Epidemiology study of the use of asbestos-cement pipe for the distribution of drinking water in Escambia County, Florida.

Cancer mortality for the population census tracts of Escambia County, FL, which use asbestos-cement (AC) pipe for public potable water distribution, was compared with cancer mortality data collected from census tracts in the same county where other types of piping materials are used. An analysis of covariance was run to test for differences in standard mortality ratios for seven cancer sites among three potential asbestos exposure groups based on AC pipe usage. Twelve variables representing nonexposure-related influences on disease rates were combined in four independent factors and used as covariates in these analyses. No evidence for an association between the use of AC pipe for carrying drinking water and deaths due to gastrointestinal and related cancers was found. The limitations on the sensitivity of the analysis are discussed.

Chlorination, water hardness and serum cholesterol in forty-six Wisconsin communities.

The Wisconsin Heart Health Research Program measured serum lipids and other clinical parameters among residents of 46 neighbouring small communities in central Wisconsin. The purpose of the study was to determine whether distribution of serum lipids, blood pressure or thyroid hormones differed according to the chlorination of water supply, or to its calcium and magnesium content (hardness). This report examines serum lipid levels in relation to the drinking water characteristics chlorination and hardness. Variables measured on individuals included age, education level, alcohol intake, cigarette smoking, dietary fat and dietary calcium. An analysis of covariance was used to estimate effects of chlorination and hardness on each of the serum lipids, with individual variables included as covariates. Among females, serum cholesterol (SC) levels are significantly higher in chlorinated communities than in non-chlorinated communities. Community SC levels are also higher for males in chlorinated communities, on the average, but differences are smaller and not statistically significant. Low density lipoprotein (LDL) cholesterol levels follow a similar pattern to that for total SC levels, higher in chlorinated communities for females, but not different for males. On the other hand, high density lipoprotein (HDL) cholesterol community means are nearly identical in the chlorinated and non-chlorinated communities for each sex.

Methaemoglobin levels in young children consuming high nitrate well water in the United States.

The EPA limit for nitrate (10 mg/l No3-N) in drinking water was established to prevent infantile methaemoglobinemia, an acute condition confined almost exclusively to infants less than three months. This condition is clinically detectable at methaemoglobin levels of approximately 10%. Several studies in the Soviet Union have suggested that elevated methaemoglobin levels from ingested nitrate may not be confined to the young infant and have reported an association between increased methaemoglobin levels of up to 7% in schoolchildren and drinking water with a nitrate concentration of 23-204 mg/l NO3-N. an epidemiologic study of 102 children aged 1-8 conducted in Washington County, Illinois, did not show that ingestion of water with a nitrate concentration of 22-111 mg/l NO3-N was related to increasing methaemoglobin levels nor that the children had high or above normal methaemoglobin levels. The potential for transmission of infections waterborne disease in this area was demonstrated, however, as a large percentage of the wells used for drinking water contained high numbers of total and faecal coliforms.

Serological analysis of a cryptosporidiosis epidemic.

BACKGROUND: A cryptosporidiosis epidemic occurred among residents and visitors to Collingwood, Ontario, during March 1996. Fifty-five per cent of 36 confirmed cases were Collingwood visitors and 57% of Collingwood resident cases were under 10 years of age. The low level of reported diarrhoeal illness among adult Collingwood residents caused government officials and physicians to question whether an epidemic had occurred in Collingwood. METHODS: To better evaluate the extent of the epidemic, anonymous surplus sera from 89 adult Collingwood residents, collected for routine tests prior to, during and after the epidemic, and from 80 adult Toronto residents were tested using a Western blot assay for IgG antibody response to two Cryptosporidium antigen groups (15/17-kDa and 27-kDa). RESULTS: For sera collected from 1 January 1996 to 17 June 1996, a higher fraction of Collingwood residents had a detectable serological response (P < 0.002) and the mean intensity of serological responses was higher for Collingwood than Toronto residents (P < 0.001). The mean intensity of serological responses for Collingwood residents was higher in specimens drawn during the 8 weeks following the initial case reports compared to those drawn before or after this period (15/17-kDa, P < 0.02; 27-kDa, P < 0.10). CONCLUSIONS: These elevated serological responses indicate that Cryptosporidium infections among Collingwood residents likely occurred more commonly than illness reports suggested, consistent with a community-wide cryptosporidiosis epidemic. Similar studies should be considered in future suspected cryptosporidiosis epidemic investigations.

