TRAINING FOR THE HEALTH SECTOR

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WATER

Children's Health and the Environment

WHO Training Package for the Health Sector
World Health Organization
www.who.int/ceh
August 2006 version
1

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Access to safe water and sanitation is a universal need and a basic human right.
This presentation will deal with the close links between children's health and the quality and availability of
water.

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LEARNING OBJECTIVES

To understand the global context of water

availability and quality

To review the major categories of water pollutants

and their sources

To learn about the effects of exposure to these

pollutants on children's health

To consider some of the options for treatment of

drinking water

<<READ SLIDE>>

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Introduction – global issues

Children's special vulnerability

Main contaminants

Sources of contamination

Water-related paediatric diseases

Diagnosis and treatment

Prevention, remediation, education

Role of the health care provider

Case studies

Outline of this module: main points to address

<< READ SLIDE>>

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LIQUID WATER IS ESSENTIAL FOR LIFE

Sources are renewable

... but finite!

70% of earth’s surface is water

Only 2.5% to 3% is fresh water

Less than 1% is accessible

Pollution and other factors further
reduce access by 2/3
Earth Observatory, NASA

1.1 billion people (1/6th

of the world’s population)
have no access to quality drinking water

Liquid water is responsible for life as we know it!

Viewed from space the earth appears to be mostly water, but only 2.5% of that water is fresh,
and most of that lies frozen and inaccessible.
As a result, less than 1% of fresh water is accessible in lakes, river channels and under ground.
Geography, environment and pollution from human activities reduce this amount by a further two
thirds, and what remains is unequally distributed around the world.

It should be noted that access to safe water, provision of sufficient supplies of water, and access
to sanitation are three factors that together can contribute to the health and safety of the world’s
population. A lack of adequate supplies of good-quality water, together with poor sanitation,
exacts a high health toll, particularly in rural areas, hindering both social and economic
development. This makes the promotion of hygienic behaviour a high priority.

Ref:
•Water for health – taking charge. Geneva, World Health Organization, 2001.
•Safer water, better health. Costs, benefits and sustainability of interventions to protect and
promote health. WHO, 2008.
•UNICEF/WHO. Progress on drinking water and sanitation. Special focus on sanitation. 2008.

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wwwga.usgs.gov/edu/waterdistribution.html

Where is Earth's water located and in what forms does it exist?

The distribution of water is illustrated in the bar charts. The left-hand bar shows where the water
on Earth exists; about 97% of all water is in the oceans. The middle bar represents the 3% of the
"other" part of the left-hand bar (that portion of all of Earth's water that IS NOT in the oceans).
Most (77%), is locked up in glaciers and icecaps, mainly in Antarctica and Greenland, and in
saline inland seas. Twenty-two per cent of this portion of the Earth's water is groundwater. The
right-hand bar shows the distribution of the "other" portion of the middle bar (the remaining 1%).
Notice how rivers make up less than 4/10th of one per cent of this remaining water – yet this is
where we get most of the water for our everyday use!

This graph and the above text are in the public domain and can be found at
wwwga.usgs.gov/edu/waterdistribution.html

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SAFE WATER BY REGION: UNEQUAL

DISTRIBUTION

Developing nations:

Most stressed

Most projected growth

Youngest populations

WHO, UNICEF, 2000

This pie-chart shows that Africa and Asia are the regions most affected by the lack of safe water
supplies.
Developing countries are the most stressed, as they lack safe water to serve the projected
growth and have large young populations groups.

Ref:
•Global water supply and sanitation assessment 2000 Report. Geneva, World Health
Organization, United Nations Children’s Fund, 2000
(www.who.int/docstore/water_sanitation_health/Globassessment/Global2.1.htm#2.1%20and%20
2.2)

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DRINKING WATER COVERAGE, 2006

WHO, 2008

The world is on track to meet the MDG drinking water target. Current trends suggest that more
than 90 per cent of the global population will use improved drinking water sources by 2015. Sub-Saharan
Africa is making the slowest progress Population forecasts suggest that an additional 784 million people
worldwide will need to gain access to improved drinking water sources to meet the MDG target.
Accelerated progress is needed especially in sub-Saharan Africa, home to more than a third of those
using unimproved drinking water sources.

Picture and text from: WHO/UNICEF. Progress on drinking water and sanitation. WHO/UNICEF, 2008.
(www.who.int/water_sanitation_health/monitoring/jmp2008.pdf)

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WORLD POPULATION GROWTH AND CHANGING

DEMANDS

100
90 RURAL
80
70
60
50
40
30
20
10 URBAN
0
1880 1900 1920 1940 1960 1980 2000 2020 2040
NASA8

At the beginning of the 20th century over 86% of humans lived rural lives, now the proportions
are about 50/50 urban/rural.
Cities and mega cities continue to evolve.
It is estimated that, between 1990 and 2000, the global population increased from 5.25 billion to
over 6 billion, an increase of over 15%. This total reflects a 25% increase in the urban
population, and an 8% increase in the rural population. This increase meant that an additional
800 million people required access to safe water supplies, just to maintain coverage at a
constant level. During this period an additional 900 million people gained access to an improved
source of water, resulting in an increase in coverage from 77% to 82%. Despite these gains,
there are still more than 1.1 billion people, or 1/6 of the world's population, who lack access to
adequate sources of drinking-water.
The decade also saw a marked shift in the urban–rural population ratio; by 2000 the proportion
of urban dwellers had risen from 43.5% to 47%, and the growth rate showed no signs of slowing.
The rate of urbanization is greater in the developing world, particularly in Africa and Asia, and
this, together with lower levels of access to a safe water supply, make these locations
particularly vulnerable to the risk of water-related diseases. By 2000, 81% of Asians and only
64% of Africans had access to safe sources of drinking-water, despite worldwide efforts.

Refs:
•United Nations Population Division, World Urbanization Prospects: The 2001 Revisions.
www.un.org/esa/population/publications/wup2001/wup2001dh.pdf
•WHO/UNICEF Joint Monitoring Programme for Water Supply and Sanitation. Global water
supply and sanitation assessment 2000 report. Geneva, World Health Organization, United
Nations Children’s Fund, 2000
(www.who.int/water_sanitation_health/Globassessment/Global1.htm#Top).

