United States
Environmental Protection
Agency

Technical Support Document for the
Final Fifth Contaminant Candidate List
(CCL 5) - Microbial Contaminants


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Office of Water (4607M)
EPA 815-R-22-004
October 2022
www. epa. gov/ safewater


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EPA-Office of Water

Technical Support Document for the
Final Fifth Contaminant Candidate List (CCL 5)-
Microbial Contaminants

EPA 815-R-22-004
October 2022

Table of Contents

Table of Contents	i

Acronyms	iv

Chapter 1 Introduction	1

Section 1.1 Background	1

Section 1.2 Overview of the CCL 5 Development Process	2

Section 1.3 Overview of CCL 5 Process for Microbes	3

Chapter 2 Public Nominations	3

Section 2.1 Overview	3

Section 2.2 Summary of Microbial Nominations for CCL 5	4

Section 2.3 Analysis of Nominated Microbial Contaminants	4

Chapter 3 Building the Universe	4

Section 3.1 Overview of the Microbial Universe	4

Chapter 4 Screening the Microbial Universe to Select the PCCL Section 4.1 Screening Criteria. 6

Section 4.2 Application of Screening Criteria to the Microbial CCL Universe	11

Chapter 5 Evaluating Microbial Contaminants for CCL 5	12

Section 5.1 Waterborne Disease Outbreak Data	12

Section 5.2 Occurrence Data	13

5.3 Health Risk Data	14

Section 5.4 Calculated Data Elements for PCCL Contaminants	16

Section 5.5 PCCL 5 Composite Score Results	16

Chapter 6 CCL 5 Microbes	18

6.1 Selecting CCL 5 Microbes	18

Section 6.2 Supplemental Support for CCL 5 Microbial Contaminants	19

Section 6.3 Microorganisms Covered by Existing Regulations	23

Section 6.4 Listing Outcomes for the Nominated Microbial Contaminants	24

Chapter 7 Microbial Data Sources for the Final CCL 5	24

References	26

Appendix A: List of CCL 5 Microbial Nominations	A-l

Appendix B: The CCL 5 Microbial Universe	B-l

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Microbial Contaminants

Appendix C: PCCL 5 Pathogen Scores	C-l

Appendix D: The Final CCL 5 for Microbes	D-l

Appendix E: Documented PCCL 5 Microbes WBDOs in the U.S. Reported by CDC Between
2009-2017	E-l

Appendix F: Microbial Contaminant Information Sheets (CISs)	F-l

Acinetobacter baumannii Scoring Data	F-5

Adenovirus Scoring Data	F-9

Aeromonas hydrophila Scoring Data	F-13

Arcobacter butzleri Scoring Data	F-l7

Aspergillus fumigatus Scoring Data	F-21

Astrovirus Scoring Data	F-26

Blastocystis hominis Scoring Data	F-30

Calicivirus Scoring Data	F-34

Campylobacter jejuni Scoring Data	F-38

Comamonas testosteroni Scoring Data	F-43

Cyclospora cayetanensis Scoring Data	F-47

Entamoeba histolytica Scoring Data	F-51

Enterovirus Scoring Data	F-55

Escherichia coli (0157)^ Scoring Data	F-60

Exophiala jeanselmei Scoring Data	F-66

Fusarium solani Scoring Data	F-70

Helicobacter pylori Scoring Data	F-74

Hepatitis A Virus Scoring Data	F-79

Hepatitis E Virus Scoring Data	F-83

Isospora belli Scoring Data	F-87

Legionella pneumophila Scoring Data	F-90

Microsporidia Scoring Data	F-95

Mycobacterium abscessus Scoring Data	F-99

Mycobacterium avium Scoring Data	F-l03

Naegleriafowleri Scoring Data	F-l08

Nontuberculous Mycobacteria (NTM) Scoring Data	F-l 12

Pantoea agglomerans Scoring Data	F-l 16

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Plesiomonas shigelloides Scoring Data	F-120

Pseudomonas aeruginosa Scoring Data	F-124

Rotavirus Scoring Data	F-127

Salmonella enterica Scoring Data	F-131

Shigella sonnei Scoring Data	F-135

Toxoplasma gondii Scoring Data	F-13 9

Vibrio cholerae Scoring Data	F-143

Yersinia enterocolitica Scoring Data	F-147

Appendix G. CCL 5 Data Source Descriptions	G-l

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EPA-Office of Water

Technical Support Document for the
Final Fifth Contaminant Candidate List (CCL 5)-
Microbial Contaminants

EPA 815-R-22-004
October 2022

Acronyms

AGI

Acute gastrointestinal illness

CCL

Contaminant Candidate List

CCL 1

EPA's First Contaminant Candidate List

CCL 2

EPA's Second Contaminant Candidate List

CCL 3

EPA's Third Contaminant Candidate List

CCL 4

EPA's Fourth Contaminant Candidate List

CCL 5

EPA's Fifth Contaminant Candidate List

CDC

Centers for Disease Control and Prevention

CIS

Contaminant Information Sheet

CNS

Central Nervous System

EPA

Environmental Protection Agency

GWR

Ground Water Rule

HUS

Hemolytic Uremic Syndrome

MAC

Mycobacterium avium complex

MCL

Maximum Contaminant Level

MCLG

Maximum Contaminant Level Goal

MCM

Manual of Clinical Microbiology

MMWR

Morbidity and Mortality Weekly Reports

NDWAC

National Drinking Water Advisory Council

NIH

National Institute of Health

NORS

National Outbreak Reporting System

NPDWR

National Primary Drinking Water Regulation

NRC

National Research Council

NTM

Nontuberculous mycobacteria

OGWDW

Office of Groundwater and Drinking Water

PCCL

Preliminary Contaminant Candidate List

PWS

Public Water System

SAB

Science Advisory Board

SDWA

Safe Drinking Water Act

SWTR

Surface Water Treatment Rule

UCMR

Unregulated Contaminant Monitoring Rule

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Microbial Contaminants

WBDO	Waterborne Disease Outbreak

WHO	World Health Organization

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Microbial Contaminants

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October 2022

Chapter 1 Introduction
Section 1.1 Background

The 1996 Safe Drinking Water Act (SDWA) Amendments (section 1412(b)(1)) require the
United States Environmental Protection Agency (EPA) to publish every five years a list of
drinking water contaminants that are known or anticipated to occur in public water systems
(PWSs) and that may cause adverse health effects. SDWA specifies that the list (referred to as
the Contaminant Candidate List, or CCL) must include contaminants that:

•	are not subject to any proposed or promulgated National Primary Drinking Water
Regulation;

•	are known or anticipated to occur in PWSs; and

•	may require regulation under the SDWA

EPA uses this list of unregulated contaminants to help identify priority contaminants for
regulatory decision making and to prioritize research and data collection efforts. SDWA also
requires the Agency to consult with the scientific community, including the Science Advisory
Board (SAB), and to provide notice and opportunity for public comment prior to the publication
of the Final CCL. In addition, SDWA directs the agency to consider the health effects and
occurrence information for unregulated contaminants to identify those chemicals and microbial
pathogens that present the greatest public health concern related to exposure from drinking
water.

In a regulatory action separate from the CCL, SDWA Section 1412(b)( 1 )(B)(ii) directs EPA to
make regulatory determinations on at least five of the contaminants from the CCL every five
years. The CCL itself does not pose a burden or place requirements on the states or PWSs.
Rather, the CCL identifies contaminants that serve as a list to be considered for research and data
collection efforts, such as for the Unregulated Contaminant Monitoring Rule (UCMR). Only
after additional data and information are collected are contaminants considered for regulatory
determination and rulemaking under the SDWA.

EPA has completed four cycles of CCLs since 1996. The previous CCLs are briefly described
below:

•	EPA published the first CCL (CCL 1) on March 2, 1998 (63 FR 10274, USEPA, 1998a).
The CCL 1 was developed based on recommendations by the National Drinking Water
Advisory Council (NDWAC) and reviewed by technical experts. CCL 1 contained 50
chemicals and 10 microbial contaminants/groups.

•	EPA published the second CCL (CCL 2) on February 24, 2005 (70 FR 9071, USEPA,
2005). EPA carried forward the 51 remaining chemical and microbial contaminants from
CCL 1 (those that did not have regulatory determinations).

•	EPA published the third CCL (CCL 3) on October 8, 2009 (74 FR 51850, USEPA,
2009a). In developing the CCL 3, EPA implemented an improved, stepwise process that
built on evaluation of the previous CCL processes and was based on expert input and

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recommendations from the National Academy of Sciences' National Research Council
(NRC), NDWAC, and SAB. CCL 3 contained 104 chemicals/chemical groups and 12
microbial contaminants/groups.

• EPA published the fourth Contaminant Candidate List (CCL 4) on November 17, 2016
(81 FR 81099, USEPA, 2016a). The Final CCL 4 contained 97 chemical s/chemical
groups and 12 microbial contaminants/groups. All contaminants listed on the Final CCL
4 were carried forward from the CCL 3, except for two contaminants,
perfluorooctanesulfonic acid (PFOS) and perfluorooctanoic acid (PFOA), that received
positive regulatory determinations.

Section 1.2 Overview of the CCL 5 Development Process

During the development of the CCL 3, EPA requested assistance from the NRC in developing a
more robust approach to identifying and prioritizing potential drinking water contaminants. NRC
formed the Committee on Drinking Water Contaminants, and the committee published their
recommendations in 1999 and 2001 (NRC, 1999a; NRC, 1999b; NRC, 2001). EPA used these
recommendations to develop the CCL classification process and implemented the process for the
CCL 3. In CCL 3, EPA established and implemented a multi-step process to select contaminants.
The CCL framework is comprised of three steps:

1.	Building the Universe

2.	Screening the Universe

3.	Classifying contaminants to select the CCL

A simplified illustration of the CCL development framework for contaminants is shown in
Figure 1.

Figure 1: CCL Development Framework

Building the Universe

to

Universe ™

	

Screening

Preliminary CCL
(PCCL)

STEP 2

Classification

STEP 3

_i

.—~ o

o

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October 2022

The remainder of this technical support document describes in detail the process used for CCL 5
microbial contaminants and the updates made in response to expert input and recommendations
provided by the previous and current SABs and public comments. The CCL 5 process for the
chemical contaminants can be found in a separate document Technical Support Document for the
Final Fifth Contaminant Candidate List (CCL 5) - Chemical Contaminants (USEPA, 2022). This
document is accessible on EPA's webpage for CCL 5 at https://www.epa.gov/ccl/contaminant-
candidate-list-5-ccl-5 or via the EPA docket (Docket ID No. EPA-HQ-OW-2018-0594) at
https://www.regulations.gov.

Section 1.3 Overview of CCL 5 Process for Microbes

For the CCL 5 microbial contaminants, EPA used the same methodology that was developed for
microbial contaminants in CCL 3. For CCL 5, EPA followed the following steps for microbes:

•	Step 1. Build a broad universe of all microbes that may cause human disease;

•	Step 2. Screen the universe of microbial contaminants to produce a Preliminary CCL
(PCCL); and

•	Step 3. Select the CCL microbial list by ranking the PCCL contaminants based on
occurrence in drinking water (including waterborne disease outbreaks and human health
risks.

These three steps are described in more detail in Chapters 3, 4, and 5 respectively of this
technical support document.

Chapter 2 Public Nominations
Section 2.1 Overview

EPA sought public nominations in a Federal Register notice on October 5, 2018, for unregulated
chemical and microbial contaminants to be considered for possible inclusion in the CCL 5 (83
FR 50364, USEPA, 2018). In accordance with the SDWA, which directs EPA to consider health
effects and occurrence information when deciding whether to place contaminants on the CCL,
EPA asked that nominations include responses to the following questions:

1.	What is the contaminant's name, CAS registry number, and/or common synonym
(if applicable)? Please do not nominate a contaminant that is already subject to a
national primary drinking water regulation.

2.	What are the data that you believe support the conclusion that the contaminant is
known or anticipated to occur in public water systems? For example, provide
information that shows measured occurrence of the contaminant in drinking water
or measured occurrence in sources of drinking water or provide information that
shows the contaminant is released in the environment or is manufactured in large
quantities and has a potential for contaminating sources of drinking water. Please
provide the source of this information with complete citations for published
information (i.e., author(s), title, journal, and date) or contact information for the
primary investigator.

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3. What are the data that you believe support the conclusion that the contaminant
may require regulation? For example, provide information that shows the
contaminant may have an adverse health effect on the general population or that
the contaminant is potentially harmful to subgroups that comprise a meaningful
portion of the population (such as children, pregnant women, the elderly,
individuals with a history of serious illness, or others). Please provide the source
of this information with complete citations for published information (i.e.,
author(s), title, journal, and date) or contact information for the primary
investigator.

Nominations were received via the EPA docket (Docket ID No. EPA-HQ-OW-2018-0594) on
the Federal eRulemaking Portal and were also accepted by mail or hand delivery. EPA compiled
and reviewed the information from the nominations process to identify the contaminants
nominated and any sources of supporting data submitted that could be used to supplement the
data gathered by EPA to inform selection of the Final CCL 5.

Section 2.2 Summary of Microbial Nominations for CCL 5

EPA received public nominations for 16 unique microbial contaminants for consideration for
CCL 5. Eight of the same microbes were nominated by more than one organization or individual.
Legionella pneumophila received the most nominations, nominated by 18 organizations or
individuals. One public commenter proposed that all CCL 4 contaminants be retained on the
CCL 5. Appendix A shows the microbial organisms or group of microbial organisms that were
nominated, along with the number of nominators and any supporting information provided.

All public nominations, both chemical and microbial contaminants, for CCL 5 can be viewed in
the EPA docket (Docket ID No. EPA-HQ-OW-2018-0594) at https://www.regulations.gov.

Section 2.3 Analysis of Nominated Microbial Contaminants

EPA reviewed the nominated microbial contaminants and any supporting information provided
by nominators to determine if any data provided had not been previously evaluated. Furthermore,
the Agency collected additional data for the nominated microbial contaminants by updating both
the CCL 3 and the CCL 4 data sources and conducting literature searches covering the time
between the CCL 4 and the CCL 5.

Chapter 3 Building the Universe
Section 3.1 Overview of the Microbial Universe

The CCL Microbial Universe is comprised of all pathogens that cause human disease. The CCL
5 Microbial Universe was developed by building upon previous CCL Microbial Universes, in
particular, the CCL 3 and the CCL 4 Microbial Universes. During the development of the CCL
3, EPA followed the NDWAC's recommendation to specifically use Taylor et al. (2001) list and
literature reviews as the starting point for the microbial CCL 3 Universe (NDWAC, 2004). For
the CCL 3, the Agency added organisms to the Taylor et al. (2001) list, with input from subject
matter experts and data collected through a literature search. For example, EPA reviewed fungi
in drinking water literature and identified six fungal species reported to occur in drinking water

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October 2022

distribution systems that did not appear on the Taylor et al. 2001 list. EPA also added reovirus to
the CCL 3 Universe based on additional health effects information (Tyler et al., 2004).

Additional microbes, Methylobacterium (with two species) and mimivirus, were added to the
universe during CCL 3. Adding these two bacterial species, two viral groups (e.g., reovirus and
mimivirus) and six fungal species brought the CCL 3 Microbial Universe list to 1,425 microbes.
These microbes remained in the CCL 4 Microbial Universe.

For CCL 5, EPA conducted a literature search, sought input from subject matter experts, and
reviewed nominations for potential microbial contaminants to add to the CCL 5 Universe. As a
result of the literature search, 14 organisms were added to the CCL 5 Universe (Table 1).
Changes to nomenclature were made as necessary (in most cases combining two species into one
organism group), which brought the total to 1,435 microbes. EPA recognizes that given the
dynamic nature of ongoing microbial research, the listing of all human pathogens on the CCL
universe needs to be periodically updated to keep up with the latest science. The full microbial
CCL 5 Universe is presented in Appendix B.

Table 1. Microbial Organisms Added to the Microbial CCL 5 Universe

Organism

Reference

Alloscardovia omnicolens (bacteria)

Brown et al., 2016

Elizabethkingia anophelis (bacteria)

Figueroa Castro et al., 2017

Neoehrlichia mikurensis (bacteria)

Portillo et al., 2018

Parachlamydia acanthamoebae (bacteria)

Greub, 2009

Waddlia chondrophila (bacteria)

Baud et al., 2014

Human bocavirus (virus)

Allander, 2008

Human coronavirus SARS-CoV-2 (virus)

Ciotti et al., 2019

KI polyomavirus (virus)

Bofill-Maset al., 2010

Kobuvirus (virus)

Ramirez-Castillo et al., 2015

Lujo virus (virus)

https://www.cdc.gov/vhf/luio/transmission/in
dex.html

Parvovirus 4 (virus)

Sharp et al., 2010

WU polyomavirus (virus)

Bofill-Mas et al., 2010

Botrytsis cinerea (fungi)

Hashimoto et al., 2017

Epiccocum purpurascens (fungi)

httDs://www.insDa.ac.ca/en/moulds/fact-
sheets/epicoccum-purpurascens

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Chapter 4 Screening the Microbial Universe to Select the PCCL
Section 4.1 Screening Criteria

The development of the microbial preliminary CCL 5 (PCCL 5) adhered to the process
developed for the CCL 3 with additional updates described below. The CCL 3 process followed
NRC recommendations by using a hierarchical framework to evaluate the potential occurrence of
microbial contaminants in drinking water (NRC, 2001). For CCL 3, EPA also followed
recommendations provided by NDWAC (2004) to select microbial contaminants for a PCCL
based upon an assessment of occurrence and potential health effects. This assessment related the
plausibility of pathogen presence, survival, and transport through drinking water to disease
manifestations from drinking water exposure. The CCL 3 screening criteria were developed
based upon epidemiology, geographical distribution, and biological properties in the host and in
the environment. The screening criteria were developed to be exclusionary, in that, if a pathogen
met one of the criteria, it would then be excluded from moving to the PCCL. The screening
criteria were recommended by NDWAC and amended by EPA following an external peer review
resulting in 12 screening criteria used for initial screening of pathogens in the microbial CCL 3
Universe for placement on the PCCL 3 (NDWAC, 2004). Additional information on
recommendations provided by NRC and NDWAC are described in EPA's Final CCL 3
Microbes: Screening to the PCCL (USEPA, 2009b) and NRC (NRC, 2001) and NDWAC reports
(NDWAC, 2004).

The 12 exclusionary screening criteria were used to evaluate the five microbial groups (bacteria,
viruses, fungi, helminths, and protozoa) that make up the microbial universe, but each criterion
did not necessarily apply to every group. Some evaluation criteria would never be used to
exclude microbes in a group because of fundamental characteristics of the microbes in that
group. For example, Criterion 5: Microflora indigenous to the gastrointestinal tract, skin, and
mucous membranes was not used to evaluate viruses and helminths. This was because viruses
and helminths do not have a commensal relationship with a human host and are not considered a
part of normal human microflora (Davis, 1996). Criteria that were not used are greyed out in
their respective columns in the screening table presented in Appendix B.

EPA restricted the PCCL to pathogens associated with source water and recreational water (e.g.,
swimming pools, hot tubs) only if the source water was also utilized for drinking water. The
screening criteria excluded those pathogens whose biological properties are incompatible with
water transmission by ingestion, inhalation, or dermal contact, and those pathogens that are
typically introduced from sources other than drinking water.

For the CCL 5, EPA re-evaluated the 12 screening criteria utilized in the CCL 3 and the CCL 4
for applicability to microbes and reviewed certain criteria in depth per recommendations
received from the SAB (USEPA, 2016c) for CCL 4. In particular, Criterion 1 (anaerobes),
Criterion 9 (natural habitat is in the environment without epidemiological evidence of drinking
water-related disease) and Criterion 10 (not endemic to North America) were closely re-
evaluated based on previous comments from CCL 4's SAB. Upon further evaluation, EPA did
not find supporting evidence to modify Criterion 1 and Criterion 10. EPA's evaluation included
literature searches for new information, internal EPA expert review, as well as feedback from
subject matter experts at the Centers for Disease Control and Prevention (CDC).

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To determine if Criterion 1, anaerobes, should be modified, EPA conducted a literature search on
the 124 anaerobic microbes excluded from the PCCL for meeting Criterion 1. With the exception
of some anaerobes being spore-forming, EPA found insufficient evidence supporting waterborne
illnesses attributed to anaerobic microbes. Therefore, Criterion 1 remains unchanged.

In response to the CCL 4 SAB's comment that Criterion 9 was too restrictive, EPA evaluated
and expanded Criterion 9 to include nosocomial infections where drinking water is implicated.
This expansion also recognized a growing concern for microbial contaminants within
distribution systems, building water systems, and biofilms. For past CCLs, microorganisms that
had outbreaks but no evidence of a contaminated PWS distribution system as their cause were
screened out. Thus, outbreaks, which were attributable to recreational water or were occurring
due to nosocomial exposure of drinking water contaminated post-delivery, were not sufficient to
place a microorganism on the PCCL unless the drinking water was shown to be contaminated. A
literature search was conducted for citations from 2009-2019 (post CCL 3 data collection) to
look for evidence of waterborne diseases for microbes that were excluded using Criterion 9, and
an additional search was performed to identify any new microbes causing water-related diseases
or outbreaks found in the United States since 2009. The peer-reviewed literature was evaluated
for evidence of disease caused by exposure to water, whether through a PWS or through
nosocomial (hospital-based) exposure where the water system was epidemiologically-linked. The
CDC's Morbidity and Mortality Weekly Report (MMWR), National Outbreak Reporting System
(NORS), and CDC's page on health care associated infections

(https://www.cdc.gov/hai/organisms/organisms.html) were also evaluated for evidence of disease
caused by exposure to water. As a result, five microbes that had not been listed previously on a
PCCL were listed on the PCCL 5 and further evaluated through the microbial CCL process.

Between the publication of the draft and final CCL 5, EPA reviewed the changes to Criterion 9
and determined that the changes were appropriate. Organisms that had been placed on the PCCL
remained on the PCCL.

EPA also evaluated Criterion 10 to determine if additional microbes not previously considered
endemic to North America should be passed through to the PCCL. The evaluation supported that
Criterion 10 should remain unchanged.

Upon completion of the re-evaluation of the 12 criteria, EPA screened all the microbes in the
CCL 5 Universe with the updated Criterion 9 along with the other criteria through the
exclusionary screening criteria listed and described below.

Criterion 1:

Anaerobes (microorganisms that cannot survive in oxygenated environments)

Anaerobes are microorganisms that cannot survive in the presence of oxygen (Murray et al.,
2007). Due to oxygen toxicity, anaerobes are unable to survive in the ambient water
environment, and they pose a negligible threat to human health from drinking water exposure.
Examples of anaerobes that were screened out based on this screening criterion included
members of the bacterial genera Actinomyces, Bacteroides, Clostridium, Eubacterium,
Fusobacterium, and Prevotella, among others (Murray et al., 2007).

Criterion 2:

Fastidious or obligate intracellular pathogens (environmental survival in water implausible)

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Fastidious or obligate intracellular pathogens rely upon their host to provide essential nutrients
and growth factors that are not present in the environment, hence these pathogens cannot survive
outside their hosts. Many fastidious or obligate intracellular pathogens have a narrow
temperature and pH range as a result of host adaptation, and they cannot survive the wide range
of temperatures and pH common in the ambient environment. Examples of fastidious or obligate
intracellular pathogens that were screened out included members of the genera Chlamydophila,
Mycoplasma, and Orientia (Murray et al., 2007). This criterion was applied only to bacteria,
since all viruses are obligate intracellular pathogens (Knipe and Howley, 2007).

Criterion 3:

Pathogens exclusively transmitted by direct or indirect contact with blood or body fluids
(including sexually transmitted diseases)

Some pathogens are transmitted by direct or indirect contact with blood or body fluids, where
fecal-oral transmission or transmission by aerosolized water is not observed (Mandell et al.
2005). Pathogens causing bloodborne diseases and sexually transmitted diseases are highly host
adapted, fastidious, and are usually not present in feces. These pathogens do not survive under
environmental conditions, and they are not transmitted by the fecal-oral route, either by direct
contact with feces or indirect contact with contaminated drinking water. Examples of pathogens
transmitted by blood or body fluids include the etiologic agents of gonorrhea and syphilis,
Chlamydia, herpes virus, human immunodeficiency virus, and hepatitis virus B, C, D and G
(Murray et al., 2007).

Criterion 4:

Pathogens transmitted by vectors

Pathogens transmitted by vectors (which include arthropods and rodents (Acha and Szyfres,
2001) depend upon either insect or other bites, or close contact with rodents, and these pathogens
are not transmitted by contact with drinking water. Mosquitoes, ticks, and fleas are the most
common vectors of arthropod-borne diseases (Krause, 2003). The genera Babesia, Borrelia,
Brugia, Dirofilaria, Ehrlichia, Leishmania, Plasmodium, Trypanosoma, Rickettsia, and all
arthropod-borne viruses were not moved to the PCCL (Murray et al., 2007).

Criterion 5:

Microflora indigenous to the gastrointestinal tract, skin, and mucous membranes

The human body is colonized with a rich and commensal microflora (Finegold et al., 1983;
Drasar and Barrow, 1985; Isenberg and D'Amato, 1995). Some microbes that colonize the
human body are transitory, while others are part of the continuing normal flora of the body.
Microbes comprising normal flora have a characteristic ecological niche, but sometimes
conditions permit their access to areas of the body where they may exhibit pathogenic potential
resulting in infection and disease. Infections with normally innocuous microbes are called
opportunistic infections, because of their ability to exploit host conditions that may periodically
predispose them to disease. Exposure to normal flora microbes is continuous throughout life, and
because the populations of normal flora microbes exceed the number of these microbes present
in drinking water by many orders of magnitude, drinking water represents an improbable source
of infection and disease. Examples of normal flora include members of the genera

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Capnocytophaga, Corynebacterium, Staphylococcus, Streptococcus, and several yeasts (Murray
et al., 2007).

Criterion 6:

Pathogens transmitted solely by respiratory secretions

Pathogens causing respiratory disease are typically transmitted by direct contact with respiratory
secretions, either by inhalation of aerosols, by direct person-to-person contact, or by contact with
fomites. Drinking water is an unlikely mode of transmission because the number of pathogens in
respiratory secretions and the continuity of exposure to respiratory secretions far exceed
exposure through drinking water (Bennett and Brachman, 2007). Examples of pathogens
transmitted by respiratory secretions include the etiologic agents of tuberculosis, diphtheria,
whooping cough, measles, rubella, and influenza (Knipe and Howley, 2007; Murray et al., 2007;
Mandell et al., 2005).

Criterion 7:

Pathogens whose life cycle is incompatible with drinking water transmission

Some pathogens, such as helminths, require intermediate hosts to complete their life cycles.
Incidental infection of humans interrupts their life cycle causing subsequent death of the
pathogen (Acha and Szyfres, 2001). Some pathogens are adapted to a single route of
transmission such as rabies virus, which is transmitted by animal bites. Some pathogens are
specifically adapted to survive in a unique ecological niche, and they cannot withstand any
alteration of conditions to which they are adapted. For example, rabies virus, Dientamoeba
fragilis, Enterobius vermicularis, and many helminths remain in the microbial CCL 5 Universe
and were not considered for the PCCL based on this criterion (Murray et al., 2007; Ashford and
Crewe, 2003).

Criterion 8:

Pathogens where drinking water-related transmission is not implicated

Some pathogens cause such rare occurrences of disease that only a few cases have been reported
in medical literature, and these rare occurrences of disease present limited opportunity to protect
public health from drinking water exposure (Acha and Szyfres, 2001; Knipe and Howley, 2007;
Murray et al., 2007; Mandell et al., 2005). Some pathogens are associated with direct
transmission from animals to humans, or other transmission routes that do not involve drinking
water (Acha and Szyfres, 2001; Krauss et al., 2003; Howard, 2003). Examples of pathogens that
remained in the microbial CCL 5 Universe after application of this criterion are Leptospira,
Listeria, Nosema, and the etiologic agents of several zoonotic virus infections (Knipe and
Howley, 2007; Murray et al., 2007).

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Criterion 9:

Natural habitat is in the environment without epidemiological evidence of drinking water-related
disease and without evidence of drinking water-related nosocomial infection7.

The environment is teeming with microorganisms, at varying concentrations, and humans are in
constant contact with these microorganisms throughout their lives (Bennett and Brachman, 2007;
Isenberg and D'Amato, 1995). Microorganisms naturally present in the environment are not
considered a threat to public health as a result of drinking water exposure unless epidemiological
evidence demonstrates a potential for water-related disease. Thus, outbreaks occurring must be
attributable to a contaminated drinking water system (Wenzel, 2003). Gordonia, Nocardicin and
most fungi were excluded from the PCCL based on this criterion (Murray et al., 2007; Howard,
2003).

Criterion 10:

Pathogens not endemic to North America

Some pathogens have an exclusive geographical distribution, and they are not naturally present
in North America (Ashford and Crewe, 2003; Murray et al., 2007; Palmer et al., 1998). Only
pathogens endemic to North America have the potential to contaminate drinking water in the
U.S. Several helminths such as most Diphyllobothrium, and Paragonimus species and several
viruses such as the hemorrhagic fever viruses and poxviruses would remain in the microbial CCL
universe after application of this criterion.

Criterion 11:

A genus and species or serotype may be chosen to represent a group of closely related organisms

EPA has chosen a few pathogens to represent a group based on all serotypes within a group
sharing essential biological properties in common with the group. Designation of a representative
group provides adequate protection of public health under the PCCL (Murray et al., 2007).
Pathogens that represent other pathogens in their group are the following: Arcobacter butzleri,
Campylobacter jejuni, Helicobacter pylori, Legionella pneumophila, Salmonella enterica,
Shigella sonnei, Adenovirus, Astrovirus, Enterovirus, Microsporidia, and Entamoeba histolytica.
For example, human adenovirus A, human adenovirus B, human adenovirus C, human
adenovirus D, human adenovirus E, and human adenovirus F could be consolidated to human
adenovirus.

Criterion 12:

Current taxonomy does not support the classification listed by Taylor et al. (2001)

Microbial taxonomy and nomenclature are a dynamic science, and taxonomic classifications are
constantly changing. Original taxonomic classifications were based upon the phenotypic
characteristics of microorganisms, but these classifications are being revised as genotypic

1 Bolded language indicates CCL 5 update to previous CCL 3 and CCL 4 Criterion 9

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information becomes available. New genera are formed, sometimes prematurely, based upon
partial genomic data, and taxonomists do not always agree with proposed changes. Under this
criterion, the genera Fluoribacter and Tatlockia were combined with the genus Legionella for
screening purposes (Murray et al., 2007).

Section 4.2 Application of Screening Criteria to the Microbial CCL Universe

As the pathogens in the microbial universe are screened through the 12 criteria, a pathogen needs
to only to meet one criterion to be excluded from moving on to the PCCL. Some pathogens may
meet multiple criteria, however, because the pathogens are evaluated through the exclusionary
screening criteria sequentially, the criteria that the pathogen meets first will exclude the pathogen
from moving on to the PCCL, and the pathogen will not be further evaluated through the rest of
the criteria. For example, if a pathogen could be excluded based on meeting Criteria 3 and 7, the
pathogen will be screened out based on meeting Criterion 3 and will not be further evaluated to
see if any other criterion is met. The pathogen will be documented as meeting just that one
criterion.

All pathogens that pass through all screening criteria are moved to the PCCL. Bacteria, viruses,
protozoa, helminths, and fungi in the CCL 5 Universe are shown screened individually through
the CCL exclusionary screening criteria in Appendix B. Each table identifies the pathogens in
each category and indicates which screening criteria were applied to remove pathogens from
further consideration in the CCL process. Those pathogens not excluded by at least 1 of the 10
screening criteria, or consolidated under Criteria 11 or 12, pass on to the PCCL. Table 2
summarized the number of microbes in the CCL 5 Universe, the number of microbes screened
out by each criterion, and the resulting number of microbes passed on to the PCCL.

Table 2. Summary of Screening the Microbial CCL 5 Universe

Pathogen
Class

Total

Number of Microbes Excluded by Each Screening Criterion

Pathogens
Screened
Out

On PCCL





1

2

3

4

5

6

7

8

9

10

11

12





Bacteria1

545

121

16

10

38

121

7

0

29

150

2

28

5

527

18

Viruses

225

0

0

29

104

0

20

1

20

0

36

8

0

218

7

Protozoa2

66

0

0

1

29

3

0

4

7

7

0

6

0

59

7

Helminths

286

0

0

0

25

0

0

105

0

0

156

0

0

286

0

Fungi

313

0

0

0

0

12

3

0

0

295

0

0

0

310

3

Total

1,435

121

16

40

196

136

30

110

56

452

194

42

5

1,400

35

1NTM were included on the PCCL as a group as well as individual Mycobacterium species.

2 Cryptosporidium and Giardia (protozoa) are considered to be regulated by the Long-Term Surface Water Treatment Rule
(LT2); even though counted in the microbial universe, they were not evaluated for screening

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Based upon this screening exercise conducted on 1,435 pathogens in the CCL 5 Microbial
Universe, 1,400 pathogens were excluded from consideration while 35 pathogens passed on to
the PCCL. Appendix A details which nominated microbes were included on the PCCL 5.

The modification made to Criterion 9 expanded the PCCL to include nosocomial infections
where drinking water was implicated. This resulted in the addition of five bacteria
(Acinetobacter baumannii, Comamonas testosteroni, Pantoea agglomerans, Pseudomonas
aerugionosa, and Mycobacterium abscessus) to the PCCL 5 for further evaluation by the CCL
process. The specific screening decisions and references are presented in Appendix B.

Chapter 5 Evaluating Microbial Contaminants for CCL 5

EPA used scoring protocols to rank pathogens on the PCCL to produce a CCL. This section
briefly describes the process developed under CCL 3 and explains the elements included in the
microbial Contaminant Information Sheets (CISs). EPA derived the CCL 3 scoring process in
part from recommendations of the NRC and an expert workgroup established by the NDWAC,
and two external workshops (USEPA, 2009c). For the CCL 5, EPA made two minor
modifications to the CCL 3 microbial scoring process regarding data sources that were used to
select microbial contaminants from the PCCL, as described below. For a more detailed
discussion on the CCL 3 scoring process and rationale used to develop the scoring process, see
Final Contaminant Candidate List 3 Microbes: PCCL to CCL Process (USEPA, 2009c).

Microbes were evaluated for their occurrence in water and their ability to cause adverse health
effects in humans. Pathogens on the PCCL were scored for placement on the CCL using a
scoring system to assign a numerical value to each pathogen and rank the pathogens based upon
both occurrence (waterborne disease outbreaks (WBDOs) and occurrence in water) and potential
health risks. WBDO information and occurrence in water information is combined to allow
consideration for 1) pathogens that are tracked by public health surveillance programs (i.e.,
NORS (CDC, 2020); and 2) pathogens that are not yet tracked by public health surveillance
programs but for which occurrence information is available (i.e., emerging pathogens). Those
microbes receiving high scores were considered for placement on the CCL.

Each microbe was scored using scoring protocols for WBDOs, occurrence in water, and potential
health effects (both for general and sensitive populations). Data collected during CCL 3 and CCL
4 were not removed from consideration and remain on the CISs presented in Appendix F. If
found, new data were added, and scores were adjusted as necessary. EPA compiled data sources
identified from the CCL 3 and the CCL 4, along with data sources recommended by the CCL 5
EPA workgroup and subject matter experts. EPA accessed each potential data source and
evaluated them using the following assessment factors: relevance, completeness, redundancy,
and retrievability.

Section 5.1 Waterborne Disease Outbreak Data

To determine the WBDO score for CCL 3 and CCL 4, EPA utilized outbreak information from
CDC's MMWRs (CDC, 2017). For the CCL 5, EPA also included the CDC's NORS data for
outbreak information (Note: NORS was launched in 2009). CCL 3 and CCL 4 examined
outbreaks that occurred between 1990 and 2004. For CCL 5, EPA determined outbreaks that
occurred in and after 2009 to capture the microbes of concern.

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WBDOs are defined by CDC as:

•	Two or more people linked epidemiological^ by time, location of exposure to water, and
type of illness,

•	Epidemiologic evidence implicates water as the probable source of illness, and

•	Environmental evidence implicates water as the source of infection.

WBDOs were scored on a five-level hierarchy ranging from never caused a WBDO (score of 1)
to two or more documented WBDOs in the U.S. (score of 5) in the timeframe specified
(Table 3).

Table 3. Waterborne Disease Outbreak Scoring Protocol

Category

Score

Has caused multiple (2 or more) documented WBDOs in the U.S. reported by CDC
between 2009-2017

5

Has caused at least one documented WBDO in U.S. reported by CDC between 2009-
2017

4

Has caused documented WBDOs at any time in the U.S.

3

Has caused documented WBDOs in countries other than the U.S.

2

Has never caused WBDOs in any country, but has been epidemiologically associated with
water-related disease

1

Although WBDO data are useful tool for supporting the determination of microbial occurrence
and exposure routes, there are limitations of WBDO data.

Many WBDOs are speculated to not be reported and therefore not counted. There are many
possible circumstances that explain underreporting of WBDOs. For example, some people may
not seek health care for their illnesses. For those people that do, laboratory testing may not be
performed and if it is, the testing, does not always identify the microbe that caused the illness,
and even when a specific microbe is identified, healthcare providers might not report all illnesses
to public health agencies. In addition, surveillance, investigation, and reporting capacity varies
across states and localities. Furthermore, there are multiple routes of exposure for many
pathogens in addition to the drinking water pathway, such as through food, person-to-person, or
animal-to-person. Therefore, it can be difficult to link illness to exposure through drinking water.

Section 5.2 Occurrence Data

The second attribute of the scoring process evaluates the occurrence of a pathogen in drinking
water and source water. Because water-related illness may also occur in the absence of
recognized outbreaks, EPA scored the occurrence (direct detection) of microbes using cultural,
immunochemical, or molecular detection of pathogens in drinking water under the Occurrence
Protocol. Occurrence characterizes pathogen introduction, survival, and distribution in the
environment. Occurrence implies that pathogens are present in water and that they may be
capable of surviving and moving through water to cause illness in persons exposed to drinking
water by ingestion, inhalation, or dermal contact.

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Pathogen occurrence is considered broadly to include treated drinking water, and all waters using
a drinking water source for recreational purposes, groundwater, and surface water bodies. This
attribute does not characterize the extent to which a pathogen's occurrence poses a public health
threat from drinking water exposure. Occurrence was scored on a three-level hierarchy ranging
from not detected in the U.S. (score of 1) to detected in drinking water in the U.S. (score of 3)
(Table 4).

Table 4. Occurrence Scoring Protocol

Category

Score

Detected in drinking water in the U.S.

3

Detected in source water in the U.S.

2

Not detected in the U.S.

1

5.3 Health Risk Data

The health risk scoring protocol evaluated the extent of illness produced in humans from
drinking water. The severity of disease manifestations produced by a pathogen was evaluated
across a range of potential endpoints. Pathogens may produce a range of illness from
asymptomatic infection to severe illness progressing rapidly to death. The seven-level hierarchy
developed for this protocol begins with mild, self-limiting illness (score of 1) and progresses to
death (score of 7) (Table 5). The protocol scored the representative or more common clinical
presentation for the specific pathogen for the population category under consideration, rather
than the extremes. These scores were based on data from recent clinical microbiology manuals
(Carroll et al., 2019).

To obtain a representative characterization of health risk in all populations, EPA evaluated
separately the general population and four sensitive populations (children, elderly, pregnant
women, and persons with chronic diseases) as to the common clinical presentation of illness for
that population. EPA added the general population score to the highest score among the four
sensitive populations for an overall health risk score. The resulting score acknowledged that
sensitive populations have increased risk for waterborne diseases. Table 5 shows the health risk
scoring protocol template for general and sensitive populations.

Table 5. Health Risk Scoring Protocol for Pathogens





Manifestation in Population Class

Outcome Category

Score

General
Population

Children/
Infants

Elderly

Pregnant
Women

Chronic
Disease1

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Microbial Contaminants

Outcome Category

Score

Manifestation in Population Class

General
Population

Children/
Infants

Elderly

Pregnant
Women

Chronic
Disease1

Does the organism cause
significant mortality (>
1/1,000 cases)?

7











Does the organism cause
pneumonia, meningitis,
hepatitis, encephalitis,
endocarditis, cancer, or other
severe manifestations of illness
necessitating long term
hospitalization (> 1 week)?

6











Does the illness result in long
term or permanent dysfunction
or disability (i.e., sequelae)?

5











Does the illness require short
term hospitalization (< 1 week)?

4











Does the illness require
physician intervention?

3











Is the illness self-limiting
within 72 hours (without
requiring medical
intervention)?

2











Does the illness result in mild
symptoms with minimal or no
impact on daily activities?

1











1 Chronic diseases are defined broadly as conditions that last one year or more and require ongoing medical attention
or limit activities of daily living or both, such as heart disease, cancer, and diabetes (CDC,
https://www.cdc.gov/chronicdisease/about/index. htm).

EPA evaluated the possibility of using antibiotic susceptibility as part of the health risk scoring
protocol, and/or antibiotic resistance as scoring consideration for microbes as part of the review
process for the development of CCL 5. Each microbe on the PCCL was evaluated for its specific
antibiotic resistance and mortality rate. The results of the literature search showed that antibiotic
resistance cannot be used as a scoring consideration for microbes in the PCCL process at this
time because there was too much variability among individual microbes and across all microbial
groups to determine a criterion that would effectively apply to the universe of microbes.

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Section 5.4 Calculated Data Elements for PCCL Contaminants

The highest of the individual WBDO score or occurrence score was added to the normalized
health risk score to produce a composite score for each pathogen on the PCCL. Although the
composite score was not shown on the CISs, the scoring summary table at the top left corner of
each CIS shows the values used to calculate the composite score. The formula for the pathogen
score was as follows:

General Population
Pathogen _ Highest Score	Score + Highest

Total Score between WBDO +	Sensitive

and Occurrence \ \ Population

EPA normalized the health risk score so that occurrence (or WBDO) score and health risk score
had equal value in determining the ranking of the CCL. The highest possible score for WBDO or
occurrence was 5 and the highest possible health risk score was 14. To normalize this imbalance
in the calculated total score, the Agency multiplied the health risk score by 5/14. An example of
this calculation is shown in Appendix F.

The CISs that had been developed for CCL 3 were updated for each CCL 5 contaminant and new
CIS sheets were developed for those microbes not previously included. The references in the
CISs were also updated to reflect information that became available after EPA published the
final CCL 3 and CCL 4. Scores were based on new and previous data available for each CCL 5
contaminant. The CIS tables present the final scores for each of the data types under
consideration and a brief description of the data used to assign those scores with their respective
references. For more information on the microbes scoring process and the CISs, see Appendix F.

Section 5.5 PCCL 5 Composite Score Results

The 35 PCCL pathogens were ranked according to an equal weighting of their summed scores
for health risk and the greater of the individual scores for WBDO and occurrence in drinking
water. EPA determined that this ranking indicated the most important pathogens to consider for
the Final CCL 5. Table 6 displays the resulting composite scores collected from their respective
CISs for the 35 microbial contaminants on the PCCL 5.

Table 6. Scores for all the PCCL 5 Pathogens

Pathogen

Ranking

WBDO

Occurrence

Health1

Total score2

Naegleria fowleri

1

5

3

5.0

10.0

Legionella pneumophila

2

5

3

3.6

8.6



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Pathogen

Ranking

WBDO

Occurrence

Health1

Total score2

Escherichia coli (0157)

3

5

3

3.2

8.2

Pseudomonas aeruginosa

4

5

3

3.2

8.2

Helicobacter pylori

5

1

3

5.0

8.0

Campylobacter jejuni

6

5

3

2.5

7.5

Mycobacterium abscessus

7

4

3

3.2

7.2

Shigella sonnei

8

4

3

3.2

7.2

Caliciviruses

9

5

3

2.1

7.1

Mycobacterium avium

10

4

3

2.9

6.9

Adenovirus

11

2

3

3.6

6.6

Enterovirus

12

2

3

3.6

6.6

Pantoea agglomerans

13

4

3

2.5

6.5

Hepatitis A virus

14

3

2

3.2

6.2

Arcobacter butzleri

15

4

3

2.1

6.1

Fusarium solani

16

1

3

2.9

5.9

Nontuberculous Mycobacteria

17

3

3

2.9

5.9

Hepatitis E virus

18

2

1

3.6

5.6

Cyclospora cayetanensis

19

3

3

2.5

5.5

Rotavirus

20

2

3

2.5

5.5

Salmonella enterica

21

3

3

2.5

5.5

Toxoplasma gondii

22

2

1

3.2

5.2

Aspergillus fumigatus group

23

1

3

2.1

5.1

Entamoeba histolytica

24

3

3

2.1

5.1

Exophiala jeanselmei

25

1

3

2.1

5.1

Vibrio cholerae

26

3

3

2.1

5.1

Aeromonas hydrophila

27

1

3

1.8

4.8

Plesiomonas shigelloides

28

3

3

1.8

4.8

Blastocystis hominis

29

4

1

0.7

4.7

Acinetobacter baumannii

30

1

2

2.5

4.5

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Microbial Contaminants

Pathogen

Ranking

WBDO

Occurrence

Health1

Total score2

Comanonas testosteroni

31

1

2

2.5

4.5

Yersinia enterocolitica

32

3

3

1.4

4.4

Astrovirus

33

2

2

1.4

3.4

Microsporidia

34

1

2

1.4

3.4

Isospora belli

35

2

1

1.1

3.1

1 Normalized health score for that microbe

2Total Score = Normalized Health Score + the higher of WBDO or Occurrence.

Chapter 6 CCL 5 Microbes
6.1 Selecting CCL 5 Microbes

To determine which of the 35 PCCL pathogens should be the highest priority for EPA's drinking
water program and included on the CCL 5, EPA considered scientific factors and the opportunity
to advance public health protection. These factors included the PCCL scores for WBDO,
occurrence, and health risks; comments and recommendations from the various expert panels
including EPA's internal workgroup and CDC's subject matter experts; and the greatest
opportunity to advance public health protection. After consideration of these factors, EPA listed
the 12 highest-ranked pathogens for CCL 5 (Table 7). A comparison to previous CCLs to current
CCL can be found in Appendix D.

Table 7. The Final Microbial CCL 5

Microorganism

Type of Microorganism

Adenovirus

Virus

Caliciviruses

Virus

Campylobacter jejuni

Bacteria

Escherichia coli (0157)

Bacteria

Enteroviruses

Virus

Helicobacter pylori

Bacteria

Legionella pneumophila

Bacteria

Mycobacterium abscessus

Bacteria

Mycobacterium avium

Bacteria

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Microorganism

Type of Microorganism

Naegleria fowleri

Protozoa

Pseudomonas aeruginosa

Bacteria

Shigella sonnei

Bacteria

The selection of microbial pathogens for the Final CCL 5 was similar to the method used for
CCL 3 with the exception that there were no "natural" breaks in the pathogen scores, meaning
there were no large numerical gaps in the PCCL scores (as was for the previous PCCL 3
microbes) for the Final CCL 5 listing.

EPA determined that the overall rankings strongly reflected the best available scientific data
employed in the CCL selection process and reflect those contaminants that are known or
anticipated to occur in PWS with the greatest potential for public health concern.

Section 6.2 Supplemental Support for CCL 5 Microbial Contaminants

In addition to following the CCL microbial process that placed the microbial contaminants on the
CCL 5, this section provides supplemental information for each of the microbes listed for CCL 5.

Adenovirus

Adenoviruses are a large group of viruses that infect the gastrointestinal tract and are shed
through the intestines. Adenoviruses produce diverse symptoms, mostly causing respiratory tract
illnesses but they can cause gastrointestinal illness as well. Serious illnesses can also occur
including hemorrhagic colitis, hemorrhagic cystitis, and hepatitis (Lynch et al., 2011). There are
many different serotypes of adenoviruses. Reported sporadic cases and outbreaks of adenovirus
have resulted from exposure to several serotypes of adenoviruses, with types 40 and 41 being of
particular concern in drinking water (Chapron et al., 2000).

Adenoviruses have been found in raw sewage, surface water and groundwater drinking water
source waters (Mena, 2007). In most cases, human adenovirus reproduces in human cells;
therefore, any adenovirus present in water has a human source, most likely from wastewater
contamination (Jiang, 2006). Wastewater treatment plants and septic systems do not completely
remove viruses, so wastewater containing viruses can be discharged to surface water, sometimes
leading to waterborne outbreaks (Leclerc et al., 2002; Reynolds et al., 2008). Adenovirus is
susceptible to inactivation by free chlorine (Page et al., 2009); however, it is highly resistant to
inactivation by both monochloramine and ultraviolet light (Cromeans et al., 2010; USEPA,
2006c). The prevalence of these enteric adenoviruses in water sources and distribution systems
has long been underestimated because they are not easily detected by conventional cell culture
(WHO, 2011). In addition, adenoviruses can persist for extended periods of time outside of a
host (Mena and Gerba, 2009).

Adenoviruses continue to be a concern for PWSs that use a groundwater source and that do not
disinfect and/or systems that are inadequately disinfected. Borchardt et al. (2012) conducted a

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community intervention study of 14 communities with an undisinfected water supply and found
adenovirus in 13 percent of over 1,200 tap water samples using quantitative PCR (qPCR).
Adenovirus was also among the several pathogens identified in groundwater wells sampled
during the South Bass Island, Ohio outbreak in 2004 (Fong et al., 2007) and Chapron's et al.
(2000) study that detected infectious adenovirus 40 and adenovirus 41 in 14 of 29 surface water
samples.

Caliciviruses

Caliciviruses are a group of highly contagious viruses comprised of noroviruses and sapoviruses.
Noroviruses are small in size and have surface properties that are favorable to infiltrating through
subsurface matrices to contaminate groundwater (Fout et al., 2017). Environmental stability
allows norovirus to survive in groundwater and they are believed to remain infectious in
groundwater for months. Noroviruses can only be detected by real-time RT-qPCR, a specific
quantitative method (that is not a requirement of any regulation). Norovirus is the most common
cause of acute gastrointestinal illness (AGI) outbreaks. Borchardt et al.'s (2012) intervention
study found a statistically significant association between norovirus (and enterovirus)
concentrations measured by qPCR in tap water and AGI health effects in the 14 communities
with a water supply that does not disinfect. Caliciviruses remain a concern for groundwater
systems that do not disinfect and/or inadequately disinfected systems.

Campylobacter jejuni

As documented in the Campylobacter CIS, there were eight Campylobacter outbreaks from 2009
to 2017 reported in NORS. Campylobacter is a bacterial pathogen that lives in the intestines of
many wild and domestic animals. Campylobacter poses a risk to human health due to it being
widely distributed by bird (avian) and mammalian feces. In August 2016, New Zealand
experienced a large outbreak of campylobacteriosis that resulted in four deaths and 5,500
illnesses (including Guillain-Barre paralysis) in a large population consuming groundwater from
a system that does not disinfect. The outbreak is thought to have resulted from agricultural runoff
containing animal (sheep) fecal material contaminating a pond, with water from this
contaminated pond entering a nearby drinking water well through subsurface flow or through a
buried wellhead. Total coliform and Escherichia coli (E. coli) are not failsafe indicators of
Campylobacter contamination. E. coli 0157 and Campylobacter sometimes co-occur in
outbreaks because both are found in animal feces. Campylobacter jejuni is of concern for water
systems that do not disinfect and/or inadequately disinfected systems.

Escherichia coli (0157)

E. coli 0157:H7 produces toxins that can cause hemolytic uremic syndrome (HUS) and can lead
to kidney failure. Those most at risk for severe health outcomes from E.coli 0157 are children
(who are less than five years old), the elderly, and people with weakened immune systems (e.g.,
people who have cancer, HIV/AIDS, or had a transplant). Total coliform presence can signal a
contamination pathway however, E.coli 0157 is not detectable with standard E. coli analytical
methods and requires specialized growth media for testing.

Enterovirus

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Enteroviruses are a group of viruses that are shed via the fecal-oral route. The three most
common enteroviruses are coxsackievirus, echovirus, and poliovirus. Enteroviruses are linked to
myocarditis and epidemiological studies have shown a strong correlation between diabetes (type
1) and enterovirus infection (Krogvold et al., 2022). According to the Borchardt et al. (2012)
intervention study, enterovirus was one of the three viruses that was most frequently found in a
water supply that does not add disinfection. In addition, coxsackievirus is somewhat resistant to
chlorine disinfection (Kahler et al., 2010), therefore if residual chlorine disinfectant applied in
the distribution system is insufficient and/or residual is not maintained throughout the system,
the residual may not be sufficient to inactivate these viruses.

Helicobacter pylori

Helicobacter pylori (H. pylori) is readily inactivated by chlorine, and the presence of H. pylori in
U.S. finished drinking water has not been supported in recent literature; however, there is
evidence of the presence of H. pylori in U.S. source waters (Richards et al., 2018) and thus a
concern for groundwater systems that do not disinfect. H. pylori takes a long time to grow and
does not cause an immediate WBDO; it may take weeks to months to recognize disease caused
by H. pylori, therefore it is unlikely that a WBDO would be recognized and reported. Infection
with H. pylori is the strongest known risk factor for gastric cancer, which is the second leading
cause of cancer-related deaths worldwide.

Legionella pneumophila

Legionella pneumophila (L. pneumophila), a pathogenic bacterium, has been identified in
numerous WBDOs and is the most common cause of reported drinking water-associated illnesses
in the United States. Legionella has been found in finished water from drinking water treatment
plants and can persist and grow in biofilms within distribution systems (USEPA, 2016d).
L. pneumophila was detected in 25 percent of the source water samples and four percent of the
treated water samples in a study that screened for nine pathogens in source water and in treated
water at 25 treatment plants during 2010-2012 (King et al., 2016). Legionella bacteria can cause
a serious type of pneumonia (lung infection) called Legionnaires' disease. Reported
Legionnaires' disease has increased 10-fold in the last 20 years. The occurrence of Legionnaires'
disease is believed to be underreported and therefore greater in prevalence than reported. The
National Academies of Science report Management of Legionella in Water Systems estimated
52,000-70,000 cases of Legionnaires' disease annually, with 3-30 percent mortality (NASEM,
2020). Anyone can develop Legionnaires' disease; however, some risk factors put certain people
at greater risk such as being a smoker, male, and/or over 50 years of age.

