study on the quality of water, sanitation and hygiene practices in the schools of moldova

SUMMARY REPORT

STUDY ON THE QUALITY OF WATER, SANITATION AND HYGIENE PRACTICES IN THE SCHOOLS OF MOLDOVA

The Government of Republic of Moldova

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SUMMARY

Summary ........................................................................................................................................2

I. Introduction .................................................................................................................................3

1.1. Study goal................................................................................................................................3

1.2. Study objectives ......................................................................................................................3

II. Methods and materials ..............................................................................................................4

III. Evaluation of schools’ drinking water supply conditions ...........................................................5

IV. Evaluation of quality parameters of drinking water in pre-university institutions and level of students’ exposure to health risks .................................................................................................7

V. Students’ access to hygiene conditions in schools ....................................................................15

VI. Students’ hygiene practices .....................................................................................................19

Conclusions ....................................................................................................................................22

Recommendations .........................................................................................................................24

Annex. List of the most disadvantaged pre-university institutions in terms of drinking water quality and conditions of the available drinking water supply and sanitation systems ...................26

Authors: A group of specialists from the National Centre of Public Health, coordinated by Ion Şalaru, Prime Vicedirector

With the contribution of: Ghenadie Ţurcanu, Health Policies Programme Coordinator, PAS CentreSvetlana Stefaneţ, Chief of Programme Equitable Access to Quality Services, UNICEFLiudmila Lefter, Education Officer, UNICEF

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I. INTRODUCTION The Republic of Moldova, like other Member States of the World Health Organisa-tion (WHO) in the European Region, has committed to prevent and significantly de-crease the morbidity and mortality due to gastrointestinal diseases and other health disorders by ensuring adequate conditions for improving all children’s access to both safe drinking water at affordable prices and adequate hygiene conditions1.

Although Moldova has not developed specific actions to ensure children’s univer-sal access to clean and healthy water so far, the Government has approved policy documents2 to address the improvement of access of the whole population to bet-ter water supply and sewerage systems and ensure the control over the quality of drinking water. This has to some extent led to the improvement of drinking water distribution systems in pre-university institutions. Children stay at school most of the day, therefore the quality of dinking water and hygiene conditions in schools have a direct impact on the formation of children’s health.

To assess the situation of children’s access to water for human consumption and im-proved hygiene conditions in schools, UNICEF has supported the Ministry of Health, Ministry of Education and the National Public Health Centre to conduct an expert Study on Drinking Water Quality and Hygiene Conditions in Pre-university Institu-tions in the Republic of Moldova.

This document summarises the results of an analytical evaluation of drinking water quality and hygiene conditions in pre-university institutions, ways of supplying drink-ing water in schools, as well as students’ hygiene practices.

Study goal:Assess students’ access to drinking water sources and hygiene conditions in pre-university institutions in the Republic of Moldova.

Study objectives:♦ Assess the conditions of drinking water supply in schools.♦ Survey the quality of drinking water in schools and assess the level of stu-dents’ exposure to health risks3.♦ Estimate students’ access to adequate hygiene conditions in schools.♦ Assess student’s hygiene practices.♦ Identify solutions for improving all children’s access to clean water and ad-equate hygiene conditions in pre-university institutions. 1 TheForthMinisterialConferenceonEnvironmentandHealth“TheChildren’sEnvironmentandHealthActionPlanforEurope”,Budapest,Hungary,23-25June2004.2 GovernmentDecision487of19June2001onapprovaloftheNationalPlanofActionforEnvironmentalHealth;GovernmentDecision662of13June2007onapprovaloftheStrategyonWaterSupplySystemsandSewerageinSettlementsoftheRepublicofMoldova,andtheGovernmentDecision934of15August2007onsettinguptheAutomatedInformationSystem“StateRegisterofBottledNaturalMineralWater,DrinkingWaterandSoftDrinks.”3 Healthriskmeansthelikelihoodofbeingexposedtoahazardcausedbynatural,anthropogenic,biologicalorsocialfactoranditsconsequencesasharmfuleffectonhealth,andtheseverityofsucheffect(Article2,Law10of3February2009onStatePublicHealthSurveillance).

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II. METHODS AND MATERIALS

The study was conducted in all the pre-university institutions (1,526 schools, gym-nasiums and lyceums4) of the Republic of Moldova, including residential ones5.

During the Study, water samples were collected, water supply and sanitation sys-tems were assessed in each pre-university institution, and interviews with students in 82 schools were conducted to assess hygiene practices. The sample of inter-viewed students (4,817 students, of which 57.3% girls and 42.7% boys) was repre-sentative and covered all the administrative-territorial units countrywide, interviews being held in one lyceum in each urban and rural area.

Evaluation of drinking water supply and hygiene conditions in schools comprised the following components: description of the school’s drinking water supply system; outline of the school’s sanitation system; and evaluation of risk of contamination of school’s water sources.

Water quality survey was done according to the WHO recommendations6, which provide 8 parameters that are more relevant for children’s health, including 7 chemi-cal parameters: nitrates, nitrites, fluoride, boron, arsenic, pesticides, cyanides and one microbiologic parameter – microbial pollution (Escherichia coli and Enterococi). Drinking water quality was checked according to the Sanitation Norms on Drinking Water Quality7. The level of students’ exposure to health risks due to consumption of drinking water depending on its non-conformity in terms of microbiological and chemical parameters was also estimated according to the WHO recommendations8.