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Gordon, WHO, 2004 9

Water is the essence of life and human dignity. As a fundamental human right “sufficient, safe,
acceptable, physically accessible and affordable water for personal and domestic uses” is vital for all.
Governments are responsible for ensuring that this human right is progressively fulfilled. As a result of
their action, in collaboration with partners, 900 million more people gained access to an improved water
supply during the 1990s. Yet 1.1 billion people in rural areas and urban slums still rely on unsafe
drinking-water from rivers, lakes and open wells. Children, in particular, suffer from water-related
illnesses. Each episode of diarrhoea sets back a child’s growth by lowering their appetite and reducing
their calorie and nutrient uptake. Persistent diarrhoea and severe diseases, such as typhoid and
dysentery, jeopardize children’s healthy development. Every year, nearly 2 million children do not survive
this struggle. Continued progress towards providing everyone with access to protected wells and,
ultimately, piped water supplies will radically reduce childhood illness. In the meantime, disinfection and
filtration at home are simple and cheap measures that make an immediate difference to the lives of the
worst affected.
Ref:
•Gordon B et al. Inheriting the world, the Atlas on Children's Health and the Environment. WHO, Myriad
Editions Ltd, 2004.

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CHILDREN ARE THE MOST VULNERABLE

1. Different and unique exposures

2. Dynamic developmental physiology

Drink more water per unit body weight

Breathe more air

More surface area

Higher absorption, variable metabolism
and elimination

Critical windows of development

3. Longer life expectancy

4. Politically powerless

WHO 10

Recalling the special vulnerabilities of children.

(See Module “Children are not Little Adults”.)

<<READ SLIDE>>
Refs:
•American Academy of Pediatrics Committee on Environmental Health. Pediatric Environmental
Health, 2nd ed. Etzel RA, Ed. Elk Grove Village, IL: American Academy of Pediatrics, 2003.
•Children's Health and the Environment – A global perspective. A resource guide for the health
sector, WHO, 2004.

Picture: WHO, C. Gaggero. Child and environment - water, Peru.

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CHILDREN ARE THE MOST VULNERABLE

Diarrhoea from unsafe water

 4 billion cases/year causing 1.8 million deaths
 Most deaths in children under 5 years
 Represent 15% of deaths of under 5s in developing
countries

Non-fatal infections
 Worms, trachoma, schistosomiasis

Chemical contamination
 Acute and chronic consequences (As, Fl,...)

11

Diarrhoea is the major public health problem caused by unsafe water and lack of sanitation. To give an
indication of the scale of the health problems caused by lack of safe water, there are approximately 4
billion cases of diarrhoea each year, causing 1.8 million deaths. These deaths occur mostly among
children under the age of 5 years and represent 15% of all deaths in this age group in developing
countries.
Waterborne intestinal worms infect nearly 10% of the population of the developing world, leading to
malnutrition, anaemia and retarded growth. Some 6 million people are blind as a result of trachoma, and
research suggests that provision of safe water could reduce infections by 25%. Some 200 million people
are infected with schistosomiasis, while the provision of safe water and sanitation could reduce infections
by as much as 77%.
Contamination of drinking-water by chemicals, particularly arsenic and fluoride, has been increasingly
recognized as a major health problem in some parts of the world.
Ref:
• WHO/UNICEF Joint Monitoring Programme for Water Supply and Sanitation. Global water supply and
sanitation assessment 2000 report. Geneva, World Health Organization, United Nations Children’s Fund,
2000 (www.who.int/water_sanitation_health/Globassessment/Global1.htm#Top).

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CHILDREN ARE THE MOST VULNERABLE

Recreational waters

Coastal and fresh water

Swimming pools
Health issues
 Drowning
 Injuries WHO

 Sharks, jellyfish and coral

 Infectious diseases
 Exposure to disinfectants
 Chlorine products and asthma
 Excess heat, cold and sunlight
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Although the main concern is safe DRINKING-water and access to sanitation, we must not forget
that "children's work is to play" and that they may spend many hours swimming, bathing and
playing in recreational waters. The water quality of pools, lakes, rivers and ponds should be
considered, as well as the many other risks that exist in a "water" environment where children
spend time. By far the most serious risk menacing children's life is DROWNING.
Burden of disease
Physical hazards: drowning and injuries
In 2000 an estimated 450 000 people drowned, making it the second leading cause of death
from unintentional injury worldwide after road traffic injuries. However, of the various age groups,
children under 5 years of age have the highest drowning mortality rates worldwide. Over half of
the global mortality and 60% of the total number of disability-adjusted life years (DALYs) lost due
to drowning occurs among children aged between 0 and 14 years. Ref:
www.who.int/violence_injury_prevention/unintentional_injuries/drowning/types/en/

Microbial hazards: infections

Millions of litres of raw or partially-treated sewage are pumped into seas every day, polluting the
environment and resulting in an estimated 250 million cases of bathing-related gastroenteritis
and upper respiratory disease each year. Pathogenic viruses and bacteria such as Escherichia
coli O157 are commonly found in untreated sewage, putting swimmers, surfers and children at
risk from infection.
Although the water quality in swimming pools and spas is generally well-monitored, there may be
outbreaks of disease due to contamination. The majority of outbreaks are caused by viruses or
bacteria linked to faecal contamination. An increasing number of infections are associated with
protozoa such as Cryptosporidium, which are resistant to commonly used pool disinfectants.
Spas present particular risks and require particularly stringent monitoring, as the warm, nutrient-
containing, aerobic waters provide an ideal habitat for bacteria to proliferate. Ref:
www.who.int/features/2003/10/en/
Pictures: WHO. Above: P. Virot, Water, Ghana, Africa, 2003.

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CLASSIFICATION OF CONTAMINANTS

BIOLOGICAL
 Bacteria
 Viruses
 Parasites
 Natural toxins

CHEMICAL
 Inorganic chemicals
 Organic chemicals WHO

 Radionuclides

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Contamination of water can be conveniently divided into two categories – biological and
chemical.

<<READ SLIDE>>

Picture on the right: WHO, C. Gaggero. Environment water, Americas

Picture on the left: WHO, C. Gaggero. Environment water pollution, Mexico

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SOURCES OF CHEMICAL CONTAMINATION

Natural trace elements and minerals

Human activities
 Agricultural run-off
 Urban run-off
 Industrial emissions and discharges
 Sewage and waste disposal
 Water treatment processes

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Water contains many trace elements and minerals which, depending on their concentration, may
be inert, beneficial or toxic.
Some minerals can be beneficial at low concentrations, but toxic at higher ones. These minerals
may occur naturally, arising from the surrounding geological features, particularly in
groundwater.

Chemicals may also be introduced into water from human activities, particularly into surface
waters. Contamination may be from agricultural chemicals, such as pesticides and fertilizers;
human activity, such as waste disposal; urban run-off from human settlements; industrial
chemicals; or the process of water treatment itself.
Many of these substances are not harmful to humans, or are present in concentrations so low as
to cause no health effects. However, some are known to cause serious health effects at low
concentrations, and treatment is needed to remove them or to reduce their concentration in
drinking-water.

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UNEP

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Pollutants move through the water cycle and can be transported long distances.
Picture: www.unep.org/vitalwater

Source: Environment Canada, 2001. (Adapted from www.ec.ca/water/index.htm)

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WATER BUDGETS

UNEP 16

Water is transported in different forms within the hydrological cycle or 'water cycle'. The water
cycle consists of precipitation, evaporation, evapotranspiration and runoff. This graphic explains
the global water cycle, showing how nearly 577 000 km3 of water circulates through the cycle
each year.

