Water, sanitation, hygiene and enteric infections in children

Water, sanitation, hygiene and enteric infections in children. Arch Dis Child doi:10.1136/archdischild-2011-301528

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Joe Brown, Sandy Cairncross, Jeroen H J Ensink
Correspondence info: Dr Jeroen H J Ensink, Environmental Health Group, Faculty of Infectious and Tropical Diseases, London School of Hygiene and Tropical Medicine, Keppel Street, London WC1E 7HT, UK; Jeroen.ensink@lshtm.ac.uk

In this article, we review the evidence linking WSH measures to faecal-oral diseases in children. Although continued research is needed, existing evidence from the last 150 years supports extending life-saving WSH measures to at-risk populations worldwide. One recent estimate held that 95% of diarrhoeal deaths in children under 5 years of age could be prevented by 2025, at a cost of US$6.715 billion, through targeted scale-up of proven, cost-effective, life-saving interventions. These include access to safe and accessible excreta disposal, support for basic hygiene practices such as hand washing with soap, and provision of a safe and reliable water supply. We present estimates of the burden of WSH-related disease followed by brief overviews of water, sanitation and hygiene-related transmission routes and control measures. We conclude with a summary of current international targets and progress.

Diarrhoea, malnutrition and environmental enteropathy
Although great strides have been made in reducing diarrhoea mortality, especially as a result of the increased use of oral rehydration therapy (ORT), diarrhoea remains the second leading cause of death in children under 5 years of age, after pneumonia. It is responsible for an estimated 1.7 billion cases of diarrhoea, or on average 2.9 episodes/child/year, and an estimated 1.87 million deaths among children under 5 years of age.The highest burden of disease is in children in the age range of 6–11 months: 4.5 episodes/child/year. It has been estimated that 50% of diarrhoea deaths can be attributed to persistent diarrhoea,7 and while ORT can prevent many deaths from acute diarrhoeal diseases,8 access to appropriate treatment is often limited in resource-poor settings.

The relationship between diarrhoeal disease and malnutrition is complex, though it is well accepted that malnourished children suffer more frequent episodes of diarrhoeal disease, while a child’s nutritional status is affected following a diarrhoeal episode. A multiple country study found that 25% of stunting in children aged 24 months could be attributable to five or more diarrhoeal episodes experienced in the first 2 years of life. Malnutrition and stunting can lead to poorer school performance, early school drop-out and, as a result, lower economic well-being in later life. Over 440 million school days are missed annually due to WSH-related illnesses. Extended exposure to faecal pathogens may, in part, cause environmental enteropathy, a postulated condition characterised by malabsorption, villus atrophy, crypt hyperplasia, T-cell infiltration and general inflammation of the jejunum. This chronic infection of the small intestine could explain why sanitation may have a stronger association with gains in growth than with reductions in diarrhoea incidence.

Extra Food Means Nothing to Stunted Kids With Bad Water

Extra Food Means Nothing to Stunted Kids With Bad Water: Health | Source: Adi Narayan, Bloomberg-Jun 12, 2013 |

Aameena Mohammed gives her 20-month-old daughter Daslim Banu plenty to eat. The girl’s mother supplements breast milk with eggs, soup and rice to help her grow. The extra food doesn’t help. Daslim still weighs only as much as a healthy infant half her age.

Mohammed’s home, in one of the poorest districts of the south Indian city of Vellore, is among the 65 percent of India’s homes without running water and safe sewage disposal. Feces and urine collect next to the doorway in an open drain — the source of odor permeating the tin-roofed shack and of the microbes likely retarding the toddler’s growth.

Polluted water runs through a sewer in the Dharavi slum area of Mumbai, India. Only 26 percent of the 6 billion gallons of sewage generated daily in India is treated.

Scientists increasingly suspect that constant exposure to bacteria, virus and parasite-laden fecal contaminants may be frustrating attempts to end malnutrition. In effect, the best diet-based measures to fight chronic hunger in the developing world are being negated by a failure to meet basic human needs: clean water and sanitation.

The problem exists not just in India. A quarter of children indeveloping countries are underweight, and malnutrition is the root cause of the deaths of more than 2 million children annually, according to the United Nations Children’s Fund inNew York. Worldwide, 870 million people are chronically hungry, almost all of them in developing countries.

