22 RBCIAMB | v.57 | n.1 | Mar 2022 | 22-33 - ISSN 2176-9478 A B S T R A C T This article analyzes the relationship between incidences of hepatitis A — a water-borne disease that can also be transmitted by lack of hygiene — and quality indicators in the provision of water supply services, through secondary data extracted from the National Information Systems for Notifiable Diseases and on Sanitation, in the period between 2007 and 2018, for the municipalities of the State of Rio de Janeiro, Brazil. The indicators were initially submitted to Principal Component Analysis (PCA) to reduce numerous variables that showed autocorrelation with each other. Subsequently, the principal components were submitted to Pearson’s correlation analysis with the incidence of hepatitis A. A correlation coefficient of -0.32 was observed, at the level of significance (p < 0.05) between the cumulative incidences of hepatitis A and the principal component (PC3) formed by a set of quality indicators for the provision of water supply services. The indicators that best described PC3, with factor loadings ranging from -0.88 to 0.70, were those related to: hydrometer, water and revenue losses, water revenue, the participation of residential water savings, micro-measurement related to water consumption, water consumption and average water consumption per economy, average duration of outages, and the incidence of non-standard total coliform analyses. Thus, the observed results point to an association between the quality of water supply services and the incidence of hepatitis A, which may indicate both failures in treatment efficiency and lack of hygiene. Keywords: hepatitis A; water supply; principal components; Rio de Janeiro; quality of public services. R E S U M O Este artigo analisa a relação entre incidências de hepatite A — doença transmitida pela água ou falta de higiene — e indicadores de qualidade da prestação dos serviços de abastecimento de água por meio de dados secundários extraídos dos Sistemas Nacionais de Informação de Agravos de Notificação e sobre Saneamento, no período entre 2007 e 2018, para os municípios do estado do Rio de Janeiro. Os indicadores foram submetidos, inicialmente, à análise de componentes principais (PCA) para redução de variáveis numerosas que apresentaram autocorrelação entre si. Posteriormente, as componentes principais foram submetidas à análise de correlação de Pearson com a incidência de hepatite A. Foi observado coeficiente de correlação de -0,32, ao nível de significância p < 0,05, entre as incidências acumuladas de hepatite A e a componente principal (PC3) formada por um conjunto de indicadores de qualidade da prestação dos serviços de abastecimento de água. Os indicadores que melhor descreveram a PC3, com cargas fatoriais variando de -0,88 a 0,70, foram aqueles relacionados: à hidrometração, a perdas de água e de faturamento, ao faturamento de água, à participação das economias residenciais de água, à micromedição relativa ao consumo, ao consumo de água e ao consumo médio de água por economia, à duração média das paralisações e à incidência das análises de coliformes totais fora do padrão. Desse modo, os resultados alcançados apontam para uma associação entre a qualidade da prestação dos serviços de abastecimento de água e a incidência de hepatite A, podendo indicar tanto falhas na eficiência do tratamento como na higienização. Palavras-chave: hepatite A; abastecimento de água; componentes principais; Rio de Janeiro; qualidade dos serviços públicos. Association between water for human consumption and health of the population of the state of Rio de Janeiro: the case of hepatitis A between 2007 and 2018 Associação entre água para consumo humano e saúde da população do estado do Rio de Janeiro: o caso da hepatite viral do tipo A entre 2007 e 2018 Daniele Gonçalves Nunes1,2 , Nuria Pistón3 , Carlos José Saldanha Machado4 1Graduate Program in Environmental Studies, Universidade do Estado do Rio de Janeiro – Rio de Janeiro (RJ), Brazil. 2Instituto Federal do Rio de Janeiro — Rio de Janeiro (RJ), Brazil. 3Graduate Program in Ecology, Universidade Federal do Rio de Janeiro – Rio de Janeiro (RJ), Brazil. 4Graduate Program in Biodiversity and Health, Fundação Oswaldo Cruz — Rio de Janeiro (RJ), Brazil. Corresponding address: Daniele Gonçalves Nunes – Rua Santo Amaro, 51 – Glória – CEP: 22211-230 – Rio de Janeiro (RJ), Brazil. E-mail: daniele.nunes@ifrj.edu.br Conflict of interest: the authors declare no conflicts of interest. Funding: Coordination for the Improvement of Higher Education Personnel (CAPES) – Financing Code 001. Received on: 08/11/2020 Accepted on: 03/11/2021 https://doi.org/10.5327/Z21769478974 Revista Brasileira de Ciências Ambientais Brazilian Journal of Environmental Sciences Revista Brasileira de Ciências Ambientais Brazilian Journal of Environmental Sciences ISSN 2176-9478 Volume 56, Number 1, March 2021 This is an open access article distributed under the terms of the Creative Commons license. https://orcid.org/0000-0001-7644-3770 https://orcid.org/0000-0003-4946-9945 https://orcid.org/0000-0002-9895-7059 mailto:daniele.nunes@ifrj.edu.br https://doi.org/10.5327/Z21769478974 http://www.rbciamb.com.br http://abes-dn.org.br/ https://creativecommons.org/licenses/by/4.0/ Association between water for human consumption and health of the population of the state of Rio de Janeiro: the case of hepatitis A between 2007 and 2018 23 RBCIAMB | v.57 | n.1 | Mar 2022 | 22-33 - ISSN 2176-9478 Introduction Water is essential for human and non-human life on this planet. For humans, adequate water quality and sufficient quantity are required to meet their needs, protect their health, and enable their economic activ- ities (Plessis, 2017; Gurung et al., 2019; Singh et al., 2019), and access to water was established as a human right by the General Assembly of the United Nations on July 28, 2010 (United Nations, 2010; Palmer et  al., 2018). However, it is possible to observe intense water degra- dation, both in quality and quantity, over the years. The worsening of climate change, disorderly urban growth, inadequate disposal of solid waste, deforestation of forests and riparian forests of rivers, the release of domestic and