SuSanA - Forum Kunena Site Syndication Fri, 31 Jul 2015 07:20:08 +0000 Kunena 1.6 SuSanA - Forum en-gb Link between poor sanitation and higher risk of Adverse Pregnancy Outcome - by: jbr
Has anyone seen this publication?

Padhi BK, Baker KK, Dutta A, Cumming O,Freeman MC, Satpathy R, et al:
Risk of Adverse Pregnancy Outcomes among Women Practicing Poor Sanitation in Rural India: A Population-Based Prospective Cohort Study.

PLoS Med 12(7): e1001851. doi:10.1371/journal.pmed.1001851

Landmark in that it seems to be the first evidence that poor sanitation is linked to a higher risk of APO (Adverse Pregnancy Outcome).

Best regards,
John Brogan
Terre des hommes]]>
Health issues and connections with sanitation Tue, 28 Jul 2015 08:59:33 +0000
Re: looking at the literature on global MHM - existing practices - by: joeturner Health issues and connections with sanitation Fri, 26 Jun 2015 12:37:24 +0000 looking at the literature on global MHM - existing practices - by: SusannahClemence I've been reviewing the current literature on menstrual management techniques across the world, and I'd like to share a version of a presentation I gave (SMCR conference, Boston, June 2015) on this study. I'd be interested to get feedback.
[attachment:1]C:\fakepath\presentation powerpoint to put online.ppt[/attachment]

Health issues and connections with sanitation Fri, 26 Jun 2015 12:11:40 +0000
Re: WASH awareness and practice among health staff in PHCs (primary health centres) - by: joeturner

I don't think they looked at sanitation systems, but they concluded that half of the surveyed facilities lacked on-site water to wash hands and none had it available 24 h a day.]]>
Health issues and connections with sanitation Tue, 23 Jun 2015 13:58:37 +0000
Re: WASH awareness and practice among health staff in PHCs (primary health centres) - by: JKMakowka
But regarding the issues you raised: I was told that here in the Philippines health care staff turnover and absenteeism is a big problem for PHCs as nurses and other health professionals can easily find much better paid jobs abroad.]]>
Health issues and connections with sanitation Tue, 23 Jun 2015 13:22:41 +0000
WASH awareness and practice among health staff in PHCs (primary health centres) - by: samanthaswasti Hello! This is my first post on the SuSanA forum. Thank you for having me! I am currently an intern with Swasti in Bangalore, and my focus is on WaSH, specifically sanitation attitudes and sustainable technologies. I have posted a piece written by one of our staff members sharing his experience with health care professionals in primary health centres (PHCs). I look forward to this learning experience!

The promotion of institutional deliveries and funds allocated for the improvement of working and infrastructure of PHCs under the strategies of the National Rural Health Mission is not uniform for all PHCs. Many facilities are ill equipped to promote maternal and child health care. After delivery, many mothers and newborns leave the hospital with an Hospital Acquired Infection (HAI). HAIs result in illness, deaths and high treatment costs. HAIs relate directly to the water, sanitation and hygiene (WASH) situation in the PHCs.

Awareness and practices
Labour rooms in the PHCs ranged from clean and well-equipped to rusty labour tables and unclean floors. In one observation, there was a tray with clots and bloodied cotton piled on the side of the toilet from a delivery conducted the previous night. Labour room toilets at certain PHCs were locked, used for storage or were only available for staff, which made it difficult for patients to access toilets. In many of the hospitals, disposal of grey water was inadequate. Rubber sheets used over the labour table were washed in the toilet used by patients. The staff was unaware how these ‘unrelated’ situations could be connected to high morbidity and mortality among mothers and newborns.
The probability of infection transfer within the wards was high due to the lack of rules or guidelines to clean the hospital. There was a clear lack of awareness about how often the ward, labour room, or other parts of the hospital should be cleaned. There was little knowledge about the required concentration of cleaning solutions and correct materials to be used for cleaning. The same broom, mop, or cloth would be used to clean the toilet and wards in some facilities, thereby transferring infections from one place to another, rendering cleaning ineffective. Patients in the wards were mostly examined without washing hands. Since hand wash basins were situated in labour rooms or OPDs, the practice of hand washing was limited only to activities such as conducting deliveries.
Dumping of waste was observed at many PHCs on the compound (especially behind the building). The waste included needles, drip sets, medicine wrappers and sanitary napkins. Such practices were observed even when the PHCs had the correct infrastructure and sufficient staff.

