The figure below shows the causal pathway by which water affects health. Structural Fund spending for water can influence different parts of this pathway. Possible approaches and actions for Structural Funds to improve health gains are shown in the blue box.

Click on any topic in the boxes to learn more.

 
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Understanding the policy context

Structural Funds investments in water infrastructure are aimed at helping Member States comply with EU legislation on emissions to water, as well as water quality and quantity overall. The main legislation that needs to be considered is:

  • The Water Framework Directive
  • The 1998 Drinking Water Directive  
  • The 2006 Bathing water Directive
  • The 1991 Urban Waste Water Directive

From 2012, the Blueprint to Safeguard Europe’s Waters will focus on water scarcity and drought.

The links between these legal and policy documents and health gains are discussed in the Approaches to Consider page.

 

 

 

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Developing projects

The causal pathway for water shows that the quality of drinking as well as bathing and recreational water is extremely important for the morbidity and mortality rates of a population. Programmes and projects in the water and wastewater sectors should acknowledge the public health implications of water-related investments and address them from an integrated perspective. 

The Approaches to Consider pages shows a few good practice examples of projects that illustrate the potential impacts of water on health gains.

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Developing Operational Programmes

There are a number of ways in which Structural Funds investment in the water sector can affect public health. These include:

  • Improvement and maintenance of sanitation (sewer) systems
  • Upgrade and extension of water supply systems
  • Improvement connection rates of the population to wastewater treatment, particularly to systems implementing tertiary treatment
  • Reduction and control of diffuse water pollution (mainly in rural areas)
  • Reduction and control of point source pollution (mainly in urban areas)
  • Enhancement and interoperability of reporting systems on water pollution, especially in the base of recreational and bathing water

The Approaches to Consider page provides examples of some of the linkages between health and water that can be considered within the Operational Programmes, and links to good examples from the project case studies and actual programme documents.

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Climate, geography and geology

The water resources of a country or a region depend on physical factors, such as climate, geography and geology (Eurostat & European Commission, 2011).

The water requirements of a country or a region are driven by population density; and by agricultural, industrial and household practices (Eurostat & European Commission, 2011). These are considered under economic activity and under Pressures.

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Economic activity

The use of water is intrinsically linked to economic activity (which in rural areas especially is closely tied to land use).

For example, water use for recreational activities is linked to the tourism industry, and the quality of such water is thus of considerable importance to tourism-dependent communities (European Environment Agency & World Health Organization Regional Office for Europe, 2002: xiii).

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Land use

The size of a population, the density of that population and the location of that population are all key factors influencing the demand for water resources. The population of the EU currently exceeds 375 million and by 2020, approximately 80% of Europeans will be living in urban areas (European Environment Agency, 2011a;European Environment Agency & World Health Organization Regional Office for Europe, 2002: 50).

Land use in urban and in rural areas is thus an important influence on water quality.

With regard to water quality the main distinction between urban and rural use is that rural use is primarily associated with diffuse water pollution whereas urban land use is primarily associated with point source pollution (although it may also be associated with diffuse water pollution from runoff).

Land use activities that are related to water quality are:

  • rural land use and intensified agricultural use,
  • urban areas, storm water and point source discharges, and
  • run-off from roads.

Landfills and the cumulative effects of on-site effluent treatment systems are other potential point source discharges, which can impact on water quality.

Point source pollution can be managed through discharge permits whereas diffuse pollution needs other management tools.

From (Hambling & Slaney, 2007)

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Abstraction

Water abstraction is a major pressure: water is abstracted for domestic, industrial (including energy production) or agricultural use. While a large part of this water is returned to the environment and its water bodies, it is often returned as wastewater with impaired quality (Eurostat & European Commission, 2011).

There are considerable differences in the per capita amounts of freshwater abstracted within each Member State, in part reflecting the resources available, but also reflecting abstraction practices for public water supply, industrial and agricultural purposes, as well as land drainage and land sealing.

These differences are also apparent when looking at the breakdown of water abstraction between groundwater and surface water resources (Eurostat & European Commission, 2011).

