Contributing Factors to Disease Outbreaks

Associated with Untreated Groundwater

by Erika K. Wallender1,2 , Elizabeth C. Ailes2,3 , Jonathan S. Yoder2 , Virginia A. Roberts2 , and
Joan M. Brunkard2,4

Abstract
Disease outbreaks associated with drinking water drawn from untreated groundwater sources represent a substantial proportion
(30.3%) of the 818 drinking water outbreaks reported to CDC’s Waterborne Disease and Outbreak Surveillance System (WBDOSS)
during 1971 to 2008. The objectives of this study were to identify underlying contributing factors, suggest improvements for data
collection during outbreaks, and inform outbreak prevention efforts. Two researchers independently reviewed all qualifying outbreak
reports (1971 to 2008), assigned contributing factors and abstracted additional information (e.g., cases, etiology, and water system
attributes). The 248 outbreaks resulted in at least 23,478 cases of illness, 390 hospitalizations, and 13 deaths. The majority of
outbreaks had an unidentified etiology (n = 135, 54.4%). When identified, the primary etiologies were hepatitis A virus (n = 21,
8.5%), Shigella spp. (n = 20, 8.1%), and Giardia intestinalis (n = 14, 5.7%). Among the 172 (69.4%) outbreaks with contributing
factor data available, the leading contamination sources included human sewage (n = 57, 33.1%), animal contamination (n = 16,
9.3%), and contamination entering via the distribution system (n = 12, 7.0%). Groundwater contamination was most often facilitated
by improper design, maintenance or location of the water source or nearby waste water disposal system (i.e., septic tank; n = 116,
67.4%). Other contributing factors included rapid pathogen transport through hydrogeologic formations (e.g., karst limestone;
n = 45, 26.2%) and preceding heavy rainfall or flooding (n = 36, 20.9%). This analysis underscores the importance of identifying
untreated groundwater system vulnerabilities through frequent inspection and routine maintenance, as recommended by protective
regulations such as Environmental Protection Agency’s (EPA’s) Groundwater Rule, and the need for special consideration of the local
hydrogeology.

Introduction Disease and Outbreak Surveillance System (WBDOSS)

Disease outbreaks5
associated with drinking water
from untreated6 groundwater sources remain a public
health problem in the United States. Of the 818 drinking
water outbreaks reported to CDC through the Waterborne
1
The CDC Experience Applied Epidemiology Fellowship,
Scientific Education and Professional Development Program Office,
Centers for Disease Control and Prevention, Atlanta, GA 30333.
2
Division of Foodborne, Waterborne, and Environmental
Diseases, National Center for Emerging and Zoonotic Infectious
Diseases, Centers for Disease Control and Prevention, Atlanta, GA
30333.
3 IHRC, Atlanta, GA 30333.
4
Corresponding author: Centers for Disease Control and
Prevention, Mailstop C-09, 1600 Clifton Road NE, Atlanta, GA
30333; (404) 718-4892; jbrunkard@cdc.gov
Received March 2013, accepted August 2013.
5
A disease outbreak associated with drinking water is the
acute illness, either infectious or from toxic chemical ingestion, of
≥2 individuals which can be epidemiologically linked to drinking
from a contaminated drinking water source.
6 No disinfection or other treatment prior to consumption.
Published 2013. This article is a U.S. Government work and is
in the public domain in the USA.
doi: 10.1111/gwat.12121
during 1971 to 2008, 30.3% (n = 248) were assigned an
untreated groundwater deficiency (Craun et al. 2010). In
addition, although the proportion of drinking water out-
breaks associated with untreated and improperly treated
surface water sources has decreased significantly over
time, the proportion of untreated groundwater-associated
outbreaks has not changed significantly, indicating that
greater prevention efforts are needed (Craun et al. 2010).
In the United States, an estimated 114 million people
receive their drinking water from public water systems
that use a groundwater source, and approximately 20 mil-
lion people drink from public groundwater systems that
have not received any disinfecting treatment (Environ-
mental Protection Agency 2009). Furthermore, approxi-
mately 15.8 million private well systems serving one to
five housing units exist in the United States, the majority
of which are untreated and not subject to regulation by
U.S. Environmental Protection Agency (EPA) under the
Safe Drinking Water Act (U.S. Congress 1974; U.S. Cen-
sus Bureau Housing and Household Economic Statistics
Division 2009).
Untreated groundwater is considered a safer water
source than untreated surface water or groundwater

