Introduction
In 2007, readers of the British Medical Journal voted that the introduction of clean
water and sewerage—the ‘sanitation revolution’ of the Victorian era—was the most important
medical milestone since the 1840s,1 over anaesthesia, antibiotics, or vaccines. These
improvements led to a dramatic reduction in morbidity and mortality associated with
faecal-oral infections, such as typhoid fever and cholera. Today, water, sanitation
and hygiene (WSH) measures remain critically important to global public health, especially
among children in lower income countries, who are at greatest risk from enteric infections
and their associated symptoms, complications and sequelae.
In this article, we review the evidence linking WSH measures to faecal-oral diseases
in children. Although continued research is needed, existing evidence from the last
150 years supports extending life-saving WSH measures to at-risk populations worldwide.2
One recent estimate3 held that 95% of diarrhoeal deaths in children under 5 years
of age could be prevented by 2025, at a cost of US$6.715 billion, through targeted
scale-up of proven, cost-effective, life-saving interventions. These include access
to safe and accessible excreta disposal, support for basic hygiene practices such
as hand washing with soap, and provision of a safe and reliable water supply. We present
estimates of the burden of WSH-related disease followed by brief overviews of water,
sanitation and hygiene-related transmission routes and control measures.
i
We conclude with a summary of current international targets and progress.
Transmission routes and health impact
Human excreta can contain over 50 known bacterial, viral, protozoan and helminthic
pathogens. The majority of excreta-related infections are obtained through ingestion,
less often through inhalation. Excreta-related infections travel through a variety
of routes from one host to the next, either as a result of direct transmission through
contaminated hands, or indirect transmission via contamination of drinking water,
soil, utensils, food and flies (figure 1). The importance of each transmission route
varies between pathogens and settings, and different pathogens are more prevalent
in some populations.
Figure 1
The F-diagram, showing the different faecal-oral transmission routes, and possible
barriers to prevent excreta-related pathogens from finding a new host.
Diarrhoea, malnutrition and environmental enteropathy
Although great strides have been made in reducing diarrhoea mortality, especially
as a result of the increased use of oral rehydration therapy (ORT), diarrhoea remains
the second leading cause of death in children under 5 years of age, after pneumonia.4
It is responsible for an estimated 1.7 billion cases of diarrhoea, or on average 2.9 episodes/child/year,
and an estimated 1.87 million deaths among children under 5 years of age.5 The highest
burden of disease is in children in the age range of 6–11 months: 4.5 episodes/child/year.6
It has been estimated that 50% of diarrhoea deaths can be attributed to persistent
diarrhoea,7 and while ORT can prevent many deaths from acute diarrhoeal diseases,8
access to appropriate treatment is often limited in resource-poor settings.
The relationship between diarrhoeal disease and malnutrition is complex, though it
is well accepted that malnourished children suffer more frequent episodes of diarrhoeal
disease, while a child's nutritional status is affected following a diarrhoeal episode.
A multiple country study found that 25% of stunting in children aged 24 months could
be attributable to five or more diarrhoeal episodes experienced in the first 2 years
of life.9 Malnutrition and stunting can lead to poorer school performance, early school
drop-out and, as a result, lower economic well-being in later life.10 Over 440 million
school days are missed annually due to WSH-related illnesses.11 Extended exposure
to faecal pathogens may, in part, cause environmental enteropathy, a postulated condition
(Humphrey, Lancet) characterised by malabsorption, villus atrophy, crypt hyperplasia,
T-cell infiltration and general inflammation of the jejunum.12 This chronic infection
of the small intestine could explain why sanitation may have a stronger association
with gains in growth than with reductions in diarrhoea incidence.13 For example, a
study in Peru found that diarrhoea could explain 16% of stunting, while access to
sanitation and water services could explain 40%.14 Environmental enteropathy may reduce
vaccine efficacy, either though induction of regulatory T cells which dampen the vaccine-specific
immune response, or through the destruction of the live attenuated vaccine by an over-vigorous
local immune response in the gut.15 This could explain why oral vaccines for the control
of rotavirus have shown a lower efficacy in sub-Saharan Africa (39.3%) and Asia (48.3%),
in contrast with efficacy in Europe/USA (85–98%).16–19
An estimated 88% of all child deaths as a result of diarrhoeal disease may be prevented
through improvements in WSH.20 While there are promising emerging vaccines, including
for rotavirus and cholera, there are several dozen pathogens transmitted in faeces,
and WSH will remain critical to prevention of diarrhoeal diseases.
