Introduction to water-

related infectious
diseases
Module 1.1

© World Health Organization 2022. Some rights reserved. This work is available under the CC BY-NC-SA 3.0 IGO license.
 Overview

• The Protocol on Water and Health and requirements relating to water

related disease surveillance and outbreak management
• International Health Regulations (IHR) core requirements:
• Definition of water related infectious disease (WRID)
• Pathogens transmitted through drinking-water
• drinking-water systems as a source of WRID
• Burden of WRID in the European Region
• The need to strengthen WRID surveillance and outbreak management
capacity
 Protocol on Water and Health

• Article 8:
• Establish and maintain surveillance and early warning
systems
• Develop national and local contingency plans for
responding to outbreaks, incidents and risks
• Strengthen response capacity
• Article 6.2:
• Establish and publish targets to reduce WRD outbreaks
and incidents
• Article 13:
• Strengthen transboundary cooperation on early-warning
and response systems
 IHR Core Capacity Requirements

Core Capacity Component Indicator

Indicator-based Early warning function for the early detection
Surveillance surveillance of a public health event
Event-based Established and functioning
surveillance
Response Rapid response capacity Public health emergency response
mechanisms are established and functioning
Preparedness Public Health Multi-hazard National Public Health
Emergency Emergency Preparedness and Response Plan
Preparedness and developed and Implemented
Response
Risk Policy and procedures Mechanisms for effective risk communication
communicatio for public during a public health emergency are
n communication established and functioning

WHO (2017): IHR Core Capacity Monitoring Framework Questionnaire for

Monitoring Progress in the Implementation of IHR Core Capacities in States
Parties, https://apps.who.int/iris/handle/10665/246237
 2030 Agenda for Sustainable Development

• Ensure healthy lives and • Ensure availability and

promote well-being for sustainable management
all of water and
at all ages sanitation for all

• Target 3.3: By 2030, (…) combat • Target 6.1: By 2030, achieve

hepatitis, water-borne universal
diseases and other and equitable access to safe and
communicable diseases affordable drinking-water for all
• Target 3.9: By 2030, • Target 6.2: By 2030, achieve
substantially reduce the access
number of deaths and to adequate and equitable
illnesses from (…) water and sanitation
soil pollution and and hygiene for all (…), paying
contamination special attention to the needs of
women and girls (…)
 Quiz

How are water-related infectious diseases

transmitted?
 What are water-related infectious diseases?
• Water-related disease
• adverse effect on human health caused by the condition of water
• Infectious or non-infectious
 Classification of WRID

Category Description Examples

Water-borne Ingestion of pathogens in Typhoid, legionellosis,

contaminated water poliomyelitis

Water-washed Poor hygiene / lack of access to Scabies, trachoma, bacillary

a) Skin and eyes safe water dysentery
b) Diarr1hoeal diseases
Water-based Infection by agents that spend Schistosomiasis
a) Skin penetration part of their life-cycle in water
b) Ingested
Water-related vectors Spread by vectors that breed or Malaria, West Nile Fever
a) Biting near water bite near water
b) Breeding in water
Primary agents of infectious waterborne outbreaks

Bacteria Viruses Protozoa

Campylobacter jejuni Hepatitis A virus Balantidium coli
Escherichia coli Norovirus Cryptosporidium spec.
Helicobacter pylori Rotavirus Cyclospora cayetanensis
Legionella spec. Adenovirus Entamoeba histolytica
Leptospira spec. Enterovirus Giardia spec.
Mycobacterium spec. Astrovirus Naegleria fowleri
Salmonella enterica
Shigella spec.
Vibrio cholerae
Pathogens transmitted through drinking-water
 Camplyobacter spp

• Important cause of acute gastroenteritis worldwide and in the

European region.
• C. jejuni, C. coli, C. laridis and C. fetus
• Incubation period: 2-4 days; illness duration 3-7 days
• Symptoms: abdominal pain, diarrhoea (sometimes bloody), vomiting,
chills and fever
• Reactive arthritis, meningitis and Guillain Barre syndrome
• Reservoir: Poultry, wild birds, cattle and pets.
• Waterborne outbreaks
• Faecal contamination of water storage reservoirs with bird faeces
• Consumption of inadequately treated surface water
 Shigella

• S. dysenteriae, S. flexneri, S. boydii and S. sonnei.

