4.6 Strategies for water, hygiene and sanitation

4.6.1 Improving access to potable water

Absence or failure of a water supply system, the cost of water, distance from a safe water point or waiting time to fill a container, a context of insecurity and/or drought, encourage the use of potentially contaminated but more accessible or affordable sources of water (e.g. rivers, ditches or shallow wells).

To provide or improve access to potable water, there are several possible options, depending on the situation:

• Implementing temporary potable water transport, storage and distribution in densely populated areas where there is no water supply system, as long as required.
• Repairing or improving a failing system when this can be done easily and quickly.
• Protecting (and disinfecting) the most regularly used unprotected water sources, on condition that they are not constantly exposed to (re)contamination.
• Negotiating temporary reduction or elimination of user fees with local authorities, public or private companies or the owner of the water source.
• Up-grading preferred protected water sources to improve distribution capacity and reduce waiting lines (if possible less than 15 minutes, less than 30 minutes maximum [1] Citation 1. The Sphere Project handbook. 2011.
  https://spherestandards.org/wp-content/uploads/2018/06/Sphere_Handbook_2011_English.pdf ).
• Distributing larger containers to families in order to increase the quantity of potable water stored at home and decrease the number of trips per day to water sources (however, these containers must not be too big to carry).

If the authorities decide to close a contaminated water source, ensure that another source of potable water is accessible.

In densely populated settings, bulk water chlorination (Section 3.3.2) is the best means to quickly provide large amounts of potable water. Household water chlorination is not recommended as first choice in these settings, unless this method has started to be implemented before the beginning of the outbreak.

In scattered or difficult-to-reach rural populations, bucket chlorination (Section 3.3.2) or household water treatment (Section 3.3.3) are often the only options. Information on water disinfectants, practical demonstrations of use, constant supply and monitoring of appropriate and consistent use are essential.
If water disinfectants are not available, and no alternative can be offered, water intended for drinking and cooking should be boiled.

4.6.2 Improving hygiene practices

Hand-washing facilities

Hand-washing facilities with water and soap (or only 0.05% chlorine solution) must be available at key locations:

• Latrines (public and familial);
• Areas used for food preparation/consumption (kitchens, markets, restaurants, etc.).

Public hand-washing facilities must be maintained for the duration of the outbreak.

Soap and other hygiene products

An important barrier to hand hygiene in low-income populations is the high cost of soap relative to household income. Mass or targeted distributions of soap should be organized when necessary and as long as required (minimum 500 g of soap/person/month for personal hygiene and laundry). Regular distributions of soap are systematic in refugee or internally displaced populations.
Information about the time and place of the distribution must be communicated to the population and associated with the promotion of hand-washing at critical times (Section 3.4.1).

In addition, “household hygiene kits“ can be provided in treatment centres (all levels) to ensure routine domestic hygiene in patients’ homes (Section 3.4.4). It is important not to include treatment (sachets of ORS) or water disinfectant products in the kit in order to avoid confusion and accidental ingestion of chemical products.

Street food

Food sold by street vendors and in restaurants is a risk if it is contaminated. The health authorities can decide to stop street food sales during an outbreak. Otherwise, an awareness raising campaign to educate vendors on food safety should be set up a Citation a. For more information see: http://www.who.int/foodsafety/fs_management/No_03_StreetFood_Jun10_fr.pdf  .

4.6.3 Improving sanitation

Refugee camps

During the early phase of an emergency, when sanitation facilities are absent, defecation fields or trenches should be set up for the first few days (Section 3.5.1).
At the same time, plans must be made for the construction of permanent latrines. Early on, it is difficult to ensure each family constructs a latrine. Depending on the means or space available, alternatives include the construction of public latrines (used by all) or shared or cluster latrines (used by 3-4 households, around 20 people). Nevertheless, individual family latrines should be provided as soon as possible, as the population will probably remain in the camp far longer than the duration of the epidemic.

Urban areas

The number of latrines needed in urban areas is high. However the large-scale construction of these during an epidemic is not usually feasible given the difficulty and delays inherent in obtaining the appropriate administrative authorization and construction material, organizing community participation, etc.

Building public latrines (or repairing existing ones) is often the only option in the immediate term.
Public latrine placement should be prioritized in those areas where the risk of transmission is very high: markets, train and bus stations, etc.
Public latrines in good condition are usually those that are fee-for-use. Negotiating the free use of these latrines (by offering to pay the owner a daily fee) makes them more widely accessible to the population.
In all events, it is essential to organize the regular cleaning and maintenance of these public latrines and associated hand-washing points for the duration of the epidemic.

In certain situations (e.g. lack of space in flooded urban areas, or difficulties in digging through debris after an earthquake), defecation into plastic bags, if common prior to the epidemic, can be continued during the first phase of the emergency (Section 3.5.1).

Rural areas

The rapid construction of latrines in rural areas is even less feasible than in urban areas. Repairing public latrines, if they exist, is a short term option. Awareness raising campaigns can be set up to encourage the population not to defecate in or near safe water sources and/or to cover excreta after defecation. Nevertheless these actions may not necessarily be sufficient to change habits, even in the short term.