Introduction to the course

Introduction to Household Water Treatment and Safe Storage, Module 1.1

Dr. Richard Johnston

Course outline
Quizzes and homework
Course forum





Introduction

Introduction to HWTS| 2
Week 1
Background
Disease
Contamination
Week 2
Water Safety
Sedimentation
Filtration
Week 3
Disinfection
Safe storage
Week 4
Implementation
Strategies
Vulnerable groups
Week 5
Validating
technologies
Monitoring and
evaluation
Health Impacts
Outline
Introduction to HWTS| 3

In-video quizzes
End of week quizzes
Peer-reviewed assignment
Final exam
Quizzes and Homework
Introduction to HWTS| 4
General discussion

Study groups
Lectures
Exercises

Course material errors
Technical issues
Online forums
Introduction to HWTS| 5
End of module

End of week


Summary
Introduction to HWTS| 6
Global Burden of Disease
Introduction to Household Water Treatment and Safe Storage, Module 1.2
Dr. Richard Johnston
Introduction to HWTS | 2
Diseases caused by unsafe water
and sanitation
Water-borne
Water-washed
Water-based
Water-related

Global burden of disease
Mortality
Morbidity
Introduction

Introduction to HWTS | 3
8.4 deaths/1,000
55 million people per year


19.9 births/1,000
135 million people per year


About 1.1% increase per year
Doubling every 60 years

Birth, taxes, and death
Introduction to HWTS | 4
Bradley Classification

Water-borne
Water-washed
Water-based
Water-related










Disease Classification System
Introduction to HWTS | 5
Water-borne diseases
Caused by ingestion of water

Diarrheal diseases
Rotavirus
Cholera, Shigella
Cryptosporidiosis
Hepatitis A and E
Polio

Improve water quality


Introduction to HWTS | 6
Water-washed diseases
Caused by poor hygiene due to
lack of water

Most water-borne diseases

Trachoma
Acute respiratory infections

Increase water quantity



Introduction to HWTS | 7
Water-based diseases
Caused by parasites which live
part of their life cycle in water

Schistosomiasis (bilharzia)
Dracunculiasis (Guinea worm)


Target aquatic organism host
Protect surface water bodies




Introduction to HWTS | 8
Water-related diseases
Caused by insects which breed
in water

Malaria
Dengue fever


Remove habitat



Introduction to HWTS | 9
Many diseases are related to poor
water, sanitation, and hygiene
Water-borne diseases are caused
by ingestion of contaminated
drinking-water
HWTS can reduce burden of water-
borne diseases
Not water-washed, water-based, or water-
related diseases
Summary

Introduction to HWTS | 10
Mini-Quiz
Arrange the following five diseases in order of the number of deaths per year
Tuberculosis
Diarrheal disease
Lower respiratory
infections
(e.g. pneumonia)
Malaria
Measles
Introduction to HWTS | 11
Mini-Quiz
Source: WHO in 2013 published figures for 2011. Data files
Tuberculosis
Diarrheal disease
Lower respiratory
infections
(e.g. pneumonia)
Malaria
Measles
976,000
1,894,000
3,203,000
589,000
167,000
Introduction to HWTS | 12
1.9 million diarrheal deaths per year
Most important water-borne disease
3.5% of all deaths
9.3% of under 5 child deaths
Second only to respiratory infection
among infectious diseases
88% of diarrheal deaths are caused
by inadequate water, sanitation and
hygiene
2011: Data not yet disaggregated
2004: 1.9 million WASH deaths out of
2.2 million diarrheal deaths
Diarrheal disease

Introduction to HWTS | 13
Disability Adjusted
Life Years (DALYs)

DALY = YLL + YLD

YLL = Years of Life Lost
Number of deaths Standard
life expectancy at age of death in
years

YLD = Years Lived with Disability
Number of incident cases
Disability weight Average
duration of the case (years)

Introduction to HWTS | 14
Diarrhea causes 52.5 M DALYs/year
3.1% of global total
9% of child disease burden


India 13.6 M
China 3.9 M
Nigeria 3.9 M
Pakistan 3.3 M
DRC 3.3 M
10% of all DALYs

Diarrheal morbidity

Source: WHO, 2008
Introduction to HWTS | 15
Global Burden of Disease 2010 Study (IHME)

Introduction to HWTS | 16
Similar approach to WHO methods

Not endorsed by WHO
Methods not fully transparent
Lacked full access to results for evaluation

Some key differences with WHO
numbers
Revised disability weights
No hygiene risk factor
No disease burden from improved water and
sanitation
GDB 2010 Study

Introduction to HWTS | 17
http://www.healthmetricsandevaluation.org/gbd
Introduction to HWTS | 18
1.5 million diarrheal deaths

