EHP Library Hygiene Bulletin No. 12, August 16, 2002

In this issue

• Spotlight from the Field
  • Managing water and sanitation, keeping it clean and simple
• Update to the Online Library
  • Cholera in 2001 – Weekly Epidemiological Record, Aug 2, 2002, vol 77 31(257-268)
• In the News
• Recent Studies/Articles
  • Personal hygiene practice and school-based health education of children in Anambra State, Nigeria.
  • Inequities in access to and use of drinking water services in Latin America and the Caribbean 
  • Relationship of breast-feeding and hand-washing with dehydration in infants with diarrhoea due to Escherichia coli.
  • Etc.

Spotlight from the Field-Managing water and sanitation: keeping it clean and simple 

Are there universally applicable operational models for delivering water and sanitation services in small towns? Is there a role for the private sector? How can public confidence in service providers be built and maintained? Do services need to be economically viable?

A study from Water and Environmental Health at London and Loughborough (WELL) warns against over-concentration on water supply services to the neglect of sanitation and health education. Globally-relevant recommendations emerge from a situation analysis of water supply and sanitation (including excreta disposal, solid waste management and storm drainage) in four small towns in Kerala State, India and Central and Eastern Uganda.

Kerala has developed a decentralised planning framework, the People’s Planning Campaign. At all levels of government, staff and the public are aware of rules, roles and responsibilities. While operation and maintenance of water supplies remains the responsibility of the Kerala Water Authority, locals identify priorities and beneficiary committees oversee implementation.

Uganda’s framework for management of small town water and sanitation is more confused. Despite recent moves towards decentralisation, central government continues with some capital investment in the sector. In one of the two towns surveyed, the failures of a complex multi-tiered management structure have resulted in widespread user dissatisfaction. The role of water user groups is unclear and interests of the majority of users are not sufficiently reflected. Provision of public toilets is inadequate. The other town with a more classical local government run system is well managed but the system itself suffers from poor initial design and construction.

Further findings include:

• In Kerala politicians are loath to tackle the perception that water should be free. Standpost users pay nothing and, despite almost universal household metering, only 40 percent of the amount due is collected. Operating costs are met from non-revenue sources.
• Sanitation is generally neglected. Officials talk of the need to improve sanitation but lack technical capacity and resources to do so. 
• In one town studied in Kerala and one in Uganda, municipal officials deliver health and hygiene education. Despite this, more than 70 percent of beneficiaries do not wash hands after defecation. 
  In one town studied in Uganda, one of the towns actively promoted the use and maintenance of domestic latrines. 
• While there is private sector involvement in ancillary services (and private water vendors fill the gap when municipal supplies are insufficient), in neither Uganda nor Kerala is there any obvious need for a conventional private sector operator. Good management seems to be the key to successfully operated systems regardless of whether they are public, private or community operated. 
• Kerala’ s model of successful franchised operation of public latrines is replicable elsewhere. 

Source(s): id21 Health News and: 
‘Provision of water and sanitation services to small towns’, WELL Task 323, by Jeremy Colin and Joy Morgan More information.

Date: 5 April 2002

Further Information:
Joy Morgan, Water, Engineering and Development Centre
Loughborough University, Leicestershire LE11 3TU UK
Email: [email protected]

Update to the Online Hygiene Library   

Cholera in 2001 – Weekly Epidemiological Record, Aug 2, 2002, vol 77 31(257-268)

Links to Other Online Documents

 EHP Hygiene improvement framework –

 IFH – http://www.ifh-homehygiene.org/2public/2pub00.htm

•   Guidelines for prevention of infection and cross infection in the domestic environment – focus on home hygiene in developing countries (April 2002)
•  Recommendations for selection of suitable hygiene procedures for use in the domestic environment (January 2002)
•  Hygiene Procedures in the home and their effectiveness: a review of the scientific evidence base (Draft, April 2002)

 UNICEF Hygiene promotion manual

WELL: Environmental health promotion capacity building: a training guide based on CARE’s Hygiene Promotion Manual –

WHO/IWA: Water quality guidelines:standards and health, 2001.

In the News (click on title to view complete article)

Earth Summit must address the food and water shortages, UN report …  – Environmental News Network – 14 Aug 2002
… and increasing environmental devastation that has left billions of people facing food and water shortages, a new UN report said Tuesday.

WSSD: Water gets expensive – News24 South Africa – 15 Aug
… year to halve the number of people without access to safe drinking water by 2015,

South Asia Facing Disease Outbreaks – Washington Post – 15 Aug
… miles southwest of Katmandu, where landslides claimed 50 lives last month, diarrhea and typhoid have spread in epidemic proportions

Recent Studies

Niger Postgrad Med J 2002 Jun;9(2):85-8 

Personal hygiene practice and school-based health education of children in Anambra State, Nigeria.

Ilika AL, Obionu CO.

Department of Community Medicine, Nnamdi Azikiwe University Teaching Hospital, Nnewi, Nigeria.

This study assessed the effect of school-based health education on the practice of personal hygiene by children in primary schools in Anambra State, Nigeria. Three hundred and ninety-five (395) and three hundred and ninety-eight (398) primary school pupils randomly recruited as intervention and control groups were rated on five key personal hygiene practices before, immediately after and three months after school-based hygiene health education. Less than 45% were rated clean before health education in both groups. Immediately after health education, more than 65% in the intervention group were rated clean. There was no change in the control group. The difference was statistically significant. However, there was a statistically insignificant decline in those rated clean three months after cessation of health education. The school-based health education improved the personal hygiene practice of the pupils. There is a need for regular reinforcement to sustain the gains.