4 StatisticalYearbookoftheRepublicofMoldova,2009,Chisinau2009,NationalBureauofStatistics.5 MinistryofHealthDirective266/dof24April2009“OnimplementingtheStudyonDrinkingWaterQualityinSchoolInstitutions”.6 GuidelinesforDrinking-waterQuality.ThirdEdition.Volume1.Recommendations.WHO.Geneva,2004.7 ApprovedthroughGovernmentDecision934of15August2007onsettinguptheAutomatedInformationSystem“StateRegisterofBottledNaturalMineralWater,DrinkingWaterandSoftDrinks.”8 GuidelinesforDrinking-waterQuality.ThirdEdition.Volume1.Recommendations.WHO.Geneva,2004

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III. EVALUATION OF SCHOOLS’ DRINKING WATER SUPPLY CONDITIONS In Moldova, children have free access to water supplied for human consumption in all (100%) pre-university institutions. In terms of drinking water source, over two thirds of schools use water supply systems and one third use wells9, springs or wa-ter transported in water-tanks (Figure 1). Only schools in rural areas use well water, spring water or water transported in tanks for drinking purposes, for the reason that about one third of them lack water supply systems.

Figure 1. Distribution of pre-university institutions in urban and rural areas in terms of type of drinking water source

Half of administrative-territorial units have water supply systems in less than in 60% of schools (Table 1). It means that 2 of 10 students have access only to well water.

9 TakingintoaccounttheUNdefinitionofimprovedwatersourcesandthecurrentnegativewellmaintenancepracticesintheRepublicofMoldova,alongwiththedensityofconstructions,thenon-observanceofwell’ssanitaryprotectionzones,thelattercanbequalifiedasunprotectedsources,haveacontinuousriskofwatermicrobialcontamination.

ShareofinstitutionsusingtransportedwaterShareofinstitutionsusingwellwaterShareofinstitutionsusingwaterfromwatersupplysystem

Urban

100%

90%

80%

70%

60%

50%

40%

30%

20%

10%

Rural TotalRM

2,1 3,4

94,5

3,4 2,9

34,428

62,269,1

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Table 1. Presentation of administrative-territorial units in terms of share of schools with water supply systems

Provision of water supply systems 80-100% 60-80% 40-60% 20-40% 0-20%Chisinau mun.Balti mun.Basarabeasca Anenii Noi Cahul Calarasi Cimislia Criuleni Dubasari ATU GagauziaTelenesti Orhei Glodeni Falesti Causeni

Drochia Stefan Voda Taraclia OcnitaFloresti Ialoveni

Briceni Straseni Singerei Soroca Riscani Nisporeni Hincesti Cantemir

Rezina Edinet Donduseni Leova Ungheni

Soldanesti

Sanitary protection zone10 of water sources, 80% of which are located in rural ar-eas, is not observed in one in five schools. Half of schools use unauthorised water sources for drinking purposes. One in twelve schools has interruptions in water supply of 4 up to 24 hours a day. Rural schools have even longer water supply inter-ruptions. Water supply is interrupted 2.7 times more often in the Southern Zone’s pre-university institutions compared to the situation in the country as a whole, and 6.3 times more frequently than in the Central Zone’ schools (Figure 2), which sup-posedly have a higher risk of microbial pollution of drinking water.

Figure 2. Pre-university institutions by geographical zones in terms of water supply interruptions

10 Theterm“sanitaryprotectionzone”delimitstheareaaroundawatersourcewhereanyactivitythatexposeswatertoexternalfactorsfavouringsoitscontaminationisprohibited.

25

20

15

10

5

0

North Centre South Totalpercountry

6,3 8,4

3,6

22,5

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IV. EVALUATION OF QUALITY PARAMETERS OF DRINKING WATER IN PRE-UNIVERSITY INSTITUTIONS AND LEVEL OF STUDENTS’ EXPOSURE TO HEALTH RISKS Almost one in six drinking water samples collected in pre-university institutions do not meet the sanitation norms in terms of chemical and microbiological parameters (Table 2). The highest proportion of non-conformity with norms was registered in terms of ni-trites - one in three non-compliant samples, followed by microbial pollution for which almost one in four samples did not meet the standards. Concentrations of fluoride and boron were non-compliant in one in eight and one in fifteen water samples, respectively.

Table 2. Structure of laboratory parameters that were non-compliant with the standards for drinking water quality in schools

No. Parameter Investigated sample Non-compliant Level of non-conformity, %

1. Microbial pollution 1,672 395 23.62. Nitrates 1,597 505 31.63. Nitrites 1,597 31 1.94. Fluoride 1,577 210 13.35. Boron 504 33 6.5Total 6,947 1,174 16.9

Schools using mainly well water have as a rule (with some exceptions) the highest non-conformity level in terms of microbiological parameters (Figure 3).

