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Global Issues in Water, Sanitation, and Health: Workshop Summary 3 Vulnerable Infrastructure and Waterborne Disease Risk OVERVIEW This chapter highlights an assortment of vulnerabilities in water and sanitation infrastructure and the various means used to assess their potential consequences on scales ranging from local to global. The first paper, by workshop speaker Michael Beach and coauthors from the Centers for Disease Control and Prevention’s (CDC’s) National Center for Zoonotic, Vector-Borne, and Enteric Diseases, demonstrates that the United States, despite its relatively light burden of waterborne disease, is home to a deteriorating public drinking water distribution system, increasing numbers of unregulated private water systems, and a limited, passive waterborne disease surveillance system. Beach and colleagues discuss major national trends in waterborne disease dynamics as detected by the CDC’s Waterborne Disease Outbreak Surveillance System (WBDOSS) and identify emerging needs in waterborne disease prevention and control, which include a deeper understanding of the ecology of waterborne disease as it pertains to drinking water distribution systems, safe water reuse programs, and an estimate of the burden of waterborne disease in toto to advocate for, as well as inform, active surveillance efforts. Climate change presents a serious challenge to safe water availability worldwide, for numerous reasons summarized by presenter Joan Rose of Michigan State University in the chapter’s second paper. In this context, she evaluates the findings of key studies relating health, climate, and water quality, and identifies critical questions for future research. Such studies have pursued three main lines of inquiry:
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Global Issues in Water, Sanitation, and Health: Workshop Summary Relationships between extreme weather events and outbreaks of water-borne disease; Associated changes in fecal bacterial concentrations in water and climate factors; and Quantitative assessments of the relationship between various environmental factors (e.g., infrastructure and climate) and transmission risk for specific waterborne pathogens. The essay concludes with a summary of critical needs that must be met in order to predict the effects of climate change on waterborne disease. The subsequent contribution, by speaker Kelly Reynolds of the University of Arizona and Kristina Mena of the University of Texas-Houston, expands on a topic introduced by Rose: quantitative microbial risk assessment of waterborne disease. Reynolds and Mena observe that human pathogens make difficult subjects for risk assessment due to their “relatively low prevalence and infectious dose, specific virulence characteristics, and variably susceptible populations”; the vast diversity of water systems in use around the globe amplifies that challenge in the case of waterborne pathogens. Following a description of microbial risk assessment methodologies for waterborne disease, the authors review representative studies (most of which were conducted in the United States) that describe drinking water contamination and the role of the water distribution system in spreading waterborne disease, as well as that played by premise plumbing and the biofilms present therein. They discuss the potential for improving risk assessment science by taking full advantage of the complementary relationship between epidemiological and forecasting studies, and also with increasingly accurate mathematical models and improved monitoring capacity. That final, essential component of assessing risk for waterborne disease—pathogen monitoring—was the subject of a presentation in the same workshop session by Mark Sobsey of the University of North Carolina at Chapel Hill, entitled “Current Issues and Approaches to Microbial Testing of Water: Applicability and Use of Current Tests in the Developing World.” While clearly beneficial in industrialized countries, water testing is “essential” to providing safe water in developing countries, Sobsey observed. Water quality data informs the selection of promising sources for drinking water and appropriate treatments to ensure its safety, as well as the classification of existing sources for the purposes of studying their health effects. Unfortunately, he observed, most water tests are not accessible, are too complicated, or are too costly for use in developing countries. Sobsey described the ideal microbial water test for low-resource settings as portable, self-contained, lab-free, electricity-free, low cost, globally available, able to support data communication, and capable of educating and mobilizing stakeholders, especially youth, to improve public health. These goals eventually may be met through a variety of approaches and options but are currently lim-
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Global Issues in Water, Sanitation, and Health: Workshop Summary ited mainly to culturing E. coli with enhanced detection. In the future, Sobsey predicted, culture-free and direct methods for detecting waterborne pathogens would predominate. These tests could be performed at ambient or body temperature (on Petri films or absorbent pads, or in small volumes of liquid, that could be incubated in a pocket or armpit). They would display simple, picture-based, shareable results. Progress toward developing such a test is being made by the Aquatest Project, an international, multidisciplinary consortium led by the University of Bristol, United Kingdom (Aquatest, 2009). “The idea was to … develop a low-cost test that would be accessible and affordable for the developing world … sort of like a home pregnancy or glucose test,” Sobsey explained. Following a successful feasibility study, the project is now in its second phase: a four-year, $13 million-plus project funded by the Bill and Melinda Gates Foundation to develop a test for E. coli, field-test it in India and South Africa, and prepare to deploy it on a global basis. Sobsey concluded his presentation with the following recommendations to build on Aquatest and support continued development of microbial water tests for developing countries: Engage a wider network of collaborators and donors; Experiment with various test formats; Explore target microbes other than E. coli; Consider potential uses of testing results by a range of sectors (e.g., water science and engineering, health, and development); Link test development to waterborne disease epidemiology and quantitative risk assessment; and Use test as a tool for education and policy making.
