Manzwaterinfo.ca

April 22, 2004
Rotary Club:
Bob Hildreth, Rob Overly, Jim Bodenner
CDC/FDDB:
Rob Quick, Eric Mintz
Professor Mark Sobsey
Daniele Lantagne, PE (dul4@cdc.gov)
Environmental Engineer
Foodborne and Diarrheal Diseases Branch
Centers for Disease Control and Prevention
Subject:
Trip Report – Dominican Republic
I. Dates and Places of Travel
27 February – March 3:
Puerto Plata, Dominican Republic
II. Purpose of Travel
A. To assist Rotary Project Teams from Michigan and Florida, specifically around issues of
evaluation and comparison of point-of-use treatment options. Specifically, the Michigan
groups are supporting implementation of BioSand filtration, and the Florida groups are
supporting and implementing the Mission Filter.
III. Principal Persons Contacted
A. Rotary Clubs
Sponsoring and Implementing Biosand Filtration
Bob Hildreth
District Grants Subcommittee Chair
District International Projects Coordinator
Dominican Republic
Jim & Susan Bodenner
Rotary Michigan
US Coordinator and Supporters of Projects
Marisela (Marie) Hernandez Community Coordinator, Playa Oeste Barrios, Puerto Plata
Sponsoring and Implementing the Mission Filter
Rob Overly
Rotary Florida
US Coordinator and Supporters of Projects
Dr. Kate Wilson-Overly
Member of Medical Mission
Draft Dominican Republic Trip Report, March 2004
IV. Presentation to Rotary/Florida, Rotary/Michigan, and Rotary/DR
After all groups arrived in the Dominican, a gathering was held at Bob Hildreth’s house to
meet, have dinner, and attend a presentation on point-of-use treatment options. The
presentation is enclosed as Annex A. The main points stressed in the presentation were:
1) There are a wide variety of options available for point-of-use treatment, 2) Health
impact is the gold standard for assessing the efficacy of point-of-use treatments, and 3) A
disinfectant step is needed after filtration to ensure that water is not recontaminated in
storage. The presentation was well received and many questions were asked.
V. BioSand Filter Project
The history of the BioSand Filter (BSF) project in the Dominican is described in the
following paragraphs. Jan Tollefson, MD and Dr. Manz were sponsored by Calgary
Chinook Rotary Club and Rotary Foundation to train 10 Dominican technicians to make
BSF’s. Dr. Tollefson has been primary contact for this project and worked with the
technicians on quality control and has returned every 3 months for 3 years to continue
working with the project. She has physically gone to most of the areas with BSF’s and
has developed a significant amount of troubleshooting knowledge. Four of the initial ten
technicians are still making BSF’s, while the other six have left due to quality control
issues, finding other jobs, or the difficulty of the job (which necessitates marketing,
organizational, and construction skills).
Dr. Tollefson met the Michigan Rotarians in Mao, Dominican Republic at a Nursing
Home project. After this meeting, Dr. Tollefson and Jim and Susan Bodinger from
Michigan began communicating. Independently, Bob Hildreth met Dr. Tollefson through
mutual friends in the DR. Bob Hildreth had been working on water supply in the
Dominican Republic already, and had experience with the installation of institutional 10
gpm systems. Based on the meetings with Dr. Tollefson, the Michigan Rotarians became
interested in, and began investing in, the Biosand filter.
A retirement home associated with the Michigan Rotarian group raised an initial amount
of 400 USD to bring BSF’s to Puerto Plata. Twelve BSF’s were installed with people
Bob knew directly or indirectly all over Puerto Plata. Initial feedback on these 12 filters
was very positive. The Bodinger’s then went back to Michigan and raised funding for 170
additional BSF’s. Families paid 12 USD to purchase a BSF, which was approximately a
70 percent subsidy at that time. The 170 filters were divided among four barrios and one
rural town. Each barrios selected a community coordinator to organize the BSFs, and to
promote and troubleshoot the filters. Bob Hildreth designed this model to determine the
minimum amount of support necessary for distributing and maintaining filters in the
homes in terms of organization and instruction.
The next step in BSF distribution in the DR was when Bob Hildreth and the Bodinger’s
thought that Peace Corps would be a good organization to work with on BSF installation.
