Water and sanitation

This summary is based on data on the proportion of the population connected to wastewater treatment facilities or to sanitation facilities in urban and rural areas. It also contains information on the environment and health context and the policy relevance and context, and an assessment of the situation in the WHO European Region.

Key message

In the European Union (EU) countries, there were significant improvements in the proportion of the population connected to wastewater treatment facilities between 1980 and 2003. On average, two thirds of the population had been connected by 2003, although there were significant variations. Further, data for the Region show that coverage in rural areas often lags behind that in urban areas, particularly in eastern Europe and central Asia.

Diarrhoeal disease, which is estimated to have caused 13 000 deaths in children aged under 14 years in the eastern European and central Asian countries of the WHO European Region in 2001, is strongly associated with poor water quality. Improved wastewater treatment can reduce this burden, and continued efforts to implement policies with this aim are essential.

Figures

Presentation of data

Fig. 1 shows the percentage of the child population living in agglomerations with more than 2000 inhabitants with home connections to wastewater treatment facilities in 2001. The differences between western and eastern European countries are clear.

Fig. 2 shows the percentage of the population with house connections to sanitation facilities in urban and rural areas for 2004 in those Member States for which data are available. Data cover domestic populations that are connected to a sewerage system, thus private septic tanks or dry sanitation are excluded.

Fig. 1. Wastewater treatment and access to improved sanitation: Percentage of the child population served by sewerage connected to a wastewater treatment facility, selected European countries, 2001

Source: EUROSTAT (1).

Fig. 2. Percentage of the population connected to sanitation facilities in urban and rural areas, selected countries in the WHO European Region, 2004

Note. Privately owed septic tanks or dry sanitation systems are not included in the data. Serbia and Montenegro became two separate Member States of WHO in September 2006. In this figure the data refer to 2004 and relate only to the then entity of Serbia and Montenegro (Serbia).

Source: WHO/UNICEF Joint Monitoring Programme (2).

[ Download Excel sheet with figure data

Rationale

This indicator assesses the potential level of pollution from domestic point sources entering the aquatic environment which may have an adverse impact on public health. It also monitors progress towards reducing this potential. In terms of population health, the indicator shows the percentage of the population at risk of infection via the faecal-oral route due to the absence of adequate sewage disposal systems.

Health and environment context

Wastewater from households and industry places a significant pressure on the water environment through the release of loads of organic matter, nutrients, hazardous substances and pathogenic microorganisms. The majority of the European population lives in urban agglomerations (three quarters in 1999) and a significant proportion of wastewater is collected in sewers connected to public wastewater treatment plants. Low water quality reduces the availability of water resources for specific uses, in particular domestic needs and irrigated agriculture, and has adverse implications for public health.

The principal effect on health of poor water quality is diarrhoeal disease. A recent estimate of mortality from diarrhoeal disease attributable to poor water, sanitation and hygiene suggested that over 13 000 children aged under 14 years die annually in Europe and central Asia due to poor water conditions (3–5).

In the European Region, the burden of diarrhoeal disease is estimated to be 5.3% of all deaths and 3.5% of all disability-adjusted life-years (DALYs) in children aged 0–14 years in 2001. The largest contribution to the burden of disease comes from those countries with low adult and low child mortality (countries in the WHO Eur-B sub-region), with over 11 000 deaths and almost 500 000 DALYs. This suggests that high potential reductions in deaths and DALYs could be made by the development of infrastructures and better personal hygiene. For instance, in, giving the entire child population in the Eur-B countries access to a regulated water supply and full sanitation coverage, with partial treatment for sewage, would save about 3700 lives and 140 000 DALYs (6).

For additional information, see ENHIS-2 fact sheet 1.1 of April 2007 on outbreaks of waterborne diseases (7).

Policy relevance and context

Pan-European and global context

The WHO-United Economic Commission for Europe (UNECE) Protocol for Water and Health, adopted in 1999, requires all countries to provide sanitation to a standard which sufficiently protects human health and the environment through the establishment, improvement and maintenance of collective systems and wastewater treatment installations, and to establish a programme for monitoring situations likely to result in outbreaks or incidents of water-related disease (8). Progress made is to be assessed in terms of suitable indicators, of which this indicator is one.

The size of the burden of disease attributable to poor sanitation and hygiene, and the availability of means to reduce it, led to the inclusion of “access to improved sanitation” in the United Nations Millennium Development Goals indicators (9).

In 2004, the Fourth Ministerial Conference on Environment and Health adopted the Children’s Health and Environment Action Plan for Europe (CEHAPE), which includes four regional priority goals to reduce the burden of environment-related diseases in children (10). One of the goals (RPG I) aims at preventing and significantly reducing morbidity and mortality arising from gastrointestinal disorders and other health effects, by ensuring that adequate measures are taken to improve access to safe and affordable water and adequate sanitation for all children.

EU context

Council Directive of 21 May 1991 (91/271/EEC) concerning urban wastewater treatment prescribes the level of treatment required before discharge (11). It requires member states to provide all agglomerations of more than 2000 population equivalents (p.e.) with collecting systems. Secondary (biological) treatment must be provided for all agglomerations of more than 2000 p.e. discharging into fresh waters and estuaries and for all agglomerations of more than 10 000 p.e. discharging into coastal waters. EU member states must identify water bodies as sensitive areas (vulnerable to eutrophication) in accordance with the criteria of the Directive. In sensitive areas, they must provide more advanced treatment of wastewater with nutrient removal, placing more stringent criteria with specific monitoring requirements. The Directive is designed to protect the ecological status of receiving waters and does not require microbiological analysis of effluents discharged from wastewater treatment facilities. Member states are required to submit biennial reports to the EU of their progress towards the implementation of the Directive.

The cohesion policy of the EU will continue to support sewage treatment plants from its €336 billion budget for 2007–2013 for all new member states. Support is greatly needed as current investments in some of the eastern European countries are at the level of €5–10 per capita and will need to be increased to €40–50 per capita to comply with the deadlines (12).

Assessment

An average of 66.5% of the population of the countries considered in the assessment were connected to wastewater treatment facilities in 2003. There are, however, wide differences between countries. In the Nordic and some northern European countries, which have the longest tradition of water purification, more than 85% of the population were connected to wastewater treatment facilities. In southern European countries coverage ranged between 40% and 60%, while in some of the new EU member states it was less than 40%.