Mycobacterium abscessus and Mycobacterium avium

Mycobacteria naturally occur in the environment and in water systems. Mycobacteria are
ubiquitous in natural waters and are found in wastewater, surface water, recreational water,
groundwater, and tap water. Mycobacterium can occur at high concentrations in drinking water
distribution system biofilms and are recognized as opportunistic pathogens. An illness caused by
Mycobacterium is not a nationally notifiable disease, therefore, the occurrence of disease is
difficult to measure and likely to be underestimated. Mycobacterium abscessus (M. abscessus)
and Mycobacterium avium (M. avium) are mycobacterial species that are clinically significant
(Donohue et al., 2016; Donohue, 2018) withM avium as the most prevalent Mycobacterium in
drinking water (Falkinham et al., 2015). Health effects are typically related to lung infections and

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occur primarily in those with suppressed immune systems, underlying respiratory conditions, or
in the very young or the elderly.

Naegleria fowleri

Naegleria fowleri (N. fowleri) is a free-living thermophilic amoeba found in warm freshwaters
(e.g., rivers, lakes), hot springs, and soil. Infection from TV. fowleri causes sudden onset primary
amebic meningoencephalitis (PAM), a severe disease of the central nervous system that occurs
when water containing the amoeba enters the nasal cavity, migrates to the brain, multiplies, and
destroys host tissue and causes inflammation. Although infection from N. fowleri is rare, the
mortality rate of PAM is greater than 90 percent (Baig et al., 2014). There have been cases of
PAM linked to domestic water supplies (Cope et al., 2015). Two people were infected after
performing nasal irrigation using contaminated tap water, and one person was infected by
contaminated tap water used on a backyard slip-n-slide.

Treating drinking water with chlorine is an effective measure to manage N. fowleri in the
drinking water distribution system, however, the loss of disinfectant residual can cause poorly
chlorinated sections to be susceptible to colonization by N. fowleri (Morgan et al., 2016). Many
factors can lead to entry of N. fowleri into drinking water distribution systems, such as pipe
breaks and pressure fluctuations.

Pseudomonas aeruginosa

Pseudomonas aeruginosa (P. aeruginosa) is ubiquitous in the environment, including in water,
soil, plants, animals, and food. Pseudomonas species are an opportunistic pathogen that can grow
in the distribution system (WHO, 2011). P. aeruginosa causes a range of infections but does not
usually cause serious disease in healthy individuals. Any type of human tissue compromised by
illness or injury, such as burn and surgical wounds, is susceptible to infection by P. aeruginosa.
This bacterium may invade the body, causing destructive lesions, septicemia, or meningitis
(WHO, 2011). Pseudomonas has caused severe infections in people who are immunosuppressed
or immunocompromised and in those with underlying disease. Infections typically present as
bacteremia in immunocompromised individuals; as pneumonia in cystic fibrosis patients; as
community-acquired ear and pneumonia infections; and as hospital-acquired outbreaks caused by
contaminated solutions or devices. Water is the source of infection in all four of these types of
infections (Falkinham et al., 2015). Tap water has been documented as a potential source of
infection from P. aeruginosa in hospital and healthcare settings and in swimming pools and hot
tubs that have not been adequately treated (WHO, 2011). The role of tap water as the source of
P. aeruginosa disease has been established through direct contact with water and aerosols,
aspiration, indirect transfer from moist environmental surfaces, or on the hands of healthcare
workers.

Shigella sonnei

Shigella sonnei is a bacterial pathogen that spreads through the oral-fecal route in humans.
Shigella is associated with bloody diarrhea and like E. coli 0157:H7, it produces toxins that can
cause hemolytic uremic syndrome (HUS), leading to potential chronic kidney disease in children
and the elderly. Shigella contamination results from human fecal contamination and is a lesser
problem than E.coli contamination (which has both human and animal sources, especially
bovines). Although, human fecal contamination is much less common than animal fecal
contamination, it has resulted in outbreaks in public water systems that do not add disinfection.

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Shigella has been linked to 20 groundwater outbreaks in the U.S. between 1971 and 2008
(Wallender et al., 2014).

Section 6.3 Microorganisms Covered by Existing Regulations

According to Section 1412(b)(1) of the 1996 SDWA Amendments, EPA must select CCL
contaminants that "at the time of publication, are not subject to any proposed or promulgated
national primary drinking water regulation." In promulgating regulations for contaminants in
drinking water, EPA can set either a legal limit (maximum contaminant level or MCL) and
require monitoring for the contaminant in drinking water or, for those contaminants that are
difficult to measure, EPA can establish a treatment technique requirement. The Surface Water
Treatment Rule (SWTR) (54 FR 27486, USEPA, 1989a) established maximum contaminant
level goals (MCLGs) of zero for Legionella, Giardia, and viruses because any amount of
exposure to these contaminants represents some public health risk. Since measuring disease-
causing microbes in drinking water was not considered to be feasible at the time of the
development of the SWTR, EPA established treatment technique requirements for these
contaminants. The purpose of subsequent treatment technique requirements (Interim Enhanced
Surface Water Treatment Rule (63 FR 69478, USEPA 1998a), Long Term 1 Surface Water
Treatment Rule (67 FR 1813, USEPA, 2002a), and the Long Term 2 Surface Water Treatment
Rule (71 FR 654, USEPA, 2006a), which included an MCLG of zero for Cryptosporidium, is to
reduce disease incidence associated with Cryptosporidium and other pathogenic microorganisms
in drinking water. These rules apply to all public water systems that use surface water or
groundwater under the direct influence of surface water.

The Ground Water Rule (GWR) (71 FR 65573; USEPA, 2006) set treatment technique
requirements to control for viruses (and pathogenic bacteria) because it was not feasible to
monitor for viruses (or pathogenic bacteria) in drinking water. Under the GWR, if systems detect
total coliforms in the distribution system, they are required to monitor for a fecal indicator
(E. coh, coliphage, or enterococci) in the source water. If fecal contamination is found in the
source water, the system must take remedial action to address contamination.

EPA considered Legionella and specific viruses in CCL even though they are regulated under the
SWTR. EPA listed Legionella pneumophila, the primary pathogenic bacterium, on the Final
CCL 5 because it has been identified in numerous WBDOs and is the most common cause of
reported drinking water-associated outbreaks in the U.S.

EPA also listed certain viruses on the Final CCL 5. Viruses include a wide range of taxa and
different viral taxa have been implicated in various WBDOs for which EPA did not have dose
response or treatment data when promulgating its treatment technique requirements.

Even though there are MCLGs for Legionella and viruses, and these contaminants are subject to
limitations as a class through the treatment techniques under the SWTRs, there are no
monitoring, treatment, or notification requirements within those NPDWRs that are specific to
Legionella pneumophila, or the specific viruses listed on CCL5 (although systems may use
coliphage for source water monitoring for groundwater systems). Therefore, EPA considers
Legionella pneumophila and the specific viruses listed on CCL5 to be unregulated contaminants
for purposes of eligibility for the CCL. Additionally, EPA received public nomination for viruses

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and Legionella for the CCL 5, with Legionella pneumophila receiving the highest number of
nominations.

Section 6.4 Listing Outcomes for the Nominated Microbial Contaminants

All of the microbes nominated for the CCL 5, except for Salmonella enterica, Aeromonas
hydrophila, and Hepatitis A, were listed on the CCL 5. Salmonella enterica, Aeromonas
hydrophila and Hepatitis A did not produce sufficient composite scores to place them on the
CCL 5. Although Salmonella enterica and Hepatitis A have numerous WBDOs, the route of
exposure was not reported as waterborne. Non-tuberculous Mycobacteria (NTM) and
Mycobacterium (species broadly found in drinking water) were nominated for the CCL 5 and
were not listed on the CCL 5 as a group; instead, they were listed as Mycobacterium avium and
Mycobacterium abscessus, two species of NTM that are found in drinking water.

Chapter 7 Microbial Data Sources for the Final CCL 5

Multiple data sources were used to gather the information for the development of the Final
CCL 5. The data sources used were evaluated by EPA to ensure they were authoritative and
appropriate. Under the CCL 3, for microbes, the universe list was defined as all known human
pathogens using the compilation of Taylor et al. (2001) as a practical starting point. This list was
supplemented with literature searches and nominations from the public. The Final CCL 5 used
the previous universes from the CCL 3 and the CCL 4 and was updated with literature searches
of peer-reviewed sources and nominations.

The hierarchy of text-based resource materials begin with recently compiled authoritative
reference books such as Manual of Clinical Microbiology (MCM), 9th Edition, and Field's
Virology, 5th Edition, both published in 2007. Both of these two-volume reference books have
become established as the leading authoritative reference sources in their respective fields. These
references have evolved through multiple editions and both publications are considered reference
standards to the scientific community for their scope and depth of coverage. They were edited by
world-recognized authorities, and chapters were written by an international team of subject
experts. The Parasites of Homo sapiens, second edition, is a comprehensive source for
information on helminths. These and other compiled sources listed in the reference list provided
the information for screening the pathogens in the microbial CCL 3 Universe. The 12th edition of
the MCM was published in 2019 and was consulted for CCL 5 (Carroll et al., 2019).

Web references were used to find information for screening rarely encountered viruses, protozoa,
and fungi, primarily for information related to Criterion 9, "natural habitat in the environment,"
and to Criterion 10, "pathogen not endemic to North America". Selected web references were
evaluated to ensure that the site sponsors possessed the expertise to authoritatively address the
issues of habitat and geographical distribution of the pathogen in question, and that the
information was presented objectively and reviewed by members of the scientific community.
Emphasis was placed upon websites sponsored and supported by government agencies or
academic institutions, with evidence of peer review, such as an editorial board and/or expert
contributors and reviewers.

Appendix B tabulates the screening decisions for the CCL 5 Microbial Universe and shows the
screening reference used to support the decision. The web addresses/links provided are as narrow
and specific as they can be, to identify the information related to the screening criterion used.

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Many pathogens could be screened by several criteria, however only one criterion is noted in the
tabulation. Understanding the complete context and rationale for a screening decision often
requires a review of the complete chapter.

The MCM (Carroll et al., 2019) was one of the main sources of information used to inform the
scoring of the PCCL microbes for the Final CCL 5. EPA also conducted a literature search
covering the time between CCL 4 and CCL 5 (2016-2019). The literature search focused on
health risks and occurrence of the nominated microbial contaminants in water.

For CCL 5 WBDOs, the primary source for scoring data was outbreak information pulled from
CDC's NORS dashboard. Outbreak information was available from 2009-2017. NORS data was
used as an alternative to CDC's MMWRs for more recent outbreak data (as of August 2019, the
most recent MMWR report was published in 2017, documenting reported outbreaks from 2014).
Appendix F contains additional detail on data sources.

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in the United States. Reviews of Environmental Contamination and Toxicology, pp. 117-158.

Richards, C.L., S.C. Broadaway, M.J. Eggers, J. Doyle, B.H. Pyle, A.K. Camper, and T.E. Ford.
2018. Detection of Pathogenic and Non-pathogenic Bacteria in Drinking Water and Associated
Biofilms on the Crow Reservation, Montana, USA. Microbiology Ecology. 76(1): 52-63. doi:
10.1007/s00248-015-0595-6.

Page 29 of 31


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EPA-Office of Water

Technical Support Document for the
Final Fifth Contaminant Candidate List (CCL 5)-
Microbial Contaminants

EPA 815-R-22-004
October 2022

Sharp, C.P., M. Vermeulen, Y. Nebie, C. F. Djoko, M. LeBreton, U. Tamoufe, A.W. Rimoin, P.
K. Kayembe, J. K. Carr, A. Servant-Delmas, S. Laperche, G.L. Abby Harrison, O.G. Pybus, E.
Delwart, N.D. Wolfe, A. Saville, Jean-Jacques Lefrere, and P. Simmonds. 2010. Changing
epidemiology of human parvovirus 4 infection in sub-Saharan Africa. Emerging Infectious
Diseases. (16)10: 1605-1607. doi: 10.3201/eidl610.101001.

Taylor, L.H., S.M. Latham, and M.E. Woolhouse. 2001. Risk factors for human disease
emergence. Philosophical Transactions of the Royal Society of London, Volume 356, Series B:
Biological Sciences, pp. 983-989.

Tyler, K.T., E.S. Barton, M.L. Ibach, C. Robinson, J.A. Campbell, S.M. O'Donnell, T. Valyi-
Nagy, P. Clarke, J.D. Wetzel, and T.S. Dermody. 2004. Isolation and molecular characterization
of a novel type 3 reovirus from a child with meningitis. Journal of Infectious Diseases. 189(9):
1664-1675.

United States Environmental Protection Agency (USEPA). 1989. National Primary Drinking
Water Regulations; Filtration, Disinfection; Turbidity, Giardia Lamblia, Viruses, Legionella, and
Heterotrophic Bacteria; Final Rule. Part III. 54 FR 27486. June 29, 1989.

USEPA. 1998a. Announcement of the Drinking Water Contaminant Candidate List; Notice. 63
FR 10274. March 2, 1998.

USEPA. 1998b. Interim Enhanced SurfaceWater Treatment; Final Rule. 63 FR 69478.

December 16, 1998.

USEPA. 2002. Long Term 1 Enhanced SurfaceWater Treatment Rule; Final Rule. 67 FR 1812
January 14, 2002.

USEPA. 2005. Drinking water Contaminant Candidate List 2; Final Notice. 70 FR 9071.
February 24, 2005.

USEPA. 2006a. Long Term 2 Enhanced Surface Water Treatment Rule; Final Rule. 71 FR 654.
January 5, 2006.

USEPA. 2006b. National Primary Drinking Water Regulations: Ground Water Rule; Final
Rule.71 FR 65573. November 8, 2006.

USEPA. 2006c. Ultraviolet Disinfection Guidance Manual for the Final Long Term 2 Enhanced
Surface Water Treatment Rule. EPA 815-R-06-007. November 2006.

USEPA. 2009a. Drinking Water Contaminant Candidate List 3; Final Notice. 74 FR 51850.
October 18, 2009.

USEPA. 2009b. Final Contaminant Candidate List 3 Microbes: Screening to the PCCL. EPA
815-R-09-0005. August 2009.

USEPA. 2009c. Final Contaminant Candidate List 3 Microbes: PCCL to CCL Process. EPA 815-
R-09-009. August 2009.

USEPA. 2016a. Drinking Water Contaminant Candidate List 4—Final. 81 FR 81099. November
17, 2016.

USEPA. 2016b. Screening Document for the Fourth Preliminary Contaminant Candidate List 4
(PCCL 4). EPA 815-R-16-008. November 2016.

Page 30 of 31


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EPA-Office of Water

Technical Support Document for the
Final Fifth Contaminant Candidate List (CCL 5)-
Microbial Contaminants

EPA 815-R-22-004
October 2022

USEPA. 2016c. Response to the Science Advisory Board's Recommendations on the Draft
Fourth Contaminant Candidate List (CCL 4). EPA 815-R-16-005. November 2016.

USEPA. 2016d. Technologies for Legionella control in Premise Plumbing Systems: Scientific
Literature Review. EPA 810-R-16-001. September 2016.

USEPA. 2018. Request for Nominations of Drinking Water Contaminants for the Fifth
Contaminant Candidate List. 83 FR 50364. October 5, 2018.

USEPA. 2022. Technical Support Document for the Final Fifth Contaminant Candidate List
(CCL 5) - Chemical Contaminants. EPA 815-R-22-002. September 2022.

Wallender, E.K., E.C. Ailes, J.S. Yoder, V.A. Roberts, and J.M. Brunkard. 2014. Contributing
factors to disease outbreaks associated with untreated groundwater. Groundwater. 52(6): 886-
897.

Wenzel, R.P. (ed.). 2003. Prevention and control of nosocomial infections. Lippincott Williams
& Wilkins, Philadelphia, PA.

World Health Organization (WHO). 2011. Guidelines for drinking-water quality, 4th Edition.
World Health Organization, Geneva.

Page 31 of 31


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EPA-Office of Water

Technical Support Document for the
Final Fifth Contaminant Candidate List (CCL 5)-
Microbial Contaminants

EPA 815-R-22-004
October 2022

Appendix A: List of CCL 5 Microbial Nominations

Common Name

Nominator(s)

Health Risk
Information
Provided with
Nomination

Occurrence
Information
Provided with
Nomination

Additional

Information Provided
with Nomination

CCL
Universe

PCCL5

Final

CCL 5

Aeromonas hydrophila

C.J. Volk

No information
provided

No information
provided

No information
provided

X

X



Adenovirus*

G. Tracy Mehan, AWWA

No information
provided

No information
provided

No information
provided

X

X

X

Caliciviruses*

G. Tracy Mehan, AWWA

No information
provided

No information
provided

No information
provided

X

X

X

Campylobacter jejuni*

C.J. Volk

No information
provided

No information
provided

No information
provided

X

X

X

G. Tracy Mehan, AWWA

No information
provided

No information
provided

No information
provided

CCL 4 contaminants (12
microbes)*

Mae Wu and Anna Reade,
NRDC

Known public health
threats.

No information
provided

No information
provided

X

X



Enterovirus*

G. Tracy Mehan, AWWA

No information
provided

No information
provided

No information
provided

X

X

X

Escherichia coli (0157)*

C.J. Volk

No information
provided

No information
provided

No information
provided

X

X

X

G. Tracy Mehan, AWWA

No information
provided

No information
provided

No information
provided

Helicobacter pylori *

C.J. Volk

No information
provided

No information
provided

No information
provided

X

X

X

G. Tracy Mehan, AWWA

No information
provided

No information
provided

No information
provided

Hepatitis A virus*

G. Tracy Mehan, AWWA

No information
provided

No information
provided

No information
provided

X

X



Legionella pneumophila *a

Anonymous

No information
provided

Typically found in
biofilms

No information
provided

X

X

X

Paul McDermott, PJM-HS
Consulting Ltd

No information
provided

No information
provided

No information
provided

Jason Dobranic, EMSL

No information

No information

No information

Page A1


-------
EPA-Office of Water

Technical Support Document for the
Final Fifth Contaminant Candidate List (CCL 5)-
Microbial Contaminants

EPA 815-R-22-004
October 2022

Common Name

Nominator(s)

Health Risk
Information
Provided with
Nomination

Occurrence
Information
Provided with
Nomination

Additional

Information Provided
with Nomination

CCL
Universe

PCCL5

Final

CCL 5



Analytical, Inc.

provided

provided

provided









Matthew Freije, hcinfo.com

No information
provided

No information
provided

No information
provided









Anonymous

No information
provided

No information
provided

No information
provided









Cam Pham, Enthalpy
Analytical, LLC

No information
provided

No information
provided

No information
provided









W.E. Pearson II, BPEARSON
Consulting LLC

No information
provided

No information
provided

No information
provided









C.J. Volk

No information
provided

No information
provided

No information
provided









Sharon Sweeney, Central
Arkansas Water

No information
provided

No information
provided

No information
provided









Philippe Hartemann

No information
provided

No information
provided

No information
provided









Anonymous

No information
provided

No information
provided

No information
provided









Patsy Root, IDEXX
Laboratories, Inc.

No information
provided

No information
provided

No information
provided









Paul R. Easley, Central
Arkansas Water

No information
provided

No information
provided

No information
provided









Stan Hazan, NSF

According to the
CDC, reported cases
of

legionella increased
286% during the time
period 2000-2014.

The bacterium is
known to propagate in
premise plumbing and
other mechanical
systems. This places
the elderly and
individuals with
compromised immune
systems at risk when
water contaminated
with the bacteria
aerosolizes and
disperses.

No information
provided









Robert Bohannon, City of

No information

No information

No information







Page A2


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EPA-Office of Water

Technical Support Document for the
Final Fifth Contaminant Candidate List (CCL 5)-
Microbial Contaminants

EPA 815-R-22-004
October 2022

Common Name

Nominator(s)

Health Risk
Information
Provided with
Nomination

Occurrence
Information
Provided with
Nomination

Additional

Information Provided
with Nomination

CCL
Universe

PCCL5

Final

CCL 5



Moline, Illinois

provided

provided

provided







Mae Wu and Anna Reade,
NRDC

No information
provided

No information
provided

No information
provided

G. Tracy Mehan, AWWA

No information
provided

No information
provided

No information
provided

Jennifer Clancy, ESPRI

There are 8,000 to
18,000 people
hospitalized with LD
each year and
estimates of ten times
that many cases that
are unrecognized.
CDC estimates that it
costs $434,000,000
to treat LD in the US
annually; LD is now
the #1 cause of
WBDOs in the US
(CDC, 2015).

Based on CDC
outbreak data, LD is
responsible for 66% of
waterborne disease
outbreaks (WBDO)
attributable to the
distribution system.

No information
provided

Mycobacterium avium *

C.J. Volk

No information
provided

No information
provided

No information
provided

X

X

X

G. Tracy Mehan, AWWA

No information
provided

No information
provided

No information
provided

Mycobacterium species
predominantly found in finished
drinking water

Anonymous

No information
provided

Typically found in
biofilms

No information
provided

X





Naegleria fowleri *

G. Tracy Mehan, AWWA

No information
provided

No information
provided

No information
provided

X

X



Nontuberculous mycobacteria

(NTM)

Jennifer Clancy, ESPRI

Pseudomonas
aeruginosa which is
the most common
cause of hospital-
acquired pneumonia
and nontuberculous
mycobacteria (NTM),
an increasing cause
of lung infections in
both

In the chloraminated
system, NTM
colonized the pipe
loops by the first
sampling round and
continued to be
observed in the bulk
water of all pipe
materials, with greater
numbers recovered

No information
provided

X

X



Page A3


-------
EPA-Office of Water

Technical Support Document for the
Final Fifth Contaminant Candidate List (CCL 5)-
Microbial Contaminants

EPA 815-R-22-004
October 2022

Common Name

Nominator(s)

Health Risk
Information
Provided with
Nomination

Occurrence
Information
Provided with
Nomination

Additional

Information Provided
with Nomination

CCL
Universe

PCCL5

Final

CCL 5





immunocompromise
d and otherwise heath
individuals.

consistently from the
high use pipe loops.









Pseudomonas aeruginosa

Anonymous



Typically found in
biofilms



X

X

X

C.J. Volk

No information
provided

No information
provided

No information
provided

Jennifer Clancy, ESPRI

Pseudomonas
aeruginosa which is
the most common
cause of hospital-
acquired pneumonia
and nontuberculous
mycobacteria (NTM),
an increasing cause
of lung infections in
both

immunocompromise
d and otherwise heath
individuals.

No information
provided

No information
provided

Salmonella enterica*

C.J. Volk

No information
provided

No information
provided

No information
provided

X

X



G. Tracy Mehan, AWWA

No information
provided

No information
provided

No information
provided

Shigella sonnei *

C.J. Volk

No information
provided

No information
provided

No information
provided

X

X

X

G. Tracy Mehan, AWWA

No information
provided

No information
provided

No information
provided

*CCL 4 microbes

Page A4


-------
EPA-Office of Water

Technical Support Document for the
Final Fifth Contaminant Candidate List (CCL 5)-
Microbial Contaminants

Appendix B: The CCL 5 Microbial Universe

The CCL 5 Microbial Universe

Table B-l presents the CCL 5 Universe and the exclusion criteria used to keep a microbe in the
universe. The source used for the exclusion criteria is listed in the reference column. Those
microbes for which a source could not found to support exclusion moved forward to the PCCL.

The CCL 5 Microbes Exclusion Screening Criteria:

1.	All anaerobes.

2.	Obligate intracellular fastidious pathogens.

3.	Transmitted by contact with blood or body fluids.

4.	Transmitted by vectors.

5.	Indigenous to the gastrointestinal tract, skin and mucous membranes.

6.	Transmitted solely by respiratory secretions.

7.	Life cycle incompatible with drinking water transmission.

8.	Drinking water-related transmission is not implicated.

9.	Natural habitat is in the environment without epidemiological evidence of drinking water-related
disease and without evidence of drinking water-related nosocomial infection.

10.	Not endemic to North America.

11.	Represented by a pathogen for the entire genus or species (that are closely related).

12.	Current taxonomy changed from taxonomy used in Universe.

Page B1


-------
EPA-Office of Water

Technical Support Document for the
Final Fifth Contaminant Candidate List (CCL 5)-
Microbial Contaminants

EPA 815-R-22-004
October 2022

Table B-l: The CCL 5 Microbial Universe and Exclusion Criteria

Bacteria

1

2

3

4

5

6

7

8

9

10

11

12

PCCL

Reference

Abiotrophies defectiva









X

















MCM-12th Edition

Achromobacter piechaudii

















X









MCM-12th Edition

Achromobacter
xvlosoxidans

















X









MCM-12th Edition

Acidaminococcus
fermentans

X

























MCM-12th Edition

Acinetobacter baumannii

























Acinetobacter baumannii



Acinetobacter
calcoaceticus

















X









MCM-12th Edition

Acinetobacter
haemolvticus

















X









MCM-12th Edition

Acinetobacter johnsonii

















X









MCM-12th Edition

Acinetobacter junii

















X









MCM-12th Edition

Acinetobacter hvoffii

















X









MCM-12th Edition

Acinetobacter
radioresistens

















X









MCM-12th Edition

Actinobacillus equuli





X





















MCM-12th Edition

Actinobacillus hominis





X





















MCM-12th Edition

Actinobacillus lignieresii





X





















MCM-12th Edition

Page B1


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EPA-Office of Water	Technical Support Document for the	EPA 815-R-22-004

Final Fifth Contaminant Candidate List (CCL 5)-	October 2022

Microbial Contaminants

Bacteria

1

2

3

4

5

6

7

8

9

10

11

12

PCCL

Reference

Actinobacillus
pleuropneumoniae





X





















MCM-12th Edition

Actinobacillus suis





X





















MCM-12th Edition

Actinobacillus ureae









X

















MCM-12th Edition

Actinomyces georgiae

X

























MCM-12th Edition

A ctinomyces gerencseriae

X

























MCM-12th Edition

Actinomyces israelii

X

























MCM-12th Edition

Actinomyces meveri

X

























MCM-12th Edition

A ctinomyces naeslundii

X

























MCM-12th Edition

Actinomyces neuii

X

























MCM-12th Edition

Actinomyces odontolvticus

X

























MCM-12th Edition

Actinomyces radingae

X

























MCM-12th Edition

Actinomyces turicensis

X

























MCM-12th Edition

Aerococcus viridans

















X









MCM-12th Edition

Aeromonas caviae

















X









MCM-12th Edition

Aeromonas hvdrophila

























Aeromonas hvdrophila



Aeromonas sobria

















X









MCM-12th Edition

Aeromonas veronii

















X









MCM-12th Edition

Aggregatibacter
actinomycetemcomitans







X

















MCM-12th Edition

Aggregatibacter
aphrophilus









X

















MCM-12th Edition

Page B2


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EPA-Office of Water	Technical Support Document for the	EPA 815-R-22-004

Final Fifth Contaminant Candidate List (CCL 5)-	October 2022

Microbial Contaminants

Bacteria

1

2

3

4

5

6

7

8

9

10

11

12

PCCL

Reference

Alcaligenes odor an s









X

















MCM-12th Edition

Alloprevotella tannerae

X

























MCM-12th Edition

A lloscardovia omnicolens









X

















Brown, M et al.. 2016

Amvcolatopsis orientalis

















X









MCM-12th Edition

Anaplasma
phagocvtophilum







X



















MCM-12th Edition

Arcanobacterium
heamolvticum









X

















MCM-12th Edition

Arcobacter butzleri

























Arcobacter butzleri



Arcobacter crvaerophilus





















X





MCM-12th Edition

Bacillus anthracis

















X









MCM-12th Edition

Bacillus cereus

















X









MCM-12th Edition

Bacillus circulans

















X









MCM-12th Edition

Bacillus coagulans

















X









MCM-12th Edition

Bacillus licheniformis

















X









MCM-12th Edition

Bacillus mvcoides

















X









MCM-12th Edition

Bacillus pumilus

















X









MCM-12th Edition

Bacillus subtilis

















X









MCM-12th Edition

Bacillus thuringiensis

















X









MCM-12th Edition

Bacteroides caccae

X

























MCM-12th Edition

Bacteroides eggerthii

X

























MCM-12th Edition

Bacteroides fragilis

X

























MCM-12th Edition

Page B3


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EPA-Office of Water	Technical Support Document for the	EPA 815-R-22-004

Final Fifth Contaminant Candidate List (CCL 5)-	October 2022

Microbial Contaminants

Bacteria

1

2

3

4

5

6

7

8

9

10

11

12

PCCL

Reference

Bacteroides
galacturonicus

X

























MCM-H^ Edition

Bacteroides ovatus

X

























MCM-H^ Edition

Bacteroides pectinophilus

X

























MCM-H^ Edition

Bacteroides stercoris

X

























MCM-H^ Edition

Bacteroides
thetaiotaomicron

X

























MCM-H^ Edition

Bacteroides uniformis

X

























MCM-H^ Edition

Bacteroides vulgatus

X

























MCM-H^ Edition

Bartonella bacilliformis







X



















MCM-H^ Edition

Bartonella elizabethae







X



















MCM-H^ Edition

Bartonella henselae







X



















MCM-H^ Edition

Bartonella quintana







X



















MCM-H^ Edition

Bergeyella zoohelcum









X

















MCM-H^ Edition

Bifidobacterium dentium

X

























MCM-H* Edition

Bilophila wadsworthia

X

























MCM-H* Edition

Blautia producta

X

























MCM-H* Edition

Bordetella avium











X















MCM-H* Edition

Bordetella bronchiseptica











X















MCM-H* Edition

Bordetella parapertussis











X















MCM-H* Edition

Bordetella pertussis











X















MCM-H* Edition

Borrelia brasiliensis







X



















MCM-H* Edition

Page B4


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EPA-Office of Water	Technical Support Document for the	EPA 815-R-22-004

Final Fifth Contaminant Candidate List (CCL 5)-	October 2022

Microbial Contaminants

Bacteria

1

2

3

4

5

6

7

8

9

10

11

12

PCCL

Reference

Borrelia burgdorferi







X



















MCM-12th Edition

Borrelia caucasica







X



















MCM-12th Edition

Borrelia crocidurae







X



















MCM-12th Edition

Borrelia duttonii







X



















MCM-12th Edition

Borrelia hermsii







X



















MCM-12th Edition

Borrelia hispanica







X



















MCM-12th Edition

Borrelia latvschewii







X



















MCM-12th Edition

Borrelia mazzottii







X



















MCM-12th Edition

Borrelia parkeri







X



















MCM-12th Edition

Borrelia persica







X



















MCM-12th Edition

Borrelia recurrentis







X



















MCM-12th Edition

Borrelia turicatae







X



















MCM-12th Edition

Borrelia venezuelensis







X



















MCM-12th Edition

Bre\'ibacillus brevis

















X









MCM-12th Edition

Bre\'imdimonas diminuta

















X









MCM-12th Edition

Bre\'imdimonas
vesicularis

















X









MCM-12th Edition

Brucella melitensis



X























MCM-12th Edition

Burkholderia cepacia

















X









MCM-12th Edition

Burkholderia mallei



















X







MCM-12th Edition

Burkholderia
pseudomallei

















X









MCM-12th Edition

Page B5


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EPA-Office of Water	Technical Support Document for the	EPA 815-R-22-004

Final Fifth Contaminant Candidate List (CCL 5)-	October 2022

Microbial Contaminants

Bacteria

1

2

3

4

5

6

7

8

9

10

11

12

PCCL

Reference

Campylobacter coli





















X





MCM-12th Edition

Campylobacter concisus









X

















MCM-12th Edition

Campylobacter cur\>us









X

















MCM-12th Edition

Campylobacter fetus















X











MCM-12th Edition

Campylobacter gracilis









X

















MCM-12th Edition

Campylobacter
hvointestinalis















X











MCM-12th Edition

Campylobacter jejuni

























Campylobacter jejuni



Campylobacter lari





















X





MCM-12th Edition

Campylobacter rectus









X

















MCM-12th Edition

Campylobacter sputorum















X











MCM-12th Edition

Campylobacter
upsaliensis















X











MCM-12th Edition

Campylobacter
ureolyticus

X

























MCM-12th Edition

Capnocytophaga
canimorsus









X

















MCM-12th Edition

Capnocytophaga
cynodegmi









X

















MCM-12th Edition

Capnocytophaga
gingivalis









X

















MCM-12th Edition

Capnocytophaga
ochracea









X

















MCM-12th Edition

Page B6


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EPA-Office of Water	Technical Support Document for the	EPA 815-R-22-004

Final Fifth Contaminant Candidate List (CCL 5)-	October 2022

Microbial Contaminants

Bacteria

1

2

3

4

5

6

7

8

9

10

11

12

PCCL

Reference

Capnocytophaga
sputigena









X

















MCM-12th Edition

Cardiobacterium hominis









X

















MCM-12th Edition

Cedecea davisae

















X









MCM-12th Edition

Cedecea lapagei

















X









MCM-12th Edition

Cedecea neteri

















X









MCM-12th Edition

Cellulomonas turbata

















X









MCM-12th Edition

Cellulosimicrobium
cellulans

















X









MCM-12th Edition

Centipede/ periodontii

X

























MCM-12th Edition

Chlamydia trachomatis





X





















MCM-12th Edition

Chlamydophila
pneumoniae



X























MCM-12th Edition

Chlamydophila psittaci



X























MCM-12th Edition

Chromobacterium
violaceum















X











MCM-12th Edition

Chryseobacterium
balustinum

















X









MCM-12th Edition

Citrobacter amalonaticus









X

















MCM-12th Edition

Citrobacter braakii









X

















MCM-12th Edition

Citrobacter farmeri









X

















MCM-12th Edition

Citrobacter freundii









X

















MCM-12th Edition

Citrobacter koseri









X

















MCM-12th Edition

Page B7


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EPA-Office of Water	Technical Support Document for the	EPA 815-R-22-004

Final Fifth Contaminant Candidate List (CCL 5)-	October 2022

Microbial Contaminants

Bacteria

1

2

3

4

5

6

7

8

9

10

11

12

PCCL

Reference

Citrobacter rodentium









X

















MCM-12th Edition

Citrobacter sedlakii









X

















MCM-12th Edition

Citrobacter werkmanii









X

















MCM-12th Edition

Citrobacter voungae









X

















MCM-12th Edition

Clostridium baratii

X

























MCM-12th Edition

Paraclostridium
bifermentans

X

























MCM-12th Edition

Clostridium botulinum

X

























MCM-12th Edition

Clostridium butvricum

X

























MCM-12th Edition

Clostridium chauvoei

X

























MCM-12th Edition

Clostridoides difficile

X

























MCM-12th Edition

Clostridium fallax

X

























MCM-12th Edition

Clostridium histolvticum

X

























MCM-12th Edition

Clostridium novvi

X

























MCM-12th Edition

Clostridium perfringens

X

























MCM-12th Edition

Clostridium ramosum

X

























MCM-12th Edition

Clostridium septicum

X

























MCM-12th Edition

Clostridium sordellii

X

























MCM-12th Edition

Clostridium sporogenes

X

























MCM-12th Edition

Clostridium tertium

X

























MCM-12th Edition

Clostridium tetani

X

























MCM-12th Edition

Collinsella aerofaciens

X

























MCM-12th Edition

Page B8


-------
EPA-Office of Water	Technical Support Document for the	EPA 815-R-22-004

Final Fifth Contaminant Candidate List (CCL 5)-	October 2022

Microbial Contaminants

Bacteria

1

2

3

4

5

6

7

8

9

10

11

12

PCCL

Reference

Comamonas testosteroni

























Comamonas testosteroni



Coryneb acteri um
afermentans









X

















MCM-12th Edition

Coryneb acteri um
argentoratense









X

















MCM-12th Edition

Corvnebacterium bovis









X

















MCM-12th Edition

Coryneb acteri um
diphtheriae











X















MCM-12th Edition

Corvnebacterium jeikeium









X

















MCM-12th Edition

Coryneb acteri um
kutscheri









X

















MCM-12th Edition

Coryneb acteri um
macginlevi









X

















MCM-12th Edition

Coryneb acteri um
minutissimum









X

















MCM-12th Edition

Coryneb acteri um
propinquum









X

















MCM-12th Edition

Coryneb acteri um
pseudodiphthericum









X

















MCM-12th Edition

Corvnebacterium
pseudotuberculosis









X

















MCM-12th Edition

Coryneb acteri um striatum









X

















MCM-12th Edition

Coryneb acteri um ulcerans









X

















MCM-12th Edition

Page B9


-------
EPA-Office of Water	Technical Support Document for the	EPA 815-R-22-004

Final Fifth Contaminant Candidate List (CCL 5)-	October 2022

Microbial Contaminants

Bacteria

1

2

3

4

5

6

7

8

9

10

11

12

PCCL

Reference

Coryneb acteri um
urealvticum









X

















MCM-12th Edition

Corynebacterium xerosis









X

















MCM-12th Edition

Coxiella burnetii



X























MCM-12th Edition

Cronobacter sakazakii

















X









MCM-12th Edition

Cutibacterium acnes









X

















MCM-12th Edition

Cutibacterium avidum









X

















MCM-12th Edition

Cutibacterium
granulosum









X

















MCM-12th Edition

Delftia acidovorans

















X









MCM-12th Edition

Dermatophilus
congolensis

















X









MCM-12th Edition

Dichelobacter nodosus

X

























MCM-12th Edition

Edwardsiella hoshinae

















X









MCM-12th Edition

Edwardsiella tarda

















X









MCM-12th Edition

Eggerthella lenta

X

























MCM-12th Edition

Ehrlichia chaffeensis







X



















MCM-12th Edition

Ehrlichia equi







X



















MCM-12th Edition

Ehrlichia ewingii







X



















MCM-12th Edition

Eikenella corrodens









X

















MCM-12th Edition

Elizabethkingia anophelis

















X









Figueroa Castro, Carlos E et
al.. 2017

Page BIO


-------
EPA-Office of Water	Technical Support Document for the	EPA 815-R-22-004

Final Fifth Contaminant Candidate List (CCL 5)-	October 2022

Microbial Contaminants

Bacteria

1

2

3

4

5

6

7

8

9

10

11

12

PCCL

Reference

Elizabethkingia
meningoseptica

















X









MCM-12th Edition

Enterobacter amnigenus

















X









MCM-12th Edition

Enterobacter asburiae

















X









MCM-12th Edition

Enterobacter
cancerogenus

















X









MCM-12th Edition

Enterobacter cloacae

















X









MCM-12th Edition

Enterobacter gergoviae

















X









MCM-12th Edition

Enterobacter hormaechei

















X









MCM-12th Edition

Enterococcus avium

















X









MCM-12th Edition

Enterococcus
casseliflavus

















X









MCM-12th Edition

Enterococcus durans

















X









MCM-12th Edition

Enterococcus faecalis

















X









MCM-12th Edition

Enterococcus faecium

















X









MCM-12th Edition

Enterococcus flavescens

















X









MCM-12th Edition

Enterococcus gaUinarum

















X









MCM-12th Edition

Enterococcus hirae

















X









MCM-12th Edition

Enterococcus mundtii

















X









MCM-12th Edition

Enterococcus raffmosus

















X









MCM-12th Edition

Erysipelothrix
rhusiopathiae

















X









MCM-12th Edition

Page Bll


-------
EPA-Office of Water	Technical Support Document for the	EPA 815-R-22-004

Final Fifth Contaminant Candidate List (CCL 5)-	October 2022

Microbial Contaminants

Bacteria

1

2

3

4

5

6

7

8

9

10

11

12

PCCL

Reference

Escherichia coli

























Escherichia coli



Eubacterium brachv

X

























MCM-12th Edition

Eubacterium cylindroides

X

























MCM-12th Edition

Eubacterium limosum

X

























MCM-12th Edition

Eubacterium moniliforme

X

























MCM-12th Edition

Eubacterium multiforme

X

























MCM-12th Edition

Eubacterium nodatum

X

























MCM-12th Edition

Eubacterium rectale

X

























MCM-12th Edition

Eubacterium saburreum

X

























MCM-12th Edition

Eubacterium saphenum

X

























MCM-12th Edition

Eubacterium sulci

X

























MCM-12th Edition

Eubacterium tenue

X

























MCM-12th Edition

Ewingella americana









X

















MCM-12th Edition

Faecalicatena contorta

X

























MCM-12th Edition

Fibrobacter intestinalis

X

























MCM-12th Edition

Filifactor alocis

X

























MCM-12th Edition

Finegoldia magna

X

























MCM-12th Edition

Fluoribacter bozemanae























X



MCM-12th Edition

Fluoribacter dumoffli























X



MCM-12th Edition

Fluoribacter gormanii























X



MCM-12th Edition

Francisella tularensis







X



















MCM-12th Edition

Page B12


-------
EPA-Office of Water	Technical Support Document for the	EPA 815-R-22-004

Final Fifth Contaminant Candidate List (CCL 5)-	October 2022

Microbial Contaminants

Bacteria

1

2

3

4

5

6

7

8

9

10

11

12

PCCL

Reference

Fusobacterium
mortiferum

X

























MCM-12th Edition

Fusobacterium
mcrophorum

X

























MCM-12th Edition

Fusobacterium nucleatum

X

























MCM-12th Edition

Fusobacterium
periodonticum

X

























MCM-12th Edition

Fusobacterium ulcerans

X

























MCM-12th Edition

Fusobacterium varium

X

























MCM-12th Edition

Gardnerella vaginalis









X

















MCM-12th Edition

Gemella morbillorum









X

















MCM-12th Edition

Gordonia amarae

















X









MCM-12th Edition

Gordonia bronchialis

















X









MCM-12th Edition

Gordonia rubropertincta

















X









MCM-12th Edition

Gordonia sputi

















X









MCM-12th Edition

Gordonia terrae

















X









MCM-12th Edition

Granulicatella adiacens









X

















MCM-12th Edition

Haemophilus ducreyi





X





















MCM-12th Edition

Haemophilus
haemolvticus









X

















MCM-12th Edition

Haemophilus influenzae









X

















MCM-12th Edition

Haemophilus
parahaemolyticus









X

















MCM-12th Edition

Page B13


-------
EPA-Office of Water	Technical Support Document for the	EPA 815-R-22-004

Final Fifth Contaminant Candidate List (CCL 5)-	October 2022

Microbial Contaminants

Bacteria

1

2

3

4

5

6

7

8

9

10

11

12

PCCL

Reference

Haemophilus
parainfluenzae









X

















MCM-12th Edition

Haemophilus
paraphrophilus









X

















MCM-12th Edition

Haemophilus segnis









X

















MCM-12th Edition

Hafnia alvei

















X









MCM-12th Edition

Helicobacter cinaedi





















X





MCM-12th Edition

Helicobacter fennelliae





















X





MCM-12th Edition

Helicobacter heilmannii





















X





MCM-12th Edition

Helicobacter pullorum





















X





MCM-12th Edition

Helicobacter pvlori

























Helicobacter pvlori



Kingella denitriflcans









X

















MCM-12th Edition

Kingella kingae









X

















MCM-12th Edition

Klebsiella aerogenes

















X









MCM-12th Edition

Klebsiella granulomatis

















X









MCM-12th Edition

Klebsiella oxvtoca

















X









MCM-12th Edition

Klebsiella pneumoniae

















X









MCM-12th Edition

Kluwera ascorbata

















X









MCM-12th Edition

Kluwera crvocrescens

















X









MCM-12th Edition

Lactobacillus sp.

X

























MCM-12th Edition

Legionella anisa





















X





MCM-12th Edition

Legionella
birminghamensis





















X





MCM-12th Edition

Page B14


-------
EPA-Office of Water	Technical Support Document for the	EPA 815-R-22-004

Final Fifth Contaminant Candidate List (CCL 5)-	October 2022

Microbial Contaminants

Bacteria

1

2

3

4

5

6

7

8

9

10

11

12

PCCL

Reference

Legionella cherrii





















X





MCM-12th Edition

Legionella cincinnatiensis





















X





MCM-12th Edition

Legionella feeleii





















X





MCM-12th Edition

Legionella hackeliae





















X





MCM-12th Edition

Legionella jordanis





















X





MCM-12th Edition

Legionella lan sin gen sis





















X





MCM-12th Edition

Legionella longbeachae





















X





MCM-12th Edition

Legionella oakridgensis





















X





MCM-12th Edition

Legionella pneumophila

























Legionella pneumophila



Legionella rubrilucens





















X





MCM-12th Edition

Legionella sainthelensi





















X





MCM-12th Edition

Legionella tucsonensis





















X





MCM-12th Edition

Legionella wadsworthii





















X





MCM-12th Edition

Leifsonia aquatica

















X









MCM-12th Edition

Leptospira borgpetersenii















X











MCM-12th Edition

Leptospira inadai















X











MCM-12th Edition

Leptospira interrogans















X











MCM-12th Edition

Leptospira kirschneri















X











MCM-12th Edition

Leptospira meveri















X











MCM-12th Edition

Leptospira noguchii















X











MCM-12th Edition

Leptospira santarosai















X











MCM-12th Edition

Page B15


-------
EPA-Office of Water	Technical Support Document for the	EPA 815-R-22-004

Final Fifth Contaminant Candidate List (CCL 5)-	October 2022

Microbial Contaminants

Bacteria

1

2

3

4

5

6

7

8

9

10

11

12

PCCL

Reference

Leptospira weilii















X











MCM-12th Edition

Leptotrichia buccal is

X

























MCM-12th Edition

Listeria ivanovii















X











MCM-12th Edition

Listeria monocytogenes















X











MCM-12th Edition

Listeria seeligeri















X











MCM-12th Edition

Listeria welshimeri















X











MCM-12th Edition

Lysinibacillus sphaericus

















X









MCM-12th Edition

Mannheimia haemolvtica









X

















MCM-12th Edition

Megamonas hvpermegale

X

























MCM-12th Edition

Megasphaera sp.

