Water Quality & Health

By A.K. Sengupta Sector Coordinator Sustainable Development & Environmental Health World Health Organization, New Delhi 13th June, 2006

Diseases related to contamination of drinking water constitute a major burden on human health. Interventions to improve the quality of drinking water provide significant benefits to health.

Global Burden of Disease attributable to selected major risk factors

Underweight Unsafe sex

Tobacco
Overweight Alcohol

Percent of total burden

(within region)

5% -

Water, sanitation and hygiene (5.5%) Indoor air (3.7 %)

Zinc deficiency Physical inactivity

Tobacco
1% -

Alcohol

Overweight Ambient air Lead Occupational injuries Climate change

Occupational risks Unsafe sex Ambient air Water, sanitation and hygiene
Lead

Developing countries
(high mortality)

Developed countries

Burden of diseases attributed to 10 selected leading risk factors in developing countries with high mortality
Percentage
0 Under w eight Unsaf e Sex Unsaf e w ater, sanitation and hygiene 2 4 6 8 10 12 14 16

Remarks

Indoor smoke f rom solid f uels Zinc def iciency Iron def iciency Vitamin A def iciency Blood pressure Tobacco Cholesterol

Source: WHO, 2002. World Health Report 2002: Reducing Risks, Promoting Healthy Life. WHO Geneva

Deaths caused by selected infectious diseases in the SEA Region, 2002 (Figures in 000)
Mortality stratum Disease Total Low child, low adult High child, high adult

Respiratory infections
Diarrhoeal diseases Tuberculosis HIV/AIDS Measles Malaria
Source: World Health Report 2002

1377
802 701 445 193 95

121
44 160 60 32 9

1256
758 541 385 161 86

Water and Health: Background

About 21% communicable diseases are water borne 50 million suffer from intestinal diseases, like diarrhoea, cholera, dysentery, typhoid etc. 5 million people die, of which 1.5 million are children below 5. Maximum morbidity and mortality occur due to diarrhoea.

Reported morbidity in 1998 was 9.6 million Infant mortality is 0.5 million every year In order to reduce morbidity/ infant mortality rate mortality, it is necessary to reduce diarrhoea and jaundice, the main causes Common water borne microbiological disease include Cholera, Diarrhoea, Dysentery, Typhoid, Bacillary, Trachoma, Amoebiasis, Giardiasis, Worm infestation, Guineaworm, Viral Hepatitis, Philariasis, Poliomyelitis etc.

Water Borne Diseases

Disease of Syndrome

Remarks

Enteric Diseases Diarrheas, Dysenteries, Gastoenteritis, etc. Skin Diseases Otitis Externa, Scabies, Skin Sepsis and Ulcers, Tineas (Ringworm) Louse-Borne Diseases Louse-borne Fever, Pediculosis, Relapsing Fever, Typhus Fever, Wolhynian Fever

Prevalence of most fecal-oral diseases is less with adequate quantity of water Prevented by personal hygiene, including frequent bathing and laundering with use of soap Prevented by personal hygiene, including bathing and laundering and changing of clothing

Treponematoses Endemic Syphilis, Pinta, Yaws Eye Diseases Conjunctivitis, Trachoma

Prevented by general public and personal hygiene. Nonvenereal. Trachoma rare where ample water is available.

Emerging diseases
Emerging pathogens are those that have appeared in a human population for the first time or have occurred previously but are increasing in incidence or expanding into areas where they have not previously been reported, usually over last 20 years

Water borne emerging diseases: Cryptosporidium Legionella Escherichia coli O157 (E. coli O157) Rotavirus, Hepatitis E virus, Norovirus Helicobacter pylori (H. pylori)

Water Quality Problems due to Chemicals in India

Quality Problem Fluoride Arsenic Iron Nitrate Remarks The population at risk is estimated to be around 66 million in 20 states The population at risk is estimated to be more than 10 million in 4 states. Around 1.5 lacks habitations spread over 16 states in the country are found to be affected. Nitrate is emerging as a major problem in the States of Tamil Nadu, Rajasthan, Gujarat, Karnataka, Maharashtra, and Uttar Pradesh A major problem in parts of the States of Gujarat, Andhra Pradesh, Karnataka, Kerala, Orissa, Punjab, Rajasthan, Tamil Nadu, Haryana and Madhya Pradesh Ground water pollution due to pesticides including certain POPs has been reported in many areas.

