Waterborne disease

(Survival manual/6. Medical/b) Disease/Waterborne disease)

The lack of clean water resources and sanitation facilities is one of the most serious environmental health problems faced today by a large fraction of the world’s population, especially those living in developing regions. The onset of waterborne diseases from water is enormous, the World Health Organization (WHO) has estimated that 1.1 billion people globally lack basic access to drinking water resources, while 2.4 billion people have inadequate sanitation facilities, which clearly accounts for many water related acute and chronic diseases.

Added to this is the rapid industrialization of many developing regions, where in the past few decades water contamination by toxic chemicals and hazardous wastes has aggravated an already serious water pollution problem. Many freshwater streams and lakes around the world have been contaminated with industrial discharges and agricultural runoffs that carry a large variety of toxic chemical substances and hazardous wastes. Many contaminated water sources contain a number of heavy metals, pesticides and other agricultural chemicals, along with persistent organic pollutants (POPs), many of which remain in the environment for long periods of time and bioaccumulate in the food web, causing many acute and chronic diseases, ranging from severe skin and liver disorders to developmental abnormalities and human cancer.

See also the post dealing with water treatment-purification, located in category:
Survival Manual/3. Food and Water/Water

Waterborne infections that may be encountered in U.S. streams and lakes.

Protozoa (little animal) Infections

and Transmission


Sources of
Agent in Water Supply

General Symptoms


Protozoan: Cryptosporidium parvum

Collects on water filters and membranes that cannot be disinfected, animal manure, seasonal runoff of water.

Flu-like symptoms, watery diarrhea, loss of appetite, substantial loss of weight, bloating, increased gas, nausea

Giardiasis (oral-fecal) (hand-to-mouth)

Protozoan: Giardia lamblia.

 Most common intestinal parasite

Untreated water, poor disinfection, pipe breaks, leaks, groundwater contamination, campgrounds where humans and wildlife use same source of water. Beavers and muskrats create ponds that act as reservoirs for Giardia.

Diarrhea, abdominal discomfort, bloating, and flatulence


Protozoan phylum (Microsporidia), but closely related to fungi

The genera of Encephalitozoon intestinalis has been detected in groundwater, the origin of drinking water

Diarrhea and wasting in immunocompromised individuals..

Parasitic Infections (Kingdom Animalia)

Disease and Transmission

Microbial Agent

Sources of Agent

in Water Supply

General Symptoms



Tapeworms of the genus Taenia

Drinking water
contaminated with eggs

Intestinal disturbances, neurologic manifestations, loss of weight, cysticercosis

Hymenolepiasis (Dwarf Tapeworm

Hymenolepis nana

Drinking water
contaminated with eggs

Abdominal pain,
severe weight loss, itching around the anus, nervous manifestation



multiceps multiceps

contaminated drinking water with eggs

increases intacranial tension




Drinking water
contaminated with eggs

Peri-anal itch,
nervous irritability, hyperactivity and insomnia

Bacterial Infections

Disease & Transmission

Microbial Agent

Sources of Agent

in Water Supply

General Symptoms



Bacteria can enter
an open wound from contaminated water sources. Can enter the gastrointestinal
tract by consuming contaminated drinking water or (more commonly)

Dry mouth, blurred and/or double vision, difficulty swallowing, muscle weakness, difficulty breathing, slurred speech, vomiting and sometimes diarrhea. Death is usually caused by respiratory failure.

Campylo bacteriosis

Most commonly
caused by Campylobacter jejuni

Drinking water
contaminated with feces

Produces dysentery like symptoms along with a high fever. Usually lasts
2–10 days.


Spread by the
bacterium Vibrio cholerae

Drinking water
contaminated with the bacterium

In severe forms it
is known to be one of the most rapidly fatal illnesses known. Symptoms include very watery diarrhea, nausea, cramps, nosebleed, rapid pulse, vomiting, and hypovolemic shock (in severe cases), at which point death can occur in 12–18 hours.


