GY339 Water &

Health

Experiences of excreta-related
diseases in less-economically
developed countries

15th May 2017

"Water and Sanitation is one of the primary drivers of public health...once we can
secure access to clean water and to adequate sanitation facilities for all people,
irrespective of the difference in their living conditions, a huge battle against all kinds
of diseases will be won." Dr Lee Jong-wook, Director-General, WHO
Lecture outline

Water-related diseases (waterborne, water-washed, water-

related insect vector and water-based)
Excreta-related diseases
Water quality or water quantity?
Experiences of overseas fieldwork
Water-Related Diseases
1. Diseases related to chemical quality of water e.g. high arsenic, mercury

2. Diseases caused by pathogenic micro-organisms associated with water

Viruses
Bacteria
Protozoa
Helminths (worms)

3. Non-communicable diseases due to lack of sufficient water for hygiene

e.g. certain cancers

In less developed countries diseases caused by pathogenic micro-organisms

are most important (they cause more deaths and illnesses).
Water-related diseases are responsible for 80% of all illnesses in developing
countries, and kill more than five million people every year (UNESCO, 2007).
Water-Related Diseases
Amoebic dysentery, Ascariasis, Bacillary dysentery
(Shigellosis), Cholera, Conjunctivitis,
Cryptosporidiosis, Dengue fever, Diarrhoeal disease,
Enterobiasis, Enterovirus infections, Gastroenteritis,
Giardiasis, Guinea worm, Infectious hepatitis,
Legionnaires disease, Leptospirosis, Malaria,
Onchocerciasis, Paratyphoid, Trichuriasis, Typhoid,
Scabies, Schistosomiasis, Skin Sepsis and Ulcers,
Yellow fever..
Lists of diseases are not useful!
Nor are lists of the causative organism (i.e. bacteria,
virus, helminth etc)
Classification of Water-Related Diseases

What is required?
an environmental classification which groups
diseases according to

common environmental transmission patterns

Environmental Classification
Developed by Professor David Bradley (London School of
Hygiene and Tropical Medicine) in East Africa in late 1960s.

Represented a major advance in our

understanding of the relationship between
water and disease.

Helps engineers to choose the

correct public health technology
Environmental Classification of
Water-Related Diseases*
FOUR CATEGORIES

I. Waterborne diseases (drinking water)

II. Water-washed diseases (caused by lack of adequate volumes of
water for personal and domestic hygiene)

III. Water-based diseases (caused by aquatic organisms that spend part of

their life cycle in water and another part as parasites and are nearly all helminthic
diseases)

IV. Water-related insect vector diseases

I. Waterborne diseases
Caused by pathogens present in drinking water

Sources of pathogens: faecal material (either direct

faecal contamination or indirect e.g. leaking pit latrine,
or cattle run-off)
Examples of diseases which can be waterborne:

Cholera- Vibrio Cholerae

Typhoid- Salmonella typhi
Shigellosis (bacillary dysentery)- Shigella
Enteroviral diseases Poliovirus, Coxsackie
Giardiasis - Giardia lamblia
Cryptosporidiosis - Cryptosporidium
Guinea worm - Dracunculus medinensis
Guinea worm (parasitic worm)
Dracunculus medinensis, waterborne helminthic disease
Life cycle: female worms (up to 1m long) form a blister
in legs or feet; larvae shed from blister when in contact
with water; larvae eaten by water fleas in water; people
infected by drinking water containing these water fleas
Guinea worm control
Narrow wall around well
(so people cannot stand on it)
Thereby preventing larvae
getting into the water

Simple plastic water filter

to remove the water fleas prior
to drinking.
The Worlds Largest Waterborne
Disease Outbreak Milwaukee, 1993 USA
Filter malfunction at water treatment works
Cryptosporidiosis is a diarrhoeal disease caused by microscopic
parasites of the genus Cryptosporidium
Extremely resistant to chlorine
Symptoms 2 to 10 days after initial infection
Symptoms: watery diarrhoea, dehydration,
weight loss, stomach cramps, nausea,vomiting
>400,000 people infected (approx 70 deaths)
Estimated cost 47 million
 Waterborne diseases are obviously very important

