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19 June 2018

Water, Sanitation and Health

Author/Compiled by
Gina S. Itchon (Xavier University)
Robert Gensch (Xavier University)
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Introduction
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In most developing countries, perhaps most easily discernible in the poorest countries, unclean water and poor sanitation exposes billion of men, women and children to a plethora of diseases that debilitate them and greatly reduce their productivity. These diseases even hasten the death of those with compromised immune systems such as small children, the malnourished and HIV/AIDS patients. Despite advances in science, engineering and legal frameworks, the majority of the wastewater from piped sewerage systems in the world is released into the environment without adequate treatment (UJANG & HENZE 2006). The same is true for most pit latrines and sludge management systems. Only a small percentage of global wastewater is treated using advanced sanitation facilities, mainly in developed countries. Faecal pathogens are transferred to the waterborne sewage system through flush toilets or latrines, and these may subsequently contaminate surface waters and groundwater (PRUESS-UESTUEN & CORVALAN 2006) (see also water pollution).

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Prevalence of waterborne diseases
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dirty water kills

Dirty water causes more deaths every year than armed conflicts. Source: WSSCC (2007)

As a result, the majority of the world’s population is still exposed to waterborne diseases, and the quality of water sources has been rapidly degraded, particularly in poor developing countries (UJANG & HENZE 2006). UNDP (2006) describes unclean water as an immeasurable greater threat to human security than violent conflict. In addition to unclean water, lack of sanitation and poor hygiene are responsible for the transmission of diarrhoea, cholera, typhoid and several parasitic infections (UN 2005).

Moreover, WHO (1997) shows that the incidence of these diseases and others linked to poor hygiene and sanitation e.g. round worm, whip worm, guinea worm, and schistosomiasis is highest among the poor, especially school-aged children. These diseases have a strong negative impact on the health and nutrition of children and their learning capacities, and contribute to significant absences from school (NOKES & BUNDY 1993). Most significant, however is the persistence and wide distribution of diarrhoeal disease throughout the developing world.

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Effects of water related diseases

Water related diseases cost 443 million school days each year, and children in poor health suffer from reduced cognitive potential. This hurts their prospects for future earnings and makes continuing poverty more likely (BORKOWSKI 2006). About 3.5 billion people in the world are infected with helminth worm parasites (CHAN 1997; CAPRON 2004; MIGUEL & KREMER 2004; UNESCO 2006). These parasitic helminth infections often lead to severe consequences such as cognitive impairment, massive dysentery, anaemia and death of around 9400 people every year (WHO 2004). In Sub-Saharan Africa, schistosomiasis kills more than 200,000 people every year (UTZINGER & KEISER 2004). Infectious diarrhoea can be caused by bacteria (e.g. E. coli, shigellosis), viruses (e.g. norovirus, rotavirus), and protozoan parasites (e.g. amoebiasis, cryptosporidiosis) (OECD 2007). Acute diarrhoea, as occurs in cholera, if left untreated can cause death within a day or less and has devastating impact on children (UNICEF 2006) (see also economic issues).

Due to the interconnectedness between water, sanitation, health and poverty, lack of safe water supply and proper sanitation has much wider impacts than on just health alone. Large-scale death and poor health are not only matters in its own right but also act as a brake on economic development (WAGSTAFF & CLAESON 2004). The interconnectedness and the impacts that unsafe water and inadequate sanitation have on human health and general well-being makes it absolutely necessary to deal with all these issues or concerns together. Water quality and sanitation are irrevocably intertwined. Poor sanitation leads to water contamination. In many parts of the world, the main source of water contamination is due to sewage and human waste (MOE & RHEINGANS 2006). Unsafe water and inadequate sanitation disproportional impacts the poor in particular. About 2/3 of people without access to a protected water source (piped water or a protected well) live on less than US$2 a day (BORKOWSKI 2006). Adequate water supplies improve the prospects of new livelihood activities, which are otherwise denied, and are often key step out of poverty (UNESCO 2006).

The relationship between the health status and the sanitation coverage can be seen in the figure below:

under five mortality compared to sanitation coverage

Under 5 mortality compared to sanitation coverage for individual developing countries. Each point is a single country with countries in Sub-Saharan Africa as red diamonds. Source: ROSEMARIN (2008); WHO/UNICEF (2008) 

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Effects of water related diseases
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UNDP (2006) emphasises that clean water and proper sanitation can make or brake human development. Furthermore, the combination of poverty, poor health and lack of hygiene means that children from unserved homes, miss school more frequently than those whose families do benefit from improved drinking water and sanitation services. The resulting lack of education and social development further marginalises the children and reduces their future chances of self-improvement (WHO/UNICEF 2005) (see also hygiene frameworks and approaches).

Learn more about health risk management in water and sanitation.

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Conclusion
Library References

Unsafe Water, Sanitation and Hygiene: Associated Health Impacts and the Costs and Benefits of Policy Interventions at the Global Level

OECD (2007): Unsafe Water, Sanitation and Hygiene: Associated Health Impacts and the Costs and Benefits of Policy Interventions at the Global Level, Working Party on National Environmental Policies. Organisation for Economic Cooperation and Development

Progress on Sanitation and Drinking-Water. 2010 Update

This well illustrated report describes the status and trends with respect to the use of safe drinking-water and basic sanitation, and progress made towards the MDG drinking-water and sanitation target. It presents some striking disparities: the gap between progress in providing access to drinking-water versus sanitation; the divide between urban and rural populations in terms of the services provided; differences in the way different regions are performing, bearing in mind that they started from different baselines; and disparities between different socioeconomic strata in society. Each JMP report assesses the situation and trends anew and so this JMP report supersedes previous reports (e.g. from 2004, 2006 and 2008).

