title: Associations between Self-Reported Gastrointestinal Illness and Water System Characteristics in Community Water Supplies in Rural Alabama: A Cross-Sectional Study.
abstract: BACKGROUND
  Community water supplies in underserved areas of the United States may be associated with increased microbiological contamination and risk of gastrointestinal disease. Microbial and health risks affecting such systems have not been systematically characterized outside outbreak investigations. The objective of the study was to evaluate associations between self-reported gastrointestinal illnesses (GII) and household-level water supply characteristics.
  
  
  METHODS
  We conducted a cross-sectional study of water quality, water supply characteristics, and GII in 906 households served by 14 small and medium-sized community water supplies in Alabama's underserved Black Belt region.
  
  
  RESULTS
  We identified associations between respondent-reported water supply interruption and any symptoms of GII (adjusted odds ratio (aOR): 3.01, 95% confidence interval (CI) = 1.65-5.49), as well as low water pressure and any symptoms of GII (aOR: 4.51, 95% CI = 2.55-7.97). We also identified associations between measured water quality such as lack of total chlorine and any symptoms of GII (aOR: 5.73, 95% CI = 1.09-30.1), and detection of E. coli in water samples and increased reports of vomiting (aOR: 5.01, 95% CI = 1.62-15.52) or diarrhea (aOR: 7.75, 95% CI = 2.06-29.15).
  
  
  CONCLUSIONS
  Increased self-reported GII was associated with key water system characteristics as measured at the point of sampling in a cross-sectional study of small and medium water systems in rural Alabama in 2012 suggesting that these water supplies can contribute to endemic gastro-intestinal disease risks. Future studies should focus on further characterizing and managing microbial risks in systems facing similar challenges.
authors.affiliation: Division of Environmental Health, School of Public Health, Georgia State University, Atlanta, Georgia, United States of America.
authors.forename: Christine E
authors.initials: CE
authors.lastname: Stauber
authors.affiliation: Department of Biological Sciences, University of Alabama, Tuscaloosa, Alabama, United States of America.
authors.forename: Jessica C
authors.initials: JC
authors.lastname: Wedgworth
authors.affiliation: Department of Civil, Construction and Environmental Engineering, University of Alabama, Tuscaloosa, Alabama, United States of America.
authors.forename: Pauline
authors.initials: P
authors.lastname: Johnson
authors.affiliation: Department of Biological Sciences, University of Alabama, Tuscaloosa, Alabama, United States of America.
authors.forename: Julie B
authors.initials: JB
authors.lastname: Olson
authors.affiliation: Division of Environmental Health, School of Public Health, Georgia State University, Atlanta, Georgia, United States of America.
authors.forename: Tracy
authors.initials: T
authors.lastname: Ayers
authors.affiliation: Department of Civil, Construction and Environmental Engineering, University of Alabama, Tuscaloosa, Alabama, United States of America.
authors.forename: Mark
authors.initials: M
authors.lastname: Elliott
authors.affiliation: School of Civil and Environmental Engineering, Georgia Institute of Technology, Atlanta, Georgia, United States of America.
authors.forename: Joe
authors.initials: J
authors.lastname: Brown
mesh_terms: D000328:Adult; D000407:Alabama / Q000453:epidemiology; D003430:Cross-Sectional Studies; D004926:Escherichia coli / Q000302:isolation & purification; D004927:Escherichia coli Infections / Q000453:epidemiology / Q000382:microbiology; D005260:Female; D005767:Gastrointestinal Diseases / Q000453:epidemiology* / Q000382:microbiology; D006801:Humans; D008297:Male; D012423:Rural Health; D012424:Rural Population; D057566:Self Report; D014871:Water Microbiology; D060753:Water Quality; D014881:Water Supply; D000069578:Waterborne Diseases / Q000453:epidemiology* / Q000382:microbiology
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