0590/frame/ch03 Page 29 Tuesday, April 11, 2000 12:02 PM Waterborne Diseases CONTENTS 3.1 3.2 3.3 3.4 Waterborne Disease and its Epidemiology 29 Reported Outbreaks of Waterborne Disease 32 Epidemiological Studies of Waterborne Disease 37 References .39 3.1 WATERBORNE DISEASE AND ITS EPIDEMIOLOGY Since John Snow proved that drinking water could transmit cholera, many diseases have been shown to be spread by water Estimates vary widely as to the actual morbidity and mortality owing to waterborne disease The World Health Organization (WHO) estimates that every seconds a child dies from a water-related disease and each year more that million people die from illnesses linked to unsafe drinking water or inadequate sanitation.1 Table 3.1 gives some estimates of the burden of disease associated with water-associated disease While the figures in this table seem alarming, the situation is likely to deteriorate substantially as the world population continues to increase The WHO also suggests that if sustainable safe drinking water and sanitation services were provided to all, each year there would be 200 million fewer diarrhoeal episodes 2.1 million fewer deaths caused by diarrhoea 76,000 fewer dracunculiasis cases 150 million fewer schistosomiasis cases 75 million fewer trachoma cases There are four ways by which water, or the lack of it, may be associated with disease.1 Waterborne diseases This is caused by the ingestion of water contaminated by human or animal faeces or urine containing pathogenic bacteria or viruses It includes cholera, typhoid, amoebic and bacillary dysentery, and other diarrhoeal diseases Water-washed diseases This is caused by poor personal hygiene and skin or eye contact with contaminated water It includes scabies, trachoma, and flea, lice, and tick-borne diseases Water-based diseases This is caused by parasites found in intermediate organisms living in water It includes dracunculiasis, schistosomiasis, and other helminths Water-related diseases This is caused by insect vectors which breed in water It includes dengue, filariasis, malaria, onchocerciasis, trypanosomiasis, and yellow fever 0-8493-????-?/97/$0.00+$.50 © 1997 by CRC Press LLC © 2000 by CRC Press LLC 29 0590/frame/ch03 Page 30 Tuesday, April 11, 2000 12:02 PM 30 Microbiological Aspects of Biofilms and Drinking Water TABLE 3.1 Estimates of Morbidity and Mortality of Water-Related Diseases Disease Morbidity (Episodes/Year, or as Stated) Mortality (Deaths/Year) Relationship of Disease to Water Supply and Sanitation 3,300,000 Strongly related to unsanitary excreta disposal, poor personal and domestic hygiene, unsafe drinking water Strongly related to unsanitary excreta disposal, poor personal and domestic hygiene Strongly related to unsanitary excreta disposal and absence of nearby sources of safe water Strongly related to unsafe drinking water Strongly related to lack of face washing, often owing to absence of nearby sources of safe water Related to poor water management, water storage, operation of water points, and drainage Related to poor solid wastes management, water storage, operation of water points, and drainage Related to unsanitary excreta disposal, poor personal and domestic hygiene, and unsafe drinking water Related to the absence of nearby sources of safe water Related to poor water management, water storage, operation of water points, and drainage Related to poor water management in largescale projects Diarrhoeal diseases 1,000,000,000 Infection with intestinal helminths Schistosomiasis 1,500,000,0001 100,000 200,000,0001 200,000 Dracunculiasis Trachoma 100,0002 150,000,0003 — — Malaria 400,000,000 1,500,000 Dengue fever 1,750,000 20,000 Poliomyelitis 114,000 — Trypanosomiasis 275,000 130,000 Bancroftian filariasis 72,800,0001 Onchocerciasis 17,700,0001,4 — 40,0005 People currently infected Excluding Sudan Case of the active disease; approximately 5,900,000 cases of blindness or severe complications of Trachoma occur annually Includes an estimated 270,000 blind Mortality caused by blindness Source: WHO data In this book, we are