The drinking water disparities framework: on the origins and persistence of inequities in exposure

A case study in participatory science with mutual capacity building between university and tribal researchers to investigate drinking water quality in rural Maine

BACKGROUND

Participatory science or citizen science is increasingly being recognized for providing benefits to scientists and community members alike. However, most participatory science projects include community researchers only in the sample collection phase of the research project. Here we describe how a rural tribal community and urban university utilized participatory science methods to engage community researchers across an entire research study, creating numerous opportunities for mutual capacity building.

OBJECTIVES

Researchers from MIT and the Sipayik Environmental Department, a tribal government department, partnered to co-launch a participatory science project to analyze municipal and private well drinking water quality in households in three Maine communities. The objective was to provide households with information about metals, primarily lead and arsenic, in their drinking water, and to improve public education, community partnerships, and local scientific capacity.

METHODS

MIT and Sipayik researchers engaged local communities through public community meetings, mailed flyers sent to residents, and meetings with local stakeholders. MIT and community researchers worked together to design and implement the study to quantify metals in community drinking water samples, as well as hold capacity-building trainings. Individual drinking water results were communicated to households, and generalized results were discussed at community meetings in the report-back phase.

RESULTS

The study attained a 29% household participation rate in the region. The researchers completed the analysis and report-back on 652 water samples. Isolated incidences of lead and geologically-attributable arsenic exceeding EPA standards were found. Individual report-backs of the results enabled local participatory scientists to make their own informed public health decisions. The study produced methodologies for navigating potential ethical issues, working with diverse communities, and collaborating over challenging geographical distances.

DISCUSSION

This project developed methodologies to build long-term relationships with local scientists and to engage community members and enhance the environmental literacy of rural communities. Both MIT and Sipayik researchers learned from each other throughout the project; Sipayik researchers built technical capacity while MIT researchers gained local and cultural understanding. Community outreach methods were most effective when sent directly to residents as mailed flyers or through Sipayik researchers' outreach.

Under-Sink Activated Carbon Water Filters Effectively Remove Lead from Private Well Water for over Six Months

Children who rely on private well water in the United States have been shown to be at greater risk of having elevated blood lead levels. Evidence-based solutions are needed to prevent drinking water lead exposure among private well users, but minimal data are available regarding the real-world effectiveness of available interventions like point-of-use water treatment for well water. In this study, under-sink activated carbon block water filters were tested for lead and other heavy metals removal in an eight-month longitudinal study in 17 homes relying on private wells. The device removed 98% of all influent lead for the entirety of the study, with all effluent lead levels less than 1 µg/L. Profile sampling in a subset of homes showed that the faucet fixture is a significant source of lead leaching where well water is corrosive. Flushing alone was not capable of reducing first-draw lead to levels below 1 µg/L, but the under-sink filter was found to increase the safety and effectiveness of faucet flushing. The results of this study can be used by individual well users and policymakers alike to improve decision-making around the use of under-sink point-of-use devices to prevent disproportionate lead exposures among private well users.

Geographies of insecure water access and the housing-water nexus in US cities

Safe, reliable, and equitable water access is critical to human health and livelihoods. In the United States, an estimated 471,000 households or 1.1 million individuals lack a piped water connection and 73% of households are located in cities, close to networked supply. In this study, we undertake a nationwide analysis of urban water access in the United States, with the aim of explaining the drivers of infrastructural inequality in the 50 largest metropolitan areas. Drawing on statistical analysis and regression modeling of census microdata at the household scale, our analysis reveals spatial and sociodemographic patterns of racialized, class-based, and housing disparities that characterize plumbing poverty. Among unplumbed households, we show that households headed by people of color are almost 35% more likely to lack piped water as compared to white, non-Hispanic households. Precarious housing conditions are an equally strong predictor: Renter-occupied households in the 50 largest US metros were 1.61 times more likely than owner-occupied households to lack piped water. We argue that insecure domestic water access in the United States should be understood as a housing issue that reflects structural inequalities of race and class, particularly in cities with widening wealth gaps. The article concludes with a call for research and action at the intersection of water provision, housing, and social inequality-a paradigm we call the housing-water nexus.