industrial effluents in natura, the diffuse pollution that causes pollutants, disorderly exploitation of water reserves, and the commodification of a common good are among the factors responsible for the pressures on water bodies, as demonstrated over two decades, by Machado and Klein (2003), Shiva (2016), Escher et al. (2019), Fon- seca et al. (2020) and the Intergovernmental Panel on Climate Change (IPCC, 2021). This reality directly impacts the access to safe water of quality and quantity for the population, especially in developing countries in Lat- in America and Africa facing severe health and environmental crises, intensified by the new coronavirus pandemic since 2020 (Britto et al., 2019; Ekumah et  al., 2020; Gaber et  al., 2021; Gwenzi, 2021; Purna- ma and Susanna, 2020). In this sense, the Progress on drinking water, sanitation and hygiene report: 2000-2017: Special focus on inequalities (UNICEF and WHO, 2019) points out that, since 2000, 1.8 billion people have been guaranteed access to basic drinking water services. Nevertheless, one in ten people (785 million) remains without access to basic water services, including 144 million who access untreated water sources. The report also shows that there is an inequality between the richest and the poorest countries, as the former have at least twice as much coverage of basic services than the later (UNICEF and WHO, 2019). According to Santos et al. (2015, p. 11), half of the urban pop- ulation in Africa, Asia, Latin America and the Caribbean suffers from one or more diseases associated with inadequate water supply and lack of sanitation. Within the Brazilian scenario, the results of the 2019 Continuous National Household Sample Survey (Continuous PNAD) demonstrate that 86% of the 72.4 million households had access to water supply through the general water network as the main source of supply, and 68.3% had a general network of sanitary sewer. However, there is re- gional inequality between North (58.8%), Northeast (80%), Midwest (87.2%), South (87.9%), and Southeast (92.3%) (IBGE, 2020). Ac- cording to these data, regarding the availability and frequency of the water supply service provided by the general water network, 88.5% of households had daily availability, whereas the remaining 11.5% had frequency variations that could range between once and three times a week. Concerning the regions, the Northeast presented lower coverage of daily water supply (69.0%), followed by the North (89%), Midwest (94.9%) and Southeast (94.8%), and the best condition was observed in the South (97.0%) (IBGE, 2020). With regard to sanitary sewer, ac- cording to PNAD, there is regional inequality in access to the general network, as follows: North (27.4%) and Northeast (47.2%) had lower coverage; the South and Midwest reached 68.7%; and the Southeast had the best performance, with 88.9% (IBGE, 2020). Among the water-borne diseases, hepatitis A stands out, a trans- mission disease associated with the quality of water for human con- sumption, hygiene habits, or water scarcity (Ensink and Cairncross, 2012; Singh and Mondal, 2019), which is the focus of the present study. In addition, Brazil recorded 1,189 deaths associated with hepatitis A between 2000 and 2018, of which 70.9% (843) had the disease as de underlying cause and 29.1% (346) as the associated cause, according to the “Epidemiological Bulletin on Viral Hepatitis” (Boletim Epide- miológico Especial sobre Hepatites Virais) published by the Brazilian Ministry of Health (Brasil, 2020). Also according to the Bulletin, the highest percentage of deaths from hepatitis A as the underlying cause occurred in the Northeast region (35.1%), followed by the Southeast (27.6%). It is noteworthy that the mortality rate due to hepatitis A as the underlying cause has shown a downward trend in all Brazilian re- gions in the last ten years (Brasil, 2020). Nevertheless, two recent out- breaks in the two largest Brazilian cities reversed the downward trend in the incidence of this disease. In 2017, in the city of São Paulo alone, there were 694 cases of this infection (one third of that recorded in the entire country in 2015). Conversely, in the municipality of Rio de Janeiro (MRJ) there was a sudden increase in the disease at the end of that year, with most cases occurring in the neighborhood of Vidigal. This neighborhood ranked as the 121st in the social development index and, in 2010, as the 123th in percentage of households with water supply among the 163 neigh- borhoods of the MRJ, according to the Census of the Brazilian Insti- tute of Geography and Statistics (IBGE), totaling 119 cases (Data Rio, 2010; Brasil, 2020); conversely, in 2016, there were only ten records. Although in São Paulo the main suspicion of the Municipal Health De- partment (Secretaria Municipal de Saúde – SMS) for the advancement of the disease was unprotected sexual intercourse, in Rio de Janeiro managers of the healthcare sector related its cause to the use of water contaminated with the virus. The high vulnerability of areas with lack of basic sanitation was highlighted, as observed in Vidigal, a slum with more than 2 million residents that gave rise to the neighborhood in the South region of the MRJ (Guimarães, 2018). Considering the public health issue in question, it is worth ques- tioning whether water supply services of the general network have been provided in sufficient quantity and quality to guarantee the hu- man right to water for the served population. Hence, the State of Rio de Janeiro (SRJ) was prioritized as an object of identification and analysis of the relationships between the incidence of hepatitis A and the quali- Nunes, D.G. et al. 24 RBCIAMB | v.57 | n.1 | Mar 2022 | 22-33 - ISSN 2176-9478 ty indicators of water supply services in its 92 municipalities, based on a quantitative database methodology, with systematization, treatment, interpretation, and representation of data extracted from Government agencies. The SRJ proved to be an important territorial selection due to the history of water supply systems, dating back to the 19th century, and the strong dependence on few centralized water supply systems — such as the Paraíba do Sul basin, which supplies