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Caroline Schönning, Swedish Institute for Infectious Disease Control (SMI), Sweden How am I exposed? From where do pathogen come? How can treatment and.

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Presentation on theme: "Caroline Schönning, Swedish Institute for Infectious Disease Control (SMI), Sweden How am I exposed? From where do pathogen come? How can treatment and."— Presentation transcript:

1 Caroline Schönning, Swedish Institute for Infectious Disease Control (SMI), Sweden How am I exposed? From where do pathogen come? How can treatment and interventions minimize transmission? Which are the health Targets and guideline Procedures? Can we manage the risks? Cases and participatory Approaches on different Community levels ! Chapter 3. Sanitation and public health What happens in me if I am exposed (different pathogens)

2 How are infectious diseases transmitted? What happens when people are exposed to pathogens? Learning objective: To know and be familiar with pathogens of concern in water and sanitation systems, including the symptoms they cause and the effect on the individuals/population 3.1 Exposure and effects in humans

3 Disability Adjusted Life Years (DALY) – morbidity: years lived with a disability – mortality: years lost DALY (loss of healthy lived years) = n x t x S n = number of affected persons t = the duration of the health effect S = measure of the severity of the health effect (mortality = 1) DALYs – a general measure for health The Global Burden of Disease (GBD) Murray and Lopez, 1996

4 Quality of life Index Age Remaining disability Years lost Premature death by 65 Acute (infectious) illness Hypothetical example of DALYs

5 Murray et al. (1996) Science 274: Leading DALYs in in the world 1990 & 2020 The sanitary revolution - the most important medical milestone since 1840 !? (BMJ, 2007)

6 DALYs attributable to risk factors Water and sanitation causes a major part (9%) of GBD, that largely could be prevented. (WHO, 2008)

7 Diseases contributing to the water-, sanitation- and hygiene-related disease burden (Adapted from WHO, 2008) PEM: protein-energy malnutrition

8 Ref: Lopez et al Global and regional burden of disease and risk factors; FAO, 2006 Child underweigth for age Unsafe water, sanitation, hygiene Low fruit & vegetable intake Zinc deficiency Iron deficiency aaemia Vitamin A deficiency Child underweight ~7.9% Nutrition deficiencies ~7.4% Water & sanitation ~3.4% Total targeted by Ecosan: ~18.6% in Sub-Saharan Africa ~7.6% 854 million chronically hungry 2 billion without food security FAO, 2006 Global risk factors for disease and premature deaths (% of DALYs)

9 Frequency of infection World´s most common – karies Commonly existing diarrhoea and food- poisoning Unusual opportunistic infections in immunocompromised individuals Symptoms None (e.g. polio) Mild diarrhoea (e.g. Staphylococcus food poisoning) Life-threatening loss of water and salts (e.g. cholera) Infectious diseases

10 Definitions – (1) The study of the relationships of the various factors determining the frequency and distribution of diseases in a human community. – (2) The field of medicine that attempts to determine the exact causes of localized outbreaks of disease. (Ologies & -Isms. Copyright 2008 The Gale Group, Inc) The start in the middle of the 19th century – Cholera epidemics in London - consumption of water implied an increased risk for disease (John Snow) – Established that germs or bacteria cause infectious disease (Pasteur, 1857) The field of Epidemiology

11 Prevalence – The number of cases in a defined population at a specified point in time Incidence – The number of new cases arising in a given period in a specified population Occurrence of disease

12 Direct transmission – Touching – Kissing – Sexual intercourse – Other contact – Airborne, short distance via droplets, coughing, sneezing – Transfusion (blood) – Transplacental Indirect transmission – Vehicle-borne (contaminated food, water, towels, farm tools etc.) – Vector-borne (insects, animals) – Airborne, long distance via dust and droplets – Parenteral (injections with contaminated syringes) Transmission of infectious agents

13 Symptoms of disease No symptoms RecoveredDeath Infection No infection Exposure Susceptible Immune Consequences of exposure

14 Minimum infectious dose ID 50 Probability of infection – Dose-response curves Severity of disease depending on – Ingested dose – The condition of the mechanical barrier – The stability of the normal enteric flora – Immunity – The nutritional status of the individual Infectious dose

15 More vulnerable groups in the society The old (elderly) Infants Pregnant women Immunocompromised Malnourished These groups comprise about 20% of the general population and are growing Immunity – vulnerable groups

16 Epidemiology - Definitions Pandemic: An epidemic (a sudden outbreak) that becomes very widespread and affects a whole region, a continent, or the world. By contrast: An epidemic affects more than the expected number of cases of disease occurring in a community or region during a given period of time. An endemic is present in a community at all times but in low frequency. (

17 Number of Cases Time Threshold for detection for an outbreak Endemic rate Outbreak detected Undetected outbreak Hyperendemic Sporadic Epidemic to endemic illnesses as detected by health surveillance

18 Causes ~1/5 of deaths in children <5 years (1.5 million) Has decreased, in 1980´s estimated 2/3 of deaths Less significant decrease in diarrhoeal disease in low-income countries Infections related to water and sanitation Diarrhoea and sanitation 4.1% of the total DALY 88% of the burden attributable to unsafe water supply, sanitation and hygiene Improved sanitation can reduce diarrhoea by ~32% 391 million cases averted if MDG target met

19 Source: Our Planet Current annual diarrhea cases in SSA: 1.2 billion which lead to dead children, mostly under 5 years Regional differences in average health burdens from diarrhoeal diseases

20 Program in the 1980´s for rehydrating children – avoiding death Infromation, campaigns by WHO, UNICEF Did not give the expected success – less use than anticipated Symptoms are common Do not visit a medical doctor Start treatment late or not at all Want antibiotics or medicine that stops diarrhoea Treatment of diarrhoea Example: Ceará in Brasil Death from diarrhoea decreases Decrease in incidence or better treatment? General improvement of livelihood e.g. water quality, sanitation, waste management, income, litearcy, health care, vaccination No single factor related to lower number of diarrhoea cases Continued studies of the real situation

21 Cholera – 36 reported outbreaks from (WHO) – Risk during flooding – Natural environmental spread Typhoid fever – Also endemic Shigellosis Diarrhoeal diseases – Outbreaks related to water and sanitation

22 Acute watery diarrhoea, very deadly without rapid treatment Affects adults as much as children, especially informal caretakers High political profile : can be used as a political leverage Characteristics for cholera outbreaks high attack rate low mortality economic and social burden Factors of spread density of population transportation facilities living conditions environmental reservoirs Cholera epidemic

23 Cholera Outbreak Social BurdenEconomic burden Health Care Facilities overwhelmed More supplies, more staff Health impact Panic Media Psychological impact Political impact Who is responsible? Consequences of cholera outbreaks

