Minsk 5-6 April 2011 Enzo Funari. Italian Higher Institute of Health

2. HEALTH RISKS FROM MICROBIAL PATHOGENS 3. HEALTH RISKS FROM CHEMICALS 4 HEALTH RISKS IN THE WATER SYSTEM 5. ESSENTIAL EPIDEMIOLOGY 6. ESSENTIAL SURVEILLANCE. 7. DATA MANAGEMENT AND ANALYSIS USING GEOGRAPHICAL INFORMATION SYSTEM

 The draft version of the publication is available at 010/wat/MP_WH/wg/unofficial_docs/Inf o_1_Technical_Guidance_WRDS.pdf 010/wat/MP_WH/wg/unofficial_docs/Inf o_1_Technical_Guidance_WRDS.pdf  157 pages, 18 tables, 22 figures

I. The problem (Introduction) II. Water safety plans III. Legal obligations with regard to disease surveillance IV. Surveillance system for water-related diseases V. How to set up an essential surveillance system for water-related diseases (OMT) VI. How a water-related disease surveillance system should work in practice VII. How to evaluate a surveillance system for water- related diseases VIII. National examples

transfer of risk factors to consumers, including pathogenic micro-organisms. Sources of exposure: drinking and bathing water, aquaculture, irrigated crops Contaminated water one of the major health concerns in the world. WRDs some two million deaths each year, primarily of children in developing countries. Diarrhoeal diseases

unsafe water, lack of sanitation and poor hygiene 95% of this disease burden attributable to the environment cholera, typhoid fever, hepatitis A, many emerging diseases WRDs

Drinking-water related outbreaks → simultaneous infection of a large number of consumers Over 30 million cases of WRDs outbreaks could be avoided annually by means of adequate water and sanitation interventions Investing in prevention produces benefits far greater than those directly related to the cost of treatment for these human pathologies

EUR B+C EUR-A Figure 1 ‑ 2 SDR diarrhoeal disease below 5 y of age (Source: WHO Health for All) While mortality data are surely the most striking, morbidity figures show that water-related diseases continues to be a serious problem in the European region, are hampering sustainable development and imposing prohibitive economic costs.

Controlling and reducing the burden of WRDs has two main tools Surveying the health status of communities Promoting adequate preventive measures in order to ensure safe access to water (adequate quality and quantity)

Examples where the system failed included an outbreak of giardiasis in Hordaland (Bergen) in 2004 – 2005 where the surveillance system proved to be “late” in detecting outbreaks.

WSPs: management multi step approach aimed at ensuring safe access to water. WSPs should be developed for each individual drinking-water system, whether large- or small-scale. Beyond drinking water

 Protection of raw waters and recognition of the pollution sources  Treatment according the level and typology of contamination;  Drinking-water: subject to surveillance for the main risk factors (special attention to microbial quality)

 Adequate education and training for the personnel Figure 8 ‑ 1 Sources of failures in the WSP approach

Added value of specific WRDs surveillance systems:  identify the diseases transmitted by water  define/estimate the burden of WRDs;  use data and information to identify communities with problems with WRTs;

 Mapping of pollution hazards and identifying risks;  promote intervention measures to control and prevent WRDs;  target resources towards areas with priority needs;  assess the effectiveness of the implemented interventions.

 Some practical examples:  High incidence of typhoid fever → need for targeted vaccine campaigns;  giardiasis and cryptosporidiosis → need for water filtration  outbreaks in adequately treated piped water supplies ( intrusion problems in the water distribution system)  high prevalence of helminth infections → need for improvements in sanitation and increased water availability for general hygiene;  High incidence of blue-baby syndrome → need to control and reduce nitrate concentrations in drinking water.

 Priority diseases (characterised by a high epidemic potential): cholera, diseases caused by enterohaemorrhagic E. coli, viral hepatitis A, bacillary dysentery and typhoid fever.  Emerging diseases: campylobacteriosis, cryptosporidiosis, giardiasis, and legionellosis.

 Local diseases : methemoglobinaemia, arsenicosis, viral infections (particularly those attributable to Norovirus) and parasitic diseases.

 Local level  An outbreak management team (OMT) should be set up at the local health unit. OMT composition: representatives of waterworks and sanitation system, water department of the regional environmental agency, expert in hygiene and environmental medicine.

 In case of a WRD outbreak, the local OMT should:  Review the evidence for an outbreak  Identify the population at risk  Decide on control measures  Provide quick and adequate information to the public  Make arrangements for the commitment of personnel and resources  Health surveillance data should be linked with data on the quality and distribution of water supplies in the same area.

 Response  Trigger event: outbreak detection and confirmation  Acute reaction: outbreak declaration, quick and preliminary descriptive hazard investigation, initial and immediate control measures  Analysis: in-depth analytical hazard investigation, continuous re-evaluation of control measures  Normalization: conclusion of outbreak and declaration of normalization  End: evaluation, formal report, lessons learned for the future, promotion of management measures.

 The draft version of the publication is available at 010/wat/MP_WH/wg/ece_mp_wh_wg_1_ 2010_L.1_policy%20guidelines_WRDs_Fi nal.pdf 010/wat/MP_WH/wg/ece_mp_wh_wg_1_ 2010_L.1_policy%20guidelines_WRDs_Fi nal.pdf  22 pages, 2 figures