Water, sanitation, and hygiene in emergencies: Summary review and recommendations for further research

Abstract

Water, sanitation, and hygiene interventions can interrupt diarrhoeal disease transmission and reduce the burden of morbidity and mortality associated with faecal-oral infections. We know that rapid response of effective WASH infrastructure and services can prevent or lessen the impact of diarrhoeal outbreaks that can exacerbate the human suffering accompanying humanitarian crises. In this review summary, we present an overview of current knowledge about what works to prevent disease in emergency WASH response. We know that providing safe water, safe excreta disposal, and basic hygiene measures such as hand washing with soap are effective interventions both within emergency settings as well as in longer-term development, but innovation and further research are needed to make WASH response more effective. We propose key areas for critical research to support the evidence base for WASH interventions in emergencies and promote innovation.

Full text

Waterlines Vol. 31 Nos. 1&2 January 2012
Joe Brown (joebrown@lshtm.ac.uk) is an environmental engineer and lecturer at the London School of Hygiene
and Tropical Medicine. Sue Cavill is the SHARE Research Manager based at WaterAid. Oliver Cumming is the Policy
Research Manager for the SHARE consortium based at LSHTM. Aurelie Jeandron is the SHARE Research Assistant based
at LSHTM.
The authors – Sue Cavill in particular – would like to thank Andy Bastable (Oxfam) and David Woolnough, John
Adlam and Brenda Coughlan (DFID) whose experience, inspiration, ideas, and collaboration led to the development
of this paper.
© Practical Action Publishing, 2012, www.practicalactionpublishing.org
doi: 10.3362/1756-3488.2012.004, ISSN: 0262-8104 (print) 1756-3488 (online)
Water, sanitation, and hygiene in emergencies:
summary review and recommendations for
further research
JOE BROWN, SUE CAVILL, OLIVER CUMMING and
AURELIE JEANDRON
Water, sanitation, and hygiene interventions can interrupt diarrhoeal
disease transmission and reduce the burden of morbidity and mortality
associated with faecal-oral infections. We know that rapid response of
effective WASH infrastructure and services can prevent or lessen the impact
of diarrhoeal outbreaks that can exacerbate the human suffering accompa-
nying humanitarian crises. In this review summary, we present an overview
of current knowledge about what works to prevent disease in emergency
WASH response. We know that providing safe water, safe excreta disposal,
and basic hygiene measures such as hand washing with soap are effective
interventions both within emergency settings as well as in longer-term
development, but innovation and further research are needed to make
WASH response more effective. We propose key areas for critical research
to support the evidence base for WASH interventions in emergencies and
promote innovation.
Keywords: emergencies, humanitarian, water, sanitation, hygiene.
Water, sanitation, and hygiene (WASH) measures are intended to protect
health by reducing exposure to pathogens. Their implementation
in non-emergency settings is supported by a wealth of evidence
suggesting signicant health gains as well as other benets (Bartram
and Cairncross, 2010). In emergency settings, rapid WASH provision
can prevent outbreaks and an escalation of the total burden of disease
and death associated with natural or man-made disasters. Outbreaks
of diarrhoeal diseases, including dysentery and cholera, are common
in emergencies. Faecal-oral diseases may account for more than 40
per cent of deaths in the acute phase of an emergency, with greater
Water, sanitation,
and hygiene
(WASH) measures
are intended to
protect health by
reducing exposure
to pathogens

