SPH 414/514

Week 5
Video 1
Water and
Public Health
 Outline for lecture:

• Safe water
• Drinking
• Sanitation
• Hygiene
• Example parasite: Hookworm in the US
• Water scarcity
• Global importance of water
• Advancements in the past 15 years
• Population growth and sanitation
• Water in Canada
• Water and wastewater treatment
• Legislation and water
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WhereWhere
does our waterour
does come from?
water come from?

• The natural water cycle is exactly

that, a cycle that circulates water
through the environment.

• While water is essential for life on

earth, it can harbor waterborne
pathogens such as viruses,
bacteria and parasites that may
cause illness or even death.
Water has many fateshas many fates
Water
Water may flow through lakes, where it is used in recreation, to cities for drinking water,
clothes washing and, toilet flushing, to farms for agriculture, through a small town, until it
finds its way to the oceans. It is important to recognize that there is only one water,
while it may be used in difference ways, in a tap or a toilet, or in the ocean. It is
important to recognize the interconnectedness of all "types" of water.

Public Health Problem: we must ensure water safety at all these stages
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SPH 414/514
Week 5
Video 2
Water and
Public Health
What does safe water look like?

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 Water: things to consider
• Water is the largest resource mass brought into and discharged from communities each day

• With respect to drinking water, enteric pathogens represent the largest public health risk due to their
acute effects and potential for certain pathogens to grow in the post-treatment system (saprozoic)
• Much work goes into understanding pathogen dynamics during and after treatment and into setting
acceptable limits on their abundance in post-treatment water

• While of perceived public risk, chemicals often do not pose a risk in most water drinking water
distribution systems – note that disinfection by products are likely the most relevant chemical risk

• Environment Canada estimates that ~90,000 cases of illness and 90 deaths occur annually in Canada
as a result of waterborne infections

• At least 288 disease outbreaks can be attributed to water in Canada between 1974 and 2001.

• Increasingly, water-based pathogens that grow in water distribution systems and in-premise plumbing
are being recognized for contributing significantly to disease – particularly in high risk groups.
• Legionella and non-tuberculosis mycobacterium. 8
Challenges associated with preventing waterborne
infections
Industry/Government
• Large volume of water consumed Environmental Challenges
• Cost for detection/inactivation • Pulse events (sporadic)
• Potential for large outbreaks • Low concentration of pathogens
• Safe water expected • Localized distributions
• Accountability • Many pathogens
• Complicated sampling & detection

Clinical Challenges
• Infections not reported
• Infections self-limiting Health
• Non-diagnosed treatment Compromised
• Similar pathology
• Cost

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 Sanitation and public health

• Access to safe water and sanitation is considered one of the

greatest public health achievements worldwide, of all time.

• Many diseases have all but been eliminated from regions where
improved sanitation and drinking water have reached the
majority of the population.

• Water, sanitation and hygiene – WASH

• Unicef: without WASH, sustainable development is impossible
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 Example: sanitation improvements and hookworm in
the US
• In 1910, it was estimated that ~40% of the population of the Southern US was infected by hookworm.
• The Rockefeller Sanitary Commission (replaced 4 years later by the International Health Division) was established
to eradicate hookworm from the region
1. Survey to map the prevalence of hookworm in the Southern US
2. Treat infected individuals at mobile drug dispensaries
3. Public education on hookworm transmission
4. Urge development of improved sanitation (construct outhouses)

[Link]

4 feet

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 Challenges associated with preventing waterborne
infections
• Diarrhea – a single set of symptoms associated with many infectious agents
• Estimated that washing hands with soap and clean water could reduce diarrheal infections by 50%
• WHO: Water for Health 2001

• We all use water in many ways, and in developed countries we expect it to be safe

The average swimmer contributes at least 0.14g of fecal

material to the water in 15 minutes of swimming
Gerba CP – Quant Microbiol. 2001

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SPH 414/514
Week 5
Video 3
Water and
Public Health
 Water usage in Canada
Oil and gas extraction
Commercial and Water treatment Mining
0.5%
institutional and distribution (except oil
3% systems and gas)
2% 1%
Agriculture
5%

