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Water, sanitation and hygiene for trachoma elimination

Watch this video to learn about the water, sanitation and hygiene (WASH) services needed to support trachoma elimination.
By the end of this presentation you should be able to: - Describe the water, sanitation and hygiene (WASH) services needed to support trachoma elimination. - Assess the requirements for water supply to practice hygiene. - Identify the key elements of the infrastructure needed to provide good quality sanitation. - Consider who is responsible for delivering WASH services. The F and E components of the SAFE strategy - facial cleanliness and environmental improvement - are thought by many to be crucial for the sustainability of trachoma elimination efforts. They address trachoma transmission at its core and contribute to the larger public health and development agenda. Trachoma programmes explicitly include all the components of the SAFE strategy and their delivery mechanisms.
It should not be assumed that implementers of S and A have the capacity to deliver F and E interventions, or that F and E components will be automatically delivered through existing water and sanitation programmes. Every national trachoma programme is expected to include sustainability at its heart. Improved access to water and sanitation infrastructure brings lasting benefits to communities through long-term use and the practice of good hygiene. Sustainability is about workable solutions based on community empowerment, indigenous knowledge and local capacity development. F and E interventions can be more effective, in terms of costs as well as outcomes, if they are delivered alongside - or at the same time as - other interventions.
For example, for neglected tropical diseases, WASH or other health related interventions. Working together across different sectors is essential to planning and delivering the full SAFE strategy.
Key considerations for water and sanitation programmes include: - Preventing open defecation - by encouraging toilet construction and changing norms especially in rural areas.
Ensuring a pathogen-free environment - this requires the construction of the entire sanitation “chain” including: pit or septic tank emptying, safe transportation, disposal / treatment of waste and protection of water sources from contamination.
Sanitation has to be improved beyond the household level - and also include community coverage - as schools, health care facilities, markets and places of worship. In healthcare settings, this must include water, sanitation and hygiene infrastructure, measures to prevent and control infection, and measures to control vectors.
Water supply has to be from safe, reliable, universally accessible and sustainable infrastructure to prevent use of contaminated water. To encourage hygiene and prevent trachoma transmission, people need access to a reliable water supply. Water supply infrastructure can be provided in various ways.
For example: - boreholes and wells, - rainwater harvesting, or - the supply can be brought using water trucks. There are many aspects of ‘upstream’ and ‘downstream’ water and sanitation which affect the control
of disease transmission: ‘Upstream’ aspects include water production and abstraction, water resource protection, river basin development, and water treatment, transport and distribution. Downstream’ aspects include wastewater and faecal sludge transport, treatment and safe disposal. Water containers, drainage channels and pit latrines/septic tanks should be constructed and maintained in a way that prevents access by animals and vector breeding. Animals, particularly livestock, are a crucial economic and cultural asset for many households and communities. Proximity to animals influences various disease transmission risks and practices should allow for safe separation of faeces from humans, animals and organisms that transmit disease.
Water supply for hygiene purposes should: - Be functional over time and measures should be put in place to sustain this. - Provide a consistent service. There must be sufficient water supply every day, all year. - Be close enough to households to provide enough water for hygiene, laundry, cleaning and consumption. - Be affordable and accessible to everyone. - And be safe. The water quality must be good and not expose people to risk of disease. Water supply options depend on factors like geology, climate, population density and the available financial and human resources. It can be relatively costly to provide water supply in trachoma endemic areas which are often hard to reach, have low population density and suffer from water scarcity.
The elements of a good quality sanitation infrastructure include: - Toilet design and construction that enables and encourages use by everyone, always. This includes small children, pregnant women, older people, and people with disabilities. - A toilet design that can be built using cement or any other local building materials - A clean toilet area and a covered pit. - Affordable options for managing faeces. In the case of low-cost pit latrines, this means knowing what to do and having the ability and means to deal with it when the pit fills up. - And ensuring that toilets or septic tanks do not contaminate the water supply.
Keep in mind that: - Poorly constructed toilets can actually increase faeces exposure. This in turn increases fly populations and puts users at risk of other diseases. - Increased ‘coverage’ of toilet provision is not enough to achieve better public health if not everyone is using the toilets, always. - People are less likely to use toilets that are unsafe or unpleasant. - Sanitation also includes disposing of household waste in covered pits, separate from latrines, and maintaining general cleanliness in living areas. - Cultural context may mean men and women require separate toilets. The government is ultimately responsible for providing water supply and sanitation. However, many governments in low income countries rely on donors, non-governmental organisations or private operators to support implementation.
At the household level, some sanitation approaches (such as community-led total sanitation) rely mainly on household self-funding and supply. However, they still need additional financing to pay for costs like management and transport of the faecal waste. Trachoma programmes can help ensure water and sanitation services are targeted to endemic areas. Successful F and E requires partners of all kinds from the WASH, health, education and corporate sectors. You can’t do it alone! Each partner can contribute to trachoma control in its own way, and it’s important to understand why they would want to collaborate.
F and E teams will need experts in: - Trachoma - with an understanding of the SAFE strategy. - WASH and an understanding of supply mechanisms. - The social context - including behaviours which will encourage acceptance and use. - Public health and epidemiology - this is to help with analysis. - National WASH planning and the local ministry guidelines. This is to make sure standards and process are adhered to. At the national level, when developing a Trachoma Action Plan, local WASH stakeholders should be identified and invited to trachoma task force meetings. Alternatively, a non-governmental agency may convene a joint meeting if that is likely to draw more participation.
Organisations or entities to consider include: United Nations agencies, international non-governmental organisations and donors, public health associations, academic institutions and representatives from the relevant ministries. F and E planning begins with a situation analysis. This is to assess what is already in place for WASH, how it is being used and sustained. However, you do not have to wait for water points to be installed to begin WASH activities. A lack of infrastructure doesn’t mean the programme cannot go forward. There are many ways to work with what the community is currently using for water.
In summary: - Building and strengthening WASH infrastucture is done through a planning process which involves a wide range of stakeholders. - The scope of works for planning to develop water supply infrastructure has to be based on a sufficient and consistent functionality, quality and quantity. Water supply must address local needs and be accessible to, and affordable by, all. - Sanitation must be designed to be relevant for the local context and culture. It must also be accessible to all and affordable to maintain and manage. - Local coordination is essential under the guidance of the national Trachoma Action Plan. There is no one size fits all approach to the successful implementation of F and E for trachoma elimination.

