OPPORTUNISTIC ORGANISMS AND THE WATER SUPPLY CONNECTION*
Edwin E. Geldreich
U.S. Environmental Protection Agency
Risk Reduction Engineering Laboratory
Cincinnati, Ohio 45268
INTRODUCTION
The heterotrophic bacterial population in drinking water is conposed of
many transient organisms that never colonize the distribution system,
while other associate organisms are more opportunistic, being capable of
surviving on minimal nutrients, attachment to pipe sediments and becoming
a participant in the developing biofilm. While these bacteria are
generally of no public health significance, some opportunistic colonizers
of the pipe network may, in addition, become colonizers of the human body
through contact with water supply.
Opportunistic pathogens are generally understood to include those
organisms which may exist as part of the normal body microflora but under
certain conditions cause disease in compromised hosts. Such organisms
become particularly invasive to susceptible individuals (elderly,
newborns, AIDS victims, cancer patients receiving chemotherapy, bum
cases, dialysis patients, trauma patients, and individuals receiving
organ transplants). The route of exposure may be ingestion, inhalation
or body contact with water supply during bathing, (whirlpool use, dental
equipment, etc.) and indoor air climate control devices (humidification,
air cooling). The purpose of this presentation is to place the subject
in a more realistic aspect relative to management of water supply
quality.
OCCURRENCE
Opportunistic pathogen infections are a serious public health threat
anywhere there are large nunbers of people in close confinonent, such as
nurseries, pre-schools, sumner camps and in particular, hospitals and
senior care facilities. At least 5 percent of patients admitted to
hospitals acquire nosocomial infections and about 1 percent of the
patients die as a direct result (1). Many of these organisms occur in
the diverse heterotrophic flora found in water supplies (2-7). In
general, these are the organisms that when found in large enough numbers
and in the wrong place at the right time, have the potential to cause an
infection. Some examples of nosocomial outbreaks associated with
contaminated potable water are shown in Table 1.
Heterotrophic bacterial densities in most nunicipal water supplies are
generally below 100 organisms per mL except at static water locations in
buildings where densities are often one or two logs higher because of
want) ambient temperatures. By contrast, the infective dose levels for
a 50 percent attack rate for an opportunistic pathogen in the hetero-
trophic population, may range up to 10*" cells per dose. While the
number of cells required to achieve an infective dose by ingestion may
seem unlikely to occur often, the volume of water used to take a shower
or bath can easily supply this density during a given exposure period.
'Presented at the AWWA Water Quality Technology Conference, Nov. 12,
1991, Orlando, Florida
GELDREICH
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By contrast, the density of such opportunistic organisms needed to
establish infection in newborn babies, post-operative or iitmino-
suppressed patients, the elderly and infirm is generally lower than for
healthy children and adults.
An additional factor to consider is colonization by these organisms in
water attachment devices used in hospitals and clinics. Acinetobacter
infections have been associated with the use of ventilator spirometers
(24), room humidifiers (25, 26) and moisturized Wright respirometers
(27). Serratia marcescens infections have been transmitted via medical
solutions (28), and peritoneal-dialysis effluents (30). While such water
related systems and equipnent may be amplifiers of opportunistic
pathogens, the source of these organisms may be the water supply,
handling of the device, or airborne contaminants, to name a few. The
contribution that water supply plays in the problem has been the subject
of two studies on water supply associated bacteria and patient illnesses
(11, 31). Both studies suggested that water supply organisms are part
of the problem but not necessarily the major source of nosocomial
infections in the hospital environment.
Water supply systems in large housing projects, highrise office
buildings, hotels, and large public buildings exacerbate the problan of
deteriorating water quality as a consequence of static water or
infrequent water demands. Static water in building plumbing networks is
often at warm water temperatures that stimulate bacterial growth in the
accumulated sediments. Even new building plumbing networks may present
a problem of deteriorating water quality as a result of construction
practices that introduce dust, dirt and excessive solder flux in the
lines during pipe assembly. Solder flux can be a nutrient source as well
as an attachment site for numerous heterotrophic bacteria. This type of
a water quality problan was experienced by a Boston hospital after the
acceptance of a new building addition to their facility complex (32).
