presenter's guide and notes · 2014. 3. 7. · diskettes. the storyboard facilitates two-way...

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Presenter's Guide and NotesSHORT VERSION

CHOLERA PREVENTION AND CONTROL

Assessing the Options in Water, Sanitation, and Hygiene Education

A Storyboard Live! Presentation

Prepared by

The Water and Sanitation for Health (WASH) ProjectOffice of Health, Bureau for Research and Development

U.S. Agency for International Development

February 1993

Water and Sanitation for Health ProjectContract No. DPE.5973-Z-0O-8081-00, Project No. 936-5973

it (poiuored by the Office of Health, Bureau for Research and DevelopmentU.S. Agency for International Development

Wadiington, DC 20523

INTRODUCTION

Background

LIBRARY, INTERNATIONAL REFERENCECENTRE FOR COMMUNITY WATER SUPPLYAND SANITATION <jWC)P.O. Bo-< 93190, 2509 AO The Hagu»Tel. (070) 8149 !1 ext 141/142 •/

This Storyboard presentation was prepared by the Water and Sanitation for Health Project(WASH) as an experiment in using non-print media to communicate information about watersupply and sanitation. Originally the presentation was to be about WASH capabilities and theimportance of water and sanitation. However, in the early stages of the task, the topic wasswitched to cholera preparedness assessment because of its timeliness and potential utility.

The thrust of the presentation is an explanation of how countries facing cholera can assesstheir options for action in water, sanitation, and hygiene education to halt or slow the spreadof the disease. It is based on the work done under Task 323, which consisted of preparationof a manual for consultants on how to carry out a rapid assessment of cholera vulnerability,and it draws heavily on WASH's experience in conducting such an assessment in Peru shortlyafter the epidemic first broke out in 1991.

The presentation argues that an effective assessment must take into consideration both thedirect causes of the disease and the indirect or contributing factors, such as weak sectorinstitutions, lack of administrative ability, or the absence of appropriate laws and regulations.Thus, it promotes a broad view of water, sanitation, and health and looks at both short- andlong-term interventions. In addition, the presentation seeks to broaden the discussion fromcholera to fecal-oral diseases in general and to stress that prevention through provision ofwater and sanitation is the cheapest cure in the long term.

The Cholera Fact Sheet and the Cholera Assessment Guide, both publications prepared byWASH, function as print supplements to the presentation.

While it might be possible for an individual to use this presentation as a self-instructional tool,it was designed mainly to be used by WASH staff or consultants meeting with small groupsin missions or bureaus. The Storyboard is a way of capturing people's attention so that themessage can be conveyed more effectively. It is also a way for the presenter to get a betteridea of what the audience knows and where they are coming from. It provides an environmentfor the exchange of information and ideas—one that is crucial to development assistance andis often lacking.

Marketing WASH capabilities via the presentation of a Storyboard requires more resourcesthan simply mailing out brochures or fact sheets, or mailing out copies of the Storyboard .diskettes. The Storyboard facilitates two-way communication. It should help the presenter toarticulate his or her message more clearly and to engage the audience in dialogue. Thisinnovative approach has been used with great success in other sectors (i.e., raising awarenessamong decisionmakers of the consequences of rapid population growth).

The presentation is usable by anyone with an IBM-compatible personal computer with a colormonitor. No other special equipment is needed unless the group to which the presentation isto be made is large. Then it could be projected via an adapter and overhead projector.

Tips for Presenters

• How to Install the Cholera Storyboard

Make a new subdirectory on the hard disk of your computer. For example, type: md cholera.(You may use any name up to 8 characters.) Then change to that subdirectory and copy allthe files from the 8 diskettes of this presentation into the subdirectory. For example, if yourhard disk is drive C: and your floppy drive is A:, at the prompt, C:\CHOLERA > , type: copya: *. *. Repeat this command for each diskette.

• How to Operate the Program

To begin the program you must be positioned within the new subdirectory that you createdfor the Storyboard presentation. Once in that subdirectory, simply type: st cholerax, and theStoryTeller identification screen will appear. (ST is the Storyboard Live! Program, StoryTeller;CHOLERA is the name of the story.)

Hit "Enter" to begin the presentation. Many of the slides have several phases, or "builds." Forexample, the first build of a slide may be a line-drawn map. In the second phase, certaincountries might be colored in; in the third phase, cholera morbidity figures might be given.When all builds have appeared, a white dot will appear in the lower right-hand comer and youcan move on to the next slide by hitting "Enter" or (almost) any other key. To quit at any timein the presentation, hit "Esc." To back up to the previous slide, hit the minus key in thenumerical keyboard pad. (You may have to hit that key several times to back up through allbuilds of the previous slide.)

The presentation is divided into five sections, which are displayed in the menu (see Slide 2):

Why there is a problem.

Assessing the options.

Transmission and prevention.

Epidemiology.

Review.

Make a selection by typing the first letter of the section you wish to view: w, a, t, e, r. Waitfor the grey box to appear in the lower left corner of the menu and then hit "Enter." At the.conclusion of each section, you are returned to the menu.

• How to Use the Presenter's Notes

The accompanying notes have been prepared to assist you in presenting the Storyboard Live!Program. For each slide, there is a suggested commentary. You can keep track of where youare in the presentation by referring to the photocopies of the slides on the right-hand side ofthe page.

You may wish to read the notes as a commentary or narrative. However, it is more likely thatyou will use the notes as a guide and as background material for your own remarks. For thatreason it is very important to familiarize yourself with the notes and the slides well in advanceof the scheduled presentation so that you can tailor your remarks on the presentation to theaudience and the setting.

Note that for some slides there are additional comments or background material the use ofwhich is optional. These sections are labeled "Additional Information."

• How to Make Your Presentation

As mentioned above, this Storyboard Live! Program and accompanying script is intended tobe used with small groups (four or five people) on a VGA color monitor or with larger groups(twenty or so) projected via an overhead projector.

The overall goal of the Storyboard on cholera is to describe what the WASH Project/USAIDcan offer in terms of assessment and planning for countries facing cholera. Since theassessment/planning process described is based on a broad framework for understandingcholera, the presentation attempts to provide background material on the disease and itstransmission and on the ways it can be prevented.

