Annotated Bibliography of Selected Studies on Water/Sanitation and Diarrheal Diseases – 2003

(Compiled by the EHP Information Center, December 11, 2003)

This annotated bibliography contains citations and abstracts of 33 studies published in 2003 that focus on diarrheal diseases and water/sanitation.

Author Index

Akter N, Hussain Z, Trankler J, Parkpian P. Hospital waste management and it’s probable health effect: a lesson learned from Bangladesh. Indian J Environ Health. 2002 Apr;44(2):124-37.

Urban Environmental Engineering Program, School of Environment, Resource and Development, Asian Institute of Technology, GPO Box 4, KlongLuang, Pathumthani 12120, Thailand.

A study was conducted to evaluate the current status of hospital waste management (HWM) in Bangladesh. The aim is to recognize the health effect of the existing practice, to determine the awareness level of doctors and nurses about hospital waste, to identify the weaknesses, and to provide suggestions for improvement. Hospital staff, waste pickers, and local residents were interviewed while in depth field observation, which included sample collection and laboratory analysis was also conducted. Through this investigation, it has been quite evident that a satisfactory hospital waste management system in government hospitals and several private clinics is severely lacking. At present, Bangladesh has no rigorous laws or regulation, which are enforced in this area. The waste is generally dumped together in a public place such as the hospital surroundings, the roadside or City Corporation dustbin. Many doctors and nurses are not fully aware about what constitutes as medical waste. Health care workers have only a basic understanding of health care and do not perceive handling or disposal of medial waste as a hazardous work. Laboratory analysis shows existing contamination of infectious agents in the environment. Some staff members interviewed were suffering from various kinds of infectious diseases such as viral hepatitis B/C, typhoid, skin disease/allergy, diarrhea, dysentery, tuberculosis, and malaria. During field observation it was discovered that improved HWM systems have only recently been introduced in a small number of private hospitals and clinics, some of which could be used as references to formulate guidelines for reaching the optimal at the national level. The study indicates that there is a need to improve the handling and disposal methods of hospital waste in almost all the available medical facilities. There are a few

NGOs that have started awareness building and training on waste management for selected hospital staff and NGO officials. Based on the analysis of the situation, several suggestions and recommendations have been made to aid in the development of a waste management system.

Bajracharya D. Myanmar experiences in sanitation and hygiene promotion: lessons learned and future directions. Int J Environ Health Res. 2003 Jun;13 Suppl 1:S141-52.

Recent activities in connection with the National Sanitation Week (NSW) and Social Mobilisation for Sanitation and Hygiene have contributed to a significant increase in access to sanitary means of excreta disposal, from 45% in 1997 to 67% in 2001. Handwashing with soap and water after defecation has also increased from 18% in 1996 to 43% in 2001. Success is attributable to high level political commitment, state or division level action and community mobilisation by village level authorities. Multi-level efforts such as mass media, planning workshops, training sessions and house-to-house visits by village authorities and health officials have raised greater awareness of sanitation and hygiene issues and led to construction of latrines on a self-help basis. The challenge ahead is to give greater attention to the ‘hard to reach’ who live in less accessible areas and are more resistant to change. The 2002 NSW has accordingly given special emphasis to activities in 73 of 324 townships where 50% or more of the households have no access to a sanitary latrine. The communication and social mobilisation package has been improved to upgrading unsanitary latrines and integrating handwashing more systematically with promotion of sanitary latrines. Programmatic follow-up to the NSW is being provided in selected townships through more intensive social mobilisation for ‘hard to reach’ households and activity-based school sanitation and hygiene education. This approach will contribute further towards improved hygienic practices and reduce diarrhoeal morbidity and mortality.

Brooks JT, Shapiro RL, Kumar L, Wells JG, Phillips-Howard PA, Shi YP, Vulule JM, Hoekstra RM, Mintz E, Slutsker L. Epidemiology of sporadic bloody diarrhea in rural Western Kenya. Am J Trop Med Hyg. 2003 Jun;68(6):671-7.

Foodborne and Diarrheal Diseases Branch, and Biostatistics and Information Management Branch, National Center for Infectious Diseases, Centers for Disease Control and Prevention, Atlanta, Georgia 30333, USA. Email: [email protected]

We conducted laboratory-based surveillance and a case-control study to characterize the epidemiology of bloody diarrhea in rural Western Kenya. From May 1997 through April 2001, we collected stool from 451 persons with bloody diarrhea presenting to four rural clinics. Cultures of 231 (51%) specimens yielded 247 bacterial pathogens: 198 Shigella (97 S. flexneri, 41 S. dysenteriae type 1, 39 S. dysenteriae type non-1, 13 S. boydii, 8 S. sonnei), 33 Campylobacter, 15 non-typhoidal Salmonella, and 1 Vibrio cholerae O1. More than 90% of the isolates (excluding Campylobacter) were resistant to trimethoprim-sulfamethoxazole and tetracycline, and more than 80% were resistant to ampicillin. Most (74%) ill persons received medication to which their isolate was resistant. Drinking Lake Victoria water and sharing latrines between multiple households increased risk of bloody diarrhea. Washing hands after defecating was protective. Providing safe drinking water and more latrines, and promoting hand washing could reduce the burden of illness from bloody diarrhea while limiting injudicious antimicrobial use.

Curtis V, Cairncross S. Effect of washing hands with soap on diarrhoea risk in the community: a systematic review. Lancet Infect Dis. 2003 May;3(5):275-81.