Picture and text: www.unep.org/vitalwater

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UNEP 17

Picture: www.unep.org/vitalwater

Source: Brian Morris, British Geological Survey, 2001.

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WATER-
WATER-RELATED INFECTIONS
PRIMARY PUBLIC CONCERN
Waterborne diseases Water-based diseases
• Cholera • Schistosomiasis
• Poliomyelitis • Dracunculiasis (guinea-worm)
• Diarrhoeal diseases
• Roundworm
• Enteric fevers: typhoid
Diseases transmitted by
• Whipworm water-related insect vectors
• Hepatitis A • Malaria
• Cryptosporidium • Onchocerciasis
• Giardia • Yellow fever
Water-washed diseases • Dengue
• Filariasis
• Scabies • African trypanosomiasis
• Typhus • Leishmaniasis
• Trachoma
• Louse infestation 18

The primary public health concern regarding water contamination is microbiological contamination of drinking-water.
Water-related infections can be classified into four categories:
•waterborne diseases: directly acquired from drinking water (contaminated);
•water-washed: indirectly acquired diseases due to lack of hygiene;
•water-based diseases: caused by aquatic organisms that spend part of their life-cycle in the water and another part as
parasites of animals; and
•diseases transmitted by water (or humidity!)-related insect vectors (includes African trypanosomiasis (tse-tse fly) and
leishmaniasis (sandfly) that require only humid environments) (Dr D. Engels, WHO, personal communication).
Microbial contamination usually results from the contamination of water with human or animal faeces. If drinking-water
is contaminated with faeces, pathogens are likely to be widely and rapidly dispersed. If the contamination is recent, and
if the faeces are from carriers of communicable enteric diseases, the microorganisms (bacteria, viruses or protozoa)
that cause these diseases may be present in the water.
The diseases range from mild gastroenteritis to severe and sometimes fatal diarrhoea, dysentery, hepatitis, cholera and
typhoid. Helminths and amoebae may also be transmitted in water and are common in poor-quality water supplies.
There are also some organisms in the environment that may cause disease in humans in certain circumstances, e.g.
Legionella may be transmitted through aerosols.
Adverse health effects arise primarily from the ingestion of pathogenic bacteria. People with low immunity, including
infants, young children, the sick and the elderly are particularly vulnerable to microbial contamination even from
ordinarily mild pathogens. Outbreaks of waterborne disease can lead to spread of infection across a wide community.
Cryptosporidium and Giardia, for instance, cause regularly diarrhoea outbreaks. They cause problems due to the
following factors:
-cyst formation (cysts are resistant in the water environment);
-cysts have a small size (problems in filtration processes);
-no specific hosts;
-cysts are resistant to chlorine.
In addition, risks are posed by some toxins that occur naturally in water, particularly in nutrient-rich surface waters
where there is profuse algal growth.

Ref:
•Satterthwaite D et al. The environment for children. New York, United Nations Children’s Fund & Earthscan, 1996.

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INORGANIC CHEMICAL: ARSENIC (As)

From natural erosion, pesticide

run-off, coal burning, smelting,
glass and electronic production
waste

Skin lesions and cancer, vascular
and neurological disease,
increased risk of cancer

WHO guideline: 0.01 mg/L (ppm)

N. Karim, NGO: Earth Identity Project, Bangladesh

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Arsenic (As) is a naturally occurring element, which can be introduced into water through the dissolution of minerals,
from industrial effluent (drainage from goldmines) and from atmospheric deposition (burning of fossil fuels and wastes).
These sources make significant contributions to the arsenic concentrations in drinking-water and may be harmful to
health. The body rapidly excretes organic forms of arsenic, and it is the inorganic trivalent form that is of most concern.
Although concentrations in natural water are generally less than 0.005 mg/litre, some countries have reported very high
concentrations, particularly in groundwater supplies. In Bangladesh, for example, over 25 000 wells are contaminated
with arsenic at levels above 0.05 mg/litre. Food is also a significant source of arsenic, but usually in highly complex
forms that are biologically unavailable and essentially non-toxic.
Although studies indicate that arsenic may be essential for some animal species, there is no indication that it is
essential for humans.
Arsenic compounds are readily absorbed by the gastrointestinal tract, and then bind to haemoglobin and are deposited
in the liver, kidneys, lungs, spleen and skin. Inorganic arsenic does not appear to cross the blood–brain barrier, but can
cross the placenta.
Approximately 45–85% of ingested arsenic is excreted in the urine within 1–3 days.
The major health effects are caused by chronic exposure to low levels from the consumption of arsenic-contaminated
water. A number of studies in Bangladesh and West Bengal have documented the effects of consuming water
containing elevated concentrations of arsenic (> 0.3 mg/litre). Consumption over periods of 5–25 years was reported to
produce skin lesions, skin cancer, vascular disease, effects on the nervous system and possibly cancer of other organs.
The only available treatment for chronic arsenic poisoning is to remove the patient from the source of exposure and
provide supportive care.
Refs:
•Kreiss K et al. Arsenic toxicity. Atlanta, GA, US Department of Health and Human Services, Agency of Toxic
Substances and Disease Registry, 1990 (Case Studies in Environmental Medicine, No. 5).
•International Programme on Chemical Safety. Arsenic. Geneva, World Health Organization, 1981 (Environmental
Health Criteria No. 18).
•United Nations Synthesis Report on Arsenic in Drinking Water
(www.who.int/water_sanitation_health/dwq/arsenic3/en/print.html).

Photographs by Nasrine Karim, NGO: Earth Identity Project, Bangladesh. Hands and feet "before" from an arsenicosis
patient. Used with permission.

