Interlinking Diarrhea Occurrence in India

The Interlinkage between diarrhea and bacterial water quality

1. Evaluating interlinkage between diarrhoea occurrence and bacteriological drinking water quality in India Gaurav Kapse Research Scholar, CTARA , IITB Monash Research Academy

2. Abstract Diarrhoea: major waterborne diseases: fecal-oral route Critical evaluation of interlinkage between bacteriological water quality, diarrhoea cases and their causes: 2017 , 2018 and 2019 Fecal coliform levels: Surface and groundwater: NWMP data Adults and childhood diarrhoea: NHM HMIS Etiological causes & risk factors: Global Burden of Disease 2019 Fecal coliform, diarrhoea inpatient percentage, and diarrhoea inpatient rate Non-uniform water monitoring data, absence of a robust interlinking tool and inability to directly correlate with diarrhoea cases Clear gap in the interlinkage: unavailability of granular water quality data as a major challenge

3. Introduction Water quality-related issues: bacteriological contamination to natural geogenic origin JJM: Tap connection to 52 % of households till Aug 2022 Large population dependent on GW and other untreated SW Unsafe drinking water-adverse health effects Health effects of poor water quality and risk associated with specific water quality parameters: Fluoride, Arsenic, Iron, Nitrate, Microbes Microbes-acute toxicity-major focus Disease burden of diarrhoea-fourth highest in India: reasons environmental changes, unsafe water and improper sanitation Global level literatures: positive correlation between improved water supply systems and a reduction in diarrhoea cases

4. Introduction Studies carried out in India on drinking water quality and diarrhoea cases depict a different picture. Thus most of these studies are reporting a poor correlation between safe water access and decreased diarrhoea cases. Presumption made that the improved water supply means the guaranteed supply of clean/safe drinking water This paper evaluates interlinkage gaps between quality aspects of drinking water and the occurrence of diarrhoea cases The mapping of water sources, and bacteriological water quality parameters in surface and groundwater have been done to find interlinkage with diarrhoea cases. This is followed by the disease burden analysis of diarrhoea to understand its etiological causes and associated risk factor. An attempt was made to study the data of drinking water sources, Fecal coliform (FC) and districtwide diarrhoea cases to critically examine the possible tools for the interlinkage.

5. Methodology Data Collection Diarrhoea-related data: HMIS 2017,18,19 (Pre-pandemic data), GBD 2019 Water Source and Quality Data : India Census, 2011, NWMP 2017, 18, 19 SW ( 2017 : 1495 Nos., 2018: 1542 Nos., and 2019: 1902 Nos ) GW ( 2017: 660 Nos., 2018: 714 Nos., and 2019: 724 Nos .) Various sources of drinking water Analysis and Interpretations District-level diarrhoea data Diarrhoea Inpatient Rate (DIR ) Time-series analysis Spatial join tool-ArcGIS District level maps of FC and Diarrhoea data

6. Results: Diarrhoea occurrence patterns in India: Child A B Fig. 1 (A) Time series (yearly) variation in childhood diarrhoea inpatient cases (< 5 years) in India (B) Time series (yearly) variation in childhood diarrhoea percentage inpatient (< 5 years) in India (Data Source: HMIS, 2017-19) 18.75 % increased inpatient hospitalization in 2019, 18.9% of child patients required hospitalization for treatment and a higher hospitalization rate was seen in June and July ,, rate of diarrhoea-related admission was seen to increase from the year 2017 to 2019 by 38.5%.

7. Results: Diarrhoea occurrence patterns in India: Child Fig. 2 (A) District-wise variation in childhood diarrhoea (< 5 years) inpatient cases (Data Source: HMIS, 2017-19) 2017: Lucknow (UP), In top 10 districts 7 were from West Bengal 2018: Aligarh (UP), In top 10 districts 5 were from West Bengal, 2019: Sonbhadra (UP) Uttar Pradesh, West Bengal and Madhya Pradesh: 42% of total childhood diarrhoea inpatient cases 2017-19 Districts on b oundary region of Karnataka, Andhra Pradesh and Telangana: high inpatient cases

