Annotated Bibliography of Selected Studies on Water/Sanitation and   
Diarrheal Diseases  2003
(Compiled by the EHP Information Center, December 11, 2003)
This annotated bibliography contains citations and abstracts of 33 studies published in 2003 
that focus on diarrheal diseases and water/sanitation.  
Author Index	
Akter N, Hussain Z, Trankler J, Parkpian P.
Hospital waste management and it's probable health effect: a lesson learned from 
Bangladesh. Indian J Environ Health. 2002 Apr;44(2):124-37.  
Urban Environmental Engineering Program, School of Environment, Resource and
Development, Asian Institute of Technology, GPO Box 4, KlongLuang, Pathumthani
12120, Thailand.
A study was conducted to evaluate the current status of hospital waste
management (HWM) in Bangladesh. The aim is to recognize the health effect of the
existing practice, to determine the awareness level of doctors and nurses about
hospital waste, to identify the weaknesses, and to provide suggestions for
improvement. Hospital staff, waste pickers, and local residents were interviewed
while in depth field observation, which included sample collection and
laboratory analysis was also conducted. Through this investigation, it has been
quite evident that a satisfactory hospital waste management system in government
hospitals and several private clinics is severely lacking. At present,
Bangladesh has no rigorous laws or regulation, which are enforced in this area.
The waste is generally dumped together in a public place such as the hospital
surroundings, the roadside or City Corporation dustbin. Many doctors and nurses
are not fully aware about what constitutes as medical waste. Health care workers
have only a basic understanding of health care and do not perceive handling or
disposal of medial waste as a hazardous work. Laboratory analysis shows existing
contamination of infectious agents in the environment. Some staff members
interviewed were suffering from various kinds of infectious diseases such as
viral hepatitis B/C, typhoid, skin disease/allergy, diarrhea, dysentery,
tuberculosis, and malaria. During field observation it was discovered that
improved HWM systems have only recently been introduced in a small number of
private hospitals and clinics, some of which could be used as references to
formulate guidelines for reaching the optimal at the national level. The study
indicates that there is a need to improve the handling and disposal methods of
hospital waste in almost all the available medical facilities. There are a few
NGOs that have started awareness building and training on waste management for
selected hospital staff and NGO officials. Based on the analysis of the
situation, several suggestions and recommendations have been made to aid in the
development of a waste management system.

Bajracharya D.
Myanmar experiences in sanitation and hygiene promotion: lessons learned
and future directions. 
Int J Environ Health Res. 2003 Jun;13 Suppl 1:S141-52. 

