Waterborne Diseases

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Introduction Microorganisms responsible for waterborne illnesses are easily dispersed, demonstrate physiological diversity, are able to adapt to extreme conditions, and are easily transferred (Theron, 2002, 1). Therefore, they pose a significant health threat to animal, human, and plant life systems. Waterborne enteric pathogens have the potential to cause severe illnesses including death and can easily contaminate water systems thereby making life systems highly susceptible to such illnesses. The purpose of this section is to identify critical elements of waterborne diseases in attempt to educate others in their pursuit of clean water. It is important for such individuals to be informed as to the contents of this section as waterborne diseases are an international health epidemic and are relatively easily contracted. The potential impact of the information provided in this section on individuals seeking clean water will likely be the extraction of practical knowledge regarding the overall health, socio-cultural, legislative, and other important factors in achieving sustainability.

Executive Summary Approximately 1.1 billion people- about one sixth of the world population- do not have access to clean sources of water (Thompson, 2003, 89). Each year, around 2.2 million people die as a result of hygiene-related diseases. Most of these people are children in underdeveloped countries. However, interventions in hygiene, sanitation, and water supply have been shown to control such illnesses in both developed and underdeveloped communities. Current public initiatives promote universal access to safe water and sanitation as essential in mitigating the amount of deaths due to waterborne diseases (Thompson, 2003, 89).

Waterborne Diseases in the United States In developed countries such as the United States, water treatment processes created to mass-produce drinking water have been regarded as one of the top engineering achievements of the 20th century (Neumann, 2005, 155). However, throughout the past decade, there have been several waterborne disease outbreaks within the international community that have increased public awareness of the economical, societal, and health effects of such diseases. The World Health Organization (WHO) estimates that 2 million people die each year as a result of consuming microbial-contaminated drinking water (, accessed 18 December 2006). Furthermore, the WHO estimates 4 billion occurrences of waterborne disease per year. During the period of 1991-1998, there were 126 outbreaks, 429,021 instances of waterborne illnesses, 653 hospitalizations, and 58 deaths resulting from contaminated water systems reported in 41 states and three U.S. territories (Craun, 2002, 16). This evidence is particularly alarming considering that 92 percent of public systems rely on groundwater sources which are relatively easily contaminated and highly susceptible to water treatment deficiencies. Despite recent engineering advancements, current public health surveillance programs are relatively insensitive in detecting waterborne disease outbreaks (Neumann, 2005, 16). Public health surveillance programs often fail to recognize when an outbreak is occurring. Research conducted by Norman Neumann et al. attributes this failure to inadequate diagnostic and epidemiological tools. Neumann et al. further cites the lack of efficient monitoring technologies for online and or rapid detection of waterborne pathogens. Within the U.S., the Office of Ground Water and Drinking Water (OGWDW) and the Environmental Protection Agency (EPA) are responsible for the implementation and oversight of the Safe Drinking Water Act (SDWA) of 1974 (, accessed 18 December 2006). The SDWA was originally passed by Congress to protect public health by establishing national drinking water standards protecting against both man-made and naturally occurring contaminants. The SDWA was amended in both 1986 and 1996 to include rivers, lakes, reservoirs, springs, and groundwater wells. The 1996 amendment to the SDWA requires that the EPA publish a list of contaminants known or anticipated to cause potential outbreaks in public water systems (, accessed 18 December 2006). In addition, the amendment compels the EPA to suggest when regulation is needed for such contaminants. Laws, statutes, and regulations outlining the EPA and states’ water requirements, as well as additional information, are available online at In accordance with EPA regulations, state and local agencies are primarily responsible for the detection and investigation pertaining to waterborne outbreaks (Craun, 2005, 243-262). Such findings are reported to both the EPA and the Center for Disease Control and Prevention (CDC). The EPA, CDC, and the Council of State and Territorial Epidemiologists maintain a surveillance system that provides information about several types of water based upon outbreaks which are voluntarily reported. Reported outbreaks are classified according to the level of compulsion regarding the epidemiologic evidence indicating water as the vehicle of transmission (Craun, 2005, 242). At least two persons are required to have experienced similar symptoms pertaining to the illness after the ingestion of or contact with water. Furthermore, epidemiologic evidence must implicate water as the source of the illness. However, outbreak investigations differ by location and, as a result, some reported outbreaks do not contain sufficient information about factors such as the number of exposed individuals and suspected sources of contamination. Additional problems concerning the surveillance system include the exclusion of endemic illnesses that may be associated with recreational water and unreported and uninvestigated illnesses associated with unrecognized outbreaks (Craun, 2005). Gunther Craun et al. identifies the following factors as essential to the likelihood that individual cases of an illness will be detected an investigated within the United States: 1. public awareness of waterborne illnesses, 2. local requirements for reporting cases of particular diseases, 3. the surveillance and investigative activities of state and local public health and environmental agencies, and 4. the availability and extent of laboratory facilities (Craun, 2005).

