small water supplies under the microscope: a case study on water quality and health from rural...
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Small water supplies under the microscope: a case study on water quality and health from rural Alabama
Joe Brown PhD PE
Lecturer, Department of Disease Control, Faculty of Infectious & Tropical Diseases, London School of Hygiene & Tropical Medicine, University of [email protected]
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AcknowledgementsFunding: US EPA (STAR)Students: Olivia Johns and Maxwell Izenberg (LSHTM)Study participants, AlabamaPauline Johnson and group (UA)Julie Olson and group (UA)Christine Stauber (GSU)Christine Moe and group (Emory)Rick Gelting and group (CDC)Shadi Eskaf (UNC)Engineers Without Borders (UA)HERO & Pam DorrSamory Pruitt and CCBP (UA)
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Alabama
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Gasteyer and Vaswani 2004 From 2000 census data
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Southeast’s $50 Billion drinking water capital needs estimate
Source: EPA 2007, Drinking Water Infrastructure Needs Survey Assessment, Shadi Eskaf EFC-UNC.
Alabama Florida Georgia Kentucky Mississippi North Carolina
South Carolina
Tennessee $ 0
$ 2,000
$ 4,000
$ 6,000
$ 8,000
$ 10,000
$ 12,000
$ 14,000
$ 0
$ 500
$ 1,000
$ 1,500
$ 2,000
$ 2,500
$ 3,000
$ 3,500
Drinking Water 20-Year Capital Needs Estimates in 2007 (billions of $)
Billi
ons o
f $
$ / S
ervi
ce C
onne
ction
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Rural water supplies• More than 94 percent of the
nation’s 156,000 public water systems serve <3,300 persons
• Disproportionate share of outbreaks related to microbial contamination
• Face a variety of challenges:– Wide service areas and
disperse populations – O & M challenges– Meeting regulatory
requirements
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Southeast’s 8,700 community water systems serve 58.5 Million People
Alabama Florida Georgia Kentucky Mississippi North Carolina
South Carolina
Tennessee 0
500
1,000
1,500
2,000
2,500
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%Large Systems Serving >10,000 People
Small Systems Serving <10,000 People
Percent of Population Served by Small Systems
Num
ber o
f Cim
mun
ity W
ater
Sys
tem
s
Source: EPA’s 2011 SDWIS data analyzed by the Environmental Finance Center at the University of North Carolina, Shadi Eskaf
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PWS Violations Alabama 1997-2012Type of systems Population
servedViolations: HAA
Violations: TTHMs
Violations: coliform
Total violations
Total violations per 100,000 people
Large (10,001-100,000) 4,136,225 15 28 100 143 3 Top third per capita income 3,248,710 11 15 51 77 2 Middle third per capita income 664,795 4 5 21 30 5 Lower third per-capita income 222,720 0 8 28 36 16Medium (3,301-10,000) 1,027,417 38 69 160 267 26 Top third per capita income 408,615 10 25 50 85 21 Middle third per capita income 384,255 23 23 58 104 27 Lower third per-capita income 234,547 5 21 52 78 33Small (501-3,300) 362,352 65 128 273 466 129 Top third per capita income 124,756 13 25 70 108 87 Middle third per capita income 139,053 34 74 107 215 155 Lower third per-capita income 98,543 18 29 96 143 145Very Small (<500) 11,168 11 13 42 66 591 Top third per capita income 2,547 6 1 9 16 628 Middle third per capita income 3,928 4 9 10 23 586 Lower third per-capita income 4,693 1 3 23 27 575Total 5,537,162 129 238 575 942 17
> 8x
197x
L Talebi
> 40x
