What does your gut instinct tell you?

In this post truth era, where objective facts are misrepresented and made more appealing to emotions, and personal beliefs shape one’s opinion, I know I belong to the feeble voiced, when I am stressing on the importance of health education. I know the odds stacked against this task, but I will endeavour to raise it to the point where we could tip the scale and overcome this challenge.

In this final part of the Helminth-related series, let me try to bring in a sense of closure to this “Helminths and its infections” discussion. I will attempt to clear the fog in our minds and fight back the untruths and exaggerations about Helminths-related illnesses.

From the earlier blogs (Everything you need to know about Helminths – Well, almost everything,  Helminths-related infections and Open Defecation – It is obvious!) I believe that we have to come to understand the transmission dynamics of the Helminth worms and eggs in our environment, and the various kinds of infections (gut, skin etc.) that it causes. The burden, due to poor sanitation and open defecation, on children is manifested as soil or water transmitted infections. In order to prevent recurring illnesses and develop mitigation measures, serious discussion is pertinent about the need for a sound health education programme catering to all sections of society.

One of the key strategy for controlling Helminth-related infections is carrying out periodic deworming among pre-schoolers, toddlers and children. The WHO recommended that medicines such as albendazole (400 mg) and mebendazole (500 mg) are reported to be effective, inexpensive and easy to administer by non-medical personnel (Eg: teachers). These antihelminthic medications are administered by the National Ministries of Health in many countries, for treatment of all children in the school-going age group. Though, this regular treatment for high-risk groups (i.e. children) is based on epidemiological surveillance and will yield benefits in the long run, let us also keep in mind the potential threat of drug resistance. Anyway, there is an urgent need to develop a multi-disease fighting approach that goes beyond just deworming, and health educators must ensure that it works towards controlling Helminths transmission and preventing recurrent illnesses.

helm 2a
Source: http://www.istockphoto.com/in/vector/child-and-parasite-gm672465844-123289505

Proper guidance on safe and hygienic handling of human faeces, wearing shoes in areas that have been designated for defecation and also while accessing public/community toilets, personal hygiene and sanitation behaviours, especially whilst using community swimming pools, safe sanitation practices including hand washing with soap, consumption of boiled water and properly cooked food etc. are some of the measures that would be effective in controlling Helminths transmission.

Long-term solutions like improving the quality of water supply, promoting safe sanitation and sustainable hygiene strategies and practices are key to the elimination of helminth infections. It is important to remember that children can be treated for helminths, but unless their living environments are secured from infection, there is a high chance of them being infected again and again. Improvements to WASH resulting in better quality of life, complemented by appropriate health education, is essential for achieving sustained control of helminths in the medium and long term.

Positive correlation between sound health education and supportive healthcare resulting in improved quality of life is evident. But to get this message through and make it a reality is indeed a difficult challenge. So are you up for the challenge or do you need more convincing? What does your gut feeling tell you? !!

For further reference

  1. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3125032/ (accessed on Sep 7, 2017)
  2. http://www.who.int/mediacentre/factsheets/fs366/en/ (accessed on Sep 7, 2017)
  3. http://www.sciencedirect.com/science/article/pii/S0001706X10001828 (accessed on Sep 7, 2017)
  4. https://www.ncbi.nlm.nih.gov/pubmed/12592987 (accessed on Sep 8, 2017)
  5. https://www.ncbi.nlm.nih.gov/pubmed/15081942 (accessed on Sep 8, 2017)

Suneethi

 

 

 

Suneethi Sundar
Specialist, TNUSSP

Advertisements

Helminths-related infections and Open Defecation – It is obvious!

When somebody says something really obvious, we usually tend to ignore it and not pay enough attention. Why is it we don’t feel the need to know about things that might one day prove to be valuable to us and others? I was in the park the other day, sitting on a bench trying to read my book. That is when I heard this very interesting conversation between two friends:

He says: I thought I should tell you this. I think it is important.

She says: Ummm ok. Is everything alright?

He says: Yes. You remember my little niece who fell ill recently. She was so sick that we were all really scared of losing her.

She says:  Yes, I remember. Isn’t she the one who eats mud?

He says: Hey! She is only 3 years old. And yeah, she eats mud. So did all of us at her age. My grandmother even thinks it is due to some deficiency and she will outgrow it, as she grows older.