Figure 3. Proportion of microbial pollution in wells supplying water for pre-university institutions from various administrative-territorial units

100%

90%

80%

70%

60%

50%

40%

30%

20%

10%

Microbialpollution,%Shareofwell-waterusers,%

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Non-compliant drinking water samples by microbiological parameters were regis-tered in 26% of schools, which host 17% of the total number of students in the coun-try, from 3411 administrative-territorial units (Figure 4). Therefore almost one in six students in the country is exposed to health risk of getting acute diarrheal illnesses as a result of microbe-polluted water consumption. Moreover, water contaminated by microbes raises the likelihood of epidemics outburst through transmissible hydric diseases.

Figure 4. Share of students exposed to microbial contamination compared to the proportion of non-compliant samples by administrative-territorial units

11 InaccordancewiththeLaw764of27December2001onAdministrative-TerritorialOrganisationoftheRepublicofMoldova,theRightBankofNistruRivercomprises32districts,2municipalitiesandtheATUGagauziawithits3districts.

PROPORTION OF MICROBE-POLLUTED WATER SAMPLES AND NUMBER OF EXPOSED STUDENTS

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Of note is that, in 2009, the structure of morbidity related to acute diarrheal diseases considered by age groups shows a share of 75.6% of children aged 0-17, the share of children aged 0-2 years constituting 69.5%12. For this reason, the aforementioned indicators cannot be used to consider the impact of microbial pollution of drinking water in schools on students’ health.

Data on disease incidence and prevalence in children 7-17 years of age in each administrative-territorial unit are missing; this fact has not allowed estimating the im-pact on students’ health condition based on the results of evaluation of water quality in schools. However we can refer to some national data13 that show an increase in the incidence of infectious and parasite diseases by 33% in children 15-17 years of age in 200714 if compared to 2004.

More children (about 21% out of the total number of students) are exposed to health risks due to consumption of nitrate polluted water. Water samples analysis has re-vealed that the water is nitrate polluted in 33% of schools in all administrative-ter-ritorial units, except for Basarabeasca district (Figure 5). Thus almost one in five students in the country is exposed to the risk of methemoglobinemia and delayed physical development. Methemoglobinemia15 reduces blood capacity to transport oxygen due to low haemoglobin level. Symptoms of methemoglobinemia include skin cyanosis (“blue baby syndrome” – peribuccal cyanosis, cyanosis of hands and feet), tiredness, dizziness, vomiting and diarrhoea.

Water pollution with nitrates is more frequently registered in schools that use well water; therefore students in those schools are exposed to a higher health risk.

Like in the case of microbial pollution of drinking water, we could not identify an eventual connection between the non-compliant water samples in terms of nitrates and the health indicators for students in those schools during this Study due to the lack of data on health of children 7-17 years of age by disease categories and administrative-territorial units. A connection between the high proportion of nitrate-polluted water samples taken in schools and the share of students identified with physical retardation during the medical check-ups, which is 2-3 times higher than the average in the country, was noticed only in two administrative-territorial units (Ungheni and Rezina districts).16

12 NationalPublicHealthCentre“Sanitary-hygieneandEpidemiologicalSituationintheRepublicofMoldova”,201013 HealthcareintheRepublicofMoldova,NationalBureauofStatisticsoftheRepublicofMoldova,Chisinau,200814 Themostrecentpublicdata.15 Source:http://www.who.int/water_sanitation_health/diseases/methaemoglob/en/16 PublicHealthinMoldova2009,NationalHealthManagementCentre,Chisinau,2010.

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Figure 5. Proportion of students exposed to nitrates compared to the share of non-compliant samples by administrative-territorial units

In terms of fluoride content, water samples are non-compliant in about 17% of schools, which host 13.5% of the total number of students, from over two thirds of administrative-territorial units (Figure 6). Thus, almost one in seven students in the country is exposed to the risk of developing dental caries and fluorosis, a disease affecting teeth and bones. It was demonstrated that the fluoride insufficiency in the body may develop dental caries, and excessive ingestion of it can cause fluorosis. Clinical dental fluorosis is characterized by staining and pitting of the teeth. Chronic

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high-level exposure to fluoride can lead to skeletal fluorosis, the main symptoms of which include stiffness and pain in the joints.17.

Figure 6. Proportion of students exposed to excessive fluoride in drinking water compared to the share of non-compliant samples detected in different administrative-territorial units

The highest concentrations of fluoride were detected in schools from Parlita, Negureni and Agronomovca villages in Ungheni district – 16.5 mg/l; in Ustia and Dusmani vil-lages, Glodeni district – 5.3mg/l, in Sipoteni village, Calarasi district – 5.3mg/l, Baurci vil-17 Source:http://www.who.int/water_sanitation_health/diseases/fluorosis/en/

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lage – 8.4mg/l and Tomai village from ATU Gagauzia – 5,3mg/l, in Sarata Veche village – 8.8mg/l, in Risipeni village and in the Falesti railway station, Falesti district – 9-11 mg/l, which means that the use of those sources for drinking purposes must be prohibited. A connection between the high proportion of non-compliant water samples in terms of fluoride content and the proportion of osteoarticular system, muscles, and conjunctive tissue diseases in children 7-17 years of age, which is 1.4 times higher than the average in the country, was revealed only in Ungheni and Ciadir-Lunga districts. 18

One in 40 students (2.4%) is exposed to health risks due to consumption of non-compli-ant water in terms of boron content19. Non-conformity of water samples in terms of boron content was identified in about one third of administrative-territorial units (Figure 7). Al-though there are no studies that could show the impact of consumption of non-compliant drinking water in terms of boron content, the surveys conducted suggest its harmfulness for heart, blood vessels, liver, reproductive organs and foetus development20.

