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Potable reuse is implemented in several countries around the world to augment strained water supplies. This article presents a public health perspective on potable reuse by comparing the critical infrastructure and institutional capacity characteristics of two well-established potable reuse schemes with conventional drinking water schemes in developed nations that have experienced waterborne outbreaks. Analysis of failure events in conventional water systems between 2003 and 2013 showed that despite advances in water treatment technologies, drinking water outbreaks caused by microbial contamination were still frequent in developed countries and can be attributed to failures in infrastructure or institutional practices. Numerous institutional failures linked to ineffective treatment protocols, poor operational practices, and negligence were detected. In contrast, potable reuse schemes that use multiple barriers, online instrumentation, and operational measures were found to address the events that have resulted in waterborne outbreaks in conventional systems in the past decade. Syndromic surveillance has emerged as a tool in outbreak detection and was useful in detecting some outbreaks; increases in emergency department visits and GP consultations being the most common data source, suggesting potential for an increasing role in public health surveillance of waterborne outbreaks. These results highlight desirable characteristics of potable reuse schemes from a public health perspective with potential for guiding policy on surveillance activities.
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