Epidemiologic studies of organic micropollutants in drinking water.

Epidemiologic studies have been conducted in order to make a quantitative statement about associations between drinking water contaminants and disease. The basic measures of the association are a rate ratio or relative risk and rate difference or attributable risk. The appropriateness of this measure is dependent on components of study design, data collection, and the analysis of epidemiologic data, and these must be evaluated for each study to determine precision (lack of random error) and validity (lack of systematic error). Internal validity includes considerations for preventing selection bias, minimizing observation bias, and assessing, preventing, and controlling confounding bias within a particular study. No single epidemiologic study is likely to provide a definitive answer, and the results of epidemiologic studies must be interpreted in the context of other scientific information. Epidemiologic studies of organic micropollutants in drinking water have been reviewed and are summarized based on these considerations.

Serological responses to Cryptosporidium-specific antigens in Czech populations with different water sources.

Serological responses to Cryptosporidium-specific antigens (15/17 and 27 kDa) were compared among populations in four areas of the Czech Republic that use drinking water from clearly defined sources: (1) wells in a fractured sandstone aquifer, (2) riverbank infiltration, or (3) two different filtered and chlorinated surface waters. Among persons surveyed in the area with riverbank-infiltration water, 33% had a strong serological response to the 15/17-kDa antigen group whereas, in the other three areas, over 72% of persons had a strong response. These response differences suggest that Cryptosporidium exposures and infection were lower in the area with bank infiltration. The large percentage of the study population with a strong serological response to both antigens suggests high levels of previous infections that may have resulted in protective immunity for cryptosporidiosis. This may be one reason why no waterborne cryptosporidiosis outbreaks and few cases of cryptosporidiosis have been reported in the Czech Republic.

Review of epidemiologic studies of aluminium and neurological disorders.

The epidemiological study of neurological disorders is just beginning and should he continued because of the potential public health impact of these diseases on society. The most important contribution of epidemiological research is the identification of risk factors, and specific disease entities, such as Alzheimer's disease, should be studied.Ecological analysis of geographical data have associated a small increase in mortality from Alzheimer's disease and dementia with the aluminium content of drinking water. These results must necessarily be interpreted with caution because serious errors may result from inferences based on ecological analysis,e.g. "the ecologic fallacy".Potential risk factors for Alzheimer's disease have been studied in case-comparison epidemiology studies conducted in Italy, Massachusetts, Colorado, Minnesota and North Carolina, but only two studies have considered aluminium exposure, through the use of antacids. Although no increased risk was found to be associated with aluminium exposure, only a small number of individuals in the studies reported antacid use, and the studies had an extremely limited statistical power to detect an association.Additional analytical epidemiology studies, either cohort or case-comparison, are required to better describe the possible relationship between aluminium and Alzheimer's disease. These studies should be designed according to well-established epidemiological principles, be conducted with no selection bias and minimum observation bias, consider potential confounding and modifying factors, and have sufficient statistical power to enable detection of low relative risks.

Waterborne giardiasis in the United States: a review.

Twenty-three waterborne outbreaks of giardiasis have been reported in the US, 1972-77. Data indicate that disinfection as the only treatment for surface water sources is ineffective in preventing waterborne transmission of this organism. To protect against transmission, all surface water should receive chemical pretreatment, preferably with sedimentation, and filtration in addition to disinfection. Outbreak data indicate that negative coliform tests do not provide assurance that water is free of Giardia cysts.

Waterborne disease outbreaks in the United States of America: causes and prevention.