water to 17.6 million people, and the Guandu River basin, which receives water from the Paraíba do Sul River through transposition, supplying about 80% of the Metropolitan Region of Rio de Janeiro (MRRJ). This article is organized into five sections, starting with this Intro- duction, followed by the presentation of the study area and the meth- ods of data collection and analysis. Subsequently, the obtained results are presented, followed by the discussions and, finally, the conclusions of this article. Study Area and Methods Territorial selection of the study: the state of Rio de Janeiro The study area covers the territorial extension of 43,750,427 km2, with an estimated population, according to IBGE, of 17,366,189 mil- lion inhabitants (IBGE, 2021). Historically, the SRJ has water supply systems centralized in large pipelines and water treatment plants; in addition, these systems are dependent on water sources transported over long distances through transposition systems, especially for the MRRJ (Britto and Quintslr, 2017). According to Britto and Quintslr (2017), there are three periods of the development of urban water systems, between the years 1870 and 1980. The first consists of wa- ter transfers over long distances to overcome the absence of water treatment techniques. The second, in turn, is marked by the advent of new water treatment techniques based on the scientific technical de- velopment of sanitary engineering. Finally, the third period includes sustainable management, which seeks sustainable water use, demand management and supply control as well as water reuse (Britto and Quintslr, 2017). Taking this into consideration, the choice for the SRJ is justified by three factors. The first is the centralized and infrastructural characteristic of the water supply systems of the state, especially the Water and Sewage Company of the State of Rio de Janeiro (Companhia Estadual de Águas e Esgotos do Rio de Janeiro – Cedae). Under public administration, this mixed-economy company fully or partially provides 64 municipalities with water supply, with an estimated population of 6,747,815 inhabi- tants in 2020, of which 97.41% were supplied with water services (Brasil, 2021c), and was recently taken to auction with a view to privatization (Silva et  al., 2021). In addition, there are seven municipalities served by autarkies of the Autonomous Water and Sewage Services (Serviços Autônomos de Água e Esgoto); five by municipal governments operating as direct public administration and, finally, 16 private companies, ac- cording to the National Sanitation Information System (Sistema Nacion- al de Informações sobre Saneamento – SNIS) (Brasil, 2021c). The second factor is related to the possibility of using secondary data on the quality of water supply services, based on the SNIS, with higher percentages of information due to the link between the filling of these data by the operators of water supply systems and the release of resources from investment programs of the Brazilian Ministry of Regional Development, including the Growth Acceleration Program (Programa de Aceleração do Crescimento – PAC). Finally, the third fac- tor is the strong dependence on water supply sources, especially the Paraíba do Sul River and the Guandu River, the former being funda- mental to maintain the quality of the water of the later through trans- position – dated in the 1950s – between the Santa Cecília reservoir, in Piraí (RJ), which, integrated with other reservoirs, such as Ribeirão das Lajes, will supply the Guandu System. Study design In this article, the authors chose to use the data available in the Information Systems of institutional databases, namely: The Notifiable Diseases Information System (SINAN-Net), which is part of the system catalog of the Unified Health System Informatics Department (DATA- SUS) of the Brazilian Ministry of Health; the National Sanitation In- formation System (SNIS), of the Brazilian Ministry of Regional De- velopment; and the 2010 Demographic Census, of IBGE (2011). Data collection was carried out through access to the database available in the aforementioned information systems, and several visits were made to the information systems until the year 2021. Then, the data were stored, organized, and processed using the R Project, version 4.0.2, and Excel software. Initially, descriptive statistics analysis techniques were used to perform exploratory analysis, as well as data pre-processing for later use in inferential statistics analysis. A percentage of zeros and failures of 45% was observed in the sam- ples of the historical series of the municipalities of the SRJ, both for the SINAN-Net and for the SNIS, making it necessary to exclude 35 municipalities. This enabled to identify that the period between 2007 and 2018 had greater data filling. In the case of SNIS, this fact can be justified by the requirement to regularly send data to the System as a criterion for selecting, ranking, and releasing financial resources. Therefore, the analysis was limited to municipalities with more com- plete data records (lower percentage of failures and zeros), reaching 57 of them (Angra dos Reis, Araruama, Arraial do Cabo, Barra do Pi- rai, Belford Roxo, Bom Jardim, Bom Jesus do Itabapoana, Cabo Frio, Cachoeiras de Macacu, Campos dos Goytacazes, Cantagalo, Duque de Caxias, Guapimirim, Itaboraí, Itaguaí, Italva, Itaperuna, Itatiaia, Japeri, Macaé, Macuco, Magé, Mangaratiba, Maricá, Mesquita, Miguel Perei- ra, Natividade, Nilópolis, Niterói, Nova Friburgo, Nova Iguaçu, Para- cambi, Paraty, Paty do Alferes, Petrópolis, Pinheiral, Porciúncula, Que- imados, Quissamã, Resende, Rio Bonito, Rio Claro, Rio das Flores, Rio Association between water for human consumption and health of the population of the state of Rio de Janeiro: the case of hepatitis A between 2007 and 2018 25 RBCIAMB | v.57 | n.1 | Mar 2022 | 22-33 - ISSN 2176-9478 das Ostras, Rio de Janeiro, São Fidelis, São Francisco de Itabapoana, São Gonçalo, São Joao da Barra, São Joao de Meriti, São Jose do Vale do Rio Preto, Sapucaia, Saquarema, Seropédica, Tanguá, Teresópolis, Trajano de Morais, Três Rios, and Volta Redonda). The same criterion was followed for data on hepatitis A. Thus, the