Bacteriological quality of drinking water and associated factors in Alemwach refugee camp in Dabat District, Northwest Ethiopia

Abstract

Access to safe drinking water is essential for preventing waterborne diseases and ensuring public health, particularly in refugee camps, where overcrowding and inadequate sanitation pose significant risks. Contaminated drinking water remains a major public health concern, contributing to outbreaks of diarrheal and other infectious diseases. This study assesses the bacteriological quality of drinking water from sources to the point of use and identifies associated factors influencing contamination in Alemwach Refugee Camp, Dabat District, Northwest Ethiopia. A laboratory-supported cross-sectional study was conducted among Alemwach refugees by collecting a total of 435 drinking water samples (10 samples from the reservoir, 2 samples from the public stand well, 1 sample from the deep well, and 422 samples from household storage containers) for bacteriological analysis. Additionally, data were collected from 422 respondents using structured interviewer-based questionnaires and through observation that assessed factors related to the bacteriological quality of drinking water. Binary and multiple logistic regression analyses were performed to find associated factors, and variables with a p-value of 0.05 were considered statistically significant variables. This study revealed that 33.3% of water samples from groundwater, 30% of water samples from reservoirs, and 78.9% of water samples from household storage drinking water were contaminated by fecal coliform. The sanitary risk score indicates a high-level risk score of 66.7% for groundwater sources and a 54.5% risk score for household storage containers, representing a medium risk score. Educational status, home-based water treatment practice, type of water storage container, cleanliness of water storage container, types of sanitation facility, and animal contact with households were significantly associated with bacteriological quality of drinking water quality at the point of use. This study reveals substantial fecal coliform contamination in drinking water, particularly at the household level, indicating a high risk of waterborne diseases in Alemwach Refugee Camp. The contamination is influenced by multiple factors, including household education, type of water storage container, type of sanitation facilities, home-based water treatment, animal contact, and container cleanliness. To improve drinking water quality, targeted interventions such as promoting safe water storage, enhancing household water treatment practices, improving sanitation infrastructure, and conducting community education programs on hygiene and water safety are recommended. Regular monitoring and risk assessment of water sources should also be strengthened to ensure sustainable access to safe drinking water.

Introduction

Access to safe drinking water is a fundamental human right, yet contamination from source to point-of-use remains a critical public health concern, particularly in vulnerable settings like refugee camps^1,1. Refugee camps are often characterized by overcrowding, insufficient sanitation facilities, limited access to clean water, poor waste disposal, and inadequate personal hygiene, all of which create conditions conducive to waterborne disease outbreaks^3,4. Children are particularly vulnerable, as inadequate water and sanitation facilities increase their exposure to diarrheal diseases, scabies, and other health crises^5,6. Globally, hostilities in regions like the Middle East and North Africa have left over 50 million people in need of humanitarian WASH assistance since 2011⁷. The bacteriological quality of water in such camps is particularly concerning, as water can be contaminated with pathogenic microorganisms at various stages from source to point-of-use⁸. This issue is exacerbated by the fact that refugees may not have the resources or knowledge to adequately treat and store water in a hygienic manner⁹.

Several factors can contribute to the bacteriological contamination of drinking water sources^5,10,11. These include inadequate protection of water sources, inadequate water treatment methods, and lack of awareness, unhygienic community practices, and poor household handling practices^5,12,]13. Studies have shown that both water sources and household water storage can be heavily contaminated during transportation and storage in households, even when water sources are initially safe with fecal coliforms, indicating non-compliance with WHO water quality guidelines^5,14. In refugee camps like Alemwach, these factors could significantly affect the health of vulnerable populations. Fecal contamination, in particular, introduces pathogens such as bacteria (e.g., Escherichia coli), viruses, protozoa, and helminths, which are the primary causes of waterborne diseases such as typhoid, cholera, and diarrhea¹⁵. These diseases disproportionately affect children under five and contribute to millions of deaths annually¹⁶. Detecting these pathogens is challenging, as many are present in low concentrations or intermittently¹⁷. However, microbial indicators coliforms like total, fecal coliform and E. coli are commonly used to assess the bacteriological quality of drinking water and identify health risks¹⁸. As a result, sanitary inspections, including assessments of water sources, storage systems, treatment facilities, and household storage conditions, are effective tools for identifying potential contamination threats^17,19.