George Washington University Study Documents Variability in Changes to Open Defecation among Sub-Saharan African Countries

Exploring changes in open defecation prevalence in sub-Saharan Africa based on national level indices

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About 215 million people in sub-Saharan Africa still defecate in fields, forests or out in the open, a practice that puts people and especially children at risk of diarrheal diseases. Public health experts are calling for an end to such practices by the year 2015 in order to protect the public health.

A new analysis by researchers at the George Washington University School of Public Health and Health Services (SPHHS) looks at how well countries in sub-Saharan Africa are doing when it comes to putting in basic sanitation facilities that would reduce this risky practice.

Jay Graham, PhD, MBA, MPH, an assistant professor of global environmental health at SPHHS and his co-authors looked at data on open defecation in 34 sub-Saharan African countries and estimated any changes in prevalence from 2005 through 2010. Deise Galan, MPH, was the lead author of the study and conducted much of the data analysis as part of her MPH thesis.

The authors found that only three countries were successful in reducing open defecation by 10 percent or more during the study’s time frame. And only one country, Angola, is on track to end the practice by the target date of 2015, according to the authors.

The authors also examined factors that might speed progress, finding that overseas development assistance might help low income sub-Saharan countries defray the cost of putting in place improved sanitation such as pit latrines or basic toilets. Additional research must be done to find other factors that might assist countries in meeting the public health goal of reducing open defecation, Graham and his colleagues said.

Community-Led Total Sanitation in East Asia and Pacific: Progress, Lessons and Directions

Community-Led Total Sanitation in East Asia and Pacific: Progress, Lessons and Directions, 2013. 

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UNICEF, Plan, WaterAid and Water and Sanitation Program (WSP).

Community-Led Total Sanitation (CLTS) is a community-wide behaviour change approach to stop open defecation which has been practiced by an estimated 100 million people in this region. Various organizations (i.e. Plan International, UNICEF, WaterAid, Water and Sanitation Program (WSP), Institute of Development Studies (IDS) and the CLTS Foundation, are supporting implementation across 12 countries in the East Asia and Pacific region; more then 50 UNICEF Country Offices across Asia, Africa and Latin America are now supporting implementation of Community Approaches to Total Sanitation.

The publication provides an up-to-date summary of CLTS status, lessons and experiences from the region, and highlights some of the key areas that require further attention and better quality uptake of CLTS at country level, and as such guide in accelerating efforts for reaching open defecation free (ODF) status and overall sanitation and hygiene improvements at scale.

Evaluating the potential of microfinance for sanitation in India

Evaluating the potential of microfinance for sanitation in India, 2013.

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Sophie Trémolet, T V S Ravi Kumar. SHARE. 

This case study investigates how household financing for sanitation can be mobilised via microfinance institutions and commercial banks in order to accelerate sustainable access to sanitation facilities and/or services. The research (conducted in India between May and June 2011) sought to document existing experiences in providing microfinance services to households to allow them to invest in sanitation solutions that meet their needs. The objective of the research was to map out the existing provision of microfinance for sanitation, identify where opportunities for future market development lie and identify how the development of such a market could be fostered (through the targeted use of public funds or regulatory changes for example).

This research has identified that there is potentially high demand for sanitation microfinance in India, due to a combination of factors. Coverage rates remain low (particularly in rural areas) and national policies emphasise household investments (combined with subsidies in some cases, such as in the Total Sanitation Campaign which provide ex-post subsidies once the household has made the investment, hence the need for pre-financing). By 2010, only 31% of India’s population had access to improved sanitation facilities (WHO/UNICEF, 2010).

Evaluating the potential of microfinance for sanitation in Tanzania

Evaluating the potential of microfinance for sanitation in Tanzania, 2013.

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Sophie Trémolet, George Muruka. SHARE.

The objectives of the case study are to investigate how household financing for sanitation can be mobilised via microfinance institutions, community banks and mass market commercial banks in order to accelerate sustainable access to sanitation facilities and/or services. 

The research conducted in Tanzania is exploratory in nature. It seeks to map out the existing provision of microfinance for sanitation, to identify where opportunities for future market development lie and to identify how the development of such a market could be fostered (through the targeted use of public funds or regulatory changes for example). The case  study in Tanzania will feed into broader research about how donors can channel financing
for water and sanitation to small-scale actors.

WASHplus Weekly on WASH-Related Diseases

This issue contains recent studies and resources on several WASH-related diseases: cholera, dengue, diarrhea, leptospirosis, neglected tropical diseases, malnutrition, and typhoid. Included are a just-published UNICEF cholera toolkit, an updated review of WASH-related diseases from DfID, typhoid case studies from Bangladesh and Fiji, and other resources. 

