To: State Water Resources Control Board
Fm: Dr Edo McGowan                                                                                                                     9/16/2007

Re: Comments related to--

Back ground:
Recycled water is a major source of water supply in California and a major component in California’s plan for
meeting the state’s growing water demand. The California Water Plan estimates that recycled water usage can
increase from half a million acre-feet per year in 2003 to two million acre-feet per year in 2030.
NOTICE IS HEREBY GIVEN that the State Water Resources Control Board
(State Water Board) will hold a public workshop to receive public comments on a proposed statewide
Water Recycling Policy as part of a State Water Board meeting to be held on October 2, 2007 in Los
Recycled water irrigation projects and groundwater recharge reuse projects provide benefits to the people of the
state. These benefits include extending the state’s limited water supply to provide water to its growing population,
reducing diversions of surface water, and reducing use of groundwater supply.
These benefits outweigh the
costs associated with lowering of water quality,
as mitigated through best practicable treatment or control,
that would be caused by a recycled water irrigation project, provided that the lowering does not cause a violation
of a water quality objective.
The California Code of Regulations, Title 22, Division 4, Chapter 3, Recycling Criteria, specify
treatment processes for ensuring proper disinfection of recycled water. They also specify
requirements for limiting public contact with recycled water to protect public health.

Dr. McGowan's Comments to the Control Board:

The document and its underpinnings are so weak on pathogens, transfer of antimicrobial resistance, lateral
transfer of genetic information to soil and aquatic microbes and environmental niches, all potentially impacting
public health as to be blatantly dangerous. Because of the potential impact on public health, an EIR warrants
preparation under CEQA to fully discuss the human and environmental health implications and alternatives. The
reference resolutions noted within the document are so old with respect to issues and impacts on public health,
that they are useless. There are provisions within the resolution (resolved 7 (b) relating to Title 22, Resolve 10
requiring CDPH to have developed MCL, but nothing on pathogens, antibiotic resistant genetic material, antibiotic
resistance and the build up of antibiotics such as macrolides that can maintain vancomycin resistance. Thus for
constituents that CDPH has not established MCLs, the regional boards may establish such---but where is the
expertise to do so?

Therefore let us take some examples for illustrative purposes----------

Let us first discuss Erythromycin, which is a bioaccumulating macrolide that has been shown to maintain or cause
cross resistance with vancomycin. Hence, since this can bioaccumulate in soils, and where there are soil
microbes, these can develop resistance to both of these antibiotics. There are soil microbes everywhere in soils.
Thus one may well see the build up of resistance or similar cellular and molecular machinery established that can
supply cross resistance. Additionally, the entrained antibiotic resistant genetic material as discussed by Pruden et
al is found in Title 22 water and the pathogens entrained in this water, as discussed by Rose et al, (WERF #00-
PUM-2T)will be delivered with the Title 22 water. Thus, we have, under each micro-emitter of a drip system a small
biological factory for producing antibiotic resistant pathogens. I have had this Title 22 water run in the lab and it
contained multi-drug resistant bacteria. In viewing the Mueller-Hinton plated two days later, we noticed secondary
growth within formerly clear areas. This may have represented bacteria in the viable but non-culturable (VBNC)
state that resuscitated. These also were resistant. Title 22 does not, as far as I can ascertain, look for either
resistance or VBNC. Rose in her paper as published by WERF comments on the fact that the indicators used in
ascertaining health risks from recycled water have long been known to be non-reflective of public health risks.

The state’s public health agencies appear to have little or no information on these phenomena. I asked the
various agencies that are presumed to have some control over public health who amongst them was dealing with
antibiotic resistance in water. Each, in response assured me that, now that they understood the situation [many
had not even thought about it], it was not within their jurisdiction, but if I would just call this number, that agency
over there would be the one that could help me. I received the same or similar reply, went full circle and never
found any state agency that was dealing with this issue. The U.S EPA has just started to look at this, but only as
relates to sewage sludge (biosolids). EPA does have standards for sewage solids but has not entered the arena
of reclaimed/recycled water; that is an area left to the states. The U.S. EPA has not done a human health risk
assessment on pathogens contained within biosolids, and none on reclaimed/recycled water. In discussing this
with both U.S. EPA and CDC&P, both admit that there had been no coordinated or focused effort in looking at
antibiotic resistance in sewage, hence its risks to man. I am on a newly established U.S. EPA/WERF scientific
panel that has been developed to look at antibiotic resistance within biosolids. Some of that work will, of course,
translate to reclaimed/recycled water questions, but as yet even the RFP for these studies in the area of biosolids
are still in the developmental state. Thus, it seems that to assume that somehow all is well within Title 22 is a
major jump and is in fact a fiction as relates to public health. Thus at a minimum, the resolution’s actions fall to
CEQA and warrant an EIR to explore the issues of public health.

