Drinking Water & Health Quarterly Winter 2005 – Volume 10, Issue 3

Chlorine Bleach: Helping to Manage the Flu Risk

A Flu Risk
Management Plan
Obtain the flu vaccine, preferably in October or November.
Cover mouth and nose when coughing or sneezing.
Wash hands often for 15-20 seconds at a time (long enough to sing “Happy Birthday”).
Disinfect surfaces with diluted chlorine bleach solution (1/4 cup per gallon water).
Remind children to practice healthy habits.

As swine flu progresses across the globe, raising the specter of a pandemic, the critical need for surface disinfection is highlighted by public health officials as a practical way to stem the rate of infection. As important as canned foods and emergency water, a bottle of chlorine bleach should be an essential part of your family’s emergency preparedness kit.

Every fall, millions of Americans rush to be vaccinated against the influenza virus, or “flu,” in the hope of avoiding the worst of the seasonal symptoms of fever, headache, fatigue, cough, sore throat, runny nose, congestion and muscle aches. According to the U.S. Centers for Disease Control and Prevention (CDC), getting an annual flu vaccine is the best way to prevent this disease.

A sound risk management plan for avoiding flu infection maximizes all known preventive measures, including “flu shots” for everyone six months old and older, frequent hand washing and smart use of a common household product–chlorine bleach.

How Viruses Operate and Propagate

A virus consists of a small collection of genetic material surrounded by a protective protein shell. As very simple microbes, viruses cannot reproduce on their own, but only by “hijacking” various living host cells, including bacteria, plant, animal and human.

Viruses inject their genetic material into the DNA of host cells and manipulate them to manufacture millions of new virus particles. And to ensure the efficient spread of the newly produced virus particles, the coughing and sneezing of human flu sufferers send droplets of virus-laden mucous streaming into the air and onto human skin, including mouths or noses of people nearby, and other surfaces. Dr. Dennis Clements, a professor of pediatrics and infectious diseases at Duke University, estimates that a single sneeze can send flu-infested water droplets as far as three feeti.

Equipped with a mode of transportation to new, fertile host cells, the virus thrives, even if, statistically speaking, most organisms fight the infection successfully. Most important to the virus’ survival, it is on the move, ever seeking and infecting new hosts.

Outsmarting the Flu Virus With Chlorine Bleach

Although viruses require live host cells to multiply and spread, they can live on inanimate surfaces for up to two hours or more, giving them a convenient window of opportunity to be picked up by unsuspecting organisms, namely, us. Likely points of infection are commonly touched surfaces: doorknobs, desks, counters, dials and handles. Managing the viral populations on these surfaces is an effective way to cut down on the spread of flu. Chlorine bleach is a logical germ-busting, readily available product to turn to for this task. It works by penetrating the protective shells of viruses.

An EPA-registered chlorine bleach solution or a dilute solution of regular laundry bleach (1/4 cup of bleach in a gallon of cool water) is an effective and inexpensive all-purpose disinfectant, used commonly in homes and healthcare facilities. Some health clubs keep spray bottles of chlorine bleach solution on hand for members to use to disinfect exercise equipment. The active ingredient in chlorine bleach, sodium hypochlorite, is one of the chlorine disinfectants routinely added to municipal drinking water to control waterborne disease. Since the introduction of water chlorination to the U.S. in 1908, death rates due to typhoid fever, cholera and hepatitis A have declined dramatically. In addition to water disinfection, chlorine bleach solutions are approved by the Environmental Protection Agency (EPA) and the Department of Agriculture (USDA) for use in safe food production, including food preparation and service in healthcare facility kitchens and cafeterias. Chlorine bleach is used routinely to kill common food pathogens such as Campylobacter, Salmonella and E. coli.

The Chlorine Bleach Surface Disinfectant formula

¼ cup chlorine bleach 1 gallon cool water

Mix and apply to surfaces. Leave wet for 10 minutes. Rinse.

