Microbial Risk Analysis 5 (2017) 314

Contents lists available at ScienceDirect

Microbial Risk Analysis

journal homepage: www.elsevier.com/locate/mran

Evaluation of microbiological risks associated with direct potable reuse

Jeffrey A. Soller a,, Sorina E. Eftim b, Isaac Warren b, Sharon P. Nappier c
a
Soller Environmental, LLC, 3022 King St., Berkeley, CA 94703, USA
b
ICF International, 9300 Lee Highway, Fairfax, VA 22031, USA
c
U.S. Environmental Protection Agency, Oce of Water, 1200 Pennsylvania Avenue, NW, Washington, DC 20460, USA

a r t i c l e i n f o a b s t r a c t

Article history: This work evaluates the potential microbial risks associated with various direct potable reuse (DPR)
Available online 31 August 2016 treatment train combinations for recycled water. The assessment methodology leverages readily avail-
able peer-reviewed pathogen density and treatment process removal data and extends a previously pub-
lished statistical approach. The results illustrate clear quantitative human health-based advantages for
DPR projects in which product water is introduced into the raw water supply upstream of a conven-
tional drinking water treatment facility, compared to those in which product water is introduced directly
into a potable water supply distribution system. The results also indicate that a single day can drive an-
nual risks, highlighting the need for robust and reliable on-line monitoring of unit treatment processes
within DPR facilities. The methodology is adaptable to other DPR treatment trains and could be itera-
tively rened as additional data become available. This work will be useful to federal and state regulators
considering DPR as source water, state and local decision makers as they consider whether to permit a
particular DPR project, and design engineers as they consider which unit treatment processes should be
employed for particular projects.
2016 Elsevier B.V. All rights reserved.

1. Introduction
As population growth, urbanization, droughts, and climate
change continue to impact natural resources, water reuse is
an increasingly important water supply option worldwide. For
example, in 2009 the State of California approved a Recycled
Water Policy, with the goal to increase the use of recycled wa-
ter, over 2002 usage levels, by 2 million acre-foot/year by 2030
(Tchoganoglous et al., 2011). Moreover, there is a growing interest
and willingness to use recycled wastewater as a drinking water
source (WRRF, 2015; Richmond, 2016). The introduction of recy-
cled wastewater into a potable water supply has, to date, most
commonly included an environmental buffer, such as an aquifer or
surface water reservoir. This reuse strategy is referred to as indirect
potable reuse (IPR). Interest is also growing in direct potable reuse
(DPR) in which recycled water is introduced into a potable water
supply distribution system or into the raw water supply immedi-
ately upstream of a conventional drinking water treatment facility,
without inclusion of an environmental buffer (WRRF, 2015).
Currently, there are no national regulatory recommendations
in the United States for the potable reuse of water. Nevertheless,
States such as Texas, New Mexico, Arizona, California, and Virginia
Corresponding author.
E-mail address: jsoller@sollerenvironmental.com (J.A. Soller).
have been asked to permit recycled water projects and munici-
palities are moving forward with IPR and DPR projects that use
a variety of multiple barrier treatment strategies for contaminant
removal (Dahl, 2014). For example, California has developed mi-
crobial regulations for groundwater replenishment IPR projects.
Californias groundwater IPR regulations include a requirement
of 12-log removal of enteric viruses, and 10-log removal of Cryp-
tosporidium spp. and Giardia (also known as the 12-10-10 Rule ),
using at least three treatment processes (from wastewater treat-
ment through advanced treatment) with no single process allowed
a credit greater than 6-log (CDPH, 2011; NWRI, 2013). California
may also use this 12-10-10 Rule for IPR surface water augmenta-
tion regulations and is considering statewide DPR regulations. The
12-10-10 pathogen log-reduction values are based on a risk goal
of 1 infection per 10,0 0 0 people per year and are derived from the
maximum reported densities of culturable enteric viruses, Giardia
lamblia, and Cryptosporidium spp. found in raw sewage (Macler and
Regli, 1993; U.S. EPA, 1998; Tchobanoglous et al., 2003; Sinclair
et al., 2015). Recent literature, however, suggests that different
reference viruses and new dose-response models also should be
considered in the aforementioned log-reduction goal calculations
(Pouillot et al., 2015; Messner and Berger, 2016; Messner et al.,
2014; Teunis et al., 2008).
For DPR projects in the State of Texas, the minimum log
removal and/or inactivation targets are 8-log for enteric virus,
5.5-log for Cryptosporidium spp., and 6-log for Giardia for the ad-

