A Systematic Review and Meta-Analysis of Fecal Contamination and Inadequate Treatment of Packaged Water.
BACKGROUND
Packaged water products provide an increasingly important source of water for consumption. However, recent studies raise concerns over their safety.


OBJECTIVE
To assess the microbial safety of packaged water, examine differences between regions, country incomes, packaged water types, and compare packaged water with other water sources.


METHODS
We performed a systematic review and meta-analysis. Articles published in English, French, Portuguese, Spanish and Turkish, with no date restrictions were identified from online databases and two previous reviews. Studies published before April 2014 that assessed packaged water for the presence of Escherichia coli, thermotolerant or total coliforms were included provided they tested at least ten samples or brands.


RESULTS
A total of 170 studies were included in the review. The majority of studies did not detect fecal indicator bacteria in packaged water (78/141). Compared to packaged water from upper-middle and high-income countries, packaged water from low and lower-middle-income countries was 4.6 (95% CI: 2.6-8.1) and 13.6 (95% CI: 6.9-26.7) times more likely to contain fecal indicator bacteria and total coliforms, respectively. Compared to all other packaged water types, water from small bottles was less likely to be contaminated with fecal indicator bacteria (OR = 0.32, 95%CI: 0.17-0.58) and total coliforms (OR = 0.10, 95%CI: 0.05, 0.22). Packaged water was less likely to contain fecal indicator bacteria (OR = 0.35, 95%CI: 0.20, 0.62) compared to other water sources used for consumption.


CONCLUSIONS
Policymakers and regulators should recognize the potential benefits of packaged water in providing safer water for consumption at and away from home, especially for those who are otherwise unlikely to gain access to a reliable, safe water supply in the near future. To improve the quality of packaged water products they should be integrated into regulatory and monitoring frameworks.
The Water Institute, University of North Carolina, Chapel Hill, NC, United States of America.
Ashley R
AR
Williams
The Water Institute, University of North Carolina, Chapel Hill, NC, United States of America; UNICEF, New York, NY, United States of America.
Robert E S
RE
Bain
The Water Institute, University of North Carolina, Chapel Hill, NC, United States of America.
Michael B
MB
Fisher
The Water Institute, University of North Carolina, Chapel Hill, NC, United States of America.
Ryan
R
Cronk
The Water Institute, University of North Carolina, Chapel Hill, NC, United States of America.
Emma R
ER
Kelly
The Water Institute, University of North Carolina, Chapel Hill, NC, United States of America.
Jamie
J
Bartram
D060766:Drinking Water / Q000382:microbiology*; D004926:Escherichia coli / Q000302:isolation & purification / Q000472:pathogenicity; D005243:Feces / Q000382:microbiology*; D006801:Humans; D019064:Product Packaging; D014871:Water Microbiology; D060753:Water Quality
D060766:Drinking Water