Water, Sanitation and Health in Alaska: A brief review of the evidence

Transcription

1 Water, Sanitation and Health in Alaska: A brief review of the evidence Tom Hennessy, MD, MPH US Centers for Disease Control and Prevention (CDC) Arctic Investigations Program Anchorage, Alaska thennessy@cdc.gov

2 Disclaimer The audience should know that this presentation represents the conclusions of the presenter and does not necessarily represent the official position of CDC

3 Why are still doing studies to evaluate water, sanitation and health?

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5 164 th Anniversary of the London Cholera Outbreak John Snow, Physician and Epidemiologist

6 1958

7 1969

8 2000

9 Many Arctic and Subarctic residents don t have adequate access to in-home running water and sewer Alaska, Canada, Greenland, Russia

10 Percentage of US homes with complete plumbing, , US Census US Alaska Rural Alaska

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13 Threats to Alaska Rural Water and Sanitation infrastructure n Decreased funding for new construction n Existing systems are aging n Operations and maintenance n Replacement n Climate change n Shoreline erosion n Sea level rise n Permafrost thaw n Source water availability and quality

14 Still not enough evidence?

15 Levels of Evidence n Compelling stories n Giardia outbreak, Ketchikan 1984 n Kivalina washeteria closure

16 Levels of Evidence n Compelling stories n Look-back studies n Cross-sectional n Exposure and outcome collected at same time n Not evidence of causation n Complicating factors

17 250 Hospitalization Rates for High and Low Water Service Regions, Alaska, Rate per 10, * * * * Low Service High Service 0 Diarrhea RSV Pneumonia MRSA Skin Infections Hennessy, AJPH, * P < 0.05

18 Hospitalization Rates for High and Low Water Service Regions, Alaska, Rate per 10, Diarrhea * * * Pneumonia Resp Syncytial Virus Skin Infections * Methicillin R S.aureus Low Service High Service Water-borne infections Water quality Water-wash infections Water quantity

19 Hierarchy of Water Requirements Drinking Cooking Personal hygiene Washing clothing Cleaning home 19

20 Factors Linking Water to n Water Quality Health n Prevents illness from drinking water n Water-borne diseases n Cholera, Typhoid fever, dysentery n Adequate water Quantity n Drink, cook, wash: hands, body, clothes n Prevents infections spread person-to-person n Water-washed diseases n Respiratory infections, skin infections

21 Serious Infections with Pneumococcus in Children < 5 years old, Southwest Alaska, Rate per 100, Water Service < 10% 10-79% >= 80% US, overall * Wenger, 2010, Pediatric Infectious Diseases

22 Number of Cavities in Primary Teeth by Village Fluoridation Status * p < 0.01 MMWR, Sept 2011 Mean number of dental caries Non-fluoridated Fluoridated US 3x * 1.5x* Age group (years)

23 Respiratory Hospitalizations, by Water Service, , Alaska Medicaid Gessner, Pediatrics, 2008

24 Complicating factors.

25 Respiratory Hospitalizations, by Education Level of Parent

26 Respiratory Hospitalizations, by Education Level of Parent

27 Levels of Evidence n Compelling stories n Look-back studies n Prospective studies n Before and after water service installation n Comparison group n Alaska 4 village study n Tim Thomas and a cast of thousands n J Water and Health 2015 n Evidence for causation n May be complicated by other factors

28 Gastrointestinal, Respiratory and Skin infection Rates, Before and After Piped Water Rate per 1, * P < %* 20%* 38%* Gastro Resp Skin Pre-Piped Post-Piped

29 Levels of Evidence n Compelling stories n Look-back studies n Prospective studies n Randomized controlled trial n Treatment trial of water/sanitation

30 Levels of Evidence n Compelling stories n Look-back studies n Prospective studies n Randomized controlled trial n Treatment trial of water/sanitation n Ethical issues

31 Types of Data n Illness and death n Hospitalizations, clinic visits n Skin infections, diarrhea, hospitalization n Humanitarian appeal n Works for people who believe pain and suffering is bad

32 Types of Data n Illness and death n Indirect consequences n Illness n School absences n Lower economic status, poorer health for life n Family burden n Lost money, work or subsistence activities

33 Types of Data n Illness and death n Indirect consequences n Reduced access to drinking water n Increased soda consumption n Dental cavities, obesity, diabetes

34 Types of Data n Illness and death n Indirect consequences n Costs n Direct medical costs $ n Compare villages with and without water/sewer n Indirect costs n Ripple effects n Stories or $$ n Useful for bottom line types n Will savings offset costs of services? n Who s budget benefits?

35 Health benefits of running water and sewer service n Prevention of: n Respiratory infections n Skin infections n Severe bacterial infections n Dental cavities n Diarrhea n Other benefits n Overall hygiene n Mental wellness n Water security n Others? 35

36 Next Steps n Revisit infectious disease outcomes n YKHC n Honey bucket, covered haul, piped systems n Develop other lines of evidence n Cost studies n Compelling personal stories n Develop a communication plan for different audiences n Alaska public n Agency and tribal leaders n Legislators: State, Congressional