Sanitation Sanitation
Centers for Disease Control and Prevention

Inadequate Sanitation

Basic sanitation is described as having access to facilities for the safe disposal of human waste (feces and urine), as well as having the ability to maintain hygienic conditions, through services such as garbage collection, industrial/hazardous waste management, and wastewater treatment and disposal (2). Many developing countries cannot provide adequate sanitation for their populations, leaving many people at risk for diseases caused by unsafe drinking water and unsanitary living conditions. Throughout the world, there are 2.6 billion people living without basic sanitation. That’s almost 40% of the world’s population! (3–4). In order to meet the United Nations’ Millennium Development Goal to halve the proportion of people without sustainable access to safe drinking water and basic sanitation by 2015, an additional 1.6 billion people will need access to basic sanitation between 2005–2015 (5).

Since 1948, the World Health Organization has recognized environmental sanitation as a foundation of a sound public health structure, and has called for the improvement of sanitation and environmental hygiene worldwide (6).

Improving Sanitation Worldwide
Worldwide, there are 1.6 million diarrheal disease deaths every year directly related to unsafe water, sanitation, and hygiene (7). The majority of these deaths occur among children younger than five years of age. Access to safe water, adequate sanitation, proper hygiene education, and industrial/hazardous waste management can reduce morbidity and mortality from disease, leading to improved health, poverty reduction, and socio-economic development. Effective sanitation programs should include efforts to promote personal hygiene, improve wastewater management processes, increase access to sanitation facilities (e.g., toilets), and improve drinking water quality.

Hygiene Promotion
As simple as hand washing may seem, it is one of the most important factors in stopping the spread of germs and staying healthy! Unwashed hands can accelerate the spread of bacteria, parasites, and viruses that are transmitted from human and animal feces or the environment. Washing hands after using the bathroom, before and after preparing and eating food, whenever hands are visibly soiled, and more frequently during times of illness can help stop the spread of disease from person to person.

Washing your hands is an easy way to promote personal hygiene.
When washing hands, it is important to remember:

• Wet your hands with clean running water and apply soap. If available, use warm water.

• Rub your hands together and scrub all surfaces and under your nails for at least 20 seconds. Many people suggest singing “Happy Birthday” twice!

• Rinse your hands well under running water.

• Dry your hands thoroughly using a paper towel if available. If possible, also turn the faucet off and open the bathroom door using a paper towel.

More information on hand washing can be found at CDC’s Clean Hands Save Lives.

Sanitation Facilities
Proper sanitation facilities (e.g., toilets and latrines) are important parts of an adequate sanitation system. Throughout the developing world, many people do not have access to suitable sanitation facilities, resulting in improper waste disposal. Inadequate waste disposal can further drive the infection cycle of many agents that can be transmitted through contaminated soil, food, and water, such as soil-transmitted helminths (also called intestinal worms). Worldwide, soil-transmitted helminths affect more than two billion people (9). Without proper sanitation facilities, waste from individuals infected with soil-transmitted helminths can contaminate a community’s land and water, increasing the risk of infection for other individuals. Proper waste disposal can slow the infection cycle of many disease-causing agents. Furthermore, sanitation facilities should include soap, water, and a sink or an area for hand washing, to reduce the risk of disease transmission from contaminated hands.

School latrines. Photo credit: Sharon Roy.
Toilets and latrines allow people to dispose of their waste appropriately and can create an environment of privacy inside and outside of the home. One in five girls of primary-school age are not in school, compared to one in six boys (10). The installation of toilets and latrines may enable school children, especially menstruating girls, to further their education by remaining in the school system.

More general information on water, sanitation, and hygiene can be found at:

• Water, Sanitation, and Hygiene

• Environmental Sanitation and Hygiene Development*, World Health Organization

For more information on school-based sanitation programs, see the report “Framework for Action on Water, Sanitation and Hygiene in Schools” from UNICEF/International Water and Sanitation Centre (IRC) at UNICEF’s Water, Sanitation and Education*.