Higher boron concentrations were detected in the drinking water in Glodeni and Falesti districts - between 1 and 1.5 mg-l, and UTA Gagauzia (Ciadir-Lunga district) - up to 3 mg/l. The area of distribution of boron covers the Southern Zone - UTA Gagauzia, Ta-raclia and Cahul districts, the Northern Zone - Falesti, Singerei and Edinet districts and the Central Zone - Straseni and Hincesti districts. There is a need for special studies to estimate the health condition of students exposed to higher boron-related risks com-pared to that of children from administrative-territorial units where water samples are non-compliant by all chemical elements. It could be interesting to survey the connec-tion between the highest proportion of non-compliant water samples in terms of boron content and the level of chronic hepatitis and hepatic cirrhoses prevalence (1,148.8 per 100,000 inhabitants in 2009) in children 0-17 years of age, which is five times above the average in the country, registered in Ciadir-Lunga district from ATU Gagauzia.21 In addi-tion, this district has registered the highest morbidity level in the country (about 3 times above the average in the country) in terms of congenital malformations, deformations and chromosomal abnormalities in children 0-17 years of age. 22

Fluoride and boron presence in water depends mostly on morpho-geological features of rocks separating aquiferous layers and are detected especially in underground waters where the impact of anthropogenic activity is almost non-existent23. The non-conformity in terms of fluoride and boron content, which is usually established in schools using water from water supply system and only in some well-defined geographical zones, confirm this situation. Consequently, to protect students’ health against the negative ef-fects of high fluoride and boron concentration, specific water cleaning procedures are needed, since those are stable and undesirable chemical elements, and their concen-tration does not change during water distribution from the source to consumer or as a result of water disinfection. Therefore they cannot be eliminated by means of existing classical methods of treatment�.

18 PublicHealthinMoldova2009,NationalHealthManagementCentre,Chisinau,2010.19 Exposuretolargeamountsofboron(about30gofboricacid)overshortperiodsoftimecanaffectthestomach,intestines,liver,kidneys,andbrainandcaneventuallyleadtodeath.Source:http://www.atsdr.cdc.gov/tfacts26.pdf20 Source:http://www.atsdr.cdc.gov/ToxProfiles/tp26.pdf21 PublicHealthinMoldova2009,NationalHealthManagementCentre,Chisinau,2010.22 Idem23 Source:NationalPublicHealthCentre.

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Figure 7. Proportion of students exposed to boron compared to the share of non-compliant water samples detected in different administrative-territorial units

Of note is that students’ health is not exposed to arsenic, pesticides, and cyanides-related risks nationally, since no deviation was registered in terms of the respec-tive chemical parameters after water samples from pre-university institutions were checked.

Depending on the proportion of students exposed to risk factors determined by mi-crobial, nitrate, fluoride and boron pollution of water for human consumption,

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28 %

33 %

17 %

22 %

over two thirds of administrative-territorial units are classified as having a mod-erate to major health risk� (Table 4).

Table 4. Distribution of administrative-territorial units depending on stu-dents’ exposure to risk factors determined by drinking water quality

1st Category –Insignificant risk

2nd Category – Minor risk

3rd Category – Moderate risk

4th Category – Major risk

5th Category - Catastrophic risk

Chisinau mun.Basarabeasca Dubasari

DrochiaCahulLeovaBriceniAnenii NoiOrheiCimislia

Balti mun. Glodeni Singerei Hincesti Telenesti Rezina Ocnita Riscani Floresti Causeni Nisporeni Calarasi Straseni Cantemir

Soldanesti Edinet Donduseni Ungheni Soroca Atu Gagauzia (Ciadir-Lunga) Criuleni Ialoveni Stefan Voda Taraclia Falesti

The computations have revealed that one in four students is exposed to a major health risk due to consumption of drinking water at school, one in three students to a moderate risk, one in six to a minim and one in five to an insignificant risk, re-spectively (Figure 8). Consequently, 61% of students are exposed to a moderate to major risk conditioned by the quality of drinking water in schools in the Republic of Moldova.

Figure 8. Students’ distribution in terms of level of exposure to risk factors

Insignificantrisk

Minorrisk

Moderaterisk

Majorrisk

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V. STUDENTS’ ACCESS TO HYGIENE CONDITIONS IN SCHOOLS

Students’ access to hygiene conditions according to the most important components of the sanitation system - wash basins, soap, single use towels, hand dryers and WCs - is lower for children in pre-university institutions from rural areas (Figure 9).

Figure 9. Proportion of pre-university institutions from urban and rural areas lacking basic hygiene conditions

Availability of wash basins was registered in 98.4% of schools, however in 15.2% of them they were in an unsatisfactory condition. Of note is that students in rural schools more often lack conditions for hand washing at school than those in urban schools. Therefore, 232 pre-university institutions lack conditions for hand washing for the reason that taps are missing or sinks are damaged.