886 Vol. 52, No. 6–Groundwater–November-December 2014 (pages 886–897) NGWA.org

under the direct influence of surface water (GWUDI)7
because infiltration through the porous overburden may
attenuate contaminants and also allow for naturally
occurring soil bacteria to degrade pathogenic organisms
or other pathogens (Schmoll et al. 2006). However,
geologic and environmental conditions as well as land
use can lead to groundwater contamination. Previous
studies have documented several examples of groundwater
contamination leading to disease outbreaks, including:
damage to a well structure, such as a cracked casing
(Dworkin et al. 1996); close proximity to a contaminant
source, such as a poorly constructed septic system or
surface water source (Beller et al. 1997; Olsen et al.
2002); contamination by animal feces or manure piles
(Clark et al. 2003); and highly vulnerable hydrogeologic
formations (O’Reilly et al. 2007; Borchardt et al. 2011).
For our review, we call risk factors for groundwater source
contamination “contributing factors.”
A better understanding of the diverse circumstances
leading to groundwater contamination and disease out-
breaks is essential to inform prevention efforts, guide
updates and revisions to WBDOSS, and suggest evidence-
based improvements for data collection during outbreaks.
To expand our current understanding, we analyzed the
contributing factors to all drinking water outbreaks associ-
ated with untreated groundwater sources reported to CDC
through WBDOSS during 1971 to 2008.
Methods
To be classified as untreated groundwater, source
water treatment methods (e.g., chlorination, filtration)
were not in place at the time of the outbreak. A drink-
ing water outbreak assigned an untreated groundwater
deficiency was defined as an outbreak “occurring due
to contamination of drinking water before it enters the
distribution system, in a water system where untreated
groundwater is intended for drinking” (Craun et al. 2010).
This review only included outbreaks with an untreated
groundwater deficiency; outbreaks that occurred in sys-
tems that used untreated groundwater as their source,
but that had previously been assigned deficiencies result-
ing solely from other components of the system (e.g.,
the distribution system, premise plumbing) were excluded
(Craun et al. 2010). However, if an outbreak had an
untreated groundwater deficiency and another deficiency
(e.g., a distribution system deficiency), it was included in
the analysis.
7 GWUDI water sources are ‘‘any water beneath the surface
of the ground with: (1) significant occurrence of insects or
other macroorganisms, algae, organic debris, or large-diameter
pathogens such as Giardia intestinalis or Cryptosporidium; or (2b)
significant and relatively rapid shifts in water characteristics
such as turbidity, temperature, conductivity, or pH which
closely correlate to climatological or surface water conditions.’’
The specific criteria used to satisfy the above criteria are
determined by the state (Environmental Protection Agency
2011).
NGWA.org E.K. Wallender et al. Groundwater 52, no. 6: 886–897
Disease outbreaks were defined as acute illness,
caused by infectious pathogens or chemicals (i.e.,
following short-term exposure to naturally occurring
or manufactured chemicals or toxins),8 affecting two
or more persons epidemiologically linked to drink-
ing water from an untreated groundwater source. Two
researchers independently abstracted information from all
outbreak reports. Data sources included biannual MMWR
Surveillance Summaries, and when available, WBDOSS
report forms, supplemental documents, and publications
describing the outbreak. Abstracted information included:
number of cases,9 hospitalizations, and deaths; type of
water source (well or spring) and water system (commu-
nity, noncommunity, or private10 ; Environmental Protec-
tion Agency 2009); outbreak etiology; use and type of any
routine or outbreak-related environmental testing; result-
ing remediation recommendations and efforts taken after
the outbreak; and contributing factors.
Contributing factors were developed based on the
WBDOSS reporting form (first created in 1975, with six
subsequent revisions from 1975 to 2003),11 supplemen-
tal information from states, literature review, and expert
opinion from CDC and EPA. Contributing factors were
defined as the structural weaknesses, environmental char-
acteristics, or events that facilitated contamination of the
untreated groundwater source. To accommodate the wide
variety of data sources available for each outbreak, a level
of evidence (documented or suspected ), was assigned to
each contributing factor. Documented contributing factors
were those factors identified by the state or reporting juris-
diction as responsible for the outbreak. Suspected con-
tributing factors were those that were not designated by
states or jurisdictions, but for which the reviewers found
evidence for the contributing factor in the outbreak report
or supporting documentation.
In addition to analyzing the contributing factors inde-
pendently, we sought to categorize outbreaks according
to mutually exclusive categories to further elucidate the
sources or pathways of contamination that resulted in the
outbreaks. We developed six “source of contamination”
categories: human sewage, animal activities or manure,
8
Health effects (e.g., cancer) associated with long-term
exposure to chemicals in water are not included in WBDOSS.
9
When available, an ‘‘estimated case count’’ was used as
the number of cases. Investigators usually calculated the estimate
by applying the attack rate to the at-risk population. When not
available, the ‘‘actual case count’’ was defined as the sum of
laboratory confirmed cases and probable cases reported by the
state.
10
Community systems are publicly or privately owned water
systems with at least 15 service connections or use by the same
25 persons for the entire year. Noncommunity systems are also
publicly or privately owned water systems that serve at least 15
service connections or 25 people either transiently or for less than
365 days per year. Private water systems are those that serve less
than 15 service connections or 25 people and are not regulated by
the federal government.
11
To view different versions of the WBDOSS reporting form,
http://www.cdc.gov/healthywater/statistics/wbdoss/nors/forms_
archive.html
887
distribution system, surface water influence (GWUDI),
multiple sources, and other sources of contamination
(either single or multiple). We stratified the sources of
contamination by the remaining contributing factors (e.g.,
design or maintenance of source water or septic systems,
preceding heavy rainfall or flooding, vulnerable hydroge-
ology, distribution system issues, or other less common
contributing factors).
Several outbreaks had previously been assigned more
than one deficiency (e.g., both an untreated groundwa-
ter deficiency and another deficiency; Craun et al. 2010).
The majority of outbreaks with multiple deficiencies had
an untreated groundwater deficiency and a distribution
system deficiency. We therefore reviewed all untreated
groundwater outbreaks for distribution system deficien-
cies or distribution system contributing factors. For an
outbreak to be assigned both a distribution system and an
untreated groundwater deficiency, the outbreak report had
to document that contamination of the untreated ground-
water source occurred either following contaminant entry
via the distribution system (e.g., cross-contamination with
a waste water system or backflow) or that the untreated
groundwater source was contaminated concurrently with
the distribution system. In these cases, both the distribu-
tion system and contamination of an untreated groundwa-
ter source were linked to cases of illness.
®
Data were entered into a Microsoft Access database
and analyzed using Statistical Analysis Systems software
®
(SAS ; SAS Institute Inc. 2008; Microsoft Office 2010).
Descriptive statistics such as chi-square tests were used
to assess differences in frequencies of variables. Where
counts were less than five in any cell, we used a Monte
Carlo simulation of Fisher’s exact test to assess differ-
ences between proportions (Agresti et al. 1979). In order
to examine whether there was any trend in the proportion
of untreated groundwater outbreaks reported from 1971
to 2008, we used the Cochran-Armitage test for trend.
Results
Outbreaks Associated with Untreated Groundwater
Among the 818 drinking water outbreaks reported
to CDC during 1971 to 2008, 248 (30.3%) were
assigned an untreated groundwater deficiency. Data were
abstracted from the following sources: biannual MMWR
Surveillance Summaries (n = 248, 100%), WBDOSS
report forms (n = 147, 59.3%), supplemental documents
(n = 152, 61.3%), and outbreak-specific publications
(n = 28, 11.3%). An MMWR Surveillance Summary
report was the only data source for 35 outbreaks (14.1%).
Outbreak Characteristics
The 248 untreated groundwater outbreaks were
reported from 44 states (Figure 1). The annual pro-
portion of waterborne disease outbreaks with untreated
groundwater deficiencies reported to WBDOSS did
not change significantly during 1971 to 2008 (Figure
2; p-value > 0.05); untreated groundwater outbreaks
888 E.K. Wallender et al. Groundwater 52, no. 6: 886–897
Figure 1. Number of untreated groundwater outbreaks by
state—United States, 1971 to 2008 (n = 247a )b . a One multi-
state outbreak involving 10 states is not shown here and
involved a private spring water source and bottled water.
b These numbers are largely dependent on reporting and
surveillance activities in individual states, and do not
necessarily indicate the true incidence of waterborne disease
outbreaks in a given state.
were reported in all years except 1997 and 2005. The
outbreaks resulted in at least 23,478 cases of illness, 390
hospitalizations, and 13 deaths (Table 1). The majority
of outbreaks (n = 135, 54.4%) and cases (n = 13,848,
59.0%) had an unidentified etiology. Bacteria were
the most frequently-reported etiology (n = 50, 20.2%),
followed by viruses (n = 32, 12.9%), parasites (n = 18,
7.3%), and chemicals (n = 8, 3.2%; Table 1).
Water System, Location, and Source
The majority of outbreaks and cases were associated
with public water systems, specifically noncommunity
water systems. Although private water systems accounted
for close to 25% of outbreaks, they contributed less than
5% of all cases. Camps, cabins or recreational areas (non-
community systems) were the most frequently identified
outbreak settings (n = 68, 27.4; Figure 3). Wells were
the water source for most outbreaks (n = 213, 85.9%);
followed by springs in 31 (12.5%) outbreaks, and com-
bined well and spring systems in four (1.6%) outbreaks.
Most (n = 132, 53.2%) outbreaks occurred in the summer
months (June, July, and August) and a large proportion
(n = 92/132, 69.7%) of this summer increase was due to
outbreaks in noncommunity water systems (Figure 4).
Water Testing
Microbiological water testing was conducted in at
least 184 (74.2%) outbreaks. Of these 184 outbreaks,
total coliform testing was reported most frequently
(n = 143, 77.7%), followed by fecal coliform testing
(n = 92, 50.0%), testing for outbreak etiology in the water
source (n = 38, 20.7%), and testing for the presence of
Escherichia coli (n = 29, 15.8%; Table 2).
Microscopic particulate analysis (MPA) testing,
which is recommended by EPA for detecting GWUDI
sources, was reported for only three (1.2%) outbreaks,
all of which occurred after 2000 (Table 2). Dye testing,
which detects connections between a contamination
source and the source water, was used to help identify
contributing factors in 23 (9.3%) outbreaks. In total, 14
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 16 60%