A recent study by the National Institute of Nursing Research showed that hot water and bleach are more effective in reducing viral infections, such as flu, than antibacterial products. This is not unexpected because antibacterial products work only on bacteria, whereas bleach destroys both viruses and bacteria. According to the study’s author, Dr. Elaine Larson, PhD, RN, Associate Dean for Research at Columbia University’s School of Nursing, households reporting bleach use for laundry at the beginning of the study experienced approximately one-fourth the rate of infection of households that did notii.

Children And Flu: Special Considerations

According to the U.S. Department of Education, approximately one-fifth of the U.S. population attends or works in schools. Additionally, large numbers of American families rely on day care facilities for full-time or after-school child care.

Compared to adults, children have fewer antibodies for fighting off illness, which allows viruses to multiply more quickly in children’s bodies. With more viruses in their bodies, youngsters can spread viruses more easily. Children under age two often suffer gastrointestinal problems when they are infected with the flu, and their stool contains the virus. Add to this the less-than-perfect hygiene practiced by many young children, and the risk of infection from contact with youngsters rises.

The CDC has issued advice for preventing the spread of flu in childcare settings. In addition to vaccinating all children between six and 23 months of age, recommendations include teaching proper hand washing and keeping childcare environments clean. Frequently touched surfaces, such as toys and other commonly shared items, should be disinfected daily with either an EPA-registered hospital disinfectant or EPA-registered chlorine bleach solution. According to the recommendations, if an EPA-registered chlorine bleach is not available, generic chlorine bleach may be used by mixing ¼ cup chlorine bleach with 1 gallon of cool water.

Getting Through Flu Season With the Help of An Old Friend

From farm animals to humans

Influenza virus ultimately originates in farm animals from which it is transferred to humans. For centuries, people noticed that flu outbreaks coincide with epidemics in pigs, ducks and horses. Human influenza probably dates back to 2000-5000 B.C.-the time of domestication of these animals. The virus owes its longevity to an ability to incorporate small changes, or mutations, as it shuttles between humans and domesticated animals.iii

Understanding how viruses use us to sustain their existence in the great web of life is an aid to developing the best flu risk management plan possible. Getting a flu shot, limiting contact with the infected, washing hands frequently and thoroughly, and mixing up an effective germ-busting solution of water and familiar household laundry bleach will go a long way to protecting us from nature’s seasonal flu scourge.

Flu Statistics

  • The time from when a person is exposed to flu virus to when symptoms appear is about one to four days, with an average of about two days.
  • The US normally vaccinates a larger proportion of its population than any other country except Canada.
  • Two-thirds of the US supply of flu vaccine usually goes to adults between 18 and 65. Yet 90 percent of deaths from flu occur in those over 65 years of age.
  • On average, approximately five to twenty percent of US residents get the flu, and more than 200,000 persons are hospitalized for flu-related complications each year.
  • The yearly death toll in the U.S. from flu varies from 17,000 to 51,000.

i Weigl, A., (2004, Oct. 14). Staying safe: Precautions can help cut the risk, newsobserver.com. On-line. Available: http://newsobserver.com/news/v-printer/story/1730341p-7996185c.html

ii Wart, P.J. (2004, Oct. 12). The virus fighting duo: Hot water and bleach, HEALTH Plus Health and Wellness, Vanderbilt University. On-line. Available: http://vanderbilttowc.wellsource.com/dh/cotent.asp?ID=1388

iii Karlen, A. (1995). Man and Microbes: Disease and Plagues in History and Modern Times. New York: Simon & Schuster.

What are the Costs/Benefits of Global Water and Sanitation Improvements?

Taking Water and Sanitation Coverage for Granted

Every day millions of North Americans freely flush their toilets, liberally run the faucet or relax under the steady stream from a warm shower. To many North Americans these activities are not considered luxuries, but basic functions of everyday life. Yet, for some in Africa or Asia it is a daily struggle to find a single cup of clean water. Nearly 40 percent of Africa has an unsafe water supply and poor sanitation coverage and in Asia, more than half the population is exposed to unsanitary conditions, according to a study conducted in 2000 by the World Health Organization (WHO) and UNICEF. The effects are demonstrable. According to the WHO, water-borne diseases spawned from unsanitary conditions resulted in roughly 1.6 million deaths in 2003, of which 90% were children under five. In addition, roughly 1.1 billion people are without access to safe water sources and 2.4 billion people lack access to improved sanitation. The following table crystallizes this global disparity in access to water supply and sanitation coverage.

