Bulletin of the World Health Organization, 63 (4): 757-772 (1985) © World Health Organization 1985

Interventions for the control of diarrhoeal diseases

among young children: improving water supplies and
excreta disposal facilities*
S. A. ESREY,' R. G. FEACHEM,2 & J. M. HUGHES3

A theoretical model is proposed that relates the level of ingestion ofdiarrhoea-causing

pathogens to the frequency of diarrhoea in the community. The implications of this model
are that, in poor communities with inadequate water supply and excreta disposal, reducing
the level of enteric pathogen ingestion by a given amount will have a greater impact on
diarrhoea mortality rates than on morbidity rates, a greater impact on the incidence rate of
severe diarrhoea than on that of mild diarrhoea, and a greater impact on diarrhoea caused
by pathogens having high infectious doses than on diarrhoea caused by pathogens of a low
infectious dose. The impact of water supply and sanitation on diarrhoea, related infections,
nutritional status, and mortality is analysed by reviewing 67 studiesfrom 28 countries. The
median reductions in diarrhoea morbidity rates are 22 % from all studies and 2 7% from a
few better-designed studies. All studies of the impact on total mortality rates show a median
reduction of 21%, while the few better-designed studies give a median reduction of 30 %.
Improvements in water quality have less of an impact than improvements in water
availability or excreta disposal.

Of the several interventions that may reduce ted, maintained and used.
diarrhoea morbidity and mortality rates (38), the The potential impacts of improved water supply
improvement of water supply and excreta disposal and excreta disposal on diarrhoea and other water-
facilities has attracted particular interest. These related diseases in developing countries have been
environmental improvements, together with discussed and debated at length over the past decade.
improvements in living standards, played a major White et al. (86) provided a conceptual framework
role in reducing diarrhoea rates and controlling for the debate in the context of studies in East Africa;
epidemic typhoid and cholera in Europe and North McJunkin (56) reviewed the topic extensively;
America between 1860 and 1920. It is anticipated that Saunders & Warford (70) summarized the water
the improvement of water supply and excreta supply impact studies; Feachem et al. (39)
disposal in poor communities in developing countries summarized the excreta disposal impact studies; and
today will have a substantial impact on diarrhoea Blum & Feachem (13) and Esrey & Habicht (28)
morbidity and mortality rates in those communities. considered the methodological difficulties inherent in
This expectation provides part of the motivation for attempts to measure the impact of water supply and
the International Drinking Water Supply and Sani- excreta disposal projects on diarrhoea.
tation Decade (1981-1990), the aims of which are to In this review we analyse the effectiveness of water
increase the rate at which new water supply and supply and excreta disposal improvements for
excreta disposal facilities are constructed and to maxi- reducing diarrhoea rates in young children in
mize the probability that they will be correctly opera- developing countries. We also examine their impact
* Requests for reprints should be sent to the Director, Diarrhoeal
on diarrhoea-related infections, nutritional status,
Diseases Control Programme, World Health Organization, 1211 and mortality. We make no attempt to analyse other
Geneva 27, Switzerland. impacts of water supply and excreta disposal
' Division of Nutritional Sciences, Cornell University, Ithaca, improvements or to compute an overall cost-benefit
New York 14853, USA. ratio for these investments. This paper is the ninth in a
2 Head, Department of Tropical Hygiene, London School of
Hygiene and Tropical Medicine, Keppel Street, London WC1E 7HT, series of reviews of potential anti-diarrhoea inter-
England. ventions (2, 25, 26, 32, 34-36, 38).a
3 Director, Hospital Infections Program, Center for Infectious
Diseases, Centers for Disease Control, Public Health Service, US aASHWORTH, A. & FEACHEM, R. G. Interventions for the
Department of Health and Human Services, Atlanta, GA 30333, control of diarrhoeal diseases among young children: improving
USA. lactation. Unpublished WHO document CDD/85.2, 1985.
4581 -757-
.
758 S. A. ESREY ET AL.

EFFECTIVENESS water-borne transmission has been documented. For

some agents there is good evidence that, at least in
For improved water supply or excreta disposal some places at some times, water is a major vehicle of
facilities to be an effective diarrhoea control transmission. Notable examples are Salmonella
intervention, it must be true that: typhi, Vibrio cholerae, and Giardia lamblia (39).
Traditional water sources are often highly con-
either taminated with faecal matter. Improved water
sources may be free of contamination or considerably
less contaminated than unimproved water sources
water supply or excreta disposal (30, 77). Uncontaminated source water may become
polluted by the time it is ingested, and water storage
improvements can reduce the inges- hypothesis in home containers may result in increased con-
tion by young children of pathogens tamination depending on storage conditions (37, 66,
causing diarrhoea 72).
Increased water availability and quantity,
and associated with improved hygiene, may reduce faecal
contamination of the hands. Proper cleaning of
a reduction in the ingestion of these utensils, food, and home environments is also likely
pathogens by young children can hypothesis to reduce transmission of faecal matter. The
reduce diarrhoea morbidity or 2 transmission of all the main diarrhoea-causing agents
mortality rates is probably influenced to some degree by increased
.
water availability and quantity, but it is Shigella
transmission that has been particularly associated
or with poor personal and domestic hygiene (45, 78).
This may be because of the low infectious dose of
water supply or excreta disposal Shigella relative to other bacterial enteric pathogens,
improvements can reduce diarrhoea hypothesis or it may be only because Shigella has been most
morbidity or mortality rates among 3
studied. The relationship between personal hygiene
young children and the newly-recognized diarrhoea agents
(especially Campylobacter jejuni, enterotoxigenic
Escherichia coli, and rotavirus) should be studied.
The effectiveness of improved water supply and All the major infectious agents of diarrhoea are
excreta disposal would be suggested by a demonstra- shed by infected persons via the faeces, and therefore
tion either of the correctness of hypotheses 1 and 2 or hygienic disposal of human excreta plays a role in
the correctness of hypothesis 3. In some other reviews controlling them. Use of toilets by all members of the
in this series (for instance, 35, 36), most of the community should reduce faecal contamination of
literature bears on hypotheses 1 and 2, and hypothesis houses, yards and gardens, and the neighbourhood.
