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Int J Hyg Environ Health. 2019 Jun;222(5):765-777. doi: 10.1016/j.ijheh.2019.05.004. Epub 2019 May 12.

Burden of disease from inadequate water, sanitation and hygiene for selected adverse health outcomes: An updated analysis with a focus on low- and middle-income countries.

Author information

1
Department of Public Health, Environment and Social Determinants of Health, World Health Organization, Geneva, Switzerland. Electronic address: pruessa@who.int.
2
Department of Public Health, Environment and Social Determinants of Health, World Health Organization, Geneva, Switzerland. Electronic address: jennyfer.wolf@gmail.com.
3
Gillings School of Global Public Health, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA. Electronic address: jbartram@email.unc.edu.
4
Department of Environmental Health, Rollins School of Public Health, Emory University, Atlanta, GA, USA. Electronic address: thomas.f.clasen@emory.edu.
5
Department of Disease Control, London School of Hygiene and Tropical Medicine, London, UK. Electronic address: Oliver.Cumming@lshtm.ac.uk.
6
Department of Environmental Health, Rollins School of Public Health, Emory University, Atlanta, GA, USA. Electronic address: matthew.freeman@emory.edu.
7
Department of Public Health, Environment and Social Determinants of Health, World Health Organization, Geneva, Switzerland. Electronic address: gordonb@who.int.
8
The Norwich School of Medicine, University of East Anglia, Norwich, UK; Department of Environmental Health, Tshwane University of Technology, Pretoria, South Africa. Electronic address: paul.hunter@uea.ac.uk.
9
Department of Public Health, Environment and Social Determinants of Health, World Health Organization, Geneva, Switzerland. Electronic address: medlicottk@who.int.
10
Department of Public Health, Environment and Social Determinants of Health, World Health Organization, Geneva, Switzerland. Electronic address: johnstonr@who.int.

Abstract

BACKGROUND:

To develop updated estimates in response to new exposure and exposure-response data of the burden of diarrhoea, respiratory infections, malnutrition, schistosomiasis, malaria, soil-transmitted helminth infections and trachoma from exposure to inadequate drinking-water, sanitation and hygiene behaviours (WASH) with a focus on low- and middle-income countries.

METHODS:

For each of the analysed diseases, exposure levels with both sufficient global exposure data for 2016 and a matching exposure-response relationship were combined into population-attributable fractions. Attributable deaths and disability-adjusted life years (DALYs) were estimated for each disease and, for most of the diseases, by country, age and sex group separately for inadequate water, sanitation and hygiene behaviours and for the cluster of risk factors. Uncertainty estimates were computed on the basis of uncertainty surrounding exposure estimates and relative risks.

FINDINGS:

An estimated 829,000 WASH-attributable deaths and 49.8 million DALYs occurred from diarrhoeal diseases in 2016, equivalent to 60% of all diarrhoeal deaths. In children under 5 years, 297,000 WASH-attributable diarrhoea deaths occurred, representing 5.3% of all deaths in this age group. If the global disease burden from different diseases and several counterfactual exposure distributions was combined it would amount to 1.6 million deaths, representing 2.8% of all deaths, and 104.6 million DALYs in 2016.

CONCLUSIONS:

Despite recent declines in attributable mortality, inadequate WASH remains an important determinant of global disease burden, especially among young children. These estimates contribute to global monitoring such as for the Sustainable Development Goal indicator on mortality from inadequate WASH.

KEYWORDS:

Burden of disease; Comparative risk assessment; Diarrhoea; Drinking water; Hand washing; Hygiene; Sanitation; Water

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