12 J. BROWN et al.
January 2012 Waterlines Vol. 31 Nos. 1&2
than 80 per cent of deaths in children under 2 years of age (Connolly
et al., 2004). In some emergencies and post-emergency situations,
diarrhoea can be responsible for the majority of deaths. During the
Kurdish refugee crisis of 1991, for example, one estimate was that
70 per cent of total deaths were attributable to diarrhoea (including
cholera) (Toole and Waldman, 1997). Post-response case studies and
outbreak investigations have identied unsafe water (at source and
point of use), lack of water (quantity), poor sanitation access or use,
scarcity of soap and hand washing, and contaminated foods as risk
factors for transmission. Kouadio et al. (2009) summarize infectious
disease outbreaks following natural disasters and conicts, many of
which are directly related to WASH.
Emergency situations are challenging environments for WASH
implementation, and recent experience from Haiti and elsewhere has
highlighted the limitations of current emergency sanitation options
(and to a lesser extent safe water supply and hygiene promotion)
within humanitarian response (Shultz et al., 2009; Patel et al.,
2011). The need for more suitable approaches and technologies for
rapid deployment to emergencies has been widely acknowledged
in the humanitarian sector and discussed at the recent Stoutenburg
workshops (Johannessen, 2011).
The need for improved WASH strategies for emergencies has
generated a number of new approaches that have been explored by
relief organizations, leading to rapid innovation. However, there
remains insufcient condence and evidence of what works, what
doesn’t, and why in emerging processes, technologies, and approaches
for humanitarian WASH services. Unknowns persist about which
strategies are suitable for the immediate emergency phase and which
technologies, practices, and approaches may permit a transition
towards more sustainable solutions and future resilience.
We reviewed the existing guidance on best practice for WASH
delivery in emergencies and published evidence on what works to
control disease transmission. Based on our summary, we propose a
number of areas for critical research to improve WASH response in
humanitarian relief. This paper is an overview of this review.
Existing guidance: Best practice for wash interventions
There is an extensive grey literature outlining ‘what works’ and best
practice in the delivery of WASH interventions in emergency settings,
spanning intra-agency brieng notes, project reports, training packs,
and lessons learnt or case study papers. Table 1 summarizes recom-
mendations for best practice in the WASH response according to the
widely cited Sphere Project (Sphere, 2011), and Table 2 illustrates
the diversity of documents providing guidance for good practice in
In some
emergencies and
post-emergency
situations, diarrhoea
can be responsible
for the majority of
deaths
More suitable
approaches and
technologies for
rapid deployment
to emergencies are
needed

WATER, SANITATION, AND HYGIENE IN EMERGENCIES 13
Waterlines Vol. 31 Nos. 1&2 January 2012
emergency response. Much of the knowledge about ‘what works’ is
the mostly tacit knowledge held by the humanitarian workers who
are mobilized in response and who learn on the job or by trial and
error. Institutional memory is therefore diffuse and grows organically
with additional experience from each crisis.
One of the challenges for practitioners seeking guidance has been
the often diverse, and sometimes disparate, sources of information
emerging from practitioners when this accumulated experience is
communicated. Knowledge sharing has occurred not just through
published papers but also through various sector forums – both
online and traditional – as well as training and capacity-building
activities held within and between operational agencies. Technical
enquiry services, for example those offered by RedR, Practical Action,
DEW Point, and KnowledgePoint, have played an important role in
responding to ad hoc requests for guidance.
Some agencies, particularly international NGOs and UN agencies,
have published conference proceedings, technical guidance manuals,
and other documents in order to share knowledge. Much of the
best practice literature has historically reected in-agency policy
rather than broader sector-level consensus but has laid important
foundations for inter-agency dialogue.
There have been various communities of practice and inter-agency
meetings convened over the last 20 years to share learning and ideas.
Perhaps the most signicant recent initiative was the establishment
of the WASH Cluster. The ‘cluster approach’ was one pillar of the
reforms agreed in 2006 by UN agencies and other organizations
active in the eld of humanitarian response. The WASH Cluster has
three key responsibilities: 1) setting standard and policy; 2) building
response capacity; and 3) providing operational support. Under the
rst objective of standard setting, the WASH Cluster seeks to both
consolidate and disseminate standards and to identify best practice.
The cluster has played an important role in both providing a platform
for the sharing of learning, and providing a source of information for
those seeking guidance through its website.
Another more formalized attempt to improve guidance within
the sector is the Sphere project and its Sphere Handbook, now in its
third edition (Sphere, 2011). Rooted in a rights-based and people-
centred approach, the Sphere Handbook provides minimum standards
for humanitarian responses across six sectors, including WASH. The
guidelines are the result of ‘sector-wide consultations…involving
a wide range of agencies, organizations and individuals, including
governments and United Nations’ and are generally accepted by the
humanitarian sector as representing ‘best practice’. Table 1 summarizes
the key standards and examples of the recommended indicators from
the Sphere Project.
Much of the
knowledge about
‘what works’ is
tacitly held by
humanitarian
workers

14 J. BROWN et al.
January 2012 Waterlines Vol. 31 Nos. 1&2
Table 1. Selected water, sanitation, and hygiene recommendations for emergency response
Water Sanitation Hygiene
Standard Indicators Standard Indicators Standard Indicators
Water quantity Total basic water Environment free All sanitation situated Hygiene promotion All facilities are
needs: 7.5–15 litres from human faeces >30 m from any implementation appropriately used
per day ground-water source and maintained
Max. distance to Toilets are used (and All wash hands after
nearest water point children’s faeces defecation/cleaning
<500 m; queuing disposed of) hygienically children, before
time <30 min eating/preparing food
Water quality No faecal coliforms Appropriate and Max. of 20 people use Identification and All have access to
per 100 ml at point adequate toilet each toilet use of hygiene items hygiene items and
of delivery and use facilities these are used
effectively
No outbreak of water- Security threats are All women and girls of
borne or water-related minimized, especially menstruating age are
diseases to women and girls provided with
appropriate menstrual
hygiene materials
Water facilities Household has min. 2
clean water collecting
containers
At least 1 washing
basin per 100 people
Source: Sphere, 2011