For the period considered, annual data were not available for a number of countries, which makes the derivation of time trends at the European level difficult. The available data show that on average there was a 70% increase in coverage from 1980 to 2003, with a 20% increase from 1995 to 2003. Some countries, including the Czech Republic, Hungary, Iceland and Poland, have made significant progress since 1995.

The European Urban Wastewater Treatment Directive has resulted in significant improvements in urban wastewater treatment capacity (13). It is anticipated that with the planned increase in capacities of treatment plants and collection networks the situation will continue to improve.

The data from the Joint Monitoring Programme for Water Supply and Sanitation (14) show a wide difference between urban and rural areas in a number of countries in terms of the percentage of the population with house connections to sanitation facilities. This underlines the urban and rural challenges of the decade in meeting the Millennium Development Goals target for drinking-water and sanitation.

Metadata

Name: Wastewater treatment and access to improved sanitation

Definition: Percentage of the population in the community or area under consideration served by a sewerage system connected to a wastewater treatment facility or a safe local wastewater disposal system

Code: RPG1_WatSan_P1

Data source

1. EUROSTAT (1)
2. WHO/UNICEF Joint Monitoring Programme (2).

Description of data

The EUROSTAT data are derived from the dataset “National population connected to wastewater treatment plants” (Table IWQ4).

The Joint Monitoring Programme data are the datasets “san_urb_hc” and “san_rur_hc”, defined as “Percentage of population with house connections to sanitation facilities in urban and rural areas”. House connections only take into account domestic connections that are connected to a sewerage system and therefore exclude septic tanks or dry sanitation, even if privately owned. Improved sanitation includes connection to a public sewer, connection to a septic system, pour-flush latrine, simple pit latrine or ventilated improved pit latrine.

Method for indicator calculation

The indicator was computed as: connected population/total population × 100.

Geographical coverage

The EUROSTAT database covers 27 EU countries and Croatia.

The Joint Monitoring Programme database covers all Member States of the WHO European Region, including the Commonwealth of Independent States.

Period of coverage

The EUROSTAT database provides data from 1970 to 2003: every five years from 1970 to 1990 and annually from 1990 to 2003.

The Joint Monitoring Programme database provides data for four time points 1990, 1995, 2002 and 2004.

Frequency of update

The EUROSTAT database is updated every two years. The Joint Monitoring Programme database is updated when a new questionnaire is filled in.

Data quality

Owing to the voluntary nature of the data collection, the data sets obtained by EUROSTAT and by the Joint Monitoring Programme are not complete and do not relate to the child population.

EUROSTAT checks the data for plausibility, for example, for logical consistency and for extraordinary changes in time series. The data are revised whenever a new questionnaire is filled in.

Because the data collected are useful in a policy context to identify areas with low sanitation coverage, there is a need for improvement in the collection, management and reporting of data. A mechanism for regular reporting as well as a widening in the data coverage and improvement in the estimates of sanitation and wastewater treatment should be set under the WHO Protocol on Water and Health.

For more information on meta data and calculation of this indicator, please refer to the methodology .

References

1. EUROSTAT [web site]. Brussels, Statistical Office of the European Communities, 2007 (http://europa.eu.int/comm/eurostat/, accessed 17 March 2007).
2. WHO and UNICEF. Joint Monitoring Programme for Water Supply and Sanitation [web site]. Geneva, World Health Organization and New York, United Nations Children’s Fund, 2006 (http://www.wssinfo.org/en/, accessed 17 March 2007).
3. WHO/UNICEF. Global water supply and sanitation assessment 2000 report. Geneva, World Health Organization, and New York, United Nations Children’s Fund, 2002 (http://www.who.int/water_sanitation_health/monitoring/jmp2000.pdf, accessed 19 March 2007).
4. Valent F et al. Burden of disease attributable to selected environmental factors and injuries among Europe’s children and adolescents. Geneva, World Health Organization, 2004 (WHO Environmental Burden of Disease Series, No. 8; http://www.who.int/quantifying_ehimpacts/publications/en/ebd8web.pdf, 19 March 2007).
5. Prüss-Üstün A et al. Unsafe water, sanitation and hygiene. In: Global and regional burden of disease attribution to selected major risk factors. Geneva, World Health Organization, 2004:1321–1352.
6. Study on environmental burden of disease in children: key findings. Copenhagen, WHO Regional Office for Europe, 2004 (Fact Sheet EURO/05/04; http://www.euro.who.int/document/mediacentre/fs0504e.pdf, accessed 15 March 2004).
7. WHO European Centre for Environment and Health. Outbreaks of waterborne diseases. Copenhagen, WHO Regional Office for Europe, 2007 (ENHIS-2 project, Fact sheet No. 1.1).
8. WHO-UNECE. Protocol on Water and Health to the 1992 Convention on the Protection and Use of Transboundary Watercourses and International Lakes. Geneva, United Nations Economic Commission for Europe and Copenhagen, WHO Regional Office for Europe, 2006 (http://www.euro.who.int/Document/Peh-ehp/ProtocolWater.pdf, accessed 26 March 2007).
9. Millennium development goal indicators. New York, United Nations, 2006 (http://mdgs.un.org/unsd/mdg/, accessed 19 March 2007).
10. Children’s Environment and Health Action Plan for Europe. Declaration. Fourth Ministerial Conference on Environment and Health, Budapest, 23–25 June 2004 (EUR/04/5046267/6; http://www.euro.who.int/document/e83335.pdf, accessed 16 March 2007).
11. Council Directive of 21 May 1991 (91/271/EEC) concerning urban waste water treatment. Brussels, European Commission, Environment Directorate-General, 2007 (http://europa.eu.int/comm/environment/water/water-urbanwaste/directiv.html, accessed 19 March 2007).
12. Effectiveness of urban wastewater treatment policies in selected countries: an EEA pilot study. Copenhagen, European Environment Agency, 2005 (Report No. 2/2005; http://reports.eea.europa.eu/eea_report_2005_2/en, accessed 19 March 2007).
13. European Environment Agency. The European environment – state and outlook 2005. Part B: Core set of indicators. Luxembourg, Office for Official Publications of the European Communities, 2005:348–391.
14. WHO/UNICEF Joint Monitoring Programme for Water Supply and Sanitation. Meeting the MDG drinking-water and sanitation target: the urban and rural challenge of the decade. Geneva, World Health Organization and New York, United Nations Children’s Fund, 2006 (http://www.who.int/water_sanitation_health/monitoring/jmpfinal.pdf, accessed 19 March 2007).

