Minsk 5-6 April 2011
Enzo Funari. Italian Higher Institute of
Health
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Inspired by a WHO public health
initiative in Asia, organized by the WHO
Collaborating Centre for Healthpromoting Water Management and Risk
Assessment at the University of Bonn,
Germany.
Multilateral co-operation programme
between the WHO Regional Office and the
central Asian countries.
Later on, further developed by this TF.
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Holistic approach;
The document reviews the main threats to health
related to water services, recalls basic concepts of
epidemiology and disease surveillance, and provides
guidance on data management and analysis.
It is in line with the International Health Regulations
(2005) which entered into force on 15 June 2007.
A sort of synthesis of scientific knowledge in the area
(basis) but then practical tools to face the possible
problems in the area.
 Aimed
specifically at the needs of local
laboratories in central Asian countries;
 Also aimed at strengthening cross
sectoral activities (water, environment
managers and health sector workers).
 In conclusion, the Guidance document is
aimed at supporting national efforts
towards national and international health
security
Editors:
 Enzo Funari, chair of Task Force on Water-related Disease Surveillance
 Thomas Kistemann, Institute for Hygiene, Rheinische Friedrich Wilhelms
Universitat, Bonn, Germany
 Dr Suzanne Herbst, Executive Director, WHO Collaborating Centre for Health
Promoting Water Management and Risk Communication
 R Aertgeerts, WHO Regional Office for Europe
Main contributors:
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Akgaev, D (Turkmenistan); Blasi, M (Italy); Classen, T (Germany); Cronin, A A (UK);
Dangendorf , F (Germany) ; Davlyatov, S K (Tajikistan); Exner, M (Germany); Funari,
E (Italy); Herbst, S (Germany); Kadar, M (Hungary); Kaitbaev, N (Tajikistan);
Kistemann, T (Germany); Loock, A (Germany); Ishankuliev, Y (Turkmenistan);
Mishina, O (Uzbekistan); Moe, C (USA); Pond, K (UK); Queste, A A (Germany);
Schoenen, D (Germany); Sharipova, N V (Uzbekistan); Wienand, I (Germany);
Vashneva, N (Kyrgyzstan)
2. HEALTH RISKS FROM MICROBIAL
PATHOGENS
3. HEALTH RISKS FROM CHEMICALS
4 HEALTH RISKS IN THE WATER SYSTEM
5. ESSENTIAL EPIDEMIOLOGY
6. ESSENTIAL SURVEILLANCE.
7. DATA MANAGEMENT AND ANALYSIS USING
GEOGRAPHICAL INFORMATION SYSTEM
 The
publication is available at
http://www.unece.org/env/documents/2
010/wat/MP_WH/wh/ece_mp_wh_2010_
L3_E.pdf
 157 pages, 18 tables, 22 figures
 Short
guidance for the organization or
improvement of health systems, with
particular attention to water-related
diseases (WRDs).
 Where safe access to water is not
ensured, political authorities should be
aware of the consequences, not limited
to the disease (sustainable development
is hampered and economic costs are
prohibitive).
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Roger Aertgeerts, WHO Regional Office
for Europe
Enzo Funari, Italy
Nana Gabriadze, Georgia
Paul Hunter, United Kingdom of Great
Britain and Northern Ireland
Frantisek Kozisek, Czech Republic
Arben Luzati, Albania
Aida Petikyan, Armenia
Andrea Rechenburg, Germany
I. The problem (Introduction)
II. Water safety plans
III. Legal obligations with regard to disease surveillance
IV. Surveillance system for water-related diseases
V. How to set up an essential surveillance system
for water-related diseases (OMT)
VI. How a water-related disease surveillance system
should work in practice
VII. How to evaluate a surveillance system for waterrelated diseases
VIII. National examples
Contaminated water
• transfer of risk factors to consumers, including
pathogenic micro-organisms.
• Sources of exposure: drinking and bathing water,
aquaculture, irrigated crops
WRDs
• one of the major health concerns in the world.
Diarrhoeal diseases
• some two million deaths each year, primarily of children
in developing countries.
WRDs
• cholera, typhoid fever, hepatitis A,
many emerging diseases
95% of this disease burden
attributable to the environment
• unsafe water, lack of sanitation and
poor hygiene
Drinking-water related outbreaks
→ simultaneous infection of a large
number of consumers
Investing in
prevention
produces benefits
far greater than
those directly
related to the cost
of treatment for
these human
pathologies
Over 30 million
cases of WRDs
outbreaks could be
avoided annually
by means of
adequate water
and sanitation
interventions
Figure 1-2 SDR diarrhoeal disease
below 5 y of age (Source: WHO Health for All)
EUR B+C
EUR-A
While mortality data are surely the most striking, morbidity figures show that water-related diseases continues to
be a serious problem in the European region, are hampering sustainable development and imposing prohibitive
economic costs.
Controlling and
reducing the
burden of WRDs
has two main
tools
Surveying the health
status of
communities
Promoting adequate
preventive measures
in order to ensure
safe access to water
(adequate quality
and quantity)
Examples where the system failed included an outbreak of giardiasis in Hordaland (Bergen) in 2004 – 2005 where the
surveillance system proved to be “late” in detecting outbreaks.
Giardiasis in Hordaland (Bergen) 2004-2005
Tidspunkt for innsykning - Giardiasis Hordaland 2004 og 2005
Tidspunkt for registrering i MSIS - prøver tatt ved HUS
Antall pasienter
700
Giardiasis - prøve tatt ved HUS - reg. mnd.