In large irrigation systems such as public parks, we have large pop-up sprinklers that are designed to produce a
spray pattern that will water the entire lawn’s area. As a second example then, let us assume a family at a picnic
on the grass of the public park irrigated with Title 22 water. Did not little Susie, just drop her lollypop on the grass,
and then pick it up to suck on it again? Or little Jim, skid across the grass attempting to catch a ball and open his
forearm with a skid-rash? Thus the skin’s protective barrier is broken.

Now we have the opportunity for entry of antibiotic resistant microbes found within Title 22. In the case of little
Susie, she may not get sick, but what is the chance that her gut bacteria will pick up that genetic information,
multiply it out. Now three weeks later she is crying and you can’t calm her down, her eardrum is infected, and she
has a bladder infection, not necessarily related to the lollipop, but from something entirely unrelated. But the
pathogens just happened to have met with and exchanged genetic information with her own internal flora that now
contain the genetic information from what was on the lollipop. Also one must consider transfer of genetic
information from these organisms to more robust organisms as highlighted by Sjolund et al. (2005) [1] indicating
that resistance in the normal flora, which may last up to four-years, might contribute to increased resistance in
higher-grade pathogens through interspecies transfer.

These bacteria that were on the lollipop were from the Title 22 water. They were able to colonize her gut bacteria
through ingestion. Once ingested, the genetic information was transferred to normal flora, and subsequently to
the pathogenic bacteria, making later treatment with particular antibiotics ineffective. Little Susie is now in the ICU
on vancomycin and that drug is tearing up her vascular system and they had to discontinue it and attempt to find
another drug. She is on a respirator, things don’t look good.

Sjolund et al go on to note that since populations of the normal biota are large, this affords the chance for multiple
and different resistant variants to develop. This thus enhances the risk for spread to populations of pathogens.
Furthermore, there is crossed resistance. For example, vancomycin resistance may be maintained by using

So, just how fast can a lethal level of antibiotic resistance develop? It does not take long as the example below will
illustrate. Schentag, et al. (2003), followed surgical patients with the subsequent results. Pre-op nasal cultures
found Staphylococcus aureus 100% antibiotic susceptible. Pre-op prophylactic antibiotics were administered.
Following surgery, cephalosporin was administered. Ninety percent of the patients went home at post-op day 2
without infectious complications. Nasal bacteria counts on these patients had dropped from 10/5 to 10/3, but were
now a mix of sensitive, borderline, and resistant Staphylococcus sp. By comparison, prior to surgery, all of the
patients’ Staphylococcus samples had been susceptible to antibiotics. For the patients remaining in the hospital
and who were switched on post-op day 5 to a second generation cephalosporin (ceftazidine), showed bacterial
counts up 1000-fold when assayed on post-op day 7 and most of these were methicillin resistant Staphylococcus
aureus (MRSA).  These patients were switched to a 2-week course of vancomycin. Cultures from those remaining
in the hospital on day 21, revealed vancomycin resistant enterococcus (VRE) and candida. Vancomycin resistant
enterococci infections can produce mortality rates of between 42 and 81%.

Note in the above, that on entry to the hospital that none of these patients harbored resistant bacteria in their
nasal cavities. But what would be the result if there had been inadvertent acquisition of resistance from
environmental contamination such as through Title 22 water? Gerba and Rusin conducted research on the
passage from finger to mouth of pathogens found on typical household objects. But we are not at home, but on a
sunny day in the park, innocently having a picnic, on grass irrigated with Title 22 water that carries antibiotic
resistant bacteria and other pathogens.

Cottage Hospital in Santa Barbara is a teaching hospital and I occasionally attend grand rounds and other
functions to maintain my continuing medical education requirements. Cottage has been, since about 2003, giving
vancomycin as a pre-op prophylactic for many surgical procedures. Vancomycin is not a benign drug. But, now
because of the levels of background and community acquired antibiotic resistance, it would be unconscionable
not to consider this drug. It was once held in reserve as the drug of last resort. Now from hospitals and nursing
homes across California, it is used to quell resistant bacteria. As a pre-op prophylactic, it is also found in the
human waste which is going to the sewer, then back into the reclaimed water along with resistant pathogens and
their genetic material, and back onto the lawns of parks----a revolving door. Sewer plants have a very hard time
with pharmaceuticals, but that connection to Title 22 seems to be seldom discussed.

