Environ Monit Assess (2018) 190: 669

Household-stored drinking water quality among households

of under-five children with and without acute diarrhea in
towns of Wegera District, in North Gondar, Northwest
Ethiopia
Hailemariam Feleke & Girmay Medhin &
Helmut Kloos & Janardhanan Gangathulasi &
Daniel Asrat

Received: 29 December 2017 /Accepted: 8 October 2018 /Published online: 23 October 2018
# The Author(s) 2018 Department of Epidemiology and Biostatistics, University of
California, San Francisco, San Francisco, CA, USA

Abstract Contamination of drinking water in J. Gangathulasi

Center for Environmental Management, Chennai, India
household water storage containers and
inadequate water supplies are common public D. Asrat
burdens in low- and middleincome countries, Faculty of Medicine, Addis Ababa University, Addis Ababa,
including towns in Wegera District, Ethiopia. Ethiopia
Our study aimed to assess the quality of (31.3%) for FC (p > 0.05); 25 (36.8%) and 3
drinking water and identify factors associated (4.5%) for FS (p < 0.001), respectively.
with diarrhea in households with under-five Contamination of the stored drinking water
(U5) children with and without diarrhea in samples with FS was significantly higher in
Ambagiorgis and Gedebge towns in Wegera households with diarrhetic U5 children in the
District. Stored drinking water samples from low- and medium-risk ranges (p < 0.05).
households with U5 children with and without Water turbidity of 47 (69.1%) and 23 (34.3%)
diarrhea had fecal coliform (FC) counts of 59 in households with U5 children with and
(86.8%) and 55 (82.1%) (p > 0.05) and fecal without diarrhea, respectively, was above the
streptococci (FS) counts of 29 (42.7%) and 24 permissible level (p < 0.001). The residual free
(35.8%) (p > 0.05), respectively. The very chlorine (RFC) in all the household-stored
high sanitary risk scores were 32 (47.1%) and drinking water samples was below the World
21 Health Organization (WHO) permissible level
and temperatures of all the household-stored
drinking water samples were permissible.
H. Feleke (*) Promotion and advocacy of good stored
Ethiopian Institute of Water Resources, Addis Ababa drinking water handling practices are essential
University, Addis Ababa, Ethiopia e-mail: for decreasing the high risk of microbial
hamar35yoseph1@gmail.com
contamination in both study areas. We
G. Medhin recommend education interventions targeting
Aklilu Lemma Institute of Pathobiology, Addis Ababapersonal hygiene and drinking water handling
University, Addis Ababa, Ethiopia at the household level.
H. Kloos
669 Page 2 of 12 Environ Monit Assess (2018) 190: 669
Keywords Household-storeddrinkingwater indicates pathogenic bacterial contamination
quality. (Chalchisa et al. 2017).
Diarrhea. Under-five children. The physical quality of drinking water can
Membranefiltration. be measured by its turbidity level; high
Ethiopia turbidity can result in increased
microbiological and chemical contamination
(Mann et al. 2007). Microbial quality of
Background drinking water has been tested using surrogate
organisms (Sinclair et al. 2012), including
About 28 in 100 people lack access to fecal coliform (FC) and fecal streptococci
sufficient and quality drinking water globally (FS). Testing of drinking water stored in
(WHO and UNICEF 2017). The disparity in households is important to ascertain its
piped drinking water access between urban physicochemical and microbial quality at the
and rural communities is highly pronounced time of consumption (WHO 2003).
worldwide (MOFED 2010; WHO/UNICEF The Ethiopian Demographic and Health
2015). Ethiopia met the 2015 Millennium Survey reported that 97% of urban households
Development target of providing drinking in Ethiopia have access to an improved source
water from improved sources (WHO/UNICEF of drinking water (CSA and ICF 2016).
2015). Nevertheless, the safe drinking water Nevertheless, no reliable information is
access rate in Ethiopia is one of the lowest available on the readability of drinking water
among sub-Saharan countries (Siraj and Rao quality reports (Roy et al. 2015). Although
2016). diarrhea is mainly a water-related disease, the
Due to inadequate access and frequent difference in diarrhea prevalence between
interruptions of piped water supply (Adane et urban areas, with nearly universal access to
al. 2017b), drinking water is commonly stored, improved water, and rural areas, with only
often for considerable lengths of time, 57% improved water access, is slight in
resulting in gross contamination (Chalchisa et Ethiopia (CSA and ICF 2016).
al. 2017). When water is handled during The Ethiopian Demographic and Health
storage in households, it may be subjected to Survey reported that for the last 10 years,
further contamination (WHO 2011). Microbial diarrhea prevalence was highest in Amhara
contamination is the most common and Region after
widespread health risk associated with Gambela and Southern Nations, Nationalities,
drinking water (Daud et al. 2017), especially and People’s Regions (CSA and ICF 2016). In
among young children, who have the highest collaboration with the Health and Finance
diarrhea rates worldwide (Nelson et al. 2012). offices of Wegera District, the Water,
Water collected from sources with good Sanitation, and Hygiene (WASH) project is
microbial quality may become contaminated working on well and spring water development
during storage in households (Tadesse et al. and latrine construction activities in Wegera
2010; Adane et al. 2017b). District. The UNICEF-led USAID Nutrition
Safe drinking water does not cause any and WASH project is also working on
significant risk to health over a lifetime of increasing the utilization of quality nutrition
consumption (WHO 2011). According to the services for young children, improving the
WHO microbiological guidelines (WHO utilization of WASH products and services,
2004), coliform bacteria must not be detected and other related activities in Wegera District.
in 100 ml samples of water for the water to be The WASH project has developed well and
considered safe; their detection in water spring water in both rural and urban settings in
the District as part of the Millennium
Environ Monit Assess (2018) 190: 669 Page 3 of 12 669
Development Goal target for urban water Wegera District is located in northwestern
supply coverage in towns of Wegera Ethiopia (Fig. 1). Based on the 2007 Ethiopian
District. census, the average family size was 4 and the
The objective of our study was to assess the total number of households inhabiting
quality of stored drinking water in households Ambagiorgis and Gedebge towns was 3629
with children under the age of 5 years (U5) and 1650, respectively (CSA 2008). The main
with and without diarrhea in Ambagiorgis and drinking water sources are protected springs,
Gedebge towns of Wegera District in Amhara protected hand pumps, and protected dug
Region, Ethiopia. The findings of this study wells. All household-stored drinking water
may assist Ethiopian water officials, primary collected from protected water sources and
health-care institutes, and health policymakers stored in households with at least one U5 child
in designing programs for increasing who used the protected water sources was
awareness about household water handling included in the survey. Based on previous
practices, hygiene, sanitation, and protection water quality surveys in the region (CSA and
and treatment of household-stored water. ICF 2016), Ambagiorgis and Gedebge towns
were selected for study.