Urbanization often, though not always, accompanies increased industrialization and economic activity. The resulting rise in the standard of living is generally associated with increased water demand, for example from the use of water-consuming household appliances. Urban water demand is, however, expected to stabilize as a result of the development and use of appliances that are more water-efficient.

(World Health Organization Regional Office for Europe, 2010: 6)

Abstraction will affect water quality and quantity.

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Affordability

The affordability of water has a significant influence on the use of water and selection of water sources.

People on low incomes, who often make do with unreliable service delivery and water of inferior quality pay, proportionally the most per litre for their water.

The high cost of water may force households to use alternative sources of water of poorer quality that represent a greater risk to health.

Furthermore, high costs of water may reduce the volume of water used by households, which in turn may influence hygiene practices and increase risks of disease transmission (World Health Organization, 2008: 92;World Health Organization Regional Office for Europe, 2010: 6).

The affordability of water is a current and important problem in all European Union countries: in 2008, approximately 425,000 consumers in Belgium (12% of the population) were in arrears with the payment of their water bills (World Health Organization Regional Office for Europe, 2010: 6).

Affordability will affect the quantity and the quality of water that people use and consume.

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Agricultural run-off

Concerns about the impact of agriculture on the quality of water resources are often related to the leaching and run-off of agricultural chemicals applied to crops and soil.

Some agricultural contamination can originate from point sources, such as livestock facilities, but most stems from diffuse sources. The use of agricultural chemicals depends on the type of agriculture practised within a country and the market price of the crops grown.

The economic conditions of the country and the agricultural subsidies available to farmers also strongly influence the extent of water use.

Contamination of water by nutrients and microbial pathogens from farm waste and animal slurry are also concerns.

From (European Environment Agency & World Health Organization Regional Office for Europe, 2002: 58).

The Nitrates Directive (91/676/EEC) addresses pollution of water bodies from nitrates that arise from the use of agricultural fertilisers and concentrations of livestock.  Its implementation will reduce this type of pollution.

Agricultural run-off will affect water quality.

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Climate change

Climate change is already having an influence on water availability and water demand throughout the EU, and its effects are expected to grow in coming decades.

In southern Europe, rainfall is already decreasing as summer rains become more scarce and summer temperatures rise. In coming decades, southern Europe is likely to face more extended periods of drought and water scarcity. In contrast, northern European countries are expected to receive higher levels of rainfall – a trend already seen in recent years – and the risk of floods is likely to increase (WISE, 2011).

Climate change is also expected to alter the epidemiology of water-related diseases, for example through changes to rainfall and flooding patterns.

(Intergovernmental Panel on Climate Change, 2008)

Infections with Salmonella can increase by 5-10 % for each degree increase in weekly temperature, at ambient temperatures above 5oC. Some emerging studies show that the disease burden in Europe could be significant (all else being constant) with potentially an extra 20,000 cases per year by 2030 and 25,000-40,000 by 2080 (European Environment Agency, 2011d).

Climate change is also likely to affect the quality of coastal waters, by changing natural ecosystems or the quality of the waters draining into the coastal zone. This poses specific risks for the recreational use of bathing waters, particularly for transient tourist populations that may not have built-in resistance to endemic water-related diseases or may be faced with water quality that does not meet the stringent conditions imposed in the home country (European Environment Agency, 2011d).

Climate change can affect a range of state, pressure and exposure factors, including water quality and functioning of infrastructure, including wastewater treatment facilities.

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Industrial effluent

Industrial demand and effects on water quality can directly affect the water supplies of a large number of people where industry coexists with highly populated urban areas.

Industrial processes can be responsible for the release of a wide range of chemical contaminants.Theyproduce contaminated wastewater that is released into fresh or marine surface water either directly or following treatment.

From (European Environment Agency & World Health Organization Regional Office for Europe, 2002: 67).

Substances that accumulate in sediment or in organisms, such as certain heavy metals and organic substances, can enter the food chain.

In addition to controlled or intentional discharges, contamination can also occur as a result of spillage, poor handling, improper disposal methods and accidents – for example, following road accidents involving chemical tankers or a fire.

Continuing pollution may result from leaking oil pipelines or chemical and oil storage tanks.

