ASSESSING THE HEALTH IMPACT OF ADVANCED WATER FILTERS AND IMPROVED COOKSTOVES IN WESTERN PROVINCE, RWANDA: A CLUSTER- RANDOMIZED CONTROLLED TRIAL

Transcription

1 ASSESSING THE HEALTH IMPACT OF ADVANCED WATER FILTERS AND IMPROVED COOKSTOVES IN WESTERN PROVINCE, RWANDA: A CLUSTER- RANDOMIZED CONTROLLED TRIAL Miles Kirby, Ghislaine Rosa, Laura Zambrano, Corey Nagel, Evan Thomas, Chris<na Barstow, Jeanine Condo, Thomas Clasen!!

2

3

4 Collec<vely, pneumonia and diarrhea responsible for 6.9M deaths annually Implementa<on of WASH and 14 other designated interven<ons could reduce diarrhoea mortality by 95% and pneumonia by 75% by 2025 Marginal cost is <$3B The Lancet Diarrhoea and Pneumonia Interven<ons Study Group 2012

5

6 Background on Rwanda 65% coverage of improved water supplies 99% of rural popula<on cooks with biomass Most common communicable diseases are malaria, HIV/AIDS, acute respiratory infec<ons, diarrhoeal diseases and tuberculosis.

7 Thomas et al. 2013

8

9 Study Aims and Study Overview Aims: To evaluate the impact of a na<onal- level water filter and cook stove program To document interven<on delivery (process evalua<on) To assess coverage and use To evaluate effects on exposure (drinking water quality, household air pollu<on) To assess impact on health (diarrhea, pneumonia, hypertension, adverse birth outcomes, mortality) To inves<gate poten<al biomarkers of exposure and enteric and respiratory disease To assess the impact of the interven<on on environmental condi<ons (University of Colorado, Boulder) To assess the cost, cost- effec<veness and cost- benefits of the program (Portland State University) Study Overview: Six- year study consis<ng of Planning, Pilo<ng, Enrolment and Baseline (6 months) Assessing Ini<al Uptake and Performance of Filter to Improve Drinking Water Quality (Phase 1a- 6 months) Assessing Sustained Uptake; Exploring Impact on Exposure and Health (Phase 1b- 12 months) Evalua<on of Full- Scale Campaign (Phase 2-6 month planning, baseline; 12 months follow up) Sustainability Study (36 months)

10 IntervenMon 1: Filters Vestergaard- Frandsen LSF 2.0, combining nanofiltra<on with safe storage Lab tes<ng demonstrated microbiological performance over 18,000L design life (Clasen 2007). Field studies of LSF1.0 in Zambia (Peletz 2012) and Congo (Boisson 2009).

11 Rural Water Sources

12 IntervenMon 2: Cook Stoves Eco- Zoom stove designed in USA and manufacted in China Evalua<ons for USAID by the Berkeley Air Monitoring Group in Hai<, Uganda and Tanzania reported fuel savings of 39% to 54% compared to open fires; also shown to cook meals faster, and was the most preferred stove by 96% of households.

13 TradiMonal Cooking on 3- Stone Fire

14 Phase I Evalua<on: Uptake and Exposure 5- month household randomized controlled trial 566 households from 3 villages Randomized by public lolery to half of village households Five monthly follow- up visits to households Observa<ons and survey ques<ons on use Water quality sampling for TTC Air quality monitoring for PM2.5 and CO in cooking area SWEETSense monitoring of filter and stove use Rosa G, Majorin F, Boisson S, Barstow C, Johnson M, et al. (2014) Assessing the Impact of Water Filters and Improved Cook Stoves on Drinking Water Quality and Household Air Pollu<on: A Randomised Controlled Trial in Rwanda. PLoS ONE 9(3): e91011.

