Risk of viral acute gastrointestinal illness from nondisinfected drinking water distribution systems

Community intervention trial for estimating risk of acute gastrointestinal illness from groundwater-supplied non-disinfected drinking water

By community intervention in 14 non-disinfecting municipal water systems, we quantified sporadic acute gastrointestinal illness (AGI) attributable to groundwater. Ultraviolet (UV) disinfection was installed on all supply wells of intervention communities. In control communities, residents continued to drink non-disinfected groundwater. Intervention and control communities switched treatments by moving UV disinfection units at the study midpoint (crossover design). Study participants (n = 1,659) completed weekly health diaries during four 12-week surveillance periods. Water supply wells were analyzed monthly for enteric pathogenic viruses. Using the crossover design, groundwater-borne AGI was not observed. However, virus types and quantity in supply wells changed through the study, suggesting that exposure was not constant. Alternatively, we compared AGI incidence between intervention and control communities within the same surveillance period. During Period 1, norovirus contaminated wells and AGI attributable risk from well water was 19% (95% CI, -4%, 36%) for children <5 years and 15% (95% CI, -9%, 33%) for adults. During Period 3, echovirus 11 contaminated wells and UV disinfection slightly reduced AGI in adults. Estimates of AGI attributable risks from drinking non-disinfected groundwater were highly variable, but appeared greatest during times when supply wells were contaminated with specific AGI-etiologic viruses.

Thinking Outside the Treatment Plant: UV for Water Distribution System Disinfection

This work critically evaluates the current paradigm of water distribution system management and juxtaposes that with the potential benefits of employing UV irradiation, which we hope will catalyze a judicial re-evaluation of the current practices in water distribution system management and spur critical research and a new way of thinking about secondary disinfection across the extent of distribution systems. Given the recent advances in UV technology and the efficacy of UV disinfection against all pathogen classes, we now see UV applications for disinfection in many aspects of consumers lives: in water coolers, dishwashers, coffee makers, and disinfection of personal items like gym bags, water bottles, and toothbrushes. Public and regulatory concern over water quality and pathogens, especially the recent interest in building plumbing, calls out for new approaches to disinfection and distribution system management. We envision a new model for secondary disinfection in water distribution systems utilizing emerging germicidal UV LED-based disinfection. UV irradiation in water treatment can achieve high levels of disinfection of all pathogens and minimize or eliminate the formation of regulated disinfection byproducts. So why is UV not considered as a secondary disinfectant for distribution systems? In this Account, we lay out the logic as to the benefits and practicality of adding distributed UV treatment to assist in protection of distribution systems and protect water quality for human exposure. The possible locations of UV irradiation in distribution systems are envisioned, potentially including UV booster stations along the distribution network, UV in storage tanks or their inlet/outlets, LEDs distributed along pipe walls, small point of use/entry treatment systems for buildings/homes/taps, or submersible swimming or rolling UV LED drones to reach problem pipes and provide a "shock" treatment or provide sterilization after main breaks or repairs. The benefits of UV applications in water also include high effectiveness against chlorine-resistant protozoa, no added disinfection byproducts, and compatibility of adding of UV to existing secondary disinfection strategies for enhanced protection. Potential challenges and research needs are described, such as use of UV-compatible pipe materials, implementation of sensors to monitor distributed LEDs, management of waste heat from the rear surface of the LED, and understanding the potential for regrowth of opportunistic microorganisms. Another notable challenge is the relatively stagnant regulatory environment in some countries to develop frameworks for evaluation and acceptance of UV technology in distribution systems that require a chemical secondary disinfectant. Rapid advances in UV LED research has propelled the growth of this field, but needs still remain, including understanding behavior of biofilms in pipes under UV irradiation, including any beneficial effects that may be lost, the potential for fouling of LED emission surfaces and monitoring points, and provision of a distributed power network to run the LEDs. Regulators may want specific monitoring approaches and advances in real-time monitoring of microbial viability, and engineers may need to develop new approaches to overall management.