Pollution of water sources is often a legacy of previous industrial practices. This is especially the case for groundwater, in which contamination persists for many decades because of the lack of volatilization and degradation and the slow recharge time.

From (European Environment Agency & World Health Organization Regional Office for Europe, 2002: 68).

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Municipal wastewater discharges

In urban areas, the concentration of large numbers of people in close proximity simplifies the processes of water supply and wastewater collection. However, the disposal of the large amounts of wastewater, if not properly treated, can compromise the water quality in the recipient body of water.

The release of untreated or partly treated wastewater to surface water produces contamination by microorganisms and nutrients and increases the biochemical oxygen demand (BOD).

Wastewater effluent is the most significant contributor of phosphorus to surface water, and detergent adds significantly to the phosphorus content of domestic sewage.

Domestic sewage can be a source of endocrine disrupting chemicals in the aquatic environment.

From (European Environment Agency & World Health Organization Regional Office for Europe, 2002: 52).

Urban wastewater and storm water are a key source of pollution in coastal and marine waters; lack of adequate treatment can make these waters unsuitable for swimming and a threat to human health.

In summer, mass tourism concentrates along coastal areas.  Heavy seasonal tourism increases the demand on the capacity of treatment plants and sewerage and also causes substantial fluctuation in the sewage load. Sewerage and treatment for fluctuating amounts of sewage present specific technical difficulties.

From (European Environment Agency & World Health Organization Regional Office for Europe, 2002: 73)

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Rural wastewater

In some areas, especially sparsely populated rural areas, installing a public sewerage network may involve excessive cost. In such cases, independent sewerage facilities such as sealed septic tanks are an acceptable alternative. Other on-site sanitation systems such as pit latrines may protect the health of the local community by improving community hygiene.

If, however, these sanitation systems are not properly designed or maintained, or they are not adapted to the local conditions then pathogens may be released and contaminate local bodies of water or the environment.

From (European Environment Agency & World Health Organization Regional Office for Europe, 2002: 53)

 

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Urban run-off

Increased urbanization and urban sprawl concentrates water demand and can lead to the overexploitation of local water resources.

One consequence of increased urbanization and sprawl is a change in runoff patterns resulting from large areas being covered with an impermeable surface such as concrete, tarmac or roofs.

Most rainfall in cities enters a storm drain system and is discharged, either directly or via a wastewater treatment plant, into surface waters.

Thus, rainfall that in a rural area might have served to replenish groundwater supplies is, instead, directed to surface sources.

From (European Environment Agency & World Health Organization Regional Office for Europe, 2002: 50).

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Urban wastewater treatment

In most European cities, human waste is removed from the house or latrine by a water-flush system. This wastewater enters a network of pipes along with other household wastewater.

This wastewater may receive varying degrees of treatment to remove contaminants, or no treatment at all, depending on the country and the location before discharge.

Wastewater in public systems is treated at municipal treatment plants, which often receive industrial wastewater as well as domestic sewage.

From (European Environment Agency & World Health Organization Regional Office for Europe, 2002: 52)

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Coastal and marine waters

The water quality of coastal zones has improved steadily from 1992 to 2004 and remained high in 2005. Compliance with mandatory values in EU coastal bathing waters increased from 82.3 % in 1992 to 95.6 % in 2009. Compliance with the supplementary guide values rose from 71.1 % to 89 %  (European Environment Agency, 2011b)

The water quality of coastal zones improved steadily from 1992 to 2004 and remained high in 2005. The new Bathing Water Directive 2006/7/EC has set higher standards for the management of bathing waters (World Health Organization Regional Office for Europe, 2007).

The quality and safety of seafood is directly linked to the quality of the water in the coastal zone.
Intestinal infectious diseases that are transmitted through food or water are sensitive to climate and weather factors. Such diseases are the main causes of infectious diarrhoea and cause significant amounts of illness each year in Europe. Approximately 20 % of the population in western Europe is affected by episodes of diarrhoea each year (van Pelt et al., 2003). Such infections have a significant economic impact in terms of treatment costs and loss of working time (Roberts et al., 2003). From (European Environment Agency, 2011d)

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Drinking water quality

A reliable and adequate source of clean drinking water is a legal requirement in the EU and is considered to be a basic human right. The way in which people obtain their water depends on the natural and financial resources of a country and historical influences. The population density and pattern of habitation also influence the extent to which consumers are supplied by piped networks or rely on local sources for drinking water.

