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Piloting an automated batch chlorination system at shared water points in an urban community of Dhaka

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Introduction Point-of-use water treatment may reduce diarrheal disease but has been poorly adopted and inconsistently used among low-income households. Community-level water treatment, such as automated disinfection at shared water points, has received little attention in part because appropriate technologies are lacking. The ZIMBA is a batch chlorinator which dispenses a preset dose of 3ml of 0.4% sodium hypochlorite solution into a holding tank for every 10L of water. Upon chlorination, water is flushed by an automatic siphon into a storage reservoir and dispensed via a tap. We conducted a study to assess acceptability and the accuracy and consistency of chlorine dosing and microbial water quality of ZIMBA chlorinated municipal water among low-income urban neighborhoods in Dhaka. Methods From February to April 2012, we enrolled 11 household (HH) compounds (with 9-30 HHs in each) from an urban slum where HHs access water from a handpump connected to the municipal piped supply. Five HHs from each compound that had at least one child <5 years were selected to participate in household surveys. At baseline, fieldworkers tested water turbidity, free and total chlorine using a digital colorimeter, and collected stored drinking water from control (N=24) and treatment (N=30) HHs to assess levels of E. coli contamination. After baseline, ZIMBA chlorine dispensers were installed at six handpumps assigned to receive water treatment. During biweekly visits, fieldworkers collected three types of water samples: pre-treated handpump water (N=23 from control HHs; N=24 from treatment HHs), ZIMBA water immediately after chlorination (N=23), and stored drinking water (N=96 from control HHs; N=84 from treatment HHs). In-depth interviews were conducted with 12 respondents (two respondents from each treatment compound). Results At baseline, mean levels of turbidity (1.5 nephelometric turbidity units [NTU]), chlorine residual (0.1 ppm), and E. coli contamination (0.67 log colony forming units [cfu] /100mL) were similar in control and treatment households. Two compounds in the treatment group withdrew from the study post-installation of the ZIMBA. Water samples collected directly from the ZIMBA devices were between 0.2-2ppm (a “safe” chlorine residual) 91% of the time (8% were slightly above 2ppm), whereas only 13% of raw handpump water samples among treatment compounds and 39% of handpump samples among control compounds had a safe chlorine residual. A total of 81% of stored drinking water samples had a safe chlorine residual among treatment HHs, compared to 29% of stored water samples in control compounds (p<0.001). Free chlorine levels in stored water were significantly higher in treatment HHs compared to control (mean difference=0.33ppm, p<0.001). Mean log E. coli was -0.2 cfu/100ml in ZIMBA chlorinated water and 0.1 log cfu/100ml in stored ZIMBA-treated water. Only 4% of the ZIMBA chlorinated water and 8% of household stored ZIMBA-treated water had E. coli >10cfu/100ml. In comparison, 26% of untreated handpump water (mean log cfu=0.4/100ml) and 28% of control household stored water samples (mean log cfu=0.5/100ml) among control HHs had E. coli >10cfu/100ml. The concentration of E. coli in stored water was lower in treatment HHs compared to control HHs (mean difference=0.4cfu/100ml, p=0.004). Among the ZIMBA users who kept using the ZIMBA for 12 weeks, 56% thought that this device was easy to use and 83% were satisfied with the device. More than 70% of mothers were satisfied with the water taste, and 69% were satisfied with the smell. All respondents (female caretakers) mentioned that the water smelled like medicine initially; with time, however, most reported they got used to the smell. By the end of the study, 67% of mothers mentioned the water taste was good. About 88% believe that drinking ZIMBA chlorinated water is healthier for their family and 50% stated their household would be willing to pay 10 taka ($0.13 USD) per week for chlorine refills and continued access to the ZIMBA. During in-depth interviews all mentioned that drinking chlorinated water is safer and can prevent diseases. Most users (9 out of 12) reported that collecting water took more time due to the batch chlorination design of the ZIMBA. Conclusion ZIMBA automated chlorine dispensers provided accurate and consistent dosing of free chlorine. The ZIMBA also successfully reduced E. coli contamination in drinking water. Our study suggested the ZIMBA may be a more appropriate technology for rural communities where there is less queuing for water. Efforts to improve the user interface should be considered before commencing scale-up.
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Research Paper
Field trial of an automated batch chlorinator system at
shared water points in an urban community of Dhaka,
Nuhu Amin, Yoshika S. Crider, Leanne Unicomb, Kishor K. Das,
Partha Sarathi Gope, Zahid Hayat Mahmud, M. Sirajul Islam,
Jennifer Davis, Stephen P. Luby and Amy J. Pickering
Point-of-use water treatment with chlorine is underutilized in low-income households. The Zimba, an
automated batch chlorinator, requires no electricity or moving parts, and can be installed at shared
water points with intermittent ow. We conducted a small-scale trial to assess the acceptability and
quality of Zimba-treated municipal water. Fieldworkers collected stored drinking water over a 10-week
period from control (n¼24 households) and treatment (n¼30 households) compounds to assess levels
of free chlorine and E. coli contamination. Overall, 80% of stored drinking water samples had a
safe chlorine residual among treatment households, compared to 29% among control households
(P<0.001). Concentrations of E. coli were lower (mean difference ¼0.4 log colony-forming units/
100 mL, P¼0.004) in treatment compared to control households. Fifty-three percent of mothers
(n¼17), thought the Zimba was easy to use and 76% were satised with the taste. The majority of
mothers mentioned that collecting water from the Zimba took more time and created a long queue at
the handpump. The Zimba successfully chlorinated household stored drinking water; however, further
technology development is required to address user preferences. The Zimba may be a good option for
point-of-collection water treatment in areas where queuing for water is uncommon.
Nuhu Amin
Leanne Unicomb
Kishor K. Das
Partha Sarathi Gope
Zahid Hayat Mahmud
M. Sirajul Islam
Stephen P. Luby
International Centre for Diarrhoeal Disease
Research, Bangladesh (icddr,b),
Yoshika S. Crider
Jennifer Davis
Stephen P. Luby
Amy J. Pickering (corresponding author)
Stanford University,
Key words |automated chlorine dispenser, Bangladesh, chlorination, household water treatment,
urban, water quality
Each year, more than 800,000 children <5 years old, mostly
from low-income countries, die of diarrhea (Liu et al. ).
