The document discusses water-related health issues in Saudi Arabia. It provides statistics on access to water and sanitation in KSA as of 2002, noting regional variations. Diarrheal cases are highest among children under 5. The most significant water-related illnesses in KSA are diarrhea, typhoid, hepatitis A, and diseases caused by Shigella and E. coli. Improved access to water and sanitation is needed to meet health targets and address problems caused by population growth, limited services, and water contamination.

1. Ghaiath Hussein MBBS, MHSc. (Bioethics)

2. overview Introduction Health risks related to water Examples of more significant diseases Figures from the KSA

4. Access to water supply as of 2002 In 2002, 1.1 billion people lacked access to improved water sources, which represented 17% of the global population. Over half of the world’s population has access to improved water through household connections or yard tap. Of the 1.1 billion without improved water sources, nearly two thirds live in Asia. In sub-Saharan Africa, 42% of the population is still without improved water. In order to meet the water supply MDG target, an additional 260,000 people per day up to 2015 should gain access to improved water sources. Between 2002 and 2015, the world’s population is expected to increase every year by 74.8 million people.

5. Access to sanitation as of 2002 In 2002, 2.6 billion people lacked access to improved sanitation, which represented 42% of the world’s population. Over half of those without improved sanitation – nearly 1.5 billion people – live in China and India. In sub-Saharan Africa sanitation coverage is a mere 36%. Only 31% of the rural inhabitants in developing countries have access to improved sanitation, as opposed 73% of urban dwellers. In order to meet the sanitation MDG target, and additional 370 000 people per day up to 2015 should gain access to improved sanitation.

6. Emergencies and disasters Almost two billion people were affected by natural disasters in the last decade of the 20th century, 86% of them by floods and droughts. Flooding increases the ever-present health threat from contamination of drinking-water systems from inadequate sanitation, with industrial waste and by refuse dumps. Droughts cause the most ill-health and death because they often trigger and exacerbate malnutrition and famine, and deny access to adequate water supplies. Disaster management requires a continuous chain of activities that includes prevention, preparedness, emergency response, relief and recovery.

7. THE GLOBAL RESPONSE Millennium Development Goals (MDGs) By including water supply, sanitation and hygiene in the MDGs, the world community has acknowledged the importance of their promotion as development interventions and has set a series of goals and targets. Goal 7: Ensure environmental sustainability Target 9: Integrate the principles of sustainable development into country policies and program and reverse the loss of environmental resources. Target 10: Halve by 2015, the proportion of people without sustainable access to safe drinking water and basic sanitation. Integrate sanitation into water resources management strategies. Target 11: Have achieved by 2020, a significant improvement in the lives of at least 100 million slum dwellers. Goal 4: Reduce child mortality Target 5: Reduce by two-thirds, between 1990 and 2015, the U5MR Goal 6: Combat HIV/AIDS, malaria, and other diseases Target 8: Have halted by 2015 and begun to reverse the incidence of malaria and other major diseases.

9. What causes water-related health problems? The great majority of evident are the result of: microbial (bacteriological, viral, protozoan or other biological) contamination. Serious health concerns may occur as a result of the chemical contamination of drinking-water. many of the waterborne diseases may also be transmitted by other routes, including person-to-person contact, droplets and aerosols and food intake.

11. Waterborne pathogens and their significance in water supplies

13. Public Health Issues Pathogenic bacteria, viruses and protozoa in water and wastewater represent potential risks to public health. ( Giardia ) ( Cryptosporidium ) Viruses (Hepatitis, Polio) Bacteria ( E.coli ) Protozoa

14. Most significant WRIs Diarrhoea Arsenicosis Ascariasis Campylobacteriosis . Cholera . Dengue and Dengue Haemorrhagic Fever . Fluorosis Guinea-Worm Disease (Dracunculiasis) . Hepatitis . Typhoid and Paratyphoid Enteric Fevers Japanese Encephalitis . Lead Poisoning . Leptospirosis Malaria . Onchocerciasis (River Blindness) . Ringworm (Tinea) Scabies Schistosomiasis .

