Flushing loos, clean water and sewers have together been voted the greatest medical advance in more than 150 years.

The British Medical Journal (BMJ) drew up a shortlist of 15 medical breakthroughs made since its launch in 1840.

Sanitation saves lives

Sanitation came top of the poll of more than 11,000 people from across the globe, beating the discovery of antibiotics into second place.

The list also included the launch of the contraceptive pill, and the development of vaccines.

Leading doctors and scientists were chosen to champion each of the breakthroughs.

Professor Johan Mackenbach of Erasmus University Medical Centre, Rotterdam, the Netherlands, who had spoken for sanitation, said he was "delighted it is recognised by so many people as such an important milestone.

The Pill was shortlisted

"The general lesson which still holds is that passive protection against health hazards is often the best way to improve population health."

The original champions of the sanitary revolution were John Snow, who showed that cholera was spread by water, and Edwin Chadwick, who came up with the idea of sewage disposal and piping water into homes.

Inadequate sanitation is still a major problem in the developing world.

In 2001, unsafe water and poor sanitation and hygiene accounted for over 1.5 million deaths from diarrhoeal disease in low and middle-income countries.

The top five:

:: Sanitation
:: Antibiotics
:: Anaesthesia
:: Vaccines
:: DNA structure