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Chapter 1 WATER QUALITY AND DISEASES

Background
Two significant events worldwide merit mention and concern. One is the United Nations Decade for Women (1976-1986), and the other is the International Drinking Water supply and Sanitation Decade - IDWSSD (19981-1990). Recently the UN millennium development goals (MDGs), still consider the supply of adequate safe drinking water a priority goal. Although the latter has resulted in increase in the number of persons with access to reliable safe drinking water, the intended objectives of IDWSSD are yet to be fully realised. Many quarters have observed, however, that few of the objectives of either event have so far been achieved especially in the developing world. Over half of the people in the developing world are still without all year round water access to potable water. In the African continent many people die because of poor water quality or irregular quantity available to them. Reasons for water treatment protect the consumers health making the water acceptable Waters requiring treatment surface waters streams, rivers, lakes and limited treatment for groundwater

Water uses
The use of water depends on the quality and some uses require treated water whilst others may need raw water. The criteria for any use define specific quality characteristics that are necessary to support various uses. Some sources of water may be suitable for specific uses. Major uses Irrigation potable water industrial Irrigation water 1
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Depending on the quality of the source, irrigation water may be used directly without any prior treatment. Common form of treatment needed is sedimentation to remove suspended solids, which may block equipment. Filtration is only necessary for trickle irrigation. Potable Water Needs to be chemically and microbiologically safe for human consumption and should be taken from best-quality source that can be developed feasibly, in view of minimizing risk of transmitting waterborne disease. Industrial Water The quality for industrial use will depend with the type of industry e.g. quenching water in the steel industry to high quality water required for electronics industry

Wastewater Effluent This is the final treated effluent to the acceptance level from wastewater treatment plants. Technologies are now available that makes it possible to use effluent from wastewater plant as a source of water supply. Indirect reuse of wastewater occurs when effluents that have been discharged and diluted in river are withdrawn downstream for irrigation or as a public water supply. Industrial effluent can be re-used directly in the industry. Low potential for use due to: High capital investments required Unsustainable operation and maintenance costs. Perceptions and acceptance of the by the community in drinking treated wastewater effluent.

Uncertainties & risks associated with recycling wastewater for potable use are difficult to justify, particularly where other options are available and where environmental ethics in terms of water pollution control are suspect. The consequences of the reuse in London in the 19th century, with the frequent outbreaks of cholera, (link established by John Snow of London) marked the beginning of The great sanitary awakening (Okun, 1984). Today many detractors of potable reuse say it can never be done, that it will never be safe, that it is impossible to answer all the questions (Gumbo, 1997). 2
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Groundwater Water stored in a permeable geological formation (aquifer). Most of the aquifers are replenished naturally by precipitation, (natural recharge). Water drained out by gravity, is called specific yield and is the amount which can be exploited. There is 40 times as much groundwater as there is surface water and about 0.25 % of it can be extracted with the present drilling technology. Groundwater is generally potable in its normal state cheaper alternative source compared to the others. The groundwater can be extracted through boreholes or hand-dug wells. Groundwater constitutes the major reliable source for potable water in the majority of rural communities in Africa.

Water quality
The assessment of quality depends on the viewpoint of the user or use. For drinking water the criteria may be related to: health aesthetic Technical impacts of the characteristics/parameters in the water source.

Consumers for health and aesthetics reasons prefer water to be clean, pleasant to taste, colourless, odourless, clear, cool and regular/reliable in supply. Public health engineers and suppliers, mainly for technical reasons prefer water: to be free from harmful agents of low turbidity, not saline, not too hard or too soft, free from colour and odour Not aggressive and of constant flow. To achieve and maintain the quality required for supply often require a sequence of: abstraction, treatment, distribution collection disposal

Physical, chemical and biological characteristics of water Water quality analysis and monitoring are carried out to determine the suitability of a water source for specific purposes and to detect and manage the anthropogenic effects on water resources. The physical, chemical and biological parameters are compared against appropriate guideline values that reflect the health, aesthetic and technical 3
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requirements for the intended use. For drinking water, the most quoted guidelines are those published by the World Health Organisation (WHO). The physical and chemical characteristics of importance for drinking water, together with their source/effect are given in Table 1.1. The inorganic constituents of health and aesthetic significance are shown in Tables 1.3 and 1.4 respectively.