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Global Issues in Water, Sanitation, and Health: Workshop Summary THE CHANGING EPIDEMIOLOGY OF WATERBORNE DISEASE OUTBREAKS IN THE UNITED STATES: IMPLICATIONS FOR SYSTEM INFRASTRUCTURE AND FUTURE PLANNING Michael J. Beach, Ph.D.1 Centers for Disease Control and Prevention Sharon Roy, M.D., M.P.H.2 Centers for Disease Control and Prevention Joan Brunkard, Ph.D.2 Centers for Disease Control and Prevention Jonathan Yoder, M.P.H., M.S.W.2 Centers for Disease Control and Prevention Michele C. Hlavsa, R.N., M.P.H.2 Centers for Disease Control and Prevention The timing for this presentation is fortuitous since it is September 23, 2008, the eve of the 100th anniversary of the addition of chlorine to the Jersey City, New Jersey drinking water supply—the first time chlorine was added to water to kill microbes and improve water quality at an American drinking water treatment plant. This centennial reminds us, as we explore current challenges in providing safe drinking water in this country, of the pivotal role that inclusion of filtration and disinfection in water treatment plants had in reducing the burden of water-borne diseases in the United States (Cutler and Miller, 2005). Since 1971, the Centers for Disease Control and Prevention (CDC) in collaboration with the U.S. Environmental Protection Agency (EPA) and the Council for State and Territorial Epidemiologists (CSTE) has tracked epidemiological trends in waterborne disease in the United States through the national Waterborne Disease and Outbreak Surveillance System3 (WBDOSS). The WBDOSS receives investigative information on individual cases and outbreaks of waterborne disease from public health departments in states, territories, and the Freely Associated States (composed of the Republic of the Marshall Islands, the Federated States 1 Corresponding author. Associate Director for Healthy Water, National Center for Zoonotic, Vector-Borne and Enteric Diseases, Centers for Disease Control and Prevention, 4770 Buford Highway, F-22, Atlanta, Georgia 30341; E-mail: email@example.com; Tel: 770-488-7763; Fax: 770-488-7761. 2 Parasitic Diseases Branch, Division of Parasitic Diseases, National Center for Zoonotic, Vector-Borne and Enteric Diseases. 3 Information on the WBDOSS can be accessed at http://www.cdc.gov/healthywater/statistics/wbdoss/index.html.
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Global Issues in Water, Sanitation, and Health: Workshop Summary of Micronesia, and the Republic of Palau; formerly parts of the United States-administered Trust Territories of the Pacific Islands). Although initially designed to collect data about drinking water outbreaks in the United States, the WBDOSS now captures outbreaks associated with drinking water, recreational water, and nonrecreational water that is not intended for drinking or where the intended use is unknown. Annual or biennial surveillance summaries of the data have been published by CDC since the system’s inception in 1971.4 This system is now the primary source of data on waterborne disease outbreaks (including those caused by pathogens, chemicals, and toxins) associated with ingestion, contact, or inhalation of drinking water, recreational water, or water not intended for drinking (i.e., cooling towers, industrial use) occurring within the United States. The WBDOSS has documented a wide range of outbreaks of waterborne illnesses including acute gastrointestinal illness (AGI), infections of the skin, ear, eye, respiratory tract, urinary tract, wounds, and neurological system. These include outbreaks of AGI caused by a variety of pathogens such as Campylobacter (Vogt et al., 1982), Cryptosporidium (CDC, 2007b, 2008b; Mac Kenzie et al., 1994; Wheeler et al., 2007), E. coli O157:H7 (McCarthy et al., 2001; Swerdlow et al., 1992), norovirus (Parshionikar et al., 2003; Podewils et al., 2007), Giardia (Katz et al., 2006; Kent et al., 1988), Salmonella (Angulo et al., 1997), and Shigella (CDC, 2001; Iwamoto et al., 2005). Other nonenteric illness outbreaks have also been documented in the United States and include illnesses such as Pseudomonas-related dermatitis/folliculitis and outer ear infections (CDC, 1982; Gustafson et al., 1983; Yoder et al., 2008a), adenovirus-related pharyngoconjunctival fever (D’Angelo et al., 1979; Turner et al., 1987), legionellosis (i.e., Legionnaire’s disease and Pontiac fever; Benin et al., 2002; Burnsed et al., 2007; Fields et al., 2001), echovirus-related aseptic meningitis (CDC, 2004), primary amebic meningo-encephalitis (CDC, 2008a; Visvesvara et al., 1990), hepatitis A (Bergeisen et al., 