Attitudes of staff at PHCs
In one of the facilities we observed, a tray with the placenta was kept in the labour room for more than 24 hours after the delivery. In contrast, there were some good exceptions; in one PHC the staff was enthusiastic about their work and the PHC had a clean ward and labour room, equipment was well arranged and the compound was clean. The difference between these hospitals is the attitude of the people who worked there. In PHCs with proactive medical officers, the staff had a positive attitude and the hospitals were clean. Conversely, hospitals with little staff or those where the staff was listless and unwilling to take initiatives were unkempt and unclean.
Lack of positive attitude towards one’s own work translated into incorrect practices and gaps in the quality of services. In addition, certain practices could be attributed to the ignorance of the staff, such as garbage littered around water sources, which may be due to lack of understanding about contamination of the water sources.

Reasons for bad practices and attitude of staff in PHCs
Inadequate staff affected the functioning of the PHCs and left little time and resources dedicated to sanitation and infection control at the hospital. As the staff struggled to complete the mandatory services provided, they tended to skip those which they did not value much or did not need to send reports for, skipping these tasks caused insufficient hygiene and sanitation. Lack of knowledge and awareness in WASH created gaps in following correct procedures and safety measures. As a result, there was no ownership, indifference towards safety of patients, and an approach towards reaching targets rather than a good WASH situaiton.
Staff tended to shift the blame on the public saying they dirtied the hospital, did not follow rules in the premises, and generally created nuisance. The senior staff held cleaning staff responsible for unsanitary conditions in the hospital, yet they only supervised cleanliness at their hospital by making morning rounds. No standard procedures or checklists were used to assess the cleanliness of the hospital. Problems occurred through absence of policies for infection control or adequate training for the cleaning and sanitation of the facilities in infection control.

Implications and next steps
The current monitoring system has very little focus on the status of infection control, review of the enabling factors (infra structure, staff, equipment, policies), and the overall maintenance of hygiene to ensure patients safety. In most of the facilities there is no point person who is responsible for infection control in health care facilities. The safety of the environment and patients against HAI is compromised.
The focus should aim to prevent the newborn baby and the mother from acquiring infections while being admitted in the hospital in the pretext of receiving skilled delivery support. Priority should be given to the provision of water at PHCs, without which it is difficult to maintain infection control. Supervision is required with a focus on the actual hygiene and sanitation situation in the facilities and not just if targets are reached. HAI should be added as a performance indicator. Capacity building, systems to improve performance and incentives to promote good practices in WASH are required.
With numerous efforts being made towards addressing maternal and child health, there should be focus on the safety of mothers and newborns at hospitals, including PHCs. In order to achieve the Millennium Development Goals (MDGs) post 2015, let the mantra be: WASH in health care facilities!

What are some sustainable solutions to ensure adequate WASH practices in PHCs?
Other experiences?]]>
Health issues and connections with sanitation Tue, 23 Jun 2015 08:58:21 +0000
health trends: burden of diarrheal disease decreasing - by: joeturner is a digest of data from 188 countries for 301 diseases and injuries between 1990 and 2013.

These show some interesting trends of various diseases of relevance to sanitation, in particular it suggests that diarrheal disease is down, intestinal nematodes are down and ascaris infections are down.

It is a long report, so it is a lot to download.

Another report from last December looking at the data says that overall global life expectancy for women is up 7 years to 71 and the WHO says that for women in low income countries it is up 10 years to 64.

This is the other report (also long)

And the World Health Organisation health statistics have also been updated for 2015, here:

If you don't want to wade through all these, I wrote an article on some of the key messages here:]]>
Health issues and connections with sanitation Mon, 22 Jun 2015 14:11:58 +0000
Re: Sanitation in Hospitals - WASH in Health Care Facilities for better health care services (WHO report) - by: muench
Interesting conversation. (jbr is John Brogan from Terre des Hommes in Switzerland)

Robyn, could you please explain a bit more about these tools? The website that you linked to states that:

The tools are to be used to perform a situation analysis of the state of hygiene (outcomes) on the maternity unit, as measured by visual cleanliness and the presence of potential pathogens, and individual and contextual/systems level determinants.

