Below are abstracts to ten 2014 studies that were authored or co-authored by Jamie Bartram as of May 2014. We will do similar searches for the latest studies by Stephen Luby, Jay Graham, Thomas Clasen, Oliver Cumming, Pavani Ram and other key WASH authors.
1. Trop Med Int Health. 2014 May 8. Global assessment of exposure to faecal contamination through drinking water based on a systematic review. Bain R, Cronk R, Hossain R, Bonjour S, Onda K, Wright J, Yang H, Slaymaker T, Hunter P, Prüss-Ustün A, Bartram J.
OBJECTIVES: To estimate exposure to faecal contamination through drinking water as indicated by levels of Escherichia coli (E. coli) or thermotolerant coliform (TTC) in water sources.
METHODS: We estimated coverage of different types of drinking water source based on household surveys and censuses using multilevel modelling. Coverage data were combined with water quality studies that assessed E. coli or TTC including those identified by a systematic review (n = 345). Predictive models for the presence and level of contamination of drinking water sources were developed using random effects logistic regression and selected covariates. We assessed sensitivity of estimated exposure to study quality, indicator bacteria and separately considered nationally randomised surveys.
RESULTS: We estimate that 1.8 billion people globally use a source of drinking water which suffers from faecal contamination, of these 1.1 billion drink water that is of at least ‘moderate’ risk (>10 E. coli or TTC per 100 ml). Data from nationally randomised studies suggest that 10% of improved sources may be ‘high’ risk, containing at least 100 E. coli or TTC per 100 ml. Drinking water is found to be more often contaminated in rural areas (41%, CI: 31%-51%) than in urban areas (12%, CI: 8-18%), and contamination is most prevalent in Africa (53%, CI: 42%-63%) and South-East Asia (35%, CI: 24%-45%). Estimates were not sensitive to the exclusion of low quality studies or restriction to studies reporting E. coli.
CONCLUSIONS: Microbial contamination is widespread and affects all water source types, including piped supplies. Global burden of disease estimates may have substantially understated the disease burden associated with inadequate water services.
2. Trop Med Int Health. 2014 May 8. Assessing the impact of drinking water and sanitation on diarrhoeal disease in low- and middle-income settings: systematic review and meta-regression. Wolf J, Prüss-Ustün A, Cumming O, Bartram J, Bonjour S, Cairncross S, Clasen T, Colford JM Jr, Curtis V, De France J, Fewtrell L, Freeman MC, Gordon B, Hunter PR, Jeandron A, Johnston RB, Mäusezahl D, Mathers C, Neira M, Higgins JP.
OBJECTIVE: To assess the impact of inadequate water and sanitation on diarrhoeal disease in low- and middle-income settings.
METHODS: The search strategy used Cochrane Library, MEDLINE & PubMed, Global Health, Embase and BIOSIS supplemented by screening of reference lists from previously published systematic reviews, to identify studies reporting on interventions examining the effect of drinking water and sanitation improvements in low- and middle-income settings published between 1970 and May 2013. Studies including randomised controlled trials, quasi-randomised trials with control group, observational studies using matching techniques and observational studies with a control group where the intervention was well defined were eligible. Risk of bias was assessed using a modified Ottawa-Newcastle scale. Study results were combined using meta-analysis and meta-regression to derive overall and intervention-specific risk estimates.
RESULTS: Of 6819 records identified for drinking water, 61 studies met the inclusion criteria, and of 12 515 records identified for sanitation, 11 studies were included. Overall, improvements in drinking water and sanitation were associated with decreased risks of diarrhoea. Specific improvements, such as the use of water filters, provision of high-quality piped water and sewer connections, were associated with greater reductions in diarrhoea compared with other interventions.
CONCLUSIONS: The results show that inadequate water and sanitation are associated with considerable risks of diarrhoeal disease and that there are notable differences in illness reduction according to the type of improved water and sanitation implemented.
3.PLoS Med. 2014 May 6. Fecal contamination of drinking-water in low- and middle-income countries: a systematic review and meta-analysis. Bain R, Cronk R, Wright J, Yang H2, Slaymaker T, Bartram J.
BACKGROUND: Access to safe drinking-water is a fundamental requirement for good health and is also a human right. Global access to safe drinking-water is monitored by WHO and UNICEF using as an indicator “use of an improved source,” which does not account for water quality measurements. Our objectives were to determine whether water from “improved” sources is less likely to contain fecal contamination than “unimproved” sources and to assess the extent to which contamination varies by source type and setting.
