Reviews/Analyses

Effects of improved water supply and sanitation on

ascariasis, diarrhoea, dracunculiasis, hookworm
infection, schistosomiasis, and trachoma
S.A. Esrey,' J.B. Potash,2 L. Roberts,3 & C. Shiff4
A total of 144 studies were analysed to examine the impact of improved water supply and sanitation
facilities on ascariasis, diarrhoea, dracunculiasis, hookworm infection, schistosomiasis, and trachoma.
These diseases were selected because they are widespread and illustrate the variety of mechanisms
through which improved water and sanitation can protect people. Disease-specific median reduction
levels were calculated for all studies, and separately for the more methodologically rigorous ones. For the
latter studies, the median reduction in morbidity for diarrhoea, trachoma, and ascariasis induced by water
supplies and/or sanitation was 26%, 27%, and 29%, respectively; the median reduction for schistoso-
miasis and dracunculiasis was higher, at 77% and 78%, respectively. All studies of hookworm infection
were flawed apart from one, which reported a 4% reduction in incidence.
For hookworm infection, ascariasis, and schistosomiasis, the reduction in disease severity, as meas-
ured in egg counts, was greater than that in incidence or prevalence. Child mortality fell by 55%, which
suggests that water and sanitation have a substantial impact on child survival.
Water for personal and domestic hygiene was important in reducing the rates of ascariasis, diar-
rhoea, schistosomiasis, and trachoma. Sanitation facilities decreased diarrhoea morbidity and mortality
and the severity of hookworm infection. Better water quality reduced the incidence of dracunculiasis, but
its role in diarrhoeal disease control was less important than that of sanitation and hygiene.

Introduction research on the health impacts of water and sani-

Water and sanitation have been the subjects of con- tation projects has focused on the incidences of diar-
siderable recent attention as a result of the declara- rhoeal diseases, malnutrition, and mortality of young
tion by the United Nations General Assembly that children, and evidence accumulated during the
the 1980s were the International Drinking-Water, decade indicates that these rates have been reduced
Supply and Sanitation Decade (IDWSSD). A major (22, 25). Although it is generally believed that the
objective of this was to improve the health of popu- rates of other diseases will decrease following
lations that received the interventions. Most of the improvements in water and sanitation, there have
been no systematic reviews of this.
The present article reviews the health impact of
1 Professor, Faculty of Agriculture and Environmental Sciences water and sanitation interventions on the following:
and Faculty of Medicine, Macdonald College of McGill University, ascariasis (Ascaris lumbricoides), diarrhoeal diseases
21111 Lakeshore Road, Ste-Anne-de-Bellevue, Canada, H9X ICO. (including measures of nutritional status and child
Requests for reprints should be sent to this address.
2
Student, School of Medicine, Johns Hopkins University, Balti-
survival), dracunculiasis (Dracunculus medinensis),
more, MD, USA. hookworm infection (Ancylostoma duodenale and
3 Student, Department of Geography and Environmental Engin- Necator americanus), schistosomiasis (Schistosoma
eering, Johns Hopkins University, Baltimore, MD, USA. haematobium and S. mansoni), and trachoma
4 Professor, Department of Immunology and Infectious Diseases, (Chlamydia trachomatis). These diseases were chosen
Johns Hopkins University, School of Hygiene and Public Health, because they are widespread in developing countries,
Baltimore, MD, USA. or because they constitute serious problems where
they exist, or both (Table 1). All developing countries
Reprint No. 5216 are affected by diarrhoeal diseases and ascariasis; the

Bulletin of the World Health Organization, 69 (5): 609-621 (1991) c World Health Organization 1991 60
S.A. Esrey et al.

Table 1: Incidence and effects of selected diseases In using larger quantities of water for personal hygiene
developing countries (excluding China) will probably interrupt the spread of trachoma. The
Estimated number of:
incidence, prevalence, and/or severity of all these dis-
eases are reduced by water and sanitation interven-
Cases per year tions.
(x 10) Deaths per year

