Drainage systems, an occluded source of sanitation related outbreaks

Blom, Kristina

Sanitation is defined by the World Health Organization (WHO) as: "Sanitation generally refers to the provision of facilities and services for the safe disposal of human urine and faeces. Inadequate sanitation is a major cause of disease world-wide and improving sanitation is known to have a significant beneficial impact on health both in households and across communities. The word 'sanitation' also refers to the maintenance of hygienic conditions, through services such as garbage collection and wastewater disposal" (http://www.who.int/topics/sanitation/en/). Sanitation is in general inadequate in rural areas and in developing countries [1, 2] while regarded as safe in the developed countries in the community as well as in healthcare. However, it is not sufficient to have access to water and modern drainage systems unless adequate sanitation is maintained. Quality assurance maintenance work is implemented in pharmaceutical and food industry in order to reduce the risk of exposure to the hazards (e.g. pathogens causing clinical manifestations) in the disposals. However, in the community or in healthcare, sanitation is not prioritized and often forgotten [3] , despite that wastewater disposal contains increased level of human microbes and that there are several reports implicating drains as a source of infection (Table 1) . For instance, in the community the severe acute respiratory syndrome (SARS) outbreak in 2003 at Amoy Garden was reported by WHO to likely have been caused by faulty plumbing due to lack of maintenance causing dry out traps [4] and in healthcare, Starlander and Melhus reported in 2012 of a minor outbreak of extended spectrum β-lactamase (ESBL) producing Klebsiella pneumoniae due to contaminated sink drains [5] . Indeed, drains are implicated as being a source of microbes causing infection both in community and healthcare [6, 7] . Breathnach et al. further pointed out that proper design and maintenance of the wastewater system are essential to prevent infections at intensive care units (ICU) [7] . However, its impact on infection rates has not yet been fully elucidated.