Risk-Management Strategies to Reduce Waterborne Disease
By Kelly A. Reynolds, MSPH, PhD
Every year on March 22, we celebrate World Water Day around the globe. This year’s theme is Leaving No One Behind. World Water Day serves as a reminder that sustainability of a safe, available water supply is not trivial or automatic, but requires constant monitoring, management and action. The World Health Organization continues to provide resources and protocols for managing drinking-water quality and availability, most recently using a Water Safety Plan (WSP) model. Building on a risk management strategy, the WSP approach is being adopted worldwide and appears to be adaptable to highly variable drinking-water systems.
Water quality concerns
Globally, about one-sixth of the population lacks access to an improved water supply within one kilometer (0.62 miles) of their homes. Diarrheal disease from contaminated water results in up to two million deaths per year and is the fourth leading cause of early death and disability around the world, affecting children and developing nations disproportionately.(1) The call for improved water safety is heard around the world in both developing and developed nations.
Within the 17 Sustainable Development Goals established by the United Nations, Sustainable Development Goal 6 is: “Ensure the availability and sustainable management of water and sanitation for all.”(2) The goal of Target 6.1 is: “By 2030, achieve universal and equitable access to safe and affordable drinking-water for all” and to ensure that populations are “using safely managed drinking-water services.” Previously, the Millennium Development Goals focused on providing access to water but lacked provisions for improved water quality. This was a gap in efforts needed to move forward in achieving SDG 6.
Important in reaching these development goals is the implementation of WSPs along with an understanding of how they effectively address water sustainability, sanitation and hygiene issues leading to the production of consistent and safe drinking-water supplies. To be successful, a supportive organizational culture is critical among water suppliers and WSP stakeholders. In other words, implementation of this new risk-management process should be perceived as a net benefit and not a punishment for water suppliers.(2)
Although WSPs have been utilized previously, in 2004, the World Health Organization published the third revision of the WHO Guidelines for Drinking-water Quality to highlight a broad-spectrum WSP approach for managing drinking-water quality and risks from catchment to consumer. Since then, numerous add-on guides have been published, including a step-by-step risk management manual for drinking-water suppliers.(3) The general WSP steps include:
a. Preliminary actions, including assembling the WSP team
2. System assessment
a. Describe the water supply system.
b. Identify hazards and risks.
c. Determine and validate control measures, reassess and prioritize risks.
d. Develop, implement and maintain an improvement/upgrade plan.
3. Operational monitoring
a. Define monitoring and control measures.
b. Verify the effectiveness of the WSP (are health-based targets being met?).
4. Management and communication
a. Prepare management procedures.
b. Develop supporting programs.
Steps associated with the system assessment/upgrade plan include the identification of financial investment needs for major system modification. Part of the management and communication follow-up is to periodically review the WSP for any changes required or system changes that evolved over time. Additionally, any incidents that occur along the way, as either part of the operational monitoring discoveries or an event emergency (i.e., an outbreak or illness case), require an immediate revision of the WSP to address the incident causes.
Key to the success of a WSP is the dynamic nature of the procedure, which requires consistent evaluation, verification and response to adapt to specific utility needs. The WHO WSP guideline is applicable to a range of supply types including: large-scale, urban water treatment utilities, shared rural-piped supply stations or individual wells.
WSP benefits include assessment and management of supplies from catchment to consumer and adaptability to local regions, while considering the inherent challenges within those regions. Implementation of the WSP approach has been rapid for some but not all countries and regions. In the 15 years since publication of the 2004 WHO WSP guidance, more than 93 countries have implemented WSPs.(4) Evidence of WSP adaptability is that nearly 72 percent of countries implementing the approach are doing so in limited-resource, rural settings.
A recent article in the International Journal of Hygiene and Environmental Health reviewed some of the barriers and resources available for WSP capacity building and training for utilities, governments and other stakeholders.(2) (Barriers to implementation continue to be financial, where sustainable investments, labor and training, and auditing practices are limited.) A variety of tools have been used to overcome site-specific barriers.(5) Online training helped to launch the implementation of WSPs in some countries. Additionally, manuals were created in local languages to improve use. Financial incentives proved effective for others. For example, in Scotland, only suppliers with a risk-assessment plan were eligible for utility improvement grants. For many regions, the biggest adoption of WSPs occurred only after national, enforceable regulations required such compliance.
Data is building in support of WSPs, not only as a health risk management tool but also a cost benefit.(5) For example, significant operational expense savings have been reported from adopters in Australia, with an estimated savings from reduced operational expenses of $7,500 to $38,000 per incident. Public utilities in Portugal reported a 56-percent reduction in laboratory testing and operating costs following WSP implementation.
Solving the world’s water crisis requires a multidisciplinary approach from experts in water harnessing; supply management; effective treatment; safe distribution; storage and consumption. Population increases in regions where water availability does not support demand require political negotiations to navigate how upstream harvesting effects downstream needs. The complexities of these issues are compounded by unpredictable changes in rainfall and hydrological cycles.
A WSP formalizes the process for controlling hazards that can be addressed and planning ahead for what is needed to address the next targeted contaminants or events. Even in developed countries with sophisticated infrastructure and well-monitored systems, risk management can fail, resulting in waterborne disease outbreaks. Increased use of WSPs is expected to reduce these risks and help to improve public health. POU water-treatment devices continue to provide risk-management solutions within the control of the consumer and are utilized by some utilities as best-practice interventions. As WSPs develop, the POU industry should consider their role in supporting utility risk-reduction targets.
(1) The Institute for Health Metrics and Evaluation (IHME). “What is the Global Burden of Disease (GBD)? Institute for Health Metrics and Evaluation.” The University of Washington. www.healthdata.org/infographic/what-global-burden-disease-gbd. Published 2019. Accessed March 10, 2019.
(2) Ferrero G, Setty K, Rickert B, et al. “Capacity building and training approaches for water safety plans: A comprehensive literature review.” Int J Hyg Environ Health. February 2019. doi:10.1016/j.ijheh.2019.01.011.
(3) Bartram J, Corrales L, Davison A, et al. “Water Safety Plan Manual: Step-by-Step Risk Management for Drinking-Water—World Health Organization, International Water Association—Google Books.” Geneva: World Health Organization; 2009. https://books.google.com/books?id=iVCV0Hd2ElYC&printsec=frontcover#v=onepage&q&f=false. Accessed March 16, 2019.
(4) Rinehold A. “GLOBAL STATUS REPORT ON WATER SAFETY PLANS: A Review of Proactive Risk Assessment and Risk Management Practices to Ensure the Safety of Drinking-Water.” 2017. https://apps.who.int/iris/bitstream/handle/10665/255649/WHO-FWC-WSH-17.03-eng.pdf;jsessionid=F2E31C0F087AE72E7896D3CEBDF5881E?sequence=1. Accessed March 10, 2019.
(5) Baum R, Bartram J. “A systematic literature review of the enabling environment elements to improve implementation of water safety plans in high-income countries.” J Water Health. 2018;16(1):14-24. doi:10.2166/wh.2017.175.
About the author
Dr. Kelly A. Reynolds is a University of Arizona Professor at the College of Public Health; Chair of Community, Environment and Policy; Program Director of Environmental Health Sciences and Director of Environment, Exposure Science and Risk Assessment Center (ESRAC). She holds a Master of Science Degree in public health (MSPH) from the University of South Florida and a doctorate in microbiology from the University of Arizona. Reynolds is WC&P’s Public Health Editor and a former member of the Technical Review Committee. She can be reached via email at email@example.com