Antimicrobial-resistance in clinically harmful bacteria contaminating household drinking water in Eastern Uganda highlights urgent need for enhanced antibiotic resistance stewardship.

Antimicrobial-resistance in clinically harmful bacteria contaminating household drinking water in Eastern Uganda highlights urgent need for enhanced antibiotic resistance stewardship - PMC Skip to main content An official website of the United States government Here's how you know Here's how you know Search Log in Primary site navigation Search Log in Search PMC Full-Text Archive Search in PMC Journal List User Guide As a library, NLM provides access to scientific literature. Inclusion in an NLM database does not imply endorsement of, or agreement with, the contents by NLM or the National Institutes of Health. Learn more: PMC Disclaimer | PMC Copyright Notice Sci Rep . 2026 Apr 13;16:17241. doi: 10.1038/s41598-026-47699-w Antimicrobial-resistance in clinically harmful bacteria contaminating household drinking water in Eastern Uganda highlights urgent need for enhanced antibiotic resistance stewardship Abdul Walusansa 1, 2, ✉ , Abdikarim Salad Elmi 4 , Jamilu E Ssenku 2 , Nulu Nansikombi 5 , Ali Kudamba 2, 3 , Alemu Shaban Okurut 2 , Abukar Mukhtar Omar 4 , Sumin Lunkuse 6 , Hussein M Kafeero 1 Author information Article notes Copyright and License information 1 Department of Medical Microbiology and Immunology, Faculty of Health Sciences, Habib Medical School, Islamic University in Uganda, Kampala, Uganda 2 Department of Biological Sciences, Faculty of Science, Islamic University in Uganda, Mbale, Uganda 3 Department of Physiology, Faculty of Health Sciences, Habib Medical School, Islamic University in Uganda, Kampala, Uganda 4 Faculty of Education, Department of Biological Science, SIMAD University, Mogadishu, Somalia 5 Department of Food Science and Postharvest Technology, Faculty of Agriculture and Environment, Gulu University, Gulu, Uganda 6 Department of Computer Science, Faculty of Science, Islamic University in Uganda, Mbale, Uganda ✉ Corresponding author. Received 2026 Jan 21; Accepted 2026 Apr 2; Collection date 2026. © The Author(s) 2026 Open Access This article is licensed under a Creative Commons Attribution-NonCommercial-NoDerivatives 4.0 International License, which permits any non-commercial use, sharing, distribution and reproduction in any medium or format, as long as you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons licence, and indicate if you modified the licensed material. You do not have permission under this licence to share adapted material derived from this article or parts of it. The images or other third party material in this article are included in the article’s Creative Commons licence, unless indicated otherwise in a credit line to the material. If material is not included in the article’s Creative Commons licence and your intended use is not permitted by statutory regulation or exceeds the permitted use, you will need to obtain permission directly from the copyright holder. To view a copy of this licence, visit http://creativecommons.org/licenses/by-nc-nd/4.0/ . PMC Copyright notice PMCID: PMC13234322  PMID: 41975183 Abstract Antimicrobial resistance (AMR) is escalating especially in waterborne bacteria, feared to cause over ten-million annual global deaths by 2050. In Eastern Uganda, bacterial contamination of household drinking water containers and sources such as boreholes is increasingly reported, but data on related AMR and contamination enables are scarce, complicating redress. On 260 random water samples, conventional culture and Kirby-Bauer disk diffusion assays were applied at Makerere University. Pre-validated semi structured questionnaires aided studying the contamination enablers. Thematic synthesis, descriptive and inferential statistics ( p < 0.05), were used to analyze data, with STATA version-15. Bacterial (167 isolates), representing eleven species were obtained from 41.2% of samples (mainly from jerricans), mostly Escherichia coli ( N = 47, 28.1%), and Klebsiella spp ( N = 34, 20.4%). Over 59 (49.2%) of isolates were resistant to at least one high-powered drug; 34% were multi-drug resistant. E. coli showed highest resistance to Cefoxitin (48%), K. pneumoniae to Ceftazidime (28%), and Salmonella spp to Nalidixic acid (70%). Contamination enablers emerged in seven themes, the largest being type of water source ( N = 11), and sociodemographic ( N = 7). Hence, this water is largely unsafe, and some of these bacteria are associated with persistent epidemics, including typhoid fever in Eastern Uganda, warranting concerted efforts to avert the burden. Keywords: Water, Contamination, Diarrheal bacteria, Antibiotic resistance, Mbale city, Eastern Uganda Subject terms: Diseases, Health care, Microbiology Introduction Diarrheal diseases are associated with devastating clinical complications such as dehydration, malnutrition, and death in individuals of all ages 1 . These diseases pose a significant public health challenge, with an estimated 1.7 billion cases that result in a half a million global deaths each year 2 . The resource-poor settings are more affected 3 . For example, in sub-Saharan Africa (SSA), diarrhea due to poor Water, Sanitation and Hygiene (WASH) practices causes 368,000 annual deaths, constituting 73.6% of the global diarrheal mortality burden 4 . Though diarrheal diseases can be caused by waterborne pathogens, including viruses, fungi and parasites, which contaminate drinking water sources 5 , the bacteria are often more implicated 6 . Access to clean water that is free of such pathogens is a basic human right 7 . However, one-sixth of the world’s population lacks access to clean drinking water 8 . According to Murphy et al., (2017), half of this population comes from sub-Saharan Africa. This largely explains the high prevalence of WASH related diarrheal pathogens in SSA, especially bacteria, including Salmonella spp, Klebsiella pneumoniae , Escherichia coli , and Pseudomonas aeruginosa among others 9 , 10 . In Uganda, the prevalence of diarrheal diseases is 20%, and the total deaths attributed to bacterial diarrhea increased from 5.0% in 2015 to 6.4% in 2023 11 . This places Uganda in the top ten most burdened countries in SSA, and the 27th worldwide 11 . Similar trends have been observed in Mbale city, which is the largest urban setting in Eastern Ugandan 12 . At present, one of the mounting threats that are reported to exacerbate infectious diseases is antimicrobial resistance (AMR). The AMR is the ability of bacteria, viruses, fungi, and parasites to survive exposure to antibiotics that previously would kill them or inhibit their growth 13 . The AMR renders effective treatment challenging or unattainable. Some of the key consequences include higher healthcare expenses, extended hospital stays, and increased morbidity and mortality rates 14 . The AMR results in more than 700,000 deaths annually on a global scale, and the situation continues to worsen rapidly all over the world 15 . The extensive use of antibiotics, especially due to improper prescriptions, mostly in African countries like Uganda, has made antibiotic resistance (ABR) a leading form of AMR 16 . The burden of antibiotic resistance is already alarming in certain waterborne diarrheal bacteria, including Staphylococcus aureus , Escherichia coli , Salmonella