Department of Infectious and Tropical Diseases, London School of Hygiene and Tropical Medicine, London, UK. Email: [email protected]

We set out to determine the impact of washing hands with soap on the risk of diarrhoeal diseases in the community with a systematic review with random effects meta-analysis. Our data sources were studies linking handwashing with diarrhoeal diseases. Seven intervention studies, six case-control, two cross-sectional, and two cohort studies were located from electronic databases, hand searching, and the authors’ collections. The pooled relative risk of diarrhoeal disease associated with not washing hands from the intervention trials was 1.88 (95% CI 1.31-2.68), implying that handwashing could reduce diarrhoea risk by 47%. When all studies, when only those of high quality, and when only those studies specifically mentioning soap were pooled, risk reduction ranged from 42-44%. The risks of severe intestinal infections and of shigellosis were associated with reductions of 48% and 59%, respectively. In the absence of adequate mortality studies, we extrapolate the potential number of diarrhoea deaths that could be averted by handwashing at about a million (1.1 million, lower estimate 0.5 million, upper estimate 1.4 million). Results may be affected by the poor quality of many of the studies and may be inflated by publication bias. On current evidence, washing hands with soap can reduce the risk of diarrhoeal diseases by 42-47% and interventions to promote handwashing might save a million lives. More and better-designed trials are needed to measure the impact of washing hands on diarrhoea and acute respiratory infections in developing countries.

Curtis V, Biran A, Deverell K, Hughes C, Bellamy K, Drasar B. Hygiene in the home: relating bugs and behaviour. Soc Sci Med. 2003 Aug;57(4):657-72.

Department of Infectious and Tropical Diseases, DCVBU/ITD London School of Hygiene and Tropical Medicine, Kepple Street, London WCIE 7HT, UK. Email: [email protected]

Much infectious intestinal disease (IID) arises in the home environment. If programmes to prevent infection are to be effective it is essential to both identify the particular practices that risk disease transmission, and to understand the reasons for these practices. An in-depth, multidisciplinary study of carer and child hygiene in the domestic environment in the Wirral, UK, employed structured observation, surface swabbing for polio vaccine virus and enteric marker organisms, semi-structured interviews, projective interviews and focus group discussions. Observations revealed that child carers washed hands with soap after changing a dirty nappy on 42% of occasions, and that one in five toilet users did not wash hands with soap afterwards. Microbiological samples were taken from household surfaces at sites thought likely to be involved in the transfer of faecal material. 15% of bathroom samples showed contamination with polio vaccine virus. Nappy changing took place mainly in living rooms. Contact with living room surfaces and objects during nappy changing was frequent and evidence of faecal contamination was found in 12% of living room samples. Evidence of faecal contamination was also found in kitchens, again on surfaces thought likely to be involved in the transmission of faeces (taps and soap dispensers). Key factors motivating hygiene were the desire to give a good impression to others, protection of the child and aesthetics. In this setting, the particular risk practices to be addressed included washing hands with soap after stool and nappy contact and preventing the transfer of pathogenic organisms to the kitchen. The occasion of the birth of a child may be a privileged moment for the promotion of safer home hygiene practices. Using polio vaccine virus as an indicator of faecal contamination produces results that could be used in large-scale studies of household disease transmission. A better understanding of the household transmission of the agents of IID using multidisciplinary methods is needed if effective hygiene promotion programmes are to be designed.

Curtis V. Talking dirty: how to save a million lives. Int J Environ Health Res. 2003 Jun;13 Suppl 1:S73-9.

London School of Hygiene and Tropical Medicine, London, UK. Email: [email protected]

Infectious diseases are still the number one threat to public health in developing countries. Diarrhoeal diseases alone are responsible for the deaths of at least 2 million children yearly – hygiene is paramount to resolving this problem. The function of hygienic behaviour is to prevent the transmission of the agents of infection. The most effective way of stopping infection is to stop faecal material getting into the child’s environment by safe disposal of faeces and washing hands with soap once faecal material has contaminated them in the home. A review of the literature on handwashing puts it top in a list of possible interventions to prevent diarrhoea. Handwashing with soap has been calculated to save a million lives. However, few people do wash their hands with soap at these critical times. Obtaining a massive increase in handwashing worldwide requires a sea-change in thinking. Initial results from a new programme led by the World Bank, with many partner organisations, suggest that health is low on people’s list of motives, rather, hands are washed to remove dirt, to rinse food off after eating, to make hands look and smell good, and as an act of motherly caring. Professional consumer and market research agencies are being used to work with the soap industry to design professional communications programmes to reach whole populations in Ghana and India. Tools and techniques for marketing handwashing and for measuring the actual impact on behaviour will be applied in new public-private handwashing programmes, which are to start up soon in Nepal, China, Peru and Senegal.

Deodhar NS. Epidemiological perspective of domestic and personal hygiene in India. Int J Environ Health Res. 2003 Jun;13 Suppl 1:S47-56.

Email: [email protected]

When the application of epidemiology moves from mass phenomenon in a society or community to the specific family or individual level occurrences, new vistas unfold. The classical epidemiological triad, with its multi-mode influences and interactions, becomes modified as a result of several lifestyle factors coming into operation. It is well known that even under severely adverse climatic conditions, microbes are able to survive, and even propagate, if an appropriate micro-climate is encountered. This principle also applies to human beings. Many incidences of disease or ailments, occurrence or absence, can be traced to the home habitat, micro-ecosystem, human behaviour and lifestyles. Hygienic practices are largely a matter of behaviour and usually have biological and social origin. Human behaviour is influenced and determined by social traditions, customs and culture. Furthermore, factors such as health consciousness, practical knowledge of health sciences, motivation and concern for taking steps for promoting health and preventing disease, can change behaviour and make the lifestyle conducive to health. In a village or slum area, families live in more-or-less the same environment. However, in the event of an outbreak of a communicable disease, many escape the attack. While some experience frequent episodes of illness, others continue to live fairly healthily. Obviously, several social and cultural factors and associated human behaviours seem to make the difference between health and disease. This discussion examines the domestic and personal hygiene in its epidemiological perspective.

Faulkner CT, Garcia BB, Logan MH, New JC, Patton S. Prevalence of endoparasitic infection in children and its relation with cholera prevention efforts in Mexico. Rev Panam Salud Publica. 2003 Jul;14(1):31-41.

