Drinking Water Disinfection in the United States: Balancing Infectious Disease, Cancer and Costs, Market and Nonmarket Failures

  • Ronnie Levin
  • Mark A. R. Kleiman
Part of the Water Science and Technology Library book series (WSTL, volume 46)


Arguably, the most important public health improvement of the 20th century is the virtual elimination of the most deadly waterborne infectious diseases, such as cholera, through the treatment of drinking water (CDCP, 1999). But current treatment practices have not reduced health risks to zero. Recent studies indicate that waterborne infectious disease (WBID) — albeit less severe — remains more widespread in the U.S. than previously thought. On the other hand, the disinfection methods used in the U.S., most commonly chlorine species, produce a variety of disinfection by-products (DBPs), some of them carcinogenic. Addressing microbial risks by increasing disinfectant doses or longer exposure times will exacerbate the DBP problem. There are solutions that address both WBID and DBPs simultaneously, such as filtration, especially microfiltration and nanofiltration, or improved distribution operations and maintenance, but they also have their advantages and disadvantages, including higher costs.


Drinking Water Water Utility Gastrointestinal Illness Giardia Infection Intestinal Infectious Disease 
These keywords were added by machine and not by the authors. This process is experimental and the keywords may be updated as the learning algorithm improves.


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  1. Akin EW, Jakubowski W., 1986. Drinking water transmission of giardiasis in the United States. Wat Sci Tech, 18(10): 219–226.Google Scholar
  2. Anadu EC, Harding AK., 2000. Risk perception and bottled water use. J Am Water Works Assoc, 92 (11): 14, 82–92.Google Scholar
  3. Aramini J, McLean M, Wilson J, Holt J, Copes R, Allen B, Sears W., 2000. Drinking water quality and health care utilization for gastrointestinal illness in Greater Vancouver. Health Canada; October 30.Google Scholar
  4. Barwick RS, Levy DA, Craun GF, Beach MJ, Calderon RL., 2000. Surveillance for waterborne-disease outbreaks B United States, 1997–1998. In: CDC Surveillance Summaries, May 26, Morb Mort Wkly Repts; 49 (No. SS04): 1–35.Google Scholar
  5. Bennett JV, Holmberg SD, Rogers MF, Solomon SL., 1987. Infectious and parasitic diseases. In: Closing the Gap: The Burden of Unnecessary Illness (ed: Amler and Dull); Oxford University Press; New York, Oxford:102–114.Google Scholar
  6. Berger PS, Regli S, Almodovar L., 1992. Cryptosporidium control in drinking water. In: Proceedings of the 1992 American Water Works Association Annual Conference, Canada: 845–864.Google Scholar
  7. Bove FJ, Fulcomer MC, Bove Klotz JB, Esmart J, Dufficy EM, Savrin JE., 1995. Public Drinking Water Contamination and Birth Outcomes. Am J Epidemiol 141 (9): 850–862.Google Scholar
  8. Cantor KP. Water chlorination, mutagenicity and cancer epidemiology., 1994. Am J Pub Health, 84(8): 1211 – 1213.CrossRefGoogle Scholar
  9. Cantor KP., 1997. Drinking water and cancer. Cancer Causes Cont, 8: 292–308.CrossRefGoogle Scholar
  10. Cantor KP, Lynch CF, Hildesheim ME, Dosemeci M, Lubin J, Alavanja M, Craun G., 1998. Drinking water source and chlorination byproducts. I. Risk of bladder cancer. Epidemiol, 9(1): 21–28.CrossRefGoogle Scholar
  11. Cantor KP, Lynch CF, Hildesheim ME, Dosemeci M, Lubin J, Alavanja M, Craun G., 1999. Drinking water source and chlorination byproducts in Iowa. III. Risk of brain cancer. Am J Epidemiol, 150(6): 552–560.CrossRefGoogle Scholar
  12. CDCP (Center for Disease Control and Prevention), 1999. Ten great public health achievements United States, 1900–1999. Morbid Mortal Wkly Rpt, 48(12): 241–243.Google Scholar
