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
Open accessAbstract
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.
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The proportion of high-burden diseases, such as diarrhoea and acute respiratory infections, in LMICs is much higher.
“and that the proportion of high-burden diseases, such as diarrhoea and acute respiratory infections, in these countries is much higher.”
From Burden of disease attributable to unsafe drinking water, sanitation, and hygiene in domestic settings: a global analysis for selected adverse health outcomes (2023) · cites this paper as [1]
Table 9 (Results, page unavailable) shows a higher WASH-attributable fraction of diarrhoea burden in LMICs than in HICs across the regions listed. That is narrower than the claim: the table compares the fraction attributable to inadequate WASH, not the proportion of diarrhoea among all diseases, and the passages do not establish a comparable LMIC–HIC difference for acute respiratory infections. (LLM, conf=0.79)
Experimental — accuracy not yet measuredThe WASH-attributable disease burden is highest in LMICs.
“Our findings of substantial variation by income status are supported by previous analyses1, 64 that found that the WASH attributable disease burden is highest in LMICs”
From Burden of disease attributable to unsafe drinking water, sanitation, and hygiene in domestic settings: a global analysis for selected adverse health outcomes (2023) · cites this paper as [1]
Table 9 (Results, page unavailable) shows substantially higher WASH-attributable diarrhoeal DALYs in LMICs than HICs in the regions where both are reported. But the Methods (Framework for estimation, page unavailable) say that estimates for most outcomes were calculated only for LMICs, so the paper does not establish the same income-group comparison for the overall WASH-attributable disease burden. (LLM, conf=0.84)
Experimental — accuracy not yet measuredQuantification of the global burden of disease related to improvements to WASH is limited by the challenge of securing reliable estimates of risk from diverse settings, conditions, and populations.
“However, quantification of the global burden of disease related to improvements to water, sanitation, and hygiene (WASH) is limited by the challenge of securing reliable estimates of risk from diverse settings, conditions, and populations.3, 6”
Estimates of the burden of inadequate WASH remain focused on disease outcomes.
“However, estimates of the burden of inadequate WASH remain focused on disease outcomes [8].”
From Water, sanitation, and women’s empowerment: A systematic review and qualitative metasynthesis (2022) · cites this paper as [8]
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- Authors
- Prüss-Ustün, A., Wolf, J., Bartram, J., Clasen, T., Cumming, O., Freeman, M. C., Gordon, B., Hunter, P. R., Medlicott, K., & Johnston, R.
- Affiliations
- World Health Organization (CH)
- University of North Carolina at Chapel Hill (US)
- Emory University (US)
- London School of Hygiene & Tropical Medicine (GB)
- University of East Anglia (GB)
- ORCID
- Venue
- International Journal of Hygiene and Environmental Health
- Publisher
- Elsevier BV
- Published
- 2019-06
- Volume
- 222
- Issue
- 5
- Pages
- 765-777
- ISSN
- 1438-4639 (ISSN-L)
- PMC
- PMC6593152
- OpenAlex
- W2944592180
- Cited by
- 1,308
- References
- 64
- Citations by year
- 2026: 174 · 2025: 161 · 2024: 155 · 2023: 276 · 2022: 134 · 2021: 117 · 2020: 276 · 2019: 13 · 2018: 2
- FWCI
- 102.74
- Type
- journal article
- Language
- en
- Open access
- hybrid
- doi.org
- Licence
- Locations
- International Journal of Hygiene and Environmental Health (publishedVersion, cc-by)
- PubMed Central (publishedVersion, cc-by)
- PubMed (publishedVersion)
- White Rose Research Online (University of Leeds, The University of Sheffield, University of York) (acceptedVersion)
- UEA Digital Repository (University of East Anglia) (acceptedVersion)
- LSHTM Research Online (London School of Hygiene and Tropical Medicine) (acceptedVersion)
- London School of Hygiene & Tropical Medicine (submittedVersion)
- Funders
- Department for International Development
- Topics
- Health Sciences › Nursing › Nutrition and Dietetics › Child Nutrition and Water Access
- Physical Sciences › Environmental Science › Health, Toxicology and Mutagenesis › Public Health and Environmental Issues
- Social Sciences › Health › Occupational Health and Global Justice
- Keywords
- disease burden, diarrhoeal diseases, respiratory infections, malnutrition, schistosomiasis, malaria, soil-transmitted helminthiasis, trachoma, population attributable fraction, disability-adjusted life years, attributable mortality, children under five, low- and middle-income countries
- MeSH terms
- Developing Countries, Diarrhea, Helminthiasis, Humans, Hygiene, Intestinal Diseases, Parasitic, Malaria, Poverty, Respiratory Tract Infections, Sanitation, Schistosomiasis, Water Supply, Risk Assessment, Malnutrition, Epidemiological Monitoring
About these checks
Registry, retraction, Cites and statistics results are computed, not judged, with one exception: a printed reference that no index lists is read once by a model before it counts as a citation error. Claims are extracted by a model and kept only when their quote appears verbatim in the text; each cited source is then checked, with a model’s help, for whether it says what the claim relies on. Those verdicts can be wrong — read the claim’s quote and the cited source before relying on one.
Statistics and arithmetic are recomputed, not judged.
Confidence bands are shown only for fields calibrated on our annotated test set. None is calibrated yet, so no band is shown.
What counts as a claim ›How we measure confidence ›How we check this ›
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