annual database referring to 57 of the 92 municipalities in Rio de Janeiro was used for this time frame regarding: • indicators of the quality of water supply services, via SNIS, consol- idated by municipalities (Brasil, 2019, 2021c) in the operational, economic-financial, and water quality categories, based on which the arithmetic means of these indicators were calculated per mu- nicipalities, in the period from 2007 to 2018. Components with excess zeros or lack of data were excluded, and 32 indicators were selected from the operational, economic-financial, and water qual- ity categories (Brasil, 2019); • cumulative incidence of hepatitis A (cases of hepatitis A per 100,000 inhabitants distributed per municipality), reported in the Brazilian Unified Health System (SUS), via SINAN-Net/DATASUS (Brasil, 2021b), with calculation of the cumulative frequency of the total reported cases of hepatitis A in the period from 2007 to 2018, divided by the respective population of each municipality x 100,000, as demonstrated by Rafael et al. (2020); • census data, via the 2010 IBGE Demographic Census (2011), of the 57 studied municipalities of the SRJ and that were used for the cal- culations of the incidence of hepatitis A as previously mentioned. Data analysis To analyze the relationship between hepatitis A and the quality indicators of water supply services, the cumulative incidence of hep- atitis A and the means of the indicators selected in the time frame of this study were calculated. Subsequently, both sets of variables were submitted to normality tests and validation of the principal compo- nent analysis. The Shapiro-Wilk normality test was chosen, with a significance level of p < 0.05. Regarding the data of the indicators of the quality of the provision of water supply services, the correla- tion matrix between the variables was first analyzed, and then the Bartlett’s test of sphericity and the Kaiser-Meyer-Olkin (KMO) test, which consists in a measure of the adequacy of the Principal Compo- nent Analysis (PCA). With regard to the normality test, the two data sets – cumulative incidence of hepatitis A and mean of the indicators of quality of the provision of water supply services – indicated a non-normal distri- bution according to the Shapiro-Wilk test, with a significance level of p < 0.0001. Thus, the authors opted for logarithmization of the vari- able “cumulative incidence of hepatitis A,” which met the normality, as demonstrated by the Shapiro-Wilk test (p > 0.05). For data on the quality indicators of the provision of water supply services, normaliza- tion took place in the development of the statistical analyses in the R Project program, using the vegan package, rda function (Legendre and Legendre, 2012; Oksanen et al., 2020). Normality was also tested after PCA using the Shapiro-Wilk test, and the authors identified that the principal components presented normal distribution (PC1, PC2, PC3, PC4 — p > 0.05). In the present study, it was observed that the quality indicators of water supply services are strongly associated with each other, a characteristic that may limit the type of statistical analysis to be used or produce spurious results – for example, the independence of the variables is a requirement for Pearson’s correlation analysis (Taylor and Bates, 2013). Thus, PCA – a technique frequently ap- plied by several authors to the most different areas, especially those related to the topic of the present article – proved to be interesting for the development of studies with these indicators as it allowed to reduce a set of correlated variables to a smaller number of principal components, independent of each other (Hernández-Flores et  al., 2017; Zeinalzadeh and Rezaei, 2017; Corrêa et  al., 2019; Tripathi and Singal, 2019). The results obtained from this statistical tech- nique consist of eigenvalues of a sample covariance matrix (Legen- dre and Legendre, 2012; Santo, 2012). In this matrix, the principal components and the resulting eigenvalues are independent of each other and can therefore be used in subsequent statistical analyses (Logan, 2015). Subsequently, the Pearson’s correlation analysis was performed be- tween the principal components and the incidence of hepatitis A. Ac- cording to Callegari-Jaques (2003 apud Feil et al., 2015), the Pearson’s correlation can be qualitatively evaluated regarding its intensity as fol- lows: null, when the correlation is 0; weak, when it is between 0 and 0.3; regular, when it is between 0.31 and 0.6; strong, when it is between 0.61 and 0.9; very strong, when it is between 0.91 and 99; and full, when it is equal to 1. The sign of the coefficient indicates the direction of the association (Moore, 2007). To perform the analyses with the PCA and correlation techniques, the free R Project software, version 4.0.2, was used, as well as its vegan, FactorMiner, and xlsx packages. Results Table 1 presents the descriptive statistics for the variables used in the analyses developed in this article: cumulative incidence of hepa- titis A and indicators of the quality of water supply services, between 2007 and 2018. Mean, median, standard deviation, and confidence intervals are presented, with their respective lower and upper limits for all variables. Hepatitis A scenario in the state of Rio de Janeiro The distribution of cumulative incidences of hepatitis A for the 2007-2018 period was determined, according to the territorial location of the highest rates, as well as the mean (20.2 cases per 100,000 inhabi- tants) for the SRJ (dashed line), as shown in Graph 1. Nunes, D.G. et al. 26 RBCIAMB | v.57 | n.1 | Mar 2022 | 22-33 - ISSN 2176-9478 Among the analyzed municipalities, 13 had values of cumula- tive incidence of hepatitis A above the estimated state average for Rio de Janeiro. Among them, Mangaratiba, Paraty, and Sapucaia presented 86.56, 72.72, and 84.27% of average water supply cover- age, respectively, in the period between 2007 and 2018. Still among these 13 municipalities, Três Rios (99.13%), Rio de Janeiro (97.41%), Petrópolis (96.93%), Angra dos Reis (90.44%), Macuco (86.94%), Duque de Caxias (84.50%), Macaé (75.05%), Porciúncula (74.95%), Magé (72.86%), and Tanguá (51.68%) stand