Waterborne Diseases: Public Health Engineering and the Primacy of Prevention

David M. Gute, Ph.D., M.P.H., FACETufts Environmental Literacy Institute

May 21, 2013

Today’s Talk

• My background in government and the practice of public health

• Tufts Environmental Literacy Institute• Primary prevention: Public health engineering• Nexus: water, health, and food • Importance of surveillance and acquisition of data • Environmental enteropathy• Renewed emphasis on sanitation

Host

Agent Environment

Vector

Epidemiological Triad

Fenwick, A. Science 8/25/06

Condition Cases in Africa % of Global Burden (Africa)

Hookworm 198 million 27-34%

Ascariasis 173 million 14-22%

Schistosomiasis 166 million 89%

Trichuriasis 162 million 20-26%

Lymphatic Filariasis

46 million 38%

Trachoma 33 million 40%

Onchocerciasis 18 million 99%

Public Health Approach

Problem Response

Surveillance:What is the

problem?

Risk FactorIdentification:What is the

cause?

InterventionEvaluation:

Whatworks?

Implementation:How do you

do it?

The Primacy of Prevention

• The public health approach• Success stories

– Impact of civil infrastructure improvements and other factors versus medical treatment

– Removal of lead in gasoline

Levels of Prevention

• Primary- prevention of the disease in a person who is well and does not have the disease in question.

• Secondary- the identification of the disease at an early stage in the natural history of the disease in question.

• Tertiary- the limitation of mortality and or disability of the disease in question.

The Questionable Impact of Medical Measures (McKinlay et al.)

An Unqualified Success: Blood Lead Measurements 1975-1981 (USA)

1975 1976 1977 1978 1979 1980 198130

40

50

60

70

80

90

100

110

8

10

12

14

16

18

Year

Predicted blood lead

Gasoline lead

Observed blood lead

Source: Pirkle et al JAMA 272:284-91, 1994

Lead used in gasoline(thousan

dsof tons)

Mean bloodlead

levels g/dl

EPA’s Perspective on Levels of Prevention

Source: http://www.epa.gov/p2/p2week2003.htm

Water

• “Water is a global dictator which sets the limits for living nature.”

Simo LaakkonenWater and Urbanization: Conceptualizing Hydrohistory” unpublished paper. As cited in The Sanitary City by Martin Melosi.

He also said, “Waste disposal-an unwelcome but necessary function-is another global dictator”.

Pollution Global Warming

Over Population Habitat Degradation

Biodiversity LossOver Consumption

Health

Mark Pokras, D.V.M.

Mark Pokras, D.V.M. EID = Emerging Infectious Disease

Surveillance• The systematic and ongoing collection, analysis and

dissemination of information on disease, injury, or hazard for the prevention of morbidity and mortality.

• Sources of data appropriate for surveillance?• Case-based: Sentinel Health Event of Occupational

Origin (SHE/O)• Rate-based: population based analysis looking down

the traditional public health/epidemiological parameters of person, place, and time.

• Surveillance can be directed either at the disease or the agent (more commonly known as monitoring).

Emerging Infectious Diseases, Volume 9, Number 5, May 2003Estimating the Incidence of Typhoid Fever and Other Febrile Illnesses in Developing CountriesJohn A. Crump,* Fouad G. Youssef,† Stephen P. Luby,* Momtaz O. Wasfy,† Josefa M. Rangel,* Maha Taalat,† Said A. Oun,‡ and Frank J. Mahoney*†*Centers for Disease Control and Prevention, Atlanta, Georgia, USA; †U.S. Naval Medical Research Unit No. 3, Cairo, Egypt; and ‡Ministry of Health and Population, Cairo, Egypt

How well do we understand theburden of waterborne diseases?….issues of surveillance

North Chicago River

• Sewage into Lake Michigan / Chicago River: drinking water source

• 1867: 2-mile tunnel provides drinking water intake away from shore

• 1869: water tower fire pumping station

• 1871: deepening of Illinois and Michigan canal, reversing current of Chicago River – sewage flows away from water intakes

South Chicago River1871

Original

2nd and 3rd stages• 1893: 4-mile intake; closure of all shoreline sewage outlets• 1917: City-wide chlorination of public water supply• Dramatic effects before chlorination due to sanitation

Adapted from Ferrie and Troesken, Explor. In Ec. Hist. 2007

2nd and 3rd stages

First intake in Lake MichiganReversal Chicago River

No sewage allowed in LMIntakes further out

Chlorination

Adapted from Ferrie and Troesken, Explor. In Ec. Hist. 2007

A Case Study: Schistosomiasis

• 200 million cases world-wide with another 600 million at risk of infection.

