National Health Mission (NHM) on Policy, technical guidelines, and strengthening SOP to build the capacity of Health Care staff to maintain a safe and clean environment in Out Patient Department, Labour Room, New-born care units, Post-natal Wards and Nutrition Rehabilitation Centers. The initiative highlights the importance of coaching and hands on training of health staff to systematically implement and monitor improvements. Importantly, UNICEF puts a strong emphasis on sustainability by leveraging requisite resources from the National Flagship programme-NHM. The enabling environment created through this initiative has resulted over 70% HCFs achieving above 4 Star rating (conforming over 75% WASH compliance) within 15 months of implementation, which was 5% at inception. This is monitored through an android based application. The consumer satisfaction enhanced significantly as 83% of respondents felt improvements. As a significant step, the initiative will now inform adoption of state strategy and guidelines to be scaled up by Government under NHM, across the State. Using the best practices from MP, UNICEF is supporting replication and scaling-up in the country. This is a crucial achievement as Sepsis is directly responsible for 11% of maternal deaths and 15% of new-born mortality

Title: Design and Operalisation of the First Community Level Manganese Removal Unit in Bangladesh

Authors: Boluwaji Onabolu, UNICEF, Ruhul Amin, UNICEF

Submission: Studies in Bangladesh and elsewhere indicate that exposure to high concentrations of manganese from drinking water poses a risk to the optimal cognitive development of children. In Bangladesh, two third of tubewells that are arsenic safe have elevated levels of manganese above the Government of Bangladesh - GoB standards (0.1mg/l). There is no community level manganese removal technology for drinking water in Bangladesh.UNICEF and (GoB) conducted an operational research project from October 2016 to June 2018 to design, install, optimise and field test a low cost community level manganese removal unit (MnRU) in two districts where 90% water sources had manganese concentrations above 0.6mg/l and less than 45% of the water sources complied with the GoB drinking water standard for manganese. The project is being implemented in partnerhip with Asia Arsenic Network and Bangladesh University of Environment and Technology.The research period is from October 2016 to June 2018. The first phase incorporated reconnaissance, baseline and KAP surveys. Technical and social aspects were considered in the design and the MnRU treatment processes utilised aeration, precipitation, slow sand filtration and manganese coated sand filtration. Turbidity, manganese, E.coli, iron, phosphate, dissolved oxygen were assessed before and after treatment. MnRUs reduced Mn, Fe, and As levels to below the WHO and GoB standards. Microbiological contamination increased significantly after treatment with both slow sand and manganese coated filters. The findings have been used to improve the design for scaling up to additional sites and treatment with chlorination incorporated into the design.


Title: Designing a Gender Neutral Household Toilet: Tales from Field Testing

Authors: Authors: Anju P. Toolaram, Jan Hennigs, Kristin T. Ravndal, Thubelihle Blose, Dani Barrington, Matt Collins, Bhavin Engineer, Pedro Talaia, Ross Tierney, Athanasios Kolios, Ewan J. McAdam, Alison H. Parker, Sean Tyrrel, Leon Williams

Submission: Since 2011, the Bill and Melinda Gates Foundation has issued the re-invent the toilet challenge to tackle the worldwide sanitation dilemma involving the access of safely managed sanitation for over 2.5 billion people. Cranfield University has answered this challenge with the design of its Nano Membrane Toilet (NMT). A toilet that aims at improving household sanitation by housing the entire sanitation chain (input-collection-treatment-hygienic disposal/reuse) in one innovated toilet system. The NMT is designed to look similar to a conventional flush toilet with unique features (e.g. a waterless rotating bowl) that should be easy to use and accessible to all. In the current phase, the NMT is undergoing field testing of its front-end i.e. the toilet superstructure in household settings. Thus far, social surveys and field testing results have revealed the complexities in designing a front-end that can meet the needs of all users both in usability and acceptance. The preliminary results have emphasized that toilet designs have to move beyond satisfying the functions of hygienic waste processing to integrating in the very society it is meant to operate in.

Title: Determinants of Intermittent Water Services in Rural Bangladesh, Pakistan, Ethiopia, and Mozambique

Authors: Ryan DuChanois, Yale University, Joe Brown, Georgia Institute of Technology

Submission: Access to continuous water supply is key for improving health and economic outcomes in rural areas of low- and middle-income countries. Unfortunately, the determinants of intermittent water access in these areas have not been well characterized. This paper quantifies technical, financial, institutional, social, and environmental risks to water service continuity, defined as the percentage of time water is available from a source, using survey estimation fractional logistic regression for rural water sources in Bangladesh, Pakistan, Ethiopia, and Mozambique. Models used about 1200 surveys per country sourced from the Value for Money in Water, Sanitation, and Hygiene (VFM-WASH) project. Missing data were handled via multiple imputation by chained equations. For all countries, models controlled for variables including water source ownership, water scarcity, and household wealth quintile. Results indicate that the number of water sources used by a household was negatively associated with water service continuity in Bangladesh, Pakistan, and Mozambique. This trend suggests that households revert to secondary sources either because of the difficulty communities have performing water source maintenance or due to secondary source accessibility. Secondly, regular tariff payments were linked with reduced water service continuity in Pakistan and Mozambique. This association is evidence of the complications communities face in collecting and maintaining funds for repairing water sources. Addressing these cost recovery and maintenance issues in rural water service delivery is critical for attaining lasting community health and economic benefits in rural communities.

Title: Determining the Relationship Between Drinking Private Well Water and Children's Blood Lead Levels

Authors: Abhishek Komandur, University of North Carolina at Chapel Hill, Frank Stillo, University of North Carolina at Chapel Hill, Jacqueline MacDonald Gibson, University of North Carolina at Chapel Hill

Submission: Over the past 50 years, the U.S. Environmental Protection Agency and other governmental organizations have been passing regulations to decrease the population’s exposure to lead, which is a potent neurotoxin. However, as recent events in Flint, Michigan and other areas have demonstrated, lead exposure through drinking water is still a prominent concern. Lead adversely impacts health when consumed through drinking water, but no research has yet been done to investigate the relationship between drinking water contaminated with lead from private wells and human health outcomes. To better understand this relationship, we are conducting a study to determine the relationship between lead contamination in private wells in North Carolina and children’s blood lead levels. Sixty children under the age of 7 were recruited from households relying on private wells for their water in Wake and Gaston counties. Throughout summer 2018, we are collecting blood samples from each child, along with water and dust samples from their respective households. We will use regression models and Bayesian networks to explore the relationship between water lead and blood lead, controlling for other lead sources and potential confounders. After controlling for background lead exposure,


we anticipate that water lead levels will have a direct effect on blood lead levels. Although prior studies have shown elevated risks of exposure to lead in water from private wells, compared to in treated municipal water, this study is the first of its kind to investigate the health risks to children of drinking private well water that is contaminated with lead.

Title: Development Process of a Sanitation Product for Low-income Consumers in Benin's Urban and Periurban Low Water Table Areas

Authors: Jules Hountondji, ABMS, Yvan-Noe ADINGNI, ABMS/PSI, Philippe LEMAY, PSI Cote d'Ivoire, Jennifer Marcy, Population Services International

Submission: BackgroundBenin, a country of 10 million people, has only 13% coverage of basic sanitation and widespread open defecation. An affordable product that meets consumers’ preferences for a safe, odor and insect free, easy-to-clean and low-cost toilet did not exist on the market. The average toilet cost was $450.To close this gap, USAID’s Sanitation Service Delivery project used an iterative approach to optimize design and reduce cost of a pour-flush double offset pit latrine, now branded as WC Mimin. This latrine is designed for low-income consumers in urban and periurban areas with low water tables, as the contents decompose and pathogenic elements die in situ, eliminating the need for mechanical emptying.Product InnovationTo keep odors and insects from rising up to the cabin, the toilet’s user interface is equipped with the SatoPan, an inexpensive plastic pan incorporated into a concrete seat that closes automatically to keep the cabin free of odors and insects. To lower the cost of materials and labor, the team supported market actors to adapt their business models to reduce the number of service providers that interact with the customer from 8 to 2. This was done by supporting concrete ring manufacturers (CRM) to become the hub and main point of contact in the market for toilet customers. CRM produce and maintain a stock of the necessary prefabricated materials, including the concrete toilet pedestal, ring and pit cover, and PVC piping. Key results and future perspectivesEnterprises now offer installation of WC Mimin for as low as $120 US. A latrine takes three days to install. In less than one year, 661 toilets were sold, and sales are increasing each month. A household survey showed a 95.3% customer satisfaction rate. WC Mimin has emerged in the nascent sanitation market in Benin as an innovative and viable option to meet low-income families’ needs and end open defecation. This product could be adapted to serve consumers in additional geographies.

Title: Electrolytic Release of Silver and Copper Ions in Point-of-use Drinking Water Interventions for Disinfection in Resource Limited Settings

Authors: Courtney Hill, University of Virginia, Amanda Gaylord, University of Virginia, James Smith, University of Virginia

Submission: Point-of-use water treatment technologies that use silver as a disinfectant have been shown to be effective by killing disease-causing bacteria and preventing potential recontamination during transport and storage in rural areas. The release of silver and copper through electrolytic generation as a new point-of-use disinfection mechanism was examined. Two voltages common to commercially available batteries, 4.5 volts and 9 volts, were applied to a point-of-use apparatus with either two silver or copper wires submerged 1 inch into 10 liters of synthetic groundwater. In addition, the effects of wire diameter and ionic strength of groundwater on metallic ion release were examined. Silver levels measured over time by graphite furnace atomic absorption spectroscopy established a proof of concept that this kind of technology could be practically implemented in a point-of-use water treatment device in a rural setting. It was determined that the apparatus including only silver wire should be run for only 2 minutes at 9 volts to yield the target 50 ppb concentration for water treatment. Further, this conclusion was supported when 50 ppb electrolytically generated silver from the apparatus yielded up to a 5 log reduction of E. coli bacteria in synthetic groundwater. Copper was less effective in disinfection and also required 62 minutes to release the target 500 ppb for disinfection when 9 volts were applied to the system. In tandem with analysis of silver release, disinfection experiments and a full cost analysis were conducted. These results affirm that an electrolytic apparatus is promising to serve as a novel point-of-use intervention and warrant further testing. In addition, although copper by itself is not suitable for this configuration, it still has potential to be introduced in a silver and copper alloy, as it would allow for more disinfection potential while still remaining under the EPA limit for metals in drinking water.

Title: Empowering Adolescent Girls in Uganda in Menstrual Management and Making of Reusable Sanitary Pads: Lessons Learned from the DREAMS Innovation Challenge


Authors: Precious Sancho, World Vision US, Julie Desoto, World Vision US, Gloria Ekpo, World Vision US

Submission: Menstrual Hygiene Management (MHM) is defined by the WHO/UNICEF Joint Monitoring Programme as "Women and adolescent girls using clean menstrual management material to absorb or collect menstrual blood, that can be changed in privacy as often as necessary for the duration of the menstruation period, using soap and water for washing the body as required, and having access to facilities to dispose of used menstrual management materials”. In Uganda one of the critical factors that undermines the benefits associated with the use of sanitary pads among girls is the limited knowledge and support from the men and boys, which appears to be informed by the societal construction of gender relations. Efforts have been made globally in closing the gender gap in education by paying attention to the specific needs of the pre and post pubescence girls. World Vision and Center for Transformative Parenting and Research conduct sessions for making reusable sanitary pads to empower adolescent girls and boys with skills in making their own reusable sanitary pads as a way of improving attendance and retention of girls in school. This also helps in prevention of gender related violence against girls and women as boys deconstruct their attitudes, beliefs and views on menstrual management as something normal and part of adolescent growth and development.The training targets 35 girls and 15 boys in every school. The trainings aimed at; Equipping girls and boys with skills to make reusable pads: Empower girls and boys with knowledge on hygiene in the reproductive organs and general body hygiene.

Title: Enhancement of Drinking Water Quality and Raising Customer Satisfaction Through Implementation of Water Safety Plan - Egypt

Author: Mahmoud Mehany, Holding Company for Water and Wastewater

Submission: Egypt is facing great challenges concerning water scarcity, deterioration of surface water quality and safe disposal of wastewater are examples of this challenge. Many stakeholders are involved in the water context i.e. Ministry of Irrigation, Ministry of Health, Holding Company for Water and Wastewater (HCWW), and NGOs. For decades the incompatibility between stakeholders leads to difficulties straggle the water sectors finally badly affect the customer trust. in year 2012 a project funded from UN union implemented by VNG International in consortium with CES Consulting EngineersSaltzgitter and WereldWaternet with total fund of 1,421,610 Euro was focused in three components (water safety plan "WSP", waste management, and bench marketing) that try to overcome those challenges. HCWW has established 23 local WSP department in 23 governorates to cover 2500 water treatment plants all over Egypt with a total production Capacity of 30 Mm3/day. HCWW has succeeded to implement the water safety plan in 2 Drinking water plants in each governorate now the total number of the plants that implement the water safety plan concepts is nearly 60.Great enhancement has been achieved in water quality together with the customer satisfaction, 30% increase in customer stratification about water quality from random customer poll for 10000 customers was achieved after completion of WSP requirements and engagement of NGOs. Also, the percentage of noncompliance samples to Egyptian drinking water standard was reduced from 2% per year to 1.5% per year.

Title: Environmental Infrastructure and Availability of Standard Precautions for Maternal and Neonatal Health Service Delivery in Rural Health Care Facilities: A 14 -Lmic Evaluation

Author: Caroline Folz, The Water Institute at UNC

Submission: Baseline evaluations of water, sanitation, and hygiene (WaSH) in rural health care facilities (HCFs) in low and middle-income countries (LMICs) demonstrate the need to improve environmental infrastructure and availability of standard precaution items in order to provide safe health care delivery, especially in facilities that provide delivery services. However, there is little data on the availability of these parameters specific to maternal and neonatal health (BabyWaSH). To address this, data were compiled from 14 LMICs (Ethiopia, Kenya, Rwanda, Uganda, Zambia, Malawi, Mozambique, Zambia, Zimbabwe, Ghana, Mali, Niger, India, and Honduras) to evaluate environmental conditions in rural HCFs that are associated with improved BabyWaSH infrastructure. Doctors and nurses were interviewed at 2,035 HCFs. Descriptive statistics were calculated to identify levels of BabyWaSH services. 66% of surveyed HCFs offered delivery services, and of those, 80% of HCFs did not meet the standards for WHO six cleans (clean perineum, clean be surface, clean sheet, clean blade, clean cord tie, and clean towels). The six cleans that were most commonly unavailable were "clean perineum" and "clean towels", with only 35% and 49% of HCFs offering these services respectively. Through regression analyses, we are currently isolating administrative factors that predict increased access to BabyWaSH in HCFs in


LMICs. For example, in Ethiopia, HCFs with an IPC protocol (OR=12) and an IPC/WaSH focal person (OR=6) were more likely to provide all WHO six cleans. In addition, HCF driven efforts to raise community awareness about IPC importance is correlated with improved environmental conditions in delivery rooms (OR=6). Our results demonstrate substantial inequalities in access to BabyWaSH in LMICs. We show that there are low-cost, high-impact opportunities to increase the availability of BabyWaSH infrastructure in order to improve the quality of neonatal and maternal care in low resource HCFs.

Title: Evaluation on the Effectiveness of Bucket Chlorination in Cholera Outbreaks

Authors: Gabrielle String, Tufts University, Daniele Lantagne, Tufts University

Submission: Bucket chlorination (BC) is a commonly implemented intervention for emergency water treatment employed during cholera outbreaks; agents stationed near a water source dose beneficiaries’ water containers with chlorine. Currently, to our knowledge, there is no published evidence on the efficacy or effectiveness of BC, although implementation guidelines exist. To understand the effectiveness of BC guidelines and the factors that impact BC implementation, we are investigating BC in both a laboratory study and field evaluations. In the laboratory, we are assessing the inactivation of Vibrio cholerae by treating with three different chlorine types at the recommended dosages in prepared waters of varying turbidity, total organic carbon concentration, and pH. Results, expected Summer 2018 include: 1) whether recommended dosages inactivate V. cholerae; 2) whether recommended dosages maintain a 0.2 mg/L free chlorine residual (FCR) 24 hours after treatment; and, 3) what dosages achieve a 2-log reduction in V. cholerae. Field evaluations use a mixed methods protocol including key informant interviews, focus group discussions, and household surveys including collection of household drinking water samples for microbiological and FCR testing 30 minutes and 8 hours after receiving BC. The first evaluation in the Democratic Republic of Congo yielded preliminary results from 10 chlorination points and 177 households including: A range of chlorine solution concentrations at the points (1.3-7.2%) and 30 minutes after dosing an average 1.3 mg/L FCR and median <1 CFU E. coli/100mL. Programmatic and staffing decisions for these chlorination points were made by the health ministry, while supervision and material support was supplied by a rotating host of NGOs. Additional field evaluations in Bangladesh and Haiti will occur in Summer 2018. Results will provide evidence-base for modification and expansion of BC guidelines.

targetTitle: Exploring the Potential of Disseminating Knowledge from Children

Author: Andrea Hatch, Splash International

Submission: Splash’s behavior change program has been pivotal in improving hygiene practices of children in Addis Ababa, Ethiopia. Using schools as a catalyst for change, Splash is implementing behavior change programs that allow children to be the voice in their schools, communities, and homes. A study was conducted to evaluate the influence of hygiene programming aimed at students in schools in Addis Ababa on the handwashing knowledge and behaviors of parents and caregivers at home. The study evaluated the difference in hygiene practices between household members of children at schools with Splash intervention compared with those without Splash intervention. 35 total participants were interviewed and observed with 26 in the intervention group and 9 in the control group. In households with Splash intervention, families were able to demonstrate 4.04 steps of the 6 standard handwashing steps compared to 1.8 steps performed by those without intervention (p<0.001). Soap was present in 84.6% of homes with Splash intervention compared to 33.3% without (p=0.007). In conclusion, household members of children at schools with Splash intervention are more likely to adopt improved hygiene practices compared with those whose children are at schools without Splash intervention.