A meeting was arranged with the Peace Corps Country Director and the Water &
Sanitation Director. Fortuitously, one of the water volunteers had completed an aqueduct
project, had extra funding, and the volunteer wanted to do water filtration. The volunteer
had decided to go with BSF unaware of the Rotary projects, and installed 80 in a
community in a province of Puerto Plata. The volunteer related a favorable review and
experience, however the volunteer then left the country. Heather Lukacs and the MIT
team went to this location with the Canadian Embassy (SIDA) in January 2004. Rotary
Draft Dominican Republic Trip Report, March 2004
has also obtained an official letter of commitment from the Peace Corps Country Director
for the purpose of writing a grant for approximately 1,000,000 USD for 150-160
communities. In addition, Dr. Tollefson and Bob Hildreth trained Peace Corps volunteers
on the BSF in the Summer of 2003 and the Fall of 2003. They trained one group during
their initial training in country, and another group after they were in the communities. In
retrospect, Rotary feels the training is more valuable after the volunteers are established,
as opposed to during their initial indoctrination. Twelve Peace Corps volunteers from
Haiti were also trained separately. Further work with volunteers will include the
development of a brochure and 30-minute orientation for volunteers at their initial
training, and then offer quarterly seminars offering training on how to become a
community organizer for interested volunteers, and other NGO’s or interested parties.
Currently, the project is funded through a Rotary Foundation grant for 25,000 USD, which
was supported by the Michigan group. Two others grants are in process from
Westhampton (New York) Rotary Club and the Oakville Rotary Club (Toronto suburb).
Michigan is also raising soft money to support the project.
Parallel to all of this, the NGO Indinor has funded a fairly large BSF distribution project.
In addition, CAWST (The Center for Affordable Water and Sanitation Technology) has
been involved by providing instructional material to Dr. Tollefson, and working with
Mount Royal College to produce manuals and educational material. Rotary feels there is
more practical implementation expertise needed in the CAWST materials. CAWST
organized two seminars in the DR, in June and November 2003, to bring together partners
working on BioSand in the DR. They did an introduction to water problems and point-of-
use technologies, emphasizing the value of BSF, and provided a forum for partners to
meet. Mark Sobsey and Heather Lukacs attended the June 2003 meeting, and began
discussing conducting a health impact study. In addition, Heather Lukacs and the MIT
team visited the DR in January 2004, and Bob Hildreth helped arrange their travel.
Based on all of the work above, Bob Hildreth estimates that there are approximately 3,000
BSF’s in the DR, although they are in many locations. The known filters are: Rotary
grants (12, 170), Peace Corps (80), and those made by Technicians (1,700).
Lastly, the Michigan Rotary Clubs planned their visit to assess projects for one week in
February/March 2004. Bob Hildreth arranged for the Michigan and Florida Rotarians to
have dinner together, and for me to give a presentation. I was also able to complete water
quality analysis and a short survey at 10 homes with BSFs in the Playa Oeste Barrio in
Puerto Plata.
Water quality monitoring results showed that turbidity was low in all filtered water
samples, that only 2 of the 10 families were chlorinating post-filtration (and that one of
the two families was under-chlorinating), and that all bacterial samples of finished,
filtered water were positive for total coliform after 24 hours using the Hach Pathoscreen
broth except for the one chlorinated sample. It is important to remember that these
samples are from a limited sampling of only 10 homes in one location, and they are not
statistically significant, nor intended for scientific analysis. This was a limited survey to
ascertain directions for future research, and for gathering of information on usage patterns.
A larger study is necessary to determine statistically significant water quality monitoring
data.
Draft Dominican Republic Trip Report, March 2004
Table 1: Water Quality Results from BioSand Filter Household Visits, Playa Oeste Barrio
Turbidity
Conductivity
Chlorine
Chlorine
Coliform
+ (24 hrs)
– (24 hrs)
+ (24 hrs)
– (24 hrs)
+ (24 hrs)
– (24 hrs)
0.05 / 0.07
0.06 / 0.08
– (24 hrs)
– (24 hrs)
0.59 / 0.52
0.74 / 0.69
Marie’s
+ (18 hrs)
– (24 hrs)
Data obtained from the household visits is detailed below:
 All families collect water from the public tap. Because of it being intermittent, many
families store water in large containers (20 – 200 L).
 All BioSand filters were installed between 15-18 months ago.
 2 families (20%) added chlorine to stored water, although only 1 family (10%) added
the correct amount.
o This 1 family lived next to Marie and had a 7-year old child with HIV
contracted from a blood donation at 2 years old. Anecdotally, her health has
improved since using filtered water.
 80% of families store water in open containers, with the majority (70%) storing in
white 20 L paint buckets
o Two families (20%) transfer their water smaller containers to either store it in
the fridge, or for ease of storing.
 Two families (20%) store their water in 5-gallon water containers, although both filter
water into other containers before pouring it into the water container.