Waterborne Diseases Outside of the United States Developing countries, especially in Africa and Asia, are especially affected by waterborne diseases due to the overall lack of hygiene and sanitation (, accessed 18 December 2006). Developing countries also struggle with higher rates of infectious diseases such as HIV, malaria, and tuberculosis than developed countries such as the United States do. Furthermore, populations in developing countries also suffer from poor nutrition due to vitamin deficiencies and starvation, exposure to chemical pollutants in food, water, and air, and harsh working environments with exposure to industrial toxins (, accessed 18 December 2006). Furthermore, developing countries also suffer from a multitude of other challenges that are generally not experienced by developed countries (, accessed 18 December 2006). Such challenges include pharmaceutical companies and governments unwilling to provide affordable drugs, the sale of toxic agricultural chemicals that are banned in developing countries, multinational corporations relocating manufacturing plants to developing countries to avoid high labor costs and environmental regulations, as well as an unregulated market for antibiotics. The misuse of antibiotics in the human population, animal husbandry, and aquaculture has created an impeding health threat by creating the emergence of antibiotic resistance in most identifiable bacterial pathogens. In fact, this antibiotic resistance has become, next to HIV/AIDS, the most serious health threat from infectious disease to date (, accessed 18 December 2006). As a result, up to 13 million people die each year in developing countries due to ingesting contaminated water (Theron, 2002, 1). In such countries, waterborne illnesses are contracted primarily through fecal-oral contact. Consumption of water contaminated by animal/human fecal matter remains the dominant concern regarding water sanitation. In many developing nations’ cities where infrastructure does exist, there is little effective watershed protection, water treatment is generally inadequate and water supply is subject to deteriorating distribution networks (, accessed 18 December 2006). Untreated waste is commonly discharged directly to receiving waters or accumulates around homes. The global water crisis has profound impacts on several other sectors in developing countries (Cain, 2005, 79). There is growing realization that inadequate water and sanitation causes decreased economic growth, can worsen conflicts over natural resources, and can affect global security by worsening conditions in states that are on the verge of failing. It is suggested that providing developing countries with access to clean water and adequate sanitation could be accomplished for a very reasonable price (Cain, 2005, 79). In fact, it could be accomplished for less than the amount that consumers in developed countries now spend on bottled water in one year. The technology exists to address the global water crisis (, accessed 18 December 2006). In countries with poor water quality and sanitation, desalination and water reuse technologies could be used to produce safe drinking water. However, until developing nations establish equity with developed nations, developing nations need to provide local solutions that are low-cost, easily maintainable, easily repairable, and do not require a high level of training to operate. In addition, developing nations must also provide some form of waste collection and treatment as well as basic education on hygiene and sanitation (, accessed 18 December 2006). The following diagram illustrates water scarcity and stress throughout the world Gardner-Outlaw, 1997, 2).The diagram is also available for viewing at

