The SODISWATER PROJECT - Solar Disinfection (SODIS) of Drinking Water Dr Kevin McGuigan Dept. of Physiology & Medical Physics Royal College of Surgeons in Ireland Dublin 2, IRELAND

SODISWATER Project, RCSI2 More than 1 billion people have no access to safe drinking water. More than 1 million children die from waterborne disease annually Salgaa, Nakuru, Kenya

SODIS Process - Fetch the water SODISWATER Project, RCSI3

Wash an ordinary plastic Bottle (supervised by husband) SODISWATER Project, RCSI4

Fill the Bottle (supervised by cat and dog) SODISWATER Project, RCSI5

Expose the water in the bottle for 6 hours - (supervised by foreman) SODISWATER Project, RCSI6

After 6 hrs in the sun, drink the water (supervised by the rest of the village) SODISWATER Project, RCSI7

8 RCSI group working on Solar Disinfection since 1992

SODISWATER Project, RCSI Indian Ocean Tsunami Despite >10 years research & > 30 papers, it became obvious that Aid Agencies were reluctant to promote SODIS as a method of water treatment in aftermath of humanitarian disasters.

SODISWATER Project, RCSI10 1. RCSI (IRELAND) 2. UUJ (UK) 3. CSIR (S AFRICA) 4. EAWAG (SWITZERLAND) 5. IWSD (ZIMBABWE) 6. PSA CIEMAT (SPAIN) 7. UL (UK) 8. ICROSS (KENYA) 9. USC (SPAIN) 10. CIC (CAMBODIA) In 2006 obtained €2.7M funding (€1.9M EU, €0.3M Irish Govt. & €0.5M others) for the 3 year SODISWATER Project to expand knowledge of solar disinfection (SODIS) and help promote technology.

SODISWATER Project, RCSI11 Health Impact Assessment study model Children under age of 5 Years Children under age of 5 Years 14 month trial 14 month trial Control group maintained usual practices. Control group maintained usual practices. All test group families given two 2-L bottles per child All test group families given two 2-L bottles per child Test group placed bottles in sun for 6h Test group placed bottles in sun for 6h Drink today what was treated yesterday Drink today what was treated yesterday

Diarrhoeal disease rates recorded using “Smiley-Face Diary” SODISWATER Project, RCSI12

SODISWATER Project, RCSI13 Health Impact Assessment - A Tale of Four Studies: “it was the best of studies, it was the worst of studies”

Zimbabwe Study SODISWATER Project, RCSI14 Total = 839 children Control group = 547 Test group = 292

SODISWATER Project, RCSI15

Results No Significant Effect Observed Political tension. Political tension. Pre- & post-election (3-4 months) suspension of all foreign funded projects. Pre- & post-election (3-4 months) suspension of all foreign funded projects. Economic hyper-inflation. Economic hyper-inflation. Cholera epidemic. Cholera epidemic. Fear of interference with bottle by neighbours. Fear of interference with bottle by neighbours. SODISWATER Project, RCSI16

South Africa Study SODISWATER Project, RCSI17 A total of 649 households were recruited with 386 children in the control group and 438 in the test group. Of the total of 824 children 402 were male and 421 female

Typical S. African brick houses SODISWATER Project, RCSI18

S. Africa Results Incidence rates were lower in those drinking solar disinfected water (incidence rate ratio* 0.64, 95% CI , P ) 0.071) but not statistically significant Incidence rates were lower in those drinking solar disinfected water (incidence rate ratio* 0.64, 95% CI , P ) 0.071) but not statistically significant Solar disinfection was not significantly associated with non-dysentery diarrhea risk overall (P = 0.419). Solar disinfection was not significantly associated with non-dysentery diarrhea risk overall (P = 0.419). SODISWATER Project, RCSI19 * IRR = Incident rate in test group / Incident rate in control group

