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Cite This: Environ. Sci. Technol. 2018, 52, 1681−1689 pubs.acs.org/est

Drinking Water Disinfection Byproducts (DBPs) and Human Health

Effects: Multidisciplinary Challenges and Opportunities
Xing-Fang Li*,† and William A. Mitch*,‡
†
Division of Analytical and Environmental Toxicology, Department of Laboratory Medicine and Pathology, Faculty of Medicine and
Dentistry, University of Alberta, Edmonton, AB T6G 2G3 Canada
‡
Department of Civil and Environmental Engineering, Stanford University, 473 Via Ortega, Stanford, California 94305, United States

ABSTRACT: While drinking water disinfection has effectively

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prevented waterborne diseases, an unintended consequence is

the generation of disinfection byproducts (DBPs). Epidemio-
logical studies have consistently observed an association
between consumption of chlorinated drinking water with an
Downloaded via 125.165.109.170 on September 1, 2023 at 11:19:31 (UTC).

increased risk of bladder cancer. Out of the >600 DBPs

identified, regulations focus on a few classes, such as
trihalomethanes (THMs), whose concentrations were hy-
pothesized to correlate with the DBPs driving the toxicity of
disinfected waters. However, the DBPs responsible for the
bladder cancer association remain unclear. Utilities are
switching away from a reliance on chlorination of pristine
drinking water supplies to the application of new disinfectant
combinations to waters impaired by wastewater effluents and
algal blooms. In light of these changes in disinfection practice, this article discusses new approaches being taken by analytical
chemists, engineers, toxicologists and epidemiologists to characterize the DBP classes driving disinfected water toxicity, and
suggests that DBP exposure should be measured using other DBP classes in addition to THMs.

■ DISINFECTION VS DISINFECTION BYPRODUCTS

(DBPS): A COMPLEX BALANCING ACT
Diarrheal diseases associated with poor water sanitation remain
a leading cause of death in the developing world, particularly
among children.1 Starting just after 1900, chlorine disinfection
of municipal drinking waters largely vanquished the outbreaks
of cholera, typhoid, and other waterborne diseases in the
developed world by the 1940s.2 Importantly, these gains from
chlorine disinfection predated the development of vaccines and
antibiotics. Chlorination of drinking water represents one of the
greatest achievements in public health.
In 1974, analytical chemists discovered that trihalomethanes
(THM4; chloroform, bromodichloromethane, dibromochloro-
methane, and bromoform) forming as byproducts of chlorine
reactions with natural organic matter (NOM) reached
concentrations up to ∼160 μg/L in finished drinking waters.3,4
Since then, epidemiological studies have suggested associations
between consumption of chlorinated tap water featuring
THM4 levels for individuals featuring particular genetic
polymorphisms (discussed below). With estimates of about
60 000 new cases per year, bladder cancer is the fourth most
common cancer among U.S. males (lifetime odds are ∼4%).9
These results spurred the optimization of disinfection
strategies to balance the acute risk posed by pathogens against
the chronic risk posed by lifetime exposure to potentially
carcinogenic DBPs. The implementation of regulatory limits on
DBPs has helped to curb the highest DBP exposures. The 1979
Total Trihalomethane Rule limiting THM4 in U.S. drinking
waters to <100 μg/L10 helped reduce the fraction of U.S.
utilities with THM4 > 100 μg/L from ∼30% to ∼3% by 1988.11
Given that pathogen inactivation is the primary goal of water
treatment and that DBPs represent a widespread environmental
exposure route to carcinogens, striking this balance is a difficult,
but important challenge. This feature article discusses factors
that have historically hindered progress in DBP research and
showcases the new approaches enabling researchers to
surmount these impediments.

■
elevated THM4 concentrations and adverse health outcomes,
including bladder cancer,5 children born small for gestational HISTORICAL CHALLENGES: THE CONUNDRUM OF
age,6,7 and miscarriages.8 The most consistent association has NOM
been for bladder cancer. For example, a meta-analysis for
European males indicated that bladder cancer was 47% more Unlike most other drinking water contaminants, DBPs form
prevalent among those consuming water with THM4 > from disinfectant application within the plant, as a result of the
50 μg/L compared to those consuming water with THM4 < final drinking water treatment process (disinfection) and
5 μg/L; additional research has demonstrated an even higher
risk associated with consumption of water featuring high Published: December 28, 2017