3 must be handled by theoretical calculations. Here In addition, proper treatment and disposal of human
the reverse is the case: there are few data on excreta would prevent faecal contamination of fields,
hypotheses 1 and 2 and an extensive literature on crops, and receiving water-bodies, which would in
hypothesis 3. The evidence for and against the three turn further reduce the transmission of faecal
hypotheses is examined below. pathogens. The hygienic disposal of the faeces of
children too young to use the toilet is of the utmost
importance, because such children constitute an
Hypothesis 1. Water supply or excreta disposal important reservoir of several agents of diarrhoea
improvements can reduce the ingestion by young (for instance, rotavirus and enterotoxigenic E. coli).
children of pathogens causing diarrhoea.
There is some evidence to suggest that three types of
water and excreta disposal improvements (improved Hypothesis 2. A reduction in the ingestion of these
water quality, increased water availability and pathogens by young children can reduce diarrhoea
quantity associated with better hygiene practices, and morbidity or mortality rates.
improved excreta disposal facilities) may reduce the The ingested dose of a pathogen required to cause
ingestion of pathogens causing diarrhoea (33). diarrhoea depends upon the particular properties of
All the major infectious agents of diarrhoea are the pathogen and upon a number of host factors. The
transmitted by the faecal-oral route, and all can be general relationship between ingested dose and
transmitted via contaminated water. For most agents proportion of exposed persons contracting diarrhoea
 IMPROVING WATER SUPPLIES AND EXCRETA DISPOSAL FOR CONTROL OF DIARRHOEAL DISEASES 759

100 _

Ex
I
/
~~~/, High

(LI
~ ~ ~ 0
mo / .1

_- A0
SCL
.~0/
Lowel
A a C D E F
He i
Dow of entbric ptsogmw gno P High

00
Fig. 2. Dose-response relationship for young children
A I D5 B under various levels of exposure to an array of enteric
Low High pathogens.
Dose of pathogen X ingested by all persons

Fig. 1. Dose-response relationship for a group of addition, in situations where large numbers of
susceptible persons, all exposed to an equal dose of
pathogen X. persons are exposed to diarrhoea-causing pathogens,
the ID, or IDo., values may be of greater
epidemiological relevance than the 1D50 values. More
is shown in Fig. 1. In the dose range below A, no one reliance can be placed on the relative ranking of
becomes ill.? In the dose range above B, all pathogens by ID50 than on the absolute dose values
susceptible persons develop diarrhoea. Between A obtained from studies on volunteers.
and B lies an intermediate range in which some The relationship depicted in Fig. 1 may be
persons become ill and others do not. The dose at generalized to a group of young children having
which 507o of challenged persons become ill is known different levels of water supply and excreta disposal
as the median infectious dose (ID50), which is the services and, consequently, different levels of
figure generally reported from volunteer studies. ingestion of enteric pathogens (Fig. 2). Consider first
Little is known about the shape of the curve in the the incidence rate of mild diarrhoea. At low levels of
intermediate range and, for this reason, a broken line ingestion (A-B), there remains an appreciable
is shown in Fig. 1. Both the shape of the curve and the incidence of mild diarrhoea, made up of an
values of A, B, and the IDso depend upon the irreducible minimum of infectious diarrhoea, plus
particular pathogen, its method of ingestion (in water diarrhoea not due to enteric pathogens. This situation
or in food), and a variety of features of the exposed is exemplified by children in wealthy communities in
group of people, such as age and immunity. developed countries. When ingestion rises above
Available ID50 and other infectious dose data have point B, the incidence rate of mild diarrhoea also
been recently reviewed for all the major diarrhoea- rises. At point D saturation is reached, and further
causing pathogens (39). For bacterial agents there is a increases in the ingestion of pathogens do not result in
wide range of ID50 values-from around 103 for an increased incidence rate of mild diarrhoea. As in
Shigella to 10'-10" for Vibrio cholerae. Less is Fig. 1, the shape of the curve between points B and D
known about the viral and protozoal agents of on the "mild diarrhoea incidence" line in Fig. 2 is
diarrhoea, although there are grounds for assuming unknown, so a broken line is shown. Poor com-
that the ID50 values are relatively low (< 102 ). Nearly munities in developed and developing countries, with
all infectious dose data are derived from studies on their elevated diarrhoea incidence rates, clearly lie to
volunteers in which the subjects were healthy adults the right of point B.
from developed countries. The doses necessary to The incidence rate of severe diarrhoea, which may
infect children, particularly malnourished children, be defined by stooling rate, stool volume, duration,
may be very different. ID5o values also depend on the degree of dehydration or other measures, is indicated
food or drink with which the pathogens are ingested; on Fig. 2 by the distance between the two lines (the
therefore, they may differ among countries with shaded band). The incidence rate of severe diarrhoea
differing dietary and child-feeding practices. In is less than that of mild diarrhoea, but it represents an
h Despite the representation in Fig. 1, it may be that for some increasing proportion of the total diarrhoea incidence
pathogens A = 0. rate as the ingestion of enteric pathogens rises above
760 S. A. ESREY ET AL.

the level represented by point C.c The incidence rate defined) are collected. Measures of diarrhoea or total
of severe diarrhoea is shown in Fig. 2 to be constant in mortality are also more likely to detect an impact in
the range A-C, to rise in the range C-E, and to be this range (see below).
constant in the range E-F. The breakpoints for severe In the range D-C in Fig. 2, both mild and severe
diarrhoea incidence rate (C and E) are offset to the diarrhoea incidence rates are falling, and a change
right of the equivalent points for mild diarrhoea inci- may be detected by surveillance of all cases. Severity,
dence rate (B and D), on the assumption that for a child growth, or mortality parameters are also likely
single pathogen a higher ingested dose is necessary to to change in this range. In the range C-B, only the
produce severe diarrhoea than mild diarrhoea. There incidence rate of mild cases is declining but, since
is direct experimental confirmation of this for entero- most cases are mild, surveillance of all cases may
toxigenic E. coli (27) and for Vibrio cholerae (19). detect an impact. In the range B-A, reductions in
Indirect evidence is also available for Salmonella, for pathogen ingestion have no effect on diarrhoea of any
which there is an inverse relationship between dose type.
and incubation period (12) and an inverse rela- This discussion of the implications of the model
tionship between incubation period and severity (10). presented in Fig. 2 may be restated in two other ways.