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INORGANIC CHEMICAL: FLUORIDE (Fl)

From natural erosion, discharge from
fertilizer and aluminum factories, or
added to drinking water

Bone disease, mottled teeth

WHO guideline: 1.5 mg/L (ppm)

A. K. Susheela. Fluorosis Research & Rural Development Foundation of India

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Fluoride occurs naturally in soil and water, and is a byproduct of industrial activities such as the aluminum and fertilizer
industries. It is also added to drinking water to help prevent dental caries.
Concentrations in surface water are usually relatively low (< 0.5 mg/litre) while deeper groundwater wells in areas high
in fluoride minerals may have concentrations as high as 10 mg/litre.
An estimated 100 million people suffer health effects from overexposure to fluoride. A wide strip from North to South
Africa, and including the Syrian Arab Republic, Jordan, Egypt, Sudan, Ethiopia, Kenya, the United Republic of Tanzania
and South Africa, is known to have high concentrations of fluoride in groundwater. In one village of 2000 people, 95%
of children are affected by dental fluorosis. Other effects, such as skeletal fluorosis and crippling fluorosis, are also
seen in some inhabitants of this village, as in other parts of the so-called “African fluoride belt”.
Fluoride is absorbed quickly following ingestion, but is not metabolized, and diffuses throughout the body. About 40% is
excreted in urine within 9 hours, and 50% over 24 hours.
Fluoride has an affinity for mineralizing tissues of the body – in young people the bones and teeth, and in older people
the bones. As the excretion rate is greater in adults, mineralization is proportionally less than in children.
The most readily identifiable health effects of consuming water with elevated levels of fluoride are a mottling of the
teeth, known as fluorosis, and sclerosis of the bones. Children are particularly affected by fluorosis, because teeth take
up fluoride during their formation.
Fluoride has been shown to be effective in preventing dental caries, from the observed association of low incidence of
dental caries with naturally occurring fluoride in drinking-water (at about 1 mg/litre). As a result, many health authorities
around the world, including the World Health Organization, recommend fluoridation of public water supplies as an
important public health measure. However, at concentrations above 1.5 mg/litre fluoride may affect tooth mineralization
in children leading to a mottling of the teeth, which can in some cases be unsightly. The regular consumption of water
with fluoride concentrations above 4 mg/litre, however, can cause progressively increasing skeletal fluorosis.
Refs:
•Marcus R. Agents affecting calcification and bone turnover. In: Hardman JG, Limbird LE. Goodman & Gillman’s The
pharmacological basis of therapeutics, 9th ed. New York, McGraw-Hill, 1996.
•National Health and Medical Research Council. Australian drinking water guidelines and framework for management of
drinking water quality (www.health.gov.au/nhmrc/publications/synopses/eh19syn.htm).
Pictures: A. K. Susheela of Fluorosis Research & Rural Development Foundation of India (used with permission)
Note the discoloured teeth of the children with fluorosis.
Discoloration appears as brown or black streaks (lines)
These have a horizontal orientation – not vertical.
The discoloration is away from the gums.
The discoloration is seen in the teeth in pairs and not in single teeth.
The discoloration seen here is the classical depiction of dental fluorosis in children.

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INORGANIC CHEMICAL: LEAD

From plumbing, solder, lead-glazed ceramics, old

paint, deposits from leaded petrol

Impaired growth and development, behavioural

problems, kidney damage

WHO guideline: 0.01 mg/L (ppm)

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High levels of lead may be found in drinking water. This is most commonly a result of human
activities, particularly where lead piping is still being used, or water supply fittings use leaded
solders. Concentrations are affected by factors such as water acidity, water hardness and
duration of contact with water. Urban run-off, particularly where leaded fuels are common, is a
source of lead contamination, particularly of surface waters.
Lead is a neurodevelopmental toxicant. It interferes with haem synthesis, and can damage the
central and peripheral nervous systems, the kidneys and the reproductive system. It can be
absorbed by the body through inhalation, ingestion or placental transfer. In adults, approximately
10% of ingested lead is absorbed, but in children this figure can be 4–5 times higher. After
absorption, the lead is distributed in soft tissues such as the kidneys, liver and bone marrow,
where it has a biological half-life in adults of less than 40 days. In skeletal bone, lead may persist
for 20–30 years. Lead is a cumulative poison, and can severely affect the central nervous
system. Infants and fetuses are the most susceptible. Placental transfer of lead occurs in
humans as early as the 12th week of gestation and continues throughout development.
Many epidemiological studies have been carried out on the effects of lead exposure on the
intellectual development of children. Other adverse effects associated with exposure to high
amounts of lead include kidney damage and interference with the production of red blood cells
and the metabolism of calcium needed for bone formation.
Refs:
•National Health and Medical Research Council. Australian drinking water guidelines and
framework for management of drinking water quality
(www.health.gov.au/nhmrc/publications/synopses/eh19syn.htm).
•Shape the future of life, World Health Day, 7 April 2003. Geneva, World Health Organization,
2003.
•www.who.int/ipcs/publications/newsletters/en/04.pdf

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INORGANIC CHEMICALS: NITRATES/NITRITES

Introduced by run-off from fertilized land, septic

tanks, sewers, erosion from natural deposits

Methaemoglobinaemia in young infants

WHO guidelines:
 nitrate 50 mg/L (ppm)
 nitrite 3 mg/L (ppm)

WHO 22

Nitrates and nitrites occur primarily as a result of run-off from the agricultural use of fertilizers
and from bacterial action on animal wastes. The intensification of farming practices, and sewage
effluent disposal to streams have led to increasing amounts of nitrate in some waters,
particularly groundwater. Whereas food is the major source of nitrate intake for adults, bottle-fed
infants may be exposed to nitrates if contaminated water is used for mixing formula milk.
The toxicity of nitrate in humans is thought to be solely due to its reduction to nitrite. The major
biological effect of nitrite in humans is its involvement in the oxidation of normal haemoglobin to
methaemoglobin, which is unable to transport oxygen to the tissues, a condition known as
methaemoglobinaemia or more commonly, “blue baby syndrome”. Young infants and pregnant
women are most susceptible to methaemoglobin formation.

Refs:
•National Health and Medical Research Council. Australian drinking water guidelines and
framework for management of drinking water quality
(www.health.gov.au/nhmrc/publications/synopses/eh19syn.htm).
•Shape the future of life, World Health Day, 7 April 2003. Geneva, World Health Organization,
2003.

Picture: WHO, I. Papadopoulos. Environmental health, children in cotton fields, wastewater,

Cyprus, 1992

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ORGANIC CHEMICALS: METHYLMERCURY (MeHg

(MeHg))

Hg is emitted into the atmosphere and circulated
globally

Ultimately enters water bodies

Deposition is:
 Close to source
 Far from source

Biotransformed by bacteria

Bioconcentrated in fish

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Mercury occurs naturally in drinking-water at extremely low levels, but contamination can result
from industrial emissions or spills. Inorganic mercury compounds are generally insoluble in water
and the major concern is the organic methylmercury, formed from inorganic mercury by
bacteriological action. Methylmercury is known to accumulate in fish and fish products, and the
consumption of these foods may cause human illness.
Methylmercury is a developmental neurotoxicant. In utero exposure leads to interference with
neuronal migration, organization of brain nuclei and layering of the cortex. These experimental
findings are consistent with the severe cerebral palsy, seizure disorders, blindness, deafness
and mental retardation that have been documented in children whose mothers ate heavily
contaminated fish during pregnancy. More subtle neurodevelopmental deficits have been
observed in some children who received much lower exposures in utero. Methylmercury can
also damage the brain after birth. Long-term exposures outside the developmentally vulnerable
periods also cause damage to the central nervous system. Progressive signs include
paraesthesia, ataxia, tremor and muscle spasticity, leading to coma and death.
Methylmercury compounds are almost completely absorbed by the gastrointestinal tract and can
cross biological membranes, especially the placenta, the brain, spinal cord and peripheral
nerves. The main effects of methylmercury poisoning are severe, irreversible, neurological
disorders and mental disability.
Less than 15% of inorganic mercury in drinking-water is absorbed by the gastrointestinal tract.
Inorganic mercury compounds have a long biological half-life, accumulating in the kidneys where
the toxic effects may lead to kidney failure.

