1. Drinking Water Contamination AOEC Teaching Module 2007

2. This educational module was produced by Michael Greenberg, MD, MPH, Arthur Frank, MD, PhD, and John Curtis, MD for The University of Texas Health Science Center at San Antonio (UTHSCSA) Environmental Medicine Education Program and South Texas Environmental Education and Research Program (STEER-San Antonio/Laredo/Harlingen,Texas) Administrative support was provided by the Association of Occupational and Environmental Clinics through funding to UTHSCSA by the Agency for Toxic Substances and Disease Registry (ATSDR), U.S. Department of Health and Human Services. Use of this program must include acknowledgement of the authors, UTHSCSA and the funding support. For information about other educational modules contact the UTHSCSA STEER office, Mail Code 7796, 7703 Floyd Curl Drive, San Antonio, Texas 78229-3900,(210)567-7407.

3. 2 Introductory case studies Examples of specific toxicants –Farm chemicals –Perchlorate –Heavy Metals –Biologicals Clinical problem solving Outline

4. Objectives After completion of this module, the student will be able to: –Describe the importance of the water supply as it relates to epidemic illness –Identify issues related to water purity as related to the use of industrial and agricultural chemicals –Demonstrate ability to evaluate illness due to biological contamination of water

5. Case Study #1 Introduction to the Problem From March 23rd to April 5th, 1993 two water treatment facilities in Milwaukee reported record setting turbulence in intake water April 5 th the Department of Health reported an outbreak of gastrointestinal illness

6. Southern Water Treatment Plant

7. Mac Kenzie W et al. N Engl J Med 1994;331:161-167 Maximal Turbidity of Treated Water in the Northern and Southern Water-Treatment Plants of the Milwaukee Water Works from March 1 through April 28, 1993

8. Mystery GI Illness 50% of the population served by the southernmost plant and 25% of those served by the northern plant become ill – Over 400,000 (26% of population) estimated to be affected GI illness: –Watery diarrhea lasting approximately 9 days –Low grade fever –Average 10 lbs. weight loss

9. Investigation Cryptosporidium was identified in over 600 stool samples (30% of those tested) No other causative organisms found in greater than 2% of samples Later, Cryptosporidium was also found in ice made from water during that period

10. Cryptosporidium in water Disease transmitted by oocysts Not destroyed by chlorine or chloramine Difficult to identify and not normally screened for by water treatment facilities Disease is usually self- limited in immunocompetent hosts

11. Illustrative Points Importance of evaluating air, water, and food supply in epidemic illness Relevant history regarding event Symptoms, evaluations of patients Impact on water-quality standards Impact on U.S. public health including impact on HIV/AIDS awareness

12. Case Study #2 In January of 2003, a resident of Hebbronville, TX contacted the Texas Department of Health concerned about elevated arsenic (As) levels in drinking water Hebbronville Library

13. Hebbronville, TX

14. Hebbronville Agency for Toxic Substances and Disease Registry (ATSDR) conducted an evaluation of local residents and water supply Water supply: –Arsenic levels in the drinking water ranged from 43.7 to 52.1 µg/L –Prior to 2006, the maximum contaminant level for As was 50 µg/L Home of the Hebbronville Longhorns

15. Evaluation of Population 2/3 of the 140 people sampled had urinary inorganic As concentrations > reference concentration of 10 µg/L Drinkers of tap water had higher-than- reference range levels Drinkers of bottled water had substantially lower levels. Hebbronville Courthouse

16. Evaluation of Population According to the ATSDR 91% of the population described themselves as Hispanic Typical regional diet included rice and beans cooked in water - potentially increasing arsenic consumption: –8-9 µg As per serving of rice –20-24 µg As per serving of beans (if cooked in water containing 50 µg/L)

17. Actions Recommended in Hebronnville Those with inorganic As levels > 20 µg/g of creatinine to be retested Individuals encouraged to discuss their results with a personal health care provider Evaluation of other (dietary) sources of As Efforts to reduce As levels in the public water system.

