Tag Archives: cholera

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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Aug 10 – Weekly Update of Selected WASH Studies

Effectiveness of emergency water treatment practices in refugee camps in South Sudan. WHO Bulletin, Aug 2015. Authors: Syed Imran Ali, Syed Saad Ali & Jean-Francois Fesselet.
Link: http://goo.gl/BtnQVh

Current guidelines for free residual chlorine in emergency water supplies are not based on field evidence and offer inadequate protection after distribution in refugee camps in South Sudan. We recommend that the free residual chlorine guideline be increased to 1.0 mg/L in all situations, irrespective of disease outbreak, pH, or turbidity conditions. This is a tentative recommendation because the degree to which these findings can be generalized to other camps in different settings is unknown.

Nutrition in Ethiopia: An emerging success story? Author: Headey, Derek D.
Link: https://goo.gl/tmMCqX

Research does not always provide the results that we expect. At the recent conference on improving nutrition in Ethiopia, Together for Nutrition 2015, we learnt about the rapid progress in Ethiopia in child nutritional outcomes that are linked to improved birth size and, hence, improved maternal health. However, most of the improvement in maternal health seems related to better sanitation, rather than to diet, care, or health factors.

Diet and specific microbial exposure trigger features of environmental enteropathy in a novel murine model. Nature Communications, Aug 2015. Authors: Eric M. Brown, et al.
Link: http://goo.gl/Sgx6XP

Here we demonstrate that early-life consumption of a moderately malnourished diet, in combination with iterative oral exposure to commensal Bacteroidales species and Escherichia coli, remodels the murine small intestine to resemble features of EE observed in humans. We further report the profound changes that malnutrition imparts on the small intestinal microbiota, metabolite and intraepithelial lymphocyte composition, along with the susceptibility to enteric infection. Our findings provide evidence indicating that both diet and microbes combine to contribute to the aetiology of EE, and describe a novel murine model that can be used to elucidate the mechanisms behind this understudied disease.

An internet-delivered handwashing intervention to modify influenza-like illness and respiratory infection transmission (PRIMIT): a primary care randomised trial. The Lancet, Aug 2015. Authors: Paul Little, Beth Stuart, et al.
Link: http://goo.gl/hHLnLI

Handwashing to prevent transmission of respiratory tract infections (RTIs) has been widely advocated, especially during the H1N1 pandemic. However, the role of handwashing is debated, and no good randomised evidence exists among adults in non-deprived settings. We aimed to assess whether an internet-delivered intervention to modify handwashing would reduce the number of RTIs among adults and their household members.

Associations between school- and household-level water, sanitation and hygiene conditions and soil-transmitted helminth infection among Kenyan school children. Parasit Vectors. 2015 Aug. Authors: Freeman MC, Chard AN, et al.
Link: http://goo.gl/HkdIyS

Results suggest mixed impacts of household and school WASH on prevalence and intensity of infection. WASH risk factors differed across individual worm species, which is expected given the different mechanisms of infection. No trend of the relative importance of school versus household-level WASH emerged, though some factors, like water supply were more strongly related to lower infection, which suggests it is important in supporting other school practices, such as hand-washing and keeping school toilets clean.

Modelling Optimal Control of Cholera in Communities Linked by Migration. Comput Math MethodsMed. 2015. Authors: Njagarah JB, Nyabadza F
Link: http://goo.gl/VU6I5G

A mathematical model for the dynamics of cholera transmission with permissible controls between two connected communities is developed and analysed. The dynamics of the disease in the adjacent communities are assumed to be similar, with the main differences only reflected in the transmission and disease related parameters. This assumption is based on the fact that adjacent communities often have different living conditions and movement is inclined toward the community with better living conditions. Our results indicate that implementation of controls such as proper hygiene, sanitation, and vaccination across both affected communities is likely to annihilate the infection within half the time it would take through self-limitation. In addition, although an infection may still break out in the presence of controls, it may be up to 8 times less devastating when compared with the case when no controls are in place.

WASHplus Weekly: Focus on Cholera and Ebola Outbreaks

Issue 157 | August 8, 2014 | Focus on Disease Outbreaks

This issue highlights recent alerts, news and publications on cholera and Ebola outbreaks. On August 1, 2014, WHO published its latest statistics on the number of cholera cases and cholera-related deaths in 2013. In 2013, there was a 47% decrease in the number of cases reported compared to 2012 and this is the second consecutive year in which reported cholera era cases declined. Resources on the Ebola outbreaks include WHO alerts, a WHO fact sheet, recent newspaper articles and reports on the One Health approach, which investigates human, animal, and environmental interconnectedness and its impact on health.