Refs:
•Goyer RA et al. Toxic effects of metals. In: Klaassen, Casarett & Doull’s toxicology: the basic
science of poisons, 5th ed. New York, McGraw-Hill, 1996.
•Grandjean P et al. Cognitive deficit in 7-year-old children with prenatal exposures to
methylmercury. Neurotoxicology and Teratology, 1997, 6:417.
•Wheeler M, Measuring mercury. Environmental Health Perspectives, 1996, 104:826
(ehpnet1.niehs.nih.gov/docs/1996/104-8/focus.html).

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ORGANIC CHEMICALS: METHYLMERCURY (MeHg

(MeHg))

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•Illustration by Connie J. Dean, U.S. Geological Survey.

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ORGANIC CHEMICALS – PESTICIDES

Extensive and intensive use, a worldwide concern

Pesticides used in agriculture may contaminate

water sources

Chronic, low-level exposure may lead to subtle
effects

Persistent organic pollutants (POPs) are the subject
of an international Convention (Stockholm Convention)

25

Pesticides are a cause of increasing concern due to their widespread and often indiscriminate
use. In both urban and rural settings, pesticides may reach water supplies from agricultural run-
off. Although they are not specifically removed by conventional water treatment processes,
natural filtration and biodegradation prior to and during treatment means that these substances
are rarely detected in treated water. However, elevated levels are often found in rural areas
where intensive agricultural practices can result in direct contamination of the water source (as
shown in the diagram).

Public health concerns regarding pesticides in water arise from their potential to accumulate in
the body. These chemicals can be absorbed orally; health effects depend on the specific type of
pesticide.

25
 Water
ORGANIC CHEMICALS –
DISINFECTION BYPRODUCTS
Disinfection Potential “The most vitally important
by-products sanitary problem confronting
health effects
American municipalities
Bromate Increased risk of at present is, unquestionably,
cancer the supply of pure water for
Chlorite Anaemia; infants and drinking and other domestic
young children: purposes.”
JAMA, 1896, 26:1004-1006
nervous system
effects
"In the face of continued high
Haloacetic Increased risk of
infant mortality rates from
acids (HAA5) cancer
water-borne disease in Mexico,
Total trihalo- Liver, kidney or the risks of chronic disease
methanes central nervous from disinfection by-products
(TTHMs) system problems; are a relatively low priority."
increased risk of books.nap.edu/books/0309052459/html/5
cancer 2.html
26

Disinfection by-products (DBPs) occur when chemicals such as chlorine are added to water to
control microbial contamination, where they combine with organic materials. Four of the DBPs
regulated by the US EPA are listed in the table along with their “potential” health effects. There
are few data available on the effects of low doses on humans, particularly infants and children.
Although there is some concern that these chemicals may pose a health risk, the potential risks
arising from not treating drinking-water are considerably greater, and the disinfection of water
should never be compromised as a result.

<<READ QUOTATION>>
This historical quotation remains true today, and particularly critical in developing countries
where large portions of the population have no access to safe drinking water.

Refs:
•Booker SM. TNP taps disinfection by-products for study. Environmental Health Perspectives,
2000, 108:A64.
•Commission on Geosciences, Environment and Resources. Mexico City's Water Supply:
Improving the outlook for sustainability. National Academies Press, 1995.
•Guidelines for drinking-water quality, 3rd ed. Geneva, World Health Organization, 2004.
(www.who.int/docstore/water_sanitation_health/GDWQ/Updating/draftguidel/draftchap1.htm).
•International Programme on Chemical Safety. Disinfectants and disinfectant by-products.
Geneva, World Health Organization, 1999 (WHO Environmental Health Criteria No. 216)
(www.inchem.org/documents/ehc/ehc/ehc216.htm).

26
 Water

RADIONUCLIDES

From natural erosion, nuclear accidents

Increased risk of cancer

Exposure through ingestion AND inhalation (during
showers)

www.epa.gov/iaq/radon/pubs/citguide.html
27
WHO

Radionuclides occur naturally in the environment from deposits of radioactive minerals, and from
the disposal and storage of radioactive materials. Concentrations in surface waters are likely to
be extremely low, and groundwater concentrations vary according to the type of aquifer minerals
and dissolved anions.
Radioactive materials cause changes in the DNA of cells, with an increased risk of cancer being
the most serious outcome. The most common exposure route is via the respiratory system by
inhalation of aerosolized droplets. People can be exposed when they take showers. The US
Environmental Protection Agency estimates that 168 cancer deaths per year in the USA are
related to radon in water, of which 89% are lung cancers, and 11% stomach cancers.

Refs:
•National Health and Medical Research Council. Australian drinking water guidelines and
framework for management of drinking water quality
(www.health.gov.au/nhmrc/publications/synopses/eh19syn.htm).
•US Environmental Protection Agency. Proposed radon in drinking water rule, EPA 815-F-99-
009. 2000 (www.epa.gov/safewater/radon/proposal.html).

Picture on the left: WHO, A. Waak. Child in environment water, Haiti.

Picture on the right: The risk of living with radon, www.epa.gov/iaq/radon/pubs/citguide.html

27
 Water

CHILD’
CHILD’S AND ADOLESCENT’
ADOLESCENT’S COMPLEX
ENVIRONMENT SETTINGS
HAZARDS Rural/Urban
Physical MEDIA Home
Chemical Water - Air - Food School
Biological Field
Street
ACTIVITIES Workplace
Eating, Drinking, Breathing, Bathing

SUSCEPTIBILITIES OUTCOME EFFECTS

Critical windows/timing
Diarrhoeal disease
Age
Nutritional status Multi-system illness
Poverty

WHO 28

In this summary slide, we see the complexity of the issues related to children’s environmental
health.
Hazards are introduced into environmental media with variable efficiency in different settings. A
child’s activities bring him or her into contact with these hazards. Depending upon the individual
susceptibility of the child, based upon age, general health and social supports, the exposure may
cause harm varying in severity from subtle changes in function to death.
Children’s environmental health is the field that synthesizes these complex issues and attempts
to make fundamental changes to improve children’s environments and prevent environment-
related illnesses.
Picture: WHO, J. Taylor. Water, Zimbabwe

28
 Water

DIAGNOSIS AND TREATMENT

Diagnosis

Exposure history

Physical examination
WHO

Confirmatory laboratory evaluations

Treatment depends on:

Type of disease

Organs & systems affected

Severity of illness

29

The diagnosis of illnesses suspected to be caused by contaminated water supplies require:

•a thorough knowledge of history of exposure;
•a complete physical examination of the patient; and
•where possible, confirmatory laboratory tests.
Standard stool cultures, tests for ova and parasites, and measurement of antibody titres may be
feasible in patients who present at hospitals or health care centres. Laboratory tests are more
likely to be useful in cases of microbial exposures and acute effects from chemical exposures
than for chronic exposures to low doses of chemicals. Testing for low concentrations of
chemicals requires sophisticated analytical techniques unlikely to be available outside research
settings. Measuring methaemoglobin in the blood will confirm acute nitrate poisoning. Testing
blood lead levels can indicate lead exposure. Measurements of urinary arsenic levels are of
limited value as arsenic is rapidly excreted from the body. None of these tests, however, will
identify the source of exposure, which is important for case-management and prevention of
further exposure. If elevated levels of chemical contaminants are known to exist then exposure
can be inferred, and confirmed by detailed patient and environmental histories and by chemical
and microbiological analyses.

Treatment depends on the type of disease that has resulted from exposure to unsafe water or
lack of water (e.g. from the microbial or chemical contamination, or dehydration), the systems
affected and the degree and severity of disease.

Picture above: WHO, C. Gaggero. Environment water, Mexico

Picture below: WHO, P. Merchez. Cholera, Peru

29
 Water

TREATMENT OF DIARRHOEA

APPROXIMATE DOSE OF ORAL REHYDRATION SOLUTION (ORS) TO

BE GIVEN IN THE FIRST 4 HOURS

Age < 4 4–11 12–23 2–4 5–14 15 years

months months months years years or older
Weight < 5 kg 5–7.9 kg 8–10.9 11– 16– 30 kg or
kg 15.9kg 29.9kg more
In ml 200– 400–600 600–800 800– 1200– 2200–
400 1200 2200 4000
WHO, 2003

30

Diarrhoeal illness is treated by controlling the infection and by aggressive fluid management.
Antimicrobial drugs are used only in cases of severe cholera and bloody diarrhoea (dysentery).
In young children, the most common cause of death is from dehydration. Correct management
may prevent up to 90% of deaths. Dehydration can usually be treated using oral rehydration
fluids. Intravenous rehydration may be needed in cases of severe dehydration, or where the
patient cannot drink or absorb water.

Sources of infection should be identified and made safe. If the infected person is potentially
contagious, isolation, strict hand-washing by staff, and the safe disposal of faeces are the
recommended control measures. For non-infectious diseases resulting from contaminated water
supplies, treatment involves removing the patient from the source of exposure and providing
supportive care. In some cases the use of a specific pharmaceutical preparation or antidote may
be indicated (e.g. succimer for lead, atropine for organophosphorus pesticides, methylene blue
for reversal of methaemoglobinaemia).

<<NOTE TO USER: Please insert the appropriate amounts of oral rehydration solution in
the bottom row of the table using local measures.>>

Ref:
•The treatment of diarrhoea, A manual for physicians and other senior health workers. Geneva,
World Health Organization, 2003.

30
 Water

IMPACT ON DIARRHOEAL DISEASE

REDUCTION BY INTERVENTION AREA

WHO, 2008

31

“Pooling” results of good quality studies from different regions (meta-analysis) can provide useful
insights into the overall impact of interventions. In a recent systematic review of the literature on
diarrhoeal disease (Ref: Fewtrell et al, 2005), 2000 abstracts were screened, and then 50 studies were
analysed; of these 50 studies, 38 were used in the meta-analysis. The overall results of the meta-analysis
are summarized in the table above. These results are generally in line with those of earlier studies.
However, the investigators detected a greater impact of intervention in drinking-water quality than had
been detected in previous reviews. This likely arises from assessment of the actual quality of water
consumed as opposed to the quality of the water at the source, as was commonly done in earlier studies.
Water, sanitation and hygiene interventions interact with one another, and available evidence indicates
that the impact of each may vary widely according to local circumstances. Prioritizing should therefore be
based on local conditions and evidence from implementation rather than from pooled data, such as the
average impacts summarized in the table above.

Text and table from: Pruess-Ustun et al, Safer water, better health: Costs, benefits and sustainability of
interventions to protect and promote health. WHO. 2008. (available at:
whqlibdoc.who.int/publications/2008/9789241596435_eng.pdf)

Ref:
Fewtrell L et al Water, sanitation, and hygiene interventions to reduce diarrhoea in less developed
countries: a systematic review and metaanalysis. The Lancet Infectious Diseases, 2005, 5(1):42–52.

31
 Water

PREVENTION, REMEDIATION, EDUCATION

Protect water sources from pollution
 Surface waters
 Groundwaters

Drinking-water treatment
 Community level
 At home WHO

Education
 Community leaders
 Consumer knowledge

32

Prevention of contamination is an essential feature of effective water quality management. A comprehensive

assessment of the water supply system enables effective risk management strategies to be identified from the
source to the consumer. When a situation that can give rise to water contamination is recognized, preventive
strategies to minimize the exposure can be identified.
Surface and groundwater sources should be protected from contamination. Possible sources of contamination
include animal and human waste, agriculture, industry, mining and quarrying run-off, and the disposal of hazardous
wastes. These and other polluting activities should be identified and controlled, or where feasible, excluded from the
water catchment area.
Groundwater in deep or confined aquifers is usually protected from local sources of contamination and
microbiological quality is generally high. However, groundwater supplies may contain high concentrations of naturally
occurring elements that affect health or the taste/appearance of the water.
Groundwater with a high salinity may be unpalatable, whereas high levels of nitrates, arsenic, boron, fluoride and
radionuclides may make water unfit for use. Groundwater may also be polluted by certain practices, such as the
drilling of wells.
Even in areas without safe drinking-water supplies, home treatment is possible. Filtration can remove some microbial
contamination and parasites, as can disinfection and boiling. Although it is possible to remove some chemical
contaminants, methods for this tend to be expensive and the costs must be weighed against the risks involved in
drinking water with potentially high levels of chemical contaminants. Water treatment carried out in the home requires
scrupulous and continuous maintenance to ensure a safe and effective supply.
Education is vitally important to ensure that consumers of water understand the routes by which contaminants may
enter the system. Health promotion activities are needed to demonstrate the importance of correct hygiene regarding
both sanitation and water supply, particularly for those most at risk. Communities should be involved in ensuring that
everyone understands the importance of clean water to health, and that the protection of safe water sources is
essential in reducing health risks.
Ref:
•Guidelines for drinking-water quality, 3rd ed. Geneva, World Health Organization, 2004
(www.who.int/docstore/water_sanitation_health/GDWQ/Updating/draftguidel/draftchap1.htm)
Picture above: WHO, P. Virot. Sustainable development healthy environment hygiene water photography, India. Safe
water system The Tappankala - Sector 1 Resettlement Area, Delhi, India, Asia, November 2002
Picture below: WHO. Health Education.