Brackishness

Pesticides

History of the WHO Guidelines for Drinking Water

1958, 1963, 1971: International Standards 1984: First edition of Guidelines: basis for formulating standards, but standard setting is a national prerogative. 1993: Second edition with increase in number of chemicals covered. 2004: Third edition introducing systematic water safety approach

WHO Water Quality Guidelines

AIM Protection of human health Advisory in Nature Facilitate national standard-setting Features Socio-Economic and environmental context Risk benefit philosophy local adaptation for health gains Best available evidence- science and practice Scientific expert consensus Approach Exploit global information and experience

Why we need to review our approach

In

all countries waterborne illness still occurs Outbreaks show us that we cannot solely rely on water treatment indicators End-point testing is too-little-too-late

Interrelation of the chapters of the Guidelines for Drinking water Quality in ensuring drinking water safety
Introduction
(Chapter 1)

The guideline requirements (Chapter 2)

SUPPORTING INFORMATION Microbial aspects (Chapters 7 and 11) Chemical aspects (Chapters 8 and 12) Radiological aspects (Chapter 9) Acceptability aspects (Chapter 10)

FRAMEWORK FOR SAFE DRINKING WATER

Health-based targets
(Chapter 3)

Public health context and health outcome

Water Safety Plans

(Chapter 4)
System assessment Monitoring Management and communication

Surveillance
(Chapter 5)

Application of the Guidelines in specific circumstances (Chapter 6)

Large buildings, Emergencies and disasters, Travellers, Desalination systems, Packaged drinking water, Food production, Planes and ships

Framework for Water Safety in 3rd Edition WHO GDWQ

Health Based Targets Water Safety Plans 1. System Assessment 2. Monitoring of control measures 3. Management Plans Independent Surveillance

Nature, application and assessment of health-based targets

Type of target Health Outcome epidemiology based Nature of target Reduction in detected disease incidence or prevalence Typical applications Microbial or chemical hazards with high measurable disease burden largely water associated Microbial or chemical hazards in situations where disease burden is low or cannot be measured directly Assessment Public health surveillance and analytical epidemiology

risk assessment based

Tolerable level of risk from contaminants in drinking water, absolute or as a fraction of the total burden by all exposures

Quantitative risk assessment

Nature, application and assessment of health-based targets

Type of target Water Quality Nature of target Guideline values applied to water quality Typical applications Chemical constituents found in source waters Assessment Periodic measurement of key chemical constituents to assess compliance with relevant guideline values Testing procedures applied to the materials and chemicals to assess their contribution to drinking water exposure taking account of variations over time.

Guideline values applied in testing procedures for materials and chemicals

Chemical additives and byproducts

Water Safety Plan

A WSP comprises, as a minimum, the three essential actions that are the responsibility of the drinking water supplier in order to ensure that drinking water is safe. These are: a system assessment; effective operational monitoring; and management

Water Safety Plan

Assemble the team Document and describe the system

Assess the existing proposed system

Undertake a hazard assessment and risk characterization

Identify control measures

Define monitoring to control measures

Develop supporting programmes

Establish procedures to verify the water safety plan

Prepare management procedures

Establish documentation and communication procedures

WHOs Response
Moving

away from reliance on output monitoring- i.e. measuring para-metres in final water More input monitoring- i.e. measuring parametres showing that the system is working Priority focus on microbial hazards Short- term chemical changes and exposures Catchment-to-consumer (farm-to-fork) Multiple barrier approach HACCP Reality check on todays water supply situations

Independent Surveillance
Systematic independent surveillance that verifies that the WSPs are operating properly

Audit of Water supply plan

Shows WSP is being adhered to

Verification

End-product final check

Updating the WHO Guidelines

Keeping the guidelines up-to-date is a formidable challenge WHO installed a rolling revision process Substantiating the positions and guidance on good practice are the two key areas Peer and public domain review are built- in

Rolling Revision of WHO Guidelines for Drinking-water quality

Application in specific settings Water and sanitation on ships and in aviation (International Health Regulations) Desalination plants Temporary water supplies Water supply in emergencies Small community water supply Water supply in large buildings Water supply in health care facilities

The WHO Guidelines for Drinking Water Quality 3rd Edition

Available at WHOs website at: http://www/who.int/water_sanitation-health/dwq/en/

Rolling Publication Schedule

First Addendum in early 2005 Second Addendum by end 2006 Final Task Force Meeting to adopt Fourth Edition in Late 2007 Fourth Edition to be published in 2008, the 50th anniversary of the first WHO publication on drinking water quality

Recent WHO Activities in India

Regional workshop to discuss Drinking Water Quality Guidelines and WQ standards. Development of Directory of Water Quality Testing Laboratories. Development of Manual for Laboratory testing of drinking water.

Environmental Health
Assisted the district authorities in strengthening environmental sanitation programme, including hygiene education, waste management and sanitary toilets in the disaster hit areas/camps and providing technical support during rehabilitation period in:
Nagapattinam , Cuddalore and Karaikal districts: Gandhi Gram
Rural University, Gandhigram

Monitoring drinking water quality in the coastal areas of Tamil Nadu TWAD Board

Health Care Waste management in 17 selected Govt. Hospitals initiated

Maintaining Basic Sanitation and Water Supply is still a Challenge

Environmental sanitation projects were set up through Gandhigram Institute with WHO support

strengthening hygiene education and management of waste water in Nagapattinam, Cuddalore and Karaikal

Environmental sanitation projects were set up through Gandhigram Institute with WHO support

strengthening monitoring of drinking-water quality in Nagapattinam, Cuddalore and Karaikal

Monitoring quality of Ground Water

The work is in progress on a project being implemented by the Tamil Nadu Water and Drainage Board with assistance from WHO, to assess the changes of drinking-water quality in the coast after the tsunami.

THANK YOU