IJERPH, Vol. 20, Pages 559: Worldwide Surveillance Actions and Initiatives of Drinking Water Quality: A Scoping Review

3.2.1. Class 1—Assessment of Coverage, Accessibility, Quantity, and Drinking Water Quality in Routine and Emergency Situations

This class represented the actions developed by authorities responsible for monitoring drinking water quality in routine and emergency situations. The actions sought to ensure adequate drinking water quality, quantity, and access (supply systems) for the population. In most cases, these actions required the articulation between services responsible for water supply and other services responsible for public health surveillance.

A total of 20.4% of the analyzed material was represented in this class (f = 36 ST), composed of words and radicals (e.g., analysis, quality, surveillance, technical, coverage, and consumption) in the interval between χ2 = 3.91 (health) and χ2 = 31.57 (action).

Surveillance actions assessing the coverage, quantity, and accessibility of drinking water for the population were poorly highlighted in studies conducted in Costa Rica [29,43], Brazil [34], and India [51]. Some studies revealed locations in which almost the entire population was supplied [29,43]. Other studies demonstrated that, although all small residences had access to water, the offer was limited to two hours per day, motivating water storage and use of pumps to obtain more water during the supply period [51], and verifying the consumption per capita was impossible due to limitations in the information system [34].In this sense, the literature indicates that the operational and maintenance costs for expanding drinking water and sanitation services hindered many countries from adequately providing these services to the population. About 2 billion people do not have access to drinking water, reflecting the worldwide crisis caused by two major structural flaws: inequality and poverty. The former results from lack of support from socioeconomic systems, while the latter is related to the unsustainable relation with aquatic ecosystems, which transforms water into a vector of disease and death [78].Most studies included in this class highlighted actions related to assessing water quality offered in routine situations according to contaminant levels [29,43,69,71,74,76]. They also mentioned a possible seasonal pattern in water contamination during winter and summer [69] or in March and April [34].It is known that changes in rainfall impact water quality (i.e., increased rainfalls may overload domestic and industrial sewage collection systems), leading to the disposal of raw sewage into water courses and increasing the risk of contamination by pathogens. Alternatively, droughts may increase the salinity of the soil and freshwater sources, decreasing the dilution of pollutants [8] and, consequently, groundwater formation and water supply for part of the population [79]. Thus, climate variables (e.g., precipitation, humidity, evaporation, and temperature) may contribute to outbreaks of diarrheal diseases [80], which may mostly affect children below five during very dry, hot, humid seasons [81].Another important result was the difference in data and information related to water quality between agencies responsible for water supply and health surveillance [37,41]. This situation is problematic since data are crucial to policy-making, development of new programs and interventions, and improvement of public communication, research assessment, and investment allocation [82]. Additionally, divergences may compromise the correct alignment of adequate interventions.Nevertheless, the availability of global indicators related to water supply, sanitation, and hygiene constantly improved in the first five years of the SDGs. Moreover, national estimations related to the safe management of drinking water increased from 96 to 138 countries, including in rural (from 20 to 65 countries) and urban regions (from 42 to 87 countries) [7].Concerns about water contaminants must also be highlighted. Currently, thermotolerant coliforms are the most reported water contaminants; however, contamination by hydrocarbons and pesticides from local industrial and agriculture models is also worrisome [29]. For example, a study in Denmark found that only 0.5% of samples from public drinking water contained pesticides, and 16% of these exceeded the recommended levels under the national standard [83]. This reality is very different from that in low-income countries, where agriculture and raw sewage threaten water quality [8]. Surveillance actions of drinking water quality in emergency situations were related to natural or anthropogenic disasters, such as tsunamis [48], dam failure accidents [50], and environmental disasters in the paper industry [30]. The actions involved the identification of priorities related to drinking water quality [48], including periodic monitoring and collective and individual supply solutions to gather water from underground sources in the affected municipalities [50]; detection of vulnerable points in the network [30] to improve the microbiological and chemical safety of water; and analysis of household wells to classify the risk in water consumption [9]. The need to create intersectoral technical working groups [30] or operating committees for integrating essential areas to attend to emergencies [50] was also highlighted, besides the installation of chlorinated water tanks; distribution of domestic water treatment reagents to residences in the affected areas [64]; and improvements in water management related to source protection, disinfection practices, and attention to contamination [48].The increased exposure to risks caused by consumption patterns, working conditions, and exposure to chemicals associated with the appropriation of nature by humankind is leading to environmental degradation, which may increase the occurrence of disasters and emergencies in public health. This implicates the need for immediate action not only in health care and surveillance but also in other areas of action according to the characteristics of the event [84].In this context, the effects of natural disasters on health represented an important challenge for public health due to several derived factors (e.g., vulnerability of the population and the economic development model adopted, which often affects the climate) and required coordinated risk management action among all levels across health sectors [85]. 3.2.2. Class 2—Analysis of Physical–Chemical and Microbiological Parameters in Public Supply Networks and Alternative Water Supply Solutions Class 2 was at the same level as class 1 (Figure 3). Class 2 was based on the assessment of parameters related to the supply of quality water and linked to specific legislation in countries that standardized and limited the contaminant levels for coliforms, physical–chemical parameters (e.g., turbidity, pH, color, and temperature), and other microbiological indicators. The essential role of routine and systematized information regarding these parameters was highlighted to support health surveillance actions.