http://dx.doi.org/10.1016/j.mran.2016.08.003
2352-3522/ 2016 Elsevier B.V. All rights reserved.
4 J.A. Soller et al. / Microbial Risk Analysis 5 (2017) 314
vanced treatment system (not including the wastewater treatment
plant). These targets are considered a starting point for the ap-
proval process and may be revised on a case-by-case basis taking
into consideration data collected from the wastewater euent
in question. Texas also uses a health risk goal of 1 infection per
10,0 0 0 people per year as a benchmark (TWDB, 2014).
Due to nature of the source water for DPR, there is a need to
quantitatively evaluate the health risks associated with exposure
to microbial contaminants resulting from implementation of the
various multi-barrier treatment strategies under consideration.
Given the low levels of target pathogens in product water that
would be needed to comply with the health goals (i.e., 107
L1 ), it is not feasible to determine whether adequate treatment
is occurring via monitoring product water for pathogens from
advanced water treatment facilities (AWTF) (Regli et al., 1991).
To our knowledge, a quantitative evaluation of the micro-
bial risks associated with the various multi-barrier IPR and DPR
treatment strategies has not been conducted. To address this
need, we applied and extended the probabilistic modeling ap-
proach suggested by Haas and Trussell (1998) and demonstrated
by Olivieri et al. (1999). The objectives of this work are to: 1)
document reference pathogen occurrence in raw wastewater and
removal from various wastewater, AWTF, and drinking water
unit treatment processes; 2) provide a methodology that can be
used and updated for evaluating the microbial risks of infection
associated with reference pathogens from DPR treatment trains
(TT); and 3) provide context regarding the adequacy of the State
log reduction goals under consideration for DPR.
2. Methods
2.1. DPR treatment trains
This study encompasses four representative AWTF TT con-
gurations that could be considered for DPR projects. These
congurations are consistent with those recommended by the
National Water Research Institute (NWRI) DPR expert panel
(NWRI, 2013; NWRI, 2015). For three of the congurations (TT 13,
Fig. 1), the DPR product water was assumed to directly enter the
drinking water distribution system after AWTF treatment. In the
fourth conguration (TT4, Fig. 1), DPR product water undergoes
further treatment via a conventional drinking water treatment
plant (DWTP) prior to entering the community drinking water
distribution system. Additionally, municipalities and States are
interested in identifying and evaluating treatment schemes that
do not include reverse osmosis (RO) due to the diculty and costs
associated with disposal of RO brine concentrate (TWDB, 2014).
Therefore, congurations without RO are also included in the
analysis (TT3 and TT4, Fig. 1).
TT1 is dened as a conventional activated sludge wastewater
treatment plant (WWTP) that produces non-disinfected secondary
euent used as the feed water to an AWTF. The AWTF consists
of microltration (MF), RO, advanced oxidation (UVAOP) (UV and
hydrogen peroxide quenching), and an engineered storage buffer
(ESB) with free chlorine disinfection (ESBCl). TT2 uses the same
conventional secondary WWTP as the feed water to an AWTF
that consists of ozonation, biologically active ltration (BAF), MF,
RO, and UVAOP. TT3 uses the conventional secondary WWTP
as the feed water to an AWTF that consists of ozonation, BAF,
ultraltration (UF), UVAOP, and an ESBCl. TT4 is TT3 followed by
a conventional DWTP comprised of occulation, sedimentation,
ltration, and disinfection via chlorination. This DWTP does not
specically address taste and odor, iron and manganese reduction,
and/or the need to reduce disinfection by-product formation, all
of which require enhanced water treatment that would be specic
to the source water.
Alternatives to the above base TT congurations were also
considered to evaluate the potential public health implications of
DPR design choices. In one alternative, the ultraviolet (UV) disin-
fection unit processes are assumed to be operated in a manner
consistent with conventional wastewater treatment disinfection
(dose of 12 mJ/cm2 or less), rather than the use of UVAOP (dose
of 800 mJ/cm2 ) typically employed for the purposes of disinfection
by-product destruction. Each of the base TT congurations is
considered for this alternative. In a second alternative, the impact
of pathogen dose-response selection is evaluated by using recently
published dose-response relationships for two of the reference
pathogens, norovirus (NoV) and Cryptosporidium spp. (Messner and
Berger, 2016; Messner et al., 2014). TT1a and TT1b (Fig. 1) base
congurations are evaluated with the alternative dose-response
models.
2.2. Pathogens
The reference pathogens in this study include NoV, aden-
ovirus (AdV), Cryptosporidium spp., Giardia lamblia, Campylobacter
jejuni, and Salmonella enterica. Together these pathogens make
up a large portion of all non-foodborne illnesses from known
pathogens in the United States (calculated based on data from
Mead et al. (1999) and Scallan et al. (2011)), are representative
of other pathogens potentially of concern from the waterborne
exposure route (Soller et al., 2010a,b; U.S. EPA, 2012, 2014), and
have published corresponding dose-response relationships (Teunis
et al., 2008; Crabtree et al., 1997; Teunis et al.; 2005; Haas
et al., 1999; U.S. EPA, 2006a). The use of reference pathogens is
an accepted practice in the eld of Quantitative Microbial Risk
Assessment (QMRA) (Regli et al., 1991; U.S. EPA, 2014; Roser and
Ashbolt, 2007; Schoen et al., 2011; Soller and Eisenberg, 2008;
Soller et al., 2003) to represent the potential adverse health effects
of members of each broader microbial group, as well as the infec-
tivity of known and unknown members of each microbial group
(WHO, 2004). The corresponding standard dose-response models
and parameter values are summarized in Table 1, along with re-
cently published newer dose-response models for Cryptosporidium
spp. and NoV (Messner and Berger, 2016; Messner et al., 2014).
The dose-response relationship for Campylobacter is based on an
outbreak study for which doses were inferred rather than mea-
sured (Teunis et al., 2005). It suggests much higher infectivity than
a previous clinical trial studys interpretation for which doses were
measured (Medema et al., 1996). This dose response relationship
was selected here as a precautionary approach to ensure that the
risk of infection from Campylobacter was not underestimated. As
indicated above, the relative impact of the dose-response relation-
ship selections are evaluated through sensitivity analyses using
methods published previously (Soller et al., 2015a).
2.3. Treatment ecacy of DPR unit processes for pathogens
Peer-reviewed literature were collected and summarized to
characterize the density of each of the reference pathogens in raw
wastewater and the reduction of each of the reference pathogens
across each of the individual unit treatment processes under con-
sideration (Fig. 1). For each unit process that is dose dependent
(such as disinfection via UV light, ozone, and free chlorine), a
xed dose was selected and applied for all pathogens across that
particular unit process (discussed below in the results section).
The reduction of each pathogen across each of the unit processes
was generally assumed to follow a uniform distribution of the log
reductions with minimum and maximum values consistent with
the literature review ndings (Eisenberg et al., 20 02, 20 06). While
the literature review captures representative reductions of each
reference pathogen across each unit process, it is not intended
 J.A. Soller et al. / Microbial Risk Analysis 5 (2017) 314 5

Treatment train 1.

Wastewater
Treatment
MF RO UV ESB + Cl2

Treatment train 2.

Wastewater O3
Treatment BAF MF RO UV

Treatment train 3.

Wastewater O3 BAF UF UV ESB + Cl2

Treatment

Treatment train 4.

Wastewater
O3 BAF UF UV ESB + Cl2
Treatment

Flocculaon/
Cl2 Filter Sedimentaon

Fig. 1. DPR treatment trains evaluated, legend: MF Microltration, RO Reverse Osmosis, UV Ultraviolet disinfection, ESB + Cl2 Engineered Storage Buffer with Free
Chlorine (ESBCl), O3 Ozonation, BAF Biologically Active Filtration, UF Ultraltration, Cl2 Disinfection via chlorine.

Table 1
Dose-response models and parameter values.