The suggested order in viewing the presentation is Epidemiology, Transmission andprevention, Why there is a problem, Assessing the Options, and Review. Depending on theaudience, you may wish to leave out certain segments of the menu or rearrange the menu tosuit your own purposes, or hurry through some parts and linger over others. As mentionedabove, the first step in preparing for your presentation is to familiarize yourself completely withthe slides and the presenters' notes.

Your Comments Are Important

This is the first Storyboard Presentation prepared by the WASH Project. We at WASH have-learned a great deal about working with this medium and already have some ideas about howthe final product could be improved and used. We would appreciate suggestions for improvingthe product and are looking for opportunities to field test it.

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Presentation Notes to AccompanyStoryboard Presentation

Introduction

Slide 1: Cholera Prevention and Control: Assessingthe options in water, sanitation, and hygieneeducation

In 1991, cholera reappeared in Latin America after a100 year absence. The epidemic in Latin America ispart of a worldwide pandemic that has resulted in16,000 deaths and 2.3 million cases over the past30 years, and it is still going strong.

The permanent solution to cholera is prevention andblocking disease transmission. This involves providingsafe water and adequate sanitation, as well aspromoting healthy hygiene practices.

Many countries of the developing world arevulnerable to cholera because they lack safe waterand adequate sanitation and the necessary resourcesto provide these services. Because universal waterand sanitation coverage is not a realistic option atpresent, careful planning is required to allocatelimited resources to situations where they are neededmost. However, the most vulnerable countries alsolack the capacity to do this planning.

A.I.D.'s Office of Health, Bureau of Research andDevelopment, through the WASH project, hasdeveloped a planning process to assist countries inassessing their options for preventing and curbing thespread of cholera.

The heart of this presentation is a description of theplanning process. In addition, backgroundinformation on how cholera is transmitted and howthe transmission cycle can be broken is presented.This information provides a sturdy framework forthinking about cholera prevention.

We see that cholera, and other fecal-oral diseases,can be prevented only through the combined effortsof various agencies and ministries, from those which

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deal with the technical problems of providing potablewater, to those which regulate irrigation, to thoseinvolved in public education. Many disciplines areinvolved: engineering, institutional development,training, legal and regulatory services, policymaking,financial management, and so on.

When the multrfaceted nature of cholera preventionefforts is understood and appreciated, it becomesobvious that there are many options for prevention,even for countries with scarce resources.

Slide 2: Menu: Cholera Prevention and Control

This presentation is divided into five sections:

Why there is a problem

Assessing the options

Transmission and prevention

Epidemiology

Review

Make a selection by typing in the first letter ofthe section you want to view:

w, a, t, e, or r. To quit, type q.

Note: Wait for the grey box to appear in thelower left comer.

You must hit "Enter" after the letter.

If viewing the full presentation, the suggestedorder is: Epidemiology, Transmission andprevention, Why there is a problem, Assessingthe options, and Review.

At the conclusion of each section, you arereturned to the menu.

Why there Is a problem



Review

Epidemiology

Slide E.I: The seven pandemics

This timeline shows the seven pandemics of thenineteenth century—the current pandemic, El Tor,began in 1961 and is still ongoing. "Modem" cholerabegan in Jessore, near Calcutta, in 1817. Unlikeearlier cholera, this one seemed to have the ability totravel long distances.

[Additional Information: The five subsequentpandemics reached Western Europe; two reachedthe United States. These pandemics were deadly.The 1829 pandemic killed 150,000 to 250,000 inthe U.S. The fourth pandemic killed half a millionpeople on the continent of Europe.]

Slide E.2: The spread of El Tor

The current pandemic began in the Celebes Islandsin 1961 and quickly spread to other Asian countriesduring the 1960s. By 1970 it had traveled westwardto the Middle East. In August 1970, the first cases inAfrica this century were identified in Guinea. Theepidemic spread along the West African coast andthen moved inland. Within two years, 29 countrieswere infected with El Tor. Like Latin America in1991, Africa had been free of the disease for morethan 70 years.

Towards the end of January 1991, cholera struckthe coast of Peru with great intensity, causing onaverage over 1,700 reported cases per day duringthe first four months. By mid-1992, the disease hadspread to all but a handful of Latin Americancountries. The reported cases totalled close to650,000 and the death toll was reported to be over5,500. Reported cases may underestimate actualcases. It is likely that the microorganism wasintroduced into Latin America via maritime trafficfrom the Pacific.

Slide E.3: Cholera cases reported to WHO

This graph shows the cholera cases in thousandsreported to the World Health Organization since theonset of El Tor in 1961. The outbreak in LatinAmerica in 1991 was severe. The number of cases inAfrica also increased markedly in 1991.

The current pandemic differs from previous ones inthat it has lasted over 30 years and shows no signsof abating. There is no clear explanation for thecyclical nature of the disease. By the end of JulyLatin America had reported approximately 240,000cases for 1992. The red line on the graph isremaining quite high.

[Additional Information: At the end of 1991, over2.3 million cases had been reported for thispandemic worldwide. Very likely many cases gounreported or are not differentiated from otherdiarrheal diseases. Also, some countries do notreport cases to WHO.]

Slide E.4: El Tor persists more tenaciously in theenvironment

The green line represents the persistence and cyclicalnature of cholera. As shown on the screen, thecurrent cholera strain, El Tor, persists moretenaciously in the environment than vibrios ofClassical cholera. El Tor has been known to surviveup to 19 days in well water and also can survive insaline coastal waters and in fish and shellfishharvested there.

[Additional Information: Investigators have reportedcholera vibrio survival times of up to two months in4° C seawater and one month in untreatedfreshwater, also at 4° C. The cholera vibrio cansurvive five days in a slice of papaya and up to twoweeks in refrigerated fish and shellfish or cookedrice.]

Slide E.5: El Tor is less deadly

Fortunately, the El Tor strain is less deadly thanClassical cholera. Among those who get choleratoday, fewer die compared to past strains.

Slide E.6: Many cases go unnoticed

Many cases go unnoticed, presenting few or nosymptoms. There are likely 100 symptomless casesfor every clinical case of cholera. These symptomlesspeople spread the disease unknowingly.

[Additional Information: Symptomless cases canshed cholera vibrios back into the environment intheir stools for up to eight days where they continueto spread rapidly along the fecal-oral route. Becausethese cases don't appear to be infected, no attempt ismade by these people to take special precautions.Cholera can be spread easily from person to personand country to country by asymptomatic peoplewithout them knowing it.]