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Rev Panam Salud Publica 2002 May-Jun;11(5-6):386-96 

Inequities in access to and use of drinking water services in Latin America and the Caribbean 
Soares LC, Griesinger MO, Dachs JN, Bittner MA, Tavares S.

Division of Health and Environment (HEP), Program of Basic Sanitation (HES), Pan American Health Organization, Washington, D.C., United States of America.

OBJECTIVE: To identify and evaluate inequities in access to drinking water services as reflected in household per capita expenditure on water, and to determine what proportion of household expenditures is spent on water in 11 countries of Latin America and the Caribbean. 
METHODS: Using data from multi-purpose household surveys (such as the Living Standards Measurement Survey Study) conducted in 11 countries from 1995 to 1999, the availability of drinking water as well as total and per capita household expenditures on drinking water were analyzed in light of socioeconomic parameters, such as urban vs. rural setting, household income, type and regularity of water supply service, time spent obtaining water in homes not served by running water, and type of water-purifying treatment, if any. 
RESULTS: Access to drinking water as well as total and per capita household expenditures on drinking water show an association with household income, economic conditions of the household, and location. The access of the rural population to drinking water services is much more restricted than that of the urban population for groups having similar income. The proportion of families having a household water supply system is comparable in the higher-income rural population and the lower-income urban population. Families without a household water supply system spend a considerable amount of time getting water. For poorer families, this implies additional costs. Low-income families that lack a household water supply spend as much money on water as do families with better income. Access to household water disinfection methods is very limited among poor families due to its relatively high cost, which results in poorer drinking water quality in the lower-income population. 
CONCLUSIONS: Multi-purpose household surveys conducted from the consumer’s point of view are important tools for research on equity and health, especially when studying unequal access to, use of, and expenditures on drinking water. It is recommended that countries improve their portion of the surveys that deals with water and sanitation in order to facilitate national health assessments and the establishment of more equitable subsidy programs.

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J Health Popul Nutr 2000 Sep;18(2):93-6 

Relationship of breast-feeding and hand-washing with dehydration in infants with diarrhoea due to Escherichia coli.

Oo KN, Aung WW, Thida M, Toe MM, Lwin HH, Khin EE.

This prospective cohort study was carried out in the neonatal unit of the Yangon Children Hospital, Myanmar, to gather more information on the types of feedings and hand-washing practices of mothers as the determinant of severe dehydration in infants with acute diarrhea due to Escherichia coli. The study subjects included 100 infants with diarrhea, aged 4 months, admitted to the hospital from June 1997 to May 1998. Data on isolation of E. coli from rectal swab samples, types of feedings, hand-washing practices, and dehydration status were collected. Of the 100 cases, E. coli was isolated from rectal swab samples of 48 infants. Of these 48 cases, 28 had some dehydration and 20 had severe dehydration. Exclusive breast-feeding was observed only in the age group 1 and 1-2 month(s). The association of the severity of dehydration with other types of feedings compared to exclusive breastfeeding was not statistically significant. In this study, most mothers washed their hands with water only after cleansing their children’s defecation, and before and after feeding their children. The severity of dehydration was statistically significant in hand-washing practices when compared to washing with water only and washing with soap and water. This study has shown the association between types of feedings and hand-washing practices with dehydration in infants with acute diarrhea due to E. coli. The results of the study suggest that there is a need for appropriate intervention programs to promote exclusive breastfeeding and hand-washing practices with soap and water after cleansing children’s defecation, and before and after feeding children.

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J Health Popul Nutr 2000 Sep;18(2):115-8 

Association of malarial parasitaemia with dehydrating diarrhoea in Nigerian children.

Ibadin OM, Airauhi L, Omoigberale AI, Abiodun PO.

Records of 402 children–216 (53.7%) males and 186 (46.3%) females–aged 1-36 months, admitted to the Diarrhea Treatment and Training Unit of the University of Benin Teaching Hospital, Benin city, Nigeria, during July 1993 to June 1996, were reviewed to document the relationship between dehydration and malaria parasitemia. There was significant association between severity of dehydration and malaria parasitemia (p 0.0001). Association of parasitemia (p 0.006) with dehydration (p 0.0001) was significantly more marked in patients with acute watery diarrhea than in those with persistent and bloody diarrhea. Parasitemia was demonstrated in 50.5% of those not initially suspected to have malaria. Parasitemia was also significantly associated with fever (p 0.001) and fever co-existing with vomiting (p 0.01). The prevalence of malaria-associated diarrhea was 61.7%. More infants (75.6%) than older children had diarrhea. It was concluded that the prevalence of malaria-associated diarrhea was high and that children with dehydration are more likely to manifest malaria parasitemia.

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J Health Popul Nutr 2000 Jun;18(1):15-22

Prevention of diarrhoea in a poor district of Santo Domingo, Dominican Republic: practices, knowledge, and barriers.

Mclennan JD.

The study, conducted in a poor periurban community of Santo Domingo, Dominican Republic, assessed the practices, knowledge, and barriers relating to prevention of diarrhea. A total of 582 caregivers of children, aged less than 5 years, were systematically sampled from four barrios. Results of the study showed that 55% of the caregivers did not boil drinking water for children; 38% did not always wash hands of the children prior to meals; 87% of the children did not always wear shoes outside their house; and 54% were breastfed for less than 1 year. Biomedical knowledge about these practices was high among the caregivers, and was not related to the reported behaviors. However, several barriers were significantly related to practices, including lapse in caregiving, limited resources, erroneous beliefs, and noncompliance by children. Health education, based on a biomedical knowledge-deficit model, may have little impact on improving the diarrhea-prevention practices in these communities. Greater attention should, therefore, be directed toward the barriers experienced by caregivers of children..