Inadequate protection of water sources, and poor household hygienic and handling practices have exacerbated fecal water contamination in Kenya. This study evaluated the rate and correlates of thermotolerant coliform (TTC) household water contamination in Kericho District, Western Kenya. Culture and multiplex polymerase chain reaction (PCR) techniques were used to characterize TTCs. The disk diffusion method was used for antibiotic susceptibility profiling of pathogenic Escherichia coli. Out of the 103 households surveyed, 48 (46.6%) had TTC contaminated drinking water (TTC levels of >10 cfu/100 mL). Five of these households were contaminated with pathogenic E. coli, including 40% enteroaggregative E. coli, 40% enterotoxigenic E. coli, and 20% enteropathogenic E. coli. All these pathogenic E. coli strains were multidrug resistant to sulfamethoxazole/trimethoprim, ampicillin, tetracycline and ampicillin/sulbactam. Rural household locality, drinking water hand contact, water storage container cleaning practice, hand washing before water withdrawal, water source total coliforms <10 cfu/100 mL, temperature, and free chlorine levels were associated with TTC contamination of household drinking water. Significant proportions of household drinking water in Kericho District are contaminated with TTCs including with pathogenic multidrug-resistant E. coli. Source and household hygiene and practices contribute significantly to drinking water contamination.

INTRODUCTION

The importance of water to human health is encapsulated in the Human Right to Water and Sanitation, which entitles everyone to ‘sufficient, safe, physically accessible and affordable water for personal and domestic uses’ (Committee on Economic, Social and Cultural Rights 2002; United Nations 2010). Unfortunately, over 275 million people in sub-Saharan Africa rely on unsafe drinking water sources from lakes, rivers, and open wells (WHO/UNICEF 2010). Consequently, in this region, many waterborne-related diarrheal diseases are responsible for significant morbidity and mortality among children, the elderly, and immunosuppressed individuals (Kariuki et al. 2006; WWAP 2006). The most common health problems associated with unsafe drinking water in Kenya include typhoid fever, cholera, diarrhea, dysentery, worms, and bilharzias (WWAP 2006).

The World Health Organization (WHO) guidelines for drinking water quality include criteria for assessing health risks and setting targets for improving water safety (WHO 2011). The guidelines recommend using either thermotolerant coliforms (TTCs) or Escherichiacoli in assessing fecal contamination of drinking water (WHO/UNICEF 2010; WHO 2011). A 100 mL water sample with <1 indicator organisms is considered ‘very low risk’; 1–10, ‘low risk’; 10–100, ‘medium risk’; >100, ‘high risk’ or ‘very high risk’ (WHO 1997).

Studies have given varied total and fecal (E. coli) coliform contamination of water samples in different settings. Over a quarter of samples from improved water sources in China, the United Kingdom, France, Portugal and in selected low and middle income countries were shown to contain fecal contamination (Bain et al. 2014). About 95% of water sources (dams, rivers, springs, and wells) in the informal settlements of Kisumu, Kenya had significant E. coli contamination (Opisa et al. 2012). In another informal settlement in Nairobi, Kenya, Chemuliti et al. (2002) identified 35% of standpipes and 95% of in-house storage containers as being contaminated with E. coli coliforms. Water source, storage practices, locality, poverty, hygiene, sanitary and environmental factors have been cited as sources for fecal water contamination (Gundry et al. 2006).

Currently, data are skewed on the quality of drinking water in Kericho District, Western Kenya. This district is faced with high population density and a growth rate of 3.6%, while the majority of urban and rural populations lack clean and safe piped water supply (Kenya Census 2010).

METHODS

Study design and setting

Kimani-Murage & Ngindu (2007) showed that 13% of the households in Kenya had their drinking water contaminated with thermotolerant E. coli. Applying the formula for estimating the population proportion with specified relative precision described by Lemeshow et al. (1990), setting the α at 0.05, and a detection rate of 20%, a total of 103 households were recruited to achieve 0.90 power. A two-stage sampling method was then used to select these households. First, a complete list of all the households in the 17 locations/villages in Kericho District was generated based on the Kenya Census of 2010. A total of 12 locations were then selected based on probability proportionate to size. Second, a systematic sampling method was then used to select every fifth household in each pre-selected location. The number of households per location varied based on their total household size.

Participants

Consent was gained from the heads of these households, who were interviewed using a structured questionnaire to gather information relating to the quality of drinking water. Further, two different water samples were collected from these households: one from source (tap, rivers, or wells) and the second from household drinking water storage vessels. This study was done between 2013 and 2014 and was approved by the Ethical Review Committee of Kenya Medical Research Institute (SSC No. 2579 on 18 July, 2013). This research has adhered to the STROBE guidelines for observational studies as outlined at: http://www.strobe-statement.org.

Interviews

Structured questionnaires adopted from the WHO/UNICEF Joint Monitoring Programme (http://www.wssinfo.org/fileadmin/user_upload/resources/1268174016-JMP_Core_Questions.pdf) were used to gather information related to water-extraction patterns, type of water transport, water-treatment methods, hygiene and sanitation related issues.