Reference pathogen Dose-response model Equation2 Parameter values

Adenovirus Exponential (Crabtree et al., 1997) 1 erd 0.4172

Campylobacter jejuni Hypergeometric (Teunis et al., 2005) 1-1 F1 ( , + , d ) 0.024, 0.011
Cryptosporidium spp. Exponential (U.S. EPA 2006a) 1 erd 0.09
P ( 1 e )
d
Fractional Poisson (Messer and Berger, 2016)1 0.737, 1
Giardia lamblia Exponential (Haas et al., 1999) 1 erd 0.0199
Norovirus Hypergeometric (Teunis et al., 2008) 1-1 F1 ( , + , d ) 0.04, 0.055
P ( 1 e )
d
Fractional Poisson (Messer et al., 2014)1 0.72, 1106
Salmonella enterica Beta-Poisson (Haas et al., 1999) 1 (1 + d ) 0.3126, 2884
1
Used in sensitivity analysis.
2
In equations d represents dose.

to be exhaustive. These data and associated distribution can be
updated in the future as additional data become available.
2.4. Numerical simulations
A stochastic, static QMRA methodology was used to estimate in-
fection from pathogenic microorganisms through ingestion of DPR
product water for the DPR TTs described above (Soller and Eisen-
berg, 2008). Individuals are assumed to ingest a xed amount of
ingested was estimated to be 2.5 L/d which represents the 90th
percentile of per capita water ingestion for adults (U.S. EPA, 2011).
This ingestion value is intentionally precautionary. The estimated
daily concentration of each pathogen in the DPR product water
is computed as the product of randomly selected raw wastewater
pathogen density and randomly selected attenuation values across
each unit process following the approach originally suggested by
Haas and Trussell (1998).

n

product water daily. This overall approach, referred to as quantita- RPProducti = RPIn f luenti x 10W W _RPi x 10DPRUnit Pr ocess_RPi (1)
tive relative risk assessment, has been used previously for the pur- 1

