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Karbala International Journal of Modern Science 4 (2018) 369e376
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Research Article
Epidemiological study evaluating the impact of front door duct slot
of a combined domestic sewererainwater drainage system on
children health in Kirkuk, 2017
Asal A. Tawfeeq a,*, Saif Al-Deen M. Taher b
a
Medical Laboratory Techniques Department, Technical College of Kirkuk, Northern Technical University, Kirkuk, Iraq
b
Engineering Unit, Technical College of Kirkuk, Northern Technical University, Kirkuk, Iraq
Received 9 February 2018; revised 11 September 2018; accepted 11 September 2018
Available online 15 October 2018

Abstracts

Total of eight districts within Kirkuk city were selected for investigating the effect of combined sewererainwater streams on
children health during the period from August 2017 to the end of January 2018. Selected districts were sub-divided into two study
cohorts (A and B) according to their sewer drainage systems and the total of (160) children living at the study cohorts at the age of
(1e5) years were volunteered as the study population and were monitored for infections by subjecting them to a specific ques-
tionnaire. Analysis of the results obtained after six months of surveillance showed a significant increase (p < 0.05) in disease
incidence among the children of cohort-A in recording (1482) infection cases compared to only (593) infection cases were recorded
amongst children of cohort-B. On the other hand, a significant increase (p < 0.05) in disease incidence was noticed in the two study
cohorts (A and B) during hot seasons with a significant increase (p < 0.05) in the disease incidence shown by children of cohort-A
compared to the recorded infection cases in cohort-B. As a consequence, a number of air samples were taken from different lo-
cations and distances above the front door duct slots of the study cohort-A regions and were subjected to a number of microbi-
ological assays where results of Gram's staining indicated the isolation of different bacterial strains mainly of the
Enterobacteriaceae strains. Further microbiological diagnosis of the isolates revealed the dominance of Escherichia coli and
Pseudomonas aeruginosa strains within the isolates. Besides, the significant decrease in rainfall and the accumulation of solid
wastes in the streams all together had possibly increased the emission of pathogenic bacteria within sewer gases discharged through
the front door rainwater duct slots which probably led to the increase in diseases incidence recorded among children of the study
cohort-A.
© 2018 The Authors. Production and hosting by Elsevier B.V. on behalf of University of Kerbala. This is an open access article
under the CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/).

Keywords: Epidemiological study; Combined sewererainwater systems; Domestic sewer; Children health; Kirkuk 2017

1. Introduction

The presence of drains in the streets was known since

the early Mesopotamian Empire in Iraq (ca. 4000e2500
* Corresponding author.
E-mail address: dr.asal1977@gmail.com (A.A. Tawfeeq). BC) [1]. While, systematic construction of pipelines and
Peer review under responsibility of University of Kerbala. ducts began at the end of the 19th century in Romania, in

https://doi.org/10.1016/j.kijoms.2018.09.003
2405-609X/© 2018 The Authors. Production and hosting by Elsevier B.V. on behalf of University of Kerbala. This is an open access article under
the CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/).
370 A.A. Tawfeeq, S.A.-D.M. Taher / Karbala International Journal of Modern Science 4 (2018) 369e376