Water entering the hospital lines was of high quality (no coliforms per
100 mL and heterotrophic plate counts averaging 3 organisms per mL) . As
the staff began to phase in the use of the new building addition, there
were numerous complaints of malaise by hospital personnel and the water
supply became a prime suspect. Laboratory analyses of the water supply
in this new facility revealed no detectable coliforms but heterotrophic
bacterial densities ranged from 3,000 to 4,000 organisms per mL. Turning
on all faucets throughout the new building for a minimum of 15 hours
discharge of building water supply was successful in flushing the
contaminants from the plumbing system. The bacterial densities decreased
to 15 organisms per mL and by the following day averaged 7 heterotrophic
bacteria per mL, thereby achieving a water quality similar to that of the
municipal water supply. The ill-defined health complaints of the
hospital staff declined following this action response, however,
incrimination of the microbial quality of the water supply remained
circumstantial.
Building water supply lines and their attachment devices have a
significant inpact on the microbial quality of water. Long stagnation
of public water supply in the warm environment of a building water systen
encourages various heterotrophic bacteria, including Legionella, to
colonize pipe joint packing materials, valve stem seals, vacuum breakers
(used in back flow prevention) and faucet aerators (34,35).
Hot water tanks in homes and building water systems attachment devices
should not be overlooked as a cause of water quality deterioration in
home or care centers. If thermostats on hot water tanks are set belcw
55°C as an energy conservation measure or to prevent scalding of
824

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patients, growth of Legionella may occur in the hot water tank. In such
situations legionellae densities may reach infective dose concentrations
either in the hot water tank or in an attached shower head (36-41) . Most
residential hot water tanks are heated from the bottom, near the cold
water entrance pipe so the water supply can be quickly heated to above
55*^, however, accumulating sediments at the bottom of the tank provide
a heat buffered environment for Legionella colonization. Water in large
institutions is often heated by internal steam coils located at mid depth
in the tank, thus the cooler water in the bottom may not be heated
sufficiently to kill Legionella. Recirculation of the hot water may
spread the organisms to all parts of the system.
Cold water storage tanks in highrise buildings must be covered to prevent
introduction of contamination from nesting birds and atmospheric dust
and to reduce or prevent algae growth. Various heterotrophic bacteria
may enter via this route and colonize in the accumulating bottom
sediments. Algae may also be introduced by the same routes and proceed
to grow in the available light from the open storage tank. Growth in an
open water supply tank and subsequent release of algal toxin was the
cause of one waterborne outbreak of diarrhea confined to a Chicago
apartment building (42).
Increasingly, water utility customers who are dissatisfied with taste,
odor or fear the potential health risks alleged to be associated with
their municipal water supply are attenpting to further refine the water
quality at the tap. While treatment devices may be very effective
initially in providing aesthetic treatment of the water, their usefulness
over time may diminish because of unpredictable service capacity to
adsorb a varying mixture of trace contaminants, quality characteristics
of water supply and the volume of water processed over time. Poor design
of attachment devices may provide recesses that do not drain. Such tiny
pools of water become active sites for biofilm development that
accelerates in the warm ambient environment and periodically diffuses
into the interrupted flows of product water. Another aspect of bacterial
proliferation is colonization in devices with carbon filters. While some
organisms may pass through the device with little or no retention, others
are amplified in these units and bacteria are released at densities
higher than those found in the in-coming public water supply. Challenge
of carbon filter devices with coliforms, opportunistic organisms and
primary pathogens (bacteria anticipated in cross-connections, line breaks
or backsiphonage) revealed that such treatment units do not provide an
effective barrier. While Escherichia coli, Salmonella and other
organisms pass through the filter, other organisms such as Klebsiella
pneumoniae, Aeromonas hydrophila and Legionella pneumophila can colonize
these devices. As a consequence, devices using carbon filters should not
be used on an untreated water supply of questionable quality (43-45).
