Exposure Risk Management in Container-Based Sanitation

Exposure Risk Management from Faecal Pathogens for Workers in Container Based Sanitation Systems Eve Mackinnon March 2019 University College London Department of Civil, Environmental and Geomatic Engineering Dissertation Submitted for Degree of Doctor of Philosophy 1 I, Eve Mackinnon, confirm the work presented in this thesis is my own. Where information is derived from other sources, I confirm that this has been indicated in the thesis. 2 Abstract This thesis addresses the need for safely managed container-based sanitation (CBS) systems to contribute to the UN’s Sustainable Development Goal 6 and explores occupational exposure risk management to faecal pathogens in CBS systems in three Case Studies. A mixed methods approach undertook qualitative and quantitative risk assessment of exposure and associated risk management strategies. The risk assessment adapted and developed the WHO Sanitation Safety Planning (SSP) framework and identifies critical points where control measures are required to manage exposure. The risk assessments found tangible evidence of occupational exposure risks from hazardous events, such as spillages and blockages of the urine diverter, and subsequent transmission along the CBS system components. Hand and fomite transmission were identified as key exposure points to operators. Frequent handling of contaminated surfaces during collection increased hand contamination. Modelling of hand contamination during collection activities suggested that the operators might be involved in a chain of infection between households, although effective hand hygiene protocols managed the exposure risk. A Cross Case analysis highlighted four causal mechanisms of occupational exposure, namely (1) technical and equipment failures, (2) behavioural failures, (3) system safety failures and (4) environmental/seasonal failures. A formative analysis of the behavioural determinants of safe sanitation management highlighted emotional and ability factors as behavioural determinants that influenced operators’ behaviour. In conclusion, the Case Studies represent the most in-depth empirical study of occupational exposure risks in CBS systems at a level not detailed in the literature to date. The study highlights work-related activities in CBS systems that bring workers into contact with faecal matter and sets out how exposure risk management frameworks can achieve safely managed sanitation. The use of an adapted SSP and a safety performance management framework is demonstrated as an effective risk management tool of CBS systems in order to achieve SDG 6. 3 Acknowledgements First, my thanks to my principal supervisor, friend and colleague Dr Luiza C. Campos with whom I have completed this research. Throughout the last three years Dr Campos has not only guided me through the intricacies of research and requirements for the PhD, but has broadened my perspectives through engagement with Beacon Bursaries, SANCOP, WHO and WSUP. These affiliations and experiences brought depth and meaning to the PhD, beyond being a merely academic exercise. I am grateful for the encouragement and guidance, structure and freedom shown by Dr Campos towards the completion of my PhD. I must reserve enormous thanks for my second supervisor Dr Priti Parikh for her generosity with time and support in the development of various draft papers and thesis chapters which always appeared ongoing! Priti’s advice is always quick and direct. I am also indebted to Dr Lena Ciric for her guidance and advice on technical and microbiological issues. In the laboratory at UCL I am wholly indebted to Melissa Canales for schooling me in the groundwork of microbiological analysis and helping me to carry out the required sample preparations. My thanks to Unilever, who not only financially supported the research, but also personally invested time and resources, and most particularly for the support of Dr Illias Soumpiasis of the SEAC team, who initiated the opportunity for research study with Dr Campos. Without their curiosity and optimism for CBS systems this research would have never been initiated. My sincere gratitude to Niteen Sawant from Unilever, for his insightful and intelligent comments on the content of my thoughts and draft attempts at coherent papers. He has given of his time freely and willingly and I am very grateful for his contributions. Kory Russel and Tracy Keatman – representing the CBSA – have supported the work and study from the outset and given valuable inputs and assistance in reaching out to the CBS community. Likewise, WHO and the SSP developer, Darryl Jackson, have been incredibly helpful and supportive. The inclusion of some initial findings into the SSP training workshop delivered with the CBSA developed the findings and my confidence. Specific thanks are due to Dr Heather Bischel at the University of Davis and Dr Timothy Julian from EAWAG who listened to my early suggestions of surface to hand transmission and helped me refine my ideas and structure a research enquiry. Their expert advice and experience in this area have been intellectually fulfilling. I reserve my sincerest, most heartfelt thanks to the toilet entrepreneurs, operators and users who accommodated me at the CBS organisations and patiently listened and responded to my questions. 4 To Sanivation I must specifically thank Emily Woods, Andrew Footman and Dr Kate Bonhert for the initial support and momentum in inviting me to participate with them early on and find my feet in the research agenda. Kate, Thomas and the field laboratory team patiently supported and assisted my field research. I was lucky enough to land in a research grade lab in the middle of Kenya – the development of which was no easy feat. I also thank the London canal boat community, and each individual canal boat operator who has discussed and opened up personally to me about their toilet and excreta management habits with gusto and abandon. Thanks too to users of the Compost toilets for boats and off-grid living, Facebook group – who have supported this work and enabled so much of the research on the canal boats in London to go ahead. Sanitation First offered me a final case study and I am grateful for this offer, and the kind reception from Padmapriya, the CEO, and the rest of the team in India. I was greeted with kindness from the operational team who freely shared their experiences and contributed to the research. Also I thank those individuals who took part and gave up their time but do not feature in the research; colleagues at SOIL with whom field research was not practically possible due to ethical issues but who made substantial efforts to support my work; and LooWatt in London, with whom I worked as an operator myself to understand the practical realities of cleaning and managing a CBS system. I must thank my fellow UCL colleagues. Without the friendship, confectionary and smiles in room 3.12 the PhD experience would have been much more solitary. There was a quiet understanding of the requirements of the PhD process to which most people are not privy. And last but by no means least, I thank my dearest family and friends for their support and love, and my small pup, with whom I share a love of fresh air and walks. 5 Impact Statement This thesis represents a penetrating investigation into occupational exposure along the CBS system using multiple Case Studies as reference. The study, at the minimum, has contributed to a body of knowledge and momentum in positioning CBS systems as a viable alternative to other onsite sanitation systems, which benefit not only the sanitation entrepreneurs, but also the 4.6 billion people who currently lack access to safely managed sanitation services. The research indicates that CBS is not just a “third world solution”, while in London it represents a community response to the pressures of urban living. The empirical evidence generated from the Case Studies highlights an unfinished agenda in ensuring that sanitation service workers are properly protected from the health risks of exposure to faecal pathogens which is of overall importance to the sector. The findings are expected to focus attention on sanitation service workers, where a previous academic focus has been on quantifying the public health risks associated with inadequate sanitation or the public health improvements associated with sanitation interventions. This thesis rightly refocuses attention on the marginalised and informal sanitation workers in low- and middle-income countries (LMICs). The findings are relevant to sanitation stakeholders at various institutional levels. At its most ambitious, the findings are directly related and of benefit to policy makers and practitioners aiming for targets associated with Sustainable Development Goal 6.2 in delivering safely managed sanitation services. The thesis sets out a framework and associated exposure risk tools for effective monitoring and delivery of safe and sustainable sanitation management of onsite sanitation systems. At the practitioners’ level, the thesis presents the methods and findings of the Case Studies to serve as practical examples for CBS service providers to develop their own SSP for future applications and assessment of risks. The research results have also provided insights into fundamental human behaviour activity in the sanitation services and the LMICs, for which little human–environment data exists, and are of benefit to academic and commercial actors in the sanitation sector. In terms of personal achievements, the thesis has led to two peer-reviewed publications

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