Table 1: Water and Sanitation Coverage By Region
Coverage (%)
Water Supply
Latin America & Caribbean
North America
Source: WHO/UNICEF, 2000

In response to these startling statistics, the United Nations Millennium Declaration established goals to halve the proportion of people without sustainable access to both improve water supply and improved sanitation by 2015.

The WHO commissioned the Swiss Tropical Institute (Institute) to conduct a comprehensive cost/benefit analysis of improved access to safe water supply and the subsequent health, economic, education and cultural benefits. The Institute recently completed its report, “Evaluation of the Costs and Benefits of Water and Sanitation Improvements at the Global Level” (to read the complete report, please go to http://www.who.int/water_sanitation_health/wsh0404/en/).

The Institute’s findings are clear: Increased access to “improved” water supply and sanitation coverage is directly related to the level of financial investment. The more money invested globally, the greater access to safe drinking water and sanitation coverage for the impoverished. Furthermore, achieving global water supply and sanitation goals would yield quantifiable benefits far exceeding the financial investments required.

What Constitutes “Improved?”

For purposes of their analysis, the authors focused on low technology improvements and defined “improved” water as water supply that involves better access and protected water sources, resulting in a significantly increased probability that water is safe and more accessible. “Improved” sanitation is quantified as better access and safer disposal of excrement. Using the above definition of “improved,” WHO identified five intervention goals and their corresponding costs, as outlined in Table 2.

Table 2

Intervention Goals
Costs (US$/per annum)
1.) Reducing by half the number of people without sustainable access to improved water supply.
$1.78 billion
2.) Reducing by half the number of people without sustainable access to both improved water supply and sanitation.
$11.3 billion
3.) Access for all to improved water and sanitation services.
$22.6 billion
4.) Household water treatment using chlorine and safe storage would cost an additional $2 billion on top of access for all to improved water and sanitation services.
$24.6 billion
5.) Access for all to regulated in-house piped water supply with quality monitoring and in-house sewage connection w/partial treatment of sewage.
$136.5 billion

The figures cited above fluctuate greatly depending on the access targets. For example, the table clearly illustrates that a high level of funding is required, $136.5 billion per annum, to secure “access for all to regulated in-house pipe water supply with quality monitoring and in-house sewage connection w/partial treatment of sewage.” Yet, the table shows that even a modest investment of $1.78 billion per annum can go a long way towards increasing access to safe water by reducing in half the number of people without sustainable access to improved water supply.

While Intervention Goal 2 requires an additional investment of approximately $10 billion annually, the benefits justify the expense. According to the WHO, Intervention Goal 2 would reduce diarrhea episodes by 10 percent and provide a global economic benefit of $84 billion.

Overall, the WHO believes that “careful consideration of all benefits and all costs of water and sanitation projects will tip the balance in favor of positive investment decisions.”

Health Benefits of Safe Water Supply and Sanitation Coverage

While policy decisions are closely tied to their expense, the underlying concern of limited access to safe water supply and sanitation coverage is the incalculable cost of human life. Most prevalent with water-borne diseases is infectious diarrhea. In fact, the WHO found that a reduction in the number of episodes of diarrhea and the resultant reduction in the number of deaths were directly tied to access to safe water supply and sanitation services (Table 3). Clearly, the health impact of “improvements” will vary from region to region.

