POLITICAL IMPLICATION OF ANTIMICROBIAL RESISTANCE BACTERIA IN
                 RECLAIMED WATER FROM TERTIARY WASTEWATER TREATMENT PLANTS.

By: Dr. Edo McGowan                                                                                                                  Posted 1/16/200

Based on wastewater industry dogma and standards, released effluent and the land application of sewage sludge are
benign and beneficial activities. If however, one reviews the current medical and scientific literature, a different picture
emerges, one that raises serious questions about the benevolence of this activity and efficacy of the underlying
standards. Thus, the issue takes on aspects of a political and not a scientific argument. In the interim, most regulatory
agencies have backed off. This leaves the citizens and patient base standing naked.

Executive Summary

ABSTRACT
This study presents an argument that accelerating risks from both antimicrobial (antibiotic) resistance and
pandemic, especially as now found emerging within the world community, may be related to the disposal of
inadequately treated sewage. In the drought-prone areas of the nation, the use of reclaimed or recycled wastewater---
a sewage byproduct, has gained unprecedented acceptance based on the need to both rapidly rid ourselves of waste
and at the same time salvage water.

Recent papers have noted the mixing of genetic material between various organisms provides for newly emerging
pathogens. This then challenges our immune systems where we may thus be faced with an unknown foe.
Interestingly, much of this mixing goes on every day in sewage treatment plants in almost every city. Down wind
movement of aerosols from sewer works now warrants more attention. Additionally, this intermixing affords the
opportunity for novel mixes of genetic information between distantly related or unrelated organisms to occur. Hence
there is the opportunity for development of new pathogens and thus newly emerging infectious diseases. Although
this paper speaks mainly to issues of antibiotic resistance, many of the mechanisms here in apply to other emerging
issues related to viruses for which antibiotics are essentially useless. For example SARS or bird flu. SARS was found
to be an aerially spread virus. Sprinkler irrigation with recycled wastewater offers a distinct form of aerosol generator
as does the flushing of toilets. Several other approved uses of reclaimed or recycled water represent aerosol
generators. These uses would include fire fighting, cooling towers, and various industrial uses.

Santa Barbara City College (SBCC) through its various courses offers the opportunity for citizens to examine some
aspects of the local community. This author took advantage of that opportunity to examine the potential public health
implications accruing to the use of tertiary treated and chlorinated recycled wastewater (a sewage water byproduct)
on areas with high public access. This quest was driven, in part, by the compound question: did recycled water, as
produced under the state criteria (Title 22) a) contain pathogens, b) were those pathogens antibiotic resistant, and c)
could that resistance be transferred to the public, and d) if so would such a use have a potential to adversely impact
public health impact?

This author noted that there is a low availability of commercial labs that can run tests on water for antibiotic
resistance. Previous attempts to locate such labs had not met with success. Thus, knowing that the medical
microbiology lab (MML) at SBCC had the capacity to run such tests, a course was taken that would allow inclusion of a
study design for such testing. That course was offered as Environmental Studies 200 under the guidance of Dr. Adam
Green (the interested reader may wish to see SBCC catalogue for a course description).

The California State Water Resources Control Board and its Regional Boards (water boards) control, through
statutory directive, the production of recycled wastewater. The production of this water, as produced and under state
Department of Health Services (DHS) criteria, is controlled by the water boards and its production is presumed to be
protective of public health. The water boards have no capacity to independently ascertain public health aspects or
standards designed for protecting public health. That function rests with DHS. The water boards merely enforce the
standards and criteria. Notwithstanding this disjointed incremental aspect of presuming to protect public health,
statutory directives indicate that public health shall be protected. However, several scientific papers from the peer-
reviewed literature over the last few decades have questioned the safety of sewage byproduct usage where there is
high public contact. These papers further question the efficacy of the underlying standards controlling that usage.
Other papers, such that of the Water Environment research foundation, the research arm of the wastewater industry
also note these inconsistencies between standards and the reality of disease.

An independent analyses have raised several compelling questions as to the efficacy of the standards to appreciate
newly emerging water born diseases, pathogens and their genetic material, and thus whether the current standards
can in fact protect public health. The more recent readings over the last decade tend to show that the standards do
not protect public health.

Recycled water can be used for a variety of uses mainly designed to allow for an offsetting in the use of potable
water. While this makes strong economic sense, especially within drought-prone areas, that water must not
compromise public health. At issue thus are the inputs to an economic analysis for looking at risk. The U.S. EPA has
not entered the picture with respect to recycled or reclaimed water. EPA has left that subject to the states. EPA does
however regulate the land application of sewer sludge (biosolids), but it is experiencing increasing difficulty in
justifying that use as health impacts are becoming increasingly well known (see notes 26,27 & 29 below).

There are a variety of definitions relating to what reclaimed or recycled water actually is. The following list of uses to
which recycled water may be put includes: irrigation of public access greenscape such as parks, playing fields, golf
courses, and roadway mediums. It may also be used for irrigation of food crops, including those consumed raw.
Additionally recycled water may be used in fire fighting, cooling towers, and flushing toilets and urinals within public
access restrooms. Further there are myriad industrial uses for this water. In certain areas, this water is injected into
aquifers to create a water mound thus is used to control seawater intrusion, or to offset overdraft.

The state statutes (California’s Water Code and California’s Health and Safety Code) also allow municipal
governments to produce recycled water and to force its use upon the community. That this has happened will be
noted through an analysis of court records. The forced use at the Montecito Country Club for its golf course is a local
example. The Club fought this on liability issue in court and lost. There are several statutory directives that deal with
recycled water that were signed into law by prior legislative sessions. Many of these extant laws and their promulgated
regulations predate an adequate understanding of the potential public health implications of using inadequately
disinfected recycled water. A digest of these code sections is beyond the scope of this paper. Nonetheless, these are
the extant directives to those producing such water. Additionally, the directives in state law dictating what knowledge
levels are needed to obtain a sewer plant operator’s license also fail to appreciate this more current information.
Accordingly, those operating sewer plants often fail to appreciate the more current scientific findings as provided by
the literature. This disconnect may thus allow sufficient slippage to adversely impact public health yet remain within
the dictates of the statutory requirements. This then is seen as a flaw in the administration of the public health
requirements, nonetheless a reality of the current political and bureaucratic process.