Recent activities in connection with the National Sanitation Week (NSW) and
Social Mobilisation for Sanitation and Hygiene have contributed to a significant
increase in access to sanitary means of excreta disposal, from 45% in 1997 to
67% in 2001. Handwashing with soap and water after defecation has also increased
from 18% in 1996 to 43% in 2001. Success is attributable to high level political
commitment, state or division level action and community mobilisation by village
level authorities. Multi-level efforts such as mass media, planning workshops,
training sessions and house-to-house visits by village authorities and health
officials have raised greater awareness of sanitation and hygiene issues and led
to construction of latrines on a self-help basis. The challenge ahead is to give
greater attention to the 'hard to reach' who live in less accessible areas and
are more resistant to change. The 2002 NSW has accordingly given special
emphasis to activities in 73 of 324 townships where 50% or more of the
households have no access to a sanitary latrine. The communication and social
mobilisation package has been improved to upgrading unsanitary latrines and
integrating handwashing more systematically with promotion of sanitary latrines.
Programmatic follow-up to the NSW is being provided in selected townships
through more intensive social mobilisation for 'hard to reach' households and
activity-based school sanitation and hygiene education. This approach will
contribute further towards improved hygienic practices and reduce diarrhoeal
morbidity and mortality.
Brooks JT, Shapiro RL, Kumar L, Wells JG, Phillips-Howard PA, Shi YP, Vulule JM,
Hoekstra RM, Mintz E, Slutsker L.
Epidemiology of sporadic bloody diarrhea in rural Western Kenya.
Am J Trop Med Hyg. 2003 Jun;68(6):671-7.  
Foodborne and Diarrheal Diseases Branch, and Biostatistics and Information
Management Branch, National Center for Infectious Diseases, Centers for Disease
Control and Prevention, Atlanta, Georgia 30333, USA. Email: [email protected]
We conducted laboratory-based surveillance and a case-control study to
characterize the epidemiology of bloody diarrhea in rural Western Kenya. From
May 1997 through April 2001, we collected stool from 451 persons with bloody
diarrhea presenting to four rural clinics. Cultures of 231 (51%) specimens
yielded 247 bacterial pathogens: 198 Shigella (97 S. flexneri, 41 S. dysenteriae
type 1, 39 S. dysenteriae type non-1, 13 S. boydii, 8 S. sonnei), 33
Campylobacter, 15 non-typhoidal Salmonella, and 1 Vibrio cholerae O1. More than
90% of the isolates (excluding Campylobacter) were resistant to
trimethoprim-sulfamethoxazole and tetracycline, and more than 80% were resistant
to ampicillin. Most (74%) ill persons received medication to which their isolate
was resistant. Drinking Lake Victoria water and sharing latrines between
multiple households increased risk of bloody diarrhea. Washing hands after
defecating was protective. Providing safe drinking water and more latrines, and
promoting hand washing could reduce the burden of illness from bloody diarrhea
while limiting injudicious antimicrobial use.
Curtis V, Cairncross S.
Effect of washing hands with soap on diarrhoea risk in the community: a
systematic review.  Lancet Infect Dis. 2003 May;3(5):275-81.  
Department of Infectious and Tropical Diseases, London School of Hygiene and
Tropical Medicine, London, UK. 
Email: [email protected]
We set out to determine the impact of washing hands with soap on the risk of
diarrhoeal diseases in the community with a systematic review with random
effects meta-analysis. Our data sources were studies linking handwashing with
diarrhoeal diseases. Seven intervention studies, six case-control, two
cross-sectional, and two cohort studies were located from electronic databases,
hand searching, and the authors' collections. The pooled relative risk of
diarrhoeal disease associated with not washing hands from the intervention
trials was 1.88 (95% CI 1.31-2.68), implying that handwashing could reduce
diarrhoea risk by 47%. When all studies, when only those of high quality, and
when only those studies specifically mentioning soap were pooled, risk reduction
ranged from 42-44%. The risks of severe intestinal infections and of shigellosis
were associated with reductions of 48% and 59%, respectively. In the absence of
adequate mortality studies, we extrapolate the potential number of diarrhoea
deaths that could be averted by handwashing at about a million (1.1 million,
lower estimate 0.5 million, upper estimate 1.4 million). Results may be affected
by the poor quality of many of the studies and may be inflated by publication
bias. On current evidence, washing hands with soap can reduce the risk of
diarrhoeal diseases by 42-47% and interventions to promote handwashing might
save a million lives. More and better-designed trials are needed to measure the
impact of washing hands on diarrhoea and acute respiratory infections in
developing countries.
Curtis V, Biran A, Deverell K, Hughes C, Bellamy K, Drasar B.
Hygiene in the home: relating bugs and behaviour.  
Soc Sci Med. 2003 Aug;57(4):657-72.  
Department of Infectious and Tropical Diseases, DCVBU/ITD London School of
Hygiene and Tropical Medicine, Kepple Street, London WCIE 7HT, UK.
Email: [email protected]
Much infectious intestinal disease (IID) arises in the home environment. If
programmes to prevent infection are to be effective it is essential to both
identify the particular practices that risk disease transmission, and to
understand the reasons for these practices. An in-depth, multidisciplinary study
of carer and child hygiene in the domestic environment in the Wirral, UK,
employed structured observation, surface swabbing for polio vaccine virus and
enteric marker organisms, semi-structured interviews, projective interviews and
focus group discussions. Observations revealed that child carers washed hands
with soap after changing a dirty nappy on 42% of occasions, and that one in five
toilet users did not wash hands with soap afterwards. Microbiological samples
were taken from household surfaces at sites thought likely to be involved in the
transfer of faecal material. 15% of bathroom samples showed contamination with
polio vaccine virus. Nappy changing took place mainly in living rooms. Contact
with living room surfaces and objects during nappy changing was frequent and
evidence of faecal contamination was found in 12% of living room samples.
Evidence of faecal contamination was also found in kitchens, again on surfaces
thought likely to be involved in the transmission of faeces (taps and soap
dispensers). Key factors motivating hygiene were the desire to give a good
impression to others, protection of the child and aesthetics. In this setting,
the particular risk practices to be addressed included washing hands with soap
after stool and nappy contact and preventing the transfer of pathogenic
organisms to the kitchen. The occasion of the birth of a child may be a
privileged moment for the promotion of safer home hygiene practices. Using polio
vaccine virus as an indicator of faecal contamination produces results that
could be used in large-scale studies of household disease transmission. A better
understanding of the household transmission of the agents of IID using
multidisciplinary methods is needed if effective hygiene promotion programmes
are to be designed.
Curtis V. 
Talking dirty: how to save a million lives. 
Int J Environ Health Res. 2003 Jun;13 Suppl 1:S73-9.  
London School of Hygiene and Tropical Medicine, London, UK.
Email: [email protected]
Infectious diseases are still the number one threat to public health in
developing countries. Diarrhoeal diseases alone are responsible for the deaths
of at least 2 million children yearly - hygiene is paramount to resolving this
problem. The function of hygienic behaviour is to prevent the transmission of
the agents of infection. The most effective way of stopping infection is to stop
faecal material getting into the child's environment by safe disposal of faeces
and washing hands with soap once faecal material has contaminated them in the
home. A review of the literature on handwashing puts it top in a list of
possible interventions to prevent diarrhoea. Handwashing with soap has been
calculated to save a million lives. However, few people do wash their hands with
soap at these critical times. Obtaining a massive increase in handwashing
worldwide requires a sea-change in thinking. Initial results from a new
programme led by the World Bank, with many partner organisations, suggest that
health is low on people's list of motives, rather, hands are washed to remove
dirt, to rinse food off after eating, to make hands look and smell good, and as
an act of motherly caring. Professional consumer and market research agencies
are being used to work with the soap industry to design professional
communications programmes to reach whole populations in Ghana and India. Tools
and techniques for marketing handwashing and for measuring the actual impact on
behaviour will be applied in new public-private handwashing programmes, which
are to start up soon in Nepal, China, Peru and Senegal.
Deodhar NS.
Epidemiological perspective of domestic and personal hygiene
in India. Int J Environ Health Res. 2003 Jun;13 Suppl 1:S47-56.  
Email: [email protected]
When the application of epidemiology moves from mass phenomenon in a society or
community to the specific family or individual level occurrences, new vistas
unfold. The classical epidemiological triad, with its multi-mode influences and
interactions, becomes modified as a result of several lifestyle factors coming
into operation. It is well known that even under severely adverse climatic
conditions, microbes are able to survive, and even propagate, if an appropriate
micro-climate is encountered. This principle also applies to human beings. Many
incidences of disease or ailments, occurrence or absence, can be traced to the
home habitat, micro-ecosystem, human behaviour and lifestyles. Hygienic
