Questions/Answers

It is generally recognized that untreated domestic sewage is mainly the transmission source of helminthiasis. According to the Department of Health, there are only 2.35 percent of the local administrative organization has a sewage treatment system and consequently, the untreated sewage is smuggled out 17,262,460 cubic meters per year. This results in an outbreak of opisthorchiasis, a factor that causes cholangiocarcinoma which is the leading cause of death in Thailand, especially in the Northeast. In accordance with cholangiocarcinoma incidence, we found in 135 men and 48 women per 100,000 population, respectively which were recorded as the highest incidence in the world. Although the Public Health Act B.E.2535 has stipulated of sewage management accountability, including collection, transportation and treatment is under the local administrative organization, in which directed operation or under supervision of outsource. We also found that most of them do not have sewage treatment services (63.21 percent of municipalities at all levels and 73.08 percent of Sub-district Administration Organization: SAO). In the Northeast, there has only 26.1 percent of sewage treatment facilities. Most of them were 28-day anaerobic digester systems, only 4.3 percent were used because the systems were far away and inadequate for sewage collection truck. Therefore, the Regional Health Promotion Center 10 has developed a sand drying bed sewage treatment system to eliminate the helminth egg stage and encourage the local administrative organization to provide a sewage treatment service covering all areas. In order to minimize smuggling out sewage and helminth contamination of water resources with the purpose of reducing cholangiocarcinoma morbidity and mortality rate.

It is a project that supports local government organizations to create a system that promotes the public health safety of local people and has more efficiency of sewage management. Encourage local government organizations to complete their duties as required by law through cooperation between public health agencies in providing academic knowledge while the local government allocates budgets and the people participate in the project approval process.

The sand drying bed sewage treatment system intended to prevent contamination of various pathogens such as cholera, dysentery, typhoid, heterophyiasis into the water, making water sources cleaner and safer. Including the ability to cut the cycle of opisthorchiasis, making it safer to consume fish. This is in line with the United Nations Sustainable Development Goals Goal 6, ensuring water and sanitation are sustainable and available for everyone, as well as reducing excretion in the open air.

Social: 1) provide understanding of importance of sewage treatment and community participation in monitoring sewage collection trucks when pumping sewage, treating in sand drying bed, and monitoring the illegal sewage dumping; 2) build capacity of Head of Provincial Environmental Health Development Group and District Public Health officer to provide guidance; 3) encourage local organization to include sewage treatment system construction in local development plan. Economic: learn how to generate income from sewage as fertilizer. Environment: 1) monitor and examine parasite’s eggs and bacteria at least once a year 2) evaluate sewage management quality standards of the local organization EHA 3002.

The sand drying bed sewage treatment system makes the work of the local government in public health more efficient by reducing the complaints and nuisance caused by sewage dumping of the local government. Be able to supervise and monitor all outsource who certified to operate sewage treatment without smuggling sewage, which is the duty of the local government organization according to the Public Health Act and other relevant laws that need to monitor sewage management in their own area.

Cholangiocarcinoma situation in 10th Health Region (2010 – 2019): total 27,866 new cases, which were 47 cases in early childhood (0-5 years) (0.17%), 37 cases in high-school student (6-14 years) (0.12%), 30 cases in university student (15-21 years) (0.11%), 9,396 cases in working-age (22-59 years) (33.72%), and 18,359 in elderly (>60 years) (65.88%) and 83.04% (23,142) died (men 15,131, women 8,011). Therefore, cutting the liver fluke cycle by implementing this system can reduce the morbidity rates, among men and women in the 10th Health Region and reduce government expenditure for cholangiocarcinoma treatment by 11,571,000,000 baht (approx. 500,000 baht per case).

1. The local administrative organization including a municipality, subdistrict administrative organization be able to utilize this sewage treatment service in their area, to prevent smuggling out sewage in a public area and reducing transmission of vector-borne diseases, and monitor the outsource sewage collection truck to comply with local ordinances. 2. Leverage living quality of community; when fish in natural water bodies are free from parasites, people will reduce the risk of cholangiocarcinoma. People can live longer in a safe environment with no interference from smelly clumps and flies resulting from unhygienic sewage disposal. The family does not have to be in debt from the treatment cost of cholangiocarcinoma.