Fig. 2 assumes that the ID5o for severe symptoms is First, since it is. severe episodes that lead in some
higher than the ID5o for mild symptoms for most instances to death, the mild diarrhoea incidence rate
enteric pathogens. in Fig. 2 may be replaced by the total diarrhoea
The model put forward in Fig. 2 is tentative and incidence rate and the severe diarrhoea incidence rate
grossly simplified. It may be more applicable to by the diarrhoea mortality rate. Diarrhoea mortality
young children than to a whole community. The rates may therefore be a more responsive indicator in
complex role of immunity is not specifically the range D-E or ranges overlapping with the range
addressed in the model and, for certain pathogens, the D-E than diarrhoea morbidity rates. Diarrhoea
improvement of hygienic conditions may lead to an mortality rates will not, however, be a good measure
increase in diarrhoea incidence rates in older age of impact in areas where oral rehydration therapy is
groups. A more complete modelling of the widely available and averts most deaths from
interrelationships between hygiene levels and dehydration. Second, since there are putative
diarrhoea incidence is difficult because of the wide differences in ID5o values, not only between degrees
differences in epidemiology and immunology among of severity of diarrhoea caused by a single pathogen,
the major diarrhoea-causing agents. This simplified but also among different pathogens, the mild
model provides some theoretical basis for the diarrhoea incidence rate may be replaced by the
explanation of a number of observed features of incidence rate of etiologies having low ID5o values,
childhood diarrhoea. We hope that it may stimulate and the severe diarrhoea incidence rate by the
others to conduct studies to define more precisely the incidence rate of etiologies having high IDso values.d
complex reality. This model is consistent with known facts, in that
The implications of Fig. 2 for diarrhoea control by developed countries, which may lie in the range A-C,
reducing pathogen ingestion are as follows. If have a small proportion of cholera and enterotoxi-
pathogen ingestion is reduced within the range F-E, genic E. coli diarrhoea (high ID5o), a high proportion
the incidence rates of mild or severe diarrhoea may of rotavirus diarrhoea (low IDso), and an
not change. In the range E-D, severe diarrhoea rates intermediate proportion of shigellosis (intermediate
may fall, but mild diarrhoea rates may not. Because ID50).e
severe cases usually represent a small proportion of all It must be emphasized that the model presented in
cases, surveillance of all cases may fail to detect a fall Fig. 2 is hypothetical and grossly simplified. It is,
in incidence rate in this range. For instance, if a water however, consistent with several established facts
supply and excreta disposal project reduced the dose and, as discussed below, it is helpful in explaining
of ingested pathogens from E to D, Fig. 2 suggests some of the variation in the recorded impacts of water
that the incidence rate of severe diarrhoea might fall supply and excreta disposal projects on diarrhoeal
by about 44/o but the incidence rate of all diarrhoea diseases. A somewhat similar model has been
by only about 12%. Many diarrhoeal disease studies previously published (73).
are unable to detect a 12% fall in total incidence rate values d
It is not implied here that pathogens having relatively low ID50
relatively mild diarrhoea and vice versa. This is clearly
or to show it to be statistically significant. In the range untrue cause
in the cases of rotavirus and Shigella, both of which have
D-E an impact is more likely to be documented if data relatively ID50 values but cause relatively severe diarrhoea.
low
on the incidence rate of severe diarrhoea (however ' This analysis probably only applies to the anthroponotic agents
mentioned here. For the zoonotic diarrhoea agents, such as
'
The highest ratios of severe diarrhoea to all diarrhoea have been Salmonella and Campylobacter, most transmission in developed
recorded in some epidemics, which may be associated with excep- countries is from infected animals to man via contaminated food
tionally high average doses of pathogens ingested by an exposed products, and so levels of pathogen ingestion depend more on
population. farming methods, food handling practices, and diet than on domestic
water supply and human excreta disposal facilities.
 IMPROVING WATER SUPPLIES AND EXCRETA DISPOSAL FOR CONTROL OF DIARRHOEAL DISEASES 761

Hypothesis 3. Water supply or excreta disposal terms of diarrhoea morbidity, Shigella infection or
improvements can reduce diarrhoea morbidity disease, cholera, Entamoeba histolytica infection,
or mortality rates among young children. Giardia lamblia infection, nutritional anthro-
Numerous attempts have been made to measure the pometry, diarrhoea mortality, or total mortality.
impact on health of improved water supply or These studies are grouped in Table 1 according to the
sanitation. We selected for review those 67 studies health impact indicator measured and ordered alpha-
from 28 countriesf that measured health impact in betically by country within each group.