Materials and methods

Sample size determination and sampling
Study design procedure

A community-based survey was conducted in Based on a similar study, we assumed that

Ambagiorgis and Gedebge towns of Wegera minimal prevalence of the fecal indicator
District from June to October 2016 with the among diarrhetic U5 children would be 71%
aim of assessing the quality of household- and among non-diarrheic 90% (Boru et al.
stored drinking water in households with U5 2013). The alpha error was set at 5% and the
children with and without acute diarrhea. power of the study at 80%. The required

Fig. 1 Location of Ambagiorgis and Gedebge towns in Wegera District

669 Page 4 of 12 Environ Monit Assess (2018) 190: 669
sample size was calculated to be 68 for 8. Is the utensil used to draw water from the Y/N
containerkeptaway fromsurfaces andstored in a hygienic
diarrhetic and 67 for nondiarrhetic children, manner?
considering 1.5% (1/69) and 2.9% (2/69) non- 9. Is the inside of the drinking water container Y/N
response rate for the diarrhetic and clean?
nondiarrhetic groups, respectively. Hence, 92 10. Is the outside of the drinking water container
Y/N clean?
children from Ambagiorgis and 43 children
Table 2 Sociodemographic characteristics of
from Gedebge towns were enrolled in the households with under-five children in Ambagiorgis
study. and Gedebge towns
Variables U5 children with U5 children withoutp
Data collection tools and procedures diarrhea (n = 68) diarrhea (n = 67) value

