EAWAG SANDEC 2008 Sandec Training Tool Module 2 Environmental Health Lecture
EAWAG SANDEC 2008 Sandec Training Tool Module 2 Environmental Health Lecture
EAWAG SANDEC 2008 Sandec Training Tool Module 2 Environmental Health Lecture
Summary
Summary
The natural and built environment in
which we live, the water we drink, the
air we breathe or the houses we occupy,
greatly affect our health. For instance, if
our drinking water is polluted and contains high numbers of pathogenic microorganisms, we shall probably suffer from
bad health. Worldwide, 1.8 million people die every year from diarrhoeal diseases, thereof, 88% are attributed to unsafe water supply, inadequate sanitation
and hygiene. Moreover, about a third of
the population of the developing world is
infected with intestinal worms in some
communities the infection rates are
even as high as 95%! Many also suffer
because of chemical contaminants in
their drinking water: In Bangladesh,
about 30 million people consume water
with elevated levels of arsenic, which
can lead to skin lesions and cancer.
In China alone, over 26 million people
suffer from dental fluorosis due to
elevated fluoride in their drinking water.
Other countries in South Asia and Africa
are similarly affected. Of these environmental health related diseases, people in
developing countries and especially children, carry a disproportionately heavy
burden.
One focus of this module is the health
aspect of environmental services, in particular sanitation, water treatment and
solid waste management. The global
improvement of these services could
contribute significantly to achieving the
Millennium Development Goals (MDGs),
especially in reducing child mortality (MDG 4), improving maternal health
(MDG 5) and ensuring environmental
sustainability (MDG 7). Global improvements in drinking water and sanitation
services could result in a 25 45% reduction of diarrhoeal disease morbidity.
Protecting human health can also lead
to improving the natural environment:
Keeping a drinking water source free
from chemical, organic and/or microbiological contaminants may also improve the water quality of a nearby lake.
Arsenic and fluoride are important geogenic contaminants of drinking water
in developing countries, whereas nitrate
and lead belong to the most relevant anthropogenic contaminants.
Water and sanitation-related diseases are usually caused by microbiological
or chemical contaminants. Microbiological pathogens, present in human excreta, follow typical transmission routes.
The most relevant pathogens are viruses (e.g. hepatitis A), bacteria (e.g. cholera), protozoa (e.g. amoebiasis) or parasitic worms (e.g. hookworm). They are
typically transmitted to the new host via
a faecal-oral route, e.g. along the pathway of excreta fingers food new
host. Whether the new host is infected and gets sick or not, is dependent on
pathogen and host factors (e.g. number
of transmitted bacteria or health condition of the new host). Certain people are
at greater infection risk than others (e.g.
host factors) if they work in close contact with faeces, such as pit emptiers or
farmers reusing excreta as fertiliser. Furthermore, certain situations cannot only
increase individual health risk but also
endanger a whole community: Emergency situations, such as flooding, war
or industrial accidents, are frequently associated with outbreaks of epidemics.
In contrast to microbial contamination,
chemicals arising in drinking water are
usually of health concern only after extended exposure over many years, rather
than months.
Water treatment and sanitation alone
do not efficiently disrupt the transmission routes of diseases. It is indispensable that they are accompanied by appropriate hygiene practices. Washing hands
after defecation or constructing safe
sanitation facilities are primary barriers,
which prevent pathogens from entering the environment. Washing hands before eating or protecting food from flies
are secondary barriers, which prevent
pathogens from infecting a new host or
contaminating food. To make hygiene
promotion effective and sustainable,
choices have to be made about which
behaviours to target. Too many messages may be confusing and counterproductive. Furthermore, hygiene promotion should build on what exists, target
a specific audience, identify the motives
for changed behaviour and communicate
positive messages. Hygiene promotion
can thus be highly effective in reducing
water and sanitation-related diseases in
developing countries.
Publishing details
Publisher: Eawag/Sandec (Department of
Water and Sanitation in Developing
Countries), P.O. 611, 8600 Dbendorf,
Switzerland. Phone +41 (0)44 823 52 86,
Fax +41 (0)44 823 53 99
Editors: Christian Zurbrgg and
Sylvie Peter
Concept and Content: Melanie Savi and
Karin Gdel
Layout: Melanie Savi and Yvonne Lehnhard
Copyright: Eawag/Sandec 2008
Eawag/Sandec compiled this material,
however much of the text and figures are
not Eawag/Sandec property and can be obtained from the internet. The modules of
the Sandec Training Tool are not commercial products and may only be reproduced
freely for non-commercial purposes. The
user must always give credit in citations to
the original author, source and copyright
holder.
These lecture notes and matching
PowerPoint presentations are available on
the CD of Sandecs Training Tool. They can
be ordered from: [email protected]
Cover photo: Woman washing clothes in
Napo province, Ecuador.
(Source: Melanie Savi)
Content
Content
1.1
1.2
1.3
1.4
4
5
6
7
2 Introduction
2.1
2.2
2.3
2.4
2.5
2.6
2.7
9
11
12
13
13
14
15
16
3 Diseases
18
18
19
19
21
22
23
25
25
26
26
27
4 Hygiene Approaches
28
28
32
33
36
References
Weblinks <www>
36
37
29
30
The environment in which we live greatly affects our health. The household,
workplace and outdoor environments
can pose a variety of health hazards from
contamination of the air we breathe, the
water we drink and the food we eat, to
the risk of accidental injury from vehicles or unsafe housing. (Cairncross et al.,
2003, p.7)
Environmental health addresses all
the physical, chemical and biological factors external to a person, and all the
related factors impacting behaviours. It
encompasses the assessment and control of those environmental factors that
can potentially affect health. It is targeted towards preventing disease and creating health-supportive environments.
<www> (WHO, 2008a)
Further questions
What effect will climate change have on
water and sanitation-related diseases in
developing countries?
The urban population is growing
rapidly as a result of rural to urban migration. Since the built and natural environment is subjected to major changes, how
will peoples health be influenced by these
changes?
Additional info
McMichael (2003): Climate change
and human health Risks and responses.
Geneva, WHO. www.who.int/globalchange/publications/cchhbook/en/index.
html (last accessed 15.07.08)
WHO/UNICEF (2006): Meeting the MDG
drinking water and sanitation target: The
urban and rural challenge of the decade.
Geneva. www.who.int/water_sanitation_
health/monitoring/jmp2006/en/ (last
accessed 15.07.08)
Climate change
Occupation
Radiation
Recreational environment
Chemicals
Noise
Disease or risk
Risk factor
Air pollution, water quality and the aforementioned environmental health factors
are specifically related to certain diseases (cf. Table 2). The most relevant
environmental health risk factors comprise a lack of sanitation and safe water
quality, which lead to a large number of
diseases.
