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As a 2010 earthquake and cholera response project, in 2013–2014, an international non-governmental organization, working with local organizations, installed water systems in two Haitian communities. In 2016, 2 years after installation, we conducted a mixed-methods evaluation to assess sustained effectiveness, including 20 infrastructure assessments, 199 household surveys, water quality testing, 30 key informant interviews, and financial analysis of two water committee records. One of 14 (7.1%) installed kiosks were functional during the evaluation, with 42–60% of survey respondents near installed sources reporting using system water for drinking. No household water sample had detectable chlorine residual and non-detectable E. coli, except when household water treatment was reported. Informants expressed appreciation for the project, and discussed difficulties with operations, maintenance, and community engagement. Revenue was initially sufficient for operations and maintenance, although not sustainable because lack of trust led to poor quality service and then lack of payment. While the functional kiosks did provide water to some residents, overall project sustained effectiveness was not reached due to operational and maintenance issues, and lack of governance and community engagement. We recommend future implementers of small-scale water systems in complex contexts like Haiti plan for the technical and social components necessary for sustained effectiveness.

Results highlight that locally-manufactured ceramic water filters from different factories have high variability in V. cholerae removal efficacy, and silver disinfection is the most critical mechanism to remove V. cholerae from drinking water.

Water, sanitation, and hygiene (WASH) interventions prevent and control disease in humanitarian response. To inform future funding and policy priorities, WASH 'gaps' were gathered from 220 focus group discussions with people affected by crisis and WASH practitioners, 246 global survey respondents, and 614 documents. After extraction, 2,888 (48%) gaps from direct feedback and 3,151 (52%) from literature were categorized. People affected by crises primarily listed "services gaps", including need for water, sanitation, solid waste disposal, and hygiene items. Global survey respondents primarily listed "mechanism gaps" to provide services, including collaboration, WASH staffing expertise, and community engagement. Literature highlighted gaps in health (but not other) WASH intervention impacts. Overall, people affected by crises wanted the what (services), responders wanted the how (to provide), and researchers wanted the why (health impacts). Our research suggests need for renewed focus on basic WASH services, collaboration across stakeholders, and research on WASH impacts beyond health.

Initial recommendations for surface disinfection to prevent SARS-CoV-2 transmission were developed using previous evidence from potential surrogates. To the best of our knowledge, no appropriate surrogate for SARS-CoV-2 has been identified or confirmed for chlorine and antimicrobial surface disinfection. We completed a study to evaluate the efficacy of two hypothesized antimicrobial surfaces, and four chlorine solutions on nonporous and porous surfaces, against SARS-CoV-2 and three potential SARS-CoV-2 surrogates [coronavirus mouse hepatitis virus (MHV) and bacteriophages Phi6 and MS2], to identify a BSL-1 or BSL-2 virus to use in future studies. We found SARS-CoV-2 can be reduced >4 log10 on porous and nonporous surfaces within 30 s upon exposure to 0.5% NaOCl. The results indicate coronavirus MHV-GFP is inactivated faster than SARS-CoV-2 (MHV-GFP >= 6.08 log(10);SARS-CoV-2 = 0.66 log(10) at 30 s with 0.05% NaOCl on steel) and MS2 is inactivated more slowly. Phi6 is inactivated like SARS-CoV-2, and we propose Phi6 as a slightly conservative surrogate for SARS-CoV-2 chlorine disinfection. Additionally, disinfection of bacteriophages on wood was challenging, and exposure to antimicrobial surfaces had no disinfection efficacy as tested. We recommend using 0.5% chlorine on surfaces for a minimum of 30 s of contact to disinfect SARS-CoV-2 and recommend additional research on Phi6 disinfection with varied surfaces and conditions.

Monitoring water, sanitation, and hygiene programs in cholera outbreaks is critical to improve humanitarian response. The objective of this research was to evaluate, and improve, WASH in cholera monitoring tools currently used in northeast Nigeria. We collected 723 forms from 2019 from three form types, combined them into one database of 980 activities, and stratified data by form type, response, implementing organization, activity, month/day, and geographical area. We conducted seven key informant interviews (KIIs) with monitoring tool users and decision-makers. Data irregularities (including in design, collection, and entry) led to an inability to meaningfully analyze monitoring forms. In KIIs, eight themes emerged: ease of use of current tools, improvement in monitoring over time, lack of access to data, need for training, inconsistent reporting practices, need for modification of current questions, need for the addition of new questions, and connectivity issues. Although informants reported monitoring helped organizations identify gaps during the response, the scarcity and inconsistency of the reported data make it difficult to draw any conclusions about program effectiveness, accountability in humanitarian response, or to make recommendations for improving programming. To improve monitoring, we recommend refining data collection by increasing the quantity of data reported, data consistency, and data relevancy. HIGHLIGHTS Monitoring helped reduce response gaps and improve coverage by allowing organizations to adjust implementation strategies and coordinate with other TWiG members.; Unclear and undefined data collection processes and ambiguous questions in the monitoring forms led to inconsistent data collection.; The scarcity and inconsistency of the reported data made it difficult to draw any conclusions about program effectiveness and accountability.