WHO ; UNICEF (2010): Progress on Sanitation and Drinking-Water. 2010 Update, Geneva: World Health Organisation (WHO) / New York: UNICEF URL [Accessed: 14.04.2011]
Further Readings

An integrated approach to peri-urban sanitation and hygiene in Maputo

This topic brief documents the approach, outcomes and learning of an integrated sanitation and hygiene programme implemented in Maputo, Mozambique during the period 2013-2017. The programme was funded by the World Bank-managed Japanese Social Development Fund (JSDF) and implemented by WSUP and the Water and Sanitation Program (WSP) of the World Bank.

DRABBLE, S. and PARENTE, V. ; (2018): An integrated approach to peri-urban sanitation and hygiene in Maputo , Water & Sanitation for the Urban Poor (WSUP) URL PDF

Toward a hygienic Environment for Infants and young Children: A Review of the Literature

The USAID Water, Sanitation, and Hygiene Partnerships and Learning for Sustainability (WASHPaLS) project conducted a review of the scientific and grey literature, complemented by dozens of key informant interviews with researchers and field implementers, to synthesize the latest understanding of key pathways of fecal microbe ingestion by infants and young children (IYC) and their links to diarrhea, EED, and poor nutrition and development outcomes.

The findings of the literature review will inform the design of research to measure the additive effects of specific measures to reduce IYC exposure to fecal pathogens and other fecal microbes in their home environments when coupled with independent or integrated WASH and nutrition interventions.

ISRAEL, M. et al. ; (2017): Toward a hygienic Environment for Infants and young Children: A Review of the Literature, USAID URL PDF

Hygiene, Sanitation, and Water: Forgotten Foundations of Health

This is the introductory article in a four-part PLoS Medicine series on water and sanitation. It highlights the massive disease burden associated with deficient hygiene , sanitation and water supply, which would be largely preventable. The total benefits of improved water, sanitation and hygiene are much greater than merely health benefits. The article calls for making water, sanitation and hygiene development priorities.

BERTRAM, J. ; CARINCROSS, S. (2010) Hygiene, Sanitation, and Water: Forgotten Foundations of Health, In: PLoS Med. 7 ,11 . URL [Accessed: 25.11.2010]

How to integrate water, sanitation and hygiene into HIV programmes

This document integrates Water, Sanitation and Hygiene (WASH) practices into HIV care. It draws on experiences from the USAID-funded Hygiene Improvement Project (USAID/HIP) . It contains guidance on implementing priority WASH practices, including WASH in global and national HIV/AIDS policy and guidance, and integrating WASH–HIV programmes.

BERY, R. ; ROSENBAUM, J. ; (2010): How to integrate water, sanitation and hygiene into HIV programmes, Geneva: Geneva, Switzerland, World Health Organization (WHO) URL [Accessed: 25.01.2011]

Hygiene, Sanitation, and Water: What Needs to Be Done?

This is the last article in a four-part PLoS Medicine series on water and sanitation. It considers what needs to be done to make significant progress towards ensuring universal access to hygiene, sanitation, and water in each sector itself, and then discusses which actors need to be involved to achieve an impact. Finally, the importance of the health sector in improving hygiene, sanitation, and water worldwide and propose a detailed Agenda for Action.

CAIRNCROSS , S. ; BARTRAM, J. ; CUMMING, O. ; BROCKLEHURST, C. (2010) Hygiene, Sanitation, and Water: What Needs to Be Done?, In: PLoS Med. 7 ,11 . URL [Accessed: 25.11.2010]

Productive Sanitation and the Link to Food Security

This factsheet provides information on the link between sanitation and agriculture as well as related implications on health, economy and environment. It shows examples of treating and using treated excreta and wastewater in a productive way and describes the potential for urban agriculture and resource recovery in rural areas. Institutional and legal aspects, business opportunities and how to manage associated health risks are also discussed

GENSCH, R. ; DAGERSKOG, L. ; WINKLER, M. ; VEENHUIZEN, R. van ; DRECHSEL, P. ; (2011): Productive Sanitation and the Link to Food Security, Sustainable Sanitation Alliance (SuSanA) URL [Accessed: 22.05.2012]

Healthy Wetlands, Healthy People: A Review of Wetlands and Human Health Interactions

Despite the production of more food and extraction of more water globally, wetlands continue to decline and public health and living standards for many do not improve. Why is this – and what needs to change to improve the situation? If we manage wetlands better, can we improve the health and well-being of people? Indeed, why is this important? This report seeks to address these questions.

HORWITZ, P. ; FINLAYSON, M. ; WEINSTEIN, P. ; (2012): Healthy Wetlands, Healthy People: A Review of Wetlands and Human Health Interactions, Ramsar Technical Report No. 6. Gland and Geneva: Secretariat of the Ramsar Convention on Wetlands and The World Health Organization (WHO) URL [Accessed: 05.03.2012]

Water Supply and Health

This article is part of a four-part PLoS Medicine series on water and sanitation. It summarises the importance of a safe and reliable water supply for h man health, and highlight the negative effects of poor water supply. Furthermore, the article also discusses the reasons for the limited progress towards universal access to adequate aware supply and highlights that strenuous efforts are needed to improve the situation.

HUNTER, P.R. ; MACDONALD, A.M. ; CARTERM R.C. (2010) Water Supply and Health, In: PLoS Med. 7 ,11 . URL [Accessed: 25.11.2010]

The Humanure Handbook

A comprehensive book on recycling human excrement without chemicals, high technology or pollution. Well written, practical, and thoroughly researched, this self-published book is built on nearly twenty years of experience by the author, who tells us about every aspect of dealing with excrement on the home-scale level. Only available for free as web book.

