Skip to main content

Thank you for visiting nature.com. You are using a browser version with limited support for CSS. To obtain the best experience, we recommend you use a more up to date browser (or turn off compatibility mode in Internet Explorer). In the meantime, to ensure continued support, we are displaying the site without styles and JavaScript.

  • Article
  • Published:

Sanitary sewage overflows, boil water advisories, and emergency room and urgent care visits for gastrointestinal illness: a case-crossover study in South Carolina, USA, 2013–2017

Journal of Exposure Science & Environmental Epidemiology volume 33, pages 102–110 (2023)Cite this article

Abstract

Background

Sanitary sewage overflows (SSOs) release raw sewage, which may contaminate the drinking water supply. Boil water advisories (BWAs) are issued during low or negative pressure events, alerting customers to potential contamination in the drinking water distribution system.

Objective

We evaluated the associations between SSOs and BWAs and diagnoses of gastrointestinal (GI) illness in Columbia, South Carolina, and neighboring communities, 2013–2017.

Methods

A symmetric bi-directional case-crossover study design was used to assess the role of SSOs and BWAs on Emergency Room and Urgent Care visits with a primary diagnosis of GI illness. Cases were considered exposed if an SSO or BWA occurred 0–4 days, 5–9 days, or 10–14 days prior to the diagnosis, within the same residential zip code. Effect modification was explored via stratification on participant-level factors (e.g., sex, race, age) and season (January-March versus April-December).

Results

There were 830 SSOs, 423 BWAs, and 25,969 cases of GI illness. Highest numbers of SSOs, BWAs and GI cases were observed in a zip code where >80% of residents identified as Black or African-American. SSOs were associated with a 13% increase in the odds of a diagnosis for GI illness during the 0–4 day hazard period, compared to control periods (Odds Ratio: 1.13, 95% Confidence Interval: 1.09, 1.18), while no associations were observed during the other hazard periods. BWAs were not associated with increased or decreased odds of GI illness during all three hazard periods. However, in stratified analyses BWAs issued between January-March were associated with higher odds of GI illness, compared to advisories issued between April-December, in all three hazard periods.

Significance

SSOs (all months) and BWAs (January-March) were associated with increased odds of a diagnosis of GI illness. Future research should examine sewage contamination of the drinking water distribution system, and mechanisms of sewage intrusion from SSOs.

Impact

Sewage contains pathogens, which cause gastrointestinal (GI) illness. In Columbia, South Carolina, USA, between 2013–2017, there were 830 sanitary sewage overflows (SSOs). There were also 423 boil water advisories, which were issued during negative pressure events. Using case-crossover design, SSOs (all months) and boil water advisories (January-March) were associated with increased odds of Emergency Room and Urgent Care diagnoses of GI illness, potentially due to contamination of the drinking water distribution system. Lastly, we identified a community where >80% of residents identified as Black or African-American, which experienced a disproportionate burden of sewage exposure, compared to the rest of Columbia.

This is a preview of subscription content, access via your institution

Access options

Buy this article

  • Purchase on Springer Link
  • Instant access to full article PDF
Buy now

Prices may be subject to local taxes which are calculated during checkout

Similar content being viewed by others

Data availability

SSO and BWA datasets are available from the corresponding author on reasonable request.

References

  1. U.S. Environmental Protection Agency (USEPA). Report to Congress on Impacts and Control of Combined Sewer Overflows and Sanitary Sewer Overflows, EPA 833-R-04-001. 2004. https://www.epa.gov/sites/default/files/2015-10/documents/csossortc2004_full.pdf (last accessed October 19, 2022)

  2. Jagai JS, Li Q, Wang S, Messier KP, Wade TJ, Hilborn ED. Extreme precipitation and emergency room visits for gastrointestinal illness in areas with and without combined sewer systems: an analysis of Massachusetts data, 2003–2007. Environ Health Perspect. 2015;123:873–9.

