United States Environmental Protection Agency Technical Support Document for the Final Fifth Contaminant Candidate List (CCL 5) - Microbial Contaminants ------- Office of Water (4607M) EPA 815-R-22-004 October 2022 www. epa. gov/ safewater ------- 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 l ------- 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 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 li ------- 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 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 in ------- 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 iv ------- 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 WBDO Waterborne Disease Outbreak WHO World Health Organization v ------- 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 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 Page 1 of 31 ------- 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 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 Page 2 of 31 ------- 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 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. Page 3 of 31 ------- 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 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 Page 4 of 31 ------- 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 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 Page 5 of 31 ------- 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 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). Page 6 of 31 ------- 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 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) Page 7 of 31 ------- 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 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 Page 8 of 31 ------- 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 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). Page 9 of 31 ------- 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 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 Page 10 of 31 ------- 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 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 Page 11 of 31 ------- 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 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. Page 12 of 31 ------- 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 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. Page 13 of 31 ------- 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 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 Page 14 of 31 ------- 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 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. Page 15 of 31 ------- 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 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 Page 16 of 31 ------- 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 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 Page 17 of 31 ------- 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 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 Page 18 of 31 ------- 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 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 Page 19 of 31 ------- 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 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 Page 20 of 31 ------- 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 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 Page 21 of 31 ------- 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 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. Page 22 of 31 ------- 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 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 Page 23 of 31 ------- 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 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. Page 24 of 31 ------- 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 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. Page 25 of 31 ------- 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 Acha, P.N and B. Szyfres (ed.). 2001. Zoonoses and Communicable Diseases Common to Man and Animals, Volume I, Bacterioses and Mycoses. Scientific and Technical Publication No. 580. Pan American Health Organization, Washington, DC. Allander, T. 2008. Human bocavirus. Journal of Clinical Virology. 41(1): 29-33. https://doi.Org/10.1016/j.jcv.2007.10.026. Ashford, R.W. and W. Crewe. 2003. The parasites of Homo sapiens: An annotated checklist of the protozoa, helminths and arthropods for which we are home. Taylor and Francis, London, UK. Baig, A.M. and N.A. Khan. 2014. Novel chemotherapeutic strategies in the management of primary amoebic meningoencephalitis due to Naegleriafowleri. CNS Neuroscience and Therapeutics. 20(3): 289-290. https://doi.org/10.llll/cns.12225. Baud, D., G. Goy, M.C. Osterheld, A. Croxatto, N. Borel, Y. Vial, A. Pospischil, and G. Greub. 2014. Role of Waddlia chondrophila placental infection in miscarriage. Emerging Infectious Diseases. 20(3): 460-464. Bennett, J.V., W.R. Jarvis, and P.S. Brachman (eds.). 2007. Bennett & Brachman's hospital infections. Lippincott Williams & Wilkins, Philadelphia, PA. Bofill-Mas, S., J. Rodriguez-Manzano, B. Calgua, A. Carratala, andR. Girones. 2010. Newly described human polyomaviruses Merkel Cell, KI and WU are present in urban sewage and may represent potential environmental contaminants. Virology Journal. 7(1): 1-5. https ://doi. org /10.1186/1743 -422X-7-141 Borchardt, M.A., S.K. Spencer, B.A. Kieke Jr., E. Lambertini, and F.J. Loge. 2012. Viruses in nondisinfected drinking water from municipal wells and community incidence of acute gastrointestinal illness. Environmental Health Perspectives. 120(9): 1272-1279. Brown, M.K., B.A. Forbes, K. Stitley, and C.D. Doern. 2016. Defining the Clinical Significance of Alloscardovia omnicolens in the Urinary Tract. Journal of Clinical Microbiology. 54(6): 1552- 1556. doi: 10.1128/JCM.03084-15. 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 Press, Washington, DC. Centers for Disease Control and Prevention (CDC). 2013. Lugo Hemorrhagic Fever (LUHF). Available online at: https://www.cdc.gov/vhf/lujo/transmission/index.html. CDC. 2017. Surveillance for Waterborne-Disease Outbreaks Associated with Drinking Water - United States. Available online at: https://www.cdc.gov/mmwr/publications/index.htmL CDC. 2019. Healthcare-Associated Infections (HAIs)-Diseases and Organisms in Healthcare Settings. Available online at: https://www.cdc.gov/hai/organisms/organisms.html. Accessed May 2022. CDC. 2020. National Outbreak Reporting System (NORS). Available online at: https://wwwn.cdc.gov/norsdashboard. Accessed August 31, 2020. Page 26 of 31 ------- 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 CDC. nd. About Chronic Diseases. Available online at: https://www.cdc.gov/chronicdisease/about/index.htm. Chapron, C.D., N.A. Ballester, J.H. Fontaine, C.N. Frades, and A.B. Margolin. 2000. Detection of astroviruses, enteroviruses, and adenovirus 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. Ciotti, M., S. Angeletti, M. Minieri, M. Giovannetti, D. Benvenuto, S. Pascarella, C. Sagnelli, M. Bianchi, S. Bernardini, and M. Ciccozzi. 