INDICATORS FOR WATERBORNE PATHOGENS

Committee on Indicators for Waterborne Pathogens

Board on Life Sciences

Water Science and Technology Board

Division on Earth and Life Studies

NATIONAL RESERACH COUNCIL OF THE NATIONAL ACADEMIES

THE NATIONAL ACADEMIES PRESS
Washington, D.C. www.nap.edu



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Indicators for Waterborne Pathogens INDICATORS FOR WATERBORNE PATHOGENS Committee on Indicators for Waterborne Pathogens Board on Life Sciences Water Science and Technology Board Division on Earth and Life Studies NATIONAL RESERACH COUNCIL OF THE NATIONAL ACADEMIES THE NATIONAL ACADEMIES PRESS Washington, D.C. www.nap.edu

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Indicators for Waterborne Pathogens THE NATIONAL ACADEMIES PRESS 500 Fifth Street, N.W. Washington, DC 20001 NOTICE: The project that is the subject of this report was approved by the Governing Board of the National Research Council, whose members are drawn from the councils of the National Academy of Sciences, the National Academy of Engineering, and the Institute of Medicine. The members of the committee responsible for the report were chosen for their special competences and with regard for appropriate balance. This study was supported by Grant X-82928901 between the National Academies and the United States Environmental Protection Agency. Any opinions, findings, conclusions, or recommendations expressed in this publication are those of the author(s) and do not necessarily reflect the views of the organizations or agencies that provided support for the project. International Standard Book Number 0-309-09122-5 (Book) International Standard Book Number 0-309-52941-7 (PDF) Library of Congress Control Number 2004108875 Cover: The Committee on Indicators for Waterborne Pathogens thanks the following organizations and individuals for use of their images on the cover of this report: City of Wilsonville, Oregon Isle Royale National Park (Michigan), National Park Service, U.S. Department of the Interior Randal Kath, The State University of West Georgia, Carrollton National Center for Infectious Diseases, Centers for Disease Control and Prevention, U.S. Department of Health and Human Services National Institute of Allergy and Infectious Diseases, National Institutes of Health, U.S. Department of Health and Human Services Southern California Coastal Water Research Project Authority, Westminster James Terry, Jr., Concord, Massachusetts Additional copies of this report are available from the National Academies Press, 500 Fifth Street, N.W., Lockbox 285, Washington, DC 20055; (800) 624-6242 or (202) 334-3313 (in the Washington metropolitan area); Internet, http://www.nap.edu. Copyright 2004 by the National Academy of Sciences. All rights reserved. Printed in the United States of America.

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Indicators for Waterborne Pathogens THE NATIONAL ACADEMIES Advisers to the Nation on Science, Engineering, and Medicine The National Academy of Sciences is a private, nonprofit, self-perpetuating society of distinguished scholars engaged in scientific and engineering research, dedicated to the furtherance of science and technology and to their use for the general welfare. Upon the authority of the charter granted to it by the Congress in 1863, the Academy has a mandate that requires it to advise the federal government on scientific and technical matters. Dr. Bruce M. Alberts is president of the National Academy of Sciences. The National Academy of Engineering was established in 1964, under the charter of the National Academy of Sciences, as a parallel organization of outstanding engineers. It is autonomous in its administration and in the selection of its members, sharing with the National Academy of Sciences the responsibility for advising the federal government. The National Academy of Engineering also sponsors engineering programs aimed at meeting national needs, encourages education and research, and recognizes the superior achievements of engineers. Dr. Wm. A. Wulf is president of the National Academy of Engineering. The Institute of Medicine was established in 1970 by the National Academy of Sciences to secure the services of eminent members of appropriate professions in the examination of policy matters pertaining to the health of the public. The Institute acts under the responsibility given to the National Academy of Sciences by its congressional charter to be an adviser to the federal government and, upon its own initiative, to identify issues of medical care, research, and education. Dr. Harvey V. Fineberg is president of the Institute of Medicine. The National Research Council was organized by the National Academy of Sciences in 1916 to associate the broad community of science and technology with the Academy’s purposes of furthering knowledge and advising the federal government. Functioning in accordance with general policies determined by the Academy, the Council has become the principal operating agency of both the National Academy of Sciences and the National Academy of Engineering in providing services to the government, the public, and the scientific and engineering communities. The Council is administered jointly by both Academies and the Institute of Medicine. Dr. Bruce M. Alberts and Dr. Wm. A. Wulf are chair and vice chair, respectively, of the National Research Council. www.national-academies.org

