Exposure of pregnant women to tap water related activities

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.

Intake of lead (Pb) from tap water of homes with leaded and low lead plumbing systems

Methods of quantifying consumer exposure to lead in drinking water are increasingly of interest worldwide, especially those that account for consumer drinking habits and the semi-random nature of water lead release from plumbing systems. A duplicate intake protocol was developed in which individuals took a sub-sample from each measured drink they consumed in the home over three days in both winter and summer. The protocol was applied in two different water company regional areas (WC1 and WC2), selected to represent high risk situations in England, with the presence or absence of lead service pipes or phosphate corrosion control. Consumer exposure to lead was highest in properties with lead service pipes, served by water without P dosing. The protocol indicated that a small number of individuals in the study, all from homes with lead service pipes, consumed lead at levels that exceeded current guidance from the European Food Standards Agency. Children's potential blood lead levels (BLLs) were estimated using the Internal Exposure Uptake Biokinetic model (IEUBK). The IEUBK model predicted that up to 46% of children aged 0-7 years old may have elevated BLLs (>5 μg/dL) when consuming the worst case drinking water quality (>99%ile). Estimating blood lead levels using the IEUBK model for more typical lead concentrations in drinking water identified in this study (between 0.1 and 7.1 μg/L), predicts that elevated BLLs may affect a small proportion of children between 0 and 7 years old.

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.

Veterinary antibiotics in food, drinking water, and the urine of preschool children in Hong Kong

Due to the harmful effects of veterinary antibiotics (VAs) residues in food on children's health, urine samples from 31 preschool and primary school children were analyzed for 13 common VAs. Samples of raw and cooked pork, chicken, fish, milk and drinking water from the children's living areas were also analyzed for residual VAs. Urinalysis revealed one to four target antibiotics in 77.4% of the sample group, with concentrations as high as 0.36ng/mL. Norfloxacin and penicillin had the highest detection rates (48.4% and 35.5%, respectively), with median concentrations of 0.037 and 0.13ng/mL, respectively. The VA burden of children in HK was lower than that in Shanghai. Enrofloxacin, penicillin, and erythromycin were the most detected VAs in raw and cooked food. Only oxytetracycline was detected in terminal tap water, and none were detected in milk. Tetracycline and doxycycline hyclate were detected in organic eggs (up to 7.1ng/g) and regular eggs (up to 6.6ng/g), which were common in children's diets. Traditional Chinese cooking processes did not completely eliminate VAs, and the concentrations of some VAs increased, especially after frying and roasting. The estimated daily intake (EDI) results show that the contribution of dietary intake and that based on the urine concentrations of VAs were far below the acceptable daily intake (ADI). The EDIs from urine were significantly lower than those based on cooked foods. The highest level of achievement percentage (LAP) based on dietary consumption and urine concentrations were 39.7% and 1.79%, respectively, and thus current levels of exposure to VAs would not seem to pose a risk to children's health. However, harmful effects of residual VAs during developmental periods may occur with exposure to much lower doses than those considered harmful to adults, and further investigation of these emerging pollutants is urgently encouraged.

Water Intake in a Sample of Greek Adults Evaluated with the Water Balance Questionnaire (WBQ) and a Seven-Day Diary

Awareness on the importance of hydration in health has created an unequivocal need to enrich knowledge on water intake of the general population and on the contribution of beverages to total water intake. We evaluated in the past water intake in a sample of Greek adults using two approaches. In study A, volunteers completed the Water Balance Questionnaire (WBQ), a food frequency questionnaire, designed to evaluate water intake (n = 1092; 48.1% males; 43 ± 18 years). In study B, a different population of volunteers recorded water, beverage, and food intake in seven-day diaries (n = 178; 51.1% males; 37 ± 12 years). Herein, data were reanalyzed with the objective to reveal the contribution of beverages in total water intake with these different methodologies. Beverage recording was grouped in the following categories: Hot beverages; milk; fruit and vegetable juices; caloric soft drinks; diet soft drinks; alcoholic drinks; other beverages; and water. Total water intake and water intake from beverages was 3254 (SE 43) mL/day and 2551 (SE 39) mL/day in study A; and 2349 (SE 59) mL/day and 1832 (SE 56) mL/day in study B. In both studies water had the highest contribution to total water intake, approximately 50% of total water intake, followed by hot beverages (10% of total water intake) and milk (5% of total water intake). These two approaches contribute information on water intake in Greece and highlight the contribution of different beverages; moreover, they point out differences in results obtained from different methodologies attributed to limitations in their use.