Quantitative microbial risk assessment and its applications in small water systems: A review

Quantitative microbial risk assessment (QMRA) has been mainstreamed in many large municipal water systems as part of a paradigm shift in the drinking water industry towards water safety planning and risk-based system assessment. Small water systems (SWSs) are generally more vulnerable to typical water system hazards, and consequently have a higher risk of waterborne disease outbreak. In this paper, a review of experiences in implementing QMRA in SWSs helps elaborate the sources of risks and highlights some of the challenges facing SWSs in developed countries. A critical review of the important elements for practical implementation of QMRA was conducted. The investigation focuses on aspects related to challenges in identifying relevant hazards to SWSs to create failure scenarios, acquiring monitoring data for pathogens' concentrations in source water, estimating treatment efficiencies of typical small system technologies, and access to software tools to support successful implementation. The review helped outline ways through which SWSs can overcome the identified challenges in implementing QMRA. An adjusted framework for implementing QMRA for small water systems was formulated and discussed.

Changes in the Drinking Water Microbiome: Effects of Water Treatments Along the Flow of Two Drinking Water Treatment Plants in a Urbanized Area, Milan (Italy)

While safe and of high quality, drinking water can host an astounding biodiversity of microorganisms, dismantling the belief of its "biological simplicity." During the very few years, we are witnessing an exponential growth in scientific publications, exploring the ecology hidden in drinking water treatment plants (DWTPs) and drinking water distribution system (DWDS). We focused on what happens to the microbial communities from source water (groundwater) throughout the main steps of the potabilization process of a DWTP, located in an urbanized area in Northern Italy. Samples were processed by a stringent water filtration to retain even the smallest environmental bacteria and then analyzed with High-Throughput DNA Sequencing (HTS) techniques. We showed that carbon filters harbored a microbial community seeding and shaping water microbiota downstream, introducing a significant variation on incoming (groundwater) microbial community. Chlorination did not instantly affect the altered microbiota. We were also able to correctly predict (through machine learning analysis) samples belonging to groundwater (overall accuracy was 0.71), but the assignation was not reliable with carbon filter samples, which were incorrectly predicted as chlorination samples. The presence and abundance of specific microorganisms allowed us to hypothesize their role as indicators. In particular, Candidatus Adlerbacteria (Parcubacteria), together with microorganisms belonging to Alphaproteobacteria and Gammaproteobacteria, characterized treated water, but not raw water. An exception, confirming our hypothesis, is given by the samples downstream the filters renewal, which had a composition resembling groundwater. Volatility analysis illustrated how carbon filters represented an ecosystem that is stable over time, probably bearing the environmental conditions that promote the survival and growth of this peculiar microbial community.

Biofilm Microbiome (Re)Growth Dynamics in Drinking Water Distribution Systems Are Impacted by Chlorine Concentration

Biofilms are the dominant form of microbial loading (and organic material) within drinking water distribution systems (DWDS), yet our understanding of DWDS microbiomes is focused on the more easily accessible bulk-water. Disinfectant residuals are commonly provided to manage planktonic microbial activity in DWDS to safeguard water quality and public health, yet the impacts on the biofilm microbiome are largely unknown. We report results from a full-scale DWDS facility used to develop biofilms naturally, under one of three chlorine concentrations: Low, Medium, or High. Increasing the chlorine concentration reduced the bacterial concentration within the biofilms but quantities of fungi were unaffected. The chlorine regime was influential in shaping the community structure and composition of both taxa. There were microbial members common to all biofilms but the abundance of these varied such that at the end of the Growth phase the communities from each regime were distinct. Alpha-, Beta-, and Gamma-proteobacteria were the most abundant bacterial classes; Sordariomycetes, Leotiomycetes, and Microbotryomycetes were the most abundant classes of fungi. Mechanical cleaning was shown to immediately reduce the bacterial and fungal concentrations, followed by a lag effect on the microbiome with continued decreases in quantity and ecological indices after cleaning. However, an established community remained, which recovered such that the microbial compositions at the end of the Re-growth and initial Growth phases were similar. Interestingly, the High-chlorine biofilms showed a significant elevation in bacterial concentrations at the end of the Re-growth (after cleaning) compared the initial Growth, unlike the other regimes. This suggests adaptation to a form a resilient biofilm with potentially equal or greater risks to water quality as the other regimes. Overall, this study provides critical insights into the interaction between chlorine and the microbiome of DWDS biofilms representative of real networks, implications are made for the operation and maintenance of DWDS disinfectant and cleaning strategies.