Title: Factors Associated with Increases Annual Maintenance and Repair Costs for Boreholes in Rural Sierra Leone and Kenya

Author: Allison Fechter, The Water Project

Submission: It is estimated that at least 30% of all boreholes with hand pumps in rural Sub-Saharan Africa are broken down at any given time. The expense associated with maintaining and repairing boreholes is often cited as a factor related to low functionality rates. In particular, it can be challenging for rural communities to mobilize the resources required to


cover this expense. In order to help communities overcome this challenge, this study seeks to better understand the cost associated with maintaining and repairing rural boreholes and identifies factors related to higher annual costs.A study of 300 rural boreholes was conducted over a two year period (2016 to 2018) in Sierra Leone and Kenya. Using detailed operation and maintenance reports and community level survey data, this study estimates the average annual cost associated with maintaining and repairing boreholes. Boreholes were characterized based on a number of factors including age, geographic location, and management. Age was the factor most strongly associated with increased annual cost. The findings from this study may help rural communities and water project implementing organizations better plan for annual expenses associated with maintaining and repairing boreholes.

Title: Fertilizer and Fluoride Effect in Illu and Becho Rural Community Drinking Water, Ethiopia

Author: Tinsae Dubale, EKHC Development Program

Submission: The consumption of fertilizers is becoming increasing in rural Ethiopia. As a result there has been a growing concern about quality of shallow water Wells (SW) and hand dug water wells. A study on the quality of well water is quite alert in rural Ethiopia. This study was therefore aimed to assess the physical and chemical quality of 220 sampled drinking waters for 55 wells in Illu and Becho districts of Oromia region.A Laboratory based comparative study was conducted to evaluate the physical and chemical quality of sampled water in every three moth interval. Analysis on the quality of drinking water from the sources, were made with WHO and Quality and Standards Authority of Ethiopia recommendations. Samples from water sources were randomly collected and analyzed from January to October, 2016.The result showed that except NO3+ and F- of the samples all the physical and chemical parameters analyzed were within the recommended limits. The NO3+ and F- values for 84 tested from sources are below the normal value set by WHO and Quality and Standards Authority of Ethiopia. Our analyses also demonstrated that 18 (8.1%) of the samples tested from sources indicated constant NO3+concentration increase and 26 (11.8%) depicted variable F- concentration during rainy and dry seasons. As the water table falls in dry seasons the [F-] reduced to 1.07mg/l form the above 21 samples out of the 26. Moreover, the concentration of [NO3+] and [F-] show an increasing trend in peak rainy season. The r values to concentration of [NO3+] and [F-] is 0.69 during peak rainy seasons. Based on the recommended limit of WHO and Authority of Ethiopia, 38% of HDWs and 9.5% SW drinking water could be considered unfit for human consumption.

Title: Fluoride Removal By Oyster Shells Enhanced with Crushing, Calcination and Phosphoric Acid Treatment

Authors: Woohang Kim, Mokpo National Maritime University, Rekha Singh, University of virginia, James Smith, University of Virginia

Submission: High concentrations of fluoride ion (F-) in natural groundwater is a worldwide problem. The World Health Organization recommended less than 1.5 mg/l F- in drinking water. The excessive intake of F- can result in dental and skeletal disorders. Herein, it is hypothesized that discarded oyster shells, which are primarily composed of calcium carbonate, can be re-sourced to create an effective sorbent for F-.Discarded oyster shell were collected from a local seafood restaurant and ground to <100 µm particle size with a Los Angeles abrasion machine to produce oyster shell powder (OS). A subset of the OS powder was heated at 700 ˚C for 2 hr to produce calcined oyster shell (COS). A subset of the COS was further treated with 1 M phosphoric acid and NaOH (1N) for 3 hrs, washed with deionized water, and dried for 24 hr at 105 ˚C to produce phosphoric-acid-treated oyster shell (POS). OS and COS were added in presence of phosphate to produce OSP (oyster shell with phosphate) and COSP (calcined oyster shell with phosphate). Phosphate from phosphoric acid and phosphate buffer was used to enhance efficacy of the oyster shells. Efficiency of F- removal was tested under different conditions. Optimum pH for a 10 mg/L F- solution was 5-9 for OSP and 8-9 for COSP. 1 g/l of OS and 2 g/l of COS in 10 mM phosphoric acid solution completely removed 10 mg/l of fluoride after a 24-hr contact time. Similar results were observed at 1.6 mM of phosphoric acid and 24-hr contact time for OSP and 3.2 mM of phosphoric acid and 48-hr contact time for COSP treatment using 1 g/l of OS or COS. It was observed that OSP has higher fluoride removal efficiency compared to COSP. Our findings suggests that oyster shells can be used as a potential low-cost material for F- removal, with the added benefit of re-use a waste product.

Title: Food Hygiene Practices in Dhaka, Bangladesh (CHoBI7 Trial)

Authors: Anne OConnor, The Johns Hopkins Bloomberg School of Public Health, Shirajum Monira, International Centre for


Diarrhoeal Disease Research, Bangladesh, Md. Sazzadul Islam Bhuyian, International Centre for Diarrhoeal Disease Research, Bangladesh, Tahmina Parvin, International Centre for Diarrhoeal Disease Research, Bangladesh, Jamie Perin, The Johns Hopkins Bloomberg School of Public Health, Jahed Masud, International Centre for Diarrhoeal Disease Research, Bangladesh, Marzia Sultana, International Centre for Diarrhoeal Disease Research, Bangladesh Md. Aminul Islam, International Centre for Diarrhoeal Disease Research, Bangladesh,Gayathri Natarajan, The Johns Hopkins Bloomberg School of Public Health

Submission: Inadequate food hygiene practices, including improper food storage, are associated with an increased risk of exposure to infectious microorganisms and diarrheal disease. In addition, consuming street vended food and water outside the home is associated with an increased risk of cholera and other diarrheal diseases. This descriptive study includes data collected as part of the Cholera-Hospital-Based-Intervention-for-7-Days (CHoBI7) study, a randomized controlled trial of 2656 participants being conducted at International Centre for Diarrhoeal Disease Research, Bangladesh Hospital in Dhaka, Bangladesh. Data was collected using a structured questionnaire which included questions regarding household and individual food hygiene practices. Fifty one percent of households reported regularly storing food overnight without refrigeration. Fifty percent of households reported adding additional water to food stored overnight before eating, which if not treated can be an additional source of fecal contamination. In addition, 93% of participants reported having consumed food or water outside the home in the past two weeks. Interventions are needed to promote food hygiene messaging encouraging safe storage of household food, and hygienic food preparation practices.

Title: For Men it is Safe” WASH needs and priorities for women and girls in the rural Solomon Islands

Author: Kelly Alexander, CARE

Submission: BackgroundUNICEF and the Solomon Islands Government (SIG) requested a "Gender and WASH" study in the rural areas of the country. National policies and guidelines call for the inclusion and integration of women in water and sanitation programming - but there is question over whether policies were being carried out and women in rural areas were included. This assessment was both a critical look at existing policies through a gender lens, and also community-level research study to understand the implications of the policies and government practices.MethodsCARE International conducted a literature review, multiple stakeholder interviews with personnel working in WASH, women or development sectors in the NGOs or SIG. We also conducted Focus Group Discussions (FGDs) and in-depth interviews (IDIs) with various groups in communities to assess the interpretation and current status of women's integration into water and sanitation initiatives.ResultsStakeholder interviews were conducted with 27 people. The research team visited 7 rural communities and conducted 33 FGDs and 16 IDIs. We found that definitions of "safety" and "privacy" were very different for males and females. Answers to questions about water collection and defecation practices were also very different coming from adolescent girls, women, men and community leaders. Women's participation on committees sometimes led to domestic violence. Three communities were certified "No Open Defecation" (NOD not ODF in Solomon Islands) and four were either pre or post-triggering. NOD status gave women more work than previously. UNICEF and SIG have already started using these findings to alter their WASH planning. They will use training and new tools (developed by CARE) to change the way their field staff approach communities and involve males and females, by having separate sessions, asking slightly different questions, and increasing the number of females who work for their programs in communities.

Title: From Red to Green: Improving WaSH in Basic Emergency Obstetric Neonatal Care (Bemonc) Sites in Mali

Author: Sory Ibrahima Bouare, Save the Children, Renuka Bery, Save the Children

Submission: From Red to Green: Improving WASH in Basic Emergency Obstetric Neonatal Care (BEmonC) sites in Mali.Sory Ibrahima BOUARÉ, Save the Children, MaliAdditional Authors: Renuka BeryContextPoor hygiene and sanitation conditions at health facilities in Mali highlight a deficiency in hygiene practices and access to appropriate WASH infrastructure. Save the Children’s Services de Sante a Grand Impact (SSGI) project is implementing its Clean Clinic Approach in institutions offering Basic Neonatal Obstetric Care in Mali. ApproachThe Clean Clinic Approach aims to improve water, sanitation and hygiene (WASH) in targeted facilities with few subsidies. SSGI launched the Clean Clinic competition in 23 facilities in Koulikoro Region and 57 facilities in Bamako District to improve water access, hand washing, waste and wastewater management. Over 12 months the institutions are inspected four times against a score sheet for different WASH components. A “Clean Clinic” (green) has received 80% or a minimum score of 19 of 24 points; yellow marks facilities that


score between 12 and 19 points and red represents facilities with scores lower than 12. Preliminary Results The mid-term results in Koulikoro show progress: initially no facility was green but at the second inspection 5 facilities or 22% of targeted facilities received 80% and have achieved "Clean Clinic status." Further initially 10 facilities had a score less than 50% indicating that WASH practices needed improvement while at the second inspection only six were in this red zone. Fifteen facilities made significant progress between the two inspections and three institutions gained 9 to 14 points in a two month period. Results from Bamako are expected in June 2018.Conclusion This session will share SSGI’s results and key learnings gathered while implementing and scaling up WASH improvement in health facilities in Mali. The presenter will emphasize the challenges overcome and the key elements of succes

Title: Health and Climate Post Hurricanes: Youth Impact in the USVI

Author: Christina Chanes, University of the Virgin Islands

Submission: As the world population is expected to reach 9.7 billion by 2050, the demand for quality drinking water, nutritious food, and increased food safety has become imperative. In a progressively more complex context and in light of recent global weather and climate change events taking place, those three essential materials have become interdependent and relate directly to community health. In order to increase food production, greater amounts of quality water and soil will be required, which in turn will make food safety education and community health more imperative as these weather and climate events take place in the territory. In addition, waterborne illnesses due to mosquitos including Zika, Dengue and Chikungunya are of concern as well as foodborne illnesses such as Ciguatera, found in fish, which can impact the population at large (1. The Modern Caribbean; Knight and Palmer). The USVI, while a territory, is similar to many international communities whereby communication, supplies, food and technology are much harder to access due to remote locations. As a result, this program was designed to address issues of cistern and public health along with food safety should an extreme weather event impact the islands. A pilot program focused on health and climate outreach and education was needed in the Unites States Virgin Islands to address and meet these needs, especially with regard to socially disadvantaged families and seniors who live in the territory and who during severe weather would be unable to leave. Consequently, it became important to develop innovative strategies through a program effort such as this funded by Astho to help educate the population at large about how and why it is necessary to guarantee an adequate supply of food and water for personal and family use in an effort to ensure food safety and healthy communities now and for future generations due to the potential of extreme weather incidents and/or drought, in the USVI and worldwide.

Title: Highest Point of Fecal Contamination in Drinking-Water Chain in Low and Middle Income Countries: A Systematic Review

Authors: Hur E Zannat, Tufts University, Daniele Lantagne, Tufts University

Submission: Diseases that are transmitted by the fecal-oral route (e.g. diarrhea) are one major portion of the global burden of childhood morbidity and mortality. One route of transmission for fecal-oral pathogens is within various components of the water chain i.e. drinking water sources, transportation or distribution to the home, household storage, and through to consumption. We are conducting a systematic review of fecal indicator bacteria results from low- and middle- income countries (LMIC) to identify the portion of the water chain with the greatest increases in fecal contamination; this would allow targeted interventions to reduce contamination in household drinking water. As part of the systematic review, we have developed inclusion criteria; are currently searching and selecting studies and plan to assess the quality of evidence and summarize available data. Inclusion criteria were categorized using PICOS: Population is household in LMIC; Intervention is drinking water used by household; Comparisons will be made between fecal bacterial count (including Escherichia coli (E. coli) or thermotolerant coliform (TTC), before and after of a component of water chain; only field-based and observational study. Studies that provide quantitative outcome for fecal contamination in drinking water will be considered. PubMed, Web of Science and Scopus were searched using relevant keywords. The search included studies published on or after 01/01/2000. In total, 1,738 articles were identified for title and abstract screening. Abstract screening is ongoing at the time of submission. This review will identify highest fecal contamination point of the water chain in LMICs and provide recommendations for designing drinking water interventions in LMICs.

Title: Household Behavior, Groundwater Use, and the Struggle to Prevent Chronic Kidney Disease of Unknown Etiology


in Sri Lanka

Authors: Soumya Balasubramanya, International Water Management Institute, Theodore Horbulyk, International Water Management Institute

Submission: Chronic Kidney Disease of unknown etiology (CKDu) is responsible for tens of thousands of deaths among rural, low-income populations in Sri Lanka. The prevalence of the disease has grown exponentially since the 1990s, not only in Sri Lanka but in a number of other countries. The cause of CKDu is undetermined. Groundwater use, dehydration, diets and pesticide exposure have been implicated. Public prevention strategies include providing substitute drinking water sources and continuing investigation of underlying causes.This paper examines systematic differences between those groundwater-dependent households who have a history of the disease and those who do not. This is achieved using methods of micro-econometric analysis with a representative survey of 1,500 households to characterize diverse household behaviors and risk perceptions.Since CKDu is understood to result from chronic rather than acute exposure to environmental or dietary toxins, household behaviors examined include historical exposure to agricultural chemicals and historical choices of domestic water sources.Examination of behavioral differences in communities’ resource-use decisions can shape the design of public disease-prevention strategies that are more cost-effective. It can guide hydrogeochemical and epidemiological analyses of the origins of the disease, which have, thus far, not controlled for the role of behaviors on disease prevalence.

Title: How City Data Hubs with Data Standards will Create Actionable Insight to Accelerate and Track Progress on SDG 6.2

Authors: John Peter Archer, Gather, Lindsey Noakes, Gather

Submission: Useful data is crucial for effective decision making. In 2017, the World Bank reported that poor data has led to an ineffective allocation of resources across the sanitation sector. The current data gap is also preventing the sanitation sector from tracking its progress on providing sanitation for people living in cities. This challenge is not insurmountable. A sector-wide response needs to include behaviour change in the collection, sharing and use of data. Our methodology is built on a collaborative approach to systems change. We interviewed and listened to the experiences and needs of the 100 sanitation professionals, and we also engaged with experienced partners in the fields of data collection and data sharing. In 2017, we developed this and tested two approaches to data collection and data sharing. First, we mapped shared sanitation infrastructure in Mathare in Nairobi, Kenya. We wanted to understand the costs and challenges of collecting, curating and analysing sanitation data. Second, we focused on the creation of a data sharing platform. We wanted to understand what was needed for sanitation providers to share the data they were already collecting, so that it could be analysed and the insights shared with sanitation providers and funders. Both approaches revealed the need for a sector-wide data standard for urban sanitation data. Without a data standard, it is impossible to collect and share data so that it can be analysed to identify where investment is needed to expand sanitation services. A data standard will ease the burden and cost of data collection on sanitation providers by simplifying the data they need to collect and share and reducing duplication of efforts. Standardised data, accessible through a data sharing platform, will allow organisations across the urban sanitation sector to work more effectively, efficiently and collaboratively to provide sanitation to people living in low income communities.

Title: How Intentions Toward Fecal Sludge Management Vary Regionally and Seasonally in Rural Cambodia

Authors: James Harper, University of Colorado Boulder, Angela Bielefeldt, University of Colorado Boulder, Amy Javernick-Will, University of Colorado Boulder, Toeur Veasna, iDE

Submission: With 45% of the world’s population defecating in pit latrines daily, safely managed fecal sludge has been difficult to achieve, particularly in rural communities, where households typically manage their own fecal sludge. A critical component of fecal sludge management (FSM) in these rural contexts - behavior - is known to affect FSM but is poorly understood. Using the Theory of Planned Behavior, which links contextual factors to the formation of behavioral intentions, this study examines the intentions of rural Cambodian latrine owners when their pits fill. Survey data collected from 3758 households in rural Cambodia between 2014 and 2017 were analyzed for regional and seasonal variations using structural equation modelling to answer the question “Do regional and seasonal contextual factors affect how rural latrine owners in Cambodia intend to manage their fecal sludge?”. Regional variations in FSM intentions were moderate. Latrine


owners in provinces with stronger economies reported more desirable FSM intentions; however, those living in poor Oddar Meanchey province also reported more desirable FSM intentions. Thus, a strong regional economy was sufficient but not necessary for more desirable FSM intentions. FSM intentions also varied seasonally. Desirable FSM intentions peaked during April’s rice harvest (73%), when farmers are most financially stable, and fell to 50% during November’s rice planting/growing season, when farmers are least financially stable. Latrine coverage and FSM marketing history did not explain the remaining variations, indicating the need for more research. While financial stability does affect FSM intentions, other relevant contextual factors must be identified to fully describe these variations. This formative research describes a part of human decision-making that can be used to predict FSM behaviors, improve FSM behavior change methods, and improve the design of latrines and FSM processes and training to achieve safely managed sanitation.

Title: How to Study a System: A Qualitative Comparative Analysis of Regulated Water Quality Monitoring in Sub-Saharan Africa

Authors: Ranjiv Khush, Aquaya, Rachel Peletz, Aquaya, Caroline Delaire, Aquaya, Sara Marks, Sandec, Eawag, Joyce Kisangani, Aquaya, Patrick Ronoh, Aquaya

Submission: The importance of the systems that underlie water and sanitation services is gaining increasing recognition in the WASH sector. There are few examples, however, of research strategies for identifying specific strengths and weaknesses in WASH systems. In this study, we demonstrate methods for analyzing the factors that determine the performance of water quality monitoring systems in Africa.We compared monitoring programs among 26 regulated water suppliers and surveillance agencies across six African countries. These institutions submitted water quality data over 18 months. We also collected qualitative data on the factors that influenced testing performance. Subsequently, we applied fuzzy-set Qualitative Comparative Analysis (fsQCA) to evaluate different combinations of institutional factors on monitoring performance. Our analysis identified motivation & leadership, knowledge, staff retention, and transport as institutional conditions that were necessary for achieving monitoring targets. In addition, equipment, procurement, infrastructure, and enforcement contributed to the pathways that resulted in strong monitoring performance. Our identification of institutional commitment, comprising motivation & leadership, knowledge, and staff retention, as a key driver of monitoring performance is not surprising: in weak regulatory environments, individuals and their motivations take-on greater importance in determining programmatic outcomes. Nevertheless, efforts to build data collection capacity largely focus on supply-side interventions: the provision of infrastructure, equipment, and training. Our results indicate that these interventions will continue to have limited long-term impacts without complementary strategies for motivating institutional leaders to achieve testing goals. More broadly, our research demonstrates an experimental approach for diagnosing the systems that underlie service provision and an analytical strategy for identifying interventions.