JENKINS, J. ; (2005): The Humanure Handbook, A Guide to Composting Human Manure. (= 3rd Edition ). Grove City: Joseph Jenkins Inc. URL [Accessed: 16.08.2010]

Global Review of Sanitation System Trends and Interactions with Menstrual Management Practices

The problem with disposing of menstrual waste into pit latrines is that it causes the pits to fill up faster. The excreta in the pit decompose and decrease in volume, while the non-biodegradable components of menstrual waste accumulate and do not break down. Furthermore, once the sludge has been removed from the pit latrine, if it is to be used in agriculture, any waste that has not completely decomposed such as menstrual pads must be removed before the sludge can be composted or applied to farmland. The cost to remove, screen, and dispose of menstrual management products from pit latrine sludge is high and not accounted for.

KJELLEN, M. ; PENSULO, C. ; NORDQVIST, P. ; FODGE, M. ; (2012): Global Review of Sanitation System Trends and Interactions with Menstrual Management Practices, Report for the Menstrual Management and Sanitation Systems Project . Stockholm: Stockholm Environment Institute URL [Accessed: 15.01.2013]

Sanitation and Health

This is one article in a four-part PLoS Medicine series on water and sanitation. It highlights that by the end of 2010, still 2.6 billion people in the world lack adequate sanitation. While in the past, government agencies have typically built sanitation infrastructure, there is now a larger focus on helping people to improve their own sanitation situation. The article further highlights the many benefits improved sanitation has on health.

MARA, D. ; LANE, J. ; SCOTT, B. ; TROUBA, D. (2010) Sanitation and Health, In: PLoS Med. 7 ,11 . URL [Accessed: 25.11.2010]

Benefits of Investing in Water and Sanitation

The report highlights that overall benefits from investing in water and sanitation are likely to be large, but that there are wide variations depending on the type of investments made along the water and sanitation services “value chain” and the local conditions.

OECD (2011): Benefits of Investing in Water and Sanitation, An OECD Perspective. Paris: Organisation for Economic Co-Operation and Development (OECD) Publishing URL [Accessed: 22.06.2011]

Toilets for health

This is a comprehensive report on why toilets matter. The report is rich in infographics, provides overview of the sanitation crisis and the related burden of disease in developing countries.

ROMA, E. ; PUGH, I, ; (2012): Toilets for health, London: London School of Hygiene & Tropical Medicine URL [Accessed: 27.11.2012]

Microbial Exposure and Health Assessments in Sanitation Technologies and Systems

This book focuses on the health factors related to pathogenic organisms. The attempt is to assess and review evidences in relation to health impact and to discuss the findings based on epidemiological evidence, risk assessment and behavioural aspects and practices.

STENSTROEM, A. ; SEIDU, R. ; EKANE, M. ; ZURBRUEGG, C. ; (2011): Microbial Exposure and Health Assessments in Sanitation Technologies and Systems, (= EcoSanRes Series , 1 ). Stockholm: Stockholm Environment Institute (SEI) URL [Accessed: 28.11.2011]

Hygiene framework

This document sets out WaterAid’s framework for hygiene promotion and behaviour change in the countries where it works. It will also help organisations that work on hygiene in the context of water, sanitation and hygiene (WASH) programmes.

WATERAID (2012): Hygiene framework, London: WaterAid URL [Accessed: 29.01.2013]

Sanitation Matters - A Magazine for Southern Africa

Content in this issue: A Tool For Measuring The Effectiveness Of Handwashing p. 3-7; Five Best Practices Of Hygiene Promotion Interventions In the WASH Sector p. 8-9; Washing Your Hands With Soap: Why Is It Important? p. 10-11; Appropriate Sanitation Infrastructure At Schools Improves Access To Education p. 12-13; Management Of Menstruation For Girls Of School Going Age: Lessons Learnt From Pilot Work In Kwekwe p. 14 -15; WIN-SA Breaks The Silence On Menstrual Hygiene Management p. 16; Joining Hands To Help Keep Girls In Schools p. 17; The Girl-Child And Menstrual Management :The Stories Of Young Zimbabwean Girls. p. 18-19; Toilet Rehabilitation At Nciphizeni JSS And Mtyu JSS Schools p. 20 - 23; Celebratiing 100% sanitation p. 24 - 26.

WATER INFORMATION NETWORK (2012): Sanitation Matters - A Magazine for Southern Africa, South Africa: Water Information Network URL [Accessed: 27.06.2012]

Progress on Sanitation and Drinking-Water. 2010 Update

This well illustrated report describes the status and trends with respect to the use of safe drinking-water and basic sanitation, and progress made towards the MDG drinking-water and sanitation target. It presents some striking disparities: the gap between progress in providing access to drinking-water versus sanitation; the divide between urban and rural populations in terms of the services provided; differences in the way different regions are performing, bearing in mind that they started from different baselines; and disparities between different socioeconomic strata in society. Each JMP report assesses the situation and trends anew and so this JMP report supersedes previous reports (e.g. from 2004, 2006 and 2008).

WHO ; UNICEF (2010): Progress on Sanitation and Drinking-Water. 2010 Update, Geneva: World Health Organisation (WHO) / New York: UNICEF URL [Accessed: 14.04.2011]

Handwashing With Soap Toolkit

This toolkit, intended for practitioners interested in behavior change, is organized into four modules: Behaviour Change, Sustainability, Integration and Results. Each has reports and presentations about the lessons learned from previous projects, as well as mass media, direct consumer contact, and interpersonal communication tools used throughout previous projects.

WORLD BANK ; (2013): Handwashing With Soap Toolkit, Washington: World Bank URL [Accessed: 15.05.2013]

Hygiene Promotion

The benefits of hygiene promotion are generally not prioritized and the costs of hygiene promotion are poorly understood and therefore not adequately budgeted into programming. In this study WASHCost examined hygiene promotion and associated costs in Ghana, Mozambique, and Burkina Faso, looking at interventions that targeted latrine use and faecal containment, hand washing with soap, and the protection of drinking water.