Drinking Water in the United States: Implications of Water Safety, Access, and Consumption

Recent water quality crises in the United States, and recognition of the health importance of drinking water in lieu of sugar-sweetened beverages, have raised interest in water safety, access, and consumption. This review uses a socioecological lens to examine these topics across the life course. We review water intakes in the United States relative to requirements, including variation by age and race/ethnicity. We describe US regulations that seek to ensure that drinking water is safe to consume for most Americans and discuss strategies to reduce drinking water exposure to lead, a high-profile regulated drinking water contaminant. We discuss programs, policies, and environmental interventions that foster effective drinking water access, a concept that encompasses key elements needed to improve water intake. We conclude with recommendations for research, policies, regulations, and practices needed to ensure optimal water intake by all in the United States and elsewhere.

Development of Conceptual Models to Guide Public Health Research, Practice, and Policy: Synthesizing Traditional and Contemporary Paradigms

This applied paper is intended to serve as a "how to" guide for public health researchers, practitioners, and policy makers who are interested in building conceptual models to convey their ideas to diverse audiences. Conceptual models can provide a visual representation of specific research questions. They also can show key components of programs, practices, and policies designed to promote health. Conceptual models may provide improved guidance for prevention and intervention efforts if they are based on frameworks that integrate social ecological and biological influences on health and incorporate health equity and social justice principles. To enhance understanding and utilization of this guide, we provide examples of conceptual models developed by the Prevention of Lower Urinary Tract Symptoms (PLUS) Research Consortium. PLUS is a transdisciplinary U.S. scientific network established by the National Institutes of Health in 2015 to promote bladder health and prevent lower urinary tract symptoms, an emerging public health and prevention priority. The PLUS Research Consortium is developing conceptual models to guide its prevention research agenda. Research findings may in turn influence future public health practices and policies. This guide can assist others in framing diverse public health and prevention science issues in innovative, potentially transformative ways.

Private well stewardship within a rural, agricultural Latino community: a qualitative study

BACKGROUND

Nitrate contamination in groundwater disproportionately impacts agricultural Latino communities, creating a significant hazard for Latinos that rely on private wells. Private well users must conduct water testing and other well stewardship behaviors to ensure that their well water is safe to drink. This study sought to identify the key factors impacting private well water testing behavior in rural, agricultural Latino communities.

METHODS

We conducted 4 focus groups with private well users, 2 in Spanish and 2 in English. We recruited 37 participants from the Lower Yakima Valley, Washington State, a rural, agricultural community with a large Latino population and elevated nitrate concentrations in groundwater. A semi-structured interview guide was developed to capture factors impacting testing as guided by the Risk, Attitudes, Norms, Ability, and Self-Regulation (RANAS) model. Inductive thematic analysis was conducted by two coders to identify common themes.

RESULTS

Themes emerged around the factors impacting well stewardship, including well water testing, treatment, and maintenance, and were not specific to nitrate contamination. Private well users reported many of the same factors reported in other communities, with the exception of home repair experience and challenges around landlords and neighbors on shared wells, which have not been reported previously. In addition to landlords and neighbors, lack of actionable information, economic limitations, and lack of technical support emerged as factors that made well stewardship burdensome for individuals. The majority of participants reported using bottled water, including many who used point-of-use or point-of-entry water treatment systems.

CONCLUSIONS

The burden of well stewardship in rural, agricultural Latino communities may suggest the need for interventions at the community, county, or state levels and not at the individual level alone. Additionally, the role of landlords, neighbors on shared wells, and home repair experience in well stewardship represent important areas of exploration for researchers and public health practitioners.

The effects of drinking water service fragmentation on drought-related water security

Drought is a critical stressor that contributes to water insecurity. In the United States, an important pathway by which drought affects households' access to clean, reliable drinking water for basic needs is through the organization and activities of community water systems. Research on the local political economy of drinking water provision reveals the constraints on community water systems that affect their performance when confronting drought hazards. Fragmentation in responsibility for drinking water contributes to disparities in drought vulnerability, preparation, and response across households and across communities. The nature and extent of these disparities require further investigation to identify strategies for expanding water security in the face of drought and other water hazards.

Agua4All: Providing Safe Drinking Water in Rural California Communities

INTRODUCTION

Drinking water instead of sugar-sweetened beverages may reduce obesity and dental caries. Tap water is more affordable and sustainable than bottled water and more likely to contain fluoride, which prevents caries. To address inequities in access to safe tap water, cross-sector partners established the Agua4All safe drinking-water program in 2 rural San Joaquin Valley, California, communities. The program's objective was to examine Agua4All's feasibility, acceptability, and effect on water intake.

