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Pathogens & Contaminants

Compiled by:
Gina S. Itchon, Robert Gensch (Xavier University), Marco Bruni (seecon international gmbh)
Adapted from:
STENSTROEM, A.; SEIDU, R.; EKANE, M.; ZURBRUEGG, C. (2011)

Executive Summary

A wide range of substances can drastically harm both public health and the environment. Hazardous substances that might be present in drinking water mainly include pathogens (microorganisms) and contaminants (inorganic chemicals, organic chemicals and metals). Contamination of drinking water with pathogens including bacteria, viruses, parasitic protozoa and helminths is the major factor for prevalence of diseases in developing countries. Faeces infiltrating drinking water sources are most often responsible for contamination with pathogens. Likewise, contaminants in drinking water originating from both human activities (anthropogenic) and natural processes (geogenic) incorporate large health risks depending on their concentration.

Sources and Dispersion of Pathogens and Contaminants

Sources of Pathogens and Contaminants

All waters (i.e. surface water, groundwater/aquifers) can become contaminated from many types of human activities as well as from natural sources. Agricultural, commercial, industrial, and residential development can all contribute to groundwater contamination (WALLIN 1997).

Potential rural contamination sources

Potential rural contamination sources. Source: BUCHANAN et al. (2010)

Examples of activities that could negatively affect groundwater if not managed properly include:

  • Chemical storage
  • Accidental spills of hazardous materials
  • Spreading of sewage treatment sludge
  • Septic systems
  • Storage and spreading of road salt
  • Animal feedlots
  • Underground pipelines or sewers
  • Use and spilling of fertilisers and pesticides
  • Landfills / open solid waste dumpings
  • Private and abandoned wells (CONSERVATION ONTARIO 2009).

Dispersion of Pathogens and Contaminants

Contaminants percolate permeable soil layers together with infiltrating water. Once reaching groundwater level, they spread not only horizontally but usually also vertically throughout the whole groundwater body (WAL 2010).

Bacteria migration

Migration of contaminants in an unconfined (left) and a confined (right) aquifer. Source: WAL (2010)

The concentration of most pathogens (but not necessarily chemicals) decreases gradually with depth as they are decomposed. Hence, in unconfined aquifers or if a confined aquifer is beyond the reach of available drilling technologies, wells should be drilled as deep as possible (WAL 2010). In a confined aquifer, the impermeable layer prevents contaminants from further vertical migration into the underlying aquifer making groundwater below this layer free from surficial contamination. As a consequence, confined aquifers generally are less susceptible to contamination (WAL 2010).

While soluble contaminants (e.g. pathogens, water-soluble contaminants, heavy metals, etc.) mix with groundwater, insoluble contaminants (e.g. oil or many solvents like trichloroethene (TCE)) do not mix with or dissolve as easily. Consequently, they accumulate either on the groundwater level or at the top of an impervious layer depending on their density.

 Insoluble contaminants being heavier than water seep down until they reach impervious layers where they spread horizontally.

Movement of insoluble contaminants in ground water. Left: Oil spills (lighter than water) accumulate on the water table and spread horizontally. Right: Insoluble contaminants being heavier than water seep down until they reach impervious layers where they spread horizontally. Adapted from FREEZE et al. (n.y.)

General Effects of Pathogens and Contaminants

Drinking water contamination result in poor drinking water quality and can cause a loss of a community’s drinking water supply, high restoration costs, high costs for providing alternative drinking water supplies, and a high potential for community health problems. Additionally, contaminants can adversely affect environmental systems and causing the provision of ecosystem functions to fail. 

Pathogens (Microorganisms)

Waterborne or excreta related diseases are still significant causes of mortality and morbidity in many developing countries. The transmission routes of these and the health risk factors involved are important, in order to design and implement or modify excreta use schemes so that the transmission of these diseases are reduced (see also health risk management). The pathogens of concern for environmental transmission through faeces mainly cause gastrointestinal symptoms such as diarrhoea, vomiting and stomach cramps. Several may also cause symptoms involving other organs and severe sequels or be an interrelated factor for malnutrition. Major pathogens may be viruses, bacteria, parasitic protozoa, and helminthes. The table below summarises the most common organisms in each category and the signs and symptoms or disease associated with them:

Pathogen

Disease (Symptoms)

Bacteria

Aeromonas spp

Enteritis

Campylobacter jejuni/coli

Campylobacteriosis (diarrhoea, cramping, abdominal pain, fever, nausea; arthritis; Guillain-Barré syndrome)

Escherichia coli (EIEC, EPEC, ETEC, EHEC)

Enteritis

Plesiomonas shigelloides

Enteritis

Salmonella typhi/paratyphi

Typhoid/paratyphoid fever (headache, fever, malaise, anorexia, bradycardia, splenomegaly, cough)

Salmonella spp.