University of Tennessee, Department of Comparative Medicine, Knoxville, Tennessee 37796-4543, United States of America. Email: [email protected]

OBJECTIVE: To investigate whether increased knowledge and use of public health measures promoted for cholera prevention is reflected in lower prevalence of parasitic infection in households in a community in the state of Tamaulipas, Mexico, that is close to the border with the United States of America. METHODS: Between 1994 and 1997, fecal samples from 438 children were collected through convenience sampling and then examined for helminth eggs/larvae and protozoan cysts as biologic indicators of household compliance with recommended cholera prevention measures. The suggested measures were to wash hands before meals and after defecation, to drink purified water, to wash fruits and vegetables, and to eat well-cooked food. In addition, information on the knowledge of and the use of cholera preventive measures was collected by interviews with adult informants in 252 households (186 of those households also provided a fecal sample for analysis). RESULTS: Parasitic infections occurred in 131 of the 438 children (30%), who resided in 79 of the 186 households (42%) that provided fecal samples. Giardia lamblia accounted for 12.5% of all infections. Infections with Hymenolepis nana, Ascaris lumbricoides, Trichuris trichiura, Enterobius vermicularis, Ancylostoma/Necator, Strongyloides stercoralis, Entamoeba coli, Entamoeba hartmanni, Entamoeba histolytica, Endolimax nana, and Iodamoeba butschlii were also noted. Infected children were older and more often had an infected sibling. Households with three or more children were also more likely to have an infected child. The primary caregivers in the households where at least one child had a parasitic infection were distinguished by their inability to list at least three cholera prevention measures from memory.

CONCLUSIONS: The 42% household prevalence of parasitic infection was relatively high and indicates that some residents of this community may not have fully embraced the public health education efforts promoted for prevention of cholera. The occurrence of nonpathogenic protozoan parasites such as Endolimax nana, Entamoeba coli, Entamoeba hartmanni, and I. butschlii are important bioindicators for the persistence of unhygienic behaviors that increase the risk of cholera and other infectious diseases dependent on fecal-oral transmission. Information obtained by similar studies can be useful for monitoring compliance with community health and hygiene programs and may indicate the need to intensify educational efforts for the prevention of diarrhea associated with enteric pathogens that cannot be controlled by drugs alone.

Guerrant RL, Carneiro-Filho BA, Dillingham RA. Cholera, diarrhea, and oral rehydration therapy: triumph and indictment. Clin Infect Dis. 2003 Aug 1;37(3):398-405.

Center for Global Health, School of Medicine, Division of Infectious Diseases and International Health, University of Virginia, Charlottesville, VA 22908, USA. Email: [email protected]

Cholera drove the sanitary revolution in the industrialized world in the 19th century and now is driving the development of oral rehydration therapy (ORT) in the developing world. Despite the long history of cholera, only in the 1960s and 1970s was ORT fully developed. Scientists described this treatment after the discovery of the intact sodium-glucose intestinal cotransport in patients with cholera. This new understanding sparked clinical studies that revealed the ability of ORT to reduce the mortality associated with acute diarrheal disease. Despite the steady reductions in mortality due to acute dehydrating diarrheal diseases achieved by ORT, the costly morbidity due to these diseases remains, the result of a failure to globalize sanitation and to control the developmental impact of diarrheal diseases and their associated malnutrition. New advances in oral rehydration and nutrition therapy and new methods to recognize its costs are discussed in this review.

Halvorson SJ. Women’s management of the household health environment: responding to childhood diarrhea in the Northern Areas, Pakistan. Health Place. 2004 Mar;10(1):43-58.

Department of Geography, The University of Montana, 59812, Missoula, MT, USA This paper examines mothers’ management of water, sanitation, hygiene, and childhood diarrhea in a mountain community in the Northern Areas, Pakistan. It draws upon qualitative data obtained from 65 in-depth interviews and other ethnographic field methods. The analysis shows that respondents were familiar with diarrhea control interventions carried out in the study site, and associated childhood diarrhea with oral-fecal transmission routes such as poor water quality, unhygienic behaviors, contaminated food, and inadequate sanitation practices. Findings also demonstrate the continuance of long-established cultural patterns of perception and behavior with regard to childhood diarrhea and the influence of socio-economic constraints to instituting new management practices.

Harvey SA, Winch PJ, Leontsini E, et al. Domestic poultry-raising practices in a Peruvian shantytown: implications for control of Campylobacter jejuni-associated diarrhea. Acta Trop. 2003 Apr;86(1):41-54.

Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD 21025, USA. Email: [email protected]

Raising poultry at home is common in many periurban communities in low-income countries. Studies demonstrate that free-range domestic poultry increase children’s risk of infection with diarrhea-causing organisms such as Campylobacter jejuni. Corralling might reduce risk, but research on the socioeconomic acceptability of corralling is lacking. To explore this issue, we studied local knowledge and practices related to poultry-raising in a Peruvian shantytown. Our objectives were to understand: (1). motives for raising domestic poultry; (2). economic and cultural factors that affect the feasibility of corralling; and (3). local perceptions about the relationship between domestic poultry and disease. During 1999-2000, we met with community health volunteers and conducted ethnographic and structured interviews with residents about poultry-raising practices. We then enrolled 12 families in a 2-month trial of corral use during which field workers made biweekly surveillance visits to each family. Most participants reported that they raise birds because home-grown poultry and eggs taste better and are more nutritious and because they enjoy living around animals. Some want to teach their children about raising animals. To prevent theft, many residents shut their birds in provisional enclosures at night, but most stated that birds are healthier, happier, and produce better meat and eggs when let loose by day. Many view bird feces in the house and yard as dirty, but few see a connection to illness. Residents consider chicks and ducklings more innocuous than adult birds and are more likely to allow them inside the house and permit children to play with them. After extensive orientation and technical assistance, participants were willing to corral birds more often. But due to perceived disadvantages, many kept birds penned only intermittently. Additional food and water costs were a significant obstacle for some. Adequate space, bird care and corral hygiene would also need to be addressed to make this intervention viable. Developing a secure, acceptable and affordable corral remains a challenge in this population.

