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Purpose of Review: This review examines the effectiveness of drinking water regulations to inform public health during extreme precipitation events. This paper estimates the vulnerability of specific populations to flooding in their public water system, reviews the literature linking precipitation to waterborne outbreaks, examines the role that Safe Drinking Water Act and Public Notification (PN) Rule have in public health emergencies, and reviews the effectiveness of the PN Rule during the 2017 Hurricane Maria in Puerto Rico., Recent Findings: Public water systems in large metropolitan areas have substantial portions of their customer base at risk for a waterborne outbreak during a flooding event. The PN Rule are ambiguous for who is responsible for declaring a "waterborne emergency" following a natural disaster like Hurricane Maria. Revisions to the current PN Rule that mandate public notification and water quality sampling during extreme precipitation events are necessary to ensure the public is aware of their drinking water quality following these events.

Water and sanitation indicators under the Millennium Development Goals failed to capture high-risk practices undertaken on a regular basis. In conjunction with local partners, fourteen rounds of household surveys using mobile phones with a customized open-source application were conducted across nine study geographies in Asia and Africa. In addition to the main water and sanitation facilities, interviewees (n = 245,054) identified all water and sanitation options regularly used for at least one season of the year. Unimproved water consumption and open defecation were targeted as high-risk practices. We defined underreporting as the difference between the regular and main use of high-risk practices. Our estimates of high-risk practices as the main option matched the widely accepted Demographic and Health Surveys (DHS) estimates within the 95% confidence interval. However, estimates of these practices as a regular option was far higher than the DHS estimates. Across the nine geographies, median underreporting of unimproved water use was 5.5%, with a range of 0.5% to 13.9%. Median underreporting of open defecation was much higher at 9.9%, with a range of 2.7% to 11.5%. This resulted in an underreported population of 25 million regularly consuming unimproved water and 50 million regularly practicing open defecation. Further examination of data from Ethiopia suggested that location and socio-economic factors were significant drivers of underreporting. Current global monitoring relies on a framework that considers the availability and use of a single option to meet drinking water and sanitation needs. Our analysis demonstrates the use of multiple options and widespread underreporting of high-risk practices. Policies based on current monitoring data, therefore, fail to consider the range of challenges and solutions to meeting water and sanitation needs, and result in an inflated sense of progress. Mobile surveys offer a cost-effective and innovative platform to rapidly and repeatedly monitor critical development metrics.

Access to water and sanitation are important determinants of behavioral responses to hygiene and sanitation interventions. We estimated cluster-specific water access and sanitation coverage to inform a constrained randomization technique in the SHINE trial. Technicians and engineers inspected all public access water sources to ascertain seasonality, function, and geospatial coordinates. Households and water sources were mapped using open-source geospatial software. The distance from each household to the nearest perennial, functional, protected water source was calculated, and for each cluster, the median distance and the proportion of households within <500 m and >1500 m of such a water source. Cluster-specific sanitation coverage was ascertained using a random sample of 13 households per cluster. These parameters were included as covariates in randomization to optimize balance in water and sanitation access across treatment arms at the start of the trial. The observed high variability between clusters in both parameters suggests that constraining on these factors was needed to reduce risk of bias., (© The Author 2015. Published by Oxford University Press for the Infectious Diseases Society of America.)

The accessibility of potable water is fundamental to public health. A private for-profit company is installing kiosk-based drinking-water systems in rural and peri-urban villages in Ghana, and we evaluated their performance. Preceding an observational study to measure the effect of these kiosks on the incidence of water-related disease in recipient communities, we conducted ethnographic research to assess local water-related practices and the ways these practices would affect adoption of the new technology. We conducted fieldwork in two communities in Ghana and interviewed stakeholders throughout the water sector. Our findings illustrate the complexity of water-related behaviors and indicate several factors that may sustain disease transmission despite the presence of the new technology. This formative ethnographic research also improved the precision of our subsequent evaluation of the intervention by providing a site-specific, culturally-appropriate knowledge base. This study demonstrates the value of incorporating qualitative research techniques into evaluations of water-related projects.

