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Governments in developing countries face financial constraints to ensure supply of clean drinking water. They may benefit from increasing water charges for those who are be willing to pay little extra in lieu of their demand for improvement in water quality and service. To check the plausibility of this proposal, we investigated drinking water supply and quality, and welloff consumers demand for improved service delivery in Shah-Rukun-e-alam and Mumtazabad towns in Multan city of Pakistan. Qualitative data obtained through a questionnaire survey was analyzed using descriptive and regression techniques. Qualitative information obtained through semi structured interviews was helpful in designing survey questionnaire and to elaborate quantitative results. Results reveal that the respondents accord high importance to the provision of safe drinking water than to other daily household needs. The demand for improvement in water supply parameters exceeds the demand for improvements in water quality parameters, with the reliable supply being the most demanded improvement. Majority realize the government’s budget constraints in improving service delivery. Most respondents would pay PKR 100 in addition to what they are paying now. Their willingness to pay (WTP) this amount correlates with their awareness on water and health nexus, and depends household income, number of children under 14 years age and awareness of actual water quality tested through laboratory. Besides recommending raise of water charges by PKR 100 per month per household in both towns, the service quality improvement may consider interventions such as mobile water testing laboratory and awareness campaigns motivate citizens to pay for safe drinking water.

Nosocomial Legionnaires’ disease, caused by the waterborne bacterial species Legionella, is a potentially preventable hospital-associated infection. Legionella bacteria are ubiquitous in both natural water sources and manmade potable water systems. Exposure of vulnerable hospitalized patients to Legionella bacteria in a hospital’s potable water system can result in clinically significant and potentially mortal disease. Testing a healthcare system’s potable water system is always indicated in the workup of healthcare-associated Legionnaires’ disease cases and may be performed for primary and secondary prevention. Legionella require specific conditions to grow, and culture methodology may affect the sensitivity of testing. The timing, methodology, and follow-up of water testing for Legionella in the healthcare setting remain controversial.

Majority African-American neighborhoods on the edges of North Carolina municipalities are less likely than white peri-urban neighborhoods to be served by a community system regulated under the Safe Drinking Water Act. These households rely on unregulated private wells, which are at much higher risk of contamination than neighboring community water supplies. Yet, risk awareness of consuming well water is low, and no prior research has tested risk communication interventions for these communities. We present a randomized-controlled trial of an oversized postcard to promote water testing among this audience. The postcard design followed the mental models approach to risk communication. To our knowledge, this is the first U.S. randomized-controlled trial of a mailed communication to promote water testing in any audience and one of few trials of the mental models approach. We evaluated the postcard's effects on self-reported water testing with and without a free water test offer (vs. no-intervention control) via a survey mailed one month after the interventions. The combined communication and free test doubled the odds of self-reported water testing, compared to the control group (p = 0.046). It increased the odds of testing by 65%, compared to the free test alone. Recall of receiving a postcard about water testing increased the odds of self-reported testing twelve-fold (p < 0.001). Although these results suggest that targeted risk information delivered by mail can promote water testing when paired with a free test, the mechanism remains unclear. Additional research on beliefs influencing perceptions about well water may yield interventions that are even more effective.

Background Haemato-oncology patients are at increased risk of infection from atypical mycobacteria such as Mycobacterium chelonae which are commonly found in both domestic and hospital water systems. Aims To describe the investigation and control measures following two patient cases of M. chelonae and positive water samples in our hospital. Methods Water testing was undertaken from outlets, storage tanks and mains supply. We utilised whole genome sequencing (WGS) to compare patient and positive water samples. We describe the subsequent infection control measures implemented. Findings The WGS results showed two main populations of M. chelonae within the group of sampled isolates. The results showed that the patient strains were unrelated to each other but that the isolate from one patient was closely related to environmental samples from water outlets, supporting nosocomial acquisition. Conclusions We describe the utility of WGS in the investigation of two patient cases of M. chelonae, and positive water samples from a hospital water supply. We discuss relevant control measures and the potential for chemical dosing of water systems to enhance proliferation of atypical mycobacteria. Postprint

‘Jivanam jivinam jivaha’ is a Sanskrit shlok, cited in an Ayurveda text ‘Bhavaprakash,’ which translates to ‘water is life to creatures.’ Water has always been an important source of life on Earth. However, today’s water crisis is gripping. In July 2019, Chennai witnessed an acute water crisis, after one of the main reservoirs completely dried up. A report by NITI AYOG pointed out that 21 major cities in India would run out water supply by 2020 (Aayog, “Composite water management index-A tool for water management,” August 2019.). In response to this national water crisis, in 2019, the government of India urged its citizens to start a mass movement for water conservation and formed a dedicated ministry to look into water-related affairs. The paper questions this preparedness of citizens of India to counter this catastrophe and whether their systems comply with the idea of the conservation of water that do not allow for an unnecessary water wastage. The blind installation of RO filters, in urban spaces, in the fear of consuming ‘impure’ water, causes three times the amount of filtered water, to be drained off through reverse osmosis reject system. This has two grave consequences, one on the underground water reserves and the other on the human body. Examining these consequences, this paper will try to understand the fascination with RO filters and its hold over the masses. The paper will make an important intervention by raising the unasked question, are the RO filters necessary and if they do more harm than good? Finally, the paper will end with a feasible solution that may replace the damaging control that RO filters have over the masses. This research started with a design perspective of rethinking how RO water filters should be seen amidst this water crisis. Tests were made, for TDS and pH value, on samples collected from raw and municipal water sources with a brief survey to understand the psychological status of the market.

