A Systematic Review of Waterborne Disease Outbreaks Associated with Small Non-Community Drinking Water Systems in Canada and the United States

Reports of outbreaks in Canada and the United States (U.S.) indicate that approximately 50% of all waterborne diseases occur in small non-community drinking water systems (SDWSs). Summarizing these investigations to identify the factors and conditions contributing to outbreaks is needed in order to help prevent future outbreaks. The objectives of this study were to: 1) identify published reports of waterborne disease outbreaks involving SDWSs in Canada and the U.S. since 1970; 2) summarize reported factors contributing to outbreaks, including water system characteristics and events surrounding the outbreaks; and 3) identify terminology used to describe SDWSs in outbreak reports. Three electronic databases and grey literature sources were searched for outbreak reports involving SDWSs throughout Canada and the U.S. from 1970 to 2014. Two reviewers independently screened and extracted data related to water system characteristics and outbreak events. The data were analyzed descriptively with 'outbreak' as the unit of analysis. From a total of 1,995 citations, we identified 50 relevant articles reporting 293 unique outbreaks. Failure of an existing water treatment system (22.7%) and lack of water treatment (20.2%) were the leading causes of waterborne outbreaks in SDWSs. A seasonal trend was observed with 51% of outbreaks occurring in summer months (p