Sewerage Systems and Wastewater Management
Wastewater management and adequate sewerage systems play important roles in sanitation and disease prevention. Wastewater can contaminate the local environment and drinking water supply, thereby increasing the risk of disease. Therefore, it is vital to develop a system to manage wastewater and sewage. Pretreatment of industrial waste before it is discharged to a regional sewer system is frequently necessary to avoid damage to the sewage treatment process and prevent the discharge of hazardous materials into the environment. In many countries, proper wastewater management is not practiced due to lack of resources, infrastructure, and available space.

More information on wastewater management is available at:

• Onsite Wastewater

• Guidelines on Municipal Wastewater Management,* United Nations Environment Programme

Drinking Water Quality
Worldwide, more than one billion people lack access to an improved water source. There is a direct connection between water, sanitation, and health. Without proper disposal of sewage, industrial/hazardous waste, and wastewater, drinking water can become contaminated by bacteria, parasites, viruses, and chemicals, leading to an increased risk of disease. In addition, regional geology can result in high levels of naturally occurring hazardous materials in drinking water supplies (e.g., arsenic, radon, uranium). When proper sanitation systems are not in place, a disease cycle can develop in which people who became ill from drinking contaminated water contaminate their own environment (land and water) through unsafe waste disposal (feces) leading to continued disease transmission.

A family in rural Madagascar using the Safe Water System – including a bottle of Sûr’Eau solution and a safe container. Photo Credit: Daniele Lantagne.
In areas where access to safe water, appropriate wastewater management, and adequate sewerage systems are not feasible, certain programs, such as CDC’s Safe Water System, can empower people to improve and protect the quality of their drinking water through simple, inexpensive technologies to treat and safely store water in their homes. The intervention consists of three steps:

• Point-of-use treatment of contaminated water;

• Safe water storage; and

• Behavior change techniques.

More information on household water treatment is available from CDC at Safe Water System (SWS) and from the World Health Organization (WHO) at Household Water Treatment and Safe Storage*. For smaller community-based organizations, technical information on developing household water treatment and safe water storage programs can be found online at Safe Water for the Community: A Guide for Establishing a Community-Based Safe Water System Program* or in hard-copy with a CD by sending an email to safewater@cdc.gov.

In many places, communities lack the capacity to effectively adapt their systems for water, sanitation, and hygiene to the community’s changing needs. Water Plus/Agua y Mas, developed by CDC and the Andean Health Organization, is a community-based, integrative approach to improving health and quality of life through increased access to improved water, sanitation, and hygiene. This methodology incorporates many aspects of a sanitation plan, including:

• A Water Safety Plan, which incorporates an assessment of the water delivery system from catchment to consumer;

• Appropriate interventions, which can include protection of source waters, improvements to the water delivery system, introduction of Safe Water Systems, improved sanitation, and hygiene education; and

• Evaluation of the impact of the interventions on the health and quality of life of the consumers.

Programs, such as CDC’s Water Plus/Agua y Mas, empower communities to take part in their own water safety plan, helping them to build skills for maintaining and sustaining improved water and sanitation program.

To learn more about water treatment and sanitation measures being taken in other countries around the world, visit the Global Health and Education Foundation.

Drinking Water in the United States
With access to sanitation facilities (e.g., toilets), proper wastewater management systems, and effective monitoring of drinking water quality, the United States’ drinking water supplies are among the safest in the world. However, even in the United States, drinking water sources can become contaminated and cause illness. Water contaminants may be the result of naturally occurring chemicals and minerals (e.g., arsenic, radon, uranium), local land use practices (fertilizers and pesticides), microbial contamination, manufacturing processes, and problems with the integrity of nearby onsite wastewater systems (e.g., septic systems). The presence of contaminants in water can lead to adverse health effects, including gastrointestinal illness, reproductive problems, and neurological disorders. The US Environmental Protection Agency (EPA) sets maximum concentration levels for many water pollutants and chemicals and regulates drinking water quality in public water systems.