EUGLOREH project
THE STATUS OF HEALTH IN THE EUROPEAN UNION:
TOWARDS A HEALTHIER EUROPE

FULL REPORT

PART III - HEALTH CAUSES, FACTORS AND DETERMINANTS

10. HEALTH DETERMINANTS

10.4. EXPOSURE ROUTES

10.4.3. Ingestion and drinking water contamination and sanitation

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10.4.3. Ingestion and drinking water contamination and sanitation

 

Acronyms

 

CIS

Commonwealth of Independent States

EC

European Commission

EEA

European Environment Agency

EU

European Union

EWGLI

European Working Group for Legionella Infections

SGU

Sveriges Geologiska Undersökningar (Swedish Geological Survey)

SMR

Standardized Mortality Rate

UNECE

United Nations Economic Commission for Europe

WFD

Water Framework Directive

WHO

World Health Organisation

WISE

Water Information System for Europe

WSP

Water Safety Plans

 

 

 

10.4.3.1. Introduction

 

Safe drinking-water is vital for the health of the population. In Western Europea almost 100% of the population have access to safe drinking water. An effective quality control and water treatment mechanism is in place and the drinking-water-related health impacts are low. The access to safe drinking-water is lower in the eastern part of the Region, but it is steadily increasing. There are important disparities between urban and rural areas: only 3040% of rural households in Eastern-European countries have access to safe drinking-water.

 

Water-borne diseases arise from the contamination of water by pathogenic viruses, bacteria or protozoa. Ground water contains, depending on the region and geology, naturally occurring toxic elements, such as arsenic, uranium radon or fluoride. In addition, human activities cause water contamination with heavy metals, industrial chemicals, nitrates, pesticides and residues of pharmaceuticals. These agents are directly transmitted to people when the water is used for drinking, food preparation, recreation, or for various domestic purposes.

 

The availability of water of good quality for consumption and recreation is continuously under threat. Consumption demands are not always balanced by availability and situations of water shortage are already occurring in some parts of Europe. Meanwhile, the availability of drinking water from natural sources is threatened by domestic, industrial and agricultural pollution. In the future, climate change is predicted to change water availability in many European regions. Some parts will be dryer, others wetter. Water scarcity in dry regions will stimulate the re-use of wastewater for human consumption and for agriculture. Potential health risks arising from these practices have to be taken seriously and proper precautions need to be developed. Drinking water supplies risk to be disrupted in situations of floods and natural disasters and distribution systems have to be designed to meet these threats. Exploitation and increased urbanisation of regions have an impact on the quality of coastal waters which are of important recreational and economic value for many European regions. Therefore, there are a number of aspects that require specific attention when discussing the quality of European drinking- and recreational waters and when reflecting upon future scenarios and developments.

 

10.4.3.2. Data sources

 

This review is based on the first outcomes of the Environment and Health Information System of the WHO, the WHO report: Children’s Health and the environment in Europe: a baseline assessment, and the underlying factsheets (WHO, 2007) and WHO Guidelines for drinking water (WHO, 2006a). Another important source is the Water Information System for Europe (WISE), which covers the European Water Framework Directive (European Commission, 2000) and additional European water-related directives including background information. Additional information has been collected from the fourth assessment report, the “Belgrade Report” (EEA, 2007), of the European Environment Agency and the State of the Environment in Europe 2005 report (SOER, 2005) (EEA, 2005)

 

10.4.3.3. Data presentation and analysis

 

Drinking water

 

Health impact of poor quality drinking water

 

Significant mortality and diarrhoeal diseases are the main health effects of poor water quality. There is no consolidated information on water-related disease outbreaks in Europe and on the specific causative agents, although such events occur throughout the European Region, even in countries with advanced drinking water and sanitation systems, in association with breakdowns or failures in the water supply systems due to missing or faulty disinfecting procedures or re-growth of micro-organisms in the distribution systems as well as to leaks of untreated waste and sewage waters resulting in the contamination of raw water supplies. In the European Union, most of the population is connected to municipal delivery systems including water treatment and quality control. However, in some rural areas drinking water is abstracted from ground water and usually consumed without any treatment.

