Table Of ContentWaterborne
Diseases
in the
United States
Editor
Gunther F. Craun
Health Effects Research Laboratory
U.S. Environmental Protection Agency
Cincinnati, Ohio
Boca Raton London New York
CRC Press, Inc.
CRC Press is an imprint of the
TayBloor c&a F rRanacist oGnro,u pF, laon rinidfoarma business
First published 1986 by CRC Press
Taylor & Francis Group
6000 Broken Sound Parkway NW, Suite 300
Boca Raton, FL 33487-2742
Reissued 2018 by CRC Press
© 1986 by CRC Press, Inc.
CRC Press is an imprint of Taylor & Francis Group, an Informa business
No claim to original U.S. Government works
This book contains information obtained from authentic and highly regarded sources. Reasonable efforts have been made to publish
reliable data and information, but the author and publisher cannot assume responsibility for the validity of all materials or the
consequences of their use. The authors and publishers have attempted to trace the copyright holders of all material reproduced in this
publication and apologize to copyright holders if permission to publish in this form has not been obtained. If any copyright material has
not been acknowledged please write and let us know so we may rectify in any future reprint.
Except as permitted under U.S. Copyright Law, no part of this book may be reprinted, reproduced, transmitted, or utilized in any form
by any electronic, mechanical, or other means, now known or hereafter invented, including photocopying, microfilming, and recording,
or in any information storage or retrieval system, without written permission from the publishers.
For permission to photocopy or use material electronically from this work, please access www.copyright.com (http://www.copyright.
com/) or contact the Copyright Clearance Center, Inc. (CCC), 222 Rosewood Drive, Danvers, MA 01923, 978-750-8400. CCC is a
not-for-profit organization that provides licenses and registration for a variety of users. For organizations that have been granted a
photocopy license by the CCC, a separate system of payment has been arranged.
Trademark Notice: Product or corporate names may be trademarks or registered trademarks, and are used only for identification and
explanation without intent to infringe.
Library of Congress Cataloging in Publication Data
Main entry under title:
Waterborne diseases in the United States.
Includes bibliographies and index.
1. Waterborne infection—United States.
2. Water quality management—United States.
I. Craun, Gunther F.
RA642.W3W38 1986 614.4’3 85-9617
ISBN 0-8493-5937-6
A Library of Congress record exists under LC control number: 85009617
Publisher’s Note
The publisher has gone to great lengths to ensure the quality of this reprint but points out that some imperfections in the original copies
may be apparent.
Disclaimer
The publisher has made every effort to trace copyright holders and welcomes correspondence from those they have been unable to
contact.
ISBN 13: 978-1-315-89856-8 (hbk)
ISBN 13: 978-1-351-07766-8 (ebk)
Visit the Taylor & Francis Web site at http://www.taylorandfrancis.com and the
CRC Press Web site at http://www.crcpress.com
To Mary, Michael, Matthew, and Emily
PREFACE
Nostalgia for the "good old days" is a common phenomenon of survivors. This book
provides a landmark of the bygone hazardous life of most people in the U.S. or in most of
the industrialized world. In the first half of the 20th century, the family of man was an
endangered species, not normally listed in legislative protection. Life expectancy at birth
was still no more than 50 years. Infant mortality frequently reached or exceeded 50/1000
births. Infectious diseases were rampant. Prevention was still elementary, even though
specific causes of transmission were gradually being understood.
During that public health gestation period, bases for literal miracles of disease prevention
were implemented. The present volume records those experiences from 1920 to 1983 — an
heroic accomplishment by Mr. Craun. No small part of the lists of waterborne diseases are
the Result of his own continuing identification of epidemic episodes throughout that period.
They were the responsible indicators upon which sanitary engineers constructed and operated
the myriads of public water supply systems of the U.S. These sophisticated devices repre-
sented one of the means by which the war against infectious diseases was largely won in
this country and in the developed countries elsewhere.
