1. Waterborne Diseases: Public Health Engineering and the Primacy of Prevention David M. Gute, Ph.D., M.P.H., FACE Tufts Environmental Literacy Institute May 21, 2013

2. Today’s Talk My background in government and the practice of public health Tufts Environmental Literacy Institute Primary prevention: Public health engineering Nexus: water, health, and food Importance of surveillance and acquisition of data Environmental enteropathy Renewed emphasis on sanitation

3. Host Agent Environment Vector Epidemiological Triad

4. Fenwick, A. Science 8/25/06 ConditionCases in Africa% of Global Burden (Africa) Hookworm198 million27-34% Ascariasis173 million14-22% Schistosomiasis166 million89% Trichuriasis162 million20-26% Lymphatic Filariasis 46 million38% Trachoma33 million40% Onchocerciasis18 million99%

5. Public Health Approach ProblemResponse Surveillance: What is the problem? Risk Factor Identification: What is the cause? Intervention Evaluation: What works? Implementation: How do you do it?

6. The Primacy of Prevention The public health approach Success stories – Impact of civil infrastructure improvements and other factors versus medical treatment – Removal of lead in gasoline

7. Levels of Prevention Primary- prevention of the disease in a person who is well and does not have the disease in question. Secondary- the identification of the disease at an early stage in the natural history of the disease in question. Tertiary- the limitation of mortality and or disability of the disease in question.

8. The Questionable Impact of Medical Measures ( McKinlay et al.)

9. An Unqualified Success: Blood Lead Measurements 1975-1981 (USA) 1975197619771978197919801981 30 40 50 60 70 80 90 100 110 8 10 12 14 16 18 Year Predicted blood lead Gasoline lead Observed blood lead Source: Pirkle et al JAMA 272:284-91, 1994 Lead used in gasoline (thousands of tons) Mean blood lead levels  g/dl

10. EPA’s Perspective on Levels of Prevention Source: http://www.epa.gov/p2/p2week2003.htm

11. Water “Water is a global dictator which sets the limits for living nature.” Simo Laakkonen Water and Urbanization: Conceptualizing Hydrohistory” unpublished paper. As cited in The Sanitary City by Martin Melosi. He also said, “Waste disposal-an unwelcome but necessary function-is another global dictator”.

12. Pollution Global Warming Over Population Habitat Degradation Biodiversity Loss Over Consumption Health Mark Pokras, D.V.M.

13. EID = Emerging Infectious Disease

14. Surveillance The systematic and ongoing collection, analysis and dissemination of information on disease, injury, or hazard for the prevention of morbidity and mortality. Sources of data appropriate for surveillance? Case-based: Sentinel Health Event of Occupational Origin (SHE/O) Rate-based: population based analysis looking down the traditional public health/epidemiological parameters of person, place, and time. Surveillance can be directed either at the disease or the agent (more commonly known as monitoring).

15. Emerging Infectious Diseases, Volume 9, Number 5, May 2003 Estimating the Incidence of Typhoid Fever and Other Febrile Illnesses in Developing Countries John A. Crump,* Fouad G. Youssef,† Stephen P. Luby,* Momtaz O. Wasfy,† Josefa M. Rangel,* Maha Taalat,† Said A. Oun,‡ and Frank J. Mahoney*† *Centers for Disease Control and Prevention, Atlanta, Georgia, USA; †U.S. Naval Medical Research Unit No. 3, Cairo, Egypt; and ‡Ministry of Health and Population, Cairo, Egypt How well do we understand the burden of waterborne diseases? ….issues of surveillance

16. North Chicago River Sewage into Lake Michigan / Chicago River: drinking water source 1867: 2-mile tunnel provides drinking water intake away from shore 1869: water tower fire pumping station 1871: deepening of Illinois and Michigan canal, reversing current of Chicago River – sewage flows away from water intakes South Chicago River 1871 Original