• A parasitic disease with a complex life cycle.• In the perspective of Nobel Laureate Joshua

Lederberg, a well “adapted” microbe.• Predominate risk management tactic today is

treatment. This is a missed opportunity to further primary as contrasted with tertiary prevention.

Neglected Tropical Diseases

• Neglected Tropical Diseases (NTDs), such as urogenital schistosomiasis (UGS), receive little global attention as measured by research and development investment. As a result, NTDs burden health care systems and are an important cause of squandered human potential.

• UGS causes anemia; fibrosis of the liver, bladder and ureter; renal damage; bladder cancer; urogenital pathology; and infertility.

Mass Chemotherapy

• Mass chemotherapy is the prevailing response to Schistosomiasis.

• However, mass chemotherapy campaigns have been unable to reduce prevalence below 5-15% (Wang et al. 2009) because they do not address the root cause of the disease which is repeated exposure to parasites.

• Emphasis on the beneficial impact of infrastructure to other water-related diseases was endorsed emphatically by the C.H. King editorial that accompanied the publication of Wang’s successful control efforts in China (King, 2009).

Impacts of our proposed clinical trial on the multi-host lifecycle of S. haematobium X1 shows the interruption of S. haematobium infection due to use of water recreation areas and borehole wells; X2 shows the interruption of morbidity and egg production in humans due to treatment with praziquantel; X3 shows the reduction of river water contamination with S. haematobium eggs because of latrine use; and X4 illustrates the interruption of multiple stages of the lifecycle due to behavior change resulting from education and access to WASH

Adapted from-http://www.dpd.cdc.gov/dpdx/HTML/ImageLibrary/S-Z/Schistosomiasis/body_Schistosomiasis_il10.htm

The Water Source on the Awusu River

Urine Samples from SchoolchildrenAdasawase, Ghana

Karen C. Kosinski, MSPH, Ph.D.

Water Recreation Area Adasawase, Ghana

Karen Kosinski, Ph.D.

The WRA in UseThe WRA features a concrete pool supplied by a bore hole well and a gravity –driven rainwater collection system in this water-rich location.

Initial baseline testing in 2008 established that 42.5% of children were egg positive. In 2009 with drug treatment alone the pre-WRA annual cumulative incidence of infection was 13.4%. In 2010, this incidence rate fell significantly (p <0.001, chi-squared) to 3.7% after installation of the WRA.

KC Kosinski, MN Adjei, KM Bosompem, JJ Crocker, JL Durant, D Osabutey, JD Plummer, MJ Stadecker, AD Wagner, M Woodin, and DM Gute. Effective Control of Schistosoma haematobium Infection in a Ghanaian Community following Installation of a Water Recreation Area. PLoS Negl Trop Dis . Jul 2012 6(7): p. e1709.

Malnutrition Infection

which worsens

which worsens Dietaryinsufficiency

Environmental factor: water

Jeffrey Griffiths, M.D.

Nice normal intestine. Notelong skinny finger-like villi, which absorb nutrients

ENVIRONMENTAL ENTEROPATHY

EE -Nasty blunted villi, and tissue is infiltrated with inflammatory cells. EE is a stateof chronic inflammation

Korpe & Petri, Trends in Molecular Medicine June 2012, Vol. 18, No. 6

Environmental EnteropathyChildren in highly contaminated environments have leaky, chronically inflamed intestines – 5% less carbohydrate, 15% less protein absorption. Leak lets ‘dirty’ contents of gut into body; chronic inflammation uses up/diverts nutrients, leads to anemia…

Gnotobiotic (sterile gut) mice – given either Normal or Kwashiorkor MB. Science:339.548-554, 2013

Mice given kwashiorkorMB bacteria – lost 1/3 oftheir weight

Mice given normal MB – maintained weight

Solutions for Environmental Enteropathy

• Classic household water & sanitation – water supply NOT same for animals unless treated; hand-washing; human and animal feces kept out of wastewater to increase food safety.

