Module 3 WATER SUPPLY IN HEALTHCARE FACILITIES WASH FIT

1. Module 3 WATER SUPPLY IN HEALTHCARE FACILITIES WASH FIT

2. Overview • Describe minimum water quantities and storage required in HCFs • Understand water quality requirements in HCF and how to assess water quality • Understand water treatment options and their effectiveness

3. Water • Water supply –type and availability for users (health workers, patients and visitors) in a HCF • Water quantity & storage – Amount of water available for use in a HCF per day • Water safety & water quality testing – Key parameters for consideration • Water treatment options-Effectiveness and examples

4. What are some of the problems linked to an inadequate water supply in a health care facility?What constitutes an ‘adequate’ water supply? Brainstorming

5. Water Supply • Water must be on-site from an improved source • i.e. Water system in buildings / water system on facility grounds / public tap/fountain / Borehole / Protected well / Protected rainwater collection. • Water should be safely treated, reliable and sufficientfor all needs • Water should be available for • drinking • personal hygiene including hand washing and bathing • personal utensils • cooking • laundry • cleaning • medical activities

6. Water Supply • Water supply should be piped into the facility or available on premises • Water should be available at all points of care (in all outpatient and inpatient treatment locations). • Water should be available throughout the year (i.e. not affected by seasonality, power outages, etc.) • Water piping must be functional (i.e. no major leaks, all end points are connected to an available water supply). • A reliable point for drinking water should be made available to staff, carers and patients at all

7. WHO suggested minimum water quantities in health care facilities Source: WHO. (2008). Essential environmental health standards in healthcare page 29.

8. Water Storage • Water storage should be sufficient to meet the needs of the facility for 2 days. • Storage tanks/reservoirs should be kept clean and have a tight lid • Acceptable storage methods include: clean, covered and well maintained containers which are free from any cracks, leaks, etc. Such containers should also allow for water to be extracted without hands or other potentially contaminated surfaces from touching the water (i.e. through use of a tap).

9. Exercise You work in a primary care facility with (on average) 40 outpatient consultations and 3 vaginal births per week No in-patients. How much water do you need per day? How big should you storage tank be?

10. Answer and example calculation of water storage needed Primary care facility with (on average) 40 outpatient consultations and 3 vaginal births per week (no in-patients) • Total water (L) per week= (40 x5) + (3 x 100) = 700 Liters • Total water (L) per day=700/7 = 100 Liters • Water storage required (two day supply)= 200 Liters

11. Why “safely managed” water matters for health MDG “basic services” Piped safely managed water results in the highest diarrhoeal disease reductions SDG “safely managed”

12. WHO’s guidance on water quality • Guidelines on Drinking-water quality (GDWQ) 4th edition present risk-based approach to managing water quality • Ideally water is free of microbial contamination; concentration limits are included for major chemicals as well as ideal chlorine residuals • Evaluating household water treatment options (2011) provides standards for point of use treatment options • Water safety plans are GDWQ implementation mechanism

13. Water Quality • Water should be free of faecal contamination (0 E. Coli/100ml), • Turbidity level should be < 5 nephelolometric turbidity units (NTU), • Free chlorine residual should be 0.2 – 0.5 mg/l at point of consumption (or up to 1.0 mg/l in emergencies) • National water quality standards should exist; check these standards and whether the water supply at the facility meets these. • Drinking-water ought to be easily accessible to all (including with disabilities) at all times and in all wards • Drinking-water should be safely stored with a clean bucket/tank and lid and tap

14. Assessing water safety • First, conduct a sanitary survey: will provide a valid indication of risk of contamination • To confirm safety and/or if risk mitigation measures are effective consider water quality testing • Can test for free chlorine residual (if applicable); if residual is present microbial safety is likely • If chlorine is not used and/or not present consider microbial testing • Certain locations will have other risks (i.e. flouride or arsenic) which may need to be assessed

15. Assessing free chlorine residual • Free chlorine residual is the concentration of chlorine available for disinfection • Accuracy of chlorine tests vary widely • Many "pool testers" and comparators will not provide accurate concentration values (only presence/absence) • Most accurate are digital meters followed by color wheels

16. Examples of chlorine test kits Digital meter Color Wheel Pool tester Test Strips

17. Question What are three main types of pathogens that can cause diarrhoeal disease? Through which transmission routes can these pathogens cause diarrhoeal disease?