Table 1 reveals that diarrhoeal diseases, intestinal nematode infections,
trachoma, schistosomiasis, lymphatic
filariasis, and malnutrition are attributable to a fraction of more than 25% to
the risk factor water, sanitation and hygiene.
The number of deaths attributable to
environmental factors is especially high
in developing countries: The number of
deaths caused by diarrhoeal diseases in
2002 amounted to over 1.5 million in developing countries, as opposed to less
than 20 000 in developed countries. This
difference (factor 75) is extremely high
despite the fact that the population in
developing countries is 3.5 times higher than in industrialised nations. (Prssstn et al., 2006, p.82)
Hence, provision of safe drinking water and improved sanitation, as well as
promotion of good hygiene practices in
developing countries, are the most important interventions to reduce the burden of these and other diseases. This
module focuses on diseases attributable to water and sanitation, on disease-causing pathogens and their main
transmission routes, as well as on hygiene approaches aiming at reducing the
burden of diseases. Detailed medical aspects of the diseases, such as pathogen
effects inside the body, disease treatment by pharmaceuticals or disease prevention by vaccines are not discussed in
this module.
Our focus is the environmental health aspect of sanitation, water treatment and storage, hygiene promotion,
stormwater drainage, and solid waste management. The module centres on diseases attributable to these
aspects, on related disease-causing pathogens and their main transmission routes and on hygiene approaches
aiming at reducing the disease burden. The chemical hazards of drinking water are also elucidated.
Lower respiratory
Upper respiratory
Diarrhoeal diseases
Malaria
Intestinal nematode infections
Trachoma
Schistosomiasis
Chagas disease
Lymphatic filariasis
Onchocerciasis
Leishmaniasis
Dengue
Japanese encephalitis
Sexually transmitted diseases
HIV
Hepatitis B and C
Tuberculosis
Perinatal conditions
Congenital anomalies
Malnutrition
Cancer
Neuropsychiatric disorders
Cataracts
Deafness
Cardiovascular diseases
Chronic obstructive pulmonary
disease
Asthma
Musculoskeletal diseases
Physical inactivity
Road traffic accident
Falls
Drowning
Fires
Poisonings
Other unintentional injuries
Violence
Suicide
: <5%
: 5 25%
: >25%
Risk factors
Related diseases
Lead
Climate change
Additional info
Cairncross (2003): Health, environment
and the burden of disease; A guidance
note. London, DFID. www.dfid.gov.uk/
Pubs/files/healthenvirondiseaseguidenote.
pdf (last accessed 15.07.08)
Unintentional injuries
Noise
Hearing loss
Carcinogenics
Cancers
Airborne particulates
Ergonomic stressors
Table 2: Diseases related to different risk factors. (Prss-stn et al., 2006, p.27)
Further questions
Can these water-related diseases also
be prevented by other means than water
and sanitation?
Besides health aspects, what are the
other problems caused by inadequate
water and sanitation services?
Further questions
Can the Millennium Development Goals
be attained by 2015?
How can water and sanitation improvements contribute to the other Millennium
Development Goals, i.e. eradicate extreme
poverty and hunger (MDG 1), achieve
universal primary education (MDG 2),
promote gender equality and empower
women (MDG 3), combat HIV/AIDS,
malaria and other diseases (MDG 6),
and develop a Global Partnership for
Development (MDG 8)?
Additional info
UN (2007): The Millennium Development Goals Report 2007. www.un.org/millenniumgoals/pdf/mdg2007.pdf (last
accessed 15.07.08)
WHO/UNICEF (2006): Meeting the MDG
drinking water and sanitation target: The
urban and rural challenge of the decade.
Geneva. www.who.int/water_sanitation_
health/monitoring/jmp2006/en/ (last
accessed 15.07.08)
The so-called Brown Agenda was established to reach the objectives of environmental health. It focuses on environmental health as defined above, whereas
the Green Agenda is concerned with
the health of the environment. Of course,
control of environmental pollution is
likely to benefit both, however, the priorities of the two agendas sometimes differ. The major health impacts are usually caused by factors affecting people in
their homes or in their neighbourhoods,
whereas the most obvious effects on the
environment in general are relatively remote from them. The difference is illustrated by Figure 5. It illustrates the urban
environment as a series of concentric domains, from the individual household to
the city as a whole and its environs. A
citys environmental infrastructure, such
as water supply, sewerage, drainage,
and refuse collection systems, is organised in a hierarchy corresponding to
these domains. In general, the closer to
the households, the greater the health
impact of environmental changes. Environmentalists are, however, more concerned with the surrounding natural environment, such as the river. Thus, the
Green Agenda might favour wastewater
treatment to reduce environmental pollution, whereas the Brown Agenda would
give priority to getting human waste and
excess water away from households and
residential neighbourhoods, even at the
cost of polluting some local streams.
(Cairncross et al., 2002, p.9)
Human health
Ecosystem health
Timing
Immediate
Delayed
Scale
Local
Worst affected
Lower-income groups
Future generations
Further questions
What makes it so difficult to reconcile both agendas?
Is implementation of the Brown Agenda alone a selfish measure with regard to future
Additional info
Cairncross (2002): Environmental health and the poor our shared responsibility.
www.lboro.ac.uk/well/ (last accessed 15.07.08)
IIED (2006): Environment & Urbanization Brief 13. Ecological Urbanization. Environment
& Urbanization 18(1). www.iied.org/pubs/ (last accessed 15.07.08)
Download available on the CD of Sandecs Training Tool and from the Internet.
2 Introduction
0%
1%
2%
3%
4%
5%
Frac tion of to tal global burden of diseas e in D ALYs *
Environment al f raction
6%
7%
Non-environment al f raction
Figure 6: Diseases with the largest environmental contribution. (Prss-stn et al., 2006, p. 11)
(For each disease the fraction attributable to environmental risks is shown in dark green. Light
green plus dark green represents the total burden of disease).
* DALY or Disability-Adjusted Life Year represents a weighted measure of death, illness and
disability (cf. Chapter 2.3).