Recent Newspaper Articles on Outbreaks – Cameroon – Aug 6, 2014 | Ghana – Aug 4, 2014 | South Sudan – July 30, 2014 | Vietnam – Aug 6 2014 |


Cholera Fact Sheet, 2014. World Health Organization. (Link)
Cholera is an acute diarrhoeal infection caused by ingestion of food or water contaminated with the bacterium Vibrio cholerae. Every year, there are an estimated 3–5 million cholera cases and 100,000–120,000 deaths due to cholera. The short incubation period of two hours to five days enhances the potentially explosive pattern of outbreaks.

USAID-IWASH Ebola Preparedness Response

USAID-IWASH Ebola Preparedness Response

Cholera in 2013. Weekly Epidem Rec, Aug 2014. WHO. (Link)
In 2013, 47 countries reported a total of 129,064 cases of cholera including 2102 deaths, giving a case-fatality rate of 1.63%. This represents a decrease of 47% in the number of cases reported compared to 2012 and this is the second consecutive year in which reported cholera era cases declined.

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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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WASHplus Weekly: Cholera Prevention and Control

Issue 111 August 9, 2013 | Cholera Prevention and Control

This issue updates the August 2012 Weekly with studies and resources published in 2013 on cholera prevention and control. Included are the latest statistics from WHO on the number of cholera cases and deaths. WHO states that annual figures in this report exclude the estimated 500,000–700,000 annual cases labeled “acute watery diarrhea” occurring in southeastern and central Asia. The actual numbers of cholera cases are known to be much higher than those reported. Other resources in this issue are the 2013 Cholera Toolkit by UNICEF, studies on socioeconomic and environmental factors that affect cholera outbreaks, country studies from Bangladesh, Cameroon, Haiti, and other studies.


August 1, 2013 – Subcommittee Hearing: The Impact of U.S. Water Programs on Global Health. (Video)
Witnesses: Panel I – Christian Holmes, Global Water Coordinator, USAID | Aaron A. Salzberg, Special Coordinator for Water Resources, U.S. Department of State. Panel II- John Oldfield, Chief Executive Officer, WASH Advocates | Malcolm Morris, Chairman, Millennium Water Alliance | Buey Ray Tut, Executive Director, Aqua Africa

June 2013 – USAID and World Vision Join Coalition to Eliminate Cholera from Haiti and the Dominican Republic. Pan American Health Organization, June 2013.(Link)
USAID and World Vision recently became the newest members of the Regional Coalition on Water and Sanitation to Eliminate Cholera in Hispaniola, an alliance of more than 20 agencies and associations that are supporting efforts by the governments of Haiti and the Dominican Republic to eliminate the transmission of cholera.


Cholera in 2012Weekly Epidem Rec, Aug 2013. WHO. (Full text)
After several years of steady increases in the number of cholera cases reported to WHO as well as the number of countries that reported cholera cases, there was an important decrease in cases in 2012. Of the 30 countries that reported deaths from cholera, 23 were from the African continent, accounting for 2042 deaths or 67% of the global total, while in the Americas, the Dominican Republic and Haiti reported 962 deaths or 31% of the global total.

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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. weekly2

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.

UNICEF launches groundbreaking cholera toolkit

To tackle the alarming resurgence of cholera, UNICEF has launched a new comprehensive Cholera Toolkit on 15 May 2013.

The toolkit launch […] will be the culmination of a thorough review of existing guidance and global consultation with UNICEF at all levels and from all divisions in Africa, along with main partners in the fight against cholera, such as the World Health Organization as the lead agency.

There are 3-5 million cholera cases each year, killing 100,000 to 120,000 people, half of whom are children under 5 years old. Only 5-10% of cases are reported. In Western and Central Africa, there were more than 80,000 cases of cholera in 2012 resulting in nearly 1,500 deaths.

The Toolkit provides the health and WASH sectors an integrated approach to cholera prevention, preparedness and response. In addition it includes specific content linked to education, nutrition, communication for development (C4D), child protection and other relevant sectors.

UNICEF Cholera Kit, p. 41

UNICEF Cholera Kit, p. 41

“What the toolkit does is harvest the best and most up-to-date knowledge in the field and brings it together in one location,” said UNICEF Chief of Water, Sanitation and Hygiene Sanjay Wijesekera. “It looks at the evidence. It looks at practices that have produced results.”

Download the Toolkit at: www.unicef.org/cholera

Related websites:

Source: UNICEF, 15 May 2013