Water, sanitation, hygiene

& environmental health

Pete Kolsky
Energy and Water Department

Outline

Some facts about water, san and

health
Historical evolution
Classification by transmission
The Literature of impact studies
The nature of the problem
Conclusions for practitioners

Some water, sanitation

and health numbers

Faecal-oral (focus of this presentation)

Diarrhoeal disease

2 million deaths/year from diarrhoea, mostly under 5

Jumbo jet crash every hour and a half

One billion cases/year

4.3% of Burden of Disease DALYs
88% (?) attributable to inadequate WSH

1/3 of developing world popn carry intestinal worms

200 million infected by schistosomiasis (bilharzia)

6-9 million blind from trachoma (1/4 reduced

by adequate water supply)

Natural chemical hazards

Arsenic

Skin lesions, various cancers

20 to 60 million exposed in Bangladesh
Major problem other parts of S. Asia, also
Argentina, Chile, China, Hungary, Mexico, Peru

Fluorosis

Dental damage, crippling bone damage

affects millions (WHO) but often of mild form

Historical evolution: water

quality and health

John Snow

Cholera
Broad Street Pump 1854
Water Companies' Studies
William Budd Typhoid in 1850's-60's
Koch
Cholera
vs. Pettenkoffer
Hamburg/Altona 1892
1937 Croydon Typhoid
And many more

Characteristics of these
(and other) waterborne
outbreaks
True outbreakssudden spikes

1.

Common sourcethe water supply

2.

3.

Very visible and dramatic!!

Politically hot!
If youre a water engineeryou dont want one on
your watch!
Cholera is the water engineers best friend
Money for chlorine suddenly becomes available

Until 1970s, water quality dominated

environmental health perception of diarrhoea

Classifications of disease

Classification usually by organism

(viral, bacterial, etc) or organ
(diseases of head, heart, liver etc.)
Classification by transmission route

Bradleys great innovation in 1970s

If you know how its spread, you know
how to stop it
so engineers loved it!

The F-Diagramme
Water
supply
Sanitatio
n

Faece
s

Fluid
s
Finger
s
Flies

Fields/
Floors

Hygien
e

Food

Future
Victim

The great debates of the 80s

Water-borne or water-washed?
Is water quality or water quantity more important?
Review of epi in 83 revealed fundamental challenges
Blum, D. and R. Feachem, Int J Epidemiol 1983, 12, pp. 357-365

Lack of control

One-to-one (clustreing)

Confounding variables (inc. age)

Recall

Diarrhoeal definition

Usage

Seasonality
These issues are real, and are still grave threats to quick and dirty project
level impact assessments!!

Results from Esrey, 1985

Type of
Intervention

No of
Results

Median
Reduction

Range

All interventions

53

22

0-100

Water quality

16

0-90

Water availability

17

25

0-100

Water quality
and availability

37

0-82

Excreta disposal

10

22

0-48

(Esrey, S.A. et al., WHO Bull, 63(4): 757-772, 1985)

Esrey (1985) by disease

Disease or
infection

No of
results

Median
reduction

Cholera

11

41

Shigella

27

48

Entamoeba
histolytica

17

Giardia
lamblia

10

Rang
e
0-91
0-81
0-80
0-20

Esreys update in 1991

Intervention
Esrey et al., WHO Bull, 69(5): 609-621 (1991)

Rigorous
All Studies
Studies
No Med
No Med
%
%
reduc
reduc
t
t
7

20

30

Sanitation

11

22

36

Water Quality and Quantity

22

16

17

Water Quality

17

15

Water Quantity

27

20

Hygiene

33

33

Water & San

2004 Fewtrell, Colford

update

Why do more?

More studies
Statistically rigorous meta-analysis
HH water treatment new player

Water, sanitation and Hygiene: Interventions and diarrhoea A

systematic review and meta-analysis, Lorna Fewtrell and John M.
Colford, Jr. HNP Discussion Paper, World Bank 2004.
Water, sanitation, and hygiene interventions to reduce
diarrhoea in less developed countries: a systematic review
and meta-analysis, L. Fewtrell, R. Kaufmann, et al. Lancet Infectious
Diseases, Vol 5, pp 42-52. Jan 2005.

Some of the main results

Multiple interventions
Hygiene (good studies)
Sanitation
Water House Conn (good studies)
HH treatment (good studies)

No
studies
5
8
2
1
8

%
reduction
33
45
32
38
39

lower
24
25
13
35
19

Above are highlights

Strong, detailed report and bibliography, and
documentation of approach

upper
41
60
47
41
54

Previous reviews:

ad

Esrey SA et al. (1991) Bull WHO 69 (5): 609-621

Curtis V, Cairncross S (2003) Lancet Inf Dis 3: 275-281.

Taken from S. Cairncross RWSSTG BBL The Health

Impact of Sanitation, Aug 2004.

Major new conclusions from

Fewtrell, Colford, Kaufmann

Water quality at HH is shown as

significant

further reviews forthcomingsome skeptics

remain

Hygiene is reconfirmed as an effective

intervention
Combining interventions does not appear
to have synergistic effect, contrary to
popular public health belief

A step back from all of

this

We dont live in an average world

Mountains of Peru are different from slums of

South Asia
e.g. soil and food contamination risks higher
in China, Vietnam than in Africa

Briscoe (Briscoe, J., Am J Epidemiol

1984;120:449-55) sheds even more light in a
non-linear world

If disease incidence not linearly proportional to

transmission, then impact attribution easily skewed

The F-diagramme revisited

Water
supply
Sanitatio
n

Faece
s

Fluid
s
Finger
s
Flies

Fields/
Floors

Hygien
e

Food

Future
Victim

How people see their city

River &
Environs
City

Home

Peri- Ward
domestic
(street,
school,
workplace)

An environmental view
Home
Peridomestic

(street,school,

Ward

workplace)

City

Central Treatment
Works
Collectors
Street
Sewers
House
Connections

A public health view

Sewer Mains

River &
Environs

Street Sewer

City
Interceptor/
Collector

Treatment
Plant/Outfall

Home

Peri- Ward
domestic
House
Connection

Take home messages

Diarrhoea is a huge problem in child health

Water, sanitation and hygiene can reduce diarrhoea between
25-50%
Very broad consensus that:

Focus on the household

Hygiene matters!
Water quality matters, but its not just water quality
faecal contamination gets around many ways
Sanitation, WS infrastructure can make hygiene possible!

Health studies are toughlive with indicators rather than

health outcome
HH water treatment continues to be a growing focus of
attentionperhaps even more relevant for chem. contam.

Thank you for your

attention!