Ascariasis' 900 20000 Methods

Diarrhoeal diseasesb 875 4.6 million
Dracunculiasisc 4 - Computer searches of articles on each of the diseases
Hookworm infection 800 considered were carried out using the MEDLINE
Schistosomiasisd 200 and MEDLINE 500 systems, which cover the period
Trachoma" 500 -9 from 1966 and 1986, respectively. For schistosomiasis,
'-' See ref. 96, 80, 97,57, and 18, respectively. an additional computer search was performed on
'Usually causes debilitation rather than death. CAB Abstracts (period, 1984-89). For hookworm
o The major disability is blindness (8 million). infection and ascariasis, Index Medicus was searched
for 1976-86, and the Science Citation Index for
other four diseases are somewhat more restricted in 1970-84. Because a thorough review of diarrhoeal
their range, although they are all prevalent in some diseases was published in 1986 (22), only studies
developing countries, except dracunculiasis, which published since then were sought. For trachoma,
only occurs in parts of Africa and Asia. additional references were provided by a recent
These diseases also illustrate the variety of review (72).
mechanisms through which improved water and References cited in the articles identified, but
sanitation can promote health (Table 2). Four basic which were not located in the computer search, were
aspects were considered: sanitation (i.e., human also sought. Only studies published in English in
excreta disposal), water quality, personal hygiene, peer-review journals were used; this methodology ex-
and domestic hygiene. Personal hygiene refers to cluded technical reports, mimeographs, and agency
water used for cleaning the body, including water for documents. An exception was made for studies
the face, hands, and eyes; domestic hygiene refers to carried out by Miller et al.,'-b because although they
water used to keep the home clean (e.g., food, had been published in peer-review journals, the
utensils, and floors). Each disease is affected by one unpublished documents upon which they were based
or more of these interventions. For example, provid- contained more information. Finally, the review was
ing safe, potable sources of drinking-water will prob- restricted to studies that presented data on the effect
ably prevent transmission of dracunculiasis, while of water and sanitation conditions on one of the six
diseases.
Table 2: Illustration of the potential relation between
Specific criteria that we have reported pre-
water and sanitation Interventions and morbidity from viously were used to identify the rigorous studies
selected diseases from the large number reviewed (22). First, studies
were divided into those that reported a statistically
Intervention significant positive association between the provision
of improved water or sanitation and better health
Water Water and those that did not. Studies were excluded from
Improved for for Human
drinking- domestic personal excreta the rigorous category if they had a single major flaw
water hygiene hygiene disposal or several known or suspected minor flaws that
could have biased their results. Each disease is
Ascariasis + ++ - ++ treated in turn, with the discussion focusing on the
Diarrhoeal + ++ ++ ++
diseases rigorous studies.
Dracunculiasis ++ The median reductions in morbidity (i.e., inci-
Hookworm - - - ++ dence and prevalence) and a range of reductions
infection attributable to improved water and sanitation were
Schistosomiasis - ++ ++ ++
Trachoma - + ++
*
Interventions marked with one or two pluses have an impact on MMiller, F.D. *t *I. Human intestinal parasitic infections and
a particular disease: an intervention marked "+ +" will have a environmental health factors in rural Egyptian communities. (EPA
stronger impact than one marked " + "; "-" = the intervention Research Reporting Series EPA-600/1-80-024), 1980.
has little or no impact on reducing disease rates. For a particular b Miller, F.D. et ai. Schistosomiasis in rural Egypt: a report of
disease, a package of interventions with pluses is expected to U.S.-Egyptian River Nile and Lake Nasser research project. (EPA
produce a larger impact than any one intervention alone. Research Reporting Series EPA-600/1-78-070), 1978.

610 WHO Bulletin OMS. Vol 69 1991.

 Effects of Improved water supply and sanitation on six endemic diseases

calculated for each disease, based on all the studies 66)c examined differences in excreta disposal facili-
reviewed. The same calculations were also made for ties, and five (3, 15, 37, 76, 77) investigated various
only the rigorous studies, the results from which combinations of water supply and sanitation condi-
more accurately represent the reductions that may tions. All five negative studies reported on excreta
be achieved by water and sanitation interventions. disposal facilities, while only one study (37) investi-
The results reported in some studies did not permit gated the influence of water supplies alone. One
determination of the median reduction in morbidity, study (31) reported both positive and negative find-
and such studies were not included in the calcu- ings; for ascariasis, significant differences were found
lations. The average reduction for each disease cate- among users of different types of excreta disposal
gory was expressed as the median value for all the facilities. The median reduction in morbidity esti-
studies considered, and not as the mean, because mated from all studies was 28%, while that for only
medians are not influenced by extreme values, while the rigorous studies (3, 37, 76, 77) was 29% (Table 3).
means are.
The definitions of morbidity reported in the Water supplies with sanitation. The four rigorous
articles reviewed included incidence, point and studies (3, 37, 76, 77), all of which reported positive
period prevalence, infection, and indicators of sever- effects, investigated the combination of water sup-
ity (e.g., duration). As far as possible, changes in inci- plies and excreta disposal facilities. The rate of morbi-
dence and prevalence have been used in the present dity reduction was dependent on the level of service
review, but the discussion of specific studies also provided, and indoor facilities were associated with
includes changes in infection and severity of disease. larger reductions than public facilities. In the USA
the prevalence of Ascaris spp. among all age groups
was reduced by 71% for people with flush toilets and
indoor plumbing compared with a group that had
Results lavatories but no well-water (77). In Saint Lucia the
prevalence of Ascaris spp. was reduced by 31% for a
Ascarlasis cohort of children with household water and latrines
For ascariasis, nine studies that reported a positive compared with a control group without such facili-
effect for water supply or sanitation were reviewed ties (37). In Iran the provision of a courtyard latrine
(3, 15, 31, 37, 63, 66, 76, 77) C together with five
negative studies (28, 44, 78, 85, 89). Three studies (63, c See footnote a, p. 610.