METHODS AND FINDINGS: Studies in Chinese, English, French, Portuguese, and Spanish were identified from online databases, including PubMed and Web of Science, and grey literature. Studies in low- and middle-income countries published between 1990 and August 2013 that assessed drinking-water for the presence of Escherichia coli or thermotolerant coliforms (TTC) were included provided they associated results with a particular source type. In total 319 studies were included, reporting on 96,737 water samples. The odds of contamination within a given study were considerably lower for “improved” sources than “unimproved” sources (odds ratio [OR] = 0.15 [0.10-0.21], I2 = 80.3% [72.9-85.6]). However over a quarter of samples from improved sources contained fecal contamination in 38% of 191 studies. Water sources in low-income countries (OR = 2.37 [1.52-3.71]; p<0.001) and rural areas (OR = 2.37 [1.47-3.81] p<0.001) were more likely to be contaminated. Studies rarely reported stored water quality or sanitary risks and few achieved robust random selection. Safety may be overestimated due to infrequent water sampling and deterioration in quality prior to consumption.
CONCLUSION: Access to an “improved source” provides a measure of sanitary protection but does not ensure water is free of fecal contamination nor is it consistent between source types or settings. International estimates therefore greatly overstate use of safe drinking-water and do not fully reflect disparities in access. An enhanced monitoring strategy would combine indicators of sanitary protection with measures of water quality. Please see later in the article for the Editors’ Summary.
4. Trop Med Int Health. 2014 Apr 30. Burden of disease from inadequate water, sanitation and hygiene in low- and middle-income settings: a retrospective analysis of data from 145 countries. Prüss-Ustün A, Bartram J, Clasen T, Colford JM Jr, Cumming O, Curtis V, Bonjour S, Dangour AD, De France J, Fewtrell L, Freeman MC, Gordon B,Hunter PR, Johnston RB, Mathers C, Mäusezahl D, Medlicott K, Neira M, Stocks M, Wolf J, Cairncross S.
OBJECTIVE: To estimate the burden of diarrhoeal diseases from exposure to inadequate water, sanitation and hand hygiene in low- and middle-income settings and provide an overview of the impact on other diseases.
METHODS: For estimating the impact of water, sanitation and hygiene on diarrhoea, we selected exposure levels with both sufficient global exposure data and a matching exposure-risk relationship. Global exposure data were estimated for the year 2012, and risk estimates were taken from the most recent systematic analyses. We estimated attributable deaths and disability-adjusted life years (DALYs) by country, age and sex for inadequate water, sanitation and hand hygiene separately, and as a cluster of risk factors. Uncertainty estimates were computed on the basis of uncertainty surrounding exposure estimates and relative risks.
RESULTS: In 2012, 502 000 diarrhoea deaths were estimated to be caused by inadequate drinking water and 280 000 deaths by inadequate sanitation. The most likely estimate of disease burden from inadequate hand hygiene amounts to 297 000 deaths. In total, 842 000 diarrhoea deaths are estimated to be caused by this cluster of risk factors, which amounts to 1.5% of the total disease burden and 58% of diarrhoeal diseases. In children under 5 years old, 361 000 deaths could be prevented, representing 5.5% of deaths in that age group.
CONCLUSIONS: This estimate confirms the importance of improving water and sanitation in low- and middle-income settings for the prevention of diarrhoeal disease burden. It also underscores the need for better data on exposure and risk reductions that can be achieved with provision of reliable piped water, community sewage with treatment and hand hygiene.
5. Sci Total Environ. 2014 Apr 17. Water quality laboratories in Colombia: A GIS-based study of urban and rural accessibility. Wright J, Liu J, Bain R, Perez A, Crocker J, Bartram J, Gundry S.
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The objective of this study was to quantify sample transportation times associated with mandated microbiological monitoring of drinking-water in Colombia. World Health Organization Guidelines for Drinking-Water Quality recommend that samples spend no more than 6h between collection and analysis in a laboratory. Census data were used to estimate the minimum number of operational and surveillance samples required from piped water supplies under national regulations. Drive-times were then computed from each supply system to the nearest accredited laboratory and translated into sample holding times based on likely daily monitoring patterns. Of 62,502 surveillance samples required annually, 5694 (9.1%) were found to be more than 6h from the nearest of 278 accredited laboratories. 612 samples (1.0%) were more than 24hours’ drive from the nearest accredited laboratory, the maximum sample holding time recommended by the World Health Organization. An estimated 30% of required rural samples would have to be stored for more than 6h before reaching a laboratory. The analysis demonstrates the difficulty of undertaking microbiological monitoring in rural areas and small towns from a fixed laboratory network. Our GIS-based approach could be adapted to optimise monitoring strategies and support planning of testing and transportation infra-structure development. It could also be used to estimate sample transport and holding times in other countries.
6. Int J Hyg Environ Health. 2014 Mar. Country clustering applied to the water and sanitation sector: a new tool with potential applications in research and policy. Onda K, Crocker J, Kayser GL, Bartram J.
