Category Archives: Sanitation and Health

Shared Sanitation versus Individual Household Latrines: A Systematic Review of Health Outcomes

Shared Sanitation versus Individual Household Latrines: A Systematic Review of Health Outcomes. PLoS One, April 2014.

Authors: Marieke Heijnen, Oliver Cumming, Rachel Peletz, Gabrielle Ka-Seen Chan, Joe Brown, Kelly Baker, Thomas Clasen.

Background: More than 761 million people rely on shared sanitation facilities. These have historically been excluded from international sanitation targets, regardless of the service level, due to concerns about acceptability, hygiene and access. In connection with a proposed change in such policy, we undertook this review to identify and summarize existing evidence that compares health outcomes associated with shared sanitation versus individual household latrines.

Methods and Findings: Shared sanitation included any type of facilities intended for the containment of human faeces and used by more than one household, but excluded public facilities. Health outcomes included diarrhoea, helminth infections, enteric fevers, other faecal-oral diseases, trachoma and adverse maternal or birth outcomes. Studies were included regardless of design, location, language or publication status. Studies were assessed for methodological quality using the STROBE guidelines. Twenty-two studies conducted in 21 countries met the inclusion criteria. Studies show a pattern of increased risk of adverse health outcomes associated with shared sanitation compared to individual household latrines. A meta-analysis of 12 studies reporting on diarrhoea found increased odds of disease associated with reliance on shared sanitation (odds ratio (OR) 1.44, 95% CI: 1.18–1.76).

Conclusion: Evidence to date does not support a change of existing policy of excluding shared sanitation from the definition of improved sanitation used in international monitoring and targets. However, such evidence is limited, does not adequately address likely confounding, and does not identify potentially important distinctions among types of shared facilities. As reliance on shared sanitation is increasing, further research is necessary to determine the circumstances, if any, under which shared sanitation can offer a safe, appropriate and acceptable alternative to individual household latrines.

THE URBAN PROGRAMMING GUIDE: How to design and implement a pro-poor urban WASH programme

Improving water, sanitation and hygiene services to low-income urban areas is a highly challenging and complex task. Traditional approaches have often failed to work. We need new approaches and fresh thinking. We need governments, donors and sector professionals genuinely committed to improving services in slum settlements. It’s challenging but it can be done! This guide offers some solutions based around WSUP’s experience: all you have to do is put them into practice!

The guide provides an introduction to urban WASH programming: how to design and implement a pro-poor urban water, sanitation and hygiene programme.

Urban Programming Guide
Who is this guide for?
This guide is primarily designed for WASH professionals working in governments, development agencies, funding agencies or civil society organisations. It will also be useful for professionals working for service providers including water utilities, local authorities and in the private sector.

How to use this guide
The guide provides an overview of some key strategies and service delivery models. It’s not intended to be encyclopaedic: it’s a rapid-reference document with the following intended uses:

  • To aid the planning, design and implementation of urban WASH programmes.
  • To assist with investment planning by service providers.
  • To point the reader towards further sources of information and guidance.

The guide is free to download from WSUP’s website:

WASHplus – WASH/Nutrition Literature Update – March 2014

WASH/Nutrition Literature Update – March 2014

The March 2014 literature update includes details on an upcoming USAID-sponsored WASH nutrition presentation on April 1, 2014, and the March 2014 issue of USAID’s Global Waters magazine with descriptions of USAID WASH and nutrition efforts in Liberia and other countries. Other resources include a 2014 WHO report on childhood stunting, an award winning poster on food hygiene, an enteropathy study in Zimbabwe, and other resources.


April 1, 2014 – Integrating WASH and Nutrition: Current Approaches, Lessons Learned, and Considerations for Future Programming, a presentation by Francis Ngure, Water and Sanitation Program.  Date: Tuesday, April 1, 2014 | Time:  3-4:30 pm | Place: USAID, Room 4.08 E/F, Ronald Reagan Bldg. (RSVP/additional info)
You are invited to a presentation on current strategic and operational approaches linking WASH and nutrition programming based on an investigation conducted by the World Bank Water and Sanitation Program. The session will include preliminary findings and lessons learned from field examples that will inform future programming.