Because resistance can be and is transferred to the flora of the human gut (skin and mucosal flora as well) the
infective dose used to estimate public health impacts is confounded. This then brings into question the current
paradigm on infection and its dose response to a certain load of a particular pathogen, i.e., ID and LD 50s.
Lateral transfer of mobile genetic elements conferring resistance is not considered in this old paradigm. With the
prodigious capacity for the gut bacteria to multiply, once the lateral transfer has taken place, very small original
numbers---well below the old paradigms can be multiplied into impressive numbers. Since viruses and phages are
also involved, their capacity to multiply, which dwarfs that of bacteria, must also be included. Thus there is a need
for a new paradigm; unfortunately, the regulatory community seems not to recognize this. When one considers
the multiplication within sewer plants and also within their byproducts, disbursement into the environment, the
transfer to background organisms, hence to man and his animals, then the remultiplication within commensals of
the gut, the emerging picture is worrisome.

Further, there are opportunities and interrelationships between microbes that can degrade antibiotics, eg.
antibiotic resistant bacteria, and those that can degrade heavy metals and pharmaceuticals brought in by the Title
22 water as well as well as pesticides and fertilizer chemicals that are already found in soils of the park. In many
cases, the involved cellular machinery is the same or similar, i.e., a duality (see for example papers by Schlüter).

Third example--------Your favorite uncle, Uncle Albert who was the youngest of the brothers, was also at the
above picnic. He is about 48, has diabetes, a toe has been removed and he has a non-healing open ulcer on the
bottom of the same foot. He is a devil-may-care fellow who still thinks he is 26, bullet-proof, and thus does not
watch his blood sugar. A week after taking his shoes off and playing ball in the park with the family, he is in the
clinic because his foot is infected. He is given a course of gorilla-cillin and it does no good, but in the interim his
foot and lower leg are all red and swollen. It is difficult to walk and now he is taking a day off work. He really does
not appreciate his situation because he can’t feel too much due to diabetic neuropathy in his lower limbs, so he
just soldiers on. Thus in a few days leg is much worse, but because of neuropathy he just does not feel things.
The gorella-cillin is not working but Albert doesn’t know that. His wife and kids tell him to go to the doctor and
finally he decides to do just that. His swollen leg is starting to turn a dusky color.

On examination, he is immediately put into the hospital and put on IV antibiotics while lab tests are run to
determine the sensitivity of the antibiotics. His foot is badly damaged already but again, Albert really can’t feel the
pain. Try as they might, because of his poor circulation, the antibiotic can not reach the infection; the infection
turns to gangrene and the foot must come off.

Let’s now move five years out and revisit Albert. He is now 53, depressed and when he attends picnics he laments
the fact that he can’t run and play catch. His depression over his state has him on antidepressants. He already
had erectile dysfunction, but now because of the anti depressants he is not really interested. His wife 15 years his
junior still has a normally functioning libido and marital discord is showing up.  
Albert’s other leg is starting to break down due to the added stress.

Move out 3 more years. Albert has just come back from the hospital, for treatment of an ulcer that developed on
the stump of the other leg which was removed. He is just like a lot of diabetics that lose a leg. They will lose the
other in about 5 years from the added stress. His numerous bouts with infection, the diabetes, his impacted
immune system, and the numerous experiences with antibiotics find that his system is easily colonized with
antibiotic resistant bacteria. He is relegated to a wheel chair, on heavy meds for depression and has not worked
full-time for two years. He lives in a small subsidized housing system. His wife left him and he sees the children on
alternate weekends. He is now seeing a cardiologist because his cardiovascular tree is coming apart. In losing his
legs he also lost the calf pumps. The calf pumps, contraction of the calf and foot muscles, move the blood back to
the heart through a series of check valves in the veins and thus pre-load the heart for normal circulation to occur.
Thus Albert’s heart is not preloaded and this causes deterioration of the entire cardiovascular tree.  

Do you think the Water Quality Board staff will come to visit him in his room at the dingy public assistance rooming-
house and cheer him up or lay flowers on Susie’s grave?

Pathogens in reclaimed Water
Reclaimed water rules

[1] Emerging Infectious Diseases (Vol. 11, # 9, Sept 2005 @ p. 1389 et seq),