Giardiasis Hordaland - innsykning
600
Outbreak
detected
500
400
The surveillance
system did not
give an ”early
warning”
Outbreak
started
300
200
100
desember
oktober
november
september
juli
august
juni
mai
april
mars
januar
februar
desember
oktober
november
september
juli
Måned (2004 og 2005)
august
juni
mai
april
mars
januar
februar
0
 WSPs: management
multi step approach
aimed at ensuring safe access to water.
 WSPs
should be developed for each
individual drinking-water system,
whether large- or small-scale.
 Beyond
drinking water
 Raw
waters should be protected against
pollution in the catchment area
 Surface and shallow waters must always be
treated before being used as a source of
drinking-water;
 the higher the level of contamination of raw
water, the greater the efficiency of the water
treatment process required;
Figure 8-1 Sources of failures in the WSP approach
 Drinking-water: subject
to surveillance
for the main risk factors (special
attention to microbial quality)
 Adequate education and training for the
personnel
Multiple barrier system,
but important to avoid this
Etc.
Inspection
Water treatment
Source/protection
Threats
Failures come from holes in the system
Possible damage
 Surveillance
systems implemented in
several countries in the EURO Region but
often do not include specific surveillance
for WRDs.
Specific WRDs surveillance systems would
provide relevant added value, as they
can:
 identify the diseases transmitted by
water
 define/estimate the burden of WRDs;
 use data and information to identify
communities where there are problems
with water related diseases;
 Mapping
of pollution hazards and
identifying risks;
 promote intervention measures to control
and prevent WRDs;
 target resources towards areas with
priority needs;
 assess the effectiveness of the
implemented water and sanitation
interventions in reducing diseases.
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In countries with limited resources:
High incidence of typhoid fever→ need for targeted vaccine
campaigns;
epidemic and endemic giardiasis and cryptosporidiosis → need
for water filtration (chlorination is not very effective against these
pathogens)
need of household water treatment of water in high-risk areas;
outbreaks in adequately treated piped water supplies ( intrusion
problems in the water distribution system) → need to keep water
pressure stable or accept additional measures like booster
chlorination
high prevalence of helminth infections → need for improvements
in sanitation and increased water availability for general hygiene;
High incidence of blue-baby syndrome → need to control and
reduce nitrate concentrations in drinking water.
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Public health surveillance systems represent the
ongoing and systematic collection, analysis and
interpretation of health data to describe and monitor
a health event.
The surveillance of WRDs should be included within
the context of more general surveillance systems for
communicable diseases.
A specific surveillance system for waterborne
disease outbreaks should include a method for
evaluating the evidence that an outbreak is indeed
attributable to contaminated water.
 WRDs:
 Priority
diseases (characterised by a high
epidemic potential): cholera, diseases
caused by enterohaemorrhagic E. coli, viral
hepatitis A, bacillary dysentery and typhoid
fever.
 Emerging diseases (showing a rapid
increase in the affected population, or are
being observed in countries where they
were previously absent):
campylobacteriosis, cryptosporidiosis,
giardiasis, and legionellosis.
 Local
diseases (diseases that are not
present throughout the country
concerned but may potentially have a
severe local impact) :
methemoglobinaemia, arsenicosis, viral
infections (particularly those attributable
to Norovirus) and parasitic diseases.
 Local
level
 An
outbreak management team (OMT)
should be set up at the local health unit.
OMT composition: representatives of
waterworks and sanitation system, water
department of the regional environmental
agency, expert in hygiene and
environmental medicine.
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In case of a WRD outbreak, the local OMT should:
Review the evidence for an outbreak
Identify the population at risk
Decide on control measures
Provide quick and adequate information to the
public
 Make arrangements for the commitment of
personnel and resources
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Health surveillance data should be linked with
data on the quality and distribution of water
supplies in the same area.
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Regional level
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An OMT with similar features should be established at
regional level, with the following tasks after WRD outbreaks:
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Prepare a notification to be sent to the national agencies
Prepare a report to be sent to the regional authorities
responsible for management measures
Promote further epidemiological and environmental studies,
as necessary;
Provide adequate information to the public; and
Provide feedback on surveillance results and analyses to the
local OMT in order to sustain the interest and co-operation
of the data collectors and data providers
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National level
With representatives from the sectors of health, environment, waterworks and
sanitation, and agriculture (including animal husbandry and aquaculture).
Tasks
Draft the notifications on WRDs and provide information to the public;
Map the WRDs on a national scale (possibly using geographic information
systems);
Identify most critical areas / situations;
Assess the burden of WRDs;
Transmit the information on WRDs at the international level;
Provide training and educational initiatives;
Promote specific surveys;
Provide feedback on surveillance results and analyses to the regional OMT in order
to sustain interest and cooperation;
Assess the functionality of the whole surveillance systems;
Prepare a report to be sent to the national authorities responsible for management
measures; and
Coordinate activities in the case of transboundary waterbodies.
 Preparedness
 First
and foremost, the local OMT should be
well-prepared to (i) detect water-related
outbreaks; and (ii) react adequately if a
water-related outbreak occurs.
 In setting up a surveillance system, it is
crucial to take into account the local
situation and focus on critical areas /
situations
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Response
Trigger event: outbreak detection and confirmation
Acute reaction: outbreak declaration, quick and
preliminary descriptive hazard investigation, initial
and immediate control measures
 Analysis: in-depth analytical hazard investigation,
continuous re-evaluation of control measures
 Normalization: conclusion of outbreak and
declaration of normalization
 End: evaluation, formal report, lessons learned for
the future
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 The
experience of Croatia, Germany,
Hungary, Norway and Slovak Republic in
the water quality monitoring and disease
outbreak detection
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 The
publication is available at
http://www.unece.org/env/documents/2
010/wat/MP_WH/wh/ece_mp_wh_2010_L
2_E.pdf
 22 pages, 2 figures