Waterborne diseases

Last updated
Waterborne diseases
Groundwater Contamination Latin America Sm.png
Waterborne diseases can be spread via groundwater which is contaminated with fecal pathogens from pit latrines
Specialty Infectious disease

Waterborne diseases are conditions caused by pathogenic micro-organisms that are transmitted in water. These diseases can be spread while bathing, washing, drinking water, or by eating food exposed to contaminated water. While diarrhea and vomiting are the most commonly reported symptoms of waterborne illness, other symptoms can include skin, ear, respiratory, or eye problems. [1]

Contents

Various forms of waterborne diarrheal disease are the most prominent examples, and affect children in developing countries most dramatically. According to the World Health Organization, waterborne diseases account for an estimated 3.6% of the total DALY (disability- adjusted life year) global burden of disease, and cause about 1.5 million human deaths annually. The World Health Organization estimates that 58% of that burden, or 842,000 deaths per year, is attributable to a lack of safe drinking water supply, sanitation and hygiene (summarized as WASH). [2]

The term waterborne disease is reserved largely for infections that predominantly are transmitted through contact with or consumption of infected water. Trivially, many infections may be transmitted by microbes or parasites that accidentally, possibly as a result of exceptional circumstances, have entered the water, but the fact that there might be an occasional freak infection need not mean that it is useful to categorise the resulting disease as "waterborne". Nor is it common practice to refer to diseases such as malaria as "waterborne" just because mosquitoes have aquatic phases in their life cycles, or because treating the water they inhabit happens to be an effective strategy in control of the mosquitoes that are the vectors.

Microorganisms causing diseases that characteristically are waterborne prominently include protozoa and bacteria, many of which are intestinal parasites, or invade the tissues or circulatory system through walls of the digestive tract. Various other waterborne diseases are caused by viruses. (In spite of philosophical difficulties associated with defining viruses as "organisms", it is practical and convenient to regard them as microorganisms in this connection.)

Yet other important classes of water-borne diseases are caused by metazoan parasites. Typical examples include certain Nematoda, that is to say "roundworms". As an example of water-borne Nematode infections, one important waterborne nematodal disease is Dracunculiasis. It is acquired by swallowing water in which certain copepoda occur that act as vectors for the Nematoda. Anyone swallowing a copepod that happens to be infected with Nematode larvae in the genus Dracunculus, becomes liable to infection. The larvae cause guinea worm disease. [3]

Another class of waterborne metazoan pathogens are certain members of the Schistosomatidae, a family of blood flukes. They usually infect victims that make skin contact with the water. [3] Blood flukes are pathogens that cause Schistosomiasis of various forms, more or less seriously affecting hundreds of millions of people worldwide. [4]

Long before modern studies had established the germ theory of disease, or any advanced understanding of the nature of water as a vehicle for transmitting disease, traditional beliefs had cautioned against the consumption of water, rather favouring processed beverages such as beer, wine and tea. For example, in the camel caravans that crossed Central Asia along the Silk Road, the explorer Owen Lattimore noted, "The reason we drank so much tea was because of the bad water. Water alone, unboiled, is never drunk. There is a superstition that it causes blisters on the feet." [5]

Socioeconomic impact

Waterborne diseases can have a significant impact on the economy, locally as well as internationally. People who are infected by a waterborne disease are usually confronted with related costs and not seldom with a huge financial burden. This is especially the case in less developed countries. The financial losses are mostly caused by e.g. costs for medical treatment and medication, costs for transport, special food, and by the loss of manpower. Many families must even sell their land to pay for treatment in a proper hospital. On average, a family spends about 10% of the monthly households income per person infected. [6]