32
 Water

SOURCE PROTECTION

Limit up-stream discharges

 Industrial
 Cottage industry
 Mining
WHO

Proper sanitation systems

Maintain well heads
 No storage or animals nearby
 No septic systems in drainage

33

Protection of the source is the most important way to protect drinking-water. Both surface and
groundwater must be protected, although surface water is more immediately vulnerable.
Contamination from human and animal waste causes microbial contamination and poses a
major threat of waterborne and water-washed infections. Industrial discharges from legal and
illegal industry, contamination from mining operations, and run-off from farms and urban centres
all contribute to contamination. Riparian buffer zones and storm-water management in cities are
necessary to control non-point sources. Point-source pollution from sewage treatment plants and
industrial discharges can be controlled by appropriate technology, monitoring and enforcement
of laws and regulations on drinking-water quality.

<<NOTE TO USER: Many of these issues are covered in depth in the sanitation and
waste modules in this series.>>

Picture above: WHO, C. Gaggero. Environment water purification, Santa Lucia, Americas.
Picture below: WHO, J. Vizcarra. Environment water purification, Bolivia.

33
 Water

REMEDIATION–
REMEDIATION–WATER TREATMENT PLANTS

Coagulation

Sedimentation

Filtration

Disinfection

Storage

34

Municipal water treatment plants usually treat drinking-water using a standard series of steps.
These are as follows:
1) coagulation which removes dirt and other particles suspended in water. Alumina and other
chemicals are added to water to form tiny sticky particles called "floc" which attract the dirt
particles. The combined weight of the dirt and the alum (floc) is heavy enough to sink to the
bottom during
2) sedimentation, and the clear water moves to
3) filtration where the water passes through filters made of layers of sand, gravel and charcoal
that help to remove even smaller particles.
4) Finally the water reaches the disinfection tank where a small amount of chlorine is added, or
some other disinfection method is used, to kill persistent bacteria or microorganisms that may be
present in the water and to provide continuing protection against recontamination during storage
and distribution.
5) Water is stored safely.

Ref :
•www.epa.gov/safewater/dwh/treat.html

34
 Water

DRINKING-
DRINKING-WATER QUALITY STANDARDS

Health-based targets

System assessment of water-supply chain

Operational monitoring of the control measures in

the supply chain

Management plans documenting the system

assessment and monitoring

A system of independent surveillance that verifies

that the above are operating properly

35

Drinking-water management requires that quality standards be developed, applied and enforced.
The components of a proper plan involve the following:

1) health-based targets that are set according to a critical evaluation of the health concerns;
2) system assessment to determine whether the water-supply chain as a whole (from source
through treatment to the point of consumption) can deliver water of a quality that meets the
above targets;
3) operational monitoring of the control measures in the supply chain which are of particular
importance in ensuring drinking-water safety;
4) management plans documenting the system assessment and monitoring protocols and
describing actions to be taken in normal operation and following incidents; including upgrade and
improvement documentation and communication; and
5) a system of independent surveillance that verifies that the above are operating properly.

Ref:
•WHO Guidelines for Drinking Water Quality, Third edition. Geneva, World Health Organization,
2003 (www.who.int/water_sanitation_health/dwq/guidelines/en/)
•Howard G et al, WHO Domestic water quantity, service level and health, Geneva, World Health
Organization, 2003 (www.who.int/water_sanitation_health/diseases/wsh0302/en/)

35
 Water

HOME TREATMENT AND STORAGE

Boiling water for 1 minute inactivates all microbes

and biological toxins
 Boiling for longer can concentrate chemical contaminants

Add 0.6 ml of 1% chlorine solution to 1 L water and

allow to stand for 30 minutes
 Filter before chlorination if cloudy
 Ensure pore size < 1 micron
 Replace or clean according to manufacturer’s instructions

Store in 10–30 litre, covered storage bottle

 Never use old chemical storage containers

36

When treated, high-quality drinking-water is not available, there are home treatment options.
•Microbial contamination can be eliminated by boiling water, but care must be taken not to over-boil.
•Home filtration and chlorination are also viable options (known as “point-of-use” treatment systems).
•Proper storage is critical to prevent recontamination.

Question: Can water be treated by individuals at the point of use?

Yes. There are several ways of treating water at home, or at the point of use, including by boiling, exposure
to sunlight and filtration. Probably the simplest, and certainly the best-studied method, is to use a
disinfectant. By adding 0.6 ml of 1% chlorine solution to 1 litre of water and allowing it to stand for 30
minutes, a residual chlorine content between 0.2 and 0.5 mg/litre can be achieved. If the water is cloudy, it
should be filtered before chlorination to decrease the quantity of organic material with which the chlorine
can combine. The chlorine solution must be stored in a clearly labelled container, out of the reach of
children to prevent poisoning. More details are available online at: www.who.int/emc-
documents/cholera/docs/whocdr954.html
Question: How should I store water at home?
The choice of storage vessel is very important. The ideal container holds 10–30 litres, is made of durable,
unbreakable and oxidation-resistant materials, equipped with handles and has an opening large enough for
cleaning and filling, but small enough to prevent a child’s hand holding a cup to be inserted. A screw-on lid
is ideal and a spigot attachment is very helpful. Recycling used containers can be dangerous if they once
contained toxic chemicals and should therefore be avoided. More information is available at:
www.cdc.gov/safewater/manual/1_toc.htm

Refs:
•Department of Health & Human Services, Centers for Disease Control and Prevention. Safe water
systems for the developing world: A handbook for implementing household-based water treatment and
safe storage projects (www.cdc.gov/safewater/manual/1_toc.htm)
•World Health Organization. Guidelines for the control of epidemics due to Shigella dysenteriae type 1
(www.who.int/emc-documents/cholera/docs/whocdr954.html).

