SuSanA - Forum Kunena Site Syndication Tue, 03 May 2016 04:56:56 +0000 Kunena 1.6 SuSanA - Forum en-gb Re: Articles warning that "Antibiotic resistance sweeping developing world" - lack of sanitation one likely culprit! - by: arno
The cartoon: The Antibiotic Apocalypse (by Kurzgesagt in Munich and supported by BMGF)
explains the influence of overuse of antibiotics in both humans and animals. Direct link to the video

The cartoon explains the origin of the problem but doesn't include the aspect of sewage systems as vector for spreading the plasmids and genomes. It does implicate faecal-oral transmission combined with global transportation.

Development of AMR in sewage treatment plants has been shown at least in one recent (2015) study to be insignificant. The title of the paper I find somewhat misleading: "Wastewater treatment plants not responsible for spreading antimicrobial resistance" by Technical University of Denmark (DTU)

This paper I find confuses the issue. I don't think it is common knowledge that AMR is being created in the activated sludge of treatment plants. AMR develops in the guts of humans and animals as well explained in the video above.

And sewage systems can be vectors in the spread of AMR plasmids and genomes. That is the issue of major significance.

This illustration (from Schmieder, R. and Edwards, R. 2012. Future Microbiol. 7(1): 73.81) is of fundamental value, showing the various vectors:

At this point what is needed is further emphasis on screening and epidemiology. But we need to be able to reduce the risk of spreading these AMR agents. Sewage systems therefore need to be counted in as significant vectors not only as vectors for spreading AMR but for the multitude of viral and bacterial infections that exist. Faecal-oral transmission is well-established. Question is whether the risks are reduced by flushing away faeces into sewer systems not designed to block transmission.]]>
Health issues and connections with sanitation Wed, 27 Apr 2016 08:58:17 +0000
Re: Sanitation in rural communities of Africa - by: Mnyororo Health issues and connections with sanitation Thu, 14 Apr 2016 07:58:00 +0000 Sanitation in rural communities of Africa - by: VERS Health issues and connections with sanitation Tue, 05 Apr 2016 23:33:55 +0000 Re: The elusive effect of water and sanitation on the global burden of disease - by: muench Thanks for telling us about this article (title: The Problem With Evidence-Based Policies) which explains nicely the problems with randomized controlled trials (RCTs)!

I bumped into this problem last year while working on the Wikipedia article on "mass deworming" ( You can see here on the talk page ( how we (in particular Joe Turner) were trying to make sense of new studies (Cochrane Review) that showed no evidence of school based deworming programs on child health, and struggeling to present everything correctly in the article. There were several factors involved but one was that RCTs were regarded by other Wikipedia editors as the "gold standard" of research and if it wasn't an RCT then it was deemed as irrelevant.

In this context, I want to point out to you the famous parachute paper which is pretty revealing and thought provoking (and funny!):
Parachute use to prevent death and major trauma related to gravitational challenge: systematic review of randomised controlled trials


P.S. the person who sent me this parachute paper also wrote the following per e-mail (he used to work for WHO but is now retired; he wants to stay anonymous):


I have checked the web page and have a comment regarding evidence on helminthiasis control. The papers you quote are systematic reviews of randomized controlled trials (RCT). Observational studies are, by the Cochrane group, not considered appropriate and are disregarded for decision making and their “golden standard” is that ONLY systematic reviews of RCT should allow for decision making for what works in health and also in public health (PH). Their patronizing message, that they include in most if not all their published papers, is: In modern medicine, the efficacy of an intervention should be investigated in well-designed randomized trials. Results from the trials should be collected in a high-quality systematic review, if possible with a meta-analysis. And finally, the evidence should have its repercussions on practice guidelines.

This in is a wrong starting point. It is wrong as many PH decision have been made by observational studies or simple “expert opinion”, have worked and continue to work for the benefit of millions of people around the world. Vaccination of small pox, “discovered” in 1798, is a typical example that has allowed us to achieve the only eradication yet of a disease. Similarly the evidence for the feasibility of the eradication of guinea worm has never been proved by any RCT. I could go and on with both examples in PH and general medicine. I am attaching a comic paper (parachutes) that was published time ago on the BMJ on parachutes……….the recommendation for the RCTs fundamentalist stands today as it did when it was published!

