Tag Archives: diarrhoeal diseases

Effect of water quality, hygiene and sanitation in preventing diarrhoea deaths

Researchers propose diarrhoea risk reductions of 48, 17 and 36%, associated respectively, with handwashing with soap, improved water quality and excreta disposal as the estimates of effect for the Lives Saved Tool (LiST) model [1].

LiST is a new computer-based planning tool to help estimate the impact of scaling-up maternal, newborn and child health interventions. LiST was developed by a consortium of academic and international organizations, led by Institute of International Programs at the Johns Hopkins Bloomberg School.

Researchers led by Prof. Sandy Cairncross of the London School of Hygiene & Tropical Medicine, drew on three systematic reviews, two of them for the Cochrane Collaboration, to determine the estimated effect on diarrhoea mortality of the three interventions.

The striking effect of handwashing with soap (48% reduction) was found to be consistent across various study designs and pathogens, though it depended on access to water. The effect of (household) water treatment appeared similarly large, but was not found in few blinded studies, suggesting that it might be partly due to the placebo effect. The researchers found very little rigorous evidence for the health benefit of sanitation; four intervention studies were eventually identified, though they were all quasi-randomized, had morbidity as the outcome, and were in Chinese.

While most of the evidence was found to be of poor quality and more trials were required, the evidence was nonetheless strong enough to support the provision of water supply, sanitation and hygiene for all.

[1] Cairncross, S., Hunt, C., Boisson, S., Bostoen, K., Curtis, V., Fung, I.C. and Schmidt, W.P. (2010). Water, sanitation and hygiene for the prevention of diarrhoea. International journal of epidemiology ; vol. 39 (Suppl. 1) ; p. i193-i205. DOI:10.1093/ije/dyq035

The complete issue of the April 2010 supplement of the International journal of epidemiology is devoted to the development and use of the Lives Saved Tool (LiST). Other articles deal with rotavirus vaccine, zinc treatment for diarrhoea, antibiotics for dysentery, and oral rehydration solution. All articles are free to download.

Haiti: Red Cross joins international organizations in hygiene drive as rains intensify

The Haitian Red Cross Society (HRCS) joined international NGOs working in water and sanitation in Haiti [on 25 May 2010] to stage a special street event opposite Port-au-Prince’s Place Saint-Pierre camp, where an estimated 6,000 people settled after the 12 January disaster.

HRCS volunteers led a crocodile of some 300 children from the camp around the Place Saint-Pierre square in Pétionville to where an interagency health promotion fair was held in tented stands.

The event was organized by the Hygiene Promotion sub-cluster and included groups like Oxfam and Save the Children.

According to Pauline Mwaniki, coordinator of the sub-cluster, “the fact that there has been no major outbreak of disease is partly due to humanitarian agencies’ efforts to spread hygiene messages.”

“With the rainy season intensifying,” Mwaniki added, “the risks are increasing though due to overcrowding in the camps so we are planning to launch a nationwide health awareness campaign.”

Storm drain

Diarrhoea is one of the leading causes of death of children under five in Haiti. Even before the earthquake, children could expect to fall ill between four and six times a year.

“There is diarrhoea in the camps but our hygiene promotion messages are helping in the fight against the disease, ” said HRCS health coordinator Sherley Bernard, who helped lead the children in songs and dances intended to convey key health messages in a fun way.

“Now that the rainy season has really started, we have to intensify our efforts to ensure camp communities practise good personal hygiene and that they know how to store water safely and dispose of waste.”

The Place Saint-Pierre camp was one of the first in the immediate aftermath of the quake to receive worldwide publicity about its insanitary, overcrowded conditions.

A week after the quake, French television reported from the camp that the focus on providing immediate medical care to victims meant hygiene had to “take a backseat”.

Things are better there now but still far from perfect. People have safe water, but as Friday’s event got underway women stripped to the waist bathed standing up in the newly dug storm drain surrounding the camp.

Hardware

Workers from Save the Children engage children from Place Saint-Pierre camp in Pétionville, Port-au-Prince, in games about key hygiene practices including hand-washing with soap. Photo: José Manuel Jiménez

Led by Red Cross volunteers and staff from the organizations taking part, children from Place Saint-Pierre camp took to the streets to sing about how washing hands with soap and water can save lives.

Amongst them was Milien Robenson, 13, whose family has been living in the camp since their house collapsed.

“It is really good to be able to sing and play games,” he said, “as it takes my mind off the earthquake and I no longer feel so afraid.”

