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Public Health Implications of Water Supply Improvements. Did Environmental Engineers save the world?. AguaClara needs a few bright (i.e. Cornell) students . To create improved and more detailed design algorithms to facilitate the global spread of the AguaClara technologies

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public health implications of water supply improvements

Public Health Implications of Water Supply Improvements

Did Environmental Engineers save the world?

aguaclara needs a few bright i e cornell students
AguaClara needs a few bright (i.e. Cornell) students
  • To create improved and more detailed design algorithms to facilitate the global spread of the AguaClara technologies
  • To identify and trap for design tool failures
  • To craft clear customized-automated documentation of the designs in both English and Spanish
  • To research methods to improve performance and reduce costs
  • To tell the AguaClara story and raise financial support
review public health implications of water supply improvements
Review: Public Health Implications of Water Supply Improvements
  • The life expectancy transition
    • The role of water supply, sanitation, and hygiene
      • In the Global North a century ago
      • In the Global South
    • The U5MR connection
  • Exposure Routes: breaking the cycle
  • Pathogens in the loop
  • Implications for successful interventions
life expectancy transition global north
Life Expectancy Transition(Global North)

Only intended to indicate trends!

Modern Cities

The transition

Early Cities

Pre-agrarian

Poor-agrarian

Who gets the credit?

life expectancy in england
Life expectancy in England

90

males

females

80

70

60

50

Life expectancy

40

30

20

From family reconstitution

(mostly rural)

From vital registration

10

0

1600

1650

1700

1750

1800

1850

1900

1950

2000

Year

life expectancy in sweden
Life Expectancy in Sweden

90

80

70

60

50

life expectancy at birth

40

30

20

10

0

1750

1800

1850

1900

1950

2000

males

females

life expectancy transition global south
Life Expectancy Transition(Global South)
  • Based on no data! (just my overly generalized thoughts…)
  • Increase in life expectancy is occurring later than in the North
  • Cities are generally benefiting sooner
  • Huge variation between and within countries

Wealthy

Poor

Pre-agrarian

Poor-agrarian

distribution of deaths by age at death with mean 75 years
Distribution of deaths by age at death with mean = 75 years

30000

Disease that takes a lifetime to kill (high blood pressure, tobacco, cholesterol…)

25000

20000

Number of deaths / yr

(for 100000 births/yr)

15000

10000

5000

0

0

3

8

13

18

23

28

33

38

43

48

53

58

63

68

73

78

82

91

Mean age at death in interval (nearest year)

distribution of deaths by age at death with mean 35 years
Distribution of deaths by age at death with mean = 35 years

25000

Mean = life expectancy

20000

Why are these people dying young?

15000

(for 100000 births/yr)

Number of deaths / yr

10000

5000

0

0

2

8

13

18

23

28

33

38

43

48

53

58

63

67

72

77

82

89

Mean age at death in interval (nearest year)

mortality due to leading factors
Mortality due to leading factors

Inadequate food

Water, Sanitation, Hygiene

Air pollution

burden of disease due to leading risk factors
Burden of disease due to leading risk factors

Disability-adjusted life year

DALY:_______________________

Our focus in this course…

the role of water supply sanitation and hygiene
The role of Water Supply, Sanitation, and Hygiene
  • Contribute significantly to mortality and morbidity on the global level
  • Have an enormous influence on U5MR (under 5 mortality rate)
  • But why are these 3 items grouped together?
    • What is the effect of safe drinking water?
    • Let’s examine the role of safe drinking water in the life expectancy transition
mills reincke phenomenon
Mills-Reincke Phenomenon

‘…. the purification of polluted public water-supplies reduces the general death-rate much more than it would be reduced by the saving of deaths from the commonly recognized water-borne disease, typhoid fever and Asiatic cholera alone.’

Sedgwick WT, MacNutt JS. On the Mills-Reincke phenomenon and Hazen's theorem concerning the decrease in mortality from diseases other than typhoid fever following the purification of public water-supplies. J.Infect.Dis. 1910; 7 : 489-564.