Infections by type of pathogen

Protozoa

Disease and TransmissionMicrobial AgentSources of Agent in Water SupplyGeneral Symptoms
Acanthamoeba keratitis (cleaning of contact lenses with contaminated water) Acanthamoeba spp. (A. castellanii and A. polyphaga)widely distributed free-living amoebae found in many types of aquatic environments, including surface water, tap water, swimming pools, and contact lens solutionsEye pain, eye redness, blurred vision, sensitivity to light, sensation of something in the eye, and excessive tearing
Amoebiasis (hand-to-mouth)Protozoan ( Entamoeba histolytica ) (Cyst-like appearance) Sewage, non-treated drinking water, flies in water supply, saliva transfer(if the other person has the disease)Abdominal discomfort, fatigue, weight loss, diarrhea, bloating, fever
Cryptosporidiosis (oral)Protozoan ( Cryptosporidium parvum )Collects on water filters and membranes that cannot be disinfected, animal manure, seasonal runoff of water. Flu-like symptoms, watery diarrhea, loss of appetite, substantial loss of weight, bloating, increased gas, nausea
Cyclosporiasis Protozoan parasite ( Cyclospora cayetanensis ) Sewage, non-treated drinking water cramps, nausea, vomiting, muscle aches, fever, and fatigue
Giardiasis (fecal-oral) (hand-to-mouth)Protozoan ( Giardia lamblia ) Most common intestinal parasiteUntreated water, poor disinfection, pipe breaks, leaks, groundwater contamination, campgrounds where humans and wildlife use same source of water. Beavers and muskrats create ponds that act as reservoirs for Giardia.Diarrhea, abdominal discomfort, bloating, and flatulence
Microsporidiosis Protozoan phylum ( Microsporidia ), but closely related to fungi Encephalitozoon intestinalis has been detected in groundwater, the origin of drinking water [7] Diarrhea and wasting in immunocompromised individuals.
Naegleriasis (primary amebic meningoencephalitis [PAM]) (nasal)Protozoan ( Naegleria fowleri ) (Cyst-like appearance) Watersports, non-chlorinated water Headache, vomiting, confusion, loss of balance, light sensitivity, hallucinations, fatigue, weight loss, fever, and coma

Bacteria

Disease and TransmissionMicrobial AgentSources of Agent in Water SupplyGeneral Symptoms
Botulism Clostridium botulinum Bacteria can enter an open wound from contaminated water sources. Can enter the gastrointestinal tract through consumption of contaminated drinking water or (more commonly) foodDry mouth, blurred and/or double vision, difficulty swallowing, muscle weakness, difficulty breathing, slurred speech, vomiting and sometimes diarrhea. Death is usually caused by respiratory failure.
Campylobacteriosis Most commonly caused by Campylobacter jejuni Drinking water contaminated with feces Produces dysentery-like symptoms along with a high fever. Usually lasts 2–10 days.
Cholera Spread by the bacterium Vibrio cholerae Drinking water contaminated with the bacteriumIn severe forms it is known to be one of the most rapidly fatal illnesses known. Symptoms include very watery diarrhea, nausea, cramps, nosebleed, rapid pulse, vomiting, and hypovolemic shock (in severe cases), at which point death can occur in 12–18 hours.
E. coli Infection Certain strains of Escherichia coli (commonly E. coli)Water contaminated with the bacteriaMostly diarrhea. Can cause death in immunocompromised individuals, the very young, and the elderly due to dehydration from prolonged illness.
M. marinum infection Mycobacterium marinum Naturally occurs in water, most cases from exposure in swimming pools or more frequently aquariums; rare infection since it mostly infects immunocompromised individualsSymptoms include lesions typically located on the elbows, knees, and feet (from swimming pools) or lesions on the hands (aquariums). Lesions may be painless or painful.
Dysentery Caused by a number of species in the genera Shigella and Salmonella with the most common being Shigella dysenteriae Water contaminated with the bacteriumFrequent passage of feces with blood and/or mucus and in some cases vomiting of blood.
Legionellosis (two distinct forms: Legionnaires' disease and Pontiac fever)Caused by bacteria belonging to genus Legionella (90% of cases caused by Legionella pneumophila )Legionella is a very common organism that reproduces to high numbers in warm water; [9] but only causes severe disease when aerosolized. [10] Pontiac fever produces milder symptoms resembling acute influenza without pneumonia. Legionnaires' disease has severe symptoms such as fever, chills, pneumonia (with cough that sometimes produces sputum), ataxia, anorexia, muscle aches, malaise and occasionally diarrhea and vomiting
Leptospirosis Caused by bacterium of genus Leptospira Water contaminated by the animal urine carrying the bacteriaBegins with flu-like symptoms then resolves. The second phase then occurs involving meningitis, liver damage (causes jaundice), and kidney failure
Otitis Externa (swimmer's ear)Caused by a number of bacterial and fungal species.Swimming in water contaminated by the responsible pathogens Ear canal swells, causing pain and tenderness to the touch
Salmonellosis Caused by many bacteria of genus Salmonella Drinking water contaminated with the bacteria. More common as a food borne illness.Symptoms include diarrhea, fever, vomiting, and abdominal cramps
Typhoid fever Salmonella typhi Ingestion of water contaminated with feces of an infected personCharacterized by sustained fever up to 40 °C (104 °F), profuse sweating; diarrhea may occur. Symptoms progress to delirium, and the spleen and liver enlarge if untreated. In this case it can last up to four weeks and cause death. Some people with typhoid fever develop a rash called "rose spots", small red spots on the abdomen and chest.
Vibrio Illness Vibrio vulnificus , Vibrio alginolyticus , and Vibrio parahaemolyticus Can enter wounds from contaminated water. Also acquired by drinking contaminated water or eating undercooked oysters.Symptoms include abdominal tenderness, agitation, bloody stools, chills, confusion, difficulty paying attention (attention deficit), delirium, fluctuating mood, hallucination, nosebleeds, severe fatigue, slow, sluggish, lethargic feeling, weakness.

