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Catching up with the Authors: Aurélie Jeandron and Ayse Ercumen on Clean Water Supply in the DRC and India

Last October PLOS Medicine published two research articles from separate groups investigating the association between continuous clean water supply and waterborne diseases.  Aurélie Jeandron and colleagues found that interruptions to the piped water supply to Ulvira, a town in Eastern Democratic Republic of the Congo (DRC) were followed by an increase in admissions to the local cholera treatment center. Ayse Ercumen and colleagues found that that upgrades to provide continuous clean water supply to households in urban Hubli-Dharwad, India were associated with decreases in typhoid, but did not observe the expected difference in diarrheal diseases. 

In the first of our “Catching up with the Authors” series, I recently emailed the first authors of the two research articles and asked them about the challenges of conducting their research, questions and projects that arose from their studies, and what they’re working on now.

The experience, challenges, and limitations of conducting research in resource limited settings: what scientific compromises must be made, or creative solutions to challenges did you come up with?

Aurélie Jeandron, London School of Hygiene & Tropical Medicine:

In my experience, the main challenge with conducting research in Eastern DRC is the complex humanitarian situation rather than the fact that it is a resource-limited setting. We face much uncertainty when planning our fieldwork, and we often need to adjust our research protocols to adapt to changing circumstances. The changes we face may be linked to raised insecurity and political events, but also to a change of operational presence of international NGOs in the research area, with new teams and new health programmes that must be integrated into the research.

I feel that the main compromise we have to make is to focus much more on the short-term and therefore more certain research goals as opposed to longer term multi-year objectives. Despite this we strive to ensure that our research is of the highest attainable quality so that our results can help build robust evidence-based responses to public health and humanitarian crises. In my own view it is more important to leave some research questions unanswered rather than producing biased or invalid results that may hinder rather than help policy.   

Given that your research demonstrated an association between water supply and suspected cholera incidence, are there efforts to improve the reliability of piped water delivery, or other measures in place to improve hygiene?


The results we published in PLOS Medicine were part of a 4 year project with the Veolia Foundation and the French Development Agency. With European Union funding, the existing tap water supply network in Uvira will be repaired and developed, with 142 community-managed public taps created and a plan to go from about 2,800 water taps to more than 5,000. It is expected to significantly improve the town’s access to drinking water by 2018 and thereby potentially reduce cholera and other diarrhoeal diseases incidence.

One goal of the project was to improve the reliability of the tap water supply by building a hydro-electric generator to prevent the frequent power cuts that prevent treated water being pumped through the system. Further engineering plans, however, determined that the geological setting was inappropriate to build a small dam at an affordable cost, which means that improving water supply reliability remains a challenge. More feasibility studies are on-going to identify another solution – for example solar panels. In any case, improvements in the water supply reliability are still expected with the construction of a new water tower that will double the tap water storage capacity, and therefore act as a buffer during shorter power cuts periods.

Hygiene promotion and sanitation improvements are not directly part of the same project. However, better water access could lead to an increased water consumption in households that is expected to be mostly devoted to hygiene practices.

Water cascading over a pair of hands.
Image credit: Hygienematters, Flickr

What are you working on now? (water related or not)


My current research priority is the design and implementation of a large-scale impact evaluation of the water supply intervention described above. Data collection for this evaluation started a few months ago, and will last for another 3 years. The evaluation focuses on the impact of these improvements in access to safe water on water quality and hygiene practices in households, and on severe diarrhoeal diseases, including cholera.

Poor access to clean water is a recognized major risk factor for cholera and diarrhoeal diseases transmission. There is however limited reliable evidence of the degree to which it is prevented by affordable improvements in water supply or how the interventions should be designed to optimise its impact on cholera, in particular in endemic settings.We are hoping this impact evaluation will address this gap.

Even if this rather ambitious study is interrupted, we are already generating descriptive data on the current cholera and water situation in Uvira that will still provide much needed data available on water supply and cholera in Eastern DRC.



The experience, challenges, and limitations of conducting research in resource limited settings: what scientific compromises must be made, or creative solutions to challenges did you come up with?

Ayse Ercumen, University of California, Berkeley:

Urban environments in low-income counties are home to dynamic populations with rapid turnover, especially in informal settlements, making retention of participants challenging in a year-long longitudinal study like ours. High rates of loss to follow-up can impact the statistical power of the study to detect associations and, if differential, also introduce bias into the findings. To ensure adequate statistical power, we inflated our number of enrolled participants by 10% in anticipation of attrition. We also conducted several analyses to check for any potential bias from differential attrition, including assessing whether loss to follow-up was associated with treatment group or any characteristics of participants, comparing the balance between study groups both in the original enrolled population and among households that completed the study, and comparing effect estimates between a complete case analysis and an inverse probability of censoring-weighted analysis that reconstructs the original enrolled population. Approximately 16% of participants were lost to follow-up throughout the one-year study period. We found similar rates of loss to follow-up in the two study groups, and while households that left the study were (not surprisingly) less likely to be homeowners, the two study groups remained well-balanced in the proportion of homeowners and other covariates. Finally, the inverse probability of censoring-weighted analysis yielded estimates similar to the complete case analysis, providing reassurance that our study findings were not biased by loss to follow-up.

Though your study found that continuous water supply was associated with reductions in typhoid fever, it was not  found to be associated with decreased diarrheal illness overall. Potential explanations for the negative result included continued reliance on stored water even in households with continuous supply, and other sources of contamination, like open sewage canals or garbage heaps. Perhaps you can comment on the importance (and difficulty?) of improving all of these potential routes of transmission in LMIC?


Fecal-oral pathogens are transmitted from feces to new hosts through a variety of complex, environmentally mediated pathways that interact with each other and are also influenced by human behavior. Studies focused on individual pathways have generally documented reductions in child diarrhea in response to efforts to reduce fecal contamination through water, sanitation and hygiene (WASH) interventions in low-income settings, such as water treatment, safe storage of water in the home, and hand-washing, while the health impact of sanitation improvements remains equivocal. Another major knowledge gap is the differential health impact achieved by individual vs. combined WASH interventions; there is no evidence to date on whether addressing multiple transmission pathways by combining interventions achieves larger reductions in diarrhea than individual interventions focused on a single pathway.

What are you working on now? (water related or not)


Currently, I am working on a randomized controlled trial of individual and combined WASH interventions in rural Bangladesh (the WASH Benefits trial), where I quantify fecal contamination along several diarrhea transmission pathways in the domestic environment beyond the waterborne route, including child and caregiver hands, courtyard soil, weaning foods and flies. These measurements will help assess the effectiveness of WASH interventions in reducing fecal contamination in various environmental media and illuminate the relative contribution of different pathogen transmission pathways to child diarrhea in low-income environments.


Featured image credit: Snapr, Flickr

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