In Ethiopia, access to improved water supply and sanitation has been estimated at low rates, contributing to a high prevalence of communicable diseases, especially among children²⁰. Studies in various regions of Ethiopia have revealed that many drinking water sources are contaminated with total coliforms and fecal coliforms, often exceeding recommended national and international guidelines^20,21. Despite significant progress in water supply infrastructure, Ethiopia continues to face challenges in ensuring safe drinking water, especially in rural and conflict-affected areas. For example, Ethiopia, which hosts over 770,000 refugees, struggles to meet the UNHCR’s water and sanitation standards in its camps due to overcrowding and limited infrastructure. The ongoing conflict in regions such as Tigray has further strained resources, with refugee camps reporting high levels of bacteriological contamination in household water storage systems.

Alemwach Refugee Camp often relies on a combination of surface water, groundwater, and aid-provided water supplies, which can be contaminated by various bacterial pathogens²². Given the challenges in ensuring safe drinking water in refugee camps, this manuscript focuses on assessing the bacteriological quality of drinking water from sources to the point of use in the Alemwach Refugee Camp in the Dabat District, Northwest Ethiopia. By evaluating the water quality and associated factors, this study aims to provide valuable insights for targeted interventions to improve water quality and public health in this vulnerable community. By providing laboratory-based evidence, this research aims to establish a baseline framework for addressing water contamination and improving water safety, particularly in vulnerable refugee populations, to reduce the burden of waterborne diseases and enhance overall health outcomes.

Methodssrials

Study design, period and area

It is a cross-sectional study that was conducted from March 21 to May 22, 2023. The study was conducted in Alemwach refugee camp, which is located in Dabat District Northwest, Ethiopia. The district is located in the Amhara National Administrative Regional State, North Gondar zone, Northwest Ethiopia. It is located 821 km northwest of Addis Ababa, the capital city of Ethiopia, 251 km southwest of Bahir Dar, and 75 km from Gondar City. The district has two health centers, three health stations, and twenty-nine health posts providing health services for the community. About 1000 to 2500 m above sea level make up the district’s elevation. There are 22,622 refugees living in the 91-hectare area, and the refugee camp was established on 31 December 2022²³. The camp contains 4391 shades. The shades are made of iron sheets, plastic, cement, and tents. However, due to the ongoing conflict in the area, the new refugee housing in the camp caused an increase in houses made of tents. The total number of shades constructed in the camp is as follows: 2737 shades made of tents, 800 shades made of iron sheets, and houses that are also shaded by the iron sheet. In the district of the Alemwach refugee camp, there are a total of 354 cement-built houses and 500 plastic-built houses. Alemwach refugee camp relies on a combination of groundwater, reservoirs, and aid-provided water supplies.

Sample size determination and sites selection

The sample size was determined by using a single population proportion formula, assuming P = 48.7% of households’ drinking water was contaminated with coliforms from previous studies (3). With a margin of error of 5%, a confidence level of 95%, and a non-response rate of 10%, the calculated total sample size was 422.

n = 384 with a non-response rate of 10% = 38; the total sample size was 422 households.

To assess the bacteriological quality, water samples were collected from each source, including 10 samples from reservoirs, 2 from public stand wells, 1 from a deep well, and 422 from household storage containers. In total, 435 drinking water samples were analyzed for fecal coliform contamination. Additionally, a sanitary survey was conducted, involving interviews with 422 household respondents.

Data collection

A sanitary survey was randomly conducted across 4931 households, with a systematic random sampling technique to select 422 households. The sample distribution was proportional to the target households across the study sites. Data collection involved a questionnaire designed to gather information on socio-demographic characteristics, environmental conditions, and behavioral factors influencing the drinking water quality. The questionnaire was initially developed in English and later translated into the local Tigrigna language to facilitate effective communication, then it was translated back into English. Interviews were conducted with individuals responsible for water handling in the household, typically mothers or eldest daughters, by trained data collectors. Additionally, a 100 mL water sample was collected from each of the 422 selected households, as well as from reservoirs, household storage and water sources, one at a time, and analyzed by the principal investigator to assess fecal coliform contamination levels.

Sampling procedures

The sampling procedure involved selecting 422 households proportionally from a total of 4391 households across four residential blocks categorized by housing materials: tents, iron sheets, cement, and plastic. A systematic random sampling method was used, where the first household was randomly selected, followed by every 10th household (Fig. 1).

Fig. 1.

Schematic presentation of the sampling procedure for selecting study participants, Alemwach Refugee Camp in Dabat District, Northwest Ethiopia.

Sample collection

Water samples were collected following the WHO Guidelines for drinking water quality assessment, which recommend aseptic collection using sterile bottles²⁴. Trained data collectors gathered samples directly from drinking water sources, reservoirs, and household storage²⁵. Each sample bottle was labeled with a unique identification number, and the sampling time was recorded. Water samples were collected in 100 ml glass bottles, which had been sterilized in a hot air oven at 160 °C for two hours, and were then transported in a cold box to the University of Gondar’s Department of Environmental and Occupational Health and Safety laboratory. Microbiological analysis was conducted within four to six hours of collection.