 Two families (20%) cover their filter with a cloth. This metric has been linked in
other studies to correct usage of the filter.
 Three families (30%) did not have filtered water at the time of the unannounced visit:
o One family (10%) clearly does not use the filter regularly.
o Two families (20%) most likely use the filter regularly, but because it was
washing day, were out of water at that point in time.
 The majority of families (60%) use the filter daily.
 No family uses the filter to its capacity – as no family indicated they use the water for
drinking, bathing, cooking, juice making, and washing.
Draft Dominican Republic Trip Report, March 2004
Table 2: Use and Storage Practices in Households with Biosand Filter
Chlorine
Use water
Container
20 L bucket
Drinking
~15 L kitchen
Drinking,
pot with lid
Every two
20 L bucket
Drinking
20 L water
Multiple
Multiple
Drinking
Filter covered.
container
times daily
times daily
Drinking,
20 L bucket
cleaning
No water at the
20 L bucket
Intermittently
Drinking
Intermittent
time of visit.
20 L bucket
then 1 gallon
Drinking
jug in fridge
20 L bucket and
Drinking,
because currently
washing.
Drinking,
Multiple
cooking,
Multiple
because currently
20 L bucket
times daily
cleaning
times daily
washing. Filter
covered.
20 L bucket
Multiple
Drinking
20 L water
times daily
container
Based on the data obtained above and conversations with Rotarians, the following
recommendations are suggested:
 One of the strong benefits of the BSF is the amount of water it can produce. It is
recommended that users use BSF water for more than just drinking. Educational
materials should stress the use of BSF water for cooking, bathing, cleaning, washing
fruit, and washing hands.
 The presence of total coliform in all non-chlorinated finished, stored water is
concerning, and it is recommended that users post-chlorinate their water in order to
ensure safe storage. A small dropper bottle is an appropriate tool to use to add 3 drops
per gallon of 5.25% strength Clorox bleach to the solution.
 Because BSF is an unproven technology in terms of health impact, it is recommended
that a health impact study be conducted. Professor Mark Sobsey at UNC would be an
ideal person to work on the health impact study, and Jim Bodenner of
Rotary/Michigan is willing to look for funding. Daniele will coordinate contact
between Mark and Jim.
Draft Dominican Republic Trip Report, March 2004
 While visiting a village with BSF’s being installed, we passed by the manufacturing
location for the filters, as well as a truck delivering four cement filters to the homes.
This transportation was extremely difficult – the truck had four filters with two people
holding them to prevent them breaking. This will be difficult to implement on a large
scale and it is recommended that Rotary investigate the use of alternate (plastic)
containers for the sand.
VI. Mission Filter Project
Concurrent to the Rotary BSF projects in the DR, there is also a Mission Filter Project
organized and supported by Rotary/Florida. Rob Overly is the coordinator of this
project. Compared with the Rotary/Michigan BSF project where Rotary/Michigan
primarily provides the funding for BSF’s and Bob Hildreth coordinates the installation
of the filters in the DR, the Rotary/Florida project is modeled more like a mission group.
Rotary/Florida members raise money to purchase the filters from Eagle Springs
Filtration, and then travel to the DR to assemble and distribute them to families. Rob
Overly is very knowledgeable about point-of-use interventions, as he had read
significant amounts of information on different interventions. He is also responsible for
funding and arranging my travel down to the DR.
This Rotary/Florida Mission was conducted jointly with a medical mission that Rob
Overly’s wife, Dr. Kate Wilson-Overly, is part of, in addition to a construction, bible
study, and education mission. During the time spent with Rotary/Florida, the focus was
on:
1. Visiting households with the Mission Filter
2. Talking with the medical mission about:
a. Symptoms seen in the clinic
b. Helping the medical mission understand the water supply in the area they
are working it
c. Potential of doing a health impact study
3. Thinking about future directions for the Mission Filter Project
Household Visits:
A total of 13 homes in three villages in the area with the Mission Filter were visited.
The results are presented in Table 3. The age of the filters visited was 15-18 months
old. The majority of the families had not had a change-out of either the cotton or the
GAC filter.
Draft Dominican Republic Trip Report, March 2004
Table 3: Findings from Household Visits in Three Communities, Mission Filter
Chlorine
Chlorine
Chlorine
Refrigerated
Top Bucket
This family appeared to chlorinate
their water (there was a bucket with >
0.02 / 0.04
> 2.20
2.2 mg/L free chlorine in it) but then
not use the filter and store the finished
water in the refrigerator.
Cracked bottom bucket.