Percent of All Drinking Water - Associated

Number of Untreated Ground Water
14

Outbreaks Reported to WBDOSSb

50%
12
40%
10

Outbreaksa
8 30%

6
20%
4
10%
2

0 0%
1971
1973
1975
1977
1979
1981
1983
1985
1987
1989
1991
1993
1995
1997
1999
2001
2003
2005
2007
Year

Figure 2. Untreated groundwater outbreaks by year—United States, 1971 to 2008 (n = 248). a Displayed as histogram.
b
Displayed as black line, P for trend >0.05.

Table 1
Etiologies of Untreated Groundwater Outbreaks—United States 1971 to 2008 (n = 248)

Etiology No. Outbreaks (%) No. Cases (%) No. Hospitalizations (%) No. Deaths (%)

Bacteria 50 (20.2%) 5,102 (21.7%) 289 (74.1%) 2 (15.4%)

Shigella 20 (8.1%) 1,620 (6.9%) 228 (58.4%) 0
Campylobacter 13 (5.2%) 308 (1.3%) 8 (2.1%) 0
Salmonella 8 (3.2%) 101 (0.4%) 11 (2.8%) 0
Escherichia coli 5 (2.0%) 174 (0.7%) 27 (6.9%) 0
Yersinia 1 (0.4%) 2 (0.0%) 0 0
Providencia 1 (0.4%) 55 (0.2%) 0 0
Multiple bacteria1 2 (0.8%) 2,842 (12.1%) 15 (3.8%) 2 (15.4%)
Viruses 32 (12.9%) 2,190 (9.3%) 25 (6.4%) 0
Hepatitis A virus 21 (8.5%) 574 (2.4%) 22 (5.6%) 0
Norovirus 11 (4.4%) 1,616 (6.9%) 3 (0.8%) 0
Parasites 18 (7.3%) 387 (1.6%) 6 (1.5%) 2 (15.4%)
Giardia intestinalis 14 (5.6%) 240 (1.0%) 1 (0.3%) 0
Entamoeba histolytica 1 (0.4%) 4 (0.0%) 1 (0.3%) 0
Naegleria fowleri 1 (0.4%) 2 (0.0%) 2 (0.5%) 2 (15.4%)
Multiple parasites2 2 (0.8%) 141 (0.6%) 2 (0.5%) 0
Chemicals3 8 (3.2%) 121 (0.5%) 2 (0.5%) 0
Multiple etiologies4 5 (2.0%) 1,830 (7.8%) 28 (7.2%) 0
Unidentified etiology 135 (54.4%) 13,848 (59.0%) 40 (10.3%) 9 (69.2%)
Total 248 23,478 390 13

1 Multiple bacteria indicates more than one genus of bacteria isolated from stool samples (i.e., Campylobacter jejuni and Plesiomonas shigelloides; E. coli O157:H7
and Campylobacter jejuni ).
2 Multiple parasites indicates more than one genus of parasite isolated from stool samples (i.e., Cryptosporidium parvum and Giardia intestinalis).
3 Arsenic, nitrate, phenol, and trichlorethylene.
4 Multiple etiologies is defined as more than one class of etiology isolated from stool samples (i.e., Campylobacter jejuni , Entamoeba spp and Giardia spp;
Campylobacter jejuni , norovirus, and Giardia intestinalis; Campylobacter jejuni and norovirus; Campylobacter jejuni , Salmonella spp, and norovirus; hepatitis A
virus and an unidentified agent).

(60.9%) of these dye tests demonstrated a connection identified: 413 (89.8%) contributing factors were docu-
from a source of contamination to water used for mented and 47 (10.2%) were suspected. One hundred
drinking. Thirty-two (12.9%) outbreaks reported results thirty-one (76.2%) outbreaks had more than one contribut-
from historic compliance water sampling. ing factor, with a median of two contributing factors per
outbreak (range: 1 to 9).
Contributing Factors Improper design, maintenance or location of the water
Among the 172 (69.4%) outbreaks with available source or septic system (n = 116/172, 67.4%) was the
contributing factor data, 460 contributing factors were most frequently described contributing factor to outbreaks

