Water and infectious diseases in Europe

What do we know?
Gertjan Medema Water and Health, A European Perspective
Koblenz, 8-9 December 2009
Water & disease in Europe: history?

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Water quality and health in Europe

Waterborne disease:
Drinking water: pathogens are of greatest concern (Craun & Calderon, 2006)
Human water systems: pathogens are of greatest concern
Bathing water quality: pathogens are of greatest concern

Water & Health workshop

• What is the size of the problem?
• How many Europeans are ill because of pathogens in their water?
• What do we know?
• Why?
• To understand burden of disease from water and relate this to other
(environmental) health impacts
• To justify interventions / improvements in water systems

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Burden of disease estimates (WHO)

Burden of disease of water, sanitation and hygiene

(Prüss et al, 2002)
• Infectious diarrhoea, (para)tyhoid, parasites
• Water supply scenario’s
• % Population in each scenario
• Relative risk of illness based on intervention studies (preventable illness)
• DALY’s (disease burden) & deaths

Europe
8000 deaths / yr (0.4% of world)
65300 DALYs / yr (0.9% of world)

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Burden of disease estimates (WHO Europe)
Environmental factors (Valent et al 2004)

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Infectious disease surveillance
European Centre for Disease Prevention and Control

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Infectious disease surveillance
Food and water-borne diseases and zoonoses

500 Million inhabitants:

5497 cases

204104 cases
17 cases (imported)
6253 cases

Water + Food + Zoonoses

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Infectious disease surveillance
Waterborne pathogens: Cryptosporidium

Limitations of surveillance
in current situation

• Data lacking from 11

countries

• Underreporting

• Assume EU = UK
= 30000 cases / EU / yr
= 471 DALY’s / EU / yr
= 7.4 Million Euro / EU / yr
(based on Van Lier & Havelaar, 2008)

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Infectious disease surveillance
Waterborne pathogens: Legionella

Assume France = EU
= 10500 cases / EU / yr

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Infectious disease surveillance
The reporting pyramid

Intestinal infectious diseases

Wheeler et al, 1999 (England)

1.4

6.2
17
136

CDC, Foodnet

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Infectious disease surveillance
Food and water-borne diseases and zoonoses

204104 cases
7.6 community cases /
reported case (Wheeler et al., 1999)
1.6 (0.7 – 3.6) million cases

Water + Food + Zoonoses

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Infectious disease surveillance
Legionella (NL)

Surveillance
Ca 300 reported cases per year
Half imported, half endemic
Legionella
outbreak
National Health Council 2003
Surveys: ~5% of pneumonia in hospitals
is Legionella
16000 pneumonia hospitalisations / yr
800 Legionella hospitalisations / yr
80 deaths / yr

If NL = EU:
24500 Legionella hospitalizations / yr

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Infectious disease surveillance
Waterborne disease

Not specific to waterborne diseases (+ food + zoonoses)

• Does provide picture for pathogens specific to water, such as
Legionella

Reporting pyramid: tip of the iceberg is visible

• More information about the size of the iceberg from population
studies, translation to true incidence becomes possible

Surveillance systems efficiency differ between countries

• Difficult to obtain Europe-wide information about incidence of
(waterborne) diseases

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WHO Europe 1986-1996: intestinal infections

2% of all reported intestinal

infections through tap water

55 outbreaks via drinking water

with on average 220 cases (2-
3500)

Microrisk: EU 1990-2004: 86
outbreaks through community
water supply, 72546 cases, 341
hospitalizations, 1 fatal

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 Community drinking waterborne outbreaks in Europe 1990-2004
(Risebro et al, 2007)

Pathogen Isolated in Cases

Water Supply
No. Bacterial Protozoal Viral
Country Viral Mixed
Outbreaks Gastroenteritis Ground- Surface Not
Campylobacter Shigella Cryptosporidium Giardia Norovirus (undete- Pathogen Mixed
water Water Reported
rmined)
Finland 12 4 - - - 6 1 - 1 10 2 - -
France 7 - - 2 - - - 3 2 5 - - 2
Germany 2 - - - 1 1 - - - 1 - - 1
Greece 3 - 2 - 1 - - - - 2 1 - -
Italy 1 - - - - - - - 1 - - - 1
Netherlands 1 - - - - - - - 1 1 - - -
Rep. Ireland 2 - - 1 - - - - 1 1 1 - -
Spain 6 1 1 1 - - - - 3 1 - 1 4
Sweden 7 3 - - - 1 - 1 2 3 3 - 1
UK (England) 29 - - 28 - - - - 1 5 14 4 6
UK (N.Ireland) 3 - - 3 - - - - - - 3 - -
UK (Scotland) 6 - - 5 - - - 1 - - 6 - -
UK (Wales) 1 1 - - - - - - - - - - 1
UK (unspecified) 6 - - 6 - - - - - 3 2 1 -
No. Outbreaks 86 9 3 46 2 8 1 5 12 32 32 6 16
Cases 72546 16222 531 7772 232 11408 2500 2511 31370* 43571 23047* 906 5022

