A nationwide survey of 125,000 public rural waterpoints installed between 2007 and 2012 reveals major changes from the pre-arsenic era and expectations of the 2004 Arsenic Policy. Shallow tubewell (STW) use has greatly reduced and deep tubewells (DTWs) now dominate in arsenic-affected areas. Arsenic contamination is greatly reduced from baseline; 3.6% of DTWs, 7.6% of STWs and 5.5% of ringwells (RWs) exceed 50 μg/L. In some sub-districts contamination is worse than previously recognised. Faecal contamination affects 48% of devices, and is most severe in RWs and surface water devices (SWDs). Manganese exceeds 0.4 mg/L in 12% of DTWs, 51% of STWs and 40% of RWs. Iron exceeds 1 mg/L in 48% of devices. Sustained operation ranges from 91% in DTWs, 84% in STWs, 68% in RWs to 47–94% in SWDs. Falling water levels in shallow and deep aquifers require replacement of suction pumps. Addressing aesthetic, water quality and level issues will require major investment in piped water systems with Fe/Mn removal and chlorination. Technologies differ in household coverage (DTW > STW > RW) and use for drinking (DTW > RW > STW). With a modest increase in investment in relatively safe, popular and cost-effective DTWs and better targeting, arsenic poisoning could be virtually eliminated in 5–10 years.

Arsenic contamination of shallow groundwater in Bangladesh is a major public health problem; the main response to date has been installing alternative water supplies. A survey of the functional status of a statistically representative sample of water supplies was undertaken in 2005 to assess whether these provide a sustainable water supply to arsenic-affected communities. A questionnaire was administered in communities containing a total 1060 water supplies. Eight percent of water supplies could not be located and only 64% of those located were working at the time of the survey. When weighted for the numbers of different technologies across the country, the results indicate 76% of alternative water supplies would be working. Water supplies working at the time of the survey often broke down. Community contributions were found to be important in determining whether a water supply would be functional. Recommendations are made for revisions of the current mitigation strategy.

In the summer of 2017, an estimated 745,000 Rohingya fled to Bangladesh in what has been described as one of the largest and fastest growing refugee crises in the world. Among numerous health concerns, an outbreak of acute jaundice syndrome (AJS) was detected by the disease surveillance system in early 2018 among the refugee population. This paper describes the investigation into the increase in AJS cases, the process and results of the investigation, which were strongly suggestive of a large outbreak due to hepatitis A virus (HAV). An enhanced serological investigation was conducted between 28 February to 26 March 2018 to determine the etiologies and risk factors associated with the outbreak. A total of 275 samples were collected from 18 health facilities reporting AJS cases. Blood samples were collected from all patients fulfilling the study specific case definition and inclusion criteria, and tested for antibody responses using enzyme-linked immunosorbent assay (ELISA). Out of the 275 samples, 206 were positive for one of the agents tested. The laboratory results confirmed multiple etiologies including 154 (56%) samples tested positive for hepatitis A, 1 (0.4%) positive for hepatitis E, 36 (13%) positive for hepatitis B, 25 (9%) positive for hepatitis C, and 14 (5%) positive for leptospirosis. Among all specimens tested 24 (9%) showed evidence of co-infections with multiple etiologies. Hepatitis A and E are commonly found in refugee camps and have similar clinical presentations. In the absence of robust testing capacity when the epidemic was identified through syndromic reporting, a particular concern was that of a hepatitis E outbreak, for which immunity tends to be limited, and which may be particularly severe among pregnant women. This report highlights the challenges of identifying causative agents in such settings and the resources required to do so. Results from the month-long enhanced investigation did not point out widespread hepatitis E virus (HEV) transmission, but instead strongly suggested a large-scale hepatitis A outbreak of milder consequences, and highlighted a number of other concomitant causes of AJS (acute hepatitis B, hepatitis C, Leptospirosis), albeit most likely at sporadic level. Results strengthen the need for further water and sanitation interventions and are a stark reminder of the risk of other epidemics transmitted through similar routes in such settings, particularly dysentery and cholera. It also highlights the need to ensure clinical management capacity for potentially chronic conditions in this vulnerable population.

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