Bacteriological water quality test

The membrane filtration method was used to identify the indicator bacteria. A Millipore 45 µm membrane filter was used to filter 100 ml water samples to count the number of fecal coliforms (FC). An absorbent pad was provided with a membrane lauryl sulfate medium. After that, the membrane-filtered samples were put on membrane lauryl sulfate medium in an aluminum Petri dish, and they were incubated for 18 to 24 h at 37 to 44 °C, respectively, to confirm the fecal coliform count. Then, we inspected the plates for growth of fecal coliforms systematically, column by column in the grid. Next, the yellow colonies were counted as coliforms. Colony forming units (CFU) were counted following separation^26,27.

Physicochemical water quality analysis

The physico-chemical parameters were analyzed by following the standard methods of the American Public Health Organization (APHA) and the American Society for Testing and Materials (ASTM) as shown in Table 1. These guidelines were followed throughout the examination process (Table 1).

Table 1.

Analysis methods used for testing various parameters.

No	Parameters	Analysis method	Reference
1	PH	pH meter, pH-208 (Wagtech pH meter)	28
2	Temperature (oC)	Thermometer (Bio Abron student mercury thermometer)
3	Turbidity (NTU)	Turbidity meter (TU-2016) (Wagtech turbidity meter)

Residual chlorine test

Residual chlorine levels were measured both at water sources and in household storage containers to assess the quality of water and to identify potential changes in water quality due to poor hygiene practices or other factors. Free residual chlorine (FRC) concentrations were determined using diethyl-phenylene diamine (DPD) reagents, which come in tablet form for ease of use. To conduct the test, one DPD1 tablet was added to a test tube filled with the water sample, then vigorously shaken to allow the chlorine to react with the reagent. The resulting change was analyzed using a disk reader, which displayed the free chlorine residual concentration in milligrams per liter.

Sanitary survey

A sanitary survey was conducted among 422 residents in the Alemwach refugee camp, located in Dabat District, Northwest Ethiopia. In this study, the sanitary survey was based on a qualitative risk categorization system determined by the sanitary risk score. According to WHO standards, a risk score of 0–2 is classified as low risk, 3–5 as intermediate risk, 6–8 as high risk, and 9–10 as very high risk.

Data quality assurance

Five data collectors, three supervisors, and three laboratory technicians received thorough training on how to collect data, how to take water samples from various sources to point of use, and how to use data collection tools in order to ensure the quality of the data a week before the commencement of the study. The questionnaire was pretested outside the study area, and necessary corrections were made accordingly. Prior to collecting samples, sampling glass bottles were thoroughly sterilized and properly labeled with information about the sample collection in accordance with international sampling guidelines. The culture media was disinfected, and their expired dates were examined. The water samples obtained from various sampling locations were transported to the laboratory’s experimental site with recommended timing while being maintained in an icebox at 4 °C for stability. Similar to this, all of the necessary lab equipment, incubators, and workspaces were thoroughly cleaned, sterilized, and calibrated measurement balances. Control samples were used to check the stability of growth media, and blank samples were used using the same procedure to ensure the validity of the analysis. The standard method for testing the bacteriological quality of drinking water was maintained as per World Health Organization guidelines²⁹.

Data management and analysis

The completeness, representativeness, and clarity of the collected data were checked by the investigators, and any situations that indicated gaps were corrected and reviewed. Raw data was imported into EpiData version 4.6 and then exported to SPSS version 26 for statistical analysis. Descriptive statistics were reported as frequency, percent, ranges, and graphs. Binary and multiple logistic regression analyses were performed to find associated factors, and variables with a p-value of 0.05 were considered statistically significant variables. Model fitness was checked with the Hosmer–Lemeshow goodness-of-fit assumption.

Ethical consideration

The study was reviewed and approved by the Institute of Public Health at the University of Gondar’s Ethical Review Committee. Ethical approval letter was obtained from Institute of Public Health. Letter was written from University of Gondar to the Ethiopian Administration for Refugees and Returnees Affairs (ARRA) to obtain support to our work. Official permission was obtained from ARRA to access the refugee camps as well as, written informed consent was obtained from the refugees’ participants and interviewee was ensured that the participant was voluntary. An inquiry was conducted in such a way that the confidentiality and full rights of respondents are protected or respected. They were informed well that they had the full right to refuse to participate or withdraw from the study at any time without any prerequisite. All methods were performed in accordance with the relevant guidelines and regulations.

