Journal Article

Effects of a large-scale distribution of water filters and natural draft rocket-style cookstoves on diarrhea and acute respiratory infection: A cluster-randomized controlled trial in Western Province, Rwanda

Clasen, Thomas, Ngirabega, Jean de Dieu, Kirby, Miles A., Rosa, Ghislaine, Thomas, Evan A., Nagel, Corey L., Zambrano, Laura D., Musafiri, Sanctus

2019

Overview

Unsafe drinking water and household air pollution (HAP) are major causes of morbidity and mortality among children under 5 in low and middle-income countries. Household water filters and higher-efficiency biomass-burning cookstoves have been widely promoted to improve water quality and reduce fuel use, but there is limited evidence of their health effects when delivered programmatically at scale. In a large-scale program in Western Province, Rwanda, water filters and portable biomass-burning natural draft rocket-style cookstoves were distributed between September and December 2014 and promoted to over 101,000 households in the poorest economic quartile in 72 (of 96) randomly selected sectors in Western Province. To assess the effects of the intervention, between August and December, 2014, we enrolled 1,582 households that included a child under 4 years from 174 randomly selected village-sized clusters, half from intervention sectors and half from nonintervention sectors. At baseline, 76% of households relied primarily on an improved source for drinking water (piped, borehole, protected spring/well, or rainwater) and over 99% cooked primarily on traditional biomass-burning stoves. We conducted follow-up at 3 time-points between February 2015 and March 2016 to assess reported diarrhea and acute respiratory infections (ARIs) among children <5 years in the preceding 7 days (primary outcomes) and patterns of intervention use, drinking water quality, and air quality. The intervention reduced the prevalence of reported child diarrhea by 29% (prevalence ratio [PR] 0.71, 95% confidence interval [CI] 0.59-0.87, p = 0.001) and reported child ARI by 25% (PR 0.75, 95% CI 0.60-0.93, p = 0.009). Overall, more than 62% of households were observed to have water in their filters at follow-up, while 65% reported using the intervention stove every day, and 55% reported using it primarily outdoors. Use of both the intervention filter and intervention stove decreased throughout follow-up, while reported traditional stove use increased. The intervention reduced the prevalence of households with detectable fecal contamination in drinking water samples by 38% (PR 0.62, 95% CI 0.57-0.68, p < 0.0001) but had no significant impact on 48-hour personal exposure to log-transformed fine particulate matter (PM2.5) concentrations among cooks (β = -0.089, p = 0.486) or children (β = -0.228, p = 0.127). The main limitations of this trial include the unblinded nature of the intervention, limited PM2.5 exposure measurement, and a reliance on reported intervention use and reported health outcomes. Our findings indicate that the intervention improved household drinking water quality and reduced caregiver-reported diarrhea among children <5 years. It also reduced caregiver-reported ARI despite no evidence of improved air quality. Further research is necessary to ascertain longer-term intervention use and benefits and to explore the potential synergistic effects between diarrhea and ARI. Clinical Trials.gov NCT02239250.

• Publisher: Public Library of Science,Public Library of Science (PLoS)
• Subject: Acute Disease / Adult / Air pollution / Air pollution control / Air pollution measurements / Air Pollution, Indoor - analysis / Air Pollution, Indoor - prevention & control / Air quality / Biology and Life Sciences / Biomass / Biomass burning / Boreholes / Burning / Caregivers / Child, Preschool / Children / Children & youth / Clinical trials / Cluster Analysis / Contamination / Cooking / Cooking - instrumentation / Cooking - standards / Demographic aspects / Diarrhea / Diarrhea - epidemiology / Diarrhea - prevention & control / Domestic stoves / Drinking water / Drinking Water - analysis / Drinking Water - standards / Ecology and Environmental Sciences / Engineering and Technology / Environmental aspects / Exposure / Fecal coliforms / Feces / Female / Filters / Follow-Up Studies / Health aspects / Health surveys / Household Articles - instrumentation / Household Articles - standards / Households / Humans / Hygiene / Indoor air pollution / Infections / Low income groups / Lung diseases / Male / Medical research / Medicine / Medicine and Health Sciences / Morbidity / Mortality / Outdoor air quality / Particulate emissions / Particulate matter / Physical Sciences / Pneumonia / Pollution control / Prevention / Public health / Public relations / Rain water / Rainwater / Respiratory tract infection / Respiratory tract infections / Respiratory Tract Infections - epidemiology / Respiratory Tract Infections - prevention & control / Retirement benefits / Rwanda - epidemiology / Supervision / Synergistic effect / Systematic review / Ventilators / Water / Water analysis / Water filters / Water pollution / Water purification / Water Purification - instrumentation / Water Purification - standards / Water quality / Water Quality - standards / Water sampling / Water treatment equipment industry