pose of evaluating the relative risks associated with recycled water
projects (Soller et al., 2015b, 20 0 0; Soller and Nellor, 2011a,b).
Two-step Monte Carlo numerical simulations (Fishman, 1995)
were conducted using Mathcad v13 (PTC, Inc.). For each TT, the
rst step was to compute an array of daily risk estimates (n = 365)
for each reference pathogen. Pathogen specic daily risks (RPrisk )
are computed through standard QMRA calculations using the
estimated daily density of each pathogen in the DPR product
water, the volume of water ingested, and the corresponding dose-
response relationships (Haas et al., 1999). The volume of water
Where
RPProducti = Reference Pathogen (i) concentration in DPR case
study product water
RPInuenti = Reference Pathogen (i) concentration in raw wastew-
ater
WW_RPi = Reduction (log10 units) of Reference Pathogen i
across conventional wastewater (WW) (starting with raw wastew-
ater and including treatment through secondary treatment)
DPRUnitProcess_RPi = Reduction (log10 units) of Reference
Pathogen i across DPR unit process
6 J.A. Soller et al. / Microbial Risk Analysis 5 (2017) 314
n = number of DPR unit processes (case study specic Fig. 1)
Cumulative daily risks from all of the evaluated pathogens
were then computed as follows (Regli et al., 1991).
i
CumDailyRisk = 1
1
(1 R Pr iski )
Where
RPriski = Daily risk of infection from Reference Pathogen i
Those daily risks are then combined in a similar manner to
generate a single cumulative annual risk estimate:
365  
CumAnnualRisk = 1 1 CumDailyRisk j
j=1
The second step iterates the rst step 10 0 0 times to generate
a distribution of estimated annual risks. This assessment process
is repeated for each of the TT congurations and alternatives. The
cumulative annual risk distributions are then compared to the
benchmark risk level of 1 infection per 10,0 0 0 people per year for
nished drinking water (Macler and Regli, 1993; U.S. EPA, 1989).
We also determine whether there are statistically signicant differ-
ences between the results from various simulations using a Mann-
Whitney-Wilcoxon non-parametric test (Mann and Whitney, 1947).
3. Results
3.1. Literature review for pathogen densities and reductions across
unit treatment processes
Peer reviewed scientic literature were obtained to quantify
the density of reference pathogens in raw wastewater, and the
attenuation of each reference pathogen across each individual
unit treatment process. When disinfecting water with chlorine
or ozone, disinfection residual concentration (mg/l) multiplied by
contact time (min) (CT) is determined to indicate the achievement
of a desired treatment ecacy. When disinfecting water with ul-
traviolet light, a UV dose in mJ/cm2 is determined to indicate the
achievement of a desired treatment ecacy. Several factors can
affect disinfectant ecacy such as pH, temperature, and turbidity.
The studies reviewed did not typically detail all of these factors,
with exception of controlled bench-scale experiments. Based on
the range of doses and results found for each disinfection method,
a threshold dose that is representative of AWTF use was selected:
For chlorine, Ct of 12 mg-min/L or below is used; for UVAOP in
an advanced water treatment facility, a UV dose of 800 mJ/cm2
or below is used; for UV in a typical wastewater disinfection
application, a UV dose of 12 mJ/cm2 or below is used; and for
ozone, a threshold Ct of 1.0 mg-min/L or below is used.
Raw wastewater microbial densities. Cryptosporidium spp. has
been detected in US wastewaters in numerous studies. Cryp-
tosporidium spp. has been recognized to occur at levels as low
as 0.3 or high as 5.0 104 oocysts/L (Yang et al., 2015; Crockett,
2007; Harwood et al., 2005; Nasser, 2016). Giardia spp. den-
sities in raw wastewater range between 3.21.0 104 cysts/L
(Harwood et al., 2005; Sykora et al., 1991; Wallis et al., 1996).
Campylobacter spp. densities in raw wastewater range between
9.0 102 4.0 104 Most Probable Number (MPN)/L (Stampi et al.,
1993) and Salmonella spp. levels vary between 3.01.1 103 Colony
Forming Units (CFU)/L (Lemarchand and Lebaron, 2003). The
range of reported viral concentrations is wider than protozoa or
bacteria. To account for the wide variability in the literature of
NoV (Pouillot et al., 2015), a normal distribution for NoV based on
occurrence in raw wastewater was created - NoV concentrations
are estimated to be present at levels of 103.76 100.93 copies/L
(Eftim et al., 2016). Too few studies were available to develop
an occurrence distribution for AdV. Thus, a range of 566.9 103
Infectious Units (IU)/L for AdV was used (Eftim et al., 2016; Hewitt
et al., 2011; Hurst et al., 1988).
Conventional secondary wastewater treatment. There are numer-
ous approaches that can be used to produce secondary treated
wastewater. Most consist of physical removal, primary settling,
anaerobic and/or aerobic activated sludge biological treatment, and
(2) secondary clarication or settling. For this evaluation, secondary
treatment that does not include disinfection or ltration was
assumed. Activated sludge in an oxidation ditch or in extended
aeration tanks achieved 0.71.5-log reduction for Cryptosporidium
spp. and 0.51.5-log reduction for Giardia spp. (Cheng et al.,
2009). However, removals as high as 3.3-log are possible for
(3) Giardia spp., e.g., following activated sludge treatment (Taran-
Benshoshan et al., 2015). Conventional secondary treatment of
viruses can achieve 0.93.2-log removal of AdV and 0.83.7-log
removal of NoV (Pouillot et al., 2015; Francy et al.; 2012). Although
these published log removal values are used, it is noteworthy that
secondary treatment also has been reported to be ineffective at
removing some viruses and protozoa (WHO, 2006). Secondary
treatment of bacteria can achieve between 1.31.7-log removal
for Salmonella typhimurium (Zhou et al., 2015) and treatment
with trickling lters, activated sludge plants, and oxidation ponds
can achieve between a 0.62.0-log removal of Campylobacter spp.
(Whiley et al., 2013). Other bacteria can be more susceptible to
treatment and secondary wastewater treatment approaches vary
considerably. For example, secondary treatment can achieve log
removals as high as 3.0-log for enteric bacteria (EPHC NHMRC and
NRMMC, 2008) or 7.0-log for other bacteria (Rose et al., 2001).
Ozone disinfection (Ct less than 1.0 mg-min/L). U.S. EPA (1991)
guidelines for ozonation during drinking water treatment dene
temperature-dependent virus and Giardia disinfection credits for
ozone. Giardia spp. inactivation is greater than 3-log at 1.0 mg-
min/L ozone at 20 C, and virus inactivation is in excess of 4-logs
at the same dose. Results from laboratory studies appear to
support these guidelines. For example, ozone concentrations of
0.070.60 mg-min/L at 5 C and pH 7 achieved a 4-log reduction
of AdV in spiked, demand free water experiments (Thurston-
Enriquez et al., 2003). At least 2-log Giardia spp. inactivation was
observed at ozone doses of 0.17 mg-min/L at 25 C and 0.55 mg-
min/L at 5 C in an experiment using clinical specimens of Giardia
spp. (Wickramanayake et al., 1985). Exposure to 5 mg-min/L ozone
can achieve 1-log reduction of Cryptosporidium spp. (Korich et al.,
1990), which indicates Cryptosporidium spp. is more resistant than
Giardia spp. to ozone (U.S. EPA, 1991). Higher doses of ozone can
achieve log reductions of protozoa as high as 4-log (EPHC NHMRC
and NRMMC, 2008). Reviews that do not specify the ozone dose
suggest higher log removals are possible for viruses (WHO, 2006;
EPHC NHMRC and NRMMC, 2008; NRWI, 2013; Ishida et al., 2008).
In the absence of pathogen-specic data, NoV removal by ozone
was assumed to be equivalent to that of male-specic coliphage,
or 5.4 logs at 0.22 mg-min/L ozone (Tanner et al., 2004). Similarly,
log removal data for bacterial species are scarce, yet reviews
that do not specify the dose of ozone suggest that log removals
between 26-log are possible (WHO, 2006; EPHC NHMRC and
NRMMC, 2008). Given these uncertainties, and the availability of
log removal data for E. coli, Salmonella spp. and Campylobacter
spp. reductions are assumed to be equal those reported for E. coli,
which are 4-log reductions at CT values less than 1.0 mg-min/L
(Sigmon et al., 2015).
Biologically active ltration. Biologically active ltration treat-
ment typically includes sand or other lter media interspersed
with microbes, activated carbon, or diatoms. Of all treatment types
included in this study, the available data to characterize microbial
attenuation across biologically active ltration was the scarcest.
Thus, conventional ltration data of wastewater was used as a
surrogate.
Due to their large size, protozoa are more susceptible to
ltration than viruses. Dual-media ltration can reduce proto-
 J.A. Soller et al. / Microbial Risk Analysis 5 (2017) 314
zoa between 13-log (WHO, 2006; EPHC NHMRC and NRMMC,
2008). Reported reductions of Giardia spp. via sand ltration are
0.93.9-log removal (Taran-Benshoshan et al., 2015; Fu et al.,
2010). Reported reductions of Cryptosporidium spp. through sand
ltration are approximately 0.9-log reduction (Taran-Benshoshan
et al., 2015; Fu et al., 2010). These recently published values
are used as maxima for the simulations, along with minimum
conservative lower estimate reductions of 0-log, consistent with
the data reported by Rose et al. (2004).
Adenovirus was reduced 00.6-log by full-scale granular media
ltration during drinking water treatment (Linden et al., 2012) and
enterovirus was reduced by 1-log by sand ltration (Goddard and
Butler, 1980). In the absence of pathogen-specic data, removal
of NoV was assumed to be similar to enterovirus by sand ltra-
tion, with a minimum of 0-log as a conservative lower estimate.
Pilot-scale rapid sand contact ltration and biological-chemical
contact ltration can achieve 0.5 and 2-log reduction of Salmonella
spp., respectively (Koivunen et al., 2001). Campylobacter spp. were
assumed to have similar removal.
Microltration. MF, UF, and RO treatments are broadly dened
by their ltration media and pore size (i.e., with MF > UF > RO
based on the pore sizes). Reduction across these treatment
processes is typically roughly proportional to the size of the
pathogen. Bacteria and protozoa are removed more readily than
viruses, which are smaller but can adhere to suspended particles.
Pathogen-specic data are scarce for MF, UF, and RO, thus general
removal for each pathogen type are reported. MF can achieve
39-log removal of bacteria and 47-log removal of protozoa
(Reardon et al., 2005). MF in a membrane bioreactor can achieve
2.44.9-log removal of AdV and 1.53.3-log removal of NoV
(Francy et al., 2012). Reviews that do not specify the virus species
suggest that ltration can generally achieve between 0.56-log
removal of viruses (WHO, 2006; EPHC NHMRC and NRMMC, 2008).
Reverse Osmosis. RO achieves up to a 4-log removal of
Salmonella spp. bacteria (National Research Council, 2012),
which is also used for Campylobacter spp.. RO with pore sizes
of 0.0 0 010.0 01 m achieved between 2.76.5-log removal for
viruses (Smeets et al., 2006; Kruithof et al., 2001; Jacangelo et al.,
2005). Protozoa were conservatively assumed to have removals
equivalent to those of viruses.
Ultraltration. UF membranes of achieved removals for 5.69-
log for E. coli, 4.46.0-log for Cryptosporidium spp., and 4.77.4-log
of Giardia spp. (EPHC NHMRC and NRMMC, 2008; Jacangelo et al.,
1997; U.S. EPA, 2001; Kachelesky and Masterson, 1995). Salmonella
spp. and Campylobacter spp. removal were assumed to be equal to
that of E. coli. UF of secondary euent has been shown to achieve
4.5-log removal for NoV and 4.9 log removal of AdV (Qiu et al.,
2015).
Ultraviolet disinfection (UVAOP dose at800 mJ/cm2 and UV at
12 mJ/cm2 ). UV disinfection ecacy can vary due to several factors
such as temperature, pH, turbidity, UV transmittance, and UV lamp
pressure (U.S. EPA, 2012). Some microorganisms can associate
or bind to particles that shield them from UV light. After UV
disinfection, once microorganisms are exposed to visible light,
their cells can begin to repair DNA damaged by the UV light in a
process known as photo reactivation (U.S. EPA, 2012).
UVAOP disinfection is used as an AWT process for potable
reuse. In these advanced treatment applications, the most com-
mon purpose of this unit process is the destruction of disinfection
byproducts such as 1,4-dioxane and N-nitrosodimethylamine
(NDMA). For this purpose, UV doses in the range of approximately
800 mJ/cm2 are common. At 800 mJ/cm2 , greater than 6-log of
inactivation of each of the reference pathogens can be achieved
(Gerba et al., 2002; U.S. EPA, 2006b).
For disinfection of wastewater via UV light, pathogen inactiva-
tion is less than for UVAOP because signicantly lower doses of
7
UV light are applied. The U.S. EPA reviewed research studies to
determine Cryptosporidium spp., Giardia spp., and AdV inactivation
due to UV treatment (U.S. EPA, 2003). That review found that at
12 mJ/cm2 , Cryptosporidium spp. was reduced from 2.03.5-log,
Giardia spp. removal ranges were between 2.03.5-log, and AdV
levels were reduced by 00.5-log. Reviews that do not specify
the virus species or UV dose suggest that UV disinfection can
achieve between 13-log removal of viruses (WHO 2006, EPHC
NHMRC and NRMMC, 2008). Data on NoV reduction across UV
treatment in the range of 12 mJ/cm2 are sparse. Incremental mean
reduction due to UV treatment is reported to be on the order of
0.8-log (Pouillot et al., 2015; Lee and Shin, 2011). This estimate
is similar to other enteric viruses reductions at UV doses in the
range of 12 mJ/cm2 , which are in the range of approximately
0.51.5-log (U.S. EPA, 2003). Based on these data, NoV reductions
were estimated to be 0.51.5-log. UV disinfection at less than
10 mJ/cm2 can achieve removals of 4.0-log for E. coli (U.S. EPA,
2003). In the absence of pathogen-specic data, Campylobacter spp.
or Salmonella spp. removals are assumed to equal that of E. coli.
Conventional drinking water treatment. Full-scale conventional
drinking water treatment can achieve between 1.54.0-log re-
moval of Cryptosporidium spp. and 0.34.0-log reduction of Giardia
spp. (Linden et al., 2012; Betancourt and Rose, 2004). The lower
bound for Giardia spp. likely differs from Cryptosporidium spp. due
to differing test conditions between the cited studies, although
actual reductions for these two reference pathogens are likely
similar (U.S. EPA, 1991). Slow sand ltration conventional drinking
water treatment can reduce E. coli, Campylobacter, and MS2-
bacteriophages by 23, 34, and 1.52 logs, respectively (Hijnen
et al., 2005; Albinana-Gimenez et al., 2006). In the absence of
pathogen-specic data, AdV and NoV removals are assumed equal
that of MS2-bacteriophage, and Salmonella spp. removal to equal
that of E. coli. These reported values are used to characterize
pathogen reduction across TT4.
Disinfection with free chlorine (Ct less than 12 mg-min/L). Bacteria
and viruses are more sensitive to free chlorine disinfection than
protozoa. US EPA guidelines suggest a 4-log reduction of viruses
can be achieved at free chlorine doses as low as 2 mg-min/L,
although more recent data suggest that there are some condi-
tions (i.e., pH > 8) under which some viruses require higher CTs
to achieve a 4-log reduction (Keegan et al., 2012). Giardia spp.
are much more resistant, with a maximum of 0.5-log reduction
at 12 mg-min/L (U.S. EPA, 1991). Cryptosporidium spp. is highly
resistant to free chlorine disinfection, with doses estimated as
high of 80 090 0 mg-min/L chlorine providing only 1-log reduction
(Nasser, 2016; Hirata and Hashimoto, 1998). No reduction data
were available for Cryptosporidium spp. at or below a dose of
12 mg-min/L; therefore, it was assumed that chlorine at a dose of
12 mg-min/L does not reduce Cryptosporidium spp. Chlorine doses
of 0.35 mg-min/L can achieve between 45-log reduction of AdV
(Baxter et al., 2007). Specic data were not available to determine
the ecacy of free chlorine disinfection relative to NoV. Reviews
that do not specify the virus species or free chlorine CT suggest
that free chlorine can achieve between 13-log inactivation of
viruses and 26-log inactivation of bacteria (WHO, 2006; EPHC
NHMRC and NRMMC, 2008). NoV reductions were assumed to be
similar to other viruses, with reductions in the range of 1-4-log.
In our analyses, we assume that all removal and/or inactivation in
the ESB was solely due to the Cl disinfection.
Literature review summary. A summary of the parameter values
selected based on the results of the literature review is provided
in Table 2. Parameters were generally characterized with uniform
distributions, with lower and upper bounds corresponding to the
minimum and maximum values reported in the literature (Soller
et al., 2010b,a; Soller and Eisenberg, 2008; Eisenberg et al., 2004;
Soller et al., 2006; Soller et al., 2014). In some cases, a single
8 J.A. Soller et al. / Microbial Risk Analysis 5 (2017) 314