WATER, SANITATION, AND HYGIENE IN EMERGENCIES 15
Waterlines Vol. 31 Nos. 1&2 January 2012
Table 2. Selection of grey literature on WASH interventions in emergencies [all websites accessed 30 January 2012]
Type of document Selected references Link
Books and John Hopkins and IFRC (2008) Public Health http://www.jhsph.edu
manuals Guide for Emergencies, 2nd edn
Davies, Jan and Robert Lambert (2002) http://developmentbookshop.com
Engineering in Emergencies: A Practical
Guide for Relief Workers, Practical Action
Publishing, Rugby
MSF (1994) Public Health Engineering in http://www.msf.org.uk
Emergency Situations
ODI and A. Chalinder (1994) Good Practice http://www.odihpn.org/
Reviews: Water and Sanitation in Emergencies
ACF International network (2005) Water, http://www.actioncontrelafaim.org
Sanitation and Hygiene for Populations at Risk
Technical Oxfam (2006) Water Treatment Guidelines http://www.oxfam.org.uk/
guidelines for Use in Emergencies
House, S.J. and R.A. Reed (1997) Emergency
Water Sources: Guidelines for Selection and
Treatment, WEDC, Loughborough
ADPC (2000) Tools and Resources for http://www.adpc.net
Post-disaster Relief
IFRC (2008) Household Water Treatment and http://www.ifrc.org/
Safe Storage in Emergencies
Technical Oxfam (2010) The Use of Poo Bags for Safe http://www.oxfam.org.uk/
briefing notes Excreta Disposal in Emergency Settings
WHO and WEDC (2011) Technical notes for http://wedc.lboro.ac.uk
emergencies
SuSanA (2009) Sustainable Sanitation for http://www.susana.org/
Emergencies and Reconstruction Situations
Conference World Water Week (2009) Abstracts volume, http://www.worldwaterweek.org/
proceedings Workshop 5: Safe Water Service in Post-
conflict and Post-disaster Context
Oxfam working paper (1995) Proceedings of http://www.oxfam.org.uk/
an International Workshop: Sanitation in
Emergency Situations
P. Paul (2005) 31st WEDC International http://www.wedc-knowledge.org
Conference, Proposals for a Rapidly
Deployable Emergency Sanitation Treatment
System
Lessons learned ALNAP (2008) Flood Disasters: Learning http://www.alnap.org/resources/lessons.aspx
from Previous Relief and Recovery Operations
Oxfam (2011) Urban WASH Lessons Learned http://www.oxfam.org.uk/
from Post-earthquake Response in Haiti
UNICEF (2010) Community Led Total http://www.unicef.org
Sanitation: Part of the Emergency Response in
Flood-Affected Villages in Central Mozambique

16 J. BROWN et al.
January 2012 Waterlines Vol. 31 Nos. 1&2
Type of document Selected references Link
Strategic UNICEF (2010) Core Commitments for http://www.unicef.org
documents Children in Humanitarian Action
Global WASH Cluster, Strategic Plan 2011–2015 http://oneresponse.info/Pages/default.aspx
WELL (2006) A Strategic Approach to Water http://www.wedc-knowledge.org
and Sanitation in Disasters
Websites WEDC publications http://wedc.lboro.ac.uk
WASH cluster website http://oneresponse.info/Pages/default.aspx
Tearfund International Learning Zone http://tilz.tearfund.org
Note: Acronyms: IFRC, International Federation of the Red Cross and Red Crescent Societies; MSF, Médecins Sans
Frontières; ODI, Overseas Development Institute; ACF, Action Contre la Faim; ADPC, Asian Disasters Preparedness
Centre; ALNAP, Active Learning Network for Accountability and Performance in Humanitarian Action; WHO,
World Health Organization; WEDC, Water, Engineering and Development Centre; SuSanA, Sustainable Sanitation
Alliance; UNICEF, United Nations Children’s Fund.
Inclusion
Whilst there are examples of good practice, it should be noted that
there is no systematic approach or guidelines to issues of inclusiveness
in the emergency context. The WASH response should be inclusive
with respect to:
Women and girls. Safety concerns of women and girls have been
documented challenges to implementing sanitation in a humanitarian
context (Atuyambe et al., 2011), and females are also usually responsible
for managing water, protecting water quality, and maintaining domestic
hygiene. Water provision, water quality interventions, and hygiene
promotion in an emergency setting must focus on women and girls,
include their active participation and empowerment, and account for
their needs and preferences in response strategies (Nawaz et al., 2010).
Although guidelines for meeting menstrual hygiene needs exist (e.g.
Sphere standards), more work is needed to characterize appropriate
strategies to meet needs (Sommer, this issue).
People with disabilities. The World Bank estimates that 20 per cent of
the world’s poorest people are disabled, yet little attention has been
paid to the needs for unrestricted access to WASH. This is especially
true in the humanitarian context. Innovation for sanitation access
must include careful consideration of meeting the needs of people
with disabilities. Some refugee and displaced persons populations
may have a high percentage of people with disabilities, and this may
be especially true after natural disasters that have resulted in bodily
harm (Wolbring, 2011).
There is no
systematic
approach to issues
of inclusiveness
in the emergency
context