primarily concerned with waterborne disease transmitted by drinking water Table 3.2 lists those infectious diseases that are associated with drinking water and describes some of the symptoms that they cause For a more detailed description of these diseases see Waterborne Disease by Hunter.2 © 2000 by CRC Press LLC 0590/frame/ch03 Page 31 Tuesday, April 11, 2000 12:02 PM Waterborne Diseases 31 TABLE 3.2 Microbial and Parasitic Disease Linked to Drinking Water Consumption Disease Dracunculiasis Giardiasis Cryptosporidiosis Organism Dracunculus medinensis Giardia duodenalis (Prev G lamblia) Usual Incubation Period Symptoms 8–10 months Painful ulcers on lower limbs and feet 7–14 days Diarrhoea, abdominal cramps, bloating and flatulence; for more prolonged disease, weight loss and failure to thrive Diarrhoea often lasting for several weeks Diarrhoea, abdominal pain, nausea, vomiting, and anorexia; weight loss in prolonged cases Varies from mild diarrhoea to a fulminating dysenteric illness A glandular fever-like syndrome; in pregnant women, can cause damage to foetus including abortion, hydrocephalus, cerebral calcification, and eye damage Painless watery diarrhoea which in severe cases can lead to dehydration, shock, and death Diarrhoea, colicky abdominal pain, and fever; may progress to more severe systemic disease in a small proportion of cases Fever, malaise, and abdominal pain; as disease progresses may develop delerium; untreated death rate is up to 15% Ranges from mild self-limiting diarrhoea to more severe diarrhoea with painful straining to empty bowels, blood loss leading to collapse and death Diarrhoea which may be bloody and cramping abdominal pain Watery diarrhoea Cryptosporidium parvum Cyclospora cayetanensis 7–10 days Amoebiasis Entamoeba histolytica 2–4 weeks Toxoplasmosis Toxoplasma gondii Varies Cholera Vibrio cholerae 1–3 days Salmonellosis Salmonella spp 12–48 hours Typhoid Salmonella typhi 10–14 days Shigellosis Shigella spp 1–3 days Campylobacteriosis Campylobacter spp 2–4 days Enterotoxigenic E coli Enterohaemorrhagic E coli E coli 12–72 hours E coli 0157 and others 3–4 days Yersiniosis Yersinia spp 3–7 days Cyclosporiasis © 2000 by CRC Press LLC 1–7 days Bloody diarrhoea which can be fatal and progress to haemolytic uraemic syndrome in children Fever, diarrhoea, and abdominal pain continued 0590/frame/ch03 Page 32 Tuesday, April 11, 2000 12:02 PM 32 Microbiological Aspects of Biofilms and Drinking Water TABLE 3.2 (continued) Microbial and Parasitic Disease Linked to Drinking Water Consumption Disease Usual Incubation Period Organism Aeromoniasis Tularaemia Aeromonas spp Francisella tularensis Uncertain 2–5 days Gastritis/ulceration Helicobacter pylori Varied Viral hepatitis Hepatitis A virus Hepatitis E virus 2–4 weeks 6–8 weeks Viral gastroenteritis Small round viruses Rotavirus Poliovirus types to 12 to 72 hours Poliomyelitis Enteroviral illness Coxsackieviruses A Echoviruses Enteroviruses 9–12 days 2–5 days Symptoms Diarrhoea Either typhoid-like or mucocutaneous with suppurative skin lesions Prolonged gastritis, peptic ulcer, and gastric cancer Mild flu-like symtoms to severe fulminating hepatitis and death; death is especially common with Hepatitis E in pregnant women Vomiting and/or diarrhoea Mostly assymptomatic though can progress to asceptic meningitis, encephalitis, and paralysis Various including diarrhoea, pneumonitis, and myalgia For the rest of this chapter, we shall consider the question of how common is disease caused by potable water We shall restrict our discussion to those studies done in the Western world Essentially, evidence on the epidemiology of waterborne disease in the West comes from two sources, reports of waterborne disease and prospective studies of sporadic disease 3.2 REPORTED OUTBREAKS OF WATERBORNE DISEASE Very few countries have satisfactory surveillance systems for waterborne disease Only the U.S and U.K have established surveillance systems with regular publication of details on waterborne outbreaks In the U.S., the Center for Disease Control (CDC) has been collating