University of Oulu

Iro Evlampidou, Laia Font-Ribera, David Rojas-Rueda, Esther Gracia-Lavedan, Nathalie Costet, Neil Pearce, Paolo Vineis, Jouni J.K. Jaakkola, Francis Delloye, Konstantinos C. Makris, Euripides G. Stephanou, Sophia Kargaki, Frantisek Kozisek, Torben Sigsgaard, Birgitte Hansen, Jörg Schullehner, Ramon Nahkur, Catherine Galey, Christian Zwiener, Marta Vargha, Elena Righi, Gabriella Aggazzotti, Gunda Kalnina, Regina Grazuleviciene, Kinga Polanska, Dasa Gubkova, Katarina Bitenc, Emma H. Goslan, Manolis Kogevinas, and Cristina M. Villanueva (2020). Trihalomethanes in Drinking Water and Bladder Cancer Burden in the European Union, Environmental Health Perspectives 128:1 CID: 017001.

Trihalomethanes in drinking water and bladder cancer burden in the European Union

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Author: Evlampidou, Iro1,2,3; Font-Ribera, Laia1,2,3,4; Rojas-Rueda, David1,2,3;
Organizations: 1ISGlobal, Barcelona, Spain
2Universitat Pompeu Fabra (UPF), Barcelona, Spain
3CIBER Epidemiologia y Salud Pública (CIBERESP), Madrid, Spain
4Hospital del Mar Medical Research Institute (IMIM), Barcelona, Spain
5Université de Rennes, Institut national de la santé et de la recherche médicale (Inserm), École des hautes études en santé publique (EHESP), Rennes, France
6London School of Hygiene & Tropical Medicine, London, UK
7Imperial College of London, London, UK
8Center for Environmental and Respiratory Health Research (CERH), University of Oulu, Oulu, Finland
9Service Public de Wallonie, Direction générale de l’Agriculture, des Ressources naturelles et de l’Environnement, Département de l'Environnement et de l’Eau, Jambes, Belgium
10Water and Health Laboratory, Cyprus International Institute for Environmental and Public Health, Cyprus University of Technology, Limassol, Cyprus
11Environmental Chemical Processes Laboratory (ECPL), Department of Chemistry, University of Crete, Heraklion, Greece
12The Cyprus Institute, Aglantzia-Nicosia, Cyprus
13National Institute of Public Health, Prague, Czech Republic
14Department of Public Health, Section for Environment, Occupation & Health, Aarhus University, Aarhus, Denmark
15Geological Survey of Denmark and Greenland (GEUS), Aarhus, Denmark
16National Centre for Register-based Research, Aarhus University, Aarhus, Denmark
17Public Health Department, Estonian Ministry of Social Affairs, Tallinn, Estonia
18Santé Publique France (French National Public Health Agency), Saint-Maurice, France
19Environmental Analytical Chemistry, Center for Applied Geosciences (ZAG), Eberhard-Karls-University Tuebingen, Tuebingen, Germany
20National Public Health Center, Budapest, Hungary
21Department of Biomedical, Metabolic and Neural Sciences, University of Modena and Reggio Emilia, Modena, Italy
22Public Health Division, Ministry of Health of the Republic Latvia, Health Inspectorate, Riga, Latvia
23Department of Environmental Sciences, Faculty of Natural Sciences, Vytautas Magnus University, Kaunas, Lithuania
24Department of Environmental Epidemiology, Nofer Institute of Occupational Medicine, Lodz, Poland
25Public Health Authority of the Slovak Republic, Bratislava, Slovak Republic
26National Institute of Public Health, Ljubljana, Slovenia
27Cranfield Water Science Institute, Cranfield University, Cranfield, Bedford, UK
Format: article
Version: published version
Access: open
Online Access: PDF Full Text (PDF, 0.5 MB)
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Language: English
Published: National Institute of Environmental Health Sciences, 2020
Publish Date: 2020-03-04


Background: Trihalomethanes (THMs) are widespread disinfection by-products (DBPs) in drinking water, and long-term exposure has been consistently associated with increased bladder cancer risk.

Objective: We assessed THM levels in drinking water in the European Union as a marker of DBP exposure and estimated the attributable burden of bladder cancer.

Methods: We collected recent annual mean THM levels in municipal drinking water in 28 European countries (EU28) from routine monitoring records. We estimated a linear exposure–response function for average residential THM levels and bladder cancer by pooling data from studies included in the largest international pooled analysis published to date in order to estimate odds ratios (ORs) for bladder cancer associated with the mean THM level in each country (relative to no exposure), population-attributable fraction (PAF), and number of attributable bladder cancer cases in different scenarios using incidence rates and population from the Global Burden of Disease study of 2016.

Results: We obtained 2005–2018 THM data from EU26, covering 75% of the population. Data coverage and accuracy were heterogeneous among countries. The estimated population-weighted mean THM level was 11.7μg/L [standard deviation (SD) of 11.2]. The estimated bladder cancer PAF was 4.9% [95% confidence interval (CI): 2.5, 7.1] overall (range: 0–23%), accounting for 6,561 (95% CI: 3,389, 9,537) bladder cancer cases per year. Denmark and the Netherlands had the lowest PAF (0.0% each), while Cyprus (23.2%), Malta (17.9%), and Ireland (17.2%) had the highest among EU26. In the scenario where no country would exceed the current EU mean, 2,868 (95% CI: 1,522, 4,060; 43%) annual attributable bladder cancer cases could potentially be avoided.

Discussion: Efforts have been made to reduce THM levels in the European Union. However, assuming a causal association, current levels in certain countries still could lead to a considerable burden of bladder cancer that could potentially be avoided by optimizing water treatment, disinfection, and distribution practices, among other possible measures.

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Series: Environmental health perspectives
ISSN: 0091-6765
ISSN-E: 1552-9924
ISSN-L: 0091-6765
Volume: 128
Issue: 1
Article number: 017001
DOI: 10.1289/EHP4495
Type of Publication: A1 Journal article – refereed
Field of Science: 3121 General medicine, internal medicine and other clinical medicine
3142 Public health care science, environmental and occupational health
Funding: This work was funded by the EU Seventh Framework Programme EXPOsOMICS Project (grant agreement no. 308610), Human Genetics Foundation agreement 17-080 ISG, and CIBER Epidemiología y Salud Pública (CIBERESP). ISGlobal is a member of the Centres de Recerca de Catalunya (CERCA) Programme, Generalitat de Catalunya.
Copyright information: © 2020 The Authors. Reproduced with permission from Environmental Health Perspectives.