Table 3: Expected reduction In morbidity and mortality from Improved water and sanitation for selected dlseases
All studiesb Rigorous studiesb
nc Median reduction (%) nc Median reduction (%)

Ascariasisd 11 28 (0-83)' 4 29 (15-83)

Diarrhoeal diseases
Morbidity 49 22 (0-100) 19 26 (0-68)
Mortality 3 65 (43-79) -

Dracunculiasis 7 76 (37-98) 2 78 (75-81)

Hookworm infection" 9 4 (0-100) 1 4 -
Schistosomiasisd 4 73 (5947) 3 77 (59-87)
Trachoma 13 50 (0-91) 7 27 (0-79)
Child mortality' 9 60 (0-82) 6 55 (20-82)
* The reduction for each individual study was calculated, if possible, directly from the data reported, usually prevalences. However, this
was not possible for studies that reported results as odds ratios or graphically. To convert the odds radios, we used prevalences, if they
were known; for the data in graphical form, estimates of the reductions were made. If a study reported the results from more than one
comparison, the largest reduction in disease was used to highlight the benefits of water and sanitation under optimal conditions. The
results from studies that reported reductions that were not statistically significant were used. If studies showed an increase in disease,
this was taken to be a reduction of zero; because medians were used, this did not affect the results.
b For every disease category, all available studies that met the criteria described in "Methods" are summarized.
c The number of studies may not equal the number of studies reviewed. For some studies, reductions could not be calculated because
data were not available or prevalences could not be determined from the odds ratios.
d Although the presence of eggs in stools was used as an indicator of the prevalence of ascariasis, hookworm infection and schistosomi-
asis, data for the reduction in egg count (an indicator of the severity of these diseases) were not used in the calculations.
' Figures in parentheses are the range.
'Results from several studies were excluded from the child mortality calculations. One study (13) used the same data as two others (23,
33), and so these three were grouped as one study. Another study (4) did not isolate the effect of water and sanitation on mortality; and
reduction levels could not be estimated from another study (98).

WHO Bulletin OMS. Vol 69 1991. 611

S.A. Esrey et al.

and public standpipes was associated with a ity (22) by including 17 more recent studies (1, 6, 7,
reduction of 16% in the prevalence of ascariasis 23, 24, 26, 27, 33, 39, 51, 52, 65, 81-83, 95, 103). The
compared with a control group with no such facili- median reduction in diarrhoeal morbidity calculated
ties (76). from all the studies was 22%, and from the rigorous
In two studies in Iran the reduction in the sever- studies only, 26% (Table 3).
ity of ascariasis was greater than that of its preva-
lence (3, 76). In one of these studies the baseline Water and sanitation. Eleven studies examined the
infection rates and egg counts in four villages that combined effect of water and sanitation without con-
had a household latrine and a community water sidering the effect of each separately; the median
supply were compared with the infection rates and reduction determined from the seven that provided
egg counts in three control villages (3). After 3-4 appropriate data was 20% (Table 4). Two studies
years, the prevalence of infection with Ascaris spp. in reported on specific pathogens, one on nutrition, and
the group with latrines and water supply had one on mortality. Of the 11 studies, seven were
decreased by 28% and the egg counts by 60%. For flawed (three of which reported positive impacts). In
the control group, the prevalence of infection and the two of the rigorous studies, an average of 30%
egg counts decreased by 19% and 29%, respectively. reduction in diarrhoea was associated with improved
In the second study, courtyard latrines and public water and sanitation conditions (47, 73). A third
standpipes reduced egg counts by 62% over a 1-2- study reported fewer malnourished children from
year period, but the prevalence of ascariasis dropped families with a sewage system and a household bath
by only 16% (76). than from families with latrines and no bath (16). In
Water supplies. The effect of water supplies on infec- Malawi, the combination of water and sanitation
tion with Ascaris spp. was compared in two studies was associated with a lower prevalence of diarrhoea,
(37, 77). In the USA the reduction in the prevalence but the results were not statistically significant
of infection was 37% for a group that had lavatories because of small sample sizes (103). Only one of the
and indoor plumbing, and 12% for those with lava- 11 studies examined mortality: among infants in
tories and a yard well, in both cases relative to a Malaysia, the addition of toilets and water versus no
control group that had only lavatories, but no well- facility was associated with an 82% reduction in
water (77). In Saint Lucia the provision of household infant mortality, particularly if the child was not
piped water supplies produced a 30% reduction in breast-fed (33).
ascariasis over a 2-year period among children under
3 years of age (37). Sanitation. The impact of sanitation was examined in
30 studies (12 of which were flawed), and 21 reported
Water and sanitation plus chemotherapy. The reduction health improvements. Overall, a 22% reduction in
in ascariasis was greater if chemotherapy was used in morbidity was calculated for 11 of the 30 studies,
conjunction with water and sanitation than if only whereas the reduction determined using data from
water and sanitation were provided. In the study in
Iran described above (3), four villages were supplied
with a household latrine and a community water Table 4: Expected reduction In dlarrhoeal dleae mor-
supply plus chemotherapy, four others with only bidity from Improvements In one or more components of
chemotherapy, and three villages remained as a water and sanItatlon
control group. For the group with latrines, water,
and chemotherapy, the prevalence of Ascaris spp. All studies Rigorous studies
among all age groups decreased by 79% and egg Reduction Reduction
counts by 88%, while the corresponding reductions n (%) n (%)
for the chemotherapy-only group were 84% and
90%. These were considerably greater than the Water and 7/1l b 20 2e/3b 30
sanitation
reductions for the group with only water and sani- Sanitation 11/30 22 5/18 36
tation (28% and 60%, respectively). The reductions Water quality 22/43 16 2/22 17
in the prevalence of ascariasis and in egg counts for and quantity
the control group over the 3-4-year study period Water quality 7/16 17 4/7 15
Water quantity 7/15 27 5/10 20
were 19% and 29%, respectively. Hygiene 6/6 33 6/6 33
Diarrhoeal diseases ' The number of studies for which morbidity reduction calcu-
lations could be made.
We have updated a previous review of 67 studies on b The total number of studies that related the type of facility to
diarrhoeal morbidity, nutritional status, and mortal- diarrhoeal morbidity, nutrition, and mortality studies.