REPRESENTATIVE ORGANISMS
There is a variety of heterotrophic organisms that can occur in any "safe
water supply." They are indeed opportunists in the broad sense,
adjusting to a harsh environment and taking advantage of selected sites
in the water supply system to colonize. Contacts with breaks in the hunan
body barriers against disease result in a similar pattern of colonization
of selected sites that lead to illness if natural defenses prove
ineffective. While many heterotrophic organisms in water supply may be
capable of colonizing the pipe network, only a few have the potential to
be significant opportunistic pathogens. Such is the nature of four
candidates among a variety of bacteria, fungi and yeast that are often
reported to be waterborne opportunistic pathoqens.
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AC ID-FAST (NOtTTUBERCULOUS) BACTERIA
Water supply may be significant in the transport of nontuberculous
bacteria that pass through treatment barriers in very low densities.
Speciation of water supply isolates reveals this group of acid-fast
bacteria includes fortuitum, M. phei, M. gordonae, M. xenopei, M.
kansasii, M. avium and	chelonae (46-51). The pathological
significance of these organisms is that human colonization may occur in
the lungs and lynph nodes, or cause skin lesions, septicania, and cause
post-surgery infections. Furthermore, nontuberculous nycobacterial
disease is the third most common opportunistic fatal infection in
patients with AIDS (46). Waterborne nycobacterial infections present the
greatest risk to patients in the hospital setting, particularly those
susceptible older individuals that bathe in aerosolized water during the
sunnier months. Extensive searches for the cause of two nosocomial
outbreaks of Mycobacterium infection (ML_ fortuitum and gordonae) in
different hospitals revealed that these organisms were associated with
ice and ice water taken from contaminated ice machines (52, 53).
Nontuberculous Mycobacteria can be isolated from human fecal material
(54, 55). These organisms were isolated from 40 percent of stool sanples
examined from healthy subjects; the mean density was 19 acid-fast
organisms per gram of feces (55). Wastes from pig farms also contained
Mycobacteria (56) and waste-water effluents were reported to contain an
approximate 104 organisms per 100 mL (57).
Raw source waters at water supply intakes have been shown to contain
acid-fast bacteria (50, 58, 59). Acid-fast bacteria were found in the
raw water to the Oakwood, Illinois water treatment plant at a geometric
mean density of 271 organisms per liter, while at Decatur, Illinois, raw
water densities were approximately one order of magnitude less. Upon
passage through treatment, the most significant reductions of acid-fast
bacteria occurs during sand filtration. In an 18 month study of these
two water systems, reductions in the concentrations of acid-fast bacteria
by rapid sand filtration ranged from 59 to 74 percent (60). In the
finished water these organisms could be isolated in 36 percent of all one
liter samples.
Reported findings of acid-fast bacteria in finished water demonstrate
that these organisms are resistant to the usual chlorine disinfectant C*T
values applied to inactivate coliforms and viruses (61). Experiments
using recent Mycobacterium isolates from chlorinated water supply
(M. fortuitum, M. gordonae and M^ avium) plus clinical isolates of M.
chelonae, M. kansasii and	intracellular revealed that chlorine
levels of less than 1.0 mg/L may not be adequate for effective
inactivatiotf of these opportunistic pathogens (62). Even the presence
of a free chorine residual (<0.2 mg/L) at a low water pH (5.9 to 7.1)
did little to reduce acid-fast bacteria in the distribution systan.
Mycobacterimi were also reported to be more resistant than E^ coli to
inactivation "fay inorganic chloramines (63) and by ozone (64).
While densities of mycobacteria entering the distribution systen may be
only a few organisms per liter, this density may change significantly
during warm water periods in the static sections of the distribution
network. Regrowth may also be intensified in older portions of the pipe
network where corrosion is a problen and water pH is elevated to combat
corrosivity. The trade-off is less effective disinfectant action of free
chlQrine at higher pH. Some regrowth was also noted in dead end areas
where chlorine residuals disappeared and total organic carbon
concentration and turbidity were higher.
