A Stepped Wedge Cluster-Randomized Trial Assessing the Impact of a Riverbank Filtration Intervention to Improve Access to Safe Water on Health in Rural India.

Sustainable and low-cost methods for delivery of safe drinking water in resource-limited settings remain suboptimal, which contributes to global diarrhea morbidity. We aimed to assess whether delivery of riverbank filtration-treated water to newly installed water storage tanks (improved quality and access, intervention condition) reduced reported diarrhea in comparison to delivery of unfiltered river water (improved access alone, control condition) in rural Indian villages. We used a stepped wedge cluster-randomized trial (SW-CRT) design involving four clusters (villages).

Effect of hygiene interventions on acute respiratory infections in childcare, school and domestic settings in low- and middle-income countries: a systematic review.

Objectives: Acute respiratory infections (ARIs) disproportionately affect those living in low- and middle-income countries (LMICs). We aimed to determine whether hygiene interventions delivered in childcare, school or domestic settings in LMICs effectively prevent or reduce ARIs.

Methods: We registered our systematic review with PROSPERO (CRD42017058239) and searched MEDLINE, EMBASE, CENTRAL, and Scopus from inception to 17 October 2017 for randomised controlled trials (RCTs) examining the impact of hygiene interventions on ARI morbidity in adults and children in community-based settings in LMICs.

Cost of gastroenteritis in Australia: A healthcare perspective.

Background: Acute gastroenteritis illness is a common illness that causes considerable morbidity, but current estimates of the cost to the Australian healthcare system are unknown.

Objective: To estimate the current healthcare utilisation and direct public healthcare system costs attributable to acute gastroenteritis illness in Australia.

Methods: This is an incidence-based cost-of-illness study focused on quantifying direct health care costs using a bottom-up approach.

Burden of Disease Attributed to Waterborne Transmission of Selected Enteric Pathogens, Australia, 2010.

AbstractUniversal access to safe drinking water is a global priority. To estimate the annual disease burden of campylobacteriosis, nontyphoidal salmonellosis, cryptosporidiosis, giardiasis, and norovirus attributable to waterborne transmission in Australia, we multiplied regional World Health Organization (WHO) estimates of the proportion of cases attributable to waterborne transmission by estimates of all-source disease burden for each study pathogen. Norovirus was attributed as causing the most waterborne disease cases (479,632; 95% uncertainty interval [UI]: 0-1,111,874) followed by giardiasis and campylobacteriosis.

Protocol for a cluster randomised stepped wedge trial assessing the impact of a community-level hygiene intervention and a water intervention using riverbank filtration technology on diarrhoeal prevalence in India.

Introduction: Diarrhoea is a leading cause of death globally, mostly occurring as a result of insufficient or unsafe water supplies, inadequate sanitation and poor hygiene. Our study aims to investigate the impact of a community-level hygiene education program and a water quality intervention using riverbank filtration (RBF) technology on diarrhoeal prevalence.

Methods And Analysis: We have designed a stepped wedge cluster randomised trial to estimate the health impacts of our intervention in 4 rural villages in Karnataka, India.

Measuring water ingestion from spray exposures.

Characterisation of exposure levels is an essential requirement of health risk assessment; however for water exposures other than drinking, few quantitative exposure data exist. Thus, regulatory agencies must use estimates to formulate policy on treatment requirements for non-potable recycled water. We adapted the use of the swimming pool chemical cyanuric acid as a tracer of recreational water ingestion to permit detection of small water volumes inadvertently ingested from spray exposures.

Variability in 24 hour excretion of cyanuric acid: implications for water exposure assessment.

Cyanuric acid (CYA) excretion in urine has been used to estimate the volume of water ingested during swimming and other recreational activities in outdoor pools containing this chemical. These estimates of water ingestion are based on the assumption of 100% excretion within 24 hours, but the supporting evidence for this is scant. While adapting this methodology to investigate other water ingestion scenarios, we observed a high degree of variability in cyanuric acid excretion among experimental subjects, with over 25% of individuals excreting less than 80% of an ingested dose.

Adoption of a microbial health-based target for Australian drinking water regulation.