During and after conflicts, many live-saving facilities are devastated and damaged including water supply. The little amount of water that may be available needs to be thoroughly checked to be sure of its safety and quality for use. Chemical compounds in plants have different benefits. However, water resources including drinking water can be poisoned or contaminated by the same phytochemicals and can cause damage to other living organisms. This chapter highlighted the different possible types of water phyto-contamination. Four analytical methods in determination of phytochemicals were discussed, namely gas chromatograph, high-performance liquid chromatography (HPLC), utra-violet visible (UV-vis) spectroscopy, and time of flight mass spectrometry coupled liquid chromatography. However, this chapter recommended HPLC as more efficient in determining the phyto-contamination in water. This method separates eluents in solid and liquid forms. However, HPLC may not be accessed by most of the developing world. UV-vis was recommended as an alternative. It is affordable and easy to use. Selected compounds, however, can respond to the UV-vis wavelength of 190–1100 nm. This chapter concludes that the determination of water phyto-contamination is essential and can assist in avoiding unnecessary damage.

Summary Background Cupriavidus pauculus is rare cause of clinical infection. We describe an outbreak of C. pauculus and other Gram-negative bacteraemias in a paediatric haemato-oncology unit secondary to a contaminated water supply and drainage system. Aim To describe the investigation and control measures implemented for a waterborne infection outbreak in a new build hospital. Methods Extensive water testing from various points within the water system was undertaken. Taps, showerheads and components including flow straighteners underwent microbiological analysis. Drains were also swabbed. Surveillance for Gram-negative infections was established on the unit. Findings Water testing revealed widespread contamination of the water and drainage system. Outlets were also heavily contaminated, including flow straighteners. Drains were found to have underlying structural abnormalities. Water testing enabled us to detect high-risk components within the water system such as the expansion vessels and outlets and the results assisted with hypotheses generation. Review of commissioning data and risk assessments revealed extensive risks present within the water system prior to and after hospital opening. Conclusion Careful design, adequate control measures and maintenance are essential for hospital water systems in order to prevent infections due to waterborne organisms. We discuss what can be learned from this incident with a view to future prevention.

Background Nitrate contamination in groundwater disproportionately impacts agricultural Latino communities, creating a significant hazard for Latinos that rely on private wells. Private well users must conduct water testing and other well stewardship behaviors to ensure that their well water is safe to drink. This study sought to identify the key factors impacting private well water testing behavior in rural, agricultural Latino communities. Methods We conducted 4 focus groups with private well users, 2 in Spanish and 2 in English. We recruited 37 participants from the Lower Yakima Valley, Washington State, a rural, agricultural community with a large Latino population and elevated nitrate concentrations in groundwater. A semi-structured interview guide was developed to capture factors impacting testing as guided by the Risk, Attitudes, Norms, Ability, and Self-Regulation (RANAS) model. Inductive thematic analysis was conducted by two coders to identify common themes. Results Themes emerged around the factors impacting well stewardship, including well water testing, treatment, and maintenance, and were not specific to nitrate contamination. Private well users reported many of the same factors reported in other communities, with the exception of home repair experience and challenges around landlords and neighbors on shared wells, which have not been reported previously. In addition to landlords and neighbors, lack of actionable information, economic limitations, and lack of technical support emerged as factors that made well stewardship burdensome for individuals. The majority of participants reported using bottled water, including many who used point-of-use or point-of-entry water treatment systems. Conclusions The burden of well stewardship in rural, agricultural Latino communities may suggest the need for interventions at the community, county, or state levels and not at the individual level alone. Additionally, the role of landlords, neighbors on shared wells, and home repair experience in well stewardship represent important areas of exploration for researchers and public health practitioners.