Many casesgo unnoticed

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if u\( v . y r

Symptomless people spreadthe disease , o o V „ e o ;unknowingly W ^ M V ^ V :

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Slide E.7: Cholera strikes rapidly

Cholera is an especially frightening disease because itstrikes suddenly and progresses rapidly. Clinicalcholera produces profuse watery stools, vomiting,and rapid dehydration, acidosis (decreased alkalinityof the blood and tissues), and circulatory collapse.Treatment must be sought or there is a highprobability of death—about 30-40%.

Treatment is effective

Slide E.8: Treatment is effective

Treatment for cholera involves replacement of lostfluids and electrolytes, normally through oralrehydration therapy. Cases that have progressed tosevere dehydration, shock, and/or unconsciousnessrequire intravenous rehydration. Antibiotic therapy ishot essential, but it may shorten the duration ofdiarrhea.

Twenty to 30% of those untreated die of cholera;rehydration alone reduces fatality rates to 1% orless.

[Additional Information: In Latin America, the deathtoll has been kept low because of a strong publichealth response and effective case management. InAfrica, where the majority of cases go untreated, thedeath toll is much higher, up to 30% in some areaswith an average of 6-10%.]

Slide E.9: Treatment is relatively inexpensive, butcholera is costly

This slide shows what the cholera epidemic cost Peruin 1991, according to a study prepared by WASH.We see that the cost of treating cholera victims wasonly a bit more than 10% of the total cost. Othercosts include losses in trade and tourism andproductivity. The analysis also placed a presentmonetary value on the productivity losses due toillness or death. The total cost, $255.5 million, isprobably on the low side because conservative datawere used in the analysis.

[Additional Information: The World Bank's WorldDevelopment Report for 1992, states that "in just thefirst ten weeks of the cholera epidemic in Peru lossesfrom reduced agricultural exports and tourism wereestimated at $1 billion—more than three times theamount that the country had invested in watersupply and sanitation during the 1980s."]

Whichever figure is chosen, it is money that Perucould ill afford to lose, and the costs hit more thanthe Ministry of Health.

TreatmentA Replacement of

lost fluids

• Antibiotic therapy

Treatment Isrelatively inexpensive,

^bp but cholera is costly

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• Dofflesttb ppoductlanl o s s e s . •^..•.•..,..;..-..:-..^, .-.";-

Slide E.10: These resources could go a long way inhelping to prevent cholera in the first place.

The $255.5 million could have gone a long way inhelping to prevent cholera (as well as other water-related diseases) in the first place. According tofigures compiled by the World Bank and UNDP,$250 million can provide:

• (High-technology) water and sewer systemsfor 450,000 urban dwellers, or

• (Intermediate-technology) public standpostsand on-site sanitation for 2 million peri-urbandwellers, or

• (Low-technology) boreholes and hand dugwells, rainwater harvesting, etc. and on-sitesanitation for 5 million rural dwellers.

Note: Figures are in 1990 US dollars based onworldwide average costs.

There are 6.6 million rural dwellers in Peru. 1.2million had water and sanitation services in 1988.$250 million would provide water for 5 million more.This means that 6.6 million, or nearly all of the ruralpopulation, could have had water for the amountlost due to cholera in Peru in 1991.

Slide E . l l : Cholera is not going away soon

Public health officials predict that cholera will spreadthroughout Latin America and the Caribbean andremain endemic there as it has in Africa and Asia.It's a serious health problem that is not going to goaway in the foreseeable future. Many countries thathad a large number of cases in 1991 are continuingto show high levels of cholera. In other LatinAmerican countries, cholera has become moreintensive in 1992. As of October 1992, only threeSouth American countries, Paraguay, Uruguay, andGuyana reported no cases.

These resources cauld go a longmay in helping to ppeventiffg||

•:ttei'; cholera, in the f i rst placas|;_

8

ten and aeiaerj{ :j";rByst:Bms for 430,000 unban duieller-s.

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on-slta sanitation for- 3.000,0•. r u r a l duiBli™r"s..i.,.J:..,_1,.J.u,i..»_....i, . ....

Slide E.12: Prevention is the permanent solution toT cholera

Public health officials agree that cholera will remainendemic in Latin America, and in Africa and Asia aswell, until the underlying condition that make peoplevulnerable to the disease are changed. This meanssafe water, adequate means of excreta disposal, andhygiene behaviors that promote health.

Prevention isthe permanent solution

E& Safe water supply

C,i- Adequate sanitation services

Healthy hygiene practices

Transmission and Prevention

Slide T.I: How cholera spreads

In cholera transmission it is useful to think of the 5Fs . The first is "feces," which contaminate fluids,fingers, fields and food. Cholera is a fecal-oraldisease. It is acquired by the ingestion of aninfectious dose of cholera vibrios, usually from wateror "fluids" contaminated with feces of an infectedperson. Poor sanitation and waste disposal practicescause this contamination. The role fecallycontaminted water plays in cholera transmission wasestablished in 1854 by John Snow, a leadingphysician, who removed the handle from the BroadStreet pump, whose water he suspsected wascontaminated by nearby privy faults. The incidenceof cholera declined following handle removal.

[Additional Information: The infective dose ofcholera is about 100 million organisms. That's thenumber of organisms in 1 cubic centimeter of acholera patient's stool, (A patient may purge up to10 liters a day—thousands of infective doses.)]

Slide T.2: How cholera spreads

Cholera can be spread by contaminated fingers, thethird F word. Fingers or hands are commonly conta-minated during defecation or by touching contami-nated articles and surfaces. Contaminated fingersand hands facilitate fecal-oral transmission of diseasethrough direct contact with the mouth, contaminationof drinking and cooking water, contamination offood, and contamination of cooking utensils andvessels for drinking water and water storage.

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Cholera is considered a classic water-borne disease,but transmission through food—another of theFs—prepared from contaminated water, or raw orundercooked seafood caught in contaminatedwaters, can also transmit the disease. Food fromstreet vendors can be especially dangerous.

[Additional Information: Cholera multiplies in waterand food. If someone reaches into a water tankbecause it doesn't leave a spigot and they have just 1or 2 cholera organisms on their fingers, in a coupleof days a glass of water from the tank can givepeople who drink it their infective dose.]


Fields is one of the F words because fruits andvegetables grown at or near ground Jevel andfertilized with nightsoil, irrigated with untreatedwastewater or "freshened" with contaminated watercan be a source of infection. Farmworkers who workin such fields are also at risk.