The availability of water basins could not be assessed in terms of their location in relationship with WCs and access during the school breaks. This would be an objec-tive for a separate special study. However the fact that water basins are located in the school does not help students observe the basic hygiene rules of washing hands before eating and after using the WC, since only 74.8% of schools have taps in can-teen and only 24.4% in WC (Figure 10). Therefore there is a danger that students do not manage to wash their hands after using the WC and before eating, being exposed to the risk of getting diseases spread24 by dirty hands.

24 Infectiousandparasitediseaseslike:ViralHepatitisA,BacterialDysentery,Colitis,Gastroenteritis,Ascaridosis,Enterobiosis,Hyme-nolepidosis,etc.

100%

90%

80%

70%

60%

50%

40%

30%

20%

10%

0,3

ProportionofinstitutionslackingwashbasinsProportionofinstitutionswithunsatisfactorysanitary-technicalconditionofwashbasinsProportionofinstitutionslackingsoapProportionofinstitutionslackingtowelsProportionofinstitutionslackinghanddryers

Urban Rural Total RM

2 1,63,7

19,215,2

11,8

29,224,6

42

56,352,3

75,9

88,284,6

16


Figure 10. Proportion of pre-university institutions in terms of water basins’ location

Students’ access to adequate hygiene conditions is inappropriate also due to lack of liquid or solid soap, since it is missing in one forth of pre-university institutions. The most disadvantaged are students in schools from Calarasi, Basarabeasca, Cimislia and Leova districts where soap is lacking in half of schools.

Two thirds of schools in the country at the end of school year 2008/2009 had no hand dryers. 70% of pre-university institutions in general lack all three facilities: soap, towels and dryers. In this regard the most disadvantaged are students in schools from Basarabeasca and Donduseni districts. About 70% of schools in one third of administrative-territorial units lack two of the three hygiene facilities.

95% of rural schools have only outside WCs on the cesspool. Thus a great majority of children in rural schools (55% in the total of students in the country) lack inside WCs (Figure 11.).

74,8

18,8

36,9

24,4

incanteeninWCincorridorinotherplaces

17


Figure 11. Proportion of pre-university institutions in urban and rural areas where WCs are in an unsatisfactory sanitary-technical condition and lack toilet paper

24.3% of schools have WCs in an unsatisfactory sanitary-technical condition. Thus two in ten children use WCs non-compliant with sanitation norms, which poses the risk of acute diarrheal and parasite diseases. The situation is alarming especially in terms of toilet paper supply, which lacks in two thirds of WCs in urban schools and almost in all WCs in rural schools. In outside WCs on the cesspool water basins are almost non-existing.

100%

90%

80%

70%

60%

50%

40%

30%

20%

10%

InstitutionswithWCsinanunsatisfactorysanitary-technicalconditionInstitutionslackingtoiletpaperinWCs

Urban Rural Total RM

18,1 26,7 24,3

72,4 95,5 75,9

18


Figure 12. Proportion of schools with outside WCs on the cesspool

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VI. STUDENTS’ HYGIENE PRACTICES The lack of opportunities for hand washing at school was confirmed by about 14.1% of interviewed students from the Southern, 9.2% - Northern and 8.3% - Central Zones. The assessment of hygiene conditions shows that 15.2% of schools have water basins in an unsatisfactory condition. The proportion of children who men-tioned the lack of conditions for hand washing in schools is higher in rural areas (11.6%) compared to urban ones areas (8.6%), which shows once again that chil-dren do not enjoy universal access to adequate hygiene conditions in schools.

87% of students wash their hands before eating at home and only 25.9% at school, with an about equal proportion by areas, sex, geographic zones (Figure 12). Conse-quently, it proves again that pre-university institutions lack conditions for adequate hygiene and educating students on hygiene culture.

Figure 13. Proportion of children in urban and rural areas who wash their hands before eating at school and at home

Only 22.7% of children have taps at home in rural areas, while in urban areas the proportion of access to these hygiene utilities is 64.5%, which decreases the op-portunity of children in villages for developing and observing the necessary hygiene practices.

Nevertheless, 69% of boys and 65% of girls, respectively, in rural areas mentioned they wash their face and hands compared to 58% of boys and 56% of girls, respec-tively, in the same groups in urban area. All this happens while the latter enjoy better sanitation conditions at home. Therefore, children in urban areas have more oppor-tunities of taking a shower in the morning (girls – 27.4%; boys – 23.7%), compared to children in rural areas (girls – 16.1%; boys – 13.1%).

100%

90%

80%

70%

60%

50%

40%

30%

20%

10%

UrbanRuralbefore eating, at home before eating, at school

87,4

26,6

84,6

25,2

20


69% of interviewed students brush their teeth in the morning and evening, and 22% reported they brush their teeth only in the morning, the latter do not observe the mouth hygiene. Perhaps this state of affairs together with the consumption of drink-ing water non-compliant in terms of fluoride content defines the high proportion (35.3% nationally, in 2009) of children who were identified by the medical check-up as being in need of dental cavity treatment 25.