Recreational Water Illnesses Recreational water illnesses (RWIs) are illnesses contracted as a result of swimming in contaminated pools, hot tubs, lakes, oceans, and other bodies of water (McClain, 2005, 670). Instances of such illnesses have been steadily increasing since the late 1990s. It is suspected that the increase is the result of a growing number of bathers and the emergence of new infectious pathogens. Symptoms of RWIs include skin, ear, eye, and respiratory infections, and gastroenteritis is the most commonly presented illness. Due to their developing immune systems and high rate of exposure to recreational water, children are especially vulnerable to RWIs. However, many parents remain uninformed about RWIs and, as a result, likely underestimate their children’s risk of contracting such illnesses. Because parents may not perceive their children to be vulnerable to RWIs, they have little motivation to adopt behavior modifications designed to reduce the risk of their children contracting RWIs and contaminating recreational water (McClain, 2005, 670). While adding chlorine to bodies of water such as swimming pools does reduce the amount of waterborne illnesses, the process requires a certain amount of time (, accessed 18 December 2006). Chlorine in properly disinfected swimming pools eliminates most germs that can cause RWIs in less than one hour. However, chlorine takes a longer amount of time to destroy some germs such as Cryptosporidium which can survive for days in a properly disinfected pool. This means that the adoption of preventative behaviors is critical to reducing the amount of RWIs (, accessed 18 December 2006) The CDC has developed six specific preventative behaviors individuals can adopt to reduce their vulnerability to RWIs when swimming: 1. do not swim when you have diarrhea, 2. do not swallow pool water, 3. practice good hygiene, 4. take children on frequent bathroom breaks, 5. change diapers in a bathroom, not poolside, and 6. wash children thoroughly (especially the rear end) with soap and water before swimming (, accessed 18 December 2006). In addition, the CDC has developed a twelve-step guideline designed to reduce germ contamination in swimming pools: 1. outline and lead staff commitment to protecting swimmers from RWIs, 2. develop health partnerships with other aquatic facilities, 3. educate pool staff, 4. educate swimmers and parents, 5. maintain water quality and equipment, 6. evaluate aquatic facility design, 7. implement disinfection guidelines, 8. evaluate hygiene facilities, 9. develop a bathroom break policy, 10. create a special policy for large groups of young children, 11. post and distribute health information, and 12. develop an outbreak/ emergency response plan. For more information regarding the above preventative behaviors, please visit the CDC’s website at Water and Travel Each year, approximately 50 million people travel from North America, Europe, Japan, and Australia to underdeveloped countries (Guerrant, 2005, 524). Individuals who travel to underdeveloped countries are often exposed to the same waterborne diseases that pose the greatest health threat to malnourished populations suffering from inadequate water and poor sanitation. In fact, food and waterborne diseases are the predominant causes of illness in travelers (Dinman, 2005, 156). Many individuals experience what is called traveler’s diarrhea. The leading cause of traveler’s diarrhea is exposure to Escherichia coli (E. coli). The risk of waterborne illness while traveling is largely contingent upon the destination (Krym, 2003, 317). Destinations identified as high-risk for such illnesses include: Africa, the Middle East, Asia, and Latin America. High-risk destinations are those wherein 20-50 percent of travelers experience a waterborne illness. The incidence of illness is high due to the lack of clean water sources and an increased amount of diarrheal illness in the local population. Symptoms in travelers are generally mild and usually last 48 hours (Krym, 2003, 317). The CDC recommends the following precautions as essential to safeguarding one’s health when traveling to underdeveloped countries or high-risk destinations: 1. drink only bottled or boiled water or carbonated drinks in cans or bottles, only thoroughly cooked vegetables that you have peeled yourself, not eat food purchased from street vendors, 4. do not eat dairy products unless you are certain that they have been pasteurized and 5. do not handle animals to avoid bites and serious diseases (Dinman, 2005, 156-157). In addition, the CDC recommends that travelers receive the following vaccines before departing for their destination: 1. Hepatitis A or immune globulin, 2. Hepatitis B, 3. Rabies, 4. Typhoid, 5. as-needed boosters for tetanus-diphtheria, and measles, and 6. a one-time dose of polio (for adults). For more information regarding precautionary health measures, please visit the CDC’s website at

Water and the United Nations’ Millennium Development Goals The member countries of the United Nations have recognized the importance of having access to clean water and adequate sanitation (Cain, 2005). As a result, the United Nations (UN) has established eight goals referred to as the Millennium Development Goals (MDGs) targeted to be achieved by the year 2015. The goals are expected to decrease the proportion of people without access to clean water and adequate sanitation by half. The MDGs include the following: 1. eradicate extreme poverty and hunger, 2. achieve universal primary education, 3. promote gender equality and empower women, 4. reduce child mortality, 5. improve maternal health, 6. combat HIV/AIDS, malaria, and other diseases, 7. ensure environmental sustainability, and 8. develop a global partnership for development. Clean water plays a substantial role in achieving each of the aforementioned MDGs. According to a Pacific Institute report, even if the UN establishes the MDGs, 34-76 million people will die from tainted water and waterborne diseases by the year 2020 (Cain, 2005). A report released by the WHO and UNICEF included the following significant predictions regarding the UN MDG drinking water and sanitation target: 1.the global sanitation target will be missed by approximately half a billion people (most of them in rural Africa and Asia) causing disease to spread, killing millions of children, and leaving others substantially worse off than now, and 2. the world is on track to meeting the drinking water target (, accessed 18 December 2006). WHO and UNICEF believe that the human and economic toll of missing the sanitation target could be minimized by closing the gap between urban and rural populations and by providing simple hygiene education. According to WHO Director-General, Dr. Lee Jong-Wook, to meet the 2015 water and sanitation targets, countries need to create the political will and resources to service one billion new urban dwellers and reduce by almost one billion the number of rural dwellers without access to adequate sanitation facilities (, accessed 18 December 2006). Otherwise, Jong-Wook states, countries run the risk of leaving billions of individuals out of the development process. The WHO and UNICEF attribute recent gains in many countries’ water and sanitation services to global leaders’ political prioritization regarding the need to identify locally effective solutions.