15 Filter Use and Water Quality High compliance overall (89.2% use), but 25% reported drinking from other sources at least once during 5 visits Effec<ve, 96.6% of drinking water samples collected directly from filters were free of TTC Overall, a 97.5% reduc<on in mean faecal indicator bacteria (Williams means 0.5 vs TTC/100 ml, p<0.001)

16 Stove Use and Air Quality Compliance 66.7% of interven<on households iden<fied the interven<on stove as their main cooking stove. Only 23.3% of interven<on households reported that their main cooking area was outdoors. Exposure Overall, the interven<on was associated with a 48% reduc<on of 24- h PM2.5 concentra<ons in the cooking area (0.485 mg/m3 and mg/m3, p = 0.005). Reduc<on was 37% for those cooking indoors (p=0.08) and 73% for those cooking outdoors (p<0.001)

17 PHASE 2 Western Province, Rwanda Cluster Randomized Controlled Trial 96 Sectors (clinic catchment area) Implementa<on: Oct Jan 2014 Sector- Level Study Province- wide CRCT to assess health effects based on clinics and and CHW records Follow up based on health records from Feb 2015 to Jan 2016 Interven<on Arm 72 Sectors (~2700 villages, 100,000 HHs) Control Arm 24 Sectors (~900 villages, 40,000 HH) Baseline (Sept 2014 Dec quarterly follow- up rounds (Feb Jan 2016 Village- Level Sub Study Nested CRT to assess focusing on coverage, use, exposure and health outcomes Interven<on Arm 87 Village Clusters Control Arm 87 Village Clusters

18

19 Exposure measurements Primary cook 16 years and older Child years at <me of enrollment 48 hour gravimetric PM 2.5 Baseline + 4 quarterly follow- up visits 226 houses (114 intv, 112 cntrl) Black carbon analysis (TBD) Sub- sample: PM 2.5 +CO Draeger tubes (cumula<ve) GasBadge Pro (minute- by- minute CO readings)

20 Light sensor compliance and loca<on indicator HPEM holds PTFE filter GasBadge Pro measures semi- con<nuous CO Tubing connec<ng HPEM to pump TuffPro Pump draws air through HPEM (1.8L/min) 20

21

22 AddiMonal measurements SpCO and SpO2 (RAD- 57) Primary cook+child U5 %CO Expirated CO (MicroCO) Primary cook+ child U5 Difficult for child under 5 to hold breath CO ppm %CO Ater 48 hour exposure monitoring period

23 Household- level health outcomes Primary outcomes: 1 week recall (reported by primary caretaker) Diarrhoea Acute respiratory illness Illness with cough + rapid/difficulty breathing Secondary outcomes: Current diarrhoea and pneumonia according to IMCI protocol Blood pressure Primary cook Spirometry Primary cook FEV 1 FVC PEFR

24 Sector- level health outcomes 96 sectors >150 health facili<es Health facility registers Under 5 Outpa<ent Maternity CHW register Periodic review and quality assurance Data extrac<on ater 12- month surveillance period

25 Under- 5 years register Primary outcomes Clinic- diagnosed diarrhoea (IMCI) ~Western Province: 25,000 cases/ yr Clinic- diagnosed pneumonia (IMCI) ~Western Province: 25,000 cases/ yr

26 Maternity register Secondary outcomes Premature birth (<37 weeks) Last menstrual period (LMP) Expected date of delivery (EDD) Gesta<onal age (weeks) Low birth weight (<2500g) S<llbirth

27 CHW sick child encounter forms 3,625 villages 2 CHWs per village Diarrhoea and pneumonia diagnosed according to IMCI protocol Treatment occurs in village or referral to health centre Western Province: ~34,000 cases of diarrhoea/yr ~54,000 cases of pneumonia/ yr

28 Biomarker Sub- study ObjecMves To assess levels of markers of inflamma<on and oxida<ve stress To assess IgG seroconversion, reflec<ng exposure to various enteric pathogens, and levels of EndoCab IgG and plasma citrulline To assess whether levels of inflammatory cytokines are associated with EE or acute GI indicators to determine cross- over effects between inflamma<on and EE or acute GI illness.

29 Sensor monitoring