Only in 27% of interviewed students mentioned they use WCs provided with water for hand washing. 15.6% of students in rural areas reported they have access to WCs provided with water for hand washing, compared to 39%, which is as much as twice, of children in urban areas. Despite this discrepancy, the provision of adequate hygiene conditions is below the standard in all pre-university institutions in the coun-try, both in rural and urban areas.

The evaluation of the level of students’ satisfaction with hygiene conditions shows that 52% of respondents are not satisfied with school WCs’ condition. 79 - 94% of children say it is first of all due to the fact that WCs are never provided with toilet paper. This was reported upon the results of the assessment of hygiene condi-tions in schools, which showed that 24.3% of schools have WCs with unsatisfactory sanitary-technical condition.

All the aforementioned pinpoints insufficient measures for providing adequate hy-giene conditions in pre-university institutions and inadequate conditions of sanita-tion systems in schools, which is a real danger for children’s health, especially in relation to the risk of getting infectious and parasite diseases. The situation is wor-risome, if we take into consideration the fact that the morbidity of infectious and parasite diseases in children 0-17 years of age increased by 21.6% in 2008 (71,800 children) compared to 2004 (56,300 children).26

25 PublicHealthinMoldova,NationalHealthManagementCentre,Chisinau,2010.26 StatisticalYearbookoftheRepublicofMoldova,2009,Chisinau2009,NationalBureauofStatistics.

21


Figure 14. The degree of combined risk for child health due to non-compliant quality of drinking water for the content of boron, fluoride, nitrates, microbe-pollution and inadequate sanitation

22


CONCLUSIONS

In spite of the expectations, pre-university institutions in the Republic of Moldova do not ensure universal access for children to safe drinking water in adequate hygiene conditions, a finding which mostly concerns children in rural schools.

Those who are more frequently exposed to the risk of illnesses due to con-sumption of unclean water and poor hygiene conditions in schools are stu-dents in rural schools. Drinking water is supplied from unprotected and exposed to the risk of contamination sources in one third of pre-university institutions. Sani-tary protection zone of the water sources, of which 80% are located in rural areas, is not observed in one in five schools in the country.

Measures for ensuring disinfection and cleaning of water for human con-sumption in Moldovan pre-university institutions are insufficient, since 61% of students are exposed to a moderate to major health risk conditioned by microbial pollution and excess of nitrate, fluoride and boron in drinking water.

In Moldova, 2 out of 10 students drink only well water at school. Otherwise, specifically the rural schools, which use well water, have registered the highest level of non-conformity of drinking water quality in terms of microbial and nitrate pollution. Therefore, students in rural schools are more often exposed to the risk of acute diarrheal illnesses and nitrates contamination.

Pre-university institutions experiencing interruptions in water supply sys-tems face a high risk of microbial pollution of drinking water. And again most affected by interruptions in water supply are students in rural schools, especially in the Southern Zone of the country, where this phenomenon occurs more often.

In Moldova almost one in four students is exposed to a major risk and one in three students to a moderate risk of consuming water that is non-compliant with the sanitation norms. In total, 20.8% of students drink water oversaturated with nitrates, 17% - microbe-polluted water, 13.5% - water non-compliant in terms of fluoride and, to a smaller extent, 2.4% - water in excess of boron.

Insufficient measures for improving access for all children both to safe water and adequate hygiene conditions in schools are among the causes preventing the decrease in child morbidity due to infections and parasites. Moreover, these diseases are spreading among children 15-17 years of age and increased by 33% in 200727 compared to 200428. There is also a connection be-tween the highest proportion of water samples non-compliant in terms of boron content (Ciadir-Lunga district in ATU Gagauzia) and the prevalence of chronic hepatitis, hepatic cirrhoses, which is five times above the average per country, as well as the level of congenital malformations, deformations and chromosomal 27 Themostrecentpublicdata28 HealthcareintheRepublicofMoldova,NationalBureauofStatisticsoftheRepublicofMoldova,Chisinau,2008

23


abnormalities, which is three times above the average, in children 0-17 years of age in 200929.

Students’ access to water basins, soap, hand dryers and single use hand towels as well as improved conditions in school WCs is low. The location of water basins in schools does not help students observe the basic hygiene rules of washing hands before eating and after using WCs, since only 74.8% of schools have water basins in canteens and only 24.4% in WCs. In addition, the sanitary-technical conditions of 24% of WCs in pre-university institutions are awful, which affects one fifth of the total number of students in the county. Over 55% of students in rural schools have access only to outside WCs on the cesspool, since this is the only type of WCs in 95% of rural schools.

Unsatisfactory hygiene conditions in schools pose a risk for students’ health also due to the fact that they do not help building and further strengthening children’s hygiene skills, since the condition of the occupational environment, where the child stays, plays an important part in the development of hygiene prac-tice.

Children in rural areas have less opportunities of developing and observing the needed hygiene practice, as they do not have access to taps at home and at school, which makes them being disadvantaged compared to children who live in urban areas and who have more opportunities for developing and ob-serving the basic hygiene practices. According to the Study findings, only 26% of interviewed students wash their hands before eating at school compared to 87% who wash their hands at home. A large number of children (52% of interviewees) are unsatisfied with this situation. Rural schools have the worst conditions, where only 15.6% of students reported they have access to WCs provided with water for hand washing.