a number of cities where they built water supply systems Table 1

and sewage networks where after the year 1910, they had Materials used in the study.
started building wastewater treatment plants [2]. Then, Materials Company Country
many communities in different counties have separated Autoclave Sakura Japan
their sewer systems for wastewater collection from the API® 20 E Kit BIOMERIUX USA
rainwater streams [3,4]. In Iraq, sewer collection and Culture media Himedia India
Disposable Petri dishes Himedia India
treatment facilities were only available in a few large Gram's Stain Kit Himedia India
cities and coverage was substantially lower than potable Incubator Memmert Germany
where it served only about 8 percent of the population [5]. Light microscope Optika Italy
Moreover, after the year 1991, Health and sanitary sectors pH- meter Sartorius Germany
in Iraq had declined considerably due to aging infra- Refrigerator Beko Turkey
Safety cabinet Daihan Labtech. Korea
structure, poorly maintained equipment, leaking water Sensitive balance Sartorius Germany
and sewer networks [5e7]. Therefore, Iraq's National
Development Strategy placed water supply and sanitation
at the top of the government's priorities, starting with (1e5) years old, living within the selected eight districts and
rehabilitation of the existing sewerage networks [5,6]. were similar in (weight, personal hygiene, drinking water
Besides, in Kirkuk city, a project was proposed during supply, food hygiene and living conditions). They were
different in sanitation systems of sewer drainage in their houses
2012 in certain districts which was designed to replace
only. Children were subjected to a questionnaire specifically
the old sewerage and to construct a number of rainwater
designed for this study (mentioned in Section 2.2.1.3) during
networks [6]. However, since the majority of water and the period from August 2017 until the end of January 2018.
sewage projects in Iraq have been awarded to private
construction and contracting companies; thus, certain 2.2.1.2. Selection of indicators of exposure. Study districts
regions in Kirkuk city had overpassed the newly con- were sub-divided into two study cohorts as shown in Table 2
structed rainwater networks and used them for the according to their sewage drainage systems where each
drainage of domestic sewer [8]. Alongside, a number of cohort involved four regions as follows:
earlier studies had recorded an increase in many infec-
tious diseases in Iraq generally and Kirkuk city specif-
Study Cohort “A” (n ¼ 4); included those regions uti-
ically in last few years which remain major cause of lizing rainwater streams for the drainage of houses
morbidity and mortality among children [9,10]. sewage with front door duct slot.
Therefore, this study was suggested in order to
Study Cohort “B” (n ¼ 4); included those regions
draining their sewage directly into sewer system (local or
inspect the epidemiological prevalence of diseases
general).
among children living in regions with different sewer
drainage systems and to evaluate the impact of dis-
charging domestic sewer within rainwater streams on 2.2.1.3. Collection of the study data. All of the study chil-
the health of children living nearby the duct slots of the dren were subjected to a questionnaire specifically designed
combined drainage system of their houses. for this study with the following questions: Date, Name, Age,
Gender, Residence, Presence of “rainwater duct slot” in front
of the house, Type of infection, Frequency of infections.
2. Materials and methods
Children were monitored during the extended
2.1. Materials period from August 2017 to the end of January 2018
and results were analyzed at the individual level and
Materials used throughout the study are all sum- were represented in tables and figures.
marized in Table 1.
Table 2
2.2. Methods Kirkuk city regions involved in the study sub-divided into cohorts and
the total number of children being monitored according to the study.
2.2.1. The study protocol Study cohort-A Child/house Study cohort-B Child/house
Methods mentioned in the study protocol were 1st of March (Athar) 20 Almas 20
following the techniques cited in Ref. [11] as follows. Al Wasty 20 Arafa 20
1st of June (Huzairan) 20 Bagdad Road 20
2.2.1.1. Selection of the study population. Total of (160) Al Qadissiya 20 Raheem Awa 20
Total 80 Total 80
children were volunteered in this study ranging in age between
 A.A. Tawfeeq, S.A.-D.M. Taher / Karbala International Journal of Modern Science 4 (2018) 369e376
2.2.2. Measurements of exposure and disease status
2.2.2.1. Preparation of culture media. Three types of culture
media (Nutrient agar, MacConkey and blood agar) were all
used for the collection of air samples during the study and
were prepared according to the instructions supplied by the
manufacturing company (Himedia/India), spread onto petri
dishes and were incubated at 37  C overnight before sample
collection.
2.2.2.2. Sample collection
1. Total of (240) air samples were collected from the study
cohort-A regions considering different heights of (5 cm,
30 cm, 1 m) from the area above the rainwater duct slot
and were cultivated directly onto the agar plates with
different types of culture media.
2. Cultivated plates were transported immediately to the
