Health Water Sanitation

Diseases related to
water, sanitation and

hygiene (WASH)
WATSAN M15 ERU Diseases related to water, sanitation and hygiene (WASH) 2
Contents
1. Public Health in Emergencies: Indicators

2. Relevance of water, sanitation and hygiene to health
3. Diseases related to water and excreta, and
transmission mechanisms.
1. Health indicators in emergencies
Causes of Death in Emergencies (Worldwide)
Diarrhoeal Diseases
Trauma (Injury)
Measles
Malnutrition
Malaria
Acute Respiratory Infections (ARI)

Health Indicators in Emergencies

 Daily Crude Mortality Rate (CMR)
• Definition: The rate of death in the entire population, including both sexes and all ages.
• Formula most commonly used during disaster:
Total number of deaths during time period x 10.000 persons
Total population No.days in time period
= deaths/10.000 persons/day
 Under 5 Mortality Rate (U5MR)

• Definition : The rate of death among children below 5 years of age in population.
• Formula most commonly used during disaster:
Total number of deaths in children
<5 years during time period x 10.000 persons
Total number of children < 5 years No.days in time period
= deaths/10.000 children/day
Mortality Rates in Emergencies

Baseline Reference Mortality Data by Region
Region CDR/CMR CDR/CMR U5DR/MR U5DR/MR

deaths/10,000/ emergency deaths/10,000 emergency
day threshold U5/day threshold
Sub- Saharan 0.44 0.9 1.14 2.3
Africa
South Asia 0.25 0.5 0.59 1.2
Middle East 0.16 0.3 0.36 0.7

and North
Africa
East Asia and 0.19 0.4 0.24 0.5
Pacific
Latin America 0.16 0.3 0.19 0.4

and
Caribbean
Fuente: UNICEF State of the World’s Children 2003

Benchmark for CMR and U5MR (worldwide)
Benchmark for CMR (world): Benchmark for U5MR (world):
•Baseline 0.5 •Baseline 0.8-1.2

•Serious 1.0-2.0 •Serious >2.0-4.0
•Crisis >2.0
For a specific area, when baseline is unknown agencies

should aim to maintain the CMR at below 1/10.000/ day.
2. Relevance of water, sanitation
and hygiene to health
The most important aim of a water and

sanitation programme…
...To minimise health risks of

the population
The main objective of water supply,

sanitation and hygiene programmes in
disasters is to reduce the transmission of
faecal-oral diseases and exposure to disease-
bearing vectors that transmit diseases with
epidemic potential, allowing people living with
good health, dignity, comfort and security.
WATER / SANITATION / HYGIENE
HEALTH
The crucial aims of water and sanitation

programmes are…..
• To supply sufficient safe water

• To supply the means for an adequate excreta
disposal and other types of waste
• To implement hygiene measures
• To train people regarding hygiene and the proper use
of water
Fewtrell L et al. (2004) Lancet Infect Dis 5(1): 42-52.

Most common routes for the transmission of Diarrhoea germs

Hygiene
DIAGRAM F
Water
quantity
Sanitation
Water quality Water
Adapted from Winblad U & Dudley E, 1997. Source: WHO PHAST

HEALTH
CARE LATRINE
Faecal-oral
transmission:
1.- Water
2.- Food
3.- Objects
SPRING SAFE
WATER
DOMESTIC AND
PERSONAL HYGIENE
3. Diseases associated with water and
excreta, and spreading mechanisms
THE MOST IMPORTANTS
DIARRHOEA
FAECAL-ORAL route TRANSMITTED by VECTORS
E. coli
Shigella
BACTERIA 10.000/g
V. cholera 10.000.000/g
10.000.000/g
Poliovirus
VIRUS Virus de
Rotavirus Hepatitis
Giardia
Entomoeba
PROTOZOAN 10.000/g
10.000/g
10.000/g
Cryptosporidium
Water-borne or Transmission
water-washed diseases mechanisms
Cholera, shigellosis, diarrhoea,

salmonellosis. FAECAL-ORAL
• Water contamination
Typhoid, paratyphoid, etc.