Results

Socio-demographic characteristics

In this study, all 422 selected households participated, resulting in a 100% response rate. The average age of respondents was 41 years. Among them, 326 (77.3%) were male. In terms of educational background, 201 (47.6%) of the participants were unable to read and write. Regarding religion, the majority, 300 (71.1%), identified as Orthodox Christians (Table 2).

Table 2.

Socio-demographic characteristics of households in Alemwach refugee camp Dabat district, Northwest Ethiopia, 2023 (n = 422).

Characteristics	Category	Frequency	Percent (%)
Head of household	Male	326	77.3
	Female	96	22.7
Sex of respondent	Male	231	54.7
	Female	191	45.3
Educational status	Unable to read and write	201	47.6
	Formal education	188	44.5
	Collage and above	33	7.8
Religion of respondent	Orthodox	300	71.1
	Muslim	93	22.0
	Protestant	29	6.9
Having additional income	Yes	190	45.0
	No	232	55.0

Environmental related factors variables

Among the total households in the refugee camp, 373 (88.4%) had an average per capita water consumption of more than 20 L, with a mean value of 28.4 L. Regarding sanitation facilities, 240 (57%) of households had access to a sanitation facility, of which 154 (64%) used unimproved sanitation. Additionally, 261 (61.8%) of households shared their living space with various animals (Table 3).

Table 3.

Descriptive analysis of environmental factor related variables of households in Alemwach refugee camp Dabat district, Northwest Ethiopia, 2023, (n = 422).

Variables	Category	Frequency	Percent (%)
Principal sources of drinking water	Improved source	116	27.5
	Unimproved source	306	72.5
Distance of water sources	< 1 km with 30 min	250	59.2
	≥ 1 km and 30 min	172	40.8
Average per capita water consumption per day	< 20 litters	49	11.6
	≥ 20 litters	373	88.4
Duration of water supply in the camp	Available everyday	160	37.9
	Available every week	262	62.1
Do you pay for water?	Yes	29	6.9
	No	393	93.1
Latrine facility	Yes	240	57
	No	182	43
Types of sanitation facility	Unimproved	154	64
	Improved	86	36
Does the latrine you use have a concrete floor?	Yes	133	55.4
	No	107	44.6
How often do you use anal cleaning paper?	Always	73	17.3
	Sometimes	242	57.3
	Never	107	25.4
Hand washing facility with soap near to the toilet	Yes	51	21.3
	No	189	78.7
Contact of household with animals	Yes	261	61.8
	No	161	38.2
The houses wall constructed materials	Plastic	199	47.2
	Concrete	173	41.0
	Iron sheet	50	11.8
The houses floor constructed materials	Mud	243	57.6
	Concrete	104	24.6
	Mud with floor matts	75	17.8

Behavioral factor related variables

Among the total respondents, 272 (64.5%) of households used wide-necked water storage containers, and 256 (60.7%) withdrew water using the dipping method. In terms of hygiene practices, 229 (54.3%) of households rarely washed their drinking water collection containers. Only 124 (29.4%) of households properly cleaned their water storage containers, while 109 (25.8%) practiced home-based drinking water treatment. Among those who treated their water, 61 (56%) used chlorination as a treatment method (Table 4).

Table 4.

Descriptive analysis of behavioral factor related variables of households in Alemwach refugee camp, Dabat district, Northwest Ethiopia, 2023 (n = 422).

Variables	Category	Frequency	Percent (%)
Do you usually treat your water before you drink home?	Yes	109	25.8
	No	313	74.2
Methods of water treatment have you used	Boiling	13	12
	Chlorination	61	56
	Filtering	35	32
Type of water storage container for the drinking water	Wide necked	272	64.5
	Narrow necked	150	35.54
Does the storage container have fitted cover?	Yes	243	57.6
	No	179	42.4
Is there any water stored within the last one month in the storage container?	Yes	134	31.8
	No	288	68.2
How can you withdraw water from wide necked storage container?	Pour directly	96	22.7
	Dipping with cup	256	60.7
	Both pouring and dipping	70	16.6
Does the storage containers accessible to children contact?	Yes	333	78.9
	No	89	21.1
Where do you regularly place cups used for drinking?	On the floor	256	60.7
	Placed prepare on it	62	14.7
	On the table/shelf	104	24.6
How often do you properly clean water collecting container?	Rarely	229	54.3
	Sometimes	139	32.9
	Always	54	12.8
How often do you properly clean drinking cups?	Rarely	70	16.6
	Sometimes	228	54.0
	Always	124	29.4
How often do you properly wash water storage container?	Rarely	70	16.6
	Sometimes	228	54.0
	Always	124	29.4

Physico-chemical parameters

Key physico-chemical parameters influencing microbial growth were assessed, including temperature, residual chlorine, pH, and turbidity, which serve as common indicators for fecal coliform presence in drinking water. Among the surveyed households, 229 (54.3%) had free residual chlorine levels between 0–0.2 mg/L in their stored water, while 160 (37.9%) reported free residual chlorine levels ranging from 0.2–0.5 mg/L. More than half of the households (59.5%) stored water at temperatures exceeding 20 °C (Table 5).

