55

Surveillance
Surveillance

A conceptual framework for

Introduction
implementing the Guidelines
(Chapter 1)
(Chapter 2)

D
D
“the
rinking-water sup-
rinking-water
ply surveillance
ply
sup-
surveillance isis
“the continuous
continuous and and
FRAMEWORK FOR SAFE DRINKING-WATER

Health-based targets Public health context

SUPPORTING
INFORMATION

Microbial aspects
vigilantpublic
vigilant public health
health as-as- (Chapter 3) and health outcome (Chapters 7 and 11)

sessment and
sessment and review
review of of Water safety plans Chemical aspects
(Chapter 4) (Chapters 8 and 12)
the safety and accept-
the safety and accept-
System Management and Radiological
ability of
ability of drinking-water
drinking‑water assessment
Monitoring
communication aspects
supplies” (WHO, 1976).
supplies” (WHO, 1976). (Chapter 9)

Thissurveillance
This surveillancecontrib-
contrib- Surveillance
Acceptability
aspects
utes to the protection of
utes to the protection of (Chapter 5)
(Chapter 10)

publichealth
public healthby by promot-
promot-
ing improvement of
ing improvement of thethe Application of the Guidelines
quality, quantity, access­
quality, quantity, access- in specific circumstances
(Chapter 6)
ibility, coverage, afford-
ibility, coverage, afford-
Climate change, Emergencies,
ability and
ability and continuity
continuity of of Rainwater harvesting, Desalination
systems, Travellers, Planes and
water supplies (known
water supplies (known ships, etc.
asasservice
serviceindicators)
indicators) and and
isis complementary
complementary to to the
the
quality control functionofofthe
quality control function thedrinking-water
drinking-watersupplier. supplier.Drinking-water
Drinking-watersupply supplysur- sur-
veillance does not remove or replace the responsibility of the drinking-watersupplier
veillance does not remove or replace the responsibility of the drinking-water supplier
totoensure
ensurethatthataadrinking-water
drinking-watersupply supplyisisofofacceptable
acceptablequality qualityand andmeets
meetspredeter-
predeter-
mined health-based targets.
mined health-based targets.
Allmembers
All membersofofthe thepopulation
populationreceive receivedrinking-water
drinking-waterbybysome somemeans—includ-
means—includ-
ing the use of piped supplies with or without treatment and withororwithout
ing the use of piped supplies with or without treatment and with withoutpump-
pump-
ing (supplied via domestic connection or public standpipe), delivery bytanker
ing (supplied via domestic connection or public standpipe), delivery by tankertruck
truck
ororcarriage
carriagebybybeasts
beastsofofburden
burdenororcollection
collectionfrom fromgroundwater
groundwatersources sources(springs
(springsoror
wells)ororsurface
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sources(lakes,
(lakes,rivers
riversand andstreams).
streams).ItItisisimportant
importantfor forthe
thesurveillance
surveillance
agency to build up a picture of the frequency of use of the different typesofofsupply,
agency to build up a picture of the frequency of use of the different types supply,
especiallyasasa apreliminary
especially preliminarystep stepininthe theplanning
planningofofa asurveillancesurveillanceprogramme.programme.There There

