Assessing the exposure of pregnant women to drinking water disinfection byproducts

Perspectives and understanding on the occurrence, toxicity and abatement technologies of disinfection by-products in drinking water

Disinfection by-products (DBPs) are one of the significant emerging contaminants that have caught the attention of researchers worldwide due to their pervasiveness. Their presence in drinking water, even in shallow concentrations (in levels of parts per billion), poses considerable health risks. Therefore, it is crucial to understand their kinetics to understand better their formation and persistence in the water supply systems. This manuscript demonstrates different aspects of research carried out on DBPs in the past. A systematic approach was adopted for the bibliographical research that started with choosing appropriate keywords and identifying the most relevant manuscripts through the screening process. This follows a quantitative assessment of the extracted literature sample, which included the most productive and influential journal sources, the most widely used keywords, the most influential authors active in the research domain, the most cited articles, and the countries most actively engaged in the research field. Critical observations on the literature sample led to the qualitative assessment, wherein the past and current research trends were observed and reported. Finally, we identified the essential gaps in the available literature, which further led to recommending the course ahead in the research domain. This study will prove fruitful for young and established researchers who are or wish to work in this emerging field of research.

Maternal urinary levels of trichloroacetic acid and association with adverse pregnancy outcomes

The current study aimed to determine the association between trichloroacetic acid (TCAA) levels and adverse pregnancy outcomes among third-trimester pregnant women who were exposed to chlorinated drinking water. A total of 205 pregnant women who participated in the disinfection by-products exposure and adverse pregnancy outcome study in South Africa were randomly asked to participate in this study by providing their morning urine sample voids. Samples were analysed for urinary creatinine and TCAA. Furthermore, participants gave individual data using a structured questionnaire. The mean (median) concentration of creatinine-adjusted urinary TCAA was 2.34 (1.95) μg/g creatinine. Elevated levels of creatinine-adjusted TCAA concentrations showed an increased risk of premature birth, small for gestational age (SGA) and low birth weight. There was no significant statistical correlation observed between creatinine-adjusted TCAA concentrations and the total volume of cold water ingested among the study population. No statistically significant association was observed between creatinine-adjusted urinary TCAA and premature birth, SGA and low birth weight newborns among the study subjects. However, the urinary TCAA concentrations identified in this study suggest potential health risks towards women and foetus. Therefore, further studies are warranted to prevent further adverse pregnancy outcomes.

Associations between Maternal Water Consumption and Birth Defects in the National Birth Defects Prevention Study (2000-2005)

BACKGROUND

Water and water-based beverages constitute a major part of daily fluid intake for pregnant women, yet few epidemiologic studies have investigated the role of water consumption on birth outcomes.

METHODS

We used data from the National Birth Defects Prevention Study to conduct a case-control study investigating associations between maternal water consumption during pregnancy and birth defects (BD). We used interview data on water consumption during the first trimester of pregnancy in 14,454 cases (major BDs n ≥ 50) and 5,063 controls. Total water consumption was analyzed as a continuous variable and in quartiles. We evaluated the role of dietary quality and sugar sweetened beverage consumption. Logistic regression models were used to assess effects of water consumption on risk of BDs with adjustment for relevant covariates.

RESULTS

Mean daily maternal water consumption among controls was 4.4 eight-ounce glasses. We observed decreases in estimated risk associated with increases in water consumption for several BDs, including neural tube defects (spina bifida), oral clefts (cleft lip), musculoskeletal defects (gastroschisis, limb deficiencies), and congenital heart defects (hypoplastic left heart syndrome, right-sided obstructions, pulmonary valve stenosis). Our results were generally unchanged when an indicator for overall dietary quality was included; however, there was evidence of effect measure modification by heavy consumption of sugar-sweetened beverages for some defects, but not all.

CONCLUSION

These analyses suggest the importance of sufficient water consumption during early pregnancy, above and beyond it being a marker of higher diet quality. Additional analyses are warranted to understand the biological mechanism for this association. Birth Defects Research 109:193-202, 2017. © 2016 Wiley Periodicals, Inc.

