World Health Organization

Water for Health

WHOs Guidelines for
Drinking-Water Quality
Water Quality and Human Health
The quality of drinking-water is a universal health concern. Water
is essential for life, but it can and does transmit disease in countries
in all continents from the poorest to the wealthiest.
Ensuring good quali ty
water for the poor is an
effective, health protec-
tive measure. Reductions
of around a third of
cases of diarrhoeal
disease in children have been reported by projects that assisted
poor households in treating water in the home and protecting
against recontamination.
Although safe drinking-water is available daily to millions, espe-
cially in the industrialized countries, improvements are needed
to prevent incidents such as the outbreak of cryptosporidiosis
in Milwaukee (USA) which affected 400,000 people, and an
E. coli O157 and Campylobacter outbreak in Walkerton (Canada)
which infected more than 2,000 people and killed seven.
Chemicals in drinking-water also continue to feature in the
headlines:
Arsenic continues to be a major public health issue in Bangladesh
and has become increasingly recognized in countries as diverse
as the USA and Viet Nam.
The presence of naturally-occurring fuoride in the groundwater
in some of the least developed countries, which has largely been
ignored, severely affects tens of millions of people with crippling
effects.
Toxic cyanobacteria in water have been headline news in
California, USA, and are of increasing concern elsewere.
Disaster relief workers, while trying to restore supplies of safe
drinking-water, sometimes struggle with unclear guidance on
the safety of emergency disinfectants.
WHO and Water
The World Health Organization (WHO) was
set up in 1948 with the objective of promoting
the attainment by all peoples of the highest pos-
sible level of health . WHO has a wide range
of functions, which include promoting (in co-
operation with other specialized agencies) the
improvement of nutrition, housing, sanitation,
recreation, economic or working conditions
with a bearing on health, and other aspects of
environmental hygiene.
One of the main roles of WHO is
to establish international norms
to protect human health. Since
1958, as part of its activities on
drinking-water and health, the
Organization has published at
around ten-year intervals sev-
eral editions of International
Standards for Drinking-Water
and, subsequently, Guidelines
for Drinking-Water Quality.
Guidelines, not Standards?
In 1982, WHO shifted its focus from International Standards
to Guidelines. The main reason for not promoting international
standards for drinking-water quality is the advantage provided by
the use of a risk-beneft approach (quantitative or qualitative) to
the establishment of national standards and regulations. The idea
is that application of the Guidelines to different countries should
take account of the sociocultural, environmental and economic
circumstances particular to those countries.
When WHO changed its terminology from International Standards
to Guidelines, it did so in order to recognize the different roles of
risk assessment and risk management. Risk assessment reports on
what is known about specifc health risks, while risk management
describes the actions to control the risks.
Work on risk assessment is best informed by pooling information,
for instance from many countries. In contrast, risk management
involves applying this information to control local risks under local
circumstances, although it may beneft from sharing experience
in effective approaches.
The water quality priorities that promise most beneft to health
vary from place to place. For instance, arsenic and fuoride are
not a problem everywhere, but can be a major health issue
where they occur.
Who uses the Guidelines?
The Guidelines are addressed to water and health regulators,
policy-makers, and their advisors, mainly to assist them in the
development of national standards. The Guidelines are also used
by many others as a source of information on water quality and
health and on effective management approaches.
The Guidelines for Drinking-Water Quality are recognized as the
UN systems position on drinking-water quality. The European
Commission and Japan use the Guidelines as the scientifc point of
departure for their drinking-water directive and drinking-water
quality standards, respectively; the Australian Drinking Water
Guidelines are based on the WHO Guidelines, while the United
States Environmental Protection Agency (USEPA) and Canada
actively observe and participate in the process of development
of the WHO Guidelines.
Many developing countries use the Guidelines directly or indirectly
in setting national standards.
The Guidelines are often used where guidelines or standards
are unavailable and are also referred to in the food standards
Titles of WHOs Water-related Guidelines
Guidelines for Drinking-Water Quality
Guidelines for Safe Use of Wastewater and Excreta in
Agriculture and Aquaculture
Guidelines for Safe Recreational Water Environments
Vol. 1. Coastal and freshwater
Vol. 2. Swimming pools and spas
Guide to Ship Sanitation
Guide to Sanitation on Aircraft
Access to safe water is a
fundamental human need and
therefore a basic human right.
Kof Annan,
United Nations Secretary-General.
developed by the Codex
Alimentarius Commission
(for instance, for mineral water
and bottled water).
Finding the Guidelines
The text of most of the
Guidelines and information on
their updating are available on
the Internet: http://www.who.int/
water_sanitation_health/GDWQ/
index.html
CD-ROMs bringing together most of WHOs
publications on water, sanitation and health are
available.