612 WHO Bulletin OMS. Vol 69 1991.

 Effects of Improved water supply and sanitation on six endemic diseases

five of 18 rigorous studies was 36% (Table 4). Of the reduction of 15% in diarrhoeal disease morbidity
remaining rigorous studies, two reported on nutri- was found for the four studies for which this could
tional status and 11 on mortality. Of the studies that be calculated. Of these, one reported little or no
compared the relative importance of water and sani- association between the quality of drinking-water
tation, most reported that sanitation had a greater and the occurrence of diarrhoea in children (39),
impact on child health, based on mortality, growth, another reported an 8% reduction in the prevalence
and morbidity indicators. Some mortality studies of Shigella spp. (87), while two found some associ-
reported that the method of disposing of excreta ation with child nutritional status, but not with diar-
determined the magnitude of the health impact. rhoea (24, 55). Because diarrhoea has many causes,
Mortality was reduced to a greater extent by flush drinking-water constitutes only one of many sources
toilets than by pit latrines (2, 34, 98), which neverthe- of infection. In areas where environmental faecal
less were associated with mortality reductions com- contamination is high, little or no health impact
pared with no sanitation facilities at all. Sanitation from water improvement can be expected. For
has also been reported to produce a differential example, studies in Lesotho (30) and Guatemala (79)
health impact depending on the presence or absence failed to detect reductions in the prevalence of diar-
of other risk factors. For example, sanitation was rhoea following improvements in water quality. Also,
most effective in reducing mortality among a recent study in Brazil (95) found no association
nonbreast-fed infants (13) and infants of illiterate between water quality and diarrhoea mortality, as
mothers (23) than among breast-fed infants or liter- did an earlier study in India (104).
ate mothers.
Water quantty. Of the 15 studies that examined the
Water quality and quantity. In most of the studies effect of increased amounts of water specifically and
reviewed, it was difficult to determine whether the independently of water quality, all but one reported
differences in health conditions were due to a positive impact. The median reduction for seven
increased amounts of water, improvements in its studies for which this could be calculated was 27%
quality, or both; these studies have therefore been (Table 4). Of the other eight studies, five reported on
grouped together. Of the 43 studies that compared pathogens and three on nutritional status. Of the 10
groups with different types of water supplies, 24 rigorous studies, a median reduction of 20% was
reported a positive impact, and for the 22 studies for found for the five for which this could be calculated.
which morbidity calculations could be made, a Health benefits were greater for children whose fam-
median reduction of 16% was calculated (Table 4). ilies used more water than for those whose families
Of the remaining studies, four reported on patho- used less, but, in some instances, the differ-nc( were
gens, four on nutritional status, 11 on mortality, small or significant only for selected age groups. In
while two had insufficient information. Fourteen of Ethiopia, the prevalence of diarrhoea among under-
the studies were rigorous. Only two of the 22 mor- 2-year-olds from families with higher water usage
bidity studies were rigorous (median reduction, rates per person was less than that among compa-
17%). Nine of the rigorous studies reported on mor- rable children from families with lower rates (32).
tality and three on nutritional status. Of these, a In Lesotho, use of smaller amounts of water was asso-
modest benefit for particular, but not all, age groups ciated with higher rates of infection with Giardia
was found. In the studies that reported a health lamblia (26). In both of these studies, the amount of
benefit, the water supply was piped into or near the water used was more important than its source. No
home, whereas in those that reported no benefit, the studies relating water quantity and mortality were
improved water supplies were protected wells (2), identified.
tubewells (74), and standpipes (27, 51, 52, 69, 98).
Hygiene. Only six studies were found that reported
Water quaity. Sixteen studies (10 of which reported on the impact of hygiene interventions on diarrhoeal
positive effects) examined the health impacts of pure morbidity (1, 6, 12, 45, 82, 93). All were rigorous, and
versus contaminated water supplies. Of the seven the median reduction was 33% (Table 4).
studies for which calculations could be made, a Several studies focused specifically on hand-
median reduction in the prevalence of diarrhoea of washing. In Burma, a 30% reduction in diarrhoea
17% was found (Table 4). Four of the other nine was reported when mothers and children were pro-
studies reported on pathogens, two on nutritional vided with soap and encouraged to wash their hands
status, two on diarrhoeal mortality, while one had after defecation and before preparing meals (6). In
insufficient information. In several of the studies, day-care centres in the USA (12), a handwashing
impacts were found only for certain age groups. regimen reduced the incidence of diarrhoea by 48%
Among the seven rigorous studies, a median compared with a control group; and in Bangladesh
WHO Bulletin OMS. Vol 69 1991. 613
S.A. Esrey et al.