Cracked bottom bucket.
Cracked bottom bucket.
Use water for drinking only.
0.05 / 0.07
0.09 / 0.06
Use water for drinking only.
Loose, unfixed spigot. Tightened while there.
Cracked bottom bucket.
Use filter watered to sell juice and for
> 2.20
0.07 / 0.05
drinking.
Use water for bathing only. Use purchased water for drinking. No water in filter.
Has dirty cotton filter.
Tap broken. Uses bottled water for drinking (30 pesos for 5 gallons).
Cracked bottom bucket.
Broken tap. Family said they use the system, but not at this point in time. Fixed
while there.
As can be seen from Table 3, there were a significant number of broken filters within the
15-18 month time frame. 8 of the 13 (62%) of the filters were broken. In addition,
another household appeared not to be using their filter (8%) for a total of 70% of filters
not in use at the time of the unannounced visit. This is problematic for the sustainability
of the program. Families did use the buckets with spigots for storing of water when the
buckets cracked.
Also of note is the common storage practice of filtering water, and pouring it into another
container to store in the refrigerator. This raises questions about the fact that there is little
residual in the water in the bottom bucket, and that this residual may not be protective
when transferred into another container.
Draft Dominican Republic Trip Report, March 2004
Medical Mission:
Symptoms:
The medical mission has been ongoing for 16 years in the Sabanetta area. Past
pharmaceutical records have indicated a preponderance of waterborne illnesses, and the
first year Dr. Kate Wilson-Overly participated in the mission, Rob Overly investigated the
water issues. He had also found the Mission Filter via the internet, and Mission Filters
were distributed based on need identified through the pharmaceutical records. During the
2004 mission, Dr. Kate Wilson-Overly was targeting questions on waterborne complaints
based on knowledge of the filter project. Dr. Wilson-Overly was noting a large variety of
parasitic worms in patients. Mission doctors were asking patients to describe the worms
in order to provide the best diagnosis and treatment. Patients described small black, small
white, and large red worms. Mebendazole was given to patients with worms. The first
two days the whole family was treated if a patient presented with worms, and subsequent
to that only the patients was treated. The was due to the fact that supplies were low and it
was determined to be unfair to patients who paid to treat patients who had not paid.
Water Supply:
Because of the amount of worms in the patients, the medical mission was interested in
determining the water supply of the families. A document to determine the water supply
system in a village, specifically for medical missions, has been attached as Annex B.
Health Impact:
The medical mission and local doctors are interested in conducting a health impact study
to follow-up on what is already known about the water supply, filter project, and medical
status of the community. Dr. Kate Wilson-Overly, Dr. Olga, Alerigo, and myself met
about the possibility of doing a health impact study. They are very interested and have the
funding and staff to supervise and visit homes weekly if they receive technical assistance
from the US. Professor Mark Sobsey of the University of North Carolina was contacted
about his potential interest in this study, and is willing to be a contact person for the
Rotary/Florida groups on this issue.
Future of Mission Filter Project:
Recent changes to the project include the hiring of a Technician and the purchase of a
motorcycle for him to service the filters. The following recommendations for future work
are:
 Visit every household with a filter and perform maintenance and administer the
survey attached as Annex C.
 Investigate selling replacement parts in stores in villages.
 Discontinue the use of the DR buckets that break.
 If possible, conduct a health impact study.
Draft Dominican Republic Trip Report, March 2004
Summary Statement:
Rotary groups are currently promoting two unproven point-of-use treatment technologies in
the Dominican Republic. A significant amount of effort, volunteer time, and expense has
gone into these two projects. The BSF project is at an ideal location to conduct a health
impact study. The Mission Filter project needs to address the sustainability issue in terms of
broken hardware before a health impact study can be completed. The goals of both projects is
to provide safe drinking water to families and to provide a model to Rotary and Rotary
International clubs doing an international water project. It is unclear to me that either of these
projects is yet at the stage that it could be an appropriate model for promotion to Rotary
International.
Draft Dominican Republic Trip Report, March 2004
Annex B: A How-to on Investigating Water Sources
(Designed for Medical Mission Teams)
Medical mission teams that note a large amount of waterborne disease in patients are often
curious about the water supply system in the local area and wish to investigate it. This
document is a brief overview of how to investigate the local water system in communities.
First, it is not recommended that medical missions ask each patient that visits the clinic where
their water comes from. This will result in a large variety of answers that will be difficult to
interpret without having a sense of the larger scale system. For example, if the water in a
community is from a river, but treated in a central location, and then piped to each home, a
patient could correctly respond to this question by saying “river”, “treatment plant”, “pipe”, or
“tap”. Thus, an understanding of the larger system is important to understand the answers
given by patients.