Ceramic filters for household water treatment can improve water quality and reduce diarrheal disease. Hydraulic performance is critical for quality control and user acceptability, and hydraulic models have previously been developed and tested with experimental full-scale filters. As filters are cumbersome, there is interest in using disks instead of filters in laboratory efficacy studies. To assess the validity of disk use, we collected experimental volume from three sets of full-scale frustum-shaped filters and matching disks with different burn-out material sieve sizes and firing temperatures. We compared the experimental and fitted data by calibrating hydraulic conductivities from filters and disks. Hydraulic conductivities increased with larger burn-out material and higher firing temperatures but were comparable between filters and disks (2.00-6.15 × 10-7m·s-1 and 2.69-6.32 × 10-7m·s-1, respectively). We found that previously described hydraulic models successfully predicted cumulative volumes for filters and disks with rRMSE ranging from 2.1 to 9.6% (filters) and 3.4 to 4.7% (disks). The error increased slightly (rRMSE: 5.0-15%) when predicting hydraulic parameters for filters from the hydraulic conductivity of disks. Our results validate a method to predict full-scale filter hydraulic performance from hydraulic conductivity of disks and can be used to simplify and increase testing capacity, resulting in higher quality, more acceptable filters that improve household drinking water quality.

Globally, cholera epidemics continue to challenge disease control. Although mass campaigns covering large populations are commonly used to control cholera, spatial targeting of case households and their radius is emerging as a potentially efficient strategy. We did a Scoping Review to investigate the effectiveness of interventions delivered through case-area targeted intervention, its optimal spatiotemporal scale, and its effectiveness in reducing transmission. 53 articles were retrieved. We found that antibiotic chemoprophylaxis, point-of-use water treatment, and hygiene promotion can rapidly reduce household transmission, and single-dose vaccination can extend the duration of protection within the radius of households. Evidence supports a high-risk spatiotemporal zone of 100 m around case households, for 7 days. Two evaluations separately showed reductions in household transmission when targeting case households, and in size and duration of case clusters when targeting radii. Although case-area targeted intervention shows promise for outbreak control, it is critically dependent on early detection capacity and requires prospective evaluation of intervention packages.

Cholera outbreaks primarily occur in areas lacking adequate water, sanitation, and hygiene (WASH), and infection can cause severe dehydration and death. As individuals living near cholera cases are more likely to contract cholera, case-area targeted interventions (CATI), where a response team visits case and neighbor households and conducts WASH and/or epidemiological interventions, are increasingly implemented to interrupt cholera transmission. As part of a multi-pronged evaluation on whether CATIs reduce cholera transmission, we compared two organizations’ standard operating procedures (SOPs) with information from key informant interviews with 26 staff at national/headquarters and field levels who implemented CATIs in Nigeria in 2021. While organizations generally adhered to SOPs during implementation, deviations related to accessing case household and neighbor household selection were made due to incomplete line lists, high population density, and insufficient staffing and materials. We recommend reducing the CATI radius, providing more explicit context-specific guidance in SOPs, adopting more measures to ensure sufficient staffing and supplies, improving surveillance and data management, and strengthening risk communication and community engagement. The qualitative results herein will inform future quantitative analysis to provide recommendations for overall CATI implementation in future cholera responses in fragile contexts.

