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Estimated Costs of Sporadic Gastrointestinal Illness Associated with Surface Water Recreation: A Combined Analysis of Data from NEEAR and CHEERS Studies.

ABSTRACT: The burden of illness can be described by addressing both incidence and illness severity attributable to water recreation. Monetized as cost, attributable disease burden estimates can be useful for environmental management decisions.We characterize the disease burden attributable to water recreation using data from two cohort studies using a cost of illness (COI) approach and estimate the largest drivers of the disease burden of water recreation.Data from the NEEAR study, which evaluated swimming and wading in marine and freshwater beaches in six U.S. states, and CHEERS, which evaluated illness after incidental-contact recreation (boating, canoeing, fishing, kayaking, and rowing) on waterways in the Chicago area, were used to estimate the cost per case of gastrointestinal illness and costs attributable to water recreation. Data on health care and medication utilization and missed days of work or leisure were collected and combined with cost data to construct measures of COI.Depending on different assumptions, the cost of gastrointestinal symptoms attributable to water recreation are estimated to be $1,220 for incidental-contact recreation (range $338-$1,681) and $1,676 for swimming/wading (range $425-2,743) per 1,000 recreators. Lost productivity is a major driver of the estimated COI, accounting for up to 90% of total costs.Our estimates suggest gastrointestinal illness attributed to surface water recreation at urban waterways, lakes, and coastal marine beaches is responsible for costs that should be accounted for when considering the monetary impact of efforts to improve water quality. The COI provides more information than the frequency of illness, as it takes into account disease incidence, health care utilization, and lost productivity. Use of monetized disease severity information should be included in future studies of water quality and health. Citation: DeFlorio-Barker S, Wade TJ, Jones RM, Friedman LS, Wing C, Dorevitch S. 2017. Estimated costs of sporadic gastrointestinal illness associated with surface water recreation: a combined analysis of data from NEEAR and CHEERS Studies. Environ Health Perspect 125:215-222;?http://dx.doi.org/10.1289/EHP130.

SUBMITTER: DeFlorio-Barker S

PROVIDER: S-EPMC5289902 | biostudies-other | 2017 Feb

REPOSITORIES: biostudies-other

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Estimated Costs of Sporadic Gastrointestinal Illness Associated with Surface Water Recreation: A Combined Analysis of Data from NEEAR and CHEERS Studies.

DeFlorio-Barker Stephanie S Wade Timothy J TJ Jones Rachael M RM Friedman Lee S LS Wing Coady C Dorevitch Samuel S

Environmental health perspectives 20160726 2

<h4>Background</h4>The burden of illness can be described by addressing both incidence and illness severity attributable to water recreation. Monetized as cost, attributable disease burden estimates can be useful for environmental management decisions.<h4>Objectives</h4>We characterize the disease burden attributable to water recreation using data from two cohort studies using a cost of illness (COI) approach and estimate the largest drivers of the disease burden of water recreation.<h4>Methods< ...[more]

PMID: 27459727

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Project description:BackgroundWastewater-impacted waters that do not support swimming are often used for boating, canoeing, fishing, kayaking, and rowing. Little is known about the health risks of these limited-contact water recreation activities.ObjectivesWe evaluated the incidence of illness, severity of illness, associations between water exposure and illness, and risk of illness attributable to limited-contact water recreation on waters dominated by wastewater effluent and on waters approved for general use recreation (such as swimming).MethodsThe Chicago Health, Environmental Exposure, and Recreation Study was a prospective cohort study that evaluated five health outcomes among three groups of people: those who engaged in limited-contact water recreation on effluent-dominated waters, those who engaged in limited-contact recreation on general-use waters, and those who engaged in non-water recreation. Data analysis included survival analysis, logistic regression, and estimates of risk for counterfactual exposure scenarios using G-computation.ResultsTelephone follow-up data were available for 11,297 participants. With non-water recreation as the reference group, we found that limited-contact water recreation was associated with the development of acute gastrointestinal illness in the first 3 days after water recreation at both effluent-dominated waters [adjusted odds ratio (AOR) 1.46; 95% confidence interval (CI): 1.08, 1.96] and general-use waters (1.50; 95% CI: 1.09, 2.07). For every 1,000 recreators, 13.7 (95% CI: 3.1, 24.9) and 15.1 (95% CI: 2.6, 25.7) cases of gastrointestinal illness were attributable to limited-contact recreation at effluent-dominated waters and general-use waters, respectively. Eye symptoms were associated with use of effluent-dominated waters only (AOR 1.50; 95% CI: 1.10, 2.06). Among water recreators, our results indicate that illness was associated with the amount of water exposure.ConclusionsLimited-contact recreation, both on effluent-dominated waters and on waters designated for general use, was associated with an elevated risk of gastrointestinal illness.