© 2017 American Chemical Society 1681 DOI: 10.1021/acs.est.7b05440

Environ. Sci. Technol. 2018, 52, 1681−1689
Environmental Science & Technology
continue to form throughout the distribution system, such that
control strategies necessarily focus on minimizing their
formation. Considered to be the primary organic precursors
for DBPs, humic substances in NOM are derived from natural
biopolymers, including humic and fulvic acids, but their
extensive degradation fosters a diversity of structures that
prevents clear characterization. Their poor structural character-
ization has driven two of the historical challenges in DBP
research. First, without the ability to predict DBPs likely to
form at high yield by applying chlorine reaction pathways to
well-characterized precursor structures, DBP identification has
been largely the domain of analytical chemists. Over 600 DBPs
have been characterized,12 most being low molecular weight
semivolatile or volatile compounds, due to the availability of gas
chromatography-based instrumentation. Yet the subset that has
been quantified constitutes only ∼30% of the total organic
halogen (TOX) in chlorinated waters on a median basis, with
THM4 and haloacetic acids (HAAs) each accounting for ∼10%
of TOX.13 Given the diversity of precursors, the total number
of DBPs likely will far exceed 1,000 in chlorinated drinking
waters, highlighting the challenge of closing the TOX mass
balance.
Second, this diversity of DBPs has hindered the identification
of those that drive the correlation between consumption of
chlorinated drinking waters and bladder cancer (hereafter
referred to as “toxicity drivers”). Regulatory agencies have
focused on a limited array of DBPs. In the U.S., regulatory
limits have been established for 11 DBPs: THM4, 5 haloacetic
acids (HAA5; chloroacetic acid, bromoacetic acid, dichloro-
acetic acid, dibromoacetic acid, trichloroacetic acid), bromate
and chlorite.14 With minor differences, the DBPs targeted for
regulation are similar in other countries.12 Importantly, THM4
and HAA5 were not targeted for regulation because they were
known to be the sole toxicity drivers, but because they served as
indicators of exposure to the complex mixture of DBPs in
chlorinated drinking waters.15 While the assumption that
THM4 and HAA5 should correlate with the toxicity drivers
in chlorinated waters appears reasonable, the regulatory focus
on THM4 and HAA5 has driven a corresponding focus among
DBP researchers, which may be risky. Are research and
regulatory efforts targeting the right compounds? For example,
epidemiological studies continue to rely on THM4 to measure
exposure, yet the associations with bladder cancer frequently
hover near the boundaries of statistical significance.5 Might
imperfect correlations between THM4 and the toxicity drivers
cloud the resolving power of epidemiological studies? Using the
primary toxicity drivers to monitor exposure should increase
the significance of the bladder cancer risk attributable to DBPs,
particularly when coupled with considerations of genotypes
conducive to DBP-associated toxicity (discussed below).
Similarly, considerable efforts by environmental chemists have
focused on limiting THM4 and HAA5 formation. Due to
inadequate precursor characterization, these efforts have
historically relied on empirical models correlating THM4 or
HAA5 formation with bulk precursor properties (e.g., specific
UV absorbance at 254 nm or the tendency to sorb to XAD
resins),16,17 and the development of treatment technologies to
remove these precursors. If the precursors for toxicity drivers
differ from those of THM4 and HAA5, are these efforts
misplaced?
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■ CHANGING DISINFECTION PRACTICES RAISE
DIFFICULT QUESTIONS
Two changes in drinking water practice have key implications
for DBP research. To meet the demands of growing
populations, utilities are increasingly exploring a variety of
impaired water supplies featuring precursor pools fundamen-
tally different from the NOM that has been the focus of prior
research. These different precursor pools should alter the array
of DBPs formed. Compared to NOM, water supplies impacted
by upstream wastewater discharges or algal blooms tend to
feature organic matter with lower aromaticity, which should
reduce THMs. However, they also exhibit higher organic
nitrogen,18 which should promote the formation of nitrogen-
based DBPs (N-DBPs).19 Among N-DBPs, nitrosamines (e.g.,
N-nitrosodimethylamine (NDMA)) have received significant
attention because low ng/L levels in drinking water are
associated with 10−6 lifetime excess cancer risks.20 Recognizing
the fundamental differences with NOM, researchers have
labeled these precursor pools effluent organic matter (EfOM)
and algal organic matter (AOM). Highlighting implications for
DBP formation, precursors for total nitrosamines are associated
more with EfOM and AOM than NOM,21 while NDMA is
strongly linked to EfOM.22 Indeed, NDMA is a key focus for
the potable reuse of wastewater, the ultimate example of an
EfOM-impacted water supply. Utilities are also exploiting
higher salinity source waters, including freshwaters impacted by
sea-level rise, or brackish groundwater and seawater reclaimed
by desalination. The higher concentrations of bromide and
iodide in these waters may change the speciation of DBPs
toward their brominated and iodinated analogues.23,24
Concurrently, utilities are switching away from a sole reliance
on chlorine disinfection to combinations of primary dis-
infectants (ozone, UV, or chlorine) with chloramines as
secondary disinfectants,25,26 changes driven at least in part by
more stringent limits on regulated DBPs. In the U.S., the Stage
1 and 2 Disinfectants and Disinfection Byproducts Rules
reduced the regulatory limits on THM4 to 80 μg/L and
regulated HAA5 at 60 μg/L for the first time.15 Because THM4
and HAA5 form predominantly from reactions of chlorine with
humic substances, these new disinfectant combinations limit
THM4 and HAA5 formation. However, each disinfectant
promotes different DBP classes. For example, chloramination
promotes nitrosamines27,28 and iodinated DBPs,29 while ozone
promotes bromate, haloacetaldehydes,30 and halonitrome-
thanes.31
These effects on DBP formation can be synergistic. For
example, chloramination drives NDMA formation in waste-
water-impacted drinking waters, particularly during potable
reuse,32 and promotes the production of iodinated DBPs in
higher salinity waters. Together, these alterations in disinfection
practice suggest that the assumed correlation between THM4
and the toxicity drivers in disinfected waters may no longer
hold. Could alterations in disinfection practice intended to
reduce THM4 ultimately increase the toxicity of disinfected
water? For example, one laboratory study indicated that the
cytotoxicity of a drinking water with elevated bromide and
iodide was higher when chloraminated than when chlori-
nated.33
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Environmental Science & Technology Feature