Local differences
The burden of disease is not evenly distributed in the world. Developing regions carry a disproportionately heavy
burden regarding communicable diseases and injuries. In 2002, infectious diseases made up the largest overall difference between the regions (as classified
by WHO). The total number of healthy
life years lost (DALYs) per capita as a result of environmental burden per capita
was 15 times higher in developing countries than in developed nations. The en-
risks and access to health care services. The world map, containing the environmental disease burden in deaths per
100 000 people, illustrates significant subregional differences. (Prss-stn et
al., 2006, p.11)
2 Introduction
O ther; 19 %
Ot her; 3 4%
Diarrhoeal
diseases; 2 9%
Ma lnutrition; 4%
Childhood clus ter
diseases; 5 %
Ma laria; 5 %
Perina tal
conditions ; 6%
Total neuropsychiatric
disorders; 6 %
Figure 8: Main diseases contributing to the environmental burden of diseases for the total population (left) and among children between 0 and 14
years of age (right). (Prss-stn et al., 2006, p. 62)
What are the specific differences in exposure to environmental risks between developed and developing regions?
By far not all people in developing countries can afford to visit a doctor in case of
illness. How does this affect statistics?
How wrong do you think they are and how
could statistics be improved?
Download available on the CD of Sandecs Training Tool and from the Internet.
2 Introduction
Injuries
9%
Indoor smoke
30%
Malnutrition
42%
Other
13%
Environmental
Health
21%
Unsafe water
& sanitation
48%
Sexual Health
issues
19%
Figure 9: The global disease burden, classified by risk factors, reveals that 21% are associated to
environmental health. In this category, almost half the disease burden can be attributed to unsafe
water and sanitation. (WHO, 2002 in Cairncross et al., 2003, p.2)
Health impact
The map (figure 10) reveals that the proportion of DALYs attributable to the risk
factor unsafe water is particularly high
in Africa, some parts of Asia and South
America.
Figure 11 illustrates the high extent
of diarrhoea morbidity reduction through
intervention activities in sanitation, water treatment and hygiene. Figure 12 reveals the impact of improved water supply, sanitation and hygiene on morbidity
and mortality for six common diseases
and child mortality.
Figure 10: Burden of disease attributable to unsafe water (% DALYs in each subregion, DALY: cf.
Chapter 2.3). (WHO, 2002, p.69)
45
Reduction (%)
39
32
25
Improved
drinking
water
Improved
sanitation
Improved Household
water
hygiene
treatment
78
77
Further questions
How meaningful are the aforementioned
studies on different disease-reducing
interventions? What are their impacts and
limitations?
The burden of disease attributable to
unsafe water is only shown at the global
and regional level. What are the differences at the local level?
55
29
27
26
4
Ascariasis Diarrhoeal
disease
(4)
(19)
Trachoma Child
(7)
mortality
(6)
Additional info
WHO/UNICEF (2005): Water for Life
Making it happen. WHO/UNICEF, Geneva. www.who.int/water_sanitation_health/
monitoring/jmp2005/en/index.html (last
accessed 15.07.08)
Download available on the CD of Sandecs
Training Tool and from the Internet.
11
2 Introduction
The concept of the DALY (DisabilityAdjusted Life Year) was introduced in the
Global Burden of Disease Study in an effort to finding a common measure to assess priorities among different diseases
and health problems. Murray and Lopez
did not think it appropriate or necessary
to attach a monetary value to the burden
of disease. They developed the DALY as
an alternative, a concept that takes the
lost life years as a benchmark and includes the following design decisions:
Ideal lifespan. This was needed in
order to define the age before which
death could be regarded as premature, and years of life considered lost.
It was set at 82.5 years for women,
and 80 for men, to correspond with
the averages for Japan.
Value of a healthy year of life. Not
all years of life were considered of
equal value. This was taken as 0 at
birth, rising steeply to a peak of 1.5
times the average at age 22, and gradually declining to 0.5 at age 80.
Effect of socio-economic or ethnic
status. None was allowed. A decision
was taken to value all peoples health
equally, except for the age and gender
effects mentioned above.
Value of life with disability. A system of weighting was devised for 22
indicator conditions, agreed by consensus at a meeting of a group of 8 to
12 health workers. The idea was that
these weightings could be extended
or interpolated to other conditions by
analogy. The 22 indicator weightings
are shown in the table 4.
Value today vs value in the future.
A discount rate of 3% was applied to
the data. This was needed to compare interventions with delayed effects. For example, hepatitis immunisation helps to prevent deaths from
liver cancer occurring 20 to 30 years
later.
(Cairncross et al., 2003, p.53)
Calculation
DALYs for a disease or health condition
are calculated as the sum of the years of
life lost due to premature mortality (YLL)
in the population, and the years lost due
to disability (YLD) for incident cases of
the health condition:
The disability weight is a weight factor that reflects the severity of the disease on a scale from 0 (perfect health) to
1 (dead). The table below lists the disability weights for several diseases or
Disability class
1
Severity
weight
Indicator
conditions
0.00 0.02
Vitiligo on face,
weight-for-height
< 2 s.d.
0.02 0.12
0.12 0.24
Watery diarrhoea,
severe sore throat,
severe anaemia
Radius fracture in a
stiff cast, infertility,
erectile dysfunction, rheumatoid
arthritis, angina
0.24 0.36
Below-the-knee
amputation, deafness
0.36 0.50
0.50 0.70
0.70 1.00
Active psychosis,
dementia, severe
migraine, quadriplegia
Further questions
What are the limitations of the DALY
concept? What factors are missing?
Is it ethically correct to value a life year
of a disabled person at a lower number
than that of a healthy person?
Additional info
Robberstad (2005): QALYs vs DALYs
vs LYs gained: What are the differences, and what difference do they make for
health care priority setting? Norsk Epidemiologi 15(2): 183-191. www.ub.ntnu.no/
journals/norepid/2005-2/052_11_Robberstad.pdf (last accessed 15.07.08)
Download available on the CD of Sandecs
Training Tool and from the Internet.
2 Introduction
2.4 What are the main causes for water and sanitation-related
diseases?
Diseases can be classified by their transmissibility into communicable (e.g. caused by microbiological
contamination of drinking water) and non-communicable (e.g. caused by chemicals in drinking water).
Diseases can be divided into communicable diseases, such as typhus or hookworm infection, and non-communicable
disease, such as diabetes or heart disease. The communicable diseases can
spread rapidly through direct person-toperson contact (e.g. the rotavirus), or
they can be transmitted indirectly, for example through human contact with water contaminated by humans excreting
Communicable
diseases
Non-communicable diseases
Microbiological
contaminants in
drinking water
Chemical
contaminants in
drinking water
Pathogens
Viruses
Bacteria
Protozoa
Helminth eggs
Origins
Natural
Agriculture
Human
settlements
Industry
Further questions
Could animals play a role in transmission routes?
What are possible transmission routes from faeces to fields, or from faeces to fluids?
Additional info
See later in this module.
