Hesperian Health Guides

Sanitation, cleanliness, and toilets

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HealthWiki > Helping Children Live with HIV > Chapter 10: How to keep children healthy > Sanitation, cleanliness, and toilets


How Ravi became ill

Ravi lives with his mother and father in a crowded area of a city in India. He is 3. It is not easy to keep clean in the city. There are few latrines, and people often use the open trenches that run through the streets between the houses.


 Illustration of the below: dog standing in water
1. One day, heavy rains flooded the open sewers and dirty water spread everywhere. A dog walked through the streets and sniffed things, looking for food scraps. The dog got feces on its feet and nose.


 Illustration of the below: child touching dog
Illustration of the below: mother squatting next to child
2. The dog went into Ravi’s house and Ravi played with him. He patted the dog, getting dirt and feces on his hands, and found an old shoe to throw so the dog could chase it. The dog ran in and out of the house a few times until Ravi’s mother chased him off. 3. Ravi cried, and his mother squatted down to comfort him. Ravi held onto his mother’s sari, and the dirt and feces on his hands got on her sari.
Illustration of the below: hand preparing flatbread
Illustration of the below: man, woman and two children looking ill
4. The busy mother prepared food for the family and used her soiled skirt — which did not look dirty — to handle the hot food. 5. The family ate the food, and soon everyone had diarrhea. Ravi became very ill.

Making sure waste and feces are not left in the open is very important for the health of the entire community. Feces and urine have germs and worm eggs that can get into our water and food. This makes all people ill, but these illnesses are more serious for children and people with HIV. Diseases caused by these germs include diarrhea, cholera, worms, schistosomiasis, and bladder infections. For how to treat many of these diseases, see Chapter 12.

Keeping the germs in human and animal waste away from people is called sanitation. It helps us stay healthy when we can keep our bodies clean, especially our hands.

Diarrhea is an annoying problem for anyone, but it is worse for small children. Diarrhea in young children makes them weak, less nourished, and more easily ill with other illnesses. Diarrhea was even worse for Ravi in the story because he has HIV. The weakness from having diarrhea makes him less able to fight HIV, and his medicines do not work as well.

The family’s illness could have been prevented if:

  • the community had not had open sewers.
  • the dog had not been allowed to come inside the house.
  • someone had helped Ravi wash his hands.
  • Ravi had not wiped his hands on his mother’s skirt.
  • Ravi’s mother had clean cloths to handle food with while cooking.


Cleanliness and sanitation are important ways to keep communities healthy. Washing children’s hands often is one of the most important ways to help them avoid illness. By working together to provide children and families with safe toilets and ways to wash, you can prevent many illnesses.

a child speaking to a baby who is crawling towards a puddle.
Wait, Ben!
Small ones are a lot of work to keep clean. As soon as you wash them, they get dirty again!

Wash children’s hands often

a child washing a baby's hands.
OK, now the other hand.

When babies are between 6 and 12 months old, they begin to put everything in their mouths. This is one way they learn about the world. Try to keep your baby’s hands clean by wiping them often. And give your baby clean things to hold and play with.

When children are small you must still wash their hands for them. As they get older, teach children to wash their hands often, especially after using the toilet and before eating or touching food.

Show them how to use soap every time they wash their hands. If you do not have soap, show them how to use sand or ashes. When possible, use clean water to wash hands. See how to treat water with bleach, boiling, or the sun.

a woman talking to a child while the child washes her hands.
Rub your hands together, Ramona, to get the dirt off. After you use the soap, rinse your hands. I have some clean water here for the last rinse.
Teach children how to wash their hands

When to wash hands

  • before preparing food
  • before eating or touching food
  • after using the toilet
  • after cleaning a child’s bottom or handling a nappy (diaper)
  • after handling chemicals of any kind


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Have them rinse their hands with clean, running water, like from a tap or pitcher. If you use the same bowl to wash and rinse hands, you and your children will still have some germs on your hands after rinsing.

Also, try to use clean water for bathing children who have HIV. If you cannot use clean water, try not to let any water get into the child’s mouth.

Avoid germs and worm eggs in food

Many illnesses such as diarrhea, vomiting, and fever are caused by germs. These germs are too small to see with our eyes alone. They can only be seen with a microscope. But germs are all around us. You might know to avoid something like rotten food or feces, even though you cannot see the germs in them. But germs can also be on things that look clean and safe.

How do germs get into us?

a woman cooking and a child playing.
We get germs on our hands when we touch things.
Flies and chickens spread germs onto food and dishes.

A child who is healthy and well fed fights off many illnesses. But weaker or poorly nourished children cannot fight germs or worms well, especially small children with HIV. To protect children from these illnesses:

HIV Ch10 Page 167-2.png Cover food with lids, cloth, or screens to keep flies off.