2019. COVID-19 Outbreak: An Overview. Chemotherapy. 64(5-6): 215-223. doi: 10.1159/000507423. Cope, J.R., R.C. Ratard, V.R. Hill, T. Sokol, J.J. Causey, J.S. Yoder, G. Mirani, B. Mull, K.A. Mukerjee, J. Narayanan, and M. Doucet. 2015. The first association of a primary amebic meningoencephalitis death with culturable Naegleria fowleri in tap water from a US treated public drinking water system. Clinical Infectious Diseases. 60(8): e36-e42. Cromeans, T.L., A.M. Kahler, and V.R. Hill. 2010. Inactivation of adenoviruses, enteroviruses, and murine norovirus in water by free chlorine and monochloramine. Applied and environmental microbiology. 76(4): 1028-1033. Davis, C.P. 1996. Normal Flora. In Baron S. (ed) Medical Microbiology, 4th Edition. Galveston (TX): University of Texas Medical Branch at Galveston. https://www.ncbi.nlm.nih.gov/books/NBK7617/. Donohue, M.J. and L. Wymer. 2016. Increasing prevalence rate of nontuberculous mycobacteria infections in five states, 2008-2013. Annals of the American Thoracic Society. 13(12): 2143- 2150. Donohue, M.J. 2018. Increasing nontuberculous mycobacteria reporting rates and species diversity identified in clinical laboratory reports. BMC infectious diseases. 18(1): 1-9. Drasar, B.S. and P.A. Barrow. 1985. Intestinal microbiology. Van Nostrand Reinhold, Berkshire. Figueroa Castro, C.E., C. Johnson, M. Williams, A. VanDerSlik, M. Graham, D. Letzer, N. Ledeboer, B. Buchan, T. Block, G. Borulaug, and L. Munoz-Price. 2017. Elizabethkingia anophelis: Clinical Experience of an Academic Health System in Southeastern Wisconsin. Open Forum Infectious Diseases. 4(4) ofx251. doi:10.1093/ofid/ofx251. Falkinham III, J.O., E.D. Hilborn, M.J. Arduino, A. Pruden, and M.A. Edwards. 2015. Epidemiology and ecology of opportunistic premise plumbing pathogens: Legionella pneumophila, Mycobacterium avium, and Pseudomonas aeruginosa. Environmental Health Perspectives. 123(8): 749-758. Finegold, S.M., S.V.L. Sutter, and G.E. Mathisen. 1983. Normal indigenous intestinal flora, p. 3- 31. In D. J. Hentges (ed.) Human intestinal microflora in health and disease. Academic Press, New York, NY. Fong, T.T., L.S. Mansfield, D.L. Wilson, D.J. Schwab, S.L. Molloy, and J.B. Rose. 2007. Massive microbiological groundwater contamination associated with a waterborne outbreak in Lake Erie, South Bass Island, Ohio. Environmental health perspectives. 115(6): 856-864. Page 27 of 31 ------- 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 Fout, G.S., M.A. Borchardt, B.A. Kieke, and M.R. Karim. 2017. Human virus and microbial indicator occurrence in public-supply groundwater systems: meta-analysis of 12 international studies. Hydrogeology journal. 25(4): 903-919. Greub, G. 2009. Parachlamydia acanthamoebae, an emerging agent of pneumonia. Clinical Microbiology and Infection. 15(1): 18-28. doi: 10.1111/j.1469-0691.2008.02633.x. Howard, D. H. (ed.) 2003. Pathogenic fungi in humans and animals, 2nd Edition. Marcel Dekker, Inc, New York, NY. Hashimoto, S., E. Tanaka, M. Ueyama, S. Terada, T. Nakanishi, N. Hamao, T. Inao, Y. Kaji, T. Hajiro, and S. Noma. 2017. A Case of Pulmonary Botrytis Species Infection in an Apparently Healthy Individual. American Journal of Respiratory and Critical Care Medicine. 195: A7155. Isenberg, H. D. and R.F. D'Amato. 1995. Indigenous and Pathogenic Microorganisms of Humans. In Murray, P.R., E.J Baron, M.A. Pfaller, F.C. Tenover, and R.H. Yolken (ed) Manual of Clinical Microbiology, 6th Edition. American Society for Microbiology Press, Washington, DC. Institut national de sante publique du Quebec.nd. Epicoccum purpurascens. Available online at: https://www.inspq.qc.ca/en/moulds/fact-sheets/epicoccum-purpurascens. Jiang, S.C. 2006. Human adenoviruses in water: occurrence and health implications: a critical review. Environmental science & technology. 40(23): 7132-7140. Kahler, A.M., T.L. Cromeans, J.M. Roberts, and V.R Hill. 2010. Effects of source water quality on chlorine inactivation of adenovirus, coxsackievirus, echovirus, and murine norovirus. Applied and environmental microbiology. 76(15): 5159-5164. King, D.N., M.J. Donohue, S.J. Vesper, E.N. Villegas, M.W. Ware, M.E. Vogel, E.F. Furlong, D.W. Kolpin, S.T. Glassmeyer, and S. Pfaller. 2016. Microbial pathogens in source and treated waters from drinking water treatment plants in the United States and implications for human health. Science of the Total Environment. 562: 987-995. Knipe, D.M. and P.M. Howley (ed.). 2007. Fields' Virology, 5th Edition. Wolters-Kluwer, Lippincott Williams & Wilkins, Philadelphia, PA. Krauss, H., A. Weber, M. Appel, B. Enders, H. D. Isenberg, H. G. Schiefer, W. Slenczka, and A. von Graevenitz, and H. Zahner. 2003. Zoonoses, Infectious Diseases Transmissible from Animals to Humans, 3rd Edition. American Society for Microbiology Press, Washington, DC. Krause, P.J. 2003. Babesiosis diagnosis and treatment. Vector-Borne and Zoonotic Diseases. 3(1): 45-51. doi: 10.1089/153036603765627451. Krogvold, L., A. Genoni, A. Puggioni, D. Campani, S.J. Richardson, C.S. Flaxman, B. Edwin, T. Buanes, K. Dahl-j0rgensen, and A. Toniolo. 2022. Live enteroviruses, but not other viruses, detected in human pancreas at the onset of type 1 diabetes in the DiViD study. Diabetologia. 1- 13. Leclerc, H., L. Schwartzbrod, and E. Dei-Cas. 2002. Microbial agents associated with waterborne diseases. Critical reviews in microbiology. 28(4): 371-409. Lynch, J.P., M. Fishbein, and M. Echavarria. 2011. Adenovirus. Seminars in Respiratory and Critical Care Medicine. 32(4): 494-511. doi: 10.1055/s-0031-1283287. Page 28 of 31 ------- 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 Mandell, G.L., J.E. Bennett, and R. Dolin (eds.). 2005. Mandell, Douglas and Bennett's Principles and Practice of Infectious Diseases, 6th Edition. Elsevier, Philadelphia, PA. Mena, K. D. 2007. Waterborne viruses: Assessing the risks, Chapter 8. In Bosch, A. (ed.) Human viruses in water. Elsevier, Amsterdam, The Netherlands. Mena K.D. and C.P. Gerba. 2009. Waterborne adenovirus. In Whitacre, D.M. (ed.) Reviews of Environmental Contamination and Toxicology, p. 133-167. Springer, New York. Morgan, M.J., S. Halstrom, J.T. Wylie, T. Walsh, A.H. Kaksonen, D. Sutton, K. Braun, and G.J. Puzon. 2016. Characterization of a drinking water distribution pipeline terminally colonized by Naegleriafowleri. Environmental Science & Technology. 50(6): 2890-2898. Murray, P.R., E.J. Baron, J.H. Jorgensen, M.L. Landry, and M.A. Pfaller (ed.). 2007. Manual of Clinical Microbiology, 9th Edition. American Society for Microbiology Press, Washington, DC. National Academies of Sciences Engineering, and Medicine (NASEM). 2020. Management of Legionella in Water Systems. The National Academies Press, Washington, DC https://doi.org/10.17226/25474. National Drinking Water Advisory Council (NDWAC). 2004. National Drinking Water Advisory Council Report on the CCL Classification Process to the U. S. Environmental Protection Agency, May 19, 2004. National Research Council (NRC). 1999a. Setting Priorities for Drinking Water Contaminants. National Academy Press, Washington, DC. NRC. 1999b. Identifying Future Drinking Water Contaminants. National Academy Press, Washington, DC. NRC. 2001. Classifying Drinking Water Contaminants for Regulatory Consideration. National Academy Press, Washington DC. Page, M.A., J.L. Shisler, and B.J. Marinas. 