WASH Benefits Study/Bangladesh & Kenya - (Website)
The WASH Benefits Study will provide rigorous evidence on the health and developmental benefits of water quality, sanitation, hand washing, and nutritional interventions during the first years of life. The study includes two cluster-randomized controlled trials to measure the impact of intervention among newborn infants in rural Bangladesh and Kenya. Both will be large in scope and measure primary outcomes after two years of intervention.

Stunting Is Characterized by Chronic Inflammation in Zimbabwean Infants.  PLoS One, Feb 2014. A Prendergas. (Link)
Stunting began in utero and was associated with low maternal IGF-1 levels at birth. Inflammatory markers were higher in cases than controls from 6 weeks of age and were associated with lower levels of IGF-1 throughout infancy. Higher levels of CRP and AGP during infancy were associated with stunting. These findings suggest that an extensive enteropathy occurs during infancy and that low-grade chronic inflammation may impair infant growth.

Could Poor Sanitation Begin Stunting Children in Utero? 2014. D Spears. (Blog post)
Evidence is building up that enteropathy may matter a great deal.  Andrew Prendergast and nine coauthors published a new paper in PLoS One: “Stunting Is Characterized by Chronic Inflammation in Zimbabwean Infants.”  They collected data on about 14,000 infants at periodic intervals in their first 18 months of life. They ended up with a sample of 101 stunted infants—meaning too short—and 101 non-stunted infants in order to have a healthy comparison group. The paper is important because it speaks to the hypothesis of enteropathy as a determinant of stunting among poor children who grow up exposed to intestinal disease.

Water, Sanitation, and the Prevention of Stunting:  An Holistic View of Why Food Isn’t Enough, 2014. J Griffiths. (Presentation)
Poor populations will likely eat aflatoxins in foods; many will have environmental  enteropathy and live without good water or sanitation. Lacking WASH and barriers to fecal contamination, they will have a different spectrum of gut bacteria than people with good WASH.

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Editorial – The elusive effect of water and sanitation on the global burden of disease

Editorial – The elusive effect of water and sanitation on the global burden of disease. Tropical Medicine and  International Health, Feb 2014.

by  Wolf-Peter Schmidt, Department of Disease Control, Faculty of Infectious and Tropical Diseases, London School of Hygiene and Tropical Medicine, Keppel St, London WC1E 7HT, UK. Tel.: +44-20-7636 8636, E-mail:

About 2.5 billion people lack access to improved sanitation, and 1 billion have no access to any form of sanitation (UNICEF 2013). About 780 million people lack access to an improved water source, a figure that is based on a fairly generous definition incorporating little with respect to reliability, proximity and convenience of access (UNICEF 2013).

While the ancient Romans may already have been aware of it (Bradley 2012), water and sanitation came to be regarded as key to improve health in the growing cities of Europe and America in the late 19th and early 20th centuries. A number of notable observational studies were carried out that even with the limited epidemiological tools available at the time all but proved the direct link between water, sanitation and health (Snow 1860; Pringle 1910). By contrast, in the early days of development aid in the post-colonial era, water and sanitation were often not regarded as a health issue, but primarily provided with the aim of making people’s life easier and enable developmental activities. Whoever tried to argue for more investment on health grounds was faced by a lack of epidemiological studies conducted in low-income settings, which led to a renewed interest in research from the 1970s.

