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

Combined Sewer Overflows and Gastrointestinal Illness in Atlanta, 2002-2013: Evaluating the Impact of Infrastructure Improvements

BACKGROUND

Combined sewer overflows (CSOs) discharge untreated sewage into surface and recreational water, often following heavy precipitation. Given projected increases in frequency and intensity of precipitation due to climate change, it is important to understand the health impacts of CSOs and mediating effects of sewerage systems.

OBJECTIVES

In this study we estimate associations of CSO events and emergency department (ED) visits for gastrointestinal (GI) illness among City of Atlanta, Georgia, residents and explore how these associations vary with sewerage improvements.

METHODS

We estimate associations using Poisson generalized linear models, controlling for time trends. We categorized CSOs by overflow volume and assessed effects of CSO events prior to ED visits with 1-, 2- and 3-wk lags. Similarly, we evaluated effects of weekly cumulative precipitation greater than the 90th percentile at the same lags. We also evaluated effect modification by ZIP Code Tabulation Area (ZCTA)-level poverty and infrastructure improvement period using interaction terms.

RESULTS

Occurrence of a large volume CSO in the previous week was associated with a 9% increase in daily ED visits for GI illness. We identified significant interaction by ZCTA-level poverty, with stronger CSO-GI illness associations in low than high poverty areas. Among areas with low poverty, we observed associations at 1-wk and longer lags, following both large and lower volume CSO events. We did not observe significant interaction by infrastructure improvement period for CSO- nor precipitation-GI illness associations; however, the number of CSO events decreased from 2.31 per week before improvements to 0.49 after improvements.

DISCUSSION

Our findings suggest that CSOs contribute to acute GI illness burden in Atlanta and that the magnitude of this risk may be higher among populations living in areas of low poverty. We did not find a protective effect of sewerage system improvements. Nonetheless, observed reductions in CSO frequency may lower the absolute burden of GI illness attributable to these events. https://doi.org/10.1289/EHP10399.

System-wide joint-dynamic-response approach to water quality evaluation in distribution networks with multiple service reservoirs and pumps

Rigorous system-wide aggregated water quality performance indices for water distribution networks are lacking in the literature due to complexities associated with high dimensional spatial and temporal water quality data. Water quality considerations unavoidably increase performance evaluation difficulties considerably. The formulation developed in this article addresses the post-extended period simulation high-dimensional data challenges. A system-wide joint-dynamic-response approach to water quality evaluation is introduced that accounts for spatial and temporal variations in nodal demands and the respective time-varying hydraulic and water quality properties of multiple service reservoirs. Effective comparisons of the water quality response of service reservoirs and their effects were achieved. This includes individual reservoirs and the combined effects of multiple reservoirs. Service reservoirs and the nodes they supply were particularly vulnerable from the standpoint of water quality. The role of the network’s topology considering water quality risks was revealed also. The correlation between the medians and flow-weighted daily means of the water quality parameters was very strong (R2 ≥ 0.994) for the service reservoirs considered. Thus, the median could be useful as a practical performance surrogate in design optimization procedures. Finally, there seems to be an association between the flow-weighted daily means and overall hydraulic effectiveness of service reservoirs.

Effects of Chloramine and Coupon Material on Biofilm Abundance and Community Composition in Bench-Scale Simulated Water Distribution Systems and Comparison with Full-Scale Water Mains

The vast majority of bacteria in drinking water distribution systems (DWDSs) reside in biofilms on the interior walls of water mains. Little is known about how water quality conditions affect water-main biofilms because of the inherent limitations in experimenting with drinking water supplies and accessing the water mains for sampling. Bench-scale reactors permit experimentation and ease of biofilm sampling, yet questions remain as to how well biofilms in laboratory reactors represent those on water mains. In this study, the effects of DWDS pipe materials and chloramine residual on biofilms were investigated by cultivating biofilms on cement, polyvinyl chloride, and high density polyethylene coupons in CDC reactors for up to 28 months in the presence of chloraminated or dechlorinated tap water. The bench-scale biofilm microbiomes were then compared with the microbiome on a water main from the full-scale system that supplied the water to the reactors. The presence of a chloramine residual (1.74 ± 0.21 mg/L) suppressed biofilm accumulation and selected for Mycobacterium-like and Sphingopyxis-like operational taxonomic units (OTUs) while the destruction of the chloramine residual resulted in a significant increase in biomass quantity and a shift toward a more diverse community dominated by Nitrospira-like OTUs, which, our results suggest, may be complete ammonia oxidizers (comammox). Coupon material, however, had a relatively minor effect on the abundance and community composition of the biofilm bacteria. Although biofilm communities from the chloraminated water reactor and the water mains shared some dominant populations (namely, Mycobacterium- and Nitrosomonas-like OTUs), the communities were significantly different. This manuscript provides novel insights into the effects of dechlorination and pipe material on biofilm community composition. Furthermore, to our knowledge, it is the first study to compare biofilm in a tap water-fed, bench-scale simulated distribution system to biofilm on water mains from the full-scale system supplying the tap water.

Burden of Disease Attributable to Inadequate Drinking Water, Sanitation, and Hygiene in Korea

BACKGROUND

Diarrheal and intestinal infectious disease caused by inadequate drinking water, sanitation, and hygiene (WASH) is not only a great concern in developing countries but also a problem in low-income populations and rural areas in developed countries. In this study, we assessed the exposure to inadequate WASH in Korea and estimated the burden of disease attributable to inadequate WASH.

METHODS

We used observational data on water supply, drinking water, sewage treatment rate, and hand washing to assess inadequate WASH conditions in Korea, and estimated the level of exposure in the entire population. The disease burden was estimated by applying the cause of death data from death registry and the morbidity data from the national health insurance to the population attributable fraction (PAF) for the disease caused by inappropriate WASH.

RESULTS

In 2013, 1.4% of the population were exposed to inadequate drinking water, and 1.0% were living in areas where sewerage was not connected. The frequency of handwashing with soap after contact with excreta was 23.5%. The PAF due to inadequate WASH as a cluster of risk factors was 0.353 (95% confidence interval [CI], 0.275-0.417), among which over 90% were attributable to hand hygiene factors that were significantly worse than those in American and European high-income countries.

CONCLUSION

The level of hand hygiene in Korea has yet to be improved to the extent that it shows a significant difference compared to other high-income countries. Therefore, improving the current situation in Korea requires a continuous hand washing campaign and a program aimed at all people. In addition, continuous policy intervention for improvement of sewage treatment facilities in rural areas is required, and water quality control monitoring should be continuously carried out.