and reporting on waterborne disease since 1971 In the U.K., the Public Health Laboratory Service Communicable Disease Surveillance Centre (CDSC) has been publishing biannual reports since 1994 Although data from both countries has been collected since before these schemes were implemented, data collection was less systematic The two systems differ from each other, each having its own strengths and weakness The U.S system is probably more comprehensive including chemical incidents and many outbreaks of unknown aetiology American citizens appear more likely to contact their health departments should they suffer from a gastrointestinal illness By contrast, in the U.K system, which is based on reporting of laboratory isolations, cases are usually only identified after © 2000 by CRC Press LLC 0590/frame/ch03 Page 33 Tuesday, April 11, 2000 12:02 PM Waterborne Diseases 33 TABLE 3.3 Waterborne Outbreaks Associated with Public Water Supplies in England and Wales 1911–1998, Number of Outbreaks in 10-Year Periods 10-Year Period 1911–1920 Number of Cases and Deaths Number of Outbreaks Site of Contamination Source Distribution 3630+ 28+ 1921–1930 2029+ 65+ 1931–1940 1941–1950 7912+ 78+ 610 1951–1960 1961–1970 Nonidentified 1971–1980 1981–1990 13 1991–1998 22 a b 90 3222 1925 2550+ Disease: Number of Outbreaks, Cases, and Deaths Typhoidb: 6, 359+, 28+ Paratyphoid: 1, 71, ? Dysentery: 1, 1700, ? Typhoid: 4, 459, 50 Paratyphoid: 1, 31, ? Dysentery: 1, 1100, 12 Gastroenteritis: 2, 439, ?3 Typhoid: 3, 686, 77+ Gastroenteritis: 3, 7200+, Typhoid: 1, 22, Dysentery: 2, 588, Paratyphoid: 1, 90, Gastroenteritis: 2, 3114, Giardiasis: 1, 60, Campylobacter: 3, 629, Cryptosporidiosis: 10, 857+, Gastroenteritis: 3, 310, Cryptosporidiosis: 22, 2550+, Case numbers are often estimates, + indicates a minimum estimate One outbreak of typhoid was also associated with 1500 cases of gastroenteritis Source: Adapted from Galbraith11 with additional data from Stanwell-Smith,12 Furtado et al.,13 and various Communicable Disease Reports.a they have been attended by doctors and samples have been taken for analysis On the other hand, once a patient attends a medical practitioner, a sample is more likely to be sent for examination and once positive, reported to the surveillance systems In any event, waterborne outbreaks are probably significantly underreported in both countries Reports of waterborne outbreaks in England and Wales are presented in Tables 3.3 and 3.4 Table 3.3 gives outbreaks related to mains water and Table 3.4 to private supplies In the U.K data, it is clear that there has been a significant change in the identified causes of waterborne disease during this century Up until 1970, waterborne disease was dominated by typhoid or paratyphoid Dysentery was © 2000 by CRC Press LLC 0590/frame/ch03 Page 34 Tuesday, April 11, 2000 12:02 PM 34 Microbiological Aspects of Biofilms and Drinking Water TABLE 3.4 Waterborne Disease from Private Supplies in England and Wales from 1941–1998 and Various Communicable Disease Reports 10-Year Period Number of Outbreaks 1941–1950 1951–1960 1961–1970 1971–1980 None detected None detected 1981–1990 1991–1998 13 Number of Cases and Deaths Disease: Number of Outbreaks, Cases, and Deaths 47+ Typhoid: 2, 9+, Paratyphoid: 1, 21, Amoebiasis: 1, 17, 166 962 Paratyphoid: 1, 6, Gastroenteritis: 1, 160, Gastroenteritis: 1, 138, Campylobacter: 3, 520, Streptobacillary fever: 1, 304, Gastroenteritis: 2, 81, Campylobacter: 6, 147, Giardia: 1, 31, Cryptosporidiosis: 2, 66, E coli: 1, 14, Mixed Campylobacter and Cryptospridiosis: 382 11 12 1, 43, 13 Source: Adapted from Galbraith et al., Stanwell-Smith, and Furtado et al the only other infection of note during this period Since the 1970s, reports of waterborne outbreaks have increased substantially, although this increase has been essentially owing to Cryptosporidium in public water supplies and Campylobacter in private supplies Both pathogens are relatively newly described with Campylobacter being described in the late 1970s and Cryptosporidium in the early 1980s The decline in the