This student study tends to confirm what previous studies had noted, mainly that current standards are not protective
of public health (see for example notes 3 & 4 above). This student study, however, noted that the recycled water
contained multi-antibiotic resistant bacteria and that these bacteria were potentially serious pathogens. This is a new
finding not previously widely reported. While current standards do not discuss issues related to antibiotic resistance,
the World Health Organization and Centers for Disease Control and Prevention have been noting an acceleration of
mortality and morbidity associated with antibiotic resistance. In fact WHO has considered antibiotic resistance to be a
global crisis for some time. Prior studies, including studies on the recycled water produced under Title 22 at the sewer
plant owned by the City of Santa Barbara, noted that recycled water did contain pathogens and that the standards in
use were not protective of public health (see notes 3 & 4 above). In one particular study conducted over a year’s time
by the Water Environment Research Foundation (WERF), the research arm of the wastewater industry, suggestions
were made as to why the sewer plant was failing (see note 4 above). This study was published in 2004.
Notwithstanding such studies, the City of Santa Barbara informed members of this student study that the City has
made no effort to change its process.

The SBCC Environmental Studies 200 student that conducted this study also ran samples of recycled water produced
by Goleta Sanitation District and found it also to contain multi-antibiotic resistant bacteria. Water from Goleta
contained bacteria that were resistant to fewer antibiotics but was still considered as multi-drug resistant. Santa
Barbara’s water contained chlorine resistant bacteria that were resistant to 11 of the 12 test antibiotics whereas
Goleta produced water with resistance to chlorine and resistance to 4 of the 12 test antibiotics. It was also suggested
by this author that Santa Barbara contact Goleta Sanitation District to ascertain differences in reported pathogen
loads and different approaches. It was hoped that Santa Barbara, in cooperation with Goleta could reduce the load of
antibiotic resistant pathogens in its produced recycled water. Goleta had significantly better water, the question was
why and what did Goleta do that was different? In later contacting Goleta on follow up, this author was informed that
Santa Barbara had not contacted Goleta to ascertain differences.

The regional water boards and the State Board are seeking public comment on a newly designed statewide policy on
the use of recycled water. This new policy would relax current standards, especially related to provisions of the Clean
Water Act (PL 92-500). In the main such relaxed provisions would relate to the control of runoff from areas where
recycled water can contact the waters of the state. This, absent an understanding of gene transfer would allow the
movement of genetic information from recycled water to waters of the state. There is a strict prohibition in statute for
contact between wastewater and state waters. Health and Safety Code 5411---no person (includes city) shall
discharge sewage or other waste, or the effluent of treated sewage or other waste, in any manner which will result in
contamination, pollution, or nuisance.

H&SC 5410 (f)----nuisance means anything which: 1) is injurious to health, 2) affects at the same time an entire
community or neighborhood or any considerable number of persons, and 3) occurs during, or as a result of, the
treatment or disposal of wastes.

5410 (d)-----contamination means impairment of the quality of the waters of the state by waste to a degree which
creates a hazard to the public health through poisoning or the spread of disease. H&SC 5410 indicates contamination
means impairment of the quality of the waters of the state by waste. The waters of the state include any water within
the boundary of the state.

This is thus a problem for the State Board’s new policy and would seem to fly in the face of current statutory law.

Here we can then bring in antibiotic resistance pathogens as well as ARGs and VIs as components of disease, hence
within the above statutes and their definitions.

Thus, if an activity of dealing with pathogens and of disease entities is in fact inherently dangerous, in spite of
meeting all requisite standards---there is either something wrong with the standards, or that activity is one that can be
classified as ultrahazardous. If ultrahazardous, then presumably strict liability would come into play. The section
13550 (a) (3) may set that up---use of recycled water will not be detrimental to public health.

The establishment of environmental niches containing this genetic material would thus provide avenues for
establishment of lending libraries and potentially movement of resistance into the environment.

Prior to this student’s study, the State Board had not generally considered the impact of recycled water on the spread
of antibiotic resistance, hence the public health implications. During the conduct of this student study, documents
were submitted to the state and regional water boards discussing the potential public health risks associated with
water that contained pathogens and especially resistant pathogens and their genetic material. Pursuant to those
comments, an informal panel was created to discuss these comments. That panel met by conference call on Thursday
December 6th, 2007, and was composed of about 16 individuals from academia, regulatory government agencies,
and industry. Minutes of the meeting are pending as this report is being written. Suffice it to say that the State Board
seems to be interested enough in these concerns to pursue the subject. Of additional interest is the result of a
meeting between the City of Santa Barbara and faculty of SBCC to discuss the public health implications in using
currently produced recycled water. This water is used for irrigation of greenscape on the SBCC campus. That meeting
between faculty and the City culminated in a MOU that would move the analysis to a next phase of inquiry. That next
phase would include a more advanced study, presumably by graduate students at UCSB and appropriate faculty.

DESIGN OF CURRENT STUDENT STUDY

The design’s final form, as discussed below, derived from a dynamically shifting interest within a variable number of
involved students. Originally, a group of 5 students was involved with the intention of looking at how water was used
on campus, where that water ended up following its use, and the various environmental impacts. This original study
concept included storm water as well as irrigation water. The latter being understood to be recycled water. Originally,
in addition to potentially carrying pathogens, both sources of water were to be analyzed for nutrient content and
chemistry. As the semester progressed, the number of students interested in this subject dwindled and the practical
constraints on the ability of the school’s lab to run water samples dictated that the study design be severely cut. The
end result was a breaking apart of the two main directions, recycled water and storm water, into separate studies,
each undertaken by a single student.

As a result of this reduced focus, the study on recycled water was expanded to include another sewer district’s
recycled water. Thus in addition to the City of Santa Barbara’s El Estero sewer plant’s recycled water, the study
added the recycled water from Goleta Sanitary District. Arrangements were made to obtain samples from both
sources. These samples were initially intended to include pre and post chlorination samples and include chemistry
and nutrient content. Samples were collected at the respective sewer plants and also at the point of use---the
sprinkler heads on both campuses. In addition, samples were taken at the flush points at the toilets the Bren school.
The Bren urinals are flushless.

In the case of Goleta, samples were obtained pre-chlorination and post chlorination. The City of Santa Barbara
required that the recipient of the pre chlorination sample sign a waver. In reading that waver, the overreach in the
legal language precluded a prudent person from signing the document, hence no pre-chlorination sample was
obtained.

Water samples were obtained in 150-ml sterile urine sample containers as supplied by SBCC’s medical microbiology
lab (MML). Samples were immediately placed on ice and run in the lab within four hours of collection through a sterile
vacuum filter system, according to protocol noted in the MML class syllabus and placed on an appropriate medium
(see MML protocol). Following initial growth on agar (see MML protocol as published elsewhere) the results were
replated to produce a lawn onto large Petri dishes containing Mueller-Hinton agar, again per MML protocol and then
subjected to antibiotic resistant disc diffusion via Kirby-Bauer process, again see MML protocols. These large Petri
dishes were then placed in the incubator as specified in MML protocol. The results were positive for the pre
chlorination sample from Goleta and for all post chlorination samples from both sewer plants.

Thus what was found in the post chlorination samples were multi-drug resistant bacteria and bacteria that were also
resistant to chlorine levels used by both plants.