The health-based targets of 1 in 10,000 for infection and 10(-6) disability adjusted life years (DALYs) per person per year are increasingly being considered, or have already been adopted, to define microbial safety targets for water. The aim of this paper is to convey information about how these two targets compare by converting each of the target values to a common metric. The metric chosen for viral (rotavirus and norovirus) and protozoan (Cryptosporidium) reference pathogens is the estimated maximum number of annual drinking water-associated cases of acute diarrhoeal disease tolerated.

Factors associated with transmission of influenza-like illness in a cohort of households containing multiple children.

Background: Household studies of influenza-like illness (ILI) afford opportunities to study determinants of respiratory virus transmission.

Objectives: We examined predictors of ILI transmission within households containing at least two children.

Methods: A prospective cohort study recorded ILI symptoms daily for 2712 adult and child participants during the 1998 influenza season in Victoria, Australia.

Evolution of regulatory targets for drinking water quality.

The last century has been marked by major advances in the understanding of microbial disease risks from water supplies and significant changes in expectations of drinking water safety. The focus of drinking water quality regulation has moved progressively from simple prevention of detectable waterborne outbreaks towards adoption of health-based targets that aim to reduce infection and disease to a level well below detection limits at the community level. This review outlines the changes in understanding of community disease and waterborne risks that prompted development of these targets, and also describes their underlying assumptions and current context.

Disease burden of selected gastrointestinal pathogens in Australia, 2010.

Objective: To estimate and compare disease burden attributable to six gastrointestinal pathogens (norovirus, rotavirus, Campylobacter, non-typhoidal Salmonella, Giardia, and Cryptosporidium) in Australia, 2010.

Methods: We estimated the number of acute gastroenteritis (AGE) cases and deaths, disability-adjusted life years (DALYs), and DALY/case for each pathogen. We included AGE cases that did not require medical care.

Risk factors for community-based reports of gastrointestinal, respiratory, and dermal symptoms: findings from a cohort study in Australia.

Background: Although gastrointestinal (GI), respiratory, and dermal symptoms are common, few studies have conducted concurrent and comparative prospective analyses of risk factors for these 3 morbidity outcomes.

Methods: We used data from a community-based randomized controlled trial among 277 South Australian families to analyze GI (diarrhea, vomiting), respiratory (sore throat, runny nose, cough) and dermal (rash, generalized itch, dermal infection) symptoms.

Results: Log-binomial regression analysis revealed similar risks of GI (adjusted risk ratio [RR], 1.

Using disability-adjusted life years to set health-based targets: a novel use of an established burden of disease metric.

Following the 1990 Global Burden of Disease (GBD) study, Disability-Adjusted Life Years (DALYs) have been used widely to quantify the population health burden of diseases and to prioritise and evaluate the impact of specific public health interventions. In the context of the recent release of the 2010 GBD study, we explore the novel use of DALYS to determine health-based targets (HBTs). As with the more traditional use of DALYs, the main advantage of using DALYs as HBTs is the ability to account for differential disease severity, identify the most appropriate public health interventions, and measure the positive and negative outcomes of these interventions.

A probabilistic model of norovirus disease burden associated with greywater irrigation of home-produced lettuce in Melbourne, Australia.

The reuse of domestic greywater has become common in Australia, especially during periods of extreme drought. Greywater is typically used in a raw, untreated form, primarily for landscape irrigation, but more than a quarter of greywater users irrigate vegetable gardens with the water, despite government advice against this practice. Greywater can be contaminated with enteric pathogens and may therefore pose a health risk if irrigated produce is consumed raw.

Comparison of response rates and cost-effectiveness for a community-based survey: postal, internet and telephone modes with generic or personalised recruitment approaches.

Background: Epidemiological research often requires collection of data from a representative sample of the community or recruitment of specific groups through broad community approaches. The population coverage of traditional survey methods such as mail-outs to residential addresses, and telephone contact via public directories or random-digit-dialing is declining and survey response rates are falling. There is a need to explore new sampling frames and consider multiple response modes including those offered by changes in telecommunications and internet technology.

Community based study to compare the incidence and health services utilization pyramid for gastrointestinal, respiratory and dermal symptoms.