METHODS

We provided bottle-filling stations dispensing safe water at 12 sites in 2 communities and provided limited promotional support. To compare the effect of different levels of promotion, sites in 1 community also received a promotions toolkit, a stipend, and assistance in developing and conducting their own promotional activities (site-led promotion). Beverage intake at sites was observed at baseline (pre-installation), at time 1 (post-installation), and at times 2 and 3 (post-promotion). Flowmeters tracked water dispensings. Staff interviews examined implementation barriers and facilitators.

RESULTS

From baseline to time 3, a nonsignificant increase (21.16%) occurred in the proportion of people drinking water at sites with water stations and site-led promotion compared with sites with water stations and limited promotion (5.13%) (P = .14). Mean daily gallons of water taken from stations per site was 3.61 (standard deviation, 3.84). Most staff members (77%) at the sites preferred water stations to traditional drinking fountains.

CONCLUSION

Bottle-filling stations with safe water and site-led promotion are a promising strategy for increasing water intake in communities without safe tap water. Larger studies should examine the effects of such stations on intake of sugar-sweetened beverages and on overall health.

Housing as a determinant of health equity: A conceptual model

Housing is a major pathway through which health disparities emerge and are sustained over time. However, no existing unified conceptual model has comprehensively elucidated the relationship between housing and health equity with attention to the full range of harmful exposures, their cumulative burden and their historical production. We synthesized literature from a diverse array of disciplines to explore the varied aspects of the relationship between housing and health and developed an original conceptual model highlighting these complexities. This holistic conceptual model of the impact of housing on health disparities illustrates how structural inequalities shape unequal distribution of access to health-promoting housing factors, which span four pillars: 1) cost (housing affordability); 2) conditions (housing quality); 3) consistency (residential stability); and 4) context (neighborhood opportunity). We further demonstrate that these four pillars can lead to cumulative burden by interacting with one another and with other structurally-rooted inequalities to produce and reify health disparities. We conclude by offering a comprehensive vision for healthy housing that situates housing's impact on health through a historical and social justice lens, which can help to better design policies and interventions that use housing to promote health equity.

Developing a national research agenda to reduce consumption of sugar-sweetened beverages and increase safe water access and consumption among 0- to 5-year-olds: a mixed methods approach

OBJECTIVE

Sugar-sweetened beverage (SSB) consumption in early childhood is a public health concern. Adequate hydration in early childhood is also important. We developed a national research agenda to improve beverage consumption patterns among 0-5-year-olds. This article focuses on the process used to develop this research agenda.

DESIGN

A mixed methods, multi-step process was used to develop the research agenda, including: (i) a scientific advisory committee; (ii) systematic reviews on strategies to reduce SSB consumption and increase water access and consumption; (iii) two stakeholder surveys to first identify and then rank strategies to reduce SSB consumption and increase water access and consumption; (iv) key informant interviews to better understand determinants of beverage consumption and strategies to improve beverage consumption patterns among high-risk groups; (v) an in-person convening with experts; and (vi) developing the final research agenda.

SETTING

This process included research and stakeholders from across the United States.

PARTICIPANTS

A total of 276 participants completed survey 1 and 182 participants completed survey 2. Key informant interviews were conducted with 12 stakeholders. Thirty experts attended the convening, representing academia, government, and non-profit sectors.

RESULTS

Thirteen key issue areas and 59 research questions were developed. Priority topics were beverage consumption recommendations, fruit-flavoured drink consumption, interventions tailored to high-risk groups, and family engagement in childcare.

CONCLUSIONS

This research agenda lays the groundwork for research efforts to improve beverage patterns of young children. The methods used can be a template to develop research agendas for other public health issues.

Perceptions of water and sugar-sweetened beverage consumption habits among teens, parents and teachers in the rural south-western USA

OBJECTIVE

The present research aimed to describe perceptions and behaviours around the consumption of water and sugar-sweetened beverages (SSB) by youths.

DESIGN

A formative, qualitative study which conducted four focus groups. Transcripts were analysed and themes related to reasons youths drink SSB and water, and conversely do not drink SSB and water, were analysed to reveal thematic clusters around sensory factors, environment and policy, access, marketing and role model influences, and health risks.

