Preface

Figures

Tables

Summary

Acknowledgments

Abbreviations

Introduction

Background

Wastewater Reuse

Treatment of Reclaimed Water

Reclaimed Water in the Montebello Forebay

Regulation of Reclaimed Water Use in California

Health Effects Study

Scientific Review of Health Effects Study

Rationale Behind Epidemiologic Studies of Reclaimed Water

Results of Study of Cancer, Mortality, and Infectious Disease

Overview of Report

Literature Review

Possible Mechanisms for Environmental Influence on Adverse Birth Outcomes

Impact of Fetal Loss on Adverse Outcomes Among Live Births

Low Birth Weight and Preterm Birth

Birth Defects

Infant Mortality

Studies of Drinking Water and Adverse Birth Outcomes

Overview of Study Designs and Methods

Studies of Drinking Water Contaminants and Spontaneous Abortions

Studies of Drinking Water and Low Birth Weight and Preterm Delivery

Studies of Drinking Water and Birth Defects

Summary

Methods

Data Sources

Birth and Death Certificates

California Birth Defects Monitoring Program

1990 Census

Definitions of Adverse Birth Outcomes

Prenatal Development and Infant Mortality

Birth Defects

Exposure to Reclaimed Water

Estimating the Percentage of Reclaimed Water in Domestic Supplies

Identifying Water Purveyors in the Montebellow Forebay

Estimating the Percentage of Reclaimed Water in Groundwater Supplies

Estimating Reclaimed Water Percentages by Service Area

Linking Exposure Data with Other Data

Selection of Control Area

Statistical Methods

Logistic Regression Analysis of Birth Outcome Data

Parameter Estimation

Variability of Parameter Estimates

Imputation, Missing Values, and Sample Sizes in Models

Sensitivity Analysis

Power of Statistical Tests

Results

Characteristics of Study Populations

Study Populations in 1990

Characteristics of Births in Study Populations

Association Between Reclaimed Water and Outcomes

Patterns of Health Outcomes in Study Populations

Hypotheses Tested

Measures of Exposure Effect and Statistical Significance

Assessing Causality of Associations

Prenatal Development and Infant Mortality

Birth Defects

All Birth Defects, Neural Tube, Other Nervous System, and Eyes, Ears, Face, and Neck Defects

Major Cardiac Defects, Patent Ductus Arteriosus, Other Cardiac, and Respiratory System Defects

Cleft Defects, Pyloric Stenosis, Intestinal Atresias, and Other Digestive System Defects

Limb, Other Musculoskeletal, Integument, and All Other Defects

Chromosomal Syndromes and Syndromes Other Than Chromosomal

Sensitivity Analyses

Summary and Discussion

Summary of Results

Interpretation of Study Results

Meaning of Null Effects

Evaluating the Dose-Response Relationship

Generalizability

Limitations of Study Design

Lack of Information on Individual Exposure

Effect of Population Mobility

Inability to Control for Potentially Confounding Variables

Effect of Spontaneous Abortions and Elective Terminations on Adverse Birth Outcomes

Comparison of Results with Other Studies

Previous Epidemiologic Studies of the Montebello Forebay

Epidemiologic Studies of Drinking Water and Adverse Birth Outcomes

Strengths of Study Design

Quality of Outcome Data

Other Strengths

Conclusions

Future Research

Appendix

A. Epidemiologic Studies of Drinking Water and Adverse Birth Outcomes

B. Methods Used to Estimate the Percentage of Reclaimed Water in Montebello Forebay Groundwater Supplies

C. Percentage of Reclaimed Water in Montebello Forebay Water System Service Areas and Zip Codes by Year, 1982--1993

D. Minimum Detectable Odds Ratio for Each Outcome and Exposure Group

E. Results of Sensitivity Analyses Using Logistic Regression Models of Prenatal Development Outcomes and Infant Mortality

F. Results of Sensitivity Analyses Using Logistic Regression Models for Birth Defect Outcomes

Bibliography