15. Modes of transmission Faecal contamination. Some organisms grow in piped water distribution systems (e.g., Legionella), whereas others occur in source waters (guinea worm Dracunculus medinensis) and may cause outbreaks and individual cases. inhalation of water droplets (aerosols) in which the causative organisms have multiplied because of warm temperatures and the presence of nutrients. These include legionellosis and Legionnaires’ disease, caused by Legionella spp., and those caused by the amoebae Naegleria fowleri (primary amoebic meningoencephalitis [PAM]) and Acanthamoeba spp. (amoebic meningitis, pulmonary infections). Schistosomiasis (bilharziasis) is a major parasitic disease of tropical and subtropical is primarily spread by contact with water.

16. Factors affecting WRI Increases in human and animal populations, Escalating use of wastewater, changes in lifestyles and medical interventions, population movement and travel and selective pressures for new pathogens and mutants or recombinations of existing pathogens. The immunity of individuals also varies considerably, whether acquired by contact with a pathogen or influenced by such factors as age, sex, state of health and living conditions.

17. From a study by: Adnan J. Al-Saati (King Abdulaziz City for Science & Technology, Riyadh)

18. Rapid Urbanization and Population Growth Urban and Rural Population Growth in Saudi Arabia for the period 2000-2030 (Millions) Source: ESCWA, 2001 Estimated Population of Saudi Arabia in the year 2000 Source: Ministry of Planning, 2002 Region 1421H (2000) Riyadh 4,730,330 Makkah 5,448,773 Madinah 1,378870 Eastern 3,008,913 Qasim 979,858 Asir 1.637,464 Hail 519,984 Al-Baha 476,382 Tabuk 593,706 Jazan 1,083,022 Najran 385,588 Al-Jouf 354,450 Northern 249,544 Kingdom 20,846,884

19. Meeting the Growing Water Demand 1024 633 376 295 233 187

22. Limited service coverage 75% of urban population covered by drinking water distribution systems One third of the urban population covered by sewerage system Water Supply, treatment and reuse in 1995 (MCM)/d Reuse Drinking water Wastewater Treated 3.3 1.31 0.28 Urban Water and Sanitation Services Operational Difficulties Water consumption averages 295 lpcd and contributes to: low quality water intermittent supply Excessive wastewater Extraordinary subsidy: Average SR 230/customer/month The Year 1995

23. Estimated urban water supply and Household use for the year 1996 Household Water Supply The Year 1996 A wide variability of water supply and per capita water use between regions Qasim has the highest per capita day and Hail has the lowest There are six regions with household use of less that 65 lpcd The average household (domestic) use is 240 lpcd. Region M3/day lpcd Riyadh 1,272,177 341 Mekkah 695,938 170 Madinah 163,707 194 Eastern 679,269 317 Qasim 221,504 432 Asir 94,418 188 Hail 6,913 32 Al-Baha na na Tabuk 14,467 35 Jazan 17,715 100 Najran na na Al-Jouf 12,698 64 Northern 10,006 54 Kingdom 3,188,818 240

24. Number of people receiving Household Water through alternative water sources for the Year 2000 Sources of Household Water Region Public Water Tank Well Water Container Other Total Riyadh 3,081,613 702,640 38,384 899,811 7,882 4,730,330 Mekkah 2,883,279 1,424,108 121,663 1,013,809 5,914 5,448,773 Madinah 786,529 411,485 9,693 167,094 4,069 1,378,870 Eastern 737,618 1,154,910 9,678 1,094,048 12,659 3,008,913 Qasim 661,371 297,388 9,505 9,804 1,790 979,858 Asir 389,500 975,606 204,363 64,492 3,503 1,637,464 Hail 98,051 381,319 23,303 9,139 8,172 519,984 Al-Baha 56,361 147,221 89,995 182,686 119 476,382 Tabuk 240,238 166,177 28,954 149,198 9,139 593,706 Jazan 605,183 331,657 66,406 4,774 75,002 1,083,022 Najran 58,411 245,408 73,136 8,211 422 385,588 Al-Jouf 228,734 103,914 17,075 4,727 - 354,450 Northern 74,841 173,329 1,374 - - 249,544 Kingdom 9,901,729 6,515,162 693,529 3,607,793 128,671 20,846,884