Natural waters, especially surface waters contain many types of living organisms: viruses, bacteria protozoa algae fungi helmets and larger organisms

Most are not pathogenic, and the most pathogens found in water are not free living but are of faecal origin. It is neither possible nor necessary to test all living organisms in water (time, cost methodology, and expertise). Samples are tested for organisms that occur only in faeces and not as free living organisms. These test organisms are called INDICATIR ORGANISMS as their presence indicates faecal pollution and possible presence of pathogens. If indicator organisms are not present, it is assumed that other pathogens of faecal origin (especially viruses) are also absent. Whilst normally correct to assume viruses are absent, it is recommended by the WHO that at least one laboratory in the country/region should be equipped for and capable of carrying out virological examination of water samples. The most indicator organisms are the Coliforms either as total or faecal. The Escherichia coli is one of the large groups of bacteria called coliforms. It can be distinguished from naturally occurring coliforms as it can grow at 44 o C whereas they cannot both grow at 37 oC. A coliform count at 37oC gives total coliforms whereas a count at 44 oC gives faecal coliforms. The guidelines for microbial and biological quality of water supply schemes are shown in Table 1.2.

Table .1.1:

Common physical & chemical drinking water parameters, source and effects 4

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Parameter Temperature Taste & odour Colour Turbidity Total dissolved solids pH Hardness Sulphate Chloride

natural and industries algae toxins many causes suspended matter industries; natural Calcium and magnesium salts natural; acid deposition salt deposits; saline intrusion; irrigation; wastewater natural

Effects solubility, colour and taste consumer acceptability consumer acceptability consumer acceptability; treatment costs taste; salinity; aggressiveness solubility; taste and odour taste; blockages of pipes laxative; corrosion; deposition; odour and taste taste; thirst and corrosion

Fluoride

Metals Organic

natural natural; agriculture

tooth decay at low concentration <0.3 mg/l; teeth mottling and skeletal damage at higher concentrations>2mg/l taste; colour; accumulative poisons e.g. mercury, copper; lead; cyanide cadmium accumulate in food chain and affect the nervous system and are carcinogenic

Water and diseases The diseases caused or related to water can be non-infectious chemicalbased, such as fluorosis from high fluoride levels and infectious such as cholera. In African countries the cases and deaths attributed to infectious diseases far outnumber those that are chemically based so these will be looked at in much detail. Disease-causing organisms (pathogens) Viruses bacteria protozoa fungi Helmets Most of these organisms or their eggs/larvae are microscopic, i.e. not visible to the naked eye so that water that looks clean may in fact contain a multitude of disease causing organisms. Table 2: Microbial and biological quality of water supplies 0rganism Unit 5
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Guideli ne

Remarks

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value I. Microbiological quality A) Piped water supplies A1 Treated water entering the distribution system Faecal coliforms Number/100 ml 0 Coliforms organisms Number/100 ml 0 A2 Untreated water entering the distribution 0 Number/100 ml Faecal coliforms In 98 % samples examined 0 Number/100 ml Coliforms organisms throughout the year In an occasional sample but not 3 Number/100 ml Coliforms organisms in consecutive samples A3 Water in the distribution 0 Number/100 ml Faecal coliforms 1n 95 % of samples throughout 0 Number/100 ml Coliforms organisms the year 3 In an occasional ample but not Number/100 ml Coliforms organisms in consecutive samples B Unzipped water supplies Number/100 ml 0 Faecal coliforms Number/100 ml 10 Should not occur repeatedly Coliforms organisms if occurrence is frequent and sanitary protection cannot be implemented an alternative source must be found C Bottled drinking water Faecal coliforms Number/100 ml 0 Source should be free from faecal contamination Coliforms organisms Number/100 ml 0 D Emergency water supplies Number/100 ml Faecal coliforms Number/100 ml Coliforms organisms Enter viruses II. Biological quality Protozoa (pathogenic) Helmets(pathogenic) Free living organisms (Algae & others) Advise to boil water in case of failure to meet guidelines no guidelines No guideline value set no guideline value set No guideline value set

Water related infections The infectious diseases related to water are frequently divided into four major categories, depending on the way by which the pathogen is spread or transmitted. The main transmission routes/categories of infection are: 6
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water-borne Where the pathogen is present in drinking water Water washed: Where disease transmission may be reduced by increasing water availability for personal hygiene (water scarce) Water-based: Where pathogens must spend part of their life cycle in an aquatic intermediate host. Water-related insect vector Where the pathogen is carried by an insect that breeds/feeds/bites near water.