practices are largely a matter of behaviour and usually have biological and
social origin. Human behaviour is influenced and determined by social
traditions, customs and culture. Furthermore, factors such as health
consciousness, practical knowledge of health sciences, motivation and concern
for taking steps for promoting health and preventing disease, can change
behaviour and make the lifestyle conducive to health. In a village or slum area,
families live in more-or-less the same environment. However, in the event of an
outbreak of a communicable disease, many escape the attack. While some
experience frequent episodes of illness, others continue to live fairly
healthily. Obviously, several social and cultural factors and associated human
behaviours seem to make the difference between health and disease. This
discussion examines the domestic and personal hygiene in its epidemiological
Faulkner CT, Garcia BB, Logan MH, New JC, Patton S. 
Prevalence of endoparasitic infection in children and its relation with cholera
prevention efforts in Mexico. Rev Panam Salud Publica. 2003 Jul;14(1):31-41.  
University of Tennessee, Department of Comparative Medicine, Knoxville,
Tennessee 37796-4543, United States of America. 
Email: [email protected]
OBJECTIVE: To investigate whether increased knowledge and use of public health
measures promoted for cholera prevention is reflected in lower prevalence of
parasitic infection in households in a community in the state of Tamaulipas,
Mexico, that is close to the border with the United States of America. 
METHODS: Between 1994 and 1997, fecal samples from 438 children were collected
 through convenience sampling and then examined for helminth eggs/larvae and protozoan
cysts as biologic indicators of household compliance with recommended cholera prevention
measures. The suggested measures were to wash hands before meals and after defecation, 
to drink purified water,  to wash fruits and vegetables, and to eat well-cooked food. In addition, 
information on the knowledge of and the use of cholera preventive measures was collected by 
interviews with adult informants in 252 households (186 of those households also provided a 
fecal sample for analysis).  RESULTS: Parasitic infections occurred in 131 of the 438 children
(30%), who resided in 79 of the 186 households (42%) that provided fecal  samples. Giardia 
lamblia accounted for 12.5% of all infections. Infections with Hymenolepis nana, Ascaris 
lumbricoides, Trichuris trichiura, Enterobius vermicularis, Ancylostoma/Necator, Strongyloides
stercoralis, Entamoeba coli, Entamoeba hartmanni, Entamoeba histolytica, Endolimax nana,
and Iodamoeba butschlii were also noted. Infected children were older and more often had an
infected sibling. Households with three or more children were also more likely to have an 
infected child. The primary caregivers in the households where at least one child had a parasitic
infection were distinguished by their inability to list at least three cholera prevention measures 
from memory. 
CONCLUSIONS: The 42% household prevalence of parasitic infection was 
relatively high and indicates that some residents of this community may not 
have fully embraced the public health education efforts promoted for prevention
of cholera. The occurrence of nonpathogenic protozoan parasites such as 
Endolimax nana, Entamoeba coli, Entamoeba hartmanni, and I. butschlii are important
bioindicators for the persistence of unhygienic behaviors that increase the risk
of cholera and other infectious diseases dependent on fecal-oral transmission.
Information obtained by similar studies can be useful for monitoring compliance
with community health and hygiene programs and may indicate the need to
intensify educational efforts for the prevention of diarrhea associated with
enteric pathogens that cannot be controlled by drugs alone.
Guerrant RL, Carneiro-Filho BA, Dillingham RA.
Cholera, diarrhea, and oral rehydration therapy: triumph and indictment.  
Clin Infect Dis. 2003 Aug 1;37(3):398-405.  
Center for Global Health, School of Medicine, Division of Infectious Diseases
and International Health, University of Virginia, Charlottesville, VA 22908,
USA. Email: [email protected]
Cholera drove the sanitary revolution in the industrialized world in the 19th
century and now is driving the development of oral rehydration therapy (ORT) in
the developing world. Despite the long history of cholera, only in the 1960s and
1970s was ORT fully developed. Scientists described this treatment after the
discovery of the intact sodium-glucose intestinal cotransport in patients with
cholera. This new understanding sparked clinical studies that revealed the
ability of ORT to reduce the mortality associated with acute diarrheal disease.
Despite the steady reductions in mortality due to acute dehydrating diarrheal
diseases achieved by ORT, the costly morbidity due to these diseases remains,
the result of a failure to globalize sanitation and to control the developmental
impact of diarrheal diseases and their associated malnutrition. New advances in
oral rehydration and nutrition therapy and new methods to recognize its costs
are discussed in this review.
Halvorson SJ.  
Women's management of the household health environment: responding to 
childhood diarrhea in the Northern Areas, Pakistan. 
Health Place. 2004 Mar;10(1):43-58.
Department of Geography, The University of Montana, 59812, Missoula, MT, USA
This paper examines mothers' management of water, sanitation, hygiene, and
childhood diarrhea in a mountain community in the Northern Areas, Pakistan. It
draws upon qualitative data obtained from 65 in-depth interviews and other
ethnographic field methods. The analysis shows that respondents were familiar
with diarrhea control interventions carried out in the study site, and
associated childhood diarrhea with oral-fecal transmission routes such as poor
water quality, unhygienic behaviors, contaminated food, and inadequate
sanitation practices. Findings also demonstrate the continuance of
long-established cultural patterns of perception and behavior with regard to
childhood diarrhea and the influence of socio-economic constraints to
instituting new management practices.
Harvey SA, Winch PJ, Leontsini E, et al.
Domestic poultry-raising practices in a Peruvian shantytown: implications for
control of Campylobacter jejuni-associated diarrhea.  
Acta Trop. 2003 Apr;86(1):41-54.  
Department of International Health, Johns Hopkins Bloomberg School of Public
Health, Baltimore, MD 21025, USA. Email: [email protected]
Raising poultry at home is common in many periurban communities in low-income
countries. Studies demonstrate that free-range domestic poultry increase
children's risk of infection with diarrhea-causing organisms such as
Campylobacter jejuni. Corralling might reduce risk, but research on the
socioeconomic acceptability of corralling is lacking. To explore this issue, we
studied local knowledge and practices related to poultry-raising in a Peruvian
shantytown. Our objectives were to understand: (1). motives for raising domestic
poultry; (2). economic and cultural factors that affect the feasibility of
corralling; and (3). local perceptions about the relationship between domestic
poultry and disease. During 1999-2000, we met with community health volunteers
and conducted ethnographic and structured interviews with residents about
poultry-raising practices. We then enrolled 12 families in a 2-month trial of
corral use during which field workers made biweekly surveillance visits to each
family. Most participants reported that they raise birds because home-grown
poultry and eggs taste better and are more nutritious and because they enjoy
living around animals. Some want to teach their children about raising animals.
To prevent theft, many residents shut their birds in provisional enclosures at
night, but most stated that birds are healthier, happier, and produce better
meat and eggs when let loose by day. Many view bird feces in the house and yard
as dirty, but few see a connection to illness. Residents consider chicks and
ducklings more innocuous than adult birds and are more likely to allow them
inside the house and permit children to play with them. After extensive
orientation and technical assistance, participants were willing to corral birds
more often. But due to perceived disadvantages, many kept birds penned only
intermittently. Additional food and water costs were a significant obstacle for
some. Adequate space, bird care and corral hygiene would also need to be
addressed to make this intervention viable. Developing a secure, acceptable and
affordable corral remains a challenge in this population.
Heller L, Colosimo EA, Antunes CM.
Environmental sanitation conditions and health impact: a case-control study.  
Rev Soc Bras Med Trop. 2003 Jan-Feb;36(1):41-50.  
Departmento de Engenharia Sanitaria e Ambiental, Escola de Engenharia,
Universidade Federal de Minas Gerais, Belo Horizonte, MG, Brasil.
This epidemiological investigation examines the impact of several environmental
sanitation conditions and hygiene practices on diarrhea occurrence among
children under five years of age living in an urban area. The case-control
design was employed; 997 cases and 999 controls were included in the
investigation. Cases were defined as children with diarrhea and controls were
randomly selected among children under five years of age. After logistic
regression adjustment, the following variables were found to be significantly
associated with diarrhea: washing and purifying fruit and vegetables; presence
of wastewater in the street; refuse storage, collection and disposal; domestic
water reservoir conditions; feces disposal from swaddles; presence of vectors in
the house and flooding in the lot. The estimates of the relative risks reached
values up to 2.87. The present study revealed the feasibility of developing and
implementing an adequate model to establish intervention priorities in the field
of environmental sanitation.