Title: Identifying Sustainability Factors of a Gravity-based Drinking Water System in Rural Haiti

Authors: Heather Nixdorff, University of Alberta, Nicholas Ashbolt, University of Alberta, Kate Storey

Submission: Background: The country of Haiti has faced myriad challenges associated with adequate water, sanitation, and hygiene (WASH) infrastructure for decades. Haiti Health Initiative (HHI) is a grassroots organization that has been present in the community of Timo, Haiti and has established a gravity-based water system serving approximately 200 residents in the region. There are growing concerns regarding the sustainability of the water system being voiced from both the organization and residents of Timo.Objective: The purpose of Heather’s MSc. research is to understand factors that may influence/improve the sustainability of a gravity-based water system in Timo, Haiti, by way of assessing the experience and perceptions of the residents. Water quality testing of the water system will also be completed to compare perceived risk to actual microbial risk. Methods: Qualitative description will be used under a community-based participatory research (CPBR) framework. Using purposeful sampling, approximately 25 semi-structured interviews will be conducted with adult residents of the community of Timo who have experience with the water system. Water quality testing of the four reservoirs will be undertaken utilizing E. coli-based assessment of faecal contamination. Intended Results: Results from this project will provide insight into the various factors that influence the sustainability of the water system in the rural village of Timo. This research will also inform those working on creating more context-specific WASH systems in rural/remote sites globally. Data collection will be completed May-June 2018.


Title: Improved Water Quality of Mountain Springs: Exploring Groundwater Quality, Spring Source Protection, and Innovative Drilled Alternatives

Authors: Monica Resto, Mercer University, Michael MacCarthy, Mercer University

Submission: Millions of people in developing communities drink water from springs on bedrock mountain slopes. Previous studies show E. coli causing many sampled springs on populated mountain slopes in southwest China to provide unsafe drinking water. Such studies are rare, but recently a reconnaissance study was initiated in a watershed in the Dominican Republic, where more than 25,000 people, spread out across small communities and one town, rely on mountain springs. E coli testing shows many of these springs to be unsafe. Water users live down-slope and distant from the springs and receive spring water via pipelines. Likely, the E. coli originates from sparse livestock grazing up-slope from springs. Small wells drilled using portable rock coring machines and completed using novel continuous seals attached above the water intake zone are proposed, as an alternative to the traditional spring box, to access safe drinking water drawn from permeable fractures tens of meters below ground, avoiding contamination near surface.The overarching research project involves investigating how groundwater flows to springs and how pathogens and nitrate enter the spring domain (which includes the spring, adjacent and up-slope area generating surficial runoff to the spring, and the presumed areas of recharge for groundwater which discharges at the spring), utilizing portable rock-corers to drill in bedrock to substantial depths for installation of conventional monitoring wells and new types of monitoring devices best suited for understanding subsurface flow. The research goal is to determine the path of entry of fecal contamination and nitrate at mountain springs and whether deeper groundwater flow to springs yields safer drinking water.The presented work, as part of the recently initiated reconnaissance study, focuses on water quality testing results from existing mountain springs in the El Cercado area of the Dominican Republic are presented, particularly fecal contamination.

Title: Improving Shared Sanitation Users’ Habitual Cleaning Behavior in Kampala Slums, Uganda: RANAS and Group Discussion Effects

Author: Innocent Tumwebaze, Temple University

Submission: Introduction: Study investigated ways to improve shared sanitation users’ habitual cleaning behavior for hygienic facility use following the Risks, Attitudes, Norms, Abilities and Self-regulation (RANAS) model of behavior change (Mosler, 2012) and group discussions. Methods: It was a longitudinal study with a before-and-after intervention evaluations. Interventions involved group discussions supplemented with public written commitment. Results: Analysis provided for a total of 305 respondents. There was nearly a five-fold improvement in respondents’ habitual cleaning behavior for shared toilets in discussions and even more when supplemented with public commitment compared to users in control groups. This was influenced by the risk factor of perceived severity of disease if contracted from using a dirty facility (Beta=0.08, p-value= 0.038), and norm factors of other facility users’ participation in cleaning (Beta=0.11, p-value= 0.002), cleaning approval by important persons (Beta=0.09, p-value= 0.016) and personal obligations towards cleaning (Beta=0.75, p-value= 0.000). The variance explained by the linear regression model was 72 percent (R Square = 0.72, Adjusted R Square = 0.70, level of statistical significance = 0.05)Conclusion: Study reveals that targeted group discussions and even more when supplemented with public commitment are fundamental in improving shared sanitation users’ habitual cleaning behavior contributing to improved health outcomes.

Title: Improving the Sustainability of WaSH Interventions Using Social Art for Behaviour Change (SABC): The Talking Mosaic of Guatemala

Author: Tania Vachon, One Drop Foundation

Submission: The SDGs, including Goal 6: “ensuring sustainable and equitable access and management, of safe and affordable water and sanitation for all”, represent a unique opportunity for the WASH community to work together creating synergy towards a common objective. In addition to supporting governments’ leadership of WASH interventions, One Drop and other stakeholders can help accelerate progress towards achieving the SDGs by addressing an important gap for the achievement of these ambitious goals: the sustainable change of key WASH behaviours both at individual and community levels.For this purpose, One Drop has developed its Social Art for Behavior Change approach, which uses Social


Art as a tool to reach populations emotionally and mobilize them towards sustainable behaviour change. This includes implementing various activities rooted in local traditions and art forms (e.g. community-led mural paintings, artistic-pedagogical workshops, video productions, radio programs, interactive theater, photo exhibitions, etc.).This verbal presentation will present: 1) the rigorous process and various steps involved for the design, implementation and evaluation of a behaviour change strategy for a typical WASH project; 2) the strategies and methodologies used to accompany and guide the process; and 3) the tools developed for monitoring, evaluation and learning (including process documentation).

Title: Inactivation of Cryptosporidium Oocysts and Clostridium Spores by a Reformulated Chlorine Disinfectant

Authors: Michael Fisher, University of North Carolina at Chapel Hill, Emanuele Sozzi, University of North Carolina at Chapel Hill, Noor Baloch, University of North Carolina at Chapel Hill

Submission: Worldwide, millions of illnesses and hundreds of thousands of deaths are caused each year by Cryptosporidium species and other pathogens that are resistant to inactivation by hypochlorite and other conventional chlorine disinfectants. Low-cost disinfection methods that can safely and efficiently inactivate chlorine-resistant pathogens in drinking water therefore have the potential to improve health outcomes in settings where populations depend on vulnerable water supplies, including low- and middle-income country settings and emergency settings. We evaluated the inactivation of a chlorine resistant indicator (Clostridium sporogenes spores) and pathogen (Cryptosporidium parvum oocysts) in the presence of a conventional chlorine disinfectant as well as a reformulated chlorine disinfectant including the addition of low concentrations of trace metal ions. Inactivation rates for both organisms were enhanced in the presence of the reformulated disinfectant. However, C. sporogenes spores were found to be a poor proxy for estimating C. parvum inactivation rates. These results suggest that while C. sporogenes spores may be suitable indicators for rapid screening of novel disinfectants, they may not be adequate process indicators for C. parvum oocyst disinfection. Effects of natural and simulated water characteristics on inactivation rates were also explored. The potential of such low-cost, reformulated disinfectants for improving the microbial safety of drinking water in emergency and non-emergency settings is discussed.

Title: Inequalities in Access to WaSHServices Among Low-income Consumers: Key Findings from one City-wide Survey

Authors: Jonathan Stokes, Water & Sanitation for the Urban Poor, Nerea Ajuriagogeascoa, WSUP

Submission: There is limited tracking of inequalities in access to water and sanitation services at the sub-national level. To address this global monitoring challenge, Water & Sanitation for the Urban Poor (WSUP) has piloted baseline citywide assessments of low-income communities and informal settlements in five cities over 2017/18. This poster will present a detailed focus on the spatial sampling methodology, based on the context of citywide poverty distribution, and the key findings to date for one city. Indicators covering accessibility, affordability and availability of water and sanitation services will be presented from data collected through a comprehensive household survey, water quality testing and third-party data from service providers and other actors allowing for generation of full JMP water and sanitation service ladders up to “safely managed” level. Key indicators will be mapped across groupings of low-income areas to visually highlight intra-city inequalities. Results will also be presented stratified by wealth quintile. This combination of data allows interesting conclusions to be drawn, particularly around access inequalities – for example, what is the effect of increased wealth in slum and non-slum areas on household positioning on the JMP ladder? Results from Dhaka indicate that increased wealth in non-slum areas is associated with a higher positioning on the JMP sanitation ladder, however this is not the case in slum areas – implying that access to JMP “basic” sanitation in slums is constrained by factors beyond household income.

Title: "It's Like a Burden on the Head": Redefining Adequate Menstrual Hygiene Management Throughout Women's Life Course in Odisha, India

Authors: Elizabeth MacRae, Emory University's Rollins School of Public Health

Submission: The growing recognition of menstrual hygiene management (MHM) as a significant public health issue has predominately focused on the experiences of adolescent girls in school settings, neglecting women and girls beyond educational settings. This research examined women's detailed accounts of menstruation in rural Odisha, India,


considered the applicability of the current definition of adequate MHM put forth by the WHO/UNICEF Joint Monitoring Programme for Water Supply, Sanitation and Hygiene, and proposed amendments to the definition of MHM to capture the range of needs and concerns reported by women. Focus group discussions and in-depth interviews were conducted to understand women's experiences of menstruation across four life stages (unmarried women, recently married women, married women, and older women). Thematic analysis was used to identify menstruation-related challenges and needs. We found women voiced needs that aligned with those articulated in the JMP definition: access to clean materials, privacy for changing materials, soap and water for bathing, and disposal facilities. However, women's menstruation-related needs were broader than those in the JMP definition: beyond access to clean materials, women required comfortable and reliable materials; soap and water was needed at times outside of bathing; privacy was needed for the full spectrum of menstruation-related practices, not just when changing; and disposal facilities needed to be private and safe, not just accessible. Additionally, we identified needs that extended beyond the existing definition: pain management, social support, and information. Given the limited scope of the current MHM framework, we proposed a revised definition of adequate MHM that more comprehensively captures the needs of women in this population. This definition can inform future research, create measures of assessment, and guide program priorities in Odisha and potentially beyond.

Title: Landscape Irrigation with Treated Gray Water at a 3-Bedroom Macon Area Habitat forHumanity Home.

Authors: Philip McCreanor, Mercer University - School of Engineering, Griffin Murphy, Mercer University, Hart Warner, Mercer University

Submission: The majority of homes served by a municipal potable water system in the U.S. irrigate their landscape with potable water. This results in extra demands on potable water sources for a use (irrigation) that does not require water treatment to potable levels. Studies on residential water consumption indicate that households have similar water demands for bathing, showering, and laundry requirements (28% combined) and irrigation (29%). This suggests that irrigation needs could be met by on-site treatment of wastewater generated from bathing, showering, and laundering clothes. A gray water treatment system consisting of a 500 gallon settling tank, a bristle-type septic filter, and an attached growth treatment unit consisting of three Eljen® GSF modules over 37 cm of #20 filter sand was installed at 3-bedroom Macon Area Habitat for Humanity home. Effluent is discharged to the lawn via sub-surface drip irrigation. Monitoring of the system includes pH, chemical oxygen demand (COD), 5-day biochemical oxygen demand (BOD5), solids, flow rates, and hydraulic behavior of the drip emitters. Results indicate that the household’s average potable water demand is 966.45 lpd (255 gpd) of which 54% or 538.2 lpd (142 gpd) is used for bathing, showering, and laundry. Gray water throughout the system has an average pH of 6.7. Settled gray water has average COD, BOD5, and suspended solids (SS) of 378, 164, and 29 mg/l, respectively. When operated in a recirculating mode (65% of inflow recirculated to the settling tank), the system achieved average effluent COD, BOD5, and SS of 59, 14, and 2.0 mg/l, respectively. Single pass operation of the system resulted in average effluent COD, BOD5, and SS of 116, 20, and 2.4 mg/l, respectively. This research demonstrates that a simple, gravity-flow gray water treatment system has the potential to produce an effluent that meets both NSF/ANSI Class I and US EPA secondary wastewater treatment standards for BOD5 and SS.

Title: Lead-Lag Series and Staged Parallel Operational Strategies Improve the Performance and Cost-effectiveness of Bone Char for Control of Fluoride in Groundwater

Authors: Josh Kearns, North Carolina State University, Aaron Krupp, Elena Diek, Sarah Mitchell, Sarah Hartman

Submission: Affordable, locally managed, and decentralized treatment technologies are needed to protect public health in resource poor regions where communities consume groundwater containing elevated levels of fluoride (F). Bone char is a promising low-cost sorbent for F that can be produced using local materials and simple pyrolysis technology. However, the sorption capacity of unmodified bone char is relatively low, especially at pH typical of groundwaters containing geogenic F. This makes necessary large bone char contactors and/or frequent sorbent replacement. One strategy for improving the feasibility of bone char water treatment is to utilize lead-lag series or staged parallel configurations of two or more bone char contactors. This study used column testing to quantify potential benefits to sorbent use rate, replacement frequency, and long-run average F concentration in treated water of lead-lag series and staged parallel operational modes compared with conventional single contactor mode. Lead-lag series operation was predicted to exhibit the largest reduction in bone char sorbent use rate (46% reduction over single contactor mode compared with 29% reduction for staged parallel) and lowest long-run average F levels when treating central Mexican groundwater at pH 8.2 containing 8.5 mg/L F.


Title: Learning from the Wheel – Sustaining and Scaling Toilet Bazaars in Bihar, India

Authors: Aprajita Singh, Population Services International India

Submission: There remains a sanitation crisis in Bihar where even in the Swachh Bharat Mission ( SBM) era; only half of its population has any access to toilet. PSI has been working as a market facilitator for over 6 years and this presentation will share the learnings on how it succeeded in making the Bihar sanitation ecosystem function; only to discover a greater challenge of ensuring the gains were sustained and scaled and the journey towards it. When PSI entered Bihar in 2012- it was a dysfunctional sanitation ecosystem where a toilet that households aspired to and could pay for was missing, there was no means of sanitation credit, there existed a revealed preference for open defecation and toilet competed with other household needs reducing its demand. Even in a situation that the household overcome all the stated barriers, getting a toilet was a long and cumbersome process taking around 90 days and interaction with more than 14 market players to get it. PSI through its market facilitation, addressed all these barriers over a period of 5 years and through funding support from the Gates Foundation and Domestos Toilet Academy, Unilever’s. The success of these intervention strategies have resulted in 200,000 toilets sold, more than 750 enterprises and disbursement of over 251 enterprise loans and over 27,800 consumer loans through the financing mechanism. The customer acquisition cost has reduced from USD 5000 to USD 13. While, the market functioned, PSI faced the larger challenge of ensuring sustainability. Sustaining demand for toilets appeared to be central to this. The demand generation cost being currently fully borne by the project needed to be transitioned to local sanitation businesses. Through, a phased approach, supported by the Gates Foundation and Grand Challenges Canada ;PSI is unlocking private investments from the enterprises who progressively own demand generation costs from 0 in phase I of the project to to 20% by July2018, 100%by December 2020.

Title: Lessons from Electronic Transfers of Incentives in the Swachh Bharat Mission in Madhya Pradesh, India

Authors: Andrés Hueso, WaterAid, VR Raman, WaterAid India, Kanika Singh, Consultant

Submission: In order to address some of the challenges facing the implementation of the Indian government's rural sanitation program, the ‘Swachh Bharat Mission’, the Madhya Pradesh state government introduced the direct benefit transfer (DBT) in 2016. This system uses an android application and web portal for digitizing the processes, resulting in the bank transfer of toilet construction cash incentives directly into beneficiaries' bank accounts.The DBT model, promoted in various government programs, has the potential to address shortcomings with regards to transparency, accountability, monitoring and efficiency. WaterAid India therefore decided to research the DBT model in the Swachh Bharat Mission in Madhya Pradesh and identify its successes, gaps and bottlenecks. The study involved review of state policy documents, followed by a household survey and key informant interviews in three districts. The study suggests that though the direct benefit transfer model has resulted in greater system efficiency, there is still a long way to go in terms of improving community's access to and ownership of the system. Due to the involvement of local functionaries in the incentive delivery process, there is scope for conflict of interests which, compounded by targets pressure on government officials, results in over-reporting and incomplete toilet construction. Equity issues emerged, including poorer households struggling due to the preferential promotion of single-instalment option, and people with disabilities and older citizens facing difficulties to withdraw the incentive from the bank account.Building community capacities and strengthening processes can help in addressing some of the bottlenecks of the DBT model, which may then be scaled up and replicated to enhance the Swachh Bharat Mission outcomes and its potential impact.

Title: Leveraging Public-Private-Development Partnerships and a National Market Systems Approach for Sustainable Sanitation Service Delivery

Authors: Greg Lestikow, iDE, Jessica MacArthur, iDE Bangladesh, Sameer Karki, iDE Bangladesh

Submission: SDG 17 calls for increased partnership and collaboration to meet the goals of health and safe waste management (SDG 17). WIth diminishing donor funds, the private sector offers great potential to distribute the cost of WaSH products and services among many stakeholders and invest in the R&D required to create advanced waste management solutions. Many available sanitation technologies fail to meet hygiene or quality standards that justify households’ investment of their own funds. The public sector holds the authority to regulate these products and ensure


health safety and consumer protection while the development sector is still a crucial resource for ensuring sanitation access for the extreme poor and vulnerable. The SDC-funded Sanitation Marketing Systems project in Bangladesh (SanMarkS) forges public, private, and development partnerships at the local, regional, and national level, to strengthen the supply and generate demand for improved sanitation products and services. The engagement of large manufacturing firms is a key component of the strategy, driving latrine prices down by leveraging economies of scale. This is paralleled by the government-led development of national sanitation marketing guidelines, which clarify sector roles and product quality standards to prevent market distortions and enable complete coverage. The project, implemented by iDE and Unicef, draws from Unicef’s sanitation marketing guidance notes and contextualizes them for the Bangladesh context. While national systems strengthening may vary between countries due to factors such as product availability, government policies, or infrastructure, SanMarkS’ example provides insights into how countries may sustainably increase access to WaSH products and services. The presentation will briefly describe the Unicef guidance notes, share learnings on building comprehensive WaSH market systems, and foster discussion around the relevance of a full systems approach to WaSH markets.