SETTING

A rural, tri-ethnic community in New Mexico, USA.ParticipantsMiddle- and high-school students, parents and teachers.

RESULTS

Although youths and adults were aware of the health risks of soda, they did not translate this information to other SSB, including sports drinks and sweetened tea. Moreover, their perceptions of risks of dyes outweighed their concern with sugar. Youths and adults were aware of water's health benefits, but they focused on short-term benefits. Youths and adults perceived water as unappealing. Adults were also concerned with water safety and access.

CONCLUSIONS

This formative research has implications for decreasing SSB consumption and simultaneously increasing water intake among youths in rural communities. Addressing unique access and safety concerns related to water in rural communities, as well as increasing awareness of the risks of all types of SSB, can work together in a positive feedback loop to change perceptions and behaviours with long-term health consequences. Specific policy suggestions include strengthening school policies to restrict all types of SSB and water promotion efforts that address access, safety and health benefits.

Sustainable and Resilient Urban Water Systems: The Role of Decentralization and Planning

Urban water systems face multiple challenges related to future uncertainty and pressures to provide more sustainable and resilient modes of service delivery. Transitioning away from fully centralized water systems is seen as a primary solution to addressing these urban challenges and pressures. We first review the literature on advantages, potential risks, and impediments to change associated with decentralized water system. Our review suggests that adopting decentralized solutions may advance conditions of sustainability and resilience in urban water management. We then explore the potential to incorporate decentralized water systems into broader urban land use patterns that include underserved residential neighborhoods, mixed-use developments, and industrial districts.

Examining differences in the implementation of school water-quality practices and water-access policies by school demographic characteristics

Ensuring safe, accessible drinking water in schools is a national health priority. The objective of this study was to identify whether there are differences in water quality, availability, and education- related practices in schools by demographic characteristics. In 2017-2018, we analyzed data from the 2014 School Health Policies and Practices Study (SHPPS), a nationally representative, cross-sectional survey of US schools. Analyses examined differences in water-related practices by school characteristics. Response rates for the 3 questionnaires used in this analysis ranged from 69%-94% (Ns ranged from 495 to 577). We found that less than half of schools flush drinking water outlets after periods of non-use (46.4%), conduct periodic inspections that test drinking water outlets for lead (45.8%), and require staff training on drinking water quality (25.6%). Most schools teach the importance of water consumption (81.1%) and offer free drinking water in the cafeteria (88.3%). Some water-related school practices differed by school demographic characteristics though no consistent patterns of associations by school characteristics emerged. In US schools, some water quality-related practices are limited, but water availability and education-related practices are more common. SHPPS data suggest many schools would benefit from support to implement best practices related to school-drinking water.

Environmental justice and drinking water quality: are there socioeconomic disparities in nitrate levels in U.S. drinking water?

BACKGROUND

Low-income and minority communities often face disproportionately high pollutant exposures. The lead crisis in Flint, Michigan, has sparked concern about broader socioeconomic disparities in exposures to drinking water contaminants. Nitrate is commonly found in drinking water, especially in agricultural regions, and epidemiological evidence suggests elevated risk of cancer and birth defects at levels below U.S. EPA's drinking water standard (10 mg/L NO3-N). However, there have been no nationwide assessments of socioeconomic disparities in exposures to nitrate or other contaminants in U.S. drinking water. The goals of this study are to identify determinants of nitrate concentrations in U.S. community water systems (CWSs) and to evaluate disparities related to wealth or race/ethnicity.

METHODS

We compiled nitrate data from 39,466 U.S. CWSs for 2010-2014. We used EPA's Safe Drinking Water Information System (SDWIS) to compile CWS characteristics and linked this information with both city- and county-level demographic data gathered from the U.S. Census Bureau. After applying multiple imputation methods to address censored nitrate concentration data, we conducted mixed-effects multivariable regression analyses at national and regional scales.

RESULTS

5.6 million Americans are served by a CWS that had an average nitrate concentration ≥ 5 mg/L NO3-N between 2010 and 2014. Extent of agricultural land use and reliance on groundwater sources were significantly associated with nitrate. The percent of Hispanic residents served by each system was significantly associated with nitrate even after accounting for county-level cropland and livestock production, and CWSs in the top quartile of percent Hispanic residents exceeded 5 mg/L nearly three times as often as CWSs serving the lowest quartile. By contrast, the percent of residents living in poverty and percent African American residents were both inversely associated with nitrate.