Extreme weather events including flooding can have severe personal, infrastructural, and economic consequences, with recent evidence pointing to surface flooding as a pathway for the microbial contamination of private groundwater supplies. There is a pressing need for increasingly focused information and awareness campaigns to highlight the risks posed by extreme weather events and appropriate subsequent post-event actions. To date, little is known about the presence, directionality or magnitude of gender-related differences regarding flood risk awareness and behaviour among private groundwater users, a particularly susceptible sub-population due to an overarching paucity of infrastructural regulation across many regions. The current study investigated gender-related differences in flood risk perception and associated mitigation behaviours via a cross-sectional, national survey of 405 (168 female, 237 male) private groundwater supply users. The developed survey instrument assessed socio-demographic profile, previous flood experience, experiential and conjectural health behaviours (contingent on previous experience), and Risk, Attitude, Norms, Ability, Self-regulation (RANAS) framework questions. Statistically significant gender differences were found between both &lsquo, Norm&mdash, Descriptive&rsquo, and &lsquo, Ability&mdash, Self-efficacy&rsquo, RANAS elements (p &lt, 0.05). Female respondents reported a lower level of awareness of the need for post-flood action(s) (8.9% vs. 16.5%), alongside a perceived &ldquo, lack of information&rdquo, as a reason for not testing their domestic well (4.9% vs. 11.5%). Conversely, male respondents were more likely to report awareness of their well location in relation to possible contamination sources (96.6% vs. 89.9%) and awareness of previous water testing results (98.9% vs. 93.0%). Gender-related gaps exist within the studied private groundwater reliant cohort, a sub-population which has to date remained under-studied within the context of climate change and extreme weather events. Accordingly, findings suggest that gender-focused communication and education may represent an effective tool for protecting current and future generations of global groundwater users.

Private well users are potentially exposed to a range of chemical contaminants through their drinking water. Point-of-use (POU) water treatment represents one potential solution to reduce harmful exposures through well water, but well users frequently do not adopt household treatment even if they learn their water is contaminated. This study elucidates the experiences, perceptions, and beliefs of 17 households on private wells in North Carolina that participated in a pilot-scale POU water treatment intervention to better understand the drivers and barriers of POU treatment adoption among well users. The intervention consisted of an under-sink activated carbon block POU filter designed to remove lead and two long-chain perfluoroalkyl acids. Filter effluents and influents were tested monthly for eight months. Questionnaires administered before and after the intervention showed a significant decrease in participants' perceived vulnerability to well water contamination, with 77% feeling vulnerable to poor well water quality before, compared to 23% after the filter was installed. However, the POU filters did not fully eliminate feelings of water insecurity (for example, concerns about exposure to contaminants when bathing remained). Lack of knowledge and skills associated with installing and maintaining POU treatment were important barriers to adoption for some well users. Perceptions of POU treatment were also significantly correlated with the intent to implement other well stewardship behaviors such as well water testing. The results highlight the need for strengthened outreach and support programs that provide technical assistance, education, and financial support for households relying on private wells.

This paper documents the association between water and sanitation infrastructure and health indicators in Canada for First Nations, Métis and Inuit individuals living on and off-reserve in Canada. We use two data sources: the Aboriginal Peoples Survey and a survey conducted in a First Nations community in northern Manitoba-St. Theresa Point First Nation. We find statistically significant relationships between water infrastructure and health status in both sources of data. In particular, among individuals living off-reserve, contaminated water is associated with a 5-7% lower likelihood of reporting good self-rated health and a 4% higher probability of reporting a health condition or stomach problem. Those in St. Theresa Point First Nation without running water are four times more likely to report an illness relative to those with running water. Off-reserve, this likely suggests a need for improved public education on the management of private water supplies and more frequent water testing. Our case study suggests that further investment in water/sanitation infrastructure and housing is needed in the community.

Hepatitis A virus (HAV) is an RNA virus primarily transmitted via the fecal-oral route and, in rare cases, causes liver failure and death in infected persons. Although drinking water-associated hepatitis A outbreaks in the United States are rarely reported (1), HAV was the most commonly reported etiology for outbreaks associated with untreated ground water during 1971-2008 (2), and HAV can remain infectious in water for months (3). This report analyzes drinking water-associated hepatitis A outbreaks reported to the Waterborne Disease and Outbreak Surveillance System (WBDOSS) during 1971-2017. During that period, 32 outbreaks resulting in 857 cases were reported, all before 2010. Untreated ground water was associated with 23 (72%) outbreaks, resulting in 585 (68.3%) reported cases. Reported outbreaks significantly decreased after introduction of Advisory Committee on Immunization Practices (ACIP) hepatitis A vaccination recommendations* and U.S. Environmental Protection Agency's (USEPA) public ground water system regulations.† Individual water systems, which are not required to meet national drinking water standards,§ were the only contaminated drinking water systems to cause the last four reported hepatitis A outbreaks during 1995-2009. No waterborne outbreaks were reported during 2009-2017. Water testing and treatment are important considerations to protect persons who use these unregulated systems from HAV infection.