(45), a 35% reduction in the incidence of diarrhoea the attack rate of dracunculiasis peaked twice during
caused by Shigella spp. occurred following an inter- the year. During the rainy season the attack rate
vention to promote handwashing. among borehole users was one-tenth of that among
Other studies have examined not only hand- non-users, while during the dry season it was two-
washing, but combinations of handwashing and fifths that of non-users.
other hygienic behaviours. For example, an educa-
tional intervention in Bangladesh (82) emphasized Seasonal transmission. A number of studies on dra-
proper handwashing before preparing food, de- cunculiasis have investigated the seasonal nature of
fecating away from the house at a proper site, and its transmission. In West Africa, attack rates corre-
suitable disposal of waste and faeces; the investiga- lated positively with periods of below-average rain-
tors reported a 26% reduction in the incidence of fall or the dry season, when the copepod vectors
diarrhoea. Another study in Bangladesh provided reached their highest density in ponds that were
hand pumps and health education to promote per- drying up (9, 20). In Nigeria, the prevalence of the
sonal and domestic hygiene (1); a greater than 40% disease remained high if the piped-water supply was
reduction in the incidence of diarrhoea was found intermittent or unreliable during the dry season (40).
among groups with good hygiene practices (irrespec- The problem of unreliable tube-wells or boreholes
tive of whether or not they received the interven- which fail, particularly during the dry season, is fre-
tion), compared with individuals with poor practices. quently cited as an important factor that contributes
The reduction attributable to the intervention itself to transmission of dracunculiasis (11, 84).
was 17%. In Guatemala the incidence of diarrhoea
was reduced by 14% following a programme to Hookworm Infection
promote health awareness and hygienic behaviour Eleven studies (3, 15, 17, 31, 44, 63, 77, 78, 86, 89)d
(93). were reviewed that related hookworm infection to
excreta disposal facilities, with or without water
Drwauncullasls supplies. Five studies reported positive findings, two
involving water supply and sanitation (15, 77) and
Seven studies (11, 21, 36, 41, 54, 75, 94), two of which three sanitation only (17, 44, 89). Only one study,
were rigorous (21, 36), examined the impact of which examined the influence of sanitation facilities
improved water supplies on the prevalence of dra- in conjunction with chemotherapy, was considered
cunculiasis. All reported a positive impact, with to be rigorous (3). The median reduction in the
similar median reductions being reported for all prevalence of the disease calculated from all studies
studies combined and for the rigorous studies only was 4%, which was the same as that calculated from
(76% and 78%, respectively). the rigorous study alone (3).
water source. The two rigorous studies (21, 36), both Excreta disposal. In the study in Iran referred to
of which were from Africa, compared the use of under ascariasis (3), villages where sanitation
borehole water and of water from unimproved improvements were carried out had a 4% decrease in
sources. In Nigeria (21), the impact of a UNICEF- the prevalence of hookworm infection, while there
assisted rural water project that provided boreholes was a 26% reduction in egg counts among those
and hand pumps, along with health education, was infected. For the group that received the sanitation
evaluated. Prior to the intervention 8600 subjects, and chemotherapy intervention, the reduction in
and 3 years after its installation, over 10000, were prevalence of infection was 69%, while the egg count
examined. The study comprised 20 serviced and five was reduced by 88%; for the chemotherapy-only
unserviced communities. Use of borehole water group, the reductions were 73% and 87%, respec-
reduced the incidence of dracunculiasis by 81%. The tively; and for the control group, 11% and 12%.
greatest reduction in the prevalence occurred in However, each cohort began with a different preva-
those villages where the boreholes were conveniently lence of hookworm infection, e.g., at the outset 77%
sited and close by, but the effect was less if the wells of the sanitation cohort and 44% of the control
were distant. The impact was also less dramatic in group were infected.
villages where the water was unpalatable or the
supply erratic. Schlstosomlasls
A study in Uganda reported data from a pre-
intervention survey (36). Over 2000 people were Twelve studies were found that examined water and
interviewed in the north-west of the country to sanitation facilities and rates of schistosomiasis (8,
determine the relationship between water use and
disease. The results were analysed by season because d
See footnote a, p. 610.