RESULTS

The water of interest from both sewer plants was the post chlorination tertiary treated recycled water produced under
state criteria as noted within Title 22. This water is used by the University of California at Santa Barbara for irrigating
greenscape, including the various sport’s playing fields and for flushing the toilets within the Bren School on its first
floor. It is also used within the City of Santa Barbara for greenscape, parks, playing fields and golf courses, and
irrigation on lands occupied by SBCC. In all cases there is a high degree of public access to these areas.

Goleta: The growth on the Muller-Hinton plate’s Kirby Bauer disk diffusion from the pre chlorination water from Goleta
demonstrated multi-drug resistant bacteria to all challenges. The post chlorination, however, showed resistance to 4
of the 12 challenge antibiotics.

Santa Barbara: Water samples from the City of Santa Barbara were all post chlorination. These samples showed two
predominant bacterial types, a serratia-like colony and a pseudomonas-like colony. No testing beyond phenotypic
identification was conducted. Both of these bacteria were resistant to 11 of the 12 test antibiotics as well as being
resistant to chlorine at levels used by the city in its recycled water.

DISCUSSION

Based on these findings, both sewer districts were appraised of the results. In addition, the University Facilities
Management as well as Bren School were informed of these preliminary results. Further, a discussion was held
between this author and a board member of Goleta West Sanitation District (GWSD) which feeds into Goleta San.
Subsequently, the topic was discussed with staff of DHS and comments were issued to the State Board.

While the results were provided to the City of Santa Barbara, staff indicated that there was not much that they could
do to change the current situation. Staff of Santa Barbara did agree to meet with SBCC faculty on the subject and see
where the issue might be taken. That meeting saw some agreement that additional studies were warranted. Such
studies would be sought through the graduate program at UCSB. This author was not present at that meeting.

Staff of DHS indicated that the State Board had initiated inquiries and that a telephone conference was conducted to
look at the issue. The board member of GWSD, who is an MD indicated that the issue warranted serious
consideration and offered to attempt to bring the topic up through the California Association of Sanitation Agencies
(CASA). In a personal communication with WERF, the topic of recycled water prompted interest since WERF is
currently looking at antibiotic resistance and pathogens as such would relate to human health risks from the land
application of sewage sludge (biosolids). This author is on that scientific panel which includes both WERF and U.S.
EPA. From the perspective of the WERF study on biosolids, the addition of recycled water within close proximity of
crops receiving biosolid applied to land could see a confounding of WERF study results. A case in point for reference
is the Sugar Creek Study (see Appendix), where land application of biosolids saw irrigation water carry antibiotic
resistant bacteria to recreational waters. If recycled water were also used in the area, this could confound the results.

The problem seems to be that the subject of antibiotic resistance coming from sewage byproducts, while fairly well
known amongst narrow academic groups, is relatively new to those working within the wastewater industry and thus to
the regulatory community that over sees this industry. Consequently a certain (potentially considerable) amount of
inertia will need to be overcome, and any resolution to the problem, if one exists, will thus not likely to be rapid.

Of the debate over the depth and breadth of water pollution, including sanitation, a considerable portion of that
debate is beset by uncertainty. The uncertainty accrues to a range of opinion on causation as well as effect. For
example, the questions may range from ones of how extensive or important the damage might be to questions asking
if the issue indeed has any merit at all.

Thus, within this area of uncertainty, at least five major sources might concern those working in the field. The first is
that of the need to measure the extents in degradation. Secondly, this then requires that there be an ability to
differentiate human effect from ongoing natural processes. Thirdly, to determine if such differentiation between
anthropomorphic versus natural causation is important. And, next, if there is deterioration, then there is likely to be
much debate over the variety of ways such deterioration can be viewed and, further if there is then a need to mitigate
and finally, how. Ultimately, it comes down to considerations related to the different approaches. What is viewed, what
is important, what may be ignored, and the who and how of interpreting the variety of data.

I would argue that water pollution is above all, a political-economic issue, and any discussion and ultimate result will
therefore rest upon partisan decisions.

Pollution may continue but remain unrecognized or be unimportant to those living in an affected area, i.e., the
stakeholder. It only reaches a social issue when deterioration becomes: 1) recognized and 2) some level of action is
required. However, until that level of action brings about conflict, pollution has not become a problem.

When the issue generates conflict, it may be expressed either politically—or it may remain unnoticed as merely the
over subscription of alternative scarce resources or the overuse of their absorptive capacities. Unfortunately, so
deeply ingrained are the traditional views of humans, which lead to pollution, or its mitigation, that any intervention
brings about contradictions within society. Intervention thus implies a mediation or an arising of conditional pressures,
especially as regulation shifts from prescriptions to proscription of behavior. An intervention may affect any or all of
the following: a) the livelihood of users, b) changes in the allocation of yet other scarce resources, c) changes of the
law, or d) rearrangement of pricing structures.

With respect to the environment within a particular basis, some of the leading opinions claim that the level of pollution
is not important. That this challenge, if it be such, will, as its advocates claim, induce innovations that can cope with
the problems, remains uncertain. These opinions are diametrically opposed to others who may claim that pollution is
widespread and serious. In my particular case, I am concerned with pathogens and within that microcosm, those
carrying multi-drug resistant mobile genetic elements. The doubts as to whether induced innovations can easily cope
with current pollution seem well founded.

Those advocating innovation will argue that, far from being finite, as assumed by the Club of Rome world models, and
those following such as the Dublin Statements, water actually becomes cheaper and more plentiful as technology
finds and creates new resources and uses existing ones more efficiently—e.g. recycled water. In this context,
degradation of water exists, but taken as a whole—is unimportant. The more technically advanced society becomes,
the less it is dependent upon the natural endowments and processes. To wit, the Israeli or former Soviet method is
one of ignoring the source—rather, effort is spent on cleaning to the appropriate use. This obviates the need to keep
all water supplies at the drinking water quality level or aquatic life sustenance level, unless there is some economic
value to that aquatic life. The trick here is in the economic analyses. This view is in complete contrast with those who
indicate that the environmental damage or over subscription is wide spread and thus of critical importance.

Resistance has been attributed to drug over-use. Pruden et al note a less well-understood mechanism for the
amplification of multi-drug resistance, sewage. The local sewer-treatment plant releases pathogens and resistance to
the environment and agriculture. Wastewater treatment intermixes organisms otherwise seldom coming together.
Selective pressures increase survival mechanisms.

