Water Supply and Sanitation

for Low Income Countries

Part I: Role of water quality,
quantity and sanitation in public
health
 Water Supply and Sanitation Coverage (%) for
Africa, Asia and L. America, 1970-2000

Supplier-based data Survey

data*
Year 1970 1980 1990 2000
Urban Water 65 74 82 92
Rural Water 13 33 50 71
Urban Sanitation 54 50 67 81
Rural sanitation 9 13 20 31
*For 72% of African, 77% of Asian, and 91% of L .American populations
Per Capita Construction & TOTAL Costs of Water
Supply & Sanitation (1990 US$)
Water Supply Const.
Annual*
House Connection 200 35
Public tap 100 17
Rural 30 5
Excreta Disposal
Sewerage 350 50
On-site 25 4
Rural 20 4
* operating and maintenance + amortized construction

Source: WHO/UNICEF Joint Monitoring Programme Report 1990

 Benefits of Water Supply
Likely: Unlikely:
• Saving in time or • Increased production
money • Better village
• Improved health organization
• Changed settlement
pattern
• Votes
 Water collection journey times in rural Africa

26%
25%

22%

19%

6%

Water on premises Less than 15 min 15 - 30 min 30 min - 1 hour 1 hour or more

Source: Unicef, based on MICS data for 23 countries; analysis by Greg Keast
 Improved Water Supplies
Benefit Women
They give women more time for:
– child care
– domestic hygiene and food preparation
– relaxation
– organizing themselves
– education (applies also to children’s time)
– production
 50
WS and Child Nutrition
Protected Water (n=98)
40
Unprotected Water (n=85)
% of sample

30

20

10

0
>90 89-80 79-70 <70
Weight/Height*

Source: Tomkins, A.M., et al. (1978) Water supply and nutritional status in rural Northern
Nigeria. Trans. Roy. Soc. Trop. Med. Hyg. 72:239-243
 Women’s Time Use with and without
Improved WS - Mueda, Mozambique
Average time per woman-day (minutes)
Activity without with Differenc
w.s. w.s. e
Water collection 131 25 -106
Other household work 126 161 +35
Grinding cereals 84 98 +14
Production 154 160 +6
Social activities, etc. 384 433 +48
Total 880 877 -3
Source: Cairncross & Cliff (1987) Trans Roy Soc Trop Med Hyg 81: 51 54
The Bradley Classification of Water-Related
Infections (1972)
Transmission Route Description
Water-borne You drink it
Water-washed Person-to-person transmission
(or water scarce) due to inadequate personal
and domestic hygiene
Water-based Transmission of infections via
an obligatory aquatic host
(e.g., snail)
Water-related insect Transmission by insects which
vector breed in (or bite near) water
Transmission Route Disease Group

1. Water-borne Faeco-oral

2. Water-washed Skin & eye infections

 Water-Related Infections
Category Examples
1. Faeco-oral Diarrhoeas & dysenteries
- amoebic dysentery
- cholera
- cryptosporidiosis, giardiasis
- salmonellosis
- shigellosis (bacillary dysentery)
- viral diarrhoeas
Enteric fevers (typhoid, paratyphoid)
Hepatitis A, E
Poliomyelitis
SARS?

2. Water-washed Skin infections – e.g. scabies?

Eye infections (conjunctivitis, trachoma)
Louse-borne typhus & relapsing fever

3. Water-based
(a) penetrating skin Schistosomiasis

(b) ingested Guinea worm

Clonorchiasis, etc.

4. Water-related insect Filariasis, malaria

vector Dengue, yellow fever
Sleeping sickness in West Africa
 Important Water-related Insect-
vector Diseases
Disease Vector Breeding Site
Bancroftian Culex quinque- Polluted water
filariasis fasciatus (drains, septic
tanks, etc.)
Malaria Anopheles spp. Various
Yellow Aedes aegypti Water storage
Fever vessels
Dengue
(+DHF)
Preventable Water-Related Disease by
Category
100
90 Deaths
80 Inpatients
70 Outpatients
60
50
40
30
20
10
0
Faeco-oral Water- Water-based WR Insect
washed (non- vector
faeco-oral)
Evidence for non-waterborne transmission
of endemic diarrhoeal disease (not cholera)
• Negative health impact results
• Food microbiology
• Seasonality of diarrhoeas
• Hand washing studies
• Fly control studies
 Waterborne vs. water-washed?

