Assessing arsenic exposure in households using bottled water or point-of-use treatment systems to mitigate well water contamination

A Mixed Methods Approach to Understanding the Public Health Impact of a School-Based Citizen Science Program to Reduce Arsenic in Private Well Water

BACKGROUND

Exposure to arsenic (As) in well water is a well-documented public health issue for Maine and New Hampshire, as well as for other states in the United States and abroad. Arsenic contamination of well water in these locations is primarily attributed to metasedimentary bedrock that leaches As into groundwater. However, As can also enter groundwater reserves from soils contaminated by the historical use of arsenical pesticides. Approximately half of the households in Maine and New Hampshire rely on private wells, many of which have elevated As. Arsenic exposure has been associated with an increased risk of cancer, cardiovascular disease, reduced infection resistance, and lower intelligence quotient in children. Despite these known health impacts, well water testing and treatment are not universal.

OBJECTIVES

We have approached the problem of low well water testing rates in Maine and New Hampshire communities by developing the All About Arsenic (AAA) project, which engages secondary school teachers and students as citizen scientists in collecting well water samples for analysis of As and other toxic metals and supports their outreach efforts to their communities.

METHODS

We assessed this project's public health impact by analyzing student data relative to existing well water quality datasets in both states. In addition, we surveyed private well owners who contributed well water samples to the project to determine the actions taken to mitigate As in well water.

RESULTS

Students collected 3,070 drinking water samples for metals testing, and 752 exceeded New Hampshire's As standard of 5  ppb . The AAA data has more than doubled the amount of information available to public health agencies about well water quality in multiple municipalities across both states. Students also collected information about well types and treatment systems. Their data reveal that some homeowners did not know what type of wells they had or whether they had filtration systems. Those with filtration systems were often unaware of the type of system, what the system was filtering for, or whether the system was designed to remove As. Through interviews with pilot survey participants, we learned that some had begun mitigating their exposure to As and other toxic metals in response to test results from the AAA project.

DISCUSSION

A school-based approach to collecting and analyzing private well water samples can successfully reach communities with low testing rates for toxic elements, such as As and other metals. Importantly, information generated through the program can impact household decision-making, and students can influence local and state policymaking by sharing information in their communities. https://doi.org/10.1289/EHP13421.

Harnessing water fleas for water reclamation: A nature-based tertiary wastewater treatment technology

Urbanisation, population growth, and climate change have put unprecedented pressure on water resources, leading to a global water crisis and the need for water reuse. However, water reuse is unsafe unless persistent chemical pollutants are removed from reclaimed water. State-of-the-art technologies for the reduction of persistent chemical pollutants in wastewater typically impose high operational and energy costs and potentially generate toxic by-products (e.g., bromate from ozonation). Nature-base solutions are preferred to these technologies for their lower environmental impact. However, so far, bio-based tertiary wastewater treatments have been inefficient for industrial-scale applications. Moreover, they often demand significant financial investment and large infrastructure, undermining sustainability objectives. Here, we present a scalable, low-cost, low-carbon, and retrofittable nature-inspired solution to remove persistent chemical pollutants (pharmaceutical, pesticides and industrial chemicals). We showed Daphnia's removal efficiency of individual chemicals and chemicals from wastewater at laboratory scale ranging between 50 % for PFOS and 90 % for diclofenac. We validated the removal efficiency of diclofenac at prototype scale, showing sustained performance over four weeks in outdoor seminatural conditions. A techno-commercial analysis on the Daphnia-based technology suggested several technical, commercial and sustainability advantages over established and emerging treatments at comparable removal efficiency, benchmarked on available data on individual chemicals. Further testing of the technology is underway in open flow environments holding real wastewater. The technology has the potential to improve the quality of wastewater effluent, meeting requirements to produce water appropriate for reuse in irrigation, industrial application, and household use. By preventing persistent chemicals from entering waterways, this technology has the potential to maximise the shift to clean growth, enabling water reuse, reducing resource depletion and preventing environmental pollution.