IRC ; (2013): Hygiene Promotion, How Effective Is It? How Much Does It Cost? . (= WASHCost Infosheet , 5 ). The Hague: International Water and Sanitation Center (IRC) URL [Accessed: 07.08.2013]

Exploring Changes in Open Defecation Prevalence in Sub-Saharan Africa Based on National Level Indices

This study estimates the changes in open defecation prevalence between 2005 and 2010 across countries in Sub-Saharan Africa. It also explores the association between national level indices and changes in open defecation prevalence and assesses how many countries can achieve “open defecation free status” by 2015.

GALAN, D.I. ; KIM, S. ; GRAHAM, J.P. (2013) Exploring Changes in Open Defecation Prevalence in Sub-Saharan Africa Based on National Level Indices, In: BMC Public Health. 13 ,1-12 . URL [Accessed: 28.08.2013]

Water, Sanitation, Hygiene and Enteric Infections in Children

This article reviews the evidence linking water, sanitation and health measures to faecal-oral diseases in children. Estimates of the burden of water-, sanitation- and health-related disease are presented, followed by brief overviews of water, sanitation and hygiene-related transmission routes and control measures. It concludes with a summary of current international targets and progress.

BROWN, J. ; CAIRNCROSS, S. ; ENSINK, J.H.J. (2013) Water, Sanitation, Hygiene and Enteric Infections in Children, In: Arch Dis Child. ,1-6 . URL [Accessed: 28.08.2013]

Predicting Water Consumption Habits for Seven Arsenic-Safe Water Options in Bangladesh

In Bangladesh, 20 million people are at the risk of developing arsenicosis because of excessive arsenic intake. Despite increased awareness, many of the implemented arsenic-safe water options are not being sufficiently used by the population. This study investigated the role of social-cognitive factors in explaining the habitual use of arsenic-safe water options.

INAUEN, J. ; TOBIAS, R. ; MOSLER, H.-J. (2013) Predicting Water Consumption Habits for Seven Arsenic-Safe Water Options in Bangladesh, In: BMC Public Health. 13 ,1-10 . URL [Accessed: 28.08.2013]

Interventions to Improve Water Quality and Supply, Sanitation and Hygiene Practices, and Their Effects on the Nutritional Status of Children

Water, sanitation and hygiene interventions are frequently implemented to reduce infectious diseases, and may be linked to improved nutrition outcomes in children. The objective of this paper is to evaluate the effect of interventions to improve water quality and supply, provide adequate sanitation and promote handwashing with soap, on the nutritional status of children under the age of 18 years and to identify current research gaps.

DANGOUR, A.D. ; WATSON, L. ; CUMMING, O. ; BOISSON, S. ; CHE, Y. ; VELLEMAN, Y. ; CAVILL, S. ; ALLEN, E. ; UAUY, R. ; (2013): Interventions to Improve Water Quality and Supply, Sanitation and Hygiene Practices, and Their Effects on the Nutritional Status of Children, (= Cochrane Database of Systematic Reviews 2013 , 8 ). Chichester: John Wiley & Sons URL [Accessed: 05.09.2013]

How much International Variation in Child Height Can Sanitation Explain?

Physical height is an important economic variable reflecting health and human capital. Puzzlingly, however, differences in average height across developing countries are not well explained by differences in wealth. This paper provides the first documentation of a quantitatively important gradient between child height and sanitation that can statistically explain a large fraction of international height differences.

SPEARS, D. ; (2013): How much International Variation in Child Height Can Sanitation Explain?, (= Policy Research Working Paper , 6351 ). Washington: The World Bank Water and Sanitation Program (WSP) URL [Accessed: 23.09.2013]

Interventions to Improve Water Quality for Preventing Diarrhoea

Diarrhoeal diseases are a leading cause of mortality and morbidity, especially among young children in developing countries. While many of the infectious agents associated with diarrhoeal disease are potentially waterborne, the evidence for reducing diarrhoea in settings where it is endemic by improving the microbiological quality of drinking water has been equivocal. The aim of the present study is to assess the effectiveness of interventions to improve water quality for preventing diarrhoea.

CLASEN, T.F. ; ROBERTS, I.G. ; RABIE, T. ; SCHMIDT, W.P. ; CAIRNCROSS, S. (2009) Interventions to Improve Water Quality for Preventing Diarrhoea, In: The Cochrane Library. . URL [Accessed: 30.09.2013]

Safe Management of Wastes from Health-care Activities

In many countries, knowledge about the potential for harm from health-care wastes has now become more prominent to governments, medical practitioners and civil society. The indiscriminate and erratic handling and disposal of waste within health-care facilities is now widely recognized as a source of avoidable infection, and is synonymous with public perception of poor standards of health care. Water pollution and inadequate wastewater treatment pose important risks to health.

WHO (2013): Safe Management of Wastes from Health-care Activities, (= Second Edition ). Geneva: World Health Organization (WHO) URL [Accessed: 30.09.2013]

Healthcare Waste

Currently, little or no management of healthcare wastes occurs in small-scale facilities in developing countries. Training and infrastructure are minimal. Common practice in urban areas is to dispose of healthcare waste along with the general solid waste or, in peri-urban and rural areas, to bury waste, without treatment. In some cities small hospitals may incinerate waste in dedicated on-site incinerators, but often fail to operate them properly. Unwanted pharmaceuticals and chemicals may be dumped into the local sanitation outlet, be it a sewage system, septic tank or latrine. The contamination of water sources represents serious health risks.

