Adoption of Household Chlorination Pre- and Post-emergency Response in Léogâne, Haiti

Background: Deep Springs International (DSI) launched a household chlorination program, “Gadyen Dlo” (“Water Guardian” in Haitian Kreyòl), in Léogâne, Haiti in June 2008. During 2010, GD responded to two separate emergencies in Léogâne: an earthquake and a cholera outbreak. We assessed adoption of household chlorination pre-earthquake during the development phase (while hypochlorite solution was sold), post-earthquake in the emergency response phase (while free Aquatabs were being distributed), post-earthquake (and pre-cholera) following the program's transition back to the development phase (when the hypochlorite solution was again sold) and finally post-cholera outbreak in the emergency response phase (when hypochlorite solution sales were ongoing).Methods: The percentage of households with positive chlorine residual in drinking water at the time of an unannounced visit were compared from four separate time points: 1) prior to the earthquake (August 2009) when Gadyen Dlo was being sold, 2) following the earthquake (March — July 2010) when free Aquatabs were being distributed, and 3) post-earthquake/pre-cholera outbreak (August — mid-October 2010) after transitioning back to the sale of GD, and 4) post-cholera outbreak (mid-October — January 2011) while sales of GD were ongoing. Free chlorine residuals for all time points were measured in treated household water samples using pool test kits with a liquid chemical, orthotolidine (OTO).Findings: The percentage of households (N=38) with a positive chlorine residual test prior to the earthquake during the sale of Gadyen Dlo was 32% (6/19) in the plains, 63% (12/19) in the mountains, and 47% (18/38) overall (plains and mountains combined). Following the earthquake when Aquatabs were being distributed, the percentage of households (N=1409) with a positive chlorine residual test was 79.3% (451/569) in the plains, 87.3% (733/840) in the Mountains and 84.0% (1184/1409) overall. With the introduction of chlorine sales prior to cholera, the percentage of households (N=483) with a positive chlorine residual test was 77.0% (104/135) in the plains, 83.6% (291/348) in the mountains, and 81.8% (395/483) overall. Following the outbreak of cholera when chlorine sales continued, the percentage of households (N=355) with a positive chlorine residual test was 92.3% (179/194) in the plains, 86.3% (139/161) in the mountains, and 89.6% (318/355) overall.Interpretation: The overall proportion of households with positive chlorine residual varied by both time (pre- versus post-earthquake) as well as by location within each time point (plains versus mountains). Prior to the earthquake, when Gadyen Dlo was being sold, just under half of the households had chlorine positive residual tests indicating microbiologically safe water. However, after the earthquake, when free Aquatabs were being distributed, the percentage of households with positive chlorine residual tests increased and the majority of the households were utilizing point of use water treatment as indicated by a positive chlorine residual test. The differences pre- and post-earthquake could be due to the methodological differences in data collection pre- versus post-earthquake, greater perceived need for household water treatment after the earthquake, greater community-level promotion efforts after the earthquake, increased numbers of CHWs promoting the product after the earthquake, or decreased cost (i.e. the Aquatabs were distributed free of cost after the earthquake).Funding: This study was funded by DSI and the Children's Nutrition Program of Haiti.