title: Effects of source- versus household contamination of tubewell water on child diarrhea in rural Bangladesh: a randomized controlled trial.
abstract: BACKGROUND
  Shallow tubewells are the primary drinking water source for most rural Bangladeshis. Fecal contamination has been detected in tubewells, at low concentrations at the source and at higher levels at the point of use. We conducted a randomized controlled trial to assess whether improving the microbiological quality of tubewell drinking water by household water treatment and safe storage would reduce diarrhea in children <2 years in rural Bangladesh.
  
  
  METHODS
  We randomly assigned 1800 households with a child aged 6-18 months (index child) into one of three arms: chlorine plus safe storage, safe storage and control. We followed households with monthly visits for one year to promote the interventions, track their uptake, test participants' source and stored water for fecal contamination, and record caregiver-reported child diarrhea prevalence (primary outcome). To assess reporting bias, we also collected data on health outcomes that are not expected to be impacted by our interventions.
  
  
  RESULTS
  Both interventions had high uptake. Safe storage, alone or combined with chlorination, reduced heavy contamination of stored water. Compared to controls, diarrhea in index children was reduced by 36% in the chlorine plus safe storage arm (prevalence ratio, PR = 0.64, 0.55-0.73) and 31% in the safe storage arm (PR = 0.69, 0.60-0.80), with no difference between the two intervention arms. One limitation of the study was the non-blinded design with self-reported outcomes. However, the prevalence of health outcomes not expected to be impacted by water interventions did not differ between study arms, suggesting minimal reporting bias.
  
  
  CONCLUSIONS
  Safe storage significantly improved drinking water quality at the point of use and reduced child diarrhea in rural Bangladesh. There was no added benefit from combining safe storage with chlorination. Efforts should be undertaken to implement and evaluate long-term efforts for safe water storage in Bangladesh.
  
  
  BACKGROUND
  ClinicalTrials.gov NCT01350063.
authors: Division of Epidemiology, School of Public Health, University of California, Berkeley, California, United States of America.
authors: Ayse
authors: A
authors: Ercumen
authors: Centre for Communicable Diseases, International Centre for Diarrhoeal Disease Research, Dhaka, Bangladesh.
authors: Abu Mohd
authors: AM
authors: Naser
authors: Centre for Communicable Diseases, International Centre for Diarrhoeal Disease Research, Dhaka, Bangladesh.
authors: Leanne
authors: L
authors: Unicomb
authors: Division of Epidemiology, School of Public Health, University of California, Berkeley, California, United States of America.
authors: Benjamin F
authors: BF
authors: Arnold
authors: Division of Epidemiology, School of Public Health, University of California, Berkeley, California, United States of America.
authors: John M
authors: JM
authors: Colford
authors: Centre for Communicable Diseases, International Centre for Diarrhoeal Disease Research, Dhaka, Bangladesh; School of Medicine, Stanford University, Stanford, California, United States of America; Centers for Disease Control and Prevention, Atlanta, Georgia, United States of America.
authors: Stephen P
authors: SP
authors: Luby
mesh_terms: D001459:Bangladesh; D003968:Diarrhea, Infantile / Q000453:epidemiology* / Q000209:etiology / Q000517:prevention & control*; D060766:Drinking Water / Q000382:microbiology / Q000592:standards*; D054879:Halogenation; D006801:Humans; D007223:Infant; D012424:Rural Population; D018508:Water Purification / Q000379:methods*; D060753:Water Quality / Q000592:standards; D060986:Water Wells
chemical_list: D060766:Drinking Water