Figure 1. Conventional mass basis vs emerging toxicity-weighted basis for evaluating the DBP-associated safety of a disinfected water. In the
conventional view, Water 1 is considered less safe than Water 2, because the THM4 concentration exceeds the MCL, and because it features higher
cumulative DBP concentrations on a mass basis. LC50, the concentration of a DBP that kills 50% of the exposed cells or animals, is a metric
commonly used to assess toxicity potency. On a toxicity-weighted basis, Water 1 is considered safer, because it features lower concentrations of the
toxicity drivers.

■ DISINFECTION OPTIMIZATION AND TOXICITY

DRIVERS
contribution of a DBP to toxicity is really a function of both
their concentrations and toxic potency. To prioritize DBP
classes, DBP researchers are beginning to compare measured
An initial response to this challenge is to target a more complex
DBP concentrations weighted by metrics of toxic potency (e.g.,
optimization of the disinfectant combinations to simultaneously
CHO cytotoxicity). By these calculations, a water featuring
control pathogens, the traditional regulated DBPs, and the
higher concentrations of some of the more toxic unregulated
emerging DBPs of interest (e.g., N-DBPs and iodinated DBPs).
DBPs but lower concentrations of regulated DBPs may be
For example, combining ozone for primary disinfection with
considered to represent a higher risk, provided the sum of the
chloramines to maintain a residual in the distribution system
toxicity-weighted concentrations of DBPs in the complex
can effectively inactivate pathogens and reduce formation of
mixture is greater (Figure 1). When applied to conventional
regulated THM4 and HAA5. Ozone can also deactivate NDMA
European drinking waters,37 chlorinated or chloraminated high
precursors, reducing NDMA formation during subsequent
salinity groundwaters,38 or chloraminated potable reuse
chloramination. However, the ozone exposure must be
effluents,39 these calculations indicate that unregulated
optimized because the benefits of increasing ozone exposure
halogenated DBP classes, particularly haloacetonitriles, may
in terms of reducing pathogens and NDMA come at the
be greater contributors to the DBP-associated toxicity of
expense of enhanced production of bromate, halonitro-
disinfected waters than the THM4, HAA5, and nitrosamines of
methanes, and haloacetaldehydes when followed by chlorina-
current regulatory interest.
tion or chloramination.19
These calculations suggest the need to refocus DBP research,
This optimization necessitates that we prioritize which DBPs
yet they still consider predominantly the low molecular weight,
to control, and re-emphasizes the need to identify toxicity
(semi)volatile DBP classes that constitute only ∼30% of TOX.
drivers. The DBP field has been blessed with strong
Identifying the toxicity drivers requires advances in analytical
collaborations between chemists and toxicologists. For example,
chemistry and toxicology. Frontiers in these areas are discussed
over 100 DBPs have been subjected to quantitative cytotoxicity
below.