The fields of global health and international development commonly cluster countries by geography and income to target resources and describe progress. For any given sector of interest, a range of relevant indicators can serve as a more appropriate basis for classification. We create a new typology of country clusters specific to the water and sanitation (WatSan) sector based on similarities across multiple WatSan-related indicators. After a literature review and consultation with experts in the WatSan sector, nine indicators were selected. Indicator selection was based on relevance to and suggested influence on national water and sanitation service delivery, and to maximize data availability across as many countries as possible. A hierarchical clustering method and a gap statistic analysis were used to group countries into a natural number of relevant clusters. Two stages of clustering resulted in five clusters, representing 156 countries or 6.75 billion people. The five clusters were not well explained by income or geography, and were distinct from existing country clusters used in international development. Analysis of these five clusters revealed that they were more compact and well separated than United Nations and World Bank country clusters. This analysis and resulting country typology suggest that previous geography- or income-based country groupings can be improved upon for applications in the WatSan sector by utilizing globally available WatSan-related indicators. Potential applications include guiding and discussing research, informing policy, improving resource targeting, describing sector progress, and identifying critical knowledge gaps in the WatSan sector.
7. Int J Hyg Environ Health. 2014 Mar. Beyond direct impact: evidence synthesis towards a better understanding of effectiveness of environmental health interventions. Rehfuess EA1, Bartram J2.
Systematic reviews are a cornerstone of evidence-based public health, and there is much discussion on how this method may need to be modified to do justice to complex interventions, such as environmental health interventions. This paper asserts that intervention effectiveness is influenced by variability in five distinct layers–direct (intrinsic) impact, user compliance, delivery, programming and policy measures–which are embedded in the broader geographical, socio-economic, political and cultural context. The multi-component, multi-sectoral nature of most environmental health interventions results in a complex relationship between these layers of influence, involving systemic interactions. As illustrated with examples, understanding environmental health interventions critically relies on considering all of these layers. These distinct layers of influence can serve as a framework towards the comprehensive analysis of environmental health interventions in systematic reviews, drawing on quantitative and qualitative methods and a variety of disciplines.
8. Int J Environ Res Public Health. 2014 Feb 21. Climate-related hazards: a method for global assessment of urban and rural population exposure to cyclones, droughts, and floods.
Christenson E1, Elliott M2, Banerjee O3, Hamrick L4, Bartram J5.
Global climate change (GCC) has led to increased focus on the occurrence of, and preparation for, climate-related extremes and hazards. Population exposure, the relative likelihood that a person in a given location was exposed to a given hazard event(s) in a given period of time, was the outcome for this analysis. Our objectives were to develop a method for estimating the population exposure at the country level to the climate-related hazards cyclone, drought, and flood; develop a method that readily allows the addition of better datasets to an automated model; differentiate population exposure of urban and rural populations; and calculate and present the results of exposure scores and ranking of countries based on the country-wide, urban, and rural population exposures to cyclone, drought, and flood. Gridded global datasets on cyclone, drought and flood occurrence as well as population density were combined and analysis was carried out using ArcGIS. Results presented include global maps of ranked country-level population exposure to cyclone, drought, flood and multiple hazards. Analyses by geography and human development index (HDI) are also included. The results and analyses of this exposure assessment have implications for country-level adaptation. It can also be used to help prioritize aid decisions and allocation of adaptation resources between countries and within a country. This model is designed to allow flexibility in applying cyclone, drought and flood exposure to a range of outcomes and adaptation measures.
9. Sci Total Environ. 2014 Jan 15, Human health and the water environment: using the DPSEEA framework to identify the driving forces of disease.
Gentry-Shields J1, Bartram J.
There is a growing awareness of global forces that threaten human health via the water environment. A better understanding of the dynamic between human health and the water environment would enable prediction of the significant driving forces and effective strategies for coping with or preventing them. This report details the use of the Driving Force-Pressure-State-Exposure-Effect-Action (DPSEEA) framework to explore the linkage between water-related diseases and their significant driving forces. The DPSEEA frameworks indicate that a select group of driving forces, including population growth, agriculture, infrastructure (dams and irrigation), and climate change, is at the root cause of key global disease burdens. Construction of the DPSEEA frameworks also allows for the evaluation of public health interventions. Sanitation was found to be a widely applicable and effective intervention, targeting the driver/pressure linkage of most of the water-related diseases examined. Ultimately, the DPSEEA frameworks offer a platform for constituents in both the health and environmental fields to collaborate and commit to a common goal targeting the same driving forces.
10. Sci Eng Ethics. 2014 Jan. Translating the Human Right to Water and Sanitation into Public Policy Reform. Meier BM, Kayser GL, Kestenbaum JG, Amjad UQ, Dalcanale F, Bartram J.
The development of a human right to water and sanitation under international law has created an imperative to implement human rights in water and sanitation policy. Through forty-three interviews with informants in international institutions, national governments, and non-governmental organizations, this research examines interpretations of this new human right in global governance, national policy, and local practice. Exploring obstacles to the implementation of rights-based water and sanitation policy, the authors analyze the limitations of translating international human rights into local water and sanitation practice, concluding that system operators, utilities, and management boards remain largely unaffected by the changing public policy landscape for human rights realization. To understand the relevance of human rights standards to water and sanitation practitioners, this article frames a research agenda to ensure that human rights aspirations lead to public policy reforms and public health outcomes.