7777
 GUIDELINES FOR DRINKING-WATER QUALITY

is little to be gained from surveillance of piped water supplies alone if these are avail-
able to only a small proportion of the population or if they represent a minority of
supplies.
Information alone does not lead to improvement. Instead, the effective manage-
ment and use of the information generated by surveillance make possible the rational
improvement of water supplies—where “rational” implies that available resources are
used for maximum public health benefit.
Surveillance is an important element in the development of strategies for incre-
mental improvement of the quality of drinking-water supply services. It is important
that strategies be developed for implementing surveillance, collating, analysing and
summarizing data and reporting and disseminating the findings and that the strat-
egies are accompanied by recommendations for remedial action. Follow-up will be
required to ensure that remedial action is taken.
Surveillance extends beyond drinking-water supplies operated by a discrete
drinking-water supplier to include drinking-water supplies that are managed by com-
munities and includes assurance of good hygiene in the collection and storage of
household water.
The surveillance agency must have, or have access to, legal expertise in addition
to expertise on drinking-water and water quality. Drinking-water supply surveillance
is also used to ensure that any transgressions that may occur are appropriately inves-
tigated and resolved. In many cases, it will be more appropriate to use surveillance as a
mechanism for collaboration between public health agencies and drinking-water sup-
pliers to improve drinking-water supply than to resort to enforcement, particularly
where the problem lies mainly with community-managed drinking-water supplies.
The authorities responsible for drinking-water supply surveillance may be the
public health ministry or other agency (see section 1.2.1), and their roles encompass
four areas of activity:
1) public health oversight of organized drinking-water supplies;
2) public health oversight and information support to populations without access to
organized drinking-water supplies, including communities and households;
3) consolidation of information from diverse sources to enable understanding of
the overall drinking-water supply situation for a country or region as a whole
as an input to the development of coherent public health–centred policies and
practices;
4) participation in the investigation, reporting and compilation of outbreaks of
waterborne disease.
A drinking-water supply surveillance programme should normally include pro-
cesses for approval of water safety plans (WSPs). This approval will normally involve
review of the system assessment, of the identification of appropriate control measures
and supporting programmes and of operational monitoring and management plans.
It should ensure that the WSP covers normal operating conditions and predictable in-
cidents (deviations) and has contingency plans in case of an emergency or unplanned
event.

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 5. SURVEILLANCE

The surveillance agency may also support or undertake the development of WSPs
for community-managed drinking-water supplies and household water treatment
and storage. Such plans may be generic for particular technologies rather than specific
for individual systems.

5.1 Types of approaches

There are two types of approaches to surveillance of drinking-water quality: audit-
based approaches and approaches relying on direct assessment. Implementation of
surveillance will generally include a mixture of these approaches according to supply
type and may involve using rolling programmes whereby systems are addressed pro-
gressively. Often it is not possible to undertake extensive surveillance of all community
or household supplies. In these cases, well-designed surveys should be undertaken in
order to understand the situation at the national or regional level.

5.1.1 Audit
In the audit approach to surveillance, assessment activities, including verification test-
ing, are undertaken largely by the supplier, with third-party auditing to verify compli-
ance. It is increasingly common that analytical services are procured from accredited
external laboratories. Some authorities are also experimenting with the use of such
arrangements for services such as sanitary inspection, sampling and audit reviews.
An audit approach requires the existence of a stable source of expertise and cap­
acity within the surveillance agency in order to:
• review and approve new WSPs;
• undertake or oversee auditing of the implementation of individual WSPs as a
programmed routine activity;
• respond to, investigate and provide advice on receipt of reports on significant
incidents.
Periodic audit of the implementation of WSPs is required:
• at intervals (the frequency of routine audits will be dependent on factors such as
the size of the population served and the nature and quality of source water and
treatment facilities);
• following substantial changes to the source, the distribution or storage system or
treatment processes;
• following significant incidents.
Periodic audit would normally include the following elements:
• examination of records to ensure that system management is being carried out as
described in the WSP;
• ensuring that operational monitoring parameters are kept within operational
limits and that compliance is being maintained;
• ensuring that verification programmes are operated by the water supplier (either
through in-house expertise or through a third-party arrangement);

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 GUIDELINES FOR DRINKING-WATER QUALITY

• assessment of supporting programmes and of strategies for improving and up-

dating the WSP;
• in some circumstances, sanitary inspection, which may cover the whole of the
drinking-water system, including sources, transmission infrastructure, treatment
plants, storage reservoirs and distribution systems.
In response to reports of significant incidents, it is necessary to ensure that:
• the event is investigated promptly and appropriately;
• the cause of the event is determined and corrected;
• the incident and corrective action are documented and reported to appropriate
authorities;
• the WSP is reassessed to avoid the occurrence of a similar situation.
The implementation of an audit-based approach places responsibility on the
drinking-water supplier to provide the surveillance agency with information re-
garding system performance against agreed indicators. In addition, a programme of
announced and unannounced visits by auditors to drinking-water suppliers should
be implemented to review documentation and records of operational practice in or-
der to ensure that data submitted are reliable. Such an approach does not necessarily
imply that water suppliers are likely to falsify records, but it does provide an important
means of reassuring consumers that there is true independent verification of the activ-
ities of the water supplier. The surveillance agency will normally retain the authority
to undertake some analysis of drinking-water quality to verify performance or enter
into a third-party arrangement for such analysis.