CONCLUSIONS

Epidemiological evidence for health effects associated with drinking water above 5 mg/L NO3-N raises concerns about increased risk for the 5.6 million Americans served by public water supplies with average nitrate concentrations above this level. The associations we observed between nitrate concentrations and proportions of Hispanic residents support the need for improved efforts to assist vulnerable communities in addressing contamination and protecting source waters. Future studies can extend our methods to evaluate disparities in exposures to other contaminants and links to health effects.

Fluid intake of children, adolescents and adults in Indonesia: results of the 2016 Liq.In7 national cross-sectional survey

PURPOSE

To report daily total fluid intake (TFI) and fluid types in Indonesia according to age, sex, socio-economic status (SES) and geographic region, and compare TFI with the Indonesian adequate fluid intake (AI) recommendations.

METHODS

Data were collected in 32 cities over nine regions from children (4-9 years, n = 388), adolescents, (10-17 years, n = 478) and adults (18-65 years, n = 2778) using a fluid intake 7-day record (Liq.In⁷); socio-economic status was also recorded. The 7-day mean TFIs were compared with the AI of water set by the Ministry of Health of the Republic of Indonesia.

RESULTS

Total median fluid intakes for all age groups exceeded 2000 mL/day. At population level, TFI was associated with household income (P < 0.001), education (P < 0.001) and Indonesian geographical regions (P < 0.001). More than 67% of participants met the AI of water from fluids. A higher percentage of children and adolescents met the AI (78 and 80%, respectively), compared with adults (72%). Drinking water was the main contributor to TFI in all age groups (76-81%). Sugar-sweetened beverages (SSB) were consumed by 62% children, 72% adolescents and 61% of adults. An SSB intake ≥ 1 serving per day was observed for 24% children, 41% adolescents and 33% adults.

CONCLUSIONS

A high percentage of the population drank enough to meet the AI of water from fluids. Water was the most frequently consumed drink; however, many participants consumed at least one serving of SSB per day. This study provides data to help direct targeted intervention programs.

Heterogeneity in the Relationship between Disinfection By-Products in Drinking Water and Cancer: A Systematic Review

The epidemiological evidence demonstrating the effect of disinfection by-products (DBPs) from drinking water on colon and rectal cancers is well documented. However, no systematic assessment has been conducted to assess the potential effect measure modification (EMM) in the relationship between DBPs and cancer. The objective of this paper is to conduct a systematic literature review to determine the extent to which EMM has been assessed in the relationship between DBPs in drinking water in past epidemiological studies. Selected articles (n = 19) were reviewed, and effect estimates and covariates that could have been used in an EMM assessment were gathered. Approximately half of the studies assess EMM (n = 10), but the majority of studies only estimate it relative to sex subgroups (n = 6 for bladder cancer and n = 2 both for rectal and colon cancers). Although EMM is rarely assessed, several variables that could have a potential modification effect are routinely collected in these studies, such as socioeconomic status or age. The role of environmental exposures through drinking water can play an important role and contribute to cancer disparities. We encourage a systematic use of subgroup analysis to understand which populations or territories are more vulnerable to the health impacts of DBPs.

Challenges and Opportunities for Tribal Waters: Addressing Disparities in Safe Public Drinking Water on the Crow Reservation in Montana, USA

Disparities in access to safe public drinking water are increasingly being recognized as contributing to health disparities and environmental injustice for vulnerable communities in the United States. As the Co-Directors of the Apsaálooke Water and Wastewater Authority (AWWWA) for the Crow Tribe, with our academic partners, we present here the multiple and complex challenges we have addressed in improving and maintaining tribal water and wastewater infrastructure, including the identification of diverse funding sources for infrastructure construction, the need for many kinds of specialized expertise and long-term stability of project personnel, ratepayer difficulty in paying for services, an ongoing legacy of inadequate infrastructure planning, and lack of water quality research capacity. As a tribal entity, the AWWWA faces additional challenges, including the complex jurisdictional issues affecting all phases of our work, lack of authority to create water districts, and additional legal and regulatory gaps-especially with regards to environmental protection. Despite these obstacles, the AWWWA and Crow Tribe have successfully upgraded much of the local water and wastewater infrastructure. We find that ensuring safe public drinking water for tribal and other disadvantaged U.S. communities will require comprehensive, community-engaged approaches across a broad range of stakeholders to successfully address these complex legal, regulatory, policy, community capacity, and financial challenges.