This is the “Environmental Engineers Saved the World” Hypothesis.

u s typhoid fever mortality
U.S. Typhoid Fever Mortality
  • Chlorination was begun in Jersey City, N.J., in 1908. Adoption by other cities and towns across the US soon followed and resulted in the virtual elimination of waterborne diseases such as cholera, typhoid, dysentery and hepatitis A

35

Chlorination begins in Jersey City

30

25

20

deaths per 100,000

15

10

5

0

1900

1910

1920

1930

1940

1950

year

Chlorine saved the day

chlorine cause and effect what else would you like to know
Chlorine Cause and Effect:What else would you like to know…
  • What was the mortality rate before the introduction of chlorine?
  • When did other cities adopt chlorination?
  • How did the mortality rate change for cities when they began chlorinating?
  • What other changes were occurring during the 1900s that may have influenced mortality?
typhoid fever mortality baden germany 1855 to 1881
Typhoid Fever Mortality Baden, Germany 1855 to 1881

Typhoid decreased here before water supply improvements!

typhoid fever death rate per 100 000 inhabitants per year in albany ny
Typhoid fever death rate per 100,000 inhabitants per year in Albany, NY

Typhoid decrease coincided with water filtration!

u s population supplied with filtered water

Typhoid

U.S. population supplied with filtered water

Reduction in typhoid might be correlated with installation of filters

correlation between water supply improvements and public health
Correlation between Water Supply Improvements and Public Health?
  • A causal link?
    • Filtration
    • Chlorination
  • Delayed response?
  • No link?
  • US 1900 – 1940 interpretation?
disease rates as measures of efficiency
Disease rates as measures of efficiency
  • “The final criterion of the efficiency of a purification plant is the absence or prevalence in the community of water-borne diseases. Typhoid fever being the most typical and widespread of such diseases, statistics of its prevalence are of much significance. Prior to the general introduction of purification works, the typhoid death rate was invariably high in many of our large cities drawing their supply from polluted rivers and lakes. Most of these cities are now supplied with satisfactory water, and many records could be given showing the marked effect of water treatment on the typhoid rate. The following data for the cities of New Orleans, Pittsburgh and Cincinnati will suffice.”

Public Water-Supplies by Turneaure, Russell, Mead, Baker. John Wiley & Sons (1924) pages 430-431.

evidence for a causal link new orleans pittsburgh cincinnati
Evidence for a Causal Link:New Orleans, Pittsburgh, Cincinnati

Pittsburgh, Cincinnati and New Orleans were used as evidence of the efficacy of filtration

Public Water-Supplies by Turneaure, Russell, Mead, Baker. John Wiley & Sons (1924)

trying to understand the data
Trying to Understand the Data
  • “The steady reduction… is probably due in part to improved operation and in part to the gradual elimination of the disease from the community and so removing sources of contamination.”
  • What do you think?

Public Water-Supplies by Turneaure, Russell, Mead, Baker. John Wiley & Sons (1924)

what else was happening education one possibility
What else was happening?…education (one possibility)
  • ‘Infant care’ (US Children’s Bureau)
    • 12,000,000 copies
  • Baby care columns in leading newspapers
    • Carried by nearly all newspapers by 1912 (though not a few years earlier)
  • ‘Baby weeks’
    • By 1919: 17,000 local committees
    • 11,000,000 directly involved
causes of diarrhoea according to diseases of children
Causes of diarrhoea according to ‘Diseases of children’

1889

1899

Sour milk

Unripe fruit

Inhalation of sewer gas

Emanations from the soil

‘no doubt that the immediate cause is an infection of the alimentary canal, by …bacteria contained in milk or other forms of food’

Powerlessness!

Empowerment

changes recommended public health campaign
Changes recommended: public health campaign
  • Breast feed
  • Boil cow’s milk, sterilize bottles
  • Protect infants from persons known to be ill
  • Control flies
  • Wash hands

You can improve your health!

education of the public
Education of the Public

...the discovery of the possibilities of widespread social organization as a means of controlling disease was one which may almost be placed alongside the discovery of the germ theory of disease itself as a factor in the evolution of the modern public health campaign.

