Rottier & Ince, 2003
Rottier & Ince, 2003
Rottier & Ince, 2003
iii
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iv
Chapter 1: Introduction 1
1.1 Definitions of commonly used terms in this manual 1
1.2 Who this manual is for 2
1.3 Scope of the manual 2
1.4 Structure of the manual 3
1.5 How to use the manual 4
Chapter 6: Sanitation 71
6.1 The transmission of excreta-related infections 72
6.2 Practical issues on sanitation 78
Chapter 7: Drainage 90
7.1 Surface water and the transmission of disease 92
7.2 Practical issues concerning drainage 94
References 275
vi
Chapter 1
Introduction
Improving health is one of the main goals of water and environmental sanitation
interventions. Despite this, many aid and development workers working in the
field of water and environmental sanitation have only a limited knowledge of the
infections they try to prevent. Although the relevant information does exist, it is
often scattered in specialised literature and rarely finds its way into the field.
This manual addresses this problem by presenting information to aid and develop-
ment workers on these infections in relation to the interventions that these
workers control: water supply, sanitation, drainage, solid waste management, and
vector control.
Infection usually means the entry and development of organisms (e.g. virus,
bacterium) in a host (human or animal) (Benenson, 1995). In this manual we
use the word infection for the development in a host of an organism(s) whose
transmission and/or prevention are influenced by WES.
Disease is a broad term normally used for any malfunction of the body resulting
from a cause other than injury. An infection is only a communicable or
infectious disease if it results in illness. Although, strictly speaking, it is not
correct to use disease and infection synonymously (most infections covered in
this manual can result in infection without symptoms), we have done so here to
improve readability.
Aid and development workers operating at various stages of the project cycle will
find this manual useful. Whether you need to assess the health risks in an existing
situation; write, or assess, a project proposal; or implement an intervention, you
will find relevant information in this book. You do not need to have extensive
knowledge, of or experience in WES or in disease to be able to use this manual.
The various components of WES up to the level at which aid and development
workers in the field usually work are covered. We focus on appropriate technology
options. The specific health problems related to industries, mines, large hospitals,
abattoirs, or sewage treatment plants are not addressed.
1.4.1 Part 1
Chapter 2: Disease and disease transmission
This chapter looks at how the infections related to WES are transmitted. The
elements of the transmission cycle of disease are presented, along with important
related issues. In addition, this chapter categorises the infections linked to WES
into groups with similar transmission cycles.
Chapters 5 to 8
In these chapters we introduce the components of WES – domestic water supply,
sanitation, drainage, and solid waste management – along with the health issues
associated with each component.
We do not specifically look at vector control here, as this subject would be too vast
to cover adequately. The role that water supply, sanitation, drainage, and solid
waste play in vector control is, of course, important, and this is covered in the
relevant chapters. Although we do not cover vector control in its own chapter, we
have included all vector-borne diseases of importance in Annexe 1, and Annexe 3
presents summary tables on both vector-borne infections and vectors and their
control.
1.4.2 Part 2
Annexe 1: Properties of infections related to WES
In this annexe we list all the common infections related to WES with their
properties relevant to WES specialists. We cover over 85 infections in a standard
format.
Annexe 5: Sizing pits for latrines and determining their infiltration capacity
This annexe explains how to size the pit for a latrine, and how much liquid the pit
can cope with.
The manual is also structured to allow the reader to extract information by disease,
by project, or by the components of WES.
The diseases
Information on individual infections is presented in Annexe 1.
More than 85 infections are covered in 60 individual sections. All sections have
the same format, although some less relevant or less important infections are only
summarised. Readers can find important information on each disease, such as
distribution of the infection, severity of the disease, how transmission occurs,
whether the infection is a risk in a disaster and preventative measures.
Chapters 5, 6, 7, and 8 briefly present some issues other than health which are
associated with components of WES and which should be taken into considera-
tion when making a project proposal.
practical aspects relating to the components which will help workers who have to
plan, design, or implement interventions, or who have to assess whether existing
structures or services are adequate.
Although this book has not been designed as as technical manual, technical
information important to the proper functioning of WES components is included
to avoid the comon frustration experienced by readers of such texts: ‘They tell us
what to do, but not how to do it!’. The technical information is not complete, but
may be useful, for example, to address rapidly specific problems that arise in an
emergency such as the chlorination of drinking-water, the design of sanitary
structures, or the removal of stormwater from a refugee camp. In addition, an
annexe has been included which presents the priorities and minimum standards of
WES in emergencies in summary form.
Chapter 2
An enormous variety of organisms exist, including some which can survive and
even develop in the body of people or animals. If the organism can cause
infection, it is an infectious agent. In this manual infectious agents which cause
infection and illness are called pathogens. Diseases caused by pathogens, or the
toxins they produce, are communicable or infectious diseases (45). In this manual
these will be called disease and infection.
This chapter presents the transmission cycle of disease with its different elements,
and categorises the different infections related to WES.
This cycle is called the transmission cycle of disease, or transmission cycle. The
transmission cycle has different elements:
The environment
Transmission
The host
The pathogen
Different categories of pathogens can infect humans. The pathogens causing the
diseases covered in this manual include viruses, bacteria, rickettsiae, fungi, proto-
zoa, and helminths (worms). All pathogens go through a lifecycle, which takes the
organism from reproducing adult to reproducing adult. This cycle includes phases
of growth, consolidation, change of structure, multiplication/reproduction, spread,
and infection of a new host. The combination of these phases is called the
development of the pathogen.
Two terms are commonly used to describe pathogens leaving the host through
faeces or urine: latency and persistence.
Active immunity is the resistance the person or animal develops against the
pathogen after overcoming infection or through immunisation (vaccination).(45).
Depending on the pathogen, the effectiveness of active immunity often decreases
over time.
*
It is important to realise that not all infections will result in disease. While a pathogen may cause illness in one
person, it may be killed or cause asymptomatic infection in another.
Usually immunity only develops against the specific pathogen that caused the
infection. If there are different types (serotypes or strains) of the same pathogen
(e.g. in dengue fever and scrub typhus), immunity will often only develop against
the particular type which caused the infection. The person or animal can still
develop the illness when infected with another serotype or strain of the patho-
gen (3).
Table 2.1 presents the different categories of pathogenic organisms with some of
their characteristics, including latency, persistence, and immunity. The informa-
tion is general, and exceptions can occur.
There are two types of host: definitive and intermediate host. The definitive host is
the person or animal infected with the adult, or sexual, form of the pathogen. In
the infections covered here, people are usually the definitive host. To keep things
simple the definitive host is called just ‘the host’.
10
Virus Particles invade living The pathogens Viruses can Where vector-
cells. The pathogen are non-latent. survive for borne,
needs structures in months in transmission to
these cells to tropical offspring is
reproduce. (45) temperatures. possible(3) .
(28)
The immunity is
often long-
lasting.(73)
Bacteria Bacteria are single cell The pathogens Persists up to The immunity
organisms. They are are non-latent. several weeks. developed is
considered more (16,73)
. Can often
primitive than animal multiply outside incomplete or
or plant cells. (45) the host. (3) short-lived. (3)
11
These hosts are called carriers, or asymptomatic carriers. Table 2.2 shows some
infections that are frequently mild or asymptomatic. The host can be infectious for
a short period in transient carriers, or over a prolonged period in a chronic
carrier (3). Incubating carriers have been infected and can spread the pathogen, but
do not yet show the symptoms of the illness. Convalescent carriers continue to
spread the pathogen even though they have recovered from illness.
12
Vectors are usually infectious for life, and several pathogens can be transmitted to
the offspring of the vector over several generations (2). A soft tick, for example, can
survive for more than five years and can pass to its offspring the pathogen which
causes tick-borne relapsing fever (73).
Some pathogens can live their entire lifecycle outside the host. These include
threadworm and several faecal-oral bacteria which cause bacillary dysentery,
(para)typhoid, and salmonellosis (3).
Water and environmental sanitation interventions that aim to improve the health
of a population usually try to reduce the risk of transmission of infection. To do
this appropriately, the WES specialist needs to be familiar with the pathogens’
transmission route(s). It is this understanding that enables the specialist to deter-
mine which control measures will be most effective in a particular situation.
13
For a water and sanitation specialist the most useful categorisation is based on the
transmission cycles of the infections. Generally speaking, diseases with similar
transmission cycles can be controlled by similar preventive measures, and will
occur in similar environments.
The infections are categorised and their transmission routes described at the same
time. More information on the transmission routes and potentially effective
preventive measures of specific diseases can be found in Annexe 1.
14
Some of these infections have mainly animal hosts, while others are limited to
humans. Faecal-oral infections include diarrhoeal diseases such as cholera and
bacillary dysentery, typhoid, hepatitis A, and poliomyelitis.
Fingers
Faeces
Water
Flies
Food
Soil
Mouth
15
2.4.1.2 Leptospirosis
The main reservoir of leptospirosis is normally rats, though many other animals
can potentially transmit the infection. The pathogen leaves the animal host
through urine. People are usually infected through direct skin contact with water,
moist soil, or vegetation contaminated with urine from infected animals. Other
ways of transmission are direct contact with body tissues of infected animals or
ingesting food contaminated with urine. Transmission from person to person is
rare (3).
The pathogen enters the body through skin or mucous membranes such as the
eyes. These infections are associated with poor personal hygiene and are water-
washed.
Few of these infections have animal hosts. The diseases in this category include
conjunctivitis, trachoma, yaws, and scabies.
16
Entrance by penetration of the skin: the pathogen enters the body through skin
which is in direct contact with contaminated soil. This is the method used by
hookworms and threadworms.
The infections covered here do not have animal hosts. Figure 2.3 presents the
transmission routes of the soil-transmitted helminths.
Faeces
Soil
Skin in direct contact
with contaminated soil
(Hookworm disease)
Food
Fingers
Mouth
(Roundworm infection)
17
Water-based helminths with two water-based intermediate hosts. The first inter-
mediate host is a freshwater snail or copepod. The second intermediate host is
a freshwater plant, fish, or crabs/crayfish. The intermediate hosts are specific to
the pathogen. These infections are food-borne and people become infected
when they eat the second intermediate host without properly cooking it. All
these infections affect both animals and people. These diseases include
opisthorchiasis, clonorchiasis, and lung fluke disease.
The transmission routes of the water-based helminths are presented in Figure 2.4.
2.4.2.4 Guinea-worm
In this infection the pathogen, a large worm, creates a blister on the person’s skin,
which erupts when it comes into contact with water, releasing the worm’s larvae.
These larvae then infect a copepod (Cyclops), in which it develops. The disease is
water-borne. People become infected by drinking water containing Cyclops, and
18
Faeces
(urine for urinary
schistosomiasis)
Mouth
Water-based helminths
with 2 intermediate hosts
Freshwater snail
(freshwater copepod
for diphyllobothriasis)
Freshwater fish
(freshwater crab-crayfish for lung fluke disease,
freshwater plants for fasciolopsiasis and fascioliasis)
19
Worm in blister
in skin
Mouth
Freshwater
copepod
are the only host to this infection. Figure 2.5 shows the transmission route of
Guinea-worm.
20
Interventions which involve WES will often modify the environment to try to
reduce the transmission risk.
The environmental factors that we will look at here are climate, landscape, human
surroundings, and human behaviour. Environmental factors are often associated,
for example higher altitudes result in lower temperatures, landscapes are formed
by the climate.
In general, direct sunlight, a dry environment, and high temperatures will reduce
the survival times of pathogens in the environment.
Conditions may not be suitable to transmission year round, and many infections
are seasonal, occurring when the environment is favourable to transmission.
Mosquito-borne infections, like malaria and yellow fever, are linked to the rainy
season (16,44). The occurrence of diarrhoeal diseases often increases with the first
rains after the dry season, as faecal pollution is washed into rivers. Ponds which
disappear in the dry season may in the wet season contain water with snails that
will transmit schistosomiasis (73).
The climate influences human behaviour. In cold climates people will crowd
together and wear more clothing. If this is combined with poor personal hygiene
the the body-louse, vector of louse-borne typhus fever and louse-borne relapsing
fever, can thrive.
21
In warmer climates children are also likely to play in surface water, where they can
be infected with schistosomiasis.
Although the WES specialist working in the field must recognise the risk-factors
linked to the landscape, he or she will normally not be able to modify the
landscape to reduce the risks of disease transmission.
Although the landscape will normally be similar for all people living in an area,
the human surroundings may be very different for people living in the same
region, village, or even household. Many infections are linked to specific circum-
stances, and people with specific occupations, socio-economic status, gender, or
religion may be far more at risk than others. While the father of an African family
may be exposed to leptospirosis and plague because he works in sugarcane fields
and regularly traps rats, the mother may be exposed to sleeping sickness as she
goes to the river to wash clothes, and the children may be exposed to schisto-
somiasis while playing in the local pond.
People adapt their surroundings to their needs. If these adaptations are well done,
they can help to prevent the transmission of disease. In practise they often
22
encourage the transmission of disease, however, as people do not have the space,
motivation, understanding, time, energy, or financial or material means to do them
properly.
In relation to the WES aspects, human surroundings are concerned with water
supply, proper handling of excreta, removal of unwanted water, adequate manage-
ment of solid waste, and control of vectors or intermediate hosts through modifi-
cation of the environment or change in behaviour.
Waste products like excreta, wastewater, and refuse are disposed of in the human
surroundings. These wastes must be properly managed to prevent them becoming
a health risk.
The WES specialist working in the field will have to know what aspects of the
human surroundings increase the risk of disease transmission. This will enable
him or her to determine which aspects play an important role in the transmission
of disease in a specific situation. Based on this, an intervention can be planned
which will reduce the health risks to the population. More on the health risks
relating to the human surroundings, and the components from WES interventions
can be found in Chapter 5.
Having access to a safe water supply, or technically adequate sanitation, does not
automatically mean people will use them (25). If people do not regard structures as
acceptable, appropriate, or as an improvement to their quality of life, they will not
be used, or will not be used to their full potential.
Interventions that have only focused on structural improvements have often given
poor results in controlling infections. Studies in disease prevention indicate that
the most important factor in reducing the transmission of diseases related to WES
23
The specialist will have to identify existing behaviour, attitudes, and behaviour
concerning WES and their causes. This will form a base from which health and
hygiene promotion can be introduced. All interventions should look at human
behaviour, and where needed, reinforce existing positive behaviour while trying
to modify behaviour that favours disease transmission.
! the infectious dose of the pathogen, and the number of infectious agents which
manage to enter the potential new host (this applies mainly to faecal-oral
infections); and
! whether the pathogen can overcome the barriers of the host.
The infectious dose is normally only used for faecal-oral infections. As every
larva of a helminth can become an adult worm, worms have a very low infectious
dose.
Infections with a low infectious dose are more likely to be spread by direct person-
to-person contact than infections with a high infectious dose. Measures such as
improving drinking-water quality, or reducing the concentration of pathogens in
surface water (for exampleby treating sewage), are more likely to have effect on
infections with high infectious doses than on those with low ones (73). Intuitively
one would say that flies are more likely to transmit infections with a low infec-
tious dose, but this is complicated by the fact that several bacteria can multiply in
food, and thus reach the infectious dose in this way.
24
The skin and mucous membranes have anti-microbial substances, and the stom-
ach is acid to act as the first barriers against pathogens. Low acidity in the stomach
or an open wound (e.g. insect bite, cut, abrasion) can make this barrier ineffective.
The next barriers are mechanisms that react to the pathogen, and try to counter its
development. These barriers are not specific to the pathogen, and the body does
not need to have been in contact with the pathogen for them to be effective. These
mechanisms are the host’s resistance against pathogens (41). Resistance is lowered
if someone is suffering from other infections (73), or is malnourished, stressed, or
fatigued (41). Women have a higher risk of infection when pregnant (73).
25
A person or animal who lacks effective barriers (has a poor resistance and/or a low
immunity) against a pathogen is susceptible to this infectious agent (45).
Communicability
Time
Figure 2.6. Communicability and disease over time in one person (adapted from 73)
26
The period of communicability is the period in which the host is infectious, or the
period in which pathogens are shed in the environment. The time between
entrance of pathogen and the onset of communicability is the latent period. This is
shown on a timeline in Figure 2.6.
27
Chapter 3
28
Susceptible persons
Births
from outside region
Susceptible persons
Infection
Recovery
Death
Immune persons
Death
29
These factors can either favour, or oppose, the transmission of the pathogen from
a host to a potential new host. Favouring and opposing factors balance each other.
Three situations are possible:
! The opposing factors are stronger than the favouring factors: the infection
disappears or does not occur. This situation is what we try to achieve.
! The opposing and favouring factors are in balance: there is a continuous
presence and transmission of the infection in the population. The disease is
endemic.
! The opposing factors are weaker than those that favour transmission: the
occurrence of the infection increases in the population. If the occurrence is
clearly more than normally expected, then the infection is epidemic.
This balancing between the opposing and favouring factors is a dynamic process
that can easily alter with changes in the pathogen, hosts, environment, or potential
new hosts.
30
because of the conditions in which they live (e.g. poor housing resulting in Chagas
disease (73)); people with certain occupations or living in specific locations may be
more exposed (e.g. farmers or sewage workers would come in contact more easily
with leptospirosis). It is important to identify the people who are most at risk, and
why to know who to target and what preventive measures to take.
The most severe epidemics are those caused by infections which are easily
transmitted, have short incubation periods (71), and have a potentially severe
outcome. The main iInfections that cause severe outbreaks are diarrhoeal diseases
(e.g. cholera, bacillary dysentery), yellow fever, malaria, epidemic louse-borne
typhus fever, and louse-borne relapsing fever, but other infections can cause
emergencies too.
31
Most of the infections covered in this manual can cause epidemics which impact
hard on society or individuals. They will not normally cause emergencies though,
as they develop slowly, are less serious, or people have high levels of immunity.
Where an infection is endemic it is impossible to give a threshold level that marks
the beginning of an epidemic, as this depends on what is ‘normal’ in a given
population, in that area, in that season. Where cholera is not endemic, one case of
locally acquired cholera will be declared an epidemic (10). Where cholera is
endemic, two new cases in a week would not necessarily cause concern. An
epidemic would be confirmed if more cases occur than occurred in the same
season in the recent past (55). Table 3.1 presents the epidemic threshold level for
several diseases.
(a)
A ‘confirmed case’ is an infection confirmed by laboratory tests.
32
The following sections will help water and sanitation specialists to take this
intuitive approach to disease prevention.
33
! Where does the disease occur (place of exposure)? What is the geographical
distribution (e.g. altitude) and the environment (e.g. slums, swamps, forests,
poor sanitation).
! When does the disease occur? Is there a season (e.g. wet season, when many
vectors are present), a specific occasion (e.g. one week after a feast, or visit to
a town, or a strong increase of the disease in years after the construction of a
dam) (71)?
Being aware of the risk factors which can cause transmission will help to identify
relevant information. More detailed information about risk factors concerning
WES can be found in Chapter 5.
The local risk factors that cause transmission will have to be identified by
surveying the environment and human behaviour. It is also important to look at
local attitudes and beliefs regarding the disease and its prevention, as these could
affect potential interventions. The survey will also have to assess the risk the
infection poses, and the capacity of the local authorities to deal with the existing
situation or with a potential outbreak. Then the relative importance of the different
risk factors will have to be determined.
In an outbreak, the primary transmission, or the way the initial cases are infected,
may be different from the secondary transmission, or the way the pathogens are
transferred from the initial cases to new cases (8). An outbreak of typhoid fever
may originate with infected drinking-water, while secondary transmission may
occur through infected food handlers. Similarly, with endemic diseases not all
cases need to be infected in the same way.
Once the local risk factors are identified and their importance assessed, the
potential effects of eliminating or controlling these factors has to be estimated. By
combining this information with what is known about local limitations and
resources, it is possible to come up with an indication of what type of intervention
would be appropriate in a particular place. When an outbreak results in an
emergency, all feasible measures that could potentially reduce transmission should
be taken.
34
This analysis will usually be enough to choose an intervention for endemic and
epidemic diseases. Trying to analyse an outbreak can be more complex, as the
process is more dynamic. The following aids can help analyse an outbreak.
It is usually qualified medical personnel who will analyse an outbreak, but the
WES specialist has to understand some of the basic aids that can be used, with a
questionnaire or survey, to assess the risks and extent of the outbreak, and the
possible sources of the epidemic.
The curve can highlight a trend and the nature of the outbreak (71).
35
period; the last ones are those with the maximum incubation period. Going back
in time for the length of the incubation period indicates when infection occurred.
By looking at where the people were and what they were doing at that time, the
source of infection can be identified (73).
Figure 3.2 shows a point-source outbreak of diarrhoea in a village. The first cases
of diarrhoea appear on the morning of 16 July. The diarrhoea is identified as
salmonellosis. As the incubation period of salmonellosis is between six hours and
three days (3), people were probably infected on the evening of 15 July. A survey
shows that on the evening of the 15th all the known cases attended a funeral. At
this funeral food was served, and the majority of those who ate meat have fallen
ill, while those who did not have no problems. In this case it is probable that the
meat served at the funeral was the source of infection.
Number of
cases
12 13 14 15 16 17 18 19 20 21 22 23 24
(July)
Time
36
The process of finding the source of infection is similar to that with the point-
source outbreak. The probable time of initial infection is determined by going
back to the time the first cases appear and back further for the shortest incubation
period of that infection. A survey of where the first cases occurred, and what those
people were doing will normally indicate the probable cause of infection (73).
Tertiary cases
Serial interval
Secondary cases (period between peaks)
Primary case
Number of
cases
Transmission resulting
in secondary cases
Time
(in days)
Transmission resulting
in tertiary cases
37
day, the initial infection probably occurred on 9 May. A survey shows that all the
cases ate at a particular food stall on the local market. The stall was closed the
evening of the 14th. Cases continued to appear until the 19 May because some of
the people infected on the 14th will have had an incubation period of five days.
Every cluster of cases will show a peak in the incidence curve. The period
between the peaks is called the ‘serial interval’ (73). The serial interval will depend
on the latent period, the period of communicability of the host, and the time it
takes for the pathogen to develop in a vector or intermediate host. This will often
be about the average incubation period, plus, if applicable, the period of develop-
ment in the vector or intermediate host. The longer the latent period, the longer
the period of communicability, and the longer the time the pathogen needs to
develop in the vector or intermediate host, the more spread out over time the
curves will be.
The number of cases that will occur will depend on how effective transmission is.
The presence of risk factors such as overcrowding, behaviour which favours
transmission, a large susceptible population, or an environment favourable to
vectors or intermediate hosts, will increase the number of cases (55,71).
3.2.2.3 Limitations of the spot map and the epidemic incidence curves
The spot map and epidemic incidence curves have several limitations:
! The reported rates always lag at least one incubation period behind the actual
situation of the infection. The cases identified now were infected one incuba-
tion period earlier. People infected since then are developing the infection, but
do not show any symptoms yet (even if transmission were to stop abruptly, new
cases would continue to appear for the length of the incubation period). Delay
is also likely because of communication problems between the field and the
central registration point.
38
Tertiary cases
Serial interval
Secondary cases (period between peaks)
Primary case
Number of
cases
Transmission resulting
in secondary cases
Time
(in days)
Transmission resulting
in tertiary cases
39
selves. The incidence curve may be the result of an accumulation of these many
little outbreaks. Cases can often transmit the infection over long periods of
time, which will ‘smear out’ the distinct peaks in a propagated-source out-
break, so the epidemic incidence curves found in practise will not rarely look
like the neat models shown here.
! its frequency in the population (i.e how common it is, or how big is the risk of
an epidemic); and
! its severity ( i.e. whether the infection causes disability or death) (71);
Seasonal rates are important in identifying seasonal health risks and potential
epidemics.
The figures for poor communities are not threshold levels, but give an idea of
what to expect. The rates for these communities are not acceptable at these levels,
and should be brought down, preferably to the CMR of developed communities.
(IMR) (± 3 deaths/10,000/day)
40
Table 3.3. Threshold levels of Crude Mortality Rate and Infant Mortality Rate in
camps
Mortality rates
Table 3.4. Indicative acceptable incidence rates and specific mortality rates in camps
for displaced persons or refugees (72)
Diarrhoea total 60
Acute watery diarrhoea 50 1
Bloody diarrhoea 20
Cholera Every suspected case must be reacted upon
Fever of unknown origin 100 0.5
Malaria 20
Skin infections 40 -
Eye infections 35 -
Children under five are more likely to develop disease, and incidence rates of
roughly 1½ times those presented here would be acceptable in this group (72).
41
Chapter 4
This chapter looks at the problems that WES projects try to address. The planning
of WES interventions is considered briefly, and the project cycle is presented.
Issues which will have to be considered to improve the impact and sustainability
of projects are discussed, and the chapter concludes with a more global perspec-
tive of development by looking at poverty in society.
Programme: is usually on a larger scale than a project, and has a goal which is
more general (e.g. a sustained improvement of health for 40,000 people living
in low-cost housing areas in Jakarta). A programme will usually have several
objectives (e.g. install adequate and sustainable services for water supplies,
sanitary services, hygiene promotion, and solid waste management), and is
usually made up of several projects (adapted from 19,20,23).
Although this manual only covers infections linked to WES, it should be remem-
bered that these are only part of the total health burden of people in developing
countries.
42
Every year an estimated 2,900,000 people die of diarrhoea (52), around 900,000 of
malaria (76), and around 600,000 of typhoid fever (3). Every year these three
diseases together kill the equivalent of the population of Norway – more than
12,000 deaths per day.
Illness more often results in (temporary) disability than in death. Infections like
leprosy, trachoma or filariasis are rarely fatal, but often result in permanent
disfigurement, blindness, and disability (59). DALYs (Disability-Adjusted Life
Years) are a measure of the cost of disease. DALYs represent the number of years
lost due to early death, and time and severity of the disability caused by the
disease. Table 4.1 shows the number of DALYs lost to several important infec-
tions every year.
The developing world is paying the highest price for disease. Only 12 per cent of
the suffering caused by disability and early death occurs in developed countries. In
developing countries, 35 per cent of all DALYs lost are a result of communicable
disease, compared to just over 4 per cent in developed countries (51).
Table 4.1. DALYs lost to disease worldwide, yearly figures (from 51 and 76)
Infection DALYs
Diarrhoeal disease 99,600,000
Malaria 31,700,000
Roundworm infection 10,500,000
Trichuriasis 6,300,000
Schistosomiasis 4,500,000
Trachoma 3,300,000
Chagas disease 2,700,000
Leishmaniasis 2,100,000
Sleeping sickness 1,800,000
Hookworm disease 1,100,000
43
Poor health is not the only price people pay for poor water supply and (environ-
mental) sanitation. Often water has to be carried over long distances, taking up
energy and time. In some regions over half the daily energy available to one
person is needed to carry the water used by the household every day (1). This time
and energy cannot be invested in other activities like going to school, or growing
vegetables for sale or consumption. Carrying heavy loads of water can result in
deformities of the body and other physical problems (20,38). Where water must be
bought from vendors, it may account for a large proportion of the household’s
expenditure (up to 40 per cent of the income of a household is mentioned) (69).
Where (environmental) sanitation is poor, people may live or work in an unpleas-
ant environment of bad smells, nuisance by insects or rats (which can carry
disease), and unsightly conditions.
To be able to assess whether a project functions well, or has been successful, every
project should have a clear goal, and a clear idea of how this goal is going to be
achieved. Figure 4.1 shows how an organisational tree could be set up for a
project. The objective must lead to the aim; to attain the objective, certain outputs
will have to be achieved; and to realise the outputs, certain activities will have to
be accomplished. In the end everything that will have to be done and achieved in
the project must be included in clear and measurable form in the organisational
tree, which is a simplified form of the logical framework.