HIGHLIGHTS • 89 surface disinfection efficacy studies were synthesized and data made available • Experimental procedures and disinfection efficacies exhibit dramatic variability • Target chlorine concentration-times were determined for 6 relevant pathogens • Improvements in consistency, reproducibility, and reporting are needed, Background Infectious diseases can be transmitted via fomites (contaminated surfaces/objects); disinfection can interrupt this transmission route. However, disinfection guidelines for low-resource outbreak settings are inconsistent and not evidence-based. Methods A systematic review of surface disinfection efficacy studies was conducted to inform low-resource outbreak guideline development. Due to variation in experimental procedures, outcomes were synthesized in a narrative summary focusing on chlorine-based disinfection against seven pathogens with potential to produce outbreaks in low-resource settings (Mycobacterium tuberculosis, Vibrio cholerae, Salmonella spp., hepatitis A virus, rotavirus, norovirus, Ebola virus). Results Data were extracted from 89 laboratory studies and made available, including 20 studies on relevant pathogens used in combination with surrogate data to determine minimum target concentration × time (“CT”) factors. Stainless steel (68%) and chlorine-based disinfectants (56%) were most commonly tested. No consistent trend was seen in the influence of chlorine concentration and exposure time on disinfection efficacy. Disinfectant application mode; soil load; and surface type were frequently identified as influential factors in included studies. Conclusions This review highlights that surface disinfection efficacy estimates are strongly influenced by each study's experimental conditions. We therefore recommend laboratory testing to be followed by field-based testing/monitoring to ensure effectiveness is achieved in situ.

Disinfecting surfaces with chlorine is commonly conducted in cholera outbreaks to prevent ongoing fomite-based transmission, yet evidence gaps have led to contradictory guidance. In this study, we tested the efficacy of spraying and wiping chlorine on five representatives non-porous and five porous surfaces to remove Vibrio cholerae. In total, 120 disinfection tests were run in replicate on carriers inoculated with 1.02 × 107–1.73 × 108V. cholerae CFU/cm2. Surfaces disinfected by spraying 0.2% chlorine had >3 log reduction value (LRV) on 7/10 and 9/10 surfaces at 1 and 10 min, respectively; and 2.0% chlorine on 9/10 and 10/10 surfaces at 1 and 10 min, respectively. Surfaces disinfected by wiping 0.2% chlorine had >3 LRV on 3/10 and 7/10 surfaces at 1 and 10 min, respectively; and 2.0% chlorine on 8/10 surfaces at 1 and 10 min. We found no significant differences between chlorine types (p < 0.05), higher reductions with spraying compared to wiping (p = 0.001), and lower reductions on porous compared to non-porous surfaces (p = 0.006 spraying and p < 0.001 wiping). Our results support using 0.2% chlorine sprayed on all surfaces, or wiped on most non-heavily soiled surfaces, and a 2.0% concentration on contaminated porous surfaces; and emphasize surfaces must be visibly wetted to achieve disinfection.

Rainwater harvesting (RWH) provides household water supply to rural and peri-urban populations that do not have access to centralised water services. The climate in south-west Uganda is particularly well suited to RWH due to bi-annual rainy seasons, which allows for the collection of rainwater to occur over two periods throughout the year. Water quality from RWH, however, depends on how well risk of contamination (ROC), from catchment to consumption, is managed. Using a mixed-methods approach, we assessed the maintenance practices and water quality of 20 RWH installations in Uganda in the dry and rainy seasons. Both domestic and institutional RWH systems were assessed. Sanitary surveys, site inspections, key informant interviews and physiochemical and bacteriological tests were conducted to identify the factors that have an impact on water quality. Water quality test results were compared to guidelines recommended by the World Health Organisation (WHO). We looked at measures that can reduce the ROC across the RWH system. We found that water quality at 75% of the sites met WHO standards. At these sites, end-users reported that they cleaned systems at least twice a year. Where training on system maintenance had been carried out, end-users reported more regular cleaning and maintenance of systems. Sanitary surveys highlighted an absence of first-flush or pre-filtration as the most prevalent ROC. Overall, we found that both access to technical specialists and capacity-building activities led to well-maintained RWH systems that provide acceptable water quality at both a household and community level.

Water trucking is a commonly implemented, but severely under-researched, drinking water supply intervention in humanitarian response. To fill this research gap, we conducted three mixed-methods water trucking program evaluations in the Democratic Republic of the Congo and Bangladesh, including interviews, water point observations, household surveys, focus groups, and water quality testing. Results indicated that the programs had complex implementation structures involving multiple agencies and limited infrastructure to properly collect, treat, and deliver water. All programs met queueing time and distance indicators, did not meet water quantity indicators, and inconsistently met water quality indicators. Free chlorine residual (FCR) declined through the water chain, and household water Escherichia coli concentrations were associated with household FCR, receiving behavior change messages, storage container type, and distance from the distribution point. Users appreciated water trucking, especially compared to previous water sources, and expressed desires for increased quantity, improved quality, and consistent delivery. If water trucking programs are implemented, it is recommended to have the financial resources to install sanitary collection and distribution infrastructure, establish a management team of all implementation partners, ensure sufficient water quantity is delivered, ensure recommended FCR levels at distribution points, monitor FCR throughout distribution, and complete behavior change communication activities about the program and safe water storage with users.