Certain strains of Escherichia coli (commonly E.

Water contaminated
with the bacteria

Mostly diarrhea.
Can cause death in immunocompromised individuals, the very young, and the elderly due to dehydration from prolonged illness.


Dysentery (Shigella)

Caused by a number of species in the genera Shigella and Salmonella with the most
common being Shigella

Water contaminated
with the bacterium

Frequent passage of
feces with blood and/or mucus and in some cases vomiting of blood.

Legionellosis (two distinct forms: Legionnaires’ disease and Pontiac fever)

Caused by bacteria
belonging to genus Legionella (90% of cases
caused by Legionella

Contaminated water:
the organism thrives in warm aquatic environments.

Pontiac fever produces milder symptoms resembling acute influenza without pneumonia. Legionnaires’ disease has severe
symptoms such as fever, chills, pneumonia (with cough that sometimes produces sputum), ataxia, anorexia, muscle aches, malaise and occasionally diarrhea and


Caused by bacterium
of genus Leptospira

Water contaminated
by the animal urine carrying the bacteria

Begins with flu-like symptoms then resolves. The second phase
then occurs involving meningitis, liver damage (causes jaundice), and renal failure

Otitis Externa (swimmer’s ear)

Caused by a number of bacterial and fungal species.

Swimming in water
contaminated by the responsible pathogens

Ear canal swells causing pain and tenderness
to the touch


Caused by many
bacteria of genus Salmonella

Drinking water
contaminated with the bacteria. More common as a food borne illness.

Symptoms include diarrhea, fever, vomiting, and abdominal cramps


Vibrio vulnificus, Vibrio
, and Vibrio

Can enter wounds from contaminated
water. Also got by drinking contaminated water or eating undercooked oysters.

Symptoms include
explosive, watery diarrhea, nausea, vomiting, abdominal cramps, and
occasionally fever.


Viral Infections

Disease and Transmission

Microbial Agent

Sources of Agent

 in Water Supply

General Symptoms



Manifests itself in
improperly treated water

Symptoms include common cold
, pneumonia, croup, and bronchitis

Hepatitis A

Hepatitis A virus

Can manifest itself
in water (and food)

Symptoms are only acute (no chronic stage to the virus) and include Fatigue, fever, abdominal pain, nausea, diarrhea,
weight loss, itching, jaundice and depression.


Two of Polyomavirus: JC virus and BK virus

Very widespread,
can manifest itself in water, ~80% of the population has antibodies to Polyomavirus

BK virus produces a
mild respiratory infection and can infect the kidneys of immunosuppressed transplant patients. JC virus infects the respiratory system  & kidneys.

Symptoms and treatment of the most common US waterborne diseases

1.  Cryptosporidiosis: protozoa/ Cryptosporidium parvum

Crypto’  is one of the most common causes of recreational water illness (disease caused by
germs spread through pool water) in the United States.
Cryptosporidium infection (cryptosporidiosis) is a gastrointestinal disease whose primary symptom is diarrhea. The illness begins when the tiny cryptosporidium parasites enter your body and travel to your small intestine. Cryptosporidium then begins its life cycle inside your body — burrowing into the walls of your intestines and later being shed in your feces.

In most healthy people, a cryptosporidium infection produces a bout of watery diarrhea, the
infection usually goes away within a week or two. If you have a compromised immune system, a cryptosporidium infection can become life-threatening without proper treatment.

You can help prevent cryptosporidium by practicing good hygiene and by avoiding drinking
water that hasn’t been boiled or filtered.

The first signs and symptoms usually appear two to seven days after infection with cryptosporidium and may include:

  • Watery diarrhea………………………………….……..93%
  • Stomach cramps or pain……………..…….….….…84%
  • Weight loss (median 10 lbs.)……………….………75%
  • Fever  (median 100.9., Range 98.7-104.9F.).…57%
  • Nausea & Vomiting ………………………………..….48%
  • Dehydration

Symptoms may last for up to two weeks, though they may come and go sporadically for up to a month, even in people with healthy immune systems. Some people with cryptosporidium infection
may have no symptoms. 

