Themes / Topics Rural Poverty & Health
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January 2, 2024 In

Making Waves: The Benefits and Challenges of Responsibly Implementing Wastewater-based Surveillance for Rural Communities

Abstract/Summary: The sampling and analysis of sewage for pathogens and other biomarkers offers a powerful tool for monitoring and understanding community health trends and potentially predicting disease outbreaks. Since the early months of the COVID-19 pandemic, the use of wastewater-based testing for public health surveillance has increased markedly. However, these efforts have focused on urban and peri-urban areas. The potential public health benefits of wastewater-based surveillance for rural communities are substantial – though so too are the methodological and ethical challenges. Practitioner observations and research findings indicate that for many rural systems, typical implementation approaches for wastewater-based surveillance will not yield sufficiently reliable or actionable results. In this paper, we discuss key challenges and potential strategies to address them. However, to support and expand the implementation of responsible, reliable, and ethical wastewater-based surveillance for rural communities, best practice guidelines and standards are needed.

December 27, 2023 In

Microbiological and chemical drinking water contaminants and associated health outcomes in rural Appalachia, USA: A systematic review and meta-analysis

Abstract/Summary: In rural areas of the United States, an estimated ~1.8 million people lack reliable access to safe drinking water. Considering the relative dearth of information on water contamination and health outcomes in Appalachia, we conducted a systematic review of primary data studies published from 2000-2019. Of the 3,452 records identified for screening, 85 met our eligibility criteria. Most studies were conducted in Northern (32%, n=27) and North Central (24%, n=20) Appalachia, and only 6% (n=5) in Central Appalachia. Across studies, E. coli were detected in 10.6% of samples. 32% (n=27) of studies assessed health outcomes, but only 4.7% (n=4) used case-control or cohort designs (all others were cross-sectional). The most commonly reported outcomes were detection of PFAS in blood serum (n=13), gastrointestinal illness (n=5), and cardiovascular-related outcomes (n=4). Overall, based on the number and quality of eligible studies identified, we could not reach clear conclusions about the state of water quality, or its impacts on health, in any of Appalachia’s subregions. More epidemiologic research is needed to understand contaminated water sources, exposures, and potentially associated health outcomes in Appalachia.

January 2, 2023 In

Drinking Water & Health in Rural Appalachia

We are working on a number of projects to better understand issues related to drinking water (access, quality, use), sanitation, and reported and measured health outcomes in the Appalachia region, with a focus on children and adults living in Central Appalachia. In 2020, we started a comprehensive systematic review and meta-analysis study to identify and synthesize published research on drinking water contamination and associated health outcomes in the Appalachian region over a 20-year time period. We pre-registered our study protocols, completed data extraction and analysis in 2022, and published our findings in 2023 – the limited number and nature of the studies identified demonstrated that more epidemiologic research is needed to understand exposures to drinking water contaminants in this region. From 2021 to 2023, in collaboration with UVA, ETSU, a regional non-profit, a local utility, and others, we conducted a water-and-health focused cross-sectional study and a prospective cohort study in southwest VA (an important component of these studies is that we also share water testing results with participating households). In 2022, we published findings from the cross-sectional study (a small community of households with private wells), and we anticipate publishing preliminary findings from the cohort study (rural households with utility-supplied and private well and spring water in two counties) in early 2024. Given the relatively high rates of bottled water use/reliance we observed in rural households, we also conducted a study to analyze the quality of bottled water sold in the region; we anticipate publishing those findings in 2024. Building on findings from these studies, in late 2023 (in collaboration with ETSU, a regional non-profit, and others) we initiated a prospective safe water intervention pilot study in rural regions of southwest VA and northeast TN.

January 2, 2023 In

The Human Right to Water: A 20-Year Comparative Analysis of Arsenic in Rural and Carceral Drinking Water Systems in California

Abstract/Summary: Access to safe drinking water is considered a universal human right. In the U.S., exposure to arsenic contamination in drinking water disproportionately impacts small, groundwater-reliant communities and communities of color. Limited research exists on water quality in prisons; however, prisons in the Southwestern U.S. have elevated arsenic concentrations compared to other community water systems (CWS) in the region. In this paper we present a comparative analysis of 20 years of data (2001-2021) on arsenic concentrations in the CWSs serving Kern Valley State Prison (KVSP) and three neighboring rural communities: Allensworth, Delano, and McFarland. Our objective was to better understand trends in water quality, compliance, and treatment following adoption of the revised arsenic MCL, and to elucidate differences, if any, between neighboring incarcerated and non-incarcerated populations.