As evidence accumulated throughout the decades as to the means of transmission via
water, the management of human wastes and potable waters made tremendous progress in
"building out" biological and physical causes of illness and death. The number of waterborne
outbreaks still occurring is infinitesimal. They are predominantly in smaller noncommunity
systems inadequately disinfected, in most instances by interruption of chlorination. Inci-
dentally, chlorine should be noted as perhaps saving more lives throughout the world than
any other chemical.
The pedestrian rehearsal in the volume conceals this dramatic extension of the lives of
people to a present expectancy of some 75 years. The book deserves a high place on the
book shelf with Von Clausewitz on the logistics of war and on the detection performances
of Sherlock Holmes, James Bond, and Maigret. Their record is no better than that of Craun.
All of this does not suggest that vigilance of water quality can now be relaxed. Much too
often we get vivid reminders that the familiar salmonellas, dysenteries, and the less familiar
giardia are disturbing us. Those who think the task is finished are unaware that the bacterial-
viral insults have a strange and long half-life.
But what of the future, only briefly noted by Craun? We entered a new and complex
world in the last 2 decades. We call it the "Chemical Era". Manmade and natural chemicals
total in the millions and thousands of new ones are synthetically produced every year. Too
many find their way into the ambient waters of the country and into sources of drinking
water. Their actual, potential, and alleged toxicities are known only for a relatively small
percentage of the total number. The challenge ahead of us in the water management field
is particularly difficult, because the manifestation of insults is 10, 20, and 30 years deferred
— some perhaps genetically affecting our great grandchildren. We live in a world of chem-
icals, many of which are necessary and salutary for health, safety, and welfare. We wait
upon major scientific clarifications. In the meantime, we should follow our past fruitful
experience by taking them out of our potable waters as we continue to do with the familiar
biological ones.
In all of this, we cannot ignore the remaining billions of people in the developing world.
They are still the victims of those infectious diseases no longer major threats to us. Their
misfortunes are now being multiplied as well by the chemical threats.
I close by recalling the wide reminder by the late great public health statesman, Prof.
C.E.-A. Winslow. He emphasized that our world is a battlefield, not a nursery.
Abel Wolman
September 1984
THE EDITOR
Gunther F. Craun* has served in various capacities over the past 20 years as an envi-
ronmental engineer and epidemiologist with the U.S. Public Health Service and U.S. En-
vironmental Protection Agency (EPA). Since 1970 he has been associated with the drinking
water and health research activities of the EPA. In addition to infectious waterborne diseases,
his current research interests include relationships between drinking water contaminants and
cardiovascular disease and cancer. He received his education in civil engineering (B.S.) and
sanitary engineering (M.S.) at Virginia Polytechnic Institute, Blacksburg, Va. and public
health (M.P.H.) and epidemiology (S.M.) at Harvard University, Cambridge, Mass.
He has authored and coauthored numerous articles in the international scientific, public
health, and engineering literature. The American Water Works Association and the New
England Water Works Association have recognized Mr. Craun for his work on waterborne
disease outbreaks and trace metals in the drinking water of the Boston metropolitan area.
The EPA awarded Mr. Craun a meritorious performance citation for his participation in the
Community Water Supply Study, which identified deficiencies in the public water supplies
of the Nation.
He is registered as a professional engineer in the Commonwealth of Virginia and is a
member of the American Water Works Association Committee on the Status of Waterborne
Disease Outbreaks in the U.S. and Canada (chairman, 1977 to 1982) and the International
Association of Milk, Food, and Environmental Sanitarians Committee on Communicable
Diseases Affecting Man. He served as liasion representative to the Safe Drinking Water
Committee of the National Research Council from 1974 to 1977 and as a member of the
World Health Organization Working Group of Sodium, Chloride, and Conductivity in Drink-
ing Water in 1978. He has also served as a member of the Water Pollution Control Federation
Research Committee and the International Association on Water Pollution Research Study
Group on Water Virology.