Historical exposure to chemicals reduces tolerance to novel chemical stress in Daphnia (waterflea)

Until the last few decades, anthropogenic chemicals used in most production processes have not been comprehensively assessed for their risk and impact on wildlife and humans. They are transported globally and usually end up in the environment as unintentional pollutants, causing long‐term adverse effects. Modern toxicology practices typically use acute toxicity tests of unrealistic concentrations of chemicals to determine their safe use, missing pathological effects arising from long‐term exposures to environmentally relevant concentrations. Here, we study the transgenerational effect of environmentally relevant concentrations of five chemicals on the priority list of international regulatory frameworks on the keystone species Daphnia magna. We expose Daphnia genotypes resurrected from the sedimentary archive of a lake with a known history of chemical pollution to the five chemicals to understand how historical exposure to chemicals influences adaptive responses to novel chemical stress. We measure within‐ and transgenerational plasticity in fitness‐linked life history traits following exposure of “experienced” and “naive” genotypes to novel chemical stress. As the revived Daphnia originate from the same genetic pool sampled at different times in the past, we are able to quantify the long‐term evolutionary impact of chemical pollution by studying genome‐wide diversity and identifying functional pathways affected by historical chemical stress. Our results suggest that historical exposure to chemical stress causes reduced genome‐wide diversity, leading to lower cross‐generational tolerance to novel chemical stress. Lower tolerance is underpinned by reduced gene diversity at detoxification, catabolism and endocrine genes in experienced genotypes. We show that these genes sit within pathways that are conserved and potential chemical targets in other species, including humans.

Defining drinking water metal contaminant mixture risk by coupling zebrafish behavioral analysis with citizen science

Contaminated drinking water is an important public health consideration in New England where well water is often found to contain arsenic and other metals such as cadmium, lead, and uranium. Chronic or high level exposure to these metals have been associated with multiple acute and chronic diseases, including cancers and impaired neurological development. While individual metal levels are often regulated, adverse health effects of metal mixtures, especially at concentrations considered safe for human consumption remain unclear. Here, we utilized a multivariate analysis that examined behavioral outcomes in the zebrafish model as a function of multiple metal chemical constituents of 92 drinking well water samples, collected in Maine and New Hampshire. To collect these samples, a citizen science approach was used, that engaged local teachers, students, and scientific partners. Our analysis of 4016 metal-mixture combinations shows that changes in zebrafish behavior are highly mixture dependent, and indicate that certain combinations of metals, especially those containing arsenic, cadmium, lead, and uranium, even at levels considered safe in drinking water, are significant drivers of behavioral toxicity. Our data emphasize the need to consider low-level chemical mixture effects and provide a framework for a more in-depth analysis of drinking water samples. We also provide evidence for the efficacy of utilizing citizen science in research, as the broader impact of this work is to empower local communities to advocate for improving their own water quality.

Months-long spike in aqueous arsenic following domestic well installation and disinfection: Short- and long-term drinking water quality implications

Exposure to high concentration geogenic arsenic via groundwater is a worldwide health concern. Well installation introduces oxic drilling fluids and hypochlorite (a strong oxidant) for disinfection, thus inducing geochemical disequilibrium. Well installation causes changes in geochemistry lasting 12 + months, as illustrated in a recent study of 250 new domestic wells in Minnesota, north-central United States. One study well had extremely high initial arsenic (1550 µg/L) that substantially decreased after 15 months (5.2 µg/L). The drilling and development of the study well were typical and ordinary; nothing observable indicated the very high initial arsenic concentration. We hypothesized that oxidation of arsenic-containing sulfides (which lowers pH) combined with low pH dissolution of arsenic-bearing Fe (oxyhydr)oxides caused the very high arsenic concentration. Geochemical equilibrium considerations and modeling supported our hypothesis. Groundwater equilibrium redox conditions are poised at the Fe(III)_(s)/Fe(II)_(aq) stability boundary, indicating arsenic-bearing Fe (oxyhydr)oxide mineral sensitivity to pH and redox changes. Changing groundwater geochemistry can have negative implications for home water treatment (e.g., reduced arsenic removal efficiency, iron fouling), which can lead to ongoing but unrecognized hazard of arsenic exposure from domestic well water. Our results may inform arsenic mobilization processes and geochemical sensitivity in similarly complex aquifers in Southeast Asia and elsewhere.