24 Classification of communicable diseases related to water and sanitation Water-borne diseases: caused by the ingestion of water contaminated by human or animal faeces or urine containing pathogenic bacteria or viruses or parasites; include cholera, typhoid, amoebic and bacillary dysentery and other diarrhoeal diseases. Water-washed diseases: caused by poor personal hygiene and skin or eye contact with contaminated water; include scabies, trachoma and flea, lice and tick-borne diseases. Water-based diseases: caused by parasites found in intermediate organisms living in water; include dracunculiasis, schistosomiasis and other helminths. (Other) Water-related diseases: caused by insect vectors which breed in water; include dengue, filariasis, malaria, onchocerciasis, trypanosomiasis and yellow fever. (WHO, 1996)

25 Bacteria – The leading cause of gastrointestinal infections according to surveillance systems – Salmonella, Shigella, Campylobacter, E. coli (toxinprod.) – EHEC – Legionella – Opportunistic e.g. Aeromonas hydrophila Virus – Probably the cause of many outbreaks, difficult to detect – Noroviruses (Calici-, Norwalk like), rotavirus, hepatitis A Waterborne pathogens – important in water and sanitation system

26 Protozoa – Complicated life cycles with resistent stages (chlorine) – Giardia, Cryptosporidium, Entamoeba – Low infectious dose – Milwaukee (USA) 1993, individuals Helminths (worms) – Varying transmission routes, e.g. soilborne – Ascaris, Trichuris, Schistosoma (bilharzia), hookworm – A large problem in many developing countries Waterborne pathogens Waterborne pathogens – important in water and sanitation system

27 Shigella

28 Salmonella infection – Salmonellosis and Typhiod fever Salmonellosis – diarrhea, fever, and abdominal cramps Caused by a variety of serotypes, e.g. Salmonella Typhimurium and Salmonella Enteridis Foods contaminated with animal feces Animal origin (meat, poultry, eggs), vegetables Pets – handwashing important Paratyphoid and Typhoid fever - fever and other symptoms, life-threatening Caused by Salmonella Typhi Contaminated food or water More common in areas with low sanitary standard

29 Schistosoma Also known as bilharzia 200 million people are infected worldwide Variety of symptoms Freshwater contaminated by urine or faeces Life-cycle requires specific snail as host

30 What is viral gastroenteritis? – Inflammation of the stomach and small or large intestines – Caused by a variety of viruses that results in vomiting or diarrhea – Often called stomach flu" (but not caused by the influenza viruses) What causes viral gastroenteritis? – Many different viruses – For example: rotaviruses, adenoviruses, caliciviruses, astroviruses, Norwalk virus, and a group of Norwalk-like viruses (later called calicivirus, norovirus) Viral gastroenteritis

31 Rotavirus Rotavirus is the most common cause of severe diarrhea among children Globally, rotavirus is estimated to cause 527,000 deaths in children annually Vomiting and watery diarrhea for days, and fever and abdominal pain occur frequently Immunity after infection is incomplete Vaccination possible but not widespread (

32 NOROVIRUS Norovirus Previously called calicivirus or Norwalk (Like) viruses Transmission Perspn-to-person Food-borne Waterborne

33 Ascaris Ascaris lumbricoides is one of the largest and most common parasites found in humans It is estimated that 10% of the world's population is infected with this nematode The adult worms live in the small intestine and eggs are passed in the feces - a single female can produce up to 200,000 eggs each day The adult worm. Adult females of this species can measure up to 18 inches long (males are generally shorter). Ascaris lumbricoides, fertilized egg. The egg is covered with a thick shell that appears lumpy approximate size = 65 µm in length.

34 Ascaris

35 Cryptosporidium is a small parasite, about 3-5 µm. It lives on the surface of the cells lining the small intestine and oocysts are passed in the feces. Transmission of the infection occurs via the oocysts. Many human infections have been traced to the contamination of drinking water with oocysts from agricultural "run-off" (i.e., drainage from pastures), so it is considered a zoonosis. Cryptosporidium


37 Giardia lamblia trophozoites live in the small intestine of the host. Cysts, which are resistant to adverse environmental conditions, are passed in the feces of an infected host, and the next host is infected when it ingests cysts in food or water contaminated with feces. Giardia The trophozoites adhere closely to the lining of the small intestine, and in heavy infections much of the lining can be covered with trophozoites. The giardiasis symptoms range from none (in light infections) to severe, chronic diarrhea (in heavy infections). Giardia intestinalis (also known as Giardia lamblia or Giardia duodenalis soil, food, or water that has been contaminated with feces Common in both developing and developed areas

38 Features of some gastrointestinal infections (Westrell, 2004)

39 Emerging diseases – Newly recognized or – Increasing importance Zoonoses – Many emerging pathogens of zoonotic origin – Animal faeces contaminate water Climate change – Increased risks related to water and sanitation – Affects food-production Emerging pathogens

40 Faecal samples from 120 urine-diverting latrines in KwaZulu-Natal, South Africa Varying features – water-filled to dry (normal) Analysing for presence of: – parasitic protozoa Giardia and Cryptosporidium – helminths Ascaris lumbricoides, Trichuris trichiura and Taenia spp (Trönnberg et al., 2010) Picture provided by Teddy Gounden Protozoa and helminths in faecal material

41 Parasites – 54% positive for Giardia – 21% positive for Cryptosporidium Helminths – 59% Ascaris lumbricoides – 48% Trichuris trichiura – 18% Taenia spp In 73% of the 120 household toilets, one or several types of helminths were found Prevalence by family (at least one member infected) Supports theory of high prevalence in certain areas Treatment needed before use of faeces Protozoa and helminths in faecal material (Trönnberg et al., 2010)


43 3.2 Environmental transmission of pathogens Where do the pathogens come from? How do pathogens in excreta contaminate the environment? Learning objective: To know and be familiar with environmental transmission routes for pathogens, especially in relation to water and sanitation.