 

In certain parts of the WHO - European Region (especially Eastern Europe and Central Asia), at least 2 million people do not have access to clean water. A recent estimate of mortality from diarrhoeal disease attributable to poor water, sanitation and hygiene suggested that in these regions over 13 000 children aged under 14 years die annually due to poor water conditions (Valent et al, 2004).

 

Figure 10.4.3.1. Deaths among children under 5 years of age due to diarrheal diseases in EUGLOREH Countries. Data from year 2000

 

 

The under-five mortality rates from diarrhoeal diseases are higher in low income groups or countries with medium level of development than in other population groups (WHO 2006). From 1993 to 2001, the standardized mortality rate (SMR) for diarrhoeal diseases in children under 5 years of age fell from 70.0 (per 100 000) to 21.6 in the Commonwealth of Independent States (CIS), and from 176.3 to 44.6 in the CARK (5 Central Asian Republics including Kazakhstan). Despite these gains, the situation is considerably worse than in the EU 15, where rates over the same period dropped from 0.64 to 0.36.

 

The information on outbreaks is patchy and related to subsets of countries. As an example, information from eight selected European countries shows there were 90 water-borne outbreaks resulting in >12 000 episodes of illness from 2000 to 2005 (Figure 10.4.3.2).

 

Figure 10.4.3.2. Number of reported drinking water-borne outbreaks in selected countries, 20002005

 

The most common causative agents were bacterial (Campylobacters, Shigella Sonnei, Aeromonas species) responsible for 45 (60%) of the outbreaks and 34.8% of the cases of illnesses. Viral agents were implicated in 20 outbreaks (27%) and 60.6% of cases of illness. Four outbreaks were caused by protozoa (3.7% of cases of illness), two by chemical contamination (0.1% of cases of illness), and in four cases an unknown microbial agent was implicated (0.8% of the cases of illness). The data must still be interpreted cautiously, as between-country differences are likely to reflect the efficiency of surveillance and reporting systems rather then differences in outbreaks; moreover, data was available for only a few countries.

 

Arsenic is a natural contaminant of ground water. Chronic arsenic poisoning is becoming an emerging epidemic particularly in Asia with over 100 million people affected. Arsenic was one of the first chemicals recognised as a cause of cancer. Long term exposure has furthermore been documented to induce cardiovascular diseases and probably also neuro-developmental effects in children. The WHO Drinking water guidelines (WHO, 2006) recommend a maximum concentration of 10 μg/l for As in drinking water . The estimated cancer risk at this level is in the range 1/100-1/1000 (Vahter et al, 2006). At 50 μg/l the risk 1/100 which is 100 times higher than for any other water contaminant listed by WHO or EU (Smith et al 2002). There are regions in several European countries where As concentration in ground water are exceeding 10 μg/l and occasionally reach 25 μg/l.

 

Access to safe drinking-water

 

In Western Europe, almost 100% of the population has had access to safe drinking-water since the 1990s. A majority is connected to municipal delivery systems including water treatment and quality control. In rural areas, drinking water is abstracted from ground water and usually consumed without any purification treatment. For example, in a sparsely populated country like Sweden, 13% of the population permanently depends on water abstracted from private wells. This portion almost doubles during cottage season when city dwellers move to their country homes (SGU, 2007). At European level, it is estimated that as many as 50 million Europeans receive drinking-water from small or very small supplies which are not controlled by the authorities. In the eastern part of the European Region, access to safe drinking water remains lower, albeit rising from 58% to 80% (Figure 10.4.3.3). According to the World Health Organization and the United Nations Children’s Fund (WHO/UNICEF) Joint Monitoring Programme assessment, there are important disparities between urban and rural areas: only 3040% of rural households have access to individual sources of safe drinking-water.

 

Figure 10.4.3.3. Percentage of population connected to public water supply in the European Union, 2002 or last available year

 

The cause of water related disease outbreaks is often a breakdown or failure in the water supply system - such as missing or faulty disinfecting procedures or re-growth of micro-organisms in the distribution system. Another cause is leaks of untreated waste and sewage water resulting in contamination of raw water supplies. A third source is ground water contaminated either by naturally occurring elements such as arsenic, radon, uranium or fluoride, industrial chemicals, or agricultural chemicals such as pesticides and nitrite. Waterborne disease outbreaks occur throughout the European Region, even in countries with advanced drinking water and sanitation systems (see Figure 10.4.3.2).

