Sanitary sewage overflows, boil water advisories, and emergency room and urgent care visits for gastrointestinal illness: a case-crossover study in South Carolina, USA, 2013-2017.

Background: Sanitary sewage overflows (SSOs) release raw sewage, which may contaminate the drinking water supply. Boil water advisories (BWAs) are issued during low or negative pressure events, alerting customers to potential contamination in the drinking water distribution system.

Objective: We evaluated the associations between SSOs and BWAs and diagnoses of gastrointestinal (GI) illness in Columbia, South Carolina, and neighboring communities, 2013-2017.

Methods: A symmetric bi-directional case-crossover study design was used to assess the role of SSOs and BWAs on Emergency Room and Urgent Care visits with a primary diagnosis of GI illness. Cases were considered exposed if an SSO or BWA occurred 0-4 days, 5-9 days, or 10-14 days prior to the diagnosis, within the same residential zip code. Effect modification was explored via stratification on participant-level factors (e.g., sex, race, age) and season (January-March versus April-December).

Results: There were 830 SSOs, 423 BWAs, and 25,969 cases of GI illness. Highest numbers of SSOs, BWAs and GI cases were observed in a zip code where >80% of residents identified as Black or African-American. SSOs were associated with a 13% increase in the odds of a diagnosis for GI illness during the 0-4 day hazard period, compared to control periods (Odds Ratio: 1.13, 95% Confidence Interval: 1.09, 1.18), while no associations were observed during the other hazard periods. BWAs were not associated with increased or decreased odds of GI illness during all three hazard periods. However, in stratified analyses BWAs issued between January-March were associated with higher odds of GI illness, compared to advisories issued between April-December, in all three hazard periods.

Significance: SSOs (all months) and BWAs (January-March) were associated with increased odds of a diagnosis of GI illness. Future research should examine sewage contamination of the drinking water distribution system, and mechanisms of sewage intrusion from SSOs.

Impact: Sewage contains pathogens, which cause gastrointestinal (GI) illness. In Columbia, South Carolina, USA, between 2013-2017, there were 830 sanitary sewage overflows (SSOs). There were also 423 boil water advisories, which were issued during negative pressure events. Using case-crossover design, SSOs (all months) and boil water advisories (January-March) were associated with increased odds of Emergency Room and Urgent Care diagnoses of GI illness, potentially due to contamination of the drinking water distribution system. Lastly, we identified a community where >80% of residents identified as Black or African-American, which experienced a disproportionate burden of sewage exposure, compared to the rest of Columbia.