Environmental exposure to:

Water, Sanitation & Hygiene

Dr Sophie Bonjour Dr Annette Prss-stn
Joint WHO/ISESCO Regional training workshop on environmental risk assessment and valuation of development policies Amman, Jordan, 23-26 April 2007

1|

Water, Sanitation & Hygiene | 24 April 2007

Water Sanitation and Hygiene

Pathogen source Medium Environment Flies

Interface

Dry sanitation involving reuse

Soil

Hands
Human excreta

Water-borne sewage Non-recycling latrines Surface water

Food

Humans

Animal excreta

Groundwater

Drinking water

2|

Water, Sanitation & Hygiene | 24 April 2007

Risk factor definition

Ingestion of water
Poor personal hygiene (in relation to sanitation)

Poor domestic hygiene (in relation to sanitation)

Agricultural practices (contamination of food through irrigation
with unsafe water)

3|

Water, Sanitation & Hygiene | 24 April 2007

Proxy for WSH-related diseases

Improved drinking water

Improved sanitation facilities

see p. 9 of the EBD series nr 14 (WSH) for a more precise definition

4|

Water, Sanitation & Hygiene | 24 April 2007

Water & sanitation coverage Eastern Mediterranean Region

100 80

% coverage

60 40 20 0
A fg ha ni st an Dj ib ou ti Eg yp t n Lib ya ** M or oc co Pa le st in e Pa ki st an Su da n Sy ria Ira n* Ira q at ar da n Tu ni sia UA E al ia ba no So m Jo r Q Ye m en

Source: Joint Monitoring Programme, WHO/UNICEF, 2006 No data available for Bahrain, Kuwait, Oman, & Saudi Arabia; * for sanitation coverage, ** for water coverage

improved water

Le

improved sanitation

5|

Water, Sanitation & Hygiene | 24 April 2007

Rationale for combined risk factor

One intervention does not necessarily reduce disease significantly, although being a precondition for improvement

6|

Water, Sanitation & Hygiene | 24 April 2007

Diseases related to unsafe WSH

Infectious diarrhoea
Malnutrition Intestinal nematode infections (100% attributable to WSH) Schistosomiasis (100% attributable to WSH) Trachoma (100% attributable to WSH) Dengue, Malaria, Japanese encephalopathy.

7|

Water, Sanitation & Hygiene | 24 April 2007

Diarrhoea: Scenario-based approach

Exposure distribution in the population Categorize the population into exposure scenarios Relative risk per exposure scenario

Impact fraction

Disease burden estimates for each disease

Disease burden attributable to risk factor

8|

Water, Sanitation & Hygiene | 24 April 2007

Example for water, sanitation and hygiene (diarrhoeal diseases - global level)
VI

No improved water supply, no basic sanitation

Vb

High

Basic sanitation, no improved water supply

Va

Improved water supply, no basic sanitation

Faecal-oral pathogen load in the environment

IV Improved water quality and/or Improved access to water and/or Improved hygiene

Improved water supply, and basic sanitation

III

II

Regulated water supply

Ideal, no disease transmission through water and sanitation

Low

9|

Water, Sanitation & Hygiene | 24 April 2007

Rough estimate with global risk estimates

Current risk estimates are based on the following:
Esreys multi-country study based on 8 countries, based on DHS surveys (Consistent with intervention studies from many countries) Intervention studies Surveys; e.g. Mead: study of the USA, where 400,000 diarrhoea infections were diagnosed according to the pathogen

10 |

Water, Sanitation & Hygiene | 24 April 2007

Example for water, sanitation and hygiene (diarrhoeal diseases - global level)
RR = 11
Basic sanitation, no improved water supply
VI

No improved water supply, no basic sanitation

High

Va

6.9
IV

8.7

Vb

Improved water supply, no basic sanitation

Faecal-oral pathogen load in the environment

RR = 6.9
Improved water quality and/or Improved access to water and/or Improved hygiene

Improved water supply, and basic sanitation

III

RR = 4.5
Regulated water supply
Ideal, no disease transmission through water and sanitation

RR = 2.5

II

RR = 1
11 |
Water, Sanitation & Hygiene | 24 April 2007

Low

Example for water, sanitation and hygiene (diarrhoeal diseases - global level)
Formula for calculating the attributable fraction
AF =

(Pex RRx)

- 1

X = exposure level Pex = prevalence of exposure at level x RRx = RR at exposure level x

(Pex RRx)

(Baseline level with RR=1 must be included) Where: RR = I exposed / I unexposed = 1/(1-reduction)

Example: Risk reduction = 60%, then RR = 2.5

12 |

Water, Sanitation & Hygiene | 24 April 2007

Example of calculation: Jordan

Exposure data:
improved water coverage: 97% improved sanitation: 93%
VI: No improved water supply,no basic sanitation

RR = 11

3%
Vb:Improved water supply, no basic sanitation

Impact fraction:
(3% * 11+ 4%* 8.7 + 93% * 6.9) - 1 IF= (3% * 11+ 4%* 8.7 + 93% * 6.9) = 86%

Va: Basic sanitation, no improved water supply

6.9 93%

8.7

4%

RR = 6.9

IV:Improved water supply, and basic sanitation III: Improved IV

Health data:
Diarrhoea deaths : (all ages) 693

RR = 4.5

Attributable deaths due to WSH:

86% x 693 = 596

RR = 2.5

II: Regulated water supply

13 |

Water, Sanitation & Hygiene | 24 April 2007

Example of calculation: Jordan

Attributable fraction: 86%

Attributable burden:

596 deaths

Deaths/1000 capita:

0.11
(Attributable burden/Total population)*1000

14 |

Water, Sanitation & Hygiene | 24 April 2007

Approximate results for Eastern Mediterranean countries

100% 80%

Fraction of diahrroeal Fraction of diarrhoeal diseases attributable to diseases attributable unsafe WSH to WSH

60% 40% 20% 0%

A fg ha ni st an Dj ib ou ti Eg yp t

ba no n M or oc co Pa ki st an So m al ia Su da n

No data or not enough data available for Bahrain, Iran, Libya, Kuwait, Palestine, Oman, & Saudi Arabia. Method not sensitive enough for Qatar.

16 |

Water, Sanitation & Hygiene | 24 April 2007

Le

Tu ni sia Ye m en

Jo r

Sy ria

q Ira

da n

Methodological issues: choices

Study population: country, city, municipality (will probably be limited by health data) Use of summary measures of population health (DALYs etc), or limit to IR, mortality Age groups (children) Use of rough method (as 1st step) or refine method and estimates & adapt to region Refinement of the method & regional adaptation for more accurate method

17 |

Water, Sanitation & Hygiene | 24 April 2007

Further information & references

Dr Annette Prss-stn: Dr Sophie Bonjour:
Website:

pruessa@who.int bonjours@who.int

www.who.int/quantifying_ehimpacts
References World Health Report (2002): www.who.int/whr/2002

Comparative Quantification of Health Risks, WHO (2004) - Chapt. 16

Fewtrell L. et al., Water, sanitation and hygiene, EBD Series, No. 14, WHO (to be published)

18 |

Water, Sanitation & Hygiene | 24 April 2007