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Devices attached to building plumbing systems may also be amplifiers of
mycobacteria. Mycobacteria are among the first organisms to colonize
reverse osmosis membranes used in producing reagent grade water, reuse
water systems and medical devices. For example, nontuberculous
mycobacteria were detected in water from 95 of 115 hemodialysis centers
that reused disposable hemodialyzers (artificial kidneys) for the same
patient (65). Increased incidence of patient infections caused by acid-
fast mycobacteria pronpted an investigation that concluded water was the
source of these opportunistic pathogens.
The water tap may also be a source of mycobacteria with the organisms
colonizing the sediment accumulations in the device itself. Apparently,
the presence of these organisms can invariably be found in scrapings or
swabbings from the cold and hot water taps (66). In a study involving
three hospitals, M. xenopei was recovered from 61 of 111 pairs of hot and
cold water taps, 20 of 74 tap pairs in another hospital, but from only
3 of 61 pairs of taps in the third hospital. Positive findings were more
often reported from the hot water tap, an observation which is not
surprising since the optimum growth temperature for acid-fast bacteria
is 42 to 44^0.
FECAL KLEBSIELLA
The sanitary significance of the klebsiellae group of coliform bacteria
can be perplexing. Most of these organisms are of environmental origin
without sanitary significance while other strains of the same genus have
their source in the intestinal tract of warm-blooded animals (67-69).
The genus includes K^ pneumoniae, K. oxytoca, K. ozaenae, K. planticola,
K. terrigena and K^_ rhinoscheromat is. Most of these species have been
detected in coliform contaminated public water supplies (70-79). K.
pneumoniae and K^_ oxytoca have often been reported to be the predominant
organisms in distribution biofilm occurrences. These occurrences in
water supply pose the questions: are these klebsiellae of fecal origin;
can they be a potential opportunistic pathogen to susceptible individuals
in the community?
In response to the first question, approximately 30 to 40 percent of all
warm-blooded animals, humans included, have Klebsiella in their
intestinal tracts, with individual densities ranging up to 10^ Klebsiella
per gram of feces (70-82). An estimated 60-85 percent of all Klebsiella
isolated from feces and clinical specimens were positive in the fecal
coliform test were identified as K^_ pneumoniae (83-86).
K. pneumoniae, particularly antibiotic resistant serotypes, can cause
human infections of the respiratory system, genito-urinary tract, nose
and throat, and occasionally meningitis and septicemia (87, 88).
Klebsie1la-caused infection is sometimes of apparent primary etiology,
but more often is found in mixed infection or as a secondary invader
(89). In the hospital environment, the nosocomial infection rate for
pathogenic K^_ pneumoniae was 16.7 infections per 100 patients from 94
hospitals (90). Klebsiella pneumoniae was the cause of 1.1 percent of
all nosocomial hospital deaths during the same period. Infections of
the urinary system, lower respiratory tract and surgical wounds were the
most frequent cause of Klebsiella associated illnesses or deatTis. The
lack of evidence of increased illness in a corrmunity during a coliform
biofilm event may relate to difficulties m gathering reports of water
related illness cases among susceptic > pe-n'.e at home or in the work
environment vs. patients in the hospi--.-.i-.c.
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Most of the Klebsiella waterborne occurrences are not of fecal origin.
In those infrequent situations where the laboratory analyses reveal fecal
Klebsiella in the distribution system, there should be a high priority
effort ta destroy the colonization sites because of the concern for more
frequent releases of this opportunistic pathogen at higher densities into
the water supply. Infective dose (ID50) values for environmental and
clinical isolates of Klebsiella have been reported to be between 3.5 x
10^- to 7.9 x 10^ cells per mL (91). Therefore, ingestion of 100 mL of
drinking water (approximately one glass of water) containing 3.5 x 10*
Klebsiella per mL could present a risk to susceptible individuals.