Evidence from randomized controlled trials suggests that
point-of-use (POU) water treatment with chlorine reduces
reported diarrheal disease (Fewtrell et al. ;Arnold & Col-
ford ;Clasen et al. ), but POU techniques have been
poorly adopted and inconsistently used among low-income
households (Rosa & Clasen ). Two major barriers to
uptake of POU technologies are the formation of new habits
and the amount of time required each day for water treatment
(Luby et al. ;Luoto et al. ). For example, one reason
for low adoption of POU chlorine technologies might be the
requirement to add chlorine each time drinking water is col-
lected, which requires personal motivation, knowledge and
behavior change. If these criteria are not met, inconsistent
and inaccurate chlorine dosage could result.
An additional limitation of current POU chlorination is
that treatment of varying batch sizes requires customized
dosage volumes (i.e., for 5, 10 or 20 L) (Clasen & Edmondson
;Kremer et al. a,b), and users may not know how
32 Research Paper © IWA Publishing 2016 Journal of Water, Sanitation and Hygiene for Development |06.1 |2016
doi: 10.2166/washdev.2016.027
to measure out different sized chlorine doses. There are lim-
ited options for low-cost, accessible water treatment for
larger (>10 L per day) quantities of water. Similarly, smaller
amounts (i.e., one glass or jug) are not easily dosed with the
same products used for more common larger collection
Because of the barriers to POU water treatment, manual
chlorine dispensers have been promoted to encourage house-
holds to treat their water at the time they collect it (Kremer
et al. a,b). Manual chlorine dispensers are designed
to add 3 mL of diluted chlorine to 1020 L of water (depend-
ing on the concentration) with the turn of a knob. These
dispensers are installed next to communal water points
(Kremer et al. a,b). Manual dispensers have certain
advantages over POU treatments with liquid chlorine at the
household level (Lantagne ), since the dispenser provides
the correct dosing if the collection container is a standard size
(no need to measure chlorine) and also takes advantage of
peer-effects when installed at public sources (Kremer et al.
a,b). Nevertheless, the manual chlorine dispenser
still requires users to add chlorine during each water collec-
tion event, and to calculate the number of turns necessary
for their vessel size (International Centre for Diarrhoeal Dis-
ease Research, Bangladesh icddr,b ).
The Zimba automated batch chlorinator was invented to
reduce barriers to water treatment by focusing on automated
treatment at the community level. The Zimba attaches to
handpumps and dispenses a dose of 3 mL of NaOCl sol-
ution into a mixing chamber for every 10 L-batch of water
that ows through the device. After chlorination, water is
ushed by an automatic siphon into a storage reservoir
and dispensed via a tap (Figure 1). The Zimba does not
Figure 1 |Zimba automated chlorine dispenser. Figure provided by inventor Suprio Das. Figure showing(a) Outer box: upper part of outer box holds dosing chamber and lower part acts as
a secondary tank which water ushes into after chlorination. (b) Dosing chamber: this chamber holds an automatic siphon and the chlorine dispenser. As untreated water from
the handpump starts lling up this chamber, 3 mL of sodium hypochlorite solution is ejected from the chlorine dispenser into this water. When the water level reaches the high
water level (10 L) the automatic siphon is triggered and this 10 L of treated water is ushed into the secondary tank. (c) Siphon: water from the dosing chamber ushes into the
secondary tank through the siphon. (d) Chlorine dispenser: this consists of a chlorine reservoir and a combination of interconnected pipes and tubes. Dimensions of the Zimba
are 76 ×45 ×25; the outer casing, dosing chamber and the siphon are made of berglass and the dispensers are made of acrylic.
33 N. Amin et al. |Field trial of an automated batch chlorinator system Journal of Water, Sanitation and Hygiene for Development |06.1 |2016
require custom-sized water collection vessels or manual
addition of chlorine. We conducted a small-scale trial to
assess acceptability, accuracy, and consistency of chlorine
dosing by the Zimba, and to assess the microbial water qual-
ity of Zimba-chlorinated municipal water.
Study site
The study was conducted from February to April (before the
rainy season) in 2012 among compounds in low-income neigh-
borhoods in the Mirpur neighborhood of Dhaka. A low-income
urban compound in these communities consists of multiple
households that share common cooking areas, toilets, and
water collection points, typically all owned by a single landlord.
In our study area, water was extracted through a motorized
pump attached to network pipes that connect to a deep bore-
well maintained by the Dhaka Water Supply and Sewerage
Authority (DWASA). The borewell was also equipped with a
broken chlorine injector; the operator of DWASA did not
know when it would be repaired. Regular interruptions in the
pumps electricity supply cause the distribution system to
become unpressurized. DWASA also intentionally distributes
water intermittently in some areas because demand exceeds
supply. When the system becomes unpressurized, sewage can
be sucked into damaged pipes that pass through the open drai-
nage system (Kumpel & Nelson ).
Each of the water collection points (handpumps) in our
study area was located within a compound and was used for
drinking and other household uses. All study compounds
met the following eligibility criteria: (1) the water point
was located in a compound and shared by 530 households,
(2) the water point delivered water from the DWASA distri-
bution system, (3) the water was extracted by a manual
handpump, and (4) the water point was the compounds pri-
mary drinking water source.
Sample frame
We selected Dhamalcot slum at Bhashantek, Mirpur, where
the household compounds were divided by four separate
streets. From these streets we purposively selected the two
longest streets and randomly assigned one street to control
and another street to treatment with the Zimba. We assigned
treatment by street to avoid contamination between treatment
and control groups. Fieldworkers used convenience sampling
to enroll six eligible compounds from the street of treatment
compounds and ve eligible compounds from the street of
control compounds. Fieldworkers also used convenience
sampling to select ve households from each treatment and
control compound to participate in household surveys at base-
line and end-line; mothers with at least one child under 5
years were given preference for enrollment (Figure S1).