Viruses

Disease and TransmissionViral AgentSources of Agent in Water SupplyGeneral Symptoms
Hepatitis A Hepatitis A virus (HAV)Can manifest itself in water (and food)Symptoms are only acute (no chronic stage to the virus) and include Fatigue, fever, abdominal pain, nausea, diarrhea, weight loss, itching, jaundice and depression.
Hepatitis E (fecal-oral) Hepatitis E virus (HEV)Enters water through the feces of infected individualsSymptoms of acute hepatitis (liver disease), including fever, fatigue, loss of appetite, nausea, vomiting, abdominal pain, jaundice, dark urine, clay-colored stool, and joint pain
Acute gastrointestinal illness [AGI] (fecal-oral; spread by food, water, person-to-person, and fomites) Norovirus Enters water through the feces of infected individuals Diarrhea, vomiting, nausea, stomach pain
Poliomyelitis (Polio) Poliovirus Enters water through the feces of infected individuals90-95% of patients show no symptoms, 4-8% have minor symptoms (comparatively) with delirium, headache, fever, and occasional seizures, and spastic paralysis, 1% have symptoms of non-paralytic aseptic meningitis. The rest have serious symptoms resulting in paralysis or death
Polyomavirus infection Two of Polyomavirus: JC virus and BK virus Very widespread, can manifest itself in water, ~80% of the population has antibodies to PolyomavirusBK virus produces a mild respiratory infection and can infect the kidneys of immunosuppressed transplant patients. JC virus infects the respiratory system, kidneys or can cause progressive multifocal leukoencephalopathy in the brain (which is fatal).

Algae

Disease and TransmissionMicrobial AgentSources of Agent in Water SupplyGeneral Symptoms
Desmodesmus infection desmodesmus armatusNaturally occurs in water. Can enter open wounds.Similar to fungal infection.