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Indicators for Waterborne Pathogens COMMITTEE ON INDICATORS FOR WATERBORNE PATHOGENS1 MARY JANE OSBORN, Chair, University of Connecticut Health Center, Farmington R. RHODES TRUSSELL, Vice Chair, Trussell Technologies, Inc., Pasadena, California RICARDO DELEON, Metropolitan Water District of Southern California, La Verne DANIEL Y.C. FUNG, Kansas State University, Manhattan CHARLES N. HAAS, Drexel University, Philadelphia, Pennsylvania DEBORAH A. LEVY, Centers for Disease Control and Prevention, Atlanta, Georgia J. VAUN MCARTHUR, University of Georgia, Savannah River Ecology Laboratory, Aiken, South Carolina JOAN B. ROSE, Michigan State University, East Lansing MARK D. SOBSEY, University of North Carolina, Chapel Hill DAVID R. WALT, Tufts University, Boston, Massachusetts STEPHEN B. WEISBERG, Southern California Coastal Water Research Project Authority, Westminster MARYLYNN V. YATES, University of California, Riverside Staff MARK C. GIBSON, Study Director JENNIFER KUZMA, Co-Study Director (until January 2003) SETH H. STRONGIN, Project Assistant 1   The activities of the Committee on Indicators for Waterborne Pathogens were organized and supported by the National Research Council’s Board on Life Sciences (lead) and Water Science and Technology Board. Biographical sketches of committee members are contained in Appendix E and current rosters of the two parent boards are contained in Appendix D.

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Indicators for Waterborne Pathogens WORKSHOP ON INDICATORS FOR WATERBORNE PATHOGENS PARTICIPANTS September 4, 2002 JOHN M. COLFORD, JR., University of California, Berkeley CHRISTOPHER S. CROCKETT, Philadelphia Water Department RAYMOND P. MARIELLA, Lawrence Livermore National Laboratory PETER MARSDEN, Drinking Water Inspectorate of the United Kingdom J. MICHAEL RAMSEY, Oak Ridge National Laboratory GEOFFREY I. SCOTT, National Oceanic and Atmospheric Administration MARK D. SOBSEY, University of North Carolina, Chapel Hill TIMOTHY J. WADE, University of California, Berkeley

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Indicators for Waterborne Pathogens Preface The use of bacterial indicator organisms to signal the possible presence of human pathogens in drinking water began more than a century ago in the United States, at a time when contamination of drinking and source waters by enteric bacterial pathogens, such as the typhoid bacillus, was a major public health threat. In subsequent decades, the use of bacterial indicators, predominantly coliforms, has been expanded to U.S. ambient, recreational, and shellfish waters and continues to focus on identification of fecal contamination, principally of human origin. Although these approaches have been extremely effective in reducing outbreaks of waterborne human disease, significant numbers of such outbreaks are still reported annually, many of unknown etiologic origin, and it is generally agreed that a substantial number of occurrences of waterborne human disease go unrecognized or unreported. Recent advances in understanding the diversity and ecology of waterborne human pathogens as well as the ongoing rapid development of new techniques for detection and identification of waterborne microbes make it timely to reevaluate the standard indicators and indicator approaches employed to determine the microbiological quality of waters used for recreation or as sources of drinking water. Accordingly, the National Research Council (NRC) formed the Committee on Indicators for Waterborne Pathogens in 2002 at the request of the U.S. Environmental Protection Agency (EPA) to report on candidate indicators and/or indicator approaches (including technologies for detection) for assessing contamination of U.S. recreational waters and source water (including groundwater) for drinking water. The original charge to the committee excluded coastal marine and marine-estuarine waters, but these were added after subsequent discussion