spp., Acinetobacter baumannii , and Klebsiella pneumoniae among others 17 , 18 . The contamination of water sources with drug-resistant bacteria is an alarming issue that has been documented in Africa and various parts of the world 15 , 19 , 20 . In East African urban settings including Mbale city in Eastern Uganda, the risk of waterborne bacterial infections is heightened due to infrastructural challenges, and escalation of environmental pollution linked to urban industrial dynamics 21 . Emerging evidence indicates that water sources contaminated with drug-resistant bacteria might contribute significantly to the burden of infectious diseases in Eastern Uganda where Mbale city is located 21 – 24 . Particularly, outbreaks of diarrheal illnesses caused by drug-resistant waterborne bacterial strains including Salmonella spp, Escherichia coli , Klebsiella pneumoniae , and Staphylococcus aureus are increasing taking place in most parts of Eastern Uganda including Mbale city 12 , 25 . These waterborne bacterial strains are resistant to common affordable antibiotics, which makes the treatment more difficult and costly. The factors promoting the contamination of household drinking water that potentially intensifies the outbreaks of diarrheal illnesses caused by drug-resistant waterborne bacterial strains in Mbale city, are poorly understood, but socioeconomic difficulties, poor sanitation, and inadequate water supply infrastructure are some of the escalators that have been implicated in related urban and peri-urban settings 26 . Interventions such as institutionalization of water supply services have been adopted in some households in this city, but the contamination challenge still persists. Besides, emerging evidence shows that water sources in urban and peri-urban areas are particularly more susceptible to contamination due to high population densities and inadequate infrastructure, but there is a paucity of essential data specific to Mbale city. This necessitates focused research to understand the local dynamics of bacterial contamination of water, the associated antibiotic resistance burden, and the contamination-enablers to support the way forward. Therefore, this research examined the drug-resistant bacterial contamination of water that humans in homesteads in Mbale city consume and the factors promoting this contamination. The rationale was to identify which types of the water sources and reservoirs such as shallow wells, boreholes, and taps are considerably laden with drug resistant diarrheal waterborne bacteria and the factors contributing to the spread of these pathogens into the water sources. The results purge the evidence gaps, thereby supporting sustainable de-escalation of the burden. Materials and methods Study design Mixed methods approach was used. A Laboratory-based descriptive experimental survey was used to obtain microbiological data. A cross-sectional survey was used to collect data on the factors associated with microbial contamination of the water in homesteads in Mbale city between August 2024 and June 2025. Description of the study sites Homesteads and the sources where water for domestic consumption is fetched, in Mbale city, were the sites of the study. Mbale city is located in Eastern Uganda, approximately 222 kilometers northeast of Kampala, the oldest and capital city of Uganda (Fig. 1 ). Mbale city is situated at an average elevation of 8,000 feet above sea level, at the coordinates: 1°04’50.0"N, 34°10’30.0"E (14.175000 latitude, 1.080556 longitude), and covers 2435 hectares of land. The city lies around 57 kilometers (35”), North-East of mountain Elgon, at the base of Mount Elgon’s Wanale Ridge, along the railway line that connects Tororo to Pakwach 27 . Fig. 1. Open in a new tab Map showing the study sites. Study population and sampling The study units were the homesteads in Mbale city. The sample size, n , was calculated using the formula previously described by 28 . P = Prevalence of lack of access to safe water in Uganda. The prevalence in this case is 83% or 0.83 ( https://water.org/ , 2023). Z = Standard normal deviate corresponding to the critical region α. At 5% precision, Z = 1.96. d = Desired precision. Thus, the minimum required sample size is 220 homesteads. From each homestead, one respondent (household head), was recruited making a total of 220 participants. In the case where the household head was unable to participate, any willing adult present in the home were adopted as the respondent. To obtain the sample size of 220 homesteads, simple random sampling was used to select 22 homesteads from each of the 10 administrative units found in the three municipal divisions (Northern, Wanale, and Industrial Divisions) of Mbale city. The 10 administrative units are; Northern division, Nakaloke town council, and Namanyonyi-, Namabasa-, Nakaloke-, Bukonde sub-counties (in Bunghokho Division), and Bugema-Nauyo town council, Industrial division, plus Bukasakya and Bunghokho-Mutoto sub-counties (in Industrial Division) 29 . Community entry and sampling were done with the guidance of the village health teams (VHTs) and other local leaders. Further, water samples from each homestead and the sources such as boreholes and wells were obtained and delivered to the microbiology research laboratory at Makerere University, School of Biosciences, College of Natural Sciences, for analysis. Data collection methods The data on the factors associated with microbial contamination of water in the households, such socio-demographic variables, knowledge about microbial contaminants, water treatment options used, possible sources of contamination, and the frequency of cleaning the water tanks, roofs, gutters and jerricans was collected with pretested semi structured questionnaires. This was supplemented with observational survey and photography using a high-resolution digital camera 30 . In each of the 220 households, one water sample of 100 ml were collected after subjecting the respondents to the questionnaires. Sterile water collection containers were used to collect samples under aseptic conditions. That is, any external fittings from the tap or Jerrican were removed and the outside of the nozzle of the tap or Jerrican cleaned using Normal saline. Then water was allowed to flow from the reservoir (tap or tank), over the nozzle for 1 min to clean it further. Thereafter, the tap was sterilized by flaming (passing the fire of a burning gas lighter around the tip of the tap for 30 s to kill germs) and left to cool by flowing water for three minutes. Then, with one hand, the sample collection container was held by its bottom while using the other to remove the cover. The container was then gently filled with water and re-capped. Each of the filled specimen containers was assigned a sample identification number written on the sample container with a waterproof marker. The sample was packaged in the ice-filled cool box and transported within eight hours of collection, to the laboratory at Makerere university for evaluation of microbiological parameters. The Microbial contamination of water was determined using already published standard protocols with minimal adjustments, involving serial dilutions, culture on suitable bacterial growth media such as Xylose Lysine Deoxycholate Agar (for Salmonella spp and Shigella spp), Vilate Red Bile Agar (for isolation of E. coli ), Mannitol