Defense strategies include going dormant, entering the viable but non-culturable (VBNC) state. These VBNC
organisms are essentially invisible to laboratory tests used in the wastewater industry. Higgins & Murthy recently
reconfirmed this in a paper that raises some serious questions about the efficacy of current standards. Those authors
noted that during centrifuged dewatering of sewer sludge, indicators in a VBNC state were resuscitated. The results
were several magnitudes greater than standard plate counts had indicated. Such findings raise logical questions. If
dewatering by centrifuge brought out the essence of VBNC, would other products of sewage that had not been
subjected to the centrifuge also in the VBNC state? If so would they revive in the field following application of irrigation
with reclaimed wastewater? This seems plausible but needs further study.

Additionally, as stresses increase organisms can acquire genes from or transfer genes to non-related organisms,
organisms even within completely different kingdoms ,. There are other materials dumped into the drain that confer
resistance. This includes industrial chemicals, heavy metals, and disinfectants. Triclosan a ubiquitous biocide is
suspected of inducing resistance, as are many other industrial materials found in sewage ,. Changes to the cellular
machinery afford the ability to deal with numerous insults, hence cross-resistance .

Many antimicrobials including metabolites enter sewage essentially unchanged to induce resistance in the
environment .  Kummerer ,,,,, and others note levels of antibiotics/pharmaceuticals in sewage able to induce or
maintain resistance, hence adding to the risks in crop production through irrigation.

Based on wastewater (sewage) industry and regulatory opinion, the standards, the released effluent, and its use for
crop irrigation or the land application of sewage sludge are benign and beneficial activities . If however, one reviews
the current medical and scientific literature, a different picture emerges, one that raises serious questions about the
benevolence of this activity and efficacy of the underlying standards . Thus, the issue takes on aspects of a political
and not a scientific argument . In the interim, most regulatory agencies have backed off . This leaves the citizens and
patient base essentially standing naked.

In 2002 the NAS/NRC called into question the U.S. EPA Part 503 guidelines for land application of sewage sludge
(biosolids) and specifically EPA’s failure to consider antibiotic resistance. As of writing this comment, EPA has shown
little if any progress in  investigating resistance. A Freedom of Information Act request to EPA on this subject was
submitted in February 2005. The agency has to this day not answered that request. Additionally, the agency has not
done health hazards risk analyses for pathogens. Notwithstanding these shortcomings, the agency and the
wastewater industry continue to promote the use of sewage byproducts in crop production. Salinas Valley is an
example. There is a fairly significant issue attached to this. The state and local regulators often defer to the U.S. EPA
on matters dealing with wastewater. In some cases this offers the lower jurisdictions an out. It is not uncommon to
hear, “the feds do it this way or the feds have not come up with what ever on this and thus we are at a loss”. But in the
case of recycled water, the feds clearly are not involved and thus the states and locals are the responsible agencies.
As can be seen by this report, the “locals” are ill prepared to act on this critical issue.

Many antimicrobials or their metabolites pass through the body essentially unchanged. Thus feces and urine do
contain some impressive levels. As later noted, Kümmerer and others (1999, 2000, 2003, 2004) [2], have followed
this and noted levels of antibiotics in sewage that are able to induce or maintain resistance. Added to this are the
other materials dumped into the toilet or down the drain that confer resistance. This includes discarded antibiotics and
disinfectants such as Triclosan [3] a ubiquitous biocide has been suspected of inducing resistance.

Based on wastewater industry dogma and standards, released effluent and the land application of sewage sludge are
benign and beneficial activities. If however, one reviews the current medical and scientific literature, a different picture
emerges, one that raises serious questions about the benevolence of this activity and efficacy of the underlying
standards. Thus, the issue takes on aspects of a political and not a scientific argument. In the interim, most regulatory
agencies have backed off. This leaves the citizens and patient base standing naked.

In one of several major studies looking at sewage treatment plants, the scientists followed bacteria through a sewer
treatment works using fecal coliforms as the test organism [4]. Coliform bacteria were isolated at various locations in
the plant, specifically a) the inlet, b) the primary sedimentation tank, c) the activated sludge digestion tank, d) the final
settling tank, e) the outlet and f) the return activated sludge drain. They were then examined the presence of drug
resistant plasmids. Using this approach, resistant bacteria and those that were still sensitive to antibiotics were
detected [5].

Several drugs were tested and included tetracycline, kanamycin, chloramphenicol and streptomycin, ampicillin,
nalidixic acid, rifampicin, and sulfisoxazole. A total of 900 separate tests were conducted, of which more than half
contained multi-drug resistant plasmids. While this is interesting, there was a new finding that raised considerable
concern. The further along that the wastewater had progressed through the treatment process, the greater the
tendency was to encounter strains that had developed multiresistance to antibiotics. Additionally, the study
demonstrated that these multi-resistant bacteria also simultaneously carried, and then passed around their multiple
transferable drug-resistance plasmids. Thus, the development of drug resistance and the transfer of multi-drug
resistance are enhanced in sewage wastewater treatment plants [5]. These findings have been documented for more
than a decade. They were a harbinger, yet little impact from such studies has been noted. Under the current
practices, sewage treatment allows the survival of up to 2-million viable coliform per gram of sludge at the point of
land application to farmlands [6].

The use of low-level indicator bacteria, along with the apparent lack in understanding of antibiotic resistance within U.
S. EPA (see FOIA search results at bottom of this file) should alert anyone that the issue is anything but closed. By its
refusal to adequately present necessary analyses in this area, EPA has not only manufactured uncertainty, but also
potentially increased the risk of human disease, disease from some serious pathogens that may not respond to
current antibiotics. All Class-B sewage sludge technologies that are normally used in the U.S. such as anaerobic
digestion and aerobic digestion and heating at these levels as well as composting and land stabilization do not
effectively destroy critical pathogens [7]. These practices also do not destroy the genetic material and this and its lack
of acknowledgement is a critical shortcoming within EPA. Thus if there is antibiotic resistance within sewer sludge, it
may be passed through these processes to background organisms including man [8]. Actually several studies have
documented the horizontal transfer of genetic information to background environmental systems and such systems
can act as lending libraries for this genetic information. Man and animals are exposed daily to such backgrounds [9].
What are the chances for inadvertent acquisition of resistance from environmental contamination such as through
sewage sludge? Gerba and Rusin [10] conducted research about the passage from finger to mouth of pathogens
found on typical household objects. Others have documented dust as a mechanical vector for pathogens. Thus what
of the dwellings and towns down wind from land application of sewer sludge or from a sewage sludge composting
facility? There are now several workmen’s comp cases filed by staff of the Chino Women’s Prison for complaints
accruing to dust from the adjacent and up-wind sewer sludge composting facility in San Bernardino County, California.

Further, there are concerns about wash-off from rains and irrigation return flows. Gerba and others have written
extensively about the survival of pathogens and their viable infectivity once they are adsorbed onto sediments [11].
Anyone who lives in an agricultural area knows that tillage and wind cause large movements of soil and dust that are
equal to that found for water erosion. The USGS has written extensively on the movement of dust from Africa, across
the Atlantic and carrying with it viable pathogens thus causing respiratory disease in the Caribbean [12].