Heller L, Colosimo EA, Antunes CM. Environmental sanitation conditions and health impact: a case-control study. Rev Soc Bras Med Trop. 2003 Jan-Feb;36(1):41-50.

Departmento de Engenharia Sanitaria e Ambiental, Escola de Engenharia, Universidade Federal de Minas Gerais, Belo Horizonte, MG, Brasil. This epidemiological investigation examines the impact of several environmental sanitation conditions and hygiene practices on diarrhea occurrence among children under five years of age living in an urban area. The case-control design was employed; 997 cases and 999 controls were included in the investigation. Cases were defined as children with diarrhea and controls were randomly selected among children under five years of age. After logistic regression adjustment, the following variables were found to be significantly associated with diarrhea: washing and purifying fruit and vegetables; presence of wastewater in the street; refuse storage, collection and disposal; domestic water reservoir conditions; feces disposal from swaddles; presence of vectors in the house and flooding in the lot. The estimates of the relative risks reached values up to 2.87. The present study revealed the feasibility of developing and implementing an adequate model to establish intervention priorities in the field of environmental sanitation.

Hoque BA. Handwashing practices and challenges in Bangladesh. Int J Environ Health Res. 2003 Jun;13 Suppl 1:S81-7.

Environment and population Research Center, EPRC, Bangladesh. Email: [email protected] Handwashing is universally promoted in health interventions. Studies in Bangladesh and elsewhere have shown a 14 – 40% reduction of diarrhoeal diseases with handwashing. The perceptions and methods related to washing of hands vary widely in Bangladesh. Socio-economic factors are also associated with methods practised. In general, the effectiveness of handwashing practices is poor. Faecal coliform bacteriological counts were reported to be high for both left and right hands. About 85% of women studied who lived in slums and 41% of rural women washed their hands using only water. However, most women rubbed their hands on the ground, or used soil, and rinsed them with water during post-defecation handwashing. Most women claimed that they could not afford to buy soap. Experimental trials showed that use of soap, ash or soil gave similar results when women washed their hands under the same conditions. The washing of both hands, rubbing of hands, and the amount and quality of rinsing water used were found to be important determinants in the reduction of bacterial counts on hands. Although handwashing messages have been revised by most of the main programmes after these studies, there is scope for further improvement, as well as evaluation of their impact.

Hosain GM, Saha S, Begum A. Impact of sanitation and health education on intestinal parasite infection among primary school aged children of Sherpur, Bangladesh. Trop Doct. 2003 Jul;33(3):139-43.

Department of Community Medicine, Community Based Medical College, Gono University, Mirzanagar, Savar, Dhaka 1344, Bangladesh. Email: [email protected] This study was carried out in 1999-2000 in the northern part of Bangladesh to determine the impact of sanitary latrine use and of health education on intestinal parasites in school-aged children. The children were between 5 and 13 years of age and stool samples revealed that more than half (53%) of the study sample was still infected with one or more intestinal parasites even after 4 years of intervention. Ascariasis was found to have the highest prevalence rate (36.2%) and hookworm the lowest (10.7%). Intestinal parasite infection was significantly lower (P < 0.05) among those who used a sanitary latrine and received health education. This result is consistent with observations that the effect of sanitation and health education is slow to develop. Concerted primary healthcare activities with community development efforts should be undertaken to improve the overall living condition of the people of this area to control this problem.

Jensen PK, Ensink JH, Jayasinghe G, et al. Effect of chlorination of drinking-water on water quality and childhood diarrhoea in a village in Pakistan. J Health Popul Nutr. 2003 Mar;21(1):26-31.

Department of Veterinary Microbiology, The Royal Veterinary and Agricultural University, Stigbojlen 4, 1870 Frederiksberg C, Denmark.

To evaluate the importance of public-domain transmission of pathogens in drinking-water, an intervention study was carried out by chlorinating the public water-supply system in a village in Pakistan. The water quality improved and reached a geometric mean of 3 Escherichia coli per 100 mL at the last standpipe of the water-supply system. Drinking-water source used and the occurrence of diarrhoea were monitored on a weekly basis over a six-month period among 144 children aged less than five years in the village. In this group, the children using chlorinated water from the water-supply scheme had a higher risk of diarrhoea than children using groundwater sources, controlled for confounding by season and availability of a toilet and a water-storage facility. The incidence of diarrhoea in the village (7.3 episodes per 10(3) person-days) was not statistically different from that in a neighbouring village where most children used water from a non-chlorinated water-supply system with very poor water quality. In this study area, under non-epidemic conditions, the reduction of faecal bacteria in the public drinking-water supply by chlorination does not seem to be a priority intervention to reduce childhood diarrhoea. However, the study was of limited size and cannot provide conclusive evidence.

Kumar Karn S, Harada H. Field survey on water supply, sanitation and associated health impacts in urban poor communities–a case from Mumbai City, India. Water Sci Technol. 2002;46(11-12):269-75.

Department of Environmental Systems Engineering, Nagaoka University of Technology, Nagaoka 940-2188, Japan.

A field survey was conducted on four slum, squatter and pavement dweller communities of Mumbai City, India with a total sample size of 1,070 households. Study revealed extremely low water consumption pattern averaging merely 30 l/c x d, no sewerage and safe excreta disposal facilities manifested by high occurrence of water-borne diseases. The annual diarrhoeal, typhoid and malaria cases were estimated to 614, 68 and 126 per thousand populations respectively. At point prevalence scale, at least 30% of all morbidity can be accounted for by water-related infections. In addition to the impacts of neighborhood water pollution and sanitation, such diseases were also found positively correlated with low water consumption and poverty related factors as, poor housing and family income. Analysis of variance also revealed intra-poor gradient both in living standards and health conditions on which the pavement dwellers were observed to be the greatest sufferers of all.