S. Africa Results – cont’d Incidence of dysentery was significantly associated with higher motivation, defined as 75% or better completion of diarrhea data. Incidence of dysentery was significantly associated with higher motivation, defined as 75% or better completion of diarrhea data. Compared with the control, participants with higher motivation achieved a significant reduction in dysentery (incidence rate ratio (IRR = 0.36, 95% CI , P = 0.014). However, there was no significant reduction in risk at lower levels of motivation. Compared with the control, participants with higher motivation achieved a significant reduction in dysentery (incidence rate ratio (IRR = 0.36, 95% CI , P = 0.014). However, there was no significant reduction in risk at lower levels of motivation. SODISWATER Project, RCSI20

S. Africa Results – cont’d A statistically significant reduction in dysentery was achieved only in households with higher motivation, showing that motivation is a significant determinant for measurable health gains. A statistically significant reduction in dysentery was achieved only in households with higher motivation, showing that motivation is a significant determinant for measurable health gains. SODIS works but only if you use it! SODIS works but only if you use it! SODISWATER Project, RCSI21

Other problems Overall compliance rate was poor (~35%). Many S. African users feared SODIS use would release local govt. from responsibility to provide clean water (S.A.) so they stopped using it! doi: /es103328j.

Kenya Study SODISWATER Project, RCSI23

Bondena Urban Slums in Nakuru SODISWATER Project, RCSI24

SODISWATER Project, RCSI25 Rural Maasailand, Kenya

SODISWATER Project, RCSI26 Test Group = 555 children in 404 households using SODIS. Control Group = 534 children in 361 households with no intervention. Post-election violence, disruption, interruption.

Kenya Results SODISWATER Project, RCSI27 Dysentery and non-dysentery diarrhea were significantly (P<0.001) reduced by use of solar disinfection: 1.dysentery days IRR = 0.56 (95% CI 0.40 to 0.79); 2.dysentery episodes IRR = 0.55 (95% CI 0.42 to 0.73); 3.non-dysentery days IRR = 0.70 (95% CI 0.59 to 0.84); 4.non-dysentery episodes IRR = 0.73 (95% CI 0.63 to 0.84).

Anthropometry – height & weight SODISWATER Project, RCSI28

Effect of SODIS on child development? SODISWATER Project, RCSI 29 Median height-for-age was significantly increased in those on SODIS, corresponding to an average of 1.3 cm taller over a 1-year period over the group as a whole (95% CI 0.54 to 2.2 cm, P=0.001). Median weight-for-age was similarly higher in those on SODIS, corresponding to a 0.4 kg heavier difference in weight after a year on SODIS (95% CI 0.16 to 0.64 kg, P<0.001).

Comment SODISWATER Project, RCSI 30 Anthropometric benefit only observed in Kenyan study. Probably because only area where we saw significant malnutrition. This is the first trial to show evidence of the effects of SODIS on childhood anthropometry & should alleviate concerns that the lower disease rates associated with household water treatment are the product of biased reporting rather than genuinely decreased incidence.

Cambodia – Prey Veng & Svay Reng provinces

SODISWATER Project, RCSI33 Cambodia - results Children drinking SODIS water were at lower risk of dysentery (IRR = 0.40, 95% CI 0.18 to 0.92, P=0.032). Incidence was low, hence wide C.I. Children drinking SODIS water were at lower risk of non- dysentery diarrhoea (IRR = 0.40, 95% CI 0.31 to 0.50, P < 0.001).

SODISWATER Project, RCSI34 General SODISWATER Conclusions: SODIS significantly reduces incidence of dysentery (0.36<IRR<0.56) in most study communities (S Africa, Kenya, Cambodia). SODIS associated with height & weight benefit in child development for Kenyan children. No genotoxic risk observed for standard SODIS method over 6 months (Recommend replace bottles every 6 months).

SODISWATER Project, RCSI35 33 countries where SODIS is currently in daily use by > 4.5 million people

SODISWATER Project, RCSI36

SODISWATER Project, RCSI37Acknowledgements Health Research Board (NS/2003/007) Health Research Board (NS/2003/007) Irish Aid and Health Research Board (GHRA/06/01) Irish Aid and Health Research Board (GHRA/06/01) European Science Foundation COST Action P9 European Science Foundation COST Action P9 European Commission (FP6-INCO-CT SODISWATER) European Commission (FP6-INCO-CT SODISWATER)