title: Water quality, compliance, and health outcomes among utilities implementing Water Safety Plans in France and Spain.
abstract: Water Safety Plans (WSPs), recommended by the World Health Organization since 2004, seek to proactively identify potential risks to drinking water supplies and implement preventive barriers that improve safety. To evaluate the outcomes of WSP application in large drinking water systems in France and Spain, we undertook analysis of water quality and compliance indicators between 2003 and 2015, in conjunction with an observational retrospective cohort study of acute gastroenteritis incidence, before and after WSPs were implemented at five locations. Measured water quality indicators included bacteria (E. coli, fecal streptococci, total coliform, heterotrophic plate count), disinfectants (residual free and total chlorine), disinfection by-products (trihalomethanes, bromate), aluminum, pH, turbidity, and total organic carbon, comprising about 240K manual samples and 1.2M automated sensor readings. We used multiple, Poisson, or Tobit regression models to evaluate water quality before and after the WSP intervention. The compliance assessment analyzed exceedances of regulated, recommended, or operational water quality thresholds using chi-squared or Fisher's exact tests. Poisson regression was used to examine acute gastroenteritis incidence rates in WSP-affected drinking water service areas relative to a comparison area. Implementation of a WSP generally resulted in unchanged or improved water quality, while compliance improved at most locations. Evidence for reduced acute gastroenteritis incidence following WSP implementation was found at only one of the three locations examined. Outcomes of WSPs should be expected to vary across large water utilities in developed nations, as the intervention itself is adapted to the needs of each location. The approach may translate to diverse water quality, compliance, and health outcomes.
authors.affiliation: The University of North Carolina, Chapel Hill, Department of Environmental Sciences and Engineering, 170 Rosenau Hall, CB #7400, Chapel Hill, NC, USA. Electronic address: ksetty@live.unc.edu.
authors.forename: Karen E
authors.initials: KE
authors.lastname: Setty
authors.affiliation: The University of North Carolina, Chapel Hill, Department of Environmental Sciences and Engineering, 170 Rosenau Hall, CB #7400, Chapel Hill, NC, USA; The University of California, San Diego, Department of Family Medicine and Public Health, 9500 Gilman Dr, 0628, La Jolla, CA 92093-0628, USA.
authors.forename: Georgia L
authors.initials: GL
authors.lastname: Kayser
authors.affiliation: The University of North Carolina, Chapel Hill, Department of Health Behavior, 302 Rosenau Hall, CB #7440, Chapel Hill, NC, USA.
authors.forename: Michael
authors.initials: M
authors.lastname: Bowling
authors.affiliation: Suez, Centre International de Recherche sur l'Eau et l'Environnement (CIRSEE), 38 rue du President Wilson, 78230 Le Pecq, France.
authors.forename: Jerome
authors.initials: J
authors.lastname: Enault
authors.affiliation: Suez, Centre International de Recherche sur l'Eau et l'Environnement (CIRSEE), 38 rue du President Wilson, 78230 Le Pecq, France.
authors.forename: Jean-Francois
authors.initials: JF
authors.lastname: Loret
authors.affiliation: Suez, Centre Tecnològic de l'Aigua (CETAQUA), Carretera d'Esplugues, 75, 08940 Cornellà de Llobregat, Barcelona, Spain.
authors.forename: Claudia Puigdomenech
authors.initials: CP
authors.lastname: Serra
authors.affiliation: Aigües de Barcelona, Carrer General Batet 1-7, 08028, Barcelona, Spain.
authors.forename: Jordi Martin
authors.initials: JM
authors.lastname: Alonso
authors.affiliation: Suez, Centre Tecnològic de l'Aigua (CETAQUA), Carretera d'Esplugues, 75, 08940 Cornellà de Llobregat, Barcelona, Spain.
authors.forename: Arnau Pla
authors.initials: AP
authors.lastname: Mateu
authors.affiliation: The University of North Carolina, Chapel Hill, Department of Environmental Sciences and Engineering, 170 Rosenau Hall, CB #7400, Chapel Hill, NC, USA.
authors.forename: Jamie
authors.initials: J
authors.lastname: Bartram
mesh_terms: D000293:Adolescent; D000328:Adult; D000368:Aged; D000535:Aluminum / Q000032:analysis; D001959:Bromates / Q000032:analysis; D002648:Child; D002675:Child, Preschool; D002713:Chlorine / Q000032:analysis; D004202:Disinfectants / Q000032:analysis; D060766:Drinking Water / Q000032:analysis; D004755:Enterobacteriaceae / Q000302:isolation & purification; D004784:Environmental Monitoring; D005602:France / Q000453:epidemiology; D005767:Gastrointestinal Diseases / Q000453:epidemiology*; D006801:Humans; D008875:Middle Aged; D012189:Retrospective Studies; D013030:Spain / Q000453:epidemiology; D022882:Trihalomethanes / Q000032:analysis; D014873:Water Pollutants / Q000032:analysis; D060753:Water Quality; D055815:Young Adult
chemical_list: D001959:Bromates; D004202:Disinfectants; D060766:Drinking Water; D022882:Trihalomethanes; D014873:Water Pollutants; D002713:Chlorine; D000535:Aluminum
keywords: Aluminum (PubChem CID: 5359268); Bromate (PubChem CID: 84979); Chlorine (PubChem CID: 24526); Drinking water quality; Gastrointestinal illness; HACCP; Regulatory compliance; Water safety plan; Water treatment