5.1.2 Direct assessment

It may be appropriate for the drinking-water supply surveillance agency to carry out
independent testing of water supplies. Such an approach often implies that the agency
has access to analytical facilities with staff trained to carry out sampling, analysis and
sanitary inspection.
Direct assessment also implies that surveillance agencies have the capacity to as-
sess findings and to report to and advise suppliers and communities. A surveillance
programme based on direct assessment would normally include:
• specified approaches to large municipality/small municipality/community sup-
plies and individual household supplies;
• sanitary inspections to be carried out by qualified personnel;
• sampling to be carried out by qualified personnel;
• tests to be conducted using suitable methods by accredited laboratories or using
approved field testing equipment and qualified personnel;
• procedures on reporting findings and follow-up to ensure that they have been
acted on.
For community-managed drinking-water supplies and where the development of
in-house verification or third-party arrangements is limited, direct assessment may be
used as the principal system of surveillance. This may apply to drinking-water supplies

80
 5. SURVEILLANCE

in small towns by small-scale private sector operators or local government. Direct as-
sessment may lead to the identification of requirements to amend or update the WSP,
and the process to be followed when undertaking such amendments should be clearly
identified.
Where direct assessment is carried out by the surveillance agency, it comple-
ments other verification testing of the water supplier. General guidance on verification
testing, which is also applicable to surveillance through direct assessment, is provided
in section 4.3.

5.2 Adapting approaches to specific circumstances

5.2.1 Urban areas in developing countries
Drinking-water supply arrangements in urban areas of developing countries are typ-
ically complex. There can often be one or more large piped supplies with household
and public connections, in combination with a range of alternative drinking-water
supplies, including point sources and vended water. In these situations, the surveil-
lance programme should take account of the different sources of drinking-water and
the potential for deterioration in quality during collection, storage and use. Further-
more, the population will vary in terms of socioeconomic status and vulnerability to
water-related disease.
In many situations, zoning the urban area on the basis of vulnerability and
drinking-water supply arrangements is required. The zoning system should include
all populations within the urban area, including informal and periurban settlements,
regardless of their legal status, in order to direct resources to where greatest improve-
ments (or benefits) to public health will be achieved. This provides a mechanism
to ensure that non-piped drinking-water sources are also included within drinking-
water supply surveillance activities.
Experience has shown that zoning can be developed using qualitative and quan-
titative methods and is useful in identifying vulnerable groups and priority commun-
ities where drinking-water supply improvements are required.

5.2.2 Community drinking-water supplies

Small community-managed drinking-water supplies are found in most countries
and may be the predominant form of drinking-water supply for large sections of the
population. The precise definition of a “community drinking-water supply” will vary,
but administration and management arrangements are often what set community
supplies apart, especially in developing countries. Community-managed supplies may
include simple piped water systems or a range of point sources, such as boreholes with
hand pumps, dug wells and protected springs.
The control of water quality and implementation of surveillance programmes for
such supplies often face significant constraints. These typically include:
• limited capacity and skills within the community to undertake process control
and verification; this may increase the need both for surveillance to assess the
state of drinking-water supplies and for surveillance staff to provide training and
support to community members;

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 GUIDELINES FOR DRINKING-WATER QUALITY

• the very large number of widely dispersed supplies, which significantly increases
overall costs in undertaking surveillance activities.
Furthermore, it is often small community-managed water supplies that present the
greatest water quality problems.
Experience from both developing and developed countries has shown that sur-
veillance of community-managed drinking-water supplies can be effective when well
designed and when the objectives are geared more towards a supportive role to en-
hance community management than towards enforcement of compliance.
Surveillance of community drinking-water supplies requires a systematic pro-
gramme of surveys that encompass all aspects of the drinking-water supply to the
population as a whole, including sanitary inspection (including catchment inspec-
tions) and institutional and community aspects. Surveillance should address variabil-
ity in source water quality, treatment process efficacy and the quality of distributed or
household-treated and household-stored water.
Experience has also shown that the role of surveillance may include health edu-
cation and health promotion activities to improve healthy behaviour towards man-
agement of drinking-water supply and sanitation. Participatory activities can include
sanitary inspection by communities and, where appropriate, community-based test-
ing of drinking-water quality using affordable field test kits and other accessible test-
ing resources.
In the evaluation of overall strategies, the principal aim should be to derive over-
all lessons for improving water safety for all community supplies, rather than relying
on monitoring the performance of individual supplies.
Frequent visits to every individual supply may be impractical because of the very
large numbers of such supplies and the limitations of resources for such visits. How-
ever, surveillance of large numbers of community supplies can be achieved through a
rolling programme of visits. Commonly, the aim will be to visit each supply periodic-
ally (once every 3–5 years at a minimum) using either stratified random sampling or
cluster sampling to select specific supplies to be visited. During each visit, sanitary
inspection and water quality analysis will normally be done to provide insight to con-
tamination and its causes.
During each visit, testing of water stored in the home may be undertaken in a
sample of households. The objective for such testing is to determine whether con-
tamination occurs primarily at the source or within the home. This will allow evalua-
tion of the need for investment in supply improvement or education on good hygiene
practices for household treatment and safe storage. Household testing may also be
used to evaluate the impact of a specific hygiene education programme.

