Primary-school children in low- and middle-income countries are often deprived of microbiologically safe water and sanitation, often resulting in a high prevalence of gastrointestinal diseases and poor school performance. We used Quantitative Microbial Risk Assessment (QMRA) to predict the probability of infection in schoolchildren due to consumption of unsafe school water. A multistage random-sampling technique was used to randomly select 425 primary schools from ten districts of Sindh, Pakistan, to produce a representative sample of the province. We characterized water supplies in selected schools. Microbiological testing of water resulted in inputs for the QMRA model, to estimate the risks of infections to schoolchildren. Groundwater (62%) and surface water (38%) were identified as two major sources of drinking water in the selected schools, presenting varying degrees of health risks. Around half of the drinking-water samples were contaminated with Escherichia coli (49%), Shigella spp. (63%), Salmonella spp. (53%), and Vibrio cholerae (49%). Southern Sindh was found to have the highest risk of infection and illness from Campylobacter and Rotavirus. Central and Northern Sindh had a comparatively lower risk of waterborne diseases. Schoolchildren of Karachi were estimated to have the highest probability of illness per year, due to Campylobacter (70%) and Rotavirus (22.6%). Pearson correlation was run to assess the relationship between selected pathogens. V. cholerae was correlated with Salmonella spp., Campylobacter, Rotavirus, and Salmonella spp. Overall, the risk of illness due to the bacterial infection (E. coli, Salmonella spp., V. cholerae, Shigella, and Campylobacter) was high. There is a dire need for management plans in the schools of Sindh, to halt the progression of waterborne diseases in school-going children.

Background: Hepatitis A Virus (HAV) is among the main endemic human enteric viral diseases that directly or indirectly affect children's performance at primary schools in low-income countries. Limited information is available on the presence of HAV, with particular reference to drinking water supplies of primary schools in Sindh, Pakistan. Objectives: The present study estimated the risk of HAV infection through drinking water sources using Quantitative Microbial Risk Assessment (QMRA) in primary schools of Sindh, Pakistan. Methods: The QMRA model was applied to estimate the potential health risks of HAV using indicator organisms, i.e., fecal coliforms. Microbial analysis was conducted using a membrane filtration method. The exponential dose-response model was used to calculate the probability of infection. Results: The highest daily risk of HAV infection for schoolchildren was calculated as 35.0 per 10,000 schoolchildren in Karachi district with an annual risk of 66%, whereas the lowest risk was 3.0 per 10,000 schoolchildren in Larkana with 7.8% of the annual risk. The mortality risk due to HAV ranged from 4.0 to 29 deaths per 10,000 children per year. Conclusions: Overall, the drinking water quality of primary schools of Sindh was found very poor. The estimated daily and annual risks of hepatitis A to primary school children were moderate to high. To halt enteric virus transmission through drinking water sources, there is a dire need to invest in the provision of comprehensive water sanitation and hygiene facilities at schools.

Primary school children in the developing world often lack potable water, which may result in a high burden of water-related diseases and poor school performance. The present study aimed to characterize the drinking water quality in primary schools of Pakistan. We used a multistage random-sampling method to select 425 primary schools from selected districts of Sindh province. Standard methods were used to characterize water quality. The results were compared with maximum acceptable values recommended by the Pakistani National Environmental Quality Standards (Pak NEQS) and the World Health Organization (WHO) drinking water quality standards. Groundwater (62%) and surface water (38%) were identified as two major drinking water sources in the selected schools with varying levels of water quality. Among all parameters, dissolved oxygen (DO), pH, and nitrate remained within WHO and Pak NEQS water quality standard limit, while total dissolved solids (TDS) (33%), electrical conductivity (EC) (46%), chloride (34%), turbidity (27%), and hardness (11%) samples exceeded standard limits. All dissolved salts had moderate to strong positive correlations with TDS and EC values. Based on a water quality index (WQI), 74% of primary schools had access to excellent or good quality drinking water compared to 26% of schools that had access to either poor, very poor or unsuitable drinking water. Among all three regions, more schools from South Sindh had either poor, very poor or unsuitable drinking water (33%) compared to the Central (25%) and North zones (15%). Hence, water from these locations is unfit for human consumption and these schools need better water quality management plans to stop the spread of water-related diseases in primary school children.

The United Nation's Sustainable Development Goals include the target of ensuring access to water and sanitation and hygiene (WASH) for all; however, very few studies have assessed comprehensive school WASH service in Pakistan. The purpose of this study was to identify WASH services in primary schools of Pakistan, and to assess how recent WASH interventions and policies are associated with the school's academic performance. A representative cross-sectional study was conducted in primary schools in the Sindh province of Pakistan. Structured observations and interviews were done to ascertain the schools' WASH conditions. The primary exposures of interest were the implementation of previous WASH interventions and National WASH policy in the school and the WASH coverage. Outcomes of interest included WASH conditions and school performance. The structural equation modeling (SEM) using a bootstrap resampling procedure was employed to characterize how WASH exposures were associated with WASH conditions and school performance. Data were collected from 425 schools. The Basic WASH facilities coverage in the primary schools of Sindh remains overall low according to WHO WASH service ladder criteria. Also, inconsistency in all three inclusive domains of WASH (availability, accessibility, and functionality) facilities were found. The school performance was significantly associated (P<0.001) with the presence of WASH interventions and/or WASH policy, while WASH policy and/or recent WASH intervention at the school were not associated with overall water quality. Our assessment unveiled several WASH gaps that exist, including high heavy metal and fecal contamination. Adoption of national WASH policy and financing of evidence-based WASH interventions are recommended in primary schools to improve educational outcomes.

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