44 Faeces – contain the major amount of pathogens, enteric infections Urine – only a few diseases transmitted through urine Greywater – e.g. laundry, washing diapers, from food stuffs Industry – abattoir, food industry (plant pathogens) Storm water – e.g. surface run-off – animal faeces Origin of pathogens in wastewater - contribution from different waste fractions

45 Origin Birds and other animals Recreational use Industrial effluent Stormwater and surface water Agricultural runoff and effluent Domestic sewage Leachate Sea Relative inputs of faecal indicator bacteria by source

46 The main ways diarrhoea is spread – by faecal pathogens contaminating fingers, flies, fields, food and fluids and then eventually swallowed (Esrey et al. 1998) The F-diagram - main routes to spread diarrhoea

47 Excreta from humans & animals Humans Shellfish Crops Aerosols Oceans and Estuaries Oceans and Estuaries Rivers and Lakes Rivers and Lakes Irrigation Solid Waste Landfills Solid Waste Landfills Sewage Land Runoff Land Runoff Recreation Water Supply Water Supply Groundwater Adapted from Gerba et al Transmission routes for pathogens in human excreta

48 Ecological Alternatives in Sanitation

49 Contamination of groundwater

50 Contamination of drinking water Drinking water quality – Heterotrophic bacteria, E. coli, metals, nitrate (other aspects smell, colour) Contaminated surface- or groundwater – Wastewater outlet, latrines, run-off Contamination during distribution – Growth in pipes, intrusion of wastewater Contamination of finished water – During storage and handling, e.g. reservoirs, vendors

51 Waterborne diseases and sanitation Waterborne diseases: caused by the ingestion of water contaminated by human or animal faeces or urine containing pathogenic bacteria or viruses; include cholera, typhoid, amoebic and bacillary dysentery and other diarrhoeal diseases. A sanitation system including reuse need to avoid disease transmission mainly by : - protecting ground- and surface water - safe handling and use of the waste products in agriculture

52 Possible transmission routes for pathogens from organic fertilisers (e.g. faeces) Handling on site The handling and reuse of all types of waste products with human or animal origin involve hygienic risks

53 Contamination of food Contaminated seeds, uptake of pathogens? Organic fertilisers – human excreta, wastewater, animal manure Irrigation – wastewater, contaminated surface water Handling and storage Cooking Storing of cooked food, growth of pathogens

54 May contain bacteria, viruses, parasitic protozoa and helminths that cause infections Diarrhoeal disease of main concern Faeces should be considered a health hazard Need to be treated before use as a fertiliser Easier to handle and treat if diverted from other waste fractions Pathogens in faeces

55 Excretion of pathogens in faeces

56 Small volumes of faeces contaminates large volumes of clean water Collection from a large number of persons – pathogens continously present Smaller systems – higher concentration of a specific pathogen Treatment not optimized for killing pathogens 10% of wastewater is treated (developing countries) 20 million ha (?) irrigated with wastewater Pathogens in mixed wastewater

57 Local environmental pollution – Accidental exposure High risk of down-stream pollution – Exposure from e.g. swimming and intended household use Pollution of drinking water sources – Surface run-of and ground water infiltration Contamination of irrigated crops – Exposure from consumption and during irrigation Health risks related to untreated wastewater

58 In wastewater treatment pathogens are concentrated in the sludge Typical concentrations of microorganisms in sludge [per g wet weight] (EC, 2001)

59 Urine is sterile in the bladder Freshly excreted urine contains < bacteria/ml Urinary tract infections - not transmitted through the environment Leptospira interrogans - low prevalence Salmonella typhi, Salmonella paratyphi - developing countries, faecal-oral transmission more common Schistosoma haematobium - fresh water snail needed for development low risk for transmission of infectious diseases through urine Microorganisms in urine

60 Pathogens in urine and importance of urine as a transmission route

61 Risk of disease transmission through urine The main risks of disease transmission from handling and using human urine are related to faecal cross- contamination of urine and not from the urine itself. EcoSanRes (2004) Health risks related to urine diversion

62 Features of excreta - hygiene Urine – Sterile in body – Naturally containing some bacteria after excretion – Few diseases transmitted through urine – Low risk to handle Faeces – Naturally containing high amounts of bacteria – Many diseases transmitted through faeces (faecal-oral) – May contain pathogenic bacteria, viruses, protozoa or helminths – Significant risk to handle Microorganisms in excreta

63 Lower concentrations of pathogens than in faeces Faecal origin of pathogens (bathroom and laundry) – Shower and bath, Washing clothes, washing diapers Pathogens from food stuffs (kitchen sink) – Faceally contaminated vegetables (e.g. from irrigation with wastewater or animal manure), soil – Contaminated meat (e.g. chicken) Health risk from disposal or reuse – Contamination of nearby surroundings – Contamination of drinking and recreational water – Irrigation of crops Pathogens in greywater

64 Zoonoses – Transmission humans animals – May cause symptoms or not in animal Vectors – Insects, rodents, birds – mechanical transport – Birds, wild and domestic animals infected without symptoms Intermediate host – Animal necessary for lifecycle of pathogen, e.g. malaria, schistosomiasis Transmission by animals

65 Run-off from agricultural land where grazing cattle were infected with EHEC (a zoonoses, i.e. transmissionn animal- human) Transport from manure to river water Irrigation of lettuce (no requiremenmts for analysis of the water) The lettuce was consumed by a large number of individuals – resulted in 100 cases (approx. 10 hospitilised) At the lab: isolating and comparing bacteria in samples from patients and in water samples Outbreak of EHEC in Sweden


67 Learning objective: To know and be familiar with the behaviour of pathogens in the environment, including the effects of treatment and the potential of minimising disease transmission by other barriers, especially in relation to agricultural use of excreta. 3.3 Pathogen reduction How persistent are pathogens in the environment? How can we prevent exposure and disease transmission in sanitation systems?

68 collection agricultural use treatment Closing the loop safely

69 Mexico, untreated wastewater: 33% higher risk of diarrhoeal diseases (Cifuentes et al. 1998) Israel (kibbutz), partially treated stabilization pond effluent: twofold excess risk of enteric disease in 0-4 year-old age group (Fattal et al. 1986) No recorded incidents associated with appropriately treated wastewater (Cooper & Olivieri 1998) National Research Council (NRC, USA, 2000) evaluated 23 studies: no proof for either risk or non-risk for reuse of sewage sludge Risk assessments a valuable tool Transmission of infectious disease during reuse

70 TemperatureLow temperature prolong survival. Inactivation - >40°C, treatment processes 55-65°C. pHNeutral pH (7) beneficial. Inactivation - highly acidic or alkaline conditions. MoistureMositure (e.g. in soil) favours the survival. Inactivation – drying. Solar radiation/ UV-light Inactivation – by natural solar radiation or UV-lamps. Other microorganismsLonger survival in sterile material. Inactivation – competition and predation. AmmoniaOften affects microorganisms negatively. Inactivation – ammonia produced at high pH. NutrientsNeeded for growth of bacteria. Inactivation – lack of nutrients. Other factorsOxygen availability, chemical compounds. Parameters affecting microbial survival in the environment

71 Eventual die-off outside the body Persistence varies depending on type Bacteria may grow in the environment Helminth eggs require latency period Natural conditions will affect inactivation – temperature, moisture, competing microflora, etc. Alter the conditions to increase the rate – temperature, pH, moisture, etc. But difficult to state exact time-parameter limits for elimination of each (all) pathogens Inactivation of microorganisms - How can we kill pathogens?