and genotoxicity assays on a Chinese hamster ovary (CHO)
cell platform.34 These results have indicated that unregulated
DBP classes, particularly N-DBPs and their brominated
analogues, are orders of magnitude more cytotoxic and
genotoxic than the regulated THM4 and HAA5; iodinated
analogues are even more cytotoxic and genotoxic. However,
until recently the focus has remained on meeting specific
regulatory targets. For example, there is a 10 ng/L Notification
Level for NDMA in California,35 and the U.S. EPA has been
considering whether to promulgate nationwide regulatory limits
on nitrosamines.36 The challenge for utilities practicing
chlorination as primary disinfection with chloramination as
secondary disinfection is to optimize these disinfection
processes to simultaneously meet limits on THM4, HAA5,
and NDMA. Are these the proper DBP targets to minimize
exposure to toxicity drivers?
While DBP chemists frequently cite high toxic potency as a
rationale for focusing on emerging DBP classes, the
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■
ADVANCES IN ANALYTICAL CHEMISTRY PAINT A
DYNAMIC PICTURE OF DBP EVOLUTION
Due to its widespread availability, GC/MS dominated DBP
characterization during the first two decades following their
discovery. Most of the DBP classes that have been identified to
date remain low molecular weight, (semi)volatile compounds
amenable to GC/MS or compounds rendered suitable for GC/
MS analysis by derivatization (e.g., HAAs).40,41 While the
increase in concentrations of these DBP classes with chlorine
contact time has been recognized, their relative contribution to
TOX has generally been considered static, such that THM4
concentrations should correlate with the production of other
halogenated DBPs. The application of high performance liquid
chromatography (HPLC) and high-resolution mass spectrom-
etry technologies is revealing the important contribution of
polar DBPs to the uncharacterized TOX, and is suggesting a
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Environmental Science & Technology
dynamic transformation of the TOX pool over time scales
relevant to drinking water distribution. Fourier transform ion
cyclotron resonance mass spectrometry (FT-ICR-MS) is a
high-resolution MS technique (resolution ∼1 million with <0.2
ppm error) capable of identifying unique elemental formulas.
Its application has demonstrated that chlorination of NOM
targets polyphenolic structures, generating products in the
range of 200−600 Da containing 1−3 halogens with relatively
high oxygen-to-carbon ratios and high double bond equiv-
alents.42,43 The lack of detection of higher molecular weight
DBPs concurs with suggestions that NOM consists of
aggregates of individual molecules containing only a few
phenolic rings. The DBP elemental formulas occurred in series
separated by mass units corresponding to CH2 groups, and
many were common across different waters.
The application of LC-MS has demonstrated the release of
hydroxybenzaldehydes, hydroxybenzoic acids, and phenols
within 1 h of NOM chlorination.44,45 Using the precursor ion
scan (PIS) option for LC-MS to target molecules containing
specific halogens revealed that chlorination of these aromatic
precursors and degradation of the high molecular weight DBPs
produces an array of halophenols, halobenzaldehydes, and
halobenzoic acids.44−47 Subsequent reactions yield halobenzo-
quinones and finally the low molecular weight (semi)volatile
aliphatic DBPs traditionally measured.46−49 The rapidity of
these reactions depends on the precursors. However, while
these transformations continue over a week, a significant
portion occurs within a day. Although additional research is
needed, these initial results suggest that the contribution of
DBP classes to TOX is not static (Figure 2). DBPs convert
from high molecular weight polar DBPs to low molecular
weight aliphatic DBPs over time scales relevant to distribution
systems.
Figure 2. Evolving understanding of the constitution of TOX.
Previously, the TOX concentration was considered to increase with
disinfectant contact time in the distribution system, but the percentage
contribution of DBP classes, including THM4, to the total was
considered static. The emerging dynamic vision considers an evolution
of DBP speciation from high molecular weight DBPs through polar
DBPs to low molecular weight (semi)volatile DBPs as end products.
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Feature
■ CLOSING THE TOX MASS BALANCE BY
PREDICTING DBPS
The transformation of lignins in leaves and other allochthonous
sources to humic substances by microorganisms, photochemical
reactions, and other processes in watersheds can occur over
time scales of months. Because less extensive degradation of
AOM and EfOM is expected (e.g., time scales of hours in
activated sludge plants), it may be possible to predict DBPs
forming at high yield by applying known disinfectant reaction
chemistry to well-characterized precursor structures. Research
has validated this approach with respect to anthropogenic