Background: Gastrointestinal (GI), respiratory and dermal symptoms are common and cause substantial morbidity, although the information on their exact incidence and comparative burden is limited. The aim of this study was to describe the epidemiology and rate these three major symptom complexes in order to improve our understanding of the health burden imposed by these symptoms.

Methods: We used data from a community based randomised control trial conducted from June 2007 to August 2008 among 277 South Australian families consuming rainwater.

Microbial quality assessment of household greywater.

A monitoring program was undertaken to assess the microbial quality of greywater collected from 93 typical households in Melbourne, Australia. A total of 185 samples, comprising 75 washing machine wash, 74 washing machine rinse and 36 bathroom samples were analysed for the faecal indicator Escherichia coli. Of these, 104 were also analysed for genetic markers of pathogenic E coli and 111 for norovirus (genogroups GI and GII), enterovirus and rotavirus using RT-PCR.

Reported waterborne outbreaks of gastrointestinal disease in Australia are predominantly associated with recreational exposure.

Objective: To examine the frequency and circumstances of reported waterborne outbreaks of gastroenteritis in Australia.

Method: Examination of data reported to OzFoodNet between 2001 and 2007.

Results: During these seven years, 6,515 gastroenteritis outbreaks were reported to OzFoodNet, most of which were classified as being transmitted person-to-person or from an unknown source.

Health status of residents of an urban dual reticulation system.

Background: Households in dual reticulation developments are supplied with recycled water from sewage effluent for some non-potable purposes, and conventional tap water for other uses. Adverse health effects from recycled water exposure are considered unlikely; however, no epidemiological studies have been undertaken to assess the public health impact of such exposures.

Methods: We compared the health status of residents of a dual reticulation housing development with residents of an adjacent conventional water supply area by assessing consultation rates with primary-care physicians for three conditions considered plausibly related to recycled water exposure (gastroenteritis, respiratory complaints and dermal complaints), and two conditions considered unrelated to water exposures (urinary tract infections and musculoskeletal complaints).

Drinking rainwater: a double-blinded, randomized controlled study of water treatment filters and gastroenteritis incidence.

Objectives: We examined whether drinking untreated rainwater, a practice that is on the rise in developed countries because of water shortages, contributes to community gastroenteritis incidence.

Methods: We conducted a double-blinded, randomized controlled trial in Adelaide, Australia. Sham or active water treatment units were installed, and participants recorded incidences of illness in a health diary for 12 months.

Sporadic gastroenteritis and recreational swimming in a longitudinal community cohort study in Melbourne, Australia.

The relation between sporadic gastroenteritis and recreational swimming was examined in a cohort of 2,811 people in Melbourne, Australia, over a 15-month period (September 1997-February 1999). Data from a prospective community-based study of gastroenteritis were used for a Poisson analysis of temporality between reported swimming (in public or private pools/spas and in marine or freshwater settings) and a highly credible gastroenteritis (HCG) event. Overall, HCG events were more likely in participants who had swum in a public pool/spa (incidence rate ratio (IRR) = 1.

Collecting household water usage data: telephone questionnaire or diary?

Background: Quantitative Microbial Risk Assessment (QMRA), a modelling approach, is used to assess health risks. Inputs into the QMRA process include data that characterise the intensity, frequency and duration of exposure to risk(s). Data gaps for water exposure assessment include the duration and frequency of urban non-potable (non-drinking) water use.

Effectiveness and cost of recruitment strategies for a community-based randomised controlled trial among rainwater drinkers.

Background: Community-based recruitment is challenging particularly if the sampling frame is not easily defined as in the case of people who drink rainwater. Strategies for contacting participants must be carefully considered to maximise generalisability and minimise bias of the results. This paper assesses the recruitment strategies for a 1-year double-blinded randomised trial on drinking untreated rainwater.

The Australian Electoral Commission Roll has good utility for 'niche' household recruitment in population health studies.

Objective: To investigate the recruitment of 'niche' household populations, defined by their household characteristics and/or water supply type for health studies.

Methods: The Australian Electoral Commission (AEC) database was used to recruit households for participation in two health-related studies, the first, a recycled water usage study and the second, an epidemiological study investigating household rainwater use.

Results: The AEC database facilitated the identification and recruitment of households using a particular water supply from among the general household population.