Salmonellosis (diarrhoea, fever, abdominal cramps)

Shigella spp.

Shigellosis (dysentery - bloody diarrhoea, vomiting, cramps, fever; Reiter’s syndrome)

Vibrio cholera

Cholera (watery diarrhoea, lethal if severe and untreated)

Yersinia spp.

Yersinioses (fever, abdominal pain, diarrhoea, joint pains, rash)

Virus

Enteric adenovirus 40 and 41

Enteritis

Astrovirus

Enteritis

Calicivirus (incl. Noroviruses)

Enteritis

Coxsackievirus

Various: respiratory illness, enteritis, viral meningitis

Echovirus

Aseptic meningitis, encephalitis (often asymptomatic)

Enterovirus types 68-71

Meningitis, encephalitis, paralysis

Hepatitis A

Hepatitis (fever, malaise, anorexia, nausea, abdominal discomfort, jaundice)

Hepatitis E

Hepatitis

Poliovirus

Poliomyelitis (often asymptomatic, fever, nausea, vomiting, headache, paralysis)

Rotavirus

Enteritis

Parasitic protozoa

Cryptosporidium parvum/hominis

Cryptosporidiosis (watery diarrhoea, abdominal cramps and pain)

Cyclospora cayetanensis

(often asymptomatic; diarrhoea; abdominal pain)

Entamoeba histolytica

Amoebiasis (often asymptomatic, dysentery, abdominal discomfort, fever, chills)

Giardia intestinalis

Giardiasis (diarrhoea, abdominal cramps, malaise, weight loss)

Helminthes (parasitic worms)

Ascaris lumbricoides

 

Ascariasis (generally no or few symptoms; wheezing; coughing; fever; enteritis; pulmonary eosinophilia)

Taenia solium/saginata

Taeniasis

Trichuris trichiura

Trichuriasis(unapparent through vague digestive tract distress to emaciation with dry skin and diarrhoea)

Ancylostoma duodenale(Hookworm)

(Itch; rash; cough; anaemia; protein deficiency)

Schistosomiasis spp

Schistosomiasis, bilharzia

Example of pathogens that may be excreted in faeces (can be transmitted through water and improper sanitation) and related diseases, including examples of symptoms they may cause. Source: STENSTROEM et al. (2010); adapted from OTTOSON (2003)

All infections related to faeces are likewise representative for anal cleansing and ablution water. Infections related to faeces have traditionally been centred on enteric pathogenic bacteria. In developing countries with insufficiently functioning sanitation systems, outbreaks of cholera, typhoid and shigellosis still are of major concern. Among the bacteria, at least Salmonella, Campylobacter and Enterohaemorrhagic E. coli (EHEC) are of general importance, both in industrialised and developing countries, when microbial risks from various fertiliser products are considered, including faeces, sewage sludge or animal manure.

conradin 2004 ganges river

The Ganges River, where a lot of untreated sewage is disposed in, is one of the most heavily polluted rivers on the earth. Source: CONRADIN (2004)

Environmental Risks of Faeces, Urine and Greywater

More than 120 different types of viruses may be excreted in faeces, including members of the enteroviruses, rotavirus, enteric adenoviruses and human caliciviruses (noroviruses) groups. Hepatitis A is also of major concern and the importance of Hepatitis E is emerging, when applying wastes to land and is considered a risk for both water- and food- borne outbreaks, especially when the sanitary standard are low.

The parasitic protozoa, Cryptosporidium and Giardia are occurring with high prevalence as an enteric pathogen. Entamoeba histolytica is also recognised as an infection of concern in developing countries. Others like Cyclospora and Isospora may also be of concern.

In developing countries, geohelminth infections are of major concern. The eggs (ova), of especially Ascaris and Taenia are very persistent in the environment. Hookworm disease is widespread in most tropics and subtropics areas, and affects nearly one billion people worldwide. These infections exaggerate malnutrition. The eggs from Ascaris and hookworms that are excreted in the faeces require a latency period and favourable conditions in soil or deposited faeces to hatch into larvae and become infectious.

Schistosoma haematobium are excreted both in faeces and urine while other types of Schistosoma, e.g. S. japonicum and S. mansoni are just excreted in faeces. More than 200 million people are currently infected with Schistosomiasis. The use of treated excreta should not have an impact but fresh or untreated faecal material, which should not be used, constitute a risk when applied close to fresh water sources where the snail is present.

