WQRA HealthStream - Issue 57

Issue 57

Public Health Newsletter of Water Quality Research Australia

In this Issue:

March 2010

Coomera Cross-Connection Incident

Coomera Cross-Connection Incident Progress on Sanitation and Drinking Water Millenium Development Goals

1

News Items

5

From The Literature

6

4

Web Bonus Articles Arsenic Bottled Water Dental Caries

A cross-connection incident at Pimpama Coomera has marred the introduction of Class A+ recycled water to this major development site in southeast Queensland. The incident, which occurred in early December 2009, is a significant public relations setback for the implementation of the Pimpama Coomera Waterfuture Master Plan (1) which has governed regional water supply strategies since August 2005.

The Master Plan, which has won a number of national and international awards for excellence and innovation, was developed in anticipation of projected population growth from a base of 5,000 residents in 2004 to around 150,000 residents by 2056. The aim of the Master Plan is to provide sustainable water management through utilisation of multiple water sources, and improved management of stormwater and sewerage systems.

Cyanobacteria Disinfection Byproducts Organotin Outbreaks Perfluoroocatnoic acid Pharmaceuticals POU Treatment Uranium Mailing List Details

20

Editor Martha Sinclair Assistant Editor Pam Hayes

WQRA Internet Address: www.wqra.com.au A searchable Archive of Health Stream articles, literature summaries and news items is available via the WQRA Web page.

HEALTH STREAM

Since implementation of the Master Plan, new residential developments in the region have been required to have a rainwater tank and a dual reticulation water supply capable of providing nonpotable recycled water as well as conventional drinking water. In addition, sewage collection systems have been designed to minimise stormwater intrusion and reduce sewage treatment costs, and water sensitive landscaping provides an attractive environment while protecting local waterways from the adverse impacts of stormwater runoff. Other expected benefits include a reduction in sewage and nutrient discharge to the Pimpama river, and a reduction in greenhouse gas emissions. The Master Plan is expected to reduce demand for conventional

MARCH 2010

PAGE 1

WATER QUALITY RESEARCH AUSTRALIA

drinking water supplies to as little as 16% of typical demand for conventional residential developments which use drinking water for all purposes.

To date about 4,400 homes with dual reticulation plumbing have been constructed. In keeping with normal practice in such developments, households have been initially supplied with drinking water through both pipe systems while the recycled water treatment plant at Pimpama was constructed. The plant was designed to supply Class A+ recycled water (2) to homes for toilet flushing and outdoor taps, however soon after recycled water was supplied to households for the first time on Tuesday 1 December, a number of residents complained that water from kitchen and bathroom taps had a foul taste and odour. Investigations by Gold Coast Water revealed that that a cross-connection had allowed recycled water to mix with the drinking water supply in over 630 homes. The problem was detected on Friday 4 December and affected residents were advised by door-knock and letter drop not to drink tap water until further notice. The recycled water supply was turned off and tap water flushed through both systems until water quality parameters returned to normal levels for drinking water. After extensive testing of the potable and recycled water networks, residents were advised they could resume drinking tap water the following Monday 7 December. The potable and recycled water supplies were restored on Friday 4 December at 6pm, about 11 hours after the problem was detected.

The cross-connection incident is being investigated by the Queensland Office of the Water Supply Regulator, the South East Queensland Water Grid Manager and Queensland Health as well as Gold Coast Water. None of these bodies has yet released their findings about the cause of the incident. While some media reports have speculated that the contamination could have been caused by deliberate illegal cross-connections within one or more households, the scale of the incident makes it appear more likely that the cross-connection occurred at the mains pipe level.

According to media reports, a number of residents reported gastroenteritis symptoms during the period

HEALTH STREAM

of the cross-connection, and have attributed this to consuming the contaminated water. However, the Chief Medical Officer for Queensland stated that health risks would have been minimal due to the low numbers of microorganisms and high residual chlorine levels in the water. Nevertheless, media reports suggest that a number of legal firms are preparing class action claims against Gold Coast City Council.

An earlier cross-connection incident at the recycled water treatment plant also came under the media spotlight, when it was revealed that up to 375 council workers, contractors and visitors had potentially been exposed to recycled water of much lower quality for a period of nine weeks during 2008. During this time the water supply to a building at the plant was contaminated with partially treated wastewater with quality ranging from predominantly Class B to Class D. The water was used for drinking, laundry and showering. An investigation by Queensland Health found that 73 of those exposed had suffered illnesses possibly related to their exposure. The Queensland government took legal action against the construction company over this cross-connection incident These incidents have caused anxiety among Pimpama Coomera residents about the safety of their water supplies and this was further heightened in January this year when, following another customer complaint about taste and odour, inspection of a home revealed a household level cross-connection.

This prompted Gold Coast Water to inspect all dual reticulation properties, revealing seven more residences with cross-connections. Five of the crossconnections were at the water meter connection to the house, two within houses and one at the sub-meter for a residential home unit.

The focus on water also led to media speculation that another cross-connection could be responsible for a gastroenteritis outbreak at a childcare centre where 30 children fell ill over a two week period in late January. The investigation by Gold Coast Water showed no problems with water quality or plumbing, and in fact the centre was not even connected to the dual reticulation water supply. There was no evidence to support the idea that the outbreak was

MARCH 2010

PAGE 2

WATER QUALITY RESEARCH AUSTRALIA

related to water, however the incident highlights the difficulty in restoring public confidence in the safety of water supplies, once it has been damaged.

Gastroenteritis is a relatively common illness and on average it is expected that around 2% to 4% of people in Australian communities would experience gastroenteritis symptoms in any given week.

Outbreaks in childcare centres are common, and not entirely preventable even with the best hygienic practices. Gastroenteritis pathogens have many routes of transmission but adverse publicity about one potential source of risk may lead people to attribute all cases of illness to this source, or to be more aware of the illness and thus perceive an apparent increase in frequency in the community when none has actually occurred. A small number of crossconnection incidents have previously happened at other dual reticulation residential developments in Australia, however investigations by health authorities have not conclusively linked such incidents with adverse health effects. This is not surprising given that the microbial quality requirements for water supplied to dual reticulation developments are relatively high. These requirements have been set in recognition of the risk of occasional household level cross-connections or inadvertent consumption of water from recycled water taps.

Risk management for dual reticulation systems is a challenging undertaking given the complexity of water supply networks and the involvement of multiple organisations and individuals in construction, commissioning and operation of these developments. In an effort to detect household level cross-connections, some water suppliers have elected to perform audits of individual households before a Certificate of Occupancy is issued (a legal requirement before residents are permitted to move into a newly built property). In such audits each internal and external tap is tested to ensure that they are supplying the intended type of water (either potable water or recycled water) by turning off the supply at the respective meters. This will reveal whether a complete cross-connection exists (incoming supply pipes connected to wrong meters).

Water quality tests (for example electrical conductivity tests) may also be done to ensure there

HEALTH STREAM

is not a partial cross-connection within the household allowing the two types of water to mix.

However, the experience of Sydney Water Corporation at the Rouse Hill dual reticulation development illustrates that even this approach is not foolproof. A household audit prior to turning on the recycled water supply revealed around 50 crossconnections among 12,000 houses inspected, and a policy was introduced to ensure subsequent newly built homes were subject to inspection before a Certificate of Occupancy was issued. However some householders move in prior to obtaining their Certificate of Occupancy. Between 2001 and 2007, three such households were found to have crossconnections which had exposed residents to drinking recycled water not intended for potable use. In a subsequent incident, a cross-connection in a home still under construction (and therefore not yet audited) allowed recycled water to enter the drinking water supply of 82 occupied homes in the local area.

Residents were exposed for a period of three weeks before taste and odour complaints triggered an investigation which revealed the problem.

It would be expected that mains level crossconnections resulting in complete switching of the two water supplies would be rapidly picked up by routine water quality monitoring if they were not first detected by a sharp rise in customer complaints, however cross-connections which result in intrusion of recycled water into the potable supply present a more complex problem for detection. In these cases the proportion of recycled water present in the potable supply will vary over time due to the changing pressure differential between the two systems. Movement of water through the pipes and storage reservoirs in the distribution network and inflows from other connecting mains will also produce a variable spatial pattern of mixing. In addition the physico-chemical properties of individual recycled water and potable water supplies may also vary somewhat over time, and this will affect the degree of contrast between potable water and the potable/recycled mixture for any given water quality parameter that might be measured by water suppliers or detected by customers. Given the increasing adoption of dual reticulation for greenfield

MARCH 2010

PAGE 3

WATER QUALITY RESEARCH AUSTRALIA

residential sites in response to water shortages in Australia, developing methods to reliably and rapidly detect cross-connections between recycled water and potable water systems is a high priority research area for the water industry.

