WATER & HEALTH

Learning Objective
 To discuss the importance of clean water as a
determinant of health
 To discuss the nature & extents of waterborne
diseases
 To list major sources of water contamination
 To discuss how drinking-water criteria are
developed
 To outline various approaches to prevention of
water-related environmental health problems
 References
 Yassi A, Kjellström T, de Kok T, Guidotti TL. Basic
Environmental Health. Chapter 6: Water and
Sanitation. New York: Oxford University Press,
2001.
 Conway JB. Chapter 37: Water Quality
Management. In: Wallace RB et al., eds. Maxcy-
Rosenau-Last: Public Health and Preventive
Medicine,
Medicine 14th edition. London: Prentice-Hall
International, 1998.
Case study

Source: ADB (2002). Beyond Boundaries Extending Services to the Urban Poor
Uses of water
 Drinking & culinary purposes
 Personal cleanliness, incl. bathing & laundering
 Household cleanliness
 Heating & air conditioning
 Urban irrigation
 Street cleaning
 Recreational purposes
 Amenity purposes, e.g. public fountains & ornamental ponds
 Power production
 Commercial & industrial purposes
 Fire protection
 Agricultural purposes
 Carrying away wastes from all manner of establishments
Some Facts
 80% of all diseases & >1/3 of deaths in developing
count’s (UN, 1993)
 consumption of contaminated water
 1/10 of every person’s productive time is sacrificed
to water-related diseases (UN, 1993)
 1.4 billion people still do not have access to safe
drinking water & 2.9 billion do not have access to
adequate sanitation (UN, 1997)
 2.5 million childhood deaths each year from
diarrhea (WRI, 1998)
 Inadequate access to water & sanitation
 Cholera outbreaks in Indonesia
2000 - 2002
94 Year 2000
100

109 Year 2001

Year 2002

5571

4328 2.50% 2.26%

1.92%
5695 2.00%
1.62%
1.50%
No. of cases No. of deaths
1.00%

0.50%

0.00%
2000 2001 2002

Source: Depkes RI (2003) CFR

 Water-associated
Diseases
Waterborne diseases
arise from the contamination of water by human or animal feces or
urine infected by pathogenic viruses or bacteria, which are
directly transmitted when the water is drunk or used in food
preparation
e.g.: cholera, typhoid & cryptosporidiosis
 Water-privation diseases
affected more by the quantity (e.g. infrequent washing & inadequate
personal hygiene) rather than quality
spread through direct contact w/ infected people or materials
contaminated w/ the infectious agent
 Water-associated
Diseases (cont’d)
Water-based diseases
water provides the habitat for intermediate host organisms in
which some parasites pass part of their life cycle  later the
cause of disease
e.g. schistosomiasis
Water-related diseases
water may provide a habitat for insect vectors
mosquitoes breed in water & the adult mosquitoes may transmit
parasite diseases, e.g. malaria, dengue, yellow fever &
Japanese encephalitis
 Water-associated
Diseases (cont’d)
Water-dispersed infections
infections whose pathogens can proliferate in freshwater
& enter the body through the respiratory tract
e.g. freshwater amoebae, Legionella
 Parameter
 Physical

 Bacteriological

 Chemical

 Radioactivity
 Physical aspects of water
quality
Color
Usually due to the presence of colored organic matter associated w/ the soil
humus fraction
Influenced by the presence of iron & other metals
Can also be resulted from the contamination of the source w/ industrial
effluents

Taste & odor

Originate from: natural & biological sources, contamination by chemicals, or
a side effect of water disinfection
May develop during storage &/or distribution
 Physical aspects of water
quality (cont’d)
Temperature
Cool water: more palatable than warm one
High-temperature enhances the growth of
microorganisms & may increase taste, odor, color
& corrosion problems
Turbidity
Caused by particulate matter that may be present as
a consequence of inadequate treatment or the
presence of inorganic particulate matter
High turbidity levels can protect microorganisms from
the effects of disinfection & can stimulate
bacterial growth
Bacteriological Quality of Drinking
Water (WHO, 1993)
Organisms Guideline

