Critical Ignorance in Water, Sanitation and Hygiene Steve Luby, MD, ICDDRB

1. Critical Ignorance in Water, Sanitation and HygieneSteve Luby, MD, ICDDRB

2. Global child deaths by cause

3. Annual Child Deaths Diarrhea 1,800,000 Typhoid fever 400,000 6000 child deaths per day

4. Diarrhea Other health consequences Stunted growth (malnutrition) Lost productivity Decreased cognitive function? Stunted growth � In a study from Brazil, there was a direct correlation with the number of days a child had diarrhea, and their with diarrhea Decreased cognitive function Niehaus Am J Trop Med Hyg 66(5), 2002 pp. 590-593. Stunted growth � In a study from Brazil, there was a direct correlation with the number of days a child had diarrhea, and their with diarrhea Decreased cognitive function Niehaus Am J Trop Med Hyg 66(5), 2002 pp. 590-593.

5. Why do children die of enteric diseases in low income countries? Youngest children Immature immune system Less physiologic reserve Multiple physiologic insults Malnutrition Protein & calorie deficient Micronutrient deficient Frequent infections Contaminated environment Limited access to effective clinical care

6. How do we improve the situation?

7. Outline What we know and don�t know Water Sanitation Hygiene Barriers to overcoming our ignorance Ways forward

8. WaterWe know We don�t know Historically introducing clean water reduced death from typhoid fever Improving water quality reduces disease Increasing water quantity probably reduces disease The greatest benefit is derived from improving the worst water How to develop a sustainable central water supply in a low income country mega-city The health impact of halfway measures Cost effectiveness of bringing clean water The contribution of point of use treatment Mortality effects

9. Typhoid Death Rates immediately before and after improved water supplies Lawrence, MA was the first city in the United States built the first slow sand filter to treat municipal water in 1893. The number of deaths from typhoid fever in the city dropped by over 80%Lawrence, MA was the first city in the United States built the first slow sand filter to treat municipal water in 1893. The number of deaths from typhoid fever in the city dropped by over 80%

10. Typhoid Death Rates immediately before and after improved water supplies In 1892 Newark NJ switched its major water supply from the heavily sewage polluted Passaic River to the substantially cleaner Pequannock River, and deaths from typhoid fever dropped by 60%.In 1892 Newark NJ switched its major water supply from the heavily sewage polluted Passaic River to the substantially cleaner Pequannock River, and deaths from typhoid fever dropped by 60%.

11. Typhoid Death Rates immediately before and after improved water supplies Throughout the 1800s Chicago drained its sewage into Lake Michigan and withdrew its drinking water from the same lake. In the late 1890s Chicago built a number of sewage canals that diverted sewage away from Lake Michigan. Typhoid fever deaths fell by 80%. When Chicago began chlorinating their water supply in 1919, typhoid mortality fell to 1 case per 100,0000Throughout the 1800s Chicago drained its sewage into Lake Michigan and withdrew its drinking water from the same lake. In the late 1890s Chicago built a number of sewage canals that diverted sewage away from Lake Michigan. Typhoid fever deaths fell by 80%. When Chicago began chlorinating their water supply in 1919, typhoid mortality fell to 1 case per 100,0000

12. Typhoid Death Rates immediately before and after improved water supplies In 1908 40% of the population of Atlanta did not have water mains or sewers. From 1911 to 1915, Atlanta made a massive investment in waterworks and sewerage, markedly increasing the coverage, and markedly decreasing the death rate from typhoid fever. In 1908 40% of the population of Atlanta did not have water mains or sewers. From 1911 to 1915, Atlanta made a massive investment in waterworks and sewerage, markedly increasing the coverage, and markedly decreasing the death rate from typhoid fever.

13. WaterWe know We don�t know Historically introducing clean water reduced death from typhoid fever Improving water quality reduces disease Increasing water quantity probably reduces disease The greatest benefit is derived from improving the worst water How to develop a sustainable central water supply in a low income country mega-city The health impact of halfway measures Cost effectiveness of bringing clean water The contribution of point of use treatment Mortality effects


15. If you hear people say �water quality does not matter� Only water quantity matters, you can safely conclude that you are talking with someone who is either uninformed or has a vested interest in a particular intervention. Consider digression on strength of evidence. If you hear people say �water quality does not matter� Only water quantity matters, you can safely conclude that you are talking with someone who is either uninformed or has a vested interest in a particular intervention. Consider digression on strength of evidence.


