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

Gates Foundation awards $10.9 million to study impacts of sanitation on diseases

Researchers at the University of California, Berkeley, have received a five-year, $10.9 million grant from the Bill & Melinda Gates Foundation to evaluate several interventions to combat diarrheal disease in developing countries.

Dr. Jack Colford

Dr. Jack Colford, professor of epidemiology at UC Berkeley’s School of Public Health, will coordinate the project, working with the International Centre for Diarrhoeal Disease Research, Bangladesh (ICDDR,B) and Innovations for Poverty Action (IPA).

An estimated 2.2 million children under the age of 5 die from diarrhoeal diseases each year, according to the World Health Organization. Most of these diseases are thought to be preventable with improvements in sanitation, water quality and hygiene.

Due to the high cost of developing and maintaining large infrastructure projects, such as networked water, there is now a movement toward simpler, alternative methods to improve health in rural areas. However, there is almost no evidence that allows direct comparison of the health benefits or cost effectiveness of these simpler interventions, such as improved latrines, household water treatment and hand washing with soap.

The goal of the new project is to determine how sanitation interventions, delivered alone or as part of combined intervention packages, impact child health and well-being. In addition to improved sanitation, the intervention packages will include drinking water improvements and hand washing solutions. The results have the potential to influence how billions of dollars are directed towards long-term improvements in health and economic outcomes for millions of children each year, said Colford.

“Increasingly, foundations, governments, the World Bank and development agencies such as the MCC (Millennium Challenge Corporation) are demanding evidence of effectiveness when awarding development funds,” said Colford. “Right now, it is unknown whether single interventions are as cost effective as combinations of these interventions. This grant will fund the first large-scale, randomized impact evaluation designed to gather rigorous evidence about this question.”

The study will test the impact of these sanitation, water and hygiene interventions using a large-scale, randomized impact evaluation in Bangladesh and Kenya. These two countries are representative of the two regions that account for the majority of the world’s gastrointestinal disease burden: Southeast Asia and sub-Saharan Africa. The researchers expect to enroll a total of 23,000 children in the trials, which will be monitored by several institutional review boards.

Of the $10.9 million, about $7.9 million will be subcontracted out to the two field sites. Dr. Stephen Luby, head of the Programme on Infectious Diseases and Vaccine Sciences with ICDDR,B, and Michael Kremer, Ph.D., a research affiliate with IPA, will lead the trials in Bangladesh and Kenya, respectively. They will be joined by a team of experts from various disciplines, including public health, economics, behavioral change, nutrition, cognitive development and tropical enteropathy.

Source: Linda Anderberg, UC Berkely News, 05 Nov 2009

SODIS under fire: study pours cold water on solar disinfection

“Doubt has been cast on a much-lauded method of disinfecting water using only sunlight, after a study found that it doesn’t reduce diarrhoea among children in families using the technique” SciDev.net reports.

“Solar Water Disinfection (SODIS), a low-cost water purification method that uses only sunlight to disinfect water, is currently used by about three million people in 30 countries, according to the SODIS Reference Centre [at SANDEC] in Switzerland”.

“Laboratory and community studies have shown that the method is effective. But a PLoS Medicine study published [on 18 August 2009] on 22 rural communities in Cochabamba, Bolivia, found no significant reduction in diarrhoea among children aged five and under in families using SODIS”.

“The authors suggest that more research is needed into how the laboratory results can be replicated on the ground and until this is done they say that campaigners should be careful about advocating SODIS”.

“Mercedes Iriarte, co-author of the study and a researcher at the Water and Environmental Sanitation Centre of San Simón University, in Bolivia, told SciDev.Net that in the laboratory there is better control of all factors”.

“Iriarte says that in the laboratory, clean, clear, pH-neutral water is contaminated with known microorganisms to evaluate the method but that in the field researchers should consider other factors such as cloudiness of the water”.

“Margot Franken, a researcher with the environmental quality unit at San Andrés University in Bolivia, told SciDev.Net that low efficacy of the method could also result from inadequate exposure to sunlight”.

Compliance was also low, with only a third of families routinely treating their water in the recommended manner despite 80 per cent claiming to use SODIS at the beginning and end of the study and an intensive promotion campaign.

Link to full article in PLoS Medicine.

See a video about the study on SciVee.

Source: Cristina Pabón, SciDev.net, 31 Aug 2009

Earlier in 2009 Wolf-Peter Schmidt and Sandy Cairncross concluded that the widespread promotion of household water treatment (HWT) is premature given the available evidence. This is echoed by the latest review of impact evaluations examining effectiveness of water, sanitation and hygiene (WSH) interventions by the International Initiative for Impact Evaluation (3ie).