The data abstracted from the studies listed in Table
f Studies were identified from previous reviews, supplemental 1 are summarized in Tables 2-5. All the studies in
enquiries to workers in the field, computer searches in five Table 1 display methodological deficiencies (13, 28)
languages, and from unpublished papers presented at the Inter- althoug'i some studies were better than others. The
national Seminar on Measuring the Health Impact of Water and
Sanitation Programmes, Cox's Bazaar, Bangladesh, 21-25 total number of studies is large (67), but only a few are
November 1983 (sponsored by the International Centre for reported in sufficient detail to allow an objective
Diarrhoeal Diseases Research, Bangladesh, and the Ross Institute,
London). assessment of their methodological and analytical

Table 1. Studies on the impact of water supply or excreta disposal on diarrhoea morbidity and mortality, enteric
infections, total mortality, and nutritional status reviewed in this paper

Indicator Country Reference

Diarrhoea morbidity Bangladesh 22, 54, 74,a
Chile 24
Colombia 51, 88
Costa Rica 62
Egypt 82
Ethiopia 40
Gambia See belowb
Guatemala 16, 72
Haiti 79
India 53, 66, 67, 81
Iran (Islamic Rep. of) 82
Kenya 86,c
Lesotho 37
Mozambique See belowd
Sri Lanka 82
Saint Lucia 44,8
Sudan 6, 82
United Kingdom 17
USA 8, 15, 55, 64, 69, 71, 84
Venezuela 82, 87
Zambia 4
Cholera Bangladesh 22, 46, 49, 50, 54, 76, 77
Philippines 3
Entamoeba histolytica Costa Rica 62
infection Egypt 20
India 59, 66
Kenya See belowc
Libyan Arab Jamahiriya 41
USA 15, 29, 57
Table 1: continued on next page
762 S. A. ESREY ET AL.

Table 1: continued

Indicator Country Reference

Giardia lamblia Costa Rica 62

infection Egypt 20
India 66
Kenya See below'
Libyan Arab Jamahiriya 41
USA 29
Shigella Bangladesh 22, 48, 65,"
infection or disease Costa Rica 62
Egypt 82
Guatemala 7
India 66
Iran (Islamic Rep. of) 82
Libyan Arab Jamahiriya 41
Panama 52
Sri Lanka 82
Sudan 82
USA 45, 55, 71, 78, 84
Venezuela 82
Nutritional status Bangladesh See belowa
Colombia 21
Fiji See below'
Nigeria 80
Philippines See belowv
Saint Lucia See below"
Diarrhoea mortality Brazil 83
India 89
Total mortality Brazil 61
Costa Rica 43
Egypt 85
Guatemala 1
Malaysia 18
Sri Lanka 60, 63
Sudan 6
a RAHAMAN, M. M. The Teknaf Health Impact Study: methods and results. Paper presented at the International
Workshop on
Measuring the Health Impacts of Water Supply and Sanitation Programmes, Cox's Bazaar, Bangladesh, 21-25 November 1983.
b PICKERING, H. The role of anthropologists in studying diarrhoea epidemiology: a case study from The
Gambia. Paper presented at
the International Workshop on Measuring the Health Impacts of Water and Sanitation Programmes, Cox's Bazaar, Bangladesh, 21 -25
November 1983.
c FENWICK, K. W. H. The short-term effects of a pilot environmental
health project in rural Africa: the Zaina scheme re-assessed
after four years. (undated manuscript).
d CAIRNCROSS, S. & CLIFF, J. Water and health in Mueda, Mozambique. Paper presented at the International Workshop on
Measuring the Health Impacts of Water and Sanitation Programmes, Cox's Bazaar, Bangladesh, 21-25 November 1983.
'
YEE, V. S. Household level correlates of child nutritional status in Fiji. MPS thesis. Division of Nutritional Sciences, Cornell
University, Ithaca, New York, 1984.
f MAGNANI, R. J. & TOURKIN, S. C. Impact of
improved urban water supplies in the Philippines: methods and results. Paper
presented at the International Workshop on Measuring the Health Impacts of Water and Sanitation Programmes, Cox's Bazaar,
Bangladesh, 21-25 November 1983.
X HENRY, F. J. Health impact of water and sanitation interventions in St. Lucia. Paper presented at the International Workshop on
Measuring the Health Impacts of Water Supply and Sanitation Programmes, Cox's Bazaar, Bangladesh, 21-25 November 1983.
 IMPROVING WATER SUPPLIES AND EXCRETA DISPOSAL FOR CONTROL OF DIARRHOEAL DISEASES 763

strength. First, therefore, we analysed the pooled Different age groups have different pre-intervention
data from all the studies to try to draw a consensus diarrhoea rates, different risk factors, and different
from the many different attempts that have been tendencies to utilize new water supply or excreta
made in many countries to measure the health impacts disposal facilities. However, no consistent difference
of water supply and excreta disposal investments. by age in the magnitude of the impact was apparent
Second, we examined the results of a few selected (data not shown). This suggests that all ages will
studies of superior quality in more detail to compare benefit from improvements, despite the fact that
their findings with those from all 67 studies. young children do not use latrines.
The studies listed in Table 1 report impacts on The type of water supply or excreta disposal service
diarrhoea incidence rates and prevalence rates, which provided is likely to influence the size of the impact.
are different measures of morbidity due to diarrhoea. Improvements in water quality had less of an impact
If a water supply or excreta disposal project did not on diarrhoea rates than did improvements in water
affect the mean duration of diarrhoea episodes, the availability or excreta disposal (Table 2). Impacts
percentage reductions in incidence rates and from water quality plus availability were greater than
prevalence rates would be equal. If, on the other from either of these improvements separately or from
hand, the intervention reduced both incidence rates improvements in excreta disposal. The magnitudes of
and duration, then the percentage reduction in the reductions due to individual service components
prevalence rate would be greater than that in shown in Table 2 are probably overestimates because
incidence rate. In Tables 2-4 reductions in incidence situations labelled, for instance, as water quality
and prevalence rates are combined under the heading improvement may well have contained some element
of diarrhoea morbidity rate reduction. of water availability improvement. Data on the
impact of water quality improvement, with both
Impact on diarrhoea morbidity. The median water availability and excreta disposal controlled, are
reduction in diarrhoea morbidity rate is 22% (Table not available. This factor may also lead to an
2). The magnitude of this reduction may vary underestimate of the magnitude of the differences
depending on a number of factors: age of study among the impacts of the different types of service
population, type of service compared, general living improvement analysed in Table 2.