Water, sanitation, and hygiene (WASH) interventions provide dignity and prevent disease transmission. Sanitary facility provision (e.g., latrines) is a key WASH priority in all phases of humanitarian response. Currently, there are evidence gaps on field effectiveness of sanitation approaches, particularly in protracted crises. Thus, we conducted a qualitative and quantitative evaluation of sanitation approaches in internally displaced persons (IDP) camps in Myanmar. We conducted 36 focus group discussions, 65 household surveys, and 32 key informant interviews in Rakhine and Kachin states; results were analyzed qualitatively. We found family-shared, gender-segregated latrines were the preferred approach. Acceptance was a result of gender segregation, followed by lighting, state of repair, cleanliness, design, and distance from household. Contextual factors influencing sanitation approach development and acceptance were cultural and religious beliefs, community cohesion, camp size, livelihood access, land ownership and availability, and responding agency type. Overall, sanitation approaches generally met IDP needs; however, access was limited for children, the elderly, and people with special needs (including persons with disabilities). We recommend implementers of latrine programs in protracted contexts conduct community consultations, consider gender segregation, be flexible in considering context-specific solutions, prioritize access and dignity, and be inclusive of vulnerable groups.

To understand how water, sanitation, and hygiene (WASH) coordination leads to humanitarian response outcomes, we conducted a nine-month mixed-method evaluation in three humanitarian contexts (Cox’s Bazar Bangladesh, Democratic Republic of Congo, and Yemen) varying in terms of humanitarian and WASH response and coordination. We completed 93 key informant interviews, 157 online surveys, and monthly activity reports with National Coordination Platform (NCP) staff and partners. We identified a key set of NCP tools, activities, and products that assisted partners in consistently reaching humanitarian WASH outcomes of “making strategic decisions” and “identifying/reducing gaps in the response”, and partially reaching “defining metrics for Monitoring and Evaluation”, “completing Monitoring and Evaluation and evaluating quality”, and “obtaining funding”. Key contextual factors enabling outcomes were stable staff; cooperation with partners; context-specific tools; and, incorporating the humanitarian-development nexus. One activity, three outcomes (“building capacity”, “strengthening relationships”, and “long-term planning”), and two enabling conditions were added into a pre-existing Theory of Change. This revised Theory of Change is being used to improve NCP strategies, including the Minimum Requirements, and ultimately, benefit affected populations.

Objective To implement and measure the effects of a multi-level multi-sectoral social behavior change (SBC) intervention in Agago District of Northern Uganda and to determine the potential for scale-up. Intervention Compare the Nutrition Impact and Positive Practice (NIPP) approach to a NIPP+ approach. The NIPP approach involves nutrition education and SBC, whereas the NIPP+ adds agricultural inputs, training, and tools to support improved farm and water quality practices. The intervention effect will be measured through lower levels of aflatoxin in grain, lower water contamination, and improved knowledge on nutrition and health. Design This is a three-arm cluster-randomized controlled superiority trial (cRCT). The study arms include the following: group 1: NIPP; group 2: NIPP+, and group 3: control. Groups 1 and 2 will receive a 12-week intervention (NIPP or NIPP+) with active monitoring and longitudinal follow-up at 2, 6, and 12 months post-intervention. Additionally, an in-depth process and performance evaluation of each intervention arm will be undertaken using quantitative and qualitative methods. A total of 60 clusters from 5 subcounties of the Agago district will be randomly selected, and 15 households per cluster will be recruited using specific inclusion/exclusion criteria for a total of 900 households (300/arm). Respondents for the qualitative portion will be purposely selected. Analysis We will collect data from all participants at 3 time points: baseline, endline, and 12 months post-intervention. The analysis will utilize intent-to-treat (ITT) using the initial randomization of the treatment arms to determine the overall impact of having the NIPP vs. NIPP+ vs. control. Mixed effects models will be used to determine the role of time-variant and invariant individual household, and community characteristics, as well as measures of exposure and integration on key outcome indicators. A difference-in-difference analysis (baseline/endline, baseline/12 months post-intervention, endline/12 months post-intervention) will also be used to triangulate findings. Trial registration NCT04209569. One Nutrition in Complex Environments (ONCE) Registered 24 December 2019