Trained eldworkers visited eligible households to
describe the study prior to collecting baseline information.
Fieldworkers introduced the Zimba to mothers in the com-
pounds, explained its advantages and disadvantages, and
showed how it worked using pictorial cue cards. The eld-
worker provided a consent form written in Bengali and
requested mothers to discuss the study and the device with
other household members, then collected the signed con-
sent on the following visit. Fieldworkers also obtained
written consent from the landlord/compound managers.
The study protocol was reviewed and approved by the Insti-
tutional Scientic and Ethical Review Committees at the
International Centre for Diarrhoeal Disease Research, Ban-
gladesh (icddr,b) (protocol number # PR-09048).
Baseline survey and household water testing
Fieldworkers conducted quantitative surveys with mothers
(ve surveys from each compound) to gather information
on demographic characteristics of households, perceptions
of drinking water quality, water collection and storage prac-
tice, water treatment practice and satisfaction with the
current water supply. In each compound, a eldworker then
tested the existing water supply (handpump and stored
water) from all households for water turbidity and free and
total chlorine using a digital colorimeter (LaMotte Model
1200, LaMotte Company, Chestertown, Maryland) and tur-
bidity meter (LaMotte Model 2020i, LaMotte Company,
Chestertown, Maryland). The eldworker then collected
handpump and stored water samples from all households
using 300 mL sterile sample collection bags containing a
sodium thiosulphate tablet (Nasco Whirl-Pak
,19×38 cm,
Fort Atkinson, Wisconsin) to neutralize any chlorine that
34 N. Amin et al. |Field trial of an automated batch chlorinator system Journal of Water, Sanitation and Hygiene for Development |06.1 |2016
could be present. Samples were immediately placed into a
cold box, maintained at <10 WC with ice packs, and sent to
the Environmental Microbiology Laboratory at icddr,b to
assess levels of E. coli and total coliform contamination.
Description of the Zimba
The Zimba is made of three parts: a dispenser containing
diluted household bleach (NaOCl), a dosing chamber contain-
ing an automated siphon, and an outer box that holds the
siphon tank and the dispenser (Figure 1). The handmade
Zimba prototype cost about 100 US$ to produce, including
labor costs; it works without electricity and has no moving
parts. The Zimbas chlorine dispenser can treat approximately
8,000 L of water (1 mg/L concentration of free chlorine in
source water) between each chlorine rell. See supplemental
information for additional details (available in the online ver-
sion of this paper). The Zimba is mounted on an iron stand
approximately 30 cm in height. A chlorine dispenser compris-
ing a chlorine reservoir connected by tubes to two chambers
(pressure chamber and constant level chamber) sits on the
dosing tank. When untreated water from the handpump falls
by gravity into the dosing tank, positive air pressure pushes
the chlorine out from the trap through the ejection tube,
where it mixes with water in the dosing chamber. After this,
the water level in the dosing chamber rises until it reaches a
water level of 10 L. Then, the treated water ows through
the siphon to the secondary storage tank. When the water
level goes down in the dosing chamber, the resulting negative
pressure pulls chlorine up from the constant level chamber to
ll the trap. The trap was designed to hold 3 mL of NaOCl.
Chlorine purchase and dilution
Two eldworkers purchased household bleach (5.25%
NaOCl) from the local market and diluted it with distilled
water to a concentration of 0.6% NaOCl to achieve 2 mg/L
of free residual chlorine when added by the Zimba to source
water. The concentration of chlorine was closely monitored
before delivery. We eventually reduced the NaOCl concen-
tration to 0.4% to achieve 1.5 mg/L of free chlorine in
source water because study participants complained about
the strong smell of chlorine. The same two eldworkers
relled all Zimba dispensers with chlorine twice a week.
Intervention delivery
At least one day prior to installation of the Zimba, an interven-
tion promoter held compound-wide meetings with study
participants to introduce chlorinated water and its potential
health benets and to give instructions for using the Zimba.
During promotional activities, eldworkers advised study par-
ticipants to drink the treated water 30 minutes after collection
to allow time for disinfection. The eldworkers also requested
that study participants share this information with other
household members. With the help of a local handpump
mechanic, eldworkers increased the height of the handpump
by 12 inches and installed Zimba chlorine dispensers in the
six treatment compounds. The mechanic also maintained
the handpumps throughout the study period.
Follow-up and end-line surveys
During twice-weekly follow-up visits and one end-line visit,
eldworkers collected two types of water samples from
treatment households: treated Zimba water directly from
its secondary tank, and household stored drinking water.
From control households they collected handpump water
and stored drinking water. At the end of the three-month
intervention, eldworkers conducted an end-line quantitat-
ive survey to assess satisfaction with the current water
system and perceptions of water taste, smell, and water qual-
ity among control and treatment compounds enrolled at
baseline. Fieldworkers also administered the survey to new
households with children under 5 years old that moved
into the compounds during the study period.
Qualitative in-depth interviews
Fieldworkers used convenience sampling to select two
mothers with at least one child <5 years old from each treat-
ment compound. A trained eldworker used a written guide
to conduct in-depth interviews focusing on how the Zimba
chlorinator performed, how regularly they drank chlorinated
water treated by the Zimba, perceptions (likes/dislikes and
advantages/disadvantages) of chlorinated water and the
Zimba device, and changes in taste and smell of treated
water over the study period. Fieldworkers collected sugges-
tions for making the Zimba more user-friendly.
35 N. Amin et al. |Field trial of an automated batch chlorinator system Journal of Water, Sanitation and Hygiene for Development |06.1 |2016
Fieldworkers elicited perceptions among other family mem-
bers, relatives, and neighbors regarding the Zimba. In-depth
interviews were recorded using a digital audio recorder.
Microbial water quality testing
All water samples were ltered within 6 hours of collection.