Lanata CF. Studies of food hygiene and diarrhoeal disease. Int J Environ Health Res. 2003 Jun;13 Suppl 1:S175-83.

Instituto de Investigacion Nutricional, Lima, Peru. Email: [email protected] Contamination of weaning foods and water with enteropathogenic micro-organisms has been recognised in the past, but its link with the development of diarrhoea by young children in developing countries is lacking. This may explain the unavailability of effective interventions to reduce the risk of diarrhoeal diseases from this contamination. The frequency of contamination of weaning foods with enteropathogens is high in developing countries, and is dependent on the food type, storage time and ambient temperature of storage, the method used, and the temperature reached on re-warming before re-feeding. Other considerations are the bacterial content of cooking and feeding utensils. Fruit and raw vegetables can become contaminated with enteropathogenic micro-organisms by sewage-containing irrigation water, by washing produce and fruits in contaminated water, and how they are processed at home. In most studies reviewed, the level of contamination is higher in weaning foods than in drinking water. Since there is a need to reach a critical level of contamination before illness can occur after the ingestion of an enteropathogen, it is postulated that weaning foods are probably more important than drinking water for transmission of diarrhoeal diseases in developing countries. Several potential interventions have been identified, which should be developed and tested in controlled trials in developing countries. These interventions are needed to reduce contamination of weaning foods in households from developing countries, while adequate facilities for the provision of clean water and sanitation to those communities are placed.

Larsen B. Hygiene and health in developing countries: defining priorities through cost – benefit assessments. Int J Environ Health Res. 2003 Jun;13 Suppl 1:S37-46.

Economist/Consultant Environment and Health at the World Bank, UK. Email: [email protected]

Presented here are the four preliminary conclusions in the assessment of health and hygiene in developing countries: (a) child mortality, and disease burden associated with hygiene, water and sanitation in the developing and the developed regions of the world, has declined substantially in the past two decades, but substantial inter-regional and cross-country differences persist; (b) while child mortality and disease burdens decline with higher income levels, a substantial number of countries have been performing far better in reducing child mortality and disease burdens than their income levels would indicate, suggesting that active policy and investment interventions can yield significant health improvements without necessarily jeopardising economic growth; (c) despite the evidence of the role of water and sanitation services in reducing mortality and morbidity, service coverage at the country level has not increased as much as one may have expected in the past decade, in part because of the substantial resource requirements; (d) the paper will provide some new perspectives and evidence on the cost-effectiveness of interventions to reduce the disease burden of poor water and sanitation services and inadequate hygiene practices, in particular with regard to economic evaluation and in reference to hygiene programmes.

Merchant AT, Jones C, Kiure A, et al. Water and sanitation associated with improved child growth. Eur J Clin Nutr. 2003 Dec;57(12):1562-8.

OBJECTIVE: To examine the relation between household water and sanitation, and
the risk of stunting and reversal of stunting in Khartoum and Crezira regions Sudan.
DESIGN: Prospective cohort study.
SETTING: A total of 25 483 children aged 6-72 months from rural Sudan enrolled in an
18-month field trial in 1988 to study the effect of vitamin A supplementation on child health and survival. RESULTS: The mean height-for-age z-scores at baseline and the end of study were -1.66 and -1.55, respectively, for the group with water and sanitation facilities, and -2.03 and -1.94 for the group without water and sanitation, after adjustment for age, region, gender, mother’s literacy, intervention group (vitamin A vs placebo), family wealth, breastfeeding and cleanliness. Among children of normal height-for-age at baseline, the risk of stunting (<-2 height-for-age z-score) was lowest in the group that came from homes that had both water and sanitation compared to children from homes without these facilities (multivariate RR=0.79, 95% CI 0.69-0.90). Among children stunted at baseline, those coming from homes with water and sanitation had a 17% greater chance of reversing stunting than those coming from homes without either facility (adjusted RR=1.17, 95% CI 0.99-1.38). We did not detect a synergistic association between access to water and sanitation. CONCLUSIONS: Water and sanitation are independently associated with improved growth of children.

Moffat T. Diarrhea, respiratory infections, protozoan gastrointestinal parasites, and child growth in Kathmandu, Nepal. Am J Phys Anthropol. 2003 Sep;122(1):85-97.

Department of Anthropology, McMaster University, Hamilton, Ontario L8S 4L9, Canada. Email: [email protected]

The differential impact of diarrhea, respiratory infections, and protozoan parasitism on growth is investigated among children under five years of age living in periurban Kathmandu, Nepal. The children’s parents are all carpet-making workers who live in an environment with crowded living conditions, poor sanitation, and contaminated water. Anthropometric data, both cross-sectional and longitudinal, were collected over a 9-month period. Morbidity data were gathered from maternal reports, and a subsample of children’s stools were examined for gastrointestinal parasites. In a comparison of current growth status and growth velocity for children with and without diarrhea and respiratory infections, it is found that body weight is most affected by infections, particularly for children under 24 months of age. For a subsample of children whose stools were tested for parasites, there is a statistically significant association between stunting (low height-for-age) and the presence of a protozoan gastrointestinal parasite. It is concluded that although growth faltering is associated with diarrhea and respiratory infections, the impact of these infections is of less importance for long-term linear growth retardation than is infection by protozoan gastrointestinal parasites.

Moraes LR, Cancio JA, Cairncross S, Huttly S. Impact of drainage and sewerage on diarrhoea in poor urban areas in Salvador, Brazil. Trans R Soc Trop Med Hyg. 2003 Mar-Apr;97(2):153-8.

Polytechnic School, Federal University of Bahia, Salvador, Brazil.