Simple before/after and case-control studies to evaluate water and sanitation programmes
The studies on water and sanitation conducted in low-income settings since the 1970s were usually simple in design (Rubenstein et al.1969; Aziz et al1990; Zhang et al20002005; Azurin & Alvero 2007). Typically, a programme to improve water access would be implemented in one or two villages, with latrine construction and some form of hygiene education being provided at the same time. Disease (for example diarrhoea, schistosomiasis or soil-transmitted helminths) would be measured at baseline and then again after the intervention. A couple of not too distant villages with ‘similar socio-economic conditions’ would have been followed up as a control group. Allocation of the intervention was unlikely to be random. Villages might have received the intervention because they had many diseases or were the poorest in the region. They might have been chosen for having been the least or the most accessible, the politically most influential or the most neglected. The commonly small number of allocated villages enabled a close supervision of the intervention, assuring that everything was carried out according to plan. However, the within-village (‘-cluster’) correlation of disease meant that statistically not much could be made of any difference between intervention and control arm if there were <5 or 6 villages on either side. Accounting for the baseline levels of disease allowed strengthening the causal inference (Norman & Schmidt 2011), but only to some extent. Larger, randomised studies were deemed unfeasible given the logistical and engineering complexities involved, and the low budgets available at the time.

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Child Feces Disposal Practices in Rural Orissa: A Cross Sectional Study

Child Feces Disposal Practices in Rural Orissa: A Cross Sectional Study. PLoS One, Feb 2014.

Fiona Majorin, et al

Background – An estimated 2.5 billion people worldwide lack access to improved sanitation facilities. While large-scale programs in some countries have increased latrine coverage, they sometimes fail to ensure optimal latrine use, including the safe disposal of child feces, a significant source of exposure to fecal pathogens. We undertook a cross-sectional study to explore fecal disposal practices among children in rural Orissa, India in villages where the Government of India’s Total Sanitation Campaign had been implemented at least three years prior to the study.

Methods and Findings – We conducted surveys with heads of 136 households with 145 children under 5 years of age in 20 villages. We describe defecation and feces disposal practices and explore associations between safe disposal and risk factors. Respondents reported that children commonly defecated on the ground, either inside the household (57.5%) for pre-ambulatory children or around the compound (55.2%) for ambulatory children. Twenty percent of pre-ambulatory children used potties and nappies; the same percentage of ambulatory children defecated in a latrine. While 78.6% of study children came from 106 households with a latrine, less than a quarter (22.8%) reported using them for disposal of child feces. Most child feces were deposited with other household waste, both for pre-ambulatory (67.5%) and ambulatory (58.1%) children. After restricting the analysis to households owning a latrine, the use of a nappy or potty was associated with safe disposal of feces (OR 6.72, 95%CI 1.02–44.38) though due to small sample size the regression could not adjust for confounders.

Conclusions – In the area surveyed, the Total Sanitation Campaign has not led to high levels of safe disposal of child feces. Further research is needed to identify the actual scope of this potential gap in programming, the health risk presented and interventions to minimize any adverse effect.

WASHplus Weekly: Focus on WASH-related disesases

Issue 135 February 21, 2014 | Focus on WASH-Related Diseases

This issue contains recent studies and reports on several WASH-related diseases: neglected tropical diseases (NTDs), malnutrition, cholera, diarrhea, fluorosis, and malaria. Some of the resources include: a WASH and NTDs global manual and country reports from the Sightsavers Innovation Fund; an article on the origins of the cholera outbreak in Haiti; a review of evidence linking WASH, anemia, and child growth; Cochrane Reviews on the prevention and control of malaria; and additional studies and resources. weekly

We welcome your suggestions for future issues of the Weekly. Topics for upcoming issues include World Water Day 2014, WASH and nutrition, behavior change, community-led total sanitation, household water treatment, and menstrual hygiene management.


Human Health and the Water Environment: Using the DPSEEA Framework to Identify the Driving Forces of DiseaseScience of the Total Environment, 2014. J Gentry-Shields.(Link)

There is a growing awareness of global forces that threaten human health via the water environment. A better understanding of the dynamic between human health and the water environment would enable prediction of the significant driving forces and effective strategies for coping with or preventing them. This report details the use of the Driving Force–Pressure–State–Exposure–Effect–Action (DPSEEA) framework to explore the linkage between water-related diseases and their significant driving forces.