 

A special case of water safety is the occurrence of Legionella pneumophila which may cause of severe pneumonia in humans. Legionella bacteria can be found in all fresh water environments and particularly in artificial environments where people may be exposed to Legionella containing aerosols. Because complete elimination of Legionella from all water systems is impossible, public health protection should be aimed at minimising the risk of contamination by taking adequate preventive measures. This requires more insight into factors that result in the formation of biofilms and that enable Legionella to colonise water systems. Moreover, the presence of Legionella in a water system does not always result in illness of exposed people. Thus, it is important to analyse the public health benefits and costs of optimising Legionella detection and preventive measures (for additional information check with the European Working Group for Legionella Infections (EWGLI) at http://www.ewgli.org).

 

Waste water treatment

 

The European Union is bringing together, across its 27 Member States, a population of around 500 million people. Waste water generated by these people, as well as by industries, is a major source of pollution of European waters. Waste water discharges may have wide-ranging impacts on our ground waters, rivers, lakes and coastal areas. There has been a significant improvement in the proportion of the European population connected to wastewater treatment facilities between 1980 and 2003. On average, two thirds of the population had been connected by 2003, although there were significant variations. Further, data for the WHO-European Region show that coverage in rural areas often lags behind urban areas, particularly in eastern Europe and central Asia. An average of 66.5% of the population in European countries (Figure 10.4.3.4) were connected to wastewater treatment facilities in 2003. There is a regional variation. In the Nordic- and some Northern European countries, which have the longest tradition of water purification, more than 85% of the population were connected to wastewater treatment facilities. In Southern European countries coverage ranged between 40% and 60%, while in some of the new EU member states it was less than 40%.

 

For the period considered, annual data were not available for a number of countries. This makes the derivation of time trends at European level difficult. The available data show that on average there was a 70% increase in coverage from 1980 to 2003, with a 20% increase from 1995 to 2003.

 

Figure 10.4.3.4. Changes over time in the population connected to wastewater treatment facilities, selected European countries,1980-2003

 

Sewage sludge

 

Sewage is an illustrative example of mixtures leading to environmental and also human health concerns. Pharmaceuticals and personal care products are not efficiently processed in sewage plants, leading to emissions into the environment of waste water and sewage sludge. Increased levels of drug residues have been observed in European rivers and lakes, with documented eco-toxicological effects on water living species. The human health relevance is unclear, but with ambitions to re-cycle waste water for drinking water there is a potential for human exposure, especially in areas with water scarcity. The increasing use of consumer disinfectant products, also implying the spreading of anti-biotical resistance, is another important early warning signal to take into account in public health management.

 

10.4.3.4. Control tools and policies

 

The United Nations Economic Commission for Europe (UNECE) 1992 Convention on the Protection and Use of Transboundary Water sources and International Lakes is the only pan-European instrument specially adopted to attain an adequate supply of drinking-water and sanitation, and to effectively protect water used as a source of drinking-water. This is a key instrument for ensuring access to safe water in an integrated manner. Several multi- and bilateral agreements between European countries are based on the principles and provisions present in the Convention. One of the most recent one is the Water Framework Directive (WFD) (European Commission, 2000) of the European Union. Within the Convention, the Protocol on Water and Health (UNECE, 1999) aims at protecting human health and well being through a better water management, including the protection of water ecosystems, and by preventing, controlling and reducing water-related diseases. The Protocol is the first international agreement of its kind adopted specifically to attain an adequate supply of safe drinking water and adequate sanitation for everyone, and effectively protect water used as a source of drinking water. Priority diseases selected for target setting and reporting are: cholera, Shigellosis, enterohemorrhagic Escheria Coli, viral hepatitis A and typhoid fever, followed by diseases induced by Campylobacter, Cryptosporidium, Giardia Intestinalis and noroviruses.

