Water, sanitation, and hygiene (WASH) interventions are key to reducing the burden of disease associated with outbreaks, and are commonly implemented in emergency response. However, there is a lack of summarized evidence on the efficacy and effectiveness of these interventions. We conducted a systematic review of published and grey literature by developing theory of change models, developing inclusion criteria, conducting the search, selecting evaluations for inclusion, assessing the quality of the evidence, and analysing the included evaluations. Overall, 15,026 documents were identified and 51 evaluations from 47 studies met inclusion criteria. Interventions from 19 countries were included, primarily in response to cholera (86 per cent). Most included evaluations (70 per cent) were at high risk of bias and nearly half were from grey literature (49 per cent). We found that WASH interventions consistently reduced both the risk of disease and the risk of transmission in outbreak contexts; however, programme design and beneficiary preferences were important considerations to ensure WASH intervention effectiveness. Critical programme design characteristics included simple interventions that were appropriately timed, community-driven, and had linkages between relief and development. Beneficiary preferences, barriers, and facilitators to WASH interventions in outbreak response were taste and smell of water treatment, communication methods, inaccurate perception of efficacy, and trust/fear. Research on commonly implemented but severely under-researched WASH interventions is recommended. It is also recommended that responders implement interventions that are: efficacious, simple, well-timed, community-driven, link relief and development, and address barriers and facilitators to use with communities.
Efficacy and effectiveness of water, sanitation, and hygiene interventions in emergencies in low- and middle-income countries: a systematic review
There are increasing numbers of people affected by natural disasters, disease outbreaks, and conflict. Water, sanitation, and hygiene (WASH) interventions are used in nearly all emergency responses to help reduce disease risk. However, there is a lack of summarized evidence on the efficacy and effectiveness of these interventions. We conducted a systematic review of the published and grey literature on the efficacy and effectiveness of short-term WASH interventions in emergency response in low- and middle-income countries, including: developing theory of change models; setting inclusion criteria; conducting the search; selecting evaluations for inclusion; assessing the quality of the evidence; and analysing the included evaluations. Overall, 15,026 documents were identified and 106 studies describing 114 evaluations met inclusion criteria. Interventions from 39 countries were included. Most included evaluations (77 per cent) had high risk of bias and half were from grey literature (50 per cent). For the majority of interventions, we found that WASH interventions consistently reduced both the risk of disease and transmission in emergency contexts; however, programme design and beneficiary preferences were important considerations to ensure WASH intervention efficacy and effectiveness. Critical programme design characteristics included simple interventions that were appropriately timed, community-driven, and had linkages between relief and development. Barriers and facilitators to WASH interventions in outbreak response were taste and smell of treated water, communication methods, inaccurate perception of efficacy, and trust/fear. Foundational research is needed on commonly implemented, under-researched interventions, as well as investigating the relative cost-effectiveness of emergency WASH interventions.
Point-of-use water treatment (PoUWT), such as boiling or chlorine disinfection, has long been recommended in emergencies. While there is increasing evidence that these and other PoUWT options improve household water microbiological quality and reduce diarrhoeal disease in the development context, it is unknown whether these results are generalizable to emergencies. The authors conducted a literature review and survey of implementers, and found that PoUWT was effective in small-scale, non-acute, high diarrhoeal disease-risk emergencies when training and materials were provided to recipients, adequate stocks were maintained, and chlorine dosage was appropriate. There was little documented effectiveness in acute emergencies, with untested products, or during large-scale distributions without training. Results were incorporated into the Sphere Revision, which recommends selecting culturally acceptable PoUWT options, providing adequate products and training to recipients, pre-placing PoUWT products in emergency-prone areas, and using locally available products if continued use in the postemergency phase is desired.