Salt Agar (for Staphylococcus aureus ), Kings Agar for Pseudomonas aeruginosa ), Bacillus cereus Agar (for Bacillus cereus ), and MacConkey Agar for the other gram negative bacteria 31 , 32 . The bacteria were identified using colony morphology analysis, gram staining, microscopy, and biochemical characterization 33 , 34 . Since water from the taps is expected to be safe because it is principally treated by the Uganda National Water and Sewerage Cooperation, the sources from taps were assessed for confirmed to the internationally permissible bacteriological standards set by World Health Organization 35 . Using the Kirby Bauer disc diffusion method, the drug susceptibility profiles of the bacteria isolated from the water were evaluated against standard antibiotics recommended by Uganda’s Ministry of Health, ensuring a diverse selection of antibiotic classes 36 . To create a standardized inoculum concentration (0.5 McFarland standard), pure colonies of each bacterial isolate grown for 18 to 24 h were emulsified in a 0.85% physiological saline solution. These standard solutions were then spread onto Mueller Hinton agar plates, onto which antibiotic discs were placed. The plates were incubated at 35 °C for 18 to 24 h. The drug susceptibility phenotypes were categorized as Sensitive (S), Intermediate (I), or Resistant (R) based on the diameter of the inhibition zones around each antibiotic disc, in accordance with the breakpoints and guidelines established by the Clinical Laboratory Standards Institute 37 . The antibiotics that were used to test the isolates include Ampicillin (AMP) 10 µg, Amoxicillin-Clavulanate (AMC) 10 µg, Ceftazidime (CAZ) 30 µg, Cefotaxime (CTX) 30 µg, Cefoxitin (FOX) 30 µg, Trimethoprim-Sulfamethoxazole (SXT) 23.5 µg, Aztreonam (ATM) 30 µg, Cefepime (FEP) 30 µg, Amikacin (AK) 30 µg, Nalidixic Acid (NA) 30 µg, Vancomycin (VAN) 30 µg, Gentamicin (CN) 10 µg, Ertapenem (ETP) 10 µg, Meropenem (MEM) 10 µg, and Imipenem (IPM) 10 µg. Quality control Water samples were collected in accordance with established standard microbiological quality protocols 38 . All specimens were labeled with water-resistant markers, transported in ice-packed cool boxes, and analyzed preferably within 12 h of collection, or stored at − 4 °C if immediate analysis was not feasible. The rationale was to avert false negatives that would rather ensue due potential death of the targeted bacterial contaminants prior to specimen processing. Ethical principles outlined in the Declaration of Helsinki were observed 39 . Participation was voluntary, and homestead leaders who declined were not coerced. Data analysis Quantitative data was analyzed by using STATA version 18.0 40 , and presented using tables and graphs. The graphs were plotted using GraphPad® software. Consequently, descriptive statistics such as frequencies and percentages were used to analyze the data, and inferential statistics like Chi-square, were used to deduce the disparities in the distribution of bacterial loads across various independent variables like water source type, general cleanliness and water collection systems among others. Study limitations A single sampling period was considered but this may possibly not have captured microbial variations that may occur in water sources across various seasons. However, to maximize the detection of all the bacterial contaminants in the water under study, the water samples were collected during the rainy season when outbreaks of bacterial diarrheal diseases are most likely to occur 41 . The study could not fully identify all the antibiotic resistance phenotypes present in the bacterial isolates, which could limit the complete understanding of the resistance traits and the development of comprehensive intervention strategies. However, this research prioritized the assessment of the potency of over 10 most essential clinical drugs which the ministry of health of the Republic of Uganda has prescribed for the management of infections caused by the pathogens that were isolated from these water samples 36 , to inform focused redress. Results Sociodemographic characteristics of respondents The majority of the participants were females ( N = 117, 53.2%), while the males were 103 (46.8%). The commonest age group was the middle aged ( N = 192, 87.3%), while the smallest was the elderly ( N = 2, 0.9%). Most of the participants had completed the primary level of education ( N = 66, 30.0%), while those with tertiary education were the fewest. Also, most respondents stated that they do not spend any money on purchasing or treating water ( N = 153, 69.5%), while the minority asserted that they spend > 38,000 Uganda Shillings (10.0 $) per month (Table 1 ). Table 1. Socio-demographic characteristics of the participants ( n = 220). Variable Number (%) Gender Female 117 (53.2%) Male 103 (46.8%) Age (years) 18–24 (Youths) 26 (11.8%) 25–63 (Middle aged) 192 (87.3%) ≥ 64 (Elderly) 02 (0.9%) Nationality Ugandan 220 (100%) Non-Ugandan 0 (0.0%) Marital status Married 138 (62.7%) Single 75 (34.1%) Other 7 (3.2%) City division inhabited Industrial division 73 (33.2%) Wanale division 73 (33.2%) Northern division 74 (33.6%) Level of education attained None 62 (28.2%) Primary level 66 (30.0%) Secondary level 59 (26.8%) Tertiary level 33 (15.0%) Estimated daily income < 7,220 (1.9) (Poverty line) 197 (89.5%) ≥ 7,220 (1.9) 19 (10.5%) Estimated monthly water bill / UGX ($) 0 (0.00) 153 (69.5%) 0 < 38,000 (10.0) 51 (23.2%) > 38,000 (10.0) 16 (7.3%) Years of residence in Mbale city 5 ≤ 10 33 (15.0%) > 10 187 (85.0%) House hold size 1–5 people 86 (39.1%) > 5 people 134 (60.9%) Occupation Formal employment 21 (9.5%) None formal employment 199 (90.5%) Type of water reservoir/source used Open shallow well 77 (35.1%) Piped shallow well 22 (11.4%) Borehole 49 (24.9%) Tap 33 (17.7%) Tank 18 (8.2%) Flowing open channel 21 (2.7%) More than one of the sources above 220 (100%) Open in a new tab Key; UGX: Uganda Shillings, $: United States Dollar, Other: Widowed, Separated. Water bill: Cost of water purchase, water treatment, cleaning of tanks, or repairs. Prevalence of selected medically important diarrheal bacteria in water consumed by humans in homesteads in Mbale city The water used for human consumption in households in Mbale city which was used for bacteriological analysis was obtained from seven major categories of reservoirs which are used in the study community. The laboratory based conventional culture (Tables 2 and 3 ), revealed a total of 167 bacterial isolates from eleven species. These bacteria were found in 107 (41.2%) of the 260 water samples screened. The most prevalent species was Escherichia coli ( N = 47, 28.0%), followed by Staphylococcus aureus ( N = 32, 19.2%), Klebsiella pneumoniae ( N = 29, 17.4%), Pseudomonas aeruginosa ( N = 15, 9.0%), Salmonella spp ( N = 14, 8.4%), Providencia stuartii and Bacteroides spp ( N = 8, 4.8% each). The least prevalent species were Citrobacter spp and Klebsiella spp ( N = 5, 3.0% each), Shigella spp ( N = 3, 1.8%), and Bacillus cereus ( N = 1, 0.6%). The majority of the bacterial isolates were found in Jerricans in homes ( N = 50, 29.9%), followed by 43 (25.7%), 24 (14.4%), 22 (13.2%), and 12 (7.2%), in open channels, open shallow wells, tanks and piped shallow wells respectively. Boreholes ( N = 10, 6.0%) and Taps ( N = 6, 3.6%) had minimal bacterial loads. Table 