Mothers came from the Place Saint-Pierre camp to hear how washing hands with soap after going to the toilet or before handling food and babies can prevent diarrhoea.

At the Pétionville event, mothers were given a bar of soap to encourage healthy behaviour, but organizers said the biggest challenge is matching messages with actual hardware like drains, toilets and washing facilities.

“We have an integrated approach,” said Gaelle Fohr, an International Federation health promotion delegate, who also spent the day at Place Saint-Pierre.

“In each of the camps where we organize health promotion activities, we also provide water, sanitation and health services.”

So far more than 150,000 people have been reached with hygiene promotion work in more than 100 camps where HRCS volunteers work with the International Federation and National Societies.

Flag day

Twenty-three-year old volunteer Jeanne Jaboin is a trained nurse and works for the French Red Cross in several camps.

Like many of the volunteers she also lost her house in the earthquake and is living with her husband and three children in a makeshift camp by the sea.

“In my camp there are no latrines and the water gets easily contaminated,” says Jaboin, “but at least I can use what I’ve learnt as a Red Cross volunteer to help my community stay healthy and avoid disease.”

Even though some of the HRCS volunteers lost homes, family and livelihoods, they remain committed to helping others less fortunate than themselves.

Saturday’s event had been originally planned for Haitian flag day on 18 May – the anniversary of the adoption of the country’s flag, made from the red and blue of the French tricolour, but it had to be postponed.

“Even at this difficult time we are proud to be Haitians,” said Bernard, “and as Red Cross volunteers we want to do everything we can to contribute to our country’s recovery.”

Source: Claire Doole, IFRC, 25 May 2010

Let’s talk about it: PATH’s promotional video on diarrhoeal disease control

Dirty drinking water, poor sanitation, and rotavirus infection can lead to diarrhoea, which is the second leading killer of children around the world. “If we talk about diarrhoea, we can defeat it”, is the slogan of this four minute promotional video produced by Final Cut Productions for the Program for Appropriate Technology in Health (PATH). The music used for the video is the 1980 disco hit “Funkytown” performed by Lipps Inc.

More information on www.defeatdd.org, PATH’s specialised web site on diarrhoeal disease control.

Kenya: plan to halve infant diarrhoea prevalence

Kenya has set its sights on halving the prevalence of infant diarrhoeal disease – which kills dozens of children daily – within five years, using new treatments and by boosting preventive measures.

Every Kenyan child under five has an average of three episodes of diarrhoea annually, according to the 2008 Demographic and Health Survey.

Hon Beth Mugo, EGH, MP

“With 86 children dying every day, diarrhoea is the third leading cause of death among under-fives in Kenya. It is unacceptable, but we can stop this!” said Beth Mugo, Minister for Public Health and Sanitation, at the 31 March 2010 launch in Nairobi of national policy guidelines [1].

The new guidelines, she said, complemented the government’s Child Survival and Development Strategy with a package of interventions based on using a new type of oral rehydration salts (ORS) containing lower concentrations of glucose and salt; zinc supplements to reduce the frequency of episodes; selective use of antibiotics; and encouraging prevention through breastfeeding.

“With exclusive breast feeding, vitamin A supplementation, strengthened routine childhood immunization, proper hygiene and access to improved water supplies, we can curb the number of deaths,”said David Okello, country representative of the World Health Organization (WHO).

“We are also looking forward to solutions such as PATH’s rotavirus vaccines. With 730,000 doses distributed this year, we could really make a difference for all the children of Kenya,” said Annah Wamae, head of the Department of Child Health at the ministry.

Kenya's new diarrhoeal disease control guidelines

According to the WHO, vaccination is the only preventive method for diarrhoeal disease cases caused by rotavirus, the most severe form of diarrhoea. In Kenya rotavirus causes 7,500 deaths each year.

At the launch, Sanjiv Kumar, the UN Children’s Fund Kenya (UNICEF) chief of health, announced a financial support package worth US$850,000 by the end of 2010. Aimed at control and management of diarrhoeal disease in Kenya, Kumar added that the focus of the funding was to scale up oral rehydration therapy to cover the whole country; train health staff in new enhanced diarrhoeal guidelines; and to support communication to promote appropriate household behaviours.

Calling for more resources from partners to implement child health programmes, Mugo said resources allocation would be increased to include training of health personnel on control and management of diarrhoeal diseases, strengthening of health systems and programmes aimed at empowering communities to control diarrhoeal diseases.