contaminants in EfOM. While the ultimate precursors for
NDMA remain unclear, application of chloramine reaction
chemistry to pharmaceutical structures containing dimethyl-
amine functional groups has demonstrated that the antacid
ranitidine50 and the opioid methadone51 form NDMA at high
yield. The occurrence of N-nitrosodiethanolamine was
predicted based on the widespread use of triethanolamine in
personal care products.52 These and similar studies focused on
sources of the low molecular weight DBPs of current interest
that may represent the final products in a longer series of
precursor transformations by disinfectants. Other research is
characterizing some intermediates, which could constitute some
of the polar constituents of the unidentified TOX. During
chlorination of the antibacterial triclosan, the initial DBPs
formed by chlorine addition to aromatic rings were converted
to chlorophenols and eventually to chloroform.53
However, because pharmaceuticals and personal care
products typically are microconstituents in water supplies
(generally <1 μg/L), even their conversion to DBPs at high
yield is unlikely to make significant inroads into the
uncharacterized TOX. The biomolecules likely to constitute
the bulk of AOM and EfOM (protein, lipids, carbohydrates,
and nucleic acids) consist of a limited array of well-
characterized monomers. For example, there are 20 common
amino acids, but research has demonstrated that they occur 10-
fold more frequently within polypeptides than as free amino
acids in water supplies.54 While the possible arrangements of
amino acids within polypeptides in water supplies is daunting,
the transformation products of amino acid side chains could be
predicted using known disinfectant reaction chemistry. This
process has been applied to demonstrate the conversion of
methionine to methionine sulfoxide, tyrosine to 3-chlorotyr-
osine and 3,5-dichlorotyrosine, and lysine to lysine nitrile
during chlorination of model proteins and MS2 bacterio-
phage.55,56 A protocol that liberates amino acids from proteins
was used to demonstrate the occurrence of lysine nitrile in
chlorinated drinking water.57 Advanced analytical techniques
also have demonstrated the formation of halotyrosylpeptides
during chlorination of small peptides.58,59 The results support
the prediction of potential products formed from chlorinated
peptides. The prediction of DBPs could be expanded to other
biomolecules. For example, one would expect halohydrins to
form during chlorination of unsaturated fatty acid precursors in
source waters.60
■ FRONTIERS IN DBP TOXICOLOGY
Toxicological evidence is critical for regulatory decisions on
DBPs.61 Animal studies have long been the gold standard in
DBP toxicology, but only 24 DBPs have been evaluated for
carcinogenicity by in vivo assays, with 22 testing positive.62 In
vivo assays are expensive and time-consuming, such that relying
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solely on in vivo assays is unlikely to make significant inroads
into the assessment of >600 DBPs. A scheme for prioritizing
DBPs for in vivo testing is needed.
As indicated previously, the application of quantitative in
vitro cytotoxicity and genotoxicity assays based on Chinese
hamster ovary (CHO) cells has generated a database of >100
DBPs enabling ranking of their toxicity.34 The database has
demonstrated that unregulated halogenated DBPs, including
haloacetaldehydes and nitrogen-based haloacetonitriles, haloa-
cetamides and halonitromethanes, are orders of magnitude
more cytotoxic and genotoxic than the carbon-based regulated
THM4 and HAA5. When used to weight measured DBP
concentrations, these assays can suggest which DBPs are likely
to be toxicity drivers, helping to prioritize DBPs for future in
vivo assays (Figure 1). Highlighting the need for in vivo testing,
CHO cells lack certain metabolic features that may be
important for the activation of DBPs to mutagens. For
example, CHO cells do not express the enzyme glutathione
S-transferase (GST) theta-1 (GSTT1), which can activate
brominated THMs and dibromonitromethane to mutagens.63
This approach can be expanded with additional cell lines
featuring these metabolic functions or others, including human
stem cell models for developmental effects,64 cells overex-
pressed with specific membrane proteins to evaluate trans-
membrane transport,65 and nontransformed (i.e., noncancer-
ous) human uroepithelial cells related to bladder cells.66 Some
of the battery of in vitro assays for analysis of water quality
based on other organisms67 may also be useful. For example,
the marine polychaete Platynereis dumerilii, which can survive
the high salinity of water concentrates, has been applied to
demonstrate the developmental toxicity of more than 20
halogenated aromatic DBPs.68
In vitro assays can also be useful to demonstrate toxic modes
of action, including the identification of enzyme systems
associated with DBP metabolism. For example, laboratory
studies have demonstrated that three enzyme systems, GSTT1,