Regarding worm infections they just do not know what they are speaking about. The issue is due to the “over-dispersed distribution” of worms in infected populations and the difference between macro and micro parasites. As these macro parasites (worms) do not replicate (at least most of them and surely the one we are discussing) in the human final host it takes time to build a worm load and those people that have high worm loads (that are few in an infected population) are those that have the worse effects of worm infections, with associated stunting, malnutrition, anaemia in case of hookworms and schistosomes, etc. Those with few worms have more subtle pathology and morbidity.

As a consequence those that have a high worm load will benefit more from intervention and those that have a few worms will of course benefit less. You do not need a rocket scientist to understand that!!! In an RCT you need to take this into account and to take this into account you need huge sample sizes and compare effects in different groups based on their original worm load. So the design of the study must be based on the host parasite relationship and dynamic of transmission and ecology of the infections. Very few RCT on helminthiasis have done this as it would cost a fortune. Furthermore different parasites have different physio-pathological effects on their hosts. Hookworm will mainly cause anaemia (and this is directly related to the number of hookworms in the host and the species (Necator americanus or Anchilostoma duodenale with A.duodenale having a more important impact on anaemia per worm as they cause more blood loss). Ascaris lumbricoides more an effect on growth, etc.

I am afraid the various Cochrane reviews on helminths did not take into account studies conducted in areas with mainly one parasite transmitted and mixed effects of one species with that of another (stunting for hookworm, etc. when hookworms will have effect on anaemia etc.). They even quoted papers I was involved in areas of hookworm transmission looking at effects on growth! They just have no knowledge on the epidemiology of helminthic infections and reach conclusions based on such biased views as they do not look at papers and read them as parasitologists but as “systematic reviwers” with no biological knowledge.

Furthermore all the present discussion on the relevance of impact large scale chemotherapy against worm infection regards more “subtle” effects such as growth, school performance, work performance and even increased wages of people treated versus workers not treated. This impact is important but forgets another element: large scale interventions prevent also deaths and severe morbidity of a small but important proportion of the population. That is per se sufficient to justify large scale chemotherapy against helminthic infections that WHO defines Preventive Chemotherapy. We could say that similarly the proportion of people with paralytic polio is “small” and that this per se should justify spending a billion USD a year to eradicate this horrid disease. If not one scientist dares to, most appropriately, argue this general point of view why does a small group of “systematic reviewers inquisition fundamentalists” argue so much on large scale Preventive Chemotherapy? What are their real objectives?

In the 19th century, in one of the most elegant studies on Ancylostoma duodenale ever performed, Italian parasitologists observed (observational studies again I am afraid!!) that the Italian workers that were drilling the St Gottard tunnel in Switzerland were becoming anaemic. Coming from the south of Italy most of them were infected with hookworms and due to the conditions of work in the tunnel and complete lack of sanitation they became severely infected with hookworms transmitted in the tunnel itself, consequently becoming very anaemic and many of them eventually dying. In 1880, Edoardo Perroncito first noted the correlation between hookworms and anaemia among miners digging the St. Gottard tunnel in the Alps. They also correlated worm loads with severity of anaemia and Grassi was the first to mention that counting worms was critical to understand the relationship with morbidity. Grassi in 1878 had looked at the importance of the worm load 40 years after Dubini and stated in Italian “la diagnosi viene agevolata dallo studio delle uova…..con queste ricerche arriviamo ad affermare la presenza dell’elminto; ma siccome dal suo numero dipende il grado della malattia, cosi’ fa profitto anche lo stabilire la diagnosi quantitativa. La quale é possibile all’occhio esercitato in base ad un fatto da me ripetutamente certificato, e cioè che la quantità delle uova è direttamente proprozionale al numero degli elminti” (reported by Ivo de Carneri page 253, Parassitologia Generale e Umana 11ª Edizione, 1989). 137 years later do we still need to have proofs that hookworm infection has an impact on anaemia based on intensity of infection and to justify large scale chemotherapy with the safest drugs ever used in medicine like albendazole and mebendazole?

