There are many types of water-related disease. This FAQ focuses on water-borne/faecal oral diseases.

The following questions are addressed: 1. 2. 3. 4. 5. 6. What are water-borne/faecal oral diseases? What harm do they do? How are the diseases transmitted? How can we help prevent these diseases? How has NEWAH promoted measures to protect against these diseases? What lessons have we learned from this work?

1. What are water-borne/faecal-oral diseases?

These diseases are largely caused by micro-organisms present in human or animal waste (faeces) finding their way into humans via the mouth (orally). This may happen through drinking from a contaminated water supply (water-borne disease), but more often faecal-oral diseases are spread through other routes, such as via hands, clothes, food, or materials use for cooking, eating or drinking.(More rarely, some of these diseases may also enter the body through the eyes, nose or open wounds.) These diseases are infectious, which means that they can spread from one person to another. So high standards of hygiene and sanitation are need to stop the disease spreading [6]. In Nepal, the main water-borne/faecal oral diseases are [1] [7]: Typhoid fever Giardia Dysentery Cholera Diarrhoea (caused by a variety of pathogens) Hepatitis Polio Worms

2. What harm do these diseases do?

These diseases are extremely harmful not only to a persons health but to their productivity, and to the welfare of the community as a whole. They: Lead to severe illness and may be fatal, in the case of a severe attack Lower the bodys resistance to infection and disease Lower the bodys intake of nourishment, and may lead to malnutrition (especially in children) Decrease individual and social productivity Hamper childrens education Hamper human resource development Increase health expenditure These diseases attack the body in a variety of ways. The main symptoms are as follows [8] [5] [9] [7]: Typhoid fever (i) Fever, increasing gradually; (ii)Abdominal discomfort, bloating, constipation; (iii) Weakness; (iv) Diarrhoea.

Giardia (i) Blood in the urine; (ii) Pain in lower belly and between the legs; (iii) After a long time the kidneys may become badly damaged causing general swelling and death. Dysentery (i) Watery diarrhoea, often with blood; (ii) Stomach cramps; (iii) Fever(iv) Liver may become enlarged and painful (after some days) Cholera (i) Diarrhoea (rice water stool); (ii) Vomiting; (iii)Dehydration. Diarrhoea (Diarrhoea can be caused by a variety of pathogens and can vary in severity. Particularly severe diarrhoea has the following characteristics) (i) Sudden onset; (ii) Explosive watery diarrhoea; (iii) Blood and mucus in the faeces; (iv) Some fever; (v) Dehydration may cause death. Hepatitis (i) Yellow urine; (ii) Vomiting; (iii) White stools; (iv) Enlarged liver; (v) Swelling of body and foot Polio (i) Headache; (ii) Slight fever; (iii) Diarrhoea; (iv) Muscular pain; (v) Limp body Worms (i) Vague abdominal pain; (ii) Nausea; (iii) Poor appetite; (iv) Vomiting even vomiting worms sometimes; (v) Severe abdominal pains; (vi) Weight loss; (vii) Sometimes diarrhoea; (viii) Tiredness; (ix) High risk of catching other diseases; (x) Itching of the anus

3. How are these diseases transmitted (spread)?

In the vast majority of cases, people become infected when material contaminated by faeces enters their mouth. One way this can happen is through drinking contaminated water. This has been the cause of many dramatic outbreaks of faecal-oral diseases such as cholera and typhoid. However, there are many other ways in which faecal material can reach the mouth, for instance on the hands or on contaminated food. The germs in the faeces can cause the diseases by even slight contact and transfer. One gramme of human or animal waste (faeces) contains 10,000,000 viruses, 1,000,000 bacteria, 1,000 parasite cysts and 100 parasite eggs.

Fig. 1. Faecal-oral routes of disease transmission Faecal-oral routes of disease transmission In Nepal, the main routes of transmission are[10]: 1. 2. 3. 4. Dirty/contaminated hands Contaminated water The practice of defecating in the open Uncovered food/drinking water Other possible transmission routes include contaminated soil, or contamination by insects or animals/ [10], [8], [1], [15]. In general, contaminated food is the single most common way in which people become infected. There are a number of ways in which food can become contaminated [1], [12], [15]: 1. 2. 3. 4. 5. Via dirty hands Via dirty cooking utensils or plates or mugs Via dirty cloths, towels etc. Via flies Food may be contaminated before it even reaches the kitchen, or may become contaminated if it is left for a long time after being cooked.