Water sample collection

Water samples were collected aseptically using sterile sampling containers. About 100 mL of the water sample was collected and immediately analyzed for bacteriological qualities and physical chemical properties (pH, temperature, turbidity, and free chlorine) on site using a DelAgua water testing kit. The cultured plates were then transported to the Micro Hub Kericho Walter Reed Project (WRP) of Kenya Medical Research Institute for further bacteriological analysis. Water source sampling (rivers, streams, or other surface waters in the district where enrolled households collect their waters) involved drawing water from 30 cm below the surface. Sampling from wells and boreholes involved drawing water using a bucket and taking 100 mL into a sterile container. This was considered to be more representative of what is actually being consumed by the household. Sampling water from taps was done directly into collecting containers (WHO 1998). Household water sampling was done by requesting the household head to draw water from their storage reservoir.

Total coliforms and TTC isolation

Water samples were filtered through a 0.45 μm pore size membrane filter, which was then incubated on lauryl sulphate agar for 18–24 hours at 35 ± 0.5 °C or 37 ± 0.5 °C for total coliforms and 18–24 hours at 44 ± 0.25 °C or 44.5 ± 0.25 °C for TTCs. To confirm TTCs and E. coli, membranes were then incubated at 35, 37 or 44 °C, and each colony (or a representative number of colonies) was sub-cultured into a tube of lactose peptone water and a tube of tryptone water. Tubes were incubated at 44 °C for 24 hr. Growth with the production of gas in the lactose peptone water confirmed the presence of TTCs. Confirmation of E. coli was made by the addition of 0.2–0.3 mL of Kovac's reagent to each tryptone water culture. Production of a red color indicated the synthesis of indole from tryptophan, which confirmed the presence of E. coli.Figure 1 shows the isolation and identification of TTCs using culture and API strips.
Figure 1

Water sample collection and laboratory testing chart.

Figure 1

Water sample collection and laboratory testing chart.

E. coli pathotype identification

The E. coli pathotypes were determined using multiplex polymerase chain reaction (PCR) as described by Gomez-Duarte (2009). The first PCR of this multiplex contained M1 primers for amplification of eae, bfpA, VT, and aggR genes for identification of shiga toxin-producing E. coli (STEC), enteropathogenic E. coli (EPEC), and enteroaggregative E. coli (EAEC) pathotypes. The second PCR contained M2 primers for amplification of LT, ST, daaE, ipaH, and virF gene targets for identification of enterotoxigenic E. coli (ETEC), diarrheagenic E. coli (DAEC), and enteroinvasive E. coli (EIEC) pathotypes. About 1 μL of genomic DNA was mixed with 24 μL of a premade mix containing primers at a 0.2 μM final concentration and Platinum Blue PCR SuperMix polymerase (Invitrogen, Carlsbad, CA, USA). The PCR amplification consisted of 2 min at 94 °C denaturing temperature, followed by 40 cycles of 30 sec at 92 °C denaturing temperature, 30 sec at 59 °C annealing temperature, and 30 sec at 72 °C extension temperature. The PCR products were visualized and recorded under ultraviolet light using a 2% agarose ethidium bromide-stained gel. The verotoxin of STEC isolates were analyzed using PCR specific for shiga-like toxin 1 (VT1) (Vidal et al. 2005) and shiga-like toxin 2 (VT2) (Nguyen et al. 2005).

Antimicrobial susceptibility testing

Antimicrobial susceptibility patterns of E. coli pathotypes were undertaken using the disk diffusion technique of Kirby-Bauer. The susceptibility was checked against the following antibiotics: ampicillin, nalidixic acid, chloramphenicol, tetracycline, cefotaxime, cotrimoxazole, ceftazidime, and ciprofloxacin. The zones' inhibition was interpreted using standards for antimicrobial susceptibility testing (CLSI 2010).

Data analysis

Frequency (%), mean, standard deviation, and medium (interquartile ranges at 25% and 27%) were used to describe the qualitative and laboratory parameters. Chi-square or Fisher's exact test were used to test for significance where applicable. In bivariate analyses, odds ratios (OR) and 95% confidence intervals (CI) for the association between pathogenic thermotolerant E. coli contaminating water and socio-demographic, hygienic and environmental characteristics were calculated using Poisson regression. In multivariate analyses, a manual backward elimination approach was used to reach the most parsimonious model, including factors that were associated with contamination with pathogenic thermotolerant E. coli at the significance level of P ≤ 0.05. All statistical analyses were performed using STATA v 13 (StataCorp LP, College Station, TX, USA).

RESULTS

Characteristics of study population

Table 1 shows the summary of characteristics of households recruited in this study. The mean age of the 103 household heads was 21.59 years (range 18–29 years) with slightly under a quarter (42.7%) aged 21–30 years. About 68.9% of households were located in rural areas, with 95.1% of them being female headed. About 57.3% had primary level education, 27.2% were farmers, while 54.4% had children below 5 years of age. Close to 36.9% of the households sourced their drinking water from rivers. Nearly all of them (91.3%) did not treat their drinking water, with 81.6% stating that their drinking water was clean regardless of the source. Most of the households (64.1%) stored the drinking water for more than 2 days, with the majority (83.5%) of them drawing drinking water by dipping the cup into the water storage container. Nearly half of the households reported having contact with drinking water during drawing. Some 60.2% used clay pots for water storage, with 64.1% of them never washing these storage containers.