18. Microbiological water quality • Three main types of pathogens cause diarrhoeal disease: bacteria, viruses and protozoa • Bacteria are usually the easiest to remove and the easiest to test; millions of different species exist • Fecal indicator bacteria are used to determine extent of fecal contamination the water and include: • Coliforms • E. coli preferred over TTC • Enterococci • Lower numbers • More persistent • Sulfate-reducing bacteria • H2S test

19. Growth media • Conventional (e.g. lauryl sulfate broth, m-FC) • Not specific to E. coli • Strict temperature requirement • Usually prepared from powder broth • Chromogenic media (MUG, X-gluc…) • Specific to E. coli, produce a characteristic color • Often pre-mixed product • More robust, more expensive • Consider refrigeration requirements

20. Films, Plates, Pads • 3M Petrifilm • Compact Dry EC plates • Sartorius Nutrient Pad sets

21. Presence / Absence • Chromogenic enzyme (colors, fluorescence) • IDEXX Colilert, Colisure • mColiBlue • Others…. • H2S test • Considerations: • Do you need to know the level of contamination? • Do you need to know contamination in 100 mL?

22. Presence / Absence

23. Combinations • Presence-Absence + 1 mL Portable MicrobiologyLaboratory, 10 mL IDEXX + 1 mLPetrifilm waterinternational.org/?page_id=270 mWater portable test kit 100 mLHyserve + 1 mL Compact Dry www.mwater.co/kits.html

24. Most probable number (MPN) • Many P/A tests combined • Statistical analysis • Most probable number • Confidence intervals • More wells, more confidence • IDEXX Quantitray • 49 x 2 mL, 48 x 0.2 mL

25. MPN Trays • Hyserve EC Blue • 5 x 10 mL, 1 mL, 0.1 mL www.hyserve.com • BluewaterColiplate • 96 x 1 mL, 0.1 mL www.bluewaterbiosciences.com

26. MPN Bag • Aquagenx • 5 compartments in bag • 56, 30, 10, 3, 1 mL • Ambient temperatureincubation • No need for UV www.aquagenx.com

27. Arsenic test kits

28. Flouride test kits

29. Water Treatment Water should be treated and collected for drinking with a proven technology that meets WHO performance standards including • filters • boiling • coagulation/flocculation • solar • chlorine (for non-turbid water) Higher performing technologies (i.e. two or three stars) are recommended for vulnerable groups (i.e. those with HIV, pregnant mothers or young infants) and where the specific pathogen of concern is not known.

30. Examples of Water Treatment Technologies Ceramic filtration Coag-Flocculant Membrane filtration Solar Chlorine

31. Water for bathing • Sufficient energy is available for pumping and boiling water (mark if not applicable). • At least one shower or bathing area is available per 40 patients in inpatient settings and is functioning and accessible • Shower(s) are adequately lit, including at night.

32. WASH FIT Water indicators (1) ESSENTIAL 1.1 Improved water supply piped into the facility or on premises and available. 1.2 Water services available at all times and of sufficient quantity for all uses. 1.3 A reliable drinking water station is present and accessible for staff, patients and carers at all times and in all locations/wards. 1.4 Drinking water is safely stored in a clean bucket/ tank with cover and tap.

33. WASH FIT Water indicators ADVANCED 1.5 Sanitary inspection risk score (using Sanitary Inspection Form). 1.6 All end points (i.e. taps) are connected to an available and functioning water supply. 1.7 Water services available throughout the year (i.e. not affected by seasonality, climate change-related extreme events or other constraints). 1.8 Water storage is sufficient to meet the needs of the facility for 2 days. 1.9 Water is treated and collected for drinking with a proven technology that meets WHO performance standards.

34. WASH FIT Water indicators 1.10 Drinking water has appropriate chlorine residual (0.2mg/l or 0.5mg/l in emergencies) or 0 E.Coli/100 ml and is not turbid. 1.11 National water quality standards exist and the facility water supply is regulated according to these standards. 1.12 Sufficient energy is available for pumping and boiling water (if applicable). 1.13 At least one shower or bathing area is available per 40 patients in inpatient settings and is functioning and accessible. 1.14 Shower(s) are adequately lit, including at night.

35. Questions?

36. References • WHO. (2008). Essential environmental health standards in health care. • WHO. (2013). Technical notes on drinking water, sanitation and hygiene in emergencies. http://www.who.int/water_sanitation_health/publications/2011/tn9_how_much_water_en.pdf • WHO (2011): Guidelines for Drinking-water Quality. 4th Ed. Geneva. • WHO (2011): Evaluating household water treatment options: health based targets and microbiological performance specifications. • WHO/UNICEF (2015). Water, sanitation and hygiene in healthcare facilities: Status in low-and middle-income countries and way forward.