Category Archives: Sanitation and Health

Shared sanitaion for the urban poor: understanding what works

The MapSan study aims to explore the links between sanitation, population density, and health outcomes in Maputo, Mozambique. The video describes a controlled, before-and-after trial of an urban sanitation intervention to reduce enteric infections in children:

Can we shift waste to value through 3D printing in Tanzania?

Can we shift waste to value through 3D printing in Tanzania? World Bank Blog, Sept 2015. Author: C. Paradi-Guilford.

Plastic waste, in particular PET, which is typically found in soda bottles, is becoming abundant in African cities. In Dar es Salaam, one of the most rapidly urbanizing cities in Africa, BORDA found that about 400 tons of plastic waste per day remains uncollected or unrecycled.  Although about 98 percent of the solid waste generated per day can be recycled or composted, 90 percent is disposed in dumpsites.

A waste collection site in Dar es Salaam, Tanzania. Photo: Cecilia Paradi-Guilford

At the same time, the recycling industry has started to grow because of new initiatives, community organizations and private companies. There are a few organizations that repurpose waste into arts and crafts, tools or apply it as a source of energy – such as WasteDar. However, the majority collect or purchase plastic waste from collectors, primarily with a view to export, rather than recycle or reuse locally.

Socially and environmentally, waste management is one of the biggest challenges for an increasingly urbanized world. Waste pickers can earn as little as US$1-2 a day in dangerous conditions with little opportunity for advancement. They make up some of the most disadvantaged communities living in deep poverty.

Through a new market for sorted waste materials, these communities may access higher income generation opportunities in a sustainable manner. This presents an opportunity to explore turning this waste into value more close to home.

At the same time, 3D Printing is expanding
3D printing is an additive manufacturing process that applies layers of materials (typically plastic) to develop an object that is made up of thinly sliced horizontal layers. The design of the object is made in a Computer-Aided Design program using a 3D modeling, then is inputted into the 3D printer. Gaining popularity, 3D scanners are also used to make a digital copy of ab object. 3D printers take an input of filament consisting of varying types of plastic to create the object.

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Oct 2015 WASH studies on toilets and health and other topics

Effect of Poor Access to Water and Sanitation as Risk Factors for Soil-Transmitted Helminth Infection: Selectiveness by the Infective Route. PLoS NTDs, Sept 30, 2015. Authors: Adriana Echazú , Daniela Bonanno, Marisa Juarez, Silvana P. Cajal, Viviana Heredia, Silvia Caropresi, Ruben O. Cimino, Nicolas Caro, Paola A. Vargas, Gladys Paredes, Alejandro J. Krolewiecki

Full text –

The aim of this study is to assess the association of lacking access to water and sanitation with STH infections, taking into account the differences in route of infection among species and the availability of adequate water and sanitation at home. After controlling for potential confounders, unimproved sanitation was significantly associated with increased odds of infection of skin-penetrators (adjusted odds ratio [aOR] = 3.9; 95% CI: 2.6–5.9). Unimproved drinking water was significantly associated with increased odds of infection of orally-ingested (aOR = 2.2; 95% CI: 1.3–3.7). The present study reports an association between poor sanitation and water access and STH infections selective to the parasite route of entry. This finding could contribute to the design of specific and rational recommendations to reduce soil-transmitted helminths transmission.

MIT-USAID program releases evaluation of water filters: Study of water filters used in Indian homes assesses suitability, scalability, and sustainability, Oct 2015. | Complete report | Summary |

CITE’s household water filter evaluation allowed us to study innovations with the potential to better the lives of India’s “water poor”—the 76 million people in the country who lack improved drinking water. CITE teams studied over 100 models of householder water filters from nine major brands available on the market in Ahmedabad, India. These models fell into three main categories: conventional particle filtration (cloth/jali mesh), gravity non-electric filters, and reverse osmosis filters.

Toilets Can Work: Short and Medium Run Health Impacts of Addressing Complementarities and Externalities in Water and Sanitation, 2015. Authors: ESTHER DUFLO, MICHAEL GREENSTONE, RAYMOND GUITERAS, AND THOMAS CLASEN

Full text:

This paper estimates the impact of an integrated water and sanitation improvement program in rural India that provided household-level water connections, latrines, and bathing facilities to all households in approximately 100 villages. The estimates suggest that the intervention was effective, reducing treated diarrhea episodes by 30-50%. These results are evident in the short term and persist for 5 years or more. The annual cost is approximately US$60 per household.

Stunting is associated with poor outcomes in childhood pneumonia. Trop Med Intl Health, Oct 2015. Authors: Peter P. Moschovis, et al.


Stunting affects 26.7% of children worldwide, and little is known about its effects on the outcomes of childhood pneumonia. We evaluated the effect of stunting on the outcomes of pneumonia among children enrolled in two large clinical trials.  Stunting increases the risk of treatment failure and is associated with a longer course of recovery in children with pneumonia. Strategies to decrease stunting may decrease the burden of adverse outcomes in childhood pneumonia in low-resource settings.


