3.5 Risk management
Learning objective: To be aware of how sanitation
systems can be evaluated and compared regarding
their potential health impact. To be familiar with the
different parts of Quantitative Microbial Risk
Analysis (QMRA).
Risk management – policy development
Theory,
basic research
Research
Policy
Guidleines
Dissemination
Communication
Education
Local experiences
Implementation
”in practice”
Treatment as a health protection measure



The most important barrier to manage risks?
Handling (contact) of excreta should be
minimized, but necessary to some extent
What is practically, socially and culturally
acceptable?



Adapted to local conditions, education and information,
sustainability
Treatment recommendations important part of the
guidelines
Will develop, on-going research
Risk reduction strategies
WHO’s multiple barrier approach from “Farm to Fork”
Wastewater
generation
Wastewater
treatment
Farmer/
Consumer
Producer
Safe
Safe
irrigation
produce
practices
Traders/
Retailers
Hygienic
handling
practices
Street food
kitchens
Safe food
washing and
preparation
Policy recognition, safer farm land, tenure security,
market incentives, safe-food labelling,…
Consumer
Awareness
…
creation
to create
demand for
safe produce
Examples of how to design regulations

Treatment

define processes,

different levels (categories)

Validation of the treatment process

Microbiological/hygienic quality

presence of microorganisms,

reduction of microorganisms

Restrictions on usage

Fertilising (irrigation) methods

Handling of the product (e.g. transport, storage)

Protection of workers

Sampling

Analytical methods
Comparison of sanitation systems

Diverted




Small volumes
Easier to treat
Suitable fertiliser
products
Handling requires
restrictions

Mixed (conventional)




Large volumes of
”hazardous” waste
Extensive treatment
Reuse products:
wastewater, sludge
Downstream
pollution
Assessment of health risks

Microbial analysis


Epidemiological studies


Indicators not always reliable
Scarce, complex
Microbial risk assessment

The main approach (?)
Microbial Risk Analysis

Risk Assessment




Risk Management



Qualitative or quantitative
Systematic procedure
Acceptable risks
To handle the risks
Aims at reducing risks
Risk Communication



Essential part in all systems
Necessary for awareness raising and health
protection
Involve ”all” stakeholders
Quantitative Microbial Risk Assessment (QMRA)

Hazard Identification


Exposure assessment




Exposure points, site-specific data on removal
Literature data on occurrence of pathogens, removal in
treatment and survival in environment
Exposure scenarios evaluated (ingestion, volumes)
Dose-response assessment


All enteric pathogens potentially in excreta
Published mathematical models
Risk characterisation


Risk of infection per exposure and yearly, DALYs
Comparison with endemic level of disease (underreporting)
Microbial risk assessment – urine (outline)

Faecal contamination


What amounts of pathogens would the faecal
contamination contribute?



IF they end up in the urine – will they survive storage?
Survival studies performed and literature data used for crop
How can people be exposed to the urine?


Incidence in the population (statistical data)
Faeces could contribute enteric pathogens to the urine


Faecal sterols analysed
Scenarios determined
What dose could they be exposed to?

Amounts ingested estimated
(Höglund et al., 2002)
Microbial risk assessment – urine (outline)


Input: faecal contamination, prevalence of infection,
excretion densities, excretion days, inactivation rates
Scenarios:
Exposure
Risk
Cleaning of blocked pipes
Ingestion of
pathogens
Accidental ingestion when
handling unstored urine
Ingestion of
pathogens
Accidental ingestion when
handling stored urine
Ingestion of
pathogens
Inhalation of aerosols
Inhalation of
created when applying urine pathogens
Consumption of crops
fertilised with urine


Dose-response models
Output: probability of infection
Ingestion of
pathogens
(Höglund et al., 2002)
Risk from accidental ingestion of 1 ml unstored urine
0
-1
epidemic
sporadic 4°C
sporadic 20°C
log10 Pinf
-2
-3
-4
-5
-6
C. jejuni
C. parvum
Rotavirus
• Unstored urine Pinf < 1:1000 except for rotavirus
• Storage for six months at 20°C all risks < 1:1000
(Höglund et al., 2002)
Risk from accidental ingestion of 100 g crop
-1
Campylobacter
Cryptosporidium
Rotavirus
-2
-3
-4
log10 Pinf
-5
-6
-7
-8
-9
-10
-11
-12
-13
-14
<10-15
-15
1 week
2 weeks
3 weeks
4 weeks
Time between crop fertilising and consumption
• Inactivation will continue in the field
• Risk dependent on time between fertilising and
consumption
(Höglund et al., 2002)
Microbial risk assessment - faeces




Faeces from dry urine diverting latrines in Denmark
No additives
Treatment by storage
Hazard identification








