Daniele Lantagne, Bobbie Person, Natalie Smith, Ally Mayer, Kelsey Preston, Elizabeth Blanton, Kristen Jellison

Centers for Disease Control and Prevention & Lehigh University

Need to revise recommendations for emergency water treatment with

bleach in the United States

Current EPA Emergency Guidelines

The 3 B’s: Bottled, boil, bleach

If you can't boil water, you can disinfect it using household bleach. Bleach will kill some, but not all, types of disease-causing organisms

that may be in the water. If the water is cloudy, filter it through clean cloths or allow it to settle, and draw off the clear water for

disinfection. Add 1/8 teaspoon (or 8 drops) of regular, unscented, liquid household bleach for each gallon of water, stir it well and let it

stand for 30 minutes before you use it. Store disinfected water in clean containers with covers.

Additionally, in the more information section, the instructions read “double the amount of chlorine for cloudy, murky or colored water or water that is extremely cold.”

Concerns with guidelines - technical

Inconsistent dosing: 1/8 teaspoon != 8 drops

High dosage:– 1/8 teaspoon (5.25% bleach in 1 gallon): 8.67 mg/L– 8 drops (5.25% bleach, 1 gallon, 15-25 drops/mL):4.44 - 5.55 mg/L

– EPA maximum: 4 mg/L– WHO maximum: 5 mg/L– Used in HWTS in developing countries: 2 mg/L

Double these doses for turbid water

Concerns with guidelines - social

How the recommendations propagate

Whether the items necessary to complete the recommended treatment method are available

Whether people feel confident in completing this water treatment method– 1/196 in Hurricane Rita knew correct dose (Ram)

Propagation of recommendations

FEMA 16 drops per gallon1/8 tsp per gallon

11.10 mg/L8.67 mg/L

FDA 1/8 tsp per gallon0.75 mL per gallon

8.67 mg/L10.42 mg/L

DHS 5-7 drops per gallon1/8 tsp per gallon

3.87-4.86 mg/L8.67 mg/L

WA State 16 drops per gallon1/8 tsp per gallon

11.10 mg/L8.67 mg/L

LAFD 8 drops per gallon 5.55 mg/L

Lifewater 5-10 drops per quart 13.87-27.74 mg/L

Methods

Addressed this in working group– Result: Need data from US

Quantitative – 6 states: Colorado, Georgia, Minnesota, Penn, Texas, Wash– 6 waters: tap, water heater, surface (filtered & not), wells– Dosage testing at 3 doses, including microbiology and CT-factor

Qualitative– 3 states: Louisiana, Florida, Georgia– Stakeholder interviews– Household visits to 9 families with four directions

• Observe and test ability to make solution

Quantitative results - water quality (36)

6 tap water, 6 water heater, 11 wells, 1 rain barrel 6 surface water (raw, filtration through linen napkin)

pH: mean 7.85 (range: 6.5-9.4)– 7/36 exceeded 8.0

Turbidity: mean 3.89 NTU (range: 0-23.2)– 18/36 (50%) >1.0 NTU; 4/36 (11%) between 10-100 NTU

Temperature varied geographically and seasonally

E. coli only in surface water (<10–180 CFU/100 mL)

Total Coliforms found in 18/36 samples

Quantitative results - Dosage

Three criteria– FCR >= 0.2 mg/L and <= 4.0 mg/L– E. coli and Total Coliform = 0 CFU/100 mL– Meeting 3-log reduction for Giardia

2.0 mg/L

4.0 mg/L

7.0 mg/L

Mixed(4.0 mg/L non-

surface, 7.0 mg/L surface)

FCR 81% 69% 14% 64%

E. Coli 97% 97% 97% 100%

TC 86% 83% 89% 89%

Giardia 56% 72% 97% 89%

Quantitative results - Standard?

What criteria are most relevant? – FCR maintenance / FCR guidelines– the inactivation of Giardia in surface waters– the absence of E. coli / Total Coliform– a CT-factor to remove the majority of bacteria and viruses

that cause diarrheal disease– a combination of the above?

In any case, current dosages are too high

Qualitative results - Stakeholder meetings (86)

The government should, and does, provide bottled water

A minority knew about bleach for treatment– None knew dosage– All reported serious concerns (Poison Control Center)

Stated instructions are too confusing– “Bleach will kill some, but not all, types of disease-causing organisms.”– “Draw off”

Prefer kit– Laminated instruction, container, pre-measured dose

Qualitative results - Household interviews

Presence of materials– 6/9 had bleach in home

• None was unscented, non-expired, near 5.25%

– 1/9 families had a 1/8 teaspoon– 2/9 had dropper – 4/9 had a gallon container

Methods– Existing (1/8 tsp), existing (8 drops), other dropper, stock

solution (WHO)– Dropper method easiest, most accurate, and preferred

• Improve by having 2-L container, pictoral directions

Summary

Based on these results, both quantitative and qualitative, it is recommended that the current recommendations for emergency water treatment with household bleach be reviewed to establish an internally consistent, scientifically verified dosage regime that balances existing regulatory criteria, recommended water sources, population exposure to pathogens of concern, and availability of items (bleach, droppers, measurers, containers) necessary to treat water in the home, including the potential for development of a commercial product for water treatment instead of recommending the use of household bleach.

Acknowledgements

The stakeholders interviewed The households who completed the

qualitative testing The households who hosted the testing

Happy to take questions:

daniele.lantagne@tufts.edu