4. How can we help prevent these diseases?

Water-borne and faecal-oral diseases can be prevented by [6], [10], [7]: Improving the quality of drinking water at source, at the tap, or in the storage vessel Interrupting the routes of transmission Reducing diarrhoea helps decrease the chances of faecal-oral contamination. Protecting food from flies interrupts the faeces-flies-food route (at a household level). Chlorination of water interrupts the faeces-fluids-food and drinking water route (at the community level). Increasing the quantity of water available. This allows better hygiene and can thus prevent disease transmission from contaminated hands, food, or household utensils. Changing hygiene behaviour Hand washing this is the most vital component of personal hygiene in disease prevention. .Hands should be washed with soap after defecation and after cleaning and disposing of an infants faeces [4]. Care in disposing of faeces. Safe and protective measures should be adopted to avoid contamination and to destroy infectious organisms while handling and disposing of infant and toddler faeces. Proper use of latrines by adults and children. Proper use and maintenance of water supply and sanitation systems. For example, sanitation facilities that are not properly maintained discourage the use of toilets and will allow pathogens back into the environment through leakage. Proper maintenance of pumps and wells. Pipes and taps should always be kept clean. Good food hygiene (food is a significant breeding ground for pathogens). Washing food prior to cooking and cooking food for long enough at a sufficiently high temperature are both important to kill harmful bacteria. Disposing of organic and animal wastes properly to avoid flies

5. How has NEWAH promoted measures to fight these diseases?

NEWAH has undertaken a variety of activities to educate communities and raise awareness of ways to prevent these diseases through its day to day activities as well as specific projects at a national level [14]. Through its regular activities, NEWAH: Conducts baseline surveys on community health and sanitation situations Trains Health Motivators, who run health education programmes at a community level Selects and trains sanitation workers Trains Community Health Volunteers Demonstrates and conducts practical sessions on the preparation of jeevanjal, simple eye and wound care, and the dangers of dehydration in cases of diarrhoea and methods of treating it (demonstrated using a doll) etc. Raises awareness of the importance of clean water and good sanitation through video shows, puppet shows, street theatre, health songs etc Provides demonstrations of training in latrine construction/latrine mishtri, and latrine installation and use Through occasional activities at national level, NEWAH [13] Participates in a variety of sanitation campaigns Publishes articles in the newsletters (e.g. describing the situation in a particular community before and after the implementation of a given project) Participates actively in the National Sanitation Steering Committee Organises community-level health and sanitation campaigns Participates in hygiene behaviour studies and surveys Organises WASH (Water for Sanitation and Hygiene) campaigns as a WASH coordinator in Nepal

6. Lessons learned by NEWAH

NEWAH has learned some lessons from the last ten years of its experiences in programme implementation [14] Advocacy. The case for the importance of promoting hygiene and sanitation at the community level needs to be argued. Best practice. Organising exchange visits at a community level to good projects helps encourage people learn new behaviours. Reinforcement. Practical hygiene behaviour sessions both in the community as well as in school health promotion programmes need to be reinforced. Messages on, for example, effective hand washing or the preparation of oral re-hydration solution should be regularly repeated. More time and effort. The length of project periods needs to be increased from current 12 months, and the focus shifted to more intensive health and hygiene promotional activities. Intensive social marketing is needed to get across some fundamental messages about the promotion of good hygiene and sanitation practices: Latrines solve the problem of defecating in monsoon rains. Women want latrines for privacy but not for health reason. More attention is needed to promoting the hand washing skills and child faeces disposal practices by conducting more home visits, re-enforcing hygiene skills and encouraging the use of childrens potties.

Bibliography and additional reading

[1] National Center for Infectious Diseases (1996) The Yellow Book: Health Information for International Travel 1996-97. Division of Quarantine, National Center for Infectious Diseases, Center for Disease

