Have we substantially underestimated the impact of improved sanitation coverage on child health?:A generalized additive model panel analysis of global data on child mortality and malnutrition

Background: Although widely accepted as being one of the most important public health advances of the past hundred years, the contribution that improving sanitation coverage can make to child health is still unclear, especially since the publication of two large studies of sanitation in India which found no effect on child morbidity. We hypothesis that the value of sanitation does not come directly from use of improved sanitation but from improving community coverage. If this is so we further hypothesise that the relationship between sanitation coverage and child health will be non-linear and that most of any health improvement will accrue as sanitation becomes universal. Methods: We report a fixed effects panel analysis of country level data using Generalized Additive Models in R. Outcome variables were under 5 childhood mortality, neonatal mortality, under 5 childhood mortality from diarrhoea, proportion of children under 5 with stunting and with underweight. Predictor variables were % coverage by improved sanitation, improved water source, Gross Domestic Product per capita and Health Expenditure per capita. We also identified three studies reporting incidence of diarrhoea in children under five alongside gains in community coverage in improved sanitation. Findings: For each of the five outcome variables, sanitation coverage was independently associated with the outcome but this association was highly non-linear. Improving sanitation coverage was very strongly associated with under 5 years diarrhoea mortality, under 5years all-cause mortality, and all-cause neonatal mortality. There was a decline as sanitation coverage increased up to about 20% but then no further decline was seen until about 70% (60% for diarrhoea mortality and 80% for neonatal mortality, respectively). The association was less strong for stunting and underweight but a threshold about 50% coverage was also seen. Three large trials of sanitation on diarrhoea morbidity gave results that were similar to what would have been predicted by our model. Conclusions: Improving sanitation coverage may be one of the more effective means to reduce childhood mortality, but only if high levels of community coverage are achieved. Studies of the impact of sanitation that focus on the individual’s use of improved sanitation as the predictor variable rather than community coverage is likely to severely underestimate the impact of sanitation

A Faecal Contamination Index for interpreting heterogeneous diarrhoea impacts of water, sanitation and hygiene interventions and overall, regional and country estimates of community sanitation coverage with a focus on low- and middle-income countries

Objectives: The impact on diarrhoea of sanitation interventions has been heterogeneous. We hypothesize that this is due to the level of prevailing faecal environmental contamination and propose a Faecal Contamination Index (FAECI) of selected WASH indicators (objective 1). Additionally, we provide estimates of the proportion of the population living in communities above certain sanitation coverage levels (objective 2). Methods: Objective 1: Faecal contamination post-intervention was estimated from WASH intervention reports. WASH indicators composing the FAECI included eight water, sanitation and hygiene practice indicators, which were selected for their relevance for health and data availability at study- and country-level. The association between the estimated level of faecal environmental contamination and diarrhoea was examined using meta-regression. Objective 2: A literature search was conducted to identify health-relevant community sanitation coverage thresholds. To estimate total community coverage with basic sanitation in low- and middle-income countries, at relevant thresholds, household surveys with data available at primary sampling unit (PSU)-level were analysed according to the identified thresholds, at country-, regional- and overall level. Results: Objective 1: We found a non-linear association between estimated environmental faecal contamination and sanitation interventions’ impact on diarrhoeal disease. Diarrhoea reductions were highest at lower faecal contamination levels, and no diarrhoea reduction was found when contamination increased above a certain level. Objective 2: Around 45% of the population lives in communities with more than 75% of coverage with basic sanitation and 24% of the population lives in communities above 95% coverage, respectively. Conclusions: High prevailing faecal contamination might explain interventions' poor effectiveness in reducing diarrhoea. The here proposed Faecal Contamination Index is a first attempt to estimate the level of faecal contamination in communities. Much of the world's population currently lives in faecally contaminated environments as indicated by low community sanitation coverage

Global assessment of exposure to faecal contamination through drinking water based on a systematic review

Objectives: To estimate exposure to faecal contamination through drinking water as indicated by levels of Escherichia coli (E. coli) or thermotolerant coliform (TTC) in water sources. Methods: We estimated coverage of different types of drinking water source based on household surveys and censuses using multilevel modelling. Coverage data were combined with water quality studies that assessed E. coli or TTC including those identified by a systematic review (n = 345). Predictive models for the presence and level of contamination of drinking water sources were developed using random effects logistic regression and selected covariates. We assessed sensitivity of estimated exposure to study quality, indicator bacteria and separately considered nationally randomised surveys. Results: We estimate that 1.8 billion people globally use a source of drinking water which suffers from faecal contamination, of these 1.1 billion drink water that is of at least 'moderate' risk (>10 E. coli or TTC per 100 ml). Data from nationally randomised studies suggest that 10% of improved sources may be 'high' risk, containing at least 100 E. coli or TTC per 100 ml. Drinking water is found to be more often contaminated in rural areas (41%, CI: 31%-51%) than in urban areas (12%, CI: 8-18%), and contamination is most prevalent in Africa (53%, CI: 42%-63%) and South-East Asia (35%, CI: 24%-45%). Estimates were not sensitive to the exclusion of low quality studies or restriction to studies reporting E. coli. Conclusions: Microbial contamination is widespread and affects all water source types, including piped supplies. Global burden of disease estimates may have substantially understated the disease burden associated with inadequate water services