Table 1

Characteristics of the study population

Household characteristics Unit Frequency Percentage 
Locality Rural 71 68.9 
Urban 32 31.1 
Gender Female 98 95.1 
Male 4.9 
Age group <20 7.8 
21–30 44 42.7 
31–40 25 24.3 
41–50 10 9.7 
>51 16 15.5 
Education level Primary 59 57.3 
Secondary 25 24.3 
Tertiary 11 10.7 
Non-formal 7.8 
Occupation Business 18 17.5 
Employee/Laborer 17 16.5 
Farmer 28 27.2 
Housewife 25 24.3 
Student/Unemployed 15 14.6 
Have children below 5 years Yes 56 54.4 
No 47 45.6 
Consider drinking water source safe Yes 95 92.2 
No 1.0 
Do not know 6.8 
Treatment of water Boil 2.9 
Filtration 3.9 
Water guard 1.9 
Do not treat 94 91.3 
Reasons for not treating water Lack of knowledge 5.8 
Water is clean 84 81.6 
Time consuming and costly 1.9 
Not applicable 11 10.7 
Water storage period 1 day 21 20.4 
2 days 16 15.5 
More than 2 days 66 64.1 
Method for drawing drinking water Dip into container 86 83.5 
Pour directly from container/use tap 17 16.5 
Hand contact with drinking water Yes 44 42.7 
No 59 57.3 
Water storage container Clay pot 62 60.2 
Plastic 41 39.8 
Wash hands before drawing water Yes 42 40.8 
No 61 59.2 
Rinse water drawing utensils Yes 99 96.1 
No 3.9 
Type of toilet facility Piped sewer system/septic tank/pit latrine 5.8 
Pit latrine without slab/open pit 51 49.5 
Ventilated improved pit latrine 5.8 
Bush/field 15 14.6 
Shared facility 25 24.3 
Toilet cleanliness Clean (no flies nor visible fecal matter) 16 15.5 
Moderately clean(flies but no visible fecal matter) 33 32 
Dirty(flies and visible fecal matter) 14 13.6 
Not applicable 40 38.8 
Disposal of children's feces Put in the latrine 32 31.1 
Put/rinsed into drain or ditch 19 18.4 
Thrown into garbage 3.9 
Not applicable 48 46.6 
Household characteristics Unit Frequency Percentage 
Locality Rural 71 68.9 
Urban 32 31.1 
Gender Female 98 95.1 
Male 4.9 
Age group <20 7.8 
21–30 44 42.7 
31–40 25 24.3 
41–50 10 9.7 
>51 16 15.5 
Education level Primary 59 57.3 
Secondary 25 24.3 
Tertiary 11 10.7 
Non-formal 7.8 
Occupation Business 18 17.5 
Employee/Laborer 17 16.5 
Farmer 28 27.2 
Housewife 25 24.3 
Student/Unemployed 15 14.6 
Have children below 5 years Yes 56 54.4 
No 47 45.6 
Consider drinking water source safe Yes 95 92.2 
No 1.0 
Do not know 6.8 
Treatment of water Boil 2.9 
Filtration 3.9 
Water guard 1.9 
Do not treat 94 91.3 
Reasons for not treating water Lack of knowledge 5.8 
Water is clean 84 81.6 
Time consuming and costly 1.9 
Not applicable 11 10.7 
Water storage period 1 day 21 20.4 
2 days 16 15.5 
More than 2 days 66 64.1 
Method for drawing drinking water Dip into container 86 83.5 
Pour directly from container/use tap 17 16.5 
Hand contact with drinking water Yes 44 42.7 
No 59 57.3 
Water storage container Clay pot 62 60.2 
Plastic 41 39.8 
Wash hands before drawing water Yes 42 40.8 
No 61 59.2 
Rinse water drawing utensils Yes 99 96.1 
No 3.9 
Type of toilet facility Piped sewer system/septic tank/pit latrine 5.8 
Pit latrine without slab/open pit 51 49.5 
Ventilated improved pit latrine 5.8 
Bush/field 15 14.6 
Shared facility 25 24.3 
Toilet cleanliness Clean (no flies nor visible fecal matter) 16 15.5 
Moderately clean(flies but no visible fecal matter) 33 32 
Dirty(flies and visible fecal matter) 14 13.6 
Not applicable 40 38.8 
Disposal of children's feces Put in the latrine 32 31.1 
Put/rinsed into drain or ditch 19 18.4 
Thrown into garbage 3.9 
Not applicable 48 46.6 

Nearly half of the households (49.5%) used pit latrines or open pits for their toilet facility. About 32% of these toilets were moderately clean, with flies but no visible fecal matter. About 31.1% of households disposed of their children's fecal waste in the pit latrine. Slightly over half of them (59.2%) did not wash their hands before drawing water. The majority (96.1%) often rinsed water drawing utensils. About 88.3% were aware of waterborne diseases while only 30% had suffered from diarrhea, vomiting, and fever in the past 3 months.

Total and TTCs

Table 2 shows a summary of total and TTC levels in source and household drinking water. The mean total coliform count in water sources was 1,029.7 (SD 1,574.1 cfu/100 mL) and a range of 5,595 (80–5,675 cfu/100 mL). Close to half (50; 48.5%) of the water sources were contaminated (had total coliforms above >10 cfu/100 mL) (P = 0.768).

