Why Sanitation Matters: Disease Edition

When thinking about diseases, infections, and viruses, we as humans often think of the worst pandemics in human history, like the Black Death, smallpox, or even COVID-19. While many of these diseases have a long and morbid history, other diseases caused by poor sanitation and water quality create more regular challenges. These types of diseases are not as well-known by the public and do not receive much media attention. This is because of (1) the low prevalence of these diseases in high-income countries and (2) the overshadowing of "more dangerous" diseases like Ebola, amongst other things. To help understand the importance of water and sanitation in preventing disease more vividly, we need to understand these other diseases and the areas they ravage.


Poor access to sanitation, hygiene, and clean water causes about 60% of the global burden of diarrheal diseases. Diarrhea kills more children in a year than malaria, AIDS, and measles combined; it is the second most common cause of death for children under five. These diseases disproportionality affect low- and middle-income areas. Other diseases come from system failures in providing clean water, trash services, and safe toilets. Many of them are even less known and more terrifying. These diseases can be uncomfortable or even life-threatening. In this blog, let's explore the often gross topic of diseases linked to sanitation.

An infested river in Kenya that could carry diseases due to poor sanitation. (Credit: FLUSH / Kim Worsham)

How Diseases Spread

These diseases have a close relationship with sanitation – or lack thereof – and indicate a broken system that needs fixing. Many organisms carrying these diseases to other animals thrive off large piles of waste and contaminated water, using them as breeding grounds.


All diseases we'll review can be caused by poor waste management, food preparation, agricultural practices, or contaminated water/objects. They can be either bacterial, viral, or fungal. Usually, these diseases spread through infected feces leaking into a space where it somehow gets in contact with uninfected people, often by getting into the water supply or someone's food. Infectious bugs can live on the hands for hours or even days; even hand sanitizers may not kill all viruses or bacteria, which means poor handwashing practices can also encourage these diseases to spread.


Sanitation plays a big role, and there are many successful interventions to subdue diarrheal diseases and neglected tropical diseases (NTDs); both remain an issue to isolated populations. While there are practical ways to stop diseases, many places do not have the resources to truly create change.

Diarrheal deaths by age (Credit: Our World in Data)

Diarrheal Diseases

Simply, diarrheal diseases are diseases that cause diarrhea. This may not sound so bad, but in reality, diarrhea majorly threatens lives if people don't have the resources to treat it. The major problem is that diarrhea causes dehydration that makes the body lose water and salts extremely quickly. Water and salt are necessary for essential biological processes, which must be replaced quickly and constantly until diarrhea ends.


However, not every case of diarrhea is the same as another either. There are three categories for diarrheal diseases: (1) acute diarrhea that lasts for less than 2 weeks, (2) persistent diarrhea that lasts for 2-4 weeks, and (3) chronic diarrhea that lasts longer than 4 weeks. Acute diarrhea is usually from a virus - such as a rotavirus in children and norovirus in adults - while bacteria and parasites more commonly cause chronic and persistent diarrhea. The longer someone has diarrhea, the more symptoms and problems they can experience. For example, chronic diarrhea can cause extreme weight loss, malnutrition, and blood loss - yes, blood loss. Without help, people can die, especially children; nearly nine out of ten child deaths from diarrhea can be prevented. Still, many people do not know or understand the link between poor sanitation and health.


You may have heard of many different kinds of diarrheal diseases: typhoid, amoebic dysentery, rotavirus, giardia, and campylobacter. There are many resources available about diarrheal diseases. For this blog, we'll focus on a more famous one - cholera.

Cholera (Credit: MedicineNet)

Cholera is an example of an acute diarrheal infection caused by ingesting dirty water or food. It can be lethal within hours of infection if left untreated, killing about 21,000-143,000 deaths each year in today's world. The truth is, many who die from this infection now shouldn't have to.





Cholera originated in India; after colonization by the UK, its rapid spread found its way to almost every corner of the globe. Cholera is extremely preventable and even easier to treat, but low- and middle-income regions often lack the right resources or medications. Sanitation can limit feces from contaminating water and food. There are even three World Health Organization-approved vaccines for cholera.


Neglected Tropical Diseases

Diarrheal diseases are not the only kinds that spread because of poor sanitation; another category of equally concerning diseases is neglected tropical diseases (NTDs). While anyone can get these diseases, they are, as the name suggests, neglected because they do not persist in higher-income nations. NTDs are most common in warmer, tropical areas, trap people in a cycle of disease and poverty, and cause lifelong cognitive and physical impairments. There are too many NTDs to detail, including leprosy and dengue fever, but we will shed light on some of these unknown diseases.