Data were collected by using pretested Age of caregivers (years)

questionnaires, sanitary inspection checklists < 25 9 (13.2%) 15 (22.4%)
(Howard 2002) (Tables 1 and 2), and a rapid 25–34 48 (70.6%) 42 (62.7%) 0.379
water testing kit (Messer and Dufour 1998). A > 34 11 (16.2%) 10 (14.9%)
150-ml stored drinking water sample was
Education of caregivers
collected in a sterile glass bottle from every
Illiterate 39 (57.4%) 23 (34.3%) 0.007*
participating household with U5 children. The
Literate 29 (42.6%) 44 (65.7%)
physicochemical and microbial analysis was
done using standard analytical techniques and Monthly household income)
instruments such as a pH 11 meter (Wagtech) ($USDa 31 (46.3%)
to measure pH and temperature, a Potalab ≤ 47USD 43 (63.2%)
turbidity meter to measure turbidity, and a > 47USD 25 (36.8%) 36 (53.7%) 0.048
color comparator to measure residual free Household 27 (39.7%) 34 (50.7%)
chlorine. Wagtech field test kits were used to size ≤ Four
detect FC as yellow color on membrane lauryl and less than
sulfate broth (MLSB) and FS as red color on four
enterococcus agar. Turbidity, pH, temperature, > Five and 41 (60.3%) 33 (49.3%) 0.197
above
and residual free chlorine were measured on
Water source
site. 26 (38.2%) 7 (10.4%)
Protected
Table 1 Checklist for the identification of sanitary spring
inspection risk factors
Tap water 42 (61.8%) 60 (89.6%) 0.001*
Question Answer a
US dollars, *p value < 0.05
1. Is drinking water kept in a separate Y/N
Data quality management and analysis
container?
2. Is drinking water kept above floor level and Y/N
away from contamination? The quality of the data was controlled by using
3. Do water containers have a narrow Y/N questionnaires and sanitary inspection
mouth/opening? checklists based on WHO standard methods
4. Do containers have a lid/cover? Y/N
for household surveys (WHO and UNICEF
5. Was the lid/cover in place at time of visit Y/N
2006). Distilled and sterile water was used as a
6. How is water taken from the container? Pouring or
dipping
quality control for the membrane filtration
7. Is a clean utensil used to draw water from Y/N technique. The instruments were calibrated
the container? before testing the physicochemical parameters.
Water samples were collected and transported
to the Angereb laboratory unit in Gondar
Town for microbial water quality analysis
within 4 h. During transportation, the samples
Environ Monit Assess (2018) 190: 669 Page 5 of 12 669
were stored below 4 °C using an icebox. The contamination of 59 (86.8%) of the
Descriptive statistics, including means, drinking water samples from households of U5
proportions, and percentages, were used, diarrhetic children with low (16.2%), medium
followed by chi-square tests to compare the (47.1%), high (13.2%), and very high (10.3%)
quality of stored drinking water among risk of FC concentrations and 55 (82.1%) of
households with U5 children with and without the samples from households of U5 non-
diarrhea. The FC and FS counts were diarrhetic children with low (22.4%), medium
compared and interpreted using the WHO (44.8%), high (9.0%), and very high (6.0%)
guidelines for drinking water (WHO 2004). risk of FC concentrations was similar (p >
0.05). However, FS concentrations of water
Operational definitions samples were significantly higher in
households with diarrhetic children in the low
Diarrhea: having two or more loose stools a and medium sanitary risk categories (p < 0.05)
day in the 2 weeks before the interviews. (Table 3).
Protected spring: a spring that is properly
protected by one or two masonry boxes and Contamination risk levels of household-stored
has a distribution site near the boxes drinking water samples
(Mengesha et al. 2017).
Protected well: a well that is properly Using FC and FS counts as a proxy to
constructed with masonry and internally determine overall health risk, 41 (60.3%), 6
plastered at least 3 m deep and with an electric (8.8%), 10 (14.7%), and 2 (2.9%) of the
pump at the top (Mengesha et al. 2017). drinking water samples from households with
Residual free chlorine: the concentration of U5 children with diarrhea (p < 0.001) and 22
chlorine in stored drinking water present as (32.8%), 22 (32.8%), 11 (16.4%), and 0
dissolved gas (Cl2), hypochlorous acid (HOCl), (0.0%) of the samples from households with
or hypochlorite ion (OCl−). U5 children without diarrhea (p < 0.01) had