Seasonal Effects of Water Quality: The Hidden Costs of the Green Revolution to Infant and Child Health in India, 2013. E Brainerd. (Link)
This paper examines the impact of fertilizer agrichemicals in water on infant and child health using water quality data combined with data on child health outcomes from the Demographic and Health Surveys of India. The results indicate that children exposed to higher concentrations of agrichemicals during their first month experience worse health outcomes on a variety of measures; these effects are largest among the most vulnerable groups, particularly the children of uneducated poor women living in rural India.

Water, Sanitation and Hygiene: Evidence Paper, 2013. Department for International Development. (Link)
This paper aims to provide an accessible guide to existing evidence, including a conceptual framework for understanding how WASH impacts health and well-being and a description of methods used for ascertaining the health, economic, and social impacts of WASH. It also presents the available evidence on the benefits and cost-effectiveness of WASH interventions.


WASH and the Neglected Tropical Diseases: A Global Manual for WASH Implementers, 2014. Sightsavers, et al. (Link) | (Blog post)
These manuals are free to download and distribute. New users must create an account to download the manuals, which are divided into disease-specific chapters that describe the transmission cycle, symptoms, and disease burden of the WASH-related NTDs. Each chapter includes information about WASH activities that are most essential to the control of each disease. Maps of disease prevalence are provided to enable identification of disease-endemic communities most in need of sustainable WASH services. Country-specific versions of the manual are available so far for Brazil, Burkina Faso, Cameroon, Chad, Ethiopia, Indonesia, Kenya, Malawi, Mali, Mozambique, Nigeria, Sudan, Tanzania, and Uganda.

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Jan 2014 – WASH/Nutrition Literature Updates

WASH/Nutrition Literature Update – January 2014

This update contains recent studies and reports on WASH and nutrition issues plus updates on new publications and resources from members of the USAID Community of Practice on WASH and Nutrition. Please contact WASHplus if you have new publications or upcoming events you would like to feature in the February 2014 update. Most of the studies below can also be found on the WASH/Nutrition Library at:

UPDATES FROM COP MEMBERS – New Publications, Upcoming Events, etc.

Alive & Thrive - Ensuring Adequate Nutrient IntakeInsight, Issue 7, 2013.  (Link)
This issue examines why infants require a much higher quality diet than other members of the household, identifies nutrient gaps in typical complementary food diets, and describes strategies for achieving adequate nutrient intake among children 6-24 months old.

FANTA III - Nutrition Assessment, Counseling, and Support (NACS): A User’s Guide, 2013. (Link)
The NACS User’s Guide is a series of modules that provide program managers and implementers with a package of essential information and resources. These modules are living documents and will be updated as appropriate when new evidence, guidelines, or field experience emerges.

London School of Hygiene & Tropical Medicine (LSHTM) - Water, Sanitation and Hygiene (WASH), Nutrition and Infection: Learning Module Update(Link)
The latest evidence from a Cochrane systematic review found a small but significant improvement in the growth of children under the age of 5 who have access to clean water and soap. Analysis of the data from 14 studies conducted in low and middle income countries suggested that interventions to improve the quality of the water in the household and provide soap resulted in an average 0.5 cm increased height growth in children under the age of 5.

USAID SPRING Project - The Nigeria Community and Facility Infant and Young Child Feeding Package, 2013. (Link)
This Infant and Young Child Feeding Package is a necessary tool to ensure uniform training and information sharing throughout Nigeria.


USAID DRAFT Agency-wide Nutrition Strategy [public comment sought], December, 2013. (Link)
A technical working group, comprising individuals across USAID, has developed a draft nutrition strategy and is seeking public comment.