= average of 5.7 outbreaks with 4836 cases / year

If EU = UK + Finland: 47 outbreaks with 40,000 cases / year
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Surveillance of waterborne outbreaks

Waterborne outbreak detection systems have a low

recovery efficiency (Risebro et al, 2007)
• Need to improve case demographics of
surveillance systems to facilitate outbreak
detection
• Use of drug prescriptions, absenteeism,
consultations are useful data to improve
outbreak detection
• Link customer complaints of water consumers to
health surveillance

Outbreak surveillance systems differ per country

• Difficult to get Europe-wide picture

Information about cause(s) of the outbreaks

• Allows prevention

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Household intervention studies GastroIntestinal (GI) illness
Community (surface) water supply

Source Treatment Interven- Excess Source

tion risk of
drinking
water Translation to USA:
Contaminated Flocculation, filtration, Reverse
34%
Payment et al, 4.3 - 11.7 million cases of
river ozonation, chlorination osmosis 1991 (Canada)
GI illness by community
Purified
drinking water supply
Contaminated Flocculation, filtration, Payment et al,
river ozonation, chlorination
bottled 12%
1997 (Canada)
(Colford et al, 2006)
water

Protected
reservoir
Chlorination
UV and 1
µm filters
4%*
Hellard et al, 2001
(Australia)
= 4 - 10% of all cases
(Roy et al, 2006)
Coagulation,
Contaminated sedimentation, UV and 1 Colford et al, 2002
24%*
river filtration, (ozonation), µm filters (USA)
chlorination
Incidences (/p/y)
Coagulation, Waterborne GI: 0.023 – 0.064
Contaminated UV and 1 Colford et al, 2005
sedimentation, 0%*
river µm filters (USA)
filtration, chlorination Total GI: 0.65
* No significant difference between study group with and without intervention

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Household intervention studies GastroIntestinal (GI) illness
Community (surface) water supply

No intervention studies in Europe

Direct translation USA = EU:

12 - 32 million cases of GI illness by community drinking water supply

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Epidemiological studies

France: risk of childhood GI illness greater in alpine villages where the water did
not satisfy drinking water standards (RR=1.7 95% CI 1.5 -1.9) (Zmirou et al, 1987)

France: correlation between drinking water turbidity and anti-diarrhoeal drug

sales (Beaudeau et al, 1999)

UK: risk of GI illness is higher in case of pressure loss of tap water supply (Odds
Ratio 12.5 (95% CI 3.5 – 45) (Hunter et al, 2005)

Norway distribution health epi study (Nygard et al, 2007)

• Consumers in area affected by repair had higher probability of intestinal
illness (OR 1.6 - 2.0)
• Estimated # of GI cases 33000 on a population of 4.5 million
• If Norway = EU: 3.7 million GI cases due to mains repairs

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Very small supplies
Risk assessment based on microbiological monitoring

E. coli monitoring
France (CISEaux): 150775 samples of 4536 systems. 17.9% with E.coli
England (UEA) : 34904 samples of 11233 systems. 18.9% with E. coli (Yip Richardson et al 2009)

Translate to risk of infection (Hunter, 2009)

• step 1: use E. coli – pathogen ratio (Campylobacter, Giardia, Cryptosporidium)
• step 2: use data on cold tap water consumption
• step 3: use dose-response data of pathogens
• step 4: compute risk of infection

Risk of infection
England 0.012/day; France 0.033/day.
= 1 / year
Number of EU citizens not connected to public supply: 34.3 million
Potential for multiple infections per year; potential for infection of visitors

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Risk of Cryptosporidium (Smeets et al, 2007)
Risk assessment based on statutory treated water data

If EU = UK surface water risk sites:

13 million Cryptosporidium infections / yr
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Quantitative Microbial Risk Assessment

QMRA allows assessment of health risk in low exposure conditions

Translation of water quality data to health effects uncertain

• Indirect relation (E. coli concentration)
• Pathogen data: infectivity?