Table 2
Summary of reference pathogen raw wastewater inuent densities and reductions across wastewater, drinking water, and DPR unit treatment processes pathogen densities
in raw wastewater and log10 reductions across unit treatment processes.

Adenovirus Campylobacter Cryptosporidium Giardia Norovirus Salmonella

Min Max Min Max Min Max Min Max Min Max Min Max

Raw wastewatera 56 6.9E+03 900 4.0E + 04 0.3 5.0E + 04 3.2 1.0E + 04 3.76 b
0.93 b
3 1.1E + 03
Conventional secondary wastewater treatment 0.9 3.2 0.6 2.0 0.7 1.5 0.5 3.3 0.8 3.7 1.3 1.7
Ozonation 4.0 4.0 1.0 3.0 5.4 4.0
Biologically active ltration 0 0.6 0.5 2 0 0.85 0 3.9 0 1 0.5 2
Microltration 2.4 4.9 3.0 9.0 4.0 7.0 4.0 7.0 1.5 3.3 3.0 9.0
Reverse osmosis 2.7 6.5 4.0 2.7 6.5 2.7 6.5 2.7 6.5 4.0
Ultraltration 4.9 5.6 9.0 4.4 6.0 4.7 7.4 4.5 5.6 9.0
Ultraviolet disinfection with advanced oxidation (800 mJ/cm2) 6.0 6.0 6.0 6.0 6.0 6.0
Ultraviolet disinfection with peroxide (12 mJ/cm2) 0.0 0.5 4.0 2.0 3.5 2.0 3.5 0.5 1.5 4.0
Conventional drinking water treatment 1.5 2.0 3.0 4.0 1.4 4.0 0.3 4.0 1.5 2.0 2.0 3.0
Disinfection with free chlorine 4.0 5.0 4.0 0.0 0.0 0.5 1.0 4.0 4.0
a
Adenovirus IU/L, Campylobacter MPN/L, Cryptosporidium oocysts/L, Giardia cysts/L, Norovirus log 10 copies/L, Salmonella CFU/L.
b
Values shown for raw wastewater are mean and standard deviation of normal distribution in log10 copies.