Muds
Image Source: https://www.scientificamerican.com/article/would-you-like-side-dirt-eating-soil/ (accessed on Aug 17, 2017)

At this point, I am intrigued and embarrassed. Embarrassed because as a child I also used to eat mud.  Intrigued because I want to know more.

He says:   The funny thing is that her geophagia- the practice of eating soil intentionally was the reason for her getting so sick. (Geophagia – that thing even has a scientific name?) The soil that she had consumed was infested with these ‘worm eggs’ that had made her fall so sick with severe diarrhoea.

She says:  No kidding. Are you talking about ‘Helminth eggs’? Everything you need to know about Helminths – Well, almost everything

He says: Oh! So you know about Helminth eggs?

She says: Of course. Helminths are worms that are widely present in areas, which are known for poor sanitary conditions and where open defecation is widely practised. The larvae of these worms, when consumed cause a variety of infections in people. But, where did your niece find soil that was contaminated with Helminth eggs?  Is there any open defecation spot near her school?

He says: Oh my God!  The school uses an open ground nearby as a makeshift playground. A part of that ground is also being used by the local communities as an open defecation spot.  You know what? When I went to pick her up from school the other day, her class teacher told me that there were atleast a dozen other children with gastro-intestinal infections.

The two friends did not realise that they now had a keen listener. I recalled the numerous occasions when I had been taken to the doctor as a child because of tummy and intestinal infections. The two friends continued their discussion on sanitation and hygiene practices of pre-schoolers.

She says: I recently read a report by Water Research Commission, which stated that, pre-schoolers are at a greater risk for getting exposed to these ‘Helminths infections’. They are infected by not just ingesting soil, but also because of inadequate hand washing, consumption of fruits and vegetables that are not properly cleaned, and consumption of food and drink on which flies sit.

He says: Is that all or is there something else you are going to frighten me with?

She says: Oh, there is a lot more. For instance, one type of Helminths – hookworm, are transmitted when the skin is in direct contact with the contaminated soil, like walking barefoot.

He says: That means I should take care to see that my niece doesn’t go out to play barefoot. But is there any other way that children get infected?

She says:  Children can catch infections from other children and adults who are already infected. The Helminth eggs live under fingernails and can be easily passed on from one person to another. Extra care has to be taken with kids frequently using public swimming pools.

He says: How do I know if a child or adult is infected? Are there any signs of Helminths-related infection?

She says: For hookworm, itching and localised rash are the initial signs, since the Helminths larva penetrate the skin.  More severe infections can cause a sore tummy, abdominal pain, diarrhoea, loss of appetite, weight loss, fatigue and anaemia. On the other hand, roundworm and whipworm display no initial signs of infection, since they get into the body through dirt, soil, food and water.  Severe roundworm infections can cause intestinal blockage and even growth impairment, which affects cognitive development in children.

He says: This is really frightening. How does one protect children from Helminths-related infections? Is it enough to give deworming medications and iron supplements?

She says: Deworming medications and iron supplements, though essential are not enough. For a long term solution, education on proper hygiene and inculcating safe sanitation practices is very important. Children should be taught to avoid food that is not carefully cooked. Fruits and vegetables should be washed thoroughly and one should make a practice of drinking boiled water. But more than everything else, I cannot emphasise enough on the importance of washing hands before handling food.

He says: I think that the importance of adequate sanitation and hygiene should be taught at school and home.

She says: I know. Besides children, parents and caretakers should be made aware of the fact that Helminths-based infections are a major source of concern. So, the next time when you play with your niece in the open grounds, you’ll know what to watch out for.

He says: Yes ofcourse. Thanks for all this information.

Soon after, the two friends bid goodbye. After being a silent (and secret) witness to this entire conversation on Helminths-related infection and its connection to open defecation, I was dumbstruck. How is it possible that something is so obvious and we are still not aware of it?  I was left wondering, how many ‘It’s so obvious’ life lessons that I could have have missed so far. Probably more than I can imagine. 
And then came the obvious question, how do we make our soil and water safe from Helminth eggs.  I decided to do some research on the subject. And what I found out was some amazing information. But more of that in the concluding part of this series on Helminths.

For further reference:

  1. WRC (2014). Investigating the practice of open defecation post sanitation provision and the practice and implications of ingesting soil which may be contaminated – Review of literature and anecdotal accounts (draft). Partners in Development, Bashomi Consulting and Projects, Amanz’abantu for Water Research Commission project K5/2379, Pretoria, South Africa
  2. Clasen, T. et al. (2015). Assessing the effectiveness of improved sanitation on diarrhoea and Helminth infection: A cluster-randomized, controlled field trial in Orissa, India – Various documents on results from research grant. London School of Hygiene and Tropical Medicine
  3. Guidelines for deworming of young children, NRHM, Assam (http://www.nrhmassam.in/pdf/guidelines_for_de-worming.pdf) accessed on July 15, 2017.