But more important are water-washed diseases

which form category ii of Bradleys environmental
classification
II. Water-washed diseases
Caused by lack of adequate volumes of
water for personal and domestic hygiene,
e.g. trachoma, scabies and other skin and eye infections
Typhoid, cholera, shigellosis, enteroviral diseases, giardiasis,
ascariasis
i.e. all the Waterborne diseases
 HANDWASHING
is really important in the prevention of water-washed
disease transmission
Scabies
Infection of the skin caused by scabies mite
Sarcoptes scabiei females burrow into the skin and
lay their eggs causing the typical scabies rash

Females: 0.3-0.4 mm
Trachoma
Caused by the bacterium Chlamydia trachomatis
Worlds leading cause of preventable blindness (public health
efforts reduced no. of sufferers by 80% in last 20 years, but still
80 million infected and 2 million blind!)
Waterborne or water-washed?
In low income communities water-washed diseases are likely to
be more important than waterborne diseases

Why? Because the transmission route is basically the same

Both waterborne and water-washed* diseases are Faeco-oral
diseases

* Except skin and eye infections

If water is scarce then the water-washed routes are the most

likely, and the waterborne route least likely (but of course possible
e.g. if a shallow well is too close to a pit latrine)
However.
If water quality is particularly poor, then disease transmission
can be substantially reduced using simple in-house treatment,
E.g. filtration through 4 layers of old sari material

Source: Colwell, R et al., 2003. Reduction of cholera in Bangladeshi villages by simple

filtration. Proceedings of the National Academy of Sciences of the United States of
America. 100 (3), 1051-1055.
III. Water-based diseases
These are all* helminthic (worm) diseases e.g. Schistosomiasis
(via snails), Oriental liver fluke (raw fish), Fasciolopsiasis
(aquatic plants)
The pathogen spends part of its life cycle in one or more
intermediate aquatic hosts (e.g. aquatic snails in which massive
asexual multiplication takes place)

*Except legionellosis and leptospirosis

which are bacterial diseases
Schistosomiasis (Bilharzia)
Parasitic infection
Human (faeces or urine) > Water > Snail > Water > Human
250 million people (74 countries) suffer from schistosomiasis,
mostly those living by slow-moving bodies of water

The impact of schistosomiasis, long underestimated, rivals that of malaria and

tuberculosis
Schistosomiasis
IV. Water-related insect vector
diseases
Vector breeds in water
E.g. Malaria, filariasis
Vector bites near water
E.g. African trypanosomiasis

Some vectors can do both!

E.g. blackflies (Simulium)

responsible for onchocerciasis
 Onchocerciasis (River blindness)
- Chronic, nonfatal disease caused by the
filarial worm Onchocerca volvulus. Adult
worms survive in nodules in the body.
Female worm discharges microfilariae that
migrate to skin & eye.
Spread only by the bite of the female
blackfly (Simulium) that breed in fast-
running rivers & streams.

Vector control and use of drugs (ivermectin) has reduced disease burden
Fear of blindness has led to a depopulation of the fertile river valleys of the west African
savannah making onchocerciasis an obstacle to socio-economic development
Preventative strategies for the control of
excreta-related diseases
Transmission Preventative strategy
mechanism
Waterborne - improve water quality
- Prevent use of unimproved sources
Water-washed - improve water quantity
- improve its accessibility
- improve hygiene
Water-based - decrease the need for water contact
- Control snails
- improve quality
Water-related - destroy breeding sites
insect vectors - decrease need to visit breeding sites
- improve surface water management
Water supply improvements
Immediate aims and benefits
Primary aims
Improve: quality, quantity, availability, reliability

Secondary aims
Save time and energy expended in water collection (labour
release, increased food, crop innovation)
Improve health
Important considerations
In order to achieve these aims & benefits
Require active community participation & support
Must observe local traditions, religious beliefs etc.
Appropriate technology
Must not create new health hazards (e.g. insect vector
breeding)
Water supply development must be part of integrated rural
development plan
Sanitary surveying
What are the 6 issues here?

Image courtesy of WEDC. Rod Shaw.