Helminths
Soil-transmitted helminths (STH); Ascaris lumbricoides, Trichuris trichiura and the
human hookworms (Necator americanus and Ancylostoma duodenale) are our most common
parasites and are estimated to infect up to 807 million, 604 million and 576 million
people worldwide, respectively.21 Roughly a third of all Ascaris and Trichuris infections
and 20% of hookworm infections are in children under the age of 15 years.22 STH ova
leave the human body in excreta, and must mature in soil before they become infective.
STH infections have shown a strong association with open defecation,23 and the use
of fresh excreta or wastewater in agriculture.24
25 Consumption of dirt or soil (pica) by children, pregnant women, and others has
also been suggested as a risk factor for STH.26
27 Schistosomiasis is estimated to infect 207 million people worldwide,21 and is caused
by open defecation or anal cleansing28 close to or in water bodies where the miracidia
can hatch and find a snail host to complete their lifecycle. The use of surface water
sources like lakes, rivers and irrigation canals for domestic water needs, like washing,
bathing and water collection have been associated with an increased risk of infection.29
Children are especially at risk as a result of their lower immunity, and because they
may have more contact with contaminated water through play or water collection.30
Although direct mortality as a result of a helminth infection is low, morbidity is
high. The global burden of disease has been variously estimated (as few as 3 million
and as many as 50 million Disability Adjusted Life Year (DALY)31
32), and is uncertain but high.33 The burden of disease is attributable to the long-term
impacts related to helminth infections, including anaemia, low birth weight, preterm
birth, retarded growth, poorer cognitive performance and early school drop-out. Hookworm,
in particular, is associated with undernutrition and possibly greater risk of malaria34–36
and HIV.37
38 The delivery of anthelminthics through schools has lately been the intervention
of choice for reducing STH infections in children. The effectiveness of these programmes,
especially with respect to improving cognitive performance, has recently been questioned,
however, a large meta-analysis did not find a significant improvement,39 underscoring
the need to interrupt transmission via effective sanitation in home and school environments.40
Prevention
Sanitation
Sanitation aims to prevent contamination of the environment by excreta and, therefore,
to prevent transmission of pathogens that originate in faeces of an infected person.
A wide range of technologies and methods exists to achieve this, which include sophisticated
and high-cost methods like waterborne sewage systems and simple low-cost methods like
the cat method, which involves the digging of a hole and covering faeces with soil
after defecation. The WHO/UNICEF Joint Monitoring Programme (JMP) classifies the following
as ‘improved’ sanitation that is more likely to be hygienic: a connection to a sewerage
system, septic tanks, pour-flush toilets, ventilated improved pit latrines and pit
latrines with a concrete slab. According to the 2010 JMP estimate, 11 countries make
up 76% of the 2.5 billion people lacking improved sanitation, with one-third in India.