18. Implications Unclear what, if any, health effects would be expected Possible parallels to areas such as Taiwan and Bangladesh that have experienced high levels of environmental arsenic

19. Bangladesh Borders India and Burma Local water wells were commonly contaminated with disease-causing microorganisms

20. Bangladesh Water Supply UNICEF and other international organizations promote the use of tube wells for safer water supply in the 1970s and 1980s –Thin tubes sunk in ground; usually < 200 meters in depth –Resulted in high levels of arsenic in soil leached into water, first confirmed in 1993

21. Quantification of Arsenic Exposure In 1980s first reports of arsenic-related dermatologic disease Analysis of water in British Geological Survey showed that >35% of wells contained > 50 g As/L –In some districts >80% of wells contained greater than 50 g As/L –8% had As concentrations of > 300 g/L

22. % of Field-tests positive for As

23. Chronic Arsenic Toxicity Approximately 125 million residents drawing from water supply In some studies 30-50% of patients had skin lesions due to arsenic –Skin lesions typically develop after latency of 10 years

24. Public Health Implications Other potential long- term effects of arsenic exposure: Cancers, including skin, bladder, kidney and lung Neurological effects Hypertension, vascular disease Pulmonary disease Diabetes Environmental Health Perspectives Volume 110, Number 2, February 2002

25. Public Health Issues - Bangladesh How to treat the millions of exposed patients? –Nutritional supplementation? –Infected hyperkeratotic lesions? What about tremendous predicted expense from excess cancer morbidity/mortality?

26. TOXICOLOGICAL AND ENVIRONMENTAL SPECIFICS Farm chemicals Perchlorates Solvents Arsenic Microbiological Agents

27. Occurrence of Nitrite/Nitrate Naturally occurring inorganic ions –Enter groundwater from fertilizer use, including anhydrous ammonia –Releases totaled over 110 million pounds –Contamination from septic systems Chemical characteristics lead to migration to ground water

28. Exposure Groundwater supplies 20% of nitrate intake, but can be higher in the setting of water contamination MCL for nitrates has been set at 10 ppm, and for nitrites at 1 ppm –US Geological survey in 1995 showed >8,000 wells had levels exceeding 10 ppm –1-2% of population estimated to be exposed to excessive levels of nitrates >600,000 homes draw from contaminated wells and rural wells are not routinely tested

29. Health Effects Nitrites and nitrates cause oxidation Nitrates are converted in vivo to nitrites –More potent oxidizers Oxidation of iron in hemoglobin results in methemoglobinemia

30. Methemoglobinemia Oxidized hemoglobin unable to carry oxygen effectively Infants at risk due to: –Increased levels of fetal hemoglobin –Reduced levels of methemoglobin reductase One cause of infantile cyanosis or Blue-baby syndrome Has resulted in numerous infant deaths

31. Methemoglobinemia Treatment Supportive care Removal from exposure Reducing agents such as methylene blue Antioxidants such as vitamin C

32. TOXICOLOGICAL AND ENVIRONMENTAL SPECIFICS Farm chemicals Perchlorates Solvents Arsenic Microbiological Agents

33. Perchlorates Naturally occurring (e.g. in saltpeter deposits) Magnesium, potassium, sodium, lithium, ammonium perchlorate are manufactured in large amounts –Uses include: solid rocket fuel, ammonium perchlorate, explosives

34. Perchlorates Perchlorates are the primary oxidizers in solid rocket fuel Perchlorates are also very stable in water

35. Exposure EPA reports that 40 of 1547 National Priority Sites contain perchlorates –Leaves soil to enter water May persist for years –No proven method for removal from water

36. Exposure Exposure pathways may include: –Drinking contaminated water –Also may occur through tobacco use –Proximity to industrial use of perchlorates

37. Perchlorate Contamination In 1997 perchlorates were discovered in drinking water Primarily affects Western States Environmental Science and Technology/News May 1, 1998

38. Health Effects Perchlorates effect the thyroid –Interferes with the thyroids ability to take up iodide –Clinical relevance is unclear –Human studies generally report insufficient evidence to determine risk of carcinogenesis

39. TOXICOLOGICAL AND ENVIRONMENTAL SPECIFICS Farm chemicals Perchlorates Solvents Arsenic Microbiological Agents

40. Solvents - including MTBE Methyl-t-butyl-ether –Manufactured by reaction of methanol and isobutylene –Flammable liquid with disagreeable odor –Evaporates quickly –Added (like ethanol) to gasoline as an oxygenator to decrease carbon monoxide emissions.

