10.4.3. Ingestion and drinking water contamination and sanitation
Acronyms
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 30–40% 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 coastal 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,
2000–2005
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 30–40% 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.
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