Minsk 5-6 April 2011

Enzo Funari. Italian Higher Institute of Health

• Inspired by a WHO public health initiative in Asia, organized by the WHO Collaborating Centre for Health-promoting 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.

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: 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 CHEMICALS4 HEALTH RISKS IN THE WATER SYSTEM5. ESSENTIAL EPIDEMIOLOGY6. ESSENTIAL SURVEILLANCE. 7. DATA MANAGEMENT AND ANALYSIS USING

GEOGRAPHICAL INFORMATION SYSTEM

The publication is available at http://www.unece.org/env/documents/2010/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).

• 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 surveillanceIV. Surveillance system for water-related diseasesV. 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 water-related diseasesVIII. National examples

EUR B+C

EUR-A

Figure 1‑2 SDR diarrhoeal disease below 5 y of age (Source: WHO Health for All)

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

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Giardiasis - prøve tatt ved HUS - reg. mnd.

Giardiasis Hordaland - innsykning

Antall pasienter

The surveillance system did not give an ”early warning”

Outbreak started

Outbreak detected

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;

Drinking-water: subject to surveillance for the main risk factors (special attention to microbial quality)

Adequate education and training for the personnel

Figure 8‑1 Sources of failures in the WSP approach

Threats

Possible damage

Multiple barrier system,but important to avoid this

Failures come from holes in the system

Source/protection

Inspection

Water treatment

Etc.

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.

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.

 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.

 

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  Health surveillance data should be linked

with data on the quality and distribution of water supplies in the same area.

Regional level   An OMT with similar features should be established at

regional level, with the following tasks after WRD outbreaks:

  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

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

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

The experience of Croatia, Germany, Hungary, Norway and Slovak Republic in the water quality monitoring and disease outbreak detection

 

The publication is available at http://www.unece.org/env/documents/2010/wat/MP_WH/wh/ece_mp_wh_2010_L2_E.pdf

22 pages, 2 figures