Water indicators. Copenhagen, European Environment Agency, 2007 (http://themes.eea.eu.int/Specific_media/water/indicators, accessed 19 March 2007).

The Protocol on Water and Health. Copenhagen, WHO Regional Office for Europe, 2006 (http://www.euro.who.int/document/wsn/WaterProtocol_2006upd_web.pdf, accessed 26 March 2007).

Author: Alexandra Katsiri, National School of Public Health, Athens, Greece.

This summary is based on data on the proportion of the population with continuous access to an adequate amount of safe drinking-water in the home. It also contains information on the environment and health context, the policy relevance and context, and an assessment of the situation in the WHO European Region.

The data mainly reflect the proportion of the population supplied from a public system controlled regularly for quality criteria compliance, and only to a lesser extent the safety and adequacy of drinking-water available to the population.

The complexity of the definition of an improved source, combined with the voluntary nature of the reporting, means that care should be taken in interpreting the data.

Key message

There is a clear east-west divide as regards access to drinking-water. In western Europe, close to 100% of the population have had access to safe drinking-water since the 1990s. In the eastern part of the Region access remains low, albeit rising, ranging from 58% to 80%. According to the World Health Organization and United Nations Children’s Fund (WHO/UNICEF) Joint Monitoring Programme assessment (1), there are important disparities between urban and rural areas: in the East only 30–40% of rural households have access to individual sources of safe drinking-water.

Figures

Presentation of data

Fig. 1 is based on EUROSTAT data covering 22 countries in Europe which show that close to 100% of the population in almost all the western countries have continuous access to adequate amounts of safe drinking-water at home.

Fig. 2 shows data covering 48 countries from the Joint Monitoring Programme database. This gives a broader view of the Region and reveals that an important proportion of the population, especially in the Commonwealth of Independent States, has poorer access to improved drinking-water sources, particularly in rural areas.

Fig. 1. Proportion of population connected to public water supply in Europe, 2002, or last available year

Note. Data for France and Germany are for 2001; data for Italy are for 1999; data for Portugal are for 1998; data for Slovakia are for 2003; data for Sweden are for 1997.

Source: EUROSTAT (1).

Fig. 2. Percentage of the population with access to an improved water supply in urban and rural areas, WHO European Region, 2004 or last available year

Note. Data for Belgium, Greece and Portugal are for 1995; data for Armenia, Azerbaijan, Belarus, Cyprus, Georgia, Kazakhstan, Kyrgyzstan, Republic of Moldova, Russian Federation, Tajikistan, Turkey, Turkmenistan, Ukraine and Uzbekistan are for 2002.

Serbia and Montenegro became two separate Member States of WHO in September 2006. In this fact sheet the data refer to 2004 and relate to the then one country of Serbia and Montenegro.

Source: WHO/UNICEF Joint Monitoring Programme (2).

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Rationale

The indicator estimates the achievement of the minimum requirements for access to an adequate supply of piped and safe water in the home. It is a core indicator for risks related to water and hygiene.

Health and environment context

Access to safe drinking-water is strongly connected to basic health benefits. Hence, from the public health point of view, the proportion of the population with access to safe drinking-water is an indicator that measures the extent to which basic needs (as defined by the United Nations in recognition of water as a fundamental human right) are met (3,4).

Outbreaks of disease related to contaminated drinking-water continue to occur even in the economically developed European countries. They can severely affect human health, with infants and young children bearing the highest risk. According to WHO estimates, poor quality drinking-water causes over 13 000 deaths from diarrhoea in children aged 0–14 years in the European Region (5.3% of all deaths in that age group) (5).

While the vast majority of outbreaks of waterborne diseases result from microbial (bacteriological, viral, protozoan or other biological) contamination, serious health concerns may also arise as a result of chemical contamination of drinking-water. These considerations explain the need to achieve high common standards for drinking-water so as to reduce the burden of diseases attributable to poor quality water, sanitation and hygiene.

Policy relevance and context

At present, there is no specific European Union (EU) legislation regarding the compulsory reporting of access to safe drinking-water.

The WHO-United Nations Economic Commission (UNECE) for Europe Protocol on Water and Health, which entered into force in August 2005, is the first legally binding instrument for the prevention and control of water-related diseases through improved and harmonized water supply and management. Article 4 of the Protocol requires parties to provide adequate supplies of wholesome drinking-water free from any microorganisms, parasites and substances which, owing to their numbers or concentration, constitute a potential danger to human health. To this end, parties are required to set targets and report on progress (6).

The Millennium Development Goal No. 7, target 10, is to “halve by 2015, the proportion of people without sustainable access to safe drinking-water and basic sanitation”. Millennium Development Goal No. 4 (reduction of child mortality) is also relevant: 90% of the circa 1.8 million deaths that occur every year from diarrhoeal diseases are in children aged under five years, mostly in developing countries (7). Target 5 is “to reduce by two thirds the under-five mortality rate between 1990 and 2015”.

In the European Region, a lack of safe water and adequate sanitation has been recognized as a major cause of child mortality and morbidity, especially in eastern countries. One of the four strands of the Children’s Environment and Health Action Plan for Europe (CEHAPE), the Regional Priority Goal 1, focuses on specific action “to increase the proportion of households with access to safe water and adequate sanitation, thereby ensuring that the proportion of children without access to clean water and sanitation is halved by 2015” (8).

The implementation of the WHO-UNECE Protocol supports the achievement of the Millennium Development Goals as well as of CEHAPE.

Assessment

By estimating the proportion of the general population with access to piped water in the home, the indicator also provides an estimate of the number of people without such access who are potentially exposed to water-related health risks. With very few exceptions accessibility is close to 100% for many western European countries, but several hot spots can be detected in countries in the eastern part of the Region. However, accessibility (i.e. a water connection in the home) does not include compliance with the other criteria for this indicator such as an adequate water supply or compliance for quality or quantity of the water or the sustainability of a water supply.

The big disparities in water and sanitation coverage are in the countries grouped in the WHO Eur-B sub-region (Albania, Armenia, Azerbaijan, Bosnia and Herzegovina, Bulgaria, Georgia, Kyrgyzstan, Poland, Romania, Serbia and Montenegro, Slovakia, Tajikistan, The former Yugoslav Republic of Macedonia, Turkey, Turkmenistan, Uzbekistan), where 86% of the population have access to an improved water source but only 63% have a household drinking-water connection. This situation accounts for the significant contribution of this region to the total burden of disease.

