Running head: WATERBORNE DISEASES AND OUTBREAKS IN THE UNITED

Waterborne Diseases And Outbreaks In The United States

Linked to Rainfall and Runoffs

Ana Y. Quintana
HSCI 616: Environmental and Occupational Health
CSU San Bernardino
May 15, 2019
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Table of Contents
Introduction ..................................................................................................................................... 3
Freshwater Is A Human Necessity To Life..................................................................................... 3
United States Legislation ................................................................................................................ 4
Environmental Protection Agency Regulations .......................................................................... 4
Waterborne Diseases and Outbreaks .............................................................................................. 6
Associations Between Precipitation And Waterborne Disease Outbreaks ................................. 7
Waterborne Disease Outbreaks ................................................................................................... 7
Giardiasis Morphology ............................................................................................................... 8
Giardia As A Waterborne Threat To Humans ............................................................................ 9
Health Effects in Humans ............................................................................................................. 10
Discussion ..................................................................................................................................... 10
References ..................................................................................................................................... 12
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Introduction
Water is a precious resource required of all living life on this planet. Globally the world is

composed of seventy-one percent of water, but despite that, the more significant part of the water

on this planet remains undrinkable (The U.S. Department of the Interior, Bureau of Reclamation,

2017). Unfortunately, ninety-seven percent of this planet's water is in oceans, which are composed

of high salt contents. Of that three percent that remains, two and a half percent is unavailable in

glaciers, polar ice caps, the atmosphere, and soil, or polluted (The U.S. Department of the Interior,

Bureau of Reclamation, 2017). The truth that freshwater on this planet is a limited and invaluable

resource makes the incentive to protect it from harm an obligation of everyone.

Taking into consideration freshwater is a limited resource on this planet, governments

across the globe, have created legislation to protect all bodies of water, including drinking water,

to be free of natural, biological, chemical, and other contaminants, since the pollution of such

limited sources of water threatens the health, environment, and economy, of everyone.

Freshwater Is A Human Necessity To Life

The human body, in particular, which is composed of 60% water, requires water to serve

the most basic essential functions to survive (The United States Geological Survey, 2019). From

regulating the internal body temperate, flushing out waste products through one's kidneys, forming

saliva, keeping mucosal membranes moist and joints lubricated, to acting as a shock absorber to

the brain and spinal cord and delivering oxygen throughout the body, water is a vital resource we

cannot live without (The United States Geological Survey, 2019). Freshwater serves other

purposes, such as feeding livestock, growing crops, sanitary, recreational, leisure, medical, and

industry use, as well, serves as a basic necessity to the millions of other species that use fresh water

to drink, live in, and cleanse themselves.

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United States Legislation

In the 1970s, the United States had a cultural revolution around preserving the land, air,

and water for current and future generations. The aim was to reduce the contamination exposure

risks to all water sources, various legislation passed. For example, the Clean Water Act of 1972

sought to regulate the nation’s waters through pollution control programs that set industry

standards (The United States Environmental Protection Agency, 2016a). The health of rivers,

lakes, bays, and coastal waters became paramount as one in three Americans access water directly

from streams (The United States Environmental Protection Agency, 2016a).

The Safe Drinking Water Act of 1974 moved the American nation a step forward in

protecting the health of the Americans be regulating public drinking water supplies from natural

and human-made contaminations (The United States Environmental Protection Agency, 2004).

Individually, this act regulated the disposal of chemicals, animal waste, waste injected

underground, and natural substances from entering drinking water sources; in addition to the

sanitary and treatment processing practices of the facilities, all the end to improve the quality and

reduce any public health contaminant risks (The United States Environmental Protection Agency,

2004).

Environmental Protection Agency Regulations

The Safe Drinking Water Act mandated a specific regulation process the Environmental

Protection Agency (EPA) must follow to identify and list unregulated contaminants (The United

States Environmental Protection Agency, 2018). The EPA defines pollutants as “any physical,

chemical, biological, or radioactive substances or matter in the water” (The United States

Environmental Protection Agency, 2016b). The EPA has three eligibility criteria on containment

regulations, such as (1) does the contaminant cause harm to humans, (2) does the contaminant has
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a likelihood or known occurrence in public water systems and presents in such levels that cause

public health concerns (The United States Environmental Protection Agency, 2018). Lastly, (3) it

grants the Administrator sole judgment in deciding whether a contaminate(s) pose meaningful

chances to reduce any public health risks to the public (The United States Environmental

Protection Agency, 2018). After completing a preliminary regulatory list, the EPA publishes its

results for public review and comment, after which time a final list is made public (The United

States Environmental Protection Agency, 2018).