I think the Cochrane group has a mentality similar to that of the 15th century inquisition and is unable to think beyond dogmas: i.e. that if you do not go through a RCTs (and especially their own review, their own “holy inquisition” to get their imprimatur) you will not be allowed to become PH policy. This is deeply and dangerously wrong and the visibility given by the press has been dangerous. Anthelminthic treatment on a large scale is only one of the PH interventions they have reviewed and “dismissed” as not evidence base. Their influence is dangerous and we need to combat it for the benefits of millions of people. For the time being I will continue to be with the heretics, the Giordano Bruno’s of today, and continue to promote large scale preventive chemotherapy, up to the time the Liverpool fundamentalists will get me and try to burn me!


PH = public health]]>
Health issues and connections with sanitation Fri, 25 Mar 2016 12:55:51 +0000
Re: Link between poor sanitation and higher risk of Adverse Pregnancy Outcome - by: muench
I have fixed the link, now it is working.

Note to all: make sure you don't put a comma, full stop, semi colon or similar directly behind the URL as it will make the hyperlink not working. And if you find a link that is not working, check if you can just omit the comma, full stop or semi colon at the end to make it work.

Health issues and connections with sanitation Mon, 21 Mar 2016 22:10:58 +0000
RE: [SuSanA forum] Re: Link between poor sanitation and higher risk of Adverse Pregnancy Outcome (Health issues and connections with sanitation) - by: Gendersan1
Thank you for your message. I did not know, the link is not working.
I hope you can access this one:

I am always open to discussion and for exchange.

Kind regards,
Health issues and connections with sanitation Mon, 21 Mar 2016 16:17:06 +0000
Re: Link between poor sanitation and higher risk of Adverse Pregnancy Outcome - by: SusanAko Thanks for sharing, i am very interested in the research you mentioned but the link does not seem to be working. I will like to know more,can help please.
Very best

Health issues and connections with sanitation Mon, 21 Mar 2016 13:27:48 +0000
Wider Beneficial of Safe Water and Improved Sanitation - by: F H Mughal Wider Benefits of Safe Water and Improved Sanitation

Water and sanitation engineers, generally, are of the view that safe drinking water, improved sanitation, and hygiene (both personal and community hygiene) have wider benefits. For example, they can help in prevention of diseases, and can prevent stunting among children. According to a recent WHO infograph (attached), 23 per cent of all global deaths are linked to the environment

Municipal officials of the local governments in developing countries, who, typically, are not technical persons, do not share these views. Their work is stereo-type – no innovation; no eagerness to seek more knowledge – like approval of the schemes by the provincial government; execution of the schemes; thriving on commissions from the contractors; and completion of the schemes. Most of the schemes, after completion, become non-functional in a short period of time.

As is known, Zika virus has become a major problem in Brazil. The United Nations Special Rapporteur on the human right to safe drinking water and sanitation, Léo Heller has now said that the improved water and sanitation services are answer to the Zika virus.

Leo Heller said: “As the world looks for hi-tech solutions to the Zika virus, we should not forget the appalling state of water and sanitation access of the poor, a key underlying determinant of the right to health.”

“We can engineer sterile mosquitos or use sophisticated Internet tools to map data globally, but we should not forget that today a hundred million people in Latin America still lack access to hygienic sanitation systems and seventy million people lack piped water in their places of residence.”

Leo Heller said: “There is a strong link between weak sanitation systems and the current outbreak of the mosquito borne Zika virus, as well as dengue, yellow fever and chikungunya, and the most effective way to tackle this problem is to improve the failing services.”

The views of Leo Heller are supported by the UN expert on adequate housing, Leilani Farha, who said:
“When people have inadequate living and housing conditions, where they do not have access to safely managed water services, they tend to store water in unsafe ways that attract mosquitos. In addition, poor sanitation systems where wastewater flows through open channels and is disposed of in unsafe pits leads to stagnant water and unfit housing – a perfect habitat for breeding mosquitos.”