 

As part of the UNECE convention, the European Union adopted in December 2000 the Water Framework Directive (WFD) (European Commission 2000), which has a holistic view on water management in the European Union. The bearing idea is that in order to ensure European citizens continued and sustainable access to water of high hygienic quality it is necessary to take a full grip of the water cycle. The Directive sets out a framework for the analysis, planning and management of water resources at river basin scales, with a major objective, i.e. to achieve a "good water status" for all waters by the year 2015. The purpose is to establish a framework for the long-term protection of freshwaters to prevent future deterioration as well as protect and enhance the status of ecosystems (aquatic, terrestrial, and wetlands); promote sustainable water use; ensure the reduction of pollutant loads; and contribute to the mitigation of floods and droughts. The Directive provides a long-term policy basis for water management at European level. Water flows do not respect national borders and WFD provides the platform for a legal obligation for the authorities in EU Member States to organize the management of water within river basin districts (rather than within administrative units). Integration is a key concept; it is interpreted in a broad sense, much broader than in the classical integrated water management approach, where the scope was typically joint consideration of surface water and groundwater as welll as of water quantity and quality aspects. In WFD, integration combines quality, ecological and quantity objectives for protecting valuable aquatic ecosystems and ensuring a general good status of other waters, including all water resources (fresh surface water and groundwater) and all water uses, functions and values.

 

Focusing on water contaminating chemicals, the European Commission adopted a proposal for a new Directive to protect surface waters from pollution (European Commission, 2006a). The proposed Directive, which is required to support the Water Framework Directive, will set limits on concentrations in surface waters of 41 dangerous chemical substances (including 33 priority substances and 8 other pollutants) that pose a particular risk to animal and plant life in the aquatic environment and to human health.

 

The World Health Organization Guidelines for drinking-water quality are the international reference point for standard setting and drinking-water safety (WHO, 2005). To ensure the delivery of safe drinking-water, the WHO advocates the development of Water Safety Plans (WSP). The primary objectives of a WSP in protecting human health and ensuring good water supply practice are the minimization of contamination of source waters, the reduction or removal of contamination through appropriate treatment processes and the prevention of contamination in the distribution network and the domestic distribution system. These objectives are applicable to all water supply chains, irrespective of their size or complexity. The water supplier is the key player in a WSP, but other stakeholders also have significant roles.

A WSP is an effective way of ensuring that a water supply is safe for human consumption and that it meets health based standards and other regulatory requirements. It is based on a comprehensive risk assessment and risk management approach towards all steps within the water supply chain from catchments to consumer.

 

The European Commission also supports the development of WSPs and is one of the drivers behind the Water Framework Directive. The EU drinking-water Directive (98/83/EC) (European Commission, 1998a) sets out criteria for water suitable for human consumption. The Directive is currently being reviewed, although a revised version will probably not be ready before 2009. The Directive specifies the values for certain parameters which should not be exceeded in order to maintain water quality and ensure human health. These parameters include naturally occurring biological and chemical parameters, by-products produced through the water purification process, and parameters which can be introduced through the water distribution system. Arsenic, as a contaminant of drinking water, is not included. However, the Directive leaves open for Member States to define additional limit values on a national basis. For arsenic most European Union Member States apply the limit value from the WHO Guidelines for drinking water, i.e. 10 μg/l (10 ppb).

 

The Drinking water directive stipulates that actions should be taken in case of contamination to prevent negative health impacts. Reports on water quality must be made publicly available and reported. It should be noted that the Directive applies only to water supplies providing more than 10m3/day or serving more than 50 people. Thus, very small water supplies (for example private wells), which serve millions of Europeans, are not within the Directive’s scope. Microbiological contamination and also chemical contamination of small water supplies is a serious problem and in many countries it can pose a significant health risk. Of further note, the Directive does not set any requirements for the monitoring and reporting of waterborne diseases. Many countries, however, have national monitoring systems in place.

 

Waste water and waste water treatment is regulated by EU Council Directive 91/271/EEuropean Commission (European Commission, 1991). The target is to protect the water environment from the adverse effects of discharges of urban waste water and from certain industrial discharges. In order to force the implementation of the Directive, the Commission issued in 1998 Directive 98/15/EEuropean Commission (European Commission, 1998b) amending to clarify the requirements of the Directive in relation to discharges from urban waste water treatment plants to sensitive areas subject to eutrophication.