Over one billion people practise open defecation, mostly in rural areas.41 Systematic
reviews of the impact of sanitation on health have estimated a mean reduction of 32–36%
in diarrhoea,42–44 though a Cochrane systematic review did not calculate a pooled
effect due to heterogeneity of studies.45 The number of rigorous studies that have
investigated the impact of sanitation on soil-transmitted helminth infections is very
limited, as most of the sanitation interventions were conducted in conjunction with
improvements in water supply. In Salvador, Brazil, neighbourhoods with storm water
drains to prevent seasonal flooding with sewage, or full waterborne sewerage, were
compared with neighbourhoods having neither. The study found that, when the level
of community sanitation was better, the prevalence of ascariasis declined by up to
40%, and that domestic domain risk factors were more numerous and more significant
in areas with better community sanitation.46
Safe child stool disposal
Many cultures consider the stools of infants fed on breast milk harmless, or at least
less harmful than those of adults, because they are smaller, their faeces smell less,
and contain less visual food residues.47–49 Additionally, most latrines are not designed
for use of, and may not be used by, small children. They might be afraid to use them
for the risk of falling in, bad smells, or the fear of dark spaces. Because nappies,
child-sized potties and washing machines are not available in many poor settings,
defecation on the floor is common and potentially seen as the most practical option
until the child is potty trained. As a result, latrine use by children is low, as
was shown by a study in Lima, Peru, where less than 25% of under five-year-olds used
a toilet.49 Because of a much higher prevalence of diarrhoea and higher egg counts
for STH in children, child stool often poses a greater health risk than those of adults.50
To date, safe disposal of children's stools has received relatively little attention
in sanitation programmes.
Water supply
While all communities have access to water, the quantity and quality available may
be insufficient to meet basic needs, and access may not be near to the household.
The physically demanding job of water collection is usually allocated to women and
children. A study in 25 countries in sub-Saharan Africa estimated that children spent
a collective four million hours every day fetching water, and keeping them away from
school.41 Carrying water can also lead to injuries and growth stunting.51 When water
is available within 1 km, or a 30 min return round trip from the household, water
use does not change significantly until water is provided on the plot or very nearby
(figure 2). When a tap is available within the household, or shared with a close neighbour,
per capita water use can go up from 10–30 L/person/day to 30–100 L/person/day. Greater
volumes of water available to a household tend to result in better hygiene, including
increased hand washing.
Figure 2
Distance to water source and use.
Figure 3
An improved form of sanitation: a household pit latrine in Tanzania.
Over 780 million people now lack access to an ‘improved’ water source, and one study
has estimated the number of people who rely on microbiologically or chemically unsafe
water to be 1.8 billion, or about 28% of the global population.52 According to WHO/UNICEF
JMP, ‘improved’ water sources include piped water, rainwater, protected springs and
protected wells, which are thought to be less likely to be contaminated with pathogenic
microbes. Recent research has shown, however, that even such improved water supplies
may be subject to faecal contamination (ibid.) and that even occasional exposure to
unsafe water—for example, from intermittent service or inadequate treatment—can undermine
health benefits.53 Providing safe, reliable, piped-in water to every household is
an essential goal, yielding optimal health gains, while contributing to the Millennium
Development Goal (MDG) targets for poverty reduction, nutrition, childhood survival,
school attendance, gender equity and environmental sustainability.
Food hygiene
Weaning food hygiene may be among the most important determinants of diarrhoeal disease
risk in young children,54
55 although the current evidence is insufficient to arrive at conclusions about its
relative importance in control of infections. It has been shown to be important in
some contexts, with estimates of up to 70% of all diarrhoea caused by contaminated
foods,54 and microbial counts that may exceed those found in drinking water.54–60
Food hygiene interventions, such as the promotion of reheating foods, preventing contact
with flies and hand washing before feeding are the subject of current research, but
effects on diarrhoeal disease risk have not been estimated from multiple trials. The
sustained effects of behaviour change from food hygiene interventions have not been
assessed.
Hand hygiene
Hand washing with soap before feeding children and after cleaning them can interrupt
the transmission of faecal-oral microbes in the domestic environment. A review of
the literature on hand hygiene suggests that hand washing with soap (HWWS) can reduce
micro-organism levels close to zero,61
62 mainly through the mechanical action of rubbing and rinsing.62
63 Good hand washing practice should include water, a washing agent such as soap and
a drying phase.50
64–66 Estimates of the impact of HWWS on health from systematic reviews suggest large
effects (up to 48% reduction in diarrhoea).42
44
67–70 Hand washing with soap can also cut the risk of acute respiratory infections
by 23%.71–73 Critically, persistent changes in behaviours may be possible following
interventions,74 although more research is needed on the longer-term effects of behaviour
change campaigns.