[Additional Information: While some people thinkflies are important, they are not a factor intransmission of cholera, but their presence indicatesunsanitary conditions.]

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Slide T.5: Disrupting cholera transmission

Just as there are many routes through which fecal-oral transmission of disease may occur, there aremany points at which behaviors may intervene tointerrupt disease transmission. These opportunitiesconstitute three barriers to disease transmission: oneprimary barrier and two secondary barriers.

The primary barrier to disease transmission ispreventing the infectious organisms from getting intothe environment in the first place. As shown on thescreen, effective isolation of feoes eliminates thepossibility of fecal contamination of fluids, fingers andhands, surfaces, food, and fields.


For the primary barrier to be effective, both adequatesanitation systems and health-promoting hygienebehavior are necessary. Adequate sanitation consistsof the proper use of a well-maintained latrine or anadequate waterborne sewage system. Good hygienebehavior includes the safe disposal of cleansingmaterials and diapers and washing hands afterdefecating or changing a diaper.

[Additional Information: For the primary barrier to beeffective 100% adherence is required. Even a minorbreakdown can have wide ramifications because ofthe way cholera bacteria multiply and persist in theenvironment. For example, latrines must beappropriately designed, well maintained, and usedby entire families to provide an effective barrier.

Where well-operating piped water and sanitationsystems are not the rule, it is not realistic to expectthese preventive methods to be carried out 100% ofthe time.]

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Disrupting cholera transmission

J Prevent infectious organisms * * * ! 'f from getting into the environ

Actequats siamtsfclon syetfamed-maintained latrines

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If there is no primary barrier to keep the infectiousorganisms out of the environment, or when, as istypically the case, the primary barrier worksimperfectly, secondary barriers must be relied on toprevent the transmission of disease. Avoidinginfectious organisms is one of these secondarybarriers.


People should avoid unsafe water or food,particularly food from vendors. They should avoidputting their fingers or other objects into theirmouths. They should realize that the organisms willbe present in the environment and take precautionsagainst getting their household items contaminated.

[Additional Information: In an area, neighborhood,or community where cholera is prevalent, it's usefulto think that the bacteria are everywhere. Peoplewho touch water or food should remember that thecholera bacteria might be on their hands. Peoplewho do not have the wherewithal to wash theirhands and to keep their food preparation areas cleancan't avoid cholera. Unfortunately, many people indeveloping countries are in just that predicament.]


If avoidance is impossible, steps should be made toremove or destroy the offending bacteria.


If the water supply is suspect, it may be disinfectedthrough boiling or chlorination. Food should becooked adequately. Hand washing is of prime .importance.

13

Slide T . l l : Example: Policy to chlorinate water

To show how complicated it can be to disruptcholera transmissions, the next few slides concentrateon one example: a government recommendation forhousehold chlorination.

Often many types of interventions must worktogether for a strong barrier to be constructed.

In our example the government would have tosupport several inter-related interventions. First,people would have to be well enough educated inhygiene and cholera transmission to understand thenecessity of disinfecting their water. Chlorine wouldhave to be available for purchase or for distributionin the appropriate quantities. This implies theexistence of effective marketing and distributioninstitutions or mechanisms and a populace that hasbeen informed about where to obtain and how touse the chlorine and, perhaps, possessing enoughmoney to go out and buy it. In areas with lowliteracy, communicating messages widely about howto chlorinate water in the home—not to mentionother aspects of cholera prevention—presupposes afairly sophisticated understanding of mediapromotional campaigns and the existence ofconsiderable resources.

When assessing the options for cholera prevention, itis necessary to have a broad view of the problemand realize how many disciplines are involved.

Slide T.12: Cholera is not the only disease spreadby fecal-oral transmission

All that has been said here about choleratransmission and prevention applies to other diseasesspread through the fecal-oral route. Such diseasesare responsible for millions of deaths per year,especially of children under five, as shown in thistable. Cholera prevention and control interventionswill reduce the death toll from other fecal-oraldiseases as well.

14

Cholera is not the4^onlydisease:$Bpi*

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Slide T.13: Diarrheal disease is a major cause ofinfant mortality

In many Latin American and Caribbean countries,diarrheal disease is among the top five causes ofdeath in infants under one year of age. In Canadaand other developing countries such diseases do notcontribute in a major way to infant mortality.

Slide T.14: In Industrialized countries, mortalityrates declined when water and sanitation wasimproved.

In the industrialized West, most diseases had beenreduced by the time vaccines or treatment therapies,such as IV therapy and ORS, were introduced. Thisslide demonstrates the stock reduction in mortality inGreat Britain following policy changes. In 1848,England created Health Board Surveys to carry outlaboratory surveys of water sources whenever diseaseoutbreaks occurred. These surveys provided agrowing wealth of data about disease and water. In1854, John Snow demonstrated the relationshipbetween disease transmission and water when heremoved the handle of the Broad Street pump. In1876, Robert Koch firmly established the GermTheory of Disease. John Snow, the Germ Theory,and Health Board Surveys data provided afoundation for public health interest groups to argue .for standards under which all water sources would bemonitored at all times, rather than only when diseaseoutbreaks occurred. England established waterquality standards in 1913.

In industrialized countries,factors other than treatment

.lr:;i':iiiere responsible .• for ^'^S'Sfi^rki;;':7reducing disease ̂ IneidencpSv

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England and Ulalds

15

Slide T.15: When services were improved inIndustrialized countries, the Impact on health wasrevolutionary

This slide portrays the dramatic decrease in mortalitythat came with water treatment and the constructionof sanitary sewers in the three largest urban areas inFrance. Diseases like cholera and typhoiddisappeared. Cleaning up the water systems not onlyreduced deaths caused by waterbome disease butalso contributed to the reduction in deaths due toairborne diseases because the reduction inwaterborne diseases improved the nutritional statusof the population, especially of infants and youngchildren (Preston and Van de Walle, 1978).

[Additional Information: Another example concernstyphoid in the United States At the turn of thecentury the average death rate from typhoid was ashigh as 36 per 100,000. In 1900, 25,000 peopledied of the disease. By 1910, the rate had gonedown to 20 per 100,000, and by 1935, followingdramatic improvements in water treatment processesand drinking water quality, it had dropped to 3 per100,000. By 1950, water quality standards had beenestablished throughout the United States. In 1960,fewer than 20 people died of typhoid in the wholeUnited States, and, researchers concluded that thehealth of the general public improved to a level farbeyond that associated with typhoid and otherwaterborne diseases.]