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Indicators for Waterborne Pathogens with EPA, and it was agreed that the study would then give less emphasis to some other aspects of the charge as described in Chapter 1. For example, the committee did not explicitly address indicators of water treatment performance. Furthermore, the report does not specifically address the threat of bioterrorism or the protection of vulnerable subpopulations such as infants and immunocompromised persons regarding microbial water quality. To address its charge, the Committee on Indicators for Waterborne Pathogens met four times, starting in April 2002. The committee quickly concluded that it is not possible to identify a single, unique indicator or even a small set of indicators that is capable of identifying all classes of waterborne pathogens of public health concern for all applications and water media. Rather, priority should be given to the development of a phased monitoring approach for assessing microbial water quality that relies on a flexible “tool box” containing a spectrum of indicators and indicator approaches (to include direct monitoring of pathogens) that can be matched according to specific circumstances and needs. Thus, the committee did not conduct a comprehensive evaluation of candidate indicators or specific pathogens per se. The committee would like to thank the many experts who contributed to this report by participating and/or speaking at committee meetings, including Rita Schoeny, Betsy Southerland, Ephraim King, Alfred Dufour, and Rebecca Calderon, EPA; and Roger Fujioka, University of Hawaii. The committee also sponsored a one-day public workshop on candidate indicators and indicator approaches for waterborne pathogens on September 4, 2002, in Washington, D.C. This workshop provided insight on a wide variety of subjects related to the committee’s charge, ranging from epidemiology to emerging detection technologies. The names and affiliations of the workshop presenters are listed in the front of this report. This report has been reviewed in draft form by individuals chosen for their diverse perspectives and technical expertise, in accordance with procedures approved by the NRC’s Report Review Committee. The purpose of this independent review is to provide candid and critical comments that will assist the NRC in making its published report as sound as possible and to ensure that the report meets institutional standards for objectivity, evidence, and responsiveness to the study charge. The review comments and draft manuscript remain confidential to protect the integrity of the deliberative process. We thank the following individuals for their review of this report: Jennifer Clancy, Clancy Environmental Consultants, Inc.; James Crook, Consultant; Mark Gold, Heal the Bay; Robert Haselkorn, University of Chicago; Mark LeChevallier, American Water; Laura Leff, Kent State University; Daniel Lim, University of South Florida; Christine Moe, Emory University; Erik Olson, Natural Resources Defense Council; David Relman, Stanford University; and Gary Toranzos, University of Puerto Rico. Although the reviewers above have provided many constructive comments and suggestions, they were not asked to endorse the conclusions or recommenda-

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Indicators for Waterborne Pathogens tions nor did they see the final draft of the report before its release. The review of this report was overseen by Edward Bouwer, Johns Hopkins University. Appointed by the NRC, he was responsible for making certain that an independent examination of this report was carried out in accordance with institutional procedures and that all review comments were carefully considered. Responsibility for the final content of this report rests entirely with the authoring committee and the NRC. This report would not have been possible without the hard work and dedication of Mark Gibson, study director and staff officer for the NRC’s Water Science and Technology Board. The committee would like to thank project assistant Seth Strongin from the Board on Life Sciences (BLS) for logistical support throughout the study. We would also like to thank former co-study director Jennifer Kuzma and research associate Laura Holliday of the BLS for their early contributions to this report. Finally, I would like to thank the 12 members of this committee for bringing this report together. Their diverse backgrounds and perspectives provided for lively and insightful discussions throughout the course of the entire study. Mary Jane Osborn, Chair

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Indicators for Waterborne Pathogens Contents     EXECUTIVE SUMMARY   1 1   INTRODUCTION AND HISTORICAL BACKGROUND,   17      Introduction,   17      Reports on Public Health Impacts of, and Indicators for, Waterborne Pathogens,   29      Historical Background,   30      Current Status of Waterborne Outbreaks and Endemic Disease,   38      Current Indicators for Waterborne Pathogens,   44      Summary and Conclusions,   46      References,   47 2   HEALTH EFFECTS ASSESSMENT   53      Introduction,   53      Surveillance and Epidemiologic Study Designs,   57      Historical Review and Current Status of Health Effects Assessment,   62      Quantitative Microbial Risk Assessment,   89      Summary: Conclusions and Recommendations,   98      References,   101 3   ECOLOGY AND EVOLUTION OF WATERBORNE PATHOGENS AND INDICATOR ORGANISMS   109      Introduction,   109      Viruses,   115

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Indicators for Waterborne Pathogens      Bacteria,   124      Protozoan Parasites,   135      Yeasts and Molds,   149      Summary: Conclusions and Recommendations,   151      References,   153 4   ATTRIBUTES AND APPLICATION OF INDICATORS   164      Introduction,   164      Indicator Attributes,   164      Indicator Applications,   170      Summary: Conclusions and Recommendations,   187      References,   190 5   NEW BIOLOGICAL MEASUREMENT OPPORTUNITIES   196      Introduction,   196      Issues in Sampling and Analysis,   205      Assessment of Methods and Their Attributes,   211      Standardization and Validation of Methods,   219      Challenges and Pitfalls of New Technology,   231      Look to the Future,   233      Summary: Conclusions and Recommendations,   235      References,   239 6   A PHASED APPROACH TO MONITORING MICROBIAL WATER QUALITY   243      Introduction,   243      Phased Monitoring Approach,   244      Application to Marine Beaches,   248      Application to Surface Drinking Water Sources,   252      Application to Groundwater Sources of Drinking Water,   257      Impediments and Drivers to Implementation,   261      Summary: Conclusions and Recommendations,   262      References,   264     APPENDIXES     A   Emerging and Reemerging Waterborne Pathogens,   267 B   Review of Previous Reports,   273 C   Detection Technologies,   287 D   National Research Council Board Membership and Staff,   308 E   Committee Biographical Information,   311