In 2008, we studied sewage management in Thailand and design a sand drying bed sewage treatment system by using a sand drying bed, small gravel, and big gravel to reduce sewage moisture by less than 5% for helminth eggs removal. The effluent will flow through a sand drying bed to the lower water intake pipe in the septic tank at Kud Bak Subdistrict. It was found that the translucent roof causing the highest heat and making the moisture content of sewage lower than 5% when dried for 12 days in the rainy season and eliminate helminth eggs by 98 percent. The limitation was found that the sewage pipe in the septic tank did not fit the size of the sewage pipe of the sewage collection truck causing sewage overflow. In 2014, we continued to develop the initiative at Tong Khob Sub-District Municipality by adjusting the type of the treatment pond to facilitate the dumping of sewage by remove the sewage pipe at the front, and let sewage pour directly into the pond. The study about using sand drying bed to eliminate ascaris eggs was found that sewage moisture content correlated with the treatment period (r=-704, p=0.016) and ascaris eggs were not detected after treatment 17 days or more (r=-0.755, p=0.007) as well as decreasingly percentage of moisture (r=0712, p=0.014). In 2015 to 2020, we have expanded to local government across Northeast provinces which increase a sand drying bed sewage treatment system to 88 places (originally 12). Some problems were found i.e. construction plan, treatment system maintenance by local staff during the follow-up site visits. These were improved by creating a standardized plan, provide a video for managing systems on the Regional Health Promotion Center 10 website, and set up a line group to communicate about giving advice, sharing, and learning together.

Obstacle 1: The construction plans are not standardized, causing implementation problems. Solution: Cooperate with engineering team from the Regional Health Service Support Center 10 to establish standard construction plan. Obstacle 2: The opposition from the local people due to the unclear understanding of the sewage treatment system. Solution: Provide knowledge about a sand drying bed sewage treatment to District Public Health and Health Promoting sub-district Hospital to clarify understanding with people. Prepare implementation guidelines and provide speakers in organizing a community forum. Obstacle 3: A sand drying bed is clogged. Solution: Create cleaning sand drying bed method video and upload to YouTube.

The previous sewage treatment system was an anaerobic digester for 42 days (fermentation 28 days, drying 14 days) with high construction cost around 3 to 12 million baht. But this initiative is aerobic digester use gravel and sand for filtration, use sunlight drying for helminth egg elimination. The resources are cheap and accessible in every area. Treatment period was only 17 days, budget around 300,000-400,000 baht. As a result, budget burden of the local government organization can be used to further improve the quality of life of the people in the area.Moreover, people can get sewage treatment services faster.

A sand drying bed sewage treatment system developed from the concept of sludge dehumidification below 5.8 percent which leading warm temperature and causing Ascaris eggs to die relatively quickly. (Crame, E.B.and Hick,D.O., 1944; Keller,p.,1951). Therefore, it was developed to build a sewage treatment pond by bringing sunlight to increase the temperature inside the pond and using sand, gravel, and stone to filter the sewage on top of the sand layer and heat it to reduce the moisture content of the sewage until it dries. The remaining moisture content is below 5% to eliminate all types of helminth eggs.

Existing modern technology has been applied to enhance the work so that the project results are more accurate and make people and local governments more confident. By using a digital Thermo-Hygrometer which can measure both temperature and relative humidity in sand drying bed. The sedimentation method used in VET 133 Clinical Pathology was used to detect fluke eggs from treated sewage. Including the determination of the moisture content of sewage using the Standard Test for Moisture, Ash, and Organic Matter of Peat and Other Organic Soil methods to determine the moisture content of the sewage in the pond.

We transfer knowledge and experiences about sand drying bed sewage treatment to network and partners as follows: 1) Environmental Health Club of Thailand, Northeast Branch 4 times 2) Head of the Northern Environmental Health Group in Chiang Mai Province 1 time 3) Local government administrators in Sisaket Province 6 times 4) Local government administrators in risky areas of Ubon Ratchathani Province 2 times 5) Local government administrators and public health officer of Ubon Ratchathani, Yasothon and Amnat Charoen province 3 times 6) Asian Institute of Technology (AIT) 1 time 7) Faculty of Medicine, Chulalongkorn University 1 time 8) Faculty of Public Health, Khon Kaen University 1 time 9) College of Medicine and Public Health, Ubon Ratchathani University 1 time 10) Department of Health 2 times 11) Presentations at the Ministry of Public Health academic conferences 2 times 12) Representatives from Lao PDR came to have study visit in 2017

The potential for knowledge transfer can be delivered in the form of lectures, discussions, giving suggestions for problem-solving and integrating cooperation among relevant agencies or organizations, and preparing manuals and operation guidelines for sand drying bed sewage treatment system model. The system was able to be a prototype area for site visits from 86 groups, totaling 250,874 people. The team has the knowledge and skills to disseminate information about sand drying bed sewage treatment systems in order to fully support network partners.