2. Cellular morphology, gram stain, and biochemical characteristics of representative Gram-negative bacteria isolated from water consumed by humans in households in Mbale city, Eastern Uganda. Isolate ID Bacterial species isolated Culture agar Gram staining, colony shape Biochemical identification TSI H 2 S Citrate Urease Indole MR VP Gas Slant Butt PA06 P. aeruginosa Kings’ media G-, Rods - K NC - + + - - + PA14 P. aeruginosa Kings’ media G-, Rods - K NC - + + - - + KP10 K. pneumoniae MacConkey G-, Rods + A A - + + - - + KP12 K. pneumoniae MacConkey G-, Rods + A A - + + - - + SM03 Salmonella spp XLD G-, Rods - K A - + - - - - SM06 Salmonella spp XLD G-, Rods - K A - + - - - - PS02 Providencia stuartii MacConkey G-, Rods + K A + - + + + - CT01 Citrobacter spp MacConkey G-, Rods - A A - + + + + + EC31 E. coli MacConkey G-, Rods - A A - - - + + - Open in a new tab Key: VP; Voges-Proskauer, H 2 S; Hydrogen sulfide, TSI; Triple Sugar Iron, MR; Methyl Red, K; Red/Alkaline, A: Yellow/Acid, NC; No colour change, G-; Gram-negative, +; Positive, -; Negative, E. coli ; Escherichia coli , P. aeruginosa ; Pseudomonas aeruginosa , K. pneumoniae : Klebsiella pneumoniae , spp; Species, XLD: Xylose-Lysine-Deoxycholate, ID; Identification Number. Table 3. Cellular morphology, gram stain, and biochemical characteristics of representative Gram-positive bacteria isolated from water consumed by humans in households in Mbale city, Eastern Uganda. Isolate ID Bacterial species Isolated Culture media Gram staining, colony shape Biochemical characteristics Catalase DNase MF Coagulase SA21 Staphylococcus aureus Mannitol Salt G+ Cocci in grape-like clusters + + + + SA18 Staphylococcus aureus Mannitol Salt G+ Cocci in grape-like clusters + + + + SA09 Staphylococcus aureus Mannitol Salt G+ Cocci in grape-like clusters + + + + Open in a new tab Key: ID. N o ; Identification Number, G+; gram-positive, +; Positive, S. aureus ; Staphylococcus aureus , MF; Mannitol fermentation. Drug resistance profiles of bacteria such as Escherichia coli , Klebsiella pneumoniae , Salmonella spp , and Staphylococcus aureus isolated from water consumed by humans in the households in Mbale city The Kirby-Bauer Disk Diffusion Susceptibility Test Protocol (Fig. 2 ), conducted on 120 bacterial isolates ( Escherichia coli ; N = 47, Klebsiella pneumoniae ; N = 29, Salmonella spp ; N = 12, and Staphylococcus aureus ; N = 32), revealed that over 59 (49.2%) isolates were resistant to at least one of the standard clinical drugs tested, which are recommended for the management of these pathogens by the 36 . In E. coli , the greatest proportion of the isolates were resistant to Cefoxitin (belonging to 2nd generation cephalosporin class of drugs); 48%, followed by Co-trimoxazole (Sulphur drugs class); 27%, Gentamicin (aminoglycoside class); 25%, and Imipenem (Carbapenem drugs class); 20%. E. coli evoked the least resistance to Ceftazidime (9%) and Cefepime (9%), (3rd and 4th generation cephalosporin drugs classes respectively) (Fig. 3 ). Klebsiella pneumoniae showed the greatest resistance to Ceftazidime (28%) and Amoxicillin+Clavulanic acid (an amoxicillin + β-Lactamase inhibitor class); 29%, and highest susceptibility to meropenem (carbapenem drugs class); 75% (Fig. 3 ). Salmonella spp showed the highest resistance to Nalidixic acid (quinolone drugs class); 70%, and highest sensitivity to Amikacin (aminoglycoside drugs class); 70%. Staphylococcus aureus evoked the greatest resistance to Ampicillin; 25% and the highest sensitivity to Oxacillin; 64% (both belonging to penicillin drug class) (Fig. 4 ). Multiple drug resistance (resistance to at least 3 drugs each belonging to a different class), was observed in 41 (34%) of the bacterial isolates tested. Fig. 2. Open in a new tab Representative images of the laboratory workflow for drug susceptibility testing of bacteria isolated from water consumed by humans in households in Mbale city using the Kirby-Bauer Disk Diffusion Susceptibility Test Protocol. A: The 24 h’s fresh smooth pink colonies of Escherichia coli on MacConkey agar. B: 0.5 McFarland’s standards of bacterial colonies in test tubes. C: Sterile Mueller Hinton Agar (MHA). D: Cartridges of Antibacterial Susceptivity Test Drug-discs procured from Oxoid Ltd-United Kingdom. Blue arrow represents the incubation of inoculated MHA plates with drugs, at 37 °C for 24 h. E: Standard cultures of Klebsiella pneumoniae NCTC 13,809 procured from Kenya Medical Research Institute, used to quality control the drugs in this study. NCTC: National Collection of Type Cultures. Drug resistant isolates on MHA for-F: E. coli , G: Pseudomonas aeruginosa , H: Staphylococcus aureus . Small or lack of clearance zone around a drug disc shows that the isolate is resistant to the drug. Fig. 3. Open in a new tab Drug susceptibility profiles of Escherichia coli and Klebsiella pneumoniae isolated from water consumed by humans in households in Mbale city. IMP: Imipenem, ETP: Ertapenem, MEM: Meropenem, FEP: Cefepime, CTX: Ceftriaxone, CAZ: Ceftazidime, CFX: Cefoxitin, AMC: Amoxicillin+Clavulanic acid, ATM: Aztreonam, SXT: Co-trimoxazole, CN: Gentamycin, MBM: Monobactams, AGS: Aminoglycosides, SD: Sulphur Drugs, AMBLI: Amoxicillin + β-Lactamase inhibitor, 2nd GC: Second Generation Cephalosporin, 3rd GC: Third Generation Cephalosporin, 4th GC: Fourth Generation Cephalosporin. Fig. 4. Open in a new tab Drug susceptibility profiles of Salmonella spp and Staphylococcus aureus isolated from water consumed by humans in households in Mbale city. IMP: Imipenem, ETP: Ertapenem, MEM: Meropenem, FEP: Cefepime, CTX: Ceftriaxone, CAZ: Ceftazidime, AMC: Amoxicillin+Clavulanic acid, AMK: Amikacin, SXT: Co-trimoxazole, NA: Nalidixic acid, CN: Gentamycin, CFZ: Cefazolin, AMP: Ampicillin, MET: Methicillin, VAN: Vancomycin, OXA: Oxacillin, CHL: Chloramphenicol, PEN: Penicillins, GPD: Glycopeptide, AGS: Aminoglycosides, QLN: Quinolones, SD: Sulphur Drugs, AMBLI: Amoxicillin + β-Lactamase inhibitor, 3rd GC: Third Generation Cephalosporin, 4th GC: Fourth Generation Cephalosporin, 1st GC: First Generation Cephalosporin. Factors enabling the bacterial contamination of water consumed by humans in the households in Mbale city A thematic synthesis identified seven categories (themes) among the factors that potentially enable the bacterial contamination of water consumed by humans in households in Mbale city. These included socio-demographic characteristics of the participants, hygiene factors, and the nature of the water sources among others (Fig. 5 ). Most of the factors were in line with the nature of the water source or reservoir ( N = 11). These were followed by the sociodemographic in stature ( N = 7), and the policy environment ( N = 6) among others (Fig. 5 ). Fig. 5. Open in a new tab Factors enabling the bacterial contamination of water consumed by humans in the households in Mbale city. WASH: Water, Hygiene and Sanitation. NGOs: Nongovernmental Organizations. NWSC: National Water and Sewerage Cooperation. There was a significant predominance of grossly contaminated hence unacceptable water samples among the respondents with the following demographic profiles; below the poverty line ( N = 109, 59.2%; χ 2 = 5.991, 95%CI = 3.71% to 32.0%, p = 0.0144), lacking training in Water, Sanitation and Hygiene (WASH) ( N = 178, 96.7%; χ 2 = 84.738, 95%CI = 53.62% to 97.02%, p < 0.0001), having inadequate