Parasitic worms

Disease and TransmissionAgentSources of Agent in Water SupplyGeneral Symptoms
Dracunculiasis [Guinea worm disease] (ingestion of contaminated water) Dracunculus medinensis Female worm emerges from host skin and releases larvae in waterSlight fever, itchy rash, nausea, vomiting, diarrhea, dizziness, followed by formation of painful blister (typically on lower body parts)

Surveillance

In the United States

The Waterborne Disease and Outbreak Surveillance System (WBDOSS) is the principal database used to identify the causative agents, deficiencies, water systems, and sources associated with waterborne disease and outbreaks in the United States. [16] Since 1971, the Centers for Disease Control and Prevention (CDC), the Council of State and Territorial Epidemiologists (CSTE), and the US Environmental Protection Agency (EPA) have maintained this surveillance system for collecting and reporting data on "waterborne disease and outbreaks associated with recreational water, drinking water, environmental, and undetermined exposures to water." [16] [17] "Data from WBDOSS have supported EPA efforts to develop drinking water regulations and have provided guidance for CDC’s recreational water activities." [16] [17]

WBDOSS relies on complete and accurate data from public health departments in individual states, territories, and other U.S. jurisdictions regarding waterborne disease and outbreak activity. [16] In 2009, reporting to the WBDOSS transitioned from a paper form to the electronic National Outbreak Reporting System (NORS). [16] Annual or biennial surveillance reports of the data collected by the WBDOSS have been published in CDC reports from 1971 to 1984; since 1985, surveillance data have been published in the Morbidity and Mortality Weekly Report (MMWR). [16]

See also

Related Research Articles

Zoonosis Disease that can be transmitted from other species to humans

A zoonosis is an infectious disease caused by a pathogen that has jumped from a non-human animal to a human. Typically, the first infected human transmits the infectious agent to at least one other human, who, in turn, infects others.

Infection Invasion of an organisms body tissues by disease-causing agents

An infection is the invasion of an organism's body tissues by disease-causing agents, their multiplication, and the reaction of host tissues to the infectious agents and the toxins they produce. An infectious disease, also known as a transmissible disease or communicable disease, is an illness resulting from an infection.

Trichuriasis Infection by the parasitic worm Trichuris trichiura (whipworm)

Trichuriasis, also known as whipworm infection, is an infection by the parasitic worm Trichuris trichiura (whipworm). If infection is only with a few worms, there are often no symptoms. In those who are infected with many worms, there may be abdominal pain, tiredness and diarrhea. The diarrhea sometimes contains blood. Infections in children may cause poor intellectual and physical development. Low red blood cell levels may occur due to loss of blood.

<i>Norovirus</i> Type of viruses that cause gastroenteritis

Norovirus, sometimes referred to as the winter vomiting bug, is the most common cause of gastroenteritis. Infection is characterized by non-bloody diarrhea, vomiting, and stomach pain. Fever or headaches may also occur. Symptoms usually develop 12 to 48 hours after being exposed, and recovery typically occurs within 1 to 3 days. Complications are uncommon, but may include dehydration, especially in the young, the old, and those with other health problems.

Intestinal parasite infection Condition in which a parasite infects the gastro-intestinal tract of humans and other animals

An intestinal parasite infection is a condition in which a parasite infects the gastro-intestinal tract of humans and other animals. Such parasites can live anywhere in the body, but most prefer the intestinal wall.

Cryptosporidiosis Parasitic disease

Cryptosporidiosis, sometimes informally called crypto, is a parasitic disease caused by Cryptosporidium, a genus of protozoan parasites in the phylum Apicomplexa. It affects the distal small intestine and can affect the respiratory tract in both immunocompetent and immunocompromised individuals, resulting in watery diarrhea with or without an unexplained cough. In immunosuppressed individuals, the symptoms are particularly severe and can be fatal. It is primarily spread through the fecal-oral route, often through contaminated water; recent evidence suggests that it can also be transmitted via fomites in respiratory secretions.

Giardiasis Parasitic disease that results in diarrhea

Giardiasis, popularly known as beaver fever, is a parasitic disease caused by Giardia duodenalis. About 10% of those infected have no symptoms. When symptoms occur they may include diarrhea, abdominal pain, and weight loss. Vomiting, blood in the stool, and fever are less common. Symptoms usually begin 1 to 3 weeks after exposure and without treatment may last up to six weeks.

Helminthiasis Macroparasitic disease in which a part of the body is infected with parasitic worms

Helminthiasis, also known as worm infection, is any macroparasitic disease of humans and other animals in which a part of the body is infected with parasitic worms, known as helminths. There are numerous species of these parasites, which are broadly classified into tapeworms, flukes, and roundworms. They often live in the gastrointestinal tract of their hosts, but they may also burrow into other organs, where they induce physiological damage.