(1) Information on the Pimpama Coomera Master Plan can be found at:http://www.goldcoastwater.com.au/ t_gcw.aspx?PID=5885 (2) Different categories of recycled water used in the state are defined under the Queensland Public Health Regulation 2005. Class A+ recycled water must contain less than one of all of the following microorganisms per 100 ml of water in 95% of samples over a 12 month period – E. coli, Clostridium perfringens, F-RNA bacteriophages, somatic coliphages. In addition water turbidity must be less than 2 NTU and a free chlorine residual of more than 0.5 mg/L must be maintained at the point of supply to households. The recycled water treatment chain for the Pimpama plant includes membrane ultra-filtration, disinfection with ultra-violet light and chlorination

Progress on Sanitation and Drinking Water Millenium Development Goals The World Health Organisation (WHO) has issued a biennial report on progress towards the Millennium Development Goal (MDG) targets relating to drinking-water and sanitation (1). When the Millenium Development Goals were developed it was estimated that in 1990 about 23% of the world’s population were without access to improved drinking water supplies, and 46 % lacked access to adequate sanitation. The MDG targets formally adopted by WHO member nations in 2000 were to halve these numbers by 2015. Progress towards these MDG targets is monitored by the WHO/UNICEF Joint Monitoring Programme (JMP) for Water Supply and Sanitation. According to data compiled for the most recent JMP report, good progress has been made towards the drinking water target, and if the current rate of improvement is maintained the MDG target will be met or even exceeded. However, the picture for sanitation is not so encouraging, and unless a very significant improvement occurs, progress will fall well short of the target.

Figures collected during 2008 indicate that worldwide, 87% of people had access either to piped water at their residence (57%) or other improved drinking water sources such as public taps or

HEALTH STREAM

standpipes, tube wells or boreholes, protected dug wells, protected springs or rainwater collection (30%). While access to piped water was already very high in developed nations, major improvements have occurred in most other regions especially East Asia (from 55% in 1990 to 83% in 2008) and Northern Africa (from 58% in 1990 to 80% in 2008).

However, there was little improvement in subSaharan Africa (from 15% in 1990 to 16% in 2008) and in the Commonwealth of Independent States (Armenia, Azerbaijan, Belarus, Georgia, Kazakhstan, Kyrgyzstan, the Republic of Moldova, Tajikistan, Turkmenistan, the Russian Federation, Ukraine and Uzbekistan) access to piped water appeared to have declined slightly over the same period (from 71% in 1990 to 69% in 2008). Sub-Saharan Africa remains the region with the highest use of unimproved drinking water sources (40%).

Urban-rural disparities in access to improved drinking water sources are relatively minor in developed nations (100% in urban areas vs 98% in rural areas), but larger in developing regions (94% vs 76%). Overall, about 748 million people in rural areas and 142 million in urban areas lacked access to improved water supplies at the end of 2008.

Population growth in urban areas between 1990 and 2008 (1089 million) was estimated to be slightly greater than increases in the number of people with access to improved water supplies (1052 million). In rural areas the improvement in access (723 million) was well ahead of population growth (370 million).

In the period from 1990 to 2008, access to improved sanitation facilities increased from 54% to 61% of the world’s population. Such facilities are defined as private (not shared with other households) and providing sewage disposal through flush/pour flush systems to piped sewers, septic tank or pit latrines, ventilated improved pit latrines, pit latrines with slab or composting toilets. Shared sanitary facilities of the above types are now available to 11% of people, while a further 11% have unimproved facilities (not ensuring hygienic separation of human excreta from human contact) and 17% have no specific sanitation facilities. Southern Asia has the highest percentage of people with no access to sanitation (44%), followed

by Sub-Saharan Africa (27%) and South Eastern Asia

MARCH 2010

PAGE 4

WATER QUALITY RESEARCH AUSTRALIA

(14%). There were insufficient data to assess the availability of different categories of sanitation for Latin America and the Caribbean, Oceania, the Commonwealth of Independent States. There are relatively small discrepancies in the availability of improved sanitation facilities between urban and rural areas in the developed world (100% vs 96% respectively), however these differences are much larger in developing nations (68% vs 40%). Overall, about 70% of people without improved sanitation facilities live in rural areas. In urban areas worldwide, population growth from 1990 to 2008 (1089 million) outstripped the number of people gaining access to improved sanitation (814 million), while in rural areas population growth (370 million) was less than sanitation growth (450 million).

The report also discusses some of the difficulties in carrying out the assessment of sanitation facilities and drinking water supplies, including uncertainties over classification of some types of widely used latrine systems, and the logistical and cost challenges of obtaining drinking water quality data to support classification categories. A pilot program in eight countries showed the technical feasibility of making water quality measurements using a rapid test method, however the costs of carrying out such a survey periodically on a global scale is not considered to be economically feasible.

Progress on Sanitation and Drinking-water: 2010 Update.

WHO/UNICEF Joint Monitoring Programme for Water Supply and Sanitation. ISBN 978 92 4 156395 6 Available from: http://www.wssinfo.org/en/welcome.html

News Items New Approach for US EPA The US EPA has announced major changes in the way it will deal with chemical contaminants in drinking water. The changes are intended to provide a more cost-effective and innovative approach based on four key principles: 路 Address contaminants as a group rather than one at a time so that enhancement of drinking water protection can be achieved cost-effectively. 路 Foster development of new drinking water treatment technologies to address health risks posed by a broad array of contaminants.

HEALTH STREAM

路 Use the authority of multiple statutes to help protect drinking water. 路 Partner with states to share more complete data from monitoring at public water systems.

This is a significant departure from the traditional chemical-by chemical approach to regulation which requires accumulation of a large amount of information on each chemical before regulations can be formulated. The new approach is expected to result in more rapid uptake of advanced treatment systems which are capable of simultaneously removing multiple categories of water contaminants.

The EPA will however, continue to regulate individual contaminants with regulations for four carcinogenic compounds currently being developed and standards for 14 other substances being reviewed or formulated.

Rotavirus Outbreak From Holy Water Investigation of a recent rotavirus outbreak affecting 360 people in the Siberian city of Irkutsk uncovered an unusual source for the exposure - holy water consumed by members of the Eastern Orthodox Church during Epiphany celebrations. Water collected from streams and lakes during this religious festival commemorating the baptism of Jesus Christ is regarded by Church followers as having restorative and curative properties. After blessing, such water is often consumed by parishioners seeking beneficial effects. In this case, water collected from a local lagoon was contaminated with sewage, leading to the large outbreak. Rotavirus antigens were detected in samples of water kept by worshippers. Although rotavirus infection may cause severe vomiting and diarrhoea, symptoms are generally of short duration and serious effects are rare.

Recycled Water guidelines for Health Facilities The Victorian Department of Health recently issued the document Guidelines for water reuse and recycling in Victorian healthcare facilities. The guidelines provide advice for healthcare agencies planning or implementing the use of alternative water supplies in healthcare facilities. They are available from: http://www.health.vic.gov.au/environment/water/recy cle.htm

MARCH 2010

PAGE 5

WATER QUALITY RESEARCH AUSTRALIA

From the Literature

Arsenic

Web-bonus articles Summaries of these additional articles are available in the web page version of Health Stream and are included in the searchable archive at: www.wqra.com.au/WQRA_publications.htm Arsenic in drinking water and adult mortality: A population-based cohort study in rural Bangladesh.

Sohel N, Persson LA, Rahman M et al. (2009) Epidemiology, 20(6); 824-830.

Arsenic in drinking water and risk of urinary tract cancer: A follow-up study from Northeastern Taiwan.

Chen CL, Chiou HY, Hsu LI et al. Cancer Epidemiology Biomarkers and Prevention, 19(1); 101-110.

Chlorination disinfection by-products in drinking water and congenital anomalies: Review and metaanalyses. Nieuwenhuijsen MJ, Martinez D, Grellier J et al.

(2009) Environmental Health Perspectives, 117(10); 14861493.

Identification of heterotrophic plate count bacteria isolated from drinking water in Japan by DNA sequencing analysis. Inomata A Chiba T and Hosaka M. (2009) Biocontrol Science, 14(4); 139-145.

Effects of elevated levels of manganese and iron in drinking water on birth outcomes. Grazuleviciene R, Nadisauskiene R, Buinauskiene J and Grazulevicius T. (2009) Polish Journal of Environmental Studies, 18(5); 819-825.

Waterborne gastroenteritis outbreak at a scouting camp caused by two norovirus genogroups: GI and GII. ter Waarbeek HLG, Dukers-Muijrers NHM, Vennema H and Hoebe CJPA. (2009) Journal of Clinical Virology doi10.1016/j.jcv.2009.12.002 Comparison of point-of-use technologies for emergency disinfection of sewage-contaminated drinking water.

McLennan SD, Peterson LA and Rose JB. (2009) Applied and Environmental Microbiology, 75(22); 7283-7286.

Sodium dichloroisocyanurate tablets for routine treatment of household drinking water in periurban Ghana: A randomized controlled trial. Jain S, Sahanoon OK, Blanton E, et al. (2010) American Journal of Tropical Medicine and Hygiene, 82(1); 16-22.