2009. Kinetics of adenovirus type 2 inactivation with free chlorine. Water Research. 43: 2916-26. doi: 10.1016/j.watres.2009.03.047. Palmer, S.R., L. Soulsby, andD.I.H. Simpson. 1998. Zoonoses: biology, clinical practice, and public health control. Oxford University Press, Oxford, UK. Portillo, A., P. Santibanez, A.M. Palomar, S. Santibanez, and J.A. Oteo. 2018. Candidatus Neoehrlichia mikurensis' in Europe. New Microbes and New Infections. 22: 30-36. doi:10.1016/j.nmni.2017.12.011. Ramirez-Castillo, F.Y., A. Loera-Muro, M. Jacques, P. Garneau, F.J. Avelar-Gonzalez, J. Harel, and A.L. Guerrero-Barrera. 2015. Waterborne Pathogens: Detection Methods and Challenges. Pathogens. 4: 307-334. doi:10.3390/pathogens4020307. Reynolds, K.A., K.D. Mena, and C.P. Gerba. 2008. Risk of waterborne illness via drinking water 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 ------- 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 4Final. 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 ------- 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 ------- 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 ------- 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 ------- 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 ------- 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 ------- 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 ------- 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 ------- 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 ------- 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 ------- 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 Page El ------- 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 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 Page E2 ------- 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, Page F1 ------- 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 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 Page F2 ------- 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 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? Page F3 ------- 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 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, 19951996. MMWR Surveillance Summaries, 47(SS-5); 1-33. 415-418. Page F4 ------- 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 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 Page F5 ------- 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 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 Page F6 ------- 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 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. Page F7 ------- 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. Page F8 ------- 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 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 Page F9 ------- 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 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 Page F10 ------- 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? 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. Page Fll ------- 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). Page F12 ------- 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 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 Page F13 ------- 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 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 Page F14 ------- 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 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. Page F15 ------- 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 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. Page F16 ------- 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 Page F17 ------- 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 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 Page F18 ------- 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. Page F19 ------- 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. Page F20 ------- 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 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 Page F21 ------- 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 Page F22 ------- 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 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 ------- 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. Page F24 ------- 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 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. Page F25 ------- 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 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 Page F26 ------- 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 ------- 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, 19891990. MMWR Surveillance Summaries. 40(SS-3): 1-21. CDC. 1993. Surveillance for Waterborne-Disease Outbreaks Associated with Drinking Water United States, 19911992. MMWR Surveillance Summaries. 42(SS-5): 1-22. CDC. 1996. Surveillance for Waterborne-Disease Outbreaks Associated with Drinking Water United States, 19931994. MMWR Surveillance Summaries. 45(SS-1): 1-33. CDC. 1998. Surveillance for Waterborne-Disease Outbreaks Associated with Drinking Water United States, 19951996. MMWR Surveillance Summaries. 47(SS-5): 1-33. CDC. 2000. Surveillance for Waterborne-Disease Outbreaks Associated with Drinking Water United States, 19971998. MMWR Surveillance Summaries. 49(SS-4): 1-35. Page F28 ------- 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 CDC. 2002. Surveillance for Waterborne-Disease Outbreaks Associated with Drinking Water United States, 19992000. MMWR Surveillance Summaries. 51(SS-8): 1-36. CDC. 2004. Surveillance for Waterborne-Disease Outbreaks Associated with Drinking Water United States, 20012002. MMWR Surveillance Summaries. 53(SS08): 23-45. CDC. 2006. Surveillance for Waterborne-Disease Outbreaks Associated with Drinking Water United States, 20032004. 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. Page F29 ------- 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 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., Page F30 ------- 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 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 Page F31 ------- 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 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. Page F32 ------- 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 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. Page F33 ------- 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 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 Page F34 ------- 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 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 Page F35 ------- 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 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 Page F36 ------- 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 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. Page F37 ------- 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 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 Page F38 ------- 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 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 Page F39 ------- 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, 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 Page F40 ------- 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 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. Page F41 ------- 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 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. Page F42 ------- 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 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 Page F43 ------- 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.? 