Although data are only available for the general population, they could be considered a good estimate for the child population as well, an indicator of progress in achieving the goals and a good marker for countries where action should be taken to increase the proportion of the (child) population with access to safe drinking-water.

Metadata

Name: Public water supply and access to improved water sources

Definition: Proportion of population with continuous access to adequate amount of safe drinking-water at home

Code: RPG1_WatSan_Ex1

Data source

1. EUROSTAT (1)
2. WHO/UNICEF Joint Monitoring Programme (2).

Description of data

Data on the total population with access to safe drinking-water are collected by questionnaire, either from the national statistics institutes (for EUROSTAT) or by WHO/UNICEF country representatives (for the Joint Monitoring Programme).

EUROSTAT data provide information on the proportion of the population with access to piped water in the home.

Joint Monitoring Programme data cover total access, that is, they include all “improved” water supply sources, both private and public. An “improved” water supply source, as defined by the Programme, is a source likely to provide at least 20 litres per person per day of safe water, such as a household connection, a borehole, a protected dug well, a protected spring or rainwater collection, within one kilometre of the user’s dwelling.

Method for indicator calculation

The indicator was computed as: connected population/total population × 100.

Geographical coverage

The EUROSTAT database covers almost all the EU countries plus some others. Data were available for Austria, Belgium, Bulgaria, the Czech Republic, Cyprus, Denmark, Estonia, France, Germany, Hungary, Iceland, Ireland, Italy, Liechtenstein, the Netherlands, Norway, Poland, Portugal, Romania, Slovakia, Slovenia and Sweden.

The Joint Monitoring Programme database covers almost all the 53 countries in the WHO European Region, including the Commonwealth of Independent States.

Period of coverage

The EUROSTAT database provides data from 1980 to 2003, with annual reporting periodicity.

The Joint Monitoring Programme database offers data for five time points: 1990, 1995, 2000, 2002 and 2004.

Frequency of update

Annually for the EUROSTAT database.

Data quality

Owing to the voluntary nature of the data collection, the data sets obtained by both EUROSTAT and the Joint Monitoring Programme are incomplete and do not relate to the child population. Because of the relevance of those data in relation to the quality of the water supplied and, consequently, to water-related risks for children, there is a need for further improvement. The data reported should be in accordance with the standardized definition of the terms “accessibility”, “safe” and “adequate” in order to reflect the real dimensions of the problem and its potential implications for health.

The collected data are useful in a policy context to identify areas where there is a need to focus on improving the water supply. For the future, however, there is a need for standardized, regular and clearly defined reporting on the proportion of the population with access to safe water, to allow for the estimation of water-related risks for children (in schools and kindergartens).

For more information on meta data and calculation of this indicator, please refer to the methodology .

References

1. EUROSTAT [web site]. Brussels, Statistical Office of the European Communities, 2007 (http://europa.eu.int/comm/eurostat/, accessed 17 March 2007).
2. WHO and UNICEF. Joint Monitoring Programme for Water Supply and Sanitation [web site]. Geneva, World Health Organization and New York, United Nations Children’s Fund, 2006 (http://www.wssinfo.org/en/, accessed 17 March 2007).
3. The right to water. Geneva, World Health Organization, 2003 (WHO Health and Human Rights Publication Series, No. 3; http://www.who.int/water_sanitation_health/rtwrev.pdf, accessed 16 March 2007).
4. Committee on Economic, Social and Cultural Rights. General Comment No. 15 (2002): The right to water (arts. 11 and 12 of the International Covenant on Economic, Social and Cultural Rights). Geneva, United Nations Economic and Social Council, 2003 (E/C.12/2002/11; http://www.unhchr.ch/tbs/doc.nsf/0/a5458d1d1bbd713fc1256cc400389e94/$FILE/G0340229.pdf, accessed 16 March 2007).
5. Valent F et al. Burden of disease attributable to selected environmental factors and injuries among Europe’s children and adolescents. Geneva, World Health Organization, 2004 (WHO Environmental Burden of Disease Series, No. 8; http://www.who.int/quantifying_ehimpacts/publications/en/ebd8web.pdf, 19 March 2007).
6. WHO-UNECE. Protocol on Water and Health to the 1992 Convention on the Protection and Use of Transboundary Watercourses and International Lakes. Geneva, United Nations Economic Commission for Europe and Copenhagen, WHO Regional Office for Europe, 2006 (http://www.euro.who.int/Document/Peh-ehp/ProtocolWater.pdf, accessed 26 March 2007).
7. Health and the millennium development goals. Geneva, World Health Organization, 2005 (http://www.who.int/hdp/publications/mdg_en.pdf, accessed 16 March 2007).
8. Children’s Environment and Health Action Plan for Europe. Declaration. Fourth Ministerial Conference on Environment and Health, Budapest, 23–25 June 2004 (EUR/04/5046267/6; http://www.euro.who.int/document/e83335.pdf, accessed 16 March 2007).

The Protocol on Water and Health. Copenhagen, WHO Regional Office for Europe, 2006 (http://www.euro.who.int/document/wsn/WaterProtocol_2006upd_web.pdf, accessed 26 March 2007).

Millennium Development Goals Report 2006. New York, United Nations, 2006 (http://mdgs.un.org/unsd/mdg/Resources/Static/Products/Progress2006/MDGReport2006.pdf, accessed 27 March 2007).

Author: Alexandra Cucu, Senior Lecturer, University of Medicine and Pharmacology “Carol Davila”, Bucharest, Romania.

This summary is based on data describing outbreaks of waterborne diseases related to drinking- and bathing water. An outbreak of waterborne disease is generally defined as a situation in which at least two people experience a similar illness after exposure to water and the evidence suggests a probable water source. The document also contains information on the environment and health context and the policy relevance and context, as well as an assessment of the situation in the WHO European Region and suggestions for further monitoring.

Key message

The indicator shows that in seven European countries surveyed there were 75 outbreaks of waterborne diseases related to drinking-water resulting in over 12 000 episodes of illness between 2000 and 2005. The data must be interpreted cautiously, as differences between countries are likely to reflect the efficiency of surveillance systems rather differences in outbreaks, and data were only available for a few countries. This underlines the need for more widespread and effective surveillance systems. Additionally, as the provision of adequate water and sanitation is associated with outbreaks of disease, the successful efforts to improve coverage in recent years must be continued.