X

























MCM-12th Edition

Me thy lob acterium
mesophilicum *















X











MCM-12th Edition

Me thy lob acterium
zatmanii *















X











MCM-12th Edition

Micromonas micros

X

























MCM-12th Edition

Mogibacterium timidum

X

























MCM-12th Edition

Moraxella atlantae









X

















MCM-12th Edition

Moraxella bovis









X

















MCM-12th Edition

Moraxella catarrhalis









X

















MCM-12th Edition

Moraxella caviae









X

















MCM-12th Edition

Moraxella cuniculi









X

















MCM-12th Edition

Page B16


-------
EPA-Office of Water	Technical Support Document for the	EPA 815-R-22-004

Final Fifth Contaminant Candidate List (CCL 5)-	October 2022

Microbial Contaminants

Bacteria

1

2

3

4

5

6

7

8

9

10

11

12

PCCL

Reference

Moraxella lacunata









X

















MCM-12th Edition

Moraxella lincolnii









X

















MCM-12th Edition

Moraxella liquefaciens









X

















MCM-12th Edition

Moraxella
nonliquefaciens









X

















MCM-12th Edition

Moraxella osloensis









X

















MCM-12th Edition

Moraxella ovis









X

















MCM-12th Edition

Morganella morganii









X

















MCM-12th Edition

Mycobacterium abscessus

























Mycobacterium abscessus



My cob acteri um african um



















X







MCM-12th Edition

Mycobacterium asiaticum

















X









MCM-12th Edition

Mycobacterium avium

























Mycobacterium avium



Mycobacterium bovis



X























MCM-12th Edition

Mycobacterium celatum

















X









MCM-12th Edition

Mycobacterium chelonae

















X









MCM-12th Edition

Mycobacterium
conspicuum

















X









MCM-12th Edition

Mycobacterium fortuitum

















X









MCM-12th Edition

Mycobacterium genavense

















X









MCM-12th Edition

Page B17


-------
EPA-Office of Water	Technical Support Document for the	EPA 815-R-22-004

Final Fifth Contaminant Candidate List (CCL 5)-	October 2022

Microbial Contaminants

Bacteria

1

2

3

4

5

6

7

8

9

10

11

12

PCCL

Reference

Mycobacterium gordonae

















X









MCM-12th Edition

Mycobacterium
haemophilum

















X









MCM-12th Edition

Mvcob acteri um kansasii

















X









MCM-12th Edition

Mycobacterium leprae



X























MCM-12th Edition

Mycobacterium
malmoense

















X









MCM-12th Edition

Mvcob acteri um mar in um

















X









MCM-12th Edition

Mycobacterium
mucogenicum

















X









MCM-12th Edition

Mycobacterium
peregrinum

















X









MCM-12th Edition

Mvcob acteri um pore in um

















X









MCM-12th Edition

Mycobacterium
scrofulaceum

















X









MCM-12th Edition

Mycobacterium
senegalense

















X









MCM-12th Edition

Mycobacterium shimoidei

















X









MCM-12th Edition

Mvcobacterium simiae

















X









MCM-12th Edition

Mycobacterium
smegmatis

















X









MCM-12th Edition

Mycobacterium szulgai

















X









MCM-12th Edition

Page B18


-------
EPA-Office of Water	Technical Support Document for the	EPA 815-R-22-004

Final Fifth Contaminant Candidate List (CCL 5)-	October 2022

Microbial Contaminants

Bacteria

1

2

3

4

5

6

7

8

9

10

11

12

PCCL

Reference

Mycobacterium
tuberculosis











X















MCM-H^ Edition

Mycobacterium ulcerans

















X









MCM-H^ Edition

Mycobacterium xenopi

















X









MCM-H^ Edition

Mycoplasma fermentans



X























MCM-H^ Edition

Mycoplasma genitalium



X























MCM-H^ Edition

Mycoplasma hominis



X























MCM-H^ Edition

Mycoplasma pneumoniae



X























MCM-H^ Edition

Mycoplasma salivarium



X









j|j













MCM-H^ Edition

Myroides odoratus















X











MCM-H^ Edition

Neisseria cinerea









X

















MCM-H^ Edition

Neisseria elongata









X

















MCM-H* Edition

Neisseria flava









X

















MCM-H* Edition

Neisseria flavescens









X

















MCM-H* Edition

Neisseria gonorrhoeae





X





















MCM-H* Edition

Neisseria lactamica









X

















MCM-H* Edition

Neisseria meningitidis











X















MCM-H* Edition

Neisseria mucosa









X

















MCM-H* Edition

Neisseria perflava









X

















MCM-H* Edition

Neisseria sicca









X

















MCM-H* Edition

Neisseria subflava









X

















MCM-H* Edition

Page B19


-------
EPA-Office of Water	Technical Support Document for the	EPA 815-R-22-004

Final Fifth Contaminant Candidate List (CCL 5)-	October 2022

Microbial Contaminants

Bacteria

1

2

3

4

5

6

7

8

9

10

11

12

PCCL

Reference

Neisseria weaveri









X

















MCM-12th Edition

Neoehrlichia mikurensis







X



















Portillo, A et al.. 2018

Neorickettsia sennetsu







X



















MCM-12th Edition

Nocardia asteroides

















X









MCM-12th Edition

Nocardia brasiliensis

















X









MCM-12th Edition

Nocardia caviae

















X









MCM-12th Edition

Nocardia farcinica

















X









MCM-12th Edition

Nocardia nova

















X









MCM-12th Edition

Nocardia otitidiscaviarum

















X









MCM-12th Edition

Nocardia
pseudobrasiliensis

















X









MCM-12th Edition

Nocardia transvalensis

















X









MCM-12th Edition

Ochrobactrum anthropi

















X









MCM-12th Edition

Odoribacter splanchnicus

X

























MCM-12th Edition

Oligella ureolvtica









X

















MCM-12th Edition

Oligella urethralis









X

















MCM-12th Edition

Orientia tsutsugamushi



X























MCM-12th Edition

Paenibacillus alvei

















X









MCM-12th Edition

Paenibacillus macerans

















X









MCM-12th Edition

Pantoea agglomerans

























Pantoea agglomerans



Parabacteroides
distasonis

X

























MCM-12th Edition

Page B20


-------
EPA-Office of Water	Technical Support Document for the	EPA 815-R-22-004

Final Fifth Contaminant Candidate List (CCL 5)-	October 2022

Microbial Contaminants

Bacteria

1

2

3

4

5

6

7

8

9

10

11

12

PCCL

Reference

Parabacteroides merdae

X

























MCM-12th Edition

Parachlamydia
acanthamoebae



X























Greub, G., 2009

Pasteurella aerogenes









X

















MCM-12th Edition

Paste ure I la cab alii









X

















MCM-12th Edition

Pasteurella canis









X

















MCM-12th Edition

Pasteurella dagmatis









X

















MCM-12th Edition

Pasteurella multocida









X

















MCM-12th Edition

Pasteurella stomatis









X

















MCM-12th Edition

Peptococcus niger

X

























MCM-12th Edition

Peptostreptococcus
anaerobius

X

























MCM-12th Edition

Peptostreptococcus
asaccharolvticus

X

























MCM-12th Edition

Peptostreptococcus
lactolvticus

X

























MCM-12th Edition

Peptostreptococcus
prevotii

X

























MCM-12th Edition

Peptostreptococcus
vaginalis

X

























MCM-12th Edition

Photobacterium damselae

















X









MCM-12th Edition

Plesiomonas shigelloides

























Plesiomonas shigelloides



Page B21


-------
EPA-Office of Water	Technical Support Document for the	EPA 815-R-22-004

Final Fifth Contaminant Candidate List (CCL 5)-	October 2022

Microbial Contaminants

Bacteria

1

2

3

4

5

6

7

8

9

10

11

12

PCCL

Reference

Porphyromonas
asaccharolvtica

X

























MCM-12th Edition

Porphyromonas catoniae

X

























MCM-12th Edition

Porphyromonas
circumdentaria

X

























MCM-12th Edition

Porphyromonas
endodontalis

X

























MCM-12th Edition

Porphyromonas gingivalis

X

























MCM-12th Edition

Porphyromonas levii

X

























MCM-12th Edition

Porphyromonas macacae

X

























MCM-12th Edition

Prevotella bivia

X

























MCM-12th Edition

Prevotella buccae

X

























MCM-12th Edition

Prevotella buccal is

X

























MCM-12th Edition

Prevotella corporis

X

























MCM-12th Edition

Prevotella dentalis

X

























MCM-12th Edition

Prevotella denticola

X

























MCM-12th Edition

Prevotella disiens

X

























MCM-12th Edition

Prevotella enoeca

X

























MCM-12th Edition

Prevotella heparinolvtica

X

























MCM-12th Edition

Prevotella intermedia

X

























MCM-12th Edition

Prevotella loescheii

X

























MCM-12th Edition

Page B22


-------
EPA-Office of Water	Technical Support Document for the	EPA 815-R-22-004

Final Fifth Contaminant Candidate List (CCL 5)-	October 2022

Microbial Contaminants

Bacteria

1

2

3

4

5

6

7

8

9

10

11

12

PCCL

Reference

Prevotella
melaninogenica

X

























MCM-12th Edition

Prevotella nigrescens

X

























MCM-12th Edition

Prevotella oralis

X

























MCM-12th Edition

Prevotella oris

X

























MCM-12th Edition

Prevotella oulora

X

























MCM-12th Edition

Prevotella ruminicola

X

























MCM-12th Edition

Prevotella veroralis

X

























MCM-12th Edition

Prevotella
zoogleoformans

X

























MCM-12th Edition

Propionibacterium
propionicus

X

























MCM-12th Edition

Proteus mirabilis

















X









MCM-12th Edition

Proteus penneri

















X









MCM-12th Edition

Proteus vulgaris

















X









MCM-12th Edition

Providencia alcalifaciens

















X









MCM-12th Edition

Providencia rettgeri

















X









MCM-12th Edition

Providencia stuartii

















X









MCM-12th Edition

Pseudomonas aeruginosa

























Pseudomonas aeruginosa



Pseudomonas alcaligenes

















X









MCM-12th Edition

Pseudomonas fluorescens

















X









MCM-12th Edition

Page B23


-------
EPA-Office of Water	Technical Support Document for the	EPA 815-R-22-004

Final Fifth Contaminant Candidate List (CCL 5)-	October 2022

Microbial Contaminants

Bacteria

1

2

3

4

5

6

7

8

9

10

11

12

PCCL

Reference

Pseudomonas
pseudoalcaligenes

















X









MCM-12th Edition

Pseudomonas putida

















X









MCM-12th Edition

Pseudomonas stutzeri

















X









MCM-12th Edition

Pseudonocardia
autotrophica

















X









MCM-12th Edition

Pseudoramibacter
alactolvticus

X

























MCM-12th Edition

Psvchrobacter
phenvlpvruvicus

















X









MCM-12th Edition

Rahnella aquatilis

















X









MCM-12th Edition

Ralstonia pickettii

















X









MCM-12th Edition

Raoultella ornithinolvtica

















X









MCM-12th Edition

Rhodococcus equi

















X









MCM-12th Edition

Rhodococcus erythropolis

















X









MCM-12th Edition

Rhodococcus fascians

















X









MCM-12th Edition

Rhodococcus rhodnii

















X









MCM-12th Edition

Rhodococcus rhodochrous

















X









MCM-12th Edition

Rickettsia africae







X



















MCM-12th Edition

Rickettsia akari







X



















MCM-12th Edition

Rickettsia australis







X



















MCM-12th Edition

Rickettsia conorii







X



















MCM-12th Edition

Page B24


-------
EPA-Office of Water	Technical Support Document for the	EPA 815-R-22-004

Final Fifth Contaminant Candidate List (CCL 5)-	October 2022

Microbial Contaminants

Bacteria

1

2

3

4

5

6

7

8

9

10

11

12

PCCL

Reference

Rickettsia felis







X



















MCM-12th Edition

Rickettsia honei







X



















MCM-12th Edition

Rickettsia japonica







X



















MCM-12th Edition

Rickettsia massiliae







X



















MCM-12th Edition

Rickettsia prowazekii







X



















MCM-12th Edition

Rickettsia rickettsii







X



















MCM-12th Edition

Rickettsia sibirica







X



















MCM-12th Edition

Rickettsia typhi







X



















MCM-12th Edition

Rodentibacter
pneumotropicus









X

















MCM-12th Edition

Rothia dentocariosa









X

















MCM-12th Edition

Saccharomonospora
viridis

















X









MCM-12th Edition

Saccharopolyspora
rectivirgula

















X









MCM-12th Edition

Salmonella bongori





















X





MCM-12th Edition

Salmonella choleraesuis





















X





MCM-12th Edition

Salmonella enteritidis





















X





MCM-12th Edition

Salmonella typhi





















X





MCM-12th Edition

Salmonella tvphimurium

























Salmonella enterica



Sebaldella termitidis

X

























MCM-12th Edition

Selenomonas artemidis

X

























MCM-12th Edition

Selenomonas dianae

X

























MCM-12th Edition

Page B25


-------
EPA-Office of Water	Technical Support Document for the	EPA 815-R-22-004

Final Fifth Contaminant Candidate List (CCL 5)-	October 2022

Microbial Contaminants

Bacteria

1

2

3

4

5

6

7

8

9

10

11

12

PCCL

Reference

Selenomonas flueggei

X

























MCM-12th Edition

Selenomonas infelix

X

























MCM-12th Edition

Selenomonas noxia

X

























MCM-12th Edition

Serratia ficaria

















X









MCM-12th Edition

Serratia marcescens

















X









MCM-12th Edition

Serratia odorifera

















X









MCM-12th Edition

Serratia plvmuthica

















X









MCM-12th Edition

Serratia proteamaculans

















X









MCM-12th Edition

Serratia rubidaea

















X









MCM-12th Edition

Shigella bovdii





















X





MCM-12th Edition

Shigella dvsenteriae





















X





MCM-12th Edition

Shigella flexneri





















X





MCM-12th Edition

Shigella sonnei

























Shigella sonnei



Sphingomonas
paucimobilis

















X









MCM-12th Edition

Spirillum minus



X























MCM-12th Edition

Staphylococcus aureus









X

















MCM-12th Edition

Staphylococcus
epidermidis









X

















MCM-12th Edition

Staphylococcus
haemolvticus









X

















MCM-12th Edition

Staphylococcus hvicus









X

















MCM-12th Edition

Page B26


-------
EPA-Office of Water	Technical Support Document for the	EPA 815-R-22-004

Final Fifth Contaminant Candidate List (CCL 5)-	October 2022

Microbial Contaminants

Bacteria

1

2

3

4

5

6

7

8

9

10

11

12

PCCL

Reference

Staphylococcus
intermedins









X

















MCM-12th Edition

Staphylococcus
lugdunensis









X

















MCM-12th Edition

Staphylococcus
saprophvticus









X

















MCM-12th Edition

Staphylococcus warneri









X

















MCM-12th Edition

Stenotrophomonas
maltophilia

















X









MCM-12th Edition

Streptobacillus
moniliformis





X





















MCM-12th Edition

Streptococcus
acidominimus









X

















MCM-12th Edition

Streptococcus agalactiae









X

















MCM-12th Edition

Streptococcus anginosus









X

















MCM-12th Edition

Streptococcus bovis









X

















MCM-12th Edition

Streptococcus canis









X

















MCM-12th Edition

Streptococcus constellatus









X

















MCM-12th Edition

Streptococcus criceti









X

















MCM-12th Edition

Streptococcus equi









X

















MCM-12th Edition

Streptococcus gordonii









X

















MCM-12th Edition

Streptococcus intermedins









X

















MCM-12th Edition

Page B27


-------
EPA-Office of Water	Technical Support Document for the	EPA 815-R-22-004

Final Fifth Contaminant Candidate List (CCL 5)-	October 2022

Microbial Contaminants

Bacteria

1

2

3

4

5

6

7

8

9

10

11

12

PCCL

Reference

Streptococcus milleri









X

















MCM-12th Edition

Streptococcus mitis









X

















MCM-12th Edition

Streptococcus mutcms









X

















MCM-12th Edition

Streptococcus
pneumoniae









X

















MCM-12th Edition

Streptococcus pyogenes









X

















MCM-12th Edition

Streptococcus salivarius









X

















MCM-12th Edition

Streptococcus sanguis









X

















MCM-12th Edition

Streptococcus sobrinus









X

















MCM-12th Edition

Streptococcus suis









X

















MCM-12th Edition

Streptococcus uberis









X

















MCM-12th Edition

Sutterella wadsworthensis

X

























MCM-12th Edition

Suttonella indologenes









X

















MCM-12th Edition

Tanerella forsvthia

X

























MCM-12th Edition

Tatlockia maceachernii























X



MCM-12th Edition

Tatlockia micdadei























X



MCM-12th Edition

Tat um ell a ptvseos















X











MCM-12th Edition

Treponema carateum















X











MCM-12th Edition

Treponema pallidum





X





















MCM-12th Edition

Trophervma whippelii

















X









MCM-12th Edition

Trueperella bernardiae









X

















MCM-12th Edition

Page B28


-------
EPA-Office of Water	Technical Support Document for the	EPA 815-R-22-004

Final Fifth Contaminant Candidate List (CCL 5)-	October 2022

Microbial Contaminants

Bacteria

1

2

3

4

5

6

7

8

9

10

11

12

PCCL

Reference

Trueperella pyogenes









X

















MCM-12th Edition

Tsukamurella inchonensis

















X









MCM-12th Edition

Tsukamurella
paurometabola

















X









MCM-12th Edition

Tsukamurella pulmonis

















X









MCM-12th Edition

Tsukamurella
tvrosinosolvens

















X









MCM-12th Edition

Ureaplasma urealvticum



X























MCM-12th Edition

Veillonella atvpica

X

























MCM-12th Edition

Veillonella dispar

X

























MCM-12th Edition

Veillonella pan'ula

X

























MCM-12th Edition

Vibrio alginolvticus

















X









MCM-12th Edition

Vibrio cholerae

























Vibrio cholerae



Vibrio cincinnatiensis

















X









MCM-12th Edition

Vibrio fluvialis

















X









MCM-12th Edition

Vibrio furnissii

















X









MCM-12th Edition

Vibrio hollisae

















X









MCM-12th Edition

Vibrio mimicus

















X









MCM-12th Edition

Vibrio parahaemolvticus

















X









MCM-12th Edition

Vibrio vulnificus

















X









MCM-12th Edition

Waddlia chondrophila



X























Baud, David et al.. 2014

Wolinella succinogenes

X

























MCM-12th Edition

Page B29


-------
EPA-Office of Water	Technical Support Document for the	EPA 815-R-22-004

Final Fifth Contaminant Candidate List (CCL 5)-	October 2022

Microbial Contaminants

Bacteria

1

2

3

4

5

6

7

8

9

10

11

12

PCCL

Reference

Yersinia bercovieri















X











MCM-12th Edition

Yersinia enterocolitica

























Yersinia enterocolitica



Yersinia frederiksenii















X











MCM-12th Edition

Yersinia intermedia















X











MCM-12th Edition

Yersinia kristensenii















X











MCM-12th Edition

Yersinia mollaretii















X











MCM-12th Edition

Yersinia pestis







X



















MCM-12th Edition

Yersinia

pseudotuberculosis

















X









MCM-12th Edition

Yersinia rohdei















X











MCM-12th Edition

Yersinia ruckeri















X











MCM-12th Edition

Viruses

1

2

3

4

5

6

7

8

9

10

11

12

PCCL

Page Reference

Andes virus

















X







MCM-12th Edition

Apoi vims





X



















Field's Virology, 5th Ed., p.
1153-1158, 1206

Australian bat lyssavirus





X



















Field's Virology, 5th Ed., p.
1364

Bagaza virus





X



















Field's Virology, 5th Ed., p.
1153-1158, 1199

Bangui virus





X



















MCM-12th Edition

Banna virus





X



















MCM-12th Edition

Banzi virus





X



















MCM-12th Edition

Page B30


-------
EPA-Office of Water	Technical Support Document for the	EPA 815-R-22-004

Final Fifth Contaminant Candidate List (CCL 5)-	October 2022

Microbial Contaminants

Viruses

1

2

3

4

5

6

7

8

9

10

11

12

PCCL

Page Reference

Barmah Forest vims





X



















MCM-12th Edition

Batken vims





X



















lUtD://Dhcnc.come. Columbia.cd
u/7thRcDort/sitcs/dcscriDtions/
Orthomvxoviridae/tho eotoviru
s.htm

Bayou vims





X



















MCM-12th Edition

Bebaru vims





X



















Field's Virology, 5th. Ed., p.
1024

Bhanja virus





X



















MCM-12th Edition

BK virus



X





















MCM-12th Edition

Black creek canal virus





X



















MCM-12th Edition

Borna disease virus









X















Field's Virology, 5th Ed., p.
1835

Bovine Ephemeral Fever
virus





X



















Field's Virology, 5th Ed., p.
1367

Bovine Papular Stomatitis
virus



X





















Field's Virology, 5th Ed., p.
2948, 2955-2956, 2963

Bovine Spongiform
Encephalopathy (BSE)
agent

















X







MCM-12th Edition

Buffalopox virus













X











Field's Virology, 5th Ed. p.
2955-2956

Bunyamwera virus





X



















MCM-12th Edition

Bussuquara virus





X



















MCM-12th Edition

Bwamba virus





X



















MCM-12th Edition

Page B31


-------
EPA-Office of Water	Technical Support Document for the	EPA 815-R-22-004

Final Fifth Contaminant Candidate List (CCL 5)-	October 2022

Microbial Contaminants

Viruses

1

2

3

4

5

6

7

8

9

10

11

12

PCCL

Page Reference

California encephalitis
vims





X



















MCM-12th Edition

Candiru vims complex





X



















MCM-12th Edition

Caraparu virus





X



















MCM-12th Edition

Catu virus





X



















MCM-12th Edition

Cercopithecine herpes
virus 1













X











Field's Virology, 5th Ed., p.
2895-2897

Chandipura virus





X



















MCM-12th Edition

Changuinola virus





X



















MCM-12th Edition

Chikungunya virus





X



















MCM-12th Edition

Cliim virus





X



















lUtD://Dhcnc.come. Columbia.cd
u/ICTVdB/11000000.htm

Creutzfeld-Jokob Disease
(CJD) agent













X











Field's Virology, 5th Ed., p.
443-444, 3077-3078

Colorado tick fever virus





X



















MCM-12th Edition

Cote d'lvoire Ebola virus

















X







Field's Virology, 5th. Ed., p.
619, 1411-1412, 1432-1434

Cowpox virus

















X







MCM-12th Edition

Crimea-Congo
Haemorrhagic Fever Virus

















X







MCM-12th Edition

Dakar bat virus













X











Field's Virology, 5th Ed., p.
1158, 1206

Dengue virus





X



















MCM-12th Edition

Dhori virus





X



















MCM-12th Edition

Page B32


-------
EPA-Office of Water	Technical Support Document for the	EPA 815-R-22-004

Final Fifth Contaminant Candidate List (CCL 5)-	October 2022

Microbial Contaminants

Viruses

1

2

3

4

5

6

7

8

9

10

11

12

PCCL

Page Reference

Dobrava-Belgrade virus

















X







MCM-12th Edition

Dugbe vims





X



















MCM-12th Edition

Duvenhage vims

















X







Field's Virology, 5th Ed., p.
1364

Eastern equine
encephalitis virus





X



















MCM-12th Edition

Edge Hill virus





X



















MCM-12th Edition

Encephalomyocarditis
virus













X











Field's Virology, 5th Ed., p.
796, 840, 858-860

European bat lyssavirus 1

















X







Field's Virology, 5th Ed., p.
1364

European bat lyssavirus 2

















X







Field's Virology, 5th Ed., p.
1364

European Tick-borne
encephalitis virus





X



















Field's Virology, 5th Ed., p.
1153-1158, 1200-1203

Everglades virus





X



















MCM-12

Eyach virus





X



















Krauss et al., 2003 p. 87-89

Far eastern Tick-borne
encephalitis virus





X



















Field's Virology, 5th Ed., p.
1153-1158, 1200-1203

Foot and mouth disease
virus













X











Field's Virology, 5th Ed., p.
796, 840, 858-860

Ganjam virus





X



















MCM-12th Edition

Getah virus





X



















Field's Virology, 5th Ed., p.
1024

Guama virus





X



















MCM-12th Edition

Page B33


-------
EPA-Office of Water	Technical Support Document for the	EPA 815-R-22-004

Final Fifth Contaminant Candidate List (CCL 5)-	October 2022

Microbial Contaminants

Viruses

1

2

3

4

5

6

7

8

9

10

11

12

PCCL

Page Reference

Guanarito vims

















X







MCM-H^ Edition

Guaroa vims





X



















MCM-H^ Edition

Hantaan virus

















X







MCM-H^ Edition

Hendra vims

















X







MCM-H^ Edition

Hepatitis A vims























Hepatitis A



Hepatitis B virus



X





















MCM-H^ Edition

Hepatitis C virus



X





















MCM-H^ Edition

Hepatitis delta virus



X





















MCM-H^ Edition

Hepatitis E virus























Hepatitis E



Hepatitis G virus



X





















MCM-H* Edition

HU39694 virus





X



















htto://www.cdc. eov/ncidod/dis

eases/hanta/hWnoframes/ohvs/

ecoloev.htm

Hughes virus





X



















Field's Virology, 5th Ed., p.
1743-1745

Human adenovirus A























Adenovirus



Human adenovirus B









X















MCM-H^ Edition

Human adenovirus C



















X





MCM-H^ Edition

Human adenovirus D









X















MCM-H* Edition

Human adenovirus E









X















MCM-H* Edition

Human adenovirus F



















X





MCM-H* Edition

Human astrovirus























Astrovirus



Human bocavirus













X











Allander, T., 2008

Page B34


-------
EPA-Office of Water	Technical Support Document for the	EPA 815-R-22-004

Final Fifth Contaminant Candidate List (CCL 5)-	October 2022

Microbial Contaminants

Viruses

1

2

3

4

5

6

7

8

9

10

11

12

PCCL

Page Reference

Human Coronavirus 229E









X















MCM-12th Edition

Human Coronavirus
OC43









X















MCM-12th Edition

Human coronavirus
SARS-CoV-2









X















Ciotti, et al.. 2019

Human enterovirus 68



















X





MCM-12th Edition

Human enterovirus 70



















X





MCM-12th Edition

Human enterovirus A























Enterovirus



Human enterovirus B



















X





MCM-12th Edition

Human enterovirus C



















X





MCM-12th Edition

Human enterovirus D



















X





MCM-12th Edition

Human Herpesvirus 1



X





















MCM-12th Edition

Human Herpesvirus 2



X





















MCM-12th Edition

Human Herpesvirus 3



X





















MCM-12th Edition

Human Herpesvirus 4



X





















MCM-12th Edition

Human Herpesvirus 5



X





















MCM-12th Edition

Human Herpesvirus 6



X





















MCM-12th Edition

Human Herpesvirus 7



X





















MCM-12th Edition

Human Herpesvirus 8



X





















MCM-12th Edition

Human

Immunodeficiency Virus
1



X





















MCM-12th Edition

Page B35


-------
EPA-Office of Water	Technical Support Document for the	EPA 815-R-22-004

Final Fifth Contaminant Candidate List (CCL 5)-	October 2022

Microbial Contaminants

Viruses

1

2

3

4

5

6

7

8

9

10

11

12

PCCL

Page Reference

Human

Immunodeficiency Vims
2



X





















MCM-12th Edition

Human papillomavirus



X





















MCM-12th Edition

Human parainfluenza
virus 1



X





















MCM-12th Edition

Human parainfluenza
virus 2









X















MCM-12th Edition

Human parainfluenza
virus 3









X















MCM-12th Edition

Human parainfluenza
virus 4









X















MCM-12th Edition

Human parechovirus type
1













X











MCM-12th Edition

Human parechovirus type
2













X











MCM-12th Edition

Human Respiratory
Syncytial virus









X















MCM-12th Edition

Human Rhinovirus A









X















MCM-12th Edition

Human Rhinovirus B









X















MCM-12th Edition

Human T-Lympho tropic
Virus 1



X





















MCM-12th Edition

Igbo-ora virus





X



















Field's Virology, 5th Ed., p.
1024, 1048

Ilheus virus





X



















MCM-12th Edition

Influenza A virus









X















MCM-12th Edition

Page B36


-------
EPA-Office of Water	Technical Support Document for the	EPA 815-R-22-004

Final Fifth Contaminant Candidate List (CCL 5)-	October 2022

Microbial Contaminants

Viruses

1

2

3

4

5

6

7

8

9

10

11

12

PCCL

Page Reference

Influenza B vims









X















MCM-12th Edition

Influenza C vims









X















MCM-12th Edition

Issyk-Kul vims





X



















MCM-12th Edition

Japanese encephalitis
vims





X



















MCM-12th Edition

JC vims



X





















MCM-12th Edition

Junin vims



X





















MCM-12th Edition

Juquitiba virus





X



















Field's Virology, 5th Ed., p.
1743-1745

KI polyomavirus



X





















Bofill-Mas, S., et al., 2010

Karslii vims

















X







MCM-12th Edition

Kasokero vims





X



















htto ://ohene .come .Columbia, ed
u/ICTVdB/11000000.htm

Kedougou virus





X



















Field's Virology, 5th Ed., p.
1153-1158, 1199

Kemerovo virus





X



















MCM-12th Edition

Kobuvirus













X











Ramirez-Castillo et al., 2015

Kokobera virus





X



















MCM-12th Edition

Koutango virus





X



















MCM-12th Edition

Kyasanur forest disease
virus





X



















MCM-12th Edition

Laguna Negra virus

















X







MCM-12th Edition

Lanjan virus





X



















htto ://ohene .come .Columbia, ed
u/ICTVdB/11000000.htm

Page B37


-------
EPA-Office of Water	Technical Support Document for the	EPA 815-R-22-004

Final Fifth Contaminant Candidate List (CCL 5)-	October 2022

Microbial Contaminants

Viruses

1

2

3

4

5

6

7

8

9

10

11

12

PCCL

Page Reference

Lassa vims

















X







MCM-12th Edition

Lebombo virus





X



















MCM-12th Edition

Lechiguanas vims





X



















lUtD://Dhcnc.come. Columbia.cd
u/7thRcDort/sitcs/dcscriDtions/
Bunvaviridae/hantavirus.htm

Louping ill vims





X



















MCM-12th Edition

Lujo virus



X





















httos://www.cdc.eov/vhf/luio/tr
ansmission/index.html

Lymphocytic
choriomeningitis virus













X











MCM-12th Edition

Machupo virus

















X







MCM-12th Edition

Madrid virus





X



















MCM-12th Edition

Marburg virus



X





















MCM-12th Edition

Marituba virus





X



















MCM-12th Edition

Mayaro virus





X



















MCM-12th Edition

Measles virus









X















MCM-12th Edition

Menangle virus

















X







htto://www.cdc. eov/ncidod/eid
/vol4no2/ohilbev.htm

Mimivirus1













X











Field's Virology, 5th Ed., p.
627-628, 637-638

Mokola virus





X



















Field's Virology, 5th Ed., p.
1363-1364

Molluscum contagiosum
virus



X





















MCM-12th Edition

Page B38


-------
EPA-Office of Water	Technical Support Document for the	EPA 815-R-22-004

Final Fifth Contaminant Candidate List (CCL 5)-	October 2022

Microbial Contaminants

Viruses

1

2

3

4

5

6

7

8

9

10

11

12

PCCL

Page Reference

Monkeypox vims

















X







MCM-12th Edition

Monongahela vims





X



















lUtD://Dhcnc.come. Columbia.cd
u/7thRcDort/sitcs/dcscriDtions/
Bunvaviridae/hantavirus.htm

Mucambo vims





X



















MCM-12th Edition

Mumps vims



X





















MCM-12th Edition

Murray Valley
encephalitis virus





X



















MCM-12th Edition

New York virus





X



















MCM-12th Edition

Newcastle disease virus









X















Field's Virology, 5th Ed., p.
1497-1498

Nipah virus

















X







MCM-12th Edition

Norwalk-like viruses























Calicivirus



Nyando virus





X



















MCM-12th Edition

Ockelbo virus





X



















MCM-12th Edition

Omsk haemorrhagic fever
virus





X



















MCM-12th Edition

O'nyong-nyong virus





X



















MCM-12th Edition

Oran virus





X



















htto ://ohene .come .Columbia, ed
u/7thRcDort/sitcs/dcscriDtions/
Bunvaviridae/hantavirus.htm

Orf virus













X











MCM-12th Edition

Oriboca virus





X



















MCM-12th Edition

Page B39


-------
EPA-Office of Water	Technical Support Document for the	EPA 815-R-22-004

Final Fifth Contaminant Candidate List (CCL 5)-	October 2022

Microbial Contaminants

Viruses

1

2

3

4

5

6

7

8

9

10

11

12

PCCL

Page Reference

Oropouche vims





X



















MCM-12th Edition

Orungo vims





X



















MCM-12th Edition

Parvovirus 4



X





















Sharp, C. P., et al.. 2010

Parvovirus B19









X















MCM-12th Edition

Phnom-Penh bat virus













X











Field's Virology, 5th Ed., p.
1153-1158, 1206

Picobirnavirus













X











MCM-12th Edition

Piry virus





X



















MCM-12th Edition

Poliovirus



















X





MCM-12th Edition

Powassan virus





X



















MCM-12th Edition

Pseudocowpox virus



X





















Field's Virology, 5th Ed., p.
2948, 2960, 2963

Punta Toro virus





X



















MCM-12th Edition

Puumala virus

















X







MCM-12th Edition

Quaranfil Virus





X



















MCM-12th Edition

Rabies virus











X













MCM-12th Edition

Reovirus













X











Field's Virology, 5th Ed., p.
1897-1900

Reston Ebola virus

















X







MCM-12th Edition

Rift Valley fever virus

















X







MCM-12th Edition

Rio Bravo virus













X











Field's Virology, 5th Ed., p.
1153-1158, 1206

Rocio virus





X



















MCM-12th Edition

Page B40


-------
EPA-Office of Water	Technical Support Document for the	EPA 815-R-22-004

Final Fifth Contaminant Candidate List (CCL 5)-	October 2022

Microbial Contaminants

Viruses

1

2

3

4

5

6

7

8

9

10

11

12

PCCL

Page Reference

Ross River vims





X



















MCM-12th Edition

Rotavirus A























Rotavirus



Rotavirus B

















X







MCM-12th Edition

Rotavirus C

















X







MCM-12th Edition

Rotavirus D

















X







MCM-12th Edition

Rotavirus E

















X







MCM-12th Edition

Rotavirus F

















X







MCM-12th Edition

Royal Farm virus





X



















Field's Virology, 5th Ed., p.
1153-1158, 1204

Rubella virus









X















MCM-12th Edition

Sabia virus

















X







MCM-12th Edition

Saimiriine herpesvirus 1













X











Field's Virology, 4th Ed., p.
2383,2483,2511,2848

Salehabad virus





X



















htto ://t>hene .cmnc .Columbia. ed
u/ICTVdB/11041008.htm

Sandfly fever Naples virus





X



















MCM-12th Edition

Sandfly fever virus group





X



















MCM-12th Edition

Saumarez Reef virus





X



















Field's Virology, 5th Ed., p.
1153-1158,1206

Sealpox virus













X











MCM-12th Edition

Seinliki Forest virus





X



















MCM-12th Edition

Seoul virus





X



















MCM-12th Edition

Sepik virus

















X







MCM-12th Edition

Page B41


-------
EPA-Office of Water	Technical Support Document for the	EPA 815-R-22-004

Final Fifth Contaminant Candidate List (CCL 5)-	October 2022

Microbial Contaminants

Viruses

1

2

3

4

5

6

7

8

9

10

11

12

PCCL

Page Reference

Sin Nombre vims





X



















MCM-12th Edition

Sindbis vims

















X







MCM-12th Edition

St. Louis encephalitis
vims





X



















MCM-12th Edition

Sudan Ebola vims

















X







MCM-12th Edition

Suid herpesvirus













X











Field's Virology, 4th Ed., p.
2385, 2484, 2707

Swine vesicular disease
virus

















X







Field's Virology, 5th Ed., p.
963

Tacaiuma virus





X



















MCM-12th Edition

Tamdy virus





X



















MCM-12th Edition

Tanapox virus

















X







MCM-12th Edition

Tataguine virus





X



















MCM-12th Edition

Thogoto virus





X



















MCM-12th Edition

Trubanaman virus





X



















MCM-12th Edition

Tyuleniy virus





X



















Field's Virology, 5th Ed., p.
1153-1158, 1206

Usutu virus





X



















MCM-12th Edition

Variola virus



X





















MCM-12th Edition

Venezuelan Equine
Encephalitis virus





X



















MCM-12th Edition

Vesicular stomatitis virus





X



















MCM-12th Edition

Wad Medani virus





X



















Field's Virology, 5th Ed., p.
1975-1977

Page B42


-------
EPA-Office of Water	Technical Support Document for the	EPA 815-R-22-004

Final Fifth Contaminant Candidate List (CCL 5)-	October 2022

Microbial Contaminants

Viruses

1 2

3

4

5

6

7

8

9

10

11

12

PCCL

Page Reference

Wanowrie vims





X



















MCM-12th Edition

Wesselsbron virus



X













MCM-12th Edition

West Nile virus



X













MCM-12th Edition

Western Equine
Encephalitis virus



X













MCM-12th Edition

WU polyomavirus







X











Bofill-Mas, S.. 2010

Wyeomyia virus





X



















MCM-12th Edition

Yaba monkey tumor virus











X





MCM-12th Edition

Yellow fever virus



X













MCM-12th Edition

Yogue virus



X













htto ://t>hene .cmnc .Columbia. ed
u/ICTVdB/11000000.htm

Zaire Ebola virus











X





MCM-12th Edition

Zika virus











X





MCM-12th Edition

Zinga virus



X













htto://www.cdc. eov/mmwr/ore
view/mmwrhtml/00001253 .ht
m

Protozoa

1 2

3

4

5

6

7

8

9

10

11

12

PCCL

Page Reference

Accmthamoeba astronvxis















X









MCM-12th Edition

Accmthamoeba castellani











X





MCM-12th Edition

Page B43


-------
EPA-Office of Water	Technical Support Document for the	EPA 815-R-22-004

Final Fifth Contaminant Candidate List (CCL 5)-	October 2022

Microbial Contaminants

Protozoa

1

2

3

4

5

6

7

8

9

10

11

12

PCCL

Page Reference

Accmthamoeba
culbertsoni















X









MCM-12th Edition

Accmthamoeba hatchetti















X









MCM-12th Edition

Acanthamoeba
pale stin en sis















X









MCM-12th Edition

Acanthamoeba polyphaga















X









MCM-12th Edition

Acanthamoeba rhysodes















X









MCM-12th Edition

Babesia bovis





X



















MCM-12th Edition

Babesia divergens





X



















MCM-12th Edition

Babesia gibsoni





X



















MCM-12th Edition

Babesia microti





X



















MCM-12th Edition

Balamuthia mandrillaris













X











MCM-12th Edition

Balantidium coli













X











MCM-12th Edition

Blastocvstis hominis























Blastocvstis hominis



Cryptosporidium parvum1











Cvclospora cavetanensis























Cvclospora cavetanensis



Dientamoeba fragilis











X













MCM-12th Edition

Encephalitozoon cuniculi



















X





MCM-12th Edition

Encephalitozoon hellem



















X





MCM-12th Edition

Encephalitozoon
intestinalis























Microsporidia



Page B44


-------
EPA-Office of Water	Technical Support Document for the	EPA 815-R-22-004

Final Fifth Contaminant Candidate List (CCL 5)-	October 2022

Microbial Contaminants

Protozoa

1

2

3

4

5

6

7

8

9

10

11

12

PCCL

Page Reference

Entamoeba chattoni



















X





htto://www.its.be/its/Distance
Learnine/LectureNotesVanden
EndenE/06 Amoebiasiso2.htm
#IX 450

Entamoeba histolytica























Entamoeba histolytica



Entamoeba moshkovskii



















X





htto://www.its.be/its/Distance
Learnine/LectureNotesVanden
EndenE/06 AmocbiasisD2.htm
#IX 450

Enterocytozoon bieneusi



















X





MCM-12th Edition

Giardia duodena/is1











Isospora belli























Lsospora belli



Leishmania aethiopica





X



















MCM-12th Edition

Leishmania amazonensis





X



















MCM-12th Edition

Leishmania braziliensis





X



















MCM-12th Edition

Leishmania chagasi





X



















MCM-12th Edition

Leishmania donovani





X



















MCM-12th Edition

Leishmania guvanensis





X



















MCM-12th Edition

Leishmania infantum





X



















MCM-12th Edition

Leishmania lainsoni





X



















MCM-12th Edition

Leishmania major





X



















MCM-12th Edition

Leishmania mexicana





X



















MCM-12th Edition

Leishmania naiffi





X



















MCM-12th Edition

Page B45


-------
EPA-Office of Water	Technical Support Document for the	EPA 815-R-22-004

Final Fifth Contaminant Candidate List (CCL 5)-	October 2022

Microbial Contaminants

Protozoa

1

2

3

4

5

6

7

8

9

10

11

12

PCCL

Page Reference

Leishmcmia part am en sis





X



















MCM-12th Edition

Leishmania peruviana





X



















MCM-12th Edition

Leishmania pifanoi





X



















MCM-12th Edition

Leishmania shawi





X



















MCM-12th Edition

Leishmania tropica





X



















MCM-12th Edition

Leishmania venezuelensis





X



















MCM-12th Edition

Naegleria fowleri























Naegleria fowleri



Nosema africanum













X











MCM-12th Edition

Nosema cevlonensis













X











MCM-12th Edition

Nosema connori













X











MCM-12th Edition

Nosema ocularum













X











MCM-12th Edition

Pentatrichomonas
hominis







X

















MCM-12th Edition

Plasmodium falciparum





X



















MCM-12th Edition

Plasmodium knowlesi





X



















MCM-12th Edition

Plasmodium malariae





X



















MCM-12th Edition

Plasmodium ovale





X



















MCM-12th Edition

Plasmodium simium





X



















MCM-12th Edition

Plasmodium vivax





X



















MCM-12th Edition

Retortamonas intestinalis







X

















MCM-12th Edition

Sarcocvstis hominis











X













MCM-12th Edition

Page B46


-------
EPA-Office of Water

Technical Support Document for the
Final Fifth Contaminant Candidate List (CCL 5)-
Microbial Contaminants

EPA 815-R-22-004
October 2022

Protozoa

1

2

3

4

5

6

7

8

9

10

11

12

PCCL

Page Reference

Sarcocvstis lindermanni











X













MCM-12th Edition

Sarcocvstis suihominis











X













MCM-12th Edition

Toxoplasma gondii























Toxoplasma gondii



Trachipleistophora
hominis



















X





MCM-12th Edition

Trichomonas tenax







X

















MCM-12th Edition

Trichomonas vaginalis



X





















MCM-12th Edition

Trypanosoma brucei





X



















MCM-12th Edition

Trypanosoma cruzi





X



















MCM-12th Edition

Vittaforma corneae













X











MCM-12th Edition



















Helminths

1

2

3

4

5

6

7

8

9

10

11

12

PCCL

Page Reference

Acanthocephalus rauschi







X









Ashford and Crewe, 2003

Achillurbainia nouveli











X





Ashford and Crewe, 2003

A chillurbainia recondita







X









Ashford and Crewe, 2003

Alaria americana







X









Ashford and Crewe, 2003

Alaria marcianae







X









Ashford and Crewe, 2003

Amphimerus
pseudofelineus











X





Ashford and Crewe, 2003

Anatrichosoma cutaneum











X





Ashford and Crewe, 2003

Page B47


-------
EPA-Office of Water	Technical Support Document for the	EPA 815-R-22-004

Final Fifth Contaminant Candidate List (CCL 5)-	October 2022

Microbial Contaminants

Helminths

12 3

4

5 6

7

8 9

10

11 12

PCCL

Page Reference

Ancvlostoma braziliense







X









Ashford and Crewe, 2003

Ancvlostoma caninum





X



Ashford and Crewe, 2003

Ancvlostoma ceylanicum





X



Ashford and Crewe, 2003

Ancvlostoma duodenale



X





Ashford and Crewe, 2003

Ancvlostoma malayanum





X



Ashford and Crewe, 2003

Anisakis phvseteris



X





Ashford and Crewe, 2003

Anisakis simplex



X





Ashford and Crewe, 2003

Aonchotheca
philippinensis





X



Ashford and Crewe, 2003

Apophallus donicus



X





Ashford and Crewe, 2003

Artyfechinostomum
mehrai





X



Ashford and Crewe, 2003

Ascaris lumbricoides



X





Ashford and Crewe, 2003

Ascaris suum



X





Ashford and Crewe, 2003

Ascocotvle sp.



X





Ashford and Crewe, 2003

A ustralob ilharzia
terrigalensis





X



Ashford and Crewe, 2003

Bavlisascaris procvonis



X





Ashford and Crewe, 2003

Bertiella mucronata



X





Ashford and Crewe, 2003

Bertiella studeri





X



Ashford and Crewe, 2003

Bilharziella polonica





X



Ashford and Crewe, 2003

Bolbosoma sp.





X



Ashford and Crewe, 2003

Page B48


-------
EPA-Office of Water	Technical Support Document for the	EPA 815-R-22-004

Final Fifth Contaminant Candidate List (CCL 5)-	October 2022

Microbial Contaminants

Helminths

12 3

4

5 6

7

8 9

10

11 12

PCCL

Page Reference

Brugia beaveri



X













Ashford and Crewe, 2003

Brugia guvanensis

X







Ashford and Crewe, 2003

Brugia malavi

X







Ashford and Crewe, 2003

Brugia pahangi

X







Ashford and Crewe, 2003

Brugia timori

X







Ashford and Crewe, 2003

Bunostomum
phlebotomum



X





Ashford and Crewe, 2003

Calodium hepaticum



X





Ashford and Crewe, 2003

Carneocephallus
brevicaea





X



Ashford and Crewe, 2003

Cathaemasia cabrerai





X



Ashford and Crewe, 2003

Centrocestus armatus





X



Ashford and Crewe, 2003

Centrocestus formosanus





X



Ashford and Crewe, 2003

Cheilospirura sp.





X



Ashford and Crewe, 2003

Clinostomum
complanatum





X



Ashford and Crewe, 2003

Contracaecum osculatum





X



Ashford and Crewe, 2003

Corvnosoma strumosum



X





Ashford and Crewe, 2003

Crvptocotvle lingua





X



Ashford and Crewe, 2003

Cyclodontostomum
pur\'isi





X



Ashford and Crewe, 2003

Dicrocoelium dendriticum



X





Ashford and Crewe, 2003

Page B49


-------
EPA-Office of Water	Technical Support Document for the	EPA 815-R-22-004

Final Fifth Contaminant Candidate List (CCL 5)-	October 2022

Microbial Contaminants

Helminths

12 3

4

5 6

7

8 9

10

11 12

PCCL

Page Reference

Dicrocoelium hospes











X





Ashford and Crewe, 2003

Dioctophvme renale



X





Ashford and Crewe, 2003

Dipetalonema arbuta

X







Ashford and Crewe, 2003

Dipetalonema reconditum

X







MCM-8, p. 634, 1209

Diphyllobothrium
cameroni





X



Ashford and Crewe, 2003

Diphyllobothrium
cordatum



X





Ashford and Crewe, 2003

Diphyllobothrium dalliae



X





Ashford and Crewe, 2003

Diphyllobothrium
dendriticum



X





Ashford and Crewe, 2003

Diphyllobothrium elegans





X



Ashford and Crewe, 2003

Diphyllobothrium
erinaceieuropaei





X



Ashford and Crewe, 2003

Diphyllobothrium hians





X



Ashford and Crewe, 2003

Diphyllobothrium
houghtoni





X



Ashford and Crewe, 2003

Diphyllobothrium
nihonkaiense





X



Ashford and Crewe, 2003

Diphyllobothrium
lanceolatum



X





Ashford and Crewe, 2003

Dibothriocephalus latus



X





Ashford and Crewe, 2003

Diphyllobothrium
mansonoides



X





Ashford and Crewe, 2003

Page B50


-------
EPA-Office of Water	Technical Support Document for the	EPA 815-R-22-004

Final Fifth Contaminant Candidate List (CCL 5)-	October 2022

Microbial Contaminants

Helminths

12 3

4

5 6

7

8 9

10

11 12

PCCL

Page Reference

Diphyllobothrium
klebanovskii











X





Ashford and Crewe, 2003

Diphvllobothrium orcini





X



Ashford and Crewe, 2003

Adenocephalus pacificus





X



Ashford and Crewe, 2003

Diphyllobothrium
scoticum





X



Ashford and Crewe, 2003

Diphyllobothrium
stemmacephalum



X





Ashford and Crewe, 2003

Diphvllobothrium theileri





X



Ashford and Crewe, 2003

Diplogonoporus
balaenopterae





X



Ashford and Crewe, 2003

Diplogonoporus brauni





X



Ashford and Crewe, 2003

Diplogonoporus
balaenopterae





X



Ashford and Crewe, 2003

Diplostom um spathaceum





X



Ashford and Crewe, 2003

Dipvlidium caninum



X





Ashford and Crewe, 2003

Dirofilaria immitis



X













Ashford and Crewe, 2003

Dirofilaria repens

X







Ashford and Crewe, 2003

Dirofilaria striata

X







Ashford and Crewe, 2003

Dirofilaria subdermata

X







Ashford and Crewe, 2003

Dirofilaria tenuis

X







Ashford and Crewe, 2003

Dirofilaria ursi

X







Ashford and Crewe, 2003

Dracunculus insignis





X



Ashford and Crewe, 2003

Page B51


-------
EPA-Office of Water	Technical Support Document for the	EPA 815-R-22-004

Final Fifth Contaminant Candidate List (CCL 5)-	October 2022

Microbial Contaminants

Helminths

12 3

4

5 6

7

8 9

10

11 12

PCCL

Page Reference

Dracunculus medinensis











X





Ashford and Crewe, 2003

Drepanidotaenia
lanceolate/



X





Ashford and Crewe, 2003

Echinochasmus japonicus





X



Ashford and Crewe, 2003

Echinochasmus jiufoensis





X



Ashford and Crewe, 2003

Echinochasmus
perfoliatus





X



Ashford and Crewe, 2003

Echinococcus granulosus



X





Ashford and Crewe, 2003

Echinococcus
multilocularis



X





Ashford and Crewe, 2003

Echinococcus oligarthus





X



Ashford and Crewe, 2003

Echinococcus vogeli





X



Ashford and Crewe, 2003

Echinoparyphium
recurvatum





X



Ashford and Crewe, 2003

Echinostoma cinetorchis





X



Ashford and Crewe, 2003

Echinostoma echinatum





X



Ashford and Crewe, 2003

Echinostoma hortense





X



Ashford and Crewe, 2003

Echinostoma ilocanum





X



Ashford and Crewe, 2003

Echinostoma jassyense





X



Ashford and Crewe, 2003

Echinostoma macrorchis





X



Ashford and Crewe, 2003

Echinostoma malayanum





X



Ashford and Crewe, 2003

Page B52


-------
EPA-Office of Water	Technical Support Document for the	EPA 815-R-22-004

Final Fifth Contaminant Candidate List (CCL 5)-	October 2022

Microbial Contaminants

Helminths

12 3

4

5 6

7

8 9

10

11 12

PCCL

Page Reference

Echinostoma revolutum











X





Ashford and Crewe, 2003

Enterobius gregorii



X





Ashford and Crewe, 2003

Enterobius vermicularis



X





Ashford and Crewe, 2003

Episthmium caninum





X



Ashford and Crewe, 2003

Eucoleus aerophilus



X





Ashford and Crewe, 2003

Eurvtrema pcmcreaticum



X





Ashford and Crewe, 2003

Eustrongylides sp.



X





Ashford and Crewe, 2003

Fasciola indica



X





Ashford and Crewe, 2003

Fasciola hepatica



X





Ashford and Crewe, 2003

Fasciola indica



X





Ashford and Crewe, 2003

Fasciolopsis buski





X



Ashford and Crewe, 2003

Neodiplostomum
seoulense





X



Ashford and Crewe, 2003

Gastrodiscoides hominis





X



Ashford and Crewe, 2003

Gigantobilharzia huttoni



X





Ashford and Crewe, 2003

Gigantobilharzia sturniae





X



Ashford and Crewe, 2003

Gnathostoma doloresi





X



Ashford and Crewe, 2003

Gnathostoma hispidum





X



Ashford and Crewe, 2003

Gnathostoma nipponicum





X



Ashford and Crewe, 2003

Gnathostoma spinigerum



X





Ashford and Crewe, 2003

Page B53


-------
EPA-Office of Water	Technical Support Document for the	EPA 815-R-22-004

Final Fifth Contaminant Candidate List (CCL 5)-	October 2022

Microbial Contaminants

Helminths

12 3

4

5 6

7

8 9

10

11 12

PCCL

Page Reference

Gongylonema pulchrum







X









Ashford and Crewe, 2003

Gvmnophalloides sp.





X



Ashford and Crewe, 2003

Haemonchus contortus





X



Ashford and Crewe, 2003

Haplorchis pumilo





X



Ashford and Crewe, 2003

Haplorchis taichui





X



Ashford and Crewe, 2003

Haplorchis vanissima



X





Ashford and Crewe, 2003

Haplorchis vokogawai



X





Ashford and Crewe, 2003

Heterobilharzia
americana



X





Ashford and Crewe, 2003

Heterophves dispar





X



Ashford and Crewe, 2003

Heterophyes





X



Ashford and Crewe, 2003

Heterophves nocens





X



Ashford and Crewe, 2003

Heterophyopsis continua





X



Ashford and Crewe, 2003

Himasthala muehlensi



X





Ashford and Crewe, 2003

Hvmenolepis diminuta



X





Ashford and Crewe, 2003

Hvmenolepis nana



X





Ashford and Crewe, 2003

Hypoderaeum conoideum





X



Ashford and Crewe, 2003

Inermicapsifer
madagascariensis





X



Ashford and Crewe, 2003

Isoparorchis hvpselobagri





X



Ashford and Crewe, 2003

Lagochilascaris minor



X





Ashford and Crewe, 2003

Page B54


-------
EPA-Office of Water	Technical Support Document for the	EPA 815-R-22-004

Final Fifth Contaminant Candidate List (CCL 5)-	October 2022

Microbial Contaminants

Helminths

12 3

4

5 6

7

8 9

10

11 12

PCCL

Page Reference

Ligula intestinalis











X





Ashford and Crewe, 2003

Loa

X







Ashford and Crewe, 2003

Macracanthorhynchus
hirudinaceus





X



Ashford and Crewe, 2003

Macracanthorhynchus
ingens



X





Ashford and Crewe, 2003

Mammomonogamus
larvngeus





X



Ashford and Crewe, 2003

Mammomonogamus
nasicola





X



Ashford and Crewe, 2003

Mansonella ozzardi

X







Ashford and Crewe, 2003

Mansonella perstans

X







Ashford and Crewe, 2003

Mansonella rodhaini

X







Ashford and Crewe, 2003

Mansonella semiclarum

X







Ashford and Crewe, 2003

Mansonella streptocerca



X













Ashford and Crewe, 2003

Marshallagia marshalli





X



Ashford and Crewe, 2003

Mathevotaenia
symmetrica





X



Ashford and Crewe, 2003

Mecistocirrus digitatus



X





Ashford and Crewe, 2003

Meningonema peruzzii





X



Ashford and Crewe, 2003

Mesocestoides lineatus





X



Ashford and Crewe, 2003

Mesocestoides variabilis



X





Ashford and Crewe, 2003

Metagonim us m in utus





X



Ashford and Crewe, 2003

Page B55


-------
EPA-Office of Water	Technical Support Document for the	EPA 815-R-22-004

Final Fifth Contaminant Candidate List (CCL 5)-	October 2022

Microbial Contaminants

Helminths

12 3

4

5 6

7

8 9

10

11 12

PCCL

Page Reference

Metagonimus yokogawai











X





Ashford and Crewe, 2003

Metastrongylus apri



X





Ashford and Crewe, 2003

Metorchis albidus



X





Ashford and Crewe, 2003

Metorchis conjunctus



X





Ashford and Crewe, 2003

Microfilaria bolivarensis

X







Ashford and Crewe, 2003

Micronema deletrix



X





Ashford and Crewe, 2003

Moniezia expansa



X





Ashford and Crewe, 2003

Moniliformis



X





Ashford and Crewe, 2003

Multiceps brauni





X



Ashford and Crewe, 2003

Taenia glomeratus





X



Ashford and Crewe, 2003

Multiceps longihamatus





X



Ashford and Crewe, 2003

Multiceps



X





Ashford and Crewe, 2003

Taenia serialis



X





Ashford and Crewe, 2003

Nanophvetus salmincola



X





Ashford and Crewe, 2003

Necator americanus



X





Ashford and Crewe, 2003

Nematodirus abnormalis



X





Ashford and Crewe, 2003

Neodiplostomum sp.





X



Ashford and Crewe, 2003

Oe soph ago stom um
aculeatum





X



Ashford and Crewe, 2003

Oe soph ago stom um
bifurcum





X



Ashford and Crewe, 2003

Page B56


-------
EPA-Office of Water	Technical Support Document for the	EPA 815-R-22-004

Final Fifth Contaminant Candidate List (CCL 5)-	October 2022

Microbial Contaminants

Helminths

12 3

4

5 6

7

8 9

10

11 12

PCCL

Page Reference

Oesoph agostom um
stephanostomum







X









Ashford and Crewe, 2003

Onchocerca volvulus

X







Ashford and Crewe, 2003

Opistorchis
(Chlonorchis) sinensis





X



Ashford and Crewe, 2003

Opistorchis felineus





X



Ashford and Crewe, 2003

Opistorchis noverca



X





Ashford and Crewe, 2003

Opistorchis viverrini





X



Ashford and Crewe, 2003

Orientobilharzia
turkestanica





X



Ashford and Crewe, 2003

Ornithobilharzia sp.





X



Kolarova, 2007

Ostertagia ostertagi





X



Ashford and Crewe, 2003

Paragonimus africanus





X



Ashford and Crewe, 2003

Paragonimus bankokensis



X





Ashford and Crewe, 2003

Paragonimus caliensis



X





Ashford and Crewe, 2003

Paragonimus
heterotremus





X



Ashford and Crewe, 2003

Paragonimus
hueitungensis





X



Ashford and Crewe, 2003

Paragonimus kellicotti



X





Ashford and Crewe, 2003

Paragonimus mexicanus



X





Ashford and Crewe, 2003

Paragonimus mivazakii





X



Ashford and Crewe, 2003

Paragonimus ohirai





X



Ashford and Crewe, 2003

Page B57


-------
EPA-Office of Water	Technical Support Document for the	EPA 815-R-22-004

Final Fifth Contaminant Candidate List (CCL 5)-	October 2022

Microbial Contaminants

Helminths

12 3

4

5 6

7

8 9

10

11 12

PCCL

Page Reference

Paragonimus
phillipinensis











X





Ashford and Crewe, 2003

Paragonimus sadoensis





X



Ashford and Crewe, 2003

Paragonimus si am en sis





X



Palmer et al., 1998, p. 736

Paragonimus skrjabini





X



Ashford and Crewe, 2003

Paragonimus
uterobilateralis





X



Ashford and Crewe, 2003

Paragonimus westermani





X



Ashford and Crewe, 2003

Parascaris equorum



X





Ashford and Crewe, 2003

Parastrongvlus
cantonensis





X



Ashford and Crewe, 2003

Parastrongvlus
costaricensis



X





Ashford and Crewe, 2003

Pearsonema plica



X





MCM-8 Edition, p. 1134

Pelodera strongvloides





X



Ashford and Crewe, 2003

Phaneropsolus bonnei





X



Ashford and Crewe, 2003

Philophthalmus
lacrvmosus





X



Ashford and Crewe, 2003

Pseudoterranova
decipiens



X





Ashford and Crewe, 2003

Phvsaloptera caucasica



X





Ashford and Crewe, 2003

Phvsaloptera transfuga





X



Ashford and Crewe, 2003

Plagiorchis harinasutai





X



Ashford and Crewe, 2003

Plagiorchis javensis





X



Ashford and Crewe, 2003

Page B58


-------
EPA-Office of Water	Technical Support Document for the	EPA 815-R-22-004

Final Fifth Contaminant Candidate List (CCL 5)-	October 2022

Microbial Contaminants

Helminths

12 3

4

5 6

7

8 9

10

11 12

PCCL

Page Reference

Plagiorchis muris











X





Ashford and Crewe, 2003

Plagiorchis philippinensis





X



Ashford and Crewe, 2003

Poikilorchis congolensis





X



Ashford and Crewe, 2003

Procerovum calderoni





X



Ashford and Crewe, 2003

Prohemistomum vivax





X



Ashford and Crewe, 2003

Prosthodendrium
molenkampi





X



Ashford and Crewe, 2003

Pseudamphistom um
aethiopicum





X



Ashford and Crewe, 2003

Pseudamphistom um
truncatum





X



Ashford and Crewe, 2003

Psilorchis hominis



X





Ashford and Crewe, 2003

Pvgidiopsis summa





X



Ashford and Crewe, 2003

Pyramicocephalus
anthrocephalus



X





Ashford and Crewe, 2003

Raillietina celebensis





X



Ashford and Crewe, 2003

Raillietina demerariensis



X





Ashford and Crewe, 2003

Rhabditis elongata





X



Ashford and Crewe, 2003

Rhabditis inermis





X



Ashford and Crewe, 2003

Rhabditis niellvi



X





Ashford and Crewe, 2003

Rhabditis pellioditis



X





Ashford and Crewe, 2003

Rictularia sp.