awareness about bacterial contamination of water and the associated hazards ( N = 119, 64.7%; χ 2 = 14.564, 95%CI = 14.33% to 42.6%, p = 0.0001). Concerning to the water storage practices and the treatment patterns, there was widespread observation of water stored in homes in Jerricans without being tightly covered hence posing contaminations risks (Fig. 6 ; C). Also, the fact that the majority of the respondents asserted that they do not spend any money on water related matters (such as payment of water bills or purchase of water treatment drugs) ( N = 153, 69.5%), and the widespread dependency on multiple sources of the water ( N = 220, 100%) could all possibly promote the observed contamination. Further, the fact that water samples from taps (supplied by the Uganda government’s National Water and Sewerage Cooperation), were predominantly free of unacceptable microbial loads could implicate the other water sources (where water is to treated before supply), in the escalation of the contamination burden. Fig. 6. Open in a new tab Representative images of the water storage and treatment, suppliers’ factors, and the policy environment, that may have a bearing on the bacterial contamination of water consumed by humans in households in Mbale city. A and B: Jerricans dumped on the ground where humans step their feet and shoes (red arrow). These Jerricans are later fastened on ropes and dipped into the wells to draw the water with potential to introduce contaminants therein. Red circle shows water that spills on the surface of the well where people step their feet, then it flows back into the well. C: Water stored in Jerricans remaining uncovered. D: Chlorine dispenser. E: Borehole and shallow well with labels of the concerned boreholes. Regarding supplier factors, water attained through Uganda National Water and Sewerage Cooperation supply chain was the safest with more than 80.0% of the samples meeting the desired international bacterial quality standards. There was also the presence of some dilapidated water sources and Jerricans indicting poor repair and maintenance practices, posing potential contamination risks. Also, there was widespread unhygienic handling of the water supply equipment at the source, with some being abandoned on the dirty ground and others placed at the same spot with peoples’ feet and/or shoes, posing a porous platform for the transmission of microbial pathogens into the water (Fig. 6 : A and B). About the policy environment, this research found that there exists a regulatory institution called the Uganda Ministry of Water and Environment (MWE), which is a national body with the possibility of promoting and ensuring the rational, sustainable utilization, development, and effective management of water and environmental resources (Uganda Ministry of Water and Environment (MWE), 2024). This ministry partners with organizations such as the National Water and Sewerage Corporation (NWSC), National Forestry Authority (NFA) and National Environment Management Authority (NEMA), to fulfill its water responsibilities. Besides the regulatory institutions, this study found out that a regulatory instrument for water quality management existed, called the Uganda Institutional Framework for Water Safety and Supply 42 . Despite the evident presence of regulatory institutions and instruments, this research revealed the absence of the necessary, effective water quality inspection and capacity building. For example, all the respondents ( N = 220, 100%), reported the enormous scarcity of water sources’ inspection and other essential activities such as water safety awareness programs in communities by the responsible regulatory institutions. Nonetheless, there was a rare presence of Non-governmental Organizations (NGOs), such as Africa Relief Project and Community Development, which construct some communal shallow wells and bore holes, sometimes installing chlorine dispensers at boreholes (Fig. 6 : D, E, F). The 18 (75%), of these chlorine dispensers were found to be empty (without the chlorine solution), while three (12.5%) were broken and nonfunctional. Hygiene concerns were observed in 221 (85.0%) out of the 260 water sources and reservoirs involved in this research. These ranged from the observable poor hygiene and sanitation of the individuals who draw the water and therefore directly interface with the water in these water sources, to the hygiene of the roofs, rain water gutters, and water tanks, and the surrounding environment, among others (Fig. 7 ), highlighting microbial contamination risks. Fig. 7. Open in a new tab Representative images of the hygiene factors potentially enabling the bacterial contamination of water consumed by humans in households in Mbale city. A: Dirty top of a tank where water drains to enter the tank. B: Dirty water gutter which collects the water to enter the tank. C: Dirty Jerrican. D: Dirty inside lining of a Jerrican. E: Waste laden environment around the borehole. F: Dirty Jerrican tapping water from the dirty borehole. As far as contamination in the different water source types or reservoirs is concerned, of the 167 bacteria that were isolated such as Escherichia coli Klebsiella spp and Staphylococcus aureus , the majority of these bacteria were found in samples drawn from Jerricans ( N = 50, 29.9%%), and these were significantly greater than those got from open channels ( N = 43, 25.7%, χ 2 = 0.200, 95%CI = -14.06% to 21.61%, p = 0.6545), Open shallow well ( N = 24, 14.4%, χ 2 = 2.057, 95%CI = -6.26% to 31.94%, p = 0.1515), tanks ( N = 22, 13.2%, χ 2 = 2.253, 95%CI = -5.74% to 32.96%, p = 0.1333), Piped shallow wells ( N = 12, 7.2%, χ 2 = 2.582, 95%CI = -6.23% to 37.72%, p = 0.1081), bore holes ( N = 10, 6.0%, χ 2 = 2.438, 95%CI = -7.72% to 38.62%, p = 0.1184), and taps ( N = 6, 3.6%, χ 2 = 1.843, 95%CI = -14.81% to 40.47%, p = 0.0401). This would imply that all the water sources except the taps have a comparable potential to harbor a considerable amount of these pathogens. Other potential source-related enablers of the contamination included the unsuitable depth (where some open shallow wells were < 12 feet deep), and the lack of a built lining in the inner wall of the well (Fig. 8 ). Fig. 8. Open in a new tab Representative images for some of the environmental factors potentiating the bacterial contamination of water consumed by humans in households in Mbale city. A: Is a housefly on a dirty Jerrican (red arrow). B: Common frog in an open shallow well (blue arrow). C: Toilet 8.0 m from the shallow well (yellow arrow). D: Polyethene waste dropped in a 13.5ft shallow well (black arrow). About the environmental factors, the existence of some water sources in the low-lying areas and in densely populated swamps raised concerns of a high-water table, which provides a suitable platform for the spilling of microbial pathogens from nearby manure in gardens, and garbage, toilets (Fig. 8 ), into the shallow water sources. There was also a worrying observation of some arthropod and amphibian vectors of microbial pathogens immersed in the water sources and/or on the Jerrican surfaces (Fig. 8 ). The arthropod vector was identified as Musca domestica (the common housefly), while the amphibian was the common frog. Discussion This study identified a total of 167 bacterial isolates from 107 (41.2%) of the 260 samples, encompassing eleven different