Maria Neira

Burden of disease from inadequate water, sanitation and hygiene in low- and middle-income settings: a retrospective analysis of data from 145 countries

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.

Assessing the impact of drinking water and sanitation on diarrhoeal disease in low- and middle-income settings: Systematic review and meta-regression

To assess the impact of inadequate water and sanitation on diarrhoeal disease in low‐ and middle‐income settings.

Health consequences of exposure to e-waste: a systematic review

BACKGROUND The population exposed to potentially hazardous substances through inappropriate and unsafe management practices related to disposal and recycling of end-of-life electrical and electronic equipment, collectively known as e-waste, is increasing. We aimed to summarise the evidence for the association between such exposures and adverse health outcomes. METHODS We systematically searched five electronic databases (PubMed, Embase, Web of Science, PsycNET, and CINAHL) for studies assessing the association between exposure to e-waste and outcomes related to mental health and neurodevelopment, physical health, education, and violence and criminal behaviour, from Jan 1, 1965, to Dec 17, 2012, and yielded 2274 records. Of the 165 full-text articles assessed for eligibility, we excluded a further 142, resulting in the inclusion of 23 published epidemiological studies that met the predetermined criteria. All studies were from southeast China. We assessed evidence of a causal association between exposure to e-waste and health outcomes within the Bradford Hill framework. FINDINGS We recorded plausible outcomes associated with exposure to e-waste including change in thyroid function, changes in cellular expression and function, adverse neonatal outcomes, changes in temperament and behaviour, and decreased lung function. Boys aged 8-9 years living in an e-waste recycling town had a lower forced vital capacity than did those living in a control town. Significant negative correlations between blood chromium concentrations and forced vital capacity in children aged 11 and 13 years were also reported. Findings from most studies showed increases in spontaneous abortions, stillbirths, and premature births, and reduced birthweights and birth lengths associated with exposure to e-waste. People living in e-waste recycling towns or working in e-waste recycling had evidence of greater DNA damage than did those living in control towns. Studies of the effects of exposure to e-waste on thyroid function were not consistent. One study related exposure to e-waste and waste electrical and electronic equipment to educational outcomes. INTERPRETATION Although data suggest that exposure to e-waste is harmful to health, more well designed epidemiological investigations in vulnerable populations, especially pregnant women and children, are needed to confirm these associations. FUNDING Childrens Health and Environment Program, Queensland Childrens Medical Research Institute, The University of Queensland, Australia.

Schistosomiasis and soil-transmitted helminth infections: forging control efforts

et al., 1992). After gradual intensification of efforts over the ensuing 10 years, the WHO and its member states and partners are implementing a combined strategy for the control of schistosomiasis and soil-transmitted helminths, integrated into ongoing health and education initiatives (WHO, in nrenaration, a). This strategy is summarized-in the World Health Assemblv (WHA) resolution of Mav 2001 KVHA. 200 1). ~l?re resolution urges member .states to ‘ensure access to essential drugs against schistosomiasis and soil-transmitted helminthiasis in all health services in endemic areas for the treatment of clinical cases and groups at high risk of morbidity such as women and children, with the goal of attaining a minimum target of regular administration of chemotherapy to at least 75% and up to 100% of all school-age children at risk of morbidity by 20 10. This policy is based on the evidence that morbidity can be controlled by periodical treatment of high-risk groups with anthelminthics. The burden of disease

Mass lead intoxication from informal used lead-acid battery recycling in dakar, senegal.

Background and objectives Between November 2007 and March 2008, 18 children died from a rapidly progressive central nervous system disease of unexplained origin in a community involved in the recycling of used lead-acid batteries (ULAB) in the suburbs of Dakar, Senegal. We investigated the cause of these deaths. Methods Because autopsies were not possible, the investigation centered on clinical and laboratory assessments performed on 32 siblings of deceased children and 23 mothers and on 18 children and 8 adults living in the same area, complemented by environmental health investigations. Results All 81 individuals investigated were poisoned with lead, some of them severely. The blood lead level of the 50 children tested ranged from 39.8 to 613.9 μg/dL with a mean of 129.5 μg/dL. Seventeen children showed severe neurologic features of toxicity. Homes and soil in surrounding areas were heavily contaminated with lead (indoors, up to 14,000 mg/kg; outdoors, up to 302,000 mg/kg) as a result of informal ULAB recycling. Conclusions Our investigations revealed a mass lead intoxication that occurred through inhalation and ingestion of soil and dust heavily contaminated with lead as a result of informal and unsafe ULAB recycling. Circumstantial evidence suggested that most or all of the 18 deaths were due to encephalopathy resulting from severe lead intoxication. Findings also suggest that most habitants of the contaminated area, estimated at 950, are also likely to be poisoned. This highlights the severe health risks posed by informal ULAB recycling, in particular in developing countries, and emphasizes the need to strengthen national and international efforts to address this global public health problem.