Estimating virus occurrence using Bayesian modeling in multiple drinking water systems of the United States

Drinking water treatment plants rely on purification of contaminated source waters to provide communities with potable water. One group of possible contaminants are enteric viruses. Measurement of viral quantities in environmental water systems are often performed using polymerase chain reaction (PCR) or quantitative PCR (qPCR). However, true values may be underestimated due to challenges involved in a multi-step viral concentration process and due to PCR inhibition. In this study, water samples were concentrated from 25 drinking water treatment plants (DWTPs) across the US to study the occurrence of enteric viruses in source water and removal after treatment. The five different types of viruses studied were adenovirus, norovirus GI, norovirus GII, enterovirus, and polyomavirus. Quantitative PCR was performed on all samples to determine presence or absence of these viruses in each sample. Ten DWTPs showed presence of one or more viruses in source water, with four DWTPs having treated drinking water testing positive. Furthermore, PCR inhibition was assessed for each sample using an exogenous amplification control, which indicated that all of the DWTP samples, including source and treated water samples, had some level of inhibition, confirming that inhibition plays an important role in PCR-based assessments of environmental samples. PCR inhibition measurements, viral recovery, and other assessments were incorporated into a Bayesian model to more accurately determine viral load in both source and treated water. Results of the Bayesian model indicated that viruses are present in source water and treated water. By using a Bayesian framework that incorporates inhibition, as well as many other parameters that affect viral detection, this study offers an approach for more accurately estimating the occurrence of viral pathogens in environmental waters.

Life Cycle Environmental Impacts of Disinfection Technologies Used in Small Drinking Water Systems

Small drinking water systems serve a fifth of the U.S. population and rely heavily on disinfection. While chlorine disinfection is common, there is interest in minimizing chemical addition, especially due to carcinogenic disinfection byproducts and chlorine-resistant pathogens, by using ultraviolet technologies; however, the relative, broader environmental impacts of these technologies are not well established, especially in the context of small (<10 000 people) water systems. The objective of this study was to identify environmental trade-offs between chlorine and ultraviolet disinfection via comparative life cycle assessment. The functional unit was the production of 1 m³ of drinking water to U.S.

STANDARDS

Treatment included cartridge filtration followed by either chlorine disinfection or ultraviolet disinfection with chlorine residual addition. Environmental performance was evaluated for various chlorine contact zone materials (plastic, concrete, steel), ultraviolet validation factors (1.2 to 4.4), and electricity sources (renewable; U.S. average, high, and low impact grids). Performance was also evaluated when filtration and chlorine residual were not required. From a life cycle assessment perspective, replacing chlorine with UV was preferred only in a limited number of cases (i.e., high pumping pressure but filtration is not required). In all others, chlorine was environmentally preferred, although some contact zone materials and energy sources had an impact on the comparison. Utilities can use these data to inform their disinfection technology selection and operation to minimize environmental and human health impacts.

Human virus and microbial indicator occurrence in public-supply groundwater systems: meta-analysis of 12 international studies

Groundwater quality is often evaluated using microbial indicators. This study examines data from 12 international groundwater studies (conducted 1992-2013) of 718 public drinking-water systems located in a range of hydrogeological settings. Focus was on testing the value of indicator organisms for identifying virus-contaminated wells. One or more indicators and viruses were present in 37 and 15% of 2,273 samples and 44 and 27% of 746 wells, respectively. Escherichia coli (E. coli) and somatic coliphage are 7-9 times more likely to be associated with culturable virus-positive samples when the indicator is present versus when it is absent, while F-specific and somatic coliphages are 8-9 times more likely to be associated with culturable virus-positive wells. However, single indicators are only marginally associated with viruses detected by molecular methods, and all microbial indicators have low sensitivity and positive predictive values for virus occurrence, whether by culturable or molecular assays, i.e., indicators are often absent when viruses are present and the indicators have a high false-positive rate. Wells were divided into three susceptibility subsets based on presence of (1) total coliform bacteria or (2) multiple indicators, or (3) location of wells in karst, fractured bedrock, or gravel/cobble settings. Better associations of some indicators with viruses were observed for (1) and (3). Findings indicate the best indicators are E. coli or somatic coliphage, although both indicators may underestimate virus occurrence. Repeat sampling for indicators improves evaluation of the potential for viral contamination in a well.

