Transcript I. Exposure - Sustainable Sanitation
Chapter 3. Sanitation and public health
How am I exposed?
What happens in me if I am exposed (different pathogens) Cases and participatory Approaches on different Community levels !
Can we manage the risks?
Which are the health Targets and guideline Procedures?
From where do pathogen come?
How can treatment and interventions minimize transmission?
Caroline Schönning, Swedish Institute for Infectious Disease Control (SMI), Sweden
3.1 Exposure and effects in humans
Learning objective :
To know and be familiar with pathogens of concern in water and sanitation systems, including the symptoms they cause and the effect on the individuals/population
DALYs – a general measure for health
The Global Burden of Disease (GBD)
Murray and Lopez, 1996
Disability Adjusted Life Years (DALY) morbidity: years lived with a disability mortality: years lost DALY (loss of healthy lived years) = n x t x S • • • n = number of affected persons t = the duration of the health effect S = measure of the severity of the health effect (mortality = 1)
Hypothetical example of DALYs
Quality of life Index 1.0
Remaining “disability”
0.8
0.4
0 20
Acute (infectious) illness
40 Age
Premature death by 65
60
Years lost
80
Leading DALYs in in the world 1990 & 2020
Disease/Injury Lower respiratory Diarrhoeal Perinatal period Depression Heart disease Tuberculosis Road accidents HIV Lung cancers Murray
et al.
(1996) Science 274:740-743 Rank 1 1990 2020 %DALYs Rank %DALYs 8.2
6 3.1
2 3 4 7.2
6.7
3.7
9 11
2
2.7
2.5
5.7
5 7 9 28 33 3.4
2.8
2.5
0.8
0.6
1
7
3
10 15
5.9
3.1
5.1
2.6
1.8
”The sanitary revolution” - the most important medical milestone since 1840 !? (BMJ, 2007)
DALYs attributable to risk factors
Water and sanitation causes a major part (9%) of GBD, that largely could be prevented. (WHO, 2008)
Diseases contributing to the water-, sanitation and hygiene-related disease burden
PEM: protein-energy malnutrition (Adapted from WHO, 2008)
Global risk factors for disease and premature deaths (% of DALYs)
Child underweigth for age Unsafe water, sanitation, hygiene Low fruit & vegetable intake Zinc deficiency Iron deficiency aaemia Vitamin A deficiency Child underweight ~7.9% Nutrition deficiencies ~7.4% Water & sanitation ~3.4%
Total targeted by ”Ecosan”: ~18.6%
in Sub-Saharan Africa ~7.6% 854 million chronically hungry 2 billion without food security FAO, 2006 Ref: Lopez et al. 2006. Global and regional burden of disease and risk factors; FAO, 2006
Infectious diseases
Frequency of infection World ´s most common – karies Commonly existing diarrhoea and food poisoning Unusual opportunistic infections in immunocompromised individuals Symptoms None (e.g. polio) Mild diarrhoea (e.g. Staphylococcus food poisoning) Life-threatening loss of water and salts (e.g. cholera)
The field of Epidemiology
Definitions (1) The study of the relationships of the various factors determining the frequency and distribution of diseases in a human community.
(2) The field of medicine that attempts to determine the exact causes of localized outbreaks of disease. (Ologies & -Isms. Copyright 2008 The Gale Group, Inc) The start in the middle of the 19th century Cholera epidemics in London - consumption of water implied an increased risk for disease (John Snow) Established that germs or bacteria cause infectious disease (Pasteur, 1857)
Occurrence of disease
Prevalence The number of cases in a defined population at a specified point in time Incidence The number of new cases arising in a given period in a specified population
Transmission of infectious agents
Direct transmission Touching Kissing Sexual intercourse Other contact Airborne, short distance via droplets, coughing, sneezing Transfusion (blood) Transplacental Indirect transmission Vehicle-borne (contaminated food, water, towels, farm tools etc.) Vector-borne (insects, animals) Airborne, long distance via dust and droplets Parenteral (injections with contaminated syringes)
Consequences of exposure
Exposure No infection Infection Susceptible Immune Recovered No symptoms Symptoms of disease Death
Infectious dose
Minimum infectious dose ID 50 Probability of infection Dose-response curves Severity of disease depending on Ingested dose The condition of the mechanical barrier The stability of the normal enteric flora Immunity The nutritional status of the individual
Immunity – vulnerable groups
More vulnerable groups in the society The old (elderly) Infants Pregnant women Immunocompromised Malnourished These groups comprise about 20% of the general population and are growing
Epidemiology - Definitions
Pandemic:
An epidemic (a sudden outbreak) that becomes very widespread and affects a whole region, a continent, or the world.