An estimated 884 million people worldwide do not have access to an improved drinking water source, and the microbial quality of these sources is often unknown. In this study, a combined tangential flow, hollow fiber ultrafiltration (UF), and real-time PCR method was applied to large volume (100 L) groundwater (N = 4), surface water (N = 9), and finished (i.e., receiving treatment) drinking water (N = 6) samples for the evaluation of human enteric viruses and bacterial indicators. Human enteric viruses including norovirus GI and GII, adenovirus, and polyomavirus were detected in five different samples including one groundwater, three surface water, and one drinking water sample. Total coliforms and Escherichia coli assessed for each sample before and after UF revealed a lack of correlation between bacterial indicators and the presence of human enteric viruses.

Small water enterprises (SWEs) are water delivery operations that predominantly provide water at the community level. SWEs operate beyond the reach of piped water systems, selling water to households throughout the world. Their ubiquity in the developing world and access to vulnerable populations suggests that these small-scale water vendors may prove valuable in improving potable water availability. This paper assesses the current literature on SWEs to evaluate previous studies and determine gaps in the evidence base. Piped systems and point-of-use products were not included in this assessment. Results indicate that SWES are active in urban, peri-urban and rural areas of Africa, Asia and Latin America. Benefits of SWEs include: no upfront connection fees; demand-driven and flexible to local conditions; and service to large populations without high costs of utility infrastructure. Disadvantages of SWEs include: higher charges for water per unit of volume compared with infrastructure-based utilities; lack of regulation; operation often outside legal structures; no water quality monitoring; increased potential for conflict with local utilities; and potential for extortion by local officials. No rigorous, evidence-based, peer-reviewed scientific studies that control for confounders examining the effectiveness of SWEs in providing potable water were identified.

The city of New Orleans, LA was severely impacted by flooding and wind damage following landfall of Hurricane Katrina in August 2005. The city's drinking water infrastructure was severely compromised and massive amounts of sediment were redeposited throughout the flooded region. Thousands of homes were water-damaged resulting in the rapid growth of mold. In September and October 2005 a convenience sample of selected homes, tap water, surface water, and sediment within New Orleans was assessed for mold contamination, microbial contamination, and heavy metal concentrations. At selected sites, indoor mold spore concentrations were compared to outdoor concentrations. The purpose of this study was to conduct a baseline environmental assessment in an effort to identify public health threats caused by wind and flood damage. Surface waters contained high concentrations of bacterial indicators whereas no bacteria were detected in tap water, even from taps containing no chlorine residual. Sediment samples contained concentrations of lead and arsenic similarto pre-Katrina concentrations. Outdoor total spore (sp) concentrations ranged from >6500 to 84 713 sp/m(3). Indoor concentrations ranged from 6142 to 735 123 sp/m(3). For the 13 locations with matched indoor/ outdoor samples, the mean indoor/outdoor spore ratio was 4.11 (ranging from 0.27 to >11.44). Inside 5 of the 13 homes, total spore counts/m(3) exceeded 100 000, with measurements in the moldiest home exceeding 700 000 sp/ m(3). In conclusion, surface waters had high concentrations of bacterial contamination but no bacterial indicators were present in tap water. Sediment samples did not have appreciable increases in lead or arsenic. Flooded homes, however, contained substantial concentrations of mold which could present a public health exposure route to individuals repopulating and restoring the City of New Orleans.

