Antibiotics in Drinking Water and Health Risks - China, 2017.

WHAT IS ALREADY KNOWN ABOUT THIS TOPIC?: Antibiotic contaminations in the environment are understood to pose human health risks including disturbing the microbiome in the human body and producing antibiotic-resistant bacteria, which pose serious public health risks. Antibiotics have been detected in aquatic environments and drinking water worldwide. WHAT IS ADDED BY THIS REPORT?: Contamination levels of antibiotics in raw, finished, and tap water were investigated systematically, to the best of our knowledge, in major Chinese water basins. Multiple antibiotic contaminations in raw water and their incomplete removal during water-treatment processes results in human exposure to antibiotics via drinking water. Human exposure to such antibiotics and its health risks were evaluated in this study. WHAT ARE THE IMPLICATIONS FOR PUBLIC HEALTH PRACTICE?: This study highlights the need to strengthen management of antibiotic exposure from drinking water. A multisectoral action plan at the national level is required to curb the effects of environmental antibiotic pollution. Copyright and License information: Editorial Office of CCDCW, Chinese Center for Disease Control and Prevention 2020.

Antibiotic contamination in the environment has become a global issue attracting substantial attention from the general public. Intake of antibiotics from the environment by food and drinking water may disturb the microbiome, especially the gut microbiota in the human body (1). More importantly, antibiotic residues in the environment have the potential to produce antibiotic-resistant bacteria (ARB), which pose serious public health risks (2). Antibiotics in aquatic environments and drinking water have been detected in China (3), but studies measuring exposure to antibiotics in drinking water and associated health risks are limited. In this study, contamination levels of antibiotics in raw, finished, and tap water were investigated systematically for the first time in major Chinese water basins during the winter and summer of 2017. Human exposure and its health risks were also evaluated. Study results indicated that multiple antibiotics were generally detected in raw water from major Chinese water basins. Concentrations of detected antibiotics were at the nanogram per liter level, which were similar to those in other developed countries (3). Based on toxicity data or data on therapeutic approaches in the literature, health risk quotients (HRQs) for water basins from exposure to antibiotics via drinking water ranged from 5.1×10−7 to 2.2×10−3, exhibiting spatial and seasonal variations. The HRQs quantified in this study were at an acceptable risk level (HRQs were much lower than 1), but the risks from antibiotic resistance are not well understood and should be researched further. Antibiotic contaminations in environments can induce environmental antibiotic-resistant bacteria (eARB) and horizontal gene transfer (HGT) between eARB and pathogens with antibiotic-resistance (pARB), which has been identified as a major threat to public health. A multisectoral action plan at the national level is required to curb the effects of environmental antibiotic pollution.

Contamination data on antibiotics were extracted from a project investigating emerging contaminants in drinking water in major Chinese river basins. In the project, the levels of contamination of 57 pharmaceuticals in raw, finished, and tap water from representative drinking water treatment plants (DWTPs) located in six large river basins, inland river areas, and key lake and reservoir areas of China during the winter and summer of 2017 were investigated. The water basins and areas investigated in the project included the Yangtze River, Yellow River, Pearl River, Songhua River, Huaihe River, Liaohe River, Northwest Rivers, Taihu Lake, Dianchi Lake, Chaohu Lake, Three Gorges Reservoir, and Danjiangkou Reservoir. Pharmaceuticals were analyzed by an ultra-performance liquid chromatography–tandem mass spectrometer (UPLC–MS/MS), as described in detail in a previous study (3). Based on a literature review and preliminary survey results, 21 antibiotics (Table 1) commonly used for human and animals were selected for analysis in this study. Removal rates (percent eliminated) of antibiotics in DWTPs were calculated by dividing the removal concentration by the concentration in raw water, and the removal concentration was obtained through subtracting finished water concentration from raw water concentration[①].

Table 1

Detection rates and concentrations of antibiotics in raw water from major Chinese water basins during the winter and the summer of 2017.