Estimating drinking-water ingestion and dermal contact with water in a French population of pregnant women: the EDDS cohort study

The aim of the present study, a part of the Endocrine Disruptor Deux-Sèvres (EDDS) cohort study, was to estimate water-use habits of pregnant French women. The study population consisted of 132 pregnant women living in Deux-Sèvres (France) in 2012-2013, in areas where drinking water is exclusively produced by surface water. Drinking-water data included ingested water (tap, bottled and filtered) and ingestion place (home, work and elsewhere). Dermal contact with water included showering, bathing, swimming, spa use, hand-washing and other water activities. Data were collected through face-to-face interviews at second and third trimesters of pregnancy with a 1-day-recall questionnaire. Intertrimestral differences in water-use habits were assessed. Predictors of water ingestion and duration of dermal contact with water were assessed with multiple linear regressions. At the second trimester of pregnancy, the mean total drinking-water ingestion was 1.8±0.6 l per day (mean and SD), 71% of which was tap water. Total drinking-water ingestion was not different between both trimesters but ingestion place differed. Dermal contact with water estimate was 188±118 and 173±92 min/week at second and third trimesters, respectively. Smoking increased water ingestion 777 ml/day 95% CI (171-1384). Duration of dermal contact in spring was 30 min/week 95% CI (13-48) higher than in winter. Obese women spend 26 min/week 95% CI (2-50) more showering than women with recommended weight. Our estimates of pregnant French women's exposure to water will help researchers to better assess water pollutant risks.

Validation of trichloroacetic acid exposure via drinking water during pregnancy using a urinary TCAA biomarker

Disinfection by-product (DBP) exposure during pregnancy may be related to reduced fetal growth, but the evidence is inconclusive and improved DBP exposure assessment is required. The authors conducted a nested exposure study on a subset (n=39) of pregnant women in the Born in Bradford cohort to assess validity of TCAA exposure assessment based on tap water sampling and self-reported water-use; water-use questionnaire validity; and use of a one-time urinary TCAA biomarker. TCAA levels in urine and home tap water supply were quantified, and water use was measured via a questionnaire and 7-day diary, at 28 weeks gestation. Diary and urine measures were repeated later in pregnancy (n=14). TCAA level in home tap water supply was not correlated with urinary TCAA (0.18, P=0.29). Cold unfiltered tap water intake at home measured by questionnaire was correlated with urinary TCAA (0.44, P=0.007), but correlation was stronger still for cold unfiltered tap water intake reported over the 3 days prior to urine sampling (0.60, P<0.001). For unemployed women TCAA ingestion at home, derived from tap water sampling and self-reported water-use, correlated strongly with urinary TCAA (0.78, P<0.001), but for employed women the correlation was weak (0.31, P=0.20). Results suggest individual tap water intake is most influential in determining TCAA exposure variability in this cohort, and that TCAA ingestion at home is a valid proxy for TCAA exposure for unemployed women but less satisfactory for employed women.

The relation between amyotrophic lateral sclerosis and inorganic selenium in drinking water: a population-based case-control study

BACKGROUND

A community in northern Italy was previously reported to have an excess incidence of amyotrophic lateral sclerosis among residents exposed to high levels of inorganic selenium in their drinking water.

METHODS

To assess the extent to which such association persisted in the decade following its initial observation, we conducted a population-based case-control study encompassing forty-one newly-diagnosed cases of amyotrophic lateral sclerosis and eighty-two age- and sex-matched controls. We measured long-term intake of inorganic selenium along with other potentially neurotoxic trace elements.

RESULTS

We found that consumption of drinking water containing ≥ 1 μg/l of inorganic selenium was associated with a relative risk for amyotrophic lateral sclerosis of 5.4 (95% confidence interval 1.1-26) after adjustment for confounding factors. Greater amounts of cumulative inorganic selenium intake were associated with progressively increasing effects, with a relative risk of 2.1 (95% confidence interval 0.5-9.1) for intermediate levels of cumulative intake and 6.4 (95% confidence interval 1.3-31) for high intake.

CONCLUSION

Based on these results, coupled with other epidemiologic data and with findings from animal studies that show specific toxicity of the trace element on motor neurons, we hypothesize that dietary intake of inorganic selenium through drinking water increases the risk for amyotrophic lateral sclerosis.

