Themes / Topics Rural Poverty & Health
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Bottled and Well Water Quality in a Small Central Appalachian Community: Household-Level Analysis of Enteric Pathogens, Inorganic Chemicals, and Health Outcomes in Rural Southwest Virginia

Abstract/Summary: Consumption of unsafe drinking water is associated with a substantial burden of disease globally. In the US, ~1.8 million people in rural areas lack reliable access to safe drinking water. Our objective was to characterize and assess household-level water sources, water quality, and associated health outcomes in Central Appalachia. We collected survey data and water samples (tap, source, and bottled water) from consenting households in a small rural community without utility-supplied water in southwest Virginia. Water samples were analyzed for physicochemical parameters, total coliforms, E. coli, nitrate, sulfate, metals (e.g., arsenic, cadmium, lead), and 30+ enteric pathogens. Among the 69% (n = 9) of households that participated, all had piped well water, though 67% (n = 6) used bottled water as their primary drinking water source. Total coliforms were detected in water samples from 44.4% (n = 4) of homes, E. coli in one home, and enteric pathogens (Aeromonas, Campylobacter, Enterobacter) in 33% (n = 3) of homes. Tap water samples from 11% (n = 1) of homes exceeded the EPA MCL for nitrate, and 33% (n = 3) exceeded the EPA SMCL for iron. Among the 19 individuals residing in study households, reported diarrhea was 25% more likely in homes with measured E. coli and/or specific pathogens (risk ratio = 1.25, cluster-robust standard error = 1.64, p = 0.865). Although our sample size was small, our findings suggest that a considerable number of lower-income residents without utility-supplied water in rural areas of southwest Virginia may be exposed to microbiological and/or chemical contaminants in their water, and many, if not most, rely on bottled water as their primary source of drinking water.

Subsewershed SARS-CoV-2 Wastewater Surveillance & COVID-19 Epidemiology Using Building-specific Occupancy & Case Data

Abstract/Summary: To evaluate the use of wastewater-based surveillance and epidemiology to monitor and predict SARS-CoV-2 virus trends, over the 2020–2021 academic year we collected wastewater samples twice weekly from 17 manholes across Virginia Tech’s main campus. We used data from external door swipe card readers and student isolation/quarantine status to estimate building-specific occupancy and COVID-19 case counts at a daily resolution. After analyzing 673 wastewater samples using reverse transcription quantitative polymerase chain reaction (RT-qPCR), we reanalyzed 329 samples from isolation and nonisolation dormitories and the campus sewage outflow using reverse transcription digital droplet polymerase chain reaction (RT-ddPCR). Population-adjusted viral copy means from isolation dormitory wastewater were 48% and 66% higher than unadjusted viral copy means for N and E genes (1846/100 mL to 2733/100 mL/100 people and 2312/100 mL to 3828/100 mL/100 people, respectively; n = 46). Prespecified analyses with random-effects Poisson regression and dormitory/cluster-robust standard errors showed that the detection of N and E genes were associated with increases of 85% and 99% in the likelihood of COVID-19 cases 8 days later (incident–rate ratio (IRR) = 1.845, p = 0.013 and IRR = 1.994, p = 0.007, respectively; n = 215), and one-log increases in swipe card normalized viral copies (copies/100 mL/100 people) for N and E were associated with increases of 21% and 27% in the likelihood of observing COVID-19 cases 8 days following sample collection (IRR = 1.206, p < 0.001, n = 211 for N; IRR = 1.265, p < 0.001, n = 211 for E). One-log increases in swipe normalized copies were also associated with 40% and 43% increases in the likelihood of observing COVID-19 cases 5 days after sample collection (IRR = 1.403, p = 0.002, n = 212 for N; IRR = 1.426, p < 0.001, n = 212 for E). Our findings highlight the use of building-specific occupancy data and add to the evidence for the potential of wastewater-based epidemiology to predict COVID-19 trends at subsewershed scales.

Vaccine Effectiveness During an Outbreak of COVID-19 Alpha Variant (B.1.1.7) in a Men’s Correctional Facility, United States

Abstract/Summary: In April 2021, a COVID-19 outbreak occurred at a correctional facility in rural Virginia, USA. Eighty-four infections were identified among 854 incarcerated persons by facilitywide testing with reverse transcription quantitative PCR (qRT-PCR). We used whole-genome sequencing to link all infections to 2 employees infected with the B.1.1.7α (UK) variant. The relative risk comparing unvaccinated to fully vaccinated persons (mRNA-1273 [Moderna]) was 7.8 (95% CI 4.8–12.7), corresponding to a vaccine effectiveness of 87.1% (95% CI 79.0%–92.1%). Average qRT-PCR cycle threshold values were lower, suggesting higher viral loads, among unvaccinated infected than vaccinated cases for the nucleocapsid, envelope, and spike genes. Vaccination was highly effective at preventing SARS-CoV-2 infection in this high-risk setting. This approach can be applied to similar settings to estimate vaccine effectiveness as variants emerge to guide public health strategies during the ongoing pandemic.