Water and Child and Maternal Mortality Waterborne diseases are responsible for approximately 33 percent of deaths across the world (, accessed 18 December 2006). Each year, waterborne diseases account for about 1 percent of deaths in developed countries and about 43 percent of deaths in developing countries. Such diseases contribute to high child mortality and decreased life expectancy rates. In fact, waterborne diseases are among the leading causes of death for children under the age of five (, accessed 18 December 2006). UNICEF’s executive director, Carol Bellamy stated that the growing disparity between the have and the have-nots in terms of access to basic water and sanitation services is killing approximately 4,000 children per day (, accessed 18 December 2006). The identification and prevention of waterborne pathogens is especially critical to children across the globe because they are more susceptible to illnesses resulting from the consumption of contaminated water (North American Report on Children's Health and Environment Indicators - A Global First, 56). In general, children eat more food and drink more water than adults do. Furthermore, children’s everyday activities, such as putting their hands in their mouths or playing outdoors, are likely to result in a higher rate of exposure to contaminants. Children with immune system deficiencies and underdeveloped organs are especially at risk (North American Report on Children’s Health and Environmental Indicators- A Global First, 56). In addition, exposure to such diseases often results in decreased physical and cognitive development in children (Guerrant, 2005, 524).

Water and HIV/AIDS The identification and prevention of waterborne illnesses is critical to individuals who are infected with the human immunodeficiency virus (HIV) or acquired immunodeficiency syndrome because such individuals possess compromised immune systems (AIDS) (Hayes, 2003, 106-111). A compromised immune system causes such individuals to be more susceptible to food and waterborne diseases than individuals with normal immune systems. Individuals with HIV/AIDS are at a greater risk of contracting secondary illnesses transmitted through consuming foods that are unsafely handled or poorly prepared from using unsafe water (Hayes, 2003, 106). Proper food preparation is significant to individuals with HIV/AIDS because food is able to transmit disease by supporting growth of the etiologic agent or toxin production or failing to support growth but still serving as a means of transmission (Hayes, 2003, 107). Symptoms of food and waterborne diseases include the following: nausea, vomiting, diarrhea, fever, chills, headache, and fatigue. However, diarrhea is the most common symptom of illness in immunocompromised individuals. Repeated exposure to food and waterborne diseases may cause chronic illnesses such as arthropathies, gastroenteritis, organ compromise, nutritional and malabsorptive disorders, and even death (Hayes, 2003, 107). Education is critical to those with compromised immune systems as well as their caretakers and health providers (Hayes, 2003, 108). Knowledge of safe food and water handling techniques can reduce the instance of potentially life threatening illnesses resulting from such. To decrease the risk of contracting such illnesses, immunocompromised individuals, caretakers, and providers should educate themselves on topics such as the proper storage of perishable foods, cross-contamination of raw and cooked foods, kitchen sanitation, personal hygiene, and using clean water (Hayes, 2003, 108).

Water and Healthcare Facilities Clean water is especially important in healthcare settings wherein healthcare professionals and patients rely upon water quality to ensure health. Within the United States, healthcare facilities are subject to a variety of legislative requirements designed to protect public health and the environment resulting from water and sanitation management in healthcare activities (, accessed 18 December 2006). However, many hospitals and clinics are not in compliance with such legislation. Healthcare waste is especially important when discussing water and sanitation management. Such waste includes sharp and non-sharp devices, blood, body parts, chemicals, pharmaceuticals, medical devices, and radioactive materials (, accessed 18 December 2006). Poor management of healthcare waste exposes healthcare professionals, waste handlers, and community members to serious health hazards including infections, toxic effects, and injuries resulting from waste contaminating food and water supplies. However, in many developing countries, legislative requirements do not exist to protect public health and the environment from such risks (, accessed 18 December 2006). Therefore, the WHO seeks to establish a world strategy targeted at achieving water and sanitation standards in all healthcare settings (, accessed 18 December 2006). The WHO recommends that countries take the following actions in attempt to increase water and sanitation management in healthcare facilities: • Secure government commitment and financial support; • Define a national policy and strategy to obtain objectives; • Designate a responsible authority involving the ministries of health and environment as well as professional organizations and NGOs; • Promote participative approaches; • Conduct an initial country-wide assessment to reveal weaknesses; • Prepare a national action plan listing specific actions that must be taken, clearly defined authorities, and indicators of achievement; • Establish a national steering committee; and • Monitor the progress and implementation of the national action plan. For additional information regarding water and sanitation management in healthcare facilities, please visit the EPA’s website at or the WHO’s website at The sites provide links to guidance documents, hotlines, and other federal requirement compliance assistance tools. For information on state and local requirements, please contact your state/ local environmental agencies.