NGWA.org E.K. Wallender et al. Groundwater 52, no. 6: 886–897 889

 Unknown the most frequently identified type of geologic formation
(n=7, 2.8%)
(n = 15/45, 33.3%; Table 3).
Othera
GWUDI was found to be a contributing factor in
Hotel, Motel, (n=26, 10.5%) Camp, Cabin, 18 (10.5%) of the 172 outbreaks. Only three (16.7%)
Lodge, Inn, or or of the outbreaks with GWUDI contributing factors were
Resort Recreational
(n=23, 9.3%) Area reclassified from groundwater to GWUDI based on state
(n=68, 27.4%) or local regulations; however, GWUDI was suspected by
Restaurant or outbreak investigators or reviewers in an additional 15
Cafeteria (83.3%) outbreaks. Wells were the source water in 15
(n=31, 12.5%) Private
Residence (83.3%) GWUDI-associated outbreaks; springs were the
Community or (n=53, 21.4%) source in two (11.1%) outbreaks; and a well and spring
Municipality were the source in one (5.6%) outbreak.
(n=40, 16.1%)
If an untreated groundwater source was contaminated
by a pathogen entering from the distribution system (e.g.,
cross-connection with wastewater disposal or backflow) or
Figure 3. Setting of exposure for untreated groundwater contamination of the groundwater source and distribution
outbreaks—United States, 1971 to 2008 (n = 248). a Other
system occurred concurrently, the outbreak was assigned
settings included childcare daycare center, church or other
place of worship, a club requiring membership, factory a distribution system deficiency. Seven (2.8%) outbreaks
or industrial facility, golf course, hall or meeting facility, were assigned both an untreated groundwater and a
indoor place of work office, amusement park, school, distribution system deficiency. In addition, 25 (10.1%)
college or university, school, college or university and a outbreaks did not meet the distribution system deficiency
church or other place of worship, sports complex, store, criteria,12 but had at least one distribution system
park and community municipal, church or other place of
worship and individual residence, restaurant or cafeteria contributing factor (Table 3).
and camp, cabin or recreational area and tourist attraction,
and temporary event or festival fair. Sources of Contamination
Using the source of contamination framework, human
sewage was the single contamination source for 57
(33.1%) outbreaks, followed by animal contamination
(n = 16, 9.3%), the distribution system (n = 12, 7.0%) and
surface water influence (n = 8, 4.7%; Table 4). Twenty-
six (15.1%) outbreaks resulted from multiple sources of
contamination and 53 (30.8%) outbreaks did not fall
within a major source of contamination category.
When outbreak etiology was examined by source
of contamination, the proportion of outbreaks with an
unidentified etiology ranged from 31.3% (n = 5) for
outbreaks associated with animal contamination to 68.4%
(n = 13) for outbreaks with multiple other sources of
contamination (Table 5). Bacteria were implicated in
half (n = 8, 50.0%) of all outbreaks resulting from
animal contamination, the highest proportion across all
sources of contamination. Viruses were implicated in 15
(26.3%) outbreaks involving sewage contamination and
underground seepage of sewage comprised the majority
(n = 12, 80%) of these sewage-associated viral outbreaks.
Figure 4. Untreated groundwater outbreaks by month and Most (n = 4, 80.0%) of the five outbreaks with mixed
water system type—United States, 1971 to 2008 (n = 247a ). etiologies were associated with sewage contamination
a
Month unavailable for one outbreak that occurred in an (Table 5).
individual system. b Includes community and individual;
noncommunity and individual; and noncommunity and
bottled.
Remediation Efforts
Information about remediation efforts and recom-
mendations to improve the quality of drinking water
(Table 3). Human sewage, an original WBDOSS con-
tributing factor, was the second most commonly identi- 12 For an outbreak to be classified as a distribution system

fied contributing factor (n = 73, 42.4%), with underground
seepage of sewage most likely to contribute to the human
sewage-associated outbreaks (n = 44/73, 60.3%). Vulner-
able hydrogeologic formations (e.g., karst) contributed
to 45 (26.2%) outbreaks; limestone hydrogeology was
deficiency, evidence must be present that the distribution system
led directly to cases of illness during the outbreak as assessed
by the review committee. When the evidence implicating the
distribution system did not reach the level necessary for deficiency
classification, but was still indicated by investigators as involved, a
distribution system contributing factor was assigned.

890 E.K. Wallender et al. Groundwater 52, no. 6: 886–897 NGWA.org

 Table 2
Environmental Testing Reported for Untreated Groundwater Outbreaks, by Water System Type—United
States 1971 to 2008 (n = 248)

Public Water Private Water Mixed Water

Systems Systems Systems Total
Reporting Positive Reporting Positive Reporting Positive Reporting Positive
Test (%)1 Test (%)2 Test (%)1 Test (%)2 Test (%)1 Test (%)2 Test (%)1 Test (%)2

Test conducted 133 (71.9%) 128 (96.2%) 48 (80.0%) 47 (97.9%) 3 (100%) 3 (100%) 184 (74.2%) 178 (96.7%)
Total coliform 109 (58.9%) 103 (94.5%) 33 (55.0%) 31 (93.9%) 1 (33.3%) 1 (100%) 143 (57.7%) 135 (94.4%)
Fecal coliform 70 (37.8%) 61 (87.1%) 22 (36.7%) 16 (72.7%) 0 (0%) n/a 92 (37.1%) 77 (83.7%)
Outbreak etiology3 20 (10.8%) 11 (55.0%) 15 (25.0%) 12 (80.0%) 3 (100%) 3 (100%) 38 (15.3%) 26 (68.4%)
Escherichia coli 20 (10.8%) 19 (95.0%) 7 (11.7%) 7 (100%) 2 (66.7%) 2 (100%) 29 (11.7%) 28 (96.6%)
Cryptosporidium or 5 (2.7%) 1 (20.0%) 1 (1.7%) 1 (100%) 1 (33.3%) 1 (100%) 7 (2.8%) 3 (42.9%)
Giardia
Microscopic 1 (0.5%) 1 (100%) 1 (1.7%) 1 (100%) 1 (33.3%) 0 (0.0%) 3 (1.2%) 2 (66.7%)
particulate analysis
testing
Surface water 2 (1.1%) 2 (100%) 1 (1.7%) 1 (100%) 0 (0%) n/a 3 (1.2%) 3 (100%)
organism testing
Other4 26 (14.1%) 25 (96.2%) 10 (16.7%) 8 (80.0%) 1 (33.3%) 1 (100%) 37 (14.9%) 34 (91.9%)
No test reported 52 (28.1%) 12 (20.0%) 0 (0%) 64 (25.8%)
Total outbreaks 185 60 47 3 3 248