National statistics on waterborne outbreaks in the United States of America show that 1,702 waterborne outbreaks with 542,018 cases of illness and 1,089 deaths have been reported. Almost all deaths prior to 1940 were due to typhoid fever; 9 deaths from other causes have occurred since 1971. During the past decade, 291 waterborne outbreaks were reported in community (43%) and noncommunity (33%) systems, and from the ingestion of contaminated water from recreational (14%) and individual (10%) water sources. Although several large waterborne outbreaks occurred during the past decade, most were in small communities. The number of illnesses per outbreak in noncommunity systems during the past decade is much larger than that reported during any previous period, and the magnitude of these outbreaks indicates the potential effect on the travelling, transient population. During 1981-1990, contaminated, untreated groundwater or inadequately disinfected groundwater was responsible for 43% of all reported waterborne outbreaks, and contaminated, untreated surface water or inadequately treated surface water was responsible for 24% of all reported outbreaks. The use of untreated groundwater has declined in importance as a cause of outbreaks, and more outbreaks are now caused by inadequate or interrupted disinfection of groundwater. The increased occurrence of outbreaks in disinfected groundwater systems may be due to (i) increased use of disinfection with little effort to reduce or eliminate sources of contamination, and (ii) not providing effective, continuous disinfection. In surface-water systems, outbreaks occur primarily because of inadequate or interrupted disinfection in systems that do not provide filtration, but a large increase in outbreaks has recently occurred in filtered systems.(ABSTRACT TRUNCATED AT 250 WORDS)

Possible information bias in a waterborne outbreak investigation.

Although an investigation of a cryptosporidiosis outbreak in 1994 in Clark County, Nevada, concluded that illness was associated with consumption of municipal water, no water treatment deficiencies or breakdowns and no water quality changes were discovered during the investigation. We evaluated the strength of the evidence for waterborne transmission and conducted a sensitivity analysis to define the limitations of the epidemiological data. Our analyses suggest a spurious inference of waterborne transmission might be due to differential misclassification bias. If exposure and disease status were incorrectly classified for a relatively small number of study participants, findings of the investigation would be interpreted differently. We offer this example to illustrate the importance of assessing the stability of a relative risk estimate and effect of possible biases during an outbreak investigation.

Waterborne disease outbreaks, 1986-1988.

From 1986 to 1988, 24 states and Puerto Rico reported 50 outbreaks of illness due to water that people intended to drink, affecting 25,846 persons. The protozoal parasite Giardia lamblia was the agent most commonly implicated in outbreaks, as it has been for the last 10 years; many of these outbreaks were associated with ingestion of chlorinated but unfiltered surface water. Shigella sonnei was the most commonly implicated bacterial pathogen; in outbreaks caused by this pathogen, water supplies were found to be contaminated with human waste. Cryptosporidium contamination of a chlorinated, filtered public water supply caused the largest outbreak during this period, affecting an estimated 13,000 persons. A large multistate outbreak caused by commercially produced ice made from contaminated well water caused illness with Norwalk-like virus among an estimated 5,000 persons. The first reported outbreak of chronic diarrhea of unknown cause associated with drinking untreated well water occurred in 1987. Twenty-six outbreaks due to recreational water use were also reported, including outbreaks of Pseudomonas dermatitis associated with the use of hot tubs or whirlpools, and swimming-associated shigellosis, giardiasis, and viral illness. Although the total number of reported water-related outbreaks has been declining in recent years, the few large outbreaks due to Cryptosporidium, Norwalk-like agent, Shigella sonnei, and Giardia lamblia caused more cases of illness in 1987 than have been reported to the Water-Related Disease Outbreak Surveillance System for any other year since CDC and the Environmental Protection Agency began tabulating these data in 1971.

Epidemiology of common-source outbreaks of shigellosis in the United States, 1961-1975.