Diseases due to unhealthy environments: an updated estimate of the global burden of disease attributable to environmental determinants of health

The update of the global burden of disease attributable to the environment is presented. The study focuses on modifiable risks to show the potential health impact from environmental interventions.; Systematic literature reviews on 133 diseases and injuries were performed. Comparative risk assessments were complemented by more limited epidemiological estimates, expert opinion and information on disease transmission pathways. Population attributable fractions were used to calculate global deaths and global disease burden from environmental risks.; Twenty-three percent (95% CI: 13-34%) of global deaths and 22% (95% CI: 13-32%) of global disability adjusted life years (DALYs) were attributable to environmental risks in 2012. Sixty-eight percent of deaths and 56% of DALYs could be estimated with comparative risk assessment methods. The global disease burden attributable to the environment is now dominated by noncommunicable diseases. Susceptible ages are children under five and adults between 50 and 75 years. Country level data are presented.; Nearly a quarter of global disease burden could be prevented by reducing environmental risks. This analysis confirms that eliminating hazards and reducing environmental risks will greatly benefit our health, will contribute to attaining the recently agreed Sustainable Development Goals and will systematically require intersectoral collaboration to be successful

Burden of disease from inadequate water, sanitation and hygiene for selected adverse health outcomes: An updated analysis with a focus on low- and middle-income countries

Background To develop updated estimates in response to new exposure and exposure-response data of the burden of diarrhoea, respiratory infections, malnutrition, schistosomiasis, malaria, soil-transmitted helminth infections and trachoma from exposure to inadequate drinking-water, sanitation and hygiene behaviours (WASH) with a focus on low- and middle-income countries. Methods For each of the analysed diseases, exposure levels with both sufficient global exposure data for 2016 and a matching exposure-response relationship were combined into population-attributable fractions. Attributable deaths and disability-adjusted life years (DALYs) were estimated for each disease and, for most of the diseases, by country, age and sex group separately for inadequate water, sanitation and hygiene behaviours and for the cluster of risk factors. Uncertainty estimates were computed on the basis of uncertainty surrounding exposure estimates and relative risks. Findings An estimated 829,000 WASH-attributable deaths and 49.8 million DALYs occurred from diarrhoeal diseases in 2016, equivalent to 60% of all diarrhoeal deaths. In children under 5 years, 297,000 WASH-attributable diarrhoea deaths occurred, representing 5.3% of all deaths in this age group. If the global disease burden from different diseases and several counterfactual exposure distributions was combined it would amount to 1.6 million deaths, representing 2.8% of all deaths, and 104.6 million DALYs in 2016. Conclusions Despite recent declines in attributable mortality, inadequate WASH remains an important determinant of global disease burden, especially among young children. These estimates contribute to global monitoring such as for the Sustainable Development Goal indicator on mortality from inadequate WASH

Burden of disease from inadequate water, sanitation and hygiene in low- and middle-income settings: a retrospective analysis of data from 145 countries

objective To estimate the burden of diarrhoeal diseases from exposure to inadequate water, sanitation and hand hygiene in low- and middle-income settings and provide an overview of the impact on other diseases. methods For estimating the impact of water, sanitation and hygiene on diarrhoea, we selected exposure levels with both sufficient global exposure data and a matching exposure-risk relationship. Global exposure data were estimated for the year 2012, and risk estimates were taken from the most recent systematic analyses. We estimated attributable deaths and disability-adjusted life years (DALYs) by country, age and sex for inadequate water, sanitation and hand hygiene separately, and as a cluster of risk factors. Uncertainty estimates were computed on the basis of uncertainty surrounding exposure estimates and relative risks. results In 2012, 502 000 diarrhoea deaths were estimated to be caused by inadequate drinking water and 280 000 deaths by inadequate sanitation. The most likely estimate of disease burden from inadequate hand hygiene amounts to 297 000 deaths. In total, 842 000 diarrhoea deaths are estimated to be caused by this cluster of risk factors, which amounts to 1.5% of the total disease burden and 58% of diarrhoeal diseases. In children under 5 years old, 361 000 deaths could be prevented, representing 5.5% of deaths in that age group. conclusions This estimate confirms the importance of improving water and sanitation in low- and middle-income settings for the prevention of diarrhoeal disease burden. It also underscores the need for better data on exposure and risk reductions that can be achieved with provision of reliable piped water, community sewage with treatment and hand hygiene

Assessing the impact of drinking water and sanitation on diarrhoeal disease in low- and middle-income settings: Systematic review and meta-regression