1 Percentages were calculated based on the number of outbreaks with the testing type listed. Since multiple test types can be reported for a single outbreak, the
percentages listed sum to greater than 100%.
2 Percent of test type with positive results.
3 E. coli O157:H7, Hepatitis A, Campylobacter jejuni , Campylobacter spp., Norovirus, Shigella sonnei , Shigella spp., Salmonella typhi , arsenic, Giardia intestinalis,
Naegleria fowleri , nitrate, phenol, Salmonella Bareilly, Salmonella typhi , Salmonella I,4,[5],12:i:-, trichloroethylene.
4 Other tests results reported (e.g., fecal streptococci, nitrates, Salmonella spp., Enterococcus faecium, Aeromonas hydrophila).

after the outbreak were available for 127 (51.2%) out-
breaks (data not shown). Among these 127 outbreaks,
initiation of continuous water source treatment (n = 45,
35.4%), construction of a new water source (n = 36,
28.3%), and decommissioning the water source (n = 31,
24.4%) were the most commonly recommended inter-
ventions. Other measures undertaken or recommended
in response to outbreaks included repairing the water
source construction (n = 18, 14.2%), repairing or replac-
ing sewer/septic systems (n = 12, 9.4%), superchlorina-
tion or well decontamination (n = 12, 9.4%), connection
to a municipal water supply (n = 10, 7.9) or permanent
closure of the establishment supplied by the water source
(n = 10, 7.9%).
Discussion
During 1971 to 2008, untreated groundwater-
associated outbreaks comprised 30% of all drinking
water outbreaks reported to CDC and represented a
substantial health burden (∼23,500 reported cases of
illness). Our review identified the design, maintenance
and/or location of the source water or nearby septic
systems as the leading contributors to groundwater
contamination (67%), followed by human sewage (42%),
and vulnerable hydrogeologic pathways (26%). Distri-
bution systems were implicated in 19% of outbreaks,
highlighting the vulnerability of untreated groundwater
systems to distribution system issues. The key contribut-
ing factor findings present several targets to improve
untreated groundwater-associated outbreak prevention
efforts.
Water Source and Septic System Location
Siting of the untreated groundwater source and/or
septic system was a leading contributing factor identified
in our review. Location-related contributing factors
resulted from both violations of minimum setback
distance regulations and water source location in poorly
protected areas subject to flooding or septic drainage.
Minimum setback distances vary by local jurisdiction
(Environmental Protection Agency 2002), however, 50 to
100 feet of separation is usually required (Placer County
Division of Environmental Health 2004; New Hampshire
Department of Environmental Services 2011; Tillamook
County Oregon 2011). Unfortunately, multiple outbreaks
described sewage sources located as close as 10 to 30 feet
from the water source. For example, an outbreak occurred
at an Alaskan restaurant where a wood-lined septic pit
was placed just 15 feet from the well (Beller et al. 1997).
Siting issues included a spring located directly down
gradient from a surface water body (Olsen et al. 2002),
a well located in a depression allowing surface water to
enter via the well casing, a spring located downhill from
newly constructed septic systems, a well near flood-prone
cattle pastures, and a shallow well in close proximity to
a hog husbandry operation.
However, outbreaks also occurred in otherwise
legally sited and protected water systems. For example,
during an outbreak at a newly opened restaurant, dye

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 Table 3
Contributing Factors for Untreated Groundwater Outbreaks—United States 1971 to 2008 (n = 1721)

No. Outbreaks No. Cases

Contributing Factor n (%)2 Median (Range) Total

Untreated groundwater contributing factors 169 (98.3%) 34 (2–2, 823) 19,149

Source water or septic system construction or location 116 (67.4%) 33.5 (2–2, 823) 14,363
Source water design and maintenance or location 83 (48.3%) 27 (2–1.450) 7,587
Source water design and maintenance 39 (22.7%) 33 (2–1, 450) 4,808
Source water location 26 (15.1%) 19 (2–230) 1,241
Other source water issue3 27 (15.7%) 18 (4–750) 1,955
Septic system design and maintenance or location 40 (23.3%) 39 (2–1, 450) 4,953
Septic system design and maintenance 30 (17.4%) 39 (4–1, 450) 4,065
Septic system location 5 (2.9%) 55 (12–220) 401
Other septic system issue3 8 (4.7%) 43 (2–384) 778
Source or septic location4 34 (19.8%) 33 (4–2, 823) 6,955
Sewage poisoning 73 (42.4%) 39 (4–2, 823) 11,444
Underground seepage of sewage 44 (25.6%) 45.5 (4–2, 823) 9,164
Overflow of sewage 13 (7.6%) 39 (11–89) 566
Other sewage poisoning4 16 (9.3%) 38.5 (5–390) 1,714
Vulnerable hydrogeology 45 (26.2%) 39 (5–2, 823) 8,821
Flooding, heavy rains 36 (20.9%) 39.5 (2–2, 823) 6,617
Contamination from wild or domestic animals5 26 (15.1%) 11 (2–1, 450) 3,081
Groundwater Under the Direct Influence of Surface Water (GWUDI) 18 (10.5%) 54 (2–1, 450) 2,572
Shallow well 16 (9.3%) 42.5 (2–2, 823) 4,284
High water table 6 (3.5%) 50.5 (5–350) 561
Other 34 (19.8%) 37.5 (2–2, 823) 6,330
Distribution system contributing factors 32 (18.6%) 39.5 (2–1, 450) 4,305
Cross-connection with nonpotable water 23 (13.4%) 43 (7–1, 450) 3,418
Contamination of storage facility 7 (4.1%) 40 (4–615) 886
Contamination of water mains during construction or repair 4 (2.3%) 26 (2–91) 145
Contamination in building/home 1 (0.6%) 2 (2–2) 2
Other 2 (1.2%) 24.5 (15–34) 49
No. of outbreaks with contributing factors 172

1 Contributing factors were not available for 76 outbreaks.

2 Percentages were calculated based on the number of outbreaks with at least one contributing factor available. Since multiple contributing factors can be reported
for a single outbreak, the percentages listed sum to greater than 100%.
3 Source water or septic system implicated as contributing factor, however, specific location or construction issue was not specified.
4 Sewage was implicated but route of contamination (above ground or underground) was unclear.
5 Domestic animals were associated with 15 (57.7%) outbreaks, wild animals for six (23.1%) and domestic and wild animals for one (3.8%); four (15.4%) outbreaks
did not specify the animal type. Specific animals included: cattle (n = 10, 38.5%), chickens (n = 3, 11.5%), rodents (n = 2, 7.7%), beavers (n = 2, 7.7%), pigs (n = 1,
3.8%), goats (n = 1, 3.8%), deer and elk (n = 1, 3.8%), and horses (n = 1, 3.8%).