Sub-category	Antibiotic	Usage*	Detection rate in winter(n=54)	Concentration in winter	Detection rate in summer(n=54)	Concentration in summer
			Percentage (%)	Median (P25, P75) (ng/L)	Percentage (%)	Median (P25, P75) (ng/L)
* 1=Use for both human and animals; 2=Use for animals only. Abbreviation: ND=not detected.
β-lactams (βLs)	Penicillin G	1	0 (0/54)	ND	0 (0/54)	ND
	Cloxacillin	1	1.9 (1/54)	11.0	1.9 (1/54)	1.2
	Cephalecxin	1	38.9 (21/54)	5.1 (2.1, 9.9)	9.3 (5/54)	0.6 (0.5, 0.8)
	Ceftiofur	2	0 (0/54)	ND	0 (0/54)	ND
Macrolides (MLs)	Clarithromycin	1	13.0 (7/54)	1.1 (1.0, 1.5)	68.5 (37/54)	0.3 (0.2, 0.6)
	Roxithromycin	1	77.8 (42/54)	1.0 (0.7,1.8)	83.3 (45/54)	0.8 (0.4, 1.7)
	Tylosin	2	3.7 (2/54)	2.8 (2.7, 2.9)	11.1 (6/54)	10.0 (2.7, 83.0)
Sulfonamides (SAs)	Sulfapyridine	2	33.3 (18/54)	0.8 (0.6, 1.1)	57.4 (31/54)	0.2 (0.1, 0.4)
	Sulfadiazine	1	50.0 (27/54)	2.5 (1.6, 3.2)	88.9 (48/54)	0.7 (0.2, 1.6)
	Sulfamethoxazole	1	88.9 (48/54)	9.1 (6.3, 14.0)	90.7 (49/54)	2.4 (1.5, 4.2)
	Sulfathiazole	1	1.9 (1/54)	98.0	37.0 (20/54)	0.1 (0.1, 0.4)
	Sulfamethazine	1	46.3 (25/54)	2.2 (1.8, 11.0)	53.7 (29/54)	1.0 (0.4, 2.6)
	Sulfaquinoxaline	2	7.4 (4/54)	1.1 (0.8, 1.3)	18.5 (10/54)	0.2 (0.1, 0.4)
	Sulfadoxin	2	0 (0/54)	ND	24.1 (13/54)	0.1 (0.1,0.2)
	Trimethoprim	1	27.8 (15/54)	2.5 (1.9, 2.7)	48.1 (26/54)	0.7 (0.4, 1.0)
Quinolones (QNs)	Norfloxacin	1	0 (0/54)	ND	0 (0/54)	ND
	Ciprofloxacin	1	0 (0/54)	ND	14.8 (8/54)	1.8 (0.8, 2.9)
	Enrofloxacin	2	0 (0/54)	ND	20.4 (11/54)	1.4 (0.9, 7.5)
	Ofloxacin	1	0 (0/54)	ND	5.6 (3/54)	1.3 (1.2, 29.0)
	Clinafloxacin	2	0 (0/54)	ND	0 (0/54)	ND
	Sarafloxacin	2	1.9 (1/54)	1.9	59.3 (32/54)	0.4 (0.2, 0.7)
The number of detected antibiotics			13		17

The HRQ for each water basin was the sum of the HRQs for each antibiotic detected in tap water. An HRQ for each antibiotic was calculated by dividing its average daily potential dose (ADD) by the acceptable daily intake (ADI) or risk-specific dose (RSD)[②]. The ADI or RSD for each antibiotic was obtained from literature research. When there were more than one ADIs or RSDs for each antibiotic, HRQs were calculated using the most restrictive ADI or RSD (4). ADD was the antibiotic exposure dose ingested through drinking and dermal absorption during water consumption, calculated with exposure parameters according to Chinese Exposure Factor Handbook and the concentrations of antibiotics in tap water. HRQ above 1 is interpreted as indicating the potential for adverse effects, while HRQ below 1 is interpreted as indicating acceptable risk.