5.2.3 Household treatment and storage systems

Where water is handled during storage in households, it may be vulnerable to contam-
ination, and sampling of household-stored water is of interest in independent surveil-
lance. It is often undertaken on a “survey” basis to develop insights into the extent and
nature of prevailing problems. Surveillance systems managed by public health author-

82
 5. SURVEILLANCE

ities for drinking-water supplies using household treatment and household storage
containers are therefore recommended.
The principal focus of surveillance of household-based interventions will be as-
sessment of their acceptance and impact through sample surveys so as to evaluate
and inform overall strategy development and refinement. Systematic determination
of continued, correct and effective use and management is recommended so that
deficiencies in use and management can be identified and corrected by those respon-
sible.

5.3 Adequacy of supply

As the drinking-water supply surveillance agency has an interest in the population at
large, its interest extends beyond water quality in isolation to include all aspects of the
adequacy of drinking-water supply for the protection of public health.
In undertaking an assessment of the adequacy of the drinking-water supply, the
following basic service parameters of a drinking-water supply should normally be
taken into consideration:
• Quality: whether the supply has regularly verified water quality and an approved
WSP (see chapter 4) that has been validated and is subject to periodic audit to
demonstrate compliance with relevant regulations (see chapters 3 and 4);
• Quantity (service level): the proportion of the population with access to different
levels of drinking-water supply (e.g. no access, basic access, intermediate access
and optimal access) as a surrogate for health impacts in relation to quantity of
water used;
• Accessibility: the percentage of the population that has reasonable access to an
improved drinking-water supply;
• Affordability: the tariff paid by domestic consumers;
• Continuity: the percentage of the time during which drinking-water is available
(daily, weekly and seasonally).

5.3.1 Quantity (service level)

The quantity of water collected and used by households has an important influence
on health. There is a basic human physiological requirement for water to maintain
adequate hydration and an additional requirement for food preparation. There is a
further requirement for water to support hygiene, which is necessary for health.
Estimates of the volume of water needed for health purposes vary widely. In
deriving World Health Organization (WHO) guideline values, it is assumed that
the daily per capita consumption of drinking-water is approximately 2 litres for
adults, although actual consumption varies according to climate, activity level and
diet. Based on currently available data, a minimum volume of 7.5 litres per capita
per day will provide sufficient water for hydration and incorporation into food for
most people under most conditions. In addition, adequate domestic water is needed
for food preparation, laundry and personal and domestic hygiene, which are also
important for health. Water may also be important in income generation and amen-
ity uses.

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Table 5.1 Service level and quantity of water collected

Service Likely volumes of Public health risk Intervention priority
level Distance/time water collected from poor hygiene and actions
No access More than 1 km / Very low: 5 litres Very high Very high
more than 30 min per capita per day Hygiene practice Provision of basic level
round-trip compromised of service
Basic consumption Hygiene education
may be Household water
compromised treatment and safe
storage as interim
measure
Basic access Within 1 km / Approximately 20 High High
within 30 min litres per capita per Hygiene may be Provision of improved
round-trip day on average compromised level of service
Laundry may occur Hygiene education
off-plot Household water
treatment and safe
storage as interim
measure
Intermediate Water provided Approximately Low Low
access on-plot through 50 litres per Hygiene should not Hygiene promotion still
at least one tap capita per day on be compromised yields health gains
(yard level) average Laundry likely to Encourage optimal
occur on-plot access
Optimal Supply of water 100–200 litres per Very low Very low
access through multiple capita per day on Hygiene should not Hygiene promotion still
taps within the average be compromised yields health gains
house Laundry will occur
on-plot
Source: Domestic water quantity, service level and health (supporting document in Annex 1)

