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Reviews/Analyses Reviews/Analyses Effects of improved water supply and sanitation on ascariasis, diarrhoea, dracunculiasis, hookworm infection, schistosomiasis, and trachoma S.A. Esrey,' J.B. Potash,2 L. Roberts,3 & C. Shiff4 A total of 144 studies were analysed to examine the impact of improved water supply and sanitation facilities on ascariasis, diarrhoea, dracunculiasis, hookworm infection, schistosomiasis, and trachoma. These diseases were selected because they are widespread and illustrate the variety of mechanisms through which improved water and sanitation can protect people. Disease-specific median reduction levels were calculated for all studies, and separately for the more methodologically rigorous ones. For the latter studies, the median reduction in morbidity for diarrhoea, trachoma, and ascariasis induced by water supplies and/or sanitation was 26%, 27%, and 29%, respectively; the median reduction for schistoso- miasis and dracunculiasis was higher, at 77% and 78%, respectively. All studies of hookworm infection were flawed apart from one, which reported a 4% reduction in incidence. For hookworm infection, ascariasis, and schistosomiasis, the reduction in disease severity, as meas- ured in egg counts, was greater than that in incidence or prevalence. Child mortality fell by 55%, which suggests that water and sanitation have a substantial impact on child survival. Water for personal and domestic hygiene was important in reducing the rates of ascariasis, diar- rhoea, schistosomiasis, and trachoma. Sanitation facilities decreased diarrhoea morbidity and mortality and the severity of hookworm infection. Better water quality reduced the incidence of dracunculiasis, but its role in diarrhoeal disease control was less important than that of sanitation and hygiene. Introduction research on the health impacts of water and sani- tation projects has focused on the incidences of diar- Water and sanitation have been the subjects of con- rhoeal diseases, malnutrition, and mortality of young siderable recent attention as a result of the declara- children, and evidence accumulated during the tion by the United Nations General Assembly that decade indicates that these rates have been reduced the 1980s were the International Drinking-Water, (22, 25). Although it is generally believed that the Supply and Sanitation Decade (IDWSSD). A major rates of other diseases will decrease following objective of this was to improve the health of popu- improvements in water and sanitation, there have lations that received the interventions. Most of the been no systematic reviews of this. The present article reviews the health impact of 1 Professor, Faculty of Agriculture and Environmental Sciences water and sanitation interventions on the following: and Faculty of Medicine, Macdonald College of McGill University, ascariasis (Ascaris lumbricoides), diarrhoeal diseases 21111 Lakeshore Road, Ste-Anne-de-Bellevue, Canada, H9X ICO. (including measures of nutritional status and child Requests for reprints should be sent to this address. survival), dracunculiasis (Dracunculus medinensis), 2 Student, School of Medicine, Johns Hopkins University, Balti- more, MD, USA. hookworm infection (Ancylostoma duodenale and Necator 3 Student, Department of Geography and Environmental Engin- americanus), schistosomiasis (Schistosoma eering, Johns Hopkins University, Baltimore, MD, USA. haematobium and S. mansoni), and trachoma 4 Professor, Department of Immunology and Infectious Diseases, (Chlamydia trachomatis). These diseases were chosen Johns Hopkins University, School of Hygiene and Public Health, because they are widespread in developing countries, Baltimore, MD, USA. or because they constitute serious problems where they exist, or both (Table 1). All developing countries Reprint No. 5216 are affected by diarrhoeal diseases and ascariasis; the Bulletin of the World Health Organization, 69 (5): 609-621 (1991) c World Health Organization 1991 60 S.A. Esrey et al. Table 1: Incidence and effects of selected diseases In using larger quantities of water for personal hygiene developing countries (excluding China) will probably interrupt the spread of trachoma. The incidence, prevalence, and/or severity of all these dis- Estimated number of: eases are reduced by water and sanitation interven- Cases per year tions. (x 10) Deaths per year Ascariasis' 900 20000 Methods Diarrhoeal diseasesb 875 4.6 million Dracunculiasisc 4 - Computer searches of articles on each of the diseases Hookworm infection 800 considered were carried out using the MEDLINE Schistosomiasisd 200 and MEDLINE 500 systems, which cover the period Trachoma" 500 -9 from 1966 and 1986, respectively. For schistosomiasis, '-' See ref. 96, 80, 97,57, and 18, respectively. an additional computer search