Achieving facial cleanliness and environmental improvement (F and E) within communities requires addressing deep-seated behaviours and practices which are rooted in social and cultural norms as well as improving access to water and sanitation infrastructure.

Unlike the surgery and antibiotic components of SAFE, F and E require strong partnerships with water and sanitation agencies and longer lead-times to allow behaviours and practices to change sustainably. These actions help sustain the results of the programme over time by reducing transmission and improving the way institutions function.

In this video we examine the water, sanitation and hygiene (WASH) services needed to deliver the F and E components of the SAFE strategy. WASH interventions have broad public health benefits that reduce multiple diseases and contribute to non-disease outcomes such as school attendance. Poor access to WASH contributes to a vicious cycle of poverty and disease and adds a substantial burden to already stretched health systems. Affected individuals and their families can be faced with catastrophic health costs, indebtedness and become less economically productive. For example, in 2003 the global economic cost of trachoma from lost productivity was estimated to be US$ 5.3 billion annually. Conversely, every dollar invested in water and sanitation is estimated to result in a return of over five dollars in health benefits (WHO, 2015). WASH activities require planning with multiple stakeholders. Transition activities can be planned at the national or district levels and embedded into the community, or even at school level. A toolkit can be used to guide this process.

As you watch the video consider who would you involve in planning for WASH activities in your setting, at national or district level?

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Eliminating Trachoma

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