The indicator organisms used for Class B biosolids commonly include Escherichia coli and sometimes Salmonella.
These are the organisms that are normally killed by low-level disinfection. They are vegetative bacteria that are highly
susceptible to both chemical disinfection and heat disinfection. However, sewage sludge contains a large range of
organisms besides E. coli, Salmonella, and Staphylococcus. Also highly susceptible and easily inactivated are the
enveloped viruses such as Hepatitis B., HIV, and influenza. While these organisms are fairly easily destroyed, Class-B
allows 2 million viable coliform per gram of land applied sewer sludge. This raises the logical question of survival for
the more robust organisms.

These bacteria are thus able to colonize environmental niches, and animals, including humans, through ingestion.
Once ingested, the plasmids may be transferred to normal flora, and subsequently to pathogenic bacteria found in
humans or animals, making later treatment with particular antibiotics ineffective. Also one must consider transfer of
genetic information from these organisms to more robust organisms as highlighted by Sjolund et al. (2005) [13]
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 authors 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
macrolides [14].

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, 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 metals as well as pesticides and farm chemicals that are already found
in agricultural soils. In many cases, the involved cellular machinery is the same or similar, i.e., a duality (see Schlüter
and abstracts of others below).

This duality may have some interesting synergistic survival advantages for the microbes, but bad-for-human-health
effects when considering sewer sludge as applied to heavily farmed lands. Thus emerging pathogens arriving through
sewer sludge are also introduced to a new suite of resistant soil-dwelling organisms with which to exchange genetic
information. The issue of resistance and risk for a pandemic is thus compounded. Since wildlife are not excludable
from these sites, this allows the intermixing of micro and macro organism systems. Canadian geese that have landed
on sewer sludge land applied areas could be potential vectors. We already know that antimicrobial resistance is now
carried by Canadian geese---how did they originally acquire this resistance? Thus, since migratory birds are a
potential route for the spread of bird flu, are we thus shooting ourselves in the foot?

The current standards controlling sewer plant operations, the land application of sewer sludge or the composting of
sewer sludge for making compost and potting soils consider none of these issues. I therefore contend that this
unconsidered avenue for the spread of antibiotic resistance and amplification of risk for a pandemic needs greater
awareness within the medical and health care community.

Without the perspective of a broader analysis of this issue, future policy may be no more that the post hoc
rationalization for a series of missed opportunities. It would seem reckless to proceed without a broader picture.
Unfortunately, the principal regulatory body, U.S. EPA seems to be essentially oblivious to these concepts, yet it has
been promoting the land application of sewer sludge. As seen below, based on a FOIA request, EPA seems less than
knowledgeable in the area of antimicrobial resistance.

+++++++++++++++++++++++++++

Citations and notes
[1] Ribeiro-Dias JC, Vicente AC, Hofer E. Fecal coliforms in sewage waters. I. Resistance to antibiotics, heavy metals
and colicinogeny. Appl Environ Microbiol 1983 Jul;46(1):227-32. Others, have found similar results. Mach PA, et al. R-
plasmid transfer in a wastewater treatment plant. AEM 1982 Dec;44(6):1395-403. Fontaine TD et al. Transferable
drug resistance associated with coliforms from hospital and domentic sewage. Health Lab Sci. 1976 Oct; 13(4): 238-
45. Walter, M. V., and J. W. Vennes. 1985. Occurrence of multiple-antibiotic-resistant enteric bacteria in domestic
sewage and oxidation lagoons. Appl. Environ. Microbiol. 50:930-933. Rhodes G, Huys G, Swings J, McGann P, Hiney
M, Smith P, Pickup RW. Distribution of oxytetracycline resistance plasmids between aeromonads in hospital and
aquaculture environments: implication of Tn1721 in dissemination of the tetracycline resistance determinant tet A.
Appl Environ Microbiol 2000 Sep;66(9):3883-90. Grol A, Szymanska B, Wejner H, Kazanowski A, Wlodarczyk K. The
role of mechanically purified city sewers in the spread of antibiotic-resistant bacteria of the Enterobacteriaceae family]
Med Dosw Mikrobiol 1989;41(2):100-5. Lewis GD, et al. Enteroviruses of human origin and faecal coliforms in river
water and sediments down stream from a sewage outfall in the Taieri River, Otago. New Zealand Journal of Marine
and Freshwater Research, 1986, Vol.20: 101-105. Marcinek H, Wirth R, Muscholl-Silberhorn A, Gauer M.
Enterococcus faecalis gene transfer under natural conditions in municipal sewage water treatment plants. Appl
Environ Microbiol 1998 Feb;64(2):626-32.


[2] Kummerer K. Resistance in the environment. J Antimicrob Chemother. 2004 Aug;54(2):311-20. Epub 2004 Jun 23.
Kummerer K. Promoting resistance by the emission of antibiotics from hospitals and households into effluent. Clin
Microbiol Infect. 2003 Dec;9(12):1203-14. Kummerer K. Standardized tests fail to assess the effects of antibiotics on
environmental bacteria. Water Res. 2004 Apr;38(8):2111-6. Kummerer K. Biodegradability of some antibiotics,
elimination of the genotoxicity and affection of wastewater bacteria in a simple test. Chemosphere. 2000 Apr;40(7):
701-10.

Kummerer K. Drugs, diagnostic agents and disinfectants in wastewater and water--a review. Schriftenr Ver Wasser
Boden Lufthyg. 2000;105:59-71. Al-Ahmad A, Daschner FD, Kummerer K.  Biodegradability of cefotiam, ciprofloxacin,
meropenem, penicillin G, and sulfamethoxazole and inhibition of waste water bacteria. Arch Environ Contam Toxicol.
1999 Aug;37(2):158-63. Rooklidge SJ. Environmental antimicrobial contamination from terraccumulation and diffuse
pollution pathways. Sci Total Environ. 2004 Jun 5;325(1-3):1-13. Review.


[3] Aiello AE, Marshall B, Levy SB, Della-Latta P, Lin SX, Larson E.
Antibacterial cleaning products and drug resistance. Emerg Infect Dis. 2005 Oct;11(10):1565-70).

[4] Ribeiro-Dias JC, Vicente AC, Hofer E. Fecal coliforms in sewage waters. I. Resistance to antibiotics, heavy metals
and colicinogeny. Appl Environ Microbiol 1983 Jul;46(1):227-32. Others, have found similar results. Mach PA, et al. R-
plasmid transfer in a wastewater treatment plant. AEM 1982 Dec;44(6):1395-403. Fontaine TD et al. Transferable
drug resistance associated with coliforms from hospital and domentic sewage. Health Lab Sci. 1976 Oct; 13(4): 238-
45.