ALL WATER INTENDED FOR DRINKING

E. coli or thermotolerant coliform bacteria Must not be detectable in any 100 ml sample

TREATED WATER ENTERING DISTRIBUTION

SYSTEM

E. coli or thermotolerant coliform bacteria Must not be detectable in any 100 ml sample

Total coliform bacteria Must not be detectable in any 100 ml sample

TREATED WATER IN DISTRIBUTION SYSTEM

E. coli or thermotolerant coliform bacteria Must not be detectable in any 100 ml sample
Total coliform bacteria Must not be detectable in any 100 ml sample*)

*) In the case of large supplies where sufficient samples are examined, must not present in 95% of samples
taken throughout any 12-month period
 Chemical substances dissolved
in water
 useful: essential ingredients of dietary intake
 dangerous

Categories:
- substances that exert an acute &/or chronic toxicity,
e.g. metals, nitrates, cyanides
- genotoxic substances, e.g. synthetic organics, chlorinated
microorganics, pesticides, arsenic
- essential elements, e.g. fluoride, iodine, selenium
Important chemicals in
water
Arsenic
Source of arsenic in drinking: groundwater enriched through
the weathering of arsenic-bearing minerals
First manifestation of arsenic enriched groundwater:
dermatological effects
Chronic poisoning levels: vascular disease, liver disease,
skin lesions, skin cancer & neurological disorders
Fluoride
An essential element, but also a toxic chemical
Too low levels  increases the incidence of dental caries
Too high levels  mottling of the teeth & skeletal fluorosis
 Important chemicals in
water (cont’d)
Iodine
Water is one of the main sources of dietary intake of iodine
Low concentration of groundwater iodine  iodine
deficiencies  goiter, mental retardation & cretinism

Nitrates
Sources of elevated nitrate concentrations in groundwater:
excessive & widespread use of nitrogenous fertilizers &
manure spraying
High levels of nitrates in drinking water  fatal
consequences in infants < 6 months
Combine w/ hemoglobin form methemoglobin
 Global total water & freshwater reserves

0.97%
2.53%

0.86%

30.10%

96%

World's oceans Freshwater reserves Other

0.34% 68.70%

Glaciers & permanent snow cover Rivers, lakes, swamps, & other
Groundwater Permafrost
Source: Shiklomanov (1993)
Source of water pollution

 Sewage
 Industrial effluents

 Storm & urban runoff

 Agricultural runoff

 Acidification (indirect)

 Eutrophication (indirect)
Gender & water
 The WHO Guidelines for Drinking
Water Quality (1993)
 designed to be realistic, adaptable, & advisory

Overriding priorities:
 An adequate supply of water
 An adequate supply of microbiologically safe water
 An adequate supply of microbiologically safe water
that meets the guidelines for chemical parameters
Major indicator organisms
of fecal pollution
 Escherichia coli
 Thermotolerant & other coliform

bacteria
 Fecal streptococci

 Sulfite-reducing clostridia
Water monitoring strategy:
 Identifies episodes of contamination

that might carry a significant risk

 Closely monitors a few specific

contaminants that could cause serious

trouble
 Principles applied in the
Guidelines for Drinking Water
Quality (WHO, 1993)
(1) A guideline value represents a concentration of a constituent that
does not result in any significant risk to the health of the consumer
over a lifetime of consumption (usually at least: 70 years)
(2) Water that meets the criteria defined by the Guidelines is
considered to be suitable for human consumption & for all usual
domestic purposes. Water of a higher quality may be required for
some special purposes, e.g. renal dialysis
(3) When a guideline value is exceeded, this should be a signal that
something has gone wrong in the protection system. It should
trigger certain actions: (a) to investigate the cause w/ a view to
taking remedial action, (b) to consult w/ & seek advice from the
authority responsible for public health; (c) to take steps to ensure
that the break in the system will not happen again
 Principles applied in the
Guidelines for Drinking Water
Quality (WHO, 1993)
(4) Although the guideline values describe a quality of water that
is acceptable for lifelong consumption, they should be
considered a minimum for acceptability. Guideline values
should not be regarded as a target that is sufficient & that
does not require improvement. The quality of drinking water
should under no circumstances be degraded to the
recommended level from a better level. Indeed, a continuous
effort should be made to maintain drinking-water quality at
the highest possible level
(5) Short-term deviations above the guideline values do not
necessarily mean that the water is unsuitable for
consumption. The amount by which, & the period for which,
a particular guideline value can be exceeded w/o affecting
public health depends upon the specific substance involved
& the degree of the deviation
 Principles applied in the
Guidelines for Drinking Water
Quality (WHO, 1993)
(6) It is recommended that when a guideline value is exceeded,
the surveillance agency should be consulted for advice on
suitable action. The significance of an excess level may
depend in part on the total intake of the substance from all
sources, taking into account the intake of the substance from
sources other than drinking water, the toxicity of the
substance, the likelihood & nature of any adverse effects, the
practicability of remedial measures, & similar factors
(7) In developing national drinking-water standards based on
these guideline values, it is necessary to take into account a
variety of geographical, socioeconomic, dietary, & other
conditions affecting potential exposure. This may lead to
national standards that differ from the guideline values
(8) In the case of radioactive substances, screening values for
total alpha & total beta activity are given, based on a
reference
 WATERBORNE PATHOGENS