Chlorination of drinking water in emergencies: a review of knowledge to develop recommendations for implementation and research needed
Clean water provision is a critical component of emergency response, and chlorination is widely used in emergencies to treat water. To provide responders with practical, evidence-based recommendations for implementing chlorination programmes and recommend areas for future research, we conducted a literature review of chlorination in emergencies, supplemented with a literature review on chlorination in general. We identified 106 total documents, including 7 with information on technical efficacy, 26 on chlorine dosage, 22 on technical challenges, 21 on product options, 8 on user acceptability, 33 on programmes for emergencies, and 8 on monitoring. We found that: 1) international chlorine dosage recommendations in emergencies are highly inconsistent; 2) high-quality information from the general chlorination literature on challenges of chlorination can be adapted for emergencies; 3) many chlorine products are available for use in point-of-delivery, point-of-source, and point-of-use emergency-response programmes; 4) information on the effectiveness of different chlorination programmes in emergencies varies, ranging from little data available to high-quality data that can inform programming; 5) information on user acceptability of chlorination in emergencies is lacking; and 6) monitoring data on chlorine programme effectiveness in emergencies are lacking. In this manuscript, we provide a summary of knowledge on chlorination in emergencies, recommendations for programme implementation, and recommendations for future research needed to assist communities and agencies responding to the increasing number of natural disasters and outbreaks worldwide.
Results from implementing a cohesive strategy and standardized monitoring programme for hygiene kit distribution in Myanmar
Hygiene kits are commonly distributed in humanitarian emergencies to interrupt disease transmission and provide dignity. Despite being commonly implemented, hygiene kit distribution interventions are under-researched, and there is a lack of knowledge on kit efficacy and effectiveness. In Myanmar, the WASH cluster developed a national hygiene kit distribution and monitoring strategy. The research was aimed at determining the effectiveness of this strategy in the context of protracted internally displaced persons camps in Myanmar. To understand programme strategy, we reviewed documents against inclusion criteria; extracted and categorized data for included documents; analysed data; and summarized results. Twenty-six documents met the inclusion criteria of describing strategy development (47 per cent), monitoring in Rakhine (47 per cent) or Kachin State (3 per cent), or monitoring menstrual health and hygiene programme (3 per cent). We identified the strategy was successfully adopted and adapted for Kachin and Rakhine states; however, limitations were identified in receiving consistent monitoring data. We found hygiene kit distributions need to consider local context, including population mobility, local markets and availability of products, and household expenses and debt. Due to these interrelated factors, the percentage of households selling kit items decreased over time; additionally, soap and sanitary pad presence was significantly associated with household income. Consistently, women reported preferring disposable pads for menstrual health and hygiene due to privacy concerns. Programmatically, it is recommended to adapt hygiene kit distributions to local contexts, continue to distribute hygiene kits in protracted contexts to identified at-risk households, distribute disposable pads, and continue revising and improving strategy and monitoring tools.
Hygiene kit distribution and use in humanitarian response: summary of information from a systematic review and key informant interviews
Hygiene kits are commonly distributed in humanitarian emergencies to provide dignity and safety, yet remain under-researched. We aimed to close evidence gaps by completing a systematic review and key informant interviews (KII) to assess current practice in hygiene kits distributions. Fourteen KIIs were conducted and >5,000 documents were screened, with nine meeting inclusion criteria. Existing evidence highlights that reported use of hygiene kit items is high, and standardization, beneficiary involvement in kit design, and post-distribution monitoring are needed. Emergent themes from KIIs were: hygiene kit design; logistics/procurement; field appropriateness/feedback; and recommendations. Unexpectedly, menstrual health management (MHM) and market-based programming (MBP) dominated the literature. Overall, hygiene kit distributions are governed by ‘best practice’ rather than ‘evidence base’. This limited evidence base is stark compared to more robust evidence for market-based programming. As a common definition of hygiene kits was lacking, we developed and present a hygiene kit typology. We recommend hygiene kit programming: 1) understands local context, cultural norms, and preferences by incorporating beneficiary consultation and feedback; 2) ensures item type and quantity is what beneficiaries need; 3) ensures hygiene kits are context-appropriate, and considers concurrent MHM and/or MBP programming; and 4) works with coordination mechanisms to harmonize kit materials, delivery, and monitoring.