Residential
9%

Manufacturing
14%
Thermal-electric
power generation
66%

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Water usage in Alberta cities

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 Black and
Surface or Grey water
Water Wastewater
ground Water supply Households Waste
treatment treatment
water

Septic
systems
 Black and
Surface or Grey water
Water Wastewater
ground Water supply Households Waste
treatment treatment
water

Septic
systems
 Assessing water treatment
• Most treatment processes are evaluated for their ability to reduce pathogen (or indicator) presence

• Removal/inactivation is often presented as a log reduction (log10)

• For example, a 3 log reduction would mean 1000x less of a target organism

• An alternative way to assess treatment is to use a health based metric

• How many people do we deem is appropriate to develop an illness from exposure?

• Log reductions are also used to sell disinfectants to the public

Atmar et al, 2008
If we had 1,000,000 bacteria If we had 1,000,000,000,000 viruses
90% -> 100,000 90% -> 100,000,000,000
99% -> 10,000 99% -> 10,000,000,000
99.9% -> 1,000 99.9% -> 1,000,000,000
99.99% -> 100 99.99% -> 100,000,000
99.999% -> 10 99.999% -> 10,000,000
99.9999% -> 1 99.9999% -> 1,000,000
Who protects water in Canada?

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 Environmental health legislation
• Legislation the regulates water is complex
• Numerous Acts and guidelines are used at various levels of
government to outline what constitutes safe water in the contexts of
health, environment and industry

• Health Canada, Environment Canada, Alberta Health and Alberta

Environment and Parks all contribute policy on the topic of water

• Examples include:
• Alberta Water Act
• Canadian Environmental Protection Act
• Alberta Environmental Protection and Enhancement Act
• Canada and Alberta Recreational Water Quality Guidelines
 Environmental health legislation
• US EPA Clean Water Act
• Officially established in 1972 as a means to provide structure for
regulating the discharge of pollutants into water in the US and to
provide standards (both methodological and regulatory) for assessing
water quality.

• Set a global standard for pollution regulation in surface water

• It provides a framework for monitoring, assessing and enforcing water

pollution and polluting events

• Many of the Canadian Water Acts and Guidelines derive methods and
standards from this Act
SPH 414/514
Week 5
Video 4
Water and
Public Health
 Global water distribution

Only 0.3% of all water is usable by humans for consumption

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Water scarcity and change in how we think about
water

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 Wastewater as a way to combat water scarcity

• Recycling or reuse of
treated or partially treated
wastewater effluent.
• Different schools of
thought, some favor
treating wastewater to
drinking water quality and
putting it back into the
drinking water supply,
others prefer matching the
quality of the water to the
application its being used
for. A concept called fit-for-
purpose water reuse.
Wastewater and the 21st century
 Case studies in water reuse

[Link]
tastrophic_drought#t-717461
SPH 414/514
Week 5
Video 5
Water and
Public Health
 A history of drinking water
• 3000 years ago the Romans designed a series of aqueducts to bring water into
the city of Rome

• While the Roman distribution system was comprised of predominantly lead pipes,
because the water was hard water (water with dissolved calcium or magnesium
salts), hard water reacts with the lead pipe to create a coating of lead carbonate
on the pipes. Lead carbonate is highly insoluble in water, and therefore prevents
lead leaching into distribution systems. We use similar principles today in
distribution systems to prevent lead leaching in older buildings.