Table 2

Total and TTCs in source and household drinking water

Total/TTC (cfu/100 mL)   Frequency P value 
Water source total coliforms 
Mean (± SD) 1,029.7 (1,574.1)    
Median 320    
Range 5,595 (80–5,675)    
 10–100  50 48.5  
 100–1,000  41 39.8 0.768 
  > 1,001  12 11.7  
Water source TTCs 
Mean (± SD) 798.6 (1,302.6)    
Median 30    
Range 3,539 (1–3,540)    
 10–100  80 77.7  
 100–1,000  8.7 0.001 
  > 1,001  14 13.6  
Household total coliforms 
Mean (± SD) 529.1 (857.5)    
Median 289    
Range 5,462 (98–5,560)    
 10–100  17 16.5  
 100–1,000  78 75.7 0.001 
  > 1,001  7.8  
Household TTCs 
Mean (± SD) 321.23 (761.5)    
Median 40    
Range 3,799 (1–3,800)    
 10–100  55 53.4  
 100–1,000  33 32.0 0.001 
  > 1,001  15 14.6  
Total/TTC (cfu/100 mL)   Frequency P value 
Water source total coliforms 
Mean (± SD) 1,029.7 (1,574.1)    
Median 320    
Range 5,595 (80–5,675)    
 10–100  50 48.5  
 100–1,000  41 39.8 0.768 
  > 1,001  12 11.7  
Water source TTCs 
Mean (± SD) 798.6 (1,302.6)    
Median 30    
Range 3,539 (1–3,540)    
 10–100  80 77.7  
 100–1,000  8.7 0.001 
  > 1,001  14 13.6  
Household total coliforms 
Mean (± SD) 529.1 (857.5)    
Median 289    
Range 5,462 (98–5,560)    
 10–100  17 16.5  
 100–1,000  78 75.7 0.001 
  > 1,001  7.8  
Household TTCs 
Mean (± SD) 321.23 (761.5)    
Median 40    
Range 3,799 (1–3,800)    
 10–100  55 53.4  
 100–1,000  33 32.0 0.001 
  > 1,001  15 14.6  

%, percentage; SD, standard deviation; TTC, thermotolerant coliforms.

The mean household drinking water total coliform count was 529.1 (SD 857.5 cfu/100 mL) with a range of 5,462 (98–5,560 cfu/100 mL). The majority (85; 83.5%) of household drinking waters were contaminated, with total coliforms above >10 cfu/100 mL (P < 0.001).

The mean TTC count in the water sources was 798.6 (SD 1,302.6 cfu/100 mL) and a range of 3,539 (1–3,540 cfu/100 mL). Only 23 of the 103 (22.3%) water sources were contaminated with TTC (>10 cfu/100 mL) (P < 0.001).

The mean TTC count in households' drinking water was 321.2 (SD 761.5 cfu/100 mL) with a range of 3,799 (1–3,800 cfu/100 mL). Slightly below half (48) of the 103 (46.6%) households' drinking water was contaminated with TTC levels of >10 cfu/100 mL (P < 0.001).

Household drinking water contamination with thermotolerant E. coli and other coliforms

In all 48 (46.6%) households with TTC, each had thermotolerant E. coli as well. Among the 48 thermotolerant E. coli, 5 (10.4%) were pathogenic E. coli: 2/5 (40%) EAEC, 2/5 (40%) ETEC, and 1/5 (20%) EPEC. There were 35 other types of TTCs isolated from household drinking water. These included 8/35 (22.8%) Serratia, 7/35 (20%) Enterobacter, 5/35 (14.3%) Klebsiella, 5/35 (14.3%) Moraxella, 4/35 (11.4%) Pseudomonas, 2/35 (5.7%) Shigella, 2/35 (5.7%) Acinetobacter, 1/35 (2.9%) Aeronomonas, and 1/35 (2.9%) Yersinia.

All the five pathogenic E. coli were multidrug resistant to four commonly prescribed antibiotics in Kenya, including sulfamethoxazole/trimethoprim, ampicillin, tetracycline and ampicillin/sulbactam.

Factors associated with TTC contamination of household drinking water

Table 3 summarizes the factors associated with TTC contamination (>10 cfu/100 mL) of household drinking water. In the bivariate analyses, drinking water of households located in the rural set-up were more likely to have TTC contamination than households located in the urban areas (OR 2.01, 95% CI 1.09–4.12). Households with a piped water supply or water from a municipal source were less likely to have TTC contamination than those households whose source of water was from a river/spring (OR 0.38, 95% CI 0.16–0.91). Households which reported hand contact with drinking water during withdrawal were more likely to be contaminated with TTC compared to households which had no hand contact during water withdrawal (OR 1.11, 95% CI 1.11–3.39). Households that washed their water storage containers regularly were less likely to be contaminated with TTC than those households who did not wash the water storage container (OR 0.58, 95% CI 0.31–0.99). Households who practiced hand washing before drawing drinking water were less likely to have TTC contamination than those households that did not wash hands (OR 0.33, 95% CI 0.15–0.67). Households whose total coliform count was less than 10 cfu/100 mL were less likely to have TTC drinking water contamination than those households with more than 10 cfu/100 mL (OR 0.45, 95% CI 0.26–0.81). Further, households whose main water source temperatures were between 15 and 20 °C were less likely to have TTC drinking water contamination than those households with water source temperatures greater than 25.1 °C (OR 0.39, 95% CI 0.16–0.96). Lastly, households whose main water source had a free chlorine concentration of less than 1 mg/L were less likely to have their drinking water contaminated with TTC compared to households with a water source free chlorine concentration of above 1 mg/L (OR 0.41, 95% CI 0.24–0.71).