In 1961-1975, there were 72 foodborne and 38 waterborne outbreaks of shigellosis reported in the United States. Foodborne outbreaks were most often caused by salads with contamination attributed to poor hygiene of a food handler. Waterborne outbreaks most often involved semipublic water systems, and were usually the result of inadequate chlorination of water contaminated by human feces. In 110 common-source outbreaks, 16,541 persons were ill. The attack rate for both food- and waterborne shigellosis was 47%, and the case-fatality ratio was 0.1% in foodborne outbreaks and 0.2% in waterborne outbreaks.

Increasing hospitalization and death possibly due to Clostridium difficile diarrheal disease.

This study calculated yearly estimated national hospital discharge (1985 to 1994) and age-adjusted death rates (1980 to 1992) due to bacterial, viral, protozoal, and ill-defined enteric pathogens. Infant and young child hospitalization (but not death) rates in each category increased more than 50% during 1990 to 1994. Age-adjusted death and hospitalization rates due to enteric bacterial infections and hospitalizations due to enteric viral infections have increased since 1988. The increases in hospitalization and death rates from enteric bacterial infections were due to a more than eightfold increase in rates for specified enteric bacterial infections that were uncoded during this period (ICD9 00849). To identify bacterial agents responsible for most of these infections, hospital discharges and outpatient claims (coded with more detail after 1992) were examined for New Mexico's Lovelace Health Systems for 1993 to 1996. Of diseases due to uncoded enteric pathogens, 73% were due to Clostridium difficile infection. Also, 88% of Washington State death certificates (1985 to 1996) coded to unspecified enteric pathogen infections (ICD0084) listed C. difficile infection.

Trace metals in drinking water: lack of influence on blood pressure.

It has been suggested that certain trace metals may affect human blood pressure. We recently measured trace metals in the tapwater from the homes of 246 male participants of the Normative Aging Study. Participants were free of any disease or medication known to influence blood pressure. No statistically significant relationship was found between lead concentration and systolic blood pressure in an analysis of covariance, controlling for age and body mass index. Diastolic pressure was examined as well and the results were almost identical. Since educational level and town of residence were potential confounders, we stratified on these variables but no association between lead concentration and blood pressure emerged. Similarly, no statistically significant relationships were found between blood pressure and copper or iron. Blood pressure did differ significantly among zinc concentration groups but no uniform trend appeared. In light of evidence from other studies suggesting that blood pressure is influenced by lead or other elements in drinking water, further investigations with more highly exposed subjects or a prospective design appear warranted.

A serological survey of college students for antibody to Cryptosporidium before and after the introduction of a new water filtration plant.

In April 1997, a large city in the northeastern United States changed their drinking water treatment practices. The city, which previously provided only chlorination for their surface water sources added filtration in addition to chlorination. To assess whether Cryptosporidium infections rates declined following filtration, we tested serological responses to 15/17-kDa and 27-kDa Cryptosporidium antigens among 107 community college students 1 month before and 225 students 5 months after filtration. Results suggest that levels of Cryptosporidium infections did not decline following water filtration. However, seasonal changes in other exposures may have confounded the findings. Swimming in a lake, stream or public pool and drinking untreated water from a lake or stream predicted a more intense response to one or both markers. Residence in the city, not drinking city tap water or drinking bottled water, gender, travel or exposure to pets, young pets, diapers or a household child in day care were not found to be predictive of more or less intense serological responses for either the 15/17-kDa and 27-kDa antigen.

Waterborne-disease outbreaks, 1989-1990.