After identifying contaminants, the EPA investigates and evaluates the health effects a

contaminant can cause to the public. This aids in establishing a maximum contaminant level goal

(MCLG) in drinking water, which, if not reached, will have no adverse effects on the health of the

public (The United States Environmental Protection Agency, 2018). In theory, these limits protect

the most vulnerable populations in our country, yet per the EPA (2018) they often do not take into

consideration the available technologies and detection effectiveness statewide agencies have (The

United States Environmental Protection Agency, 2018), thus creating an unachievable burden to

reach MCLGs; in addition to MCLGs are non-enforceable goals (The United States Environmental

Protection Agency, 2018).

The EPA has strict guidelines for any microbial and chemical contaminants since their risk

to the health of the public is elevated. In the example of microbial contaminants, the EPA

guidelines set MCLGs at zero since the presence of one microbial organism, such as viruses,

protozoans, or bacterium, will be enough to cause harm (The United States Environmental

Protection Agency, 2018). In comparison, chemical contaminants that are suspected to be

carcinogenic may be set to zero if dangers exist at any level, versus non-carcinogenetic chemicals

always have values greater than zero (The United States Environmental Protection Agency, 2018).
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Waterborne Diseases and Outbreaks

Waterborne diseases pose a significant threat to human health. For this reason, public

health officials collect, test, and monitor different types of water sources in this country. Water

contaminated with germs, chemicals, or toxins, according to the Centers for Disease Control and

Prevention, “can lead to waterborne illness if you drink it, breathe it in, or it touches your skin,

eyes, ears, or to the mucous membranes” (Centers for Disease Control and Prevention, 2019). In

the United States, public health officials have been tracking waterborne borne diseases and

outbreaks for over one hundred years, yet in 1971 the Centers for Disease Control and Prevention

created a national surveillance system called the Waterborne Disease and Outbreak Surveillance

System (WBDOSS) (Centers for Disease Control and Prevention, 2019).

Its goal is to collects and retains data regarding the waterborne disease and outbreaks

associated with different types of water sources, such as recreational, drinking, and environmental

and undetermined exposes to water (Centers for Disease Control and Prevention, 2019). As well,

to the collection of other important factors, such as hospitalizations, death, illnesses, types of water

sources, water systems, and water settings (Centers for Disease Control and Prevention, 2019).

Investigators hope to learn more about the causes of waterborne diseases and outbreaks to then be

able to control and prevent additional harm to come to the public. For an event to be as a

waterborne disease outbreak, the CDC describes that the outbreak must (1) have two more

individuals infected within a similar time frame, location, and illness, (2) outbreaks must have a

connection to a water source, and (3) environmental and epidemiological links must link back to

the outbreaks (Centers for Disease Control and Prevention, 2019).

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Associations Between Precipitation And Waterborne Disease Outbreaks

Given that climate change is an established global threat in the scientific community,

determining how changes to the weather might influence waterborne disease outbreaks have

become a public health concern priority (Curriero, Patz, Rose, & Lele, 2001). Statistical data

collected from researchers, Curriero, Patz, Rose, and Lele (2001), have implicated rainfall and

runoffs with outbreaks in the United Kingdom and the United States (Curriero et al., 2001). In

the United States, the daily average temperature has increased by one degree (Curriero et al.,

2001). The warming of the planet is a big problem for public health because the warmer the air

becomes, the more moisture it can hold, thus altering the hydrologic cycle, which trickles down

to increase clouds and precipitation (Curriero et al., 2001). In the past few years alone, many

states across the country have seen abnormal floods due to excessive rainfall.

Waterborne Disease Outbreaks

For over a hundred years, statistical data on waterborne diseases and outbreaks have been

collected in the United States by public health officials. In 1993, the United States had the most

significant waterborne disease outbreaks of giardiasis ever reported from 1948-1994 in

Milwaukee, Wisconsin (Curriero et al., 2001). In this case, public health officials estimated

intestinal illness cases were as high as four hundred thousand and fifty-four people perished as a

result of giardiasis contamination in drinking water; coincidently following “periods of heavy

rainfall and runoff” (Curriero et al., 2001). Authors Curriero et al. (2001) examined statistical data

collected from 1948-1994 in eighteen hydrologic regions and four seasons in the United States.

Their study found 548 reported cases of waterborne disease outbreaks in the regions mentioned

above, with the highest number occurring in the summer and the lowest in the winter. Also, of the
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548 outbreaks, 133 were from surface water contamination, 197 from groundwater contamination,

and 218 were from unknown water sources (Curriero et al., 2001).

Giardiasis Morphology

Members of the Giardia genus are a binucleate flagellated protozoan parasite, which occurs

in trophozoite and cyst forms. The parasite reportedly infects a variety of mammals and in lower

vertebrates by attaching to the wall of the small intestine (The United States Environmental

Protection Agency, 1999). In humans, particular Giardia parasites are keen on the human small

intestines, such as G. duodenalis, G. intestinalis, and G. lamblia (The United States Environmental

Protection Agency, 1999). Giardia has two modes of transportation into its host's body. Either

through the ingestion of a vertebrate host or the fecal contamination in a water source and the

human body, cyst’ incubation periods range from three to twenty-five days (The United States

Environmental Protection Agency, 1999).