  13. Chauret C, Armstrong N, Fisher J, Sharma R, Springthorpe S, Sattar S.,1995. Correlating Cryptosporidium and Giardia with microbial indicators. J Am Water Works Assoc, 87(11): 76–84.Google Scholar
  14. Colford JM, Rees JR, Wade TJ, Khalakdina A, Hilton JF, Ergas U, Burns S, Benker A, Ma C, Bowen C, Mills DC, Vugia DJ, Juranek DD, Levy DA, 2002. Participant blinding and gastrointestinal illness in a randomized, controlled trial of an in-home drinking water system. Emerging Infectious Diseases 8 (1), January. Available at–0481.html.Google Scholar
  15. Doyle TJ, Zheng W, Cerhan JR, Hong C-P, Sellers TA, Kushi LH, Folsom AR, 1997. The association of drinking water source and chlorination by-products with cancer incidence among post-menopausal women in Iowa: a prospective cohort study. Am J Public Health 1997, 87(7): 1168–1176.CrossRefGoogle Scholar
  16. Dunnick JK, Melnick RL, 1993. Assessment of the carcinogenic potential of chlorinated water: experimental studies of chlorine, chloramine and trihalomethanes. J Natl Cancer Inst, 85(10): 817–822.CrossRefGoogle Scholar
  17. EPA, 1994a. Proposed Enhanced Surface Water Treatment Rule. 59 FR 38832 (July 29).Google Scholar
  18. EPA, 1994b. Proposed Disinfectants and Disinfection By-product Rule. 59 FR 38668 (July 29).Google Scholar
  19. EPA, 1994c. Proposed Monitoring Requirements for Public Drinking Water Supplies. 59 FR 6332 (Feb. 10).Google Scholar
  20. EPA, 1997. Guidelines for Preparing Economic Analyses. Office of Policy, Planning and Evaluation; Washington, D.C.Google Scholar
  21. EPA, 1998a. Interim Enhanced Surface Water Treatment Rule. 63 FR 69477 (December 16).Google Scholar
  22. EPA, 1998b. Disinfectants and Disinfection Byproducts Rule. 63 FR 69389 (December 16).Google Scholar
  23. EPA, 1998c. Quantification of Bladder Cancer Risk from Exposure to Chlorinated Surface Water. Office of Water; Office of Science and Technology; Washington DC (November 9).Google Scholar
  24. EPA, 1998d. Regulatory Impact Analysis for the Interim Enhanced Surface Water Treatment Rule. Prepared by the Cadmus Group and SAIC for EPA Office of Water; US EPA contract 68-C6–0059.Google Scholar
  25. EPA, 1998e. Regulatory Impact Analysis for the Stage I Disinfectants/Disinfection Byproducts Rule. Prepared by the Cadmus Group and SAIC for EPA Office of Water; US EPA contract 68-C6–0059.Google Scholar
  26. EPA, 2002. Drafi Handbook for Non-Cancer Health Effects Valuation. Available at: Scholar
  27. Ford TE, 1999. Microbiological safety of drinking water: United States and global perspectives. Envir Health Persp, 107 (Supplement 1): 191–206.Google Scholar
  28. Freedman DM, Cantor KP, Lee NL, Chen LS, Hei HH, Ruhl CE, Wang SS, 1997. Bladder cancer and drinking water: a population-based case-control study in Washington County, Maryland (United States). Cancer Causes Control, 8(5): 738–744.CrossRefGoogle Scholar
  29. French AS, Copeland CB, Andrews D, Williams WC, Riddle MM, Luebke RW, 1999. Evaluation of the potential immunotoxicity of bromodicholoromethane in rats and mice. J Toxicol Environ Health A, (Mar 12): 56(5): 297–310.CrossRefGoogle Scholar
  30. Frost FJ, Craun GF, Calderon RL, 1996. Waterborne disease surveillance. J Am Water Works Assoc, 88(9): 66–75.Google Scholar
  31. Garthright WE, Archer DL, Kvenberg JE, 1988. Estimates of incidence and costs of intestinal infectious diseases in the United States. Public Health Rpts, 103(2): 107–115.Google Scholar
  32. George SE, Nelson GM, Swank AE, Brooks LR, Bailey K, George M, DeAngelo A, 2000. The disinfection by-products dichloro-, dibromo-, and bromochloroacetic acid impact intestinal microflora and metabolism in Fischer 344 rats upon exposure in drinking water. Toxicol Sci, 56(2- August): 282–289.CrossRefGoogle Scholar