Stored drinking water: water that is very high, high, medium, and low sanitary risk
intended for drinking and is stored in a scores for FC, respectively (Table 4, Figs. 2
container.
and 3). Twenty-five (36.8%), 3 (4.4%), 1
(1.5%), and 0 (0.0%) of the drinking water
Results and discussion samples from households with U5 children
with diarrhea (p < 0.001) and 4 (6.0%), 3
Sociodemographic characteristics (4.5%), 17 (25.4%), and 0 (0.0%) of the
samples from households of U5 children
The ages of the caregivers in households with without diarrhea (p < 0.001) also had very
diarretic and non-diarrhetic U5 children were high, high, medium, and low sanitary risk
similar (p > 0.05). Significantly more scores for FS, respectively (Table 4, Figs. 4
caregivers in households with U5 children and 5).
without diarrhea were literate (p < 0.05) and
had higher monthly incomes than those in Physicochemical analysis of stored drinking
households with diarrhea cases (p < 0.05). The water samples
use of tap water was also associated with the
absence of diarrhea (p < 0.01) (Table 2). Forty-seven (69.1%) of the drinking water
samples from households with U5 children
Microbial quality of household-stored drinking with diarrhea and 23 (34.3%) of the samples
water from households with U5 children without
diarrhea had turbidity values above the WHO
669 Page 6 of 12 Environ Monit Assess (2018) 190: 669
permissible level (p < 0.001). Five (7.4%) of FC or FS. Consistent with our finding, the
the drinking water samples from households microbiological quality of drinking water in
with U5 children with diarrhea and 4 (6.0%) of the Rift Valley area of Ethiopia has been
the samples from households with U5 children reported as very poor (Amenu et al. 2014).
without diarrhea had pH above the WHO Furthermore, a study in Myanmar revealed that
permissible level (p > 0.05). None of the 94% of household-stored drinking water
household drinking water samples had samples were contaminated with
permissible amounts of residual free chlorine, thermotolerant coliforms (Myint et al. 2015).
but the temperatures of all the household- The highlevel ofdrinkingwater
stored drinking water samples were in contamination in our study might be due to
conformity with the WHO standards. contamination at the source, inadequate
The use of protected spring water sources chlorine treatment, and improper water
was significantly higher in households with U5 handling at the household level. Inappropriate
children with diarrhea than in households with water handling, as well as unhygienic
U5 children without diarrhea. A study in activities, and environmental contamination
Kenya revealed that total coliform was appear to be the contributors to water
abundant in most of the spring water sources contamination at the point of use. A finding in
studied including protected springs, whereas Addis Ababa slum areas revealed that shared
fecal coliform was present in 29% of spring sanitation facilities were significantly
water sources. The authors noted that the associated with the occurrence of
presence of coliform may pose a high risk of
water-borne diarrhea diseases (Simiyu et al.
2009). A study on the effect of improved water
supplies on U5 diarrhea prevalence showed
that improved water supply reduced diarrhea in
U5 children by only 11% (Cha et al. 2015).
The present study may raise questions about
the quality of WHO-recommended improved
water sources (protected springs and protected
wells).
The percentage of caregivers who were
illiterate was significantly higherin households
with U5 children with diarrhea than without
diarrhea. An observational casecontrol study in
Jamaica showed that children of caregivers
with low knowledge scores about the
prevention and treatment of diarrhea were at
increased risk of presenting with
gastroenteritis (Bachrach and Gardner 2002).
Our study reveals a need to enhance
caregivers’ education to protect under-five
children from diarrhea and associated diseases.
WHO recommends that 100 ml samples of
ready-todrink water be free from microbial
indicator organisms (WHO 2011). The
majority ofour household-stored drinking
water samples were grossly contaminated with
Environ Monit Assess (2018) 190: 669 Page 7 of 12 669
Table 3 Fecal coliform and fecal streptococci counts per 100 ml of stored drinking water samples in households with under-five
children with and without diarrhea