Arsenic: Various species with different effects on cytochrome P450 regulation in humans

Arsenic is well-recognized as one of the most hazardous elements which is characterized by its omnipresence throughout the environment in various chemical forms. From the simple inorganic arsenite (iAsIII) and arsenate (iAsV) molecules, a multitude of more complex organic species are biologically produced through a process of metabolic transformation with biomethylation being the core of this process. Because of their differential toxicity, speciation of arsenic-based compounds is necessary for assessing health risks posed by exposure to individual species or co-exposure to several species. In this regard, exposure assessment is another pivotal factor that includes identification of the potential sources as well as routes of exposure. Identification of arsenic impact on different physiological organ systems, through understanding its behavior in the human body that leads to homeostatic derangements, is the key for developing strategies to mitigate its toxicity. Metabolic machinery is one of the sophisticated body systems targeted by arsenic. The prominent role of cytochrome P450 enzymes (CYPs) in the metabolism of both endobiotics and xenobiotics necessitates paying a great deal of attention to the possible effects of arsenic compounds on this superfamily of enzymes. Here we highlight the toxicologically relevant arsenic species with a detailed description of the different environmental sources as well as the possible routes of human exposure to these species. We also summarize the reported findings of experimental investigations evaluating the influence of various arsenicals on different members of CYP superfamily using human-based models.

Reduction in drinking water arsenic exposure and health risk through arsenic treatment among private well households in Maine and New Jersey, USA

Over 2 million mostly rural Americans are at risk of drinking water from private wells that contain arsenic (As) exceeding the U.S. Environmental Protection Agency (USEPA) Maximum Contaminant Level (MCL) of 10 micrograms per liter (μg/L). How well existing treatment technologies perform in real world situations, and to what extent they reduce health risks, are not well understood. This study evaluates the effectiveness of household As treatment systems in southern-central Maine (ME, n = 156) and northern New Jersey (NJ, n = 94) and ascertains how untreated well water chemistry and other factors influence As removal. Untreated and treated water samples, as well as a treatment questionnaire, were collected. Most ME households had point-of-use reverse-osmosis systems (POU RO), while in NJ, dual-tank point-of-entry (POE) whole house systems were popular. Arsenic treatment systems reduced well water arsenic concentrations ([As]) by up to two orders of magnitude, i.e. from a median of 71.7 to 0.8 μg/L and from a mean of 105 to 14.3 μg/L in ME, and from a median of 8.6 to 0.2 μg/L and a mean of 15.8 to 2.1 μg/L in NJ. More than half (53%) of the systems in ME reduced water [As] to below 1 μg/L, compared to 69% in NJ. The treatment system failure rates were 19% in ME (>USEPA MCL of 10 μg/L) and 16% in NJ (>NJ MCL of 5 μg/L). In both states, the higher the untreated well water [As] and the As(III)/As ratio, the higher the rate of treatment failure. POE systems failed less than POU systems, as did the treatment systems installed and maintained by vendors than those by homeowners. The 7-fold reduction of [As] in the treated water reduced skin cancer risk alone from 3765 to 514 in 1 million in ME, and from 568 to 75 in 1 million in NJ.

Time scales of arsenic variability and the role of high-frequency monitoring at three water-supply wells in New Hampshire, USA

Groundwater geochemistry, redox process classification, high-frequency physicochemical and hydrologic measurements, and climate data were analyzed to identify controls on arsenic (As) concentration changes. Groundwater was monitored in two public-supply wells (one glacial aquifer and one bedrock aquifer), and one bedrock-aquifer domestic well in New Hampshire, USA, from 2014 to 2018 to identify time scales of and controls on As concentration changes. Concentrations of As and other geochemical constituents were measured bimonthly. Specific conductance (SC), pH, dissolved oxygen, and pumping rate/water level were measured at high frequency (every 5 to 15 min). Median (and 95% confidence interval) As concentrations at the three wells were 4.1 (3.7-4.6), 18.9 (17.2-23.6), and 37.5 (30.4-42.9) μg/L. Arsenic variability in each of the three wells, in relative standard deviation, ranged from 9 to 12%. Median quarterly As concentrations were highest in all wells in the spring. The bedrock-aquifer public-supply well As concentration increased over the period of study while pumping rate decreased. In the public-supply wells, As variability was correlated with SC and pH, and As species were related to SC, pH, pumping, precipitation, and changes in redox process. Specific conductance also had a seasonal pattern in the two public-supply wells and was correlated with Na and Cl. Excess Na in water samples suggests possible ion exchange with dissolved Ca, creating more capacity to dissolve CaCO₃ from calcareous rocks, which can increase pH and in turn, As concentrations in wells. High-frequency monitoring data are cost effective to collect, which could be advantageous in other parts of the United States and in the many parts of the world where glacial aquifers are in direct contact with other water supply aquifers or where water from different aquifers have potential to mix.

