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Evaluating the Long-Term Health Impact of Household Chlorination of Drinking Water in Rural Haiti

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Background: In September 2002, a household water chlorination program was established at the Missions of Love clinic in the rural, northwestern community of Jolivert, Haiti. The non-governmental organization Deep Springs International (DSI) currently operates the program, training Haitian technicians to: 1) manufacture quality-controlled sodium hypochlorite solution branded “Gadyen Dlo”; 2) enroll new families through sale of safe storage containers consisting of a modified bucket with lid and tap; 3) sell Gadyen Dlo and maintain sales records for each participant family; and 4) provide ongoing education on, and monitoring of, Gadyen Dlo use. In this study, the long-term health benefits of household chlorine treatment were evaluated.

Methods: A total of 708 surveys (201 cases, 507 controls) were administered by trained enumerators. Cases were randomly selected from program sales records and controls were three houses right of each case. Two controls were completed for every case to account for potential cohort differences in analysis. At each surveyed household, free chlorine residual in drinking water and volume of remaining Gayden Dlo were recorded. Survey results were analyzed in SAS 9.2. Additionally, handwritten program records of chlorine sales and household visits were recorded and analyzed in Excel.

Findings: The DSI program has reached over 4,500 participants since program inception and about 48,000 chlorine refills have been sold (enough to treat 600,000,000 liters of water total, averaging 10.7 bottles per family). The only significant demographic differences found between cases and controls were that more cases attended school (p=0.020) and more controls practiced voodoo (p<0.001). Significantly more cases than controls believed their water was safe to drink (p<0.001), and believed this because it was free from bacteria (p<0.001). Chlorine residuals greater than 0.1 mg/L were detected in 61.9% of cases and 11.2% of controls (p<0.001) at time of unannounced survey visit. Clorox and other forms of locally-available on-the-market chlorine were frequently used; 15.4% of cases and 38.6% of controls self-reported using Clorox to treat drinking water (p<0.001). In children under five, the odds of diarrhea was 58% less for cases than controls (OR=0.42; 95% CI 0.26, 0.67; p=0.0003). Analysis of DSI program records since 2002 from regular unannounced household visits by technicians found 74.8% of chlorine tests yielded chlorine residuals greater than 0.1 mg/L.

Interpretation: Household chlorine treatment has been well-documented to reduce diarrheal disease; however, critics claim there is little long-term chlorine uptake. This study clearly indicates consistent use and diarrheal disease reduction in a long-term, cost-recovery chlorination program. This is a highly successful program that should be expanded and replicated in other areas; however, the ability of programs to scale up successfully should be carefully considered so that funding can be self-sufficient, consistency of chlorine use can be maintained, and diarrheal disease reduction can be sustained. These findings will provide valuable information for implementers of household chlorination programs when considering expanding their programs or starting new programs.

Funding: This study was funded by the Global Health Institute and Sustainability Initiatives at Emory University and by the Eugene Gangarosa Endowment at the Centers for Disease Control and Prevention (CDC) Foundation.
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Keywords: Haiti; Household chlorine disinfection; impact evaluation; non-governmental organization

Document Type: Research Article

Publication date: 2011-01-01

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