X





Ashford and Crewe, 2003

Page B59


-------
EPA-Office of Water	Technical Support Document for the	EPA 815-R-22-004

Final Fifth Contaminant Candidate List (CCL 5)-	October 2022

Microbial Contaminants

Helminths

12 3

4

5 6

7

8 9

10

11 12

PCCL

Page Reference

Schistocephalus solidus







X









Ashford and Crewe, 2003

Schistosoma bovis





X



Ashford and Crewe, 2003

Schistosoma haematobium





X



Ashford and Crewe, 2003

Schistosoma intercalatum





X



Ashford and Crewe, 2003

Schistosoma japonicum





X



Ashford and Crewe, 2003

Schistosoma malayensis





X



Ashford and Crewe, 2003

Schistosoma mansoni



X





Ashford and Crewe, 2003

Schistosoma mattheei





X



Ashford and Crewe, 2003

Schistosoma mekongi





X



Ashford and Crewe, 2003

Schistosoma rodhaini





X



Ashford and Crewe, 2003

Schistosoma spindale





X



Ashford and Crewe, 2003

Schistosom ati um do uthitti



X





Ashford and Crewe, 2003

Setaria equina

X







Ashford and Crewe, 2003

Spirocerca lupi





X



Ashford and Crewe, 2003

Stellantchasmus falcatus



X





Ashford and Crewe, 2003

Stictodora fuscata





X



Ashford and Crewe, 2003

Strongvloides fuelleborni





X



Ashford and Crewe, 2003

Strongvloides papillosus



X





Ashford and Crewe, 2003

Strongvloides ransomi



X





Ashford and Crewe, 2003

Page B60


-------
EPA-Office of Water	Technical Support Document for the	EPA 815-R-22-004

Final Fifth Contaminant Candidate List (CCL 5)-	October 2022

Microbial Contaminants

Helminths

12 3

4

5 6

7

8 9

10

11 12

PCCL

Page Reference

Strongyloides stercoralis







X









Ashford and Crewe, 2003

Strongyloides westeri



X





Ashford and Crewe, 2003

Svphacea obvelata





X



Ashford and Crewe, 2003

Taenia crassiceps



X





Ashford and Crewe, 2003

Taenia saginata



X





Ashford and Crewe, 2003

Taenia solium



X





Ashford and Crewe, 2003

Taenia taeniaeformis





X



Ashford and Crewe, 2003

Teladorsagia
circumcincta





X



Ashford and Crewe, 2003

Ternidens deminutus





X



Ashford and Crewe, 2003

Thelazia californiensis

X







Ashford and Crewe, 2003

Thelazia callipaeda





X



Ashford and Crewe, 2003

Thelazia rhodesi





X



MCM-8, p. 363

Toxascaris leonina



X





Ashford and Crewe, 2003

Toxocara canis



X





Ashford and Crewe, 2003

Toxocara cati



X





Ashford and Crewe, 2003

Trichinella britovi





X



Ashford and Crewe, 2003

Trichinella nativa



X





Ashford and Crewe, 2003

Trichinella nelsoni





X



Ashford and Crewe, 2003

Trichinella pseudospiralis





X



Ashford and Crewe, 2003

Trichinella spiralis



X





Ashford and Crewe, 2003

Page B61


-------
EPA-Office of Water	Technical Support Document for the	EPA 815-R-22-004

Final Fifth Contaminant Candidate List (CCL 5)-	October 2022

Microbial Contaminants

Helminths

12 3

4

5 6

7

8 9

10

11 12

PCCL

Page Reference

Trichinella T5







X









Ashford and Crewe, 2003

Trichobilharzia brevis





X



Ashford and Crewe, 2003

Trichobilharzia ocellata



X





Ashford and Crewe, 2003

Trichobilharzia
stagnicolae



X





Ashford and Crewe, 2003

Trichostrongylus afftnis



X





Ashford and Crewe, 2003

Trichostrongylus axei



X





Ashford and Crewe, 2003

Trichostrongylus brevis





X



Ashford and Crewe, 2003

Trichostrongylus
calcaratus





X



Ashford and Crewe, 2003

Trichostrongylus
capricola





X



Ashford and Crewe, 2003

Trichostrongylus
colubriformis



X





Ashford and Crewe, 2003

Trichostrongylus
in stab His





X



Ashford and Crewe, 2003

Trichostrongylus lerouxi





X



Ashford and Crewe, 2003

Trichostrongylus
orientalis





X



Ashford and Crewe, 2003

Trichostrongylus
probolurus





X



Ashford and Crewe, 2003

Trichostrongylus skrjabini





X



Ashford and Crewe, 2003

Trichostrongylus vitrinus





X



Ashford and Crewe, 2003

Trichuris suis



X





Ashford and Crewe, 2003

Page B62


-------
EPA-Office of Water

Technical Support Document for the
Final Fifth Contaminant Candidate List (CCL 5)-
Microbial Contaminants

EPA 815-R-22-004
October 2022

Helminths

1

2

3

4

5

6

7

8

9

10

11

12

PCCL

Page Reference

Trichuris trichiura







X









Ashford and Crewe, 2003

Trichuris vulpis







X









Ashford and Crewe, 2003

Uncinaria stenocephala







X









Ashford and Crewe, 2003

Watsonius macaci











X





Ashford and Crewe, 2003

Wuchereria bancrofti



X













Ashford and Crewe, 2003

Wuchereria lewisi



X













Ashford and Crewe, 2003















Fungi

1

2

3

4

5

6

7

8

9

10

11

12

PCCL

Page Reference

Absidia corymbifera









X







MCM-12th Edition

A cremonium kiliense









X







MCM-12th Edition

Acremonium potronii









X







MCM-12th Edition

Acremonium recifei









X







MCM-12th Edition

A cremonium striatum









X







MCM-12th Edition

A crophialophora









X







MCM-12th Edition

fusispora



















Actinomadura madurae









X







MCM-12th Edition

Actinomadura pelletieri









X







MCM-12th Edition

Alternaria alternata









X







MCM-12th Edition

Alternaria caespitosa









X







Howard, 2003 p. 575

Page B63


-------
EPA-Office of Water	Technical Support Document for the	EPA 815-R-22-004

Final Fifth Contaminant Candidate List (CCL 5)-	October 2022

Microbial Contaminants

Fungi

12 3 4

5

6

7 8

9

10

11 12

PCCL

Page Reference

A Item aria chlamydospora









X







MCM-12th Edition

A Item aria dianthicola





X





MCM-12th Edition

Alternaria infectoria





X





MCM-12th Edition

A Item aria longipes





X





MCM-12th Edition

Alternaria stemphyloides





X





htto://www.doctorfuneus.ore/t
hefunsi/Alternaria.htm

Alternaria tenuissima





X





MCM-12th Edition

Aphanoascus fulvescens





X





MCM-12th Edition

Apophysomyces elegans





X





MCM-12th Edition

Arachnomyces
nodosetosus





X





MCM-12th Edition

Arthrinium
phaeospermum





X





htto://www.doctorfuneus.ore/t
hefunsi/Artlirinium. htm

Arthroderma uncinatum





X





MCM-12th Edition

Arthrographis kelrae*





X





Warns et al.. 2001

Aspergillus candidus





X





MCM-12th Edition

Aspergillus clavatus





X





MCM-12th Edition

Aspergillus fisherianus





X





MCM-12th Edition

Aspergillus fia\'ipes





X





MCM-12th Edition

Aspergillus flavus group





X





MCM-12th Edition

Aspergillus fumigatus
group









Aspergillus fumigatus



Page B64


-------
EPA-Office of Water	Technical Support Document for the	EPA 815-R-22-004

Final Fifth Contaminant Candidate List (CCL 5)-	October 2022

Microbial Contaminants

Fungi

12 3 4

5

6

7 8

9

10

11 12

PCCL

Page Reference

Aspergillus glaucus









X







MCM-12th Edition

Aspergillus nidulans
group





X





MCM-12th Edition

Aspergillus niger





X





MCM-12th Edition

Aspergillus orvzae





X





MCM-12th Edition

Aspergillus terreus group





X





MCM-12th Edition

Aspergillus versicolor





X





MCM-12th Edition

Aspergillus wentii





X





MCM-12th Edition

A ureobasidium pullulans





X





MCM-12th Edition

Basidiobolus ranarum





X





MCM-12th Edition

Beauveria bassiana





X





MCM-12th Edition

Bipolaris australiensis





X





MCM-12th Edition

Blastomyces dermatitidis





X





MCM-12th Edition

Botryosphaeria
subglobosa





X





httD://nc\\Dortal. ebif.ore/soecie
s/14373513 and
httt>://www.cabri.ore/CABRI/s
rs-bin/weetz?-newld+-e+-
Daac+ciRcsult+l CAB I FIL-
id:'IMI%20287616'l

Botrvtsis cinerea



X







Hashimoto et al.. 2017

Byssochlamvs spectabilis





X





MCM-12th Edition

Candida

acidothermophilum





X





MCM-12th Edition

Page B65


-------
EPA-Office of Water	Technical Support Document for the	EPA 815-R-22-004

Final Fifth Contaminant Candidate List (CCL 5)-	October 2022

Microbial Contaminants

Fungi

12 3 4

5

6

7 8

9

10

11 12

PCCL

Page Reference

Candida albicans









X







MCM-12th Edition

Candida catenulata





X





MCM-12th Edition

Candida famata





X





MCM-12th Edition

Candida fmietaria var.
fimetaria





X





MCM-12th Edition

Candida glabrata

X









MCM-12th Edition

Candida haemulonis





X





MCM-12th Edition

Candida intermedia





X





htto://www.doctorfuneus.ore/t
hefunei/Candida simhtm

Candida lodderae





X





MCM-12th Edition

Candida mycoderma var.
annulata





X





MCM-12th Edition

Candida parapsilosis





X





MCM-12th Edition

Candida tropicalis





X





MCM-12th Edition

Cephaliophora irregularis





X





htto://www.doctorfuneus.ore/i
maacban/svnonvms/CcDhalioD
hora.htm

Cerinosterus cvanescens





X





htto://www.doctorfuneus.ore/t
hefunei/Soorothrix. htm

Chaetomium
atrobrunneum





X





MCM-12th Edition

Chaetomium funicola





X





htto://www.doctorfuneus.ore/t
hefunsi/Chaetomium. htm

Chaetomium globosum





X





MCM-12th Edition

Page B66


-------
EPA-Office of Water	Technical Support Document for the	EPA 815-R-22-004

Final Fifth Contaminant Candidate List (CCL 5)-	October 2022

Microbial Contaminants

Fungi

12 3 4

5

6

7 8

9

10

11 12

PCCL

Page Reference

Chaetomium perpulchrum









X







httt>://www.doctorfuneus.ore/t
hefunei/Chaetomium. htm

Chaetomium strumarium





X





MCM-12th Edition

Chaetophoma dermo-
unguis





X





httt>://www.doctorfuneus.ore/i
maeeban/svnonvms/Chaetooho
ma. htm

Chlamvdoabsidia padenii





X





htto://www.doctorfuneus.ore/i
maeeban/svnonvms/Chlamvdo
absidia.htm

Chlorella protothecoides





X





htto://ocaoxfordiournals.ore/c
ei/content/abstract/9/1/87

Chrysosporium zonatum *





X





Arvanitidou et al.. 1999

Cladophialophora arxii





X





MCM-12th Edition

Cladophialophora
bantiana





X





MCM-12th Edition

Cladophialophora boppii





X





MCM-12th Edition

Cladophialophora
carrionii





X





MCM-12th Edition

Cladophialophora
devriesii





X





MCM-12th Edition

Cladorrhinum bulbillosum





X





htto ://uwadmnweb .uwvo .edu/b
otanv/Soil%20Microfuneal%2
0Collection/RMF%20collectio
n%20(Rockv%20Mountain%2
OFiinai)DartII.htm

Page B67


-------
EPA-Office of Water	Technical Support Document for the	EPA 815-R-22-004

Final Fifth Contaminant Candidate List (CCL 5)-	October 2022

Microbial Contaminants

Fungi

12 3 4

5

6

7 8

9

10

11 12

PCCL

Page Reference

Cladosporium
cladosporioides









X







MCM-12th Edition

Cladosporium elatum





X





htto://www.doctorfuneus.ore/t

hcfunai/CladosDO rium.htm

Cladosporium oxvsporum





X





htto://www.doctorfuneus.ore/t

hcfunai/CladosDO rium.htm

Cladosporium
sphaerosphermum





X





MCM-12th Edition

Clavispora lusitaniae





X





MCM-12th Edition

Coccidioides immitis





X





MCM-12th Edition

Cochliobolus pallescens





X





Howard, 2003 p. 584-586

Cokeromyces recur\>artus





X





MCM-12th Edition

Colletotrichum coccodes





X





Howard, 2003 p. 662-664

Colletotrichum
gloeosporioides





X





Howard, 2003 p. 662-664

Conidiobolus coronatus





X





MCM-12th Edition

Conidiobolus incongruus





X





MCM-12th Edition

Conidiobolus lamprauges





X





Howard, 2003 p. 133-137

Coniochaeta hoffmannii





X





MCM-12th Edition

Coniochaeta mutabilis





X





MCM-12th Edition

Coniothyrium fuckelii





X





htto://www.doctorfunsus.ors/i

maeeban/svnonvms/Coniothvri

um.htm

Page B68


-------
EPA-Office of Water	Technical Support Document for the	EPA 815-R-22-004

Final Fifth Contaminant Candidate List (CCL 5)-	October 2022

Microbial Contaminants

Fungi

12 3 4

5

6

7 8

9

10

11 12

PCCL

Page Reference

Coprinopsis cinerea









X







MCM-12th Edition

Cryptococcus neoformcms





X





MCM-12th Edition

C unninghameUa
bertholletiae





X





MCM-12th Edition

Cun'ularia brachvspora





X





Howard, 2003 p. 584-586

Cun'ularia clavata





X





Howard, 2003 p. 584-586

Cun'ularia gen icu lata





X





MCM-12th Edition

Cun'ularia hawaiiensis





X





MCM-12th Edition

Cun'ularia lunata





X





MCM-12th Edition

Cun'ularia senegalensis





X





Howard 2003 p. 584-586

Cun'ularia spicifera





X





MCM-12th Edition

Cun'ularia verucculosa





X





Howard, 2003 p. 584-586

Dichotomophthora
portulacae





X





httt>://www.doctorfuneus.ore/i
maeeban/svnonvms/Dichotom
ODhthora.htm

Dichotomophthoropsis
nymphaerum





X





httt>://www.doctorfuneus.ore/i
maeeban/svnonvms/Dichotom
ODhthoroDsis.htm

Dissitimurus exedrus





X





Howard, 2003 p. 588

Diutina rugosa





X





MCM-12

Doratomyces stemonitis





X





htto://www.doctorfunsus.ors/i

maeeban/svnonvms/Doratomvc

es.htm

Emm on si a crescens





X





MCM-12th Edition

Page B69


-------
EPA-Office of Water	Technical Support Document for the	EPA 815-R-22-004

Final Fifth Contaminant Candidate List (CCL 5)-	October 2022

Microbial Contaminants

Fungi

12 3 4

5

6

7 8

9

10

11 12

PCCL

Page Reference

Emm on si a pan'a









X







MCM-12th Edition

Epiccocum purpurascens



X







httos ://www .insoa. ac .ca/en/mo

ulds/fact-sheets/emcoccum-

DiirDiirasccns

Epidermophytia
floccosum





X





MCM-12th Edition

Exophiala dermatitidis





X





MCM-12th Edition

Exophiala jeanselmei









Exophiala jeanselmei



Exophiala moniliae





X





Howard, 2003 p. 590-596

Exophiala pisciphila





X





Howard, 2003 p. 590-596

Exophiala psychrophila





X





htto://www.doctorfunsus.ors/t
hefunei/exoohiala.htm

Exophiala salmonis





X





Howard, 2003 p. 590-596

Exophiala spinifera





X





MCM-12th Edition

Exosporium dematium





X





Howard, 2003 p. 662-664

Exserohilum
longirostratum





X





MCM-12th Edition

Exserohilum macginnisii





X





Howard, 2003 p. 596-597

Falciformispora
senegalensis





X





MCM-12th Edition

Falciformispora
tompkinsii





X





MCM-12th Edition

Fonsecaea compacta





X





htto://www.doctorfunsus.ors/t
hefunei/Fonsecaea.htm

Page B70


-------
EPA-Office of Water	Technical Support Document for the	EPA 815-R-22-004

Final Fifth Contaminant Candidate List (CCL 5)-	October 2022

Microbial Contaminants

Fungi

12 3 4

5

6

7 8

9

10

11 12

PCCL

Page Reference

Fusarium aquaeductuum









X







Howard, 2003 p. 402

Fusarium
chlamvdosporum





X





MCM-12th Edition

Fusarium dimerum





X





MCM-12th Edition

Fusarium falciforme





X





MCM-12th Edition

Fusarium moniliforme





X





MCM-12th Edition

Fusarium napiforme





X





MCM-12th Edition

Fusarium

neocosmosporiellum





X





Howard, 2003 p. 434-436

Fusarium nivale





X





Howard, 2003 p. 431

Fusarium oxvsporum





X





MCM-12th Edition

Fusarium pallidoroseum





X





Howard p. 320,418-421

Fusarium proliferatum





X





MCM-12th Edition

Fusarium sacchari





X





MCM-12th Edition

Fusarium solani









Fusarium solani



Fusarium subglutinans





X





MCM-12th Edition

Fusarium ventricosum





X





htto://www.doctorfunsus.ors/t
hefunsi/fusarium. htm

Fusarium verticillioides





X





MCM-12th Edition

Geotrichum candidum *





X





Rosenzweig et al., 1986

Gliomastix roseogrisea





X





Howard, 2003 p. 384

Hansenula anomala





X





MCM-12th Edition

Page B71


-------
EPA-Office of Water	Technical Support Document for the	EPA 815-R-22-004

Final Fifth Contaminant Candidate List (CCL 5)-	October 2022

Microbial Contaminants

Fungi

12 3 4

5

6

7 8

9

10

11 12

PCCL

Page Reference

Histoplasma capsulatum









X







MCM-12th Edition

Hortaea werneckii





X





MCM-12th Edition

Humicola lanuginosa





X





Howard, 2003 p. 623

Hvpocrea pseudokoningii





X





MCM-12th Edition

Kiflimonium cur\'ulum





X





MCM-12th Edition

Kluweromvces marxianus





X





MCM-12th Edition

Lasiodiplodia theobromae





X





MCM-12th Edition

Lophophvton gallinae





X





MCM-12th Edition

Madurella ikedae





X





MCM-12th Edition

Magnusiomvces capitatus





X





MCM-12th Edition

Malassezia globosa

X









MCM-12th Edition

Malassezia obtusa

X









MCM-12th Edition

Malassezia pachvdermatis

X









MCM-12th Edition

Malassezia restricta

X









MCM-12th Edition

Malassezia slooflae

X









MCM-12th Edition

Malassezia svmpodialis

X









MCM-12th Edition

Meverozyma
guilliermondii





X





MCM-12th Edition

Microascus cinereus





X





MCM-12th Edition

Page B72


-------
EPA-Office of Water	Technical Support Document for the	EPA 815-R-22-004

Final Fifth Contaminant Candidate List (CCL 5)-	October 2022

Microbial Contaminants

Fungi

12 3 4

5

6

7 8

9

10

11 12

PCCL

Page Reference

Microascus cirrosus









X







MCM-12th Edition

Microsporian audouinii





X





MCM-12th Edition

Microsporian canis





X





MCM-12th Edition

Microsporian equinum





X





MCM-12th Edition

Microsporian ferrugineum





X





MCM-12th Edition

Microsporian nanum





X





MCM-12th Edition

Microsporian praecox





X





MCM-12th Edition

Moniliella suaveolens





X





htto://www.doctorfuneus.ore/i

maeeban/svnonvms/Moniliella.

htm

Mucor circinelloides





X





MCM-12th Edition

Mucor hiemalis





X





MCM-12th Edition

Mu cor in die us





X





Howard p. 70, 98-99, 101

Mucor racemosus





X





MCM-12th Edition

Mucor ramosissimus





X





MCM-12th Edition

Mvceliophthora
thermophila





X





MCM-12th Edition

Mycocentrospora acerina





X





Howard, 2003 p. 602-603

Mycoleptodiscus indicus





X





Howard, 2003 p. 602-603

Myriodontium
keratinophilum





X





MCM-12th Edition

Nannizzia cajetani





X





Howard, 2003 p. 155

Page B73


-------
EPA-Office of Water	Technical Support Document for the	EPA 815-R-22-004

Final Fifth Contaminant Candidate List (CCL 5)-	October 2022

Microbial Contaminants

Fungi

12 3 4

5

6

7 8

9

10

11 12

PCCL

Page Reference

Nannizzia fulva









X







MCM-12th Edition

Nannizzia gypsea





X





MCM-12th Edition

Ncmnizzia persicolor





X





MCM-12th Edition

Ncmnizzia racemosa





X





MCM-12th Edition

Nattrassia mangiferae





X





MCM-12th Edition

Neocosmospora
cvanescens





X





MCM-12th Edition

Neocosmospora
keratoplastica





X





Howard, 2003 p. 394

Neocosmospora
lichenicola





X





MCM-12th Edition

Neoscytalidium hyalinum





X





MCM-12th Edition

Neotestudina rosatii





X





MCM-12th Edition

Neurospora sitophila





X





htto://www.doctorfuneus.ore/i
maeeban/svnonvms/Chrvsonili
a.htm

Nigrospora sphaerica





X





htto://www.doctorfuneus.ore/t

lie fYumi/Ni arosDora.htm

Ochroconis gallopava





X





MCM-12th Edition

Ochroconis tshawvtschae





X





Howard, 2003 p. 617

Oidiodendron cereale





X





htto://www.doctorfunsus.ors/i
maeeban/svnonvms/Oidiodend
ron.htm

Oidium chartarum





X





Doggett, 2000

Page B74


-------
EPA-Office of Water	Technical Support Document for the	EPA 815-R-22-004

Final Fifth Contaminant Candidate List (CCL 5)-	October 2022

Microbial Contaminants

Fungi

12 3 4

5

6

7 8

9

10

11 12

PCCL

Page Reference

Oospora sulphureo-
ochracea









X







Howard, 2003 p. 230-232

Ovadendron ochraceum





X





htto: //www. catalo eueoflife .ore/
show soccics details.DliD'.'rcco
rd id=3330913

Paecilomyces farinosus





X





httt>://www.doctorfuneus.ore/t
hefunei/Paecilomvces.htm

Paecilomvces
fumerosoreus





X





Howard, 2003 p. 361-362

Paecilomvces javanicus





X





MCM-12th Edition

Paecilomvces lilacinus





X





MCM-12th Edition

Paecilomyces marquandii





X





MCM-12th Edition

Paecilomvces viridis





X





Howard, 2003 p. 357-359

Paracoccidioides
brasiliensis





X





httt>://www.doctorfuneus.ore/t
hefunei/Lacazia. htm

Paracoccidioides
brasiliensis





X





MCM-12th Edition

Parendomvces
zevlanoides





X





MCM-12th Edition

Parengyodontium album





X





MCM-12th Edition

PeniciIlium chrysogenum





X





MCM-12th Edition

PeniciIlium citrinum





X





MCM-12th Edition

Penici Ilium commune





X





MCM-12th Edition

Page B75


-------
EPA-Office of Water	Technical Support Document for the	EPA 815-R-22-004

Final Fifth Contaminant Candidate List (CCL 5)-	October 2022

Microbial Contaminants

Fungi

12 3 4

5

6

7 8

9

10

11 12

PCCL

Page Reference

PeniciIlium decumbens









X







MCM-12th Edition

PeniciIlium expcmsum





X





MCM-12th Edition

Penici Ilium marneffei





X





MCM-12th Edition

Penicillium
purpurogenum





X





MCM-12th Edition

Phaeoanellomyces
elegans





X





Howard, 2003 p. 605-606

Phaeoanellomyces
werneckii





X





MCM-12th Edition

Phaeosclera dematioides





X





htto://www.doctorfuneus.ore/i

maeeban/svnonvms/Phaeoscler

a.htm

Phaeotrichoconis
crotalariae





X





Howard, 2003 p. 606-607

Phanerochaete
chrvsosporium





X





Doggett, 2000

Phialemoniopsis cur\'ata





X





MCM-12th Edition

Phialemonium obovatum





X





MCM-12th Edition

Phialophora bubakii





X





Howard, 2003 p. 607-612

Phialophora pedrosoi





X





htto://www.doctorfunsus.ors/t
hefunei/Fonsecaea.htm

Phialophora richardsiae





X





MCM-12th Edition

Phialophora verrucosa





X





MCM-12th Edition

Phoma cava





X





htto://www.doctorfunsus.ors/t
hefunei/ohoma. htm

Page B76


-------
EPA-Office of Water	Technical Support Document for the	EPA 815-R-22-004

Final Fifth Contaminant Candidate List (CCL 5)-	October 2022

Microbial Contaminants

Fungi

12 3 4

5

6

7 8

9

10

11 12

PCCL

Page Reference

Phoma cruris-hominis









X







Howard, 2003 p. 666-668

Phoma eupvrena





X





Howard, 2003 p. 666-668

Phoma glomerate/





X





Howard, 2003 p. 666-668

Phoma herbarum





X





httt>://www.doctorfuneus.ore/t
hefunei/ohoma. htm

Phoma hibernica





X





Howard, 2003 p. 666-668

Phoma minutella





X





Howard, 2003 p. 666-668

Phoma oculo-hominis





X





Howard, 2003 p. 666-668

Phyllosticta citricarpa





X





httt>://www.doctorfuneus.ore/t
hefunei/ohoma. htm

Piedraia hortae





X





MCM-12th Edition

Pitvrosporum orbiculare

X









MCM-12th Edition

Pleurophoma pleurospora





X





Howard, 2003 p. 666-668

Pleurostoma repens





X





MCM-12th Edition

Pneumocystis carinii



X







MCM-12th Edition

Prototheca wickerhamii





X





MCM-12th Edition

Prototheca zopfii





X





MCM-12th Edition

Pseudoallescheria bovdii





X





MCM-12th Edition

Pseudomicrodochium
suttonii





X





MCM-12th Edition

Pyrenochaeta
mackiimonii





X





MCM-12th Edition

Page B77


-------
EPA-Office of Water	Technical Support Document for the	EPA 815-R-22-004

Final Fifth Contaminant Candidate List (CCL 5)-	October 2022

Microbial Contaminants

Fungi

12 3 4

5

6

7 8

9

10

11 12

PCCL

Page Reference

Pvrenochaeta romeroi









X







MCM-12th Edition

Pyrenochaeta unguis-
hominis





X





Howard, 2003 p. 666-668

Pvrenophora biseptata





X





Howard, 2003 p. 588-589

Pvthium insidiosum





X





MCM-12th Edition

Ramichloridium
obovoidea





X





httt>://www.doctorfuneus.ore/i
maeeban/svnonvms/Ramichlor
idium.htm

Rhinocladiella
aquaspersa





X





MCM-12th Edition

Rhinocladiella schulzeri





X





httt>://www.doctorfuneus.ore/i
maeeban/svnonvms/Ramichlor
idium.htm

Rhinosporidium seeberi





X





MCM-12th Edition

Rhizomucor miehei





X





MCM-12th Edition

Rhizomucor pusilhis





X





MCM-12th Edition

Rhizopus azvgosporus





X





MCM-12th Edition

Rhizopus microsporus





X





MCM-12th Edition

Rhizopus orvzae





X





MCM-12th Edition

Rhizopus stolonifer





X





MCM-12th Edition

Rhodotorula glutinis

X









MCM-12th Edition

Rhodotorula minuta

X









MCM-12th Edition

Rhodotorula mucilaginosa

X









MCM-12th Edition

Rhodotorula rubra

X









MCM-12th Edition

Page B78


-------
EPA-Office of Water	Technical Support Document for the	EPA 815-R-22-004

Final Fifth Contaminant Candidate List (CCL 5)-	October 2022

Microbial Contaminants

Fungi

12 3 4

5

6

7 8

9

10

11 12

PCCL

Page Reference

Saccharomyces cerevisiae









X







MCM-12th Edition

Saksenaea vasiformis





X





MCM-12th Edition

Sarcinomyces
phaeom uri form is





X





MCM-12th Edition

Scedosporium prolificans





X





MCM-12th Edition

Schizophylhtm commune





X





MCM-12th Edition

Scolecobasidium
humicola





X





Howard, 2003 p. 617

Scopulariopsis
acremonium





X





MCM-12th Edition

Scopulariopsis asperula





X





MCM-12th Edition

Scopulariopsis brevicaulis





X





MCM-12th Edition

Scopulariopsis brumptii





X





MCM-12th Edition

Scopulariopsis Candida





X





MCM-12th Edition

Scopulariopsis fla\>a





X





MCM-12th Edition

Scopulariopsis fusca





X





MCM-12th Edition

Scytalidium infestans





X





htto ://www. scielo .br/scielo .oho
?scriDt=sci arttext&md=S0036

46651999000500009&lns=Dt&
nrm=iso&tlna=Dt

Septonema exile





X





Howard, 2003 p. 621

Setosphaeria rostrata





X





MCM-12th Edition

Page B79


-------
EPA-Office of Water	Technical Support Document for the	EPA 815-R-22-004

Final Fifth Contaminant Candidate List (CCL 5)-	October 2022

Microbial Contaminants

Fungi

12 3 4

5

6

7 8

9

10

11 12

PCCL

Page Reference

Sporothrix schenckii









X







MCM-12th Edition

Stemphvlium
macrosporoideum *





X





West 1986

Stenella araguata





X





htto://www.doctorfuneus.ore/i
maeeban/svnonvms/Stenella. lit
m

Streptomyces somaliensis





X





MCM-12th Edition

Taeniolella stilbaspora





X





Howard, 2003 p. 621

Tetraploa aristata





X





Howard, 2003 p. 621-623

Thermomvces dupontii





X





Howard, 2003 p. 340-346

Thielavia terrestris





X





MCM-12th Edition

Torulopsis magnoliae





X





htto://www.doctorfunsus.ors/i
maeeban/svnonvms/T oruloosis
.htm

Trematosphaeria grisea





X





MCM-12th Edition

Trichoderma viride





X





MCM-12th Edition

Trichomaris invadens





X





httt>://www.oac.dfo-
mt>o.ec.ca/sci/shelldis/t>aees/ch
itfdcb e.htm

Trichophyton
concentricum





X





MCM-12th Edition

Trichophyton equinum





X





MCM-12th Edition

Trichophyton gallinae





X





MCM-12th Edition

Trichophyton gour\>ilii





X





MCM-12th Edition

Page B80


-------
EPA-Office of Water	Technical Support Document for the	EPA 815-R-22-004

Final Fifth Contaminant Candidate List (CCL 5)-	October 2022

Microbial Contaminants

Fungi

12 3 4

5

6

7 8

9

10

11 12

PCCL

Page Reference

Trichophyton megninii









X







MCM-12th Edition

Trichophyton
mentagrophytes





X





MCM-12th Edition

Trichophyton rubrum





X





MCM-12th Edition

Trichophyton schoenleinii





X





MCM-12th Edition

Trichophyton simii





X





MCM-12th Edition

Trichophyton soudanense





X





MCM-12th Edition

Trichophyton tonsurans





X





MCM-12th Edition

Trichophyton verrucosum





X





MCM-12th Edition

Trichophyton violaceum





X





MCM-12th Edition

Trichosporon asahii





X





MCM-12th Edition

Trichosporon beigelii





X





MCM-12th Edition

Trichosporon cutaneum





X





MCM-12th Edition

Trichosporon inkin





X





MCM-12th Edition

Trichosporon mucoides





X





MCM-12th Edition

Trichosporon ovoides





X





MCM-12th Edition

Tritirachium oryzae





X





htto://www.doctorfuneus.ore/i
maeeban/svnonvms/T ritirachiu
m.htm

Tubercularia vulgaris





X





Howard, 2003 p. 448-449

Ulocladium chartarum





X





Howard, 2003 p. 623-624

Page B81


-------
EPA-Office of Water	Technical Support Document for the	EPA 815-R-22-004

Final Fifth Contaminant Candidate List (CCL 5)-	October 2022

Microbial Contaminants

Fungi

12 3 4

5

6

7 8

9

10

11 12

PCCL

Page Reference

Veronaea botryosa









X







htto://www.doctorfuneus.ore/i
maeeban/svnonvms/Veronaea.
htm

Verticillium nigrescens





X





Howard, 2003 p. 449-450

Volutella cinerescens





X





Howard, 2003 p. 451

Yarrowia lipolytica





X





MCM-12th Edition

Page B82


-------
EPA-Office of Water

Technical Support Document for the
Final Fifth Contaminant Candidate List (CCL 5)-
Microbial Contaminants

EPA 815-R-22-004
October 2022

Appendix C: PCCL 5 Pathogen Scores

Pathogen

WBDO

Occurrence

Normalized health
score

Total score

Naegleria fowleri

5

3

5.0

10.0

Legionella pneumophila

5

3

3.6

8.6

Escherichia coli (0157)

5

3

3.2

8.2

Pseudomonas aeruginosa

5

3

3.2

8.2

Campylobacter jejuni

5

3

2.5

7.5

Mycobacterium abscessus

4

3

3.2

7.2

Shigella sonnei

4

3

3.2

7.2

Caliciviruses

5

3

2.1

7.1

Helicobacter pylori

1

2

5.0

7.0

Mycobacterium avium

4

3

2.9

6.9

Adenovirus

2

3

3.6

6.6

Enterovirus

2

3

3.6

6.6

Pantoea agglomerans

4

3

2.5

6.5

Hepatitis A virus

3

2

3.2

6.2

Fusarium solani

1

3

2.9

5.9

Nontuberculous Mycobacteria (NTM)

3

3

2.9

5.9

Hepatitis E virus

2

1

3.6

5.6

Cyclospora cayetanensis

3

3

2.5

5.5

Rotavirus

2

3

2.5

5.5

Salmonella enterica

3

3

2.5

5.5

Toxoplasma gondii

2

1

3.2

5.2

Aspergillus fumigatus group

1

3

2.1

5.1

Entamoeba histolytica

3

3

2.1

5.1

Exophiala jeanselmei

1

3

2.1

5.1

Vibrio cholerae

3

3

2.1

5.1

Aeromonas hydrophila

1

3

1.8

4.8

Plesiomonas shigelloides

3

3

1.8

4.8

Blastocystis hominis

4

1

0.7

4.7

Acinetobacter baumannii

1

2

2.5

4.5

Comanonas testosteroni

1

2

2.5

4.5

Yersinia enterocolitica

3

3

1.4

4.4

Page CI


-------
EPA-Office of Water	Technical Support Document for the	EPA 815-R-22-004

Final Fifth Contaminant Candidate List (CCL 5)-	October 2022

Microbial Contaminants

Astrovirus

2

2

1.4

3.4



Microsporidia

1

2

1.4

3.4



Isospora belli

2

1

1.1

3.1



Page C2


-------
EPA-Office of Water

Technical Support Document for the
Final Fifth Contaminant Candidate List (CCL 5)-
Microbial Contaminants

EPA 815-R-22-004
October 2022

Appendix D: The Final CCL 5 for Microbes

Microbe

Final
CCL 3

Final
CCL 4

Final
CCL 51

Adenovirus

X

X

X

Caliciviruses

X

X

X

Campylobacter jejuni

X

X

X

Enterovirus

X

X

X

Escherichia coli (0157)

X

X

X

Helicobacter pylori

X

X

X

Legionella pneumophila

X

X

X

Mycobacterium abscessus





X

Mycobacterium avium

X

X

X

Naegleria fowleri

X

X

X

Pseudomonas aerugionosa





X

Shigella sonnei

X

X

X

hepatitis A and Salmonella enterica were listed on CCL 3 and CCL 4 but are not listed on CCL 5.

Page D1


-------
EPA-Office of Water

Technical Support Document for the
Final Fifth Contaminant Candidate List (CCL 5)-
Microbial Contaminants

EPA 815-R-22-004
October 2022

Appendix E: Documented PCCL 5 Microbes WBDOs in the U.S. Reported by
CDC Between 2009-2017

Microorganism

2009

2010

2011

2012

2013

2014

2015

2016

2017

Total

Acinetobacter baumannii



















0

Adenovirus



















0

Aeromonas hydrophila



















0

Arcobacter butzleri



















0

Aspergillus fumigatus



















0

Astrovirus



















0

Blastocystis hominis







1











1

Caliciviruses



1



1



2

1





4

Campylobacter jejuni

1

4



1





2



1

9

Comamonas testosteroni



















0

Cyclospora cayetanensis



















0

Entamoeba histolytica



















0

Enterovirus



















0

Escherichia coli (0157)



1

1



1

1



1



5

Exophiala jeanselmei



















0

Fusarium solani



















0

Helicobacter pylori



















0

Hepatitis A virus



















0

Hepatitis E virus



















0

Isospora belli



















0

Legionella pneumophila

9

12

11

12

6

17

13

24

21

125

Microsporidia



















0

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Technical Support Document for the
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Microbial Contaminants

EPA 815-R-22-004
October 2022

Microorganism

2009

2010

2011

2012

2013

2014

2015

2016

2017

Total

Mycobacterium
abscessus











1







1

Mycobacterium avium















1



1

Naegleria fowleri

















1

1

Nontuberculous
Mycobacteria (NTM)



















0

Pantoea agglomerans







1











1

Plesiomonas shigelloides



















0

Pseudomonas aeruginosa









1





1



2

Rotavirus



















0

Salmonella enterica



















0

Shigella sonnei













1





1

Toxoplasma gondii



















0

Vibrio cholerae



















0

Yersinia enterocolitica



















0

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EPA-Office of Water

Technical Support Document for the
Final Fifth Contaminant Candidate List (CCL 5)-
Microbial Contaminants

EPA 815-R-22-004
October 2022

Appendix F: Microbial Contaminant Information Sheets (CISs)

Microbes Infographics

Selection of microbes from the CCL Universe for placement on the PCCL is based upon
exclusionary screening criteria that assess the potential of water-related transmission
(occurrence) and the plausibility of causing waterborne disease by ingestion, inhalation, or
dermal contact (health risk). Microbes that met any of the exclusionary criteria were not
included on the PCCL.

Elements of each CIS include:

Scoring Summary - shows the scores used to calculate the final composite score for each
microbial contaminant which included the highest score between the WBDO and occurrence, the
health risk score for the general population, and the highest health risk score of the sensitive
populations.

Data Table - shows the categories for each potential score, the scoring data, if applicable, and
reference(s) used to support a score. The highest-ranking score for each of the three scoring
categories is shown in bold font. The WBDOs scoring results are presented first, followed by the
occurrence results and the health risks.

References - presents the full references for the data presented in the table.

The pages below provide examples of the CCL decision making process Adenovirus, which
was included on the CCL 5. Following the example are CISs for each of the PCCL 5 and
nominated microbes.

This infographic shows Adenovirus as an example of a contaminant that was listed on the CCL
5.

The graphic shows a box for each of the three attributes (Occurrence, WBDO, and Health Risk)
that serve as input to the scoring model.

The attribute boxes show:

•	The data used for scoring each attribute, in bold, and indicated by a "yes" in the right
hand column.

•	The score the contaminant received for that particular attribute (in the left hand column).

•	The occurrence score (of 3) for Adenovirus was chosen, as shown in the upper left hand
corner, because it is greater than the WBDO score (of 2).

•	The health risk scores for the general population (of 6) and the sensitive population (of 4)
are added together (equaling 10) and multiplied by 5/14 (the health risk score equalizing
value), which equals 3.6.

•	The occurrence score is added to the adjusted health risk score for a total score for
Adenovirus of 6.6,

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EPA-Office of Water

Technical Support Document for the
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EPA 815-R-22-004
October 2022

Pathogen
Total Score

Highest Score
between WBDO
and Occurrence

((

General Population
Score + Highest
Sensitive
Population

l X 5/14 |

Example: Calculation of Adenovirus Total Score

Adenovirus Total Score = 3 (Occurrence Score) + ((6 (General Population Score) + 4
(Children/CD) x 5/14); Adenovirus Total Score = 3 + 3.6;

Adenovirus Total Score = 6.6

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EPA-Office of Water

Technical Support Document for the
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Microbial Contaminants

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October 2022

Adenovirus: Microbe Included on the CCL 5

Scoring Summary



Occurrence

3

Total Score: 6.6

Health Risk



General population

6

Waterbome Disease Outbreaks

Sensitive population

4

Score

Data Element

Scoring Data

Occurrence

5

Multiple WBDOs in US (2009-2017)



Score

Data Element

Scoring Data

4

At least one WBDOs in US (2009-2017)



3

Detected in drinking water in the US

Yes23

3

Caused WBDOs at any time in US



2

Detected in Source water in the US



2

Caused WBDOs hi countries other
than US

Yes: Europe1

1

Not detected in the US



1

Never caused WBDOs, associated w/
water related disease



Health Risk

Score

Data Element

Scoring Data

7

Does the organism cause significant mortality (> 1/1,000
cases)



6

Does the organism cause pneumonia, meningitis,
hepatitis, encephalitis, endocarditis, cancer, or other
severe manifestations of illness necessitating long
term hospitalization (> week)?

[General population! A frequent cause of pneumonia among
(unvaccinated) military recruits. Two deaths hi previously-healthy
adults.4

ARD is still significant problem hi military. Less common
manifestations include fatal neonatal disease, meningoencephalitis and
myocarditis.5

5

Does the illness result in long term or permanent
dysfunction or disability, i.e. sequelae?



4

Does the illness require short term hospitalization (<
week) ?

[Chronic Disease] Children with chronic disease required respiratory
ventilation.6

[ChildrenJ Young adults may contract acute respiratory disease.7

3

Does the illness require physician intervention?



2

Is the illness self-limiting within 72 hours (without
requiring medical intervention)?



1

Does the illness result in mild symptoms with minimal
or no impact on daily activities?



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EPA 815-R-22-004
October 2022

Pathogen Total Score = Highest Score between WBDO and Occurrence + ((General Population Score +
Highest Sensitive population Score) x 5/14)

Adenovirus Total Score = 3 (Occurrence Score) + ((6 (General Population Score) + 4 (Children/CD) x
5/14); Adenovirus Total Score = 3 + 3.6 = 6.6

1 Kukkula, M., Arstila P., Klossner M.L., Maunula L., Bonsdorff C.H., and P. Jaatinen. 1997. Scandinavian Journal of Infectious Disease, 29(4):

2	O'Reilly, C.E., A.B. Bowen, E.P. Nytzia, J.P. Sarisky, C.A. Shepherd, M.D. Miller, B.C. Hubbard, M. Herring, S.D. Buchanan, C.C. Fitzgerald,
V. Hill, M.J. Arrowood, L.X. Xiao, R.M. Hoekstra, E.D. Mintz, M.F. Lynch, and the Outbreak Working Group. 2007. A Waterborne Outbreak of
Gastroenteritis with Multiple Etiologies among Resort Island Visitors and Residents: Ohio, 2004. Clinical Infectious Diseases, 44:506-512.

3	Fong, T., L. Mansfield, D. Wilson, D. Schwab, S. Molloy and J. Rose. 2007. Massive Microbiological Groundwater Contamination Associated
with a Waterborne Outbreak in Lake Erie, South Bass Island, OH. Environmental Health Perspectives. 115(6): 856-864.

4	Gray, G.C., P.R. Goswami, M.D. Malasig, A.W. Hawksworth, D.H. Trump, M.A. Ryan and D.P. Schnurr. 2001. Adult Adenovirus Infections:
Loss of Orphaned Vaccines Precipitates Military Respiratory Disease Epidemics. Clinical Infectious Diseases, 31: 663-70.

5	Robinson, C. and M. Echavarria. 2007. Adenoviruses. In Murray, P.R., E.J. Baron, J.H. Jorgensen, M.L. Landry, and M.A. Pfaller (ed.) Manual
of Clinical Microbiology, 9th. edition, American Society for Microbiology, Washington, DC. Vol. 2: p. 1592.

6	CDC, 1983. Adenovirus type 7 outbreak in a pediatric chronic-care facility - Pennsylvania. 1972. MMWR, 1983:32;258-60.

7	CDC, 1998. Surveillance for Waterborne-Disease Outbreaks Associated with Drinking Water — United States, 1995—1996. MMWR
Surveillance Summaries, 47(SS-5); 1-33.

415-418.

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EPA 815-R-22-004
October 2022

Acinetobacter baumannii Scoring Data

Scoring Summary1'2

Occurrence

2

Health Risk

General population

1

Sensitive subpopulation(s) [CD, P]

6

1 Bolded text indicates the highest score for that particular protocol. For the health risk protocol two scores were selected: the
general population [G] and the highest score for a sensitive subpopulation. These 2 scores were added and normalized by
multiplying by 5/14 for a final health risk score. The higher score between the WBDO and Occurrence protocols was used for
total pathogen score calculation. Health Risk protocol: G - General, C - Child, E - Elderly, P - Pregnant Women, CD - Chronic
Disease

Score2

Data Element

Scoring Data

Reference3



Waterborne Disease Outbreaks

5

Has caused multiple (2 or
more) documented WBDOs
in the U.S. reported by CDC
between 2009-2017

No

CDC-NORS, 2020

4

Has caused at least one
documented WBDOs in U.S.
reported by CDC between
2009-2017

No

CDC-NORS, 2020

3

Has caused documented
WBDOs at any time in the
U.S.?





2

Has caused WBDOs in
countries other than the U.S.?





1

Has never caused WBDOs in
any country, but has been
epidemiologically associated

Yes. Outbreaks occur
most commonly in
hospitals to very ill
patients by person to

CDC, 2010

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Microbial Contaminants

Score2

Data Element

Scoring Data

Reference3



with water related disease?

person contact or via
contaminated surfaces.
However, it is still can
occur and be
transmitted in water.





Occurrence

3

Detected in drinking water in
the U.S.?





2

Detected in source water in
the U.S.?

Yes. It was detected
in untreated
groundwater used as
drinking water in
Preston County, W.
VA.

Bifulco, 1989

1

Not detected in the U.S.?







Health Risk

7

Does the organism cause
significant mortality (>
1/1,000 cases)





6 [CD, P]

Does the organism cause
pneumonia, meningitis,
hepatitis, encephalitis,
endocarditis, cancer, or
other severe manifestations
of illness necessitating long
term hospitalization (>
week)?

People with
weakened immune
systems due to
chronic diseases or
serious illnesses are
the most susceptible.
It causes various
diseases including
pneumonia and
serious blood or
wound infections.
Acinetobacter
baumannii infection
during pregnancy can
lead to premature
contractions and
chorioamnionitis. it

CDC, 2010

Aivazova, 2009

Cools et al. in MCM,
2019

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Microbial Contaminants

Score2

Data Element

Scoring Data

Reference3





can also cause septic
complications in the
puerperium
associated with long
duration of
hospitalization.



5

Does the illness result in long
term or permanent
dysfunction or disability, i.e.
sequelae?





4

Does the illness require short
term hospitalization (<
week)?





3

Does the illness require
physician intervention?





2

Is the illness self-limiting
within 72 hours (without
requiring medical
intervention)?





1[G, C, E]

Does the illness result in
mild symptoms with
minimal or no impact on
daily activities?

[G, C, E]
Acinetobacter
baumannii poses a
very limited health
threat to individuals
without a health
condition. Most
studies only report
outbreaks in hospitals
with patients that
have a health
condition.

CDC, 2010

1 Bolded text indicates the highest score for that particular protocol. For the health risk protocol two
scores were selected: the general population [G] and the highest score for a sensitive subpopulation.

These 2 scores were added and normalized by multiplying by 5/14 for a final health risk score. The higher
score between the WBDO and Occurrence protocols was used for total pathogen score calculation. Health
Risk protocol: G - General, C - Child, E - Elderly, P - Pregnant Women, CD - Chronic Disease.

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EPA-Office of Water

Technical Support Document for the
Final Fifth Contaminant Candidate List (CCL 5)-
Microbial Contaminants

EPA 815-R-22-004
October 2022

2See Final Contaminant Candidate List 3 Microbes: PCCL to CCL Process. EPA 815-R-09-009. Final.
August 2009 for a detailed description on how to calculate the total pathogen score.

3EPA based the WBDO scores on the CDC MMWR reports from 1991 -2017 and then collected
occurrence citations if there were no CDC WBDOs.

References

Aivazova, V., F. Kainer, K. Friese, and I. Mylonas. 2010. Acinetobacter baumannii infection
during pregnancy and puerperium. Archives of Gynecology and Obstetrics. 281(1): 171-174.

Bifulco, J.M., J.J. Shirey, and G.K. Bissonnette. 1989. Detection of Acinetobacter spp. in rural
drinking water supplies. Applied and Environmental Microbiology. 55(9): 2214-2219.

Centers for Disease Control and Prevention (CDC). 2010. Acinetobacter in Healthcare Settings.
(2010, November 24). Available online at:
https://www.cdc.gov/hai/organisms/acinetobacter.html.

CDC, 2020. National Outbreak Reporting System (NORS). Available online at:
https://wwwn.cdc.gov/norsdashboard/. Accessed August 31, 2020.

Cools, P., A. Nemec, P. Kampfer, and M. Vaneechoutte. 2019. Acinetobacter,
Chryseobacterium, Moraxella, and Other Nonfermaentive Gram-Negative Rods. In Carroll,
K.C., M.A. Pfaller, M.L. Landry, A.J. McAdam, R. Patel, S.S. Richter, and D.W. Warnock (ed).
Manual of Clinical Microbiology, 12th Edition, pp. 829-857. American Society for Microbiology
Press, Washington, DC.

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EPA 815-R-22-004
October 2022

Adenovirus Scoring Data

Scoring Summary1'2

Occurrence

3

Health Risk

General population

6

Sensitive subpopulation(s) [CD, C]

4

1 Bolded text indicates the highest score for that particular protocol. For the health riss protocol two scores were selected: the
general population [G] and the highest score for a sensitive subpopulation. These 2 scores were added and normalized by
multiplying by 5/14 for a final health risk score. The higher score between the WBDO and Occurrence protocols was used for
total pathogen score calculation. Health Risk protocol: G - General, C - Child, E - Elderly, P - Pregnant Women, CD - Chronic
Disease

Score2

Data Element

Scoring Data

Reference3



Waterborne Disease Outbreaks

5

Has caused multiple (2 or
more) documented WBDOs
in the U.S. reported by CDC
between 2009-2017

No

CDC-NORS, 2020

4

Has caused at least one
documented WBDOs in U.S.
reported by CDC between
2009-2017

No

CDC-NORS, 2020

3

Has caused documented
WBDOs at any time in the
U.S.?





2

Has caused WBDOs in
countries other than the
U.S.?

Yes

Europe; S. Korea

Kukkula et al., 1997
Lee et al., 2002

1

Has never caused WBDOs in
any country, but has been
epidemiologically associated





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Microbial Contaminants

Score2

Data Element

Scoring Data

Reference3



with water related disease?







Occurrence

3

Detected in drinking water
in the U.S.?

Yes

PCR in connection with
an outbreak.

O'Reilly et al., 2007
Fong et al., 2007

2

Detected in source water in
the U.S.?

Yes

38% of surface water
samples collected as part
of the Information
Collection Rule contained
Adenovirus 40 and
Adenovirus 41.

USEPA, 2007

1

Not detected in the U.S.?







Health Risk

7

Does the organism cause
significant mortality (>
1/1,000 cases)?





6 [G]

Does the organism cause
pneumonia, meningitis,
hepatitis, encephalitis,
endocarditis, cancer, or
other severe manifestations
of illness necessitating long
term hospitalization (>
week)?

[G] A frequent cause of
pneumonia among
(unvaccinated) military
recruits. Two deaths in
previously-healthy
adults.

ARD is still a significant
problem in military. Less
common manifestations
include fatal neonatal
disease,

meningoencephalitis and
myocarditis.

Gray et al., 2001

Robinson in MCM,
2010

Heim in MCM,
2019

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Microbial Contaminants

Score2

Data Element

Scoring Data

Reference3

5

Does the illness result in
long term or permanent
dysfunction or disability, i.e.
sequelae?

None reported



4[C,
CD]

Does the illness require
short term hospitalization
(< week)?

[CD] Children with
chronic disease required
respiratory ventilation.

[C] Young adults may
contract acute
respiratory disease.

CDC, 1983
CDC, 1998

3

Does the illness require
physician intervention?

Physician office visits are
indicated for ocular
infections.

Robinson in MCM,
2010

2 [E, P]

Is the illness self-limiting
within 72 hours (without
requiring medical
intervention)?

[E, P] Approximately 50%
of cases are asymptomatic,
symptomatic cases usually
present as upper
respiratory infections
similar to the common
cold.

Robinson in MCM,
2010

1

Does the illness result in
mild symptoms with minimal
or no impact on daily
activities?





1 Bolded text indicates the highest score for that particular protocol. For the health risk protocol two
scores were selected: the general population [G] and the highest score for a sensitive subpopulation.

These 2 scores were added and normalized by multiplying by 5/14 for a final health risk score. The higher
score between the WBDO and Occurrence protocols was used for total pathogen score calculation. Health
Risk protocol: G - General, C - Child, E - Elderly, P - Pregnant Women, CD - Chronic Disease.