Patterns of water use and exposure to trihalomethanes among children in Spain

Few studies characterizing trihalomethane (THM) exposure or examining potential health effects were conducted in children. The present study describes patterns of water use in children as a source of THM exposure, and estimates the daily THM uptake and the relative contribution of each pathway of exposure. A cross-sectional population-based study was conducted in children 9-12 years of age in Sabadell, Catalonia, Spain (N=2037). We collected individual information on ingestion, frequency and duration of showering, bathing and swimming, source of drinking water, age, sex and parental education. Chloroform, dibromochloroform, bromodichloroform and bromoform in tap, bottled and swimming pool water were measured. The daily chloroform and brominated THM uptakes were estimated combining environmental levels with individual water activities using algorithms reported in the literature. Among the studied group, 80% of children drank bottled water and 20% regularly attended swimming pools. Mean THM concentration in bottled, tap and chlorinated pool water were, respectively, 0.3, 117 and 92 microg/L. Brominated THM predominated in the tap water (84% of total THM) and chloroform predominated in the swimming pool (84% of total THM). Children attending swimming pools had four times higher THM uptake compared to non-swimmers (p-value<0.05). Showering was the main pathway of exposure for non-swimmers. Girls and children with low parental education had a higher THM uptake (p-value<0.05) as they reported taking longer showers and more frequent baths. In conclusion, total and specific THM uptake varied considerably with the personal water uses among children. As drinking water was mainly bottled and bathing was infrequent, showering and swimming in pools were the main pathways of THM exposure. Specific water uses among children slightly differed by sociodemographic characteristics.

Tap water use amongst pregnant women in a multi-ethnic cohort

BACKGROUND

Studies of disinfection by-products in drinking water and measures of adverse fetal growth have often been limited by exposure assessment lacking data on individual water use, and therefore failing to reflect individual variation in DBP exposure.

METHODS

Pregnant women recruited to the Born in Bradford cohort study completed a questionnaire which covers water exposure. Information was collected on water consumption, showering, bathing and swimming. Water exposure data from a subset of 39 women of the cohort are described here.

RESULTS

Mean total tap water intake was 1.8 l/day, and women on average spent 146 minutes per week showering and bathing. Most tap water intake occurred at home (100% for unemployed, 71.8% for employed). Differences between age groups were observed for total tap water intake overall (p = 0.02) and at home (p = 0.01), and for bottled water intake (p = 0.05). There were differences between ethnic groups for tap water intake at home (p = 0.02) and total tap water intake at work (p = 0.02). Total tap water intake at work differed by income category (p = 0.001). Duration per shower was inversely correlated with age (Spearman's correlation -0.39, p = 0.02), and differed according to employment status (p = 0.04), ethnicity (p = 0.02) and income (p = 0.02).

CONCLUSION

This study provides estimates of water exposure in pregnant women in a multi-ethnic population in the north of England and suggests differences related to age, employment, income and ethnicity. The findings are valuable to inform exposure assessment in studies assessing the relationship between DBPs and adverse birth outcomes.

Collecting household water usage data: telephone questionnaire or diary?

Background

Quantitative Microbial Risk Assessment (QMRA), a modelling approach, is used to assess health risks. Inputs into the QMRA process include data that characterise the intensity, frequency and duration of exposure to risk(s). Data gaps for water exposure assessment include the duration and frequency of urban non-potable (non-drinking) water use. The primary objective of this study was to compare household water usage results obtained using two data collection tools, a computer assisted telephone interview (CATI) and a 7-day water activity diary, in order to assess the effect of different methodological survey approaches on derived exposure estimates. Costs and logistical aspects of each data collection tool were also examined.

Methods

A total of 232 households in an Australian dual reticulation scheme (where households are supplied with two grades of water through separate pipe networks) were surveyed about their water usage using both a CATI and a 7-day diary. Householders were questioned about their use of recycled water for toilet flushing, garden watering and other outdoor activities. Householders were also questioned about their water use in the laundry. Agreement between reported CATI and diary water usage responses was assessed.

Results

Results of this study showed that the level of agreement between CATI and diary responses was greater for more frequent water-related activities except toilet flushing and for those activities where standard durations or settings were employed. In addition, this study showed that the unit cost of diary administration was greater than for the CATI, excluding consideration of the initial selection and recruitment steps.

Conclusion

This study showed that it is possible to successfully 'remotely' coordinate diary completion providing that adequate instructions are given and that diary recording forms are well designed. In addition, good diary return rates can be achieved using a monetary incentive and the diary format allows for collective recording, rather than an individual's estimation, of household water usage. Accordingly, there is merit in further exploring the use of diaries for collection of water usage information either in combination with a mail out for recruitment, or potentially in the future with Internet-based recruitment (as household Internet uptake increases).