  33. Goldstein ST, Juranek DD, Ravenholt O, Hightower AW, Martin DG, Mesnik JL, Griffiths SD, Bryant AJ, Reich RR, Herwaldt BL, 1996. Cryptosporidiosis: An outbreak associated with drinking water despite state-of-the-art water treatment. Annals Int Med (March), 124(5): 459–468.CrossRefGoogle Scholar
  34. Grubbs WD, Macler BA, Regli S, 1992. Simulation of microbial occurrence, exposure and health risks after drinking water treatment processes. Prepared for EPA Office of Drinking Water; EPA Report 811-B-92–005; Washington, DC.Google Scholar
  35. Guerrant RL and Hughes JM, 1985. Nausea, vomiting, and noninflammatory diarrhea. In: Principles and Practice of Infectious Diseases’, Mandeli, Douglas, Bennett, editors; John Wiley and Sons; New York: 646–655.Google Scholar
  36. Harrington W, Krupnick AJ, Spofford WO, 1991. Economics and Episodic Disease. Resources for the Future; Washington, DC.Google Scholar
  37. Harvey S, Greenwood JR,Pickett MJ, Man RA, 1976. Recovery of Yersinia enterocolitica from streams and lakes of California. Appl Envir Microbiol, 32(3): 352–354.Google Scholar
  38. Havelaar AH, De Hollander AEM, Teunis PFM, Evers EG, Van Kranen HJ, Versteegh JFM, Van Koten JEM, Slob W, 2000. Balancing the risks and benefits of drinking water disinfection: disability adjusted life-years on the scale. Environ Health Persp, 108(4): 315–321.CrossRefGoogle Scholar
  39. Herwaldt BL, Craun GF, Stokes SL, Juranek DD, 1991. Waterborne disease outbreaks, 1989–1990. In: CDC Surveillance Summaries, December Morb Mort Wkly Repts, 40 (No. SS-3): 1–22.Google Scholar
  40. Hildesheim ME, Cantor KP, Lynch CF, Dosemeci M, Lubin J, Alavanja M, Craun G, 1998. Drinking water source and chlorination byproducts. II. Risk of colon and rectal cancers. Epidemiol, 9(1): 29–35.CrossRefGoogle Scholar
  41. Hill DR, 1985. Giardia lamblia. In: Principles and Practice of Infectious Diseases’, Mandeli, Douglas, Bennett, editors; John Wiley and Sons; New York: 1552–1556.Google Scholar
  42. Hunter PR, Quigley C, 1998. Investigation of an outbreak of cryptosporidiosis associated with treated surface water finds limits to the value of case control studies. Commun Dis Public Health, 1 (4- Dec): 234–238.Google Scholar
  43. Hurst CJ, 1991. Presence of enteric viruses in freshwater and their removal by the conventional drinking water treatment process. Bull World Health Org, 69 (1): 113–119.Google Scholar
  44. Ijesselmuiden CB, Gaydos C, Feighner B, Novakoski WL, Serwadda D, Cans LH, Viahov D, Comstock G, 1992. Cancer of the pancreas and drinking water: a population-based case-control study in Washington County, Maryland. Am J Epidemiol, 136(7): 836–842.CrossRefGoogle Scholar
  45. Immerman FW, 1997. 1986 Survey of Community Water Systems. Report prepared by Research Triangle Institute for US EPA, Office of Drinking Water; Research Triangle Park, NC; report RTI/7805/02–02F.Google Scholar
  46. International Bottled Water Association, 1996. Sales and market data from: Beverage Marketing Corporation, Bottled Water in the US; Alexandria, Virginia.Google Scholar
  47. Jones TC, 1985. Other protozoa, including Cryptosporidium, Sarcocystis, Isospora, and Balantidium coli. In: Principles and Practice of Infectious Diseases; Mandeli, Douglas, Bennett, editors; John Wiley and Sons; New York: 1560–1562.Google Scholar
  48. Keswick BH, Satterwhite TK, Johnson PC, DuPont HL, Secor SL, Bitsura JA, Gary GW, Hoff JC, 1985. Inactivation of Norwalk Virus in drinking water by chlorine. Appl Environ Microbiol 51 (Aug;): 261–264.Google Scholar
  49. Koivusalo M, Jaakkola JJK, Vartiainen T, Hakulinen T, Karjaleinen S, Pukkala E, Tuomisto J, 1994. Drinking water mutagenicity and gastrointestinal and urinary tract cancers: an ecological study in Finland. Am J Public Health: 84(8): 1223–1228.CrossRefGoogle Scholar
  50. Koivusalo M, Vartiainen T, Hakulinen T, Pukkala E, Jaakkola JJK, 1995. Drinking water mutagenicity and leukemia, lymphomas, and cancers of the liver, pancreas and soft tissue. Arch Environ Health, 50(4): 269–275.CrossRefGoogle Scholar
