The epidemiology of chemical contaminants of drinking water.

A number of chemical contaminants have been identified in drinking water. These contaminants reach drinking water supplies from various sources, including municipal and industrial discharges, urban and rural run-off, natural geological formations, drinking water distribution materials and the drinking water treatment process. Chemical contaminants for which epidemiologic studies have reported associations include the following: aluminium, arsenic, disinfection by-products, fluoride, lead, pesticides and radon. Health effects reported have included various cancers, adverse reproductive outcomes, cardiovascular disease and neurological disease. In evaluating epidemiologic studies for risk assessment, considering whether the study design was qualitative (hypothesis generating) or quantitative (hypothesis testing) is important and whether sufficient epidemiologic data of a quantitative nature exists to determine the dose-response curve. Each of the chemical contaminants mentioned are summarized by study designs (qualitative and quantitative) and whether a dose-response curve based on epidemiologic data has been proposed. Environmental epidemiology studies are driven by environmental exposures of interest. For drinking water contaminants, the design of epidemiologic studies and their interpretation should consider the following exposure issues: the source of the contaminant; other sources of the contaminant; the route of exposure; the frequency, duration and magnitude of exposure; the ability to document an actual internal dose; and the ability to document the dose to the target organ. Health effects of concern have other risk factors that must be measured in the conduct of these studies. In evaluating epidemiologic studies, potential errors and biases that may occur must be considered given the very low magnitude of associations (less than 2.0 for either odds ratio or risk ratio). Given the issues, the next generation of drinking water epidemiologic studies should include a multidisciplinary team beyond traditional epidemiologists and statisticians. Study teams will require toxicologists, chemists, engineers and exposure assessors. Arsenic is briefly discussed as an example of the importance of susceptible populations. Disinfection by-products are discussed as an example of epidemiologic studies of mixtures.