Background An estimated four million and 43 million people in Canada and the USA use private water supplies. Private water supplies are vulnerable to waterborne disease outbreaks. Private water supplies in Canada and the USA are often unregulated and private water management is often a choice left to the owner. Perceptions of water quality become important in influencing the adoption of private water stewardship practices, therefore safeguarding public health. Methods We conducted a systematic literature review to understand factors that shape perceptions of water quality among private water users. We searched six computer databases (Web of science, Medline, Scopus, EBSCO, PubMed and Agricola). The search was limited to primary peer-reviewed publications, grey literature and excluded conference proceedings, review articles, and non-peer review articles. We restricted the search to papers published in English and to articles which published data on surveys of private water users within Canada and the USA. The search was also restricted to publications from 1986 to 2017. The literature search generated 36,478 records. Two hundred and four full text were reviewed. Results Fifty-two articles were included in the final review. Several factors were found to influence perceptions of water quality including organoleptic preferences, chemical and microbiological contaminants, perceived risks, water well infrastructure, past experience with water quality, external information, demographics, in addition to the values, attitudes, and beliefs held by well owners. Conclusions Understanding the factors that shape perceptions of water quality among private water users is an important step in developing private water management policies to increase compliance towards water testing and treatment in Canada and the USA. As many jurisdictions in Canada and the USA do not have mandatory private water testing or treatment guidelines, delineating these factors is an important step in informing future research and guiding policy on the public health of private water systems. Electronic supplementary material The online version of this article (10.1186/s13643-019-1013-9) contains supplementary material, which is available to authorized users.

We investigated the quality of treated drinking water in Aida Camp and Alazzah Camp, two Palestinian refugee camps in the West Bank. Water supply in the two camps is intermittent: Water deliveries are first stored in a centrally located community tank before being pumped through distribution networks to users, who then store the water in rooftop tanks. Between March 2016 and June 2017, we examined water quality within the distribution system in the camps, testing 520 samples in Aida Camp and 198 samples in Alazzah Camp for total coliforms, Escherichia coli (E. coli) bacteria, and residual chlorine. We observed deterioration in water quality in both camps, but the deterioration was more pronounced in Aida Camp where 2.5% of community-tank samples, 5.0% of network samples, and 10% of rooftop-tank samples contained one or more colonies (per 100 mL) of total coliform bacteria. In Alazzah Camp, 3.7% of community-tank samples, 2.5% of network samples, and 5% rooftop-tank samples contained one or more colonies (per 100 mL) of total coliform bacteria. E. coli was detected in two samples from Aida Camp and one sample from Alazzah Camp. In both camps, average residual chlorine concentrations were higher in the community tanks than in rooftop tanks. The main factor influencing water quality deterioration in rooftop tanks in Aida Camp appears to be air temperature. We recommend more systematic water testing in the camps and greater transparency in reporting test results to camp residents.