testing revealed rapid transport of septic system effluent
through karst hydrogeologic formations into the aquifer
supplying the well, leading to norovirus contamination
(Borchardt et al. 2011). Importantly, the well and sep-
tic systems complied with minimum setback distances
and dug test pits predating the water source showed
sandy loam top soil that is favorable for septic sys-
tem siting (Borchardt et al. 2011). In this review, more
than 25% of outbreak reports mentioned the potential
contribution of vulnerable hydrogeologic pathways to
groundwater contamination. At locations with vulnera-
ble hydrogeology, adherence to traditional minimum set-
back distance and siting regulations may be insufficient to
prevent outbreaks associated with untreated groundwater
sources. Evaluating local hydrogeology prior to establish-
ing a groundwater source using hydrogeologic sensitiv-
ity assessments (HSA), and routine water source testing
throughout the life of the water source are important tools
in outbreak prevention (Environmental Protection Agency
2008).
Water Source and Septic System Design and
Maintenance
Water source or nearby septic system design and
maintenance failures were identified as contributors
to 35% of untreated groundwater-associated outbreaks.
Some of these outbreaks occurred in systems built prior to
regulation development, and included system components
such as well pits, hand dug shallow wells, or pit priv-
ies. For example, one outbreak in Alaska resulted from
sewage entering the drinking water source after a clogged
sewage drainage pipe flooded a well pit and submerged
the wellhead (Centers for Disease Control and Prevention
1972). Construction and maintenance issues have been
relevant contributing factors for outbreaks during all peri-
ods of WBDOSS reporting. Water systems and nearby

892 E.K. Wallender et al. Groundwater 52, no. 6: 886–897 NGWA.org

 Table 4
Sources of Contamination by Contributing Factors, Untreated Groundwater Outbreaks—United States,
1971 to 2008 (n = 1721)

Surface Single Multiple

Human Distribution Water Multiple Other Other
Contributing Sewage Animal System (GWUDI) Sources Contributing Contributing
Factor n (%)2 n (%)2 n (%)2 n (%)2 n (%)2 Factor n (%)2 Factors n (%)2

Location or 44 (77.2%) 12 (75.0%) 6 (50.0%) 5 (62.5%) 20 (76.9%) 13 (38.2%) 16 (84.2%)

construction of
septic system or
source water
Construction 28 (49.1%) 4 (25.0%) 5 (41.7%) 2 (25.0%) 8 (30.7%) 2 (5.9%) 12 (63.2%)
Location 30 (52.6%) 9 (56.3%) 1 (8.3%) 2 (25.0%) 10 (38.5%) 2 (5.9%) 8 (42.1%)
Other 12 (21.1%) 1 (6.3%) 1 (8.3%) 1 (12.5%) 5 (19.2%) 9 (26.5%) 3 (15.8%)
Vulnerable 25 (43.9%) 0 (0%) 2 (16.7%) 3 (37.5%) 7 (26.9%) 6 (17.7%) 2 (10.5%)
hydrogeology
Flooding, heavy rains 12 (21.1) 2 (12.5%) 2 (16.7%) 3 (37.5%) 6 (23.1%) 4 (11.8%) 7 (36.8%)
Other3 14 (24.6%) 4 (25.0%) 1 (8.3%) 3 (37.5%) 10 (38.5%) 11 (32.4%) 8 (42.1%)
No other contributing 3 (5.3%) 2 (12.5%) 3 (25.0%) 0 (0%) 3 (11.5%) 0 (0%) 0 (0%)
factors
Total 57 16 12 8 26 34 19

1 Contributing factors were not available for 76 outbreaks.

2 Percentages were calculated based on the number of outbreaks with at least one contributing factor available. Since multiple contributing factors can be reported
for a single outbreak, the percentages listed sum to greater than 100%.
3 Other untreated groundwater contributing factors include: shallow well, high water table, and other.

infrastructure (e.g., septic systems, distribution lines, or
irrigation systems) may be used for decades and must be
maintained to prevent outbreaks. In one Washington out-
break, contaminated water accumulated around a wellhead
following damage to a nearby irrigation system which
utilized treated wastewater. The wastewater entered the
water source via the well’s rusted casing, sickening 134
people with Giardia or Cryptosporidium and hospitalizing
one person (Dworkin et al. 1996).
Properly constructed and maintained water sources
are also at risk for contamination from nearby septic sys-
tems that have construction or maintenance issues. Septic
system insufficiencies observed in this review included:
sewage line breaks, overflows of septic tank sewage
(commonly facilitated by rainfall or flooding), illegal
construction of septic systems, neglected septic system
maintenance, and inadequately sized septic tanks for the
number of users. A 2006 norovirus outbreak in Wyoming
was caused by contamination from a poorly maintained
septic tank (constructed in the 1950s) that lacked a
properly constructed leach field (Van Houten et al. 2007).
Overall, the diverse and unique array of construction
scenarios identified in our review suggests that thorough
environmental assessment of source water and surround-
ing areas, including nearby septic systems and leach
fields, must occur routinely throughout the lifespan of
water and septic systems in order to identify construction
and maintenance issues before an outbreak occurs.
Distribution System Issues
Nineteen percent of outbreaks in our review had
distribution system deficiencies or contributing factors,
principally cross-connections or backsiphonage. For
example, standing water from a vacant house’s poorly
designed distribution system (e.g., blind-ended pipes)
was backsiphoned into a well, leading to an outbreak of
chronic diarrhea among 72 restaurant patrons, including
nine who required hospitalization (Parsonnet et al. 1989).
Finding such a large proportion of outbreaks with distri-
bution system contributing factors or deficiencies suggests
that testing for distribution system vulnerabilities, such as
cross-connections, may be necessary to fully understand
the source of groundwater contamination. Additionally,
for untreated groundwater outbreaks with a distribution
system contributing factor, remediation efforts focused
on water treatment alone may be insufficient to prevent
illness. Chlorine resistant pathogens such as enteric
viruses and Cryptosporidium spp., entering via the
distribution system may not be fully inactivated by free
chlorine residuals as high as 0.5 mg/L in the presence of
cultured organisms or 0.7 mg/L in the presence of raw
sewage (Payment 1999).
Groundwater Under the Direct Influence of Surface
Water
Although GWUDI was only indicated in 18 out-
breaks, hydraulic connections between surface and
groundwater sources likely contributed to a larger
number of outbreaks. The strict definition of GWUDI
used for this review, requiring a “high risk” MPA test or
evidence that the contamination source was a permanent
or semi-permanent body of surface water, may be one
of the reasons for the low number of outbreaks with
a GWUDI contributing factor classification. Methods
for determining GWUDI differ by state (Washington
State Department of Health 2003; Chaudhary et al. 2009;