These and hard copies of the Guidelines can
be bought through WHO sales agents, the list
of which is available at: http://www.who.int/dsa/cat97/zsale.htm or from
WHO Heaquarters:
WHO, Marketing and Dissemination
CH-1211 Geneva 27, Switzerland
Tel: +41 22 791 24 76, Fax: +41 22 791 48 57
E-mail: [email protected]
The Guidelines today
The current, second edition
of the Guidelines deals wi th
infectious diseases (microbes),
hazardous chemicals, radiologi -
cal hazards, and acceptability
aspects.
The approach to microbial
hazards advocates protection
of water sources and treatment
according to source quality and
disinfection, with monitoring,
including a combination of
sanitary inspection and water
testing for faecal indicator
organisms to ensure that the
targets are met.
For hazardous chemicals, ex-
haustive chemical -by-chemical
reviews are prepared and lead
to Guideline Values represent-
ing concentrations that should
be safe even with lifelong
consumption.
Signifcant improvements are
planned for the third edition in
response to new information
and developments in risk as-
sessment and management for
chemicals and microbes.
Updating the Guidelines
The pace of development in water supply and in the understand-
ing of water and health has accelerated dramatically. Keeping
the Guidelines up to date when information and knowledge are
moving so quickly is a major challenge.
As a result, since 1994 WHO has been carrying out a process of
ongoing rolling revision to update the Guidelines.
Most of the work concerns either developing and substantiating the
recommendations in the Guidelines, or of supporting guidance on
good practice to assist in implementing programmes and projects on
drinking-water quality.
Since 2001, information on the process and on individual areas of
work and their progress has been put on the Internet.
There are around 40 lines of work in the rolling revision, plus ongo-
ing reviews of around 100 individual chemicals (see box overleaf ).
Some of the lines of work are close to completion and others have
a development programme that will extend over several years.
Making sure that the Guidelines are of the highest quality is a
priority. Phases of peer review and public domain review have
been built into the rolling revision process as key elements of the
approach to ensure quality and relevance.
Ensuring that the right subjects are included in the rolling revision
is also an important part of the future strategy. New proposals
are considered at intervals and access to the process is promoted
through the Internet.
Managing water-borne disease properly
How can water safety be ensured?
Analytical monitoring has increasingly become the cornerstone
of assuring water quality. However, by the time results are avail -
able the water has generally been supplied and may have been
consumed. For microbial hazards in particular, adverse health
effects may be unavoidable by the time a problem has been
detected. The cost of analyses and, in some circumstances, lack
of laboratory facilities may be additional constraints.
The rolling revision of the Guidelines is placing more emphasis on
preventive management of water safety.
Comprehensive management of water quality, from catchment
to consumer, rather than relying primarily on treatment to
comply with numerical targets is the most
valuable preventive approach in the provision
of safe drinking-water. This approach can be
applied to any type of water supply from a
complex piped supply in a major city through
to a village well.
Dates of publication of
the Guidelines for
Drinking-Water Quality
1984: Volume 1
(Summary, frst edition)
1985: Volume 2
(Supporting information,
frst edition)
1987: Volume 3
(Community supplies, frst
edition)
1993: Volume 1
(Summary, second edition)
1996: Volume 2
(Supporting information,
second edition)
1997: Volume 3
(Community supplies,
second edition
1998: Addendum to Vol. 1
(Selected chemicals)
1999: Addendum to Vol. 2
(Selected chemicals)
2000: Toxic Cyanobacteria
in Water (Supporting
document)
2002: Addendum on
microbial aspects
2003: Target date for
preparation of the third
edition
Thereafter: Continuous
rolling revision, with
expanded use of
electronic publication
What about those who dont have
piped drinking-water?
Most of the worlds population does not have access to piped
water (see Table).
Source: Global water supply and sanitation assessment 2000
report. WHO/UNICEF/WSSCC, 2000.
To contribute effectively to health protection the Guidelines have
to be relevant to the way people get their water, including:
vendor-provided water, protected wells and springs, rainwater
catchment tubewells ftted with hand pumps;
complex piped supplies, small community piped supplies;
emerging types of supply such as desalinated water and
bottled/packaged water; as well as
special situations such as water supply in emergencies and in
health care facilities.
From the frst edition, the Guidelines have given special consid-
eration to small community supplies through Volume 3. In the
third edition, it has been proposed that the Guidelines should
contain guidance on their application to a wider range of different
circumstances (see box overleaf )
Securing microbial safety
The key activities required in actively controlling for safety and
security are:
Checking whether systems are capable of delivering safe drink-
ing-water through a system risk assessment from catchment
to consumer. This requires developing an understanding of
occurrence, control and treatment of the different microbes
(and other contaminants) in a particular water supply. To sup-
port these assessments, detailed characterizations of microbial
hazards and critical reviews of control measures are being
prepared.