WATER, SANITATION, AND HYGIENE IN EMERGENCIES 17
Waterlines Vol. 31 Nos. 1&2 January 2012
Children. Children need different excreta disposal facilities depending
on age. If nappies are distributed, waste management is an issue;
however with non-disposable nappies there is the problem of washing.
Providing potties for children is an option where children are afraid
of falling into a pit latrine or might not want to use a toilet for other
reasons such as darkness, snakes and other animals, the smell, and
dirtiness. Few sanitation options have been documented specically
for use by children, although they are among the most susceptible
group to faecal-oral disease.
People living with HIV/AIDS. Populations affected by HIV/AIDS are
especially susceptible to WASH-related illnesses and appropriate WASH
responses may need to consider this and other vulnerable populations
in response; high levels of HIV itself can lead to interruption in WASH
services and increased vulnerability to disease (Moss, 2004).
Review of published evidence: Water supply and quality
There is strong evidence that both sufcient water (quantity) and safety
(quality) are critical to interrupting disease transmission in humanitarian
settings. Better models are needed for rapid delivery of water to dispersed
populations and more research is needed to support adherence to water
quality interventions.
There are established and accepted methods for water provision in
emergencies (e.g. Sherlock, 1988) although context-specic factors
such as political, economic, social, and environmental constraints
may impact how these are put into place (Shelley, 1994), how effective
they are, and whether they may result in increased risk of vector-borne
diseases such as malaria or dengue (Bayoh et al., 2011). Installation
may be complex, requiring special expertise, and time-consuming,
slowing response time and the delivery of safe drinking water in the
critical early stages of response. The pursuit of more sustainable water
supplies in the rst instance may delay response time but may have
longer-term advantages (Randall et al., 2008). The process of selecting
from available technologies itself may not be straightforward in
rapid response, where there is a need for immediate access to potable
drinking water but acknowledgement that the supply needs to be
sustainable. The need for immediate water provision often takes
precedence, justiably. The delayed water supply response following
the 1999 earthquake in Turkey, for example, was linked to higher
faecal-oral disease seroconversion in children (Sencan et al., 2004).
There is evidence that sufcient water (quantity) for health and
well-being, including hygiene needs, is protective against disease
in emergency settings, and international standards exist for water
Few sanitation
options have been
documented
specifically for use
by children
There are
established and
accepted methods
for water provision
in emergencies