Figures

Presentation of data

Fig. 1 shows the number of outbreaks of disease arising from drinking-water reported in Croatia, Estonia, Finland, Greece, Hungary, Slovakia and the United Kingdom (England and Wales) from 2000 to 2005. Outbreaks were seen in all reporting nations except Estonia.

Fig. 2 shows the number of illness episodes attributable to outbreaks of disease carried in drinking-water reported in the same countries over the same period. The data reflect cases in whole populations as child-specific data are not available.

Fig. 1. Number of reported outbreaks of diseases arising from drinking-water in selected European countries, 2000-2005

Source: Surveys of various national agencies (see below under Data underlying the indicator).

Fig. 2. Number of reported episodes of illness attributable to diseases carried in drinking-water in selected countries, 2000–2005

Notes. Child-specific data are not available. Number of episodes shown on a log-scale.

Source: Surveys of various national agencies (see below under Data underlying the indicator).

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Rationale

Safe drinking- and bathing water is vital for the health of the population, particularly children. The number of outbreaks of waterborne diseases provides an indication of the quality of the drinking- or bathing water.

Health and environment context

Waterborne diseases arise from the contamination of water either by pathogenic viruses, bacteria or protozoa, or by chemical substances. These agents are directly transmitted to people when the water is used for drinking, preparing food, recreation or other domestic purposes. An outbreak of waterborne disease is usually defined as an event meeting two criteria: (i) at least two people have experienced similar illness after exposure to water, and (ii) epidemiological evidence implicates water as the probable source of the illness. The occurrence of outbreaks of waterborne diseases is not limited to developing countries: affluent nations are also affected (1).

Drinking-water

The risk of outbreaks of waterborne diseases increases where standards of water, sanitation and personal hygiene are low. Globally, the proportion of people with access to safe drinking-water and basic sanitation rose from 78% in 1990 to 83% in 2004. Despite this progress, an estimated 425 million children aged under 18 years still have no access to an improved water supply. In 2004 it was estimated that diarrhoea due to unsafe water and the lack of basic sanitation contribute to the death of 1.5 million children aged under five years each year (2). In the European Region the burden of diarrhoeal disease attributable to poor water, sanitation and hygiene in children aged 0–14 years is estimated at 13 548 (5.3% of all deaths) and 31.5 disability-adjusted life-years per 10 000 children The burden of disease attributable to poor quality water, sanitation and hygiene is estimated to be 5.3% of all deaths in children aged 0–14 years in the Region (3).

Contaminated drinking-water is a frequent cause of diseases including cholera, typhoid, viral hepatitis A and dysentery. Water may be contaminated with naturally occurring inorganic elements such as arsenic, radon or fluoride. Human activities may also cause water contamination through agents such as lead, nitrates and pesticides (4).

Bathing water

In addition to the potential risks posed by poor quality drinking-water, contaminated bathing water can cause serious and potentially fatal diseases. These include severe diseases such as typhoid and leptospirosis as well as a number of minor infections. Health risks are highest among people with impaired immune systems or among specific risk-groups, such as tourists who do not have immunity against local endemic diseases (5). At present, the general quality of bathing water in Europe, as measured by the presence of faecal indicators and pathogens in bathing waters (6,7), poses limited health risks. The quality has improved since the 1990s: in 2003, 97% of the monitored coastal bathing waters and 92% of inland bathing waters complied with the mandatory standards. However, high compliance with mandatory standards (for example, occurrence of indicator bacteria) does not necessarily mean there are no factors which could potentially affect public health (8–10).

Policy relevance and context

The WHO-United Nations Economic Commission for Europe (UNECE) Protocol on Water and Health (11) includes legally binding targets covering the prevention of waterborne diseases. In addition to general targets concerning access to safe drinking-water and provision of sanitation, common requirements for surveillance systems and contingency plans for detection and prevention of waterborne outbreaks are specified.

WHO has developed the concept of water safety planning. This is a new approach to ensure safe drinking-water through enhanced risk assessment and management systems for the production and distribution of drinking-water. The three major components are system assessment, monitoring and management and communications (4,12). Water safety planning is at an early stage in Europe.

In 2004, the Fourth Ministerial Conference on Environment and Health adopted the Children’s Health and Environment Action Plan for Europe (CEHAPE), which includes four regional priority goals to reduce the burden of environment-related diseases in children. One of the goals (RPG I) aims at preventing and significantly reducing morbidity and mortality arising from gastrointestinal disorders and other health effects, by ensuring that adequate measures are taken to improve access to safe and affordable water and adequate sanitation for all children (13).

In the European Union (EU), the Drinking-water Directive (98/83/EC) presents parametric and indicator values for water intended for human consumption and how the quality should be controlled to obtain safe drinking-water (14). The Directive requires that all possible action should be taken in cases of contamination to prevent any negative health impact.

The European Water Framework Directive (15) represents a single system for all water management replacing seven earlier directives. The main goal is to achieve a good status for all waters by 2015 in Europe. The key objectives are the general protection of aquatic ecology, the specific protection of unique and valuable habitats, the protection of drinking-water resources, and the protection of bathing water (15).

Bathing water

The Council Directive on the Quality of Bathing Waters (76/160/EEC) included mandatory and guidelines values for bathing water quality and instructions for reporting the results to the EU (16). According to the Directive, a reduction in the pollution of bathing waters is necessary to protect both the environment and public health. A new bathing water directive 2006/7/EC entered into force in March 2006, containing instructions on improving the management of bathing sites by, for example, using bathing water profiling, emergency planning and better information for the public (17).

Assessment

This indicator assesses the number of reported outbreaks of waterborne diseases in a country. The data must be interpreted cautiously: the reported numbers may underestimate the real situation, and variations between countries are partially due to differences in surveillance systems. The chain of events leading to the detection of outbreaks is complex: an affected person must have symptoms and seek medical care, the surveillance agency must be notified, the number of cases must be noted as unusually high for a given time and place, and an effective outbreak investigation must be carried out. Owing to such complexity, the effectiveness of surveillance systems varies greatly. As an example, a high number of reported outbreaks may paradoxically be seen in countries with high quality drinking-water and an efficient surveillance system.