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Alabama’s Black Belt region
• Common demographic and socio-economic characteristics– High poverty– High unemployment– Decreasing population– High percentage of minorities
• Common themes– Decaying infrastructure– Poor access to basic services
and health care– High percentage of vulnerable
people (the young, elderly and infirm, HIV+)
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Results from scoping assessment• In collaboration with HERO• Customer complaints: outages, cloudy or
smelly water • High cost to connect and tariffs
– Post-meter leakages– Services disconnected
• Alternatives are potentially unsafe water sources (i.e. shallow wells near failing septic systems)
• Poor septic access and apparent function
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Phase 1: pilot study
• Pilot cross-sectional study of 300 households in Hale County to examine:
• (i) drinking water quality at the household level (both private wells and county public supply),
• (ii) possible associations between water infrastructure characteristics and drinking water quality, and
• (iii) risk of Highly Credible Gastrointestinal Illness (HCGI)
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Data collection overview• One survey on water use, basic demographics,
health, and access to and perception of infrastructure
• All households submitted a water quality sample at the time of the visit– Some households submitted two samples
• Analysis for fecal coliform, turbidity, pH, and total and free chlorine– Membrane filtration, EPA 1904/Standard Methods– pH and Cl measured at point of sampling, colorimetric
tests– Turbidity
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Not in the Job description
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Results overview
• 8% of system samples positive for FC• 30% of well samples positive for FC• No Cl in >35% of samples from the county water
supply system – Cl presence associated with FC
• Frequently intermittent service: 8% of households• 18% of households had no onsite sanitation• Wells more likely to be contaminated
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Results overview, continued
• 12 cases of GI illness among 507 people: 2.4% 7-day prevalence– High risk
• Individuals whose drinking water was found to contain ≥ 1 cfu/100 ml of FC were 4 times as likely to have also reported HCGI in the previous 7 days as those whose water sample was negative for FC (<1 cfu/100 ml) – (OR 4.0, 95% CI 1.2 – 14)
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Fecal Coliforms per 100 ml sample<1 1-10 11-100 101 +
All Households
260 27 12 1
County supply
206 12 5 0
Well 54 15 7 1
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FC <1 cfu/100ml
FC ≥ 1 cfu/100ml
OR (95% CI)
p-value
Number of households 263 42 Connected to system 182 16 0.27(0.14-0.54) <0.001 Well users 46 20 4.3 (2.2-8.5) <0.001 On-site septic tank
172
28
0.51 (0.064 - 4.1)
0.528
No or unknown sanitation 184 29 0.98 (0.47-1.9) 0.905 Reported “poor or very poor” Taste Odor Color Clarity Perceived safety
2120231812
31311
0.89 (0.25-3.1)0.30 (0.039-2.3)0.80 (0.23-2.8)0.33 (0.043-2.6)0.51 (0.065-4.0)
0.8510.2420.7300.2900.523
Intermittent service (piped supply only)
23
2
0.52 (0.12 - 2.3)
0.390
Functional problems, well 6 4
4.5 (1.2 - 17) 0.024
Free chlorine between 0.2 and 2 mg/l
146
7
0.16 (0.069 - 0.37)
<0.001
Mean free chlorine (mg/l) 0.691 0.164
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FC <1 cfu/100ml
FC ≥ 1 cfu/100ml
OR (95% CI)
p-value