The quantities of water collected and used by households are primarily a func-
tion of the distance to the water supply or total collection time required. This broad-
ly equates to the level of service. Four levels of service can be defined, as shown in
Table 5.1.
Service level is a useful and easily measured indicator that provides a valid sur-
rogate for the quantity of water collected by households and is the preferred indicator
for surveillance. Available evidence indicates that health gains accrue from improving
service level in two key stages: the delivery of water within 1 km or 30 minutes of to-
tal collection time; and when supplied to a yard level of service. Further health gains
are likely to occur once water is supplied through multiple taps, as this will increase
water availability for diverse hygiene practices. The volume of water collected may also
depend on the reliability and cost of the water. Therefore, collection of data on these
indicators is important.

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 5. SURVEILLANCE

5.3.2 Accessibility
From the public health standpoint, the proportion of the population with reliable ac-
cess to safe drinking-water is the most important single indicator of the overall success
of a drinking-water supply programme.
There are a number of definitions of access (or coverage), many with qualifica-
tions regarding safety or adequacy. Access to safe drinking-water for the Millennium
Development Goals is currently measured by the WHO/ United Nations Children’s
Fund (UNICEF) Joint Monitoring Programme for Water Supply and Sanitation
through a proxy that assesses the use of improved drinking-water sources by house-
holds. An improved drinking-water source is one that by the nature of its construction
and design adequately protects the source from outside contamination, in particular
by faecal matter. The underlying assumption is that improved sources are more likely
to supply safe drinking-water than unimproved sources. Improved and unimproved
water supply technologies are summarized below:
• Improved drinking-water sources:
—— piped water into dwelling, yard or plot
—— public tap or standpipe
—— tubewell or borehole
—— protected dug well
—— protected spring
—— rainwater collection.
• Unimproved drinking-water sources:
—— unprotected dug well
—— unprotected spring
—— cart with small tank or drum provided by water vendor
—— tanker truck provision of water
—— surface water (river, dam, lake, pond, stream, canal, irrigation channel)
—— bottled water.1
Determining the proportion of a population with reliable access to drinking-
water is an important function of a drinking-water surveillance agency. This task can
be facilitated by establishing a common defi nition for reasonable access, appropriate
to a local context, which may describe a minimum quantity of water supplies per
person per day together with a maximum tolerable distance/time to a source (e.g. 20
litres, and within 1 km/30 minutes, respectively, for basic access).

5.3.3 Affordability
The affordability of water has a significant influence on the use of water and selec-
tion of water sources. Households with the lowest levels of access to safe water supply
frequently pay more for their water than do households connected to a piped water
system. The high cost of water may force households to use alternative sources of
water of poorer quality that represent a greater risk to health. Furthermore, high costs

1
Bottled water is considered to be improved only when the household uses drinking-water from an
improved source for cooking and personal hygiene.

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 GUIDELINES FOR DRINKING-WATER QUALITY

of water may reduce the volumes of water used by households, which in turn may
influence hygiene practices and increase risks of disease transmission.
When assessing affordability, it is important to collect data on the price at the
point of purchase. Where households are connected to the drinking-water supplier,
this will be the tariff applied. Where water is purchased from public standpipes or
from neighbours, the price at the point of purchase may be very different from the
drinking-water supplier tariff. Many alternative water sources (notably vendors) also
involve costs, and these costs should be included in evaluations of affordability. In
addition to recurrent costs, the costs for initial acquisition of a connection should also
be considered when evaluating affordability.

