sanipath presentation_sanitation crisis in accra

The Sanitation Crisis in Accra: The Evidence and Investment Options in Low Income Urban Communities (The SaniPath Rapid Assessment

Tool) August, 26th 2014

National Level Learning Alliance Platform, Accra

The SaniPath Study: Fecal Exposure Pathways in Low-Income Neighborhoods of Accra, Ghana

Global Urbanization

• 2008 – first time in human history number of people living in cities worldwide outnumbered population in rural areas

• 2050 - UN projects 65% of global population will live in cities

• In next 30 years, almost all urban growth will occur in developing countries

• Urban migration in sub-Saharan Africa – 15 million people move to cities each year

SaniPath Background and Rationale

The Sanitation Crisis ~2.5 billion people practice open

defecation or lack adequate sanitation facilities

An additional 2.1 billion urban residents use facilities that do not “safely” dispose of human waste (generously calculated)

Urban populations are growing rapidly, services are not

Development sector has severely underinvested in this growing challenge

Low-income Urban Environments are Complex!

SaniPath Background and Rationale

• Rapid growth outpaced ability of government to provide basic services

• Government may decide not to supply basic services to “illegal” settlements, eg. squatter settlements

• Extremely difficult to retrofit water and sanitation services using traditional approaches – economies of scale, but LITTLE SPACE!

Crowded Blurring Communal Disease population Private/public spaces exposure transmission

Source: Hidden Cities: Unmasking and overcoming health inequities in urban settings. WHO and UN-Habitat, 2010

Child Mortality Varies in Different Low-Income Urban Areas Highest in Sub-Saharan Africa – WHY?

MDGs targeting WASH access have been concerned about rural populations

Source: WHO-UNICEF, 2010

But, is that where there is the greatest risk of disease from inadequate sanitation?

Inadequate Sanitation leads to Multiple Fecal Exposure Pathways

Hands

Drinking Water

Flies Food

Soil

Surface Water Slide courtesy of Dr. Karen Levy

Excreta-Related Infections: 1

Category

Epid

Infection Environ

transmission

Control measures

I. Non-latent; low

infective dose

Enteric viruses and

protozoa

e.g. noroviruses,

hepatitis A and E,

cryptosporidium

Person-to-person Increased water access,

improved personal

hygiene, health

education provision of

toilets

II. Non-latent;

Med-high infective dose

Enteric bacteria

e.g. Vibrio cholera

Person-to-person

Fecal contam of water

and food

Same as above

Feachem et al., 1983


Category

Epid

Infection Environ transmission Control measures

III. Latent & persistent;

no intermediate host

Soil-transmitted

worms (geohelminths)

e.g. Ascaris

Fecal contam of soil, fields

and crops. (Hookworm trans

via soil contact.)

Provision of toilets,

treatment of excreta prior to

land application

IV. Latent & persistent;

animal intermediate host

Tapeworm Depends on animal access to

human feces and humans

eating poorly cooked meat

Provision of toilets,

treatment of excreta prior to

land application, better

cooking and meat inspect.

V. Latent & persistent;

aquatic intermediate

host

Schisto and other

worm infections

Foodborne via raw or

smoked fish, raw water

plants, Contact with water

All of above and control of

animal reservoirs, reducing

water contact and treatment

of excreta prior to discharge


Category

Epid

Infection Environ

transmission

Control

measures

VI. Spread by excreta-

related insects

Filariasis, trachoma,

infections

mechanically

transmitted by flies

and cockroaches

Insects breeding and

contact with fecal

contamination

Eliminate insect

breeding sites

Feachem et al., 1983

Which or How many exposure pathways do you need to cut before you see an impact on

health?

Study Goals

– Identify and describe:

• Sources and movement of human fecal contamination in low-income urban environment

• Behavior of adults and children that leads to exposure to various fecal contamination pathways

– Use new multi-disciplinary tools and approaches to determine which exposure pathways pose the greatest risk –eg. Quantitative microbial risk assessment

– Address the scarcity of data available to sanitation policy makers and implementers

In-depth, multi-disciplinary assessment of exposure to HUMAN fecal contamination in low-income neighborhoods in Accra, Ghana.