Effects of Climate and Sewer Condition on Virus Transport to Groundwater

Pathogen contamination from leaky sanitary sewers poses a threat to groundwater quality in urban areas, yet the spatial and temporal dimensions of this contamination are not well understood. In this study, 16 monitoring wells and six municipal wells were repeatedly sampled for human enteric viruses. Viruses were detected infrequently, in 17 of 455 samples, compared to previous sampling at these wells. Thirteen of the 22 wells sampled were virus-positive at least once. While the highest virus concentrations occurred in shallower wells, shallow and deep wells were virus-positive at similar rates. Virus presence in groundwater was temporally coincident, with 16 of 17 virus-positive samples collected in a six-month period. Detections were associated with precipitation and occurred infrequently during a prolonged drought. The study purposely included sites with sewers of differing age and material. The rates of virus detections in groundwater were similar at all study sites during this study. However, a relationship between sewer age and virus detections emerged when compared to data from an earlier study, conducted during high precipitation conditions. Taken together, these data indicate that sewer condition and climate affect urban groundwater contamination by human enteric viruses.

Refined assessment of associations between drinking water residence time and emergency department visits for gastrointestinal illness in Metro Atlanta, Georgia

Recent outbreak investigations suggest that a substantial proportion of waterborne disease outbreaks are attributable to water distribution system issues. In this analysis, we examine the relationship between modeled water residence time (WRT), a proxy for probability of microorganism intrusion into the distribution system, and emergency department visits for gastrointestinal (GI) illness for two water utilities in Metro Atlanta, USA during 1993-2004. We also examine the association between proximity to the nearest distribution system node, based on patients' residential address, and GI illness using logistic regression models. Comparing long (≥90th percentile) with intermediate WRTs (11th to 89th percentile), we observed a modestly increased risk for GI illness for Utility 1 (OR = 1.07, 95% CI: 1.02-1.13), which had substantially higher average WRT than Utility 2, for which we found no increased risk (OR = 0.98, 95% CI: 0.94-1.02). Examining finer, 12-hour increments of WRT, we found that exposures >48 h were associated with increased risk of GI illness, and exposures of >96 h had the strongest associations, although none of these associations was statistically significant. Our results suggest that utilities might consider reducing WRTs to <2-3 days or adding booster disinfection in areas with longer WRT, to minimize risk of GI illness from water consumption.

EPA Method 1615. Measurement of Enterovirus and Norovirus Occurrence in Water by Culture and RT-qPCR. Part III. Virus Detection by RT-qPCR

EPA Method 1615 measures enteroviruses and noroviruses present in environmental and drinking waters. This method was developed with the goal of having a standardized method for use in multiple analytical laboratories during monitoring period 3 of the Unregulated Contaminant Monitoring Rule. Herein we present the protocol for extraction of viral ribonucleic acid (RNA) from water sample concentrates and for quantitatively measuring enterovirus and norovirus concentrations using reverse transcription-quantitative PCR (RT-qPCR). Virus concentrations for the molecular assay are calculated in terms of genomic copies of viral RNA per liter based upon a standard curve. The method uses a number of quality controls to increase data quality and to reduce interlaboratory and intralaboratory variation. The method has been evaluated by examining virus recovery from ground and reagent grade waters seeded with poliovirus type 3 and murine norovirus as a surrogate for human noroviruses. Mean poliovirus recoveries were 20% in groundwaters and 44% in reagent grade water. Mean murine norovirus recoveries with the RT-qPCR assay were 30% in groundwaters and 4% in reagent grade water.

Estimating the number of cases of acute gastrointestinal illness (AGI) associated with Canadian municipal drinking water systems

The estimated burden of endemic acute gastrointestinal illness (AGI) annually in Canada is 20·5 million cases. Approximately 4 million of these cases are domestically acquired and foodborne, yet the proportion of waterborne cases is unknown. A number of randomized controlled trials have been completed to estimate the influence of tap water from municipal drinking water plants on the burden of AGI. In Canada, 83% of the population (28 521 761 people) consumes tap water from municipal drinking water plants serving >1000 people. The drinking water-related AGI burden associated with the consumption of water from these systems in Canada is unknown. The objective of this research was to estimate the number of AGI cases attributable to consumption of drinking water from large municipal water supplies in Canada, using data from four household drinking water intervention trials. Canadian municipal water treatment systems were ranked into four categories based on source water type and quality, population size served, and treatment capability and barriers. The water treatment plants studied in the four household drinking water intervention trials were also ranked according to the aforementioned criteria, and the Canadian treatment plants were then scored against these criteria to develop four AGI risk groups. The proportion of illnesses attributed to distribution system events vs. source water quality/treatment failures was also estimated, to inform the focus of future intervention efforts. It is estimated that 334 966 cases (90% probability interval 183 006-501 026) of AGI per year are associated with the consumption of tap water from municipal systems that serve >1000 people in Canada. This study provides a framework for estimating the burden of waterborne illness at a national level and identifying existing knowledge gaps for future research and surveillance efforts, in Canada and abroad.