Inhalation of moisture from vaporizers using drinking water contaminated
with Klebsiella should also be considered a risk to some individuals.
LEGIONELLA
Legionella pneumophila is an important waterborne opportunistic pathogen
that causes Legionnaire's disease in susceptible individuals exposed to
contaminated aerosols from shower baths and air conditioner heat
exchanges. The respiratory disease results in a conplex colonization of
the body that is responsible for pneumonia with significant mortality
rates among senior citizens. Pontiac fever, another illness caused by
legionellae, is a non-pneumonic, non-fatal and self-limiting disease.
Apparently, there is no human carrier state or reservoir for legionellae
bacteria in warm-blooded animals.
While this group of small, gram-negative bacteria have an absolute
nutritional requiranent for L-cysteine (92) it is somewhat surprising to
find legionellae widespread in the aquatic environment. These organisms
have been detected in freshwater streams and lakes in both North America
and Europe, plus the tropical waters of Puerto Rico (93-95) . In one
study of 793 water samples collected from 67 different lakes and rivers
throughout the United States, virtually all sources were positive for L.
pneumophila, using the direct fluorescent antibody technique for
detection (96). There is some indication that legionellae are very
infrequently found in groundwater, unless there is some surface water
runoff seepage or poor soil barrier protection (97,98).
Water treatment processes may play some role in the development of an
ecological niche for Legionella through the release of assimilable
organic nutrients, particulates and various heterotrophic organisms into
the distribution system as a result of uneven, interrupted or failed
treatment processes (99-104). Among the microorganisms in the raw source
water that sequester Legionella and provide safe passage through the
disinfection process are algae, amoebae and ciliates (105, 106).
Airborne legionellae in dust or particulate laden rain showers may find
their way to the open air treatment basins. Conrnon pathways for their
entry into the distribution system include reservoir air vents, main
construction, pipe line repairs, cross-connections and back-siphonage
(107).
Establishment of Legionella in the distribution system is most likely to
occur in biofilm locations where symbiotic relationships with other
heterotrophic bacteria (Flavobacterium breve, Pseudomonas, Alcaligenes,
or Acinetobacter) provide the critical nutrient requirenents necessary
for long term persistence of this opportunistic pathogen (108-110). Many
of these sites will be found at the periphery of the systan (long pipe
runs into dead ends) and in little used service connections throughout
the pipe network where the water can stagnate. Densities of Legionella
may be only a few cells per liter in water supply (105-106) and the mere
presence of these few Legionella in drinking water does not pose a direct
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health threat until there are opportunities for amplification (hot water
tanks, shower heads, v«ter evaporator cooling devices, etc.).
Efforts to eliminate low levels of these organisms (a few per liter) in
water supply treatment processes and in the distribution system network
are not cost-effective. Water utility operations, however, can minimize
regrcwth potential through good housekeeping practices that include
removal of scums and biofilm accumulations at air-water interfaces in
treatment basins, connecting flumes and attachments to agitator paddles
in flocculation basins. System-wide flushing with particular emphasis
on dead end sections during warm water periods, will significantly
suppress further development of biofilm and introduce detectable
disinfectant residuals to those areas where Legionella and other
heterotrophic bacteria may persist. The net effect desired is to
suppress microbial symbiotic relationships that are essential to
Legionella metabolism.
PSEUDOMONAS AERUGINOSA
Pseudomonas species are ubiquitous bacteria that are able to flourish in
a wide variety of habitats (surface waters, aquifers, sea water, soils
and vegetation). Some pseudomonads are among the prominent denitrifiers
while others grow prodigiously in and on tertiary treatment devices such
as reverse osmosis and electrodialysis membranes and in sand or carbon
filtration beds. Pseudomonads reported in some drinking water supplies
include: P^ aeruginosa, P. cepacia, P. fluorescens, P. mallei, P.
maltophilia, P. putida and P^_ testosteroni (111,112). Perhaps the most
significant species of concern in drinking water is P^_ aeruginosa. To
this list can be added: P^_ stutzeri, P. diminuta and P^ acidovoran which
have been found in bottled waters at densities ranging from 10-3 to 10^
organisms per mL (113-115). These organisms metabolically adapt to
survive on minimal nutrient concentrations typical of protected aquifers
and treated drinking water.