laboratory where they were incubated at 37  C for 24 h.
3. Next day, cultured plates were examined for any growth
and results were recorded.
4. Bacterial colonies grown on culture plates were further
examined by Gram's staining.
5. The same procedure was repeated with (100) air samples
collected from the regions of study cohort-B at different
locations.
6. Results were recorded in tables and were compared.
2.2.2.3. Gram's staining. This procedure was followed after
the protocol supplied by the manufacturing company Kit
(Himedia/India) and results were recorded after slide exami-
nation under a 100 objective of a light microscope where the
bacterial isolates that were stained with deep violet to blue
were considered as Gram-positive and the bacterial isolates
which stained with pink to red were considered as Gram-
negative bacteria. Then, slides were photographed.
2.2.2.4. Analytical profile index system for identification of
Enterobacteriaceae using (API 20 E kit). This procedure was
followed according to the methodology supplied by the
manufacturing company (API® 20 E Kit/BIOMERIUX/USA)
and strips were recorded by referring to “Reading Table”
where strains were identified with the numerical profile [12].
2.2.3. Analysis of the relationship between exposure and
disease incidence
This procedure was implemented specifically for
this investigation as follows: -
1. The basic measures of disease incidence rate in each pop-
ulation were described through the estimation of the (the
number of new cases of disease per unit of person-time).
2. The differences between the two study cohorts (A and B)
in the disease incidence rate were measured in order to
estimate the magnitude of an association between
exposure and disease.
371
3. An association was proposed between the likelihood of
developing the disease in the study cohort-A in relative
to the given data.
4. Results were plotted in figures and tables after statistical
analysis.
2.2.4. Statistical analysis
Data from the study were analyzed using T-test by
using SPSS program Ver.10 for Windows. A p value of
<0.05 was considered indicative of a statistically sig-
nificant difference.
3. Results and discussion
Domestic sewer management was always considered
as an efficacious element in consolidating a healthy
society through the creation of the suitable environment
for sewer drainage [13]. Therefore, Kirkuk Sewer
Directionate had conducted a project in 2012 to resolve
the problems of lack and aging sewer systems in the city
where in the 2013 this project was awarded by the
Kirkuk Government to (PALKANA Company for
Construction) in order to construct (The Wasty Rain-
water System) [14]. But, the absence of new projects for
wastewater treatment since 1986 in most of Kirkuk
province had led many regions in Kirkuk city to illegally
combine their domestic sewer drainage alongside with
the rainwater network of their districts [6]. Conse-
quently, an increased burden of infections and diseases
among small children and infants was observed in those
districts which combined their drainage in the last few
years [10,15,16]; leading probably to the conviction
that, combining domestic sewererainwater streams
might distress the health of children living nearby. Thus,
this study was suggested aimed to address that convic-
tion through the following objectives.
3.1. Selection of the study population
Eight different districts in Kirkuk city were selected
according to the utilized sewer system and were
divided into two cohorts (A and B); where all of the
houses in the study cohort-A investigated had a rain-
water duct slot in the front of the houses resembled in
Fig. 1. However, many families living in cohort-A re-
gions had refused to cooperate due to their illegal
bypassing on the rainwater network.
3.2. Selection of exposure indicator
As a result, only twenty children from each region
of the two cohorts were volunteered as they matched
372 A.A. Tawfeeq, S.A.-D.M. Taher / Karbala International Journal of Modern Science 4 (2018) 369e376
Fig. 1. A house in the 1st of March (Athar) region in Kirkuk city
with combined SewereRainwater drainage stream showing a front
door rainwater duct slot as the red arrow shows.
the criteria of a questionnaire specifically designed for
this study. Each child from each group was monitored
for the incidence of infections during the period of the
study and results are shown in Table 3.
Careful examination of this table, showed a signif-
icant increase (p < 0.05) in disease incidence in about
(889) infection cases among study cohort-A children
during six months of the study compared with the
disease incidence recorded among the study cohort-B
children. In other words, results revealed that, chil-
dren living in regions from the study cohort-A had
manifested sickness for about three times per month in
comparison to the children from the study cohort-B
regions where they had recorded a single infection
per month during the period of the study.
Besides, most of the infectious cases manifested by
the study cohort-A children included sever cases of
diarrhea, urinary tract infection, scabies and whooping
cough where regions of (1st of June e Huzairan and Al
Wasty) which had demonstrated the highest recurrence
of these diseases followed by (1st of March e Athar
