Driven by Data: Targeting WASH Interventions for Enteric Disease Prevention

On Wednesday, August 26, 2020, the Coalition against Typhoid and the World Bank Group convened the World Water Week At Home session, “Driven by Data: Targeting WASH Intervention for Enteric Disease Prevention.” The session included a robust and comprehensive discussion and Q&A with a group of expert panelists, including Dr. Steve Luby (Stanford University), Dr. George Joseph (World Bank Group), Dr. Ranjiv Khush (Aquaya Institute) and Dr. Aidan Cronin (UNICEF Zimbabwe).

Below is a continuation of this discussion and audience Q&A. You can view the full recorded session here.

What are the current barriers to accomplishing SDG 6, which sets out ensure availability and sustainable management of water and sanitation for all, and how may the methods and data presented in the session help to overcome them?

SL: A primary barrier to accomplishing SDG 6 is that it is so ambitious that it does not provide clear prioritization or a pathway for progress. We have a growing global population, falling groundwater, decreasing levels of surface water and so a combined year on year reduction in per capita water availability. There have been global commitments to extend water and sanitation services to the poor at least since the International Drinking Water Decade of 1981-1990. When admirable sounding goals are not combined with a realistic implementation pathway, and the requisite resources to accomplish these goals, then the goals will not be achieved. The historical record and scale of the problem make fairly clear that the world will not achieve SDG 6. Given that framing, and a paucity of resources, it is reasonable to ask where we should focus our efforts. Environmental surveillance is a tool that helps to identify settings that are particularly important for the fecal oral transmission of typhoid and cholera. Investments to ameliorate this environmental contamination are likely to be particularly effective and so should be assigned a higher priority.

GJ: The main barrier that is always cited first is financing. The World Bank estimates that constructing the infrastructure alone will cost $114 billion USD per year between now and 2030 – excluding the cost of operation and maintenance. However, frequently, after construction, water and sanitation infrastructure falls quickly into disrepair, so if investments are not properly targeted, that financing can go to waste.  In order to effectively target the infrastructural investments needed, data can help to prioritize where to invest, and in what. For example the World Bank WASH Poverty Diagnostics showed that between 40-60% of water points in rural Nigeria and Tanzania were non-functioning in 2018. Having data to know where we need maintenance and repair rather than new construction can help each dollar go further into making a greater impact towards achieving SDG 6.

RK: The fundamental challenge is the unwillingness or inabilities of national governments to adequately invest in all of the requirements (water resources management, infrastructure, human capacity, governance and enforcement, pro-poor subsidies and services, etc) needed to achieve SDG 6. Better data may motivate greater government commitment by highlighting areas of progress and areas of greatest need.

AC: Its clear from the session how important good quality data is to inform interventions – this is the case from emergency response up to longer term decisions around reaching SDG 6. My intervention was that the initial data collection in a cholera/typhoid outbreak is very important and we saw this around the Case Area targeted interventions we established in Zimbabwe to tackle the 2018-19 cholera outbreak. We know that there is an increased risk of transmission of neighboring households of at least 200 m during the 5 days immediately following case presentation (Azman, A. et al. 2018) and living within 50 m of confirmed cholera cases 36 times more risk in first 3 days (Debes, A.K. et al. 2016).  With rapid response teams (RRTs) visiting each case household within 24 hours (and their neighbors) we monitored this intervention very carefully. With the use of RRTs expanding in cholera outbreaks, more evidence is needed to improve implementation. US CDC worked with UNICEF and partners on the ground to develop a standard monitoring framework that was piloted in Zimbabwe and can be adapted to other settings.  The monitoring framework included 5 main components:

  • The assignment and supply forms used to manage the teams, both in terms of knowing where to respond and keeping track of inventory
  • The case investigation form to identify risk factors at the household
  • The household barrier form to assess the characteristics of the cordon sanitaire, and finally
  • Post intervention monitoring forms to assess uptake of interventions.

How can we increase the use of data to drive WASH interventions, investments and evidence-based decision-making?