Drinking-water

The comparative assessment in this indicator was made using the data on outbreaks of disease caused by drinking-water gathered from a CEHAPE questionnaire completed by Croatia, Estonia, Finland, Greece, Hungary, Slovakia and the United Kingdom (England and Wales). All the participating countries had a routine surveillance system for waterborne outbreaks, based on a legal framework. Child-specific data were not available. In the seven participating countries, there were 75 outbreaks during 2000–2005, resulting in 12 348 episodes of illness (Fig. 1,2). The most common causative agents were bacterial (Campylobacters, Shigella Sonnei, Aeromonas species) and were responsible for 45 (60%) of the outbreaks and 34.8% of the cases of illness cases. Viral agents were implicated in 20 outbreaks (27%) and 60.6% of cases of illness. Four outbreaks were caused by protozoa (3.7% of cases of illness), two by chemical contamination (0.1% of cases of illness), and in four cases an unknown microbial agent was implicated (0.8% of the cases of illness). There are no trends either between or within countries evident in the data.

Bathing water

For bathing water, the indicator showed that associated outbreaks were infrequent (from zero to seven annual outbreaks) (18). This may be partially due to the known improvements in EU bathing water quality (see under Health and Environment Context above) as well as to the relative lack of routine surveillance systems for bathing water outbreaks.

While the numbers of outbreaks reported varied greatly between the countries, they might not reflect the true situation (for reasons outlined above). It must also be noted that this indicator is only available for few a countries and provides a very limited picture of the situation in the Region.

In general, there is a need for widespread and effective monitoring and reporting systems for outbreaks of waterborne diseases to give a better idea of the true magnitude of such outbreaks and their impact on health in the Region.

Metadata

Name: Outbreaks of waterborne diseases

Definition: Number of outbreaks of waterborne diseases attributable to drinking-water and bathing water each year.

Code: RPG1_WatSan_E1

Data source

The data are based on a questionnaire (18) concerning outbreaks of waterborne diseases in Europe and surveillance systems for such outbreaks. The questionnaire covered items such as the legal framework for outbreak monitoring, the number of outbreaks and cases of illness, age groups and causative agents. It was completed by the following organizations: National Institute of Public Health, Croatia; Health Protection Inspectorate, Estonia; Health Protection Agency, United Kingdom; National School of Public Health, Greece; National Public Health Institute, Finland; Public Health Authority, Slovakia; National Centre for Epidemiology and National Institute of Environmental Health, Hungary.

Description of data

Data were mainly obtained from national surveys. In most countries the information concerning outbreaks of waterborne diseases is included in the general infectious diseases monitoring system. Finland applies a separate monitoring system for outbreaks of diseases attributable to drinking-water. Croatia, Estonia, Hungary, Slovakia and the United Kingdom (England and Wales) have monitoring and reporting systems for bathing water outbreaks. Only Croatia was able to produce statistics concerning cases of illness among young people aged under 18 years.

Method for indicator calculation

Geographical coverage

Croatia, Estonia, Finland, Greece, Hungary, Slovakia and the United Kingdom (England and Wales).

Period of coverage

In all the countries except Greece (2004–2005) the data cover the whole period 2000–2005.

Frequency of update

All the countries confirmed that routine reporting/monitoring systems were used. It must therefore be assumed that all the countries have continuous monitoring systems that include a periodic/annual national reporting system for such outbreaks.

Data quality

Reporting systems vary. Croatia, Finland and Greece use a compulsory reporting system for outbreaks of waterborne disease. Other countries use national surveys that may include information collected using both compulsory and voluntary reporting systems.

For more information on meta data and calculation of this indicator, please refer to the methodology .

References

1. Hrudey SE, Hrudey EJ. Safe drinking water. Lessons from recent outbreaks in affluent nations. London, International Water Association Publishing, 2004.
2. Water, sanitation and hygiene links to health: facts and figures. Geneva, World Health Organization, 2004 (http://www.who.int/water_sanitation_health/factsfigures2005.pdf, accessed 15 March 2007).
3. Study on environmental burden of disease in children: key findings. Copenhagen, WHO Regional Office for Europe, 2004 (Fact Sheet EURO/05/04; http://www.euro.who.int/document/mediacentre/fs0504e.pdf, accessed 15 March 2004).
4. Guidelines for drinking-water quality, 3rd ed., Vol. 1. Recommendations. Geneva, World Health Organization, 2004 (http://www.who.int/water_sanitation_health/dwq/GDWQ2004web.pdf, accessed 15 March 2007).
5. Pond K. Water recreation and disease. Plausibility of associated infections: acute effects, sequelae and mortality. London, IWA Publishing, 2005 (http://www.who.int/water_sanitation_health/bathing/recreadis.pdf, accessed 15 March 2007).
6. Kueh CSW et al. Epidemiological study of swimming-associated illnesses relating to bathing-beach water quality. Water Science and Technology, 1995, 31:1–4.
7. Pruss A. Review of epidemiological studies on health effects from exposure to recreational water. International Journal of Epidemiology, 1998, 27:1–9.
8. European Environment Agency [web site]. Bathing water quality (CSI 022). Copenhagen, European Environment Agency, 2005 (http://themes.eea.europa.eu/IMS/IMS/ISpecs/ISpecification20041007132021/IAssessment1116508884876/view_content#Keyassessment, accessed 15 March 2007).
9. European Commission. Quality of bathing water (2004 bathing season). Luxembourg, Office for Official Publications of the European Communities, 2005 (http://ec.europa.eu/water/water-bathing/report2005/2005_report_complete_en.pdf, accessed 15 March 2007).
10. Schvoerer E, et al. PCR detection of human viruses in bathing areas, waste waters and human stools in south-western France. Research in Microbiology, 2000, 151:693–701.
11. Protocol on Water and Health to the 1992 Convention on the Protection and Use of Transboundary Watercourses and International Lakes. Second Meeting of the Parties to the Protection and Use of Transboundary Watercourses and International Lakes, The Hague, Netherlands, 23–25 March 2000. Copenhagen, WHO Regional Office for Europe and Geneva, United Nations Economic Commission for Europe, 1999 (http://www.unece.org/env/documents/2000/wat/mp.wat.2000.1.e.pdf, accessed 16 March 2007).
12. Davison A et al. Water safety plans. Managing drinking-water quality from catchment to consumer. Geneva, World Health Organization, 2005 (http://www.who.int/water_sanitation_health/dwq/wsp170805.pdf, accessed 15 March 2007).
13. Children’s Environment and Health Action Plan for Europe. Declaration. Fourth Ministerial Conference on Environment and Health, Budapest, 23–25 June 2004 (EUR/04/5046267/6; http://www.euro.who.int/document/e83335.pdf, accessed 16 March 2007).
14. Council Directive 98/83/EC of 3 November 1998 on the quality of water intended for human consumption. Official Journal of the European Union, 1998, L330:32–54.
15. Directive 2000/60/EC of the European Parliament and of the Council establishing a framework for the Community action in the field of water policy. Official Journal of European Communities, 2000, L327:1–73.
16. Council Directive 76/160/EEC of 8 December 1975 concerning the quality of bathing water. Official Journal of the European Union, 1976, L31:1–7.
17. Directive 2006/7/EC of the European Parliament and of the Council of 15 February 2006 concerning the management of bathing water quality and repealing Directive 76/160/EEC. Official Journal of the European Union, 2006, L64:37–51.
18. Children’s Environment and Health Action Plan for Europe. Implementing the commitments of the Fourth Ministerial Conference on Environment and Health 2004 “The future for our children”. Copenhagen, WHO Regional Office for Europe, 2006 (EUR/06/5067855/8; http://www.euro.who.int/Document/EEHC/CEHAPE_Cyprus_8.pdf, accessed 21 March 2007).