Persistence Relative Important

Health Resistance to
Pathogen in Water Infective Animal
significance Chlorine
Supplies Dose Reservoir
BACTERIA
Campylobacter jejuni, C. coli High Moderate Low Moderate Yes

Pathogenic E. coli High Moderate Low High Yes

Salmonella typhi High Moderate Low High No

Other Salmonellae High Long Low High Yes

Shigella spp. High Short Low Moderate No

Vibrio cholerae High Short Low High No

Yersinia enterocolitica High Long Low High (?) Yes

Pseudomonas aeruginosa Moderate May multiply Moderate High (?) No

Aeromonas spp. Moderate May multiply Low High (?) No

 WATERBORNE PATHOGENS
(cont’d)

Persistence Relative Important

Health Resistance to
Pathogen in Water Infective Animal
significance Chlorine
Supplies Dose Reservoir
VIRUSES
Adenoviruses High ? Moderate Low No

Enteroviruses High Long Moderate Low No

Hepatitis A High ? Moderate Low No

Enterically transmitted
non-A, non-B hepatitis viruses,
hepatitis E High ? ? Low No
Norwalk virus High ? ? Moderate No (?)

Rotavirus High ? ? Moderate No (?)

Small round viruses Moderate ? ? Low (?) No

 WATERBORNE PATHOGENS
(cont’d)

Persistence Relative Important

Health Resistance to
Pathogen in Water Infective Animal
significance Chlorine
Supplies Dose Reservoir
PROTOZOA
Entamoeba histolytica High Moderate High Low No

Giardia lambia High Moderate High Low Yes

Cryptosporidium parvum High Long High Low Yes

HELMINTHS

Dracunculus medinensis High Moderate Moderate Low Yes

 Acceptable Daily Intake (ADI)
NOAEL or LOAEL
ADI = —————————
UF
NOAEL : no-observed-adverse-effect level
LOAEL : lowest-observed-adverse-effect level
UF : uncertainty factor

Factor Comments
10 x factor Applied to data from valid experimental studies on prolonged human intake. This protects
the sensitive members of the population
100 x factor Applied when experimental results from studies of human intake are not available, or are
inadequate but there are valid results from low-dose intake studies on one or more
species of experimental animals. This accounts for species-to-species extrapolation
1000 x factor Applied when there are no low-dose or acute human data & only scanty results on
experimental animals. This is applied to account for species to species extrapolation,
from high dose to low dose, & from short-term to long-term effects, as well as protecting
sensitive members of the population
Guideline value (GV):

ADI x bw x P
GV = ———————
C
bw : body weight (60 kg for adults, 10 kg for children, 5 kg for infants)
P : fraction of the ADI allocated to drinking water
C : daily drinking-water consumption (2 liters for adults, 1 liters for

children, 0.75 liters for infants)