Variability and predictors of changes in water use during pregnancy

Disinfection by-products in tap water have been found in some studies to be associated with adverse pregnancy outcomes, but little is known about how water use and consumption might change during early pregnancy. Estimating water-related activities only at one time during pregnancy could easily lead to exposure misclassification. To evaluate changes in water use among pregnant women, we used data from a large epidemiologic study in which 1990 women were interviewed around 9 and 20 weeks' gestation. The water variables that were examined included ingestion of cold and hot tap water as well as of bottled water, showering and bathing. Changes were detected between early and mid-pregnancy for ingested cold tap water and showering. Thirty-three percent of the subjects changed cold-water ingestion by > or =1.0 liters/day and 44% changed their time showering by > or =35 min per week during this period. Increases in cold tap water intake were associated with age >35 years, income < $40,000, and non-Hispanic white ethnicity. We also found that the proportion of the total variation due to within-subject variability was 62% for hot tap water ingestion but only 35% for showering and approximately 50% for cold tap water, bottled water and bathing. Limited resources in epidemiologic studies often require a decision between collecting data for a large number of people or collecting multiple measurements for a smaller number of people. The results in this study will be useful to researchers who need to determine where to invest their effort when assessing water-related exposures and should help in evaluation of previously performed studies.

Preterm delivery and exposure to active and passive smoking during pregnancy: a case-control study from Italy

The aim of this study was to assess the relationship between preterm/early preterm delivery and active smoking as well as environmental tobacco smoke (ETS) exposure in a sample of pregnant Italian women. A case-control study was conducted in nine cities in Italy between October 1999 and September 2000. Cases of preterm birth were singleton babies born before the 37th gestational week; babies born before the 35th gestational week were considered early preterm births. Controls were babies with gestational ages >or= 37th week. A total of 299 preterm cases (including 105 early preterm) and 855 controls were analysed. A self-administered questionnaire was used to assess active smoking and ETS exposure, as well as potential confounders. Multivariable logistic regression analysis showed a relationship between active smoking during pregnancy and preterm/early preterm delivery [adjusted ORs: 1.53; 95% CI 1.05, 2.21 and 2.00; 95% CI 1.16, 3.45, respectively]. A dose-response relationship was found for the number of cigarettes smoked daily. The adjusted ORs were 1.54 and 1.69 for preterm babies and 1.90 and 2.46 for early preterm babies for 1-10 and >10 cigarettes/day respectively. ETS exposure was associated with early preterm delivery [adjusted OR 1.56; 95% CI 0.99, 2.46] with a dose-response relationship with the number of smokers in the home. Smoking during pregnancy was strongly associated with preterm delivery with a dose-response effect. ETS exposure in non-smoking women was associated only with early preterm delivery.

Predictors of use and consumption of public drinking water among pregnant women

Disinfection by-products (DBPs) in drinking water may be associated with adverse pregnancy outcomes. However, the results from previous epidemiological studies are not consistent, perhaps in part due to individual variation in water use and consumption. This study was performed to evaluate and describe demographic and behavioral characteristics as predictors of ingested water, showering, bathing, and swimming among pregnant women. Water use and consumption data were collected through telephone interviews with 2297 pregnant women from three geographical sites in the southern United States. The data were analyzed according to demographic, health, and behavioral variables expected to be predictors of water use and thus potential confounding factors relating water use to pregnancy outcome. The candidate predictors were evaluated using backward elimination in regression models. Demographic variables tended to be more strongly predictive of the use and consumption of water than health and behavior-related factors. Non-Hispanic white women drank 0.4 (95% confidence interval (CI) 0.2; 0.7) liters more cold tap water per day than Hispanic women and 0.3 (95% CI 0.1; 0.4) liters more than non-Hispanic black women. Non-Hispanic white women also reported drinking a higher proportion of filtered tap water, whereas Hispanic women replaced more of their tap water with bottled water. Lower socioeconomic groups reported spending a longer time showering and bathing, but were less likely to use swimming pools. The results of this study should help researchers to anticipate and better control for confounding and misclassification in studies of exposure to DBPs and pregnancy outcomes.