Resources were mobilized by the Environment Office Region 9, Udon Thani, in drawing a pond treatment plan. Kutbak Sub-district Municipality and Tongkob Sub-District Municipality support the area and budget for the construction of the sewage treatment system. Sakon Nakhon Rajabhat University and Kasetsart University, Chalermprakiat, Sakon Nakhon Province, support personnel in laboratory testing. Sakon Nakhon Provincial Public Health Office supports personnel in following up operations. All provincial public health offices support personnel in creating community forums and monitoring local operations.

Factors contributing to sustainability were: 1) Public health executives realized the importance and defined as a policy of public health region and the governor sets as a provincial agenda at provincial level, for example, in Sisaket province, every local must have a sewage treatment system. In Yasothon province, a sewage treatment system is set within three years. Amnat Charoen Province requires all districts to have a sewage treatment system at least one by the year 2021, etc.

Si

Department of Parasites, Faculty of Medicine, Chulalongkorn University studied and analyzed the relationship between sewage management system, liver fluke infection and other intestinal parasites by analyzing the relationship between the quality of the toilets, sewage treatment systems with liver fluke infection rate and other intestinal helminths. analyzing the relationship between the quality of sewage system toilets and the infection rates of liver fluke and other intestinal helminths. Comparison between areas without sewage treatment and areas with sewage treatment systems in four areas in Tongkop Subdistrict and Kok Pla Siu Subdistrict, Sakon Nakhon Province. Performed a stool test in 780 people.

The indicators were 1) Liver fluke infection rate and other intestinal worms in the population 2) Number of liver fluke eggs in sludge and effluent fertilizers released from the treatment system. The tools used in the assessment were: 1) Detection of helminths in population 2) Sampling of sewage sludge in the treatment pond, in the soil around, in treated effluent and sewage sludge in areas without treatment system by World Health Organization (WHO) standard method.

The parasite infection rate in areas without sewage treatment system (28.5%) was higher than an area with sewage treatment systems (9.1%) and found heavy infection at 4.5% in areas where there is no sewage treatment. The efficacy of the sewage treatment system, including sludge in the digester, was found to reduce the number of liver fluke eggs from 108.5 egg per gram to 22 egg per gram, with only 14 living egg per gram. Live liver fluke eggs were not detected in the effluent from the treatment system and in fertilizers prepared from sludge. The results of this evaluation can be used to formulate a policy guideline for having a sand drying bed for sewage treatment systems in different areas of Thailand leading to sustained cutting of liver fluke and other parasites. Educating students and the public can help to solve the problem of helminthiasis spreading, reduce environmental contamination, solve the problem of complaints and nuisances caused by improper sewage management.

Regional Environment Office 9, Udon Thani participate in the design and consult on the sewage treatment system. Tongkop Sub-district Municipality allocates a budget for the construction of a sewage treatment system and joins the project until the completion. Faculty of Science and Engineering, Kasetsart University, Chalerm Phra Kiat Campus, Sakon Nakhon Province, participated in the detection of parasitic eggs in sewage and check the quality of sewage water that passes through sand filters. Cooperation was expanded to the Provincial Public Health Office, the Environmental Health Club of Thailand, and other provinces within the 10th health area by enhancing knowledge and understanding. Set up a meeting to exchange knowledge, develop a model area for study visits. The Public Health Service Support Center Region 10 assists in drawing up a standard sewage treatment system plan, so that the local government organization can immediately apply for the budget.

Before starting the project, the administrators of the municipality, the municipal council, and the public health office of Sakon Nakhon Province were invited to discuss operational guidelines. Set up a meeting to listen to people's opinions. People have a high level of satisfaction with the sewage treatment system at 56.1%. People get the convenience of sewage pumping services, reduce the nuisance problem from smuggling. We receive recommendations from the local government through follow-up and evaluation via Line Group and Facebook. Led to the formulation of guidelines and plans for the local government organization to manage sewage treatment to reduce contamination of water sources from pathogens and parasites, reduce mortality of people from the water, and unsafe hygiene.

Sewage treatment is the development of the primary health care system for the people of the area. People in the area must have knowledge and understanding of problems and impacts that will occur both in themselves and communities and take part in expressing their opinions by focusing on the use of knowledge, methods, and resources that are cheap and available in all areas in order to reduce dependency or seeking outside assistance. It must also be based on correct academic principles, with support, advice, and monitoring from relevant sectors such as public health agencies and local government organizations allocating budget for ongoing management of the sewage system to provide the management of sewage treatment system and to maintain treatment efficiency, which is to ultimately promote health security.