The Urban Wastewater Directive requires that “treated wastewater shall be reused whenever appropriate” under the requirement of “minimising the adverse effect on the environment” in the light of the objective of first article of the same directive, clearly defined as the protection of the environment from the adverse effects of wastewater discharges. Since an increased re-use of wastewater is foreseen in arid areas because of climate change and of population pressures, the EU has started a process for a comprehensive analysis in order to prepare possible future legislation. A first result is (European Commission, 2007) addressing the Challenge of Water Scarcity and Drought in the European Union.

10.4.3.5. Future developments

 

A safe drinking water supply and safe bathing water is vital for the health of the population. Many processes in the modern society have direct impacts on water supply and on quality. Water flows are not limited by national borders and water is a common commodity for the whole European region. Fortunately, there are strong international conventions in place to manage and protect water sources. The Protocol on Water and Health under the UNECE 1992 Convention and the European Water Framework Directive will both be implemented in the years to come up to 2015.

 

There are several threats, both old and new, to a sustainable supply of high quality drinking- and recreational water. Many countries depend on groundwater to meet the demand for drinking water, and are quickly depleting precious aquifers, especially around cities. Today, the water supply of some 140 million European city dwellers comes from overexploited groundwater resources. Agriculture is using excessive amounts of ground water for irrigation. These processes are inflicting irreversible damages to our environment, as they are lowering groundwater tables and threatening natural wetlands as well as causing salt-water intrusion into coastal aquifers. In order to avoid a large scale environmental break-down, it is important to develop a strategy for a sustainable management of the whole water cycle and particularly to develop instruments to balance the demand in relation to supply.

 

Water scarcity is already a problem in Southern Europe and climate change scenarios are predicting these areas to be even dryer in the future. The pressure on water availability will increase and approaches to re-using of waste water and increased desalination of sea water will be reinforced. The potential health risks and impacts connected to these practises have to be analysed and addressed. Climate change scenarios are also predicting some areas in Europe to become wetter with increasing risks of flooding. Historically we know that the delivery of drinking water is highly vulnerable to natural disasters as flooding, earthquakes or landslide even in societies with well developed infrastructures such as in Western and Central Europe. Future flood risks are underlining the importance for a careful design and maintenance of water delivery systems, both on the supply and on the waste side.

 

Water sources in many areas are threatened by pollution from industries, agriculture or insufficient waste water treatment. New potential pollutants of drinking water are appearing, e.g. nano-materials or residues of human- and veterinary pharmaceuticals. Chemicals from industry, agriculture and households are contaminating natural waters and drinking water sources. Current sewage and waste water treatment processes are not designed to deal with this type of pollution, thus new technologies need to be developed. Ground waters are occasionally contaminated by natural contaminants such as arsenic, radon, uranium and fluorides depending on the region and geology. At local level, the health impact can be significant. In general, safe limit values are well established. These combined with monitoring and local treatment at household level significantly reduce the threat to the individual consumer. However, in the view of new scientific findings, the health consequences of low levels of arsenic in drinking water may currently be underestimated in Europe and may need further attention in the future.

 

10.4.3.6. References

 

European Commission (1976): Council Directive 76/160/EC of 8 December 1975 concerning the quality of bathing water. Available at: http://eur-lex.europa.eu/LexUriServ/LexUriServ.do?uri=CELEX:31976L0160:EN:HTML

European Commission (1991): Directive 91/271/EC on Urban Waste Water. Available at: http://eur-lex.europa.eu/LexUriServ/LexUriServ.do?uri=OJ:L:1991:135:0040:045:EN:HTML

European Commission (1998a): The Drinking Water Directive (DWD), Council Directive 98/83/EC. Available at: http://eur-lex.europa.eu/LexUriServ/LexUriServ.do?uri=CELEX:31998L0083:EN:HTML

European Commission (1998b): Commission Directive 98/15/EC amending Council Directive 91/271/EEC . Available at: http://eur-lex.europa.eu/LexUriServ/LexUriServ.do?uri=CELEX:31998L0015:EN:HTML