The ability of P^ aeruginosa to rapidly colonize a variety of
environments, including the susceptible human, makes it a major
opportunistic pathogen; particularly P^_ aeruginosa serogroups 11 and
possibly serogroup 9 which are the most frequently isolated pathogenic
strains. Bacteremia attributable to Pseudomonas has become a major
concern in the management of trauma as well as in the management of
susceptible patients recovering from burns, intensive surgery and others
exposed to cancer therapy (116-120). Other serious infections for
susceptible individuals involve eye, ear, nose, and occasionally the
gastrointestinal tract (121, 122).
The infrequent occurrence (3-19 percent) of Pseudomonas in the human
intestinal tract (123) suggests that colonization of the gastrointestinal
system rarely occurs in healthy adults, indicating that there are potent
host-defense mechanisms against this group of gram negative bacteria
(124, 125). Since municipal sewage contains a mixture of domestic
wastes, industrial discharges and intermittent stormwater runoff, it is
not unexpected to find P^ aeruginosa in 90% of sewage sarnples (126).
Densities of ^ aeruginosa in surface waters receiving waste and
stormwater discharges may range from 1 x 10° to 1 x 10^ cells per 100
mL, and are influenced by available nutrients and seasonal water
temperatures (127).
P. aeruginosa found in a contaminated wa-er supply has been linked to one
waterborne outbreak that occurred in i	nursery (128). In this
case study, the ground water supply was • i-.n^ted by seepage of sewage
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and infiltration of contaminated surface water. Since P. aeruginosa is
the most prevalent Pseudomonas in human disease (129) its occurrence has
been limited to less than one organism in 250 mL of bottled drinking
water by the European comnunity. Other Pseudomonas species found
occasionally in water (P^ fluorescens, P. putida, P. multivorans, P.
maltophilia and P^_ stutzeri) have not yet been linked to water borne
outbreaks suggesting they are indigenous aquatic bacteria in every water
environment.
JOIOT RESPONSIBILITY FOR WATER QUALITY
Fulfilling the obligation for the production, delivery, and rtaintenance
of high quality water supply to the consumer is the joint responsibility
of the water utility and the user conmunity of hospitals, highrise
building complex management and the individual family. Water quality is
created at the water plant and is a reflection of treatment operations
and distribution system maintenance and management. While treatment
technology will provide a water free of health risks associated with
primary pathogens, treatment processes were never intended to produce a
sterile water supply. Opportunistic organisms will pass through or
circumvent treatment barriers as now defined. Same of these pathways
include passage of dust contaminants into open air process basins,
organism protection in clurrping, viable cell transport by aquatic
invertebrates, movement with carbon fines, or unsettled particulates and
infiltration through fractured pipes, line breaks and line repair
practices.
WATER OTILITIES
Opportunistic organisms are very adaptable in establishment of a biofilm
colonization that promotes the amplification of cell densities to levels
that may be several logs higher than the initial levels. In treatment
basins, colonization occurs at the solid surface-water interfaces of
process basins and connecting flumes and agitator paddles in the
coagulation basin. This problsn is best controlled fcy scheduling
application of high pressure washing of compartment walls and mechanical
scraping of paddle surfaces. Colonization in the distribution system may
occur in the slow flow and dead end sections of the pipe network, and on
the walls and in the accumulated sediments of water storage tanks.
Static water locations in the pipe systan and stratified water in storage
tanks promotes colonization fcy a variety of bacteria during warm water
periods.
The key to suppressing colonization is to keep the water moving
throughout the system and to remove accumulating pipe sediments.
