3.5 risk management learning objective: to be aware of how sanitation systems can be evaluated and...
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3.5 Risk management
Learning objective: To be aware of how sanitation systems can be evaluated and compared regarding their potential health impact. To be familiar with the different parts of Quantitative Microbial Risk Analysis (QMRA).
Can we measure a risk of disease
transmission?
How can sanitation systems be evaluated?
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PolicyGuidleines
Local experiences
Research
Implementation”in practice”
Theory, basic
research
DisseminationCommunicatio
nEducation
Risk management – policy development
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The most important barrier to manage risks? Handling (contact) of excreta should be
minimized, but necessary to some extent What is practically, socially and culturally
acceptable? Adapted to local conditions, education and information,
sustainability Treatment recommendations important part of the
guidelines Will develop, on-going research
Treatment as a health protection measure
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Wastewater generation
Consumer
Wastewater treatment
Safe produce
…
Wastewater generation
Consumer
Wastewater treatment
Safe produce
…
WHO’s multiple barrier approach from “Farm to Fork”
Wastewater generation
Farmer/ Producer
Traders/Retailers
Street food kitchens
Consumer
Wastewater treatment
Safe irrigationpractices
Hygienichandlingpractices
Safe food washing and preparation
Awareness creation to create
demand for safe produce
Policy recognition, safer farm land, tenure security, market incentives, safe-food labelling,…
Risk reduction strategies
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Treatment define processes, different levels (categories)
Validation of the treatment process Microbiological/hygienic quality
presence of microorganisms, reduction of microorganisms
Restrictions on usage Fertilising (irrigation) methods Handling of the product (e.g. transport, storage) Protection of workers Sampling Analytical methods
Examples of how to design regulations
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Diverted Small volumes Easier to treat Suitable fertiliser
products Handling requires
restrictions
Mixed (conventional) Large volumes of
”hazardous” waste Extensive treatment Reuse products:
wastewater, sludge Downstream
pollution
Comparison of sanitation systems
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Microbial analysisIndicators not always reliable
Epidemiological studiesScarce, complex
Microbial risk assessmentThe main approach (?)
Assessment of health risks
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Risk Assessment Qualitative or quantitative Systematic procedure Acceptable risks
Risk Management To handle the risks Aims at reducing risks
Risk Communication Essential part in all systems Necessary for awareness raising and health protection Involve ”all” stakeholders
Microbial Risk Analysis
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Hazard Identification All enteric pathogens potentially in excreta
Exposure assessment Exposure points, site-specific data on removal Literature data on occurrence of pathogens, removal in
treatment and survival in environment Exposure scenarios evaluated (ingestion, volumes)
Dose-response assessment Published mathematical models
Risk characterisation Risk of infection per exposure and yearly, DALYs Comparison with endemic level of disease (underreporting)
Quantitative Microbial Risk Assessment (QMRA)
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Faecal contamination Faecal sterols analysed
What amounts of pathogens would the faecal contamination contribute? Incidence in the population (statistical data)
Faeces could contribute enteric pathogens to the urine IF they end up in the urine – will they survive storage? Survival studies performed and literature data used for crop
How can people be exposed to the urine? Scenarios determined
What dose could they be exposed to? Amounts ingested estimated
(Höglund et al., 2002)
Microbial risk assessment – urine (outline)
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Input: faecal contamination, prevalence of infection,excretion densities, excretion days, inactivation rates
Scenarios:
Dose-response models Output: probability of infection
Exposure Risk
Cleaning of blocked pipes Ingestion ofpathogens
Accidental ingestion whenhandling unstored urine
Ingestion ofpathogens
Accidental ingestion whenhandling stored urine
Ingestion ofpathogens
Inhalation of aerosolscreated when applying urine
Inhalation ofpathogens
Consumption of cropsfertilised with urine
Ingestion ofpathogens
(Höglund et al., 2002)
Microbial risk assessment – urine (outline)
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C. jejuni C. parvum Rotavirus
log 1
0 P
inf
-6
-5
-4
-3
-2
-1
0
epidemic sporadic 4°C sporadic 20°C
• Unstored urine Pinf < 1:1000 except for rotavirus
• Storage for six months at 20°C all risks < 1:1000
(Höglund et al., 2002)
Risk from accidental ingestion of 1 ml unstored urine
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Time between crop fertilising and consumption
log 1
0 P
inf
-15
-14
-13
-12
-11
-10
-9
-8
-7
-6
-5
-4
-3
-2
-1Campylobacter Cryptosporidium Rotavirus
<10-15
1 week 2 weeks 3 weeks 4 weeks
• Inactivation will continue in the field
• Risk dependent on time between fertilising and consumption
(Höglund et al., 2002)
Risk from accidental ingestion of 100 g crop
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Faeces from dry urine diverting latrines in Denmark No additives Treatment by storage Hazard identification
Bacteria: Salmonella, EHEC Viruses: rotavirus, hepatitis A Protozoa: Giardia, Cryptosporidium Helminth: Ascaris
Compiled studies (literature) for pathogen survival Incidence (surveillance), excretion numbers and times
(duration) also input for calculation of doses Model organisms – dose-response relation Exposure when handling and using in garden
Microbial risk assessment - faeces
(Schönning et al., 2004)
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The faeces-soil intake (Larsen,1998) - children around 200 mg of soil (max of 5-10 g).
