Minsk 5-6 April 2011 Enzo Funari. Italian Higher Institute of Health

1. Technical and policy guidance for setting up, implementing and assessing surveillance systems of water-related disease Minsk 5-6 April 2011 Enzo Funari. ItalianHigherInstituteofHealth

2. TECHNICAL GUIDANCE DOCUMENT ONWATER-RELATED DISEASE SURVEILLANCEorigin, story oftheirpreparation • Inspired by a WHO public health initiative in Asia, organized by the WHO Collaborating Centre for Health-promoting Water Management and Risk Assessment at the University of Bonn, Germany. • Multilateral co-operation programme between the WHO Regional Office and the central Asian countries. • Later on, further developed by this TF.

3. Approach, contents , aims • Holistic approach; • The document reviews the main threats to health related to water services, recalls basic concepts of epidemiology and disease surveillance, and provides guidance on data management and analysis. • It is in line with the International Health Regulations (2005) which entered into force on 15 June 2007. • A sort of synthesis of scientific knowledge in the area (basis) but then practical tools to face the possible problems in the area.

4. Approach, contents , aims • Aimed specifically at the needs of local laboratories in central Asian countries; • Also aimed at strengthening cross sectoral activities (water, environment managers and health sector workers). • In conclusion, the Guidance document is aimed at supporting national efforts towards national and international health security

5. Scientists, experts involved Editors: • Enzo Funari, chair of Task Force on Water-related Disease Surveillance • Thomas Kistemann, Institute for Hygiene, Rheinische Friedrich Wilhelms Universitat, Bonn, Germany • Dr Suzanne Herbst, Executive Director, WHO Collaborating Centre for Health Promoting Water Management and Risk Communication • R Aertgeerts, WHO Regional Office for Europe Main contributors: • Akgaev, D (Turkmenistan); Blasi, M (Italy); Classen, T (Germany); Cronin, A A (UK); Dangendorf , F (Germany) ; Davlyatov, S K (Tajikistan); Exner, M (Germany); Funari, E (Italy); Herbst, S (Germany); Kadar, M (Hungary); Kaitbaev, N (Tajikistan); Kistemann, T (Germany); Loock, A (Germany); Ishankuliev, Y (Turkmenistan); Mishina, O (Uzbekistan); Moe, C (USA); Pond, K (UK); Queste, A A (Germany); Schoenen, D (Germany); Sharipova, N V (Uzbekistan); Wienand, I (Germany); Vashneva, N (Kyrgyzstan)

6. Technicalguidelines 2. HEALTH RISKS FROM MICROBIAL PATHOGENS 3. HEALTH RISKS FROM CHEMICALS 4 HEALTH RISKS IN THE WATER SYSTEM 5. ESSENTIAL EPIDEMIOLOGY 6. ESSENTIAL SURVEILLANCE. 7. DATA MANAGEMENT AND ANALYSIS USING GEOGRAPHICAL INFORMATION SYSTEM

7. Technicalguidelines The publication is available at http://www.unece.org/env/documents/2010/wat/MP_WH/wh/ece_mp_wh_2010_L3_E.pdf 157 pages, 18 tables, 22 figures

8. Policy guidelines • Short guidance for the organization or improvement of health systems, with particular attention to water-related diseases (WRDs). • Where safe access to water is not ensured, political authorities should be aware of the consequences, not limited to the disease (sustainable development is hampered and economic costs are prohibitive).

9. Co-authors • Roger Aertgeerts, WHO Regional Office for Europe • Enzo Funari, Italy • Nana Gabriadze, Georgia • Paul Hunter, United Kingdom of Great Britain and Northern Ireland • Frantisek Kozisek, Czech Republic • Arben Luzati, Albania • Aida Petikyan, Armenia • Andrea Rechenburg, Germany

10. Contents II. Water safety plans III. Legal obligations with regard to disease surveillance IV. Surveillance system for water-related diseases V. How to set up an essential surveillance system for water-related diseases (OMT) VI. How a water-related disease surveillance system should work in practice VII. How to evaluate a surveillance system for water-related diseases VIII. National examples I. The problem (Introduction)

11. The Problem

12. The Problem

14. Figure 1‑2 SDR diarrhoeal disease below 5 y of age (Source: WHO Health for All) EUR B+C EUR-A While mortality data are surely the most striking, morbidity figures show that water-related diseases continues to be a serious problem in the European region, are hampering sustainable development and imposing prohibitive economic costs.

15. Controlling and reducing the burdenofWRDs Surveying the health status of communities Controlling and reducing the burden of WRDs has two main tools Promoting adequate preventive measures in order to ensure safe access to water (adequate quality and quantity)

16. Examples where the system failed included an outbreak of giardiasis in Hordaland (Bergen) in 2004 – 2005 where the surveillance system proved to be “late” in detecting outbreaks.

17. WHO Water safety plans one of the most important tools in ensuring safe water. • WSPs: management multi step approach aimed at ensuring safe access to water. • WSPs should be developed for each individual drinking-water system, whether large- or small-scale. • Beyond drinking water

18. WHO WSPs Raw waters should be protected against pollution in the catchment area Surface and shallow waters must always be treated before being used as a source of drinking-water; the higher the level of contamination of raw water, the greater the efficiency of the water treatment process required;

19. Figure 8‑1 Sources of failures in the WSP approach WHO WSPs Drinking-water: subject to surveillance for the main risk factors (special attention to microbial quality) Adequate education and training for the personnel

20. Surveillance systems for WRDs Surveillance systems implemented in several countries in the EURO Region but often do not include specific surveillance for WRDs.