41. Potential Exposure Pathways Possible ingestion of MTBE in water Concentration dependant Dermal exposure while showering or swimming –Medically important systemic absorption is unlikely

42. MTBE - possible health effects Any adverse effects are expected to be a function of exposure and dose Vapor exposure (at high concentration for prolonged periods) may have mild but reversible effects Ingestion –Potential cancer risk is unproven Not classified by the IARC Only weak evidence of carcinogenicity in some animal studies

43. Water Purity Standards EPA recommends < 4 mg MTBE/Liter State-specific limits exist Taste/odor threshold is 20-40 ppb

44. TOXICOLOGICAL AND ENVIRONMENTAL SPECIFICS Farm chemicals Perchlorates Solvents Arsenic/Heavy Metals Microbiological Agents

45. Heavy Metal Occurrence Mostly natural –Mineral deposits –Natural soil constituents Increased levels may exist at some industrial sites

46. Potential Exposure Pathways Contaminated water supply Food grown in contaminated soil or with contaminated water

47. Potential Health Effects - Arsenic Acute –Possible GI illness, neuropathy –Uncommon from environmental exposure –Intentional exposures Suicidal Homicidal Chronic –Dermatologic, vascular and malignant disease –Environmental exposure Bangladesh

48. Treatment for Arsenic/Metals For chronic exposure the treatment is REMOVAL FROM EXPOSURE For acute exposure, consultation with a Poison Control Center or medical toxicologist is advisable –Chelation may be considered in some extreme cases

49. TOXICOLOGICAL AND ENVIRONMENTAL SPECIFICS Farm chemicals Perchlorates Solvents Arsenic Microbiological Agents

50. Microbiological Water Contamination Several broad categories, including: –Bacterial –Protozoa –Viruses

51. Bacterial Contamination Travellers diarrhea –Up to 50% of international travelers may be afflicted depending on region Approximately 10 million people –High-risk areas Latin/Central America Africa Middle-East Asia

52. Travellers Diarrhea Caused by infectious agents –Primarily Escherichia coli Produces enterotoxins –Watery diarrhea lasting several days E.coli 0157:H7

53. Travellers Diarrhea Prevention: –Avoidance of local waters and ice –Bottled water for consumption –Daily bismuth (e.g.Pepto-Bismol) preparations –Avoidance of strong antacids (PPIs) –Possibly prophylactic antibiotics for select patients

54. Treatment Usually self-limited Only symptomatic treatment usually required Antibiotics (sulfa drugs, quinolones) may slightly reduce duration of illness

55. Dysentery Enteroinvasive disease caused by any of several organisms –Salmonella, Shigella, Campylobacter Bloody mucoid diarrhea with fever, fecal leukocytes Antibiotic treatment recommended Salmonella infantis

56. Protozoan Infections

57. Protozoal Infections Common cause of endemic diarrheal illness Typically spread through fecal-oral transmission Common types include –Cryptosporidium –Giardia

58. Cryptosporidium parvum Worldwide presence in water supply –Not effectively killed by chemical purification methods Prevention through –Boiling of drinking water –Water filtration with 1 micron pores

59. Chen X et al. N Engl J Med 2002;346:1723-1731 Life Cycle of Cryptosporidium and Infection of Host Epithelial Cells

60. Cryptosporidium - Health Effects Watery diarrhea lasting 1-2 weeks in normal hosts May result in dehydration, weight-loss Usually self-limited, but may be severe in immunocompromised hosts –Treatment includes anti-retrovirals for those with HIV –Possible role for nitrazoxanide

61. Giardia Lamblia Very common parasitic disease More common in warmer climates Prevention is similar to measures for cryptosporidium –Boiling of water –Filtration Reverse osmosis 1 micron pores

