Study quantifies link between poor sanitation and child, maternal mortality

In countries with the poorest sanitation, child mortality is nearly 7 times higher than in countries with the best access to sanitation. This is one of the findings of a new study [1] by Canadian-based researchers who say they are the first to quantify the impact of unsafe water and poor sanitation on child and maternal mortality.

Researcher June J. Cheng. Photo: McMaster University

Researchers at the United Nations University and McMaster University analysed data on access to safe water and adequate sanitation across 193 countries and compared them with maternal and child deaths.

Dividing the countries into four tiers (“quartiles”), they found that countries ranked in the bottom 25% in terms of adequate sanitation had about 6.6 more deaths per 1,000 children under five years old compared to countries in the top 25% tier.

Similarly, when judged on access to safe water, countries ranked in the bottom quartile, child mortality was 4.7 higher than in the top quartile.

Relating adequate sanitation provision and maternal death rates (death within a year of childbirth), the paper says the odds of dying increase 48% from the top tier to each lower tier of countries; the corresponding odds with respect to unsafe inadequate sanitation: 42%.

[1] Cheng, J.J. et al., 2012. An ecological quantification of the relationships between water, sanitation and infant, child, and maternal mortality. Environmental Health, 11 (4). Available at:  http://dx.doi.org/10.1186/1476-069X-11-4 [accessed 17 Feb 2012]

Related news:

• Diarrhoeal diseases: study predicts decline in global deaths, E-Source, 20 April 2011
• Health impact: effect of water quality, hygiene and sanitation in preventing diarrhoea deaths, E-Source, 22 Jun 2010

Related web sites:

• UNU-INWEH – Water-Health Nexus
• WHO – Water Sanitation and Health (WSH) – Burden of disease and cost-effectiveness estimates

Contact: June J Cheng (june.cheng@medportal.ca), Public Health and Preventive Medicine Residency Program, Dept. of Clinical Epidemiology and Biostatistics, McMaster University and United Nations University Institute for Water, Environment and Health (UNU-INWEH), Canada

Source: United Nations University, EurekaAlert!, 14 Feb 2011

Access to safe water and sanitation among top global public health achievements

Access to safe water and sanitation are among the ten top global public health achievements in the first decade of 21st century identified by the Centers for Disease Control and Prevention (CDC).

CDC asked experts in global public health to nominate noteworthy public health achievements that occurred outside of the United States during 2001–2010. CDC selected ten of these achievements and published an overview in Morbidity and Mortality Weekly Report (MMWR) of 24 June 2011.

Between 2000 and 2008, CDC reports that an additional 800 million people gained access to improved drinking water sources, and additional 570 million people gained access to improved sanitation. In addition, education and safe water technology have eradicated Guinea worm in all but four countries (Southern Sudan, Mali, Ethiopia, and Ghana), with complete eradication expected in 2012.

64th World Health Assembly approves three WASH resolutions

The 64th World Health Assembly (WHA) has adopted a resolution on drinking-water, sanitation and health, and two other related resolutions on cholera and Guinea worm (dracunculiasis).

Yael Velleman at the WHA in Geneva with a copy of the WaterAid report "The sanitation problem - What can and should the health sector do". Photo: WaterAid

WaterAid had issued a call to leaders participating in the WHA in Geneva to prioritise sanitation and water in the fight against diseases including cholera and dracunculiasis. In support of their campaign, WaterAid published a new report
The sanitation problem: What can and should the health sector do?. WaterAid’s Senior Health Policy Analyst Yael Velleman wrote an opinion piece in the Guardian and posted daily updates from the WHA.

Global deaths from diarrhoea, malaria, AIDS declining, study predicts

Under-five child mortality from diarrhoeal diseases, which was 1.7 million in 2005, is expected to fall to just over half a million by 2030 and around 130,000 in 2060, a new study [1] predicts.

The study notes that headway is being made in fighting communicable diseases such as diarrhoea, malaria and AIDS. At the global level disease burdens are shifting from communicable diseases to chronic ones such as cancer, diabetes and heart disease.

PLoS Medicine publishes four-part series on water and sanitation

In November 2010, PLoS Medicine, a peer-reviewed open-access journal, published a four-part series on water and sanitation.

In the first article, Jamie Bartram and Sandy Cairncross argue that the massive burden of ill health associated with poor hygiene, sanitation, and water supply is largely preventable with proven, cost-effective interventions and demands more attention from health professionals and policymakers. The total benefits of these interventions are greater than the health benefits alone and can be valued at more than the costs of the interventions. Even though hygiene, sanitation, and water supply are development priorities, the authors state that the ambition of international policy on drinking water and sanitation is inadequate.

