Why Sanitation is important for Afghanistan

1. Why Sanitation is important for Afghanistan AFCOSAN 22 November 2016

2. Why Sanitation ……… • Sanitation and Health • Global Disease Burden • Diarrhoea • Effectiveness WASH interventions • Other diseases • Sanitation and Nutrition • Sanitation and Education • Social outcomes of improved sanitation • The cost/benefits of sanitation

3. 11% of U5 mortality is caused by diarrhoea Global Burden of Diseases amongst children under 5

4. Global Burden of Diseases - Diarrhoea • The number of children under five years of age dying each year declined from more than 12 million in 1990 to 6.9 million in 2011. • Diarrhoea remains the second largest cause of under-five mortality (U5M). The total share of U5M attributable to diarrhoea is 11% (a total of 1% in the neonatal period, 10% in 1-59 months) • Eliminating Open Defecation is essential to preventing the spread of diarrhoea, globally over 800 children die every day from diarrhoea.

5. 2.5 billion cases among children U5 each year (morbidity) Incidence is highest in the first two years of life and declines as a child grows older (UNICEF/WHO) Proportional distribution of diarrhoea cases among children under five years of age, by region (UNICEF /WHO)

6. In terms of illness, of the 2.5 BILLION cases of diarrhoea a year, incidence is highest in the first two years of life and declines as a child grows older (UNICEF/WHO)Children under 2 years experience an average of three to five episodes of diarrhoea per year in developing countries In some countries, the rate is six to eight episodes per year (Dewey and Mayers 2011). While diarrhoeal incidence peaks at 6–11 months of age.

7. Outcomes of various sanitation meta-analyses on the reduction in diarrhoea morbidity in children under 5 (‘sanitation’ here means to use of toilets/latrines)

8. Sanitation (Mortality) Anew study(Semba et al) analysing 40,000 randomly selected households from poor urban and rural areas concludes the following.  Compared to having an improved latrine • Among rural families, lack of an improved latrine increased under 5 mortality by 29% • Among urban families, lack of an improved latrine increased under 5 mortality by 22% • Among rural families, open defecation increased child mortality by 43% • Among urban families, open defecation increased child mortality by 30%

9. Other WASH related Diseases

10. WASH Disease Burden (excluding diarrhoea) Soil Transmitted Helminthes: Hookworm, Roundworm Whipworm Prevalence: 2 billion Mortality: 12,000 Trachoma (blindness) Prevalence: 5 million Mortality: 0 Schistosomiasis (Bilharzia); Prevalence: 200 million Mortality: 15000 Respiratory Infections (23% reduction in morbidity through handwashing with soap) Guinea worm disease (Dracunciliasis) Incidence: <5,000

11. Prevalence of Soil Transmitted Helminthes is astounding More than 1 billion people are infected with one or multiple species of STH (intestinal worms)

12. Total WASH related Disease Burden WASH accounts for 19% of all deaths in 0-14 year olds globally And 16% of illnesses (DALYs/Morbidity) among 0-14 year olds globally

13. Deaths and DALYs attributable to water supply, sanitation and hygiene WASH related Deaths WASH related DALYs PEM: protein–energy malnutrition Summary statistics on deaths and disability related to water, sanitation and hygiene (WHO)

14. WASH and Nutritional Status

15. The association between WASH and Nutritional Status Source: WHO

16. Undernourished children are at higher risk of dying due to diarrhoea Odds ratio of dying due to pneumonia and diarrhoea among undernourished children relative to well nourished children A child who is severely underweight is 9.5 times more likely to die of diarrhoea than a child who is not underweight.