1985; Mahoney et al., 1992), leptospirosis (Morgan et al., 2002), and conditions caused or exacerbated by waterborne chemicals or toxins (for example, there are apparent links between bronchial health effects and chloramines, which are volatile irritants formed when nitrogenous waste such as urine or sweat is oxidized by hypochlorous acid used to disinfect swimming pools) (Bowen et al., 2007; CDC, 2007a, 2009; Kaydos-Daniels, 2008; Weisel et al., 2008). Trends in Drinking Water-Associated Disease Outbreaks Over the course of its existence, WBDOSS surveillance has revealed four major trends in drinking water-related outbreaks that reflect the positive impact 4 All WBDOSS surveillance summaries of data from 1971 to the latest summary can be found electronically on CDC’s Healthy Water website at http://www.cdc.gov/healthywater/statistics/wbdoss/surveillance.html.
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Global Issues in Water, Sanitation, and Health: Workshop Summary of regulation in improving drinking water safety in the United States, as well as where gaps in regulation exist: Public drinking water system-related disease outbreaks have decreased, reflecting the positive impact of national regulations (e.g., the Safe Drinking Water Act of 19745 and its amendments in 19866 and 19967; primary drinking water standards set in 1985; the Surface Water Treatment rule of 19898), as well as improved water system practices (Figure 3-1). However, this apparent correlation of decreasing outbreaks with improved regulation underscores how disease prevention efforts must be maintained and improved. This includes a continued emphasis on enforcing and improving existing regulation as new data become available or new pathogens emerge, implementation of new regulation as needed, source water protection, drinking water infrastructure investment, and other efforts responsible for the gains made to this point. The proportion of surface water-related disease outbreaks has declined in relation to groundwater-related disease outbreaks. Many regulations, including the Surface Water Treatment Rule of 1989, have focused on improving treatment of public drinking water supplies using surface water sources (e.g., rivers, lakes). It is therefore not surprising that while surface water-related disease outbreaks have decreased (Figure 3-2), groundwater- 5 The Safe Drinking Water Act of 1974 put into motion a new national program to reclaim and ensure the purity of the water we consume. Under the Act, each level of government, every local water system, and the individual consumer have well-defined roles and responsibilities. But both the opportunity and the challenge of implementing the Act begins with EPA (for more information, see http://www.epa.gov/history/topics/sdwa/07.htm). 6 The 1986 amendment created a demonstration program to protect aquifers from pollutants, mandated state-developed critical wellhead protection programs, required the development of drinking water standards for many contaminants now unregulated, and strengthened EPA’s enforcement powers in dealing with recalcitrant water systems and underground injection well operators. It also imposed a ban on lead-content plumbing materials. Studies have found that excessive levels of lead in drinking water can harm the central nervous system in humans, especially children. The measure also provides substantial new authority to EPA to enforce the law including increased civil and criminal penalties for violations (for more information, see http://www.epa.gov/history/topics/sdwa/04.htm). 7 The 1996 amendments established a strong new emphasis on preventing contamination problems through source water protection and enhanced water system management. This emphasis transformed the previous law, with its largely after-the-fact, regulatory focus, into a truly environmental statute that can better provide for the sustainable use of water by the nation’s public water systems and their customers. The states are central, creating and focusing prevention programs and helping water systems improve operations and avoid contamination problems (for more information, see http://www.epa.gov/ogwdw/sdwa/theme.html). 8 The Surface Water Treatment Rule of 1989 was designed to prevent waterborne diseases caused by viruses, Legionella, and Giardia intestinalis. These disease-causing microbes are present at varying concentrations in most surface waters. The rule requires that water systems filter and disinfect water from surface water sources to reduce the occurrence of unsafe levels of these microbes (for more information, see http://epa.gov/ogwdw/therule.html#Surface).