Rapidly growing populations and migration to urban areas in developing countries has resulted in a vital need for the establishment of centralized water systems to disseminate potable water to residents. Protected source water and modern, well-maintained drinking water treatment plants can provide water adequate for human consumption. However, ageing, stressed or poorly maintained distribution systems can cause the quality of piped drinking water to deteriorate below acceptable levels and pose serious health risks. This review will outline distribution system deficiencies in developing countries caused by: the failure to disinfect water or maintain a proper disinfection residual; low pipeline water pressure; intermittent service; excessive network leakages; corrosion of parts; inadequate sewage disposal; and inequitable pricing and usage of water. Through improved research, monitoring and surveillance, increased understanding of distribution system deficiencies may focus limited resources on key areas in an effort to improve public health and decrease global disease burden.

Microbial monitoring was conducted over a period of more than 1 year at three full-scale riverbank filtration (RBF) facilities, located in the United States along the Ohio, Missouri, and Wabash Rivers. Results of this study demonstrated the potential for RBF to provide substantial reductions in microorganism concentrations relative to the raw water sources. Cryptosporidium and Giardia were detected occasionally in the river waters but never in any of the well waters. Average concentrations and log reductions of Cryptosporidium and Giardia could not be accurately determined due to the low and variable concentrations in the river waters and the lack of detectable concentrations in the well waters. Average concentrations of aerobic and anaerobic spore-forming bacteria, which have both been proposed as potential surrogates for the protozoans, were reduced at the three facilities by 0.8 to > 3.1 logs and 0.4 to > 4.9 logs, respectively. Average concentrations of male-specific and somatic bacteriophage were reduced by > 2.1 logs and 3.2 logs, respectively. Total coliforms were rarely detected in the well waters, with 5.5 and 6.1 log reductions in average concentrations at the two wells at one of the sites relative to the river water. Average turbidity reductions upon RBF at the three sites were between 2.2 and 3.3 logs. Turbidity and microbial concentrations in the river waters generally tracked the river discharge; a similar relationship between the well water concentrations and river discharge was not observed, due to the low, relatively constant well water turbidities and lack of a significant number of detections of microorganisms in the well waters. Further research is needed to better understand the relationships among transport of pathogens (e.g., Cryptosporidium, Giardia, viruses) and potential surrogate parameters (including bacterial spores and bacteriophage) during RBF and the effects of water and sediment characteristics on removal efficiency.

BACKGROUND: Chronic arsenic exposure has been associated with an increased risk of cardiovascular disease; diabetes; cancers of the lung, pancreas and prostate; and all-cause mortality in American Indian communities in the Strong Heart Study. OBJECTIVE: The Strong Heart Water Study (SHWS) designed and evaluated a multilevel, community-led arsenic mitigation program to reduce arsenic exposure among private well users in partnership with Northern Great Plains American Indian Nations. METHODS: A cluster randomized controlled trial (cRCT) was conducted to evaluate the effectiveness of the SHWS arsenic mitigation program over a 2-y period on a) urinary arsenic, and b) reported use of arsenic-safe water for drinking and cooking. The cRCT compared the installation of a pointof- use arsenic filter and a mobile Health (mHealth) program (3 phone calls; SHWS mHealth and Filter arm) to a more intensive program, which included this same program plus three home visits (3 phone calls and 3 home visits; SHWS Intensive arm). RESULTS: A 47% reduction in urinary arsenic [geometric mean (GM)=13.2 to 7.0 μg/g creatinine] was observed from baseline to the final follow-up when both study arms were combined. By treatment arm, the reduction in urinary arsenic from baseline to the final follow-up visit was 55% in the mHealth and Filter arm (GM=14.6 to 6.55 μg/g creatinine) and 30% in the Intensive arm (GM=11.2 to 7.82 μg/g creatinine). There was no significant difference in urinary arsenic levels by treatment arm at the final follow-up visit comparing the Intensive vs. mHealth and Filter arms: GM ratio of 1.21 (95% confidence interval: 0.77, 1.90). In both arms combined, exclusive use of arsenic-safe water from baseline to the final follow-up visit significantly increased for water used for cooking (17% to 53%) and drinking (12% to 46%). DISCUSSION: Delivery of the interventions for the community-led SHWS arsenic mitigation program, including the installation of a point-of-use arsenic filter and a mHealth program on the use of arsenic-safe water (calls only, no home visits), resulted in a significant reduction in urinary arsenic and increases in reported use of arsenic-safe water for drinking and cooking during the 2-y study period. These results demonstrate that the installation of an arsenic filter and phone calls from a mHealth program presents a promising approach to reduce water arsenic exposure among private well users. [ABSTRACT FROM AUTHOR]