Relationship between race and community water and sewer service in North Carolina, USA

Previous evidence has identified potential racial disparities in access to community water and sewer service in peri-urban areas adjacent to North Carolina municipalities. We performed the first quantitative, multi-county analysis of these disparities. Using publicly available data, we identified areas bordering municipalities and lacking community water and/or sewer service in 75 North Carolina counties. Logistic regression was performed to evaluate the relationship between race and access to service in peri-urban areas, controlling for population density, median home value, urban status, and percent white in the adjacent municipality. In the peri-urban areas analyzed, 67% of the population lacked community sewer service, and 33% lacked community water service. In areas other than those with no black residents, odds of having community water service (p<0.01) or at least one of the two services (p<0.05) were highest for census blocks with a small proportion of black residents and lowest in 100% black census blocks, though this trend did not hold for access to community sewer service alone. For example, odds of community water service were 85% higher in areas that were greater than 0% but less than 22% black than in 100% black areas (p<0.001). Peri-urban census blocks without black populations had the lowest odds of community water service, community sewer service, and at least one of the two services, but this difference was only statistically significant for sewer. Peri-urban areas lacking service with no black residents were wealthier than 100% black areas and areas with any percent black greater than 0%. Findings suggest two unserved groups of differing racial and socioeconomic status: (1) lower-income black populations potentially excluded from municipal services during the era of legal racial segregation and (2) higher-income non-black populations. Findings also suggest greater racial disparities in community water than community sewer services statewide.

Blood Lead Levels and Dental Caries in U.S. Children Who Do Not Drink Tap Water

INTRODUCTION

This study's purpose is to determine whether nonconsumption of tap water is associated with lower prevalence of elevated blood lead levels and higher prevalence of dental caries in children and adolescents.

METHODS

Cross-sectional data from the National Health and Nutrition Examination Survey 2005-2014 recorded drinking water source (n=15,604) and blood lead levels (n=12,373) for participants aged 2-19 years, and dental caries experience for the 2011-2014 subset (n=5,677). The threshold for elevated blood lead level was ≥3 μg/dL. A binary outcome indicated presence or absence of dental caries experience. Multivariable generalized linear models estimated adjusted prevalence ratios with 95% confidence limits.

RESULTS

In analysis conducted in 2017, 15% of children and adolescents did not drink tap water, 3% had elevated blood lead levels ≥3 μg/dL, and 50% had dental caries experience. Children and adolescents who did not drink water were less likely than tap water drinkers to have an elevated blood lead level (adjusted prevalence ratios=0.62, 95% confidence limits=0.42, 0.90). Nonconsumers of tap water were more likely to have dental caries (adjusted prevalence ratios=1.13, 95% confidence limits=1.03, 1.23). Results persisted after adjustment for other covariates and using a higher threshold for elevated blood lead level.

CONCLUSIONS

In this nationally representative U.S. survey, children and adolescents who did not drink tap water had lower prevalence of elevated blood lead levels and higher prevalence of dental caries than those who drank tap water.

Disparities in plain, tap and bottled water consumption among US adults: National Health and Nutrition Examination Survey (NHANES) 2007-2014

OBJECTIVE

Differences in bottled v. tap water intake may provide insights into health disparities, like risk of dental caries and inadequate hydration. We examined differences in plain, tap and bottled water consumption among US adults by sociodemographic characteristics.

DESIGN

Cross-sectional analysis. We used 24 h dietary recall data to test differences in percentage consuming the water sources and mean intake between groups using Wald tests and multiple logistic and linear regression models.

SETTING

National Health and Nutrition Examination Survey (NHANES), 2007-2014.

SUBJECTS

A nationally representative sample of 20 676 adults aged ≥20 years.

