are the primary users of domestic water, that women used water in their key food production roles, and that women and children were the most vulnerable to water-related disasters. global goals further information: sustainable development goal 6 world map for indicator 6.2.1a in 2015: share of population using safely managed sanitation facilities since 1990, the joint monitoring program for water supply and sanitation (jmp) of who and unicef has regularly produced estimates of global wash progress. the jmp was already responsible for monitoring the un's millennium development goal (mdg) target 7.c, which aimed to "halve, by 2015, the proportion of the population without sustainable access to safe drinking water and basic sanitation". this has been replaced in 2015 by the sustainable development goal 6 (sdg 6), which is to "ensure availability and sustainable management of water and sanitation for all" by 2030. to establish a reference point from which progress toward achieving the sdgs could be monitored, the jmp produced "progress on drinking water, sanitation and hygiene: 2017 update and sdg baselines". the jmp is responsible for tracking progress toward the two sdg 6 targets focused on improving the standard of wash services. in addition, the jmp collaborates with other organizations and agencies responsible for monitoring other wash-related sdgs, including sdg target 1.4 on improving access to basic services, sdg target 3.9 on reducing deaths and illnesses from unsafe water, and sdg target 4.a on building and upgrading adequate wash services in schools. health aspects mortality rate attributable to unsafe water, sanitation, and hygiene (wash). the "f-diagram" (feces, fingers, flies, fields, fluids, food), showing pathways of fecal-oral disease transmission. the vertical blue lines show barriers: toilets, safe water, hygiene and handwashing. wash-attributable burden of diseases and injuries health impacts resulting from a lack of safe sanitation systems belong to three categories: direct impact (infections), sequelae (conditions caused by preceding infection) and broader well-being.: 2 the direct impacts include fecal-oral infections (through the fecal-oral route), helminth infections and insect vector diseases (see also waterborne diseases, which can contaminate drinking water). conditions caused by preceding infection include stunting or growth faltering, consequences of stunting (obstructed labour, low birthweight), impaired cognitive function, pneumonia (related to repeated diarrhea in undernourished children), anemia (related to hookworm infections). the third category is "broader well-being" which includes: anxiety, sexual assault (and related consequences), adverse birth outcomes as well as long-term problems such as school absence, poverty, decreased economic productivity, antimicrobial resistance. lack of clean water and proper sanitation can result in feces-contaminated drinking water and cause life-threatening diarrhea for infants. most of the diseases resulting from lack of sanitation have a direct relation to poverty. for example, open defecation – which is the most extreme form of "lack of sanitation" – is a major factor in causing various diseases, most notably diarrhea and intestinal worm infections. a report by world health organization in 2019 found that "the wash-attributable disease burden amounts to 3.3% of global deaths and 4.6% of global dalys. among children under 5 years, wash-attributable deaths represent 13% of deaths and 12% of dalys. worldwide, 1.9 million deaths and 123 million dalys could have been prevented in 2016 with adequate wash." an earlier study from 2002 had estimated that up to 5 million people die each year from preventable waterborne diseases. list of diseases further information: waterborne diseases twelve diseases associated with inadequate wash where "population attributable fractions" include: diarrheal diseases respiratory infections soil-transmitted helminth infections malaria trachoma schistosomiasis lymphatic filariasis onchocerciasis dengue japanese encephalitis protein–energy malnutrition drowning diseases where adverse health outcomes or injuries linked to inadequate wash are described but not yet quantified: arsenicosis fluorosis legionellosis leptospirosis hepatitis a and hepatitis e cyanobacterial toxins lead poisoning scabies spinal injury poliomyelitis neonatal conditions (see also infant mortality) and maternal outcomes (such as maternal deaths) other diseases, e.g. most neglected tropical diseases diarrhea, malnutrition and stunting a child receiving malnutrition treatment in northern kenya further information: undernutrition in children diarrhea is primarily transmitted through fecal-oral routes. in 2011, infectious diarrhea resulted in about 0.7 million deaths in children under five years old and 250 million lost school days. this equates to about 2000 child deaths per day. children suffering from diarrhea are more vulnerable to become underweight (due to stunted growth). this makes them more vulnerable to other diseases such as acute respiratory infections and malaria. chronic diarrhea can have a negative effect on child development (both physical and cognitive). numerous studies have shown that improvements in drinking water and sanitation wash lead to decreased risks of diarrhea. such improvements might include for example use of water filters, provision of high-quality piped water and sewer connections. diarrhea can be prevented - and the lives of 525,000 children annually be saved (estimate for 2017) - by improved sanitation, clean drinking water, and hand washing with soap. in 2008 the same figure was estimated as 1.5 million children. the combination of direct and indirect deaths from malnutrition caused by unsafe water, sanitation and hygiene (wash) practices was estimated by the world health organization in 2008 to lead to 860,000 deaths per year in children under five years of age. the multiple interdependencies between malnutrition and infectious diseases make it very difficult to quantify the portion of malnutrition that is caused by infectious diseases which are in turn caused by unsafe wash practices. based on expert opinions and a literature survey, researchers at who arrived at the conclusion that approximately half of all cases of malnutrition (which often leads to stunting) in children under five is associated with repeated diarrhea or intestinal worm infections as a result of unsafe water, inadequate sanitation or insufficient hygiene. this section is an excerpt from diarrhea. an electron micrograph of rotavirus, the cause of nearly 40% of hospitalizations from diarrhea in children under five diarrhea, also spelled diarrhoea or diarrhœa, is the condition of having at least three loose, liquid, or watery bowel movements each day. it often lasts for a few days and can result in dehydration due to fluid loss. signs of dehydration often begin with loss of the normal stretchiness of the skin and irritable