Multiple antibiotics were generally detected in raw water from major Chinese water basins (Table 1), and the detection of antibiotics exhibited seasonal variation. The composition of antibiotic contamination in raw water during the summer was more complex than that during the winter. A total of 17 antibiotics were detected in raw water during the summer with median detected concentrations ranging from 0.1 ng/L to 10.0 ng/L. Among which, seven antibiotics had detection rates above 50%, with 2 of these used for animals only, and the others used for both humans and animals. A total of 13 antibiotics were detected in raw water during the winter, and only two antibiotics detected had detection rates above 50%.

The removal efficiency of each antibiotic from DWTPs was shown in Figure 1. A total of 17 antibiotics detected in raw water had average removal rates of above 50%. β-lactams had average removal rates above 98% and were rarely detected in finished and tap water. Although macrolides (MLs), sulfonamides (SAs), and quinolones (QNs) had average removal rates of 51%–97%, incomplete removal of these antibiotics by conventional technologies in drinking-water treatment plants leaves antibiotic residues in finished and tap water. A total of 16 antibiotics were detected in finished water, and similar results were observed in tap water.

Figure 1

Removal efficiency of 17 antibiotics detected in raw water with positive removal rates in the DWTPs. Removal rates (% elimination) were calculated by dividing the removal concentration by the concentration in raw water, and the removal concentration was obtained through subtracting finished water concentration from raw water concentration.

HRQs for water basins ranged from 4.79×10−6 to 2.15×10−3 in the summer and from 5.10×10−7 to 1.69×10−3 in the winter (Table 2). HRQs of human exposure to antibiotics through drinking water exhibited spatial and seasonal variations. Huaihe River and Chaohu Lake basins had HRQs above 10−3 during the summer and the main antibiotic residues in drinking water in these areas were ciprofloxacin and sarafloxacin. Songhua River Basin had HRQs above 10−3 during the winter and the main antibiotic residues in drinking water were clarithromycin and roxithromycin. Additionally, among six large Chinese water basins investigated, the contamination risks in the Yangtze River and Yellow River basins were mainly from sarafloxacin and clarithromycin. The contamination risk in the Pearl River Basin was mainly attributable to tylosin.

Table 2

Health risk quotients of exposures to antibiotics via drinking water for people from major Chinese water basins during the winter and the summer of 2017.

Water Basins	Season	Health risk quotient
		Minimum	Median	Maximum
* No antibiotic was detected in drinking water samples from Northwest Rivers Basin area during the winter.
Yangtze River (n=10)	Winter	8.62×10−6	1.89×10−5	2.57×10−5
	Summer	3.71×10−5	4.19×10−5	1.04×10−4
Yellow River (n=10)	Winter	2.33×10−5	4.23×10−5	4.40×10−5
	Summer	7.17×10−5	1.52×10−4	9.67×10−4
Pearl River (n=10)	Winter	5.10×10−7	1.33×10−6	1.73×10−6
	Summer	3.33×10−4	5.31×10−4	7.67×10−4
Songhua River (n=10)	Winter	9.63×10−5	8.75×10−4	1.69×10−3
	Summer	3.67×10−5	3.08×10−4	3.64×10−4
Huaihe River (n=10)	Winter	7.48×10−5	2.83×10−4	3.96×10−4
	Summer	1.09×10−3	1.81×10−3	2.15×10−3
Liaohe River (n=10)	Winter	2.83×10−5	3.01×10−5	6.35×10−5
	Summer	1.16×10−4	1.52×10−4	1.80×10−4
Northwest Rivers (n=2)	Winter	ND*	ND*	ND*
	Summer	4.79×10−6	4.79×10−6	4.79×10−6
Taihu Lake (n=10)	Winter	1.51×10−5	5.73×10−5	1.23×10−4
	Summer	4.40×10−5	7.86×10−5	8.22×10−5
Dianchi Lake (n=10)	Winter	2.03×10−5	2.86×10−5	3.00×10−5
	Summer	3.35×10−5	7.16×10−5	3.73×10−4
Chaohu Lake (n=10)	Winter	3.74×10−5	6.27×10−5	8.02×10−5
	Summer	2.95×10−4	1.40×10−3	1.44×10−3
Three Gorges Reservoir (n=10)	winter	3.71×10−5	9.59×10−5	1.78×10−4
	Summer	1.67×10−5	3.07×10−5	4.20×10−5
Danjiangkou Reservoir (n=8)	Winter	3.92×10−5	4.88×10−5	4.92×10−5
	Summer	2.32×10−5	1.62×10−4	2.98×10−4