89.5 million DALYs
India 27 M
DRC 6.4 M
Nigeria 6.2 M
Pakistan 5.5 M
China 1.3 M

Only 25% diarrheal deaths due to
poor water and sanitation
Water and sanitation: 0.9% of DALYs
Hygiene not included
GDB 2010 Study

Introduction to HWTS | 19
WHO calculations
2011: data and maps
1.9 million diarrheal deaths
52.5 million DALYs from diarrhea
Disaggregated by disease and age
2004: data and maps
2.2 million diarrheal deaths
Disaggregated by disease, age, country, region, risk factor

IHME calculations
2010: data and maps
1.5 million diarrheal deaths
89.5 million DALYs from diarrhea

Burden of Disease
Summary

Introduction to HWTS | 20
Burden of disease from poor WASH
is high

Diarrheal disease is a leading cause
of mortality and morbidity

Different online resources

Next: Microbial Water Quality
Conclusion

Water-borne pathogens
Introduction to Household Water Treatment and Safe Storage, Module 1.3
Dr. Richard Johnston
Different classes of pathogens
Helminths
Protozoa
Bacteria
Viruses



Introduction


Protozoa
E. coli
Toxic forms
Shigella
Vibrio cholera


Bacteria
Rotavirus
Hepatitis A and E
Polio

Viruses




Guinea worm

Credit: The Carter Center




Guinea worm

Credit: The Carter Center / L. Gubb




Guinea worm

Credit: The Carter Center / L. Gubb




Guinea worm

Credit: The Carter Center / E. Staub
Summary
Helminths
Dracunuculiasis (Guinea worm)
Larvae in insect host
~1000 m
Protozoa
Cryptosporidium, Entamoeba, Giardia
Can form resistant cysts
~10 m
Bacteria
E. coli, Shigella, Vibrio cholera
~1 m
Viruses
Rotavirus, Hepatitis A and E, poliovirus
~0.1 m

How does Drinking Water become unsafe?
Introduction to Household Water Treatment and Safe Storage, Module 1.4
Dr. Richard Johnston
Introduction to HWTS | 2
Microbial safety
Diarrheal disease
Faecal pathogens

Indicators of faecal contamination

F-diagram

Chemical safety
Introduction

Introduction to HWTS | 3
be universally present in faeces of humans and animals
in large numbers
be present in higher numbers than faecal pathogens
not be pathogenic
be readily detected by simple, inexpensive methods
persist in water in a similar manner to faecal pathogens
not multiply in natural waters
respond to treatment in a similar fashion to faecal pathogens
The ideal faecal indicator should

Introduction to HWTS | 4

Total coliforms (TC)










Common faecal indicators
Total Coliforms
Introduction to HWTS | 5

Total coliforms (TC)
Ferment lactose, producing acid and gas at 35
o
C
Citrobacter, Klebsiella, Hafnia
Enterobacter
E. coli, Salmonella, Shigella, Yersinia

Not useful as faecal indicator
Many non-faecal sources

Operational monitoring
Effectiveness of treatment
Cleanliness and integrity of distribution system










Common faecal indicators
Total Coliforms
Introduction to HWTS | 6

Total coliforms (TC)

Thermotolerant coliforms (TTC)










Common faecal indicators
Total Coliforms
Thermotolerant
Coliforms
Introduction to HWTS | 7

Total coliforms (TC)

Thermotolerant coliforms (TTC)
Ferment lactose within 48 h at 44
o
C
Previously: Faecal coliforms
10
6
-10
9
cells per gram faeces

Some indication of non-faecal TTC
Klebsiella, some Enterobacter spp.

May grow or die off at ambient temperature










Common faecal indicators
Total Coliforms
Thermotolerant
Coliforms
Introduction to HWTS | 8

Total coliforms (TC)

Thermotolerant coliforms (TTC)

Escherichia coli (EC)










Common faecal indicators
Total Coliforms
Thermotolerant
Coliforms
E. coli
Introduction to HWTS | 9

Total coliforms (TC)

Thermotolerant coliforms (TTC)

Escherichia coli (EC)
Generally considered most suitable indicator
Some possibility of growth in environment
Only moderately persistent, resistant











Common faecal indicators
Total Coliforms
Thermotolerant
Coliforms
E. coli
Introduction to HWTS | 10
Indicator count
per 100 mL
Risk level
<0 A Conformity
1-10 B Low
11-100 C Intermediate
101-1000 D High
>1000 E Very high










Relative risk
Introduction to HWTS | 11









Relative risk matrix
0 1 2 3 4 5 6 7 8 9
E
D
C
B
A
No
Action
Low
Risk
Intermediate
Risk
Very high
Risk
Sanitary Inspection Score
E
.

c
o
l
i

l
e
v
e
l

Introduction to HWTS | 12










Other faecal indicators

Coliphage viruses
Require bacteria for hosts

Faecal streptococci
Lower numbers than coliforms
More persistent, resistant

Bacterial spores
Similar to protozoa
Highly persistent, resistant
Clostridium perfringens
Bacillus spp.