Table 5.

Descriptive analysis of physic-chemical parameters in Alemwach refugee camp, Dabat district, Northwest Ethiopia, 2023 (n = 422).

Variables	Category	Frequency	Percent (%)
The amount of free residual chlorine (mg/L) in stored water	0	24	5.7
	> 0 to < 0.2	229	54.3
	0.2–0.5	160	37.9
	> 0.5	9	2.1
The measure of turbidity	< 5 NTU	163	38.6
	> 5 NTU	259	61.4
The measure of temperature	< 20 °C	171	40.5
	> 20 °C	251	59.5
Measure of PH	< 6.5	69	16.4
	6.5–8.5	280	66.4
	> 8.5	73	17.3

Prevalence of fecal coliform from source to point of use

The bacteriological analysis of drinking water from different points, including water sources, reservoirs, and household storage, reveals significant contamination levels. Among the sampled water sources, 33.3% tested positive for fecal coliform, while water samples from household storage indicated that 78.9% were contaminated with fecal coliform (Fig. 2).

Fig. 2.

Trends of fecal coliform contamination from water source to point of use in Alemwach refugee camp, Dabat district, Northwest Ethiopia, 2023.

Sanitary risk score

The risk assessment of bacteriological contamination across different water points shows varying levels of risk. The majority of water sources fall within the medium-risk category, accounting for 66.7%. This suggests that although some water sources maintain relatively safe conditions, a significant portion still requires improved management and monitoring to minimize contamination risks. In contrast, storage containers at the household level exhibit a higher contamination risk, with 54.5% categorized as high risk (Fig. 3).

Fig. 3.

Sanitary risk score of household drinking water storage condition and respective water sources that households used in Alemwach refugee camp, Dabat district, Northwest Ethiopia, 2023 (n = 422).

Fecal coliform risk contamination level

The bacteriological quality of drinking water samples was assessed based on fecal coliform (FC) contamination levels across different sampling locations, including water sources, reservoirs, and household storage. Among the water source samples, 66.7% showed no fecal coliform contamination, classifying them as having no risk of contamination. Similarly, 70% of water samples from the reservoirs resulted in a low risk of contamination, while 10.7% of water samples from household storage showed high fecal coliform contamination (Table 6).

Table 6.

Risk contamination level of fecal coliform at drinking water sources, reservoirs, and point of use in Alemwach refugee camp, Dabat district, Northwest Ethiopia, 2023.

Area of samples	FC risk level, cfu/100 ml	Frequency	Percent	Risk level	Quality remark
Water sources	0	2	66.7	No	Excellent
	1–10	1	33.3	Low	Acceptable
Reservoirs	0	7	70	No	Excellent
	1–10	3	30	Low	Acceptable
Households	0	89	21.1	No	Excellent
	1–10	79	18.7	Low	Acceptable
	11–100	209	49.5	Intermediate	Unacceptable
	101–1000	45	10.7	High	Unacceptable

Factors affecting the bacteriological quality of drinking water

The multivariable logistic regression analysis identified several statistically significant factors influencing the bacteriological quality of drinking water. These factors included educational status, type of drinking water storage container, type of sanitation facility, household water treatment practices, contact of houses with animals, and the frequency of cleaning water storage containers.

Households using wide-necked water storage containers were 2.71 times more likely to have fecal coliform contamination than those using narrow-necked storage containers (AOR = 2.71, 95% CI 1.57, 9.46).

Similarly, households relying on unimproved sanitation facilities were 5.57 times more likely to have fecal coliform contamination in their drinking water compared to those with improved sanitation facilities (AOR = 5.57, 95% CI 1.98, 15.66).

Moreover, households that did not implement home-based water treatment had 3.53 times higher odds of drinking water contamination than those that practiced water treatment (AOR = 3.53, 95% CI 1.27, 9.82) (Table 7).

Table 7.

Factor analysis for bacteriological quality of drinking water with binary and multivariable logistic regression model in Alemwach refugee camp, Dabat district, Northwest Ethiopia, 2023 (n = 422).