Estimated burden of disease from arsenic in drinking water supplied by domestic wells in the United States

Well water around the world can be contaminated with arsenic, a naturally occurring geological element that has been associated with myriad adverse health effects. Persons obtaining their drinking water from private wells are often responsible for well testing and water treatment. High levels of arsenic have been reported in well water-supplied areas of the United States. We quantified - in cases and dollars - the potential burden of disease associated with the ingestion of arsenic through private well drinking water supplies in the United States. To estimate cancer and cardiovascular disease burden, we developed a Monte Carlo model integrating three input streams: (1) regional concentrations of arsenic in drinking water wells across the United States; (2) dose-response relationships in the form of cancer slope factors and hazard ratios; and (3) economic cost estimates developed for morbidity endpoints using 'cost-of-illness' methods and for mortality using 'value per statistical life' estimates. Exposure to arsenic in drinking water from U.S. domestic wells is modeled to contribute 500 annual premature deaths from ischemic heart disease and 1,000 annual cancer cases (half of them fatal), monetized at $10.9 billion (2017 USD) annually. These considerable public health burden estimates can be compared with the burdens of other priority public health issues to assist in decision-making.

Arsenic concentrations after drinking water well installation: Time-varying effects on arsenic mobilization

Chronic exposure to geogenic arsenic via drinking water is a worldwide health concern. However, effects of well installation and operation on arsenic concentrations and mobilization are not well understood. This knowledge gap impacts both reliable detection of arsenic in drinking water and effective public health recommendations to reduce exposure to arsenic. This study examines changes in arsenic and redox geochemistry over one year following installation of 254 new domestic water wells in three regions of the north-central USA that commonly have elevated arsenic concentrations. Our regions' geologic settings share some important characteristics with other high-arsenic aquifers: igneous bedrock aquifers; or late Pleistocene-age glacial sand and gravel aquifers interbedded with aquitards. Over the study, arsenic concentrations increased by 16% or more in 25% of wells in glacial aquifer regions, and the redox conditions changed towards more reducing. In wells in the bedrock region, there was no significant change in arsenic concentrations, and redox conditions changed towards more oxidizing. Our findings illustrate the importance of understanding short- to moderate-term impacts of well installation and operation on arsenic and aqueous chemistry, as it relates to human exposure. Our study informs water quality sampling requirements, which currently do not consider the implications sampling timing with respect to well installation. Evaluating arsenic concentrations in samples from new wells in the context of general regional pH and redox conditions can provide information regarding the degree of disequilibrium created by well drilling. Our analysis approach may be transferable and scalable to similar aquifer settings across the globe.

Health protective behavior following required arsenic testing under the New Jersey Private Well Testing Act

Exposure to naturally occurring arsenic in groundwater is a public health concern, particularly for households served by unregulated private wells. At present, one of the greatest barriers to exposure reduction is a lack of private well testing due to difficulties in motivating individual private well owners to take protective actions. Policy and regulations requiring testing could make a significant contribution towards universal screening of private well water and arsenic exposure reduction. New Jersey's Private Well Testing Act (PWTA) requires tests for arsenic during real estate transactions; however, the regulations do not require remedial action when maximum contaminant levels (MCLs) are exceeded. A follow-up survey sent to residents of homes where arsenic was measured above the state MCL in PWTA-required tests reveals a range of mitigation behavior among respondents (n = 486), from taking no action to reduce exposure (28%), to reporting both treatment use and appropriate maintenance and monitoring behavior (15%). Although 86% of respondents recall their well was tested during their real estate transaction, only 60% report their test showed an arsenic problem. Treatment systems are used by 63% of households, although half were installed by a previous owner. Among those treating their water (n = 308), 57% report that maintenance is being performed as recommended, although only 31% have tested the treated water within the past year. Perceived susceptibility and perceived barriers are strong predictors of mitigation action. Among those treating for arsenic, perceived severity is associated with recent monitoring, and level of commitment is associated with proper maintenance. Mention of a treatment service agreement is a strong predictor of appropriate monitoring and maintenance behavior, while treatment installed by a previous owner is less likely to be maintained. Though the PWTA requires that wells be tested, this study finds that not all current well owners are aware the test occurred or understood the implications of their arsenic results. Among those that have treatment installed to remove arsenic, poor monitoring and maintenance behaviors threaten to undermine intentions to reduce exposure. Findings suggest that additional effort, resources, and support to ensure home buyers pay attention to, understand, and act on test results at the time they are performed may help improve management of arsenic water problems over the long term and thus the PWTA's public health impact.