And SoapBox is a small NGO from the UK, did I understand that right from their website?

How did the connection with WaterAid come about and how have the tools been used in Zanzibar? Why Zanzibar in particular?

There are generally lots of tools around, but the hard part is to get them into practice and to get them used routinely by the intended target audience. How have you achieved this step?

Kind regards,
Health issues and connections with sanitation Tue, 16 Jun 2015 13:42:58 +0000
WASH in the context of maternal health and menstrual hygiene (research project by Sandec, Switzerland and others) - by: Gendersan1
Sandec/Eawag contributes also to the topic of Menstrual Hygiene Management (MHM) in an
interdisciplinary two-year (2014-2016) research project, which combines social anthropology and gender studies with sanitary engineering. We aim to provide solid information about users’ needs for WASH infrastructure in public health care facilities in Uganda and India. The project focus is to deepen our understanding on how to respond to women’s special needs during special times (menstruation, pregnancy, and childbirth). The expected research outcomes are a WASH indicators checklist for health care facilities, supplemented with a gender perspective, allowing for the assessment of the infrastructure, as well as providing practical guidance on necessary improvements. The data will provide evidence for possible interventions that are needs-based, technically appropriate and socially acceptable.

For more information please see:

Petra Kohler\sesp]]>
Health issues and connections with sanitation Mon, 01 Jun 2015 09:37:13 +0000
Re: Water, Sanitation and Hygiene – WASH - by: pkjha
Thanks for the informative post.
Sanitation is always lagging behind water. One of the reasons is both the sectors are clubbed together under the same budgetary head and water sector always get higher share than sanitation. Secondly Public health engineers are more interested with water than sanitation as it not considered as a dignified work.
In India there is a separate Ministry for water and sanitation for rural areas having separate Joint Secretary with separate budget for the water and sanitation. The result is good.
Sanitation has direct linkage with health. However, it has been observed that Health Department is rarely involved with sanitation program. If a patient suffering from water borne diseases go to Doctor, he gets some antibiotics. Doctor never advise such patients not to go for open defecation and use only toilets. The sanitation program can be more effective in achieving its goals when Health Department / Doctors in villages get involve into the program.
Health issues and connections with sanitation Mon, 25 May 2015 11:39:07 +0000
Water, Sanitation and Hygiene – WASH - The neglect of hygiene promotion in developing countries - by: F H Mughal Water, Sanitation and Hygiene – WASH

The mindset of politicians and decision-makers in the developing countries is such that they always give priority to water – when it comes to giving priority. They avoid talking about sanitation. Sanitation is given a low priority. However, in India, the government is giving high priority to sanitation.

Hygiene component, however, has not yet received the priority in developing countries. It has failed to receive the attention of decision-makers in developing countries – even to this day.

Recently, I happen to lay my hands on the paper: The neglect of hygiene promotion in developing countries, as shown by the Global Analysis and Assessment of Sanitation and Drinking-Water survey. The paper is authored by Alejandro Jiménez, Sue Cavill and Sandy Cairncross.

The abstract reads:

“The UN-Water Global Analysis and Assessment of Sanitation and Drinking-Water (GLAAS) report is one of the three periodic UN reports dealing with water supply, sanitation and hygiene. This paper analyses the data on hygiene promotion which were collected for the 2012 edition, but not included in the report. Despite the limitations of the information, this is the best picture available of the global status of hygiene promotion in developing countries. Results show the low priority given to hygiene when it comes to implementation. On average, the staff in place meets 40% of the estimated needs to achieve national targets. Countries report that over 60% of their population is reached by hygiene promotion messages, but we estimate that there are barely enough hygiene promoters to reach 10% of the people. Government officials’ greatest concerns are the lack of human resources and funds, but they also point to the absence of strategy, responsible agency and basic coordination and monitoring mechanisms as challenges. This has serious implications for the poor working conditions and low recognition of hundreds of thousands of hygiene promoters, who in most cases are women capable of playing a crucial role for public health. There is an urgent need for further development of capacity for hygiene promotion in developing countries.”

The abstract clearly indicates that low priority given to hygiene. Only 10% of the population is impacted by hygiene promotion.