SL: There are many particular pathways that fecal-oral transmitted pathogens can use to move from one infected host to the next uninfected person. It is prohibitively expensive to interrupt all pathways in all environments. Environmental surveillance data can help identify dominant pathways that would benefit from WASH interventions.

GJ: There is data everywhere, and in recent years, the quantity and type of data available has grown exponentially, especially with the growth of social media and big data. However, despite this, a lot of the data which could be used for analysis is either not properly shared or made use of to its full potential. Both internationally and at a country level, more integration and collaboration is needed. The World Bank’s own Open Data Platform is one initiative that has sought to do this globally, and within the Bank there are constant efforts to integrate data in decision making through analytics such as that presented here. However, to facilitate such efforts, integrated systems would cut out a lot of the work, saving time, money and energy which could be better channeled towards targeted investments.

RK: It is critical to improve the capacity of government decision makers at all administrative levels to interpret and use data.

AC: This is a very big question indeed and needs advocacy from every part of the programming cycle – first for more funds for WASH and then more allocations within WASH budget for data collection, monitoring, evaluation etc. The recent COVID-19 experience has shown that the quality of the response is based on the quality of the preparedness – both in terms of available infrastructure and capacity within the response teams and eventually the quality of the data being collected to drive the interventions and eventually the effectiveness of those interventions based on no or poor quality data – hence it is a real integrated circle.  Perhaps some additional ideas on this in a country context can be seen at Cronin, A.A., Thompson, N. (2014) Data and Monitoring in the Indian Rural Water and Sanitation Sector – a review of current status and proposed ways forward, Journal of Water, Sanitation and Hygiene for Development, Vol. 4, No. 4, p590-603.

COVID-19 has emphasized the importance of public health and the need for global preparedness to infectious diseases. In this context, what can organizations do to enhance international collaboration for preparing responses to disease outbreaks? Where could integrated data-driven approaches be useful?

GJ: In a sense, the coronavirus pandemic offers a rare opportunity for global collaboration to inform disease preparedness given that it reached at least 188 countries (JHU) on every continent except Antarctica. With regards to data, on the face of it, it is tempting to simply compare summary statistics  such as case numbers and deaths. However, a collaborative approach can help us to get beyond these headline figures into understanding how and why different countries experienced the outbreak differently. Sometimes data can serve to raise more questions than answers: for example – why are case numbers so much lower in many Sub Saharan African countries than initially anticipated? To what extent is the timing of imposition of movement restrictions important? Are younger children less infectious, as well as less frequently experiencing severe symptoms? What role do asymptomatic cases play? In the process of asking these questions on a global, collaborative level, we are more likely to be able to collectively address the questions with a greater body of information to draw upon for an answer.

Steve, in the infectious disease and public health sector, we often view water and sanitation systems improvements as “long-term solutions” given the high cost and resources needed to implement. This has led to the prioritization of other interventions such as vaccines as a way to prevent and control waterborne diseases including typhoid and cholera. Now with vaccines for both cholera and typhoid available, how should we shift our view of WASH and its role in disease prevention?

SL: Especially given the increasing prevalence of drug resistance, we cannot view the interruption of typhoid transmission as a choice between vaccine or WASH. The typhoid conjugate vaccine (TCV) is super important to protect people against what is becoming an increasingly difficult to treat infection, but it is not a panacea. The current TCV leaves 15% of people who are vaccinated unprotected. The vaccine has no effect against Salmonella paratyphi. We know from other vaccine programs that many people at risk will not be vaccinated. The oral cholera vaccine leaves even more vaccinated people unprotected. At the same time, however, WASH interventions characteristically have incomplete coverage in low- and middle-income country settings. As we increasingly appreciate the capacity for these pathogens to rapidly kill previously healthy people, broadening the set of tools to protect populations is important. Both vaccine and WASH interventions offer the prospect of interrupting transmission, including transmission of drug-resistant strains.

Steve, in your presentation, did the environmental surveillance work described look at the proportion of resistant Salmonella Typhi?