Hoque BA.
Handwashing practices and challenges in Bangladesh.

Int J Environ Health Res. 2003 Jun;13 Suppl 1:S81-7. 

Environment and population Research Center, EPRC, Bangladesh.
Email: [email protected]
Handwashing is universally promoted in health interventions. Studies in
Bangladesh and elsewhere have shown a 14 - 40% reduction of diarrhoeal diseases
with handwashing. The perceptions and methods related to washing of hands vary
widely in Bangladesh. Socio-economic factors are also associated with methods
practised. In general, the effectiveness of handwashing practices is poor.
Faecal coliform bacteriological counts were reported to be high for both left
and right hands. About 85% of women studied who lived in slums and 41% of rural
women washed their hands using only water. However, most women rubbed their
hands on the ground, or used soil, and rinsed them with water during
post-defecation handwashing. Most women claimed that they could not afford to
buy soap. Experimental trials showed that use of soap, ash or soil gave similar
results when women washed their hands under the same conditions. The washing of
both hands, rubbing of hands, and the amount and quality of rinsing water used
were found to be important determinants in the reduction of bacterial counts on
hands. Although handwashing messages have been revised by most of the main
programmes after these studies, there is scope for further improvement, as well
as evaluation of their impact.
Hosain GM, Saha S, Begum A.
Impact of sanitation and health education on intestinal parasite infection
among primary school aged children of Sherpur, Bangladesh.  
Trop Doct. 2003 Jul;33(3):139-43.  
Department of Community Medicine, Community Based Medical College, Gono
University, Mirzanagar, Savar, Dhaka 1344, Bangladesh. 
Email: [email protected]
This study was carried out in 1999-2000 in the northern part of Bangladesh to
determine the impact of sanitary latrine use and of health education on
intestinal parasites in school-aged children. The children were between 5 and 13
years of age and stool samples revealed that more than half (53%) of the study
sample was still infected with one or more intestinal parasites even after 4
years of intervention. Ascariasis was found to have the highest prevalence rate
(36.2%) and hookworm the lowest (10.7%). Intestinal parasite infection was
significantly lower (P < 0.05) among those who used a sanitary latrine and
received health education. This result is consistent with observations that the
effect of sanitation and health education is slow to develop. Concerted primary
healthcare activities with community development efforts should be undertaken to
improve the overall living condition of the people of this area to control this
Jensen PK, Ensink JH, Jayasinghe G, et al.
Effect of chlorination of drinking-water on water quality and childhood
diarrhoea in a village in Pakistan.  J Health Popul Nutr. 2003 Mar;21(1):26-31.  
Department of Veterinary Microbiology, The Royal Veterinary and Agricultural
University, Stigbojlen 4, 1870 Frederiksberg C, Denmark.
To evaluate the importance of public-domain transmission of pathogens in
drinking-water, an intervention study was carried out by chlorinating the public
water-supply system in a village in Pakistan. The water quality improved and
reached a geometric mean of 3 Escherichia coli per 100 mL at the last standpipe
of the water-supply system. Drinking-water source used and the occurrence of
diarrhoea were monitored on a weekly basis over a six-month period among 144
children aged less than five years in the village. In this group, the children
using chlorinated water from the water-supply scheme had a higher risk of
diarrhoea than children using groundwater sources, controlled for confounding by
season and availability of a toilet and a water-storage facility. The incidence
of diarrhoea in the village (7.3 episodes per 10(3) person-days) was not
statistically different from that in a neighbouring village where most children
used water from a non-chlorinated water-supply system with very poor water
quality. In this study area, under non-epidemic conditions, the reduction of
faecal bacteria in the public drinking-water supply by chlorination does not
seem to be a priority intervention to reduce childhood diarrhoea. However, the
study was of limited size and cannot provide conclusive evidence.
Kumar Karn S, Harada H.
Field survey on water supply, sanitation and associated health impacts 
in urban poor communities--a case from Mumbai City, India.  
Water Sci Technol. 2002;46(11-12):269-75.  
Department of Environmental Systems Engineering, Nagaoka University of
Technology, Nagaoka 940-2188, Japan.
A field survey was conducted on four slum, squatter and pavement dweller
communities of Mumbai City, India with a total sample size of 1,070 households.
Study revealed extremely low water consumption pattern averaging merely 30 l/c x
d, no sewerage and safe excreta disposal facilities manifested by high
occurrence of water-borne diseases. The annual diarrhoeal, typhoid and malaria
cases were estimated to 614, 68 and 126 per thousand populations respectively.
At point prevalence scale, at least 30% of all morbidity can be accounted for by
water-related infections. In addition to the impacts of neighborhood water
pollution and sanitation, such diseases were also found positively correlated
with low water consumption and poverty related factors as, poor housing and
family income. Analysis of variance also revealed intra-poor gradient both in
living standards and health conditions on which the pavement dwellers were
observed to be the greatest sufferers of all.