ADI is an estimate of the amount of a substance in food or drinking water,
expressed on a body weight basis, that can be ingested daily over a
lifetime without appreciable health risk
The proposed ADIs are regarded as tolerable throughout life; they are not set
with such precision that they cannot be exceeded for short periods of time.
Short-term exposure to levels exceeding the ADI is not a cause for
concern, provided the individual’s intake averaged over longer periods of
time does not exceed the ADI
It is impossible to make generalizations concerning the length of time during
which intakes in excess of the ADI would be toxicologically detrimental. The
induction of detrimental effects will depend upon factors that vary from
contaminant to contaminant. The biological half-life of the contaminant , the
nature of the toxicity, & the amount by which the exposure exceeds the ADI
are all crucial
The large uncertainty factors generally involved in establishing an ADI also
serve to provide assurance that exposure exceeding the ADI for short time
periods is unlikely to result in any deleterious effects upon health.
Consideration should be given to the potentially acute toxic effects that are
not normally considered in the assessment of an ADI
The GV is generally rounded to one significant figure to reflect the uncertainty in
animal toxicity data & exposure assumptions made. More than one
significant figure is used for GVs only when extensive information on
toxicity & exposure provides greater certainty
 DRINKING-WATER
PURIFICATION
Organic matters  ammonia + CO2 nitrite  nitrate
 Natural
- slow sand filter
- sedimentation
- destruction
- reduction
 Chemical

 coagulation, filtration, disinfection

The most common treatment
methods of drinking water

(a) Pretreatment in reservoirs

(b) Coagulation, flocculation, & sedimentation
(c) Filtration
(d) Disinfection
Cleaning & disinfection
of wells
When to disinfect?
 Protected well

- pollution believed to have occurred

 Unprotected well

- disease outbreak
- pollution believed to have occurred
Cleaning & disinfection
of wells (cont’d)
Making the disinfectant
Product (% by weight Amount for 0.2%
available chlorine) solution
Calcium hypochlorite (70%) 60 grams in 20 liters of water

Bleaching powder or chlorinated lime (30%) 132 grams in 20 liters of water

Sodium hypochlorite (5%) 1 liter in 20 liters of water

Sodium hypochlorite (10%) 440 ml in 20 liters of water

Cleaning & disinfection
of wells (cont’d)
 Scrub the inside walls with chlorine
solution
 Clean any pumping system

 Add 40 liters chlorine solution to well

 Wastewater treatment
Primary treatment
Sewage is held in settling tanks & solid materials are
allowed to settle out of the water
Bacterial action digests organic materials & the sludge
that remains is dried & disposed of
Excess sludge from biological treatment plants can be
composted to produce a stable biomass that is free of
pathogens & can be applied to agricultural land as a
soil conditioner
 Wastewater treatment
Secondary treatment
Further degradation of wastewater organics is
accomplished by bacteria in an oxygen-rich
environment, created by blowing or shipping air into
the wastewater

Tertiary treatment
Involves chemical separation of phosphates & nitrates &
in some cases further action by bacteria in ponds or
through filtration
The most common tertiary treatment systems
used are based on processes as follows:

 Stabilization ponds
 Activated sludge
 Trickling filters & towers
 Aerated lagoons
 Upflow anaerobic sludge blanket reactors
Integrated safeguard measures used to
protect the health of people who may be at
risk from wastewater use systems:
 Wastewater treatment, to ensure that the wastewater applied to
crops has low levels of pathogenic organisms
 Wastewater application techniques, e.g. drip irrigation, that
avoid wastewater coming into contact with the edible parts of crops
 Crop selection, to limit the use of wastewater for irrigating the
crops that are not consumed directly (industrial & fodder crops) or that
grow well above the ground (tomatoes & chili), or crops not eaten raw
(potatoes)
 Human exposure control, by advising farm workers, crop
handlers, & consumers of potential hazards through programs of
health education, by immunizations, by providing treatment &
adequate medical facilities to treat diarrheal diseases
 The Principle of House Hold Water
Purification
A Coconut Shell Charcoal
(arang batok kelapa)
10 gr/100 L water
10 gr/100 L water
Al2(SO4)3 Palm Fiber
Ca(OH)2 1gr/100 L water (ijuk)
Kaporit

Glass
B

15 cm height
15 cm
Content with Sand

5 cm height
Content with glaver 5 cm

(Gleiver)

Clean Waters
 Guide Lines
For Well
Roof

Pail

Height of Wall

1m
From The
Surface

3m

Plastered Wall

Brick

Glaver