out for their percentage of water supply. Graph 2 shows the percentages of coverage for water supply, based on SNIS data, for the 57 municipalities observed in the present study. Table 1 — Descriptive statistics of hepatitis A incidences and quality indicators of water supply services. Variables Description of variables Mean Median Standard Deviation Confidence Interval (95%) Lower Limit Upper Limit IHepA Cumulative incidence of hepatitis A 20.70 10.97 43.55 9.40 32.01 IN001 Density of water economy per connection 16.28 15.66 3.74 15.30 17.25 IN005 Average water rate 37.86 37.06 12.26 34.68 41.05 IN009 Hydrometer index 807.46 892.23 343.77 718.21 896.71 IN010 Micro-measurement index related to the available volume 474.45 472.12 227.13 415.49 533.42 IN013 Revenue loss index 498.82 552.97 217.41 442.38 555.26 IN014 Micro-measurement of water consumption per economy 180.61 190.90 39.21 170.43 190.79 IN017 Water consumption billed per economy 169.64 173.80 41.57 158.85 180.43 IN020 Extension of the water network per connection 143.96 137.80 81.92 122.70 165.23 IN022 Average per capita water consumption 2,173.62 2,208.20 569.69 2,025.73 2,321.52 IN023 Urban water service index 983.62 1,025.60 185.87 935.37 1,031.88 IN025 Volume of water provided per economy 357.84 330.60 147.81 319.47 396.22 IN028 Water revenue index 653.81 622.36 211.05 599.02 708.60 IN043 Participation of residential water economies in the total water economies 1,060.38 1,094.74 109.03 1,032.08 1,088.69 IN044 Micro-measurement index related to consumption 782.20 803.90 333.97 695.50 868.90 IN049 Distribution loss index 430.09 407.69 149.32 391.33 468.86 IN050 Gross linear loss index 637.06 531.56 489.78 509.91 764.21 IN051 Loss index per connection 6,830.62 5,570.45 4,596.5 5,637.33 8,023.91 IN052 Water consumption index 722.54 742.93 143.90 685.18 759.90 IN053 Average water consumption per economy 195.04 202.10 50.31 181.98 208.10 IN055 Total water service index 935.65 980.37 198.62 884.08 987.21 IN057 Water fluoridation index 420.17 104.10 472.51 297.50 542.83 IN058 Electric energy consumption index in water supply systems 7.14 4.90 7.61 5.17 9.12 IN071 Economies affected by outages 29,210.16 7,759.00 51,791.53 15,764.65 42,655.67 IN072 Average duration of outages 62.61 52.70 43.41 51.34 73.89 IN073 Economies affected by intermittences 7,685.46 0.00 3,4031.93 -1,149.52 16,520.43 IN074 Average duration of intermittences 10.88 0.00 28.24 3.55 18.21 IN075 Incidence of non-standard residual chlorine analyses 13.84 4.60 21.69 8.21 19.47 IN076 Incidence of non-standard turbidity analyses 54.65 14.78 76.65 34.75 74.54 IN079 Sample quantity compliance index (free residual chlorine) 1,350.15 1,264.04 710.13 1,165.79 1,534.51 IN080 Sample quantity compliance index (turbidity) 1,378.55 1,291.36 705.73 1,195.33 1,561.76 IN083 Average duration of provided services 947.05 825.58 875.85 719.67 1,174.43 IN084 Incidence of non-standard total coliform analyses 25.98 6.81 37.45 16.25 35.70 IN085 Sample quantity compliance index (total coliform) 1,497.51 1,268.90 955.93 1,249.34 1,745.68 Source: Prepared by the authors based on data from SINAN-Net and SNIS, based on the cumulative incidence of hepatitis A and the average quality of water supply indicators, using the R Project software, version 4.0.2. Association between water for human consumption and health of the population of the state of Rio de Janeiro: the case of hepatitis A between 2007 and 2018 27 RBCIAMB | v.57 | n.1 | Mar 2022 | 22-33 - ISSN 2176-9478 Analysis of principal components of the indicators of the National Sanitation Information System As for the set of quality indicators of water supply services, the KMO suitability test obtained a value of 0.52, higher than the accept- able critical limit of 0.5 (Hair et al., 2009). Furthermore, Bartlett’s test of sphericity was statistically significant (p > 0.0001). In both cases, the tests suggest that the data are suitable for statistical treatment. Thus, the PCA of the quality indicators of the provision of water supply services evidenced those that significantly contributed to the variance of the main axes of the set of analyzed variables. Hence, the authors could identify four principal components (PC1 to PC4), which explain 54.5% of the variance of the set of analyzed variables. PC1 ex- plains 21.4% of the total variance of the data and presents high posi- tive factor loadings for the indicators concerning: micro-measurement related to the available volume (IN010), micro-measurement related to water consumption (IN044), hydrometer (IN009), and water rev- enue (IN028); and moderate-to-strong negative factor loading for the indicators concerning revenue losses (IN013) and the volume of water provided per economy (IN025), with correlation coefficients ranging from 0.92 to -0.72, at a significance level of p < 0.001. PC2, in turn, explains 15.8% of the total variance of the data and presents high positive factor loadings for the indicators concerning average per capita water consumption (IN022), micro-measurement related to water consumption per economy (IN014), water consump- Source: Prepared by the authors based on SINAN-Net data (Brasil, 2021b). Graph 1 — Hepatitis A incidence per 100,000 inhabitants and per municipalities in the state of Rio de Janeiro and state average (orange line) for the period between 2007 and 2018. Nunes, D.G. et al. 28 RBCIAMB | v.57 | n.1 | Mar 2022 | 22-33 - ISSN 2176-9478 tion billed per economy (IN017), and average water consumption per economy (IN053), with correlation coefficients ranging from 0.80 to -0.43, at a significance level of p < 0.001. Conversely, PC3 corresponds to 9.3% of the total variance of the data and presents a weak-to-moderate positive factor loading for in- dicators concerning water consumption (IN052) and the incidence of non-standard total coliform analyses (IN084) and strong negative fac- tor loading for the indicator related to distribution losses (IN049), with correlation coefficients ranging from 0.71 to -0.88, at a significance level of p < 0.001. Lastly, PC4 explains 7.9% of the total variance of the data and presents a weak-to-moderate positive factor loading for the indicators concerning economy achieved