Lanata CF.
Studies of food hygiene and diarrhoeal disease.
Int J Environ
Health Res. 2003 Jun;13 Suppl 1:S175-83. 

Instituto de Investigacion Nutricional, Lima, Peru. Email: [email protected]
Contamination of weaning foods and water with enteropathogenic micro-organisms
has been recognised in the past, but its link with the development of diarrhoea
by young children in developing countries is lacking. This may explain the
unavailability of effective interventions to reduce the risk of diarrhoeal
diseases from this contamination. The frequency of contamination of weaning
foods with enteropathogens is high in developing countries, and is dependent on
the food type, storage time and ambient temperature of storage, the method used,
and the temperature reached on re-warming before re-feeding. Other
considerations are the bacterial content of cooking and feeding utensils. Fruit
and raw vegetables can become contaminated with enteropathogenic micro-organisms
 by sewage-containing irrigation water, by washing produce and fruits in
contaminated water, and how they are processed at home. In most studies
reviewed, the level of contamination is higher in weaning foods than in drinking
water. Since there is a need to reach a critical level of contamination before
illness can occur after the ingestion of an enteropathogen, it is postulated
that weaning foods are probably more important than drinking water for
transmission of diarrhoeal diseases in developing countries. Several potential
interventions have been identified, which should be developed and tested in
controlled trials in developing countries. These interventions are needed to
reduce contamination of weaning foods in households from developing countries,
while adequate facilities for the provision of clean water and sanitation to
those communities are placed.
Larsen B.
Hygiene and health in developing countries: defining priorities through
cost - benefit assessments.  Int J Environ Health Res. 2003
Jun;13 Suppl 1:S37-46.  
Economist/Consultant Environment and Health at the World Bank, UK.
Email: [email protected]
Presented here are the four preliminary conclusions in the assessment of health
and hygiene in developing countries: (a) child mortality, and disease burden
associated with hygiene, water and sanitation in the developing and the
developed regions of the world, has declined substantially in the past two
decades, but substantial inter-regional and cross-country differences persist;
(b) while child mortality and disease burdens decline with higher income levels,
a substantial number of countries have been performing far better in reducing
child mortality and disease burdens than their income levels would indicate,
suggesting that active policy and investment interventions can yield significant
health improvements without necessarily jeopardising economic growth; (c)
despite the evidence of the role of water and sanitation services in reducing
mortality and morbidity, service coverage at the country level has not increased
as much as one may have expected in the past decade, in part because of the
substantial resource requirements; (d) the paper will provide some new
perspectives and evidence on the cost-effectiveness of interventions to reduce
the disease burden of poor water and sanitation services and inadequate hygiene
practices, in particular with regard to economic evaluation and in reference to
hygiene programmes.

Merchant AT, Jones C, Kiure A, et al. 
Water and sanitation associated with improved child growth.

Eur J Clin Nutr. 2003  Dec;57(12):1562-8. 

OBJECTIVE: To examine the relation between household water and sanitation, and
the risk of stunting and reversal of stunting in Khartoum and Crezira regions Sudan.
DESIGN: Prospective cohort study.
SETTING: A total of 25 483 children aged 6-72 months from rural Sudan enrolled in an
18-month field trial in 1988 to study the effect of vitamin A supplementation on child health and survival.
RESULTS: The mean height-for-age z-scores at baseline and the end of study were -1.66 and -1.55, respectively, for the group with water and sanitation facilities, and -2.03 and -1.94 for the group without water and sanitation, after adjustment for age, region, gender, mother's literacy, intervention group (vitamin A vs placebo), family wealth, breastfeeding and cleanliness. Among children of normal height-for-age at baseline, the risk of stunting (<-2 height-for-age z-score) was lowest in the group that came from homes that had both water and sanitation compared to children from homes without these facilities (multivariate RR=0.79, 95% CI 0.69-0.90). Among children stunted at baseline, those coming from homes with water and sanitation had a 17% greater chance of reversing stunting than those coming from homes without either facility (adjusted RR=1.17, 95% CI 0.99-1.38). We did not detect a synergistic association between access to water and sanitation.
CONCLUSIONS: Water and sanitation are independently associated with improved growth of children.

Moffat T.
Diarrhea, respiratory infections, protozoan gastrointestinal parasites, and
child growth in Kathmandu, Nepal.  Am J Phys Anthropol. 2003 Sep;122(1):85-97.  
Department of Anthropology, McMaster University, Hamilton, Ontario L8S 4L9,
Canada. Email: [email protected]
The differential impact of diarrhea, respiratory infections, and protozoan
parasitism on growth is investigated among children under five years of age
living in periurban Kathmandu, Nepal. The children's parents are all
carpet-making workers who live in an environment with crowded living conditions,
poor sanitation, and contaminated water. Anthropometric data, both
cross-sectional and longitudinal, were collected over a 9-month period.
Morbidity data were gathered from maternal reports, and a subsample of
children's stools were examined for gastrointestinal parasites. In a comparison
of current growth status and growth velocity for children with and without
diarrhea and respiratory infections, it is found that body weight is most
affected by infections, particularly for children under 24 months of age. For a
subsample of children whose stools were tested for parasites, there is a
statistically significant association between stunting (low height-for-age) and
the presence of a protozoan gastrointestinal parasite. It is concluded that
although growth faltering is associated with diarrhea and respiratory
infections, the impact of these infections is of less importance for long-term
linear growth retardation than is infection by protozoan gastrointestinal

Moraes LR, Cancio JA, Cairncross S, Huttly S.
Impact of drainage and sewerage on diarrhoea in poor urban areas in
Salvador, Brazil. 
Trans R Soc Trop Med Hyg. 2003 Mar-Apr;97(2):153-8. 