[5] Nakamura S, Shirota H. Behavior of drug resistant fecal coliforms and R plasmids in a wastewater treatment plant]
Nippon Koshu Eisei Zasshi 1990 Feb;37(2):83-90.

[6]  Reference--National Research Council of the National Academy of Sciences (NAS) Biosolids Applied to Land:
Advancing Standards and Practices. Washington, DC: National Academy Press, 2002.

[7] This report incorporates portions of a personal conversation with Dr. David Lewis of the EPA on the processes
used for preparation of sewer sludge. Lance JC et al. Virus movement in soil columns flooded with secondary sewage
effluent. AEM Oct 1976 p. 520-26. Gerba CO. Poliovirus removal from primary and secondary sewage effluent by soil
filtration. AEM Aug 1978 p. 247-51. Schaub SA et al, Virus and bacteria removed from wastewater by rapid infiltration
through soil. Bacteriophage movement in ground water at distances of 600 feet from site of application. AEM 33:609-
18. Ward RL et al. Inactivation of poliovirus in digested sludge. AEM 31:921-930. Digested sludge also protects
poliovirus during heat treatment. Polio virus nucleic acid from heat ruptured capsuls will maintain infectivity. Breindl M.
The structure of heated poliovirus particles. J. Jen Vir 11:147-156. Ward RL, et al. Minimum infective dose of animal
viruses. Curt Rev Environ Control 14:278-310. Abbaszadegan M et al. Detection of of enteroviruses in groundwater
with PCR. AEM May 1993 1318-24.

[8] Rooklidge SJ. Environmental antimicrobal contamination from terraaccumulation and difuse pollution pathways. Sci
Toatl Environ 2004 Jun 5;325(1-3):1-13. Golet EM et al. Determination of fluoroquinolone antimicrobial agents in
sewage sludge and sludge treated soils using accelerated solvent extraction followed by solid phase extraction. Anal
Chem. 2002 Nov 1;74(21):5455-62.Overall recovery ranged from 82 to 94% from sludge and 75 to 92% for soils.
Golet EM, et al. Environmental exposure assessment of fluoroquinolone antibacterial agents from sewage to soil.
Environ Sci Technol. 2003 Aug 1;37(15):3243-9. These results suggest sewage sludge as the main reservoir of FQ
residues.

[9] Ray JL, Nielsen KM. Experimental methods for assaying natural transformation and inferring horizontal gene
transfer. Methods Enzymol. 2005;395:491-520. Occurrence and reservoirs of antibiotic resistance genes in the
environment. Seveno, Nadine A. et al. Reviews in Medical Microbiology. Jan 2002, 13(1): 15-27. Hassen A., et al.
Microbial characterization during composting of municipal solid waste. Bioresour Technol 2001 Dec;80(3):217-25. Ray
JL, et al. Experimental methods for assaying natural transformation and inferring horizontal gene transfer. Methods
Enzymol. 2005;395:491-520. Fontaine, T. D., III, and A. W. Hoadley. 1976. Transferrable drug resistance associated
with coliforms isolated from hospital and domestic sewage. Health Lab. Sci. 4:238-245.  Grabow, W. O. K., and O. W.
Prozesky. 1973. Drug resistance of coliform bacteria in hospital and city sewage. Antimicrob. Agents Chemother. 3:
175-180.
Linton, K. B., M. H. Richmond, R. Bevan, and W. A. Gillespie. 1974. Antibiotic resistance and R factors in coliform
bacilli isolated from hospital and domestic sewage. J. Med. Microbiol. 7:91-103. Walter, M. V., and J. W. Vennes.
1985. Occurrence of multiple-antibiotic-resistant enteric bacteria in domestic sewage and oxidation lagoons. Appl.
Environ. Microbiol. 50:930-933.  Rhodes G, Huys G, Swings J, McGann P, Hiney M, Smith P, Pickup RW. Distribution
of oxytetracycline resistance plasmids between aeromonads in hospital and aquaculture environments: implication of
Tn1721 in dissemination of the tetracycline resistance determinant tet A. Appl Environ Microbiol 2000 Sep;66(9):3883-
90. Seveno NA. Occurrence and reservoirs of antibiotic resistance genes in the environment. Reviews in Medical
Microbiology. 13(1):15-27, January 2002.
Cooley MB. Colonization of Arabidopsis thaliana with Salmonella enterica and Enterohemorrhagic Escherichia coli
O157:H7 and Competition by Enterobacter asburiae.  Applied and Environmental Microbiology, August 2003, p. 4915-
4926, Vol. 69, No. 8. Marcinek H, Wirth R, Muscholl-Silberhorn A, Gauer M. Enterococcus faecalis gene transfer
under natural conditions in municipal sewage water treatment plants. Appl Environ Microbiol 1998 Feb;64(2):626-32.
Iversen A, Kuhn I, Franklin A, Mollby R. High prevalence of vancomycin-resistant enterococci in Swedish sewage. Appl
Environ Microbiol 2002 Jun;68(6):2838-42.  Reinthaler FF, Posch J, Feierl G, Wust G, Haas D, Ruckenbauer G,
Mascher F, Marth E. Antibiotic resistance of E. coli in sewage and sludge. Water Res 2003 Apr;37(8):1685-90. Cenci
G, Morozzi G, Daniele R, Scazzocchio F. Antibiotic and metal resistance in "Escherichia coli" strains isolated from the
environment and from patients. Ann Sclavo 1980 Mar-Apr;22(2):212-26.  Heberer T, Reddersen K, Mechlinski A.
From municipal sewage to drinking water: fate and removal of pharmaceutical residues in the aquatic environment in
urban areas. . Water Sci Technol 2002;46(3):81-8.




[10]  Rusin P, et al. Comparative surface-to-hand and fingertip-to-mouth transfer efficiency of gram-positive bacteria,
gram-negative bacteria, and phage. J Appl Microbiol. 2002;93(4):585-92.

[11] Gerba CP et al. Effect of sediments on the survival of Ericherichia coli in marine waters. AEM July 1976 114-20.
LaBelle RL, et al. Influence of pH, salinity and organic matter on the absorption of enterovirus to estuarine sediments.
AEM July 1979 93-101---sediment can act as a reservoir for enterovirus.

