The true incidence of endemic acute gastrointestinal illness (AGI) attributable to drinking water in Canada is unknown. Using a systematic review framework, the literature was evaluated to identify methods used to attribute AGI to drinking water. Several strategies have been suggested or applied to quantify AGI attributable to drinking water at a national level. These vary from simple point estimates, to quantitative microbial risk assessment, to Monte Carlo simulations, which rely on assumptions and epidemiological data from the literature. Using two methods proposed by researchers in the USA, this paper compares the current approaches and key assumptions. Knowledge gaps are identified to inform future waterborne disease attribution estimates. To improve future estimates, there is a need for robust epidemiological studies that quantify the health risks associated with small, private water systems, groundwater systems and the influence of distribution system intrusions on risk. Quantification of the occurrence of enteric pathogens in water supplies, particularly for groundwater, is needed. In addition, there are unanswered questions regarding the susceptibility of vulnerable sub-populations to these pathogens and the influence of extreme weather events (precipitation) on AGI-related health risks. National centralized data to quantify the proportions of the population served by different water sources, by treatment level, source water quality, and the condition of the distribution system infrastructure, are needed.
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