NEHA November 2023 Journal of Environmental Health

sumption of unsafe drinking water (Batool et al., 2019). Further, the dry season in desert areas leaves people with limited options such that they often utilize unsafe drinking water. Drinking contaminated water causes 20–40% of all diseases and approximately 40% of all deaths in Pakistan. Moreover, the financial losses of approximately 25–58 billion PKR (87–202 million USD), or 0.6– 1.44% of the country’s gross domestic prod- uct annually, are also attributed to water- borne diseases (Global Water Partnership, n.d.; Nabeela et al., 2014). Myriad environmental and microbial fac- tors contribute to waterborne diseases (e.g., cholera, diarrhea, gastroenteritis). The bur- den of waterborne diseases might become worse in the near future in response to increasing population, rapid urbanization, changing climate conditions, decreasing groundwater, and ine˜ective implementation of regulations regarding standards for drink- ing water quality. Therefore, we reviewed the occurrence of important waterborne diseases in Pakistan in locally relevant conditions (Figure 1). We also present prevention strate- gies for waterborne diseases in Pakistan. We reviewed the published data from the last 14 years (2010–2023) of waterborne dis- ease outbreaks and infections in Pakistan wher- ever an association with a water source could be established. If outbreaks and infections were not present, we included the studies on the identification of waterborne pathogens from drinking water. The priority of selection criteria for the review was based on three stages. At the first stage, we shortlisted research articles hav- ing reports of waterborne outbreaks (bacterial or viral). In the second stage, we added articles reporting sporadic cases related to waterborne pathogens. Lastly, if there was no report of an outbreak or cases related to a waterborne pathogen, we included detection studies. Data were collected from Google Scholar, PubMed, and ScienceDirect using the follow- ing keywords (Table 1): waterborne, drinking water, freshwater, microbial load, diarrhea, hepatitis A, hepatitis E, rotavirus, cholera, typhoid, E. coli , coliforms, and Pakistan. Alternative keywords were used wherever required. Our article has special relevance to countries with similar socioeconomic, demo- graphic, and climatic conditions, including Afghanistan, Bangladesh, India, Iran, Nepal, and Sri Lanka.

FIGURE 1

Waterborne Diseases Caused by Bacterial and Viral Pathogens in Major Cities in Pakistan

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Waterborne Diseases • Coliforms • E . coli 0 Hepatitis A Virus Hepatitis E Virus r-, '--) Rotavirus • Salmonella Typhi

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TABLE 1

Studies Showing Percent Positivity of Waterborne Pathogens in Drinking Water Samples From Pakistan, 2010–2023

Pathogen

Positive Cases (%)

Region

Reference

Hepatitis A virus

13 21 41 45 23 23

Lahore

Ahmad et al., 2018 Ahmad et al., 2018 Ahmad et al., 2010 Ahmad et al., 2010 Rashid et al., 2021 Umair et al., 2018

Rawalpindi Islamabad Rawalpindi

Hepatitis E virus

Rotavirus

Karachi

Lahore and Rawalpindi

Vibrio cholerae Salmonella Typhi

22 42 75 52

Peshawar

Israr et al., 2022 Younas et al., 2016 Jadoon et al., 2021 Israr et al., 2022 Fatima et al., 2021 Hisam et al., 2014 Zareen et al., 2014

E. coli

At provincial level

Abbottabad Peshawar

Coliforms

60–69

Karachi

40 73

Islamabad

Lahore

The population of Pakistan is growing at a very rapid pace, along with an accompanying constant decrease in water resources (Has- san Rashid et al., 2018). People seek alterna-

tive water sources when there is not a source for safe drinking water. Likewise, in densely populated areas, limited availability of water purification systems also leads to the con-

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November 2023 • Journal of Environmental Health

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