[12] Griffin DW. African desert dust in the Caribbean atmosphere: Microbiology and public health. Aerobiologia. 2001
Sept : Volume 17, Number 3, pp. 203 - 213


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

[14]  Giacometti A, Cirioni O, Kamysz W, Silvestri C, Licci A, D'Amato G, Nadolski P, Riva A, Lukasiak J, Scalise G.  In
vitro activity and killing effect of uperin 3.6 against gram- positive cocci isolated from immunocompromised patients.
Antimicrob Agents Chemother. 2005 Sep;49(9):3933-6. Robertson GT, Zhao J, Desai BV, Coleman WH, Nicas TI,
Gilmour R, Grinius L, Morrison DA, Winkler ME. Vancomycin tolerance induced by erythromycin but not by loss of
vncRS, vex3, or pep27 function in Streptococcus pneumoniae. J Bacteriol. 2002 Dec;184(24):6987-7000. ].

++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++

My group had requested, via Freedom of Information Act, certain data from the U.S. EPA on their progress dealing
with biosolids and resistance. In providing us answers to this request, EPA delayed its response for about 6 months
and then merely directed us to a section of the NERL’s website, which contained no usable information. This site was
(www.epa.gov/nerlesd1/chemistry/pharma/fq.htm#disposal), as evidenced by the following search results. Similar
results were found for other EPA web addresses.
Results of Searching the "Environmental Sciences" Area of EPA's Web Site
No matches found for transposon; 1402 files searched
No matches found for antibiotic resistance + biosolids; 1402 files searched.
No matches found for antimicrobial resistance + biosolids; 1402 files searched
No matches found for virulent pathogens + biosolids; 1402 files searched.
No matches found for plasmids + biosolids; 1402 files searched.
No matches found for mobile genetic elements; 1402 files searched.
No matches found for high level disinfection + biosolids; 1402 files searched.
Results of Searching EPA's Entire Web Site
We have searched the entire EPA site and found the following results. You may also return to searching for the same
terms within Environmental Sciences.
No matches found for high level disinfection + biosolids; 494732 files searched.
No matches found for plasmids + biosolids; 494732 files searched.
No matches found for transposons + biosolids; 494732 files searched.
No matches found for mobile genetic elements + biosolids; 494732 files searched.
No matches found for virulent pathogens + biosolids; 494732 files searched.
No matches found for antibiotic resistance + biosolids; 494732 files searched.
No matches found for antimicrobial resistance + biosolids; 494732 files searched.
Results of Searching the "Exposure Research" Area of EPA's Web Site
We have searched the area of EPA's site related to Exposure Research and found the following results. You may also
search for the same terms across EPA's entire site.
No matches found for prions + biosolids; 3352 files searched.
Results of Searching EPA's Entire Web Site
We have searched the entire EPA site and found the following results. You may also return to searching for the same
terms within Exposure Research.
No matches found for prions + biosolids; 530969 files searched.
+++++++++++++++++++++++++++=
The 64 508 bp IncP-1 antibiotic multiresistance plasmid pB10 isolated from a waste-water treatment plant provides
evidence for recombination between members of different branches of the IncP-1 group
A. Schlüter, et al
The complete 64 508 bp nucleotide sequence of the IncP-1 antibiotic-resistance plasmid pB10, which was isolated
from a waste-water treatment plant in Germany and mediates resistance against the antimicrobial agents amoxicillin,
streptomycin, sulfonamides and tetracycline and against mercury ions, was determined and analysed. A typical class
1 integron with completely conserved 5' and 3' segments is inserted between the tra and trb regions. The two mobile
gene cassettes of this integron encode a -lactamase of the oxacillin-hydrolysing type (Oxa-2) and a gene product of
unknown function (OrfE-like), respectively. The pB10-specific gene load present between the replication module
(trfA1) and the origin of vegetative replication (oriV) is composed of four class II (Tn3 family) transposable elements:
(i) a Tn501-like mercury-resistance (mer) transposon downstream of the trfA1 gene, (ii) a truncated derivative of the
widespread streptomycin-resistance transposon Tn5393c, (iii) the insertion sequence element IS1071 and (iv) a
Tn1721-like transposon that contains the tetracycline-resistance genes tetA and tetR. A very similar Tn501-like mer
transposon is present in the same target site of the IncP-1 plasmid R906, suggesting that pB10, R906 and pJP4 are
derivatives of a common ancestor. Interestingly, large parts of the predicted pB10 restriction map, except for the
tetracycline-resistance determinant, are identical to that of R906. It thus appears that plasmid pB10 acquired as many
as five resistance genes via three transposons and one integron, which it may rapidly spread among bacterial
populations given its high promiscuity…”.
++++++++++++++++++++++++++++++++++++++++
Risk Analysis
Volume 24 Page 221 - February 2004
doi:10.1111/j.0272-4332.2004.00425.x Volume 24 Issue 1
A Dynamic Model to Assess Microbial Health Risks Associated with Beneficial Uses of Biosolids Joseph N. S.
Eisenberg1* Jeffrey A. Soller2, James Scott1, Don M. Eisenberg2, and John M. Colford, Jr.1
There is increasing interest in the development of a microbial risk assessment methodology for regulatory and
operational decision making. This document presents a methodology for assessing risks to human health from
pathogen exposure using a population-based model that explicitly accounts for properties unique to an infectious
disease process, specifically secondary transmission and immunity. To demonstrate the applicability of this risk-based
method, numerical simulations were carried out for a case study example in which the route of exposure was direct
consumption of biosolids-amended soil and the pathogen present in the soil was enterovirus. The output from the
case study yielded a decision tree that differentiates between conditions in which the relative risk from biosolids
exposure is high and those conditions in which the relative risk from biosolids is low. This decision tree illustrates the
interaction among the important factors in quantifying risk. For the case study example, these factors include biosolids
treatment processes, the pathogen shedding rate of infectious individuals, secondary transmission, and immunity.
Further refinement in methods for determining biosolids exposures under field conditions would certainly increase the
utility of these approaches.

McGowan's comments on the Risk Analysis paper------
A brief read of this paper produced the following comments. Principal amongst my thoughts is the paper’s limit to
pathogens that would not likely multiply outside the host---i.e., viruses. Thus, the model is quite limited from this
important perspective. Secondly, there is no consideration of transfer of mobile genetic elements (MGEs) to terrestrial
reservoirs, the potential for shifts in genetic information passing through multiple species, and thus the potential for
newly emerging diseases. Consequently the issue of transferred antibiotic resistance and similar molecular and
cellular machinery is missed. They also do not discuss colonization or later acquiring of resistance, the fecal veneer
and thus movement into other organ systems or orifices.
+++++++++++++++++++++++++


From: "Strutzel, Jon (DHS-DDWEM)" <JStrutze@dhs.ca.gov>
To: "Edo McGowan" <edo_mcgowan@hotmail.com>
Subject: RE: exams??
Date: Thu, 3 Nov 2005 08:33:08 -0800

Dr McGowan
We do not provide study material for our exams. WE have a list of suggested reading material but it does not cover
the subjects you are researching.
-----Original Message-----
From: Edo McGowan [mailto:edo_mcgowan@hotmail.com]
Sent: Thursday, November 03, 2005 6:54 AM
To: abc@abccert.org
Cc: Strutzel, Jon (DHS-DDWEM); scfong@waterboards.ca.gov
Subject: exams??