Title: Looking at the Drops: Community Level Audit of Water Supply, Consumption and Quality in Urban Slums of Delhi, India

Author: Naved Mohammad, Independent - WASH Professional

Submission: Background: The access to safe water and sanitation is unjust in urban India, reflecting vast inequalities based on socio-economic conditions of the settlements. Water loss due to leakage during distribution process also leads to reduction in the actual per-capita consumption of water, aggravated by poor quality of supplied water at times.Objective: Water audit was conducted in 25 slums of East and New Delhi, India in 2015, with objectives to analyse the demand and supply gaps, the level of final consumption by people and reasons for the same; to assess quality of water suppliedMethodology: The study prepared estimates of quantities of water supply, leakages and consumption; it also assessed quality of supplied water. These were done through mapping of water source points; calculating water supply both through piped supply & supply through mobile tankers; mapping leakages in water supply; calculating water consumption (drinking water usage was assessed using jar measurement method and consumption for washing, flushing and other domestic usage was assessed through focused group discussions); and assessing quality of supplied water using H2S Vials test. Results: The results highlighted striking variations in water supply patterns by the government within study areas. Supply of water ranged from 2 lpcd to 409 lpcd; the range in consumption of water varied from 18 lpcd to 106 lpcd. Higher consumption rate compared to lesser supply was explained by the illegal water connections, and use of sources such as hand pumps and bore wells; looking at the intra-community distribution dynamics, the study found that the supply ranged from 20 lpcd to 130 lpcd mainly explained by variations in water pressure. There was a direct correlation between shortage of water supply & number of households per functional water tap. Location of the slums also did determine the benefits with reference to water supply. Water quality samples from 7 out of 25 slums were quality affected.

Title: Managing Conjunctive Use of the Subsurface for on-site Water Supply and Sanitation: An Evaluation of Health Risks in a Small Town in Uganda

Authors: Jacintha Nayebare, Makerere University, Michael Owor, Makerere University, Robinah Kulabako, Makerere University, Richard Taylor, University College London

Submission: Inadequate community and household-level hygiene coupled with the conjunctive use of the shallow subsurface as both a source of safe water and repository of faecal matter poses substantial risks to human health in low-income countries undergoing rapid urbanisation. We assess the water supply, sanitation and hygiene (WASH) conditions in a small town Lukaya in central Uganda using household surveys, risk assessments and water quality analyses. Sanitation systems are entirely on-site and 94% of the surveyed water sources derive from shallow groundwater. Using WHO, (1997) sanitary inspection tool, high risk scores (7-14) for on-site sanitation facilities reflect observed inadequacies in construction and maintenance. Household surveys indicate high awareness of basic hygiene (e.g. hand-washing, boiling water) but failures to practice basic hygiene are common (82%) as reflected by an absence of facilities and unsanitary water containers (p = 0.005). Sanitary risk surveys and rapid risk assessments reveal further that community hygiene, in practice, is often inadequate contributing to reported incidences of diarrhoeal diseases; a clear association between malaria and local ponding of water was also of high significance (p <001). Faecal contamination of water points was


widespread and often gross featuring high counts of enumerated Escherichia Coli (3-330 cfu/100mL) and thermotolerant coliforms (173-2518 cfu/100mL) as well as generally high nitrate concentrations (2.4-345 mg/L) and turbidity (11-126 NTU). Our analysis reveals an awareness and ability to implement WASH improvements exploiting the shallow subsurface but also the fragility and vulnerability of these on-site water supply and sanitation systems with important implications for the practical realisation of UN Sustainable Development Goal 6 in urban Africa.

Title: Market-based Approaches and the Sanitation Economy

Authors: Jasmine Burton, Toilet Board Coalition, Portia Persley, USAID, Jennifer Marcy, Population Services International, Cheryl Hicks, Toilet Board Coalition

Submission: The acceleration of sanitation systems that are designed for inclusion, circularity, preventative health and to leverage new technology trends requires new levels of business and societal leadership today to realise benefits in this decade.The Toilet Board Coalition has framed the opportunity of the Sanitation Economy and has assembled growing evidence of significant new benefits for business and society across sectors - an estimated $62 billion opportunity by 2021 in India alone. The Sanitation Economy leverages innovative toilet design, recovery of biological resources within the Circular Economy, and smart digital technologies driving preventative healthcare, to create a double win – accelerated scale up of sanitation, together with multiple business opportunities.The shift to a Sanitation Economy presents vast potential for global economic growth and the societal benefits of universal access to smart, sustainable sanitation (SDG6).Session objectives:1. To present the Toilet Board Coalition’s newest research findings and evidence for the rise of the Sanitation Economy - including examples of business approaches2. To provide examples of how the Sanitation Economy is working in practice. Toilet Board Coalition members, USAID and Population Services International (PSI) who will share highlights from Toilet Board work in the development of business solutions for the Sanitation Economy including the area of innovative investment mechanisms for sanitation sector business models, and the generation of market demand via Toilet Board projects with the Tea Sector, and with the Municipality of Pune in India.3. To engage in discussion with participants on opportunities to link market based approaches more broadly with the Sanitation Economy.

Title: Max Payment-by-results: Measuring, Monitoring & Managing for Greater Impact

Authors: Joke Le Poole, Max Foundation, Kate Pearson, Max Foundation

Submission: To achieve the ambitious SDGs, there needs to be a focus on achieving results in an effective and efficient way. We plan to present our Max Payment-by-Results (MaxPBR) system, launched in 2017, as an innovative way to focus on (tangible) results by incentivising this and thereby increasing value for money. MaxPBR is being implemented in the flagship program of Max Foundation which aims to reduce water-and faecal-borne disease levels and improve child health in a sustainable manner in Bangladesh. It targets SDGs 2, 3, 5, 6 & 8. Payment-by-results (PBR) style systems that link payment to predefined results, mark a shift away from traditional input-based payments. This is still new in the international development sector with few examples in WASH, and fewer still at field implementation level. Our aim is to increase results, innovation and efficiency. ‘Results’ in this context means changes in the lives of people the intervention aims to support, i.e. outcome-level results. Payment is the incentive, but the aim is results-based management at field level.This has required organizational changes: in the finance system, also organizing the program into phases, to facilitate incentive payments based on verified results in each phase, and allow us to track progress throughout and make corrections if necessary in real time. Our local partners cannot pre-finance everything so we provide 60-70% of the funds per phase upfront, and the rest upon delivery of results: thus, a hybrid, not a true PBR model. We had to change our system of data gathering, monitoring and evaluation. For example, registering each beneficiary (households, entrepreneurs, etc.) with phone numbers, and setting up a call center for verification of the data by random sample of registered beneficiaries. While this requires an investment (time/effort and money), we expect it will pay off in increased efficiency and ultimately impact, and that we’re at the forefront of a new trend in the sector.

Title: Max Water Social Business- Piped Water for Healthy Homes in Rural Bangladesh

Author: Kate Pearson, Max Foundation

Submission: Max Foundation aims to address rural water supply through a financially viable piped scheme model (Max


Water Social Business) that will transform access to safe, reliable and affordable water for poor, rural Bangladesh communities, and with the potential to go to scale. Currently, only 1% of households in rural Bangladesh have a piped water connection. The market value of water utilities in rural Bangladesh for people that have not yet been serviced is estimated to be $285 million. Even with access to water from wells or other water points, it often becomes contaminated through improper transport and storage. Research has shown that making safe (piped) water available inside the house has a positive impact on health, children’s development, the position of women and girls in society and economic development of the country. The potential market and the need is significant. The Max Water Social Business model provides 1) A physical solution for water supply; small-scale piped schemes. This requires relatively low investment with simple technology and easy maintenance. Households will have a pipe to their doorstep and from there they can connect their latrine, kitchen and bathing area with running water. 2) A business model for water supply that is managed by a water service provider (Max Water Social Business) and operated by small-scale local entrepreneurs (men and women), supervised and regulated by local government. The operators will be trained to manage the pumps, undertake routine maintenance and minor repairs, check water quality, deal with end-users and collect water fees. They will operate the systems for the water service provider which will own the hardware and is responsible for set-up, supervision, large-scale repairs, and troubleshooting/liaising with community and local government. To date, we have implemented six pilot piped schemes and at least fifteen more are planned.

Title: Measuring and Tackling Obstacles to SDG 6 Progress: Practical Experiences of Designing WaSHProgrammes That Respond to Weaknesses in the ‘System’

Authors: Vincent Casey, WaterAid, Ceaser Kimbugwe, WaterAid

Submission: Measuring progress towards the achievement of SDG 6 requires governments to track not only service levels, but also the underlying blockages constraining progressive realisation of the SDG target. Blockages include unclear institutional arrangements, ineffective coordination mechanisms, poor planning, limited monitoring, insufficient financing, fragmented service delivery, weak accountability and poor water resource management. Whereas processes to identify and address these issues often exist at the national level, mechanisms for effective review and responsive action remain weak at the sub-national level. The author presents results from practical trials of a participatory framework for measuring the strength of city and district level environments into which WASH services are introduced and, more significantly, designing and implementing district wide programmes that respond to sustainability blockages identified. Government, utilities, service users, the private sector and civil society are involved in the process. The author discusses the efficacy of the framework and some of its limitations. There is a focus on ensuring that hygiene, sanitation and water system strengthening components receive equal attention. Lessons will be shared from Kampala, Uganda, rural Ethiopia, rural Cambodia and Maputo, Mozambique.

Title: Measuring SDG Target 6.1 in Intermittent Water Supplies: Quantifying `Available When Needed’ with Utility Data

Authors: David Taylor, MIT, Andrew Whittle, MIT

Submission: Intermittent water supplies (IWS) serve one billion people, but their water is not always available. The highest level in the Joint Monitoring Program’s (JMP’s) ladder for water services is “safely managed,” which requires that a water supply be “available when needed.” Given the prevalence of IWS, understanding and measuring when IWS are “available when needed” will be key to tracking progress towards the Sustainable Development Goal’s (SDG’s) target 6.1. But how should utility data on availability (in hours/day of supply) be interpreted? Is the JMP’s “global benchmark” of 12 hours/day optimal?We summarize a recent model of the hydraulic behavior of IWS. It demonstrates that the behavior of IWS changes when customers receive as much water as they would like. We use this change to quantify the percent of customer demand that has been satisfied. Finally, we argue that customers receiving the water they demand defines a system that is “available when needed.” Our proposed availability metric can be assessed using a single flow logger at a system’s reservoir. Despite the potential of this new utility-level metric, it cannot assess inequalities across the population. We conclude, therefore, by suggesting how our analysis could be extended to quantify inequity.

Title: Meeting the Challenge of Improving Program Capacity in the Management of Private Drinking Water Systems

Author: Raquel Sabogal, Centers for Disease Control & Prevention


Submission: In September 2015, the Centers for Disease Control and Prevention’s National Center for Environmental Health initiated a 5-year cooperative agreement with 19 state and local public health departments focused on addressing the problems with private drinking water systems in their communities. The goal of the cooperative agreement is to support health departments to help people manage their private water systems to reduce drinking water exposure to contaminants. We will present on the first three years of progress made by participating health departments and highlight potential accomplishments for the end of this 5-year program. Using the 10 Essential Environmental Public Health Services as a framework, health departments identified gaps in their programs and focused on activities to address the management of private wells. These activities helped health departments build a network of resources for private well owners. Using the framework, health departments were better able to promote their resources, develop educational materials, and build partnerships with agencies and stakeholders that deal with private wells.Our presentation will highlight the most relevant essential services addressed by health departments, and highlight approaches we will take to share results, tools, and resources with all state and local health departments throughout the US. With 34 million US residents using private wells, it is essential that we disseminate what we have learned in support of safe water for community health.

Title: Mental Models Risk Communication to Promote Private Well Testing in Underserved Minority Communities, Part I: Communication Design

Authors: Erica Wood, UNC Chapel Hill, Frank Stillo, University of North Carolina at Chapel Hill, Wandi Bruine de Bruin, Leeds University Business School, Sydney Lockhart

Submission: Effective risk communications contribute to a more informed public, which can lead to individual and collective decisions that better protect health. Residents of a number of peri-urban, predominantly African-American neighborhoods in NC, historically excluded from water and sewer services, are at higher risk for water contamination from bacteria and lead than neighbors on municipal water. Using the mental models approach to risk communication, we created a mailer promoting testing of unregulated private wells used for drinking water. Content was chosen to address the most common decision-relevant information needs of our target population, according to a 2017 survey. From that data, we focused on several points that were predictive of well water testing within the previous two years: high perceived knowledge of how/where/when to test, a sense of urgency and importance around testing, non-reliance on sensory perceptions to decide when to test, and low perceptions of cost barriers to testing. The resulting postcard used the headlines, “Time to test your well” and “It’s easy”. It concisely provided the recommended testing schedule for health-relevant contaminants and contact information for an easy next step. Common misperceptions (i.e. reliance on senses to know if there is a problem) were countered in a direct and straightforward tone. Pilot testing through in-person interviews confirmed that main messages stood out, that the design was well-received and that the tone was direct and informative. No significant misunderstandings or sources of confusion were uncovered. Concerns focused largely on whether the process would actually be easy. To address these concerns, we revised the postcard to give the direct line of a state employee familiar with our project, who is in regular contact with well owners. This communication will be tested in a randomized controlled trial to see whether it results in changes in perceived knowledge, beliefs and testing behavior.

Title: Monitoring & Iterative Programming for Safe Water in Ethiopia

Author: Noah McColl, charity: water

Submission: Background:charity: water funds rural WASH programs through local implementing organizations in developing countries. In Ethiopia, charity: water has funded 6,765 water supply projects, including 2,679 hand-dug wells with handpumps (HDW). charity: water employs a consultant to inspect 10% of implementer’s projects 3-6 months after construction (spot checks) to ensure quality. As a result of a separate technical assessment which found bacterial presence in 7 of 9 sampled HDWs, 0 of 12 other technologies sampled (mainly shallow boreholes), E. coli testing has been included in HDW spot checks since 2014. Spot check results are discussed with the implementer to improve subsequent programs. Methods & Results:Spot checks, including semi-quantitative E. coli testing (Aquagenx CBTs) and water point observations, were completed on 75 randomly-selected HDWs from 2015-2017. Multivariate logistic regression was used to identify spot check observations associated with higher E. coli levels (>=10MPN/100mL). Variables significantly associated with higher E. coli contamination were sampling in the wet season (OR: 16.3, CI: 4.2-62.4), HDW siting close to a stream (OR: 3.9, CI: 1.1-13.8), and HDWs not having a gate that closed (OR: 4.3, CI: 1.1-16.7).Discussion:HDW spot check results have


facilitated water quality conversations with the implementing partner, to strive for wider access to safe drinking water in our program areas. Associations identified with project siting and importance of a fence and gate empowered partnership decisions to reduce risk that was within our control. Siting HDWs far from streams, however, subsequently resulted in lower well yields, which remains a challenge. Acknowledging other technologies offer higher water quality, we have worked with our implementor to reduce the proportion HDWs in annual grants over time (from 37% in 2014 to 8% in 2018).

Title: Moving from Emergency Response to Sustainability: Water, Sanitation, Hygiene, and Waste Management in Azraq Refugee Camp, Jordan

Authors: Nikki Behnke, The Water Institute at UNC, Ryan Cronk, UNC Water Institute, Brandie Branner, The Water Institute at UNC, Marielle Snel, World Vision International, Jamie Bartram, The Water Institute at UNC

Submission: Over half of the Syrian population has been displaced since 2011. Approximately 600,000 Syrian refugees have fled to neighboring Jordan, and now make up 10 per cent of the Jordanian population. Jordan, one of the world’s most water-poor countries, has limited capacity to provide environmental health services to Syrian refugees. As a result, much of the responsibility for the provision and management of these services falls upon external actors such as international non-governmental organizations (INGOs).Azraq refugee camp opened in 2014, and is the second-most populous Syrian refugee camp in Jordan, with over 30,000 Syrian refugees. World Vision International (WV) is one of the many partners working to provide environmental health services and infrastructure in the camp. We analyzed results from WV monitoring surveys, and complemented this quantitative data with 25 semi-structured interviews with environmental health stakeholders, ranging from waste collectors to camp officials, in order to evaluate the sustainability of related WV programs. This qualitative data gave us a more holistic understanding of management structures, social networks, and other key components of sustainability. Our key findings include: waste separation has become more of a priority since WV began operating the “Green Center” where solid waste is sorted; incentive-based volunteers, who are responsible for sorting solid waste, are concerned about hygiene at work, and have requested soap to wash their hands; INGOs have clearly defined sectors for which they are responsible; WV is responsible for WaSH and waste management. By investigating how different stakeholders interact and share responsibilities, we identify financial, human, and knowledge resource gaps where further investment could help foster long-term sustainability. This study has implications for environmental health services and infrastructure in other humanitarian crises that outlast the emergency stage.

Title: Multiple Community-owned Water Resources Management for Climate Change Adaptation

Author: Samuel Diarra, World Vision International

Submission: With 80% of the population living on less than US$1 per capita per day, the commune of Dah in the San district of Mali is among the poorest in the world. The local economy is based on rainfed agriculture and animal breeding; all strongly dependent of rainfall.Rainfall has been changing substantially over the last 30 years. In the semiarid and sub-humid zones of West Africa, including Mali, recording 12% lower rainfall over the last 60 years and a temperature increase of 0.8 degrees Celsius. Variable temperatures and declining rainfall lead to unpredictable droughts and flooding, posing enormous threats to food security and deficits leading to localized and general food crises. Given the general lack of social and economic infrastructure and widespread extreme and chronic poverty, government, development institutions and populations have to find ways to adapt to these climatic conditions and turn threats into opportunities for greater production.World Vision worked with 18 communities in Dah to improve the ‘Djebe’ pond, a natural rainwater storage, which was seen as the main source of production. Prior to the drought in the early 1970s, this area produced 150 tons of rice and 400 tons of millet. Today, climate change has resulted in a decline of crop yields, primary due to insufficient or prematurely ending rains. This poster describes the resilience plan and its impact on the socio-economic life of these 18 communities. It depicts hydrological changes; the impacts of climate change on water resources; the effect on socio-economic activities; and their efforts to build resilience and adapt productive measures. This poster shows how government and development organizations can support local and regional development with better community organization for the management of water, soil, and environment to boost and diversify production.