Suneethi

 

 

Suneethi Sundar
Specialist, TNUSSP

Everything you need to know about Helminths – Well, almost everything

It had been such a warm day in Chennai and like everyone else I was also looking at the clear skies wondering how much hotter it could get. As I was thirsty and hungry, I went to a nearby street vendor selling some fruits which he had cut and laid out on display. Just as I was making my decision on what to buy, I overheard a conversation from other buyers who were talking about some kind of ‘worms’ that causes serious ‘illness’ in people. Being the curious type, I went ahead and joined in the conversation, while I continued to gulp down the pieces of mangoes which the vendor had wrapped in the previous day’s newspaper.

Here is the gist of the conversation from the alleged ‘worm expert’.

It turns out the worms the person was talking about are called Helminths. So what are Helminths? And how do they make people fall ill? Well, Helminths are basically worms that are widely present in areas which plagued by poor sanitation and where open defecation is widely practised. The Helminth worms are usually tape worm (Taenia solium), hook worm (Anclostoma duodenale and Necator americanus), round worm (Ascaris lumbricoides), whip worm (Trichuris trichiura) etc., I realised that the Helminths eggs and larvae are the agents that cause infection, and are usually discharged into the environment via faeces. The ‘Worm expert’ told me that the viable eggs will be infective when it develops as a larva and gets attached to a suitable host such as humans.

But, “Why is it important to know about Helminths?” I wanted to know. “Because it causes various kinds of illnesses in human beings,” he said, adding that these illnesses are commonly known as Helminthiases. Helminths are transmitted mainly through water and soil through the oral – faecal transmission pathway (popularly referred as the F-diagram). “Synergy between WASH and nutrition” – It’s complicated The worms are widely present in faeces, sewage, sludge and fecal sludge and crops. Consuming infected water or food, physical contact when handling infected soil and water, or even walking barefoot on contaminated soil, can lead to one getting infected. Wow! who would have thought of that, right?

Screen Shot 2556-06-23 at 1.43.49 AM (2)
Relative sizes of Helminth eggs.                                                                             Source: http://ogimed.blogspot.in/2013/06/relative-sizes-of-helminth-eggs.html (dated Aug 4, 2017)

The worm expert told me, that worms come in sizes varying from 1 mm to several metres in length. The eggs range from 20 to 80 microns’ size, which means they cannot be seen by the naked eye. Interestingly, the eggs are also sticky in nature, and can stick to vessels, furniture, cash, food, water, door handles, stair cases rails, fingers and nails etc., thereby escalating the risk of infection without people even realising it.

The situation is so alarming that the World Health Organisation in 2015 called Helminthiases a major health concern. Helminths infections in human beings affect the nutritional status by causing poor absorption of nutrients, loss of appetite, bowel obstruction and increased blood loss. Long term and heavy infections can cause abdominal pain, diarrhoea, blood and protein loss, and slow down the physical and cognitive growth. Heavy infections with whipworm and roundworm can even impair growth in children. Hookworm infections are a major cause of anaemia in pregnant women and children.

Wow, not only had I learnt something about these ‘dangerous worms’ that makes people sick, but thanks to my newly established camaraderie with the ‘Worm expert’, I went on to ask him more questions:  How do we ensure that Helminths are eliminated from our surroundings? There are various ways, he said. But the most important one is to make sure that all those materials which consists of Helminths are treated before being released into the environment. In that way, we can minimise the risk of infection, if not completely eliminate it.

I realised that we have reached the end of our intense conversation. But there was one more question to which I needed an answer. How do we reduce the incidence of Helminths -related infections in our day-to-day activities, I wanted to know? “Well, the obvious yet often overlooked practice of hand washing, is one of the most effective ways to beat the infection cycle. In addition to that, thorough washing of vegetables and fruits before consumption should be compulsorily followed,” the worm-expert said. I thought of the delicious mangoes that I had just gulped down. I had not bothered to find out if the fruit had been washed properly, and how long ago it had been cut.