SaniPath Study Site: Accra

• Capital of Ghana • Coastal city • Rapid population growth – now about 4 million people • ~60% of pop live in slums and informal settlements • ~28% of pop are below national poverty level

Metro Accra: Critical sanitation issues

Lack of sanitation infrastructure

Open drains of all sizes throughout city

NO functional municipal wastewater treatment plant

Ocean dumping of fecal sludge from latrines

Open defecation on beaches and in drains

Metro Accra: Critical sanitation issues

• Estimated 1.5 million people depend on public latrines

• Open defecation on beaches and in drains

• “Flying toilets” discarded in open drains and on the street

Source: WHO-UNICEF, 2010

Study Area: Four Low-Resource Neighborhoods in Accra, Ghana

Examine wide range of exposures in both

public and private domains and via common vehicles during different seasons in four low-income urban neighborhoods

– Beaches

– Drinking water- piped water, sachet, stored HH water

– Drainage and flooding

– Urban agriculture (wastewater irrigation)

– Primary schools and nurseries

– Public latrines

– Households

SaniPath Methods: Sub-Studies

Behavioral Methods

• Map fecal sources in study neighborhoods

• Assess human behavior associated with risk of exposure to fecal contamination:

Environmental Methods

• Assess fecal contamination in the environment where exposure occurs: – Collect wide range of environmental samples:

marine water, surface water, drinking water, irrigation water, open drains, septage from tanker trucks and public latrines, soil, sand, dust, produce, surface swabs, hand rinses

– Test samples for pathogens (norovirus, adenovirus, helminths) and microbial indicators (E. coli, enterococci, coliphage) of fecal contamination

Sanitation Conditions and Behaviors

Behavioral Methods

• Map fecal sources in study neighborhoods • Assess human behavior associated with risk of exposure to fecal

contamination: – Data collection approaches

– Key informant interviews – Focus group discussions – Structured observations – Surveys

• What types of activities? • Where? • Duration of activities? • Frequency? • Who? Adults? Children?

Behavioral Sample Sizes

Type of behavioral data Number Hours

Child observations (homes) 128 >550

Child observations (nurseries) 25 >125

Beach observations 11 >30

Drain observations 23 >60

Urban agriculture observations 80 N.A.

Public toilet observations 32 >150

Public toilet exit interviews 146 N.A.

Primary school data 27 N.A.

Household survey 800 N.A.

Neighborhood Characteristics (household survey data)

Alajo Bukom Old Fadama Shiabu

% with child under 5 58 55 45 55

% with no formal education 12 13 43 8

% Christian 79 88 38 97

% Muslim 21 8 60 2

% own their home 51 80 64 54

average years of residency 13 27 6 11

average # households in compound 7 5 2 8

% operating business from home 60 68 50 56

% keeping animals in the compound 33 22 14 35

% with sanitation facility in compound 58 6 1 47

% with bathing facility in compound 91 59 3 84

How do feces enter the environment?

Sanitation Facilities in Study Neighborhoods

wide range of types (flush, pit, bucket)

and conditions (safety, privacy, visible

feces, odor, flies)

58% 6% 1% 47%

% of households with private sanitation facility

widespread use of “take-aways” and

public spaces (beaches, dumps)

Public Toilet Conditions & Use (toilet inspections & observations, household survey)

• Variety of types and frequency of use

• Most public toilets have some visible feces; conditions unpredictable – Some pan latrines in Old Fadama among the cleanest – All but Alajo have at least one foul public latrine – Even flush latrines often have some bad odor

• Public latrines in all neighborhoods were well used – Median across all neighborhoods was 90 adult uses / 6 hours) – Busiest were in Bukom (several ~200 adult uses / 6 hours)

• Public latrines in Alajo not used by children

Alajo Bukom Old Fadama Shaibu

mostly flush mostly flush,

a couple unimproved pit mostly pan,

a couple improved pit flush, pit, and improved pit

fewer than 5 stalls mostly 20-30 stalls mostly 10 stalls mostly 10 stalls

55% never use; 30% use every day

65% use every day; 25% use frequently

78% use every day; 22% use frequently

40% never use; 45% use every day

Child Defecation Practices (FGDs, household survey, structured observation)

• Most recent defecation event for children under 5 split evenly between in potties and into diaper/nappies (survey data) – 50% of respondents said feces were put in trash

– 30% of respondents said feces were disposed of at public latrine

– But this was observed very rarely at public latrines (9/3003 adults)

Alajo (N = 11) Bukom (N = 12) Old Fadama (N = 8) Shaibu (N = 13)

most defecate into a bag, potty, or nappy

varied (ground, bag, potty, drain, diaper)

defecate into a bag or on ground

defecate on ground or into potty or nappy

feces mostly disposed of in trash

feces disposed of in drain or in trash

feces mostly disposed of in trash

feces mostly disposed of in drain or in trash

few defecation events followed by handwash



5/13 defecation events followed by handwash

% of respondents living near a drain who say they see children defecate into it daily


4 15 22 9

“Some [child feces] goes in the gutter while others are

disposed of at the beach.”

