This paper investigates potential exposure to endotoxin in drinking water through the inhalation of aerosols generated by showers and humidifiers. Adverse health effects attributable to the inhalation of airborne endotoxin in various occupational settings are summarized, as are controlled laboratory inhalation studies. Data from investigations estimating aerosolization of particulate matter by showers and humidifiers provide a basis for similar analyses with endotoxin, which like minerals in water, is nonvolatile. A theoretical assessment of the inhalation of aerosolized endotoxin showed that while the likelihood of an acute response while showering is minimal, the same is not true for humidifiers. Ultrasonic and impeller (cool mist) humidifiers efficiently produce large numbers of respirable particles. It is predicted that airway inflammation can occur if humidifier reservoirs are filled with tap water, sometimes even at typical drinking-water distribution-system endotoxin concentrations. Higher endotoxin levels occasionally found in drinking water (>1,000 EU/ml) are very likely to induce symptoms such as chills and fever if used as humidifier feed water. While it is unlikely that treated drinking water would contain extremely high endotoxin levels occasionally observed in cyanobacterial blooms (>35,000 EU/ml), the potential for serious acute health consequences exist if used in humidifiers.

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