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Global Issues in Water, Sanitation, and Health: Workshop Summary FIGURE 3-1 Number of reported waterborne-disease outbreaks in public drinking water systems—United States, 1971-2006 (N = 680). SOURCE: CDC, unpublished WBDOSS data. FIGURE 3-2 Proportion of deficiencies in public drinking water systems associated with untreated or improperly treated surface water—United States, 1971-2006. Deficiency = antecedent event or situation that results in exposure of persons to a disease-causing agent or agents. May be single or multiple deficiencies associated with each outbreak. SWTR = Surface Water Treatment Rule. SOURCE: CDC, unpublished WBDOSS data.
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Global Issues in Water, Sanitation, and Health: Workshop Summary FIGURE 3-3 Proportion of deficiencies in public drinking water systems associated with untreated or improperly treated ground water—United States, 1971-2006. Deficiency = antecedent event or situation that results in exposure of persons to a disease-causing agent or agents. May be single or multiple deficiencies associated with each outbreak. SOURCE: CDC, unpublished WBDOSS data. related disease outbreaks have continued to be reported (Figure 3-3). CDC is hopeful that the Groundwater Rule,9 published by EPA in the Federal Register in November 2006 (EPA, 2006), will eventually produce a decline in groundwater-related disease outbreaks similar to the results observed after enactment of the Surface Water Treatment Rule. Individual or unregulated water systems represent an important gap in waterborne disease prevention. Approximately 15.6 million households—about 12 percent of U.S. households—receive their water from private wells or small well water systems serving fewer than 25 people that are not regulated by EPA (U.S. Census Bureau, 2008). Although some of the smaller systems may be partially regulated by the state, private residential wells go unregulated. Generally, private well owners are not legally compelled to test or treat their drinking water, or to maintain the system to any standards. As a result, testing and maintenance schedules are likely to be less than optimal, resulting in increased vulnerability for well contamina- 9 The purpose of the rule is to reduce disease incidence associated with disease-causing microorganisms in drinking water. The rule established a risk-based approach to target groundwater systems that are vulnerable to fecal contamination. Groundwater systems that are identified as being at risk of fecal contamination must take corrective action to reduce potential illness from exposure to microbial pathogens. The rule applies to all systems that use groundwater as a source of drinking water (for more information, see http://www.epa.gov/safewater/disinfection/gwr/regulation.html and EPA, 2006).
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Global Issues in Water, Sanitation, and Health: Workshop Summary tion. The potential ramifications for the health of children drinking private well water recently prompted an American Academy of Pediatrics policy statement providing recommendations for inspection, testing, and remediation for wells providing drinking water for children (AAP, 2009). As Figure 3-4 demonstrates, an increasing proportion of reported waterborne disease outbreaks are associated with use of individual private wells. Legionella is a continuing threat. Although the outbreak that led to the identification of Legionella as a pathogen occurred in 1976 (Fraser et al., 1977), only Pontiac fever, primarily associated with hot tub exposure, was reported to WBDOSS until 2001. In 2001, the system began capturing data on outbreaks of Legionnaires’ disease. In the latest surveillance summary (Yoder et al., 2008b), which covers drinking water–associated disease outbreaks reported from 2005 to 2006, half of all reported drinking water–related disease outbreaks were attributed to Legionella (Figure 3-5). Until Legionella outbreaks were included in the WBDOSS, AGI was the predominant type of illness associated with waterborne-disease outbreaks. Legionella, a thermophilic bacterium, colonizes and amplifies in premise plumbing systems (hot water heaters, taps, shower heads) as well as other sources of water (e.g., recreational hot tubs, cooling towers, etc.) and is transmitted by inhaling aerosols containing the bacterium (Fields et al., 2002). It can cause fatal pneumonia in vulnerable populations, such FIGURE 3-4 Percentage of waterborne-disease outbreaks in public and individual drinking water systems—United States, 1971-2006 (N = 762). Excludes 18 outbreaks occurring in multiple system types at the same time, bottled water, bulk water purchase, and unknown system types. SDWA: drinking water systems covered by the Safe Drinking Water Act; Non-SDWA: drinking water systems not covered by the Safe Drinking Water Act. SOURCE: CDC, unpublished WBDOSS data.
