03373nas a2200601   4500000000100000008004100001653001000042653002100052653002000073653002500093653001300118653001900131653002700150653001100177653001100188653001200199653001100211653001100222653000900233653003200242653002600274653001700300653001500317653001800332653001700350100002000367700001400387700001300401700001400414700001400428700001300442700001400455700001400469700001600483700001500499700001500514700001300529700001400542700001600556700001500572700001700587700001600604700001200620700001300632700001100645700001700656245015700673856006100830300001200891490000700903520184700910022001402757       2014                            d10aChild10aChild, Preschool10aCost of Illness10aDeveloping countries10aDiarrhea10aDrinking water10aEnvironmental Exposure10aFemale10aHumans10aHygiene10aIncome10aInfant10aMale10aQuality-Adjusted Life Years10aRetrospective Studies10aRisk Factors10aSanitation10aWater Quality10aWater Supply1 aPrüss-Ustün A1 aBartram J1 aClasen T1 aColford J1 aCumming O1 aCurtis V1 aBonjour S1 aDangour A1 aDe France J1 aFewtrell L1 aFreeman MC1 aGordon B1 aHunter PR1 aJohnston RB1 aMathers CD1 aMäusezahl D1 aMedlicott K1 aNeira M1 aStocks M1 aWolf J1 aCairncross S00aBurden of disease from inadequate water, sanitation and hygiene in low- and middle-income settings: a retrospective analysis of data from 145 countries.  uhttp://onlinelibrary.wiley.com/doi/10.1111/tmi.12329/pdf  a894-9050 v193 a<p><strong>OBJECTIVE: </strong>To estimate the burden of diarrhoeal diseases from exposure to inadequate water, sanitation and hand hygiene in low- and middle-income settings and provide an overview of the impact on other diseases.</p>

<p><strong>METHODS: </strong>For estimating the impact of water, sanitation and hygiene on diarrhoea, we selected exposure levels with both sufficient global exposure data and a matching exposure-risk relationship. Global exposure data were estimated for the year 2012, and risk estimates were taken from the most recent systematic analyses. We estimated attributable deaths and disability-adjusted life years (DALYs) by country, age and sex for inadequate water, sanitation and hand hygiene separately, and as a cluster of risk factors. Uncertainty estimates were computed on the basis of uncertainty surrounding exposure estimates and relative risks.</p>

<p><strong>RESULTS: </strong>In 2012, 502,000 diarrhoea deaths were estimated to be caused by inadequate drinking water and 280,000 deaths by inadequate sanitation. The most likely estimate of disease burden from inadequate hand hygiene amounts to 297,000 deaths. In total, 842,000 diarrhoea deaths are estimated to be caused by this cluster of risk factors, which amounts to 1.5% of the total disease burden and 58% of diarrhoeal diseases. In children under 5 years old, 361,000 deaths could be prevented, representing 5.5% of deaths in that age group.</p>

<p><strong>CONCLUSIONS: </strong>This estimate confirms the importance of improving water and sanitation in low- and middle-income settings for the prevention of diarrhoeal disease burden. It also underscores the need for better data on exposure and risk reductions that can be achieved with provision of reliable piped water, community sewage with treatment and hand hygiene.</p>
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