Case studies in several countries, difficult to translate to Europe-wide

image
• QMRA valuable to identify water supply systems at risk in
EU/country

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Burden of drinking waterborne disease in Europe (/ yr)

Burden of disease estimates (water, sanitation, hygiene)

• 13,500 deaths, 550,000 DALY’s

Health surveillance
• Total unknown (due to combination with food and zoonoses) Different
Differentareas
areas
• Typical waterborne pathogens:
• Cryptosporidium EU: 6253 reported, 30000 estimated
• Legionella EU: 5497 reported, 10500 – 24500 estimated
Different
Differentoutcomes
outcomes
Waterborne outbreaks
• Reported: 5.7 outbreaks with 4836 GI cases
• Estimated: 47 outbreaks with 40,000 GI cases
Different
Differentdiseases
diseases
Epidemiological studies
• Household intervention studies (US): 12 – 32 million GI cases
• Distribution system repair study: 3.7 million GI cases
Different
Differentmethods
methods
Quantitative Risk Assessment
• Small supplies: 34.3 million infections
• Cryptosporidium: 13 million infections
Different
Differentassumptions
assumptions
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Bathing waters

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Burden of disease estimates
Epidemiological + water quality data + exposure data

South California estimates (Dwight, 2005, Pendleton)

• Exposure data
• 28 beaches
• 90 million beach days per year
• 28% swim in ocean Kay et al, 1994

• Water quality data (enterococci)

• Epi relation enterococci – GI risk
Cabelli et al, 1982

• Annual disease
Cases Cost (USD)
• GI 0.6 – 1.5 million 21 – 49 million

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Epidemiological studies

Bartram, 2009

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Pond, 2005
Translate water quality data to health risk
England & Wales (Georgiou & Langford, 2002)

Bathing waters (n=557)

95.15 complied with EU mandatory level
65.53 complied with guideline value
Exposure data (survey 809 persons)
• 3.1 million exposures (swimming with head immersions)
Water quality data (fecal streptococci) translated to excess risk of GI illness
• 0.065 per exposure
Excess cases of GI illness due to swimming
• 1.96 million
• Corrected for immunity: 1.75 million

If UK = EU: 16.5 million GI illness cases

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Health risk estimates based on water quality data
and epidemiology

Allows translation of water quality monitoring to

burden of illness and cost of illness
• Conduct such studies!

Many water quality data available from statutory

monitoring

Exposure data (beach visits, swimming and other

water activities) limited
• EU surveys

Consistency of “dose-response” relation

• Additional epi-studies (fresh water)
• Validation studies

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Bathing water studies

Epibathe (marine and fresh waters)

17 sites, 4 countries (UK, Ger, Hun, Sp), 7217 citizens

Wyn-Jones et al, 2009 29

Bathing water studies

Epibathe marine waters

Wyn-Jones et al, 2009 30

Bathing water studies

Epibathe fresh waters

Wyn-Jones et al, 2009 31

Bathing water studies

Epibathe fresh waters, E. coli

Wyn-Jones et al, 2009 32

Quantitative risk assessment

NL
Pathogen data in bathing waters (Cryptosporidium & Giardia)
• Crypto 4 – 200 / L; Giardia 1 – 53 / L
Exposure scenarios
• Incidental, occasional, frequent
Calculated risk of infection
• Per swim event: 0.2 – 4.7%
• Per year: 0.2 – 71%

Using data from UK: NL 9.3 million swim events with head immersion
• 20,000 – 430,000 Crypto/Giardia infections per year

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Use of Quantitative Risk Assessment

Risk estimate based on water quality data

• Pathogens (surveys needed)
• E. coli / enterococci (US EPA, 2009)

Allows comparison of risk from different sources

Allows comparison of risk (or improvements) of

different scenarios

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Conclusions?

Water and health in Europe, what do we know?

• Mostly fragments
• Burden of disease on European scale: rough
estimate
• Drinking water
• Outbreak study on European scale: tip of iceberg
• Drinking water disease burden is low
– Disease prevented by interventions
• Areas of concern: outbreaks, very small supplies (both
esp. under climate change)
• Water systems
• Legionella is still significant and water-specific health
burden in Europe
• Bathing water
• Epi + water quality: disease burden is significant (esp.
under climate change)

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Recommendations

Improve assessment of waterborne burden of disease in Europe

• Disease prevented by good water practice Acceptable
risk
HEALTH
TARGETS

Improve outbreak surveillance

Assess
Risk Assessment
Environmental
Improve small system surveillance Management Exposure of risk

Improve Legionella surveillance PUBLIC

HEALTH
STATUS

From: Fewtrell & Bartram, 2001. in Water Quality Guidelines, Standards and Health (WHO). IWA publishing.

Determine bathing water associated burden of disease

• European assessment based on available data
• Validate with epi-study and QMRA

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