Flushing that is done at least every Spring in a systsnatic fashion from
water plant to end of the pipe network often contributes to control of
biofilm incursions. Draining and cleaning of all water storage tanks and
standpipes may be more difficult to manage but nevertheless should be
done as frequently as possible to suppress biofilm growth at these sites.
For water utilities that use chloramination as the post-disinfectant, it
may be desirable to change to free chlorine for a two week period each
year to effectively reduce chloramine resistant heterotrophic bacteria
population in biofilms.
HOSPITALS
Hospitals also have a responsibility in the management of water supply
quality. The entire pipe network needs to be flushed every six months
because this water is always in a warm environment regardless of seasonal
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weather changes. Flushing in this case needs to be done at each faucet
throughout the facility for a 15 minute period or until a measurable
disinfectant residual is obtained. Attachment devices must also be
disassembled and cleaned of incrustations and sediments before
reassembly. Flexible hose connections should be replaced at this time
as well as any gaskets and washers that have visible slime growth or
incrustations. Prior to the activation of a new hospital wing or
reactivation of closed patient wards or operating theaters, all faucets
should be opened for 24 hours to flush out the stagnate water and
sediments in an effort to achieve water supply that is representative of
public water supply quality.
BUILDING MANAGERS
Highrise buildings also have complex water supply networks that are
subject to quality changes. Water supply tanks in apartment buildings,
office buildings and hotels should be flushed and cleaned each year.
Unoccupied apartments, office space and hotel rooms vacant for 3 months
or more may have a significant deterioration in the water quality in the
static service lines. Flushing overnight from each water tap in the
vacant rooms will restore water quality which is characteristic of the
building supply.
INDIVIDUAL CONSUMERS
Consumers must also be aware of their responsibility to protect the
public water supply in their home. Perhaps the most common problem with
static water quality is in the first draw of water supply in the morning.
Microbial growth will occur in the water during overnight periods of no
flow due to warm ambient tanperatures associated with proximity to
furnace pipes, hot water lines and under the sink locations. As a
general practice, it is a good habit to flush the tap water line for 30
seconds each morning before ingesting that first glass of water. If the
family has been away on an extended vacation, again flushing water lines
from the bathroom and kitchen taps for several minutes will do much to
remove higher bacterial densities in static water lines. For families
that attach point-of-use devices to the water supply line for additional
treatment, there should be a scheduled effort to change carbon filters
every 4 to 6 weeks, depending on usage, or as reconmended by the
manufacturer. Morning flush of these devices is very inportant because
of the microbial build-up in the unit overnight that often exceeds what
occurs in static water at other home faucets.
SUMiARY
Organisms that become established in water supply may also be
opportunistic pathogens. Representative opportunistic pathogens that are
waterbome include acid-fast bacteria, fecal klebsiellae, Legionella and
Pseudomonas aeruginosa. These organisms may be found in the
heterotrophic bacterial population of treated drinking water and if
appropriate conditions exist, may colonize and become part of the
biofilm.
Maintaining a high quality water supply requires careful treatment and
a clean water distribution system. Users of the cornnunity water supply
also have a responsibility to preserve this water quality from
deterioration as it leaves the service meter and traverses the building
supply lines. The goal is to minimize exposure to various heterotrophic
bacteria that may pose a risk to those consumers of varying health status
in the comnunity of people.
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Table 1. Documented Nosocomial Outbreaks Associated With
Contaminated Potable Water*
Etiologic Agent
Illness
Reference
Pseudomonas
Wound
Cross, et al. (9)

Wound
Bassett, et al. (10)

Dermatitis
Highsmith, et al. (11)

Meningitis
Ho, et al. (12)

Respiratory
duMoulin, et al. (13)

Respiratory
Saepan, et al. (14)

Cellulitis
McGuekin, et al. (15)
Acinetobacter
Peritonitis
Abrutyn, et al. (16)
Mycobacterium
Septicemia
Carson, et al. (17)

Bacteremia
Bolan, et al. (18)

Peritonitis
duMoulin and Stottmeir (19)
Flavobacterium
Septicemia
Herman and Himnelsbach (20)

Respiratory
duMoulin, (21)
Legionella
Respiratory
Cordes, et al. (22)
Klebsiella
Urinary, Respiratory
Kelly, et al. (23)
*Infornation adapted from Highsmith, et al.