Mr. Craun is currently Coordinator of the Environmental Epidemiology Program in the
Health Effects Research Laboratory of the EPA, Cincinnati. In his present capacity, he
works with a number of other governmental agencies, including the National Cancer Institute,
Bethesda, Md. and Oak Ridge National Laboratory, Oak Ridge, Tenn. on epidemiological
studies of drinking water contaminants. He is also involved in projects with the National
Academy of Sciences, Washington, D.C. and the Center for Environmental Epidemiology,
University of Pittsburgh, Pittsburgh, Pa. to identify new research areas and methodologies
for environmental epidemiology.
This book was edited by Gunther F. Craun in his private capacity. No official support or endorsement by the
Environmental Protection Agency or any other agency of the Federal Government is intended or should be
inferred.
CONTRIBUTORS
Frank L. Bryan John C. Hoff
Food Microbiologist Research Microbiologist
Food Safety Consultation and Training Drinking Water Research Division
Tucker, Georgia U.S. Environmental Protection Agency
Cincinnati, Ohio
Gunther F. Craun
Epidemiologist and Sanitary Engineer
Peter C. Karalekas, Jr.
Health Effects Research Laboratory
Sanitary Engineer
U.S. Environmental Protection Agency
Water Supply Branch
Cincinnati, Ohio
U.S. Environmental Protection Agency
Boston, Massachusetts
Alfred P. Dufour
Chief, Bacteriology Group
Edwin C. Lippy
Health Effect Research Laboratory
Sanitary Engineer
U.S. Environmental Protection Agency
Health Effects Research Laboratory
Cincinnati, Ohio
U.S. Environmental Protection Agency
Cincinnati, Ohio
T. H. Ericksen
Microbiologist
Gary S. Logsdon
Health Effects Research Laboratory
Research Sanitary Engineer
U.S. Environmental Protection Agency
Drinking Water Research Division
Cincinnati, Ohio
U.S. Environmental Protection Agency
Cincinnati, Ohio
Jeffrey R. Harris
Medical Epidemiologist
Enteric Diseases Branch Floyd B. Taylor
Division of Bacterial Diseases Executive Director
Centers for Disease Control New England Water Works Association
Atlanta, Georgia Dedham, Massachusetts
Abel Wolman
Professor Emeritus
Department of Sanitary Engineering and
Water Resources
The Johns Hopkins University
Baltimore, Maryland
TABLE OF CONTENTS
SECTION I: WATERBORNE DISEASES
Chapter 1
Introduction 3
Gunther F. Craun
Chapter 2
Clinical and Epidemiological Characteristics of Common Infectious
Diseases and Chemical Poisonings Caused by Ingestion of
Contaminated Drinking Water 11
Jeffrey R. Harris
Chapter 3
Diseases Caused by Water Contact 23
Alfred P. Dufour
Chapter 4
Chemical Drinking Water Contaminants and Disease 43
Gunther F. Craun
SECTION II: WATERBORNE OUTBREAK STATISTICS
Chapter 5
Statistics of Waterborne Outbreaks in the U.S. (1920—1980) 73
Gunther F. Craun
Chapter 6
Recent Statistics of Waterborne Disease Outbreaks (1981—1983) 161
Gunther F. Craun
SECTION III: INVESTIGATION OF WATERBORNE OUTBREAKS
Chapter 7
Epidemiologic Procedures for Investigation of Waterborne Disease Outbreaks 171
Frank L. Bryan
Chapter 8
Methods to Identify Waterborne Pathogens and Indicator Organisms 195
T. H. Ericksen and Alfred P. Dufour
Chapter 9
Engineering Aspects of Waterborne Outbreak Investigation 215
Edwin C. Lippy
SECTION IV: PREVENTION OF WATERBORNE OUTBREAKS
Chapter 10
Regulations and Surveillance 233
Peter C. Karalekas, Jr. and Floyd B. Taylor
Chapter 11
Barriers to the Transmission of Waterborne Disease 255
Gary S* Logsdon and John C. Hoff
Epilogue 275
Gunther F. Craun
Index 279
Section I: Waterborne Diseases