Natural reservoir A living host, such as an animal or a plant, inside of which an infectious pathogen naturally lives and reproduces

In infectious disease ecology and epidemiology, a natural reservoir, also known as a disease reservoir or a reservoir of infection, is the population of organisms or the specific environment in which an infectious pathogen naturally lives and reproduces, or upon which the pathogen primarily depends for its survival. A reservoir is usually a living host of a certain species, such as an animal or a plant, inside of which a pathogen survives, often without causing disease for the reservoir itself. By some definitions a reservoir may also be an environment external to an organism, such as a volume of contaminated air or water.

<i>Cryptosporidium</i> genus of apicomplexan parasitic alveolate

Cryptosporidium, sometimes informally called crypto, is a genus of apicomplexan parasitic alveolates that can cause a respiratory and gastrointestinal illness (cryptosporidiosis) that primarily involves watery diarrhea with or without a persistent cough in both immunocompetent and immunodeficient humans.

Cyclosporiasis infection caused by Cyclospora cayetanensis

Cyclosporiasis is a disease caused by infection with Cyclospora cayetanensis, a pathogenic protozoan transmitted by feces or feces-contaminated food and water. Outbreaks have been reported due to contaminated fruits and vegetables. It is not spread from person to person, but can be a hazard for travelers as a cause of diarrhea.

<i>Cyclospora cayetanensis</i> protozoan that causes disease in humans

Cyclospora cayetanensis is a coccidian parasite that causes a diarrheal disease called cyclosporiasis in humans and possibly in other primates. Originally reported as a novel pathogen of probable coccidian nature in the 1980s and described in the early 1990s, it was virtually unknown in developed countries until awareness increased due to several outbreaks linked with fecally contaminated imported produce. C. cayetanensis has since emerged as an endemic cause of diarrheal disease in tropical countries and a cause of traveler's diarrhea and food-borne infections in developed nations. This species was placed in the genus Cyclospora because of the spherical shape of its sporocysts. The specific name refers to the Cayetano Heredia University in Lima, Peru, where early epidemiological and taxonomic work was done.

The 1993 Milwaukee Cryptosporidiosis outbreak was a significant distribution of the Cryptosporidium protozoan in Milwaukee, Wisconsin, and the largest waterborne disease outbreak in documented United States history. The Howard Avenue Water Purification Plant was contaminated, and treated water showed turbidity levels well above normal. It was one of two water treatment plants for Milwaukee. The root cause of epidemic was never officially identified; initially it was suspected to be caused by the cattle genotype due to runoff from pastures. It was also thought that melting ice and snowmelt carrying Cryptosporidium may have entered the water treatment plants through Lake Michigan. MacKenzie et al. and the CDC showed that this outbreak was caused by Cryptosporidium oocysts that passed through the filtration system of one of the city's water-treatment plants, arising from a sewage treatment plant's outlet 2 miles upstream in Lake Michigan.

Neglected tropical diseases Diverse group of tropical infection diseases which are common in developing countries

Neglected tropical diseases (NTDs) are a diverse group of tropical infections which are common in low-income populations in developing regions of Africa, Asia, and the Americas. They are caused by a variety of pathogens such as viruses, bacteria, protozoa and parasitic worms (helminths). These diseases are contrasted with the big three infectious diseases, which generally receive greater treatment and research funding. In sub-Saharan Africa, the effect of these diseases as a group is comparable to malaria and tuberculosis. NTD co-infection can also make HIV/AIDS and tuberculosis more deadly.

The discovery of disease-causing pathogens is an important activity in the field of medical science. Many viruses, bacteria, protozoa, fungi, helminthes and prions are identified as a confirmed or potential pathogen. In the United States, a Centers for Disease Control program, begun in 1995, identified over a hundred patients with life-threatening illnesses that were considered to be of an infectious cause, but that could not be linked to a known pathogen. The association of pathogens with disease can be a complex and controversial process, in some cases requiring decades or even centuries to achieve.