Second, to assess the system, a basic knowledge of water treatment practices and their impact
on human health is necessary. Essentially, there are two ways water is treated: 1)
Mechanisms to remove large material in the water, and 2) Disinfection to inactivate disease-
causing organisms. Mechanisms to remove large material in water include filtration through
sand, ceramic, membranes, or another medium, and/or coagulation and settling of material to
the bottom of the tank or bucket. Disinfection includes chlorination, or a more advanced
process such as ozonation or exposure to UV-light. The general relationship between water
treatment processes and their effectiveness at removing waterborne disease-causing agents is
depicted in the table below.
Effectiveness of Water Treatment Processes at Removing Waterborne Disease-causing
Disease-causing
Removal of agent
Inactivation of agent
by Filtration
by Disinfectants
Helminths
Significant
Protozoa
Significant
Bacteria
Minor – Signficant1
Significant
Significant
1: Depending on pore size of the filter.
Generally, water supply in developing countries comes from the following sources:
 Surface water
 Unprotected open wells
 Protected wells
 Community systems, such as:
o Reservoir flowing to community tap
o Sand filter flowing to community tap
o Reservoir flowing to household taps
 Infrastructure systems, such as:
o Water treatment plant to community tap
o Water treatment plant to household taps
Draft Dominican Republic Trip Report, March 2004
During the assessment process, it is important to consider what treatment processes water
from each different source is receiving. For example, water from a protected well may be
filtered by the soil, removing many helminthes and protozoa, but not disinfected, leading
users to be potentially exposed to bacteria and viruses, especially if water is stored and
transported in unsafe containers. Water from a chlorinated community reservoir may be
stored, unfiltered surface water, potentially exposing users to helminthes and protozoa.
To conduct a water supply system assessment, complete the following steps:
 Designate one person who will investigate the water supply system (this activity
would take approximately ½ - 1 day).
 Talk with knowledgeable residents about the different options for water in the
community.
 Visit each option, particularly noting the downstream and upstream points along the
supply chain. For example,
o If there are wells in the community, visit the well and then walk with a family
collecting water and note how they store the water in their home.
o If the water is treated centrally, visit the intake to the treatment system, the
treatment system, and then follow the pipes to the end point. The end point is
always the glass that is used to put drinking water into a child’s mouth. Pay
particular attention to homes at the outer reaches of the system.
o Pay especial note to potential lapses in the system, such as a lack of chlorine at
the water treatment plant, or intermittent supply that necessitates a large
volume of stored water, or dirty buckets used to carry water from a well.
 Draw a map of the community with water supply points and potential lapses clearly
 Present the map to all health workers interacting with patients.
 Ask patients presenting with suspected waterborne disease where they obtain their
drinking water and correlate that information with the map created. Specifically ask
questions that allow you as the health care provider to understand their drinking water
source within the community context. This approach prevents the need for individual
household visits to those presenting with suspected waterborne disease.
If trends are noted regarding water supply and waterborne disease, then water supply
improvements can be considered. For example, areas of high need for intervention can be
identified and improvements completed. For more information on water supply
improvements, please or email safewater@cdc.gov.
Draft Dominican Republic Trip Report, March 2004
Annex C: Mission Filter Household Survey
Community Name: ______________________
Household Number: _________________
Date of survey: ____________________
Where do you obtain your water that you use in the filter?
______________________
Do you always have access to enough water?
______________________
What is the estimated color of the untreated water?
______________________
Age of Mission Filter: ___________________
Age of GAC Filter: __________
Age of String Filter: _______________
Is the filter in operational order? _________________________
If NO, what is broken? _________________________
How long has it been broken? _________________
Is there filtered water in the home for drinking? __________________
If NO, why not?
______________________________
What is the current drinking water in the home? ___________________
If YES, how many hours ago was it prepared?
________________________
Where is drinking water taken from?
________________________
Free chlorine residual in drinking water: ________________________
What do you like about using the Mission Filter? ______________________________
What is difficult about using the Mission Filter?
______________________________
Have you had any problems with the Mission Filter?
________________________
Would you be willing to participate in a study to determine the health impact of the Mission
Filter. This study would ask you to provide information about diarrhea in every member of
your family once per week for a few months? ___________________
Draft Dominican Republic Trip Report, March 2004
Draft Dominican Republic Trip Report, March 2004

Source: http://www.manzwaterinfo.ca/documents/CDCtripreport_dominicanrepublic.pdf