Benchmark Risk Annual risk estimate

10-4 Benchmark Risk
10-4 Norovirus
Norovirus
10-5 10-5 Adenovirus
Adenovirus
Cryptosporidium
Cryptosporidium
10-6 10-6 Giardia
Giardia
Daily Risk of Infection Campylobacter
Daily Risk of Infection

10-7 Campylobacter 10-7

Salmonella Salmonella
10-8 Combined Daily Risk Combined Daily Risk
Annual risk estimate 10-8
10-9 10-9

10-10 10-10

10-11 10-11

10-12 10-12

10-13 10-13
a b
10-14 10-14

10-15 10-15
0.001 0.01 0.1 1 10 30 50 70 90 99 99.9 0.001 0.01 0.1 1 10 30 50 70 90 99 99.9

Percent of Values Less than Corresponding Value Percent of Values Less than Corresponding Value

Fig. 2. Daily pathogen risks for TT1 (WWTP MF RO UV ESBCl), (a) Simulation using UVAOP dose of 800 mJ/cm2 ; (b) Simulation using UV dose of 12 mJ/cm2 .

point estimate value was used where appropriate data were not annual risk estimate (Fig. 3a). The estimated annual risk of infec-
available to specify a uniform distribution. tion associated with the lower UV dose simulation is 1.8 107
(Fig. 3b), with the annual risk estimate driven by the two highest
3.2. Simulation results daily risks estimates for NoV, three highest daily risks estimates
for AdV, and the single highest daily risk estimate for Cryp-
Fig. 2 presents the results for one simulation for TT1 (estimated tosporidium spp. Together, these six daily risk estimates account
distributions of cumulative annual risks of infection based on 10 0 0 for approximately 70% of the annual risk.
simulations for each of the TT congurations are summarized The estimated annual risk of infection associated with the TT3
in Fig. 6). Fig. 2 shows the estimated daily risks of infection for base simulation is 1.2 108 (Fig. 4a). The annual risk estimate is
each of the reference pathogens, the estimated cumulative daily dominated by the Cryptosporidium spp. daily risk estimates, with
risk from all reference pathogens, and the estimated annual risk the twenty days with the highest Cryptosporidium spp. daily risks
of infection (2.5 109 , red line, Fig. 2a). In this simulation, the accounting for approximately 70% of the estimated annual risk
annual risk estimate is driven by the highest individual daily risks estimate. The estimated annual risk of infection associated with
estimates for NoV. Together, the seven highest daily risk estimates the lower UV dose simulation is 3.9 105 (Fig. 4b). The annual
account for approximately 80% of the annual risk estimate. When risk estimate is driven by the Cryptosporidium spp. risks estimates,
the UV unit treatment process in this TT is operated at the which accounts for the vast majority of the annual risk.
lower dose (12 mJ/cm2 ), consistent with traditional wastewater The estimated daily risks of infection for each of the reference
disinfection rather than for destruction of disinfection byproducts, pathogens for the TT4 base simulation (TT3 followed by a conven-
the estimated pathogen risks are signicantly higher (p = < 0.001) tional DWTP) along with the estimated cumulative daily risk from
(Fig. 2b). In this simulation, the estimated annual risk of infection all reference pathogens are presented (Fig. 5). The estimated an-
is 5.0 104 (red line, Fig. 2b), which is above the benchmark risk nual risk of infection is 8.7 1011 . Similar to the results presented
level. The annual risk estimate is driven by the ve highest daily for TT3, the annual risk is dominated by the Cryptosporidium spp.
risks estimates for NoV, which together account for approximately daily risk estimates. The estimated annual risk of infection asso-
80% of the annual risk. ciated with the lower UV dose simulation is 2.5 107 (Fig. 5b).
In the TT2 base scenario simulation, the annual risk (1.0 1011 ) These results illustrate that circulation of the DPR water into
is dominated by one NoV and ve Cryptosporidium spp. daily risk a conventional DWTP, prior to consumer exposure, provides risk
values, together accounting for approximately 90% of the total reduction levels of approximately 2-log for the scenarios evaluated.
 J.A. Soller et al. / Microbial Risk Analysis 5 (2017) 314 9

Benchmark risk
Benchmark risk
10-4
10-4
10-5 Norovirus 10-5 Norovirus
Adenovirus Adenovirus
10-6 Cryptosporidium 10-6 Cryptosporidium Annual risk estimate
Giardia Giardia
10-7
Daily Risk of Infection

Campylobacter 10-7

Daily Risk of Infection

Campylobacter
Salmonella Salmonella
10-8 10-8
Combined Daily Risk Combined Daily Risk
10-9 10-9

10-10 10-10
Annual risk estimate
10-11 10-11

10-12 10-12

10-13 10-13

10-14
a 10-14
b
10-15 10-15
0.001 0.01 0.1 1 10 30 50 70 90 99 99.9 0.001 0.01 0.1 1 10 30 50 70 90 99 99.9

Percent of Values Less than Corresponding Value Percent of Values Less than Corresponding Value

Fig. 3. Daily pathogen risks for TT 2 (WWTP O3 BAF MF RO - UV), Simulation using UVAOP dose of 800 mJ/cm2 ; (b) Simulation using UV dose of 12 mJ/cm2 .