Title: Natural and Anthropogenic Determinants of Groundwater Contamination in Kisumu City, Kenya


Authors: Japhet Kanoti, University of Nairobi, Daniel Olago, University of Nairobi, Richard Taylor, University College London

Submission: Groundwater constitute a safe domestic water source in the informal settlements when developed through shallow wells. This study, sponsored by Royal Society and DFID-UK aimed at determining the groundwater chemistry and the factors that contribute to water chemistry changes over time and the implication to groundwater management and human health in Kisumu, Kenya. The physical chemical parameters, such as electrical conductivity, pH, temperature, dissolved oxygen and salinity were measured in the field while the major cations and anions were measured in the laboratory. Rock samples were also collected and analysed using XRF and XRD to determine background levels of the trace elements. The study has revealed high concentrations of iron, aluminum and fluorine in groundwater. Interpretation of hydrochemical data suggests that calcium carbonate dissolution, ion-exchange processes and silicate weathering are responsible for the groundwater chemistry. Anthropogenic activities within the water catchment area and the rock chemistry are the major sources of the anomalously high concentrations of iron and fluoride in groundwater. The high concentration of these elements in groundwater poses a threat to human health. The community should be informed of this threat. Water from these sources can be used for other domestic purposes and not for drinking.

Title: One Size Does Not Fit All: Learnings from a Six-Year Impact Evaluation on Measuring Intermittency, Multiple Source Use, and Other Urban Water Phenomena

Authors: Carina Rosado, Social Impact, Inc., Danae Roumis, Social Impact, Inc., Olga Rostapshova, Social Impact, Inc., John Feighery, mWater

Submission: As SDG and JMP indicators and targets evolve, are we measuring urban water access and use effectively? Global indicators are useful for spurring action, rounding up financial commitments, and establishing benchmarks. An important challenge with the SDG agenda is the need to move beyond water access to also measure availability, quality, and affordability of water services in contexts that include rapidly urbanizing regions. However, important dynamics in urban areas are not always captured by these global indicators – dynamics such as the presence of multiple sources accessible simultaneously to households, the ability to substitute between sources with varying prices and quality, habitual practices to mitigate against chronic intermittency, and others. We advocate for better consideration of these phenomena drawing on key learnings from a six-year impact evaluation in urban Tanzania (Dar es Salaam and Morogoro), funded by the Millennium Challenge Corporation. We will discuss measurement of intermittency in networked water systems, multiple concurrent source use, water quality, substitution between water sources and household water treatment, storage and other coping practices, and other phenomena specific to urban contexts. We draw these insights from a unique dataset collected over several years, including repeated household surveys, in-depth qualitative interviews, gold-standard water quality testing, sensors on household taps, direct observation at water treatment plants, and interviews with a variety of utility staff. We will discuss how our learnings might be applied to programs and research in other urban contexts, and how we might be able to consider these nuances in the context of the new global monitoring indicators for drinking water.

Title: Piloting and Adapting a Behavioral Determinant Questionnaire to Inform Baby WASH Interventions in Eastern Democratic Republic of the Congo (REDUCE Trial)

Authors: Christine Marie George, The Johns Hopkins Bloomberg School of Public Health, Nicole Coglianese, Food for the Hungry, Elizabeth Thomas, Johns Hopkins Bloomberg School of Public Health and Food for the Hungry Partnership funded by USAID, Jamie Perin, Johns Hopkins Bloomberg School of Public Health, Anthony Koomson, Food for the Hungry, Ariel Caldwell, The Johns Hopkins Bloomberg School of Public Health, Geoffrey Arijole Nyakuni, Food for the Hungry, Patrick Mirindi, Food for the Hungry

Submission: Recent findings from large scale studies of WASH interventions focused on the traditional exposure pathways from the F diagram for young children have not shown the expected improvements on diarrheal disease, environmental enteropathy, and child growth. This has highlighted the need for further research identifying the unique exposure pathways to fecal pathogens for susceptible pediatric populations, and WASH interventions tailored to young children extending beyond the standard approach of latrines, handwashing with soap, and household water treatment. The


objective of REDUCE is to identify the exposure pathways to fecal pathogens that are significant contributors to morbidity for young children in the Democratic Republic of the Congo, and to develop and evaluate scalable interventions reducing fecal contamination from these pathways. To achieve this objective we are conducting a cohort study, formative research, and a randomized controlled trial. The cohort study of 400 households with children under 2 years of age is being conducted to identify the household, environmental, and behavioral risk factors for enteric infections, environmental enteropathy, and impaired growth among young children. The formative research is being conducted to understand behaviors and preferences with respect to caregiver hygiene practices, child mouthing behavior, and child health. This includes participant observation, in-depth interviews, and focus group discussions. The findings from the cohort study and qualitative research are being used to develop the REDUCE interventions which are being refined through a pilot study, and evaluated through a randomized controlled trial later this year. During our presentation we will describe the facilitators and barriers to the adoption of interventions promoting protected child play spaces, animal corrals, and safe child feces disposal that were identified through our formative research activities and report on our cohort study findings.

Title: Planning for Uiversal Access to Water in Rural Areas: The Cost Savings of Applying the Supported Self-supply Approach

Authors: Matthias Saladin, Skat Foundation, Sally Sutton

Submission: Millions of people living in low-density settings still are without improved water and sanitation services. Traditionally, most efforts of governments, NGOs and donors have focused on drilling boreholes in relatively concentrated areas and on equipping these with water lifting devices. This approach is not feasible for areas where people live dispersed as its costs would be prohibitvely high. One alternative strategy for service delivery in such areas is to harness the capacities of the private sector and help small and micro-entrepreneurs delivering services directly to target households. Capacity building in the private sector, combined with efforts of standardization and quality control, can empower these local actors to offer products and services to private households. Under this approach, which often is called "Supported Self-supply", the products - typcally low-cost, locally repairable technologies such as the Rope Pump but also options like electrical pumps with solar panels - are purchased, maintained and operated directly by the households, offering a clear and simple management set-up. The authors present results from two UNICEF-funded studies (Zambia, Zimbabwe) which evaluated local initiatives of Supported Self-supply in terms of per-capita costs under different strategies and overall costs for reaching universal coverage. The results show significant costs savings from a government perspective when including a specific policy and strategy of Supported Self-supply, complementing other efforts to reach universal coverage. An important part of the costs savings comes from using more cost-effective technologies, another one from better performance of facilities managed by one household, rather than a group or a community. For the cases of Zambia and Zimbabwe, applying a stategy of combining centralized approaches with Supported Self-Supply offers costs savings of around 400 million USD, compared to a strategy relying on centralized approaches only.

Title: Plasticizers and the Risk of Leaching in BSF Outlet Tubing

Authors: Candice Young-Rojanschi, CAWST, Kit Dashwood

Submission: Plasticizers are chemicals added to plastics to improve flexibility and durability. Plasticizers have shown the ability to migrate from the plastics to water and many are known to be toxic. The BSF is a biological household water treatment technology, with approximately 1 million implemented globally. The V10 BSF, in use since 2012, uses about 0.9 m of flexible plastic tubing for the outlet. During the pause period, water can sit in this tubing for up to 24 hours, providing an opportunity for leaching. Production of the BSF is decentralized, so there is not a single entity overseeing quality control of these devices. Production is local, with local labour and materials. Producers learn about the technology through workshops given by various organizations, or through manuals available online. Producers are encouraged to use food grade tubing, but the realities of the field mean that tubing is often supplied from local markets without identification and are of unknown plastics. This study consisted of testing five different tubes used in BSF construction in Nepal to identify the plastic and plasticizers in the tubes. It was found that two of the five samples contained the diethylhexyl phthalate (DEHP), known to be an endocrine disruptor in animals, while the remaining three contained chlorinated paraffins (CPs), a possible carcinogen. A risk assessment of BSF effluent in tubes containing these plasticizers was conducted and it was found that the levels of CPs consumed by users drinking BSF water would be below guideline


values under all considered scenarios and so not of concern. However, in higher ambient temperatures, the water sitting for more than 24 hours in the tubing containing DEHP would have high levels of DEHP leaching. It is recommended either to be diligent about finding food grade plastics for the tubes used in constructing BSFs, or to recommend that users discard the first 50 mL of water coming from the filter, which was sitting in the tube.

Title: Process Learning on Partnerships: Building Functioning Research and Practice Organizational Relationships

Authors: Darren Saywell, AECOM, Jonny Crocker, University of Washington

Submission: In recent years, implementers and researchers have responded to increasingly strong incentives to work together closely. Donors have begun to place a high value on data, rigor and evidence of impact from development assistance projects. This is seen in policy debates emphasizing value-for-money in foreign assistance programs, and funding tied more clearly to results and performance. As a result, implementing organizations are increasingly collaborating with research partners. Effective partnerships between implementers and researchers require time, an appreciation of preconditions for success, and incremental changes to business as usual. Such arrangements are not without costs (financial and other), but the return on investment and potential to deliver quality outcomes is high. Investments in relationship building between partners, open and frequent communications, a clear understanding of partners’ objectives and non-negotiable requirements, and a mindset of problem solving are important priorities in setting productive implementation science partnerships.We document present process learning from developing a partnership between an implementing organization – Plan International, and a research institute – the Water Institute at the University of North Carolina, and make the case that:•Effective partnerships drive significant returns on investment, but have preconditions for success•Building institutional respect takes time; establishing a partnership early and a long start-up period are advisable•Accountability and research relevancy are increased through shared roles during project design and interpretation of results•Mutual understanding and respect for non-negotiable aspects of partnership is important•Research message development requires regular review meetings with increasing frequency toward the end of a project

Title: Race, Class and WaSH in the Continental United States: A Systematic Review

Authors: David Fuente, University of South Carolina, Anna Boring, University of South Carolina

Submission: A growing concern within low-income communities nationwide is the quality of the potable water being delivered homes via deteriorating water infrastructure. The experience of Flint, Michigan brought this issue to national attention, but communities across the country face similar challenges. Previous research indicates that there is a clear connection between communities with low-income and/or minorities receiving contaminated water due to failing or poorly maintained infrastructure that is out of compliance with federal, state, and local regulations. Additionally, these communities are being required to pay higher rates for access to properly serviced water as well as updates to the physical systems. Lack of clean, potable water in poor communities will have long term sociological and health ramifications requiring additional attention and resources. This paper presents results from a systematic review on water, sanitation, and marginalized communities in the continental United States. Drawing upon literature from the fields of public health, urban planning, sociology, anthropology, and geography, this paper will present the first multi-disciplinary review of scholarship related to WaSH and marginalized communities in the United States.

Title: Reaching the Unreached Populations for WaSH Services in Southern Nepal: Experiences of Wine to Water Nepal

Authors: Guneshwar Prasad Mahato, Wine to Water Nepal, Roshani Karki, Wine to Water Nepal

Submission: This paper draws the experiences of the authors of implementing holistic Water, Sanitation and Hygiene (WASH) programs in southern rural Nepal. Since its establishment in 2015 after devastating earthquake, Wine to Water Nepal (WWN) has become successful to provide clean drinking water, basic sanitation and hygiene awareness services to more than 29,000 populations of 20 villages and more than 6,000 students of 10 schools in Chitwan district. Adopting the programmatic and sustainable WASH service delivery approach, WWN has been collaborating with the Municipalities, local NGOs/ CBOs and Rotary club both in co-funding and social mobilization processes. WWN has adopted 5 pillars of WASH sustainability in all grass root level WASH projects at local level. Within the short period of 3 years after responding


to the earthquake relief works, WWN has become successful on supporting the unserved communities and schools to increase the access to sustainable WASH services and thus supporting the GoN’s target/action on “reaching the unreached”. It has been also supporting to increase the access of population and students to safe water through the water quality improvement from water source to the mouth (HWTS). WWN has followed the bases for reaching the unserved communities by applying various WASH technologies like rain water harvesting, solar powered pumping, dug well improvements and household level water purification systems (Sawyer filters). The US volunteers’ mobilizations have created a unique opportunity of cross-cultural sensitization in communities and WASH awareness in schools. WWN has considered a great importance of using mWater in all field level activities, monitoring and reporting. The program approach of WWN to implement rural water projects has increased the ownership of local bodies in federated Nepal.

Title: Recognising the Needs of the Poor in Small Town WaSH

Authors: Katrina Charles, University of Oxford, Catherine Grasham, Cheryl Doss, Alemseged Aregay

Submission: Urban and rural experiences of poverty differ. Many approaches to measurement of poverty are focused on definitions that are appropriate for rural users: e.g. for WASH, distance to basic water and sanitation facilities. However, these methods of measurements may not adequately reflect urban poverty, where services are present but unaffordable or unreliable. Based on a multidisciplinary study of a small town, Wukro, Ethiopia, the aim of this research was to provide a detailed characterisation of the WASH challenges that the urban poor face, and help identify indicators of urban poverty. The multidisciplinary methodology involves integrating historical and contemporary data. Multiple datasets were fused to support characterisation of urban poverty, and WASH challenges, including HDSS data on household socio-economic indicators (2009 -2017), household WASH surveys (n=2730) and focus group discussions to characterise experiences of the urban poor, including in WASH and utility data on household water consumption.A traditional multidimensional approach to poverty indicates that urban residents experience lower poverty levels that the surrounding rural areas. Urban residents live in brick or rock houses, with most residents (94%) having access to a piped water supply on premises and a sanitation facility (97%). However, despite having piped access, predominantly on premises, water availability has been unreliable which has implications for livelihoods and for the financial sustainability of the utility as utility income fluctuates by a factor of two. The urban poor, who have low educational attainment, face a greater challenge to maintain water access and are more likely to have accessed water from more than one source (including surface water when available), and spent more time collecting water than less poor groups. Lack of water availability affects livelihoods for these groups, which is not reflected in current metrics.

Title: Reflecting on Measurements of Capacity Development in Rural Sanitation and Hygiene

Author: Antoinette Kome, SNV

Submission: Over the past 4 years, SNV has been implementing an integrated rural sanitation and hygiene programme: Sustainable Sanitation and Hygiene for All (SSH4A) across 13 countries. Eight of these countries were funded through a Results based financing (RBF) contract. As part of the contract, the programmes had to provide evidence of results, within 11 result packages over the 4 years. The premise of the SSH4A approach is that sustainable service delivery systems are the basis for sustainable services, and that strengthening the capacities within those systems, is a priority. The concern was this commitment could be eroded under results based funding, unless we were able to link capacity to measurable, quantifiable results and link payments to those. Hence evidence on capacity development was part of a number of results packages.Whereas the methods and indicators are similar to those in other SSH4A programmes, in the RBF funded programmes the results are audited by a third party. With nearly 60 districts in the programme, the implementation of detailed protocols for information on capacity development per district became incredibly complex. Even more challenging was information about the capacity &influence of women, people living with disability, elderly and poorest wealth quintiles across all these areas. Also, some capacity development areas became less relevant over time, such as the "capacity of local agencies to deliver demand creation at at scale". On others, the programme was not able to show much progress. Looking back at this experience, the presentation will reflect about the useful and less useful parts of measuring capacity development at scale, and what it takes to keep measurement meaningful for the people involved, including under and RBF funding.


Title: Reframing the Last Mile: Pathways to Improved Sanitation for Poor and Socio-economically Marginalized Groups in Rural Cambodia

Authors: Allison Salinger, Emory University, Reimar Macaranas, Causal Design, James Dumpert, WaterAid Cambodia

Submission: Background: This study stems from formative work that sought to assess social factors that influence sanitation uptake in rural Cambodia through the lens of collective efficacy and related sub-constructs, social capital and social equity, among others. This study utilizes data from the formative work to identify acceptable and effective pathways for reaching poor and socioeconomically marginalized groups in communities targeted by participatory sanitation approaches such as Community-Led Total Sanitation (CLTS). Methods: Investigators administered 600 household (HH) surveys across four provinces and conducted 19 key informant interviews and 12 focus group discussions across six provinces. The study was commissioned by WaterAid in partnership with Plan International, Emory University, and with support from WSSCC.Results: Government-assigned ID Poor status was strongly and inversely associated with latrine ownership and access but was not associated with social capital. Pro-poor programming, including programs subsidizing latrines, were widely accepted. Other acceptable mechanisms for redistribution of community wealth include intra-village financial assistance for illness or death and collection of funds for roads, canals, or religious ceremonies. Cambodia’s National CLTS Guidelines and the theory of change underlying CLTS suggest that the community would also work together to find solutions for HHs that cannot afford latrines; however, the data demonstrate that this tends not to occur organically despite evidence of collective efficacy. Implications: These findings indicate the need for formal, institutionalized pathways for reaching poor HHs. Few communities reported the presence of formal community groups or associations that could serve to leverage collective efficacy. Existing groups were formed by NGOs or local authorities rather than by communities themselves. Thus, involvement of local authorities and local NGOs is key to reaching the last mile.

Title: Remote Sensing and Environmental Monitoring forImproved RWSS Monitoring

Authors: Miguel Vargas-Ramirez, The World Bank, Sabrina Zimmerman, The World Bank

Submission: Collecting information from Rural Water Systems is a difficult task given remote locations and limited capacity of the water service providers. Maintaining that information regularly updated to be useful for decision making in terms of resources allocation and sector policy development is even a harder task. The recent evolution of digital electronic sensors and wireless communication technologies provides many opportunities in terms of cost reduction and adaptability to the rural context. This session will present the experience and lessons learned of an initial phase of a pilot process in Panama and Colombia in order to establish remote sensing systems in disperse indigenous rural communities in very different contexts, the semi-arid Guajira Peninsula in Colombia and the rainforest of Bocas del Toro in Panama. The systems are designed to collect basic information on water flow and storage level, as well as minimum water quality parameters that can be transmitted via wireless or satellite to improve monitoring and response times contributing to overall sustainability.