When to see a doctor
Seek medical attention if you develop watery diarrhea that does not get better within several days.

Cryptosporidium infection begins when you ingest the cells of one of nearly a dozen species of the
one-celled cryptosporidium parasite. The Cryptosporidium parvum (C. parvum) species is responsible for the majority of infections in humans.

The parasites travel to your intestinal tract, where they settle into the walls of your intestines.
Eventually, more cells are produced and shed in massive quantities into your feces, where they are highly contagious.

You can become infected with cryptosporidium by touching anything that has come in contact with contaminated feces. Methods of infection include:
•  Swallowing or putting something contaminated with cryptosporidium into your mouth
•  Drinking water contaminated with cryptosporidium
•  Swimming in water contaminated with cryptosporidium and accidentally swallowing some of it
•  Eating uncooked food contaminated with cryptosporidium
•  Touching your hand to your mouth if your hand has been in contact with a contaminated surface or object
•  Hardy parasites

Cryptosporidium is one of the most common causes of diarrhea in humans. This parasite is difficult to eradicate because it’s resistant to many chlorine-based disinfectants and can’t be effectively removed by many filters. Cryptosporidium can also survive in the environment for many months at varying temperatures, though the parasite can be destroyed by freezing or boiling.

Risk factors
People who are at increased risk of developing cryptosporidiosis
•  Those who are exposed  to contaminated water
•  Animal handlers
•  International  travelers, especially those traveling to developing countries
•  Backpackers, hikers  and campers who drink untreated, unfiltered water
•  Swimmers who swallow water in pools, lakes and rivers
•  People who drink water from shallow, unprotected wells

Complications of cryptosporidium infection include:
•  Malnutrition resulting from poor absorption of nutrients from your intestinal tract  (malabsorption)
•  Severe dehydration
•  Significant weight loss (wasting)

Treatments and drugs
There’s no commonly advised specific treatment for cryptosporidiosis, and recovery usually depends on the health of your immune system. Most healthy people recover within two weeks without medical attention. If you have a compromised immune system, the illness can last and lead to significant malnutrition and wasting. The goal of treatment is to alleviate symptoms and improve your immune response.
Cryptosporidium treatment options include:
•  Anti-parasitic drugs. Medications such as nitazoxanide (Alinia) can help alleviate diarrhea by attacking the metabolic processes of the cryptosporidium organisms. Azithromycin (Zithromax) may be
given along with one of these medications in people with compromised immune systems.
•  Anti-motility agents. These medications slow down the movements of your intestines and increase fluid absorption to relieve diarrhea and restore normal stools. Anti-motility drugs include
loperamide and its derivatives (Imodium A-D, others). Talk with your doctor before taking any of these medications.

Fluid replacement
You’ll need replacement of fluids and electrolytes — minerals such as sodium, potassium and calcium that maintain the balance of fluids in your body — lost to persistent diarrhea. These precautions will help keep your body hydrated and functioning properly.

Cryptosporidium infection is contagious, so take precautions to avoid spreading the parasite to other
people. All preventive methods aim to reduce or prevent the transmission of the cryptosporidium germs that are shed in human and animal feces. Precautions are especially important for people with compromised immune systems. Follow these suggestions:
  Practice good hygiene. Wash your hands with soap and water after using the toilet, changing
diapers, and before and after eating.
•  Thoroughly wash all fruits and vegetables that you will eat raw, and avoid eating any food you suspect might be contaminated.
•  Purify drinking water if you have a weakened immune system or are traveling in an area with a high risk of infection. Methods include boiling — at least one minute at a rolling boil — or  filtering, although filtering may not be as effective as boiling.
•  Limit swimming activities in lakes, streams and public swimming pools, especially if the water is
likely to be contaminated or if you have a compromised immune system.