The Sawyer PointOne™ household hollow fiber membrane filter (PointOne) efficaciously removes microbiological indicators in the laboratory, and is increasingly considered for emergency response. To our knowledge, PointOne effectiveness in emergencies had not been evaluated. In South Sudan, 773 PointOnes were distributed. For 13 months after distribution, household surveys were completed quarterly, water quality testing was conducted monthly, and post-mortem analysis was completed at study midline to assess acceptability, effectiveness, and membrane fouling, respectively. Recipients found PointOnes acceptable, with high rates of demonstrated correct use (97–100%) and correct backflushing (96–100%). PointOnes effectively reduced thermotolerant coliforms for four months. When surface water use increased, effectiveness dropped, with 38% of filtrate samples contaminated. After backflushing filters with 0.2% chlorine solution, effectiveness improved; however, 5–38% of PointOne filtrate samples remained contaminated over subsequent months. Irreversible fouling was documented during post-mortem analysis. These results highlight that while PointOnes can improve household water quality within an emergency, PointOnes can foul within 4–6 months of use, depending on influent water quality. It is recommended that future PointOne distributions include continuous monitoring and an appropriate cleaning regime, based on influent water quality, to ensure continued performance. Further research on source water quality impacts on PointOne performance is recommended.

During outbreaks, contaminated surfaces can contribute to the spread of cholera; as such, surface disinfection with chlorine is widely recommended. However, confirmation of surface disinfec...

Background Provision of safe water, sanitation, and hygiene (WASH) to affected populations in humanitarian emergencies is necessary for dignity and communicable disease control. Additional evidence on WASH interventions is needed in humanitarian settings. Between 2008 and 2019, we completed six multi-country, mixed-methods effectiveness studies in humanitarian response on six different WASH interventions. In each evaluation, we conducted: key informant interviews; water point observations and water quality testing; household surveys with recipients, including survey and water quality testing; focus group discussions; and/or, secondary data analysis. The research questions were: “What is the effectiveness of [intervention] in reducing the risk of diarrhea/cholera transmission; and, what programmatic factors lead to higher effectiveness?” Discussion In all six multi-country, mixed-methods evaluations, policy-relevant outcomes were obtained. We found, in our individual research results, that: interventions could reduce the risk of disease in humanitarian contexts; this reduction of risk did not always occur, as there were large ranges in effectiveness; and, implementation factors were crucial to intervention effectiveness. When collaboratively reviewing our research process across evaluations, we found strategies for successfully conducting this research included: 1) working with partners to identify and evaluate programs; 2) rapidly obtaining approvals to deploy; and, 3) conducting research methodologies consistently. Personal connections, in-person communication, trust, and experience working together were key factors for success in identifying partners for evaluation. Successes in evaluation deployment occurred with flexibility, patience, commitment of adequate time, and understanding of processes; although we note access and security concerns in insecure contexts precluded deployment. Consistent and robust protocols, flexibility, and a consistent researcher on the ground in each context allowed for methodological consistency and high-quality results. Conclusions In conclusion, we have found multi-country, mixed-methods results to be one crucial piece of the WASH evidence base in humanitarian contexts. This is particularly because evaluations of reductions in risk from real-world programming are policy-relevant, and are directly used to improve programming. In future, we need to flexibly work with donors, agencies, institutions, responders, local governments, local responders, and beneficiaries to design safe and ethical research protocols to answer questions related to WASH interventions effectiveness in humanitarian response, and, improve WASH programming.

Fecal indicator bacteria (FIB) values are widely used to assess microbial contamination in drinking water and to advance the modeling of infectious disease risks. The membrane filtration (MF) testing technique for FIB is widely adapted for use in low- and middle-income countries (LMICs). We conducted a systematic literature review on the use of MF-based FIB data in LMICs and summarized statistical methods from 172 articles. We then applied the commonly used statistical methods from the review on publicly available datasets to illustrate how data analysis methods affect FIB results and interpretation. Our findings indicate that standard methods for processing samples are not widely reported, the selection of statistical tests is rarely justified, and, depending on the application, statistical methods can change risk perception and present misleading results. These results raise concerns about the validity of FIB data collection, analysis, and presentation in LMICs. To improve evidence quality, we propose a FIB data reporting checklist to use as a reminder for researchers and practitioners.