Preface and Welcoming Remarks The Worldwide Drinking Water: Problems and Prospects The Water Challenge Safe Drinking Water The Continuing Threat of Waterborne Pathogens World of Water: Beyond the International Drinking Water Supply and Sanitation Decade Ensuring the Sustainability of Small Systems Community Water Supply and Sanitation Conference Sustainable Design for Small Systems Community Participation and Management of Water Systems Linking Full-Cost Recovery and Sustainability Willingness to Pay for Improved Water Supply in Rural Communities in Venezuela Industrial Water Conservation: A Mechanism for Sustainable Resource Management Small Water Supplies in Urban Areas of Developing Countries Essential Elements for the Sustainability of Small Water Systems Water Treatment Technologies: Disinfection of Waterborne Pathogens Chlorination Systems Overview of Chlorine Dioxide, Ozone and UV Chlorine Dioxide and the Small Drinking Water System Ozone Treatment of Small Water Systems Inactivation of Cryptosporidium parvum Oocysts by Medium Pressure Ultra Violet Light Risk Management of Cryptosporidium: An Engineer's Perspective Low Cost UV Disinfection System for Developing Countries Disinfection by Mixed Oxidant Technology in a Portable Package Plant Stabilized Formulation of Hydrogen Peroxide with Silver: A Secondary Disinfectant Performance of a Small Portable Disinfection System Using Iodinated Resin Solar Water Pasteurizers Rural Disinfection Technologies in Latin America Water Treatment Technologies: Filtration and Other Treatment to Remove Microbial or Chemical Contaminants Multi-Stage Filtration: A Practical Low Cost Technology Experiences Introducing "New" Technology: Slow Sand Filtration Membrane Separation Technologies - Practical Applications Application of Immersed Microfiltration Membranes for Drinking Water Treatment Photovoltaic Electrodialysis Reversal Technology New Developments in Desalination Bag Filtration for Small Systems Appropriate Technology for Removal of Arsenic From Drinking Water of Rural West Bengal Sulfur-Limestone Autotropic Denitrification for Treatment of Nitrate-Contaminated Water During Fixed Bed Column Experiments Pre-Engineered Water Treatment Systems: Point of Entry, Point of Use, Package Plants, and Bottled Water Point-of-Entry (POE) and Point-of-Use (POU) Water Treatment Overview Selecting Residential or Personal Water Treatment Systems Point-of-Entry Treatment for a Small Community Point-of-Use Demonstration Project in Suffolk, VA Military Field Drinking Water Supply Package Water Treatment Plants in China, Ecuador and Mexico Verification Testing of Packaged Drinking Water Treatment Systems Project: Results Is Bottled Water a Feasible Alternative for Small Community Drinking Water Supply? Analytical Monitoring Effective Monitoring of Small Drinking Water Supplies Overview of Microbial Methods Chemical and Physical Measurement Methods for Small Systems Monitoring Small Water Supply Systems in the UK and Controlling the Risk of Contamination by Cryptosporidium Water Quality Monitoring in Canadian Aboriginal Communities Selection and Management of Remote Telemetry Systems for Monitoring and Operation of Small Drinking Water Treatment Plants Toward Global Drinking Water Quality Monitoring Well Remediation, Energy Sources, and Delivery of Water: Emerging Technologies and Approaches Impact of Well Remediation Chemicals on Water Quality and Deterioration Handpump Developments Wind-Electric Pumping Systems for Communities Solar Power Technology for Supplying Safe Drinking Water Systems Solutions: Management, Operation and Maintenance Experiences in Improvement of Safe Water Delivery to Poor Rural Communities by Including the Private Sector Integrated Rural Utility Systems Pre-Payment Metering of Water Area-Wide Treatment Optimization Programs Achieve Broad Scale Improvements in Drinking Water Quality Implementation of Water Supply Projects in Indigenous Communities of Northern Canada and Africa - Linkage of Experiences Management of Small Rural Systems: A Case Study in South Africa Experience With Implementation in Honduras, CA., of a Voluntary Water Association Sponsored Training and Technical Assistance Program Developed in the United States Circuit Rider Training Program in First Nations Communities Upgrading Small Military Water Works in Korea Upgrading Water Quality in Health Care Facilities Small Water System Assistance and Training Programs The Current Situation and Needs of International Assistance for Rural Water Supply in South East Asian Countries Overview of Canadian International Development Agency's Assistance Program Private Finance for Water Projects in Developing Countries Capacity Building and Resource Center Development in Water Supply and Sanitation The World University Service of Canada (WUSC) A Review of Technical Assistance and Training Programs in the United States Considerations in the Development of External Training Programs Regulatory Structures For Small Systems How the "Tapestry" of Integrated Provisions in the New Safe Drinking Water Act can Benefit Small Systems Impact of Regulatory Programs on the Quality of Drinking Water in Small Systems Problems and Successes of Small Systems in the Unites States The Case of Latin America South African Oversight of Small Water Supplies: North West Water Board Case Study Epilogue Symposium Overview and Closing Remarks Indices Author Index Exhibitor Index Key Word Index

Suppliers of potable water would benefit from a sustainable business as long as consumers continue to prefer their brand. Some of the reasons for choosing a particular brand include water quality, cost of the finished product, reliability of supply, and supplier ethics. These important determinant factors form the basis of this work. The objective is to delineate consumer preferences for water supplied to the Njala campus community, in southern Sierra Leone, and the underlying determinant factors. A list of questions administered to 140 respondents, are used to help achieve the objective. The results of water quality tests are also used to determine if quality has anything to do with consumer preference. The Oxfam Delagua water testing kit is customized to incubate and enhance counting of fecal and no-fecal coliform bacteria in water samples. Bacterial contamination is the major concern in the study area. The survey results reveal the consumers prefer package water for drinking. Treated water from Tia River is only used for other domestic purposes. The consumers do not trust the quality of water supplied from Tia River, albeit filtration and disinfection at the University’s treatment center. This distrust is confirmed by the bacterial test. None of the campus water sources meet recommended guidelines for drinking water. The consumers are, however, willing to shift preference from package to tap drinking water if treatment comes with quality assurance. The university could benefit through economic gratification, customer protection, and reduced plastic waste from package drinking water.

Background: Pre-emptive management of the water supply can reduce hospital-onset legionellosis associated with building water systems. In 2014, an outbreak of Legionella pneumonia occurred in a 1,150-bed academic medical center (with ∼0.557 km2 or ∼6 million ft2 of space) among hematology-oncology patients. A comprehensive water safety and management program was implemented after the outbreak was controlled. We describe our experience implementing this prevention program. Methods: After the Legionella outbreak was controlled, an air and water safety committee (AWSC) was established and cochaired by the healthcare epidemiologist and the chief facilities officer. The AWSC established protocols for proactive environmental testing and the development of the an infection control risk assessment (ICRA) dedicated to water safety known as the water system construction and renovation risk assessment (WSCRRA).The water system management plan (WSMP) was developed (prior to the publication of ASHRAE 188) to direct the risk assessments and mitigation of any risks throughout the campus. Results: The WSMP identifies critical control measures, points, and limits that need to be maintained to control and monitor Legionella growth in the water systems. A control point is any step in a process at which biological, chemical, or physical factors can be controlled. The UAB Medicine WSMP includes 7 control points that are monitored on a daily basis. Examples of these control steps include monitoring of the hot water temperatures at the water heaters and distal outlets, managing the levels of mono-chloramines and chlorines in the water system, and managing water system components. To validate the efficacy of the WSMP, >610 water samples are collected from 19 hospital buildings over a year to be tested for Legionella. The results of water testing have shown significant decrease in distal site positivity due to managing and controlling these control points. This WSMP also evaluated the efficacy of 2 different methods for disinfecting water systems on campus as a corrective measure to Legionella growth. These methods are hyperchlorination and temporary copper silver ionization; based on the culture results of the water samples collected post disinfection, WSMP data show that the copper silver ionization method was more effective than hyperchlorination in controlling Legionella growth and decreasing the distal site positivity. Conclusions: The WSMP has provided ongoing management of building water systems and proactive actions around construction and renovation projects that involve water systems to prevent healthcare-acquired legionellosis. We strongly recommend other healthcare facilities to implement a similar program to avoid outbreaks.Funding: NoneDisclosures: Rachael Anne Lee reports speaker honoraria from Prime Education, LLC.

