New System Brings Safe Water at Low Cost to Individual Third World Households Can Save Millions of Children’s Lives

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(Sally Cowal, Vice President of Population Services International, and Eric Mintz, M.D., CDC epidemiologist, are available for interviews by telephone or in person [Ms. Cowal in Washington, DC, Dr. Mintz in Atlanta] Please call 703-820-2244 to schedule time.)

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The newly developed Safe Water System (SWS), using diluted bleach and safe containers, is bringing clean water to poor people around the world for just pennies a month per person, without huge water projects costing millions of dollars, says Population Services International (PSI).

“The worst aspect of dirty water is that it gives diarrheal diseases to children, some 4 to 5 billion episodes of diarrhea yearly that cause 2.2 million child deaths under the age of five,” says Sally Cowal, Vice President of PSI, a non-profit organization headquartered in Washington D.C that is marketing the Safe Water System in the developing world.

“We saw an unexpected and dramatic drop in diarrhea cases that has transformed a very poor and rural community where we first introduced the SWS,” says Philip Makutsa, Manager of the WASEH and Nyanza Healthy Water Projects for CARE International in Kenya. “Before the SWS, most villagers in this community were struggling just to meet their basic survival needs. They accepted this new system rapidly, and overall, they have become much more healthy and productive.”

“The SWS provides women in the developing world with the means to ensure safe water for her family on her own,” says Eugene J. Gangarosa, MD, Professor Emeritus at Emory University’s Rollins School of Public Health and a former scientist at the U.S. Centers for Disease Control and Prevention (CDC). “It’s a low-tech solution that brings dramatically high results, and it’s simple and inexpensive enough to be extended to every family now without safe water.”

The CDC developed the Safe Water System in partnership with the Pan American Health Organization/World Health Organization. It is based on a dilute sodium hypochlorite solution, or bleach, ranging from 0.4 to 1 percent in strength which is then mixed into unsafe water. This method kills harmful microbes, including those that cause diarrhea.

The CDC says that the SWS has no adverse health affects. “Water treated with this solution does have a slight taste, but if the mixture is done correctly, it will taste like tap water,” says Robert Quick, M.D., a CDC epidemiologist involved in the development of the new method. “We teach people that the slight whiff of chlorine is a signal that the water is safe to drink.”

PSI, the CDC and UNICEF (United Nations Children’s Fund) will make a joint presentation of the Safe Water System to the upcoming 3rd World Water Forum, to be held in Kyoto, Japan March 16-23. The organizations will also describe opportunities to expand to the program to 20 or more nations in the coming years, and will seek partners to expand to those countries. Extensive pilot programs are currently underway in 16 countries in Asia, Africa and Latin America.

“We want to demonstrate to the 3rd World Water Forum that the Safe Water System is a simple, affordable method that can be used throughout the developing world, in both urban and rural settings, for all those without safe water, and can save millions of young lives,” says Ms. Cowal. “Simply put, the diluted bleach solution, sold in bottles, is added to unsafe water in measured proportions, then the treated water is kept free of contamination by being stored in specially designed vessels.”

“Comprehensive testing in six countries has demonstrated that the Safe Water System cut the diarrhea rate by approximately 50 percent in households where it is used,” says Dr. Quick. “The SWS is proving to be everything we thought it could be.”

The SWS can also prevent the waterborne transmission of hepatitis A, typhoid fever and some parasitic infections. In addition, by promoting hygiene with the SWS, impetigo, a skin infection that is generally caused by bacteria and affects children, can be prevented.

“More than one billion people still lack access to safe water, despite billions of dollars spent on water infrastructure in the developing world,” says Eric Mintz, MD, Chief of the CDC’s Diarrheal Disease Epidemiology Section, also involved in the development of the new method. “With capital tight for huge new projects around the world, the SWS provides immediate help to people who have little reasonable prospect of safe water otherwise.”

The CDC developed the Safe Water System in the 1990s as a low-cost alternative to these capital-intensive projects. The Safe Water System utilizes:

  • Point-of-use treatment of contaminated water using low-cost dilute bleach that is manufactured locally and sold for 15-30 cents (U.S.) per family for a monthly supply, which kills nearly all microbes in 20 minutes;
  • Safe water storage in containers with a narrow mouth, lid and, ideally, a spigot, to prevent recontamination, which is common in the developing world even in places with modern water systems, when people fail to wash their hands before dipping them into household water.
  • Behavior change techniques, including education, social marketing, community mobilization, communication and motivational interviewing to increase awareness of the link between contaminated water and disease and the benefits of safe water and good hygiene.

“The SWS grew out of CDC experiences in the Latin American cholera epidemic of the early 1990s,” says Dr. Quick. “The CDC did a number of studies of outbreaks, and over and over, we saw that dirty water was responsible. Either the ground water was polluted or people drank contaminated surface water. Even in big cities, we saw that many people took their water from crumbling or leaking piped water systems, so that the water was polluted by the time these urban residents used it.”

Dr. Quick said that although ministries of health conducted campaigns during the cholera epidemic to advise people that their water should be boiled, few did so, because of either the time or the expense of fuel involved.

The CDC designed the safe water system for populations that must obtain their water from the following sources:

  • Surface water sources such as rivers or lakes;
  • Shallow groundwater that is potentially contaminated, particularly open shallow wells;
  • Piped systems in which the water is inadequately treated or pipes are cracked, allowing contaminants to enter the system;
  • Piped water systems in which intermittent flow requires households to store water
  • Water vendors whose source of water is not safe or whose tanker or storage tank is not likely to be clean.