A recent blog post by Hanna Woodburn, Deputy Secretariat Director for the Global Public-Private Partnership for Handwashing, has an eye-catching caption: Harnessing the “H” in WASH: The need to ensure hygiene’s place in the SDGs.

In her post, Hanna highlights the importance of including targets and indicators on hygiene, into the post-2015 development agenda under the Sustainable Development Goals (SDGs).

She points out that, while the proposed goal for water under the SDGs is a step in the right direction, there is a need to develop global level indicators that more accurately assess progress on hygiene. She calls hygiene as an overlooked area. Hanna underlines the need to develop global level indicators on hygiene.

An important comment in her post reads:

“Some of the world’s greatest development challenges have the simplest solutions. If you are reading this blog, you likely know the facts about water, sanitation, and hygiene (WASH). You probably know that diarrhea and pneumonia are the top killers of children under the age of five, and that WASH can make a big difference in saving these lives. You might be able to cite statistics about how many days of school children miss due to diarrhea (272 million per year, in case you were wondering), or be able to describe the impact that a lack of facilities have on menstruating girls’ education.”

Hanna’s post can be seen here:

These two references show importance of hygiene. But, the key point is how to motivate and sensitize the politicians, decision-makers and key government functionaries, so that priority is given to hygiene. At the moment, I think, the top-brass of the government, and the officials working in the relevant department in the developing countries, are miles away from hygiene.

F H Mughal]]>
Health issues and connections with sanitation Sun, 24 May 2015 06:01:09 +0000
Re: SaniPath - Assessment of Fecal Exposure Pathways in Low-Income Urban Settings (Emory University, USA) - by: YWAN446
I can explain in some more detail how the SaniPath analysis is planning to deal with the issue of sample variability.

The SaniPath study has three phases so far (Phase 1, Phase 1.5, and Phase 2). Right now we are working on a methodology to incorporate the variability from samples into our results. We have used phase 1 data, which has a larger sample size, to decide what types of distributions the environmental concentrations and frequencies of behavior follow. In order to see how robust a sample size of 10 was for each pathway, we used the bootstrap method and found that the variance of the mean of the log 10 concentrations for ten random samples was small. This enabled us to compare pathways on a log 10 scale. In order to prioritize pathways, we don't need an accurate estimate of the dose for each pathway, we just need the ranking. Since our goal is to distinguish 100 from 1000 rather than 20 from 50, ten samples are enough. Currently, we are conducting more analysis and trying to use a larger sample size for those pathways with a larger variability to increase the accuracy and robustness.

Furthermore, Bayesian Analysis ( can be used to estimate the distribution of both the environmental concentration and frequency of behavior, which account for variability. For example, if you sampled from the distribution and you had one accidentally highly contaminated sample while others were very clean, our new output could tell us that most of time this pathway is clean, but that there is a small probability that it could be very contaminated. This should be a good estimate of reality. If we sampled from the distribution again and we got ten samples that were all very clean, we could get results similar to the first time given the assumptions about the distribution. Though we didn't pick a highly contaminated sample the second time around, the distribution assumption can still inform us that there is a very small probability of getting a highly contaminated sample. Our results would depend on both the assumption of the distribution, which comes from our larger SaniPath phase 1 study, and the data people collect when they use the tool. I hope this helps answer your question about how our tool is trying to deal with chance variability.

Yuke (Andrew) Wang

Yuke Wang, MSPH
Data Analyst
Emory University
Rollins School of Public Health–Hubert Department of Global Health
Center for Global Safe Water
1518 Clifton Road, NE
MS: 002-7BB CNR6040B
Atlanta, GA 30322
Phone: 404-727-2238
Fax: 404-727-4590]]>
Health issues and connections with sanitation Tue, 12 May 2015 13:37:14 +0000
Re: SaniPath - Assessment of Fecal Exposure Pathways in Low-Income Urban Settings (Emory University, USA) - by: YWAN446
I work as a biostatistician/data analyst in SaniPath group. I hope I can answer your questions about QMRA.