A longitudinal prospective study of the effect of drainage and sewerage systems on diarrhoea in children aged < 5 years was conducted in 9 poor urban areas of the city of Salvador (population 2.44 million) in north-east Brazil in 1989-90. Due to complex political and administrative reasons, 3 areas had benefited from drainage improvements, 3 from both drainage and sewerage improvements, and 3 from neither. An extensive questionnaire was applied to collect information on each child and on the conditions of the household, and mothers recorded diarrhoea episodes in their children aged < 5 years daily for 1 year, using calendars. Fortnightly home visits were made to collect the data. The incidence of diarrhoea in children in neighbourhoods with drainage was less than two-thirds, and in neighbourhoods with drainage and sewerage less than one-third, of the incidence in neighbourhoods with neither. After controlling for potential confounders, the proportion of children with ‘frequent diarrhoea’ showed the same significant trend across the study groups. Though the groups were not exactly comparable, more than one child was monitored per household, and it was not possible to rotate fieldworkers between study groups, the study provides evidence that community sanitation can have an impact on diarrhoeal disease, even without measures to promote hygiene behaviour.

Nanan D, White F, Azam I, Afsar H, Hozhabri S. Evaluation of a water, sanitation, and hygiene education intervention on diarrhoea in northern Pakistan. Bull World Health Organ. 2003;81(3):160-5.

Department of Community Health Sciences, The Aga Khan University, Karachi, Pakistan. Email: [email protected]

OBJECTIVE: Inadequate water and sanitation services adversely affect the health and socioeconomic development of communities. The Water and Sanitation Extension Programme (WASEP) project, undertaken in selected villages in northern Pakistan between 1997 and 2001, was designed to deliver an integrated package of activities to improve potable water supply at village and household levels, sanitation facilities and their use, and awareness and practices about hygiene behaviour. METHODS: A case-control study was conducted during July-September 2001 to evaluate whether, after selected confounders were controlled for, children aged <6 years with diarrhoea were more or less likely to reside in villages that participated in the project than in villages that did not participate. Descriptive and logistic regression analyses were performed. FINDINGS: Children not living in WASEP villages had a 33% higher adjusted odds ratio for having diarrhoea than children living in WASEP villages (adjusted odds ratio, 1.331; P<0.049). Boys had 25% lower odds of having diarrhoea than girls (adjusted odds ratio, 0.748; P<0.049). A 2.6% decrease was found in the odds of diarrhoea for every yearly increase in the mother’s age (adjusted odds ratio, 0.974; P<0.044) and a 1.4% decrease for every monthly increase in the child’s age (adjusted odds ratio, 0.986; P<0.001). CONCLUSIONS: The findings in this study may help refine the approach to future water, sanitation, and hygiene initiatives in northern Pakistan. The integrated approach taken by WASEP, which incorporates engineering solutions with appropriate education to maximize facility usage and improve hygiene practices, is a useful example of how desired health benefits can be obtained from projects of this type.

Nath KJ. Home hygiene and environmental sanitation: a country situation analysis for India. Int J Environ Health Res. 2003 Jun;13 Suppl 1:S19-28.

The Institution of Public Health Egineers, India. Email: [email protected]

Problems of the environment and of domestic hygiene are always related to poverty of population and the sanitation of settlements. Most cities and towns in developing countries, like India, are characterised by over-crowding, congestion, inadequate water supply and inadequate facilities of disposal of human excreta, waste water and solid wastes. Inadequacy of housing for most urban poor invariably leads to poor home hygiene. Personal and domestic hygiene practices cannot be improved without improving basic amenities, such as water supply, waste water disposal, solid waste management and the problems of human settlements. But even under the prevailing conditions, there is significant scope of improving hygiene practices at home to prevent infection and cross-infection. Unfortunately, in developing countries, public health concerns are usually raised on the institutional setting, such as municipal services, hospitals, environmental sanitation, etc. There is a reluctance to acknowledge the home as a setting of equal importance along with the public institutions in the chain of disease transmission in the community. Managers of home hygiene and community hygiene must act in unison to optimise return from efforts to promote public health. Current practices and perceptions of domestic and personal hygiene in Indian communities, the existing levels of environmental and peri-domestic sanitation and the ‘health risk’ these pose will be outlined, as well as the need for an integrated action for improving hygiene behaviour and access to safe water and sanitation.

Nielsen M, Hoogvorst A, Konradsen F, et al. Causes of childhood diarrhea as perceived by mothers in the Punjab, Pakistan. Southeast Asian J Trop Med Public Health. 2003 Jun;34(2):343-51.

International Water Management Institute (IWMI), Lahore, Pakistan.

This study was carried out in the southern Punjab, Pakistan, to outline the causes of childhood diarrhea as perceived by mothers. Two hundred households in ten villages were randomly selected. Information was obtained from mothers, through a questionnaire, in-depth interviews, and direct observations. The focus was on obtaining information from mothers of children who were below five years of age. Causes of diarrhea reported by mothers were categorized in seven different domains. Causes relating to the digestive system, especially consumption of too much food, were the most important, followed by causes pertaining to contamination and those pertaining to the humoral theory of ‘hot’ and ‘cold’. The mothers’ health status was perceived as determining the health of her child through her breast milk. Through in-depth interviews, diarrhea as a symptom of envy and malice was brought up. The study draws attention to the complexity and heterogeneity of beliefs, attitudes and practices concerning diarrhea. This makes it difficult to come up with general rules for health education campaigns. Rather, in health education, the outstanding ‘good’ and ‘bad’ behavior should be selected and should be the focus. On the other hand, the heterogeneity of beliefs, attitudes and practices prevailing in the community could make mothers more receptive to new ideas than when a small set of rigid cultural norms would dominate thinking on disease transmission and hygiene. The study found that despite the mother’s central role as caretaker one should not focus only on the traditional mother-child relationship, but also include the husband-wife relationship, and target other individuals involved in setting norms within the household or within the nearby community.

