Estimate of Burden and Direct Healthcare Cost of Infectious Waterborne Disease in the United States

Sarah A. Collier; Li Deng; Elizabeth A. Adam; Katharine M. Benedict; Elizabeth M. Beshearse; Anna J. Blackstock; Beau B. Bruce; Gordana Derado; Chris Edens; Kathleen E. Fullerton; Julia W. Gargano; Aimee L. Geissler; Aron J. Hall; Arie H. Havelaar; Vincent R. Hill; Robert M. Hoekstra; Sujan C. Reddy; Elaine Scallan; Erin K. Stokes; Jonathan S. Yoder; Michael J. Beach


Emerging Infectious Diseases. 2021;27(1):140-149. 

In This Article

Abstract and Introduction


Provision of safe drinking water in the United States is a great public health achievement. However, new waterborne disease challenges have emerged (e.g., aging infrastructure, chlorine-tolerant and biofilm-related pathogens, increased recreational water use). Comprehensive estimates of the health burden for all water exposure routes (ingestion, contact, inhalation) and sources (drinking, recreational, environmental) are needed. We estimated total illnesses, emergency department (ED) visits, hospitalizations, deaths, and direct healthcare costs for 17 waterborne infectious diseases. About 7.15 million waterborne illnesses occur annually (95% credible interval [CrI] 3.88 million–12.0 million), results in 601,000 ED visits (95% CrI 364,000–866,000), 118,000 hospitalizations (95% CrI 86,800–150,000), and 6,630 deaths (95% CrI 4,520–8,870) and incurring US $3.33 billion (95% CrI 1.37 billion–8.77 billion) in direct healthcare costs. Otitis externa and norovirus infection were the most common illnesses. Most hospitalizations and deaths were caused by biofilm-associated pathogens (nontuberculous mycobacteria, Pseudomonas, Legionella), costing US $2.39 billion annually.


At the beginning of the 20th century, diseases commonly transmitted by water, such as cholera and typhoid, were major causes of death in the United States.[1] Reliable provision of treated, safe drinking water dramatically reduced the burden of these diseases and has been recognized as one of the greatest public health achievements of the 20th century.[2] Despite this achievement, waterborne disease in the United States persists.[3–5]

In the United States, outbreaks associated with large public drinking water systems have sharply declined in the past 40 years,[3,6] likely the result of improvements in regulation and operation. However, transmission of disease via drinking water systems still occurs, often attributable to aging infrastructure, operational challenges, and the private or unregulated water systems (e.g., private wells) that serve an estimated 43 million persons.[7] At the same time, the complexity and scope of water use has increased; drinking, sanitation, hygiene, cooling, and heating needs are supported by 6 million miles of plumbing inside US buildings (i.e., premise plumbing).[8,9] Premise plumbing water quality can be compromised by long water residency times, reduced disinfectant levels, and inadequate hot water temperatures, creating environments where pathogens (e.g., nontuberculous mycobacteria [NTM], Pseudomonas, and Legionella) can amplify in biofilms.[10] People can be exposed to these pathogens through contact, ingestion, or inhalation of aerosols (e.g., from showerheads, building cooling towers, or decorative fountains).

As leisure time has increased, swimming pools, waterparks, water playgrounds, and hot tubs have proliferated.[5] These venues rely largely on chlorination as the major barrier against disease transmission. Cryptosporidium has emerged as the major cause of outbreaks associated with treated aquatic venues because it is extremely chlorine resistant and has a low infectious dose.[5,11,12] Warmer oceans have led to Vibrio-associated wound infections farther north than previously documented.[13]

Estimates of the overall burden of foodborne disease in the United States, including both known and unknown agents, have been useful in directing prevention activities and setting public health goals.[14,15] Quantifying the burden of infectious waterborne disease in the United States would also be beneficial.

Previous studies have attempted to estimate the burden of gastrointestinal illness[16,17] or all illness associated with drinking water[18] and untreated recreational water[19] in the United States, but the burden of disease from all water sources (drinking, recreational, environmental) and exposure routes (ingestion, contact, inhalation) has not been estimated. We present an estimate of the burden of waterborne disease in the United States that includes gastrointestinal, respiratory, and systemic disease; accounts for underdiagnosis; and includes all water sources and exposure routes.