• Agricultural hygiene – barriers to keep feces out of water - vegetated buffer zones- riparian buffers to slow entry into open water (stream or irrigation canal), nutrient management, grazing practices …

January 4 2013: US FDA proposes rules to “ensure water used in irrigation meets standards…” http://www.fda.gov/Food/FoodSafety/FSMA/ucm334114.htm

Integrated Approach• Providing food to undernourished people only solves

some of the problem. Recent science: contaminated environments, infections, and toxins adversely change the child’s gut via EE.

• Water & sanitation have much more potential to eliminate malnutrition than had been thought.

• Integrated programming has the best chance to improve the nexus of water, health, and food. One can’t dig irrigation canals without affecting nutrition & health!

• Schistosomiasis = disease of “progress”.

Definition of Engineering

Engineering is the invention of solutions for the improvement of the human condition - often in the face of incomplete understanding and always under the constraints of natural laws and available resources.

Source: Dean Paul Fleury. Engineering Program @ Yale University

Selected Data Points Regarding the Schism

• 1922, MIT & Harvard abandoned a joint program: the School for Health Officers. Harvard School of Public Health emerges-like the Phoenix.

• 1970, US EPA created out of the US Public Health Service.

• 1970, (MA) Department of Environmental Quality Engineering (DEQE) created.

Engineering Village 2 Citations for “Public Health Engineering” Expressed as a Title by Date of Publication (English Only)

Date of Publication Counts

Present -1990 9

1989-1970 5

1969-1950 14

1949-1930 28

1929-1910 13

1909-1890 2

Source: D.M. Gute

OVID Citations for “Public Health Engineering” Expressed as a Title by Date of Publication (Any Language)

Date of Publication Counts

Present -1990 2

1989-1970 4

1969-1950 11

1949-1930 N.A.

1929-1910 N.A.

1909-1890 N.A.

Source: D.M. Gute

Sir Joseph Bazalgette• Sir Joseph Bazalgette (1819-91).

Bazalgette was one of the greatest of Victorian engineers who, between 1856 and 1889, built more of London than anyone else before or since in his role as Chief Engineer to the Metropolitan Board of Works. The sewers, pumping stations and treatment works that he built are still keeping the capital clean.

• Before Bazalgette's time London's sewage flowed into the Thames from which it leaked into adjacent springs, wells and other sources of drinking water: hence the cholera epidemics.

Sir Edwin Chadwick• Father of sanitary engineering in

England• A lawyer by training• Health depended on sanitation• Sanitation was in the province of

engineering• One local authority should

administer sanitary infrastructure in an area

• Took on the entrenched power structure of engineers and private water companies

• For his trouble, he was fired. Knighted barely one year before his death.

Lemuel Shattuck

• New Englander influenced by the work of Chadwick.

• In 1850 drafts a report laying out the rationale for the creation of Board of Health for the Commonwealth of Massachusetts. (See handout).

• The plan is acted on 19 years later!• Founder of the American Statistical

Association.

Shattuck and Satcher

• Shattuck: “public health requires such laws and regulations, as will secure to man associated in society, the same sanitary enjoyments that he would have as an isolated individual ”.

• Satcher: “scope has broadened to include: identifying elusive patterns and origins of human behaviors that so frequently result in adverse health consequences”.

Deer Island

Source: MWRA Homepage

Biology of Water and Health 9/21/10

Vector Borne Disease Comes to NYC or at least to the New Yorker

Conclusion

• Engineering and public health will benefit from a re-convergence.

• The hope is that primary prevention can be emphasized and that emerging technologies can be harnessed to both enhance the understanding of disease etiology and mechanisms of control.

• Integrate environmental concepts and material in outreach and communication materials