Introduction to HWTS | 13
The F-Diagram
Introduction to HWTS | 14
Opportunities for contamination
1
Water Resource
2
Delivery system
3
Collection and Transport
4
Household storage
5
Consumption
Introduction to HWTS | 15
E. coli is the preferred indicator
bacteria for faecal contamination

The F-Diagram shows how faecal
pathogens can be distributed in the
environment, and be ingested by a
new host

Drinking water can become
contaminated in a variety of ways
along the water chain.


Summary

What is HWTS?
Introduction to Household Water Treatment and Safe Storage, Module 1.5
Dr. Richard Johnston
Household Water Treatment
Sedimentation
Filtration
Disinfection

Safe Storage

Introduction

Removal of suspended solids,
turbidity

Gravity Settling

Coagulation
Plant-based
Aluminium and iron salts

Sedimentation
Water is passed through porous
material
Ceramic filters
Synthetic membranes
Biological filters

Gravity or external pressure

Particles removed

Challenge of fouling, clogging
Filtration

Disinfection: heat

Disinfection: ultraviolet radiation

Disinfection: chlorine
To prevent recontamination

Small opening
Possible to clean

Tap to dispense water hygienically


Safe storage
Introduction to future processes

Detailed explanations will consider
Efficiency against different classes of
pathogens
Advantages
Challenges

No one process is the best


Summary

HWTS and the MDGs
Introduction to Household Water Treatment and Safe Storage, Module 1.6
Dr. Richard Johnston
What are the Millennium
Development Goals?

How does HWTS fit into them?


Introduction

Introduction to HWTS| 2
The Millennium Development Goals

1. Eradicate extreme poverty and hunger
2. Achieve universal primary education
3. Promote gender equality and empower women
4. Reduce child mortality
5. Improve maternal health
6. Combat HIV/AIDS, malaria and other diseases
7. Ensure environmental sustainability
8. Develop a global partnership for development

Introduction to HWTS| 3
The Millennium Development Goals

1. Eradicate extreme poverty and hunger
2. Achieve universal primary education
3. Promote gender equality and empower women
4. Reduce child mortality
5. Improve maternal health
6. Combat HIV/AIDS, malaria and other diseases
7. Ensure environmental sustainability
8. Develop a global partnership for development

Target 7C: To halve, by 2015, the proportion of people without
sustainable access to safe drinking water and basic
sanitation.
Introduction to HWTS| 3
HWTS can contribute to sustainable
access to safe water
Short- or medium-term measure
MDG 7 needs quantity and access
HWTS contributes to other MDGs
MDG 4: reduce child mortality
MDG 6: combat HIV/AIDS, malaria, and other
diseases
MDG 1: links with malnutrition
MDG 2: links with education



Sustainable access to safe water

Introduction to HWTS| 4
HWTS contributes to the MDG
target for safe water
And other targets

Not an indicator in its own right
Doesnt equal sustainable access to safe
water


Summary

Introduction to HWTS| 5
International Network on Household Water
Treatment and Safe Storage (The Network)
A platform for researchers, practitioners and policy makers in HWTS
Michael Forson, (co-host of the Network)
WASH Specialist (Water Supply and quality)
UNICEF, New York
The HWTS Network | 2
The issue What triggered the network
Why a network?
The Network strategy
Network mission
Network objectives
Network Targets
Hosting and implementation arrangements
Membership and Benefits of participation
Key Achievements
Challenges what worked (is working) and what
did not
Way forward
Participation and benefits
Outline

The HWTS Network | 3
A large part of the worlds population is without access to drinking-water from
improved sources (768 million; 2011); several billion more, without access to SAFE
drinking-water.
Millions, often in urban areas, served by unreliable piped systems are force to store
drinking-water with significant risks of contamination.
Millions are affected by emergency situations where water, sanitation and health
services may have broken down partially or completely, posing risk to the safety of
the drinking water.
Diarrhoeal death major cause of child mortality; safe drinking-water important
prevention intervention
The Issue . What triggered the Network?
Stanford University/AmyPickering
The HWTS Network | 4
Why a Network?
WHO convened a multi-stakeholder meeting
in Feb 2003 to identify a platform that will
cover all stakeholders to address the issues
identified, and a network was deemed the
best forum to be used in this case

The HWTS Network | 5
A network is a forum, information
clearinghouse and vehicle to
promote collective, bilateral and
individual action on the part of its
stakeholders
A network encourages
communication, cooperation and
coordinated action while optimizing
flexibility, participation and
creativity.
As a network we can
Monitor and map global efforts to inform
advocacy, implementation and investment
Raise awareness about the role of HWTS
with one understanding and support
governments in decision making
Conduct agreed targeted and coordinated
research to increase effective use of HWTS
=> health gains (impacts)
Maximize collective gains in HWTS based
on individual gains