17. Increasing water quantity probably reduces disease 7 studies that looked at the impact of water quantity independent of water quality Median reduction in diarrhea 27% Esrey et. Al, Bull of WHO, 69(5):609-621 (1991) Methodologically weak Several studies have noted improved child health with increased access to water Per capita water consumption increased with proximity to water More time for child care More water for handwashing? Urban Health Newsl. 1997 Mar;(32):34-47. Links Reviewing the health impacts of improvements in water supply. * Lewin S, * Stephens C, * Cairncross S. Level of evidence is not as strong, based on description and cross sectional studies, but it remains fairly convincing to me. Urban Health Newsl. 1997 Mar;(32):34-47. Links Reviewing the health impacts of improvements in water supply. * Lewin S, * Stephens C, * Cairncross S. Level of evidence is not as strong, based on description and cross sectional studies, but it remains fairly convincing to me.

18. WaterWe know We don�t know Historically introducing clean water reduced death from typhoid fever Improving water quality reduces disease Increasing water quantity probably reduces disease The greatest health benefit is derived from improving the worst water How to develop a sustainable central water supply in a low income country mega-city The health impact of halfway measures Cost effectiveness of bringing clean water The contribution of point of use treatment Mortality effects

19. The greatest benefit is derived from improving the worst water Insert the Bob Black where do children die graphicInsert the Bob Black where do children die graphic

20. WaterWe know We don�t know Historically introducing clean water reduced death from typhoid fever Improving water quality reduces disease Increasing water quantity probably reduces disease The greatest health benefit is derived from improving the worst water The historical effect of clean central water supplies on child mortality How to develop a sustainable central water supply in a low income country mega-city The health impact of halfway measures Cost effectiveness of bringing clean water The contribution of point of use treatment Mortality effects

21. Number of surviving children during the first 5 years of life, Tilburg, Netherlands, 1904 - 1906


23. How do we develop a sustainable central water supply in a low income country mega-city? Successes Countries that have paid for their own infrastructure Challenges The population being served is living on less than $2 per day There is not an effective functioning system for collecting money from the population in need Water distribution systems are severely compromised Demand far outstrips supplies

24. Sustainable urban water supply key research questions Careful analysis of interventions Effect on Household water quantity Household water quality Health impact Financing Maintenance Long term effectiveness Critical assessment of failures Might one of the failure of the large infrastructure projects have been failure of research, failure to identify the questions, and address them systematically?


26. The health impact of halfway measures Improving a water treatment plant, but not the distribution system. Increasing the quantity of water from 4 hours per week to an hour per day. The health impact of improved water supplies in rural areas


28. Cost effectiveness of bringing clean water We cannot tell policy makers how investments in improved water compare to investments in nutrition, vaccination, or improved roads. Consider the discussion. Do you want clean water? Yes, should we have clean water yes? How can you supply clean water that is available 24 hours a day and is not contaminated by major biological or chemical contaminants? I don�t know. How much will it cost? I don�t know. Compare this to my health colleague who is meeting with the minister of finance directly afterward promoting rotavirus vaccine.Consider the discussion. Do you want clean water? Yes, should we have clean water yes? How can you supply clean water that is available 24 hours a day and is not contaminated by major biological or chemical contaminants? I don�t know. How much will it cost? I don�t know. Compare this to my health colleague who is meeting with the minister of finance directly afterward promoting rotavirus vaccine.


