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Waterborne pathogens

The two things chlorine cannot reach

Chlorine does not kill Cryptosporidium, and it never gets to the Legionella growing in a building’s hot water. Six years of CDC surveillance shows the organisms that make the most people ill are not the ones that kill them.

A woman wrapped in a blanket on a sofa, coughing into a tissue.

In the spring of 1993, pharmacies across Milwaukee ran out of anti-diarrheal medicine. Absenteeism climbed at the city’s hospitals and schools. It took health officials days to work out what they were looking at, because the thing making people ill was arriving through a system that was, by every measure then in use, working.

Roughly 400,000 people fell ill. At least 69 died, most of them people living with AIDS. The cause was Cryptosporidium, a parasite that had passed through the filters at the city’s southern treatment plant. The water had been treated. It had been chlorinated. And none of that mattered, because chlorine does not kill Cryptosporidium.

Milwaukee remains the largest documented waterborne outbreak in United States history, and more than thirty years on it is still the clearest illustration of something most people find counterintuitive: the two organisms that matter most in drinking water are the two that ordinary disinfection does not reach.

The parasite that survives the chlorine

Part of what makes Cryptosporidium difficult is a matter of packaging. The parasite spends part of its life cycle sealed inside an oocyst — a thick-walled capsule between four and six micrometers across, spherical to oval, tough enough to survive conditions that would destroy a bacterium.

The Environmental Protection Agency’s health advisory on the organism is blunt about the consequence. Ozone is the most effective chemical disinfectant against it, with chlorine dioxide second. Conventional chlorination is not reliable. The Centers for Disease Control and Prevention puts it more plainly still: Cryptosporidium is “poorly inactivated by chlorine or iodine disinfection.”

It also does not take much. In human challenge studies cited by the EPA, 62 percent of subjects given thirty or more oocysts became infected. The dose that infected half of healthy adults worked out at roughly 132 oocysts — but that figure varied enormously between strains, from as few as 9 to as many as 1,042 depending on the isolate. A handful of organisms, in the wrong strain, is enough.

Because the chemistry does not work, the control has to be physical. Under the Interim Enhanced Surface Water Treatment Rule, filtered systems must achieve at least 2-log removal of Cryptosporidium — that is, 99 percent. It is worth sitting with the EPA’s own description of what good practice delivers: “a well-operated water filtration system is capable of removing at least 99 of 100 Cryptosporidium oocysts.”

That is an engineering tolerance, not a guarantee. Ninety-nine percent removal of a large number is still a number. Giardia, which also forms cysts and also tolerates chlorine far better than bacteria do, presents the same basic problem in a slightly more forgiving form.

What actually puts Americans in hospital

Here is where the intuition breaks down.

The CDC’s surveillance summary of drinking-water outbreaks covering 2015 through 2020 — the most recent full accounting — recorded 214 outbreaks across 28 states, causing 2,140 illnesses, 563 hospitalizations and 88 deaths.

Of those 214 outbreaks, 187 were biofilm-associated: organisms growing inside plumbing rather than arriving from the source. One hundred and eighty-four of them were Legionella. Only 24 outbreaks — 11 percent — were the enteric illnesses most people picture when they think of contaminated water: norovirus, Shigella, Giardia, Campylobacter, Cryptosporidium, E. coli.

Now look at who got hurt. Those 24 enteric outbreaks produced 1,299 cases — 61 percent of all illness in the period — but only 10 hospitalizations and no deaths at all. Legionella produced 786 cases, a little over a third of the total, and from that smaller number came 544 hospitalizations and 86 deaths: 97 percent of all hospitalizations and 98 percent of all deaths in six years of national surveillance.

The organisms that make the most people ill and the organisms that kill people are not the same organisms.

The hazard that grows after the treatment plant

Legionella is not a source-water failure. It is a building problem. The bacterium establishes itself in premise plumbing — the pipes, tanks, and fixtures downstream of the water main — where it shelters inside biofilm and multiplies in water that has sat warm for too long.

The contributing factors CDC recorded read like a maintenance audit rather than a treatment failure: Legionella already present in a building’s water system, temperature and disinfectant conditions that favor growth, water sitting at or above 86°F, and aging plumbing. By the time water has traveled through a large building, the disinfectant residual that protected it in the main has often decayed to nothing.

That is why the outbreaks cluster where they do. Hospitals, long-term care and assisted living accounted for 113 outbreaks — 53 percent of the total — and within them 372 hospitalizations and 75 deaths, which is 85 percent of all deaths recorded. Hotels and lodges accounted for another 35. These are buildings with long pipe runs, large hot water systems, low-flow guest rooms that sit unused, and populations who are already unwell.

There is one detail in that surveillance period worth noting for what it may signal. For the first time, Legionella was reported in three outbreaks traced to private residences, in 2015 and 2019.

Why you cannot drink your way into Legionnaires’ disease

This is the most widely misunderstood fact about the most lethal organism in American drinking water: you do not catch Legionnaires’ disease by drinking contaminated water. You catch it by breathing it — inhaling aerosolized droplets small enough to reach the lungs. Showers, cooling towers, decorative fountains, hot tubs and misters are the exposure routes that matter.