Bottled water quality and associated health outcomes: A systematic review and meta-analysis of 20 years of published data from China

Abstract/Summary: Bottled water is a rapidly growing yet relatively understudied source of drinking water globally. In addition to concerns about the safety of bottled water, the adverse environmental health and social impacts associated with bottled water production, distribution, consumption, and reliance are considerable. Our objective was to comprehensively review, analyze, and synthesize ∼20 years of publicly available data on bottled water quality and associated health outcomes in China. We conducted a systematic review and meta-analysis of publicly available studies of bottled water quality and associated health outcomes in China published between 1995 and early 2016 (in Chinese and English). We pre-specified and registered our study protocol, independently replicated key analyses, and followed standardized reporting guidelines. Our search identified 7059 potentially eligible records. Following screening, after full-text review of 476 publications, 216 (reporting results from 625 studies) met our eligibility criteria. Among many findings, 93.7% (SD = 10.1) of 24 585 samples tested for total coliforms (n = 241 studies), and 92.6% (SD = 12.7) of 7261 samples tested for nitrites (n = 85 studies), were in compliance with China’s relevant bottled water standards. Of the studies reporting concentration data for lead (n = 8), arsenic (n = 5), cadmium (n = 3), and mercury (n = 3), median concentrations were within China’s standards for all but one study of cadmium. Only nine publications reported health outcome data, eight of which were outbreak investigations. Overall, we observed evidence of stable or increasing trends in the proportions of samples in compliance over the ∼20 year period; after controlling for other variables via meta-regression, the association was significant for microbiological but not chemical outcomes (p = 0.017 and p = 0.115, respectively). Bottled water is typically marketed as being safe, yet in most countries it is less well-regulated than utility-supplied drinking water. Given the trend of increasing bottled water use in China and globally—and the associated environmental health impacts—we hope this work will help to inform policies and regulations for improving bottled water safety, while further highlighting the need for substantially expanding the provision of safe and affordable utility-supplied drinking water globally.

Poverty, Water, & Health Indicators in Sub-Saharan Africa

As described below (see other project summaries), the Multidimensional Poverty Assessment Tool (MPAT) was created in two phases (from 2008 to 2014) via a collaborative, international initiative to develop, test, and pilot a new tool for local-level rural poverty assessment. The work was guided by a Sounding Board of experts from the International Fund for Agricultural Development (IFAD), other United Nations agencies, international and regional organizations, and universities around the world (see

Following MPAT’s finalization and institutionalization in 2014, it was used in multiple countries including many in Sub-Saharan Africa. We are currently working on multiple research studies with a variety of collaborators to analyze data from ~7,000 households across Eswatini, Kenya, Lesotho, Mali, Tanzania, and Zimbabwe. Because MPAT was developed based primarily on data from Bangladesh, China, India, and Mozambique, one study we are leading is an updated assessment and evaluation of MPAT’s indicator structure and robustness based on its use in the sub-Saharan region. Another study we will be leading will focus on a cross-county analysis of MPAT’s water and health focused components and sub-components. In addition, we are assisting other colleagues leading studies focused on climate change and rural poverty with their statistical analyses.

Arsenic in Rural & Carceral Drinking Water Systems

Source: Adapted from

In the United States, millions of people lack reliable access to safe drinking water, a problem that is particularly acute in low-income rural areas. California legally recognized the human right to water in 2012, but this right remains unevenly realized. To better understand the status of the human right to water in rural communities, we analyzed 20 years of publicly available drinking water quality monitoring and violation data from 2001-2021, with a focus on arsenic contamination (a carcinogenic heavy metal) from a state prison as well as public water systems in three neighboring rural communities in southern California. We found that all four of these drinking water systems repeatedly exceeded the legal limit for arsenic during the study period, with mean served arsenic levels ranging from 3.4 (SD=6.7) to 9.3 (SD:=2.9) μg/L across the systems (based on 2,426 samples from four systems). In addition to arsenic-specific findings and comparisons across these four sites, our analyses demonstrate how publicly reported annually averaged water quality data (used to monitor system violations and to track progress toward the human right to water) provide only a partial guide to whether the right to safe water is being realized. We expect to publish our findings in 2022.