conditions of the area studied, and etiology of The magnitude of the impact is likely to be
diarrhoea. Each of these factors is examined below. influenced not only by the type of service installed but
The impact of water supply and excreta disposal also by the level of service both before and after the
improvements on diarrhoea is probably age-specific. intervention and the living conditions of the study
area. All studies of diarrhoea morbidity (Table 1)
were therefore divided according to the magnitude of
the difference between pre-intervention and post-
Table 2. Percentage reductions in diarrhoeal morbidity intervention levels of service (big difference or small
rates attributed to water supply or excreta disposal difference)9 and according to the adult literacy rate of
improvements the country in which the study was conducted
(<40%7o, 40-75%0, > 750/o). Adult literacy is used
Percentage here as a proxy for pre-intervention levels of hygiene
reduction and faecal contamination; in other words, to define
Type of Number of the pre-intervention point on the horizontal axis of
intervention resultsa Median Range Fig. 2. Current adult literacy figures are used,
All interventions 53 22 0-100 assuming that the relative ranking of countries,
Improvements in 9 16 0-90
according to adult literacy, has not changed over the
water quality past 30 years. The impacts of studies, categorized by
Improvements in 17 25 0-100 adult literacy rate and magnitude of service
water availability, improvement, are shown in Table 3.
Improvements in 8 37 0-82 Impacts attributed to large service-level improve-
water quality and ments are consistently higher than impacts attributed
availability
I
Improvements in 10 22 0-48 A study was considered to have investigated a large service
excreta disposal improvement if one or more of the following comparisons was made:
in-house water vs. public water source, piped water vs. unpiped
a water, water near and plentiful vs. water scarce or far, any toilet vs.
There are 53 results in total but only 44 attributed to specific no toilet, flush toilet vs. other toilet, or studies in which more than
interventions. The remaining 9 results are for other interventions one service component was improved (water quality and water
or combinations of interventions having less than 3 results, and availability, water quality and excreta disposal, water availability and
include interventions in fly control and health education together excreta disposal, water quality and water availability and excreta
with water supply or excreta disposal. disposal).
764 S. A. ESREY ET AL.

Table 3. Percentage reductions in diarrhoea morbidity anticipated that the impact on enterotoxigenic E. coli
rates attributed to water supply or excreta disposal will be considerable and on rotavirus negligible. The
improvements by adult literacy rate of the country and latter prediction is indirectly supported by data show-
magnitude of service improvement ing that the incidence rate of rotavirus diarrhoea
among children under 2 years of age is 0.3-0.4
Small service Large service
Adult improvementsb improvementsb episodes per child per year in both Bangladesh (11)
literacy and Winnipeg, Canada (42).
ratea No. of Median No. of Median
(%) results (%) results (%) Impact on nutritional anthropometry. If water
supply and excreta disposal improvements reduce
<40 11 18 7 46 diarrhoea incidence rates or duration among young
40-75 4 20 8 39 children, then nutritional anthropometric indicators
> 75 10 16 13 32 should also improve because of the inverse relation-
ship between time spent with diarrhoea and child
e Data on adult literacy, by country, from World development growth (58, 68). Six studies that investigated the
report, 1983 (Washington, World Bank). relationship between water supply or excreta disposal
b
See footnote g, page 762. improvements and nutritional status are summarized
in Table 5. All six studies reported an association
between improved water supply or excreta disposal
and improved nutritional status. In two studies, in
to small service-level improvements (Table 3). If a Fiji and the Philippines, attempts to control for
large service-level improvement is made, the extraneous risk factors reduced the differences
percentage reduction in diarrhoea morbidity rates between the control and intervention groups, but
achieved is inversely related to the pre-intervention some of these differences were nonetheless found to
level of hygiene (Table 3). The greatest impact is be statistically significant.
achieved when the pre-intervention hygiene level is
worst. For small improvements in service level, Impact on mortality. Only two studies were located
impacts appear less dependent upon the pre- that reported the impact of water supply or excreta
intervention hygiene level. These conclusions are disposal improvements on diarrhoea mortality rates
consistent with the hypothetical model depicted in (Table 1); a 41 o median reduction in diarrhoea
Fig. 2 and suggest that the impact of water and mortality rate was calculated from them. Both studies
sanitation improvements depends in part on the were concerned with the impact of improved water
presence and interaction of other risk factors. supplies in urban areas, and in neither was the study
method well described. A further eight studies
Impact on specific infections. When impact on reported impacts of water supply or excreta disposal
total diarrhoea morbidity is broken down by etiology, improvements on mortality from all causes (Table 1),
it is likely, as discussed above, that different specific and they indicated a 21 % (range, 0-81O7o) median
dOiarrhoeas will be reduced by different amounts. reduction in mortality rate.
Table 4 presents data on impacts on cholera, Shigella
infection or disease, and infection by Ent. histolytica
and G. lamblia. Since the distinction between the
severe and mild diarrhoea bands in Fig. 2 is merely
one of infectious dose (ID), in ranges including D-E, Table 4. Percentage reductions in morbidity or infection
any reduction in pathogen ingestion will produce a rates of cholera, Shigella, Entamoeba histolytica, and
greater percentage reduction in the incidence rate of Giardia lamblia attributed to water supply or excreta
the high ID etiologies than the low ID etiologies. Thus disposal improvements
the impact of a water supply and excreta disposal
improvement (in ranges including D-E) on specific Percentage
reduction
etiologies may be in the following descending order of
magnitude: cholera, enterotoxigenic E. coli, Shigella, Disease or No. of Median Range
the protozoa, rotavirus. The relative impacts on infection results (%) (%)
Shigella and the protozoa are supported by the data in
Table 4. The anomalous cholera data are discussed Cholera 11 41 0-91
elsewhere (31). Shigella 27 48 0-81
Data on the impact of water supply and excreta Entamoeba histolytica 17 2 0-80
disposal projects on enterotoxigenic E. coli and Giardia lamblia 10 0 0-20
rotavirus incidences are not yet available, but it is
 IMPROVING WATER SUPPLIES AND EXCRETA DISPOSAL FOR CONTROL OF DIARRHOEAL DISEASES 765

Table 5. Improvements in nutritional status attributed to various types of water supply or excreta disposal improve-
ment

Value of indicator

Country Nutritional Age Type of Control Target Reference

indicator' (months) intervention group group

Bangladesh Percentage with H/A > 90% of standard 0-11 Q+A+E 75 76 See belowd
12-23 Q+A+E 50 51
24-35 Q+A+E 45 48
Percentage with W/A > 75% of standard 0-11 Q+A+E 59 63
12-23 Q+A+E 44 43
24-35 Q+A+E 47 50
Colombia Percentage with W/A > 90% of standard 6-30 E 26 47 21
6-30 A 22 51
Percentage with H/A > 95% of standard 6-30 E 26 48
6-30 A 20 53
Fiji Mean percentage of: See belowe
standard W/A
urban 0-59 E 102 100
rural 0-59 E 95 102
standard H/A
urban 0-59 E 100 100
rural 0-59 E 99 103
Nigeria Percentage with: 80
W/A > 75% of standard 6-59 A 50 69
H/A > 90% of standard 6-59 A 80 69
W/H > 80% of standard 6-59 A 63 90
Philippines Percentage with W/A > 75% of standard See belowf
pre-intervention 6-54 74 75
post-intervention 6-54 Q+A 71 80
Saint Lucia Percentage with W/A > 90% of standard 1-3 A (A+E) 93 92 (86)C See belowg
4-6 72 90 (88)
7-9 51 78 (76)
10-12 44 76 (73)
13-15 50 76 (58)
16-18 51 74 (57)
19-21 53 75 (66)
22-24 54 79 (71)
a W/A = weight for age; W/H = weight for height; H/A = height for age.