“The rate of exposure to diarrhoea and waterborne diseases in this country is extremely high because of the high fluoride content in groundwater and the poor wastewater treatment,” James Gesami, Assistant Minister for Public Health and Sanitation, told IRIN.

“In 2010, no single town in Kenya has a sustainable water supply,” he added. “We can’t do much about quantity, but when it comes to quality, the Ministry of Health is working together with USAID and other partners to set up a strategy that will include the protection of springs ready by 2015.”

Training parents

The new guidelines include training parents in home-based care to under-fives to help them recognize the symptoms of dehydration.

This follows the health ministry’s recognition that about 30 percent of children with diarrhoeal diseases are not getting any oral rehydration salts or fluids. Home therapy will include information about recommended fluid intake to prevent dehydration at the onset of diarrhoea as well as feeding, including breastfeeding, during and after diarrhoea.

“Together with our partners, we can save thousands of lives. A coordinated approach involving already proven prevention and treatment methods is the way to do it,” said Olivia Yambi from UNICEF.

[1] Wamae, A. … [et al.] (2010). Policy guidelines on control and management of diarrhoeal diseases in children below five years in Kenya. Division of Child and Adolescent Health, Ministry of Public Health and Sanitation. Download PDF file [407 KB]

Source: IRIN, 01 Apr 2010.

See also the press release by PATH “New policy unveiled to combat diarrhoeal disease, a leading killer of Kenyan children”, 31 Mar 2010

Brazil: Sanitation deficit “shameful” – expert

Nearly 50% of the nearly 200mn inhabitants of Brazil do not have access to sewerage networks, according to sanitation sector experts at a seminar in capital Brasília.

In addition, only a third of the sewage in the country is adequately treated, according to Raul Pinho, president of the institute Trata Brasil, which specializes in basic sanitation. Pinho said it is “shameful” that Brazil is among the most backward nations in the world in this sector, paper Ultimo Segundo reported.

While the government has invested around US$5.7bn in sanitation works during the last three years, different studies from the private sector show that about US$254bn needs to be invested to guarantee sewerage networks for the whole population, the report said.

It is an agenda that goes beyond the present government, because what are missing are long-term policies, compatible with the growth of cities and the population, Pinho said.

Experts that participated at the seminar attributed illnesses such as diarrhoea to the lack of sanitation. This illness is responsible for the annual deaths of nearly 2,500 children under five years in Brazil.

Source: BNamericas. com [subscription site], 22 Oct 2009

Bringing proper sanitation to rural Afghanistan

The second Global Handwashing Day was celebrated on 15 October 2009 in Kabul and 34 provinces of Afghanistan.

“At home, I wash my hands every morning and noon and evening, and also when I come from the toilet,” said 11-year-old Abdullah Farzad.

Afghanistan’s mortality rates are among the highest in the world. One out of four children dies before her or his fifth birthday. High diarrhoea prevalence resulting from poor hygiene practices, lack of access to sanitation facilities and clean water impact heavily on children’s survival and development. According to a joint UNICEF/WHO report released this week, more than 80,000 children under five died as a result of diarrhoea in Afghanistan in 2007.

“When I started to go to school one year ago, one of the first things our teacher explained to us was the importance of washing the hands before eating,” said Abdullah. “Since then, I have explained this to my mother. In the beginning she was skeptical, but when I told her about the examples that we heard at school – from babies who get sick and die – she started to change.”

Promoting a life-saving intervention

The village of Sohol, Afghanistan is enclaved within mountains. Its residents have no running water and access to safe water and sanitation supplies has been difficult for many.

Despite its life-saving potential, hand-washing with soap is seldom practiced in Afghanistan and not always easy to promote. About 22 per cent of households have access to safe water and less than one out of 10 families has access to latrine facilities.

“We have a water-point in Sohol, our village. Usually it is my sister who goes to fetch the water in the morning and the evening, but sometimes I have to help her. It takes about ten minutes from our house to the water-point,” said Abdullah.

Although people may be aware that water alone is not enough, many families still do not want to invest in buying soap.

“In the past many parents said that it is too expensive to buy soap. Last year, community animators came and made clear to them how much this little investment can do, to ensure the health of their families.” said teacher Mohammad Abdullah.

“It was not easy to make them change their mind, because in a remote place like Sohol it is not always simple to have water and soap at hand when you should have it.”

The ‘Healthy School Initiative’

As a follow-up to the 2008 International Year of Sanitation, UNICEF has initiated clean village projects promoting sustainable behaviour changes on key hygiene practices among families.