Many people in cities make clandestine connections to urban water systems. They will dig down to water pipes and punch holes in them to access water, which allows sewage to enter the system.

The CDC/PSI’s model encourages the private sector to produce the bleach solution and proper containers, and looks to governments for support. The CDC also relies on national governments to certify the bleach product as safe and correctly formulated.

“The CDC firmly believes that people should pay for this product rather than getting it free, because they will value it more and will therefore be more likely to use it,” says Dr. Mintz. “In Zambia alone, PSI has sold a million bottles of the chlorine disinfectant each of the last two years.”

People generally buy the solution at the times of highest risk, usually during the rainy season. Families may buy two bottles of bleach disinfectant a year to get them through these periods.

The CDC has also issued a manual that it gives to other groups interested in starting a safe water program. The Massachusetts Institute of Technology, for example, has started working with local non-government organizations in Nepal to introduce the safe water system there, while the World Health Organization has begun a program in Laos.

In 2001, PSI sold almost two million bottles of the SWS solution in two countries. In terms of “person years of protection,” a figure based on the number of bottles of safe water solution necessary to disinfect the drinking water of one person for one year, these sales translate into 1.1 million person years of protection. Assuming an average of three diarrhea episodes per year, and a 30-50 percent reduction attributable to safe water use, this translates into 1-3 million diarrhea episodes prevented annually.

“If used correctly, we think the SWS can offer higher rates of protection than 50 percent, but that is the proven figure for now,” Dr. Quick says.

Two other main routes of infection are contaminated hands and food. Correct hand washing, building latrines and keeping them clean, and leftover food handling are valuable steps households can take to prevent infection. Breastfeeding infants is also very effective, both in preventing infection and in providing babies with extremely important nutrients, such as vitamin A, that fight infection.

Examples – Zambia, Kenya and India

In poor neighborhoods of Zambia, families rely on contaminated shallow wells for their water. Consequently, children have high rates of diarrhea, which is a leading cause of death. Each year during the rainy season, the risk of cholera threatens everyone.

In 1998, PSI, with its organization in Zambia, the Society for Family Health, began a SWS field trial in one town, followed by a pilot test-marketing project in three sites located in different parts of the country. Following this successful pilot, the social marketing campaign has expanded to all provinces of Zambia.

PSI produces the hypochlorite disinfectant locally, using appropriate technology and utilizing the brand name CLORIN. The other three aspects of the campaign in Zambia included:

  • Promotion of the use of locally available plastic 2.5-liter, 5-liter, and 20-liter jerry cans for water storage;
  • Social marketing of CLORIN;
  • CDC safe water storage vessel, a 20-liter vessel with a spigot.

Radio ads, billboards, and peer educators performing in markets teach people about Clorin and how to store the water treated with it. During each of the past two years, more than one million bottles of Clorin have been sold in Zambia.

The CDC did a project evaluation by randomly selecting a total of 166 intervention households and 94 control households. Active diarrhea surveillance was conducted weekly, water was tested for chlorine residuals biweekly, and a follow-up survey was conducted. Intervention households exhibited high compliance: 97 percent reported using disinfectant and between 72 percent and 95 percent had measurable total chlorine residuals in their water. The percentage of intervention households storing water safely increased from 48 percent to 89 percent. Escherichia coli contamination – a flag for fecal contamination that indicates a whole range of diarrhea-causing microbes may be present – — of stored water was detected in a lower percentage of intervention households than control households. Residents of intervention households had diarrhea rates that were 48 percent of the rates among the control households.

In Kenya, CARE International worked with the CDC to introduce the SWS in pilot projects in the province of Nyanza.

“Our testing, carried out with the CDC, showed a 58 percent reduction in diarrhea in families using the SWS,” says Mr. Makutsa. “In another community we also operated a sanitation project, the results were even more dramatic, a 72 percent reduction in diarrhea.”

PSI is now working with CARE and the CDC to bring the system to the entire nation. CARE is managing SWS projects in 72 communities in which 42,000 people are using the system.

“We didn’t expect the magnitude of how quickly people in rural areas would accept this new system – in one region, 33 percent of the families were using it after just three weeks of marketing,” says Mr. Makutsa.

Another example comes from India, where PSI and CDC worked with the World Health Organization (WHO). PSI developed the Safewat brand name and logo for India’s sodium hypochlorite disinfectant, produced locally by a private sector manufacturer. PSI also arranged for the manufacture of 20-liter CDC-designed vessels for water storage, also with the brand name Safewat.

PSI is currently collaborating with the WHO, UNICEF, the Delhi municipal government and a local health institute to develop a household water intervention model for poor neighborhoods of west Delhi. One hundred community “change agents” – all women – have been trained to convey hygiene and sanitation messages through door-to-door house calls, to conduct Safewat SWS dosage demonstrations and to promote the benefits of the Safewat SWS. Safewat is available at retail outlets throughout the project communities.

While investigators believe that the ultimate solution to the problem of lack of access to safe water is piped treated water to every home, they recognize that this will cost hundreds of billions of dollars and will take decades to accomplish. The Safe Water System, as exemplified by the Clorin project, gives families the means to make their water safe for as long as they need to wait.

The SWS is currently being utilized in full national programs in Madagascar Malawi, Rwanda and Zambia,, and in regional programs in Afghanistan, Ecuador, Haiti, India, Kenya, Laos, Nepal, Pakistan, Peru, Tanzania, Uganda.

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