Validation of a water consumption questionnaire for a study of the adverse health outcomes associated with disinfection by-products

The aim of this study was to assess the validity and reliability of a questionnaire to estimate water exposure through drinking, showering, bathing or swimming. Forty-seven pregnant women were recruited from antenatal or exercise classes and were randomly allocated into three groups. The first group completed the water exposure questionnaire one-week apart. The second group completed a three-day diary and then the questionnaire. The third group completed the questionnaire first followed by the diary. Agreement was assessed by the Intraclass correlation coefficient (ICC) and the Kappa statistic. The questionnaire demonstrated good reliability (ICC 0.93 for water consumption and 0.91 for time spent showering). With regard to validity, average daily water consumption was estimated to be 8.1 glasses/day (2 litres) from the diary compared with 12.2 (3 litres) from the questionnaire. The ICCs comparing the diary and questionnaire responses were 0.31 for water consumption and 0.72 for showering. The water exposure questionnaire overestimated levels of exposure when compared with diary-reporting of consumption. While a water exposure questionnaire may be a less intrusive research instrument than a diary, further development is required to improve the validity of this instrument.

Exposure of pregnant women to tap water related activities

BACKGROUND

Evidence for an association between exposure of pregnant women to chlorination disinfection by-products and adverse birth outcomes is inconsistent and inconclusive.

AIMS

To evaluate the use of a questionnaire in a population of pregnant women to assess their exposure to water, examine the validity of the questionnaire by a seven day diary, and to obtain a better understanding of the exposure of pregnant women to water in Central London.

METHODS

A total of 147 pregnant women were asked to complete a questionnaire. Information was requested on their exposure to water from cooking and washing up, showering and bathing, food and drink, and swimming. Demographic and socioeconomic information were also recorded. For validation purposes, women were asked to complete a seven day diary at home.

RESULTS

The average exposure duration was 338.5 min/week for cooking and washing up, 172.2 min/week for bathing and showering, and 67.9 min/month for swimming. The total fluid intake was 18.9 l/week of which, on average, 18% was cold tap water; 30% of this tap water was consumed outside the home. The correlation between questionnaire and diary data was generally good to very good, although women tended to overestimate their exposure in the questionnaire compared to the diary.

CONCLUSIONS

Information was obtained on the daily exposure of pregnant women in Central London to chlorinated water at home, work, and elsewhere. The questionnaire was found to be a valid method to assess the exposure of pregnant women to water and the response rate was higher than for diaries.

Exposures to drinking water chlorination by-products in a Russian city

Exposures to water disinfection by-products (DBPs) via ingestion of drinking water, and dermal absorption and inhalation during showering/bathing were assessed in the city of Cherepovets, Russia, which uses heavy chlorination to disinfect organic-rich surface water. Concentrations of DBPs (mean +/- standard deviation) in tap water were the following: total trihalomethanes (THMs) 205 +/- 70 micrograms/l, five haloacetic acids (HAAs) 150 +/- 30 micrograms/l, and 3-chloro-4-(dichloromethyl)-5-hydroxy-2(5H)-furanone (mutagen X or MX) 160 +/- 50 ng/l. Concentrations of THMs and HAAs exceeded the corresponding US standards by a factor of 2.5, while MX concentrations were the highest ever reported. The mutagenic activity of tap water extracts in the Salmonella TA-100 assay was 14,900 net revertants/l. Concentrations of chloroform in breathing zone air in bathrooms during showering were 330 +/- 260 micrograms/m3, shower room air at an industrial plant 2,600 +/- 1,100 micrograms/m3, and bedrooms of local residents 2 +/- 2 micrograms/m3. The mean concentration of chloroform was 3.2 micrograms/m3 in exhaled air samples collected before showering and 110 micrograms/m3 after showering. Data on water ingestion and water use practices in the general population and for pregnant women were collected using questionnaires and diaries. Due to concerns over microbiological safety of water, average daily consumption of non-boiled tap water in pregnant women was only 0.01 l/day, while consumption of boiled tap water was 0.81 l/day. This resulted in low ingestion exposures to volatile THMs. Inhalation and dermal absorption determined total exposures to these compounds. HAAs and MX persist in boiled water and drinks resulting in high ingestion exposures. Several brands of inexpensive home water filters were tested for removal of these compounds. To demonstrate a method of exposure reduction in a sensitive subpopulation, the most efficient filters were given to a group of pregnant women. These women and a control group of pregnant women without filters maintained water ingestion diaries for two weeks. The use of home filters resulted in reduction of exposures to HAAs by a factor of three and a greater reduction in exposures to MX.