Low-level arsenic exposure from drinking water is associated with prostate cancer in Iowa

Inorganic arsenic is a toxic naturally occurring element in soil and water in many regions of the US including the Midwest. Prostate cancer is the second most common type of cancer in men in Iowa, surpassed only by non-melanotic skin cancer. Epidemiology studies have evaluated arsenic exposure from drinking water and prostate cancer, but most have focused on high-level exposures outside the US. As drinking water from groundwater sources is a major source of arsenic exposure, we conducted an ecologic study to evaluate prostate cancer and arsenic in drinking water from public water sources and private wells in Iowa, where exposure levels are low, but duration of exposure can be long. Arsenic data from public water systems were obtained from the Iowa Safe Drinking Water Information System for the years 1994-2003 and for private wells from two Iowa Well Water Studies, the Iowa Community Private Well Study (ICPWS, 2002-2003) and Iowa Statewide Rural Well Water Survey Phase 2 (SWIRL2, 2006-2008) that provided data for 87 Iowa counties. Prostate cancer incidence data from 2009 to 2013 for Iowa were obtained from Surveillance, Epidemiology and End Results' SEER*Stat software. County averages of water arsenic levels varied from 1.08 to 18.6 ppb, with three counties above the current 10 ppb limit. Based on the tertiles of arsenic levels, counties were divided into three groups: low (1.08-2.06 ppb), medium (2.07-2.98 ppb), and high (2.99-18.6 ppb). Spatial Poisson regression modeling was conducted to estimate the risk ratios (RR) of prostate cancer by tertiles of arsenic level at a county level, adjusted for demographic and risk factors. The RR of prostate cancer were 1.23 (95% CI, 1.16-1.30) and 1.28 (95% CI, 1.21-1.35) in the medium and high groups, respectively, compared to the low group after adjusting for risk factors. The RR increased to 1.36 (95% CI, 1.28-1.45) in the high group when analyses were restricted to aggressive prostate cancers (Gleason score ≥ 7). This study shows a significant dose-dependent association between low-level arsenic exposure and prostate cancer, and if this result is replicated in future individual-level studies, may suggest that 10 ppb is not protective for human health.

Effectiveness of table top water pitcher filters to remove arsenic from drinking water

Arsenic contamination of drinking water is a serious threat to the health of hundreds of millions of people worldwide. In the United States ~3 million individuals drink well water that contains arsenic levels above the Environmental Protection Agency (EPA) maximum contaminant level (MCL) of 10μg/L. Several technologies are available to remove arsenic from well water including anion exchange, adsorptive media and reverse osmosis. In addition, bottled water is an alternative to drinking well water contaminated with arsenic. However, there are several drawbacks associated with these approaches including relatively high cost and, in the case of bottled water, the generation of plastic waste. In this study, we tested the ability of five tabletop water pitcher filters to remove arsenic from drinking water. We report that only one tabletop water pitcher filter tested, ZeroWater®, reduced the arsenic concentration, both As³⁺ and As⁵⁺, from 1000μg/L to < 3μg/L, well below the MCL. Moreover, the amount of total dissolved solids or competing ions did not affect the ability of the ZeroWater® filter to remove arsenic below the MCL. Thus, the ZeroWater® pitcher filter is a cost effective and short-term solution to remove arsenic from drinking water and its use reduces plastic waste associated with bottled water.

The Case for Universal Screening of Private Well Water Quality in the U.S. and Testing Requirements to Achieve It: Evidence from Arsenic

BACKGROUND

The 1974 Safe Drinking Water Act (SDWA) regulates >170,000 public water systems to protect health, but not >13 million private wells. State and local government requirements for private well water testing are rare and inconsistent; the responsibility to ensure water safety remains with individual households. Over the last two decades, geogenic arsenic has emerged as a significant public health concern due to high prevalence in many rural American communities.