RESULTS

In 2011-2014, 81·4 (se 0·6) % of adults drank plain water (sum of tap and bottled), 55·2 (se 1·4) % drank tap water and 33·4 (se 1·4) % drank bottled water on a given day. Adjusting for covariates, non-Hispanic (NH) Black and Hispanic adults had 0·44 (95 % CI 0·37, 0·53) and 0·55 (95 % CI 0·45, 0·66) times the odds of consuming tap water, and consumed B=-330 (se 45) ml and B=-180 (se 45) ml less tap water than NH White adults, respectively. NH Black, Hispanic and adults born outside the fifty US states or Washington, DC had 2·20 (95 % CI 1·79, 2·69), 2·37 (95 % CI 1·91, 2·94) and 1·46 (95 % CI 1·19, 1·79) times the odds of consuming bottled water than their NH White and US-born counterparts. In 2007-2010, water filtration was associated with higher odds of drinking plain and tap water.

CONCLUSIONS

While most US adults consumed plain water, the source (i.e. tap or bottled) and amount differed by race/Hispanic origin, nativity status and education. Water filters may increase tap water consumption.

Community Engaged Cumulative Risk Assessment of Exposure to Inorganic Well Water Contaminants, Crow Reservation, Montana

An estimated 11 million people in the US have home wells with unsafe levels of hazardous metals and nitrate. The national scope of the health risk from consuming this water has not been assessed as home wells are largely unregulated and data on well water treatment and consumption are lacking. Here, we assessed health risks from consumption of contaminated well water on the Crow Reservation by conducting a community-engaged, cumulative risk assessment. Well water testing, surveys and interviews were used to collect data on contaminant concentrations, water treatment methods, well water consumption, and well and septic system protection and maintenance practices. Additive Hazard Index calculations show that the water in more than 39% of wells is unsafe due to uranium, manganese, nitrate, zinc and/or arsenic. Most families' financial resources are limited, and 95% of participants do not employ water treatment technologies. Despite widespread high total dissolved solids, poor taste and odor, 80% of families consume their well water. Lack of environmental health literacy about well water safety, pre-existing health conditions and limited environmental enforcement also contribute to vulnerability. Ensuring access to safe drinking water and providing accompanying education are urgent public health priorities for Crow and other rural US families with low environmental health literacy and limited financial resources.

Racial/Ethnic and Socioeconomic Disparities in Hydration Status Among US Adults and the Role of Tap Water and Other Beverage Intake

OBJECTIVES

To evaluate whether differences in tap water and other beverage intake explain differences in inadequate hydration among US adults by race/ethnicity and income.

METHODS

We estimated the prevalence of inadequate hydration (urine osmolality ≥ 800 mOsm/kg) by race/ethnicity and income of 8258 participants aged 20 to 74 years in the 2009 to 2012 National Health and Nutrition Examination Survey. Using multivariable regression models, we estimated associations between demographic variables, tap water intake, and inadequate hydration.

RESULTS

The prevalence of inadequate hydration among US adults was 29.5%. Non-Hispanic Blacks (adjusted odds ratio [AOR] = 1.44; 95% confidence interval [CI] = 1.17, 1.76) and Hispanics (AOR = 1.42; 95% CI = 1.21, 1.67) had a higher risk of inadequate hydration than did non-Hispanic Whites. Lower-income adults had a higher risk of inadequate hydration than did higher-income adults (AOR = 1.23; 95% CI = 1.04, 1.45). Differences in tap water intake partially attenuated racial/ethnic differences in hydration status. Differences in total beverage and other fluid intake further attenuated sociodemographic disparities.

CONCLUSIONS

Racial/ethnic and socioeconomic disparities in inadequate hydration among US adults are related to differences in tap water and other beverage intake. Policy action is needed to ensure equitable access to healthy beverages.

Environmental Justice and Underserved Communities

Underserved communities suffer from environmental inequities. Gases lead to hypoxia and respiratory compromise, ozone to increased respiratory illnesses and decreased mental acuity, and mercury to prenatal cognitive disabilities and antisocial behaviors. Lead toxicity is associated with developmental delays. Cadmium is linked with cancer. The smaller sizes of air pollution particulate matter are pathogenic and are associated with cardiovascular and pulmonary disease and nervous system disorders. Bisphenol A is being studied for possible links to cancer and pregnancy risks. Physicians should be aware of these dangers, especially in underserved communities and populations. Investigating possible environmental risks and education are key.

Exposure to Contaminated Drinking Water and Health Disparities in North Carolina

OBJECTIVES

To examine drinking water quality in majority Black periurban neighborhoods in Wake County, North Carolina, that are excluded from nearby municipal water service and to estimate the health benefits of extending water service.