I thanked the worm-expert profusely for answering all my questions and bade him goodbye. As I left, he said: “Don’t underestimate the power of what you can’t see or smell.” I was strangely intrigued. So I decided to find out more. And what I found out included a wealth of information on the universe of microbial pathogens and their implication on public health, and how the very act of defecating in the open can lead to Helminth infection and what can be done to keep ourselves safe.
But more of that in the next part, where we will talk about Helminths infection and its very obvious relationship to open defecation.

For further reference

https://www.unicef.org/media/files/IntegratingWASHandNut_WHO_UNICEF_USAID_Nov2015.pdf (accessed on April 24, 2017)

http://atm.eisai.co.jp/english/ntd/helminthiasis.html (accessed on April 25, 2017)

B.E. Jimenez-Cisneros and C. Maya-Rendon (2007) “Helminths and Sanitation”, Communicating Current Research and Educational Topics and Trends in Applied Microbiology

Suneethi

 

 

 

Suneethi Sundar
Specialist, TNUSSP

A loo that is usable too!

In the winter of 1999, when I was a post graduate student of social work in Mumbai, we were taken to a remote village in Banaskantha District, Gujarat. The objective of this visit was to understand the rural way of life, their customs and practices, the formal and informal institutions at work and so on. As young 20 somethings, we all were very excited about the trip but for one aspect. There were no toilets!! We were all told that we would have to use the open fields just like all the other women in the village did. At some point or the other in our growing up years, we would have definitely relieved ourselves in public; either while travelling by bus, or while visiting our native village or sometimes even within the city while going from point A to point B where public conveniences were either absent or open defecation (OD) was better than using these toilets.

Pics for blog
Photo Courtesy: Nitin Kumar Gupta/NavShrishti NGO

However, in our early twenties, defecating in the open seemed quite an uncomfortable task to do especially when you had to choose between early morning or late night. During the course of those ten days, while some of us got adjusted to the open toilets, few others had severe gastrointestinal problems on our return back to Mumbai. Of course there were a fair share of humorous incidents such as the one where after an “evening visit” to the anointed spot, as we were collecting the “lotas” to leave, we suddenly saw a huge black thing move right next to us. To our utter alarm, we realized we had been blissfully unaware of the camel sitting right next to us while we defecated under the star-lit sky!

Our experience with inadequate toilets didn’t quite end in the village. As we waited in Ahmedabad for our train to Mumbai, we were forced to use the toilets in a movie hall which repulsed us to the core.   Badly maintained, with no running water, poor electricity and broken doors, it made us want to run back to the open fields in the villages. When I look back at this episode in light of the recent attention to sanitation and OD, I am able to relate to all the reasons people gave for not cultivating the toilet-using habit. Despite having built toilets, poor maintenance, lack of water and hygiene were the main reasons which made several women in the villages to prefer open fields to toilets, risking their safety, privacy and convenience.

So, why is that though there are several schemes and programmes for toilet construction, OD is still a major concern in India? The answer, I believe, lies in the usability of the toilets constructed. By usability, I don’t mean only the cleanliness and maintenance of the facility. Usability comprises of several other factors: availability of the toilet, followed by the distance to the facility, accessibility i.e is there sufficient lighting, are there ramps for the disabled and senior citizens, are the toilet pans appropriate for different age groups such as children? Is there privacy and safety for adolescent girls, and so on. The sanitation infrastructure in India lacks the human life-cycle thinking. The recognition that different people have different sanitation requirements at different stages in their life which affects the way they use toilets is neglected in toilet design and construction. Although a handful of organisations working at the grassroots have incorporated some aspects of this life-cycle thinking by making smaller pans for children, open dwarf-walled cubicles where children can see their mothers or defecate under the mothers’ supervision and so on, these modifications in design are exceptions and not the norm.

With rampant construction of toilets under the SBM and attention to behavior change where people are encouraged to use toilets, it might be worthwhile to conduct rapid assessments of the different needs of toilet users in order to reorient the current toilet designs. With several players getting involved in sanitation construction and campaigns targeting behavior change, we need to mainstream studies on usability to bring about a shift in the guidelines on toilet specifications. For our multi-crore schemes to be effective and reach the target audience, it is time to pause and pay attention to the needs of the end user. Achieving universal access to sanitation is a good thing, but let us ensure people can use it too.

Harini Pic for website

Sriharini Narayanan
Senior Specialist, TNUSSP

Is your child’s shit affecting your health?

