Project Partners

• CDC
• 
  CARE
• 
  Population Services International (PSI)
• 
  National CDC Foundation
• 
  USAID
• 
  Centre National de Recherches sur l'Environnement
• 
  Catholic Relief Services
• 
  UNICEF

Target Populations and Location

• The project began with a PSI-distributed product for water treatment branded Sûr'Eau targeting populations in the urban flood zone of Antananarivo in CARE’s Programme MAHAVITA as well as populations affected by cyclones and cholera epidemics. It has grown to a national-scale program with national-level PSI-distribution combined with local implementation by CARE and Catholic Relief Services community motivators.

Project Implementation Date

• April 2000

Project Design

• Stage 1: In 2000, a pilot SWS implementation project, funded by the CARE/CDC Health Initiative, was incorporated into CARE’s existing Programme MAHAVITA in communities within the urban flood zone of Antananarivo. PSI developed a water disinfectant solution that was given the brand name Sûr'Eau and embarked on a social marketing campaign. CARE utilized a community mobilization approach to promote Sûr'Eau. In response to cyclones on the east coast of the country and a nation-wide cholera outbreak, the project was launched four months early, and expanded more quickly than anticipated.
• Stage 2: The Sûr'Eau social marketing campaign has expanded to a national scale, with PSI concentrating on wide distribution of Sûr'Eau in urban and rural areas. CARE has continued with community mobilization efforts, focusing on working with teams of community based sales agents to sell a basket of health products within their communities. CARE has community health agent coverage in two large geographical areas on the eastern coast of Madagascar, and is actively working to expand this program. This combined top-down and bottom-up approach has led to both wide availability of Sûr'Eau, and the mobilization necessary to encourage use of the product. PSI and CARE, in cooperation with CDC, recently changed the Sûr'Eau product to a smaller bottle with more concentrated solution to facilitate transport and adoption in rural and remote areas. The new bottle has been well received by rural populations in Madagascar.

Intervention Elements

• Sodium hypochlorite solution produced locally by a private company. The brand name is Sûr’Eau.
• Community mobilization by CARE.
• Social marketing coordinated by PSI.
• Limited distribution and marketing of both the CDC safe water storage vessel and a locally available safe water storage vessel.

Results of Project Evaluations

• Results of Project MAHAVITA Evaluation (CDC): Observed use of Sûr’Eau, as determined by the presence of detectable free chlorine residual in the stored water, was 11.2% of the total population after six months. In neighborhoods that had undergone the full community mobilization process, observed Sûr'Eau use was 19.7, while neighborhoods in early stages of the mobilization process had utilization of 8.4%. Use of improved storage containers increased from 2.9% to 12.2% during the first 6 months of the project. The free chlorine levels did not appear to be higher in the jerry can than in the bucket, and the cover on the bucket did not seem to make a difference in the ability of the treated water to maintain its free chlorine concentration.
• In response to the April 2000 landfall of Cyclone Hudah in Madagascar, 11,700 relief kits (consisting of a 5-gallon foldable jerry can, Sûr'Eau disinfectant, and education messages) were distributed to affected populations between April 13 and August 14, 2000. A follow-up survey to determine the impact of this intervention was conducted in 12 villages in September 2000. In unannounced visits, 43% of households were using the jerry cans for drinking water storage. Of the 43% of households using the jerry cans from drinking water storage, 78% had detectable total chlorine residual, and 45% had detectable free residual chlorine. In microbiological testing of drinking water stored in the home, jerry cans had significantly lower E. coli colony counts than buckets. This research PDF 168KB was published in the American Journal of Public Health.
• A case-control study to investigate risk factors for cholera transmission was conducted in Fort-Dauphin, Madagascar from February 11 to 20, 2001. Cholera reached Fort-Dauphin in February of 2000, and Sûr'Eau was introduced to the region in December 2000. Patients were more likely than control subjects to have drunk untreated water. Boiling water, treating water with Sûr'Eau, drinking heated rice water, and drinking from a tap were all protective against cholera. In addition, using soap to wash hands was protective against cholera. This study showed that untreated water was the principal vehicle of endemic cholera in Fort-Dauphin, and that the SWS and handwashing initiatives can reduce the risk of this disease. This research PDF 215KB was published in the American Journal of Public Health.
• In addition to these two research studies, the project partners also wrote a paper describing the implementation process of the project. This paper PDF 167KB was published in the American Journal of Public Health.
• In 2002, CDC evaluated SWS project impact in coastal eastern Madagascar. The implementation approach in this area consisted of community mobilization through entrepreneurial community-based sales agents (CBSA). The evaluation was performed in five villages during the rainy season. A standardized questionnaire to assess water-handling practices and self-reported SWS utilization was administered and chlorine residuals were tested in stored water during surprise home visits. We conducted 276 household interviews in five villages. 90% reported having used the SWS at least once and 60% reported current use. 43 to 75% of households who reported SWS use had detectable chlorine residuals in stored water at the time of surprise visits. The relative risk of diarrheal illness among users vs. non-users, was 0.37 [p= .065]. This evaluation in a remote, impoverished population demonstrated high SWS adoption rates and suggests that the CBSA can be a highly effective behavior change agent. This data was presented at the American Society of Tropical Medicine and Hygiene meeting in December 2003. For more information, please contact safewater@cdc.gov.

For More Information

• CARE/Madagascar: ekelsey@dts.mg
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  PSI/Madagascar: mcaron@psi.mg
• 
  CDC: safewater@cdc.gov
• 
  Dunston C, McAfee D, Kaiser R, Rakotoarison D, Rambeloson L, Hoang A, and Quick R. Collaboration, Cholera, and Cyclones: Improving Point-of-Use Water Quality in Madagascar. American Journal of Public Health. October 1, 2001; 91 (10). PDF 167KB
  
• Mong Y, Kaiser R, Ibrahim D, Rasoatiana, Razafimbololona L, and Quick R. Impact of the Safe Water System on Water Quality in Cyclone-Affected Communities in Madagascar. American Journal of Public Health. October 1, 2001; 91 (10). PDF 168KB
  
• Reller M, Mong Y, Hoekstra M, and Quick R. Cholera Prevention With Traditional and Novel Water Treatment Methods: A Report of an Outbreak Investigation in Fort-Dauphin, Madagascar. American Journal of Public Health. October 1, 2001; 91 (10). PDF 215KB

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Email: safewater@cdc.gov