1. Water.org

2. Water and Public Health Pathogens and waterborne disease 2 million deaths annually due to unsafe water, sanitation and hygiene 4% of the global disease burden could be prevented by improving water supply, sanitation, and hygiene – WHO 2013

3. http://www.smashinglists.com/10-leading-causes-of-mortality-worldwide/

4. Prüss-Üstün et al., 2008

6. Burden of Diarrheal Diease Diarrheal burden – 90% of deaths are in children <5 – 80% of deaths in children <2 1 in 200 children die from diarrhea worldwide 88% of diarrheal disease due to unsafe water, inadequate sanitation and hygiene – Significant improvement in morbidity and mortality can be achieved thru sanitation and minimal water treatment – 95% of diarrheal deaths in children <5 could be prevented with sanitation upgrades and provision of safe water supply WHO 2004; Green et al. 2009

8. Fecal-Oral Transmission Enteric Origin Bacteria Viruses Helminths Protozoa

9. Some Water Related Diseases Campylobacteriosis Salmonellosis Shigellosis Leptospirosis Typhoid fever Cholera Rotavirus Norovirus Hepatitis A Ascaris Ringworm

10. ‘F-Diagram’ Enteric Disease Transmission

11. Barriers to Transmission Improved Sanitation

13. 2.5 billion people still lacked access to improved sanitation facilities in 2011 (WHO, 2013)

14. Green et al. 2009

15. Barriers to Transmission Improved Hygiene / Access

16. 768 million people still relied on unimproved drinking water sources in 2011 (WHO, 2013)

17. Disinfection (~1905)

18. Efforts in Sanitation and Hygiene may need to be increased to ameliorate higher risk of enteric disease with climate change IPCC 2007. Working Group II

19. Water.org More than 3.4 million people die each year from water, sanitation, and hygiene-related causes. Lack of access to clean water and sanitation kills children at a rate equivalent of a jumbo jet crashing every four hours. Of the 60 million people added to the world's towns and cities every year, most move to informal settlements (i.e. slums) with no sanitation facilities. 9 780 million people lack access to an improved water source; approximately one in nine people. 14 "[The water and sanitation] crisis claims more lives through disease than any war claims through guns." 11 An American taking a five-minute shower uses more water than the average person in a developing country slum uses for an entire day. 11 Over 2.5X more people lack water than live in the United States. 3 More people have a mobile phone than a toilet. 5

20. Cholera Sanitation, Hygiene, Environment, Climate

21. Cholera Derived from Greek word referring to rain rushing from a gutter – Causes profuse watery diarrhea Known since Hippocrates First epidemic described in 1563 in India 7 seven known pandemics – 7th began in 1961 icddr,b

22. 1858 - London

23. Historical Perspective Cholera linked to water source – John Snow – London 1854 cholera outbreak – 500 fatal cases, 10 days – Linked to Broad St. pump First link to water Causative agent identified – Robert Koch – 1883 isolated bacterium – Vibrio cholerae (comma)

24. http://www.sewerhistory.org/images/bm/bms9/1899_bms902.gif Sanitation Improvements and Cholera, 1800s

25. 2011, 58 countries from all continents reported cases (589,854 - vastly underestimates true burden) Case burden has shifted to the Americas (Haiti, Dominican Republic) Globally, cholera incidence has increased since 2004

26. Vibrio cholerae Infection via – Water – Shellfish (crabs and bivalves) – Person-to-person Only Vibrio that can grow in fresh waters (optimal growth at low salinities) – Vibrio are most commonly cultured bacterial genus from marine waters Since 1978, known to occur in warm estuarine waters world-wide Disease of sanitation AND the environment

27. Seventh Cholera Pandemic 2010 Environment and climate

28. Vibrio cholerae >200 serotypes –O1 in pandemics (El Tor & Classical) –O139 new toxigenic strain Cholera toxin (CTX) –Phage encoded –Acts in intestines to produce profuse diarrhea

29. Cholera Transmission Dynamics

30. Vibrio & V. cholerae are strongly temperature associated. Very rapid doubling times as temperatures rise.

31. Vibrio cholerae in the Environment Up to 10 4 cells/copepod

32. PROBLEM Prevention of Cholera Transmission

33. 0.2 – 0.8 µm

34. Prevention of Cholera Transmission

37. Colwell et al. 2003