Class 2 comprised 45 ST (25.60%), with words between χ2 = 4.48 (total coliforms) and χ2 = 39.09 (sample). The following words were presented: residual free chlorine (χ2 = 28.72), parameter (χ2 = 22.60), turbidity (χ2 = 14.55), thermotolerant coliforms (χ2 = 11.92), Escherichia Coli (χ2 = 11.43), improper (χ2 = 10.89), and legislation (χ2 = 5.26).

Residual-free chlorine is a widely searched indicator used to assess water quality [32,34,35,37,39,41,51,64]. Inadequate chlorination was identified as a vulnerable factor in alternative solutions for water supply, exposing the population to microbiological contamination [32]. In addition, turbidity was analyzed as a relevant indicator [34,35,37,39,40,41,49,51,53] and frequently associated with acute diarrhea when the maximum limit was exceeded [37]. Bacterial contamination by coliform [32,33,34,37,39,41,45,51,68,72] and Escherichia coli [33,35,39,45,51,64,75] were also correlated with the emergence of acute diarrhea [75]. The assessment of fluoride levels was indicated as a potential parameter for preventing cavities in the population [31,35,36,41,47].Similar to our findings, a study in Zimbabwe investigated the quality of alternative water sources and their distribution system. The authors revealed that, although samples met the WHO recommendations for physical–chemical parameters, the microbiological requisites were not met due to coliform contamination regardless of water source and location. Moreover, Escherichia coli and Salmonella spp. were found in some samples. Multidrug resistance (amoxicillin, ampicillin, and cephalothin) was also identified, indicating that water without further treatment was unsafe for human consumption [86].Other problems identified by studies included in this review were the need for more information or irregular registration of some parameters [35,75], lack of inspection of water quality and registration of water sources [34], and reduced compliance with surveillance actions in rural areas [39]. In this sense, it is essential to use open-access databases to centralize the register of analyses and allow the assessment of drinking water using a spatial–temporal categorization [83]. 3.2.3. Class 3—Identification of Household Water Contamination, Communication, and Education with the Community

This class was linked to Classes 1 and 2 on the external level of the dendrogram and represented the identification of water contaminants at the household level and dissemination and education needed with the community, especially in situations of risk.

Class 3 comprised 33% of ST analyzed (f = 58 ST) and considered words in the interval between χ2 = 16.96 (use) and χ2 = 4.88 (affected). The following words were presented: well (χ2 = 13.99), family (χ2 = 13.43), community (χ2 = 11.29), drinking (χ2 = 11.29), residence (χ2 = 10.47), counseling (χ2 = 7.14), warning (χ2 = 6.21), domestic (χ2 = 6.21), communication (χ2 = 5.16), and domicile (χ2 = 5.16).