    Article  Google Scholar 

  3. Redman, RL, Nenn, CA, Eastwood, D, Gorelick, MH. Pediatric emergency department visits for diarrheal illness increased after release of undertreated sewage. Pediatrics. https://doi.org/10.1542/peds.2007-0283 2007.

  4. Alabama Center for Rural Enterprise (ACRE), The Columbia Law School Human Rights Clinic, The Institute for the Study of Human Rights at Columbia University. Flushed and Forgotten: Sanitation and Wastewater in Rural Communities in the United States. https://www.humanrightscolumbia.org/sites/default/files/Flushed%20and%20Forgotten%20-%20FINAL%20%281%29.pdf (last accessed October 19, 2022) 2019.

  5. Craig DL, Fallowfield HJ, Cromar NJ. Use of microcosms to determine persistence of Escherichia coli in recreational coastal water and sediment and validation with in situ measurements. J Appl Microbiol. 2004;96:922–30.

    Article  CAS  Google Scholar 

  6. Garzio-Hadzik A, Shelton DR, Hill RL, Pachepsky YA, Guber AK, Rowland R. Survival of manure-borne E. coli in streambed sediment: effects of temperature and sediment properties. Water Res. 2010;44:2753–62.

    Article  Google Scholar 

  7. Shelton DR, Pachepsky YA, Kiefer LA, Blaustein RA, McCarty GW, Dao TH. Response of coliform populations in streambed sediment and water column to changes in nutrient concentrations in water. Water Res. 2014;59:316–24.

    Article  CAS  Google Scholar 

  8. Ercumen A, Gruber JS, Colford JM Jr. Water distribution system deficiencies and gastrointestinal illness: a systematic review and meta-analysis. Environ Health Perspect. 2014;122:651–60.

    Article  Google Scholar 

  9. Karim MR, Abbaszadegan M, LeChevallier M. Potential for pathogen intrusion during pressure transients. J Am Water Work Assoc. 2003;95:124–46.

    Google Scholar 

  10. LeChevallier MW, Gullick RW, Karim MR, Friedman M, Funk JE. The potential for health risks from intrusion of contaminants into the distribution system from pressure transients. J Water Health. 2003;1:3–14.

    Article  Google Scholar 

  11. National Research Council (NRC). Drinking Water Distribution Systems: Assessing and Reducing Risks. 2006. https://www.nap.edu/catalog/11728/drinking-water-distribution-systems-assessing-and-reducing-risks (last accessed October 19, 2022).

  12. Reynolds KA, Mena KD, Gerba CP. Risk of waterborne illness via drinking water in the United States. Rev Environ Contam Toxicol. 2008;192:117–58.

    Article  Google Scholar 

  13. Teunis PFM, Xu M, Fleming KK, Yang J, Moe CL, LeChevallier MW. Enteric virus infection risk from intrusion of sewage into a drinking water distribution network. Environ Sci Technol. 2010;44:8561–6.

    Article  CAS  Google Scholar 

  14. Hunter, PR, Chalmers, RM, Hughes, S, Syed, Q Self-reported diarrhea in a control group: a strong association with reporting of low-pressure events in tap water. Clin Infect Dis. https://doi.org/10.1086/427750 2005.

  15. Lin GJ, Richardson DB, Hilborn ED, Weinberg H, Engel LS, Wade TJ. Emergency department visits for acute gastrointestinal illness after a major water pipe break in 2010. Epidemiology. 2019;30:893–900.

    Article  Google Scholar 

  16. Nygård K, Wahl E, Krogh T, Tveit OA, Bøhleng E, Tverdal A, et al. Breaks and maintenance work in the water distribution systems and gastrointestinal illness: a cohort study. Int J Epidemiol. 2007;36:873–80.

    Article  Google Scholar 

  17. South Carolina Department of Health and Environmental Control (SCDHEC). Wastewater (Sewer) Overflows. https://scdhec.gov/wastewater-sewer-overflows (last accessed October 19, 2022)

  18. U.S. Environmental Protection Agency (USEPA). The United States of America and State of South Carolina v. The City of Columbia, 2013. https://www.epa.gov/sites/default/files/2013-09/documents/columbia-cd.pdf (last accessed October 19, 2022)

  19. U.S. Census Bureau. American Community Survey, 5-Year Estimates, 2015-2019. 2022. https://data.census.gov/cedsci/ (last accessed October 19, 2022).