In the second article, Paul Hunter and colleagues focus on water supply and argue that much more effort is needed to improve access to safe and sustainable water supplies. A poor water supply not only impacts health by water-related diseases but can also affect health by limiting productivity and the maintenance of personal hygiene. Reasons for the limited progress towards universal access to an adequate water supply include high population growth rates in developing countries, insufficient rates of capital investment, difficulties in appropriately developing local water resources, and the ineffectiveness of institutions mandated to manage water supplies (in urban areas) or to support community management (in rural areas).

David Trouba and colleagues discuss the importance of improved sanitation to health and the role that the health sector can play in its advocacy in the third article. Lack of sanitation contributes to about 10% of the global disease burden, causing mainly diarrhoeal diseases. In the past, government agencies have typically built sanitation infrastructure, but sanitation professionals are now concentrating on helping people to improve their own sanitation and to change their behaviour. Improved sanitation has significant impacts not only on health, but on social and economic development, particularly in developing countries. The authors believe that three major strategies could achieve success in sanitation: (i) political leadership, (2) a shift from centralised supply-led infrastructure provision to decentralised, people-centred demand creation coupled with support to service providers to meet that demand, and (3) the full involvement of the health sector in sanitation through policy development and the implementation of sanitation programmes.

In the final article, Sandy Cairncross and colleagues outline what needs to be done to make significant progress in providing more and better hygiene, sanitation, and water for all. They discuss the differences between these three subsectors and the possible reasons for poor rates of progress towards achieving universal access in recent years. The actors whose engagement is essential for the sector, include the poor households themselves who are significant investors, local and central government, donors, and international agencies. The active involvement of health professionals in hygiene, sanitation, and water supply is crucial to accelerating and consolidating progress for health, argue the authors. They propose a detailed Agenda for Action for seven domains: health policy, health institutions, health research, health surveillance, health delivery programmes, health protection regulations and standards, and health advocacy.

Since publication, between 9 and 16 November 2010, the four articles together have been viewed 13,000 times, with most views (5,400) going to the first article by Jamie Bartram and Sandy Cairncross.

Dirty water kills more people than violence, says UN

Saving half the water lost through leaky pipes and ill-maintained sewage networks could supply 90 million people with clean water, says a UN report [1] released on World Water Day.

Dirty water is killing more people than wars and other violence, the United Nations announced on World Water Day.

Almost all dirty water produced in homes, businesses, farms, and factories in developing countries is washed into rivers and seas without being decontaminated.

And up to 60 percent of supplies that have been purified to the point that they are potable are lost through leaky pipes and ill-maintained sewage networks, according to a report released on 22 March 2010. Saving half of these lost supplies could give clean water to 90 million people without the need for costly new infrastructure, says the UN.

“The sheer scale of dirty water means more people now die from contaminated and polluted water than from all forms of violence including wars,” the United Nations Environment Programme (UNEP) said.

This includes 2.2 million people whose deaths are attributed to diarrhea, mostly from dirty water, and 1.8 million children aged under five who succumb to water-borne diseases. This equates to one infant every 20 seconds.

The findings were presented during a three-day conference held in the Kenyan capital, Nairobi, to coincide with the annual focus on clean and sustained water supplies for a human population expected to grow by 50 percent in the next four decades.

“If the world is to survive on a planet of 6 billion people heading to over 9 billion by 2050, we need to get smarter about how we manage wastewaters,” Achim Steiner, UNEP’s director, said in a press release. “Wastewater is quite literally killing people.”

Rivers of sewage in the slums

Less than five miles from the downtown conference center hosting the water conference, Grace Gathura spent Monday morning as she always does – queuing for water at a communal tap in Nairobi’s Kibera slum.

The shantytown, home to 1 million people largely ignored by the city authorities, is notorious for its “flying toilets.”

Without decent latrines in their iron-walled huts, people are forced to defecate into plastic bags, which are then unceremoniously thrown out of the door.

The waste is among the 2 million tons of sewage and industrial or agricultural waste that ends up in rivers and streams each day.

Most of those water sources are then also used for cooking and cleaning water.

“I have lived here in Kibera for 12 years, and it is only two years ago that this tap was constructed,” Mrs. Gathura said. “Before, there were people selling clean water at prices which are too high for us. But even now, there are many of us who do not find clean water every day, and so many are sick.”

According to the UNEP report, more than half of the world’s hospital beds are occupied by people struggling with illnesses linked to contaminated water.

Easy solutions?

“It may seem like an overwhelming challenge but there are enough solutions where human ingenuity allied to technology and investments in nature’s purification systems such as wetlands, forests, and mangroves can deliver clean water for a healthy world,” said Mr Steiner.

Aside from recommending a focus on fixing leaky pipes, the World Water Day meeting called for water recycling systems and multi-million dollar investments in sewage treatment works.

But, the UN added, just $20 million could pay for drip-irrigation and tread pumps to draw water from wells, which could lift 100 million poor farming families out of extreme poverty.