b Q = water quality improvement, A = water availability improvement, E = excreta disposal improvement.
'
Figures not in parentheses refer to the communities receiving water availability improvements (A). Figures in parentheses refer to
communities receiving water availability improvements plus excreta disposal facilities (A + E).
d
See footnote a to Table 1.
' See footnote e to Table 1.
f See footnote f to Table 1.
8 See footnote g to Table 1.
766 S. A. ESREY ET AL.

Fig. 2 predicts a larger impact on diarrhoea areas. In the other,' water quality improvements had
mortality than morbidity over a wide range of an impact only among higher income households.
conditions. The impact on total mortality will depend Studies on diarrhoea morbidity were not as well
on the proportion of all mortality that is due to controlled as the mortality studies referred to above.
diarrhoea and the degree to which water supply and A median reduction in diarrhoea morbidity rates of
excreta disposal improvements affect the causes of 27% (range, 0-68%) was found in the studies judged
death other than diarrhoea. Since water supply and to be most satisfactory (40, 51, 55, 71). ji k, I
excreta disposal improvements will have little impact This brief review of selected studies of superior
on some major causes of death (for instance, design leads to two conclusions. First, the median.
respiratory infection, measles, malaria, and neonatal reductions in diarrhoea morbidity rates (27%) and
tetanus), it is to be expected that the impact on total mortality rates (30%) are a little higher than the
diarrhoea mortality is considerably greater than the values found by analysing all studies. Second, the
impact on all mortality. magnitude of the impact depends greatly on the
presence of other risk factors. More knowledge of
Results from selected studies. For the analyses so these interactions would enable the appropriate type
far, we have used pooled data from all studies listed in of intervention to be targeted to families that are
Table 1 to give an overview of all documented likely to benefit the most.
experiences on the impacts of water supply and
excreta disposal improvements on diarrhoea. It is
instructive to compare these findings with the results FEASIBILITY
of a few of the better studies. Criteria for judging the
quality of each study have been developed and are Nearly all developing countries are currently
reported elsewhere (28). engaged in substantial programmes to improve water
The first finding from this selective analysis was supplies in both rural and urban areas. The urban
that all studies that reported a negative impact were programmes date back, in many cases, to the 1920s or
flawed in one or more major respects. In other words, earlier, while many of the rural programmes were
the better studies consistently reported positive initiated in the 1960s. This considerable experience in
impacts. water supply programmes throughout the world has
The best studies were on total mortality (18, 43, been copiously documented (e.g., 23) and is con-
60), and the median impact on total mortality rates tinuously monitored by WHO.m Improved water
reported from these studies was a reduction of 30%o. supplies can be provided to almost all people in all
Analysis for statistical interactions revealed a range developing countries, and the technologies for
of reductions in mortality rates of 8-64%, depending achieving this are, for the most part, well established.
on the type of intervention and on the presence of Several problems remain, however, such as poor
other risk factors, such as poor feeding practices and operation and maintenance, inappropriate choice of
low literacy rates. For example, in one study (18) technology, inadequate revenue collection, failure to
excreta disposal improvements were reported to have sustain community participation, and high rates of
a larger impact on infant mortality rates than water water leakage and wastage.
supply, but the magnitudes of these impacts were All countries have experience in excreta disposal
greatly affected by whether the infants were breast- MAGNANI, R. J. & TOURKIN, S. C. Impact of improved urban
fed. The impact of the environmental interventions water supplies in the Philippines: methods and results. Paper
was greater for non-breast-fed infants than for breast- presented at the International Workshop on Measuring the Health
Impacts of Water and Sanitation Programmes, Cox's Bazaar,
fed infants. Thus, it is likely that non-breast-fed Bangladesh, 21-25th November 1983.
infants were further to the right along the horizontal j CAIRNCROSS, S. & CLIFF, J. Water and health in Mueda,
axis in Fig. 2 than were breast-fed infants. Another Mozambique. Paper presented at the International Workshop on
Measuring the Health Impacts of Water and Sanitation Programmes,
study reported that excreta disposal improvements Cox's Bazaar, Bangladesh, 21-25 November 1983.
had a greater impact on mortality in families with k PICKERING, H. The role of anthropologists in studying
literate mothers than in families with illiterate diarrhoea epidemiology: a case study from the Gambia. Paper
mothers (60). This may reflect an increased ability of presented at the International Workshop on Measuring the Health
Impacts of Water and Sanitation Programmes, Cox's Bazaar,
literate mothers to make correct use of the new Bangladesh, 21-25 November 1983.