The Centers for Disease Control and Prevention suggested the topic for this issue, and we welcome other suggestions for topics. Future issues will focus on menstrual hygiene management, innovation, water point mapping, mobile applications, and WASH in schools; more than 100 past issues of the Weekly are archived on the WASHplus website.

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Sanitation innovator Peter Morgan named 2013 Stockholm Water Prize Laureate

Dr. Peter Morgan has been named the 2013 Stockholm Water Prize Laureate for his work to protect the health and lives of millions of people through improved sanitation and water technologies. | Source: Stockholm International Water Institute |

H.M. King Carl XVI Gustaf of Sweden will present the prize to Dr. Morgan at a Royal Award Ceremony during the 2013 World Water Week in Stockholm on September 5.

Over the past four decades, Dr. Morgan has invented and advanced low-cost practical solutions to provide access to safe sanitation and clean water that are being used by millions of people worldwide.

“Many currently existing solutions to provide clean water and sanitation are unaffordable, impractical and out of reach for the world’s poorest people,” said the Stockholm Water Prize Committee in its citation. “As a result of Dr. Morgan’s pioneering work to develop practical water and sanitation technologies for those most in need, countless communities now enjoy safer water, a cleaner environment and quality of life.”

More than 780 million people live without access to safe water and 2.5 billion people lack access to adequate sanitation. Diseases caused by unsafe water, sanitation, and hygiene kill more than 5,000 people each day.

Upon receiving the news, Dr. Morgan said: “Great strides have been made to bring safe water and sanitation to people around the world, yet countless millions are currently still denied access. This prestigious award encourages me to carry on to play my part to improve the conservation and supply of this most precious resource – water – and provide more people with access to clean sanitation.”

New Global Study Pinpoints Main Causes of Childhood Diarrheal Diseases

New Global Study Pinpoints Main Causes of Childhood Diarrheal Diseases, Suggests Effective Solutions

A new international study published today in The Lancet provides the clearest picture yet of the impact and most common causes of diarrheal diseases, the second leading killer of young children globally, after pneumonia. The Global Enteric Multicenter Study (GEMS) is the largest study ever conducted on diarrheal diseases in developing countries, enrolling more than 20,000 children from seven sites across Asia and Africa.

GEMS, coordinated by the University of Maryland School of Medicine’s Center for Vaccine Development, confirmed rotavirus – for which a vaccine already exists – as the leading cause of diarrheal diseases among infants and identified other top causes for which additional research is urgently needed. GEMS found that approximately one in five children under the age of two suffer from moderate-to-severe diarrhea (MSD) each year, which increased children’s risk of death 8.5-fold and led to stunted growth over a two-month follow-up period.

Developing and Monitoring Protocol for the Elimination of Open Defecation

Developing and Monitoring Protocol for the Elimination of Open Defecation in Sub-Saharan Africa, 2013.  UNICEF.

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Eliminating open defecation is increasingly seen as a key health outcome, with links to reduced stunting, improved educational and positive health outcomes for children. In Sub Saharan Africa, over 35 countries are implementing some form of CLTS, ranging from TATS in Tanzania to CLTSH in Ethiopia. Since the introduction of CLTS in 2005 in the region, rapid scale-up has been achieved with suggested numbers of ODF communities in the range of 30,000 affecting over 15 million people in SubSaharan Africa. Several countries have set aggressive targets for elimination of Open Defecation in rural areas for the next five years which often include not only safe disposal of faeces but handwashing facilities, cleanliness and solid waste management.

Sustaining the progress made through the application of the CLTS process is emerging as a challenge with experience suggesting that sustainability is determined by the process followed to achieve ODF. Rapid scale up in SSA is arguably linked to the fact that CLTS is based on the concept of triggering community-wide behaviour change, requires no subsidies and integrates easily into existing health programming structures. Current focus is on ‘triggering’ communities into action; while considerably less resources and emphasis on following up and mentoring of communities ‘post-triggering’.

This paper reviews process and protocol for defining, reporting, declaring, certifying ODF and sustaining ODF, highlighting where the process varies between countries and potential determinants of sustainability within the process itself. Critical questions include what elements (should) constitute an ODF protocol, what are the determinants of sustainability and what impact does target-setting have on achievement of ODF goals in country?