Water and Gender Equality As defined by the United Nations Development Programme (UNDP), gender refers to the roles and responsibilities of men and women and the relationship between them (, accessed 18 December 2006). The term gender refers to more than an anatomical distinction, but to the way men and women’s behaviors and identities are determined through the process of socialization. Men’s and women’s roles and responsibilities are determined by their culture and can change over time. Furthermore, gender is considered to be the social construction of men’s and women’s roles is a specific culture or location. These roles are influenced by a multitude of factors including history, religion, economy, culture, and ethnicity (, accessed 18 December 2006). As a result of the need for a gender-sensitive approach regarding water and sanitation programs, especially in developing countries, the UN developed a strategy referred to as Integrated Water Resources Management (IWRM) (, accessed 18 December 2006). IWRM focuses on the coordinated development of water, land, and related resources in attempt to improve economic and social welfare without compromising the sustainability of environmental systems. The key principles of IWRM include the following: • Water should be treated as an economic, social, and environmental good; • Water policies should focus on the management of water as a whole and not just on the provision of water; • Governments should facilitate and enable sustainable development of water resources by the provision of integrated water policies and regulatory frameworks; • Water resources should be managed at the lowest appropriate level; and • Women should be recognized as central to the provision, management, and safeguarding of water.

IWRM is significant in that it focuses on the concept that a community is not merely a collection of equal people living in a given location (, accessed 18 December 2006). Rather, IWRM recognizes that a community generally consists of individuals and groups that possess varying levels of power, wealth, influence, concerns, and rights. IWRM also recognizes that where resources are scarce, there is competition for supplies and those with the least amount of power (often women and the poor) will be forced to go without. Therefore, IWRM attempts to alleviate this power struggle and increase the likelihood of achieving sustainability by offering a people-sensitive approach to ensure that gender perspectives are taken into account (, accessed 18 December 2006). It is especially important to consider both women and the poor because poor women generally have less access to water supplies and greater time and labor constraints than other men and women (, accessed 18 December 20060. Poor women are also more likely to be in poorer health and their children have a higher risk of contracting waterborne illnesses. Therefore, poor women benefit the most from initiatives that bring water supplies closer to their homes. Unfortunately, however, they are the least likely to participate in the decision process that would make this possible (, accessed 18 December 2006). A World Bank review of 121 rural water supply projects revealed that women’s participation was among the strongest variables associated with project effectiveness (, accessed 18 December 2006). The review also revealed that the failure to consider gender differences and inequalities often results in project failure. An example of this is a project concerning compost pits in India. Pits located outside of villages were unused and women continued to deposit waste outside of their homes (even when fined for doing so) because they did not wish to be seen carrying large quantities of waste to the outskirts of the village. If there had been an initial consultation with women regarding their perspectives on this project, the project may have been successful (, accessed 18 December 2006). It is important to consider gender when analyzing and developing water and sanitation management strategies because doing so allows planners to gain a more accurate depiction of communities, natural resources, households, and water users (, accessed 18 December 2006). An effective community analysis includes an understanding of the differences among men and women such as who does what work, who makes which decisions, who uses water for what purpose, who controls which resources, and who is responsible for different familial obligations. In addition, performing an effective community analysis increases the likelihood of developing a successful strategy. For further information regarding water and gender equality, please visit the UNDP website at