From (European Environment Agency & World Health Organization Regional Office for Europe, 2002: 75)

Because of logistical difficulties, political priorities and relative cost, rural populations are less likely than urban populations to have piped water and house connections. However, the historical and current economic and organizational status of a country also strongly influences the extent of water infrastructure.

From (European Environment Agency & World Health Organization Regional Office for Europe, 2002: 77).

The EU’s Drinking Water Directive (98/83/EC) sets quality standards for drinking water to protect human health as well as requirements for regular monitoring of drinking water quality. Water supply systems serving less than 50 people, such as those in rural areas, can be exempted. While meeting the Directive’s standards is a key issue for urban areas, it is also important to ensure that rural inhabitants receive good drinking water.

Drinking water quality will affect exposure to contaminated water.

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Freshwater water quality

The water quality in freshwater zones has fallen. Some of the new EU Member States have experienced problems with relatively poor water quality and the organization of sampling activities. 

From (World Health Organization Regional Office for Europe, 2007).

At present, the general quality of bathing water in Europe, as measured by the presence of faecal indicators and pathogens in bathing waters, poses limited health risks. Quality has improved  significantly since the 1990s:  in 1992, 37.4 % of EU inland bathing areas complied with mandatory values; the level has risen to 89.4 % in 2009. Similarly, the rate of compliance with the supplementary guide values moved from 22 % in 1992 to 70.7 % in 2009. From European Environment Agency website: Bathing water quality (CSI 022) - Assessment (published Dec 2010).

The EU’s Water Framework Directive (2000/60/EC), calls for the achievement of good status – a measure that combines both chemical pollution and the health of water ecosystems – by 2015 (though specific exemptions are allowed). The EU has specific legislation for bathing water: this was revised in the new Directive, 2006/7/EC, has set higher standards for the management of bathing waters.

Freshwater quality will affect exposure to recreational water and also to contaminated water.

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Sanitation: private system

In some areas, especially sparsely populated rural areas, installing a public sewerage network may involve excessive cost. In such cases, independent sewerage facilities such as sealed septic tanks are an acceptable alternative. Other on-site sanitation systems such as pit latrines may protect the health of the local community by improving community hygiene.

If, however, these sanitation systems are not properly designed or maintained, or they are not adapted to the local conditions then pathogens may be released and contaminate local bodies of water or the environment.

From (European Environment Agency & World Health Organization Regional Office for Europe, 2002: 53)

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Sanitation: wastewater treatment

About 80% of the population is connected to waste water treatment in Northern and Southern European countries. The connection rate in Central European countries is even higher, at 90%. On the basis of data reported in 2006-2007, about 65% of total population is connected to wastewater treatment in the countries of Eastern Europe. The average connection rate in South-Eastern Europe (Turkey, Bulgaria and Romania) is about 40%.

More than 70% of the population in Northern and Central Europe is connected to a wastewater treatment plant that implements tertiary treatment, substantially removing nutrients and organic matter. Wastewater generated by more than 40% of the population in Southern and Eastern Europe receives tertiary treatment. This represents a 20% increase over last five years. In South-Eastern Europe the percentage of population connected to treatment plants with tertiary treatment is low (8.5%), with 21% of the population of the region being connected to secondary treatment.

From (European Environment Agency, 2011c).

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Access to sanitation

In the European Union (EU) countries, there were significant improvements in the proportion of the population connected to wastewater treatment facilities between 1980 and 2005. However, in at least nine Member States, less than two thirds of the population had been connected by 2007; in at least three of these countries, the share was less than one-half.

Overall, coverage is lower in rural areas. This is particularly noticeable in Eastern Europe (World Health Organization Regional Office for Europe, 2009a).

Lack of coverage is a potential factor in the unequal occurrence of water-related diseases across Europe (World Health Organization Regional Office for Europe, 2010: 12).