Table 3:

Intervention Goals
Global Diarrhea Reduction
Intervention 1 (water only)
4% (episodes)
Intervention 2
10% (episodes)
Intervention 3
16.7% (episodes)
Intervention 4
53% (episodes)
Intervention 5
69% (episodes)

Economic Benefits of Safe Water Supply and Sanitation Coverage

The economic benefits of improved access to a safe water supply and sanitation coverage are extensive. Healthcare constitutes a considerable expense, particularly in nations where access to healthcare is limited. For example, if access to safe water and sanitation coverage were improved there would be a smaller frequency of diarrhea cases. As a result, patients would avoid costs accrued with treatment expenditures, such as care, drugs, transportation and time spent seeking care.

There are four distinct groups that stand to receive direct economic benefits from water and sanitation improvements: the health sector, patients, consumers and agricultural and industrial sectors. Realized direct benefits for these groups include less expenditure on treatment of diarrheal disease, less expenditure on transport in seeking treatment, less time lost due to treatment seeking. While indirect benefits would include the value of less health workers falling sick with diahrrea, avoided days lost at work or at school, avoided time lost of parents/caretakers of sick children and avoided deaths. The total economic benefits of interventions are impossible to ignore (Table 4).

Table 4:

Intervention Goals
Economic Benefits
(US$ year 2000)
Intervention 1
$18.143 billion
Intervention 2
$84.4 billion
Intervention 3
$262.879 billion
Intervention 4
$344.106 billion
Intervention 5
$555.901 billion

The WHO report validates the premise that “improved” access to safe water supply and sanitation coverage would bear health care related benefits that would significantly reduce global healthcare costs. This analysis concluded that every $1 US invested would yield an economic benefit ranging from $3 to $34 US depending on the region. Further, additional improvements to drinking water quality, “such as point of use disinfection” would portend benefits varying from $5 to $60 US for every $1 US invested.


Water-borne diseases have plagued the global population for centuries. Unfortunately, many people remain exposed to the pathogens that trigger these deadly illnesses. The WHO analysis of this issue is not complex: increased funding to improve access to safe water and sanitation will go a long way towards eradicating this problem. Different intervention strategies have been captured to provide policy makers with guidance. As is generally the case, those who do not have a seat at the decision making table often do not have their voices heard. Clean water and sanitation is not a privilege, it is a right.

Avian Influenza – How Serious is the Threat to Human Health?

For the past several months, news reports have centered on a specific strain of avian influenza, H5N1, and its role in the deaths of 32 people in Vietnam and Thailand and tens of millions of birds in Asia.

Coupled with widely reported comments by Dr. Shigeru Omi, regional director for Asia and the Pacific with the World Health Organization (WHO), concern has mounted that a possible global pandemic of avian influenza could emerge, threatening the lives of millions.

A December 8, 2004 statement on the WHO’s web site ominously reinforced the concern:

“Influenza pandemics are recurring and unpredictable calamities. WHO and influenza experts worldwide are concerned that the recent appearance and widespread distribution of an avian influenza virus, Influenza A/H5N1, has the potential to ignite the next pandemic.”

What is Avian Influenza?

First identified 100 years ago in Italy, avian influenza is an infectious disease found mainly in chickens, ducks and other birds. There are 15 virus subtypes. Most influenza viruses cause mild infection in birds yet the range of symptoms in birds varies greatly depending on the strain of virus. Infection with certain avian influenza A viruses, H5 and H7 strains, can cause widespread disease and death among some species of wild and especially domestic birds.

Yet what alarms health officials is how these viruses mutate into highly pathogenic viruses. In fact, influenza A viruses H5 and H7 have been identified as being responsible for several outbreaks due to their highly pathogenic nature. Two epidemics in the last 20 years illustrate the virus’s potency and its impact on the bird population.

Virus Strain
Epidemic Length
6 months
17 million birds dead or destroyed
9 months
13 million birds dead or destroyed

Avian Influenza, H5N1 and Humans

Typically, avian influenza viruses do not infect species other than birds and pigs but in the last ten years there have been three documented outbreaks of human infection. All of the human cases have involved the H5N1 strain.