18 J. BROWN et al.
January 2012 Waterlines Vol. 31 Nos. 1&2
provision in emergencies (Table 1). Cronin et al. (2008) observed that
households reporting diarrhoea within the previous 24 hours had a
mean 26 per cent less water available. In a seven-country review of 51
camps from 1998 to 2000, Spiegel et al. (2002) concluded that camps
with lower than the recommended 15 litres of water per person per
day had signicantly higher under-ve mortality in a systematic risk
factor analysis. Following the arrival of 800,000 Rwandan refugees
into the Democratic Republic of the Congo in 1994, 85 per cent of the
rst month’s 50,000 deaths were due to diarrhoeal diseases (cholera
and shigellosis). The primary risk factor was lack of access to water:
the per capita water allowance was 0.2 L per day in the rst week of
the crisis (Connolly et al., 2004). Further, water that is supplied must
be accessible and acceptable to users. Atuyambe et al. (2011) found
that the inconsistent nature of tanked water provision as well as taste
acceptability issues resulted in camp residents using untreated surface
water. This also underscores the importance of prior knowledge about
water safety among the population being served. Water supplies must
be both safe and acceptable to users, although quantity may take
precedence over quality (Luff, 2004) in terms of delivering a wide
range of health benets, including those that are primarily linked to
hygiene.
There is some evidence that community ownership of water
supplies and demand-driven approaches may increase the sustain-
ability of water supplies (Boydell, 1999), but how anything but a
top-down, supply-side solution for water provision can be effected
in an emergency situation is unclear. In many cases, there would be
ethical obstacles to requiring community investment in these types of
situation. Transition to a longer-term, sustainable approach to water
supply following an emergency often requires a change of approach.
Solutions that are both rapidly deployable and come with a plan for
the transition to long-term sustainability are needed, especially if
new systems and services make communities more resilient against
future emergencies. The management of water supplies in post-
emergency transition has received some attention (e.g. Pinera and
Reed, 2009), but the well-known institutional, nancial, environ-
mental, and social constraints that limit water infrastructure services
in low-income settings threaten access to safe water once any special
attention (funding, human resources) that may have been the result
of an emergency has been redirected.
Water quality interventions (point-of-use treatment and safe
storage)
There is evidence that drinking water quality at the point of
consumption is an important determinant of risk of disease, so a
Solutions that
are both rapidly
deployable and
come with a plan
for long-term
sustainability are
needed
The management
of water supplies
in post-emergency
tran-sition has
received some
attention

WATER, SANITATION, AND HYGIENE IN EMERGENCIES 19
Waterlines Vol. 31 Nos. 1&2 January 2012
number of studies have focused on point-of-use (POU) water quality
in humanitarian response (Clasen and Boisson, 2006; Gupta et al.,
2007; Steele et al., 2008). Water quality interventions such as POU
water treatment and safe storage have been studied for their effec-
tiveness in reducing risk of diarrhoeal diseases (including cholera) in
emergency response and refugee camp situations. Current evidence
is suggestive of protective effects of both active treatment and safe
water storage (such as narrow-mouth containers or containers with
controlled access) with documented effects against cholera (Hatch et
al., 1994; Reller et al., 2001; Hashizume et al., 2008; Shultz et al.,
2009) and all diarrhoeal diseases (Roberts, 2001; Kunii et al., 2002;
Mourad, 2004; Walden et al., 2005; Doocy and Burnham, 2006;
Hashizume et al., 2008). Chlorination, chlorination preceded by
occulation, boiling, and ceramic lters have been studied. Work by
Lantagne (2011) has shown that the use of POU water quality inter-
ventions in emergencies has the greatest likelihood of success when
effective technologies are distributed to households with contami-
nated water who are familiar and comfortable with the option before
the emergency, and have the training and support necessary to use
the option after the emergency.
Critically, consistency of use or adherence may limit the impact of
POU water treatment, and some evidence for low adherence exists
from studies conducted in humanitarian response. Mong et al. (2001)
reported 50 per cent adherence to POU chlorination and Clasen and
Boisson reported approximately the same level of adherence to POU
ceramic candle ltration at 16 weeks post-implementation. Colindres
et al. (2007) reported 45 per cent adherence to a POU combined
occulent-disinfectant at 3 weeks after distribution. Atuyambe et al.
(2011) reported ‘unsuccessful’ uptake of boiling in Uganda due to
taste acceptability issues in the target population. Water quality inter-
ventions can only protect public health if they are used correctly and
consistently, and adherence is especially important when the risk of
disease associated with untreated water is high.
Research needs: Water supply and water quality
Research is needed to modify or develop technologies for rapid distri-
bution in emergencies so that beneciaries in dispersed emergency
situations have faster, more predictable, and longer-lasting access to
safer drinking water. This includes both rapid deployment of drinking
water treatment and distribution methods for safeguarding water to
the POU. Because safe water may be distributed and subject to recon-
tamination, appropriate distribution methods to the POU with a
focus on protecting water quality are needed. Dedicated safe storage
containers or packaged water distribution may be needed to safeguard
Current evidence
is suggestive of
protective effects
of both active
treatment and safe
water storage
Research is
needed to modify
or develop
technologies for
rapid distribution in
emergencies