Water and Agricultural Practices Recent changes in the U.S.’ agricultural practices have had an immense impact on the instances of waterborne pathogens (Theron, 2002, 4). The emergence of new pathogens may be the result of changes in agricultural production methods. Due to the decreasing amount of livestock farms, farms have been consolidated into more intensive farming operations. As a result, there has been a greater concentration of animal waste thus causing increased pollution of surrounding waterways by agricultural waste and runoff. This is significant in that several of the new pathogens of concern in drinking water have known or suspected animal hosts. Therefore, there is mounting public concern regarding direct or indirect animal-to-human transmission through drinking water supplies contaminated with animal wastes containing these pathogens (Theron, 2002, 4). Agricultural waste contaminating water has additional environmental repercussions (, accessed 18 December 2006). Currently, the primary environmental concerns include excess nutrients in water resulting from dairy waste causing algal blooms which deplete dissolved oxygen as they decompose thereby killing fish and other aquatic life, unhealthy levels of nitrate in groundwater causing infants to develop a potentially fatal blood disorder known as Blue Baby Syndrome, and Cryptosporidium in dairy waste causing diarrhea. Additionally, microorganisms or nitrate levels exceeding the standards established in the Safe Water Drinking Act have forced well owners to find new drinking water sources-a very difficult and expensive task (, accessed 18 December 2006). The EPA recommends the following actions for communities attempting to mitigate the amount of agricultural waste contaminating water supplies: • Install watertight plastic or clay waste lagoon liners to prevent contaminants from seeping through the bottom and sides of lagoons; • Properly measure and time the application of waste water to agricultural fields to minimize polluted runoff and seepage into ground water; and • Install buffer strips -- permanent strips of vegetation between farm fields and streams – to absorb nutrients that would otherwise enter waterways as polluted runoff (, accessed 18 December 2006).

The following diagram depicts global annual water withdrawal by sector from 1900 to 2000 (Abramovitz, 1996, 5). The diagram is available for viewing at

Water and Climate Change and Animals According to the WHO, zoonoses are diseases that are naturally transmitted from non-human vertebrates to humans (Charron, 2005, 24-28). Many zoonoses occur on a seasonal basis. Studies have shown a direct correlation between climate change and the prevalence of such diseases. Climate variability has several effects on organisms that transmit diseases (commonly referred to as vectors) and animals that store diseases (commonly referred to as disease reservoirs) and their habitat, as well as on the disease victim. However, these effects are complex and can be difficult to predict (Charron, 2005, 24). Zoonoses can be transmitted through a variety of methods (Charron, 2005, 24). While some zoonoses are transmitted directly through contact with animals or animal products, other zoonoses are transmitted from their animal sources to humans by insects. Other zoonoses are transmitted by contaminated food or water. This is critical as the pathogens, their animal hosts, and the insects transmitting them are all affected by climate change. Changes in temperature, humidity, and other environmental factors increase the instances of such diseases. Climate variability directly affects populations of wild animals thereby affecting the transmission of diseases within both domestic animal and human populations (Charron, 2005, 24). Many food- and waterborne diseases are zoonotic (Charron, 2005, 26). Pathogens residing in livestock and wildlife are transferred into the environment in the animals’ feces or urine and contaminate food and water sources consumed by human, plant, and animal life. Increased temperatures and humidity increase the survival rates of such pathogens causing contamination of food and water sources. Additionally, certain seasonal behaviors, such as outdoor grilling or consuming untreated water while camping, can increase the likelihood of disease transmission (Charron, 2005, 26). The global climate is changing and is affecting weather patterns and human and animal disease patterns (Charron, 2005, 26). It is anticipated that within the next decades, zoonotic pathogens will evolve with climate change. The effects of such are significant as animals and humans will be vulnerable to more diseases than ever before. The best way to prevent zoonotic pathogens is to initiate direct intervention into the ecosystem. Examples of such interventions include planting trees, improving water management processes, and zoning critical watersheds to minimize contamination of sources of drinking water. Additionally, regional and national education initiatives could also increase the international population’s understanding of such pathogens and promote sustainable and healthy communities (Charron, 2005, 26).