E. coli and total coliform concentrations were enumerated
using membrane ltration following the United States
Environmental Protection Agency (USEPA) Standard
Method 1604 (USEPA ). In brief, 100 mL of each
sample was ltered through a 0.45 micrometre lter, then
the lter was placed on MI agar media and incubated at
35 WC for 24 hours. Blue-colored colonies were enumerated
as E. coli and colonies that uoresced under long-wave
UV light (366 nm) were enumerated as total coliforms
(E. coli were included in the total coliform count). Agar
plates with 500 colony-forming units (CFU) were designated
as too numerous to count (TNTC) which follows previous
published protocols (Pickering et al. ;Peletz et al. ).
One duplicate sample was analyzed for every 10th sample col-
lected; one lab blank (100 mL distilled water) was ltered
each day as a control. Plates with >500 CFU were not feasible
to count because the colonies cannot be distinguished from
each other; growth is also inhibited due to crowding.
Quantitative data analysis
To compare the mean difference between groups, microbial
water quality samples under the detection limit were assigned
the value of 0.5 CFU/100 mL and samples above the detec-
tion limit were assigned the value of 500 CFU/100 mL. To
compare the mean difference within groups and between con-
trol and treatment stored water samples we converted
bacterial counts into log
scale and performed regression
modeling, adjusted for clustering at the compound level. We
adjusted compound level clustering using robust standard
error of the mean difference. See supplemental information
for further details.
Qualitative data analysis
The eldworker who recorded all in-depth interviews down-
loaded them and transcribed them in Bengali so thematic
content analysis could be performed. The investigator,
N.A., manually coded the transcripts according to our
research objectives. After coding, he categorized the data
under different themes and matched these themes to factors
inuencing acceptability and feasibility.
Two compounds (comprising 10 households each) in the
treatment group withdrew from the study after installation
of the Zimba and were not included in the analysis. One
withdrew because the additional time required to pump
the water into the siphon tank was inconvenient and the
other because the amount of space that the device occupied
interfered with cleaning utensils and washing clothes. Three
households in treatment compounds moved out during the
study period and were not included in the analysis. A total
of 24 (96%) control households (one household decided
not to participate following enrollment) and 30 (100%) treat-
ment households were interviewed at baseline. During the
end-line survey, eldworkers conducted interviews with 24
(96%) control and 17 (57%) treatment households. Mothers
from 12 treatment households (2 per compound) partici-
pated in qualitative data collection.
Baseline characteristics of control and treatment
Demographic and socioeconomic
At baseline, the age, education of respondents, number of
<5 years old children and other members per household,
and monthly income were comparable across control and
treatment households (Table S1).
Water collection and storage practice
Fourteen (58%) mothers in control households and 13 (43%)
mothers in treatment households collected their drinking
water using a plastic pitcher/jug (23 L). All control and treat-
ment households (100%) stored their drinking water; 19
(79%) control households and 20 (67%) treatment house-
holds reported usually covering their stored water with a lid.
36 N. Amin et al. |Field trial of an automated batch chlorinator system Journal of Water, Sanitation and Hygiene for Development |06.1 |2016
On average, water was available at handpumps for more than
20 hours per day in all households (Table S1). About 8 L of
water per person was collected for cooking, storing and drink-
ing in a typical day in both control and treatment households.
Among all treatment and control households, only one treat-
ment household reported treating their drinking water by
boiling (Table S1).
Stored water quality
Stored water samples at baseline contained negligible amounts
of free and total chlorine (mean free chlorine ¼0.10 mg/L,
SD ¼0.06 in control compounds, and 0.08 mg/L, SD ¼0.05
in treatment compounds). Microbial quality of stored water
was similar in control (log-mean CFU of E. coli ¼0.8) and
treatment (log-mean CFU of E. coli ¼0.6) households. At base-
line, samples of stored water from two (7%) treatment
households and one (4%) controlhousehold had free chlorine
within the 0.22.0 mg/L range (Table S1).
Follow-up and end-line visits
Accuracy and consistency of chlorine dosing at treatment
All water samples collected immediately after chlorination
from the Zimba (100%) were within the 0.22 mg/L range
for free chlorine (mean ¼1.3 mg/L, SD ¼0.54) and total
chlorine (mean ¼1.4 mg/L, SD ¼0.58). Mean free and
total chlorine levels in household stored water samples
were signicantly higher in treatment households compared
to control households (mean difference of free chlorine ¼
0.33, P<0.001). In treatment households, 16 (20%) stored
water samples contained <0.2 mg/L of free chlorine
(Table 1). Average free chlorine in water samples collected
directly from the Zimba was 1.3 mg/L and in stored water
was 0.5 mg/L (Table 1,Figure 2).
Microbial water quality in control and treatment
All processed laboratory blanks were free from contami-
nation with E. coli. After installation of the Zimba, levels
of bacterial contamination in stored water samples were
lower in treatment households compared to control house-
holds (log-mean difference E. coli count between
treatment vs. control households ¼0.43 CFU/100 mL,
P¼0.002 of water; and log-mean difference total coliform
count between treatment vs. control households ¼0.61
CFU/100 mL of water, P¼0.029) (Table 1). In treatment
households, 72% of stored water samples had <1 CFU/
100 mL E. coli, compared to 51% in control households
(proportion difference ¼21%, P¼0.004) (Figure 3). In treat-
ment households, stored water samples with free chlorine
within the 0.22 mg/L range had less bacterial contami-
nation (log-mean E. coli ¼0.3CFU/ 100 mL) compared
to samples with chlorine level <0.2 mg/L (log-mean E. coli
¼0.5 CFU/100 mL; log-mean difference ¼0.52, P¼0.001).
Only 6% of E. coli samples were TNTC so this did not
meaningfully affect E. coli analysis, but it may have affected
the total coliform analysis.
End-line surveys
Acceptability and perception of water supply in control
and treatment households
At end-line, 3 (12%) mothers from control households stated
that they were not satised with their water due to its poor
quality, and 5 (29%) mothers from treatment households
mentioned that they were not satised with their water
due to the bad smell (chlorine). In control and treatment
households 100% of mothers mentioned that the drinking
water from their current water source is safe to drink (Sup-
plemental information Table S2).
