03296nas a2200373   4500000000100000008004100001260001600042653002100058100001100079700001600090700001300106700001400119700001100133700001300144700001200157700001400169700001300183700001500196700001300211700001200224700001500236700001300251700001100264700001400275700001700289700002000306700001400326700001400340700001400354245016200368856007500530520230300605022001402908       2023                            d  bElsevier BV10aGeneral Medicine1 aWolf J1 aJohnston RB1 aAmbelu A1 aArnold BF1 aBain R1 aBrauer M1 aBrown J1 aCaruso BA1 aClasen T1 aColford JM1 aMills JE1 aEvans B1 aFreeman MC1 aGordon B1 aKang G1 aLanata CF1 aMedlicott KO1 aPrüss-Ustün A1 aTroeger C1 aBoisson S1 aCumming O00aBurden of disease attributable to unsafe drinking water, sanitation, and hygiene in domestic settings: a global analysis for selected adverse health outcomes  uhttps://www.thelancet.com/action/showPdf?pii=S0140-6736%2823%2900458-03 a<h3>Background</h3>

<p>Assessments of disease burden are important to inform national, regional, and global strategies and to guide investment. We aimed to estimate the drinking water, sanitation, and hygiene (WASH)-attributable burden of disease for diarrhoea, acute respiratory infections, undernutrition, and soil-transmitted helminthiasis, using the WASH service levels used to monitor the UN Sustainable Development Goals (SDGs) as counterfactual minimum risk-exposure levels.</p>

<h3>Methods</h3>

<p>We assessed the WASH-attributable disease burden of the four health outcomes overall and disaggregated by region, age, and sex for the year 2019. We calculated WASH-attributable fractions of diarrhoea and acute respiratory infections by country using modelled WASH exposures and exposure–response relationships from two updated meta-analyses. We used the WHO and UNICEF Joint Monitoring Programme for Water Supply, Sanitation and Hygiene public database to estimate population exposure to different WASH service levels. WASH-attributable undernutrition was estimated by combining the population attributable fractions (PAF) of diarrhoea caused by unsafe WASH and the PAF of undernutrition caused by diarrhoea. Soil-transmitted helminthiasis was fully attributed to unsafe WASH.</p>

<h3>Findings</h3>

<p>We estimate that 1·4 (95% CI 1·3–1·5) million deaths and 74 (68–80) million disability-adjusted life-years (DALYs) could have been prevented by safe WASH in 2019 across the four designated outcomes, representing 2·5% of global deaths and 2·9% of global DALYs from all causes. The proportion of diarrhoea that is attributable to unsafe WASH is 0·69 (0·65–0·72), 0·14 (0·13–0·17) for acute respiratory infections, and 0·10 (0·09–0·10) for undernutrition, and we assume that the entire disease burden from soil-transmitted helminthiasis was attributable to unsafe WASH.</p>

<h3>Interpretation</h3>

<p>WASH-attributable burden of disease estimates based on the levels of service established under the SDG framework show that progress towards the internationally agreed goal of safely managed WASH services for all would yield major public-health returns.</p>

<h3>Funding</h3>

<p>WHO and Foreign, Commonwealth &amp; Development Office.</p>
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