COVID-19 is a WASH disease and it is coming to a water point near you.
I had an alarming conversation with public health colleagues in Tanzania this week. They tell me that misinformation about COVID-19 is rampant and the leading false message is that Africans cannot get the virus. Nothing could be further from the truth.
As infectious disease expert, Michael T. Osterholm, wrote in the New York Times, “In nations with few or no reported cases so far, particularly in South America and Africa, the absence of evidence shouldn’t be interpreted as evidence of absence. More likely, it reflects lack of testing.”
COVID-19, originally named Coronavirus, spreads like any cold or flu by coughing and sneezing, kissing and hugging, shaking hands and sharing surfaces. But it also spreads in feces. When a COVID-19-infected person has diarrhea, the virus aerosolizes, meaning a bowel movement in an uncovered pit latrine, improperly vented toilet, or worse, defecated out in the open has the potential to infect a large number of people. In China, in apartment complexes that have latrines that global health professionals would consider at the top of the sanitation service ladder, a regional practice of constructing latrines without P traps resulted in large amounts of apartments being exposed when a single case emerged on an upper floor. So, in addition to considering the hygiene factors that will make COVID-19 a danger in low-resource countries, the global health community needs to consider the direct vector of feces.
As of this writing (February 27, 2020*), COVID-19 has been verified in cases in 49 countries — largely countries with strong health monitoring infrastructures. It can be assumed the virus is also in many low-resource countries and is currently spreading undetected. The early symptoms of the virus — fever, cough, diarrhea, and weakness — are frighteningly similar to already-present endemic illnesses in low-resource regions, namely malaria and typhoid. However, in approximately 14% of cases, around 28 days into the infection, the virus progresses to acute respiratory distress syndrome, a potentially fatal condition that is fueled by a cytokine storm that uses the body’s own immune response against itself. In China and Italy, two of the largest populations to see cases at scale so far, this stage results in death in about 2.8–4.8% of cases.
Since a person is contagious in the 14 to 29 days it takes for symptoms to begin, they can walk around feeling healthy, work in offices, eat in public places, worship in crowds, and kiss their grandmothers and children without any idea they are spreading the virus. The virus sheds before and during sickness and it is evidently possible the virus can even later become dormant in the body to re-emerge and reinfect. As a result, the originally calculated R0 of 2 to 3 infections caused on average by one infected person may actually be higher — we just haven’t lived with the virus long enough to realize it.
As we have previously seen in cholera, Ebola, and Zika, the water, sanitation, and hygiene (WASH) relationships of a health outbreak are not handled gracefully in aid structures that silo WASH from health. Health-oriented aid organizations often have infrequent interchange with water and sanitation-oriented aid organizations. Cluster responses UN agencies organize to emergencies tend to fund and assign professionals along the lines of silos. This crisis requires us to once and for all break the silos blocking coordination between WASH and health. Healthcare facilities, for example, are among the most threatened by dangerous WASH conditions. Healthcare facilities, as a result, turn into points of exposure and transmission for both patients and providers. In the recent West African Ebola outbreak, healthcare workers were 20–30 times more likely to become infected than the general population. Scarce PPE and WASH conditions were to blame.
A lack of abundant water and soap for handwashing is the top risk factor for low-resource countries. To be added are too few safely managed and piped water systems, close living quarters in an increasingly urban world, transportation networks that expose populations to crowded vehicles many times a day, and crowded shopping markets. But a lack of sanitation infrastructure in the form of properly built latrines and widespread cultural acceptance of open defecation are among the most dangerous factors that will make COVID-19 a serious threat to health in low-resource countries. At best, our planet has this virus for another year before a vaccine. This means behavioral and infrastructure adjustments are the most important steps we can take for now.
*Update: As of March 2, 68 countries now have confirmed cases.
This artilce is also available in Swahili, translated by Jackline Bwana.