20 J. BROWN et al.
January 2012 Waterlines Vol. 31 Nos. 1&2
quality. The challenge of rapidly providing 15+ litres per person per
day of safe water (and the means to protect it from recontamination)
is formidable.
Also, more research is needed on appropriate means of creating high
adherence to POU water treatment and safe storage through effective
technology design and behaviour change. The available evidence
from POU interventions in the humanitarian context suggests that
water quality interventions may be protective against disease but high
adherence is probably required to maintain health impact. A number
of studies of POU water treatment from non-emergency settings have
shown reduced use of interventions over time, raising questions about
the potential for sustained use (Luby et al., 2001; Brown et al., 2007;
Mausezahl et al., 2009) and therefore health impact when untreated
water is unsafe.
Review of published evidence: Sanitation
Effective sanitation can prevent disease and rapid response is important.
Whilst basic options exist, innovation is needed to meet known challenges.
Safe excreta disposal is the rst line of defence against faecal-oral
pathogen transmission. Sanitation options for the humanitarian
context have been widely studied and it is widely recognized that no
one solution is appropriate for all cases (Howard, 1996; Wisner and
Adams, 2002; Harvey and Reed, 2005). Excreta need to be contained in
the quickest time possible to prevent the spread of infection (Sencan
et al., 2004), but currently available options may not be adequate
to meet the challenge of rapid response. Some emerging sanitation
solutions are not developed or rened enough to be available for
immediate dispatch in the rst phase of an emergency.
Sanitation is often a defecation eld, trench latrine, or communal
latrine solution until the immediate emergency phase is over, during
which capacity is quickly overwhelmed by the numbers of users, pits
ll up and become a hazard, and maintaining hygienic conditions
becomes a challenge. Open defecation, and the use of plastic bags
(ying latrines) are commonly practised alternatives (Patel et al.,
2011). Lora-Suarez et al. (2002) noted a signicant increase in
giardiasis among children associated with shared sanitation (compared
with individual household sanitation) following an earthquake in
Colombia. Standards recommend no more than 20 people per latrine
(Table 1), but for maintaining hygienic conditions one household per
latrine is ideal.
Problems with safe excreta disposal were particularly evident
in Haiti (Johannessen, 2011; Bastable and Lamb, this issue). The
inability to dig pit latrines – due to a high water table, concrete sites,
Safe excreta
disposal is the first
line of defence
against faecal-oral
pathogen
transmission

WATER, SANITATION, AND HYGIENE IN EMERGENCIES 21
Waterlines Vol. 31 Nos. 1&2 January 2012
or lack of permission – slowed the aid effort considerably. Agencies
took many days, if not weeks, to construct wooden raised latrines
with small holding tanks. In 2009 similar problems were experienced
in the oods in Greater Manila, the Philippines. The use of Portaloos
as a temporary measure in these contexts proved inadequate owing
to high cost and small storage capacity. Such examples illustrate that
agencies may be poorly equipped to deal with the rapid provision of
safe excreta disposal in urban emergency contexts.
Research needs: Sanitation
Wastewater and faecal sludge treatment and disposal. There is a clear
need for innovation in managing wastewater and faecal sludges that
are generated in the humanitarian context. Innovative, decentralized
wastewater treatment options (membrane bioreactors, constructed
wetlands, anaerobic lters) have been studied (e.g. Paul, 2005; Randall
et al., 2008) but have not been widely adopted. Current solutions for
sludges, such as desludging and sludge disposal and treatment kits,
may be too costly and require skilled management, and may result in
health risks where the sludge is nally dumped. There has been some
innovation with desludging (Oxfam GB’s work with diaphragm mud
pumps, supernatant water pump), but more work remains to be done
to drive down costs and expand the range of appropriate, practical
options. Where and how waste is disposed of is critically important to
containing faecal-oral disease (Howard, 1996).
Containment and chemical disinfection of waste and wastewater
from cholera- and other infectious disease-impacted environments
has been practised using chlorine, lime, and other means, although
the effectiveness of these strategies in situ in reducing target microbial
contaminants has not been formally assessed and deserves greater
attention.
Sanitation under challenging conditions. Implementing effective excreta
containment under challenging physical conditions such as unstable
soils, high water tables, and in ood-prone areas remains a challenge in
both the development and the post-emergency context (Djonoputro
et al., 2010). Alternative systems may be required, including lining of
pits to prevent pits from collapsing or building raised latrines (when
digging down is not an option). There is potential to develop new
technologies (such as septic tanks that can be rapidly constructed in
areas with a high water table) as well as a need for more research
on the effect of existing and emerging strategies for sanitation on
available water sources.
Some settings may require unconventional approaches. Technical
solutions need to be innovative and responsive to the specic
physical, social, and cultural circumstances of the disaster-affected
The use of Portaloos
as a temporary
measure in these
contexts proved
inadequate
There is a need
for more research
on the effect
of existing and
emerging strategies
for sanitation on
available water
sources