Objective: To assess the impact of inadequate water and sanitation on diarrhoeal disease in low- and middle-income settings. Methods: The search strategy used Cochrane Library, MEDLINE & PubMed, Global Health, Embase and BIOSIS supplemented by screening of reference lists from previously published systematic reviews, to identify studies reporting on interventions examining the effect of drinking water and sanitation improvements in low- and middle-income settings published between 1970 and May 2013. Studies including randomised controlled trials, quasi-randomised trials with control group, observational studies using matching techniques and observational studies with a control group where the intervention was well defined were eligible. Risk of bias was assessed using a modified Ottawa-Newcastle scale. Study results were combined using meta-analysis and meta-regression to derive overall and intervention-specific risk estimates. Results: Of 6819 records identified for drinking water, 61 studies met the inclusion criteria, and of 12 515 records identified for sanitation, 11 studies were included. Overall, improvements in drinking water and sanitation were associated with decreased risks of diarrhoea. Specific improvements, such as the use of water filters, provision of high-quality piped water and sewer connections, were associated with greater reductions in diarrhoea compared with other interventions. Conclusions: The results show that inadequate water and sanitation are associated with considerable risks of diarrhoeal disease and that there are notable differences in illness reduction according to the type of improved water and sanitation implemented

From Cancer to Diarrhea: The Moving Target of Public Concern about Environmental Health Risks

Public concern about the environment can be unpredictable because it is influenced by numerous factors. Environmental health issues often emerge as important because the public is worried about their health especially when it comes to cancer. Public fear of cancer from environmental exposures is reinforced by many of the US regulations that set pollutant limits based on reducing the risk of cancers rather than other health outcomes. While fear of cancer will never dissipate, recent foodborne outbreaks are contributing to raising public awareness of the health effects from microbes. This paper adds to the dialogue about the challenges of enhancing public understanding of environmental health issues. Internal factors, such as worry, that contribute to public outrage are sometimes more important than external factors such as the media. In addition, relying on the media to inform the public about imminent public health risks may be an ineffective approach to enhancing understanding. In the end, scientists and risk communicators are forced to compete with politicians who are often very effective at manipulating public understanding of risk

Interpreting the Global Enteric Multicenter Study (GEMS) Findings on Sanitation, Hygiene, and Diarrhea

Sanitation and hygiene are global concerns, as reflected in international development and human rights policy . The Sustainable Development Goals (SDGs) include target 6.2: to “achieve access to adequate and equitable sanitation and hygiene for all and end open defecation”. Globally, about 2.5 billion people do not use improved sanitation, of whom 1 billion defecate in the open. Fecal contamination of the environment and poor handwashing are responsible for an estimated 577,000 deaths annually. This is likely an underestimation: there is emerging evidence that poor sanitation and hygiene contribute to undernutrition and could be responsible for approximately half of all child stunting. Much of the health impact of inadequate sanitation and hygiene is attributed to diarrheal disease and its secondary effects. However, diarrhea is difficult to measure, and sanitation and hygiene are difficult to link to health outcomes

Data Integration Model for Air Quality: A Hierarchical Approach to the Global Estimation of Exposures to Ambient Air Pollution

This is the author accepted manuscript. Available from arXiv via the URL in this record.Air pollution is a major risk factor for global health, with both ambient and household air pollution contributing substantial components of the overall global disease burden. One of the key drivers of adverse health effects is fine particulate matter ambient pollution (PM2:5) to which an estimated 3 million deaths can be attributed annually. The primary source of information for estimating exposures has been measurements from ground monitoring networks but, although coverage is increasing, there remain regions in which monitoring is limited. Ground monitoring data therefore needs to be supplemented with information from other sources, such as satellite retrievals of aerosol optical depth and chemical transport models. A hierarchical modelling approach for integrating data from multiple sources is proposed allowing spatially-varying relationships between ground measurements and other factors that estimate air quality. Set within a Bayesian framework, the resulting Data Integration Model for Air Quality (DIMAQ) is used to estimate exposures, together with associated measures of uncertainty, on a high resolution grid covering the entire world. Bayesian analysis on this scale can be computationally challenging and here approximate Bayesian inference is performed using Integrated Nested Laplace Approximations. Model selection and assessment is performed by cross-validation with the final model offering substantial increases in predictive accuracy, particularly in regions where there is sparse ground monitoring, when compared to previous approaches: root mean square error (RMSE) reduced from 17.1 to 10.7, and population weighted RMSE from 23.1 to 12.1 gm3. Based on summaries of the posterior distributions for each grid cell, it is estimated that 92% of the world’s population reside in areas exceeding the World Health Organization’s Air Quality Guidelines.Matthew Lloyd Thomas is supported by a scholarship from the EPSRC Centre for Doctoral Training in Statistical Applied Mathematics at Bath (SAMBa), under the project EP/L015684/1. Amelia Jobling was supported for this work by WHO contracts APW 201255146 and 201255393