bacterial species. This significant diversity in bacterial species underscores the complexity and multifaceted nature of water contamination concerns in Mbale city. The most prevalent bacterial species identified was Escherichia coli ( N = 47, 28.1%). The high prevalence of E. coli is a well-known indicator of fecal contamination and poses a significant health risk due to its potential to cause severe gastrointestinal diseases 43 , 44 . This finding aligns with numerous studies that have highlighted the presence of E. coli as a primary concern in water quality assessments, particularly in settings with inadequate sanitation and waste management practices 45 – 47 . Klebsiella spp ( N = 34, 20.4%) and Staphylococcus aureus ( N = 32, 19.2%) were the next most common isolates. Klebsiell a spp are often associated with various severe clinical diseases, including diarrhea, pneumonia, urinary tract infections, and septicemia, making their presence in drinking water particularly alarming 48 . Staphylococcus aureus , known for its role in skin infections and respiratory diseases, further emphasizes the health risks posed by contaminated water 49 , 50 . The presence of other bacterial species in the water examined in the current study, such as Bacillus cereus and Acinetobacter spp ( N = 1, 0.6% each), although minimal, cannot be overlooked. Bacillus cereus is known for causing foodborne illnesses, and Acinetobacter spp are increasingly recognized for their role in hospital-acquired infections and antibiotic resistance 51 , 52 . The detection of these bacteria therefore, even in small numbers, suggests potential routes for graver contamination and health threats. The majority of bacterial isolates were found in water samples drawn from jerricans used for water storage in homes. This is a critical finding, as it highlights the role of storage practices in exacerbating water contamination. Jerricans, if not properly cleaned and maintained, can become breeding grounds hence replication hubs for bacteria, leading to high microbial loads in the water therein. This finding is consistent with other research that has demonstrated the risks associated with inadequate water storage practices 53 – 55 . In contrast, water samples from taps showed the least bacterial contamination. This suggests that water supplied through regulated systems, such as those managed by national institutions like the Uganda National Water and Sewerage Corporation (UNWSC), undergoes generally effective treatment processes that significantly reduce bacterial loads. This underscores the importance of centralized water treatment and distribution systems in ensuring safe drinking water. In the current study, the few isolates of E. coli ( N = 4, 2.4%) and Salmonella spp ( N = 2, 1.2%), that were identified in chlorinated tap water could highlight the mounting reports of the global emergence of chlorine resistance especially in gram-negative bacterial pathogens like E. coli , Enterobacter spp, Citrobacter spp, Salmonella spp, and Klebsiella spp among others 56 , 57 . This underscores the need to implement the additional use of other water disinfection strategies besides chlorine alone, such as filtration, and electrochemical oxidation among others 58 , 59 . The presence of pathogenic bacteria such as Salmonella spp in tap water also calls for the effective boiling of this water before human and animal consumption. Altogether, the presence of pathogenic bacteria like E. coli , Klebsiella spp, Staphylococcus aureus and Salmonella spp in drinking water poses serious public health risks. These bacteria can cause a range of severe clinical diseases, from gastrointestinal infections to respiratory and urinary tract infections, particularly in vulnerable populations such as children, the elderly, and those with compromised immune systems 60 – 63 . Therefore, this study’s findings underscore the urgent need for interventions to improve water quality and prevent waterborne diseases, for example through improving water storage practices, enhancing sanitation infrastructure, promoting safe water sources, and regular monitoring. The findings revealed that 49.2% of the isolates exhibited resistance to at least one of the standard clinical drugs tested. This high prevalence of antimicrobial resistance (AMR) underscores the urgent need for effective antibiotic stewardship and robust surveillance programs to manage the escalating threat of AMR. Among the E. coli isolates, the highest resistance was observed to Cefoxitin (48%), a second-generation cephalosporin. This high resistance rate indicates the possible prevalence of β-lactamase-producing E. coli , which can hydrolyze cephalosporin drugs 64 . Co-trimoxazole, a combination of sulfamethoxazole and trimethoprim, showed a 27% resistance rate, aligning with global trends of increasing resistance to sulfa drugs due to their widespread use 65 , 66 . Resistance to Gentamicin, an aminoglycoside, was found in 25% of the isolates, reflecting the adaptability of E. coli to diverse antibiotic pressures. Imipenem, a carbapenem, exhibited a 20% resistance rate, which is concerning given its status as a last-resort antibiotic for multidrug-resistant infections 67 . Notably, the lowest resistance rates were seen with third and fourth-generation cephalosporins, Ceftazidime and Cefepime (both 9%), suggesting their continued efficacy against E. coli infections in Mbale city. The Klebsiella pneumoniae isolates demonstrated significant resistance to Ceftazidime (28%) and Amoxicillin+Clavulanic acid (29%). The resistance to Amoxicillin+Clavulanic acid, a combination of a penicillin and a β-lactamase inhibitor, indicates the possible presence of extended-spectrum β-lactamases (ESBLs) in these isolates 68 , 69 . Conversely, the highest susceptibility was observed to Meropenem, a carbapenem, with a 75% sensitivity rate, suggesting that carbapenems remain an effective treatment option for Klebsiella pneumoniae infections that may arise from the consumption of contaminated water in this city. Salmonella spp. showed an alarming 70% resistance to Nalidixic acid, a first-generation quinolone, highlighting the reduced efficacy of this drug. However, these isolates displayed high sensitivity to Amikacin (70%), an aminoglycoside, suggesting that aminoglycosides could be a reliable alternative for treating Salmonella infections in this setting. Staphylococcus aureus isolates exhibited the greatest resistance to Ampicillin (25%), a penicillin drug type, which is consistent with the global challenge of penicillin-resistant Staphylococcus aureus strains 70 , 71 . The highest sensitivity was noted for Oxacillin (64%), another penicillin-class antibiotic, indicating its potential utility in treating Staphylococcus aureus infections in Mbale city. The study revealed that 34% of the bacterial isolates demonstrated multiple drug resistance (MDR), defined as resistance to at least three drugs, each belonging to a different class. This finding is particularly worrying as MDR organisms complicate treatment regimens, increase healthcare costs, and are associated with higher morbidity and mortality rates 13 , 14 , 72 . Therefore, there is urgent need for the establishment of optimal interventions to mitigate the spread of resistant strains. Such interventions may include rationalizing antibiotic use in both clinical and agricultural