25. Diarrhoeal cases by age and sex in 1421H (2000) Population by age and sex in 1421H (2000) Rate of diarrhoeal cases by age and sex in 1421H (2000) (cases per 1,000 of population) Incidents of water-borne related diseases Age Group Male Female Total % of Total 0-4 Years 115,189 86,356 201,545 73 5 Years and More 42,389 32,124 74,513 23 Total 157,578 118,489 276,058 100 Age Group Male Female Total % of Total 0-4 Years 1,538,508 1,476,477 3,014,985 14.5 5 Years and More 9,776,458 8,055,441 17,831,699 85.5 Total 11,314,966 9,531,918 20,846,884 100 Age Group Male Female % of Total 0-4 Years 74.5 58.5 66.8 5 Years and More 4.3 4.0 4.2 Total 13.9 12.4 13.2

26. Diarrhoeal Cases by result of treatment in 1421H (2000) Incidents of water-borne related diseases Result of Treatment Number of Cases % Improved 251,923 91.3 Admitted to hospital 5,990 2.2 Death 1 0.0003 Unknown 18,144 6.6 Total 276,056 100

27. Reported Cases of Diarrhoeal Related Diseases in KSA for the year 2000 Year Diseases Cases Salmonellosis Shigellosis 1996 Reported cases 2349 925 Incidence rate per 100,000 12.80 5.04 1997 Reported cases 2379 819 Incidence rate per 100,000 12.62 4.34 1998 Reported cases 2383 628 Incidence rate per 100,000 12.35 3.25 1999 Reported cases 2145 551 Incidence rate per 100,000 10.69 2.75 2000 Reported cases 2045 501 Incidence rate per 100,000 10.02 2.45 Incidents of water-borne related diseases

28. Reported cases of diarrhoeal related diseases in KSA during the period (19996-2000) Incidents of water-borne related diseases

29. Reported monthly cases of diarrhoeal related diseases in KSA during for the 2000 Incidents of water-borne related diseases

30. Reported cases of environmental health related diseases by region for 2000 Incidents of water-borne related diseases Region Amoebic dysentery Typhoid & Paratyphoid Shigellosis salmonellosis Hepatitis A Riyadh 96 52 78 320 164 Makkah 2058 60 72 106 656 Madinah 19 32 9 33 189 Eastern 246 73 120 1321 195 Qassim 94 17 25 39 98 Asir 419 76 1 35 254 Hail 29 40 1 0 10 Al-Baha 0 3 0 34 8 Tabuk 75 28 90 92 176 Jazan 98 22 1 2 100 Najran 80 2 74 143 202 Al-Jouf 30 3 29 1 78 Northern 0 12 1 1 20 Kingdom 3244 420 501 2045 2250

31. Key messages Outbreaks of waterborne disease may affect large numbers of persons, and the first priority in developing and applying controls on drinking-water quality should be the control of such outbreaks. failure to detect outbreaks is not a guarantee that they do not occur; nor does it suggest that drinking-water should necessarily be considered safe. Contaminated drinking-water lead to severe and sometimes life-threatening disease. Examples include typhoid, cholera, infectious hepatitis (caused by hepatitis A virus [HAV] or HEV) and disease caused by Shigella spp. and E. coli O157. Others are typically associated with less severe outcomes, such as self-limiting diarrhoeal disease (e.g., Norovirus, Cryptosporidium). sensitive subgroups (e.g., the young, the elderly, pregnant women and the immunocompromised) in the population may have a greater probability of illness or the illness may be more severe, including mortality. Not all infected individuals will develop symptomatic disease.