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Global Issues in Water, Sanitation, and Health: Workshop Summary FIGURE 3-5 Percentage of waterborne-disease outbreaks associated with drinking water use, by illness and etiology—United States, 2005-2006 (N = 20); ARI: acute respiratory illness; AGI: acute gastrointestinal illness. SOURCE: Yoder et al. (2008b). as residents of health-care facilities and nursing homes. Mycobacterium avium also appears to be filling the same ecologic habitats colonized by Legionella, and it too has been associated with waterborne disease outbreaks (Falkinham, 2003). This underscores the need to focus on contamination of drinking water after it leaves regulated infrastructure, enters a building, or emerges at its point of use. Threats to drinking water safety from premise plumbing or public health challenges resulting from other uses of water (i.e., cooling towers, hot tubs) represent an important target for waterborne disease prevention. Limitations of Waterborne Disease Surveillance While the WBDOSS has been useful in elucidating the aforementioned trends and, therefore, highlighting areas of emerging public health need, this surveillance system has a number of critical limitations. First and foremost, the WBDOSS is a passive system based on outbreak reports from state and local public health agencies that do not necessarily actively track waterborne disease outbreaks. In many instances, waterborne disease outbreaks go unrecognized and therefore are neither investigated nor reported to CDC; thus, the WBDOSS provides, at best, an underestimate of waterborne disease outbreak occurrence
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Global Issues in Water, Sanitation, and Health: Workshop Summary and trends. Waterborne disease outbreaks tend to be reported more consistently by health departments with adequate resources for investigation; therefore, the geographic distribution of reported outbreaks is unlikely to be representative of the true geographic distribution of outbreaks. Another shortcoming of WBDOSS is that it does not collect data on endemic waterborne disease. At this time, there are no reliable estimates of the total burden of disease for these illnesses in the United States. Several reviews of existing epidemiologic studies of drinking water use have produced preliminary estimates ranging from 4 million to 33 million cases of AGI per year that result from drinking water supplied by public water systems (Colford et al., 2006; Messner et al., 2006). However, these estimates need to be refined as better data and improved methods of estimating endemic waterborne disease become available. Furthermore, these estimates do not include the full scope of waterborne illness in the United States (e.g., illness other than AGI), illness in the 15.6 million households served by private wells (U.S. Census Bureau, 2008), and illness in the more than 55 million swimmers using recreational water six or more times a year in the United States (U.S. Census Bureau, 2009). Emerging Challenges Drinking Water Distribution System Infrastructure Public drinking water systems in the United States supply 34 billion gallons per day of drinking water to approximately 87 percent of U.S. households (NRC, 2006; U.S. Census Bureau, 2008). The nation’s drinking water infrastructure contains more than 50,000 community water systems that rely on water treatment plants and distribution systems that include over one million miles of pipes plus associated pumps, valves, storage tanks, reservoirs, meters, and fittings (NRC, 2006). Most of the pipes in these systems will reach the end of their expected lifespan within the next 30 years; some are already overdue for replacement, as attested by water main breaks and the appearance of sinkholes in cities across the United States. Water pipes typically are located on top of sewers and sewer pipes. When water mains break, there is potential for contamination of the entire system. Based on a simple Google search for the term “boil water advisory,” hundreds to perhaps thousands of such incidents may occur in the United States each year. Such breaches in the water infrastructure result in costly repairs, increase the risk of water supply contamination, and impose a huge burden on local utilities and public health or environmental agencies. EPA has estimated that $276.8 billion will be needed over the next 20 years to repair and replace aging infrastructure, including $183.6 billion for transmission and distribution systems (EPA, 2005). Although the total number of drinking water-associated disease outbreaks has declined, the proportion of outbreaks caused by deficiencies in public water distribution systems (before the building point-of-entry) has been fairly consistent over
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Global Issues in Water, Sanitation, and Health: Workshop Summary health risks from various agents to determine exposure standards or levels of contamination in various media that must not be exceeded. In addition, the necessary efficacy of preventative measures can be quantitatively evaluated to meet the acceptable risk level. For quantitative microbial risk assessment, key pieces of information are needed to be either known or predicted, including the infectious dose response of the pathogen of interest; concentration at which the agent can be found in water; the impact of various water treatment strategies on reducing pathogen infectivity; and pathogenicity factors. Values of exposure and dose-response parameters may correspond to a point estimate of interest. Typical point estimates may reflect the best calculation of risk or to a maximum reasonable exposure or other justified value. Interval estimates are useful for looking at a range of values. In the latter, parameters are not single values but probability distributions. Risk assessment is subject to large uncertainty and variability. Uncertainty occurs when there is an error in the estimate. For example, measurement errors, reporting errors, or inferences from a small, unrepresentative population lead to uncertainty in the estimate. Variability occurs due to intrinsic heterogenicity, such as differences in population consumption patterns, cultures and ethnicity, dose-response sensitivity, and immune function. The advantage of modeling probabilistically is to propagate these uncertainties through the model. Using distribution analysis, a range of possible outcomes can be assessed and key data contributors identified. A range of outcomes can be reviewed under different conditions of uncertainty and mitigations to evaluate parameters that have the greatest health impacts. This process helps to define when better data can be most valuable and identify parameters that can be influenced by policy. Monte Carlo analysis is a widely applied tool for risk distribution analysis. Using random numbers in a computational process, a desired output as a function of changing variables (i.e., dose, exposure, survival, etc.) can be estimated for known and assumed distribution inputs. The process can be easily repeated for thousands of trials. As part of the risk characterization process, however, a number—or series of numbers—is needed to inform decisions about acceptable risk, possible risks, risk reduction potentials, and risk management decisions. Questions remain regarding acceptable risk limits, susceptible populations, and the use of conservative, worst-case, protective, or interval estimates. Recommendations and Conclusions While the discussion of how to appropriately estimate risks associated with contributing values continues, other factors must also be considered. We have learned that water quality variability affects long-term risk and that exposure is not constant over time. In addition, there is no threshold for infectivity with microbes. Even low-level exposures can have a significant impact on risk over time. Where average doses have been used in risk, the possibility of widespread exposure to low doses and limited exposures to large doses should be considered.