Comparative study of enteric viruses, coliphages and indicator bacteria for evaluating water quality in a tropical high-altitude system. Espinosa AC, Arias CF, Sanchez-Colan S and Mazari-Hiriart M. (2009) Environmental Health: A Global Access Science Source, 8(1); art no. 49 Water quality in dental chair units. A random sample in the canton of St. Gallen. Barben J, Kuehni CE and Schmid J. (2009) Schweizer Monatsschrift fur Zahnmedizin, 119(10); 976-985.

Tap water use amongst pregnant women in a multiethnic cohort. Smith RB, Toledano MB, Wright J et al (2009) Environmental Health: A Global Access Science Source, 8(Suppl. 1); S7. doi:10.1186/1476-069X-8-S1-S7

HEALTH STREAM

Arsenic in public water supplies and cardiovascular mortality in Spain.

Medrano MJ, Boix R, Pastor-Barriuso R. et al.

Environmental Research, (2009) doi:10.1016/ j.envres.2009.10.002 Long-term arsenic exposure in drinking water (greater than 100 micro g/L) has been associated with increased cardiovascular disease risk including a severe form of peripheral arterial disease known as black foot disease. Exposure has also been associated with coronary and cerebrovascular diseases and with subclinical markers of atherosclerosis. In Region II Chile, following a period of high arsenic exposure in drinking water, acute myocardial infarction mortality increased and then decreased after arsenic remediation was implemented. Associations between high arsenic exposure via drinking water and cardiovascular risk factors such as hypertension and diabetes have been reported in Bangladesh, Mexico and Taiwan. However there have been few epidemiological studies on moderate or low chronic arsenic exposure (less than 100 micro g/L) and cardiovascular endpoints. In Spain, there are number of communities with arsenic concentrations in drinking water between 50 and 10 micro g/L. This study was conducted to evaluate the association of municipal tap drinking water arsenic concentrations during 1998-2002 with cardiovascular mortality.

Municipal-level arsenic concentrations in drinking water and mortality data was available for 1721 municipalities located in 49 out of 52 Spanish provinces. The population of theses area was 24.8 million or almost 61% of the Spanish population in 2001. Tap drinking water arsenic concentrations at the municipal level during 1998-2002 were obtained from the National Information System of Consume Water Control. Cardiovascular mortality was analysed for the period 1999-2003 to allow for 1-year delay with regard to arsenic determinations. The number of deaths from cardiovascular disease, coronary heart disease and cerebrovascular disease at the municipal level for men and women was obtained from the National Institute for Statistics. There were a total of 361,750 cardiovascular diseases deaths,

MARCH 2010

PAGE 6

WATER QUALITY RESEARCH AUSTRALIA

113,000 coronary disease deaths and 103,590 cerebrovascular disease deaths included in the analysis. Municipal-level water characteristics (hardness and magnesium content, pH and temperature) were obtained from the National Information System of Consume Water Control.

Municipal-level socioeconomic indicators were obtained from bank statistics. Other relevant sociodemographic, dietary and cardiovascular risk factors were considered at the provincial level as there were not available at the municipal level.

All the available arsenic determinations in drinking water for each municipality during 1998-2002 were averaged as an approximation to long-term arsenic exposure. Municipalities were classified according to mean arsenic concentrations as less than 1, 1-10, and greater than 10 micro g/L. Mean levels of sociodemographic and water characteristics and dietary and cardiovascular risk factors were compared across categories of municipal arsenic concentrations using linear regression models. For each municipality the expected number of cardiovascular, coronary and cerebrovascular disease deaths for the period 1999-2003 was calculated. The expected number of deaths was compared with the observed number of deaths. For risk assessment, twolevel hierarchical Poisson models were used to evaluate the association of municipal drinking water arsenic concentrations with cardiovascular, coronary and cerebrovascular disease mortality adjusting for social determinants, cardiovascular risk factors, diet and water characteristics at municipal or provincial levels for the 651 municipalities (200,376 cardiovascular disease deaths) with complete covariate information.

The mean municipal drinking water arsenic concentrations ranged from less than 1 to 118 micro g/L, with 7 villages having mean arsenic concentrations greater than 50 micro g/L. When municipalities with arsenic concentrations less than 1 micro g/L were compared with municipalities with concentrations greater than 10 micro g/L, those in the higher exposure category tended to be younger, have higher levels of water hardness and pH and were located in provinces with less hospital beds per 1000 inhabitants, higher sex- and age-adjusted prevalence

HEALTH STREAM

of cardiovascular risk factors and lower intake of fish, wine, olive oil and total energy-adjusted folate.

In comparison to the overall Spanish population, sexand age-adjusted mortality rates for cardiovascular diseases (SMR 1.10, 95% CI 1.08-1.12), coronary heart disease (SMR 1.18, 95% CI 1.15-1.22) and cerebrovascular disease (SMR 1.04, 95% CI 1.011.08) were increased in the 89 municipalities with mean arsenic concentrations in drinking water of greater than 10 micro g/L, with no substantial sex differences. In the arsenic category of 1-10 micro g/L no increase in disease was observed except for coronary heath disease mortality among women (SMR 1.04, 95% CI 1.02-1.06).

In multivariable models adjusted for social determinants, cardiovascular risk factors, diet and water characteristics, cardiovascular mortality increased 0.8% (95% CI 0.1-1.6%) for each doubling in arsenic concentration. Compared to municipalities with arsenic concentrations less than 1 micro g/L, cardiovascular disease mortality was increased by 2.2% (95% CI -0.9% to 5.5%) in municipalities with concentrations between 1 and 10 micro g/L and by 2.6% (95% CI -2.0% to 7.5%) in municipalities with arsenic concentrations greater than 10 micro g/L, with consistent findings by sex, except a stronger association for arsenic 1-10 micro g/L category among women. For coronary heart disease mortality, fully adjusted relative risks were increased by 5.2% (95% CI 0.8% to 9.8%) in municipalities with arsenic concentrations between 1 and 10 micro g/L and by 1.5% (95% CI --4.5% to 7.9%) in municipalities with arsenic concentrations greater than 10 micro g/L and risks were stronger among women than men. For cerebrovascular disease mortality, the corresponding figures were 0.3% (-4.1% to 4.9%) and 1.7% (-4.9% to 8.8%), the association was weaker and not statistically significant.

This ecological study suggested that elevated arsenic concentrations in drinking water were associated with increased cardiovascular mortality even for low-tomoderate arsenic exposure levels. The association found for cardiovascular disease and coronary disease mortality among women was seen at arsenic concentrations below current standards (1-10 micro g/L). The results of this study need to be confirmed

MARCH 2010

PAGE 7

WATER QUALITY RESEARCH AUSTRALIA

by prospective cohort studies with individual measures of arsenic exposure, standardised cardiovascular outcomes and adequate adjustment for confounders. The findings of this study along with evidence of the carcinogenic, developmental and metabolic effects of arsenic emphasise the need to implement arsenic remediation treatments in water supply systems which are currently above the WHO guideline level of 10 micro g/L. Bottled Water A battle against the bottles: Building, claiming, and regaining tap-water trustworthiness.

Parag, Y. and Timmons Roberts, J. (2009) Society and Natural Resources, 22(7); 625-636.

It has been estimated that consumption of bottled water results in a 100 times greater environmental impact than consumption of tap water, and therefore increasing bottled water consumption has serious environment and societal impacts. The rise in bottled water consumption cannot be explained on a rational basis as the cost is many times greater than tap water and almost 60% of bottled water is made from tap water. Regulation of bottled water is generally less stringent than tap water and testing by independent or government scientists is less frequent. In most instances bottled water is not of better quality than tap water. This paper argues that the increasing departure from drinking tap water is at least partly the result of the growing distrust of tap water quality and of the state’s ability to protect the health of its citizens.

The bottled water industry continues to grow at a rapid pace in both the developed and developing world. In 2005, the global revenues of the bottled water industry were estimated at over $45 billion, and its consumption was growing faster than that of any other drink. The reasons why people chose to drink bottled water over tap water vary from person to person. Some prefer the taste of bottle water over tap water, for others it is a status symbol and others find it more convenient. Many drink bottled water because they perceive it as being a healthier and more trustworthy water source than tap water. There is much concern over the quality of tap water and for

HEALTH STREAM

over two decades there has been distrust in government regarding drinking water. The bottled water industry markets bottled water to be of superior quality to tap water for healthy lifestyles and therefore conveys to the public that tap water is not trustworthy. The consumer shift from tap to bottled water has only a minor economic effect on water providers and therefore there is no incentive for water providers to counter these marketing claims and to question the industry trustworthiness. The state also does not question the trustworthiness of the bottled water industry and therefore the public is only exposed to the message that tap water can not be trusted.

The question is, how can trust be restored among the roughly 50% of adults concerned with their tap water quality and health? The media typically focuses on negative and trust destroying stories such as waterborne epidemics or concerns about water contaminations and hazardous chemicals. Positive events, such as reports that indicate good tap water quality are overlooked and do not capture the public’s attention. Bottled water industry campaigns tend to focus on healthy lifestyles and the importance of good quality water consumption and are never challenged with any contradicting statements from water suppliers or the government that claim that tap water is as good and healthy for you as bottled water.