2See Final Contaminant Candidate List 3 Microbes: PCCL to CCL Process. EPA 815-R-09-009. Final.
August 2009 for a detailed description on how to calculate the total pathogen score.

3EPA based the WBDO scores on the CDC MMWR reports from 1991 -2017 and then collected
occurrence citations if there were no CDC WBDOs.

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EPA-Office of Water

Technical Support Document for the
Final Fifth Contaminant Candidate List (CCL 5)-
Microbial Contaminants

EPA 815-R-22-004
October 2022

References

Centers for Disease Control and Prevention (CDC). 1983. Adenovirus type 7 outbreak in a
pediatric chronic-care facility - Pennsylvania. 1972. MMWR. 32: 258-260.

CDC. 1998. Civilian Outbreak of Adenovirus Acute Respiratory Disease - South Dakota, 1997.
MMWR. 47(27): 567-570.

CDC. 2020. National Outbreak Reporting System (NORS). Available online at:
https://wwwn.cdc.gov/norsdashboard/. Accessed August 31, 2020.

Fong, T., L. Mansfield, D. Wilson, D. Schwab, S. Molloy, and J Rose. 2007. Massive
Microbiological Groundwater Contamination Associated with a Waterborne Outbreak in Lake
Erie, South Bass Island, OH. Environmental Health Perspective. 115(6): 856-864.

Gray, G.C., P.R. Goswami, M.D. Malasig, A.W. Hawksworth, D.H. Trump, M.A. Ryan, and
D.P. Schnurr. 2001. Adult Adenovirus Infections: Loss of Orphaned Vaccines Precipitates
Military Respiratory Disease Epidemics. Clinical Infectious Diseases. 31: 663-70.

Heim, A. and R.T. Hayden. 2019. Adenoviruses. In Murray, P.R., E.J. Baron, J.H. Jorgensen,
M.L. Landry, and M.A. Pfaller (ed.) Manual of Clinical Microbiology, 12th Edition, pp. 1831-
1846. American Society for Microbiology Press, Washington DC.

Kukkula, M., P. Arstila, M.L. Klossner, L. Maunula, C.H. Bonsdorff, and P. Jaatinen. 1997.
Waterborne outbreak of viral gastroenteritis. Scandinavian Journal of Infectious Disease. 29(4):
415-418.

Lee, S. and S. Kim. 2002. Detection of infectious enteroviruses and adenoviruses in tap water in
urban areas in Korea. Water Research. 36(1): 248-256. doi:10.1016/S0043-1354(01)00199-3.

O'Reilly, C.E., A.B. Bowen, E.P. Nytzia, J.P. Sarisky, C.A. Shepherd, M.D. Miller, B.C.
Hubbard, M. Herring, S.D. Buchanan, C.C. Fitzgerald, V. Hill, M.J. Arrowood, L.X. Xiao, R.M.
Hoekstra, E.D. Mintz, M.F. Lynch, and the Outbreak Working Group. 2007. A Waterborne
Outbreak of Gastroenteritis with Multiple Etiologies among Resort Island Visitors and
Residents: Ohio, 2004. Clinical Infectious Diseases. 44: 506-512.

Robinson, C. and M. Echavarria. 2010. Adenoviruses. In Murray, P.R., E.J. Baron, J.H.
Jorgensen, M.L. Landry, and M.A. Pfaller (ed) Manual of Clinical Microbiology, 10th Edition,
Volume 2, p. 1600. American Society for Microbiology Press, Washington, DC.

United States Environmental Protection Agency. 2007. Adenovirus Health and Criteria
Document (Draft).

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October 2022

Aeromonas hydrophila Scoring Data

Scoring Summary1'2

Occurrence

3

Health Risk

General population

2

Sensitive subpopulation(s) [C]

3

1 Bolded text indicates the highest score for that particular protocol. For the health risk protocol two scores were selected: the
general population [G] and the highest score for a sensitive subpopulation. These 2 scores were added and normalized by
multiplying by 5/14 for a final health risk score. The higher score between the WBDO and Occurrence protocols was used for
total pathogen score calculation. Health Risk protocol: G - General, C - Child, E - Elderly, P - Pregnant Women, CD - Chronic
Disease

Score2

Data Element

Scoring Data

Reference3



Waterborne Disease Outbreaks

5

Has caused multiple (1 or more)
documented WBDOs in the
U.S. reported by CDC between
2009-2017

No

CDC-NORS, 2020

4

Has caused at least one
documented WBDOs in U.S.
reported by CDC between
2009-2017

No

CDC, 1991 - CDC, 2017

3

Has caused documented
WBDOs at any time in the
U.S.?

No



2

Has caused WBDOs in
countries other than the U.S.?

No



1

Has never caused WBDOs in
any country, but has been
epidemiologically associated

Yes

Gavriel et al., 1998

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Microbial Contaminants

Score2

Data Element

Scoring Data

Reference3



with water related disease?







Occurrence

3

Detected in drinking water in
the U.S.?

Yes

EPA found A.
hydrophila in the
distribution systems
of 42 public water
systems out of 293
systems tested.

EPA, 2006 and EPA,
2003

2

Detected in source water in the
U.S.?

Yes

Holmes et al., 1996
EPA, 2006

1

Not detected in the U.S.?







Health Risk

7

Does the organism cause
significant mortality (> 1/1,000
cases)?

Wound infections are
usually preceded by
injury that occurs in
contact with water.
These infections
range from cellulitis
to myronecrotic
infections with a poor
prognosis.

Horneman and Ali in
MCM, 2010

6

Does the organism cause
pneumonia, meningitis,
hepatitis, encephalitis,
endocarditis, cancer, or other
severe manifestations of illness
necessitating long term
hospitalization (> week)?

Septicemia occurs
rarely in

immunocompetent
hosts. Can cause
HUS.

Horneman and Ali in
MCM, 2010

5

Does the illness result in long





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Microbial Contaminants

Score2

Data Element

Scoring Data

Reference3



term or permanent dysfunction
or disability, i.e. sequelae?





4

Does the illness require short
term hospitalization (< week)?





3 [C]

Does the illness require
physician intervention?

[C] Children may
require

hospitalization due
to dehydration.

Horneman and Ali in
MCM, 2010

2 [G, P, E,
CD]

Is the illness self-limiting
within 72 hours (without
requiring medical
intervention)?

[G, P, E, CD] Acute
watery disease is the
most common form
as well as
abdominal pain,
vomiting, fever.

Horneman and Ali in
MCM, 2010

1

Does the illness result in mild
symptoms with minimal or no
impact on daily activities?





1 Bolded text indicates the highest score for that particular protocol. For the health risk protocol two
scores were selected: the general population [G] and the highest score for a sensitive subpopulation.

These 2 scores were added and normalized by multiplying by 5/14 for a final health risk score. The higher
score between the WBDO and Occurrence protocols was used for total pathogen score calculation. Health
Risk protocol: G - General, C - Child, E - Elderly, P - Pregnant Women, CD - Chronic Disease.

2See Final Contaminant Candidate List 3 Microbes: PCCL to CCL Process. EPA 815-R-09-009. Final.
August 2009 for a detailed description on how to calculate the total pathogen score.

3EPA based the WBDO scores on the CDC MMWR reports from 1991 -2017 and then collected
occurrence citations if there were no CDC WBDOs.

References

Centers for Disease Control and Prevention (CDC). 2020. National Outbreak Reporting System
(NORS). Available online at: https://wwwn.cdc.gov/norsdashboard/. Accessed August 31, 2020.

Gavriel, A.A., J.P.B. Landre, and A.J. Lamb. 1998. Incidence of mesophilic Aeromonas within a
public drinking water supply in northeast Scotland. Journal of Applied Bacteriology. 84: 383-
392.

Holmes, P., L.M. Niccolls, and D.P. Sartory. 1996. The ecology of mesophilic Aeromonas in the
aquatic environment. In Austin, B., M. Altwegg, P.J. Gosling, and S. Joseph, (ed.) The Genus
Aeromonas. John Wiley & Sons, Inc. Chichester, UK.

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Microbial Contaminants

EPA 815-R-22-004
October 2022

Horneman, A. and A. Al. 2010. Aeromonas. In Murray, P.R., E.J. Baron, J.H. Jorgensen, M.L.
Landry, and M.A. Pfaller (ed.) Manual of Clinical Microbiology, 10th Edition, Volume 1, p.658,
American Society for Microbiology Press, Washington, DC.

United States Environmental Protection Agency (USEPA). 2003. Unpublished data on
occurrence results from the Unregulated Contaminant Monitoring Rule. FR 49094. August 22,
2005.

USEPA. 2006. Aeromonas: Human Health Criteria Document.

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EPA-Office of Water

Technical Support Document for the
Final Fifth Contaminant Candidate List (CCL 5)-
Microbial Contaminants

EPA 815-R-22-004
October 2022

Arcobacter butzleri Scoring Data

Scoring Summary1'2

Waterborne Disease Outbreak

4

Health Risk

General population

3

Sensitive subpopulation(s) [CD, C, P,

E]

3

1 Bolded text indicates the highest score for that particular protocol. For the health risk protocol two scores were selected: the
general population [G] and the highest score for a sensitive subpopulation. These 2 scores were added and normalized by
multiplying by 5/14 for a final health risk score. The higher score between the WBDO and Occurrence protocols was used for
total pathogen score calculation. Health Risk protocol: G - General, C - Child, E - Elderly, P - Pregnant Women, CD - Chronic
Disease

Score2

Data Element

Scoring Data

Reference3



Waterborne Disease Outbreaks

5

Has caused multiple (1 or
more) documented WBDOs
in the U.S. reported by CDC
between 2009-2017

No

CDC-NORS, 2020

4

Has caused at least one
documented WBDOs in
U.S. reported by CDC
between 2009-2017

Yes

Not listed in CDC's
MMWR, however,
linked to outbreak
and drinking water.
Symptom severity
also suggests
Arcobacter.

Fong et al., 2007

3

Has caused documented
WBDOs at any time in the
U.S.?





2

Has caused WBDOs in
countries other than the





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Final Fifth Contaminant Candidate List (CCL 5)-	October 2022

Microbial Contaminants

Score2

Data Element

Scoring Data

Reference3



U.S.?





1

Has never caused WBDOs
in any country, but has been
epidemiologically
associated with water
related disease?







Occurrence

3

Detected in drinking water
in the U.S.?

Yes

Fong et al., 2007

2

Detected in source water in
the U.S.?

Yes

Arcobacter butzleri
was isolated from
groundwater in Idaho
after a WBDO.

Rice et al., 1999

1

Not detected in the U.S.?







Health Risk

7

Does the organism cause
significant mortality (>
1/1,000 cases)?

Unknown



6

Does the organism cause
pneumonia, meningitis,
hepatitis, encephalitis,
endocarditis, cancer, or
other severe manifestations
of illness necessitating long
term hospitalization (>
week)?

Persons with
underlying disease
such as liver disease,
cirrhosis, or alcoholism
may be at increased
risk of complications.

Has been isolated from
patients with
bacteremia,

endocarditis, peritonitis
and diarrhea. Clinical
significance unknown.

Hsueh et al., 1997
Lerner et al., 1994
Yan et al., 2000

Fitzgerald in MCM,
2010

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EPA-Office of Water	Technical Support Document for the	EPA 815-R-22-004

Final Fifth Contaminant Candidate List (CCL 5)-	October 2022

Microbial Contaminants

Score2

Data Element

Scoring Data

Reference3

5

Does the illness result in
long term or permanent
dysfunction or disability, i.e.
sequelae?





4

Does the illness require
short term hospitalization (<
week)?





3 [G, C, P,
E, CD]

Does the illness require
physician intervention?

[All populations]
Displays clinical
features similar to
Campylobacter jejuni,
however is more
frequently associated
with a persistent
diarrhea. Twenty-six
percent of Belgian
patients required
antibiotics.

Vandenberg et al.,
2004

2

Is the illness self-limiting
within 72 hours (without
requiring medical
intervention)?

Usual symptoms are
diarrhea, abdominal
pain, vomiting, and
nausea resolving in < 3
days.

Wybo et al., 2004
Rice et al., 1999

1

Does the illness result in
mild symptoms with
minimal or no impact on
daily activities?





1 Bolded text indicates the highest score for that particular protocol. For the health risk protocol two
scores were selected: the general population [G] and the highest score for a sensitive subpopulation.

These 2 scores were added and normalized by multiplying by 5/14 for a final health risk score. The higher
score between the WBDO and Occurrence protocols was used for total pathogen score calculation. Health
Risk protocol: G - General, C - Child, E - Elderly, P - Pregnant Women, CD - Chronic Disease.

2See Final Contaminant Candidate List 3 Microbes: PCCL to CCL Process. EPA 815-R-09-009. Final.
August 2009 for a detailed description on how to calculate the total pathogen score.

3EPA based the WBDO scores on the CDC MMWR reports from 1991 -2017 and then collected
occurrence citations if there were no CDC WBDOs.

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EPA-Office of Water

Technical Support Document for the
Final Fifth Contaminant Candidate List (CCL 5)-
Microbial Contaminants

EPA 815-R-22-004
October 2022

References

Centers for Disease Control and Prevention (CDC). 2020. National Outbreak Reporting System
(NORS). Available online at: https://wwwn.cdc.gov/norsdashboard/. Accessed August 31, 2020.

Fitzgerald, C. and I. Nachamkin. 2010. Campylobacter and Arcobacter. In Murray, P.R., E.J.
Baron, J.H. Jorgensen, M.L. Landry, and M. A. Pfaller (ed.) Manual of Clinical Microbiology,
10th Edition, Volume 1, p.885. American Society for Microbiology Press, Washington, DC.

Fong, T., L. Mansfield, D. Wilson, D. Schwab, S. Molloy, and J. Rose. 2007. Massive
Microbiological Groundwater Contamination Associated with a Waterborne Outbreak in Lake
Erie, South Bass Island, OH. Environmental Health Perspectives. 115(6): 856-864.

Hsueh, P R., L.J. Teng, P.C. Yang, S.K. Wang, S.C. Chang, S.W. Ho, W.C. Hsieh, and K.T Luh.
1997. Bacteremia caused by Arcobacter cryaerophilus IB. Journal of Clinical Microbiology.
35(2): 489-491.

Nachamkin. 2019. Campylobacter and Arcobacter. In Carroll, K.C., M.A. Pfaller, M.L. Landry,
A.J. McAdam, R. Patel, R., S.S. Richter, and D.W. Warnock (ed). 2019. Manual of Clinical
Microbiology, 12th Edition. American Society of Microbiology Press, Washington, DC.

Lerner, J., V. Brumberger, and V. Preac-Mursic. 1994. Severe diarrhea associated with
Arcobacter butzleri. European Journal of Clinical Microbiology and Infectious Diseases. 13(8):
660-662.

Rice, E.W., M.R. Rodgers, I.V. Wesley, C.H. Johnson, and S.A. Tanner. 1999. Isolation of
Arcobacter butzleri from ground water. Letters in Applied Microbiology. 28: 31-35.

Vandenberg, O., A. Dediste, K. Houg, S. Ibekwen, H. Souayah, S. Cadranel, N. Douat, G. Zissis,
J. Butzler, and P. Vandamme. 2004. Arcobacter Species in Humans. Emerging Infectious
Diseases. 10(10): 1863.

Wybo, I., J. Breynaert, S. Lauwers, F. Lindenburg, and K. Houf. 2004. Isolation of Arcobacter
skirrowii from a patient with chronic diarrhea. Journal of Clinical Microbiology. 42(4): 1851-
1852.

Yan, J.J., W.C. Ko, A.H. Huang, H.M. Chen, Y.T. Jin, and J.J Wu. 2000. Arcobacter butzleri
bacteremia in a patient with liver cirrhosis. Journal of the Formosan Medical Association. 99(2):
166-169.

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Technical Support Document for the
Final Fifth Contaminant Candidate List (CCL 5)-
Microbial Contaminants

EPA 815-R-22-004
October 2022

Aspergillus fumigatus Scoring Data

Scoring Summary1'2

Occurrence

3

Health Risk

General population

3

Sensitive subpopulation(s) [C, P, E, CD]

3

1 Bolded text indicates the highest score for that particular protocol. For the health risk protocol two scores were selected: the
general population [G] and the highest score for a sensitive subpopulation. These 2 scores were added and normalized by
multiplying by 5/14 for a final health risk score. The higher score between the WBDO and Occurrence protocols was used for
total pathogen score calculation. Health Risk protocol: G - General, C - Child, E - Elderly, P - Pregnant Women, CD - Chronic
Disease

Score2

Data Element

Scoring Data

Reference3



Waterborne Disease Outbreaks

5

Has caused multiple (1 or
more) documented
WBDOs in the U.S.
reported by CDC between
2009-2017

No

CDC-NORS, 2020

4

Has caused at least one
documented WBDOs in
U.S. reported by CDC
between 2009-2017

No

CDC, 1991 - CDC,
2017

3

Has caused documented
WBDOs at any time in the
U.S.?

No



2

Has caused WBDOs in
countries other than the
U.S.?

No



1

Has never caused
WBDOs in any country,
but has been
epidemiologically

Yes

Study on two bone
marrow transplantation

Anaissie et al., 2002

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EPA-Office of Water	Technical Support Document for the	EPA 815-R-22-004

Final Fifth Contaminant Candidate List (CCL 5)-	October 2022

Microbial Contaminants

Score2

Data Element

Scoring Data

Reference3



associated with water
related disease?

units at a Little Rock,
AR hospital.

Anaissie et al., 2003
Warris et al., 2003



Occurrence

3

Detected in drinking
water in the U.S.?

Yes

Anaissie et al., 2002

Anaissie et al., 2003

Nagy and Olson,
1982

Rosenzweig et al.,
1986

Doggett, 2000
Vesper et al., 2007

2

Detected in source water
in the U.S.?

Yes

Nagy and Olson, 1982

1

Not detected in the U.S.?







Health Risk

7

Does the organism cause
significant mortality (>
1/1,000 cases)?

Invasive infections
caused by Aspergillus
species are associated
with high rates of
morbidity and mortality,
especially in
immunosuppressed
patients.

Verweij and Brandt in
MCM, 2010

Chen in MCM, 2019

6

Does the organism cause
pneumonia, meningitis,
hepatitis, encephalitis,
endocarditis, cancer, or
other severe

manifestations of illness
necessitating long term
hospitalization (> week)?

Sporadic cases of
invasive aspergillosis
have been reported in
immunocompetent hosts
(chronic meningitis,
endocarditis, pericarditis,
osteomyelitys).

Bodey and
Vartivarian, 1989

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Final Fifth Contaminant Candidate List (CCL 5)-	October 2022

Microbial Contaminants

Score2

Data Element

Scoring Data

Reference3





Invasive aspergillosis is
primarily an infection of
severely

immunocompromi sed
patients.







Serious infection can also
occur in patients with
more modest
impairments of host
immune system such as
diabetics.

Nagy and Olson, 1982

5

Does the illness result in
long term or permanent
dysfunction or disability,
i.e. sequelae?

None reported.



4

Does the illness require
short term hospitalization
(< week)?

Requirement for
hospitalization depends
upon the manifestation of
disease (e.g., superficial
skin and ear infections do
not require
hospitalization).

Bodey and
Vartivarian, 1989

3 [G, C, P,
E, CD]

Does the illness require
physician intervention?

[All populations] Most
infections and allergies
caused by this organism
require physician
intervention.

Bodey and
Vartivarian, 1989

CDC, 2019

2

Is the illness self-limiting
within 72 hours (without
requiring medical
intervention)?





Page F23


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EPA-Office of Water	Technical Support Document for the	EPA 815-R-22-004

Final Fifth Contaminant Candidate List (CCL 5)-	October 2022

Microbial Contaminants

Score2

Data Element

Scoring Data

Reference3

1

Does the illness result in
mild symptoms with
minimal or no impact on
daily activities?

Aspergillus spores are
allergens and persons
who become sensitized
experience symptoms of
allergy and asthma.

Horner et al., 1995

1 Bolded text indicates the highest score for that particular protocol. For the health risk protocol two
scores were selected: the general population [G] and the highest score for a sensitive subpopulation.

These 2 scores were added and normalized by multiplying by 5/14 for a final health risk score. The higher
score between the WBDO and Occurrence protocols was used for total pathogen score calculation. Health
Risk protocol: G - General, C - Child, E - Elderly, P - Pregnant Women, CD - Chronic Disease.

2See Final Contaminant Candidate List 3 Microbes: PCCL to CCL Process. EPA 815-R-09-009. Final.
August 2009 for a detailed description on how to calculate the total pathogen score.

3EPA based the WBDO scores on the CDC MMWR reports from 1991 -2017 and then collected
occurrence citations if there were no CDC WBDOs.

References

Anaissie, E.J., S.L. Stratton, M.C. Dignani, R.C. Summerbell, J.H. Rex, T.P. Monson, T.

Spencer, M. Kasai, A. Francesconi, and T.J. Walsh. 2002. Pathogenic Aspergillus species
recovered from a hospital water system: a 3-year prospectie study. Clinical Infectious Diseases.
34: 780-789.

Anaissie, E.J., S.L. Stratton, M.C. Dignani, C. Lee, R.C. Summerbell, J.H. Rex, T.P. Monson,
and T.J. Walsh. 2003. Pathogenic molds (including Aspergillus species) in hospital water
distribution systems: a 3-year prospective study and clinical implications for patients with
hematologic malignancies. Blood. 101(7): 2542-2546.

Bodey, G.P. and S. Vartivarian. 1989. Aspergillosis. European Journal of Clinical Microbiology
and infectious diseases. 8(5): 413-437.

Centers for Disease Control and Prevention (CDC). 2019. Aspergillus homepage. Available
online at: www.cdc.gov/fungal/diseases/aspergillosis/index.html.

CDC, 2020. National Outbreak Reporting System (NORS). Available online at:
https://wwwn.cdc.gov/norsdashboard/. Accessed August 31, 2020.

Chen, S.C.-A., W. Meyer, T.C. Sorrell, and C. L. Halliday. 2019. Apergillus, Talarmyces, and
Penicillium. In Carroll, K.C., M.A. Pfaller, M. L. Landry, A.J. McAdam, R. Patel, S.S. Richter,
and D.W. Warnock (ed). Manual of Clinical Microbiology, 12th Edition. American Society of
Microbiology Press, Washington, DC.

Doggett, M.S. 2000. Characterization of fungal biofilms within a municipal water distribution
system. Applied and Environmental Microbiology. 66(3): 1249-1251.

Horner, W.E., A. Helbling, J.E. Salvaggio, and S.B. Lehrer. 1995. Fungal allergens. Clinical
Microbiology Reviews. 8(2): 161-179.

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Microbial Contaminants

EPA 815-R-22-004
October 2022

Nagy, L.A. and B.H. Olson. 1982. The occurrence of filamentous fungi in drinking water
distribution systems. Canadian Journal of Microbiology. 28: 667-671.

Rosenzweig, W.D., H. Minnigh, and W.O. Pipes. 1986. Fungi in potable water distribution
systems. Journal of the American Water Works Association. 78(1): 53-55.

Verweij, P.E. and M.E. Brandt. 2010. Aspergillus, Fusarium, and Other Opportunistic
Moniliaceous Fungi. In Murray, P.R., E.J. Baron, J.H. Jorgensen, M.L. Landry, and M.A. Pfaller
(ed.) Manual of Clinical Microbiology, 10th Edition, Volume 2, p. 1836. American Society for
Microbiology Press, Washington, DC.

Vesper, S.J., M.E. Rogers, A.N. Neely, and R.A. Haugland. 2007. Opportunistic Aspergillus
pathogens measured in home and hospital tap water by quantitative PCR (QPCR). Journal of
Water and Health. 5(3): 427-431.

Warris, A., C.H. Klassen, J.F. Meis, M.T. De Ruiter, H.A. de Valk, T.G. Abrahamsen, P.
Gaustaad, and P.E. Verweij. 2003. Molecular epidemiology of Aspergillus fumigatus isolates
recovered from water, air, and patients shows two clusters of genetically distinct strains. Journal
of Clinical Microbiology. 41(9): 4101-4106.

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Technical Support Document for the
Final Fifth Contaminant Candidate List (CCL 5)-
Microbial Contaminants

EPA 815-R-22-004
October 2022

Astrovirus Scoring Data

Scoring Summary1'2

Waterborne Disease Outbreak

2

Health Risk

General population

2

Sensitive subpopulation(s) [C, P, E, CD]

2

1 Bolded text indicates the highest score for that particular protocol. For the health risk protocol two scores were selected: the
general population [G] and the highest score for a sensitive subpopulation. These 2 scores were added and normalized by
multiplying by 5/14 for a final health risk score. The higher score between the WBDO and Occurrence protocols was used for
total pathogen score calculation. Health Risk protocol: G - General, C - Child, E - Elderly, P - Pregnant Women, CD - Chronic
Disease

Score2

Data Element

Scoring Data

Reference3



Waterborne Disease Outbreaks

5

Has caused multiple (1 or
more) documented WBDOs
in the U.S. reported by CDC
between 2009-2017

No

CDC-NORS, 2020

4

Has caused at least one
documented WBDOs in
U.S. reported by CDC
between 2009-2017

No

CDC, 1991 - CDC, 2017

3

Has caused documented
WBDOs at any time in the
U.S.?

No



2

Has caused WBDOs in
countries other than the
U.S.?

Yes

England and Wales

Smith et al., 2006

1

Has never caused WBDOs
in any country, but has been
epidemiologically

Yes

Gofti-Laroche et al., 2003

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EPA-Office of Water	Technical Support Document for the	EPA 815-R-22-004

Final Fifth Contaminant Candidate List (CCL 5)-	October 2022

Microbial Contaminants

Score2

Data Element

Scoring Data

Reference3



associated with water
related disease?







Occurrence

3

Detected in drinking water
in the U.S.?

No



2

Detected in source water
in the U.S.?

Yes

Astrovirus was
detected in 15 of 29
samples collected
under the
Information
Collection Rule.

Chapron et al., 2000

1

Not detected in the U.S.?







Health Risk

7

Does the organism cause
significant mortality (>
1/1,000 cases)?

No



6

Does the organism cause
pneumonia, meningitis,
hepatitis, encephalitis,
endocarditis, cancer, or
other severe manifestations
of illness necessitating long
term hospitalization (>
week)?

No



5

Does the illness result in
long term or permanent
dysfunction or disability, i.e.
sequelae?

No



4

Does the illness require
short term hospitalization (<
week)?

No



Page F27


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EPA-Office of Water	Technical Support Document for the	EPA 815-R-22-004

Final Fifth Contaminant Candidate List (CCL 5)-	October 2022

Microbial Contaminants

Score2

Data Element

Scoring Data

Reference3

3

Does the illness require
physician intervention?

No



2 [G, C,
P, E, CD]

Is the illness self-limiting
within 72 hours (without
requiring medical
intervention)?

[All populations]
Asymptomatic
infections common.
Moderate self-
limiting
gastroenteritis
(vomiting and
diarrhea).

Farkas in MCM, 2010

1

Does the illness result in
mild symptoms with
minimal or no impact on
daily activities?





1 Bolded text indicates the highest score for that particular protocol. For the health risk protocol two
scores were selected: the general population [G] and the highest score for a sensitive subpopulation.

These 2 scores were added and normalized by multiplying by 5/14 for a final health risk score. The higher
score between the WBDO and Occurrence protocols was used for total pathogen score calculation. Health
Risk protocol: G - General, C - Child, E - Elderly, P - Pregnant Women, CD - Chronic Disease.

2See Final Contaminant Candidate List 3 Microbes: PCCL to CCL Process. EPA 815-R-09-009. Final.
August 2009 for a detailed description on how to calculate the total pathogen score.

3EPA based the WBDO scores on the CDC MMWR reports from 1991 -2017 and then collected
occurrence citations if there were no CDC WBDOs.

References

Centers for Disease Control and Prevention (CDC). 1991. Surveillance for Waterborne-Disease
Outbreaks Associated with Drinking Water —United States, 1989—1990. MMWR Surveillance
Summaries. 40(SS-3): 1-21.

CDC. 1993. Surveillance for Waterborne-Disease Outbreaks Associated with Drinking Water —
United States, 1991—1992. MMWR Surveillance Summaries. 42(SS-5): 1-22.

CDC. 1996. Surveillance for Waterborne-Disease Outbreaks Associated with Drinking Water —
United States, 1993—1994. MMWR Surveillance Summaries. 45(SS-1): 1-33.

CDC. 1998. Surveillance for Waterborne-Disease Outbreaks Associated with Drinking Water —
United States, 1995—1996. MMWR Surveillance Summaries. 47(SS-5): 1-33.

CDC. 2000. Surveillance for Waterborne-Disease Outbreaks Associated with Drinking Water —
United States, 1997—1998. MMWR Surveillance Summaries. 49(SS-4): 1-35.

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Microbial Contaminants

EPA 815-R-22-004
October 2022

CDC. 2002. Surveillance for Waterborne-Disease Outbreaks Associated with Drinking Water —
United States, 1999—2000. MMWR Surveillance Summaries. 51(SS-8): 1-36.

CDC. 2004. Surveillance for Waterborne-Disease Outbreaks Associated with Drinking Water —
United States, 2001—2002. MMWR Surveillance Summaries. 53(SS08): 23-45.

CDC. 2006. Surveillance for Waterborne-Disease Outbreaks Associated with Drinking Water —
United States, 2003—2004. MMWR Surveillance Summaries. 55(SS12): 31-58.

CDC. 2008. Surveillance for Waterborne Disease and Outbreaks Associated with Drinking
Water and Water not Intended for Drinking — United States, 2005-2006. MMWR. 60(SS12):
38-68.

CDC. 2011. Surveillance for Waterborne Disease Outbreaks Associated with Drinking Water —
United States, 2007-2008. MMWR. 60(SS12): 38-68

CDC. 2013. Surveillance for waterborne disease outbreaks associated with drinking water and
other nonrecreational water — United States, 2009-2010. MMWR. 62(35): 714-20.

CDC. 2015. Surveillance for waterborne disease outbreaks associated with drinking water —
United States, 2011-2012. MMWR. 64(31): 842-848.

CDC. 2017. Surveillance for waterborne disease outbreaks associated with drinking water —
United States, 2013-2014. MMWR. 66 (44): 1216-21.

CDC. 2020. National Outbreak Reporting System (NORS). Available online at:
https://wwwn.cdc.gov/norsdashboard/. Accessed August 31, 2020.

Chapron, C.D., N.A. Ballester, J.H. Fontaine, C.N. Frades, and A.B. Margolin. 2000. Detection
of astroviruses, enteroviruses, and adnovirus types 40 and 41 in surface waters collected and
evaluated by the information collection rule and an integrated cell culture-nested PCR procedure.
Applied and Environmental. Microbiology. 66(6): 2520-2525.

Farkas, T. and X. Jiang. 2010. Rotaviruses, Caliciviruses, Astroviruses, Enteric Adenoviruses,
and Other Diarrheic Viruses. In Murray, P.R., E.J. Baron, J.H. Jorgensen, M.A. Pfaller, and R.H.
Yolken (ed) Manual of Clinical Microbiology, 10th Edition, Volume 2, p. 1456. American
Society for Microbiology Press, Washington, DC.

Gofti-Laroche, L., B. Gratacap-Cavallier, D. Demanse, O. Genoulaz, J.-M. Segneurin, and D.
Zmirou. 2003. Are waterborne astrovirus implicated in acute digestive morbidity (E. MI. RA
study)? Journal of Clinical Virology. 27: 74-82.

Pang, X.L. and M. Smieja. Gastroenteritis Viruses. In Carroll, K.C., M.A. Pfaller, M.L. Landry,
A.J. McAdam, R. Patel, S.S. Richter, and D.W. Warnock (ed). 2019. Manual of Clinical
Microbiology, 12th Edition. American Society of Microbiology Press, Washington, D.C.

Smith, A., M. Reacher, W. Smerdon, G.K. Adak, G. Nichols, and R.M. Chalmers. 2006.
Outbreaks of waterborne infectious intestinal disease in England and Wales, 1992-2003.
Epidemiology & Infection. 134(6): 1141-1149.

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Microbial Contaminants

EPA 815-R-22-004
October 2022

Blastocystis hominis Scoring Data

Scoring Summary1'2

Waterborne Disease Outbreak

4

Health Risk

General population

1

Sensitive subpopulation(s) [C, P, E, CD]

1

1 Bolded text indicates the highest score for that particular protocol. For the health risk protocol two scores were selected: the
general population [G] and the highest score for a sensitive subpopulation. These 2 scores were added and normalized by
multiplying by 5/14 for a final health risk score. The higher score between the WBDO and Occurrence protocols was used for
total pathogen score calculation. Health Risk protocol: G - General, C - Child, E - Elderly, P - Pregnant Women, CD - Chronic
Disease

Score2

Data Element

Scoring Data

Reference3



Waterborne Disease Outbreaks

5

Has caused multiple (1 or
more) documented
WBDOs in the U.S.
reported by CDC between
2009-2017

No

CDC-NORS, 2020

4

Has caused at least one
documented WBDOs in
U.S. reported by CDC
between 2009-2017

Yes

2012: 1 Transient

noncommunity

(suspected)

CDC-NORS, 2020

3

Has caused documented
WBDOs at any time in
the U.S.?

No



2

Has caused WBDOs in
countries other than the
U.S.?

No



1

Has never caused
WBDOs in any country,

Yes

Drinking untreated water

Leelayoova et al.,

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Microbial Contaminants

Score2

Data Element

Scoring Data

Reference3



but has been
epidemiologically
associated with water
related disease?

has been associated with
infection.

2004

Stenzel and Boreham,
1996

Taamasri et al., 2000



Occurrence

3

Detected in drinking
water in the U.S.?

No



2

Detected in source water
in the U.S.?

No



1

Not detected in the U.S.?

Yes

Karanis, 2006



Health Risk

7

Does the organism cause
significant mortality (>
1/1,000 cases)?

No



6

Does the organism cause
pneumonia, meningitis,
hepatitis, encephalitis,
endocarditis, cancer, or
other severe

manifestations of illness
necessitating long term
hospitalization (> week)?

No



5

Does the illness result in
long term or permanent
dysfunction or disability,
i.e. sequelae?

No



4

Does the illness require
short term hospitalization
(< week)?

No



3

Does the illness require
physician intervention?

No



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Microbial Contaminants

Score2

Data Element

Scoring Data

Reference3

2

Is the illness self-limiting
within 72 hours (without
requiring medical
intervention)?

Symptoms may be more
pronounced and prolonged
in immunocompromised;
neoplasia and abnormal
intestinal tract function.

Leber in MCM, 2010

1[G, C, P,
E, CD]

Does the illness result in
mild symptoms with
minimal or no impact on
daily activities?

[All populations]
Pathogenicity of B.
hominis is controversial.
Symptoms may include
diarrhea, vomiting and
abdominal pain.

Leber in MCM,
2010; Novak-Weekly
and Leber in MCM,
2019

1 Bolded text indicates the highest score for that particular protocol. For the health risk protocol two
scores were selected: the general population [G] and the highest score for a sensitive subpopulation.

These 2 scores were added and normalized by multiplying by 5/14 for a final health risk score. The higher
score between the WBDO and Occurrence protocols was used for total pathogen score calculation. Health
Risk protocol: G - General, C - Child, E - Elderly, P - Pregnant Women, CD - Chronic Disease.

2See Final Contaminant Candidate List 3 Microbes: PCCL to CCL Process. EPA 815-R-09-009. Final.
August 2009 for a detailed description on how to calculate the total pathogen score.

3EPA based the WBDO scores on the CDC MMWR reports from 1991 -2017 and then collected
occurrence citations if there were no CDC WBDOs.

References

Centers for Disease Control and Prevention (CDC), 2020. National Outbreak Reporting System
(NORS). Available online at: https://wwwn.cdc.gov/norsdashboard/. Accessed August 31, 2020.

Karanis, P. 2006. A review of an emerging waterborne medical important parasitic protozoan.
Japanese Journal of Protozoology. 39(1): 5-19.

Leber, A. and S. Novak-Weekley. 2010. Intestinal and Urogenital Amebae, Flagellates, and
Ciliates. In Murray, P.R., E.J. Baron, J.H. Jorgensen, M.L. Landry, and M.A. Pfaller (ed.)
Manual of Clinical Microbiology, 10th. Edition, Volume 2, p. 2149. American Society for
Microbiology Press, Washington, DC.

Leelayoova, S., R. Rangsin, P. Taamasri, T. Naaglor, U. Thathaisong, and M. Mungthin. 2004.
Evidence of waterborne transmission of Blastocystis hominis. American Journal of Tropical
Medicine & Hygiene. 70(6): 658-662.

Novak-Weekly, S. and A. Leber. 2019. Intestinal and Urogenital Amebae, Flagellates, and
Ciliates. In Carroll, K.C., M.A Pfaller, M.L. Landry, A.J. McAdam, R. Patel, S.S. Richter, and
D.W. Warnock (ed). Manual of Clinical Microbiology, 12th Edition. American Society of
Microbiology Press, Washington, DC.

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Microbial Contaminants

EPA 815-R-22-004
October 2022

Stenzel, D.J. and P.F. Boreham. 1996. Blastocystis hominis revisited. Clinical Microbiology
Reviews. 9(4): 563-584.

Taamasri, P., M. Mungthin, R. Rangsin, B. Tongupprakarn, W. Areekul, and S. Leelayoova.
2000. Transmission of intestinal blastocystosis related to the quality of drinking water. Southeast
Asian Journal of Tropical Medicine & Public Health. 31(1): 112-117.

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Technical Support Document for the
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Microbial Contaminants

EPA 815-R-22-004
October 2022

Calicivirus Scoring Data

Scoring Summary1'2

Waterborne Disease Outbreak

5

Health Risk

General population

2

Sensitive subpopulation(s) [C, E, CD]

4

1 Bolded text indicates the highest score for that particular protocol. For the health risk protocol two scores were selected: the
general population [G] and the highest score for a sensitive subpopulation. These 2 scores were added and normalized by
multiplying by 5/14 for a final health risk score. The higher score between the WBDO and Occurrence protocols was used for
total pathogen score calculation. Health Risk protocol: G - General, C - Child, E - Elderly, P - Pregnant Women, CD - Chronic
Disease

Score2

Data Element

Scoring Data

Reference3



Waterborne Disease Outbreaks



Has caused multiple (2
or more) documented
WBDOs in the U.S.
reported by CDC
between 2009-2017

Yes

2010: 1 Nontransient
noncommunity

CDC-NORS, 2020

5



2012: 1 Transient
noncommunity

2014: 2 Transient
noncommunity

2015: 1 community



4

Has caused at least one
documented WBDOs in
U.S. reported by CDC
between 2009-2017





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Microbial Contaminants

Score2

Data Element

Scoring Data

Reference3

3

Has caused documented
WBDOs at any time in
the U.S.?

1971-2008: 11 Community
30 Noncommunity

CDC-NORS, 2020

2

Has caused WBDOs in
countries other than the
U.S.?





1

Has never caused
WBDOs in any country,
but has been
epidemiologically
associated with water
related disease?







Occurrence

3

Detected in drinking
water in the U.S.?

Yes

Detection by PCR.

Huffman et al., 2003

2

Detected in source
water in the U.S.?

Yes

Detected in groundwater by
PCR.

Borchardt et al., 2003
Fout et al., 2003

1

Not detected in the
U.S.?







Health Risk

7

Does the organism
cause significant
mortality (> 1/1,000
cases)?





6

Does the organism
cause pneumonia,
meningitis, hepatitis,
encephalitis,
endocarditis, cancer, or
other severe

manifestations of illness

No long term sequelae have
been reported.

CDC, 2001

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Microbial Contaminants

Score2

Data Element

Scoring Data

Reference3



necessitating long term
hospitalization (>
week)?





5

Does the illness result
in long term or
permanent dysfunction
or disability, i.e.
sequelae?

No

CDC, 2001

4 [C, E, CD]

Does the illness
require short term
hospitalization (<
week)?

[E, CD] (Norovirus)
Although rare, severe
dehydration can be fatal,
with this outcome
occurring among
susceptible persons (e.g.,
older persons with
debilitating health
conditions).

[C] Sappoviruses cause
disease mainly in children.

CDC, 2019

Farkas in MCM,
2007

3

Does the illness require
physician intervention?





2[G, P]

Is the illness self-
limiting within 72
hours (without
requiring medical
intervention)?

[G, P] Acute
gastroenteritis. Highly
contagious, able to cause
large outbreaks and
environmentally stable.

Farkas in MCM,
2007

1

Does the illness result
in mild symptoms with
minimal or no impact
on daily activities?





1 Bolded text indicates the highest score for that particular protocol. For the health risk protocol two
scores were selected: the general population [G] and the highest score for a sensitive subpopulation.

These 2 scores were added and normalized by multiplying by 5/14 for a final health risk score. The higher

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Microbial Contaminants

EPA 815-R-22-004
October 2022

score between the WBDO and Occurrence protocols was used for total pathogen score calculation. Health
Risk protocol: G - General, C - Child, E - Elderly, P - Pregnant Women, CD - Chronic Disease.

2See Final Contaminant Candidate List 3 Microbes: PCCL to CCL Process. EPA 815-R-09-009. Final.
August 2009 for a detailed description on how to calculate the total pathogen score.

3EPA based the WBDO scores on the CDC MMWR reports from 1991 -2017 and then collected
occurrence citations if there were no CDC WBDOs.

References

Borchardt, M.A., P.D. Bertz, S.K. Spencer, and D.A. Battigelli. 2003. Incidence of enteric
viruses in groundwater from household wells in Wisconsin. Applied and Environmental.
Microbiology. 69: 1172-1180.

Centers for Disease Control and Prevention (CDC). 2001. Norwalk-like viruses: Public health
consequences and outbreak management. Morbidity and Mortality Weekly Report (MMWR).
50(RR-9):1-18.

CDC. 2003. Managing acute gastroenteritis among children. MMWR. 52(RR-16):1-16.

CDC. 2019. Norovirus home page. Available online at:
https://www.cdc.gov/norovirus/index.html

CDC. 2020. National Outbreak Reporting System (NORS). Available online at:
https://wwwn.cdc.gov/norsdashboard/. Accessed August 31, 2020.

Farkas, T. and X. Jiang. 2007. Rotaviruses, Caliciviruses, Astroviruses, Enteric Adenoviruses,
and Other Diarrheic Viruses. In Murray, P.R., E.J. Baron, J.H. Jorgensen, M.A. Pfaller, and R.H.
Yolken (ed) Manual of Clinical Microbiology, 9th Edition, Volume 2, pp. 1454-1457. American
Society for Microbiology Press, Washington, DC.

Fout, G.S., B.C. Martinson, M.W. Moyer, and D.R. Dahling. 2003. A multiplex reverse
transcription-PCR method for detection of human enteric viruses in groundwater. Applied and
Environmental Microbiology. 69: 3158-3164.

Huffman, D.E., K.L. Nelson, and J.B. Rose. 2003. Calicivirus - an emerging contaminant in
water: state of the art. Environmental Engineering Science. 20: 503-515.

Pang, X. and M. Smieja. Gastroenteritis Viruses. In Carroll, K.C., M.A. Pfaller, M.L. Landry,
A.J. McAdam, R. Patel, S.S. Richter, and D.W. Warnock (ed). Manual of Clinical Microbiology,
12th Edition. American Society of Microbiology Press, Washington, DC.

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Microbial Contaminants

EPA 815-R-22-004
October 2022

Campylobacter jejuni Scoring Data

Scoring Summary1'2

Waterborne Disease Outbreak

5

Health Risk

General population

3

Sensitive subpopulation(s) [C, E]

4

1 Bolded text indicates the highest score for that particular protocol. For the health risk protocol two scores were selected: the
general population [G] and the highest score for a sensitive subpopulation. These 2 scores were added and normalized by
multiplying by 5/14 for a final health risk score. The higher score between the WBDO and Occurrence protocols was used for
total pathogen score calculation. Health Risk protocol: G - General, C - Child, E - Elderly, P - Pregnant Women, CD - Chronic
Disease

Score2

Data Element

Scoring Data

Reference3



Waterborne Disease Outbreaks



Has caused multiple (2
or more) documented
WBDOs in the U.S.
reported by CDC
between 2009-2017

Yes

2009: 1 Community

CDC-NORS, 2020

5



2010: 3 Community

1 Nontransient
Noncommunity

2012: 1 Community
(Campylobacter unknown)

2015: 2 Community

2017: 1 Community



4

Has caused at least one
documented WBDOs in





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Microbial Contaminants

Score2

Data Element

Scoring Data

Reference3



U.S. reported by CDC
between 2009-2017





3

Has caused documented
WBDOs at any time in
the U.S.?

Yes

1971-2008: 13 Community
and 15 Noncommunity

CDC-NORS, 2020

2

Has caused WBDOs in
countries other than the
U.S.?

Yes

Finland, New Zealand

Kuusi, 2005;
waterandhealth. org

1

Has never caused
WBDOs in any country,
but has been
epidemiologically
associated with water
related disease?







Occurrence

3

Detected in drinking
water in the U.S.?

Yes

Sacks et al., 1986
O'Reilly, 2007

2

Detected in source water
in the U.S.?

Yes

Carter et al., 1987

1

Not detected in the
U.S.?







Health Risk

7

Does the organism
cause significant
mortality (> 1/1,000
cases)?

Death is uncommon.

Fitzgerald in MCM,
2007

6

Does the organism
cause pneumonia,

Complications include
hepatitis, bacteremia

Fitzgerald in MCM,
2007

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Microbial Contaminants

Score2

Data Element

Scoring Data

Reference3



meningitis, hepatitis,
encephalitis,
endocarditis, cancer, or
other severe

manifestations of illness
necessitating long term
hospitalization (>
week)?

cholecystitis, pancreatitis,
nephritis, abortion and
neonatal sepsis, urinary tract
infection, meningitis and
septic arthritis. Bacteremia
occurs in 0.15% of
intestinal infections with
elderly mostly affected.



5

Does the illness result in
long term or permanent
dysfunction or
disability, i.e. sequelae?





4[C, E]

Does the illness require
short term
hospitalization (<
week)?

[C, E] Most cases do not
require hospitalization,
pediatric cases and elderly
are more likely to require
hospitalization than
normal adult cases.

The highest incidence is in
children and infants.

Bacteremia occurs at 1.5
per 1,000 cases with the
highest rate occurring in
the elderly.

Fitzgerald in MCM,
2007

3 [G, P, CD]

Does the illness require

physician

intervention?

[G, P, CD] Guillain-Barre
syndrome, reactive
arthritis.

Guillain-Barre 1/1000
cases.

Reactive arthritis 1/100
cases.

Fitzgerald in MCM,
2007

Altekruse et al., 1999

2

Is the illness self-
limiting within 72 hours
(without requiring

Duration 2-5 days, usually
self-limiting.

Several days to more than 1

Heymann, 2005

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Microbial Contaminants

Score2

Data Element

Scoring Data

Reference3



medical intervention)?

week, self-limiting, relapse
in 5-10% cases.

Fitzgerald in MCM,
2007

CDC, 2019

1

Does the illness result in
mild symptoms with
minimal or no impact on
daily activities?

Asymptomatic to acute
diarrhea, abdominal pain,
malaise, and fever.

Fitzgerald in MCM,
2007

1 Bolded text indicates the highest score for that particular protocol. For the health risk protocol two
scores were selected: the general population [G] and the highest score for a sensitive subpopulation.

These 2 scores were added and normalized by multiplying by 5/14 for a final health risk score. The higher
score between the WBDO and Occurrence protocols was used for total pathogen score calculation. Health
Risk protocol: G - General, C - Child, E - Elderly, P - Pregnant Women, CD - Chronic Disease.

2See Final Contaminant Candidate List 3 Microbes: PCCL to CCL Process. EPA 815-R-09-009. Final.
August 2009 for a detailed description on how to calculate the total pathogen score.

3EPA based the WBDO scores on the CDC NORS reports from 1971 - 2017 and then collected
occurrence citations if there were no CDC WBDOs.

References

Altekruse, S.F., N.J. Stern, P.I. Fields, and D.L. Swerdlow. 1999. Campylobacter jejuni - An
Emerging Foodborne Pathogen. Emerging Infectious Diseases. 5(1): 28-35.

Carter, A.M., R.E. Pacha, G.W. Colark, andE.A. Williams. 1987. Seasonal occurrence of
Campylobacter spp. in surface waters and their correlation with standard indicator bacteria.
Applied and Environmental. Microbiology. 53(3): 523-526.

Centers for Disease Control and Prevention (CDC), 2019. Campylobacter home page. Available
online at: https://www.cdc.gov/campylobacter/index.html.

CDC, 2020. National Outbreak Reporting System (NORS). Available online at:
https://wwwn.cdc.gov/norsdashboard/. Accessed August 31, 2020.

Heymann, D. (ed.). 2005. Control of Communicable Diseases Manual, 18th Edition. American
Public Health Association, Washington, DC.

Kuusi, M., J.P. Nuorti, M.L. Hanninen, M. Koskela, V. Jussila, E. Kela, I. Miettinen, and P.
Ruutu. 2005. A large outbreak of campylobacteriosis associated with a municipal water supply in
Finland. Epidemiology & Infection. 133(4): 593-601.

Fitzgerald, C. and I. Nachamkin. 2007. Campylobacter and Arcobacter. In Murray, P.R., E.J.
Baron, J.H. Jorgensen, M.L. Landry, and M. A. Pfaller (ed.) Manual of Clinical Microbiology,
9th Edition, Volume 1, pp. 933-935. American Society for Microbiology Press, Washington, DC.

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Microbial Contaminants

EPA 815-R-22-004
October 2022

Nachamkin, I. 2019. Campylobacter and Arcobacter. In Carroll, K.C., M.A. Pfaller, M.L.

Landry, A.J. McAdam, R. Patel, S.S. Richter, and D.W. Warnock (ed). Manual of Clinical
Microbiology, 12th Edition. American Society of Microbiology, Washington, DC.

O'Reilly, C.E., A.B. Bowen, N.E. Perez, J.P. Sarisky, C.A. Shepherd, M.D. Miller, B.C.

Hubbard, M. Herring, S.D. Buchanan, C.C. Fitzgerald, V. Hill, M.J. Arrowood, L.X. Xiao, R.M.
Hoekstra, E.D. Mintz, F. Lynch, and Outbreak Working Group. 2007. A Waterborne Outbreak of
Gastroenteritis with Multiple Etiologies among Resort Island Visitors and Residents: Ohio, 2004.
Clinical Infectious Diseases. 44(4): 506-512.

Sacks, J.J., S. Lieb, L.M. Baldy, S. Berta, C.M. Patton, M.C. White, W.J. Bigler, and J.J. Witte.
1986. Epidemic campylobacteriosis associated with a community water supply. American
Journal of Public Health. 76(4): 424-429.

Water Quality and Health Council. 2017 Update: New Zealand's Largest Drinking Water
Outbreak. Available online at: https://waterandhealth.org/safe-drinking-water/update-new-
zealands-largest-drinking-water-outbreak-2.

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Microbial Contaminants

EPA 815-R-22-004
October 2022

Comamonas testosteroni Scoring Data

Scoring Summary1'2

Occurrence

2

Health Risk

General population

1

Sensitive subpopulation(s) [CD]

6

1 Bolded text indicates the highest score for that particular protocol. For the health risk protocol two scores were selected: the
general population [G] and the highest score for a sensitive subpopulation. These 2 scores were added and normalized by
multiplying by 5/14 for a final health risk score. The higher score between the WBDO and Occurrence protocols was used for
total pathogen score calculation. Health Risk protocol: G - General, C - Child, E - Elderly, P - Pregnant Women, CD - Chronic
Disease

Score2

Data Element

Scoring Data

Reference3



Waterborne Disease Outbreaks

5

Has caused multiple (2 or
more) documented WBDOs
in the U.S. reported by CDC
between 2009-2017

No

CDC-NORS, 2020

4

Has caused at least one
documented WBDOs in U.S.
reported by CDC between
2009-2017

No

CDC-NORS, 2020

3

Has caused documented
WBDOs at any time in the
U.S.?





2

Has caused WBDOs in
countries other than the U.S.?





1

Has never caused WBDOs
in any country, but has
been epidemiologically





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Microbial Contaminants

Score2

Data Element

Scoring Data

Reference3



associated with water
related disease?







Occurrence

3

Detected in drinking water in
the U.S.?





2

Detected in source water in
the U.S.?

Comamonas
testosteroni is often
found in freshwater,
soil, plants, and in
hospital devices such
as intravenous lines
and the reservoir
water in the
humidifiers of
respiratory therapy
equipment.

Tiwari and Nanda,
2019

1

Not detected in the U.S.?







Health Risk

7

Does the organism cause
significant mortality (>
1/1,000 cases)?





6 [CD, G]

Does the organism cause
pneumonia, meningitis,
hepatitis, encephalitis,
endocarditis, cancer, or
other severe manifestations
of illness necessitating long
term hospitalization (>
week)?

Comamonas
testosteroni has been
shown to cause
pneumonia in
patients with AIDS.
(Franzetti et al.,
1992). It has also
been documented
causing meningitis in
a patient that had
recurrent

cholesteatoma (Arda
et al., 2008). It also
been shown to infect
those who were

Franzetti et al., 1992

Arda et al., 2003

LaPuma et al. in
MCM, 2019

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Reference3





previously healthy.



5

Does the illness result in long
term or permanent
dysfunction or disability, i.e.
sequelae?





4

Does the illness require short
term hospitalization (<
week)?





3

Does the illness require
physician intervention?





2

Is the illness self-limiting
within 72 hours (without
requiring medical
intervention)?





1 [G]

Does the illness result in
mild symptoms with
minimal or no impact on
daily activities?

Infrequently cause
human infections on
healthy individuals

LaPuma et al. in
MCM, 2019

1 Bolded text indicates the highest score for that particular protocol. For the health risk protocol two
scores were selected: the general population [G] and the highest score for a sensitive subpopulation.