44
Aim:
A sustainable improvement in health
and well being for 15,000 poor people in
the city of Luanda
Objective:
establishment of appropriate and sustainable
services in water supply, sanitation and hygiene
promotion for 15,000 poor people by the year 2004
Figure 4.1. Example of an organisational tree for planning a project (adapted from 23)
A project goes through a cycle, the project cycle, which consists of a sequence of
assessment, planning, implementation and evaluation activities.
45
(11) Evaluation
(2) What are the priorities?
46
At the end of the project its functioning
Which problems should be dealt with first?
and effects are analysed.
What the local population see as priorities?
46
During implementation the project
should be monitored. (4) What will be done?
The agency decides with all people and
structures involved on the problems that will
be addressed in the project.
(8) Appraisal and approval
The project proposal is examined, if
necessary adapted, and accepted. (5) How will it be done?
Specific activities needed to solve the
problems are decided upon.
(7) Proposal
A project proposal is made in co-operation (6) What resources are needed?
17/03/2003, 11:46
CONTROLLING AND PREVENTING DISEASE
with the stakeholders. What human, material and financial inputs are
needed? The inputs and responsibilities of all
stakeholders must be agreed upon.
This section looks at some of the cross-cutting issues which must be addressed in
the project planning phase to improve impact and sustainability.
Health is affected by many factors other than WES. Programmes should try to
combine components of all relevant sectors (e.g. WES, medical, environmental,
economic) to achieve maximum impact. Programmes are most effective when
projects from different sectors are integrated (26,38).
Technical aspects
Infrastructure must be designed to fulfil needs. Where the population density is
high and the infiltration capacity of the soil low, a sewage system may be
appropriate. In most other cases, however, sewerage will be inappropriate because
it is expensive and requires demanding operation and maintenance.
47
good, but may also be too expensive for local people. If people use corncobs to
clean after defecating, a pour-flush latrine will soon be blocked.
Socio-cultural aspects
Even if the population understands the importance of improved infrastructure and
behaviour, there is no guarantee that the infrastructure will be used or good
behaviour practised (18). If users believe the components are inadequate, they will
not respect them.
Societies are not homogeneous; they are made up of people of different sex, age,
religion, ethnic origin, socio-economic status, occupation, and caste. Some are
more vulnerable than others, particularly women, children, religious and ethnic
minorities, and people who are old, disabled, or poor. These groups of people
must be identified and included in the project as much as possible. As domestic
WES is often the responsibility of women, they should play an important role in
the planning of an intervention (23). All components must be acceptable to all users.
48
If certain groups do not see the infrastructure as adequate, they will either not use
it or use it incorrectly. It cannot be assumed that the agency, authorities, or
communities’ representatives know what type of structures are most appropriate
to all users.
The groups that are most at risk in a society (e.g. single women, people who are
older, disabled, or poor) will often suffer most because of poor accessibility, and
accessibility for these groups must be taken into account during planning.
Financial aspects
Improvements are more likely to be sustainable if the full costs of operation and
maintenance can be borne by the users. How much people are able and willing to
pay for the services must be determined in an open discussion between the people
and the agency. Where people buy water from vendors the price they are already
paying is an indication of what people are prepared to pay (15). It is not realistic to
say that all families will be willing to pay the same percentage of their income for
water and sanitation. What people are willing to pay for improved services will
depend on the importance of WES to them, how much they pay for the service
already, what level of service is on offer, and their expectations from authorities or
agency.
Where possible the initial costs of construction should be (at least partly) recuper-
ated in the form of money, labour, or material. Again, the community’s contribu-
tion must be adapted to what they are able and willing to provide. This has to be
determined in discussions between the agency and the community, and by realisti-
cally assessing the availability of resources.
If there is a central regulating body (e.g. for a piped water supply or communal
latrines), an adequate system of collecting fees must be installed. Where the
infrastructure is at a household level, the family can cover its own maintenance
and operation costs. If subsidies are offered, they should be used to make services
accessible to people who would otherwise not be able to afford them. To prevent
abuse, the policy for allocating subsidies must be transparent (23).
49
Institutional aspects
The agency does not plan and run projects on its own. It usually works with one or
several governmental bodies. Other authorities or organisations will often be
given the responsibility to implement the project, or operate or maintain infra-
structure.
It is important to identify all the organisations that are, or could be, connected to
the project. They have to be assessed on their organisational skills, capabilities,
level of motivation, availability of time as well as their access to resources,
transport, and materials. Transparency and accountability will be important is-
sues. Training or help buying materials will be necessary.
The general guidelines and regulations of the country have to be followed, and the
project should fit as closely as possible in the programmes, plans, or guidelines of
the government or other organisations.
The poor are usually most at risk of infection because of their degraded environ-
ment and inadequate nutrition, so they are the hardest hit when ill as they have no
reserves or rights to fall back upon, have difficulty accessing medical care, and
pay the most for it. Few poor people can afford to create a healthy environment
with good housing, adequate water supply and (environmental) sanitation.
Disease can also be very expensive because of the direct costs (e.g. treatment,
transport) and loss of income (sick people cannot work).
Poor health often leads to poverty, and poverty often leads to poor health. Once
people are in this vicious circle, it is very difficult to escape. Most people in
developing countries live in poverty. In 1993 it was estimated that half of the over
1.5 billion people who inhabit cities live in extreme poverty (81).
Poverty, and with it poor health, is not only crippling for individuals, it is a serious
handicap to developing countries as a whole. Improving environmental hygiene,
water supply, housing, education, nutrition, and health facilities is only possible if
50
51
Chapter 5
Domestic water supply means the source and infrastructure that provides water to
households. A domestic water supply can take different forms: a stream, a spring,
a hand-dug well, a borehole with handpump, a rainwater collection system, a
piped water supply with tapstand or house connection, or water vendors.
Households use water for many purposes: drinking, cooking, washing hands and
body, washing clothes, cleaning cooking utensils, cleaning the house, watering
animals, irrigating the garden, and often for commercial activities. Different
sources of water may be used for different activities, and the water sources
available may change with the seasons.
There is always some kind of water source present where people live, as they
could not survive without one. The source may be inadequate, however; it may be
far away, difficult to reach, unsafe, or give little water, making it inaccessible or
unavailable. It may give water of poor quality.
Although both problems play an important role in people’s health and well-being,
the availability of water is often more important than quality.
52
selective about what they use the water for. Figure 5.1 shows the implications of
poor water availability to people.
If a limited number of water sources are available, the areas around the sources
may become degraded if too many people or animals use them. If unsustainable
amounts of water are extracted, the environment may become degraded through
falling groundwater levels or surface water sources such as rivers or streams may
dry up. Be careful to ensure that short-term gain does not result in long-term loss.
53
People need access to enough water to be able to maintain good personal hygiene.
Although good access to water does not automatically result in good personal
hygiene, poor water availability will usually result in poor personal hygiene. Once
there is enough water, health and hygiene promotion will often be needed to
improve personal hygiene practises.
5.1.1.1 Handwashing
Contaminated hands can carry pathogens to where these can enter the body. Hands
contaminated with faecal matter can transmit faecal-oral pathogens to food, water,
or directly to the mouth. The soil-transmitted helminths that cause roundworm
infection and trichuriasis can be transmitted if hands are contaminated with soil
containing their eggs. Hands contaminated with the discharge from the eyes of
people suffering from conjunctivitis or trachoma, or the contagious liquid from
papules of people with yaws, can transmit these infections to other people through
direct contact.
Washing hands after every contact that could potentially pick up the pathogen, and
before doing anything that could transmit the pathogen onward, can prevent
transmission. Faecal-oral infections can largely be prevented if hands are washed
after defecation, after coming in contact with animals, and after contact with
anything that could be contaminated with faeces. In addition, hands should be
washed before preparing or handling food, and before eating.
Washing hands after contact with soil or anything contaminated with soil and
before handling food can reduce the risk of transmitting helminths.
Washing hands removes the pathogens as well as the dirt containing and protect-
ing the pathogens (7). How effective handwashing is depends mainly on how
thoroughly the hands are rubbed, and for how long. Water alone is not as effective
54
as water with a handwashing agent such as soap or ash, which are both effective in
removing pathogens from hands.
The number of pathogens will be reduced significantly if the hands are rubbed
with a handwashing agent for at least 10 seconds and then rinsed with water (33).
Table 5.1 shows the groups of infections associated with poor handwashing.
Body lice, the vector of louse-borne typhus, louse-borne relapsing fever, and
trench fever live on people’s unwashed clothes (61). Fleas, which transmit plague
and murine typhus fever prefer people with poor personal hygiene (73). Keeping
body and clothes clean will reduce the transmission risk of all these infections.
The disease groups linked to poor hygiene of body and clothes are shown in Table 5.1.
s
o th m ct
tw in or n ta ns
ns h l m w t i o o n tio
it o i t ts he p e c c c
Risk-factors related ec is w os d ta fe ct fe
nf i as sed e h itte r k s in i re in
to poor personal l i t o s i m d n e
ra om -ba ia sm d p ro or by or
hygiene l-o t os ter ed ran a n s pi a -w d r -b
a s m t o e a o
ec hi Wa ter oil- ef pt in re ct
Fa Sc in S Be Le Gu Sp Ve
(a) (b)
Poor handwashing
and clothes
(a)
: the ingested soil-transmitted helminths: roundworm infection and trichuriasis
(b)
: only cysticercosis
(c)
: louse-borne and flea-borne infections
55
Table 5.2. Reduction in infections associated with improved water availability and
personal hygiene
Disease (group) Reduction in Remarks
occurrence
Diarrhoea 20% (26) increase water availability (handwashing)
Infant diarrhoea 30% (32)
wash hands with soap after defecation and before eating
Roundworm 12-37% (26)
increase water availability (handwashing)
Trachoma 30% (26) increase water availability (washing of hands and face) (3)
The amount of water that people need, or use, will depend on its availability and
what it is used for. Factors that influence water use include the socio-economic
status of the users, whether and how people have to pay for the water, whether
water is easy to get, and whether water is used for special activities (e.g. irrigation
of vegetable gardens, watering of animals). Table 5.3 presents figures on water
needs and demands and shows the amount of water people need and how develop-
ment will change water demand. Future changes in population and development
level will have to be considered. Water is lost during distribution, and this will
have to be taken into account when looking at how much water must be provided
to a population.
In the initial phase of an emergency internally displaced people and refugees will
need a minimum of three to five litres per person per day to survive, and as soon as
possible this will have to be increased to 15 to 20 l/p/d to allow for water for
personal hygiene (21). In a stable situation, the minimum amount of water available
to people should be 25 l/p/d(68).
56
Interestingly, the amount of water collected if the collection time is between three
and 30 minutes remains constant. This means that if it takes eight minutes to fetch
water, the amount of water used will be more or less the same as if it took 20
minutes to collect it. If collecting water takes more than 30 minutes (i.e. a distance
of roughly 1km), the amount of water used decreases again (15). Figure 5.2 plots
water collection time against the quantity of water used.
The largest health benefit from an improved water supply will result if collection
times are below three minutes. Although bringing the water collection time down
from 25 minutes to six minutes will result in an important saving in time and
energy (in itself a large benefit), but will probably not reduce water-washed
infections.
57
Water
quantity
used
3 minutes 30 minutes
To avoid long waiting times at the sources, their numbers and yield must be
sufficient. There should be a maximum of 500 to 750 people using each functional
handpump, and 200 to 250 people per tap. If tapstands with multiple taps are used,
no more than six to eight taps per tapstand should be installed (47).
The minimum flow at a supply should be around 7.5 litres per minute (66). During
all seasons the sources’ yield should be high enough, and seasonal changes in
supply must be taken into account.
If a source has a low but constant yield it may be possible to collect the water in a
reservoir (e.g. a spring box) then put a tap on the reservoir.
58
Storing water
Water is only available if it is at hand when needed. Unless the source is on the
household plot, access to water is limited. This problem can be overcome by
storing water on the plot.
Where the water supply is unreliable (e.g. harvesting rainwater, piped water with
intermittent supply) storage improves availability when water is not accessible.
An additional advantage of storing water is that the water quality improves over
time. If water is stored for one day over 50 per cent of the bacteria will die.
Suspended solids, which can contain pathogens, will often settle out during
storage. By pouring the clear water out carefully, the settled solids can be sepa-
rated from the water (64).
Vessels that can be used to store water include local traditional clay pots, mortar
jars, ferrocement tanks, and plastic or fibreglass vessels or tanks.
How much water should be stored will depend on the situation. In general the less
reliable the supply, the more effort needed to obtain the water, and the higher the
water need, the larger the storage capacity should be. If there is a reliable,
continuous piped water supply with a house connection then storage will not
usually be necessary; but if people rely on rainwater storage needs may be large.
Where there is a reliable source throughout the year, a storage capacity equivalent
to the amount of water used in one to two days is probably adequate.
59
If the water is treated, polluting sludge (e.g. the sludge produced during coagula-
tion) may be produced.
If water is contaminated with the urine of animals infected with leptospirosis, the
pathogen can be transmitted through direct skin contact with the water. Rats are
the main reservoir of leptospirosis.
Table 5.4 presents the different disease-groups linked to water of poor quality.
60
hs ct
w o i nt rm n ta ns
Risk-factors related n s t l m o i o n io
o t h s e e w t o t
to poor water quality ti wi ost d h p c tc c
ec is ta fe fe
nf as sed e h itte r k s in i r ec in
i i e
l t o si rm d rn
i Drinking-water ra om -ba ia sm d p iro wo by
l -o t os ter ed ran n p - d - bo
ii Skin contact with a s m t a os ea a o r
ec hi Wa ter oil- ef pt in re ct
surface water Fa Sc in S Be Le Gu Sp Ve
i Contaminated with H/A
excreta
Contaminated by H
Guinea- worm
ii Contaminated with H/A A
excreta
H: human host
A: animal host
negligible (70)
if neighbourhood sanitation is poor (open defecation in
Infant diarrhoea neighbourhood)
40% (70)
if neighbourhood sanitation is good (no open defecation in
neighbourhood)
61
The quality of the water used for washing hands, body, and clothes is not really
important as long as it is not heavily polluted. The risk of transmitting pathogens
other than schistosomiasis (15) and leptospirosis during bathing in surface water is
limited.
Animals do not need water of very high quality, but most domestic animals can be
infected with faecal-oral infections, and cattle and pigs can be infected with beef
and pork tapeworm, so their water quality should be as high as possible.
Water sources
One of the priorities in selecting a water source is quality. The quality and
protection of the source is important regardless of whether the water will be
treated or not. Good quality water needs less, or no, treatment; and if treatment
fails there will be fewer health risks. Sources must be protected from pollution by
installing adequate structures for protecting, collecting, and distributing the water.
Health and hygiene promotion will probably be needed to make people aware of
the importance of protecting the water source.
If a spring has a low yield, a spring box might be constructed to collect and store
water that can then be withdrawn through a tap. The spring box should be well
constructed, and all openings (e.g. man-holes, overflow pipes) should be closed
securely or covered with fly screen.
62
Rock marking
position of Hedge
spring eye or fence
Area inside fence Fence across
Ditch
planted with headwall
creeping grass
Path
Ditch
Wastewater drain
63
groundwater into the tube-well, install a good grout seal. A watertight apron
sloping away from the pump must extend for at least 1 metre around the tube-well.
The borehole casing must be intact or else polluted water could enter. If water
must be added to prime a suction pump, be careful to use clean water to avoid
contaminating the water in the tube-well (43). The apron must drain into a drainage
channel that leads spilt water at least 4 metres away from the tube-well before
disposing of it in a garden or soakaway. If possible, a fence or hedge should be
installed around the borehole to keep animals at distance (82).
If possible, water should be withdrawn using a system that prevents the vessel and
rope from being contaminated (e.g. by being left on the ground). A headwall must
be installed to prevent surface water or other contamination from entering the
well. The headwall should discourage people from standing on it, as this could
result in soil or spilt water contaminating the well. Children must be prevented
from throwing material in the well (15). Where possible, a fence or hedge should be
installed to keep animals at distance. Figure 5.4 shows an appropriate hand-dug
well.
If a hand-dug well is covered with a lid and a handpump is installed, several risk
factors are eliminated or reduced. A raised manhole should be installed to ease
maintenance, and to allow people to get to the water without demolishing the
structure if the pump breaks down.
64
Windlass
(water abstraction system)
Headwall
Drainage channel
If existing wells are assessed in a sanitary survey, it is best to assume that the
underground structures are not adequate. Risk factors to look for include broken
or cracked apron and drainage channel, ponding of water within two metres of the
well, and the presence of human or animal excreta, refuse, or surface water within
10 metres of the well (82).
65
Distribution points, vessels, and reservoirs must be designed so that the risk of
contamination during filling is minimal. Transport and storage vessels should
have a small neck so that water cannot be dipped out. (Be practical, however, as
the difficulty of filling a vessel with a small neck at a handpump must be
considered.) The vessels should be properly covered to keep animals, insects, dust
and other contaminants out. The water should be taken from the vessel either by
pouring, or by using a tap. Vessels used for transporting and storing drinking-
water should only be used for this purpose. If they have been used for something
else, or have been empty for some time, they must be properly cleaned and
possibly disinfected before being used for drinking-water. Vessels can be cleaned
with boiling water or a chlorinated solution. Health and hygiene promotion will
probably be needed to improve behaviour concerning water handling and storage.
A piped water system with intermittent supply is also at risk of pollution. Intermit-
tent supply means that the pressure in the pipes will occasionally be lower than the
pressure in the surrounding soil, which means that contaminated water can seep
back into the pipes. Installing an electric pump to draw water from a piped water
supply with a low water pressure, as often happens in cities in developing
countries, can draw polluted water into the system.
Water treatment
The term water treatment is used here to mean manipulating the water to remove
water-borne pathogens (e.g. those that cause diarrhoeal diseases). This will often
be accomplished by chlorinating the water.
66
Water treatment at communal level requires funds and adequate support, while
treatment at household level will rarely be reliable. The priority should therefore
be to find a source that provides water of an adequate quality, and to maintain this
quality by protecting the source.
Water from safe sources used by small communities does not usually need to be
treated. The priority should be on health and hygiene promotion to both protect
the source and handle and store the water properly.
Although it is not possible to go into much detail on water treatment here, there
are some important points concerning chlorination and boiling of water.
! Part of the chlorine will oxidise contamination, including pathogens. The more
contamination there is, the more chlorine will be used up. This is ‘consumed
chlorine’.
! Part of the chlorine will combine with matter in the water, and form ‘combined
residual chlorine’. Combined residual chlorine functions as a disinfectant, but
is less effective than ‘free residual chlorine’ (15).
! Part of the chlorine will form free residual chlorine. The free residual chlorine
has a remaining or residual effect in water. If pathogens contaminate the water
during distribution, handling, or storage, the free residual chlorine in the water
will normally kill them.
67
Proper chlorination therefore has two effects: it kills pathogens present in the
water at the time of treatment, and it will, to some degree, protect water from
future contamination.
After the chlorine is added, it needs time to react with the contamination and turn
into combined residual chlorine. A contact time of at least 30 minutes should
therefore be allowed before the water is safe to drink, or before the free residual
chlorine can be measured. In a cold climate chlorine acts more slowly, and the
contact time will have to be longer (15). If the pH of the water is high, chlorine is
less effective in killing pathogens. At a pH of over 8, the free residual chlorine
content of the water should be between 0.4 and 1.0mg/l (22).
Sometimes the boiling of water is promoted to make it safe. To be certain that all
pathogens are dead, water has to be boiled for 5-10 minutes, although bringing
water above 75oC will normally kill the vast majority of the pathogens (28). Unlike
chlorination, boiling water is effective on water of high turbidity, and against
protozoa. Boiling water has several disadvantages though, which often makes it
less useful than chlorination. Around 1kg of firewood is needed to boil one litre of
water, which will often make it environmentally and financially unsustainable.
And unlike chlorinated water, boiled water has no residual effect against patho-
gens (21).
68
Treated water should be free of any coliforms when it enters the distribution
system. At the distribution point treated water should contain no faecal coliforms.
The presence of (faecal) coliforms in treated drinking-water is an indication that
treatment is not working properly, or that the water is being contaminated during
distribution. Instead of determining which coliforms are present, it is often
enough to verify that the water has a sufficient level of free residual chlorine, and
that there has been enough contact time between the chlorine and water.
Unlike treated water, any source of untreated water can be expected to contain
faecal coliforms, and it will be virtually impossible to obtain water free of faecal
coliforms without treatment (15). In rural areas it will often be difficult to reach
WHO or national guidelines even with appropriate structures.
5.3.3 Sullage
Chapter 7 goes into more detail on drainage, so here we will only briefly point out
the health risks associated with the disposal of sullage (or domestic waste water).
All water supply systems will produce waste water in the form of used water,
water spilled at the distribution point, and water leaking from pipes or taps.
Although sullage normally contains fewer pathogens than sewage, it will often
69
If the casings or linings of boreholes or hand-dug wells are not properly sealed,
waste water could seep back in, contaminating the water.
Where waste water keeps soil moist, a favourable environment for soil-transmit-
ted helminths (e.g. hookworm and roundworm) or sandflies could be created (80).
Accumulated polluted waste water can become a breeding site for domestic flies,
which transmit several faecal-oral infections and diseases spread by direct con-
tact. Culex mosquitoes, which transmit filariasis and several arboviral infections,
breed in polluted waste water too (21). Anopheles mosquitoes can breed in ponds or
puddles formed by unpolluted waste water.
70
Chapter 6
Sanitation
This chapter looks at how excreta and excreta-related infections are linked, and
how these infections can be prevented by improved sanitation. Several sanitation-
related issues are considered in some detail, and we look at issues which are
important to the planning, design, and construction of sanitary structures.
The uncontrolled discharge of excreta, sewage, or effluent into surface water may
result in environmental problems. The organic matter in excreta-related waste will
use oxygen to oxidise, and it will draw its oxygen from the water. The amount of
oxygen used is called the Biochemical Oxygen Demand (BOD) of the excreta. If
the waste is discharged into surface water without being adequately treated, the
natural aquatic life in the water may die from lack of oxygen.
*
Excreta can be faeces and urine, and can be human as well as animal
71
Beef tapeworm and pork tapeworm have to be ingested by cattle or pigs and
development in them. People are infected by eating poorly cooked beef or pork.
Vectors which benefit from inadequate sanitation include domestic flies, cock-
roaches, and Culex mosquitoes.
Domestic flies, which can transmit several faecal-oral infections including con-
junctivitis, trachoma, and yaws, can breed in, and feed on, excreta (67).
72
As there are many disease-groups related to excreta and sanitation, the following
concept should help to assess when these infections could pose a risk.
Table 6.1 shows the different elements that the pathogens have to come in direct
contact with to be transmitted.
Table 6.1. Disease groups and the elements that play a role in disease transmission
(adapted from 60)
hs ct
o nt m
ns
The element excreta ns t w
l m
i
w or i o n n ta
io
it o ti h ts he p e c t c o c t
must come in direct w os fe ct fe
ec is d ta in in
contact with: i nf i as sed e h itte r k i s i re e
l t
om -ba ia sm d p
o s rm d rn
ra iro wo by
l -o t os ter ed ran n p - d - bo
a s m t a o s e a a o r
ec hi Wa ter oil- ef pt in re ct
Fa Sc in S Be Le Gu Sp Ve
People H/A H(a) A
Animals H/A H A
(b) (c)
Insects H/A
Crops, food,
vegetation H/A H A
Soil H/A H A
H: Human excreta
A: Animal excreta
(a)
: Only cysticercosis, a complication of pork tapeworm
(b)
: Domestic flies can breed in excreta and can transmit conjunctivitis, trachoma, and yaws
(c)
: The mosquito Culex quinquefasciatus, vector of filariasis and several arboviral infections, can breed in
sanitary structures or surface water polluted by excreta
73
Several of these problems can be broken down further into specific risk-factors.
These specific risk-factors with their associated disease-groups are presented in
Table 6.2.
74
sanitary structure
sanitary structure
structure or pit
structure
surface water
Sanitary structure
pollutes groundwater
O&M
v Access of animals to
living quarters
Close contact between
people and animals
(work, play)
Animal faeces on (b)
domestic plot
75
(a)
: Leptospirosis, if transmitted by excreta, is usually transmitted by animal urine and therefore almost
impossible to confine through improved sanitation
(b)
: A potential for breeding and feeding of domestic flies
(c)
: A risk of cysticercosis, a complication of pork tapeworm; all other ‘positives’ in this column can result
in both cysticercosis and in infection of cattle or pork
(d)
: A potential for breeding of the mosquito Culex quinquefasciatus
29% (26) improved sanitation and water supply; reduction when improved
Roundworm
sanitation and medical treatment were combined: 80%
Tapeworms important (73)
improved sanitation
Except for roundworm, all the infections in Table 6.4 are faecal-oral. It is less
useful to look at the survival times of pathogens which need intermediate hosts, as
these usually remain viable for as long as the intermediate host survives.
76
Table 6.4. Maximum survival times (in days) of pathogens in different media (from 28)
Media in which s
is ) se
pathogens survive it ry
er e ru
(at 20 to 30oC) nt nt vi
l
le ) si
s is yse ra
a lo l os y d i s -o o) rm
r i li e l l
e r as l
ca oli wo
e o
ct E.c o n h i g i l l a lera bi e p d
Ba by l m S ac o oe Fa .g un
( Sa (b Ch Am (e Ro
The health risk of contaminated material (water, food, other objects) will usually
decrease over time if no multiplication or recontamination occurs. As the number
of pathogens discharged is often very large, the potential for transmission can
remain high, even if most pathogens die off or if the excreta is diluted in surface
water. A person with cholera can defecate up to 1x1012 bacteria per litre of
diarrhoea, for example, a person with urinary schistosomiasis can discharge
50,000 eggs per litre of urine, and people infected with hookworm disease can
shed 1x106 eggs per day (73).
Several bacteria and helminths can multiply outside the host. The bacteria Salmo-
nella spp. (causing salmonellosis and (para-)typhoid), Shigella spp. (causing
bacillary dysentery) (3) and E.coli (causing bacterial enteritis) (28) can all multiply in
food. The food can be contaminated through faeces, hands, utensils, domestic
flies, or cockroaches. Meat and dairy products pose the greatest risk. Thus food
which is not initially harmful because it contains too little bacteria can become
infectious over time because the bacteria have multiplied.
Excreta poses a large and prolonged health risk because of its potentially high load
of pathogens, the persistence of pathogens in the environment, and the potential
for multiplication outside the host, so excreta-related wastes must be dealt with
carefully.
77
Each infected person usually has great potential to spread pathogens, so sanitary
structures will only be effective in preventing disease if they are used by everyone,
all the time. Even if only some people in the population (e.g. children) defecate in
the open, the health benefits of sanitary structures will be limited. Some examples
to illustrate this problem (adapted from 2,3,16,73):
Even though open defecation is a serious health threat, it should not be con-
demned categorically in areas with low population densities. Open defecation
might be preferable to using poorly maintained latrines (57) which can become foci
for the transmission of diarrhoea (40) and hookworm (9).
Sanitary structures must be kept clean to reduce health risks and to make them
acceptable to users. Installing a SanPlat, which is a smooth concrete latrine slab,
78
makes it easier to clean the latrine. A SanPlat can be built into a new latrine or an
existing latrine can be upgraded (9). The slab should slope towards the drop-hole so
that spilled water, or water used for cleaning, flows into the hole. Figure 6.1 shows
an example of a SanPlat.
79
The discharge of excreta, nightsoil, or raw sewage into fresh surface water should
be limited as much as possible. The practise would only be acceptable where the
waste was diluted in a large volume of moving water, where people are not in
contact with the water (including people downstream), and where the risk from
food taken from the river is very small. This combination is unlikely to occur in
developing countries.
80
As seawater is not used for drinking, the main health risk comes from handling or
eating contaminated fish and shellfish. Fish can harbour pathogens in their body
for weeks and can therefore be a risk if they are caught close to a sewage outfall.