Innovative WASH interventions to prevent cholera

Innovative WASH interventions to prevent cholera. Source: WHO Wkly Epid Rec, Oct 2, 2015

Authors: Daniele Lantagne, Andy Bastable, Jeroen H. J. Ensink, and Eric Mintz.

In the late 19th and early 20th centuries, epidemic cholera was virtually eliminated in industrialized countries through municipal water supply with treatment and sanitation infrastructure.1 A century later, in 2014, only 58% of the global population had access to piped-on premises water,2 and an estimated 1.8 billion people (28% of the global population) drank microbiologically contaminated water.3 Within this inadequate water and sanitation context, cholera transmission continues. wer

In 2014, 32 countries – many of which are struggling with poverty, rapid population growth, and instability – reported cholera transmission.4

A recent model found that national improved water access of 71%, and improved sanitation access of 39%, predicted whether a country would have endemic cholera with 62%–65% sensitivity and specificity.5

As progress is made towards universal access to reliable piped-on-premises water, reducing the remaining cholera burden requires a comprehensive strategy. Community- and household level water, sanitation, and hygiene (WASH) interventions are one part of that strategy.

Common cholera-prevention WASH interventions include: water supply, water treatment (well, pot, or bucket chlorination and household treatment); sanitation options (latrines); and, promotion of hand washing and environmental hygiene.6

The effectiveness of these interventions varies7 : water supply and chlorine-based, filtration, and solar disinfection household options have been shown to reduce cholera transmission among users;8, 9, 10, 11, 12 well/pot chlorination effectively treats water only for a few hours,13, 14, 15 unless chlorine is regularly added;16 there is little research on bucket chlorination, sanitation, and hygiene interventions.

Recent innovations in chlorine-prevention WASH include identification of factors leading to programmatic success, and new product design (such as sourcebased water treatment and personal use sanitation options).

An investigation of 14 household treatment programmes implemented in 4 emergencies (including 3 cholera emergencies) found that reported use ranged from 1% to 93% and effective use (the percentage of recipients who improved their drinking water microbiological quality to international standards) ranged from 0 to 68%.17

The most successful programme provided an effective method (chlorine tablets), with the necessary supplies to use it (bucket and tap), and ongoing training by local community health workers to people using contaminated water who were familiar with chlorination before the emergency. Conversely, the least successful programme distributed only chlorine tablets in a relief kit labeled in English to populations without previous chlorination experience.

Similar results were found in an evaluation of dispensers, an innovative source-based intervention that includes a chlorine dispenser and dosing valve installed at water sources, community education, and chlorine refills. Across seven evaluations in four emergencies (including 3 cholera emergencies), reported dispenser use ranged from 9-97% and effective use from 0 to 81%.18

More effective programmes installed dispensers at point-sources, maintained a high-quality chlorine solution manufacturing and distribution chain, maintained hardware, integrated dispenser projects within larger water programmes, compensated promoters, had experienced staff, worked with local partners to implement the project, conducted ongoing monitoring, and had a sustainability plan.

The Peepoo is a personal, single-use, biodegradable selfsanitizing double-plastic bag toilet. Peepoos contain sufficient powdered urea to inactivate harmful pathogens in urine and feces after 4 weeks, at which time the waste can be used as fertilizer. Peepoos have been used where latrines are not feasible due to population density, and to bridge the gap between emergency onset and latrine construction.19

One emergency programme concluded that products should be pre-positioned before the emergency, all products necessary for use (including a sitting/squatting stool) should be provided to recipients, training for community health workers should occur before distribution, compensation for collection activities should be provided, and that the disposal mechanism and exit strategy should be predefined before distribution.

As can be seen, lessons learned from the programmes described above are similar: WASH interventions can successfully improve water quality, isolate feces from the environment, and reduce the potential for cholera transmission if they are wisely implemented and distributed with appropriate supplies and training to at-risk populations.

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Handwashing practices added as new risk factor in latest Global Burden of Disease study

Global, regional, and national comparative risk assessment of 79 behavioural, environmental and occupational, and metabolic risks or clusters of risks in 188 countries, 1990–2013: a systematic analysis for the Global Burden of Disease Study 2013. The Lancet, Sept 11, 2015.

GBD 2013 Risk Factors Collaborators

The Global Burden of Disease, Injuries, and Risk Factor study 2013 (GBD 2013) is the first of a series of annual updates of the GBD. Risk factor quantifi cation, particularly of modifi able risk factors, can help to identify emerging threats to population health and opportunities for prevention. The GBD 2013 provides a timely opportunity to update the comparative risk assessment with new data for exposure, relative risks, and evidence on the appropriate counterfactual risk distribution.