GST zeta-1 (GSTZ1), and cytochrome P450 2E1 (CYP2E1),
can activate brominated THMs to mutagens (GSTT1), or
inactivate HAAs and certain other halogenated DBPs (GSTZ1
and CYP2E1).63 DBP research should take advantage of the
21st Century ToxCast69,70 Program, a unique program initiated
by multiple U.S. federal agencies, including the National
Institutes of Health, the U.S. Environmental Protection Agency,
and the Food and Drug Administration, that has advanced high
throughput in vitro toxicology assays to characterize modes of
action. With CRISPR-Cas9 gene-editing technology,71,72
engineered cell models may become available to facilitate
screening for specific mechanisms of action. Understanding the
mechanisms of action can help prioritize DBPs likely to be
associated with specific end points (e.g., bladder cancer) for
confirmation using in vivo assays. Additionally, characterizing
mechanisms of action can lead to the development of
biomarkers of DBP exposure for use in epidemiology studies.
Although DBPs occur within complex mixtures, how
individual DBPs interact with respect to the toxicity of the
mixture has received little attention. The toxicities of DBPs
determined in single compound assays generally are assumed to
be additive when measured DBP concentrations are weighted
by metrics of toxicity to prioritize DBPs.38,39 Because previous
research using in vivo assays has demonstrated that the
assumption of additivity is not always valid for DBP
mixtures,61,73 research is needed to understand when DBPs
in mixtures exhibit synergistic or antagonistic interactions.
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Feature
Indeed, researchers have applied bioassays to bulk waters to
optimize disinfection schemes without identification of specific
toxicity drivers,33 but methodological improvements are
needed. Toxicological assays generally require concentration
of water samples (i.e., >1000-fold) to observe significant effects,
yet it is precisely the low molecular weight (semi)volatile DBPs
of current focus that are partially lost during the extraction and
concentration procedures employed to prepare samples for
these bioassays. Current methods to surmount this challenge
include spiking back specific volatile DBPs lost during
concentration into the extracts, but this assumes that all
volatile DBPs have been characterized.61 Alternatively, raw
water samples could be concentrated and then disinfected, but
retaining a wide range of organic precursors without
concentrating inorganic components (which could exert
toxicity via high salinity, for example) has proven challeng-
ing.74,75 Given the focus on volatile DBPs to date, capturing
and concentrating volatile DBPs is a key challenge that must be
overcome to measure the DBP-associated toxicity of disinfected
bulk waters.
■ CHALLENGES FOR EPIDEMIOLOGY
While meta-analyses of epidemiological studies have indicated a
significant association between consumption of drinking waters
with high levels of THM4 and bladder cancer incidence, the
95% confidence intervals on their odds ratios hover near the
border of statistical significance (e.g., an odds ratio of 1.47 with
a 95% confidence interval of 1.05−2.05).5 Many of the
individual studies constituting these meta-analyses do not
indicate a significant association.5 Exposure assessment is a
primary challenge limiting the resolution of epidemiological
studies. Particularly for the bladder cancer end point, the cancer
would result from the accumulated lifetime exposure to DBPs.
Most epidemiological studies have relied on THM4 measure-
ments to quantify exposure because of the widespread
availability of THM4 data resulting from their early discovery
and their collection as part of regulatory compliance. However,
THM4 concentrations can vary seasonally and even diurnally.
Furthermore, THM4 measurements are typically infrequent
(e.g., quarterly for compliance in the U.S.). Unlike many other
contaminants, DBP concentrations also exhibit significant
spatial variability since they continue to form within the
distribution system.49,76 For example, nitrosamine concen-
trations increase with distance from the plant, while HBQ-
DBPs are transformed to hydroxy-HBQs throughout the
distribution systems.49,76 Even within neighborhoods, DBP
concentrations can vary significantly in ways that are difficult to
predict due to inadequate modeling of water age within
distribution systems.
It is important to reiterate that THM4 concentrations have
been targeted to measure exposure to DBPs not because they
have been demonstrated to be the primary drivers of cancer
risk, but because THMs are carcinogens and their concen-
trations were assumed to correlate with those of other
DBPs.10,14,15 This assumption is questionable for two reasons.
First, the emerging concept of the dynamic transformation of
NOM over time scales relevant to drinking water distribution
would suggest that the percentage contribution of THM4 to
TOX is not static (Figure 2). Consumers close to the drinking
water facility may consume a different array of DBPs (e.g., more