Vector (epidemiology) Agent that carries and transmits an infectious pathogen into another living organism

In epidemiology, a disease vector is any agent which carries and transmits an infectious pathogen into another living organism; agents regarded as vectors are organisms, such as intermediate parasites or microbes.

Protozoan infection Parasitic disease caused by a protozoan

Protozoan infections are parasitic diseases caused by organisms formerly classified in the Kingdom Protozoa. They are usually contracted by either an insect vector or by contact with an infected substance or surface and include organisms that are now classified in the supergroups Excavata, Amoebozoa, SAR, and Archaeplastida.

The Waterborne Disease and Outbreak Surveillance System (WBDOSS) is a national surveillance system maintained by the U.S. Centers for Disease Control and Prevention (CDC). The WBDOSS receives data about waterborne disease outbreaks and single cases of waterborne diseases of public health importance in the United States and then disseminates information about these diseases, outbreaks, and their causes. WBDOSS was initiated in 1971 by CDC, the Council of State and Territorial Epidemiologists (CSTE), and the Environmental Protection Agency (EPA). Data are reported by public health departments in individual states, territories, and the Freely Associated States. Although initially designed to collect data about drinking water outbreaks in the United States, WBDOSS now includes outbreaks associated with recreational water, as well as outbreaks associated with water that is not intended for drinking (non-recreational) and water for which the intended use is unknown.

Soil-transmitted helminthiasis A type of helminth infection caused by different species of roundworms

Soil-transmitted helminthiasis is a type of helminth infection (helminthiasis) caused by different species of roundworms. It is caused specifically by those worms which are transmitted through soil contaminated with faecal matter and are therefore called soil-transmitted helminths. Three types of soil-transmitted helminthiasis can be distinguished: ascariasis, hookworm infection and whipworm infection. These three types of infection are therefore caused by the large roundworm A. lumbricoides, the hookworms Necator americanus or Ancylostoma duodenale and by the whipworm Trichuris trichiura.

Viruses are a major cause of human waterborne and water-related diseases. Waterborne diseases are caused by water that is contaminated by human and animal urine and feces that contain pathogenic microorganisms. A subject can get infected through contact with or consumption of the contaminated water. Viruses affect all living organisms from single cellular plants, bacteria and animal to the highest forms of plants and animals including human beings. Within a specific kingdom the localization of viruses colonizing the host can vary: Some human viruses, for example, HIV, colonizes only the immune system, while influenza viruses on the other hand can colonize either the upper respiratory tract or the lower respiratory tract depending on the type. Different viruses can have different routes of transmission; for example, HIV is directly transferred by contaminated body fluids from an infected host into the tissue or bloodstream of a new host while influenza is airborne and transmitted through inhalation of contaminated air containing viral particles by a new host. Research has also suggested that solid surface plays a role in the transmission of water viruses. In a experiments that used E.coli phages, Qβ, fr, T4, and MS2 confirmed that viruses survive on a solid surface longer compared to when they are in water. Because of this adaptation to survive longer on solid surfaces, viruses now have a prolonged opportunities to infect humans. Enteric viruses primarily infect the intestinal tract through ingestion of food and water contaminated with viruses of fecal origin. Some viruses can be transmitted through all three routes of transmission.

