Linkages between Water, Sanitation and Health

By

Water Sanitation and Health

Diseases related to contamination of drinking water constitute a major burden on human health. Interventions to improve the quality and availability of drinking water provide significant benefits to health.

Global Burden of Disease attributable to selected major risk factors

Underweight Unsafe sex

Tobacco
Overweight Alcohol

Percent of total burden

(within region)

5% -

Water, sanitation and hygiene (5.5%) Indoor air (3.7 %)

Zinc deficiency Physical inactivity

Tobacco
1% -

Alcohol

Overweight Ambient air Lead Occupational injuries Climate change

Occupational risks Unsafe sex Ambient air Water, sanitation and hygiene
Lead

Developing countries
(high mortality)

Developed countries

Burden of diseases attributed to 10 selected leading risk factors in developing countries with high mortality
Percentage
0 Under w eight Unsaf e Sex Unsaf e w ater, sanitation and hygiene 2 4 6 8 10 12 14 16

Remarks

Indoor smoke f rom solid f uels Zinc def iciency Iron def iciency Vitamin A def iciency Blood pressure Tobacco Cholesterol

Source: WHO, 2002. World Health Report 2002: Reducing Risks, Promoting Healthy Life. WHO Geneva

Deaths caused by selected infectious diseases in the SEA Region, 2002

(Figures in 000)
Mortality stratum Disease Total Low child, low adult 121 44 160 60 32 9 High child, high adult 1256 758 541 385 161 86

Respiratory infections Diarrhoeal diseases Tuberculosis HIV/AIDS Measles Malaria

Source: World Health Report 2002

1377 802 701 445 193 95

Burden of disease in DALYs caused by selected infectious diseases in the SEA Region, 2002 (Figures in 000)
Mortality stratum
Disease Total Low child, low adult 2497 1128 3549 1850 1151 353 High child, high adult 30407 21249 12149 11758 5771 3327

Respiratory infections Diarrhoeal diseases Tuberculosis HIV/AIDS Measles Malaria

Source: World Health Report 2002

32904 22377 15968 13608 6922 3680

Government of India Agencies involved in Water & Sanitation Programme

Planning Commission Ministry of Urban Development/ CPHEEO Ministry of Rural Development/ RGNDWM

Ministry of Water Resources/ CWC & CGWB.

Ministry of Environment & Forests/ CPCB. Ministry of Health & Family Welfare/ NICD.

Ministry of Social Welfare.

Water and Health: Background

About 21% communicable diseases are water borne 50 million suffer from intestinal diseases, like diarrhoea, cholera,

dysentery, typhoid etc. 5 million people die, of which 1.5 million are children below 5. Maximum morbidity and mortality occur due to diarrhoea.
-

Reported morbidity in 1998 was 9.6 million Infant mortality is 0.5 million every year In order to reduce morbidity/ infant mortality rate (IMR)/ B5 mortality, it is necessary to reduce diarrhoea and jaundice, the main causes Common water borne microbiological disease include Cholera, Diarrhoea, Dysentery, Typhoid, Bacillary, Trachoma, Amoebiasis, Giardiasis, Worm infestation, Guineaworm, Viral Hepatitis, Philariasis, Poliomyelitis etc.

Water Usage by Sector A Birds Eye View

Per Capita Availability of Water

1947 2000

5150 Cu.m 2200 Cu.m

2017

1600 Cu.m
(Water Stressed Condition)

Demand and Available Utilizable Water in India

1990 25 BCM 52 BCM 34 BCM 191 BCM 770 BCM

Urban demand

2025 1990

Industrial Demand Agricultural Demand

2025 2025

Total 1013 BCM

Aggregate annual utilizable water in India 1100 BCM

Groundwater Depletion in India

The blocks in red are areas where, due to extraction of groundwater, especially for irrigation, the groundwater levels have fallen by more than 4 metres (@ > 20 cm/year) during 19812000

Source: CGWB

Water Borne Diseases

Disease of Syndrome

Remarks

Enteric Diseases

Diarrheas, Dysenteries, Gastoenteritis, etc.

Prevalence of most fecaloral diseases is less with adequate quantity of water Prevented by personal hygiene, including frequent bathing and laundering with use of soap Prevented by personal hygiene, including bathing and laundering and changing of clothing Prevented by general public and personal hygiene. Nonvenereal. Trachoma rare where ample water is available.