The Giardia life expectancy is significantly affected by temperature, where the parasite

prefers colder climates. For example, the authors from The United States Environmental Protection

Agency (1999) described how Giardia cysts could withstand freezing temperatures and remain

viable for long periods under “typical environmental conditions” (p. 1). Purposely, authors

exposed parasites to various temperature conditions and found that cysts survived about twenty-

six days at 21 degrees Celcius versus surviving six days at 37 degrees Celcius and inactivate at

boiling temperatures. Moreover, as for the morphology of the cysts, they are typically ovoid shape,

range from 10-15 micrometers in length and 7-10 micrometers in width, and divide by binary

fission, where they attach to the international epithelium wall (The United States Environmental

Protection Agency, 1999).

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Giardia As A Waterborne Threat To Humans

Author Erlandsen (as cited In The United States Environmental Protection Agency, 1999)

described how cysts from symptomatic human donors could infect a beaver and muskrat. The

author's findings suggest these animals can contract the infection from humans is vital in

understanding a type of waterborne contamination in the United States. Both mammals are known

to defecate into water sources and thus, supporting the argument that they transmit the parasite to

humans through contaminated water. As well, their experimental data suggested other mammals

can harbor the parasite in their bodies and spread to humans, such as rats, mice, dogs, cats, gerbils,

and mule deer. Moreover, previous studies by Cruan (1999) and Issac-Renton (1994) (as cited in

the United States Environmental Protection Agency, 1999) have implicated both marine mammals

in waterborne outbreaks and harboring two types of Giardia parasites. (The United States

Environmental Protection Agency, 1999)

Giardia exists in surface water sources from the Arctic to the topics throughout the entire

year. (The United States Environmental Protection Agency, 1999). Authors suggest cysts forms

have a proclivity to water sources near agricultural and residential areas, such as cattle or dairy

farming or sewage discharge. Also, in North America, Giardia is found with higher frequency in

the late summer to early winter months. For example, Rose et al. (1998) (as cited in The United

States Environmental Protection Agency, 1999) reported that Giardia cysts were present in 31%

of samples take from a lake near cattle pastures, and sewage waste. Aligning itself with Roach et

al. (1993) (as cited in The United States Environmental Protection Agency, 1999), which found

32% of samples taken from pristine streams in northern Canadia had Giardia cysts as well. (The

United States Environmental Protection Agency, 1999)

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Health Effects in Humans

Giardiasis causes terrible health effects on humans. The United States Environmental

Protection Agency (1999) reports that they present with “(1) asymptomatic infection; (2) acute

diarrhea; (3) chronic diarrhea” (p.7). Characteristically authors report, symptoms range from

adnominal cramps, bloating, weight loss, diarrhea, vomiting, and abnormal stools. In children, the

Giardia infection is asymptomatic, and in other patients, the symptoms range from three to four

days to months. Hospitalization rates in the United States because of giardiasis infections occur as

often as 4,6600 times annual (rates might differ since 1999). However, studies from 1979-1999 in

the United States report that it most often occurs with children under the age of five. Mortality as

a result of giardiasis is rare but has been reported to occur. (The United States Environmental

Protection Agency, 1999)

Discussion

Waterborne diseases and outbreaks occur due to contamination and pose a severe public

health concern. In the United States, a public health official has been monitoring the occurrence

of waterborne disease outbreaks over a hundred years and has increased their knowledge in

identifying the sources of contamination, frequency, and advocating for legislation that will

regulate all bodies of water. While large outbreaks globally have occurred vary on the origin of

contamination, they have brought attention to the broad issues surrounding the conservation and

managing the limited drinking waters that exist today.

In May 2000, Walkerton, Ontario, had a deadly waterborne outbreak from Escherichia coli

and Campylobacter jejuni (Hrudey, Payment, Huck, Gillham, & Hrudey, 2003). Hrudey et al.

reported the outbreak infected over 2300 individuals, including the hospitalization of sixty-five
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and death of seven. This particular outbreak was relevant globally since it implicated multiple-

barrier failures that were completely avoidable in the twenty-first century. For example, more

effective and robust measures “dealing with the following main elements: (1) source, (2) treatment,

(3) distribution, (40 monitoring, and (5) response” (p. 8) were necessary to develop.
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Curriero, F. C., Patz, J. A., Rose, J. B., & Lele, S. (2001). The Association Between Extreme

Precipitation and Waterborne Disease Outbreaks in the United States, 1948–1994.

American Journal of Public Health, 91(8), 1194–1199.

https://doi.org/10.2105/AJPH.91.8.1194

Hrudey, S. E., Payment, P., Huck, P. M., Gillham, R. W., & Hrudey, E. J. (2003). A fatal

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