22 J. BROWN et al.
January 2012 Waterlines Vol. 31 Nos. 1&2
population. There has been some experience with people using a
Peepoo bag (a double bag system containing powdered urea which
prevents bad smells and speeds up the biodigestion process) or simple
biodegradable bags (Patel et al., 2011), although more research is
needed to characterize the role of Peepoo or conventional bags in
meeting emergency sanitation needs and their implications for sludge
treatment and disposal.
Design. Some sanitation options may benet from design improve-
ments for specic contexts. Plastic sheeting as a superstructure
material, used in rapid response, often gets ripped, which has impli-
cations for dignity and security and often means the latrine isn’t
used (Johannessen, 2011). Oxfam has done some innovative work
with prefabricated superstructure(s) that can be shipped or easily
assembled with local materials and easily erected over latrines on site.
Sanitation options that are user-friendly for women, men, children,
and disabled persons exist, but innovation may increase available
options’ acceptability, effectiveness in excreta containment, safety,
and maintenance over time. This is an area of rapid development by
sectoral stakeholders, but focused research is needed to evaluate and
implement emerging options.
Review of published evidence: Hygiene
The role of hand washing in preventing faecal-oral disease transmission
is known, including in outbreaks. Promotion of hand washing with soap
involves behaviour change, which can be slow. Are there rapid approaches
that work? Is there a role for hardware?
Hygiene interventions can interrupt faecal-oral disease trans-
mission and hand washing with soap in particular may be critical
in outbreaks. Peterson et al. (1998) demonstrated that regular soap
distribution (240 g bar soap per person per month) resulted in a 27
per cent reduction in diarrhoeal disease among households with
consistent soap availability in a refugee camp in Malawi, and two
studies have suggested a protective effect of hand washing with soap
against cholera in outbreaks (Reller et al., 2001; Hutin et al., 2003).
Soap availability and use behaviour is also critical, however, and user
preferences and knowledge must be addressed, as suggested by data
from a Ugandan emergency response in 2010 (Atuyambe et al., 2011)
where hand washing was limited by soap type preferences and incon-
sistent availability. These factors suggest that hygiene promotion in
emergencies is recommended and should accompany soap provision.
There are examples of innovative hygiene promotion approaches
such as Community Health Clubs that have been promoted in IDP
The role of
hand washing
in preventing
faecal-oral disease
transmission is
known, including in
outbreaks

WATER, SANITATION, AND HYGIENE IN EMERGENCIES 23
Waterlines Vol. 31 Nos. 1&2 January 2012
camps in Uganda. No peer-reviewed studies exist on the associated
hygiene ‘hardware’ such as hand washing stations or hygiene kits that
may promote healthy hygiene behaviours in an emergency context.
Rapidly deployable hardware that may aid in hygiene promotion is
an area of potentially important innovation for WASH emergency
response.
Research needs: Hygiene
Hygiene hardware innovation and research may facilitate more
effective behaviour change. Hand washing stations or personal
hygiene kits may increase uptake and consistency of hand washing.
Their use in humanitarian response should be formally assessed.
Hygiene promotion software that rapidly increases hand washing
and healthy hygiene behaviours should be the focus of innovation
and evaluation. Soap distribution may need to be supplemented by
specic supporting activities to be most effective. Given the critical
role of hand hygiene in protecting health – especially during an
outbreak – hand washing behaviours may merit further research to
make the available interventions more effective.
The need for more research
Within the humanitarian emergency sector, the importance of the
research and evidence base is well recognized. There is a culture that
is supportive of research as well as key champions together with the
motivation to undertake further research. NGOs and operational
agencies (such as Oxfam, ACF, MSF, Tearfund, IRC, and IFRC) are
proactively innovating in humanitarian response technologies and
appropriate WASH product design, either individually or with inter-
agency cooperation. They are working closely with product designers
and suppliers to generate new technologies for rapid deployment
in humanitarian settings. Experience has shown that the outputs
of research – technologies, techniques, and processes – tend to be
rapidly adopted.
There is a need to investigate innovative relief support services, tools,
and technologies for water, sanitation, and hygiene (WASH) regionally
and globally to meet the needs of disaster-affected communities in a
modern context and deliver solutions at scale. The WASH response
must be rapid to be effective: outbreaks happen quickly. Whilst there
are kit-based and other rapidly deployable solutions (particularly for
water), this is an area that deserves further research and innovation to
improve response time post-emergency. Few WASH agencies currently
stockpile standardized kits, even though kits are probably necessary
to achieve rapid response.
Hygiene promotion
software that
rapidly increases
hygiene behaviours
should be the focus
of innovation and
evaluation
Within the
humanitarian
emergency sector,
the importance of
the research and
evidence base is
well recognized