T.16: Improved water and sanitation services lead tobetter health in developing countries.

Water and sanitation can have a positive effect inreducing diarrheal diseases in developing countries.

Ulaten and sanitation can ."; have a positive e f fect irf ..,,.••-?:-0S-i. reducing V diarrhea! diseaseate

. MeMiititi^Bductlon'In mcanblcHty duet t o Impfavlrigiil

goo million fewer* d iarrhea episodesa million <ftswer> child deaths

16

Why there is a cholera problem

Slide W.I: Why there is a problem

In this section we will examine some of theconditions that account for cholera's suddenappearance in Latin America. These conditionsexemplify problems prevalent in many developingcountries, although Latin American countries aregenerally better off when it comes to water andsanitation.

• Lack of safe water supply• Inadequate sanitation services• Poor hygiene practices

These are exacerbated by rapid population growthand urbanization; growing environmental pollution;lack of resources; and, weak policies and institutions.

We will look at each of these in more detail.

Slide W.2: Many people still lack safe water andsanitation services

Despite the advances and improvements of theWater and Sanitation Decade (1981-1990), manypeople in Latin America and the Caribbean still donot have access to safe water and adequate servicesfor excreta disposal.

According to figures provided by the United Nations,104 million people in LAC do not have a safe watersupply, and 159 million have no sanitation services.

;-!thepe.vlsi;:a" ppobfem^S| gv^

L a c k o f safe water supply

Inadequate sanitation services

^?$ Poor hygiene practices

17

Slide W.3: Many systems function improperly ornot at all

Unfortunately, the statistics on the previous slidepaint too rosy a picture. Many services arefunctioning improperly or do not meet minimumstandards. Here are some of the problems that mightbe encountered in situations where services do exist.

• Intermittent supplies may jeopardize systemintegrity.

• Wastewater may be collected but it is usuallydumped without being treated. In fact, inLatin America and the Caribbean wastewatercollected in sewerage systems is not treatedin over 90% of the cases.

• Water quality control programs might not beefficiently implemented. Recent WHO studiesindicated that 75% or more of water supplysystems surveyed did not disinfect the waterat all or had operational problems thatinterfered with effective and continuousdisinfection.

• Wastewater might be used for irrigationpurposes without any control.

[Additional Information: According to PAHO,ensuring the supply of adequate quality water, bothfor those who already have services and for thosewho will receive new service, poses one of thegreatest challenges that most of the countries in LatinAmerica and the Caribbean will have to face inupcoming years.]

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Slide W.4: More people have water today andmore people lack water

Despite significant accomplishments, the unservedpopulation continues to grow.

Between 1980 and 1990, there was a 43%improvement in water coverage for the urbanpopulation of LAC. However, the number ofunserved people in urban areas actually grew by5%.

The situation in rural water coverage and insanitation is not as bad; in these areas, advanceshave been made in decreasing the absolute numberof people unserved. However, many still remainwithout access to water and sanitation services.

[Additional Information: Worldwide, those receivingwater increased from 1.1 billion to 1.8 billion {66%}over the course of the Decade. The numberunserved decreased slightly: from 1.1 billion to 1billion. Worldwide in sanitation, those receivingservice increased from 635 million to a little over abillion, while those still without sanitation increasedfrom 1.6 to 1.8 billion—a 12% increase.]

More people have water today

WithImprovGd

More people have water todayand more people lack water

AS i Without:

Improved

19BO 133O

19

Slide W.5: There are more people

Population growth is the main reason the number ofunserved people continues to increase. As this graphshows, during the 1980s, the population of LACgrew by 85 million people. By the year 2000, it isexpected to be about 550 million, nearly doublewhat it was in 1970.

This translates to a current annual growth rate ofabout 2%. Although there has been a decline in therate of population growth over the past two decades,this still means that the LAC population is growingby about 9 million people every year.

The urban population is growing at the even fasterrate of 3.6%. This slide shows what proportion ofthe population is urban for each of the time intervals.It is obvious that most of the growth is in urbanareas—most like peri-urban squatter settlements. Bythe year 2000, 77% of the LAC population will beurban.

The ill effects of poor environmental sanitation aregreatest in high-density urban environments. In thenext decade, the greatest demand for water andsanitation will be in marginal urban areas wheremostly poor people reside.

Slide W.6: Environmental pollution degrades watersources

Population growth and growing agricultural andindustrial activity place tremendous pressures onwater sources and lead to pollution and depletion.

This results in the need for more aggressivetreatment of water supplies, or selection of distantwater sources. Both greatly increase the costs ofproviding safe water.

20

Slide W.7: Resources are scarce

Resources just aren't there to Improve health throughthe provision of water and sanitation.

As this graph shows, from 1981 to 1989, $29 billionwas spent on water and sanitation in LAC—20%from external support agencies. This is about $3.2billion annually. This was more than usual becausecountries were putting forth a greater effort for theWater Decade.

In 1989 it was estimated that investment required toachieve 100% coverage in 1990 would be in.the......neighborhood of $13.6 billion. This is about 1.6% ofthe 1989 estimated GNP for the region. It must bepointed out, however, that this amount would notcover the operation and maintenance costs of thesenew systems.

Resources • are scarce

ReQUIneiJ [nvsetmontfor- \OOV. coveraBB

|*HS billion for- the dBcada

13BB 1BBO

21

Slide W.8: Incremental costs are rising

Because easy to develop sources have already beendeveloped or have been degraded by environmentalpollution or are being depleted through overuse,costs of providing water supplies are rising rapidly.

This graph shows how much the "next scheme" willcost in United States dollars per cubic meter of waterfor a number of representative cities.

The solid red line indicates that the cost of the watersupply system will be the same as the current supplyper cubic meter of water produced.

The broken orange line indicates that the futurescheme will be twice as expensive as the current,and the purple line indicates that the next schemewill be three times as expensive as the current one.

A few cities are placed on this graph to demonstratethe rising cost of water supply. For example, inLima, during 1981, the average increment cost of aproject to meet short to medium-term needs, usingthe Rimac River and groundwater, was 25 C percubic meter. However, now the aquifer has beenseverely depleted and groundwater sources cannotbe used to satisfy needs beyond the early 1990s. Inorder to meet long-term needs, a transfer of waterfrom the Atlantic watershed has been planned at anestimated cost of 53 C per cubic meter—over twice asmuch as the present system.