SL: We did not look at drug-resistant Salmonella typhi in the studies in Bangladesh and Nepal, but as part of the outbreak investigation in Pakistan, studies in Hyderabad during the peak of the ceftriaxone-resistant Salmonella typhi outbreak were also frequently positive.

George, you mentioned in your presentation that you see scope to conduct similar such work in other countries around the world. From the countries you are currently working in, can you think of any where some of the geo-spatial approaches or mobility analysis that you mentioned would be useful?

GJ: The benefit of the analysis conducted here is that it can be conducted in any country around the world which has available data sources. Especially now, with extensive mobile phone coverage even in the least developed countries, we have new opportunities to conduct data analysis if appropriate agreements can be set up. For example, GSMA tracks coverage of different cell phone providers worldwide. This data can in turn inform all kinds of water, sanitation and hygiene  infrastructure investments with knock on implications for health and the economy.

Some of the more traditional data sources are already available on a country by country basis, such as the census or household survey data sets such as the USAID Demographic and Health Survey (DHS), World Bank Living Standards and Measurement Survey (LSMS) and UNICEF Multiple Indicator Cluster Survey (MICS) initiatives. Put in combination, these data sources can constitute a powerful opportunity to inform new initiatives.

Bangladesh, the DRC and Mozambique are just a few countries where further work of this nature may be possible. Countries which have rich epidemiological data, high population density and extensive network coverage are particularly good candidates.

Ranjiv, in 2004 the World Health Organization introduced Water Safety Plans to help manage and ensure the safety of countries’ drinking water supply. Since then, you and your colleagues have conducted several impact assessments and analyses on these plans, including those in the Asia-Pacific Region. How do you think the data and surveillance methods presented in this session could be integrated into the WHO’s Water Safety Plans approach?

RK: The primary goal of a Water Safety Plan is to establish a preventative risk management approach for water supplies.  Data is necessary for monitoring water supply risks, and Water Safety Plan development could include capacity building in the collection, interpretation and use of data.

George, SDG 17.18 focuses on “the availability of high-quality, timely and reliable data.” There are now several initiatives, including the World Bank’s Open Data platform, which increases data access and transparency. How can we build on these initiatives and ensure that data, particularly at the country level, is available to the public without sacrificing anonymity and privacy?

GJ: Systematic, collaborative efforts between both national and global institutions can strengthen the use of data for decision-making. However, as mentioned in the question, with an ever increasing quantity of data there is a need for it to be managed according to principles which pay due consideration to privacy and security. Though this is well established in many higher income countries such as through the GDPR in Europe, some developing countries have less well established frameworks for data processing and sharing. The UN has formed the Global Partnership for Sustainable Development Data which outlines principles for how governments, companies and civil society can participate in data sharing within an ethics and integrity framework. UNCTAD has also been keeping track of countries adopting legislation on data privacy worldwide. Though there are still ways to go, thus far in Africa and Asia, 55% of countries have adopted some data privacy and security legislation, 11% below the global average.

Steve, you mentioned in your presentation two localities, Nepal and India, which face growing water scarcity. How might climate change and urbanization impact already fragile water supplies and the transmission of diseases like typhoid and cholera in these areas? 

SL: Climate change increases the risk and severity of drought and other extreme weather events. Urbanization is increasing globally, driven by economic returns of living in cities. Many cities are living well beyond their water budgets, that is they are drawing more water out of their aquifers than are naturally being recharged and they are transporting water from further and further away. Urban populations continue to grow. Climate change continues to worsen. Intermittent delivery of piped water introduces contaminants. In the setting of all of these major trends worsening, we need to develop new engineering approaches to provisioning safe water to urban residents, while simultaneously supporting the ecosystems and watersheds that nourish the biosphere.

Aidan, what broader data collection initiatives does UNICEF Zimbabwe have? Have you seen how the data that you collect be used by governments for WASH and other public health interventions?

