1 Food Security and Nutrition Network Regional Knowledge Sharing Meeting Washington, DC November 15, 2012 WASH and Health and Nutrition Chris Seremet, PE Technical Advisor – Water Supply and Sanitation Catholic Relief Services Baltimore, MD

Food For Peace Goal To minimize hunger in the world so that people everywhere can enjoy active and productive lives and, ultimately, to ensure that one day no one needs food aid 2

However, there are barriers to realizing healthy, productive lives……. 3

Diarrhea 2.2 million deaths each year –1.6 million preventable child deaths per year 73 million DALYs lost per year 80% of cases of diarrhea worldwide are attributable to the ingestion of pathogens, especially in unsafe drinking water, in contaminated food or from unclean hands. Cholera, typhoid and dysentery 4

Neglected Tropical Diseases Soil-transmitted Helminths (Ascariasis, Trichuriasis and Hookworm) –2 billion infections—affecting one third of the world’s population—that could be prevented –4 million DALYs lost per year –Affects 400 million school-aged children per year –Transmission of intestinal parasitic worm infections occurs through soil contaminated with feces. –Entirely preventable by adequate sanitation, and intervention outcomes are reinforced by good hygiene. 5

Neglected Tropical Diseases Schistosomiasis –200 million people with preventable infections –1.7 million DALYs lost per year –Caused by contact with water bodies contaminated with the excreta of infected people 6

Malnutrition 860,000 preventable child deaths per year 17 million DALYs lost per year Childhood underweight causes about 35% of all deaths of children <5 years worldwide. An estimated 50% of this underweight or malnutrition is associated with repeated diarrhea or intestinal parasite infections –a result of unsafe water, inadequate sanitation or insufficient hygiene. 7

Tropical Enteropathy Changing the structure and function of the small intestine leads to undernutrition Reduced surface area of small intestine - decreased villous height - ‘flat architecture’ –Lowers nutrient absorption ‘Leaky gut’ (increased permeability of the intestinal tract) and impaired ability to prevent pathogens from breaching the intestinal barrier –Elevated immune response –Nutrients diverted from growth to defense 8

Tropical Enteropathy Thought to be caused by chronic ingestion of pathogenic microorganisms. Linked to living conditions with poor sanitation and hygiene practices. Likely to be prevalent in developing countries. 9

Fecal – Child Undernutrition Pathway 10 Source: Humphrey (2009)

Evidence is Lacking Many studies, many methodological issues Limited evidence –Suggests that nutrition interventions can substantially reduce or even eliminate the negative effect of diarrheal disease on child growth. –Can’t conclude that high rates of infection make nutrition interventions ineffective for improving child growth. Likely a combination of improved nutrition and infection prevention and control efforts 11

Evidence is Lacking Most studies agree with WASH interventions Randomized controlled trials of toilet provision and handwashing promotion that include tropical enteropathy and child growth as outcomes 12

The F-Diagram 13 Source: UNICEF

Nutrition and infection prevention and control interventions Hygiene Behavior Change –Handwashing with soap at key times –PHAST / CLTS Sanitation –Latrines – household and at the fields –Improve drainage around muddy areas Water –Drinking Water Supply from a protected source Drinking water system at same time as irrigation system The potential health gains are reduced sharply with even occasional consumption of untreated drinking water –POU Treatment and Storage 14

FFP Standard WASH Indicators Percentage of households using an improved drinking water source Percentage of households with access to an improved sanitation facility Percentage of households with children aged 0– 23 months that have water and soap or locally available cleansing agent at a hand washing place 15

Improved Drinking Water Source An improved water source is an infrastructure improvement to a water source, a distribution system, or a delivery point. By nature of its design and construction, the improvement is likely to protect the water source from external contamination, in particular fecal matter. Improved drinking water sources are: –Piped water into dwelling, plot, or yard –Public tap/standpipe –Tube well/borehole –Protected dug well –Protected spring –Rainwater collection 16

Improved Sanitation Facility A sanitary facility in the household and whether that sanitary facility meets the improved sanitation standards defined in the Millennium Development Goals (MDGs). Improved sanitation is defined as: –Flush or pour/flush facilities connected to a: Piped sewer system Septic system Pit latrine –Pit latrines with a slab –Composting toilets –Ventilated improved pit latrines 17

Improved hygiene practices At households with children aged 0–23 months: –Presence of a hand washing station –Presence of water in hand washing station –Presence of soap or other cleansing agent at hand washing station 18

Thank You Chris Seremet Technical Advisor – Water Supply and Sanitation Catholic Relief Services Website for CRS publications:

Fecal – Child Undernutrition Pathway 20