Cyclosporiasis: An Emerging Potential Threat for Water Contamination. Water and Health 2014. H Ahmad. (Abstract)
Cyclospora cayetanensis is an emerging protozoan parasite that causes small intestine gastroenteritis. There is apparently a worldwide distribution, including regions of endemicity, for example, in Nepal, Haiti, and Peru. Due to the lack of a quantification technique, there is limited information on the prevalence of Cyclospora in water environments, necessitating the need for further research on pathways and transmission dynamics and encouraging innovative research in water treatment for improving sanitation and public health.

Public Health and Social Benefits of At-House Water Supplies, 2013. (Link)
B Evans et al.
The headline conclusion from this research is that at-home water supply has significant, measurable benefits when compared with shared water supply outside the home provided that the service is reliable enough to ensure access to adequate quantities of water when required. Reliable at-home water supply results in higher volumes of water consumption, greater practice of key hygiene behaviors, a reduction in musculoskeletal impacts associated with carrying water from outside the home, and improved water quality.

Sanitation and Externalities: Evidence from Early Childhood Health in Rural India, 2014. The World Bank. (Link)
This paper examines two sources of benefits related to sanitation infrastructure access on early childhood health: a direct benefit a household receives when moving from open to fixed-point defecation or from unimproved sanitation to improved sanitation, and an external benefit (externality) produced by the neighborhood’s access to sanitation infrastructure.

Social Protection and Resilient Food Systems: The Role of Cash Transfers, 2013. Overseas Development Institute. (Link)
If linked to education and awareness-raising, cash transfer programs can improve water and sanitation hygiene practices.

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WASHplus Weekly: Focus on Inclusive WASH

Issue 127 December 20, 2013 | Focus on Inclusive WASH

Many thanks to Shamila Jansz from WaterAid who contributed many of the reports, training materials, etc. to this issue on inclusive water, sanitation, and hygiene (WASH). The resources fall under the following categories: fact sheets, stories from the field, training resources, reports, journal articles, conference papers, and websites. Reports and videos from Ethiopia, Kenya, Mali, Nepal, Uganda, and other countries are also included.

If you haven’t done so already, the WASHplus Knowledge Management (KM) team would appreciate your comments and suggestions about WASHplus KM services. The link to the KM survey is


Briefing Note on WASH and People with Disabilities and Leprosy, 2013. WaterAid/Ethiopia. (Link)
Using case studies from a WaterAid/Ethiopia-supported project, this briefing note discusses the links between WASH and disability and leprosy.

Factsheet: WASH and HIV, 2013. WaterAid; StopAIDS Coalition. (Link)
This fact sheet sets out to explain the connection between WASH and HIV and AIDS, and provides recommendations on how HIV interventions can integrate WASH into their programming.

Inclusive WASH Development: Technology Adaptations for Persons with Disabilities, 2013. N Kamban. (Link)
It is the objective of this briefing paper to describe the findings, recommendations, and guidelines for inclusive WASH development gleaned from experience with the Africa WASH & Disabilities Study.


A Difficult Journey to Toilet, 2013. WaterAid/Nepal. (Video)
In Nepal more than 500,000 people live with disability. This video tells the story of the 350,000 disabled who do not have access to toilets. For example, in Kathmandu, no public toilets are designated disabled-friendly.

Kenya: Four Stories from the Field, 2013. WASHplus.
String, Jug, & a Bucket | Community Volunteers | Simple Actions | Innovative Solution |
WASHplus is helping communities in Kenya make the connection between healthy hygiene habits and improved sanitation and positive outcomes for people living with HIV and AIDs and their families.

Undoing Inequity: Inclusive Water, Sanitation and Hygiene Programmes that Deliver for All, 2013. WaterAid; SHARE. (Video)
This video discusses the cost of inclusive WASH service delivery in Uganda. A SHARE-funded WaterAid project reaches out to all community members who struggle to use standard WASH facilities—persons with disability, the elderly, and the chronically ill— in hopes of moving them up the sanitation ladder along with the rest of their neighbors.

