Table 1

 Examples of indicators in each of the four categories of access and infrastructure, technology, behaviour, and agents and vectors for selected environmental risk factors that are of particular relevance in developing countries

Global health effects in 2000*Access and infrastructure†TechnologyBehaviour‡Agents and vectors
*Health effects include mortality and burden of diseases as % of total global burden of disease (GBD), measured in disability adjusted life years (DALYs). Health effects are shown for high mortality developing countries (HMD), lower mortality developing countries (LMD), and industrialised countries (I) (source Ezzati et al5 and World Health Organisation6). †Because access to technology is a key determinant of its use and applies to all the technological indicators considered, we use “access” to specifically refer to basic infrastructure and geo-ecological characteristics that would allow households and individuals to choose a technology, if compatible with household means and preferences. For example, meteorological characteristics (for example, temperature and number of sunny/cloudy days) and energy infrastructure (for example, fuel markets and distance to the power grid) are important determinants of using various energy technologies above and beyond household income. Access and infrastructure can at times indicate simultaneous exposure to multiple risks, driven by the same underlying population level determinants. For example, living in urban slums in many developing countries can be an indicator for exposure to poor water and sanitation, indoor and outdoor air pollution, and malaria. Such population level indicators can therefore not only provide information on exposure to a risk, but also vulnerability to its hazards because of simultaneous exposure to other factors. ‡For many diseases affected by the environmental health risks and factors considered, an additional aspect of behaviour includes health seeking behaviour and case management that may be effective interventions for reducing long term morbidity or mortality. The behavioural indicators in the table are associated with prevention of disease through exposure reduction. §Health effects measured by ambient particle concentration (that is, excluding lead and ozone).
Water, sanitation, and hygiene Mortality: 1.7 MThe source of water and ease of access; the quantity of water available at the source; feasibility of individual on-plot supply; average time to collect water; surface water drainage and sewage disposal; waste disposal infrastructureLatrine type; household and community level waste disposal techniques; the source of water (quality and quantity); water transportation and in-house storage means; point of use decontamination technologies (for example, boiling or filtration); hand and food washing technologies (for example, soap)Household and community level waste disposal behaviour especially regarding children’s defecation; hygiene behaviour (for example, the means and frequency of washing hands with soap and storing food); water transportation methods and frequency; water storage methods and duration; and point of use decontaminationThe level of faecal contamination, of pathogens, or the concentration of harmful chemicals (above a certain threshold) in consumed water and food, on ground, or on hands
HMD: >1.5 M
LMD: 170000
I: 20000
GBD: 3.7%
HMD: 3.2%
LMD: 0.5%
I: 0.1%
Indoor air pollution from household energy use Mortality: 1.6 MEnergy infrastructure including distance to electrical grid, and vendors for provision of various fuels and stoves; regional ecology including available sources of biomassHousehold energy technologies including fuel type(s) and stove type(s) including multi-fuel and multi-stove use; housing characteristics including the location of cooking, number and size of rooms, the relation between stove location and other rooms, number and size of doors and windows, and house construction materialLength of cooking and heating intervals; fuel handling practices including drying and size of individual pieces of fuel; status of doors and windows during cooking and heating; participation of individual household members in cooking and other energy related tasks; amount of time spent indoors and near the stove when burningIndoor concentration of one or multiple indicator pollutants such as respirable particles, carbon monoxide and poly-aromatic hydrocarbons (PAH); fuel chemical composition especially for specific pollutants such as arsenic and fluorine in coal; pollutant specific biomarkers
HMD: >1.0 M
LMD: 560000
I: 20000
GBD: 2.6%
HMD: 2.1%
LMD: 0.5%
I: <0.1%
Urban ambient air pollution Mortality: 0.8 M§Regional energy, transportation, and industrial infrastructure; urban residential, commercial, and industrial design layouts; road networks; population density; meteorological and topographical variables (for example, wind)Industrial, residential, and transportation energy consumption, fuel types, combustion technology, and pollution control technologies; building design and ventilationPopulation distribution of time activity budgets including time spent in different urban microenvironments (for example, residential compared with industrial parts of the city, inside buildings or vehicles); energy and vehicle use behavioursAmbient concentration and physical/chemical characteristics of indicator pollutants (for example, particle concentration, particle size distribution and chemical composition) in multiple urban sites
HMD: 220000
LMD: 425000
I: 150000
GBD: 0.4%§
HMD: 0.2%
LMD: 0.2%
I: 0.1%
Malaria Mortality: 1.1 MClimate suitability (mainly driven by temperature and precipitation); nature and capacity of local vector species; vegetation and land cover; distance to standing bodies of freshwater suitable for mosquitoes; population density; community housing infrastructure and available materials for house mosquito proofing; distribution and availability of bed nets and insecticides for re-impregnationIrrigation technologies; mosquito proofing of houses, including screens for doors and windows, closing eaves, and installation of ceilings; machinery for environmental management interventions (for example, drains in an urban setting); type and useful lifespan of bed nets; insecticides for impregnation and re-impregnation of bed nets and curtainsPersonal protection for reducing human-vector contacts (for example, avoiding outdoor activities during peak hours of transmission, mending house screens after disintegration, sleeping under bed nets, re-impregnation of bed nets and curtains)Entomological inoculation rate (number of infectious bites per person per time unit); parasitaemia above a certain threshold (for example, >5000 parasites/μl of blood)
HMD: 1.1 M
LMD: 20000
I: ≅0
GBD: 2.9%
HMD: 2.8%
LMD: 0.1%
I: ≅0