Author: Ilkka Miettinen, National Public Health Institute, Kuopio, Finland.

This summary is based on data on bathing water quality reported by European Union (EU) member states. It also contains information on the environment and health context and the policy relevance and context, and an assessment of the situation in the EU.

Key message

The water quality of coastal zones improved steadily from 1992 to 2004 and remained high in 2005. The new Bathing Water Directive 2006/7/EC has set higher standards for the management of bathing waters.

The water quality in freshwater zones has fallen. Some of the new EU member states have experienced problems with relatively poor water quality and the organization of sampling activities.

Figures

Presentation of data

Fig. 1 shows trends in bathing water quality in the EU for 1990-2005. Fig. 2 and 3 show the results of bathing water quality assessments in coastal and freshwater zones in 2005, as shown in the EU’s annual bathing water quality report for 2005 (3), expressed as a percentage of the total number of bathing sites. The water quality parameters were based on criteria set by Bathing Water Directive 76/160/EEC. Insufficiently sampled sites could not meet the required sampling frequency. Mandatory requirements were not fulfilled by bathing sites which did not meet the compulsory criteria set by the Directive.

Fig. 1. Bathing water quality in the EU, 1990–2005

Source: EU (3).

Fig. 2. Bathing water quality for coastal zones in the EU, 2005

Source: EU (3).

Fig. 3. Bathing water quality for freshwater zones in the EU, 2005

Source: EU (3).

Download Excel sheet with Figure Data

Rationale

EU member states have been successful in implementing the Bathing Water Quality Directive 76/160/EEC (1) and maintaining high quality bathing waters. The adoption of a new Bathing Water Directive 2006/7/EC in 2006 introduced new principles for the management of bathing waters (2). Member states now face the challenge of meeting the new requirements.

Health and environment context

Safe bathing water is an essential factor in public health. Poor quality of recreational waters has been shown to be the cause of outbreaks of waterborne diseases involving many tourists as well as local people (4).

The quality of bathing waters may be affected by inadequate sewage treatment and agricultural pollution, resulting in microbial and chemical contamination and eutrophication.

There is considerable epidemiological evidence in the literature to suggest that contact with recreational waters is associated with illness, primarily gastrointestinal symptoms, although outbreak data also suggest that there is a risk from more serious illnesses such as Shigella sonneri, Escherichia coli O157 infection, protozoan parasites and enteric viruses (5,6). A recent assessment of the global burden of disease attributable to gastroenteric infections arising from unsafe recreational marine water environments has estimated it as 66 000 disability-adjusted life-years (DALYs) (7).

The population groups that may be at higher risk of disease include the young and tourists who do not have immunity against locally occurring endemic diseases. Children tend to play for longer periods in recreational waters and are more likely than adults to swallow water intentionally or accidentally (8).

Policy relevance and context

In 2004, the Fourth Ministerial Conference on Environment and Health adopted the Children’s Environment and Health Action Plan for Europe (CEHAPE), which includes four regional priority goals to reduce the burden of environment-related diseases in children (9). One of the goals (RPG I) aims to prevent and significantly reduce morbidity and mortality arising from gastrointestinal disorders and other health effects, by ensuring that adequate measures are taken to improve access to safe and affordable water and adequate sanitation for all children.

Directive 76/160/EEC on Bathing Water Quality defined quality criteria for bathing waters and obliged the member states to monitor bathing sites. This has been replaced by Directive 2006/7/EC, which sets new standards for the monitoring and management of bathing waters and for providing relevant information to the public, taking into account the scientific evidence of recent years. The requirements of the Bathing Water Directive are coherent with Water Framework Directive 2000/60/EC (10), which established an overall framework for water management.

The owners of bathing sites may not be able to improve the quality of water when intervention is needed at regional or national level to establish and enforce proper monitoring schemes, construct sewage treatment plants and take action to limit industrial and agricultural emissions.

The new Bathing Water Directive requires member states to have a management plan for each site, based on an assessment of the pollution sources. Sites with poor water quality must be prepared to close the bathing area when conditions conducive to pollution are forecast. If the quality standards are not met, remedial measures must be taken.

The new Directive also obliges member states to disseminate information on bathing water quality, the reasoning behind assessments of resulting health risks and recommendations for the safest behaviour to the public.

These principles are in accordance with the WHO guidelines for bathing water management (8) which may be applied to meet the requirements of the Bathing Water Directive.

Assessment

From 1990 to 2005, the mean number of freshwater and coastal bathing areas complying with EU standards was relatively stable or improved, indicating the general willingness of member states to implement the Bathing Water Directive (Fig. 1).

Compliance of coastal bathing waters with the mandatory standards slipped back from 96.7% in 2004 to 96.1% in 2005 as a result of the higher number of banned areas and areas which were insufficiently sampled in 2005 (273 and 90, respectively). The percentage of bathing areas failing to comply with the mandatory values was 1.3% compared to 1.5% in 2004.

Reversing the slight decrease in the 2004 season, compliance with the more stringent guide values rose from 88.5% in 2004 to 89.8% in 2005. The number of areas which were insufficiently sampled more than doubled, from 38 areas in the 2004 bathing season to 90 in 2005. The number of areas banned increased for the fifth consecutive year to 273, or 1.9% of the total number of coastal bathing waters.