reporting of typhoid, a disease with a high mortality without adequate treatment, reflects improved water treatment and the disappearance of the pathogen from the general population The increase in the new pathogens reflects our ability to diagnose them The relative paucity of Campylobacter in public compared to private water supplies reflects this pathogen’s sensitivity to disinfection In the U.K., virtually all public supplies have some form of disinfection, usually with chlorine Cryptosporidium is relatively resistant to disinfection, hence its prevalence in public supplies Although there are much fewer outbreaks reported from private supplies, a very small proportion of the population of England and Wales have a private supply Also, given their smaller size, private supply outbreaks are probably more likely to be missed Consequently, the relative risk of being involved in a waterborne outbreak is probably much higher in people drinking private water The U.S data are shown in Table 3.5 In many ways, the U.S data show the same trend over the century, as does the U.K data Over the years, typhoid declines in importance from its once preeminent position There are, however, some major © 2000 by CRC Press LLC 0590/frame/ch03 Page 35 Tuesday, April 11, 2000 12:02 PM Waterborne Diseases 35 TABLE 3.5 Aetiology of Waterborne Outbreaks in the U.S., 1920–1996 Time Period 1971–1990 Typhoid Gastroenteritis Shigellosis Amoebiasis Hepatitis Chemical poisoning 372 144 10 1 13,767 176,725 3,308 1,416 28 92 530 195,336 Gastroenteritis Typhoid Shigellosis Hepatitis Salmonellosis Chemical poisoning Paratyphoid Amoebiasis Tularaemia Leptospirosis Poliomyelitis 265 94 25 23 4 2 1 54,439 1,945 8,951 930 31 44 19 36 16 424 66,426 39 30 19 14 9 3 26,546 903 1,666 104 16,706 46 188 176 39 Subtotal 1961–1970 Number of Cases Subtotal 1941–1960 Number of Outbreaks Subtotal 1920–1940 Disease 130 46,374 Gastroenteritis Giardiasis Chemical poisoning Shigellosis Viral gastroenteritis Hepatitis A Salmonellosis Campylobacteriosis Typhoid Cryptosporidiosis 293 110 55 42 27 25 12 12 67,367 26,531 3,877 8,947 12,699 762 2,370 5,233 282 13,117 Gastroenteritis Hepatitis Shigellosis Typhoid Salmonellosis Chemical poisoning Toxigenic E coli Giardiasis Amoebiasis continued © 2000 by CRC Press LLC 0590/frame/ch03 Page 36 Tuesday, April 11, 2000 12:02 PM 36 Microbiological Aspects of Biofilms and Drinking Water TABLE 3.5 (continued) Aetiology of Waterborne Outbreaks in the U.S., 1920–1996 Time Period Disease Yersiniosis Toxigenic E coli E coli O157 Chronic gastroenteritis Cyclosporiasis Cholera Amoebiasis Number of Outbreaks Number of Cases 1 1 1 103 1,000 243 72 21 17 591 142,645 Gastroenteritis Chemical poisoning Giardiasis Cryptosporidiosis Shigellosis Campylobacteriosis Hepatitis A E coli 0157 Salmonellosis Viral gastroenteritis Plesiomonas Vibrio cholera non 01 38 20 11 2 1 1 14,228 486 1,967 406,822 592 223 56 35 625 146 60 11 Subtotal 95 Subtotal 1991–1996 Source: Adapted from Craun and Levy.17 14 with additional data from Moore et al., 425,251 15 Kramer et al.,16 differences between the U.S and U.K data The first thing to note is the much larger number of outbreaks in the U.S., even accounting for the larger population In part this is owing to the American detection of outbreaks where no pathogen was isolated, but it also probably relates to the different nature of the water supply industry in the U.S There are many more isolated small communities with their own water supplies in the U.S than in the U.K Many of these smaller supplies get little or no treatment The other important difference is the large number of Giardia cases in the U.S It is not totally clear why the U.S sees so many Giardia cases compared to the U.K., although we suspect part of the explanation relates to the reported prevalence of Giardia in wild animals, who then contaminate small water supplies One advantage of the U.S presentation is a more detailed analysis of the treatment failures which gave rise to the outbreaks It can be seen from Table 3.6 that the vast majority of