Not only that, the views of Leo Heller are also supported by the Special Rapporteur on health, Dainius Pūras, and the Special Rapporteur on extreme poverty, Philip Alston.

More details can be seen at:

It is encouraging to note the importance of safe water and sanitation given by the UN officials. They need to talk to the municipal governments in developing countries, so that the developing countries also realize the wider benefits of safe water, improved sanitation and proper hygiene.

F H Mughal]]>
Health issues and connections with sanitation Tue, 15 Mar 2016 16:53:53 +0000
Emergency Triggers Action in Sanitation (example: Zika Epidemic Offers Sanitation a Chance in Brazil) - by: F H Mughal Emergency Triggers Action in Sanitation

It is common in some developing countries to see the governments’ lack of interest towards pressing problems, especially sanitation. The prime reason being the low priority of the municipal governments towards sanitation, as a result, no action is taken. People suffer because of this, with degree of suffering being faced more by women.

In the informal settlements, typically located at the periphery of the city, the municipal governments do not provide sanitation facilities, and their ready-made reply is: the area is not a sanctioned area in the municipal government’s documents; or, the area is not within our jurisdiction.

With that being said, sometimes, emergency by default, triggers action. A recent post in IPS makes an interesting reading. According to the post (, “three decades of dengue fever epidemic did not manage to awaken a sense of urgency in Brazil regarding the need for improving and expanding basic sanitation. But the recent surge in cases of microcephaly in newborns, associated with the Zika virus, apparently has.”

“Brazil did not declare all-out war on the Aedes aegypti mosquito until studies showed that Zika can cause microcephaly and other neurological damage in the unborn infants of women infected with the virus in the early months of pregnancy.”

While the Zika episode in Brazil has turned into a major emergency - on 1 February 2016, the World Health Organization declared an international public health emergency after Zika virus was linked to thousands of birth defects in Brazil – the fact remains that in some developing countries, it is somewhat difficult to sensitize the municipal departments in taking action in the field of sanitation.

F H Mughal]]>
Health issues and connections with sanitation Wed, 09 Mar 2016 16:37:55 +0000
Re: SaniPath - Assessment of Fecal Exposure Pathways in Low-Income Urban Settings (Emory University, USA) - and appeal to SuSanA members for input - by: SDickin This is a really interesting project. I previously met Katherine at WWW but it is very helpful to learn more about all the different aspects of the work in this thread.

I recently reviewed research on wastewater irrigation and health risks (, and one of the findings was that other exposure pathways (e.g. WASH, use of animal manure) were frequently ignored in these studies, which provides an incomplete picture. A gap it seems like SaniPath can address!

Another finding of this review was that there was little work examining different exposures during the farm to fork pathway. In the Sanipath case, I guess that only the end-product 'produce' would be assessed, but being able to compare farm level, transport/handling or marketplace contamination (washing of produce with contaminated water) could allow more targeted actions. Perhaps a targeted path could be developed to examine the greatest risk pathway in finer detail.

Do you see any potential for expanding beyond urban areas. During some research fieldwork in Uganda I observed that peri-urban or even 'rural'areas nearby towns were growing rapidly and poor planning of sanitation was occurring (and causing contamination of water resources with impacts on downsteam communities). It would be interesting to develop the tool to inform planning in areas that are rapidly growing like this.

best regards,
Health issues and connections with sanitation Mon, 07 Mar 2016 12:28:40 +0000
Re: The elusive effect of water and sanitation on the global burden of disease - by: JKMakowka]]> Health issues and connections with sanitation Wed, 02 Mar 2016 14:08:40 +0000 Re: Roman toilets gave no clear health benefit, and Romanisation actually spread parasites - by: JKMakowka
One possibility Mitchell offers is that it may have actually been the warm communal waters of the bathhouses that helped spread the parasitic worms. Water was infrequently changed in some baths, and a scum would build on the surface from human dirt and cosmetics. “Clearly, not all Roman baths were as clean as they might have been,” said Mitchell.
Another possible explanation raised in the study is the Roman use of human excrement as a crop fertilizer. While modern research has shown this does increase crop yields, unless the faeces are composted for many months before being added to the fields, it can result in the spread of parasite eggs that can survive in the grown plants.
“It is possible that sanitation laws requiring the removal of faeces from the streets actually led to reinfection of the population as the waste was often used to fertilise crops planted in farms surrounding the towns,” said Mitchell.

