Sanitation and health: what do we want to know?

Experts meet to discuss reaching a consensus on what the evidence tells us.

Radu Ban

Jan Willem Rosenbom

This is the first of two blogs written about the “Sanitation and health evidence consensus meeting”, convened by the World Health Organization (WHO) in Seattle on May 24 and 25 of 2018. It was written by Jan Willem Rosenboom and Radu Ban, who are both Sr. Program Officers on the Water, Sanitation and Hygiene (WSH) team at the Bill & Melinda Gates Foundation. This first blog will describe the process used to arrive at the consensus, while the second blog will describe the outcome of the consensus and will come out once the results of the consensus meeting have been published. Also, mark your calendars for a session during the 2018 UNC Water and Health conference dedicated to this consensus!

Two sides of sanitation: rubbish and cleanliness. Credit Bill & Melinda Gates Foundation, Cambodia/India

Introduction: What is this about?

It is hard to imagine that making improvements in sanitation wouldn’t play a role in improving health. After all, we know that shit spreads disease and the F diagram shows us that sanitation is an important tool in blocking the transmission of pathogens from one person to the next, thus lowering exposure. And sure enough: we have strong evidence about the effectiveness of sanitation interventions and improving health and human capital outcomes from rigorous historical studies, from high- as well as low- and middle-income countries.

At the same time, looking at the specific impact of programmatic sanitation interventions, it can be hard to figure out what the evidence is really telling us. On the one hand, a systematic review of the whole body of evidence on sanitation and health (carried out by Freeman et al. in 2017) suggests that sanitation protects against diarrhoea, active trachoma, some soil-transmitted helminth (STH) infections and schistosomiasis. It also improves height-for-age scores of children (i.e. it decreases stunting, which is an important measure of human capacity). On the other hand, several recent sanitation intervention studies have found limited or no impact on different health outcomes. The table below (copied with permission from a presentation by Tom Clasen), provides a summary of key findings from the most recent sanitation studies:

1. Fewer observed flies and feces; no change in fecal contamination of water
2. Fewer observed soiled hands and less fecal contamination of water
3. Except in the study arm considering just water quality improvements

This seeming lack of agreement is confusing, and partly in response to questions from practitioners, on May 24 and 25 of this year WHO convened a meeting of experts to review the existing evidence and reach a consensus about what it is telling us. The group of experts consisted of researchers across multiple disciplines who had written extensively on the topic of sanitation and health. We thought it was necessary to reach consensus among researchers before engaging, in a unified voice, the practitioner community.

At the same time, to make sure that the concerns of practitioners would be considered in the meeting, we published a “request for input” online (through the SuSanA network as well as the Sanitation Updates blog) and we will summarise the responses here. But first…

Poor sanitation cost global economy US$ 223 billion in 2015

Lack of access to sanitation cost the global economy US$222.9 billion in 2015, up from US$182.5 billion in 2010, a rise of 22% in just five years, according to a new report released on 25 August 2016 by LIXIL Group Corporation (“LIXIL Group”), a global leader in housing and building materials, products and services.

The true cost of poor sanitation, published in collaboration with WaterAid and Oxford Economics, which conducted economic modeling to develop up-to-date estimations of the global cost of poor sanitation, brings to light the high economic burden in low-income and lower-middle income countries.

More than half (55%) of all costs of poor sanitation are a consequence of premature deaths, rising to 75% in Africa. A further quarter are due to treating related diseases, and other costs are related to lower productivity as a result of illnesses and time lost due to lack of access to a private toilet.

Impact of WASH in improving health of school children reviewed

More attention should be given to the assessment of nutrition practices when assessing the impact of WASH on the health of school children. We also don’t know enough about the long term impact of WASH interventions on child health. These are some of the conclusions that researchers from the Center for Global Health and Development at the the University of Nebraska Medical Center (UNMC) drew from a review of the literature [1].

Dr. Ashish Joshi and research assistant Chioma Amadi reviewed the impact of water treatment, hygiene, and sanitary interventions on improving child health outcomes such as absenteeism, infections, knowledge, attitudes, and practices and adoption of point-of-use water treatment.  For their final analysis they selected 15 peer-reviewed English-language studies published between 2009 and 2012 that focused on the effects of access to safe water, hand washing facilities, and hygiene education among school-age children.

Estimating inequities in sanitation-related disease burden and estimating the potential impacts of propoor targeting,

Estimating inequities in sanitation-related disease burden and estimating the potential impacts of propoor targeting, 2012.

• Full-text (pdf)

Richard Rheingans, et al. SHARE.