DISCUSSION

Investigation of antibiotic contaminations in raw, finished, and tap water in major Chinese river basins indicated that the general population had been exposed to multiple antibiotics through drinking water. Concentrations of detected antibiotics were at the nanogram per liter level in raw, finished, and tap water samples. Contamination levels were similar to those in other developed countries (3). Among these antibiotics detected in tap water, seven were used for animals only including sarafloxacin and tylosin. Sarafloxacin was one of the main risk components of antibiotic contaminant exposure for people in the Huaihe River, Yellow River, and Yangtze River basins. Tylosin was the main risk component in the Pearl River Basin. Antibiotic contaminations in the environment were mainly attributed to the extensive use and emission of antibiotics in livestock farming and aquaculture (5–6).

The removal rate of each antibiotic in DWTPs investigated in this study showed that conventional purification methods during water treatment cannot remove antibiotics from raw water completely. Similar removal effects of antibiotics were also seen in previous studies (7). Incomplete removal during water-treatment processes results in human exposure to antibiotics from contaminated environments via drinking water. Antibiotics can enter an aquatic environment through effluents from sewage treatment plants (STPs) because of the limited removal efficiency from such plants (8). In addition to emissions of antibiotics from livestock farming and aquaculture, industrial effluent from drug manufacturing is another major source of antibiotic contamination, contributing high-level contaminations by some antibiotics in surface water and thus in drinking water through water system.

HRQs of antibiotic contaminations in drinking water were less than or equal to 10-3level, which were much lower than 1, indicating an acceptable level of risk from exposure to antibiotics via drinking water. However, these risks from exposure to antibiotics via drinking water varied across water basins and seasons. HRQs above 1×10-3 were observed in Huaihe River and Chaohu Lake Basins during the summer and in Songhua River Basin during the winter.

There are three limitations in our analysis. First, contamination data used in this study were collected from representative DWTPs in major river basins, which did not cover all river basins and regions in China. Hence, study results only represented the population in water-supply areas of these DWTPs. Second, ADIs used in this study to calculate HRQs of antibiotics were derived from the data based on the toxicity of experimental animal or microbiological effects in the literature. There is a lack of study on the adverse effects induced by antibiotics exposure from environments among all age groups and sensitive groups such as children and pregnant women. Finally, antibiotic contaminations in environments can induce eARB (9). Previous studies have highlighted the potential for environmental HGT between eARB and pARB, which has been identified as a major threat to public health (10). However, the risk of antibiotic resistance is not quantified in this study because of the limited research data. A study on the health risks of environmental antibiotic pollution is crucially needed to provide data to support for risk management in China.

From both human and environmental health perspectives, it is a significant task to establish a systematic project for curbing the effects of environmental antibiotic pollution. A multisectoral action plan at the national level is required: (a) to strengthen the control of antibiotic use in livestock farming and aquaculture, taking steps to reduce usage and emissions of antibiotics at national levels; (b) to improve a standard wastewater discharge system for antibiotic industries and to establish an emission standard for antibiotics to strengthen discharge management; (c) to conduct further research on removal mechanisms of antibiotics by water-treatment technology, exploring the applicability of upgrading treatment processes in STPs and DWTPs; (d) to carry out systematic research on environmental antibiotic pollution and antibiotic resistance; and (e) to conduct research on and investigate antibiotic contamination exposure and health risk assessment among all age groups and sensitive groups.

Conflict of interests: No conflicts of interest were reported.