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.

Bisphenol a and its chlorinated derivatives in human colostrum

The health effects related to bisphenol A (BPA) and its exposure sources have undergone extensive investigation, but no consensus has been reached. Hitherto, the major source of human BPA exposure considered in the literature remains food-contact material. However, the chlorine present in drinking water may react with BPA to form chlorinated derivatives (ClxBPA), which have indeed been shown to have a heightened level of estrogenic activity. In this study, we have evaluated colostrum concentrations of BPA and ClxBPA in order to confirm our hypothesis according to which BPA water contamination leads to ClxBPA human exposure. BPA and its ClxBPA were assessed through online solid-phase extraction coupled to ultra high-performance liquid chromatography tandem mass spectrometry (SPE-UPLC-MS/MS) using the isotope dilution method in the colostrums of 21 women who had completed a water exposure questionnaire. BPA was detected in 19 colostrums and its ClxBPA in 21 colostrums. Mean concentrations were 1.87 ± 1.38 ng mL(-1) (n = 19) for BPA, 1.87 ± 1.23 ng mL(-1) (n = 7) and 1.56 ± 0.74 (n = 18) ng mL(-1) for 2,2'-Cl2BPA and 2,6-Cl2BPA, respectively, and 0.68 ng mL(-1) (n = 1) for trichloro-BPA. These findings confirm our hypothesis that ClxBPA should be taken into account in human health risk assessment.

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.

Drinking-water exposure to a mixture of nitrate and low-dose atrazine metabolites and small-for-gestational age (SGA) babies: a historic cohort study

BACKGROUND

Groundwater, surface water and drinking water are contaminated by nitrates and atrazine, an herbicide. They are present as a mixture in drinking water and with their endocrine-disrupting activity, they may alter fetal growth.

OBJECTIVES

To study an association between drinking-water atrazine metabolites/nitrate mixture exposure and small-for-gestational-age(SGA).

METHODS

A historic cohort study based on birth records and drinking-water nitrate and pesticide measurements in Deux-Sèvres (France) between 2005 and 2009 was carried out. Exposure to drinking-water atrazine metabolites/nitrate mixture was divided into 6 classes according to the presence or absence of atrazine metabolites and to terciles of nitrate concentrations in each trimester of pregnancy. Regression analysis of SGA by mixture exposure at second trimester was subsequently conducted.

RESULTS

We included 11,446 woman-neonate couples of whom 37.0% were exposed to pesticides, while 99.9% of the women were exposed to nitrates. Average nitrate concentration was from 0 to 63.30 mg/L. In the second trimester of pregnancy, the risk of SGA was different with mixture exposure when drinking-water atrazine metabolites, mainly 2 hydroxyatrazine and desethylatrazine, were present and nitrate dose exposure increased: compared to single first tercile of nitrate concentration exposure, single second tercile exposure OR was 1.74 CI 95% [1.10; 2.75] and atrazine metabolites presence in the third tercile of nitrate concentration exposure OR was 0.87 CI 95% [0.45;1.67].

CONCLUSIONS

It is possible that the association found at the second trimester of exposure with regard to birth weight may likewise be observed before birth, with regard to the estimated fetal weight, and that it might change in the event that the atrazine metabolites dose were higher or the nitrate dose lower. It would appear necessary to further explore the variability of effects.