USAID (2013): Healthcare Waste, Sector Environmental Guidelines. Washington: United States Agency for International Development (USAID) URL [Accessed: 30.09.2013]

Water, Sanitation and Hygiene (WASH) in Health-Care Facilities in Emergencies

Health-care facilities play a vital role within the community by providing essential medical care at all times including during emergencies. Any incident which causes loss of infrastructure, energy supply, loss of equipment, loss of staff or staff attrition, interruption to supply chains, or patient surge - such as sudden communicable disease epidemics, natural disasters (e.g. floods, earthquakes), or conflict - requires a holistic health response and recovery effort which includes actions to assess and restore basic WASH services.

HARVEY, B. ; (2012): Water, Sanitation and Hygiene (WASH) in Health-Care Facilities in Emergencies, Technical Notes on Drinking-water, Sanitation and Hygiene in Emergencies. (= Technical Notes on Drinking-Water, Sanitation and Hygiene in Emergencies , 17 ). Geneva: World Health Organization (WHO) URL [Accessed: 30.09.2013]

Sludge Treatment and Disposal

Sludge Treatment and Disposal is the sixth volume in the series Biological Wastewater Treatment. The book covers in a clear and informative way the sludge characteristics, production, treatment (thickening, dewatering, stabilisation, pathogens removal) and disposal (land application for agricultural purposes, sanitary landfills, landfarming and other methods). Environmental and public health issues are also fully described.

ANDREOLI, C.V. ; SPERLING, M. von ; FERNANDES, F. (2007): Sludge Treatment and Disposal, (= Biological Wastewater Treatment Series , 6 ). London: International Water Association (IWA) Publishing URL [Accessed: 01.11.2013]

Biological Wastewater Treatment in Warm Climate Regions Volume 2

Biological Wastewater Treatment in Warm Climate Regions gives a state-of-the-art presentation of the science and technology of biological wastewater treatment, particularly domestic sewage. The book covers the main treatment processes used worldwide with wastewater treatment in warm climate regions given a particular emphasis where simple, affordable and sustainable solutions are required. The 55 chapters are divided into 7 parts over two volumes: Volume One (also available in the SSWM library): Introduction to wastewater characteristics, treatment and disposal; Basic principles of wastewater treatment; Stabilisation ponds; Anaerobic reactors; Volume Two: Activated sludge; Aerobic biofilm reactors; Sludge treatment and disposal.

SPERLING, M. von ; LEMOS CHERNICHARO, C.A. de ; (2005): Biological Wastewater Treatment in Warm Climate Regions Volume 2, London: International Water Association (IWA) Publishing URL [Accessed: 01.11.2013]

Guide for Small Community Water Suppliers and Local Health Officials on Lead in Drinking Water

This Guide is an abbreviated compilation of the wide range of scientific, engineering, health and operational issues concerned with the control of lead in drinking water in small water supply systems. It explains why lead in drinking water may still be a threat to public health in small communities. It is aimed at Local Health Officials and the operators of drinking water supply systems that serve small communities. Its objectives are to raise awareness, to provide a basis for assessing the extent of problems, and to identify control options.

HAYES, C. (2010): Guide for Small Community Water Suppliers and Local Health Officials on Lead in Drinking Water, London: International Water Association (IWA) Publishing URL [Accessed: 01.11.2013]

Hygiene Intervention Reduces Contamination of Weaning Food in Bangladesh

This study was conducted to measure the impact of a hygiene intervention on the contamination of weaning food in Bangladesh.

ISLAM, M.S. ; MAHMUD, Z.H. ; GOPE, P.S. ; ZAMAN, R.U. ; HOSSAIN, Z. ; ISLAM, M.S. ; MONDAL, D. ; SHARKER, M.A.Y. ; ISLAM, K. ; JAHAN, H. ; BHUIYA, A. ; ENDTZ, H.P. ; CRAVIOTO, A. ; CURTIS, V. ; TOUR, O. ; CAIRNCROSS, S. (2013) Hygiene Intervention Reduces Contamination of Weaning Food in Bangladesh, In: Tropical Medicine and International Health. 18 ,250-258 . URL [Accessed: 25.11.2013]

Integrating WASH into Neglected Tropical Disease Programs

This desk review clearly indicates that the international community recognizes that drug administration alone is insufficient to break the cycle of disease transmission. Although past programs have largely left out a WASH component, the current renewed interest in securing WASH to any global Neglected Tropical Diseases (NTD) control or elimination strategy and adding WASH interventions to NTD treatment programs is essential to achieving sustained control and elimination.

WASHPLUS (2013): Integrating WASH into Neglected Tropical Disease Programs, Experience and Recommendations. Washington: WASHplus Project URL [Accessed: 19.12.2013]

From Joint Thinking to Joint Action: A Call to Action on Improving Water, Sanitation, and Hygiene for Maternal and Newborn Health

There is sufficient evidence that water, sanitation, and hygiene (WASH) may impact maternal and newborn health (MNH) to warrant greater attention from all stakeholders involved in improving MNH and achieving universal WASH access. This article disusses current challenges and monitoring strategies aimed at maximizing healthy lives and increasing access to quality health care'

VELLEMAN, Y. ; MASON, E. ; GRAHAM, W. ; BENOVA, L. ; CHOPRA, M. ; CAMPBELL, O. M. R. ; GORDON, B. ; WIJESEKERA, S. ; HOUNTON, S. ; ESTEVES MILLS, J. ; CURTIS, V. ; AFSANA, K. ; BOISSON, S. ; MAGOMA, M. ; CAIRNCROSS, S. ; CUMMING, O. (2014) From Joint Thinking to Joint Action: A Call to Action on Improving Water, Sanitation, and Hygiene for Maternal and Newborn Health, In: PLOS Medicine. 11 . URL [Accessed: 01.12.2015]

Water, Sanitation, and Hygiene (WASH), Environmental Enteropathy, Nutrition, and Early Child Development

Environmental enteropathy, a prevalent subclinical condition of the gut, may be a key mediating pathway linking poor hygiene to developmental deficits. Current early child development research and programs lack evidence-based interventions to provide a clean play and infant feeding environment in addition to established priorities of nutrition, stimulation, and child protection. This report proposes the concept of baby WASH as an additional component of early childhood development programs.