Number of households 263 42 Connected to system 182 16 0.27(0.14-0.54) <0.001 Well users 46 20 4.3 (2.2-8.5) <0.001 On-site septic tank
172
28
0.51 (0.064 - 4.1)
0.528
No or unknown sanitation 184 29 0.98 (0.47-1.9) 0.905 Reported “poor or very poor” Taste Odor Color Clarity Perceived safety
2120231812
31311
0.89 (0.25-3.1)0.30 (0.039-2.3)0.80 (0.23-2.8)0.33 (0.043-2.6)0.51 (0.065-4.0)
0.8510.2420.7300.2900.523
Intermittent service (piped supply only)
23
2
0.52 (0.12 - 2.3)
0.390
Functional problems, well 6 4
4.5 (1.2 - 17) 0.024
Free chlorine between 0.2 and 2 mg/l
146
7
0.16 (0.069 - 0.37)
<0.001
Mean free chlorine (mg/l) 0.691 0.164
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FC <1 cfu/100ml
FC ≥ 1 cfu/100ml
OR (95% CI)
p-value
Number of households 263 42 Connected to system 182 16 0.27(0.14-0.54) <0.001 Well users 46 20 4.3 (2.2-8.5) <0.001 On-site septic tank
172
28
0.51 (0.064 - 4.1)
0.528
No or unknown sanitation 184 29 0.98 (0.47-1.9) 0.905 Reported “poor or very poor” Taste Odor Color Clarity Perceived safety
2120231812
31311
0.89 (0.25-3.1)0.30 (0.039-2.3)0.80 (0.23-2.8)0.33 (0.043-2.6)0.51 (0.065-4.0)
0.8510.2420.7300.2900.523
Intermittent service (piped supply only)
23
2
0.52 (0.12 - 2.3)
0.390
Functional problems, well 6 4
4.5 (1.2 - 17) 0.024
Free chlorine between 0.2 and 2 mg/l
146
7
0.16 (0.069 - 0.37)
<0.001
Mean free chlorine (mg/l) 0.691 0.164
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FC <1 cfu/100ml
FC ≥ 1 cfu/100ml
OR (95% CI)
p-value
Number of households 263 42 Connected to system 182 16 0.27(0.14-0.54) <0.001 Well users 46 20 4.3 (2.2-8.5) <0.001 On-site septic tank
172
28
0.51 (0.064 - 4.1)
0.528
No or unknown sanitation 184 29 0.98 (0.47-1.9) 0.905 Reported “poor or very poor” Taste Odor Color Clarity Perceived safety
2120231812
31311
0.89 (0.25-3.1)0.30 (0.039-2.3)0.80 (0.23-2.8)0.33 (0.043-2.6)0.51 (0.065-4.0)
0.8510.2420.7300.2900.523
Intermittent service (piped supply only)
23
2
0.52 (0.12 - 2.3)
0.390
Functional problems, well 6 4
4.5 (1.2 - 17) 0.024
Free chlorine between 0.2 and 2 mg/l
146
7
0.16 (0.069 - 0.37)
<0.001
Mean free chlorine (mg/l) 0.691 0.164
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FC <1 cfu/100ml
FC ≥ 1 cfu/100ml
OR (95% CI)
p-value
Number of households 263 42 Connected to system 182 16 0.27(0.14-0.54) <0.001 Well users 46 20 4.3 (2.2-8.5) <0.001 On-site septic tank
172
28
0.51 (0.064 - 4.1)
0.528
No or unknown sanitation 184 29 0.98 (0.47-1.9) 0.905 Reported “poor or very poor” Taste Odor Color Clarity Perceived safety
2120231812
31311
0.89 (0.25-3.1)0.30 (0.039-2.3)0.80 (0.23-2.8)0.33 (0.043-2.6)0.51 (0.065-4.0)
0.8510.2420.7300.2900.523
Intermittent service (piped supply only)
23
2
0.52 (0.12 - 2.3)
0.390
Functional problems, well 6 4
4.5 (1.2 - 17) 0.024
Free chlorine between 0.2 and 2 mg/l
146
7
0.16 (0.069 - 0.37)
<0.001
Mean free chlorine (mg/l) 0.691 0.164
WELL WATER WITH SIGNIFICANTLY HIGHER FC
WELL PROBLEMS ASSOCIATED WITH FC
Cl RESIDUALS ASSOCIATED WITH LESS FC
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FC <1 cfu/100ml
FC ≥ 1 cfu/100ml
OR (95% CI)
p-value
Number of people 450 57
Mean age 34.7 37.1
Self-reported symptoms, 7 day
Diarrhea 6 4 5.6 (1.5 - 20) 0.009
Abdominal cramps 11 2 1.5 (0.31 - 6.7) 0.634
Nausea 10 3 2.4 (0.65 - 9.2) 0.185
Vomiting 7 1 1.1 (0.14 - 9.4) 0.910
Fever 5 4 6.7 (1.8 - 26) 0.006
HCGI*
8
4
4.0 (1.2 - 14)
0.027
*73 people reported pre-existing conditions – diverticulitis, heartburn, irritable bowel syndrome, milk intolerance, stomach ulcer, colitis, or migraine - these are excluded