2 Introduction
If a person comes into contact with pathogens, this does not necessarily mean
that an infection occurs. Several factors
at the pathogen and host level influence
transmission and infection (cf. Figure
16). Agricultural or aquacultural use of
excreta and wastewater can, for example, only lead to an actual risk to public
health if all of the following occurs:
a) Either an infective dose of an excreted pathogen reaches the field or
pond or the pathogen multiplies in
the field or pond to form an infective
dose.
b) This infective dose reaches a human
host.
c) This host becomes infected.
d) This infection causes disease or further transmission.
(a), (b) and (c) constitute the potential risk and (d) the actual risk to public
health. If (d) does not occur, the risks
to public health remain only potential.
(Strauss, 1994, p.1)
Different pathogen factors contribute
to the potential risk: The excreted load
is the number of pathogens excreted in a
certain amount of waste. The time needed until the excreted pathogens become
infective is described as latency. Multiplication describes whether the pathogens can multiply outside the host, and
finally the infective dose expresses the
number of pathogens required to cause
an infection.
Pathogen factors
Host factors
Excreted load
Natural immunity
Latency
Persistence
Multiplication
Infective dose
Health state
Nutrition
Possible health
outcome
No transmission
Transmission and
symptomless
infection
Transmission
and infection
with manifest
sickness
Die-off or persistence of excreted pathogens is an important factor influencing transmission. In principle, all
pathogens die off upon excretion. Prominent exceptions are pathogens whose
intermediate stages multiply in intermediate hosts, as Schistosoma that multiply
in aquatic snails and are later released
into the water body. Another important
factor is the infective dose of a pathogen. It is the dose required to create disease in a human host. For helminths,
protozoa and viruses, the infective dose
is low (<10 2 ). For bacteria, it is medium (10 4 ) to high (>10 6 ). Manifestation of disease is different for the various pathogens: with viruses, protozoa
and bacteria, an infected person will either become sick or not. With helminths,
however, an infected person will exhibit various degrees of disease intensities
depending on the number of worms it
carries in its intestine. Thus, implementation of a nightsoil or wastewater treatment strategy, leading to a reduction
In temperate
climate
(10 15C)
In moderate
climate
(20 30C)
Viruses
<100
<20
Salmonella
<100
<30
Cholera
<30
<5
Faecal
coliforms*
<150
<50
<30
<15
2 3 years
10 12
months
Bacteria
Protozoa
Amoebic
cysts
Helminths
Ascaris eggs
2 Introduction
Further questions
What factors other than lack of water
and sanitation services could be responsible for the increased disease burden in
emergency situations?
What measures should be taken in such
situations?
Additional info
Connolly (2005): Communicable disease
control in emergencies A field manual,
WHO. www.who.int/hac/techguidance/pht/
communicable_diseases/field_manual/en/
(last accessed 15.07.08)
Photo 5: Washing facility in a temporary refugee camp. (Source: WEDC Bob Reed)
2 Introduction
Wastewater
components
Faeces
Urine
Greywater
Industrial
wastewater
Stormwater
Table 6: Main risks from different wastewater components. (Heeb et al., 2007, Module 4-5)
Photo 6: Woman emptying compost in Dhaka, Bangladesh. (Source: Eawag/San- Photo 7: Man working in a compost container in India. (Source:
dec)
Eawag/Sandec)
2 Introduction
Area or activity
leading to pathogen
exposure
Toilet
Transmission route
Technical measure
Behavioural measure
Direct contact.
Direct contact.
Consumption; contamination of
kitchen.
Primary handling
collection and transport
Treatment
Secondary handling
use, fertilising
Fertilised field
Fertilised crop
Additional info
Schnning (2004): Guideline for the
safe use of urine and faeces in ecological sanitation systems. Stockholm, Swedish Institute for Infectious Disease Control
(SMI). www.ecosanres.org/pdf_files/ESRfactsheet-05.pdf (last accessed 15.07.08)
Download available on the CD of Sandecs
Training Tool and from the Internet.
Photo 8: Farmers using compost on their fields in India. (Source: Eawag/Sandec)
3 Diseases
Classification of diseases into communicable (pathogen-related) and non-communicable (e.g. caused by exposure to
chemicals) was discussed in the chapter Definitions. The communicable
diseases can be further subdivided. This
chapter describes the currently used environmental classification and uses the
biological classification to discuss the
different diseases.
An environmental classification of disease groups, such as water-related and
excreta-related diseases, is more useful to environmental engineers than one
based on biological types because it
groups the diseases into categories of
common environmental transmission
routes. Thus, an environmental intervention designed to reduce transmission of
pathogens in a particular category is likely to be effective against all pathogens
in that category, irrespective of their biological type.
An important distinction is made
between waterborne and waterwashed diseases. Water-borne diseases are caused by pathogens in the water
a person drinks. Whereas water-washed
diseases are diseases where transmission is facilitated by insufficient quantities of water (regardless of its quality),
thus, directly linked to issues of personal and domestic hygiene. All diseases, commonly considered waterborne,
can also be transmitted by the waterwashed route. Epidemiological studies
have revealed that the latter is more
important under conditions of water
scarcity, such as in rural and periurban areas of developing countries. The
water-washed transmission route is likely to be important even in areas with
adequate water supplies but poor
personal and/or domestic (including
food) hygiene. Table 8 provides an overview of an environmental classification
of water and excreta-related diseases.
(Mara et al., 1999, p.334)
Further questions
Is it better to use unsafe water to wash
hands than no water at all?
Examples of pathogens
(Bold = described in this
Module)
Hepatitis A and E (virus)
Rotavirus
Cholera (bacterium)
Amoebiasis (protozoa)
Ascariasis (helminth)
Non-feco-oral water-washed
Skin infection:
diseases
Leprosy (bacterium)
Eye infection:
Control strategies
Trachoma (bacterium)
Geohelminthiases
Ascariasis (helminth)
Hookworm infection
(helminth)
Water-based diseases
Legionellosis (bacterium)
Clonorchiasis (helminth)
Schistosoma (helminth)
Ingestion or
through skin
Insect-vector diseases
Water-related:
Malaria (protozoa)
Dengue (virus)
Yellow fever (virus)
Excreta-related:
Fly-borne and cockroachborne excreted infections.
Rodent-vector diseases
Rodent-borne excreted
infections.
Taeniases
3 Diseases
3.2 What are the main microbial hazards associated with water
and excreta?
Viruses
Since viruses are infectious sub-microscopic agents lacking an independent metabolism, they can only grow
or reproduce within a living host cell and cannot multiply within the environment. Many viruses are hostspecific, causing disease in humans or specific animals only. Rotaviruses and hepatitis A and E viruses are
the most relevant water and excreta-related viruses.