The QMRA wiki website summarizes some concepts about QMRA. On this website, QMRA was defined as a framework and approach that brings information and data together with mathematical models to address the spread of microbial agents through environmental exposures and to characterize the nature of the adverse outcomes. As far as I understand, using quantitative data (microbial and behavioral) and mathematical models distinguishes QMRA from traditional risk assessments . As for the mathematical models and calculations, they don’t have to be as complex as Bayesian Analyses or Monte Carlo Simulations. They could be as simple as multiplying frequency of behavior and dose per contact together.

SaniPath is an application of QMRA. However, since our goal for SaniPath is to provide overall fecal microbe exposure information instead of information specific to one pathogen, the SaniPath methodology doesn't use a dose response model, which must correspond to one specific pathogen. Therefore, the SaniPath methodology functions as an exposure assessment rather than an estimate of the probability of infection.

An exposure assessment is a two part process that includes 1) evaluation of pathways that allow microorganisms to be transported from the source to the point of contact with human beings and 2) estimation of the amount of exposure that is possible between humans and contaminants. Conducting a realistic exposure assessment is important for good risk characterization as well as risk management. (ref:

The SaniPath exposure assessment for the Phase 1 in-depth analysis tracks back the source of fecal microbes that enters the human body and estimates its amount using a huge Monte Carlo Simulation. The microbial and behavioral data are all based on distributions, which are estimated using Bayesian Analysis. We can provide more detailed information about our exposure assessment after our exposure paper is finished.

Yuke (Andrew) Wang

Yuke Wang, MSPH
Data Analyst
Emory University
Rollins School of Public Health–Hubert Department of Global Health
Center for Global Safe Water
1518 Clifton Road, NE
MS: 002-7BB CNR6040B
Atlanta, GA 30322
Phone: 404-727-2238
Fax: 404-727-4590]]>
Health issues and connections with sanitation Tue, 12 May 2015 13:02:32 +0000
Re: SaniPath - Assessment of Fecal Exposure Pathways in Low-Income Urban Settings (Emory University, USA) - by: muench
This might be a stupid question but could you please explain to me how QMRA* relates to your Sanipath tool, i.e. is Sanipath an application of QMRA or an extension (or simplification) of it?
You mentioned QMRA once in your project description under objectives:
o Conduct an exposure assessment and quantitative microbial risk assessment (QMRA).


* QMRA = Quantitative Microbiological Risk Assessment, see also:]]>
Health issues and connections with sanitation Mon, 11 May 2015 09:48:12 +0000
Viruses in WWTP and the Microbiome - by: KeithBell virome is a hot topic, but little is known about how viruses affect general health via interaction with bacteria. But we do know viruses are hugely abundant in wastewater.

Why are we still mixing waste with water, infecting ourselves and creatures everywhere?

Our view of the virome in our intestines is changing, now seen as part of our immune system, actually protective. But out of balance with other microbes, viruses cause disease:

Did you know 95% of all polio cases are asymptomatic? Interaction with certain bacteria dramatically increase polio infectivity. In one study, the bacillus, B. cereus, was found to increase poliovirus infectivity over 500%.
Intestinal microbiota promote enteric virus replication and systemic pathogenesis

Similar studies about bacterial interaction with measles virus do not exist. So, why would measles be a mild childhood disease in most people, but lethal in others? Lack of a protective microbial balance . . .

Viruses bind to the sugar (LPS, etc.) in the cell wall of bacteria to increase infectivity. There's also a genetic component where viruses bind to host glycans. But a diet high in sugar and starch is more important than genes in shifting flora associated with viral disease.

This new paper reveals how we've been impudently releasing viruses into surface water:
The Detection Rate of Enteric Viruses and Clostridium difficile in a Waste Water Treatment Plant Effluent, 2015

And here we see how airborne viruses put WWTP workers at risk of gastrointestinal imbalance:
Assessment of airborne virus contamination in wastewater treatment plants, 2014

"20 out of 174 wastewater samples were positive" for polio in Switzerland:
Isolation of Sabin-Like Polioviruses from Wastewater in a Country Using Inactivated Polio Vaccine

Vaccination masks the issue: poor sanitation: polio in 7 Italian cities
Sporadic Isolation of Sabin-Like Polioviruses and High-Level Detection of Non-Polio Enteroviruses during Sewage Surveillance in Seven Italian Cities, after Several Years of Inactivated Poliovirus Vaccination, 2014]]>
Health issues and connections with sanitation Sat, 02 May 2015 17:18:48 +0000