Acceptability of Zimba
At end-line, only one (4%) respondent from a control house-
hold and ve (29%) respondents from treatment households
reported a bad (chlorine) smell in their drinking water.
Among the Zimba users who kept using the Zimba for 12
weeks, only half (53%) the mothers thought the device
was easy to use, but most (88%) were satised with it. Thir-
teen (76%) mothers were satised with the water taste, and
12 (71%) were satised with the smell. Fourteen (85%)
mothers believed that drinking Zimba chlorinated water
was healthier for their families.
37 N. Amin et al. |Field trial of an automated batch chlorinator system Journal of Water, Sanitation and Hygiene for Development |06.1 |2016
Qualitative assessment
During the qualitative in-depth interviews (n¼12) in treat-
ment households, most of the mothers (9 out of 12)
mentioned that the machine puried the water by killing
germs. Some respondents also described the Zimba as a
water lter. All mentioned that the water had a medicinal
smell, but they became accustomed to it during the course
Figure 2 |Free chlorine level in control (n¼24) and treatment (n¼23) handpumps, and
in stored water at control (n¼83) and stored water at treatment (n¼96)
households over time during follow-up visits, in Mirpur, Dhaka, 2012.
Figure 3 |Percentage of household on y-axis (control n¼83 and treatment n¼96) with 0
E. coli per 100 mL in stored water over time during follow-up visits, in Mirpur,
Dhaka, 2012.
Table 1 |Water chlorine residual, turbidity, and fecal indicator bacteria concentration among control and treatment households during bi-weekly follow-up household visits, Mirpur,
Control group n(%) Treatment group n(%)
Mean difference between control vs.
treatment households (P-value)
Water quality
Source water
Stored water
Source water at
baseline (n¼24)
Zimba water
Zimba stored
water (n¼82)
Untreated source
water Stored water
Turbidity (NTU)
<5 23 (100) 96 (100) 24 (100) 23 (100) 82 (100)
Mean (SD) 1 (0.52) 0.72 (0.47) 0.73 (0.39) 1 (0.33) 0.73 (0.34) 0.30 (0.006) 0.02 (0.724)
Free chlorine (mg/L)
<0.2 14 (61) 69 (72) 21 (88) 0 16 (20)
0.22 9 (39) 27 (28) 3 (12) 23 (100) 66 (80)
Mean (SD) 0.18 (0.17) 0.17 (0.12) 0.12 (0.08) 1.3 (0.54) 0.5 (0.5) 0.06 (0.054) 0.33 (0.001)
Total chlorine (mg/L)
<0.2 13 (57) 57 (59) 17 (71) 0 9 (11)
0.22 10 (43) 39 (41) 7 (29) 19 (83) 71 (87)
>2 0 0 0 4 (17) 2 (2)
Mean (SD) 0.22 (0.17) 0.2 (0.12) 0.16 (0.09) 1.4 (0.58) 0.55 (0.52) 0.06 (0.102) 0.35 (0.001)
Log-mean E. coli
CFU/100 ml (SD)
0.45 (1) 0.54 (1.1) 0.4 (1) 0.16 (0.4) 0.11 (0.84) 0.05 (0.773) 0.43 (0.002)
Log-mean total
CFU/100 ml (SD)
1.3 (1) 1.6 (1.1) 1.2 (1) 0.5 (0.9) 1 (1.2) 0.09 (0.029) 0.61 (0.002)
38 N. Amin et al. |Field trial of an automated batch chlorinator system Journal of Water, Sanitation and Hygiene for Development |06.1 |2016
of the study. All mothers also mentioned that they obtained
all drinking water from the Zimba because it was safe for
their children. Most mothers (10 out of 12) mentioned that
the rst few weeks after installation of the Zimba they
noticed a strong smell of chlorine but only two respondents
complained of bad taste. All mothers also mentioned that
they considered drinking chlorinated water to be safer
than drinking untreated water and that treating water with
chlorine could prevent diseases. Most users (9 out of 12)
reported that they liked the Zimba but collecting small
amounts of water (i.e., one glass or one jug [23 L]) took
more time and created a long queue. One mother said,
Before installing the machine (Zimba) we did not need to
wait for water, but now we have to wait for water which
makes a long queue.Some (3 out of 12) mentioned that
the increased height of the handpump made it difcult to
pump water, particularly for children. Mothers also men-
tioned that they would not be able to rell the Zimba
chlorine dispenser because of its complexity. They also
requested technical assistance for repair and relling of
the Zimba dispenser.
The concentration of free residual chlorine in water samples
collected directly from Zimba automated chlorine dispen-
sers was consistently observed to be within the World
Health Organization (WHO) recommended range (0.2
2 mg/L). Over a 10-week period, the percentage of house-
holds with stored water with a safe level of free chlorine
was 80% in treatment households, while it remained low
(28%) in control households. Despite the apparent dosing
success of the Zimba, 20% of stored water samples from
treatment households did not contain the WHO-rec-
ommended chlorine level, and 28% were contaminated
(>1 CFU/100 mL) with E. coli. Possible explanations for
the absence of detectable free chlorine include collecting
water from other sources, undetected Zimba dosing incon-
sistencies, or consumption of free chlorine as a result of
water handling that leads to re-contamination (Quick et al.
One important contribution to the low adoption rates of
POU water treatment using NaOCl is the unpleasant taste
and/or smell in treated water (Clasen & Edmondson ;
Albert et al. ;Luoto et al. ). A study in southeast
Africa suggested that participants in Ethiopia did not taste
the chlorine residual at 1.0 mg/L (sodium hypochlorite),
noticed the presence of chlorine at 2.0 mg/L, and found
the taste objectionable at 3.0 mg/L. But in Zambia partici-
pants found the taste of chlorine to be too strong at
2.0 mg/L (Lantagne ). In our study, the average free
residual in stored water was low (0.5 mg/L, SD ¼0.5, range
¼0.071.8 mg/L), but 29% of Zimba users had not become
accustomed to the chlorine taste and smell after three
months of use. It is possible that the combination of chlorine
compounds with organic materials in the water affects taste
perceptions, which would vary by geographic location, high-
lighting the importance of adjusting the dose of NaOCl in
future studies according to participant preferences. A
higher dose of free chlorine could improve disinfection,
but it is unlikely that users in this study would have accepted
a dose higher than 1.0 mg/L.