NGURE, F.M. ; REID, B.M. ; HUMPHREY, J.H. ; MBUYA, M.N. ; PELTO, G. ; STOLTZFUS, R. J. (2014) Water, Sanitation, and Hygiene (WASH), Environmental Enteropathy, Nutrition, and Early Child Development, Making the Links. In: Annals of the The New York Academy of Science. 1308 ,118–128 . URL [Accessed: 03.05.2016]

The Sanitation Hygiene Infant Nutrition Efficacy (SHINE) Trial

Child stunting and anemia are intractable public health problems in developing countries and have profound short- and long-term consequences. The Sanitation Hygiene Infant Nutrition Efficacy (SHINE) trial is motivated by the premise that environmental enteric dysfunction (EED) is a major underlying cause of both stunting and anemia, that chronic inflammation is the central characteristic of EED mediating these adverse effects, and that EED is primarily caused by high fecal ingestion due to living in conditions of poor water, sanitation, and hygiene (WASH).

HUMPHREY, J.H. ; (2015): The Sanitation Hygiene Infant Nutrition Efficacy (SHINE) Trial, Rationale, Design, and Methods. (= Clinical Infectious Diseases , 685 / 61 ). URL

Design of an Intervention to Minimize Ingestion of Fecal Microbes by Young Children in Rural Zimbabwe

The resulting WASH intervention comprises material inputs and behavior change communication to promote stool disposal, handwashing with soap, water treatment, protected exploratory play, and hygienic infant feeding. Nurture and disgust were found to be key motivators, and are used as emotional triggers. The concept of a safe play space for young children was particularly novel, and families were eager to implement this after learning about the risks of unprotected exploratory play.

MBUYA, M.N.N. et al. ; (2015): Design of an Intervention to Minimize Ingestion of Fecal Microbes by Young Children in Rural Zimbabwe, (= Clinical Infectious Diseases 61 , 703 / 61 ). URL [Accessed: 11.05.2016]
Case Studies

World Bank – Water, Sanitation and Children’s Health: Evidence from DHS surveys

This paper combines survey data sets from 70 countries. The collected data gives an estimation of the effects of water and sanitation on child mortality and morbidity and shows a clear relationship among these two factors. A lower level of technology level in terms of water and sanitation infrastructure increases the odds of children to die.

GUENTHER, I. ; FINK, G. ; (2010): World Bank – Water, Sanitation and Children’s Health: Evidence from DHS surveys, The Hague: International Water and Sanitation Centre (IRC) URL [Accessed: 07.10.2010]

Perception of Water, Sanitation and Health – a Case Study from the Mekong Delta, Vietnam

A case study from Vietnam which determined the following: community’s perception of water, sanitation and health, actual sanitation situation of the community, water and sanitation-related hygiene behaviour and links to cultural and traditional background.

HERBST, S. ; BENEDIKTER, S. ; KOESTER, U. ; RECHENBURG, A. ; PHAN TRI THUNG NGOC ; KISTEMANN, T. ; (2008): Perception of Water, Sanitation and Health – a Case Study from the Mekong Delta, Vietnam, Bonn: Institute for Hygiene and Public Health URL [Accessed: 17.04.2012]

Estimating Inequities in Sanitation-related Disease Burden and Estimating the Potential Impacts of Propoor Targeting

The objectives of this study are to model for 10 low-income countries in sub-Saharan Africa and South Asia: 1) The distribution of sanitation-related health burden by wealth quintile; 2) The distribution of health benefits for targeting different wealth quintile groups; 3) The spatial distribution of sanitation-related health burden and benefits

RHEINGANS, R. ; CUMMING, O. ; ANDERSON, J. ; SHOWALTER, J. (2012): Estimating Inequities in Sanitation-related Disease Burden and Estimating the Potential Impacts of Propoor Targeting, London: London School of Hygiene and Tropical Medicine URL [Accessed: 16.03.2012]

DIARRHOEA DIALOGUES From Policies to Progress

This review looks at the policy environment for diarrhoea control in three African countries, in order to glean lessons learnt about what more we can do to address this problem. While solutions are available to prevent and treat diarrhoea, the political will and health prioritisation are still lacking to make these solutions widely available to those who need them most. To accelerate progress in cutting mortality from diarrhoea, global and national decision-makers need to take urgent action.

GILL, S. ; HAYES, J. ; COATES, S. ; (2012): DIARRHOEA DIALOGUES From Policies to Progress, A call for urgent action to prevent the biggest killer of children in sub-Saharan Africa. Teddington and Washington, D.C.: Tearfund and Path URL [Accessed: 30.05.2012]

At-scale Hygiene and Sanitation in Ethiopia and Madagascar: Experiences and Lessons Learned

This paper reviews the Hygiene Improvement Project’s (HIP) overall approach to “at-scale” hygiene and sanitation improvement, describes HIP’s two at-scale applications in Ethiopia and Madagascar, and reflects on the scale experiences and their lessons for future at-scale applications. An at-scale framework and tools for potential implementers are included in the annex.

U.S. AID (2011): At-scale Hygiene and Sanitation in Ethiopia and Madagascar: Experiences and Lessons Learned, Washington, D.C.: U.S. AID URL [Accessed: 27.06.2012]

Nudging to Use

This paper presents results from two complementary field experiments conducted in rural western Kenya and the urban slums of Dhaka, Bangladesh. In both settings, participating households received free trials with a variety of point of use products as well as repeated educational messages about the importance of safe drinking water and its link with diarrheal illness.

