Category Archives: Sanitation and Health

A Simple Yet Brilliant $1.50 Sanitation Idea

A Simple Yet Brilliant $1.50 Sanitation Idea - Made by the toilet manufacturer American Standard, this “trap door” seals off open pit latrines that are a major source of disease in the developing world.

This article discusses a sanitation solution by bathroom and kitchen fixture company American Standard. Funded by the  Gates Foundation, American Standard has developed a $1.50 latrine pan that cuts down on sanitation-related disease transmission by sealing off pit toilets. american_standard-sanitation

The $1.50 pan has been a hit in field trials in Bangladesh; in addition to being more sanitary, the pan also blocks off nasty smells from the latrine. While American Standard hoped to get the price down to a $1, McHale still believes the product is affordable.

So far, American Standard has sold close to 70,000 units in Bangladesh, and in 2013, the company donated 533,352 of the pans for distribution this year. The company is now thinking about how to launch the product in India. It’s also working on a design for Africa that uses less water.

Human diarrhea infections associated with domestic animal husbandry

Human diarrhea infections associated with domestic animal husbandry: a systematic review and meta-analysis. Trop Med Intl Health, Mar 2014.

Authors: Laura D. Zambrano, Karen Levy, Neia P. Menezes and Matthew C. Freeman

Domestic animal husbandry, a common practice globally, can lead to zoonotic transmission of enteric pathogens. However, this risk has received little attention to date. This systematic review and meta-analysis examines the evidence for an association between domestic exposure to food-producing animals and cases of human diarrhea and specific enteric infections.

We performed a systematic review of available literature to examine domestic livestock and poultry as risk factors for diarrhea and applied pre-determined quality criteria. Where possible, we carried out meta-analysis of specific animal–pathogen pairs.

We found consistent evidence of a positive association between exposure to domestic food-producing animals and diarrheal illness across a range of animal exposures and enteric pathogens. Out of 29 studies included in the review, 20 (69.0%) reported a positive association between domestic animal exposure and diarrhea. Domestic exposure to poultry revealed a substantial association with human campylobacteriosis (OR 2.73, 95% CI 1.90–3.93).

Our results suggest that domestic poultry and livestock exposures are associated with diarrheal illness in humans. Failure to ascertain the microbial cause of disease may mask this effect. Exposure to domestic animals should be considered a risk factor for human diarrheal illness and additional studies may identify potential mitigation strategies to address this risk.



Researcher Looks ‘Inside the Box’ for Sustainable Solution to Control Intestinal Parasites

George Washington University researcher Looks ‘Inside the Box’ for Sustainable Solution to Control Intestinal Parasites: Biogas System Offers Sanitation, Parasite Control, and Energy Supply for Underdeveloped Areas, May 6, 2014.

According to the World Health Organization, more than 450 million people worldwide, primarily children and pregnant women, suffer illness from soil-transmitted helminths (STH), intestinal parasites that live in humans and other animals. Considerable effort and resources have been, and continue to be, spent on top-down, medical-based programs focused on administering drugs to control STH infections, with little success. John Hawdon, Ph.D., associate professor of microbiology, immunology, and tropical medicine at the George Washington University School of Medicine and Health Sciences, advocates a more sustainable solution for controlling STH infections.

In a review published in the Journal of Parasitology, Hawdon proposes a new emphasis on sustainable, long-term investments in sanitation-based approaches. He promotes the use of improved latrines (the “box”) to provide bottom-up, culturally appropriate, and economically desirable solutions to control STH in endemic areas.



May 2, 2014 – WASHplus Weekly: Focus on Sanitation

Issue 144 | May 2, 2014 | Focus on Sanitation

This issue features some of the most recent reports, blog posts, and videos on fecal sludge management, community-led total sanitation, sanitation marketing and other sanitation topics. Included are a 2014 UNICEF evaluation of its Community Approaches to Total Sanitation, updated statistics and country reports from the Joint Monitoring Programme, videos from the Toilet Fair in India, and other resources.


Faecal Sludge Management Conference (FSM3), Jan 18-22, 2015, Hanoi, Vietnam, Call for Papers and Workshops(Link)
FSM3 will share research and experience and build upon practical developments since the last FSM2 Conference, which was held in Durban, South Africa, in October 2012. Some of the themes include: FSM as an enterprise—commercial viability, financing arrangements, and cost recovery—desludging, collection, and transportation; FS characterization and technologies; and pit emptying operations and maintenance.


2014 Updates from the UNICEF/WHO Joint Monitoring Programme (JMP) for Water Supply and Sanitation. UNICEF; WHO. (Link)
The latest JMP estimates are now available and include 2014 country files, the latest statistical table, and a 2014 snapshot. washplusweekly

Anaerobic Digestion of Biowaste in Developing Countries: Practical Information and Case Studies, 2014. Y Vögeli, Eawag—Swiss Federal Institute of Aquatic Science and Technology. (Link)
This book aims to compile existing and recently generated knowledge on issues of anaerobic digestion of organic solid waste at small and medium-scale with special consideration of low- and middle-income country conditions. The book is divided into two parts: Part 1 focuses on practical information related to anaerobic digestion and biogas production, and Part 2 presents selected case studies from around the world.