The DWASA pump supplying the study area was
equipped with a broken chlorine injector. The spike of
chlorine in the stored water of control households during
the 3rd to 5th weeks of the study (Figure S2) may have
been due to the chlorine injector being activated by
DWASA. The chlorine level of Zimba treated water did
not go beyond the WHO recommended range of free chlor-
ine when the injector was on. These results suggest that even
though DWASA was attempting to chlorinate the municipal
water, it did not provide safe water consistently, as has been
found in municipal systems in India (Brick et al. ;
Kumpel & Nelson ).
The Zimba dispensers dose in 10 L batches, so if the sec-
ondary tank empties then users need to ll the 10 L tank
even when only a small quantity of water is required. To
pump 10 L of water using a typical handpump in Dhaka
takes an average of 60 seconds (range ¼32117 seconds,
n¼18) if pumped continuously (Yoshika Crider, unpub-
lished data). Since mothers already spend substantial time
collecting water and carrying out other household tasks
(Hanchett et al. ), they might be unwilling to spend
the additional time for pumping 10 L water when they
require only 23 L. Since the water sources were close to
the households, the users did not collect or store large
volumes. A smaller batch chlorination volume could make
39 N. Amin et al. |Field trial of an automated batch chlorinator system Journal of Water, Sanitation and Hygiene for Development |06.1 |2016
water collection from the Zimba more efcient in this
Several design changes could improve the Zimba. The
Zimba dispenser occupies signicant space (45 ×25 cm)
when installed, thus installation may not always be possible
due to space limitations in urban slums. Future iterations of
the Zimba could be more compact. The Zimba required fre-
quent visits from trained eld staff to rell the dispensers,
which is an issue for its sustainability. The reservoir capacity
could be increased so that the need for relling is less fre-
quent. In addition the Zimba used a low concentration
NaOCl solution (0.4%), which is non-standard and requires
dilution before lling the Zimba dispenser. Future models of
the Zimba could aim to use a higher concentration of
NaOCl to reduce the need for dilution (Lantagne et al. ).
Some limitations to this study should be acknowledged.
No other similar technologies were available at the time of
this study to compare the efcacy of the device. Further
studies should aim to compare the effectiveness of the
Zimba with other chlorine water treatment options. Techni-
cal assistance with the technology for the rst few weeks
might have increased adoption rates. In addition, the study
population was drawn from a small geographic area in a
low-income community in Mirpur, Dhaka; thus, the accept-
ability and uptake results may not be generalizable to other
low-income urban communities.
The Zimba automated dispenser overcomes some of the
most important barriers to low-cost decentralized chlori-
nation of drinking water. First, it eliminates the extra step
of adding chlorine after water collection, which saves time
for other household work (Luby et al. ). Second, the
Zimba is attached/locked to the handpump and automati-
cally treats water without the active participation of users.
Since household members cannot choose whether to chlor-
inate, they may be more likely to adjust to the smell and taste
of the consistently chlorinated water. Third, users do not
need to consider the size of their water collection vessel
since the collected water is passively dosed with a safe
residual chlorine level before they collect it in their vessels.
Although the Zimba was able to successfully and consist-
ently chlorinate household stored drinking water, further
work must be done to take this technology or other similar
technologies to scale. Essential next steps include improving
the user experience (Ahuja et al. ) and developing an
appropriate business model for relling chlorine and main-
tenance of the device.
This research protocol was funded by the United States
Agency for International Development (USAID). icddr,b
acknowledges with gratitude the commitment of USAID to
its research efforts. icddr,b is also thankful to the
Governments of Australia, Bangladesh, Canada, Sweden
and the UK for providing core/unrestricted support. The
authors gratefully acknowledge Meghan Scott for
thoughtful guidance and review of the manuscript. Suprio
Das, the inventor of the Zimba, contributed Figure 1 in
this manuscript. We would also like to thank Suprio Das
and Laura Stupin for manufacturing and installing the
Zimba devices evaluated in this study. We also thank
Nazrin Akter, Wasim Ahmed and Arifur Rahman for their
eld activities. We are also grateful to the study
participants for their valuable time.
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41 N. Amin et al. |Field trial of an automated batch chlorinator system Journal of Water, Sanitation and Hygiene for Development |06.1 |2016
... The largest projected health impact in this study was for a new tool for small-scale water treatment that automatically chlorinates water to a safe concentration without using electricity or moving parts [16,17]. An estimated 1.5 million deaths from diarrheal disease among children under the age of five could be prevented between now and 2030 (Fig. 3). ...
Full-text available
Background Innovations that improve the affordability, accessibility, or effectiveness of health care played a major role in the Millennium Development Goal achievements and will be critical for reaching the ambitious new Sustainable Development Goal (SDG) health targets. Mechanisms to identify and prioritize innovations are essential to inform future investment decisions. Methods Innovation Countdown 2030 crowdsourced health innovations from around the world and engaged recognized experts to systematically assess their lifesaving potential by 2030. A health impact modeling approach was developed and used to quantify the costs and lives saved for select innovations identified as having great promise for improving maternal, newborn, and child health. Results Preventive innovations targeting health conditions with a high mortality burden had the greatest impact in regard to the absolute number of estimated lives saved. The largest projected health impact was for a new tool for small-scale water treatment that automatically chlorinates water to a safe concentration without using electricity or moving parts. An estimated 1.5 million deaths from diarrheal disease among children under five could be prevented by 2030 by scaling up use of this technology. Use of chlorhexidine for umbilical cord care was associated with the second highest number of lives saved. Conclusions The results show why a systematic modeling approach that can compare and contrast investment opportunities is important for prioritizing global health innovations. Rigorous impact estimates are needed to allocate limited resources toward the innovations with great potential to advance the SDGs. Electronic supplementary material The online version of this article (doi:10.1186/s12962-017-0074-7) contains supplementary material, which is available to authorized users.