behaviour. this can progress to decreased urination, loss of skin color, a fast heart rate, and a decrease in responsiveness as it becomes more severe. loose but non-watery stools in babies who are exclusively breastfed, however, are normal. the most common cause is an infection of the intestines due to either a virus, bacterium, or parasite—a condition also known as gastroenteritis. these infections are often acquired from food or water that has been contaminated by feces, or directly from another person who is infected. the three types of diarrhea are: short duration watery diarrhea, short duration bloody diarrhea, and persistent diarrhea (lasting more than two weeks, which can be either watery or bloody). the short duration watery diarrhea may be due to cholera, although this is rare in the developed world. if blood is present, it is also known as dysentery. a number of non-infectious causes can result in diarrhea. these include lactose intolerance, irritable bowel syndrome, non-celiac gluten sensitivity, celiac disease, inflammatory bowel disease such as ulcerative colitis, hyperthyroidism, bile acid diarrhea, and a number of medications. in most cases, stool cultures to confirm the exact cause are not required. neglected tropical diseases further information: mass deworming approximately two billion people are infected with soil-transmitted helminths worldwide. this type of intestinal worm infection is transmitted via worm eggs in feces which in turn contaminate soil in areas where sanitation is poor. water, sanitation and hygiene interventions help to prevent many neglected tropical diseases (ntds), for example soil-transmitted helminthiasis. an integrated approach to ntds and wash benefits both sectors and the communities they are aiming to serve. this is especially true in areas that are endemic with more than one ntd. in august 2015, the world health organization (who) unveiled a global strategy and action plan to integrate wash with other public health interventions in order to accelerate elimination of ntds. the plan aims to intensify control or eliminate certain ntds in specific regions by 2020. it refers to the ntd roadmap milestones that included for example eradication of dracunculiasis by 2015 and of yaws by 2020, elimination of trachoma and lymphatic filariasis as public health problems by 2020, intensified control of dengue, schistosomiasis and soil-transmitted helminthiases. the plan consists of four strategic objectives: improving awareness of benefits of joint wash and ntd actions; monitoring wash and ntd actions to track progress; strengthening evidence of how to deliver effective wash interventions; and planning, delivering and evaluating wash and ntd programmes with involvement of all stakeholders. the aim is to use synergies between wash and ntd programmes. evidence regarding health outcomes effective sanitation separates human excreta from contact with people, and this can prevent many diseases such as (but not only) waterborne diseases. there is debate in the academic literature about the effectiveness on health outcomes when implementing wash programs in low- and middle-income countries. many studies provide poor quality evidence on the causal impact of wash programs on health outcomes of interest. the nature of wash interventions is such that high quality trials, such as randomized controlled trials (rcts), are expensive, difficult and in many cases not ethical. causal impact from such studies are thus prone to being biased due to residual confounding. blind studies of wash interventions also pose ethical challenges and difficulties associated with implementing new technologies or behavioral changes without participant's knowledge. moreover, scholars suggest a need for longer-term studies of technology efficacy, greater analysis of sanitation interventions, and studies of combined effects from multiple interventions in order to more sufficiently gauge wash health outcomes. many scholars have attempted to summarize the evidence of wash interventions from the limited number of high quality studies. hygiene interventions, in particular those focusing on the promotion of handwashing, appear to be especially effective in reducing morbidity. a meta-analysis of the literature found that handwashing interventions reduced the relative risk of diarrhea by approximately 40%. similarly, handwashing promotion has been found to be associated with a 47% decrease in morbidity. however, a challenge with wash behavioral intervention studies is an inability to ensure compliance with such interventions, especially when studies rely on self-reporting of disease rates. this prevents researchers from concluding a causal relationship between decreased morbidity and the intervention. for example, researchers may conclude that educating communities about handwashing is effective at reducing disease, but cannot conclude that handwashing reduces disease. point-of-use water supply and point-of-use water quality interventions also show similar effectiveness to handwashing, with those that include provision of safe storage containers demonstrating increased disease reduction in infants. specific types of water quality improvement projects can have a protective effect on morbidity and mortality. a randomized control trial in india concluded that the provision of chlorine tablets for improving water quality led to a 75% decrease in incidences of cholera among the study population. a quasi-randomized study on historical data from the united states also found that the introduction of clean water technologies in major cities was responsible for close to half the reduction in total mortality and over three-quarters of the reduction in infant mortality. distributing chlorine products, or other water disinfectants, for use in the home may reduce instances of diarrhea. however, most studies on water quality improvement interventions suffer from residual confounding or poor adherence to the mechanism being studied. for instance, a study conducted in nepal found that adherence to the use of chlorine tablets or chlorine solution to purify water was as low as 18.5% among program households. a study on a water well chlorination program in guinea-bissau in 2008 reported that families stopped treating water within their households because of the program which consequently increased their risk of cholera. it was concluded that well chlorination without proper promotion and education led to a false sense of security. studies on the effect of sanitation interventions alone on health are rare. when studies do evaluate sanitation measures, they are mostly included as part of a package of different interventions. a pooled analysis of the limited number of studies on sanitation interventions suggest that improving sanitation has a protective effect on health. a unicef funded sanitation intervention (packaged into a broader wash intervention) was also found to have a protective effect on under-five diarrhea incidence but not