Environmental exposure assessment in European birth cohorts: results from the ENRIECO project

Environmental exposures during pregnancy and early life may have adverse health effects. Single birth cohort studies often lack statistical power to tease out such effects reliably. To improve the use of existing data and to facilitate collaboration among these studies, an inventory of the environmental exposure and health data in these studies was made as part of the ENRIECO (Environmental Health Risks in European Birth Cohorts) project. The focus with regard to exposure was on outdoor air pollution, water contamination, allergens and biological organisms, metals, pesticides, smoking and second hand tobacco smoke (SHS), persistent organic pollutants (POPs), noise, radiation, and occupational exposures. The review lists methods and data on environmental exposures in 37 European birth cohort studies. Most data is currently available for smoking and SHS (N=37 cohorts), occupational exposures (N=33), outdoor air pollution, and allergens and microbial agents (N=27). Exposure modeling is increasingly used for long-term air pollution exposure assessment; biomonitoring is used for assessment of exposure to metals, POPs and other chemicals; and environmental monitoring for house dust mite exposure assessment. Collaborative analyses with data from several birth cohorts have already been performed successfully for outdoor air pollution, water contamination, allergens, biological contaminants, molds, POPs and SHS. Key success factors for collaborative analyses are common definitions of main exposure and health variables. Our review emphasizes that such common definitions need ideally be arrived at in the study design phase. However, careful comparison of methods used in existing studies also offers excellent opportunities for collaborative analyses. Investigators can use this review to evaluate the potential for future collaborative analyses with respect to data availability and methods used in the different cohorts and to identify potential partners for a specific research question.

Water consumption and use, trihalomethane exposure, and the risk of hypospadias

OBJECTIVES

Hypospadias is a congenital anomaly that affects up to 70 in 10 000 males. Ingestion of drinking-water-disinfection byproducts such as trihalomethanes (THMs) has been associated with hypospadias in a small sample. We examined risk of hypospadias and exposure to THMs through water consumption and use.

METHODS

Between September 2000 and March 2003, we interviewed mothers of 471 boys with hypospadias and 490 controls in southeast England about maternal water consumption, dishwashing, showering, bathing and swimming. We obtained residential THM concentrations from the water companies and linked them by using Geographical Information Systems, which provided data on 468 case-subjects and 485 controls.

RESULTS

THM exposures, except for ingestion of ≥ 6 μg/day of bromodichloromethane (odds ratio [OR]: 1.65 [95% confidence interval (CI): 1.02-2.69]), were not associated with risk of hypospadias. Elevated risk of hypospadias was associated with estimates of consumption of cold tap water at home (OR: 1.71 [95% CI: 1.07-2.76]), total water (OR: 1.70 [95% CI: 1.09-2.67]), bottled water (OR: 1.64 [95% CI: 1.09-2.48]), and total fluid (OR: 1.55 [95% CI: 1.01-2.39]) for the highest versus the lowest categories; the first 2 showed dose-response trends.

CONCLUSIONS

Evidence for an association between maternal water consumption and risk of hypospadias did not seem to be explained by THM exposure. Factors that influence maternal water consumption or other contaminants in tap or bottled water might explain this finding. It is important that women maintain an adequate fluid intake during pregnancy.

Influence of water and food consumption on inadvertent antibiotics intake among general population

Antibiotic entry into the water environment has been of growing concern. However, few investigations have been performed to examine the potential for indirect human exposure to environmental antibiotic residues. We evaluated the contribution of drinking water and major food consumption to inadvertent intake of antibiotic residues among general human population in Korea. We estimated daily human intake of six antibiotics, i.e., sulfamethazine (SMZ), sulfamethoxazole (SMX), sulfathiazole (STZ), trimethoprim (TMP), enrofloxacin (EFX), and roxithromycin (RTM), by measuring the concentrations of the antibiotics and their major metabolites in urine from general population in Korea (n=541). In addition, we measured antibiotics from source water of drinking water as well as in tap water samples, and surveyed water consumption rates among the study population. To assess the contribution of dietary factor, we also surveyed consumption pattern for several major foods which are suspected of antibiotics residue. SMZ, Sulfamethazine-N4-acetyl (SMZ-N4), TMP, EFX, ciprofloxacin (CFX), and RTM were detected up to 448, 6210, 11,900, 6970, 32,400, and 151pg/ml in the urine samples, respectively. Estimates of daily intake of major antibiotics did not appear to be related with consumption of drinking water although antibiotics were frequently detected in source waters (10-67ng/l). Consumption of several foods correlated significantly with urinary excretion of several antibiotics. Daily intake estimates of EFX and CFX were associated with consumption of beef, pork, and dairy products; those of SMZ and TMP associated with pork and dairy products; and that of TMP related with raw fish. Daily antibiotics intake estimates however did not exceed the acceptable daily intake levels.