• Poor sanitation
Amoebic dysentery, giardiasis

• Poor personal hygiene
Hepatitis A, poliomyelitis,
rotavirus diarrhoea • Crop contamination
DIARRHOEA DISEASES
According to Curtis and Cairncross (2003),

hand washing with soap and water after
contact with faecal material can reduce
diarrhoeal diseases by 42% or more.
Curtis, V. and Cairncross, S. (2003). Effect of washing hands with soap on

diarrhoea risk in the community: a systematic review. Lancet Infectious
Diseases 3: 275-281.
DIARRHOEA DISEASES
• Acute watery diarrhoea:
Watery stools without visible blood, vomit and fever. Dehydration
• Cholera
• Bacillary Dysentery (shigellosis):
Acute bloody diarrhoea with fever, abdominal cramps and rectal pain.
Complications include sepsis, rectal prolapse, haemolytic uraemic syndrome
and seizures.
• Giardiasis:
Watery stools, flatulence, greasy stools, stomach cramps, nausea, weight loss
and dehydration.
• Amebiasis or Amebic Dysentery:
Bloody stools or loose stools, stomach pain, stomach cramping and fever.
CHOLERA
• Caused by the Vibrio Cholerae (bacteria)
• Endemic or with epidemic potential (Africa,South America,Asia...)
• Watery diarrhoea classically rice-water stools, with or without vomiting,
dehydration, shock
• IMPORTANT!! faecal-oral route
-Faecal material and vomit mist be properly disinfected and disposed of
-Adequate water supply
-Clean water whenever food is being handled
-Hand washing promotion
• Cause outbreaks with case-fatality rates

TYPHOID FEVER
• Caused by Salmonella Typhi (bacteria)
• Low grade fever, malaise and dry cough, abdominal discomfort, diarrhoea
or constipation, altered mental status and multiples complications.
•FAECAL-ORAL
- Waste water with human and animal faeces
- Faeces contaminated food
•PREVENTION
- Health education
- Safe food and water, proper food handling
- Adequate excreta disposal
- Personal hygiene
- Safe water collection points
KEY FACTORS FOR PREVENTING

DIARRHOEA DISEASES
• Safe drinking water (Extraction, transport
and storage)
• Controlled excreta disposal
• Safe food and proper food handling
• Hand washing with soap
• Breastfeeding
• Education
HEPATITIS
• Virus A and E.(exist B ,C,Δ)
• Clinical: fever, tiredness, nauseas, digestive problems and later jaudince
(yellow skin and mucous) with dark urine and whitish stools.
• Usually complete cure. No chronic, no carrier.
• Attention the A and E transmission FAECAL-ORAL route

• Risk factors
• Food and water contaminated
• Poor sanitation infrastructure
• Crowding
• Waste water with human and animal faeces
POLIOMYELITIS
• Virus polio virus (serotypes 1,2,3)
• In endemics areas epidemics usually affect children < 5 years of age. In
non endemic areas where vaccination coverage is low, young
adults are most commonly affected
• 90% a symptomatic
• 10% disease
• Non paralytic form: fever, muscle pain,tiredness, headache,
intestinal problems (nausea ,vomits ,diarrhoea), backache, non
neurological involvement
•Paralytic form: after the non specific signs,the patient develops rapid
onset acute flaccid paralysis flaccid and meningeal symptoms .
• There is no cure. Prevention vaccination
• FAECAL-ORAL
•Point of contagious:Food and water contaminated by infected faeces,
nose and mouth infected secretion.
Most common routes for the transmission of Diarrhoea germs

Hygiene
DIAGRAM F
Water
quantity
Sanitation
Water quality Water
Adapted from Winblad U & Dudley E, 1997. Source: WHO PHAST