614 WHO Bulletin OMS. Vol 69 1991.

 Effects of Improved water supply and sanitation on six endemic diseases

29, 38, 43, 46, 49, 50, 53, 59, 64, 86)&. All four of the impact on schistosomiasis is by reducing human
rigorous studies examined the degree of protective contact with infected water. A distinction should
efficacy of water supplies (8, 43, 50, 59). Extensive therefore be made between possession of an
water supply and washing facilities were provided to improved water supply and having contact with
the study populations. One study also examined the pathogen-laden water. In Saint Lucia (42, 43) and
effect of water supply and the provision of latrines south-east Brazil (50), access to improved supplies
(8). For all studies combined, the median reduction that included laundry and shower facilities was
in morbidity was 69%, and for the rigorous studies associated with reduced contact with infected waters
only, 77% (Table 3). and thus reduced infection. In Saint Lucia, this led to
an 82% reduction in the frequency that people had
Water supplies. The presence of piped-water in the contact with infected water and a 96% reduction in
home (43, 50) was associated with larger reductions water-contact time. In Kenya, the installation of
in the prevalence of schistosomiasis than that pro- boreholes, without laundry or shower facilities, failed
duced by community water supplies (59). In Saint to reduce the reliance on high-risk marshes and
Lucia over a 5-year period following the provision of ponds for bathing (46).
household piped-water and community washing and
showering facilities, the overall prevalence of schisto- Water suppiles and chemotherapy. Reinfection can
somiasis was reduced by 27% and that among child- rapidly diminish or negate health improvements
ren aged under 10 years of age, by 59% (43). In brought about by community-wide schistosomiasis
south-east Brazil, children aged 5-14 years were 2.3 programmes devoted exclusively to drug therapy (10,
times more likely to be infected if they had no piped- 101). Drug treatment combined with improved
water in their home (50). sources of water produces a greater reduction in the
In Zimbabwe the prevalence of S. mansoni prevalence of schistosomiasis than that resulting
among schoolchildren who lived on communal lands from provision of water facilities alone (43, 60, 64,
without a piped-water supply was 4.8% and of S. 68). Programmes that adopt a multifaceted approach
haematobium, 4.4% (59). Among children who lived have repeatedly been successful (64, 67, 90), and the
on the same lands, but with piped water, the preva- provision of adequate water supplies to those who
lence of S. mansoni and S. haematobium was 0.8% have been treated with drugs can prevent reinfection
and 0.4%, respectively. (43). For example, in Saint Lucia oxamniquine
In Brazil the severity of schistosomiasis was caused a precipitous drop in the rates for infection
reduced more than was its prevalence (50). Children with schistosomiasis and a 4-year follow-up pro-
aged 5-14 years were 7.3 times more likely to have vided no evidence for reinfection (43).
splenomegaly (an indication of severe schistoso-
miasis) if they had no piped water in their home. Trachoma
Malaria, which can also cause splenomegaly, was
not a confounder, because its prevalence in the study Sixteen studies on the role of water, sanitation,
area was low. The risk of severe infection (7.3) was and/or hygiene in the reduction of trachoma were
much greater than the risk of the prevalence of schis- reviewed. Thirteen reported positive effects (5, 14, 19,
tosomiasis (2.3). 35, 56, 58, 61, 62, 71, 88, 91, 92, 99) and three, nega-
tive (48, 70, 102). Five of the rigorous studies were
Sanitation and water supplies. One study in north-east positive (5, 61, 91, 92, 99) and two, negative (48, 102).
Brazil reported the prevalence of S. mansoni before The median reduction in trachoma calculated for all
and after a water, sanitation, and health education studies was 50% and for the rigorous studies only,
campaign (8). In the treatment villages, latrines were 27%.
built for each house, and communal taps, laundry
facilities, showers, latrines, and hand pumps were Distance and time to water source. Four studies (5, 61,
installed. Over a 7-year period, children under 14 92, 99) reported a 30% median reduction in tra-
years of age exhibited a net drop in the prevalence of choma that was associated with shorter distances or
schistosomiasis, and this was 77% greater in the time to water sources. In China (Province of Taiwan)
treatment than in the control villages. the prevalence of trachoma among people with
household water connections was 45% less than
Water contact. One of the primary mechanisms among those whose water source was over 500 m
through which improved water supplies have an away (5); and in India those who had a water supply
within 200 m exhibited 30% less trachoma than those
who obtained water from a more distant source
@ See footnote b, p. 610. (61). In Malawi there was 26% less trachoma among

WHO Bulletin OMS. Vol 69 1991. 615

S.A. Esrey et al.