31. Research agenda for point of use water treatment Can this be deployed at scale Sustainably With an impact on health?

32. WaterWe know We don�t know Historically introducing clean water reduced death from typhoid fever Improving water quality reduces disease Increasing water quantity probably reduces disease The greatest benefit is derived from improving the worst water The historical effect of clean central water supplies on child mortality How to develop a sustainable central water supply in a low income country mega-city The health impact of halfway measures Cost effectiveness of bringing clean water The contribution of point of use treatment Mortality effects

33. SanitationWe know We don�t know Human enteric pathogen move from the feces of infected persons to un-infected persons There is an important difference between having a sanitary latrine and using it A number of community based behavior change strategies have been developed that have improved the prevalence and use of latrines The health impact of improved sanitation on its own. in combination with other interventions Which approaches are optimum Immediate Mid-range Long-term How to develop sustainable interventions.




37. How to Prevent DiarrheaCross National Comparison Based on work by Steve Esrey and others, comparing the incidence of diarrhea in settings with different levels of each of these interventions. Conclusions included it was more important to work on sanitation than on water, and water quantity was more important than water quality. This is the conceptualization that has underlied water and sanitation interventions for the last 3 decades.Based on work by Steve Esrey and others, comparing the incidence of diarrhea in settings with different levels of each of these interventions. Conclusions included it was more important to work on sanitation than on water, and water quantity was more important than water quality. This is the conceptualization that has underlied water and sanitation interventions for the last 3 decades.

38. Problems with cross national comparisons With settings that were so different it is hard to know if the differences were a result of the infrastructure or program. Quite far from a randomized controlled trial

39. The health impact of improved sanitation

40. The health impact of sanitationResearch Agenda We lack convincing data on the impact of sanitation No randomized control trials No rigorous assessments of the relative importance of sanitation, water supply and hygiene Absence of convincing data have limited investment For 35 years commentators have noted we do not have this information. Sanitation believers advocate, but in the absence of data their advocacy has been insufficient



43. Hygiene : Handwashing

44. HandwashingWe know We don�t know Handwashing has health benefits Diarrhea Respiratory disease Effective in sub-optimal situations Where water and sanitation are not improved Where drying is imperfect There are important community benefits Soap requires water How to effectively improve handwashing behavior at scale How effective handwashing is in preventing severe pneumonia What effect handwashing has on child mortality

45. In highly contaminated settings :What role for soap and personal hygiene?

46. ObjectiveSoap Health Study, Karachi, Pakistan, 2002 Measure effect of handwashing with soap on diarrhea acute respiratory illness Measure effect of skin washing with soap on impetigo Measure the marginal benefit of including an antibacterial compound in soap on preventing impetigo

47. Environmental SettingKarachi Soap Health Study, 2002 Squatter settlements Sewage contaminated drinking water 10,900 colony forming units of fecal coliforms per 100 ml Feces contaminated environment

48. Disease SettingKarachi Soap Health Study, 2002 10% of children die before their 5th birthday 40% from diarrhea 13% from acute respiratory disease 30-40% of children are malnourished

49. Cluster Randomized Study




53. Interventions Antibacterial soap Chemically identical to commercially available Safeguard� soap Generic package & bar Contains 1.2% triclocarban Inhibits the growth of gram positive bacteria Plain soap Identical to antibacterial soap except no triclocarban added Generic package & bar School supplies

54. Handwashing Promotion Households visits, at least weekly, by HOPE, a trusted, local NGO Discussions in households native language Pictures used to promote discussions about handwashing Questions answered Diarrhea data collected Soap re-supplied

55. Soap group instructions Wash skin once a day

56. Soap group instructions Wash hands thoroughly lathering with soap After Defecation Cleaning an infant Before Preparing food Eating Feeding an infant

60. Baseline I rounded 3000Rs to $60I rounded 3000Rs to $60

61. Diarrhea longitudinal prevalence by week and handwashing intervention

62. Percent of days with diarrhea by age and intervention Karachi, Pakistan 2001/02

63. Percent of days with diarrhea by age and intervention Karachi, Pakistan 2001/02

64. Pneumonia Definition Followed WHO clinical case definition Cough or difficulty breathing with respiratory rate >60 among children < 60 days respiratory rate >50 among children 60�365 days respiratory rate >40 among children 1 � 5 years Respiratory rate counted for 1 minute, timed with a watch