24 J. BROWN et al.
January 2012 Waterlines Vol. 31 Nos. 1&2
Incorporating applied research into emergency response and
publishing the results can help accelerate innovation. Most disaster
response experience related to water, sanitation, and hygiene is not
recorded in the peer-reviewed literature: communication of ndings in
the form of peer-reviewed research or case studies is understandably a
second consideration after more immediate needs are met. Moreover,
crisis situations themselves are often not suited to controlled research,
and experimental methods may not be applied for ethical, logistical,
nancial, or human resource reasons. Therefore, few experimental
studies of WASH interventions are conducted in humanitarian
settings. Nevertheless, there is an urgent need to learn more about
how to do research in this context, and the implications of different
methods for the rigour of research in emergencies and thus the
reliability of the evidence. Of the available observational and retro-
spective studies, case studies are most common and report context-
specic data on acceptability, use, and impact of strategies employed.
Whilst such studies are useful as ‘snapshots’ of the success of available
practice, they may be more a commentary on the operational and
programmatic responses to specic emergency situations themselves
rather than controlled experiments of specic WASH interventions.
Communication of ndings is critical to collective learning about
what works in WASH response.
Conclusion and recommendations
Evidence suggests that providing safe water, safe excreta disposal, and
basic hygiene measures such as hand washing are effective interven-
tions both within emergency settings and in longer-term development.
Recent experience from humanitarian relief suggests progress has
still to be made in meeting the basic WASH needs of people in crisis,
however. We propose the following immediate priorities for research
and innovation:
• Innovative sanitation options for difcult settings. To identify and/
or develop new emergency kits that are appropriate to a number
of difcult settings including: high water tables, urban settings,
and unstable soil situations (Bastable and Lamb, this issue). In
addition improved promotional messaging is required for rapid
take up of the facilities. Work in this area is expected to ll an
important gap in understanding the solutions required in both
in situ and displaced situations including in dense/urban and
scattered contexts.
• Technologies for water provision for dispersed communities. Whilst
there is an abundance of technologies available for bulk water
treatment for rapid provision of clean water in emergencies,
Recent experience
suggests progress
has still to be made
in meeting the basic
WASH needs of
people in crisis

WATER, SANITATION, AND HYGIENE IN EMERGENCIES 25
Waterlines Vol. 31 Nos. 1&2 January 2012
the picture is less clear when it comes to providing water for
dispersed affected populations (Johannessen, 2011; Bastable and
Lamb, this issue; Luff and Dorea, this issue). There is a need to
modify or develop technologies for rapid distribution in dispersed
emergency situations to ensure faster, more predictable, and
longer-lasting access to safe drinking water.
• Approaches to promote consistent, correct, and sustained use of water
quality interventions. Point-of-use (POU) water treatment and safe
storage has been shown to be effective and suitable for rapid
access to safe water in relief settings (Lantagne and Clasen, this
issue). Documented low adherence may, however, limit the
protective effects of these interventions. More research is needed
on whether new technologies, new approaches, or new behaviour
change interventions – or more likely a combination of all three –
may play a role in providing sustained access to safer water at the
point of consumption.
• Effective hygiene hardware and software. Hand washing stations,
safe water in sufcient quantity, and the availability of soap can
contribute to more effective hygiene. Rapidly deployable hand
washing stations have not been systematically evaluated in a
humanitarian setting. As for POU, further research is required to
assess whether and how new technologies, new approaches, or
new behaviour-change interventions may increase the uptake of
hand washing as a sustained practice in the relief context.
Emergency response happens within the longer-term development
process (Davis, 1988) and WASH strategies that promote or are
consistent with sustainable development over time are needed.
Institutional memory of organizations is an important factor in
ensuring appropriate response in emergency settings, since program-
matic lessons learned may help improve WASH response (Anema and
Fesselet, 2003). Also, many refugee or displaced persons camps are in
existence for long periods, up to many years (e.g. Sudan, Palestine:
Mourad, 2004; Walden et al., 2005). Although this subject is too big
to deal with adequately in this paper, it is one that requires further
research.
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Rapidly deployable
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stations have not
been systematically
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Institutional
memory is an
important factor
in ensuring
appropriate
response in
emergencies

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