Nunez FA, Lopez JL, de la Cruz AM, Finlay CM. Risk factors for Giardia lamblia infection in children in daycare centers in Havana, Cuba. Cad Saude Publica. 2003 Mar-Apr;19(2):677-82.

Instituto de Medicina Tropical ‘Pedro Kouri’, La Habana, Cuba. Email: [email protected]

We conducted a longitudinal study on giardiasis in three daycare centers in Havana City for a period of 18 months and described a group of children with a “predisposition” or tendency towards re-infection with Giardia lamblia. This group was found to be more frequently associated with clinical symptoms such as diarrhea. A case-control study was designed to determine whether socioeconomic factors and hygiene were associated with this phenomenon. We found no differences between the groups with regard to overcrowding rates, number of persons per bed, absence of certain electric appliances, mother’s schooling, or mean family income. However, there were proportionally more fathers with less than complete secondary education among cases as compared to controls. In addition, we found no differences in lack of hand-washing before eating and after defecation; however, we found a higher percentage of families who washed vegetables insufficiently among predisposed children. Finally, a lower percentage of families with predisposed children boiled their water. Our results demonstrate the important role of water as a vehicle for transmission of giardiasis and the importance of various epidemiologic factors.

Prado MS, Strina A, Barreto ML, et al. Risk factors for infection with Giardia duodenalis in pre-school children in the city of Salvador, Brazil. Epidemiol Infect. 2003 Oct;131(2):899-906.

Instituto de Saude Coletiva, Universidade Federal da Bahia, Brazil.

A cross-sectional study of 694 children aged 2 to 45 months selected from 30 clusters throughout the city of Salvador, Bahia (pop. 2.3 million) was carried out as part of a longitudinal study of diarrhoea in order to identify risk factors for infection with Giardia duodenalis. Variables studied included three social and demographic factors (such as mother’s education and marital status), five relating to the peri-domestic environment (rubbish disposal, open sewers, paving of the street), seven relating to the home itself (house construction, susceptibility to flooding, water supply and sanitation) as well as a score for hygiene behaviour based on structured observation. After multivariate analysis using a hierarchical model, only four significant risk factors were found: (a) number of children in the household under five years (b) rubbish not collected from the house (c) presence of visible sewage nearby, and (d) absence of a toilet. All four were significant at the 1% level.

Quick R. Changing community behaviour: experience from three African countries. Int J Environ Health Res. 2003 Jun;13 Suppl 1:S115-21.

Centers for Disease Control and Prevention, Atlanta, Georgia 30333, USA. Email: [email protected]

In the developing world, more than 1 billion people lack access to safe water. To address this problem, the US Centers for Disease Control and Prevention developed the Safe Water System (SWS), a household-based intervention with three elements: water disinfection, safe storage and behaviour change techniques, and tested these in three countries. In Zambia, social marketing (SM) was used to implement the SWS, and 100 randomly selected households also received motivational interviewing (MI). In Madagascar, the SWS was implemented using SM and community mobilisation (CM). In rural Western Kenya, the SWS was also implemented with SM and CM. In Zambia, 3 months after the SM project launch, 14% of households in the SM-only group had adopted the disinfectant compared with 78% of households in the SM plus MI group. Through SM, over 1 million bottles of disinfectant were sold in 3 years in Zambia. In Antananarivo, Madagascar, 6 months after launch of the water disinfectant, 8% of households in an early stage of the CM process were using the disinfectant compared with 20% in households at a late stage of the CM process. In 1 year, over 500,000 bottles of disinfectant were sold in Madagascar. In Kenya, adoption of the water disinfectant exceeded 60% in intervention households and diarrhoea rates decreased by 58% in children < 5 years. Social marketing permits widespread dissemination of interventions, but may have limited penetration into economically disadvantaged communities. Additional, targeted interventions, such as MI and CM, can increase product adoption. A combination of behaviour change interventions can increase project impact.

Rego RC, Barreto ML, Killinger CL. [What is garbage, anyway? The opinions of women from an outlying neighborhood in a large Brazilian city].

Cad Saude Publica. 2002 Nov-Dec;18(6):1583-91. Instituto de Saude Coletiva, Universidade Federal da Bahia, Salvador, BA, 40110-170, Brasil.

Domestic solid waste is cause for current environmental concern in large cities around the world. Little is known about the human health consequences of solid waste disposal in open-air dumps. In addition, there are few studies on people’s health practices in relation to solid waste. As the initial step in epidemiological research on the relationship between solid waste and diarrhea, this study describes women’s perception of the definition of garbage and the popular understanding of the relationships between garbage and disease, and between garbage and the environment. The study used a qualitative approach in a slum neighborhood in Salvador, Bahia. A total of 13 women were interviewed using a semi-structured questionnaire in 1999. The FileMaker “diaricamp” application was used for data analysis. Interviewees defined garbage as anything useless and considered it a problem whenever it accumulated in the surroundings producing a bad smell or visual pollution, attracted animals, caused disease in children or adults, or was shifted from the individual to the collective/institutional sphere of action to solve the problem.

Reller ME, Mendoza CE, Lopez MB, et al. A randomized controlled trial of household-based flocculant disinfectant drinking water treatment for diarrhea prevention in rural Guatemala. Am J Trop Med Hyg. 2003 Oct;69(4):411-9.

Division of Bacterial and Mycotic Diseases, National Center for Infectious Diseases, Centers for Disease Control and Prevention, Atlanta, Georgia 30333, USA.