How are people exposed to feces in the environment?

Exposures in the Home

• Children spent >25% of the time on unpaved ground

• Frequent mouthing of objects & hands

• Handwashing was rare

• >50% of the food children consumed during

structured observations was purchased – 20% of survey respondents operate a food vending business

Exposures Related to Urban Agriculture

• Based on HH survey (few differences by neighborhood):

– 35% of respondents eat raw produce daily

– 51% eat it a few times each week

– 14% never eat it

• Urban agriculture observations confirmed

use of drainwater for irrigation/washing

• Waste-water irrigated produce is sold in

markets all over the city

Exposures Related to Drinking Water

• >70% of households in all neighborhoods rely on sachets as primary drinking water source

• Ironically, highest sachet use in poorest neighborhood

• Remainder primarily rely on piped network for drinking

• In schools and nurseries, piped water is most common for drinking

• Many households (43-74%) also store water due to intermittent supply

• Possibly consumed

Exposures Related to Beaches

• Untreated sewage routinely dumped directly into ocean

– Open drains/canals

– Lavender Hill tipping point

• Variable number of open defecators observed (6-10 am)

– 4 observations with <20 people; 4 with 35-65; 3 with >120

– In Bukom almost entirely adults; in Shiabu more children

• Similar variation in kids observed entering water

– Most kids observed in water submerged their heads

• However, only subset of the population exposed

– From household survey, >2/3 of households never

go to the beach, even in coastal neighborhoods

Shiabu

Bukom

Exposures Related to Drains: Flood Zones


35% of survey respondents reported flooded compound in past year Bukom floods due to drains clogged with trash other neighborhoods due to lack of drainage

Exposures Related to Drains

• Child contact with drains was observed, but to completely describe behaviors would require much larger investment – rare but very high risk events

• Defecation in open drains was not observed but likely occurred at other times (i.e. in the early mornings) • Reported in focus group discussions

• Drains may also be contaminated by take-aways, septic

tanks, bucket-based public toilets, illegal septage dumping

• Flooding regularly moves drainage contamination into homes, business and public soils and vice versa

Where Children (< age 5) Spend Time Households Nurseries

Off ground

Off ground

Unpaved ground Paved

ground

Out of view

Unpaved ground

Paved ground

Out of view

Exposures in Schools

• 30% of students reported drinking school water supply

• Only 1/3 of schools had a handwashing station at the latrine

• Half of schools did not meet the recommended number of students per latrine

• Most schools provide anal cleansing materials

• 20% of students reported eating vendor food on day of classroom survey

• Consistent w/ household survey: aside from Alajo, >25% of respondents said child purchases food at school every day

Exposures in Nurseries

• Half of the children under age 5 in our neighborhoods go to nursery full time

• More hand washing by caregivers in nurseries than in households

• Children were frequently observed putting hands and objects in their mouths

Exposures Related to Vendor Food

• Roughly 30% of household survey respondents reported eating vendor food daily

• 30% of vendors left salads exposed

• 14% of vendors used bare hands when serving

Key Take-Away Points

• Variety of methodological approaches led to rich dataset, allows triangulation (especially important for sensitive / rare behaviors)

• Linked behavioral data collection and environmental sampling

• Qualitative phase informed overall sampling strategy

• Specific sample collection determined by concurrent observations

Environmental Sampling and Testing

Methods used for environmental sample collection

• Internationally-accepted standard operating protocols were employed for most of the samples collected – AWWA-APHA, and other peer-reviewed protocols

• We developed new protocols and modified some internationally-accepted protocols to suit our purposes making sure the principle of sterility was upheld at all times and cross contamination was avoided – – New protocol developed for collection of sediment from open

drains, modified soil collection protocol for households and public domains, and septage