When anything threatens the legitimacy of the bottled water industry they respond promptly and firmly, unlike the state and water providers.

Before tap water quality standards are set, the proposed standards are analysed so to explore and present the full extent of their implications. If the analysis process is transparent, and the public is exposed to the analysis procedure and reports, then the public can reflect on the analysis and present their own point-of-view and knowledge. This has the potential to build trust in the governing institutions.

Citizen representation in the monitoring, analysis and evaluation process can contribute to building trust.

Public participation at this stage will enable the public to be exposed to the various problems, conflicts and compromises involved in drinking water issues and may encourage decision makers to improve tap water quality. Transparent decision

MARCH 2010

PAGE 8

WATER QUALITY RESEARCH AUSTRALIA

making procedures provide the public with some control over the decision making and reduces suspicions about inappropriate, biased or interestdriven policy decisions.

Once standards are set, it would be useful it the government and providers used risk communication practices to communicate the real meaning of the standards to the public in a language that is clear so they can understand and process the information.

Risk communication should be seen as an opportunity to show trustworthiness and an open, responsible and caring attitude. Involvement of independent third parties to monitor water quality has the potential to reassure the public of tap water quality and the trustworthiness of water providers.

Policy implementation and enforcement are real evidence of government trustworthiness when policymakers’ actions are visible. According to the U.S. Environmental Protect Agency (EPA), tap water quality implementation rates in the US are not high.

Enforcement procedures exist but appear to be currently not well used by governments. It has been suggested that some of the implementation and enforcement burdens are transferred from the state and water providers to other third party groups such as nongovernmental organisations (NGOs), local community representatives or commercial businesses. Independent checks by credible third parties have the potential to reassure the public about the tap water quality. If initial tests are not satisfactory, then providers have the opportunity to demonstrate their improvements to the public with each subsequent evaluation. Incentives for good implementation, subsidies, taxation and penalties can all contribute to trust building, as water providers’ preferences and interests may be changed and shaped in a way that meets with the public’s interest for good and trustworthy drinking water. There needs to be a public display that the tap water industry is being backed, for example, no longer having bottled water available at city-sponsored events and not drinking bottled water in government meetings and formal events. The ongoing evaluation of the policy and its performance as well as the introduction of new improvements all indicates trustworthiness. Both governments and water providers therefore must be

HEALTH STREAM

kept up-to-date with the latest research findings regarding water treatment, standards, health effects and technical innovations. Again these procedures need to be published and communicated with the public so they know what is going on.

Some complementary policies which only indirectly relate to tap water trustworthiness but are needed to reduce the environmental impacts of bottled water have been suggested. Currently the public is not informed well about the environmental impact of bottled water. If each bottle however carried a label about its full environmental impacts as compared to tap water then consumers may realise that they have a more environmental friendly option and reconsider purchasing the bottled water. There is no valid reason why people who do not drink bottle water should finance the handling and disposal of bottled water waste. The authors suggest that a small amount of every bottled water purchase should be dedicated to treating bottled plastic waste.

Dental Caries Factors associated with inter-municipality differences in dental caries experience among Danish adolescents. An ecological study.

Ekstrand, K.R., Christiansen, M.E.C., Qvist, V. and Ismail, A. (2010) Community Dentistry and Oral Epidemiology, 38(1); 29-42.

In Denmark, there is a national program for the dental care of children and adolescents which is organised at the municipality level. There are public clinics in 206 municipalities and in about 70 very small municipalities private practitioners provide dental care. All of the dental services are free of charge. Data is reported annually by each municipality on the oral health status of children using the same forms and criteria. The DMF index is used to express caries experience where D is cavitated caries, M is teeth extracted due to caries and F is restorations made due to caries. The first valid Danish national data on caries experience in 15 year olds were collected in 1988 and the mean DMFS score was 6.7, this declined to 3.0 in 2003. In 1999, an ecological evaluation reported large intermunicipality variation in caries experience. About

MARCH 2010

PAGE 9

WATER QUALITY RESEARCH AUSTRALIA

45% of the disparity in mean DMFS scores can be explained by variation in fluoride concentration in drinking water supply and in the educational status of the mother of 15 year old children. Therefore over 50% of the variation is unexplained. The aims of this current study were to repeat the analysis done on the 1999 sample, but now on a 2004 sample and then compare it with the 1999 results and by interviewing chief dental officers (CDOs), determine their interpretation of relevant conditions in the public dental health service in relation to the disparities in caries experience across Denmark.

To be included in this analysis, municipalities had to provide data on dental caries experience of at least 60% of the 15 year old children in 2004 and a similar threshold was used in 1999. Of the 206 municipalities, 191 and 204 met the initial inclusion criteria in 2004 and 1999, respectively. Mean DMFS among 15 year olds was used as the outcome variable. Comparison between mean DMFS in 1999 and 2004 was based on 189 municipalities as there were two municipalities in 1999 which did not match the inclusion criteria. The eight variables that were used to model the differences among the municipalities were: cost per child per year (mean) DKK, children/dentist ratio (mean), auxiliary personnel/dentist ratio (mean), concentration of fluoride in the water supply (mean) ppm, personal income (mean) DKK, mother with greater than or equal to 10 years education to 15 year olds (percentage), immigrants (median), size of the municipalities in terms of number of 0-18 years (mean) and DMFS. The municipality was the unit, not the individual child. All the data used were based on the means or medians from the period 1995/1996 to 2004 in the present sample and from 1987 to 1999 in the former sample.

The interview with the CDOs evaluated four areas within the dental service in the municipalities: (i) stability concerning manpower, number of patients and economy (stability); (ii) continuing education in cariology of the dental staff (continued education); (iii) availability of stated goals for dental health in the municipality (goals); and (iv) the level of emphasis placed on prevention of caries in the operations of the clinics (prevention of caries). There

HEALTH STREAM

were three groups of CDOs selected representing 30 municipalities. Group 1 included the 10 CDOs representing those municipalities with the most positive improvement in mean DMFS scores, based on the residuals, between 1999 and 2004. Group 2 included the 10 CDOs representing the municipalities where the standardised residual were closest to 0, indicating no change in mean DMFS between the two periods and Group 3 included the 10 CDOs representing those municipalities with the most negative change between 1999 and 2004.

In 2004, the lowest mean DMFS among the municipalities was 0.56, the highest was 6.19 and the national mean was 2.82. The corresponding measures in 1999 were 0.88, 8.73 and 3.53. There were 80% of municipalities that had achieved a lower mean DMFS in 2004 relative to their 1999 status. There were 16% of municipalities that had a higher caries level in 2004 compared to 1999 and about 4% that had the same mean DMFS status. Nationally the level of improvement from 1999 to 2004 was 18% (P less than 0.01). Multiple regression analyses of the background variables associated with the change in caries experience found that only fluoride in the water supply and the length of the education of the mothers had a significant influence over the variation in the mean DMFS scores, explaining about 44% of the variation. Analyses of 2004 and 1999 data of fluoride concentration in the water supply and DMFS found a clear drop in mean DMFS as the fluoride concentration in the water supply increased from trace levels up to a level of about 0.35 ppm. After this level there was no clear trend. Interviews with the CDOs found that two factors were of significance in achieving better caries experience data in the municipalities; (i) that the CDO had stated goals, and (ii) that the CDO had a strong focus on caries prevention. Instability concerning manpower, number of children in the service and economy, were also found to be important for those municipalities which achieved worse results. A confounding factor was that both the observed caries experience and the predicted caries experience in 1999 in those municipalities that had the best improvement was higher than in those with the worse or no improvement. It may however be easier for municipalities with high caries levels to obtain a

MARCH 2010

PAGE 10

WATER QUALITY RESEARCH AUSTRALIA

significant reduction. Those municipalities which had a worsening in their caries status from 1999 to 2004 had, however, on average higher mean DMFS scores than the national average in 1999.

The data from this study supports that fluoride in the water supply is important in caries prevention. The fluoride concentration in the water supply was the single strongest factor in both 1999 and 2004 and was moderately and negatively correlated to mean DMFS. It appears that stability of manpower and economy, implementation of goals in the dental service as well as modern focus on carries prevention are all important factors if an improvement in caries status is desired.

Disinfection Byproducts The formation and control of emerging disinfection by-products of health concern.

Krasner, S.W. (2009) Philosophical Transactions of the Royal Society A: Mathematical, Physical and Engineering Sciences, 367(1904); 4077-4095.