Water washed or
water scarce Transmission
diseases mechanisms
Skin and eye infections. • Inadequate water
Louse borne typhus or • Poor personal hygiene

louse-borne relapsing fever.
SKIN DISEASES
• Scabies:
• Sarcoptes scabiei hominis (parasite)
• Larvae dig tunnels in the external skin
layers.
- Rash, scab skin.
- Wrinkles, between fingers, elbows,
writs, penis, nipples.
• Impetigo:
• Streptococcus and staphylococcus
Contagious superficial skin infection.
- Blisters with pus-scab
- Face, nasal cavity, mouth, neck,
groin.
EYE DISEASES
• Conjunctivitis:
• Acute inflammation of the conjunctiva due to
bacterial or viral infection.
* Irritation, teardrop, secretion.
* Contagious : contact with infected
conjunctivitis secretions,hands and
clothes contaminated,fly….
• Trachoma:
• Keratoconjunctivitis due to Chlamydia
trachomatis
* Progressive conjunctivitis and most
common cause of blindness in
endemic areas.
* Contagious : contact with infected
conjunctivitis secretions,hands and
clothes contaminated,fly….
TYPHUS
• Caused of the genus Rickettsia pathogen R.prowasekii (bacteria)
• Clinical:
Sudden onset of fever (temp of over 39 Cº), headache, myalgias.
Exanthema maculopapular
• TRANSMISSION: Body louse due to lack of personal hygiene, crowding.
RELAPSING FEVER
• Caused of the genus Borrelia pathogen B.recurrentis, B.hispanica,
B.persica.... (spirochetes)
• Clinical:
High fever, artralgia, shivering, jaundice, bleeding.
A febrile interval
• TRANSMISSION: Body louse and tick due to lack of personal hygiene,
crowding..
KEY FACTORS FOR PREVENTING WATER-WASHED

AND WATER-SCARCE DISEASES
• Non contaminated water for hygiene

• Laundry with soap
• Fly vector control
• Louse vector control
• No crowding
Excreta-related helminths Transmission

(Parasite worms in human
intestine) mechanisms
Soil transmitted Helminths

Roundworm, hookworm,
whipworm
• Open defecation
• Ground contamination
ASCARIDIASIS
• Nematodiasis due to Ascaris lumbricoides (Parasite)
• Clinical
Phase of larva migration: pulmonary and allergic signs (non
productive cough, mild fever)
Established infection: non specifics digestive signs nausea, vomits,
diarrhoea, intestinal irritation,
• TRANSMISSION: Faecal -Oral
KEY FACTORS FOR PREVENTING HELMINTHS
• Controlled excreta disposal

• Non contaminated food
Water-based Transmission
diseases mechanisms
Long stay in infected waters

Schistosomiasis, Guinea worm
(Dracunculosis), clonorchiasis .
• Water contamination
SHISTOSOMIASES
• Infections by Schistosoma haematobium, S. mansoni are frequently, by

S. japonicum y S. intercalatum lowness.(Parásitos)
• Clinical:
• Each species give rise to specific clinical form,it depends the
parasite load
Shistosomiases urinary S. haematobium signs : haematuria,
frequent and painful micturation evolution to fibrosis urethral.
Shistosomiases intestinal: S. mansoni signs : bloody diarrhoea ,
abdominal pain, nauseas, vomit and it evolution liver fibrosis
• TRANSMISSION: By contact with the parasite when bathing or
swimming in contaminated water.
KEY FACTORS FOR PREVENTING

WATER-BASED DISEASES
• Safe drinking water supply
• Adequate drainage of stagnant waters

Water-related
insect vectors
Transmission
mechanisms
Excreta-related
insect vectors
Bitting by mosquitoes, flies.