Fecal coliform counts per 100 ml sample of stored drinking water

0 n (%) 1–9 n (%) 10–99 n (%) 100–999 n (%) ≥ 1000 n (%) Total n (%) p

Water samples 0.454

U5 children with diarrhea (n = 68) 9 (13.2) 11 (16.2) 32 (47.1) 9 (13.2) 7 (10.3) 59 (86.8)

U5 children without diarrhea (n = 67) 12 (17.9) 15 (22.4) 30 (44.8) 6 (9.0) 4 (6.0) 55 (82.1)

Risk category* Conformed* Low risk Medium risk High risk Very high risk

p value (p) 0.970 0.488 0.310 0.264

Fecal streptococci counts per 100 ml sample of stored drinking water
0 n (%) 1–9 n (%) 10–99 n (%) 100–999 n (%) ≥ 1000 n (%) Total n (%) p

Water samples 0.417

U5 children with diarrhea (n = 68) 39 (57.4) 1 (1.5) 23 (33.8) 3 (4.4) 2 (2.9) 29 (42.7)

U5 children without diarrhea (n = 67) 43 (64.2) 8 (11.9) 11 (16.4) 5 (7.5) 0 (0.0) 24 (35.8)

Risk category Conformed* Low risk Medium risk High risk Very high risk

p value 0.036 0.048 0.586 0.143

*Conforming with WHO standards (WHO 2011)

acute diarrhea and hand washing with soap

before preparing food and after defecation
were the most important of the recommended
times for preventing the occurrence of acute
diarrhea in the slums of Addis Ababa, Ethiopia
(Adane et al. 2017a, c).
Using the WHO water standard (WHO
2011), the current study found that the
microbial quality of household-stored drinking
water in most of the stored drinking water
samples from both households with U5
children with diarrhea and households with U5
children without diarrhea was contaminated
with FC. Consistent with our findings, a study
in Canada showed that exposure to water-
borne pathogens and lack of sanitation
contributed to major health issues in some
communities (Metcalfe et al. 2011). Similarly,
a study in southern Ethiopia identified FC in
80% of drinking water samples, with counts
ranging between 0.67 and 266.67 CFU/100 ml
(Yasin
669 Page 8 of 12 Environ Monit Assess (2018) 190: 669
etal.2015).Astudyonwaterhandlingpracticesand in household-stored drinking water was lowest
levels of contamination in another highland when consumers used chlorine (Luoto et al.
town in Ethiopia reported that all household- 2011). The present study demonstrates the
stored drinking water samples were positive need to treat water to meet acceptable RFC
for total coliform and 33% for FC (Sharma et levels to decrease the risk of contamination of
al. 2013). In our study, 29 (43%) of the stored stored drinking water.
drinking water samples among households Water temperatures were within the WHO
with U5 children with diarrhea and 24 (36%) permissible range (between 15 and 20 °C) due
of the samples among households with under- to the high
five children without diarrhea were
contaminated by FS. These rates are lower
than those recorded by Abbas et al., who found
67% of their samples positive for FS in a
community in Pakistan (Abbas et al. 2007). A
study in Nepal reported that 15% of the tap
water samples
inanurbanareainNepalwerecontaminatedwithF
S(Pant et al. 2016). A study in China recorded
32.3% of spring water samples contaminated
with FS (Wei et al. 2017). According to
research findings in Ghana, FC and FS were
consistently present in the water sources in a
peri-urban area in Ghana, suggesting
anthropogenic pollution
(Boamahetal.2011).Thecontaminationratesinou
rstudy were in the middle range of those found
in the studies, indicating the need for
continuous monitoring and surveillance of
sources and good practices for handling
household-stored drinking water.
According to the WHO guidelines, drinking
water should contain >0.5 mg/l RFC.
However, we found that allthehousehold-
stored drinking watersampleshad smaller
amounts of RFC than necessary to safeguard
against the risk of subsequent microbial
contamination. In another small Ethiopian
town, 85% of stored water samples had no
RFC (Sharma et al. 2013). The importance of
RFC in stored drinking water was emphasized
by several researchers (Chiller et al. 2006;
Arnold and Colford 2007; Harshfield et al.
2012; Mengistie et al. 2013). A study in
Tanzaniaconcludedthatchlorinedisinfectionwas
effective against both water-borne bacteria and
viruses (Mohamed et al. 2015). A trial study in
Bangladesh revealed that E. coli concentration
Environ Monit Assess (2018) 190: 669 Page 9 of 12 669
Table 4 Sanitary inspection risk scores in relation tofecal coliform and fecal streptococci counts per 100 ml sample of stored
drinking water of households with under-five children with and without diarrhea

