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\begin{document}

\title{The era of ``multi-demic'' and potable use of Roof harvested rainwater
(RHRW), is it safe?: a letter to the editor from Pakistan}



\author[1]{Amna Siddiqui}%
\author[1]{Anood Choudhary}%
\author[1]{Aliza Ayaz}%
\affil[1]{Karachi Medical and Dental College}%


\vspace{-1em}



  
  \date{June 14, 2024}


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\selectlanguage{english}
\begin{abstract}
Pakistan is one of the 36 water-stressed countries, with less than 1000
cubic per person annual water availability. Factors like global warming,
urbanization, and irrigation for agribusiness have come into play in
skyrocketing the need for water globally. As a low-middle income
country, inhabitants of Pakistan are actively moving toward resolving
the water crisis through rainwater harvesting during the monsoon period.
Though the practice is simple, feasible, and cost-effective, there are
certain health risks associated with it. Due to its virological and
microbial quality, rainwater is highly contraindicated for potable use
without proper treatment. Pathogens like Campylobacter jejuni,
Salmonella spp., Giardia lamblia, hepatitis A virus, rotaviruses, etc,
and fecal matter of animals like birds, mammals, and reptiles,
contaminate the roof harvested rainwater (RHRW) and result in diseases
such as Human enteritis, Acute diarrheal disease, Giardiasis, among many
others. Apart from this, the sporadic multi-demics of dengue, malaria,
and cholera being directly or indirectly related to the monsoon period
impose a burden on Pakistan's public health sector and improper Rooftop
Rainwater Harvesting (RTRWH) adds to the stress. It is now imperative
that doctors and public health officials join hands to counsel the
public on individual and national levels to contain the recurring
outbreaks of these diseases associated with the monsoon period.
Procedures of RHRW treatment such as ultra-membrane filtration, UV
treatment, safe roofing material, and first-flush diversion devices
should be strategically promoted through awareness campaigns. Our
article discusses the limitations for potable use of RHRW in this era of
multi-demic and suggests strategies to retrieve favorable outcomes to
cater to the water scarcity through RTRWH in the state effectively.%
\end{abstract}%



\sloppy


\textbf{Title: The era of ''multi-demic'' and potable use of Roof
harvested rainwater (RHRW), is it safe?: a letter to the editor from
Pakistan}

\textbf{Author Sequence:} Anood Choudhary\textsuperscript{1}, Aliza
Ayaz\textsuperscript{2}, Amna Siddiqui\textsuperscript{3*}

\textbf{Author details:}

\begin{enumerate}
\tightlist
\item
  Name: Anood Choudhary Affiliation: Karachi Medical and Dental College,
  Karachi, Pakistan, 74700, Department of MBBS Email:
  anoodch30@gmail.com ORCID; 0000-0001-9094-8214
\item
  Name: Aliza Ayaz Affiliation: Karachi Medical and Dental College,
  Karachi, Pakistan, 74700, Department of MBBS Email:
  aliza.ayaz.edu@gmail.com ORCID; 0000-0002-0076-6378
\item
  Name: Amna Siddiqui Affiliation: Karachi Medical and Dental College,
  Karachi, Pakistan, 74700, Department of MBBS Email:
  siddiquie.amna@gmail.com ORCID; 0000-0001-9372-0362
\end{enumerate}

*Corresponding author

\textbf{Abstract:}

Pakistan is one of the 36 water-stressed countries, with less than 1000
cubic per person annual water availability. Factors like global warming,
urbanization, and irrigation for agribusiness have come into play in
skyrocketing the need for water globally. As a low-middle income
country, inhabitants of Pakistan are actively moving toward resolving
the water crisis through rainwater harvesting during the monsoon period.
Though the practice is simple, feasible, and cost-effective, there are
certain health risks associated with it. Due to its virological and
microbial quality, rainwater is highly contraindicated for potable use
without proper treatment. Pathogens like Campylobacter jejuni,
Salmonella spp., Giardia lamblia, hepatitis A virus, rotaviruses, etc,
and fecal matter of animals like birds, mammals, and reptiles,
contaminate the roof harvested rainwater (RHRW) and result in diseases
such as Human enteritis, Acute diarrheal disease, Giardiasis, among many
others. Apart from this, the sporadic multi-demics of dengue, malaria,
and cholera being directly or indirectly related to the monsoon period
impose a burden on Pakistan's public health sector and improper Rooftop
Rainwater Harvesting (RTRWH) adds to the stress. It is now imperative
that doctors and public health officials join hands to counsel the
public on individual and national levels to contain the recurring
outbreaks of these diseases associated with the monsoon period.
Procedures of RHRW treatment such as ultra-membrane filtration, UV
treatment, safe roofing material, and first-flush diversion devices
should be strategically promoted through awareness campaigns. Our
article discusses the limitations for potable use of RHRW in this era of
multi-demic and suggests strategies to retrieve favorable outcomes to
cater to the water scarcity through RTRWH in the state effectively.