was performed on 'Usually causes debilitation rather than death. CAB Abstracts (period, 1984-89). For hookworm o The major disability is blindness (8 million). infection and ascariasis, Index Medicus was searched for 1976-86, and the Science Citation Index for other four diseases are somewhat more restricted in 1970-84. Because a thorough review of diarrhoeal their range, although they are all prevalent in some diseases was published in 1986 (22), only studies developing countries, except dracunculiasis, which published since then were sought. For trachoma, only occurs in parts of Africa and Asia. additional references were provided by a recent These diseases also illustrate the variety of review (72). mechanisms through which improved water and References cited in the articles identified, but sanitation can promote health (Table 2). Four basic which were not located in the computer search, were aspects were considered: sanitation (i.e., human also sought. Only studies published in English in excreta disposal), water quality, personal hygiene, peer-review journals were used; this methodology ex- and domestic hygiene. Personal hygiene refers to cluded technical reports, mimeographs, and agency water used for cleaning the body, including water for documents. An exception was made for studies the face, hands, and eyes; domestic hygiene refers to carried out by Miller et al.,'-b because although they water used to keep the home clean (e.g., food, had been published in peer-review journals, the utensils, and floors). Each disease is affected by one unpublished documents upon which they were based or more of these interventions. For example, provid- contained more information. Finally, the review was ing safe, potable sources of drinking-water will prob- restricted to studies that presented data on the effect ably prevent transmission of dracunculiasis, while of water and sanitation conditions on one of the six diseases. criteria that we have Table 2: Illustration of the potential relation between Specific reported pre- water and sanitation Interventions and morbidity from viously were used to identify the rigorous studies selected diseases from the large number reviewed (22). First, studies were divided into those that reported a statistically Intervention significant positive association between the provision of improved water or sanitation and better health Water Water Improved for for Human and those that did not. Studies were excluded from drinking- domestic personal excreta the rigorous category if they had a single major flaw water hygiene hygiene disposal or several known or suspected minor flaws that could have biased their results. Each disease is Ascariasis + + + - ++ treated in Diarrhoeal + + + + + + + turn, with the discussion focusing on the diseases rigorous studies. Dracunculiasis + + The median reductions in morbidity (i.e., inci- Hookworm - - - + + dence and prevalence) and a range of reductions infection to Schistosomiasis - + + + + + + attributable improved water and sanitation were Trachoma - + + + * Interventions marked with one or two pluses have an impact on Miller,M F.D. *t *I. Human intestinal parasitic infections and a particular disease: an intervention marked "+ +" will have a environmental health factors in rural Egyptian communities. (EPA stronger impact than one marked " + "; "-" = the intervention Research Reporting Series EPA-600/1-80-024), 1980. has little or no impact on reducing disease rates. For a particular b Miller, F.D. et ai. Schistosomiasis in rural Egypt: a report of disease, a package of interventions with pluses is expected to U.S.-Egyptian River Nile and Lake Nasser research project. (EPA produce a larger impact than any one intervention alone. Research Reporting Series EPA-600/1-78-070), 1978. 610 WHO Bulletin OMS. Vol 69 1991. Effects of Improved water supply and sanitation on six endemic diseases calculated for each disease, based on all the studies 66)c examined differences in excreta disposal facili- reviewed. The same calculations were also made for ties, and five (3, 15, 37, 76, 77) investigated various only the rigorous studies, the results from which combinations of water supply and sanitation condi- more accurately represent the reductions that may tions. All five negative studies reported on excreta be achieved by water and sanitation interventions. disposal facilities, while only one study (37) investi- The results reported in some studies did not permit gated the influence of water supplies alone. One determination of the median reduction in morbidity, study (31) reported both positive and negative find- and such studies were not included in the calcu- ings; for ascariasis, significant differences were found lations. The average reduction for each disease cate- among
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