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).

Drinking-water herbicide exposure in Indiana and prevalence of small-for-gestational-age and preterm delivery

BACKGROUND

Atrazine and other corn herbicides are routinely detected in drinking water. Two studies on potential association of atrazine with small-for-gestational-age (SGA) and preterm birth prevalence found inconsistent results. Moreover, these studies did not control for individual-level potential confounders.

OBJECTIVES

Our retrospective cohort study evaluated whether atrazine in drinking water is associated with increased prevalence of SGA and preterm birth.

METHODS

We developed atrazine concentration time series for 19 water systems in Indiana from 1993 to 2007 and selected all births (n = 24,154) based on geocoded mother's residences. Log-binomial models were used to estimate prevalence ratios (PRs) for SGA and preterm delivery in relation to atrazine concentrations during various periods of the pregnancy. Models controlled for maternal demographic characteristics, prenatal care and reproductive history, and behavioral risk factors (smoking, drinking, drug use).

RESULTS

Atrazine in drinking water during the third trimester and the entire pregnancy was associated with a significant increase in the prevalence of SGA. Atrazine in drinking water > 0.1 microg/L during the third trimester resulted in a 17-19% increase in the prevalence of SGA compared with the control group (< 0.1 microg/L). Mean atrazine concentrations over the entire pregnancy > 0.644 microg/L were associated with higher SGA prevalence than in the control group (adjusted PR = 1.14; 95% confidence interval, 1.03-1.24). No significant association was found for preterm delivery.

CONCLUSIONS

We found that atrazine, and perhaps other co-occurring herbicides in drinking water, is associated with an increased prevalence of SGA, but not preterm delivery.

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.

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.

The impact of water consumption, point-of-use filtration and exposure categorization on exposure misclassification of ingested drinking water contaminants

The use of population-level indices to estimate individual exposures is an important limitation of previous epidemiologic studies of disinfection by-products (DBPs). We examined exposure misclassification resulting from the use of system average DBP concentrations to estimate individual-level exposures. Data were simulated (n=1000 iterations) for 100 subjects across 10 water systems based on the following assumptions: DBP concentrations ranged from 0-99 microg/L with limited intra-system variability; water intake ranged from 0.5-2.5 L/day; 20% of subjects used bottled water exclusively; 20% of subjects used filtered tap water exclusively; DBP concentrations were reduced by 50% or 90% following filtration. DBP exposure percentiles were used to classify subjects into different exposure levels (e.g., low, intermediate, high and very high) for four classification approaches. Compared to estimates of DBP ingestion that considered daily consumption, source type (i.e., unfiltered tap, filtered tap, and bottled water), and filter efficiency (with 90% DBP removal), 48-62% of subjects were misclassified across one category based on system average concentrations. Average misclassification across at least two exposure categories (e.g., from high to low) ranged from 4-14%. The median classification strategy resulted in the least misclassification, and volume of water intake was the most influential modifier of ingestion exposures. These data illustrate the importance of individual water use information in minimizing exposure misclassification in epidemiologic studies of drinking water contaminants.

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.

Assessment of lifetime exposure to trihalomethanes through different routes

OBJECTIVES

To evaluate lifetime exposure to trihalomethanes (THM) through ingestion, inhalation, and dermal absorption in a hospital based case-control study of bladder cancer conducted between 1998 and 2001 in five areas of Spain. The study base was comprised of subjects living in the catchment areas of the participating hospitals.

METHODS

Individual information on water related habits was obtained from personal interviews of 1219 cases and 1271 controls: residential and occupational history, drinking water source at each residence and job, amount of water consumption, frequency and duration of showering, bathing, and swimming pool attendance. THM levels, water source history, and year when chlorination started in study areas were ascertained through measurements in drinking water samples and questionnaires to water companies and local authorities. Estimates of THM levels covered 79% of the subjects' person-years of exposure.