As shellfish can accumulate pathogens in their bodies, they are a larger health risk
than fish. Fish and shellfish should always be properly cooked before eating.
The additional health risks from contaminated seawater will normally be limited
if people already live in an environment with poor sanitation (28).
It is important to remember that the health risks from open defecation or from
using inadequate sanitary structures are usually greater than the health risk of
polluting the groundwater by sanitation.
81
Shallow groundwater tables usually follow roughly the form of the terrain (34). As
water flows from high to low areas, groundwater will normally move in the same
direction that water on the surface would flow. As a rough rule, the steeper the
terrain and the coarser the soil particles (if there are no small particles like silt and
clay), the faster the groundwater will flow (24).
When the polluted liquid meets the groundwater, the liquid will be carried with
the groundwater flow. The liquid forms a ‘tongue’ which follows the flow of the
groundwater, but the liquid and the groundwater do not really mix (30). This is
shown in Figure 6.2.
Bacteria will not normally travel further than the distance the groundwater flows
in 10 days (42). Predicting the exact distance that pathogens will travel from a
sanitary structure is difficult, as this will depend strongly on the local situation. In
terrain with a low gradient and medium to fine sands, bacteria will probably not
travel further than 10 metres. Viruses can travel further, as can bacteria in coarse
sands or fissured rocks (42). In fine soils a safety distance of 15 metres will usually
be adequate (57).
These values can be used for sanitary structures which have to deal with up to 50
litres of liquid per horizontal m2 per day (30), and family structures will usually not
exceed this.
Even though pathogens are removed from the flow, they are not necessarily killed,
and if large volumes of liquid are suddenly discharged, viable pathogens which
were ‘stuck’ may be flushed out. Pathogens will not travel as far if the same
amount of liquid is discharged continuously than if it is discharged in gushes.
82
SECTION
(side view)
Flow of polluted liquid in the groundwater: the liquid will follow the flow of groundwater,
but there will be little diffusion between the liquid and the groundwater. Pathogens will
normally not travel very far in finer soils.
Contour line
PLAN
(top view)
83
Fresh excreta, nightsoil, sludge, sewage, or effluent can all contain large quanti-
ties of pathogens, and thus pose a serious health risk to the people who handle the
waste and those around them. People who work directly with waste or who live or
work close to where excreta-related wastes can all be at risk from excreta-related
infections. But excreta, effluents, and sludge can be treated to make them rela-
tively safe to handle and re-use.
! Pass the waste through properly designed and working waste stabilisation
ponds (15).
! Let the effluent from a sewage treatment plant sit for enough time in matura-
tion ponds.
84
Fresh excreta, nightsoil, and any type of excreta-related sludge or effluent that has
not been treated adequately can contain pathogens and should therefore be iso-
lated as much as possible from people, animals, insects, food, crops, vegetables,
soil, and water. Conventional sewage treatment plants usually do not reduce the
number of pathogens to safe levels, and their effluent can still contain high levels
of pathogens.
Consumers of the crops are at risk of faecal-oral infections and ingested soil-
transmitted helminths (e.g. roundworm and whipworm).
The health risks of using excreta-related waste for fertiliser should be reduced by
minimising the contact between crops and pollution as much as possible (e.g.
through subsurface irrigation). Excreta-related wastes should only be applied
before the crops are planted or up to one month before the crops are harvested.
This will reduce, though not eliminate, the risks of faecal-oral pathogens. The
health risks of soil-transmitted helminths will not be reduced significantly.
The health threat to people can be reduced by feeding these crops to animals,
though several infections (e.g. salmonellosis and beef and pig tapeworm) will
remain a health threat to people through infections in the animals (28).
85
Keeping the live fish in unpolluted water for two to three weeks before eating
them will reduce the health risks.
As the eggs of water-based helminths with two intermediate hosts settle out easily
in water, the risk of these pathogens can be reduced by putting ponds in series, and
only harvesting fish from ponds which have not been fed with excreta-related
wastes (6).
Production of biogas
Handling excreta and the sludge that has to be removed regularly from a biogas
plant could be a health risk. The sludge could be heavily contaminated with
pathogens and should be handled and disposed of with the same care as fresh
excreta.
Assessment
To maximise the impact of improved sanitation, everyone must have access to
adequate structures, and these structures must be used correctly.
The structures have to be adapted to local behaviour, traditional beliefs, and the
population’s needs. In addition, sanitation has to be affordable to the users, and
appropriate for local institutional capabilities and restrictions. The structures also
have to be adapted to the physical situation in which they will have to operate. A
thorough assessment will be needed, and it is likely that different groups will
identify different issues, needs, and preferences, and these must be identified and
86
There should be no more than six cubicles per communical latrine (21), with not
more than 20 (66) or at most 25 users per cubicle (21). Structures should be sited less
than 50 metres (66) from people’s houses, and at most 250 metres (21).
87
Sanitation in emergencies
In the early stages of an emergency it is not usually feasible to provide household
latrines or even enough communal latrines. It may be necessary to construct
structures with 50 to 100 users per cubicle or metre of trench (if trench latrines are
used) to begin with. This must be upgraded as soon as possible to communal
latrines with 20 users per cubicle, or household latrines (47). As it is not normally
possible to provide adequate structures from the beginning, and the aim should be
to decrease the health risks and increase the convenience to the users as quickly as
possible.
Start by discouraging people from defecating near any water source used by
people and animals, or in fields where crops for consumption are grown. As soon
as possible defecation should be confined to specific areas: open defecation fields
or trench defecation fields. The next step could be to install trench latrines, or
communal borehole or pit latrines. Following that latrines could be installed at
household level if feasible (64). Provision should progress through these steps as
soon as possible, to use the best feasible structures at all times.
If insects can access the contents of the latrines, the excreta should be covered
with 0.1 metre of soil every two to three days (21).
Where soil stability, soil erosion, or rats could become a problem, the top 0.5
metres of a pit should be protected with a closed lining. If the soil cannot carry
much weight the superstructure should be light. It may be necessary to make a
foundation in the form of a concrete ring beam to make the latrine structurally
sound (30). The more complex a latrine becomes, the more expensive and demand-
ing its construction will be.
Latrines should be built so that insects cannot enter the pit. This can be achieved
by installing a tight-fitting lid (this is difficult in a communal structure), a water
88
seal (this will only be adequate if water or soft paper is used for anal cleansing), or
a VIP-latrine (this type of latrine is probably less adapted to use at household level
as they are expensive and rather complex; in addition, VIP latrines usually do not
stop mosquito breeding). If the latrine is ‘wet’, polystyrene beads can be used to
create a floating layer which will prevent mosquitoes from breeding in the pit (61).
All other openings which give access to the pit containing excreta should either be
sealed or closed with flyproof netting.
Vandalism and theft must be prevented by sealing the lids of access-holes with
mortar or locking them and by making structures as solid as possible; this is
especially important in communal structures.
This example of a pit latrine (Figure 6.3) shows some of most important points for
proper use.
89
Chapter 7
Drainage
This chapter looks at the health risks caused by the presence of water1 in the
human environment and how this water can be drained. The purpose of drainage is
to remove unwanted water from the human environment (17). It is often difficult to
make a clear separation between ‘unwanted’ and ‘wanted’ water, as people will
usually use surface water, for example for irrigation or watering animals. What is
unwanted, however, are the health risks associated with surface water.
From a health point of view, the properties of the surface water are usually more
important than its origin. The WES specialist needs to separate the different
sources, as different types of structure will be needed to deal with them properly.
In the section on surface water and the transmission of disease we will look
generally at surface water, while in the section on the practical aspects of drainage
we focus on the sources of water and how to cope with them.
Drainage must handle water of different origins: domestic waste water (or sul-
lage), rainwater (or stormwater, runoff), floodwater, and water from natural
sources (e.g. springs).
Sullage includes used water (e.g. washing water), water spilled at the distribution
point, water from leaks in the system, or from taps. Sullage is usually produced
in low volumes, and without seasonal fluctuations.
Stormwater is that rainwater that has not infiltrated into the soil, was not
intercepted by the vegetation, and did not evaporate. This surplus water will
either collect in depressions in the surface, or flow over the surface until it
reaches channels, streams, or rivers, through which it will be evacuated.
Stormwater often occurs in large volumes, and is a seasonal problem.
Floodwater is generally water from overflowing rivers or channels. Flooding is a
seasonal problem which usually involves large volumes of water (15).
1
The health risks associated with water in the human environment are normally caused by fresh surface water
90
Natural water sources can result in unwanted water if the water is able to collect
in large puddles or ponds.
In addition, industry, agriculture, mining, and other activities (e.g. medical facili-
ties, abattoirs) may produce waste water. Most of the health risks related to these
will be similar to the other types of surface water, but there may be specific health
risks related to these types of waste water. These specific health risks are not
covered by this manual.
Surface water can exist in many types of reservoirs. Naturally occurring surface
water is found in lakes, marshes, natural ponds, streams, rivers, puddles – even
leaf axils collecting rainwater can form ‘reservoirs’. Artificial reservoirs of sur-
face water include irrigation systems, channels, artificial water reservoirs (e.g. for
hydroelectric power generation), overhead tanks, swimming pools, and pits re-
sulting from construction work, agriculture, mining, brickmaking or other activi-
ties. Even small ‘vessels’ like old tyres, drums, blocked roof gutters, empty plant
pots, or old cans that accumulate (rain)water may serve as a reservoir for ‘surface
water’.
On the other hand improved drainage may degrade the environment if natural
wetlands or ponds dry out or are filled in, if the local water-balance is disturbed, or
if organically polluted drainage water is discharged into surface water, using up all
its oxygen.
Artificial reservoirs are built to benefit people, for example by providing electric-
ity or water for irrigation. In addition dams may benefit people downstream, as the
flow of rivers or streams can be regulated, reducing the risks of floods or draughts.
On the down side, people are often displaced and land and property lost when
large artificial reservoirs are created. A dam may become a problem if people – or
nature – are deprived of the water they depend on. If a dam bursts, a dangerous
situation is likely to result.
91
If sullage or stormwater is discharged into fresh surface water (e.g. streams, rivers,
lakes), the surface water will be polluted with excreta. This will result in a risk of
faecal-oral infections and beef and pork tapeworm if people and animals use this
water as drinking-water.
Any type of fresh surface water which is contaminated with urine or faeces can
become a transmission risk for schistosomiasis. As the pathogen multiply in
snails, even a light contamination of the water can create a large potential for
transmission. Only fast-flowing rivers and streams, and deep water at a good
distance from the shores, will be relatively safe (15). Schistosomiasis is often
associated with irrigation schemes and artificial reservoirs (36).
Temporary pools and small containers (e.g. cans, drums, blocked gutters) full of
relatively clean water are potential breeding sites for the Aedes mosquitoes which
transmit filariasis, yellow fever, dengue fever, and several other arboviruses. The
eggs of Aedes mosquitoes can survive for months outside the water, but must be in
the water to hatch.
Where organically polluted water can accumulate (e.g. stagnant water polluted
with waste from sanitary structures, organic refuse, or rotting plants), Culex
mosquitoes, which transmit filariasis and several arboviral infections, can breed.
Culex quinquefasciatus is often a problem in urban areas.
Where ponds or puddles of relatively clean water form, preferably with some form
of vegetation, Anopheles mosquitoes, vectors of malaria and filariasis, can breed.
Anopheles mosquitoes also breed in lakes, rice fields, and calm areas in slow
92
streams (61). Malaria is a problem associated with the presence of artificial reser-
voirs (6).
Surface water does not need to be permanent to be a risk; mosquitoes and snails
can breed and survive in temporary or seasonal puddles and ponds. Mosquitoes
can develop from egg to adult in less than two weeks (80). Snails transmitting
schistosomiasis can survive in ponds that dry up seasonally (5), and one snail can
grow out into an infectious colony within two months (73).
If drainage water comes in contact with soil, it can become contaminated with
soil-transmitted helminths (e.g. hookworm disease, roundworm infection). The
soil-transmitted helminths need moist soil in which to breed, an environment
which can be created by inadequate drainage. Sandflies, the vector of leishmania-
sis, Bartonellosis and several arboviruses, breed in humid, organic soils (61).
Rats are attracted to surface water, and can be a host for a multitude of infections
including plague (80).
93
hs ct
Risk-factors related to drainage w o i nt rm n ta ns
s t m o o
io
n
i th ts he
l ew c ti c o n
c tio
t w s p
i Water accumulates c
si
s
d ho ted ta fe ct fe
fe in in
ii The drainage functions poorly, l in ia se te i t o rk i s m d ire e
m a a m s or n
or is badly designed ra so r-b di ns
p ro by or
l-o to te me tra a nd s pi a -w d r -b
a s o e a o
ec hi Wa ter oil- ef pt in re ct
Fa Sc in S Be Le Gu Sp Ve
Although most mosquitoes do not like salt water, some can breed in slightly salty
water. Anopheles mosquitoes are in general more sensitive to salt water than
Culex and Aedes mosquitoes (77). Some species of Aedes mosquitoes are able to
breed in coastal salt marshes (61).
94
Where waste water is not polluted with pathogens (e.g. water spilt at a hand-dug
well or handpump), it can be fed directly into a garden or vegetation. Care should
be taken that no ponding can occur.
Soakaway pits and trenches can be used where waste water could be polluted,
space is available, and the infiltration capacity of the soil is sufficient. A soakaway
will have to be adapted to the physical situation and the characteristics of the
sullage to prevent blockage or overloading.
Baffle
Water towards
Sullage
soakaway
95
Figure 7.2. Section of a drain for evacuating stormwater and sullage (17)
Where sullage contains solids, they should be removed by straining the waste
water or feeding it through a silt trap (i.e. a small reservoir which allows the solids
to settle) . If the waste water contains grease or soap, a grease trap will have to be
installed. Silt and grease traps should be impenetrable to insects and rats cannot
enter. Figure 7.1 shows a model of a grease trap. Regular maintenance is necessary
to ensure that these structure function properly.
Where the population density is high or the soil relatively impermeable, on-site
disposal may not be possible. If there is a sewage system sullage can normally be
discharged this way. If on-site disposal and sewerage are not present or possible, it
may be necessary to dispose of the waste water in drains. Figure 7.2 shows a drain
96
which can dispose of sullage as well as stormwater. The small channel in the drain
is to discharge sullage, and its rounded form allows small amounts of water to
flow at sufficient velocity to keep solids in suspension. This practise is not ideal as
people, animals, and insects can come into direct contact with the waste water, but
it is better than allowing waste water to pond. The health risks of discharging the
waste water will have to be assessed, and if necessary, reduced.
Before considering using existing structures (e.g. pit latrines) for disposoing of
waste water, investigate whether the existing structure can cope with the quantity
of waste water that is to be discharged. Up to 80 per cent of the water supplied to
users may become sullage (17).
Annexe 5 can be used to estimate the infiltration capacity of an existing pit already
used for excreta. Discharging more liquid into the pit will also increase the
distance that pathogens from the excreta in the soil will travel.
The size, type, and finish of the drainage system will depend on the availability of
funds and the potential damage a flood could cause. The greater the risk, the
greater the amount that should be invested in preventing flooding. Drainage
systems need to be designed in combination with other structures (e.g. roads,
buildings) to adapt the structures to one another.
Refuse, soil, and the vegetation which accumulates in drainage channels will
reduce the capacity of the system, and regular maintenance will be needed to keep
it functional. Regular maintenance and inspection will also deal with collapse or
other structural damage in the system.
97
but the basic maintenance of the system at neighbourhood level (e.g. removing
blockages, cleaning the channels) is probably best done at household level (17). The
problem of solid waste management should be addressed in the planning phase of
the drainage system as poor management of refuse (e.g. domestic waste or waste
from construction) will result in inappropriate waste ending up in the drainage
system.
Where the channels are not protected with a lining, erosion can be a problem if
water flows at high speed or if the sides of the drains are too steep.
If tools or other materials are required for maintenance, these must be available to
those who need them.
The best way to deal with potential breeding sites for Aedes mosquitoes depends
on the situation: solid waste must be removed, water tanks and drums must be
covered with a lid or mosquito-proof netting, gutters should be maintained,
hollow construction blocks or bricks should be filled, containers that are needed
but not used should be turned upside down, and holes in trees must be filled (61). It
will only be possible to control Aedes by teaching people to be very vigilant and
attentive to the problem.
Where springs result in ponding they can be protected (see Figure 5.3) to reduce
the health risks.
98
Chapter 8
Solid waste management is about dealing with refuse. This chapter looks at
communicable disease in relation to solid waste, and presents some practical
issues about managing refuse. Solid waste management up to neighbourhood
level, including local health structures, is considered, but the management of
wastes from industries, mining, or structures like large hospitals or abattoirs are
more specialised, and will not be covered here.
Poor solid waste management will result in an unpleasant and often unsafe
environment to live or work in. In addition, piles of refuse can be a fire hazard (15).
In urban areas refuse often ends up in drainage systems, creating drainage prob-
lems (see Chapter 7).
As drainage systems are frequently used for defecation, the solid waste that
accumulates in the system is often contaminated, and is a health risk to those who
have to handle it (39). (For the health risks related to blocked drainage systems see
Chapter 7.)
99
Organic waste from households, restaurants, and markets attracts rats, which are
potential hosts for many infections (e.g. leptospirosis, plague). Organic waste also
serves as food and a place to rest and hide for domestic flies, which can transmit
faecal-oral infections and infections spread by direct contact, and cockroaches,
which can transmit faecal-oral infections.
Other animals which use refuse dumps to rest and hide include mosquitoes;
sandflies, vector of leishmaniasis, bartonellosis, and several arboviruses; and
reduviid bugs, which can transmit American trypanosomiasis (61,80).
Refuse often includes materials which can collect rainwater, such as tin cans, jars,
and old car tyres. Aedes mosquitoes, which transmit filariasis, urban yellow fever,
dengue fever, and several other arboviral infections, can breed in these small
water-filled vessels (67).
Table 8.1 summarises the health risks relating to poor solid waste management.
It is not always necessary to collect waste. In rural areas much of the refuse is re-
used (e.g. feed for animals, containers, toys) and solid waste will often be less of a
problem. In high-density (peri-) urban areas, however, waste may become a
serious problem if poorly managed.
If on-site burial or burning are not possible, waste has to be collected. If afford-
able, household bins will usually be the most appropriate way of collecting and
storing household wastes. Where this is not feasible, communal storage of the
waste will be necessary. Collection points must be convenient if they are to be
used, and their location must be chosen in collaboration with users. The structures
should be designed and built so that insects, rats, and rainwater are kept out, and
so that people are discouraged from using them for defecation. The emptying and
maintenance of the structures by workers must be made as easy as possible.
100
Table 8.1. Disease groups where poor solid waste management playa a role in
transmission (adapted from 60)
hs ct
Risk factors of poor solid waste w o i nt rm n ta ns
s t m o o
management: io
n
i th ts he
l ew c ti c o n
c tio
t w s p
c
si
s
d ho ted ta fe ct fe
fe in in
i Animals have access to l in ia se te i t o rk i s m d ire e
m a a m s or n
ra so r-b di ns
p ro by or
organic waste
l-o to ate me tra a nd s pi a -w d r -b
ii No regular collection a s o e a o
ec hi W ter oil- ef pt in re ct
iii Other Fa Sc in S Be Le Gu Sp Ve
i Rats (a)
Domestic flies/
cockroaches
Excreta in refuse
(a)
: Flea-borne infections (plague, murine typhus fever)
(b)
: The risk is caused by domestic flies
(c)
: Vectors use refuse as a hiding/resting place: mosquitoes, sandflies, reduviid bug
(d)
: Aedes mosquitoes
(e)
: For humans: cysticercosis; for cattle and pork: beef and pork tapeworm
(f)
: Culex mosquitoes
The collection points have to be managed correctly, otherwise they will become a
health threat. Regular collection is essential. In hot climates flies and rats can be
attracted to solid waste within two days, so the refuse probably needs to be
collected daily or every other day (17,21).
101
In developing countries burying the refuse will usually be the most practical way
of disposal. To prevent animals from accessing the refuse, it should be covered
daily with 0.15m of soil. The last layer of soil covering the waste should be at least
0.5m thick (253,350). Incineration is usually not feasible because of the frequently
high content of moist (organic) waste, which would use too much fuel to burn.
There are different types of medical waste: sharp objects (e.g. needles, syringes,
blades), material which has been in contact with blood, puss, or other body fluids
(e.g. bandages or cotton wool), and organic waste (e.g. placentas).
There are many infections which could be transmitted through these wastes, and it
is therefore important that they are disposed of so that the pathogens are isolated
from people or animals.
To make sure the medical waste is properly dealt with, and to ensure that
scavengers (e.g. children, animals) do not have access to it, the waste should not
leave the compound of the health structures. The incinerator and waste disposal pit
should be near each other, and should be fenced off to keep people and animals away.
Although the medical waste disposal pit is similar to a pit latrine, latrines should
not be used for medical wastes as there is a risk of contaminating the slab or
superstructure.
102
Whether normal waste from the health structure can be disposed of without
special precautions will depend on how well the medical and uncontaminated
waste are separated. If there is any doubt, all normal waste should be treated as
medical waste and incinerated.
People dealing with waste in a health centre must be aware of the health risks, and
be provided with protective clothing and adequate tools.
The exceptions are people who die during outbreaks of cholera, louse-borne
typhus, or plague (21). The dead bodies of people who die during these epidemics
should be handled carefully. The bodies (and clothes) should be disinfected or
treated rapidly; and the bodies should be manipulated as little as possible before
burial or cremation.
103
104
Annexe 1
Annexes
A1
105
106
A diarrhoeal disease with fever. Often the diarrhoea contains blood (dysentery). Usually a disease of
infants. The infection will often be transmitted by domestic animals.
Oral Faeces
Human
Annexes
Transmission:
e.g. food, fingers, Human
water
Animal
Faeces Oral
A1
Transmission : transmission takes place through contaminated food, water, or through contact
with infected animals. The infective dose is around 500 bacteria (16)
Reservoir : humans, cattle, poultry, swine, sheep, cats, dogs, rodents, birds. Animals
(especially poultry and cattle) (3) are the major reservoir for the pathogen.
C.jejuni can survive for up to 5 weeks in milk or water at 4oC (16)
Vector/int. host : none
Water-related : water-washed and water-borne (in developing countries transmission often
occurs through surface water contaminated by animals) (16)
Excreta-related : faecal-oral (15)
Environment : an environment with poor sanitation, poor personal hygiene (44), inadequate
water availability, use of water of poor quality, close contact between food or
people and reservoir animals (e.g. poultry, cattle, goats and dogs) (16)
Risk in disaster : the infection is a risk where poor sanitation is combined with mass feeding(3)
Remarks : an estimated 5-14% of all diarrhoea worldwide is caused by C.jejuni (3)
107
People with symptoms should not handle food or come in close contact with institutionalised persons
(1)
Epidemic measures : groups of patients should be reported to health authorities. If feasible the
source of infection should be determined and eliminated (3)
Annexes
A1
108
A diarrhoeal infection with a wide range of symptoms. The infection can be severe, and one group of
E.coli is able to cause dysentery outbreaks.
Annexes
Oral Faeces
Human
Transmission:
e.g. food, fingers, Human
water
(a)
Cattle
Faeces Oral
(a)
: cattle is a reservoir for E.coli 0157:H7 A1
(a)
: cattle is a reservoir for E.coli 0157:H7
Transmission : through the ingestion of contaminated food or water, or through contact with
an infected person. For E.coli 0157:H7, contact with cattle. The infective
dose of E.coli 0157:H7 is very low (3)
Reservoir : for most strains: only humans (3), though dogs are mentioned as a potential
reservoir (73). E.coli can multiply outside the host on food. Cattle is a reservoir
for E.coli 0157:H7 (3)
Vector/int. host : none
Water-related : water-washed and water-borne (15)
Excreta-related : faecal-oral (15)
Environment : an environment with inadequate sanitation, poor personal hygiene, poor water
availability, poor drinking water quality (44)
109
People who are sick should not handle food, or work with institutionalised persons (3)
.
Epidemic measures : in outbreaks the source of infection should be searched for and eliminated (3)
Annexes
A1
110
Oral Faeces
Human
Annexes
Transmission:
e.g. food, fingers, Human
water
Animal
Faeces Oral
Transmission : cattle, pigs, poultry, dogs, cats, birds, and turtles, are potential reservoirs of
the pathogen. Sick people or carriers are also important sources of the A1
pathogen. Usually transmission occurs through contaminated animal products
(poultry, meat, egg). Other ways of transmission are contaminated water
(though water-borne transmission is rare) (16), or contact with infected persons
or animals. Transmission through contaminated hands can be important.
The bacteria can multiply in infected food (especially milk) (3). The infective
dose is from very small to high (16)
Reservoir : human, dogs, cats, cattle, pigs, poultry, rodents, turtles, tortoises (3)
Vector/int. host : none
Water-related : water-washed and water-borne (15)
Excreta-related : faecal-oral
Environment : an environment with inadequate sanitation, poor water availability, poor
personal hygiene, and poor food hygiene
Risk in disaster : the infection is a risk where poor sanitation is combined with mass feeding (3)
Remarks : -
111
Adequate food hygiene during the slaughtering of animals, and the preparation and distribution of
food is important. Cooked food and raw meat should not be brought into contact with each other (16).
People who are sick should not handle food, or care for institutionalised persons. Individuals handling
food should have clean fingernails (3)
Epidemic measures : the source of the infection should be identified, and dealt with (3)
Annexes
A1
112
Oral Faeces
Human
Transmission:
Annexes
e.g. food, fingers, Human
water
Animal
Faeces Oral
113
Infected people should not handle food or care for institutionalised persons (3)
Epidemic measures : groups of patients should be reported to health authorities. The source of
infection should be determined and eliminated (3)
Annexes
A1
114
The most important infection causing dysentery (83). The infection is a disease of poor and crowded
communities (16). Shigellosis has the ability to cause large outbreaks, especially in displaced
populations (47).
Annexes
Oral Faeces
Human
Transmission:
e.g. food, fingers,
water, domestic flies
Human
Faeces Oral
A1
115
Risk in disaster : a serious risk where overcrowding is combined with poor personal hygiene
and poor sanitation (4)
Outbreaks : the signs for potential outbreaks are an unexpected increase of cases of
dysentery in a population, or an increase in the number of death caused by
bloody diarrhoea. In an outbreak, all age groups will be attacked (contrary to
endemic shigellosis, which mainly occurs in children). Epidemic dysentery is
caused by Sd1 (Shigella Dysenteriae type 1) which has a case fatality rate of
5 to 15% (83). With appropriate treatment this can be reduced to 2 to 5% or
lower (47).
In a stable population around 5% (47) to over 10% (16) of the total population
can be expected to develop the disease. Of the sick around 10% will need
hospitalisation (47).
In a refugee setting however, over 30% of the population may fall ill, with
weekly attack rates of 2 to 10% of the total population. The total attack rate
seems to be related to population density (47)
Remarks : In many places Shigella spp. is responsible for 5 to 10% of normally occurring
diarrhoeal diseases (4). Shigella is estimated to be responsible for around
600,000 deaths per year worldwide, most of which are children.
It must be assumed that only a small proportion of the total number of cases
will be reported (3).
The pathogen can develop resistance to antibiotics during an epidemic (83)
People who are infected should not handle food, or care for institutionalised persons or children.
Fingernails should be kept clean and short (3)
Epidemic measures : groups of patients should be reported to the health authorities, the source of
infection should be determined and reacted upon (3). During large outbreaks
the places where dysentery cases are treated should be isolated from other
health services (47). Management of the outbreak should be similar to that of
cholera (73). If malnutrition is a problem, sufficient food should be made
available. If people have no easy access to soap, it must be made available
if appropriate (47).