The ‘healthy schools’ initiative – which includes the construction of separate toilets for girls and boys, safe drinking water systems and the training of teachers on effective hygiene promotion – is also being implemented.

To date, 1,000 schools with a total of about 320,000 students benefit directly from this intervention.

Abdullah’s school is also one out of 126 schools chosen across 11 provinces for a pilot project of the World Food Programme (WFP) and UNICEF, where water and sanitation facilities are combined with a hot meal.

Water-points, toilets and hygiene education are taken care of by UNICEF, while WFP is providing food commodities and kitchen equipment.

It is estimated that more than 70,000 school children participated in this year’s Global Handwashing Day in Afghanistan. In spite of continued conflict, they celebrated together with millions of other children across five continents.

Source: Cornelia Walther, UNICEF, 16 Oct 2009

South Africa, Cape Town: basic services needed to save babies

Toddler Sanele Qaqa should have been running around his home by now. Instead, his family is grieving his death, which could have been prevented. Sanele, the youngest of six children, died in March [2009], just two weeks ahead of his second birthday.

[…] A shocking 37 city children younger than five died of diarrhoea in February, March and April [2009] – deaths that could easily have been avoided. In 2005, more than 100 children, most of them from poverty-stricken areas, died, statistics show.

But health officials are making headway in the war on this disease. According to the Department of Health, the main contributors to the death rate are lack of access to potable water, and inadequate sanitation, sewerage services, and hygiene practices. The deaths earlier this year were largely concentrated in informal settlements where access to clean water was limited.

[Cape Town] has said that although it spends R10-million a year installing sanitation infrastructure, it is costing it R60m a year to repair infrastructure that has been damaged.

Broken toilets, stagnant pools of dirty water and human waste are common in informal settlements. These are the conditions in which disease thrives.

[Sanele Qaqa died on 28 March 2009, two days after falling ill]. One week earlier, on March 17, one-year-old Unabantu Mali died, tied to the back of his grandmother, as she made the two-hour walk home after allegedly being turned away from three health-care centres at which she had sought help for the boy, who had diarrhoea. A probe later cleared the facilities of wrongdoing.

Sanele was one of 3 586 children admitted to hospital for diarrhoea in the past year. Provincial health department spokeswoman Faiza Steyn said there was no accurate picture of deaths from diarrhoea that occurred outside hospitals.

[…] Of the 37 children who died, four had malnutrition and 12 were HIV-positive. Dehydration was the direct cause of the deaths of 14 of the children, said Steyn.

[…] According to Jaco Muller, of the City of Cape Town’s water and sanitation department, the capital expenditure for these services was R23m, while operating expenditure was R80m. The city has 223 informal settlements. The number of toilets needed was 27 052. In May, there were 2 078. The required number of standpipes providing potable water was 5 148, compared with the 4 402 that were in place.

“If all families were to have ready access to clean potable water, the risk of contamination would be considerably reduced,” said Steyn. “The risk would be further reduced if water was stored in clean containers that were cleaned regularly.”

While 37 deaths in three months is high, the mortality rate has improved since 2005, when more than 100 children in the metropole died. The provincial and city health departments have tried to curb the number of deaths through, among other things, awareness campaigns.

From April 1, [2010], a new vaccine is to be introduced that can reduce the incidence and severity of diarrhoea.

Source: Esther Lewis and Lavern De Vries, Cape Argus / Mercury & Independent Online, 05 Oct 2009

Child undernutrition, tropical enteropathy, toilets, and handwashing

The impact of sanitation and hygiene on child mortality and health has been underestimated, contends Dr Jean Humphrey in The Lancet of 19 September 2009 [free registration required].

“Of the 555 million preschool children in developing countries, 32% are stunted and 20% are underweight. Child underweight or stunting causes about 20% of all mortality of children younger than 5 years of age and leads to long-term cognitive deficits, poorer performance in school and fewer years of completed schooling, and lower adult economic productivity.”

“A key cause of child undernutrition is a subclinical disorder of the small intestine known as tropical enteropathy”, Dr. Humphrey states, which “is caused by faecal bacteria ingested in large quantities by young children living in conditions of poor sanitation and hygiene”. “Provision of toilets and promotion of handwashing after faecal contact could reduce or prevent tropical enteropathy and its adverse effects on growth”. “The primary causal pathway from poor sanitation and hygiene to undernutrition is tropical enteropathy and not diarrhoea”.

Dr. Humphrey concludes that “that prevention of tropical enteropathy, which afflicts almost all children in the developing world, will be crucial to normalise child growth, and that this will not be possible without provision of toilets”.