Bacteria: Salmonella, EHEC
Viruses: rotavirus, hepatitis A
Protozoa: Giardia, Cryptosporidium
Helminth: Ascaris
Compiled studies (literature) for pathogen survival
Incidence (surveillance), excretion numbers and
times (duration) also input for calculation of doses
Model organisms – dose-response relation
Exposure when handling and using in garden
(Schönning et al., 2004)
Exposure scenarios






The faeces-soil intake (Larsen,1998) - children around
200 mg of soil (max of 5-10 g).
Assumed that adults ingest 15-50% of this amount, with a
maximum of 100 mg.
The container emptied once a year assuming only adults
exposed.
The number of exposures through recreation was a
median value of 3.5 times per week (during June-August).
50% of the households were exposed through gardening
once a week (during May-September).
It was assumed that one exposure corresponded to two
hours of gardening occurring a maximum two times per
day.
(Schönning et al., 2004)
Conclusions - pathogens

There is an “unacceptably” high (>1:10 000) risk of
infection when faeces is used without treatment


12 months storage – sufficient reduction of most
pathogens (compared to a risk level 1:10 000)



The highest risk from exposure to unstored material was
attributable to rotavirus
The highest risk from exposure to stored faeces was
attributable to Ascaris
the protozoa Giardia and Cryptosporidium are of greater
concern in the European population
The risks of infection can be reduced by simple measures
such as longer storage, or treatment with a pH elevating
compound
(Schönning et al., 2004)
Risk for infection when emptying container
Salmonella
Ascaris
Examples of how risk for infection are presented as probability density
functions. The typical risk equals the 50th-percentile and worst case
equals the 95th-percentile.
(Schönning et al., 2004)
Microbial risk assessment – wastewater
and sludge

Hässleholm municipality with 28 600 residents

12 500 m3 wastewater per day

Wastewater treatment: pre-aeration, presedimentation, activated sludge, chemical
precipitation, three-media filter

Sludge treatment: anaerobic digestion, dewatering,
outdoor storage

Sludge use: Application to vegetables (theoretical)
(Westrell et al., 2004)
Microbial risk assessment – wastewater
and sludge

Hazard Identification



Exposure assessment




Exposure points identified together with WWTP staff
Site-specific data on removal of indicators in WWT
Literature data on occurrence of pathogens in ww, removal in
sludge treatment and survival in environment
Dose-response assessment


All entero-pathogens potentially in wastewater
Enterohaemmorhagic E.coli (EHEC), Salmonella, Giardia,
Cryptosporidium, rotavirus and adenovirus
Published dose-response models
Risk characterisation




Monte Carlo simulations
Risk of infection per exposure
Yearly number of infections in study population
Comparison with endemic level of disease (epidemiological
statistics adjusted for underreporting and morbidity rates)
(Westrell et al., 2004)
3, 4
2
1
5
Exposure scenarios – wastewater treatment
8
6
7
(Westrell et al., 2004)
Exposure scenarios – wastewater treatment
Volume ingested
(mL or g)
Frequency
(times*year-1)
Number of
persons
affected
1. WWTP worker at pre-aeration
1
52
2
2. WWTP worker at belt press
5
208
1
3. (Un)intentional immersion at
wetland inlet
30
1
2
4. Child playing at wetland inlet
1
2
30
5. Recreational swimming
50
10
300
6. Child playing at sludge storage
5
1
2
7. Contractor spreading sludge
2
30
2
8. Consumption of raw vegetables
1
2
500
Type of exposure
(Westrell et al., 2004)
Risk of infection per exposure
All risks >10-4 are shown in orange
Exposure
EHEC
Salmonella
Giardia
Cryptosporidium
Rotavirus
Adenovirus
1
6x10-4
3x10-5
1x10-3
2x10-4
9x10-2
2x10-1
2
2x10-3
1x10-4
4x10-3
9x10-4
1
1
3
3x10-5
2x10-6
3x10-4
3x10-5
5x10-2
1x10-1
4
1x10-6
6x10-8
1x10-5
1x10-6
2x10-3
4x10-3
5
9x10-10
5x10-11
2x10-7
5x10-8
1x10-5
6x10-5
6
1x10-2
6x10-4
2x10-2
6x10-3
4x10-1
9x10-1
7
5x10-3
3x10-4
1x10-2
2x10-3
3x10-1
1
8
2x10-6
9x10-8
2x10-6
9x10-6
2x10-4
4x10-4
(Westrell et al., 2004)
Number of yearly infections
Exposure
EHEC
Salmonella
Giardia
Cryptosporidium
1
2
0.57
(0.05-0.99)
Rotavirus
Adenovirus
1.98
(1.69-2.00)
1.99
(1.30-2.00)
1.00
(0.99-1.00)
1.00
(0.97-1.00)
3
0.21
(0.02-1.87)
4
0.23
(0.02-5.21)
5
0.18
(0.01-4.26)
6
7
8
0.52
(0.04-1.75)
0.13
(0.006-1.25)
0.76
(0.23-1.28)
1.87
(0.22-2.00)
2.00
(1.64-2.00)
2.00
(1.49-2.00)
0.41
(0.01-20.51)
0 is equivalent to <0.0001 infections
(Westrell et al., 2004)
Severity of hazards
(Westrell et al., 2004)
Classification of exposures
(Westrell et al., 2004)
Exposure
1
EHEC
Salmonella
Giardia
Crypto.
Rotavirus
Median
95-percentile
2
3
4
5
6
7
8
Catastrophic
Major
Moderate
Minor
Insignificant
Adenovirus
Control measures