All risks combined account for 57·2% (95% uncertainty interval [UI] 55·8–58·5) of deaths and 41·6% (40·1–43·0) of DALYs. Risks quantified account for 87·9% (86·5−89·3) of cardiovascular disease DALYs, ranging to a low of 0% for neonatal disorders and neglected tropical diseases and malaria. In terms of global DALYs in 2013, six risks or clusters of risks each caused more than 5% of DALYs: dietary risks accounting for 11·3 million deaths and 241·4 million DALYs, high systolic blood pressure for 10·4 million deaths and 208·1 million DALYs, child and maternal malnutrition for 1·7 million deaths and 176·9 million DALYs, tobacco smoke for 6·1 million deaths and 143·5 million DALYs, air pollution for 5·5 million deaths and 141·5 million DALYs, and high BMI for 4·4 million deaths and 134·0 million DALYs.

Risk factor patterns vary across regions and countries and with time. In sub-Saharan Africa, the leading risk factors are child and maternal malnutrition, unsafe sex, and unsafe water, sanitation, and handwashing.

Behavioural, environmental and occupational, and metabolic risks can explain half of global mortality and more than one-third of global DALYs providing many opportunities for prevention. Of the larger risks, the attributable burden of high BMI has increased in the past 23 years. In view of the prominence of behavioural risk factors, behavioural and social science research on interventions for these risks should be strengthened. Many prevention and primary care policy options are available now to act on key risks.

Now available on WSUP-website for free download: masters-level professional training module “Water and Sanitation for Urban Low-Income Communities”

WSUP/WEDC have developed a teaching resource on urban WASH that is now available online for free, It aims at helping the urban WASH sector to professionalize. We hope it will be helpful for academics and practitioners to use or adapt if they feel it can be of value to them.

In short: this is a masters-level professional training module called “Water and Sanitation for Urban Low-Income Communities”. It was primarily designed to give engineering masters students in low-income countries an overview of things they need to know in order to apply their technical skills in low-income communities, and that’s how WSUP and WEDC are currently using it, in partnership with universities in Africa and Asia. But of course it may be adaptable to other teaching contexts.

It’s designed for classroom delivery, over about 45 hours of contact time. It’s made up of 16 thematic units, and within each unit the materials essentially comprise a Powerpoint presentation plus Lecturer Notes outlining the unit’s aims and content, and providing guidance on how to deliver the class. Some units are flexible in content, to enable adaptation to local contexts.

It can be delivered as an off-the shelf package; or you might want to cut-and-paste parts of it into your own materials; or you might simply use it as guidance in developing other materials.

It’s absolutely free to download, but we do ask that you fill in a brief Use Request Form explaining who you are and how you might use it: evidently, it’s useful for us to be able to communicate this to the funder of the work (DFID).


For information, we expect to have a French-language version available within the next few months.

The module was developed by (alphabetical order): Louise Medland, Guy Norman, Brian Reed, Pippa Scott, Regine Skarubowiz, and Ian Smout; inputs also came from Richard Franceys and Valentina Zuin.

WASHplus Weekly: Focus on Community-Led Total Sanitation (CLTS)

Issue 202 | August 14, 2015 | Focus on Community-Led Total Sanitation (CLTS)

This issue updates the March 6, 2015 Weekly on CLTS. Studies and resources in this issue include a webinar series on what constitutes success for CLTS, new reports from the UNC Water Institute and the Institute of Development Studies, a presentation by Kamal Kar on CLTS and scaling up, and a UNICEF report on CLTS in fragile and insecure contexts. Also included are recent studies on the health impacts of open defecation in India and Nepal and a Waterlines review on the safety of burial or disposal with garbage as forms of child feces disposal.


What Constitutes Success for CLTS? Measuring Community Outcomes and Behavior Changes, 2015.
The webinar had a chat show format where, following a panel interview, the audience will have the chance to interact with the panelists. This webinar was organized under the Knowledge Management initiative of the Building Demand for Sanitation (BDS) program of the Bill & Melinda Gates Foundation. Organizers included Euforic Services, the SuSanA secretariat and the Stockholm Environment Institute.

  • Introduction by Pippa Scott, Link to recording on YouTube
  • Chat show. Speakers: Ada Oko Williams, Technical Support Manager, Sanitation and Hygiene, WaterAid UK; Darren Saywell, Senior Director, Water, Sanitation and Health, Plan International USA and others, Link
  • Feedback from breakout rooms, Link
  • Closing panel, Link
  • More information and links to audio files are available on the SuSanA discussion forum

Seminar: CLTS at Stockholm World Water Week, August 23rd, 9:00 – 10:30, FH 202. Link
In this 90-minute event, speakers from Plan International and the Water Institute at UNC will discuss with the audience the results of an operational research program on the role and potential of local actors to sustain CLTS outcomes. Highlights will be shared from activities in 10 countries across Africa, Asia, and the Caribbean.

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