2.  Giardaisis: protozoa/Giardia lamblia
Giardaisis is one of the  most common waterborne diseases in the United States. It is an intestinal infection marked by abdominal cramps, bloating, nausea and bouts of watery diarrhea. Giardaisis in is caused by the microscopic parasite, Giardaisis, found worldwide, especially in areas with poor sanitation and unsafe water.

The protozan parasites are found in backcountry streams and lakes, but also in municipal water
supplies, swimming pools, whirlpool spas and wells.

Giardia infections usually clear up within six weeks. But you may have intestinal problems long after the parasites are gone. Several drugs are generally effective against Giardia parasites, but not everyone
responds to them. Prevention is your best defense.

Some people with Giardia infection never develop signs or symptoms but still carry the parasite and can spread it to others through their stool. For those who do get sick, signs and symptoms usually appear one to two weeks after exposure and may include:
•  Watery, sometimes foul-smelling diarrhea that may alternate with soft, greasy stools
•  Fatigue
•  Abdominal cramps and bloating
•  Belching gas with a bad taste
•  Nausea
•  Weight loss

Signs and  symptoms of Giardia infection usually improve in two to six weeks, but in some people they last longer or recur. Giardia infection is almost never fatal in industrialized countries, but it can cause lingering symptoms and serious complications, especially in infants and children under age 5.

The most common, possible complications include
•  DehydrationOften a result of severe diarrhea, dehydration occurs when the body doesn’t have enough water to carry out its normal functions.
•  Failure to thrive. Chronic diarrhea from Giardia infection can lead to malnutrition and harm children’s physical and mental development.
•  Lactose intolerance. Many people with Giardia infection develop lactose intolerance — the
inability to properly digest milk sugar. The problem may persist long after the infection has cleared.

When signs and symptoms are severe or the infection persists, doctors usually treat Giardiasis
with medications such as:
•  Metronidazole (Flagyl). Metronidazole is the most commonly used antibiotic for Giardia
infection. Side effects may include nausea and a metallic taste in the mouth. Don’t drink alcohol while taking this medication.
•  Tinidazole (Tindamax). Tinidazole works as well as metronidazole and has many of the same side effects, but it can be given in a single dose.
•  Nitazoxanide (Alinia). Because it comes in a liquid form, nitazoxanide may be easier for
children to swallow.
•  Paromomycin. Although paromomycin is less effective than other treatments, it also is less likely to cause birth defects during pregnancy.

No drug can prevent Giardia infection. But common-sense precautions can go a long way toward reducing the chances that you’ll become infected or spread the infection to others.
•  Wash your hands. This is the simplest and best way to prevent most kinds of infection. Wash your hands after using the toilet or changing diapers and before eating or preparing food. When soap and water aren’t available, alcohol-based sanitizers are an excellent alternative.
•  Purify wilderness water. Avoid drinking untreated water from shallow wells, lakes, rivers, springs, ponds and streams unless you filter it or boil it for at least 10 minutes at 158 F (70 C) first.
•  Keep your mouth closed. Try not to swallow water when swimming in pools, lakes or streams.
•  Use bottled water. When traveling to parts of the world where the water supply is likely to be unsafe, drink and brush your teeth with bottled water that you open yourself. Don’t use ice, and
avoid raw fruits and vegetables, even those you peel yourself.
•  Practice safer sex. If you engage in anal sex, use a condom every time. Avoid oral-anal sex unless you’re fully protected.

Self-Care at Home
•  Drink fluids such as sports drinks, diluted fruit juices, flat soda (such as 7-Up or ginger ale, none with caffeine), broth, soups, or preparations such as Pedialyte for children. Fluids should be taken in small
amounts frequently throughout the day. Avoid fluids containing caffeine.
•  Suck on ice chips to keep from becoming dehydrated if you cannot keep fluids down.
•  After 12 hours, the diet can be advanced to bland foods such as potatoes, noodles, rice, toast, cereal, crackers, and boiled vegetables. Avoid spicy, greasy, and fried foods until diarrhea is gone and you feel recovered.
•  After stools become formed, return to a regular diet. Avoid milk for several weeks.