Jerricans are commonly used to store household drinking water. However, biofilms can grow on jerrican surfaces and contaminate water. To investigate mechanisms to inhibit biofilm growth, 72 5 L jerricans containing E. coli-spiked water were incubated for 10 weeks in the laboratory. Jerricans were stratified by: water treatment with chlorine; turbidity; and, regular cleaning with NaOCl, rocks, sand, NaOCl/rocks, and NaOCl/sand. At study end, surface E. coli was enumerated and biofilms imaged using epifluorescence microscopy; free chlorine residual was tested regularly. We found biofilms grew rapidly in jerricans (presence confirmed in 3 weeks), and chlorine demand within jerricans increased over time as FCR decreased from 1.16 to 0.59 mg L−1 over the course of the study in 5 NTU treated waters. Biofilm growth was significantly inhibited by water treatment with chlorine (p = 0.03), and was inhibited by cleaning with NaOCl or NaOCl/rocks. Cleaning with rocks increased surface roughness, which promotes biofilm growth. These results highlight the need for research on locally-appropriate cleaning methods and/or alternatives (e.g. replacement, biofilm-resistant surfaces) to ensure jerricans provide safe storage of drinking water.

Hollow-fiber membrane filters (HFMFs) for household water treatment (HWT) can efficaciously remove disease-causing organisms in laboratory settings. However, lower effectiveness in use in low- and middle-income countries (LMICs) and humanitarian contexts (HCs) has been observed and attributed to membrane fouling and the associated cleaning. In LMICs/HCs, it is not possible to prevent and control fouling using commonly known methods (e.g., testing influent water, maintenance regimes), and the literature on fouling/cleaning of HFMFs distributed in LMICs is scarce. As such, controlled laboratory experiments were conducted to determine the efficacy of locally available (in LMICs/HCs) backwashing solutions at removing fouling using different influent waters and HFMF types. Four commonly distributed HFMFs were selected, fouling layers were developed by filtering three influent water compositions, representing LMIC/HC waters, for 10-days, and bleach, water, or vinegar backwashing solutions were used for daily backwashing. Filter performance indicators included: fiber mechanical properties (strain at break, break force), water quantity performance (flow), water quality performance (turbidity, E. coli), and imaging. The study found fouling developed rapidly and altered mechanical properties and water quantity indicators within 200 h of filtration. Fouling did not decrease water quality indicators. Backwashing improved the filter’s mechanical properties and water quantity performance, but it did not fully recover the initial performance. Additionally, recovery differed between backwashing solutions, and no universal cleaning recommendation appropriate for HFMFs in LMICs/HCs was identified. Overall, fouling development and control depended on HFMF type, influent water quality, and backwashing solution type, thus, caution before distributing HFMFs for long-term use in LMICs/HCs is recommended.

We conducted a systematic review of hygiene intervention effectiveness against SARS-CoV-2, including developing inclusion criteria, conducting the search, selecting articles for inclusion, and summarizing included articles. Overall, 96 268 articles were screened and 78 articles met inclusion criteria with outcomes in surface contamination, stability, and disinfection. Surface contamination was assessed on 3343 surfaces using presence/absence methods. Laboratories had the highest percent positive surfaces (21%

We conducted a systematic review of hygiene intervention effectiveness against SARS-CoV-2, including developing inclusion criteria, conducting the search, selecting articles for inclusion, and summarizing included articles. We reviewed 104,735 articles, and 109 articles meeting inclusion criteria were identified, with 33 additional articles identified from reference chaining. Herein, we describe results from 58 mask disinfection and reuse studies, where the majority of data were collected using N95 masks. Please note, no disinfection method consistently removed >3 log of virus irrespective of concentration, contact time, temperature, and humidity. However, results show it is possible to achieve >3 log reduction of SARS-CoV-2 using appropriate concentrations and contact times of chemical (ethanol, hydrogen peroxide, peracetic acid), radiation (PX-UV, UVGI), and thermal (autoclaving, heat) disinfection on N95 masks. N95 mask reuse and failure data indicate that hydrogen peroxide, heat, and UV-GI are promising for mask reuse, peracetic acid and PX-UV need more data, and autoclaving and ethanol lead to mask durability failures. Data on other mask types is limited. We thus recommend focusing guidelines and further research on the use of heat, hydrogen peroxide, and UVGI for N95 mask disinfection/reuse. All of these disinfection options could be investigated for use in LMIC and humanitarian contexts.TOC ArtSynopsisIn resource-limited contexts, N95s are reused. We recommend using heat, hydrogen peroxide, or UVGI to disinfect and reuse N95 masks.

