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ACCESS TO CLEAN WATER AND INCIDENCE OF WATERBORNE DISEASES: A STUDY IN UNIVERSITY OF MAIDUGURI TEACHING HOSPITAL AND RURAL PHCs

CHAPTER ONE

INTRODUCTION

 

 

Abstract

Access to clean and safe drinking water remains one of the most pressing public health challenges in northeastern Nigeria. This study investigates the relationship between water access and the incidence of waterborne diseases among patients attending the University of Maiduguri Teaching Hospital (UMTH) and selected Rural Primary Healthcare Centres (PHCs) in Borno State. Drawing on recent epidemiological evidence from conflict-affected northern Nigeria, the study contextualizes water insecurity within the broader frames of humanitarian displacement, inadequate sanitation infrastructure, and climate-related flooding. The chapter covers the background, problem statement, objectives, research questions, significance, scope, and definition of key terms.

 

1.1 Background to the Study

Safe water is a basic human right, and a prerequisite to the enjoyment of health, dignity, and economic productivity. In the world, as of 2020, an estimated two billion people lacked access to safely managed drinking water services, and an estimated 4.2 billion people lacked access to safe sanitation facilities ( Sustainable Development Goals Report, 2022). This water crisis has dire effects on health, well-being, and productivity, contributing to a population of millions of deaths each year due to waterborne diseases such as cholera, diarrhoea, and typhoid fever (Southern Voice, 2024).

The situation is especially acute in Nigeria. Though nearly 86% of the Nigerian population has no access to a source of safely managed drinking water, approximately 70% of Nigerian population is connected to the basic water services (Elimian et al., 2022). Over fifty percent of the available water is polluted and the goals of equitable and sustainable water access continue to be a national issue. It is estimated that the number of children who die every year due to waterborne diseases is 70,000 in Nigeria (NIH, 2025). These statistics highlight a public health crisis, which disproportionately targets marginalized groups within rural and conflict-affected localities.

The University of Maiduguri Teaching Hospital is located in Borno State, which has one of the most dire water security crises in Nigeria. Since 2009, the Boko Haram insurgency has had significant impacts on the state, such as displacement of millions of people, destruction of water, sanitation and hygiene (WASH) infrastructure in the rural communities. As UNICEF (2022) notes, over 2.5 million Nigerian residents, following the 2022 floods, were at higher risk of waterborne diseases, with the State of Borno being one of the worst affected.

The Alau Dam flood in September of 2024, showed the combination of infrastructure failures and water insecurity to create acute public health emergencies. The damage caused by the overflow of the dam resulted in disastrous flooding in Maiduguri that displaced some 400,000 people, severely damaged health facilities, and created conditions in which 30 makeshift displacement sites (most of which lacked adequate latrines and safe drinking water) became breeding grounds of cholera and other waterborne diseases (Doctors Without Borders, 2024). This culminated in an outbreak of acute watery diarrhoea and confirmed cholera cases at UMTH which had appeared to underscore the vulnerability of the water security in the area.

Cholera infection is a reoccurring disease in Nigeria, and the epidemics tend to affect mostly the northern states. In 2021, Nigeria recorded the highest cholera outbreak in 10 years. By November 2022, the Nigerian Centre for Disease Control (NCDC) recorded 23,550 cases of COVID-19 across the nation, with Borno State alone having 12,459 of the 23,550 cases reported by the state (Elimian et al., 2022). The interaction between conflict-related displacement, lack of water, and spread of cholera in northern Nigeria indicates how social and political realities increase the environmental health risks facing rural and peri-urban populations.

Primary Healthcare Centres (PHCs) in the rural Borno are the first line of disease identification and treatment in managing waterborne disease. Such facilities often work under the conditions of staff shortage, deficit of diagnostic equipment, inadequacy of supplying oral rehydration salts and antibiotics. Determining which level in the tertiary UMTH or the rural PHC level bears the burden of waterborne disease and how it is related to patterns of water access in the catchment populations, is therefore vital in the design of effectiveness and context-sensitive interventions.

1.2 Statement of the Problem.

Although access to clean water has become a global development agenda under the Sustainable Development Goals 6, Borno State is still facing an endemic outbreak of waterborne diseases due to poor WASH infrastructures, conflict displacement, and climatic events. A significant and poorly measured burden of cholera, typhoid, and diarrhoeal disease is present in the University of Maiduguri Teaching Hospital, and in the rural PHCs in the state.

In this respect, little evidence has been found on the exact relationship between the type of water source, water treatment and household sanitation behaviour and the incidence of clinically diagnosed waterborne diseases. This paper fills this gap by thoroughly recording the water access conditions of patients who present with waterborne diseases at UMTH and rural PHCs, and quantifying the relationship between clean water access and disease occurrence.

1.3 Objectives of the Study

The general objective is to examine the relationship between access to clean water and the incidence of waterborne diseases among patients at UMTH and selected rural PHCs in Borno State.