E. coli Infection: bacteria/ Escherichia coli Definition
Escherichia coli (E. coli) bacteria live in the intestines of people and animals. Most varieties of E.
coli are harmless or cause relatively brief diarrhea, such as occurs in travelers to developing countries.

But a few particularly nasty strains can cause severe, bloody diarrhea and abdominal cramps, followed by serious organ system damage such as kidney failure. You may be exposed to E. coli from contaminated water or food — especially raw vegetables and undercooked ground beef.

Healthy adults usually recover from infection with E. coli O157:H7 within a week, but young children and older adults can develop a life-threatening form of kidney failure called hemolytic uremic syndrome (HUS).

Signs and symptoms of  E. coli infections typically begin three or four days after exposure to the bacteria, though you may become ill as soon as one day afterward to more than a week later. Signs and symptoms include:
•  Diarrhea, which may range from mild and watery to severe and bloody
•  Abdominal cramping, pain or tenderness
•  Nausea and vomiting, in some people

 When to see a doctor
Contact your doctor if:
•  You become ill after eating fresh produce or undercooked ground beef
•  Your diarrhea is persistent or severe
•  Your diarrhea is bloody

•  Contaminated water.  Human and animal feces may pollute ground and surface water, including streams, rivers, lakes and water used to irrigate crops. Drinking or inadvertently swallowing untreated water from lakes and streams can cause E. coli infection.
Although public water systems use chlorine, ultraviolet light or ozone to kill E. coli, some outbreaks have been linked to contaminated municipal water supplies. Private wells are a greater cause for concern. Some people have been infected after swimming in pools or lakes contaminated with
•  Personal contact.   E. coli bacteria can easily travel from person to person, especially when
infected adults and children don’t wash their hands properly. Family members of young children with E. coli infection are especially likely to acquire it themselves
Restaurant workers who don’t wash their hands after using the bathroom can transmit E. coli bacteria to food. Outbreaks have also occurred among children visiting petting zoos and in animal barns at county fairs.

Risk factors
E. coli can affect anyone who is exposed to the bacteria. But some people are more likely to develop problems than others. Risk factors include:
•  Age. Young children and older adults are at higher risk of experiencing illness caused by E. coli and more-serious complications from the infection.
•  Weakened immune systems. People who have weakened immune systems — from AIDS or drugs to treat cancer or to prevent the rejection of organ transplants — are more likely to  become ill from ingesting E. coli.
•  Eating certain types of food. Risky foods include undercooked hamburger; unpasteurized milk, apple juice or cider; and soft cheeses made from raw milk.
•  Stomach-reduction surgery. People who’ve had surgery to reduce the size of their stomachs are more likely to develop symptoms from E. coli, possibly because they have less stomach acid to kill the bacteria.

Treatments and drugs
For illness caused by E. coli, no current treatments can cure the infection, relieve symptoms or prevent
 complications. For most people, the best option is to rest and drink plenty of fluids to help with dehydration and fatigue. Avoid taking an anti-diarrheal medication — this slows your digestive system down, preventing your body from getting rid of the toxins.

Lifestyle and home remedies
Follow these tips to prevent dehydration and reduce symptoms while you recover:
•  Clear liquids. Drink plenty of clear liquids, including water, clear sodas and broths, gelatin, and juices. Avoid apple and pear juices, caffeine and alcohol.
  Add foods gradually. When you start feeling better, stick to low-fiber foods at first. Try soda crackers, toast, eggs or rice.
•  Avoid certain foods. Dairy products, fatty foods, high-fiber foods or highly seasoned foods can make symptoms worse.