It was September 2008. It took me almost two-and-a-half hours to reach G-plot, one of the remotest islands among the deltoid labyrinth of Sundarbans. My colleague – a native to G-plot was waiting to receive me at the jetty. We got on a van fitted with a motorcycle engine, popularly known as Vano in this part of the world. Assaulting our eardrums with more than 85 decibels and leaving behind a deep dark trail of fume, the Vano set out for Satyadaspur, one of our intervention villages in G-plot.  Reaching the destination, we immediately jumped into action and rushed to meet the beneficiaries who had built their household toilets under the Total Sanitation Campaign Programme.

We reached a house located near the centre of the village. Stepping into the yard, I noticed a small child defecating on the other side of the premises near a bush. We knocked on the door and a lady in her mid-twenties came out. My colleague introduced me and told her the purpose of our visit. The lady welcomed us indoors, offered us a glass of water with sugar candy and started answering my questions. I was curious to know whether all members of her family were using the toilet. She answered in the affirmative. I pointed to the toddler and asked if he was using the toilet. With a chuckle she replied that the toddler could not sit on toilet. There was a danger of his falling down and injuring himself. The lady then took a mug of water and got busy cleaning the child. Once she had finished washing the child, she wiped her hand with her saree and continued talking to us. The shit was lying unattended.

“Don’t you use soap after going to the toilet?” I could not resist asking. “Of course we do. In fact, after using the toilet the women bathe in the village pond and only then get into the kitchen.”  Seeing me staring at the child who had just finished defecating in the open, she said. “Öh, him? He is not even three, his stool is not harmful at all.”

June 2014 – Odisha: While entering a large slum called Bapuji Nagar Railway Basti right in the heart of Bhubaneswar, a familiar sight of a small child defecating on a newspaper caught my eye. After some time, an aged woman, probably the child’s grandmother picked up the shit, wrapped it in the newspaper and threw it on the nearby railway tracks.

Unlike in the earlier case, none of the families in Bapuji Nagar Railway Basti had their own toilets. Adults used the railway track in the wee hours of the morning or late at night. Since it was not safe for children to use the tracks, an alternative arrangement was made using the toilet.

February 2017 – Tamil Nadu: We arrived at a small town to do an assessment of a community toilet. The toilet block was full of faeces indicating a high prevalence of open defecation.  A little probing showed that while adults from the neighbouring slums were using the community toilet, children were using the toilet premises itself.

These three instances from different parts of the country indicate a widespread perception about children’s faeces not being harmful.  According to the NFHS 3 (2005-2006) data, stools of around 79 percent children in India are disposed of unsafely. Two subsequent studies in rural Odisha and West Bengal show that the prevalence is around 81 percent (Majorin et al, 2014) and 72 percent (Preeti PS et al, 2016), respectively.  The commonly held belief that faeces of infants and young children is not harmful is untrue. There is evidence that children’s faeces could be more harmful than that of adults due to higher prevalence of diarrhoea, Hepatitis A, Rotavirus and E Coli in children (Feachem R G et al, 1983).

Often impact of poor sanitation and hygiene is measured by the effect it has on children, either in terms of infant mortality or morbidity due to diarrhoeal diseases, loss of intellectual capacity due to stunting or worm infestation. However, most sanitation and hygiene interventions target adults. According to JMP[1] 2015,  globally 68% population have access to improved toilets[2].  These estimates are based on the households’ primary sanitation facility and may have overlooked the disposal practices of faeces of young children. In many cases children might have access to improved toilets, but are not able to use it because of their age, stage of their physical development or just because of safety concerns of their caregiver.

In 2015, the Water and Sanitation Programme of World Bank released a research brief on management of child faeces. In this paper, the methods of disposal of children’s faeces from 26 locations across Africa, East Asia and Pacific, Latin America and South Asia were presented (see charts).  The key findings from the research showed that faeces of children under the age of three was less likely to be safely disposed of than that of the adult population, across the three study sites.  Not surprisingly, there was a higher rate of unsafe disposal of child faeces in populations practicing open defecation. Households with access to improved toilets have also reported exhibiting unsafe disposal traits when it comes to child faeces. This clearly shows that the belief that child faeces is less harmful is equally prevalent in many parts of the globe.

Chart

Poor management of child faeces can result in substantial health impacts on children, including a higher prevalence of diarrheal disease, intestinal worms, enteropathy, malnutrition, and death. A series of empirical studies across different countries (Baltazar J. C., et al, 1989; Curtis, Valerie, et al. 2011, Aulia, H. et al, 1994; Mihrete, T.,2014; Bawankule R, 2017) have proved the strong association between unsafe disposal of child’s faeces and clinically diagnosed diarrhoea among young children.  Based on the findings of several studies, The Child Health Epidemiology Reference Group (CHERG) has concluded that safe stool disposal has protection effect.