The results of the Study have clearly highlighted the fact that the conditions of sanitation systems are much below the standard in most pre-university institutions in the Republic of Moldova, which does not allow ensuring the uni-versal access for students to adequate hygiene conditions and building and apply-ing the hygiene practices.

29 PublicHealthinMoldova,NationalHealthManagementCentre,Chisinau,2010.

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RECOMMENDATIONS

Define and approve a new Plan of Actions for Environmental Health in the Re-public of Moldova, which would include the priorities of Children’s Environment and Health Action Plan for Europe, adopted by the Forth Ministerial Conference on Environment and Health held in June 2004 in Budapest, and the Declaration of the Fifth Ministerial Conference on Environment and Health held in March 2010 in Parma under the motto “Protecting Children’s Health in a Changing En-vironment”. Identify among the actions of the Strategy on Water Supply Systems and Sew-erage in Settlements of the Republic of Moldova or, if needed, supplementing it with specific measures for developing rural schools’ infrastructure, which would focus on deferred regions and ensure that all students have access to improved water supply systems and adequate hygiene conditions.

Promote/Include as a priority the most deferred settlements in terms of quality of drinking water, water supply factors and students’ access to hygiene conditions in projects on water supply and sewerage system’s infrastructure modernisation, supported by international development partners (about 100 schools presented in Annex).

Ensure the disinfection and cleanness of human consumption water by imple-menting adequate water treatment technologies to change water properties be-fore distribution in order to decrease or avoid the risk of water non-conformity with the value parameters when supplied. Such systems shall be applied prima-rily in schools that are connected to water supply systems with non-compliant drinking water quality (over 500 schools were identified during the Study).

Raise the responsibility of education institutions’ managers and specialized cen-tral and local public administration authorities, which have education institutions in their subordination, for ensuring children’s access to adequate hygiene condi-tions in schools, first of all through setting up and modernising sanitation sys-tems in all pre-university institutions in the country.

Based on regular controls on quality of drinking water in schools, the State Pub-lic Health Surveillance Service’s institutions should inform the pre-university institutions’ administration, specialized central and local public administration authorities, students and parents on the results of water quality controls and provide counselling on any measure for possible improvements which they will be required to implement.

Inform and raise students’ and teachers’ awareness on issues related to drinking water protection and its impact on health, and promote positive hygiene prac-tices among students.

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Place the Study results and information on conformity (non-conformity) of water supplied to students with the Sanitation Norms on Drinking Water Quality30, as well as the negative impact of non-compliant water on health, in a visible place in each pre-university institution in the country.

The State Public Health Surveillance Service’s institutions shall expand and di-versify measures for adequate and updated consumer’s information on quality of water for human consumption, also by placing the results of controls on drinking water from checked water sources on the web-pages of the State Public Health Surveillance Service’s institutions.

30 ApprovedthroughGovernmentDecision934of15August2007onsettinguptheAutomatedInformationSystem“StateRegisterofBottledNaturalMineralWater,DrinkingWaterandSoftDrinks.”

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ANNEXList of the most disadvantaged pre-university institutions in terms of drinking water quality and conditions of the available drinking water supply and sanitation systems

n/o

Institution Quality of drinking water supplied in

school

Conditions of school’s drinking water supply sys-

tems

Conditions of school’s sanitation

systems

Compli-ant

Non-compliant

Adequate Ina-dequate

Adequate Ina-dequate

1 Secondary school no. 65, Condrita village, Chisinau mun. X X X2 Gymnasium, Telita village, Anenii Noi district X X X3 Gymnasium, Maximovca village, Anenii Noi district X X X4 Secondary school, Delacau village, Anenii Noi district X X X5 Theoretical Lyceum, Abaclia village, Basarabeasca district X X X6 Theoretical Lyceum, Drepcauti village, Briceni district X X X7 Gymnasium, Balcauti village, Briceni district X X X