Mexico City, Bangalore, and Shenyang will also paytwice as much for the next schemes, while Ammanand Hyderabad will pay three times as much.

22

Slide W.9: Financial resources alone will not solvet the problem

Increased financial investments arc needed but they• alone will not solve the problem of water supply. As

the purple line on the graph shows, if the currentinvestment level is maintained (1.7% of totaldeveloping country investment), the problem willsimply worsen as the purple line on the graphshows. Significantly more people would be withoutwater. Even if investment were to grow by 50%, thenumbers of unserved would rise, though not assharply. Only if policy reforms are undertaken canone see improvement in the future. A similar graphcould be prepared for sanitation.

Slide W.10: An enabling environment is essential toimproving access

Policy reforms include use of a range oftechnologies, involvement of the private sector,better cost recovery, more efficient institutions,integrated planning and the like, as this list indicates.Many countries lack a policy environment thatencourages healthy growth of the sector. Forexample, the private sector can make a clearcontribution in water and sanitation but may holdback because the lack of a policy framework makesparticipation too risky.

Similarly, the lack of strong sector institutions is agreat problem for the sector. In many countries, thefirst step in trying to extend water and sanitationcoverage is not to launch a large well-drillingprospect or to build a wastewater treatment plant.Instead, the first step is to make sector institutionsmore effective and efficient. The characteristics ofstrong institutions in the water sector are listed on thescreen.

An': ehabjirig

Policies£••! Legislation to enable uiatnr jnapksts

Gil Contract laws to encourage privatet BBctfiPi consumers and NGO participat

ua Environmental and economic regulation

G3 Financial nandatsa to eneouPBgeconservation ;

ts Quality standards .

n:/er^bhna!;er^essehtial^toimpPDving access

; • / ' • Institutions ; . ,

;?S'£'f'*i BS Oi-a»nteatlonal autonomy •::':i^''.: ':i '

Vy-;.'Sj;;'! *& Leader-ship ,: I;;';.-V"'•-''•:•',

*& Commorclal ortentatJon'tot. ConsumiBn.orientation«s"lnt:erao«ncy'coilatjor'aftlon

23


Slide A. I : Assessing cholera prevention and controloptions

Universal water and sanitation coverage wouldprovide a solution to the cholera problem, as thearrow in the slide shows, but it is not a realisticsolution in the short or medium term, as indicated bythe ever-lengthening arrow in the slide. Instead,governments must use wisely the resources availableto control cholera—and other diarrheal diseases intothe bargain—and to lay the groundwork for futureoverall improvements in water and sanitation.

Faced with slim resources and the threat of a diseasethat can be very costly, governments need to knowhow to choose among the possible preventionoptions to select those with the highest potentialpayoff.

In response to the need, A.I.D. has developed acholera prevention planning process to assistcountries to assess their cholera risks and to act toprevent cholera outbreaks and future spread of thedisease.

It is designed to explain how countries can assesstheir realistic options for prevention. It does not offera prescription—but it offers a planning process thatcan enable countries to raise an effective defenseagainst cholera with the resources that are at hand orthat may reasonably be obtained.

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Slide A.2: The framework

The process is based on a framework for thinkingabout cholera that considers (1) the standardmeasures that may be undertaken to directlyinfluence cholera risk, and (2) factors indirectlyinfluencing cholera risk. We look first at the directmeasures.

• Water quality.

Cholera can be directly attacked, if safe water isprovided for drinking. The bacteriological quality ofdrinking water must be guaranteed at the point ofconsumption. The words "at the point ofconsumption" are extremely important. It's not goodenough to pipe safe water to the home. The watermust still be safe when a person is drinking it out ofa glass. Also, the piped water must flow 24 hours aday every day.

• Water quantity. ,

Another direct measure is to provide an adequateamount of water. A sufficient quantity of water forpersonal and domestic hygiene as well as fordrinking and cooking must be guaranteed. Aninadequate supply of water means that people'shygiene will suffer. Uses for water will be prioritized,and uses such as handwashing will probably not beperceived as important as drinking and cooking. Ifthe water supply is inadequate, people must learn touse water from chlorinated sources for drinking andscavenged water for other needs. They must alsounderstand the importance of using even scarcewater for hygienic purposes.

The frametuork

Direct;, messure s *.Water- quality

: , ;• ; Indirect, factors

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Direct: meseures Indirect factors;

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25

• Excreta disposal.

As we have seen, contaminated water is the singlemost important route of cholera transmission. Sincecontamination from fecal matter is due to poorsanitation, water and sanitation are inseparablylinked.

The third direct measure is to dispose of excretasafely. In some instances this means latrines ofvarious kinds, or it may simply mean identifying andreserving isolated places for defecation. In otherinstances it means construction of waterbome sewagesystems.

• Solid waste disposal.

The fourth direct measure is to collect and dispose ofsolid wastes in a safe manner. Solid wastes aretypically heavily contaminated with fecal matter. Thetwo main sources of fecal contamination aredisposable diapers and soiled toilet paper. Whensolid waste is disposed of with no controls, in opendumps or directly into bodies of water, it cancontribute to the pollution of surface waters andgroundwater and may present a direct threat toindividuals who come in contact with it, such aschildren playing on dump heaps or scavengerslooking for recyclable items. Of special concern arethe disposal sites and practices at hospitals and otherplaces where cholera victims are treated.

• Health practices.

Finally, cholera can be directly impacted if personal,family, and community health practices are safe.

26

• Indirect factors.

These five measures have a direct, mitigating impacton the spread of waterbome diseases. In addition,"indirect" or "influencing" measures also play a role.A number of key indirect measures have beenidentified: community participation, institutionaldevelopment, financial planning, and laws andregulations. Although they do not directly influencecholera control. The success or failure of choleraprograms may depend on these indirect measures.

Indirect factors are cross cutting; they operatethrough direct measures. Let's take guaranteeing thequality of drinking water as an example. Thisinvolves not just soundly engineered water systems;other measures also come into play.

• Community participation.

Assuring that water is safe when it is drunk, not justwhen it comes out of the tap, implies educatingcommunity groups in the proper handling andstorage of water in the home.