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 Page F44 ------- 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 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. Page F45 ------- 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 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. Page F46 ------- 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 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.? Page F47 ------- 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 Page F48 ------- 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. Page F49 ------- 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. Page F50 ------- 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.? Page F51 ------- 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 Page F52 ------- 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. Page F53 ------- 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. Page F54 ------- 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 Page F55 ------- 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., Page F56 ------- 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 Page F57 ------- 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. Page F58 ------- 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. Page F59 ------- 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 Page F60 ------- 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 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 Page F61 ------- 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 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)? Page F62 ------- 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 [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. Page F63 ------- 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. Page F64 ------- 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 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. Page F65 ------- 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 Page F66 ------- 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 Page F67 ------- 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. Page F68 ------- 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. Page F69 ------- 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 Page F70 ------- 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? Page F71 ------- 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 [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. Page F72 ------- 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. Page F73 ------- 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 Page F74 ------- 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? 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 Page F75 ------- 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, 19891990. MMWR Surveillance Summaries. 40(SS-3): 1-21. Page F76 ------- 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 CDC. 1993. Surveillance for Waterborne-Disease Outbreaks Associated with Drinking Water United States, 19911992. MMWR Surveillance Summaries. 42(SS-5): 1-22. CDC. 1996. Surveillance for Waterborne-Disease Outbreaks Associated with Drinking Water United States, 19931994. 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, 19951996. MMWR Surveillance Summaries. 47(SS-5): 1-33. CDC. 2000. Surveillance for Waterborne-Disease Outbreaks Associated with Drinking Water United States, 19971998. MMWR Surveillance Summaries. 49(SS-4): 1-35. CDC. 2002. Surveillance for Waterborne-Disease Outbreaks Associated with Drinking Water United States, 19992000. MMWR Surveillance Summaries. 51(SS-8): 1-36. CDC. 2004. Surveillance for Waterborne-Disease Outbreaks Associated with Drinking Water United States, 20012002. MMWR Surveillance Summaries. 53(SS08): 23-45. CDC. 2006. Surveillance for Waterborne-Disease Outbreaks Associated with Drinking Water United States, 20032004. 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. Page F77 ------- 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 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. Page F78 ------- 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 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 Page F79 ------- 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 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 Page F80 ------- 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 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. Page F81 ------- 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. Page F82 ------- 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 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 Page F83 ------- 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 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 Page F84 ------- 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 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. Page F85 ------- 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. Page F86 ------- 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 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 Page F87 ------- 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.? 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 Page F88 ------- 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 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. Page F89 ------- 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 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) Page F90 ------- 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 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.? Page F91 ------- 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 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 Page F92 ------- 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? 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. Page F93 ------- 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 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. Page F94 ------- 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 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 Page F95 ------- 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 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)? Page F96 ------- 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? 