116
Cholera
A diarrhoeal disease with a potential of causing large outbreaks. The disease is a serious health
threat where poor sanitation, crowding and poor hygiene exist.
Annexes
Incubation period : 1 to 5 days (73)
Duration : the disease lasts for up to one week (2)
Communicability : infected persons without symptoms will discharge bacteria for up to 2 weeks
(83)
. The sick will often discharge pathogens for up to some days after recovery.
Some persons will become carriers for several months. Chronic carriers do
exist but are very rare. If antibiotics are effective against the type of V.cholerae
causing infection, treating people with these will reduce the period of
communicability (3)
Human
Transmission:
e.g. food, fingers,
water, domestic flies
Human
Faeces Oral
117
The usual infective dose is 106 to 108 bacteria, though with some persons
103 may suffice. A severe case can excrete 107 to 109 Vibrio/ml of diarrhoea
while an asymptomatic case may shed 102 to 105 Vibrio/mg of faeces (73).
Reservoir : humans are the only host (16), marine shellfish and plankton can be reservoirs
(83)
, and V.cholerae can survive in association with these reservoirs for several
months. Some information on the viability of the bacteria in food (16):
At 30 to 31oC At 5 to 10oC
Fruits 1-3 3-5
Cereal 1-3 3-5
Cooked foods 2-5 3-5
Fresh vegetables 1-7 7-10
Fish and seafood 2-5 7-14
Milk and dairy products 7-14 more than 14
Where people use drinking water of poor quality (73). Where cholera is endemic,
it tends to be a disease of the poor (3).
Risk in disaster : a serious risk where the disease is endemic, overcrowded conditions, and
where sanitation is poor (3)
Outbreaks : where an outbreak is likely, the preparation must start well before an outbreak
occurs. In a refugee setting a number of precautions must be taken: an early
detection system must be operational and units where cholera cases can be
treated must be planned. When the risk of an outbreak increases, material
to deal with the outbreak should be present and cemeteries must be planned.
Medical personnel should be trained in detecting cases and dealing with
A1
them. The population should receive health and hygiene promotion (47).
The attack rates in a population will depend on the level of overcrowding, the
situation concerning sanitation, and the level of immunity in the population.
In a refugee setting, around 5% of the population can be assumed to develop
a severe form, though higher attack rates are possible. In Goma (1994) 8%
of the total population was struck. In a refugee camp an epidemic will generally
last 3 weeks to 3 months.
In an open setting, 1-2% of the total population can be expected to develop
a severe form of the disease (47).
Some information on logistics: in a refugee setting around ¾ of the severe
cases will need 8 litres of Ringer Lactate (intravenous rehydration fluids) (47).
The needs of a patient in fluids can sometimes be over 20 litres per day (73).
Large quantities or ORS (Oral Rehydration Salts) should be available. In an
open setting the requirements will be lower than those in a refugee setting (47).
118
Population
Number of at risk
=
beds needed 200
Annexes
Control of domestic flies where contaminated waste is present (47)
(see Annexe 3)
Prompt and hygienic burial of the dead (73)
Corpses of people who died of cholera should be disinfected. Travel restrictions are not effective in
preventing the disease (47), neither are the restrictions of food movements (3).
Epidemic measures : if feasible, the source of the outbreak should be determined and eliminated. A1
Treatment facilities separated from other health services should be arranged
to be able to deal adequately with the potentially large numbers of cases.
Drinking water should be chlorinated. Where possible, sanitation should be
improved (3).
If soap is not easily available to the population, it should be supplied (47) if
feasible and adequate.
119
An acute diarrhoeal disease. Relatively little is known on the transmission of the disease and its
prevention.
Oral/ Faeces/
Respiratory Respiratory
Human
Transmission:
e.g. fingers,
water, air
Human
Annexes
Faeces/ Oral/
Respiratory Respiratory
Transmission : transmission from person to person is probably the main way the pathogen
is spread (3). Water-borne transmission does occur (16). Rotavirus can be present
in lung secretions and respiratory transmission is possible (3,73). In tropical
A1
zones the disease occurs throughout the year with a slight increase in the
cool period. In temperate zones the infection occurs in the colder seasons(3).
The infective dose is 102 to 104 viruses. An infected person can excrete 1011
pathogens per ml of faeces (16)
Reservoir : humans are the only known reservoir (3)
Vector/int. host : none
Water-related : water-borne (16)
Excreta-related : faecal-oral (73)
Environment : unknown. The infection often occurs in institutions like school or hospitals
(44)
120
Prevent. measures : effective preventative measures are not obvious (3). The infection is as frequent
in developing countries as in developed countries, and it is therefore unlikely
that improved personal and environmental hygiene could prevent the infection
(16)
Annexes
A1
121
Oral/ Faeces
Respiratory?
Human
Transmission:
e.g. food, water,
fingers, air?
Human
Faeces Oral/
Respiratory?
Annexes
Transmission : probably faecal-oral transmission. Food and water have been linked to
outbreaks. Airborne spread is suggested (3)
Reservoir : only humans have been identified as reservoir (3)
Vector/int. host : none
Water-related : the infection is probably water-borne and water-washed (3)
Excreta-related : most likely faecal-oral (3)
Environment : -
A1
Epidemic measures : if possible, the source of infection should be identified and eliminated (3)
122
A very common diarrhoeal infection. A typical symptom is gradually developing bloody diarrhoea.
Where sanitation is poor, over 50% of the population may be carrier of the pathogen.
Annexes
Communicability : the period of communicability can be years (3)
Oral Faeces
Human
Transmission:
e.g. food, fingers,
water, domestic flies
Human
A1
Faeces Oral
123
Vector/int. host : domestic flies can function as mechanical vectors, and can carry the cysts
for up to 5 hours (73)
Water-related : water-washed and water-borne (15)
Excreta-related : faecal-oral
Environment : common in an environment with poor personal hygiene, inadequate sanitation
(2)
, poor food hygiene, and use of drinking water of poor quality (16). The
infection can be a problem in mental institutions (3)
Risk in disaster : the disease could be a potential problem (3)
Remarks : It is estimated that around 480,000,000 people are infected worldwide,
and that the infection causes around 100,000 deaths per year (44).
Cysts are killed at temperatures over 50°C (3). Chlorination of drinking water at normal concentrations
is not very effective against cysts (3). A chlorine concentration of over 3.5 mg/l is needed to kill the
cysts (recommended chlorine concentration for drinking water: 0.2-0.5 mg/l at distribution point).
Iodine is more effective against the pathogen than chlorine (73).
Epidemic measures : the source of infection should be identified, and dealt with (3)
A1
124
Oral Faeces
Annexes
Human
Transmission:
e.g. food, fingers,
water, domestic flies
Human
Faeces Oral
A1
Transmission : faecal-oral. Transmission seems to occur mainly through hand to mouth
contact (3). Water-borne and food-borne transmission do take place, but are
probably less common than transmission through contaminated hands (16).
Still, water-borne outbreaks have occurred where people have used
contaminated water supplies (2); and small food-borne outbreaks have
happened (3).
The infective dose is 10 to 100 cysts (16)
Reservoir : the main reservoirs are humans and contaminated surface water (16). An animal
reservoir seems to exist (3), but its role in human infections is not clear (16).
The cysts of Giardia are resistant, and in cold water they can remain viable
for months (44)
Vector/int. host : none
Water-related : water-washed and water-borne (15)
Excreta-related : faecal-oral (44)
Environment : a common infection where sanitation is poor (2), personal hygiene is
inadequate, and the quality of drinking water is poor (16)
Risk in disaster : the infection will normally not be a risk (3)
125
Normal chlorination of drinking water is not effective against giardia cysts (73)
.
Epidemic measures : if clustered cases occur, the source of infection should be determined and
dealt with (3)
Annexes
A1
126
Cryptosporidiosis
Oral Faeces
Human
Annexes
Transmission:
e.g. food, fingers, Human
water
Animal
Faeces Oral
127
Remarks : In developing countries the infection can be responsible for 4 to 17% of the
cases of childhood diarrhoea (16), and the pathogen may be found in the
stools of in 3 to 20% of the population (3)
Persons with an infection should not handle food, or work with institutionalised people. Chlorination
of drinking water will not kill the pathogen (3).
Epidemic measures : if cases occur in clusters, the source of infection should be determined, and
eliminated (3)
Annexes
A1
128
A relatively rare diarrhoeal disease. The source of human infection is usually pigs.
Oral Faeces
Human
Transmission:
e.g. fingers, Human
water, food
Swine
Annexes
(primarily)
Faeces Oral
Transmission : transmission is faecal-oral. Pigs seem to be the main source of infection (2).
Single cases occur through hand to mouth contact, or through ingestion of
contaminated water or food. Outbreaks are often water-borne (3).
The infective dose is low (15)
Reservoir : the main reservoir transmitting the disease to people are pigs. Other reservoirs
are humans, rodents (2) and primates (3). A1
Cysts of B.coli are rapidly destroyed in hot and dry conditions but can survive
for several weeks in a moist environment (16)
Vector/int. host : none
Water-related : water-washed and water-borne (15)
Excreta-related : faecal-oral (15)
Environment : an environment with close contact between pigs and humans (16). Use of
poor quality drinking water; where personal hygiene is poor and sanitation
inadequate (3)
Risk in disaster : the infection does not pose a large risk (3)
Remarks : the disease is relatively rare in humans (3). In some places 40 to 90% of the
pigs are though to be carriers of the pathogen (16)
129
Chlorination of drinking water is not effective in killing the cysts of B.coli (3)
Epidemic measures : if a group of infections appears, the source of infection should be looked for
and eliminated (3)
Annexes
A1
130
Faecal-oral diseases that cause sustained fever. Typhoid is more severe and more easily transmitted
than paratyphoid. (Small) outbreaks can occur. Permanent carriers do exist and play an important
role in transmission.
Annexes
Communicability : Typhoid: 2 to 5 % of the untreated cases will turn into chronic carriers (3)
(who do not necessarily have a history of being sick (4)).
Permanent carriers in paratyphoid exist, but are less common than in typhoid
fever (3).
Urinary carriers excreting pathogens after the third month of infection are
rare, except in persons with urinary schistosomiasis (16)
Faeces/
Oral Urine A1
Human
Transmission:
e.g. fingers, water,
food, domestic flies
Human
Faeces/
Urine Oral
131
paratyphoid (3) (the infective dose of typhoid is 103 to 109 bacteria (73)). The
higher the ingested dose of bacteria is, the higher the attack rate will be (2).
While typhoid is more frequently transmitted by water than by food (4),
paratyphoid is less often water-borne as it has a high infective dose (16).
In an outbreak of typhoid fever the number of cases can be expected to
double every 2 weeks (47)
Reservoir : humans are the only reservoir for typhoid, and the normal reservoir for
paratyphoid. Domestic animals can be a sporadic reservoir for paratyphoid
(3)
.
In fresh water S.typhi can survive for up to 4 weeks, in raw sewage possibly
for over 5 weeks (73). S.typhi can survive in sea water, which makes seafood
dangerous (4)
Vector/int. host : domestic flies can be mechanical vectors (3)
Water-related : both infections are water-washed and water-borne (15)
Excreta-related : faecal/urinary-oral (73)
Environment : an environment with poor personal hygiene, inadequate sanitation (2), poor
quality of drinking water, and inadequate food hygiene (45)
Risk in disaster : large outbreaks are unusual, but smaller outbreaks or single cases can appear
over longer periods (47). The infections can be a problem where sanitation is
inadequate, and the quality of water poor (3). Typhoid is often a problem after
disasters involving flooding (74)
Remarks : every year roughly 17,000,000 cases of typhoid occur worldwide, of whom
around 600,000 will die (3)
Carriers should not handle food or work with institutionalised persons (3). Fingernails should be kept
short and clean (73). Pasteurisation of milk at 60°C is effective in killing typhoid bacteria (73).
Epidemic measures : the ultimate source of infection is always a person (16). If possible this source
of infection should be identified and dealt with. Food believed to play a role
in transmission should be avoided. Water used for drinking should be
chlorinated (3)
132
Faecal-oral diseases with fever and jaundice. Hepatitis E occurs mainly in outbreaks, and is very
dangerous to pregnant woman.
Annexes
Transmission cycle (3)
Oral Faeces
Human
Transmission:
e.g. water, food,
fingers
(Hepatitis A: blood
Human
and secretions?)
Faeces Oral A1
Transmission : transmission occurs through the ingestion of contaminated water or food (73).
Transmission from person to person is possible (4). Faeces of people in the
incubation period of hepatitis A contain very large numbers of viruses (16).
Outbreaks of hepatitis A are uncommon as people are normally infected at
an early age and develop immunity (73). The risk of an outbreak increases
though if part of the population is not immune because of improved sanitation
and personal hygiene (3).
The carrier state in hepatitis A is not important. Salads, cold meat and raw
seafood are often implied in the transmission of hepatitis A (73). Hepatitis A
can possibly be transmitted through blood and secretions (4).
Hepatitis E occurs mainly in outbreaks (73), with the highest attack rates in
young adults. Outbreaks of hepatitis E are often caused by water-borne
transmission (3).
The infective doses for the infections are high (73)
Reservoir : humans are the main reservoir for the hepatitis A virus. In exceptional cases
133
primates can be a reservoir. The reservoirs for the hepatitis E virus are not
known, and animal reservoirs
are possible. The virus can be transmitted to certain primates and pigs (3)
Vector/int. host : none
Water-related : the infections are water-washed and water-borne (15)
Excreta-related : faecal-oral
Environment : the diseases occur where people have poor personal hygiene, inadequate
sanitation, live under crowded conditions, and have drinking water of poor
quality (3)
Risk in disaster : a potential problem where crowding, poor sanitation and poor water supply
occur (3). Hepatitis E will probably pose the largest risk.
Remarks : people who have been infected with hepatitis A are probably immune for life
(3)
, though there are indications that people can be re-infected if they ingest
a large quantity of pathogens (73).
Epidemic measures : the source of infection should be determined and dealt with. Personal hygiene,
sanitation and the quality of the drinking water should be brought up to
standard (3)
A1
134
A highly contagious faecal-oral disease. The infection has disappeared from most parts of the world.
A typical symptom which appears in a small number of infected persons is lasting paralysis.
Oral/ Faeces/
Respiratory Respiratory
Transmission: Human
Annexes
e.g. water, food,
fingers, respiratory secretions:
transmission through
food and water Human
is rare
Faeces/ Oral/
Respiratory Respiratory
Transmission : poliomyelitis is a very contagious infection (4), and is mainly spread by direct
person to person contact. Respiratory transmission is possible, and can be A1
important if sanitation is adequate (3) or during outbreaks (47). It is rare that
food or water are associated with transmission (3). Transmission of poliomyelitis
will stop in a population when 80 to 85% of the people have been immunised
successfully (50).
The infective dose of the infection is low (15)
Reservoir : human (3)
Vector/int. host : none
Water-related : water-washed and sporadically water-borne (15)
Excreta-related : faecal-oral
Environment : the disease is linked to poor personal hygiene (73). In the tropics a small
seasonal increase in cases can be expected in the hot and rainy season.
Outbreaks can occur in regions where people have a low immunity to the
infection (either because they have not been immunised, or because the
infection is not endemic) (3).
Risk in disaster : a potential problem where crowding, poor sanitation, and poor personal
hygiene are found in a non-immune population (3, 73)
135
136
Oral Faeces
Human
Transmission:
e.g. fingers, water, food,
swallowing an insect which
injested Hymenolepis eggs Human
Annexes
Insect
Faeces Oral
Transmission : faecal-oral. The eggs are often directly infective when excreted. Transmission
is water-borne, food-borne, or hand to mouth (3). Insects (e.g. fleas (45)) which
ingested eggs of Hymenolepis can transmit the pathogen when swallowed (3)
Reservoir : humans, mice could play a role as a reservoir, insects (3) A1
Vector/int. host : contaminated insects could transmit the pathogen if ingested (3)
Water-related : water-washed and water-borne (15)
Excreta-related : faecal-oral (15)
Environment : more common in warm and dry climates (3)
Risk in disaster : the infection is not a risk in a disaster (3)
Remarks : -
137
Epidemic measures : -
Annexes
A1
138
Annexes
Improving handwashing practise (73)
Long fingernails can more easily gather eggs and should therefore be kept short (3)
Epidemic measures : systematic treatment of cases, their family, and other contacts (3)
A1
139
The source of this potentially severe infection is dog faeces (or faeces of other canines). Transmission
of the disease is faecal dog – human oral.
Oral
Human
Transmission:
e.g. food, water, soil, Body tissue
direct contact with Herbivore
infected dogs,
(domestic flies)
Canine
Faeces (dog) Oral
A1
Transmission : dogs or wild canines excrete infective eggs. The normal transmission cycle
involves herbivores (e.g. sheep, cattle) who ingest the eggs, and develop
cysts in their body. When the herbivores are eaten by dogs, the tapeworms
will develop in the intestines of the dog, completing the transmission cycle
(2)
.
The eggs excreted by dogs and canines can cause an infection in humans
which is similar to the infection in herbivores. People can be infected by the
eggs through food, drinking water (73), soil, or any other object contaminated
by dog faeces (3). Transmission is possible through direct close contact with
dogs (through touching their fur, or being licked) (73). Occasionally domestic
flies have transmitted the pathogen (3)
Reservoir : the reservoirs of the adult worm are canines: dogs, jackals, and wolves (73).
The infective eggs can survive for several months in the environment (3)
140
Vector/int. host : the normal intermediate hosts are sheep, pigs, goats, cattle, camels, horses
and other herbivorous animals (73). Humans function as an intermediate host,
but are a dead end in the transmission cycle
Water-related : water-washed (3) and water-borne (73)
Excreta-related : the pathogen leaves canines (dogs) through their faeces (73). The infection is
canine faecal - human oral
Environment : the infection occurs mainly where sheep and cattle are reared (2) and people
and dogs live in close association (73)
Risk in disaster : the infection is not a priority in disasters (3)
Remarks : the pathogen is common in the Turkana region in Kenya (73)
Dogs should be kept away from water sources and food gardens (73)
Annexes
Epidemic measures : control of dogs (elimination of wild and stray dogs and treatment of domestic
dogs), slaughtering of reservoir animals should be controlled so that dogs
have no access to any parts of the carcass (3).
A1
141
Schistosomiasis, Bilharziasis
A very common infection affecting around 200,000,000 people worldwide. The infection is associated
with engineering schemes like irrigation systems and artificial lakes.
are:
S.haematobium: urinary problems including blood in urine, painful urination
(3)
, and reduced bladder capacity (2).
Other Schistosoma: intestinal problems including diarrhoea, enlarged liver
and spleen, and intestinal pain (3).
Occurrence in age-groups: S.haematobium is most common in 10 to 14
year olds; S.mansoni has a peak prevalence at 10 to 24 years; and
S.japonicum does not seem to have a typical age-distribution (16)
Severity : the severity of the infection is usually related to the number of flukes causing
A1
the infection (16). S.japonicum is in general more severe than the other
Schistosoma (73). In the majority of cases the infection is not severe, but
(fatal) complications do occur (2)
Incubation period : the incubation period is variable (73)
Duration : the flukes normally live for 3 to 5 years, but some survive for up to 30 years
(2)
. Reinfection will often occur though
Communicability : people with infections can release eggs (infective to snails) for over 10 years,
or the time the infection lasts. Snails remain infected for life and can release
infective cercariae for up to 3 months (3)
142
Penetration Urine or
of skin faeces
Human
Transmission:
through direct contact
with contaminated Animal
surface water (S.japonicum)
(e.g. through playing,
wading, washing)
Freshwater
snail Fresh surface water
Transmission : The eggs of persons infected with S.haematobium leave the body through
urine. The eggs of the other Schistosoma leave the body through faeces (73).
In fresh water, the eggs can turn into miracidia, which can infect specific
freshwater snails that serve as intermediate hosts. In the snails the miracidia
will multiply, and turn into cercariae (this process takes a few weeks) (2). One
single miracidium can multiply into many thousands of cercariae (16). The
cercariae emerge from the infected snails; S.heamatobium and S.mansoni
at mid-day to late afternoon, and S.japonicum late in the evening. The longer
Annexes
the period between emergence from the snail and infection of a person, the
smaller the chance of successfully infecting a person (73). Cercariae are able
to survive for up to 48 hours in water (16). The pathogen needs water
temperatures between 10°C and 30°C (73). People are infected when a
cercarium penetrates the skin which is in direct contact with infective fresh
water (2)
Reservoir : S.haematobium: humans are the only reservoir.
S.mansoni: humans are the main reservoir, though animal hosts are possible.
S.japonicum: humans are an important reservoir, but in addition animals can
serve as a reservoir to the pathogen. Some important reservoirs are dogs, A1
cattle, pigs, rats, and water buffaloes.
Children are particularly important as reservoirs as the infection is most
common in this age-group and because of their behaviour (16)
Vector/int. host : freshwater aquatic snails are the intermediate hosts for schistosomiasis. The
genera that act as intermediate host:
S.haematobium: the genus Bulinus (preferring still, or very slow moving water).
S.mansoni: most commonly the genus Biomphalaria (which can live in slow
flowing water, generally occurring in streams and irrigation systems).
S.japonicum: usually the genera Oncomelania (an amphibious snail) and
Tricula (15).
Usually only 1 to 2% of the snails are infected. As these snails discharge high
numbers of cercariae (up to 3,000 per day), the potential to infect people
remains high (73). The snails which transmit Schistosoma can survive for up to
months outside water, which takes the infection from one wet season to
another (16,73). The snails can reproduce themselves very rapidly; one snail
can grow out into an infective colony within 60 days (73)
143
Water-related : the infection is water-based. The pathogen penetrates the skin in contact
with contaminated fresh surface water (15)
Excreta-related : S.haematobium is excreted by urine. The other Schistosoma are excreted
through faeces (73)
Environment : the infection is most common in rural areas of developing countries, but is
not limited to this environment (16). As the snails adapt themselves easily,
they can be found in a wide variety of water bodies. From lakes and seasonal
or temporary ponds, to rice-fields or slow-flowing streams (73).
The infection has become a large problem around many man-made structures
like artificial lakes and irrigation schemes (15)
Risk in disaster : the infection will not be an urgent problem in an emergency (47)
Remarks : the dynamics of transmission can change rapidly in an endemic area where
a water resource development scheme is taking place (16). The distribution of
the pathogens in a mass of water is not necessarily regular; while the pathogen
may be present in one zone, it may be absent in another. The distribution
depending on the presence of snails (73). It is estimated that 200,000,000
persons are infected worldwide (16), and that the infection could cause up to
1,000,000 deaths per year (59). In many regions the occurrence of the infection
is on the rise (15)
The effect of improving sanitation is often limited as only a few infected persons need to contaminate
the surface water to maintain an infected snail population (73).
A1
As the snails can reproduce very quickly, the use of chemical control of snails as only measure will
usually not be very effective. It can be effective however where the environment can be controlled,
and in combination with treatment of infected persons (2)
Epidemic measures : mass treatment (73), reducing the contact of the population with contaminated
water (3)
144
An infection which has to go through two water-based intermediate hosts: a freshwater snail and a
freshwater plant. Reservoirs of the pathogen are pigs and people, who are infected when ingesting
the cysts which are found on uncooked freshwater plants.
Severity : in heavy infections the flukes can cause severe health problems (16)
, and in
weakened children the infection may be fatal (73)
Incubation period : 3 months (73)
Duration : around 1 year (3)
Communicability : if untreated, eggs are probably shed for around 1 year (3)
Annexes
Oral Faeces
Transmission: Human
freshwater plants eaten
raw, or peeled with the
teeth or lips Pig (dog)
Freshwater
plant
Freshwater
snail
A1
Fresh surface water
Transmission : the eggs of the fluke leave the body through faeces. The eggs will produce
miracidia after a development of 3 to 7 weeks in fresh water (3). These miracidia
can infect freshwater snails. The pathogens multiply in the snail, and are
released as cercaria. The cercaria form cysts on water plants (e.g. water
caltrop, water chestnut, water bamboo) (73). If these plants are eaten raw, or
peeled with teeth or lips while still raw, the cysts can be ingested, and infection
can follow (3)
Reservoir : reservoirs of the pathogen are pigs, humans, and occasionally dogs (3)
Vector/int. host : the pathogen has to go through developmental stages in two intermediate
hosts. The first is a freshwater snail of the genus Segmentina. After a
development in the snail the pathogen has to form a cyst on freshwater
plants (73)
145
Epidemic measures : improve sanitation, identification of plants that play a role in transmission,
Annexes
146
An infection with two water-based intermediate hosts: a freshwater snail and freshwater plant. Infection
follows the ingestion of uncooked water plants.
Oral Faeces
Human
Transmission:
Annexes
freshwater plants
eaten raw Herbivore
Freshwater Freshwater
plant snail
Vector/int. host : the intermediate hosts of the pathogen are freshwater snails (Lymnaea spp.)
and water-plants living in fresh water (73) (e.g. watercress) (2)
Water-related : the intermediate hosts are water-based (73)
Excreta-related : the pathogen leaves the host through faeces (73)
Environment : the infection is more common where sheep or other reservoir animals live in
close association with humans (73)
147
Remarks : -
Epidemic measures : the source of infection should be determined and dealt with (3)
Annexes
A1
148
Two similar infections with two water-based intermediate hosts: freshwater snails and freshwater fish.
People are infected by eating poorly cooked fish.
Annexes
time eggs are passed in stools (4)
Oral Faeces
Transmission: Human
freshwater fish
eaten without
adequate cooking Animal
A1
Freshwater Freshwater
fish snail
Transmission : the infected host sheds the eggs from the pathogen through faeces. When
these eggs are ingested by a freshwater snail, the pathogen will multiply in
the snail, and cercariae will be released in the water (3). The cercariae will
actively seek freshwater fish, and encyst in its flesh or under its scales (73).
When people ingest the infective fish raw or undercooked, infection occurs
(16)
. Smoking or pickling the fish will not necessarily kill the pathogen (73)
Reservoir : the reservoirs of the pathogen are humans, dogs, cats, pigs, rats, and other
animals which eat fish (3)
149
Vector/int. host : the intermediate hosts are freshwater snails (Bulimus spp., Bithynia spp.
and Parafossarulus spp.) (73) and freshwater fish (many species are potential
intermediate hosts) (3)
Water-related : the intermediate hosts are water-based (15)
Excreta-related : the pathogen leaves the host through faeces (73)
Environment : where fish is eaten without adequate preparation
Risk in disaster : the infections are not a problem in disasters (3)
Remarks : an estimated 30,000,000 are infected with C.sinensis (73) and over
20,000,000 people are believed to be infected with Opisthorchis (16). In parts
of Northern Thailand, over 50% of the population is infected with O. viverrini.
Pla ra, fermented fish eaten in Northern Thailand, will not transmit the
pathogen (2)
Epidemic measures : search for the source of the outbreak, and eliminate it (3)
A1
150
A usually mild infection transmitted to humans through poorly prepared freshwater fish.
Gen. description : the infection occurs in sub-arctic, temperate and tropical regions. In general
infections are asymptomatic. Persons frequently carry several worms, and
occasionally infections of over 100 worms do occur (16). Even though these
worms take an important amount of nutrients, the main problem is the
absorption of vitamin B12 by the pathogen (73). In 1 to 2% of the infections
this develops into a deficiency of vitamin B12 (44) which can lead to anaemia.