72 for microorganisms in faeces, sludge, soil and on crop (according to Faechem a 1983 and Kowan b 1985, in EPA 1999), in days if not other stated Estimated survival times

73 Organism to be modelled4°C/low temp range20°C/high temp range E.coli*T 90 = daysT 90 = days Enterococci*T 90 = daysSame as 4°C BacteriophagesT 90 = daysT 90 = days Salmonella*T 90 = days EHEC*T 90 = daysSame as 4°C Rotavirusconservative model – no reduction T 90 = days T 90 = days GiardiaT 90 = daysT 90 = 5-50 days CryptosporidiumT 90 = daysT 90 = days AscarisT 90 = daysT 90 = days *Possible growth not taken into consideration Inactivation of microorganisms in faeces ( Arnbjerg-Nielsen et al. 2005)

74 To prevent and decrease disease transmission – Reduction of pathogens – Hindering actual exposure to the pathogen-containing material In analogy with different steps in e.g. drinking water treatment Health protection measures (WHO terminology) – Technical, behavioural, medical, etc. Barriers

75 (Esrey et al. 1998) Barriers required to prevent the spread of pathogens

76 Treatment as a barrier A combination of barriers to decrease exposure of humans to excreta should be applied in order to reduce risks for disease transmission in ecological sanitation systems. Treatment of the excreta is considered as a necessary step for the subsequent use as fertiliser on (agricultural) land. The goal is to significantly reduce risks – zero risk is not possible – Minimise risks (considering viable/practical/realistic measures) – Insignificant amounts of pathogens – No additional individuals diseased Treatment as a barrier (EcoSanRes, 2004)

77 Incoming wastewater Wastewater effluent Sludge Reduction, die-off Concentration Dilution Wastewater treatment Faeces Treatment steps - barriers Microorganisms generally reduced 70-99,99% in STP (Sweden) Not optimised for pathogen removal Generally no regulations on outgoing (treated) wastewater Disinfection efficient, but other problems Limit exposure from outlet important Sewage sludge – concentration of pathogens

78 ProcessBacteriaHelminthsVirusesCysts Primary sedimintation Plain Chemically assisted Activated sludge Biofiltration Aerated lagoon Oxidation ditch Disinfection Waste stabilization ponds Effluent storage reservoirs Large variations, depend on organism, difficult to predict Expected removal (log 10 ) of microorganisms in various wastewater treatments

79 Faeces Urine Greywater Stormwater Industry Wastewater Sludge (Treated wastewater) Treated sludge Source-separationWastewater treatment Sludge treatment Restrictions on usage Control/Regulations Sludge application Barriers to pathogens in sludge handling

80 Greywater treatment Treatment to remove grease, N, P, chemicals….and pathogens (see chapter 4) Treatment results - great variation Need dependent on use Specific risks related to use Irrigation, subsurface Treatment in ponds – limit exposure Infiltration, drinking water Handling to avoid smell

81 Primary treatment – In the toilet (on-site) – Some reduction of pathogens – Reduce risks in subsequent handling Secondary treatment – After finished collection Off-site or on-site (scale dependent) – Significant reduction of pathogens – Rendering the material safe to use as fertiliser/soil improver – Possibilities will be dependent on primary treatment Treatment of faeces

82 Storage – Ambient conditions Biological methods – Composting (heat, microbial competition, pH-changes) – Anaerobic digestion (heat, microbial competition, pH- changes) Chemical treatment – Alkaline treatment Ash, lime (pH-elevation and desiccation) Urea (ammonia) Incineration Treatment of faeces

83 Will result in (compared to mixing of faeces and urine): – Less smell – Less volume (slower filling up, less to handle) – Prevention of dispersal of pathogen-containing material (spilling, leaching) – Safer and easier handling and use of excreta (volume, treatment) Less risk for disease transmission Urine diversion is recommended Urine diversion in dry sanitation systems

84 Organism group (ex.)Survival Bacteria (Salmonella, E. coli)-Short (T 90 = days) Protozoa (Cryptosporidium)-Average (T 90 = ~1 month) Virus (rotavirus, bacteriophage)-Long (no reduction at 4°C, T 90 = ~ 1-2 months at 20°C) Factors that increase die-off elevated pH (7 9, urea ammonia) higher temperature lower dilution Survival of microorganisms in human urine

85 The most appropriate treatment method (?) Other methods tried out in order to reduce the volume – Easier handling for agricultural use Storage with low air exchange (tight containers) best method to keep the nutrients in urine Only necessary in large-scale systems Existing guidelines in module 3.4 Storage of urine

86 12 double-vault latrines (different design) Ascaris and bacteriophage (model for virus) added to the material Study the effect of pH, temperature and moisture Survival study –latrines in Vietnam (Carlander & Westrell 1999)

87 Reduction of Salmonella typhimurium phage 28B (Carlander & Westrell 1999)

88 Reduction of Ascaris suum eggs (Carlander & Westrell 1999)

89 A total inactivation of Ascaris and the model virus (bacteriophage) was achieved within 6 months pH played a significant role in the inactivation of the bacteriophage in the faecal material The inactivation of the bacteriophage and Ascaris was dependent on a combination of high pH ( ), high temperature (31-37°C) and low moisture (24-55%) Conclusions from the Vietnam study

90 Inactivation of Giardia and Ascaris on coriander leaves Inactivation on crops


92 Learning objective: To know and be familiar with faecal indicators and the risk concept and to understand their application in guidelines for reuse of excreta and greywater. 3.4 Health targets Which targets can be achieved in relation to exposure and treatment? How are barriers used in guidelines to minimise health risks?

93 Used to indicate faecal contamination – from human faeces, sewage, animals, etc. Why do we need to use indicators? There are hundreds of pathogens Pathogens are often present in low concentrations – hard to detect Pathogens are difficult and expensive to analyse What is a faecal indicator organism?