AIMS To evaluate a low-cost water quality test for at-scale drinking water safety estimation in rural India. METHODS AND RESULTS Within a longitudinal study to characterize variability in household drinking water safety in rural Maharashtra, we piloted a low-cost presence-absence (LCPA) microbial test designed to be used by volunteer residents in rural areas. In comparing the LCPA results with standard laboratory methods for enumeration of Escherichia coli, we found that LCPA tests using modified mTec media were highly sensitive in detecting drinking water of moderate risk (88% of tests were positive at E. coli counts of 11-100 CFU per 100 ml) and high risk (96% of tests were positive at E. coli counts of 101 + CFU per 100 ml). The LCPA tests demonstrated low specificity for E. coli specifically, due to concurrent detection of Klebsiella: 38% of LCPA tests were positive even when E. coli was not detected in a 100 ml sample by membrane filtration, suggesting the test would be conservative in risk estimation. We also found that 47% of participants in rural villages in India were willing to conduct tests and return results after a brief training, with 45% of active participants sending their water testing results via short message service. CONCLUSIONS Given their low cost (~US$0.50 as piloted) and open-source format, such tests may provide a compelling alternative to standard methods for rapid water quality assessments, especially in resource-limited settings. SIGNIFICANCE AND IMPACT OF THE STUDY The lack of availability of water quality data constrains efforts to monitor, evaluate and improve the safety of water and sanitation infrastructure in underserved settings. Current water testing methods are not scalable because of laboratory and cost constraints. Our findings indicate the LCPA or similar low-cost microbial tests could be useful in rapid water safety estimation, including via crowdsourcing.

In Canada, over 400,000 enteric diseases related to drinking water occur each year, highlighting the importance of understanding sources of Canadians’ drinking and recreational water exposures. To address this need, a population-based telephone survey of 10,942 Canadians was conducted between 2014 and 2015, assessing Canadian's drinking water sources and recreational water exposures using a seven-day recall method. Results were analyzed by province/territory, season, age group, gender, income, education, and urban/rural status. Store-bought bottled water was reported by nearly 20% of survey respondents as their primary drinking water source, while approximately 11% of respondents reported private well. The proportion of private well users was significantly greater than the national average in the Maritime Provinces where approximately 40–56% of respondents reported this as their primary drinking water source. As expected, Canadians’ recreational water activities and exposures (e.g., swimming, pool, lake, and waterpark) peaked during summer and were most commonly reported among children aged 0–9 years. Waterborne disease in Canada requires a multi-faceted public health approach. Canadian baseline data on water exposures can inform policy and public health strategies (e.g., recreational water guidelines, private well water testing recommendations) and support research and risk assessment related to mitigating waterborne illness.

An estimated 11 million people in the US have home wells with unsafe levels of hazardous metals and nitrate. The national scope of the health risk from consuming this water has not been assessed as home wells are largely unregulated and data on well water treatment and consumption are lacking. Here, we assessed health risks from consumption of contaminated well water on the Crow Reservation by conducting a community-engaged, cumulative risk assessment. Well water testing, surveys and interviews were used to collect data on contaminant concentrations, water treatment methods, well water consumption, and well and septic system protection and maintenance practices. Additive Hazard Index calculations show that the water in more than 39% of wells is unsafe due to uranium, manganese, nitrate, zinc and/or arsenic. Most families’ financial resources are limited, and 95% of participants do not employ water treatment technologies. Despite widespread high total dissolved solids, poor taste and odor, 80% of families consume their well water. Lack of environmental health literacy about well water safety, pre-existing health conditions and limited environmental enforcement also contribute to vulnerability. Ensuring access to safe drinking water and providing accompanying education are urgent public health priorities for Crow and other rural US families with low environmental health literacy and limited financial resources.