Disinfection of public drinking water supplies with chlorine and other disinfectants has been extremely important in the prevention of infectious waterborne diseases. However, a wide range of disinfection byproducts (DBPs) of health and regulatory concern are formed through the reaction of a chemical disinfectant with an organic precursor (natural organic matter) and an inorganic precursor (certain halide ions). Toxicological studies have shown that certain DBPs cause cancer in the liver, kidney and/or large intestine of laboratory animals and that certain DBPs can cause adverse reproductive of developmental effects. Epidemiological studies have indicated a slightly increased risk for bladder, colon and rectal cancers in those who have been exposed to chlorinated surface waters for many years. Also, some epidemiology studies have found an association between consumption of chlorinated drinking water and adverse reproductive or developmental health effects, such as spontaneous abortion or foetal anomalies. Many countries regulate (or provide guidance for) selected DBPs (e.g. trihalomethanes (THMs) and haloacetic acids (HAAs)) in drinking water. The regulation of THMS (and HAAs in the

HEALTH STREAM

USA) is based on their use as ‘surrogates’ for the toxicity associated with chlorinated water. It is also known that the control of THMs and HAAs has resulted in general, in a reduction in the concentration of many other DBPs, as well as unknown chlorination DBPs, which may be associated with adverse health effects. Recent studies however, suggest that certain emerging DBPs of potential health concern can be formed when alternative disinfectants to chlorine (i.e. ozone, chloramines, chlorine dioxide) are used to minimise the formation of the regulated chlorination DBPs. The formation of some of these emerging DBPs may be due to impaired drinking water supplies (e.g. impacted by treated wastewater, algae, iodide).

Surveys in the USA and Canada in the 1990s and 2000s have provided data for assessing the formation, occurrence and control of emerging DBPs that are not currently regulated in the USA. The emerging byproducts of concern include: iodinated disinfection by-products, haloacetaldehydes, halonitromethanes (HNMs) and nitrosamines that may be more toxic than some of the regulated ones. Iodinated THMs can occur under both chlorination and chloramination conditions. However, their formation is highest when chloramines are used with ammonia added before chlorine. Dichloroacetaldehyde was found in highest concentrations in some waters disinfected with chloramines and ozone (with no biological filtration).

Some of the HNMs have been formed at higher levels during post-disinfection when pre-ozonation was used. N-nitrosodimethylamine (NDMA) formation has been primarily associated with waters that were chloraminated.

Disinfection/oxidation and treatment practices may be optimised to minimise (within limits) the formation of both the regulated and emerging DBPs. Pre-oxidation with chlorine, chlorine dioxide or ozone may destroy or transform the precursors for NDMA. Pre-oxidation with chlorine or ozone can oxidise iodide to iodate which can then minimise the formation of iodinated DBPs during postchloramination. However, pre-ozonation has been found to increase the formation potential for trihaloacetaldehydes and HNMs (and form bromate), although subsequent biological filtration may reduce

MARCH 2010

PAGE 11

WATER QUALITY RESEARCH AUSTRALIA

the formation potential of these two classes of organic DBPs. Exposure to DBPs is highly prevalent because of the use of some disinfectant or oxidant at drinking water treatment plants in most parts of the world. The challenge for scientists, engineers, utility staff, regulators, toxicologists and epidemiologists is to be aware of both emerging DBPs and emerging sources of DBP precursors and how their formation and control may be similar to and/or different from that of the currently regulated DBPS. A cost-effective means of controlling a wide range of DBPs which have varying degrees of toxicity and therefore human health consequences is required.

Organotin Using probabilistic modeling to evaluate human exposure to organotin in drinking water transported by polyvinyl chloride pipe.

Fristachi, A., Xu, Y., Rice, G., Impellitteri, C.A., Carlson-Lynch, H. and Little, J.C. (2009) Risk Analysis, 29(11); 1615-1628.

In the U.S. and Canada, the most commonly used pipe materials in residential plumbing system are polyvinyl chloride (PVC) and chlorinated polyvinyl chloride (CVPC), hereinafter referred to as PVC. Several compounds are added to PVC during manufacturing to produce pipes which are durable and resistant to biofilm formation, including mixtures of organotin (OT) compounds that act as stabilisers protecting the polymer from the high temperature and pressure encountered during the manufacturing process. These OT stabilisers contain mainly monoand di-substituted alkyltin chloride species of butyltins and methyltins. These OT compounds do not react completely with the PVC polymer and some OT remain unbound in the polymer after manufacture. OT mixtures are also used to lubricate the pipes during manufacture and residual OT may remain on the inner surface of the pipe. When the pipe is being used, unbound OT can migrate towards the pipe surface and leach into the water supply. This is a potential health concern because OT may be a human nervous system, developmental and reproductive toxicant. Health Canada studies have

HEALTH STREAM

demonstrated that OT compounds can occur in drinking waters passing through PVC pipes, however these data are of limited use for evaluating human OT exposures through contact with U.S. drinking waters because of the small number of samples taken and the lack of data on the temporal variability of OT concentrations. The problem of insufficient occurrence data is addressed in this article by using mathematical models to simulate the leaching of OT from PVC pipe into transported waters, then predicting the resulting concentrations in the transported drinking waters.

The models used were based on diffusion and convection mass-transfer theory and accounted for partitioning between the polymer and the external phase, which is defined as the water contacting the inner surface of the PVC pipe. The models required the input of several physical properties of the OT, the polymer and the external phase. OT leaching is influenced by several factors including the mobility of the OT in the polymer relative to that of the external phase, the relative volumes and surface areas of the external phase to the polymer and the degree of mixing in the external phase. A human exposure model was then used which integrated the predicted leaching rates and OT concentrations with drinking water intake data and then the probability distributions of U.S. population exposures to OT mixtures were estimated through drinking contaminated tap water.

The mean rate at which OT was leached (Mt ) was estimated to be 12.26 plus or minus 3.32 x 10-3 micro g/m2-day (90th percentile = 12.94 micro g/m2-day).

The mean predicted OT concentration in drinking water (Cw) was estimated to be 0.768 plus or minus 5.05 x 10-4 micro g/L (90th percentile = 0.895 micro g/L). To develop a realistic estimate of the distribution of OT exposures from the consumption of drinking water, OT concentrations were reestimated based on data from a case study that estimated the amount of piping in a drinking water system for a “typical larger single-family home in California�. The mean predicted case study OT concentration (Ccs) was 27.35 plus or minus 7.40 x 10-3 micro g/L (90th percentile = 28.88 micro g/L).

The concentrations increased during the first 24 h

MARCH 2010

PAGE 12

WATER QUALITY RESEARCH AUSTRALIA

with a gradual decrease over the course of a year. OT concentrations were also estimated for residences where there is no water use during extended absences (e.g. vacation homes). Mt is predicted to reach a steady state value of 0.523 micro g/m2-day after about 8 days, corresponding to an estimated OT concentration at first draw equal to 2.67 micro g/L. The predicted OT exposures for a 1-m pipe with an average surface area of 0.06 m2 (micro g/kg-day) by life stage were calculated. The largest mean exposures were seen for male infants (birth to less than 1 month): 0.136 plus or minus 0.053 micro g/kgday (90th percentile = 0.187 micro g/kg-day) and female infants (1 to less than 3 months): 0.156 plus or minus 0.041 micro g/kg-day (90th percentile = 0.196 micro g/kg-day). Overall, the mean exposure for infants was the largest among all life stages (0.053 plus or minus 0.034 micro g/kg-day [90th percentile = 0.086 micro g/kg-day]). Case study OT exposures were found to be higher reflecting the high pipe surface area to water volume ratio which can exist in residential plumbing. The largest overall mean exposures were seen for infant males (birth to less than 1 month): 4.69 plus or minus 1.53 micro g/kg-day (90th percentile = 6.16 micro g/kg-day) and infant females (1 to less than 3 months): 5.38 plus or minus 0.97 micro g/kg-day (90th percentile = 6.32 micro g/kg-day). Overall the mean exposure for infants was the largest among all life stages (1.83 plus or minus 1.06 micro g/kg-day [90th percentile = 2.86 micro g/kg-day]). Exposures for males during the ages 21-30 years were found to have the most impact on lifetime exposures and exposures during the ages of 70-85 years to have the least impact.

Exposures for females during the ages 50-70 years have the most impact on lifetime exposures and exposures during the ages 11-16 years were found to have the least impact.

The results of this analysis suggest that human OT exposures through tap water consumption are likely to be considerably lower than the World Health Organization (WHO) “safe� long-term concentration in drinking water (150 micro g/L) for dibutyltin (DBT) which was the most toxic OT considered in the analysis. The estimated 90th percentile Cw and Ccs are approximately 20 and 550 times greater,

HEALTH STREAM

respectively than the highest level reported in occurrence studies (0.053 micro g/L). The overall 90th percentile average daily dose (ADD) estimate in this study was 0.034 plus or minus 2.92 x 10-4 micro g/kg-day which is approximately 125 times lower than the WHO-based ADD for DBT (4.2 micro g/kgday). The 90th percentile ADD estimate for the case study of 1.15 plus or minus 6.29 x 10-3 micro g/kgday is approximately four times lower than the WHO ADD for DBT. The model results found here suggest that intakes associated with ingestion of tap water contaminated with OT mixtures that leach form PVC pipe are below levels that are know to be associated with adverse health effects. The OT leaching model used in this analysis appears to provide reasonable estimates of OT leaching rates based on comparisons with the limited occurrence data. Future OT exposure assessments need to include information on other exposure pathways such as dermal absorption of OT and OT exposure via consumer goods and foods. A thorough validation of the leaching rate model has not been conducted and it is recommended that the models be tested using a variety of data.

