Burden of disease from inadequate water, sanitation and hygiene for selected adverse health outcomes: An updated analysis with a focus on low- and middle-income countries.
BACKGROUND
To develop updated estimates in response to new exposure and exposure-response data of the burden of diarrhoea, respiratory infections, malnutrition, schistosomiasis, malaria, soil-transmitted helminth infections and trachoma from exposure to inadequate drinking-water, sanitation and hygiene behaviours (WASH) with a focus on low- and middle-income countries.


METHODS
For each of the analysed diseases, exposure levels with both sufficient global exposure data for 2016 and a matching exposure-response relationship were combined into population-attributable fractions. Attributable deaths and disability-adjusted life years (DALYs) were estimated for each disease and, for most of the diseases, by country, age and sex group separately for inadequate water, sanitation and hygiene behaviours and for the cluster of risk factors. Uncertainty estimates were computed on the basis of uncertainty surrounding exposure estimates and relative risks.


FINDINGS
An estimated 829,000 WASH-attributable deaths and 49.8 million DALYs occurred from diarrhoeal diseases in 2016, equivalent to 60% of all diarrhoeal deaths. In children under 5 years, 297,000 WASH-attributable diarrhoea deaths occurred, representing 5.3% of all deaths in this age group. If the global disease burden from different diseases and several counterfactual exposure distributions was combined it would amount to 1.6 million deaths, representing 2.8% of all deaths, and 104.6 million DALYs in 2016.


CONCLUSIONS
Despite recent declines in attributable mortality, inadequate WASH remains an important determinant of global disease burden, especially among young children. These estimates contribute to global monitoring such as for the Sustainable Development Goal indicator on mortality from inadequate WASH.
['Prüss-Ustün|Annette|A|', 'Wolf|Jennyfer|J|', 'Bartram|Jamie|J|', 'Clasen|Thomas|T|', 'Cumming|Oliver|O|', 'Freeman|Matthew C|MC|', 'Gordon|Bruce|B|', 'Hunter|Paul R|PR|', 'Medlicott|Kate|K|', 'Johnston|Richard|R|']
D003906:Developing Countries D003967:Diarrhea D062665:Epidemiological Monitoring D006373:Helminthiasis D006801:Humans D006920:Hygiene D007411:Intestinal Diseases, Parasitic D008288:Malaria D044342:Malnutrition D011203:Poverty D012141:Respiratory Tract Infections D018570:Risk Assessment D012499:Sanitation D012552:Schistosomiasis D014881:Water Supply
Burden of disease Water Sanitation Hygiene Diarrhoea Comparative risk assessment Drinking water Hand washing