These 2 scores were added and normalized by multiplying by 5/14 for a final health risk score. The higher
score between the WBDO and Occurrence protocols was used for total pathogen score calculation. Health
Risk protocol: G - General, C - Child, E - Elderly, P - Pregnant Women, CD - Chronic Disease.

2See Final Contaminant Candidate List 3 Microbes: PCCL to CCL Process. EPA 815-R-09-009. Final.
August 2009 for a detailed description on how to calculate the total pathogen score.

3EPA based the WBDO scores on the CDC MMWR reports from 1991 -2017 and then collected
occurrence citations if there were no CDC WBDOs.

References

Arda, B., S. Aydemir, T. Yamazhan, A. Hassan, A. Tiinger, andD. Serter. 2003. Comamonas
testosteroni meningitis in a patient with recurrent cholesteatoma: Case report. Apmis. 111(4):
474-476.

Franzetti, F., M. Cernuschi, R. Esposito, and M. Moroni. 1992. Pseudomonas infections in
patients with AIDS and AIDS-related complex. Journal of internal medicine. 231(4): 437-443.

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Microbial Contaminants

EPA 815-R-22-004
October 2022

Centers for Disease Control and Prevention (CDC). 2020. National Outbreak Reporting System
(NORS). Available online at: https://wwwn.cdc.gov/norsdashboard/. Accessed August 31, 2020.

LaPuma, J.J., B.J. Currie, S.J. Peacock, and P.A.R. Vandamme. 2019.

Burkholderia, Stenotrophomonas, Ralstonia, Cupriavidus, Pandoraea, Brevundimonas,
Comamonas, Delftia, and Acidovorax. In Carroll, K.C., M.A. Pfaller, M.L., Landry, A.J.
McAdam, R. Patel, S.S. Richter, and D.W. Warnock (ed). 2019. Manual of Clinical
Microbiology, 12th Edition. American Society for Microbiology, Washington, DC.

Tiwari, S. and M. Nanda. 2019. Bacteremia caused by Comamonas testosteroni an unusual
pathogen. Journal of laboratory physicians. 11(1): 87.

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Technical Support Document for the
Final Fifth Contaminant Candidate List (CCL 5)-
Microbial Contaminants

EPA 815-R-22-004
October 2022

Cyclospora cayetanensis Scoring Data

Scoring Summary1'2

Waterborne Disease Outbreak

3

Health Risk

General population

3

Sensitive subpopulation(s) [C]

4

1 Bolded text indicates the highest score for that particular protocol. For the health risk protocol two scores were selected: the
general population [G] and the highest score for a sensitive subpopulation. These 2 scores were added and normalized by
multiplying by 5/14 for a final health risk score. The higher score between the WBDO and Occurrence protocols was used for
total pathogen score calculation. Health Risk protocol: G - General, C - Child, E - Elderly, P - Pregnant Women, CD - Chronic
Disease

Score2

Data Element

Scoring Data

Reference3



Waterborne Disease Outbreaks

5

Has caused multiple (1 or
more) documented WBDOs
in the U.S. reported by CDC
between 2009-2017

No

CDC-NORS, 2020

4

Has caused at least one
documented WBDOs in U.S.
reported by CDC between
2009-2017

No

CDC-NORS, 2020

3

Has caused documented
WBDOs at any time in the
U.S.?

Yes

1971-2008: 2
Community

CDC-NORS, 2020

2

Has caused WBDOs in
countries other than the
U.S.?





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EPA-Office of Water	Technical Support Document for the	EPA 815-R-22-004

Final Fifth Contaminant Candidate List (CCL 5)-	October 2022

Microbial Contaminants

Score2

Data Element

Scoring Data

Reference3

1

Has never caused WBDOs
in any country, but has been
epidemiologically associated
with water related disease?

Yes

Huang et al., 1995



Occurrence

3

Detected in drinking water
in the U.S.?

Yes

CDC, 2019

2

Detected in source water in
the U.S.?

No



1

Not detected in the U.S.?

Detected in drinking
water in Guatemala.

Dowd et al., 2003



Health Risk

7

Does the organism cause
significant mortality (>
1/1,000 cases)?

No



6

Does the organism cause
pneumonia, meningitis,
hepatitis, encephalitis,
endocarditis, cancer, or other
severe manifestations of
illness necessitating long
term hospitalization (>
week)?

No



5

Does the illness result in
long term or permanent
dysfunction or disability, i.e.
sequelae?

Guillain-Barre and
Reiter's syndromes
have been reported.

Connor et al., 2001

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EPA-Office of Water	Technical Support Document for the	EPA 815-R-22-004

Final Fifth Contaminant Candidate List (CCL 5)-	October 2022

Microbial Contaminants

Score2

Data Element

Scoring Data

Reference3

4 [C]

Does the illness require
short term hospitalization
(< week)?

[C] Most cases do not
required
hospitalization,
infants may require
hospitalization for
rehydration therapy.

Fisk et al., 2005

3 [G, P, E,
C, CD]

Does the illness require
physician intervention?

[All populations] Can
cause diarrhea and
biliary disease.

In patients not
treated, illness can be
protracted with
relapsing symptoms.

Lindsay in MCM,
2010

Heymann, 2005
CDC, 2019

2

Is the illness self-limiting
within 72 hours (without
requiring medical
intervention)?





1

Does the illness result in
mild symptoms with
minimal or no impact on
daily activities?





1 Bolded text indicates the highest score for that particular protocol. For the health risk protocol two
scores were selected: the general population [G] and the highest score for a sensitive subpopulation.

These 2 scores were added and normalized by multiplying by 5/14 for a final health risk score. The higher
score between the WBDO and Occurrence protocols was used for total pathogen score calculation. Health
Risk protocol: G - General, C - Child, E - Elderly, P - Pregnant Women, CD - Chronic Disease.

2See Final Contaminant Candidate List 3 Microbes: PCCL to CCL Process. EPA 815-R-09-009. Final.
August 2009 for a detailed description on how to calculate the total pathogen score.

3EPA based the WBDO scores on the CDC MMWR reports from 1991 -2017 and then collected
occurrence citations if there were no CDC WBDOs.

References

Centers for Disease Control and Prevention (CDC). 2019. Cyclospora homepage. Available
online at: https://www.cdc.gov/parasites/cvclosporiasis/index.html.

CDC. 2020. National Outbreak Reporting System (NORS). Available online at:
https://wwwn.cdc.gov/norsdashboard/. Accessed August 31, 2020.

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EPA-Office of Water

Technical Support Document for the
Final Fifth Contaminant Candidate List (CCL 5)-
Microbial Contaminants

EPA 815-R-22-004
October 2022

Connor, B.A., E. Johnson, and R. Soave. 2001. Reiter syndrome following protracted symptoms
of Cyclospora infection. Emerging infectious diseases. 7: 453-454.

Dowd, E.S., D. John, J. Eliopolus, C.P. Gerba, J. Naranjo, R. Klein, B. Lopez, M. de Mejia, C.E.
Mendoza, and I. Pepper. 2003. Confirmed detection of Cyclospora cayetanesis, Encepalitozoon
intestinalis and Cryptosporidium parvum in water used for drinking. Journal of Water and
Health. 1(3): 117-123.

Fisk, T.L., J.S. Keystone, and P. Kozarsky. 2005. In Mandell, G.L., J.E. Bennett, and R. Dolin
(eds.). Mandell, Douglas and Bennett's Principles and Practice of Infectious Diseases, 6th
Edition. Elsevier, Philadelphia, PA.

Heymann, D.(ed.). 2005. Control of Communicable Diseases Manual, 18th Edition. American
Public Health Association, Washington, DC.

Huang, P., J.T. Weber, D.M. Sosin, P.M. Griffin, E.G. Long, J.J. Murphy, F. Kocka, C. Peters,
and C. Kallick. 1995. The first reported outbreak of diarrheal illness associated with Cyclospora
in the United States. Annals of Internal Medicine. 123: 409-414.

Lindsay, D., S. Upton, and L. Weiss. 2010. Isospora, Cyclospora and Sarcocystis. In Murray,
P.R., E.J. Baron, J.H. Jorgensen, M.A. Pfaller, and R.H. Yolken (ed.) Manual of Clinical
Microbiology, 10th Edition, Volume 2, p. 2172. American Society for Microbiology Press,
Washington, DC.

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EPA-Office of Water

Technical Support Document for the
Final Fifth Contaminant Candidate List (CCL 5)-
Microbial Contaminants

EPA 815-R-22-004
October 2022

Entamoeba histolytica Scoring Data

Scoring Summary1'2

Waterborne Disease Outbreak

3

Health Risk

General population

3

Sensitive subpopulation(s) [C, P, E, CD]

3

1 Bolded text indicates the highest score for that particular protocol. For the health risk protocol two scores were selected: the
general population [G] and the highest score for a sensitive subpopulation. These 2 scores were added and normalized by
multiplying by 5/14 for a final health risk score. The higher score between the WBDO and Occurrence protocols was used for
total pathogen score calculation. Health Risk protocol: G - General, C - Child, E - Elderly, P - Pregnant Women, CD - Chronic
Disease

Score2

Data Element

Scoring Data

Reference3



Waterborne Disease Outbreaks

5

Has caused multiple (1 or
more) documented WBDOs
in the U.S. reported by CDC
between 2009-2017

No

CDC-NORS, 2020

4

Has caused at least one
documented WBDOs in U.S.
reported by CDC between
2009-2017

No

CDC-NORS, 2020

3

Has caused documented
WBDOs at any time in the
U.S.?

1971-2008:3
Community (one is
"Entamoeba
unknown')

1 Noncommunity

CDC-NORS, 2020

2

Has caused WBDOs in
countries other than the U.S.?





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EPA-Office of Water	Technical Support Document for the	EPA 815-R-22-004

Final Fifth Contaminant Candidate List (CCL 5)-	October 2022

Microbial Contaminants

Score2

Data Element

Scoring Data

Reference3

1

Has never caused WBDOs in
any country, but has been
epidemiologically associated
with water related disease?







Occurrence

3

Detected in drinking water
in the U.S.?

Found during WBDO.

CDC, 2006

2

Detected in source water in
the U.S.?





1

Not detected in the U.S.?







Health Risk

7

Does the organism cause
significant mortality (>
1/1,000 cases)?

500 million infected (E.
dispar and E.
histolytica) each year
with approximately 50
million cases of colitis
and liver abscess and
100,000 deaths
worldwide.

Leber in MCM,
2010

6

Does the organism cause
pneumonia, meningitis,
hepatitis, encephalitis,
endocarditis, cancer, or other
severe manifestations of
illness necessitating long
term hospitalization (>
week)?

Infections in the U.S.
rarely progress to
complications, amoebic
colitis may result in
perforation of the
intestinal wall, resulting
in peritonitis;
dissemination to
extraintestinal sites may
involve the liver, lungs,
or brain. Liver abscess
is the most common
complication.

Heymann, 2005

5

Does the illness result in long
term or permanent

Abdominal perforations
and peritonitis are rare

Leber in MCM,
2010

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EPA-Office of Water	Technical Support Document for the	EPA 815-R-22-004

Final Fifth Contaminant Candidate List (CCL 5)-	October 2022

Microbial Contaminants

Score2

Data Element

Scoring Data

Reference3



dysfunction or disability, i.e.
sequelae?

complications. Up to
5% develop liver
abscess.



4

Does the illness require short
term hospitalization (<
week)?

Intestinal invasion can
lead to lesions, ulcers.

Leber in MCM,
2010

3 [G, C, P,
E, CD]

Does the illness require
physician intervention?

[All populations]

Clinical symptoms are
dysentery, colitis or
rarely amoeboma).

Fulminant colitis
occurs most often in
children who present
with diffuse
abdominal pain,
profuse bloody
diarrhea and fever.

Leber in MCM,
2010

Marshall, 1997

2

Is the illness self-limiting
within 72 hours (without
requiring medical
intervention)?

Most human infections
(90%) are
asymptomatic,
symptomatic non-
invasive strains cause
gastrointestinal
symptoms such as
cramping and increased
frequency of bowel
movements,
constipation may
alternate with diarrhea,
invasive strains may
cause amoebic
dysentery.

Heymann, 2005

1

Does the illness result in mild
symptoms with minimal or
no impact on daily activities?





1 Bolded text indicates the highest score for that particular protocol. For the health risk protocol two
scores were selected: the general population [G] and the highest score for a sensitive subpopulation.

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EPA-Office of Water

Technical Support Document for the
Final Fifth Contaminant Candidate List (CCL 5)-
Microbial Contaminants

EPA 815-R-22-004
October 2022

These 2 scores were added and normalized by multiplying by 5/14 for a final health risk score. The higher
score between the WBDO and Occurrence protocols was used for total pathogen score calculation. Health
Risk protocol: G - General, C - Child, E - Elderly, P - Pregnant Women, CD - Chronic Disease.

2See Final Contaminant Candidate List 3 Microbes: PCCL to CCL Process. EPA 815-R-09-009. Final.
August 2009 for a detailed description on how to calculate the total pathogen score.

3EPA based the WBDO scores on the CDC MMWR reports from 1991 -2017 and then collected
occurrence citations if there were no CDC WBDOs.

References

Centers for Disease Control and Prevention (CDC). 2020. National Outbreak Reporting System
(NORS). Available online at:https://wwwn.cdc.gov/norsdashboard/. Accessed August 31, 2020.

Heymann, D. (ed.). 2005. Control of Communicable Diseases Manual, 18th Edition. American
Public Health Association, Washington, DC.

Leber, A. and S. Novak-Weekley. 2010. Intestinal and Urogenital Amebae, Flagellates, and
Ciliates. In Murray, P.R., E.J. Baron, J.H. Jorgensen, M.L. Landry, and M.A. Pfaller (ed.)
Manual of Clinical Microbiology, 10th Edition, Volume 2, p. 2149. American Society for
Microbiology Press, Washington, DC.

Marshall, M., D. Naumovitz, Y. Ortega, and C. Sterling. 1997. Waterborne protozoan pathogens.
Clinical Microbiology Reviews. 10(1): 67-85.

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EPA-Office of Water

Technical Support Document for the
Final Fifth Contaminant Candidate List (CCL 5)-
Microbial Contaminants

EPA 815-R-22-004
October 2022

Enterovirus Scoring Data

Scoring Summary1'2

Occurrence

3

Health Risk

General population

4

Sensitive subpopulation(s) [C]

6

1 Bolded text indicates the highest score for that particular protocol. For the health risk protocol two scores were selected: the
general population [G] and the highest score for a sensitive subpopulation. These 2 scores were added and normalized by
multiplying by 5/14 for a final health risk score. The higher score between the WBDO and Occurrence protocols was used for
total pathogen score calculation. Health Risk protocol: G - General, C - Child, E - Elderly, P - Pregnant Women, CD - Chronic
Disease

Score2

Data Element

Scoring Data

Reference3



Waterborne Disease Outbreaks

5

Has caused multiple (2 or
more) documented
WBDOs in the U.S.
reported by CDC between
2009-2017

No

CDC-NORS, 2020

4

Has caused at least one
documented WBDOs in
U.S. reported by CDC
between 1990-2009

No

CDC-NORS, 2020

3

Has caused documented
WBDOs at any time in the
U.S.?

No



2

Has caused WBDOs in
countries other than the
U.S.?

Yes

Switzerland and others.

Hafliger et al., 2000

1

Has never caused WBDOs
in any country, but has





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EPA-Office of Water	Technical Support Document for the	EPA 815-R-22-004

Final Fifth Contaminant Candidate List (CCL 5)-	October 2022

Microbial Contaminants

Score2

Data Element

Scoring Data

Reference3



been epidemiologically
associated with water
related disease?







Occurrence

3

Detected in drinking
water in the U.S.?

Yes

Mack et al., 1972
Lieberman et al.,
2003

Keswick et al., 1984

2

Detected in source water
in the U.S.?

Yes

Borchardt et al., 2003

1

Not detected in the U.S.?







Health Risk

7

Does the organism cause
significant mortality (>
1/1,000 cases)?





6 [C]

Does the organism cause
pneumonia, meningitis,
hepatitis, encephalitis,
endocarditis, cancer, or
other severe
manifestations of illness
necessitating long term
hospitalization (> week)?

[C] Aseptic meningitis
and neonatal sepsis are
the most common
complications.

EVs are the most
common cause of
meningitis in the U.S.,
over 80% of all viral
meningitides (estimated
30,000 to 50,000
hospitalizations for non-
polio EV each year
(principally echo and
coxsackie)).

Enterovirus causes
myocarditis, viral

Heymann, 2005

Romero in MCM,
2007

Khetsuriani et al.,

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EPA-Office of Water	Technical Support Document for the	EPA 815-R-22-004

Final Fifth Contaminant Candidate List (CCL 5)-	October 2022

Microbial Contaminants

Score2

Data Element

Scoring Data

Reference3





meningitis, encephalitis
and

meningioencephalitis.

2002





Widespread illness in
children with asthma.

Kim et al., 2001
Khetsuriani, 2003

Midgely at al, 2015

5

Does the illness result in
long term or permanent
dysfunction or disability,
i.e. sequelae?

Diabetes has been
associated with
enterovirus infection.

Heymann, 2005

4 [G]

Does the illness require
short term

hospitalization (< week)?

[G] Hospitalization may
be required for severe
manifestations of
disease. Approximately
20-30% of meningitis
outbreak cases in young
adults require
hospitalization.

During the summer and
fall, responsible for 50 -
60% of hospital
admissions for
evaluation of febrile
illnesses for infants and
children.

Sawyer, 2002

Romero in MCM,
2007

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EPA-Office of Water	Technical Support Document for the	EPA 815-R-22-004

Final Fifth Contaminant Candidate List (CCL 5)-	October 2022

Microbial Contaminants

Score2

Data Element

Scoring Data

Reference3

3

Does the illness require
physician intervention?

Children with acute
pharyngitis may be taken
to a physician to
differentiate between
streptococcal and viral
sore throat. Upper
respiratory illness lasts 4-
6 days, lower respiratory
illness lasts 5-7 days, and
meningitis lasts 7-10
days.

Romero in MCM,
2007

Heymann, 2005

2 [E, P, CD]

Is the illness self-limiting
within 72 hours (without
requiring medical
intervention)?

[E, P, CD] Most cases are
asymptomatic. Most
common symptoms are
acute nonspecific febrile
illness.

Romero in MCM,
2007

1

Does the illness result in
mild symptoms with
minimal or no impact on
daily activities?





1 Bolded text indicates the highest score for that particular protocol. For the health risk protocol two
scores were selected: the general population [G] and the highest score for a sensitive subpopulation.

These 2 scores were added and normalized by multiplying by 5/14 for a final health risk score. The higher
score between the WBDO and Occurrence protocols was used for total pathogen score calculation. Health
Risk protocol: G - General, C - Child, E - Elderly, P - Pregnant Women, CD - Chronic Disease.

2See Final Contaminant Candidate List 3 Microbes: PCCL to CCL Process. EPA 815-R-09-009. Final.
August 2009 for a detailed description on how to calculate the total pathogen score.

3EPA based the WBDO scores on the CDC MMWR reports from 1991 -2017 and then collected
occurrence citations if there were no CDC WBDOs.

References

Borchardt, M.A., P.D. Bertz, S.K. Spencer, and D.A. Battigelli. 2003. Incidence of enteric
viruses in groundwater from household wells in Wisconsin. Applied and Environmental
Microbiology. 69(2): 1172-1180.

Centers for Disease Control and Prevention (CDC). 2020. National Outbreak Reporting System
(NORS). Available online at:https://wwwn.cdc.gov/norsdashboard/. Accessed August 31, 2020.

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EPA-Office of Water

Technical Support Document for the
Final Fifth Contaminant Candidate List (CCL 5)-
Microbial Contaminants

EPA 815-R-22-004
October 2022

Hafliger D., P. Hubner, and J. Luthy. 2000. Outbreak of viral gastroenteritis due to sewage-
contaminated drinking water. International Journal of Food Microbiology. 54(1-2): 123-126.

Heymann, D. (ed.). 2005. Control of Communicable Diseases Manual, 18th Edition. American
Public Health Association, Washington, DC.

Keswick, B., C. Gerba, H. DuPont, and J. Rose. 1984. Detection of Enteric Viruses in Treated
Drinking Water. Applied and Environmental Microbiology. 47(6): 1290-1294.

Khetsuriani N., R. Holman, and L. Anderson. 2002. Burden of Encephalitis-Associated
Hospitalizations in the United States, 1988-1997. Clinical Infectious Diseases. 35(2): 175-182.

Khetsuriani, N., E.S. Quiroz, R.C. Holman, and L.J. Anderson. 2003. Viral meningitis-associated
hospitalizations in the United States, 1988-1999. Neuroepidemiology. 22(6): 345-352.

Kim, K-S., G. Hufnagel, N.M. Chapman, and S. Tracy. 2001. The group B coxsackieviruses and
myocarditis. Reviews in Medical Virology. 11(6): 355-368.

Lieberman, R.J., L.C. Shadix, B.S. Newport, C.P. Frebis, M.W.N. Moyer, R.S. Safferman, R.E.
Stetler, D. Lye, G.S. Fout, and D. Dahling. 2002. Microbial monitoring of vulnerable public
ground water supplies, p. 142. American Water Works Association, Dever, CO.

Mack, W.N., L. Yue-Shoung, and D.B. Coohon. 1972. Isolation of poliomyelitis virus from a
contaminated well. Health Services Report. 87(3): 271-274.

Midgley, C.M., J.T. Watson, W.A. Nix, A.T. Curns, S.L. Rogers, B.A., Brown, C. Conover, S.R.
Dominguez, D.R. Feikin, S. Gray, and F. Hassan. 2015. Severe respiratory illness associated
with a nationwide outbreak of enterovirus D68 in the USA (2014): a descriptive epidemiological
investigation. The Lancet Respiratory medicine. 3(11): 879-887.

Romero, J. 2007. Enteroviruses and Parechoviruses. In Murray, P.R., E.J. Baron, J.H. Jorgensen,
M.L. Landry, and M.A. Pfaller (ed) Manual of Clinical Microbiology, 9th Edition, Volume 2, p.
1394. American Society for Microbiology Press, Washington, DC.

Sawyer, M.H. 2002. Enterovirus infections: diagnosis and treatment. Seminars in Pediatric
Infectious Diseases. 13(1): 40-47.

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EPA-Office of Water

Technical Support Document for the
Final Fifth Contaminant Candidate List (CCL 5)-
Microbial Contaminants

EPA 815-R-22-004
October 2022

Escherichia coli (0157)' Scoring Data

Scoring Summary1'2

Waterborne Disease Outbreak

5

Health Risk

General population

3

Sensitive subpopulation(s) [C, E]

6

1 Bolded text indicates the highest score for that particular protocol. For the health risk protocol two scores were selected: the
general population [G] and the highest score for a sensitive subpopulation. These 2 scores were added and normalized by
multiplying by 5/14 for a final health risk score. The higher score between the WBDO and Occurrence protocols was used for
total pathogen score calculation. Health Risk protocol: G - General, C - Child, E - Elderly, P - Pregnant Women, CD - Chronic
Disease

Score2

Data Element

Scoring Data

Reference3



Waterborne Disease Outbreaks



Has caused multiple (2 or
more) documented
WBDOs in the U.S.
reported by CDC between
2009-2017

Yes

2010: 1 Community

2011: 1 Transient
Noncommunity

CDC-NORS, 2020

5



2013: 1 Transient
Noncommunity

2014: 1 Nontransient
Noncommunity

2016: 1 Community



4

Has caused at least one
documented WBDOs in
U.S. reported by CDC





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Final Fifth Contaminant Candidate List (CCL 5)-	October 2022

Microbial Contaminants

Score2

Data Element

Scoring Data

Reference3



between 2009-2017





3

Has caused documented
WBDOs at any time in
the U.S.?

1971-2008: 5 Community
5 Noncommunity

CDC-NORS, 2020

2

Has caused WBDOs in
countries other than the
U.S.?





1

Has never caused
WBDOs in any country,
but has been
epidemiologically
associated with water
related disease?







Occurrence

3

Detected in drinking
water in the U.S.?

Yes

Bopp et al., 2003

2

Detected in source water
in the U.S.?

Yes

As a result of animal
fecal contamination.

Kramer et al., 1996

1

Not detected in the U.S.?







Health Risk

7

Does the organism cause
significant mortality (>
1/1,000 cases)?

No

Approximately 60 deaths
per 73,000 cases per year
(nearly >1/1,000) are
reported due to E. coli
(0157). A case fatality
rate of 0.5 has been
reported for outbreak-
related cases caused by
E. co//0157:H7

Nataro in MCM, 2007

Rangel et al., 2005
Buchan in MCM, 2019

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Final Fifth Contaminant Candidate List (CCL 5)-	October 2022

Microbial Contaminants

Score2

Data Element

Scoring Data

Reference3

6 [C, E]

Does the organism cause
pneumonia, meningitis,
hepatitis, encephalitis,
endocarditis, cancer, or
other severe
manifestations of illness
necessitating long term
hospitalization (>
week)?

[C, E] Patients at
extremes of age have an
increased risk for
infection and associated
complications.

Children under 5 are
most frequently
diagnosed with infection
and are at greatest risk
of developing HUS. The
elderly also appear to
be an increased risk of
complications.

HUS develops in 10% of
patients under the age
of 10.

Chinyu, 1995

Nataro and Kaper,
1998

Heymann, 2005
CDC, 2019



Does the illness result in
long term or permanent
dysfunction or disability,
i.e. sequelae?

25% of HUS survivors
develop long term renal
sequelae.

Garg et al., 2003

5



3.2% of children with
diarrhea plus HUS
develop diabetes.

Adults have a greater
likelihood of
hypertension and reduced
renal function.

Suri et al., 2005
Garg et al., 2005

4

Does the illness require
short term hospitalization
(< week)?





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Final Fifth Contaminant Candidate List (CCL 5)-	October 2022

Microbial Contaminants

Score2

Data Element

Scoring Data

Reference3

3 [G, P, CD]

Does the illness require
physician intervention?

[G, P, CD] Fluid
replacement is the
cornerstone of
treatment for EHEC
diarrhea; some
clinicians choose to
hospitalize all patients
with E. coli 0157:H7
for hydration to prevent
HITS.

Heymann, 2005

2

Is the illness self-limiting
within 72 hours (without
requiring medical
intervention)?





1

Does the illness result in
mild symptoms with
minimal or no impact on
daily activities?

Can present as mild
nonbloody diarrhea.

Nataro in MCM, 2007

"The names E. coli 0157 and E. coli 0157:H7 are used interchangeably for CCL 5 due to
ongoing taxonomical debate in the scientific literature.

1 Bolded text indicates the highest score for that particular protocol. For the health risk protocol two
scores were selected: the general population [G] and the highest score for a sensitive subpopulation.

These 2 scores were added and normalized by multiplying by 5/14 for a final health risk score. The higher
score between the WBDO and Occurrence protocols was used for total pathogen score calculation. Health
Risk protocol: G - General, C - Child, E - Elderly, P - Pregnant Women, CD - Chronic Disease.

2See Final Contaminant Candidate List 3 Microbes: PCCL to CCL Process. EPA 815-R-09-009. Final.
August 2009 for a detailed description on how to calculate the total pathogen score.

3EPA based the WBDO scores on the CDC MMWR reports from 1991 -2017 and then collected
occurrence citations if there were no CDC WBDOs.

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EPA-Office of Water

Technical Support Document for the
Final Fifth Contaminant Candidate List (CCL 5)-
Microbial Contaminants

EPA 815-R-22-004
October 2022

References

Bopp, D.J., B.D. Sauders, A.L. Waring, J. Ackelsberg, N. Dumas, E. Braun-Howland, D.
Dziewulski, B.J. Wallace, M. Kelly, T. Halse, K. ArudaMusser, P.F. Smith, D.L. Morse, and
Limberger, R.J. 2003. Detection, Isolation, and Molecular Subtyping of Escherichia coli
0157:H7 and Campylobacter jejuni Associated with a Large Waterborne Outbreak. Journal of
Clinical Microbiology. 41(1): 174-180.

Buchan, B., M.L. Faron, R. Humphries, J. Dekker, and N.A. Ledeboer. 2019. Escherichia,
Shigella and Salmonella. In Carroll, K.C., M.A Pfaller, M.L. Landry, A.J. McAdam, R. Patel,
S.S. Richter, and D.W. Warnock (ed). Manual of Clinical Microbiology, 12th Edition. American
Society of Microbiology Press, Washington DC.

Chinyu S., and L.J. Brandt. Escherichia coli: H7 Infection in Humans. 1995. Annals of Internal
Medicine. 123(9): 698-707.

Centers for Disease Control and Prevention (CDC). 2019. E. coli (Escherichia coli) homepage.
Available online at: https://www.cdc.gov/ecoli/index.html.

CDC, 2020. National Outbreak Reporting System (NORS). Available online at:
https://wwwn.cdc.gov/norsdashboard/. Accessed August 31, 2020.

Garg, A.X., L. Moist, D. Matsel, H.R. Thiessen-Philbrook, R.B. Haynes, R.S. Suri, M. Salvadori,
J. Ray, and W.F. Clark. 2005. Risk of hypertension and reduced kidney function after acute
gastroenteritis from bacteria-contaminated drinking water. CMAJ. 173(3): 261-268.

Garg, A.X., R.S. Suri, N. Barrowman, F. Rehman, D. Matsell, M.P. Rosas-Arellano, M.
Salvadori, R.B. Haynes, and W.F. Clark. 2003. Long-term Renal Prognosis of Diarrhea-
Associated Hemolytic Uremic Syndrome. Journal of the American Medical Association.
290(10): 1360-1370.

Heymann, D. (ed.). 2005. Control of Communicable Diseases Manual, 18th Edition. American
Public Health Association, Washington, DC.

Karch, H., P.I. Tarr, and M. Bielaszewska. 2005. Enterohaemorrhagic Eschericia coli in human
medicine. International Journal of Medical Microbiology. 295: 405-418.

Kramer, M.H., B.L. Herwaldt, G.F. Craun, R.L. Calderon, and D.D. Juranek. 1996. Surveillance
for waterborne-disease outbreaks - United States, 1993-1994. MMWR Surveillance
Summaries. 45(SS-1): 1-33.

Nataro, J., C. Bopp, P. Fields, J. Kaper, and N. Strockbine. 2007. Escherichia, Shigella and
Salmonella. In Murray, P.R., E.J. Baron, J.H. Jorgensen, M.L. Landry, and M.A. Pfaller (ed.)
Manual of Clinical Microbiology, 9th Edition, Volume 1, pp. 670 - 672. American Society for
Microbiology Press, Washington, DC.

Nataro, J.P. and J.B. Kaper. 1998. Diarrheagenic Escherichia coli. Clinical microbiology
reviews. 11(1): 142-201.

Rangel, J.M., P.H. Sparling, C. Crowe, P.M. Griffin, and D.L. Swerdlow. 2005. Epidemiology of
Escherichia coli 0157:H7 outbreaks, United States, 1982-2002. Emerging infectious diseases.
11(4): 603-609.

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Final Fifth Contaminant Candidate List (CCL 5)-	October 2022

Microbial Contaminants

Suri, R.S., W.F. Clark, N. Barrowman, J.L. Mahon, H.R. Thiessen-Philbrook, M.P. Rosas-
Arellano, K. Zarnke, J.S. Garland, and A.X. Garg. 2005. Diabetes during diarrhea-associated
hemolytic uremic syndrome: a systematic review and meta-analysis. Diabetes Care. 28(10):
2556-2562.

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EPA-Office of Water

Technical Support Document for the
Final Fifth Contaminant Candidate List (CCL 5)-
Microbial Contaminants

EPA 815-R-22-004
October 2022

Exophiala jeanselmei Scoring Data

Scoring Summary1

Occurrence

3

Health Risk

General population

3

Sensitive subpopulation(s) [C, P, E, CD]

3

1 Bolded text indicates the highest score for that particular protocol. For the health risk protocol two scores were selected: the
general population [G] and the highest score for a sensitive subpopulation. These 2 scores were added and normalized by
multiplying by 5/14 for a final health risk score. The higher score between the WBDO and Occurrence protocols was used for
total pathogen score calculation. Health Risk protocol: G - General, C - Child, E - Elderly, P - Pregnant Women, CD - Chronic
Disease

Score2

Data Element

Scoring Data

Reference3



Waterborne Disease Outbreaks

5

Has caused multiple (1 or
more) documented WBDOs
in the U.S. reported by CDC
between 2009-2017

No

CDC-NORS, 2020

4

Has caused at least one
documented WBDOs in U.S.
reported by CDC between
2009-2017

No

CDC-NORS, 2020

3

Has caused documented
WBDOs at any time in the
U.S.?

No



2

Has caused WBDOs in
countries other than the U.S.?

No



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EPA-Office of Water	Technical Support Document for the	EPA 815-R-22-004

Final Fifth Contaminant Candidate List (CCL 5)-	October 2022

Microbial Contaminants

Score2

Data Element

Scoring Data

Reference3

1

Has never caused WBDOs
in any country, but has
been epidemiologically
associated with water
related disease?

Yes

Nucci et al., 2002



Occurrence

3

Detected in drinking water
in the U.S.?

Yes

West, 1986

2

Detected in source water in
the U.S.?

Yes

Nucci et al., 2001

1

Not detected in the U.S.?







Health Risk

7

Does the organism cause
significant mortality (>
1/1,000 cases)?

No



6

Does the organism cause
pneumonia, meningitis,
hepatitis, encephalitis,
endocarditis, cancer, or other
severe manifestations of
illness necessitating long
term hospitalization (>
week)?

Infections increase in
severity in patients
with impaired
immunity and
metabolic diseases
such as diabetes.

De Hoog and Vitale in
MCM, 2007

5

Does the illness result in long
term or permanent
dysfunction or disability, i.e.
sequelae?

No



4

Does the illness require short
term hospitalization (<
week)?

No



3 [G, C, P,

Does the illness require

[All populations] A
chronic spreading

Heymann, 2005

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EPA-Office of Water	Technical Support Document for the	EPA 815-R-22-004

Final Fifth Contaminant Candidate List (CCL 5)-	October 2022

Microbial Contaminants

Score2

Data Element

Scoring Data

Reference3

E, CD]

physician intervention?

mycosis.

The frequency of
infection is low, yet
potential severe
outcome and high
degrees of resistance
to antifungal drugs
requires medical
attention.

De Hoog and Vitale
in MCM, 2007

2

Is the illness self-limiting
within 72 hours (without
requiring medical
intervention)?





1

Does the illness result in mild
symptoms with minimal or
no impact on daily activities?





1 Bolded text indicates the highest score for that particular protocol. For the health risk protocol two
scores were selected: the general population [G] and the highest score for a sensitive subpopulation.

These 2 scores were added and normalized by multiplying by 5/14 for a final health risk score. The higher
score between the WBDO and Occurrence protocols was used for total pathogen score calculation. Health
Risk protocol: G - General, C - Child, E - Elderly, P - Pregnant Women, CD - Chronic Disease.

2See Final Contaminant Candidate List 3 Microbes: PCCL to CCL Process. EPA 815-R-09-009. Final.
August 2009 for a detailed description on how to calculate the total pathogen score.

3EPA based the WBDO scores on the CDC MMWR reports from 1991 -2017 and then collected
occurrence citations if there were no CDC WBDOs.

References

Centers for Disease Control and Prevention (CDC). 2020. National Outbreak Reporting System
(NORS). Available online at: https://wwwn.cdc.gov/norsdashboard/. Accessed August 31, 2020.

Heymann, D. (ed.). 2005. Control of Communicable Diseases Manual, 18th Edition. American
Public Health Association, Washington, DC.

Nucci, M., T. Akiti, G. Barreiros, F. Silveira, S.G. Revankar, D.A. Sutton, and T.F. Patterson.
2001. Nosocomial fungemia due to Exophiala jeanselmei var. jeanselmei and a Rhinocladiella
species: newly described causes of bloodstream infection. Journal of Clinical. Microbiology.
39(2): 514-518.

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EPA-Office of Water

Technical Support Document for the
Final Fifth Contaminant Candidate List (CCL 5)-
Microbial Contaminants

EPA 815-R-22-004
October 2022

Marcio, N., A. Tiyomi, B. Gloria, S. Fernanda, S.G. Revankar, L.W. Brian, D.A. Sutton, and
T.F. Patterson. 2002. Nosocomial outbreak of Exophiala jeanselmei fungemia associated with
contamination of hospital water. Clinical infectious diseases. 34: 1475-1480.

De Hoog, G. and R. Vitale. 2007. Bipolaris, Exophiala, Scedosporium, Sporothrix, and Other
Dematiaceous Fungi. In Murray, P.R., E.J. Baron, J.H. Jorgensen, M.L. Landry, and M.A.
Pfaller (ed.) Manual of Clinical Microbiology, 9th Edition, Volume 2, pp.1908 and 1918.
American Society for Microbiology Press, Washington, DC.

West, P.R. 1986. Isolation rates and characterization of fungi in drinking water distribution
systems. Proceedings of the Water Quality Technology Conference. American Water Works
Association, Denver, CO.

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EPA-Office of Water

Technical Support Document for the
Final Fifth Contaminant Candidate List (CCL 5)-
Microbial Contaminants

EPA 815-R-22-004
October 2022

l usarinm solani Scoring Data

Scoring Summary1'2

Occurrence

3

Health Risk

General population

4

Sensitive subpopulation(s) [C, P, E, CD]

4

1 Bolded text indicates the highest score for that particular protocol. For the health risk protocol two scores were selected: the
general population [G] and the highest score for a sensitive subpopulation. These 2 scores were added and normalized by
multiplying by 5/14 for a final health risk score. The higher score between the WBDO and Occurrence protocols was used for
total pathogen score calculation. Health Risk protocol: G - General, C - Child, E - Elderly, P - Pregnant Women, CD - Chronic
Disease

Score2

Data Element

Scoring Data

Reference3



Waterborne Disease Outbreaks

5

Has caused multiple (1 or
more) documented WBDOs
in the U.S. reported by CDC
between 2009-2017

No

CDC-NORS, 2020

4

Has caused at least one
documented WBDOs in U.S.
reported by CDC between
2009-2017

No

CDC-NORS, 2020

3

Has caused documented
WBDOs at any time in the
U.S.?

No



2

Has caused WBDOs in
countries other than the U.S.?

No



1

Has never caused WBDOs
in any country, but has
been epidemiologically
associated with water
related disease?

Yes

Houston TX

Annaissie et al., 2001

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EPA-Office of Water	Technical Support Document for the	EPA 815-R-22-004

Final Fifth Contaminant Candidate List (CCL 5)-	October 2022

Microbial Contaminants

Score2

Data Element

Scoring Data

Reference3



Occurrence

3

Detected in drinking water
in the U.S.?

Yes

Nagy and Olson,
1982

Annaissie et al., 2001

2

Detected in source water in
the U.S.?

Yes



1

Not detected in the U.S.?







Health Risk

7

Does the organism cause
significant mortality (>
1/1,000 cases)?

Mortality associated
with cutaneous
Fusarium infection is
high in

immunocompromi sed
patients but low for
immunocompetent
hosts.

Nucci and Annaissie,
2002

6

Does the organism cause
pneumonia, meningitis,
hepatitis, encephalitis,
endocarditis, cancer, or other
severe manifestations of
illness necessitating long
term hospitalization (>
week)?

Most severe disease
occurs in severely
immunocompromised.

Fusarium has been
associated with
pneumonia and
disseminated
infections

Fridkin and Jarvis,
1996; Annaissie et al.,
2001

Sutton and Brandt, in
MCM, 2010

5

Does the illness result in long
term or permanent
dysfunction or disability, i.e.
sequelae?





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Final Fifth Contaminant Candidate List (CCL 5)-	October 2022

Microbial Contaminants

Score2

Data Element

Scoring Data

Reference3

4 [G, C, P,
E, CD]

Does the illness require short
term hospitalization (<
week)?

[All populations] Can
cause infections that
may require
hospitalization,
particularly in
immunocompromised
patients

(endophthalmitis,
central nervous
system infections,
endocarditis)

Dignani and
Anaissie, 2004



Does the illness require
physician intervention?

Treatment and/or
removal of the foreign
body is usually
required as well as
antifungal therapy.

Dignani and Anaissie,
2004

3



In immunocompetent
patients manifestations
include keratitis,
localized skin lesions,
onychomycosis, and
occasionally cellulitis
and peritonitis.



2

Is the illness self-limiting
within 72 hours (without
requiring medical
intervention)?





1

Does the illness result in mild
symptoms with minimal or
no impact on daily activities?





1 Bolded text indicates the highest score for that particular protocol. For the health risk protocol two
scores were selected: the general population [G] and the highest score for a sensitive subpopulation.

These 2 scores were added and normalized by multiplying by 5/14 for a final health risk score. The higher
score between the WBDO and Occurrence protocols was used for total pathogen score calculation. Health
Risk protocol: G - General, C - Child, E - Elderly, P - Pregnant Women, CD - Chronic Disease.

2See Final Contaminant Candidate List 3 Microbes: PCCL to CCL Process. EPA 815-R-09-009. Final.
August 2009 for a detailed description on how to calculate the total pathogen score.

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EPA-Office of Water

Technical Support Document for the
Final Fifth Contaminant Candidate List (CCL 5)-
Microbial Contaminants

EPA 815-R-22-004
October 2022

3EPA based the WBDO scores on the CDC MMWR reports from 1991 -2017 and then collected
occurrence citations if there were no CDC WBDOs.

References

Anaissie, E.J., R.T. Kuchar, J.H. Rex, A. Francesconi, M. Kasai, F-M.C. Muller, M. Lozano-
Chiu, R.C. Summerbell, M.C. Dignani, S.J. Chanock, and T.J. Walsh. 2001. Fusariosis
Associated with Pathogenic Fusarium Species Colonization of a Hospital Water System: A New
Paradigm for the Epidemiology of Opportunistic Mold Infections. Clinical Infectious diseases.
33: 1871-1878.

Centers for Disease Control and Prevention (CDC). 2020. National Outbreak Reporting System
(NORS). Available online at: https://wwwn.cdc.gov/norsdashboard/. Accessed August 31, 2020.

Dignani, M. and E. Anaissie. 2004. Human Fusariosis. Clinical and Infection Microbiology. 1:
67-75.

Fridkin, S. and W. Jarvis. 1996. Epidemiology of Nosocomial Fungal Infections. Clinical
microbiology reviews. 9(4): 499-511.

Nagy L. and B. Olson. 1982. The occurrence of filamentous fungi in drinking water distribution
systems. Canadian Journal of Microbiology. 28(6): 667-71.

Nucci, M. and E. Anaissie. 2002. Cutaneous infection by Fusarium species in health and
immunocompromised hosts: implications for diagnosis and management. Clinical Infectious
diseases. 35: 909-920.

Sutton, D. and M. Brandt. 2007. Fusarium, and Other Opportunistic Hyaline Fungi. In Murray,
P.R., E.J. Baron, J.H. Jorgensen, M.L. Landry and M.A. Pfaller (ed) Manual of Clinical
Microbiology, 10th. Edition, Volume 2, p. 1853. American Society for Microbiology Press,
Washington, DC.

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EPA-Office of Water

Technical Support Document for the
Final Fifth Contaminant Candidate List (CCL 5)-
Microbial Contaminants

EPA 815-R-22-004
October 2022

Helicobacter pylori Scoring Data

Scoring Summary1'2

Occurrence

2

Health Risk

General population

7

Sensitive subpopulation(s) [E]

7

1 Bolded text indicates the highest score for that particular protocol. For the health risk protocol two scores were selected: the
general population [G] and the highest score for a sensitive subpopulation. These 2 scores were added and normalized by
multiplying by 5/14 for a final health risk score. The higher score between the WBDO and Occurrence protocols was used for
total pathogen score calculation. Health Risk protocol: G - General, C - Child, E - Elderly, P - Pregnant Women, CD - Chronic
Disease

Score2

Data Element

Scoring Data

Reference3



Waterborne Disease Outbreaks

5

Has caused multiple (2 or
more) documented WBDOs
in the U.S. reported by CDC
between 2009-2017

No

CDC-NORS, 2020

4

Has caused at least one
documented WBDOs in
U.S. reported by CDC
between 2009-2017.

No

CDC, 1991 - CDC,
2017

3

Has caused documented
WBDOs at any time in the
U.S.?

No



2

Has caused WBDOs in
countries other than the
U.S.?

No



1

Has never caused WBDOs
in any country, but has
been epidemiologically

Yes

Klein and Graham,
1991

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Final Fifth Contaminant Candidate List (CCL 5)-	October 2022

Microbial Contaminants

Score2

Data Element

Scoring Data

Reference3



associated with water
related disease?



Hulten et al., 1996

Rolle-Kampczyk,
2004

Aziz et al., 2015



Occurrence

3

Detected in drinking water
in the U.S.?

Yes

Hegarty and Baker,
1999

2

Detected in source water
in the U.S.?

Yes

Richards et al., 2018

1

Not detected in the U.S.?







Health Risk

7 [G, E]

Does the organism cause
significant mortality (>
1/1,000 cases)?

[G, E] 6500 deaths per
year.

1.2 Million acute cases
per year (>1/1,000
deaths).

46% of deaths occur
before age of 64.

CDC, 1997
Stratton et al., 2000

6

Does the organism cause
pneumonia, meningitis,
hepatitis, encephalitis,
endocarditis, cancer, or
other severe manifestations
of illness necessitating long
term hospitalization (>
week)?

40 - 50% infection rates
in the elderly. More
likely to suffer from
gastric ulcer, gastric
adenocarcinomas and
MALT.

Fox in MCM, 2007

Couturier in MCM,
2019

5

Does the illness result in
long term or permanent
dysfunction or disability, i.e.
sequelae?

Main cause for peptic
ulcers and a major risk
factor for gastric cancer.

Fox in MCM, 2007

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EPA-Office of Water	Technical Support Document for the	EPA 815-R-22-004

Final Fifth Contaminant Candidate List (CCL 5)-	October 2022

Microbial Contaminants

Score2

Data Element

Scoring Data

Reference3

4

Does the illness require
short term hospitalization (<
week)?





3 [C, P, CD]

Does the illness require
physician intervention?

[C, P, CD] Many
patients have recurrent
abdominal symptoms;
16% develop duodenal
ulcers. NIH( 1994)
recommends diagnosis
and antimicrobial
treatment for anyone
with peptic ulcers.

Fox in MCM, 2007

2

Is the illness self-limiting
within 72 hours (without
requiring medical
intervention)?

No

Infection persists
lifelong without
treatment.

Fox in MCM, 2007

1

Does the illness result in
mild symptoms with
minimal or no impact on
daily activities?





1 Bolded text indicates the highest score for that particular protocol. For the health risk protocol two
scores were selected: the general population [G] and the highest score for a sensitive subpopulation.

These 2 scores were added and normalized by multiplying by 5/14 for a final health risk score. The higher
score between the WBDO and Occurrence protocols was used for total pathogen score calculation. Health
Risk protocol: G - General, C - Child, E - Elderly, P - Pregnant Women, CD - Chronic Disease.

2See Final Contaminant Candidate List 3 Microbes: PCCL to CCL Process. EPA 815-R-09-009. Final.
August 2009 for a detailed description on how to calculate the total pathogen score.

3EPA based the WBDO scores on the CDC MMWR reports from 1991 -2017 and then collected
occurrence citations if there were no CDC WBDOs.

References

Aziz, R.K., M.M. Khalifa, and R.R. Sharaf. 2013. Contaminated water as a source of
Helicobacter pylori infection: A review. Journal of Advanced Research. 6(4): 539-547.
doi:10.1016/j.jare.2013.07.007.

CDC. 1991. Surveillance for Waterborne-Disease Outbreaks Associated with Drinking Water —
United States, 1989—1990. MMWR Surveillance Summaries. 40(SS-3): 1-21.

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Technical Support Document for the
Final Fifth Contaminant Candidate List (CCL 5)-
Microbial Contaminants

EPA 815-R-22-004
October 2022

CDC. 1993. Surveillance for Waterborne-Disease Outbreaks Associated with Drinking Water —
United States, 1991—1992. MMWR Surveillance Summaries. 42(SS-5): 1-22.

CDC. 1996. Surveillance for Waterborne-Disease Outbreaks Associated with Drinking Water —
United States, 1993—1994. MMWR Surveillance Summaries. 45(SS-1): 1-33.

CDC. 1997. Knowledge About Causes of Peptic Ulcer Disease — United States, March-April
1997, October 24, 1997. 46(42):985-987

CDC. 1998. Surveillance for Waterborne-Disease Outbreaks Associated with Drinking Water —
United States, 1995—1996. MMWR Surveillance Summaries. 47(SS-5): 1-33.

CDC. 2000. Surveillance for Waterborne-Disease Outbreaks Associated with Drinking Water —
United States, 1997—1998. MMWR Surveillance Summaries. 49(SS-4): 1-35.

CDC. 2002. Surveillance for Waterborne-Disease Outbreaks Associated with Drinking Water —
United States, 1999—2000. MMWR Surveillance Summaries. 51(SS-8): 1-36.

CDC. 2004. Surveillance for Waterborne-Disease Outbreaks Associated with Drinking Water —
United States, 2001—2002. MMWR Surveillance Summaries. 53(SS08): 23-45.

CDC. 2006. Surveillance for Waterborne-Disease Outbreaks Associated with Drinking Water —
United States, 2003—2004. MMWR Surveillance Summaries. 55(SS12): 31-58.

CDC. 2008. Surveillance for Waterborne Disease and Outbreaks Associated with Drinking
Water and Water not Intended for Drinking — United States, 2005-2006. MMWR. 60(SS12):
38-68.

CDC. 2011. Surveillance for Waterborne Disease Outbreaks Associated with Drinking Water —
United States, 2007-2008. MMWR. 60(SS12): 38-68

CDC. 2013. Surveillance for waterborne disease outbreaks associated with drinking water and
other nonrecreational water — United States, 2009-2010. MMWR. 62(35): 714-20.

CDC. 2015. Surveillance for waterborne disease outbreaks associated with drinking water —
United States, 2011-2012. MMWR. 64(31): 842-848.

CDC. 2017. Surveillance for waterborne disease outbreaks associated with drinking water —
United States, 2013-2014. MMWR. 66 (44): 1216-21.

CDC. 2020. National Outbreak Reporting System (NORS). Available online at:
https://wwwn.cdc.gov/norsdashboard/. Accessed August 31, 2020.

Roger-Couturier, M. Helicobacter. 2019. In Carroll, K.C., M.A Pfaller, M.L. Landry, A.J.
McAdam, R. Patel, S.S. Richter, and D.W. Warnock (ed). Manual of Clinical Microbiology, 12th
Edition. American Society for Microbiology Press, Washington, DC.

Fox, G. and F. Megraud. 2007. Helicobacter. In Murray, P.R., E.J. Baron, J.H. Jorgensen, M.L.
Landry, and M.A. Pfaller (ed.) Manual of Clinical Microbiology, 9th Edition, Volume 1, p. 950.
American Society for Microbiology Press, Washington, DC.

Hegarty, J.P. and K.H. Baker. 1999. Occurrence of Helicobacter pylori in surface water in the
United States. Journal of Applied Microbiology. 87: 697-701.

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Technical Support Document for the
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Microbial Contaminants

EPA 815-R-22-004
October 2022

Hulten, K., S.W. Han, H. Enroth, P.D. Klein, A.R. Opekun, R.H. Gilman D.G. Evans, L.
Engstrand, D.Y. Graham, and F.A.K. El-Zaatari. 1996. Helicobacter pylori in the drinking water
in Peru. Gastroenterology. 110: 1031-1035.

Klein, P.D, A.R. Opekun, E.O. Smith, D.Y. Graham, A. Gaillour, and Gastrointestinal
Physiology Working Group. 1991. Water source as risk factor for Helicobacter pylori infection in
Peruvian children. The Lancet. 337(8756): 1503-1506.

Richards C.L., S.C. Broadaway, M.J. Eggers, J. Doyle, B.H. Pyle, A.K. Camper, and T.E. Ford.
2018. Detection of Pathogenic and Non-pathogenic Bacteria in Drinking Water and Associated
Biofilms on the Crow Reservation, Montana, USA. Microbial Ecology. 76(1): 52-63. doi:
10.1007/s00248-015-0595-6.

Rolle-Kampczyk, U.E., G.J. Fritz, U. Diez, I. Lehman, M. Richter, and O. Herbarth. 2004. Well
water - one source for Helicobacter pylori colonization. International Journal of Hygiene and
Environmental Health. 207: 363-368.

Stratton, K.R., J.S. Durch, and R.S. Lawrence (eds.). 2000. Committee to Study Priorities for
Vaccine Development. Institute of Medicine. Vaccines for the 21st century: a tool for decision
making. National Academies Press, Washington, DC.

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Technical Support Document for the
Final Fifth Contaminant Candidate List (CCL 5)-
Microbial Contaminants

EPA 815-R-22-004
October 2022

Hepatitis A Virus Scoring Data

Scoring Summary1'2

Waterborne Disease Outbreak

3

Health Risk

General population

3

Sensitive subpopulation(s) [E]

6

1 Bolded text indicates the highest score for that particular protocol. For the health risk protocol two scores were selected: the
general population [G] and the highest score for a sensitive subpopulation. These 2 scores were added and normalized by
multiplying by 5/14 for a final health risk score. The higher score between the WBDO and Occurrence protocols was used for
total pathogen score calculation. Health Risk protocol: G - General, C - Child, E - Elderly, P - Pregnant Women, CD - Chronic
Disease

Score2

Data Element

Scoring Data

Reference3



Waterborne Disease Outbreaks

5

Has caused multiple (2
or more) documented
WBDOs in the U.S.
reported by CDC
between 2009-2017

No

CDC-NORS, 2020

4

Has caused at least one
documented WBDOs in
U.S. reported by CDC
between 2009-2017

No



3

Has caused
documented WBDOs
at any time in the U.S.?