It's actually the long known fact that towards the end of the Roman empire the bathhouse hygiene was hugely neglected and lots of diseases spread through them... thus I am bit skeptical about warm water hypothesis.

The part about the mandatory removal of feces leading to more (untreated) agricultural reuse is certainly feasible and a relevant topic to this very day.

However then the researcher is quoted saying:
This latest research on the prevalence of ancient parasites suggests that Roman toilets, sewers and sanitation laws had no clear benefit to public health. The widespread nature of both intestinal parasites and ectoparasites such as lice also suggests that Roman public baths surprisingly gave no clear health benefit either.

Which I think is a gross over-simplification and totally neglects the significant population increase in the cities and thus higher population densities that also took place in that time as far as I know. So I would rather say the interventions were not as effective as they have been assumed so far, but only through them it was possible to actually have larger cities in the first place.
And last but not least one should also not forget that the Romanization also brought a lot of trade and human travelling (incl. slave trade), which is generally related to the spread of diseases.]]>
Health issues and connections with sanitation Sat, 09 Jan 2016 17:42:39 +0000
Research: Roman toilets gave no clear health benefit, and Romanisation actually spread parasites - by: F H Mughal Roman toilets gave no clear health benefit, and Romanisation actually spread parasites

Recent research, conducted by Dr Piers Mitchell from University of Cambridge’s Archaeology and Anthropology Department and published in the journal Parasitology, is interesting and informative.

According to the research, archaeological evidence shows that intestinal parasites such as whipworm became increasingly common across Europe during the Roman Period, despite the apparent improvements the empire brought in sanitation technologies.

The Romans are well known for introducing sanitation technology to Europe around 2,000 years ago, including public multi-seat latrines with washing facilities, sewerage systems, piped drinking water from aqueducts, and heated public baths for washing. Romans also developed laws designed to keep their towns free of excrement and rubbish.

However, new archaeological research has revealed that – for all their apparently hygienic innovations – intestinal parasites such as whipworm, roundworm and Entamoeba histolytica dysentery did not decrease as expected in Roman times compared with the preceding Iron Age, they gradually increased.

The author, Piers Mitchell says (probably in a lighter vien): “It seems likely that while Roman sanitation may not have made people any healthier, they would probably have smelt better.”

More details can be seen at:

F H Mughal]]>
Health issues and connections with sanitation Fri, 08 Jan 2016 16:30:56 +0000
Re: Publishing a state-of-the-art reference work on water-related disease risks and intervention measures (UNESCO) - by: muench This means when it's done, we can use content from it to update the relevant Wikipedia pages which will be awesome.

I have a question regarding the focus on waterborne diseases. You said that
It aims at helping to reduce mortality linked to water pathogens (in particular viruses, bacteria, protists and helminths)

However, not all helminths are waterborne (in fact many of them are not).
How about soil-transmitted helminths ( or the fecally transmitted infections (i.e. not transmitted via water but via soil or faeces directly)? See e.g. here on the forum:

This is closely linked to waterborne diseases and should therefore be part of the book? I know that the project leader, Blanca Jiménez-Cisneros, is very active in reseach on helminths (see e.g. her helminth identification project here on the forum: - so I am sure that she will ensure this is not forgotten about, I am just puzzled by the terminology used ("water pathogens such as helminths").

Also you said that:
in order to improve the management of wastewater in the developing world

shouldn't it say "management of wastewater and excreta", i.e. including such sanitation systems which do not rely on water to transport the excreta?