and Al Qadissiya) regions where all of the houses
investigated processed a front door duct slot of com-
bined rainwateresewer drainage resembled in Fig. 3.
The obtained results however, came in agreement
with the remarks of Refs. [7,15,16] were they had
pointed out that, the unhygienic sanitary practices in
certain Iraqi regions led to the alarming increase in the
water-borne diseases especially among infants and
children under five years old.
Furthermore, another comparison was also executed
which included disease prevalence according to
different seasons in the regions of the study and results
are displayed in Fig. 2.
Table 3
Diseases incidence per child according to the comparison between
children of study cohort-A and study cohort-B in Kirkuk city during
the period of the study.
Study cohort “A” Disease Study Disease
incidence/child cohort “B” incidence/child
1st of March 367 Almas 120
(Athar)
Al Wasty 388 Arafa 125
1st of June 402 Bagdad Road 231
(Huzairan)
Al Qadissiya 325 Raheem Awa 117
Total 1482 Total 593
It was noticed in the above figure, a significant in-
crease (p < 0.05) in diseases incidence during summer
and autumn seasons while, a non-statistically signifi-
cant decrease (p > 0.05) was recorded in the beginning
of winter in the regions of the two study cohorts with
the reference to the increased causalities among the
children in cohort-A regions. The same results were
obtained by Refs. [15,16] where they declared a sea-
sonal distribution of infections in Kirkuk city within
the years 2009e2016 including different parasitic,
bacterial and fungal infections that increased in sum-
mer and autumn whilst a slight decrease was encoun-
tered in winter.
The most probable explanation of disease incidence
increase might be probably due to the emission of
sewer gas from the rainwater duct slot (Fig. 3) con-
taining pathogenic microorganisms as Refs. [13,17]
had indicated that, domestic wastewater could in-
crease the environmental problems by increasing the
pollution of rivers and groundwater. However, there
were no previous studies carried out in Kirkuk city for
the evaluation of the impact of the combined domestic
sewer erainwater duct slot neither on health nor on the
environment.
3.3. Measurement of exposure
In order to proof the postulation that, the combined
domestic sewererainwater duct slot in front of houses
had gas emissions included pathogenic microorgan-
isms. The total of (240) air samples were taken from
three different distances within cohort-A regions as
shown in Fig. 3 and were immediately cultivated on a
culture media.
Likewise, air samples were also collected from
cohort-B regions and as a result, the total of (340) air
samples were examined for bacterial growth where air
samples collected from eighty rainwater duct slots from
 A.A. Tawfeeq, S.A.-D.M. Taher / Karbala International Journal of Modern Science 4 (2018) 369e376
Fig. 2. Diseases prevalence according to seasons in comparison with the study cohorts-A and B Kirkuk city during the period of the study; where;
red columns refer to the study cohort-A and blue columns refer to the study cohort-B.
different locations within the study cohort-A regions
were positive for mixed bacterial colonies whilst few
separated colonies on culture media and Fig. 4 showed
the results obtained from air samples cultivation on
different media.
Isolated bacterial colonies were examined micro-
scopically and results are shown in Fig. 5.
Most of the isolated bacterial colonies were Gram's
negative Enterobacteriaceae. Thus, they were further
investigated by subjecting them to the (Analytical
Profile Index System for Identification of Enterobac-
teriaceae using API 20 E Kit) where most of the col-
onies were identified as strains of Escherichia coli and
Pseudomonas aeruginosa as shown in Fig. 6.
However, these results came in agreement with the
results obtained by the researches of Refs. [5,13,16]
where they declared that, about 40% of children
attending health centers suffered from gastrointestinal
infections where bad sanitary conditions had the re-
sponsibility of 25% of death cases in Iraq.
Fig. 3. Front door duct slot where samples were taken from three
locations for each sample (5 cm, 30 cm and 1 m) above the duct slot
within the study cohort-A in Kirkuk city during the period of the
study.
373
3.4. Analysis of the relationship between exposure
and disease
Isolation and diagnosis of pathogenic bacterial
strains from most of air samples collected from cohort-
A regions probably indicated sever contamination of
the air surrounding the front door duct slots. However,
one of the most probable explanation was the elevated
gas emission from the rainwater duct slots overloaded
with pathogenic bacteria. Though, the increase in gas
emission through duct slots might be due to several
reasons.
First: the differences in pipe materials, diameter,
depth and slope between pipelines used for rainwater
drainage and the domestic sewer drainage systems
[18]. However, a more detailed explanation declared in
Table 4.
The attentive examination of this table showed
many differences in the design details between rain-
water and sewer pipelines which included differences
in the pipe material; where materials such as (plastic or
polyvinyl chloride (PVC)) is used as rainwater pipe-