Read UNEP’s press release and coverage on CNN

In his blog, sanitation expert Prof. Duncan Mara called the report “a remarkable little book, extremely well presented – basically it is (well, it seems to me to be) an advocacy document, but nonetheless very well worth reading”.

[1] Corcoran, E. (ed) … [et al.] 2010. Sick water? : the central role of wastewater management in sustainable development : a rapid response assessment. Arendal, Norway, UNEP/GRID-Arendal and UN-HABITAT. 85 p. Read full report [PDF file]

Source: Mike Pflanz, Christian Science Monitor, 22 Mar 2010

Rotavirus data must propel immunization – experts

Health experts hope the release of data showing the success of rotavirus vaccine will help compel policymakers to ensure all children will be immunized.

Rotavirus – the top cause of severe and often fatal diarrhoea and dehydration in children – kills some 527,000 children a year globally, nearly half of them in sub-Saharan Africa.

“It is our hope that these data will catalyze action so that one day we can live in a world where no child dies from diarrhoea,” Kathy Neuzil, senior clinical advisor for vaccines at the international health non-profit PATH, said in a 27 January statement.

Published on 27 January 2010 in the New England Journal of Medicine, results from first-ever clinical trials in South Africa and Malawi show that a live, oral rotavirus vaccine significantly reduces the episodes of severe rotavirus gastroenteritis in African children during the first year of life.

The data “provide policymakers with the critical information they need to make decisions about rotavirus vaccine introduction,” George Armah, professor and rotavirus expert at Ghana’s Noguchi Memorial Institute for Medical Research, said.

The trial results led the World Health Organization in June 2009 to recommend global use of the vaccine.

The Africa trials focused on the vaccine’s performance in high mortality, low-income settings, according to a 27 January 2010 communiqué by PATH and GAVI Alliance.

Health experts point out that while rotavirus infection in treatable, it has devastating and deadly impact in rural and poor areas where people cannot access medical care. “Vaccines represent the best hope for preventing the severe consequences of rotavirus infection,” Nigel Culiffe of University of Liverpool said in statement.

The trials were coordinated and co-funded through a partnership between GlaxoSmithKline Biologicals and the GAVI Alliance-funded Rotavirus Vaccine Trials Partnership – PATH, WHO and the US Centers for Disease Control and Prevention.

Source: IRIN, 27 Jan 2010

Emergencies: water-related lessons from earthquakes

As aid agencies launch Haiti earthquake relief efforts, a blog post on the Overseas Development Institute web site, has showcased a report by learning and accountability network, ALNAP [Active Learning Network for Accountability and Performance in Humanitarian Action], outlining 28 lessons learned over 30 years of earthquake responses.

The report covers the 1976 Guatemala earthquake that killed 23,000 people and the 2006 Yogyakarta earthquake that left 5,749 dead. Earthquakes are uniquely challenging, with high mortality rates, severe road and infrastructure destruction, debris delaying recovery efforts and the risk of aftershocks, stated ALNAP in the 2008 report.

“Every time there is a major evaluation, it states [that] emergency responses did not apply lessons from previous emergencies,” ALNAP head of research and development, Ben Ramalingam, told IRIN. “Decisions we make now in Haiti can influence the way operations go for quite some time.”

He has high hopes. Comparing Haiti now with the immediate aftermath of the 2004 tsunami, he says: “Now there is much more focus on what can be done better; there is a lot of debate about coordination and quality – this is potentially unique.”

The most important lesson aid agencies must apply is to address emergency relief and longer-term recovery efforts together, ALNAP says. “Recovery is the overriding challenge. Agency planning should not overstate the need for relief, and should quickly move into recovery activities.”

Physical recovery is likely to take three to five years in Haiti.

Recovery

“In Haiti recovery is also social, political and economic – not just physical – and there is a limit to what humanitarian assistance can do in this,” Ramalingam said. “The entire international community needs to rise to this challenge.”

Other immediate priorities for Haiti include identifying an institution – be it existing government bodies, the UN or the American administration – to lead the response, he pointed out.

And when planning their response all aid groups must not forget a simple lesson: “The majority of life-saving work in any disaster is done by populations themselves… the most important resource Haitians have is their own social capital. Agencies must give good information to communities so they can plan their own recovery from the start.”

Two water-related lessons from the ALNAP report:

• Do not overstate the risk of disease as this leads to misallocation of resources. Only three out of 600 geophysical disasters led to disease epidemics, according to research published in the Emerging Infectious Diseases Journal. The real risk posed by dead bodies after natural disasters is mental illness caused by shock and grief. [The ALNAP report (p. 11) states that "outbreaks of communicable disease are rare after natural disasters unless large numbers are displaced from their homes and placed in camps". It warns against wasting money on "imaginary" problems, using an example from the 2004 Tsunami disaster: "Even though there was no confirmed case of cholera in Aceh, an immunisation campaign targeted 160,000 people with preparations for cholera using an expensive twodose oral vaccine"].
• Livelihoods are key to recovery; listen to affected populations about their priorities for livelihood recovery. [The ALNAP report (p. 18) cites the example of the earthquake disaster in Bam (Iran) where "interveners gave a low priority to irrigation for orchards, ranking such support lower than shelter, schools and drinking water. The affected population gave water for orchards their highest priority because of the risk of losing their orchard assets".]