Skin Diseases

Otitis Externa, Scabies, Skin Sepsis and Ulcers, Tineas (Ringworm)

Louse-Borne Diseases

Louse-borne Fever, Pediculosis, Relapsing Fever, Typhus Fever, Wolhynian Fever

Treponematoses

Endemic Syphilis, Pinta, Yaws

Conjunctivitis, Trachoma

Eye Diseases

Water Contact Diseases

Disease or Syndrome Drowning Enteric Disease Granulomal Skin Infections Ichthyotoxism Ingestion during bathing or swimming Mycobacteria in water. Swimming of occupational exposure Poisonous coelenterates or fish Remarks

Hirudiniasis
Leptospirosis

Aquatic leeches
Zoonosis; contact of abarded skin or drinking of water contaminated by infective rat urine

Otitis
Pharyngoconnunctival Fever Primary Amoebic Meningoencephalitis

Ear infection from immersion

Virus infection associated with swimming pools Rare but fatal disease of swimmers and divers

Water Habitat Vector Borne Diseases

Disease or Syndrome Remarks

Schistosomiasis

Major tropical disease transmitted through direct contact and penetration of immersed skin by schistosome cercariae. 200 million people are infected.
Human infection by eating raw or partly cooked infective fish.

Clonorchiasis (Asiatic liver fluke)

Opisthorchiasis (Cat liver fluke)

Fascioliasis (Liver fluke) Fasciologsiasis (intestinal fluke)

Human infection by eating raw or partly cooked infective fish.

Human infection by eating raw, infective aquatic plants, especially watercress. Human infection by eating raw, infective aquatic plants, especially water chestnut and water caltrop

Water Habitat Vector Borne Diseases

Disease or Syndrome Remarks

Arboviruses
Filariasis

Many different viral diseases including yellow fever and dengue.

Bancroftian form increasing in populous areas due to propensity of Culex fatigans for breeding in polluted waters. 250 million people are infected. Classical tropical disease with high death toll. Mangrove fly of genus Chrysops breeds in water in West and Central Africa Simulium spp. Breeds in flowing water in Africa and Central America. Blindness common in W. Africa.

Malaria Loaiasis (Loa Loa) Onchocerciasis

Emerging diseases
Emerging Disease of Infectious origin AIDS (Acquired Immune Deficiency Syndrome) Ebola Severe Acute Respiratory Syndrome Water borne emerging diseases Cryptosporidium Legionella Escherichia coli O157 (E. coli O157) Rotavirus, Hepatitis E virus, Norovirus Helicobacter pylori (H. pylori)

Water Quality Problems

Quality Problem Fluoride Arsenic Remarks The population at risk is estimated to be around 66 million Arsenic contamination ground water exceeding the permissible limit of .05 mg per litre in part of West Bengal has been found as a major quality problem and health hazard affecting rural population of 4000 habitations. A total of 1,38,670 habitations spread over 16 states in the country are found to be affected with iron contamination. Nitrate is emerging as a major problem in the States of Tamil Nadu, Rajasthan, Gujarat, Karnataka, Maharashtra, and Uttar Pradesh 29 projects were sanctioned for Andhra Pradesh, Karnatka, Kerala, Orissa, Punjab, Rajasthan, Tamil Nadu and Madhra Pradesh

Iron

Nitrate

Brackishness

Fresh Water Crisis

Increased Pollution of Surface and Ground Water. Improper Water Resource Management Shortcomings in the Design. Lack of implementation of legislation and regulations. Increase in Population. Undue aspiration of the rich

Environmental Problems

Industrialization Urbanization Agricultural Modernization Rapid Growth without taking into account environmental issues

Loss due to water related diseases

21% of all communicable diseases are water related 200 million mandays lost annually 30.3 million DALYs are lost Rs. 36.6 billion total annual loss

Water Related Environmental Health Hazard

Rural

unsafe drinking water Inadequate excreta disposal Agricultural run-off containing chemicals and pesticides

Urban

Lack of infrastructure to meet rapid population rise Uncontrolled industrialization Lack of waste management

Shortage of water due to

Excessive extraction of groundwater.

Chemical and bacteriological contaminants in drinking water. Ingress of seawater into coastal aquifers. Pollution of ground and surface water from agrochemicals and industrial waste. Pollution of ground and surface water due to urban bodies not resorting to adequate waste management.

Household Water Security

Polluted water sources create fresh water crisis calls for additional

investment and long distance water systems.

