FSM2

30 October 2012

PIT EMPTYING AND PUBLIC HEALTH

Bobbie Louton Partners in Development

CAN TOILETS REALLY SAVE THE WORLD?

Or:

what has

brought us all

here together?

DIGNITY

PREVENTABLE DEATH

Diarrhoeal diseases

• 88% diarrhoael deaths worldwide from unsafe water, inadequate sanitation and poor hygiene

• 2nd killer of children under 5 globally (> than AIDS + malaria + measles) • Responsible for 11.0% of under 5 deaths in SA

• Persistent diarrhoea associated with an 11-fold

increase in mortality for children with HIV

EXTRA BAGGAGE

… at a price

Local helminthic infections

Study Ascaris lumbricoides

Trichuris trichiura

KZN health facilities (5 733 samples, Kwitshana et al, 2008)

11% 7%

Children in Durban slum (996 subjects, Appleton et al, 2008)

89% 71%

Improved sanitation (UD) in eThekwini (120 UD toilets, Trönnberg et al 2010)

59% 48%

Ascaris lumbricoides

(roundworm)

Ascaris lumbricoides

• often asymptomatic

• Ascariasis: nutritional deficiencies, blockages by masses of worms

• eggs extremely resistant to treatment processes – useful as marker

• eggs bond to particles of soil and are not easily washed away; attach strongly to surfaces.

Trichuris trichiura

(whipworm)

Trichuris trichiura

• + 1 billion people infected worldwide • prevalence may be as high as 95% among

children in some parts of the world • Light infections are often asymptomic • Heavy infections may result in Trichuris Dysentery

Syndrome (chronic dysentery, rectal prolapse, anaemia, poor growth)

• Children with heavy infections can become severely anaemic and growth-retarded developmental and cognitive deficits

Taenia

species (tapeworm)

Taenia solium • Burden of disease is possibly twice as high in Eastern Cape

than other parts of South Africa (Mafojane et al, 2003).

• A 2004 study found the burden of disease for the Eastern Cape alone to be between USD 18-34 million per annum; epilepsy accounted for the largest overall impact (Carabin et al, 2006).

• The free ranging of pigs, poor sanitation and lack of knowledge among the public about modes of transmission combine to make disease reduction a challenge

• Seventy-six percent of respondents in one study reported having seen cysts in the pork that they ate; only 80% knew what the cysts were (Carabin et al, 2006).

Nearly 1 in 4 of the world’s population still defecates in the open

The answer: TOILETS WILL SAVE LIVES!!

INTERVENTION:

Improve sanitation: put a safe distance

between us and our faeces

break the faecal-oral transmission

of disease

YES, BUT ….

Reducing disease doesn’t begin and end with the provision of a toilet

Improved sanitation is often onsite

Onsite systems get full

When systems get full they have to be emptied

When they get emptied things get

messy

When things get messy the gains of

improved sanitation may be

reversed (or worse)

THE HEIGHT AND BREADTH AND DEPTH OF THE PROBLEM

Awareness of sludge as hazardous material is not adequately reflected in policy and practice

“public works” approach rather than

“biohazard” approach

Awareness of risks to householders during servicing of onsite sanitation is inadequate

Improved sanitation for health benefits

ends with provision of a toilet

• Sludge remains highly pathogenic even after years in the pit

• There is no guarantee that helminth eggs will deactivate in sludge over

time

• Large numbers of Ascaris lumbricoides, Trichuris trichiura and Taenia solium have been recovered from the face masks of pit emptiers

• Viable ova left on hands of waste handler: Mean- 90; Max-2 300

• 100% risk of helminth infection for workers -- use of multiple barriers (gloves, hand washing with soap) reduces risk, does not eliminate it

• Bucket washers -- both their PPE gloves and their hands heavily contaminated. Bacterial counts from the hands of some workers upon reporting for work in the morning showed high levels of contamination not originating from their jobs

Sanitation workers have higher exposure to the pathogens found in sludge than the general public and may be at greater risk for infection.

Or are they?

Pit / septic tank emptiers may be at the greatest risk (raw sludge and on-site work conditions).

ALL SLUDGES ARE NOT EQUAL

Holding the tension between the good, the bad and the ugly

Sludge is … a “hazardous resource”

ROUTES OF EXPOSURE

• Inhalation

• Ingestion

• Contact with skin/membranes/wounds

• Injection

SITUATION

Splashes

Inhaling dust or aerosols

Eating and smoking

Contaminated protective gear

Transport of sludge and equipment

Care of tools and equipment

PROTOCOLS SHOULD ADDRESS:

• Donning/removing contaminated protective gear

• Situations where equipment cannot be coupled/decoupled while wearing gloves

• Accidents where hands, face or clothing come into direct contact with sludge

• Safe transport and cleaning of clothing, boots, bins, tools and equipment in order to prevent contamination of walkways and vehicles and to prevent workers from carrying pathogens home on their clothing

• Provision of immunizations and 6 monthly deworming treatments for all workers

It is equally important that pit emptiers be trained to protect the household environment of the families whose pits they empty

• During servicing of UD toilets:

• sludge was left exposed at the site in 72% cases • Viable ova left on the ground around emptying site Mean: 8 500 Max: 184 000

• None of the households marked the burial area • (84% of cases in close proximity to human activity)

• Only 12% left the area alone

Other sources of contamination?