94 A member of the intestinal microflora Present in greater numbers than the pathogen Do not multiply in the environment Non-pathogenic Present simultaneously as pathogens Equal resistence as pathogens Can be detected with easy, rapid and affordable methods - There is no ideal indicator ! Ideal features of a faecal indicator


96 Indicator% presenceDensity in faeces [per g] Total coliforms Faecal or thermo- tolerant coliforms E. coli (presumtive) – 10 9 Faecal streptococci / Enterococci 100 (74-76) 10 5 – 10 6 Clostridia – 10 7 Coliphages ?<10 3 (Geldreich 1978, Havelaar et al. 1991) Faecal indicators – abundance in faeces

97 Concentrations of indicator bacteria in faeces, incoming and outgoing wastewater from wastewater treatment plants and in raw sludge (Geldreich 1978; Stenström 1996; Sundin 1999) Presence in different media

98 An indicator indicates presence of other organisms, i.e. pathogens An index organism mimics the behaviour of another organism – e.g. the reduction of clostridia for Cryptosporidium in drinking water treatment A model organism - an organism representing a whole group of organisms – e.g. rotavirus representing enteric viruses in risk assessments How can we use the indicators?

99 If Ascaris has been killed during treatment of excreta, all other pathogens are probably inactivated as well – Ascaris functions as a process indicator Bacteriophages have been used as tracers, i.e. modelling the transport of viruses in soil How can we use the indicators? Temperature – safety zone (Feachem 1983; EC 2001)

100 Drinking water – heterotrophic bacteria, E. coli Recreational water – E. coli, total coliforms (previously), faecal streptococci (EU) Excreta and wastewater (for irrigation) – coliforms, intestinal nematodes (WHO 1989) Sewage sludge – coliforms, Salmonella, (Ascaris, viruses – validation, US EPA) Guidelines & regulations – now rely less on indicators Indicators for water and wastewater quality Examples:

101 Faecal sterols, e.g. coprostanol, cholesterol Chemical indicator found in faeces, with the exception of very young children Not used routinely Have been used for research purposes – Tracing the origin of faecal pollution (human/animal) – Estimating faecal contamination (used in risk assessments) Alternative indicator

102 Possible growth in greywater – E. coli ~1000 times higher faecal contamination than coprostanol – Faecal streptococci ~100 times higher than coprostanol (Ottoson, 2005) Possible growth in wastewater (to a lesser extent than greywater) – Indicator bacteria ~10 times higher faecal contamination than coprostanol (Ottoson, 2005) Overestimation of the risk Are the indicators always reliable?

103 No E. coli – sensitive to the conditions prevailing in urine Very high numbers of faecal streptococci – possible growth in the pipes (sludge formed) No reduction of clostridia (spores) during storage – resistant to most conditions – Would mean that the faecal cross-contamination is either underestimated or overestimated – How do the survival of pathogens relate to the behaviour of the indicators? Faecal indicators in urine

104 Quality guidelines (e.g. WHO) – indicators limited value – expensive, time-consuming to monitor Process guidelines (e.g. sludge treatment) – monitoring of process parameters – validation may be needed Other practical recommendations – e.g. restrictions for use Combinations of the above Alternatives for guidelines/recommendations – related to sanitation and agricultural practises

105 Inactivation affected by pH (~9) and ammonia, avoid dilution of the urine From potential faecal cross-contamination and possibly remaining after storage * * Recommendations for the use of human urine – large systems

106 For crops that are to be consumed raw, one month should pass between application and harvesting (withholding/waiting period) For single households the urine mixture can be used for all type of crops, provided that – the crop is intended for own consumption – one month passes between fertilisation and harvesting Can we apply even simpler or less strict guidelines for urine? – Compared to faeces – low risk (high fertiliser value) – If system seems to function well – no visible faecal cross-contamination – Information to workers (e.g. farmers) handling the urine – Shorter storage at higher temperatures? Recommendations for the use of human urine

107 Surveillance systems underestimate number of cases Emerging pathogens Indicator organisms – Coliforms, enterococci, clostridia, bacteriophages – Difficult to detect pathogens Epidemiological investigations – Limited detection level – Expensive – Retrospective To refine the establishment of guidelines Prospective studies – Compare future systems, e.g. sanitation systems Why risk assessment?

108 Risk – The probability of injury, illness or death for individuals, or in a population, at a specific situation/event – In quantitative terms the risk is expressed in values between 0 (e.g. harm will not be done) and 1 (harm will be done) Risk assessment/analysis – The qualitative or quantative characterization and estimation of potential adverse health effects associated with exposure of individuals or populations to hazards (materials or situations, physical, chemical, and/or microbial agents) (Haas et al., 1999) Risk terminology

109 Risk assessment – Qualitative or quantitative estimation of possible negative health effects associated with exposure to a certain hazard Risk management – Control and management of risks, weighing alternatives, standpoints, implementation of legislation etc. Risk communication – Communication (two way-communication) of risks to responsible, stakeholders, the public Risk analysis Includes:Hazard identification Exposure assessment Dose-response assessment Risk characterisation

110 Assure the quality of provisions (food) during production and further handling From an accepted level of infection in society determine if the drinking water treatment is satisfactory In new systems, e.g. local reuse of faeces or greywater, assess different exposures and how the transmission can be avoided In comparisons of e.g. different wastewater systems Microbial risk assessment - Examples of application (1)

111 Predict the burden of waterborne diseases in the society during endemic and epidemic situations Find the most cost-effective alternative to reduce health risks for food consumers One of the largest problems with all types of risk assessments is the quality of available data Microbial risk assessment - Examples of application (2)

112 Direct counts – problematic if the risk density must be below the detection level e.g. 500 samples á 2000 L to detect acceptable Cryptosporidium risk Analysis of index organisms – the density assumed to be proportional to pathogen(s) e.g. Clostridium perfringens for viruses/protozoa (in water treatment) Indirect measurements – measure the density in incoming water and the reduction of indexorganism, e.g. 10 Cryptosporidium/20 L raw water and the reduction of Bacillus spores in the treatment plant indicates a 2,9 log 10 reduction Estimates from e.g. reported cases (surveillance, epidemiological data, urine example) Methods to estimate the concentration of pathogens – Hazards and exposure (dose)

113 Exposure assessment - examples Exposure MedianMaxReference Shower6.8 min20 min Finley et al Ingestion of soil81 mg/day5.6 g/day Calabrese et al (children)

114 American study non- boiled water (Roseberry och Burmaster 1992) Large variations in the world Daily water consumption (L) Water consumption - drinking

115 Ex. Ingestion of drinking water contact rate 1.4 L/day exposure frequency365 days/year if the drinking water is assumed to contain 0,001 virus/L 1.4 x 0,001 = 1.4 x viruses/day will be ingested Theoretical examples - Exposure Ex. Ingestion of bathing water (surface water) contact rate 50 mL/h 2.6 h/swim exposure frequency7 swims/year daily average 7/365 x 2.6 x 0.05 = L/day If the bathing water is assumed to contain 0.1 virus/L x 0.1 = 2.5 x viruses/day will be ingested