settings to reduce selective pressure, implementing continuous monitoring of resistance patterns in both clinical settings and the environment to inform empirical treatment guidelines and detect emerging resistance trends, supporting the development of new antibiotics and alternative therapies such as bacteriophages, antimicrobial peptides, herbal products among others to combat resistant pathogens. Also, increasing awareness about the prudent use of antibiotics among healthcare providers and the general public, to prevent misuse and overuse is warranted. Subsequently, it is essential to elucidate whether the contaminant bacteria isolated in this study attained the resistance traits within the water, or before contaminating the water, for example when they were still circulating in the human and/or the veterinary healthcare value chains. In the past few decades, global evidence implicating environmental reservoirs like soil and water resources, as genetic reactors where microbial pathogens may evolve resistance against essential clinical drugs has been mounting 65 , 73 – 76 . Moreover, surface water acts as the final collector for all the environmental pharmaceutical molecules that may induce drug resistance in critical human pathogens like Salmonella spp, Klebsiella pneumoniae , Acinetobacter spp and Escherichia coli among others 73 . As such, the current study provides vital insights into the up-to-date AMR landscape in Mbale city which is the largest city in Eastern Uganda, and underscores the need for a coordinated, multi-faceted/one health approach to address this escalating public health crisis. Individuals living below the poverty line had a significantly higher prevalence of grossly contaminated water samples ( p = 0.0144). This may suggest that economic constraints can limit access to clean water and effective water treatment options. In alignment with this, previous reports have reported that economic deprivation often limits the ability to afford safe water and necessary water treatment solutions, increasing reliance on unsafe water sources 77 , 78 . Lack of training in Water, Sanitation, and Hygiene (WASH) emerged as a major factor, with an overwhelming majority of respondents without WASH training experiencing higher contamination rates ( p < 0.0001). Similarly, inadequate awareness about bacterial contamination and its hazards was significantly associated with higher contamination levels ( p = 0.0001). These findings underscore the importance of educational initiatives to improve water quality awareness and practices. Interestingly, no significant differences were observed in the prevalence of contaminated water samples based on education levels, gender, or city division. This suggests that while some sociodemographic factors are influential, others may not be as critical in determining water contamination levels. The study found widespread improper water storage practices, such as storing water in jerricans without tight covers, which pose contamination risks. Additionally, a significant number of respondents reported not spending money on water-related matters ( N = 153, 69.5%), which likely contributes to the prevalence of untreated water. The reliance on multiple water sources ( N = 220, 100%) further complicates the issue, as inconsistent water quality from different sources can increase the risk of contamination 79 , 80 . Notably, water samples from taps supplied by the Uganda National Water and Sewerage Corporation (NWSC) were predominantly free from unacceptable microbial loads, implicating other water sources in the contamination burden. This highlights the importance of reliable and well-maintained water supply systems. Water supplied through the NWSC was the safest, with over 80.0% of samples meeting international quality standards for hazardous bacterial loading. However, issues such as dilapidated water sources and poorly maintained jerricans were found to potentially pose significant contamination risks. Further, unhygienic handling of water supply equipment, including placing containers on dirty ground or near feet and shoes, could explain the observed high contamination levels in sources such as open shallow wells and channels. These findings point to the need for improved maintenance and hygiene practices at water sources. The regulatory framework for water quality management in Uganda involves several institutions, including the Ministry of Water and Environment (MWE), NWSC, National Forestry Authority (NFA), and National Environment Management Authority (NEMA). Despite the presence of these regulatory bodies and frameworks such as the Uganda Institutional Framework for Water Safety and Supply 42 , the current study identified significant gaps in water quality inspection and capacity building. That is to say, all respondents ( N = 220, 100%) reported a scarcity of water source inspections and water safety awareness programs. While NGOs such as Africa Relief Project and Community Development contribute to constructing communal wells and installing chlorine dispensers, the effectiveness of these interventions is limited by issues such as empty or broken dispensers. This underscores the need for more robust and sustained efforts in water quality management and community education. This research has revealed a significant hygiene crisis affecting water quality, with 85.0% of the water sources and reservoirs displaying notable hygiene concerns. These findings underscore the complicated nature of the problem and highlight several critical areas that contribute to microbial contamination risks. The hygiene and sanitation practices of individuals who draw water from these sources are paramount. Observable poor hygiene among these individuals directly interfaces with water, facilitating the introduction of pathogens 81 . Contaminated hands, clothing, or containers can significantly compromise water quality during the collection process 38 . This issue is compounded by the lack of proper training and awareness regarding hygienic water handling practices 82 . Previous studies have similarly found that human interaction with water sources is a critical vector for contamination, emphasizing the need for comprehensive WASH (Water, Sanitation, and Hygiene) training programs to educate communities on safe water handling practices 83 , 84 . The research observed poor hygiene conditions in the roofs, rainwater gutters, and water tanks. Dirty roofs and gutters can introduce contaminants into rainwater harvesting systems, while unclean water tanks can harbor and propagate microbial pathogens. These findings align with earlier studies that have identified the cleanliness of water collection and storage infrastructure as crucial determinants of water quality. Regular cleaning and maintenance of these structures are essential to prevent contamination 85 , 86 . Also, the surrounding environment of the water sources plays a critical role in water quality. The current study found that many water sources were located in areas with poor environmental hygiene, including unclean surroundings and the presence of contaminants such as toilets and solid waste heaps near water collection points. This environmental neglect facilitates the entry of pathogens into water sources, significantly increasing the risk of waterborne diseases. Previous research has similarly highlighted