Minsk 5-6 April 2011

Enzo Funari. Italian Higher Institute of Health

Inspired by a WHO public health initiative in Asia, organized by the WHO Collaborating Centre for Health-promoting Water Management and Risk Assessment at the University of Bonn, Germany.Multilateral co-operation programme between the WHO Regional Office and the central Asian countries. Later on, further developed by this TF.

Holistic approach;The document reviews the main threats to health related to water services, recalls basic concepts of epidemiology and disease surveillance, and provides guidance on data management and analysis.It is in line with the International Health Regulations (2005) which entered into force on 15 June 2007. A sort of synthesis of scientific knowledge in the area (basis) but then practical tools to face the possible problems in the area.

Aimed specifically at the needs of local laboratories in central Asian countries;Also aimed at strengthening cross sectoral activities (water, environment managers and health sector workers).In conclusion, the Guidance document is aimed at supporting national efforts towards national and international health security

Editors:Enzo Funari, chair of Task Force on Water-related Disease Surveillance Thomas Kistemann, Institute for Hygiene, Rheinische Friedrich Wilhelms Universitat, Bonn, GermanyDr Suzanne Herbst, Executive Director, WHO Collaborating Centre for Health Promoting Water Management and Risk Communication R Aertgeerts, WHO Regional Office for Europe

Main contributors:Akgaev, D (Turkmenistan); Blasi, M (Italy); Classen, T (Germany); Cronin, A A (UK); Dangendorf , F (Germany) ; Davlyatov, S K (Tajikistan); Exner, M (Germany); Funari, E (Italy); Herbst, S (Germany); Kadar, M (Hungary); Kaitbaev, N (Tajikistan); Kistemann, T (Germany); Loock, A (Germany); Ishankuliev, Y (Turkmenistan); Mishina, O (Uzbekistan); Moe, C (USA); Pond, K (UK); Queste, A A (Germany); Schoenen, D (Germany); Sharipova, N V (Uzbekistan); Wienand, I (Germany); Vashneva, N (Kyrgyzstan)

2. HEALTH RISKS FROM MICROBIAL PATHOGENS3. HEALTH RISKS FROM CHEMICALS4 HEALTH RISKS IN THE WATER SYSTEM5. ESSENTIAL EPIDEMIOLOGY6. ESSENTIAL SURVEILLANCE. 7. DATA MANAGEMENT AND ANALYSIS USING GEOGRAPHICAL INFORMATION SYSTEM

The publication is available at http://www.unece.org/env/documents/2010/wat/MP_WH/wh/ece_mp_wh_2010_L3_E.pdf157 pages, 18 tables, 22 figures

Short guidance for the organization or improvement of health systems, with particular attention to water-related diseases (WRDs). Where safe access to water is not ensured, political authorities should be aware of the consequences, not limited to the disease (sustainable development is hampered and economic costs are prohibitive).

Roger Aertgeerts, WHO Regional Office for EuropeEnzo Funari, ItalyNana Gabriadze, GeorgiaPaul Hunter, United Kingdom of Great Britain and Northern IrelandFrantisek Kozisek, Czech RepublicArben Luzati, AlbaniaAida Petikyan, ArmeniaAndrea Rechenburg, Germany

I. The problem (Introduction) II. Water safety plans III. Legal obligations with regard to disease surveillanceIV. Surveillance system for water-related diseasesV. How to set up an essential surveillance system for water-related diseases (OMT)VI. How a water-related disease surveillance system should work in practiceVII. How to evaluate a surveillance system for water-related diseasesVIII. National examples

EUR B+CEUR-AFigure 12 SDR diarrhoeal disease below 5 y of age (Source: WHO Health for All)While mortality data are surely the most striking, morbidity figures show that water-related diseases continues to be a serious problem in the European region, are hampering sustainable development and imposing prohibitive economic costs.

Examples where the system failed included an outbreak of giardiasis in Hordaland (Bergen) in 2004 2005 where the surveillance system proved to be late in detecting outbreaks.

WSPs: management multi step approach aimed at ensuring safe access to water. WSPs should be developed for each individual drinking-water system, whether large- or small-scale.Beyond drinking water

Raw waters should be protected against pollution in the catchment areaSurface and shallow waters must always be treated before being used as a source of drinking-water; the higher the level of contamination of raw water, the greater the efficiency of the water treatment process required;

Drinking-water: subject to surveillance for the main risk factors (special attention to microbial quality) Adequate education and training for the personnel

Figure 81 Sources of failures in the WSP approach

Surveillance systems implemented in several countries in the EURO Region but often do not include specific surveillance for WRDs.

