Tackling global inequalities in access to Water, Sanitation and Hygiene (WASH) remains an urgent issue-58% of annual diarrhoeal deaths are caused by inadequate WASH provision. A global context of increasing urbanisation, changing demographics and health transitions demands an understanding and impact of WASH on a broad set of health outcomes. We examine the literature, in terms of health outcomes, considering WASH access and interventions in urban sub-Saharan Africa from 2000 to 2017. Our review of studies which evaluate the effectiveness of specific WASH interventions, reveals an emphasis of WASH research on acute communicable diseases, particularly diarrhoeal diseases. In contrast, chronic communicable and non-communicable health outcomes were notable gaps in the literature as well as a lack of focus on cross-cutting issues, such as ageing, well-being and gender equality. We recommend a broader focus of WASH research and interventions in urban Africa to better reflect the demographic and health transitions happening.

Little has been studied about the potential risks and hazards arising from the use and operation of container-based sanitation (CBS) systems. Building on existing risk assessment frameworks, this case study aimed to identify exposure risks from faecal pathogens and relevant control measures in a CBS service chain. The case study employed a mixed-methods approach that included environmental sampling, key informant interviews, and direct observation. This inclusion of a behavioural dimension reflects a socio-cultural approach to risk analysis that is less evident in overtly quantitative approaches to risk assessment that are typical of the health risk field. Data from this case study was collected in Naivasha, Kenya in July 2016. The hazard intensity and role of specific transmission routes was validated by environmental sampling, which found a high level of faecal contamination on toilet surfaces and a consequent high risk of hand-to-mouth infection for users and operators. The hazard analysis identified nine critical control points where exposure risks may be either prevented or reduced via the implementation of relevant control measures. We discovered that the production of exposure risks was related to multiple, interrelated causal mechanisms and risk factors, findings we expect will guide approaches to exposure risk management in the future.

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