Long-lasting treated mosquito nets: a breakthrough in malaria prevention

Editor – Regardless of views expressed recently in the Bulletin (1–2), insecticide-treated mosquito nets are currently the only viable option to prevent malaria transmission in large parts of Africa. To be effective, mosquito nets have to be treated by dipping them in suitable insecticides at least once a year. Less than 5% of the nets currently used in Africa are properly treated or retreated. Looking for practical solutions, WHO stimulated industry to produce long-lasting insecticide-treated mosquito nets (LLNs), using new bioactive fabric technologies. Long-lasting nets are treated only once, at factory level. The insecticide can resist multiple washes and is released over time to the surface of the netting fibres. The major criteria for LLNs is that efficacy should last as long as the average lifespan of the net, i.e. 4–5 years. Compared with nets treated by conventional dipping, LLNs have several important advantages: no need for re-treatment; reduced insecticide consumption; and minimum potential environmental impact: release of insecticide in natural water bodies during washing is greatly reduced. There are two LLNs commercially available, currently being evaluated through the WHO Pesticide Evaluation Scheme (WHOPES). R&D is crucial in further improving the technology. Second-generation LLNs are now emerging with even better performance. They are major technical breakthroughs, significantly changing prospects for successful implementation of ITN programmes, especially in Africa. To protect the most vulnerable groups in Africa (children under five, pregnant women and people living below the poverty line) and to meet the objective set by the Heads of State of African countries in Abuja (60% of net coverage by 2005), it is estimated that a total of 115 million nets will be needed. To reach full coverage, ideally by the year 2007, an additional 97 million nets will be needed and maintenance of this coverage after 2007 will require 28 to 30 million nets per year. Protection of the whole population at risk of malaria in Africa would require about twice these numbers. When envisaging further development of LLNs, it is important to involve the net industry in Africa and to facilitate technology transfer. Strengthening production capacity of LLNs in Africa and further reducing the price through well-targeted public– private partnerships will be an effective way to go to scale, reduce the malaria burden, and contribute to poverty alleviation. It also offers an opportunity to African countries to develop a profitable ITN economy and to play an increasing role in …

HIV Due to Female Sex Work: Regional and Global Estimates

Introduction Female sex workers (FSWs) are at high risk of HIV infection. Our objective was to determine the proportion of HIV prevalence in the general female adult population that is attributable to the occupational exposure of female sex work, due to unprotected sexual intercourse. Methods Population attributable fractions of HIV prevalence due to female sex work were estimated for 2011. A systematic search was conducted to retrieve required input data from available sources. Data gaps of HIV prevalence in FSWs for 2011 were filled using multilevel modeling and multivariate linear regression. The fraction of HIV attributable to female sex work was estimated as the excess HIV burden in FSWs deducting the HIV burden in FSWs due to injecting drug use. Results An estimated fifteen percent of HIV in the general female adult population is attributable to (unsafe) female sex work. The region with the highest attributable fraction is Sub Saharan Africa, but the burden is also substantial for the Caribbean, Latin America and South and Southeast Asia. We estimate 106,000 deaths from HIV are a result of female sex work globally, 98,000 of which occur in Sub-Saharan Africa. If HIV prevalence in other population groups originating from sexual contact with FSWs had been considered, the overall attributable burden would probably be much larger. Discussion Female sex work is an important contributor to HIV transmission and the global HIV burden. Effective HIV prevention measures exist and have been successfully targeted at key populations in many settings. These must be scaled up. Conclusion FSWs suffer from high HIV burden and are a crucial core population for HIV transmission. Surveillance, prevention and treatment of HIV in FSWs should benefit both this often neglected vulnerable group and the general population.