Table 3

Factors associated with household drinking water TTC contamination

    Drinking water TTC contamination
 
Bivariate Multivariate 
Socio-demographic characteristic Sample size No. OR (95% CI) OR (95% CI) 
Locality 
 Rural 71 39 54.9 2.01 (1.09–4.12) 1.13 (0.12–10.37) 
 Urban 32 28.2 Referent Referent 
Education level 
 Primary 59 29 49.2 0.99 (0.54–1.82) 1.23 (0.52–2.91) 
 Secondary 25 11 44 0.96 (0.49–1.84) 1.13 (0.44–2.91) 
 Tertiary 11 36.4 0.91 (0.42–1.94) 1.33 (0.44–4.06) 
 Non-formal 50 Referent Referent 
Stay with child below 5 years 
 Yes 56 20 35.7 0.85 (0.62–1.17) NS 
 No 47 28 59.5 Referent Referent 
Main drinking water source water 
 Piped supply/municipal 34 26.5 0.38 (0.16–0.91) 0.78 (0.33–1.87) 
 Rain water/roof catchment 12 50 0.73 (0.52–1.92) 0.89 (0.39–2.02) 
 River 38 21 55.3 0.81 (0.41–1.61) 0.98 (0.58–1.63) 
 Spring 19 12 63.2 Referent Referent 
How do you treat drinking water 
 Boil 66.7 1.04 (0.34–3.18) 0.95 (0.22–4.1) 
 Filtration 66.7 0.62 (0.07–4.99) 0.61 (0.07–5.09) 
 Water guard 0.91 (0.44–1.85) 1.11 (0.32–3.92) 
 Do not treat 94 43 45.7 Referent Referent 
Water storage period 
 1 day 21 38.1 0.92 (0.54–1.58) 0.88 (0.48–1.61) 
 2 days 16 50.0 1.01 (0.65–1.57) 0.99 (0.59–1.67) 
 More than 2 days 66 32 48.4 Referent Referent 
Hand contact with drinking water 
 Yes 36 24 66.7 1.11 (1.11–3.39) 1.19 (0.77–1.83) 
 No 67 24 35.8 Referent Referent 
Type of water storage container 
 Clay pot 62 31 50 1.06 (0.76–1.47) NS 
 Plastic 41 17 41.6 Referent  
Washing of water storage container 
 Yes 37 12 32.4 0.58 (0.31–0.99) NS 
 No 66 36 54.6 Referent  
Household kind of toilet facility 
 Piped sewer system/septic tank/pit latrine 33.3 0.92 (0.43–1.99)  
 Pit latrine without slab/open pit 51 22 43.1 0.99 (0.66–1.48) NS 
 Ventilated improved pit latrine 33.3 0.92 (0.43–1.99)  
 Bush/field 15 11 73.3 1.2 (0.72–1.99)  
 Shared facility 25 11 44 Referent  
Wash hands before drawing water 
 Yes 42 21.4 0.33 (0.15–0.67) NS 
 No 61 39 63.9 Referent  
Household total coliforms (cfu/100 mL) 
  ≤ 10 cfu/100 mL 17 0.45 (0.26–0.81) NS 
  > 10 cfu/100 mL 86 48 55.8 Referent  
 Water source temperature (°C)      
 15–20 47 12 25.5 0.39 (0.16–0.96)  
 20.1–25 41 20 48.8 0.67 (0.29–1.52) NS 
  > 25.1 100 Referent  
Water source pH 
 5–7 24 14 58.3 1.1 (0.76–1.59) NS 
  > 7.1 79 34 43 Referent  
Water source free chlorine (mg/L) 
  ≤ 1 80 33 41.3 0.41 (0.24–0.71) NS 
  > 1.1 23 23 100 Referent  
    Drinking water TTC contamination
 