Full-text available
This paper describes the WaterAid-supported programme of water, sanitation and hygiene education implemented by local NGOs in the "slums" of Bangladesh's two largest cities, Dhaka and Chittagong. This includes descriptions of the design and management of community-managed water points and sanitation blocks. The paper also summarizes the findings of an external evaluation of their effectiveness and discusses the difficulties of reaching the poorest while also getting full cost-recovery from users (which is required if the millions of urban dwellers in need of improved provision are to be reached with the limited funds available).
Full-text available
Background: Unsafe drinking water presents a particular threat to people living with HIV/AIDS (PLHIV) due to the increased risk of opportunistic infections, diarrhea-associated malabsorption of essential nutrients, and increased exposure to untreated water for children of HIV-positive mothers who use replacement feeding to reduce the risk of HIV transmission. This population may particularly benefit from an intervention to improve water quality in the home. Methods and findings: We conducted a 12-month randomized, controlled field trial in Zambia among 120 households with children <2 years (100 with HIV-positive mothers and 20 with HIV-negative mothers to reduce stigma of participation) to assess a high-performance water filter and jerry cans for safe storage. Households were followed up monthly to assess use, drinking water quality (thermotolerant coliforms (TTC), an indicator of fecal contamination) and reported diarrhea (7-day recall) among children <2 years and all members of the household. Because previous attempts to blind the filter have been unsuccessful, we also assessed weight-for-age Z-scores (WAZ) as an objective measure of diarrhea impact. Filter use was high, with 96% (596/620) of household visits meeting the criteria for users. The quality of water stored in intervention households was significantly better than in control households (3 vs. 181 TTC/100 mL, respectively, p<0.001). The intervention was associated with reductions in the longitudinal prevalence of reported diarrhea of 53% among children <2 years (LPR=0.47, 95% CI: 0.30-0.73, p=0.001) and 54% among all household members (LPR=0.46, 95% CI: 0.30-0.70, p<0.001). While reduced WAZ was associated with reported diarrhea (-0.26; 95% CI: -0.37 to -0.14, p<0.001), there was no difference in WAZ between intervention and control groups. Conclusion: In this population living with HIV/AIDS, a water filter combined with safe storage was used correctly and consistently, was highly effective in improving drinking water quality, and was protective against diarrhea. Trial registration: NCT01116908.
Full-text available
There is evidence that household point-of-use (POU) water treatment products can reduce the enormous burden of water-borne illness. Nevertheless, adoption among the global poor is very low, and little evidence exists on why. We gave 600 households in poor communities in Dhaka, Bangladesh randomly-ordered two-month free trials of four water treatment products: dilute liquid chlorine (sodium hypochlorite solution, marketed locally as Water Guard), sodium dichloroisocyanurate tablets (branded as Aquatabs), a combined flocculant-disinfectant powdered mixture (the PUR Purifier of Water), and a silver-coated ceramic siphon filter. Consumers also received education on the dangers of untreated drinking water. We measured which products consumers used with self-reports, observation (for the filter), and chlorine tests (for the other products). We also measured drinking water's contamination with E. coli (compared to 200 control households). Households reported highest usage of the filter, although no product had even 30% usage. E. coli concentrations in stored drinking water were generally lowest when households had Water Guard. Households that self-reported product usage had large reductions in E. coli concentrations with any product as compared to controls. Traditional arguments for the low adoption of POU products focus on affordability, consumers' lack of information about germs and the dangers of unsafe water, and specific products not meshing with a household's preferences. In this study we provided free trials, repeated informational messages explaining the dangers of untreated water, and a variety of product designs. The low usage of all products despite such efforts makes clear that important barriers exist beyond cost, information, and variation among these four product designs. Without a better understanding of the choices and aspirations of the target end-users, household-based water treatment is unlikely to reduce morbidity and mortality substantially in urban Bangladesh and similar populations.
Supplying piped water intermittently is a common practice throughout the world that increases the risk of microbial contamination through multiple mechanisms. Converting an intermittent supply to a continuous supply has the potential to improve the quality of water delivered to consumers. To understand the effects of this upgrade on water quality, we tested samples from reservoirs, consumer taps, and drinking water provided by households (e.g. from storage containers) from an intermittent and continuous supply in Hubli-Dharwad, India, over one year. Water samples were tested for total coliform, Escherichia coli, turbidity, free chlorine, and combined chlorine. While water quality was similar at service reservoirs supplying the continuous and intermittent sections of the network, indicator bacteria were detected more frequently and at higher concentrations in samples from taps supplied intermittently compared to those supplied continuously (p < 0.01). Detection of E. coli was rare in continuous supply, with 0.7% of tap samples positive compared to 31.7% of intermittent water supply tap samples positive for E. coli. In samples from both continuously and intermittently supplied taps, higher concentrations of total coliform were measured after rainfall events. While source water quality declined slightly during the rainy season, only tap water from intermittent supply had significantly more indicator bacteria throughout the rainy season compared to the dry season. Drinking water samples provided by households in both continuous and intermittent supplies had higher concentrations of indicator bacteria than samples collected directly from taps. Most households with continuous supply continued to store water for drinking, resulting in re-contamination, which may reduce the benefits to water quality of converting to continuous supply.
Household water treatment with dilute hypochlorite solution has been shown to improve microbiological water quality and reduce diarrheal disease in developing countries. One concern raised by governmental agencies, implementers, and nongovernmental organizations is whether the hypochlorite solution remains stable during distribution and after the bottle is opened and usage begins. In this study, laboratory and field research was conducted to determine the expiration date and stability in the home of hypochlorite solution. Expiration-date testing found that pH-stabilized similar to 1.25% hypochlorite solution made using various production techniques in Ethiopia, Guinea, and Nigeria was stable for a minimum of 12 months in temperatures less than 35 C. Stability testing during laboratory simulated normal usage showed no degradation, and 77-91% of bottles collected from households tested met standards. Hypochlorite solution concentration drops rapidly when pH is not stabilized, when pH levels fall, and when solution is exposed to direct sunlight.