Providing water, sanitation, and hygiene (WASH) to emergency-affected populations is necessary for dignity and disease control. Humanitarian response is coordinated via the 'cluster approach'. We summarized the outcomes and impacts of WASH cluster coordination using; literature review; UNICEF document review; and, key informant interviews. Across these three data sets, consistent themes were identified, including: the cluster approach evolved into a cost-effective 'best-fit' model; cluster staff require technical and coordination skills; context is related to cluster performance; and, there are trade-offs of cluster participation for members. Additionally, consistent intractable challenges were identified, including: accountability to beneficiaries; cross-cluster and sub-national cluster coordination; working with national governments; and, transition to post-emergency. We found previous research was largely subjective and did not address future cluster challenges. Evaluation of cluster outcomes and impacts, including member and beneficiary perspectives is needed. To enable this research, a theory of change for cluster coordination was also developed. This article is protected by copyright. All rights reserved.

Typhoid fever transmission occurs through ingestion of food or water contaminated with Salmonella Typhi, and case–control studies are often conducted to identify outbreak sources and transmission vehicles. However, there is no current summary of the associations among water, sanitation, and hygiene (WASH); and food exposures and typhoid from case–control studies. We conducted a systematic review and meta-analysis of case–control studies to evaluate the associations among typhoid fever and predicted WASH or food exposure risk factors (13), and protective factors (7). Overall, 19 manuscripts describing 22 case–control studies were included. Two studies were characterized as having low risk of bias, one as medium risk, and 19 as high risk. In total, nine of 13 predicted risk factors were associated with increased odds of typhoid (odds ratio [OR] = 1.4–2.4, I(2) = 30.5–74.8%.), whereas five of seven predicted protective factors were associated with lower odds of typhoid (OR = 0.52–0.73, I(2) = 38.7–84.3%). In five types of sensitivity analyses, two (8%) of 26 summary associations changed significance from the original analysis. Results highlight the following: the importance of household hygiene transmission pathways, the need for further research around appropriate food interventions and the risk of consuming specific foods and beverages outside the home, and the absence of any observed association between sanitation exposures and typhoid fever. We recommend that typhoid interventions focus on interrupting household transmission routes and that future studies provide more detailed information about WASH and food exposures to inform better targeted interventions.

Biofilms are aggregates of microorganisms attached to surfaces that can (re)contaminate water by releasing microorganisms. We grew E. coli biofilms on household taps and on storage container coupons, and cleaned them with locally-available agents (bleach, boiled water, soapy water, vinegar) and methods (flowing, scrubbing, or soaking taps; soaking and wiping container coupons). After cleaning, we enumerated surface E. coli and imaged biofilms using epifluorescence microscopy. Biofilms were removed from taps when: soaking assembled for five minutes (bleach, boiled water); and, scrubbing and soaking unassembled for five minutes (bleach, boiled water, vinegar). Only soaking methods removed E. coli from container coupons. To remove biofilms, we recommend soaking assembled taps in boiled water for five minutes. No recommendation for cleaning containers emerged as soaking storage containers is impractical. Results are consistent with biofilm research, and highlight the need for technical research to develop realistic cleaning recommendations for water storage containers in households.

Hygiene kits are commonly distributed in humanitarian emergencies to interrupt disease transmission and provide dignity. Despite being commonly implemented, hygiene kit distribution interventions are under-researched, and there is a lack of knowledge on kit efficacy and effectiveness. In Myanmar, the WASH cluster developed a national hygiene kit distribution and monitoring strategy. The research was aimed at determining the effectiveness of this strategy in the context of protracted internally displaced persons camps in Myanmar. To understand programme strategy, we reviewed documents against inclusion criteria; extracted and categorized data for included documents; analysed data; and summarized results. Twenty-six documents met the inclusion criteria of describing strategy development (47 per cent), monitoring in Rakhine (47 per cent) or Kachin State (3 per cent), or monitoring menstrual health and hygiene programme (3 per cent). We identified the strategy was successfully adopted and adapted for Kachin and Rakhine states; however, limitations were identified in receiving consistent monitoring data. We found hygiene kit distributions need to consider local context, including population mobility, local markets and availability of products, and household expenses and debt. Due to these interrelated factors, the percentage of households selling kit items decreased over time; additionally, soap and sanitary pad presence was significantly associated with household income. Consistently, women reported preferring disposable pads for menstrual health and hygiene due to privacy concerns. Programmatically, it is recommended to adapt hygiene kit distributions to local contexts, continue to distribute hygiene kits in protracted contexts to identified at-risk households, distribute disposable pads, and continue revising and improving strategy and monitoring tools.