5.3.4 Continuity
Interruptions to drinking-water supply, either because of intermittent sources or re-
sulting from engineering inefficiencies, are a major determinant of the access to and
quality of drinking-water. Analysis of data on continuity of supply requires the con-
sideration of several components. Continuity can be classified as follows:
• year-round service from a reliable source with no interruption of flow at the tap
or source;
• year-round service with frequent (daily or weekly) interruptions, of which the
most common causes are:
—— restricted pumping regimes in pumped systems, whether planned or due to
power failure or sporadic failure;
—— peak demand exceeding the flow capacity of the transmission mains or the
capacity of the reservoir;
—— excessive leakage within the distribution system;
—— excessive demands on community-managed point sources;
• seasonal service variation resulting from source fluctuation, which typically has
three causes:
—— natural variation in source volume during the year;
—— volume limitation because of competition with other uses, such as irriga-
tion;
—— periods of high turbidity when the source water may be untreatable;
• compounded frequent and seasonal discontinuity.
These classifications reflect broad categories of continuity, which are likely to affect
hygiene in different ways. Any interruption of service is likely to result in degradation of
water quality, increased risk of exposure to contaminated water and therefore increased
risk of waterborne disease. Daily or weekly discontinuity results in low supply pressure
and a consequent risk of in-pipe recontamination. Other consequences include reduced
availability and lower volume use, which adversely affect hygiene. Household water
storage may be necessary, and this may lead to an increase in the risk of contamination
during such storage and associated handling. Seasonal discontinuity often forces users
to obtain water from inferior and distant sources. As a consequence, in addition to the
obvious reduction in quality and quantity, time is lost in water collection.

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 5. SURVEILLANCE

5.4 Planning and implementation

For drinking-water supply surveillance to lead to improvements in drinking-water
supply, it is vital that the mechanisms for promoting improvement are recognized and
used.
The focus of drinking-water supply-related improvement activities (whether these
are establishment of regional or national priorities, hygiene education programmes or
enforcement compliance) will depend on the nature of the drinking-water supplies
and the types of problems identified. A list of mechanisms for drinking-water supply
improvement based on the output of surveillance is given below:
• Establishing national priorities: When the most common problems and shortcom-
ings in the drinking-water system have been identified, national strategies can
be formulated for improvements and remedial measures; these might include
changes in training (of managers, administrators, engineers or field staff), rolling
programmes for rehabilitation or improvement or changes in funding strategies
to target specific needs.
• Establishing subnational/regional priorities: Regional offices of drinking-water sup-
ply agencies can decide in which communities to work and which remedial activities
are priorities; public health criteria should be considered when priorities are set.
• Establishing hygiene education programmes: Not all of the problems revealed by
surveillance are technical in nature, and not all are solved by drinking-water sup-
pliers; surveillance also looks at problems involving community and household
supplies, water collection and transport and household treatment and storage.
The solutions to many of these problems are likely to require educational and
promotional activities.
• Auditing of WSPs and upgrading: The information generated by surveillance can
be used to audit WSPs and to assess whether these are in compliance. Drink-
ing-water systems and their associated WSPs should be upgraded where they are
found to be deficient, although feasibility must be considered, and enforcement
of upgrading should be linked to strategies for progressive improvement.
• Ensuring community operation and maintenance: Support should be provided by a
designated authority to enable community members to be trained so that they are
able to assume responsibility for the operation and maintenance of community
drinking-water supplies.
• Establishing public awareness and information channels: Publication of informa-
tion on public health aspects of drinking-water supplies, water quality and the
performance of suppliers can encourage suppliers to follow good practices, mo-
bilize public opinion and response and reduce the need for regulatory enforce-
ment, which should be an option of last resort.
• Implementing programmes for household water treatment and safe storage: If infor-
mation from surveillance reveals no or only basic access to water service, as de-
fined in Table 5.1, or unsafe supplied water, the implementation of programmes to
promote household water treatment and safe storage may be advised to improve
water quality and promote hygienic water management at the household level.
These may be effective interim measures for provision of safer water supported
by appropriate outreach, education and training activities and creating supply