Bivariate Multivariate 
Socio-demographic characteristic Sample size No. OR (95% CI) OR (95% CI) 
Locality 
 Rural 71 39 54.9 2.01 (1.09–4.12) 1.13 (0.12–10.37) 
 Urban 32 28.2 Referent Referent 
Education level 
 Primary 59 29 49.2 0.99 (0.54–1.82) 1.23 (0.52–2.91) 
 Secondary 25 11 44 0.96 (0.49–1.84) 1.13 (0.44–2.91) 
 Tertiary 11 36.4 0.91 (0.42–1.94) 1.33 (0.44–4.06) 
 Non-formal 50 Referent Referent 
Stay with child below 5 years 
 Yes 56 20 35.7 0.85 (0.62–1.17) NS 
 No 47 28 59.5 Referent Referent 
Main drinking water source water 
 Piped supply/municipal 34 26.5 0.38 (0.16–0.91) 0.78 (0.33–1.87) 
 Rain water/roof catchment 12 50 0.73 (0.52–1.92) 0.89 (0.39–2.02) 
 River 38 21 55.3 0.81 (0.41–1.61) 0.98 (0.58–1.63) 
 Spring 19 12 63.2 Referent Referent 
How do you treat drinking water 
 Boil 66.7 1.04 (0.34–3.18) 0.95 (0.22–4.1) 
 Filtration 66.7 0.62 (0.07–4.99) 0.61 (0.07–5.09) 
 Water guard 0.91 (0.44–1.85) 1.11 (0.32–3.92) 
 Do not treat 94 43 45.7 Referent Referent 
Water storage period 
 1 day 21 38.1 0.92 (0.54–1.58) 0.88 (0.48–1.61) 
 2 days 16 50.0 1.01 (0.65–1.57) 0.99 (0.59–1.67) 
 More than 2 days 66 32 48.4 Referent Referent 
Hand contact with drinking water 
 Yes 36 24 66.7 1.11 (1.11–3.39) 1.19 (0.77–1.83) 
 No 67 24 35.8 Referent Referent 
Type of water storage container 
 Clay pot 62 31 50 1.06 (0.76–1.47) NS 
 Plastic 41 17 41.6 Referent  
Washing of water storage container 
 Yes 37 12 32.4 0.58 (0.31–0.99) NS 
 No 66 36 54.6 Referent  
Household kind of toilet facility 
 Piped sewer system/septic tank/pit latrine 33.3 0.92 (0.43–1.99)  
 Pit latrine without slab/open pit 51 22 43.1 0.99 (0.66–1.48) NS 
 Ventilated improved pit latrine 33.3 0.92 (0.43–1.99)  
 Bush/field 15 11 73.3 1.2 (0.72–1.99)  
 Shared facility 25 11 44 Referent  
Wash hands before drawing water 
 Yes 42 21.4 0.33 (0.15–0.67) NS 
 No 61 39 63.9 Referent  
Household total coliforms (cfu/100 mL) 
  ≤ 10 cfu/100 mL 17 0.45 (0.26–0.81) NS 
  > 10 cfu/100 mL 86 48 55.8 Referent  
 Water source temperature (°C)      
 15–20 47 12 25.5 0.39 (0.16–0.96)  
 20.1–25 41 20 48.8 0.67 (0.29–1.52) NS 
  > 25.1 100 Referent  
Water source pH 
 5–7 24 14 58.3 1.1 (0.76–1.59) NS 
  > 7.1 79 34 43 Referent  
Water source free chlorine (mg/L) 
  ≤ 1 80 33 41.3 0.41 (0.24–0.71) NS 
  > 1.1 23 23 100 Referent  

No., number; %, percentage; TTC, thermotolerant coliforms; OR, odds ratio; CI, confidence interval; NS, not significant.

The following variables, which have been linked with drinking water contamination, were included in the multivariate model: socio-demographic characteristics (e.g., household locality, household headship, gender, age, educational level, and occupation), attitude and knowledge, water handling (e.g., water collection, treatment, storage, and handling practices) and sanitation (e.g., waste disposal and pollution alongside water source). None was found to be independently associated with TTC contamination of household drinking water.

DISCUSSION

Kenya has experienced recurrent cases of waterborne diseases like cholera (TDN 2007; Wambua 2008). In the last 10 years, the morbidity patterns ranked diarrhea as the fourth priority disease (HSSR 2005). Western Kenya and part of Rift Valley Province, notably the districts of Bungoma, Busia, Kakamega, and Kericho are among the most affected regions (Onyango & Angienda 2010). This study was a build up of the limited data in Kericho District, evaluating the quality of household drinking water and highlighting the role of source and household water handling and hygiene practices in the contamination of drinking water with TTC. Invariably, the extent of safe water handling was determined by the local people's knowledge and attitudes towards water safety and sanitation (Özdemir et al. 2011).

The current study detected significantly high (46.6%) numbers of household drinking water contaminated with TTC. The fecal contamination of water sources and a further deterioration between the collection points and homes has been observed in other studies. In Kibera, Nairobi, Chemuliti et al. (2002) observed higher contamination levels of fecal coliforms (95%) in in-house sources and (35%) of outdoor sources. In Western Kenya, Muruka et al. (2012) observed a lower (2%) source water fecal coliform contamination. In Masaba, Kisii, Nyagwencha et al. (2012) observed that 16% of the households accessed unsuitable water for human consumption. In Chinese, English, French, Portuguese, and Spanish populations over a quarter of samples from improved sources were shown to contain fecal contamination (Bain et al. 2014). In Peru, Gil et al. (2014) found TTCs in 48% of all water samples. In India, Boisson et al. (2013) found that 20% of the household drinking water had fecal contamination. Our study shows that a significant population in Kericho District, Kenya lacks safe clean drinking water according to the WHO guidelines.

