Groundwater Recharge with Reclaimed Water

This book is an assessment of the effects on human health of reclaimed water. The assessment focuses on adverse outcomes among liveborn infants, including low birth weight, preterm birth, infant mortality, and birth defects from 1982 to 1993. Outcome rates in the Montebello Forebay area, which has received some reclaimed water in its water supply since 1962, are compared with a control area that received no reclaimed water. Using a cohort study design, this epidemiologic assessment analyzes outcome data on individuals classified by a ZIP code-level percentage of reclaimed water. The results of the study do not provide evidence of an association between reclaimed water and adverse birth outcomes.

Preface

iii

Figures

ix

Tables

xi

Summary

xv

Acknowledgments

xvii

Abbreviations

xix

Introduction

1

(16)

Background

2

(13)

Wastewater Reuse

3

(1)

Treatment of Reclaimed Water

4

(1)

Reclaimed Water in the Montebello Forebay

5

(1)

Regulation of Reclaimed Water Use in California

6

(2)

Health Effects Study

8

(5)

Scientific Review of Health Effects Study

13

(1)

Rationale Behind Epidemiologic Studies of Reclaimed Water

13

(1)

Results of Study of Cancer, Mortality, and Infectious Disease

14

(1)

Overview of Report

15

(2)

Literature Review

17

(10)

Possible Mechanisms for Environmental Influence on Adverse Birth Outcomes

17

(1)

Impact of Fetal Loss on Adverse Outcomes Among Live Births

18

(1)

Low Birth Weight and Preterm Birth

18

(1)

Birth Defects

19

(2)

Infant Mortality

21

(1)

Studies of Drinking Water and Adverse Birth Outcomes

21

(4)

Overview of Study Designs and Methods

21

(1)

Studies of Drinking Water Contaminants and Spontaneous Abortions

22

(1)

Studies of Drinking Water and Low Birth Weight and Preterm Delivery

23

(1)

Studies of Drinking Water and Birth Defects

24

(1)

Summary

25

(2)

Methods

27

(22)

Data Sources

27

(2)

Birth and Death Certificates

27

(1)

California Birth Defects Monitoring Program

28

(1)

1990 Census

29

(1)

Definitions of Adverse Birth Outcomes

29

(2)

Prenatal Development and Infant Mortality

29

(1)

Birth Defects

30

(1)

Exposure to Reclaimed Water

31

(5)

Estimating the Percentage of Reclaimed Water in Domestic Supplies

32

(2)

Identifying Water Purveyors in the Montebellow Forebay

34

(1)

Estimating the Percentage of Reclaimed Water in Groundwater Supplies

34

(2)

Estimating Reclaimed Water Percentages by Service Area

36

(1)

Linking Exposure Data with Other Data

36

(2)

Selection of Control Area

38

(1)

Statistical Methods

39

(10)

Logistic Regression Analysis of Birth Outcome Data

41

(1)

Parameter Estimation

42

(2)

Variability of Parameter Estimates

44

(1)

Imputation, Missing Values, and Sample Sizes in Models

45

(1)

Sensitivity Analysis

46

(1)

Power of Statistical Tests

47

(2)

Results

49

(18)

Characteristics of Study Populations

49

(1)

Study Populations in 1990

49

(1)

Characteristics of Births in Study Populations

50

(1)

Association Between Reclaimed Water and Outcomes

51

(1)

Patterns of Health Outcomes in Study Populations

52

(4)

Hypotheses Tested

52

(1)

Measures of Exposure Effect and Statistical Significance

53

(1)

Assessing Causality of Associations

54

(2)

Prenatal Development and Infant Mortality

56

(1)

Birth Defects

57

(10)

All Birth Defects, Neural Tube, Other Nervous System, and Eyes, Ears, Face, and Neck Defects

58

(2)

Major Cardiac Defects, Patent Ductus Arteriosus, Other Cardiac, and Respiratory System Defects

60

(1)

Cleft Defects, Pyloric Stenosis, Intestinal Atresias, and Other Digestive System Defects

61

(1)

Limb, Other Musculoskeletal, Integument, and All Other Defects

61

(2)

Chromosomal Syndromes and Syndromes Other Than Chromosomal

63

(1)

Sensitivity Analyses

64

(3)

Summary and Discussion

67

(68)

Summary of Results

67

(1)

Interpretation of Study Results

68

(3)

Meaning of Null Effects

68

(2)

Evaluating the Dose-Response Relationship

70

(1)

Generalizability

70

(1)

Limitations of Study Design

71

(3)

Lack of Information on Individual Exposure

71

(1)

Effect of Population Mobility

72

(1)

Inability to Control for Potentially Confounding Variables

73

(1)

Effect of Spontaneous Abortions and Elective Terminations on Adverse Birth Outcomes

73

(1)

Comparison of Results with Other Studies

74

(1)

Previous Epidemiologic Studies of the Montebello Forebay

74

(1)

Epidemiologic Studies of Drinking Water and Adverse Birth Outcomes

75

(1)

Strengths of Study Design

75

(1)

Quality of Outcome Data

75

(1)

Other Strengths

76

(1)

Conclusions

76

(1)

Future Research

77

(2)

Appendix

A. Epidemiologic Studies of Drinking Water and Adverse Birth Outcomes

79

(8)

B. Methods Used to Estimate the Percentage of Reclaimed Water in Montebello Forebay Groundwater Supplies

87

(4)

C. Percentage of Reclaimed Water in Montebello Forebay Water System Service Areas and Zip Codes by Year, 1982--1993

91

(8)

D. Minimum Detectable Odds Ratio for Each Outcome and Exposure Group

99

(4)

E. Results of Sensitivity Analyses Using Logistic Regression Models of Prenatal Development Outcomes and Infant Mortality

103

(12)

F. Results of Sensitivity Analyses Using Logistic Regression Models for Birth Defect Outcomes

115

(20)

Bibliography

135

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Groundwater Recharge with Reclaimed Water Birth outcomes in Los Angeles County 1982-1993

Summary

Table of Contents

Supplemental Materials