36
 Water

WHICH CONTAMINANTS ARE REMOVABLE BY

WHICH TYPE OF HOME TREATMENT SYSTEM?
Contaminant Cation Anion Activated Reverse Distillation
exchange exchange carbon osmosis
Arsenic No Yes No Yes Yes
Fluoride No No No Yes Yes
Lead No No No Yes Yes
Organic Hg* No No Yes No No
Nitrate No Yes No Yes Yes
VOC** No No Yes No No
Radium Yes No No Yes No
Coliforms No No No Yes Yes

*Hg, mercury.
**VOC, volatile organic compounds.
37

<<NOTE TO USER: The systems here may not be available or feasible for your area.
Please substitute a regionally appropriate menu of options for home treatment and
storage of drinking-water.>>

Other kinds of treatment can be used to reduce chemical contaminants, but they are often
expensive and difficult to maintain. Proper maintenance is critical, otherwise home treatment
systems can be both ineffective and dangerous.
Products must be quality controlled. A complete listing of certified home treatment systems can
be found at the web site of NSF, The Public Health and Safety Company at:
www.nsf.org/Certified/DWTU/

37
 Water

A SUCCESS STORY

38

<<NOTE TO USER: To be completed locally.>>

38
 Water

CONSERVATION FOR THE FUTURE

By 2025:
40% of the world’s
population will live in
areas of water stress

By 2050:
WHO
25% of the world’s
population will live in
areas of water scarcity

39

Finally, water is critical to life; it is essential for drinking, cooking, hygiene, agriculture and
recreation.
As the world’s population increases, increasing numbers of people are living in areas that are
water stressed or where water is scarce.
Not only is water a quality issue, it is also a quantity issue.
Projections indicate that some constraints on water use will be placed on 40% of the world’s
population by 2025, and water scarcity may affect up to one quarter of the world’s population by
2050. Protecting this precious resource from pollution is critical to assuring public health.

Refs:
• Gleick PH. Making every drop count. Scientific American, 2001
(www.sciam.com/article.cfm?chanID=sa006&colID=1&articleID=00088224-0964-1C71-
84A9809EC588EF21).
• Tibbetts J. Water World 2000. Environmental Health Perspectives, 2000, 108:A69.

Picture above: WHO, H. Bower. Children collecting water, drought-stricken, Gulran district, Herat
province, Afghanistan, Sept 2001.
Picture below: WHO, H. Anenden. Environment water distribution, Guinea-Bissau, Africa.

39
 Water

WATER BUDGETS

UNEP

40

We must learn to live within the limits of the renewable, rechargeable freshwater budgets of our
region.
Deep aquifers can take centuries or millennia to recharge.
Excessive withdrawal is not sustainable.
Picture: www.unep.org/vitalwater/05.htm

40
 Water

WATER BUDGETS

UNEP 41

The water cycle consists of precipitation, evaporation, evapotranspiration and runoff. This
graphic explains the global water cycle, showing how nearly 577 000 km3 of water circulates
through the cycle each year.

Picture: www.unep.org/vitalwater/05.htm

41
 Water

CRITICAL ROLE OF HEALTH AND

ENVIRONMENT PROFESSIONALS

Diagnose and treat

Do research and publish results
 Detect sentinel cases
 Inspire community-based interventions

Educate
 Patients and families
 Colleagues and students

Advocate

Provide good role model
42

Health and environment professionals have a critical role to play in maintaining and stimulating
changes that will ensure children's access to safe water and protect their health.
Although the human genome project is very important and scientifically exciting, we all know that
genes express themselves within an environment and that understanding the gene–environment
interactions is what will keep our children healthy.
So, as we look to our political and personal lives to support sustainable development, we can
look to our practices for ways of enhancing the environmental health of our patients.
All of us can do something.
•At the one-to-one patient level we can include environmental etiologies in our differential
diagnoses and in our preventive advice: is the disease linked to the quality or availability of
water? It is important to limit the number of diagnoses given as “idiopathic” and to look hard for
environmental, water-related, causes of disease and disability.
•Health care providers should be alert and detect the "sentinel" cases. Their detection and study
will be essential for developing, proposing and supporting community-based interventions.
Publication of cases and research studies enables the communication of knowledge and
experience that will benefit other communities and countries.
•It is important to inform and educate our patients, families, colleagues and students didactically,
on the importance of water-related diseases and how to avoid them.
•Finally, we must all become vigorous advocates for the protection of water sources from
pollution, the appropriate treatment and storage of water, respect for drinking-water quality
standards, and water conservation. These and other measures are crucial for protecting the
environmental health of our children and future generations. It is not enough to be an informed
citizen, we need to write letters, testify at hearings, convince decision-makers, approach our
elected officials with information, education and clear messages based upon the evidence.
•And, we must all recognize that as professionals with an understanding of both health and the
environment, we are powerful role models. Our choices and opinions with respect to water and
to other environmental factors will be noticed: they should be thoughtful and sustainable.

42
 Water

POINTS FOR DISCUSSION

43

<<NOTE TO USER: Add points for discussion according to the needs of your audience.>>

43
Water
ACKNOWLEDGEMENTS
WHO is grateful to the US EPA Office of Children’
Children’s Health Protection for the
financial support that made this project possible and for some ofthe data,
graphics and text used in preparing these materials.

First draft prepared by Katherine M. Shea MD MPH, USA

With the advice of the Working Group Members on Training
Package for the Health Sector: Cristina Alonzo MD (Uruguay);
Yona Amitai MD MPH (Israel); Stephan Boese-O’Reilly MD MPH
(Germany); Irena Buka MD (Canada); Lilian Corra MD
(Argentina); Ruth A. Etzel MD PhD (USA); Ligia Fruchtengarten
MD (Brazil); Amalia Laborde MD (Uruguay); Leda Nemer TO
(WHO/EURO); R. Romizzi MD (ISDE, Italy); S. Borgo MD (ISDE,
Italy).
Reviewers: F. Were MD (Kenya), Y. Amitai MD MPH (Israel), F. van
Hoof (Belgium), Ruth A. Etzel, MD, PhD (USA)
Update: July 2008
WHO CEH Training Project Coordination: Jenny Pronczuk MD
Medical Consultant: Katherine M. Shea MD MPH
Technical Assistance: Marie-Noël Bruné MSc
44

44
 Water

DISCLAIMER
 The designations employed and the presentation of the material in this publication do not imply the
expression of any opinion whatsoever on the part of the World Health Organization concerning the
legal status of any country, territory, city or area or of its authorities, or concerning the delimitation of
its frontiers or boundaries. Dotted lines on maps represent approximate border lines for which there
may not yet be full agreement.
 The mention of specific companies or of certain manufacturers’ products does not imply that they are
endorsed or recommended by the World Health Organization in preference to others of a similar
nature that are not mentioned. Errors and omissions excepted, the names of proprietary products are
distinguished by initial capital letters.
 The opinions and conclusions expressed do not necessarily represent the official position of the World
Health Organization.
 This publication is being distributed without warranty of any kind, either express or implied. In no
event shall the World Health Organization be liable for damages, including any general, special,
incidental, or consequential damages, arising out of the use of this publication
 The contents of this training module are based upon references available in the published literature as
of the last update. Users are encouraged to search standard medical databases for updates in the
science for issues of particular interest or sensitivity in their regions and areas of specific concern.
 If users of this training module should find it necessary to make any modifications (abridgement,
addition or deletion) to the presentation, the adaptor shall be responsible for all modifications made.
The World Health Organization disclaims all responsibility for adaptations made by others. All
modifications shall be clearly distinguished from the original WHO material.

45

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