116 Minimum infectious dose ID 50 Probability of infection Dose-response curves Clinical manifestation depending on – Ingested dose – The condition of the mechanical barrier – The stability of the normal enteric flora – Immunity – The nutritional status of the individual Calculated from outbreak data Infectious dose

117 Fit data from experiments on voluntary persons to mathematical models Is available for some organisms, however not for pathogens causing severe illness Possibility to fit data from outbreaks to mathematical models Probabilities 0-1 – Infection (P inf ) – Illness (P ill ) – Death (P dth ) Dose response

118 The graph shows best fitted curves and 95% confidence interval (Teunis et al. 2000) D = dose P inf = probability of infection Hypergeometric model for 3 Cryptosporidium (bovine) strains

119 Dose-response models based on healthy individuals Do not consider vulnerable population – The elderly and very young, immunocompromised, pregnant women – In total approx. 20% of the population Most models do not include a whole population – Secondary spread, immunity – Dynamic models – Requires complicated mathematics Drawbacks in microbial risk assessment

120 Integration of earlier steps for calculation of the probability of infection, and importance in the society. In this step variation and uncertainty in the data used should be discussed. Risk characterisation Variability – internal variation in your data, can not be reduced Uncertainty – variation in the data set, can be reduced by collection of more data (more extensive investigations)

121 Earlier – only used point estimates in QMRA Examples – The average concentration of Salmonella in wastewater is bacteria per liter – Wastewater treatment removes 99.9% – The infectious dose is organisms Intervals – the model can get closer to reality Variation can be included – The concentration of Salmonella in wastewater varies e.g. with the prevalence in the conected population Random sampling (e.g times) with Monte Carlo simulation or Latin Hybercube Example – The drinking water consumption can be described as a lognormal distribution with median 0.96 L and 95% confidence interval of L Point estimates vs interval estimates

122 An add-on programme to Excel A free 10-day testversion can be down- loaded from More advanced modelling is done in specific mathematical programmes, e.g. Mathematica or MathLab Modelling in Excel

123 Health-based targets and acceptable risk Simplified framework for WHO Guidelines (Bartram et al. 2001) Acceptable risk (suggested) US-EPA (drinking water) 1: per year (10 -4 ) Haas (1996) (waste products) 1:1 000 per year (10 -3 ) Health-based target Based on standard metric of disease (e.g. DALYs, WHO ) Appropriate health outcome (prevention of exposure…)

124 Linking tolerable disease burden and source water quality for reference pathogens Example calculation (WHO, 2004)

125 Performance targets for selected bacterial, viral and protozoan pathogens in relation to raw water quality (to achieve DALYs per person a year) (WHO 2004) WHO Guidelines – risk

126 Overly strict standards borrowed from other countries often fail Guidelines are not just numbers = good practice + microbial water quality standards Low-cost effective treatment technologies needed Risk reduction strategies necessary (and possible) where wastes receive no or inadequate treatment Wastewater, excreta and grey water use – Lessons learned

127 WHO Guidelines – Safe use of wastewater, excreta and greywater in agriculture (2006)

128 WHO Guidelines on sanitation Objective: Maximize the protection of human health and the beneficial use of important resources Target audience: Policy makers, people who develop standards and regulations, environmental and public health scientists, educators, researchers and sanitary engineers Advisory to national standard setting – flexible to account local social, cultural, economic and environmental context Risk-benefit - adaptation to local priorities for health gain Builds on: – Best available evidence - science and practice – Scientific consensus – Use global information and experience WHO Guidelines – Safe use of wastewater, excreta and greywater in agriculture (2006)

129 Wastewater use is extensive worldwide – 10% of worlds population may consume wastewater irrigated foods – 20 million hectares in 50 countries are irrigated with raw or partially treated wastewater The use of excreta (faeces & urine) is important worldwide – The extent has not been quantified The use of greywater is growing in both developed and less developed countries Direct Health Effects – Disease outbreaks (developing and developed countries) – Contribution to background disease (e.g. helminths, + others?) Indirect Health Effects – Impacts on the safety of drinking water, food and recreational water – Positive impacts on household food security and nutrition Wastewater, excreta and greywater use – Background and health concerns

130 Guidelines provide an integrated preventive management framework for maximizing public health and environmental benefits of waste use. Health components: Defines a level of health protection that is expressed as a health-based target for each hazard Identifies health protection measures which used collectively can achieve the specified health-based target Implementation components: Establishes monitoring and system assessment procedures Defines institutional and oversight responsibilities Requires: System documentation Confirmation by independent surveillance. WHO Guidelines – Safe use of wastewater, excreta and greywater in agriculture (2006)

131 Structure of WHO Guidelines for the safe use of excreta and greywater

132 Health protection measures Aimed at different groups at risk of exposure Food produce consumers Workers and their families Local communities Different types of measures, examples Technical barriers: treatment, application methods Behavioural aspects: hand hygien, food preparation, use of personal protective equipment Medical: Immunization Education: health and hygien promotion Environment: Vector control

133 Treatment of excreta and greywater Faeces Storage, composting and alkaline treatment Further research and adaption to local conditions recommended Compare to module (builds on further research) Urine As table above, builds on Swedish recomendations Compare to module 4.2 Greywater Different techniques described, dependent on local conditions Compare to module (details on treatment processes)

134 Waiting or withholding periods – Stopping irrigation several days before harvest to allow natural pathogen die-off can be implemented in a cooler season or climate but makes leafy vegetables look unfit for sale under hotter conditions. Application techniques – In some countries, like India or Kenya, drip kits are easily available while in others, they are rare. Crop restriction – Depending on local diets and market demand, some farmers have the option to change crops, while others are constrained in this respect. FAO supports reuse (recycling) by (own) guidelines Health protection measures - agriculture

135 Control measure Pathogen reduction (log units) Notes Wastewater treatment 16 The required pathogen removal to be achieved by wastewater treatment depends on the combination of health-protection control measures selected Localized irrigation (low-growing crops) 2 Root crops and crops such as lettuce that grow just above, but partially in contact with, the soil. Localized irrigation (high-growing crops) 4 Crops, such as tomatoes, the harvested parts of which are not in contact with the soil. Spray/sprinkler drift control 1 Use of micro-sprinklers, anemometer-controlled direction-switching sprinklers, inward-throwing sprinklers, etc. Spray/sprinkler buffer zone 1 Protection of residents near spray or sprinkler irrigation. The buffer zone should be at m. Pathogen die-off 0.52 per day Die-off on crop surfaces that occurs between last irrigation and consumption. The log unit reduction achieved depends on climate (temperature, sunlight intensity), crop type, etc. Produce washing with water 1 Washing salad crops, vegetables and fruit with clean water. Produce disinfection 2 Washing salad crops, vegetables and fruit with a weak disinfectant solution and rinsing with clean water. Produce peeling 2 Fruit, root crops. Produce cooking 56 Immersion in boiling or close-to-boiling water until the food is cooked ensures pathogen destruction. Pathogen reductions (log units) achieved by health-protection control measures