Assumed that adults ingest 15-50% of this amount, with a maximum of 100 mg.
The container emptied once a year assuming only adults exposed.
The number of exposures through recreation was a median value of 3.5 times per week (during June-August).
50% of the households were exposed through gardening once a week (during May-September).
It was assumed that one exposure corresponded to two hours of gardening occurring a maximum two times per day.
Exposure scenarios
(Schönning et al., 2004)
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There is an “unacceptably” high (>1:10 000) risk of infection when faeces is used without treatment The highest risk from exposure to unstored material was
attributable to rotavirus 12 months storage – sufficient reduction of most
pathogens (compared to a risk level 1:10 000) The highest risk from exposure to stored faeces was
attributable to Ascaris the protozoa Giardia and Cryptosporidium are of greater
concern in the European population The risks of infection can be reduced by simple measures
such as longer storage, or treatment with a pH elevating compound
Conclusions - pathogens
(Schönning et al., 2004)
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Risk for infection when emptying container
Salmonella Ascaris
Examples of how risk for infection are presented as probability density functions. The typical risk equals the 50th-percentile and worst case equals the 95th-percentile.
(Schönning et al., 2004)
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Hässleholm municipality with 28 600 residents
12 500 m3 wastewater per day Wastewater treatment: pre-aeration, pre-
sedimentation, activated sludge, chemical precipitation, three-media filter
Sludge treatment: anaerobic digestion, dewatering, outdoor storage
Sludge use: Application to vegetables (theoretical)
Microbial risk assessment – wastewater and sludge
(Westrell et al., 2004)
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Hazard Identification All entero-pathogens potentially in wastewater Enterohaemmorhagic E.coli (EHEC), Salmonella, Giardia,
Cryptosporidium, rotavirus and adenovirus Exposure assessment
Exposure points identified together with WWTP staff Site-specific data on removal of indicators in WWT Literature data on occurrence of pathogens in ww, removal in
sludge treatment and survival in environment Dose-response assessment
Published dose-response models Risk characterisation
Monte Carlo simulations Risk of infection per exposure Yearly number of infections in study population Comparison with endemic level of disease (epidemiological
statistics adjusted for underreporting and morbidity rates)
Microbial risk assessment – wastewater and sludge
(Westrell et al., 2004)
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Exposure scenarios – wastewater treatment
12
3, 4
5
67
8
(Westrell et al., 2004)
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Type of exposureVolume ingested
(mL or g)Frequency
(times*year-1)
Number of persons affected
1. WWTP worker at pre-aeration 1 52 2
2. WWTP worker at belt press 5 208 1
3. (Un)intentional immersion at wetland inlet
30 1 2
4. Child playing at wetland inlet 1 2 30
5. Recreational swimming 50 10 300
6. Child playing at sludge storage 5 1 2
7. Contractor spreading sludge 2 30 2
8. Consumption of raw vegetables 1 2 500
Exposure scenarios – wastewater treatment
(Westrell et al., 2004)
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Risk of infection per exposure
All risks >10-4 are shown in orange
(Westrell et al., 2004)
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Exposure EHEC Salmonella Giardia Cryptosporidium Rotavirus Adenovirus
1 1.98
(1.69-2.00) 1.99
(1.30-2.00)
2 0.57
(0.05-0.99)
1.00 (0.99-1.00)
1.00 (0.97-1.00)
3 0.21
(0.02-1.87)
4 0.23
(0.02-5.21)
5 0.18
(0.01-4.26)
6 0.76
(0.23-1.28) 1.87
(0.22-2.00)
7 0.52
(0.04-1.75) 0.13
(0.006-1.25) 2.00
(1.64-2.00) 2.00
(1.49-2.00)
8 0.41
(0.01-20.51)
0 is equivalent to <0.0001 infections
Number of yearly infections
(Westrell et al., 2004)
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Severity of hazards
(Westrell et al., 2004)
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Exposure EHEC Salmonella Giardia Crypto. Rotavirus Adenovirus
1 Median
95-percentile
2
3
4
5
6
7
8
Catastrophic Major Moderate Minor Insignificant
Classification of exposures
(Westrell et al., 2004)
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Exposure 1 Easy to control with
Personal Protective Equipment (PPE)
Covering of basins
Exposure 2 Easy to control with PPE Optimisation of sludge treatment
(baffles against short-circuiting, thermophilic digestion etc.)