Rotavirus
Rotavirus can infect people of all ages,
as well as many animals, however, in
humans its primary targets are infants,
the elderly, and people with compromised immune systems, as seen in
AIDS. Human rotaviruses are the most
important single cause of infant death
in the world. Typically, 50 60% of cases of acute gastroenteritis of hospitalised children throughout the world are
caused by human rotaviruses. By the age
of three, most children have been infected at least once by rotavirus, with a significant number infected two or more
times. Although no natural immune state
exists for rotavirus, secondary infections
are usually less severe than primary infections. The viruses infect cells in the
villi of the small intestine, with disruption of sodium and glucose transport.
Acute infection has an abrupt onset of
severe watery diarrhoea with fever, abdominal pain and vomiting. Though easily treated with intravenous fluids in developed nations, these supplies are often
3 Diseases
lated to one another, are both transmitted via the faecal-oral route, most often
through contaminated water and from
person to person. Both hepatitis A and E
are found worldwide. Hepatitis A is particularly frequent in countries with poor
sanitary and hygienic conditions. Countries with economies in transition and
some regions of industrialised countries
with sub-standard sanitary conditions
are also highly affected, e.g. in southern
and eastern Europe and some parts of
the Middle East. Outbreaks of hepatitis
E have occurred in Algeria, Bangladesh,
China, Ethiopia, Indonesia, Iran, Libyan Arab Jamahiriya, Mexico, Myanmar,
Nepal, Pakistan, Somalia, and the Central Asian Republics of the CIS. The mortality rate is low (0.2% of icteric cases)
and the disease ultimately resolves. Occasionally, extensive necrosis of the liver
occurs during the first 6 8 weeks of illness. In such cases, high fever, marked
abdominal pain, vomiting, jaundice, and
hepatic encephalopathy (with coma and
seizures) are the signs of fulminant hepatitis, leading to death in 70 90%
of the patients. In these cases, mortality is highly correlated with increasing age, and survival is uncommon over
50 years of age. Among patients with
chronic hepatitis B or C or underlying
liver disease, who are super infected
with hepatitis A virus, the mortality rate
increases considerably. Hepatitis E is
mainly found in young to middle-aged
adults. Women in the third trimester of
pregnancy are especially susceptible to
acute fulminant hepatitis arising from
hepatitis E infection. <www> (WHO,
2008f)
Dengue virus
Dengue is transmitted by the bite of an
Aedes mosquito infected with any one of
the four dengue viruses. It occurs in tropical and sub-tropical areas of the world.
Symptoms appear 3 14 days after the
infective bite. Dengue fever is a febrile
illness that affects infants, young children and adults. Symptoms range from
a mild fever, to incapacitating high fever, with severe headache, pain behind
the eyes, muscle and joint pain, and rash.
There are no specific antiviral medicines
for dengue. It is important to maintain
hydration. Dengue haemorrhagic fever
(fever, abdominal pain, vomiting, bleeding) is a potentially lethal complication,
Photos 9: Examples of mosquito breeding sites for dengue. <www> (WHO, 2008f)
3 Diseases
Bacteria
Bacteria are microorganisms a few micrometers in size and of varying shapes, such as spheres, rods or spirals.
Unlike animal cells, they do not contain a nucleus (prokaryotes). Bacteria are ubiquitous: growing in soil, in
the deep ocean or even in acidic hot springs. A gram of soil or a millilitre of water can contain several million
bacterial cells. Though the vast majority is harmless or even beneficial to humans, a few can cause diseases,
such as cholera, trachoma or salmonellosis.
Vibrio cholerae
Cholera is an acute diarrhoeal infection
caused by ingestion of the bacterium
Vibrio cholerae. Transmission occurs
through direct faecal-oral contamination
or via ingestion of contaminated water
and food. The disease is characterised in
its most severe form by a sudden onset
of acute watery diarrhoea that can lead
to death by severe dehydration and kidney failure. The extremely short incubation period two hours to five days enhances the potentially explosive pattern
of outbreaks, as the number of cases
can rise very quickly. About 75% of people infected with cholera do not develop any symptoms. However, the pathogens stay in their faeces for 7 to 14 days
and are shed back into the environment,
potentially infecting other individuals.
Cholera is an extremely virulent disease
that affects both children and adults.
Unlike other diarrhoeal diseases, it can
kill healthy adults within hours. Individuals with lower immunity, such as malnourished children or people with HIV,
are at greater risk of death if infected by
cholera. Cholera is mainly transmitted
through contaminated water and food
3 Diseases
Chlamydia trachomatis
Trachoma is the result of infection of the
eye with Chlamydia trachomatis. Infection spreads from person to person, and
is frequently passed from child to child
and from child to mother, especially in
areas of water shortage, numerous flies
and crowded living conditions.
Infection often begins during infancy
or childhood and can become chronic.
If left untreated, the infection eventually causes the eyelid to turn inwards and
the eyelashes to rub on the eyeball, resulting in intense pain and scarring of the
front of the eye. This ultimately leads to
irreversible blindness, typically between
30 and 40 years of age. <www> (WHO,
2008f)
Trachoma: Facts & figures
500 million people are at risk from
trachoma.
Photo 10: Variable-sized flies on the face of a child infected by trachoma in Gambia.
(Source: Johnson, 2004, Fig. 17)
Diarrhoea (can be caused by several viruses, bacteria or protozoa): Facts & figures
1.8 million people die every year from diarrhoeal diseases (including cholera); 90% are
children under five, mostly in developing countries.
88% of diarrhoeal diseases are attributed to unsafe water supply, inadequate sanitation
and hygiene.
(WHO, 2004)
Protozoa
Protozoa are one-celled eukaryotes (in contrast to prokaryotic cells, such as bacteria, eukaryotic cells
contain a nucleus) about 10 50 micrometers in size. Many protozoa are parasitic, such as plasmodium
(malaria), entamoeba histolytica (amoebiasis), and giardia lamblia (giardiasis), and can affect human health.
Some protozoa have the ability to form a cyst to survive harsh conditions, such as exposure to extreme
temperature, chemicals or long periods without water or food. In parasitic species, the cyst allows survival
outside the host and transfer from one host to another.
Entamoeba histolytica
Person-to-person contact and contamination of food by infected food handlers
appear to be the most significant means
of transmission, although contaminated
water also plays a substantial role. Ingestion of faecally contaminated water and
consumption of food crops irrigated with
contaminated water can both lead to
transmission of entamoeba histolytica.