Benchmark risk Benchmark risk

10-4 10-4
Norovirus
10-5 Adenovirus 10-5 Norovirus Annual risk estimate
Cryptosporidium Adenovirus
10-6 Giardia 10-6 Cryptosporidium
Campylobacter Giardia
Daily Risk of Infection
Daily Risk of Infection

10-7 Salmonella 10-7 Campylobacter

Combined Daily Risk Annual risk estimate
10-8 10-8 Salmonella
Combined Daily Risk
10-9 10-9
10-10 10-10
10-11 10-11

10-12 10-12

10-13 10-13
a b
10-14 10-14

10-15 10-15
0.001 0.01 0.1 1 10 30 50 70 90 99 99.9 0.001 0.01 0.1 1 10 30 50 70 90 99 99.9

Percent of Values Less than Corresponding Value Percent of Values Less than Corresponding Value

Fig. 4. Daily pathogen risks for TT 3 (WWTP O3 BAF UF UV ESBCl), (a) Simulation using UVAOP dose of 800 mJ/cm2 ; (b) Simulation using UV dose of 12 mJ/cm2 .

Benchmark risk
10-4 Benchmark risk
10-4
10-5
Norovirus 10-5 Norovirus
10-6 Adenovirus Adenovirus
10-6 Annual risk estimate
Cryptosporidium Cryptosporidium
10-7 Giardia Giardia
Daily Risk of Infection

10-7
Daily Risk of Infection

Campylobacter Campylobacter
10-8 Salmonella Salmonella
10-8
Combined Daily Risk Combined Daily Risk
10-9
Annual risk estimate 10-9
10-10 10-10
10-11 10-11
10-12 10-12

10-13 10-13

10-14 a 10-14 b
10-15 10-15
0.001 0.01 0.1 1 10 30 50 70 90 99 99.9 0.001 0.01 0.1 1 10 30 50 70 90 99 99.9

Percent of Values Less than Corresponding Value Percent of Values Less than Corresponding Value

Fig. 5. Daily pathogen risks for TT4 (WWTP O3 BAF UF UV ESBCl DWTP), (a) Simulation using UVAOP dose of 800 mJ/cm2 ; (b) Simulation using UV dose of
12 mJ/cm2 .
10 J.A. Soller et al. / Microbial Risk Analysis 5 (2017) 314
Fig. 6. Cumulative annual pathogen risks of infection for DPR TTs.
The estimated distributions of cumulative annual risks of infec-
tion (based on 10 0 0 simulations) for each of the TT congurations
are summarized in Fig. 6. Overall, the results illustrate that under
normal operating conditions, the TTs can be congured to be
extremely effective in removing reference pathogens to levels that
present low public health risk. The results also reveal that when
the UV unit treatment process is operated at the higher UVAOP
dose, the associated relative pathogen risk is signicantly less than
the risk associated with the lower UV dose (p < 0.001, comparison
of TT1a to TT1b). Finally, a statistical comparison of TT3 with
TT4 reveals that circulating DPR product water through a DWTP
provides incremental pathogen risk reductions of approximately
two logs for the TT evaluated (p < 0.001).
3.3. Sensitivity analysis results
The sensitivity analysis evaluated the relative effect of using al-
ternative dose-response relationships (fractional-Poisson) for NoV
and Cryptosporidium spp. on the risk estimates for TT1 (Messner
and Berger, 2016; Messner et al., 2014). Because aggregation of
NoV particles is a signicant source of uncertainty in the dose-
response relationship (Teunis et al., 2008), an aggregation size of
1106 viral particles was assumed in the sensitivity analysis, as
compared to an aggregation size of 1 (i.e., disaggregated) in the
base simulations NoV (Teunis et al., 2008).
Fig. 7 presents the estimated daily risks of infection for NoV
and Cryptosporidium spp. for TT1a. The results indicate that the
estimated daily risks of infection differ signicantly for both NoV
and Cryptosporidium spp. when then alternative dose-response
relationships are employed (Cryptosporidium spp., p < 0.001; NoV,
p < 0.001). However, the use of the alternative Cryptosporidium
spp. dose-response relationship signicantly elevates the daily risk
estimates, while the alternative NoV dose-response relationship
signicantly lowers the daily risk estimates.
The effect of the alternative dose-response models on the
cumulative annual risks of infection for TT1a and TT1b was also
explored (Fig. 8). The overall annual risks are reduced by approx-
imately 1.5 log10 and 2.5 log10 units when the Fractional Poisson
dose-response relationship is used for only NoV for TT1a and
TT1b, respectively. Overall annual risks are relatively unchanged
when the Fractional Poisson dose-response relationship is used
for only Cryptosporidium spp. in both TT1a and TT1b. When the
Fractional Poisson model is used for both NoV and Cryptosporidium
spp., overall annual risks are reduced (compare TT1a to Both FP,
Fig. 8). This sensitivity analysis indicates that use of the alternative
dose-response models inuences the predicted overall annual risk
estimates and illustrates the overall impact that uncertainty in the
dose-response relationships can have on the simulation results.
4. Discussion
Recycled water is an increasingly important and valued re-
source worldwide and potable reuse is an important component
of those plans. DPR is now being considered as a viable option in
many communities. Communities may lack an alternative water
supply or suitable hydrology for IPR groundwater recharge, DPR
may be less costly than the use of tertiary treated water for irri-
gation once the capitol costs of distribution are considered, and/or
DPR may require less energy than other water supply options
(Tchoganoglous et al., 2011). DPR projects can take two distinct
forms those in which the product water is introduced directly
into a potable water supply distribution system, and those in
which the product water is introduced into the raw water supply
immediately upstream of a conventional DWTP. The relative health
 J.A. Soller et al. / Microbial Risk Analysis 5 (2017) 314 11

Benchmark Risk
10-4
NoV (Hypergeometric DR)
10-5 NoV (Fractional Poisson DR)
Cryptosporidium (Exponential DR)
10-6
Cryptosporidium (Fractional Poisson DR)

Daily Risk of Infection

10-7

10-8

10-9

10-10

10-11

10-12

10-13

10-14

10-15
0.001 0.01 0.1 1 10 30 50 70 90 99 99.9

Percent of Values Less than Corresponding Value

Fig. 7. TT1a (WWTP MF RO UVAOP ESBCl) Daily Norovirus and Cryptosporidium spp. Risks for alternative Dose-Response (DR) Relationships.