Why a Network? The advantages
The HWTS Network | 6






Strategic
consultations

PHASE 2 PHASE 1
How things evolved down the timeline .
2
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WHO conceived
the idea to
facilitated a forum
for promotion of
HWTS based on
health gains
Multi-
stakeholder
consultative
meeting in
Feb 2003
7-point strategy
for comprehensive
diarrhoea control
adopted by WHO
and UNICEF. HWTS
is mentioned as a
key intervention
Letters of exchange
to co-host the
Network was signed
between UNICEF and
WHO
HWTS/WSP
workshop in
Nagpur India to
explore linkages
between the 2
West African
Regional HWTS
workshop held in
Accra, Ghana
South African
Regional HWTS
Workshop Held
in Mozambique
East African
Regional
HWTS
Workshop
Held in
Uganda
Plenary Meeting
Nairobi, Kenya
June 2004.
1
st
5 year strategic
plan (2003 2008)
developed.
Strategic
consultation in
Geneva proposing
co-hosting with
UNICEF
We are now
here
The HWTS Network | 7
To contribute to a significant
reduction in water-borne and water-
related vector-borne diseases,
especially among vulnerable
populations, by promoting household
water treatment and safe storage as
a key component of community-
targeted environmental health
programmes.
HWTS Network Global Strategy 2011 - 2016

Mission statement
The HWTS Network | 8
Objectives
HWTS evidence base of public health
relevance significantly strengthened
Tangible results in the scaling-up of
household water treatment and safe
storage achieved globally
National policies and institutional
frameworks developed (=> integration of
environmental health interventions)
Best practice in HWTS programmes
evaluated and disseminated for
advocacy purposes
Targets
By 2015, 30 countries have established
policies on household water treatment
and storage.
By 2015, strengthened evidence to
guide effective and replicable HWTS
programmatic approaches to achieve
long-term widespread use and public
health impact.
By 2020, 50 countries have achieved
country-wide scale up of project-based
HWTS.

HWTS Network Global Strategy 2011 - 2016
The HWTS Network | 9
Currently over 160 membership
Connect with a global Network of HWTS experts, including
senior officials, programme implementers, researchers, and
on-the-ground practitioners
Receive the latest news on HWTS projects, meetings, and
events through the Network listserv and newsletter
Find out who is active where and engage with those who
have faced similar challenges
Have your work disseminated and highlighted in Network
communications material
Have a voice in the annual network meeting and therefore to
have input to the annual work plan
Have access to an online, interactive webspace to share files
and discuss matters of interest with Network participants


Participation and benefits
The HWTS Network | 11
Responsibilities within the secretariat
WHO
Knowledge Advancement
Research
Knowledge Management
Technology assessment
Policy and Advocacy
Global and National level
advocacy
Policy formulation and review
UNICEF
Capacity Development
Training workshops
dissemination of best practices,
etc
Monitoring
Global progress in HWTS
Mapping country level
implementations
UNC
Maintain Regular and
constant communication
within the secretariat
The HWTS Network | 14

Key Achievements
Hosted over half-dozen regional workshops
leading to the formation of over 20 national HWTS
action plans
Developed toolkit and harmonized indicators to
strengthen monitoring and implementation
Raised awareness for integration among key
public health efforts (HIV/AIDS, maternal/child
health, nutrition) on role of HWTS
Supporting quality assurance through the HWTS
evaluation scheme
Global capacity building through strategic webinars

The HWTS Network | 15
What worked (is working)
Co-hosting arrangement harnessed the strengths of
both organizations
Regional workshops (focused, controlled)
Integration with other environmental health projects
On-going challenges
Working groups started well, but died off. Like a
community of practice
Ambitious budget
Need clear alignment and harmonization between Water
Safety Plans and HWTS
Advisory group was working great, however faced with
challenges of participation

What worked (is working) and on-going challenges

The HWTS Network | 16
HWTS Network webpage:
http://www.who.int/household_water/network/en/
HWTS Network communications portal
http://waterinstitute.unc.edu/hwts


More information and links
Week 1 Summary
Introduction to Household Water Treatment and Safe Storage, Module 1.8
Dr. Richard Johnston
Global Burden of Disease
Disease classification system
Morbidity (DALYs) and mortality from diarrheal
disease
Estimates from WHO and IHME

Water-borne pathogens
Helminths, protozoa, bacteria, viruses





Week 1 Summary

Contamination pathways
F-diagram
Faecal indicator bacteria

First glance at treatment processes
Sedimentation
Filtration
Disinfection (heat, ultraviolet, chemical)
Safe storage





Week 1 Summary

HWTS and the MDGs

The HWTS Network





Week 1 Summary