-Winslow (1929)

confounding factors order of interventions
Confounding Factors:Order of Interventions
  • If the drinking water was contaminated with typhoid and you mounted an education campaign to encourage hand washing…
    • You would conclude
  • If you installed a water treatment plant, but no one washed their hands…
    • You would conclude
  • These interventions are necessary, but not sufficient because there are ________ disease transmission routes

No need to wash hands

No need for clean water

multiple

reading the typhoid data
Reading the Typhoid Data
  • How long did it take for typhoid incidence to decrease? _____________
  • If typhoid was waterborne how long should it have taken for filtration and chlorination to eliminate typhoid? _____________
  • How does milk get typhoid?

30 to 40 years

A few weeks

Human excrement (milker’s hands?) or bovine excrement

my typhoid conclusions
My Typhoid Conclusions
  • The reduction was not due to a one time centralized change
    • Not due to filtration
    • Not due to chlorination
  • Was due to changes that occurred at different times throughout the population
    • Improved hygiene
      • Installation of toilets in bathrooms with sinks to wash hands
      • Education encouraging hand washing
    • Better food handling practices
      • Milk pasteurization
      • Refrigeration
    • Public Health Education
maybe env eng saved the world from cholera
Maybe Env. Eng. saved the world from Cholera
  • Check for evidence that it was waterborne
  • Check for evidence of protection by filtration and/or chlorination
sniffing out cholera
Sniffing out Cholera

Courtesy of the National Library of Medicine

john snow the great experiment
John Snow: The great experiment
  • Snow's definitive work concerned the spread of cholera through water supplied by the Southwark Company and the Lambeth Company
  • Southwark obtained its water from the Thames at Batttersea, in the middle of London in an area almost certainly polluted with sewage
  • Lambeth Company obtained its water considerably upstream on the Thames, above the major sources of pollution
  • In an area containing about 300,000 residents the pipes of both companies were laid in the streets, and houses were connected to one or the other sources of supply.
beautiful buildings but the water
Beautiful buildings, but the water…

The view of three water companies by Hampton is southwest from the north side of the River Thames.  The nearest building of the three companies is the Southwark and Vauxhall Water Company

Source: Anonymous. Illustrated London News, 1855. Graciously provided by Bryce Caller, January 10, 2001.

southwark and vauxhall water company
Southwark and Vauxhall Water Company
  • In 1850, the microbiologist Arthur Hassall wrote of the River Thames water they were using,"...a portion of the inhabitants of the metropolis are made to consume, in some form or another, a portion of their own excrement, and moreover, to pay for the privilege." 
  • Next Cartoon presents John Edwards, owner of the Southwark Water Company, posing as Neptune ("Sovereign of the Scented Streams").  He is seen crowned with a chamber-pot, seated on a stool on top of a cesspool which doubles as the water-intake for the Southwark Water Company customers in south London. 
southwark and vauxhall water company1
Southwark and Vauxhall Water Company

Give us Clean water

Devilish thick!

Yea, have I slick!

It makes me sick!

Give us pure water

We shall all have the Cholera

Courtesy of the National Library of Medicine

the grand cholera experiment
The Grand Cholera Experiment
  • Those houses served by the Lambeth Company had a low incidence of cholera, lower than the average population of London as a whole
  • Those served by the Southwark Company had a very high incidence
  • The socioeconomic conditions, climate, soil, and all other factors were identical for the populations served by the two companies
  • Snow concluded that the water supply was transmitting the cholera agent
  • Snow's study is impressive since the germ theory of disease had not yet been established

Proof that cholera was waterborne

drinking water treatment and germ theory
Drinking Water Treatment and Germ Theory
  • 1829: First sand filter used to treat some of London's drinking water
  • 1850: John Snow established the link between drinking water (from a contaminated well) and Cholera
  • 1872: Poughkeepsie, NY installs first filter in US
  • 1885: Sand filters are shown to remove bacteria
  • 1892: Cholera outbreak in Hamburg, Germany
1892 cholera outbreak in hamburg germany
1892 Cholera outbreak in Hamburg Germany
  • Large outbreak of Cholera in Hamburg
  • 17,000 cases; 8,600 deaths
  • Very few cases in neighborhoods served by Altona's filtered water supply
  • Hamburg's sewers were upstream from Altona's intake!