Exposure 1


Easy to control with
Personal Protective
Equipment (PPE)
Covering of basins

Exposure 2


Easy to control with PPE
Optimisation of sludge treatment
(baffles against short-circuiting,
thermophilic digestion etc.)
(Westrell et al., 2004)
Control measures

Exposure 6



Fence storage area
Optimisation of sludge
treatment
Exposure 8





Crop restrictions
Minimum time between
fertilisation and harvest
Optimisation of sludge
treatment
Prolonged sludge storage
Exposure 7



Use of PPE
Optimisation of sludge
treatment
Prolonged sludge storage
(Westrell et al., 2004)
Worst-case situation 2002
Acknowledgements



(Westrell et al., 2004)
Per-Åke Nilsson and staff at Hässleholm wastewater treatment
plant
Swedish research council FORMAS
MISTRA Urban Water program
Epidemiological study - El Salvador
107 households, 449 people
 Prevalence of parasitic infections
 Type of latrines

UD solar desiccating latrine (single vault)
 UD double-vault desiccating latrine (LASF)
 Pit latrines
 No latrines


UD = urine diverting
(Corrales et al., 2006)
Prevalence of parasitic infections

Use of UD-latrines (both solar
and LASF) – lower
prevalence of the less
environmentally persistent
pathogens (hookworm,
Giardia, Entamoeba)

Use of LASF – higher
prevalence of more
environmentally
persistent pathogens
(Ascaris, Trichuris)
(Corrales et al., 2006)
Summarised results

LASF (this design) does not achieve
conditions needed to inactivate these
organisms
UD solar latrines – lower prevalence of
most parasites compared with LASF and
pit-latrine
 Use of ”biosolids” (faecal matter) in
agriculture – higher prevalence of
infections compared to burying the material

(Corrales et al., 2006)
Conclusions

In El Salvador, the solar latrine is recommended



High prevalence of some infections in diverting
latrines identifes the need for




Includes urine diversion
Better results than pit latrine
Further work on better designs
Better use and maintenance, information
Further evaluation under different local environments
and cultures
Limitations of the study


Different communities compared
Small sample size
Epidemiological study South Africa

Peri-urban area, eThekwini
Municipality, Durban


Intervention




1337 households incl. in study
Sanitation – dry UD-toilets
Safe water (200 L per day)
Health and hygiene education
Purpose and method



Measure reduction in
diarrhoea associated with the
interventions
Prospective cohort study
Disease incidence
questionnaire (6 visits)
Picture provided by Teddy Gounden
(Knight et al., manuscript)
Type of Sanitation Intervention in Sample Area
10
2
Exposed Area
(N=660)
88
Pit/VIP
No sanitation
UD
14
7
Unexposed Area
(N=667)
79
Pit/VIP
No sanitation
Flush
Provided by Renuka Lutchminarayan
Epidemiological study South Africa - Results

41% reduction in diarrhoea




Benefits 3 times greater for
children <5 years
Fewer acute water related
health outcomes
Duration of diarrhoea
episodes decreased (54%
fewer days reported)
Not possible to
disaggregate the effect of
each separate
intervention
Picture provided by Teddy Gounden
(Knight et al., manuscript)
Incidence Rate per 1000 person dayss
4.00
3.50
3.00
Incidence Rate & Incidence Rate Ratio of
Diarrhoea Episodes by Gender & Total
IRR:
IRR:
IRR:
0.50
0.65
0.58
2.50
2.00
1.50
1.00
0.50
0.00
Female
Male
Total
Gender
36
Non-exp
Exp
(Knight SE, Esterhuizen T,
Lutchminarayan R, Stenström T-A)
Impacts on diarrhoeal disease reduction by
interventions
Intervention area
Hygiene
Sanitation
Water supply
Water quality
Multiple
Reduction in diarrhoea
frequency
37%
32%
25%
31%
33%
(In WHO, 2008, adapted from Fewtrell et al., 2005)
Summary of module on risk management

Different types of studies


Possible to investigate the ”real” situation?
Epidemiology – underestimation in disease incidence
• Interviews, surveillance




Illustrates the importance of various studies
Range of interventions possible and
needed in combination


Risk assessments – assumptions made, over- or
underestimating risks (?)
Sampling and microbial analysis
Difficult to differentiate effects
Identifying need of risk management
and barriers

Health protection measures of
different kinds