NGWA.org E.K. Wallender et al. Groundwater 52, no. 6: 886–897 893

894
Table 5
Sources of Contamination by Outbreak Etiology, Untreated Groundwater Outbreaks—United States, 1971 to 2008 (n = 172)

Single Other Multiple Other

Human Distribution Surface Water Multiple Contributing Contributing
Sewage Animal System (GWUDI) Sources Factor Factors Total1
n (%) n (%) n (%) n (%) n (%) n (%) n (%) n (%)

Bacteria 13 (22.8%) 8 (50.0%) 1 (8.3%) 1 (12.5%) 8 (50.0%) 7 (20.6%) 2 (10.5%) 40 (23.3%)

Campylobacter 2 (3.5%) 4 (25.0%) 0 (0%) 0 (0%) 3 (11.5%) 2 (5.9%) 0 (0%) 11 (6.4%)
Escherichia coli 0 (0%) 3 (18.8%) 0 (0%) 0 (0%) 1 (3.8%) 1 (2.9%) 0 (0%) 5 (2.9%)
Providencia 1 (1.8%) 0 (0%) 0 (0%) 0 (0%) 0 (0%) 0 (0%) 0 (0%) 1 (0.6%)
Salmonella 3 (5.3%) 1 (6.3%) 0 (0%) 0 (0%) 1 (3.8%) 2 (5.9%) 1 (5.3%) 8 (4.7%)
Shigella 6 (10.5%) 0 (0%) 1 (8.3%) 1 (12.5%) 3 (11.5%) 2 (5.9%) 1 (5.3%) 14 (8.1%)
Mixed bacteria2 1 (1.8%) 0 (0%) 0 (0%) 0 (0%) 0 (0%) 0 (0%) 0 (0%) 1 (0.6%)
Viruses 15 (26.3%) 0 (0%) 1 (8.3%) 1 (12.5%) 0 (0%) 1 (2.9%) 3 (15.8%) 21 (12.2%)
Hepatitis A 10 (17.5%) 0 (0%) 1 (8.3%) 0 (0%) 0 (0%) 1 (2.9%) 1 (5.3%) 13 (7.6%)

E.K. Wallender et al. Groundwater 52, no. 6: 886–897

Norovirus 5 (8.8%) 0 (0%) 0 (0%) 1 (12.5%) 0 (0%) 0 (0%) 2 (10.5%) 8 (4.7%)
Parasites 3 (5.3%) 2 (12.5%) 3 (25.0%) 1 (12.5%) 3 (11.5%) 2 (5.9%) 0 (0%) 14 (8.1%)
Giardia intestinalis 3 (5.3%) 1 (6.3%) 2 (16.7%) 1 (12.5%) 2 (7.7%) 2 (5.9%) 0 (0%) 11 (6.4%)
Naegleria fowleri 0 (0%) 0 (0%) 1 (8.3%) 0 (0%) 0 (0%) 0 (0%) 0 (0%) 1 (0.6%)
Mixed parasites3 0 (0%) 1 (6.3%) 0 (0%) 0 (0%) 1 (3.8%) 0 (0%) 0 (0%) 2 (1.2%)
Chemicals 0 (0%) 1 (6.3%) 0 (0%) 0 (0%) 0 (0%) 4 (11.8%) 1 (5.3%) 6 (3.5%)
Multiple etiologies4 4 (7.0%) 0 (0%) 0 (0%) 0 (0%) 1 (3.8%) 0 (0%) 0 (0%) 5 (2.9%)
Unidentified 22 (38.6%) 5 (31.3%) 7 (58.3%) 5 (62.5%) 14 (53.8%) 20 (58.8%) 13 (68.4%) 86 (50.0%)
Total 57 16 12 8 26 34 19 172

1 Differs from Table 1 because this table is restricted to outbreaks with contributing factor information available.
2 Includes one outbreak of E. coli and Campylobacter jejuni .
3 Includes two outbreak of Cryptosporidium parvum and Giardia intestinalis.
4 Multiple etiologies is defined as more than one class of etiology (i.e., bacteria and virus, bacteria, virus and parasite); includes one outbreak of Campylobacter jejuni , Entamoeba spp and Giardia spp; one outbreak of Campylobacter jejuni ,
norovirus and Giardia intestinalis; one outbreak of norovirus G1, Campylobacter jejuni and norovirus G2; one outbreak of Norovirus GI, Campylobacter and Salmonella; and one outbreak of an unidentified agent and Hepatitis A.