Hamburg

Altona's water intake and filter beds

Altona

Hamburg's sewer outfalls

Hamburg's water intake

Elbe River

altona vs hamburg cholera cases
Altona vs. Hamburg: Cholera Cases

Cholera cases

Cases in Altona acquired in Hamburg

Received water from Altona

Altona

Cholera was waterborne

Hamburg

Slow sand filtration may have protected Altona

environmental engineers are saving the world attempt 3
Environmental Engineers are saving the world: Attempt #3
  • Environmental engineers probably didn’t save us all from typhoid.
  • We have some evidence that filtration and water source affect public health from cholera
  • Could we make a case for our relevance by comparing current populations?
  • Compare modern countries with low and high U5MR and see what is correlated with infant mortality
u5mr by national income in the early 1990s
U5MR by National Income in the Early 1990s

Low performers (l to r): Congo, Gabon, Botswana, Turkey, Brazil

High performers (l to r): Sri Lanka, China, Surinam, Jamaica, Costa Rica

good and poor performers
Good and poor performers

High: Sri Lanka, China, Surinam, Jamaica, Costa Rica

Good

Poor

Low : Congo, Gabon, Botswana, Turkey, Brazil

26

the

<5 mortality rate

104

3488

contrast

GNP/person

4214

19

%underweight (<5yrs)

nutrition

18

87

% with safe water

public

65

85

health

immunization %

76

3.6

spend on health*

* as % of GNP

2.7

political

2440

pop'n per doctor

3638

support

8

soldiers per doctor

13

good and poor performers1
Good and poor performers

High: Sri Lanka, China, Surinam, Jamaica, Costa Rica

Good

Poor

Low : Congo, Gabon, Botswana, Turkey, Brazil

26

the

<5 mortality rate

104

3488

contrast

GNP/person

4214

2.7

total fertility rate

4.6

status of

5

yrs school f's >25**

2

women

116

maternal mortality

446

34

radios per 100

communications

18

6

newspapers per 100

3

Income disparity?

** mean yrs of schooling for women over 25

conclusions good and poor performers
Conclusions: Good and Poor Performers
  • Safe water supply is correlated with decreasing U5MR
  • Lower fertility rate, higher female education, lower maternal mortality rate are all correlated with lower U5MR
  • Increased communication correlated with lower U5MR!

Can’t prove cause and effect using this type of study

fecal oral pathways

Hygiene

Water treatment

Sanitation

Fecal-Oral Pathways

Sanitation method

Pathogen source

Environment

Transport

washing

Drinking water

Human excreta

Hands

Dry sanitation involving reuse

Surface water

Water

Waterborne sewage

Oral

Ground water

Crops

Non recycling latrines

Food

Animal excreta

Land application

Flies

Soil

what would it take to reduce diarrhea and u5mr

Read this as a critic.

  • What questions do you have?
What would it take to reduce Diarrhea (and U5MR)?
  • 88% of diarrhoeal disease is attributed to unsafe water supply, inadequate sanitation and hygiene.
  • Improved water supply reduces diarrhea morbidity by 21%.
  • Improved sanitation reduces diarrhea morbidity by 37.5%.
  • The simple act of washing hands at critical times can reduce the number of diarrhoeal cases by up to 35%.
  • Additional improvement of drinking-water quality, such as point of use disinfection, would lead to a reduction of diarrhea episodes of 45%.

1.8 million people die every year from diarrhoeal diseases (including cholera); 90% are children under 5, mostly in developing countries.

1.6 9/11 attacks per day…

the case against looking for a public health outcome
The case against looking for a Public Health Outcome
  • Epidemiological studies to measure a decrease in diarrhea in young children are
    • Expensive
    • Take a good deal of time
    • Are not guaranteed to produce any meaningful results even from the most successful program
  • Diarrhea is caused by many different pathogens through many different transmission routes
  • Confounding factors
  • Need to have an adequate control group
  • Results have little diagnostic power
an alternative to epidemiology
An Alternative to Epidemiology
  • WHO’s Minimum Evaluate Procedure

functioningO&M

construction

use

benefits

Assumption that by implementing good practices that health will follow

We need to identify the crucial good hygiene practices

Develop infrastructure that reliably delivers safe water and that minimizes contact with human waste

a few good practices
A few good practices

1

Convenient water source to facilitate washing

Education about the disease pathways and good hygiene practices

Safe waste handling to reduce contamination in the home and to others in the local community

Safe storage of water (or continuous supply) to prevent contamination in the home

Safe water at the tap to eliminate pathogens from the water source

2

3

?