children whose water was less than 5 minutes away dracunculiasis, hookworm infection, schistosomiasis,
than among those who required a trip of more than and trachoma. Despite the mix of both positive and
1 hour to obtain water (92). In the United Republic negative studies, the overwhelming evidence is in
of Tanzania, 26% fewer households had trachoma favour of positive impacts, with the exception of
that affected all the children if the source of water hookworm infection, for which the impact was negli-
was less than 30 minutes away, compared to a water gible. The reduction in morbidity from the rigorous
source that was more than 2 hours distant (99). Two studies ranged from 26% for diarrhoea, 27% for tra-
other studies (one in Morocco (48) and one in choma, and 29% for ascariasis to 77% for schisto-
Mexico (91)) failed to find such an association somiasis and 78% for dracunculiasis. For the
between the prevalence of trachoma and distance to rigorous studies the median reduction in diarrhoea-
water supply. specific mortality was 65% and in overall child mor-
Distance to water has been taken to be a proxy tality, 55%, which suggests the important role that
for the amount of water used, but the above- water and sanitation play in enhancing child sur-
mentioned Tanzanian study did not find a direct vival.
association between the distance to water and the Studies that reported reductions for one disease
amount of water brought into the household (99). (or even more than one) most probably underesti-
Also in the study in Morocco there was no corre- mated the total effect of water and sanitation in
lation between distance to the source and the per improving health. This was particularly true if
capita use of water (48). Similarly, several studies of several diseases that are affected by water and sani-
diarrhoeal diseases have reported no significant tation were prevalent simultaneously in the interven-
association between improved water or distance to tion area. Even though studies often report on only
water and the amount of water used (27,51, 100). one indicator of health for a selected age group,
other health indicators may also be changing for
Personal hygiene. In India people with good hygiene other age groups.
practices had 79% less trachoma than those whose In addition to reducing the incidence or preva-
practices were poor (61). In Mexico a study of the lence of disease, improvements in water and sani-
relationship between the prevalence of trachoma and tation can be expected to affect other aspects of
a variety of possible risk factors reported a signifi- health. When infection rates are reduced by chemo-
cant association only for the frequency of face- therapy, as was the case for some parasitic diseases,
washing (91). Children who washed their faces seven water and sanitation facilities prevented infection
or more times a week had 69% less trachoma than rates from increasing again to pretreatment levels.
those who washed their faces less frequently; Furthermore, the severity of infection was often
however, the importance of this aspect of personal reduced more than that of the incidence or preva-
hygiene was not confirmed in a follow-up investiga- lence. For example, the reductions in egg counts for
tion in Mexico near the original study site (102). The ascariasis, schistosomiasis, and hookworm infection
different findings in these two studies might be were greater than those in the incidence or preva-
accounted for by the different conditions: in villages lence of these diseases. In addition, reductions in
included in the follow-up study, almost twice as childhood diarrhoea and overall mortality rates were
many children washed their faces frequently as did greater than for diarrhoea incidence or prevalence,
those in the original villages. which suggests that the severity of diarrhoea was
In the United Republic of Tanzania observa- reduced more than its incidence.
tions of hygiene practices indicated that a child was The expected reductions in disease rates provide
1.7 times more likely to have trachoma if all the a guide. The studies reviewed were of variable
children in the family had unclean faces (99). Also, quality, and therefore reductions may be smaller or
distance to water was related to the proportion of larger depending on several factors; for example, the
children with unclean faces. There were 14% fewer success with which an intervention was installed, the
households where all the children had unclean faces overall health status of the recipients, and the pres-
when the source of water was less than 30 minutes ence or absence of environmental factors that can
away, compared with more than 2 hours away. also reduce transmission of disease agents. If the
interventions do not work, break down, remain
Conclusions underused, or do not change behaviour sufficiently,
they will probably result in small impacts at best. No
The results of this review indicate that improvements study, irrespective of how well it is conducted, can
in one or more components of water supply and produce substantial impacts under such conditions.
sanitation can substantially reduce the rates of mor- On the other hand, considerable impacts will prob-
bidity and severity of ascariasis, diarrhoeal diseases, ably result if the intervention was successfully imple-
616 WHO Bulletin OMS. Vol 69 1991.
 Effects of Improved water supply and sanitation on six endemic diseases

mented, properly utilized, and the population disease - the minimum quantities of water that are neces-
rates were high enough for benefits to be measured. sary to produce positive health impacts under a
Results published since 1986 on diarrhoeal dis- variety of environmental conditions (e.g. peri-
eases concur with previous findings (25), and the rig- urban, rural, etc.);
orous studies conducted in the last few years show a - the hygienic behaviours most conducive to better
greater reduction in disease: while this may reflect health;
better studies, it may also indicate better-conceived - appropriate methods for introducing and reinfor-
interventions. Interventions to improve excreta dis- cing behavioural change;
posal and water quantity, which are associated with - the conditions under which water and sanitation
better hygiene practices, produce greater impacts facilities are likely to be sustained;
than improvements in water quality. This is particu- - the possibility of increasing the amount of water
larly so in highly contaminated environments where used and of changing behaviours in the absence
diarrhoea rates are high. Because the use of more of interventions to install piped supplies;
water is not automatic following the installation of - the conditions (including environmental, cultural,
water supplies, hygiene education is a necessary part and level of development) under which installa-
of the intervention. tion of water and sanitation facilities are likely to
The following recommendations can therefore produce the greatest health benefits; and
be made: - the health indicators that are most susceptible to