Other lessons from the ALNAP report:

• Give cash and buy locally wherever possible. Ramalingam warns this must be applied carefully in Haiti given security concerns.
• Focusing on emergency shelter while neglecting permanent shelter is a mistake. The most sensible solution is “transitional shelter” that can be turned into permanent dwellings.
• Recovery operations are not neutral. They will reinforce or reduce existing inequalities and must be actively designed to do the latter.
• Listen to recipients and make sure the assistance is appropriate.
• Be prepared for land-ownership disputes.
• Try to build back better, for instance by improving building codes, but be realistic; disaster response is not a magic bullet.

Source: IRIN, 21 Jan 2010

Diarrhoea kills over a million over-fives each year

Diarrhoea kills three times more over-five-year-olds in Africa and South-East Asia than previously thought, new research finds.

Some 1.15 million over-fives — thought to be mostly adolescents and the elderly — are dying in these regions each year from diarrhoeal diseases, according to the research, commissioned by the WHO. Until now the death toll estimate for these regions came to 380,000.

Preliminary results from the study — which has yet to be published — were presented at this week’s meeting of the Foodborne Disease Burden Epidemiology Reference Group (FERG) (29 October) in Switzerland.

“These estimates highlight the significant burden of diarrhoeal diseases in adolescents and adults in the developing world,” said Martyn Kirk, chair of the FERG Enteric Diseases Task Force, who presented the results.

For the study, Christa Fischer-Walker and Robert Black from Johns Hopkins School of Public Health in the US searched 25,000 journal articles for information on diarrhoea in the over-fives. Only six of the articles contained reliable figures on diarrhoeal deaths in developing countries for this age group (compared to hundreds for younger children) — and there was no data for China, Latin America, the Middle East or South Asia.

The new estimate is on a par with the global annual death toll for malaria. It is also equivalent to nearly one-third of all HIV deaths and to almost half the number of global deaths from tuberculosis, says Claudia Stein, medical officer of the WHO’s Department of Food Safety and Zoonoses.

“What makes the tragedy even greater is that many of these diseases are clearly preventable,” said Jørgen Schlundt, director of FOS. Schlundt calls for policymakers to be alerted to cheap strategies known to prevent diarrhoea.

Improvements in food safety, sanitation and hygiene are critical, says Kirk. He told the meeting that nearly half (48.9 per cent) of diarrhoeal deaths in the developing world are caused by the bacteria Enterotoxigenic Escherichia coli and Vibrio cholerae, both of which are associated with poor sanitation and are common in resource-poor countries.

Stein says major gaps remain in scientists’ understanding of diarrhoeal deaths. Research focusing on older people attracts little funding, as a result of which the problem has never been thoroughly assessed in this group.

But it is expected that some of these gaps will be filled next year, when results emerge from studies in China and India. The FERG is also planning country-level studies across the world, the results of which should begin to emerge in 2010.

Source: Sian Lewis, SciDev.net, 30 Oct 2009

Tackling global health risks prevents premature deaths

Global life expectancy could be increased by nearly five years by addressing five factors affecting health – childhood underweight, unsafe sex, alcohol use, lack of safe water, sanitation and hygiene, and high blood pressure, according to a new WHO report.

These are responsible for one-quarter of the 60 million deaths estimated to occur annually.

Global health risks describes 24 factors affecting health. These are mixture of environmental, behavioural and physiological factors, such as air pollution, tobacco use and poor nutrition.

The report also draws attention to the combined effect of multiple risk factors. Many deaths and diseases are caused by more than one risk factor and may be prevented by reducing any of the risk factors responsible for them.

Read the full press release: WHO, 27 Oct 2009

Read the full report

The report mentions that unsafe water, sanitation and hygiene is one of the the leading global risks for burden of disease, accounting for 4% of disability-adjusted life years (DALYs), The others are childhood underweight (6% of global DALYs), unsafe sex (5%) and alcohol use (5%) [see fig. 7].

In developing countries, unsafe water, sanitation and hygiene comes second behind childhood underweight as the highest risk for burden of disease [see tab 2.].

In the annexes of the report there are more detailed tables on health risk factors by WHO region (Africa, Southeast Asia, the Americas, Eastern Mediterranean, Europe and Western Pacific).

Source: WHO, 2009. Global health risks

Source: WHO, 2009, Global health risks