Outbreaks Mixed viral infections causing acute gastroenteritis in children in a waterborne outbreak.

Rasanen, S., Lappalainen, S., Kaikkonen, S., Hamalainen, M., Salminen, M. and Vesikari, T. (2010) Epidemiology and Infection, 1-8. doi:10.1017/S0950268809991671 Gastroenteritis viruses cause both seasonal acute gastroenteritis (AGE) and occasional outbreaks in developed countries which are associated with contaminated food or water. In children, rotaviruses (RVs) are the most common cause of seasonal AGE and are also infrequently associated with outbreaks.

Noroviruses (NoVs) which are human caliciviruses (HuCV), are the second most common cause of seasonal AGE in young children in Finland and elsewhere. NoVs are the most common causative agents in outbreaks of AGE in both children and adults worldwide. An outbreak of AGE occurred in

MARCH 2010

PAGE 13

WATER QUALITY RESEARCH AUSTRALIA

late 2007 near Tampere in southern Finland, due to contamination of drinking water with sewage. This study investigated cases of AGE in children from the contaminated area who were seen in Tampere University Hospital between 28 November and 31 December 2007 and examined the stool specimens for various causative agents.

On 28 November 2007 in Nokia, a town of about 30,000 inhabitants near Tampere, drinking water was contaminated with treated sewage. It was estimated that thousands of people had symptoms of AGE and there were at least 758 patients who visited public health centres in the following days and weeks. There were 115 children requiring rehydration therapy that were referred to Tampere University Hospital. There were 65 children who were enrolled in the study and stool samples were obtained from 50 cases, 28 who were hospitalised and 22 who were treated as outpatients. Clinical information was collected from a questionnaire completed by parents and from hospital records on each AGE episode including the date of onset of symptoms, frequency of vomiting and diarrhoeal stools and fever. Information was also collected on whether the child had received one or more RV vaccines. AGE episodes were scored for severity using a 20-point scoring system. Using PCR methods, RVs, HuCV, Adenoviruses (AdVs), human bocaviruses (HBoVs) and Aichi viruses (AiVs) were detected in stool specimens. All positive amplicons were sequenced to confirm the results and to determine the virus genotype. Thirty-three of the 50 stool specimens were studied for enteropathogenic bacteria by bacterial culture, which detects Campylobacter, Salmonella, Shigella, Yersinia, Aeromonas and Pleisomonas.

Out of the 50 stool specimens, 33 (66%) were RV positive, 31 (62%) were HuCV positive, five (10%) were AdV positive and 25 (50%) were AiV positive.

In 20 (40%) of cases both RV and HuCV were found; 10 (20%) of cases also had a third virus and two (4%) of cases had four viruses present. C. jejuni was found in 20 of the 33 (61%) and Salmonella sp. in 4 of the 33 (12%) cases. Of the 33 RV positive cases, 32 were of genotype G1p[8] and one was of genotype G4P[8].

All of the RVs of genotype G1 were identical. RV was the only identified viral AGE pathogen in six

HEALTH STREAM

stool samples for the rest of the samples RV was mixed with other viruses. Of the 31 HuCVs, 20 were NoVs and 11 were sapoviruses (SaV). Of the NoVs, 10 out of 20 belonged to genogroup GII and only one to genogroup GI. Of genogroup GII NoVs, 12 were genotype GII.4. Of the 11 SaVs, eight different genotypes were found. In five out of the 50 cases NoV it was the only viral pathogen found. There were no cases in which SaV was the only viral pathogen. Two of the five cases of AdV were of group A, one of group C and two of group F. All of the AdV-positive cases occurred in mixed infections.

In 24 of the 25 cases of AiV it was found in mixed infections and in only one case no other AGE viruses were found. This if the first AGE outbreak in which AiVs have been found in Finland. HBoV was found in four of the stool samples and the only pathogen identified in one of the four positive stool samples. In the other three cases, HBoV was presented as part of a mixed infection. C. jejuni and Salmonella sp. were both always found in mixed infections with one or more AGE viruses. There were three children that had been vaccinated again RV. In all of these cases ELISA for RV antigen was negative, but in one case a weak positive RV-type G1 was detected with RTPCR. This finding suggests that vaccination probably protected these children from RV AGE and only minimal replication of wild-type RV occurred in this one case. In all three cases other pathogens were found.

The median age of children in the study was 2 years and 6 months. The median severity score of the hospitalised children (n=28) was 17, which indicates an unusually severe disease. The simultaneous and massive exposure to several pathogens of children in this study explains the unusually severe clinical picture found in these cases. There was no difference in severity scores of cases caused by single viruses or different combinations of viruses, or combinations of viruses and bacteria. The only significant difference between the various pathogens or combinations of pathogens and symptoms was that bloody diarrhoea occurred only when C. jejuni was found in the stool samples. Four children had bloody diarrhoea and in each of these cases a combination of pathogens including C. jejuni and RV was found.

MARCH 2010

PAGE 14

WATER QUALITY RESEARCH AUSTRALIA

Perfluorooctanoic acid (PFOA) Congenital anomalies, labor/delivery complications, maternal risk factors and their relationship with perfluorooctanoic acid (PFOA)contaminated public drinking water.

Nolan, L.A., Nolan, J.M., Shofer, F.S., Rodway, N.V. and Emmett, E.A. (2009) Reproductive Toxicology, doi:10.1016/j.reprotox.2009.10.012 Perfluorooctanoic acid (PFOA) and it salts have been used for decades in a variety of industrial and commercial applications including the production of tetrafluoroethylene and the manufacturing of protective coatings for carpets, apparel, house wares and fire-fighting foams. PFOA is highly water soluble and resistant to biological, environmental and photochemical degradation. PFOA is ubiquitous in ground water and wildlife. In the general U.S. population, median serum PFOA values are at 4-5 ng/mL and a mean serum half-life ranging from 2-4 years. Rodent studies have shown that chronic PFOA exposure is associated with developmental toxicity.

Studies in humans examining the relationship between serum PFOA levels and foetal development have shown some consistent results (e.g. lack of an association between PFOA and gestational age) and others have not (e.g. the negative association between PFOA and birth weight). The associations between PFOA exposure, birth weight and gestational age in individuals exposed to PFOA-contaminated residential drinking water from the Little Hocking Water Association (LHWA) in Washington County, Ohio have previously been examined by the authors and no evidence of a negative association was found.

Since the original findings were published, the association between PFOA exposure and selfreported pregnancy outcome among LHWA residents was reassessed using direct measurement of maternal serum PFOA levels. No apparent association was found between PFOA exposure and low birth weight or preterm birth. Preeclampsia was weakly associated with PFOA exposure as were birth defects with exposures above the 90th percentile. This current investigation expands on the scope of the prior analysis in the same cohort of neonates and mothers.

HEALTH STREAM

This cross-sectional study used de-identified, recordlevel, archival data for all births occurring in Washington County from January 1, 2003 until September 1, 2005. A dataset with medically validated rather than self-reported pregnancy outcomes was provided by the Ohio Department of Health. The zip codes in Washington County were divided into three categories. The first category obtained public water service exclusively from the LHWA (LHWA Only). The second category (Partial LHWA) included zip codes with water in part from the LHWA, the Belpre Water System and others. The third category comprised zip codes in Washington County entirely outside the service area of the LHWA or Belpre water System (No LHWA). Mean PFOA levels were available for several of the public water facilities in Washington County and indicated substantial PFOA contamination in the LHWA and to a lesser extent, Belpre Water. There were 1548 live born neonates included in the study that were born to mothers residing in Washington County, during the study period for which complete records were available for the covariates of interest. Logistic regression analyses were performed on singleton neonatal birth outcome data to examine the associations of interested. When possible, models were adjusted for maternal age, preterm birth, neonatal sex, race, maternal education, alcohol use, tobacco use and diabetic status.

There were 1171 newborns born to mothers residing in the No LHWA category, 209 were born to mothers residing in the Partial LHWA category and 168 were born to mothers residing in the LHWA Only category. There were 1.8% of neonates born to LHWA Only mothers that were diagnosed with one or more congenital anomalies compared to 2.0% in the No LHWA category and 1.9% in the Partial LHWA. After adjustment for maternal age, preterm birth, parity, sex, race, maternal education, diabetic status, alcohol and tobacco use, the likelihood of any congenital anomaly was not significant across water service strata (p greater than 0.05). The rate of congenital anomalies for each water service category was not statistically significantly different from the national birth prevalence rate of 3% (p greater than 0.05).

MARCH 2010

PAGE 15

WATER QUALITY RESEARCH AUSTRALIA

There were 31.5% of LHWA Only mothers who developed complications associated with labour and delivery, 41.9% of No LHWA mothers and 35.9% of Partial LHWA mother. Overall, LHWA Only births were associated with a decreased likelihood of complications (p=0.016) in comparison to No LHWA births. LHWA only mothers had an increased likelihood of being diagnosed with dysfunctional labour in comparison to No LHWA mothers (crude OR: 5.3, 95% CI: 1.2-24), but the number of cases was small. No association between dysfunction labour and the Partial LHWA category was found.