17. The association between WASH and Nutritional Status

18. Association between diarrhoea/growth and helminths/growth Left: average height-for-age z-score (haz) by age and number of episodes of diarrhoea in the first 2 years of life Right: mean height-for-age z-scores by age in children with (diamonds) and without (squares) intestinal helminths

19. Lancet 2008, Checkley, data pooled from 9 studies 25% of all stunting in 24-month-old children attributable to having five or more episodes of diarrhoea. Lancet 2004, Peru, Checkley. Children lacking adequate sewage connections and using small water-storage containers had a 1·8 cm growth deficit compared with those in households with sewage connections and which used large containers. Esrey 1996, multi-country analysis, sample size almost 17.000 Improvements in sanitation were associated with increases in height ranging from 0.8cm to 1.9cm. (decrease in stunting 4–37% (rural) and 20–46% (urban) WASH conditions are a determinant of Nutritional Status These studies suggests a considerably greater effect than the 2·4% decrease in prevalence of stunting previously estimated in the Lancet Series of 2008 (Lancet, Humphrey).

20. WASH and Education

21. Poor WASH affects School performance

22. Opportunity Costs of children to attend school On 52.9% of pupils’ hands in Greece faecal pathogens were present (Kyriacou et al 2009). Handwashing in primary schools and daycare centers reduces the incidence of diarrhea by 30% (Cochrane 2008) More on WASH and Education Sanitation in schools increases attendance, especially for adolescence girls? Handwashing among school children plays a role in reducing absence (Bowen et al 2007 - Lopez-Quintero et al 2009) Children enduring intense infections with whipworm miss twice as many school days as their infection-free peers (WHO 2005). Female primary school attendance ratio in least developed countries = 63%

23. Evidence Specific to Handwashing with Soap

24. Outcomes of various handwashing meta-analyses on the reduction in diarrhoea morbidity in children under 5

25. Handwashing with Soap Most Cost-effective …to prevent diarrhoea related deaths and disease. Acute respiratory infections (ARI’s) Reduction by around 23 % Maternal handwashing 44% increase in neonatal survival rate (1 study in Nepal) Critical measure in controlling pandemic outbreaks of respiratory infections. e.g. Washing hands with soap more than 10 times a day cut the spread of SARS (2006) by 55 per cent. Water alone is not enough, but soap is rarely used for handwashing. Laundry, bathing and washing dishes are seen as the priorities for soap use.

26. Rates are low. Observed rates of handwashing with soap at critical - range from zero per cent to 34 per cent. Primary schools and daycare centers Handwashing with soap reduces the incidence of diarrhoea by an average of 30 per cent. Handwashing with Soap The lack of soap is not a significant barrier to handwashing With the vast majority of even poor households having soap. Soap was present in 95 per cent of households in Uganda, 97 per cent of households in Kenya and 100 per cent of households in Peru. School Absenteeism. In China, for example, promotion and distribution of soap in primary schools resulted in 54 per cent fewer days of absence among students compared to schools without such an intervention.

27. Child Faces Disposal and Diarrhea • Meta analysis: “risky behaviors” associated with a significant increased risk for diarrheal diseases -> 23% higher (Gil, Lanata et al. (2004) • “Neglected target for hygiene promotion”

28. Question: Why does this happen / How can this be prevented? % Frequency of Contaminated Samples Mother’s hands Mother’s breasts 2nd caregiver’s hands Baby bed/mattres Baby supply area Bedroom doorknob Mother’s dining table Water jug handle Food prep. Area Family dining table Food storage area Entrance doorknob Wash tub Clothing line

29. DCPP estimates of effectiveness Source: Disease Control Priorities in Developing Countries, Chapter 41.

30. Cost effectiveness Source: Disease Control Priorities in Developing Countries. Jamison et al 2006 chapter 2 p.41

31. Relationship between the degree of Open-Defecation and the Prevalence of Diarrhoea in villages in Himachal Pradesh, India, 2004 Question: What could explain the enormous difference in diarrhea prevalence when latrine usage goes from 95% to 100%? In effect, even if a small segment of the population continues to practice open defecation, the risk of bacteriological contamination and disease transmission may continue to be high.