62. Viral Diseases Multiple viral pathogens –Rotaviruses –Hepatitis A –Enteroviruses Most common epidemic (not endemic) diarrheal illnesses No specific treatment

63. Norwalk Virus Common cause of epidemic diarrheal illness Responsible for recent outbreaks on cruise ships

64. Prevention Hygiene –Reduce fecal-oral transmission –Hand-washing –Sanitization of surfaces Vaccination –Effective for hepatitis A prevention

65. Reported Cases of Hepatitis A, United States 1995: Vaccine Licensed 1996: ACIP recommendations 1999 ACIP recommendations Source: NNDSS, CDC

66. Rate > 20/100,000 Rate 10-20/100,000 Rate < 10/100,000 States with Hepatitis A Rates > 10/100,000 1987-97

67. Number of years that Reported Incidence of Hepatitis A Exceeded 10 Cases per 100,000, by County, 1987-1997

68. Hepatitis A Incidence, United States 2002 incidence 1987-97 average incidence > = 20 10 - 19 5 - 9 0 - 4 Rate per 100,000

69. Thielman N and Guerrant R. N Engl J Med 2004;350:38-47 Approach to the Evaluation and Management of Infectious Diarrhea

70. Water as a Terrorist Target Watersheds and reservoirs contain a centralized depot of an essential resource for large numbers of people Often inadequately protected Impossible to monitor for all possible pathogens at all times

71. Prevention of Water Terrorism Certain chemical properties of water are monitored continuously Very large volume of water –Would require very large amounts of toxins to reach harmful levels –Attractive terrorism agents would have to be extraordinarily potent to be effective (such as botulinum toxin)

72. Clinical Problem Solving 40 patients present over a 2-3 day period with GI illness –Watery diarrhea –Crampy abdominal pain –No fever/vomiting No occupational, social, or family connection between most patients

73. Key Physician Actions Recognize cluster of illnesses Try to find shared exposure –Attendance at a gathering Family/workplace picnic etc. –Eating at same restaurant or similar unusual foods –Face-to-face contact (same school, workplace)

74. Observations Some hospitals receive many more patients than others Most patients come from same geographic area No particular meals, restaurants, or workplaces occur with greater than expected frequency

75. Investigation Comparing geographical distribution of patients to water distribution plans reveals that areas affected all receive water from same reservoir and treatment plant.

76. Role of Community Physician Physicians are on the front-line They are the interface between the public and the public health agencies Therefore, physicians must treat not only individual patients, but be vigilant to protect and treat their entire community

77. Key Physician Actions Recognition of illness cluster Recognition of probable environmental illness Development of rational evaluation and treatment options Reporting responsibilities –Contact the CDC and local public health officials

78. Treatment and Disposition of Patients Evaluate and resuscitate as necessary –Identify and treat dehydration –Check stool for blood and/or fecal leukocytes to screen for enteroinvasive disease (dysentery) –Symptomatic treatment Obtain stool cultures, send stool for evaluation for ova and parasites

79. References http://www.atsdr.cdc.gov/hac/pha/hebbr onville/hae_p1.html#sum http://www.atsdr.cdc.gov/hac/pha/hebbr onville/hae_p1.html#sum Agency for Toxic Substances and Disease Registry. 2001. Case studies in environmental medicine: taking an exposure history. Atlanta: US Department of Health and Human Services

80. References American Academy of Pediatrics. 1970. Policy statement. Infant methemoglobinemia: the role of dietary nitrate. Pediatrics 46(3):475-8

81. References U.S. EPA. Integrated Risk Information System: Perchlorate and Perchlorate Salts. 2/18/2005 U.S. EPA. Assessment Guidance for Perchlorate. January 26, 2006 Chen X.-M. et al. Current Concepts: Cryptosporidiosis. N Engl J Med 2002; 346:1723-1731, May 30, 2002. Thielman NM, Guerrant RL. Acute Infectious Diarrhea. N Engl J Med 2004; 350:38-47, Jan 1, 2004