The tapeworms can survive for several years (3)
Oral Faeces
Transmission: Human
freshwater fish
eaten without
adequate cooking Animal
Annexes
Freshwater Freshwater
fish copepod
Transmission : the pathogen leaves the body through faeces. When the eggs come in contact
with water, a coracidium emerges, which is ingested by a copepod. When the
copepod is eaten by a fish, the pathogen works its way into the muscles of A1
the fish. Infection of people follows when this fish is eaten without proper
cooking (73)
Reservoir : the most important reservoir of the pathogen are humans (16). Other reservoirs
are dogs, cats (73), pigs, other fish-eating mammals (3), and birds (16)
Vector/int. host : the intermediate hosts are freshwater copepods (species of Cyclops and
Diaptomus) and freshwater fish (e.g. pike, salmon, perch, turbots) (3)
Water-related : the intermediate hosts are water-related (16)
Excreta-related : the pathogen leaves the host through faeces (73)
Environment : the infection is generally found in cooler regions, close to lakes (73)
Remarks : it is believed that 13,000,000 are infected worldwide (73)
151
152
A pathogen which has to go through two water-based intermediate hosts: a freshwater snail and a
freshwater crustacean (freshwater crab, crayfish, or shrimp). Infection occurs through eating
inadequately prepared infective crustaceans.
Symptoms : the symptoms are coughing, chest pain, and sputum (lung secretions) with
orange-brown flecks (3). The infection can be mistaken for tuberculosis (2)
Severity : the infection can be severe if the flukes develop in other organs than the
lungs (2), and deaths are reported (16). In the lungs, only heavy and repeated
infections will cause problems in the lung function (2)
Incubation period : variable, but normally long (3)
Duration : the flukes may live for up to 20 years (16)
Communicability : eggs may be discharged by a person for up to 20 years (3)
Oral Faeces/Sputum
Annexes
Transmission: Human
freshwater crustacean
(crab, crayfish, or shrimp)
eaten without adequate Animal
cooking
Freshwater Freshwater
crustacean snail
A1
Fresh surface water
Transmission : eggs leave the body through sputum or faeces. Miracidia are released from
the eggs after 2 to 4 weeks. These miracidia infect freshwater snails. In the
snail a development of around 2 months will take place before cercariae
emerge. The cercariae penetrate the body of crabs, crayfish (3), or shrimps (16)
and form cysts. When infected crustaceans are eaten without proper cooking,
infection can follow (3). Ingestion of the cysts during preparation of the
crustaceans is possible (16)
Reservoir : the main reservoirs of the infection are wild and domestic cats (16). Dogs can
play an important role as reservoir too (73). Other reservoirs are humans, pigs
and wild carnivores (3)
Vector/int. host : freshwater snails (Semisulcospira, Thiara, Aroapyrgus and other genera) (3),
and freshwater crabs, crayfish (73) and shrimps are the intermediate hosts of
the pathogen (16)
Water-related : the intermediate hosts are water-based (2)
Excreta-related : the pathogens leaves the body through faeces if sputum is swallowed (73)
153
Environment : the infection is likely to occur in endemic regions where freshwater crabs,
crayfish or shrimps are eaten without adequate cooking
Risk in disaster : the infection is not a priority in disasters (3)
Remarks : in China around 10,000,000 people are believed to be infected. In Ecuador
the number of infections is estimated at 500,000 (3)
As carnivores play an important role as reservoir, the effect of improved sanitation as only measure is
limited. The most effective preventive measure is correct preparation of Crustaceans. Pickling processes
are often not effective in killing the pathogen (2).
Epidemic measures : the source of the infection should be determined and dealt with (3)
Annexes
A1
154
A very common infection; ¼ of the world’s population is estimated to be infected with this pathogen.
People become infected when larvae which developed in soil penetrate bare skin.
Annexes
Transmission cycle (73)
Penetration of
Faeces
skin (ingestion)
Transmission: Human
contact of bare skin to
contaminated soil for
5 to 10 minutes
Eggs develop
A1
into larvae
Transmission : the eggs excreted by an infected person will develop into larvae in the soil.
These larvae cause infection in humans by penetrating (intact) skin. A contact
time of 5 to 10 minutes of the skin with the infected soil is necessary for
successful penetration (44). In addition to penetrating the skin, Ancylostoma
can be transmitted by ingestion of the developed larvae (3)
Reservoir : man is the only reservoir for A.duodenale and N.americanus (16). Dogs and
cats are reservoirs for A.ceylanicum (3). In warm and damp soil the infective
form can live for several months (73) though up to 2 years is mentioned (16)
Vector/int. host : none
Water-related : no
Excreta-related : the pathogen leaves the body through faeces (2)
155
Environment : the infection is common where inadequate sanitation occurs in a warm and
wet climate (3). The ideal environment for the pathogen outside the host is
moist, shaded, humus-rich soil at a temperature of 25°C to 30°C (73). In
cooler or drier climates transmission may be seasonal in the hot or wet
season (16). Where the climate is unfavourable, the infection can occur where
conditions are warm and humid, for example in mines (3). If human faeces
are used as fertiliser, the risk of infection is high (16). Latrines must be kept
clean; if excreta can soil the floor of latrines, these can become foci for
transmission of hookworm (9,57)
Risk in disaster : the infection will not be an urgent problem in a disaster (3)
Remarks : it is believed that around 25% of the world’s population is infected with
hookworm (4)
The number of eggs released by a single female worm can be up to 35,000. Persons with heavy
infections can be host to 1,000 worms (16). This means that the potential of contamination of the
environment is huge. As it is unlikely that everybody will use the sanitary structures correctly, improved
sanitation as only preventive measure is usually not very effective if many people remain infected.
Improved sanitation as preventative measure is very important to reduce the reinfection of people
though, and a combination of mass treatment and improved sanitation is very effective in reducing
the infection in a population (a reduction of 80% is mentioned) (26).
Epidemic measures : a combination of mass treatment, health and hygiene promotion and
improvement of sanitation (3)
A1
156
A pathogen which leaves the body through faeces, and develops in warm and moist soil. The pathogen
can either go through its reproductive adult form in the human body, or in soil.
Penetration of Faeces
skin (injestion)
Transmission:
contact of bare skin to
Annexes
contaminated soil, Human
faecal-oral
Development
in the soil
A1
Transmission : the eggs hatch in the intestine of the person (4), to form rhabditiform larvae
which leave the body through faeces. Either the rhabditiform larvae develop
directly into infective filariform larvae, or they start a free-living cycle. The
free-living cycle occurs when the larvae are in warm and moist soil (2). The
larvae will become adults which can reproduce (73). This cycle outside the
human body can be repeated many times (2).
People are usually infected by filariform larvae in soil which penetrate the
skin (44). Autoinfection can occur: rhabditiform larvae penetrate the intestinal
mucous membrane without leaving the body. Faecal-oral transmission is also
possible (73)
Reservoir : humans and soil are the most important reservoirs. On rare occasions dogs
and cats do transmit a similar infection to humans. In Africa, primates can
be a reservoir for S.fülleborni (3).
Infective larvae can remain viable in suitable soil for many weeks. Larvae will
not survive in dry conditions, or temperatures under 8o, or over 40o (16)
157
158
A very common disease; one billion people are estimated to be infected. The pathogen leaves the
body through faeces. Infection occurs through ingestion of contaminated soil. The eggs are very
resistant and can survive for years in suitable soil.
Annexes
Oral Faeces
Transmission:
contaminated soil or
food, fingers or dust Human
contaminated with soil
Transmission : female worms discharge around 200,000 eggs per day (2). These eggs leave
the body through faeces. Eggs become infective after a development of 2 to
3 weeks (3) in warm (44), shady, and damp soil (16). A person is infected after
ingestion of eggs from contaminated soil. Infection can occur when children
play around the house (16) or when food gets contaminated by soil. Hands
contaminated with soil play an important role in transmission too (16). Feet
can take contaminated soil into the house. Contaminated dust can also play
a role in transmission (3). Outbreaks have occurred where raw sewage or
waste-water were used for irrigation, and where contaminated vegetables
were imported (16)
Reservoir : humans. The infective eggs are very resistant to drying or cold (73) and can
remain infective for years in soil (3). Temperatures over 45°C or direct sunlight
will kill the eggs (16).
A similar infection of pigs (A.suum) can infect humans (2), but this is rare (3)
159
Vector/int. host : cockroaches and other animals can serve as mechanical vectors by ingesting,
and excreting viable eggs (16)
Water-related : the infection is water-washed (73)
Excreta-related : eggs leave the body through faeces (2)
Environment : the infection is most common in moist, tropical zones (3) in a population with
poor personal hygiene, inadequate sanitation, and poor food hygiene (73).
Where the climate is drier, the period of transmission is limited to the rainy
season (16)
Risk in disaster : roundworm infection will not be a priority in a disaster (3)
Remarks : the infection is very common, and it is estimated that one billion people are
infected worldwide (73). In parts of Africa 95% of the population are infected
(16)
Increased water availability has been associated with a reduction of 12 to 37% in hookworm infection;
improved water availability combined with improved sanitation with a reduction of around 29%; and
improved water availability and sanitation in combination with mass treatment has been associated
with a reduction of 80% in roundworm infection (26). Mass treatment alone will result in a short term
reduction in the number of infections, but will not be effective on the long run, as the cause of
infection has not been removed.
A1
Epidemic measures : mass treatment, health and hygiene promotion, and improved sanitation (2, 3)
160
A very common, usually mild, infection. The pathogen leaves the body through faeces, develops in
soil into an infective form, and infects people through the oral route.
Oral Faeces
Annexes
Transmission:
contaminated soil, stale Human
faeces, fingers, food
Transmission : the pathogen leaves the human body through faeces. In warm, moist soil the A1
eggs will become infective after a development of 2 weeks (2). Infection occurs
when the infective eggs from stale faeces or contaminated soil are ingested
by a person. Transmission is often through hand to mouth contact (16), or
through contaminated food (73)
Reservoir : primarily humans and soil. The eggs in the soil are resistant to low
temperatures, but need moisture to survive (16). Pigs can be infected with a
similar worm (T.suis) which is able to infect humans (2,16)
Vector/int. host : none
Water-related : the infection is water-washed (73)
Excreta-related : the eggs leave the body through faeces (73)
Environment : the infection is common where poor sanitation is combined with high rainfall
and humidity, and dense shade (16). In urban slums the infection can become
a public health problem (2). Persons who handle pigs have a higher incidence
of the infection (16)
Risk in disaster : the infection is not a problem in disasters (3)
Remarks : the infection is very common, and over 500,000,000 people are estimated
to be infected (73)
161
162
Symptoms : the infections are usually asymptomatic (16). Symptoms are insomnia, loss of
weight, abdominal pain, and finding segments of worms in faeces (3). People
who are infected will often carry several worms (16)
Severity : the infection is usually mild (73)
Incubation period : 10 to 14 weeks (73)
Duration : worms may survive for 30 years or longer (3)
Communicability : the period of communicability is as long as the tapeworm persists, which can
be over 30 years (3)
Oral Faeces
Human
Transmission:
Annexes
raw or undercooked beef
Cattle
Body tissue
Oral
(meat)
Transmission : the eggs leave the host through faeces, either individually, or in complete
segments of the worm (2). Cattle is infected by ingesting the eggs. After
ingestion, the pathogen will implant itself in the flesh of the cow as cysticerci
(3)
. Cattle can become infected when its pastures are polluted with human A1
faeces, or by drinking water contaminated with sewage (73). Birds can play a
role in taking the pathogen from sewage outflows to pastures (2). Possibly
domestic flies can play a role in the transmission of the eggs to cattle (73).
People are infected through ingesting raw or undercooked beef containing
the pathogen (3)
Reservoir : humans are the only definitive host of the pathogen (16). The eggs can survive
for months in the environment (3)
Vector/int. host : cattle is the intermediate host of the pathogen (2)
Water-related : no
Excreta-related : the pathogen leaves the human body through faeces (2)
Environment : the pathogen is often found in areas of cattle breeding (44). The infection is
common in poorer areas where beef is eaten raw, or without proper cooking
(16)
163
Epidemic measures : -
Annexes
A1
164
This pathogen causes two different infections. The first infection is by the adult tapeworm which is
transmitted through eating improperly cooked pork. Although this infection is mild, the hosts and
their contacts are at serious risk of cysticercosis. Cysticercosis is the second infection caused by the
pathogen. It is caused by the larvae of the worm, is transmitted through the faecal-oral route, and is
potentially a severe disease.
Annexes
Cysticercosis is potentially a severe and dangerous infection (2)
Incubation period : infections with adult worms: 8 to 12 weeks (73). Cysticercosis has an incubation
period which ranges from days, to over 10 years (3)
Duration : worms may survive for 30 years or longer (3)
Communicability : as long as the tapeworm persists, which can be over 30 years (3)
Oral Faeces
A1
Human
Transmission:
raw or undercooked
pork
Pig
Transmission:
e.g. food, water,
Body tissue (a)
Human (fingers)
(meat)
Oral
(a)
: cysticercosis
Transmission : the eggs leave the human body through faeces (2). Pigs are infected by ingesting
these eggs through eating human faeces, or ingesting water or food
contaminated with human faeces or sewage. The ingested eggs will implant
themselves in the flesh of the pig as cysticerci. People are infected with the
adult tapeworm when raw or undercooked pork containing the pathogen is
eaten (3).
165
The eggs excreted by a person are directly infective through the faecal-oral
route. This results in cysticercosis. The eggs can either infect the host carrying
the adult worm, or persons around the host (73)
Reservoir : humans are the only definitive host of the pathogen (16). The eggs can survive
in the environment for months (3)
Vector/int. host : the intermediate host of the pathogen is the pig. In cysticercosis people
function as intermediate host (though they are a dead end in the transmission
cycle) (2)
Water-related : cysticercosis is water-washed (3) and water-borne (73)
Excreta-related : the pathogen leaves the human body through faeces (2). Cysticercosis is spread
through the faecal-oral route (73)
Environment : the infection can occur where pigs have access to human faeces, or to food
or water contaminated by human faeces or sewage, and where pork is eaten
without adequate preparation
Risk in disaster : the infection is not a priority in disasters (3)
Remarks : pork tapeworm is less common than beef tapeworm (2)
Epidemic measures : -
A1
166
A usually mild infection which is mainly transmitted through skin contact with water or other material
contaminated with urine of infected animals.
Annexes
Urine, body
Human
tissue
Transmission:
e.g. water, soil, Animal
vegetation, direct
contact, food (air)
Animal
Urine, body
Direct contact with
tissue
broken skin, oral
Fresh water (respiratory) A1
167
The pathogen can survive for longer periods in a moist, non-acidic environment.
In fresh water with a pH of about 7, survival of Leptospira can be up to 4
weeks. In a pH of 5, the pathogen will survive for up to 2 days. Leptospira will
not survive in saline water (16) and is sensitive to chlorine (73)
Vector/int. host : the disease is spread through animals (the main risk comes from rats); these
are final hosts and not vectors or intermediate hosts
Water-related : water contaminated with infected urine plays an important role in the
transmission of the disease (3)
Excreta-related : the pathogen is mainly spread through contact with urine from infected animals
(16)
Environment : the infection is common where rats are numerous and the environment is
favourable (73). The infection is a hazard to people in direct contact with fresh
water, urine, or body tissues of animals (3), and is linked to specific occupations
like workers in sugar-cane plantations or rice-paddies, mine workers, farmers,
people working with fish, in canals, or in sewerage systems (73)
Risk in disaster : the infection could be a potential problem in regions with a high water table,
or where flooding has occurred (3)
Remarks : -
Epidemic measures : the source of infection should be determined and, if possible, dealt with (3)
168
Guinea-worm is the only pathogen transmitted exclusively by drinking contaminated water (all other
water-borne infections can be transmitted in several other ways). The infection can result in severe
complications. In the past decade the number of infections in the world has reduced strongly.
Symptoms : fever and localised complaints like swellings, itching, and local pains (2). A
blister containing a worm will appear (3), usually on the legs. Worms which
are not removed will calcify in the body (2).
Most affected are people in the age group of 15 to 40 years (16)
Severity : the infection can be the cause of severe illness and disability (44). Worms
entering in joints may cause arthritis. Adequate removal of the worm will
reduce the risks of complications (2). In up to 50% or more of the cases (16)
secondary, potentially life-threatening infections of the blister can occur (2)
Incubation period : around 12 months (3)
Duration : several weeks if no complications occur
Communicability : people who harbour the worm can contaminate water from the moment the
Annexes
blister bursts to (generally) 2 to 3 weeks after. Copepods are infective for
around 3 weeks after infection, then they will die (3)
Fresh water
Transmission : the blister containing the female worm will burst when in contact with water
(16)
. The worm emerges, and discharges its larvae into the fresh water. When
these larvae are ingested by Cyclops, infection of the copepod can follow (73).
In Cyclops the pathogen has to go through a development of 12 to 14 days
before it can infect humans (3). People become infected when they drink
water containing the infective Cyclops (73). Most infections occur during a few
months of the year (16)
169
Risk in disaster : the infection is not a priority in a disaster. If the pathogen is present in the
population, control of the infection could be started when the emergency
phase is dealt with (47)
Remarks : the infection typically appears in the agricultural season (84). As a large part
of the farmers may be disabled by the infection, the agricultural production
may be severely reduced because of the disease (16).
Progress is being made in the WHO programme of eradication of guinea-
worm infection (2), therefore the geographical distribution of the infection is
likely to change in the years to come. In 1989 the number of cases were
estimated at 1,000,000; in 1997 it was estimated at less than 80,000
cases (84)
Annexes
Epidemic measures : search for sources of infection and deal with them; health and hygiene
promotion, assure drinking water quality (3)
170
Conjunctivitis
Infections which affect the eyes and are transmitted through direct contact. Large outbreaks are
possible where the population has poor personal hygiene and lives in overcrowded conditions.
Pathogen : the infection can be caused by several types of bacteria (acute bacterial
conjunctivitis); adenoviruses (adenoviral keratoconjunctivitis, adenoviral
haemorrhagic conjunctivitis) and picarnoviruses (enteroviral haemorrhagic
conjunctivitis)
Distribution : the infections occur worldwide (3)
Symptoms : acute bacterial conjunctivitis: irritation, purulent discharge from the eye (4),
swelling of the eyelids. Children under 5 are most affected.
keratoconjunctivitis: sudden onset, swelling of the eyelids, pain, photophobia,
and blurred vision.
haemorrhagic conjunctivitis: swollen eyelids, bleedings on the eyes (3), eye
discharges are clear (4)
Severity : most infections are not severe (3)
Incubation period : acute bacterial conjunctivitis: 1 to 3 days
keratoconjunctivitis: 5 to 12 days or longer
haemorrhagic conjunctivitis: 12 hours to 12 days (3)
Duration : the conjunctivitis lasts between some days and some weeks (3)
Communicability : communicability of the infection is variable; normally up to 2 weeks, or as
long as the infection lasts (3)
Annexes
Transmission cycle (3)
Transmission : the pathogens leave the body through discharges of the eyes or nose. These
discharges can transmit the infection to a susceptible person through hands,
contaminated material (especially if used around eyes), or domestic flies
and eye gnats. The importance of domestic flies or eye gnats in transmission
is not entirely clear (3). Epidemics can take place where the environment is
favourable to transmission (73). Attack rates of up to 50% in the population
are possible (3,47)
Reservoir : humans are the only reservoir of the pathogens (3)
Vector/int. host : domestic flies and eye gnats can be mechanical vectors (3)
Water-related : the infections are water-washed (73)
Excreta-related : not directly; poor sanitation may increase the population of domestic flies
171
Environment : the infection occurs especially where crowding, poor personal hygiene (as
well poor handwashing as inadequate hygiene of clothes and other materials),
exposure to wind and dust, and poor sanitation (risk of domestic fly breeding)
are found (47)
Risk in disaster : the infection will not be a priority in a disaster. Epidemics are possible where
overcrowding is combined with poor personal hygiene (47)
Remarks : it may be necessary to provide separate treatment facilities during outbreaks
(3)
.
Chlamydial conjunctivitis (which is not trachoma) is an infection which is
transmitted sexually, or from mother to new-born baby. Obviously the
transmission cycle and preventative measures of this infection will be different
Improvement of sanitation
Control of domestic flies or eye gnats (where these are suspected to
play a role in transmission) (3) (for control of domestic flies, see
Annexe 3)
Children with active infection may have to be barred from school (3)
Annexes
Epidemic measures : make sure that people have access to water and soap to allow adequate
personal hygiene. Cases and close contacts must be treated rapidly, if
necessary in separate facilities. Health and hygiene promotion, and where
A1
172
Trachoma
An infection affecting the eye. The disease is the most common cause of preventable blindness in the
world. Transmission is through direct contact with contaminated hands, domestic flies, clothing, or
other objects.
Annexes
Human
Transmission:
e.g. hands, clothing, toilet
articles, domestic flies
Human
A1
Transmission : the pathogen is found in eye (73) or nasal discharges. Infection occurs through
contact with these discharges (3). Transmission of the infection is through
hands, clothing or other objects, and domestic flies. A common way of
transmission is rubbing infected eyes of a child with a cloth or hands. The
pathogen is carried over when the cloth or hand is used on a susceptible
person without proper cleaning or washing. Where the infection is endemic,
up to 90% can be infected by the age of 3 years (73)
Reservoir : humans are the only reservoir (3)
Vector/int. host : domestic flies are a mechanical vector for the pathogen (16)
Water-related : the infection is water-washed (73)
Excreta-related : not directly; inadequate sanitation can increase the domestic fly population
(16)
Environment : the infection is most common in poor, rural communities (3). The typical
environment for trachoma is: poor personal hygiene, crowded conditions, a
dry and dusty environment, and inadequate sanitation (human and animal)
which results in a large domestic fly population (16)
173
Risk in disaster : the infection is not an urgent problem in case of a disaster (3)
Remarks : trachoma is the most important cause of preventable blindness in many
regions in the world (44). It is believed that 150,000,000 people are affected
by the infection. Around 5,500,000 people are estimated to be blind, or at
risk of becoming blind because of the infection (16)
Epidemic measures : health and hygiene promotion in combination with improved water availability,
improved sanitation, and mass treatment.
Annexes
A1
174
An infection which can be crippling and disfiguring. Transmission occurs when pathogens from the
infectious skin papules of an infected person come in contact with abraded skin of a susceptible
person.
Annexes
Contact with cut Discharges from
or abraded skin skin papules
Transmission: Human
e.g. direct skin contact,
fingers, clothing or other
contaminated material,
domestic flies Human
Transmission : the pathogens are found in the liquid which is discharged from the papules.
This liquid is highly contagious and infection can occur when it is brought in
contact with damaged skin (73). Transmission occurs either by direct skin
contact, by infected material, or domestic flies. The pathogen can not
penetrate intact skin (16)
Reservoir : reservoirs are humans and possibly primates (73)
Vector/int. host : domestic flies are possibly a mechanical vector (16)
Water-related : the infection is water-washed (73)
Excreta-related : not directly. Inadequate sanitation can increase the number of domestic flies
Environment : the infection is found in the warm and humid tropics. It is most common in
rural areas (16) in large crowded families with poor personal hygiene (73). In
endemic zones infectious yaws is more common in the rainy season (16)
Risk in disaster : the infection will not be a priority in a disaster (3)
Remarks : -
175
Cases and their contacts should be searched for and treated. When the active disease occurs in over
10% of the population, treatment of the entire population is justified (3).
176
An infection which can potentially be very disabling and disfiguring. As the transmission route, and
the role water plays in prevention of the infection are not clear, a summary listing is presented.
Annexes
Preventative measures Potential effect
Improving water availability is mentioned (29)
A1
177
An infection which affects the skin. The disease is linked to poor personal hygiene and crowding.
Transmission is through direct contact.
Skin Skin
Human
Transmission:
e.g. direct skin contact,
clothing, bedding
Human
Skin Skin
A1
Transmission : the infection is spread by a fertilised female mite (16). The skin of an affected
person is infective. Direct skin to skin contact will be the most common way
of transmission. Transmission through clothing or bedding occurs, but is less
common as the mites can only survive for a short period of time outside the
human body (4). An exception is ‘Norwegian scabies’, where the risk of
transmission through clothes and bedding is high. It takes mites 2½ minutes
to ‘dig’ into the skin (3)
Reservoir : humans are the only reservoir (3)
Vector/int. host : none
Water-related : the infection is water-washed (73)
Excreta-related : no
178
Environment : the pathogen is most common in conditions of poverty, overcrowding (3), and
poor personal hygiene. The infection occurs in all climates, but is widespread
in the tropics (16)
Risk in disaster : the infection is a potential problem, especially in conditions of overcrowding
and poor personal hygiene (47)
Remarks : A fully developed case of scabies may be infected with as little as 20 adult
mites or even less (16)
Searching for cases and their contacts and treatment of these (3)
Treatment of individual cases is not enough, and all contacts (e.g. school, village) should be treated
(73)
. Where possible, ‘Tetmosol soap’ should be used (3).
Epidemic measures : mass treatment and health and hygiene promotion (3). If the infection is an
important public health problem distribution of soap may be useful (47)
Annexes
A1
179
Skin Skin
Annexes
Human
Transmission:
e.g. direct skin contact,
clothes, seats, toilet articles Human
Animal
Skin Skin
A1
Transmission : transmission occurs when the skin of a susceptible person comes into contact
with the pathogen. Transmission can be direct through skin contact, or indirect
through contaminated floors, seats, benches, toilet articles (3), or clothes (73)
Reservoir : reservoirs are humans, dogs, cats, cattle, other animals, and soil.
Contaminated material can stay infectious for long periods (3)
Vector/int. host : none
Water-related : the infection is water-washed (73)
Excreta-related : no
Environment : common in most tropical countries. Especially in an environment with high
humidity (16) and elevated temperatures (3).
Risk in disaster : the infection is not a priority in disasters (3)
Remarks : -
180
Epidemic measures : health and hygiene promotion and improvement of personal hygiene (3)
Annexes
A1
181
Yellow fever
An infection transmitted by mosquitoes. There are two transmission cycles, the first occurs in the
jungle and involves monkeys and forest mosquitoes, people become infected incidentally. The second,
epidemic, cycle can occur when infected persons or mosquitoes are introduced in an urban
environment.
Mosquito injects
pathogen while Jungle, or sylvatic, cycle
feeding
Human
Monkey
A1
Infected person
goes from jungle
to the city
Forest
mosquito
Blood
Human
Infected forest mosquito
feeds on person in the city
Mosquito
(A. aegypti)
Oral
Transmission to
Urban, epidemic, cycle
offspring
182
Two transmission cycles exist: the sylvatic cycle and the urban, epidemic, cycle. The sylvatic cycle
occurs in the jungle. This cycle involves monkeys and forest mosquitoes. Monkeys are usually not
affected by the infection (if monkeys start dying however, it could be an indication that the infection
will spread to humans soon) (73). Man does not play an essential role in the sylvatic cycle (3). In this
cycle people are infected incidentally when they get bitten by infected forest mosquitoes, either
because they went into the jungle and got bitten (most common), or because forest mosquitoes
leave the jungle (73). When an infected person goes back to the city, or when infected forest mosquitoes
infect someone in the urban environment, the urban, epidemic, cycle can begin. This cycle involves
humans and the mosquito Aedes aegypti (3). Large outbreaks can occur where Aedes aegypti is found
in large numbers with many non-immune persons (16).
Transmission : mosquitoes are infected when they feed on the blood of a person or monkey
who carries the infection (73). At 37°C mosquitoes will become infective 4
days after biting an infected person; at 18°C this will be prolonged to 18
days (16). Transmission to a person occurs through the bite of an infected
mosquito (73).
Reservoir : monkeys are the reservoir for the rural cycle. The reservoir for the urban cycle
are humans (73). As infected mosquitoes can pass the pathogen to their
offspring, they too are a reservoir of the pathogen. This transmission from
mosquito to its young ensures that the infection can be passed on between
the rainy seasons (83)
Vector/int. host : mosquitoes are the vector of the disease: in rural environment in Africa Aedes
spp. serves as vector; while in America Aedes spp. and Haemagogus spp.
are the main vectors. In urban environment Aedes aegypti is the main vector
(73)
Annexes
Water-related : the infection is spread by a water-related insect vector (15)
Excreta-related : no
Environment : the infection occurs in the tropics. In the rural, or sylvatic, cycle the infection
is most common in males working in forested areas (3). By cutting forests
man encourages transmission of the infection to humans (16).