Knowledge, attitudes, and practices (KAP) surveys are commonly conducted by humanitarian actors at project baseline and endline. We hypothesized summarized KAP data could inform water, sanitation, and hygiene (WASH) programming and strategies. In conflict-affected Myanmar, the WASH Cluster collated KAP documents from 2011 to 2016. After developing a methodology for KAP temporal analysis, we reviewed provided documents against inclusion criteria; extracted and categorized data; created a WASH activities and emergency events timeline; completed temporal analysis; and triangulated and summarized results. Sixteen documents met inclusion criteria assessing WASH data at the national level (19%), in Rakhine (56%) or Kachin State (25%). Twenty-five WASH metrics were extracted and categorized. We found WASH knowledge and attitudes (e.g. handwashing knowledge) increased over time; practices (e.g. handwashing) also increased, but at a lower rate and less consistently; and increases were related to WASH programming. Using this methodology, we identified gaps (safe water storage, risk of children's feces, focus on vulnerable populations), barriers (cultural and religious beliefs), and programmatic recommendations (continue hygiene promotion, focusing on closing gaps, and improve waste collection systems) in Myanmar. Additionally, to enable temporal analysis and improve WASH programming, we recommend WASH Clusters standardize KAP data collection tools and analysis in the future.

Applying silver nanoparticles (nAg) or silver nitrate (AgNO3) to ceramic water filters improves microbiological efficacy, reduces biofilm formation, and protects stored water from recontamination. A challenge in ceramic filter production is adding sufficient silver to achieve these goals without exceeding the maximum recommended silver concentration in drinking water. Silver release is affected by silver type, application method, and influent water chemistry. Despite a lack of data, there is an assumption that chlorinated water should not be used as influent water because it may increase silver elution. Thus, the objective of this work was to systematically evaluate the impact of chlorinated water (0–4 mg/L free chlorine residual, FCR) on silver release from ceramic filter disks painted with casein-coated nAg, painted with AgNO3, or containing fired-in nAg over a range of ionic strength (IS = 0–10 mM as NaNO3) in the presence or absence of natural organic matter (NOM). Influent deionized water containing chlorine increased silver release 2–5-fold compared to controls. However, this effect of chlorine was mitigated at higher IS (≥1 mM) or in the presence of NOM (3 mg C/L). For filter disks painted with nAg or AgNO3, silver release increased with increasing IS (with or without chlorine), and effluent concentrations remained above the World Health Organization (WHO) guideline of 0.1 mg/L even after 30 h (80 pore volumes, PVs) of flow with a background solution of 10 mM NaNO3. Silver speciation (nAg vs. Ag+) was monitored in effluent samples from painted or fired-in nAg filter disks. Results indicated that in general, greater than 90% of the eluted silver was due to Ag+ dissolution rather than nAg release. Additionally, a filter disk prepared with fired-in nAg exhibited a lower % released in the nanoparticle form (nAg = 5% of total Ag in effluent) compared to painted on nAg (nAg = 14% of total Ag in effluent). The findings of this study suggest that chlorinated influent water has minimal impact on silver elution from ceramic filters under simulated natural water conditions, and thus, the recommendation to avoid the use of chlorinated water with ceramic filters is not necessary under most conditions.

Point-of-use water chlorination is one of the most effective means to prevent diarrhea in under-five children although challenges remain in its adoption and effective use. In Ethiopia, evidence of point-of-use water chlorination among households with under-five children in rural and urban settings that is verified with water testing is scarce. A comparative cross-sectional study was conducted among urban and rural households with under-five child in Kersa Health and Demographic Surveillance Site, Eastern Ethiopia from June to August, 2016. Data were collected from a caregiver of systematically selected households and analyzed using multivariable logistic regression. A total of 1,912 households were included in the analysis with a 96.5% response rate. In rural areas, 4.6% of caregivers were reportedly chlorinating water at point-of-use and 1.2% were confirmed with free residual chlorine. In urban areas, 17.1% of caregivers were reportedly chlorinating water and 6.6% were confirmed to have free residual chlorine. In two settings, caregivers' point-of-use water chlorination was associated with chlorine taste and water quality perception. Inaccessibility to treatment products in rural areas and use of bottled water in urban areas were among the reasons to discontinue point-of-use water chlorination. Behavior changing interventions with proper distribution and marketing is needed for sustainable point-of-use chlorination.