non-community waterborne outbreaks were owing to untreated or inadequately chlorinated groundwater For the larger community outbreaks, the causes of failure were more diverse, including inadequate disinfection of surface water, distribution deficiencies, groundwater problems, and filtration deficiencies © 2000 by CRC Press LLC 0590/frame/ch03 Page 37 Tuesday, April 11, 2000 12:02 PM Waterborne Diseases 37 TABLE 3.6 Causes of Waterborne Outbreaks, U.S., 1981–1990 Cause of Outbreak Community Total Source: Reprinted from Craun Other 15 (12.1) 17 (13.7) — 35 (28.2) 30 (24.2) 16 (12.9) (5.6) (1.6) (1.6) 43 (44.3) 32 (33.0) — (9.3) (3.1) (1.0) (3.1) (4.1) (2.1) 19 (27.1) — 41 (58.6) — (4.3) — (1.4) (4.3) (4.3) 124 Untreated groundwater Inadequate disinfection of groundwater Ingestion of contaminated water while swimming Inadequate disinfection of surface water Distribution deficiencies Filtration deficiencies Unknown Untreated surface water Miscellaneous Noncommunity 97 70 14 Although outbreaks are useful in identifying the microbiological and engineering causes of waterborne disease, they cannot give an accurate estimate of the burden of waterborne disease in a community Many outbreaks will go undetected To gain an insight into overall disease burden, we have to turn to other epidemiological methods In the next section we will consider some of the epidemiological studies which have investigated the relationship between disease and water consumption 3.3 EPIDEMIOLOGICAL STUDIES OF WATERBORNE DISEASE There is very comprehensive literature on the effects of drinking water quality on health Unfortunately, for this review, the vast majority concerns studies undertaken in developing countries.3 By contrast, there have been very few studies in the Western world There are essentially two approaches The first approach is to conduct casecontrol studies on diagnosed sporadic infection Clearly, this approach reveals information on just a small proportion of infections, those owing to the specific disease under investigation Consequently, we have to rely on prospective studies of illness rates, either in cohort studies or experimental studies Of the prospective cohort studies of drinking water and ill health, in our view, the work of a group of French researchers is preeminent Their first work was a prospective longitudinal study over 18 months of 52 French Alpine villages.4,5 They collected data on water quality for each village and recorded the number of patients who were diagnosed with gastroenteritis each week by their physician All villages were supplied with untreated surface water Those villages whose water did not meet the European standard had a significant excess of cases of gastroenteritis (RR equal to 1.36, 95% CI 1.24 to 1.49) The most predictive marker of illness was faecal streptococci, although faecal coliforms were also independently associated By contrast, total coliforms and aerobic plate counts were not independently associated with risk © 2000 by CRC Press LLC 0590/frame/ch03 Page 38 Tuesday, April 11, 2000 12:02 PM 38 Microbiological Aspects of Biofilms and Drinking Water In a subsequent study, the group looked at the effect on health of chlorination of substandard water.6 In much the same way as they had done in their previous study, they recorded the rate of diarrhoea in some 2033 school children living in 24 French villages In these 24 villages, 13 did not give their water any treatment as it already met statutory standards The other villages chlorinated their water but did no other treatment Those children living in the villages with initially substandard water were 1.4 times more likely to suffer from a diarrhoeal illness (95% CI 1.30 to 1.50) Interestingly, this excess risk was associated with the occurrence of small epidemics Thus faecally polluted water continued to pose an excess risk even after chlorination An interesting approach to the issue of trying to quantify risk to health from water was developed by two groups who looked at the temporal correlation between physician reported gastrointestinal illness rates