It follows that a boil-water notice, which is aimed squarely at organisms you swallow, does very little about Legionella. It is worth understanding what such a notice actually buys you. CDC guidance during a boil advisory is a rolling boil for one minute, extended to three minutes above 6,562 feet. Boiling does handle Cryptosporidium, which is precisely why it is the advice given when a treatment barrier has failed — heat succeeds where the chlorine could not.

Where boiling is impractical, CDC points to filters certified under NSF/ANSI Standard 53 or 58 for cyst removal or cyst reduction, to an absolute one-micron filter, or to reverse osmosis.

The indicator problem

Water utilities test constantly for coliform bacteria, and a clean coliform result is often reported as though it settles the question. It does not, and it was never meant to.

Coliforms are an indicator organism. Their presence suggests a pathway exists by which fecal contamination could be reaching the water; their absence suggests it probably is not. That is a genuinely useful signal, and it is not the same thing as a survey of what is in the water. A clean coliform test says nothing about Legionella multiplying in the hot water tank of the building you are standing in, and it is a poor proxy for chlorine-resistant parasites that behave nothing like the bacteria being counted.

Passing the test you are required to run is not the same as being free of the hazards you are not testing for. That is not an accusation against water utilities, which generally do difficult work well. It is a statement about what a test result means.

Where the regulation stops

Roughly 43 million Americans — about 15 percent of the population — drink from private wells. Those wells are not regulated by the federal government under the Safe Drinking Water Act, and, as the EPA notes, not by most state governments either. There is no mandatory testing, no required treatment, and no one who sends a report.

The outbreak data shows the shape of that gap. Individual and private systems accounted for just 17 outbreaks in the 2015–2020 period — 8 percent of the total — but 944 cases, which is 44 percent of all illness, and 14 deaths. Among enteric outbreaks where the water source could be identified, wells accounted for 13 of 14.

The causes were mostly structural rather than exotic. Contamination through limestone and fissured rock. Improper well construction. Flooding and heavy rain. And, in a quarter of enteric outbreaks, a treatment deficiency — most often no disinfection at all, sometimes no filtration.

The size of the problem

Outbreak surveillance captures clusters that someone noticed, investigated and reported. It is a floor, not a total. To estimate the real burden, CDC researchers modeled 17 pathogens across every water exposure route for a single year, 2014, and published the result in Emerging Infectious Diseases.

Their estimate: 7.15 million waterborne illnesses annually in the United States, around 601,000 emergency department visits, roughly 117,900 hospitalizations, about 6,630 deaths, and $3.33 billion in direct healthcare costs.

Drinking water specifically accounted for an estimated 1.13 million illnesses — but 47,700 hospitalizations, 3,300 deaths and $1.39 billion, the largest share of the cost. The pattern holds: drinking water produces fewer illnesses than recreational water and far more of the serious outcomes.

And the cost is dominated by organisms that grow in plumbing rather than organisms that arrive in it. Nontuberculous mycobacteria accounted for 46 percent of direct costs, followed by acute otitis externa at 17 percent, Pseudomonas pneumonia at 14 percent and Legionnaires’ disease at 12 percent.

What you can actually find out

If you are on a community water system, your utility is required to publish an annual Consumer Confidence Report. It will tell you what was detected, at what level, and against which limit. It is a genuinely informative document and almost nobody reads it.

What a CCR will not tell you is what happened to the water between the main and your tap, because that stretch is not the utility’s to monitor. The temperature of your water heater, how long water sits in unused lines, and the age and material of your plumbing are all on your side of the meter.

If you are on a well, the position is simpler and harder: nobody is testing it, so the only results that exist are the ones you pay for. State and county health departments generally maintain lists of certified laboratories.

The thirty years since Milwaukee have produced better filtration standards, tighter turbidity limits and a surveillance system that catches more than it used to. They have also revealed that the hazard moved. It is no longer mainly a question of what gets into the reservoir. It is increasingly a question of what grows in the pipes afterwards — and that is a part of the system no treatment plant can reach.

This article is general information about waterborne pathogens and public health data. It is not medical advice, and it does not describe or evaluate any particular treatment equipment. If you have a specific health concern, speak to your doctor; if you have a specific water concern, start with your utility’s report or a certified laboratory.

Sources

  1. CDC MMWR — Surveillance of Waterborne Disease Outbreaks Associated with Drinking Water, United States, 2015–2020
  2. CDC Emerging Infectious Diseases — Estimating Waterborne Infectious Disease Burden by Exposure Route, United States, 2014
  3. US EPA — Cryptosporidium: Drinking Water Health Advisory
  4. CDC — Preventing Crypto during a boil water advisory
  5. US EPA — Private Drinking Water Wells
  6. Encyclopedia of Milwaukee — the 1993 cryptosporidium outbreak

Every figure in this article comes from the published sources listed above. This is general information, not advice about the water at any particular address.

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