European Commission (2000): European Water Framework Directive 2000/60/EC. Available at: http://eur-lex.europa.eu/LexUriServ/LexUriServ.do?uri=CELEX:32000L0060:EN:HTML

European Commission (2006a): The Commission proposal setting environmental quality standards for surface waters of 41 dangerous chemical substances includes the 33 priority substances and 8 other pollutants. COM(2006)397 final. Available at: http://ec.europa.eu/prelex/detail_dossier_real.cfm?CL=en&DosId=194497

European Commission (2006b): Bathing water Directive, Directive 2006/7/EC of the European parliament and of the Council of 15 February 2006 repealing Directive 76/160/EEC. http://eur-lex.europa.eu/LexUriServ/LexUriServ.do?uri=OJ:L:2006:064:0037:01:EN:HTML

European Commission (2007): Communication from the Commission to the European Parliament and the Council: Challenge of water Scarcity and Drought in the European Union. COM (2007) 414 final. Available at: http://eur-lex.europa.eu/LexUriServ/LexUriServ.do?uri=CELEX:52007DC0414:EN:HTML

European Environment Agency (EEA) (2005): The European Environment. State and outlook 2005 (SOER 2005). Available at: http://reports.eea.europa.eu/state_of_environment_report_2005_1/en/EN-summary.pdf

European Environment Agency (EEA) (2007): Europe’s Environment. The fourth assessment. (“Belgrade Report2007). Available at: http://reports.eea.europa.eu/state_of_environment_report_2007_1/en

European Environment Agency (EEA) (2008): Bathing water assessment (draft). EEA - IMS Indicators - Bathing water quality (CSI 022) - Assessment DRAFT created Mar 2008. Available at.

http://ims.eionet.europa.eu/IMS/ISpecs/ISpecification20041007132021/IAssessment1204881733549/view_content

Swedish Geological Survey (SGU) (2007): Brunnsregistret (in Swedish). See: http://www.sgu.se/sgu/sv/index.html

Smith AH, et al (2002): Arsenic epidemiology and drinking water standards. Science 296: 2145-2146.

The United Nations Economic Commission for Europe (UNECE) (1992): Convention on Protection and Use of Transboundary Water sources and International Lakes http://www.unece.org/env/water/welcome.html

The United Nations Economic Commission for Europe (UNECE) (1999): Protocol on Water and Health to the 1992 Convention on the Protection and Use of Transboundary Watercourses and International Lakes. EUR/ICP/EHCO 020205/8Fin, 18 October 1999. Available at: http://www.unece.org/env/water/

Vahter M, et al (2006): Arsenic – a global health problem. Toxicology Letters 164S: S324-S325

Valent F, et al (2004): Burden of disease attributable to selected environmental factors and injuries among Europe’s children and adolescents. WHO Environmental Burden of Disease Series, No 8. Geneva.

Water Information System for Europe (WISE): Environment - Water - Water Framework Directive - Wise Main Page, Available at: http://water.europa.eu/content/view/20/36/lang,en/

WHO (2005): Water Safety Plans. Managing drinking-water quality from catchment to consumer. WHO/SDE/WSH/05.06. Available at: http://www.who.int/water_sanitation_health/dwq/wsp0506/en/index.html

WHO (2006a): Guidelines for drinking-water quality. First addendum to third edition. Volume 1: recommendations. Available at: http://www.who.int/water_sanitation_health/dwq/gdwq3rev/

WHO (2006b) World Health Statistics 2006. Available at: http://www.who.int/whosis/whostat2006/en/index.html

WHO (2007): Children’s Health and the environment in Europe: A baseline assessment. WHO-Europe, Copenhagen. Available at: http://www.euro.who.int/Document/E90767.pdf

WHO – World Health Statistics. Core health indicators. http://tinyurl.com/3osrs2

WHO – Health Statistics; WHO | WHOSIS. Available at: http://www.who.int/whosis/en/index.html

WHO – Water; WHO | Drinking water. Available at: http://www.who.int/topics/drinking_water/en/