(Mis)perception and Use of Unsterile Water in Home Medical Devices

PN View 360+ Survey, United States, August 2021

Shanna Miko; Sarah A. Collier; Claire E. Burns-Lynch; Ashley A. Andújar; Katharine M. Benedict; Julia C. Haston; Catherine O. Hough; Jennifer R. Cope

Disclosures

Emerging Infectious Diseases. 2023;29(2):397-401.

Abstract and Introduction

Abstract

Tap water is not sterile, and its use in home medical devices can result in infections from waterborne pathogens. However, many participants in a recent survey in the United States said tap water could safely be used for home medical devices. These results can inform communication materials to reduce the high consequence of infections.

Introduction

Tap water in the United States is treated to meet safe drinking standards; however, low levels of microorganisms remain in drinking water distribution systems, wells, and premise plumbing.^[1,2] Although most of these microorganisms are harmless and the water is safe for drinking and cooking, it might not always be safe for other uses, such as aerosolized inhalation and ocular or nasal irrigation.^[2–4] Microorganisms that can be found in water systems include Pseudomonas aeruginosa, nontuberculous mycobacteria (NTM), Legionella spp., Acanthamoeba spp., and Naegleria fowleri.^[1,2] In the United States, biofilm-associated pathogens such as Pseudomonas spp., NTM, and Legionella spp. are responsible for a large portion of the 120,000 hospitalizations, 7,000 deaths, and billions in direct healthcare costs annually related to waterborne diseases.^[5]

Persons who are at a higher risk for acquiring high-consequence opportunistic infections include the elderly, infants and young children, and persons who have weakened immune systems and other concurrent conditions.^[2,6] Some persons who have weakened immune systems might want to take precautions and use water free from microbes. Sterile water does not contain organic microbes but might contain inorganic materials, such as minerals; distilled water does not contain organic and inorganic materials.^[7]

At home, water is used for various health activities, including filling nasal rinsing devices and respiratory devices such as continuous positive airway pressure (CPAP) machines, vaporizers, and portable humidifiers. We hypothesize that people might not understand that tap water is not sterile, leading to its use for specific purposes, such as nasal rinsing, inhalation, and contact lens rinsing that are not recommended.

One study reported demographic data on household water use for home medical devices.^[8] Few data sources describe the understanding of sterile water sources by the population of the United States. This study aimed to quantify perceptions of sterile water, water sources, and actual use of water for home medical purposes among US adults and identify differences among demographic groups regarding perceptions and use of water. These findings can help focus educational efforts to increase awareness of safe water use practices for home medical activities, supporting healthcare providers and public health practitioners in advising their patients and communities about safe water practices for home medical activities.

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Abstract and Introduction
The Study
Conclusions
References