National and sub-national governments develop and enforce regulations to ensure the delivery of safe drinking water in the United States (US) and countries worldwide. However, periodic contamination events, waterborne endemic illness and outbreaks of waterborne disease still occur, illustrating that delivery of safe drinking water is not guaranteed. In this study, we examined the potential added value of a preventive risk management approach, specifically, water safety plans (WSPs), in the US in order to improve drinking water quality. We undertook a comparative analysis between US drinking water regulations and WSP steps to analyze the similarities and differences between them, and identify how WSPs might complement drinking water regulations in the US. Findings show that US drinking water regulations and WSP steps were aligned in the areas of describing the water supply system and defining monitoring and controls. However, gaps exist between US drinking water regulations and WSPs in the areas of team procedures and training, internal risk assessment and prioritization, and management procedures and plans. The study contributes to understanding both required and voluntary drinking water management practices in the US and how implementing water safety plans could benefit water systems to improve drinking water quality and human health.

Arsenic is a class I human carcinogen that has been identified as the second most important global health concern in groundwater supplies after contamination by pathogenic organisms. Hydrogeological assessments have shown naturally occurring arsenic to be widespread in groundwater across the northeastern United States and eastern Canada. Knowledge of arsenic risk exposure among private well users in these arsenic endemic areas has not yet been fully explored but research on water quality perceptions indicates a consistent misalignment between public and scientific assessments of environmental risk. This paper evaluates knowledge of arsenic risk exposure among a demographic cross-section of well users residing in 5 areas of Nova Scotia assessed to be at variable risk (high-low) of arsenic occurrence in groundwater based on water sample analysis. An integrated knowledge-to-action (KTA) methodological approach is utilized to comprehensively assess the personal, social and local factors shaping perception of well water contaminant risks and the translation of knowledge into routine water testing behaviors. Analysis of well user survey data (n=420) reveals a high level of confidence in well water quality that is unrelated to the relative risk of arsenic exposure or homeowner adherence to government testing recommendations. Further analysis from the survey and in-depth well user interviews (n=32) finds that well users' assessments of risk are influenced by personal experience, local knowledge, social networks and convenience of infrastructure rather than by formal information channels, which are largely failing to reach their target audiences. Insights from interviews with stakeholders representing government health and environment agencies (n=15) are used to reflect on the institutional barriers that mediate the translation of scientific knowledge into public awareness and stewardship behaviors. The utilization of local knowledge brokers, community-based networks and regulatory incentives to improve risk knowledge and support routine testing among private well users is discussed.

Significant volumes of research over the past four decades has sought to elucidate the social, infrastructural, economic, and human health effects of climate change induced surface flooding. To date, epidemiological and public health studies of flooding events have focused on mental health effects, vector-borne diseases, and infectious enteric disease due to floodwater contact (i.e. typically low consumption rates). The inherent nature of groundwater (i.e. out of sight, out of mind) and the widely held belief that aquifers represent a pristine source of drinking water due to natural attenuation may represent the "perfect storm" causing direct consumption of relatively large volumes of surface flood-contaminated groundwater. Accordingly, the current study sought to systematically identify and synthesize all available peer-reviewed literature pertaining to the nexus between surface flooding, groundwater contamination and human gastroenteric outcomes. Just 14 relevant studies were found to have been published during the period 1980-2017, thus highlighting the fact that this potentially significant source of climate-related exposure to environmental infection has remained understudied to date. Studies differed significantly in terms of type and data reporting procedures, making it difficult to discern clear trends and patterns. Approximately 945 confirmed cases of flood-related enteric disease were examined across studies; these concurred with almost 10,000 suspected cases, equating to approximately 20 suspected cases per confirmed case. As such, no regional, national or global estimates are available for the human gastrointestinal health burden of flood-related groundwater contamination. In light of the demonstrable public health significance of the concurrent impacts of groundwater susceptibility and climate change exacerbation, strategies to increase awareness about potential sources of contamination and motivate precautionary behaviour (e.g. drinking water testing and treatment, supply interruptions) are necessary. Mainstreaming climate adaptation concerns into planning policies will also be necessary to reduce human exposure to waterborne sources of enteric infection.