  51. Klotz JB, Pyrch LA, 1999. Neural tube defects and drinking water disinfection by-products. Epidemiol, 10(4-July): 383–390.CrossRefGoogle Scholar
  52. Kramer MH, Herwaldt BL, Craun GF, Calderon RL, Juranek DD, 1996. Waterborne disease: 1993 and 1994. J Am Water Works Assoc, 88(3): 66–80.Google Scholar
  53. Landi S, Hanley NM, Warren SH, Pegram RA, DeMarini DM, 1999. Induction of genetic damage in human lymphocytes and mutations in Salmonella by trihalomethanes: role of red blood cells and GSTT1–1 polymorphism. Mutagenesis, 14(5- Sept.): 479–482.CrossRefGoogle Scholar
  54. LeChevallier MW, Norton WD, Lee RG. 1991a. Occurrence of Giardia and Cryptosporidium spp. in surface water supplies. Appl Environ Microbiol, 57 (9): 2610–2616.Google Scholar
  55. LeChevallier MW, Norton WD, Lee RG. 1991b. Giardia and Cryptosporidium spp. in filtered water supplies. Appl Environ Microbiol, 57 (9): 2617–2621.Google Scholar
  56. Levin R, Kleiman MAR. 1999. Drinking water treatment: balancing infectious disease, cancer and cost. In: The Substance of Public Policy, ed: SS Nagle, Nova Science Publishers, Inc; New York: 117–137.Google Scholar
  57. Levin R, Epstein P, Ford TE, Harrington H, Olson E, Riechard E, 2002. US drinking water challenges in the 21st century. Envir Health Persp Annual Review 110 (Suppl 1): 43–52.CrossRefGoogle Scholar
  58. Levine WC, Stephenson WT, Craun GF, 1990. Waterborne disease outbreaks, 1986–1988. In: CDC Surveillance Summaries, March 1990. Morb Mort Wkly Repts, 39 (No. SS-1): 1–14.Google Scholar
  59. Levy DA, Bens MS, Craun GF, Calderon RL, Herwaldt BL, 1998. Surveillance for waterborne-disease outbreaks United States, 1995–1996. In: CDC Surveillance Summaries, December 11, Morb Mort Wkly Repts; 47(5): 1–34.Google Scholar
  60. MacKenzie WR, Hoxie NJ, Proctor ME, Gradus MS, Blair KA, Peterson DE, Kazmierczak JJ, Addiss DG, Fox KR, Rose JB, Davis JP, 1994. A massive outbreak in Milwaukee of Cryptosporidium infection transmitted through the public water supply. New Eng J Med, 331: 161–167.CrossRefGoogle Scholar
  61. Mitchell RC, Carson R, 1986. Valuing Drinking Water Risk Reductions using Contingent Valuation Methods: A methodological study of risks from THM and Giardia. Resources for the Future; Washington, DC.Google Scholar
  62. Moore AC, Herwaldt BL, Craun GF, Calderon RL, Highsmith AK, Juranek DD, 1993. Surveillance for waterborne disease outbreaks — United States, 1991–1992. In: CDC Surveillance Summaries, November 1993. Morb Mort Wkly Repts, 42 (No. SS-5): 1–22.Google Scholar
  63. Moore MJ, Viscusi WK, 1988. Doubling the estimated value of life: results using new occupational fatality data. J Policy Anal Mgmt, (3): 476–490.CrossRefGoogle Scholar
  64. Morris RD, Audet A-M, Angelillo IF, Chalmers TC, Mosteller F, 1993. Chlorination, chlorination byproducts, and cancer: a meta-analysis. Am J Public Health 1992; 82(7): 955–963.CrossRefGoogle Scholar
  65. Also, Erratum. 1993. Am J Public Health, 83(9): 1257.CrossRefGoogle Scholar
  66. Morris RD., and R. Levin, 1995. Estimating the incidence of waterborne infectious disease related to drinking water in the United States. In: Assessing and Managing Health Risks from Drinking Water Contamination: Approaches and Applications (Reichard and Zapponi, editors); IAHS Press (International Association of Hydrological Sciences); Great Britain: 75–88.Google Scholar
  67. Morris RD, Naumova EN, Levin R, Munasinghe RL, 1996. Temporal variation in drinking water turbidity and physician diagnosed gastrointestinal infections in Milwaukee. Am J Public Health, 86(2): 237–239.CrossRefGoogle Scholar
  68. Morris RD, Naumova EN, Griffiths JK, 1998. Did Milwaukee experience waterborne cryptosporidiosis before the large documented outbreak in 1993? Epidemiol, 9(3): 264–270.CrossRefGoogle Scholar