Water Supply Improvement & Health Promotion Campaigns in Rural Areas — China, 1949−2020

Abstract/Summary: In the 1950s, shortly after the founding of the People’s Republic of China (PRC), the central government created the Patriotic Health Campaign (PHC) in order to standardize and disseminate health focused educational materials intended to control and prevent infectious diseases (1). “Water improvement”, meaning measures aimed at providing safe drinking water for households in China, was an important part of the PHC. After 60 years of water improvement policies, programs, and investments, the rural water supply sanitation and hygiene in China has improved dramatically, and water-related diseases no longer negatively impact the rural population as they once did. In addition to improvements related to the quantity and quality of the rural water supply, water improvement programs also promoted improved hygiene, sanitation, and other health-related behaviors among rural households. Together, such initiatives have improved the quality of life and the health of hundreds of millions of rural residents, while also contributing to economic and social advancement across rural China (2). The purpose of this article is to describe how the PHC served as a foundation for the expansion and improvement of drinking water supply in rural China, and to summarize the key programs, projects, and initiatives that followed over the last 60 years.

Refinement & Finalization of the Multidimensional Poverty Assessment Tool (MPAT)

Following the release of the working-paper User’s Guide for the Multidimensional Poverty Assessment Tool (MPAT) in 2009, a number of agencies and universities used the beta-version of MPAT in a variety of settings. In order to finalize MPAT and develop a comprehensive User’s Guide and associated resources, we built on the lessons learned from early adopters of the the tool (e.g., an NGO in Kenya) and iteratively used and evaluated the tool with IFAD-supported projects in Bangladesh and Mozambique. Details on the participatory expert elicitation methods we used are provided in a Journal of Development Studies paper. We developed an Excel-based data entry platform so users could easily calculate MPAT’s indicators at household, village, and project levels. We also wrote a comprehensive, 300+ page, 2014 MPAT User’s Guide which provides step-by-step instructions for using MPAT as well as training modules and materials, all with the goal of making MPAT an accessible open-source tool. The User’s Guide and accompanying resources were presented at a 2014 launch event in Rome. Since its 2014 release, MPAT has been translated into a number of languages, an optional 11th component focused on climate change was added, and MPAT has been used by a variety of agencies and institutions around the world. MPAT publications and related resources are available at

Evaluating Household-level Drinking Water Treatment in Rural China

After extensive discussion and planning, we started a collaborative research project with colleagues at the NCRWSTG and China CDC to characterize and assess methods of household water treatment (HWT) in low-income regions of rural China. During the first phase of this research, in the summer of 2013, we collected drinking water samples and administered surveys to 450 households across 15 rural villages in Guangxi province. To assess seasonal factors, we undertook a second round of data collection in the winter of 2013/2014 during which time we also affixed remote temperature sensors to kettles and pots to help corroborate reported boiling data. In 2014, under the supervision of China CDC colleagues Director Tao Yong and Dr. Qing Luo, we replicated the study in Henan province, collecting data from 450+ rural households during the summer.  Using a variety of modeling approaches, we evaluated the microbiological effectiveness of the HWT methods used – including bottled water (large 19L bottles) – and isolated socioeconomic predictors associated with HWT and water-related beliefs and behaviors. Among other findings, we observed that indicators of fecal contamination were lowest in drinking water samples from households using electric kettles. Our analyses of boiling-associated air pollution indicated that switching from boiling with pots and solid fuels to boiling with electric kettles would result in a measurable reduction in indoor air pollution. We also observed relatively high rates of microbiological contamination in samples from households using bottled water; and our analyses of socioeconomic factors suggested that rural bottled water use will continue to increase in the future. Results from these studies – as well as a systematic review on boiling and health outcomes – were also used to support and inform the design of an intervention to promote the use of electric kettles in low-income rural communities (see project summary above).

Water Utilities & Intermittent Drinking Water Supply in China

Led by our colleague, Dr. Hongxing Li at the China CDC, this project focused on the management and use of drinking water supply in areas where utilities provide piped drinking water, but for a variety of reasons it is not provided continuously (i.e., piped connections are not supplied with treated drinking water 24 hours a day, 7 days a week). This situation – that of intermittent water supply (IWS) – is relatively widespread in many low- and middle-income countries, as well as in parts of China. This research project, conducted in two Chinese provinces (Shandong and Hubei), assessed and compared management and consumer adaptation strategies, as well as drinking water quality, storage practices, and behaviors and beliefs associated with IWS, with comparison to similar communities living under conditions of continuous water supply (CWS). Water samples (from taps and rooftop storage units) and survey data were collected from 400 households across four villages (2 IWS, 2 CWS) in the two provinces. One of the main reasons the utilities in these regions provided water intermittently was to reduce the electricity costs associated with water supply pumps. Indicators of microbiological contamination were higher in samples from the IWS villages compared with the CWS villages, and we observed higher rates of bottled water use in the IWS villages compared with the CWS villages. As a result of this work, we were able to offer evidence-based recommendations utilities could adopt to reduce water-and-health related risks associated with IWS or transition to CWS.