Environmental transmission of urinary excreted pathogens is of limited concern in temperate climates, but any faecal cross-contamination that may occur by misplacement of faeces in the urine-diverting toilet ends up in the urine fraction and is a determinant of possible health risk. Also in tropical climates, faecal contamination of collected urine may be considered as the greatest risk but some urinary-transmitted pathogens also need to be considered. The pathogens excreted in urine are Leptospira interrogans, Salmonella typhi, Salmonella paratyphi and Schistosoma haematobium. There is a range of other pathogens, including some of the human viruses that have been detected in urine but their presence may normally be considered insignificant for further risk of environmental transmission.

The main hazard of greywater is, as for urine, due to faecal cross-contamination. Faecal contamination is limited in amounts when one is considering the traditional fractions of greywater, like washing faecally contaminated laundry (i.e. diapers), childcare and showering. If anal cleansing is combined in greywater the risk is enhanced. In many situations, other sources of faecal contamination in greywater occurs, but is often forgotten or not considered in a system perspective. In reality, these will be the main drivers for the subsequent microbial health risks.

See also use of urine and faeces in agriculture.

Transmission of Diseases

HESPERIAN 2004 F Diagram

Faecal-oral transmission routes include: Fingers, flies (and other insects), fields (agriculture), food, and fluids, e.g. contaminated water. Source: HESPERIAN & UNDP (2004)

The infectious organisms are released from the bodies of infected persons in their excreta, eventually reaching other people, that may be infected via either the mouth, for example when being in contact with contaminated areas and accidentally transmitting minute quantities to the mouth, when contaminated crops are eaten or when drinking contaminated water) or through contact with the skin (e.g., hookworm and schistosomiasis) or through inhalation of contaminated aerosols or particulate material.

The relative importance of these pathogens in causing illnesses depends in addition on a number of factors including their persistence in the environment, minimum infective dose, ability to induce human immunity, and latency periods (SHUVAL et al. 1986). Thus pathogens with a higher probability of causing infections are those that:

  • Have long persistence in the environment.
  • Have low minimal infective doses.
  • Elicit little or no human immunity.
  • Have long latency periods.

The amount and variability of the pathogens will depend mainly on the infection among the population served and the scale of the sanitation system (see also health risk management). Thus, in low income countries, where there is a high prevalence of excreta related diseases, a greater number of pathogens are more likely to be introduced into a sanitation systems, compared to a developed countries where the prevalence of such diseases is generally low (see also toilet systems).

Incidence Rate of Diseases

The incidence rate of a disease is the yearly number of reported cases divided by the total population, often expressed per 100 000 people. The incidence will vary due to the prevailing epidemiological situation within an area. The reported number of cases is often substantially underestimated and pathogens causing less severe symptoms are less likely to be reported. The disease incidence and excretion factors will, in general terms, give their concentration at the time of excretion and the subsequent risks will relate to environmental persistence and die-off, dilution factors, exposure and the dose that humans are exposed to. The later further relate to the efficiency of technical and behavioural barriers within the system context (see also health risk management).

Contaminants

Contaminants in water sources affecting public health can be divided into three categories:

 
Inorganic Chemicals

Inorganic chemicals comprise some of the most common and mobile contaminants in groundwater. Such contaminants include nitrate, ammonia, sodium, chloride, fluoride, and arsenic. Nitrate contamination from sewage and agricultural practices occurs over large areas. Salt in groundwater can be the result of the upwelling of highly mineralised geothermal or sea water in coastal areas, and road de-icing. Fluoride and arsenic can occur naturally in areas containing sediments derived from igneous rocks. Nitrate and chloride do not adsorb readily on to soil materials and can be transported great distances.

E.g. nitrate, ammonia, sodium, chloride, fluoride, cyanide, arsenic, etc.

Organic Chemicals

Organic compounds are carbon and hydrogen-based chemicals, some of which occur naturally. However, it is mainly the human-produced chemicals that are of concern. These chemicals include solvents, pesticides, and other industrial chemicals. Organic chemicals are removed from groundwater by chemical reactions and microbial activity. Many organic compounds, however, particularly those containing chlorine, can remain in the subsurface for many years. Many organic chemicals are highly toxic and cause severe health problems such as birth defects and cancer. 

E.g. petro-chemicals (oil, diesel), plastic, solvents, pesticides, chlorine, paint, etc.

Metals

Metals, including heavy metals, are also of environmental concern. The transport of metals is controlled by their solubility. The solubility of metals is dependent on pH. The pH of water can be affected by acid drainage from mining activities. Dissolved metals can also be adsorbed onto large organic molecules in water and be transported by them.

E.g. cadmium, copper, lead, mercury, etc. 

Contaminant groups. Source: WALLIN (1997)

References Library

BUCHANAN, B; DE LA CRUZ, N.; MACPHERSON, J.; WILLIAMSON, K. (2010): Water Wells that Last for Generations. Edmonton: Alberta Agriculture and Rural Development. URL [Accessed: 23.04.2012].