NGWA.org
Oregon Department of Health 2009), and although the
EPA developed MPA testing to aid in identifying GWUDI
(Vasconcelos and Harris 1992), a negative MPA test
alone is insufficient to rule out a hydraulic connection
with surface water. MPA testing measures the number of
surface water organisms found within a single groundwa-
ter sample, and based on the presence of these organisms
rates the water source as low, intermediate or at high
risk of surface water contamination (Vasconcelos and
Harris 1992). MPA tests are limited in their utility due to
their inability to capture changes in water quality over
time or adjust for the baseline risk of the system such as
local hydrogeology. Further, since they rely on source
water testing alone, they cannot be used to help plan for
safe well placement (Chin and Qi 2000). For example,
in a large New Hampshire Giardia intestinalis outbreak,
the untreated groundwater source’s close proximity to a
river, a violation of New Hampshire’s setback distance
regulations, and presence of some surface water organ-
isms on testing, caused investigators to suspect GWUDI
(Daly et al. 2010). Despite their strong suspicion, MPA
testing after the outbreak’s detection indicated only a
“moderate” risk for surface water influence (Daly et al.
2010). In such cases where water testing yields variable
results and remediation decisions are needed to prevent
illness, we suggest fully implementing EPA guidance by
integrating an area’s hydrogeologic mapping, the water
system’s design and construction, and employing serial
microbial testing to rigorously identify GWUDI water
sources (Environmental Protection Agency 2006).
Sources of Contamination and Etiology
More than 54% of outbreaks and nearly 60% of
cases in our review had an unidentified etiology, with
the highest unidentified proportions weighted toward the
earliest outbreaks. It is likely that improved diagnostic
technology and identification of new pathogens as well
as adoption of methods by labs between 1971 and 2008
has led to improvement in etiology identification over
time. For example, norovirus was first identified in stool
in 1972 (Kapikian et al. 1972) and though norovirus
likely caused outbreaks since WBDOSS began, the first
drinking water-associated outbreak caused by norovirus
was not reported until 1978 (Centers for Disease Control
and Prevention 1980).
Our review found that outbreaks associated with
sewage contamination sources, particularly underground
seepage of sewage, were more likely to have a viral
etiology. Human norovirus can cause illness for at least
61 days following water source contamination and the
virus can be detected in groundwater samples by reverse
transcription-quantitative PCR for up to 3 years after
initial contamination (Seitz et al. 2011). Bacteria were
more likely to be implicated in outbreaks associated with
animal contamination. For example, in one Minnesota
outbreak, Campylobacter jejuni was isolated from both
the case-patients and cattle housed near the well. Although
we hypothesized that parasites would be more likely iden-
tified in outbreaks associated with GWUDI contributing
NGWA.org E.K. Wallender et al. Groundwater 52, no. 6: 886–897
factors, we were limited by a small sample size and most
of the GWUDI outbreaks had an unidentified etiology.
Understanding the typical etiologies associated with
sources of contamination may help future investigators
identify and address outbreak contributing factors.
Limitations
This review is subject to several limitations. First,
WBDOSS is a passive surveillance system and due to
possible under-reporting across states and years, may
not have provided a complete or representative report of
groundwater-associated outbreaks in the United States for
the time period assessed in this review (Brunkard et al.
2011). The wide range of outbreaks reported by individual
states during 1971 to 2008, from 0 to 42 outbreaks, likely
indicates that some states have better capacity to detect,
investigate and report outbreaks associated with untreated
groundwater. Second, the review process was complicated
by changes in outbreak detection methodologies and in
CDC’s surveillance system over time. From 1971 to
2003, the WBDOSS reporting form underwent six major
revisions with changes in both contributing factor types
and terminology. Thirdly, the data sources used to identify
contributing factors varied in detail and quality, from peer-
reviewed publications to short progress updates from field
investigators. This affected our confidence in some of
the contributing factor designations, limited the amount
of data available for review and abstraction, and made
it difficult to determine a primary contributing factor
for an outbreak. We also suspect that investigators were
more likely to report the positive results of environmental
or dye testing and may not have always reported
negative results. Finally, we had limited power to detect
statistically significant differences among the sources of
contamination or the impact of regulatory changes and
improvements due to the small number of outbreaks,
especially when examined by contributing factors and
etiologies.
Recommendations
On the basis of the findings of this review, we suggest
several recommendations for preventing untreated ground-
water outbreaks. The predominance of design, mainte-
nance and location contributing factors, and of outbreaks
with multiple contributing factors, highlight the impor-
tant role of thorough and frequent sanitary surveys in
the identification and correction of groundwater con-
tamination pathways. For public water systems using
untreated groundwater, EPA’s Groundwater Rule, to be
fully enacted in 2014, will require sanitary surveys and
additional water testing triggered by the positive results
of routine water testing under the Total Coliform Rule
(Environmental Protection Agency 2006). Our review
also detected the contribution of vulnerable hydrogeo-
logic formations in outbreak-associated groundwater con-
tamination. Although not required by the Groundwater
Rule, HSAs are a necessary tool for identifying untreated
groundwater sources at ongoing risk for contamination
and for guiding the remediation efforts if an outbreak
895
occurs. Importantly, private water systems will remain
unregulated at the federal level, and will rely on local
or state environmental health efforts and owner aware-
ness and action (Environmental Protection Agency 2011).
Of note, 24% of outbreaks occurred in private water sys-
tems. Reliable local and state funding for investigation
and reporting of disease outbreaks, water source regu-
lation enforcement, and community education about the
risks of drinking untreated groundwater is essential for
outbreak and illness prevention.
Furthermore, the findings from this review can be
used to improve the quality of waterborne disease out-
break surveillance data. Looking ahead, contributing fac-
tors could be aligned with those identified in this review
and similar efforts could be made to evaluate other types
of drinking water-associated outbreak reports. Efficient
and accurate contributing factor identification and reme-
diation in response to an outbreak may be facilitated by
developing practical outbreak investigation guidelines and
supporting their adoption at local and state levels. Focus
on groundwater source and septic system construction
and siting, and local hydrogeologic conditions would be
particularly useful. Finally, regulations alone will not suf-
ficiently protect all individuals at risk for illness due to
contaminated untreated groundwater. Public health cam-
paigns should focus on educating water systems managers,
private well owners (whose wells are not subject to federal
regulations), and visitors to settings supplied by transient
noncommunity water systems, such as seasonal camps and
recreational areas, about contributors to untreated ground-
water contamination and illnesses associated with drinking
contaminated water.
Conclusions
With more than 36 million people using an untreated
groundwater source as their primary drinking water
supply and 22 million households using septic systems
for their household waste management, drinking water
outbreaks associated with untreated contaminated ground-
water will continue to be a health risk in the United States
(Environmental Protection Agency 2006; U.S. Census
Bureau Housing and Household Economic Statistics
Division 2009). This review identified both well-known
contributors to outbreaks such as violations of con-
struction and location regulations, as well as the role of
distribution system contributors to untreated groundwater-
associated outbreaks. The findings of this review present
opportunities to improve data collection on waterborne
outbreaks and more importantly, to provide additional
empirical data on the leading factors for contamination
of groundwater sources. Only a fraction of waterborne
disease outbreaks associated with untreated groundwater
are reported to WBDOSS each year. Though reporting
limitations are multifactorial, using an evidence-based
contributing factor framework such as the one offered
in this review has the potential to improve outbreak
investigations and reporting, and prevent waterborne
disease associated with untreated groundwater.
896 E.K. Wallender et al. Groundwater 52, no. 6: 886–897
Acknowledgments
The authors gratefully acknowledge the contributions
of the epidemiologists, laboratorians, and environmental
health personnel at the local, state, and territorial levels,
without whom this study would not have been possible.
We also thank Dr. Philip Berger from EPA for his insights
into untreated groundwater systems and hydrogeology.
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