Table 1. Demographic characteristics of 1,004 respondents to question about potential uses for tap water, by response, in survey of knowledge about uses for tap water, PN 360 View 2021, United States*
Characteristic	Do you agree or disagree with the following statements about US tap water?
Characteristic	Can be used for drinking	Can be used for rinsing contact lenses	Can be used for nasal rinsing	Can be used in respiratory devices†	Bacteria and other living things are not present in US tap water
I don't know	38	140	157	194	119
General population	81 (78–83)	50 (47–54)	62 (59–66)	42 (38–45)	33 (30–36)
Sex
F	77 (73–81)	43 (38–48)	58 (52–63)	37 (32–42	24 (20–28)
M	84 (81–88)	57 (52–62)	67 (62,72)	46 (41–51)	42 (37–47)
p value	0.0090	0.0002	0.0073	0.0153	<0.0001
Race
Black or African American	76 (68–84)	47 (37–57)	58 (48,68)	48 (37–58)	48 (38–58)
Other‡	69 (59–78)	46 (35–57)	57 (46,68)	35 (24–45)	26 (17–35)
p value	0.0013	0.5781	0.2917	0.2145	0.0039
Ethnicity
Hispanic**	67 (58–76)	48 (38–58)	60 (51,70)	38 (28–48)	31 (22–40)
Non-Hispanic	83 (81–86)	50 (47–54)	63 (59,66)	42 (38–46)	33 (30–37)
p value	<0.0001	0.7034	0.6528	0.4189	0.6011
Age, y
18–34	73 (68–79)	50 (44–56)	65 (59,71)	45 (38–52)	38 (31–44)
35–54	80 (75–85)	52 (46–58)	58 (52,64)	37 (31–43)	35 (29–40)
≥55	86 (82–90)	49 (43–55)	64 (58,70)	43 (36–49)	28 (23–33)
p value	0.0008††	0.7743	0.2784	0.1910	0.0378††
Region
Northeast	80 (74–87)	59 (51–67)	66 (57,74)	49 (41–58)	34 (26–41)
Midwest	85 (80–90)	46 (38–54)	60 (53,68)	41 (33–49)	33 (26–41)
South	82 (78–86)	48 (42–54)	63 (58,69)	40 (34–45	34 (29–39)
West	75 (68–81)	51 (44–58)	61 (54,68)	39 (32–47)	30 (24–37)
p value	0.0663	0.1199	0.7756	0.2810	0.8283
Metro status
Urban	81 (76–86)	59 (52–65)	66 (60,72)	49 (43–56)	44 (38–50)
Suburban	79 (75–83)	46 (40–51)	59 (54,64)	38 (32–43)	28 (24–33)
Rural	83 (78–88)	47 (40–55)	64 (57,72)	39 (31–46)	28 (21–34)
p value	0.5218	0.0052‡‡	0.1933	0.0163‡‡	<0.001‡‡
Household income
<$59,999	79 (76–83)	48 (43–53)	62 (57,66)	39 (35–44)	31 (26–35)
≥$60,000	82 (78–86)	53 (47–58)	63 (58,68)	44 (39–50)	36 (31–41)
p value	0.2638	0.2013	0.6294	0.1722	0.0978
Water source, n = 932
Private well	90 (85–96)	63 (54–72)	71 (63–79)	55 (46–65)	48 (39–57)
Municipal	81 (78–84)	48 (44–52)	61 (57–65)	39 (35–43)	30 (26–34)
p value	0.0101	0.0046	0.0540	0.0009	0.0002

*Values are percentages agreeing (95% CIs) unless otherwise indicated. Boldface indicates significance (p<0.05 by χ² or by Wald F-tests where there are ≥3 categories). "I don't know" was not included in analysis; "Agree" and "Strongly Agree" were analyzed as "Agree"; "Disagree" and "Strongly Disagree" were not included in analysis. PN, Porter Novelli Public Services and the ENGINE Insights' PN View 360+ Survey.
†Respiratory devices include vaporizers, humidifiers, and continuous positive airway pressure machines.
‡Other race grouped persons who identified as >1 race, Asian, Native American, Alaska Native, or other because of small sample size.
§For comparison between White and other race categories.
¶For comparison between Black or African American and other race categories.
#For comparison between White and Black or African American.
**Hispanic, Spanish, or Latino.
††For comparison between 18–34-y and ≥55-y age groups.
‡‡For comparisons between urban and suburban and between urban and rural.