The presence of TTCs in water indicates actual contamination with feces (human and non-human) and potential contamination by disease-causing pathogens of all kinds. In this study, pathogenic bacteria including E. coli, Serratia, Enterobacter, Klebsiella, Moraxella, Pseudomonas, Shigella, Acinetobacter, Aeromonas, and Yersinia were isolated. This is worrying given that these bacteria are associated with waterborne human diseases. Similar coliforms have been isolated by others from water sources (Kämpfer et al.2008). All of the thermotolerant pathogenic E. coli were resistant to various important antibiotics including ampicillin, sulfamethoxazole/trimethoprim, and tetracycline. In Nigeria, resistance patterns of 80.9% ampicillin, 95.4% tetracycline, and 46.5% chloramphenicol were observed; while in Tanzania, resistance rates of 83.1% to ampicillin, 57% chloramphenicol, 87.7% tetracycline, and 90.8% co-trimoxazole were found (Vila et al. 2000). Of major concern with our findings is that antibiotics such as ciprofloxacin and cefotaxime, which are prescription antibiotics in Kenya, showed considerable resistance. This indicates misuse of these and other classes of antibiotics which would have major implications in the treatment of E. coli causing diarrhea in Kenya.

The rural locality of the household and the type of water source contributed significantly to TTC household drinking water contamination. These findings mirror those of Bain et al. (2014), who showed water sources in low-income countries and rural areas as being more likely to be contaminated. As expected, households located in rural areas are prone to poor waste disposal, poor household hygiene, lack of resources, and knowledge of water treatment. These factors were likely to contribute to the higher TTC drinking water contamination. This argument is supported by the study of Bain et al. (2014), who observed that a defective water delivery system and inadequate environmental sanitation are shown to be a potential source of contamination for household drinking water. The poor levels of environmental hygiene coupled with a dilapidated water delivery system are major contributors to TTC water contamination (Chemuliti et al. 2002).

Household hygiene, and practices such as hand washing, hand contact with drinking water during withdrawal, household water storage type, cleanliness, water treatment, and human waste disposal were important for TTC household drinking water contamination. Eshcol et al. (2009), in India, showed that fecal contamination occurs principally during storage due to poor water handling. In Zimbabwe, homes where traditional drinking water containers have been replaced with covered, narrow-mouthed pots with a tap outlet have significantly less contamination (Mazengia et al. 2002). A combination of special storage vessels with point-of-use treatment has been shown to be very effective (Rose et al. 2006). Hand washing initiatives and the introduction of point-of-use disinfection can reduce diarrheal incidence (Ejemot et al. 2008).

CONCLUSIONS

Other water quality surveys have shown natural ecosystems (geological, topographical, hydrological in the drainage basin), seasonal differences, weather conditions, water levels as well as other human hygiene and practices affect the quality of water. The cross-sectional nature of this study, relatively small sample size, inadequate assessment using the full WHO/JMP standardized questionnaires for household water handling and sanitation, could partly explain the observed lack of association between household drinking water TTC contaminations in our multivariate analyses.

Given these limitations, a reasonable conclusion that can be drawn from these data is that a significant number of household drinking waters in Kericho District are unsafe in line with WHO guidelines, and some are contaminated with pathogenic multidrug-resistant E. coli. Water source and household hygiene and practices contribute significantly to the quality of drinking water.

ACKNOWLEDGEMENTS

This work was carried out at the Micro Hub Kericho Walter Reed Project (WRP), Kenya Medical Research Institute, Kericho District, Western Kenya. The work was funded by Field Epidemiology Laboratory Training Programme, Ministry of Health, Nairobi, Kenya. We thank the study participants for their invaluable support by consenting to the use of their samples in the study. This work was part of Master of public health degree for J.K.T. The work is published with the permission of Director KEMRI. The authors declare that they have no competing interest. J.K.T., W.S., Z.N., and M.O.N. conceived the study. J.K.T. supervised sample collections and testing while W.S. and M.O.N. supervised laboratory analysis. M.O.N. and J.K.T. analyzed the data and prepared the draft manuscript. W.S., Z.N., and M.O.N. provided guidance and mentorship during the implementation of the study. All authors reviewed and approved the final manuscript.