Control measures
(Westrell et al., 2004)
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Exposure 6 Fence storage area Optimisation of sludge
treatment
Exposure 7 Use of PPE Optimisation of sludge
treatment Prolonged sludge storage
Control measures
Exposure 8 Crop restrictions Minimum time between
fertilisation and harvest Optimisation of sludge
treatment Prolonged sludge storage
(Westrell et al., 2004)
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Per-Åke Nilsson and staff at Hässleholm wastewater treatment plant
Swedish research council FORMAS MISTRA Urban Water program
Acknowledgements
Worst-case situation 2002
(Westrell et al., 2004)
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107 households, 449 people Prevalence of parasitic infections Type of latrines
UD solar desiccating latrine (single vault) UD double-vault desiccating latrine (LASF)Pit latrinesNo latrines
UD = urine diverting
Epidemiological study - El Salvador
(Corrales et al., 2006)
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Prevalence of parasitic infections
Use of UD-latrines (both solar and LASF) – lower prevalence of the less environmentally persistent pathogens (hookworm, Giardia, Entamoeba)
Use of LASF – higher prevalence of more environmentally persistent pathogens (Ascaris, Trichuris)
(Corrales et al., 2006)
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LASF (this design) does not achieve conditions needed to inactivate these organisms
UD solar latrines – lower prevalence of most parasites compared with LASF and pit-latrine
Use of ”biosolids” (faecal matter) in agriculture – higher prevalence of infections compared to burying the material
Summarised results
(Corrales et al., 2006)
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In El Salvador, the solar latrine is recommended Includes urine diversion Better results than pit latrine
High prevalence of some infections in diverting latrines identifes the need for Further work on better designs Better use and maintenance, information Further evaluation under different local environments and
cultures Limitations of the study
Different communities compared Small sample size
Conclusions
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Epidemiological study South Africa
Peri-urban area, eThekwini Municipality, Durban 1337 households incl. in study
Intervention Sanitation – dry UD-toilets Safe water (200 L per day) Health and hygiene education
Purpose and method Measure reduction in
diarrhoea associated with the interventions
Prospective cohort study Disease incidence
questionnaire (6 visits) (Knight et al., manuscript)
Picture provided by Teddy Gounden
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2
88
10
Pit/VIP No sanitation UD
14
7
79
Pit/VIP No sanitation Flush
Exposed Area (N=660)
Unexposed Area (N=667)
Type of Sanitation Intervention in Sample Area
Provided by Renuka Lutchminarayan
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(Knight et al., manuscript)
Epidemiological study South Africa - Results
41% reduction in diarrhoea Benefits 3 times greater for
children <5 years Fewer acute water related
health outcomes Duration of diarrhoea
episodes decreased (54% fewer days reported)
Not possible to disaggregate the effect of each separate intervention Picture provided by Teddy Gounden
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36
0.00
0.50
1.00
1.50
2.00
2.50
3.00
3.50
4.00
Female Male Total
Gender
Inci
den
ce R
ate
per
100
0 p
erso
n d
ayss
Non-exp Exp
Incidence Rate & Incidence Rate Ratio of Diarrhoea Episodes by Gender & Total
IRR:
0.50
IRR:
0.65
IRR:
0.58
(Knight SE, Esterhuizen T, Lutchminarayan R, Stenström T-A)
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Impacts on diarrhoeal disease reduction by interventions
Intervention areaReduction in diarrhoea
frequency
Hygiene 37%
Sanitation 32%
Water supply 25%
Water quality 31%
Multiple 33%
(In WHO, 2008, adapted from Fewtrell et al., 2005)
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Different types of studies Possible to investigate the ”real” situation? Epidemiology – underestimation in disease incidence
• Interviews, surveillance Risk assessments – assumptions made, over- or underestimating risks (?) Sampling and microbial analysis
Illustrates the importance of various studies Range of interventions possible and
needed in combination Difficult to differentiate effects
Identifying need of risk management and barriers Health protection measures of
different kinds
Summary of module on risk management