Both LHWA Only and Partial LHWA mothers had significantly decreased likelihoods of developing other labour and delivery complications not specifically categorised by the dataset (crude OR: 0.57, 95% CI: 0.38-0.85; crude OR: 0.51, 95% CI: 0.35-0.74, respectively).

There were 37.5% of LHWA Only mothers that had one or more risk factor commonly associated with potentially adverse pregnancy outcomes compared to 39.3% of mothers in the No LHWA category and 34.4% of mothers in the Partial LHWA category. In the adjusted model, the overall likelihood of any maternal risk factor across water service strata was not significantly different (p greater than 0.05).

LHWA Only mothers had a significant increase in the likelihood of anaemia compared to mothers outside the LHWA (crude OR: 11, 95% CI: 1.8-64) however the number of cases was small. A modest increase in the likelihood of eclampsia was seen among No LHWA mothers but this was not statistically significant. Mothers residing in the Partial LHWA also had a significantly decreased risk of small for gestational age compared to the No LHWA mothers (crude OR: 0.14 95% CI: 0.02-0.99).

These findings suggest that PFOA is not associated with an increased risk of congenital anomalies, most labour and delivery complications and maternal risk factors. Further studies are required to assess the findings of associations between anaemia, dysfunctional labour and PFOA. Pharmaceuticals Occurrence of pharmaceuticals and hormones in drinking water treated from surface waters.

HEALTH STREAM

Vulliet, E., Cren-Olive, C. and Grenier-Loustalot, M.F. (2009) Environmental Chemistry Letters, 1-12. doi:10.1007/s10311-009-0253-7 Interest has grown in the last decade concerning the presence of organic compounds such as pharmaceuticals and hormones in aquatic environments. These compounds enter the environment mostly through wastewater effluents from municipal treatment plants, hospital effluents and from livestock activities. There has been much published data concerning their occurrence in sewage effluents and receiving water but little data concerning pharmaceutical products or hormones in drinking waters. This present study aimed to determine the levels of a wide variety of pharmaceuticals, including hormones, in surface and potable-water supplies in French drinking water treatment plants (DWTP), in order to assess the potential for these compounds to resist drinking water treatments. This type of data is necessary to design appropriate monitoring and to provide a basis for the assessment of potential human health risks.

Water samples were collected in March-April 2007, January 2008 and September-October 2008 in influents (surface waters) and finished water of 8 DWTP currently operated in France. There were 51 target compounds tested for including: beta-blockers, psycholeptics, diuretic antibiotics, analgesics and anti-pyretic, antihyperlipidemics, contraceptives, natural hormones, antimicrobial and veterinary products. The 51 compounds were divided into four groups corresponding to the four analytical methods developed to determine their concentration.

Of the 51 compounds, there were 27 present at least once in a sample of surface water, with a level superior to limits of quantification (LOQ). None of the surface water sampled was steroid free. There were three pharmaceuticals that were quantified in more than 80% of the samples. These were analgesics (paracetamol and salicylic acid, the main metabolite of aspirin) and psycholeptic (carbamazepine). Paracetamol and aspirin are the two most widely used drugs in France and carbamazepine is one of the most prescribed psycholeptics. There was a wide disparity in concentrations of compounds

MARCH 2010

PAGE 16

WATER QUALITY RESEARCH AUSTRALIA

among surface waters and even within samples from the same site. There were 12 other substances that were widely found in the influents studied, and they contaminated between 33 and 80% of the samples.

These substances correspond to families of drugs dispensed at the highest levels in France: analgesics (ibuprofen, ketoprofen, naproxen and diclofenac), psychotropic drugs (oxazepam), antibiotics (sulphamethoxazole, trimethoprim), antihyperlipedemics (bezafibrate, fenofibric acid and pravastatine) and beta-blockers (atenolol, metoprolol). The regular detection of 15 of the 26 pharmaceuticals in raw waters is consistent with previous reports. In surface samples there were 7 out of the 25 target steroids determined.

All of the final waters of the DWT plant contained at least one compound above the LOQ. Of the target compounds, 25 of them were present at least one in one of the final samples. Most treatments therefore fail in their total elimination of these compounds. In particular the pharmaceutical salicylic acid is regularly present in drinking waters with concentrations above LOQ. This was the most frequently detected compound, with 19 ng/L quantified in one treatment plant. Carbamazepine (maximal concentration 10.7 ng/L) and beta-blocker atenolol found at lower levels (maximum 2 ng/L) were present in more than 30% of the drinking waters. The pharmaceuticals showed different reactivity towards the treatments with some surviving and others reduced to non-detectable concentrations.

However, progestagens and androgens seem to be resistant to most treatments. In general, the plants that included the largest number of processes during treatment appeared to be the most effective at eliminating pharmaceuticals. The plant which had only a filtration step seemed less effective at eliminating these compounds. Treatment processes such as sand filtration or coagulation/flocculation using iron or polyaluminium chloride have not been found to be effective in removing some pharmaceuticals from surface water and therefore it is not surprising to detect pharmaceutical compounds at the end of these treatments. The reactivity of ozone with most pharmaceuticals is expected to be high however this was not the case in the analysed

HEALTH STREAM

samples from five plants in which salicylic acid, atenolol and carbamazepine were detected.

When comparing the results of drinking water samples with those of surface waters tested in this study, the same steroids were detected with comparable frequencies with concentrations in the same order of magnitude. Only the natural oestrogen E1 was rarely detected in the finished water.

Potential risks from indirect exposure to a range of pharmaceutical compounds via drinking water consumption have been evaluated in the literature.

Findings are in agreement that risks are low for adult populations. The concentrations determined in this study were lower or in the same order as those tested by these authors, and therefore the risks to adults consuming drinking water tested in this study are low. This may not be the case for sensitive populations such as children and pregnant women however. Risks of pharmaceuticals also have only been assessed on the basis of individual compounds and the potential effects of a mixture of pharmaceuticals on human health, short or long term, are not yet known.

POU treatment Intermittent slow sand filtration for preventing diarrhoea among children in Kenyan households using unimproved water sources: Randomized controlled trial.

Tiwari, S.S.K., Schmidt, W.P., Darby, J., Kariuki, Z.G. and Jenkins, M.W. (2009) Tropical Medicine and International Health, 14(11); 1374-1382.

Diarrhoeal diseases account for around 1.9 million child deaths per year with about 38% of these occurring in Africa. In developing countries, inadequate water quality and quantity along with poor sanitation and hygiene all contribute to the endemic transmission of pathogens. There is still 1/5th of the world’s population that depends on unimproved water sources. There have been recent efforts to reduce endemic childhood diarrhoea by the development and promotion of treating water at the point of use (POU). It is thought that by improving water quality in the home through low cost household water treatment (HHWT) and safe storage, childhood diarrhoea will be reduce by 25-35%. Intermittent

MARCH 2010

PAGE 17

WATER QUALITY RESEARCH AUSTRALIA

show sand filtration, known as the Manz or BioSand Filter (BSF) is one of the HHWT technologies that has been promoted as it is robust and durable, simple to use and maintain, has no recurring purchases, high flow rate (3-60 l/h) sufficient for domestic and drinking needs, can treat highly turbid waters and can be locally fabricated and therefore is affordable (US $15-25/unit). Under controlled conditions the BSF has been found to remove 100% of Giardia lamblia cysts, 99.98% of Cryptosporidium oocysts, 95-99% of bacteria, variable and lower amounts of virus and reduce turbidity to below 2 NTU. Even though BSF has been used by an estimated half million people, there has been relatively little focus on its effectiveness in reducing childhood diarrhoea.

Significant improvements have been recently reported in drinking water quality and all-age reduction of diarrhoea incidence from the first randomised controlled trial of BSF. This study was undertaken to gather further evidence by evaluating the health effects of the BSF on child diarrhoea in poor rural Kenyan households at high risk for childhood diarrhoeal diseases using unimproved polluted drinking water sources.

A randomised controlled trial was conducted of households living in the River Njoro watershead (RNW). Households were eligible if they had at least one child under the age of 3 (later changed to 4 years), used river water as a primary or secondary drinking water source, had a monthly income less than Ksh 40000 (US $65) for the upper and less than Ksh 6000 (US $97) for middle watershed areas, lived in hatched roof homes with mud floors, lived near the river, the mother had less than an 8th grade education and they had stable residence for the next 12 months.

There were 60 qualifying households in the final enrolment. Households were stratified by river section into 10 strata, according to the household’s river watering point location, to account for faecal pollution trends along the river. Households were randomly assigned to the intervention (BSF users) or control (continue with usual water use practices) groups. One control dropped out leaving 29 households in the control arm.