Keep flies away from food

Flies that land on your food can leave eggs or germs that cause diarrhea illnesses. See Diarrhea, dehydration, and vomiting for how to treat these illnesses.

Keep animals away from food

All animals carry germs. Keep animals out of the house, and away from food and the areas where you prepare and cook food. To keep food away from animals, store it sealed in something they cannot chew through.

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Cook foods well

Raw meats, fish, shellfish, eggs, and milk often contain dangerous germs. These germs can harm anyone, but they are worse for people with HIV. To prevent illness, cook foods fully, so there are no raw parts inside. This kills germs and makes food safe to eat. Wash your hands with clean water before and after handling foods and before eating. See Diarrhea, dehydration, and vomiting for how to treat diarrhea illnesses from uncooked foods.

Wash and peel vegetables and fruit if eating them raw

Fresh fruits and vegetables may have germs or pesticides on their skins. Peel fruits and vegetables before eating them or wash them in water with a little bleach in it.

Juices and unbottled drinks can also carry germs. It is better to make these yourself from foods and water that you know are clean, rather than buy them at markets or roadside stands.

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Washing fruits and vegetables with 1 spoon of bleach in a basin of water will kill any germs on them..

And always wash children’s hands before they eat, and wash your own hands before you touch or prepare food.

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Avoid spoiled foods

Do not eat food that looks or smells bad, or comes from a can that is swollen or squirts when you open it. Before eating leftover cooked foods, heat them again so they get very hot — hot enough to kill germs.

Toilets

HIV Ch10 Page 169-1.png

Feces and urine that are left in the open can spread germs. These germs are especially dangerous for small children and anyone with HIV. Toilets and latrines keep feces away from our water and food, and from the animals, flies, and our own feet that spread germs from feces.

There are toilets to meet the needs of every setting and community. For how to build different kinds of toilets, see A Community Guide to Environmental Health, Chapter 7.

Until a child is big enough to use a toilet, put the child’s feces in a toilet yourself. Show the child where feces go — this prepares him for using the toilet later. Make sure to wash a baby’s bottom after he defecates. And wash your own hands after wiping the baby or handling feces.

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You can keep a special toilet pot in the house for small children. Empty it into a latrine after the child uses it.

Learning to use toilets

Children need toilets they can use and feel safe using. For example, sometimes children are scared of pit toilets because of the large, dark hole. If children can help build a toilet, they may be less afraid.

an older child speaking to a younger child using a latrine.
Good job, Tigist! You are such a big girl using the toilet all by yourself!

Teaching a child to use a toilet happens over many months. Every child is different, but most children are ready to start learning between 18 and 24 months. Here are some signs that show your child may be ready:

HIV Ch10 Page 170-1.png
  • Children point to wet or soiled clothes and ask to be changed.
  • Children stay dry for longer amounts of time, or overnight.
  • Children have words for using the toilet.
  • Children stand and sit well on their own.
  • Children pull their pants up and down without help.


a woman speaking to a sad looking child.
It’s OK, Lin, let’s get you some clean pants.

In the beginning, you will need to clean the child yourself. Then you can help your child clean herself with paper or water. Girls should be taught to wipe themselves from front to back. This will keep germs from being wiped into the vagina and urinary tract where they can cause infections.

It can take as long as 2 years or more for children to learn to use the toilet by themselves. Be patient. It is normal for children to have accidents even after they have learned to use the toilets. Even when children are 4, 5, or 6 years old, they may occasionally have accidents, especially at night. That is normal. Keep encouraging your child.

Children who have lost their parents or moved to a new household may have more accidents than other children their age. Because this means more work, it is understandable to feel upset when this happens. Try not to treat the child angrily.

Get rid of trash

Open piles of trash breed disease. Trash attracts and holds germs, along with rats, flies, cockroaches, and other insects, which carry disease into homes.

To make trash easier to handle, separate it:

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Wet waste can become compost. Sort dry waste into things you can reuse or recycle, as well as trash.

Why throw it away? Make a toy instead!

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  • With rice bags you can teach children letters and numbers.
  • With cans or bottles you can make toy cars or boats — cover anything sharp with strong tape.
  • Children love to get into and out of boxes, or put small things into them, or into other containers.
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  • Put small rocks into a can or jar for a noisemaker.
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HIV Ch10 Page 171-5.png Managing trash is usually easier if the community takes responsibility for it together and does not leave it all up to each household.

To get rid of trash you cannot reuse or recycle, it is safer and better to bury it than to leave it in an open pile. Make sure your trash pit is deep enough to keep animals and bugs away.

Only burn trash as a last resort. Do not burn plastic. Plastic fumes can be toxic.



This page was updated:27 Nov 2019