Project description:Runoff from heavy precipitation events can lead to microbiological contamination of source waters for public drinking water supplies. Philadelphia is a city of interest for a study of waterborne acute gastrointestinal illness (AGI) because of frequent heavy precipitation, extensive impervious landcover, and combined sewer systems that lead to overflows. We conducted a time-series analysis of the association between heavy precipitation and AGI incidence in Philadelphia, served by drinking water from Delaware River and Schuylkill River source waters. AGI cases on each day during the study period (2015-2017) were captured through syndromic surveillance of patients' chief complaint upon presentation at local emergency departments. Daily precipitation was represented by measurements at the Philadelphia International Airport and by modeled precipitation within the watershed boundaries, and we also evaluated stream flowrate as a proxy of precipitation. We estimated the association using distributed lag nonlinear models, assuming a quasi-Poisson distribution of the outcome variable and with adjustment for potential confounding by seasonal and long-term time trends, ambient temperature, day-of-week, and major holidays. We observed an association between heavy precipitation and AGI incidence in Philadelphia that was primarily limited to the spring season, with significant increases in AGI that peaked from 8 to 16 days following a heavy precipitation event. For example, the increase in AGI incidence related to airport precipitation above the 95th percentile (vs no precipitation) during spring reached statistical significance on lag day 7, peaked on day 16 (102% increase, 95% confidence interval: 16%, 252%), and declined while remaining significantly elevated through day 28. Similar associations were observed in analyses of watershed-specific precipitation in relation to AGI cases within the populations served by drinking water from each river. Our results suggest that heavy precipitation events in Philadelphia result in detectable local increases in waterborne AGI.

Project description:BackgroundCombined sewer overflows (CSOs) discharge untreated sewage into surface and recreational water, often following heavy precipitation. Given projected increases in frequency and intensity of precipitation due to climate change, it is important to understand the health impacts of CSOs and mediating effects of sewerage systems.ObjectivesIn this study we estimate associations of CSO events and emergency department (ED) visits for gastrointestinal (GI) illness among City of Atlanta, Georgia, residents and explore how these associations vary with sewerage improvements.MethodsWe estimate associations using Poisson generalized linear models, controlling for time trends. We categorized CSOs by overflow volume and assessed effects of CSO events prior to ED visits with 1-, 2- and 3-wk lags. Similarly, we evaluated effects of weekly cumulative precipitation greater than the 90th percentile at the same lags. We also evaluated effect modification by ZIP Code Tabulation Area (ZCTA)-level poverty and infrastructure improvement period using interaction terms.ResultsOccurrence of a large volume CSO in the previous week was associated with a 9% increase in daily ED visits for GI illness. We identified significant interaction by ZCTA-level poverty, with stronger CSO-GI illness associations in low than high poverty areas. Among areas with low poverty, we observed associations at 1-wk and longer lags, following both large and lower volume CSO events. We did not observe significant interaction by infrastructure improvement period for CSO- nor precipitation-GI illness associations; however, the number of CSO events decreased from 2.31 per week before improvements to 0.49 after improvements.DiscussionOur findings suggest that CSOs contribute to acute GI illness burden in Atlanta and that the magnitude of this risk may be higher among populations living in areas of low poverty. We did not find a protective effect of sewerage system improvements. Nonetheless, observed reductions in CSO frequency may lower the absolute burden of GI illness attributable to these events. https://doi.org/10.1289/EHP10399.

Project description:Gastrointestinal illness (GI) has been associated with heavy rainfall. Storm events and periods of heavy rainfall and runoff can result in increased microbiological contaminants in raw water. Surface water supplies are open to the environment and runoff can directly influence the presence of contaminants. A time-stratified bi-directional case-crossover study design was used to estimate associations of heavy rainfall and hospitalizations for GI. Cases of GI were identified as in-patient hospitalization with a primary diagnosis of infectious disease associated diarrhea [ICD-9 codes: specified gastrointestinal infections 001-009.9 or diarrhea 787.91] among the residents of New Jersey from 2009 to 2013 resulting in a final sample size of 47,527 cases. Two control days were selected on the same days of the week as the case day, within fixed 21-day strata. Conditional logistic regression was used to estimate odds ratios controlling for temperature and humidity. To determine potential effect modification estimates were stratified by season (warm or cold) and drinking water source (groundwater, surface water, or 'other' category). Stratified analyses by drinking water source and season identified positive associations of rainfall and GI hospitalizations in surface water systems during the warm season with no lag (OR = 1.12, 95% CI 1.05-1.19) and a 2-day lag (OR = 1.09, 95% CI 1.03-1.16). Positive associations in 'Other' water source areas (served by very small community water systems, private wells, or unknown) during the warm season with a 4-day lag were also found. However, there were no statistically significant positive associations in groundwater systems during the warm season. The results suggest that water systems with surface water sources can play an important role in preventing GI hospitalizations during and immediately following heavy rainfall. Regulators should work with water system providers to develop system specific prevention techniques to limit the impact of heavy rainfall on public health.

Dataset Information

Estimated Costs of Sporadic Gastrointestinal Illness Associated with Surface Water Recreation: A Combined Analysis of Data from NEEAR and CHEERS Studies.

Publications

Estimated Costs of Sporadic Gastrointestinal Illness Associated with Surface Water Recreation: A Combined Analysis of Data from NEEAR and CHEERS Studies.

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