198512 Boiling Mad: Impact of Point-of-Use Chlorination Compared with Boiling and Bottled Water on Water Quality and Diarrheal Illness —Tangerang, Indonesia, March-June 2008

Tuesday, November 10, 2009: 10:30 AM

Kavita Kishor Trivedi, MD , Enteric Diseases Epidemiology Branch, Centers for Disease Control and Prevention, Atlanta, GA
Samir Sodha, MD, MPH , Enteric Diseases Epidemiology Branch, Centers for Disease Control and Prevention, Atlanta, GA
Elizabeth Blanton, MPH , Enteric Diseases Epidemiology Branch, Centers for Disease Control and Prevention, Atlanta, GA
Abigael Ati , Center for Communication Programs, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD
Amy Boore, PhD, MPH , Enteric Diseases Epidemiology Branch, Centers for Disease Control and Prevention, Atlanta, GA
Thai-An Nguyen, MPH , Enteric Diseases Epidemiology Branch, Centers for Disease Control and Prevention, Atlanta, GA
Kristin C. Delea, MPH, REHS , Enteric Diseases Epidemiology Branch, Centers for Disease Control and Prevention, Atlanta, GA
Robert Ainslie , Center for Communication Programs, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD
Maria Elena Figueroa, PhD , Center for Communication Programs, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD
Rob Quick, MD, MPH , Enteric Diseases Epidemiology Branch, Centers for Disease Control and Prevention, Atlanta, GA
  
Background: Despite government promotion of boiling drinking water in Indonesia, diarrhea remains a major cause of morbidity and mortality among children <5yo. Point-of-use chlorination is currently promoted as a less time-consuming alternative to boiling. We evaluated the impact of this strategy on water quality and diarrhea. Methods: We enrolled households with children <5yo in Tangerang, Indonesia; conducted a baseline survey; and measured Escherichia coli contamination in source and stored water. Households were visited weekly for 12 weeks to collect diarrhea incidence data in children <5yo and to test stored water for residual chlorine and E. coli.

Results: We enrolled 289 households with 297 children <5yo. Household water treatment practices included boiling (81%) and chlorination (5%); 9% of households used bottled water without treatment. In households that chlorinated, stored water was less likely to yield E. coli than in households that boiled (30% vs. 57%, relative risk [RR] 0.5; 95% confidence interval [CI] 0.4–0.7) or used bottled water (30% vs. 50%, RR 0.6; 95% CI 0.5–0.8). The proportion of children with diarrhea tended to be lower in households that chlorinated than in those that boiled (2% vs. 5%, RR 0.3; 95% CI 0.1–1.3) or used bottled water (2% vs. 6%, RR 0.3; 95% CI 0.1–1.1).

Conclusions: Chlorination resulted in significantly better microbiologic quality of stored water and a lower, though not significant, proportion of children with diarrhea compared with boiling or use of bottled water. However, chlorine use was low. Enhanced efforts to promote chlorination are warranted.

Learning Objectives:
Describe how to evaluate a point-of-use water treatment program. Describe the challenges of promoting point-of-use chlorination in a location where boiling has been heavily promoted by the government. Assess the association between water quality and diarrhea incidence in lower income, peri-urban populations in Indonesia.

Keywords: Diarrhea, Water Quality

Presenting author's disclosure statement:

Qualified on the content I am responsible for because: I have experience working with low-income, peri-urban populations in the developing world, both during the completion of my medical degree and fellowship. I am currently completing an Epidemic Intelligence Service fellowship at the Centers for Disease Control and Prevention (CDC) during which I have designed and implemented a 12-week longitudinal study on a peri-urban population in Tangerang, Indonesia evaluating children's diarrhea, water treatment and water quality. During this project, I worked in conjunction with CARE International Indonesia as well as Johns Hopkins University - Center for Communcication Programs. Prior to this work, I aided in completing the baseline evaluation of a similar population in South Sulawesi, Indonesia with colleagues at CDC.
Any relevant financial relationships? No

I agree to comply with the American Public Health Association Conflict of Interest and Commercial Support Guidelines, and to disclose to the participants any off-label or experimental uses of a commercial product or service discussed in my presentation.

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