Variables	Category	Positive FC (n = 422)		COR (95% CI)	AOR (95% CI)
		Yes (%)	No (%)
Educational status	Unable to read &write	176(41.7)	25(5.9)	4.58(2.03, 10.33)	2.38(1.32–4.37) **
	Formal education	137(32.5)	51(12.1)	1.75(0.81,3.77)	1.68(0.46, 6.21)
	Collage and above	20(4.7)	13(3.1)	1	1
Principal sources of drinking water	Unimproved source	266(63)	40(9.2)	4.86(2.96, 7.99)	1.51(0.55, 4.11)
	improved source	67(15.9)	49(11.9)	1	1
Water treatment practice at home	No	276(65.4)	37(8.8)	6.81(4.09, 11.32)	3.53(1.27, 9.82) *
	Yes	57(13.5)	52(12.3)	1	1
Type of storage container of drinking water	Wide necked container	233(55.3)	39(9.4)	3.02(1.87, 4.88)	2.71(1.57, 9.46) **
	Narrow necked	99(23.5)	50(11.8)	1	1
Withdraw water from wide necked storage	Pour directly	61(14.5)	35(8.3)	1	1
	Both pouring & dipping	214(50.7)	42(10)	2.92(1.72, 4.97)	1.54(0.517, 4.57)
	Dipping	58(13.7)	12(2.8)	2.77(1.31, 5.86)	3.04(0.63, 14.54)
Storage containers accessible to children contact	Yes	280(66.4)	53(12.6)	3.59(2.14, 6.01)	1.72(0.59, 5.02)
	No	53(12.6)	36(8.4)	1	1
Regularly place of cups used for drinking	On the floor	212(50.2)	44(10.4)	2.05(1.20, 3.48	0.92(0.31, 2.76)
	Placed prepare on it	48(11.4)	14(3.3)	1.46(0.70, 3.02)	1.79(0.41, 7.87)
	On the table/shelf	73(17.3)	31(7.4)	1	1
Properly clean drinking cups	Rarely	57(13.5)	13(3.1)	2.41(1.19, 4.89)	0.60(0.12, 3.02)
	Sometimes	196(46.5)	32(7.5)	3.37(1.99, 5.69)	0.92(0.32, 2.65)
	Always	80(19)	44(10.4)	1	1
Properly wash of water storage container	Rarely	184(43.6)	30(7.1)	3.07(1.62, 5.82)	2.53(1.32, 4.60) *
	Sometimes	105(24.9)	37(8.7)	1.42(0.75, 2.68)	2.19(0.45, 10.62)
	Always	44(10.4)	22(5.2)	1	1
Types of sanitation facility	Unimproved	134(55.8)	20(4.7)	10.25(5.41,19.4)	5.57(1.98, 15.66) **
	Improved	34(14.2)	52(12.3)	1	1
Hand washing facility near to the toilet	No	137(57)	2(21.7)	1.84(0.92, 3.36)	1.56(0.54, 4.57)
	Yes	30(12.5)	521(8.8)	1	1
Contact with animals	Yes	231(54.7)	30(7.1)	4.45(2.72, 7.33)	3.94(1.61, 9.65) **
	No	102(24.2)	59(14)	1	1
Sanitary risk score in water sample	Low	5(1.2)	9(2.1)	1	1
	Medium	66(15.7)	52(12.3)	0.45(0.14 ,1.41)	0.76(0.09, 6.49)
	High	207(49)	23(5.5)	0.06(0.02, 0.20)	2.75(0.31, 24.79)
	Very high	55(13)	5(1.2)	0.04(0.01, 0.18)	2.31(0.13, 40.38)

The symbol “*” represent, P < 0.05, ** = P < 0.01, and *** = P < 0.001.

Discussion

This study assessed the bacteriological quality of drinking water from sources to point-of-use and the associated factors in Alemwach refugee Camp, Northwest Ethiopia. The current study revealed that 33.3% of drinking water from water sources, 30% from reservoirs, and 78.9% of water from household storage was positive for fecal coliform. This finding is supported by a study conducted in South Darfur, Sudan, where the highest water contamination was observed in household storage containers, followed by reservoirs, and the lowest was at the water source³⁰. The highest proportion of bacteriological contamination in drinking water quality among households in this study was 78.9% (95% CI 74.9, 83.2), which is closely similar to a study conducted in Eastern Ethiopia¹⁸, and greater than findings from a study conducted in Northwest Ethiopia³¹. The discrepancy in the level of fecal coliform may be attributed to differences in sample sources, water handling behavior, accessibility of water, household hygienic practices, the water transport pathways and the effectiveness of water treatment practices.

A systematic review conducted in Sub-Saharan countries revealed that almost half of the investigations included in the review showed an increase in the microbial load after drinking water left the reservoirs^32,33. The current study confirms and aligns positively with the findings of the review. Microbial problems are highly investigated at household storage containers and reservoirs, which might be due to loss of disinfectant and water treatment, poor hygienic practices, bacteria re-growth, excessive detention time, and the presence of leakage³⁴.

