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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 pop’n 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
1. True outbreaks…sudden spikes
 Very visible and dramatic!!
 Politically hot!
2. Common source…the water supply
 If you’re a water engineer…you don’t want one on
your watch!
 Cholera is the water engineer’s best friend…Money for
chlorine suddenly becomes available…
3. 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
 Bradley’s great innovation in 1970s
 If you know how it’s spread, you know how
to stop it…
 …so engineers loved it!
The F-Diagramme
Water supply

Sanitation Fluids Hygiene

Fingers
Faeces Food Future
Victim
Flies

Fields/
Floors
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 No of Median Range
Intervention Results Reduction
All interventions 53 22 0-100
Water quality 9 16 0-90
Water availability 17 25 0-100
Water quality 8 37 0-82
and availability
Excreta disposal 10 22 0-48

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


Esrey (1985) by disease

Disease or No of Median Range


infection results reduction
Cholera 11 41 0-91
Shigella 27 48 0-81
Entamoeba 17 2 0-80
histolytica
Giardia 10 0 0-20
lamblia
Esrey’s update in 1991
Rigorous
All Studies Studies
No Med % No Med %
Intervention reduct reduct
Esrey et al., WHO Bull, 69(5): 609-621 (1991)

Water & San 7 20 2 30


Sanitation 11 22 5 36
Water Quality and Quantity 22 16 2 17
Water Quality 7 17 4 15
Water Quantity 7 27 5 20
Hygiene 6 33 6 33
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
No %
studies reduction lower upper
Multiple interventions 5 33 24 41
Hygiene (good studies) 8 45 25 60
Sanitation 2 32 13 47
Water House Conn (good studies) 1 38 35 41
HH treatment (good studies) 8 39 19 54

•Above are highlights…


• Strong, detailed report and bibliography, and
documentation of approach
Previous reviews:

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


e 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 forthcoming…some 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 don’t 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

Sanitation Fluids Hygiene

Fingers
Faeces Food Future
Victim
Flies

Fields/
Floors
How people see their city
River &
Environs
City
Peri- Ward
domestic
Home
(street,
school,

work-
place)
An environmental view
Home

Peri-
domestic (street,school,

Ward workplace)

City

Central Treatment
Works

Collectors

Street
Sewers
House
Connections
A public health view
Street Sewer River &
Sewer Mains Environs
City
Peri- Ward
Interceptor/ domestic
Collector Home
House
Connection

Treatment
Plant/Outfall
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 it’s not “just” water quality…faecal
contamination gets around many ways
 Sanitation, WS infrastructure can make hygiene possible!
 Health studies are tough…live with indicators rather than “health
outcome”
 HH water treatment continues to be a growing focus of attention…
perhaps even more relevant for chem. contam.
Thank you for your attention!

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