Specific WRDs surveillance systems would provide relevant added value, as they can:identify the diseases transmitted by waterdefine/estimate the burden of WRDs;use data and information to identify communities where there are problems with water related diseases;

Mapping of pollution hazards and identifying risks;promote intervention measures to control and prevent WRDs;target resources towards areas with priority needs; assess the effectiveness of the implemented water and sanitation interventions in reducing diseases.

In countries with limited resources:High incidence of typhoid fever need for targeted vaccine campaigns;epidemic and endemic giardiasis and cryptosporidiosis need for water filtration (chlorination is not very effective against these pathogens) need of household water treatment of water in high-risk areas;outbreaks in adequately treated piped water supplies ( intrusion problems in the water distribution system) need to keep water pressure stable or accept additional measures like booster chlorination high prevalence of helminth infections need for improvements in sanitation and increased water availability for general hygiene;High incidence of blue-baby syndrome need to control and reduce nitrate concentrations in drinking water.

Public health surveillance systems represent the ongoing and systematic collection, analysis and interpretation of health data to describe and monitor a health event.The surveillance of WRDs should be included within the context of more general surveillance systems for communicable diseases.

A specific surveillance system for waterborne disease outbreaks should include a method for evaluating the evidence that an outbreak is indeed attributable to contaminated water.

WRDs: Priority diseases (characterised by a high epidemic potential): cholera, diseases caused by enterohaemorrhagic E. coli, viral hepatitis A, bacillary dysentery and typhoid fever. Emerging diseases (showing a rapid increase in the affected population, or are being observed in countries where they were previously absent): campylobacteriosis, cryptosporidiosis, giardiasis, and legionellosis.

Local diseases (diseases that are not present throughout the country concerned but may potentially have a severe local impact) : methemoglobinaemia, arsenicosis, viral infections (particularly those attributable to Norovirus) and parasitic diseases.

Local level An outbreak management team (OMT) should be set up at the local health unit.

OMT composition: representatives of waterworks and sanitation system, water department of the regional environmental agency, expert in hygiene and environmental medicine.

In case of a WRD outbreak, the local OMT should:Review the evidence for an outbreakIdentify the population at riskDecide on control measuresProvide quick and adequate information to the publicMake arrangements for the commitment of personnel and resourcesHealth surveillance data should be linked with data on the quality and distribution of water supplies in the same area.

Regional level An OMT with similar features should be established at regional level, with the following tasks after WRD outbreaks:Prepare a notification to be sent to the national agenciesPrepare a report to be sent to the regional authorities responsible for management measuresPromote further epidemiological and environmental studies, as necessary;Provide adequate information to the public; andProvide feedback on surveillance results and analyses to the local OMT in order to sustain the interest and co-operation of the data collectors and data providers

National levelWith representatives from the sectors of health, environment, waterworks and sanitation, and agriculture (including animal husbandry and aquaculture).

TasksDraft the notifications on WRDs and provide information to the public;Map the WRDs on a national scale (possibly using geographic information systems);Identify most critical areas / situations;Assess the burden of WRDs;Transmit the information on WRDs at the international level;Provide training and educational initiatives;Promote specific surveys;Provide feedback on surveillance results and analyses to the regional OMT in order to sustain interest and cooperation;Assess the functionality of the whole surveillance systems;Prepare a report to be sent to the national authorities responsible for management measures; andCoordinate activities in the case of transboundary waterbodies.

Preparedness First and foremost, the local OMT should be well-prepared to (i) detect water-related outbreaks; and (ii) react adequately if a water-related outbreak occurs. In setting up a surveillance system, it is crucial to take into account the local situation and focus on critical areas / situations

Response Trigger event: outbreak detection and confirmationAcute reaction: outbreak declaration, quick and preliminary descriptive hazard investigation, initial and immediate control measuresAnalysis: in-depth analytical hazard investigation, continuous re-evaluation of control measuresNormalization: conclusion of outbreak and declaration of normalizationEnd: evaluation, formal report, lessons learned for the future

The experience of Croatia, Germany, Hungary, Norway and Slovak Republic in the water quality monitoring and disease outbreak detection

The publication is available at http://www.unece.org/env/documents/2010/wat/MP_WH/wh/ece_mp_wh_2010_L2_E.pdf22 pages, 2 figures