Legislative Initiatives Within the United States, water and sanitation requirements are the result of multiple pieces of legislation. These requirements have been created by the following: the Clean Air Act (CAA), Clean Water Act (CWA), Emergency Planning and Community Right-to-Know Act (EPCRA), Federal Insecticide, Fungicide, and Rodenticide Act (FIFRA), Resource Conservation and Recovery Act (RCRA), Safe Water Drinking Act (SWDA), and the Toxic Substances Control Act (TSCA) (, accessed 18 December 2006). The CAA regulates air emissions from area, stationary, and mobile sources (, accessed 18 December 2006). The CAA also established programs regarding acid rain, stratospheric ozone protection, and air toxics. The CWA is the primary federal statute designed to regulate and protect the United States’ water. The CWA established national programs for the prevention, reduction, and elimination of pollution in navigable water and groundwater. The EPCRA requires that the EPA publish a toxic chemical release inventory made available to the public. The FIFRA regulates the sale and use of pesticides in the United States. The RCRA controls solid and hazardous waste by establishing management requirements on generators, operators, and transporters of hazardous waste. The SWDA protects public drinking water from contaminants. The SWDA also protects underground drinking water from improper underground injection. The TSCA requires the testing of potentially hazardous chemicals and establishes regulations regarding the manufacturing, processing, and use of such chemicals (, accessed 18 December 2006). In May 2003, Kenya established a precedent for developing countries’ struggle for clean water and sanitation (http://www.irc,nl/page/2850, accessed 18 December 2006). For a little over two years, the Constitution of Kenya Review Commission consulted individuals from all regions of the country regarding their opinions on water and sanitation. Following the consultations, the Commission wrote a 77-page draft constitution granting all Kenyan citizens a right to a reasonable standard of sanitation. However, the Commission’s attempts to obtain approval and adoption of the draft constitution have been repeatedly blocked. Nonetheless, Kenya’s inclusion of a right to a reasonable standard of sanitation serves as a model conscientious attempt for other developing nations (http://www.irc,nl/page/2850, accessed 18 December 2006). According to the CDC, handwashing is cheap, easy, effective, and the single most important factor in preventing waterborne diseases (North American Report on Children's Health and Environment Indicators - A Global First, 2006, 56). Within the United States, numerous towns have enacted handwashing legislation in attempt to reduce the instances of waterborne disease in their communities. For example, the New Jersey Franklin Township Council recently passed the Franklin Township Handwashing Ordinance wherein all public restrooms must be kept in a sanitary condition at all times, possess both hot and cold running water, and offer sanitary devices such as hand soap and paper towels. The ordinance also provides for enforcement and education in areas not covered under the Retail Food Code. The Township Council believes that the ordinance will encourage community members to wash their hands thereby hindering the spread of germs (North American Report on Children's Health and Environment Indicators - A Global First, 2006, 56).

Water Treatment Methods In areas where tap water is not chlorinated or where sanitation is poor, there are several alternative means to ensure safe drinking water (, accessed 18 December 2006). Such methods include boiling the water, chemically disinfecting it, filtering it, using various combinations of the aforementioned methods, or buying bottled water. However, boiling water is the best way to kill bacterial, parasitic, and viral causes of illnesses such as diarrhea. Also, adding a pinch of salt to each quart of water boiled will improve the taste. The CDC provides the following instructions for boiling water: 1. Boil water vigorously for 1 minute and allow it to cool to room temperature (do not add ice), and 2. At altitudes greater than 6,562 feet, boil water for 3 minutes or use chemical disinfection after water has been boiled for 1 minute. When boiling water is not possible, the next best method to employ is chemical disinfection using iodine (, accessed 18 December 20060. Globaline, Potable-Aqua, and Coghlan’s are recommended brands to use and are commonly sold at sporting goods stores and online. However, it is important to know that Cryptosporidium (a parasite that can cause diarrhea) and other coccidian parasites (e.g., Cyclospora, Toxoplasma) might not be killed using this method. When disinfecting with iodine, cloudy water should first be strained through a clean cloth into a container to remove any sediment or floating matter, and then the water should be treated with iodine. The CDC’s instructions for disinfecting with iodine are as follows: Iodine tablets: Warning: Water that has been disinfected with iodine is NOT recommended for pregnant women, people with thyroid problems, those with known hypersensitivity to iodine, or continuous use for more than a few weeks at a time. • Follow the tablet manufacturers' instructions. • If water is cloudy, double the number of tablets. • If water is extremely cold, less than 5° C (41° F), try to warm the water, and the recommended contact time (standing time between adding a chemical disinfectant to the water and drinking the water) should be increased to achieve sufficient disinfection. Note: be sure the tablet size is correct for a Liter of water. Tincture of Iodine: • Measure out your dose to water. • If using tincture of iodine 2% solution, add 5 drops to a Liter or Quart of clear water. If the water is cloudy, add 10 drops per Liter or Quart. (Note: 20 drops=1 ml.) • Allow the water to stand for 30 minutes before drinking when the water temperature is at least 25°C (77°F). Increase the standing time for colder water: (e.g., for each 10° less than 25°C (77°F), allow the water to stand for double the time before drinking it. Crystalline Iodine: First make a saturated solution and then measure your own dose to add to water. The crystalline form stores well indefinitely and new batches of the saturated solution can be made from a small amount of crystals each time you take a trip. To prepare a stock of Crystalline Iodine saturated solution: • Place 4-8 grams of crystalline iodine into a 1-2 oz container and fill with water. Note: 1oz=6 teaspoons. Warning: crystalline iodine at 4-8 grams is a lethal dose if accidentally swallowed in a single dose. Keep out of the reach of children. • Shake the bottle vigorously for 1 minute. Allow several additional minutes for the iodine to maximally dissolve in the available water. Some crystals should always be visible; if they totally dissolve, then more crystals should be added to the container to insure that iodine saturation of the stock solution has been achieved. • If the water to be treated is clear, add 13 ml of saturated iodine solution -- liquid above the crystals, not the crystals themselves -- per Liter or Quart. Note: 5 ml= 1 teaspoon. 13 ml = about 2.5 teaspoons. • In cloudy water, add 26 ml of saturated solution per Liter or Quart. Note: Allow the solution to stand 20 minutes before drinking the disinfected water when the water temperature is 20-25°C (68-77°F). Increase the standing time with colder water. For each 10° less than 25°C (77°F), allow the water to stand for double the time before drinking.