  20. Brokamp C, Beck AF, Muglia L, Ryan P. Combined sewer overflow events and childhood emergency department visits: a case-crossover study. Sci Total Environ. 2017;607-608:1180–7.

    Article  CAS  Google Scholar 

  21. Jagai, JS, DeFlorio-Barker, S, Lin, CJ, Hilborn, ED, Wade, TJ. Sanitary sewer overflows and emergency room visits for gastrointestinal illness: analysis of Massachusetts data, 2006-2007. Environ Health Perspect. https://doi.org/10.1289/EHP2048 2017.

  22. Wade, TJ, Lin, CJ, Jagai, JS, Hilborn, ED. Flooding and emergency room visits for gastrointestinal illness in Massachusetts: a case-crossover study. PLoS One. https://doi.org/10.1371/journal.pone.0110474 2014.

  23. Lin CJ, Wade TJ, Hilborn ED. Flooding and Clostridium difficile infection: a case-crossover analysis. Int J Environ Res Public Health. 2015;12:6948–64.

    Article  Google Scholar 

  24. Emmons AM, Bizimis M, Lang SQ, Stangler W, Geidel G, Baalousha M, et al. Enrichments of metals, including methylmercury, in sewage spills in South Carolina, USA. J Environ Qual. 2018;47:1258–66.

    Article  CAS  Google Scholar 

  25. Maclure M. The case-crossover design: a method for studying transient effects on the risk of acute events. Am J Epidemiol. 1991;133:144–53.

    Article  CAS  Google Scholar 

  26. Maclure M, Mittleman MA. Should we use a case-crossover design? Annu Rev Public Health. 2000;21:193–221.

    Article  CAS  Google Scholar 

  27. Lee, RM, Lessler, J, Lee, RA, Rudolph, KE, Reich, NG, Perl, TM, et al. Incubation periods of viral gastroenteritis: a systematic review. BMC Infect Dis, https://doi.org/10.1186/1471-2334-13-446 2013.

  28. Drayna P, McLellan SL, Simpson P, Li S-H, Gorelick MH. Association between rainfall and pediatric emergency department visits for acute gastrointestinal illness. Environ Health Perspect. 2010;118:1439–43.

    Article  Google Scholar 

  29. Wilson SM, Heaney CD, Cooper J, Wilson O. Built environment issues in unserved and underserved African-American neighborhoods in North Carolina. Environ Justice. 2008;1:63–72.

    Article  Google Scholar 

  30. Kaufman JS, MacLehose RF. Which of these things is not like the other? Cancer. 2013;119:4216–22.

    Article  Google Scholar 

  31. Hanley JA. A heuristic approach to the formulas for population attributable fraction. J Epidemiol Community Health. 2001;55:508–14.

    Article  CAS  Google Scholar 

  32. Heaney C, Wilson S, Wilson O, Cooper J, Bumpass N, Snipes M. Use of community-owned and -managed research to assess the vulnerability of water and sewer services in marginalized and underserved environmental justice communities. J Environ Health. 2011;74:8–17.

    Google Scholar 

  33. Wade TJ, Sandhu SK, Levy D, Lee S, LeChevallier MW, Katz L, et al. Did a severe flood in the Midwest cause an increase in the incidence of gastrointestinal symptoms? Am J Epidemiol. 2004;159:398–405.

    Article  Google Scholar 

  34. Gullick RW, LeChevallier MW, Svindland RC, Friedman MJ. Occurrence of transient low and negative pressures in distribution systems. J Am Water Work Assoc. 2004;96:52–66.

    Article  CAS  Google Scholar 

  35. Marsili V, Meniconi S, Alvisi S, Brunone B, Franchini M. Experimental analysis of the water consumption effect on the dynamic behavior of a real pipe network. J Hydraul Res. 2021;59:477–87.