• The distribution system in the city state was also highly sophisticated, with water
entering the systems and collecting into a large basin which diverted all incoming
water into three separate distribution systems. This system also enabled the
government to restrict water for certain uses in times of drought, or even at
different times of the day.
 Water:Sanitation:Hygiene - WASH
• Drinking water, sanitation and hygiene are tightly linked
• Each contributes to disease spread and persistence

• A large proportion of foodborne disease is attributed to water

• Washing of food
• Irrigation
• Cooling on ice
• Contaminated hands

• According to the US CDC, 88% of diarrheal diseases are associated with unsafe water, inadequate
sanitation or poor hygiene
• This equates to ~1.5 million deaths per year
• These estimates do not include water-based pathogen infections or vector-transmitted diseases that are
passed by water-reliant vectors

• Total estimates can surpass 3 million deaths per year depending on inclusion criteria
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 Water-borne pathogens/parasites
Viruses Bacteria
• Adenovirus • Escherichia coli (enterohemorrhagic,
• Astrovirus enterotoxigenic)
• Calicivirus • Campylobacter spp.
• Coxsackievirus • Salmonella spp.
• Echovirus • Shigella spp.
• Enterovirus • Vibrio spp.
• Norovirus Helminths • Yersinia spp.
• Poliovirus • Ascaris • Clostridium spp
• Group A Rotavirus • Fasciola • Aeromonas spp
• Hepatitis A and E • Onchocerciasis • Mycobacterium spp.
• Hymenolepis
• Dracunculus
• Taenia
Protozoans • Echinococcus
• Enterobius Toxins
• Cryptosporidium
• Blue Green Algae (microcystins)
• Giardia lamblia
• Botulinum
• Entamoeba histolytica
• Ricin
• Toxoplasma gondii
• Staphylococcus b-enterotoxin
• Cyclospora cayetanensis
• Aflatoxin
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 Water-based pathogens/parasites
Viruses Bacteria
• Adenovirus • Escherichia coli (enterohemorrhagic,
• Astrovirus enterotoxigenic)
• Calicivirus • Campylobacter spp.
• Coxsackievirus • Salmonella spp.
• Echovirus • Shigella spp.
• Enterovirus • Vibrio spp.
• Norovirus Helminths • Yersinia spp.
• Poliovirus • Schistosoma • Clostridium spp
• Group A Rotavirus • Ascaris • Aeromonas spp
• Hepatitis A and E • Fasciola • Mycobacterium spp.
• West Nile virus • Onchocerciasis • Legionella spp.
• Dengue • Hymenolepis
• Dracunculus
Protozoans • Taenia
• Echinococcus Toxins
• Cryptosporidium
• Enterobius • Blue Green Algae (microcystins)
• Giardia lamblia
• Botulinum
• Entamoeba histolytica
• Ricin
• Toxoplasma gondii
• Staphylococcus b-enterotoxin
• Cyclospora cayetanensis
• Aflatoxin
• Plasmodium 32
 Water as a focus for global development
Millennium Development Goals
2000-2015 Sustainable Development Goals
2015-2030

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Progress due to the Millennium Development Goals

MDG were achieved in terms of drinking water access MDG were not achieved in terms of access to
improved sanitation

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Global coverage of safe drinking water

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Global coverage of sanitation
infrastructure

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Improvements to global access to safe drinking water
and sanitation

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Improvements to global access to safe drinking water
and sanitation

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Population growth and sanitation

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Hygiene as part of water safety

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 Conclusions
• There are a number of points in the water treatment train where
contamination or improper treatment can compromise health

• A combination of drinking water, sanitation and hygiene are important for

preventing parasitic diseases transmitted via water

• Thinking about waterborne infection routes must move beyond only

considering those parasites/pathogens that cause enteric disease to include
• Recreational water
• Water based infectious agents
• Water and its relationship to food
• Consideration of the relationship between animals, humans,
environment and water

• Even in well developed countries possessing enhanced water treatment

facilities, parasites can use water as a vehicle for transmission
• Important to understand infection dynamics
• Source of the agents?
• Treatment efficacy
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 Conclusions: World Water Day – March 22
• Scarcity: A number of rivers do not reach the ocean anymore due to
overuse
• Colorado - US
• Indus – Pakistan
• Rio Grande – US
• Yellow River – China Cuyahoga River, Ohio
• Murray River – Australia

• Pollution and waste

• Silver linings
Ganges River, India Citarum River, Indonesia

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