RESULTS

Current and historical average THM levels in water were correlated. Control subjects reported that drinking water source in the last residence was municipal for 63%, bottled for 22%, private well for 2%, and other sources for 13%. For the time window between age 15 and the time of interview, average residential THM level was 32.2 mug/l. THM exposure through ingestion was 23.7 mug/day on average, and was correlated with the ingestion THM level in the workplace. Overall, 79% usually took showers, 16% usually took baths, and 13% had ever attended a swimming pool. Between 21% and 45% of controls unexposed to THM through ingestion were evaluated as moderately or highly exposed through showering or bathing, and 5-10% were exposed through swimming in pools.

CONCLUSION

The importance of evaluating different routes is underscored by findings from experimental studies showing substantial differences in THM uptake and internal distribution by route.

The effect of boiling water on disinfection by-product exposure

Chloraminated and chlorinated waters containing bromide were used to determine the impact of boiling on disinfection by-product (DBP) concentrations. No significant changes were detected in the concentrations of the dihalogenated haloacetic acids (DXAAs) (i.e., dichloro-, bromochloro-, dibromoacetic acid) upon boiling of chloraminated water, whereas the levels of the trihalogenated haloacetic acids (TXAAs) (i.e., trichloro- (TCAA), bromodichloro- (BDCAA), dibromochloroacetic acid (DBCAA)) decreased over time (e.g., 9-37% for TCAA). Increased DXAA concentrations (58-68%) were detected in the boiled chlorinated sample, which likely resulted from residual chlorine reacting with DXAA precursors. TCAA concentration was unchanged after boiling chlorinated water for 1 min, but a 30% reduction was observed after 5 min of boiling. BDCAA concentrations decreased 57% upon boiling for 1 min and were completely removed after 2 min of boiling, whereas DBCAA was removed after boiling chlorinated water for 1 min. Trihalomethane concentrations were reduced in both chloraminated (74-98%) and chlorinated (64-98%) water upon boiling. Boiling chloraminated water for 1 min reduced chloroform concentration by 75%. Chloroform was reduced by only 34% in chlorinated water after a 1 min boil, which indicates that simultaneous formation and volatilization of chloroform was occurring. Most of the remaining DBPs (e.g. haloketones, chloral hydrate, haloacetonitriles) were removed by at least 90% after 1 min of boiling in both samples. These data suggest that other mechanisms (e.g., hydrolysis) may have been responsible for removal of the non-volatile DBPs and further highlight the importance of examining individual species when estimating thermal effects on DBP concentrations.

Relation of trihalomethane concentrations in public water supplies to stillbirth and birth weight in three water regions in England

We investigated the association between total trihalomethanes (TTHMs) and risk of stillbirth and low and very low birth weight in three water regions in England, 1992-1998; associations with individual trihalomethanes (THMs) were also examined. Modeled estimates of quarterly TTHM concentrations in water zones, categorized as low (< 30 microg/L), medium (30-59 microg/L), or high (> or = 60 microg/L), were linked to approximately 1 million routine birth and stillbirth records using maternal residence at time of birth. In one region, where there was a positive socioeconomic deprivation gradient across exposure categories, there was also a positive, significant association of TTHM with risk of stillbirth and low and very low birth weight. Overall summary estimates across the three regions using a random-effects model to allow for between-region heterogeneity in exposure effects showed small excess risks in areas with high TTHM concentrations for stillbirths [odds ratio (OR) = 1.11; 95% confidence interval (CI), 1.00-1.23), low birth weight (OR = 1.09; 95% CI, 0.93-1.27), and very low birth weight (OR = 1.05; 95% CI, 0.82-1.34). Among the individual THMs, chloroform showed a similar pattern of risk as TTHM, but no association was found with concentrations of bromodichloromethane or total brominated THMs. Our findings overall suggest a significant association of stillbirths with maternal residence in areas with high TTHM exposure. Further work is needed looking at cause-specific stillbirths and effects of other disinfection by-products and to help differentiate between alternative (noncausal) explanations and those that may derive from the water supply.