• Human resources development.

In the ease of community water supplies, the villagepump operators must be well trained in pumpmaintenance and repair. When pumps break down,water users may be forced to return to unimproved,sometimes contaminated, sources.

The framework

Direct: measures:

' Educntlon In water* ••'p> handling ond ELarago

• \ • ' • • ' . • :

: • " " • • • ' ' • -;

, •'•'.'.<

; ..: Indirect:;factors'Communitypartiiati

Institutional

•.Solid masts disposal 3££.ivt~.*: Human rpaogrcas .«;iw',•:•'.li". d e v o i o p m o n t £K

The framework

Direct'measures'-.•.•Water* Quality ; •,.

Ulster* quantity ' ,'' Excr*QtH disposal ^'.Solid waste disposal "-iy.

7 ' OianrNaLorG uiotl \ •• Lr-aini'd In • • •' •/

f7 muintonance and • .;.'•• \ ' • r9P I? i r*. :- , ;• • '•;. •." .":•* •?••• •• ;.. Indirect factors''••':•' ': Comniunitv Z

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Human resources x?d

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27

• Laws and regulations.

Country standards for drinking water quality shouldbe established and upheld.

Understanding this framework for thinking aboutcholera helps planners and policymakers to keeptheir field of vision wide enough so that they canfully understand all factors that make their countriesvulnerable to cholera.

The focus of this planning process is on cholera butat the same time other waterbome diseases are alsobeing addressed. In 1986, such diseases accountedfor more than 5 million deaths in the developingworld.

Slide A,3: Cholera prevention planning

The cholera prevention planning process comprisesfour basic steps generally carried out by amultidisciplinary team of consultants with the fullcollaboration of host country officials. It has beendeveloped and used successfully by A.I.D.'s Waterand Sanitation for Health (WASH) Project. A.I.D.,through WASH, can provide consultant assistance tocountries that wish to go through this planningprocess.

Slide A.4: Step One: Gathering and analyzinginformation

The first step is a rapid, multidisciplinary fact-findingmission whose goal is to point out what populationsare most at risk of contracting cholera and why theyare vulnerable. Normally, it is completed in two tothree weeks. Two or three specialists, ideally onefrom the health sciences, one from the engineeringsciences, and a third, an institutional specialist, carryout the assessment.

28

Direct' massures <>;* Water* quality I ' ' ^Water quantity' Wy « ; ?.-,• • #• ^*. ***'. ̂ F ... .„." r^lt *ifgf S*»* •

f l :and upheld • . . I 3 ; .• , ; " \ ; - N •"•. .••v^'.••;'•• ••; •••• •'• •••'• a - i

•^MJ; IndirectvfBctops'hSSHBi* community - ' •'•••.

^par t ic ipat ion'Institutional'

. development:

'Heal th praat toes ;^-;:j7iv-,.v;arirt manoaemnnt

"Jt Stop One |Gathering and analysing information

Multldlsclptinary. faafc-fIndtag mission

V Identify populations e»t rWtand their* vulnerabilities • •,;jg;;;

Slide A.5: Step One

• Preparation.

The team must be well prepared. Preparationincludes a two-day planning meeting on how theassessment will be conducted. Assessment topics areassigned to team members according to theirinterests and background and a team leader isselected. Through discussion, the team membersdecide what topics should be given priority on thebasis of time available and country-specificconsiderations. Team members also make up surveyinstruments or questionnaires if needed. Finally, theteam draws up a detailed work plan.

• Gathering information.

Before and during the field visit, the team intensivelygathers information. This activity is guided by theassessment guide prepared by the WASH Project. Itprovides questions to ask to collect the necessarydata. Assessment questions cover both the conditionsthat have a direct impact on cholera transmissionand those with only an indirect one.

The assessment guide is more than a list ofquestions. It also tells where to go to find answersand how the information is used to developrecommendations. Information gathering in-countryconsists of perusing documents and reports;interviewing representatives of pertinent governmentministries, organizations, and agencies, as well ascommunity leaders, extension agents, and heads ofhouseholds; and visiting cholera sites. Allassessments should include at least one visit to acholera-afflicted community. More than one site maybe necessary to cover all concerns. In countrieswhere cholera outbreaks have not yet occurred, sitevisits are also essential in order to take a look atexisting conditions and risk behaviors. The choice ofsites should correspond to the presumed risks ofcholera. Photographs or videos of conditions at thesite may be useful.

29

• Analyzing information.

After the information-gathering is complete, the teammembers analyze and synthesize the information inorder to make sense out of what they have found.The leader of the team facilitates this process.

Slide A.6: Initial recommendations

With their lists of findings in hand, individual teamnumbers get together to integrate their analysis toproduce, through discussion, an initial set ofrecommendations. Here are four suchrecommendations from the Peru assessment.

Note that the actions are both long- and short-term:some relate specifically to the present choleraemergency; others look to the future.

The list may be quite long and perhaps beyond thereach of the country in question. However, at thisstage, it is important to state all validrecommendations so that the "universe" of actionsneeded to overcome the cholera threat is clear. Laterthe list will be honed down in light of what canreasonably be done.

The recommendations are then discussed andanalyzed further in terms of the resources requiredand the resources available to carry them out.

•J3 Step Ono

Initial recommendations:]

C* Chlorinate all existing piped mater supplies

for* all urban fringe cSmmunlUH In ^?

ulster" coverage targots by year EOOOiJ,BOX of urban population , |SOX of rural population .:,J

30

Slide A.7: Step Two: Prioritizing recommendedactions

At this point in the process, as it is implemented byWASH, government officials from the country inwhich the assessment is taking place are asked tojoin in the deliberations.

The assessment team presents its list ofrecommended actions to the governmentcounterparts along with an explanation of how it wascompiled. After discussing this list, governmentpersonnel may wish to propose additional actions.

Involving government counterparts in this exercisewill enhance the likelihood of the recommendationsbeing in tune with government policy and beingcarried out. An additional advantage is that the teamcan use the opportunity to promote anunderstanding that cholera is a symptom of adevelopmental problem, not just a problem in and ofitself.

By explaining the framework for thinking aboutcholera, which includes factors such as communityparticipation, institutional capacity and the like, theteam will be promoting strategies for permanentlyreducing vulnerability to outbreaks of preventabledisease and for strengthening the social andeconomic fabric of the country.