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. Page F97 ------- 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 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. Page F98 ------- 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 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 Page F99 ------- 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 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 (> Page F100 ------- 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 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. Page F101 ------- 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 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. Page F102 ------- 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 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 Page F103 ------- 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 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 Page F104 ------- 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 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. Page F105 ------- 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 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. Page F106 ------- 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 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. Page F107 ------- 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 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 Page F108 ------- 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 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 Page F109 ------- 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 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 Page F110 ------- 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 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. Page Fill ------- 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 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 Page F112 ------- 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 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)? Page F113 ------- 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 [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. Page F114 ------- 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 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. Page F115 ------- 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 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.? Page F116 ------- 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 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 Page F117 ------- 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 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. Page F118 ------- 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 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 ClinicIllinois, 2012-2013. Infection Control & Hospital Epidemiology. 38(3): 314-319. Page F119 ------- 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 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, Page F120 ------- 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 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 Page F121 ------- 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)? 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. Page F122 ------- 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 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. Page F123 ------- 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 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 Page F124 ------- 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 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 Page F125 ------- 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 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. Page F126 ------- 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 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 Page F127 ------- 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 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 Page F128 ------- 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 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. Page F129 ------- 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 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. Page F130 ------- 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 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 Page F131 ------- 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 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 Page F132 ------- 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 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. Page F133 ------- 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 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. Page F134 ------- 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 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 Page F135 ------- 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 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 Page F136 ------- 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)? 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. Page F137 ------- 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 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. Page F138 ------- 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 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 Page F139 ------- 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 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 Page F140 ------- 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 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. Page F141 ------- 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 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. Page F142 ------- 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 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? Page F143 ------- 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 (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 Page F144 ------- 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? 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. Page F145 ------- 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 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. Page F146 ------- 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 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, Page F147 ------- 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 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 Page F148 ------- 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 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. Page F149 ------- 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 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. Page F150 ------- 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 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 Page G1 ------- 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 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 Page G2 ------- 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 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 Page G3 ------- 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 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 Page G4 ------- |