8 Secondary school "Nicolae Neculce", Baurci-Moldoveni village, Cahul district X X X

9 Gymnasium “Mihai Sadoveanu”, Andrusul de Sus village, Cahul district X X X

10 Gymnasium “Mircea cel Batrin”, Trifesti village, Cahul district X X X11 Secondary school, Vadul lui Isac village, Cahul district X X X12 Gymnasium, Capaclia village, Cantemir district X X X 13 Scoala primara, Ghioltosu village, Cantemir district X X X14 Theoretical Lyceum, Baimaclia village, Cantemir district X X X15 Theoretical Lyceum, Dereneu village, Calarasi district X X X16 Gymnasium, Bahmut village, Calarasi district X X X17 Gymnasium, Hoginesti village, Calarasi district X X X18 Gymnasium, Baimaclia village, Causeni district X X X19 Gymnasium, Ursoaia village, Causeni district X X X 20 Gymnasium, Florica village, Causeni district X X X 21 Gymnasium, Cenac village, Cimislia district X X X22 Gymnasium, Sagaidac village, Cimislia district X X X23 Theoretical Lyceum, Batir village, Cimislia district X X X24 Gymnasium, Pohrebea village, Dubasari district X X X25 Gymnasium, Pascani village, Criuleni district X X X26 Theoretical Lyceum, Cimiseni village, Criuleni district X X X27 Secondary school, Hirtopul-Mare village, Criuleni district X X X28 Gymnasium, Codrenii Noi village, Donduseni district X X X 29 Gymnasium, Pivniceni village, Donduseni district X X X30 Gymnasium, Donduseni town, Donduseni district X X X31 Secondary school, Nicoreni village, Drochia district X X X32 Gymnasium, Macareuca village, Drochia district X X X33 Gymnasium, Volodeni village, Edinet district X X X 34 Theoretical Lyceum, Brinzeni village, Edinet district X X X35 Gymnasium, Burnulanesti village, Edinet district X X X36 Secondary school, Ruseni village, Edinet district X X X37 Gymnasium, Calugar commune, Falesti district X X X38 Theoretical Lyceum, Risipeni village, Falesti district X X X 39 Gymnasium, Burghelea, Falesti district X X X40 Gymnasium, Nicolaevca village, Floresti district X X X 41 Theoretical Lyceum, Sanatauca village, Floresti district X X X42 Gymnasium, Sevirova village, Floresti district X X X43 Gymnasium, Fundurii Noi village, Glodeni district X X X

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44 Gymnasium, Viisoara village, Glodeni district X X X 45 Secondary school, Iabloana village, Glodeni district X X X46 Gymnasium, Obileni, Hincesti district X X X47 Theoretical Lyceum, Mingir village, Hincesti district X X X48 Gymnasium, Dancu village, Hincesti district X X X 49 Gymnasium, Cataleni village, Hincesti district X X X 50 Gymnasium, Sarata-Mereseni village, Hincesti district X X X51 Gymnasium, Hansca village, Ialoveni district X X X52 Gymnasium, Vasieni village, Ialoveni district X X X53 Gymnasium, Pojareni village, Ialoveni district X X X54 Gymnasium, Carbuna village, Ialoveni district X X X55 Gymnasium Tochile - Raducani, Leova district X X X56 Secondary school, Tomai village, Leova district X X X 57 Gymnasium, Covurnului village, Leova district X X X58 Gymnasium, Hanasenii Noi village, Leova district X X X59 Gymnasium, Valea-Traisteni village, Nisporeni district X X X60 Theoretical Lyceum, Seliste village, Nisporeni district X X X61 Theoretical Lyceum, Varzaresti village, Nisporeni district X X X62 Gymnasium, Paladea village, Ocnita district X X X 63 Gymnasium, Naslavcea village, Ocnita district X X X64 Theoretical Lyceum, Biesti village, Orhei district X X X 65 Gymnasium, Discova village, Orhei district X X X66 Gymnasium, Gordinesti village, Rezina district X X X67 Theoretical Lyceum, Echimauti village, Rezina district X X X 68 Gymnasium, Horodiste village, Riscani district X X X69 Gymnasium, Pociumbeni village, Riscani district X X X70 Gymnasium, Sturzeni village, Riscani district X X X71 Gymnasium, Tiplesti village, Singerei district X X X72 Secondary school, Draganesti village, Singerei district X X X73 Theoretical Lyceum, Radoaia village, Singerei district X X X74 Gymnasium, Darcauti village, Soroca district X X X 75 Theoretical Lyceum, Vasilcau village, Soroca district X X X76 Secondary school, Septelici village, Soroca district X X X77 Gymnasium, Dubna village, Soroca district X X X 78 Secondary school, Panasesti village, Straseni district X X X79 Gymnasium, Draguseni village, Straseni district X X X80 Gymnasium, Chirianca village, Straseni district X X X81 Gymnasium, Fuzauca village, Soldanesti district X X X82 Theoretical Lyceum, Vadul-Rascov village, Soldanesti district X X X83 Gymnasium, Poiana village, Soldanesti district X X X84 Theoretical Lyceum, Ermoclia village, Stefan Voda district X X X 85 Secondary school, Purcari village, Stefan Voda district X X X86 Theoretical Lyceum, Caplani village, Stefan Voda district X X X87 Gymnasium Hirtop village, Taraclia district X X X88 Theoretical Lyceum, Albota de Jos village, Taraclia district X X X89 Gymnasium, Bogzesti village, Telenesti district X X X90 Gymnasium, Cucioaia village, Telenesti district X X X91 Gymnasium, Codru Nou village, Telenesti district X X X92 Gymnasium, Boghenii Noi village, Ungheni district X X X93 Gymnasium, Napadeni village, Ungheni district X X X94 Gymnasium, Untesti village, Ungheni district X X X95 Gymnasium, Negurenii Vechi village, Ungheni district X X X96 Theoretical Lyceum, Russcaia-Chiselia village, Comrat district X X X 97 Theoretical Lyceum, Besalma village, Comrat district X X X 98 Secondary school, Cazaclia village, Cadir Lunga district X X X99 Gymnasium, Gaidar village, Cadir Lunga district X X X100 Gymnasium, Cismichioi village, Vulcanesti district X X X101 Primary school, Carbalia village, Vulcanesti district X X X