The H5N1 strain mutates rapidly and is capable of acquiring genes from viruses, thereby infecting other animal species. As a result, the spread of infection in birds increase the opportunities for direct infection to humans. Symptoms of avian influenza in humans have ranged from typical influenza-like symptoms (e.g., fever, cough, sore throat and muscle aches) to eye infections, pneumonia, acute respiratory distress, viral pneumonia, and other severe and life-threatening complications.

The first confirmation of the avian influenza H5N1 strain infecting humans was cited in Hong Kong in 1997. In this particular instance, the H5N1 strain caused severe respiratory disease in 18 humans, resulting in six deaths. Health officials believed that the infection in humans was propelled by a concurrent epidemic of a highly pathogenic avian influenza in Hong Kong’s poultry population.

An investigation revealed that the source of the outbreak and subsequent human infection was the close contact between live infected poultry and humans. This link was confirmed by studies at the genetic level, which showed that the virus had been transmitted directly from birds to humans. Many experts believed that a pandemic was fortunately averted, by the rapid destruction – within three days – of Hong Kong’s entire poultry population, estimated at around 1.5 million birds.

To global health officials this was a seismic event. For the first time it was realized that the deadly avian influenza virus had the capability to wreak its havoc on humans. A second far more minor H5N1 avian influenza outbreak took place in February 2003 resulting in the death of one person in Southern China.

While anecdotal evidence of human infection by avian influenza was supported by the two aforementioned outbreaks, laboratory research also showed that isolates from this virus had caused severe disease in humans because of the virulent composition of their pathogens. In addition, birds that survived infection and excreted the virus for at least 10 days, either orally or through their feces, facilitated spread of the virus.

In mid-December of 2003 a third epidemic of the highly pathogenic avian influenza of H5N1, was identified in the Republic of Korea. This epidemic has spread to other Asian countries, causing considerable concern among world health officials.

What is the Threat of Human to Human Transmission?

H5N1 variants have demonstrated a capacity to directly infect humans. Of the 32 human deaths in 2004 attributed to this most recent epidemic, only one has been verified as stemming from human-to-human transmission, according to data from the WHO (the only instance of human-to-human transmission of the 32 human deaths in 2004 involved a mother who had cradled her dying daughter all night).

With the human death toll from this latest epidemic showing no signs of abating, agreement exists in the global health community of the risk for further casualties. Dr. Omi’s recent comment that a global pandemic is “very, very likely” marked the first time a health official had publicly voiced such concern.

While Dr. Omi is not alone in his worry about a possible pandemic, some scientists are not as prepared to publicly sound alarm and question the potential ease with which an outbreak could take place. Dr. Mark Peiris, a top influenza researcher at Hong Kong University, told the New York Times last month that he wondered whether the disease could maintain its lethalness and ability to readily transmit from human to human.

Health officials believe that there are several reasons why the virus could be spread from human to human.

  • The virus has proved quite adept at mixing genetic material with other viruses
  • The disease has begun to survive in domesticated ducks making it harder for farmers to identify which animals to destroy
  • If more humans become infected over time, the likelihood also increases that humans, if concurrently infected with human and avian influenza strains, could serve as the “mixing vessel” for the emergence of a novel subtype with sufficient human genes to be easily transmitted from person to person.

As the year 2004 comes to a conclusion, disconcerting signs continue. Just two weeks ago, a dead gray heron was found near Hong Kong’s border with China and tested positive for avian influenza. Health officials are bracing themselves for an uncertain year ahead.

Given the current threat, WHO has urged all countries to develop or update their influenza pandemic preparedness plans for responding to the widespread socioeconomic disruptions that would result from having large numbers of people unwell or dying.

For further information from the WHO regarding avian influenza, please go to: http://www.who.int/csr/disease/avian_influenza/en/

Washington Update

Winter Newsletter 2005

EPA Reports on Water Security Progress
On September 30th, the U.S. Environmental Protection Agency’s (EPA) top water official has reported “good news” to a subcommittee of the U.S. House of Representatives on agency efforts to improve security on nationwide water and wastewater systems.