In a comment about the study on its website, the SODIS Reference Centre says that “numerous studies have reported health benefits of SODIS when it is correctly and consistently used”. They cite the example of a study where “the incidence of cholera during an epidemic in Kenya was 88% lower among SODIS than non-users”.

“A well-known weakness of the SODIS process is that it is often not used consistently or is used to treat only a fraction of the drinking water consumed”, the statement continues. “Beneficial health impacts associated with the use of SODIS may also be compromised by poor sanitation and hygiene. Nonetheless, we feel that people should not be discouraged from continuing to use SODIS or from adopting it unless an alternate supply of safe drinking water is available”.

The SODIS Reference Centre/Sandec has also had to respond to “allegations circulating in a number of print media in developing countries on the carcinogenic risk of (re-)using PET bottles”. These “unfounded media reports” are drawn from research that show that antimony and phthalic acid and phthalate esters can leach from PET bottles. Sandec conducts its own study, together with Empa (Swiss Federal Laboratories for Materials Testing and Research) on “the migration of organic compounds – with special focus on plasticisers – into the water contained in PET bottles bottles under typical SODIS conditions”. “According to the results of this study, the risk of negative health effects caused by reused PET bottles for SODIS treatment is negligible”. SANDEC plans to repeat the study in India “to confirm the harmless nature of the technology in a country where media reports on the dangers of PET bottles are particularly widespread”.

Source: Samuel Luzi, Reuse of PET Bottles for SODIS – Blessing or Curse?, Sandec News, no. 10, July 2009

But SODIS is not off the hook yet, as a new danger is looming. In April 2009, scientists at Goethe University found that PET plastics may contain hormone-disrupting chemicals that leach into the water, Discovery News reported. According to researchers, it now appears that some as-yet-unidentified chemicals in PET plastics have the potential to interfere with estrogen and other reproductive hormones in the same manner that bisphenol A (BPA) and phthalates are suspected of doing.

Household water treatment: scaling-up is premature say researchers

A critical review concludes that the widespread promotion of household water treatment (HWT) is premature given the available evidence. Further acceptability studies and large blinded trials or trials with an objective health outcome are needed before HWT can be recommended to policy makers and implementers, say Wolf-Peter Schmidt and Sandy Cairncross of the London School of Hygiene and Tropical Medicine (LSHTM) [1].

Point-of-use water treatment (household water treatment, HWT) has been advocated as a means to substantially decrease the global burden of diarrhea and to contribute to the Millennium Development Goals (MDGs). To determine whether HWT should be scaled up now, the LSHTM researchers reviewed the evidence on acceptability, scalability, adverse effects, and nonhealth benefits as the main criteria to establish how much evidence is needed before scaling up. These aspects are contrasted with the evidence on the effect of HWT on diarrhea. The researchers found that the acceptability and scalability of HWT is still unclear, and that there are substantial barriers making it difficult to identify populations that would benefit most from a potential effect. The nonhealth benefits of HWT are negligible. Health outcome trials suggest that HWT may reduce diarrhea by 30-40%, but current evidence does not exclude that the observed reductions are largely or entirely due to bias.

[1] Schmidt, W. and Cairncross, S. (2009). Household water treatment in poor populations : is there enough evidence for scaling up now? Environmental science & technology ; vol. 43, no. 4 ; p. 986–992. doi:10.1021/es802232w

Read the full review here

Providing toilets, safe water is top route to reducing world poverty: UN University

Mapping vulnerable communities essential to global health and poverty

Simply installing toilets where needed throughout the world and ensuring safe water supplies would do more to end crippling poverty and improve world health than any other possible measure, according to an analysis released [on 19 Oct 2008] by the United Nations University – International Network on Water, Environment and Health (UNU-INWEH).

The analysis says better water and sanitation reduces poverty in three ways.

• New service business opportunities are created for local entrepreneurs;
• Significant savings are achieved in the public health sector; and
• Individual productivity is greater in contributing to local and national economies.

UNU-INWEH also calls on the world’s research community to help fill major knowledge gaps that impede progress in addressing the twin global scourges of unsafe water and poor sanitation.

Information gaps include such seemingly obvious measures as common definitions and worldwide maps to identify communities most vulnerable to health-related problems as a result of poor access to sanitation and safe water. UNU-INWEH also calls for creation of a “tool-box” to help policy-makers choose between available options in local circumstances.

[...]

In the analysis, prepared for global policy makers and released Oct. 20 at the start of a two-day UNU-INWEH-hosted international meeting [Sanitation: Innovations for Policy and Finance] in Hamilton, Canada, experts offer a prescription for policy reform.