Application of salivary antibody immunoassays for the detection of incident infections with Norwalk virus in a group of volunteers

Norovirus infection is the most common cause of acute gastroenteritis in developed countries. Developing an assay based on a non-invasive biomarker for detecting incident norovirus infections could improve disease surveillance and epidemiological investigations. This project involved analysis of IgA and IgG norovirus-specific antibody responses in saliva samples from a Norwalk virus (Genogroup I, genotype 1 norovirus) challenge study involving infected and symptomatic, and non-infected asymptomatic individuals. Saliva was collected at the challenge, and two weeks and 40 days post-challenge. Samples were analyzed using the Luminex fluorometric and Meso Scale Discovery (MSD) electrochemiluminescence immunoassays. Recombinant P domains of Norwalk virus capsid protein, as well as similar recombinant proteins of two genogroup II noroviruses (VA387 and VA207) were used as antigens. Immunoconversions were defined as >4-fold increase in antibody responses to the norovirus antigens. Various sample pre-treatment options, buffers, saliva dilution ratios, and data adjustment approaches to control for sample-to-sample variability in saliva composition were compared using the Luminex assay. The results suggest that adjusting responses to the norovirus antigens for responses to the protein purification tag, glutathione-S-transferase (GST), significantly improved the odds of producing a correct immunoconversion test result. IgG-based tests were more accurate compared to IgA-based tests. At optimal conditions, both Luminex and MSD assays for Norwalk-specific IgG antibodies correctly identified all infected and non-infected individuals. There was no evidence of cross-reactivity of anti-Norwalk virus antibodies with genogroup II noroviruses. These results suggest that salivary antibody responses can be used for the detection of incident infections with Norwalk virus in prospective surveys.

Microbial Contamination of Drinking Water and Human Health from Community Water Systems

A relatively short list of reference viral, bacterial and protozoan pathogens appears adequate to assess microbial risks and inform a system-based management of drinking waters. Nonetheless, there are data gaps, e.g. human enteric viruses resulting in endemic infection levels if poorly performing disinfection and/or distribution systems are used, and the risks from fungi. Where disinfection is the only treatment and/or filtration is poor, cryptosporidiosis is the most likely enteric disease to be identified during waterborne outbreaks, but generally non-human-infectious genotypes are present in the absence of human or calf fecal contamination. Enteric bacteria may dominate risks during major fecal contamination events that are ineffectively managed. Reliance on culture-based methods exaggerates treatment efficacy and reduces our ability to identify pathogens/indicators; however, next-generation sequencing and polymerase chain reaction approaches are on the cusp of changing that. Overall, water-based Legionella and non-tuberculous mycobacteria probably dominate health burden at exposure points following the various societal uses of drinking water.

Acute gastrointestinal illness following a prolonged community-wide water emergency

The drinking water infrastructure in the United States is ageing; extreme weather events place additional stress on water systems that can lead to interruptions in the delivery of safe drinking water. We investigated the association between household exposures to water service problems and acute gastrointestinal illness (AGI) and acute respiratory illness (ARI) in Alabama communities that experienced a freeze-related community-wide water emergency. Following the water emergency, investigators conducted a household survey. Logistic regression models were used to estimate adjusted prevalence ratios (aPR) and 95% confidence intervals (CI) for self-reported AGI and ARI by water exposures. AGI was higher in households that lost water service for ⩾7 days (aPR 2·4, 95% CI 1·1-5·2) and experienced low water pressure for ⩾7 days (aPR 3·6, 95% CI 1·4-9·0) compared to households that experienced normal service and pressure; prevalence of AGI increased with increasing duration of water service interruptions. Investments in the ageing drinking water infrastructure are needed to prevent future low-pressure events and to maintain uninterrupted access to the fundamental public health protection provided by safe water supplies. Households and communities need to increase their awareness of and preparedness for water emergencies to mitigate adverse health impacts.