Polytechnic School, Federal University of Bahia, Salvador, Brazil.
A longitudinal prospective study of the effect of drainage and sewerage systems
on diarrhoea in children aged < 5 years was conducted in 9 poor urban areas of
the city of Salvador (population 2.44 million) in north-east Brazil in 1989-90.
Due to complex political and administrative reasons, 3 areas had benefited from
drainage improvements, 3 from both drainage and sewerage improvements, and 3
from neither. An extensive questionnaire was applied to collect information on
each child and on the conditions of the household, and mothers recorded
diarrhoea episodes in their children aged < 5 years daily for 1 year, using
calendars. Fortnightly home visits were made to collect the data. The incidence
of diarrhoea in children in neighbourhoods with drainage was less than
two-thirds, and in neighbourhoods with drainage and sewerage less than
one-third, of the incidence in neighbourhoods with neither. After controlling
for potential confounders, the proportion of children with 'frequent diarrhoea'
showed the same significant trend across the study groups. Though the groups
were not exactly comparable, more than one child was monitored per household,
and it was not possible to rotate fieldworkers between study groups, the study
provides evidence that community sanitation can have an impact on diarrhoeal
disease, even without measures to promote hygiene behaviour.
Nanan D, White F, Azam I, Afsar H, Hozhabri S.
Evaluation of a water, sanitation, and hygiene education intervention on
diarrhoea in northern Pakistan.  Bull World Health Organ. 2003;81(3):160-5.  
Department of Community Health Sciences, The Aga Khan University, Karachi,
Pakistan. Email: [email protected]
OBJECTIVE: Inadequate water and sanitation services adversely affect the health
and socioeconomic development of communities. The Water and Sanitation Extension
Programme (WASEP) project, undertaken in selected villages in northern Pakistan
between 1997 and 2001, was designed to deliver an integrated package of
activities to improve potable water supply at village and household levels,
sanitation facilities and their use, and awareness and practices about hygiene
METHODS: A case-control study was conducted during July-September
2001 to evaluate whether, after selected confounders were controlled for,
children aged <6 years with diarrhoea were more or less likely to reside in
villages that participated in the project than in villages that did not
participate. Descriptive and logistic regression analyses were performed.
FINDINGS: Children not living in WASEP villages had a 33% higher adjusted odds
ratio for having diarrhoea than children living in WASEP villages (adjusted odds
ratio, 1.331; P<0.049). Boys had 25% lower odds of having diarrhoea than girls
(adjusted odds ratio, 0.748; P<0.049). A 2.6% decrease was found in the odds of
diarrhoea for every yearly increase in the mother's age (adjusted odds ratio,
0.974; P<0.044) and a 1.4% decrease for every monthly increase in the child's
age (adjusted odds ratio, 0.986; P<0.001). 
CONCLUSIONS: The findings in this study may help refine the approach to future 
water, sanitation, and hygiene initiatives in northern Pakistan. The integrated approach 
taken by WASEP, which incorporates engineering solutions with appropriate education
to maximize facility usage and improve hygiene practices, is a useful example of how desired
health benefits can be obtained from projects of this type.
Nath KJ.
Home hygiene and environmental sanitation: a country situation analysis for
India.  Int J Environ Health Res. 2003 Jun;13 Suppl 1:S19-28.  
The Institution of Public Health Egineers, India. Email: [email protected]
Problems of the environment and of domestic hygiene are always related to
poverty of population and the sanitation of settlements. Most cities and towns
in developing countries, like India, are characterised by over-crowding,
congestion, inadequate water supply and inadequate facilities of disposal of
human excreta, waste water and solid wastes. Inadequacy of housing for most
urban poor invariably leads to poor home hygiene. Personal and domestic hygiene
practices cannot be improved without improving basic amenities, such as water
supply, waste water disposal, solid waste management and the problems of human
settlements. But even under the prevailing conditions, there is significant
scope of improving hygiene practices at home to prevent infection and
cross-infection. Unfortunately, in developing countries, public health concerns
are usually raised on the institutional setting, such as municipal services,
hospitals, environmental sanitation, etc. There is a reluctance to acknowledge
the home as a setting of equal importance along with the public institutions in
the chain of disease transmission in the community. Managers of home hygiene and
community hygiene must act in unison to optimise return from efforts to promote
public health. Current practices and perceptions of domestic and personal
hygiene in Indian communities, the existing levels of environmental and
peri-domestic sanitation and the 'health risk' these pose will be outlined, as
well as the need for an integrated action for improving hygiene behaviour and
access to safe water and sanitation.
Nielsen M, Hoogvorst A, Konradsen F, et al.
Causes of childhood diarrhea as perceived by mothers in the Punjab, 
Southeast Asian J Trop Med Public Health. 2003 Jun;34(2):343-51.  
International Water Management Institute (IWMI), Lahore, Pakistan.
This study was carried out in the southern Punjab, Pakistan, to outline the
causes of childhood diarrhea as perceived by mothers. Two hundred households in
ten villages were randomly selected. Information was obtained from mothers,
through a questionnaire, in-depth interviews, and direct observations. The focus
was on obtaining information from mothers of children who were below five years
of age. Causes of diarrhea reported by mothers were categorized in seven
different domains. Causes relating to the digestive system, especially
consumption of too much food, were the most important, followed by causes
pertaining to contamination and those pertaining to the humoral theory of 'hot'
and 'cold'. The mothers' health status was perceived as determining the health
of her child through her breast milk. Through in-depth interviews, diarrhea as a
symptom of envy and malice was brought up. The study draws attention to the
complexity and heterogeneity of beliefs, attitudes and practices concerning
diarrhea. This makes it difficult to come up with general rules for health
education campaigns. Rather, in health education, the outstanding 'good' and
'bad' behavior should be selected and should be the focus. On the other hand,
the heterogeneity of beliefs, attitudes and practices prevailing in the
community could make mothers more receptive to new ideas than when a small set
of rigid cultural norms would dominate thinking on disease transmission and
hygiene. The study found that despite the mother's central role as caretaker one