LUOTO, J. ; LEVINE, D. ; ALBERT, J. ; LUBY, S. ; (2013): Nudging to Use, Achieving Safe Water Behaviors in Kenya and Bangladesh. Berkeley: Center for Effective Global Action URL [Accessed: 07.08.2013]

Teaching Handwashing with Soap for Schoolchildren in a Multi-Ethnic Population in Northern Rural Vietnam

This study aimed to investigate responses to a teacher-centered participatory Handwashing With Soap intervention in a multi-ethnic population of primary schoolchildren in northern rural Vietnam. It demonstrated that it is feasible to engage teachers and implement active teaching methods for behaviour change of hand washing with soap in a group of multi-ethnic primary schoolchildren without the need for major investments in water and hygiene infrastructures.

XUAN, T. T. ; RHEINLAENDER, T. ; HOAT, L. N. ; DALSGAARD, A. ; KONRADSEN, F. (2013) Teaching Handwashing with Soap for Schoolchildren in a Multi-Ethnic Population in Northern Rural Vietnam, In: Global Health Action. 6 ,1-12 . URL [Accessed: 28.08.2013]

Cluster-Randomised Controlled Trials of Individual and Combined Water, Sanitation, Hygiene and Nutritional Interventions in Rural Bangladesh and Kenya

Water quality, sanitation, handwashing and nutritional interventions can independently reduce enteric infections and growth faltering. There is little evidence that directly compares the effects of these individual and combined interventions on diarrhoea and growth when delivered to infants and young children. The objective of the WASH Benefits study is to help fill this knowledge gap.

ARNOLD, B.F. ; NULL, C. ; LUBY, S. ; UNICOMB, L. ; STEWART, C. ; DEWEY, K. ; AHMED, T. ; ASHRAF, S. ; CHRISTENSEN, G. ; CLASEN, T. ; DENTZ, H.N. ; FERNALD, L.C.H. ; HAQUE, R. ; HUBBARD, A. ; KARIGER, P. ; LEONTSINI, E. ; LIN, A. ; NJENGA, S.M. ; PICKERING, A.J. ; RAM, P.K. ; TOFAIL, F. ; WINCH, P. ; COLFORD, J.M. (2013) Cluster-Randomised Controlled Trials of Individual and Combined Water, Sanitation, Hygiene and Nutritional Interventions in Rural Bangladesh and Kenya, The WASH Benefits Study Design Rationale. In: BMJ Open.. . URL [Accessed: 23.09.2013]

Open Defecation and Childhood Stunting in India

Poor sanitation remains a major public health concern linked to several important health outcomes; emerging evidence indicates a link to childhood stunting. In India over half of the population defecates in the open; the prevalence of stunting remains very high. Recently published data on levels of stunting in 112 districts of India provide an opportunity to explore the relationship between levels of open defecation and stunting within this population.

SPEARS, D. ; GHOSH, A. ; CUMMING, O. (2013) Open Defecation and Childhood Stunting in India, An Ecological Analysis of New Data from 112 Districts. In: PLOS ONE. 9 . URL [Accessed: 23.09.2013]

Growing Taller Among Toilets

Child height is an important indicator of human capital and human development. Recent medical evidence suggests that exposure to poor sanitation - and speci cally to widespread open defecation - can pose a critical threat to child growth. This paper identi es an effect of open defecation on child height from within-province changes in the local area open defecation to which children are exposed.

KOV, P. ; SMETS, S. ; SPEARS, D. ; VYAS, S. ; (2013): Growing Taller Among Toilets, Evidence from Changes in Sanitation and Child Height in Cambodia, 2005-2010. Amston: Research Institute for Compassionate Economics (RICE) URL [Accessed: 23.09.2013]

Village Sanitation and Children's Human Capital

Open defecation is exceptionally widespread in India, a country with puzzlingly high rates of child stunting. This paper reports a randomized controlled trial of a village-level sanitation program implemented in one district by the government of Maharashtra. The program caused a large but plausible average increase in child height, which is an important marker of human capital. The results demonstrate sanitation externalities: an effect even on children in households that did not adopt latrines.

HAMMER, J. ; SPEARS, D. ; (2013): Village Sanitation and Children's Human Capital, Evidence from a Randomized Experiment by the Maharashtra Government. (= Policy Research Working Paper , 6580 ). Washington: The World Bank Water and Sanitation Program (WSP) URL [Accessed: 01.10.2013]

Designing a Handwashing Station for Infrastructure-Restricted Communities in Bangladesh Using the Integrated Behavioural Model for Water, Sanitation and Hygiene Interventions (IBM-WASH)

In Bangladesh diarrhoeal disease and respiratory infections contribute significantly to morbidity and mortality. Handwashing with soap reduces the risk of infection; however, handwashing rates in infrastructure-restricted settings remain low. Handwashing stations - a dedicated, convenient location where both soap and water are available for handwashing - are associated with improved handwashing practices. The aim of this study was to identify a locally feasible and acceptable handwashing station that enabled frequent handwashing for two subsequent randomized trials testing the health effects of this behaviour.

HULLAND, K. ; LEONTSINI, E. ; DREIBELBIS, R. ; UNICOMB, L. ; AFROZ, A. ; DUTTA, N.C. ; NIZAME, F.A. ; LUBY, S.P. ; RAM, P.K. ; WINCH, P.J. (2013) Designing a Handwashing Station for Infrastructure-Restricted Communities in Bangladesh Using the Integrated Behavioural Model for Water, Sanitation and Hygiene Interventions (IBM-WASH), In: BMC Public Health. 13 ,877 . URL [Accessed: 30.09.2013]
Training Material

Environmental Health. Lecture notes

This book contains information on environmental health aspects of water and sanitation. It contains a definition of environmental health, describes various water-related diseases and also hygiene approaches. There is also a related PowerPoint to this document.