The objectives of this study are to model for 10 low-income countries in sub-Saharan Africa and South Asia:

• The distribution of sanitation-related health burden by wealth quintile
• The distribution of health benefits for targeting different wealth quintile groups
• The spatial distribution of sanitation-related health burden and benefits

Key results
Although inadequate data and knowledge prevent definitive answers to the questions outlined in the objectives for this study, the results of this modeling exercise based on exisiting information suggest the following:

• The health burden of poor sanitation falls disproportionately on children living in the poorest households
• This increased health burden is the result of both greater exposure to infection and increased susceptibility among children in these households
• The increased exposure among these children is a function of their increased likelihood of having no access to a private facility, having to use shared facilities and being more likely to live in an area with a high density of people without sanitation
• Children in poor households are more likely to be susceptible (resulting from lower nutritional status) to diarrhoeal diseases and suffer higher mortality
• Improvements in sanitation for households in the poorest quintile may bring significantly greater health benefits than improvements in the richest quintiles
• The sanitation-related burden differs between rural and urban settings, but children in poor households in both settings consistently suffer disproportionately
• While rural populations generally have lower levels of access, the sanitation associated risk may be greater for the urban poor due to the increased likelihood of these households being in areas with a high density of people without sanitation

Conclusions

• There are important limitations of this study that must be highlighted: (1) the relative importance of the three exposure variables which are modeled as being equal; (2) the susceptibility index contains only three variables (nutritional vulnerability, Vitamin Adose, and ORS treatment); (3) only diarrhoeal mortality is considered in estimating the distribution of health impacts, and the total burden and its distribution would change if other sanitation-related health impacts were included
• More effective targeting strategies to reach children in the poorest households are required to both protect those children and households most at risk and to maximize the potential impact of sanitation investments. Although the study did not directly consider
  the relative costs associated with reaching the poorest households, the results suggest that targeting the poorest households could yield substantially higher health returns and may also bring greater economic returns
• Better use of available information on the distribution of sanitation-associated risk and health burden could strengthen planning and resource allocation
• Current monitoring indicators at the national and global levels fail to incentivise targeting the areas of greatest need and potential greatest impact. Existing limitations in monitoring efforts include a focus on household coverage rather than child coverage; the use of household access, not community level exposure measures; no direct targets for focusing improved access on the poorest; and, in some settings, the under counting of the most vulnerable urban populations
• Additional information on the relative risk of shared facilities and density of population without sanitation would allow for better identification of priority areas and targeting of interventions.

See the related press release, policy briefing and podcast.

Health impacts of WASH & IAP interventions

Issue 40 January 27, 2012 | Year in Review – Health Impacts of WASH and IAP Interventions from 2011

This WASHplus Weekly issue contains nine 2011 studies on the health impacts of water, sanitation, and hygiene (WASH) interventions and seven 2011 studies on the health impacts of interventions to prevent or reduce indoor air pollution.

One WASH study (Water and Sanitation Program) calculates the economic costs to five East Asia countries due to losses related to poor sanitation.

On the IAP side, a study (Dix-Cooper) investigated whether early life chronic exposure to wood smoke is associated with children’s neurodevelopmental and behavioral performance. This seems to be the first study of its kind.

• Link

India: inadequate sanitation costs the equivalent of 6.4 percent of GDP

Inadequate sanitation costs India US$ 53.8 billion, which is equivalent to 6.4 percent of India’s GDP in 2006, according to a new report [1] from the Water and Sanitation Program (WSP).

The study analyzed the evidence on the adverse economic impacts of inadequate sanitation, which include costs associated with death and disease, accessing and treating water, and losses in education, productivity, time, and tourism. The findings are based on 2006 figures, although a similar magnitude of losses is likely in later years.

The report indicates that premature mortality and other health-related impacts of inadequate sanitation, were the most costly at US$ 38.5 billion, 71.6 percent of total impacts, followed by productive time lost to access sanitation facilities or sites for defecation at US$ 10.7 billion, 20 percent, and drinking water-related impacts at US$ 4.2 billion, 7.8 percent.

“The cost is more than I expected,” UNICEF’s water, sanitation and hygiene chief Clarissa Brocklehurst said in an interview with news site Bloomberg. “Yet, if you know the scale of open defecation in India, it’s not all that surprising.”

South Asian Sanitation edition of Waterlines

There are more people in south Asia without adequate sanitation than anywhere else in the world. Nevertheless, this is a region where great progress is being made, where there is much to learn about approaches that work, and where the optimism is tangible.

The July 2008 edition of Waterlines, which includes papers from IRC/WaterAid’s South Asian Sanitation conference in January 2008, features some of the most promising approaches. How has the replication of the Orangi small-bore sewerage project to other Pakistani cities worked out? Should total sanitation campaigns always be free of hardware subsidy? Learn about using teachers to run village sanitation campaigns. What are the health impacts in open-defecation free villages, one year after the campaign? These and other questions are discussed in this edition.