17. 2 nd and 3 rd stages 1893: 4-mile intake; closure of all shoreline sewage outlets 1917: City-wide chlorination of public water supply Dramatic effects before chlorination due to sanitation Adapted from Ferrie and Troesken, Explor. In Ec. Hist. 2007

18. 2 nd and 3 rd stages First intake in Lake Michigan Reversal Chicago River No sewage allowed in LM Intakes further out Chlorination Adapted from Ferrie and Troesken, Explor. In Ec. Hist. 2007

19. A Case Study: Schistosomiasis 200 million cases world-wide with another 600 million at risk of infection. A parasitic disease with a complex life cycle. In the perspective of Nobel Laureate Joshua Lederberg, a well “adapted” microbe. Predominate risk management tactic today is treatment. This is a missed opportunity to further primary as contrasted with tertiary prevention.

20. Neglected Tropical Diseases Neglected Tropical Diseases (NTDs), such as urogenital schistosomiasis (UGS), receive little global attention as measured by research and development investment. As a result, NTDs burden health care systems and are an important cause of squandered human potential. UGS causes anemia; fibrosis of the liver, bladder and ureter; renal damage; bladder cancer; urogenital pathology; and infertility.

21. Mass Chemotherapy Mass chemotherapy is the prevailing response to Schistosomiasis. However, mass chemotherapy campaigns have been unable to reduce prevalence below 5-15% (Wang et al. 2009) because they do not address the root cause of the disease which is repeated exposure to parasites. Emphasis on the beneficial impact of infrastructure to other water-related diseases was endorsed emphatically by the C.H. King editorial that accompanied the publication of Wang’s successful control efforts in China (King, 2009).

22. Impacts of our proposed clinical trial on the multi-host lifecycle of S. haematobium X 1 shows the interruption of S. haematobium infection due to use of water recreation areas and borehole wells; X 2 shows the interruption of morbidity and egg production in humans due to treatment with praziquantel; X 3 shows the reduction of river water contamination with S. haematobium eggs because of latrine use; and X 4 illustrates the interruption of multiple stages of the lifecycle due to behavior change resulting from education and access to WASH Adapted from- http://www.dpd.cdc.gov/dpdx/HTML/Ima geLibrary/S- Z/Schistosomiasis/body_Schistosomiasi s_il10.htm

23. The Water Source on the Awusu River

24. Urine Samples from Schoolchildren Adasawase, Ghana Karen C. Kosinski, MSPH, Ph.D.

25. Water Recreation Area Adasawase, Ghana Karen Kosinski, Ph.D.

26. The WRA in Use The WRA features a concrete pool supplied by a bore hole well and a gravity –driven rainwater collection system in this water-rich location. Initial baseline testing in 2008 established that 42.5% of children were egg positive. In 2009 with drug treatment alone the pre-WRA annual cumulative incidence of infection was 13.4%. In 2010, this incidence rate fell significantly (p <0.001, chi- squared) to 3.7% after installation of the WRA. KC Kosinski, MN Adjei, KM Bosompem, JJ Crocker, JL Durant, D Osabutey, JD Plummer, MJ Stadecker, AD Wagner, M Woodin, and DM Gute. Effective Control of Schistosoma haematobium Infection in a Ghanaian Community following Installation of a Water Recreation Area. PLoS Negl Trop Dis. Jul 2012 6(7): p. e1709.

27. MalnutritionInfection which worsens Dietary insufficiency Environmental factor: water Jeffrey Griffiths, M.D.

28. Nice normal intestine. Note long skinny finger-like villi, which absorb nutrients ENVIRONMENTAL ENTEROPATHY EE -Nasty blunted villi, and tissue is infiltrated with inflammatory cells. EE is a state of chronic inflammation Korpe & Petri, Trends in Molecular Medicine June 2012, Vol. 18, No. 6

29. Environmental Enteropathy Children in highly contaminated environments have leaky, chronically inflamed intestines – 5% less carbohydrate, 15% less protein absorption. Leak lets ‘dirty’ contents of gut into body; chronic inflammation uses up/diverts nutrients, leads to anemia…