Title: Restore Survey: A Routine Evaluation for Community-managed WaSH Programs

Author: Julia Sherry, Water Mission

Submission: Water Mission has long been committed to routinely measuring the objective outputs of our work such as accessibility, safety, and reliability of water and sanitation services. However, behavioral-related outcomes and impacts were only evaluated on an ad hoc basis through rigorous research initiatives. This absence of routine evaluation led to unclear linkages between program activities and intended results, and limited or slow responsiveness in terms of program adaptation.In an effort to address this, Water Mission has developed a routine survey designed to evaluate the outcomes and impacts of our community-managed WASH projects in the following areas:1)Management Skills: Financial, Human Resources, Water System, and Leadership;2)Community Well-being: Material, Social, Emotional, and Spiritual; and3)WASH Behaviors: Handwashing, Water, and Sanitation.The survey is self-enumerated and is conducted on tablets or smartphones, allowing participants to listen and respond to survey statements that have been recorded in the local language at their own pace. As this survey is designed to be used as a program management tool, rather than for research, it is fully functional in an offline field-based setting. This allows data to be collected, synced and analyzed offline and shared with community leaders in the same day. Results can also be analyzed by sub-population, for comparison by


gender, age, household wealth, etc. To ensure this survey tool was accurate and reliable, Water Mission undertook a rigorous multi-phase process for developing, validating, and testing the survey across seven countries (USA, Kenya, Uganda, Peru, Haiti, Indonesia, and Honduras) over the course of two years. This included the collection and analysis of over 1,400 user surveys, 110 focus group discussions, and an extensive literature review.Key aspects of survey development and validation will be presented, as will a demonstration of the survey tool and its field application.

Title: Ritu Study Protocol: A Randomized Controlled Trial on Breaking Down Menstrual Barriers in Bangladesh

Authors: Lidwien Sol, Maastricht University, Kellie Liket, Vera Scholmerich

Submission: Around the time of menarche, the gap in academic achievement and psychosocial health between girls and boys in low and middle income countries substantially widens to the detriment of girls. Girl’s poor ability to manage their Menstrual Health (MH) plays a role in the barriers to education, which is also the case in Bangladesh. This paper presents the protocol for a cluster randomized controlled trial of the impact of a complex intervention facilitating MH in Bangladesh: the Ritu RCT study. 150 schools in a rural district in Bangladesh were randomized into three groups: i) receiving the school program (MHM-friendly sanitation facilities, teachertraining and MH module for the schoolcurriculum); ii) the school program and the household program (parental education and a MH take-home booklet); iii) a control group. The primary beneficiaries are schoolgirls from age 11-15. The program started in 2017 and will last for 3 years. The primary outcomes are academic attainment and psychosocial outcomes of schoolgirls and MH attitudes of parents. We will make use of administrative data, experimental data and survey data. A subsample of 4,172 girls will be surveyed throughout the study, and a subset of 1,000 parents will take Implicit Association Tests on their MH attitudes. Data collection took place at baseline (2017), and planned midline (2019) and endline (2022). We will analyse both the short-term and long-term effects of both treatment arms and in addition, we will conduct cost-effectiveness evaluations and a process evaluation of the entire intervention. This protocol describes the exact set up of the RCT study. Even though MH programs are becoming more popular, there is very limited evidence on such programs. We aim to reduce these knowledge gaps by providing rigorous evidence. Different to most evaluations of public health programs, we evaluate a complex intervention and will include cost-effectiveness analysis for both treatment arms.

Title: Rural Market-based Sanitation Programming: A Global Review and Assessment of Intervention Characteristics, Outcomes, and Program Costs

Authors: Jesse Shapiro, USAID, Rishi Agarwal, FSG, Subhash Chennuri, FSG, Marion Jenkins, University of California Davis

Submission: Market-based sanitation (MBS) interventions, also called Sanitation Marketing, engage with the private sector to develop businesses that sell affordable and appealing hygienic toilets to households. They aim to develop local sanitation markets at scale to ensure sustainable access to appropriate products to support SDG6. While there are some MBS project successes, notably in Asia, many MBS projects have struggled and there is little systematic evidence on what leads to large-scale outcomes, particularly in rural areas. Rural contexts where basic sanitation access is low may pose particular challenges for MBS development―viable business models, availability of sanita on entrepreneurs, and access to customer and business finance, among others.As part of a desk study for USAID/WASHPaLS, we conducted a systematic review of sanitation projects since the 1980s that employed a MBS approach. For each project, we assessed the strategies used to develop the sanitation market, the number of toilets sold, and per toilet program costs where information was available. We present findings on: i) the number and global distribution of MBS projects, ii) funding levels and implementation characteristics, iii) toilets sold and coverage impacts, and iv) costs. Of 107 prima facie MBS projects identified (between 1980 and 2020), 44 single-country projects had scaled to more than 10,000 toilets. Of these, 18 projects actually used a market-based approach by our definition. Estimated program cost per toilet sold for 11 at-scale interventions, selected based on funding data availability, ranged from $0 to $168, with the majority costing between $20 and $50 per toilet. Implications for the timeframe and structure of funding for MBS projects and insights on intervention strategies from the 44 single-country MBS projects achieving the largest scale (>10,000 toilets sold) are discussed.

Title: Sand Dams as a Dry Season Water Supply: Water Quality and Sustainability

Authors: Alison Parker, Cranfield University, Ruth Quinn, Ken Rushton


Submission: Sand dams are concrete dams constructed across seasonal rivers which trap water and sand behind them, providing a water supply into the dry season, which is protected from evaporation and vectors. Over one thousand have been constructed in south east Kenya and other semi-arid regions around the world. This research examines their effectiveness as a dry season water source, looking specifically at their water quality and sustainability into the dry season. The microbiological quality of water both contained in the sand dam via test holes and abstracted from it through covered wells and scoop holes is tested. The water from covered wells was microbiologically of better quality than the scoop holes with median TTC levels of 0/100 mL and 159/100 mL respectively. The water from all the test holes was 0/100mL. This suggests that the water within the dams is of good microbiological quality but it is easily contaminated during abstraction. In addition the conductivity of water from 23% of scoop holes and 26% of covered wells is above the recommended WHO limit. Sanitary surveys also identified areas in which improvement of water sources is needed, for example cracks in the apron. Three sand dams were further selected for water level monitoring in installed piezometers over a 3 month period, from the start of the dry season. Only one dam still contained water after three months. A water balance was subsequently constructed using measurements of evaporation and transmissivity taken during the fieldwork period. This revealed that the dam with the highest water levels was fed additionally by water from the river banks throughout the dry season, whereas the other two dams leaked water into the banks, especially later in the dry season.

Title: Sanitation Coverage in the Limpopo Province of South Africa

Authors: Natasha Potgieter, University of Venda, Afsatou N Traore, University of Venda, Mpumeleo C Rikhotso, University of Venda

Submission: Sanitation facilities are not adequate in many countries including South Africa and in spite of investments in sanitation programmes, the number of people with access to safe sanitation remains low, especially in rural areas. The need for good quality water and adequate sanitation are widely recognized as two essential components of social and economic development because it contributes to the enhancement of human dignity and provides a kind of freedom to people, mainly women and children. The primary objective of this study was to assess the sanitation coverage of rural households in three wards (15, 18 and 19) of the Thulamela Municipality region in Vhembe district, Limpopo of South Africa. In addition 20% of toilet seats were swabbed for microbiological assessment to establish prevalence of pathogenic E. coli strains which could pose a health risk to vulnerable people in the households. Demographic questionnaires were used to assess the study households. A total of 408 households were visited during the study and 136 samples were collected from each ward. A total of 84 (20%) toilet seat swab(s) samples were collected from all three wards for microbiological assessment using Total coliforms and E. coli. counts. An m-PCR protocol was used to determine pathogenic E. coli strains in swab samples. The findings of this study indicated that most of the households had functional VIP (Ventilated improved latrine) latrines. However most of the sanitation facilities required maintenance especially on the superstructures. Some latrines had unstable and collapsing walls while some of the facilities had broken seats and seat covers. Atypical and typical Enteropathogenic E. coli, Enterotoxigenic E. coli and Enterohaemorrhagic E. coli were identified on toilet seats indicating a potential for disease transmission in these households. This study has showed encouraging practices in the use of latrines and the utilization of latrines was satisfactory.

Title: Sanitation Equity in Rural Lowndes County, Alabama

Authors: Brandon Hunter, Duke University, Elizabeth Albright, Duke University School of the Environment, David Schaad, Duke University Civil & Environmental Engineering, Emily Stewart, Duke University Human Rights Center at John Hope Franklin Humanities Institute, Edgard Ngaboyamahina, Duke University Center for WaSH-AID, Catherine Flowers, Alabama Center for Rural Enterprise

Submission: Over recent years, there has been an increase in media and public attention focused directly on the issue of inadequate water and sanitation infrastructure in urban America. However, less awareness has been raised about the human health implications and challenging economic circumstances which result from compromised water and sanitation infrastructure in rural America.Lowndes County, Alabama demonstrates one of the many cases where social and environmental inequalities, including endemic poverty, lack of economic opportunity, and inadequate infrastructure disproportionately affect many communities of color in the rural American South.The inadequate water and sanitation infrastructure of Lowndes County poses many hazardous health risks. The Baylor College of Medicine observed evidence of five tropical diseases, including hookworm (formerly thought to be eradicated in the U.S.), in fecal samples from


residents. In 2014, the Alabama Center for Rural Enterprise (ACRE) partnered with Duke’s Human Rights Center at the Franklin Humanities Institute to address these inadequacies of wastewater treatment infrastructure, which is an economic, racial and environmental injustice deep-rooted particularly in many rural Black communities throughout the country. Through the lens of providing water and sanitation frameworks which incorporate environmental, legal, and economic equity, three interdependent components were examined: the technical engineering sanitation process component, the legal and political framework, and the financial dimensions and implication. A cost-benefit analysis of the most efficient options for low-cost, equitable, individual and clustered wastewater treatment technologies for the Lowndes County, Alabama context will be presented and discussed at the conference.

Title: Sanitation Marketing and Financing: Ladder to Accelerate Sanitation Towards SDG in Katsina State, Nigeria (Case Study)

Authors: Bhawna M Vajpai, UNICEF, Farooq Khan, UNICEF

Submission: DFID supported SHAWN project significantly contributed towards reduction in open defecation practices in Katsina state of Nigeria, and over 1800 villages have been independently certified as Open Defecation Free (ODF). Although 82.7% household are using toilet in project area, out of which 52.1% uses unimproved toilet and 28.2% sanitation facilities falls under the Basic or Limited Sanitation on SDG indicators, and does not match with SDG targets. Only 2.6% population using safely managed sanitation facilities. Poor availability of supply chain for safely managed facilities at local level, deplorable poverty and economic indicators remained an area of constraint for poor progress on safe sanitation. Recognizing the challenge to meet the SDG indicators of safely managed sanitation services to 6 million population of Katsina, Sanitation marketing and financing project was piloted to accelerate access to safely managed toilet, locally known as ‘Smart Toilet’ or ‘Ingantacen Masai’ (in Hauza language). The ‘San Mark’ project adopted two key strategies; Involvement of Toilet Business owners to provide one stop technical solution for smart toilet installation, and Linking households with all possible microfinance options for a range of improved toilets. This paper entails two year of experience in Sanitation marketing and financing, wherein establishes a range of sanitary material supply points for improved smart toilets and helping needy through available financing along with regular promotion campaigns. The results after one years of such arrangement led to construction of 4000 smart toilets, which is 7-fold increase in the rate of safely managed toilets.

Title: Sanitation Slippage: Trends in Rates of Open Defecation in Ethiopia from 2014 to 2016

Authors: Genevieve Kelly, Bloomberg School of Public Health & Carey Business School, Johns Hopkins University, Kellog Schwab, Department of Environmental Health and Engineering, Johns Hopkins Bloomberg School of Public Health, Selamawit Desta, Dept of Population, Family & Reproductive Health, Johns Hopkins Bloomberg School of Public Health, Solomon Shiferaw, Dept of Reproductive Health & Health Service Mgmt, School of Public Health, Addis Ababa University, Natalie G. Exum, Department of Environmental Health and Engineering, Johns Hopkins Bloomberg School of Public Health

Submission: Despite considerable investment from government and development partners progress on sanitation coverage in Ethiopia has been limited. Using data from Performance, Monitoring and Accountability 2020, this study highlights the key findings at the national level with a regional level analysis to understand more localized trends. In 2014 a pit latrine without a slab was the most frequently reported sanitation facility by 54.3% (95% CI: 53.1, 55.4) of the population and this increased to 56.9% (95% CI: 55.8, 58.1) in 2016. This increase was not consistent at the regional level and the greatest change in sanitation coverage was found in the Tigray region where open defecation (OD) increased by 7.3% from 35.0% (95% CI: 32.3, 37.8) in 2014 to 42.3% (95% CI: 39.5, 45.1) in 2016. When Tigray households were stratified by wealth quintile the lowest wealth quintile had increased OD by 18.1% (95% CI: 8.5, 35.2) while to two highest reported no significant change. A concurrent decrease was reported for the lowest wealth quintile with the use of pit latrines without slabs. This trend observed in Tigray suggests a slippage effect in access to sanitation where those using pit latrines without a slab revert back to open defecation practices within a short timeframe. The implications for future sanitation investments will be discussed and whether a minimum standard of latrine is necessary for prevention of reversion to open defecation.

Title: Soak Away Pits Are Moneymakers for Landlords in Abidjan


Authors: Jennifer Marcy, Population Services International, Serge Seiba, PSI Cote d'Ivoire, Claudine Loa, PSI Cote d'Ivoire

Submission: BackgroundAbidjan, Cote d’Ivoire is experiencing unprecedented population growth, and only 33% of the country’s urban population has access to basic sanitation. In the populous Abidjan communes of Yopougon, Attecoube and Abobo, of the 35% of households with a septic tank, 45% frequently experience overflow, thereby contaminating the environment . To avoid overflow, many landlords report having to empty their tanks at least every two months. USAID’s Sanitation Service Delivery Project (SSD) supports local entrepreneurs to develop business solutions that respond to this challenge, including installation of soak pits. Product Description and Business Model:In Abidjan, the average multi-family compound houses 40 people. Many compounds have an existing holding tank or septic tank connected to one or two latrines. The project’s research revealed several frequent underlying causes of overflowing tanks: high cost and low perceived quality of mechanical emptying; the lack of available services/trucks capable of de-sludging compacted fecal matter; and the connection of showers directly to the tanks. Moreover, most landlords lack the space and finances to build new tanks. To respond to this problem, the project developed two affordable, high quality solutions to reduce septic tank overflow and the need for frequent emptying: installation of soak pits lined with cement rings and connected to existing tanks; and redirection of grey water directly into the soak pits.ResultsIn the first quarter of 2018, a cumulative total of 60 soakaway pits were sold and installed in housing compounds at a cost of $330. The customers, who are landlords, estimate that they will save an average of $990 annually, due to reduced frequency of emptying tanks. In Abidjan, adding soak pits to existing tanks allows landlords to save money while improving sanitation conditions for tenants who live in densely populated housing compounds.

Title: Soil Transmitted Helminth Risk Factors in the Mapsan Trial

Authors: Trent Sumner, Georgia Institute of Technology, Jacqueline Knee, Georgia Institute of Technology, Joe Brown, Georgia Institute of Technology

Submission: Soil transmitted helminths (STHs) are parasitic intestinal worms that infect more than a billion people worldwide. Severe STH infections can cause gastro-intestinal distress including blockages, though less severe and even sub-clinical infections can cause stunted growth, delayed cognitive development and anemia. This cross-sectional analysis assesses risk factors of STH infection in children living in low-income, unplanned neighborhoods in Maputo, Mozambique. We collected and analyzed stool and survey data, including water, sanitation, and hygiene, environmental, and socio-demographic data, from 695 children under 4 years old. We used Kato-Katz to analyze stool for STH ova.Infections with Ascaris lumbricoides and Trichuris trichiura were the only common STH infections in our study population. Overall prevalence of having either of those infections was 45% (95% CI 41-.8%), with Trichuris being the most common at 37% (34-41%). Approximately 16% of children were coinfected with Ascaris and Trichuris. Boys and girls had similar levels of infection, though increasing age was a strong predictor of infection; children 2-4 years old were almost three times more likely to have an STH infection than children less than 1 years old, when adjusting for sex, breastfeeding status, education of the caregiver, and household wealth(aRR 2.8, 95% CI 1.8-4.3). Exclusive breastfeeding was associated with decreased risk of STH infection (aRR 0.55 95% CI 0.40-0.70). The condition of the sanitation facilities impacted risk of infection with Ascaris but not Trichuris. Presence of a drophole cover (aRR .68 95%CI .51-.92) or ventpipe (aRR .55 95% CI .30-1.0) was associated with decreased risk of Ascaris. Drophole covers and ventpipes are generally used for fly control, suggesting flies as a potential vector for Ascaris. They are also easy and cheap interventions that could have an important impact on the health of children around latrines.

Title: Strengthening the Enabling Environment for City-wide Inclusive Water and Sanitation: An Evaluative Framework

Authors: Sam Drabble, Water & Sanitation for the Urban Poor, Jonathan Stokes, Water & Sanitation for the Urban Poor, Nerea Ajuriagogeascoa, WSUP

Submission: Progress towards SDG6 is contingent on the development of city-level and national enabling environments, capable of supporting at-scale service provision. Without key enabling factors, water and sanitation utilities and municipalities will not be positioned to deliver services at the scale required, including to the most vulnerable. New monitoring tools are required which respond to this reality by evaluating sector functionality and identifying priority areas for strengthening. WSUP has developed the Urban WASH Sector Functionality Framework (SFF) for this purpose: the SFF comprises individual frameworks for water and sanitation, each with 21 predominantly qualitative indicators across 7


areas: sustainability; commitment; policy/mandates; financial flows; investment planning; capacity; and attitudes/behaviours. The framework expands on the UNICEF WASH-BAT enabling factors categories, and is further grounded in WSUP’s experience of implementing urban WASH programmes in six countries.This poster presentation will give conference participants the opportunity to observe the framework in its entirety, and to learn about its evaluative application. In addition to presenting the framework, we will document the process for national-level assessments, consisting of an initial participant survey followed by a workshop bringing together key stakeholders – ministries, utilities, municipalities, regulators, asset holders and civil society – to finalize scoring through negotiated consensus. We will also detail results from a pilot of the framework involving baseline assessments in six countries – Bangladesh, Ghana, Kenya, Madagascar, Mozambique and Zambia – conducted by Oxford Policy Management; and discuss the implications of these baseline findings for sector-wide system strengthening activities.