Early-life prevention of non-communicable diseases

Non-communicable diseases (NCDs) are major causes of death worldwide and underlie almost two-thirds of all global deaths.1 Although all countries face epidemics of these diseases, low-income and middle-income countries, and the poorest and most vulnerable populations within them, are affected the most. There is a global imperative to create and implement effective prevention strategies, because the future costs of diagnosis and treatment are likely to be unaffordable. At the UN High-Level Meeting on the Prevention and Control of Non-Communicable Diseases, held in New York, USA, in September, 2011, the so-called four by four strategy for NCD prevention was proposed. Prevention efforts for the priority NCDs discussed at the meeting (diabetes, cardiovascular disease, cancer, and chronic obstructive pulmonary disease) focus on four, mainly adult, risk factors: poor diet, physical inactivity, tobacco use, and alcohol consumption. Although paragraphs 26 and 28 of the UN Political Declaration refer to the roles of prenatal nutrition, maternal diseases, and household air pollution on NCD risk in later life, these paragraphs only partially describe the full scope of the problem and opportunities for intervention. As scientific knowledge emerges on the role of both nutritional factors and exposures to environmental chemicals in the developmental origins of health and disease, evidence suggests that much more attention is needed on early-life interventions, optimisation of nutrition, and reduction of toxic exposures to curtail the increasing prevalence of NCDs. The present state of the science on the developmental origins of health and disease and NCDs was discussed at the Prenatal Programming and Toxicity III conference, Environmental Stressors in the Developmental Origins of Disease: Evidence and Mechanisms, held in Paris, France in May, 2012, and at a symposium just before the conference.2 Studies in human beings have shown that nutritional deprivation and maternal metabolic status (eg, diabetes) in early intrauterine life increase the risk of metabolic disorders and cardiovascular disease in adulthood.3,4 These effects occur not only in settings of extreme deprivation, but also throughout the normal range of population weights at birth and in early childhood.3 Investigators have also reported associations between in-utero exposures and childhood diseases, including type 2 diabetes.5 In-utero and early-life exposures to environmental toxicants, ranging from heavy metals to endocrine-disrupting chemicals, affect adult metabolism, immune system function, neurodevelopment, and reproductive function.2 Although causal relations have not yet been established, the new science of epigenetics offers insight into mechanisms of early life predisposition to adult disease risk. During development, epigenetic marks, such as DNA methylation, histone modifications, and noncoding RNA expression, undergo substantial changes. These changes affect genes that are essential for both early life development and later life physiological functions. Epigenetic modifications are stable during cell division and can be transmitted transgenerationally.6 An increasing amount of evidence suggests that developmental exposure to nutritional imbalance or environmental contaminants—including metals, pesticides, persistent organic pollutants, and chemicals in drinking water, such as triethyltin, chloroform, and trihalomethanes—can affect epigenetic changes, thus suggesting a mechanism for their effects on adult health.7,8 Similarly, prenatal exposure to air pollutants has been associated with epigenetic changes and subsequent effects on children’s respiratory health.9 Knowledge that in-utero and early childhood experiences affect the risk of NCD development provides an opportunity to target interventions at the time when they have the greatest effect. Because these exposures are not controlled directly by the individual, especially when the exposures might have occurred to the individual’s parents or grandparents, early-life interventions can reduce the perception of blame that the individual’s own lifestyle has caused his or her disease. This notion has policy implications, because the prevailing viewpoint often assumes that NCDs are mainly a matter of individual responsibility, thus obviating societal and governmental responsibility. Substantial reductions of NCD risks could be achieved through the use of existing maternal–child health platforms to educate mothers about both nutritional and environmental exposures and to integrate the health promotion and disease prevention agendas within social and economic development efforts. For example, the Millennium Development Goals (MDGs) address not only maternal and child health problems, but also poverty and malnutrition, sex inequality, and lack of education, all of which are notable drivers of social disadvantage in low-income and middle-income countries and are underlying causes of NCDs.10,11 Poverty alleviation, sustainable food production, and reductions in exposures to toxic chemicals are all key themes emerging from the Rio+20 UN Conference on Sustainable Development12 held in Rio de Janeiro, Brazil, in June, 2012, and the development of Sustainable Development Goals (SDGs) and appropriate environmental, nutritional, and health indicators provides another opportunity to incorporate NCD prevention into broader, multisector programmes. The integration of NCD prevention with the attainment of the MDGs and SDGs could leverage major worldwide investments in health and development.

Global climate change: implications for international public health policy

This warming has been linked to more extreme weather conditions such as intense floods and droughts, heavier and more frequent storms, and a possible increase in frequency and intensity of the El Nino Southern Oscillation. These changes are largely caused by human activities, mainly the burning of fossil fuels releasing carbon dioxide (CO

E-Waste and Harm to Vulnerable Populations: A Growing Global Problem.

Background: Electronic waste (e-waste) is produced in staggering quantities, estimated globally to be 41.8 million tonnes in 2014. Informal e-waste recycling is a source of much-needed income in many low- to middle-income countries. However, its handling and disposal in underdeveloped countries is often unsafe and leads to contaminated environments. Rudimentary and uncontrolled processing methods often result in substantial harmful chemical exposures among vulnerable populations, including women and children. E-waste hazards have not yet received the attention they deserve in research and public health agendas. Objectives: We provide an overview of the scale and health risks. We review international efforts concerned with environmental hazards, especially affecting children, as a preface to presenting next steps in addressing health issues stemming from the global e-waste problem. Discussion: The e-waste problem has been building for decades. Increased observation of adverse health effects from e-waste sites calls for protecting human health and the environment from e-waste contamination. Even if e-waste exposure intervention and prevention efforts are implemented, legacy contamination will remain, necessitating increased awareness of e-waste as a major environmental health threat. Conclusion: Global, national, and local levels efforts must aim to create safe recycling operations that consider broad security issues for people who rely on e-waste processing for survival. Paramount to these efforts is reducing pregnant women and children’s e-waste exposures to mitigate harmful health effects. With human environmental health in mind, novel dismantling methods and remediation technologies and intervention practices are needed to protect communities. Citation: Heacock M, Kelly CB, Asante KA, Birnbaum LS, Bergman AL, Bruné MN, Buka I, Carpenter DO, Chen A, Huo X, Kamel M, Landrigan PJ, Magalini F, Diaz-Barriga F, Neira M, Omar M, Pascale A, Ruchirawat M, Sly L, Sly PD, Van den Berg M, Suk WA. 2016. E-waste and harm to vulnerable populations: a growing global problem. Environ Health Perspect 124:550–555; http://dx.doi.org/10.1289/ehp.1509699