Downstream of the Toilet: Transforming Poo into Profit, 2013. WASHplus. (Link)
WASHplus engaged the NGO Practica to design and pilot a private-sector service delivery model to sustainably manage fecal sludge generated in Ambositra, Madagascar, using low-cost decentralized technologies. Working closely with the commune authorities, the project selected and trained a local entrepreneur, developed a sludge burial site, experimented with a range of manual extraction methods and tools, and engaged in a social marketing campaign to promote the service.

Evaluation of the WASH Sector Strategy “Community Approaches to Total Sanitation” (CATS): Final Evaluation Report, 2014. UNICEF. (Link)
In the context of the recent evolution of the sanitation sector, CATS can be seen in two ways: as a move from technically based supply-driven approaches toward behavior change, demand-driven approaches, and also as a recognition that a new social norm around ending open defecation is a key issue to be addressed because of its impacts on and linkages with other sectors (health, education, etc.). CATS successfully contributed to shifting the sanitation sector toward demand-driven rather than directly subsidized approaches. The evaluation shows that CATS has given a new momentum to rural sanitation in the more than 50 countries supported by UNICEF. This new momentum has translated into a change in how rural communities regard sanitation, invest in it, commit to new behaviors around ending open defecation—and eventually improve their living conditions.

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Burden of disease from inadequate water, sanitation and hygiene in low- and middle-income settings

Burden of disease from inadequate water, sanitation and hygiene in low- and middle-income settings: a retrospective analysis of data from 145 countries. Trop Med Intl Health, Early View, 2014.

Authors: Annette Prüss-Ustün, et al.

tmihObjective – To estimate the burden of diarrhoeal diseases from exposure to inadequate water, sanitation and hand hygiene in low- and middle-income settings and provide an overview of the impact on other diseases.

Methods – For estimating the impact of water, sanitation and hygiene on diarrhoea, we selected exposure levels with both sufficient global exposure data and a matching exposure-risk relationship. Global exposure data were estimated for the year 2012, and risk estimates were taken from the most recent systematic analyses. We estimated attributable deaths and disability-adjusted life years (DALYs) by country, age and sex for inadequate water, sanitation and hand hygiene separately, and as a cluster of risk factors. Uncertainty estimates were computed on the basis of uncertainty surrounding exposure estimates and relative risks.

Results – In 2012, 502 000 diarrhoea deaths were estimated to be caused by inadequate drinking water and 280 000 deaths by inadequate sanitation. The most likely estimate of disease burden from inadequate hand hygiene amounts to 297 000 deaths. In total, 842 000 million diarrhoea deaths are estimated to be caused by this cluster of risk factors, which amounts to 1.5% of the total disease burden and 58% of diarrhoeal diseases. In children under 5 years old, 361 000 deaths could be prevented, representing 5.5% of deaths in that age group.

Conclusions – This estimate confirms the importance of improving water and sanitation in low- and middle-income settings for the prevention of diarrhoeal disease burden. It also underscores the need for better data on exposure and risk reductions that can be achieved with provision of reliable piped water, community sewage with treatment and hand hygiene.

Proceedings of the Menstrual Hygiene Management in Schools Virtual Conference

WASH in Schools Empowers Girls’ Education: Proceedings of the Menstrual Hygiene Management in Schools Virtual Conference 2013.

There is increasing interest in exploring and addressing the menstrual hygiene management (MHM) barriers facing schoolgirls and female teachers in educational settings. Around the globe, WASH in Schools (WinS) focuses on fostering social inclusion and individual self-respect – and addresses MHM as a key agenda. By offering an alternative to the stigma and marginalization associated with hygiene issues, integrating MHM into WinS empowers all students, and especially encourages girls and female teachers. mhm

Columbia University’s Mailman School of Public Health and UNICEF convened the Second Annual Virtual MHM in WinS Conference at UNICEF Headquarters in New York City on 21 November 2013. Building on recommendations from the MHM 2012 virtual conference, the 2013 conference focused on the research
tools and instruments being used to explore MHM barriers and practices and to evaluate the interventions being trialed or implemented in various contexts.

The one-day event brought together over 150 participants online, involving a range of water, sanitation and hygiene (WASH) and MHM experts, global health and education researchers, social entrepreneurs and policymakers – from academic institutions, non-governmental organizations, the private sector, advocacy organizations and UNICEF country offices implementing MHM-related activities.

Using WebEx, 16 presentations were made from countries around the world, on a wide range of MHM research being conducted in educational settings. The presentations focused on: (1) the tools and and instruments utilized to explore MHM requirements of schoolgirls; and (2) the tools/instruments utilized for monitoring MHM interventions for schoolgirls.

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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