Yes

1 Community

1 Noncommunity

(Previously

unreported)/A

1971-2008: 10

CDC-NORS, 2020

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Microbial Contaminants

Score2

Data Element

Scoring Data

Reference3





Community
9 Noncommunity



2

Has caused WBDOs in
countries other than the
U.S.?





1

Has never caused
WBDOs in any country,
but has been
epidemiologically
associated with water
related disease?







Occurrence

3

Detected in drinking
water in the U.S.?





2

Detected in source
water in the U.S.?

Yes

Abbaszadegan et al.,
2003

Borchardt et al., 2004

1

Not detected in the
U.S.?







Health Risk

7

Does the organism cause
significant mortality (>
1/1,000 cases)?

Reported case fatality is
normally low, 0.1% -
0.3%; it can reach 1.8%
for adults over 50.

Heymann, 2005

6[E]

Does the organism
cause pneumonia,
meningitis, hepatitis,
encephalitis,
endocarditis, cancer,
or other severe
manifestations of

[E] Fulminant hepatitis
may develop. Disease
severity shows a
general increase with
age.

Anderson in MCM,
2007

CDC, 2019

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Final Fifth Contaminant Candidate List (CCL 5)-	October 2022

Microbial Contaminants

Score2

Data Element

Scoring Data

Reference3



illness necessitating
long term
hospitalization (>
week)?





5

Does the illness result in
long term or permanent
dysfunction or
disability, i.e. sequelae?





4

Does the illness require
short term
hospitalization (<
week)?





3 [G, C, P,
CD]

Does the illness require

physician

intervention?

[G, C, P, CD]
Commonly begins with
"flu-like" symptoms.
May develop jaundice.
Physician office visit is
common for diagnosis
and/or vaccination.

Anderson in MCM,
2007

2

Is the illness self-
limiting within 72 hours
(without requiring
medical intervention)?





1

Does the illness result in
mild symptoms with
minimal or no impact on
daily activities?





1 Bolded text indicates the highest score for that particular protocol. For the health risk protocol two
scores were selected: the general population [G] and the highest score for a sensitive subpopulation.

These 2 scores were added and normalized by multiplying by 5/14 for a final health risk score. The higher
score between the WBDO and Occurrence protocols was used for total pathogen score calculation. Health
Risk protocol: G - General, C - Child, E - Elderly, P - Pregnant Women, CD - Chronic Disease.

2See Final Contaminant Candidate List 3 Microbes: PCCL to CCL Process. EPA 815-R-09-009. Final.
August 2009 for a detailed description on how to calculate the total pathogen score.

3EPA based the WBDO scores on the CDC MMWR reports from 1991 -2017 and then collected
occurrence citations if there were no CDC WBDOs.

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EPA-Office of Water

Technical Support Document for the
Final Fifth Contaminant Candidate List (CCL 5)-
Microbial Contaminants

EPA 815-R-22-004
October 2022

References

Abbaszadegan, M., M. LeChevallier, and C. P. Gerba. 2003. Occurrence of viruses in U. S.
groundwaters. Journal American Water Works. A95: 107-120.

Anderson, D. 2007. Hepatitis A and E Viruses. In Murray, P.R., E.J. Baron, J.H. Jorgensen, M.L.
Landry, and M.A. Pfaller (ed) Manual of Clinical Microbiology, 9th Edition, Volume 2, pp.
1428-1429. American Society for Microbiology Press, Washington, DC.

Borchardt, M.A., N.L. Haas, and R.L. Hunt. 2004. Vulnerability of drinking-water wells in La
Crosse, Wisconsin to enteric-virus contamination from surface water contributions. Applied and
Environmental Microbiology. 10: 5937-5946.

Centers for Disease Control and Prevention (CDC). 2019. Viral Hepatitis-Hepatitis A home
page. Available online at: https://www.cdc.gov/hepatitis/hav/index.htm.

CDC. 2020. National Outbreak Reporting System (NORS). Available online at:
https://wwwn.cdc.gov/norsdashboard/. Accessed August 31, 2020.

Heymann, D. (ed.). 2005. Control of Communicable Diseases Manual 18th Editon. American
Public Health Association, Washington, DC.

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Microbial Contaminants

EPA 815-R-22-004
October 2022

Hepatitis E Virus Scoring Data

Scoring Summary1'2

Waterborne Disease Outbreak

2

Health Risk

General population

3

Sensitive subpopulation(s) [P]

7

1 Bolded text indicates the highest score for that particular protocol. For the health risk protocol two scores were selected: the
general population [G] and the highest score for a sensitive subpopulation. These 2 scores were added and normalized by
multiplying by 5/14 for a final health risk score. The higher score between the WBDO and Occurrence protocols was used for
total pathogen score calculation. Health Risk protocol: G - General, C - Child, E - Elderly, P - Pregnant Women, CD - Chronic
Disease

Score2

Data Element

Scoring Data

Reference3



Waterborne Disease Outbreaks

5

Has caused multiple (1 or
more) documented WBDOs
in the U.S. reported by CDC
between 2009-2017

No

CDC-NORS, 2020

4

Has caused at least one
documented WBDOs in U.S.
reported by CDC between
2009-2017

No

CDC-NORS, 2020

3

Has caused documented
WBDOs at any time in the
U.S.?

No



2

Has caused WBDOs in
countries other than the
U.S.?

Yes

Waterborne
outbreaks have
occurred in Asia and
Africa.

Guthmann et al.,
2006

Panda et al., 2006

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Final Fifth Contaminant Candidate List (CCL 5)-	October 2022

Microbial Contaminants

Score2

Data Element

Scoring Data

Reference3

1

Has never caused WBDOs
in any country, but has been
epidemiologically associated
with water related disease?

Yes

California camping.

Tsang et al., 2000



Occurrence

3

Detected in drinking water
in the U.S.?

No



2

Detected in source water in
the U.S.?

No



1

Not detected in the U.S.?

Yes
India

Jothikumar et al.,
2000



Health Risk

7 [P]

Does the organism cause
significant mortality (>
1/1,000 cases)?

[P] May progress to
fulminant disease in
pregnant women
when infection occurs
during the third
trimester. High
mortality (for fetus)
when infection occurs
during pregnancy.

The case-fatality rate
is similar to that of
hepatitis A except in
pregnant women,
where it may reach
20% among those
infected during the
third trimester of
pregnancy.

Anderson in MCM,
2010; Isopet and
Kamar in MCM
2019

Heymann, 2005

6 [E]

Does the organism cause
pneumonia, meningitis,
hepatitis, encephalitis,
endocarditis, cancer, or other

[E] Fulminant hepatitis
may develop. Disease
severity shows a
general increase with

Anderson in MCM,
2010

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Final Fifth Contaminant Candidate List (CCL 5)-	October 2022

Microbial Contaminants

Score2

Data Element

Scoring Data

Reference3



severe manifestations of
illness necessitating long
term hospitalization (>
week)?

age.



5

Does the illness result in
long term or permanent
dysfunction or disability, i.e.
sequelae?





4

Does the illness require short
term hospitalization (<
week)?





3 [G, C]

Does the illness require
physician intervention?

[G, C] Commonly
begins with "flu-like"
symptoms. May
develop jaundice.
Physician office visit
is common for
diagnosis and/or
vaccination.

Anderson in MCM,
2010

2

Is the illness self-limiting
within 72 hours (without
requiring medical
intervention)?





1

Does the illness result in
mild symptoms with
minimal or no impact on
daily activities?





1 Bolded text indicates the highest score for that particular protocol. For the health risk protocol two
scores were selected: the general population [G] and the highest score for a sensitive subpopulation.

These 2 scores were added and normalized by multiplying by 5/14 for a final health risk score. The higher
score between the WBDO and Occurrence protocols was used for total pathogen score calculation. Health
Risk protocol: G - General, C - Child, E - Elderly, P - Pregnant Women, CD - Chronic Disease.

2See Final Contaminant Candidate List 3 Microbes: PCCL to CCL Process. EPA 815-R-09-009. Final.
August 2009 for a detailed description on how to calculate the total pathogen score.

3EPA based the WBDO scores on the CDC MMWR reports from 1991 -2017 and then collected
occurrence citations if there were no CDC WBDOs.

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EPA-Office of Water

Technical Support Document for the
Final Fifth Contaminant Candidate List (CCL 5)-
Microbial Contaminants

EPA 815-R-22-004
October 2022

References

Anderson, D., and N. Counahan. 2010. Hepatitis A and E Viruses. In Murray, P.R., E.J. Baron,
J.H. Jorgensen, M.L. Landry, and M.A. Pfaller (ed) Manual of Clinical Microbiology, 10th
Edition, Volume 2, p. 1423. American Society for Microbiology Press, Washington, DC.

Centers for Disease Control and Prevention (CDC). 2020. National Outbreak Reporting System
(NORS). Available online at: https://wwwn.cdc.gov/norsdashboard/. Accessed August 31, 2020.

Guthmann, J.P., H. Klovstad, D. Boccia, N. Hamid, L. Pinoges, J.Y. Nizou, M. Tatay, F. Diaz,
A. Moren, R.F. Grais, I. Ciglenecki. 2006. A large outbreak of hepatitis E among a displaced
population in Darfur, Sudan, 2004: the role of water treatment methods. Clinical Infectious
Diseases. 42: 1685-1691.

Heymann, D. (ed.). 2005. Control of Communicable Diseases Manual, 18th Edition. American
Public Health Association, Washington, DC.

Isopet, J. and N. Kamar. 2019. Hepatitis A and E Viruses. In Carroll, K.C., M.A. Pfaller, M.L.
Landry, A.J. McAdam, R. Patel, S.S. Richter, and D.W. Warnock, Manual of Clinical
Microbiology, 12th Edition, American Society of Microbiology Press, Washingon, DC.

Jothikumar N., R. Paulmurugan, P. Padmanabhan, R.B. Sundari, S. Kamatchiammal, andK.S.
Rao. 2000. Duplex RT-PCR for simultaneous detection of hepatitis A and hepatitis E virus
isolated from drinking water samples. Journal of Environmental Monitoring. 2(6): 587-90.

Panda, S.K., D. Thakral, and S. Rehman. 2007. Hepatitis E virus. Reviews in Medical Virology.
17(3): 151-180.

Tsang, T.H., E.K. Denison, H.V. Williams, L.V. Venczel, M.M. Ginsberg, and D.J. Vugia.
Acute Hepatitis E Infection Acquired in California. Clinical Infectious Diseases. 30: 618-9.

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Technical Support Document for the
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Microbial Contaminants

EPA 815-R-22-004
October 2022

Isospora belli Scoring Data

Scoring Summary1'2

Waterborne Disease Outbreak

2

Health Risk

General population

1

Sensitive subpopulation(s) [C]

2

1 Bolded text indicates the highest score for that particular protocol. For the health risk protocol two scores were selected: the
general population [G] and the highest score for a sensitive subpopulation. These 2 scores were added and normalized by
multiplying by 5/14 for a final health risk score. The higher score between the WBDO and Occurrence protocols was used for
total pathogen score calculation. Health Risk protocol: G - General, C - Child, E - Elderly, P - Pregnant Women, CD - Chronic
Disease

Score2

Data Element

Scoring Data

Reference3



Waterborne Disease Outbreaks

5

Has caused multiple (1 or
more) documented
WBDOs in the U.S.
reported by CDC between
2009-2017

No

CDC-NORS, 2020

4

Has caused at least one
documented WBDOs in
U.S. reported by CDC
between 2009-2017

No

CDC-NORS, 2020

3

Has caused documented
WBDOs at any time in the
U.S.?

No



2

Has caused WBDOs in
countries other than the
U.S.?

Yes

Karanis, 2006

1

Has never caused WBDOs
in any country, but has

Yes



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Final Fifth Contaminant Candidate List (CCL 5)-	October 2022

Microbial Contaminants

Score2

Data Element

Scoring Data

Reference3



been epidemiologically
associated with water
related disease?







Occurrence

3

Detected in drinking water
in the U.S.?

No



2

Detected in source water
in the U.S.?

No



1

Not detected in the U.S.?

No





Health Risk

7

Does the organism cause
significant mortality (>
1/1,000 cases)?





6

Does the organism cause
pneumonia, meningitis,
hepatitis, encephalitis,
endocarditis, cancer, or
other severe

manifestations of illness
necessitating long term
hospitalization (> week)?





5

Does the illness result in
long term or permanent
dysfunction or disability,
i.e. sequelae?





4

Does the illness require
short term hospitalization
(< week)?





3

Does the illness require
physician intervention?

Can cause serious and
sometimes fatal disease
in immunocompetent
humans, more severe in

Lindsay in MCM,
2010

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Microbial Contaminants

Score2

Data Element

Scoring Data

Reference3





immunocompromi sed
patients.



2 [C]

Is the illness self-limiting
within 72 hours (without
requiring medical
intervention)?

[C] Symptoms are more
severe in infants and
children.

Lindsay in MCM,
2010

1 [G]

Does the illness result in
mild symptoms with
minimal or no impact on
daily activities?

[G] Symptoms include
diarrhea, steatorrhea,
headache, fever,
malaise, abdominal
pain, vomiting,
dehydration, and
weight loss.

Lindsay in MCM,
2010

1 Bolded text indicates the highest score for that particular protocol. For the health risk protocol two
scores were selected: the general population [G] and the highest score for a sensitive subpopulation.

These 2 scores were added and normalized by multiplying by 5/14 for a final health risk score. The higher
score between the WBDO and Occurrence protocols was used for total pathogen score calculation. Health
Risk protocol: G - General, C - Child, E - Elderly, P - Pregnant Women, CD - Chronic Disease.

2See Final Contaminant Candidate List 3 Microbes: PCCL to CCL Process. EPA 815-R-09-009. Final.
August 2009 for a detailed description on how to calculate the total pathogen score.

3EPA based the WBDO scores on the CDC MMWR reports from 1991 -2017 and then collected
occurrence citations if there were no CDC WBDOs.

References

Centers for Disease Control and Prevention (CDC). 2020. National Outbreak Reporting System
(NORS). Available online at: https://wwwn.cdc.gov/norsdashboard/. Accessed August 31, 2020.

Karanis P. 2006. A review of an emerging waterborne medical important parasitic protozoan.
Japanese Journal of Protozoology. 39(1): 5-19.

Lindsay, D., S. Upton, and L. Weiss. 2010. Isospora, Cyclospora and Sarcocystis. In Murray,
P.R., E.J. Baron, J.H. Jorgensen, M.A. Pfaller, and R.H. Yolken (ed.) Manual of Clinical
Microbiology, 10th Edition, Volume 2, p. 2172. American Society for Microbiology Press,
Washington, DC.

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Technical Support Document for the
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Microbial Contaminants

EPA 815-R-22-004
October 2022

Legionella pneumophila Scoring Data

Scoring Summary1'2

Waterborne Disease Outbreak

5

Health Risk

General population

4

Sensitive subpopulation(s) [E, CD]

6

1 Bolded text indicates the highest score for that particular protocol. For the health risk protocol two scores were selected: the
general population [G] and the highest score for a sensitive subpopulation. These 2 scores were added and normalized by
multiplying by 5/14 for a final health risk score. The higher score between the WBDO and Occurrence protocols was used for
total pathogen score calculation. Health Risk protocol: G - General, C - Child, E - Elderly, P - Pregnant Women, CD - Chronic
Disease

Score2

Data Element

Scoring Data

Reference3



Waterborne Disease Outbreaks



Has caused multiple (1 or
more) documented WBDOs
in the U.S. reported by CDC
between 2009-2017

Yes

9 Community (2009)
12 Community (2010)

CDC-NORS,
2020

5



11	Community (2011)

12	Community (2012)
6 Community (2013)
17 Community (2014)

13	Community (2015)



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Final Fifth Contaminant Candidate List (CCL 5)-	October 2022

Microbial Contaminants

Score2

Data Element

Scoring Data

Reference3





24 Community (2016)
21 Community (2017)



4

Has caused at least one
documented WBDOs in
U.S. reported by CDC
between 2009-2017





3

Has caused documented
WBDOs at any time in the
U.S.?

1971-2008: 30 Community
25 Noncommunity

CDC-NORS,
2020

2

Has caused WBDOs in
countries other than the
U.S.?





1

Has never caused WBDOs
in any country, but has been
epidemiologically
associated with water
related disease?







Occurrence

3

Detected in drinking water
in the U.S.?

Yes

AWWARF, 2004

Lin et al., 1998

Maier et al.,

2000

2

Detected in source water in
the U.S.?

Yes

Maier et al., 2000

1

Not detected in the U.S.?





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Final Fifth Contaminant Candidate List (CCL 5)-	October 2022

Microbial Contaminants

Score2

Data Element

Scoring Data

Reference3



Health Risk



Does the organism cause
significant mortality (>
1/1,000 cases)?

Avg. 12% fatality rate; death
rates of 15% (general pop.) up
to 75%

(immunocompromised) if
untreated.

Edel stein in
Murray, 2007

7



Avg. 25% death rate (between
20-40%) during an outbreak.

AWWARF, 2004





10 - 15%) death rate.

Fatality rate has been as high
as 39%o in hospitalized cases; it
is generally higher in those

with compromised immunity.

CDC, 2005
Heymann, 2005

6 [E, CD]

Does the organism cause
pneumonia, meningitis,
hepatitis, encephalitis,
endocarditis, cancer, or
other severe
manifestations of illness
necessitating long term
hospitalization (> week)?

[E, CD] Acute pneumonia
may progress to respiratory
collapse and death if
diagnosis and effective
antibiotic therapy are
delayed. The elderly and
individuals with chronic
diseases are at higher risk.

Edelstein in
MCM, 2007;
MCM, 2019

CDC, 2005

5

Does the illness result in
long term or permanent
dysfunction or disability,
i.e. sequelae?

No



4 [G, C, P]

Does the illness require
short term hospitalization
(< week)?

[G, C, P] Hospitalization is
required for treatment of
acute pneumonia.

Edelstein in
MCM, 2007

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Microbial Contaminants

Score2

Data Element

Scoring Data

Reference3

3

Does the illness require
physician intervention?





2

Is the illness self-limiting
within 72 hours (without
requiring medical
intervention)?

Pontiac fever resolves without
treatment and has flu-like
symptoms.

Edelstein in
MCM, 2007

Heymann, 2005

1

Does the illness result in
mild symptoms with
minimal or no impact on
daily activities?





1 Bolded text indicates the highest score for that particular protocol. For the health risk protocol two
scores were selected: the general population [G] and the highest score for a sensitive subpopulation.

These 2 scores were added and normalized by multiplying by 5/14 for a final health risk score. The higher
score between the WBDO and Occurrence protocols was used for total pathogen score calculation. Health
Risk protocol: G - General, C - Child, E - Elderly, P - Pregnant Women, CD - Chronic Disease.

2See Final Contaminant Candidate List 3 Microbes: PCCL to CCL Process. EPA 815-R-09-009. Final.
August 2009 for a detailed description on how to calculate the total pathogen score.

3EPA based the WBDO scores on the CDC MMWR reports from 1991 -2017 and then collected
occurrence citations if there were no CDC WBDOs.

References

Centers for Disease Control and Prevention (CDC). 2005. Legionellosis: Legionnaires' Disease
(LD) and Pontiac Fever. Disease Listing. October 12, 2005.
http://www.cdc.gov/ncidod/dbmd/diseaseinfo/legionellosis t.htm

CDC. 2020. National Outbreak Reporting System (NORS). Available online at:
https://wwwn.cdc.gov/norsdashboard/. Accessed August 31, 2020.

Edelstein, P. 2007. Legionella. In Murray, P.R., E.J. Baron, J.H. Jorgensen, M.L. Landry, and
M.A. Pfaller (ed.) Manual of Clinical Microbiology, 9th Edition, Volume 1, p. 837. American
Society for Microbiology Press, Washington, DC.

Edelstein, P. 2019. Legionella. In Carroll, K.C., M.A. Pfaller, M.L. Landry, A.J. McAdam, R.
Patel, S.S. Richter, and D.W. Warnock (ed) Manual of Clinical Microbiology, 12th Edition.
American Society for Microbiology Press, Washington, DC.

Heymann, D.(ed.). 2005. Control of Communicable Diseases Manual, 18th Edition. American
Public Health Association, Washington, DC.

Lin, Y.S., J.E. Stout, V.L. Yu, and R.D. Vidic. 1998. Disinfection of water distribution systems
for Legionella. Seminars in Respiratory Infections. 13: 147-159.

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Microbial Contaminants

EPA 815-R-22-004
October 2022

Maier, R.M., I.L. Pepper, and C.P. Gerba (eds.) 2000. Environmental Microbiology, pp. 454-455,
539. Academic Press.

Riffard, S., S. Springthorpe, L. Filion, and S. Sattar. 2002. Occurrence of Legionella in
Groundwater. AWWA Research Foundation Reports, American Water Works Association,
Dever, CO.

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Microbial Contaminants

EPA 815-R-22-004
October 2022

Microsporidia Scoring Data

Scoring Summary1'2

Occurrence

2

Health Risk

General population

2

Sensitive subpopulation(s) [CD, C, P, E]

2

1 Bolded text indicates the highest score for that particular protocol. For the health risk protocol two scores were selected: the
general population [G] and the highest score for a sensitive subpopulation. These 2 scores were added and normalized by
multiplying by 5/14 for a final health risk score. The higher score between the WBDO and Occurrence protocols was used for
total pathogen score calculation. Health Risk protocol: G - General, C - Child, E - Elderly, P - Pregnant Women, CD - Chronic
Disease

Score2

Data Element

Scoring Data

Reference3



Waterborne Disease Outbreaks

5

Has caused multiple (1 or
more) documented
WBDOs in the U.S.
reported by CDC between
2009-2017

No

CDC-NORS, 2020

4

Has caused at least one
documented WBDOs in
U.S. reported by CDC
between 2009-2017

No

CDC-NORS, 2020

3

Has caused documented
WBDOs at any time in the
U.S.?

No



2

Has caused WBDOs in
countries other than the
U.S.?

No



1

Has never caused
WBDOs in any country,

Yes

Cotte et al., 1999

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Final Fifth Contaminant Candidate List (CCL 5)-	October 2022

Microbial Contaminants

Score2

Data Element

Scoring Data

Reference3



but has been
epidemiologically
associated with water
related disease?



Enriquez et al., 1998
Hutin et al., 1998



Occurrence

3

Detected in drinking water
in the U.S.?

No



2

Detected in source water
in the U.S.?

Yes

Didier et al., 2004
Dowd et al., 1998

1

Not detected in the U.S.?







Health Risk

7

Does the organism cause
significant mortality (>
1/1,000 cases)?





6

Does the organism cause
pneumonia, meningitis,
hepatitis, encephalitis,
endocarditis, cancer, or
other severe

manifestations of illness
necessitating long term
hospitalization (> week)?





5

Does the illness result in
long term or permanent
dysfunction or disability,
i.e. sequelae?





4

Does the illness require
short term hospitalization
(< week)?





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Final Fifth Contaminant Candidate List (CCL 5)-	October 2022

Microbial Contaminants

Score2

Data Element

Scoring Data

Reference3

3

Does the illness require
physician intervention?

Antimicrobial therapy
available for
immunodeficient
patients.

Weber in MCM, 2010

2[G, C, P,
E, CD]

Is the illness self-limiting
within 72 hours (without
requiring medical
intervention)?

[All populations]
Diarrhea and weight
loss lasting in up to 2 - 3
weeks in

immunocompetent
hosts. Has been
identified among elderly
persons with acute or
chronic diarrhea.

Weber in MCM,
2010

1

Does the illness result in
mild symptoms with
minimal or no impact on
daily activities?





1 Bolded text indicates the highest score for that particular protocol. For the health risk protocol two
scores were selected: the general population [G] and the highest score for a sensitive subpopulation.

These 2 scores were added and normalized by multiplying by 5/14 for a final health risk score. The higher
score between the WBDO and Occurrence protocols was used for total pathogen score calculation. Health
Risk protocol: G - General, C - Child, E - Elderly, P - Pregnant Women, CD - Chronic Disease.

2See Final Contaminant Candidate List 3 Microbes: PCCL to CCL Process. EPA 815-R-09-009. Final.
August 2009 for a detailed description on how to calculate the total pathogen score.

3EPA based the WBDO scores on the CDC MMWR reports from 1991 -2017 and then collected
occurrence citations if there were no CDC WBDOs.

References

Centers for Disease Control and Prevention (CDC). 2020. National Outbreak Reporting System
(NORS). Available online at: https://wwwn.cdc.gov/norsdashboard/. Accessed August 31, 2020.

Cotte, L., M. Rabondonira, F. Chapuis, F. Bailly, F. Bissuel, and C. Raynal. 1999. Waterborne
outbreak of intestinal microsporidiosis in persons with and without human immunodeficiency
virus infection. Journal of Infectious Diseases. 180: 2003-2008.

Didier, E.S., M.E. Stovall, L.C. Green, P.J. Brindley, K. Sestak, and P.J. Didier. 2004.

Veterinary parasitology,. 126: 145-166.

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Dowd, S.E., C.P. Gerba, and I.L. Pepper. 1998. Confirmation of the human-pathogenic
microsporidia Enterocytozoon bieneusi, Encephalitozoon intestinalis, and Vittaforma corneae in
water. Applied and Environmental Microbiology. 64(9): 3332-3335.

Enriquez, F.J., D. Taren, A. Cruz-Lopez, M. Muramoto, J.D. Palting, and P. Cruz. 1998.
Prevalence of intestinal encephalitozoonosis in Mexico. Clinical Infectious Diseases. 26: 1227-
1229.

Hutin, Y.J.F., M.N. Sombardier, O. Ligoury, C. Sarfati, F. Derouin, J. Modai, and J.M. Molina.
1998. Risk factors for intestinal micorspooridiosis in patients with human immunodeficiency
virus infection: a case control study. Journal of Infectious Diseases. 178: 904-907.

Weber R., A. Mathis, and P. Deplazes. 2010. Microsporidia. In Murray, P.R., E.J. Baron, J.H.
Jorgensen, M.A. Pfaller, and R.H. Yolken (ed) Manual of Clinical Microbiology, 10th Edition,
Volume 2, p. 2190. American Society for Microbiology Press, Washington, DC.

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Microbial Contaminants

EPA 815-R-22-004
October 2022

Mycobacterium abscessus Scoring Data

Scoring Summary1'2

Waterborne Disease Outbreak

4

Health Risk

General population

4

Sensitive subpopulation(s) [CD]

5

1 Bolded text indicates the highest score for that particular protocol. For the health risk protocol two scores were selected: the
general population [G] and the highest score for a sensitive subpopulation. These 2 scores were added and normalized by
multiplying by 5/14 for a final health risk score. The higher score between the WBDO and Occurrence protocols was used for
total pathogen score calculation. Health Risk protocol: G - General, C - Child, E - Elderly, P - Pregnant Women, CD - Chronic
Disease

Score2

Data Element

Scoring Data

Reference3



Waterborne Disease Outbreaks

5

Has caused multiple (2 or
more) documented WBDOs
in the U.S. reported by CDC
between 2009-2017



CDC-NORS, 2020

4

Has caused at least one
documented WBDOs in
U.S. reported by CDC
between 2009-2017

2014: 1 Hospital

CDC-NORS, 2020

3

Has caused documented
WBDOs at any time in the
U.S.?





2

Has caused WBDOs in
countries other than the
U.S.?





1

Has never caused WBDOs in
any country, but has been
epidemiologically associated





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Data Element

Scoring Data

Reference3



with water related disease?







Occurrence

3

Detected in drinking water
in the U.S.?

Yes. Idaho public
health officials and
pediatric infectious
disease physicians
investigated a US
documented
outbreak of
Mycobacterium
abscessus skin
infections in children
whose only common
exposure was an
indoor wading pool
(Carter et al., 2019).
Another outbreak
occurred in the Duke
University Hospital
linked to the hospital
tap water (Baker et
al., 2017).

Baker et al., 2017
Carter et al., 2019

2

Detected in source water in
the U.S.?





1

Not detected in the U.S.?







Health Risk

7

Does the organism cause
significant mortality (>
1/1,000 cases)?





6

Does the organism cause
pneumonia, meningitis,
hepatitis, encephalitis,
endocarditis, cancer, or other
severe manifestations of
illness necessitating long
term hospitalization (>





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Scoring Data

Reference3



week)?





5 [CD]

Does the illness result in
long term or permanent
dysfunction or disability,
i.e. sequelae?

[CD] M. abscessus
complex can cause
pulmonary disease,
especially in
vulnerable hosts with
underlying structural
lung disease, such as
cystic fibrosis,
bronchiectasis, and
prior tuberculosis.

Griffith, 2007

4 [G]

Does the illness require
short term hospitalization
(< week)?

Yes. Prolonged
intravenous (IV)
therapy and side
effects are often
necessary to treat
Mycobacterium
abscessus infections.

Novosad, 2016

3

Does the illness require
physician intervention?





2

Is the illness self-limiting
within 72 hours (without
requiring medical
intervention)?





1

Does the illness result in
mild symptoms with minimal
or no impact on daily
activities?





1 Bolded text indicates the highest score for that particular protocol. For the health risk protocol two
scores were selected: the general population [G] and the highest score for a sensitive subpopulation.

These 2 scores were added and normalized by multiplying by 5/14 for a final health risk score. The higher
score between the WBDO and Occurrence protocols was used for total pathogen score calculation. Health
Risk protocol: G - General, C - Child, E - Elderly, P - Pregnant Women, CD - Chronic Disease.

2See Final Contaminant Candidate List 3 Microbes: PCCL to CCL Process. EPA 815-R-09-009. Final.
August 2009 for a detailed description on how to calculate the total pathogen score.

3EPA based the WBDO scores on the CDC MMWR reports from 1991 -2017 and then collected
occurrence citations if there were no CDC WBDOs.

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October 2022

References

Baker, A.W., S.S. Lewis, B.D. Alexander, L.F. Chen, R.J. Wallace Jr., B.A. Brown-Elliott, and
J.M. Reynolds. 2017. Two-phase hospital-associated outbreak of Mycobacterium abscessus:
investigation and mitigation. Clinical Infectious Diseases. 64(7): 902-911.

Carter, K.K., I. Lundgren, S. Correll, T. Schmalz, T. McCarter, J. Stroud, and C.G. Hahn. 2018.
First United States outbreak of Mycobacterium abscessus hand and foot disease among children
associated with a wading pool. Journal of the Pediatric Infectious Diseases Society. 8(4): 291-
296.

Centers for Disease Control and Prevention (CDC). 2020. National Outbreak Reporting System
(NORS). Available online at: https://wwwn.cdc.gov/norsdashboard/. Accessed August 31, 2020.

Griffith, D.E., T. Aksamit, B.A. Brown-Elliott, A. Catanzaro, C. Daley, F. Gordin, and M.
Iseman. 2007. An official ATS/IDSA statement: diagnosis, treatment, and prevention of
nontuberculous mycobacterial diseases. American journal of respiratory and critical care
medicine. 175(4): 367-416.

Novosad, S.A., S.E. Beekmann, P.M. Polgreen, K. Mackey, and K.L. Winthrop. 2016. Treatment
of Mycobacterium abscessus infection. Emerging Infectious Diseases. 22(3): 511.

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Microbial Contaminants

EPA 815-R-22-004
October 2022

Mycobacterium avium Scoring Data

Scoring Summary1'2

Waterborne Disease Outbreak

4

Health Risk

General population

3

Sensitive subpopulation(s) [E]

5

1 Bolded text indicates the highest score for that particular protocol. For the health risk protocol two scores were selected: the
general population [G] and the highest score for a sensitive subpopulation. These 2 scores were added and normalized by
multiplying by 5/14 for a final health risk score. The higher score between the WBDO and Occurrence protocols was used for
total pathogen score calculation. Health Risk protocol: G - General, C - Child, E - Elderly, P - Pregnant Women, CD - Chronic
Disease

Score2

Data Element

Scoring Data

Reference3



Waterborne Disease Outbreaks

5

Has caused multiple (2 or
more) documented WBDOs
in the U.S. reported by CDC
between 2009-2017

No

CDC-NORS, 2020

4

Has caused at least one
documented WBDOs in
U.S. reported by CDC
between 2009-2017

Yes

2016: 1 Community

(.Mycobacterium
"other")

CDC-NORS, 2020

3

Has caused documented
WBDOs at any time in the
U.S.?

Yes

Not listed in CDC's
NORS however, data
linking patient,
outbreak and drinking
water.

Tobin-D' Angelo et al.,
2004

2

Has caused WBDOs in

No



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Data Element

Scoring Data

Reference3



countries other than the U.S.?





1

Has never caused WBDOs in
any country, but has been
epidemiologically associated
with water related disease?

Yes

Glover et al., 1994
Aronson et al., 1999
von Reyn et al., 1994



Occurrence

3

Detected in drinking water
in the U.S.?

Yes

Glover et al., 1994

Covert et al., 1999

Falkinham et al.,
2001

2

Detected in source water in
the U.S.?

Yes

Covert etal., 1999
Falkinham et al., 2004

1

Not detected in the U.S.?







Health Risk

7

Does the organism cause
significant mortality (>
1/1,000 cases)?





6

Does the organism cause
pneumonia, meningitis,
hepatitis, encephalitis,
endocarditis, cancer, or other
severe manifestations of
illness necessitating long
term hospitalization (>
week)?

Disseminated MAC
infections are a major
problem in HIV-
infected individuals.

Heymann, 2005

5[E]

Does the illness result in
long term or permanent
dysfunction or disability,
i.e. sequelae?

[E] Most commonly
immunocompetent
patients develop a
slowly evolving
cavitary disease that
resembles

Murray et al., 2005
Carroll et al., 2019

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tuberculosis. Elderly
non-smoking females,
can develop "Lady
Windermere's
syndrome" which has
been associated with
significant morbidity
and mortality.



4 [CD]

Does the illness require short
term hospitalization (<
week)?

[CD] Tuberculosis-like
upper lobe
fibrocavitary disease
occurs typically in men
45 - 60 who have
preexi siting lung
disease.

Pfyffer in MCM, 2007

3 [G]

Does the illness require
physician intervention?

[G] Symptoms of
infection include
pulmonary disease,
lymphadenitis, post-
traumatic wound
infection. Diagnosis
of disease and
treatment requires
physician
intervention.

Pfyffer in MCM,
2007

Heymann, 2005

2

Is the illness self-limiting
within 72 hours (without
requiring medical
intervention)?





1

Does the illness result in mild
symptoms with minimal or
no impact on daily activities?





1 Bolded text indicates the highest score for that particular protocol. For the health risk protocol two
scores were selected: the general population [G] and the highest score for a sensitive subpopulation.

These 2 scores were added and normalized by multiplying by 5/14 for a final health risk score. The higher
score between the WBDO and Occurrence protocols was used for total pathogen score calculation. Health
Risk protocol: G - General, C - Child, E - Elderly, P - Pregnant Women, CD - Chronic Disease.

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EPA 815-R-22-004
October 2022

2See Final Contaminant Candidate List 3 Microbes: PCCL to CCL Process. EPA 815-R-09-009. Final.
August 2009 for a detailed description on how to calculate the total pathogen score.

3EPA based the WBDO scores on the CDC MMWR reports from 1991 -2017 and then collected
occurrence citations if there were no CDC WBDOs.

References

Aronson, T., A. Holtzman, N. Glover, M. Boian, S. Froman, O.G.W. Berlin, H. Hill, and G.
Stelma Jr. 1999. Comparison of large restriction fragments of Mycobacterium avium isolates
recovered from AIDS and non-AIDS patients with those of isolates from potable water. Journal
of Clinical Microbiology. 37: 1008-1012.

Carroll, K.C., M.A. Pfaller, M.L. Landry, A.J. McAdam, R. Patel, S.S. Richter, and D.W.
Warnock (ed). 2019. Manual of Clinical Microbiology, 12th Edition. American Society of
Microbiology Press, Washington, DC.

Centers for Disease Control and Prevention (CDC). 2020. National Outbreak Reporting System
(NORS). Available online at: https://wwwn.cdc.gov/norsdashboard/. Accessed August 31, 2020.

Covert, T.C., M.R. Rodgers, A.L., Reyes, and G.N. Stelma Jr. 1999. Occurrence of
nontuberculous mycobacteria in environmental samples. Applied and environmental
microbiology. 65(6): 2492-2496.

Falkinham III, J.O., C.D. Norton, and M.W. LeChevallier. 2001. Factors influencing numbers of
Mycobacterium avium, Mycobacterium intracellulare, and other mycobacteria in drinking water
distribution systems. Applied and Environmental Microbiology. 67: 1225-1231.

Falkinham III, J.O., G. Nichols, J. Bartram, A. Dufour, and F. Portaels. 2004. Natural ecology
and survival in water of mycobacteria of potential public health importance. In Pedley, S., J.
Bartram, G. Rees, A. Dufour, and J. A. Cotruvo (eds.) Pathogenic mycobacteria in water: a guide
to public health consequences, monitoring and management. IWA Publishing, London, UK.

Glover, N., A. Holtzman, T. Aronson, S. Froman, O.G.W. Berlin, P. Dominguez, K.A. Kunkel,
G. Overturf, G. Stelma, Jr., C. Smith, and M. Yakrus. 1994. The isolation and identification of
Mycobacterium avium complex (MAC) recovered from Los Angeles potable water, a possible
source of infection in AIDS patients. International Journal of Environmental Health Research. 4:
63-72.

Heymann, D. (ed.). 2005. Control of Communicable Diseases Manual, 18th Edition. American
Public Health Association, Washington, DC.

Murray, P.R., K.S. Rosenthal, and M.A. Pfaller. 2005. Medical Microbiology, 5th Edition.
Elsevier Inc., Mosby, New York.

Pfyffer, G. 2007. Mycobacterium: General Characterises, Laboratory Detection, and Staining
Procedures. In Murray, P.R., E.J. Baron, J.H. Jorgensen, M.L. Landry, and M.A. Pfaller (ed.)
Manual of Clinical Microbiology, 9th Edition, Volume 1, pp. 547-548. American Society for
Microbiology Press, Washington, DC.

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Tobin-D'Angelo, M.J., M. A. Blass, C. del Rio, J.S. Halvosa, H.M. Blumberg, and C.R.
Horsburg, Jr., 2004. Hospital water as a source of Mycobacterium avium complex isolates in
respiratory specimens. Journal of Infectious Diseases. 189: 98-104.

von Reyn, C.F., J.N. Maslow, T.W. Barber, J.O. Falkinham III, and R.D. Arbeit. 1994. Persistent
colonization of potable water as a source of Mycobacterium avium infection in AIDS. Lancet.
343:1137-1141.

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Microbial Contaminants

EPA 815-R-22-004
October 2022

Naegleria fowleri Scoring Data

Scoring Summary1'2

Waterborne Disease Outbreak

5

Health Risk

General population

7

Sensitive subpopulation(s) [C, P, E, CD]

7

1 Bolded text indicates the highest score for that particular protocol. For the health risk protocol two scores were selected: the
general population [G] and the highest score for a sensitive subpopulation. These 2 scores were added and normalized by
multiplying by 5/14 for a final health risk score. The higher score between the WBDO and Occurrence protocols was used for
total pathogen score calculation. Health Risk protocol: G - General, C - Child, E - Elderly, P - Pregnant Women, CD - Chronic
Disease

Score2

Data Element

Scoring Data

Reference3



Waterborne Disease Outbreaks

5

Has caused multiple (2 or
more) documented
WBDOs in the U.S.
reported by CDC between
2009-2017

Yes, 1 Community (note
an outbreak is only one
case for Naegleria)

CDC, 2017

4

Has caused at least one
documented WBDOs in the
U.S. as reported by CDC
surveillance between 1990
and 2014?





3

Has caused documented
WBDOs at any time in the
U.S.?

1971-2008: 1 Community

CDC-NORS, 2020

2

Has caused WBDOs in
countries other than the
U.S.?





1

Has never caused WBDOs in





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Reference3



any country, but has been
epidemiologically associated
with water related disease?







Occurrence

3

Detected in drinking water
in the U.S.?

Yes

Arizona storage -

Sampled pre-treatment
multiple-well study in
Arizona.

Louisiana

Gerba et al., 2007

Marciano-Cabral et
al., 2003

LA, 2013

2

Detected in source water in
the U.S.?

Yes

Schuster and
Visvesvara, 2004

1

Not detected in the U.S.?







Health Risk

7[G, C, P,
E, CD]

Does the organism cause
significant mortality (>
1/1,000 cases)?

[All populations]
Recovery from primary
amoebic

meningoencephalitis is
rare.

Heymann, 2005
Cope and Ali, 2016.

6

Does the organism cause
pneumonia, meningitis,
hepatitis, encephalitis,
endocarditis, cancer, or other
severe manifestations of
illness necessitating long
term hospitalization (>
week)?

Acute fulminating
disease. Only a few
patients have survived.

Visvesvara in MCM,
2010

Cope et al, in MCM,
2019

5

Does the illness result in

No



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Scoring Data

Reference3



long term or permanent
dysfunction or disability, i.e.
sequelae?





4

Does the illness require short
term hospitalization (<
week)?

All cases are hospitalized
for diagnosis and
treatment.

Visvesvara in MCM,
2010

3

Does the illness require
physician intervention?





2

Is the illness self-limiting
within 72 hours (without
requiring medical
intervention)?





1

Does the illness result in
mild symptoms with
minimal or no impact on
daily activities?





1 Bolded text indicates the highest score for that particular protocol. For the health risk protocol two
scores were selected: the general population [G] and the highest score for a sensitive subpopulation.

These 2 scores were added and normalized by multiplying by 5/14 for a final health risk score. The higher
score between the WBDO and Occurrence protocols was used for total pathogen score calculation. Health
Risk protocol: G - General, C - Child, E - Elderly, P - Pregnant Women, CD - Chronic Disease.

2See Final Contaminant Candidate List 3 Microbes: PCCL to CCL Process. EPA 815-R-09-009. Final.
August 2009 for a detailed description on how to calculate the total pathogen score.

3EPA based the WBDO scores on the CDC MMWR reports from 1991 -2017 and then collected
occurrence citations if there were no CDC WBDOs.

References

Centers for Disease Control and Prevention (CDC). 2017. Naegleria fowleri in Louisiana Public
Water Systems. Available online at: https://www.cdc.gov/parasites/naegleria/public-water-
svstems-louisiana. html.

Centers for Disease Control and Prevention (CDC). 2020. National Outbreak Reporting System
(NORS). Available online at: https : //wwwn.cdc.gov/norsdashboard/. Accessed August 31, 2020.

Cope, J.R. and I.K. Ali. 2016. Primary Amebic Meningoencephalitis: What Have We Learned in
the Last 5 Years?. Current Infectious Disease Reports. 18(10): 31.
https://doi.org/10.1007/sll908-016-Q539-4

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October 2022

Cope J.R., I.K. Ali, and G. Visvesvara. 2019. Pathogenic and Opportunistic Free-Living
Amebae. In Carroll, K.C., M.A. Pfaller, M.L. Landry, A.J. McAdam, R. Patel, S.S. Richter, and
D. W. Warnock (ed). Manual of Clinical Microbiology, 12th Edition. American Society of
Microbiology Press, Washington, DC.

Gerba, C., B. Blair, P. Sarkar, and K. Bright. 2007. Occurrence and Control of Naegleria fowleri
in Well Water and Chlorine Resistance. Proceedings, Water Quality Technology Conference,
American Water Works Association, November 5-8, 2007.

Heymann, D. (ed.). 2005. Control of Communicable Diseases Manual, 18th Edition, pp. 417-419.
American Public Health Association, Washington, DC.

Louisiana Department of Health, 2013. DHH Issues Emergency Rule Requiring Drinking Water
Systems in Louisiana to Raise the Level of Disinfectant in their Water, Increase Monitoring by
25 Percent. Available online at: http://ldh.la.gov/index.cfm/newsroom/detail/2906

Marciano-Cabral, F., R. MacLean, A. Mensah, and L. LaPat-Polasko. 2003. Identification of
Naegleria fowleri in domestic water source by nested PCR. Applied and Environmental
Microbiology. 69(10): 5864-5869.

Schuster, F.L. and G.S. Visvesvara. 2004. Free-living amoebae as opportunistic and non-
opportunistic pathogens of humans and animals. International Journal for Parasitology. 34: 1001-
1027.

Visvesvara, G. 2007. Pathogenic and Opportunistic Free-Living Amebae. In Murray, P.R., E.J.
Baron, J.H. Jorgensen, M.A. Pfaller, and R.H. Yolken (ed) Manual of Clinical Microbiology,
10th Edition, Volume 2, p. 3129. American Society for Microbiology Press, Washington, DC.

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EPA 815-R-22-004
October 2022

Nontuberculous Mycobacteria (NTM) Scoring Data

Scoring Summary1'2

Occurrence

3

Health Risk

General population

3

Sensitive subpopulation(s) [E]

5

1 Bolded text indicates the highest score for that particular protocol. For the health risk protocol two scores were selected: the
general population [G] and the highest score for a sensitive subpopulation. These 2 scores were added and normalized by
multiplying by 5/14 for a final health risk score. The higher score between the WBDO and Occurrence protocols was used for
total pathogen score calculation. Health Risk protocol: G - General, C - Child, E - Elderly, P - Pregnant Women, CD - Chronic
Disease

Score2

Data Element

Scoring Data

Reference3



Waterborne Disease Outbreaks

5

Has caused multiple (2 or
more) documented WBDOs
in the U.S. reported by CDC
between 2009-2017

No

CDC-NORS, 2020

4

Has caused at least one
documented WBDOs in U.S.
reported by CDC between
2009-2017

No

CDC-NORS, 2020

3

Has caused documented
WBDOs at any time in the
U.S.?

No



2

Has caused WBDOs in
countries other than the U.S.?

No



1

Has never caused WBDOs
in any country, but has
been epidemiologically
associated with water

Yes

Johnson and Odell,
1994

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Reference3



related disease?







Occurrence

3

Detected in drinking water
in the U.S.?

Yes

Falkinham et al.,
2011

2

Detected in source water in
the U.S.?

Yes

Covert etal., 1999
Falkinham et al., 2004

1

Not detected in the U.S.?







Health Risk

7

Does the organism cause
significant mortality (>
1/1,000 cases)?





6

Does the organism cause
pneumonia, meningitis,
hepatitis, encephalitis,
endocarditis, cancer, or other
severe manifestations of
illness necessitating long
term hospitalization (>
week)?

Disseminated MAC
infections are a major
problem in HIV-
infected individuals.

Heymann, 2005

5[E]

Does the illness result in
long term or permanent
dysfunction or disability,
i.e. sequelae?

[E] Most commonly
immunocompetent
patients develop a
slowly evolving
pulmonary disease.

Murray et al., 2005

4

Does the illness require short
term hospitalization (<
week)?





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Final Fifth Contaminant Candidate List (CCL 5)-	October 2022

Microbial Contaminants

Score2

Data Element

Scoring Data

Reference3

3 [G]

Does the illness require
physician intervention?

[G] Symptoms of
infection include
pulmonary disease;
diagnosis of disease
and treatment
requires physician
intervention.

Pfyffer in MCM,
2007

2

Is the illness self-limiting
within 72 hours (without
requiring medical
intervention)?





1

Does the illness result in mild
symptoms with minimal or
no impact on daily activities?





1 Bolded text indicates the highest score for that particular protocol. For the health risk protocol two
scores were selected: the general population [G] and the highest score for a sensitive subpopulation.

These 2 scores were added and normalized by multiplying by 5/14 for a final health risk score. The higher
score between the WBDO and Occurrence protocols was used for total pathogen score calculation. Health
Risk protocol: G - General, C - Child, E - Elderly, P - Pregnant Women, CD - Chronic Disease.

2See Final Contaminant Candidate List 3 Microbes: PCCL to CCL Process. EPA 815-R-09-009. Final.
August 2009 for a detailed description on how to calculate the total pathogen score.

3EPA based the WBDO scores on the CDC MMWR reports from 1991 -2017 and then collected
occurrence citations if there were no CDC WBDOs.

References

Centers for Disease Control and Prevention (CDC). 2020. National Outbreak Reporting System
(NORS). Available online at: https://wwwn.cdc.gov/norsdashboard/. Accessed August 31, 2020.

Covert, T.C., M.R. Rodgers, A.L., Reyes, and G.N. Stelma Jr. 1999. Occurrence of
nontuberculous mycobacteria in environmental samples. Applied and environmental
microbiology. 65(6): 2492-2496.

Falkinham III, J.O. 2011. Nontuberculous mycobacteria from household plumbing of patients
with nontuberculous mycobacteria disease. Emerging Infectious Diseases. 17: 419-424

Hernandez-Garduno, E. and K. Elwood. 2012. Nontuberculous mycobacteria in tap water.
Emerging Infectious Disease. 18(2): 353.

Heymann, D. (ed.). 2005. Control of Communicable Diseases Manual, 18th Edition, pp. 417-419.
American Public Health Association, Washington, DC.

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Microbial Contaminants

EPA 815-R-22-004
October 2022

Johnson, M.M. and J.A. Odell. 2014. Nontuberculous mycobacterial pulmonary infections.
Journal of Thoracic Disease. 6(3): 210-220.

Murray, P.R., K.S. Rosenthal, and M.A. Pfaller. 2005. Medical Microbiology, 5th Edition, p.304.
Elsevier Mosby

Pfyffer, G. 2007. Mycobacterium'. General Characterises, Laboratory Detection, and Staining
Procedures. In Murray, P.R., E.J. Baron, J.H. Jorgensen, M.L. Landry, and M.A. Pfaller (ed.)
Manual of Clinical Microbiology, 9th Edition, Volume 1, pp. 547- 548. American Society for
Microbiology Press, Washington, DC.

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Technical Support Document for the
Final Fifth Contaminant Candidate List (CCL 5)-
Microbial Contaminants

EPA 815-R-22-004
October 2022

Pantoea agglomerans Scoring Data

Scoring Summary1'2

Waterborne Disease Outbreak

4

Health Risk

General population

1

Sensitive subpopulation(s) [C, CD]

6

1 Bolded text indicates the highest score for that particular protocol. For the health risk protocol two scores were selected: the
general population [G] and the highest score for a sensitive subpopulation. These 2 scores were added and normalized by
multiplying by 5/14 for a final health risk score. The higher score between the WBDO and Occurrence protocols was used for
total pathogen score calculation. Health Risk protocol: G - General, C - Child, E - Elderly, P - Pregnant Women, CD - Chronic
Disease

Score2

Data Element

Scoring Data

Reference3



Waterborne Disease Outbreaks

5

Has caused multiple (2 or
more) documented WBDOs
in the U.S. reported by CDC
between 2009-2017

No

CDC-NORS, 2020

4

Has caused at least one
documented WBDOs in U.S.
reported by CDC between
2009-2017

Yes.

2012: 1 Community
Outbreak of Pantoea
agglomerans
bloodstream infection
occurred in a health
care facility linked to
the drinking water
system.

CDC-NORS, 2020

3

Has caused documented
WBDOs at any time in the
U.S.?





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Final Fifth Contaminant Candidate List (CCL 5)-	October 2022

Microbial Contaminants

Score2

Data Element

Scoring Data

Reference3

2

Has caused WBDOs in
countries other than the
U.S.?





1

Has never caused WBDOs in
any country, but has been
epidemiologically associated
with water related disease?







Occurrence

3

Detected in drinking water
in the U.S.?

Yes. Outbreak of
Pantoea agglomerans
bloodstream infection
occurred in a health
care facility linked to
the drinking water
system.

Yablon et al., 2017

2

Detected in source water in
the U.S.?





1

Not detected in the U.S.?







Health Risk

7

Does the organism cause
significant mortality (>
1/1,000 cases)?





6 [C, CD]

Does the organism cause
pneumonia, meningitis,
hepatitis, encephalitis,
endocarditis, cancer, or
other severe manifestations
of illness necessitating long
term hospitalization (>
week)?

[C, CD] Yes. There are
documented cases of
long-term
hospitalization and
death in children with
pneumonia (Biiviikcam,
2018).

It can also cause
infections in cuts and in
immunocompromised
individuals in health

Biiyiikcam, 2018

Dutkiewicz et al.,
2016

Forsythe et al. in
MCM, 2019

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Microbial Contaminants

Score2

Data Element

Scoring Data

Reference3





care settings.

Septic arthritis or
synovitis appears as a
common clinical
outcome of exogenous
infection with P.
agglomerans, others
include

endophthalmitis,
periostitis, endocarditis
and osteomyelitis

(Dutkiewicz et al.,
2016).



5

Does the illness result in
long term or permanent
dysfunction or disability, i.e.
sequelae?





4

Does the illness require short
term hospitalization (<
week)?





3

Does the illness require
physician intervention?





2

Is the illness self-limiting
within 72 hours (without
requiring medical
intervention)?





1 [G]

Does the illness result in
mild symptoms with
minimal or no impact on
daily activities?

Pantoea agglomerans is
not generally an
infectious agent in
healthy humans
(Dutkiewicz, et al.
2016).

Dutkiewicz et al.,
2016

1 Bolded text indicates the highest score for that particular protocol. For the health risk protocol two
scores were selected: the general population [G] and the highest score for a sensitive subpopulation.

These 2 scores were added and normalized by multiplying by 5/14 for a final health risk score. The higher
score between the WBDO and Occurrence protocols was used for total pathogen score calculation. Health
Risk protocol: G - General, C - Child, E - Elderly, P - Pregnant Women, CD - Chronic Disease.

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Microbial Contaminants

EPA 815-R-22-004
October 2022

2See Final Contaminant Candidate List 3 Microbes: PCCL to CCL Process. EPA 815-R-09-009. Final.
August 2009 for a detailed description on how to calculate the total pathogen score.