Water distribution system deficiencies and gastrointestinal illness: a systematic review and meta-analysis

BACKGROUND

Water distribution systems are vulnerable to performance deficiencies that can cause (re)contamination of treated water and plausibly lead to increased risk of gastrointestinal illness (GII) in consumers.

OBJECTIVES

It is well established that large system disruptions in piped water networks can cause GII outbreaks. We hypothesized that routine network problems can also contribute to background levels of waterborne illness and conducted a systematic review and meta-analysis to assess the impact of distribution system deficiencies on endemic GII.

METHODS

We reviewed published studies that compared direct tap water consumption to consumption of tap water re-treated at the point of use (POU) and studies of specific system deficiencies such as breach of physical or hydraulic pipe integrity and lack of disinfectant residual.

RESULTS

In settings with network malfunction, consumers of tap water versus POU-treated water had increased GII [incidence density ratio (IDR) = 1.34; 95% CI: 1.00, 1.79]. The subset of nonblinded studies showed a significant association between GII and tap water versus POU-treated water consumption (IDR = 1.52; 95% CI: 1.05, 2.20), but there was no association based on studies that blinded participants to their POU water treatment status (IDR = 0.98; 95% CI: 0.90, 1.08). Among studies focusing on specific network deficiencies, GII was associated with temporary water outages (relative risk = 3.26; 95% CI: 1.48, 7.19) as well as chronic outages in intermittently operated distribution systems (odds ratio = 1.61; 95% CI: 1.26, 2.07).

CONCLUSIONS

Tap water consumption is associated with GII in malfunctioning distribution networks. System deficiencies such as water outages also are associated with increased GII, suggesting a potential health risk for consumers served by piped water networks.

Public health and pipe breaks in water distribution systems: analysis with internet search volume as a proxy

Drinking water distribution infrastructure has been identified as a factor in waterborne disease outbreaks and improved understanding of the public health risks associated with distribution system failures has been identified as a priority area for research. Pipe breaks may pose a risk, as their occurrence and repair can result in low or negative pressure, potentially allowing contamination of drinking water from adjacent soils. However, measuring this phenomenon is challenging because the most likely health impact is mild gastrointestinal (GI) illness, which is unlikely to result in a doctor or hospital visit. Here we present a novel method that uses data mining techniques and internet search volume to assess the relationship between pipe breaks and symptoms of GI illness in two U.S. cities. Weekly search volume for the terms diarrhea and vomiting was used as the response variable with the number of pipe breaks in each city as a covariate as well as additional covariates to control for seasonal patterns, search volume persistence, and other sources of GI illness. The fit and predictive accuracy of multiple regression and data mining techniques were compared, with the best performance obtained using random forest and bagged regression tree models. Pipe breaks were found to be an important and positively correlated predictor of internet search volume in multiple models in both cities, supporting previous investigations that indicated an increased risk of GI illness from distribution system disturbances.

Drinking water systems, hydrology, and childhood gastrointestinal illness in Central and Northern Wisconsin

OBJECTIVES

This study investigated if the type of drinking water source (treated municipal, untreated municipal, and private well water) modifies the effect of hydrology on childhood (aged < 5 years) gastrointestinal illness.

METHODS

We conducted a time series study to assess the relationship between hydrologic and weather conditions with childhood gastrointestinal illness from 1991 to 2010. The Central and Northern Wisconsin study area includes households using all 3 types of drinking water systems. Separate time series models were created for each system and half-year period (winter/spring, summer/fall).

RESULTS

More precipitation (summer/fall) systematically increased childhood gastrointestinal illness in municipalities accessing untreated water. The relative risk of contracting gastrointestinal illness was 1.4 in weeks with 3 centimeters of precipitation and 2.4 in very wet weeks with 12 centimeters of precipitation. By contrast, gastrointestinal illness in private well and treated municipal areas was not influenced by hydrologic conditions, although warmer winter temperatures slightly increased incidence.

CONCLUSIONS

Our study suggests that improved drinking water protection, treatment, and delivery infrastructure may improve public health by specifically identifying municipal water systems lacking water treatment that may transmit waterborne disease.