and drinking water turbidity.7,8 The first group looked at historical data correlated over time from January 1992 to April 1993 from Milwaukee County, WI (better known as the place where the world’s biggest documented waterborne outbreak occurred).7 The authors noted that a rise in turbidity of 0.5 NTU was associated with a 2.35 (95% CI 1.34 to 4.12) increase risk of gastroenteritis in children and 1.17 (0.91 to 1.52) in adults The second group looked at the relationship between emergency visits and admissions to the Children’s Hospital in Philadelphia for gastrointestinal illness The authors reported that an interquartile increase in drinking water turbidity was associated with a 9.9% (2.9 to 17.3%) increase in visits in children, aged years and over, days later, a 5.9% (0.2 to 12%) increase 10 days later in children years and younger Hospital admissions followed the same trend In the first study of its kind, Payment and co-workers8 randomly allocated pointof-use reverse-osmosis filters to one half of a study population in Montreal Volunteers kept a health diary and the researchers were able to compare self-reported episodes of gastroenteritis in the two groups Throughout the study period, rates of gastroenteritis were significantly higher in the group drinking unfiltered tap water, although laboratory investigations were unable to identify any pathogen responsible for this excess The authors estimated that about 30% of all cases of gastrointestinal infections were attributable to the drinking water In a subsequent experimental study, Payment and colleagues compared randomly allocated volunteers to one of four study arms: tap water, tap water from a continuously running tap, bottled plant water, and purified bottled plant water.9 The results of this study was much less convincing than the previous one, although the authors still felt able to suggest that 14 to 40% of gastrointestinal illnesses were related to drinking water However, a major problem with Payment’s studies were that all his volunteers knew which arm of the study they were in and thus the outcome of both his studies could have been affected by reporting bias on the part of his volunteers At the time of publication, variations of Payment’s studies were being repeated with the study design, ensuring that volunteers would be unaware of whether they were drinking filtered or unfiltered water These studies should be reported during the year 2000 or 2001 All the epidemiological studies reported previously have reported evidence for the association between drinking water and gastrointestinal illness It would appear that even the drinking water meeting current microbiological standards might be © 2000 by CRC Press LLC 0590/frame/ch03 Page 39 Tuesday, April 11, 2000 12:02 PM Waterborne Diseases 39 associated with illness It is still difficult to extrapolate from these studies some national estimate of disease burden related to mains drinking water consumption The most extreme estimate from Payments work is 30% of all cases of gastrointestinal infections Another approach to estimating disease burden is to determine the prevalence of various infectious diseases and then estimate the proportion owing to water Morris and Levin10 has done this for the U.S and produced estimates of between 520,000 and 690,000 (midpoint 560,000) cases of moderate to severe infection owing to water consumption and 400,000 to 27,000,000 (midpoint 7,100,000) cases of mild to moderate infection Despite the amount of analysis that went into this work, many of the important variables had to be estimated Consequently, the final estimates at best represent only an educated guess We cannot rely on currently available information to give reliable estimates of the total disease burden owing to mains drinking water We know from outbreaks that there is a positive association between drinking water and some disease More detailed estimates of sporadic disease will require further epidemiological work 3.4 REFERENCES Anon., 1996, Water and sanitation, WHO Fact Sheet No 112, World Health Organization, Geneva