8. Results: Diarrhoea occurrence patterns in India: Child Fig. 2 (B) District-wise variation in childhood diarrhoea (< 5 years) inpatient percentage (Data Source: HMIS, 2017-19) H ighest percentage of inpatient diarrhoea children were reported in the northeastern part of India with 7 out of 10 highest reporting districts Anjaw , Upper Subansiri , and Kra Daadi districts of Arunachal Pradesh, Senapati , and Chandel districts of Manipur and Nalbari in Assam reported the highest childhood diarrhoea inpatient percentage out of total inpatient children

9. Results: Diarrhoea occurrence patterns in India: Adult A B Fig. 3 (A) Time series (yearly) variation in adult diarrhoea inpatient cases in India (B) Time series (yearly) variation in adult diarrhoea percentage inpatient in India (Data Source: HMIS, 2017-19) M onsoon months (June, July, and August) accounted for around 40-42 % of yearly cases in India I npatient hospitalization increased at rate of 6.5 to 8 % per year from 2017 to 2019 June 2019 reported a maximum of 5.9 % inpatient cases, percentage of hospitalization increased from 2017 to 2019

10. Results: Diarrhoea occurrence patterns in India: Adult Fig. 4 (A) District-wise variation in adult diarrhoea inpatient cases (Data Source: HMIS, 2017-19) Top 10 districts : Andhra Pradesh and West Bengal only: 2017-19: Chitoor , Anantapur , Cuddapah , and Kurnool districts of Andhra Pradesh are in the top ten list with Chitoor reporting the highest, West Bengal’s North Twenty-Four Parganas , South Twenty-Four Parganas , Nadia, Murshidabad , Purba Barddhaman and Hugli E astern coastal districts of India indicate a higher prevalence, West Bengal-4 th populous state-reports maximum cases than that Uttar Pradesh, Maharashtra and Bihar which are more populous

11. Results: Diarrhoea occurrence patterns in India: Adult Fig. 4 (B) District-wise variation in adult diarrhoea inpatient percentage (Data Source: HMIS, 2017-19) The northeastern part of India has again shown a similar trend as childhood diarrhoea Kra Daadi , Kurung Kumey , Anjaw districts of Arunachal Pradesh, Poonch in Jammu and Kashmir, Chandel and Bishnupur districts of Manipur, Bhadrak in Odisha, Kamareddy in Telangana, and Daman & Diu were the top reporting districts of percentage adult diarrhoea inpatients

12. Results: Diarrhoea occurrence patterns in India: Adult + Child Fig. 5 District-wise variation in diarrhoea inpatient (adult + child) rate per lakh of population (Data Source: HMIS, 2017-19, India Census, 2011) N ortheastern region along with West Bengal, Odisha and Andhra Pradesh (eastern coast of India) have higher inpatient diarrhoea rates Balrampur in Chhattisgarh, Cuddapah in Andhra Pradesh, New Delhi, Kalimpong in Westbengal , Kulgam & Poonch in Jammu & Kashmir, Dangs in Gujarat, Bhadrak in Odisha, Karauli in Rajasthan, West Jaintia Hills in Meghalaya are the top 10 districts

13. Results: Percentage source of drinking water Central, eastern and northeastern part of India is mostly with low access/ supply of treated tap water Most districts of West Bengal, Bihar, Jharkhand, Odisha, Madhya Pradesh and Uttar Pradesh: more than 75% untreated drinking water sources. 12 districts on the boundary of Andhra Pradesh, Karnataka and Telangana have untreated water sources in the range of 50% to 75%. Bihar, Jharkhand, Odisha, Madhya Pradesh, Chhattisgarh, Uttar Pradesh, West Bengal, Assam, Tripura, Kerala and Nagaland are more than 70% groundwater dependence Fig. 6 (A) District-wise variation in percentage supply/access to treated drinking water sources (B) District-wise variation in percentage supply/access to untreated drinking water sources (C) District-wise variation in the percentage of groundwater as a drinking water source (Data Source: India Census, 2011)

14. Results: Percentage source of drinking water: Untreated Water Fig. 7 (A) District-wise variation in percentage source of untreated drinking water (untreated tap water, hand pumps and tube wells) (Data Source: India Census, 2011) Fig. 7 (B) District-wise variation in percentage source of untreated drinking water (uncovered wells, springs and rivers) (Data Source: India Census, 2011)