Although water-borne infections may spread through water, the majority are spread by other routes; i.e. on hands, clothes, food, eating and drinking implements. As the faeces reach the mouth by one of these routes the transmission is often called faecal-oral. Common water related diseases and their control Schistosomiasis (Bilharzia) The disease is caused by the presence of parasitic worms (Schistosoma species) in the bloodstream or lymphatic system of the host and acquired through repeated contact with surface water contaminated with infected excreta. Transmission of the parasite is water-based, being dependent on aquatic or amphibian snails acting as intermediate hosts. Schistosoma eggs passed in the urine or faeces must enter water before they can develop into miricadia, the stage that enters snails. The larvae develop and multiply, producing cercariae, which are released by the snail. The cercariae seek out and penetrate the skin of a host infecting the people. Therefore infection occurs when people use water for washing, laundry, fishing and swimming. The cycle of transmission for Schistosomiasis is shown in Fig. 1.2. Diarrhoeal Diseases These include: dysentery, cholera typhoid. They are very common and frequently a major cause of infant and child mortality in the African continent. Ample quantities of water for washing, good family hygiene is all-important in reducing morbidity of diarrhoeal diseases. Hygiene education and primary health care have vital roles to play in the reduction of diarrhoeal infections 7
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and deaths, especially where water supply provision is concerned. The impact of different measures on disease varies as is illustrated in Table 1.5. The transmission cycles are shown in Figs. 1.3 and 1.4. Control of health impacts Most human contact with pathogens/disease-causing agents occurs in human settlements and therefore many of the solutions to control diseases need to be implemented there. For any type of disease, it is often useful to know how common the disease is in the community involved, e.g. when planning a water supply program. In this respect, incidence and prevalence are useful indicators. Incidence relates to the number of new cases that occur over a defined period and prevalence is an indication of the number of people actually suffering from a disease at a particular time. It takes into account time period of suffering. Incidence = No of new cases No. of people exposed in a defined period

For example, 3 cases/1000 people per year Prevalence = No. of people actually sick at any one time No. of people exposed

The main types of control methods are those directed to the pathogen and/or its vector, or at humans themselves. The methods may be classified as: Chemical e.g. spraying the insecticides or use of preventive or curative pharmaceuticals Biological e.g. introducing a harmless predator for disease vector Environmental e.g. modification or manipulation of the environment, including changes in human behaviour or habitat.

Water and health issues As mentioned earlier, water in rural areas is derived from different sources and most of it is untreated The most practical approach to the problem of improving and maintaining the water delivered in rural water supply schemes is to insist on adequate measures of sanitary protection It must be noted that the level of contamination of water will rise immediately as it is drawn, transported and stored, even if it is a perfectly pure source. Whilst improved drinking water sources are vital since they overcome the harmful effects, gross pollution can occur in unprotected sources. The full effects of improved drinking water quality can be gained when individuals practise improved hygiene This is because there is very little scientific evidence which shows 8
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conclusively that the provision of improved drinking water alone will result in an improved health pattern in the population. By providing health and hygiene education (and soap) at the same time as improving the water supply or sanitation facilities, the benefits to the health of the community are likely to be greater than with water changes alone The importance of good hygienic practice including methods of water collection, transportation, storage and distribution as a meaningful method of reducing morbidity due to enteric diseases is becoming widely acknowledged, and this is illustrated in the following case study. Inorganic constituents of health significance Unit mg/l mg/l mg/l mg/l mg/l mg/l mg/l mg/l mg/l N mg/l Guideline value 0.05 no guideline value set no guideline value set no guideline value set 0.005 0.05 0.1 1.5 Natural or deliberately added No health-related guideline value set 0.05 0.001 no guideline value set 10 no guideline value set 0.01 no guideline value set no guideline value set

Table 1.3: Constituent Arsenic Asbestos Barium Beryllium Cadmium Chromium Cyanide Fluoride Hardness Lead Mercury Nickel Nitrate Nitrite Selenium Silver Sodium

Table 1.4:

Aesthetic quality

Constituent or 9
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Characteristic Aluminium Chloride Chlorobenzenes and Chlorophenols Colour Copper Zinc Detergents

Unit mg/l mg/l mg/l TCU mg/l mg/l odour

Guideline 0.2 50 No guideline value may affect Taste and odour 15 10 5 no guideline set; there should not Be any foaming or taste and Problems 500 as CaCO3 0.3 0.1 no guideline value set 6.5-8.5 200 1000 400 no guideline value set 5 preferably <1 for disinfection efficiency

Hardness Iron Manganese Dissolved oxygen pH Sodium TDS Sulphate Temperature Turbidity

mg/l mg/l mg/l

mg/l mg/l mg/l NTU

Table 1.5

Different effects of improvements in water supply and hygiene 10

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practices on infectious diseases. Transmission mechanism Faecal oral Level of Preventive measures water supply high improve water quality change the source hygiene education Diarrhoeas medium improve water quality change source improve access hygiene education Typhoid high improve water quality change the source hygiene education Roundworm low improve water quality change the source hygiene education Scabies high improve water quality Water change the source washed not hygiene education faecal-oral Water-based Schistosomiasis medium Reduce water contact control aquatic host improve water quality change the source hygiene education not remove chemical Chemicalflurosis (fluoride) prevent chemical based diarrhoeas(sulphate) significant entering water methaemoglobinae change water source mia (nitrate) Examples of infection Cholera

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Fig. 1.3

Transmission cycle of Guinea worm

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Fig. 1.4:

Transmission cycle for filarial diseases (elephantiasis)

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Fig. 1.5

Transmission cycle for Schistosomiasis (Bilharzia)

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Fig. 1.6:

Transmission cycle for malaria

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