Water quality
Because universal safe, reliable, on-plot water supply remains an elusive goal for
the majority of the world's population, household-level water treatment (HWT) has
been proposed as an interim solution to provide safer drinking water at the point
of use.75
76 In many settings, both rural and urban, populations may have access to sufficient
quantities of water, but that water may be unsafe for consumption as a result of microbial
or chemical contamination. Effective HWT, such as boiling, filtration or chlorination,
has been shown to improve microbial water quality significantly.77–79 Safe storage
of treated water is necessary to prevent recontamination through unsafe water handling.80
Improving water quality at the point of consumption can protect children from waterborne
disease. The findings of meta-analyses show a much stronger protective effect for
water quality interventions at the household level (rather than at source level) on
diarrhoeal disease outcomes (up to 40%42
44
81: but no blinded trials of household water treatment have shown protective effects.
HWT is unique among WSH interventions in that it may, in some forms, be possible to
blind with a placebo device, chemical, or method. A review by Cairncross et al
67 estimated diarrhoea risk reductions of 17% associated with improved water quality,
which is consistent with earlier reviews by Esrey et al,43
68 and issues of bias potentially affecting the evidence base for water quality interventions
have been articulated.81
82
One of the challenges that promoters of HWT have reported is low adherence—consistent,
correct and sustained use—which can limit expected health gains.83
84 Unlike centrally treated, piped-in water supplies, HWT is normally a batch process
that must be undertaken by the end users on a daily basis in order to provide consistent
protection against waterborne pathogens. A number of studies of HWT have reported
reduced use of interventions over time, suggesting that low adherence may limit the
usefulness of HWT as a strategy.77
85–88
Progress toward and beyond the MDGs
Improvements in water supply and sanitation, if implemented sustainably, will have
an important impact on a wide variety of different infectious diseases, and could
improve the quality of life of millions of children worldwide, and provide them a
proper start in life. In 2010, the UN General Assembly affirmed that clean drinking
water and sanitation are human rights, with the UN Human Rights Council later recognising
these rights to be derived from the rights to an adequate standard of living, health,
life and dignity.41 These pronouncements cannot by themselves drive progress in expanding
services, but do add moral weight to the pursuit of universal coverage. Although great
strides have been made in the provision of sanitation and water, it is estimated that
if current trends continue, 605 million people will still lack access to an improved
water source in 2015, and 2.4 billion people will lack access to basic sanitation.41
Implementing better measures of what constitutes ‘access’ to water and sanitation—currently,
monitoring is based primarily on technology types, without regard to key quality or
accessibility factors—would paint an even bleaker picture of the global shortfall
in coverage.
Households with a so-called ‘improved’ water supply connection that is intermittent
and provides microbiologically unsafe water are counted among those with access to
water meeting the MDG target for ‘sustainable access to safe drinking water’.89 Similarly,
sanitation progress made in some areas have accounted only for construction of latrines,
when there are no good options for treatment or disposal of waste after they fill
up (figure 3).
In order to consolidate the gains of the last decade, and contribute to lowering the
burden of childhood morbidity and mortality, post-MDG goals for water and sanitation
should focus on strengthening key WSH institutions, creating demand and ownership,
and fostering sustainable behaviour change. This requires an acknowledgment that the
motivations for improving access are different for policy makers and intended recipients.
The MDGs include language on reducing poverty and disease mortality, but for most
of the beneficiaries the advantages and motives for the adoption of WSH measures are
not directly health-related, but improvements in quality of life, including factors
related to privacy, comfort, status, dignity, protection from harassment and savings
in cost and time. Harnessing the power of these motivations to expand access to WSH,
by leveraging investment by households—not only by governments and donor agencies—may
help increase coverage of these life-saving measures among those who would most benefit
from them.