Sanipath Presentation_Sanitation Crisis in Accra
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Transcript of 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
Excreta-Related Infections: 2
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
Excreta-Related Infections: 3
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
few defecation events followed by handwash
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
Alajo Bukom Old Fadama Shaibu
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
Alajo Bukom Old Fadama Shaibu
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
Data Collection Activities
Handrinse (School) Surfaces (Public latrine wall)
Data Collection Activities
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)
Gaussian kernel with STATA optimal width
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)
Gaussian kernel with STATA optimal width
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)
Gaussian kernel with STATA optimal width
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)
Gaussian kernel with STATA optimal width
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)
Gaussian kernel with STATA optimal width
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)
Gaussian kernel with STATA optimal width
Handrinsesby Age
0.1
.2.3
.4
Den
sity
-2 0 2 4 6 8log CFU/pair of hands
E. coli (287) Enterococci (287)
Gaussian kernel with STATA optimal width
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)
Gaussian kernel with STATA optimal width
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)
Gaussian kernel with STATA optimal width
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
Piped Water (17) Sachet Water (10)
Stored Water (15) Soil (11)
Swab (42) Handrinse (60)
Gaussian kernel with STATA optimal width
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
Piped Water (16) Sachet Water (5)
Stored Water (16) Soil (9)
Swab (38) Handrinse (54)
Gaussian kernel with STATA optimal width
Nursery Domainby Sample Type