Impact of Water Chlorination Impact on Diarrhoeal Disease:

Results of a double-blind crossover trial in the village of Sao
Joao, Ceara, Brazil

Group Water Diarrhoea

Quality Incidence
FC/100 ml days/year
Hipochlorite 70 26.9

Placebo 16,000 27.7

Source: Kirchhoff L.V., McLelland, K.E., Pinho, M.C. (1982) J. Hyg. Camb. 94:173-180
 Food Microbiology
Millet-based weaning gruels in the
Gambia
Hours since preparation E. coli per 100 ml
1 104
2 105
4 106
8 107
Water used for preparation 1.7 x 103

Source: Barrell R.A.E. and Rowland, M.G.M. (1980) J. Hyg. Camb. 84: 191-202
Diarrhoea Seasonality in Lesotho,
Southern Africa

Scan in diarrhoeal seasonality in

Lesotho GRAPH
 Shigella secondary infection rates in
handwashing and control groups, by age
60

50 Intervention Families
Control Families
40

% 30

20

10

0
0-4 5-9 10-19 20-40 40+ All 2nd All 2nd
Infections Cases
Ages
Source: M.U. Khan (1982) Trans. Roy. Soc. Med. Hyg. 76 (2): 164-168
Shigella transmission & Soap
35

30 2nd Infection Rate

2nd Case Rate
25

20

15
10

0
Control Water Soap Soap &
Water
Source: M.U. Khan (1982) Trans. Roy. Soc. Med. Hyg. 76 (2): 164-168
 Lima, Peru: vendors

Burundi: < 5 l.c.d.

Malawi: refugee camp

Meta-analysis of 17 studies of handwashing & diarrhoea. Mean reduction 43%.

Curtis V, Cairncross S (2003) Lancet Inf. Dis. 3: 275-281.
 Fly Control Studies
1. NW Frontier Province, Pakistan
Diarrhoea Incidence
(episodes/child-year)
Year 1995 1996
3 group A villages 6.3* 6.5
3 group B villages 7.1 4.4*
* Sprayed Villages

Mean reduction (adjusted for year): 23%

(p=0.007)
Source: Chavasse D.C. et al. (1999) Lancet 353: 22-25
 Fly Control Studies
2. The Gambia
Diarrhoea Prevalence
(%
individuals/season)
Season Wet Dry
Intervention 14 6
village
Control
Mean village in D prevalence:
reduction 19 824%
(Mean reduction in trachoma incidence:
75%!)
Source: Emerson P.M.. et al. (1999) Lancet 353: 1401-1403
Kosti, Sudan 1976
Water Storage Tank

Water Pumping &

Treatment Station

Intake
Kosti Typhoid Cases
 Risk of Diarrhoea – Cebu, Phillipines
Feacal Contamination of Drinking Water
E. Coli/ Diarrhoea Cases/
100 ml Populaton at Risk (% cases)
<1 104/1125 9.2
2-10 13/196 6.6
11-100 20/235 8.5
101- 25/248 10.1
1000
>1000 33/220 15.0
Source: Moe, C.L., et al. (1991) Bull. WHO 69: 305-317
Water use (l.c.d.) Water Quantity
60

40

20

30
Time (min.)
Source: Cairncross S, Feachem R 1993. Environmental Health Engineering in the
Tropics; an Introductory Text. 2nd edition. Chichester: John Wiley & Sons, p. 63
 Water Use with and without Improved
WS - Mueda, Mozambique
without w.s. with w.s.
Use l.c.d % l.c.d %
Bathing 0.80 25 4.75 39
Bathing children 0.04 1 1.23 10
Washing clothes 0.54 17 2.64 21
Drinking 0.21 6 0.36 3
Cooking 0.67 21 1.93 16
Washing of dishes & food 0.50 15 1.36 11
Production (animals, drinks, 0.48 15 0.03 0.3
pottery)
Total 3.24 100 12.3 100

Source: Cairncross & Cliff (1987) Trans Roy Soc Trop Med Hyg 81: 51 54.
Typical outcome from water supply
Effect on health:
Water quality: 1) Feacal-oral group
greatly improved - water-borne:
reduced
Water use per capita: - water-washed:
little changed unchanged

Hygiene: 2) Water-washed group:

little changed unchanged
 Water Supplies in Palmares, NE Brazil
(infants < 4 months)
Type of Water Supply % of deaths due
to diarrhoea
Public piped system:
(60% of population)
- house connections 20.0
- tap < 100 m from house 57.1
- tap > 100 m from house 68.0
Unprotected well: 57.6
(40% of population)
Source: Wagner, E.G., and Lanoix, J.N. (1959) Water Supply for Rural Areas and
Small Communities. Geneva, WHO
 The Feachem Classification of Excreta-Related
Infections (1983)
Category Transmission Examples
features
1. Nonbacterial feco- viral; protozoan; heminthic
oral Non-latent vs.
2. Bacterial feco-oral Latent cholera, typhoid, shigellosis,
Persistence salmonellosis, others
3. Geohelminthiases Ability to multiply ascaris, hookworm,
outside host trichiuriasis, others
4. Taeniases Infectivity Taeniasis
Y/N intermediate
5. Water-based host Schistosomiasis, others
helminthiases
6. & 7. Insect- & 1. – 3. infections transmitted by flies,
rodent-vector cockcoaches, rodents
 The F-Diagram
Fluids Water
Sanitation
Quality

Fields
New
Feces Food Host

Flies

Fingers Water Quantity

Hand Washing
Source: Wagner and Lanois, 1958
 Effectiveness of WatSan Interventions for
% Reduction in Diarrhoeal Incidence Reducing Diarrhea Morbidity
50

45

40

35

30

25

20

15

10

0
Latrine Water Quantity Water Quality Hygiene Handwash with
Promotion Soap

Source: Esrey et al. 1991; Hutly et al. 1997; Curtis, in press.

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