The specific objectives are:

1. To determine the prevalence of waterborne diseases (cholera, typhoid, diarrhoea, and hepatitis A) among patients at UMTH and rural PHCs.
2. To assess the types of water sources used by the study population and the proportion with access to safely managed drinking water.
3. To examine the association between water source type, water treatment practices, and the incidence of waterborne diseases.
4. To identify sociodemographic factors including displacement status, gender, age, and education that moderate the water-disease relationship.
5. To recommend practical, context-sensitive WASH interventions for Borno State’s healthcare and humanitarian response frameworks.

1. What is the prevalence and distribution of waterborne diseases among patients presenting at UMTH and rural PHCs in Borno State?
2. What are the predominant water sources available to the study population, and what proportion use safely managed water?
3.  Is there a significant association between water source type and the incidence of waterborne diseases in the study population?
4. Which sociodemographic and behavioural factors predict higher risk of waterborne disease in this context?
5. What WASH interventions are most feasible and effective for reducing waterborne disease burden in Borno State?

H1: There is a significant association between reliance on unimproved water sources and higher incidence of waterborne diseases among the study population.

H2: Displaced persons relying on camp water distribution systems have higher incidence of waterborne disease than settled community members with household water access.

H3: Households that practice regular water treatment have significantly lower rates of waterborne disease than those that do not.

This study is significant because it generates locally grounded epidemiological evidence on water-disease linkages in one of Nigeria’s most water-insecure regions. For UMTH clinicians and hospital management, it provides data to support resource allocation for diarrhoeal disease management. For Borno State health authorities and humanitarian actors, the study informs the design of targeted WASH interventions that address the needs of both settled and displaced populations. For national policymakers working toward SDG6, the findings contribute baseline data on the current gap between access and safety in water provision. Given that point-of-use chlorination has been identified as a highly cost-effective approach to reducing diarrhoeal disease (NIH, 2025), this study’s findings can directly support advocacy for scaling such interventions.

The study is confined to patients presenting at UMTH and up to five rural PHCs in Borno State over a twelve-month period. Both adult and paediatric cases of clinically or laboratory-confirmed waterborne diseases are included. Key limitations include the difficulty of conducting water quality testing in conflict-affected areas, potential underreporting of cases at PHC level due to staff capacity constraints, and the inability to fully account for all environmental confounders influencing disease transmission in displacement contexts.

Clean Water:

Water that is free from harmful microorganisms, chemical contaminants, and physical pollutants, meeting WHO or national standards for potable drinking water.

Waterborne Disease:

An illness caused by consuming or coming into contact with water contaminated with pathogenic microorganisms, including bacteria (Vibrio cholerae, Salmonella typhi), viruses (hepatitis A, rotavirus), and protozoa (Giardia lamblia).

Primary Healthcare Centre (PHC):

A first-level health facility providing essential preventive, promotive, curative, and rehabilitative health services to a defined catchment population.

WASH:

An acronym encompassing Water, Sanitation, and Hygiene, the three pillars of environmental health infrastructure required to prevent waterborne and sanitation-related diseases.

Internally Displaced Person (IDP):

A person or group of persons forced or obliged to flee or leave their homes or habitual residence due to conflict, violence, or disaster, and who have not crossed an internationally recognized State border.

Safely Managed Drinking Water:

Drinking water sourced from an improved facility located on the premises, available when needed, and free from contamination — meeting the SDG6 higher-level definition of water access.

References

Doctors Without Borders (MSF). (2024). Fears of outbreaks grow after severe floods in Nigeria. https://www.doctorswithoutborders.org/latest/fears-outbreaks-grow-after-severe-floods-nigeria

Elimian, K. O., Yennan, S., Musah, A., Myles, P., Nguyen-Van-Tam, J., & Ihekweazu, C. (2022). Epidemiology, diagnostics and factors associated with mortality during a cholera epidemic in Nigeria, October 2020–October 2021: A retrospective analysis of national surveillance data. BMJ Open, 12(9), e063703. https://doi.org/10.1136/bmjopen-2022-063703

Kida, I. M., & Badaru, B. (2024). The interplay among conflict, water scarcity, and cholera in northern Nigeria. PLOS Global Public Health, 4(4), e0003021. https://doi.org/10.1371/journal.pgph.0003021

National Bureau of Statistics & UNICEF. (2022). Nigeria 2021 Multiple Indicator Cluster Survey (MICS) and National Immunization Coverage Survey (NICS) report. Federal Republic of Nigeria.

National Institutes of Health. (2025). Expanding access to safe water in Nigeria. ClinicalTrials.gov Identifier: NCT07246824.

Oluwole, O., Okeibunor, J. C., Yahaya, A. A., & Oyelaran, O. A. (2025). Prevalence and factors associated with water, sanitation and hygiene (WASH) facilities deprivation among children in Nigeria. BMC Public Health, 25(1), 421. https://doi.org/10.1155/2025/2688500

Southern Voice. (2024). The importance of clean water and sanitation in Nigeria. https://southernvoice.org/the-importance-of-clean-water-and-sanitation-in-nigeria/

UNICEF Nigeria. (2022). Waterborne diseases: Nigeria flooding emergency response. https://www.unicef.org/nigeria/topics/water-borne-diseases

World Health Organization. (2022). Progress on household drinking water, sanitation and hygiene 2000–2022: Special focus on gender. WHO/UNICEF Joint Monitoring Programme for Water Supply, Sanitation and Hygiene.