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Access to water

There is a clear difference between geographical areas in the burdens of mortality and morbidity attributable to outbreaks of water-related diseases across Europe. This factor is directly linked to the access to improved water supply at home in urban and rural areas (World Health Organization Regional Office for Europe, 2010: 11).

Surface water used for drinking generally represents the major vehicle of human disease transmission. In contrast to groundwater, surface water can be more easily contaminated by animal husbandry, pasture farming, sewage discharge and the disposal of dangerous substances (World Health Organization Regional Office for Europe, 2011: 1).

Access to safe drinking-water is strongly connected to basic health benefits. Hence, from a public health point of view, the proportion of the population with access to safe drinking-water is an indicator of the extent to which basic needs (as defined by the United Nations in recognition of water as a fundamental human right) are met (Office of the High Commissioner for Human Rights, 2002;World Health Organization, 2003b).

In Western Europe, close to 100% of the population have had access to a public water supply since the 1990s (World Health Organization Regional Office for Europe, 2009c).

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Exposure to chemicals

 

The vast majority of outbreaks of waterborne diseases result from bacteriological, viral, protozoan or other biological contamination.

Serious health concerns may also arise as a result of chemical contamination of drinking-water. These considerations explain the need to achieve high common standards for drinking-water so as to reduce the burden of diseases attributable to poor-quality water, sanitation and hygiene (World Health Organization Regional Office for Europe, 2009c: 4).

From a human health point of view, the chemical contamination of drinking‐water is generally of much less importance than microbiological contamination. Nevertheless, in some situations, some chemicals (for example, nitrate, fluoride, arsenic) can reach particularly high concentrations and can constitute an issue of public concern (World Health Organization Regional Office for Europe, 2011: 2).

Most chemicals arising in drinking-water are of health concern only after extended exposure of years, rather than months. The principal exception is nitrate. Typically, changes in water quality occur progressively, except for those substances that are discharged or leach intermittently to flowing surface waters or groundwater supplies from, for example, contaminated landfill sites (World Health Organization, 2008: 145).

Categorization of sources of chemical constituents

Source of chemical constituents

Examples of sources

Naturally occurring

Rocks, soils and the effects of the geological setting and climate

Industrial sources and human dwellings

Mining (extractive industries) and manufacturing and processing industries, sewage, solid wastes, urban runoff, fuel leakages

Agricultural activities

Manures, fertilizers, intensive animal practices and pesticides

Water treatment or materials in contact with drinking-water

Coagulants, DBPs, piping materials

Pesticides used in water for public health

Larvicides used in the control of insect vectors of disease

Cyanobacteria

Eutrophic water bodies

From (World Health Organization, 2008: 147)

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Recreational use of water

Contaminated bathing, or recreational, water can cause serious and potentially fatal diseases. These include severe diseases such as typhoid and leptospirosis, as well as a number of minor infections (World Health Organization Regional Office for Europe, 2009b: 3).

There is considerable epidemiological evidence to suggest that contact with recreational waters is associated with illness, primarily gastrointestinal symptoms, although outbreak data also suggest that there is a risk from more serious illnesses such as Shigella sonneri, Escherichia coli O157 infection, protozoan parasites and enteric viruses (Pond, 2005;Pruss, 1998).

An assessment of the global burden of disease attributable to gastroenteric infections arising from unsafe recreational marine water environments has estimated it as 66,000 disability-adjusted life-years (DALYs) (Shuval, 2003).

The population groups that may be at higher risk of disease include the young and tourists who do not have immunity against locally occurring endemic diseases as well as people with impaired immune systems. Children tend to play for longer periods in recreational waters and are more likely than adults to swallow water intentionally or accidentally (World Health Organization, 2003a).

From (World Health Organization Regional Office for Europe, 2007)

Exposure via recreational use of waters is linked to mortality and morbidity from bathing water.

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Use of recreational/bathing water

There is considerable epidemiological evidence in the literature to suggest that contact with recreational waters is associated with illness, primarily gastrointestinal symptoms, although outbreak data also suggest that there is a risk from more serious illnesses such as Shigella sonneri, Escherichia coli O157 infection, protozoan parasites and enteric viruses (Pond, 2005;Pruss, 1998).

