1. WASH and Health and Nutrition
Food Security and Nutrition Network Regional Knowledge Sharing Meeting Washington, DC November 15, 2012
WASH and Health and Nutrition
Chris Seremet, PE
Technical Advisor – Water Supply and Sanitation
Catholic Relief Services
Baltimore, MD

2. Food For Peace Goal
To minimize hunger in the world so that people everywhere can enjoy active and productive lives and, ultimately, to ensure that one day no one needs food aid

3. However, there are barriers to realizing healthy, productive lives…….

4. Diarrhea 2.2 million deaths each year
1.6 million preventable child deaths per year
73 million DALYs lost per year
80% of cases of diarrhea worldwide are attributable to the ingestion of pathogens, especially in unsafe drinking water, in contaminated food or from unclean hands.
Cholera, typhoid and dysentery
These are the main WASH-related illnesses linked to malnutrition

5. Neglected Tropical Diseases
Soil-transmitted Helminths (Ascariasis, Trichuriasis and Hookworm)
2 billion infections—affecting one third of the world’s population—that could be prevented
4 million DALYs lost per year
Affects 400 million school-aged children per year
Transmission of intestinal parasitic worm infections occurs through soil contaminated with feces.
Entirely preventable by adequate sanitation, and intervention outcomes are reinforced by good hygiene.

6. Neglected Tropical Diseases
Schistosomiasis
200 million people with preventable infections
1.7 million DALYs lost per year
Caused by contact with water bodies contaminated with the excreta of infected people

7. Malnutrition 860,000 preventable child deaths per year
17 million DALYs lost per year
Childhood underweight causes about 35% of all deaths of children <5 years worldwide.
An estimated 50% of this underweight or malnutrition is associated with repeated diarrhea or intestinal parasite infections
a result of unsafe water, inadequate sanitation or insufficient hygiene.
abnormal nutrient loss

8. Tropical Enteropathy
Changing the structure and function of the small intestine leads to undernutrition
Reduced surface area of small intestine - decreased villous height - ‘flat architecture’
Lowers nutrient absorption
‘Leaky gut’ (increased permeability of the intestinal tract) and impaired ability to prevent pathogens from breaching the intestinal barrier
Elevated immune response
Nutrients diverted from growth to defense
Subclinical condition receiving attention

9. Tropical Enteropathy
Thought to be caused by chronic ingestion of pathogenic microorganisms.
Linked to living conditions with poor sanitation and hygiene practices.
Likely to be prevalent in developing countries.

10. Fecal – Child Undernutrition Pathway
The figure shows a model of these pathways. Children living in poor sanitary conditions ingest high concentrations of faecal bacteria, which colonise the small intestine and induce tropical enteropathy through a T-cell-mediated process. The hyperpermeable gut facilitates translocation of microbes, which trigger the metabolic changes of the immune response. Growth falters when these changes coincide with reduced nutrient absorption by atrophied villi, marginal dietary intake, and the high growth demands of the first 2 years of life.
Source: Humphrey (2009)

11. Evidence is Lacking Many studies, many methodological issues
Limited evidence
Suggests that nutrition interventions can substantially reduce or even eliminate the negative effect of diarrheal disease on child growth.
Can’t conclude that high rates of infection make nutrition interventions ineffective for improving child growth.
Likely a combination of improved nutrition and infection prevention and control efforts
Many studies looking at nutrition, diarrhea, WASH, stunting but using poor methodologies
Limited evidence showing relation between nutrition, infection and growth

12. Evidence is Lacking Most studies agree with WASH interventions
Randomized controlled trials of toilet provision and handwashing promotion that include tropical enteropathy and child growth as outcomes

13. The F-Diagram Fecal-oral pathway showing barriers to transmission
Source: UNICEF

14. Nutrition and infection prevention and control interventions
Hygiene Behavior Change
Handwashing with soap at key times
PHAST / CLTS
Sanitation
Latrines – household and at the fields
Improve drainage around muddy areas
Water
Drinking Water Supply from a protected source
Drinking water system at same time as irrigation system
The potential health gains are reduced sharply with even occasional consumption of untreated drinking water
POU Treatment and Storage
These are the barriers.
Point-of-use water treatment with diluted bleach, flocculent-disinfectant combinations, boiling, solar disinfection and filters

15. FFP Standard WASH Indicators
Percentage of households using an improved drinking water source
Percentage of households with access to an improved sanitation facility
Percentage of households with children aged 0–23 months that have water and soap or locally available cleansing agent at a hand washing place
Lastly….

16. Improved Drinking Water Source
An improved water source is an infrastructure improvement to a water source, a distribution system, or a delivery point. By nature of its design and construction, the improvement is likely to protect the water source from external contamination, in particular fecal matter.
Improved drinking water sources are:
Piped water into dwelling, plot, or yard
Public tap/standpipe
Tube well/borehole
Protected dug well
Protected spring
Rainwater collection

17. Improved Sanitation Facility
A sanitary facility in the household and whether that sanitary facility meets the improved sanitation standards defined in the Millennium Development Goals (MDGs).
Improved sanitation is defined as:
Flush or pour/flush facilities connected to a:
Piped sewer system
Septic system
Pit latrine
Pit latrines with a slab
Composting toilets
Ventilated improved pit latrines
Sanitation reduces or prevents human faecal pollution of the environment, thereby reducing or eliminating transmission of diseases from that source (although other sources, such as animal excreta, may remain important). Effective sanitation isolates excreta and/or inactivates the pathogens within faeces

18. Improved hygiene practices
At households with children aged 0–23 months:
Presence of a hand washing station
Presence of water in hand washing station
Presence of soap or other cleansing agent at hand washing station

19. Thank You Chris Seremet
Technical Advisor – Water Supply and Sanitation
Catholic Relief Services
Website for CRS publications:
Thank you.

20. Fecal – Child Undernutrition Pathway