[...]

The UNU-INWEH analysis identifies population growth, poverty, climate change, globalization and inappropriate policies on investment, urbanization, and intensification of agriculture as the five global trends most likely to exacerbate water supply and sanitation problems in years to come.

[...]

“As the International Year of Sanitation winds down, UNU invites and welcomes the help of all scientists who agree we can and must do more,” says Prof. Susan Elliott, a Senior Research Fellow at UNU-INWEH and a professor at McMaster University.

[...]

The “toolbox” idea would involve “a virtual library and database of educational materials, technologies, governance, models, etc. would facilitate information exchange of both established and innovative tools.”

As well, “validated models need to be developed that will predict the impact of climate change on water and wastewater infrastructure, water availability, water quality and waterborne / water-associated diseases.”

UNU-INWEH was created in 1996 to strengthen water management capacity, particularly of developing countries, and to provide on-the-ground project support. With core funding provided by the Government of Canada, it is hosted by McMaster University, Canada.

Source: UNU / EurekAlert, 19 Oct 2008 – see also Fiona Harvey, Financial Times, 20 Oct 2008 and Reuters, 19 Oct 2008

The tragic consequences of climate change for the world’s children

A new UNICEF UK report reveals that the world’s poorest and most vulnerable children are being hit the hardest by the impact of climate change. The report, ‘Our climate, our children, our responsibility: the implications of climate change for the world’s children’ draws attention to the fact that climate change is impacting very seriously on children and their rights. It calls for immediate action from the UK Government to make children a priority in the climate change agenda and calls on UK companies to substantially reduce emissions and contribute to the costs of mitigating and adapting to climate change.

The report maps the consequences of climate change for children in the context of the MDGs and children’s rights, including:

• Fewer children able to attend school, especially girls (MDG 2 and 3): The negative impact on livelihoods may make it more likely that parents remove their children from school – and in most cultures this will almost certainly mean removing girls first – so that they can collect water and fuel and supplement household income
• Increased childhood disease (waterborne/communicable) (MDG 6 and 7): Malaria: changes in environmental factors mean malaria – which already kills 800,000 children every year – is now being seen in areas which were previously outside the range of malarial mosquitoes, such as the highlands of Kenya and Jamaica. Diarrhoea: Climate change will increase the burden of diarrhoeal disease in low income countries by between 2 and 5 per cent by 2020. Dengue: Estimates suggest the population at risk could increase to 3.5 billion by 2080 (from 1.5 billion today) due to climate changes.

Read more: UNICEF UK, 29 Apr 2008

Rich must pay climate change health costs

Countries, mostly in the developing world, could spend between US$6 to $18 billion a year by 2030 to manage additional costs to health services as a result of climate change, according to independent research cited by a World Health Organisation (WHO) official, hence the need for rich countries responsible for global warming to help pay towards these additional health costs.

“That figure was based on a WHO assessment, which found that modest global warming since the 1970s was already causing over 150,000 excess deaths every year by 2000 – the costs and the estimates would now be higher,” said Diarmid Campbell-Lendrum, one of the authors of a new WHO report “Protecting health from climate change”, released on World Health Day.

The assessment was based on studies on the impact of climate-sensitive illnesses like diarrhoeal disease, which is the second leading infectious cause of childhood mortality, and accounts for a total of around 1.8 million deaths each year. “For example, rates of diarrhoeal disease in Lima, Peru, are 3-4 times higher in the summer than in the winter, increasing by 8 percent for every 1°C increase in temperature,” he said. “But the 2000 assessment did not take into account the impact of climate change on water stress or displacement of people as a result of famines.” The WHO has announced the launch of a new assessment.

Read more: IRIN, 7 Apr 2008

In her introduction in the WHO report, Director-General, Margaret Chan, summarised the major health impacts of climate change.  These included more frequent extreme weather events such as flooding, which ” can be followed by outbreaks of diseases, such as cholera, especially when water and sanitation services are damaged or destroyed”. Also, “both scarcities of water, which is essential for hygiene, and excess water due to more frequent and torrential rainfall will increase the burden of diarrhoeal disease, which is spread through contaminated food and water”.  In addition “changing temperatures and patterns of rainfall are expected to alter the geographical distribution of insect vectors that spread infectious diseases. Of these diseases, malaria and dengue are of greatest public health concern”.

WHO/Christopher Black

People forced to use one water source for all daily chores – like this girl in Pakistan – face increasing risks of gastrointestinal infections and other waterborne diseases. Together these diseases kill around 2.2 million people globally each year, mostly children in developing countries. Potential population displacement resulting from an increase in frequency and severity of climate sensitive events would add to this number.