AC:  We work very closely with the Government of Zimbabwe and have developed with them the Rural WASH Information Management system in Zimbabwe. In the mid-1990s, Zimbabwe had attained very high levels of service delivery in both rural and urban water supply, sanitation and hygiene. However, by the early 2000s, economic decline resulted in diminishing capacity to manage the aging infrastructure and limited further expansion of the WASH sector. With needs increasing and resources dwindling, it was imperative for the sector to come up with an effective WASH information management system to provide regular, reliable data for use in planning for equitable WASH services. The WASH sector has a decentralised governance structure from national to village levels that recognises the role of communities in planning, implementing, monitoring and evaluating services. The National Action Committee (NAC) has developed a comprehensive roadmap for the WASH sector to guide sector recovery, transition and development efforts. An important aspect of this strengthening process is the transparent availability of reliable and complete data for planning and decision making at all levels. These data are critical because most national surveys such as MICS and DHS provide only provincial level data which mask district, ward and village level inequities.

In response to the need for accurate up-to date data, the Government with support from UNICEF, SNV and other partners established the Rural WASH Information Management System (RWIMS). RWIMS is a mobile-to-web-based system which captures and stores WASH data in near real-time thereby providing quick access to up-to- date national data on WASH infrastructure at all governance levels. The data is used for planning and decision-making to ensure equitable use of safe drinking water, sanitation and improved hygiene practices.

Currently RWIMS’ design is hinged on 3 blocks: RWIMS Field Force, RWIMS Geodatabase, and RWIMS Online. RWIMS Field Force is the data entry platform for RWIMS data. The Field Force is handled by community-based government extension workers who are responsible for in-putting data on pre-defined indicators on any changes in infrastructure as observed during their daily extension routines or as reported by community members. RWIMS Geodatabase is the data storage facility which is hosted by a server at the Ministry of Environment, Water and Climate. RWIMS Online is the web-based platform through which data and reports can be accessed. This configuration allows for communities to supply data for updating on RWIMS Geodatabase and for stakeholders to generate reports through RWIMS Online.

A major constraint with this system is that data flows only in one direction – from the communities to the stakeholders. The absence of a mechanism to provide feedback to communities and ensure that breakdowns in infrastructure are reported by communities and repaired timeously has often resulted in communities not seeing the need to report because of the length of time it takes for reports to be received and acted upon.

A second challenge relates to real-time updating of the WASH databases. While districts have various strategies for local level updating of database, there is currently no mechanism that obtains this data in real-time. The current design requires multi-stage information conveyance with an average time lag of one month, a period that is too long for communities. By the time updates are sent in, a lot would have happened. In addition communities incur SMS charges to communicate changes in WASH infrastructure. This then constraints effective planning and response in service delivery. These challenges can therefore be put into two broad categories:

  1. Lack of feedback and response mechanism to communities for sustained access to WASH services;
  2. Absence of a village-level mechanism for updating the WASH database in real-time. Current mechanisms take too long.

The proposed solution to these two challenges is the development of an SMS-based RWIMS interface that enables communities to report changes in infrastructure functionality through SMS directly to the extension worker. This avoids a long reporting mechanism. Once an SMS on a breakdown is sent to the extension worker, the system automatically toggles an SMS to the service provider (e.g. village pump mechanic, village health worker, etc.) to follow up and attend to the issue as reported.   This has helped a lot to speed up response times to service porovision challenges. District authorities are able to track the time taken by the service provider to respond to issues raised by the community thereby holding them accountable. This accountability platform serves to reduce downtime of WASH infrastructure for sustained access to safe drinking water and adequate sanitation. This solution is based on the development of an interface “RWIMS SMS Notification and Response System” (RWIMS SNR) which integrates data from RapidPro SMSes to georeferenced data of facilities and villages in RWIMS. The schematic below shows how this system will work. The RWIMS SNR interface stretches the capabilities of RapidPro to enable the system to function as depicted below. A registered community member (key informant) sends an SMS through RapidPro to the RWIMS Server which links the number of the key informant to particular infrastructure and in turn RWIMS Server toggles RapidPro to send messages to service providers and government extension workers responsible for the infrastructure being reported on.