References

  1. 1 2 3 4 Guidelines for drinking-water quality. World Health Organization (Fourth edition incorporating the first addendum ed.). Geneva. ISBN   9789241549950. OCLC   975491910.CS1 maint: others (link)
  2. "Burden of disease and cost-effectiveness estimates". World Health Organization. Archived from the original on February 13, 2014. Retrieved April 5, 2014.
  3. 1 2 3 Janovy J, Schmidt GD, Roberts LS (1996). Gerald D. Schmidt & Larry S. Roberts' Foundations of parasitology. Dubuque, Iowa: Wm. C. Brown. ISBN   978-0-697-26071-0.
  4. Centers for Disease Control and Prevention: National Center for Emerging and Zoonotic Infectious Diseases (NCEZID), Division of Global Migration and Quarantine (DGMQ) (2011). "Chapter 3". In Brunette GW (ed.). CDC Health Information for International Travel 2012. The Yellow Book . Oxford University Press. ISBN   978-0-19-976901-8.
  5. Lattimore (1928). "The caravan routes of inner Asia". The Geographical Journal. 72 (6): 500. doi:10.2307/1783443. JSTOR   1783443. quoted in Wood F (2002). The Silk Road: two thousand years in the heart of Asia . p.  19.
  6. Schnabel B. "Drastic consequences of diarrhoeal disease". Archived from the original on 2015-09-23.
  7. 1 2 Nwachcuku N, Gerba CP (June 2004). "Emerging waterborne pathogens: can we kill them all?" (PDF). Current Opinion in Biotechnology. 15 (3): 175–80. doi:10.1016/j.copbio.2004.04.010. PMID   15193323. Archived from the original (PDF) on 2008-03-07. Retrieved 2007-08-09.
  8. Baldursson S, Karanis P (December 2011). "Waterborne transmission of protozoan parasites: review of worldwide outbreaks - an update 2004-2010". Water Research. 45 (20): 6603–14. doi:10.1016/j.watres.2011.10.013. PMID   22048017.
  9. "Legionnaires' Disease eTool: Facts and FAQs". www.osha.gov. Archived from the original on 15 November 2017. Retrieved 29 April 2018.
  10. "Legionella - Causes and Transmission - Legionnaires - CDC". www.cdc.gov. 8 December 2017. Archived from the original on 25 March 2016. Retrieved 29 April 2018.
  11. Dziuban EJ, Liang JL, Craun GF, Hill V, Yu PA, Painter J, Moore MR, Calderon RL, Roy SL, Beach MJ (December 2006). "Surveillance for waterborne disease and outbreaks associated with recreational water--United States, 2003-2004". MMWR. Surveillance Summaries. 55 (12): 1–30. PMID   17183230. Archived from the original on 29 October 2017.
  12. Petrini B (October 2006). "Mycobacterium marinum: ubiquitous agent of waterborne granulomatous skin infections". European Journal of Clinical Microbiology & Infectious Diseases. 25 (10): 609–13. doi:10.1007/s10096-006-0201-4. PMID   17047903.
  13. Nwachuku N, Gerba CP, Oswald A, Mashadi FD (September 2005). "Comparative inactivation of adenovirus serotypes by UV light disinfection" (PDF). Applied and Environmental Microbiology. 71 (9): 5633–6. doi:10.1128/AEM.71.9.5633-5636.2005. PMC   1214670 . PMID   16151167. Archived (PDF) from the original on 2007-09-26.
  14. Gall AM, Mariñas BJ, Lu Y, Shisler JL (June 2015). "Waterborne Viruses: A Barrier to Safe Drinking Water". PLoS Pathogens. 11 (6): e1004867. doi:10.1371/journal.ppat.1004867. PMC   4482390 . PMID   26110535.
  15. Westblade, Lars F.; Ranganath, Sangeetha; Dunne, William Michael; Burnham, Carey-Ann D.; Fader, Robert; Ford, Bradley A. (March 5, 2015). "Infection with a Chlorophyllic Eukaryote after a Traumatic Freshwater Injury". New England Journal of Medicine. The New England Journal of Medicine. 372 (10): 982–984. doi:10.1056/NEJMc1401816. PMID   25738686.
  16. 1 2 3 4 5 6 "Waterborne Disease & Outbreak Surveillance Reporting | Water-related Topics | Healthy Water | CDC". www.cdc.gov. 2017-10-16. Retrieved 2018-12-07.PD-icon.svgThis article incorporates text from this source, which is in the public domain.
  17. 1 2 Craun, Gunther F. (2004). Methods for the investigation and prevention of waterborne disease outbreaks; EPA/600/1-90/005A. Health Effects Research Laboratory, U.S. Environmental Protection Agency. OCLC   41657130.
Classification
D