30. Gnotobiotic (sterile gut) mice – given either Normal or Kwashiorkor MB. Science:339.548-554, 2013 Mice given kwashiorkor MB bacteria – lost 1/3 of their weight Mice given normal MB – maintained weight

31. Solutions for Environmental Enteropathy Classic household water & sanitation – water supply NOT same for animals unless treated; hand-washing; human and animal feces kept out of wastewater to increase food safety. Agricultural hygiene – barriers to keep feces out of water - vegetated buffer zones- riparian buffers to slow entry into open water (stream or irrigation canal), nutrient management, grazing practices … January 4 2013: US FDA proposes rules to “ensure water used in irrigation meets standards…” http://www.fda.gov/Food/FoodSafety/FSMA/ucm334114.htm

32. Integrated Approach Providing food to undernourished people only solves some of the problem. Recent science: contaminated environments, infections, and toxins adversely change the child’s gut via EE. Water & sanitation have much more potential to eliminate malnutrition than had been thought. Integrated programming has the best chance to improve the nexus of water, health, and food. One can’t dig irrigation canals without affecting nutrition & health! Schistosomiasis = disease of “progress”.

33. Definition of Engineering Engineering is the invention of solutions for the improvement of the human condition - often in the face of incomplete understanding and always under the constraints of natural laws and available resources. Source: Dean Paul Fleury. Engineering Program @ Yale University

34. Selected Data Points Regarding the Schism 1922, MIT & Harvard abandoned a joint program: the School for Health Officers. Harvard School of Public Health emerges-like the Phoenix. 1970, US EPA created out of the US Public Health Service. 1970, (MA) Department of Environmental Quality Engineering (DEQE) created.

35. Engineering Village 2 Citations for “Public Health Engineering” Expressed as a Title by Date of Publication (English Only) Date of PublicationCounts Present -19909 1989-19705 1969-195014 1949-193028 1929-191013 1909-18902 Source: D.M. Gute

36. OVID Citations for “Public Health Engineering” Expressed as a Title by Date of Publication (Any Language) Date of PublicationCounts Present -19902 1989-19704 1969-195011 1949-1930N.A. 1929-1910N.A. 1909-1890N.A. Source: D.M. Gute

37. Sir Joseph Bazalgette Sir Joseph Bazalgette (1819-91). Bazalgette was one of the greatest of Victorian engineers who, between 1856 and 1889, built more of London than anyone else before or since in his role as Chief Engineer to the Metropolitan Board of Works. The sewers, pumping stations and treatment works that he built are still keeping the capital clean. Before Bazalgette's time London's sewage flowed into the Thames from which it leaked into adjacent springs, wells and other sources of drinking water: hence the cholera epidemics.

38. Sir Edwin Chadwick Father of sanitary engineering in England A lawyer by training Health depended on sanitation Sanitation was in the province of engineering One local authority should administer sanitary infrastructure in an area Took on the entrenched power structure of engineers and private water companies For his trouble, he was fired. Knighted barely one year before his death.

39. Lemuel Shattuck New Englander influenced by the work of Chadwick. In 1850 drafts a report laying out the rationale for the creation of Board of Health for the Commonwealth of Massachusetts. (See handout). The plan is acted on 19 years later! Founder of the American Statistical Association.

40. Shattuck and Satcher Shattuck: “public health requires such laws and regulations, as will secure to man associated in society, the same sanitary enjoyments that he would have as an isolated individual ”. Satcher: “scope has broadened to include: identifying elusive patterns and origins of human behaviors that so frequently result in adverse health consequences”.

41. Deer Island Source: MWRA Homepage

42. Biology of Water and Health 9/21/10

43. Vector Borne Disease Comes to NYC or at least to the New Yorker

44. Conclusion Engineering and public health will benefit from a re-convergence. The hope is that primary prevention can be emphasized and that emerging technologies can be harnessed to both enhance the understanding of disease etiology and mechanisms of control. Integrate environmental concepts and material in outreach and communication materials