65. Pneumonia incidence by week and intervention group among children < 5 years of age

66. Impetigo prevalence by week and intervention Include bullous impetigoInclude bullous impetigo

67. Karachi Soap Health Summary Children who washed their hands and skin with plain soap had 52% less diarrhea 50% less pneumonia 45% less impetigo Children receiving antibacterial soap had a similar disease experience as those who received plain soap

68. Other evidence of handwashing effectiveness Diarrhea Meta analysis Val Curtis, 2003, 47% reduction in diarrhea with handwashing Loma Fewtrell, 2005, 33% reduction in diarrhea with handwashing Additional studies on handwashing and ARI Child care centers Canada 14% reduction in URI Australia 12% reduction in URI U.S. 32% reduction in URI School intervention 21% reduction in colds US Navy : 45% reduction in outpatient visits for pneumonia

69. HandwashingWe know We don�t know Handwashing has health benefits Diarrhea Respiratory disease Effective in sub-optimal situations Where water and sanitation are not improved Where drying is imperfect There are important community benefits Soap requires water How to effectively improve handwashing behavior at scale How effective handwashing is in preventing severe pneumonia What effect handwashing has on child mortality

70. HandwashingWe know We don�t know Handwashing has health benefits Diarrhea Respiratory disease Effective in sub-optimal situations Where water and sanitation are not improved Where drying is imperfect There are important community benefits Soap requires water How to effectively improve handwashing behavior at scale The importance of addressing handwashing barriers How effective handwashing is in preventing severe pneumonia What effect handwashing has on child mortality

71. Improving Handwashing Behavior at Scale Intensive interpersonal communication Effective Prohibitively expensive Without analogy in public health Mass media Has been tried, but not rigorously evaluated Research difficulties Expensive Difficult design to randomize Outcomes difficult to assess


73. Barriers to Handwashing How important? The accessibility of water? The volume of water? The cost of water? The cost of soap? The proximity of handwash stations to latrines and kitchens?



76. Why are we so ignorant? Separation of Environment and Health Institutional Professional Fundamentally difficult technical issues Diarrhea is hyper-variable Microbiological quality does not correlate neatly with health Large interventions are difficult to randomize and assess

77. 1975 Expert Panel Convened by the World Bank Large-scale longitudinal studies are probably the only means of assessing the health benefits of water and sanitation projects Such studies should NOT be undertaken High cost Limited possibility of success Restricted applications of results After 30 years with so little progress in this sector, should we re-think this conclusions?After 30 years with so little progress in this sector, should we re-think this conclusions?

78. Summary We know Global importance of the target diseases Routes of disease transmission Effectiveness of small scale interventions What we don�t know Effectiveness at scale Optimal intervention mix Sustainability

79. Our options Plodding ignorance Hope that the advocates will be persuasive Hope that what we know is good enough Strategic research on key issues Identify key issues, and a strategic plan for addressing them Work together as a research community To identify opportunities for collaborative investigation Garner the support to advance the agenda Remain practical

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Critical Ignorance in Water, Sanitation and Hygiene Steve Luby, MD, ICDDRB

Critical Ignorance in Water, Sanitation and Hygiene Steve Luby, MD, ICDDRB

Presentation Transcript

Sanitation and Hygiene

Field Hygiene and Sanitation

School Water, Sanitation and Hygiene SNV Experience

FSM in the Foundation’s Water, Sanitation and Hygiene Strategy

Water, Sanitation & Hygiene Technology

Food Sanitation and Hygiene

Water, Sanitation & Hygiene in Thailand

Sanitation Hygiene

Integrating Advocacy in Water Sanitation and Hygiene Programmes

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The IASC WASH Cluster Water, Sanitation and Hygiene

Social Entrepreneurs in the Water, Sanitation and Hygiene Sector

Civil Society Water, Sanitation and Hygiene Fund

Diseases related to water, sanitation and hygiene (WASH)

Investing in Water, Sanitation and Hygiene Services for Children

Water, Sanitation and Hygiene (WASH) Cluster Working Group

WASH Water, Sanitation and Hygiene A Review

Water, sanitation, hygiene & environmental health

HYGIENE, SANITATION, AND SAFETY

SANITATION & HYGIENE

Critical Ignorance in Water, Sanitation and Hygiene Steve Luby, MD, ICDDRB