Those with the intervention were visited by technicians to check on proper filter functioning and

HEALTH STREAM

use and instruct on filter maintenance. Intervention households were advised to use BSF treated river water for all domestic purposes. Monthly monitoring including BSF influent, effluent and drinking water quality for faecal coliforms was conducted from April to September 2007. During the same period, mothers were asked whether each child in the household had had diarrhoeas during the previous 7 days, and if so, the number of days of diarrhoea.

Drinking water geometric mean faecal coliform concentration was significantly better in the intervention households (30.0 CFU/100 ml, 95% CI: 21.3, 42.1; n=175) than in control households (88.9 CFU/100 ml, 95% CI: 58.7, 135; n=173) (P less than 0.001). Improved drinking water quality in the intervention over control households was notably more pronounced among trial households in the upper watershed compared to those in the middle.

Upper watershed households had no access to improved water sources and very limited rainwater storage unlike middle watershed households, and therefore, used river or equally contaminated spring water for drinking more frequently. Among all-age children, daily prevalence of diarrhoea in the intervention group was 2.0% compared to 5.2% in the control group. Age-adjusted estimated relative risk for daily diarrhoea, controlled for repeated measures at the child-level and household clustering was 0.46 (95% CI = 0.22, 0.96, P=0.038) for all children and 0.49 (95% CI=0.24, 1.02, P=0.057) for children under 5 years. When age-adjusted relative risk was analysed separately by watershed position, a greater reduction in child diarrhoea due to use of the BSF to treat river water was seen in households located in the upper watershed (RR = 0.23, 95% CI=0.10, 0.51), where they depend on river water for drinking all or most of the time, than in the middle watershed (RR = 0.81, 95% CI=0.24, 2.69) where improved sources and rainwater storage were more likely available and to be consumed.

This study provides additional support for adding intermittent slow sand filtration to the current range (chlorination, ceramic filtration, solar disinfection and flocculation/disinfection) of established POU treatment technologies. This study suggests that BSF may be more effective for improving health among

MARCH 2010

PAGE 18

WATER QUALITY RESEARCH AUSTRALIA

low-income households with no or limited access to improved water sources.

Uranium Uranium in drinking water: Renal effects of longterm ingestion by an aboriginal community.

Zamora, M.L.L., Zielinski, J.M., Moodie, G.B., Falcomer, R.A.F., Hunt, W.C. and Capello, K. (2009) Archives of Environmental and Occupational Health, 64(4); 228-241.

In 1993in Kitigan Zibi, a community located in Quebec, approximately 120 km north of Ottawa, Canada, routine analysis of groundwater samples showed that five wells in the community exceeded the Canadian uranium guideline of 100 ppb for drinking water. An extensive survey was then conducted in 1994 which showed that of the 113 wells sampled, 10 contained water with a uranium concentration exceeding 100 ppb, 11 with concentrations between 50 and 100 ppb, 36 with uranium levels between 20 and 50 ppb, and 56 with concentrations between 10 and 20 ppb. The highest value found was 845 ppb. Between 1995 and 1997, water treatment devices were installed in the17 homes with the highest uranium levels and concentrations were reduced to less than 2 ppb. In 1996, in response to community concerns about the potential heath effects of consuming ground water with elevated uranium levels, it was requested that a study be conducted to determine if health problems seen in Kitigan Zibi residents were uranium-intake related. The study was designed to detect adverse effects on kidney function as a result of consuming drinking water containing uranium.

Volunteers were chosen for the study from 3 groups: (1) homes with uranium levels exceeding the federal guideline of 100 ppb uranium but which, after installation of treatment devices were in compliance at the time of sampling; (2) residences in which uranium levels were below the guideline but well above background and had not yet been remediated; and (3) homes in which the uranium concentrations were at or close to background levels. There were four indicators of exposure considered to determine the correlation between uranium intake and urinary biomarkers levels. These included: (1) the uranium

HEALTH STREAM

concentration in 24-h urine samples collected at the time of the survey (U_Excr); (2) intake during the most recent period of exposure (U_Last; up to 2.8 years), taken to be from the time of sampling back to the date of water treatment plus one year; (3) the highest concentration of uranium in drinking water ingested by each participant over the 15-uear period preceding the study (U_Max); and (4) the total timeintegrated uranium intake over a period of up to 15 years preceding the study (Tot_In). Questionnaires were administered to participants to gather information related to water supply history (e.g., source, treatment), residential history, health history as well as fluid consumption. The fluid consumption questionnaire included information on intake of tap water at home and work as well as nontap water beverages. There were two types of biomarkers used: (1) indicators of kidney function and (2) markers for the location of cell damage. Three urine samples were collected from each participant: (1) a spot urine sample to screen for casts as well as for blood and urinary tract infections, which may interfere in subsequent bio-indicator measurements; (2) an 8-h urine sample collected between 10pm and 6pm for B2-microglobulin (BMG) and enzyme (ALP, GGT; NAG and LDH) measurements; and (3) a 24-h urine sample for measurements of urine volume, specific gravity, glucose, albumin, creatinine and uranium.

There were 54 volunteers (15 males, 39 females) who were included in the statistical analysis. Males were aged 12 to 61 years and females were aged 12 to 73 years. As no clear reference group could be identified from this population because even those with the lowest concentration of uranium in their drinking water were potentially exposed to uranium at previous addresses or through intake from other sources, the results for the 3 groups of homes were pooled for statistical analysis regardless of place of residence or source of drinking water. The range for uranium concentration in 24-h urine (U_Excr) samples collected at the time of survey was 0.2-1.3 micro g U/day, whereas the range for the highest concentration of uranium in drinking water (U_Max) was 0.4-845 micr g U/L of water over the 15-year exposure period. Total intake over the 2.8 years immediately preceding the study (U_Last) varied from 0 to 302 mg U, whereas the total uranium intake

MARCH 2010

PAGE 19

WATER QUALITY RESEARCH AUSTRALIA

over the 15-year period preceding the study (Tot_In) ranged from 0 to 1761 mg U. Uranium excreted in the urine (U-Excr) correlated best with the 15-year time-integrated intake (Tot_In) and was the most direct indicator of kidney exposure to uranium, therefore conclusions drawn in this study from outcomes of the correlation analyses were between this parameter and the measured markers of kidney toxicity. For pooled unadjusted data, urine volume, which was found to be gender independent, correlated positively with U_Excr (rs = 0.46, p = 0.004). Specific gravity which was gender dependent, correlated negative with U_Excr for unadjusted female results (rs = -0.37, p = 0.02). For glucose which was gender-specific, no correlation was observed for males (rs = 0.29, p = 0.30) or females (rs = 0.13, p = 0.44). For pooled data that was adjusted for fluid intake, positive correlations with U-Excr were found for markers of tubular injury: urine volume (rs = 0.50, p = 0.001), specific gravity (rs = 0.35, p = 0.0088), GGT (rs = 0.37, p = 0.0064) and BMG (rs = 0.49, p = 0.0047). These correlations were weak to moderately strong and all were highly statistically significant.

This study suggests that in humans, the primary kidney function that is adversely affected by longterm uranium ingestion is the reabsorption of small molecules by the renal tubules. This kidney function affects water balance, electrolyte balance and acidbase balance, all of which affect human health. Some of the biomarker values found in this study exceeded published normal or reference ranges however the bio-effects reported here are mild and represent a manifestation of subclinical toxicity that will not necessarily lead to overt illness or kidney failure.

From the results of this study it was possible to show that the increased cancer risk was not likely to be more than 13 in 100,000 for the highest (2.1 mSv) 15-year exposure to uranium. This increase would be difficult to detect in a community as small as Kitigan Zibi (1,480 people). Therefore at the levels of uranium intake in drinking water for this community, the results suggest that chemical toxicity would be of greater health concern than radiological toxicity.

Disclaimer Whilst every effort is made to reliably report the data and comments from the journal articles reviewed, no responsibility is taken for the accuracy of articles appearing in Health Stream, and readers are advised to refer to the original papers for full details of the research.

Health Stream is the quarterly newsletter of Water Quality Research Australia. Health Stream provides information on topical issues in health research which are of particular relevance to the water industry, news and updates on the recent literature. This newsletter is available free of charge to the water industry, public health professionals and others with an interest in water quality issues. An electronic version of the newsletter and a searchable archive of Health Stream articles are available via the WQRA Web page. Summaries of Web-bonus articles are available only in the electronic version.

To be placed on the print mailing list for Health Stream please send your postal address details to: Pam Hayes Epidemiology and Preventive Medicine Monash University - SPHPM Alfred Hospital, Melbourne VIC 3004 AUSTRALIA

Phone +61 (0)3 9903 0571 Fax +61 (0)3 9903 0556 Email pam.hayes@med.monash.edu.au

To be placed on the email notification list for Health Stream, please fill in the form on our website under Publications at: http://www.wqra.com.au Š Copyright WQRA. Health Stream articles may be reproduced and communicated to third parties provided WQRA is acknowledged as the source. Literature summaries are derived in part from copyright material by a range of publishers.

Original sources should be consulted and acknowledged.

HEALTH STREAM

MARCH 2010

PAGE 20