July 21, 2022 In

Bottled and Well Water Quality in a Small Central Appalachian Community: Household-Level Analysis of Enteric Pathogens, Inorganic Chemicals, and Health Outcomes in Rural Southwest Virginia

Abstract/Summary: Consumption of unsafe drinking water is associated with a substantial burden of disease globally. In the US, ~1.8 million people in rural areas lack reliable access to safe drinking water. Our objective was to characterize and assess household-level water sources, water quality, and associated health outcomes in Central Appalachia. We collected survey data and water samples (tap, source, and bottled water) from consenting households in a small rural community without utility-supplied water in southwest Virginia. Water samples were analyzed for physicochemical parameters, total coliforms, E. coli, nitrate, sulfate, metals (e.g., arsenic, cadmium, lead), and 30+ enteric pathogens. Among the 69% (n = 9) of households that participated, all had piped well water, though 67% (n = 6) used bottled water as their primary drinking water source. Total coliforms were detected in water samples from 44.4% (n = 4) of homes, E. coli in one home, and enteric pathogens (Aeromonas, Campylobacter, Enterobacter) in 33% (n = 3) of homes. Tap water samples from 11% (n = 1) of homes exceeded the EPA MCL for nitrate, and 33% (n = 3) exceeded the EPA SMCL for iron. Among the 19 individuals residing in study households, reported diarrhea was 25% more likely in homes with measured E. coli and/or specific pathogens (risk ratio = 1.25, cluster-robust standard error = 1.64, p = 0.865). Although our sample size was small, our findings suggest that a considerable number of lower-income residents without utility-supplied water in rural areas of southwest Virginia may be exposed to microbiological and/or chemical contaminants in their water, and many, if not most, rely on bottled water as their primary source of drinking water.

July 21, 2022 In

Subsewershed SARS-CoV-2 Wastewater Surveillance & COVID-19 Epidemiology Using Building-specific Occupancy & Case Data

Abstract/Summary: To evaluate the use of wastewater-based surveillance and epidemiology to monitor and predict SARS-CoV-2 virus trends, over the 2020–2021 academic year we collected wastewater samples twice weekly from 17 manholes across Virginia Tech’s main campus. We used data from external door swipe card readers and student isolation/quarantine status to estimate building-specific occupancy and COVID-19 case counts at a daily resolution. After analyzing 673 wastewater samples using reverse transcription quantitative polymerase chain reaction (RT-qPCR), we reanalyzed 329 samples from isolation and nonisolation dormitories and the campus sewage outflow using reverse transcription digital droplet polymerase chain reaction (RT-ddPCR). Population-adjusted viral copy means from isolation dormitory wastewater were 48% and 66% higher than unadjusted viral copy means for N and E genes (1846/100 mL to 2733/100 mL/100 people and 2312/100 mL to 3828/100 mL/100 people, respectively; n = 46). Prespecified analyses with random-effects Poisson regression and dormitory/cluster-robust standard errors showed that the detection of N and E genes were associated with increases of 85% and 99% in the likelihood of COVID-19 cases 8 days later (incident–rate ratio (IRR) = 1.845, p = 0.013 and IRR = 1.994, p = 0.007, respectively; n = 215), and one-log increases in swipe card normalized viral copies (copies/100 mL/100 people) for N and E were associated with increases of 21% and 27% in the likelihood of observing COVID-19 cases 8 days following sample collection (IRR = 1.206, p < 0.001, n = 211 for N; IRR = 1.265, p < 0.001, n = 211 for E). One-log increases in swipe normalized copies were also associated with 40% and 43% increases in the likelihood of observing COVID-19 cases 5 days after sample collection (IRR = 1.403, p = 0.002, n = 212 for N; IRR = 1.426, p < 0.001, n = 212 for E). Our findings highlight the use of building-specific occupancy data and add to the evidence for the potential of wastewater-based epidemiology to predict COVID-19 trends at subsewershed scales.

July 21, 2022 In

Bottled water quality and associated health outcomes: A systematic review and meta-analysis of 20 years of published data from China