EAWAG ; SANDEC (2008): Environmental Health. Lecture notes, (= Sandec Training Tool 1.0, Module 2 ). Duebendorf: Swiss Federal Institute of Aquatic Science (EAWAG), Department of Water and Sanitation in Developing Countries (SANDEC) URL [Accessed: 23.05.2012]

Environmental Health. Presentation

This PowerPoint presentation contains information on environmental health aspects of water and sanitation. It contains a definition of environmental health, describes various water-related diseases and also hygiene approaches. There is also a related lecture to this document.

EAWAG ; SANDEC (2008): Environmental Health. Presentation, (= Sandec Training Tool 1.0, Module 2 ). Duebendorf: Swiss Federal Institute of Aquatic Science (EAWAG), Department of Water and Sanitation in Developing Countries (SANDEC) URL [Accessed: 23.05.2012]

Menstrual hygiene matters

Menstrual hygiene matters is an essential resource for improving menstrual hygiene for women and girls in lower and middle-income countries. Nine modules and toolkits cover key aspects of menstrual hygiene in different settings, including communities, schools and emergencies.

HOUSE, S. ; MAHON, T. ; CAVILL, S. ; (2012): Menstrual hygiene matters, A resource for improving menstrual hygiene around the world. London: WaterAid URL [Accessed: 29.01.2013]

Inter-sectoral Decision-making Skills in Support of Health Impact Assessment of Development Projects

A course which helps mid-level officials to familiarise them with Health Impact Assessment in the planning of water resources development.

WHO (2000): Inter-sectoral Decision-making Skills in Support of Health Impact Assessment of Development Projects, Geneva: World Health Organisation (WHO) URL [Accessed: 07.10.2010]

Choose Soap Toolkit

This toolkit was created to promote hand washing with soap in households in low income settings and draws on ideas and best practices from different fields, including hygiene and health promotion, behavioural sciences, and marketing. It is designed to be used to promote hand washing with soap: at key times; within a realistic budget and time frame; and for an organization working at village level across multiple villages.

LSHTM ; (2013): Choose Soap Toolkit, London: London School of Hygiene and Tropical Medicine (LSHTM) URL [Accessed: 29.07.2013]

Facilitator’s Reference Guide for Frontline Activators on Interpersonal Communication

This guide is designed to help facilitators train Frontline Activators (FLA) on interpersonal communication skills to enable them to promote hand washing with soap in their communities. It also serves as a detailed reference guide.

WSP ; (2013): Facilitator’s Reference Guide for Frontline Activators on Interpersonal Communication, Washington: The World Bank Water and Sanitation Program (WSP) URL [Accessed: 28.08.2013]

A Guide to Personal Hygiene

This poster is part of the series of Water, Sanitation and Hygiene posters designed by the Water, Engineering and Development Center of Loughborough University.

INCE, M.E. ; SHAW, R. ; DAVEY, K. ; (2013): A Guide to Personal Hygiene, Poster. (= WEDC Posters , 3 ). London: Water, Engineering and Development Center (WEDC) URL [Accessed: 28.08.2013]

The “F” Diagram

This poster is part of the series of Water, Sanitation and Hygiene posters designed by the Water, Engineering and Development Center of Loughborough University.

REED, B. ; SKINNER, B. ; SHAW, R. ; (2013): The “F” Diagram, (= WEDC Posters , 4 ). London: Water, Engineering and Development Center (WEDC) URL [Accessed: 28.08.2013]

Guidelines for Handwashing with Soap

This poster is part of the series of Water, Sanitation and Hygiene posters designed by the Water, Engineering and Development Center of Loughborough University.

REED, B. ; SHAW, R. ; CHATTERTON, K. ; (2013): Guidelines for Handwashing with Soap, Poster. (= WEDC Posters , 6 ). London: Water, Engineering and Development Center (WEDC) URL [Accessed: 28.08.2013]
Awareness Raising Material

Sanitation and Cleanliness for a Healthy Environment

This book contains well-written information about both personal and public cleanliness including instructions on how to build safe toilets that respect the principles of sustainable Sanitation. The book is also available in Spanish and Creole.

HESPERIAN FOUNDATION ; UNDP (2004): Sanitation and Cleanliness for a Healthy Environment, Berkeley: The Hesperian Foundation URL [Accessed: 17.04.2012]

1854 Broad Street cholera outbreak

The Broad Street cholera outbreak was a severe outbreak of cholera that occurred near Broad Street in Soho district of London, England in 1854. This outbreak is best known for the discovery that cholera is spread by contaminated water. This discovery came to influence public health and the construction of improved sanitation facilities beginning in the 19th century.

WIKIPEDIA (n.y): 1854 Broad Street cholera outbreak, San Francisco: Wikimedia Foundation Inc URL [Accessed: 05.02.2013]

Global WASH Campaign – Posters

A set of posters addresses the current water and sanitation crisis. The material can be used by individuals as well as organisation to raise awareness if it is not modified.

WSSCC (2007): Global WASH Campaign – Posters, Geneva: Water Supply & Sanitation Collaborative Council (WSSCC)

Integrating Water, Sanitation and Hygiene into Nutrition Programming

Diarrhea, pneumonia, and birth complications are the top three killers of children under age 5 worldwide. Diarrhea is also a leading cause of undernutrition in this age group, and one-third to one-half of all child mortality cases are linked to undernutrition. If mothers and other caregivers used basic hygiene practices and had better access to safe water and adequate sanitation this could greatly reduce under-5 deaths and improve child nutrition.

USAID ; WASH PLUS (2013): Integrating Water, Sanitation and Hygiene into Nutrition Programming, Washington: United States Agency for International Development (USAID), WASHplus URL [Accessed: 23.09.2013]

Alternative Versions to