4

5

review public health implications of water supply improvements1
Review: Public Health Implications of Water Supply Improvements
  • The life expectancy transition
  • The role of water supply, sanitation, and hygiene
    • In the Global North a century ago
    • In the Global South
  • The U5MR connection
  • Exposure Routes: breaking the cycle
  • Contaminants
  • Implications for successful interventions

Cornell Engineering Alumni Association <ceaa@cornell.edu>

would a cornell education help
Would a Cornell Education help?
  • If you moved to a poor neighborhood in Tegucigalpa, Honduras and raised a family would your children have a lower risk of dying than your neighbors?
  • Is there anything that you might do that would increase the survival odds for your children?
  • Does education help the individual?
  • Is there specific knowledge that makes a difference?
role of hygiene and education
Role of Hygiene and Education
  • Research in developing countries has shown that improvements in hygiene and sanitation have an even greater impact upon water-related diseases than improvements in water quality
  • Improvements in sanitation and personal hygiene reduce fecal-oral transmission 3 ways
    • Objects (especially household items and including hands)
    • Water
    • Food
  • Water QUANTITY may be more important than water quality

Consistent with my Typhoid hypothesis (indoor toilets with sinks)

Remember the Millennium Development Goal?

_________________________________________

Improved, not necessarily safe is a good first step!

the whole country runs better as the education level increases
The whole country runs better as the education level increases

Increased knowledge and

changed outlook

Institutional

modernization

Changed public under-

standing & behaviour

Better use of public

and private resources

Increased effects

of professional

‘interventions’

Increased income and better nutrition

Better health

how might education increase child survival
How might education increase child survival?
  • The whole country runs better as the education level increases
    • Education as an indicator of how well the country responds to the needs of its citizens
    • Education helps the group
  • Individuals make changes in personal habits that
    • improve their own health
    • and the health of those they interact with
    • Education helps the individual
intervention waterborne sewage replace land application

Increase

No Change

Decrease

Unknown

Intervention - Waterborne Sewage replace Land Application

Sanitation method

Pathogen source

Environment

Transport

washing

Drinking water

Human excreta

Hands

Dry sanitation involving reuse

Surface water

Water

Waterborne sewage

Oral

Ground water

Crops

Non recycling latrines

Food

Animal excreta

Land application

Flies

Soil

intervention personal hygiene

Increase

No Change

Decrease

Unknown

Intervention – Personal Hygiene

Sanitation method

Pathogen source

Environment

Transport

washing

Drinking water

Human excreta

Hands

Dry sanitation involving reuse

Surface water

Water

Waterborne sewage

Oral

Ground water

Crops

Non recycling latrines

Food

Animal excreta

Land application

Flies

Soil

hypothetical intervention
Hypothetical Intervention
  • What are the public health effects of providing pure drinking water in abundance to a community that practices land application of waste and poor personal hygiene?

Continued transmission of pathogens on solid objects (hands, food, dishes)

Hygiene education and empowerment could improve health substantially especially given the abundance of water