We conducted a study to determine if use of a new flocculant-disinfectant home water treatment reduced diarrhea. We randomly assigned 492 rural Guatemalan households to five different water treatment groups: flocculant-disinfectant, flocculant-disinfectant plus a customized vessel, bleach, bleach plus a vessel, and control. During one year of observation, residents of control households had 4.31 episodes of diarrhea per 100 person-weeks, whereas the incidence of diarrhea was 24% lower among residents of households receiving flocculant-disinfectant, 29% lower among those receiving flocculant-disinfectant plus vessel, 25% lower among those receiving bleach, and 12% lower among households receiving bleach plus vessel. In unannounced evaluations of home drinking water, free chlorine was detected in samples from 27% of flocculant-disinfectant households, 35% of flocculant-disinfectant plus vessel households, 35% of bleach households, and 43% of bleach plus vessel households. In a setting where diarrhea was a leading cause of death, intermittent use of home water treatment with flocculant-disinfectant decreased the incidence of diarrhea.

Sakisaka K, Wakai S, Wongkhomthong SA. Domestic hygiene behaviour of mothers with children aged 0-5 years old in Tayabo village, Nueva Ecija, the Philippines. Asia Pac J Public Health. 2002;14(2):91-8.

Department of Community Health, School of International Health, Graduate School of Medicine, University of Tokyo, Japan. Email: [email protected]

A cross-sectional survey was carried out in a rural village in Nueva Ecija province in the Philippines to identify the association between mothers’ hygiene behaviour and their socioeconomic status and household environment. A total of 206 mothers with children aged 0-5 years old participated in this study. Household visits with face-to-face interviews using a structured questionnaire and observation of household environments were conducted. Logistic regression analysis revealed that the frequency of water boiling in mothers was significantly associated with children aged under two years old and the availability of domestic electricity. Availability of domestic electricity, mother’s educational level, possession of a private lavatory and of a private well were significant predictors of whether hand-washing with soap was practiced after defecation. For hand-washing with soap before feeding children, child’s age under one year old and the volume of the water supply were statistically significant. The volume of the water supply was identified as a significant predictor. Although health educational programme participation rates were very high (83.2%), no significant association with hygiene behaviour was observed. This study indicates that improvements in water availability, household environment and health education may contribute to more frequent hand-washing.

Sobsey MD, Handzel T, Venczel L. Chlorination and safe storage of household drinking water in developing countries to reduce waterborne disease. Water Sci Technol. 2003;47(3):221-8.

Dept of Environmental Sciences & Engineering, University of North Carolina, Chapel Hill, NC 27599-7400, USA. Email: [email protected]

Simple, effective and affordable methods are needed to treat and safely store non-piped, gathered household water. This study evaluated point-of-use chlorination and storage in special plastic containers of gathered household water for improving microbial quality and reducing diarrhoeal illness of consumers living under conditions of poor sanitation and hygiene. Community families were recruited and randomly divided into intervention (household water chlorination and storage in a special container) and control (no intervention) households. Microbes in stored household water were extensively inactivated by 1-5-mg/L doses of hypochlorite. Escherichia coli levels in stored household waters were < 1/100 mL in most intervention households but readily detectable at high levels in control households. Stored water of intervention households was also lower in Clostridium perfringens and heterotrophic plate count bacteria than in control households. The intervention reduced household diarrhoeal illness. In Bolivia, monthly episodes of household diarrhoeal illness were 1.25 and 2.2 in intervention and control families, respectively (P = < 0.002) indicating that 43% of community diarrhoea was preventable by using the intervention. In Bangladesh, mean episodes of child diarrhoea/1,000 d were 19.6 and 24.8 in intervention and control groups respectively (P = < 0.03) indicating that about 24% of observed diarrhoea was preventable by using the intervention. Chlorine disinfection and storage in an appropriate container significantly improved the microbiological quality of non-piped household drinking water and reduced community diarrhoeal disease. Widespread use of this simple treatment and storage system for non-piped domestic water has the potential to dramatically reduce the global burden of waterborne diarrhoeal disease.

Strina A, Cairncross S, Barreto ML, Larrea C, Prado MS. Childhood diarrhea and observed hygiene behavior in Salvador, Brazil. Am J Epidemiol. 2003 Jun 1;157(11):1032-8.

Institute of Public Health, Federal University of Bahia, Salvador, Brazil.

Brief biweekly home visits, made as part of a cohort study of diarrhea in young children under age 5 years that was carried out in Salvador, Brazil, in 1998-1999, were used as a low-cost way to collect structured observation data on domestic hygiene behavior. Field-workers were trained to check a list of 23 forms of hygienic or unhygienic behavior by the child or the child’s caretaker, if any behaviors were seen during the visit. Children were grouped according to whether mainly unhygienic behavior or mainly hygienic behavior had been recorded. This permitted study of the determinants of hygiene behavior and of its role in the transmission or prevention of diarrheal disease. Observations were recorded on roughly one visit in 20. Households with adequate excreta disposal were significantly more likely to be in the “mainly hygienic” group. The prevalence of diarrhea among children for whom mainly unhygienic behavior was recorded was 2.2 times that among children in the “mainly hygienic” group. The relative risk for prevalence was 2.2 (95% confidence interval: 1.7, 2.8). The relative risk fell to 1.9 (95% confidence interval: 1.5, 2.5) after data were controlled for confounding, but the difference was still highly significant.

Thompson T, Sobsey M, Bartram J. Providing clean water, keeping water clean: an integrated approach. Int J Environ Health Res. 2003 Jun;13 Suppl 1:S89-94.

World Health Organization, South-East Asia Regional Office, New Delhi, India. Email: [email protected]

Millions of people, most of whom are children in developing countries, die of basic hygiene-related diseases every year. Interventions in hygiene, sanitation and water supply have been shown to control disease burden. Universal access to improved water sources and basic sanitation remains elusive but is an important long-term goal. Studies have shown that improving the microbiological quality of household water by on-site or point-of-use treatment and safe storage in improved vessels reduces diarrhoeal and other waterborne diseases in communities and households of developing and developed countries. The extent to which improving drinking water quality at the household level reduces diarrhoeal disease probably depends on a variety of technology-related and site-specific environmental and demographic factors that require further investigation, characterisation and analyses.