OBJECTIVES

We build the case for universal screening of private well water quality around arsenic, the most toxic and widespread of common private water contaminants. We argue that achieving universal screening will require policy intervention, and that testing should be made easy, accessible, and in many cases free to all private well households in the United States, considering the invisible, tasteless, odorless, and thus silent nature of arsenic.

DISCUSSION

Our research has identified behavioral, situational and financial barriers to households managing their own well water safety, resulting in far from universal screening despite traditional public health outreach efforts. We observe significant socioeconomic disparities in arsenic testing and treatment when private water is unregulated. Testing requirements can be a partial answer to these challenges.

CONCLUSIONS

Universal screening, achieved through local testing requirements complemented by greater community engagement targeting biologically and socioeconomically vulnerable groups, would reduce population arsenic exposure greater than any promotional efforts to date. Universal screening of private well water will identify the dangers hidden in America's drinking water supply and redirect attention to ensure safe water among affected households. https://doi.org/10.1289/EHP629.

Mobility and speciation of geogenic arsenic in bedrock groundwater from the Canadian Shield in western Quebec, Canada

High arsenic concentrations occur in groundwater collected from a fractured crystalline bedrock aquifer in western Quebec (Canada). Sampling and analysis of water from 59 private wells reveal that more than half of the bedrock wells exceed the Canadian guideline value of 10μg/l for arsenic, whereas shallow wells in unconsolidated surficial deposits are not affected by the contamination. The weathering of arsenic-bearing sulfides present along the mineralized fault zone is considered to be the primary source of arsenic in groundwater. High-arsenic wells are generally characterized by mildly reducing conditions (Eh<250mV), weak alkaline conditions (pH>7.4), low Ca/Na ratios, elevated dissolved Fe and Mn concentrations and high proportions of As(III). Private bedrock wells are open boreholes that likely receive groundwater from multiple contributing fractures. Hence, it is proposed that dissolved arsenic is mainly derived from the contribution to the well discharge of reducing and alkaline geochemically evolved groundwater that contains arsenic as As(III). Geochemically evolved groundwater provides favorable conditions to release arsenic by reductive dissolution of iron and manganese oxyhydroxides and alkaline desorption from mineral surfaces. Thus, high-arsenic wells would contain a high proportion of geochemically evolved groundwater, while oxidizing low-pH recharge water causes dilution and sequestration of arsenic. In relation with the chemical evolution of groundwater along the flow path, most contaminated wells are located in confined areas whereas most of the wells located in unconfined recharge areas are not contaminated. The occurrence of boreholes with high dissolved arsenic as As(V) and oxidizing conditions is attributed to extensive sulfide oxidation and alkaline desorption. This work shows that the determination of arsenic speciation provides a valuable tool to investigate the behavior of arsenic in bedrock groundwater.

Arsenic in private well water part 1 of 3: Impact of the New Jersey Private Well Testing Act on household testing and mitigation behavior

Regularly ingesting water with elevated arsenic increases adverse health risks. Since September 2002, the NJ Private Well Testing Act (PWTA) has required testing untreated well water for arsenic during real estate transactions in 12 counties. Its implementation provides an opportunity to investigate the effects of policy intervention on well testing and treatment behavior. Here we analyze results of a survey mailed to 1943 random addresses (37% response), including responses from 502 private well households who purchased their homes prior to PWTA commencement and 168 who purchased after. We find the PWTA has significantly increased arsenic testing rates in an area where 21% of wells contain arsenic above the 5μg/L NJ drinking water standard. The PWTA has allowed identification of more wells with arsenic (20% of post-PWTA vs. 4% of pre-PWTA households) and more treatment for arsenic (19% of post-PWTA vs. 3% of pre-PWTA households). Such an Act is a partial answer to significant socioeconomic disparities in testing observed among households for whom it is not required. Additionally residents purchasing homes since 2002 are younger and disproportionately more likely to have children in their household (60% vs. 32%), a priority group given their particular vulnerability to effects of arsenic. Despite more wells tested under the PWTA, post-PWTA well owners forget or misremember arsenic test results more often, are more likely to report not knowing what kind of treatment they are using, and are not reporting better maintenance or monitoring of their treatment systems than pre-PWTA households. This suggests serious challenges to reducing arsenic exposure remain even when testing is a requirement. Furthermore, only a fraction of wells have been tested under the PWTA due to the slow pace of housing turnover. We recommend more public resources be made available to support private well testing among socially and biologically vulnerable groups.