Fecal coliform counts per 100 ml sample of household-stored drinking water

10– 100–999 n ≥ 1000 n (%) p

1–9
99 (%) Total value
Risk scores Risk score 0 n (%) n
n n (%)
(%)
(%)
U5 diarrhetic children with (n = 68)
0–2 Low 0 (0.0) 0 (0.0) 0 (0.0) 0 (0.0) 2 (2.9) 2 (2.9)
3–5 Medium 2 (2.9) 4 (5.9) 0 (0.0) 5 (7.4) 1 (1.5) 10
(14.7)
6–8 High 7 (10.3) 2 (2.9) 0 (0.0) 1 (1.5) 3 (7.4) 6 (8.8)

9–10 Very high 0 (0.0) 5 (7.4) 32 (47.1) 3 (4.4) 1 (1.5) 41 <

(60.3) 0.001
Total 9 11 32 9 7 59

U5 non-diarrheti c children (n = 67)

0–2 Low 1 (1.5) 0 (0.0) 0 (0.0) 0 (0.0) 0 (0.0) 0 (0.0)
3–5 Medium 6 (9.0) 6 (9.0) 1 (1.5) 2 (3.0) 2 (3.0) 11 0.005
(16.4)
6–8 High 5 (7.5) 1 (1.5) 16 (23.9) 3 (4.5) 2 (3.0) 22
(32.8)
9–10 Very high 0 (0.0) 0 (0.0) 21 (31.3) 1 (1.5) 0 (0.0) 22
(32.8)
Total 12 7 38 6 4 55

Fecal streptococci counts per 100 ml sample of household-ored ater

Risk score Risk score 0 n (%) st drinking w 100–
1–9 10– 999 n ≥ p
n 99 (%) 1000 value
(%) n n Total
(%) (%) n (%)
U5 diarrhetic chi ldren (n = 68)
0–2 Low 2 (2.9%) 0 (0.0) 0 (0.0) 0 (0.0) 0 (0.0) 0 (0.0)
3–5 Medium 29 (42.7) 0 (0.0) 0 (0.0) 1 (1.5%) 0 (0.0) 1 (1.5) <
0.001
6–8 High 8 (11.8%) 1 (1.5%) 1 (1.5%) 1 (1.5%) 0 (0.0) 3 (4.4)

9–10 Very high 0 (0.0) 0 (0.0) 25 (36.8%) 0 (0.0) 0 (0.0) 25

(36.8%)
Total 39 1 26 2 0 29

U5 non-diarrheti c children (n = 67) 23 (34.3%)