\textbf{Keywords;} Multidemic, Water scarcity, Roof Harvested Rainwater
(RHRW), Monsoon, South Asia, Summer Monsoon, LMIC, Pakistan, Tropical
diseases, Climate change.

Dear Editor,

Increasing demand for water due to high population size, rapid
industrialization, climate change, and expanding agriculture has
produced a scarcity of water globally. Pakistan is one of the 36
water-stressed countries. Followed by the annual water availability
being less than 1000 cubic per person, it is currently categorized as a
water-scarce country, bearing potential of becoming absolutely
water-scarce by year 2025 if the availability reduces down to 500 cubic
per person (1). Further, it is a low-middle income country, with a
predominant agriculture-based economy, thus growing scarcity of water
has prompted the general community to move towards the practice of
different strategies for water conservation to supplement the
conventional sources of water supply at both domestic and commercial
levels (2). Therefore, considering eight-tenths~of the annual
rainfall~in the country that occurs during the South Asian Summer
Monsoon period, rainwater harvesting, if implemented properly, is one of
the best solutions to tackle the water crisis of the country (3).
Rooftop Rainwater Harvesting (RTRWH) being one of the methods for
rainwater harvesting, is a simple, sustainable, and an economical
approach for conserving, and utilising the rainwater for potable and
non-potable uses (2). However, evidence from a few epidemiological
studies contradicts the~ safety of the roof-harvested rainwater (RHRW)
for potable use as there lies a potential human health risk, because of
the microbial and virological quality of this RHRW and the risks of its
faecal contamination. Hence, our letter discusses limitations for
potable use of RHRW in this era of multi-demic and suggests strategies
to retrieve favourable outcomes to cater the water scarcity through
RTRWH in the state effectively.

Rainwater itself is contaminated with various pathogenic bacteria i.e.,
Campylobacter spp., Salmonella spp., Citrobacter spp., and E. coli (4).
Further, the excreta of birds, mammals, and reptiles that have easy
access to the roofs may contain pathogens i.e., Campylobacter jejuni,
Legionella pneumophila, Salmonella spp., Giardia lamblia, and
Cryptosporidium parvum. Thus, could also contaminate the rainwater by
washing off into the rainwater tanks or simply because of transport of
faecal matter into the said tank, following rain events (5).
Subsequently, these pathogens could cause diseases like i.e., Human
enteritis, Legionnaires' disease, Acute diarrheal disease, Giardiasis,
and Cryptosporidiosis respectively, ensuing to be a significant threat
to those who use this RHRW, especially in the elderly and
immunocompromised cohorts. Notably, studies by Prado T, et al and Shubo
T, et al consolidate the occurrence of viruses like Hepatitis A virus,
Human Klasse virus 1, Human adenovirus, noroviruses, and rotaviruses in
samples of roof harvested rainwater from various rainfall events (6, 7).
The following disease outbreaks due to these pathogens, in addition to
the on and off endemics of dengue, malaria, cholera, and several other
water-borne diseases, that are directly or indirectly linked to the
heavy precipitation in the monsoon season add to the burden on the
public healthcare system of the country (8).

Keeping this pathogen-associated risk in mind, we suggest that proper
precautions should be taken during the utilization of RHRW. The
pathogen-associated risk could be tackled by procedures like filtration
of RHRW followed by disinfection by UV treatment, ozone disinfection, or
ultra-membrane filtration (9). In addition to that, the selection of
safe roofing material and the use of first-flush diversion devices
should be considered to improve the physio-chemical properties of the
roof-harvested rainwater (10). Risks could also be reduced simply by
improving the sanitary conditions of the residences and the surrounding
environments, along with maintenance of good roof hygiene which would
help in lessening the contamination of the accumulated rainwater on the
roof (9). The removal of overhanging tree branches and other such
structures to prevent the flocking of birds could further aid in
alleviating the risks of potential faecal contamination of the RHRW (9).
Lastly,~conducting public awareness campaigns and ensuring proper
awareness regarding the risks and treatment procedures before the
installation of RRWH systems can prove to be a comprehensive approach to
the matter at hand.

\textbf{Ethics approval and consent to participate:} None to declare.

\textbf{Consent for publication:} None to declare.

\textbf{Availability of data and materials:} None to declare.

\textbf{Competing interests:} None to declare.

\textbf{Funding:} None to declare.

\textbf{Authors' contributions:} Conceptualisation and Writing Original
draft: Anood Choudhary \& Aliza Ayaz. Reviewing and editing final draft:
Amna Siddiqui.

\textbf{Acknowledgements:} None to declare.

\textbf{References} :

\begin{enumerate}
\tightlist
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\item
  Ahmed A, Mustafa U, Nasir M.\emph{Impact of Rooftop Rain Water
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\end{enumerate}

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