- to achieve broad health impact, greater attention

change and most related to disease.
should be given to safe excreta disposal and
proper use of water for personal and domestic Acknowledgements
hygiene rather than to drinking-water quality;
- sanitation facilities should be installed at the This study was supported by the Water and Sanitation for
Health Project (WASH). A more detailed report, (Health
same time as water facilities when faecal-related benefits from improvements in water supply and sani-
diseases are prevalent; tation: survey and analysis of the literature on selected
- access to the water supply should be as close to
diseases), including an annotated summary of each
the home as possible, in order to foster the use of study, can be obtained from WASH, 1611 North Kent
larger amounts of water for hygiene practices; Street, Room 1001, Arlington, VA 22209-2111, USA. We
-water supply and health programmes should thank S. Blumenfeld, J. Burns, S. Cairncross, J. Kalber-
emphasize hygiene education to encourage the matten, L. Laugeri, A.D. Long, R. Middleton, J. Newman,
use of more water for personal and domestic D. Okun, F. Reiff, P. Roark, M. Scott, H. Taylor, J.
hygiene; Tomaro, J.E. Turner, and J. Walker for their comments.
D. Campbell is thanked for his relentless efforts to iden-
sanitation facilities should be culturally appropri- tify and obtain literature for the present article and K.
ate to ensure their use; Leccisi and B. Reddaway are thanked for their editing
use of facilities is essential during critical seasonal skills.
transmission periods for diseases such as dracun-
culiasis; and
water and sanitation programmes should com- Resume
plement those in other sectors (e.g., chemo-
therapy) to reduce disease rates. Amelloration de l'approvisionnement en eau
et de l'assalnissement: consequences sur
Isues for future research l'ascarldlase, la dlarrhee, la dracunculose,
Despite the accumulation of knowledge during the I'ankylostomiase, la schistosomiase et le
IDWSSD, questions remain about the health bene- trachome
fits associated with water and sanitation. Many of On analyse ici les resultats de 144 etudes portant
these issues could be examined using well-established sur l'impact de l'amelioration de l'approvi-
epidemiological methods (22) in areas where water sionnement en eau et des installations d'assai-
and sanitation systems are working and used by the nissement sur l'ascaridiase, les maladies diar-
recipients. Rigorous studies should focus on the fol- rheiques, la dracunculose, I'ankylostomiase, la
lowing issues: schistosomiase et le trachome. On a choisi ces
-the maximum travel distance/time that will result affections parce qu'elles sont tres repandues,
in appropriate use of an improved water supply constituent des risques graves pour la sante et
under a variety of socioeconomic and environ- illustrent bien la diversite des mecanismes par
mental conditions; lesquels I'am6lioration de l'approvisionnement en

WHO Bulletin OMS. Vol 69 1991. 617

S.A. Esrey et al.

eau et de l'assainissement peut proteger les popu- Khuzestan, south-west Iran. American journal of
lations. On a calcule pour 1'ensemble des etudes tropical medicine and hygiene, 26: 230-233 (1977).
la diminution mediane du nombre de cas de 4. Ascoll, W. et al. Nutrition and infection field study in
chaque maladie qu'elle entraine et l'on a tire des Guatemalan villages, 1959-1964. IV. Death in pre-
etudes les plus rigoureuses sur le plan methodolo- school children. Archives of environmental health,
15: 439-449 (1967).
gique une deuxieme valeur de la diminution me- 5. Aaaad, F.A. et al. Use of local variations in tra-
diane. choma endemicity in depicting interplay between
Les resultats montrent que l'approvision- socio-economic conditions and disease. Bulletin of
nement en eau et l'assainissement entrainent une the World Health Organization, 41: 181-194 (1969).
amelioration de la sante des populations concer- 6. Aung Myo Han & TheIn Hlalng. Prevention of diar-
nees. En ce qui concerne la diarrhee, le trachome rhoea and dysentery by handwashing. Transactions
et l'ascaridiase, la diminution mediane de la mor- of the Royal Society of Tropical Medicine and
bidite (c'est-a-dire de l'incidence et de la Hygiene, 83: 128-131 (1989).
prevalence) a ete respectivement de 26%, 27% et 7. Baltazar, J. et al. Can the case-control method be
used to assess the impact of water supply and sani-
29% dans les etudes rigoureuses. La diminution tation on diarrhoea? A study in the Philippines. Bul-
correspondante pour la schistosomiase et la dra- letin of the World Health Organization, 66: 627-635
cunculose a ete plus importante, a savoir 77% et (1988).
78%, respectivement. Toutes les etudes sur 8. Barbosa, F.S. et al. Control of schistosomiasis
l'ankylostomiase ont ete defectueuses, a mansoni in a small north east Brazilian community.
1'exception d'une seule dans laquelle on a trouve Transactions of the Royal Society of Tropical Medi-
une diminution de 4% de la prevalence. cine and Hygiene, 65: 206-213 (1971).
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on 6galement eu un impact important sur la survie Schistosoma mansoni after treatment. Transactions
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les six etudes rigoureuses; malheureusement, Banaskantha District of Gujarat-some important
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efforts d'assainissement peuvent donc avoir des relationship between breast feeding and infant mor-
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