Epidemic or urban yellow fever can occur where the mosquito Aedes aegypti
and enough non-immune people are present. The infection is linked to the
rainy season (44)
Risk in disaster : the infection could be a problem in disasters (47)
Remarks : the WHO estimates that there are 200,000 cases of yellow fever per year A1
resulting in 30,000 deaths (83)
One confirmed urban case is considered an outbreak (83) and occurrence of
the infection should be notified to the WHO (3).
183
184
A mosquito-borne infection. The infection is seen as the most important Arbovirus (arthropod-borne
virus) worldwide and can cause large, explosive outbreaks. Dengue fever is less dangerous than
dengue haemorrhagic fever which can have a case fatality rate of 50%.
Annexes
disease which, if untreated, can have a case fatality rate of up to 50%. With
adequate treatment this can be brought down to 1 to 2% (3)
Incubation period : 3 to 15 days (73)
Duration : the infection normally lasts for up to some weeks (44)
Communicability : people can infect mosquitoes as long as fever persists. After infection people
become immune to the serotype which infected them, but not to the other
serotypes. Mosquitoes, once infected, remain infective for life (3)
Monkey
Mosquito
(Aedes) Oral
Transmission to offspring
185
occurs in urban zones with high population densities (2). In epidemics attack
rates of susceptible people are often 40 to 50%, but can be up to 90% (83).
As there are 4 serotypes of viruses which can all cause epidemics in a
population, previous outbreaks do not necessarily mean that the population
is immune to the infection (16)
Reservoir : humans are the main reservoir of the pathogen (2). Monkeys can be reservoirs
in South-east Asia and West Africa (3). It seems that mosquitoes can transmit
the pathogen to their offspring, but the role of this in the transmission of the
pathogen is not clear (16)
Vector/int. host : Mosquitoes are the vector of the infection. Different species of Aedes are
vectors, with Aedes aegypti being the most important (3). Ae.albopictus and
Ae.scutellaris are other important vectors of the infection (73)
Water-related : the infection is spread by a water-related insect vector (15)
Excreta-related : no
Environment : transmission occurs throughout the year. In many areas there is an increase
of cases in the rainy season (16). Outbreaks are possible where the vectors
are present in a susceptible population. Outbreaks occur as well in urban as
in rural environment (3)
Risk in disaster : the infection can be a risk in case of a disaster (47)
Remarks : the WHO estimates the number of cases per year at 50,000,000 (83). Dengue
fever is seen as the most important arthropod-borne viral disease (Arboviral
infection) of the moment. It is expected that in the future the number of
cases will increase (47)
186
Annexes
Transmission cycle (73)
Mammal
(Malayan fil.)
A1
Mosquito
Oral
Transmission : the worms in the lymphatic system produce microfilariae which are present
in the blood of an infected person. When a mosquito ingests microfilariae in
a blood meal, it will become infected (73). The mosquito becomes infective to
people from 10 days after the infective blood meal (16) up to 21 days in
colder temperatures. When an infected mosquito bites a person, the larva of
the worm will emerge and be deposited on the skin. The larva will have to
find its way (generally through the wound of the mosquito bite) in the human
body. It is estimated that around 15,500 infective bites are needed to result
in a reproducing couple of worms (73).
187
(see Annexe 3)
Mass treatment is the main method of control (73)
Vector control methods will only show a reduction in infections after 2 to 3 years. Where Anopheles
is the vector, mosquito control will have to be maintained for 10 years, or mass treatment for at least
A1
Epidemic measures : mass treatment and vector control (16) (it will take time before the effects will
show) (3)
188
A group of mosquito-borne infections. The infections can be severe, and can present as encephalitis.
Pathogen : several arboviruses (arthropod-borne viruses) named after the infection they
cause (3)
Distribution : Japanese encephalitis (J.E.): South-east Asia, East Asia, India, Sri Lanka,
former USSR (73), and the Pacific islands.
Murray valley encephalitis (M.V.E.): Australia and New Guinea.
St. Louis encephalitis (S.L.E.): Trinidad, Jamaica, Panama, Brazil, and North
America.
Rocio encephalitis (R.E.): Brazil (3).
Eastern equine encephalitis (E.E.E.): North America, Central America, South
America, and the Caribbean islands.
Western equine encephalitis (W.E.E.): North America, Central America, and
South America.
Venezuelan equine encephalitis (V.E.E.): northern South America, Central
America, the Caribbean, and the USA (73)
Symptoms : most infections are asymptomatic. In J.E.: 1 infection in 1,000 is symptomatic
(44)
; E.E.E.: in adults 1 out of 4-50 infections are symptomatic, in children
Annexes
this is 1 out of 2-8; W.E.E. in adult less than 1 in 1,000 infections are
symptomatic, in children 1 in 8-50 (16).
Symptoms are headache, high fever, and coma (73). Severe cases will develop
encephalitis (3)
Severity : the case fatality rate for J.E. can be up to 50% (16), M.V.E. up to 60% (73), for
E.E.E. it can be 50 to 80% (44), while for W.E.E. the case fatality rate is 10%
(16)
. Children and older people are most at risk (73). V.E.E. can be fatal, and
the infection is especially dangerous in the malnourished (16)
Incubation period : all infections have incubation periods of 5 to 15 days except for V.E.E. which
has an incubation period of 2 to 6 days (3,73) A1
Duration : V.E.E. usually lasts 3 to 5 days (3)
Communicability : only in V.E.E. will people be infectious to mosquitoes. For all these infections
mosquitoes remain infective for life (3)
189
Oral
Transmission
to offspring
accidental, as are infections in horses for J.E., E.E.E., W.E.E., and V.E.E. (16).
With all infections, except V.E.E., it is unusual that humans (or horses) infect
mosquitoes (3). In J.E. birds can spread the infection from the rural to the
urban environment. Human infection occurs if there is a high density of
mosquitoes. In W.E.E. outbreaks in horses often precede outbreaks in humans
(16)
.
The pathogens are transmitted to people when an infected mosquito takes a
blood meal.
With V.E.E. mosquitoes can be infected by people and horses, and
transmission is possible from person to person through air-borne droplets (3)
A1
190
Annexes
Health and hygiene promotion (3)
A1
191
Mosquito-borne infections. The infections usually present themselves as fevers. Some of these
infections can result in outbreaks.
Pathogen : the infections are caused by arboviruses specific to the infection (3)
Distribution : Rift valley fever (R.V.F.): Africa (73)
West Nile fever (W.N.F.): Africa, South-east Asia, and France (2)
Bwamba virus disease (B.V.D.): Africa
Group C virus fever (G.C.V.F.): occurs in the tropical parts of South America,
Panama, and Trinidad (3)
Oropouche virus disease (O.V.D.): South America and Trinidad (73)
Symptoms : asymptomatic infections are common (3). General symptoms are headache,
fever and, malaise (73). Often a light form of conjunctivitis will occur. Infections
of R.V.F. may show eye problems, meningitis, and bleedings (3). In W.N.F. a
skin rash is common; and inflammation of the brain and its membranes
(meningoencephalitis) may occur. Meningoencephalitis is possible in O.V.D..
In endemic areas the infections are most common in children (73)
Severity : variable (3)
Incubation period : 3 to 12 days (73)
Duration : usually up to one week (3)
Communicability : mosquitoes remain probably infected for life (3)
Annexes
Human
A1
Animal
Mosquito
Oral
Transmission : people get infected through the bite of an infective mosquito. R.V.F. and
O.V.D. can cause larger outbreaks (3)
Reservoir : R.V.F.: domestic animals (73) (e.g. sheep) (3)
W.N.F.: birds (73)
B.V.D.: unknown
G.C.V.F.: rodents (3)
O.V.D.: monkeys, sloths, and birds (73)
Vector/int. host : the vectors of these infections are mosquitoes:
R.V.F.: several species of Aedes (Ae.caballus (73), Ae.mcintoshi (3)), and Culex
(C.quinquefasciatus, C.theileri) (73)
192
Epidemic measures : control of mosquitoes; for R.V.F. immunise sheep, goats and cattle (3)
Annexes
A1
193
Mosquito-borne infections. Typical symptoms of these infections are fever and arthritis.
Blood
Human
Humans are
possibly the
Animal reservoir for
A1
infection in
O.N.N.
Mosquito
Transmission Oral
to offspring
Transmission : mosquitoes either receive the pathogen from their parents, or are infected
when feeding on an infected host. People are infected when bitten by an
infective mosquito. R.R.F. can cause major outbreaks (3)
Reservoir : C.V.D.: rodents, baboons, monkeys and bats
O.N.N.: possibly humans (73)
S.V.D.: birds (3)
M.V.D.: -
R.R.F.: rodents (73)
194
with most of these infections mosquitoes can transmit the infections to their
offspring, which makes them reservoirs of the pathogens (3)
Vector/int. host : the vector of these infections are mosquitoes:
C.V.D.: Aedes aegypti, Ae.africanus, Ae.luteocephalus, Culex spp. (73)
O.N.N.: species of Anopheles (3) (A.gambiae, A.funestus) (73)
S.V.D.: Culex spp.
M.V.D.: Mansonia spp. and Haemagogus spp.
R.R.F.: Culex annulirostris, Aedes vigilax, Ae.polynesiensis, and other Aedes
spp. (3)
Water-related : the infections are transmitted by water-related insect vectors (3)
Excreta-related : some may be excreta-related insect vectors
Environment : where the right mosquito vector is found
Risk in disaster : these infections will not be a priority in case of a disaster (3)
Remarks : -
Annexes
A1
195
Malaria
A mosquito-borne infection. Every year an estimated 300,000,000 cases occur (73). Large outbreaks
are possible in non-immune populations.
Severity : attacks of P.falc. are usually the most severe, and almost all deaths and
severe illnesses are caused by this pathogen (16). Most at risk are young
children who have not yet developed an immunity, pregnant women, and
non-immune people (73). In non-immune persons the case fatality rate for
P.falc. is over 10% (3). Severe disease with P.viv., P.mal., and P.oval. are unusual
(16)
; still, fatal infections can occur in weakened people (3)
Incubation period : P.falc.: 7 to 14 days (3).
P.viv.: 12 to 17 days. In temperate climates the incubation period may be
prolonged to up to 9 months.
A1
196
Mosquito
(Anopheles)
Oral
Annexes
(2)
. Where transmission rates of P.falc. are high, local adults will never develop
severe malaria. Where transmission rates are lower, severe illness will occur
at all ages (16). The immunity which is built up will be lost in some years if the
individual does not come into contact with the pathogen during this time (2).
If transmission is possible all year round, endemic malaria will occur. If
transmission is only possible every few years (e.g. because of exceptional
climatic circumstances), there will be a large risk of outbreaks (73)
Reservoir : people are the only important reservoir for malaria (3)
Vector/int. host : the vectors of the infection are Anopheles mosquitoes (3).
How effective the mosquito is in transmitting the pathogen depends on its A1
length of survival, its preferred source of blood (only man, or preferably animal
and incidentally man) and other factors. All anopheles feed at night-time,
making this the dangerous period. Mosquitoes can adapt to long-term changes
in environment, like lighting and use of insecticides (73).
Water-related : malaria is transmitted by a water-related insect vector (73)
Excreta-related : no
Environment : transmission occurs only at temperatures between 16°C and 33°C and at
altitudes below 2,000 metres (16). Temperatures below which the pathogen
can not be maintained: P.falc. below 19°C, P.viv. below 17°C, P.mal. below
20°C (73). High humidity is favourable to the vector. Malaria is often a seasonal
infection with a peak in the rainy season. If the rains are too intense the
number of mosquitoes will reduce though. Transmission of malaria is
influenced by many factors related to the population, the vectors, and the
environment. Changes in use of land and deforestation can have important
effects on transmission (16)
Risk in disaster : the infection is a risk in case of disasters (3)
197
Remarks : every year an estimated 3,000,000 people are killed by malaria (73). Most of
these deaths are children in Africa. The number of cases of malaria in the
world is increasing (16). P.falc. has in many areas built up a resistance to
commonly used anti-malarial drugs (44).
The most effective measures of vector control will depend on the mosquitoes which transmit malaria,
the environment in which transmission occurs, and the population affected. A good understanding of
the local circumstances will be needed to plan an appropriate mosquito control programme (73).
198
Infections transmitted by the tsetse fly. Two types of infections exist, a more chronic infection which
is found in tropical western and Central Africa, and an acute infection found in tropical eastern and
southern Africa. Both infections will lead to death if untreated.
Annexes
after the infective bite. The tsetse fly remains infective for life (3)
Human
Tsetse fly A1
Oral
T.b. gambiense
Human
Wild game/
cattle
Tsetse fly
T.b. rhodesiense
199
Transmission : when a tsetse fly feeds on an infected person or animal, it can become
infected. When the fly feeds on a susceptible person, the pathogen will be
transmitted (73).
In endemic regions 0.1 to 2% of the population can be infected. In epidemics
this can be up to 70%. Outbreaks can occur when infected persons or flies
move into a new zone, or when contact between humans and tsetse flies is
intensified (3). Outbreaks in T.g.rhod. are less common (2), but an indication
that one is developing is when children and women start being affected (73).
Reservoir : T.b.gam.: humans are the main reservoir. Pigs and other animals are possible
reservoirs, but their role in transmission is minor (2).
T.b.rhod.: the normal reservoir are wild game and cattle. Humans are less
important as reservoirs (3)
Vector/int. host : the vector for the infections is the tsetse fly (Glossina spp.) (3).
T.b.gam.: is transmitted by tsetse flies which breed and live in forest which
edges rivers; the riverine tsetse flies of the Glossina palpalis group (2). People
or animals coming close to the river are attacked.
T.b.rhod.: is transmitted by tsetse flies that move in open forest and savannah;
mainly Glossina morsitans, which are not confined to water.
The percentage of infected flies is usually small (73)
Water-related : T.b.gam. has a water-related insect vector (16)
Excreta-related : no
Environment : T.b.gam.: is usually linked to rivers (water collection points, washing sites,
river crossings) (16), or lakes. The flies occur in forest galleries (up to 20 metres
from the river banks) along rivers, streams or lakes (2). Women are often most
affected because of their contact to this zone (e.g. washing clothes) (73).
Annexes
Reducing the need for people to come in contact with the river (install
a convenient alternative source of water). Only effective against
T.b.gam. (+++) (29)
Active search for cases and their treatment (2) This is more effective in
outbreaks of T.b.gam. than in outbreaks of T.b.rhod. as the infection is
less acute (++) (2)
Control of tsetse flies (see Annexe 3)
Health and hygiene promotion (47)
Epidemic measures : active case finding and treatment, and control of tsetse flies (3)
200
Annexes
between 2 weeks and years (2)
Duration : cut.l. and muc.l.: the infection can last for years (3,73)
vis.l.: persons can survive for over 2 years (2)
Communicability : untreated persons can be infective to sandflies for up to 2 years, or as long
as the infection lasts (3)
Human
Animal
Sandfly
Oral
Transmission : the sandfly takes up the pathogen when feeding on an infected animal or
person. It takes a minimum of 8 days for the sandfly to become infective (3).
A person will be infected by the bite of an infective sandfly. Sandflies usually
bite in the period between dusk and dawn (2), or in shady or overcast conditions
(73)
.
The infection is usually sporadic (73) but outbreaks do occur (2)
201
Reservoir : reservoirs are humans, rodents, dogs, jackals, foxes (73), and sloths (3). The
importance of the reservoir in the transmission cycle varies from region to
region (2)
Vector/int. host : the vector of the infection is the sandfly; in Africa, Asia and Europe:
Phlebotomus spp., in South and Central America: Lutzomyia spp.. Adult
sandflies live for around 2 weeks. Sandflies stay low to the ground, and can
not fly in windy conditions (73). Sandflies breed in moist and dark places (like
cracks in masonry, caves, termite mounds, rubble) (2). Usually they will not be
found more than 200 m from their breeding place (2), but wind can take them
further (16)
Water-related : no
Excreta-related : no
Environment : the infection is more linked to a rural environment than to an urban
environment. In Central and South America the disease is connected to people
working or living in forested areas (3)
Risk in disaster : can be a problem if a population enters an endemic region (47)
Remarks : Every year there are an estimated 1,500,000 cases of cutaneous
leishmaniasis and 500,000 cases of visceral leishmaniasis (85)
inappropriate in others. A good understanding of the dynamics of transmission will be needed before
effective control of the infection is possible.
Epidemic measures : treatment of cases, and control of sandflies and animal reservoirs (3)
202
An infection transmitted by sandflies. The infection occurs in Colombia, Peru, and Ecuador in mountain
valleys. The infection has two distinctive forms.
Annexes
Sandfly
Oral
Transmission : the sandflies are infected when biting a person carrying the pathogen. The
pathogen is transmitted when the sandfly feeds on a person (3). Outbreaks of
the infection can occur (16) A1
Reservoir : humans are the only reservoir. Where the infection is endemic, 5% of the
population may be asymptomatic carrier of the pathogen (3).
Vector/int. host : the vector of the infection is the sandfly (Lutzomyia spp.). The flies feed at
night (16)
Risk in disaster : could be a problem if people are placed in an endemic area (16)
203
Infections transmitted by sandflies. The illnesses last only some days and are not fatal. Outbreaks are
possible if non-immune people enter endemic areas.
Sandfly
Transmission Oral
to offspring
Transmission : sandflies are infected either through biting an infected person, or by receiving
the infection from its parents (16). Sandflies become infective one week after
biting an infected person. People are infected by the bite of an infective
A1
sandfly (3). Outbreaks can occur when non-immune people enter into an
endemic area (16)
Reservoir : the main reservoirs are humans and sandflies. Sandflies can transmit the
pathogens to their offspring (16). Rodents can be potential reservoirs (3)
Vector/int. host : the main vector is the common sandfly (Phlebotomus papatasi). This sandfly
bites at night. The sandfly Sergentomyia spp. is a probable vector. In Central
and South America the vectors are sandflies belonging to Lutzomyia. Sandflies
remain infective for life (up to one month) (3)
Epidemic measures : control of sandflies and health and hygiene promotion (3)
204
An infection transmitted by blackflies. The infection is associated with fast-flowing rivers. The pathogen
can cause blindness. The socio-economic consequences of the disease are important as it has
pushed people to abandon fertile areas.
Annexes
Transmission cycle (73)
Blackfly A1
Oral
Transmission : the adult worms shed microfilariae which are found in the skin of the host.
When blackflies feed on a person microfilariae will infect the vector (3). It will
take around 7 days before the fly will become infective to humans (16). When
an infective fly feeds on a person infection can take place (3)
Reservoir : humans are the only reservoir of importance (3)
Vector/int. host : the vector of the infection is the blackfly (Simulium spp.) (73). The flies lay
their eggs in fast-flowing, oxygenated rivers (turbulent, ‘white’ rivers). And
can travel long distances, normally 5 to 10 km from the river. The chances of
being bitten are largest close to breeding sites. The flies feed at dusk and
dawn (16)
Water-related : the infection is transmitted by a water-related insect vector
Excreta-related : no
205
Environment : close to turbulent streams. During the rainy season flies may search for new
sites to breed. In the dry season they stay close to permanent streams (16)
Risk in disaster : the infection will not be a priority in a disaster (3)
Remarks : it is estimated that around 18,000,000 people are infected, with around
360,000 people permanently blinded by the disease. Up to 15% of the
population living near fast flowing rivers may be infected (16). The disease has
a big socio-economic impact on society as it has often pushed people to
abandon fertile soils (3).
As the blackfly can travel great distances (up to 80 km in a day), control measures using chemical
vector control will need to cover large areas and be conducted over longer periods to have a lasting
effect (2,16).
206
A mild infection transmitted by tabanid flies. The public health importance of the pathogen is limited.
Deer fly
Annexes
Oral
207
An infection spread by reduviid bugs. The infection is associated with poor quality housing (poverty).
The pathogen only occurs in Central and South America. The disease commonly results in disability
and death.
Symptoms : asymptomatic infections are common (2). Symptoms are fever, malaise,
affected lymph system, and enlarged liver and spleen (3). Many people will
initially not show any symptoms, but will develop complications years after
the infective bite occurred (2)
Severity : the infection commonly results in disability or death (73)
Incubation period : 5 to 14 days (3)
Duration : the duration of the infection is variable; months to years (44)
Communicability : as long as the infection lasts the bug can take up the pathogen. Infected
bugs remain infective for life. The bugs can live for up to 2 years (3)
Human
Animal
Reduviid bug
A1
Oral
Transmission : A bug becomes infected when feeding on a host. The reduviid bug will become
infective to people 10 to 30 days after biting the host. When feeding, the
bug will excrete, and it is in these excreta that the pathogens are found.
Infection occurs when the excreta of the infected bug come in contact with
broken skin (e.g. the bite wound), mucous membranes, or conjunctiva (3). It
is possible that excreta from bugs are infective when ingested (73), this route
of transmission will not be very common though
Reservoir : reservoirs are humans and many wild or domestic animals. Dogs can introduce
the pathogen from the ‘wild cycle’ which occurs outside the house to the
‘domestic cycle’ which occurs inside the house. In Central America the rat is
an important reservoir (73). In Argentina goats may play a role in transmission.
Animals which can be infected, but whose role in the transmission cycle are
limited, are cats, pigs, cattle, and horses (16)
208
Vector/int. host : the vector is the reduviid bug (Reduviidae spp.), also called kissing bug or
assassin bug (2). The bugs live in rural (poor) houses; cracked mud walls and
thick palm roofs are ideal hiding places (16). One single hut may contain
thousands of reduviid bugs (2)
Water-related : no
Excreta-related : no
Environment : the infection is linked to poverty (73). The quality of the housing and the
presence of bugs are related. Walls with cracks, thatched roofs (16), and
reservoir animals living in or close to the house (73) are all risk factors
Risk in disaster : the infection will normally not be a priority in disasters (3)
Remarks : it is estimated that 10,000,000 people are infected with the pathogen (44)
Annexes
A1
209
A flea-borne infection. The disease is severe, and outbreaks can occur. In many regions the disease
is naturally present in a wild rodent–flea cycle, where this cycle is disturbed, people can get infected.
Pneumonic
Respiratory
droplets
Human
A1
Human
5% of people with
bubonic plague
evolve towards
Animal pneumonic plague
(usually rats)
(Rat) flea
Wild rodent
Rural
Bubonic
210
and fleas, this is the sylvatic or rural cycle (3). When domestic rats enter into
this cycle, infected fleas can colonise them. As these rats are less resistant
to the infection than wild rodents, they will die, leaving the fleas without a
source of food (73) (a sudden die-off of domestic rats can be an indication
that a human outbreak is going to occur) (16). Domestic rats live normally
close to humans, and the infective fleas will search for new sources of blood,
transmitting the infection to people when feeding on them (73).
Domestic animals may take wild rodent fleas into the human environment (3).
Another way of transmitting the infection is through direct contact with body
tissues of infected animals (3). Pne.P. can be spread through air-borne
transmission and is highly contagious (47)
Reservoir : the domestic black rat (Rattus rattus) and the brown sewer rat (R.norvegicus)
are the main reservoirs which transmit the infection to humans (16). Other
animals which can play a role as reservoir are mice, other rodents, dogs,
camels, monkeys, rabbits (73), cats, and wild carnivores (3). Over 340 animal
species can be infected with the pathogen (73).
The pathogen can survive for months in the cool, damp environment of animal
burrows. In dry conditions they may survive for a few days, but longer in dried
blood or secretions. They are killed after being for 15 minutes at 56°C or by
being exposed to direct sunlight for 4 hours (16)
Vector/int. host : fleas are the vector of the infection. The most important is Xenopsylla cheopsis
(a rat flea) (3), though X.brasiliensis and X.astia are implied too (73). In the
Andes region in South America the human flea (Pulex irritans) plays a role in
transmission (3).
Water-related : the infection is water-washed (73)
Annexes
Excreta-related : no
Environment : presence of the pathogen in the rural cycle is obviously a risk factor (73). The
infection is more likely to occur in rural areas. Crowding and unhygienic
conditions are risk factors, as are occupations like hunting or trapping (3).
The disease is associated with war and civil disturbance (73). Most cases
occur in the warm and dry season (16)
Risk in disaster : the infection is a risk where the disease is endemic, in conditions of
overcrowding and poor environmental hygiene (3)
Remarks : the infection should be notified to the WHO (3). Sporadic cases in endemic
areas do not necessarily indicate an outbreak. The pathogen occurs in the A1
rural cycle between wild rodents and fleas in many regions. In some of these
regions, humans are not infected while in others outbreaks have occurred (73)
211
Epidemic measures : search for cases and treat them, health and hygiene promotion, flea control,
control of rats after successful control of fleas, protection and/or treatment
of contacts, protection of workers against fleas (3)
A1
212
A flea-borne infection which should not be confused with epidemic louse-borne typhus fever or scrub
typhus. The infection is generally endemic, and has a low mortality.
Human
Annexes
Rat (mouse)
(Rat) flea
Excreta of fleas/crushed flea body
Oral
Transmission : fleas become infected by feeding on a host (73). It is the excreta of the fleas A1
which contain the pathogen. The infective excreta can infect a person by
contaminating the flea bite or other wound (3), mucous membranes, or
conjunctiva. The faeces are infective too if inhaled by a person. Which
transmission route is most common is not clear. In addition, the body of the
flea is infective, and crushed fleas are as dangerous as their faeces. Crushing
fleas between teeth can result in infection (73).
The infection is generally an endemic infection, with sporadic cases occurring
(3)
Reservoir : the main reservoirs of the pathogen are the domestic black rat (Rattus rattus)
and the sewer brown rat (R. norvegicus) (73). Mice can play a role as a reservoir
for human infection. Rodents do not suffer seriously from the infection (16). In
addition to rodents, the infection occurs in cats, opossums, shrews, and
skunks, their role as a reservoir of the infection is minor though (73)
Vector/int. host : the main vector of the infection is the rat flea (Xenopsylla cheopsis) (3). Other
vectors which have been found to carry the pathogen are the human flea
(Pulex irritans), lice (this is not epidemic louse-borne typhus), mites (this is
213
not scrub typhus), and ticks. These will generally not be very important in the
transmission of the infection (73). In some places cat fleas (Ctenocephalides
felis) could be the vector of a similar infection, the importance of this vector
will be limited though (3)
Water-related : the infection is water-washed (73)
Excreta-related : no
Environment : the infection is linked to an urban environment (73) where people and rats (or
mice) live in close association (3). People in close contact with rats or mice
are most at risk (e.g. workers in granaries, food stores, breweries, shops, or
garbage workers). The domestic environment may be a risk too (16)
Risk in disaster : where people and rats live closely together cases are likely to occur (3). The
infection will not be a priority in the initial emergency phase (47)
Remarks : -
214
A louse-borne infection with a high case fatality rate. Where people live in crowded conditions, have
poor personal hygiene, and are infested with lice, the infection can cause outbreaks. Where these
conditions exist, preventative measures should be taken before an outbreak occurs. The infection
should not be mistaken for endemic typhus fever or scrub typhus.
Annexes
Infection occurs through broken
skin (e.g. wound of the bite),
conjunctiva, or by inhalation Blood of a person with
the active disease
Human
Body louse
Excreta of body louse/crushed body
of the louse Oral A1
Transmission : lice are infected when feeding on a person with the active disease. As well
the excreta as the body of the louse are infective. If infective louse faeces, or
crushed lice, come in contact with broken skin (e.g. the biting wound), infection
can follow (3). Crushing lice between teeth is dangerous. Inhaling dried faeces
of lice is a potential transmission route, as is contact of the conjunctiva with
the infective excreta of the lice (73)
Reservoir : humans are probably the only reservoir (73).