CONSERVATION ONTARIO (Editor) (2009): Wellhead Protection Areas. Newmarket: Conservation Ontario. URL [Accessed: 17.04.2012]. PDF

FREEZE, R.A.; ATWATER, J.; LIEBSCHER, H. (n.y.): Water Stewardship . Ground Water Resources of British Colombia. Victoria: The Province of British Columbia. URL [Accessed: 17.04.2012].

HESPERIAN FOUNDATION (Editor); UNDP (Editor) (2004): Sanitation and Cleanliness for a Healthy Environment. Berkeley: The Hesperian Foundation. URL [Accessed: 17.04.2012]. PDF

See document in SPANISH, CREOLE

OTTOSSON (2003): Hygiene Aspects of Greywater and Greywater Reuse. (= Licenciate thesis). Royal Institute of Technology/ Swedish Institute of Infectious Disease Control.

SHUVAL, H.I.; ADIN, A.; FATTAL, B.; RAWITZ, E.; YEKUTIEL, P. (1986): Wastewater Irrigation in Developing Countries. Health Effects and Technical Solutions. Washington, D.C.: The World Bank. URL [Accessed: 27.03.2012].

STENSTROEM, A.; SEIDU, R.; EKANE, M.; ZURBRUEGG, C. (2011): Microbial Exposure and Health Assessments in Sanitation Technologies and Systems. (= EcoSanRes Series, 1). Stockholm: Stockholm Environment Institute (SEI). URL [Accessed: 28.11.2011]. PDF

WAL, A. van der (2010): Understanding Groundwater & Wells in Manual Drilling. Instruction Handbook for Manual Drilling Teams on Hydro-geology for Well Drilling, Well Installation and Well Development. Papendrecht: Practica Foundation. URL [Accessed: 21.03.2012].

WALLIN, R. (1997): Wellhead Protection: A Guide for Arizona Communities. TUCSON: Arizona Department of Environmental Quality, Water Quality Division. URL [Accessed: 17.04.2012]. PDF

Further Readings Library

Reference icon

BARRETT, M. (2002): Groundwater and Sanitation; Nutrient Recycling and Waterborne Disease Cycles. (= Proceedings of the First International Conference on Ecological Sanitation, 5th to 8th November 2001). Stockholm: EcoSanRes, Stockholm Environmental Institute. URL [Accessed: 11.10.2010]. PDF

A short summary about the waterborne disease cycle. Groundwater is often contaminated with pathogens which originate from human excreta. Therefore, the aim should be to break the waterborne disease cycle. At the same time, it should be possible to use excreta as nutrients without contaminating groundwater. The author proposes some methods how this can be reached.


Reference icon

CONFALONIERI, U.; MENNE, B.; AKHTAR, R.; EBI, K.L.; HAUENGUE, M.; KOVATS, R.S.; REVICH, B.; WOODWARD, A.; Parry, M.L. (Editor); Canziani, O.F. (Editor); Palutikof, J.P. (Editor); Linden, P.J. van der (Editor); Hanson, C.E. (Editor) (2007): Human Health. Climate Change 2007: Impacts, Adaptation and Vulnerability. Contribution of Working Group II to the Fourth Assessment Report of the Intergovernmental Panel on Climate Change. Cambridge: Cambridge University Press. PDF

A chapter about the impacts of climate change on human health. There is evidence that the climate change altered the distribution of some infectious disease vectors. The burden of diarrhoeal diseases will increase as well as the number of people which suffer from dengue as just to cite some effects of the ongoing climate change.


Reference icon

COTRUVO, J.A.; DUFOUR, A.; REES, G.; BATRAM, J.; CARR, J.; CLIVER, D.O.; CRAUN, G.F.; FAYER, R.; GANNON, V.P.J. (2004): Waterborne Zoonoses: Identification, Causes, and Control. Geneva: World Health Organisation (WHO). URL [Accessed: 11.10.2010]. PDF

An encyclopaedia which contains everything about waterborne diseases. It handles also the prevention, the controls and risk of these diseases as well as the description of them. Furthermore, the document contains an outlook for the future.


Reference icon

HAVELAAR, A. H.; MELSE, J. M. (2003): Quantifying Public Health Risk in the WHO Guidelines for Drinking Water Quality. Geneva: World Health Organisation (WHO). URL [Accessed: 11.10.2010]. PDF

This edition of WHO Guidelines contains a preventive management framework for safe drinking water. The framework provides the methodology of DALY (Disability Adjusted Life Years), which allows an exact classification of diseases. This can help to evaluate health priorities.


Reference icon

JENKINS, J. (2005): The Humanure Handbook. A Guide to Composting Human Manure. (= 3rd Edition). Grove City: Joseph Jenkins Inc. . URL [Accessed: 16.08.2010].