3EPA based the WBDO scores on the CDC MMWR reports from 1991 -2017 and then collected
occurrence citations if there were no CDC WBDOs.

References

Buyiikcam, A., O. Tuncer, D. Giir, B. Sancak, M .Ceyhan, A.B. Cengiz, and A. Kara. 2018.
Clinical and microbiological characteristics of Pantoea agglomerans infection in children.
Journal of Infection and Public Health. 11(3): 304-309.

Dutkiewicz, J., B. Mackiewicz, M.K. Lemieszek, M. Golecand, and J. Milanowski. 2016.
Pantoea agglomerans: a mysterious bacterium of evil and good. Part III. Deleterious effects:
infections of humans, animals, and plants. Annals of Agricultural and Environmental Medicine.
23(2).

Centers for Disease Control and Prevention (CDC). 2020. National Outbreak Reporting System
(NORS). Available online at: https://wwwn.cdc.gov/norsdashboard/. Accessed August 31, 2020.

Forsythe, S., J. Pitout, A. Charnot-Katsidkas, K. Alby, and K. Frank. 2019. Klebsiella and
Selected Enterobacterales. In Carroll, K.C., M.A. Pfaller, M.L. Landry, A.J. McAdam, R. Patel,
S.S. Richter, and D.W. Warnock (ed). Manual of Clinical Microbiology, 12th Edition. American
Society of Microbiology Press, Washington, DC.

Yablon, B.R., R. Dantes, V. Tsai, R. Lim, H. Moulton-Meissner, M. Arduino, B. Jensen, M.T.
Patel, M.O. Vernon, Y. Grant-Greene, and D. Christiansen. 2017. Outbreak of Pantoea
agglomerans Bloodstream Infections at an Oncology Clinic—Illinois, 2012-2013. Infection
Control & Hospital Epidemiology. 38(3): 314-319.

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Microbial Contaminants

EPA 815-R-22-004
October 2022

Plesiomonas shigelloides Scoring Data

Scoring Summary1'2

Waterborne Disease Outbreak

3

Health Risk

General population

2

Sensitive subpopulation(s) [C, E]

3

1 Bolded text indicates the highest score for that particular protocol. For the health risk protocol two scores were selected: the
general population [G] and the highest score for a sensitive subpopulation. These 2 scores were added and normalized by
multiplying by 5/14 for a final health risk score. The higher score between the WBDO and Occurrence protocols was used for
total pathogen score calculation. Health Risk protocol: G - General, C - Child, E - Elderly, P - Pregnant Women, CD - Chronic
Disease

Score2

Data Element

Scoring Data

Reference3



Waterborne Disease Outbreaks

5

Has caused multiple (1 or
more) documented
WBDOs in the U.S.
reported by CDC between
2009-2017

No

CDC-NORS, 2020

4

Has caused at least one
documented WBDOs in
U.S. reported by CDC
between 2009-2017

No

CDC-NORS, 2020

3

Has caused documented
WBDOs at any time in
the U.S.?

1971-2008:2
Noncommunity

CDC-NORS, 2020

2

Has caused WBDOs in
countries other than the
U.S.?





1

Has never caused
WBDOs in any country,





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Microbial Contaminants

Score2

Data Element

Scoring Data

Reference3



but has been
epidemiologically
associated with water
related disease?







Occurrence

3

Detected in drinking
water in the U.S.?

Yes

CDC, 1998

2

Detected in source water
in the U.S.?

Yes

Abbott in MCM,

2010

Holmberg and
Farmer, 1984

Holmberg et al., 1986

1

Not detected in the U.S.?







Health Risk

7

Does the organism cause
significant mortality (>
1/1,000 cases)?

No



6

Does the organism cause
pneumonia, meningitis,
hepatitis, encephalitis,
endocarditis, cancer, or
other severe

manifestations of illness
necessitating long term
hospitalization (> week)?

No



5

Does the illness result in
long term or permanent
dysfunction or disability,
i.e. sequelae?

No



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Final Fifth Contaminant Candidate List (CCL 5)-	October 2022

Microbial Contaminants

Score2

Data Element

Scoring Data

Reference3

4

Does the illness require
short term hospitalization
(< week)?

Hospitalization may be
required for severe
infections and/or
underlying diseases.

Abbott in MCM,
2010

3 [C, E]

Does the illness require
physician intervention?

[C, E] Physician
office visit may be
required for
diagnosis and
treatment of
dysenteric form of
the disease in
children or the
elderly. Bacteremia
more common with
advanced age.

Abbott in MCM,
2010

2 [G]

Is the illness self-
limiting within 72 hours
(without requiring
medical intervention)?

[G] Diarrhea may
persist up to two
weeks.

Abbott in MCM,
2010; Forsythe in
MCM, 2019

1

Does the illness result in
mild symptoms with
minimal or no impact on
daily activities?

Plesiomonas is
associated with
travelers' diarrhea or a
history of seafood
consumption, most
infections are self-
limiting.

Abbott in MCM,
2010

1 Bolded text indicates the highest score for that particular protocol. For the health risk protocol two
scores were selected: the general population [G] and the highest score for a sensitive subpopulation.

These 2 scores were added and normalized by multiplying by 5/14 for a final health risk score. The higher
score between the WBDO and Occurrence protocols was used for total pathogen score calculation. Health
Risk protocol: G - General, C - Child, E - Elderly, P - Pregnant Women, CD - Chronic Disease.

2See Final Contaminant Candidate List 3 Microbes: PCCL to CCL Process. EPA 815-R-09-009. Final.
August 2009 for a detailed description on how to calculate the total pathogen score.

3EPA based the WBDO scores on the CDC MMWR reports from 1991 -2017 and then collected
occurrence citations if there were no CDC WBDOs.

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Microbial Contaminants

EPA 815-R-22-004
October 2022

References

Abbott, S.L. 2007. Klebsiella, Enterobacter, Citrobacter, Serratia, Plesiomonas, and other
Enterobacteriaceae. In Murray, P.R., E.J. Baron, J.H. Jorgensen, M.A. Pfaller, and R.H. Yolken
(ed.) Manual of Clinical Microbiology, 10th Edition, Volume 1, p. 639. American Society for
Microbiology Press, Washington, DC.

Centers for Disease Control and Prevention (CDC). 1998. Plesiomonas shigelloides and
Salmonella serotype Hartford infections associated with a contaminated water supply -
Livingston County, New York, 1996. MMWR. 47(19): 394-396.

CDC, 2020. National Outbreak Reporting System (NORS). Available online at:
https://wwwn.cdc.gov/norsdashboard/. Accessed August 31, 2020.

Forsythe, S., J. Pitout, A. Charnot-Katsidkas, K. Alby, and K. Frank. 2019. Klebsiella and
Selected Enterobacter ales. In Carroll, K.C., M.A. Pfaller, M.L. Landry, A.J. McAdam, R. Patel,
S.S. Richter, and D.W. Warnock (ed). Manual of Clinical Microbiology, 12th Edition. American
Society of Microbiology Press, Washington, DC.

Holmberg, S.D. and J.J. Farmer. 1984. Aeromonas hydrophila and Plesiomonas shigelloides as
causes of intestinal infections. Reviews of Infectious Diseases. 6(5):633-639.

Holmberg, S.D., K. Wachsmith, F.W. Hickman-Brenner, P.A. Blake, and J.J. Farmer. 1986.
Plesiomonas enteric infections in the United States. Annals of Internal Medicine. 105(5): 690-
694.

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Microbial Contaminants

EPA 815-R-22-004
October 2022

Pseudomonas aeruginosa Scoring Data

Scoring Summary1'2

Waterborne Disease Outbreak

5

Health Risk

General population

3

Sensitive subpopulation(s) [C, CD]

6

1 Bolded text indicates the highest score for that particular protocol. For the health risk protocol two scores were selected: the
general population [G] and the highest score for a sensitive subpopulation. These 2 scores were added and normalized by
multiplying by 5/14 for a final health risk score. The higher score between the WBDO and Occurrence protocols was used for
total pathogen score calculation. Health Risk protocol: G - General, C - Child, E - Elderly, P - Pregnant Women, CD - Chronic
Disease

Score2

Data Element

Scoring Data

Reference3



Waterborne Disease Outbreaks

5

Has caused multiple (2 or
more) documented WBDOs in
the U.S. reported by CDC
between 2009-2017

Yes

2013: 1 Community
2016: 1 Community

CDC-NORS, 2020

4

Has caused at least one
documented WBDOs in U.S.
reported by CDC between
2009-2017

No

CDC-NORS, 2020

3

Has caused documented
WBDOs at any time in the
U.S.?

Yes; tap water in
NICU

Kinsey et al., 2017

2

Has caused WBDOs in
countries other than the U.S.?

NA



1

Has never caused WBDOs in

NA



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Microbial Contaminants

Score2

Data Element

Scoring Data

Reference3



any country, but has been
epidemiologically associated
with water related disease?







Occurrence

3

Detected in drinking water in
the U.S.?

Yes

Kinsey et al., 2017

2

Detected in source water in the
U.S.?





1

Not detected in the U.S.?







Health Risk

7 [C]

Does the organism cause
significant mortality (> 1/1,000
cases)?

Nosocomial
pneumonia.

Henry and Speert in
MCM, 2010

6 [C, CD]

Does the organism cause
pneumonia, meningitis,
hepatitis, encephalitis,
endocarditis, cancer, or other
severe manifestations of
illness necessitating long term
hospitalization (> week)?

Septicemia and
meningitis occur
rarely in

immunocompetent
hosts but can occur
in neonates and
cystic fibrosis
patients.

Henry and Speert in
MCM, 2010

CDC, 2019

Hoiby et al. in MCM,
2019

5

Does the illness result in long
term or permanent dysfunction
or disability, i.e. sequelae?





4

Does the illness require short
term hospitalization (< week)?





3 [G]

Does the illness require
physician intervention?

Antibiotics

Henry and Speert in
MCM, 2010

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Final Fifth Contaminant Candidate List (CCL 5)-	October 2022

Microbial Contaminants

Score2

Data Element

Scoring Data

Reference3

2

Is the illness self-limiting
within 72 hours (without
requiring medical
intervention)?





1

Does the illness result in mild
symptoms with minimal or no
impact on daily activities?





1 Bolded text indicates the highest score for that particular protocol. For the health risk protocol two
scores were selected: the general population [G] and the highest score for a sensitive subpopulation.

These 2 scores were added and normalized by multiplying by 5/14 for a final health risk score. The higher
score between the WBDO and Occurrence protocols was used for total pathogen score calculation. Health
Risk protocol: G - General, C - Child, E - Elderly, P - Pregnant Women, CD - Chronic Disease.

2See Final Contaminant Candidate List 3 Microbes: PCCL to CCL Process. EPA 815-R-09-009. Final.
August 2009 for a detailed description on how to calculate the total pathogen score.

3EPA based the WBDO scores on the CDC MMWR reports from 1991 -2017 and then collected
occurrence citations if there were no CDC WBDOs.

References

Centers for Disease Control and Prevention (CDC). 2019. Pseudomonas aeruginosa. Available
online at: https://www.cdc.gov/hai/organisms/pseudomonas.html.

CDC. 2020. National Outbreak Reporting System (NORS). Available online at
https://wwwn.cdc.gov/norsdashboard/. Accessed August 31, 2020.

Henry, D. and D. Speert. 2010. Pseudomonas. In Murray, P.R., E.J. Baron, J.H. Jorgensen, M.A.
Pfaller, and R.H. Yolken (ed.) Manual of Clinical Microbiology, 8th Edition, p. 666. American
Society for Microbiology Press, Washington, DC.

Hoiby, N., O. Ciofu, and T. Bjarnsholt. 2019. Pseudomonas. In Carroll, K.C., M.A. Pfaller, M.L.
Landry, A.J. McAdam, R. Patel, S.S. Richter, and D.W. Warnock (ed). 2019. Manual of Clinical
Microbiology, 12th Edition. American Society of Microbiology Press, Washington, DC.

Kinsey, C.B., S. Koirala, B. Solomon, J. Rosenberg, B.F Robinson, A. Neri, A.L. Halpin, M.J.
Arduino, H. Moulton-Meissner, J. Noble-Wang, andN. Chea. 2017. Pseudomonas aeruginosa
outbreak in NICU linked to contaminated tap water. Infection Control & Hospital Epidemiology.
38(7): 801-808.

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Microbial Contaminants

EPA 815-R-22-004
October 2022

Rotavirus Scoring Data

Scoring Summary1'2

Occurrence

3

Health Risk

General population

1

Sensitive subpopulation(s) [C]

6

1 Bolded text indicates the highest score for that particular protocol. For the health risk protocol two scores were selected: the
general population [G] and the highest score for a sensitive subpopulation. These 2 scores were added and normalized by
multiplying by 5/14 for a final health risk score. The higher score between the WBDO and Occurrence protocols was used for
total pathogen score calculation. Health Risk protocol: G - General, C - Child, E - Elderly, P - Pregnant Women, CD - Chronic
Disease

Score2

Data Element

Scoring Data

Reference3



Waterborne Disease Outbreaks

5

Has caused multiple (1 or more)
documented WBDOs in the U.S.
reported by CDC between 2009-
2017

No

CDC-NORS, 2020

4

Has caused at least one
documented WBDOs in U.S.
reported by CDC between 2009-
2017

No

CDC-NORS, 2020

3

Has caused documented
WBDOs at any time in the
U.S.?

Yes

1971-2008: 1
Community

CDC-NORS, 2020

2

Has caused WBDOs in countries
other than the U.S.?

Yes

China and Sweden.

Hardy, 1987
Gerba et al., 1996

1

Has never caused WBDOs in any





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Microbial Contaminants

Score2

Data Element

Scoring Data

Reference3



country, but has been
epidemiologically associated with
water related disease?







Occurrence

3

Detected in drinking water in
the U.S.?

Yes

Banks, 2001
Gerba et al., 1996

2

Detected in source water in the
U.S.?

Yes

Abbaszadegan et al., 2003
Gerba et al., 1996

1

Not detected in the U.S.?







Health Risk

7

Does the organism cause
significant mortality (> 1/1,000
cases)?

No

For children under 5
years of age:
Estimated 37 deaths
in 60,000

hospitalized cases per
year in U.S. (1/1621
hospitalizations).

Fischer et al., 2007

6 [C]

Does the organism cause
pneumonia, meningitis,
hepatitis, encephalitis,
endocarditis, cancer, or other
severe manifestations of illness
necessitating long term
hospitalization (> week)?

[C] Rotavirus
infects all children;
causes severe
gastroenteritis in
infants. Significant
numbers of
physician visits and
hospitalizations and
high medical and
societal costs.

A sporadic,
seasonal, often
severe

gastroenteritis of
infants and young
children,

Pang in MCM, 2010;
MCM, 2019

CDC, 2019

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Microbial Contaminants

Score2

Data Element

Scoring Data

Reference3





characterized by
vomiting, fever and
watery diarrhea.







Rotaviral enteritis is
occasionally
associated with
severe dehydration
and death in young
children. In
developing
countries, an
estimated 600,000-
870,000 diarrheal
deaths each year.

Heymann, 2005

5

Does the illness result in long
term or permanent dysfunction or
disability, i.e. sequelae?





4

Does the illness require short
term hospitalization (< week)?





3

Does the illness require physician
intervention?





2

Is the illness self-limiting within
72 hours (without requiring
medical intervention)?





1 [G, P,
E, CD]

Does the illness result in mild
symptoms with minimal or no
impact on daily activities?

[G, E, P, CD]

Self-limiting acute
watery diarrhea,
vomiting, fever.

Heymann, 2005

1 Bolded text indicates the highest score for that particular protocol. For the health risk protocol two
scores were selected: the general population [G] and the highest score for a sensitive subpopulation.

These 2 scores were added and normalized by multiplying by 5/14 for a final health risk score. The higher
score between the WBDO and Occurrence protocols was used for total pathogen score calculation. Health
Risk protocol: G - General, C - Child, E - Elderly, P - Pregnant Women, CD - Chronic Disease.

2See Final Contaminant Candidate List 3 Microbes: PCCL to CCL Process. EPA 815-R-09-009. Final.
August 2009 for a detailed description on how to calculate the total pathogen score.

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Microbial Contaminants

EPA 815-R-22-004
October 2022

3EPA based the WBDO scores on the CDC MMWR reports from 1991 -2017 and then collected
occurrence citations if there were no CDC WBDOs.

References

Abbaszadegan, M., M. LeChevallier, and C.P. Gerba. 2003. Occurrence of viruses in U. S.
groundwaters. Journal of American Waterworks Association. 95(9): 107-120.

Centers for Disease Control and Prevention (CDC). 2019. Rotavirus home page. Available
online at: https://www.cdc.gov/rotavirus/index.html.

CDC. 2020. National Outbreak Reporting System (NORS). Available online at:
https://wwwn.cdc.gov/norsdashboard/. Accessed August 31, 2020.

Fischer, T.K., C. Viboud, U. Parashar, M. Malek, C. Steiner, R. Glass, and L. Simonsen. 2007.
Hospitalizations and deaths from diarrhea and rotavirus among children < 5 years of age in the
United States, 1993-2003. Journal of Infectious Diseases. 195: 1117.

Gerba, C.P., J.B. Rose, C.N. Haas, and K.D. Crabtree. 1996. Waterborne rotavirus: a risk
assessment. Water Research. 30: 2929.

Heymann, D. (ed.). 2005. Control of Communicable Diseases Manual, 18th Edition, pp. 417-419.
American Public Health Association, Washington, DC.

Pang, X. and X. Jiang. 2010. Gastroenteritis Viruses. In Murray, P.R., E.J. Baron, J.H.

Jorgensen, M.A. Pfaller, and R.H. Yolken (ed) Manual of Clinical Microbiology, 10th Edition,
Volume 2, pp. 1454-1457. American Society for Microbiology Press, Washington, DC.

Pang, X. and M. Smieja. 2019. Gastroenteritis Viruses. In Carroll, K.C., M.A. Pfaller, M.L
Landry, A.J. McAdam, R. Patel, S.S. Richter, and D.W. Warnock (ed) Manual of Clinical
Microbiology, 12th Edition. American Society of Microbiology Press, Washington, DC.

Banks, W.S, C.A. Klohe, and D.A. Battigelli. 2001. Occurrence and Distribution of Enteric
Viruses in Shallow Ground Water and Factors Affecting Well Vulnerability to Microbiological
Contamination in Worcester and Wicomico Counties, Maryland. Water Resources Investigations
Report. 01-4147: 14, 21.

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Microbial Contaminants

EPA 815-R-22-004
October 2022

Salmonella enterica Scoring Data

Scoring Summary1'2

Waterborne Disease Outbreak

3

Health Risk

General population

3

Sensitive subpopulation(s) [C, E]

4

1 Bolded text indicates the highest score for that particular protocol. For the health risk protocol two scores were selected: the
general population [G] and the highest score for a sensitive subpopulation. These 2 scores were added and normalized by
multiplying by 5/14 for a final health risk score. The higher score between the WBDO and Occurrence protocols was used for
total pathogen score calculation. Health Risk protocol: G - General, C - Child, E - Elderly, P - Pregnant Women, CD - Chronic
Disease

Score2

Data Element

Scoring Data

Reference3



Waterborne Disease Outbreaks

5

Has caused multiple (2 or
more) documented
WBDOs in the U.S.
reported by CDC between
2009-2017

No

CDC-NORS, 2020

4

Has caused at least one
documented WBDOs in
U.S. reported by CDC
between 2009-2017

No



3

Has caused documented
WBDOs at any time in
the U.S.?

Yes

1971-2008: 13
Community

7 Noncommunity

CDC-NORS, 2020
(some are "Salmonella
unknown")

2

Has caused WBDOs in
countries other than the
U.S.?





1

Has never caused WBDOs





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Microbial Contaminants

Score2

Data Element

Scoring Data

Reference3



in any country, but has
been epidemiologically
associated with water
related disease?







Occurrence

3

Detected in drinking
water in the U.S.?

Yes

Angulo et al., 1997
CDC, 1998

2

Detected in source water
in the U.S.?





1

Not detected in the U.S.?







Health Risk

7

Does the organism cause
significant mortality (>
1/1,000 cases)?

Each year, 1.4 M cases
of illness and 600 deaths
are caused by non-
typhoidal salmonellosis
in the U.S.

Estimated 800 cases per
year of typhoid fever in
the U.S., with fewer than
5 deaths/yr.; >70% of
U.S. cases related to
foreign travel.

Nataro et al. in MCM,
2007

Buchan in MCM, 2019

6

Does the organism cause
pneumonia, meningitis,
hepatitis, encephalitis,
endocarditis, cancer, or
other severe

manifestations of illness
necessitating long term
hospitalization (> week)?

Nontyphoidal
salmonellosis usually
causes intestinal
infection; can cause
extraintestinal infections
in rare cases (bacteremia,
urinary tract infection,
osteomyelitis), especially
in immunocompromised

Nataro et al. in MCM,
2007

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Microbial Contaminants

Score2

Data Element

Scoring Data

Reference3





persons.



5

Does the illness result in
long term or permanent
dysfunction or disability,
i.e. sequelae?

None reported.





Does the illness require
short term

hospitalization (< week)?

[C] Extra-intestinal
infections highest in
infants and young
children.

Nataro et al. in MCM,
2007

4[C, E]



[E] Dehydration,
especially among
infants or in the elderly,
may be severe. Deaths
are uncommon, except
in the young and old,
the debilitated and
immunosuppressed.

Heymann, 2005
CDC, 2019

3 [G, P,
CD]

Does the illness require
physician intervention?

[G, P, CD] Antibiotic
and rehydration may
be necessary.

Heymann, 2005

2

Is the illness self-limiting
within 72 hours (without
requiring medical
intervention)?

Non-typhoidal
Salmonella usually cause
intestinal infection that
often lasts 1 week or
longer.

Nataro et al. in MCM,
2007

1

Does the illness result in
mild symptoms with
minimal or no impact on
daily activities?





1 Bolded text indicates the highest score for that particular protocol. For the health risk protocol two
scores were selected: the general population [G] and the highest score for a sensitive subpopulation.

These 2 scores were added and normalized by multiplying by 5/14 for a final health risk score. The higher
score between the WBDO and Occurrence protocols was used for total pathogen score calculation. Health
Risk protocol: G - General, C - Child, E - Elderly, P - Pregnant Women, CD - Chronic Disease.

2See Final Contaminant Candidate List 3 Microbes: PCCL to CCL Process. EPA 815-R-09-009. Final.
August 2009 for a detailed description on how to calculate the total pathogen score.

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EPA 815-R-22-004
October 2022

3EPA based the WBDO scores on the CDC MMWR reports from 1991 -2017 and then collected
occurrence citations if there were no CDC WBDOs.

References

Angulo, F.J., S. Tippen, D. J. Sharp, B.J. Payne, C. Collier, J.E. Hill, T.J. Barrett, R.H. Clark,
E.E. Geldreich, H.D. Donnell Jr., and D.L. Swerdlow. 1997. A community waterborne outbreak
of salmonellosis and the effectiveness of a boil water order. American Journal of Public Health.
87(4): 580-584.

Buchan, B., M. Faron, R. Humphries, J. Dekker, and N. Ledeboer. 2019. Escherichia, Shigella
and Salmonella. In Carroll, K.C., M.A. Pfaller, M.L., Landry, A.J. McAdam, R. Patel, S.S.
Richter, and D.W. Warnock (ed). Manual of Clinical Microbiology, 12th Edition. American
Society of Microbiology Press, Washington, DC.

Centers for Disease Control and Prevention (CDC). 1998. Plesiomonas shigelloides and
Salmonella serotype Hartford infections associated with a contaminated water supply -
Livingston County, New York, 1996. MMWR. 47(19): 394-396.

CDC, 2019. Salmonella home page, https://www.cdc.gov/salmonella/index.html

CDC, 2020. National Outbreak Reporting System (NORS). Available online at:
https://wwwn.cdc.gov/norsdashboard/. Accessed August 31, 2020.

Heyman, D. (ed.). 2005. Control of Communicable Diseases Manual, 18th Edition. American
Public Health Association, Washington, DC.

Nataro, J.P., C.A. Bopp, P.I. Fields, J.B. Kaper, andN.A. Strockbine. 2007. Escherichia,
Shigella, and Salmonella. In Murray, P.R., E.J. Baron, J.H. Jorgensen, M.L. Landry, and M.A.
Pfaller (ed.) Manual of Clinical Microbiology, 9th Edition, Volume 1, pp. 680-687. American
Society for Microbiology Press, Washington, DC.

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Microbial Contaminants

EPA 815-R-22-004
October 2022

Shigella sonnei Scoring Data

Scoring Summary1'2

Waterborne Disease Outbreak

4

Health Risk

General population

3

Sensitive subpopulation(s) [C, E]

6

1 Bolded text indicates the highest score for that particular protocol. For the health risk protocol two scores were selected: the
general population [G] and the highest score for a sensitive subpopulation. These 2 scores were added and normalized by
multiplying by 5/14 for a final health risk score. The higher score between the WBDO and Occurrence protocols was used for
total pathogen score calculation. Health Risk protocol: G - General, C - Child, E - Elderly, P - Pregnant Women, CD - Chronic
Disease

Score2

Data Element

Scoring Data

Reference3



Waterborne Disease Outbreaks

5

Has caused multiple (2 or more)
documented WBDOs in the
U.S. reported by CDC between
2009-2017

No

CDC-NORS, 2020

4

Has caused at least one
documented WBDOs in U.S.
reported by CDC between
2009-2017

Yes

2015: 1 Community
(suspected, not
confirmed)

CDC-NORS, 2020

3

Has caused documented
WBDOs at any time in the
U.S.?

1971-2008:15
Community

23 Noncommunity (some
unknown)

CDC-NORS, 2020

2

Has caused WBDOs in
countries other than the U.S.?





1

Has never caused WBDOs in
any country, but has been
epidemiologically associated





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Microbial Contaminants

Score2

Data Element

Scoring Data

Reference3



with water related disease?







Occurrence

3

Detected in drinking water in
the U.S.?

Yes

Craun,2003

2

Detected in source water in the
U.S.?

Yes

Black et al., 1978

1

Not detected in the U.S.?







Health Risk

7

Does the organism cause
significant mortality (> 1/1,000
cases)?

In U.S. approximately
450,000 cases occur each
year with 70 deaths.

Nataro et al. in
MCM, 2007

Buchan in MCM,
2019

6 [C, E]

Does the organism cause
pneumonia, meningitis,
hepatitis, encephalitis,
endocarditis, cancer, or other
severe manifestations of
illness necessitating long term
hospitalization (> week)?

[C, E] S. dysentariae is
associated with more
serious symptoms than
other species with
complications such as
toxic megacolon,
hemolytic uremic
syndrome and intestinal
perforation. Cases may
be severe in infants and
the elderly and
convulsions may occur
in young children.

Heymann, 2005

5

Does the illness result in long
term or permanent dysfunction
or disability, i.e. sequelae?

Reiter's syndrome.

Heymann, 2005

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Microbial Contaminants

Score2

Data Element

Scoring Data

Reference3

4

Does the illness require short
term hospitalization (< week)?

Hospitalization is usually
required for intravenous
antibiotic therapy due to
bacteremia, which is
uncommon.

Heymann, 2005

3 [G]

Does the illness require
physician intervention?

[G] Most cases occur in
children under 10
years, infants under 6
months rarely infected,
increased severity in
children and elderly,
high secondary case
rate in outbreaks,
outbreaks occur in
daycare centers,
institutions, refugee
camps, among
homosexual men, 20%
of U.S. cases result from
international travel,
specific antibiotic
therapy available for
prolonged or severe
cases, multi-antibiotic
resistance occurs.

Heymann, 2005

2

Is the illness self-limiting
within 72 hours (without
requiring medical
intervention)?

Acute diarrhea, fever,
nausea, vomiting, cramps
and tenesmus, stools
contain blood and mucus
(dysentery), usually self-
limiting in 4-7 days
without treatment.

Heymann, 2005
CDC, 2019

1

Does the illness result in mild
symptoms with minimal or no
impact on daily activities?

S. sonnei causes most of
the shigellosis cases in
the U.S., cases may be
asymptomatic or mildly
symptomatic, but they
are frequently acute.

Heymann, 2005

1 Bolded text indicates the highest score for that particular protocol. For the health risk protocol two
scores were selected: the general population [G] and the highest score for a sensitive subpopulation.

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Microbial Contaminants

EPA 815-R-22-004
October 2022

These 2 scores were added and normalized by multiplying by 5/14 for a final health risk score. The higher
score between the WBDO and Occurrence protocols was used for total pathogen score calculation. Health
Risk protocol: G - General, C - Child, E - Elderly, P - Pregnant Women, CD - Chronic Disease.

2See Final Contaminant Candidate List 3 Microbes: PCCL to CCL Process. EPA 815-R-09-009. Final.
August 2009 for a detailed description on how to calculate the total pathogen score.

3EPA based the WBDO scores on the CDC MMWR reports from 1991 -2017 and then collected
occurrence citations if there were no CDC WBDOs.

References

Black, R.E., G.F. Craun, and P. A. Blake. 1978. Epidemiology of common-source outbreaks of
shigellosis in the United States, 1961-1975. American Journal of Epidemiology. 108: 47-52.

Buchan, B., M. Faron, R. Humphries, J. Dekker, and N. Ledeboer. 2019. Escherichia, Shigella
and Salmonella. In Carroll, K.C., M.A. Pfaller, M.L. Landry, A.J. McAdam, R. Patel, S.S.
Richter, and D.W. Warnock (ed.). Manual of Clinical Microbiology, 12th Edition. American
Society of Microbiology, Washington, DC.

Centers for Disease Control and Prevention (CDC). 2019. Shigella home page. Available online
at: https://www.cdc.gov/shigella/index.html.

CDC. 2020. National Outbreak Reporting System (NORS). Available online at:
https://wwwn.cdc.gov/norsdashboard/. Accessed August 31, 2020.

Craun, G., R. Calderon, and M. Craun. 2003. Waterborne Outbreaks in the United States, 1971-
2000, pp. 45-60. In Pontius, F. (ed.) Drinking Water Regulation and Health. John Wiley & Sons.

Heymann, D. (ed.). 2005. Control of communicable diseases manual, 18th edition. American
Public Health Association, Washington, DC.

Nataro, J., C. Bopp, P. Fields, J. Kaper, and N. Strockbine. 2007. Escherichia, Shigella, and
Salmonella. In Murray, P.R., E.J. Baron, J.H. Jorgensen, M.A. Pfaller, and R.H. Yolken (ed.)
Manual of Clinical Microbiology, 9th Edition, Volume 1, pp. 670, 677-678. American Society
for Microbiology Press, Washington, DC.

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Microbial Contaminants

EPA 815-R-22-004
October 2022

Toxoplasma gondii Scoring Data

Scoring Summary1

Waterborne Disease Outbreak

2

Health Risk

General population

2

Sensitive subpopulation(s) [P]

7

1 Bolded text indicates the highest score for that particular protocol. For the health risk protocol two scores were selected: the
general population [G] and the highest score for a sensitive subpopulation. These 2 scores were added and normalized by
multiplying by 5/14 for a final health risk score. The higher score between the WBDO and Occurrence protocols was used for
total pathogen score calculation. Health Risk protocol: G - General, C - Child, E - Elderly, P - Pregnant Women, CD - Chronic
Disease

Score2

Data Element

Scoring Data

Reference3



Waterborne Disease Outbreaks

5

Has caused multiple (1
or more) documented
WBDOs in the U.S.
reported by CDC
between 2009-2017

No

CDC-NORS, 2020

4

Has caused at least one
documented WBDOs
in U.S. reported by
CDC between 2009-
2017

No

CDC-NORS, 2020

3

Has caused
documented WBDOs
at any time in the U.S.?

No



2

Has caused WBDOs
in countries other
than the U.S.?

Yes

Canada and Brazil.

Bowie et al., 1997
de Moura, 2006

1

Has never caused





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Microbial Contaminants

EPA 815-R-22-004
October 2022

Score2

Data Element

Scoring Data

Reference3



WBDOs in any
country, but has been
epidemiologically
associated with water
related disease?







Occurrence

3

Detected in drinking
water in the U.S.?

No



2

Detected in source
water in the U.S.?

No



1

Not detected in the
U.S.?

Yes

Groundwater in Poland
and Canada.

Sroka et al., 2006

Isaac-Renton et al.,
1998



Health Risk

7[P]

Does the organism
cause significant
mortality (> 1/1,000
cases)?

[P] Congenital infection
of neonates severe.

Infection during early
pregnancy may lead to
fetal infection with death
of the fetus or other
severe manifestations.
Later in pregnancy,
maternal infection
results in mild or
subclinical fetal disease.

Wilson in MCM,
2007; McAuley and
Singh in MCM,
2019

Heymann, 2005

6

Does the organism
cause pneumonia,
meningitis, hepatitis,
encephalitis,
endocarditis, cancer, or
other severe
manifestations of

Immunocompromi sed
hosts may experience
CNS, pneumonitis, and
myocarditis.

Wilson in MCM,
2007

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Microbial Contaminants

Score2

Data Element

Scoring Data

Reference3



illness necessitating
long term
hospitalization (>
week)?





5

Does the illness result
in long term or
permanent dysfunction
or disability, i.e.
sequelae?





4

Does the illness require
short term
hospitalization (<
week)?





3

Does the illness require
physician intervention?

Treatment is indicated
only for pregnant women,
infants and
immunocompromi sed
hosts.

Wilson in MCM,
2007

2 [G, C,
E, CD]

Is the illness self-
limiting within 72
hours (without
requiring medical
intervention)?

[G, C, E, CD] Infection
is generally

asymptomatic; however,
10 - 20% of patients
with acute infection may
develop cervical
lymphadenopathy
and/or flu-like
symptoms.

Wilson in MCM,
2007

1

Does the illness result
in mild symptoms with
minimal or no impact
on daily activities?





1 Bolded text indicates the highest score for that particular protocol. For the health risk protocol two
scores were selected: the general population [G] and the highest score for a sensitive subpopulation.

These 2 scores were added and normalized by multiplying by 5/14 for a final health risk score. The higher
score between the WBDO and Occurrence protocols was used for total pathogen score calculation. Health
Risk protocol: G - General, C - Child, E - Elderly, P - Pregnant Women, CD - Chronic Disease.

2See Final Contaminant Candidate List 3 Microbes: PCCL to CCL Process. EPA 815-R-09-009. Final.
August 2009 for a detailed description on how to calculate the total pathogen score.

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Final Fifth Contaminant Candidate List (CCL 5)-
Microbial Contaminants

EPA 815-R-22-004
October 2022

3EPA based the WBDO scores on the CDC MMWR reports from 1991 -2017 and then collected
occurrence citations if there were no CDC WBDOs.

References

Bowie, W.R., S.A. King, D.H. Werker, J.L. Isaac-Renton, A. Bell, S.B. Eng, and S.A. Marion.
1997. Outbreak of toxoplasmosis associated with municipal drinking water. Lancet. 350: 173-
177.

Centers for Disease Control and Prevention (CDC). 2020. National Outbreak Reporting System
(NORS). Available online at: https://wwwn.cdc.gov/norsdashboard/. Accessed August 31, 2020.

de Moura L., L.M. Bahia-Oliveira, M.Y. Wada, J.L. Jones, S.H. Tuboi, E.H. Carmo, W.M.
Ramalho, N.J. Camargo, R. Trevisan, R.M. Graca, A.J. da Silva, I. Moura, J.P. Dubey, and D.O.
Garrett. 2006. Waterborne toxoplasmosis, Brazil, from field to gene. Emerging Infectious
Diseases. 12(2): 326-329.

Heymann, D. (ed.). 2005. Control of Communicable Diseases Manual, 18th Edition. American
Public Health Association, Washington, DC.

Isaac-Renton, J., W.R. Bowie, A. King, G.S. Irwin, C.S. Ong, C.P. Fung, M.O. Shokeir, and J.P.
Dubey. 1998. Detection of Toxoplasma gondii Oocysts in Drinking Water. Applied and
Environmental Microbiology. 64(6): 2278-2280.

McAuley, J. and K. Singh. 2019. Toxoplasma. In Carroll, K.C., M.A. Pfaller, M.L. Landry, A.J.
McAdam, R. Patel, S.S. Richter, and D.W. Warnock (ed). Manual of Clinical Microbiology, 12th
Edition. American Society of Microbiology Press, Washington, DC.

Sroka J., A. Wojcik-Fatla, and J. Dutkiewicz. 2006. Occurrence of Toxoplasma Gondii in Water
from Wells Located on Farms. Annals of Agricultural and Environmental Medicine. 13:169-175.

Wilson, M., J. Jones, and J. McAuley. 2007. Toxoplasma. In Murray, P.R., E.J. Baron, J.H.
Jorgensen, M.L. Landry, and M.A. Pfaller (ed.) Manual of Clinical Microbiology, 9th Edition,
Volume 2, p. 2070. American Society for Microbiology Press, Washington, DC.

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Microbial Contaminants

Vibrio cholerae Scoring Data

Scoring Summary1'2

Waterborne Disease Outbreak

3

Health Risk

General population

3

Sensitive subpopulation(s) [C, E, P, CD]

3

1 Bolded text indicates the highest score for that
particular protocol. For the health risk protocol two
scores were selected: the general population [G] and the highest score for a sensitive subpopulation. These 2 scores were added
and normalized by multiplying by 5/14 for a final health risk score. The higher score between the WBDO and Occurrence
protocols was used for total pathogen score calculation. Health Risk protocol: G - General, C - Child, E - Elderly, P - Pregnant
Women, CD - Chronic Disease

Score2

Data Element

Scoring Data

Reference3



Waterborne Disease Outbreaks

5

Has caused multiple (2 or
more) documented WBDOs
in the U.S. reported by CDC
between 2009-2017

No

CDC-NORS, 2020

4

Has caused at least one
documented WBDOs in U.S.
reported by CDC between
2009-2017

No

CDC-NORS, 2020

3

Has caused documented
WBDOs at any time in the
U.S.?

1971-2008: 1 Bulk
Water Purchase

CDC-NORS, 2020

2

Has caused WBDOs in
countries other than the U.S.?





1

Has never caused WBDOs in
any country, but has been
epidemiologically associated
with water related disease?





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Microbial Contaminants

Score2

Data Element

Scoring Data

Reference3



Occurrence

3

Detected in drinking water
in the U.S.?

Yes (outbreak data)

CDC, 1996

2

Detected in source water in
the U.S.?

Yes

Rhodes et al., 1986
Kaper et al., 1982

1

Not detected in the U.S.?







Health Risk

7

Does the organism cause
significant mortality (>
1/1,000 cases)?

V. cholerae Non-01:
third most commonly
isolated in U.S. -
Septicemia case fatality
rate from 47-65%.

Abbott in MCM,
2010; Tarr et al. in
MCM, 2019

6

Does the organism cause
pneumonia, meningitis,
hepatitis, encephalitis,
endocarditis, cancer, or other
severe manifestations of
illness necessitating long
term hospitalization (>
week)?

V. cholerae 01:
Extremely rare cases
cause severe
extraintestinal infection.
If untreated, V. cholerae
01 infection causes
severe dehydration which
leads to hypovolemic
shock, acidosis,
circulatory collapse, and
death. Unlike 01 strains,
non-01 isolates are
commonly associated
with extrainstestinal
infections such as
septicemia.

Abbott in MCM,
2010

5

Does the illness result in long
term or permanent





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Microbial Contaminants

Score2

Data Element

Scoring Data

Reference3



dysfunction or disability, i.e.
sequelae?





4

Does the illness require short
term hospitalization (<
week)?

In severely dehydrated
cases (cholera gravis),
death may occur within a
few hours, and the case-
fatality rate may exceed
50%. With proper and
timely rehydration, this
can be less than 1%.

Heymann, 2005

3 [G, C,
P, E, CD]

Does the illness require
physician intervention?

[All populations] In
most cases infection is
asymptomatic or causes
self-limiting diarrhea.

Treatment consists of
fluid replacement by
oral rehydration
therapy and/or
intravenous fluids.

Abbott in MCM,
2010

2

Is the illness self-limiting
within 72 hours (without
requiring medical
intervention)?





1

Does the illness result in mild
symptoms with minimal or
no impact on daily activities?





1 Bolded text indicates the highest score for that particular protocol. For the health risk protocol two
scores were selected: the general population [G] and the highest score for a sensitive subpopulation.

These 2 scores were added and normalized by multiplying by 5/14 for a final health risk score. The higher
score between the WBDO and Occurrence protocols was used for total pathogen score calculation. Health
Risk protocol: G - General, C - Child, E - Elderly, P - Pregnant Women, CD - Chronic Disease.

2See Final Contaminant Candidate List 3 Microbes: PCCL to CCL Process. EPA 815-R-09-009. Final.
August 2009 for a detailed description on how to calculate the total pathogen score.

3EPA based the WBDO scores on the CDC MMWR reports from 1991 -2017 and then collected
occurrence citations if there were no CDC WBDOs.

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EPA 815-R-22-004
October 2022

References

Abbott, S.L., J.M. Janda, and J.J. Farmer. 2010. Vibrio and Related Organisms. In Murray, P.R.,
E.J. Baron, J.H. Jorgensen, M.A. Pfaller, and R.H. Yolken (ed.) Manual of Clinical
Microbiology, 8th Edition, Volume 1, p. 666. American Society for Microbiology Press,
Washington, DC.

Centers for Disease Control and Prevention (CDC). 2020. National Outbreak Reporting System
(NORS). Available online at: https://wwwn.cdc.gov/norsdashboard/. Accessed August 31, 2020.

Heymann, D. (ed.). 2005. Control of Communicable Diseases Manual, 18th Edition, pp. 113-127.
American Public Health Association, Washington, DC.

Kaper, J.B., H.B. Bradford, N.C. Roberts, and S. Falkow. 1982. Molecular epidemiology of
Vibrio cholerae in the U.S. Gulf Coast. Journal of Clinical Microbiology. 16(1): 129-134.

Rhodes, J.B., H.L. Smith Jr., and J.E. Ogg. 1986. Isolation of Non-Ol Vibrio cholerae Serovars
from Surface Waters in Western Colorado. Applied and Environmental Microbiology. 51(6):
1216-1219.

Tarr, C., W. Glover II, Y. Boucher, and J.J. Farmer III. 2019., Vibrio and Related Organisms. In
Carroll, K.C., M.A. Pfaller, M.L. Landry, A.J. McAdam, R. Patel, S.S. Richter, and D.W.
Warnock (ed). Manual of Clinical Microbiology, 12th Edition. American Society of
Microbiology Press, Washington, DC.

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Microbial Contaminants

EPA 815-R-22-004
October 2022

Yersinia enterocolitica Scoring Data

Scoring Summary1'2

Waterborne Disease Outbreak

3

Health Risk

General population

2

Sensitive subpopulation(s) [C]

2

1 Bolded text indicates the highest score for that particular protocol. For the health risk protocol two scores were selected: the
general population [G] and the highest score for a sensitive subpopulation. These 2 scores were added and normalized by
multiplying by 5/14 for a final health risk score. The higher score between the WBDO and Occurrence protocols was used for
total pathogen score calculation. Health Risk protocol: G - General, C - Child, E - Elderly, P - Pregnant Women, CD - Chronic
Disease

Score2

Data Element

Scoring Data

Reference3



Waterborne Disease Outbreaks

5

Has caused multiple (2
or more) documented
WBDOs in the U.S.
reported by CDC
between 2009-2017

No

CDC-NORS, 2020

4

Has caused at least one
documented WBDOs in
U.S. reported by CDC
between 2009-2017

No

CDC-NORS, 2020

3

Has caused
documented WBDOs
at any time in the
U.S.?

1971-2008:1
Noncommunity

CDC-NORS, 2020

2

Has caused WBDOs in
countries other than the
U.S.?





1

Has never caused
WBDOs in any country,





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Microbial Contaminants

Score2

Data Element

Scoring Data

Reference3



but has been
epidemiologically
associated with water
related disease?







Occurrence

3

Detected in drinking
water in the U.S.?

Yes

Highsmith et al.,
1977

Eden et al., 1977

2

Detected in source
water in the U.S.?

Yes

Meadows and
Snudden, 1982

1

Not detected in the
U.S.?







Health Risk

7

Does the organism
cause significant
mortality (> 1/1,000
cases)?

No



6

Does the organism
cause pneumonia,
meningitis, hepatitis,
encephalitis,
endocarditis, cancer, or
other severe

manifestations of illness
necessitating long term
hospitalization (>
week)?

An uncommon
complication of
gastroenteritis is
septicemia for which the
elderly and

immunocompromised are
at higher risk, particularly
those with metabolic
diseases associated with
iron overload
(hemochromatosis),
cancer, liver disease and
steroid therapy.

Wanger in MCM,
2010; Kingry et al. in
MCM, 2019

5

Does the illness result
in long term or
permanent dysfunction
or disability, i.e.

Uncommon sequelae
include: reactive arthritis,
inflammatory bowel
disease, autoimmune

Wanger in MCM,
2010

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Score2

Data Element

Scoring Data

Reference3



sequelae?

thyroid disorders.



4

Does the illness require
short term
hospitalization (<
week)?





3

Does the illness require
physician intervention?

The elderly are at greater
risk for septicemia.

Wanger in MCM,
2010

2 [G, C]

Is the illness self-
limiting within 72
hours (without
requiring medical
intervention)?

[G, C] (No information
available for other
populations) Young
children most
commonly develop
gastroenteritis and
present with fever,
diarrhea, and
abdominal pain.
Symptoms typically
resolve within 7 days.

Infection typically
manifested by acute
febrile diarrhea with
abdominal pain
(especially in young
children). Diarrhea may
be absent in up to a
third of Y. enterocolitica
infections.

Wanger in MCM,
2010

Heymann, 2005

1

Does the illness result
in mild symptoms with
minimal or no impact
on daily activities?





1 Bolded text indicates the highest score for that particular protocol. For the health risk protocol two
scores were selected: the general population [G] and the highest score for a sensitive subpopulation.

These 2 scores were added and normalized by multiplying by 5/14 for a final health risk score. The higher
score between the WBDO and Occurrence protocols was used for total pathogen score calculation. Health
Risk protocol: G - General, C - Child, E - Elderly, P - Pregnant Women, CD - Chronic Disease.

2See Final Contaminant Candidate List 3 Microbes: PCCL to CCL Process. EPA 815-R-09-009. Final.
August 2009 for a detailed description on how to calculate the total pathogen score.

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Microbial Contaminants

EPA 815-R-22-004
October 2022

3EPA based the WBDO scores on the CDC MMWR reports from 1991 -2017 and then collected
occurrence citations if there were no CDC WBDOs.

References

Centers for Disease Control and Prevention (CDC). 2020. National Outbreak Reporting System
(NORS). Available online at: https://wwwn.cdc.gov/norsdashboard/. Accessed August 31, 2020.

Eden, K.V., M.L. Rosenberg, M. Stoopler, B.T. Wood, A.K. Highsmith, P. Skaliy, J.G. Wells,
and J.C. Feeley. 1977. Waterborne gastrointestinal illness at a ski resort-Isolation of Yersinia
enterocolitica from drinking water. Public Health Reports. 92(3): 245-50.

Heymann, D. (ed.). 2005. Control of Communicable Diseases Manual, 18th Edition. American
Public Health Association, Washington, DC.

Highsmith, A.K., J.C. Feeley, P. Skaliy, J.G. Wells, and B.T. Wood. 1977. Isolation of Yersinia
enterocolitica from well water and growth in distilled water. Applied and Environmental
Microbiology. 34: 745-750.

Kingry, L., C. Tarr, and J. Petersen. 2019. Yersinia. In Carroll, K.C., M.A. Pfaller, M.L. Landry,
A.J. McAdam, R. Patel, S.S. Richter, and D.W. Warnock (ed). Manual of Clinical Microbiology,
12th Edition. American Society of Microbiology Press, Washington, DC.

Meadows, C.A. and B.H. Snudden. 1982. Prevalence of Yersinia enterocolitica in waters of the
lower Chippewa river basin, Wisconsin. Applied and Environmental Microbiology. 43: 953-954.

Wanger, A. 2007. Yersinia. In Murray, P.R., E.J. Baron, J.H. Jorgensen, M.L. Landry, and M.A.
Pfaller (ed.) Manual of Clinical Microbiology, 9th Edition, Volume 1, p. 689-690. American
Society for Microbiology Press, Washington, DC.

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Microbial Contaminants

EPA 815-R-22-004
October 2022

Appendix G. CCL 5 Data Source Descriptions

Data Sources for Microbial Contaminants

Data Source Name
Data Source Description

The National Outbreak Reporting System (NORS)

Launched in 2009 for Health Departments to report to CDC cases
of enteric disease outbreaks caused by bacterial, viral, parasitic,
chemical, toxin, and unknown agents, as well as foodborne and
waterborne outbreaks of non-enteric disease. NORS was designed
to integrate data on waterborne as well as foodborne outbreaks, but
for CCL only the waterborne data were used.

Proprietor
Contact Information

CDC

CDC, 1600 Clifton Road, N.E., MS C-9,
Atlanta, GA 30333.

Telephone: 404-639-1700;

E-mail: healthywater@cdc.gov

Type of Data Elements
Relevance Explanation

Completeness Explanation
Redundancy Explanation
Retrievability Explanation

Source URL

Waterborne outbreak data

This source is considered relevant for the CCL process because it
contains information on drinking water outbreaks caused by
microbial contaminants which is a major component of the scoring
process.

It meets considerations because it is peer reviewed.

This source is not redundant.

This source meets retrievability criteria because it is in tabular
format.

https://www.cdc.gov/nors/index.html

Data Source Name

Data Source Description

Center for Disease Control and Prevention's Morbidity and
Mortality Weekly Reports (MMWR)

Since 1971, CDC, EPA and the Council of State and Territorial
Epidemiologists (CSTE) have maintained a collaborative
surveillance system for collecting and periodically reporting data
related to occurrences and causes of Waterborne Disease
Outbreaks (WBDOs). These reports from the CDC are published

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Microbial Contaminants

periodically in the MMWR. For CCL EPA used CDC's MMWR
summaries as the source for the WBDO scoring protocol. The
summaries include data on outbreaks associated with drinking
water, recreational water, water not intended for drinking
(excluding recreational water) and water use of unknown intent.
Public health agencies are responsible for investigating outbreaks
and reporting them voluntarily to CDC using a standard form.

Only data on outbreaks associated with drinking water, water not
intended for drinking (excluding recreational water) and water use
of unknown intent are summarized in this report. CDC and EPA
acknowledge that the WBDOs reported in the surveillance system
represent only a portion of the burden of illness associated with
drinking water exposure. The surveillance information does not
include endemic waterborne disease risks. (Description adapted
from website.)

Proprietor	CDC

Contact Information	Division of Foodborne, Waterborne, and Environmental Diseases,

National Center for Emerging and Zoonotic Infectious Diseases,
CDC, 1600 Clifton Road, N.E., MS C-9,

Atlanta, GA 30333.

Telephone: 404-639-1700;

E-mail: healthywater@cdc.gov

Type of Data Elements
Relevance Explanation

Completeness Explanation
Redundancy Explanation
Retrievability Explanation

Source URL

Waterborne outbreak data

This source is considered relevant for the CCL process because it
contains information on drinking water outbreaks caused by
microbial contaminants which is a major component of the scoring
process.

It meets considerations because it is peer reviewed.

This source is not redundant.

This source meets retrievability criteria because it is in tabular
format.

http://www.cdc.gov/mmwr/indss 2011.html

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October 2022

Data Source Name

Data Source Description

Proprietor
Contact Information

EPA Literature Search for Supplemental Data for Microbial
Contaminants

As part of its ongoing assessment of microbes in drinking water,
EPA conducted a literature review of peer-reviewed, published
journal literature for health risks and occurrence data for
nominated microbes from 2016-2019. EPA reviewed all relevant
research reports found to identify papers that might present data for
the nominated microbes that might help inform CCL 5. EPA also
reviewed studies submitted and referenced by nominators.

U.S. EPA

Nicole Tucker

Email: Tucker.Nicole@epa.gov

Type of Data Elements
Relevance Explanation

Completeness Explanation
Redundancy Explanation

Retrievability Explanation

Source URL

Health risks, drinking water occurrence data elements

This source is considered relevant for the CCL process because it
contains information on health risks and occurrence in water.

It meets considerations because the studies were peer-reviewed.

This source is not redundant (though some, but not all, data may
overlap among papers by the same authors).

Data not retrievable. This source contains written and tabulated
data that can be copied and formatted.

Not applicable

Data Source Name
Data Source Description

Proprietor
Contact Information

Manual of Clinical Microbiology (MCM), 12th Edition

The 12th edition of the MCM is the result of collaborative efforts
of 22 editors and more than 267 authors from around the world, all
experienced researchers and practitioners in medical and
diagnostic microbiology. The manual has been brought fully up to
date, resulting in 149 chapters containing the latest research
findings, infectious agents, methods, practices and safety
guidelines. Now entering its fifth decade the Manual strives to
continue to be the leading, most authoritative reference for the
"real-world" practice of clinical microbiology. This publication
builds on the content of past editions. The process requires about 3
years of careful planning, design, writing and review of chapters
before the final phases of copyediting, composition, printing and
binding. (Description adapted from website.)

American Society for Microbiology Press, Washington, DC

James Versalovic

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Technical Support Document for the
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Microbial Contaminants

EPA 815-R-22-004
October 2022

Microbiology Laboratories
Texas Children's Hospital
Houston, Texas
Production Volume

This source is considered relevant for the CCL Universe because it
contains health risks and occurrence information on microbial
pathogens.

It meets considerations because it is peer reviewed.

This source is not redundant.

This source is not automatically retrievable. It is a book available
for purchase.

Not applicable

Type of Data Elements
Relevance Explanation

Completeness Explanation
Redundancy Explanation
Retrievability Explanation

Source URL

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