Fig. 8. Cumulative annual risks of infection based on alternative dose-response relationships for Norovirus and Cryptosporidium spp., TT1a and TT1b.

protection afforded by both types of DPR strategies was evaluated
in this study.
There are several notable ndings from this work and some un-
certainties that should be considered in context. First, our results
illustrate statistically signicant predicted human health-based
advantages for DPR projects in which AWTF product water is
introduced into the raw water supply immediately upstream of a
conventional drinking water treatment facility compared to those
in which AWTF product water is introduced directly into a potable
water supply distribution system (compare TT3 to TT4, Fig. 6).
The TT evaluated here demonstrated 2 log reduction in risk. This
incremental benet of the conventional drinking water treatment
facility could vary across treatment systems because pathogen
reductions (Table 2) can vary for the pathogens of primary con-
cern, which can change from TT to TT. Additional benets to this
approach (inclusion of conventional drinking water treatment)
may include public perception benets, source water diversica-
tion benets, and a time dimension that would be unavailable (or
much more limited) in a system in which AWTF product water is
introduced directly into the drinking water distribution system.
Second, annual risk estimates for any particular TT are driven
by the highest daily risks for any of the individual reference
pathogens. This nding indicates that even a single day can drive
annual risks and highlights the need for robust and reliable on-
line monitoring of unit treatment processes within DPR facilities.
Higher relative risks on any particular day could stem from high
concentrations in the raw wastewater, treatment ecacy at the
lower end of the expected range, or due to an excursion from
design operations. In this context, this study highlights the po-
tential public health importance of even short term excursions
12 J.A. Soller et al. / Microbial Risk Analysis 5 (2017) 314
from design operations and the potential public health implica-
tions of high pathogen loading that can occur, particularly during
outbreak conditions (e.g., when sewage loading from an upstream
community may be highest for one or more pathogens). Moreover,
these particular results, based on a probabilistic approach raise
questions about the interpretation of the more simplistic log re-
moval credits that States often use to determine the adequacy of
proposed TTs. To effectively understand the likelihood of achieving
the benchmark level of public health protection, a robust and
rigorous method for TT evaluation within a public health context
is needed. The methodology employed here offers a transparent
approach that can be used for this purpose.
Third, this analysis indicates that NoV is an important reference
pathogen for several of the TTs evaluated, and thus, should be con-
sidered carefully. There has been resistance among recycled water
professionals to specically consider NoV risks related to the use of
recycled water. Part of the resistance has been due to the fact that
NoV cannot be readily cultured and is thus monitored by molecular
methods (i.e. qPCR) that identify viral RNA, rather than infectious
viral particles. Herein our sensitivity analyses capture a represen-
tative range of NoV infectivity reported in the literature (Van Abel
et al., 2016). While the differences between alternative and com-
monly used dose-response models may be statistically signicant,
they are not enough to change the relative risk comparisons and
overall conclusions of this work. They are sucient, however,
to raise questions about which pathogens drive the estimated
risks for specic treatment train congurations. Additionally, the
literature indicates that NoV has been reported in densities as high
as 109 genome copies/L in raw wastewater (da Silva et al., 2007). If
NoV were to be present in source water used for DPR at densities
of this magnitude, the previously suggested 12-log of viral reduc-
tion may not adequately ensure the benchmark level of public
health protection (data not shown). Therefore, understanding NoV
presence in raw wastewater, NoV attenuation across individual unit
treatment processes, the relationship between viral RNA and infec-
tious viral particles, and NoV infectivity after DPR treatment should
be areas of active research and considered in DPR project approval.
Fourth, our results illustrate that proposed DPR project designs
need to carefully consider reduction of both Cryptosporidium spp.
and human enteric viruses, such as NoV. For example, DPR TTs that
employ non-reverse osmosis processes for advanced treatment are
preferred by some inland communities due to the brine disposal
issues associated with RO treatment. However, this work indicates
that treatment trains lacking RO should be congured upstream
of a conventional drinking water treatment facility and/or with
a UVAOP unit process operating at high UV doses (800 mJ/cm2 )
to reliably achieve the benchmark level of infection due to risks
from Cryptosporidium spp. On the other hand, an AWTF treatment
system comprised of MF-RO-UV-ESBCl may require the use of high
UV doses to reliably achieve the benchmark level of infection due
to risks from NoV. Alternatively, conguring an MF-RO-(low dose)
UV-ESBCl DPR facility upstream of a conventional drinking water
treatment facility may also provide condence that the desired
level of protection is achieved, although that conguration was
not specically evaluated here.
Finally, our results indicate that expected performance of
individual unit treatment processes within an integrated TT can
be critical for consistently achieving the benchmark level of public
health protection. This observation reinforces the importance of
robust and reliable monitoring systems for critical unit treatment
processes, and highlights the need to understand the potential
vulnerability of integrated systems with respect to unit treatment
process failures or upsets.
A series of assumptions were made regarding the ecacy of
unit treatment processes that are dose dependent, such as UV
light treatment, chlorination, and ozonation. Selected doses rep-
resent common usage. As illustrated above, changing the selected
dose values can have a profound inuence on the associated level
of public health protection. This point was highlighted by simu-
lating the UV unit treatment process under two very different, yet
feasible operational conditions. Similar effects could also be seen
by varying the type or dose of chlorine and the dose of ozone. It
was also assumed that pathogen reduction across each of the unit
treatment processes could reasonably be estimated based on the
minimum and maximum vales reported in the literature. Targeted
future work may rene these estimates, potentially inuencing the
interpretation of the results. For example, because the upper tails
of the statistical distributions inuence the annual risks, updated
pathogen-specic log removal data or statistical distributions may
be useful renements to (or conrmation of) this work. The most
commonly employed peer reviewed dose-response relationships
were used for the reference pathogens. However there is un-
certainty embedded in each of those relationships, particularly
as the probability of adverse health effects from a relatively
homogenous feeding trial subpopulation is extrapolated to the
widely heterogeneous general population. Nevertheless, when the
results of this work are viewed within the context of a relative
health assessment rather than an estimate of absolute risk, the
uncertainty surrounding these issues is clearly overshadowed by
importance of the overall ndings of this work.
5. Conclusions
This study leveraged readily available peer-reviewed data and
extended a previously published statistical approach to estimate
daily and annual infection risks associated with the consumption
of product water from a series of DPR treatment trains. Overall,
the methodology resulted in several important ndings for DPR
implementation, is adaptable to other DPR treatment trains, and
could be iteratively rened as additional data become available.
This work should be useful for federal and state regulators con-
sidering DPR as source water, state and local decision makers as
they consider whether to permit a particular DPR project, risk
managers identifying the impact of treatment failures, and design
engineers as they consider which unit treatment processes should
be employed for particular projects.
Acknowledgments
The research described in this article was funded by the U.S.
EPA Oce of Water, Oce of Science and Technology under con-
tract # EP-C-11-005 to ICF International, LLC. This work has been
subject to formal Agency review but does not necessarily reect
the views of the Agency, and no ocial endorsement should be
inferred. The authors gratefully acknowledge the valuable contri-
butions of Michael Messner, Margaret Nellor, Stig Regli, and Jamie
Strong for their critical review of the manuscript and insightful
comments.
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