A comprehensive book on recycling human excrement without chemicals, high technology or pollution. Well written, practical, and thoroughly researched, this self-published book is built on nearly twenty years of experience by the author, who tells us about every aspect of dealing with excrement on the home-scale level. Only available for free as web book.


Reference icon

JIMENEZ, B.; NAVARRO, I.; MAYA, C. (Editor) (n.y.): Pathogens in Dry Sanitations Systems and Risk of Using Sludge Produced in Agriculture. Mexico: University of Coyocan. URL [Accessed: 06.10.2010]. PDF

A paper about the most common pathogens which exist in faecal sludge and how to control these.


Reference icon

ROMA, E.; PUGH, I, (2012): Toilets for health. London: London School of Hygiene & Tropical Medicine. URL [Accessed: 27.11.2012]. PDF

This is a comprehensive report on why toilets matter. The report is rich in infographics, provides overview of the sanitation crisis and the related burden of disease in developing countries.


Reference icon

WHO (Editor) (2007): Chemical Safety of Drinking Water Assessing Priorities for Risk Management. Geneva: World Health Organization (WHO). URL [Accessed: 12.10.2011]. PDF

Identifying and prioritizing chemical risks presents a challenge, especially in developing countries, because information on the presence of chemicals in water supplies is often lacking. This document provides guidance to help readers to meet that challenge. It shows how information on aspects such as geology and industrial and agricultural development, which is often readily available, can be used to identify potential chemical contaminants (and potential sources of chemicals), from catchment to consumer, and thus prioritize risks. This is a supporting document to the Guidelines for Drinking-water Quality (WHO 2008 and WHO 2011), and it is aimed at policy-makers, regulators, managers and public health practitioners at national and local level.


Reference icon

WHO (Editor) (2007): Combating Waterborne Diseases at the Household Level. The International Network to Promote Household Water Treatment and Safe Storage. Geneva: World Health Organisation (WHO). URL [Accessed: 11.10.2010]. PDF

This document is divided into three main parts. The first part contains an introduction to the topic and depicts some possible, simple techniques for treating water at the household level. The second part describes the possibility of collaborating to fight against waterborne diseases and the last part presents again some low-cost solutions.


Reference icon

UNEP (2013): Costs of Inaction on the Sound Management of Chemicals. UNEP. URL [Accessed: 28.03.2013]. PDF

This document provides a practical assessment of the current state of knowledge of the economic costs of inaction on the sound management of chemicals. It aims to raise political awareness of the benefits stated in economic terms of providing resources to sound management of chemicals and to strengthen the rationale for inclusion of sound chemicals management priorities into national development policies and plans. It also aspires to build capacity for ongoing assessment at international, national, and local levels through demonstration and practical application of proven techniques. The report includes an extensive literary review in order to identify economic information on the health, environmental, and development planning effects of harmful chemicals. Chemicals reviewed within the scope of study include industrial, minerals and metals, agricultural, household chemicals and pharmaceuticals among others.


Reference icon

Graham, J.; Polizotto, M.L. (2013): Pit Latrines and Their Impacts on Groundwater Quality: a systematic Review. Advance Publication. In: Environmental Health Perspectives. URL [Accessed: 09.04.2013]. PDF

This study reviews empirical studies on the impact of pit latrines on groundwater quality and identifies knowledge gaps regarding the potential and consequences of groundwater contamination by latrines.


Reference icon

WORLD BANK (2013): Handwashing With Soap Toolkit. Washington: World Bank. URL [Accessed: 15.05.2013].

This toolkit, intended for practitioners interested in behavior change, is organized into four modules: Behaviour Change, Sustainability, Integration and Results. Each has reports and presentations about the lessons learned from previous projects, as well as mass media, direct consumer contact, and interpersonal communication tools used throughout previous projects.


Reference icon

GALAN, D.I.; KIM, S.; GRAHAM, J.P. (2013): Exploring Changes in Open Defecation Prevalence in Sub-Saharan Africa Based on National Level Indices. In: BMC Public Health 13, 1-12. URL [Accessed: 28.08.2013]. PDF

This study estimates the changes in open defecation prevalence between 2005 and 2010 across countries in Sub-Saharan Africa. It also explores the association between national level indices and changes in open defecation prevalence and assesses how many countries can achieve “open defecation free status” by 2015.


Reference icon

BROWN, J.; CAIRNCROSS, S.; ENSINK, J.H.J. (2013): Water, Sanitation, Hygiene and Enteric Infections in Children. In: Arch Dis Child, 1-6. URL [Accessed: 28.08.2013]. PDF

This article reviews the evidence linking water, sanitation and health measures to faecal-oral diseases in children. Estimates of the burden of water-, sanitation- and health-related disease are presented, followed by brief overviews of water, sanitation and hygiene-related transmission routes and control measures. It concludes with a summary of current international targets and progress.