Full reference:

Humphrey, J.H. (2009). Child undernutrition, tropical enteropathy, toilets, and handwashing. The Lancet ; vol. 374, no. 9694 ; p. 1032-1035. doi:10.1016/S0140-6736(09)60950-8

In an earlier WHO study, the authors estimated that 860 000 deaths per year in children under five years of age were “caused directly and indirectly by malnutrition induced by unsafe water, inadequate sanitation and insufficient hygiene”. This raises the total number of children that die every year as a result of unsafe water, inadequate sanitation or insufficient hygiene to 2.2 million instead of the 1.4 million usually quoted.

Full reference:

Pruss-Ustun, A.; Bos, R.; Gore, F. and Bartram, J. (2008). Safer water, better health : costs, benefits and sustainability of interventions to protect and promote health. Geneva, Switzerland, World Health Organization (WHO). Read the full report [PDF file].

Nepal: Government failing to curtail rural diarrhoea deaths – health workers

Neglect of the rural health system and poor preparedness result in thousands of avoidable diarrhoea-related deaths annually in Nepal, health analysts warn. “The diarrhoea epidemic has repeated again due to the government’s lack of effective preventive measures which we have been reminding the officials of every monsoon,” said Prakash Amatya, director of NGO Forum for Water and Sanitation.

Most deaths occurred in remote villages in the mid-west region where a large percentage of the population remains vulnerable due to poor sanitation, unsafe drinking water and illiteracy. Many are uneducated about basic hygiene and healthcare.

In addition, there are issues of access [impassable roads] and logistics [lack of electricity].

[…] While much of the mid-west was affected, worst hit was Jajarkot district (400km northwest of the capital), where 106 people have reportedly died since 1 May [2009], according to the District Public Health Office, followed by Rukum, about 300km northwest of Kathmandu, where 25 people died between 29 June and 13 July [2009]. Deaths have also been reported from the region’s remote Dailekh, Salyan, Dang and Doti districts.

Nearly 14 percent of the country’s 27 million people live [in mid-west region], despite limited access to health, education, roads, telephones, electricity, water supply and sanitation services. The region has long been isolated from development initiatives, held back by a decade-long armed conflict and political instability.

According to UNICEF, about 13,000 children under five die annually from diarrhoea because of poor hygiene and sanitation. A government report, Nepal Country Plan for International Year of Sanitation 2008 estimated that only 46 percent of the population had access to basic sanitation. More than 14 million people, mainly in rural areas, do not have access to latrines, states the report, while over 30 percent do not have access to potable water, according to the Department of Water Induced Disaster Prevention.

“This problem would have never existed if more attention was paid to improving health hygiene and sanitation situation in the rural areas,” Pitamber Sharma, director of the disaster department of the Nepal Red Cross Society (NRCS), said.

[…] But according to the UN: “It doesn’t help to blame but to look at what needs to be strengthened, what could have been done in terms of prevention and to make this a priority for our development partners,” said Wendy Cue, head of the UN Office for the Coordination of Humanitarian Affairs (OCHA)

Source: IRIN, 17 Jul 2009

Kenya: water shortage increases cholera toll

An acute water shortage in parts of eastern and northeastern Kenya is fuelling the spread of acute watery diarrhoea (AWD) and cholera, with deaths from new cases being reported, a senior health official has said.

“People are resorting to drinking water from anywhere because of the shortage,” Shahnaaz Sharif, director of public health in the Ministry of Public Health, told IRIN.

“Recently, four deaths have been reported in Garbatulla [District] where about 280 AWD cases have been reported in the last three weeks,” Sharif said, adding that samples from those affected had been collected for laboratory testing. […] “In total, 24 cholera deaths and 1,452 cases of diarrhoea have been recorded since January [2009],” he said.

[…]

Inadequate sanitation has exacerbated the situation. “We only have one toilet for 600 pupils. It is the main reason why our school has been affected,” Sora Boru, a head teacher at Bullesa primary school in Isiolo, told IRIN. “Many children have [not] reported for school… Parents are keeping them at home.”

Hygiene awareness campaigns have been intensified in the water-scarce region.

According to Yussuf Ali, a trader, the price of bottled water has increased. “A half litre [bottle] of water is selling at Ksh.100 [about US$1.3]… even higher than petrol.

See also: Kenya: Acute watery diarrhoea kills eight in Coast Province, IRIN, 18 Jun 2009

SourceIRIN, 17 Jun 2009