  69. Murphy PA, Craun GF, 1990. A review of recent epidemiologic studies reporting associations between drinking water disinfection and cancer. In: Water Chlorination: Chemistry, Environmental Impact and Health Effects (Jolley et al, editors); Lewis Publishers; Chelsea, Michigan: 361–372.Google Scholar
  70. Ongerth JE, 1989. Giardia cyst concentrations in river water. J Am Water Works Assoc, 81(9): 81–86.Google Scholar
  71. Payment P, 1999. Poor efficacy of residual chlorine disinfectant in drinking water to inactivate waterborne pathogens in distribution systems. Can J Microbiol, 45: 709–715.CrossRefGoogle Scholar
  72. Payment P, Richardson L, Siemiatycki J, Dewar R, Edwardes M, Franco E, 1991. A randomized trial to evaluate the risk of gastrointestinal disease due to the consumption of drinking water meeting current microbiological standards. Am J Public Health, 81:703–708.CrossRefGoogle Scholar
  73. Payment P, Siemiatycki J, Richardson L Renaud G, Franco E, Prevost M, 1997. A prospective epidemiological study of gastrointestinal health effects due to the consumption of drinking water. Internatl J Environ Health, 1:5–31.CrossRefGoogle Scholar
  74. Perz JF, Ennever FK, Le Blanq SM, 1998. Cryptosporidium in tap water: comparison of predicted risks with observed levels of disease. Am J Epidemiol, 147(3) 289–301.CrossRefGoogle Scholar
  75. Raucher RS, Dixon AM, Trabka E, Drago JA, 1994. Cost effectiveness of SDWA regulations. J Am Water Works Assoc, 88 (8- Aug.): 28–36.Google Scholar
  76. Rose JB, Gerba CP, Jakubowski W, 1991. Survey of potable water supplies for Cryptosporidium and Giardia. Envir Sci Tech, 25(8): 1393–1400.CrossRefGoogle Scholar
  77. Sax NI, Lewis RJ, 1989. Dangerous Properties of Industrial Materials. Von Nostrand; Reinhold, New York.Google Scholar
  78. Schwartz J, Levin R, Hodge K, 1997. Drinking water turbidity and pediatric hospital use for gastrointestinal illness in Philadelphia. Epidemiol, 8: 615–620.Google Scholar
  79. Schwartz J, Levin R, Goldstein R, 2000. Drinking water turbidity and gastrointestinal illness in Philadelphia=s elderly. J Epidemiol Comm Health, 54: 45–51.CrossRefGoogle Scholar
  80. Singer PC. 1993. Formation and characterization of disinfection by-products. In: Safety of Water Disinfection: Balancing chemical and microbial risks (Craun, editor); ILSI (International Life Sciences Institute) Press; Washington, DC: 201–220.Google Scholar
  81. St. Louis ME, 1988. Water-related disease outbreaks, 1985. In: CDC Surveillance Summaries, June 1988. Morb Mort Wkly Repts, 37 (No. SS-2): 15–24.Google Scholar
  82. Swan SH, Waller K, Hopkins B, Windham G, Fenster L, Schaefer C, Neutra, RR, 1998. A prospective study of spontaneous abortion: relation to amount and source of drinking water consumed in early pregnancy. Epidemiology 9(2): 126–133.CrossRefGoogle Scholar
  83. Thomas C, Gibson H, Hill DJ, Mabey M, 1999. Campylobacter epidemiology: an aquatic perspective. J Appl Microbiol Symposium Supplement, 85: 168S–177S.CrossRefGoogle Scholar
  84. Vena JE, Graham S, Freudenheim J, Marshall J, Zielezny M, Swanson M, Sufrin G, 1993. Drinking water, fluid intake, and bladder cancer in western New York. Arch Environ Health, 48(3): 191–198.CrossRefGoogle Scholar
  85. Waller K, Swan SH, DeLourenze G, Hopkins B, 1998. Trihalomethanes in drinking water and spontaneous abortion. Epidemiology 9(2): 134–140.CrossRefGoogle Scholar
  86. Water Quality Association, 1996. Customer Survey, Lisle, Illinois.Google Scholar

Copyright information

© Springer Science+Business Media Dordrecht 2003

Authors and Affiliations

  • Ronnie Levin
    • 1
  • Mark A. R. Kleiman
    • 2
  1. 1.Harvard University School of Public HealthUSA
  2. 2.University of CaliforniaLos AngelesUSA

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