(8)
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Bact. 64:841-845 (1952).
841

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127.	Hoadley, A.W., E. McCoy, and G.A. Rohlich. Untersuchungen uber
Pseudomonas aeruginosa in Oberflachengewassern. I. Quellen.
Arch. Hyg. Bakteriol. 152:328-338.
128.	Weber, G., H.P. Werner and H. Matschnigg. Pseudomonas
aeruginosa in Trinkwasser als Todesursache bei Neugeborenen.
Zentralbl. Bakteriol. Parasitenk. Infektionskr. Hyg. I Abt.
Orig., 216:210-214 (1971).
129.	Lennette, E.H., Balows, A., Hausler, Jr., W.J. and Shadomy, H.J.
Manual of Clinical Microbiology. 4th edition, p 350-373. Amer.
Soc. Microbiol., Washington, D.C. (1985).
842

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TECHNICAL REPORT DATA
(Please read /nstrjctioni on the rcrene before compter'
1. REPORT NO. 2.
EPA/600/A-92/094
3.
J. TITLE AND SUBTITLE
Opportunistic Organisms and the Water Supply
Connection
5. REPORT DATE
6. PERFORMING organization CODE
7. AUTHOR(S)
Edwin E. Geldreich
8. PERFORMING ORGANIZATION REPORT NO.
".performing organization name and address
Risk Reduction Engineering Laboratory-Cincinnati, OH
Office of Research and Development
U.S. Environmental Protection Agency
Cincinnati, OH 45268
10. PROGRAM ELEMENT NO.
11. CONTRACTjGRA.NT no.
12. SPONSORING AGENCY NAME ANO adoress
Risk Reduction Engineering Laboratory-Cincinnati, OH
Office of Research and Development
U.S. Environmental Protection Agency
Cincinnati, OH 45268
13. TYPE OF REPORT AND PERIOO COVERED
Published Paoer
1-1. SPONSORING AGENCY CODE
EPA/600/14
is.sLP»L=M£.MTAay notes po = Edwin E. Geldreich (513)569-7232, Technology Conference
Proceedings, Part II, Sessions Ed Throuyh ST6, AWWA Water Quality Technology Conf,
11/10-14/91, Orlando, Florida. P:823-842		
1o, AaS'RACT
Organisms that become established in water supply may also be opportunistic
pathogens. Representative opportunistic pathogens that are waterborne include
acid-fast bacteria, fecal klebsiellae,' Legionella and Pseudomonas aeruginosa.
These organisms may be found in the heterotrophic bacterial population of treated
drinking water and if appropriate conditions exist, may colonize and becane part
of the biofilm.
Maintaining a high quality water supply requires careful treatment and a
clean water distribution systan. Users of the comnunity water supply also have
a responsibility to preserve this water quality from deterioration as it leaves
the service meter and traverses the building supply lines. The goal is to
minimize exposure to various heterotrophic bacteria that may pose a risk to
those consumers of varying health status in the conmunity of people, v.
< = Y V/CfiCS and document analysis
.1
OE5CRIP7CRS
b.IDENTIFIERS/OPEN ENDSO TERMS
c. cosati PiciJ Croup
Pseudomonas
aeruginosa
opportunistic pathogens
heterotrophic bacteria
water supply quality
Fecal Klebsiella
Acid-fast bacteria
Legionella

13. CI3TRISUTICN ST
A T E M £ N 7 -
19. SECURITY CLASS iTIus Xeport,
UNCLASSIFIED
31. NO. OF pages
22
RELEASE TO
PUBLIC
20. SECURITY CLASS (Tins pn£ti
1TNCT.ASSTFTEI)
22. PRICE
epa 2::o
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