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World Population Day

Drinking Water Chlorination - 2

The Risks of Waterborne Disease

It is easy to take for granted the safety of modern municipal drinking water, but prior to widespread filtration and chlorination, contaminated drinking water presented a significant public health risk. The microscopic waterborne agents of cholera, typhoid fever, dysentery and hepatitis A killed thousands of U.S. residents annually before disinfection methods were employed routinely, starting about a century ago. Although these pathogens are defeated regularly now by technologies such as chlorination, they should be thought of as ever-ready to “stage a come-back” given conditions of inadequate or no disinfection.

Illnesses Associated with Waterborne Pathogens

Worldwide, about 1.2 billion people lack access to safe drinking water, and twice that many lack adequate sanitation. As a result, the World Health Organization estimates that 3.4 million people, mostly children, die every year from water-related diseases (WHO, 2002a). In the U.S., outbreaks are commonly associated with contaminated groundwater which has not been properly disinfected. In addition, contamination of the distribution system can occur with water main breaks or other emergency situations (CDC, 2002).

Drinking water pathogens may be divided into three general categories: bacteria, viruses and parasitic protozoa. Bacteria and viruses contaminate both surface and groundwater, whereas parasitic protozoa appear predominantly in surface water. The purpose of disinfection is to kill or inactivate microorganisms so that they cannot reproduce and infect human hosts. Bacteria and viruses are well-controlled by normal chlorination, in contrast to parasitic protozoa, which demand more sophisticated control measures. For that reason, parasitic protozoan infections may be more common than bacterial or viral infections in areas where some degree of disinfection is achieved.


Bacteria are microorganisms often composed of single cells shaped like rods, spheres or spiral structures. Prior to widespread chlorination of drinking water, bacteria like Vibrio cholerae, Salmonella typhii and several species of Shigella routinely inflicted serious diseases such as cholera, typhoid fever and bacillary dysentery, respectively. As recently as 2000, a drinking water outbreak of E. coli in Walkerton, Ontario sickened 2,300 residents and killed seven when operators failed to properly disinfect the municipal water supply. While developed nations have largely conquered water-borne bacterial pathogens through the use of chlorine and other disinfectants, the developing world still grapples with these public health enemies.


Viruses are infectious agents that can reproduce only within living host cells. Shaped like rods, spheres or filaments, viruses are so small that they pass through filters that retain bacteria. Enteric viruses, such as hepatitis A, Norwalk virus and rotavirus are excreted in the feces of infected individuals and may contaminate water intended for drinking. Enteric viruses infect the gastrointestinal or respiratory tracts, and are capable of causing a wide range of illness, including diarrhea, fever, hepatitis, paralysis, meningitis and heart disease (American Water Works Association, 1999).

Protozoan Parasites

Protozoan parasites are single-celled microorganisms that feed on bacteria found in multicellular organisms, such as animals and humans. Several species of protozoan parasites are transmitted through water in dormant, resistant forms, known as cysts and oocysts. According to the World Health Organization, Cryptosporidium parvum oocysts and Giardia lamblia cysts are introduced to waters all over the world by fecal pollution. The same durable form that permits them to persist in surface waters makes these microorganisms resistant to normal drinking water chlorination (WHO, 2002b). Water systems that filter raw water may successfully remove protozoan parasites.

Emerging Pathogens

An emerging pathogen is one that gains attention because it is one of the following:

* a newly recognized disease-causing organism
* a known organism that starts to cause disease
* an organism whose transmission has increased

Source: Guerrant, 1997

Cryptosporidium is an emerging parasitic protozoan pathogen because its transmission has increased dramatically over the past two decades. Evidence suggests it is newly spread in increasingly popular day-care centers and possibly in widely distributed water supplies, public pools and institutions such as hospitals and extended-care facilities for the elderly. Recognized in humans largely since 1982 and the start of the AIDS epidemic, Cryptosporidium is able to cause potentially life-threatening disease in the growing number of immunocompromised patients. Cryptosporidium was the cause of the largest reported drinking water outbreak in U.S. history, affecting over 400,000 people in Milwaukee in April, 1993. More than 100 deaths are attributed to this outbreak. Cryptosporidium remains a major threat to the U.S. water supply (Ibid.).

The EPA is developing new drinking water regulations to reduce Cryptosporidium and other resistant parasitic pathogens. Key provisions of the Long Term 2 Enhanced Surface Water Treatment Rule include source water monitoring for Cryptosporidium; inactivation by all unfiltered systems; and additional treatment for filtered systems based on source water Cryptosporidium concentrations. EPA will provide a range of treatment options to achieve the inactivation requirements. Systems with high concentrations of Cryptosporidium in their source water may adopt alternative disinfection methods (e.g., ozone, UV, or chlorine dioxide). However, most water systems are expected to meet EPA requirements while continuing to use chlorination. Regardless of the primary disinfection method used, water systems must continue to maintain residual levels of chlorine-based disinfectants in their distribution systems.

Giardia lamblia, discovered approximately 20 years ago, is another emerging waterborne pathogen. This parasitic microorganism can be transmitted to humans through drinking water that might otherwise be considered pristine. In the past, remote water sources that were not affected by human activity were thought to be pure, warranting minimal treatment. However, it is known now that all warm-blooded animals may carry Giardia and that beaver are prime vectors for its transmission to water supplies.

There is a distinct pattern to the emergence of new pathogens. First, there is a general recognition of the effects of the pathogen in highly susceptible populations such as children, cancer patients and the immuno-compromised. Next, practitioners begin to recognize the disease and its causative agent in their own patients, with varied accuracy. At this point, some may doubt the proposed agent is the causative agent, or insist that the disease is restricted to certain types of patients. Finally, a single or series of large outbreaks result in improved attention to preventive efforts. From the 1960’s to the 1980’s this sequence of events culminated in the recognition of Giardia lamblia as a cause of gastroenteritis (Lindquist, 1999).

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