Perhaps this is just semantics, but I just wanted to be sure I fully understand the scope and focus of this planned book. It certainly sounds like a great project!]]>
Health issues and connections with sanitation Thu, 17 Dec 2015 00:56:57 +0000
Publishing a state-of-the-art reference work on water-related disease risks and intervention measures (UNESCO) - by: muench "Sanitation and Disease Health Aspects of Excreta and Wastewater Management" by Feachem et al, 1983.

The information about the project below was sent to me by Anaïs Chagankerian from UNESCO who's asked me to post it.

Title of grant: Global Water Pathogen Project
- Publishing a state-of-the-art reference work on water-related disease risks and intervention measures to replace Sanitation and Disease Health Aspects of Excreta and Wastewater Management by Feachem et al, 1983.

Name of lead organization: UNESCO
Primary contact at lead organization: Blanca Jiménez-Cisneros, Director of UNESCO’s Division of Water Sciences, This e-mail address is being protected from spambots. You need JavaScript enabled to view it ; Bruno Nguyen, Consultant at UNESCO, This e-mail address is being protected from spambots. You need JavaScript enabled to view it .
Grantee location: UNESCO Headquarters, Paris, France
Developing country where the project will take place: The project has a global scope
Start and end date: 3 November 2015 - 30 April 2017
Grant type: Other
Grant size in USD: 300,000 USD as per BMGF grant database here

Short description of the project:

This Global Water Pathogen Project is aimed at developing a knowledge resource to guide future goals for achieving safe water. It aims at helping to reduce mortality linked to water pathogens (in particular viruses, bacteria, protists and helminths) and the lack of safe drinking water and basic sanitation through creating, publishing and disseminating the state-of-the-art replacement of the current benchmark reference work on water related disease risks and intervention measures, the book “Sanitation and Disease: Health Aspects of Excreta and Wastewater Management” (Feachem et al. 1983).

This book has not been rewritten in more than 30 years. Current information technologies, such as a collaborative online platform that includes a book authoring tool, will help in re-writing and disseminating the new book in printed and electronic format. The book will be available in at least three official languages of the United Nations (French, English and Spanish) and following the open access policy of UNESCO. The book is inspired by the structure and scope of Feacham et al, but it will expand beyond it, in every respect.


The goal of the project is to reduce mortality linked to waterborne pathogens and the lack of sustainable access to safe drinking water and basic sanitation, mainly in the developing world, in support of the development of quantitative microbial risk assessment (a framework supported globally for developing management strategies), water security and Sustainable Development Goals (SDGs).


The project will compile new data available regarding emerging pathogens, new technologies for measuring pathogens, new information on pathogen occurrence and persistence and new means of treatment and their evaluation. It will then disseminate the new knowledge globally, through UNESCO’s and contributors’ networks and in international events, in order to improve the management of wastewater in the developing world and reduce mortality linked to enteric and diarrheal diseases.

The project will produce and publish a benchmark reference publication, under open access license and in at least three official languages of the United Nations (English, French and Spanish).

Knowledge will be gathered thanks to the online platform currently being developed by AgroKnow and which will present data on pathogens, key indicators, source tracking markers and pathogen risks from excreta.

Research or implementation partners: Michigan State University, USA, in charge of coordinating the online platform and the network of contributors.

Links, further readings – results to date: Project website:

Current state of affairs:

A workshop is being prepared to take place in Ghana in May 2016. It is aimed at bringing together the Global Water Pathogen Project (GWPP) network and end-users of the African region and different disciplines in order to optimize the scope and efficiency of the GWPP resource according to regional issues, experience and needs.

Biggest successes so far:

A worldwide network of more than 140 volunteering authors and editors, invited to contribute for their outstanding contribution to the field, has been built to write each chapter of the book. The online platform ( already presents the content of the book and the summaries of each chapter are progressively being uploaded.

Main challenges / frustration:

The main challenges linked to the project relate to the coordination of a very wide network of contributors.

Anaïs Chagankerian
Programme Assistant
International Hydrological Programme (IHP)
Division of Water Sciences
7, Place de Fontenoy
75352 Paris 07 SP
Health issues and connections with sanitation Thu, 17 Dec 2015 00:48:45 +0000