Sample collection sites in Alajo

Sample collection sites in Bukom

Sample collection sites in Old Fadama

Sample collection sites in Shaibu

Flood areas: - Water - Soil

Food providers: - Produce at markets - Prepared salads from vendors - Flies

Public play areas: - Soil

Urban farms: - Soil - Irrigation water - Produce

Public water: - Sand - Ocean water

Drains: - Water - Sediment - Flies

Public latrines: - Soil - Swabs - Sewage - Hand rinses - Flies

Nurseries and primary schools: - Soil - Drinking water - Swabs - Hand rinses - Drinking water

- Source - Stored

Households: - Soil - Drinking water

- Source - Stored

- Swabs - Hand rinses - Child food - Flies

Environmental Sampling to Lab Analysis

Data Collection Activities

Soil Flies


Handrinse (School) Surfaces (Public latrine wall)


Drains Septage

Numbers of Environmental Samples Type of sample Number

Particulate (soil and sand) 319

Small volume drinking (stored and sachet) 127

Small volume environmental (drains) 91

Large volume drinking water (schools, nursery and HH’s) 117

Large volume ocean water 38

Swabs (HHs, nurseries schools and public latrines) 273

Handrinse (HHs, nurseries, schools and public latrines) 287

Food (HHs, nurseries, schools, and market) 249

Flies 61

Septage (public latrines) 40

Urban Agriculture 261

Total 1863

Using E. coli and human enteric viruses as indicators of faecal contamination in the urban environment

Environmental Samples Tested For E. coli and Viruses

Type of sample Number

Particulate (soil and sand) 376

Small volume drinking (household (HH) stored and sachet) 127

Small volume environmental (drains, floods, irrigation) 197

Large volume drinking water (piped municipal) 120

Large volume ocean water 38

Swabs (HHs, nurseries schools and public latrines) 273

Food (HHs, nurseries, schools, farm and market) 336

Septage (public latrines) 40

Total 1507

Additional handrinse and flies samples NOT tested for norovirus and adenovirus

Results

0.1

.2.3

.4

De

nsity

0 2 4 6 8log E. coli CFU/100 mL or 100 g

Ocean Water (38) Sand (38)

Gaussian kernel with STATA optimal width

Beachesby Sample Type

• E. coli concentrations in sand and water are very high. • As expected, E. coli accumulate to higher

concentrations in sand compared to water • Adenovirus concentration in sand was high • Norovirus concentration in both ocean water and sand

was high

Beaches: Water and Sand

Drain: Sediment and Water

E. coli concentrations in sediment and water from open drains are VERY high (similar to raw septage). Drains as contaminated as raw Sewage

0.5

11.5

De

nsity

2 4 6 8 10 12log E. coli CFU/100 mL or 100 g

Drain Water (91) Sediment (57)


Open Drainsby Sample Type

Latrines: Septage, Particulate, Handrinse, Swabs

• Septage has the highest concentration of E. coli. • Soil samples also show mod-high fecal

contamination of E.coli and Adenovirus. • Swabs indicate that surfaces have variable levels of

fecal contamination. Objects swabbed: handles (of doors and anal cleansing

containers), latrine walls, latrine floors, others

0.1

.2.3

.4

De

nsi

ty

-5 0 5 10 15log E. coli CFU/ gram, pair of hands, or swab

Septage (40) Particulate (16)

Handrinse (81) Swabs (68)


Public Latrinesby Sample Type

Flood: Sediment and Water

0.1

.2.3

.4

De

nsi

ty

0 5 10 15log E. coli CFU/100 mL or 100 g

Flood Water (19) Sediment (23)


Flood Environmentby Sample Type

Flood: Sediment and Water

• Norovirus detection was low in Flood water but relatively high in sediment samples

• Flood water is more contaminated with adenoviruses than sediment.

Drinking Water: Piped, Sachet, Stored

• Piped water did not meet WHO standards for residual chlorine

• Many stored water samples did not meet microbial standards

• Sachet water had variable levels of contamination, but the majority of samples were clean

0.2

.4.6

De

nsi

ty

0 1 2 3 4 5log E. coli CFU/100 mL

Piped (120) Sachet (61)

Stored (64)


Drinking Waterby Type

Household: Particulate, Water (piped, sachet, stored), Handrinse, Swabs

• Floors/dirt in households were highly contaminated.