A recent assessment of the global burden of disease attributable to gastroenteric infections arising from unsafe recreational marine water environments has estimated it as 66,000 disability- adjusted life-years (DALYs) (Shuval, 2003).

The population groups that may be at higher risk of disease include the young and tourists who do not have immunity against locally occurring endemic diseases. Children tend to play for longer periods in recreational waters and are more likely than adults to swallow water intentionally or accidentally (World Health Organization, 2003a).

From (World Health Organization Regional Office for Europe, 2007)

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Mortality and morbidity from bathing water

Poor quality of recreational waters has been shown to be the cause of outbreaks of waterborne diseases (World Health Organization Regional Office for Europe, 2007).

Data on the number of outbreaks of waterborne diseases attributable to bathing water each year is collected by WHO. An assessment of this indicator shows that associated outbreaks were infrequent between 2000 and 2007: there were 4–14 annual out-breaks among the 9 countries (of which 8 are EU Member States) that have a monitoring system for bathing water outbreaks.

The total number of bathing water outbreaks was 70 and resulted in 3,132 cases of illness.

Owing to the scarcity of data and difficulties in verifying the results, only summary information is presented.

  • The most common causative agents for bathing water outbreaks were protozoa, with 38 out-breaks (54.3%) and 59.3% of cases of illness.
  • Viruses caused 12 outbreaks (17.1%) and 27.8% of cases of illness.
  • Bacteria caused 11 outbreaks (15.7%) and 4.3% of cases of illness.
  • Likewise, the chemical contamination caused 9 outbreaks (8.6% of cases of illness).

Overall, the number of out-breaks and cases of illness were low compared with drinking-water outbreaks. This may be partly due to the known improvements in EU bathing water quality, as well as to the relative lack of routine surveillance systems for bathing water outbreaks.

From (World Health Organization Regional Office for Europe, 2009b: 4)


 

 

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Mortality and morbidity from drinking water

Outbreaks of disease related to contaminated drinking water continue to occur even in the economically developed European countries. They can severely affect human health, with infants and young children at highest risk.

Drinking‐water‐related outbreaks often cause the simultaneous infection of a large number of consumers, who may represent a substantial proportion of a community (World Health Organization Regional Office for Europe, 2011: 1).

Contaminated drinking-water is a frequent cause of diseases such as cholera, typhoid, viral hepatitis A and dysentery (World Health Organization Regional Office for Europe, 2009b: 3).

According to WHO estimates, in 2001, poor-quality drinking-water caused over 60 deaths from diarrhoea in children aged 0–14 years in the current EU Member States WHO European Region (5.3% of all deaths in that age group) (Valent et al., 2004: 19). Countries with an effective surveillance system (e.g. Finland, Norway, Sweden and the United Kingdom) record and are able to manage such outbreaks, which occur mostly in small agglomerations (World Health Organization Regional Office for Europe, 2009c: 3).

As regards drinking water, the actual disease burden in Europe is difficult to approximate and likely to be underestimated. In 2006, 17 water-borne outbreaks were reported by five countries. They involved a total of 3,952 patients, of which 181 were hospitalised (European Centre for Disease Prevention and Control, 2011).  

In 14 European countries (including 12 EU Member States) between 2000 and 2007 there were 354 outbreaks of waterborne disease relating to drinking water. This resulted in approximately 47,500 episodes of illness.

  • The most common causative agents were bacterial (Campylobacter and Aeromonas spp. and Shigella sonnei) and were responsible for 163 (44.9%) of the outbreaks and 33.3% of cases of illness.
  • Viral agents were implicated in 136 outbreaks (37.5%) and 49.4% of cases of illness, while protozoa caused 17 of the outbreaks (4.7%) and 9.9% of cases of illness.
  • Ten cases were caused by chemical contamination (0.2%), while in 37 cases (7.1%) an unknown microbial agent was implicated.

The data present no evidence of trends either between or within countries.

From (World Health Organization Regional Office for Europe, 2009b: 4)