21. WRDs Surveillance systems Specific WRDs surveillance systems would provide relevant added value, as they can: •  identify the diseases transmitted by water • define/estimate the burden of WRDs; • use data and information to identify communities where there are problems with water related diseases;

22. WRDsSurveillancesystems Mapping of pollution hazards and identifying risks; promote intervention measures to control and prevent WRDs; target resources towards areas with priority needs; assess the effectiveness of the implemented water and sanitation interventions in reducing diseases.

23. WRD Surveillancesystems In countries with limited resources: High incidence of typhoid fever→ need for targeted vaccine campaigns; epidemic and endemic giardiasis and cryptosporidiosis → need for water filtration (chlorination is not very effective against these pathogens) need of household water treatment of water in high-risk areas; outbreaks in adequately treated piped water supplies ( intrusion problems in the water distribution system) → need to keep water pressure stable or accept additional measures like booster chlorination high prevalence of helminth infections → need for improvements in sanitation and increased water availability for general hygiene; High incidence of blue-baby syndrome → need to control and reduce nitrate concentrations in drinking water.

24. How to set up an essential surveillance system for WRDs •  Public health surveillance systems represent the ongoing and systematic collection, analysis and interpretation of health data to describe and monitor a health event. • The surveillance of WRDs should be included within the context of more general surveillance systems for communicable diseases. • A specific surveillance system for waterborne disease outbreaks should include a method for evaluating the evidence that an outbreak is indeed attributable to contaminated water.

25. How to set up an essential surveillance system for WRDs • WRDs: • Priority diseases (characterised by a high epidemic potential): cholera, diseases caused by enterohaemorrhagicE. coli, viral hepatitis A, bacillary dysentery and typhoid fever. • Emerging diseases (showing a rapid increase in the affected population, or are being observed in countries where they were previously absent): campylobacteriosis, cryptosporidiosis, giardiasis, and legionellosis.

26. How to set up an essential surveillance system for WRDs Local diseases (diseases that are not present throughout the country concerned but may potentially have a severe local impact) : methemoglobinaemia, arsenicosis, viral infections (particularly those attributable to Norovirus) and parasitic diseases.

27. Essentialsurveillance system for WRDs • Local level • An outbreak management team (OMT) should be set up at the local health unit. OMT composition: representatives of waterworks and sanitation system, water department of the regional environmental agency, expert in hygiene and environmental medicine.

28. Essential surveillance system for WRDs • In case of a WRD outbreak, the local OMT should: • Review the evidence for an outbreak • Identify the population at risk • Decide on control measures • Provide quick and adequate information to the public • Make arrangements for the commitment of personnel and resources • Health surveillance data should be linked with data on the quality and distribution of water supplies in the same area.

29. Essential surveillance system for WRDs • Regional level • An OMT with similar features should be established at regional level, with the following tasks after WRD outbreaks: • Prepare a notification to be sent to the national agencies • Prepare a report to be sent to the regional authorities responsible for management measures • Promote further epidemiological and environmental studies, as necessary; • Provide adequate information to the public; and • Provide feedback on surveillance results and analyses to the local OMT in order to sustain the interest and co-operation of the data collectors and data providers

30. Essential surveillance system for WRDs • National level • With representatives from the sectors of health, environment, waterworks and sanitation, and agriculture (including animal husbandry and aquaculture). • Tasks • Draft the notifications on WRDs and provide information to the public; • Map the WRDs on a national scale (possibly using geographic information systems); • Identify most critical areas / situations; • Assess the burden of WRDs; • Transmit the information on WRDs at the international level; • Provide training and educational initiatives; • Promote specific surveys; • Provide feedback on surveillance results and analyses to the regional OMT in order to sustain interest and cooperation; • Assess the functionality of the whole surveillance systems; • Prepare a report to be sent to the national authorities responsible for management measures; and • Coordinate activities in the case of transboundarywaterbodies.

31. How a WRD surveillance system should work in practice • Preparedness • First and foremost, the local OMT should be well-prepared to (i) detect water-related outbreaks; and (ii) react adequately if a water-related outbreak occurs. • In setting up a surveillance system, it is crucial to take into account the local situation and focus on critical areas / situations

32. How a WRD surveillance system should work in practice • Response • Trigger event: outbreak detection and confirmation • Acute reaction: outbreak declaration, quick and preliminary descriptive hazard investigation, initial and immediate control measures • Analysis: in-depth analytical hazard investigation, continuous re-evaluation of control measures • Normalization: conclusion of outbreak and declaration of normalization • End: evaluation, formal report, lessons learned for the future

33. National examples • The experience of Croatia, Germany, Hungary, Norway and Slovak Republic in the water qualitymonitoring and diseaseoutbreak detection

34. Policy guidelines The publication is available at http://www.unece.org/env/documents/2010/wat/MP_WH/wh/ece_mp_wh_2010_L2_E.pdf 22 pages, 2 figures