Reference icon

INAUEN, J.; TOBIAS, R.; MOSLER, H.-J. (2013): Predicting Water Consumption Habits for Seven Arsenic-Safe Water Options in Bangladesh. In: BMC Public Health 13, 1-10. URL [Accessed: 28.08.2013]. PDF

In Bangladesh, 20 million people are at the risk of developing arsenicosis because of excessive arsenic intake. Despite increased awareness, many of the implemented arsenic-safe water options are not being sufficiently used by the population. This study investigated the role of social-cognitive factors in explaining the habitual use of arsenic-safe water options.


Reference icon

WHO (Editor) (2013): Safe Management of Wastes from Health-care Activities. (= Second Edition). Geneva: World Health Organization (WHO). URL [Accessed: 30.09.2013]. PDF

In many countries, knowledge about the potential for harm from health-care wastes has now become more prominent to governments, medical practitioners and civil society. The indiscriminate and erratic handling and disposal of waste within health-care facilities is now widely recognized as a source of avoidable infection, and is synonymous with public perception of poor standards of health care. Water pollution and inadequate wastewater treatment pose important risks to health.


Reference icon

USAID (Editor) (2013): Healthcare Waste. Sector Environmental Guidelines. Washington: United States Agency for International Development (USAID). URL [Accessed: 30.09.2013]. PDF

Currently, little or no management of healthcare wastes occurs in small-scale facilities in developing countries. Training and infrastructure are minimal. Common practice in urban areas is to dispose of healthcare waste along with the general solid waste or, in peri-urban and rural areas, to bury waste, without treatment. In some cities small hospitals may incinerate waste in dedicated on-site incinerators, but often fail to operate them properly. Unwanted pharmaceuticals and chemicals may be dumped into the local sanitation outlet, be it a sewage system, septic tank or latrine. The contamination of water sources represents serious health risks.


Reference icon

HARVEY, B. (2012): Water, Sanitation and Hygiene (WASH) in Health-Care Facilities in Emergencies. Technical Notes on Drinking-water, Sanitation and Hygiene in Emergencies. (= Technical Notes on Drinking-Water, Sanitation and Hygiene in Emergencies, 17). Geneva: World Health Organization (WHO). URL [Accessed: 30.09.2013]. PDF

Health-care facilities play a vital role within the community by providing essential medical care at all times including during emergencies. Any incident which causes loss of infrastructure, energy supply, loss of equipment, loss of staff or staff attrition, interruption to supply chains, or patient surge - such as sudden communicable disease epidemics, natural disasters (e.g. floods, earthquakes), or conflict - requires a holistic health response and recovery effort which includes actions to assess and restore basic WASH services.


Reference icon

SPERLING, M. von (2007): Wastewater Characteristics, Treatment and Disposal. (= Biological Wastewater Treatment Series, 1). London: International Water Association (IWA) Publishing. URL [Accessed: 01.11.2013]. PDF

Wastewater Characteristics, Treatment and Disposal is the first volume in the series Biological Wastewater Treatment, presenting an integrated view of water quality and wastewater treatment. This book covers the following topics: wastewater characteristics (flow and major constituents), impact of wastewater discharges to rivers and lakes, overview of wastewater treatment systems, complementary items in planning studies.


Reference icon

SPERLING, M. von (2007): Basic Principles of Wastewater Treatment. (= Biological Wastewater Treatment Series, 2). London: International Water Association (IWA) Publishing. URL [Accessed: 01.11.2013]. PDF

Basic Principles of Wastewater Treatment is the second volume in the series Biological Wastewater Treatment, and focusses on the unit operations and processes associated with biological wastewater treatment. The major topics covered are: microbiology and ecology of wastewater treatment, reaction kinetics and reactor hydraulics, conversion of organic and inorganic matter, sedimentation, aeration.


Reference icon

WHO (Editor) (2011): Guidelines for Drinking-water Quality, Fourth Edition. Geneva: World Health Organization (WHO) . URL [Accessed: 08.08.2011]. PDF

This volume of the Guidelines for Drinking-water Quality explains requirements to ensure drinking-water safety, including minimum procedures and specific guideline values, and how those requirements are intended to be used. The volume also describes the approaches used in deriving the guidelines, including guideline values. It includes fact sheets on significant microbial and chemical hazards.