By contrast: An
epidemic
affects more than the expected number of cases of disease occurring in a community or region during a given period of time. An
endemic
is present in a community at all times but in low frequency. (http://www.medterms.com/script/main/art.asp?articlekey=4751)
Epidemic to endemic illnesses as detected by health surveillance
Outbreak detected Threshold for detection for an outbreak Endemic rate Undetected outbreak Hyperendemic Sporadic
Time
Diarrhoea and sanitation
Causes ~1/5 of deaths in children <5 years (1.5 million) Has decreased, in 1980 ´s estimated 2/3 of deaths Less significant decrease in diarrhoeal disease in low income countries Infections related to water and sanitation 4.1% of the total DALY 88% of the burden attributable to unsafe water supply, sanitation and hygiene Improved sanitation can reduce diarrhoea by ~32% 391 million cases averted if MDG target met
Regional differences in average health burdens from diarrhoeal diseases
Source:
Our Planet Current annual diarrhea cases in SSA: 1.2 billion which lead to 769.000 dead children, mostly under 5 years
Treatment of diarrhoea
Program in the 1980 ´s for rehydrating children – avoiding death Infromation, campaigns by WHO, UNICEF Did not give the expected success – less use than anticipated Symptoms are common Do not visit a medical doctor Start treatment late or not at all Want antibiotics or medicine that stops diarrhoea
Example: Ceará in Brasil
Death from diarrhoea decreases Decrease in incidence or better treatment?
General improvement of livelihood e.g. water quality, sanitation, waste management, income, litearcy, health care, vaccination No single factor related to lower number of diarrhoea cases Continued studies of the real situation
Diarrhoeal diseases – Outbreaks related to water and sanitation
Cholera 36 reported outbreaks from 2006-2009 (WHO) Risk during flooding “Natural environmental” spread Typhoid fever Also endemic Shigellosis
Cholera epidemic
Acute watery diarrhoea, very deadly without rapid treatment Affects adults as much as children, especially informal caretakers High political profile : can be used as a political leverage Characteristics for cholera outbreaks high attack rate low mortality economic and social burden Factors of spread density of population transportation facilities living conditions environmental reservoirs
Consequences of cholera outbreaks
Social Burden
Cholera Outbreak
Health impact
Health Care Facilities overwhelmed More supplies, more staff
Economic burden “Psychological” impact
Panic Media
Political impact
Who is responsible?
Classification of communicable diseases related to water and sanitation
Water-borne diseases:
caused by the ingestion of water
contaminated by human or animal faeces or urine
containing pathogenic bacteria or viruses or parasites; include cholera, typhoid, amoebic and bacillary dysentery and other diarrhoeal diseases.
Water-washed diseases:
caused by poor personal hygiene and skin or eye contact with contaminated water; include scabies, trachoma and flea, lice and tick-borne diseases.
Water-based diseases:
caused by parasites found in intermediate organisms living in water; include dracunculiasis, schistosomiasis and other helminths.
(Other) Water-related diseases:
caused by insect vectors which breed in water; include dengue, filariasis, malaria, onchocerciasis, trypanosomiasis and yellow fever. (WHO, 1996)
Waterborne pathogens
– important in water and sanitation system
Bacteria
The leading cause of gastrointestinal infections according to surveillance systems
Salmonella
,
Shigella
,
Campylobacter, E. coli (toxinprod.)
EHEC
Legionella
Opportunistic e.g.
Aeromonas hydrophila
Virus
Probably the cause of many outbreaks, difficult to detect Noroviruses (Calici-, Norwalk like), rotavirus, hepatitis A
Waterborne pathogens
– important in water and sanitation system
Protozoa
Complicated life cycles with resistent stages (chlorine)
Giardia
,
Cryptosporidium, Entamoeba
Low infectious dose Milwaukee (USA) 1993, 400 000 individuals
Helminths (worms)
Varying transmission routes, e.g. soilborne
Ascaris, Trichuris, Schistosoma
(bilharzia), hookworm A large problem in many developing countries
Shigella
Salmonella infection – Salmonellosis and Typhiod fever
Salmonellosis
cramps – diarrhea, fever, and abdominal Caused by a variety of serotypes, e.g.