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Global Issues in Water, Sanitation, and Health: Workshop Summary Additional epidemiological data are necessary to prove the plausibility of models, and models should be evaluated with increased inputs related to the mechanisms of the host and pathogen interactions. In addition to the many variables in water quality, treatment, and distribution, of particular concern are sensitive populations in the United States that are susceptible to higher rates of infections and to more serious health outcomes from waterborne pathogens. These subpopulations include not only individuals experiencing adverse health status, but also those experiencing “normal” life stages (e.g., pregnancy or those very young or old). Acceptable risk goals need to be evaluated for a changing population as persons move through these normal life stages that impact their susceptibility to waterborne illness. Risks may be acute or chronic and sequelae are common outcomes that must be considered (Parkin, 2000). With exposure-related inputs contributing the greatest uncertainty in models, more monitoring is needed to inform risk and minimize uncertainty in risk characterization. Finally, better communication between water quality professionals, public health researchers, and health-care providers is needed to design studies that comprehensively assess the impact of waterborne disease and address the multibarrier approach necessary to preserve water quality. OVERVIEW REFERENCES Aquatest. 2009. Aquatest research programme, http://www.bristol.ac.uk/aquatest/ (accessed April 15, 2009). BEACH ET AL. REFERENCES AAP (American Academy of Pediatrics). 2009. Drinking water from private wells and risks to children. Pediatrics 123(6):1599-1605. Angulo, F. J., S. Tippen, D. J. Sharp, B. J. Payne, C. Collier, J. E. Hill, T. J. Barrett, R. M. Clark, E. E. Geldreich, H. D. Donnell, and D. L. Swerdlow. 1997. A community waterborne outbreak of salmonellosis and the effectiveness of a boil water order. American Journal of Public Health 87(4):580-584. Arctic Council and IASC (International Arctic Science Committee). 2004. Impacts of a warming arctic. Cambridge, UK: Cambridge University Press. Benin, A. L., R. F. Benson, K. E. Arnold, A. E. Fiore, P. G. Cook, L. K. Williams, B. Fields, and R. E. Besser. 2002. An outbreak of travel-associated Legionnaires disease and Pontiac fever: the need for enhanced surveillance of travel-associated legionellosis in the United States. Journal of Infectious Diseases 185(2):237-243. Bergeisen, G. H., M. W. Hinds, and J. W. Skaggs. 1985. A waterborne outbreak of hepatitis A in Meade County, Kentucky. American Journal of Public Health 75(2):161-164. Bowen, A., J. Kile, C. Austin, C. Otto, B. Blount, N. Kazerouni, H.-N. Wong, H. Mainzer, J. Mott, M. J. Beach, and A. M. Fry. 2007. Outbreaks of short-incubation illness following exposure to indoor swimming pools. Environmental Health Perspectives 115(2):267-271. Burnsed, L. J., L. A. Hicks, L. M. Smithee, B. S. Fields, K. K. Bradley, N. Pascoe, S. M. Richards, S. Mallonee, L. Littrell, R. F. Benson, M. R. Moore, and Legionellosis Outbreak Investigation Team. 2007. A large, travel-associated outbreak of legionellosis among hotel guests: utility of the urine antigen assay in confirming Pontiac fever. Clinical Infectious Diseases 44(2):222-228.