Cysticercosis is a parasitic infection from tapeworm eggs or larva, but this condition is not the same as having a tapeworm. The eggs are passed from the stool of someone with a tapeworm parasite and can end up in people's food or drinking water. The larval cysts infect the brain, muscle, and other tissues and lead to seizures, blindness, and body lumps. If not treated properly, this disease can be fatal or cause a lifetime of cognitive problems.

The life cycle of Guinea Worm (Credit: US CDC, Public Domain)

Dracunculiasis, also known as Guinea Worm, is a parasite that is passed through unsafe water – either by drinking it or wading through dirty water. The larva in the water enters the body and matures for a year, becoming a 2-3-foot-long worm that moves just under the skin, usually in the arms or legs. At this spot, a blister will form that eventually will burst with the emerging worm. This can be an extremely painful process, and the worm can take several days to move out. The resulting wound can easily get infected, and some people are left disabled by the process; Guinea Worm can leave people bed-ridden for weeks or even kill them. Sadly, there is no cure for guinea worm and no drug to treat or make the process faster.

Trypanosoma brucei rhodesiense in a Giemsa-stained blood smear. (Credit: DPDx via CDC)

African Trypanosomiasis, also known as African Sleeping Sickness, is caused by microscopic parasites that enter the body through the bite of a tsetse fly. While not extremely common anymore, with cases in 2009 being around 10,000 and in 2019 being less than 2,000, it is a prevalent problem for certain areas. The common symptoms are fever, severe headaches, aching muscles and joints, and extreme fatigue. Should the illness progress further without intervention or treatment, it can invade the central nervous system, causing confusion, personality changes, and neurological damage. The result of this illness is death, however, there is a working treatment plan that involves medication and a specific treatment course for the current stage of the illness. Those infected are watched closely for 24 months after treatment to make sure they are in the clear. People can become re-infected, as well as testing and treatment being difficult.


Prevention

The prevention trio - water, sanitation, and hygiene (Credit: Defeat DD)

Many of these diseases are preventable. Afflicted areas need to start making health a priority, saving employers from missed workdays, keeping children in school, and ultimately saving lives. This economic benefit to putting in the time and resources into these interventions would be massive and help stop the spread of other diseases and maintain a social atmosphere of safety and protection.


An essential way to stop the spread of these diseases is by ensuring communities have functional water treatment facilities. For areas that can't afford the infrastructure, households can minimize contamination through point-of-use water treatment with chlorine and household water treatment and storage. These are low-cost interventions that give households more power over protecting their water supply.


Another key prevention measure is sanitation, which reduces diseases like malaria and African Sleeping Sickness. Sanitation's main role is to get human and animal waste out of and away from water supplies. Every year, more than 200 million tons of human waste goes uncollected and untreated, contaminating water, food, and people's hands. The most basic sanitation intervention is to discourage open defecation and encourage people to use covered latrines.


Education is another major intervention that can support areas. This means educating the public on how disease can spread from poor sanitation, what they can do to protect themselves, and available resources they can use. This also means educating the public on vaccinations. Some NTDs and diarrheal diseases can be prevented using vaccines, such as rabies, typhoid, leprosy, dengue fever, and cholera. Many of these vaccines are quite new, but they can effectively reduce infections and mortalities. These strategies are preventative, meaning that they only work to stop interaction or educate, but cannot truly help when someone becomes infected.


Treatment

Treatment for diseases can be difficult.


Diarrheal diseases can be treated successfully depending on severity, though it is a question of resources and adequate facilities. The main treatment for diarrhea is rehydration, which means drinking a lot of water or getting intravenous fluids. Paradoxically, infected people are often forced to continue drinking the very contaminated water that made them sick in the first place. Also, fluids should be taken with oral-rehydration salts, which contain salts and glucose, to replace lost electrolytes and return the body to equilibrium. This is a cheap treatment, costing just a few cents, and can safely and effectively treat 90% of non-severe cases, but sometimes it can cause more problems than it fixes. For example, there are some side effects, including nausea, rash, and acute toxicity. These are even more pronounced if mixing errors occur in the treatment, which is common in household remedies. Another treatment for diarrhea is antibiotics, which can be more effective at treating severe cases, but only those caused by bacteria. These are often less available and more expensive than other options and can create antibiotic resistance if used for the wrong diseases.


NTDs that are treatable but treatments don't reach areas in need. For example, many drugs are effective against parasitic worms, and many more therapies exist to reduce pain and stop morbidity. Some companies give drugs to low-income areas at no cost, but many drugs and treatments can be expensive or require international travel, which is impossible to manage for many places. Another issue is that medications struggle with drug resistance. The infection agents and parasites are starting to develop strategies to combat medications and therapies. This creates an even bigger problem as people do not trust the effectiveness of the drugs. However, help already exists for those suffering from NTDs it is now just about how to get it to people.

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