higher molecular weight polar DBPs) than those at the ends of
the distribution system (e.g., a higher percentage contribution
to TOX by low molecular weight (semi)volatile DBPs like
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THM4). Second, the shift in disinfection practices from
chlorination to combinations of alternative primary disinfec-
tants and chloramination for secondary disinfection can reduce
THM4 while promoting nitrosamines, iodinated DBPs and
other DBP classes.
Using the primary toxicity drivers to measure exposure would
presumably enhance the resolution of epidemiological studies,
highlighting the value of the close collaboration between
chemists and toxicologists needed to identify these forcing
agents. Initial efforts weighting measured DBP concentrations
by metrics of toxic potency obtained from in vitro assays have
underscored the potential importance of certain unregulated,
low molecular weight DBPs (e.g., haloacetonitriles).38,39
However, research is needed regarding the bioavailability of
these compounds. Researchers have evaluated the pharmaco-
kinetics of THMs77 and demonstrated that exposure via
inhalation and dermal contact may be more important than
via ingestion.78 Are the unregulated halogenated DBPs
sufficiently volatile such that skin absorption or inhalation
during showering is important? Research is needed regarding
the pharmacokinetics of these other DBP classes. THMs are
rapidly excreted by exhalation, but is the same true of
haloacetonitriles? If haloacetonitriles are not readily excreted,
is this because of efficient detoxification? Understanding of
adsorption (bioavailability), distribution, metabolism, and
excretion of different classes of DBPs requires further research
using advanced approaches.
Even if the toxicity drivers are identified, their incorporation
into retrospective cancer epidemiology studies would be
challenging due to the lack of concentration measurements
over the previous decades and the spatiotemporal variations in
concentrations alluded to previously. However, initiating
relevant data collection of toxicologically important DBPs
would contribute to epidemiological studies focusing on
shorter-term end points, such as developmental toxicity, and
would lay the groundwork for future cancer epidemiology
studies. Another key factor is analytical cost, particularly given
the number of measurements that might be needed to address
spatiotemporal variability in concentrations. It is noteworthy
that some of the putative toxicity drivers (e.g., haloacetonitriles)
can be measured using essentially the same analytical methods
employed for THM4. Commercially available THM4 analyzers
capable of providing results with roughly half-hour frequencies
could be modified to include such potential toxicity drivers.
Incorporating consideration of genotypes exhibiting a higher
susceptibility to DBP-associated toxicity would also increase the
statistical significance of the association of bladder cancer with
DBP exposure. For example, an epidemiological study by
Cantor et al.63 found an adjusted odds ratio of 1.8 (0.9−3.5
95% confidence interval) for bladder cancer for waters with >49
μg/L THM4 relative to waters with ≤8 μg/L. However, the
adjusted odds ratio for these two THM4 concentration
categories increased to 5.9 (1.8−19.0) when only the
subpopulation featuring the GSTT1 and GSTZ1 CT/TT
enzyme systems were considered. Laboratory research had
demonstrated that these enzyme systems are involved in the
transformation of brominated THMs, HAAs, dibromonitro-
methane, and potentially other halogenated DBPs, in some
cases (e.g., GSTT1 activation of brominated THMs and
dibromonitromethane) forming mutagens.63 The laboratory
studies suggest one plausible mechanism by which DBPs, such
as brominated THMs, could cause cancer. While the correlation
between THM4 concentrations and these genotypes may
1686
Feature
suggest that brominated THMs are drivers of the cancer risk,
the data are insufficient to draw a conclusion regarding the
importance of THMs for the cancer risk. Research is needed to
determine whether these genotypes are involved with the
activation of other DBPs, particularly those that correlate with
THM4 concentrations in the predominantly chlorinated waters
evaluated in that epidemiological study. Determining the DBP
classes serving as the drivers of the cancer risk will become
increasingly important as changes in disinfection practice alter
the relative proportion of the DBP classes in disinfected
drinking waters.
Another approach is to identify chemicals excreted in urine
or exhaled breath that correlate with DBP exposure. For
example, the exhaled concentrations of brominated THMs in
swimmers were linked to DBP concentrations in a swimming
pool,79 whereas excretion of trichloroacetic acid and TOX have
been measured in urine.80,81 Could byproducts or DBP-
biomolecule adducts be identified that are indicative of in vivo
exposure to toxicity drivers and that are linked to modes of
action associated with cancer development? The formation of