Background: Use of engineered nanoparticles (NPs) in consumer products is resulting in NPs in drinking water sources. Subsequent NP breakthrough into treated drinking water is a potential exposure route and human health threat. Objectives: In this study we investigated the breakthrough of common NPs-silver (Ag), titanium dioxide (TiO2), and zinc oxide (ZnO)-into finished drinking water following conventional and advanced treatment. Methods: NPs were spiked into five experimental waters: groundwater, surface water, synthetic freshwater, synthetic freshwater containing natural organic matter, and tertiary wastewater effluent. Bench-scale coagulation/flocculation/sedimentation simulated conventional treatment, and microfiltration (MF) and ultrafiltration (UF) simulated advanced treatment. We monitored breakthrough of NPs into treated water by turbidity removal and inductively coupled plasma-mass spectrometry (ICP-MS). Results: Conventional treatment resulted in 2-20%, 3-8%, and 48-99% of Ag, TiO2, and ZnO NPs, respectively, or their dissolved ions remaining in finished water. Breakthrough following MF was 1-45% for Ag, 0-44% for TiO2, and 36-83% for ZnO. With UF, NP breakthrough was 0-2%, 0-4%, and 2-96% for Ag, TiO2, and ZnO, respectively. Variability was dependent on NP stability, with less breakthrough of aggregated NPs compared with stable NPs and dissolved NP ions. Conclusions: Although a majority of aggregated or stable NPs were removed by simulated con­ventional and advanced treatment, NP metals were detectable in finished water. As environmental NP concentrations increase, we need to consider NPs as emerging drinking water contaminants and determine appropriate drinking water treatment processes to fully remove NPs in order to reduce their potential harmful health outcomes. [ABSTRACT FROM AUTHOR]

Decentralized membrane filtration systems (DMFS) have the potential to supply safe drinking water in low-income countries (LICs) where centralized municipal water treatment is practically infeasible. This study aimed at applying an integrated bench-scale and field-testing approach to assess the sustainability of a DMFS in producing safe drinking water in LICs. The state-of-the-art DMFS employed in this study was capable of removing bacteria, surrogate parasites, and viruses at log reductions above 7, 5, and 4, respectively, from evaluated waters (n=4). The technological sustainability of the DMFS was primarily affected by membrane fouling, and a linear correlation was found between the reversible/irreversible fouling rates of a miniature bench-scale system and those of the full-size DMFS caused by representative types of source waters. The total and irreversible fouling rates of the full-size DMFS were approximately 50% of those of the miniature system, regardless of the properties of the source waters. Similar quantitative relationships may be established between the fouling rates of the bench-scale system and those of other full-size DMFS. Overall, easy and cost-effective fouling control is warranted for sustainable application of DMFS in LICs, and bench-scale membrane testing serves as a potential screening tool for this purpose. [ABSTRACT FROM AUTHOR]

The routine use of multiple water sources to meet household water needs is widely practiced and has been reported in many developing countries. However, it is typically neglected by implementers, development organizations, and researchers who tend to focus exclusively on the "main source of drinking water." In this Perspective, we explain the nature and scope of multiple water source use (MWSU) at the household level in developing countries. We also describe the implications of MWSU for human health and water resilience, and identify key knowledge gaps, risks, and opportunities associated with MWSU. Finally, we argue that understanding MWSU is feasible for researchers and implementers and is essential for properly designing research studies and water supply projects. [ABSTRACT FROM AUTHOR]