Single hardcopies of the July edition (cost £12.50) can be ordered from Practical Action, publishinginfo@practicalaction.org.uk

Non-subscribers can download articles (US$ 9 each) here

Waterlines – VOLUME 27 NUMBER 3 JULY 2008 – Contents

• Crossfire: ‘Community-led total sanitation is the best method of achieving sustainable sanitation for all in rural areas’ – ARUMUGAM KALIMUTHU and YAKUB HOSSAIN
• Sanitation and hygiene in South Asia: Progress and challenges – CHRISTINE SIJBESMA
• Subsidy and sustainability in urban sanitation: The case of Quetta Katchi Abadis Environment Management Programme – SYED AYUB QUTUB, NASEEMA SALAM, KHALID SHAH and DAANISH ANJUM
• School-led sanitation promotion: Helping achieve total sanitation outcomes in Azad Jammu and Kashmir – FAROOQ KHAN, RABIA T. SYED, MOHAMMED RIAZ, DEIRDRE CASELLA and VICTOR KINYANJUI
• Cross-sectional health indicator study of open defecation-free villages in Madhya Pradesh, India – TAPAS CHAKMA, SAM GODFREY, J. BHATT, P.V. RAO, P. MESHRAM and S.B. SINGH

Keeping it clean: New landmark study confirms the importance of home and personal hygiene in reducing infectious diseases and infections

“ACCORDING to results from the Hygiene Promotion and Illness Reduction study, children aged five years or under experienced significantly fewer respiratory, gastrointestinal, and skin diseases when their families participated in intensive hygiene education plus the use of hygiene products.

The results of the three year study, which was conducted in impoverished urban communities in South Africa and presented during the 13th International Congress on Infectious Diseases (ICID) held in Kuala Lumpur recently, also show that hygiene education alone offers meaningful improvements in illness reduction compared to no education at the start of the study.

However when effective hygiene products (antibacterial soap, surface cleanser/disinfectant, and skin antiseptic) were used in addition to education, an even greater reduction in the risk of illness was noted”.

[…]

Prof. Eugene Cole

“The study was developed and conducted under the guidance of the Health and Hygiene Promotion Partnership (HPP), a community-based project founded in 2005 by cooperation between Reckitt Benckiser Inc and Brigham Young University [lead investigator Dr Eugene Cole], with members of the participating housing communities, under the approval of the Cape Town City Health Department”.

References:

1. Cole E, Hawkley M, Rubino J, McCue K, Crookston B, and Dixon J. Comprehensive family hygiene promotion in peri-urban Cape Town: Gastrointestinal and skin disease reduction in children under five. 13th ICID; Read abstract no 68.012.

2. Cole E, Crookston B, Rubino J, McCue K, Hawkley M, and Dixon J. Comprehensive family hygiene promotion in peri-urban Cape Town: Reduction of respiratory illness in children under five. 13th ICID; Read abstract no 68.030

Read more: The Star Online (Malaysia), 06 July 2008

See also: Aeysha Kassiem, How to cut infection, Cape Times / IOL,  22 Jul 2008

Sanitation ‘crucial’ for tackling water-borne disease

Effective and affordable interventions that provide the global population with access to safe drinking water and adequate sanitation are needed if water-borne diseases are ever to be controlled.

This is the conclusion of a World Health Organization (WHO) report entitled ‘Safe Water, Better Health’, released in June.

The report provides for the first time country-by-country estimates of disease caused by poor water quality, sanitation and hygiene.

It finds that children, particularly in developing countries, suffer a disproportionate share of the disease burden caused by unsafe drinking water and poor sanitation.

The WHO estimates that almost ten per cent of the global disease burden is caused by unsafe water and sanitation and that the economic return of investing in improved access to safe drinking water was ten-fold.

The WHO’s findings echo a study by researchers from the University of Michigan, who published a paper on the challenges of achieving global sanitation coverage in the journal Environmental Science and Technology.

More – TropIKA

Pakistan – Diarrhoeal diseases cost country

ISLAMABAD: The diarrhoeal diseases are costing Pakistan Rs 55 billion to Rs 84 billion annually, as 91 million population – 74 million in rural areas and 17 million in urban areas – lack access to improved sanitation in the country, said Caretaker Minister for Environment Syed Wajid Ali Bukhari on Tuesday.

He was addressing the inaugural ceremony of International Year of Sanitation (IYS 2008).

Bukhari said 1.5 million under-five children died every year in the world due to diarrhoea, of which 88 percent deaths were due to lack of sanitation and adequate water.

Read More – Daily Times