Inequitable distribution of drinkable water leading to wastage. All these lead to low availability of drinking water and of

questionable quality.
Lack of storage and handling of drinking water at HH level.

Environmental Sanitation

Inadequate municipal waste water treatment facilities add to 75% of water pollution. Surface water sources get polluted due to municipal and industrial waste and agricultural runoff Quality of ground water deteriorates due to over exploitation, leaching of chemical fertilizers and or land disposal of municipal and industrial waste Lack of HH toilet facilities in the vulnerable areas Inadequate solid waste management and landfill dumping Lack of hygiene education and adaptation of poor personal hygiene practices. Poor drainage facilities leading to silage / rain water collection

Unsafe water and sanitation

About 1.6 Million deaths a year worldwide are attributed to unsafe water, sanitation and hygiene, mainly through infectious diarrhoea. Nine out of ten such deaths are in children, and virtually all the deaths are in developing countries. In India, the lack to access safe water and proper sanitation facilities is a major cause for diarrhoeal infections, and kills 600,000 people annually.

History of the WHO Guidelines for Drinking Water

1958, 1963, 1971: International Standards 1984: First edition of Guidelines: basis for formulating standards, but standard setting is a national prerogative 1993: Second edition with increase in number of chemicals covered

2004: Third edition introducing systematic water safety approach

WHO Water Guidelines

AIM

Protection of human health Advisory in Nature Facilitate national standard-setting

Socio-Economic and environmental context Risk benefit philosophy local adaptation for health gains Best available evidence- science and practice Scientific expert consensus

Features

Approach

Exploit global information and experience

Why we need to review our approach

In all countries waterborne illness still occurs Outbreaks show us that we cannot solely rely on water treatment indicators End-point testing is too-little-too-late

Interrelation of the chapters of the Guidelines for Drinking water Quality in ensuring drinking water safety
Introduction
(Chapter 1)

The guideline requirements (Chapter 2)

SUPPORTING INFORMATION Microbial aspects (Chapters 7 and 11) Chemical aspects (Chapters 8 and 12) Radiological aspects (Chapter 9) Acceptability aspects (Chapter 10)

FRAMEWORK FOR SAFE DRINKING WATER

Health-based targets
(Chapter 3)

Public health context and health outcome

Water Safety Plans

(Chapter 4)
System assessment Monitoring Management and communication

Surveillance
(Chapter 5)

Application of the Guidelines in specific circumstances (Chapter 6)

Large buildings, Emergencies and disasters, Travellers, Desalination systems, Packaged drinking water, Food production, Planes and ships

Framework for Water Safety in 3rd Edition WHO GDWQ

Health Based Targets Water Safety Plans

1. 2. 3.

System Assessment Monitoring of control measures Management Plans

Independent Surveillance

Water Safety Plan

A WSP comprises, as a minimum, the three essential actions that are the responsibility of the drinking water supplier in order to ensure that drinking water is safe. These are: a system assessment; effective operational monitoring; and management

WHOs Response

Moving away from reliance on output monitoring- i.e. measuring para-metres in final water More input monitoring- i.e. measuring para-metres showing that the system is working Priority focus on microbial hazards Short- term chemical changes and exposures Catchment-to-consumer (farm-to-fork) Multiple barrier approach HACCP Reality check on todays water supply situations

Independent Surveillance
Systematic independent surveillance that verifies that the WSPs are operating properly
Audit of Water supply plan

Shows WSP is being adhered to

Verification

End-product final check

Start Up Activities

Initial meetings/workshops with Ministry of Urban Development, CPHEEO, BWS&SB, HMWS&SB and other partners in 2004 : jointly by USEPA and WHO. September 2004: Workshop for strengthening Drinking Water Quality Surveillance programme involving five Ministries, ten research agencies and ten selected water boards/ PHEDs. March 2005: Workshop to introduce the concept of WSP, Development of Directory of DWQ Labs., Development of Manuals for Lab. Practitioners.

Development of Support Documents for DWQ Laboratories

1. Directory of Drinking Water Quality Test Laboratories.

2. Guidance Manual for Drinking Water Quality Monitoring and Assessment.

What made Water Safety Plan Acceptable?

Since WSPs are a risk management tool to prevent the contamination of drinking water before it occurs, WS Managers accepted the concept. Some basic questions to build a WSP: 1. What are the hazards to safe drinking water? 2. How will these hazards be controlled? 3. How will the control for the hazard be monitored? 4. What actions must be taken to restore control? 5. How can the effectiveness of the system be verified?