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 GUIDELINES FOR DRINKING-WATER QUALITY

chains for appropriate household water treatment and safe storage technologies.
Further information is available in section 7.3.2 and the 1997 volume, Surveil-
lance and control of community supplies (WHO, 1997).
In order to make best use of limited resources where surveillance is not yet prac-
tised, it is advisable to start with a basic programme that develops in a planned man-
ner. Activities in the early stages should generate enough useful data to demonstrate
the value of surveillance. Thereafter, the objective should be to progress to more ad-
vanced surveillance as resources and conditions permit.
The activities normally undertaken in the initial, intermediate and advanced stages
of development of drinking-water supply surveillance are summarized as follows:
• Initial phase:
—— Establish requirements for institutional development.
—— Provide training for staff involved in the programme.
—— Define the role of participants (e.g. quality assurance/quality control by
supplier, surveillance by public health authority).
—— Develop methodologies suitable for the area.
—— Commence routine surveillance in priority areas (including inventories).
—— Limit verification to essential parameters and known problem substances.
—— Establish reporting, filing and communication systems.
—— Advocate improvements according to identified priorities.
—— Establish reporting to local suppliers, communities, media and regional
authorities.
—— Establish liaison with communities; identify community roles in surveillance
and means of promoting community participation.
• Intermediate phase:
—— Train staff involved in the programme.
—— Establish and expand systematic routine surveillance.
—— Expand access to analytical capability (often by means of regional laboratories,
national laboratories being largely responsible for analytical quality control
and training of regional laboratory staff).
—— Undertake surveys for chemical contaminants using wider range of analytical
methods.
—— Evaluate all methodologies (sampling, analysis, etc.).
—— Use appropriate standard methods (e.g. analytical methods, fieldwork
procedures).
—— Develop capacity for statistical analysis of data.
—— Establish national database.
—— Identify common problems and improve activities to address them at regional
and national levels.
—— Expand reporting to include interpretation at the national level.
—— Draft or revise health-based targets as part of a framework for safe drinking-
water.
—— Use legal enforcement where necessary.
—— Involve communities routinely in surveillance implementation.

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 5. SURVEILLANCE

• Advanced phase:
—— Provide further or advanced training for staff involved in the programme.
—— Establish routine surveillance for all health and acceptability parameters at
defined frequencies.
—— Use a full network of national, regional and local laboratories (including
analytical quality control).
—— Use national framework for drinking-water quality.
—— Improve water services on the basis of national and local priorities, hygiene
education and enforcement of standards.
—— Establish regional database archives compatible with national database.
—— Disseminate data at all levels (local, regional and national).
—— Involve communities routinely in surveillance implementation.

5.5 Reporting and communicating

An essential element of a successful surveillance programme is the reporting of results
to stakeholders. It is important to establish appropriate systems of reporting to all
relevant bodies. Proper reporting and feedback will support the development of ef-
fective remedial strategies. The ability of the surveillance programme to identify and
advocate interventions to improve water supply is highly dependent on the ability to
analyse and present information in a meaningful way to different target audiences.
The target audiences for surveillance information will typically include:
• public health officials at local, regional and national levels;
• water suppliers;
• local administrations;
• communities and water users;
• local, regional and national authorities responsible for development planning and
investment.

5.5.1 Interaction with community and consumers

Community participation is a desirable component of surveillance, particularly for
community and household drinking-water supplies. As primary beneficiaries of im-
proved drinking-water supplies, com-
munity members have a right to take part
in decision-making. The community The right of consumers to information on
the safety of the water supplied to them for
represents a resource that can be drawn domestic purposes is fundamental.
upon for local knowledge and experi-
ence. They are the people who are likely
to first notice problems in the drinking-water supply and therefore can provide an
indication of when immediate remedial action is required. Communication strategies
should include:
• provision of summary information to consumers (e.g. through annual reports or
the Internet);
• establishment and involvement of consumer associations at local, regional and
national levels.

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In many communities, however, the simple right of access to information will not
ensure that individuals are aware of the quality or safety of the water supplied to them.
The agencies responsible for surveillance should develop strategies for disseminating
and explaining the significance of results obtained.
It may not be feasible for the surveillance agency to provide feedback informa-
tion directly to the entire community. Thus, it may be appropriate to use community
organizations, where these exist, to provide an effective channel for providing feed-
back information to users. Some local organizations (e.g. local councils and com-
munity-based organizations, such as women’s groups, religious groups and schools)
have regular meetings in the communities that they serve and can therefore provide a
mechanism of relaying important information to a large number of people within the
community. Furthermore, by using local organizations, it is often easier to initiate a
process of discussion and decision-making within the community concerning water
quality. The most important element in working with local organizations is to ensure
that the organization selected can access the whole community and can initiate discus-
sion on the results of surveillance (see sections 7.6.1 and 8.7).

