Drinking Water Contamination

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

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

6. Southern Water Treatment Plant

7. 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 Mac Kenzie W et al. N Engl J Med 1994;331:161-167

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 1970’s and 1980’s • 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 1980’s 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 thyroid’s 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