For the 2-year period 1989-1990, 16 states reported 26 outbreaks due to water intended for drinking; an estimated total of 4,288 persons became ill in these outbreaks. Giardia lamblia was implicated as the etiologic agent for seven of the 12 outbreaks in which an agent was identified. The outbreaks of giardiasis were all associated with ingestion of unfiltered surface water or surface-influenced groundwater. An outbreak with four deaths was attributed to Escherichia coli O157:H7, the only bacterial pathogen implicated in any of the outbreak investigations. An outbreak of remitting, relapsing diarrhea was associated with cyanobacteria (blue-green algae)-like bodies, whose role in causing diarrheal illness is being studied. Two outbreaks due to hepatitis A and one due to a Norwalk-like agent were associated with use of well water. Eighteen states reported a total of 30 outbreaks due to the use of recreational water, which resulted in illness for an estimated total of 1,062 persons. These 30 reports comprised 13 outbreaks of whirlpool- or hot tub-associated Pseudomonas folliculitis; 13 outbreaks of swimming-associated gastroenteritis, including five outbreaks of shigellosis; one outbreak of hepatitis A associated with a swimming pool; and three cases of primary amebic meningoencephalitis caused by Naegleria. The national surveillance of outbreaks of waterborne diseases, which has proceeded for 2 decades, continues to be a useful means for characterizing the epidemiology of waterborne diseases.

Paired city cryptosporidium serosurvey in the southwest USA.

In 1996, serological responses to two Cryptosporidium antigens were determined for 200 Las Vegas (LV), Nevada, and 200 Albuquerque, New Mexico, blood donors to evaluate associations between endemic infections, water exposures, and other risk factors. LV uses chlorinated filtered drinking water from Lake Mead while Albuquerque uses chlorinated ground water. The intensity of serological response to both markers was higher for older donors (P < 0.05). donors who washed food with bottled water (P < 0.05) and donors from LV (P < 0.05). A decreased serological response was not associated with bottled water consumption, nor was an increased response associated with self-reported cryptosporidiosis-like illness or residence in LV at the time of a cryptosporidiosis outbreak 2 years earlier. Although these findings suggest the serological response may be associated with type of tap water and certain foods, additional research is needed to clarifythe role of both food and drinking water in endemic Cryptosporidium infection.

An epidemiologic study of the relationship between hepatitis A and water supply characteristics and treatment.

Outbreaks of hepatitis A (HA) attributable to water contamination have been reported; however, the impact of water supply characteristics on the endemic rates of HA has not been quantified. This study did not detect any statistically significant associations between endemic HA rates and water supply characteristics. Because of the sample size, this finding suggests that the total variation of HA rates attributable to water supply characteristics is probably less than 8 per cent of the annual reported cases of HA in the United States.

An epidemic of gastroenteritis traced to a contaminated public water supply.

Between January 1 and March 15, 1974, approximately 1200 cases of acute gastrointestinal illness occurred in Richmond Heights, Florida, a residential community of 6500 in south Dade County. Over one-third of all families in the area had at least one member affected. The findings of 10 culture-proven cases of shigellosis among those who became ill and clinical signs and symptoms in the others suggest that most of the other cases that were not cultured may have been shigellosis also. Epidemiologic investigation showed that consumption of tap water was associated with illness in the initial cases of affected families. Evaluation of the Richmond Heights public water supply disclosed numerous inadequacies in both design and operation. One of the wells providing water to the community was continuously contaminated with excessive levels of fecal coliforms from a nearby septic tank, and a breakdown in chlorination on January 14-15 caused approximately 1 million gallons of inadequately chlorinated water from the contaminated well to be distributed to the community 48 hours before the epidemic began. Correction of deficiencies in the water plant was undertaken by the utility company; the residents of Richmond Heights were instructed to boil their drinking water or to use commercially bottled water pending completion of corrective measures. A FUll scale study is planned for all similar public water supplies in Dade County.

An investigation of the use of asbestos cement pipe for public water supply and the incidence of gastrointestinal cancer in Connecticut, 1935-1973.

The age adjusted sex specific incidence data for stomach, colon, and rectal cancer for Connecticut townships for the period 1935 to 1973 were used to investigate whether asbestos cement pipe usage for domestic drinking water is associated with gastrointestinal cancer. The townships were grouped according to the Assessment of Exposure (AOE) and Risk Factor (RF) for asbestos. These are composite indices of asbestos exposure including factors relating to the age of the pipe, the ability of water to leach asbestos from the pipe, and the length of pipes used by the population. No association was noted between these asbestos risk scores and gastrointestinal tumor incidence.