For the 1.1 billion people worldwide who do not have access to improved drinking water supply, point-of-use (POU) water treatment with sodium hypochlorite (NaOCl) is proven to reduce the incidence of diarrheal disease. However, NaOQ dosage recommendations for both household water treatment and disaster response water treatment vary significantly. In this study, 106 water samples front a variety of unproved and unimproved sources in 16 countries were tested ep ascertain whether a standardized NaOCl dosage regime could be developed. Results indicated that for household water treatment with NaOCl alone, a dose of 1.875 mg/L NaOCl proved effective in 86.6% of samples with turbidity < 10 ntu and a dose of 3.75 mg/L NaOCl was effective in 91.7% of unimproved sources with turbidity of 10-100 ntu. On the basis of test results, it is also recommended that POU chlorination programs adopt a proposed criteria for a free chlorine residual of < 2.0 mg/L 1 hour after NaOCl addition and > 0.2 mg/L after 24 hours of storage.
This paper uses a public economics framework to review evidence from randomized trials on domestic water access and quality in developing countries and to assess the case for subsidies. Water treatment can cost-effectively reduce reported diarrhea. However, many consumers have low willingness to pay for cleaner water; few households purchase household water treatment under retail models. Free point-of-collection water treatment systems designed to make water treatment convenient and salient can generate take-up of approximately 60% at a projected cost as low as $20 per year of life saved, comparable to vaccine costs. In contrast, the limited existing evidence suggests that many consumers value better access to water, but it does not yet demonstrate that better access improves health. The randomized impact evaluations reviewed have also generated methodological insights on a range of topics, including (a) the role of survey effects in health data collection, (b) methods to test for sunk-cost effects, (c) divergence in revealed preference and stated preference valuation measures, and (d) parameter estimation for structural policy simulations.
Information about the distribution of causes of and time trends for child mortality should be periodically updated. We report the latest estimates of causes of child mortality in 2010 with time trends since 2000. Updated total numbers of deaths in children aged 0-27 days and 1-59 months were applied to the corresponding country-specific distribution of deaths by cause. We did the following to derive the number of deaths in children aged 1-59 months: we used vital registration data for countries with an adequate vital registration system; we applied a multinomial logistic regression model to vital registration data for low-mortality countries without adequate vital registration; we used a similar multinomial logistic regression with verbal autopsy data for high-mortality countries; for India and China, we developed national models. We aggregated country results to generate regional and global estimates. Of 7·6 million deaths in children younger than 5 years in 2010, 64·0% (4·879 million) were attributable to infectious causes and 40·3% (3·072 million) occurred in neonates. Preterm birth complications (14·1%; 1·078 million, uncertainty range [UR] 0·916-1·325), intrapartum-related complications (9·4%; 0·717 million, 0·610-0·876), and sepsis or meningitis (5·2%; 0·393 million, 0·252-0·552) were the leading causes of neonatal death. In older children, pneumonia (14·1%; 1·071 million, 0·977-1·176), diarrhoea (9·9%; 0·751 million, 0·538-1·031), and malaria (7·4%; 0·564 million, 0·432-0·709) claimed the most lives. Despite tremendous efforts to identify relevant data, the causes of only 2·7% (0·205 million) of deaths in children younger than 5 years were medically certified in 2010. Between 2000 and 2010, the global burden of deaths in children younger than 5 years decreased by 2 million, of which pneumonia, measles, and diarrhoea contributed the most to the overall reduction (0·451 million [0·339-0·547], 0·363 million [0·283-0·419], and 0·359 million [0·215-0·476], respectively). However, only tetanus, measles, AIDS, and malaria (in Africa) decreased at an annual rate sufficient to attain the Millennium Development Goal 4. Child survival strategies should direct resources toward the leading causes of child mortality, with attention focusing on infectious and neonatal causes. More rapid decreases from 2010-15 will need accelerated reduction for the most common causes of death, notably pneumonia and preterm birth complications. Continued efforts to gather high-quality data and enhance estimation methods are essential for the improvement of future estimates. The Bill & Melinda Gates Foundation.
Low-cost point-of-use (POU) safe water products have the potential to reduce waterborne illness, but adoption by the global poor remains low. We performed an eight-month randomized trial of four low-cost household water treatment products in Dhaka, Bangladesh. Intervention households (n = 600) received repeated educational messages about the importance of drinking safe water along with consecutive two-month free trials with each of four POU products in random order. Households randomly assigned to the control group (n = 200) did not receive free products or repeated educational messages. Households' willingness to pay for these products was quite low on average (as measured by bids in an incentive-compatible real-money auction), although a modest share was willing to pay the actual or expected retail price for low-cost chlorine-based products. Furthermore, contrary to our hypotheses that both one's own personal experience and the influence of one's peers would increase consumers' willingness to pay, direct experience significantly decreased mean bids by 18-55% for three of the four products and had no discernible effect on the fourth. Neighbor experience also did not increase bids. Widespread dissemination of safe water products is unlikely until we better understand the preferences and aspirations of these at-risk populations.
Household point-of-use (POU) water treatment technologies targeted at vulnerable populations are microbiologically effective and, in small trials, improve health. We do not understand the factors that influence preference for and adoption of these technologies by target end-users. We cycled 400 rural subsistence farm households in western Kenya through three randomly ordered two-month trials of three POU products: dilute hypochlorite solution, porous ceramic filtration, and a combined flocculant-disinfectant powdered mixture to compare relative end-user preferences and usage. Households reported higher usage of both dilute hypochlorite and filters than the flocculant-disinfectant. Averaged among all participating households, Escherichia coli reductions in treated water were generally higher among those that received dilute hypochlorite solution than among those receiving either of the other two products. Among those households that self-reported product usage, the E. coli reductions achieved by dilute hypochlorite and the flocculant-disinfectant are statistically equivalent to one another and higher than the reductions achieved by filters. At the same time, households ranked filters most frequently as their most preferred product.