Table 2. Demographic characteristics of 1,004 respondents to question about how they use tap water, by response, in survey of knowledge about tap water, PN 360 View 2021, United States*
Characteristic	How do you use your household tap water?
Characteristic	Consumption†	Bathing/showering	Washing hands	Rinsing contact lenses	Nasal rinsing	Filling respiratory devices‡
General population	66 (63–69)	84 (82–86.4)	88 (86–90)	9 (7–11)	13 (11–15)	24 (21–27)
Sex
F	64 (59–68)	83 (80–87)	87 (84–90)	8 (5–10)	12 (9–15)	24 (21–28)
M	68 (63–72)	85 (81–88)	89 (86–92)	10 (7–13)	14 (11–17)	23 (20–27)
p value	0.2140	0.6004	0.3666	0.3034	0.3902	0.7322
Race
White	71 (68–74)	87 (84–89)	89 (87–92)	9 (7–11)	13 (11–16)	24 (21–27)
Black or African American	53 (44–62)	77 (70–85)	85 (78–91)	10 (5–16)	10 (5–,15)	22 (15–30)
Other§	52 (42–62)	77 (69–86)	83 (75–91)	8 (3–14)	14 (7–20)	24 (15–32)
p value	<0.0001¶	0.0078¶	0.0814	0.8320	0.5920	0.9130
Ethnicity
Hispanic#	51 (42–61)	71 (63–79)	78 (70–86)	13 (7–19)	21 (14–29)	25 (17–33)
Non-Hispanic	69 (65–72)	87 (84–89)	90 (88–92)	8 (6–10)	11 (9–13)	24 (21–27)
p value	0.0003	<0.0001	0.0003	0.0813	0.0012	0.7937
Age, y
18–34	57 (51–63)	73 (67–78)	81 (76–86)	14 (10–18)	19 (14–24)	25 (20–30)
35–54	64 (58–69)	83 (79–88)	87 (83–91)	10 (7–14)	13 (10–17)	25 (20–30)
≥55	74 (70–79)	93 (90–96)	94 (9–97)	4 (2–5)	8 (5–11)	22 (18–26)
p value	<0.0001**	<0.0001††	<0.0001**	<0.0001**	0.0002**	0.5591
Region
Northeast	70 (63–77)	82 (76–88)	89 (84–94)	10 (5–14)	12 (7–16)	31 (24–38)
Midwest	69 (63–76)	84 (78–89)	85 (80–91)	8 (4–12)	12 (8–17)	27 (21–34)
South	66 (61–71)	87 (84–91)	89 (86–93)	8 (5–11)	12 (8–15)	18 (14–22)
West	58 (52–65)	81 (75–86)	87 (82–91)	10 (6–15)	15 (11–20)	25 (19–31)
p value	0.0601	0.2120	0.5344	0.7265	0.5647	0.0054‡‡
Community setting
Urban	62 (56–67)	82 (78–87)	88 (84–2)	13 (9–17)	16 (12–20)	24 (19–28)
Suburban	65 (60–69)	83 (79–87)	86 (83–90)	8 (5–10)	13 (10–16)	24 (20–28)
Rural	74 (68–80)	89 (85–93)	91 (86–95)	6 (3–9)	7 (4–11)	24 (18–30)
p value	0.0189§§	0.1004	0.3463	0.0115¶¶	0.0147§§	0.9797
Household income
<$59,999	63 (59–67)	83 (80–87)	86 (83–89)	7 (5–10)	9 (7–12)	20 (17–24)
≥$60,000	69 (65–74)	85 (82–89)	90 (87–93)	11 (8–14)	17 (14–21)	29 (25–34)
p value	0.0608	0.4593	0.0837	0.0355	0.0003	0.0024
Water source, n = 932
Private well	68 (61–76)	76 (69–83)	82 (75–88)	14 (8–19)	18 (12–24)	38 (29–46)
Municipal	67 (63–70)	87 (84–89)	90 (87–92)	8 (6–10)	12 (10–14)	22 (19–25)
p value	0.6712	0.0016	0.0102	0.0179	0.0388	0.0001

*Values are percentages (95% CIs) unless otherwise indicated. Boldface indicates significance (p<0.05 by χ² or by Wald F-tests where there are ≥3 categories; specific comparisons are footnoted). PN360 View, Porter Novelli Public Services and the ENGINE Insights' PN View 360+ Survey.
†Includes drinking, rinsing produce, or making ice.
‡Respiratory devices include vaporizers, humidifiers, and continuous positive airway pressure machines.
§Other race grouped persons who identified as >1 race, Asian, Native American, or Alaska Native, or other because of small sample size.
¶For comparison between White and Black or African American and between White and other race categories.
#Hispanic, Spanish, or Latino.
**For comparisons between 18–34-y and ≥55-y age groups and between 35–54-y and ≥55-y age groups.
††For comparisons between 18–34-y and 35–54-y age groups, between 18–34-y and ≥55-y age groups, and between 35–54-y and ≥55-y age groups.
‡‡For comparisons between Northeast and South, between Midwest and South, and between South and West.
§§For comparisons between urban and rural and between suburban and rural.
¶¶For comparisons between urban and suburban and between urban and rural.

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(Mis)perception and Use of Unsterile Water in Home Medical Devices

PN View 360+ Survey, United States, August 2021

Abstract and Introduction

Abstract

Introduction

Tables

Tables

References

Authors and Disclosures

Authors and Disclosures

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