0–2 Low 0 (0.0) 0 (0.0) 0 (0.0) 0 (0.0) 0 (0.0)
3–5 Medium 15 (22.4%) 3 (4.5%) 11 (16.4%) 3 (4.5%) 0 (0.0) 17 <
(25.4) 0.001
6–8 High 5 (7.5%) 1 (1.5%) 1 (1.5%) 1 (1.5%) 0 (0.0) 3 (4.5)

9–10 Very high 0 (0.0) 0 (0.0) 3 (4.5) 1 (1.5%) 0 (0.0) 4 (6.0%)

Total 43 4 15 5 0 24
669 Page 10 of 12 Environ Monit Assess (2018) 190: 669
altitude of the study sites (Ambagiorgis is at safe storage measures was significantly less
around 2900 m and Gedebge at 2700 m contaminated with Escherichia coli than water
altitude). in households without such measures (Quick
Our study showed that almost 70% of the et al. 2002). A systematic review in low- and
studied households with U5 children with middle-income countries concluded that few
diarrhea and 23 (34%) of the households with previous studies examined stored water quality
U5 children without diarrhea had turbid stored and sanitary risk (Bain et al. 2014) and their
water that exceeded the WHO permissible roles in acute diarrhea infection.
limit for turbidity. A study in Jimma Zone in Sanitary risk scores based on our sanitary
Ethiopia recorded turbidity of drinking water inspections of household vessels ranged from
samples up to 65 NTU (Yasin et al. 2015). low to very high, with most vessels having
Researchers (Tinker et al. 2010; Hsieh et al. medium and very high sanitary risk scores for
2015) have demonstrated an association FS and FC. Similarly, a study conducted in
between water turbidity and emergency Nyala Town, Sudan, and Bahr Dar Town,
department visits for gastrointestinal illness. Ethiopia, found nearly half (46%) of the water
The poor water quality widely observed in samples examined to have very high levels of
storage vessels might be due to lack of proper FC (Abdelrahman and Eltahir 2011; Tabor et
procedures for retrieving water from storage al. 2011). A study in northeastern Ethiopia
containers. The behavioral and hygienic showed that 138 (72.0%) households in which
practices of communities may contribute to the people drew water from a container by dipping
burden of drinking water contamination. A were at high risk of FC (Tiku et al. 2003).
report from Addis Ababa slums revealed that It is possible that microbial qualities and
retrieving water fromwater storage vessels physicochemical indicators of drinking water
using handle-less vessels was associated with quality are differentially informative of
acute diarrhea (Adane et al. 2017b). A study in diarrhea risk in various settings (Strauss et al.
Zambia showed that stored water in 2001). However, our study revealed that
households that implemented treatment and

Fig. 2 Sanitary inspection risk scores and fecal coliform counts (CFU/100 ml) in households with U5 children with diarrhea
(HCWD)

Fig. 3 Sanitary inspection risk scores and fecal coliform count (CFU/100 ml) in households with U5 children without
diarrhea (HCWOD)
Environ Monit Assess (2018) 190: 669 Page 11 of 12 669

Fig. 4 Sanitary inspection risk scores and fecal streptococci counts (CFU/100 ml) in households with U5 children
with diarrhea (HCWD)
FS contamination and higher turbidity of amounts of RFC were detected in any of the
householdstored drinking water are associated water samples tested. Frequent exposure to
with diarrhea in U5 children (p < 0.05) within stored drinking water that does not conform to
the context of inadequate supply and poor WHO standard may result in diarrhea among
water quality conditions that are typical of under-five children. We recommend that the
Wegera District. local authorities implement interventions
focused on the provision of safe water
supplies, behavioral change in personal
Conclusions hygiene and drinking water handling practices,
and the protection and treatment of household-
This study found that household-stored stored water. These measures can improve the
drinking water was grossly contaminated with microbial quality by effectively preventing
FC and FS in both households with U5 coliforms and pathogenic contaminants from
children with diarrhea and households with U5 entering the ready-to-drink water supply. We
children without diarrhea in the northwestern recommend that further research be carried out
Ethiopian highlands. FS contamination at on health aspects of householdstored drinking
lowand medium-risk categories and turbidity water handling and use in communities with
of householdstored drinking water were different water sources and socioeconomic
significantly higher in households with U5 situations and that the WASH and other
children with diarrhea than in households with water/sanitation programs consider this issue
U5 children without diarrhea. No permissible in their behavioral intervention programs.