by outages (IN071), duration of outages (IN072) and water fluoridation (IN057) and presented a weak negative Source: prepared by the authors based on SNIS data (Brasil, 2021c). Graph 2 — Water supply coverage of the municipalities of the state of Rio de Janeiro for the 2007-2018 period. Association between water for human consumption and health of the population of the state of Rio de Janeiro: the case of hepatitis A between 2007 and 2018 29 RBCIAMB | v.57 | n.1 | Mar 2022 | 22-33 - ISSN 2176-9478 Table 2 — Pearson’s correlation coefficients between cumulative incidence of hepatitis A and the principal components of the means of the indicators of the quality of the provision of water supply services. Significant results (p < 0.05) in bold. Dimensions Pearson’s correlation coefficient p-value Confidence intervals Lower limit Upper limit PC1 -0.06 0.69 -0.21 0.31 PC2 0.21 0.13 -0.06 0.44 PC3 -0.32 0.02 -0.53 -0.06 PC4 -0.14 0.30 -0.39 0.13 Source: Prepared by the authors based on data from SINAN-Net (Brasil, 2021b) and SNIS (Brasil, 2021c). factor loading for the indicator regarding extension of water network (IN020), with correlation coefficients ranging from 0.61 to -0.45, at a significance level of p < 0.001. Association between hepatitis A and the principal components of the water supply Based on the results achieved with the PCA technique in the study of water supply indicators, it was possible to solve multicollinearity and reduce the set of variables in the main axes for the analysis of the asso- ciation with the incidence of hepatitis A. It is worth emphasizing that the choice for the PCA technique was made to meet the fundamental assumptions of many data analyses, including the Pearson’s correlation — according to which the data are independent and the errors are in- dependent and identically distributed (Taylor and Bates, 2013) — as well as to reduce the number of variables. Therefore, Pearson’s correlation analyses showed an association be- tween the incidence of hepatitis A and the PC3 axis, with a correlation coefficient of -0.32, at a significance level of p < 0.05, as shown in Table 2. As aforementioned, the most explanatory variables of PC3 are indi- cators related to water consumption (IN052), incidence of non-standard total coliform analyses (IN084), and distribution losses (IN049), as pre- viously mentioned. Thus, observing the positive factor loadings of the IN052 and IN084 indicators, it is possible to infer that there is an inverse- ly proportional relationship between them and the cumulative incidence of hepatitis A. In the case of IN052, this may indicate that greater wa- ter consumption means greater access to treated and distributed water, which contributes to the maintenance of hygiene habits, subsequently reducing the incidence of hepatitis A cases due to water scarcity. Conversely, the IN084 initially indicates a strange relationship, as it was expected that the higher incidence of total coliform analyses with non-standard samples could increase the risk of contamination by the hepatitis A virus, whether due to failures in water treatment, or due to poor water quality in water supply sources or recontamination in the distribution networks. It was observed that 23 of the 57 municipali- ties present less than 85% of the required samples. However, it can be assumed that municipalities with the highest IN084 values are those that periodically monitor water supply systems, following the protocols defined by Ordinance No. 888 of May 4, 2021 (Brasil, 2021a), among other regulations and guidelines for the control and surveillance of wa- ter quality for human consumption. Therefore, the prior diagnosis of risk situations in monitoring the quality of water supply systems may contribute to reducing the incidence of hepatitis A. Finally, the negative factor loading of IN049, related to distribution losses, demonstrates that the high rate of these losses can cause several problems in the access to water, compromising the health of the popu- lation due to increased risk of hepatitis A contamination, among other diseases that were not addressed in this study. Discussion The obtained results point to an association between the incidence of hepatitis A and indicators of the quality of water supply services — of the principal component (PC3), which explains 9.3% of the total vari- ance of the data — in addition to what has already been found in oth- er studies concerning the relationship between health and sanitation (Siqueira et  al., 2017; Paiva and Souza, 2018; Dall’agnol et  al., 2019). Some authors highlighted the presence of hepatitis A virus in urban sanitation networks (Holanda and Vasconcellos, 2015), especially in the MRJ (Prado et al., 2012), demonstrating high viral activity in sum- mer and spring, under the presence of coliforms (Prado et al., 2012). This association indicates a relationship between the cumulative incidence of hepatitis A and PC3, in which the quality indicators of the provision of water supply services IN052, IN084, and IN049 stand out, with higher factor loadings. In this sense, it is suggested that this rela- tionship may be due to several factors, such as: poor quality of water from water supply sources, inefficiency in water treatment in ensuring its potability for human consumption, absence or precariousness in the monitoring and control of the surveillance of water quality in the sup- ply systems, interruptions and outages in supply, which compromise water and food security, and the hygiene habits of the population. With regard to the loss of water quality in water sources, the presence of viruses in sewage becomes more severe when there is low coverage of sanitary sewer, as was evidenced in the SRJ, especially in the state capital and in the metropolitan region, according to data on average sanitation coverage of sanitary sewer presented in this article, which corroborate the discussions of Britto et al. (2019). Moreover, the release of untreated effluents contributes to the degradation of water quality of water sources in the SRJ, as highlighted by Nunes (2021), in line with the historical framework of the abandonment of water sources to degradation, rectifi- cation, and channeling