METHODS

We tested 3 samples collected July through December 2014 in 57 private wells for microbial contaminants. We compared contaminant prevalences to those in adjacent community water systems (35 280 samples from routine monitoring). Using a population intervention model, we assessed the number of annual emergency department visits for acute gastrointestinal illness that is preventable by extending water services to the 3799 residents of these periurban communities.

RESULTS

Overall, 29.2% of 171 private well samples tested positive for total coliform bacteria and 6.43% for Escherichia coli, compared with 0.556% and 0.00850% of municipal system samples. An estimated 22% of 114 annual emergency department visits for acute gastrointestinal illness could be prevented by extending community water service.

CONCLUSIONS

Predominantly Black periurban neighborhoods excluded from municipal water service have poorer quality drinking water than do adjacent neighborhoods with municipal services. These disparities increase the risk of emergency department visits for acute gastrointestinal illness.

Reducing Emergency Department Visits for Acute Gastrointestinal Illnesses in North Carolina (USA) by Extending Community Water Service

BACKGROUND

Previous analyses have suggested that unregulated private drinking water wells carry a higher risk of exposure to microbial contamination than regulated community water systems. In North Carolina, ~35% of the state's population relies on private wells, but the health impact associated with widespread reliance on such unregulated drinking water sources is unknown.

OBJECTIVES

We estimated the total number of emergency department visits for acute gastrointestinal illness (AGI) attributable to microbial contamination in private wells in North Carolina per year, the costs of those visits, and the potential health benefits of extending regulated water service to households currently relying on private wells for their drinking water.

METHODS

We developed a population intervention model using 2007-2013 data from all 122 North Carolina emergency departments along with microbial contamination data for all 2,120 community water systems and for 16,138 private well water samples collected since 2008.

RESULTS

An estimated 29,400 (95% CI: 26,600, 32,200) emergency department visits per year for acute gastrointestinal illness were attributable to microbial contamination in drinking water, constituting approximately 7.3% (95% CI: 6.6, 7.9%) of all AGI-related visits. Of these attributable cases, 99% (29,200; 95% CI: 26,500, 31,900) were associated with private well contamination. The estimated statewide annual cost of emergency department visits attributable to microbiological contamination of drinking water is 40.2 million USD (95% CI: 2.58 million USD, 193 million USD), of which 39.9 million USD (95% CI: 2.56 million USD, 192 million USD) is estimated to arise from private well contamination. An estimated 2,920 (95% CI: 2,650, 3,190) annual emergency department visits could be prevented by extending community water service to 10% of the population currently relying on private wells.

CONCLUSIONS

This research provides new evidence that extending regulated community water service to populations currently relying on private wells may decrease the population burden of acute gastrointestinal illness.

CITATION

DeFelice NB, Johnston JE, Gibson JM. 2016. Reducing emergency department visits for acute gastrointestinal illnesses in North Carolina (USA) by extending community water service. Environ Health Perspect 124:1583-1591; http://dx.doi.org/10.1289/EHP160.

Identification of the sources of metal (lead) contamination in drinking waters in north-eastern Tasmania using lead isotopic compositions

This study utilises a range of scientific approaches, including lead isotopic compositions, to differentiate unknown sources of ongoing lead contamination of a drinking water supply in north-eastern Tasmania, Australia. Drinking water lead concentrations are elevated above the Australian Drinking Water Guideline (10 μg/L), reaching 540 μg/L in the supply network. Water lead isotopic compositions from the town of Pioneer ((208)Pb/(207)Pb 2.406, (206)Pb/(207)Pb 1.144 to (208)Pb/(207)Pb 2.360, (206)Pb/(207)Pb 1.094) and Ringarooma ((208)Pb/(207)Pb 2.398, (206)Pb/(207)Pb 1.117) are markedly different from the local bedrock ((208)Pb/(207)Pb 2.496, (206)Pb/(207)Pb 1.237). The data show that the lead in the local waters is sourced from a combination of dilapidated drinking water infrastructure, including lead jointed pipelines, end-of-life polyvinyl chloride pipes and household plumbing. Drinking water is being inadvertently contaminated by aging infrastructure, and it is an issue that warrants investigation to limit the burden of disease from lead exposure.