5.5.2 Regional use of data

Strategies for regional prioritization are typically of a medium-term nature and have
specific data requirements. While the management of information at a national level is
aimed at highlighting common or recurrent problems, the objective at a regional level
is to assign a degree of priority to individual interventions. It is therefore important
to derive a relative measure of health risk. Although this information cannot be used
on its own to determine which systems should be given immediate attention (which
would also require the analysis of economic, social, environmental and cultural fac-
tors), it provides an extremely important tool for determining regional priorities. It
should be a declared objective to ensure that remedial action is carried out each year
on a predetermined proportion of the systems classified as high risk.
At the regional level, it is also important to monitor the improvement in (or de-
terioration of) both individual drinking-water supplies and the supplies as a whole.
In this context, simple measures, such as the mean sanitary inspection score of all
systems, the proportion of systems with given degrees of faecal contamination, the
population with different levels of service and the mean cost of domestic consump-
tion, should be calculated yearly and changes monitored.
As shown in Table 7.10 in section 7.4, the aim should be to provide drinking-
water that contains no faecal indicator organisms, such as Escherichia coli. However, in
many developing and developed countries, a high proportion of household and small
community drinking-water systems, in particular, fail to meet requirements for water
safety, including the absence of E. coli. In such circumstances, it is important that
realistic goals for progressive improvement are agreed upon and implemented. It is
practical to classify water quality results in terms of an overall grading for water safety
linked to priority for action, as illustrated in Table 5.2.
Grading schemes may be of particular use in community supplies where the
frequency of testing is low and reliance on analytical results alone is especially in-
appropriate. Such schemes will typically take account of both analytical findings

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Table 5.2 Example of categorization of drinking-water systems on the basis of population size
and quality rating in order to prioritize actions (see also Table 7.10)
Proportion (%) of samples negative for E. coli
Quality of drinking-
water systema < 5000 population 5000–100 000 population > 100 000 population
A 90 95 99
B 80 90 95
C 70 85 90
D 60 80 85
a
Quality decreases from A to D.

Table 5.3 Example of assessment of priority of remedial actions of community drinking-water

supplies based on a grading system of microbial quality and sanitary inspection
rating or scorea
Sanitary inspection risk score
(susceptibility of supply to contamination from human and animal faeces)

0–2 3–5 6–8 9–10

A
classificationb

B
E .coli

Low risk: Intermediate risk: low High risk: Very high risk: urgent
no action required action priority higher action priority action required

a
Where there is a potential discrepancy between the results of the microbial water quality assessment and the sanitary
inspection, further follow-up or investigation is required.
b
Classifications based on those shown in Table 5.2. Quality decreases from A to D.
Source: Adapted from Lloyd & Bartram (1991). See also the supporting document Rapid assessment of drinking-water
quality (Annex 1).

and results of the sanitary inspection through matrices such as the one illustrated
in Table 5.3.
Combined analysis of sanitary inspection and water quality data can be used to
identify the most important causes of and control measures for contamination. This
is important to support effective and rational decision-making. For instance, it will
be important to know whether on-site or off-site sanitation could be associated with
contamination of drinking-water, as the remedial actions required to address either
source of contamination will be very different. This analysis may also identify other
factors associated with contamination, such as heavy rainfall. As the data will be non-
parametric, suitable methods for analysis include chi-square, odds ratios and logistic
regression models.
Combined analysis of sanitary inspection and water quality data is especially use-
ful in assessing household water management systems. Microbial water quality data

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Table 5.4 Example of assessment of priority of remedial action for household drinking-water
systems based on a grading system of microbial quality and sanitary inspection
rating or scoresa
Sanitary inspection risk score
(susceptibility of supply to contamination from human and animal faeces)

0–2 3–5 6–8 9–10

<1
concentration/100)
E .coli classification
(as decimal

1–10

11–100

> 100

Low risk: no action Intermediate risk: low High risk: higher Very high risk: urgent
required action priority action priority action required

a
Where there is a potential discrepancy between the results of the microbial water quality assessment and the sanitary
inspection, further follow-up or investigation is required.

are often limited, and sanitary inspection risk scoring therefore becomes an important
consideration in assessing household water systems, their management and priority
for remedial actions. An example of a combined system to assess risk and prioritize
remedial actions for household water systems is shown in Table 5.4.

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