Improving water access in order to combat cholera

Cholera, a water-borne disease that causes vomiting and diarrhoea, is experiencing a dramatic resurgence in the Democratic Republic of Congo (DRC). Every year, thousands of people fall victim to the disease. The factors leading to contamination are well known: the cholera bacterium is transmitted, among other things, by contaminated water when water treatment and sanitation conditions are inadequate. The link between the disease and access to drinking water was first demonstrated in 19th-century England. Today, it's a proven fact. Yet in the DRC, only 16% of the population has access to drinking water*.

An initial phase dedicated to epidemiological studies

Initial studies carried out in 2007 by Congolese doctors and French epidemiologists from the University of Besançon, supported by the Veolia Foundation, highlighted the correlation between the development of cholera epidemiology and the lack of access to drinking water in the DRC. In response, the Congolese Ministry of Public Health launched a major national strategic plan for the elimination of cholera (2008-2012), based on an integrated approach to health, water, hygiene and sanitation. The approach is based on a strengthened partnership involving the relevant Congolese ministries, local and international NGOs, experts in urban water and energy infrastructure, and international donors (Agence française de développement, European Union, private foundations). The plan was extended in 2012 by a Multisectoral Cholera Elimination Plan (PMSEC), a five-year program validated by representatives of many DRC provinces at a major meeting organized by the Veolia Foundation in March 2016.

In the field, implementation of the plan involved, during an initial four-year phase, gathering information to understand the dynamics of the disease's spread. This work led to a precise mapping of the source zones of cholera epidemics in order to target priority intervention areas and recommend the necessary work in terms of creating and rehabilitating drinking water networks and stations. Eight towns in the east of the DRC have been identified as sources of cholera outbreaks, most of them on lakeshores.

Kalemie, first intervention zone

Kalemie, located on the shores of Lake Tanganyika in Katanga province, was the first to benefit from the anti-cholera program. Many international players were involved in the field: Congolese doctors, representatives of the Congolese water utility Regideso, NGOs such as Solidarités International and Médecins sans Frontières, and Veoliaforce volunteers. The missions carried out by these Veolia Foundation experts led to the creation of a master plan for the city's water networks, with a dual objective: to target drinking water supply needs, and to define priority measures to reinforce epidemiological surveillance.

Work to rehabilitate and secure the existing water network was successfully completed. The number of Regideso water subscribers increased by 46%! The treatment capacity of the drinking water treatment plant built with the Katanga province governorate has doubled. A new reservoir has been built, and the network has been extended to the north and south of the city, thanks to Médecins sans Frontières and Solidarités International. Regideso also benefits from greater financial autonomy.

Rehabilitating and securing water networks in Uvira

In 2008, the Foundation began work on a second project, in parallel with its involvement in Kalemie. Exploratory missions took Veoliaforce experts to another area pre-identified by epidemiological studies: Uvira, in the province of South Kivu. Objective? To assess the state of the drinking water infrastructure.

The analyses carried out led to the implementation of emergency measures, carried out by Oxfam Great Britain with Regideso, to rapidly secure the production and distribution of drinking water in the town. This work was extended by the Veolia Foundation, which, with the support of the Artelia Foundation, designed a development plan to rehabilitate and extend the town's drinking water infrastructure. In 2013, AFD and the EU agreed to finance the three-year implementation of this water infrastructure development program.

Three stages of work have been defined:

• Rehabilitation and extension of the distribution network;
• Construction of a large-capacity reservoir;
• Doubling the plant's production capacity.

In 2016, invitations to tender were issued to start the work, monitor it, conduct audits and start structuring the community fabric around the new water access that will soon be opened up. The Veolia and Artelia foundations are responsible for technical studies relating to the installation of the network and reservoir. The NGO Oxfam Great Britain is overseeing the societal aspect: education, prevention and hygiene awareness measures. Finally, a Congolese NGO, ADIR, is responsible for structuring the communities of Uvira into user associations, thereby increasing the population's awareness of the need for access to drinking water in the fight against cholera.

Scientific monitoring of the program

The program, which has been running in the DRC for ten years, is subject to scientific evaluation by a long-standing partner of the Veolia Foundation. The London School of Hygiene & Tropical Medicine (LSHTM) has been monitoring the project from the outset to measure its effectiveness.

The impact evaluation financed by the Foundation follows a cluster randomized controlled trial (RCT) methodology. The town of Uvira, at the heart of the study, was divided into 16 "clusters". Work to improve the drinking water network, and therefore access to water, is carried out cluster by cluster, and defined in such a way that the work can be carried out on each one separately and in roughly the same time. The order in which the work is carried out is random, determined by drawing lots. As the work progresses, the clusters that have benefited from improved access to water can be used to assess the impact of this improvement on the incidence of cholera, in comparison with control clusters that have not yet benefited from the work.

The pre-study conducted over the period 2009-2013 demonstrates the tangible reality of the link between access to drinking water and cholera in Uvira. The LSHTM reveals that the Uvira Cholera Treatment Centre receives three times as many admissions in the ten days following an interruption in drinking water production, and that 25.3% of cholera cases are inherent to a drop in drinking water production. A prestigious scientific journal, PLoSMed (Public Library of Science Medicine), echoed this demonstration.

Ultimately, the results, if they confirm the pre-study, will be a powerful advocacy tool in favor of structural actions in the water sector to combat cholera.

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*Source: WHO}