This study reveals that the majority of samples taken from drinking water sources, reservoirs, and household storages exhibited higher concentrations of fecal coliform bacteria than the World Health Organization (WHO) recommended level of 0 CFU per 100 ml. This study is similar with findings from studies conducted in the Gedeo Zone¹⁵, Southern Ethiopia and South Darfur, Sudan, albeit with differing proportions³⁵. The variation in proportion may be attributed to poor hygiene and sanitation practices, inadequate water storage behavior, and the influence of environmental instability around the camp.

This study clearly indicated that samples with intermediate and high sanitary risk scores had intermediate and high numbers of fecal coliforms per 100 ml of water³⁶. This implies that the microbial load of drinking water is directly proportional to the sanitary risk score of the storage or handling environment. A higher risk score indicates greater exposure to water contaminants, resulting in high concentrations of microbes. In this study, samples taken from sites with low sanitary risk scores revealed an absence or low risk of coliform contamination, while water samples with medium and high sanitary risk scores had low to high colonies per 100 ml of water. This study finding aligns with similar studies conducted in the Bona district of Ethiopia and Eastern Ethiopia³⁷, which indicate that water sources with high sanitary risk scores had inferior bacteriological quality, while those with low sanitary risk scores had excellent bacteriological quality³⁸. The majority of water sources are located very near to the overcrowded populations in the refugee camp, with inadequate protection, poor site selection, maintenance, and inappropriate waste management practices, including open defecation, contributing to positive test results. This is also supported by a study conducted in Ambo, Ethiopia, which found that human habitation of water banks and the discharge of various wastes, including open defecation, near the surrounding environment contaminate water sources³⁹.

In this study, some of the physico-chemical measurements disagree with the WHO permissible standard limits. This study’s findings demonstrated a decrease in free chlorine residual levels alongside an increase in fecal coliform bacteria. This inverse relationship suggests that as free chlorine residual decreases, fecal coliform levels rise. The likely reasons for this include insufficient disinfectant concentrations at the point of consumption, allowing bacterial regrowth, and poor sanitation and hygiene practices at the household level. Most of the water samples from Alemwach refugee camp exceeded the turbidity limit of 5 NTU (61.4%). Similarly, a survey of water quality at two rural water treatment plants in South Africa indicated that turbidity at the WTPs and most points of use (POU) exceeded the aesthetic (5 NTU) and operational (1 NTU) risk guidelines. High turbidity can indicate problems with water disinfection⁴⁰. Moreover, the pH measurements showed that 66.4% of samples were within the acceptable range of 6.5–8.5, but 16.4% were below 6.5 and 17.3% were above 8.5. Also, a large proportion of water samples had temperatures above 20 °C (59.5%). Warm water is generally less appealing than cool water, and elevated water temperatures can promote microbial growth, leading to issues such as unpleasant taste, odor, discoloration, and corrosion, as outlined by WHO standards⁴¹. Since cooler water is more desirable for consumption, it is recommended that drinking water temperatures remain below 15–20 °C. Furthermore, temperature significantly influences the chemical and biological processes occurring in water bodies⁴².

In the multivariable logistic regression analysis, educational status, type of drinking water storage container, type of sanitation facility, household water treatment practice, contact of houses with animals, cleaning of water storage container was statistically significant factors.

Household respondents who were unable to read and write had more than twice the odds of experiencing fecal coliform contamination in their drinking water compared to those with a college education or higher (AOR = 2.38, 95% CI 1.32, 4.37). This finding is consistent with a study conducted in Pakistan that emphasized the importance of awareness in ensuring water quality⁴⁴. Similarly, a study conducted in Gambella, Ethiopia, found that households without formal education had a significantly higher likelihood of fecal contamination³. Additionally, research from Bona District in the Sidama Zone of Southern Ethiopia reported a comparable association¹⁸. The increased risk of contamination among those with lower educational attainment may be attributed to a lack of awareness regarding safe water consumption and hygiene practices, as individuals with higher education levels are generally more informed about health-related issues.

The type of sanitation facility used by households was a significant determinant of the bacteriological quality of drinking water. Households that relied on unimproved sanitation facilities had more than five times odds of fecal coliform contamination in their drinking water compared to those using improved sanitation facilities (AOR = 5.57, 95% CI 1.98, 15.66). This finding aligns with a study conducted in Ethiopia, which identified that households using pit latrines had 3.169 times higher odds of fecal coliform contamination compared to those using improved sanitation facilities⁴⁵. Similarly, research from Eastern Ethiopia reported a significant association between unimproved sanitation and contamination¹⁸. The higher risk of contamination in households with unimproved sanitation facilities may be due to increased exposure of human feces to the surrounding environment. Additionally, individuals using these facilities may inadvertently contribute to the cross-contamination of drinking water through direct or indirect contact during defecation. Consequently, the proximity of storage water to household latrines could be a potential pathway for contamination.