Sexual transmission, particularly among
male homosexuals, has also been documented. (WHO, 2006, p.266)
3 Diseases
Ascaris lumbricoides
Ascariasis is an infection of the small intestine caused by Ascaris lumbricoides,
a large roundworm. Children are infected
more often than adults, the most common age group being 3 8 years. The infection is likely to be more serious if nutrition is poor. They often become infected
upon putting their hands to their mouths
after playing in contaminated soil. Eating
uncooked food grown in contaminated
soil or irrigated with inadequately treated wastewater is another frequent avenue of infection. The first sign may be
the passage of a live worm, usually in
the faeces. In a severe infection, intestinal blockage may cause abdominal pain,
particularly in children. People may also
experience cough, wheezing and difficulty in breathing or fever. Ascariasis is
found worldwide. Infection occurs with
greatest frequency in tropical and subtropical regions, and in any areas with inadequate sanitation. Worldwide, severe
Ascaris infections cause approximately
60 000 deaths per year, mainly in chil-
Hookworm
Figure 19: Life cycle of Ascaris lumbricoides.
<www> (CDC; WHO, 2008f)
dren. Infected individuals (and domestic animals) should be treated with medicine to reduce disease transmission.
Ascaris lumbricoides is the largest
nematode parasitising the human intestine. (Adult females: 20 35 cm;
adult males: 15 30 cm.). Adult worms
live in the lumen of the small intestine.
A female may produce approximately
200 000 eggs per day, which are passed
with the faeces. Unfertilised eggs
may be ingested but are not infective.
Fertile eggs embryonate and become infective after 18 days to several weeks,
depending on the environmental conditions (optimum: moist, warm, shaded
3 Diseases
Guinea worm
Dracunculiasis is an infection with Dracunculus medinensis, a nematode worm.
It is caused by drinking water containing
water fleas (Cyclops species) that have
ingested Dracunculus larvae.
In the human body, the larvae are released and migrate through the intestinal
wall into body tissues, where they develop into adult worms. The female worms
move through the persons subcutaneous tissue, causing intense pain, and
eventually emerge through the skin, usually at the feet, producing oedema, a blister and eventually an ulcer, accompanied
by fever, nausea and vomiting. If they
come into contact with water as they are
emerging, the female worms discharge
their larvae, setting in motion a new life
cycle. There are no drugs available for
the treatment of this disease. However,
Further questions
Could the use of disinfected drinking
water especially for children lead to
missing immunisation in adult age?
What happens if medical treatment,
such as antibiotics against bacteria, is applied on a large scale? What is the risk of
bacteria becoming resistant?
Schistosoma
Schistosomiasis or bilharzia is a parasitic
disease caused by trematode flatworms
of the genus Schistosoma. Larval forms
of the parasites, which are released by
freshwater snails, penetrate the skin of
people in the water. In the body, the
larvae develop into adult schistosomes,
which live in the blood vessels. The females release eggs, some of which are
passed out of the body in the urine
or faeces. Others are trapped in body
tissues, causing an immune reaction.
In urinary schistosomiasis, there is progressive damage to the bladder, ureters
and kidneys. In intestinal schistosomiasis, there is progressive enlargement of
the liver and spleen, intestinal damage
and hypertension of the abdominal blood
vessels. Control of schistosomiasis is
based on drug treatment, snail control,
as well as improved sanitation and health
education. <www> (WHO, 2008f)
Additional info
WHO (2006): Guidelines for drinking water quality [electronic resource]: incorporating first addendum. Vol. 1, Recommendations. 3rd ed. Geneva, WHO. www.
who.int/water_sanitation_health/dwq/gdwq0506begin.pdf (last accessed 15.07.08)
Download available on the CD of Sandecs
Training Tool and from the Internet.
WHO, World Health Organization,
<www> www.who.int/en/
3 Diseases
Sources
Examples
Arsenic
Naturally occurring
chemicals (including
algal toxins)
Chemicals from
agricultural
activities (including
pesticides)
Application of
manure, fertilisers
and pesticides,
intensive animal production practices.
Chemicals from
human settlements (including
those used for public health purposes,
e.g. vector control)
Chemicals from
industrial activities
Manufacturing,
processing and
mining.
Chemicals from
water treatment and
distribution
Water treatment
chemicals; corrosion
of and leaching from
storage tanks and
pipes.
3 Diseases
Fluoride
Ingestion of excess fluoride, most commonly in drinking water, can cause
fluorosis that affects the teeth and
bones. Moderate amounts lead to dental
effects, but long-term ingestion of large
amounts can lead to potentially severe
skeletal problems. Paradoxically, low
levels of fluoride intake help to prevent
dental caries. The control of drinking water quality is therefore critical in preventing fluorosis. Chronic high-level exposure
to fluoride can lead to skeletal fluorosis. In skeletal fluorosis, fluoride accumulates progressively in the bone over
many years. The early symptoms include
stiffness and pain in the joints. In severe
cases, the bone structure may change
and ligaments may calcify, with resulting
impairment of muscles and pain. People
affected by fluorosis are often exposed
to multiple sources of fluoride, such as
in food, water, air (due to gaseous industrial waste), and excessive use of
ed, defluoridation may be the only solution (cf. defluoridation filters in Module
3). Mothers in affected areas should be
encouraged to breastfeed since breast
milk is usually low in fluoride. <www>
(WHO, 2008f)
Fluorosis: Facts & figures
Over 26 million people in China suffer
from dental fluorosis due to elevated
fluoride in their drinking water.
In China, over 1 million cases of skeletal
fluorosis are thought to be attributable
to drinking water.
The principal mitigation strategies
include exploitation of deep-seated
water, use of river water, reservoir
construction, and defluoridation.
(WHO, 2004)
Lead
Exposure to lead causes a variety of
health impairments, particularly among
children. Water is rarely an important
source of lead exposure except where
lead pipes are common, such as in old
buildings. Removal of old pipes is costly but the most effective measure to
reduce lead exposure from water.
Too much lead can damage the nervous and reproductive systems and the
kidneys, and can cause high blood pressure and anaemia. Lead accumulates in
the bones and lead poisoning may be
diagnosed from a blue line around the
gums. Lead is especially harmful to the
developing brains of foetuses and young
children and to pregnant women. Lead
interferes with the metabolism of calcium and vitamin D. High blood lead
levels in children can cause consequences which may be irreversible, including
learning disability, behavioural problems,
and mental retardation.
A recent report suggests that even a
blood level of 10 micrograms per decilitre can have harmful effects on childrens learning and behaviour. <www>
(WHO, 2008f)
3 Diseases
Nitrate
Nitrate and nitrite are naturally occurring
ions that form part of the nitrogen cycle.