Checking that systems are being managed as well as possible.
Systematic monitoring for safe management can be achieved
through approaches commonly used in other areas, such as the
Hazard Analysis Critical Control Point (HACCP) approach for
food, and which build on sanitary inspectionand the multiple
barrier principle in water supply practice. This will require greater
emphasis on monitoring individual barriers or steps (control
points).
Ensuring water safety management plans are in place and realistic
for both normal and incident circumstances.
Ensuring independent oversight surveillance, often through
auditing-type approaches.
Managing chemical quality better: learning
from mistakes
As for microbial quality, emphasis on preventive approaches
has been proposed for the third edition of the Guidelines. Again,
system-based risk assessments will be required. In the past this
has not been done effectively,
as demonstrated by the
disastrous series of events in
Bangladesh.
In trying to tackle infectious
disease transmission through changing drinking-water sources
from surface water to groundwater, millions ended up drinking
water that contained high levels of arsenic with severe health
effects of a magnitude that is still not fully understood.
Many lessons are still being learned about arsenic which occurs
in drinking-water in countries worldwide and hopefully the same
mistake will not be repeated elsewhere.
But looking towards the future, we have to ask what will be
tomorrows arsenic ? Monitoring for all of the chemicals that might
be a health risk is simply not possible in many countries, but there
are some fairly simple ways to rule out some chemicals and to
prioritize others using readily available information. Guidance
on identifying chemicals that should be included in making as-
sessments and in monitoring is being developed to accompany
the Guidelines.
More guidance on managing
the biggest chemical problems
There are a limited number of chemical hazards in drinking-water
that cause widespread health effects. The big issues are probably
arsenic, fuoride and nitrate/nitrite. But guidance on managing
them is not readily available in the countries and regions where
the problems are greatest.
Work is progressing towards publication of guidance on arsenic,
fuoride and on nitrate/nitrite. Some chemicals such as lead, are
of concern because of multiple routes of exposure and guidance
is also in preparation.
Drinking-water safety in emergencies
Emergencies accidental and deliberately induced may lead to
contamination of drinking-water supplies. Public concern about
drinking-water safety may be a major issue even where the actual
risk is low. If a suffcient quantity of toxic or in-
fectious material contaminates a drinking-water
supply, it may lead to actual health effects.
The preventive management approach pro-
posed for the third edition of the Guidelines
can support planning for pre-
vention and early detection of,
and response to contamina-
tion events. Work is in hand
to provide more guidance
on drinki ng- water quali ty
in emergen-
cies and to
include this
in the third
edition of the
Guidelines.
Number with
no access
(millions)
Access to
improved
sources
(millions)
Access through
household
connections
1990 1126 (21%) 1981 (38%) 2159 (41%)
2000 1099 (18%) 2110 (35%) 2846 (47%)
The Guidelines:
proposed contents
(Third edition)
Guidelines:
associated texts
Key
chemicals
Arsenic
Fluoride
Nitrate/
nitrite
Monitoring
Chemical monitoring
protocol
Community supplies
Monitoring in urban areas
Analytical quality in
monitoring
Management
Materials and chemicals
(additives)
Groundwater
Spills and exceedences
Setting national standards
Managing microbial safely
Risk assessments on key
pathogens (hepatitis viruses,
Shigella, E. coli O157,
Cryptosporidium, Legionella)
Source water quality
Treatment
Piped distribution systems
Household treatment and
management
Role of H
2
S, HPC testing
Water Safety Plans and
Hygiene codes
Hazard characterization in
food and water
Others
Toxic cyanobacteria in water
Desalination
Legionella management
Work in hand in the rolling revision of the
Guidelines for Drinking-Water Quality
Microbial
Aspects
P a t h o g e n s
of concern;
system risk
assessment; safe management
practices; safety management
plans; surveillance; and guideline
requirements.
Application of
the Guidelines to:
Emergencies
Bottled water
Rainwater catchment
Desalinated water
Travellers
Health care facilities
Chemical Safety
More than 100 chemical - by-
chemical reviews covering health
effects, occurrence, technical
and analytical achievabili ty
and derived Guideline Values,
where appropriate.
Overall management approach
for chemicals, by source type.
Acceptability Aspects
Radiological Aspects
WHO
Documentation Centre
Protection of the Human Environment
CH-1211 Geneva 27, Switzerland
Tel: +41 22 791 38 72
Fax: +41 22 791 43 21
E-mail: [email protected]
World Health Organization