Salmonella
Typhimurium and
Salmonella
Enteridis Foods contaminated with animal feces Animal origin (meat, poultry, eggs), vegetables Pets – handwashing important
Paratyphoid and Typhoid fever
- fever and other symptoms, life-threatening Caused by
Salmonella
Typhi Contaminated food or water More common in areas with low sanitary standard
Schistosoma
Also known as bilharzia 200 million people are infected worldwide Variety of symptoms Freshwater contaminated by urine or faeces Life-cycle requires specific snail as host
Viral gastroenteritis
What is viral gastroenteritis? Inflammation of the stomach and small or large intestines Caused by a variety of viruses that results in vomiting or diarrhea Often called ”stomach flu" (but not caused by the influenza viruses) What causes viral gastroenteritis? Many different viruses For example: rotaviruses, adenoviruses, caliciviruses, astroviruses, Norwalk virus, and a group of Norwalk-like viruses (later called calicivirus, norovirus)
Rotavirus
Rotavirus is the most common cause of severe diarrhea among children Globally, rotavirus is estimated to cause 527,000 deaths in children annually Vomiting and watery diarrhea for 3 8 days, and fever and abdominal pain occur frequently Immunity after infection is incomplete Vaccination possible but not widespread (http://www.cdc.gov/rotavirus)
Previously called calicivirus or Norwalk (Like) viruses Transmission
Perspn-to-person Food-borne Waterborne
Ascaris
Ascaris
Ascaris lumbricoides
is one of the largest and most common parasites found in humans It is estimated that 10% of the world's population is infected with this nematode The adult worms live in the small intestine and eggs are passed in the feces - a single female can produce up to 200,000 eggs each day
Ascaris lumbricoides
, fertilized egg. The egg is covered with a thick shell that appears lumpy approximate size = 65 µm in length. The adult worm. Adult females of this species can measure up to 18 inches long (males are generally shorter).
Ascaris
Cryptosporidium
Cryptosporidium
is a small parasite, about 3 5 µm.
It lives on the surface of the cells lining the small intestine and oocysts are passed in the feces.
Transmission of the infection occurs via the oocysts.
Many human infections have been traced to the contamination of drinking water with oocysts from agricultural "run-off" (i.e., drainage from pastures), so it is considered a zoonosis.
Cryptosporidium
Giardia
Giardia intestinalis Giardia duodenalis
(also known as
Giardia lamblia
or soil, food, or water that has been contaminated with feces Common in both developing and developed areas
Giardia lamblia
trophozoites live in the small intestine of the host. Cysts, which are resistant to adverse environmental conditions, are passed in the feces of an infected host, and the next host is infected when it ingests cysts in food or water contaminated with feces.
The trophozoites adhere closely to the lining of the small intestine, and in heavy infections much of the lining can be covered with trophozoites. The giardiasis symptoms range from none (in light infections) to severe, chronic diarrhea (in heavy infections).
Features of some gastrointestinal infections
Salmonella Campylobacter
EHEC Hepatitis A Rotavirus Norovirus Adenovirus
Cryptosporidium Giardia Ascaris
Morbidity (%)
6-80 25 76-89 70 50 70 54 39 20-40 15
Excretion (g -1 faeces)
10 4-8 10 6-9 10 2-3 10 4-6 10 7-11 10 5-9 10 11 10 7-8 10 5-8 10 4
Excretion time (days)
26-51 1-77 5-12 13-30 1-39 5-22 1-14 2-30 28-284 107-557
ID 50
23 600 900 1 120 30 6 10? 1.7 165 35 0.7 (Westrell, 2004)
Emerging pathogens
Emerging diseases Newly recognized or Increasing importance Zoonoses Many emerging pathogens of zoonotic origin Animal faeces contaminate water Climate change Increased risks related to water and sanitation Affects food-production
Protozoa and helminths in faecal material
Faecal samples from 120 urine-diverting latrines in KwaZulu-Natal, South Africa Varying features – water-filled to dry (normal) Analysing for presence of: parasitic protozoa
Giardia Cryptosporidium
and helminths
Ascaris lumbricoides,
T
richuris trichiura
and
Taenia
spp (Trönnberg et al., 2010)
Protozoa and helminths in faecal material
Parasites 54% positive for Giardia 21% positive for Cryptosporidium Helminths 59%
Ascaris lumbricoides
48%
Trichuris trichiura
18%
Taenia
spp In 73% of the 120 household toilets, one or several types of helminths were found Prevalence by family (at least one member infected) Supports theory of high prevalence in certain areas Treatment needed before use of faeces (Trönnberg et al., 2010)