Households with unimproved pit latrines in Tanzania: • Floors of homes were more highly

contaminated than the floors of latrines. • Surfaces in and around home -- soil, floors,

walls, cups and vegetables -- widely contaminated with faecal pathogens.

SITUATIONS

Spilling, spraying household surfaces

Dust

Washing contaminated equipment/hands at household tap

Using household tools

Tracking sludge on boots

The level of exposure to pathogens during sanitation work is related to a number of different factors

Policy and enforcement

Knowledge and attitudes

Procedures and protocols

Safety doesn’t begin and end with PPE

Interventions require resources

and must therefore be strategic

in order to be feasible

Oblivious

Aware

Willing

Implementing

BARRIERS TO BARRIERS

• Lack of resources

• Lack of education/awareness

• Desensitizaton

• “Public works” mentality

• Lack of policy

• Lack of procedure/protocol

• Lack of monitoring/supervision/enforcement

FURTHER INVESTIGATIONS

POLICY REVIEW

ATTITUDES, BELIEFS,BEHAVIOURS

INTERVIEWS AND OBSERVATIONS

VIABILITY OF PATHOGENS

EFFICACY OF DISINFECTANTS

GAPS AND RELATIONSHIPS

Thanks to

Nicola Rodda, UKZN

Colleen Archer, PRG, UKZN

eThekwini Municipality

Steven Sugden, Water for people

for photos and resources

REFERENCES

Appleton, CC and Gouws, E (1996). The distribution of common intestinal nematodes along an altitudinal transect in Kwazulu-Natal, South Africa. Liverpool School of Tropical Medicine. Buckley CA, Foxon KM, Hawksworth HJ, Archer C, Pillay S, Appleton C, Smith M and Rodda N (2008a). Prevalence and die-off of Ascaris ova in urine diversion waste. WRC TT 356/08, Pretoria. Carabin, H, Krecek, RC, Cowan, LD, Michael, L, Foyaca-Sibat, H, Nash, T and Willingham, AL (2006) Tropical Medicine & International Health, 11(6): 906–916. Jia T-W, Melville S, Utzinger J, King CH, Zhou X-N (2012) Soil-Transmitted Helminth Reinfection after Drug Treatment: A Systematic Review and MetaAnalysis. PLoS Negl Trop Dis 6(5): e1621. doi:10.1371/journal.pntd.0001621 Kwitshana, ZL, Tsoka, JM and Mabaso, MLH (2008). Intestinal parasitic infections in adult patients in KwaZuluNatal. SAMJ: 98:9. Lehola, P. 2007. Community Survey, 2007 (Revised Version). Report No. P0301, Statistics South Africa, Pretoria, South Africa M. Mnguni, S. Ndlovu, B. Pfaff, T. Gounden, N. Rodda and C. Buckley (2008). Health risk assessment of the operation and maintenance of a urine diversion toilet. Proceedings of the Biennial Conference of the Water Institute of Southern Africa, 18-22 May, Sun City, South Africa. Lourens E, Potgieter E, Bruwer M, Venter W, Du Bruyn JL, Stephen EM & Du Toit A (2002). Bacterial counts from hands and personal protective equipment of sewage workers. Presented at the National Conference – Environmental Health, 18-20 November 2002, Durban South Africa. Mafojane, NA, Appleton, CC, Krecek, RC, Michael, LM, Willingham III, AL (2003) The current status of neurocysticercosis in Eastern and Southern Africa. Acta Tropica 87:25-33.

Mayo Clinic (2012). www.mayoclinic.com, accessed 29 October.

Pickering, A, K, Julian, Marks, S, Mattioli, M, Boehm, A, Schwab, T, Davis, J. Fecal Contamination and Diarrheal Pathogens on Surfaces and in Soils among Tanzanian Households with and without Improved Sanitation. Environmental Science and Technology.

PUB, 2012. Singapore’s National Water Agency http://www.pub.gov.sg/dtss/Pages/default.aspx Accessed 19 September 2012.

Stephenson LS, Holland CV, Cooper ES (2000). The public health significance of Trichuris trichiura Parasitology. 2000;121 Suppl:S73-95.

Still D, Louton B, Bakare B, Taylor C Foxon K, Lorentz (2012). Investigating the potential of deep row entrenchment of pit latrine and waste water sludges for forestry and land rehabilitation purposes. Report to the Water Research Commission Project K5/1829.

Trönnberg, L, Hawsworth, D, Hansen, A, Archer, C and Stenström, T (2010). Household-based prevalence of helminths and parasitic protozoa in rural KwaZulu-Natal, South Africa, assessed from faecal vault sampling. Transactions of the Royal Society of Tropical medicine and Hygiene, 104: 646-652.

United Nations Children’s Fund (UNICEF)/World Health Organization (WHO) (2009): Diarrhoea: Why children are still dying and what can be done.

World Health Organization/United Nations Children’s Fund, Progress on Drinking Water and Sanitation: Special focus on sanitation, UNICEF, New York, 2008