Another method for disinfecting drinking water is the use of portable filters (, accessed 18 December 2006). However, most portable filters fail to effectively remove viruses, thus chemical disinfection of water is needed after filtering to make the water safe for drinking. Additionally, because viruses might also pass through the filtering stage, you would need to add iodine to the filtered water before drinking. Chlorine is also an alternative disinfectant, however, it is not as reliable as iodine for killing disease causing organisms in the wide range of water-quality conditions that travelers might encounter (, accessed 18 December 2006).

Practical Information In places where surface water is scarce, digging a well provides an excellent alternative (, accessed 18 December 2006). Wells can provide a reliable source of water for home uses, irrigation, and industries. Hand dug wells are especially suitable for developing communities because the equipment required is light and simple, construction techniques are easy for an unskilled worker to learn, and the necessary materials are generally locally available (, accessed 18 December 2006). However, hand dug wells possess certain limitations including a 200 foot practical limit of depth, slow construction, and water table fluctuations. When digging a well by hand, it is ideal to install a pump (, accessed 18 December 2006). When installed on a well with a full cover, a pump considerably reduces the risk of contamination. In rural areas where pump maintenance and repair is hindered, large diameter wells are the best solution to water supply problems. Pumps can be installed while leaving an access way through which water can be derived using a rope and a bucket if the pump should break (, accessed 18 December 2006). It is ideal to have at least five individuals when digging a well by hand (, accessed 18 December 2006). A team of five workers plus additional laborers to lower and raise loads in the well can usually dig three feet per day in relatively loose soil that does not cave in. However, the bottom portion of the well generally takes two to three days per foot due to the challenge of working while water continually enters the well. It is imperative to dig the well during the dry season when the water table is near its lowest point. For additional information on how to dig a well by hand, please visit Another practical alternative for reducing pathogens in drinking water is the use of solar sterilization devices (, accessed 18 December 2006). Several devices have been created to concentrate the sun’s energy in attempt to make water safer to drink. One device, referred to as a solar box, consists of a cardboard or wooden box with an insulated bottom and sides and a glass or clear plastic lid. The inside surfaces of the solar box should be painted black to obtain higher temperatures. A covered pot (black is best) with water is placed inside the box. The pot needs to remain inside the box until the water reaches 150 degrees Fahrenheit (65 degrees Celsius) for a couple of minutes. Generally, a solar box is able to pasteurize about one gallon of water in three hours on a very sunny day. Pasteurization kills bacteria and viruses but does not remove chemical contaminants. For further information on constructing a solar box, please visit

Discussion There is growing public concern as the epidemiology of waterborne illnesses is evolving and new microbial pathogens are emerging within the global community (Theron, 2002, 1). These emerging diseases are easily transmitted via such pathways as recreational, surface, and ground water, placing entire communities at risk. However, recent developments regarding waterborne diseases, such as the adoption of public health measures, have helped to reduce the instances of the more common waterborne pathogens. Despite such recent progress, due to the numerous amounts of infectious agents, reservoirs, and asymptomatic infected persons, absolute eradication of waterborne diseases may not be possible in the near future. However, by practicing preventative behaviors, educating community members, and enacting legislation, the likelihood of achieving sustainability becomes greater.


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