should not focus only on the traditional mother-child relationship, but also
include the husband-wife relationship, and target other individuals involved in
setting norms within the household or within the nearby community.
Nunez FA, Lopez JL, de la Cruz AM, Finlay CM.
Risk factors for Giardia lamblia infection in children in daycare centers in
Havana, Cuba. Cad Saude Publica. 2003 Mar-Apr;19(2):677-82.  
Instituto de Medicina Tropical 'Pedro Kouri', La Habana, Cuba.
Email: [email protected]
We conducted a longitudinal study on giardiasis in three daycare centers in
Havana City for a period of 18 months and described a group of children with a
"predisposition" or tendency towards re-infection with Giardia lamblia. This
group was found to be more frequently associated with clinical symptoms such as
diarrhea. A case-control study was designed to determine whether socioeconomic
factors and hygiene were associated with this phenomenon. We found no
differences between the groups with regard to overcrowding rates, number of
persons per bed, absence of certain electric appliances, mother's schooling, or
mean family income. However, there were proportionally more fathers with less
than complete secondary education among cases as compared to controls. In
addition, we found no differences in lack of hand-washing before eating and
after defecation; however, we found a higher percentage of families who washed
vegetables insufficiently among predisposed children. Finally, a lower
percentage of families with predisposed children boiled their water. Our results
demonstrate the important role of water as a vehicle for transmission of
giardiasis and the importance of various epidemiologic factors.
Prado MS, Strina A, Barreto ML, et al.
Risk factors for infection with Giardia duodenalis in pre-school children in the
city of Salvador, Brazil.  Epidemiol Infect. 2003 Oct;131(2):899-906.  
Instituto de Saude Coletiva, Universidade Federal da Bahia, Brazil.
A cross-sectional study of 694 children aged 2 to 45 months selected from 30
clusters throughout the city of Salvador, Bahia (pop. 2.3 million) was carried
out as part of a longitudinal study of diarrhoea in order to identify risk
factors for infection with Giardia duodenalis. Variables studied included three
social and demographic factors (such as mother's education and marital status),
five relating to the peri-domestic environment (rubbish disposal, open sewers,
paving of the street), seven relating to the home itself (house construction,
susceptibility to flooding, water supply and sanitation) as well as a score for
hygiene behaviour based on structured observation. After multivariate analysis
using a hierarchical model, only four significant risk factors were found: (a)
number of children in the household under five years (b) rubbish not collected
from the house (c) presence of visible sewage nearby, and (d) absence of a
toilet. All four were significant at the 1% level.
Quick R. 
Changing community behaviour: experience from three African countries. 
Int J Environ Health Res. 2003 Jun;13 Suppl 1:S115-21.  
Centers for Disease Control and Prevention, Atlanta, Georgia 30333, USA.
Email: [email protected]
In the developing world, more than 1 billion people lack access to safe water.
To address this problem, the US Centers for Disease Control and Prevention
developed the Safe Water System (SWS), a household-based intervention with three
elements: water disinfection, safe storage and behaviour change techniques, and
tested these in three countries. In Zambia, social marketing (SM) was used to
implement the SWS, and 100 randomly selected households also received
motivational interviewing (MI). In Madagascar, the SWS was implemented using SM
and community mobilisation (CM). In rural Western Kenya, the SWS was also
implemented with SM and CM. In Zambia, 3 months after the SM project launch, 14%
of households in the SM-only group had adopted the disinfectant compared with
78% of households in the SM plus MI group. Through SM, over 1 million bottles of
disinfectant were sold in 3 years in Zambia. In Antananarivo, Madagascar, 6
months after launch of the water disinfectant, 8% of households in an early
stage of the CM process were using the disinfectant compared with 20% in
households at a late stage of the CM process. In 1 year, over 500,000 bottles of
disinfectant were sold in Madagascar. In Kenya, adoption of the water
disinfectant exceeded 60% in intervention households and diarrhoea rates
decreased by 58% in children < 5 years. Social marketing permits widespread
dissemination of interventions, but may have limited penetration into
economically disadvantaged communities. Additional, targeted interventions, such
as MI and CM, can increase product adoption. A combination of behaviour change
interventions can increase project impact.
Rego RC, Barreto ML, Killinger CL.
[What is garbage, anyway? The opinions of women from an outlying 
neighborhood in a large Brazilian city]. Cad Saude Publica. 2002 
Instituto de Saude Coletiva, Universidade Federal da Bahia, Salvador, BA,
40110-170, Brasil.
Domestic solid waste is cause for current environmental concern in large cities
around the world. Little is known about the human health consequences of solid
waste disposal in open-air dumps. In addition, there are few studies on people's
health practices in relation to solid waste. As the initial step in
epidemiological research on the relationship between solid waste and diarrhea,
this study describes women's perception of the definition of garbage and the
popular understanding of the relationships between garbage and disease, and
between garbage and the environment. The study used a qualitative approach in a
slum neighborhood in Salvador, Bahia. A total of 13 women were interviewed using
a semi-structured questionnaire in 1999. The FileMaker "diaricamp" application
was used for data analysis. Interviewees defined garbage as anything useless and
considered it a problem whenever it accumulated in the surroundings producing a
bad smell or visual pollution, attracted animals, caused disease in children or
adults, or was shifted from the individual to the collective/institutional
sphere of action to solve the problem.
Reller ME, Mendoza CE, Lopez MB, et al. 
A randomized controlled trial of household-based flocculant 
disinfectant drinking water treatment for diarrhea prevention in 
rural Guatemala.  Am J Trop Med Hyg. 2003 Oct;69(4):411-9.  
Division of Bacterial and Mycotic Diseases, National Center for Infectious
Diseases, Centers for Disease Control and Prevention, Atlanta, Georgia 30333,
We conducted a study to determine if use of a new flocculant-disinfectant home
water treatment reduced diarrhea. We randomly assigned 492 rural Guatemalan
households to five different water treatment groups: flocculant-disinfectant,
flocculant-disinfectant plus a customized vessel, bleach, bleach plus a vessel,
and control. During one year of observation, residents of control households had
4.31 episodes of diarrhea per 100 person-weeks, whereas the incidence of
diarrhea was 24% lower among residents of households receiving
