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

Tom Hennessy, MD, MPHUS Centers for Disease Control and Prevention (CDC)

Arctic Investigations ProgramAnchorage, Alaskathennessy@cdc.gov

DisclaimerThe audience should know that…

this presentation represents the conclusions of the presenter and

does not necessarily represent the official position of CDC

Why are still doing studies to evaluate water, sanitation and

health?

164th Anniversary of the London Cholera Outbreak

John Snow, Physician and Epidemiologist

1958

1969

2000

Many Arctic and Subarctic residents don’t have adequate access to in-home running water and sewer

Alaska, Canada, Greenland, Russia

Percentage of US homes with complete plumbing, 1940 – 2010, US Census

0102030405060708090

100

1940 1950 1960 1970 1980 1990 2000 2010

USAlaskaRural Alaska

Threats to Alaska Rural Water and Sanitation infrastructure

n Decreased funding for new constructionn Existing systems are aging

n Operations and maintenancen Replacement

n Climate changen Shoreline erosionn Sea level risen Permafrost thawn Source water availability and quality

Still not enough evidence?

Levels of Evidencen Compelling stories

n Giardia outbreak, Ketchikan 1984n Kivalina washeteria closure

Levels of Evidencen Compelling storiesn Look-back studies

n “Cross-sectional”n Exposure and outcome collected at same time

n Not evidence of causationn Complicating factors

17

Hospitalization Rates for “High” and “Low” Water Service Regions, Alaska,

2000-2004

0

50

100

150

200

250

Diarrhea

Pneumonia

RSVSkin Infections

MRSA

Low ServiceHigh Service

* **

*

Hennessy, AJPH, 2008

Rat

e pe

r 10,

000

* P < 0.05

050

100150200250

Diarrhea

Pneumonia

Resp Syncytial Virus

Skin Infections

Methicillin R S.aureus

Low ServiceHigh Service

Hospitalization Rates for “High” and “Low” Water Service Regions, Alaska,

2000-2004

* **

*

Rat

e pe

r 10,

000

Water-borne infectionsWater quality

Water-wash infectionsWater quantity

Hierarchy of Water Requirements

19

Drinking

Cooking

Personal hygiene

Washing clothing

Cleaning home

Factors Linking Water to Health

n Water Qualityn Prevents illness from drinking water

n Water-borne diseasesn Cholera, Typhoid fever, dysentery

n Adequate water Quantityn Drink, cook, wash: hands, body, clothesn Prevents infections spread person-to-person

n Water-washed diseasesn Respiratory infections, skin infections

Serious Infections with Pneumococcusin Children < 5 years old,

Southwest Alaska, 2001- 2007

0

50

100

150

200

250

300

350

400

450

< 10%10 - 79%>= 80%US, overallR

ate

per 1

00,0

00 Water Service

* Wenger, 2010, Pediatric Infectious Diseases

Number of Cavities in Primary Teeth by Village Fluoridation Status

4.6

9.8

3.7 3.1

0

2

4

6

8

10

4 – 5 6 – 11Age group (years)

Mea

n nu

mbe

r of d

enta

l car

ies Non-fluoridated Fluoridated US

*

*

* p < 0.01

3x

1.5x

1.6 1.8

MMWR, Sept 2011

Respiratory Hospitalizations, by Water Service, 1998 – 2003, Alaska Medicaid

Gessner, Pediatrics, 2008

… Complicating factors….

Respiratory Hospitalizations, by Education Level of Parent

Respiratory Hospitalizations, by Education Level of Parent

Levels of Evidencen Compelling storiesn Look-back studiesn Prospective studies

n Before and after water service installationn Comparison groupn Alaska “4 village study”

n Tim Thomas and a cast of thousandsn J Water and Health 2015

n Evidence for causationn May be complicated by other factors

0

200

400

600

800

1000

1200

1400

1600

Gastro Resp Skin

Pre-PipedPost-Piped

Gastrointestinal, Respiratory and Skin infection Rates, Before and After Piped Water

* P < 0.05

Rat

e pe

r 1,0

00

↓16%*

↓20%*↓38%*

Levels of Evidencen Compelling storiesn Look-back studiesn Prospective studiesn Randomized controlled trial

n “Treatment trial” of water/sanitation

Levels of Evidencen Compelling storiesn Look-back studiesn Prospective studiesn Randomized controlled trial

n “Treatment trial” of water/sanitation n Ethical issues

Types of Datan Illness and death

n Hospitalizations, clinic visitsn Skin infections, diarrhea, hospitalization

n Humanitarian appealn Works for people who believe pain and suffering is bad

Types of Datan Illness and deathn Indirect consequences

n Illness n School absences

n Lower economic status, poorer health for lifen Family burden

n Lost money, work or subsistence activities

Types of Datan Illness and deathn Indirect consequences

n Reduced access to drinking watern Increased soda consumption

n Dental cavities, obesity, diabetes

Types of Datan Illness and deathn Indirect consequencesn Costs

n Direct medical costs $n Compare villages with and without water/sewer

n Indirect costsn “Ripple effects”n Stories or $$

n Useful for “bottom line” typesn Will savings offset costs of services?n Who’s budget benefits?

Health benefits of running water and sewer service

n Prevention of:n Respiratory infectionsn Skin infectionsn Severe bacterial infectionsn Dental cavitiesn Diarrhea

n Other benefitsn Overall hygienen Mental wellness

n Water securityn Others?

35

Next Stepsn Revisit infectious disease outcomes

n YKHC 2013 – 2016n Honey bucket, covered haul, piped systems

n Develop other lines of evidencen Cost studiesn Compelling personal stories

n Develop a communication plan for different audiencesn Alaska publicn Agency and tribal leadersn Legislators: State, Congressional