15. Results: Drinking water quality: Fecal coliform: Groundwater 95% stations reported the occurrence of FC in groundwater, 9% stations > 50 MPN/100 mL FC level, 8% stations >100 MPN/100 mL FC level Kerala, Odisha, Delhi, West Bengal and Assam have shown high FC levels for consecutive three years from 2017 to 2019. 13 districts in the state of Bihar starte d reporting higher FC values in 2019 which was not reported in earlier years i.e. 2017 and 2018 Fig. 8 (A) District-wise variation in fecal coliform (max MPN/100 mL) in groundwater (Data Source: CPCB, 2017-19)

16. Results: Drinking water quality: Fecal coliform: Surface water 95% stations: non-zero MPN value, 74% stations >50 MPN/100 mL FC, 42% stations > 1000 MPN/100 mL Ganga basin (Fig. 8B) has a maximum concentration of FC 123 monitoring stations: Assam, Bihar, Delhi, Goa, Karnataka, Odisha, Tamil Nadu, Uttar Pradesh and West Bengal showed > 100,000 / 100 mL West Bengal showed around a 150% increase in the average FC level from the year 2017 to 2019. Kamrup M, Darrang in Assam, Imphal , Chandel in Manipur, East Khasi Hills in Meghalaya and Dimapur and Mon in Nagaland reported a high occurrence of FC levels than 50 MPN/100 mL Fig. 8 (B) District-wise variation in fecal coliform (max MPN/100 mL) in surface water (Data Source: CPCB, 2017-19)

17. Results: Diarrhoea & Water Quality Interlinkage O verlap among the regions with higher diarrhoea inpatient percentage and use of untreated drinking water or more particularly groundwater 75% (17 out of 23) districts of West Bengal, 67% (20 out of 30) districts of Odisha, 45% (12 out of 27) districts of Chhattisgarh and, 38% (12 out of 31) districts of Telangana have higher diarrhoea inpatient rate as per 2019 HMIS data. 35% (18 out of 51) districts of Madhya Pradesh are with more than 500 diarrhoea inpatient rates. The Dangs in Gujarat reported a 2340 diarrhoea inpatient rate in 2019. These districts and states with a higher dependency on untreated groundwater as a source of drinking water Springs and rivers were majorly used as drinking water sources in the northeastern part of India

18. Results: Diarrhoea & Water Quality Interlinkage

19. Results: Diarrhoea & Water Quality Interlinkage

20. Results: Diarrhoea & Water Quality Interlinkage

21. Discussion H igh recharge potential of Ganga basin more than 246-300 mm/ year The overlapping of diarrhoea prevalence with FC levels though visibly helpful has some associated problems. The FC was hardly available for an average of 400 districts in the study period i.e. 2017 to 2019. Thus many districts with zero FC value fall under the non-reporting or FC parameter not tested category. C omplete absence of NWMP stations in around 150 districts of India Inverse Distance Weightage (IDW) interpolation tool for predicting the water quality Water Quality Index (WQI) as a tool to interlink water quality with waterborne diseases Impact of untreated groundwater consumption can be considered more prominent and possibly have a significant role in diarrhoea prevalence in India. Unfortunately, the districts like New Delhi, Karaikal , and Shahdara have improved piped water connectivity but still reported high diarrhoea rates Lack of a more robust interlinking tool, methodology or framework to fill the gap. Thus, the interlinkage gap and etiological observation significantly point toward the possible usage of the more prominent health-based tools such as Disability Adjusted Life Years (DALYs)

22. Conclusions Adult and childhood diarrhoea is a continuing problem in India despite major efforts in the improved drinking water supply The interlinkage between diarrhoea prevalence pattern, water sources and fecal coliform contamination is a complex activity. Exposure to other than taped water supplies and direct consumption of groundwater is an important factor in increased diarrhoea cases in such areas The analysis of data showed fair but not clear interlinkage between the bacteriological water quality, diarrhoea occurrence and its causes and thus requires a more robust tool such as DALYs. There is a need for a study to incorporate DALYs in water quality assessment which in turn will measure the disease burden.

23. Thank You…