Abstract/Summary: Bottled water is a rapidly growing yet relatively understudied source of drinking water globally. In addition to concerns about the safety of bottled water, the adverse environmental health and social impacts associated with bottled water production, distribution, consumption, and reliance are considerable. Our objective was to comprehensively review, analyze, and synthesize ∼20 years of publicly available data on bottled water quality and associated health outcomes in China. We conducted a systematic review and meta-analysis of publicly available studies of bottled water quality and associated health outcomes in China published between 1995 and early 2016 (in Chinese and English). We pre-specified and registered our study protocol, independently replicated key analyses, and followed standardized reporting guidelines. Our search identified 7059 potentially eligible records. Following screening, after full-text review of 476 publications, 216 (reporting results from 625 studies) met our eligibility criteria. Among many findings, 93.7% (SD = 10.1) of 24 585 samples tested for total coliforms (n = 241 studies), and 92.6% (SD = 12.7) of 7261 samples tested for nitrites (n = 85 studies), were in compliance with China’s relevant bottled water standards. Of the studies reporting concentration data for lead (n = 8), arsenic (n = 5), cadmium (n = 3), and mercury (n = 3), median concentrations were within China’s standards for all but one study of cadmium. Only nine publications reported health outcome data, eight of which were outbreak investigations. Overall, we observed evidence of stable or increasing trends in the proportions of samples in compliance over the ∼20 year period; after controlling for other variables via meta-regression, the association was significant for microbiological but not chemical outcomes (p = 0.017 and p = 0.115, respectively). Bottled water is typically marketed as being safe, yet in most countries it is less well-regulated than utility-supplied drinking water. Given the trend of increasing bottled water use in China and globally—and the associated environmental health impacts—we hope this work will help to inform policies and regulations for improving bottled water safety, while further highlighting the need for substantially expanding the provision of safe and affordable utility-supplied drinking water globally.

October 18, 2021 In

Poverty, Water, Climate Change, & Health in Sub-Saharan Africa

As described below (see other project summaries), the Multidimensional Poverty Assessment Tool (MPAT) was created in two phases (from 2008 to 2014) via a collaborative, international initiative to develop, test, and pilot a new tool for local-level rural poverty assessment. The work was guided by a Sounding Board of experts from the International Fund for Agricultural Development (IFAD), other United Nations agencies, international and regional organizations, and universities around the world (see www.ifad.org/mpat). Following MPAT’s finalization and institutionalization in 2014, it was used in multiple countries including many in Sub-Saharan Africa. We are currently working on multiple desk-based studies with a variety of collaborators to analyze data from ~7,000 households across Eswatini, Kenya, Lesotho, Mali, Tanzania, and Zimbabwe. Because MPAT was developed based primarily on data from Bangladesh, China, India, and Mozambique, one study we are leading is an updated assessment and evaluation of MPAT’s indicator structure and robustness based on its use in the sub-Saharan region. Other studies we are working on focus on a cross-county analyses of MPAT’s water, climate change, and health focused components and sub-components, and related programs and interventions. We anticipate publishing a number of papers on this research in 2024.

October 18, 2021 In

Arsenic in Rural & Carceral Drinking Water Systems

Source: Adapted from www.USGS.gov

In the United States, millions of people lack reliable access to safe drinking water, a problem that is particularly acute in low-income rural areas. California legally recognized the human right to water in 2012, but this right remains unevenly realized. To better understand the status of the human right to water in rural communities, we analyzed 20 years of publicly available drinking water quality monitoring and violation data from 2001-2021, with a focus on arsenic contamination (a carcinogenic heavy metal) from a state prison as well as public water systems in three neighboring rural communities in southern California. We found that all four of these drinking water systems repeatedly exceeded the legal limit for arsenic during the study period, with mean served arsenic levels ranging from 3.4 (SD=6.7) to 9.3 (SD:=2.9) μg/L across the systems (based on 2,426 samples from four systems). In addition to arsenic-specific findings and comparisons across these four sites, our analyses demonstrate how publicly reported annually averaged water quality data (used to monitor system violations and to track progress toward the human right to water) provide only a partial guide to whether the right to safe water is being realized. We published our findings in 2022.

March 1, 2021 In

Water Supply Improvement & Health Promotion Campaigns in Rural Areas — China, 1949−2020

Abstract/Summary: In the 1950s, shortly after the founding of the People’s Republic of China (PRC), the central government created the Patriotic Health Campaign (PHC) in order to standardize and disseminate health focused educational materials intended to control and prevent infectious diseases (1). “Water improvement”, meaning measures aimed at providing safe drinking water for households in China, was an important part of the PHC. After 60 years of water improvement policies, programs, and investments, the rural water supply sanitation and hygiene in China has improved dramatically, and water-related diseases no longer negatively impact the rural population as they once did. In addition to improvements related to the quantity and quality of the rural water supply, water improvement programs also promoted improved hygiene, sanitation, and other health-related behaviors among rural households. Together, such initiatives have improved the quality of life and the health of hundreds of millions of rural residents, while also contributing to economic and social advancement across rural China (2). The purpose of this article is to describe how the PHC served as a foundation for the expansion and improvement of drinking water supply in rural China, and to summarize the key programs, projects, and initiatives that followed over the last 60 years.