The House Committee on Energy and Commerce heard testimony from Acting Assistant Administrator for Water, Benjamin Grumble on the EPA’s nationwide improvements on security of water utilities and wastewater systems. Grumble credited administrators of U.S. water systems for a “remarkable” response to the 2002 congressional mandate to submit vulnerability assessments, adopt security measures and certify completion of updated emergency response plans (ERPs). Grumbles reported that water systems serving a collective 230 million people have completed vulnerability assessments.

The EPA reported that it will devote additional resources to public water and wastewater security to identify the best technologies and practices, strengthen partnerships and information-sharing capabilities, and provide ERP training. In addition, the U.S. Department of Homeland Security will expand its secure counter terrorism communications network to include the energy and water infrastructure sectors.

For a copy of Benjamin Grumble’s September 30th testimony, please go to

Technology Program Aims to Improve Water Quantity, Quality
A bipartisan group of U.S. Senators and Members of Congress introduced legislation to create a federal water technology program designed to address the issue of regional droughts. The “Department of Energy National Laboratory Water Technology Research and Development Act of 2004” seeks to expand and coordinate water technology research across the country and improve water quality and quantity in regions susceptible to drought conditions.

The bill calls for the formation of a partnership between the Department of Energy national laboratory system and universities to design and deploy technologies that would provide more clean water for residential, commercial, industrial and natural resource use nationwide.

Under the proposal, an annual appropriation of $200 million would be authorized for basic and applied research and development of water supply technologies.

For a reading of the bill, please go to http://www.theorator.com/bills108/s2658.html

EPA Issues New Lead and Copper Guidance
On November 23rd, the U.S Environmental Protection Agency (EPA) issued a guidance memorandum based on its ongoing national review of the 1991 Lead and Copper Rule (LCR). It reiterates and clarifies several requirements regarding the collection of at-the-tap water samples and how to use them to determine LCR compliance. The official memorandum from the EPA’s Office of Water addresses issues the agency has determined to be confusing and inconsistently applied by states and water utilities.

The guidance memo includes a chart detailing sampling-site classification requirements for community and “non-transient/non-community” systems. The new LCR guidelines provide that states must calculate compliance even if the minimum number of samples are not collected. Utilities that fall short of the guideline requirements will incur a monitoring and reporting violation, may be subject to fine, and are required to notify the public of current water issues in their community.

Critics suggest that confusing and inconsistent regulations governing at-the-tap water sample tests have been a contributing factor in non-compliance with the 1991 rule over the past decade. The new LCR guidelines were developed to help state officials accurately calculate compliance with established baseline regulations, aiding the overall effort to improve public drinking water quality.

For a copy of the EPA memorandum, please go to: http://www.epa.gov/safewater/lcrmr/pdfs/memo_lcmr_samplingrequirements_1104.pdf

Airlines Agree to New EPA Drinking Water Tests
In November, as a response to the recent discovery of the coliform bacteria in the drinking water of one in every eight commercial airplanes tested, the U.S. Environmental Protection Agency (EPA) initiated a new water quality inspection procedure for aircraft. The EPA announced commitments from 12 major U.S. passenger airlines to implement new aircraft water testing and disinfection protocols.

In August and September, the EPA tested drinking water aboard 158 randomly selected domestic and international aircraft and found 12.6 percent did not meet federal standards. EPA initiated additional water quality testing on 169 randomly selected domestic and international passenger aircraft at 14 airports throughout the United States. Those results will be available to the public by early January 2005.

The current interim agreements call for airlines to provide comprehensive monitoring data from every aircraft in each airline’s fleet. While baseline data is being collected, the airlines are obligated to perform quarterly disinfection and flushing of aircraft potable water systems. EPA says that the newly adopted protocols will further protect the traveling public while existing guidelines for the handling, storage and use of potable water aboard passenger aircraft are reviewed and new regulations are developed.

For more information on the regulation of water supplies aboard passenger aircraft and to view the publicly available data, please go to: http://www.epa.gov/airlinewater.

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