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Improved Sanitation and Its Impact on Children: An Exploration of Sanergy

Improved Sanitation and Its Impact on Children: An Exploration of Sanergy. Impact Case Study No. 2, 2013.

Esper, H., London, T., and Kanchwala, Y. The William Davidson Institute.

We explore the impacts that Sanergy, a venture providing sanitation facilities and franchising opportunities to the BoP, has on children age eight and under and on pregnant women from the BoP. Sanergy designs and builds 250 USD modular sanitation facilities, called Fresh Life Toilets (FLTs), and sells them to local entrepreneurs for 50,000 Kenyan shillings (KES) or about 588 USD in the Mukuru slum of Nairobi, Kenya. Franchisees receive business management and operations training from Sanergy and earn revenues by charging customers 3-5 KES (0.04-0.06 USD) per use.

We found that Sanergy has the greatest impact on its customers’ children. Sanergy also has substantial impacts on children of franchisees and children in the broader community. The majority of impacts that occur on franchisees’ children are the same as those that occur on customers’ children. In addition, franchisees’ children benefit from the income their parents receive from owning the toilets. However, if parents take out loans to purchase the franchise, their ability to provide for their children may be reduced during the loan repayment period. Franchisees’ children are likely to have greater health benefits from using the toilets, since they are able to use them for free and as often as required, as these are located right outside their homes. Although franchisees’ children will have greater health benefits at an individual level, at an aggregate level, customers’ children will have larger health benefits since the number of franchisees’ children will always be less than the number of customers’ children.

Children living in the community surrounding the FLTs (non-customer children), experience many of the same health benefits as customer’s children as a result of improved cleanliness of the nearby environment. As more people use FLTs, a reduced amount of human waste is found on the ground, resulting in better health outcomes for children. People also begin to have an increased sense of respect for their environment. It is important to note that despite these health benefits, children are still at risk of contracting sanitation-related diseases from exposure to polluted water and other contaminated sources. The impacts we observed on the children of Sanergy’s stakeholders varied within and between the age categories of 0-5 and 6-8 years. We expect that children ages 0-5 receive greater health benefits, as they are more likely to be exposed to contaminants from crawling and playing on the ground and have more vulnerable immune-systems.

Based on the likely outcomes Sanergy has on children across its value chain, we identify opportunities that Sanergy can explore to enhance, deepen, and expand its impacts on children age eight and under and on pregnant women.

WASHplus Weekly: Community-Led Total Sanitation

Issue 126 December 13, 2013 | Focus on Community-Led Total Sanitation

This issue updates the May 2013 Weekly on CLTS with more recent reports and other resources. Included are presentations from a sanitation workshop in Benin, reviews of CLTS successes and shortcomings, a UNICEF overview of CLTS in Asia and the Pacific, a video on school-led total sanitation in Nepal, among others. weekly


Testing CLTS Approaches for Scalability: Systematic Literature Review (Grey Literature), 2012. V Venkataramanan. (Full text)
This study presents findings from a systematic literature review on the effectiveness and impact of CLTS programs. This document was prepared by The Water Institute at UNC for Plan International USA as part of the project Testing CLTS Approaches for Scalability, funded by the Bill & Melinda Gates Foundation.

Community-Led Total Sanitation in Africa: Helpdesk Report, 2013. Health & Education Advice & Resource Team (HEART). (Full text)
Decreases in diarrhea, cholera, and skin infections were the main health outcomes reported in this study. However, methodological weaknesses, including the lack of clarity around the proportions of the population exposed before and after implementation of CLTS to these conditions, made it challenging to determine the quality of the evidence presented.

The Cost of a Knowledge Silo: A Systematic Re-Review of Water, Sanitation and Hygiene Interventions, 2013. M Loevinsohn. (Full text)
The health impacts of CLTS have yet to be comprehensively assessed, although it is evident that people realize a range of benefits such as dignity, privacy, security—especially for women—and a clean environment, which they may value more than protection from infection.

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