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Global Issues in Water, Sanitation, and Health: Workshop Summary CDC (Centers for Disease Control and Prevention). 1982. Otitis due to Pseudomonas aeruginosa serotype 0:10 associated with a mobile redwood hot tub system—North Carolina. Morbidity and Mortality Weekly Report 31(40):541. ———. 1998. A survey of the quality of water drawn from domestic wells in nine midwest states. CDC funded multi-state report, http://www.cdc.gov/nceh/hsb/disaster/pdfs/A%20Survey%20of%20the%20Quality%20ofWater%20Drawn%20from%20Domestic%20Wells%20in%20Nine%20Midwest%20States.pdf (accessed March 16, 2009). ———. 2001. Shigellosis outbreak associated with an unchlorinated fill-and-drain wading pool—Iowa, 2001. Morbidity and Mortality Weekly Report 50(37):797-800. ———. 2004. Aseptic meningitis outbreak associated with echovirus 9 among recreational vehicle campers—Connecticut, 2003. Morbidity and Mortality Weekly Report 53(31):710-713. ———. 2007a. Ocular and respiratory illness associated with an indoor swimming pool—Nebraska, 2006. Morbidity and Mortality Weekly Report 56(36):929-932. ———. 2007b. Cryptosporidiosis outbreaks associated with recreational water use—five states, 2006. Morbidity and Mortality Weekly Report 56(29):729-32. ———. 2008a. Primary amebic meningoencephalitis—Arizona, Florida, and Texas, 2007. Morbidity and Mortality Weekly Report 57(21):573-577. ———. 2008b. Communitywide cryptosporidiosis outbreak—Utah, 2007. Morbidity and Mortality Weekly Report 57(36):989-993. ———. 2009. Respiratory and ocular symptoms among employees of a hotel indoor waterpark resort—Ohio, 2007. Morbidity and Mortality Weekly Report 58(4):81-85. Colford, J. M., S. L. Roy, M. J. Beach, A. Hightower, S. E. Shaw, and T. J. Wade. 2006. A review of household drinking water intervention trials and an approach to the estimation of endemic waterborne gastroenteritis in the United States. Journal of Water and Health 4(Suppl 2):71-88. Curriero, F. C., J. A. Patz, J. B. Rose, and S. Lele. 2001. The association between extreme precipitation and waterborne disease outbreaks in the United States, 1948-1994. American Journal of Public Health 91(8):1194-1199. Cutler, D., and G. Miller. 2005. The role of public health improvements in health advances: the twentieth-century United States. Demography 42(1):1-22. D’Angelo, L. J., J. C. Hierholzer, R. A. Keenlyside, L. J. Anderson, and W. J. Martone. 1979. Pharyngoconjunctival fever caused by adenovirus type 4: report of a swimming pool-related outbreak with recovery of virus from pool water. Journal of Infectious Diseases 140(1):42-47. Denno, D. M., W. E. Keene, C. M. Hutter, J. K. Koepsell, M. Patnode, D. Flodin-Hursh, L. K. Stewart, J. S. Duchin, L. Rasmussen, R. Jones, and P. I. Tarr. 2009. Triof risk factors for sporadic reportable bacterial enteric infection in children. Journal of Infectious Diseases 199(4):467-476. EPA (Environmental Protection Agency). 2005. Drinking water infrastructure needs survey and assessment, http://www.epa.gov/safewater/needssurvey/index.html (accessed February 20, 2009). ———. 2006. National primary drinking water regulations: ground water rule; final rule. Federal Register 71(216):65573-65660. ———. 2009a. Agreement in principal. Total coliform rule/distribution system advisory committee. Federal Register 74(8):1683-1684. ———. 2009b. Agreement in principal. Total coliform rule/distribution system advisory committee, http://www.epa.gov/OGWDW/disinfection/tcr/regulation_revisions_tcrdsac.html#aip (accessed March 16, 2009). Falkinham, J. O., 3rd. 2003. Mycobacterial aerosols and respiratory disease. Emerging Infections Diseases 9(7):763-767. Fields, B. S., T. Haupt, J. P. Davis, M. J. Arduino, P. H. Miller, and J. C. Butler. 2001. Pontiac fever due to Legionella micdadei from a whirlpool spa: possible role of bacterial endotoxin. Journal of Infectious Disease 184(10):1289-1292.