Nitrate is used mainly in inorganic fertilisers. The nitrate concentration in groundwater and surface water is normally low
but can reach high levels as a result of
leaching or runoff from agricultural land
or contamination from human or animal
waste as a consequence of the oxidation
of ammonia and similar sources. (WHO,
2006, p.417)
The main disease associated with
high nitrate levels in drinking water is
methaemoglobinemia. It is characterised by reduced ability of the blood to
carry oxygen due to reduced levels of
normal haemoglobin. Infants are most
often affected and may seem healthy
but show signs of blueness around the
mouth, hands and feet, hence the common name blue baby syndrome. These
children may also have trouble breathing as well as vomiting and diarrhoea. In
extreme cases, there is marked lethargy, an increase in the production of saliva, loss of consciousness and seizures.
Some cases may be fatal. Methaemoglobinaemia is now rare in most of the
industrialised countries due to control
of nitrate contamination in water supplies, although occasional cases continue to be reported from rural areas. It is a
risk in developing countries, for example
where the drinking water is from shallow
wells in farming areas. <www> (WHO,
2008g)
Additional info
WHO (2006): Guidelines for drinking water quality [electronic resource]: incorporating first addendum. Vol. 1, Recommendations. 3rd ed. Geneva, WHO. www.
who.int/water_sanitation_health/dwq/gdwq0506begin.pdf (last accessed 15.07.08)
Download available on the CD of Sandecs
Training Tool and from the Internet.
4 Hygiene Approaches
The most effective ways of reducing disease transmission is to erect primary barriers to prevent pathogens from entering
the environment. This can be done by:
Washing hands with soap after defecation or after cleaning childrens bottoms after their defecation.
Constructing sanitation facilities to
prevent the spread of diseases by
flies and contamination of drinking
water, fields and floors.
Where sanitation facilities are badly
planned and constructed, poorly maintained, used wrongly or not used at all,
their construction can set up further
potential disease transmission routes,
and lead to contamination of the environment. Selection of the right technologies, good design, appropriate use
and proper management are required
to protect against these additional risks.
(WHO, 2005, p.10)
Primary interventions with the greatest impact on health often relate to the
management of faeces at the household level. This is because (a) a large percentage of hygiene-related activity takes
place in or close to the home and (b)
first steps to improving hygienic practices are often easiest to implement at the
household level. However, to achieve full
health benefits and in the interest of human dignity, other sources of contamination and disease also need to be managed, such as:
Sullage (dirty water that has been
used for washing people, clothes,
pots, pans etc).
Drainage (natural water that falls as
rain or snow).
Solid waste (also called garbage,
refuse or rubbish).
All these sources of contamination must
be managed in all the locations where
they are generated.
Thus, a full-scale programme to
improve hygiene would need to address
the management of excreta, sullage,
drainage, and solid waste at the following levels:
idemiological studies, it seems reasonable to conclude that the hygiene practices of prioritisation should be those that
constitute the primary barriers to pathogen transmission. These practices prevent faecal material from entering the
domestic environment of the susceptible
child. Human stools should be regarded
as the public enemy number one. (Curtis
et al., 2000, p.30)
Interventions to establish primary and
secondary barriers comprise hardware
approaches, such as water supply and
sanitation facilities and services, as well
as software approaches of hygiene
behaviour. Cf. Modules 3 7 for details about the approaches related to water treatment, sanitation, excreta, faecal sludge or solid waste management,
and the planning approaches. Motivation
and implementation of hygiene promotion are described in this Module.
An additional approach to reducing
the burden of diseases is the preventive
use of vaccines and disease-treatment
with pharmaceutical drugs. This does
not only protect the individual person
from illness, but can also help to interrupt the transmission route of diseases
and thus benefit the entire community
(despite the risk of pathogens becoming
resistant to the drugs).
Further questions
Engineers building water treatment and
sanitation facilities need to understand all
the transmission routes: Building a septic
tank without air-ventilation does not solve
the problem of fly transmission. How realistic is implementation of the required
interdisciplinary approach?
Additional info
Curtis, Cairncross et al. (2000): Review:
Domestic hygiene and diarrhoea pinpointing the problem. Tropical Medicine
& International Health 5(1): 22-32. www3.
interscience.wiley.com/journal/119190686/
abstract (last accessed 16.07.08)
Download available on the CD of Sandecs
Training Tool and from the Internet.
4 Hygiene Approaches
Additional info
WHO (2005): Sanitation and hygiene
promotion. Programming guidance. Geneva, WHO. www.who.int/water_sanitation_
health/hygiene/sanitpromotionguide/en/index.html (last accessed 16.07.08)
Download available on the CD of Sandecs
Training Tool and from the Internet.
4 Hygiene Approaches
Photo 18: Children in Karnataka, India, playing with water. (Source: Marcel Kessler)
4 Hygiene Approaches
Further questions
Dont people in developing countries have their own, culturally individual hygiene behaviour? Dont people feel patronised and restricted in their independence if told how to behave?
Hygiene workshops and implementation of hygiene behaviour can be very time-consuming.
How is this time investment compensated?
Who should be conducting hygiene promotion in the villages outsiders or locals? Whose
teaching is more effective?
Additional info
Appleton and Sijbesma (2005): Hygiene promotion. Thematic overview paper 1. Delft, IRC.
www.irc.nl/content/download/23457/267837/file/TOP1_HygPromo_05.pdf (Iast accessed
16.07.08)
Conant (2005): Sanitation and Cleanliness for a healthy environment. Berkeley, Hesperian
Foundation. www.hesperian.info/assets/environmental/EHB_Sanitation_EN_lowres.pdf (Iast
accessed 16.07.08)
Conant and Fadem (2008): A Community Guide to Environmental Health. Berkeley, Hesperian Foundation. www.hesperian.info/assets/EHB/EnviroBook4DL.pdf (Iast accessed 16.07.08)
Download available on the CD of Sandecs Training Tool and from the Internet.
4 Hygiene Approaches
Photo 20: Monitoring of a mapping exercise with children in Ethiopia. (Source: Kar, 2008)
Generally, monitoring observes a situation for any changes that may occur
over time, using one or more appropriate
measuring device. Evaluation in contrast
is the systematic determination of the
merit and significance of something.
It is essential to monitor key results
(ideally improved health) to ensure
that public investments result in public
benefits. However, monitoring long-term
health trends is difficult and can probably only be the subject of periodic evaluations. Instead, it is often more practical to measure service coverage, use of
facilities and hygiene behaviour. (WHO,
2005, p.57). Monitoring systems provide
a rapid and continuous assessment of
what is happening. Monitoring is primarily needed at the project level to show
whether:
Inputs (investments, activities, decisions) are being made as planned.