Hunter, P R., 1997, Waterborne Disease: Epidemiology and Ecology, Wiley, Chichester Esrey, S A., 1996, Water, waste, and well-being: a multicountry study, Am J Epidemiol., 143(6), 608 Ferley, J P., Zmirou, D., Collin, J F., and Charrel, M., 1986, Etude longitudinale des risques liés la consommation deaux non conformes aux normes bactériologiques, Rev Epidemiol Sante Publ., 34, 89 Zmirou, D., Ferley, J P., Collin, J F., Charrel, M., and Berlin, J., 1987, A follow-up study of gastro-intestinal diseases related to bacteriologically substandard drinking water, Am J Public Health, 77, 582 Zmirou, D., Rey, S., Courtois, X., Ferley, J P., Blatier, J F., Chevallier, P., Boudot, J., Potelon, J L., and Mounir, R., 1995, Residual microbiological risk after simple chlorine treatment of drinking ground water in small community systems, Eur J Public Health, 5, 75 Morris, R D., Naumova, E N., Levin, R., and Munasinghe, R L., 1996, Temporal variation in drinking water turbidity and diagnosed gastroenteritis in Milwaukee, Am J Publich Health, 86, 237 Payment, P., Richardson, L., Siemiatycki, J., Dewar, R., Edwards, M., and Franco, E., 1991, A randomized trial to evaluate the risk of gastrointestinal disease due to consumption of drinking water meeting currently accepted microbiological standards, Am J Public Health, 81, 703 Payment, P., Siemiatycki, J., Richardson, L., Renaud, G., Franco, E., and Prévost, M., 1997, A prospective epidemiological study of gastrointestinal health effects due to the consumption of drinking water, Int J Environ Health Res., 7, 10 Morris, R D and Levin, R., 1995, Estimating the incidence of waterborne infectious disease related to drinking water in the United States, in Assessing and Managing Health Risks from Drinking Water Contamination, Reichard, E G and Zapponi, G A., Eds., International Association of Hydrological Sciences, Wallingford, U.K., 75 © 2000 by CRC Press LLC 0590/frame/ch03 Page 40 Tuesday, April 11, 2000 12:02 PM 40 Microbiological Aspects of Biofilms and Drinking Water 11 Galbraith, N S., 1994, A historical review of microbial disease spread by water in England and Wales, in Water and Public Health, Golding A M B., Noah, N., and Stanwell-Smith, R., Eds., Smith-Gordon & Co., London, 15 12 Stanwell-Smith, R., 1994, Water and public health in the United Kingdom Recent trends in the epidemiology of water-borne disease, in Water and Public Health, Golding A M B., Noah, N., and Stanwell-Smith, R., Eds., Smith-Gordon & Co., London, 39 13 Furtado, C., Stuart, J M., Adak, G K., Evans, H S., Knerer, G., and Casemore, D P., 1996, Waterborne outbreaks of gastroenteritis in England and Wales: a four year review, in PHLS 21st Annual Scientific Conference, University of Warwick, PHLS, London, Poster No 22 14 Craun, G F., 1992, Waterborne disease outbreaks in the United States of America: causes and prevention, World Health Stat Q., 45, 192 15 Moore, A C., Herwaldt, B L., Craun, G F., Calderon, R L., Highsmith, A K., and Juranek, D D., 1993, Surveillance for waterborne disease outbreaks — United States, 1991–1992, MMWR, 42 (SS-5), 16 Kramer, M H., Herwaldt, B L., Craun, G F., Calderon, R.L., and Juranek, D D., 1996, Surveillance for waterborne-disease outbreaks — United States, 1993–1994, MMWR, 45 (SS-1), 17 Levy, D A., Bens, M S., Craun, G F., Calderon, R L., and Herwaldt, B L., 1996, Surveillance for waterborne-disease outbreaks — United States, 1995–1996, MMWR, 47 (SS-5), © 2000 by CRC Press LLC ...0590/frame/ch 03 Page 30 Tuesday, April 11, 2000 12:02 PM 30 Microbiological Aspects of Biofilms and Drinking Water TABLE 3. 1 Estimates of Morbidity and Mortality of Water- Related Diseases... (1.6) 43 (44 .3) 32 (33 .0) — (9 .3) (3. 1) (1.0) (3. 1) (4.1) (2.1) 19 (27.1) — 41 (58.6) — (4 .3) — (1.4) (4 .3) (4 .3) 124 Untreated groundwater Inadequate disinfection of groundwater Ingestion of contaminated... PM 34 Microbiological Aspects of Biofilms and Drinking Water TABLE 3. 4 Waterborne Disease from Private Supplies in England and Wales from 1941–1998 and Various Communicable Disease Reports 10-Year