Activities initiated under WSP

WSPs in Hyderabad Metropolitan Areas. - Training of Laboratory personnel to make use of the developed Manual.

Composite planning for selected WTPs at Hyderabad, Pune and Delhi.

Drinking Water Quality Monitoring & Development of Surveillance Mechanism to support Water Safety Plan

Pune WSPs

WSP Demonstration Projects in Hyderabad

Three Locations

* Adikmet area 24X7 water supply maintained by HMWS&SB. Comparatively new system. * Serilingampally area- Bulk supply by HMWS&SB augmented by ground water sources. Maintained by Local Body. * Moin Bagh area Old city, narrow lanes, intermittent water supply maintained by MHWS&SB. Old system.

WSP Demonstration Projects in Hyderabad

Adikmet area
Health 5% of Water

Serilingampally Municipality
Health Data Not

Moin Bagh Area

Socio- economic

Borne diseases cases reported from this area in Fever Hospital -Mostly reported from Slums Socio- economic conditions LIG 30% MIG - 40% HIG - 30%

available
Socio- economic

conditions LIG 70% MIG- 20% HIG - 10%

conditions LIG 20%

MIG- 40%
HIG - 40%

Health-Based Targets for DWS Objectives

The overall objective of the study is to conduct a risk assessment in each of the three project sites that would provide baseline data for establishing health based targets to guide and evaluate the implementation of the WSPs in these sites. Specifically, in each of the project areas, the study aims to: Estimate incidence of acute gastroenteritis Estimate intra-household and distribution point prevalence of drinking water contamination Assess relative risk relationship between exposure factors (drinking water and hygiene practices and water quality) and health outcomes Assess socioeconomic determinants influencing exposure to risks and disease burden

Incidence of Acute Gastroenteritis

Area Slum GE Cases (Last Seven Days)
Adikmet Moinbagh Serilingampally Total 5 45 27 77 896 1320 796 3012 5.58 34.09 33.92 25.56

Non Slum
5 32 23 60 1511 1343 1493 4347 3.31 23.83 15.41 13.80

Total
10 77 50 137 2407 2663 2289 7359 4.15 28.91 21.84 18.62

Population Covered
Adikmet Moinbagh Serilingampally Total Adikmet Moinbagh Serilingampally Overall

Incidence Rate of GE Per 1000

Findings

Incidence rates of gastroenteritis from survey is several fold higher than that reported by the public health surveillance system Incidence rate of Acute GE in slum areas almost double than that in non slum areas Contamination of source water a significant risk for GE in non slum areas. Risk of Gastroenteritis is lower in households having Metro domestic connections and significantly higher in households using pit taps as a drinking water source 24x7 water supply significantly reduces risk for gastroenteritis

Drinking Water Quality Monitoring & Development of Surveillance Mechanism to support Water Safety Plan: Delhi pilot project.

Number of households water samples collected from different areas and their bacteriological characterization during Dec. 2006 to June 2007
Category Area No. of households No. of samples No. of samples with+ve Total Coliforms No. of samples with+ve Faecal Coliforms HIG 1 3 42 2 MIG 1 3 42 2 LIG 3 12 168 6 Society 2 8 112 Nil Slum 3 12 168 47

Nil

Nil

Nil

Nil

Bacteriological characterization of water samples

Location WTP Source RAW Total Sample 72 Positive Sample 64

Source
HIG Consumer Point Source MIG Consumer Point Source SOCIETY 1 SOCIETY 2 Consumer Point Consumer Point

16
48 16 48 16 64 64

0
0 0 1 0 0 0

Bacteriological characterization of water samples

Location Source Source LIG 1 Consumer Point Source LIG 2 Consumer Point Source LIG 3 Consumer Point Total Sample 16 64 16 64 20 80 Positive Sample 0 3 0 0 1 5

Source SLUM 1 Consumer Point

Source SLUM 2 Consumer Point Source SLUM 3 Consumer Point

21 84
21 84 21 84

5 25
1 6 5 19

Conclusion
WSPs protect from contamination

from catchments to consumer

WSPs are comprehensive

management strategies to prevent outbreak of disease

WSPs assist water boards with

making targeted investments for maximum benefit

*picture courtesy HMWS & SB