Sanitary surveying

Excellent Very poor

Figure 2. Sanitary surveys
were conducted in order to
assess the condition of each
water point and to quantify
the level of likely risk from
contamination sources
Simple sanitary
scoring of
water pumps
can be a
surrogate for
expensive and
unachievable
water testing
 Reducing excreta-borne diseases in rural communities in
semi-arid climates: Evidence to support the formulation of
household WASH safety plans

Mario Peres
Environmental and Public Health
Research Group (EPRHeG) - UoB
 Introduction

Brazilian semi-arid

Source: ANA/MI.
 600
Progression of diarrhoeal diseases in the
Number of acute diarrhoeal

past 11 years
500

400
cases

300

200

100 Nova
Picu
0
2006 2007 2008 2009 2010 2011 2012 2013 2014 2015 2016
Year
 Development of Methodology

Advanced
QMRA
(risk assessment)

Faecal indicator

Intermediate
organisms
(hazard screening of
critical-control-points)

Community survey

Basic
(identification of exposure pathways and
behaviour)
Water sources and Sampling
Water sources and Sampling
Water sources
Water sources
Water sources
 Household and Sanitary Survey

87% - two or three water sources

79% - at least two water storage systems
Buckets (89%) vs. hand pumps (14%)
HRW, TW and DW for drinking
POU treatment (50%)
89% - pour-flush toilet - soakaways
Sanitary inspection
Microbiological analyses
 Microbiological monitoring results
Low detection of somatic coliphages (19% - SS and 20% - DWSC)

Roof run-off
Tankered harvested
Desalinated
water (Army rainwater
water
operation)
4
3.5
4

3.0

3
3
2.5 E. coli vs. IE
Log10 (CFU/100 mL)

2.0
2
2
1.5
Increase level of
1.0
1
FIO in the SS?
0.5

0.0
0

DWSC
DWSC
DWSC SS SS
WSWS DWSC
DWSC
DWSC SS WS
SS WS
E.E.coli
coli Intestinal
Intestinal enterococci
enterococci
 Domestic water-use routes in rural communities

Irrigation Personal hygiene Domestic hygiene Food preparation Drinking

Water Supply System in Rural Communities
Microbial Transmission Routes at the Household Level
Thank you!
Mario Rodrigues Peres
EPHReG SET
University of Brighton
m.peres@brighton.ac.uk
Tel.: +44 1273 643455
Learning resources
Cairncross, S., and Feachem, R. (1993). Environmental Health Engineering in the Tropics. Chapter 1. Engineering and infectious
disease. Wiley, UK.
Mara, D.D. (1996). Low-cost Urban Sanitation. Chapter 2: Sanitation and Health. Wiley, UK.
UNESCO, (2007). UNESCO Water Portal newsletter No.161: Water-related Diseases. (Accessed Oct 2012)
http://www.unesco.org/water/news/newsletter/161.shtml

http://www.youtube.com/watch?v=YQ44_UaNTvU
Malaria prevention film

http://www.youtube.com/watch?v=BwxmJ0NhNJI
Now that there are point-of-care rapid diagnostic tests for malaria, health care providers face a new and daunting
challenge.

http://www.youtube.com/watch?v=A2-XTlHBf_4
A quick introduction to the complex lifecycle of the malaria parasite. The narration is by Dr. Joe Cohen, co-inventor of
the RTS,S malaria vaccine candidate.

http://www.youtube.com/watch?v=pl9I9IScutY
Bacteria is a music video for the Jonathan Coulton song of the same title. Footage was captured from The Sims 2.
Music is from JonathanCoulton.com and is released under a Creative Commons Attribution-Noncommercial license.

http://www.youtube.com/watch?v=5Xi2Nc1UicQ&list=PLg4wHw0EwqfGTmLmqcw6DbnSCNbpcm_-r
A song about how bacteria multiply exponentially. Bugs are everywhere!

http://www.youtube.com/watch?v=bQYu-pG8ofg
Researchers at the Universidade Estadual do Ceara in Fortaleza, Brazil are investigating new community and
environmental approaches to reduce the numbers of mosquitoes that can carry dengue.
https://www.youtube.com/watch?v=f-nICK2XaNs
 Combining the results of the many studies and reviews conducted, it becomes evident that
improvements in excreta management, hygiene and water supply may reduce diarrhoeal morbidity,
diarrhoea mortality and child mortality by significant amounts (WHO 1993).
For example, Esrey et al.(1991) found reductions in diarrhoea mortality and overall child mortality
of 65% and 55% respectively when improved water and sanitation were introduced.

However, the size of the impact is likely to vary according to a wide range of factors, including
current sanitary conditions, food supply, education level and uptake of new facilities and
behaviours. Clearly, tackling the problem at source assists in reducing transmission via all routes.
Source: WEDC, 2011
http://wedc.lboro.ac.uk/resources/factsheets/FS009_FDI_A3_Poster.pdf
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