Inputs are leading to expected outputs
(latrines built, behavioural change).
Inputs are being made within the
agreed vision and rules.
Evaluation provides a more systematic
assessment of whether visions and objectives are being met in the long run and
in the most effective manner possible.
(WHO, 2005, p.56)
Further questions
Hygiene promotion programmes are
often implemented within a specific framework along with technical water and sanitation improvements. In many cases, it is
ethically unjustifiable to conduct real experiments, i.e. experiments with a test or
control group. How can the health effect of
hygiene promotion alone be evaluated?
What objectives other than improved
health does hygiene promotion have?
Additional info
WHO (2005): Sanitation and hygiene
promotion. Programming guidance. Geneva, WHO. www.who.int/water_sanitation_
health/hygiene/sanitpromotionguide/en/index.html. (last accessed 16.07.08)
Download available on the CD of Sandecs
4 Hygiene Approaches
To ensure that hygiene approaches are implemented and effective along with hardware and hygiene promotion, political,
socio-cultural and economic aspects also
have to be considered. The so-called Hygiene Improvement Framework is a useful conceptual model for planning and implementing water and sanitation projects
(cf. Figure 23). The three components,
i.e. access to hardware, hygiene promotion and enabling environment, are all
appropriate. Health and hygiene efforts
can have positive results even if not accompanied by hardware interventions in
sanitation and water provision. However,
an integrated programme with all three
components would be ideal. (Appleton
et al., 2005, p.13)
Communication
Hygiene
Social mobilization
Promotion
Improved sanitation
facilities
Community participation
Household technologies
and materials
Social marketing
Soap
Safe water containers
Effective water treatment
Advocacy
Hygiene
Diarrheal Disease Prevention
Policy improvement
Enabling
Institutional strengtening
Environment
Community organization
Financing and cost
recovery
Crosssector & PP partnerships
Figure 23: The hygiene improvement framework. (WHO, 2005, p.14)
In addition to direct hygiene and healthrelated objectives, there may also be wider developmental objectives: strengthen
the sense of community and community
action, increase the analytical, managerial and problem solving capacities of community members, reduce inequalities
between genders and social and economic groups, enhance self-confidence
and self-respect of various groups, including those that are disadvantaged or
marginalised.
Community-managed hygiene promotion programmes are best undertaken
with relatively well-organised communities with active leaders and their own
resources. The communities need not
be homogeneous and well off, but unity and solidarity have to be sufficiently
strong. Otherwise, interested communities may first need to demonstrate that
they can form active organisations and
effectively manage some form of locally initiated change. A community may
vary from a single neighbourhood or village to administrative clusters, covering
a number of distinct settlements. In the
latter case, there are often two organisational layers:
The organisation at the neighbourhood
or village level organises the participatory planning, implementation and
monitoring.
The organisation at the overall community level manages the overall programme, dealing with such aspects
as aggregation or co-ordination of
lower level plans, contracting and procurement, financial management, and
accounting for their work to the contributing male and female heads of
households.
Community organisations that manage
local hygiene promotion must represent
the different interest groups and capabilities in their neighbourhood, village
or larger settlement. Typically, members are women and men from the difSandec Training Tool: Module 2 33
4 Hygiene Approaches
Intervention
Cost-effectiveness
(US$ per DALY
averted)
Cholera
immunisation
1658 8274
Rotavirus
immunisation
1402 8357
Measles
immunisation
257 4565
Oral rehydration
therapy
132 2570
Breastfeeding
promotion
527 2001
270
House connection
water supply
223
Hand pump or
standpost
94
47
Sanitation promotion
11.15
Socio-cultural aspects
Those who plan, implement, manage,
and study hygiene improvements often
want to educate people by informing
them about the interrelation of good hygiene and improved health. However,
local people themselves often do not
consider health benefits as the primary
reason for improving their hygiene or for
investing in improved water and sanitation facilities.
These views are in many ways quite
right. The different transmission patterns
for different diseases reveal that improvements may depend on large numbers of people changing a wide range of
risky behaviours and conditions. It thus
seems paradox that the quickest and
4 Hygiene Approaches
Zimbabwes community health clubs create demand for better hygiene and sanitation
In rural Zimbabwe, community health clubs (CHCs) have been set up to change health
behaviour and increase demand for better sanitation. A study of the clubs impact suggests
that they have helped to change up to 17 key hygiene practices. This approach could now be
replicated in other countries. Researchers at the London School of Hygiene and Tropical
Medicine report from rural Zimbabwe where a model of community mobilisation is working to
change hygiene and sanitation practices.
The project began in 1995 in the form of a pilot study and has since led to the creation of hundreds of CHCs across rural Zimbabwe. The CHCs are voluntary groups led by local health
technicians. CHCs aim to improve health and sanitation in villages by providing information
and group support through weekly meetings. The study reports on the results of this approach in two rural districts with more than 13 000 CHC members. The researchers found
that:
The CHCs were very popular and increased the sense of unity within communities.
Participants felt a sense of achievement from improving their hygiene practices through the
clubs.
Women were more prominent in CHCs in communities where men were absent. Participation in the clubs increased womens confidence and social standing in their communities.
Many families who attended the clubs improved their sanitation practices, including the
correct methods of hand-washing with soap. Families who had no access to latrines began
to practise faecal burial.
Levels of demand for sanitation and latrines increased substantially in the population. As a
result, 47% of the population in the areas with functioning CHCs had access to latrines as
compared to 2% in the non-CHC control area.
In sum, the study found that CHCs were an effective way to improve the sanitation and
hygiene practices in poor rural areas because they create a culture of cleanliness among a
population. It also showed that a strong community structure may help improve sanitation and
hygiene behaviour. <www> (Waterkeyn et al., 2005) and (id21)
Further questions
Why are the very cost-effective hygiene
approaches not established globally?
Why do some people have difficulties in
making the link between the diseases
occurring in their families or communities
and their hygiene behaviour?
Additional info
Appleton and Sijbesma (2005): Hygiene promotion. Thematic overview paper
1. Delft, IRC. www.irc.nl/content/download/23457/267837/file/TOP1_HygPromo_
05.pdf (last accessed 16.07.08)
WHO (2005): Sanitation and hygiene
promotion. Programming guidance. Geneva, WHO. www.who.int/water_sanitation_
health/hygiene/sanitpromotionguide/en/index.html (last accessed 16.07.08)
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