brainstorm
Brainstorm
  • What are the public health issues of the way water is handled?
  • You are about to eat lunch in this home. What are the risks?
    • Water is carried from a spring that is 0.5 km away
    • Water from a mountain stream is piped to the house (every 3rd day)
contaminants
Contaminants
  • Pathogens
  • Sediment
    • Turbidity (light scatter)
    • Inorganic or organic particles
    • Inhibits disinfection
      • pathogens “hide”
      • Chlorine demand
  • Dissolved Natural organic matter
    • Color (absorb light)
    • Chlorine demand
    • Combine with chlorine to produce Disinfection By Products
  • Arsenic
  • Nitrate
  • Synthetic organic compounds
a sample of waterborne pathogens
A sample of Waterborne Pathogens
  • Enteropathogenic Escherichia coli (EPEC)
  • Vibrio cholerae - Cholera
  • Salmonellatyphi - Typhoid
  • Cryptosporidium parvum
  • Hepatitis A
enteropathogenic escherichia coli epec
Enteropathogenic Escherichia coli (EPEC)
  • Enteropathogenic Escherichia coli (EPEC) strains are one of several categories of pathogenic E. coli strains that cause diarrhea. EPEC infections are prevalent on six continents
  • In many parts of the world, EPEC strains are the most common bacterial cause of diarrhea in infants
  • Disease due to EPEC can be severe, refractory to oral rehydration, protracted, and lethal
cryptosporidium parvum
Cryptosporidium parvum
  • Cryptosporidium parvum, a single-celled animal, i.e., a protozoa, is an obligate intracellular parasite.
  • Cryptosporidium sp. infects many herd animals (cows, goats, sheep among domesticated animals, and deer and elk among wild animals). It is currently thought that the form infecting humans is the same species that causes disease in young calves.
  • The infective stage of the organism, the oocyst is 3 mm in diameter.
  • The sporocysts are resistant to most chemical disinfectants, but are susceptible to drying and the ultraviolet portion of sunlight.
  • How widespread is Cryptosporidium?
  • This might affect our interventions.
hepatitis a virus
Hepatitis A Virus
  • Hepatitis A is usually a mild illness characterized by sudden onset of fever, malaise, nausea, anorexia, and abdominal discomfort, followed in several days by jaundice. The infectious dose is unknown but presumably is 10-100 virus particles.
  • HAV is excreted in feces of infected people and can produce clinical disease when susceptible individuals consume contaminated water or foods.
  • In developing countries, the incidence of disease in adults is relatively low because of exposure to the virus in childhood. (Immunity!)
  • In the U.S., the percentage of adults with immunity increases with age (10% for those 18-19 years of age to 65% for those over 50).
what works to improve health
What works to improve health?
  • Residual protection is necessary*
    • Chlorine
    • Locked down POU treatment systems (with faucet)
      • User can’t get their hands into the system
      • But they could still put the water into a cup that isn’t clean
    • SODIS (because you drink out of the container)
  • Product is key for chlorine (technology matters!)
    • Quality assured
    • Technically correct
    • Implementable

CDC safe water program results

*Is it the chlorine residual or is it that to get a chlorine residual the water has to be clear?

implications for successful interventions
Implications for Successful Interventions
  • Break the major pathogen loops…
  • …for the major pathogens
  • Remove sediment and color for effective disinfection
  • Household Hygiene is important
  • Sanitation (waste disposal) is important
  • We need more information on the efficacy of the various water purification technologies so we can break the waterborne route
conclusions on hygiene and health and water 1
Conclusions on Hygiene and Health and Water (1)
  • In order to achieve the primary objective of improving the health status of the community there is a need to improve attitudes, both with respect to hygiene in home and general health education, and implement these in conjunction with community water supply and environmental sanitation programs
  • Most waterborne diseases spread through exposure of food and drinking water to human feces
  • Hence, the rate of infection may be reduced by improving practice for disposal of human waste, as well as improving hygiene in the home and water quality and food hygiene

Home hygiene and environmental sanitation: a country situation analysis for India

K.J. NATH

conclusions on hygiene and health and water 2
Conclusions on Hygiene and Health and Water (2)
  • A supply of safe water would be of little benefit if it became contaminated because of unhygienic practices in the home
  • Correct storage and handling of food and drinking water should be an important component of any program for promoting domestic hygiene
  • On the other hand, improvement in the hygiene behavior of a community cannot be sustained without a concurrent improvement in the quality of environmental sanitation and the supply of safe drinking water

Home hygiene and environmental sanitation: a country situation analysis for India

K.J. NATH

conclusions on hygiene and health and water 3
Conclusions on Hygiene and Health and Water (3)
  • Consistent supply of clean water is important
    • Hand washing
    • Household hygiene (food, dishes, work surfaces)
  • Clean water must be protected from contamination in the home
    • Pilas used for water storage in Central America provide a direct path for contamination within a household
    • Elevated enclosed tanks would be a much better solution (see Mexico!)
what did we forget
What did we forget?
  • What do people want?
    • Easy access to plenty of safe, aesthetically pleasing water
    • Judge based on __________________________
  • Will they be willing to pay for and maintain more expensive infrastructure to have aesthetically pleasing water?
    • We are competing with bottled water
    • Can we make tap water as reliable as bottled water?

looks and taste/smell