The surveillance actions of water quality highlighted in this class addressed the identification of chemical contaminants in households (i.e., lead [70,72], arsenic [66,71,72], iron [70,72,77], nitrate [68,72,77], fluoride [46,77], aluminum, manganese, strontium, and nitrogen [72]), revealed locations that did not fully comply with regulations of chemical contamination [48], and identified volatile organic compounds within the allowed level [68]. Identifying these contaminants has been part of testing programs at residences of people from at-risk groups (e.g., women with children [70], low-income families with pregnant women, and young children [72]) and assessments of supply sources and sources needing treatment after a disaster [50]. Chemical contamination represents a major challenge for public health because of its effects after long-term exposures, interfering with the comprehension of risky situations and elaboration of preventive measures. Furthermore, emerging pollutants (e.g., medicines, endocrine deregulators, pesticides, organic products, metals, and illicit drugs) are not routinely monitored because they are not listed as common chemical contaminants [87]. In this sense, efforts are needed to regulate the monitoring of these substances, considering the economic activities or local characteristics of sanitary sewage [87]. For instance, the extensive use of nitrogen-containing fertilizers raises nitrate levels in groundwater and increases the risk for people consuming this water; thus, the protection of groundwater source areas is needed to meet the supply needs of economic development [88].For this reason, it is important to assess the quality of drinking water, especially regarding household chemical levels, since the availability of drinking water is at risk due to natural and anthropogenic activities. A study conducted in a rural region of Bangladesh observed that most families consumed drinking water of poor quality and containing high levels of iron, manganese, and arsenic [89].The following methods of education and communication with the community were developed in situations of microcystin contamination: alerts to the population (e.g., warnings to boil water) [62], risk classification of wells (including with Salmonella spp.) [48], guidance for families affected by disasters [50], counseling in residential and commercial systems [38], and conscientization campaigns for the rural population to improve water sources and comprehend the role of drinking water in health [77].In this context, risk communication by professionals working with drinking water may occur on many occasions, such as unexpected events or disasters (e.g., chemical spills, outbreaks, hurricanes, and power outages) or during a routine inspection [90]. Water systems or agencies must provide information to the population, encourage action preparation and recommendations, or comply with precepts of public legal notification when its quality is compromised. These warnings must include information about water boiling and avoiding its use for drinking or other purposes [91].The risks from environmental issues may be seen as more alarming and be less understood than other health risks because they are often invisible and disproportionately affect part of the population; thus, requiring communication professionals with the ability to explain situations clearly, succinctly, and empathically [90].The effectiveness of risk communication relies on health literacy issues, which represent the ability to receive information, comprehend, and act adequately to make decisions [91]. Furthermore, recognizing the characteristics of the target audience (e.g., age, socioeconomic level, educational level, culture, language, environmental preoccupation, and environmental health literacy) is essential for effective and transparent communication [92]. The recognition of work, continuing education of workers, community participation, social responsibility, social accountability, political support, and personal commitment were also reported as essential elements for successful surveillance actions of water quality [49]. Furthermore, the training of health workers is needed, especially in low-income countries, to improve the use of geographical information tools and increase the interconnection between human and environmental health, socioeconomic transitions, and climate changes. Data from passive surveillance, disease outbreak reporting systems, and environmental and climatic observations may also be used to assess patterns and trends of diseases [93].Public health surveillance systems must be strengthened by adequately allocating resources and constantly training to use information in the prioritization, planning, action, and assessment of actions [23]. Furthermore, the participation of citizens in monitoring population health should be explored [93]. 3.2.4. Class 4—Investigation of Water-Borne Disease OutbreaksClass 4 comprised the most different topic and represented the investigation of factors associated with WBDOS, including data analysis regarding drinking water affected by outbreaks that caused illness, hospitalization, and death [53,56,57,58,59,60,61,62,68].

This class comprised 21% of the material analyzed (f = 37 ST) and considered words in the interval between χ2 = 124.60 (outbreak) and χ2 = 4.24 (positive). It presented representative words, such as associated (χ2 = 64.98), WBDOS (χ2 = 44.08), transmitting (χ2 = 38.71), disease (χ2 = 36.49), death (χ2 = 35.63), etiology (χ2 = 31.49), investigation (χ2 = 22.60), chemical (χ2 = 22.21), infectious (χ2 = 19.33), intoxication (χ2 = 15.38), virus (χ2 = 11.47), parasite (χ2 = 10.78), and bacteria (χ2 = 5.34).

Several states of the USA and Canada investigated reported or suspected cases of WBDOS, in which etiological agents were unknown [67], unidentified [52,56], or linked to infectious agents (i.e., bacteria, viruses, and parasites) [55,56,57,58,59,60,61,67]; some cases were related to multiple etiology [60,61]. Chemical poisoning by sodium hydroxide [55,57,61], copper [55,56,58], nitrate [52,57], nitrite [55], tilbenzene, toluene, xylene [58], and toxins [59] was also reported.Outbreaks in the USA and Canada were associated with the community, non-community, or individual water systems [55,56] and unregulated private or non-community wells [57]; nearly half of the outbreaks investigated were in semi-public systems [67]. Superficial [56] and groundwater [52,57,60] sources of these systems were also linked to outbreaks.In the USA, the public health authority uses data from the states to monitor diseases, risk factors, and public health issues of collective interest. They also screen for outbreaks related to contaminated water, such as Escherichia coli or other non-infectious causes (e.g., lead poisoning) [82], to reveal deficiencies in the water supply system.Deficiencies possibly associated with the emergence of outbreaks were linked to a water source, treatment plant or distribution system [59,60,61], and use of non-treated groundwater [61]; some were unknown or out of the jurisdiction of water utility or location of use [59,60]. Gastrointestinal diseases [46,52], acute diarrhea [53], hepatitis A, cryptosporidiosis, and giardiasis [52] were also present, and more serious cases resulted in death (e.g., chemical poisoning by fluoride) [52].

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