No vaccine or medication can protect you from E. coli-based illness, though researchers are investigating potential vaccines. To reduce your chance of being exposed to E. coli, avoid risky foods
and avoid cross-contamination.

_A. Risky foods
Avoid pink hamburger. Hamburgers should be well-done. Meat, especially if grilled, is likely to brown before it’s completely cooked, so use a meat thermometer to ensure that meat is heated to
at least 160 F (71 C) at its thickest point. If you don’t have a thermometer, cook ground meat until no pink shows in the center.
•  Drink pasteurized milk, juice and cider. Any boxed or bottled juice kept at room temperature is likely to be pasteurized, even if the label doesn’t say so.
•  Wash raw produce thoroughly. Although washing produce won’t necessarily get rid of
all E. coli — especially in leafy greens, which provide many spots for the bacteria to attach themselves to — careful rinsing can remove dirt and reduce the amount of bacteria that may be clinging to the produce.

_B. Avoid cross-contamination
•  Wash utensils. Use hot soapy water on knives, countertops and cutting boards before and after they come into contact with fresh produce or raw meat.
•  Keep raw foods separate. This includes using separate cutting boards for raw meat and foods such as vegetables and fruits. Never put cooked hamburgers on the same plate you  used for raw patties.
•  Wash your hands. Wash your hands after preparing or eating food, using the bathroom or changing diapers. Make sure that children also wash their hands before eating, after using the  bathroom and after contact with animals.

4.  Dysentery: bacteria/Shigella
Shigella infection (shigellosis, dysentery) is an intestinal disease caused by a family of bacteria known as Shigella. The main sign of Shigella infection is diarrhea, which often is bloody.
Shigella can be passed through direct contact with the bacteria in the stool. Shigella bacteria can be passed in contaminated food or by drinking or swimming in contaminated water.
Children between the ages of 2 and 4 are most likely to get Shigella infection. A mild case usually clears up on its own within a week. When Shigella infection requires treatment, doctors generally prescribe antibiotics.

Signs and symptoms of Shigella infection usually begin a day or two after exposure to Shigella. Signs and symptoms may include:
•  Diarrhea (often containing blood or mucus)
•  Abdominal cramps
•  Fever
Although some people have no symptoms after they’ve been infected with Shigella, their feces are still contagious.

 When to see a doctor.  Contact your doctor or seek urgent care if you or your child has bloody diarrhea or diarrhea severe enough to cause weight loss and dehydration.

Infection occurs when you accidentally ingest Shigella bacteria. This can happen when you:
•  Touch your mouth. If you don’t wash your hands well after changing the diaper of a child who has Shigella infection, you may become infected yourself. Direct person-to-person contact is the most common way the disease is transmitted.
•  Eat contaminated food. Infected people who prepare food can transmit the bacteria to people who eat the food. Food can also become contaminated if it grows in a field that contains sewage.
•  Swallow contaminated water. Water may become contaminated either from sewage or from a person with Shigella infection swimming in it.

Treatments and drugs
Shigella infection usually runs its course in five to seven days. Replacing lost fluids from diarrhea may
be all the treatment you need, particularly if your general health is good and your Shigella infection is mild. Avoid drugs intended to treat diarrhea, such as loperamide (Imodium) and diphenoxylate with atropine (Lomotil), because they can make your condition worse.
•  Antibiotics For severe Shigella infection, antibiotics may shorten the duration of the illness. However, some Shigella bacteria have become drug resistant. So it’s better not to take antibiotics unless your Shigella infection is severe. Antibiotics may also be necessary for infants, older adults and people who have HIV infection, as well as in situations where there’s high risk of spreading the disease.
•  Fluid and salt replacement. For generally healthy adults, drinking water may be enough to counteract the dehydrating effects of diarrhea. Persons who are severely dehydrated need treatment in a hospital emergency room, where they can receive salts and fluids intravenously, rather than by mouth. Intravenous hydration provides the body with water and essential nutrients much more quickly than oral solutions do.

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