flocculant-disinfectant, 29% lower among those receiving flocculant-disinfectant
plus vessel, 25% lower among those receiving bleach, and 12% lower among
households receiving bleach plus vessel. In unannounced evaluations of home
drinking water, free chlorine was detected in samples from 27% of
flocculant-disinfectant households, 35% of flocculant-disinfectant plus vessel
households, 35% of bleach households, and 43% of bleach plus vessel households.
In a setting where diarrhea was a leading cause of death, intermittent use of
home water treatment with flocculant-disinfectant decreased the incidence of
Sakisaka K, Wakai S, Wongkhomthong SA.
Domestic hygiene behaviour of mothers with children aged 0-5 years 
old in Tayabo village, Nueva Ecija, the Philippines. Asia Pac J Public 
Health. 2002;14(2):91-8.  
Department of Community Health, School of International Health, Graduate School
of Medicine, University of Tokyo, Japan. Email: [email protected]
A cross-sectional survey was carried out in a rural village in Nueva Ecija
province in the Philippines to identify the association between mothers' hygiene
behaviour and their socioeconomic status and household environment. A total of
206 mothers with children aged 0-5 years old participated in this study.
Household visits with face-to-face interviews using a structured questionnaire
and observation of household environments were conducted. Logistic regression
analysis revealed that the frequency of water boiling in mothers was
significantly associated with children aged under two years old and the
availability of domestic electricity. Availability of domestic electricity,
mother's educational level, possession of a private lavatory and of a private
well were significant predictors of whether hand-washing with soap was practiced
after defecation. For hand-washing with soap before feeding children, child's
age under one year old and the volume of the water supply were statistically
significant. The volume of the water supply was identified as a significant
predictor. Although health educational programme participation rates were very
high (83.2%), no significant association with hygiene behaviour was observed.
This study indicates that improvements in water availability, household
environment and health education may contribute to more frequent hand-washing.
Sobsey MD, Handzel T, Venczel L.
Chlorination and safe storage of household drinking water in developing
countries to reduce waterborne disease. Water Sci Technol. 2003;47(3):221-8.  
Dept of Environmental Sciences & Engineering, University of North Carolina,
Chapel Hill, NC 27599-7400, USA. Email: [email protected]
Simple, effective and affordable methods are needed to treat and safely store
non-piped, gathered household water. This study evaluated point-of-use
chlorination and storage in special plastic containers of gathered household
water for improving microbial quality and reducing diarrhoeal illness of
consumers living under conditions of poor sanitation and hygiene. Community
families were recruited and randomly divided into intervention (household water
chlorination and storage in a special container) and control (no intervention)
households. Microbes in stored household water were extensively inactivated by
1-5-mg/L doses of hypochlorite. Escherichia coli levels in stored household
waters were < 1/100 mL in most intervention households but readily detectable at
high levels in control households. Stored water of intervention households was
also lower in Clostridium perfringens and heterotrophic plate count bacteria
than in control households. The intervention reduced household diarrhoeal
illness. In Bolivia, monthly episodes of household diarrhoeal illness were 1.25
and 2.2 in intervention and control families, respectively (P = < 0.002)
indicating that 43% of community diarrhoea was preventable by using the
intervention. In Bangladesh, mean episodes of child diarrhoea/1,000 d were 19.6
and 24.8 in intervention and control groups respectively (P = < 0.03) indicating
that about 24% of observed diarrhoea was preventable by using the intervention.
Chlorine disinfection and storage in an appropriate container significantly
improved the microbiological quality of non-piped household drinking water and
reduced community diarrhoeal disease. Widespread use of this simple treatment
and storage system for non-piped domestic water has the potential to
dramatically reduce the global burden of waterborne diarrhoeal disease.
Strina A, Cairncross S, Barreto ML, Larrea C, Prado MS.
Childhood diarrhea and observed hygiene behavior in Salvador, Brazil. 
Am J Epidemiol. 2003 Jun 1;157(11):1032-8.  
Institute of Public Health, Federal University of Bahia, Salvador, Brazil.
Brief biweekly home visits, made as part of a cohort study of diarrhea in young
children under age 5 years that was carried out in Salvador, Brazil, in
1998-1999, were used as a low-cost way to collect structured observation data on
domestic hygiene behavior. Field-workers were trained to check a list of 23
forms of hygienic or unhygienic behavior by the child or the child's caretaker,
if any behaviors were seen during the visit. Children were grouped according to
whether mainly unhygienic behavior or mainly hygienic behavior had been
recorded. This permitted study of the determinants of hygiene behavior and of
its role in the transmission or prevention of diarrheal disease. Observations
were recorded on roughly one visit in 20. Households with adequate excreta
disposal were significantly more likely to be in the "mainly hygienic" group.
The prevalence of diarrhea among children for whom mainly unhygienic behavior
was recorded was 2.2 times that among children in the "mainly hygienic" group.
The relative risk for prevalence was 2.2 (95% confidence interval: 1.7, 2.8).
The relative risk fell to 1.9 (95% confidence interval: 1.5, 2.5) after data
were controlled for confounding, but the difference was still highly

Thompson T, Sobsey M, Bartram J.
Providing clean water, keeping water clean: an integrated approach. 
Int J Environ Health Res. 2003 Jun;13 Suppl 1:S89-94. 

World Health Organization, South-East Asia Regional Office, New Delhi, India.
Email: [email protected]
Millions of people, most of whom are children in developing countries, die of
basic hygiene-related diseases every year. Interventions in hygiene, sanitation
and water supply have been shown to control disease burden. Universal access to
improved water sources and basic sanitation remains elusive but is an important
long-term goal. Studies have shown that improving the microbiological quality of
household water by on-site or point-of-use treatment and safe storage in
improved vessels reduces diarrhoeal and other waterborne diseases in communities
and households of developing and developed countries. The extent to which
improving drinking water quality at the household level reduces diarrhoeal
disease probably depends on a variety of technology-related and site-specific
environmental and demographic factors that require further investigation,
characterisation and analyses.