REFERENCES

REFERENCES
Chemuliti
J. K.
Gathura
P. B.
Kyule
M. M.
Njeruh
F. M.
2002
Bacteriological qualities of indoor and out-door drinking water in Kibera Sub-location of Nairobi, Kenya
.
East African Med. J.
79
,
271
274
.
CLSI
2010
Performance Standards for Antimicrobial Susceptibility Testing
.
June 2010 Update
,
Clinical and Laboratory Standards Institute
,
Wayne, PA
,
USA
.
Committee on Economic, Social and Cultural Rights
2002
General Comment No. 15, The right to water
.
UN Doc. E/C.12/2010
.
United Nations
,
New York
,
USA
.
Ejemot
R. I.
Ehiri
J. E.
Meremikwu
M. M.
Critchley
J. A.
2008
Hand washing for preventing diarrhoea
.
Cochrane Database Syst. Rev.
23
(
1
),
CD004265
.
Gil
A.
Lanata
C. F.
Hartinger
S. M.
Mäusezahl
D.
Padilla
B.
Ochoa
T. J.
Lozada
M.
Pineda
I.
Verastegui
H.
2014
Fecal contamination of food, water, hands, and kitchen utensils at the household level in rural areas of Peru
.
J. Environ. Health
76
(
6
),
102
106
.
Gomez-Duarte
O. G.
2009
Rapid diagnostics for diarrhoeal disease surveillance in less developed countries
.
Clin. Lab. Int.
33
,
7
10
.
Health Sector Reform Secretariat (HSSR)
2005
The National Health Sector Strategic Plan, Ministry of Health, Republic of Kenya, 1999–2004
.
Kämpfer
P.
Nienhüser
A.
Packroff
G.
Wernicke
F.
Mehling
A.
Nixdorf
K.
Fiedler
S.
Kolauch
C.
Esser
M.
2008
Molecular identification of coliform bacteria isolated from drinking water reservoirs with traditional methods and the Colilert-18 system
.
Int. J. Hyg. Environ. Health
211
(
3–4
),
374
384
.
Kenya Census
.
2010
The 2009 Kenya Population and Housing Census, population distribution by administrative units volume 1 A
,
247
248
.
Kimani-Murage
E. M.
Ngindu
A. M.
2007
Quality of water the slum dwellers use: The case of a Kenyan slum
.
J. Urban Health
84
(
6
),
829
838
.
Lemeshow
S.
Hosmer
D. K.
Klar
J.
Lwanga
S. K.
1990
World Health Organization. Adequacy of samples size in health studies. www.tbrieder.org/publications/books_english/lemeshow_samplesize.pdf (accessed February 2015)
.
Mazengia
E.
Chidavaenzi
M. T.
Bradley
M.
Jere
M.
Nhandara
C.
Chigunduru
D.
Murahwa
E. C.
2002
Effective and culturally acceptable water storage in Zimbabwe: maintaining the quality of water abstracted from upgraded family wells
.
J. Environ. Health
64
(
8
),
15
18
.
Nguyen
T. V.
Le Van
P.
Le Huy
C.
Gia
K. N.
Weintraub
A.
2005
Detection and characterization of diarrheagenic Escherichia coli from young children in Hanoi, Vietnam
.
J. Clin. Microbiol.
43
,
755
760
.
Nyagwencha
J. M.
Kaluli
J. W.
Home
P. G.
Hunja
M.
2012
Water and water-borne diseases in North Masaba District, Kenya
.
JAGST
14
(
1
),
114
127
.
Onyango
D. M.
Angienda
P. O.
2010
Epidemiology of waterborne diarrhoeal diseases among children aged 6–36 months old in Busia –Western Kenya
.
Int. J. Biol. Life Sci.
6
(
2
),
92
99
.
Opisa
S.
Odiere
M. R.
Jura
W. O.
Karanja
M. S.
Mwinzi
P. M.
2012
Faecal contamination of public water sources in informal settlements of Kisumu City, western Kenya
.
Water Sci. Technol.
66
(
12
),
2674
2681
.
Özdemir
S.
Elliott
M.
Brown
J.
Nam
P.
Hien
V.
Sobsey
M.
2011
Rainwater harvesting practices and attitudes in the Mekong Delta of Vietnam
.
J. Water Sanitation Hyg. Dev.
1
,
171
177
.
Rose
A.
Roy
S.
Abraham
V.
Holmgren
G.
George
K.
Balraj
V.
Abraham
S.
Muliyil
J.
Joseph
A.
Kang
G.
2006
Solar disinfection of water for diarrhoeal prevention in southern India
.
Arch. Dis. Child.
91
(
2
),
139
141
.
Tropical Disease News (TDN)
2007
Seven people killed by cholera in Western Kenya, more affected. www.medindia.net/news/Seven-People-Killed-by-Cholera-in-Western-Kenya-More-Affected-30819-1.htm (accessed 10 February 2015)
.
United Nations
2010
Resolution on Human Right to Water and Sanitation
.
United Nations General Assembly. A/64/292
.
United Nations
,
New York
,
USA
.
Wambua
J
.
2008
Cholera in Kenyan situation a worry. http://keyscientist.org/talk/viewtopic.php?f=4&t=3 (accessed 7 March 2015)
.
WHO
1997
Guidelines for Drinking-water Quality
.
2nd edition, Volume 3 Surveillance and Control of Community Supplies. http://www.who.int/water_sanitation_health/dwq/gdwqvol32ed.pdf (accessed 1 February 2015)
.
WHO
1998
Guidelines for Drinking-water Quality. 2nd edition, Volume 2 Health Criteria and Other Supporting Information – Addendum. http://www.who.int/water_sanitation_health/dwq/2edaddvol2a.pdf (accessed 1 February 2015)
.
WHO
2011
Guidelines for Drinking-water Quality
. .
WHO/UNICEF
2010
JMP Technical Task Force Meeting on Monitoring Drinking-water Quality. WHO/UNICEF Joint Monitoring Programme. Geneva and New York. http://www.wssinfo.org/fileadmin/user_upload/resources/JMP-Task-Force-Meeting-on-Monitoring-Drinking-water-Quality.pdf (accessed 1 February 2015)
.
World Health Organization & United Nations Children's Fund (WHO/UNICEF)
2010
Joint Monitoring Programme for Water Supply and Sanitation: Progress on Sanitation and Drinking-water: 2010 Update. http://www.unicef.org/eapro/JMP-2010Final.pdf (accessed 1 February 2015)
.
WWAP
2006
Kenya National Water Development Report. Case Study. UN-Water/WWAP/2006/12. http://unesdoc.unesco.org/images/0014/001488/148866E.pdf (accessed 1 February 2015)
.