    Article  Google Scholar 

  36. Yang J, LeChevallier MW, Teunis PFM, Xu M. Managing risks from virus intrusion into water distribution systems due to pressure transients. J Water Health. 2011;9:291–305.

    Article  CAS  Google Scholar 

  37. Gibson, J, Karney, B, Guo, Y. Predicting health risks from intrusion into drinking water pipes over time. J Water Resour Plann Manage; https://doi.org/10.1061/(ASCE)WR.1943-5452.0001039 2019.

  38. Calderon, JS, Verbyla, ME, Gil, M, Pinongcos, F, Kinoshita, AM, Mladenov, N. Persistence of fecal indicators and microbial source tracking markers in water flushed from riverbank soils. Water Air Soil Pollut. https://doi.org/10.1007/s11270-022-05542-8 2022.

  39. Byappanahalli MN, Fujioka RS. Evidence that tropical soil environment can support the growth of Escherichia coli. Water Sci Technol. 1998;38:171–4.

    Article  CAS  Google Scholar 

  40. Mika KB, Imamura G, Chang C, Conway V, Fernandez G, Griffith JF, et al. Pilot- and bench-scale testing of faecal indicator bacteria survival in marine beach sand near point sources. J Appl Microbiol. 2009;107:72–84.

    Article  CAS  Google Scholar 

  41. Zimmer-Faust AG, Thulsiraj V, Marambio-Jones C, Cao Y, Griffith JF, Holden PA, et al. Effect of freshwater sediment characteristics on the persistence of fecal indicator bacteria and genetic markers within a Southern California watershed. Water Res. 2017;119:1–11.

    Article  CAS  Google Scholar 

  42. Centers for Disease Control and Prevention (CDC). How Norovirus Spreads. 2021. https://www.cdc.gov/norovirus/about/transmission.html (last accessed October 19, 2022).

  43. Navarro G, Sala RM, Segura F, Arias C, Anton E, Varela P, et al. An outbreak of norovirus infection in a long-term-care unit in Spain. Infect Control Hosp Epidemiol. 2005;26:259–62.

    Article  Google Scholar 

  44. Centers for Disease Control and Prevention (CDC). E. coli (Escherichia coli). 2014. https://www.cdc.gov/ecoli/general/index.html (last accessed October 19, 2022)

  45. Awofisayo-Okuyelu A, Hall I, Arnold E, Byrne L, McCarthy N. Analysis of individual patient data to describe the incubation period distribution of Shiga-toxin producing Escherichia coli. Epidemiol Infect. 2019;147:1–10.

    Article  Google Scholar 

  46. Centers for Disease Control and Prevention (CDC). Salmonella. 2019. https://www.cdc.gov/salmonella/general/index.html (last accessed October 19, 2022)

  47. Eikmeier D, Medus C, Smith K. Incubation period for outbreak-associated, non-typhoidal salmonellosis cases, Minnesota, 2000-2015. Epidemiol Infect. 2018;146:423–29.

    Article  CAS  Google Scholar 

  48. Matsui T, Suzuki S, Takahashi H, Ohyama T, Kobayashi J, Izumiya H, et al. Salmonella Enteritidis outbreak associated with a school-lunch dessert: cross-contamination and a long incubation period, Japan, 2001. Epidemiol Infect. 2004;132:873–9.

    Article  CAS  Google Scholar 

  49. MacDougall L, Majowicz S, Dore K, Flint J, Thomas K, Kovacs S, et al. Under-reporting of infectious gastrointestinal illness in British Columbia, Canada: who is counted in Provincial communicable disease statistics? Epidemiol Infect. 2007;136:248–56.

    Article  Google Scholar 

  50. Hong R, Baumann BM, Boudreaux ED. The emergency department for routine healthcare: race/ethnicity, socioeconomic status, and perceptual factors. J Emerg Med. 2007;32:149–58.