• Abdominal cramps, fever and water diarrhoea; bacillary dysentery
is characterized by bloody diarrhoea.
• Incubation period: 24-72 hours
• Faecal-oral transmission through person-to-person contact,
contaminated food, water and flies
• Waterborne outbreaks are occurring more frequently due to
faecally contaminated drinking-water.
• Control of Shigella in drinking-water is of special public health
importance
• Sensitive to disinfection
 Legionella

• L. pneumophila is responsible for most human infections:

Legionellosis
• Legionnaires’ disease
• Pontiac fever
• Infection through inhalation of aerosols containing the bacteria
(showers, jacuzzi, sinks and cooling towers etc.)
In rare cases transmitted by aspiration
• Risk management strategies in high-risk settings:
• Temperature control (in cold water systems <20˚C; in hot water systems >55°C)
• Disinfection
• Minimise biofilm growth
 Hepatitis A virus

• Highly infectious with a low infectious dose

• Average incubation period 28-30 days
• Mostly asymptomatic, disease severity increases with age
• Hepatitis A / infectious hepatitis – sudden onset, fever, malaise,
nausea, anorexia, abdominal pain, jaundice and liver damage –
prolonged illness
• Mortality <1%
• Source: faecally contaminated food and water
• Person to person and faecal oral transmission most common
• Strong evidence of waterborne transmission
• Highly resistant to disinfection E. coli or thermotolerant
coliforms are not a reliable indicator of the presence/absence of HAV
in drinking-water supplies.
 Hepatitis E

• Much less widespread and mostly confined to tropical and

subtropical areas. It has caused large waterborne outbreaks
– Recent evidence indicates that HEV might also be prevalent at a
low level in Europe.
• Infection can be more severe than, HAV, increased mortality in
pregnant women
 Norovirus

• 90% of epidemic nonbacterial outbreaks of gastroenteritis

worldwide
• Usually self-limiting- severe illness is rare
• Transmission:
• Faecally contaminated food or water
• Person-to-person
• Aerosolization of vomited virus and subsequent contamination of surfaces
• Outbreaks often occur in closed communities
• Long-term care facilities, overnight camps, mass gatherings, hospitals,
schools, prisons, dormitories and cruise ships
 Cryptosporidium

• 13 species – C. hominis and C. parvum predominant in humans

• Self-limiting abdominal pain and diarrhea (1 week on average); can be prolonged
and severe in immunosuppressed
• Large waterborne outbreaks, and outbreaks associated with visiting farms and
contact with animals
• Oocysts shed in faeces can survive for weeks or months in fresh water
• Faecal oral and person to person transmission; consumption of contaminated food
and water and transmission from animals.
• Highly infectious – 10 oocysts
• Resistant to disinfection E.coli or thermotolerant coliforms are not a
reliable indicator of their presence/absence.
• UV radiation inactivates oocysts.
 Giardia

• Giardiasis – G. intestinalis/G. lamblia or G. duodenalis

• Diarrhoea, abdominal cramps and malabsorption deficiencies
• Self-limiting illness, but prolonged illness can occur
• Asymptomatic carriage is common
• Cysts are shed in faeces; prolonged survival of cysts in fresh water
• Infectious dose <10 cysts
• Person to person transmission, contaminated drinking-water,
recreational water and food
• Well established source of waterborne outbreaks
• Resistant to disinfection E.coli or thermotolerant coliforms are
not a reliable indicator of their presence/absence.
Drinking-water systems as a source of WRID

Source water
quality

Treatment,
handling and Treatment
storage at effectiveness
home

Drinking-
water
Transport of quality Residual
collected disinfectant
water levels

Integrity of Integrity of
distribution storage
systems reservoirs

Nokes (2008): A Guide to the Ministry of Health Drinking-water Standards

for New Zealand,
https://environment.govt.nz/assets/Publications/Files/guide-moh-drinking-
water-standards-nz-jun08.pdf
 Hazardous events at different points of the water
supply system
Point of Examples of hazardous events
contamination The water treatment and
Source water • Runoff of animal and human waste and sewage during wet weather
distribution process
(surface or • Leakage of faecal matter from on-site sanitation or damaged sewers
groundwater)
Treatment • Inundation of filtration beds with contaminated water during
system flooding
• Failures in treatment (e.g. coagulation, filtration and/or disinfection
processes
Distribution • Ingress of contaminated water from the environment through
system cracked or eroded pipes, especially during pressure drops
• Cross-contamination of drinking-water systems with wastewater,
rain water etc
• Unhygienic conditions of containers carrying water from source to
home
Storage system • Faecal contamination of water stored in reservoirs and storage tanks

Source: https://interestingengineering.com/dirty-
clean-how-water-treatment-plant-works
Drinking-water systems as cause of WRID outbreaks

Treatment deficiencies

Raw water (groundwater )

0 5 10 15 20 25 30
Number of outbreaks (2000-2014)

Systematically assess and manage risks to water supply from catchment to

consumer

Source/catchment
Treatment Distribution Consumer
protection

Moreira and Bondelind (2017): Safe drinking water and waterborne

outbreaks. Journal of Water & Health, https://doi.org/10.2166/wh.2016.103
 Water safety plans

• Best way to ensure a safe drinking-water supply

• Identify hazards and events (e.g. technical defects, malpractices,
accidents, natural causes) that pose a risk to the supply system or
fail to remove them

• Multi-barriers to contamination
– Preventing hazards entering to water system (catchment)
– Removing hazards from the water (treatment)
– Preventing re-occurrence (storage and distribution)
 Burden of WRID in the European Region

