publications,. About 88 % of diarrheal cases globally are attributed to water, sanitation and hygiene (Pruss-Ustun et al, 2004). This is a conservative approach where malnutrition impact on early childhood diseases is omitted. If considered, this additional indirect impact would approximately double the mortality attributed to water supply, sanitation and hygiene (WSH) (World Bank, 2010). However, a major part of these losses are in the form of acute respiratory mortality that was accounted for in the indoor air pollution section. To avoid double counting and be on a conservative side we considered only direct impact of inadequate water supply, sanitation and hygiene (WSH).

Mortality for children under 5 and diarrheal-based child mortality are high in India. Baseline health data for estimating the health impacts of inadequate water supply, sanitation and hygiene are presented in Table 4.1. The Office of the Registrar General (2004) indicates that 14 percent of child mortality was due to intestinal diseases. A baseline diarrheal mortality rate of 14 percent of under-5 child mortality is thus used for diarrheal mortality estimation.

For diarrheal morbidity, however, it is very difficult or practically impossible to identify all cases of diarrhea. The main reason is that substantial numbers of cases are not treated or do not require treatment at health facilities, and are therefore never recorded. A second reason is that cases treated by private doctors or clinics are often not reported to public health authorities. Household surveys therefore provide the most reliable indicator of total cases of diarrheal illness. Most household surveys, however, contain only information on diarrheal illness in children. Moreover, the surveys only reflect diarrheal prevalence at the time of the survey. As there is often high variation in diarrheal prevalence across seasons of the year, extrapolation to an annual average will result in either an over- or underestimate of total annual cases. Correcting this bias is often difficult without knowledge of seasonal variations.

In spite of all these difficulties a reasonable estimate has been made of the number of cases and prevalence of diarrhea in the population, along with the number of DALYs per 100,000 cases of diarrhea. The figures summarized in Table 4.1.

**<u>Table 4.1: Baseline Data for Estimating Health Impacts</u>**

||**Baseline**|**Source:**|
|---|---|---|
|Under-5 child mortalityrate in 2006|52-82|NFHS-3|
|Diarrheal mortality in children under 5 years (% of child<br>mortality)|14 %|Office of Registrar General<br>(2004)|
|Diarrheal 2-week Prevalence in Children under 5years|8.9-9%|NFHS-3|
|Estimated annual diarrheal casesper child under 5years|1.85-1.87|Estimated from NFHS-3|
|Estimated annual diarrheal cases per person (> 5 years)|0.37-0.56|International experience<br>(Krupnick et al,2006)|
|Hospitalization rate (% of all diarrheal cases) –children<br>under 5years|0.15%|NSS (2004)|
|Hospitalization rate (% of all diarrheal cases) –children<br>under 5years|0.3-0.6 %||
|Percent of diarrheal cases attributable to inadequate water<br>supply,sanitation and hygiene|90 %|WHO (2002b)|
|DALYs per 100 thousand cases of diarrhea in children<br>under 5|70|Estimated from WHO tables|
|DALYs per 100 thousand cases of diarrhea in persons >5<br>years|100-130||

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