Case Studies Library

Reference icon

RHEINGANS, R. (Editor); CUMMING, O. (Editor); ANDERSON, J. (Editor); SHOWALTER, J. (Editor) (2012): Estimating Inequities in Sanitation-related Disease Burden and Estimating the Potential Impacts of Propoor Targeting. London: London School of Hygiene and Tropical Medicine. URL [Accessed: 16.03.2012]. PDF

The objectives of this study are to model for 10 low-income countries in sub-Saharan Africa and South Asia: 1) The distribution of sanitation-related health burden by wealth quintile; 2) The distribution of health benefits for targeting different wealth quintile groups; 3) The spatial distribution of sanitation-related health burden and benefits


Reference icon

CONTZEN, N.; MOSLER, H.J. (2012): Factors Determining the Effectiveness of Oxfam’s Public Health Promotion Approach in Haiti. Duebendorf: Swiss Federal Institute of Aquatic Science and Technology (EAWAG). URL [Accessed: 24.04.2012]. PDF

In response to the devastating Earthquake of January 12th 2010 and the cholera outbreak of October of that same year Oxfam Great Britain, Oxfam Quebec and Intermón Oxfam conducted public health promotion and cholera response in Haiti. Different promotion activities were applied which aimed at changing hygiene behavior by changing perceptions and beliefs about healthy behaviors amongst people affected by crisis. In February 2011 four Oxfam affiliates in Haiti in partnership with a team of behavior change researchers from Eawag launched the present research project to do an in-depth evaluation of the promotional activities that had been conducted with the goal of further improving the WASH situation for people in Haiti and worldwide by understanding how to make hygiene promotion more effective. The main focus of the research project was around the question which specific promotion activities were strongly associated with perceptions and beliefs about handwashing with soap and were thus capable of changing handwashing behavior at key times.


Reference icon

OXFAM (Editor) (2012): Hygiene Promotion: Determining what Works. Cholera Response in Haiti. Boston: Oxfam International. URL [Accessed: 24.04.2012]. PDF

When a massive earthquake struck Haiti in January 2010, followed by a cholera epidemic that broke out in October of that year, Oxfam rushed assistance—clean water, sanitation, and hygiene materials and information—to hard-hit areas to protect public health.


Reference icon

LUOTO, J.; LEVINE, D.; ALBERT, J.; LUBY, S. (2013): Nudging to Use. Achieving Safe Water Behaviors in Kenya and Bangladesh. Berkeley: Center for Effective Global Action. URL [Accessed: 07.08.2013]. PDF

This paper presents results from two complementary field experiments conducted in rural western Kenya and the urban slums of Dhaka, Bangladesh. In both settings, participating households received free trials with a variety of point of use products as well as repeated educational messages about the importance of safe drinking water and its link with diarrheal illness.


Reference icon

XUAN, T. T.; RHEINLAENDER, T.; HOAT, L. N.; DALSGAARD, A.; KONRADSEN, F. (2013): Teaching Handwashing with Soap for Schoolchildren in a Multi-Ethnic Population in Northern Rural Vietnam. In: Global Health Action 6, 1-12. URL [Accessed: 28.08.2013].

This study aimed to investigate responses to a teacher-centered participatory Handwashing With Soap intervention in a multi-ethnic population of primary schoolchildren in northern rural Vietnam. It demonstrated that it is feasible to engage teachers and implement active teaching methods for behaviour change of hand washing with soap in a group of multi-ethnic primary schoolchildren without the need for major investments in water and hygiene infrastructures.


Awareness Raising Material Library

Reference icon

GEORGE, R. (2012): Dirty Little Secret: The Loo that Saves Lives in Liberia. London: The Guardian. URL [Accessed: 13.02.2012]. PDF

Diarrhoea kills more children than HIV/Aids, tuberculosis and malaria combined – and its main cause is food and water contaminated with human waste. Liberia's president is trying to change all that.


Reference icon

WIKIPEDIA (Editor) (n.y.): 1854 Broad Street cholera outbreak. San Francisco: Wikimedia Foundation Inc. URL [Accessed: 05.02.2013].

The Broad Street cholera outbreak was a severe outbreak of cholera that occurred near Broad Street in Soho district of London, England in 1854. This outbreak is best known for the discovery that cholera is spread by contaminated water. This discovery came to influence public health and the construction of improved sanitation facilities beginning in the 19th century.


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WSP (Editor) (2012): Behavioral Determinants of Handwashing with Soap Among Mothers and Caretakers: Emergent Learning from Senegal and Peru. Washington, D.C: Water and Sanitation Program (WSP). URL [Accessed: 27.02.2012]. PDF

A new Water and Sanitation Program (WSP) Learning Note found that beliefs and ease of access to soap and water were correlated with handwashing with soap behaviors for given proxy measures among mothers and caretakers in Peru and Senegal.