I'm looking for certification exams guides and study material in wastewater or drinking water that would include
discussions in the area of transferred genetic information conferring antibiotic resistance, virulence, or transfer
genetic materials between organisms. I am also looking for information on pharmaceuticals in raw water or finished
water or wastewater.

Please indicate which of your study guides might contain such information or whether your organization or agency
deals with or tests for these subjects.
I look forward to your rapid response via return email.
Dr Edo McGowan, member, Citizens Planning Association of Santa Barbara

++++++++++++++
Rick, while EPA does not enter the picture with respect to reclaimed/recycled water, having left that charge to the
states, here are some useful ideas from the feds on pollution. Below these excerpts is a discussion on what California
state law has to say.

Federal

503.9(t) Pollutant is an organic substance, an inorganic substance, a combination of organic and inorganic
substances, or a pathogenic organism that, after discharge and upon exposure, ingestion, inhalation, or assimilation
into an organism either directly from the environment or indirectly by ingestion through the food chain, could, on the
basis of information available to the Administrator of EPA, cause death, disease, behavioral abnormalities, cancer,
genetic mutations, physiological malfunctions (including malfunction in reproduction), or physical deformations in
either organisms (humans) or offspring (children) of the organisms.

The CWA is even more specific: 13) The term ``toxic pollutant'' means those pollutants, or combinations of pollutants,
including disease-causing agents, which after discharge and upon exposure, ingestion, inhalation or assimilation into
any organism, either directly from the environment or indirectly by ingestion through food chains, will, on the basis of
information available to the Administrator, cause death, disease, behavioral abnormalities, cancer, genetic mutations,
physiological malfunctions (including malfunctions in reproduction) or physical deformations, in such organisms or
their offspring [Humans are one category of Organisms]

The RCRA classifies this pollutants as: (5) The term ``hazardous waste'' means a solid waste, or combination of solid
wastes, which because of its quantity, concentration, or physical, chemical, or infectious characteristics may--
(A) cause, or significantly contribute to an increase in mortality or an increase in serious irreversible, or incapacitating
reversible, illness; or (B) pose a substantial present or potential hazard to human health or the environment when
improperly treated, stored, transported, or disposed of, or otherwise managed.

State

Per Calif Water Code 13552.4, a city can force upon residential areas the use of recycled water. Several districts and
cities, including Santa Barbara want to ultimately expand with the use of recycled water. By doing so, they can offset
potable water and thus allow for expanded development. The other option, of course, is to then sell the offset amount
of potable supply to someone else. It would appear that Los Vegas would buy this water credit as an exchange. Thus
in the water trade environment, there is much incentive to shift to non-potable sources. If the issues below are not
adequately solved from a public health perspective, then whatever expansion occurs will see yet more people put at
potential health risks.

Accordingly here is where the work begins for us. How to get the appropriate decision-makers focused on water
quality and just not on freeing up more supply and the profits to be gained.

California Water Code Section 13550 (a)(3) states that use of recycled water will not be detrimental to public health.
This is echoed in 13521, which controls Title 22. Since Title 22 was put together in 1977, much of the then available
science did not and could not consider later scientific findings that have vastly changed the landscape. Thus Title 22
does not consider antibiotic resistance nor antibiotic resistant genes (ARGs) or virulence islands (VI) which are not
amenable to chlorine disinfection at levels used by the wastewater industry. These genetic fragments also go through
many of the current filter systems. This was confirmed by the work of Amy Pruden. Title 22 also does not consider
VBNC and some of the newly emerging infectious diseases. Nor for that matter, does it consider interactions of heavy
metals and pharmaceuticals which may foster the development of resistance.

There are extant technologies that can deal with some of these issues. Accordingly when considering approval of a
new treatment plant where designs do not consider the issues discussed above, many of the currently examined
projects, considering pathogens, are not achieving BAT and I think that is an important point.

Dried out settling pond or percolation pond surfaces will have a coating of bacterial cells and thus dust containing
endotoxins (LPS). LPS as well as high pH materials are serious irritants and allergens as well as inflammatory reaction
exciters. These act in concert with pathogens to cause irritation and disruption of protective barriers and thus easier
access to disease organisms.

While it would seem that a Regional Water Quality Control Board, in pronouncing on the adequacy of sewer plant
designs, must conform to these statutes, these regional boards often merely rubber-stamp projects and give no
consideration to these issues.

Health and Safety Code 5410 indicates contamination means impairment of the quality of the waters of the state by
waste. The waters of the state include any water within the boundary of the state.

Now the trick would be to also include that water in sewage ponds that is to be used under Title 22, hence water
delivered in pipes. That may take some clever thought. Did the law exclude water in pipes? The legislature to exempt
something must explicitly state such. I think your legal people need to go to work on this overall problem. Another
issue that is being considered by the State Board in its newly revised policy on recycled water is incidental runoff. This
while contrary to the CWA, seems to be something encouraged by industry. The issue is the contamination, not with
chemicals, but with biological systems that can multiply. These multiplying biological systems can thus establish niches
that will constitute lending libraries for terrestrial and aquatic foci of pathogens.

5411---no person (includes city) shall discharge sewage or other waste, or the effluent of treated sewage or other
waste, in any manner which will result in contamination, pollution, or nuisance.

5410 (f)----nuisance means anything which: 1) is injurious to health, 2) affects at the same time an entire community
or neighborhood or any considerable number of persons, and 3) occurs during, or as a result of, the treatment or
disposal of wastes.

This 5410 (f) seems then to loop back to the delivery of Title 22 water to residential areas per 13550 (a) (3) noted
above.

5410 (d)-----contamination means impairment of the quality of the waters of the state by waste to a degree which
creates a hazard to the public health through poisoning or the spread of disease.

Here we can then bring in antibiotic resistance pathogens as well as ARGs and VIs as components of disease. To the
extent that LPS is toxic to tissues, this may fall under the poison as well as disease. The vector issue is another
avenue for disease transmission that will likely result.

Those that have access to law libraries may want to look at Toxic Torts as absolute nuisance---see: 16 Western St.
LR 5. Being something that falls under absolute, there is no escape for the defendant. This is the beauty of absolute.
Same for absolute or strict liability---no excuse is allowed. Thus, if the activity of dealing with pathogens of disease
entities is in fact inherently dangerous, in spite of meeting all requisite standards---there is either something wrong
with the standards, or that activity is one that can be classified as ultrahazardous. If ultrahazardous, then presumably
strict liability would come into play. The section 13550 (a) (3) may set that up---use of recycled water will not be
detrimental to public health.