Control and Prevention, Atlanta, Georgia. Retrieved November 19, 2003, from the World Wide Web:http://web.idirect.com/pscap/public/Yellbook/vacccert.htm Provides information on food-borne and water-borne diseases as well as other hazards prevalent in Asia. [2] Global Water Supply and Sanitation Assessment 2000 Report: A snapshot of water supply and sanitation worldwide at the turn of the millennium. (2000) WHO and UNICEF. Retrieved September 12, 2003 from the World Wide Web:http://www.wateryear2003.org/en/ev.php@ URL_ID=1600&URL_DO=DO_TOPIC&URL_SECTION=201.html Provides facts and figures about every category of water-related disease and their prevalence. It outlines their effects on the lives of human beings, and describes the routes of transmission and simple methods for prevention. [3] South Pacific Applied Geoscience Commission. (2001) Water and Health Fact Sheet. Currently not available on internet. Provides information on how water affects health. It describes five different kinds of water-related diseases; it also gives information on health and hygiene, water and sanitation and tips for prevention of spread of diseases. [4] Carr R (2002) Health Aspects.Publication on health aspects of sanitation, prepared by Richard Carr for the WHO, and published on the Sanitation Connection website. Retrieved September 12, 2003 from the World Wide Web:http://www.sanicon.net/titles/topicintro.php3?topicId=2 Provides information on environmental sanitation and human health, and gives data on access to sanitation and on the prevalence of water-related diseases. Describes the different factors responsible for the scarcity of high-quality freshwater resources. [5] The Sanitation Report 1999/2000. Nepal Department of Water Supply and Sewerage and UNICEF. Feature article "Improving sanitation in South Asia", refers to this report. National Daily - The Rising Nepal, 12 Apr 2003. Retrieved November 27 Sep, 2005, from World Wide Web:http://www.nepalnews.com.np/contents/englishdaily/trn/2003/apr/apr12/features1.htm Details the situation regarding water and sanitation throughout Nepal. It also describes the sanitation and hygiene practices and behaviour of the Nepalese people. The report focuses on the need for local level sanitation efforts, local initiatives, and local leadership. For additional information -- Dept. of Water Supply and Sewerage, e-mail:cpmo@dwss.mos.com.np [6] Shrestha N.L. and Nakarmi R.L. (1999) common Diseases of Children and Ways to Prevent Communicable Disease, 10th edition (Nepali version). UNICEF Drinking Water and Sanitation Section, Pulchowk, the Central Public Resources Development Unit, the Department of Water Supply and Sewerage and the Ministry of Housing and Physical Planning, Kathmandu. Translated by Ananda Pokhrel, NEWAH Includes details about common childhood diseases, prevention of disease, transmission routes of faecal oral disease, as well as issues related to water, sanitation and immunisation. [7] Werner, D. (1993) Where There is no Doctor: a Village Health Care Handbook. Macmillan Education, Oxford. (First published in Spanish during 1970s.) Provides comprehensive information about what to do when someone gets sick and when to seek help. It gives advice on emergency measures that can be taken to stabilise critical health conditions when you are a long way from the nearest doctor or health worker. It also explains how water-borne diseases are spread and how they can be controlled. [8] Sanjib, D.; Narayan, P.U. Infectious Diseases. (Nepali version with topics in both Nepali and English). Provides an introduction to various types of communicable disease, their nature, symptoms and methods of prevention.

[9] Sharma, P. Childrens Health, 1st edition. WHO-UNDP, Health Learning Materials Project, Institute of Medical Science, Tribun University, Kathmandu Provides in-depth information on child health, including disease symptoms and disease prevention. [10] NEWAH (1996) Preventing disease: A Manual of Ways to Improve Health in Nepali Villages. Nepal Water For Health (NEWAH)/ WaterAid Nepal (WAN), Kathmandu. Chap 3: How is food contaminated? (pp 4, 5) This is a manual developed jointly by NEWAH and Water Aid Nepal. It outlines the scientific basis of preventing diseasean approach that marked a change in focus of NEWAH's health programme. The information within these pages is designed to empower health supervisors and health educators to think and challenge and start to make a real impact on disease control in the villages in which NEWAH works. Contact: Ms. Renuka Rai, Head of the Social Division, NEWAH, Lohasal, Chakrapath, Kathmandu, Nepal. [12] Feachem, R.; Cairncross, S. and Bradley, D. (2002). Water-related infectious diseases, sanitation, hygiene behaviour and the determinants of diarrhoea. In: Thompson, J. et.al. (eds.). Drawers of Water II. London, UK, IIED. P. 72 - 84. Retrieved September 27, 2005 from the World Wide Web:http://www.iied.org/pubs/pdf/full/9049IIED.pdf Gives information about faecal-oral diseases and different classification systems. It describes changes in water use and the health effects of alternative sanitation facilities, hygiene behaviour and socio-economic background. [13] NEWAH Polic y Guideline. (Guidelines for NEWAHs Two-Year Health Education Programme). NEWAH, Kathmandu. This policy paper contains the criteria for NEWAHs Two-Year Health Education Programme. It details the programmes first- and second-year activities, and the activities of the Health Motivator's Health Education Programme . [14] Rai, R. (2003) Nepal: Sustainability of Behavioral change. Findings (2001-2003): Analysis (draft report). Looks at the hygiene situation and latrine construction and use In Nepal. Analyses whether hygiene behaviours had been sustained in communities that had previously been involved in projects to improve hygiene and sanitation behaviour. This study mainly focuses on: hand washing, the construction, use and maintenance of latrines, and environmental hygiene. Contact: Ms. Renuka Rai, Head of the Social Division, NEWAH, Lohasal, Chakrapath, Kathmandu. [15] Faecal-oral transmission route. [F diagram]. WaterAid, India. This diagram was constructed for use by development workers in the community. It shows the transmission route of faecal-oral diseases very clearly. It shows how pathogens enter our mouths on food that has been contaminated via the five Fs: Fingers, Faeces, Fields, Flies/pet animals, and Fluids.

Contact person
Ms. Renuka Rai, Head of the Social Division, Nepal Water for Health (NEWAH), Lohasal, Chakrapath, Kathmandu ___________________________________ Creation date: September 22, 2003 Revised date: February 24, 2004 Author: Ananda Pokhrel (Shahi), Nepal Water for Health (NEWAH Peer reviewers: Jabu Masondo, Junior Professional Officer ; Leonie Postma, Senior Programme Officer,

both from IRC International Water and Sanitation Centre ____________________________________