Rickettsia in dead lice can remain infective for weeks (3). The pathogen can
remain viable for over 100 days in louse faeces (73)
215
Vector/int. host : the main vector transmitting the infection is the body louse (Pediculus
humanus corporis). Other lice (Phthirus pubis and Pediculus humanus capitis)
are possibly involved in transmission.
Body lice live between underclothing and body, and lay eggs in the seams of
clothing. Adult lice which have no access to a blood meal die within 10 days,
and clothes which have not been worn for 1 month will be free of adults and
eggs. Body lice can not survive if clothes are frequently washed or changed.
Ironing, and washing clothes at over 60°C, will kill the lice. Lice do not support
high ambient temperatures (73)
Water-related : the infection is water-washed (3)
Excreta-related : no
Environment : epidemic louse-borne typhus fever is a risk where a combination of crowding
(84)
, cold weather (people wear more clothes), poor personal hygiene, and
infestation of the population with body louse occurs (3). The infection is
associated with mountainous areas (cold weather) (15), war, and famine (3)
Risk in disaster : the infection is a serious risk in circumstances of overcrowding, poor personal
hygiene, and if body louse is present in the population. If people carry body
louse, the population should be treated against the vector before the first
cases occur (47)
Remarks : the infection is under surveillance by the WHO (73)
(47)
Epidemic measures : control of body louse, search for the source of the outbreak (3)
216
A louse-borne infection. The infection usually occurs in outbreaks and can have high case fatality
rates. The infection is a risk in places of overcrowding, poor personal hygiene, and where the population
carries lice. Preventative measures against lice should be taken before an outbreak occurs. The
infection should not be mistaken for tick-borne relapsing fever.
Annexes
skin, mucous membranes, and
possibly through unbroken skin The blood of a person
with the active disease
Human
Body louse
Crushed body of louse
Oral
A1
Transmission : Lice take up the pathogen by feeding on a person who is ill (73). Lice will
become infective 4 to 5 days after biting the host (3). The pathogen is present
in the body of the louse, which must be crushed and brought in contact with
the bite wound, an abrasion (3), or mucous membranes for infection to take
place. Possibly the pathogen can cause infection through unbroken skin.
Crushing lice between teeth or fingernails is dangerous.
Outbreaks of louse-borne relapsing fever occur under similar circumstances
as outbreaks of epidemic louse-borne typhus, and sometimes the two
infections occur at the same time (73).
If relapsing fever is transmitted by lice, it is usually epidemic (contrary to
tick-borne relapsing fever which is endemic) (3). Endemic occurrence of the
infection is possible though (2)
Reservoir : humans are the only reservoir (3)
217
Vector/int. host : the main vector is the body louse (Pediculus humanus corporis) (2).
Body lice are maintained between clothing and body. Eggs are deposited in
the seams of clothing. Body lice will not survive if clothes are frequently
washed or changed. Ironing clothes and washing them at over 60°C will kill
the lice. Body louse does not support high ambient temperatures (73).
The head louse (Pediculus humanus capitis) can play a role in transmission
(16)
, but this is rare (2)
Water-related : the infection is water-washed (47)
Excreta-related : no
Environment : the infection is one of overcrowding, poor personal hygiene, and cold climate
(people wearing clothes). In the tropics it is encountered in mountainous
areas (16)
Risk in disaster : the infection is a major risk in disasters. If people carry body lice, the population
should be treated against lice before the first cases occur (47)
Remarks : the infection is under surveillance by the WHO (3)
218
Trench fever
A usually fairly mild louse-borne infection. Occurrence of the disease is an indication of a risk for
outbreaks of epidemic louse-borne typhus or louse-borne relapsing fever.
Annexes
Human
Body louse
Excreta of the louse
Oral
Transmission : lice are infected by ingesting blood containing the pathogen. Their excreta A1
become infective 5 to 12 days after their infective blood meal. People are
infected when infective louse-faeces come in contact with broken skin (e.g.
the bite-wound) (3), or the conjunctiva (4)
Reservoir : humans are the reservoir of the pathogen (3). Though it is possible that rodents
act as a reservoir (16)
Vector/int. host : the vector of the pathogen is the human body louse (16) (Pediculus humanus
corporis) (3)
Water-related : the infection is water-washed (73)
Excreta-related : no
Environment : the infection occurs where people have poor personal hygiene, live in
overcrowded circumstances, and are carriers of body louse (3)
Risk in disaster : there is a risk where louse-infested people live in crowded conditions (3)
Remarks : -
219
If trench fever occurs in a population, there is a risk of outbreaks of epidemic louse-borne typhus
fever and louse-borne relapsing fever (3). If body louse is a problem in a population, a rapid control of
the vector is very important (47)
220
An infection transmitted by the larvae of mites. The infection occurs in Asia, and is generally very
localised in ‘typhus islands’. The infection is often severe and can cause large outbreaks if susceptible
people are brought into these ‘typhus islands’.
Symptoms : a skin ulcer will form where the larval mite was attached. Other symptoms
are fever, malaise, headache, enlarged spleen, conjunctivitis, rash, delirium,
and deafness (2)
Severity : the case fatality rate in untreated cases is 1 to 60 % (3)
Incubation period : 1 to 3 weeks (73); usually 10 to 12 days (3)
Duration : around 2 weeks (3)
Communicability : mites remain infective over several generations (2)
Annexes
Human
Wild rodent
Larva of mite
Transmission : mites acquire the pathogen either from their parents, or by feeding on an
infected rodent (73). The rodents and mites live together in specific zones:
‘typhus islands’ (3). The extent of this ‘community’ is limited to where the
rodents are present (73). When people enter into these zones they can get
infected if bitten by the infective larva of the mite (2). In military operations up
to 50% of the soldiers have been infected (3)
Reservoir : reservoirs for the pathogens are wild rodents (16). Mites are important as
reservoirs as they can pass the infection to their offspring. The infection can
be maintained in mites without reinfection from an infected rodent for several
generations (2)
Vector/int. host : the vector of the infection are the larvae of mites (Leptotrombidium akamushi,
L.deliensis and related species) (3). The mites live in transitional or fringe
zones (73)
221
Water-related : no
Excreta-related : no
Environment : the infection occurs in rural zones where the pathogen, mites, and rodents
coexist. These areas can be small (measured in some square metres) (3) or
large. They are almost always created by human activity (73); e.g. where jungle
has been cut and been replaced by scrub (2) (jungle grass) (16). Infection
occurs to an altitude of up to 3,500 metres above sea level (3)
Risk in disaster : the infection is a risk if people are placed close to ‘typhus islands’ (3)
Remarks : -
Control of rodents does not have a direct effect as the mite transmits the pathogen to its offspring (2)
Epidemic measures : control of mites by personal protection and clearing of areas containing the
Annexes
mites (3)
A1
222
A tick-borne infection which should not be confused with louse-borne relapsing fever. The infection is
endemic in Africa.
Pathogen : in Africa caused by Borrelia duttoni; elsewhere other species are responsible
(2)
(Rickettsia)
Distribution : the infection occurs in the whole of tropical Africa (3), where the infection is
endemic (73). The infection occurs in foci in northern Africa, the Middle-east,
and Central Asia up to China, Central America, South America, Spain, Portugal
(16)
, and northern America (3)
Symptoms : infections may be asymptomatic (2). Symptoms are fever and headache, usually
lasting 4-5 days. An attack of fever will reoccur after an interval of 2 days to
3 weeks (16) (usually 7 to 10 days) (73). These attacks will repeat themselves 3
to 6 times (in Africa up to 11 times) (16).
Where the infection is endemic, it is mainly a disease of babies, young children,
and pregnant women (73)
Severity : the case fatality rate of the infection is low (16)
Incubation period : 3 to 10 days (73), though may be up to 14 days (16)
Duration : illness lasts for as long as relapses occur
Communicability : ticks remain infective for life (3) (they can live for over 5 years (73))
Annexes
Endemic domestic
Infection occurs through African cycle
tick bite, or contact of tick
body fluids with skin or
mucous membranes Blood
Human A1
Transmission
to offspring
Wild rodent
Soft tick
223
two transmission cycles occur: in Africa the infection is endemic and the cycle is between people and
domestic ticks. Elsewhere an alternative cycle exists; the infection is normally transmitted between
rodents and ticks, and people are infected by chance. If contact becomes more intense a cycle
similar to the African endemic cycle may occur (73).
Transmission : Ticks are infected by feeding on infected blood, or receive the infection from
their parents (73). The infection is transmitted to humans through the bite of
an infective tick (3). Body fluids of the ticks are infective too, and infection
can occur through contact with mucous membranes, conjunctiva, or intact
skin (16). Limited outbreaks are possible (16)
Reservoir : in the endemic domestic African cycle reservoirs are humans and ticks (73). In
the alternative cycle the normal reservoirs are wild rodents and ticks. The
ticks transmit the pathogen to their offspring (3), and the infection can be
maintained in ticks for at least 5 generations (2)
Vector/int. host : in the endemic domestic African cycle the vector is the soft tick Ornithodorus
moubata which lives in cracks and fissures in houses. The ticks can survive 5
years without blood, which means that empty houses can remain infested
with ticks for years (73).
For the alternative cycle; in Africa: O.hispanica; in the Near East and Middle
East: O.tholozani; in Central and South America: O.rudis and O.talaje; and in
the USA: O.hermsi and O.turicata. The ticks usually feed at night (3)
Water-related : no
Excreta-related : no
Environment : in the endemic domestic African cycle the infection occurs in houses which
allow ticks to hide in cracks in walls and floors. In the alternative rodent-tick
Annexes
Once ticks have infested a house it is very difficult to get rid of them (73)
224
Typhus – African tick, Boutonneuse fever, Kenya tick typhus, India tick
typhus, Mediterranean tick typhus, Mediterranean spotted fever/
Siberian tick typhus, North Asian tick fever/ Queensland tick typhus
Pathogen : African tick typhus (Afr.T.T.): Rickettsia conorii and closely related Rickettsia.
Siberian tick typhus (Sib.T.T.): Rickettsia sibirica.
Queensland tick typhus (Que.T.T.): Rickettsia australis (3) (Rickettsia)
Distribution : Afr.T.T.: Africa, the Mediterranean, the Middle-east, India (16), and possibly
Mexico.
Sib.T.T.: the Asian parts of the former USSR, Mongolia, and China.
Que.T.T.: Australia (3)
Symptoms : mild infections do occur. Occasionally a small black ulcer is visible where the
tick was attached (3). Other symptoms are a skin rash and fever (2)
Severity : the infections have a negligible case fatality rate (210,221)
Incubation period : Afr.T.T.: usually 5 to 7 days.
Sib.T.T.: 2 to 7 days.
Que.T.T.: 7 to 10 days (3)
Duration : in some cases the illness can last up to 2 weeks (3)
Communicability : the ticks remain infective for life (about 18 months) (3)
Annexes
Infection occurs through the
bite of an infective tick; or
through contact of broken
skin or mucous membranes with
body tissue or faeces of the tick Blood
Human
Animal
A1
Tick
Transmission : the tick can either receive the infection from its parents, or by feeding on an
infected animal. People are usually infected when a tick bites. Crushed ticks,
or tick excreta, can cause infection when in contact with broken skin or
mucous membranes. The tick must be attached for at least 4 to 6 hours
before the pathogen is able to cause infection (3)
Reservoir : the reservoirs for all infections are rodents (2,3), dogs (3,16), and other animals.
Ticks are a reservoir as they can transmit the infection to their offspring (3)
225
The entire body should be searched every 3 to 4 hours in a risk area (3)
226
An infection transmitted by ticks. The pathogen causes a potentially dangerous illness. The infection
only occurs in South, Central, and North America.
Symptoms : sudden onset of fever, malaise, headache, muscle pains, and skin rash (73)
Severity : the case fatality rate is between 13 and 25%; with adequate treatment this
can be brought down to below 5% (3)
Incubation period : 3 to 13 days (73)
Duration : the illness lasts several weeks (44)
Communicability : ticks remain infective for life (3)
Annexes
Human
Animal
Tick
A1
Transmission : ticks can pass the pathogen to their offspring, and are either infected in this
way, or when feeding on a host (73). Humans are infected by the bite of a tick
(a tick must be attached for at least 4 hours to transmit the pathogen), or
through contact of tick faeces, or a crushed tick, with broken skin or mucous
membranes (3)
Reservoir : rodents and other small mammals are the main reservoir (45). Dogs are a
potential reservoir (3). As the ticks transmit the infection to their offspring
they serve as a reservoir to the pathogen (16)
Vector/int. host : the vector of the infection are ticks: in Central and South America the main
vector is Amblyomma cajennense (3); in Mexico: Rhipicephalus sanguineas
(44)
. In the USA, the American dog tick (Dermacentor variabilis), the Rocky
Mountain wood tick (D. andersoni) and occasionally the Lone Star tick
(Amblyomma americanum) play a role in transmission (3)
Water-related : no
Excreta-related : no
Environment : where contact with ticks is likely
227
Remarks : -
228
Pathogen : Crimean-Congo haemorrhagic fever virus, Omsk haemorrhagic fever virus and
Kyasanur forest disease virus (3)
Distribution : Crimean-Congo haemorrhagic fever (C.C.H.F): tropical and South Africa, the
former USSR, the southern parts of eastern Europe, Middle-east, Pakistan,
and China (3).
Omsk haemorrhagic fever (O.H.F.): the Omsk region in Siberia (16).
Kyasanur forest disease (K.F.D.): the Kyasanur forest in India (3)
Symptoms : C.C.H.F.: asymptomatic infections do occur (16). Symptoms are fever, malaise,
pains, skin rash, possibly bleeding from gums, nose and intestines (3). In
Africa cases with bleeding are rare (16)
O.H.F. and K.F.D. : symptoms are chills, headache, fever, pains, conjunctivitis
is common, diarrhoea, and vomiting. Severe cases may develop bleeding.
Cases of K.F.D. sometimes develop problems in the central nervous system
(3)
Severity : C.C.H.F.: the case fatality rate is between 2% (3) and 30% to 50%. The higher
fatality rates tend to occur in outbreaks. In Africa deaths due to the infection
are uncommon.
Annexes
O.H.F.: the case fatality rate is 1% to 3% (16).
K.F.D.: the case fatality rate is estimated at 1% to 10% (3)
Incubation period : C.C.H.F.: transmission through a tick-bite: 1 to 3 days (with a maximum of 9
days); transmission through contact with infected blood, secretions, or body
tissues: 5 to 6 days (with a maximum of 13 days) (83).
O.H.F.: usually 3 to 8 days (3).
K.F.D.:3 to 12 days (73)
Duration :the illnesses may last for weeks. Complete recovery may take a long time (3)
Communicability : ticks remain infective for life (3)
Transmission to offspring
229
Transmission : ticks are infected either through their parents, or by feeding on an infected
host. The infections are transmitted to people through the bite of an infective
tick. C.C.H.F. can be transmitted through contact with blood and secretions
of infected persons or reservoir animals (3). Persons commonly acquire O.H.F.
through direct contact with infected muskrats. The possibility of air-borne
transmission is suspected with C.C.H.F. and O.H.F..
Outbreaks are possible with all of the infections. Epidemics of C.C.H.F. can
occur in endemic areas. For O.H.F. there is risk of an outbreak if there is a
high mortality in muskrats (16)
Reservoir : C.C.H.F.: hares, birds, and domestic animals (sheep, goats, cattle) (3).
O.H.F.: the main reservoir is the muskrat, but other rodents serve as reservoirs
too (16).
K.F.D.: probably rodents, shrews, and monkeys (3).
Ticks transmit the pathogens to their offspring, and are therefore reservoirs
(3,16)
230
Infections transmitted by ticks. The pathogens occur in the former USSR, Europe, and northern
America
Annexes
Infection occurs through the bite
of an infected tick; C.E.E. has
been transmitted by raw milk
Human
Blood
Animal
Tick A1
Oral
Transmission to offspring
Transmission : ticks are infected either by receiving the pathogen from their parents, or by
feeding on an infected host. Humans are infected when an infective tick
feeds on them. C.E.E. has been transmitted by ingesting raw milk (3). Outbreaks
can occur after periods in which voles have been numerous (16)
Reservoir : the reservoirs of the infections are rodents, other mammals, and birds (3).
Infected ticks can pass the pathogens to their offspring and are therefore a
reservoir (221, 241)
Vector/int. host : the vectors of the infections are ticks: in the eastern parts of the former
USSR mainly Ixodes persulcatus, in the western parts of the former USSR
and Europe the main vector is I.ricinus, and in the USA and Canada I.cookei
(3)
231
Water-related : no
Excreta-related : no
Environment : F.E.E. occurs mainly in spring and early summer, and is an infection of the
forest and taiga. C.E.E. is associated with forests and occurs in late spring to
early autumn (16). P.V.E. can mainly be found in rural or forested zones (3)
Risk in disaster : the infections will not be a priority in a disaster (3)
Remarks : -
the entire body should be regularly searched for ticks when in an area
at risk (3)
Control of ticks (3)
232
An infections transmitted by ticks. The pathogen occurs in the former USSR, China, Japan, Europe,
and northern America.
Human
Blood
Animal
Annexes
Tick
Oral
Transmission to offspring
Transmission : ticks are infected either through their parents or by feeding on an infected A1
host. Humans are infected through an infective tick-bite. In tests ticks had to
be attached for over 24 hours to animals before transmission of the pathogen
occurred (3)
Reservoir : the reservoirs of the infection are rodents and other animals. Dogs, cattle,
and horses can develop the illness. Ticks serve as reservoirs as they can
transmit the pathogen to their offspring (3)
Vector/int. host : the vectors of the infections are ticks: in Asia Ixodes persulcatus, in Europe
I.ricinus, and in the USA I.pacificus and I.scapularis (3)
Environment : infection usually occurs in summer (when the ticks are most active) (3)
233
Regularly search the entire body for ticks when in an area at risk (3)
234
Annexe 2
Annexes
A2
235
cpd-annexe2.pmd
Table A2.1: Faecal-oral infections
y s
al
236
a i lit m
ic ng ni es
er l ity il ab hi ne a fli
m a a s n g ie ic
.A qu av io ic
S ir r r wa t at hy e st e st
Infection or r vo te te nd ni od Additional
/ se wa wa ha sa fo d om d om
nd re g g measures
la in in i ng i ng i ng l of l of
a ra al ov ov ov ov ov
c t m pr pr pr pr pr n tro n tro
A fri A sia en A ni Im Im Im
C Im Im Co Co
236
Campylobacter enteritis ! ! ! ! ++ +++ +++ ++ ++ ++ –
17/03/2003, 12:12
– +++ +++ +++ +++ ++ – n.s.(a)
CONTROLLING AND PREVENTING DISEASE
! ! ! of the dead
+++: very effective; ++: effective; +: some effect; n.s.: extent of effectiveness is not specified; p: possible, depending on the pathogen ;
- : no, or not effective
(a)
: where contaminated wastes are present
*caused by E.coli
cpd-annexe2.pmd
Table A2.1: Faecal-oral infections (continued)
237
y s
a ilit al
ic y b n g e i m es
er lit ila hi n en an fli
m a a s i
.A qu av wa tio h yg tic tic
Infection ir er er ta d es es Additional
o rS r vo t t nd ni o m m
d/ se wa wa ha sa fo do do measures
n e g g ng f f
la lr i ng i ng vin vin i lo lo
a ov ov o o ov ro ro
ri ca ia n tra i m pr pr pr pr pr nt nt
Af As Ce An Im Im Im Im Im Co Co
Rotaviral enteritis ! ! ! – ? ? ? ? ? – ?
237
! ! !
Amoebiasis ! ! ! – n.s. ++ ++ ++ + – n.s.
Giardiasis – ++ ++ ++ + + – –
! ! !
Cryptosporidiosis n.s. n.s. n.s. n.s. n.s. n.s. –
! ! ! !
Balantidiasis ! n.s. n.s. n.s. n.s. n.s. n.s. –
! ! !
ANNEXE 2: TABLES OF INFECTIONS
(para-) typhoid fever ! ! ! – +++ +++ +++ ++ ++ – n.s. control of food handlers
17/03/2003, 12:12
Hepatitis A and E ! ! ! – n.s. +? n.s.? + + – –
+++: very effective; ++: effective; +: some effect; n.s.: extent of effectiveness is not specified; ?: uncertain - : no, or not effective
A2 Annexes
A2 Annexes
cpd-annexe2.pmd
Table A2.1: Faecal-oral infections (continued)
y s
238
a ilit al
ic y b n g e i m es
er lit ila hi n en an fli
m a a as i
.A qu av tio h yg tic tic
Infection ir er er dw ita d es es Additional
o rS r vo t t n n o m m
d/ se wa wa ha sa fo do do measures
n e g ng ng of of
la lr i ng i ng vin i i l l
a ov ov o ov ov
ri ca ia n tra i m pr pr pr pr pr n tro n tro
Af As Ce An Im Im Im Im Im Co Co
238
Hydatid disease ! ! ! !(b) – ++ ++ n.s.(b) n.s. n.s.(b) –
(a)
: possibly mice
(b)
: dogs
17/03/2003, 12:12
CONTROLLING AND PREVENTING DISEASE
cpd-annexe2.pmd
Table A2.2: Water-based helminths (schistosomiasis and water-based helminths
with 2 intermediate hosts)
239
n s
a io a ils al
ic t t m
er ac a ra r sn a ni
m nt n te ic
A o t io ep a t
S. r rc ita pr es t
Infection r v oi te n od s hw en Additional
/o er sa fo f re d om m
d s wa t measures
an re ng i ng i ng l of l of ea
a l al ci ov tr
c t ra m u ov tro tro s
fri sia ni ed pr pr n n as
A A C en A R Im Im Co Co M
239
Fasciolopsiasis – ! – ! – +(b) +++ – n.s.(b) –
+++: very effective; ++: effective; +: some effect; n.s.: extent of effectiveness is not specified; - : no, or not effective
17/03/2003, 12:12
(a)
: for S.japonicum
(b)
: pigs
(c)
: domestic animals
A2 Annexes
A2 Annexes
cpd-annexe2.pmd
Table A2.3: Soil-transmitted helminths
240
a lit
ic bi g
er ila h in ne s
m a n g ie oe
.A av as io sh
S o ir r dw t at hy d t
Infection rv te n ni od en Additional
/ or e wa ha sa o se m
nd es g fo cl measures
ng ng ng at
la a lr i vin i i g tre
ca tra m ov o ov ov rin s
ri ia n i pr pr pr pr ea as
Af As Ce An Im Im Im Im W M
240
Roundworm infection ! ! ! – ++ ++ +++ + – +++
Trichuriasis ! ! ! – + + + + – n.s.
+++: very effective; ++: effective; +: some effect; n.s.: extent of effectiveness
– is not specified;
– - : no, or not effective
17/03/2003, 12:12
CONTROLLING AND PREVENTING DISEASE
cpd-annexe2.pmd
Table A2.4: Beek and pork tapeworm
a
ic
er ne
m n g ie
.A r io
S t at hy n
241
Infection oi ni
/ or e rv od c tio Additional measures
sa fo
a nd r es g g s pe
a r al al o vin o vin t in
ric ia nt im pr pr ea
Af As Ce An Im Im M
241
Occurrence Measures of control
s
a al
ic l ity t i m
er ua t ac e ne an
Am q on gi
. r t er c hy tic
rS oi er es
Infection /o rv wa at od om Additional measures
e g w fo
nd r es in g fd
a r iv n lo
ANNEXE 2: TABLES OF INFECTIONS
a r al al ov rce cing
p ou o r o
ric ia nt im Im t s du pr nt
Af As Ce An a Re Im Co
17/03/2003, 12:12
Leptospirosis ! ! ! ! – +++ ++ n.s. control of rodents
(a)
: in Yemen
A2 Annexes
A2 Annexes
cpd-annexe2.pmd
Table A2.6: Infections transmitted through direct contact
y
y od
242
a i lit b
ic ab ng of es
er il hi th
e fli
m a s wi i c
.A r av wa i en
g s t es
Infection S oi t er n d yg es c as
o r r v a h a
e i
lin mal
o m Additional
d/ e wa h g of
an es g g in es d an of d nt measures
l a lr v in v in r ov oth e in tic l e
a ra o o p cl ar es ro tm
ric ia nt im pr pr Im nd C om nt ea
Af As Ce An Im Im a d Co Tr
242
Yaws ! ! ! – ++ – n.s. – n.s. n.s.
Leprosy ! ! ! – p – p – – n.s.
+++: very effective; ++: effective; +: some effect; n.s.: extent of effectiveness is not specified; p: possibly effective - : no, or not effective
17/03/2003, 12:12
CONTROLLING AND PREVENTING DISEASE
ANNEXE 3: TABLES OF VECTOR-BORNE INFECTIONS
Annexe 3
Annexes
A3
243
cpd-annexe3.pmd
Table A3.1: Vector-borne infections with their vectors (3,73)
Infection g
bu e
to fly d us
ui e fly fly fly vii lo
244
o sq e ts nd a ck er du ea dy ite k
M Ts Sa Bl De Re Fl Bo M Tic
Yellow fever Ae
Dengue fever Ae
Ae; Cu;
Filariasis
Ma; An
Mosquito-borne arboviral encephalitis Cu
244
Mosquito-borne arboviral fevers Ae; Cu
Ae; Cu;
Mosquito-borne arboviral arthritis Ma; An
Malaria An
Sleeping sickness !
Leishmaniasis !
Bartonellosis !
17/03/2003, 12:12
CONTROLLING AND PREVENTING DISEASE
River blindness !
Loiasis !
American trypanosomiasis !
Mosquito: Ae (Aedes spp.); Cu (Culex spp.); Ma (Mansonia spp.); An (Anopheles spp.)
cpd-annexe3.pmd
Table A3.1: Vector-borne infections with their vectors (continued) (3,73)
Infection g
bu e
to fly d us
245
ui e f ly k fly f ly vii lo
o sq e ts nd ac er du ea dy ite k
M Ts Sa Bl De Re Fl Bo M Tic
Plague !
245
Trench fever !
Scrub typhus !
… tick typhus !
17/03/2003, 12:12
Tick-borne arboviral haemorrhagic fever !
Lyme disease !
… tick typhus: African tick typhus, Siberian tick typhus, Queensland tick typhus
Oc.: occasional transmission is possible.
A3 Annexes
A3 Annexes
cpd-annexe3.pmd
Table A3.2: The vectors and their characteristics (rats have been included) (from 61,67,77,80)
Vector I/O(a) D/N(b) Breeding sites Resting sites Range Additional information
Mosquito I/O D water bodies with most species outdoors, 0.1-0.8 km eggs can withstand
Aedes spp. fluctuating water levels, but Aedes aegypti in and desiccation for
containers in refuse, water around houses months.Generation cycle:
246
storage tanks, usually 8-10 days
clean water
Mosquito I/O N organically polluted water: indoors and outdoors in 0.1-0.8 km Generation cycle: 8-10
Culex spp. latrines, sceptic tanks, sheltered, shaded places days
blocked drains
Mosquito I/O N water bodies with usually outdoors ?