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FC <1 cfu/100ml
FC ≥ 1 cfu/100ml
OR (95% CI)
p-value
Number of people 450 57
Mean age 34.7 37.1
Self-reported symptoms, 7 day
Diarrhea 6 4 5.6 (1.5 - 20) 0.009
Abdominal cramps 11 2 1.5 (0.31 - 6.7) 0.634
Nausea 10 3 2.4 (0.65 - 9.2) 0.185
Vomiting 7 1 1.1 (0.14 - 9.4) 0.910
Fever 5 4 6.7 (1.8 - 26) 0.006
HCGI*
8
4
4.0 (1.2 - 14)
0.027
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FC <1 cfu/100ml
FC ≥ 1 cfu/100ml
OR (95% CI)
p-value
Number of people 450 57
Mean age 34.7 37.1
Self-reported symptoms, 7 day
Diarrhea 6 4 5.6 (1.5 - 20) 0.009
Abdominal cramps 11 2 1.5 (0.31 - 6.7) 0.634
Nausea 10 3 2.4 (0.65 - 9.2) 0.185
Vomiting 7 1 1.1 (0.14 - 9.4) 0.910
Fever 5 4 6.7 (1.8 - 26) 0.006
HCGI*
8
4
4.0 (1.2 - 14)
0.027
ODDS OF HCGI ARE 4x HIGHER IF WATER SAMPLE IS POSITIVE FOR FECAL COLIFORM
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Summary: Alabama, Phase 1
• Systems and wells at risk for microbiological contamination
• Onsite sanitation a (potentially big) problem• High prevalence of gastro-intestinal illness
– Suggestive evidence that water may play a role
• Need for assistance with DBP rules
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Phase 2: Current study• Water Infrastructure
Sustainability and Health in Alabama's Black Belt – Advancing Public Health
Protection through Water Infrastructure Sustainability (EPA-G2009-STAR-F1)
• 2011 – 2015, 14 water systems, 3 counties
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Goals: Phase 2• 1. Assess system performance and
water quality– Fecal indicators and pathogens
• 2. GI illness associations – Directly measured (epidemiology)– Modeled using QMRA
• 3. Identify possible transmission pathways
• 4. Identify risk mitigation strategies– Working with operators
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Methods• Household-level water quality data
– Microbiological indicators, pressure, Cl, pH, turbidity
• Health GI measures– HCGI health diaries & interviews– Salivary antibody assay pilot
• Pathogens and indicators from concentrated ultrafiltration samples– Cryptosporidium, Giardia, E. histolytica,
norovirus, rotavirus, adenovirus, Enterococcus, E. coli, Campy, Salmonella
• Other system-level data– System modeling – Operation and maintenance– Infrastructure characteristics
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Methods, continued• Survey of 900 randomly selected
connected households (300 in each county)– Health outcomes– Grab vs flamed drinking water samples – Septic access and function– Perceptions and water use
• Ongoing surveillance• Selection of sampling sites
– Selected households, key system points
– Up to 10 sample points per system• Dead-end ultrafiltration
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Turbidity – cross-sectional TC– cross-sectional
Selecting sampling points
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System data• Flow modeling • O&M records• Existing monitoring data• Offering PDHs to
operators
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Onsite sanitation• Surveys of OSS function and access
– Public records vs survey– Previous study: 90% of septic
systems in the Black Belt were failing (ADPH 1997)
• Microbial source tracking of E. coli isolates– Household-level samples, drainfield
samples, system samples– Partner study: household well
samples• Technology innovation for
underserved communities– Urgent need
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COURTESY OFR GELTING + CDC
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