0.2

.4.6

De

nsi

ty

0 2 4 6 8log E. coli CFU/100 mL, 100 g, swab, or pair of hands

Piped Water (86) Sachet Water (46)

Stored Water (35) Soil (63)

Swab (124) Handrinse (92)


Household Domainby Sample Type

Fecal Contamination on Hands 0

.1.2

.3

Den

sity

-2 0 2 4 6 8log E. coli CFU/pair of hands

Adult (123) Children 5-12yrs (64)

Children under 5yrs (100)


Handrinsesby Age

0.1

.2.3

.4

Den

sity

-2 0 2 4 6 8log CFU/pair of hands

E. coli (287) Enterococci (287)


Handrinsesby Organism

0.1

.2.3

.4

Den

sity

-2 0 2 4 6 8log E. coli CFU/pair of hands

Household (92) Public Latrine (81)

School (60) Nursery (54)


Handrinsesby Domain

• Greater contamination on adult hands than children’s hands? • More adult samples collected at public latrines

• Greater contamination on hands at public latrines • Enterococci is more persistent than E. coli on

hands. • May be better indicator of fecal contamination

Urban Agriculture: Soil, Produce, Irrigation water

• High levels of E. coli contamination measured in irrigation water samples

• Soil and produce also contaminated

0.1

.2.3

.4

De

nsi

ty

0 2 4 6 8log E. coli CFU/100 mL, 100 g, or piece of produce

Soil (87) Produce (87)

Irrigation Water (87)


Urban Agricultureby Sample Type

Urban Agriculture: Irrigation water

High levels of Adenovirus and Norovirus contamination measured in irrigation water samples

Study Phase Results Comparison

Risk Assessment Results

1

10

100

1000

10000

100000

0 10 20 30 40 50 60

Do

se (

CFU

/eve

nt)

Frequency (events/month)

Bukom

Drain Water

Latrines

Ocean Water

Piped Water

Produce

1

10

100

1000

10000

100000

0 10 20 30 40 50 60

Do

se (

CFU

/eve

nt)

Frequency (events/month)

Shiabu

Drain Water

Latrines

Ocean Water

Piped Water

Produce

Key Points

• Widespread detection of high concentrations of E. coli in different compartments of this environment

• Detection of adenovirus and norovirus confirm presence of human fecal contamination in the environment

– Detection and concentration of adenovirus and norovirus are likely an underestimate of the true occurrence and magnitude of human fecal contamination

– Need for improved methods to concentrate, recover and quantify human enteric viruses in environmental samples

Summary This study has generated the first quantified evidence of environmental fecal contamination in dense, low-income communities of Accra: •Beaches (both water and sand) are very contaminated •Open drains are ubiquitous in these neighborhoods and are highly contaminated. Some exposure to children observed. •Frequent flooding causes exposure to contaminated water and soil. •Soil around schools and public toilets is very contaminated •Produce, which is often eaten raw, is very contaminated and moves throughout the city. •Public tap water and sachet water is safer than expected, although residual chlorine was lower than recommended •Children observed to frequently mouthing objects in a highly contaminated environment •Handwashing was rarely observed and most hands had fecal contamination

Preventing exposure to fecal contamination will require a combination of infrastructure improvements, better WASH services and management, and behavior change.

Ho

use

ho

ld

Which Pathways Poses the Greatest Risk?? How should governments and NGOs prioritize sanitation investments?

Lavender Hill Open Drains Soil and Sand Solid Waste

Surface Water and Sand

Irrigation Water Flood Waters

Public Latrines HH Latrines Open Defecation Source Fa

te

Humans

Sanitation Intervention

Sanitation Intervention

Drinking Water Produce Surfaces

Downstream Intervention

Downstream Intervention

Extra slides

Schools: Particulate, Sachet, Handrinse, Piped, Stored, Swaps

• Surface swabs from desks, eating utensils, etc. showed a wide range of contamination levels

• Soil samples were highly contaminated

0.1

.2.3

.4

De

nsity

0 2 4 6 8log E. coli CFU/100 mL, 100 g, swab, or pair of hands





School Domainby Sample Type

Nursery: Particulate, Sachet, Handrinse, Piped, Stored, Swaps

• Surfaces in nurseries (toys, cups, furniture) show variable but high levels of contamination.

• Soil samples had very high levels of contamination.

0.1

.2.3

.4.5

De

nsity

0 2 4 6 8log E. coli CFU/100 mL, 100 g, or swab





Nursery Domainby Sample Type

sanipath presentation_sanitation crisis in accra

Documents

urban growth

urban populations

sanitation services

urban residents

urban settings

person fecal contam

sanitation crisis

inadequate sanitation