• Estimated 2700 deaths due to WASH related diarrhoea in 2016

which indicates 7 people die every day (WHO, 2019)
• The diseases with the highest number of reported outbreaks
are shigellosis, E. coli diarrhoea, hepatitis A and
cryptosporidiosis*
• Available data do not allow to distinguish the transmission
routes (water, sanitation or food)
• Under-reporting of outbreaks to insufficient surveillance and
outbreak investigation capacity

*Global Infectious Disease and Epidemiology Online Network, data for

2010-2021 https://www.gideononline.com/
Waterborne outbreaks in Europe, 2000 - 2013

Global Infectious Disease and Epidemiology Online Network,

https://www.gideononline.com/
 Viral gastroenteritis
Example: Prague
experienced large
waterborne outbreak
of norovirus infection
(estimated 11,000 to
12,000 cases) caused
by cross contamination
resulting from
breakages of water
and sewage pipes
(2015)
 Burden of mortality

• Burden of disease ≠ burden of mortality

– the burden of disease caused by pathogens transmitted by
the faecal oral route is greatest, BUT
– the burden of mortality may be caused by pathogens
transmitted by other routes is greatest

• Legionella, pseudomonas and non-tuberculus mycobacteria

– Caused 91% of WRID deaths in the USA between 2003 and
2009
• Germany: >3 deaths every day due to legionellosis

Gargano et al. (2017): Mortality from selected diseases that can be

transmitted by water – United States, 2003–2009. Journal of Water & Health,
https://doi.org/10.2166/wh.2017.301
Outbreaks of legionellosis in Europe, 2010 – 2021
(published data)
 Drivers of WRID in the pan-European region

• Emergence and re-emergence of pathogens: Cryptosporidium parvum

and Legionella pneumophila
• Climate change and international travel
– Geographic dissemination of WRID pathogens to new areas – Giardia lamblia
• Small scale and community operated water and sanitation systems
– Vulnerable to environmental contamination
– Untreated or insufficiently treated ground or surface water
• Changes in how water is used
• Increasing age and number of immunodeficient persons
Surveillance and outbreak management capacity
in the pan-European region
• Passive surveillance of a limited number of pathogens
• Wide variation in number and types of pathogens, diseases and events under
surveillance
• Variable sampling, laboratory testing and reporting protocols
• Limited routine testing of enteric pathogens; less testing of viruses and parasites
• Under-ascertainment of uncommon pathogens and those not covered by
surveillance
• Limited laboratory capacity for testing
• Limited human and financial resources for surveillance and outbreak response
• Limited epidemiological capacity to investigate source of infection – cases not
categorised as water-related
Surveillance and outbreak management capacity cont.

• Foodborne versus waterborne

• No standard definition of an outbreak and thresholds for
outbreak detection not defined
• Inadequate early-warning and response systems
• Inadequate communication and coordination between public
health agencies, water providers and those responsible for
monitoring water quality
 The need to strengthen WRID surveillance and
outbreak management capacity
• Surveillance and outbreak response procedures need to be
harmonised and strengthened in order to:

– Generate more robust data on the true burden of WRID

– Generate data on the causes of outbreaks

→ Inform investments in water supply systems

→ Inform public health action to control WRID

Useful references for further reading

ESGLI (2017): European Technical Guidelines for the Prevention,

WHO (2017): Legionella and the prevention of Control and Investigation of Infections caused by Legionella
legionellosis. species, June 2017. , https://www.ecdc.europa.eu/en/publications-
https://apps.who.int/iris/handle/10665/43233 data/european-technical-guidelines-prevention-control-and-
investigation-infections
 Acknowledgement
The training modules on water-related disease surveillance and outbreak management were developed within the programme of
work of the WHO Regional Office for Europe and United Nations Economic Commission for Europe Protocol on Water and Health.
Maureen O’Leary (Independent Consultant Epidemiologist, United Kingdom) and Bernardo Guzmán Herrador (Ministry of Health,
Spain) prepared the presentations and manuals for the facilitator and participants. Enkhtsetseg Shinee (WHO European Centre for
Environment and Health (ECEH), Germany) coordinated the process and provided conceptual input to content development of
the training package under the strategic direction of Oliver Schmoll (WHO ECEH, Germany). WHO gratefully acknowledges the
helpful feedback provided by Krešimir Čohar (Institute of Public Health, Croatia), Laura Huber (WHO Collaborating Centre for
Research on Drinking-water Hygiene, German Environment Agency, Germany) and Susanne Hyllestad and Karin Nygård (Institute
of Public Health, Norway) during the review process. Imre Sebestyén (Unitgraphics, Serbia) and Dennis Schmiege (WHO ECEH,
Germany) prepared the design and layout, and administrative support was provided by Andrea Rhein (WHO ECEH, Germany). The
WHO Regional Office for Europe and UNECE gratefully acknowledge the financial support provided by the Norwegian Ministry of
Health and Care Services.