Title: Study of the Quality of Water and its Various Types of Utilization in Guédiawaye, Senegal

Authors: Diongue Mayassine, the Institute of Health and Development (ISED), Faculty of Medicine, University Cheikh Anta Diop (UC, Anta TAL DIA, Institute of Health and Development (ISED), Faculty of Medicine, University Cheikh Anta Diop (UCAD), Papa Samba DIEYE, Sanitary District (DS) of Guédiawaye

Submission: Introduction: The high demand and frequency of tap water interruptions contributed to the installation of artisanal water pumps here referred to as "diambar pumps". The objective is to study the quality of water and its various types of utilization in Guédiawaye/Senegal.Methodology: Water quality control, according to WHO standards, was carried out by the National Hygiene Service. A complementary household survey carried out to determine the use of this water, household satisfaction on tap water.Results: For diambar pump water, the mean pH was 6.58 ( 0.71), the mean temperature was 29.04 ° C ( 1.94). The results of samples from diambar pumps indicated: 38.1% had a turbidity higher than the norm, 75% a conductivity higher than optimal and 89.7% had faecal coliforms. The survey showed that: the use of water from diambar pumps was mainly for washing utensils (100%) and for cleaning the house (96.6%); 97.8% of households with diambar pumps had also tap water. Regarding tap water, water outages were frequent (66.7%) while heads of households were dissatisfied with its quality (81.6%).Conclusion: In order to reduce the risks associated with the use of water, there is a need to improve the treatment of water by households, and the quality and accessibility of tap water by the government.Keywords: Quality, use, Water, Diambar pump, Senegal.Keywords: Quality, use, Water, Diambar pump, Senegal

Title: Succeeding at Scale: Developing a Sustainability Strategy for 1,100+ Water Projects in China

Author: Leslie Llado, Splash

Submission: In 2018, Splash completed installation of water filtration systems in every orphanage in China--over 1,100 sites spread across 3.7 million square miles. The completion of this milestone means that 90,000 of China’s most vulnerable children have access to clean water. This has been an unprecedented, nation-wide project, especially for a non-profit in China, requiring close cooperation and support from national and regional government entities. This feat marks a critical step in our efforts to ensure that every child has access to clean water. Splash is now actively working to ensure our exit strategy will be just as successful as our implementation and can be maintained, locally, long after we leave. Strong private sector and government partnerships, data-driven programming, and deep investment in local leadership are all essential to the kind of scale and sustainability we have achieved in China. This presentation will focus on what has worked, what has not, and what is still a work in progress as we map our exit from China. We will highlight the pitfalls we have faced along the way and the approach we are taking to promote sustainability and exit gracefully. We will also discuss the tools that allowed us to scale. This includes the potential ongoing role we see for technology in community building and program implementation, highlighting our use of the Chinese social media application WeChat, for regular maintenance and repair support.

Title: Supported Self-supply as a Key to Reach the Goal “Water forAll” in Africa

Author: Henk Holtslag, SMART Centre group

Submission: ContextThe goal “water for all“ in rural Africa is a challenge since many of unserved live in small


communities. Rural water points with machine drilled boreholes and imported handpumps (India M 2, Afridev, Blue pump) serve 250 people who live less than 500 meters from the water point. With an investment cost (CAPEX) of $6000 the cost per capita is $24. However rural areas in Zambia, Mozambique, etc, have less than 100 people/square km. so using the same technologies is very costly. Support family wells /Self-supplyA solution can be supported Self-supply (support family wells). Shallow wells can be dug by hand and tube wells to 40 m deep can be hand drilled with Rotary jetting or a SHIPO drill. Water can be pumped from 35 m deep with locally produced handpumps like EMAS or Rope pumps so spares are available and affordable. Depending on geology an improved family water source cost $500 to $1500. To make sure water is safe to drink household water filters of $25 can be used. Support would stimulate families to improve their existing well or make a new well. Donors could fund 50% of the cost with the conditions that, a) families invest 50% of the total cost with labour, basic materials, b): share water with neighbours. Compared to communal wells family wells have high functionality as proven in Zambia and Tanzania, (families do maintain). Experience is also that water is shared with 20 to 50 other people, so the cost for a donor for a “SDG6 person” is a 1 time support of $15 to $25 per capita. Other advantages of a family well are increased hygiene (water is nearby), increased food security (life stock, garden irrigation) and income. Building local capacity in production, quality etc. can be arranged via SMART Centres. See www.smartcentrezambia.com and www.smartcentregroup.comConclusionSupported Self-supply has much potential in helping to reach the SDG6.1 and other water related SDGs at a relatively low donor support

Title: Sustainability Indices of Drinking-Water Supply Systems: A Tale from the Town to the Village

Authors: Enovwo Odjegba, Federal University of Agriculture, Abeokuta, Ogun State Southwest Nigeria, Grace Oluwasanya, Federal University of Agriculture, Abeokuta, Ogun State Southwest Nigeria, Olufemi Idowu, Federal University of Agriculture, Abeokuta, Ogun State Southwest Nigeria, Olufunke Shittu, Federal University of Agriculture, Abeokuta, Ogun State Southwest Nigeria

Submission: Water Supply Systems Sustainability Index (WSSI) was designed to assess the sustainability of 194 selected Water Supply Systems (WSS) across three urban and one peri – urban towns, and two rural communities in Ogun State, Southwest, Nigeria. Existing sustainability indices address water, within poverty, water/waste-water infrastructure and water resource management context. However, WSSI as a tool assesses sustainability of drinking-water supply systems using 5 sustainability factors, namely access, reliability, quality, cost and management with respective scoring criteria. WSS were ranked using the WSSI rating as either, Low, Medium, High or Very High Sustainability. Low WSSI rating implies that WSS is not reliable irrespective of seasonal changes, while Medium rating implies that WSS is reliable during a part of the year. High WSSI implies that WSS is reliable and accessible but requires abstraction effort due to absence of plumbing connection to building, while Very High indicates that WSS is reliable, accessible (connected to the building) and water quality is good. Findings show that 66% of the WSS are located in the urban areas, 11% in the peri - urban and 23% in rural areas. WSSI rating for WSS in urban areas are Very high (63%), High (23%) and Medium (9%). For peri – urban, rating shows Very high (48%), High (47%) and Medium (5%); while for rural areas, Very high (62%), High (31%) and Medium (7%). There are no WSS in the Low Sustainability category. Findings suggest that drinking-water supply sources in the study area are generally sustainable. Also, WSS within Medium to High WSSI rating are upgradable by taking appropriate level of actions to move the sources towards the desired sustainability status. Therefore, WSSI may be useful in Integrated Water Resources Management practices, aid decision making in policy formulation and help achieve the relevant Sustainability Development Goal, especially, in low income countries.

Title: The Adequacy of Environmental Health in Emergency Displacement Situations

Authors: Brandie Banner, The Water Institute at UNC-CH, Nikki Behnke, The Water Institute at UNC, Brittany Cooper, The Water Institute at UNC-CH

Submission: In 1997, there were 33.9 million displaced persons. Today, the number of forcibly displaced people has nearly doubled to 65.6 million persons, half of whom are children. Rapid population growth, increasing political instability, and the imminent threat of climate change are likely to increase the magnitude of this crisis globally. Eighty-four percent of displaced persons live in developing countries, placing additional strain on host governments who face infrastructure, food security, and environmental health challenges. The Center for Disease Control and Prevention (CDC) estimates that the mortality rates of displaced persons are more than double those prior to displacement during an emergency. According to the World Health Organization, inadequate environmental conditions account for 13-37% of the global disease burden


globally. In emergencies, environmental health interventions, such the provision of water and sanitation services, are often among the first needs addressed, especially in camps where 40% of the displaced live. However, there is little evidence on the adequacy of environmental health services during the emergency phase of a displacement situation. We conducted a systematic review on environmental health conditions and services in emergencies lasting longer than six months. Peer-reviewed and grey literature from 400 studies were reviewed for information on environmental health in emergencies. We analyzed environmental health conditions, interventions, exposures, and health outcomes to identify opportunities to improve environmental health conditions of displaced persons in emergencies. Many of the services provided in displaced person settlements were not meeting the Sphere Standards. Additionally, most interventions were designed to address diarrheal disease from inadequate water, sanitation, and hygiene services, with few interventions focusing on environmental-related respiratory illnesses, skin conditions, and vector transmitted diseases

Title: The Applicability of Decentralized Sanitation Systems in Refugee Settlements

Authors: August Frechette, Duke University, Jeffrey Hallowell, Biomass Controls, Jeffrey Piascik, Biomass Controls

Submission: Situation:The treatment of human excreta in refugee communities is essential to preventing the spread of waterborne illnesses, such as cholera. Unfortunately, the people living in these communities are often lacking access to proper sanitation solutions due to their temporary living conditions.Solution:Since 2015, Biomass Controls has been working to develop and deploy decentralized sanitation systems to communities in need. Biomass Controls’ technology portfolio includes a Reinvented Toilet technology, created in partnership with Duke University, and a Biogenic Refinery. The Reinvented Toilet accomplishes the onsite treatment and reuse of liquid excreta and volume reduction of solid excreta as an end-to-end sanitation system. The Reinvented Toilet has been deployed to two test sites in India, and one test site in Africa. The Biogenic Refinery provides a decentralized, community-scale, portable treatment unit for safe treatment of human excreta, including menstrual hygiene products. The Biogenic Refinery has been deployed to three test sites in India, and one test site in Alaska. Both technologies are capable of addressing the specific requirements of communities that are too difficult or expensive to reach with conventional treatment solutions. Further, these technologies can be implemented individually, or together, providing complete non-sewered sanitation systems to communities in need. To ensure that communities without access to a constant electrical source are able to utilize these technologies, Biomass Controls is working to ensure that both technologies are energy positive.

Title: The Economics of Centralized Fecal Sludge Treatment Using Supercritical Water Oxidation

Authors: Marc Deshusses, Duke University, Kobe Nagar, Duke University, Shelly Eisen Livneh, Duke University

Submission: Since 2013, we have worked a supercritical water oxidation (SCWO) system to treat the fecal waste produced by roughly 1000-1200 persons daily. We have conducted experiments treating concentrated slurries of sewage sludge and dog feces since 2016. The process is relatively simple. After moderate preheating, the waste slurry is mixed with supercritical water (~600 C) and air (which serves as oxidant), which rapidly brings the waste undergoing treatment to supercritical conditions (~400 C, 240 bars). Under these conditions, all organics are rapidly (i.e., few seconds) oxidized to CO2. After the reaction, heat recovery follows in a 39 m long heat exchanger. Experiments were conducted with various fecal wastes and sludges and served to assess the economic feasibility of this novel process. Typically, over 99.9% removal of COD, over 98% removal of total nitrogen and total phosphorous are observed and clean water is produced. Nitrogen in the waste is converted to harmless nitrogen gas whereas the phosphorous precipitates as inert mineral, which can be reused. We recently conducted in-depth process optimization, which included determining the sensitivity of the size of the unit on CAPEX, as well as optimizing the process for energy recovery. This led to the design of two systems, one that can handle the fecal waste of 6000 users per day, and one that can handle the fecal waste of 30,000 users per day. Our current efforts are directed towards the commercialization of the technology. This includes defining use case scenarios, developing cost-revenues estimates for systems with various treatment capacities, and developing detailed CAPEX and OPEX estimates. The results show that SCWO can be a net energy producing facility when sized for 25,000 people and more, and that CAPEX and OPEX are cost-competitive with other technologies. Detailed process economics, as well as simplified business cases will be presented and discussed at the conference.

Title: The Impact of Antecedent Growth Conditions and Primary Effluent Derived Test Organisms in Point-of-use


Disinfection Testing

Authors: Robert Coleman, UNC, AJ Karon, Sharon Jiang, Eric Mai, Mark Sobsey, University of North Carolina

Submission: Chlorine disinfection has been readily accepted worldwide as a useful means for treating household drinking water for decades. However, little research has been done to rigorously assess how chlorine disinfection contrasts among different types of fecal indicator bacteria in varying preparation and growth conditions. While the objective of point-of-use (POU) testing is to provide a rigorous and conservative environment for the testing of devices, the use of lab strain organisms grown in ideal conditions may not be representative of organisms found in fecally contaminated natural waters. These experiments assessed variation in disinfection efficacy of free chlorine on lab strain S. typhimurium LT2 and R. terrigena grown in ideal and antecedent growth conditions as well as comparing lab strain organisms to environmentally derived Salmonella spp., E. coli, and Total Coliforms. We compared disinfection in buffered test waters spiked with lab strains grown at 20°C and 37°C in both high and low nutrient conditions. Results demonstrated that the CT needed to achieve effective chlorine disinfection of at least a 6log10 target reduction varied greatly, changes in temperature growth conditions impacted predicted microbial reductions by as much 30 min*mg/L for S. typhimurium and R. terrigena. Low nutrient and low temperature growth conditions displayed consistently greater resistance to disinfection and thus higher 6log10 CT values ranging from 0.4 – 180 min*mg/L for low glucose M9 Minimal Media and 0.1x TSB as compared to test organisms grown in standard 1x TSB at 37°C. Furthermore, presumptive total E. coli, Coliforms, and Salmonella spp. derived from primary effluent displayed predicted CT values of 43, 95, and 414 min*mg/L respectively for a target 4log10 reduction. All primary effluent derived organisms displayed orders of magnitude higher CT values for 2log10, 4log10, and 6log10 reduction targets as compared ideal growth lab strain S. typhimurium and R. terrigena.

Title: The Invisible Crisis: The Law of Water Affordability and Accessibility

Authors: Hannah Paton, The Center for Water Security and Cooperation, Alexandra Campbell-Ferrari, The Center for Water Security and Cooperation, Luke Wilson, The Center for Water Security and Cooperation

Submission: Water and sanitation affordability in the United States is the invisible crisis of our time. Little data exists on the circumstances and prevalence of water shutoffs in the United States, including the role and impact of laws on the affordability and accessibility of water and sewer services. Law plays an essential role in determining who provides these services, who regulates these services, the tariffs charged, the restrictions on and circumstances of water shutoffs and the financial consequences of water shutoffs. This absence of data allows water unaffordability to persist, making shutoffs a constant threat for those in poverty. While protective laws exist in other sectors like food and energy, low-income rate assistance programs for drinking water either do not exist or are insufficient to meet needs.The Center for Water Security and Cooperation published an innovative report examining the state-, county-, and municipal-level laws impacting water affordability and accessibility in the State of Maryland. The report illustrates the disparate impact of the law on affordability and accessibility from zip code to zip code. While most municipalities allow for water to be shut off for bill nonpayment, few offer low-income rate assistance programs, impacting residents who cannot pay versus those who do not pay. At the same time, laws threaten the financial sustainability of the infrastructure by allowing payments from water users to be included in the general fund rather than reinvested into water infrastructure. Our report concludes that while laws and policies are often at the root of the problem, they are also the tool for generating greater equity.SDG 6 requires “universal and equitable access to safe and affordable drinking water for all” by 2030. It is only with a clear and comprehensive understanding of the impact of our laws on water affordability that we can create the enabling conditions for ensuring a healthy and equitable water future.

Title: The Sanipath Exposure Assessment Tool: An Integrated Project Management, Data Analysis, and Visualization Platform

Authors: Suraja Raj, Emory University, Yuke Wang, Emory University, Aaron White, EpiTech Consultants, Nishant Kishore, EpiTech Consultants, Casey Siesel, Emory University

Submission: The SaniPath Tool examines human exposure to fecal contamination in low-resource urban settings. It provides guidance for primary data collection, automated exposure analysis, and results visualizations that are accessible to people from a range of scientific backgrounds. This poster describes the development of a tool that allows users to plan a SaniPath deployment, set up and manage mobile data collection, analyze results, and generate reports. The tool guides


users through steps of implementing the tool–from planning to data analysis. The tool is composed of a project planning and management interface, mobile data collection and data repository, and a data analysis and visualization dashboard. The tool can be customized to suit context-specific data collection needs. The SaniPath Tool is built on an integrated system of existing open source technologies and a tailored project management interface. It guides users through project configuration, training, and deployment by automating the customization and analysis processes. The Tool also uses an open source mobile data collection software, KoboToolbox (KT), which provides the backbone of data collection and storage. Data is collected via downloadable mobile forms used on Android devices and is uploaded to KT, which is paired with Enketo for online web data entry or editing. The tool automatically retrieves data from KT and generates exposure assessments for each study site and exposure pathway. Users can view and analyze the collected data, access data visualizations, and create a draft final report. The services are deployed on Amazon Web Services (AWS) infrastructure and backups are stored in S3 buckets for redundant data storage. The SaniPath Tool is an innovative use of mHealth in the WASH sector and can serve as an example of how open source software can be used to synthesize and analyze complex information and encourage public health evidence-based decision-making about urban sanitation investmen

Title: Thermal Treatment for Menstrual Hygiene Sanitary Products: A Study of Optimal Conditions and Results

Authors: Claire Welling, Duke University, Sonia Grego, Duke University, Myles Elledge, Biomass Controls, Jeffrey Piascik, Biomass Controls, Jeffrey Hallowell, Biomass Controls, Taylor Myers, Brian Stoner, Duke University

Submission: An estimated 121 million women in India dispose of 112,000 tons of menstrual hygiene waste annually. Lack of appropriate and safe disposal mechanisms may lead to unhygienic menstrual hygiene management (MGM). Improper disposal practices pose numerous health and environmental hazards. Thermal treatment is a valid option, but done improperly, yields incomplete pathogen treatment, waste reduction, and generates health harming air emissions. Emissions from three thermal treatment options were compared, including a commercially-available electronic-plate burner incinerator, a simple ceramic pot burner, and a Biomass Controls Thermal Treatment Prototype (TTP). The electronic-plate burner incinerator was easy to use but produced excessive particulate matter (PM). The ceramic pot burners were difficult to ignite and often vented in a manner that exposed users to emissions. The Biomass Controls TTP was easy to use, produced manageable emissions, and is vented outdoors, minimizing the effects of PM emissions. Fundamental analysis of the combustion of a menstrual pad was performed using micro-combustion calorimetry, providing information necessary to accurately model fuel burning and design improved combustors that minimize emissions. Ongoing optimization of the Biomass Controls TTP across varied pad loadings, pad types, moisture content, air flow, and co-fuel scenarios will be pursued. This will result in a compact and hygienic pad disposal method to reach the typically neglected MHM sector.

