Abstract
BackgroundWater, sanitation, and hygiene (WASH) interventions are amongst the most crucial in humanitarian crises, although the impact of the different WASH interventions on health outcomes remains unclear.AimTo examine the quantity and quality of evidence on WASH interventions on health outcomes in humanitarian crises, as well as evaluate current evidence on their effectiveness against health outcomes in these contexts.MethodsA systematic literature review was conducted of primary and grey quantitative literature on WASH interventions measured against health outcomes in humanitarian crises occurring from 1980–2014. Populations of interest were those in resident in humanitarian settings, with a focus on acute crisis and early recovery stages of humanitarian crises in low and middle-income countries. Interventions of interest were WASH-related, while outcomes of interest were health-related. Study quality was assessed via STROBE/CONSORT criteria. Results were analyzed descriptively, and PRISMA reporting was followed.ResultsOf 3963 studies initially retrieved, only 6 published studies measured a statistically significant change in health outcome as a result of a WASH intervention. All 6 studies employed point-of-use (POU) water quality interventions, with 50% using safe water storage (SWS) and 35% using household water treatment (HWT). All 6 studies used self-reported diarrhea outcomes, 2 studies also reported laboratory confirmed outcomes, and 2 studies reported health treatment outcomes (e.g. clinical admissions). 1 study measured WASH intervention success in relation to both health and water quality outcomes; 1 study recorded uptake (use of soap) as well as health outcomes. 2 studies were unblinded randomized-controlled trials, while 4 were uncontrolled longitudinal studies. 2 studies were graded as providing high quality evidence; 3 studies provided moderate and 1 study low quality evidence.ConclusionThe current evidence base on the impact of WASH interventions on health outcomes in humanitarian crises is extremely limited, and numerous methodological limitations limit the ability to determine associative, let alone causal, relationships.
Highlights
Diarrheal disease—nearly 90% of which has been attributed to suboptimal water, hygiene, and sanitation (WASH)—is one of the largest causes of morbidity and mortality in children under five years of age in low and middle-income countries, where it kills more children than HIV, malaria, and measles combined.[1]
Outbreak of suspected Shigella began early May, Mass (water) container disinfection (MCD) occurred last week of June (13,224 containers, an estimated 88% of total, disinfected); watery and bloody diarrhea cases decreased within 5 days post MCD
It should be noted that none of the six studies included in this review formally evaluated the Centers for Disease Control and Prevention (CDC)/Pan American Health Organization (PAHO) Safe Water System, which—based upon the available WASH literature in stable contexts—recommends a combined delivery of safe water storage (SWS), point of use treatment, and behavior change
Summary
Diarrheal disease—nearly 90% of which has been attributed to suboptimal water, hygiene, and sanitation (WASH)—is one of the largest causes of morbidity and mortality in children under five years of age in low and middle-income countries, where it kills more children than HIV, malaria, and measles combined.[1]. WASH are amongst the principal challenges— in the acute and early recovery phases, when diarrheal disease has been found to account for nearly 40% of deaths in camp residents and 80% of deaths in children under two years of age.[10,11,12] A recent review of infectious disease outbreaks after natural disasters highlighted the role of WASH in relation to a majority of disease outbreaks.[13] Water related pathogens (cholera, Shigella) were responsible for 85% of the 50,000 deaths after the sudden influx of 800,000 refugees from Rwanda into the Democratic Republic of Congo in July 1994.[11, 14] More recent large-scale outbreaks of cholera (e.g. Haiti, 2010) and hepatitis E (e.g., South Sudan, 2011) have demonstrated the absolute necessity of rapid and efficient deployment of WASH interventions in complex emergency settings.[15,16,17]. Sanitation, and hygiene (WASH) interventions are amongst the most crucial in humanitarian crises, the impact of the different WASH interventions on health outcomes remains unclear
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