/
excreta disposal facilities. RAHAMAN, M. M. The Teknaf Health Impact Study: methods
Two studies on nutritional status also examined and results. Paper presented at the International Workshop on
Measuring the Health Impacts of Water Supply and Sanitation
statistical interactions. In one,h excreta disposal was Programmes, Cox's Bazaar, Bangladesh, 21-25 November 1983.
reported to have more impact in rural than in urban "' See, for example, World Health Statistics Report, Vol. 26, No.
11, 1973; World Health Statistics Report, Vol. 29, No. 10, 1976; and
h Y EE, V. S. Household level correlates of child nutritional status The International Drinking Water Supply and Sanitation Decade.
in Fiji. MPS thesis. Division of Nutritional Sciences, Cornell Review of national baseline data (as at 31 December 1980), Geneva,
University, Ithaca, New York, 1984. World Health Organisation, 1984 (WHO Offset Publication No.85).
 IMPROVING WATER SUPPLIES AND EXCRETA DISPOSAL FOR CONTROL OF DIARRHOEAL DISEASES 767

programmes in urban areas, in some cases dating upon the costs of labour and materials. The costs of
back thousands of years. Rural excreta disposal operation and maintenance (recurrent costs) must be
programmes are typically a new phenomenon, and added to the construction costs, and data on these
some countries still lack concerted efforts in this costs are not readily available. One study of excreta
sector. Problems commonly encountered in excreta disposal in 12 countries estimated that operation and
disposal programmes include the inappropriate maintenance accounted for between 4%o and 520/o of
choice of technology, poor operation and main- the total project costs per year, depending on the
tenance, inadequate revenue collection, and the lack technology under consideration (47). Several widely
of perception in many rural communities of the used technologies (for instance, sewerage and pour-
importance of improved excreta disposal practices. flush latrines) had operation and maintenance costs
Research into the technical, economic, and social that comprised approximately 30% of the total
aspects of excreta disposal in developing countries annual project costs. For rural water supplies, data
(e.g., see 47) over the past decade has led to some assembled by a UNDP/World Bank project' suggest
promising new approaches. that the same figure, 300/, is a reasonable estimate of
the proportion of the total annual costs taken up by
operation and maintenance. The 307o figure is
COSTS adopted in Table 6 for both water supplies and excreta
disposal.' Reliable data on the costs of software
Despite the extensive experience with water supply support (such as the promotion of community par-
and excreta disposal projects throughout the world,
the cost data on these projects are often of poor o
UNDP project INT/81/026.
quality and not strictly comparable. Data on The computation of the percentage of total annual costs due to
operation and maintenance requires the adoption of a discount rate
operation and maintenance costs, on institutional (or opportunity cost of capital). Choosing the discount rate is partly a
overhead costs, and on the costs of community matter of judgement, and different economists may advocate
mobilization and education, are especially deficient. different rates for the analysis of the same project. The choice of a
high discount rate (say, 20%) will reduce the apparent importance of
Table 6 presents cost data from 87 developing recurrent costs within total project costs. If a low discount rate (say,
countries. Costs vary widely depending upon the 5%) is chosen, perhaps to reflect the scarcity of recurrent funds (5),
the proportion of total costs that is attributed to operation and
design criteria adopted in different countries and maintenance will be greatly increased.

Table 6. Costs for urban and rural water supply and excreta disposal projects

Annual Annual
construction total
Construction cost cost per cost per
per capita Lifetime capita capita
Type of service (1982, US$)° (years)b (1982, US$) (1982, US$)d
Water supply
Urban
House connection 116 20 14 20
Publictap 66 20 8 11
Rural' 60 20 7 10
Sanitation
Urban
Sewerage 174 50 18 26
Other 66 20 8 11
Rural 19 10 3 4
a
Median values of the costs from 87 developing countries reported to WHO. For further information, see The International Drinking
Water Supply and Sanitation Decade. Review of national baseline data (as at 31 December 1980), Geneva, World Health Organization, 1984
(WHO Offset Publication No. 85).
b
Commonly assumed values.
c Assuming an opportunity cost of capital (discount rate) of 10%.
d
Assuming that construction costs are 70% of the total annual costs (see text).
' A variety of technologies are included here, but predominantly public taps and handpumps.
768 S. A. ESREY ET AL.

ticipation or hygiene education) and of apportioned impact of improvements in water quality plus
institutional overheads have not been located, and so availability together with excreta disposal. Likewise,
these costs, which are not trivial, have been omitted the available data do not permit an assessment of the
from the calculations. advantages of adding a hygiene education component
Total annual costs per capita are derived in Table 6, to a project, but analysis of hygiene education alone
assuming that recurrent costs comprise 30% of the suggests that it may further enhance the impact (34).
total annual costs, that project lifetimes are between Taking all this evidence together, and in view of the
10 and 50 years (depending upon the technology), and impact of large service-level improvements shown in
that the appropriate discount rate is 1007o. The total Table 3, it is possible that well-designed projects
annual costs per capita in Table 6 may be aggregated combining water supply, excreta disposal and hygiene
to derive the costs of complete water supply and education may achieve diarrhoea morbidity rate
excreta disposal interventions. For instance, a rural reductions of 35-50%. It is to be expected that, in any
water supply and excreta disposal project might cost given project, the impact on diarrhoea mortality rates
US$ 14 per capita annually ($10 + $4), whereas a will be larger than that on diarrhoea morbidity rates,
combination of in-house water and sewerage in an except in areas where other interventions, such as oral
urban area might have an annual cost of US$ 46 per rehydration programmes, have substantially reduced
capita ($20 + $26). the risk of death from diarrhoea.