The results for the freshwater zones showed a negative trend between 2004 and 2005. Compliance with the mandatory values went down by 3.8% to 85.6% in the 2005 season. This fall can be explained by the significant increase in the number of bathing water areas that were insufficiently sampled: from 98 areas (1.6%) in 2004 to 361 areas (5.4%) in 2005.

Compliance with the guide values fell from 66.5% in 2004 to 63.1% in 2005. The percentage of freshwater bathing areas failing to comply with the mandatory values increased slightly from 3.4% to 3.5%. This was the second consecutive year that the quality of freshwater bathing areas deteriorated. After 2003 the rate of compliance fell by 6.8% for the mandatory values and by 4.8% for the guide values.

A further 0.1% of freshwater bathing areas were banned in the 2005 season, resulting in approximately 5% of freshwater areas being banned since the 2003 season.

Some of the new EU member states seem to have difficulties in implementing monitoring schemes, resulting in a high percentage of insufficiently sampled bathing sites. However, because of the limited time frame (1–2 years) it is impossible to show any trends (Fig. 2,3).

The resulting data published in the annual bathing water quality report (3), collected since 1990 and improved every year, have made it possible to develop useful tools for both specialists and lay persons to assess bathing water quality in given places (11). The establishment of monitoring schemes, improved transmission of the results to the public and action taken to improve bathing water quality have considerably improved the management of bathing waters.

In general, the Bathing Water Directive 76/160/EEC was successfully implemented until it was repealed. The same can be expected for the new Directive, which presents new challenges for EU member states.

Metadata

Name: Bathing water quality

Definition: Proportion of identified bathing waters falling under the Bathing Water Directive definition complying with the EC mandatory standards

Code: RPG1_WatSan_S1

Data source

European Commission (3).

European Environment Agency (12).

Description of data

Data are available as PDF documents in the EU 2005 report on bathing water quality (3) or Excel tables in the EEA database BATHSEA_EN_V2 (12).

Data include:

Year; country name and country code according to ISO 3166-1; zone (freshwater or coastal); total number of bathing areas; C(G): percentage of bathing areas sufficiently sampled which comply with guide values; C(I): percentage of bathing areas sufficiently sampled which comply with guide values and mandatory values; NB: percentage of bathing areas where bathing was prohibited throughout the bathing season; NC: percentage of bathing areas which do not comply with mandatory values; NF: percentage of bathing areas not sufficiently sampled.

Method for indicator calculation

The indicator RWC can be computed as RWC = 100 × (C/T), where C is the number of bathing waters complying with the mandatory coliform standards and T is the total number of bathing waters identified for compliance monitoring.

Geographical coverage

Countries belonging to the EU before 2004 (1990–2005), Gibraltar (1992–2004), Cyprus, the Czech Republic, Estonia, Latvia, Lithuania, Slovakia and Slovenia (since 2004).

Period of coverage

1990–2005.

Frequency of update

Annual reporting from Member States. Sampling and assessment procedures are carried out according to Directive 76/160/EEC.

Data quality

Accurate information on the number of bathing waters and compliant bathing waters are available at EU level in the EU bathing water quality report (3).

For more information on meta data and calculation of this indicator, please refer to the methodology .

References

1. Council Directive 76/160/EEC of 8 December 1975 concerning the quality of bathing water. Brussels, European Commission, 1975 (http://eur-lex.europa.eu/LexUriServ/LexUriServ.do?uri=CELEX:31976L0160:EN:HTML, accessed 20 March 2007).
2. Directive 2006/7/EC of the European Parliament and of the Council of 15 February 2006 concerning the management of bathing water quality and repealing Directive 76/160/EEC. Official Journal of the European Union, 4.3.2006, L64/37 (http://eur-lex.europa.eu/LexUriServ/site/en/oj/2006/l_064/l_06420060304en00370051.pdf, accessed 20 March 2007).
3. Quality of bathing water, 2005 bathing season. Luxembourg, Office for Official Publications of the European Union, 2006 (http://ec.europa.eu/water/water-bathing/report_2006.html, accessed 20 March 2007).
4. Nichols G. Infection risks from water in natural and man-made environments. Eurosurveillance, 2006, 11(4):76–78 (http://www.eurosurveillance.org/em/v11n04/1104-221.asp, accessed 20 March 2007).
5. Pruss A. Review of epidemiological studies on health effects from exposure to recreational water. International Journal of Epidemiology, 1998, 27:1–9.
6. Pond K. Water recreation and disease. Plausibility of associated infections: acute effects, sequelae and mortality. London, IWA Publishing, 2005 (http://www.who.int/water_sanitation_health/bathing/recreadis.pdf, accessed 20 March 2007).
7. Shuval H. Estimating the global burden of thalassogenic diseases: human infectious diseases caused by wastewater pollution of the marine environment. Journal of Water and Health, 2003, 01(2):53-64. (http://www.iwaponline.com/jwh/001/0053/0010053.pdf, accessed 26 March 2007).
8. Guidelines for safe recreational water environments. Vol. 1 – Coastal and fresh waters. Geneva, World Health Organization, 2003 (http://www.who.int/water_sanitation_health/bathing/srwe1/en/, accessed 20 March 2007).
9. Children’s Environment and Health Action Plan for Europe. Fourth Ministerial Conference on Environment and Health, Budapest, 23–25 June 2004 (EUR/04/5046267/7) (http://www.euro.who.int/document/e83338.pdf, accessed 2 March 2007).
10. Directive 2000/60/EC of the European Parliament and of the Council of 23 October 2000 establishing a framework for Community action in the field of water policy. Official Journal of the European Union, 22.12.2000, L327/1 (http://europa.eu.int/eur-lex/pri/en/oj/dat/2000/l_327/l_32720001222en00010072.pdf, accessed 20 March 2007).
11. Bathing water quality. Wandering around in the atlas. Brussels, European Commission. (http://ec.europa.eu/water/cgi-bin/bw.pl, accessed 20 March 2007).
12. Compliance to the Bathing Water Quality Directive 76/160/EEC: coastal and fresh water zones [online database]. Copenhagen, European Environment Agency, 2006 (http://dataservice.eea.europa.eu/dataservice/metadetails.asp?id=683, accessed 20 March 2007).

Bathing water quality [web site]. Brussels, European Commission, 2006 (http://ec.europa.eu/water/water-bathing/index_en.html, accessed 20 March 2007).

Author: Jüri Ruut, Health Protection Inspectorate, Tartu, Estonia.