DNA adducts following GSTT1 activation of brominated
THMs82 could be expanded to other DBP classes. Could such
byproducts or adducts be used as biomarkers to measure
exposure in shorter-term epidemiological studies relevant to
bladder cancer? In light of the trend toward combinations of
disinfectants, toxicity-relevant biomarkers reflecting recent
exposure to DBPs could foreshadow the results of future
epidemiological studies evaluating these changes in disinfectant
practice.
■ TRANSLATING RESEARCH INTO PRACTICE
Utilities have attempted to optimize the combination of
disinfectants to simultaneously meet pathogen reduction goals
and regulatory limits on DBPs. The identification of toxicity
drivers will demand close collaboration between chemists,
toxicologists, and epidemiologists, but is critical to ensure that
efforts toward disinfection optimization do not inadvertently
increase exposure to toxicity drivers. Given the clear trade-offs
between pathogen inactivation and DBP formation, it is
imperative to better coordinate research efforts into both
aspects, a harmony which is unfortunately infrequent. This is
particularly important in light of the changes occurring in
disinfection practice. For example, recent research has indicated
that use of chloramines as a secondary disinfectant may aid
inactivation of Legionella pneumophila in premise plumbing, yet
promote the growth of Mycobacterium avium.83 How should the
benefits of chloramination associated with DBP reduction be
weighed against the potential promotion of certain opportun-
istic pathogens?
An intriguing opportunity for collaboration between these
disciplines is to better characterize pathogen inactivation. While
pathogen inactivation kinetics have been determined, the
detailed mechanisms by which chemical disinfectants inactivate
pathogens remain poorly understood. Inactivation fundamen-
tally involves the chemical transformation of important
biomolecules by the disinfectant. These reactions are essentially
the same as those involved with DBP production. The skills
developed by DBP researchers to characterize such chemical
transformations could aid in the understanding of the
mechanisms of pathogen inactivation. For example, research
on bacteriophage inactivation has defined the extent to which
different disinfectants react with the protein capsid, which
would inhibit binding of the phage to the host, or the genomic
DOI: 10.1021/acs.est.7b05440
Environ. Sci. Technol. 2018, 52, 1681−1689
Environmental Science & Technology
material, hindering replication.84 Additional research has
characterized the modifications to amino acid side chains
within the protein capsid of MS2 bacteriophage caused by
application of chlorine, bromine, or ozone.54 Understanding
how these side chain modifications alter capsid protein
structure and thereby hinder binding to host cells might reveal
how altered amino acid sequences in viral capsid proteins
resulting from mutations could promote resistance to
inactivation by disinfectants.
Lastly, optimization of disinfectant combinations has been
favored as a low-cost option to balance the acute risk posed by
pathogens against the chronic risk associated with DBPs. Yet
this balance is extremely complex. A higher cost alternative is to
pursue physical treatment processes (e.g., activated carbon,
nanofiltration) to remove organic precursors prior to
disinfectant application. In addition to removing the organic
precursors, such techniques could reduce the applied
disinfectant dose by reducing the oxidant demand. In its
ultimate manifestation, precursor removal could achieve a
biostable water, obviating the need to maintain significant
disinfectant residuals in distribution systems to prevent the
growth of opportunistic pathogens. This practice is applied to
various degrees in certain northern European countries. The
Netherlands is an extreme case, with no disinfectants applied
for the distribution system.85 In addition to the physical
treatment processes, this practice also requires significant
capital costs associated with maintenance of the distribution
system. Given the widespread nature of disinfected drinking
water as an exposure route to carcinogens, such outlays may be
justified. However, the collaborations between chemists,
toxicologists, and epidemiologists discussed herein will be
crucial for defining the toxicity drivers and developing the
epidemiological data required for the cost-benefit analyses
needed to justify such expenses.
■
AUTHOR INFORMATION
Corresponding Authors
*(X.-F.L.) E-mail: xingfang.li@ualberta.ca.
*(W.A.M.) Phone: 650-725-9298; fax: 650-723-7058; e-mail:
wamitch@stanford.edu.
ORCID
Xing-Fang Li: 0000-0003-1844-7700
William A. Mitch: 0000-0002-4917-0938
Notes
The authors declare no competing financial interest.
■
ACKNOWLEDGMENTS
We thank Ms. Lindsay Jmaiff Blackstock and Dr. Ping Jiang for
their assistance in the preparation of the manuscript.
■
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DOI: 10.1021/acs.est.7b05440
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