This study also identified a significant association between bacteriological water quality at the point of use and household-based water treatment practices. Households that did not practice home-based water treatment had more than three and a half times higher odds of fecal coliform contamination in their drinking water compared to those that did (AOR = 3.53, 95% CI 1.27, 9.82). This finding is consistent with a study conducted in Eastern Ethiopia, which reported that households without water treatment were 3.42 times more likely to have contaminated drinking water¹⁸, and with the 2016 Ethiopian Socioeconomic Survey on drinking water quality, which found that households that treated their own water were 19% more likely to experience a reduction in E. coli contamination compared to those that did not³³. Additionally, a study conducted in rural Ethiopia supports this finding, indicating that household water chlorination significantly reduces bacteriological contamination, as drinking water samples from households that used chlorination were more likely to meet WHO guidelines than those from households that did not⁴⁶. The effectiveness of household water treatment can be attributed to its ability to eliminate microorganisms, thereby improving drinking water quality. Furthermore, the use of chlorine as a disinfectant not only kills pathogens but also provides residual protection, reducing the risk of recontamination.

Households with animal contact had more than three times higher odds of fecal coliform contamination in their drinking water compared to those without animal contact (AOR = 3.94, 95% CI 1.61, 9.65). This finding aligns closely with a 2021 study conducted in Ethiopia, which reported that households sharing their living space with animals were 3.73 times more likely to have contaminated drinking water than those that did not⁵. Animal fecal markers were widely detected in both public and domestic domains, indicating ubiquitous risks of exposure to animal feces and zoonotic pathogens⁴⁷. This is supported by a cross-sectional study in India during the monsoon season, which revealed that animal fecal markers were widely detected in ponds (74%) and households (96%), further emphasizing the risk of exposure to animal feces⁴⁷. In Kenya, a study found that both household animal ownership and the presence of animal waste in the household compound were significantly associated with household drinking water contamination. This highlights the importance of managing animal waste to prevent water contamination⁴⁸.

Additionally, households that rarely cleaned their water storage containers had more than two times higher odds of fecal coliform contamination compared to those that consistently maintained clean storage containers (AOR = 2.53, 95% CI 1.32–4.60). This result is consistent with a study conducted in Murewa District, Zimbabwe, which emphasized that washing water collection containers before fetching water, especially using soap or ash, prevents the formation of a slimy biofilm layer inside the storage containers. Improper washing and inadequate rinsing of containers can lead to contamination and algal growth, creating favorable conditions for pathogen proliferation and increasing the risk of waterborne contamination¹³.

The strengths of this study include adherence to standard procedures for data collection, the use of blank samples and controls, conducting a pre-test, and regular follow-ups to ensure the validity and reliability of the data. However, a limitation of this study is its cross-sectional design, which captures only a single point in time and does not account for seasonal variations in the bacteriological quality of drinking water in the study area.

Conclusion

In this study, a high prevalence of fecal coliform was observed. Additionally, most of the water samples were not meeting the WHO standard of bacteriological quality of drinking water. People use such water for drinking purposes, which might expose them to waterborne diseases. Educational status, type of storage container of drinking water, type of sanitation facility, household water treatment practice, contact of houses with animals, and cleanliness of water storage container were statistically significant variables. It is recommended that targeted interventions be implemented to improve the bacteriological quality of drinking water in Alemwach Refugee Camp. Efforts should focus on promoting household water treatment practices, improving sanitation facilities, and enhancing hygiene education, particularly for individuals with lower educational attainment. Regular cleaning of water storage containers should be encouraged to prevent microbial contamination. Additionally, measures should be taken to minimize household contact with animals to reduce the risk of waterborne contamination.

Author contributions

HB conceived the design and research concept, F.W, L.Y, A.E.B and H.B, M.T, A.A.Y analyzed and interpreted data and presented the results drafted. L.Y, B.B.B and F.W revised the manuscript. All authors read and approved the final manuscript.

Funding

No funding agent.

Data availability

The dataset is accessible from the corresponding author upon reasonable request.

Declarations

Competing interests

The authors declare no competing interests.

Ethics approval and consent to participate

Ethical clearance and approval were obtained from the Institutional Ethical Review Board (IERB) of the University of Gondar, College of Medicine and Health Sciences, Institute of Public Health.

Consent for publication

Not applicable.