presented by Britto and Quintslr (2018). Furthermore, this scenario of degradation of water quality of the water supply sources compromises, a posteriori, the water that will be used in water catchment, treatment, and distribution to supply the pop- ulation (SOS Mata Atlântica, 2019). This is because the water from water sources may not meet the quality standards required by Resolution No. Nunes, D.G. et al. 30 RBCIAMB | v.57 | n.1 | Mar 2022 | 22-33 - ISSN 2176-9478 357/2005 of the National Environment Council of Brazil (Conselho Na- cional do Meio Ambiente – CONAMA) for human supply, influencing the efficiency of water treatment. In turn, compromising this efficiency may lead to non-compliance with potability standards, as established by Ordinance No. 888 of the Brazilian Ministry of Health of May 4, 2021, which amends Annex XX of the GM/MS Consolidation Ordinance No. 5, of September 28, 2017, to provide information on the control and sur- veillance procedures for the quality of drinking water and its potability standard. For illustrating this type of situation, what the MRRJ has been facing can be mentioned, in which the presence of geosmin has been associated with poor water quality in water bodies and the inefficiency of water treatment in achieving the potability standard required by Ordi- nance No. 888 of the Brazilian Ministry of Health (Brasil, 2021a). This corroborates what some authors have demonstrated regarding the association of hepatitis A and other fecal-oral diseases, transmitted by water or due to lack of hygiene habits or water scarcity, with the quality of consumed water and access to water services (Holanda and Vasconcellos, 2015; Santos, 2019; Jesus, 2020). With regard to access, the water consumption indicator (IN052) – which showed a strong correlation (0.71) with PC3 – may indicate that, when access to water is guaranteed, higher consumption rates imply lower incidence of hepati- tis A. Furthermore, higher consumption rates may be related to socio- economic factors, as demonstrated by Fan et al. (2017). In other words, according to the authors of the aforementioned study conducted in China, the socioeconomic situation was one of the main factors that contributed to high water consumption and, in cities with low water consumption, this consumption was lower than the minimum amount required to sustain life, being “restricted by water supply capacity and household economic status” (Fan et al., 2017, p. 131). As for the indicator related to the incidence of analyses of total coliforms with non-standard samples (IN084), it is suggested that effi- cient monitoring of water supply systems may lead to the recording of incidents, which in turn contributes to the monitoring of water quali- ty for human consumption. In this sense, studies have shown that the monitoring performed by the quality control of the water supply was relevant in reducing diarrhea and hepatitis A, including during periods with records of intermittent supply (Castro et al., 2019). With regard to the indicator related to distribution losses (IN049), Orellana et al. (2018) stress that the ageing of water supply systems is in- evitable because they are among the first infrastructures installed and also because they accompany the development of cities. The authors emphasize that, as systems age, the trend is the increase in the number of leaks, rup- tures, and interruptions in supply, as well as incrustation in the pipes. Such impacts can compromise water quality, increase internal roughness, re- duce the hydraulic diameter and consequently the pressures that, in turn, cause intermittences and outages (Orellana et al., 2018). Concerning distribution losses – which can aggravate intermit- tences and outages –, the impermanence of water supply through the general network interferes with access to water in quantity and quality due to problems of under pressure and recontamination in the net- work, as well as induces the search for alternative sources of supply, enabling the spread of water-borne diseases or those transmitted due to lack of hygiene habits resulting from water scarcity, such as hepatitis A — as discussed in the manuals prepared by the Secretariat of Health Surveillance of the Brazilian Ministry of Health (Brasil, 2006a, 2006b). Another factor related to intermittences is the operation of the gen- eral network, which guides the performance of systematic discharges to clean the pipes, preventing contamination of the water inside them (Brasil, 2006a, 2006b). This procedure is essential for monitoring and controlling the quality of water for human consumption. However, more detailed studies are needed in order to expand the knowledge of this relationship, using, for this purpose, other water-borne diseases or those transmitted due to lack of hygiene resulting from water scarcity, under multiple methods of analysis, and even considering the increase in historical series on specific regions and intra-urban studies. Although the correlation between the incidence of hepatitis A and the principal component is not strong, it is still significant, with a sig- nificance level of p < 0.05, which encourages further investigation of this relationship. Hepatitis A is an oligosymptomatic disease, that is, it is presented by several factors that interact with each other and influ- ence its manifestation. As previously discussed, among these factors are: lack of hygiene and access to water; consumption of water contam- inated by animal feces, for example, through inadequate disposal of sewage into water bodies; and the risk associated with water contam- ination in the general network, which may occur due to losses, inter- mittences and supply outages, which produce a negative pressure in the pipes and, consequently, end up absorbing whatever is on the ground. Furthermore, diseases such as hepatitis A, persistent in developing countries, are characterized as “diseases of poverty” because they are more prevalent among vulnerable social groups, or neglected diseases triggered by the absence or precariousness of sanitation and water sup- ply services and housing conditions (Machado et  al., 2017). Accord- ingly, Sotero-Martins et  al. (2020) developed