BACKGROUND: The burden of waterborne disease in the United States has not been well quantified, and an estimate of the total number of illnesses, hospitalizations, and deaths due to waterborne diseases is needed to direct prevention activities and set public health goals. A single, comprehensive estimate that includes all disease outcomes and water exposures (i.e., drinking, recreational, environmental and undetermined) and accounts for the proportions of the diseases transmitted through other pathways (i.e., food, animal contact, person-to-person) is needed for succinct and impactful communication, similar to the foodborne disease estimate that 1 in 6 Americans (48 million people) are sickened annually.
METHODS: Large administrative databases, or “big data” (National Vital Statistics System mortality data, Health Care Cost and Utilization Project Nationwide Inpatient Sample and Nationwide Emergency Department Sample, the National Ambulatory Medical Care Survey, and MarketScan), were used to estimate the annual number of deaths, number and costs of hospitalizations, and number and costs of emergency department visits for select infections that can be transmitted by water. Rates of community illness were estimated using previous research on healthcare seeking behavior for specific diseases and infectious syndromes.
RESULTS: Annual estimates included 6,940 deaths (91% from premise plumbing pathogens), 90,000 hospitalizations at a cost of $1.8 billion, and 376,000 treat-and-release emergency department visits at a cost of $194 million for selected diseases that can be transmitted through water. Identified data gaps include burden of diseases not well-captured in administrative databases, the proportion of disease transmission attributable to water for non-enteric diseases (e.g., Pseudomonas), and the proportion of waterborne disease transmission attributable to drinking vs. recreational vs. other water contact.
CONCLUSIONS: Although data gaps were identified, several building blocks for an estimate of the burden of waterborne disease in the United States are complete. Results of analyses quantifying the amount of waterborne disease experienced by the US population are already informing CDC’s waterborne disease prevention efforts. For example, estimates of hospitalizations and deaths due to pathogens that can be transmitted by water have highlighted the importance of premise plumbing pathogens such as non-tuberculous mycobacteria and Pseudomonas. Additionally, recognition of the substantial burden of emergency department and physicians’ office visits for otitis externa led to the creation of specific prevention materials for the public and for physicians. Work is well underway to estimate the burden of waterborne disease in the United States; this estimate will be vital in prioritizing resources and informing policy makers.