lines. While, sewer pipelines were mainly made from
(Ferrous or ductile concrete) in order to maintain the
flow of heavy water [19].
On the other hand, the difference in the approximate
depth between both of the pipelines (e.g. 1e2.5 m for
rainwater pipes and at least 3 m for the sewer pipes
encountered in Table 4) also had added another burden on
the capacity of the rainwater pipelines where those pipes
are always subjected to traffic bearing loads and proper
embedment gives them strength in performance [20].
Moreover, slope variation among the two types of
pipelines encountered in Table 4 the slope of rainwater
pipelines beer maximum flow velocity of (0.7 m/s),
374 A.A. Tawfeeq, S.A.-D.M. Taher / Karbala International Journal of Modern Science 4 (2018) 369e376
Fig. 4. Examples of bacterial colonies grown on different culture media from atmosphere samples taken from front door duct slot of study cohort-
A regions under investigation in Kirkuk city.
Fig. 5. Gram's staining of a bacterial culture grown on MacConkey
agar at 37  C for 24 h showing Gram's negative rods examined under
(100) of a light microscope for an air sample taken from (1 m)
distance above a front door duct slot of combined domestic sew-
ererainwater network in Kirkuk city.
whereas, sewer pipelines were designed to beer over
(0.9 m/s) in order to prevent solid accumulation
[19e21].
Thus, the drainage of sewer water using the rain-
water streams had led to the accumulation of solid
debris and clogging the pipes which eventually caused
streets to fall as remarked in Fig. 7.
Fig. 6. Examples of Bacterial colonies grown on different culture media from atmosphere samples taken from front door duct slot of cohort-A
regions under investigation in Kirkuk city.
Second: the second factor that probably stands
behind the increase in gas emission from the rainwater
duct slots was the significant decrease of rainfall in
Kirkuk city during the last couple of years as the re-
ports of (The Iraqi Meteorological Organization and
Seismology of Kirkuk province) had declared [6]. This
decrease had led to the accumulation of solid waste in
the rainwater pipes alongside with the elevated tem-
perature (over 60  C) during summer season had all
increased the evaporation rate inside the pipes which
was probably the reason behind the foul smell emitted
from the rainwater duct slots mentioned by the citizens
of the study cohort-A.
However, these explanations came in agreement
with the results of Refs. [15,16] in conjunction with the
results obtained previously in this study and presented
in Fig. 2 where a significant increase in disease prev-
alence was encountered in cohort-A regions in the hot
seasons.
On the other hand, other same reports had shown
that, most of the gastrointestinal cases of children
admitted to hospitals occur during heavy rainfalls
whilst the combined sewererainwater systems can
 A.A. Tawfeeq, S.A.-D.M. Taher / Karbala International Journal of Modern Science 4 (2018) 369e376
Table 4
Design details of sewerage and rainwater pipes utilized in Kirkuk city.
Drainage Pipe Pipe
system material diameter (mm)
Rainwater PVC plastic 300
Sewerage Ferrous 300e1200
Ductile
Concrete
Source: Kirkuk Sewer Directionate 2015.
Fig. 7. Street falls in rainwater stream in one of the areas under study.
become overloaded, and water utilities discharge the
excess sewer overflows suggesting that, the rainwater
duct slot might probably have been a source for
infection with pathogenic bacteria [22e24].
The same differences were also pointed out by Refs.
[25,26] where the sewerage system in Sulaimania city
was also classified under the combined type that
collected two types of run-offs (domestic sewer and
rainwater) with the same design problem.
No previous study was encountered in this context
which concerned in studying the epidemiological ef-
fect of combining sewer and rainwater streams not in
Kirkuk city and neither in Iraq.
4. Conclusions
Results of this epidemiological study showed that,
regions which are illegally combining their domestic
sewer with rainwater in the same drainage would
encounter a significant increase in disease incidence
among their children especially in the regions with
front door duct slot where diseases were prevalent
during hot seasons. Besides, combined domestic sew-
ererainwater network duct slots showed gas emission
contained pathogenic bacteria led to the increase in
children chances of illness. In addition, drainage of
375
Approximate Slope Flow velocity (m/s)
depth (m)
1e2.5 2e3 cm/pipe 0.7
Depending on the design
3 Minimum slopes for pipes 0.4e0.9
(3e4 cm/m) length depending
on pipe material
domestic sewer into rainwater streams had increased
the presence of floating debris which led to the
impairment of the transferring pipes and eventually to
street fall.
5. Recommendations
1. It is important that the Directorate of municipality
to develop a realistic strategic plan and feasibility
studies for projects to be implemented in order to
reduce gaps in service standards, leading to better
services in order to save the drain for rain.
2. More researches are needed in this context to face
environmental pollution sources in order to
decrease the financial burdens for communities due
to cleanup expenses and emergency repairs.
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