a study that evaluated the spatial distribution of municipalities and subnormal clusters of the SRJ according to the regional concession blocks for the privatization of Cedae, relating it to data on the incidence of diseases associated with inadequate environmental sanitation (Doenças Relacionadas ao San- eamento Ambiental Inadequado – DRSAI). The results achieved by the authors show that there is a spatial association between the municipal- ities of the SRJ and the incidence rate of DRSAI in 31 municipalities covered by Cedae. Also according to this study, 45.6% of the munici- palities in the SRJ have subnormal clusters, especially the capital, Rio de Janeiro, which has the highest percentage of subnormal clusters in the entire state, 57.3% (Sotero-Martins et al., 2020). In addition, it is worth deepening the investigation into the knowl- edge and formulation of these indicators of the quality of the provi- sion of water supply services, enabling a better understanding of the information contained by them. Given the importance for the quality Association between water for human consumption and health of the population of the state of Rio de Janeiro: the case of hepatitis A between 2007 and 2018 31 RBCIAMB | v.57 | n.1 | Mar 2022 | 22-33 - ISSN 2176-9478 of life and health of the population served by the general water supply network, such research may contribute to the improvement of the in- formation system and the quality of the provided service. Nonetheless, the association of these indicators of the quality of the provision of water services with the analyzed disease points to the existence of deficiencies or inadequacies in the water supply systems for human consumption. In addition to the technical aspects of water supply systems, it is worth highlighting the structural nature of the decision-making processes regarding the choices of political-institu- tional actors. Hence, Britto and Quintslr (2018, p. 9, free translation) state that the review of the historical and structural process in the development of water supply macrosystems – such as in the case of the MRRJ – enabled to observe that the decisions were centralized “by political actors and engineers from the civil engineering sector, acting as builders of these urban service networks,” which led to the concentration of supply in a single system for this region to the pres- ent day. According to the authors, Cedae has been operating since 1975 as a “developer of this macrotechnical system,” although the development and expansion of the macrosystem over the years has not guaranteed the universalization of water services for the entire population, in terms of quality and quantity. Conversely, the privatization process of Cedae demonstrates that social groups lacking the access to quality and quantity water services, residing in more vulnerable regions, may end up remaining outside the urgent universalization of access to safe water for human consumption (Nunes, 2021). Furthermore, centralization in a single system can also increase the risk of collapse in the face of the worsening of successive water crises and the worsening of the water quality conditions of the water sources. This was evidenced in the consecutive geosmin crises in the city of Rio de Janeiro (Formiga-Johnsson and Britto 2020; Nunes, 2021), but it had already been observed in a study for almost two de- cades (Machado, 2004). During the water crisis, the transposition flows of the Paraíba do Sul River, the main water supply source of the SRJ, were reduced; together with the degraded waters of the Guandu River, they supplied the MRRJ (Castro et  al., 2019), which could justify the poor quality of the water and the worsening of interruptions in their supply networks. Finally, no studies were found in the literature that explored the relationship between hepatitis A and SNIS variables based on the PCA technique, specifically in the SRJ, although some authors have analyzed this relationship to a lesser extent, using other methodologies. Conclusions The results achieved in this study contribute to a deeper under- standing of the indicators contained in official databases and data sys- tems regarding water supply and their relationship with the health of the population served, regarding the cumulative incidence of hepatitis A. They also contribute to a proposal for a differentiated analysis, such as the one performed with the application of the PCA technique, which allowed the identification of the principal components and their re- spective sets of variables with higher factor loadings, aiming to later analyze the correlation between the components and the cumulative incidence of hepatitis A. The use of this technique may allow further analyses with other types of dependent variables other than hepatitis A. In addition, the association between hepatitis A and indicators of the quality of the provision of water supply services also proves to be important, as it indicates a certain vulnerability in the supply system, especially due to failures in water distribution, evidenced by the in- crease in the disease when related to indicators concerning distribution losses (IN049). The results also demonstrate the importance of moni- toring and controlling water quality from treatment, undergoing dis- tribution, and up to consumption, as a way of guaranteeing safe water for the population, in the face of environmental degradation and the negligence of the Government in solving a public health issue. Finally, we emphasize the need – already pointed out by Machado and Klein (2004) for almost two decades – to rethink and promote ac- tions in an integrated manner with policies on public health, environ- ment, water resources, and sanitation, seeking to meet the fundamen- tal needs of the population in a safe, equitable, and fair manner. The universalization of good quality water supply services for human con- sumption is an existential imperative of present and future generations and which integrates the right to health, as determined by Article 225 of the 1988 Federal Constitution of Brazil. In democratic state ruled by law, the Constitution is above everyone else. 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