136 From WHO Guidelines for the Safe Use of Wastewater in Agriculture, 2006 Health protection measures – pathogen reduction

137 Because normally microorganisms content in wastewater is very high what it is defined is log removal/inactivation Options for the reduction of viral, bacterial and protozoan pathogens that achieved a health based target of DALYS pppy (examples) Less treatment maybe more economical Less treatment implies more supervision sites Washing = More public involvement Involuntary soil ingestion from farmers Developing countries Developed countries California Title FC/100 ml (virtually Zero) ONLY with treatment Monitoring WWTP at T level

138 FunctionDefinition ValidationTesting the system or components thereof to ensure if it is meeting e.g. microbial reduction targets. Mainly relates to new systems/components. Operational monitoring Relates to design specifications e.g. temperature. Indicate proper functions and variations and is the base for direct corrective actions. VerificationMethods, procedures and tests to determine compliance with design parameters AND specific requirements (guideline values, E coli, helminth eggs, microbial and chemical analysis of crops). Definition of monitoring functions

139 Guideline values for verification monitoring

140 Verification monitoring Greywater, faecal sludge and (dry) faeces – Harmonised with wastewater use in agriculture (volume 2) Mainly applicable in larger systems E. coli – caution due to growth Helminth eggs – where applicable Sampling and laboratory procedures Guideline values for verification monitoring

141 Starting point: Wastewater performance target for unrestricted irrigation 1 egg /l Yearly helminth load from irrigation (using an average of e.g. 500 mm/year): 500 helminth eggs/m² Application of faecal matter (in same quantities as in good agricultural practice of manure application): 10 t manure/ha per year at 25 % TS = 250 g TS/m² per year [helminth eggs]tolerable 500/250 = 2 helminth eggs/g TS Performance targets for viable helminths eggs in faecal matter and faecal sludges


143 3.5 Risk management Learning objective: To be aware of how sanitation systems can be evaluated and compared regarding their potential health impact. To be familiar with the different parts of Quantitative Microbial Risk Analysis (QMRA). Can we measure a risk of disease transmission? How can sanitation systems be evaluated?

144 Theory, basic research Dissemination Communication Education Risk management – policy development

145 The most important barrier to manage risks? Handling (contact) of excreta should be minimized, but necessary to some extent What is practically, socially and culturally acceptable? – Adapted to local conditions, education and information, sustainability Treatment recommendations important part of the guidelines Will develop, on-going research Treatment as a health protection measure

146 Wastewater generation Consumer Wastewater treatment Safe produce … Wastewater generation Consumer Wastewater treatment Safe produce … WHOs multiple barrier approach from Farm to Fork Wastewater generation Farmer/ Producer Traders/ Retailers Street food kitchens Consumer Wastewater treatment Safe irrigation practices Hygienic handling practices Safe food washing and preparation Awareness creation to create demand for safe produce Policy recognition, safer farm land, tenure security, market incentives, safe-food labelling,… Risk reduction strategies

147 Treatment – define processes, – different levels (categories) Validation of the treatment process Microbiological/hygienic quality – presence of microorganisms, – reduction of microorganisms Restrictions on usage Fertilising (irrigation) methods Handling of the product (e.g. transport, storage) Protection of workers Sampling Analytical methods Examples of how to design regulations

148 Diverted – Small volumes – Easier to treat – Suitable fertiliser products – Handling requires restrictions Mixed (conventional) – Large volumes of hazardous waste – Extensive treatment – Reuse products: wastewater, sludge – Downstream pollution Comparison of sanitation systems

149 Microbial analysis – Indicators not always reliable Epidemiological studies – Scarce, complex Microbial risk assessment – The main approach (?) Assessment of health risks

150 Risk Assessment – Qualitative or quantitative – Systematic procedure – Acceptable risks Risk Management – To handle the risks – Aims at reducing risks Risk Communication – Essential part in all systems – Necessary for awareness raising and health protection – Involve all stakeholders Microbial Risk Analysis

151 Hazard Identification – All enteric pathogens potentially in excreta Exposure assessment – Exposure points, site-specific data on removal – Literature data on occurrence of pathogens, removal in treatment and survival in environment – Exposure scenarios evaluated (ingestion, volumes) Dose-response assessment – Published mathematical models Risk characterisation – Risk of infection per exposure and yearly, DALYs – Comparison with endemic level of disease (underreporting) Quantitative Microbial Risk Assessment (QMRA)

152 Faecal contamination – Faecal sterols analysed What amounts of pathogens would the faecal contamination contribute? – Incidence in the population (statistical data) Faeces could contribute enteric pathogens to the urine – IF they end up in the urine – will they survive storage? – Survival studies performed and literature data used for crop How can people be exposed to the urine? – Scenarios determined What dose could they be exposed to? – Amounts ingested estimated (Höglund et al., 2002) Microbial risk assessment – urine (outline)

153 Input: faecal contamination, prevalence of infection, excretion densities, excretion days, inactivation rates Scenarios: Dose-response models Output: probability of infection (Höglund et al., 2002) Microbial risk assessment – urine (outline)

154 Unstored urine P inf < 1:1000 except for rotavirus Storage for six months at 20°C all risks < 1:1000 (Höglund et al., 2002) Risk from accidental ingestion of 1 ml unstored urine

155 Inactivation will continue in the field Risk dependent on time between fertilising and consumption (Höglund et al., 2002) Risk from accidental ingestion of 100 g crop

156 Faeces from dry urine diverting latrines in Denmark No additives Treatment by storage Hazard identification – Bacteria: Salmonella, EHEC – Viruses: rotavirus, hepatitis A – Protozoa: Giardia, Cryptosporidium – Helminth: Ascaris Compiled studies (literature) for pathogen survival Incidence (surveillance), excretion numbers and times (duration) also input for calculation of doses Model organisms – dose-response relation Exposure when handling and using in garden Microbial risk assessment - faeces (Schönning et al., 2004)

157 The faeces-soil intake (Larsen,1998) - children around 200 mg of soil (max of 5-10 g). Assumed that adults ingest 15-50% of this amount, with a maximum of 100 mg. The container emptied once a year assuming only adults exposed. The number of exposures through recreation was a median value of 3.5 times per week (during June-August). 50% of the households were exposed through gardening once a week (during May-September). It was assumed that one exposure corresponded to two hours of gardening occurring a maximum two times per day. Exposure scenarios (Schönning et al., 2004)