In 2015, a typhoid fever outbreak began in downtown Kampala, Uganda, and spread into adjacent districts. In response, an environmental survey of drinking water source types was conducted in areas of the city with high case numbers. A total of 122 samples was collected from 12 source types and tested for Escherichia coli , free chlorine, and conductivity. An additional 37 grab samples from seven source types and 16 paired large volume (20 liter) samples from wells and springs were also collected and tested for the presence of Salmonella enterica serovar Typhi. Escherichia coli was detected in 60% of kaveras (drinking water sold in plastic bags) and 80% of refilled water bottles; free chlorine was not detected in either source type. Most jerry cans (68%) contained E. coli and had free chlorine residuals below the WHO-recommended level of 0.5 mg/liter during outbreaks. Elevated conductivity readings for kaveras, refilled water bottles, and jerry cans (compared to treated surface water supplied by the water utility) suggested that they likely contained untreated groundwater. All unprotected springs and wells and more than 60% of protected springs contained E. coli . Water samples collected from the water utility were found to have acceptable free chlorine levels and no detectable E. coli . While S . Typhi was not detected in water samples, Salmonella spp. were detected in samples from two unprotected springs, one protected spring, and one refilled water bottle. These data provided clear evidence that unregulated vended water and groundwater represented a risk for typhoid transmission. IMPORTANCE Despite the high incidence of typhoid fever globally, relatively few outbreak investigations incorporate drinking water testing. During waterborne disease outbreaks, measurement of physical-chemical parameters, such as free chlorine residual and electrical conductivity, and of microbiological parameters, such as the presence of E. coli or the implicated etiologic agent, in drinking water samples can identify contaminated sources. This investigation indicated that unregulated vended water and groundwater sources were contaminated and were therefore a risk to consumers during the 2015 typhoid fever outbreak in Kampala. Identification of contaminated drinking water sources and sources that do not contain adequate disinfectant levels can lead to rapid targeted interventions.

The Gulf Cooperation Council (GCC) countries consist of Bahrain, Kuwait, Oman, Qatar, Saudi Arabia, and the United Arab Emirates. These countries depend mainly on seawater desalination to meet their water needs. Although great emphasis is given to characterize desalinated water for its physicochemical and microbial properties, e.g. presence of metals, other organic contaminants and for bacteria, sensorial characteristics including smell, taste and color have not received the same attention. This is possibly attributed to the fact that inhabitants of GCC States do not use desalinated tap water for drinking consumption, rather they depend on locally produced or imported bottled water where color, taste and odor are not problematic. To address the consumer needs and perceptions of drinking desalinated water in GCC countries, water quality standards and guidelines, should respond to the public concern about other sensorial characteristics (organoleptic properties) including taste, odor, and trigeminal sensations. Often the root causes of color and smell in water are attributed to the presence of organic and inorganic contaminants and to bacterial growth which is frequently accompanied by the production of metabolites and byproducts that are obnoxious. The unpleasant sensorial problems associated with desalinated drinking tap water may constitute the driving force for most people in GCC countries to depend on bottled water. To encourage people in the GCC countries to consume desalinated tap water, it is essential that water testing include measurements of physicochemical properties, biofilm presence and organoleptic parameters to improve overall water quality. This review highlights the contribution of organoleptics for consumers of desalinated tap water. It extends water quality research to be addressed by standards for organoleptic parameters in desalinated drinking water. Accordingly, consumer awareness and outreach campaigns should be implemented to encourage people to drink tap water in the GCC countries.

Private well stewardship, including on-going testing and treatment, can ensure private well users are able to maintain source-water quality and prevent exposures to potentially harmful constituents in primary drinking water supplies. Unlike municipal water supplies, private well users are largely responsible for their own testing and treatment and well stewardship is often minimal. The importance of factors influencing regular testing, and treatment behaviors, including knowledge, risk perception, convenience and social norms, can vary by geography and population characteristics. The primary goals of this study were to survey a general statewide population of private well users in Wisconsin in order to quantify testing and treatment patterns and gather data on motivations and barriers to well stewardship. The majority of respondents reported using and drinking well water daily but only about one half of respondents reported testing their wells in the last ten years and of these, only 10% reported testing in the last 12 months. Bacteria and nitrates were contaminants most often tested; and, a private laboratory most often conducted testing. The most commonly reported water treatment was a water softener. Living in a particular geographic region and income were the most significant predictors of water testing and treatment. Iron and hardness, which influence water aesthetics but not always safety, were the most commonly reported water quality problems. Health concerns or perceived lack thereof were, respectively, motivators and barriers to testing and treatment. Limited knowledge of testing and treatment options were also identified as barriers. Results confirm previous findings that well stewardship practices are minimal and often context specific. Understanding the target population’s perceptions of risk and knowledge are important elements to consider in identifying vulnerable populations and developing education and policy efforts to improve well stewardship.

Faced with a severe drought, the residents of the regional city of Toowoomba, in South East Queensland, Australia were asked to consider a potable wastewater reuse scheme to supplement drinking water supplies. As public risk perceptions and trust have been shown to be key factors in acceptance of potable reuse projects, this research developed and tested a social-psychological model of trust, risk perceptions and acceptance. Participants (N = 380) were surveyed a few weeks before a referendum was held in which residents voted against the controversial scheme. Analysis using structural equation modelling showed that the more community members perceived that the water authority used fair procedures (e.g., consulting with the community and providing accurate information), the greater their sense of shared identity with the water authority. Shared social identity in turn influenced trust via increased source credibility, that is, perceptions that the water authority is competent and has the community's interest at heart. The findings also support past research showing that higher levels of trust in the water authority were associated with lower perceptions of risk, which in turn were associated with higher levels of acceptance, and vice versa. The findings have a practical application for improving public acceptance of potable recycled water schemes.