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Global Issues in Water, Sanitation, and Health: Workshop Summary Parshionikar, S. U., S. Willian-True, G. S. Fout, D. E. Robbins, S. A. Seys, J. D. Cassady, and R. Harris. 2003. Waterborne outbreak of gastroenteritis associated with a norovirus. Applied Environmental Microbiology 69(9):5263-5268. Patz, J. A., D. Engelberg, and J. Last. 2000. The effects of changing weather on public health. Annual Review of Public Health 21:271-307. Patz, J. A., S. J. Vavrus, C. K. Uejio, and S. L. McLellan. 2008. Climate change and waterborne disease risk in the Great Lakes region of the U.S. American Journal of Preventive Medicine 35(5):451-458. Podewils, L. J., L. Zanardi-Blevins, M. Amundson, D. Itani, A. Burns, M. J. Beach, C. Otto, L. Browne, S. Adams, S. Monroe, V. Hill, C. Lohff, and M.-A. Widdowson. 2007. Outbreak of norovirus illness associated with a swimming pool. Epidemiology and Infection 135(5):827-833. Prüss, A. 1998. Review of epidemiological studies on health effects from exposure to recreational water. International Journal of Epidemiology 27(1):1-9. Rose, J. B., P. R. Epstein, E. K. Lipp, B. H. Sherman, S. M. Bernard, and J. A. Patz. 2001. Climate variability and change in the United States: potential impacts on water- and foodborne diseases caused by microbiologic agents. Environmental Health Perspectives 109(Suppl 2):211-221. Shields, J. M., V. R. Hill, M. J. Arrowood, and M. J. Beach. 2008. Inactivation of Cryptosporidium parvum under chlorinated recreational water conditions. Journal of Water and Health 6(4):513-520. Swerdlow, D. L., B. A. Woodruff, R. C. Brady, P. M. Griffin, S. Tippen, D. Donnell, E. Geldreich, B. J. Payne, A. Meyer, Jr., J. G. Wells, K. D. Greene, M. Bright, N. H. Bean, and P. A. Blake. 1992. A waterborne outbreak in Missouri of Escherichia coli O157:H7 associated with bloody diarrhea and death. Annals of Internal Medicine 117(10):812-819. Turner, M., G. R. Istre, H. Beauchamp, M. Baum, and S. Arnold. 1987. Community outbreak of adenovirus type 7a infections associated with a swimming pool. Southern Medical Journal 80(6):712-715. U.S. Census Bureau. 2008. Current housing reports, series H150/07, American housing survey for the United States: 2007. Washington, DC: U.S. Government Printing Office. ———. 2009. Statistical abstract of the United States. Recreation and leisure activities: participation in selected sports activities 2006, www.census.gov/compendia/statab/tables/09s1209.pdf (accessed March 16, 2009). Visvesvara, G. S., and J. K. Stehr-Green. 1990. Epidemiology of free-living ameba infections. The Journal of Protozoology 37:25S-33S. Vogt, R. L., H. E. Sours, T. Barrett, R. A. Feldman, R. J. Dickinson, and L. Witherell. 1982. Campylobacter enteritis associated with contaminated water. Annals of Internal Medicine 96(3):292-296. Wade, T. J., R. L. Calderon, E. Sams, M. Beach, K. P. Brenner, A. H. Williams, and A. P. Dufour. 2006. Rapidly measured indicators of recreational water quality are predictive of swimming-associated gastrointestinal illness. Environmental Health Perspectives 14(1):24-28. Wade, T. J., R. L. Calderon, K. P. Brenner, E. Sams, M. Beach, R. Haugland, L. Wymer, and A. P. Dufour. 2008. A rapid method of measuring recreational water quality demonstrates an enhanced sensitivity of children to swimming associated gastrointestinal illness. Epidemiology 19:375-383. Weisel, C. P., S. D. Richardson, B. Nemery, G. Aggazzotti, E. Baraldi, E. R. Blatchley III, B. C. Blount, K.-H. Carlsen, P. A. Eggleston, F. H. Frimmel, M. Goodman, G. Gordon, S. A. Grinshpun, D. Heederik, M. Kogevinas, J. S. LaKind, M. J. Nieuwenhuijsen, F. C. Piper, and S. A. Sattar. 2008. Childhood asthma and environmental exposures at swimming pools: state of the science and research recommendations. Environmental Health Perspectives 117(4):500-507. Wheeler, C., D. Vugia, G. Thomas, M. J. Beach, S. Carnes, T. Maier, J. Gorman, L. Xiao, M. Arrowood, D. Gilliss, and S. B. Werner. 2007. Outbreak of cryptosporidiosis at a California waterpark: employee and patron roles and the long road towards prevention. Epidemiology and Infection 135(2):302-310.
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