the importance of maintaining clean environments around water sources to prevent contamination 87 , 88 . The findings of this study on the bacterial contamination of various water sources in Mbale city provide critical insights into the microbial quality and safety of household water. The isolation of 167 bacterial strains, including Escherichia coli , Klebsiella spp., and Staphylococcus aureus , from different water sources underscores the grave nature of contamination and highlights the need for targeted interventions to improve water safety. The distribution of bacterial isolates across different water sources reveals significant variations in contamination levels. The highest number of bacterial isolates were found in samples drawn from jerricans ( N = 50, 29.9%), significantly higher compared to other sources such as open channels, open shallow wells, tanks, piped shallow wells, boreholes, and taps. This distribution indicates that jerricans, as a primary water storage method, are particularly susceptible to contamination. The statistical analysis (χ2) showed no significant differences in contamination levels between jerricans and open channels (χ2 = 0.200, p = 0.6545), open shallow wells (χ2 = 2.057, p = 0.1515), tanks (χ2 = 2.253, p = 0.1333), piped shallow wells (χ2 = 2.582, p = 0.1081), and boreholes (χ2 = 2.438, p = 0.1184). The only significant difference was observed between jerricans and taps (χ2 = 1.843, p = 0.0401), suggesting that tap water is generally safer compared to other sources. These findings imply that most water sources, except for taps, have a comparable potential to harbor significant amounts of pathogens. This highlights the urgent need for improved water handling and storage practices, especially concerning jerricans, which are widely used but prone to contamination. With regards to the structure of the water source, several factors were identified to potentially contribute to the contamination of water sources in Mbale city. One considerable enabler among these is the unsuitable depth of some open shallow wells, with some being less than 13.5 feet (4.1 m) deep. Shallow wells are more vulnerable to contamination from surface runoff and nearby pollution sources due to their proximity to the surface. To avert this contamination, WHO recommends a depth of 5 m to 20 m for a hund dug shallow well in average water table depth 89 . When a well is less than 7 m deep, it is called and shallow well. It is called a deep well if greater than 7 m deep (Food and Agriculture Organization (FAO), 2022). Additionally, the lack of a built lining in the inner walls of wells facilitates the entry of contaminants from the soil through seepage. This study also identified environmental factors that potentially underpin the observed microbial contamination. The location of water sources in low-lying areas and densely populated swamps poses significant risks. These areas are characterized by a high-water table, which facilitates the movement of microbial pathogens from nearby sources of contamination, such as manure in gardens, garbage, and toilets, into shallow water sources. This observation is consistent with previous studies that have highlighted the risks associated with water sources located in areas prone to surface runoff and high levels of human activity 91 , 92 . Moreover, the presence of arthropod and amphibian vectors, such as Musca domestica (the common housefly) and common frogs, in and around water sources further contributes to microbial contamination. These vectors can introduce and spread pathogens, significantly compromising water quality. Addressing these issues requires a multifaceted approach, including the implementation of better water storage practices, infrastructure improvements, and environmental management. Public health interventions should focus on educating communities about safe water handling and storage, as well as enhancing the maintenance and protection of water sources. Policymakers and water management authorities need to prioritize these interventions to ensure the provision of safe and clean water to households in Mbale city. The high prevalence of hygiene concerns in Mbale city’s water sources and reservoirs highlights a critical area of intervention to improve water quality. Addressing the hygiene of individuals, infrastructure, and the surrounding environment is essential to reduce microbial contamination risks. By implementing targeted educational programs, infrastructure maintenance routines, and environmental management strategies, and by strengthening regulatory oversight, it is possible to significantly improve the safety and quality of water consumed by households in Mbale city. Conclusion The study presents a novel report of a high prevalence of bacterial contaminants which are highly resistant to conventional medicines in household drinking water from domestic sources such as boreholes and wells. This points to a potential treatment failure when the contaminants get involved in clinical diseases. The factors enabling this contamination are multifaceted, hence the desired interventions to avert this threat owe to be concerted across government and non-government stakeholders. Acknowledgements We wish to thank the office of the Resident City Commissioner (RCC) of Mbale City, which authorized conducting of this study. We also thank the Village Health Teams and Village Local Council leaders who supported the research team during field data collection. We gladly acknowledge the assistance of Emmanuel Tumwebaze of Makerere University in conducting the laboratory experiments. Abbreviations NWSC National Water and Sewerage Cooperation RHRW Roof-Harvested Rain Water (RHRW) SSA Sub-Saharan Africa UBOS Uganda Bureau of Statistics UTI Urinary Tract Infection VHTs Village Health Teams WASH Water Sanitation and Hygiene WHO World Health Organization Author contributions AW and ASE conceived the research idea, and were involved in field data collection and manuscript writing. Then JES, NN, AK, ASO, AMO, and SL were involved in data collection, data analysis and manuscript writing. HMK was the overall supervisor and administrator, and was involved in manuscript writing. All the authors proofread and approved the final draft of the manuscript. Funding This study did not receive a financial grant. Data availability All data generated and analyzed during this study are included in the article. Competing interests The authors declare no competing interests. Ethical approval This research was conducted in conformity to the national guidelines for the conduct of research in the post COVID-19 pandemic era, set by Uganda National Council for Science and Technology 93 . The study sought ethical approval from the Research Ethics Committee of Islamic University in Uganda (Ref. IUIUREC-2024-69). Written informed consent to participate in this study was obtained in writing from the study participants. The chairpersons of the Village Local Councils, and the Mbale District Health Officer (DHO) granted their approval for community entry and research conduct. Consent for publication Consent to publish the findings of this study was obtained in writing from the study participants. Footnotes Publisher’s note Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations. References 1. Getachew, Z. et al. 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