Malaria, dengue, sleeping Transmited by flies, cockroaches
sickness, filariasis, yellow fever.
Diarrhoea and dysentery • Bite near water
• Breed in water
• Dirty environment
VECTORS RELATED TO DISEASES
• Mosquitoes
• Flies
• Louse (Typhus, Relapsing Fever)
• Fleas (Plague)
• Ticks
MALARIA
• Pathogen: Plasmodium falciparum, vivax and ovale (Parasite)
• Vector: Mosquito Anopheles female
• Clinical:
Painful muscles and joints,high fever with chills, headache, possybly
diarrhoea and vomiting
• Stagnant waters are the breeding place.
DENGUE
• Pathogen: Virus (Flaviviridiae)
• Vector: Aedes aegypti
• Clinical:
High fever, headaches, pain in muscles and joints, red spots on
skin. Classic dengue, hemorrhagic dengue .
• Larva growth in water containers (tyres, vases, barrels) or other natural
places (lagoons, pools).
Epidemic dengue (red)

YELLOW FEVER
• Pathogen: Virus (Flaviviridiae)
• Vector: Aedes aegypti
• Clinical:
Fever, headache, myalgia, nausea, red eyes, jaundice.
• Stagnant waters. Only bites during daylight.
• Vector Control
KEY FACTORS FOR PREVENTING WATER-RELATED

INSECT VECTOR AND EXCRETA-RELATED INSECT
VECTOR DISEASES
• Adequate drainage of stagnant water
• Disposal of waste water
• Excreta controlled disposal
• Safe storage of drinking water
• Vector control
Thank you……….

Health Water Sanitation

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Diseases related to

water, sanitation and

1. Public Health in Emergencies: Indicators

Causes of Death in Emergencies (Worldwide)

Acute Respiratory Infections (ARI)

Health Indicators in Emergencies

 Under 5 Mortality Rate (U5MR)

Mortality Rates in Emergencies

Region CDR/CMR CDR/CMR U5DR/MR U5DR/MR

South Asia 0.25 0.5 0.59 1.2

Middle East 0.16 0.3 0.36 0.7

Latin America 0.16 0.3 0.19 0.4

Fuente: UNICEF State of the World’s Children 2003

Benchmark for CMR and U5MR (worldwide)

Benchmark for CMR (world): Benchmark for U5MR (world):

•Baseline 0.5 •Baseline 0.8-1.2

For a specific area, when baseline is unknown agencies

The most important aim of a water and

...To minimise health risks of

The main objective of water supply,

WATER / SANITATION / HYGIENE

The crucial aims of water and sanitation

• To supply sufficient safe water

Fewtrell L et al. (2004) Lancet Infect Dis 5(1): 42-52.

Most common routes for the transmission of Diarrhoea germs

Adapted from Winblad U & Dudley E, 1997. Source: WHO PHAST

THE MOST IMPORTANTS

Cholera, shigellosis, diarrhoea,

Typhoid, paratyphoid, etc.

Amoebic dysentery, giardiasis

According to Curtis and Cairncross (2003),

Curtis, V. and Cairncross, S. (2003). Effect of washing hands with soap on

• Cause outbreaks with case-fatality rates

KEY FACTORS FOR PREVENTING

• Attention the A and E transmission FAECAL-ORAL route

Most common routes for the transmission of Diarrhoea germs

Adapted from Winblad U & Dudley E, 1997. Source: WHO PHAST

Skin and eye infections. • Inadequate water

Louse borne typhus or • Poor personal hygiene

KEY FACTORS FOR PREVENTING WATER-WASHED

• Non contaminated water for hygiene

Excreta-related helminths Transmission

Soil transmitted Helminths

KEY FACTORS FOR PREVENTING HELMINTHS

• Controlled excreta disposal

Long stay in infected waters

• Infections by Schistosoma haematobium, S. mansoni are frequently, by

KEY FACTORS FOR PREVENTING

• Safe drinking water supply

• Adequate drainage of stagnant waters

Bitting by mosquitoes, flies.

VECTORS RELATED TO DISEASES

Epidemic dengue (red)

KEY FACTORS FOR PREVENTING WATER-RELATED

• Adequate drainage of stagnant water

• Disposal of waste water

• Excreta controlled disposal

• Safe storage of drinking water

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