158 There is an unacceptably high (>1:10 000) risk of infection when faeces is used without treatment – The highest risk from exposure to unstored material was attributable to rotavirus 12 months storage – sufficient reduction of most pathogens (compared to a risk level 1:10 000) – The highest risk from exposure to stored faeces was attributable to Ascaris – the protozoa Giardia and Cryptosporidium are of greater concern in the European population The risks of infection can be reduced by simple measures such as longer storage, or treatment with a pH elevating compound Conclusions - pathogens (Schönning et al., 2004)

159 Risk for infection when emptying container Salmonella Ascaris Examples of how risk for infection are presented as probability density functions. The typical risk equals the 50th-percentile and worst case equals the 95th-percentile. (Schönning et al., 2004)

160 Hässleholm municipality with residents m 3 wastewater per day Wastewater treatment: pre-aeration, pre- sedimentation, activated sludge, chemical precipitation, three-media filter Sludge treatment: anaerobic digestion, dewatering, outdoor storage Sludge use: Application to vegetables (theoretical) Microbial risk assessment – wastewater and sludge (Westrell et al., 2004)

161 Hazard Identification – All entero-pathogens potentially in wastewater – Enterohaemmorhagic E.coli (EHEC), Salmonella, Giardia, Cryptosporidium, rotavirus and adenovirus Exposure assessment – Exposure points identified together with WWTP staff – Site-specific data on removal of indicators in WWT – Literature data on occurrence of pathogens in ww, removal in sludge treatment and survival in environment Dose-response assessment – Published dose-response models Risk characterisation – Monte Carlo simulations – Risk of infection per exposure – Yearly number of infections in study population – Comparison with endemic level of disease (epidemiological statistics adjusted for underreporting and morbidity rates) Microbial risk assessment – wastewater and sludge (Westrell et al., 2004)

162 Exposure scenarios – wastewater treatment 1 2 3, (Westrell et al., 2004)

163 Type of exposure Volume ingested (mL or g) Frequency (times*year -1 ) Number of persons affected 1. WWTP worker at pre-aeration WWTP worker at belt press (Un)intentional immersion at wetland inlet Child playing at wetland inlet Recreational swimming Child playing at sludge storage Contractor spreading sludge Consumption of raw vegetables12500 Exposure scenarios – wastewater treatment (Westrell et al., 2004)

164 Risk of infection per exposure All risks >10 -4 are shown in orange (Westrell et al., 2004)

165 Number of yearly infections (Westrell et al., 2004)

166 Severity of hazards (Westrell et al., 2004)

167 ExposureEHECSalmonellaGiardiaCrypto.RotavirusAdenovirus 1 Median 95-percentile CatastrophicMajorModerateMinorInsignificant Classification of exposures (Westrell et al., 2004)

168 Exposure 1 – Easy to control with Personal Protective Equipment (PPE) – Covering of basins Exposure 2 – Easy to control with PPE – Optimisation of sludge treatment (baffles against short-circuiting, thermophilic digestion etc.) Control measures (Westrell et al., 2004)

169 Exposure 6 – Fence storage area – Optimisation of sludge treatment Exposure 7 – Use of PPE – Optimisation of sludge treatment – Prolonged sludge storage Control measures Exposure 8 Crop restrictions Minimum time between fertilisation and harvest Optimisation of sludge treatment Prolonged sludge storage (Westrell et al., 2004)

170 Per-Åke Nilsson and staff at Hässleholm wastewater treatment plant Swedish research council FORMAS MISTRA Urban Water program Acknowledgements Worst-case situation 2002 (Westrell et al., 2004)

171 107 households, 449 people Prevalence of parasitic infections Type of latrines – UD solar desiccating latrine (single vault) – UD double-vault desiccating latrine (LASF) – Pit latrines – No latrines – UD = urine diverting Epidemiological study - El Salvador (Corrales et al., 2006)

172 Prevalence of parasitic infections Use of UD-latrines (both solar and LASF) – lower prevalence of the less environmentally persistent pathogens (hookworm, Giardia, Entamoeba) Use of LASF – higher prevalence of more environmentally persistent pathogens (Ascaris, Trichuris) (Corrales et al., 2006)

173 LASF (this design) does not achieve conditions needed to inactivate these organisms UD solar latrines – lower prevalence of most parasites compared with LASF and pit- latrine Use of biosolids (faecal matter) in agriculture – higher prevalence of infections compared to burying the material Summarised results (Corrales et al., 2006)

174 In El Salvador, the solar latrine is recommended – Includes urine diversion – Better results than pit latrine High prevalence of some infections in diverting latrines identifes the need for – Further work on better designs – Better use and maintenance, information – Further evaluation under different local environments and cultures Limitations of the study – Different communities compared – Small sample size Conclusions

175 Epidemiological study South Africa Peri-urban area, eThekwini Municipality, Durban 1337 households incl. in study Intervention Sanitation – dry UD-toilets Safe water (200 L per day) Health and hygiene education Purpose and method Measure reduction in diarrhoea associated with the interventions Prospective cohort study Disease incidence questionnaire (6 visits) (Knight et al., manuscript) Picture provided by Teddy Gounden

176 Exposed Area (N=660) Unexposed Area (N=667) Type of Sanitation Intervention in Sample Area Provided by Renuka Lutchminarayan

177 (Knight et al., manuscript) Epidemiological study South Africa - Results 41% reduction in diarrhoea Benefits 3 times greater for children <5 years Fewer acute water related health outcomes Duration of diarrhoea episodes decreased (54% fewer days reported) Not possible to disaggregate the effect of each separate intervention Picture provided by Teddy Gounden

178 178 Incidence Rate & Incidence Rate Ratio of Diarrhoea Episodes by Gender & Total IRR: 0.50 IRR: 0.65 IRR: 0.58 (Knight SE, Esterhuizen T, Lutchminarayan R, Stenström T-A)

179 Impacts on diarrhoeal disease reduction by interventions Intervention area Reduction in diarrhoea frequency Hygiene37% Sanitation32% Water supply25% Water quality31% Multiple33% (In WHO, 2008, adapted from Fewtrell et al., 2005)

180 Different types of studies – Possible to investigate the real situation? – Epidemiology – underestimation in disease incidence Interviews, surveillance – Risk assessments – assumptions made, over- or underestimating risks (?) – Sampling and microbial analysis Illustrates the importance of various studies Range of interventions possible and needed in combination – Difficult to differentiate effects Identifying need of risk management and barriers – Health protection measures of different kinds Summary of module on risk management

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