1TomHennessy,MD,MPHArcticInvestigationsProgramNationalCenterforEmergingandZoonoticInfectiousDiseasesCentersforDiseaseControlandPrevention(CDC)Anchorage,AlaskaWaterandHumanHealth

inAlaska23ProportionofUShomeswithcompleteplumbing,1940-20004ProportionofUShomeswithcompleteplumbing,1940-20005ProportionofUShomeswithcompleteplumbing,1940-20006ProportionofUShomeswithcompleteplumbing,1940-20007ProportionofUShomeswithcompleteplumbing,1940-20008WhatweknowAlaskarankslastamongU.S.Statesforin-homewaterservicesIncreasingevidencethatAccesstowaterservicelinkedtoimprovedhealth9Water-relatedinfections:

TheBradleyClassification*Water-bornePathogeningestedwithwaterCholera,otherentericinfectionsWater-washedPerson-to-person,lackofwaterforhygieneSkininfections,trachomaWater-basedAquaticintermediatehostSchistosomiasis,guineawormWater-relatedinsectvectorInsectsbreedorbitenearwaterMalaria,dengue*“DrawersofWater〞;White,Bradley,White;UofChicagoPress,197210Examplesof“Water-washed〞DiseasesHandwashingeducationinNavyrecruits45%lessclinicvisitsforrespiratoryillnessRyan,AmJ.PrevMed,2001CommunitytrialofhandwashingpromotionKarachi,PakistanSoap,antibacterialsoap,educationonlyLuby,Lancet,2005Soapandeducation: 50%lessdiarrhea,pneumonia33%lessskininfection(impetigo)11WhatweknowAlaskarankslastamongU.S.Statesforin-homewaterservicesIncreasingevidencethatin-homewaterservicelinkedtobetterhealthPriorto2021,datalinkingwaterservicetohealthinAlaskawerelimitedHashurtfundingforwaterinfrastructureprograms121314Doesprovidingin-homewaterandsanitationserviceresultinimprovedhealthforAlaskaNativepeople?15Statewidesurvey“Served〞homeshaveinternalplumbingMunicipalpipedwater,pressuretanks,privatewells“Unserved〞withoutinternalplumbingSelf-hauledwaterRuralAlaskaHousingSanitationInventory,200116In-HomeWaterandSewerService,RuralAlaskaRegions,2001RegionCommunitiessurveyedHomessurveyedHomeswithpipedwaterHomeswithFlushToiletsA4368100%100%B25155589%87%C26283488%85%D1083475%75%E49551361%60%F14137657%55%Total12812,48073%71%17HospitalizationRatesfor“High〞and“Low〞WaterServiceRegions,Alaska,2000-2004*****P<0.05Rateper10,0001819HospitalizationratesforAlaskaNativeinfants,accordingtopercentofhomeswithwaterservice

1999-2004*Rateper1,000births*Hennessy,AJPH,202120Hospitalizationratesforinfantsinvillageswith<10%ofhomeswithwaterservice,

comparedwithU.S.infantsRateper1,000births5x11x5x21Skininfectionrates,allages,

byvillagewaterservice,

SouthwestAlaska,1999-2000Rateper1,000personsWaterService22SeriousinfectionswithStreptococcuspneumoniaeinchildren<5yearsold,

SouthwestAlaska,2001-2007Rateper100,000WaterService*JWenger,2021,PediatricInfectiousDiseases20XLRIIncidenceAmongAlaskaChildren<2years,EnrolledinMedicaid1998-2003Communityin-homewaterserviceIncidenceper100child-yearsGessner,JPediatrics,202124DentalCaries,aWater-washedDisease?DentalcariesagrowinghealthproblemWaterfluoridationinruralAlaskaislessavailableinlast15yearsFluoridepoisoningdeathin1992FluoridationonlyofferedinmunicipalpipedsystemsSouthwestAlaskavillages1990s:appx.25of52fluoridatedwater2021:4of52villages25DentalCariesinPrimaryTeethby

VillageFluoridationStatus,

SouthwestAlaska,2021***p<0.013x1.5x1.61.82627SummaryofAlaskaData-Lowwaterserviceregionshavehigherhospitalizationratesof -Pneumonia&influenza-RSV -Skininfections -NOTinfectiousdiarrheaInSouthwestregion,lowwaterserviceislinkedtohigherratesofRespiratoryhospitalizationsininfantsSkininfections,allagesSeriouspneumococcalinfectionsinchildrenDentalcariesinchildren28OtherStudiesinProgressEvaluateinfectiousdiseaseratesinvillageswithnewwatersystems“4villagestudy〞ANTHC–CDCproject(TroyRitter,P.I.)WaterusepromotionandhealthevaluationDataanalysisongoingOpportunitiestorepeatinothervillagesEconomicanalysesCostofRSVhospitalizationsCosteffectivenessofwaterfluoridationandotherpreventivedentistryapproachesIn-homewaterserviceandinfectiousdiseasesinotherI.H.S.AreasRemainingquestionsHowmuchwaterisneededtomaximizehealthybehaviors?Highcost,limitedwatersupplyleadtorationinginsome“served〞homesWhatotherindicatorsarelinkedtoin-homewaterservice?DiarrheaInjuriesLosteconomicopportunities2930CollectingWater:

RedDevil,AKLimitationsofHealthDataWateravailabilityisnottheonlydeterminantofinfectiousdiseaseriskHouseholdcrowding,indoorairquality,nutrition,individualimmunity,pathogenfactorsProvisionofin-homewaterwillnoteliminatediseasecompletelyEconomicgainsfromimprovedhealthwillnotequalcostsofwatersystems31UsesofHealthDataProvidesaddedjustificationfornewconstructionWaterservicesdeliveryisatooltoaddressongoinghealthdisparitiesAwaytomeasureprogressMayprovideinformationaboutoptimalwaterquantityneededWaterusepromotionactivitiescanacceleratebenefitsofnewwatersystems32SummaryProvisionofin-homewaterserviceisassociatedwithimprovedhealthinruralAlaskaAlaskarankslastamongUSStatesforin-homewaterserviceProvidingadequatewatertomorehomescanbeexpectedtoresultinimprovedhealthforruralAlaskaNativepersons333435Thanksto…AlaskaNativeTribalHealthConsortiumTroyRitterJeffSmithRosSingletonYukonKuskokwimHealthCorporationJoeKlejkaStateofAlaskaJoeMcLaughlinBradWhistlerCDCAlaskaDanaBrudenLisaBulkowJayWengerMichaelBruceTimThomasCDCAtlanta BobHolmanKathyByrdIndianHealthServiceJimCheek36InfectiousDiseaseHospitalizationsbyRegion,2000-2004RegionHomeswithPlumbingRateper10,000personsperyearDiarrheaPneumoniaandInfluenzaResp.SyncytialVirusSkinInfectionMRSAAnchorage(urban)100%76379515Barrow100%698214411BristolBay89%686148473Southeast88%104230261“High”Service91%86375434“Low”Service61%71582499316Kotzebue75%610113634<1YukonKuskokwim61%819931411327NortonSound57%49112939137VillagesGroupedbyWaterService,

YKRegionHomeswithPlumbingBethel,

100%<10%10–79%≥80%Villages2013141Population6956474364155459VillageSize,(median)312370493545938TypeofWaterService,YKRegion39404142Incidenceofpneumoniainchildrenyoungerthan5years,PakistanEffectofhandwashingonchildhealth:arandomisedcontrolledtrial.S.Luby,M.Agboatwalla,D.Feikin

TheLancet.2005;(366)948143RiskFactorsforDentalCaries,MultivariateAnalysisPrimary