Fig. 5 Sanitary inspection risk scores and fecal streptococci counts (CFU/100 ml) in households with U5 children without diarrhea
(HCWOD)
669 Page 12 of 12 Environ Monit Assess (2018) 190: 669
Acknowledgements The authors would interruptions and acute diarrhea among under-
liketoacknowledge the Ethiopian Institute of Water fivechildren in Addis Ababa slums, Ethiopia: a
Resources, Addis Ababa University, Assosa matched case-control study. PLoS One, 12,
University, USAID, and the University of Connecticut e0181516.
for funding this project. We also acknowledge Wegera Adane, M., Mengistie, B., Mulat, W., et al. (2017c).
District Water Development Bureau and Gondar Town The most important recommended times of hand
Water and Sewerage Authority for facilitating the washing with soap and water in preventing the
laboratory work and want to thank Ann Byers for occurrence of acute diarrhea among children
editing the manuscript at short notice. under five years of age in slums of Addis Ababa,
Ethiopia. Journal of Community Health, 43, 400–
405.
Funding information This work was supported by Amenu, K., Spengler, M., André, M., & Zárate, A. V.
USAID through the USAID/HED funded grant in the (2014). Microbial quality of water in rural
Africa-US Higher Education Initiative-HED 052-9740- households of Ethiopia: implications for milk
ETH-11-01. safety and public health. Journal of Health,
Population, and Nutrition, 32, 190.
Compliance with ethical standards Arnold, B. F., & Colford Jr., J. M. (2007). Treating
water with chlorine at point-of-use to improve
Ethical clearance Ethical approval was obtained from water quality and reduce child diarrhea in
the Ethiopian Public Health Institute in Addis Ababa developing countries: a systematic review and
and a study permit from the Wegera District Health meta-analysis. The American Journal of Tropical
and Water Development bureaus was obtained prior to Medicine and Hygiene, 76, 354–364.
data collection. Written consent for the interviews was Bachrach, L. R., & Gardner, J. M. (2002). Caregiver
given by the respondents enrolled in the survey. knowledge, attitudes, and practices regarding
Oralrehydrationsolution was given toU5children with childhood diarrhea and dehydration in Kingston,
diarrhea at the time of the survey. Jamaica. Rev Panam Salud Pública, 12, 37–44.
Bain, R., Cronk, R., Wright, J., Yang, H., Slaymaker,
T., & Bartram, J. (2014). Fecal contamination of
drinking-water in low-and middle-income
Open Access This article is distributed under the terms countries: a systematic review and meta-analysis.
of the Creative Commons Attribution 4.0 International PLoS Medicine, 11, e1001644.
License (http:// creativecommons.org/licenses/by/4.0/), Boamah, V. E., Gbedema, S. Y., Adu, F., & Ofori-
which permits unrestricted use, distribution, and Kwakye, K. (2011). Microbial quality of
reproduction in any medium, provided you give household water sources and incidence of
appropriate credit to the original author(s) and the diarrhoea in three peri-urban communities in
source, provide a link to the Creative Commons Kumasi, Ghana. Journal of Pharmaceutical
license, and indicate if changes were made. Sciences and Research, 3, 1087–1091.
Boru, W. G., Omollo, J., Abade, A., et al. (2013).
Aetiology and factors associated with bacterial
diarrhoeal diseases amongst urban refugee
children in Eastleigh, Kenya: a case control study.
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