Title: Towards Elimination of Open Defecation in Madagascar

Authors: Carole Abourached, Medical Care Development International, Rija Fanomeza, Medical Care Development International, Jeremia Rakotozafy, Medical Care Development International, Rado Randrianavoson, Medical Care Development International, Fano Randriamanantsoa, Medical Care Development International, Clara Rudholm, WSSCC, Asu Durmus, WSSCC Lee Yellott, Medical Care Development International, Megan Perry, Medical Care Development International

Submission: In Madagascar in 2010, an estimated 42% of the population practiced open defecation while 80% of the people lacked access to improved sanitation facilities. To address such need and with funding from the Global Sanitation Fund (GSF) established by the Water Supply and Sanitation Collaborative Council (WSSCC), Medical Care Development International (MCDI) has been promoting behavior change to improve hygiene practices and management of human excreta in Madagascar. The program started in 2010 and is expected to reach a total of 10.9 million people by the end of 2020. It aims to eliminate open defecation through Community-Led Total Sanitation (CLTS) with "zero subsidy" for latrine construction along with sanitation marketing. The program objectives are to 1) increase the number of people a) living in Open Defecation Free (ODF) environments, b) using improved sanitation infrastructure and c) washing their hands with soap; 2) engage institutional and private actors in sanitation promotion; and 3) disseminate successful approaches and innovative methods of improving sanitation and hygiene. As of December 2017, 16,295 villages reached ODF status, and gained access to improved sanitation and handwashing facilities. The program has become an important catalyst for creating a local, regional, and national movement to eradicate open defecation. Due to this success, MCDI staff in


Madagascar have provided peer-to-peer support to other GSF-funded programs in Togo, Uganda and Benin. Key achievements, reasons for success, and lessons learned will be presented.

Title: Transgender-inclusive Sanitation: Insights from South Asia

Author: Andrés Hueso, WaterAid

Submission: Building on the recognition of sanitation as a human right, the Sustainable Development Goals made it a priority to ensure everyone has access to adequate and equitable sanitation and hygiene by 2030, leaving no one behind. The needs and requirements of transgender people, however, have so far been neglected. When using public, community or institutional toilets, transgender people tend to face exclusion, verbal harassment and physical abuse. This presentation provides insights from pioneering initiatives in South Asia to include transgender people in sanitation. It first introduces some of the histories and identities of transgender communities in the region. It presents three case studies, based on literature review and interviews, of transgender inclusive sanitation experiences in India and Nepal. Finally, it suggests ways for the sector to become more transgender-inclusive, underlining that context and consultation with transgender people is the key to ensuring their inclusion and determining the best solutions for each setting. For example, although in some contexts a separate third gender block might be an appropriate solution for public toilets, in others the appropriate way forward might be an additional gender-neutral toilet cubicle, while in still other spaces, neither may be an appropriate, safe or desirable option. In all instances; 1) understanding the terminology; 2) avoiding further stigmatisation or exposure to vulnerability; and 3) considering sanitation within the overall experiences of someone’s life and reality are essential rules for ensuring transgender inclusion in WASH.

Title: Understanding Latrine Use in Rural India Using the Risks, Attitudes, Norms, Abilities and Self-Regulation (RANAS) Approach

Authors: Hans-Joachim Mosler, EAWAG, Max Friedrich, Eawag, Arundati Muralidharan, WaterAid India, Tejaswi Balasundaram, WaterAid India

Submission: Open defecation is a major reason for stunting in children. In India, the Swachh Bharat Mission (SBM) has given impetus to sanitation in the country more than ever before, with the explicit agenda to make India open defecation free by 2nd of October 2019. While the Mission has been very successful in boosting latrine coverage, actual latrine use remains low in many areas of the country. The aim of this study was to develop low-cost and scalable behaviour change interventions to promote latrine use in rural India. This case study was conducted among 2328 households in rural Karnataka, India. We used the risks, attitudes, norms, abilities and self-regulation (RANAS) approach to gain a systematic understanding of the drivers and barriers steering latrine use and to develop interventions accordingly. Data were collected through standardized, quantitative face-to-face interviews and through spot-check observations of the household latrine. In addition, qualitative in-depth interviews were conducted. The findings of this study revealed that latrine use was predominantly driven by the mind sets and beliefs of participants. In a regression model, the psycho-social factors postulated in the RANAS model, explained latrine use very well (R-square = .74). Positive attitudes towards open defecation (negative correlation), perception of others’ behaviour (descriptive norm), perception that latrine use was right whereas open defecation was wrong (personal norm) and respondent’s awareness of his or her goal to use the latrine (action control) were the strongest predictors of latrine use. This was mostly in line with qualitative findings. In order to effectively change behaviour towards latrine use, the interventions have to target these behavioural factors. We present detailed suggestions for interventions, presently under evaluation in a cluster-randomized controlled trial.

Title: User Dynamics for Resource Recovery and Water Reuse in on-site Sanitation

Author: Myles Elledge, Biomass Controls

Submission: The world has grown urban, as more people live in cities than in rural communities. By 2050, 70 percent of the world’s population, some 6.4 billion people, are expected to live in towns and cities. Cities of the future will experience difficulties in managing scarce and unreliable water supplies. New solutions are needed that increase the efficiency of urban water systems, and deploy new sustainable solutions. Future water systems will need to apply technologies for water reuse and recycling, and advance use of technologies to generate energy and nutrients from wastewater. Given


water constraints and the water stress found in many locations, solutions for recycling wastewater for reuse are gaining attention. As water recycling technologies become increasingly available, the question of end-user attitudes towards and acceptance of reused waste water remains. This question is particularly important because understanding the acceptance of waste water for different reuse applications provides feedback for the development of technologies and helps inform social marketing strategies, which target users’ most prevalent barriers to adoption. This presentation draws upon projects under the Reinvent the Toilet program, aimed at onsite human waste treatment. Drawing on a series of technology adoption studies, the presentation will share findings on knowledge, attitudes, beliefs and preferences surrounding reused water. The session will draw from baseline survey research from Coimbatore, India at women's dormitory factory setting, and with male and female community toilet block users in Durban, South Africa. Observations from varied demographics and social groups are broadly positive about the practice of treated and recycled water for flush water, and are more nuanced for other body wash or household use purposes. This presentation adds important field insights to what is a limited literature on consumer water reuse.

Title: Using Integrated Community Approaches to Promote and Sustain WaSH Results

Authors: N'Tji dit Tiémoko Coulibaly, Save the Children International, Renuka Bery, Save the Childdren

Submission: Background: USAID’s Nutrition and Hygiene project (PNH) uses an integrated WASH approach to improve the nutritional status of the most vulnerable population: pregnant women and children under age 2 in Sikasso Region, Mali.Description of InterventionSectoral integration with a strong WASH component focuses on advocacy, community mobilization and strengthened governance. The project has cultivated a strong cadre of community actors (WASH and village coordination committees and nutrition groups) that use social behavior change and social marketing to improve nutritional status. Results/Lessons LearnedVillage leaders and WASH committees are engaging communities. They advocate for integrating nutrition and WASH efforts into community and then district action plans with a budget line for WASH. PNH supported over 200 villages (reaching 200,000+ people) participating in CLTS are ODF certified. A new post-ODF strategy--the national Clean Community Competition--seeks to anchor WASH gains and prevent recidivism.During nutrition group sessions, mother leaders orient members on improved practices to enhance nutritional status and motivate them to try these practices—e.g. using a latrine/potty, washing hands with soap before touching food, saving for water point repairs, beautifying community with regular environmental clean-up days. Since the project started, most families now have latrines with a cement slab (98.5%) constructed by project-trained local masons and most use latrines regularly. Handwashing stations increased from 8% to 77%.The most visible changes stem from sanitation efforts. Men note that their villages are cleaner and families spend less money on health center visits for diarrheal disease and malnutrition. Children under 5 use potties and teenagers organize village cleaning efforts. WASH committees have at least 30% female members and in many villages women lead the activities.

Title: Using Metrics to Influence Government and the Private Sector, and Achieve Increased Functionality of Rural Water Schemes - The Case of Dera Woreda, Ethiopia

Authors: Peter Lochery, CARE, Adugnaw Tadesse, CARE Ethiopia, Abebaw Kebede, CARE Ethiopia

Submission: When appropriately assessed along with other contextual information and matched with country priorities, metrics can help to illuminate a path forward that is more nuanced than investments focused on new infrastructure.Access to safe water in rural Ethiopia has substantially increased over the last decade through the support of government and donors. While the resources and effort devoted to additional infrastructure have been laudable, the functionality of rural water schemes has received much less attention. Functionality rates in South Gondar Zone, for example, have languished in the 60-70 per cent range until recently. Two factors, weak governance and poor access to spare parts, were considered to be key challenges but there were limited data to substantiate their importance. With the support of CARE, the zonal and regional governments of Amhara State carried out an inventory of water schemes in South Gondar Zone (covering approximately 1.4m people) collecting technical, governance and functionality data, and a study of spare parts availability in five zones of Amhara (covering 11.1m people). The results confirmed a functionality rate of 70 percent across South Gondar, an unmet demand for spare parts and a lack of timely maintenance. The data convinced the Dera woreda administration to engage with communities, strengthening governance, and support repairs and maintenance to 588 water schemes (about 50 per cent of the total schemes in Dera) over the period 2016-2018. Similarly, local retailers appreciated the business opportunity and marketed spares to meet the unmet demand. The functionality


rate in Dera increased from 75 percent in 2016 to 82 percent in 2018.

Title: Using Water Quality Data to Approximate Quantitative Risk forSmall Drinking Water Systems in Atlantic Canada

Authors: Kaycie Lane, Dalhousie University, Graham Gagnon, Dalhousie University

Submission: In many small Atlantic Canadian communities, water quality management and safety have been largely reactionary: measuring water quality parameters at the tap and comparing to known regulatory standards to determine compliance. However, in the past ten years, there has neither been an improvement in the water quality community members are receiving, nor a reduction in the prevalence of drinking water advisories being issued: this is true for privately owned water supplies, small municipal water supplies and First Nations. A proactive, risk-based water management tool, such as a water safety plan (WSP), is needed to improve the safety and security of drinking water in these communities. This study explores the potential added benefits of using a WSP in Atlantic Canadian communities and explores alternative methods of calculating and understanding risk and probability of occurrence using existing water quality data. A WSP tool for use in small municipal communities, was used to assess qualitative risk within a community by assigning a risk score of “high”, “moderate” or “low” to identified hazards for different treatment processes. Data from SCADA systems and log books were collected to calculate probability of occurrence as a measure of risk for comparison to the qualitative results. Individual water quality parameters were fit to probability density functions and probability of occurrence was calculated using compliance recommendations for water operations. In general, the qualitative method overestimated risk for most of the small systems but underestimated risk in some communities. This study also determined the same distribution cannot be fit universally to a water quality parameter; the best fit distribution depends on sample size and the type of water system. Qualitative risk determined by a WSP tool and quantitative risk from probability of occurrence calculations did not always align, indicating perceived and actual risk differ in small communities

Title: Virus Removal By Biofilms in Ceramic Pot Filters

Authors: Mona soliman, Delft University of Technology (TU Delft), Doris Van Halem, Delft University of Technology (TU Delft), Gertjan medema, Delft University of Technology (TU Delft)

Submission: Ceramic pot filters are household water treatment systems aiming to improve the microbial quality of drinking water. They are regarded as a cost-effective promising technology for users with no access to safe or treated drinking water, such as in rural areas. The broad base of consumers leads to variability in treated water quality. Therefore, the current study investigates virus removal, using bacteriophages MS2 as a model virus, by biofilms grown on ceramic filter disks surface due to filtration of water varying in nutrients content. The results show that after five weeks of biofilm formation, an increased nutrient feed level yielded an increased MS2 LRV. For the High nutrient (HN) disks, this was already observed in week 4, while in the low nutrient (LN) and medium nutrient (MN) fed disks, week 4 showed no significant increase in MS2 LRV. Stabilizing biofilm conditions for LN & MN disks for additional five months had a negligible impact on MS2 LRV. However, cleaning the surface by scrubbing lead partial or total loss in achieved LRVs, yet faster recovery of biofilms and log reductions associated with it. Overall, sorption capacity of “same” matured biofilm is limited, regardless of its age. MS2 –LRV ranged between 0.8-1.2 logs for LN, 1.6 -1.8 logs for MN and 1.7-2.7 logs biofilms, with exception to change in feed conditions for the latter. Preliminary results show that for HN filters the LRV can peak up to 5±1 LRV, although promising, this result was only obtained under specific conditions, and the mechanisms behind it need further investigation.

Title: WaSH and Oral Cholera Vaccine – Opportunity and Challenge for Symbiosis

Authors: W. Abdullah Brooks, JHU Bloomberg School of Public Health, Anne Ballard, JHU Bloomberg School of Public Health, Melissa Roskosky, JHU Bloomberg School of Public Health, Moise Ngwa, JHU Bloomberg School of Public Health, Peggy Adamo, JHU Bloomberg School of Public Health, David Sack, JHU Bloomberg School of Public Health

Submission: BackgroundCholera is endemic in Uganda, occurring annually during rainy seasons, but localised to hotspots in border districts, fishing villages, farming communities, refugee camps and internally displaced persons. In January 2018, national and regional representatives of the Uganda MOH, Water Ministry and partners developed a plan for combined oral cholera vaccine (OCV) and Water, Sanitation and Hygiene (WASH) rollout in four targeted western districts, and which


WASH interventions have been problematic. ObjectivesTo identify and correct challenges to WASH interventions in order to support targeted OCV use.MethodsAn open discussion was used to list, describe and then provide solutions to prior challenges implementing WASH, and how these could be solved in hotspots, including fishing landing sites/markets, targeted for OCV rollout. ResultsTwo WASH limitations were emphasised, hand washing stations and latrines. Hand washing stations not serviced with soap or water went unused. Some latrines were built in poor soil that collapsed shortly after construction. Logistics for resupplying handwashing stations, and resources for improving latrine construction were discussed. Local attitudes were also addressed.ConclusionsIn cholera hotspots, while OCV can reduce transmission, sustainable WASH interventions for waste disposal and handwashing are essential, as is behaviour change, to achieve cholera elimination.

Title: Water Scarcity in the Middle East: The Role of Water Conservation Schemes

Author: Marielle Snel, World Vision International

Submission: Water shortage has become an increasingly difficult problem to manage in the Middle East. More than 5% of the world's population live in a region where the demand for water exceeds its supply. The imbalance between supply and demand, along with persisting issues such as climate change and exponential population growth, has made reflecting on water reuse a necessary method for conserving water. Water conservation through WASH (Water, sanitation and hygiene) schemes is a critical element which includes policies, strategies and activities that are made to sustainably manage the natural resource fresh water, to protect the water environment, and to meet the current and future human demand. Population, household size, and growth and affluence all affect how much water is used. Factors such as climate change have increased pressures on natural water resources. This verbal presentation would focus on a number of case studies around World Vision’s (WV) water conservation schemes in the Middle East with a focus on water conservation in ground water resources (Iraq), utilising group water resources (Afghanistan) and communication and education outreach (Jordan and Lebanon). As a means of analyzing these WV water conservation schemes, a focus is placed on quantitative data gathered from 10 semi-structured interviews around these water conservation schemes in each of the noted countries. These results have been placed in case study format. Some of the key findings include the important on undertaken practical low cost appropriate water schemes that communities can own and maintain, a focus on improved water management practices that reduce the use and enhance the beneficial use of water for generations to come.

Title: Water Scarcity: Delhi Water Outlook By 2030

Author: Nasiruddin Nasir, WASH Professional

Submission: Escalating water scarcity, that imposes critical threat to the sustainability of the one of the most vibrant city and national capital of India - Delhi. The dependency on the only lifeline water source -Yamuna River, has brought the situation of collapsing of the waterbody challenging the governance associated with sustainable water supply and wastewater management. The democratic socio-political milieu of Delhi is changing rapidly around water and sanitation issues, while the climate change phenomenon is aggravating the pressure to oblige ensuring equitable access to safe drinking water and sustainable water resource management and sustainability of the city. In human rights context, establishing Delhi Water Outlook by 2030 will help strategic positioning of city’s water governance and sustainability. The paper will scientifically analyse the scale, magnitude and trend of water scarcity in Delhi highlighting key sustainable water governance issues and its impact on socio-political milieu around imbedding human rights perspective in pursuit of SDG-6, 2030.The contents supported by recent case studies from the field both in well off and low-income communities. Methodology & Result: the paper will follow case based methods. The Delhi Water Outlook by 2030 will establish strategic positioning of city’s water governance and sustainability.

Title: Water, Sanitation and Hygiene and Infection Prevention and Control Conditions and Practices: The Status of Health Care Facilities in Karamoja and West Nile Sub-Regions of Uganda

Authors: Habib Yakubu, Emory University, Rollins School of Public Health, Center for Global Safe WASH, Lindsay Denny, Emory University, Rollins School of Public Health, Center for Global Safe WASH, Yuke Wang, Emory University, Christine Moe, Emory University, Fred Owera-Odom, Care International in Uganda, Constance Bwire, Makerere University School of


Public Health, Department of Disease Control and Environmental Health, Richard Mugambe, Makerere University School of Public Health, Department of Disease Control and Environmental Health Visa Tuominen, UNICEF Uganda,

Submission: Improving water, sanitation and hygiene (WASH) and infection prevention and control (IPC) conditions and practices in healthcare facilities (HCFs) can reduce the spread of healthcare-associated infections. However, there is little data on WASH and IPC conditions to inform planning and prioritizing interventions to improve quality of healthcare. The goal of this assessment was to provide evidence to inform interventions and advocacy for WASH and IPC in Uganda.In August-October 2017, the WASH conditions assessment tool (WASHCon) was deployed in 139 HCFs in Uganda. We assessed 40 HCFs in the Karamoja region and 99 HCFs in the West Nile region. The WASHCon tool assesses WASH and IPC conditions using surveys with the HCF director, observation of key wards, water sample collection and analysis. The WASHCon tool provides a systematic method of data collection to inform WASH and IPC interventions.In Karamoja, only 15% of the HCFs provided basic water supply services, 21% of the water samples tested positive for E. coli, 3% provided basic sanitation services, and no HCF provided basic healthcare waste management service. In addition only 6% of the HCFs had a functional WASH/IPC committee, and only 50% reported providing IPC training for staff each year. In West Nile, 16% of the HCFs provided basic water supply service, 51% of the water samples tested positive for E. coli, 7% provided basic sanitation service, 1% provided basic hand hygiene service, and 2% provided basic health care waste management services. Furthermore, only 41% of the HCFs had a functional WASH/IPC committee and 5% reported providing IPC training for staff each year. The major reason given for the poor services was inadequate budget for staff training and infrastructureOverall, none of the HCFs surveyed in both regions provided basic WASH and IPC services. The results of this assessment are being used to plan interventions, starting with the HCFs that had the poorest WASH and IPC services.

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