A goal of this series of reviews (38) is to derive cost- This review highlights some of the deficiencies in
effectiveness estimates for each intervention. Special our knowledge of the impacts of water supply and
difficulties are inherent in applying the cost- excreta disposal on diarrhoea. More studies of these
effectiveness analysis to interventions having multiple impacts are required, and it is expected that current
benefits, and water supply and excreta disposal advances in methodologyP will enable such studies to
interventions present these difficulties in an extreme be undertaken retrospectively and at reasonable cost.
form (9, 14). In addition to their impact on diarrhoea The model discussed under hypothesis 2 suggests that
rates among young children, these interventions may there may be advantages in measuring the impact on
avert diarrhoea in other age groups, reduce the severe diarrhoea rather than all diarrhoea. Where
incidence of other infectious diseases, and have a etiology-specific studies are being conducted, they are
variety of benefits unrelated to health. In view of this, more likely to record impacts on diarrhoea due to
a treatment of the cost-effectiveness of water supply agents having high infectious doses than on diarrhoea
and excreta disposal in relation to other diarrhoea due to agents having low infectious doses. The most
control measures will be left to a later publication. pressing research need is to document the impact on
diarrhoea of projects that combine improvements in
water quality, water availability and excreta disposal
CONCLUSIONS with hygiene education that are functioning satis-
factorily and are being utilized by the intended bene-
The results in Tables 2-4 show that substantial
ficiaries.q
reductions in diarrhoea morbidity and mortality rates P BRISCOE, J. ET AL. Measuring the impacts of water supply and
can be expected from investments in water supply and sanitation projects on diarrhoea: prospects for case-control methods
excreta disposal. Table 2 suggests that investments (in preparation).
" Minimum evaluation procedure (MEP) for water supply and
that improve both water quality and availability are sanitation projects. Unpublished document WHO/ETS/83.1,
especially effective. There are no adequate data on the 1983.

ACKNOWLEDGEMENTS

We are grateful for the constructive criticisms of earlier drafts of this paper provided by R. C. Ballance, D. Blum,
J. Briscoe, A. M. Cairncross, I. de Zoysa, B. H. Dieterich, F. L. Golladay, M. B. Grieveson, R. C. Hogan, J. S.
Koopman, L. Laugeri, D. D. Mara, M. H. Merson, R. N. Middleton, M. Phillips, M. M. Rahaman, G. Schultzberg,
S. Unakul, and A. M. Wright. Secretarial, bibliographic and editorial assistance were most ably provided by Caprice
Mahalla, Susanne O'Driscoll, and Dianne Fishman.
 IMPROVING WATER SUPPLIES AND EXCRETA DISPOSAL FOR CONTROL OF DIARRHOEAL DISEASES 769

R-SUMt
LA LUTTE CONTRE LES MALADIES DIARRHEIQUES DU JEUNE ENFANT: INTERVENTIONS VISANT A AMELIORER
L'APPROVISIONNEMENT EN EAU ET L'ELIMINATION DES EXCRETA

Cet article est le neuvieme d'une serie d'analyses etudes mieux concues. L'amelioration de la qualite de l'eau
consacrees aux mesures possibles pour lutter contre les importante moins que celle de I'approvisionnement ou de
diarrhees. Dans les pays en developpement, l'impact des 1'evacuation des excreta. Mieux vaut ameliorer la qualite de
projets d'approvisionnement en eau et d'evacuation des 1'eau et I'approvisionnement qu'un seul de ces elements ou
excreta sur les maladies diarrheiques a e au centre de tres que l'elimination des excreta. Les projets d'approvisionne-
nombreuses discussions et recherches. Quelques observa- ment en eau et d'evacuation des excreta ont un impact plus
tions donnent A penser que des ameliorations portant sur la important sur la shigellose que sur les infestations a
qualite de l'eau, l'approvisionnement en eau, l'hygiene Entamoeba histolytica ou a Giardia lamblia, mais on ignore
individuelle et l'evacuation des excreta, reduiraient quelles peuvent en etre les repercussions sur les diarrhees
l'ingestion des agents pathogenes A l'origine de diarrhees. causees par Escherichia coli enterotoxigene ou les rotavirus.
On expose ici un modele theorique qui etablit une relation Les six etudes portant sur les repercussions de l'approvision-
entre la quantite ingeree d'agents pathogenes responsables nement en eau ou de l'evacuation des excreta sur l'etat
de diarrhees et la frequence de ces affections dans la nutritionnel ont fait etat d'une amelioration.
communaute. L'article presente ensuite une analyse des donnees sur les
Ce modele montre que, dans des communautes pauvres, coQts de construction pour les projets d'approvisionnement
mal approvisionnees en eau et ou l'evacuation des excreta se en eau et d'assainissement dans 87 pays en developpement.
fait de faqon insalubre, la diminution de la quantite d'agents Si l'on ajoute les coQts d'exploitation et d'entretien, sans
enteropathogenes ingeree exerce, A valeur egale, un impact tenir compte des couts lies a la mobilisation et a l'education
plus grand sur les taux de mortalite que sur ceux de de la communaute ni des frais generaux institutionnels, on
morbite. Elle ameloire davantage les diarrhees graves que arrive a un total median de 14-46 dollars E.-U. (prix de
les diarrhees benignes et plutOt celles dont les agents etiolo- 1982) par tete, selon l'importance du service.
giques agissent A dose elevee. I1 faudra effectuer davantage d'etudes concernant
Le recensement de 67 etudes effectuees dans 28 pays l'impact des projects d'approvisionnement en eau et
permet d'analyser l'impact de l'approvisionnement en eau et d'evacuation des excreta sur les maladies diarrheques. En
de l'evacuation des excreta sur les maladies diarrheiques, les tout premier lieu, on etudiera l'impact de projets combi-
infections apparentees, l'etat nutritionnel et la mortalite. nant une amelioration de la qualite de l'eau, de l'appro-
Toutes ces etudes montrent une diminution mediane de 22%7 visionnement en eau et de l'evacuation des excreta A une
des taux de morbidite associes aux maladies diarrheiques, la education en matiere d'hygiene, en s'interessant A des
diminution atteignant 27% dans quelques etudes mieux installations qui donnent satisfaction et sont effectivement
concues; pour le taux de mortalite global, la diminution utilisees par les personnes visees.
re'diane a e de 21 %, atteignant 30% dans les quelques

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