Selecting Household Water Treatment Options on the Basis of World Health Organization Performance Testing Protocols

The World Health Organization's International Scheme to Evaluate Household Water Treatment Technologies serves to benchmark microbiological performance of existing and novel technologies and processes for small-scale drinking water treatment according to a tiered system. There is widespread uncertainty around which tiers of performance are most appropriate for technology selection and recommendation in humanitarian response or for routine safe water programming. We used quantitative microbial risk assessment (QMRA) to evaluate attributable reductions in diarrheal disease burden associated with water treatment technologies meeting the three tiers of performance under this Scheme, across a range of conditions. According to mean estimates and under most modeling conditions, potential health gains attributable to microbiologically improved drinking water are realized at the middle tier of performance: "comprehensive protection: high pathogen removal (star star)" for each reference pathogen. The highest tier of performance may yield additional marginal health gains where untreated water is especially contaminated and where adherence is 100%. Our results highlight that health gains from improved efficacy of household water treatment technology remain marginal when adherence is less than 90%. While selection of water treatment technologies that meet minimum WHO efficacy recommendations for comprehensive protection against waterborne pathogens is critical, additional criteria for technology choice and recommendation should focus on potential for correct, consistent, and sustained use.