Mansonia spp. permanent vegetation:
swamps, ponds, canals
Mosquito I/O N lakes, pools, puddles, indoors and outdoors in 2 km Generation cycle: 10-14
Anopheles spp. slow-flowing streams; sheltered places days
246
often in sunlight and with
vegetation, clean water
Tsetse fly O D in shaded moist soil: under in shaded places in 2-4 km Generation cycle: 60
(Glossina spp.) bushes, logs, stones, leaf forests, vegetation days
litter
Sandfly I/O D/N humus-rich damp soil; shaded, sheltered, humid 200 m Generation cycle: 6-8
(Phlebotomus spp.; deep cracks in soil, rodent places weeks
Lutzomyia spp.) burrows, termite hills
Blackfly O D fast-flowing, shallow, outdoors 10 km Generation cycle: 2-3
(Simulium spp.) ‘white water’ in rivers and weeks
streams
17/03/2003, 12:12
CONTROLLING AND PREVENTING DISEASE
Reduviid bug I N cracks in walls, other cracks in walls or floors, 10-20 m The bugs can survive for
(Triatoma spp.) indoor hiding places furniture, thatched roofs up to 4 months without a
blood meal. Generation
cycle: 6-24 months
(a)
I/O: the biting place is indoors (I) or outdoors (O)
(b)
D/N: the time of activity is during the day (D) or during the night (N)
n/a: not applicable
cpd-annexe3.pmd
Table A3.2: The vectors and their characteristics (continued) (from 61,67,77,80)
Vector I/O(a) D/N(b) Breeding sites Resting sites Range Additional information
Flea I D/N close to sleeping and animals, beds, clothing n/a vector fleas are associ-
247
(Xenopsylla spp.; resting place of the host; ated with rats; may
Pulex irritans) in cracks in walls or floors, survive for up to 1 year in
animal burrows vacant houses. Genera-
tion cycle: 8 weeks
Body louse n/a D/N seams in clothing clothes n/a can only survive for up to
(Pediculus humanus 1 week off people.
corporis) Generation cycle: 3
weeks
Mite O D often artificially created often artificially created n/a
(Leptotrombidium environments: where environments: where
jungle has been replaced jungle has been replaced
247
spp.)
by scrubs, jungle grass by scrubs, jungle grass
Tick I/O D depending on the sort indoors: cracks in walls, n/a different ticks can act as
(many different types) floors and furniture; vector of different
outdoors: sheltered places diseases
Domestic fly n/a D organic material: faeces, outdoors and indoors 5 km domestic flies are
(Musca spp.) corpses, food mechanical vectors.
Generation cycle: 7-14
days
Cockroach n/a N sheltered, warm and damp sheltered, warm and damp ? Generation cycle: 2-3
(several types) places places months
17/03/2003, 12:12
Rat n/a N buildings, burrows, sewers, buildings, burrows, sewers, 50-80 m Generation cycle: 3-4
(Rattus spp.) refuse dumps refuse dumps months
ANNEXE 3: TABLES OF VECTOR-BORNE INFECTIONS
(a)
I/O: the biting place is indoors (I) or outdoors (O)
(b)
D/N: the time of activity is during the day (D) or during the night (N)
n/a: not applicable
A3 Annexes
A3 Annexes
cpd-annexe3.pmd
Table A3.3: Preventative measures against vectors (rats have been included) (adapted from 21,61,67,73,77,78)
ne n
, g ie e n io ity
t s y a st g e i o t at
h t oc es
248
e n es l o n e w r a a g e l l ur
ll h a ti o g t ve ve s
Vector ts on i ta n ag o lid t st s in ge w n tro ea
r e pe clot e r s n a i s n d u v e i c o o
dn pe sa dr o d at fl lm
of ive be ve e fo ho qu g lc
f v e v e v e p ro gem ve v e l an a g in i ca o na
s e ect
o o o o o o r r s iti
U rot e pr pr pr Im ana pr pr ea ea an em ap d
p Us Im Im Im m Im Im Cl Cl Ch Ch Tr Ad
248
Mosquito: Mansonia ++ ++ – – + – – ++ – ++ +(1) – – (b)
Tsetse fly + – – – – – – – ++ – – + ++
++ : effective; + : limited effect; n.s. : extent of effectiveness is not specified; - : not effective
17/03/2003, 12:12
CONTROLLING AND PREVENTING DISEASE
(1)
: increasing velocities in streams, rivers, channels
(2)
: modifying streams so that the creation of ‘white’, turbulent water is avoided
(a): fill up, remove, cover or repair all ‘vessels’ in the domestic area (e.g. old tyres, buckets, domestic water storage reservoirs, barrels, gutters, holes in
construction blocks, old cars or machines)
(b): introduce larvivorous fish
(c): it is sometimes possible to divert mosquitoes to domestic animals
(d): destruction of rodent colonies; avoiding places where sandflies rest or breed
(e): avoidance of areas where the blackfly is abundant (e.g. rapids in streams)
cpd-annexe3.pmd
Table A3.3: Preventative measures against vectors (continued) (adapted from 21,61,67,73,77,78)
ne n
, g ie e tio ity
s h y a st ge i on ta s
n t s
l o n e w r a a t g e l oc l re
ll e the a ti g id o g t v e u
ts on na st in ge ve w tro as
Vector e pe clo
n e r s n ita a i s ol nt d u s v e t i c l o o n e
r
249
sa o f l m
of ive ed pe dr ve e fo ho nd ua g lc
fb ve ve ve p ro gem ve v e la aq g in i ca na
s e ect
o o o o a o o r r s tio
U rot e pr pr pr Im an pr pr ea ea an em ap di
p Us Im Im Im m Im Im Cl Cl Ch Ch Tr Ad
249
Mite ++ – – – – – – – + – – ++ – (h)
++ : effective; + : limited effect; n.s. : extent of effectiveness is not specified; - : not effective
17/03/2003, 12:12
(3)
: only effective against soft ticks (the vector of tick-borne relapsing fever) which live in the house
(4)
: correct use of fly-nets will prevent flies and cockroaches from reaching food or babies
ANNEXE 3: TABLES OF VECTOR-BORNE INFECTIONS
(5)
: where flea-borne infections (plague, murine typhus fever) are present, or a risk, fleas must be successfully controlled before rat control begins
(f): improve hygiene of the house
(g): clothing has to be cleaned and treated with insecticide; mass treatment is necessary; treatment of bedding
(h): avoid ‘mite islands’
(i): check body after visiting tick-infested areas; treating domestic animals with insecticide
A3 Annexes
CONTROLLING AND PREVENTING DISEASE
Annexes
A3
250
Annexe 4
Chlorination of drinking-water
Annexes
A4
251
Materials needed:
! Turbidity tube (preferably)
! Chlorine-generating product (e.g. HTH)
! Tablespoon (or other object which contains around 15 ml)
! Measuring jug
! Non-metallic vessels (e.g. plastic buckets) with a volume of 5 litres or more
! Syringe (without needle)
! Pooltester with DPD1 tablets
! A watch
! Possibly a calculator
and chlorination will only be effective if the water contains little suspended
material.
The amount of suspended matter in the water can be determined by measuring its
turbidity. This can be done with a turbidity tube. A turbidity tube is a closed tube
with a mark on the bottom. The tube is completely filled with water and the mark
is observed through the water in the tube. The water is tipped out in small
quantities until the mark is just visible. The turbidity of the water is determined by
reading up to where the water comes on the scale on the side of the tube.
It should be remembered that the turbidity of surface water will normally fluctuate
with the seasons.
252
The mother solution is made by mixing the chemical which generates chlorine
with water. How much of the chemical is needed to make a 1% solution will
depend on its chlorine content. Table A4.1 present some common chlorine-
generating products with their form, their chlorine content in percentage, and how
1 litre of mother solution of 1% chlorine can be made.
Annexes
Bleaching powder powder ± 30 % Mix 33 grams (± 2 tablespoons (a))
with 1 litre of water
Liquid laundry bleach liquid ±5% Mix 200 ml of liquid bleach with 800
ml of water
(a)
: 1 tablespoon has a volume of 15 ml
100
Qty = 10 x ( Clcont
)
A4
Thus if stabilised tropical bleach would be used with a chlorine content of 25%, the
amount that would have to be dissolved in 1 litre of water to make a 1% mother solution
is (10 x 100/25) = 40 grams.
253
A number of non-metallic vessels (e.g. plastic buckets or jerrycans) are filled with
a known amount of the raw water (e.g. 4 buckets filled with 10 litres of water).
Specific amounts of mother solution are added to each of the buckets with a
syringe (e.g. 0.5 ml, 1.0 ml, 1.5 ml and 2 ml). The water is well mixed, and left for
30 minutes.
The content in free residual chlorine is determined by comparing the colour of the
water with a colour scale. We are looking for the dose which results in a free
residual chlorine content of 0.2-0.5 mg/l.
Bucket Mother solution added to 10 litres Free residual chlorine (in mg/l)
1 1.5 ml 0 mg/l
2 2.0 ml 0 mg/l
3 2.5 ml 0.1 mg/l
4 3.0 ml 0.5 mg/l
A4
In this case a dose of 2.7 ml to 3.0 ml of mother solution per 10 litres of raw water would
normally be adequate to reach a free residual chlorine content of 0.2-0,5 mg/l.
This method gives a rough indication of the chlorine demand of the raw water.
The free residual chlorine should be 0.2-0.5 mg/l at the point of distribution. As
the content of free residual chlorine may reduce during distribution, we may want
254
to have a higher content of free residual chlorine when the water leaves the
treatment plant.
The content of the free residual chlorine in chlorinated water will have to be tested
continuously to make sure that treatment is still adequate. The chlorine demand of
the raw water will often not be constant over time.
Msbat = ( Volbat
) x Mstest
Voltest
Msbat : the amount of mother solution required to chlorinate the batch of raw
water (in ml)
Volbat : the volume of the batch of water which has to be treated (in litres)
Voltest : the volume of water that was used in the test (in litres)
Annexes
Mstest : the amount of mother solution which was required to chlorinate the
water in the test (in ml)
Thus, if in our example we need a free residual chlorine content of 0.5 mg/l, and we want
to treat the water in a reservoir of 15m3 (15,000 litres), the amount of mother solution
we would have to add would be (15,000/10 x 3) = 4,500 ml (= 4.5 litres).
RateMs = ( Flowsup
) x Mstest
Voltest
A4
RateMs : the rate at which mother solution has to be added to the supply (in
ml/second)
Flowsup : the flow of the supply of raw water (in litres/second)
Voltest : the volume of water that was used in the test (in litres)
255
Mstest : the amount of mother solution which was required to chlorinate the
water in the test (in ml)
If we would want to treat the raw water of our example in a system with continuous supply
which has to deliver 1.67 litres/second (100 litres/minute), the mother solution would
have to be added to the raw water at a rate of (1.67/10 x 3) = 0.5 ml/second.
Annexes
A4
256
Annexe 5
Annexes
A5
257
Materials needed:
! Ruler which allows to measure in mm
! A transparent jar with cover
! A watch which indicates seconds
! Possibly a calculator
To determine what volume a pit will have to be, we have to know how much of
these solids (sludge) will accumulate during its period of use. Table E.1 presents
Annexes
estimates on how much solids will accumulate in pits used under different
circumstances. These are the sludge accumulation rates.
(a)
: a pit in which the excreta are in the (ground)water
(b)
: a pit in which the excreta are not in liquid
A5
The values presented in table A5.1 are values that can be used when designing a
latrine which will be used for several years.
258
It takes time for the solids to decompose, and the sludge will accumulate at a
higher rate over the short term. If a latrine is designed for short term use, the
accumulation rates from table E.1 will have to be multiplied by 1½.
The volume of the sludge that will accumulate over the design life (i.e. the total
time over which the pit will be used) can be calculated with the formula (30):
Vs = R x P x N
A family of 6, who would build a latrine with a dry pit, and who would use water for anal
cleansing, would accumulate over a period of 15 years a volume of around (0.06 x 6 x
15) = 5.4 m3.
Two additional things have to be taken into account when sizing the pit that has to
Annexes
be dug: the pit should be taken out of use when the level of the sludge in the pit has
reached 0.5 metres below the slab (57), and if the pit needs to be lined, the lining
may take an important volume.
Thus, if in our example a rectangular pit would be dug of 1.6 x 1.4 metres, and it would
have to be lined from the bottom to the top1 with blocks 0.1 metres wide, the pit would
only have an effective size of around 1.4 x 1.2 metres (we lose the width of the blocks on
two sides). The horizontal surface of the pit would be (1.4 m x 1.2 m) = 1.68 m2. To be
able to contain 5.4 m3 of sludge, the pit would need to be (5.4 m3/1.68 m2) = 3.2
metres deep. As the top 0.5 metres of the pit can not be used, the total depth of the pit
should be (3.2 m + 0.5 m =) 3.7 metres.
The liquid that seeps out of a latrine pit will cause a partial blockage of the pores
in the soil. This means that the infiltration capacity of a pit used for excreta will be
1
Only the top 0.5 metres of a lining should be completely sealed. Below this, the lining should have sufficient openings
to allow the liquid to seep into the surrounding soil
259
much lower than the infiltration capacity of an identical pit used for clean water.
The figures we present here take into account this reduced capacity of infiltration
of the soil.
The bottom of the pit will most probably clog up and become impermeable.
Therefore only the vertical sides of the pit will be used to calculate the infiltration
capacity (30).
The area of the pit which allows infiltration is the surface area of the bare soil. An
impermeable lining (e.g. bricks, blocks, concrete) hinders infiltration. Only the
openings in the lining should therefore be used to determine the surface of the
infiltration area.
Liquid infiltrates into the soil because its hydraulic gradient is higher than that of
the water in the surrounding soil. Therefore only the surface of the pit above the
water table should be used to calculate the infiltration area (57).
In other words, the effective infiltration area is all bare soil on the vertical sides of
a pit which are above the groundwater table (and below 0.5 metres under the slab).
Annexes
In our example the actual size of the pit is 1.4 x 1.2 x 3.7 metres. As the top 0.5 metres
of the pit should not be used, the effective depth of the pit is 3.2 metres. The pit will thus
have two sides of 1.4 x 3.2 metres, and two sides of 1.2 x 3.2 metres. This gives a total
surface area of ((2 x (1.4 x 3.2)) + (2 x (1.2 x 3.2))) = 16.6 m2. If the blocks are laid in
a honeycomb structure which leaves ¼ of the soil exposed, the effective area of
infiltration will be (¼ x 16.6 m2) = 4.2 m2. As the pit is dry, all this area is used.
(However, if during the wet season there is 1.5 metres of water in the pit, the effective
depth of the pit would be (3.2 – 1.5 m) = 1.7 metres. The effective size of the pit would
be ((2 x (1.4 x 1.7)) + (2 x (1.2 x 1.7))) = 8.8 m2, and the area of infiltration (¼ x 8.8
m2) = 2.2 m2).
To estimate the potential infiltration capacity of the soil the following method can
be used.
A transparent jar is half filled with soil, and topped up to three quarters with water.
The jar is shaken vigorously to bring all soil in suspension and to break up all soil
A5
(no lumps of soil should be left). The jar is placed on a flat surface and the time
taken. A mark is made to where the particles have settled after 25 seconds; this
part are stones and sand. A second mark is made after 60 seconds, this part is silt.
After 24 hours, clay will have settled out.
260
If the sample contains sand, silt and clay, three layers will have been identified. An
estimate of the percentages of the different categories of particles can be found
with the formula:
Perlay = ( Thlay
) x 100 %
Thtot
Annexes
over 90% - - around 33 l/m2/d
- : percentage is unimportant
If we would find in our test a layer of sand of 31 mm, silt 20 mm, and clay 6 mm (total
thickness of all layers: 57 mm), than the percentages of the different particles would be:
sand ((31/57 mm) x 100%) = 54%; silt ((20/57 mm) x 100%) = 35%; and clay ((6/57
mm) x 100%) = 11%. This would mean that the infiltration capacity of our soil would
probably be around 25 l/m2/d.
In the latrine of our example, the pit could deal with a supply of around (4.2 m2 x 25 l/m2/
d) = 105 litres per day. This means that if the local water usage is around 15 litres per
person per day, it would be acceptable for the 6 users to dispose of their wastewater in
the latrine. If the water supply would be upgraded though, the latrine would probably not
be able to cope with the wastewater.
261
262
Annexe 6
Annexes
A6
263
Materials needed:
! A map of the catchment area with gradient lines, or a study of the catchment
area from which it is possible to calculate its gradients and boundaries
! Ruler
! Paper with gridlines
! A calculator with the option ‘y to the power x’ (yx)
! Preferably the IDF-curves (intensity-duration-frequency curves) of the zone
studied
to identify the catchment area on a map with the aid of the gradient lines. Once the
catchment area is identified, its surface must be estimated. This can be done by
transferring the contours of a catchment area on paper with gridlines, and count-
ing the grids.
Now the average gradient in the catchment area has to be identified. This can be
done on the map with the aid of the gradient lines and the horizontal distances.
Figure A6.1 shows how to determine the gradient in a terrain. Usually the average
gradient of the terrain can be taken.
a
Surface Gradient =
b
(Difference
a
in altitude)
b
(Horizontal distance)
A6
264
The next step is to assess the surface of the terrain. This information is needed to
determine the runoff coefficient of the area. The runoff coefficient is that part of
the rainwater which becomes stormwater; a runoff coefficient of 0.8 means that
80% of the rainfall will turn into stormwater. The runoff coefficient depends on
the type of terrain, and its slope. Future changes in the terrain must be anticipated
in the design of the drainage system to avoid problems at a later date. If no other
values are available, the values from table A6.1 can be used.
Table A6.1. Runoff coefficients of different types of terrain (these values are
approximate figures assuming a low soil permeability) (adapted from 49).
Annexes
Dense construction and 1.0 1.0
heavy industry
If the IDF curves of the area can be obtained, these should be used. IDF curves
show the rainfall intensity (in mm per hour) against the duration of the rains (in
minutes) for specific return periods. Several curves from different return periods
may be presented in one graph. A curve with a return period of 1 year will show
the worst storm that will on average occur every year, a curve with a return period
of 2 years is the worst storm that can be expected in a 2 year period, and so on.
A6
To know which value to take from the IDF curve, the time of concentration has to
be calculated. The time of concentration is the time the water needs to flow from
the furthest point in the catchment area to the point where it will leave the area (the
265
discharge point). The time of concentration is determined with the formula (49):
If the furthest point of our catchment area is at a distance of 500 metres from the
discharge point, and the difference in altitude between this point and the discharge point
is 10 metres, than the time of concentration would be around (0.02 x (500)0.77 x (10/
500)-0.383 =) 11 minutes.
The curve with the appropriate return period is chosen (for residential areas often
the curve with a 2 year return period (39)).
We look for the rainfall intensity on the chosen curve, at the duration of a storm
equal to the time of concentration which we calculated.
Annexes
Qdes = 2.8 x C x i x A
Qdes : the design peak runoff rate, or the maximum flow of stormwater the
system will be designed for (in litres per second)
C : the runoff coefficient (see table F.1)
i : the rainfall intensity at the time of concentration read from the chosen
IDF curve; if no IDF curves are available, a value of 100 mm/h can be
taken (in mm/h)
A : the surface area of the catchment area (in ha (10,000 m2))
Thus, if our catchment area would be a residential area, with a surface of 12 ha, a
gradient of 0.02, and a rainfall intensity of 100 mm/h, than the design peak runoff rate
would be around (2.8 x 0.7 x 100 x 12 =) 2350 litres per second.
A6
It should be remembered that this figure is not a fixed value. Every once in a while
storms will occur which produce more water than the drainage system can deal
with (normally, on average, periods just above the return period). The larger the
266
capacity of the system (the longer the return period the system is designed for) the
less often it will overflow, and the higher its costs.
Unlined drains are at risk of erosion, and should therefore have a relatively low
gradient to control the velocity of the stormwater. Gradients in unlined drains
should probably not exceed 0.005 (1 metre drop in 200 metres horizontal dis-
tance). In less stable soil unlined drains should be made with a slope less steep
than 1/2 (see figure A6.2), in more cohesive material a steeper slope could be used
(17)
.
The size of the drain can be calculated with the formula (17):
Annexes
N
a
a
Slope =
b
b
A6
267
the hydraulic radius is the surface area of the cross section of the flow/the total length of
the contact between water and drain;
Hydraulic radius = (a x b) / (a + b + c)
a c
This calculation will probably have to be repeated a number of times to find the
adequate size of drain (17).
Some reserve will be needed so that the drain is not completely filled with water,
and because the calculated discharge rate does not take into account deposited
solids, and lack of maintenance, which will usually reduce the efficiency of the
system (39).
A6
268
Annexe 7
Annexes
A7
269
cpd-annexe7.pmd
Priorities and standards in emergency situations
In this annexe we present the requirements for survival, and the minimum standards in service in WES required by a
population living in an unstable situation (e.g. after a natural disaster, internally displaced persons, refugees).
Survival level
Table A7.1 presents the minimum requirements so that healthy people can survive in the short term. This is an absolute
270
minimum, and a rapid improvement, possibly within days, will be necessary to prevent a rapid deterioration of the health
situation in a population. The survival levels do not cover the special needs of the sick, the wounded, or the
undernourished.
Table A7.1. The minimum immediate requirements for survival of healthy people in an emergency
Water and personal hygiene Sanitation Environmental sanitation Other possible needs
270
! A water supply of 3 to 5 litres Drainage ! Adequate protection from the
per person per day is needed, ! People must be located so that elements (blankets, clothing,
providing water of reasonable stormwater or floodwater is not a material to make shelters) (47)§
quality, accessible to all (21). direct threat to them. Adequate supply of food
! Every household should have ! Cooking pots and fuel (66)
water containers which provide ! People must be located so that
a storage capacity of 3 litres they are not under direct threat
per person or more. (e.g. hostile population, landmines)
If the water supply is unreli-
able, or access to water poor,
17/03/2003, 12:15
Parallel to survival
CONTROLLING AND PREVENTING DISEASE
Medical personnel will have to set up a surveillance system of disease to identify oncoming epidemics and important
271
health problems in the population. Emergency supplies needed in the case of epidemics have to be present locally, and
local medical personnel have to be trained in advance on how to cope with outbreaks.
Table A7.2. The minimum standards in water and (environmental) sanitation in an emergency
271
! Existing water sources must be protected. in, or close to, streams, ponds, any other ! The site must have adequate drainage which
! A water supply of 15 litres per person per source of water, or on agricultural land with rapidly removes stormwater (66).
day should be accessible to all. crops (64). ! An adequate system of dealing with waste
The maximum distance to the water points ! Structures that deal with the excreta will water from water points, leakage, domestic
should be <150 metres. have to be installed. waste water and waste water from communal
The maximum number of people per tap Usually it is not possible to construct structures must be present.Waste water from
should be: 200-250. adequate structures in sufficient numbers water points can usually be led into vegeta-
The maximum number of taps per distribu- immediately, and therefore the situation will tion.
tion point: 6-8. have to be improved gradually.
The maximum number of people per
17/03/2003, 12:15
handpump: 500-750.
ANNEXE 7: MINIMUM EMERGENCY STANDARDS
A7 Annexes
A7 Annexes
cpd-annexe7.pmd
Table A7.2. The minimum standards in water and (environmental) sanitation in an emergency (continued)
! The water quality must be reasonable to ! The sanitary structures that can be used (in ! If waste water containing solids is led into a
start with, and be improved as soon as order of low preference (but ease to install) soakaway, it must be strained or led through a
possible. to high preference (but more demanding to silt trap. If the waste water led into a
It is often better to have enough water of install)): soakaway contains grease or soap, it should
272
intermediate quality than to have little water be led through a grease-trap.
of high quality.At the beginning of the – open defecation fields ! No unwanted open water should be present
distribution system, a free residual chlorine – trench defecation fields close to, or in, the camp.
content of 0.6-1.0 mg/litre is usually – communal trench latrines
! Tools needed to maintain the drainage system
adequate to obtain water with a free – communal pit or borehole latrines
should be provided (47).
residual chlorine content of 0.3-0.5 mg/litre – household pit latrines (21)
at the distribution point (47).
Solid waste management
Gradually the structures will have to be
! Where domestic refuse is not buried or burnt
Water storage improved, depending on the feasibility (e.g.
‘on-plot’, waste will have to be collected every
272
! Every household must have a minimum of 2 start with trench defecation field, than
day, or every other day, to avoid attracting
water collection vessels of 10-20 litres and communal pit latrines, than household pit
flies or rats.Every 10 households will need
an additional storage capacity of 20 litres. latrines).
one container of 100 litres to collect and
The vessels should have a narrow neck and In communal structures personnel for
store the waste.
be covered. cleaning and maintenance will have to be
The container should be within 15 metres of
employed.
the dwelling. If a communal waste pit is used,
The sexes should be separated in communal
it should not be more than 100 metres from
structures, and the issues of safety to
the dwelling.
women must be addressed.
Public latrines must be installed in public ! There have to be adequate waste collection
places. points on markets and slaughtering areas.
17/03/2003, 12:15
CONTROLLING AND PREVENTING DISEASE
All structures need some kind of water These wastes should be collected daily (66).
source for handwashing, anal cleansing, ! Wastes should be disposed of in a pit. Every
cleaning of the structure and flushing. day it should be covered by at least 0.15
metres of soil, and the ultimate layer of soil
should be at least 0.5 metres thick.
cpd-annexe7.pmd
Table A7.2. The minimum standards in water and (environmental) sanitation in an emergency (continued)
Personal hygiene ! The latrines should be technically sound and ! Medical wastes must be properly disposed of
! A minimum of 250 grams of soap must be acceptable to all users. by incineration and/or disposal in a deep
available per person per month. Initially 1 latrine, or metre of trench, per 50 protected pit.
to 100 users must be installed (47), as soon
273
! If household bathing facilities are not
available, communal facilities will be needed. as possible this must be improved to 1 Disposal of the dead
These should be culturally acceptable, and latrine per 20 users. ! Usually the health hazard associated with
the sexes must be separated. Latrines should if possible not be further dead bodies is negligible (66), but during
Communal laundry facilities may be required. away than 50 metres from dwellings (66). epidemics of cholera, plague, or louse-borne
Women must be able to wash undergarments Water sources used for drinking should not typhus fever, dead bodies must be dealt with
and sanitary cloths in privacy. be at risk from sanitary structures. adequately (21).
A minimum of 1 washing basin per 100 ! Often anal cleansing material will have to be ! Graveyards or mass graves should be located
people is needed (66). provided. In defecation fields, soil to cover at least 30 metres from a groundwater source
faeces may have to be given to users. used for drinking.
273
Other
! Cemeteries should be planned early. Possibly
" If diarrhoeal diseases are a risk, Oral cloth or other material needed for burial or
Rehydration Therapy (ORT) units must be set cremation have to be provided to the family
up.The minimum is one ORT unit per health (66)
.
structure. In case of a diarrhoeal outbreak,
decentralised ORT units are needed (47). Vector control
! Where the population is infested with body
louse, they must be deloused.
! Where possible the environment should be
made unfavourable to vectors or intermediate
17/03/2003, 12:15
hosts (e.g. through drainage and solid waste
ANNEXE 7: MINIMUM EMERGENCY STANDARDS
management).
! If adequate and feasible, people have to be
supplied with material that allows them to
protect themselves against vectors (e.g.
impregnated mosquito nets) (47).
A7 Annexes
CONTROLLING AND PREVENTING DISEASE
Annexes
A7
274
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Emergency Sanitation
Assessment and programme design
Peter Harvey, Sohrab Baghri and Bob Reed
This book is designed to assist those involved in planning and implementing
emergency sanitation programmes. The main focus of the book is a systematic
and structured approach to assessment and programme design. It provides a
balance between the hardware (technical) and software (socio-cultural, institu-
tional) aspects of sanitation programmes, and links short-term emergency re-
sponse to long-term sustainability. The book is relevant to a wide range of
emergency situations, including both natural and conflict-induced disasters, and
open and closed settings. It is suitable for field technicians, engineers and hygiene
promoters, as well as staff at agency headquarters. Included free with each book is
a mini CD and an ‘aide-memoire’ to the process of planning and implementation.
384pp. (250/176) 2002
Price: £29.95 ISBN: 1 84380 005 5
http://www.lboro.ac.uk/wedc/publications/es.htm
285
This revised handbook is designed for aid workers working in cool temperate or
cold regions. It is designed to provide specific supplementary information that
can be used together with the information given in more general emergency
manuals.
120pp. (250/176) 2002
Price: £19.95 ISBN: 0 906055 91 1
http://www.lboro.ac.uk/wedc/publications/oitc.htm
286