Slide A.8: Prioritizing recommended actions

After all proposed actions have been listed, they areranked according to their impact and feasibility.Continuing with the examples from Peru. Theimpact rating is based on the effect of the proposedaction on the spread of cholera. If a proposed actionis a true preventative barrier to a cholera epidemicand if it is targeting the people most at risk, it shouldbe given a high impact rating.

The feasibility rating is based mainly on whatfinancial, technical, and human resources arerequired to undertake the action and what resourcesare available.

OlSisepTufo • , . . . • . . .

"Prioritizing proposed adtions.Impact feasibility

Chlorinate plpudwater* supplies

Start uo household

OaBfarV health _„ „ ',.serioote

31

Here are the four examples of proposed actions usedearlier with their impact and feasibility ratings.

• Prioritizing proposed actions—ranking.

The first two proposed actions would take prioritybecause of their high ratings on both impact andfeasibility related to the second two actions. Notethat increasing investments in water supply andsanitation is given a high impact rating in the long-term. In a case such as this, when impact is high andfeasibility is low, a great attempt should be made tofind the resources necessary to make the actionfeasible.

Slide A.9: Step Three: Finalizing list ofrecommendations

In step three the assessment team writes a final list ofrecommended priority actions for the government.These are normally a part of the team's report.Those actions with high rankings in feasibility andimpact make up this list. They are organizedaccording to the topics in the framework and statedas simply and clearly as possible. Also, to be mostuseful, a recommendation includes the persons ororganizations responsible for carrying the action out,specific quantities or numbers as appropriate, andthe time frame.

Slide A.10: Finalizing list of recommendations

We return again to the sample proposed actions toshow how they might be given as finalrecommendations.

32

Slide A. 11: Step Four: Developing an action plan

The process can end at step three if the governmentis in a position to implement the recommendationswithout further assistance. Such a situation is rare,however, because the recommendations willprobably not all be aimed at one agency or oneministry. Efforts that require coordination amongseveral governmental entities, each guarding theirprerogatives and unused to working together, arehard to get going. Normally there are nomechanisms in place for encouraging suchcoordination. Recognizing the problems inherent ininter-ministerial planning, a government may elect tomove on to step four, developing an action plan.

•!* Step FourDeveloping an aotion plan

T i l •••••• '

\ Promote coordination among5. Implementing Institutionsjj t Recommendations uiijl InvolveI multiple institutions thatI one unaccustomed -tosj working together --i C Macbaniomo to promotei coordination pro usuallyI absent

Slide A. 12: Step Four

For example, in the case of Peru, the WASHassessment team concluded that the country hadmany of the resources it needed to fight cholera, butlacked an overall plan of action. Preventive measureswere not as effective as they should have beenbecause there was little coordination amonggovernment agencies involved. The teamrecommended that a "cholera czar" be appointed bythe President of Peru to direct all choleraactivities—both preventive and curative—and that aworkshop be held to assist an inter-ministerialcommittee design a unified national cholera controlplan.

•a Step Four*

t Reaourees available, bub overallplan of action lacking

t Preventive HIBBBUPBS netoptimally effective due to task ofgovernment coordination

nflooniniandedt

Si Convona Inter-nlnfatarlal uorkehen• Mold recommendations into unifiedcholera control plan .• eneouraga committment to plan

During such a workshop, representatives fromconcerned ministries would mold therecommendations into an effective, unified choleracontrol plan involving interagency cooperation andcoordination.

33

Slide A. 13: Cholera prevention planning

The four-step process just described can helpcountries under threat of cholera to be prepared andto make environmental health improvements thatkeep cholera at bay and ultimately improve theireconomies and the health of their people.

Throughout the process the spotlight is clearlytrained on short-term cholera prevention, but theusers of this process should not forget that, evenbefore cholera arrived in Latin America, the toll ofenvironmentally-induced disease was high, and thatlong-term, permanent solutions must be at least apart of every cholera prevention plan.

Cholera prevention planning ,:•_ S3 S t e p O n e ' ' • • , • • . '. • ::''- • -• ":^

•"Gathering and analyzing information,)'-i- *£3 S t e p T w o ••••: 31 „,__ ,...>r^._

•:; Prioritizing recommended actions\%• ;\viaStep Three;ri""""li"""—••••-•— - ^'':'•{ Finalizing list a

:si Step Four

34

lUJhy?;thore":is;:a"prob!ntti:



Epidemiology

Review

Slide R.I: Review

Epidemiology Review

Cholera leapt onto the stage in the WesternHemisphere in January 1991, and has killedover 6,000 people in LAC since then.

It is part of the El Tor pandemic that first hitAsia in 1961 and spread to Africa in the1970s and shows no signs of abating.

Prevention is the longer-term, permanentsolution to cholera. Availability of safe waterand sanitation services, together, with healthyhygiene practices, are essential.

EpidemiologyC- Cnolera leant onto the stage in trie ,

Ulestern rlemlEpherB In January 1991, .and Has killed almost: 3.ODD peopleIn Latin America end the Caribbean -s i n c e t h e n . . . . . . • - , • . . • • • . - • • • . V '

EL; It Is rar*t of trie El Tor panAnHclMBtfirst Hit Asia In 19B1. sorBBd to Africain the 137OE, and Etioius no signsof ebstina

C3 Provention is the lanserwter-m,paraianeot jetolutlsn to cnolafa:avallatiility sf safo uiattir* andsanitation services, togetheruiltH Healthy hysiene pr-acticest

I are essential

Slide R.2: Review


• Cholera is a fecal-oral disease spread bywater, food, poor hygiene, and lack ofsanitation.

• Transmission is blocked through provisionand use of improved water supply andsanitation services, and healthy hygienepractices.

Review

Transmission and proventionC> Owlsra IB a uiaterborne dtsoasa

spread lay fecal-oral transmission

BE Transmission la blocked throughprovision and use of Improved mater-supply and sanitation services, andHealthy Hygiene practices

Health boneflts from ImprovementsIn water supply and sanitationservices are enormous

35

Slide R.T: To request assistance or for moreinformation, contact:

Water and Sanitation for Health Project1611 N. Kent Street, Room 1001Arlington, Virginia 22209-2111 USA

Telephone:FAX:

Sponsored by:

(703) 243-8200(703) 243-9004

U.S. Agency for International DevelopmentBureau for Research and Development/Office ofHealth

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