    Article  Google Scholar 

Download references

Acknowledgements

We wish to thank Dr. Mark LeChevallier and Dr. Tyler Radniecki for providing critical advice on the manuscript. The authors also thank Dr. Kwadwo Adu Boakye for providing GIS maps.

Funding

DH was supported in part by a US Department of Veterans Affairs Research Career Scientist award RCS 21-136. The views expressed in this manuscript are those of the authors and do not necessarily reflect the position or policy of the Department of Veterans Affairs or the United States government.

Author information

Authors and Affiliations

  1. Oregon State University, College of Public Health and Human Sciences, Corvallis, OR, 97331, USA

    Sarah E. Rothenberg, Stephanie A. Foster, Perry Hystad, Denise M. Hynes, Adam J. Branscum & Pemika Kruearat

  2. Benedict College, Department of Computer Science, Physics, and Engineering, Columbia, SC, 29204, USA

    Jessica M. Furrer

  3. University of South Carolina, Arnold School of Public Health, Columbia, SC, 29208, USA

    Lucy A. Ingram

  4. Benedict College, Department of Health and Sport Management, Columbia, SC, 29204, USA

    Tami S. Ashford-Carroll

  5. Oregon State University, Center for Quantitative Life Sciences, Corvallis, OR, 97331, USA

    Denise M. Hynes

  6. US Department of Veterans Affairs, VA Portland Health Care System, Center to Improve Veteran Involvement in Care, Portland, OR, 97239, USA

    Denise M. Hynes

  7. Oregon State University, College of Engineering, Corvallis, OR, 97331, USA

    Tala Navab-Daneshmand

Authors
  1. Sarah E. Rothenberg
    View author publications

    You can also search for this author in PubMed Google Scholar

  2. Jessica M. Furrer
    View author publications

    You can also search for this author in PubMed Google Scholar

  3. Lucy A. Ingram
    View author publications

    You can also search for this author in PubMed Google Scholar

  4. Tami S. Ashford-Carroll
    View author publications

    You can also search for this author in PubMed Google Scholar

  5. Stephanie A. Foster
    View author publications

    You can also search for this author in PubMed Google Scholar

  6. Perry Hystad
    View author publications

    You can also search for this author in PubMed Google Scholar

  7. Denise M. Hynes
    View author publications

    You can also search for this author in PubMed Google Scholar

  8. Tala Navab-Daneshmand
    View author publications

    You can also search for this author in PubMed Google Scholar

  9. Adam J. Branscum
    View author publications

    You can also search for this author in PubMed Google Scholar

  10. Pemika Kruearat
    View author publications

    You can also search for this author in PubMed Google Scholar

Contributions

SR designed the study, acquired and analyzed the data, and wrote the manuscript; JF, LI, TA-C, PH, DH and TN-D helped design the research; and SF, AB, and PK contributed to data analyses. All authors read and approved the final manuscript.

Corresponding author

Correspondence to Sarah E. Rothenberg.

Ethics declarations

Competing interests

The authors declare no competing interests.

Ethical approval

The Oregon State University Institutional Review Board reviewed and approved the protocols for this study.

Additional information

Publisher’s note Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

Supplementary information

Rights and permissions

Springer Nature or its licensor (e.g. a society or other partner) holds exclusive rights to this article under a publishing agreement with the author(s) or other rightsholder(s); author self-archiving of the accepted manuscript version of this article is solely governed by the terms of such publishing agreement and applicable law.

Reprints and permissions

About this article

Check for updates. Verify currency and authenticity via CrossMark

Cite this article

Rothenberg, S.E., Furrer, J.M., Ingram, L.A. et al. Sanitary sewage overflows, boil water advisories, and emergency room and urgent care visits for gastrointestinal illness: a case-crossover study in South Carolina, USA, 2013–2017. J Expo Sci Environ Epidemiol 33, 102–110 (2023). https://doi.org/10.1038/s41370-022-00498-7

Download citation

  • Received:

  • Revised:

  • Accepted:

  • Published:

  • Issue Date:

  • DOI: https://doi.org/10.1038/s41370-022-00498-7

Keywords

Search

Advanced search

Quick links