Despite such empirical evidence, sanitation for children has been a neglected area of research, policy and programme. There are significant knowledge gaps in this domain, and it is evident that we are trying to estimate the magnitude of the problem by referring to pretty outdated data. Nevertheless, to reach the proposed Sustainable Development Goal of universal coverage or end of Open Defecation by 2030, we must ensure that children’s faeces is disposed of safely. The World Bank report is undoubtedly indicating that India is far behind its neighbouring countries like Pakistan, Afghanistan and many countries from Africa, East Asia and Pacific in terms of safe disposal.

However, we are already witnessing an increased international acknowledgement of the importance of monitoring the practice. The Joint Monitoring Programme on Sanitation has recommended that the “percentage of children under five whose stools are hygienically disposed of” as a sub-indicator under the eliminating open defecation target.  Our own Swachh Bharat Mission also has laid “effective disposal of child faeces” as an essential indicator for obtaining an Open Defecation Free certificate.

References:

  1. International Institute for Population Sciences. National Family Health Survey (NFHS-3), 2005-06: India; 2007. Available from: http://dhsprogram.com/pubs/pdf/FRIND3/ FRIND3-Vol1andVol2.pdf.
  2. Ministry of Urban Development (India). Guidelines for Swachh Bharat Mission (Gramin); 2014 [cited 2016 Sep 26]. Available from: http://phed.bih.nic.in/Docs/Guidelines-Swachh-BharatAbhiyan.pdf.
  3. Majorin, F., Freeman, M. C., Barnard, S., Routry, P., Boisson, S., & Clasen, T. (2014). Child Feces Disposal Practices in Rural Orissa: A Cross Sectional Study. PLOS One, 9(2). doi:10.1371/journal.pone.0089551
  4. Unsafe Disposal of Child Faeces: A Community-based Study in a Rural Block in West Bengal, India. (2016, September 8). Journal of Preventive Medicine and Public Health, 323-328. doi:https://doi.org/10.3961/jpmph.16.020
  5. Feachem, R. G., Bardley, D. J., Garelick, H., & Mara, D. D. (1983). Sanitation and Disease Health Aspects of Excreta and Wastewater Management. John Wiley & Sons.
  6. Baltazar J. C., and F. S. Solon. 1989. “Disposal of Faeces of Children under Two Years Old and Diarrhoea Incidence: A Case-Control Study.” International Journal of Epidemiology 18(4 Suppl 2):S16–S19
  7. Curtis, Valerie, et al. 2011. “Hygiene: New Hopes, New Horizons.” The Lancet Infectious Diseases 11(4):312–321; Curtis, Valerie, et al. 1995. “Potties, Pits and Pipes: Explaining Hygiene Behaviour in Burkina Faso.” Social Science & Medicine 41(3):383–393
  8. Aulia, H., S. C. Surapaty, E. Bahar, et al. 1994. “Personal and Domestic Hygiene and Its Relationship to the Incidence of Diarrhea in South Sumatera.” Journal of Diarrheal Diseases Research 12(1):42–48.
  9. Mihrete, T., G. Alemie, and A. Teferra. 2014. “Determinants of Childhood Diarrhea among Underfive Children in Benishangul Gumuz Regional State, North West Ethiopia.” BMC Pediatrics 14:102. http://www.biomedcentral.com/1471-2431/14/102
  10. Bawankule, R., Singh, A., Kumar, K., & Pedgaonkar, S. (2017). Disposal of children’s stools and its association with childhood diarrhea in India. Biomed Central Public Health, 3. doi: 10.1186/s12889-016-3948-2
  11. UNICEF and WHO, WASH Targets and Indicators Post-2015: Recommendations from International Consultations. Comprehensive Recommendations – Updated April 2014. 2014. 5
  12. Government of India MoUD. Swachh Bharat Mission; 2015. Available at http://www.swachhbharaturban.in/sbm/home/#/SBM. Accessed 21 May 2015.

_MG_9729

Niladri Chakraborti
Senior Specialist, TNUSSP

[1] Joint Monitoring Program by WHO/UNICF

[2] The JMP standardized definition for an improved sanitation facility is one that hygienically separates human excreta from human contact.