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UN Water; UN Water (Editor) (2013): Water Quality Factsheet. UN Water. URL [Accessed: 09.04.2013]. PDF

Thematic factsheet. Every day, 2 million tons of human wastes are disposed of in watercourses, and in developing countries 70 % of industrial wastes are dumped untreated into waters where they pollute the usable water supply. But not only industry contaminates our water resources, so do also agriculture. The contribution of the food sector to the production of organic water pollutants, are in high-income countries 40 % and in low-income countries 54 %.


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MBUYA, M. N.; HUMPHREY, J. H. (2015): Preventing Environmental Enteric Dysfunction through Improved Water, Sanitation and Hygiene. An Opportunity for Stunting Reduction in Developing Countries. In: Maternal & Child Nutrition. URL [Accessed: 03.05.2016]. PDF

In 2011, one in every four (26%) children under 5 years of age worldwide was stunted. The realization that most stunting cannot be explained by poor diet or by diarrhoea, nor completely reversed by optimized diet and reduced diarrhoea has led to the hypothesis that a primary underlying cause of stunting is subclinical gut disease. Essentially, ingested microbes set in motion two overlapping and interacting pathways that result in linear growth impairment.


Training Material Library

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EAWAG (Editor); SANDEC (Editor) (2008): Environmental Health. Lecture notes. (= Sandec Training Tool 1.0, Module 2). Duebendorf: Swiss Federal Institute of Aquatic Science (EAWAG), Department of Water and Sanitation in Developing Countries (SANDEC). URL [Accessed: 23.05.2012]. PDF

This book contains information on environmental health aspects of water and sanitation. It contains a definition of environmental health, describes various water-related diseases and also hygiene approaches. There is also a related PowerPoint to this document.


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EAWAG (Editor); SANDEC (Editor) (2008): Environmental Health. Presentation. (= Sandec Training Tool 1.0, Module 2). Duebendorf: Swiss Federal Institute of Aquatic Science (EAWAG), Department of Water and Sanitation in Developing Countries (SANDEC). URL [Accessed: 23.05.2012]. PDF

This PowerPoint presentation contains information on environmental health aspects of water and sanitation. It contains a definition of environmental health, describes various water-related diseases and also hygiene approaches. There is also a related lecture to this document.


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LSHTM (2013): Choose Soap Toolkit. London: London School of Hygiene and Tropical Medicine (LSHTM). URL [Accessed: 29.07.2013].

This toolkit was created to promote hand washing with soap in households in low income settings and draws on ideas and best practices from different fields, including hygiene and health promotion, behavioural sciences, and marketing. It is designed to be used to promote hand washing with soap: at key times; within a realistic budget and time frame; and for an organization working at village level across multiple villages.


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WSP (2013): Facilitator’s Reference Guide for Frontline Activators on Interpersonal Communication. Washington: The World Bank Water and Sanitation Program (WSP). URL [Accessed: 28.08.2013]. PDF

This guide is designed to help facilitators train Frontline Activators (FLA) on interpersonal communication skills to enable them to promote hand washing with soap in their communities. It also serves as a detailed reference guide.


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INCE, M.E.; SHAW, R.; DAVEY, K. (2013): A Guide to Personal Hygiene. Poster. (= WEDC Posters, 3). London: Water, Engineering and Development Center (WEDC). URL [Accessed: 28.08.2013]. PDF

This poster is part of the series of Water, Sanitation and Hygiene posters designed by the Water, Engineering and Development Center of Loughborough University.


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REED, B.; SKINNER, B.; SHAW, R. (2013): The “F” Diagram. (= WEDC Posters, 4). London: Water, Engineering and Development Center (WEDC). URL [Accessed: 28.08.2013]. PDF

This poster is part of the series of Water, Sanitation and Hygiene posters designed by the Water, Engineering and Development Center of Loughborough University.


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REED, B.; SHAW, R.; CHATTERTON, K. (2013): Guidelines for Handwashing with Soap. Poster. (= WEDC Posters, 6). London: Water, Engineering and Development Center (WEDC). URL [Accessed: 28.08.2013]. PDF

This poster is part of the series of Water, Sanitation and Hygiene posters designed by the Water, Engineering and Development Center of Loughborough University.


Important Weblinks

http://www.who.int/water_sanitation_health/en/ [Accessed: 01.06.2010]

This website is a description of the WHO’s work on water, sanitation and hygiene as well as an interesting collection of documents on the issues.

http://www.cdc.gov/ [Accessed: 07.10.2010]

This homepage by the Centres for Disease Control and Prevention provides an overview about global water, sanitation and hygiene topics.

http://water.epa.gov [Accessed: 19.12.2011]

National Primary Drinking Water Regulations (NPDWRs or primary standards) are legally enforceable standards that apply to public water systems. Primary standards protect public health by limiting the levels of contaminants in drinking water. Visit the list of regulated contaminants with links for more details.